Professional Documents
Culture Documents
MCN - 7262611-Lect-Mcn
MCN - 7262611-Lect-Mcn
MCN - 7262611-Lect-Mcn
A. Mons Pubis or Veneris – pad of fat which lies over the symphysis
pubis covered by skin and at puberty, by short hairs; protects the
surrounding delicate tissues from trauma.
B. Labia Majora – two folds of skin with fat underneath; contain
Bartholin’s glands (believed to secrete a yellowish mucus which acts
as a lubricant during sexual intercourse. The openings of the
Bartholin’s glands are located posteriorly on either side of the vagina
orifice.
C. Labia Minora – two thin folds of delicate tissues; form an upper fold
encircling the clitoris (called the prepuce) and unite posteriorly (called
the fourchetes, which is highly sensitive to manipulation and trauma
that is why it is often torn during a woman’s delivery.)
D. Clitoris – small, erectile structure at the anterior junction of the labia
minora, which is comparable to the penis in its being extremely
sensitive. Landmark for catheterization
E. Vestibule – narrow space seen when the labia minora are separated.
F. Urethral Meatus – external opening of the urethra; slightly behind and
to the side are the openings of the Skene’s glands (which are often
involved in infections of the external genitalia).
G. Vaginal orifice/Introitus – external opening of the vagina, covered by
a thin membrane (called hymen) in virgins. Myrtiform caruncle
H. Perineum – area from the lower border of the vaginal orifice to the
anus; contains the muscles (e.g., pubococcygeal and levator ani)
which support the pelvic organs, the arteries that supply blood and the
pudendal nerves which are important during delivery under anesthesia.
A. Vagina – a 3-4 inch long dilatable canal located between the bladder
and the rectum; contains rugae (which permit considerable stretching
without tearing); passageway for menstrual discharges, copulation and
fetus. CBQ
B. Uterus – hollow pear-shaped fibromuscular organ 3 inches long, 2
inches wide, 1 inch thick, and weighing 50-60 grams in a non-pregnant
woman; hold in place by broad ligaments (from sides of the uterus to
pelvic wall; also hold Fallopian tubes and ovaries in place) and round
ligaments (from sides of uterus to mons pubis); abundant blood supply
from uterine and ovarian arteries; composed of three muscle layers
(perimetrium, myometrium, and endometrium). Consists of three parts:
corpus (body) – upper portion with triangular part called fundus;
isthmus – area between corpus and cervix which forms part of the
lower uterine segment; and, - cylindrical portion. Organ of
menstruation, site of implantation and retainment and nourishment of
the products of conception. Main support comes from cardinal
ligaments
C. Fallopian Tubes – 4 inches long from each side of the fundus; widest
part (called ampulla) spreads into fingerlike projections (called
fimbriae). Responsible for transport of mature ovum from ovary to
uterus; fertilization takes place in its outer third or outer half.
D. Ovaries – almond-shaped, dull white sex glands near the fimbriae,
kept in place by ligaments. Produce, mature and expel ova and
manufacture estrogen and progesterone.
A. Structure
1. 2 Os Coxae/Innominate bones – made up of:
a. Ilium – upper, extended part; curved upper border is
the iliac crest.
b. Ischium – under part; when sitting, the body rests on
the ischial tuberosities; ischial spines are important
landmarks.
c. Pubes – front part; join to form an articulation of the
pelvis called the symphysis pubis.
2. Sacrum – wedge-shaped, form the back part of the pelvis.
Consists of 5 fused vertebrae, the first having a prominent under
margin called the sacral promontory. Articulates with the ilium,
the sacroiliac joint.
3. Coccyx – lowest part of the spine; degree of movement
between sacrum and coccyx, made possible by the third
articulation of the pelvis called sacrococcygeal joint which
allows room for delivery of the fetal head.
C. Types/Variations
1. Gynecoid – “normal female pelvis. Inlet is well rounded forward
and back. Most ideal for childbirth.
2. Anthropoid – transverse diameter is narrow, AP diameter is
larger than normal.
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis. Inlet has a narrow, shallow posterior
portion and pointed anterior portion.
D. Measurements
1. External – suggestive only of pelvic site.
a. Intercristal – distance between the middle points of the iliac
crests.
Average = 28 cm.
b. Interspinous – distance between the anterosuperior iliac
spines. Average = 25 cm.
c. Intertrochanteric – distance between the trochanters of the
femur. Average = 31 cm.
d. External conjugate/Daudelocque’s – the distance between
the anterior aspect of the symphysis pubis and depression
below L5. Average = 18-20 cm.
2. Internal – give the actual diameters of the inlet and outlet
a. Diagonal conjugate – distance between sacral promontory
and inferior margin of the symphysis pubis. Average = 12.5 cm.
b. True conjugate/conjugata vera – distance between the
anterior surface of the sacral promontory and the superior
margin of the symphysis pubis. Very important measurement
because it is the diameter of the pelvic inlet. Average = 10.5 -
11 cm.
c. Bi-ischial diameter/tuberischial – transverse diameter of
the pelvic outlet. Is measured at the level of the anus. Average
= 11 cm
A. General Considerations
1. 300,000 – 400,000 immature oocytes per ovary are present at
birth (ware formed during the first 5 months of intrauterine life);
many, however, degenerate and atrophy (process called
atresia). About 300 – 400 mature during the entire reproductive
cycle of women.
2. Ushered in by the menarche, (first menstruation in girls) and
ends with menopause (permanent cessation of menstruation; no
more functioning oocytes in the ovaries). Age of onset and
termination vary widely, depending on heredity, racial
background, nutrition and climate.
3. Normal period (days when there is menstrual flow) lasts for 3-6
days; menstrual cycle (from first day of menstrual period to first
day of next menstrual period) maybe anywhere from 25-35
days, but accepted average length in 28 days.
4. Anovulatory states after menarche not unusual because of
immaturity of feedback mechanism (anovulatory states occur
also in pregnancy, lactation and related disease conditions).
5. Associated terms:
a. Amenorrhea – temporary cessation of menstrual flow
b. Oligomenorrhea – markedly diminished menstrual flow,
nearing amenorrhea
c. Menorrhagia – excessive bleeding during regular
menstruation
d. Metrorrhagia – bleeding at completely irregular intervals
e. Polymenorrhea – frequent menstruation occurring at
intervals of less than three weeks
6. Body structures involved:
a. Hypothalamus
b. Anterior pituitary gland
c. Ovary
d. Uterus
7. Hormones which regulate cyclic activities:
a. Follicle-stimulation hormone (FSH)
b. Luteinizing hormone (LH)
8. Effects of estrogen in the body:
a. Inhibits production of FSH
b. Causes hypertrophy of the endometrium
c. Stimulates growth of the ductile structures of the breasts
d. Increases quantity and pH of cervical mucus, causing it to
become thin and watery and can be stretched to a distance of
10-13 cm. (Spinnbarkeit test of ovulation)
9. Effects of progesterone in the body:
a. Inhibits production of LH
b. Increases endometrial tortuosity
c. Increases endometrial secretions
d. Inhibits uterine motility
e. Decreases muscle tone of gastrointestinal and urinary tracts
f. Increases musculoskeletal motility
g. Facilitates transport of the fertilized ovum through the Fallopian
tubes
h. Decreases renal threshold for lactose and dextrose
i. Increases fibrinogen levels; decreases hemoglobin and
hematocrit
j. Increases body temperature after ovulation. Just before
ovulation, basal body temperature decreases slightly (because
of low progesterone level in the blood) and then increases
slightly a day after ovulation (because of the presence of
progesterone).
C. Additional Information
1. When the ovary releases the mature ovum on the day of
ovulation, sometimes a certain degree of pain in either the right
or left lower quadrant is felt by the woman. This sensation is
normal and is termed mittelschmerz.
2. The first 14 days of the menstrual cycle is a very variable
period. The last 14 days of the menstrual cycle is a fixed period
exactly 2 weeks after ovulation, menstruation will occur (unless
a pregnancy has taken place) because the corpus luteum has a
life span of only 2 weeks. Implication: when given options
regarding the exact date of ovulation, choose two weeks before
menstruation.
3. In a 28-day cycle, ovulation takes place on the 14 th day. In a
32-day cycle, ovulation takes place on the 18th day. In a 26-day
cycle, ovulation takes place or the 12th day (Subtract 14 days
from the cycle).
4. Menstruation can occur even without ovulation (as in women
taking oral contraceptives). Ovulation can likewise occur even
without menstruation (as in lactating mothers).
PREGNANCY AND PRENATAL CARE
II. Fertilization
A. Definition: the union of the sperm and the mature ovum in the outer third
or outer half of the Fallopian tube.
B. General considerations:
1. Normal amount of semen per ejaculation = 3 – 5 cc = 1 teaspoon
2. Number of sperms in an ejaculate = 120 – 150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after
ovulation. Sperms are capable of fertilizing even for 3-4 days after ejaculation
4. Normal life span of sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix
within 90 seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid
number of daughter cells); therefore, they contain only 23 chromosomes (the rest
of the body cells have 46 chromosomes). Sperms have 22 autosomes and 1 X
sex chromosome or 1 Y sex chromosome; ova contain 22 autosomes and 1 X
sex chromosome. The union of an X-carrying sperm and a mature ovum results
in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum results in
a baby boy (XY). Important: Only fathers determine the sex of their children.
III. Implantation
General Consideration:
A. Once implantation has taken place, the uterine endothelium is now termed
decidua
B. Occasionally, a small amount of vaginal spotting appears with implantation
because capillaries are ruptured by the implanting throphoblasts =
implantation bleeding. Implication: this should not be mistaken for the
Last Menstrual Period (LMP).
2. Chorion – together with the deciduas basalis gives rise to the placenta,
which starts to form on the 8th week of gestation. Develops into
15-20 subdivision called cotyledons. Placenta serves the
following purposes:
a. Respiratory system – exchange of gases takes place in the placenta,
not in the fetal lungs
b. Renal system – waste products are being excreted through the
placenta (Note: it is the mother’s liver which detoxifies the fetal waste
products).
c. Gastrointestinal system – nutrients pass to the fetus via the placenta
by diffusion through the placental tissues.
d. Circulatory system – feto-placental circulation is established by
selective osmosis
e. Endocrine system – it produces the following hormones (before 8
weeks gestation, the corpus luteum is the one producing these
hormones):
Human chronionic gonadotropin (HCG) – “order’s the corpus
luteum to keep on producing estrogen and progesterone that is
why menstruation does not ta ke place during pregnancy. It is
also the basis for pregnancy test.
Human placental lactogen (HPL)/human chronionic
somatomammotropin – promotes growth of the mammary
glands necessary for lactation. Also has growth-stimulating
properties
Estrogen
Progesterone
f. Protective barrier – inhibit passage of some bacteria and large
molecules.
A. Systemic Changes
1. Circulatory/Cardiovascular
a. Beginning the end of the first trimester, there is gradual increase of
about 30%-50% in total cardiac volume, reaching its peak during
the 6th month. This causes a drop in hemoglobin and hematocrit
values since the increase is only in the plasma volume=physiologic
anemia of pregnancy. Consequences of increased total cardiac
volume are:
Easy fatigability and shortness of breath because of increased
workload of the heart
Slight hypertrophy of the heart, causing it to be displaced to
the left, resulting in torsion on the great vessels (the aorta and
pulmonary artery)
Systolic murmurs are common due to lowered blood viscosity
Nosebleeds may occur because of marked congestion of the
nasopharynx as pregnancy progresses
b. Palpitations due to:
Sympathetic nervous system stimulation during first half of
pregnancy
Increased pressure of uterus against the diaphragm during 2nd
half of pregnancy
c. Because of poor circulation resulting from pressure of the gravid
uterus on the blood vessels of the lower extremities:
Edema of the lower extremities occurs.
Management: raise legs above hip level
Important: Edema of the lower extremities is NOT a sign of
toxemia.
Varicosities of the lower extremities can also occur.
Management:
• Use/wear support hose or elastic stocking to
promote venous flow, thus preventive stasis in the
lower extremities
• Apply elastic bandage – start at the distal end of
the extremity and work toward the trunk to avoid
congestion and impaired circulation in the distal
part; do not wrap toes so as to be able to
determine the adequacy of circulation (Principle
behind bandaging: blood flow thru tissues is
decreased by applying excessive pressure on
blood vessels)
• Avoid use of constricting garters, e.g., knee-high
socks
d. Because of poor circulation in the blood vessels of the genitalia due
to pressure of the gravid uterus, varicosities of the vulva and
rectum can occur. Management:
Side-lying position with hips elevated on pillows
Advise modified knee-chest position
e. There is increased level of circulating fibrinogen, that is why
pregnant women are normally safeguarded against undue bleeding.
However, this also predisposes them to formation of blood clots
(thrombi). The implication is that pregnant women should not be
massaged since blood clots can be released an cause
thromboembolism.
2. Gastrointestinal changes
a. Morning sickness (-nausea and vomiting during the first trimester) is
due to increased human chorionic genadotropin (HCC). It may also
be due to increased acidity or even to emotional factors.
Management:
Eat dry toast or crackers 30 minutes before arising in the
morning (or dry, high carbohydrate, low fat and low spices in
the diet).
Hyperemesis gravidarum – excessive nausea and vomiting
which persists beyond 3 months; will result in dehydration,
starvation and acidosis. Management
• D10 NSS 3000 ml in 24 hours is the priority of treatment
• Complete bed rest is also an important
b. Constipation and flatulence are due to the displacement of the
stomach and intestines, thus slowing peristalsis and gastric-
emptying time; may also be due to increased progesterone during
pregnancy. Management:
Increase fluids and roughage in the diet
Establish regular elimination time
Increase exercise
Avoid enemas
Avoid harsh laxatives like Dulcolax; stool softeners, e.g.
Colace, are better
Mineral oil should not be taken because it interferes with
absorption of fat-soluble vitamins
c. Hemorrhoids are due to pressure of enlarged uterus. Management:
Cold compress with witch hazel or Epsom salts.
d. Heartburn, especially during the last trimester, is due to increased
progesterone which decreases gastric motility, thereby causing
reverse peristaltic waves which lead to regurgitation of stomach
contents through the cardiac sphincter into the esophagus, causing
irritation.
Management:
Pats of butter before meals
Avoid fried, fatty foods
Sips of milk at frequent intervals
Small, frequent meals taken slowly
Bend at the knees, not at the waist
Take antacids (e.g. Milk of Magnesia) but NEVER sodium
bicarbonate (e.g. Alka Seltzer or baking soda) because it
promotes fluid retention.
5. Musculoskeletal changes
a. Because of the pregnant woman’s attempt to change her center of
gravity, she makes ambulation easier by standing more straight and
taller, resulting in a lordotic position (“pride of pregnancy”)
b. Due to increased production of the hormone relaxin, pelvic bones
become more supple and movable, increasing the incidence of
accidental falls due to the wobbly gait.
Implication: Advise use of low-heeled shoes after the first trimester.
c. Leg cramps are caused by:
Increased pressure of gravid uterus on lower extremities
Fatigue
Chills
Muscle tenseness
Low calcium high phosphorus intake
Management:
Frequent rest periods with feet elevated
Wear warm, more comfortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage – blood clots can cause embolism
Most effective relief: Press knee of the affected leg and
dorsiflex the foot
7. Endocrine changes
a. Addition of the placenta as an endocrine organ, producing large
amounts of estrogen, progesterone, HCG and HPL
b. Moderate enlargement of the thyroid gland due to hyperplasia of
the glandular tissues and increased vascularity. Could also be
due to increased basal metabolic activity of the products of
conception.
c. Increased size of the parathyroids, probably to satisfy the
increased need of the fetus for calcium
d. Increased size and activity of the adrenal cortex, thus increasing
the amount of circulating cortisol, aldosterone and ADH, all of
which affect carbohydrate and fat metabolism
e. Gradual increase in insulin production but the body’s sensitivity
to insulin is decreased during pregnancy
8. Weight
a. During first trimester, weight gain of 1.5 – 3 lbs
b. On 2nd trimester and 3rd trimesters, weight gain of 10-11 pounds
per trimester is recommended
c. Total allowable weight gain during entire period of pregnancy is
20 - 25 lbs ( = 10 – 12 kgs)
d. Pattern of weight gain is more important than the amount of
weight gained
e. Distribution of weight gain during pregnancy:
Fetus 7 lbs
Placenta 1 lb
Amniotic fluid 1 ½ lbs
Increased weight of uterus 2 lbs
Increased blood volume 1 lb
Increased weight of the breast 1 ½ - 3 lbs
Weight of additional fluid 2 lbs
Fat fluid accumulation 4 – 6 lbs
Characteristic of pregnancy _________
TOTAL = 20 – 25 lbs
9. Emotional responses
a. First trimester: the fetus is an unidentified concept with great
future implications but without tangible evidence of reality.
Some degree of rejection, denial and disbelief, even repression.
(Implication: when giving health teachings, be sure to
emphasize the bodily changes in pregnancy)
b. Second trimester: fetus is perceived as a separate entity.
Fantasizes appearance of the baby
c. Third trimester: has personal identification with a real baby about
to be born and realistic plans for future child care
responsibilities. Best time to talk about preparation of layette
and infant feeding method. Fear of death, though, is prominent
(To allay fears, let pregnant woman listen to the fetal heart
tones).
B. Local Changes
1. Uterus
a. Weight in crease to about 1,000 grams at full term; due to
increase in the amount of fibrous and elastic tissues.
b. Change in shape from pear-like to ovoid
c. Change in consistency of the lower uterine segment causes
extreme softening, known as Hegar’s sign, seen at about the 6th
week
d. Mucous plugs in the cervix, called operculum, are produced to
seal out bacteria
e. Cervix becomes more vascular and edematous, resembling the
consistency of an earlobe, known as Goodell’s sign.
2. Vagina
a. Increased vascularity causes change in color from light pink to
deep purple or violet known as Chadwick’s sign
To prevent confusion as to pregnancy signs arrange the
body “out to xxx” and the different signs alphabetically.
Thus:
Vagina - Chadwick’s sign
Cervix - Goodell’s sign
Uterus - Hegar’s sign
b. Due to increase estrogen, activity of the epithelial cells
increases, thus increasing amount of vaginal discharges called
leukorrhea. As long as the discharges are not smelling or
irritatingly itchy, it is normal. Management: Maintain or
increase cleanliness by taking twice daily shower baths using
cool water.
c. pH of vagina changes from the normally acidic (because of the
presence of the Doderlein bacilli) to alkaline (because of
increased estrogen). Alkaline vaginal environment is supposed
to protect against bacterial infection, however, there are two
microorganisms which love to thrive in an alkaline environment:
Trichomonas, a protozoa or flagellate. The condition is called trichomonas
vaginalis or trichomonas vaginitis or trichomoniasis. Symptoms are:
Frothy, cream-colored, irritatingly itchy, foul-smelling discharges
Vulvar edema and hyperemia due to irritation from the discharges
Treatment:
Flagyl for 10 days p.o. or vaginal suppositories of
Trichomonicidal compounds (e.g., Tricefuron, Vagisec,
Devegan). Note: Is carcinogenic during the first
trimester. Treat male partner also, with Flagyl.
(Important: avoid alcoholic drinks when taking Flagyl –
can cause Antabuse-like reactions: vomiting, flushed
face and abdominal cramps.) Dark brown urine a minor
side effect-no need to discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar to 1 quart
of water or 15 ml white vinegar in 1000 ml water) to
counteract alkaline-preferred environment of the
protozoa.
Avoid intercourse to prevent re-infection.
Monilia, a fungus called Candida albicans. The condition is called Moniliasis or
Candidiasis. Fungus also lives to thrive in environment right in carbohydrates
(that is why it is common among poorly-controlled diabetics) and in those on
steroid and antibiotic therapy when acidic environment is altered.
Symptoms:
White, patchy, cheese-like particles that adhere to
vaginal walls. Irritatingly itchy and foul-smelling
vaginal discharges
Treatment:
Mycostatin/Nystatin p.o. or vaginal
suppositories/pessaries (100,000 U) twice a day for
15 days
Gentian violet swab to vagina (use panty
shields to prevent staining of clothes or underwear)
Correct diabetes
Avoid intercourse
Acidic vaginal douche
Moniliasis is seen as oral thrush in the newborn when
transmitted during delivery through the birth canal of the
infected mother.
3. Abdominal Wall
a. Striae gravidarum – increased uterine size results in rupture
and atrophy of the connective tissue layers, seen as pink or
reddish streaks (gently rubbing oil on the skin helps prevent
diastasis)
b. Umbilicus pushed out
4. Skin
a. Linea nigra – brown line running from umbilicus to symphysis
pubis
b. Melasma or chloasma – extra pigmentation on cheeks and
across the nose due to the increased production of
melanocytes by the pituitary gland
c. Sweat glands unduly activated
5. Breasts
a. All changes due to increased estrogen
b. Increase in size due to hyperplasia of mammary alveoli and
fat deposits. Proper breast support with well-fitting brassiere
necessary to prevent sagging
c. Feeling of fullness and tingling sensation in the breasts
d. Nipples more erect (For mothers who intend to breastfeed,
advise nipple rolling, drying nipples with rough towel to help
toughen the nipples and not to use soap or alcohol so as to
prevent drying which could lead to sore nipples).
e. Montgomery glands become bigger and more protruberant
f. Areolae become darker and diameter increase
g. Skin surrounding areolas turns dark
h. By the fourth month, a thin, watery, high-protein fluid, called
colostrums, is formed. It is the precursor of breast milk.
3. Important Estimates
a. Estimates of age of gestation (AOG):
Naegele’s Rule – calculation of expected date of confinement
(EDC). Count back three months from the first day of the last
menstrual period (LMP) then add 7 days. Substitute number
for month for easy computation.
McDonald’s Method – determines age of gestation by
measuring from the fundus to the symphysis pubis (in cm.)
then divide by 4 = AOG in months. E.g., fundic height of 16
cm. divided by 4 = 4 months AOG = 16 weeks AOG.
Bartholomew’s Rule – estimates AOG by the relative position of
the uterus in the abdominal cavity.
o By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis
o On the 5th lunar month, the fundus is at the level of the umbilicus
o On the 9th lunar month, the fundus is below the xiphoid process
b. Arey’s Rule – determines the length of the fetus in centimeters.
During the first half of pregnancy, square the number of the month (E.g., first
lunar month: 1 x 1 = 1 cm.)
During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar
month: 6 x 5 = 30 cm.)
o Vitamin D – fish, liver, eggs, milk (excess Vit. D during
pregnancy can lead to fetal cardiac problems
o Vitamin E – green leafy vegetables, fish
o Vitamin C – tomatoes, guava, papaya
o Vitamin B – foods rich in proteins
o Calcium/phosphorus – milk, cheese
o Iron – especially important during the last trimester when
the pregnant woman is going to transfer her iron
stores from herself to her fetus so that the baby has
enough iron stores during the first 3 months of life
when all he takes is milk (which is deficient in iron).
Iron has a very low absorption rate; only 10% of the
iron intake can be absorbed by the body. Thus, for
optimum absorption, give Vitamin C. Iron should be
given after meals because it is irritating to the
gastric mucosa. Sources: liver and other internal
organs camote tops, kangkong, egg yolk, ampalaya.
A. Importance – From an obstetrical point of view the fetal skull is the most
important part of the fetus because:
1. It is the largest part of the body
2. It is the most frequent presenting part
3. It is the least compressible of all parts
B. Cranial bones – the first 3 are not important because they lie at the base
of the cranium and, therefore, are never the presenting parts:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. Parietal
C. Membrane spaces – suture lines are important because they allow the
bones to move and overlap; changing the shape of the fetal head in
order to fit through the birth canal, a process called molding:
1. Sagittal suture line – the membranous interspace which joins the 2
parietal bones
2. Coronal suture line – the membranous inter-space which joins the
frontal bone and the parietal bones
3. Lambdoid suture line – the membranous inter-space which joins the
occiput and the parietals
A. Lightening – the settling of the fetal head into the pelvic brim. In primis, it
occur 2 weeks before EDC; in multis, on or before labor
onset.
Results of lightening:
1. Increase in urinary frequency
2. Relief of abdominal tightness and diaphragmatic pressure
3. Shooting pains down to legs because of pressure on the sciatic nerve
4. Increase in the amount of vaginal discharges.
5. Lightening should not be confused with engagement. Engagement
occurs when the presenting part has descended into the pelvic inlet.
C. Loss of weight – of about 2-3 lbs 1 to 2 days before labor onset, probably
due to decrease in progesterone production, leading to
decrease in fluid retention.
D. Braxton Hicks contractions – painless, irregular practice contractions
E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “butter-
soft”.
A. Uterine Contractions – the surest sign that labor has begun is the initiation
of effective, productive uterine contractions.
1. Pain in uterine contractions results from:
a. Contraction of uterine muscles when in an ischemic state
b. Pressure on nerve ganglia in the cervix and lower uterine segment
c. Stretching of ligaments adjacent to the uterus and in the pelvic joints
d. Stretching and displacement of the tissues of the vulva and
perineum
2. Phases of uterine contractions
a. Increment – first phase during which the intensity of contraction
increases; also known as crescendo
b. Acme – the height of the uterine contraction; also know as apex
c. Decrement – last phase during which intensity of contraction
decreases; also known as decrescendo
2. Generally confined to the abdomen 2. First felt in the lower back and
sweep around to the abdomen in a
girdle-like fashion
B. Effacement – shortening and thinning of the cervical canal from 1-2 cm. to
one in which no canal as distinct from the uterus exists. It is
expressed in percentage.
Primis Multis
A. First Stage (Stage of Dilatation) – begins with true labor pains and ends
with complete dilatation of the cervix.
1. Power/Forces: Involuntary uterine contractions
2. Phases:
a. Latent – early time in labor
Cervical dilatation is minimal because effacement is occurring
Cervix dilates 3-4 cm. only
Contractions are of short duration and occur regularly 5-10 minutes apart (during
which time the pregnant woman may seek admission to the hospital)
Mother is excited, with some degree of apprehension but still with ability to
communicated
Takes up 8 of the 12-hour first stage
b. Active/accelerated
Cervical dilatation reaches 4-8 cm.
Rapid increase in duration, frequency and intensity of
contractions
Mother fears losing control of herself
2. Nursing Care
a. Hospital admission – provide privacy and reassurance from the very
start
Personal data – name, age, address, civil status
Obstetrical data – determine EDC; obstetrical score; amount and
character of show; and whether or not membranes have ruptured
b. General physical examination, internal exam and Leopold’s
maneuvers are done to determine:
Effacement and dilatation
Station – relationship of the fetal presenting part to the level of
the ischial spines
Station 0 – at the level of the ischial spines;
synonymous to engagement
Station -1 – presenting part above the level of
the ischial spines
Station +1 – presenting part below the level of
the ischial spines
Station +3 or +4 – synonymous to
crowning (= encirclement of the largest
diameter of the fetal had by the vulvar
ring)
Presentation – relationship of the long axis of the fetus to the long axis of the
mother; also known as lie
Presenting part – the fetal part which enter the pelvis first and
covers the internal cervical os
I. VERTICAL
A. Cephalic – he is the presenting part
1. Vertex – head sharply flexed, making the parietal bone the presenting
part
2. Face)
3. Brow) if in poor flexion
4. Chin )
Vaginal bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning
Encourage the mother to void very 2-3 hours by offering the
bedpan because:
B. Transition Period – when the mood of the woman suddenly changes and the
nature of the contractions intensify.
1. Characteristics :
a) If membranes are still intact, this period is marked by a
sudden gush of amniotic fluid as fetus is pushed into the
birth canal. If spontaneous rupture does not occur,
amniotomy (snipping of BOW with a sterile pointed
instrument e.g. Kelly or Allis forceps or amniohook to allow
amniotic fluid to drain), is done to prevent fetus from
aspirating the amniotic fluid as it makes its different fetal
position changes. Amniotomy, however cannot be if station
is still “minus” as this (can lead to cord compression).
b) Show becomes prominent.
c) There is an uncontrollable urge to push with contractions, a
sign of impending second stage of labor. Profuse
perspiration and distention of neck veins are seen.
d) Nausea and vomiting is a reflex reaction due to decreased
gastric motility and absorption.
e) In primis, baby is delivered within 20 contractions (=40
minutes); in multis, in 10 contractions (=20 mintues)
3. Nursing Care
a. When positioning legs or lithotomy,
put them up at the same time to
prevent injury to the uterine
ligaments
b. As soon as the fetal head crowns,
instruct mother not to push, but to
pant instead ( rapid and shallow
breathing) to prevent rapid expulsion
of the baby. If panting is deep and
rapid, called hyperventilation the
patient will experience light-
headedness and tingling sensation
of the fingers leading to carpopedal
spasms, because of respiratory
alkalosis. Management: let the
patient breath into brown paper bag
to recover lost carbon dioxide; a
cupped hand will serve the same
purpose.
c. Assist in episiotomy – incision made
in the perineum primarily to prevent
lacerations.
Other purpose of episiotomy:
o Prevent prolonged and severe stretching of
muscles supporting bladder or rectum
o Reduce duration of second stage when there is
hypertension or fetal distress
o Enlarge outlet, as in breech presentation or
forceps delivery
Types of episiotomy:
o Median – from middle portion of the lower vaginal
border directed towards the anus
o Mediolateral – begun in the midline but directed
laterally away from the anus
Natural anesthesia is used in episiotomy, i.e., no
anesthetic is injected because pressure of fetal
presenting part against the perineum is so intense that
nerve endings for pain are momentarily deadened.
d. Apply the Modified Ritgen’s Maneuver:
Cover the anus with sterile towel and exert upward and
forward pressure on the fetal chin, while exerting gentle
pressure with two fingers on the head to control
emerging head. This will not only support the perineum,
thus preventing lacerations, but will also favor flexion so
that the smallest sub-occipitobregmatic diameter of the
fetal head is presented.
Ease the head out and immediately wipe the nose and
mouth of secretions to establish and maintain a patent
airway (REMEMBER: the first principle in the care of
the newborn is establish and maintain a patent airway).
(The head should be delivered in between
contractions.)
Insert 2 fingers into the vagina so as to feel for the
presence of a cord looped around the neck (nuchal
cord). If so, but loose, slip it down the shoulders or up
over the head; but if tight; clamp cord twice, an inch
apart, and then cut in between.
As the head rotates, deliver the anterior shoulder by
exerting a gentle downward push and then slowly give
an upward lift to deliver the posterior shoulder
While supporting the head and the neck, deliver the rest
of the body. Take note of the exact time of delivery of
the baby.
e. Immediately after delivery, newborn should be held below the
level of the mother’s vulva for a few minutes to encourage
flow of blood from the placenta to the baby.
f. The infant is held with his head in a dependent position (-head
lower than the rest of the body) to allow for drainage of
secretions. REMEMBER: Never stimulate a baby to cry
unless you have drained him out of his secretions first.
g. Wrap the bay in a sterile diaper to keep him warm.
REMEMBER: Chilling increases the body’s need for oxygen.
h. Put the bay on the mother’s abdomen. The weight of the
baby will help contract the uterus.
i. Cutting of the cord is postponed until the pulsations have
stopped because it is believe that 50 – 100 ml of blood is
flowing from the placenta to the baby at this time. After cord
pulsations have stopped, clamp it twice, an inch apart, and
then cut in between
j. Show the baby to the mother, inform her of the sex and time of
delivery then give the baby to the circulating nurse.
VII. Dystocia – bread term for abnormal or difficult labor and delivery.
D. Uterine Rupture – occurs when the uterus undergoes more strain that it
is capable of sustaining.
1. Causes:
a. Scar from a previous classic Cesarean Section (CS)
b. Unwise use of oxytocins
c. Overdistention
d. Faulty presentation or prolonged labor
2. Signs and symptoms:
a. Sudden, severe pain
b. Hemorrhage and clinical signs of shock (restlessness, pallor,
decreasing BP, increasing respiratory and pulse rates)
c. Changing abdominal contour, with two swellings on the
abdomen, the retracted uterus and the extrauterine fetus
3. Management: hysterectomy
E. Uterine Inversion – fundus is forced through the cervix so that the uterus
is turned inside out
1. Causes:
a. Insertion of placenta at the fundus, so that as fetus is rapidly
delivered, especially if unsupported, the fundus is pulled down
b. Strong fundal push when mother fails to bear down properly
c. Attempts to deliver the placenta before signs of placental
separation appear.
2. Management: hysterectomy
PUERPERIUM
I. Definitions
2. Infection
a. Sources:
• Endogenous (primary) sources – bacteria in the normal flora
become virulent when tissues are traumatized and general
resistance is lowered
• Exogenous sources – pathogens introduced from external
sources. Organism most frequently responsible for
postpartum infections: Anaerobic streptococci.
• Common exogenous sources:
• Hospital personnel
• Excessive obstetric manipulations
• Breaks in aseptic techniques – faulty hand washing,
unsterile equipments and supplies
• Coitus in late pregnancy
• Premature rupture of the membranes
b. General symptoms: malaise, anorexia, fever, chills and headache
c. General management: complete bed rest (CBR), proper nutrition,
increased fluid intake, analgesics, antipyretics and antibiotics, as
ordered
d. Types of infection:
A. Infection of the perineum
• Specific symptoms:
• Pain, heat and feeling of pressure in the
perineum
• Inflammation of the suture line, with 1 or 2 stitches
sloughed off
• With or without elevated temperature
• Specific management:
• Doctor removes sutures to drain area and re-
sutures
• Hot Sitz bath or warm compress
B. Endometritis – inflammation/infection of
the lining of the uterus
• Specific symptoms:
• Oxytocin
• Fowler’s position to drain out lochia and prevent pooling
of infected discharge
C. Thrombophlebitis – infection of the lining
of a blood vessel with formation of clots;
usually an extension of endometritis
• Specific symptoms:
• Pain, stiffness and redness in the affected part of the
leg
• Leg beings to swell below the lesion because venous
circulation has been blocked
• Skin is stretched to a point to shiny whiteness, called
milk leg – phlegmasia alba dolens
• Positive Homan’s Sign – pain in the calf when the foot
is dorsiflexed
• Specific management:
• Bed rest with affected leg elevated
• Anticoagulants, e.g., Dicumarol or Heparin, to prevent
further clot formation or extension of a thrombus
Side effects: hematuria & increased lochia
• Considerations:
• Discontinue breastfeeding
• Monitor prothrombin time
• Always have Protamin sulfate or Vitamin at bedside to
counteract toxicity
• Analgesics are given but NEVER Aspirin because it inhibits prothrombin
formation; since patient is already receiving an
anticoagulant, bleeding may occur
26 32
- 18 - 11
8 21
her fertile period would be from the 8th to the 21st day
of her cycle, i.e., she should not have sexual intercourse
during these days
5. Natural Family Planning (NFF) – periods
abstinence:
a. Cervical mucus/Billing method
• Basis: the flow of mucus from the cervix of the
uterus
• Method: a woman can discern her fertile and infertile days
based on her sensory and visual observations of the
cervical mucus (when it becomes thin and watery –
spinnbarkeit), intercourse is avoided 4 days prior to and 3
days after the spinnbarkeit
b. Basal Body Temperature (BBT)
• Method: involves observing the temperature of the woman
at rest, free from any factor that may cause it to fluctuate
(immediately upon waking up, before doing anything else).
As soon as the temperature drops slightly and then
increases (which means ovulation has taken place), she
counts 3-4 days, after which sexual intercourse may be
resumed.
c. Sympto-Thermal method – fertile and infertile days are
determined after having established an accurate record of
the six immediately preceding menstrual cycles and then
watching out for BBT fluctuations.
6. Surgical methods
a. Tubal ligation – the Fallopian tubes are ligated in order to
prevent passage of sperms. Menstruation and ovulation
continue
b. Vasectomy – small incision made into each side of the
scrotum and the vas deferens is and cut and tied, blocking
passage of sperms. Sperm production continues, only
passage into the exterior is prevented. (Sperms in the vas
deferens at the time of surgery may remain viable for as long
as 6 months. Implication: couple should still observe a form
of contraception during this time to ensure protection against
a subsequent pregnancy.)
7. Social methods
a. Abstinence
b. Withdrawal or coitus interruptus
RISK PREGNANCY
I. BLEEDING IN PREGNANCY
Table 9. Outline of Classification
D. Details:
1. Preeclampsia
a. Underlying causes:
• Insufficient production of blood and platelets
• Generalized vasoconstriction and associated
microangiopathy (-disease of capillaries)
• Abnormal retention of sodium and water by
body tissues
b. Medical complications:
• Cerebrovascular hemorrhage
• Acute pulmonary edema
• Acute renal failure
c. Types:
• Mild preeclampsia
• Signs and symptoms:
• Sudden, excessive weight gain of 1-5 lbs per week
(earliest sing of preeclampsia) due to edema which is
persistent and found in the upper half of the body
(e.g., inability to wear the wedding ring)
• Systolic BP of 140, or an increase of 30 mmHg, or
more and a diastolic of 90, or a rise of 15 mmHg or
more, taken twice, 6 hours apart
• Proteinuria of 0.5 gm/liter or more
• Severe preeclampsia
• Signs and symptoms
• BP of 160/110 mmHg
• Proteinuria of 5 gm/liter or more in 24 hours
• Oliguria of 400 ml or less in 24 hours (normal urine
output in 24 hours = 1560 ml)
• Cerebral or visual disturbances
• Pulmonary edema and cyanosis
• Epigastric pain (considered an aura to the
development of convulsions)
• Anarsavea/pitting edema; dependent type
• Headache
• Blurred vision
• Oliguria
• Epigastric pain (Aura)
2. Eclampsia – the main difference between
preeclampsia and eclampsia is the
presence of convulsions in eclampsia.
a. Signs and symptoms – as in preeclampsia plus:
• Increased BUN
• Increased uric acid
• Decreased CO2 combining power
E. Management:
1. Complete bed rest – sodium tends to be excreted at a more
rapid rate if the patient is at rest. Energy conservation is
important in decreasing metabolic rate to minimize demands
for oxygen. Lowered oxygen tension in toxemia is the result
of vasoconstriction and decreased blood flow that diminishes
the amount of nutrients and oxygen in the cells. In any
condition wherein there is a possibility of convulsions, bed
rest should be in a darkened, non-stimulating environment
with minimal handling.
2. Diet:
a. For mile preeclampsia – high protein, high carbohydrate,
moderate salt restriction (no added table salt, (including
“bagoong”, “patis” and “toyo”), dired fish (e.g., “daing” and
“tuyo”), canned goods, bottled drinks, preserved foods and
cold cuts)
b. For severe preeclampsia – highprotein, high carbohydrate
and salt-poor (3 gms of salt per day)
3. Medications:
a. Diuretics – hourly urine output should be at least 20-30 ml
(normally 50-60 ml per hour). E.g.,
chlorothiazide/Diuril.
• Pharmacologic effect: decrease reabsorption of sodium
and chloride at the proximal tubules, thereby increasing
renal excretion of sodium, chloride and water, including
potassium.
• Side effects: fatigue and muscle weakness due to fluid and
electrolyte imbalance
• Nursing care: closely monitor intake and output
b. Digitalis – if with heart failure
• Pharmacologic action: Increase the force and contraction
of the heart, thereby decreasing heart rate. Should not be
given, therefore, if heart rate is below 60/minute.
(Implication: take the heart rate before giving the drug.)
c. Potassium supplements – any patient receiving diuretics are
prone to hypokalemia; if digitalis is given at the same time,
hypokalemia increases the sensitivity of the patient to the
effects of digitalis. Potassium supplements (e.g. banana)
must be given to prevent cardiac arrhythmias.
d. Barbiturates – sedation by means of CNS depression
e. Analgesics: antihypertensives; antibiotics; anticonvulsants
f. Magnesium sulfate – drug of choice
• Actions:
• CNS depressant – lessens possibility of
convulsions
• Vasodilator – decreases the BP
• Cathartic – it reduces edema by causing a shift of fluid
from the extracellular spaces into the
intestines from where the fluid can be
excreted
• Dosage: 10 Gms initially, either by slow IV push over 5-10
minutes, or deep IM, 5 Gms/buttock; then IV drip
of 1 Gm/hour (1 GM/100 ml D1 xxxxx) IF:
• Deep tendon reflexes are present
• Respiratory rate is at least 12 per minute
• Urine output is at least 100 ml
• Antidote for Magnesium sulfate toxicity: Calcium gluconate
10% IV to maintain cardiac and vascular tone
• Earliest sing of Magnesium sulfate toxicity: disappearance
of the knee jerk/patellar reflex
4. Methods of Delivery – preferably vaginal, but it not possible, CS
will have to be done
F. Prognosis: the danger of convulsions is present until 48 hours
postpartum.
C. Compications:
1. Toxemia
2. Polyhydramnios
3. Anemia
4. Abruptic placenta
5. Prematurity
6. Postpartum hemorrhage
IX. INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum – a spirochete which enters the
body during coitus or through cuts and other breaks in
the skin or mucous membrane.
2. Treatment: 2.4 – 4.8 million units of Penicillin (if allergic, 30 – 40
gms. of erythrocin) will usually prevent congenital syphilis in the
newborn because Penicillin readily crosses the placenta. If
untreated, syphilis can cause midtrimester abortion, CNS
lesions in the newborn or even death.
3. The newborn with congenital syphilis
a. Signs and symptoms:
• Jaundice at 2 weeks of life – first signs of the disease
• Anemia and hepatosplonomegaly
• “snuffles” (persistent rhinorrhea); coppery rashes on plams
and soles; mucous patches; condylomas; pseudoparalysis
due to bone inflammation
• If untreated, can progress on to deformed bones, teeth,
nose, joints and CNS syphilis
b. Management: Penicillin IM for 10 days or one long-acting
Penicillin (Penadur LA)
B. Rubella/German Measles
1. Incidence:
a. Mother – the earlier the mother contacted the disease, the
greater the likelihood that the baby will be affected. The
rubella virus slows down division of infected cells during
organogenesis.
b. Newborn – can carry and transmit the virus for as long as 12-
24 months after birth
2. Signs and symptoms of Congenital Rubella Syndrome:
a. Low birth weight; jaundice; petechiae; anemia;
thrombocytopenia; hepatosplenomegaly
b. Classes sequelae;
• Eyes: choricretinitis, cataract, glaucoma
• Heart: Patent Ductus arteriosus, stenosis,
coarctations
• Xxxx nerve deafness
• Dental and facial clefts
THE NEONATES
SIGN 0 1 2
1. Interpretation of results:
a. 0 – 3 - the baby is in serious danger and needs immediate
resuscitation
b. 4 – 6 - condition is guarded and may need more extensive
clearing of the airway
c. 7 – 10 - baby is in the best possible health
1. Sole creases Anterior transverse Occasional creases, Sole covered with creases
crease only anterior two-thirds
2. Breast nodule diameter 2 mm 4 mm 7 mm
3. Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
V. Nursery Care
A. Check identification band
B. Take anthropometric measurements:
1. Length – average: 50 cm (20 in.) = 19 - 21 ½ inches (47.5-
53.75 cm.)
2. Head circumference = 33 – 35 cm.
3. Chest circumference = 31 – 33 cm.
4. Abdominal circumference = 31 – 33 cm.
C. Take the temperature – at birth is 37.2 oC or 99oF, but because of
evaporation from the moist skin and the cool delivery room, will
stabilize in 8 hours time and must be maintained at 35.5oC – 36.5oC
(97oF – 99oF) so as to prevent hypoglycemia and acidosis due to
hypothermia. Axillary and rectal temperatures are approximately the
same immediately following birth but the rectal route is preferred in
order to check patency of the anus.
D. Specific nursing actions:
1. Give initial oil bath to cleanse the baby of blood, mucus and
vernix
2. Dress the umbilical cord. Inspect for the presence of 2 arteries
and 1 vein. Suspect a congenital anomaly if blood vessels are
not complete; a more thorough physical assessment is indicated
and closer observation in an ICU is done.
3. Crede’s prophylaxis – prophylactic treatment of the newborn’s
eyes against gonorrheal conjunctivitis (ophthalmic neonatorum)
which the baby acquires as he passes through the birth canal of
his mother who has untreated gonorrhea:
a. Wipe and face dry.
b. Shade the eyes from light and open one eye at a time by
exerting gentle pressure on the upper and lower lids.
c. 2 drops of 1% silver nitrate are instilled one at a time into the
lower conjunctival sac. (Be careful not to drop on the cheeks
because parents may worry about the stain)
d. Wash silver nitrate away with sterile NSS after 1 minute to
prevent chemical conjunctivitis (inflammation, edema,
purulent discharge)
e. Penicillin/chloromycetin/terramycin ophthalmic ointment may
be used since it does not irritate the eyes (although the baby
may develop sensitivity at an early age). Apply from the
inner to the outer canthus of the eye.
4. Vitamin K administration
a. Rationale: Vitamin K facilitates production of the clotting
factor, thus preventing bleeding. But Vitamin K is
synthesized in the presence of normal bacterial
flora in the intestines. Since the newborn’s
intestines are still relatively sterile, therefore, they
will not be able to synthesize Vitamin K; that is
why synthetic Vitamin K is given to prevent
hemorrhage.)
b. Method: 1 mg. Aquamephyton (generic name is
phytonadione) is injected IM into the lateral anterior
thigh (vastus lateralis). In children below 12 months
of age how have not yet learned how to walk, this is
the preferred site of injection because gluteal
muscles are not yet fully developed.
5. Weight-taking
a. Average birth weight = 6 ½ - 7.5 lbs = 3 – 3.4 kgs = 300 –
3400 gms.
b. Arbitrary lower limit – below which the newborn is said to be
of low birth weight: 5.5 lbs = 2.5 kgs = 2500 gms.
c. Ideal procedure
• Weigh the clothes first
• Put on the baby’s clothes
• Weigh the baby with his clothes on
• Subtract the weight of the clothes from the total
weight of the baby and his clothes
d. Physiologic weight loss of 5 – 10% of birth weight (6-10 oz)
during the first 10 days of life because the newborn:
• Is no longer under the influence of maternal
hormones
• Voids and passes out stools
• Has limited intake
• Has beginning difficulty establishing sucking
6. Feeding
a. Initial feeding – is a test feeding consisting of an ounce of
sterile water (glucose water has been found to irritating to
the lungs if aspirated) is given to find if the newborn can
swallow without aspirating.
b. Subsequent feedings – preferably given by demand
E. Physical Assessment
1. Pulse – normally irregular and 120-140 per minute. Apical pulse
(stethoscope below the left nipple) is recommended since
radial pulses are not ordinarily palpable (if prominent, in fact,
may b ea sign of congenital heart anomaly).
2. Respirations – are gentle, quiet, rapid but shallow; normally 30-
60 per minute. Largely diaphragmatic and abdominal (watch
for the rise and fall of the chest and abdomen).
3. Blood pressure – not routinely measured in newborns unless
coarctation of the aorta is suspected.
a. Normal values:
• At birth – 80/46 mm Hg
• After 15 days – 100/50 mm Hg
b. Size of cuff in children: Must not be more than 2/3 the size of
the extremity (will result in false low BP) nor less than ½ the
length of the extremity (will result in false high BP).
c. Procedure – flush method:
• Cuff is applied to an extremity
• Extremity is elevated and an elastic bandage is wrapped
around the distal portion of the extremity
• Slowly inflate the cuff up to 100 mm Hg, then remove the
bandage (extremity is expectedly pale)
• As soon as the extremity turns pink (flushes), read the
manometer.
• Only one reading can be obtained, the average between
the diastolic and the systolic pressures, called flush
pressure (therefore, is normally 60).
4. Skin
a. Color – normally ruddy because of the increased
concentration of RBCs and the decreased amount of
subcutaneous fat
• Acrocynosis – body pink, extremities blue. Normal during
the first 24-48 hours of life.
• Generalized mottling is common due to an immature
circulatory system
• Pallor – due to anemia which results from excessive blood
loss when cord is cut, inadequate blood flow from
cord to infant at birth, inadequate iron stores
because of poor maternal nutrition. May also be
due to blood incompatibility.
• Gray color – indicated infection
• Jaundice – yellowish discoloration of the skin
sclerae:
• Cause: Inability of the newborn to conjugate
bilirubin.
• Normal Values
• Total bilirubin = 15 mg%
• Direct bilirubin = 1.7
• Indirect bilirubin = 13.3
• Most accurate method of assessing presence of
jaundice: Use natural light and blanch skin on the
chest or tip of the nose
• Physiologic jaundice – from the 2nd to the 7th day of
life.
• Breastfed babies, however, have longer physiologic
jaundice because human milk has pregnanediol
which depresses the action of glucose
xxxxxxxxxxxxxxx (the enzyme responsible for
converting indirect bilirubin to direct bilirubin)
• Harlequin Sign – because of immaturity of circulation,
an infant who ahs been lying on his
side will appear red on the
dependent side and pale on the
upper side.
• Mongolian spots – slate-gray patches seen across the
sacrum/buttocks and consist of
collections of pigment cells
(melanocytes). Disappear by
school age. Seen only among
Southern European, Asian and
African children.
• Lanugo – fine, downy hair that covers the shoulders,
back and upper arms.
• Desquamation – drying of newborn’s skin
• Cephalhematoma – due to increased intravascular
pressure during delivery
• Milia – unopened sebaceous glands found on the
nose, chin and cheeks; disappear
spontaneously by 2-4 weeks.
5. Head – largest part of the infant’s body (1/4 of his total length).
a. Forehead is large and prominent
b. Chin is receding and quivers when startled or crying
c. Fontanelles are neither sunken (a sign of dehydration) nor
bulging (a sign of increased intracranial pressure)
d. Suture lines should neither be separated nor fontanelles
prematurely closed (-craniosynostosis; leads to mental
retardation)
e. Craniotabes – localized softening of the cranial bones can be
indented by pressure of a finger. Corrects itself without
treatment after some months. More common among first-
borns because of early lightening.
Period of absorption (most On or about the third day Takes several weeks
significant differences)
6. Eyes
a. Method of assessment: Put infant on upright position
b. Characteristics:
• Cry tearlessly during first 2 months because of immature
lacrimal ducts
• Cornea should be round and adult-sized
• Pupils should be round, not key-holed (- coloboma).
7. Ears – level of top part of external (should be in line with outer
canthus of the eye. If set lower, maybe a sign of kidney
malfunction or Down’s syndrome
8. Nose – may appear large for the face; there should be no septal
deviation
9. Mouth
a. Should open evenly when crying; if not, suspect cranial nerve
injury
b. Tongue appears large
c. Palate should be intact; no break on the lips
d. Epstein’s pearls – 1 or 2 small, round, glistening cysts seen
on the palate; due to extra load of calcium while in utero
e. A tooth may be seen; if loose, should be extracted to prevent
aspiration when feeding.
f. Oral thrush – white or gray patches on the tongue and side of
the cheeks due to Candida albicans acquired during
passage of the baby through the birth canal of the mother
with untreated Moniliasis; also known as oral moniliasis.
10. Neck
a. Thyroid gland is not palpable
b. Appears soft and chubby and creased with skin folds
c. Head should rotate freely on the neck and flex forward and
back
11. Chest – as large as, or smaller than, the head:
a. Should be symmetrical
b. Breasts maybe engorged, a result of the influence of maternal
hormones
c. Witch’s milk – thin, watery fluid also due to maternal
hormones
12. Abdomen:
a. Liver, spleen and kidneys are palpable at birth. Liver is about
1-2 cm below the right costal margin
b. Normally dome-shaped; if scaphoid, suspect Diaphragmatic
Hernia
13. Anogenital area
a. Take note of the time meconium is first passed (it should be
within the first 24 hours of life)
b. Female genitalia: may have swollen labia and drops of blood
due to maternal hormones
c. Male genitalia:
• Scrotum maybe edematous – also due to maternal
hormones
• Foreskin should be retracted to test for phimosis (-tight
foreskin)
• Testes should be present; if not descended, the condition
is called crypto-orchidism (repair of undescended testes is
called orchidopexy).
• Circumcision – maybe done prior to discharge from the
nursery, preferably by the end of the first
week.
• Procedure:
• Vitamin E injected IM
• Infant is restrained; penis is cleansed with soap and
water
• Yellen clamp is used
• Petrolatum gauze dressing is applied to prevent
adherence of circumcised site to the diaper while
applying pressure to prevent bleeding
• Nursing care:
• Check hourly for bleeding (most common
complication) during the first day. If small amount of
bright red blood is observed, apply gentle pressure to
the area with a sterile gauze pad
• Do not attempt to remove exudate which persists for
2-3 days. Just wash with warm water
• Diaper must be pinned loosely during first 2-3 days
when the base of the penis is tender
14. Back – on prone, appears flat (curves start to form only when
sitting or waling has been achieved).
15. Extremities
a. Arms and legs are short; hands are plump and clenched into
fists
b. Should move symmetrically
c. Abnormalities:
• Erb-Duchenne paralysis/Brachial plexus injury
• Causes:
• Lateral traction exerted on head and neck during
delivery of the shoulder in vertex presentation
• Excessive traction on the shoulders during breech
extraction, especially when the arms are extended
over the head
• Signs and symptoms:
• Inability to abduct arm from the shoulder, rotate arm
externally or supinate forearm
• Absent Moro reflex on affected arm
• Some sensory impairment in the outer aspect of
affected arm
• Management: Abduct the affected arm in external
rotation position with the elbow flexed
• Congenital hip dislocation/dysplasia
• Signs and symptoms:
• Assist in replacing head of the femur into the
acetabulum of the hip bone by using 3 diapers instead
of one, or by putting a pillow between the thighs to
maintain abduction of the thighs and flexion of the hip
and knee joints
• Infant preferably carried astride mother’s hip
• Hip spica cast is applied at a later age, before the
infant starts to walk. Cast extends from the waistline
to below the knee of the affected leg and above the
knee of the unaffected leg. If treatment is delayed
(after the baby has already learned how to walk), the
child will become xxxxxxxxx walk with xxxxxxxxxxxxx
at a later age.
F. Systemic Evaluation
1. Cardiovascular System
a. Major Differences in fetal circulation:
• Exchange of oxygen and carbon dioxide takes place in the
placenta, not in the fetal lungs
• Because little blood goes to the fetal lungs, pressure in the
left side of the fetal heart is less than the pressure in the
right side of the fetal heart.
• Presence of fetal accessory structures:
• Foramen ovale – bypasses the pulmonary circulatory
system since it is the opening between the right and left
atria
• Ductus arteriosus – communication between the
pulmonary artery and the aorta
• Ductus venosus – communication which bypasses
the liver
• Umbilical vein – carries the most highly oxygenated
blood
• Umbilical arteries – carry deoxygenated blood
b. Neonatal/adult circulation – as soon as breathing has been
initiated, oxygenation now takes place in the newborn’s lungs.
The change from fetal to neonatal circulation is, therefore,
associated with lung expansion, causing pressure in the left side
of the newborn’s heart to become higher compared to pressure
in the right side of the newborn’s heart.
• Increased pressure on the left side of the newborn’s heart
results in:
• Closure of the foramen ovale
• Change of the ductus arteriosus into a mere ligament
(ligamentum arteriosum)
• The decreased pressure on the right side of the newborn’s
heart causes the ductus venosus to become a mere
ligament (ligamentum venosum)
• Since no more blood goes through the umbilical vein and
arteries, these blood vessels atrophy and degenerate.
c. Blood values – are all high in their newborn period as a response
to the pulmonary circulation:
• Red blood cells – 6 millon/ml3
• Hemoglobin – 17-18 Gms %
• Hematocrit – 52%
• White blood cells – 15,000 – 45,000 per ml 3. A high WBC
count during the newborn period, therefore, is not a sign of
infection; with or without infection all newborns have high
WBC count.
2. Gastrointestinal tract – differences in stools:
a. Colostrum – xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx formed from
mucus, vernix, lanugo, hormones and
carbohydrates that accumulated while in utero
b. Transitional – on the 2nd to the 10th day of life in response to the
feeding pattern; are xxxx, green and loose,
resembling diarrhea to the untrained eye
c. Breastfed – golden yellow, xxxxx, more frequent (3-4 times/day)
and sweet-smelling because breast is high in lactic
acid which reduces the amount of putrefactive
organisms
d. Bottlefed – pale yellow, firm, less frequent (2-3 times/day) and
with a more noticeable odor
3. Urinary system – newborns should avoid within the first 24 hours of
life
a. Female newborn – form a strong stream when voiding
b. Male newborn – form a small produced arc when voiding. If not,
suspect a defect in the urethral meatus:
• Epispadia – urethral meatus located in the ventral (under)
surface of the penis
• Hypospadia – urethral opening located in the dorsal (above)
surface of the penis
• Management:
• Inspect for cryptoorchidism often found associated with
hypo-/epispadias
• Meatotomy is done to establish better urinary
function
• When the child is older (12-18 months), adherent
chordae (-fibrous bands that cause the penis to curve
downward) may be released surgically. If repair will be
extensive, surgery might be delayed until 3-4 years old.
• Child should not be circumcised because at the time of
repair, the surgeon may wish to use a portion of the
foreskin
• Surgical correction is done before school age so that the
child appears normal to his schoolmates
4. Autoimmune system
a. Type of immunity transferred from mother to newborn: passive
natural immunity
b. Newborns have antibodies from the mother against poliomyelitis,
diphtheria, tetanus, pertussis, rubella and measles (present in
the infant for one year). But little or no immunity against
chickenpox (that is why chickenpox is often fatal in the
newborn).
c. Newborns have difficulty forming antibodies until 2 months of age
(that is why immunizations are started at 2 months).
5. Neuromuscular system
a. Blink reflex – rapid eyelid closure when strong light is shone;
always present
b. Feeding reflexes:
• Rooting reflex – head will turn to the direction where
cheek is stroked near the corner of the mouth; will
help infant find food; disappears by 6 weeks of age
when infant is already capable of seeing things past
the visual midline.
• Sucking reflex – anything placed between the lips will
be sucked; disappears by 6 months. IMPORTANT:
Sucking reflex disappears immediately if not
stimulated regularly. IMPLICATION: Any infant who
will be put on NPO should be given a pacifier not only
for psychological reasons, but also to prevent
premature disappearance of the sucking reflex.
• Extrusion reflex – anything placed on the anterior
portion of the tongue will be spit out; disappears by 4
months of age when infant is about ready for semi-
solid foods.
• Swallowing reflex – anything place at the back of the
tongue will be swallowed and will never disappear.
c. Tonic neck reflex – (TNR)/Fencing reflex/boxer reflex – when on
his back, the infant’s arm and leg are extended on the side
where the head is turned, while the arm and the leg on the
opposite side are flexed; disappears by 2-3 months
d. Babinski reflex – when side of the sole is stroked with a “j” from
heel upward, the infant will fan out his toes; starts to disappear
by 3 months of age. (If the adult’s sole is stroked, the adult will
curve in his toes).
e. Landau reflex – when on prone, the newborn should
demonstrate some muscle tone; a test of spinal cord integrity
f. Palmar or plantar grasp/step-in-place reflexes – accessory
reflexes.
g. Moro reflex – singular most important reflex indicative of
neurological status. If he bassinet is jarred or the infant’s head
is allowed to drop backward in supine position (change infant’s
equilibrium), the infant will abduct and then adduct his arms.
Disappears by 4-5 months.
6. Senses – all are functional at birth:
a. Sight – all newborns can see at birth, although they cannot see
objects past the visual midline (not until 6-8 weeks). The
visual field is 20-22 cm or 9 inches
b. Hearing – as soon as amniotic fluid has been absorbed, the
newborn can already hear
c. Taste – as soon as secretions have been suctioned, newborns
can already taste
d. Smell – as soon as the nose has been cleared of mucous and
fluid, newborns can smell
e. Touch – the most developed of all the senses
G. Discharge Instructions
1. Bathing – maybe given anytime convenient for the parents as long as
it is not within 30 minutes after a feeding because the increased
handling during bathing can cause regurgitation. Sponge baths are
done until the cord falls off (7th-14th day).
2. Cord care
a. Fold down diapers so that cord does not get wet during voiding
b. Dab rubbing alcohol (10%) once or twice a day
c. Small, pink granulating area may be clean on the day of the cord
falls off. If remains moist for a week, advise mother to bring
baby to the doctor’s clinic where cautery with silver nitrate stick
will be done to speed healing.
3. Nutrition
a. Recommended Daily Allowances
• Calories – 120 cal/kg body weight
(KBW) = 50-55 cal/lb body weight
= more or less 3000 cal/day
• Proteins = 96 Gms/KBW/day
• Fluids = 16-20 cc/KBW = 2.5 – 3 oz per lb body
weight = more or less 20 oz/day
• Vitamins – Vitamins A, C and D are recommended
for both bottlefed and breastfed babies during the
entire first year of life.
RISK NEWBORNS
B. Characteristics
1. Have underdeveloped subcutaneous tissues and less fat to act as
insulation. Are thin-skinned. This is the reason why rapid drying and
warming inside incubators are important. In incubator care:
a. Temperature = 92o – 94oF (33.3o – 34.4oC)
b. Humidity = 55 – 65%
c. Frequent positioning on the right side will favor closure of the
foramen ovale because of the increased pressure of the left
ventricle
2. Are poikilothermic (- easily take on the temperature of the
environment). Temperature stabilizes at a lower rate: 35o – 36oC.
Take the axillary, not the rectal temperature before crying will mean
increased energy expenditure. (Important: A special consideration in
the care of premature babies is conservation of energy for growth
and development.)
3. Physiologic weight loss is exaggerated.
4. General activity is more feeble and weak; they often assume frog-like
position; extremities have less muscle tone (scarf sign – elbow
passes the midline of the body; square window wrist – wrist at a 90 o
angle).
5. CNS centers for respiration are underdeveloped, which results in
irregular breathing with short periods of apnea. Oxygen administered
should never be more than 40% because it can lead to retrolental
fibroplasias (- an overgrowth of retinal blood vessels causing
blindness).
6. Nutritional requirements – are high in order to maintain rapid growth
appropriate for the developmental stage. Birth weight, kidney and
GIT functioning should be considered in determining nutritional
requirements of the preemies.
a. Method of feeding – basically by NGT.
• Rationale
• Prematures often have ineffective sucking which is not
coordinated with swallowing and, therefore, may aspirate.
• Minimal handling is necessary in order to
conserve energy.
• Procedure
• Determine the distance to which the NGT is to be inserted
by measuring from the ear lobe to the nose to the distal
end of the sternum
• Mummify (restrain) the baby as the NGT is
being inserted
• Check location after NGT has been inserted:
• Submerge tip of the NGT in a glass of water; if bubbles
appear, it is inside the lungs
• Inject 5 cc. of air, then auscultate. If no sound is heard
as air is injected, it means that the NGT is not in the
stomach but in the lungs
• Aspirate contents; if acids are aspirated, the NGT is in
the stomach
• Determine amount of residual milk or undigested milk and
subtract the same amount from the next feeding because
this means that the baby is not able to digest all the milk
that is given to him. Be sure to put back the residual milk
since it contains acids and the baby can develop metabolic
alkalosis if not give back to the baby.
• Keep the NGT always closed to avoid
abdominal distention
• Fill syringe with formula before opening NGT; let formula
flow by gravity
• Feed with sterile water after the formula in order to prevent
clogging the NGT.
C. Special Problems
1. Hyperbilirubiremia – because of immaturity of the liver, kernicterus
(-staining of brain cells with bilirubin, causing brain damage or even
death) appears to occur at a lower bilirubin level. Management:
phototherapy – photooxidation by the use of artificial blue light in
order to convert bilirubin into an excretable form. Nursing
responsibilities in phototherapy care:
a. Expose all areas of the body to light by turning the infant every 2
hours
b. Cover eyes and genitalia
c. Give plenty of fluids to prevent dehydration
d. Check for loose stools and increased body temperature
IV. Chalasia
A. Pathophysiology: On the 3rd to the 10th day of life, the cardiac sphincter
muscles fail to function, causing it to be relaxed and constantly patent.
B. Characteristics: Unknown cause; self-limiting – disappears
spontaneously within 3 months
C. Signs and symptoms
1. Prolonged, repeated non-projectile vomiting which is more
pronounced when patient is lying flat on his back
2. Often hungry after each vomiting episode
3. Aspiration may occur
4. Pressure on abdomen causes reflux of stomach contents into the
esophagus
D. Management:
1. Thickened feedings (formula + cereals) – because they are less
easily vomited
2. Put on upright position for 30 minutes after every feeding
V. Imperforate Anus
A. Unknown etiology – arrest in embryologic development at 8 weeks of
intrauterine life
B. Types
C. Signs and symptoms
1. Normal opening
2. No meconium
3. Green-tinged urine – due to fistula
4. Inability to insert rectal thermometer
5. Abdominal distention
D. Diagnosis: xxxxxxxxxxx xxxxx method – infant is held upside down
while abdomen is filmed to determine distance from rectum to anal
dimple
E. Management:
1. NPO; IV xxxxx gastric xxxxxxxxxxx
2. Temporary colostomy – if poor surgical risk (very young baby,
malnourished; high agenetic or stretic type
3. Surgery:
a. Anoplasty
b. Abdominoperineal pull-through
4. Postoperative care:
a. Expose perineum to air by putting infant on supine with legs
suspended straight up or on prone position
b. Check bowel sounds frequently
c. NGT for gastric decompression
d. Change position from side to side to decrease tension on suture
line
e. Oral feedings resumed 1-2 days postop, when peristalsis has
resumed (fluids are retained; stools/flatus passed)
D. Surgical correction
1. Early excision of the sac if it is small and then primary closure is done
2. If base of the defect is too large for primary closure, conservative
treatment is carried out first while waiting for epithelization to take
place and then closure is done at a later time.
E. Postoperative care
1. Keep on prone position
2. Monitor urine output – bladder injury is a high possibility in operations
involving the spinal column
3. Measure head circumference daily
4. Monitor movement of lower extremities
F. Complications
1. Meningitis
2. Severe neurologic deficits
3. Hydrocephalus
a. Types:
• Noncommunicating – blockage within the ventricles which
prevents CSF from entering the subarachnoid space
• Communication – obstruction in the subarachnoid cistern at the
base of the brain and/or within the subarachnoid space
b. Management
• 1.5 – 2 Gms. Mannitol 20%/KBW over 10 -15 minutes –
since Mannitol is a diuretic, an indwelling, catheter should
be inserted for accurate recording of intake and output
• Ventriculo-peritoneal/ventriculo-atrial shunt – to bring the
CSF to an area from where it can be excreted from the
body. After the procedure, the child should be positioned
on the side where the shunt is to prevent sudden decrease
in intracranial pressure.