Professional Documents
Culture Documents
Maternity and Child
Maternity and Child
(NCLEX – RN)
Table of Content
Abortion or Miscarriage
Abdominal Pregnancy
Abruptio Placenta
Adolescent or Teen-age Pregnancy
Alpha-fetoprotein Screening (AFP)
Amenorrhea
Amniocentesis
Amniotic Fluid and Membranes
Anemia in Pregnancy
Apgar Scoring
Breastfeeding
Cardiac Diseases during Pregnancy
Cesarean Birth
Childbirth Health Education
Cystitis after Delivery
Danger Signs and Discomfort of Pregnancy
Diabetes Mellitus during Pregnancy (Gestational DM)
Discharge Instructions (Postpartum)
Dystocia during Pregnancy
Ectopic Pregnancy
Episiotomy in Assisting Delivery
Exercise during Pregnancy
Family Planning
Female Reproductive Anatomy
Fetal Blood Circulation
Fetal Heart Tone
Fetal Monitoring
Fetal Movement and Fetal Heart Rate Patterns
Forceps Delivery
High Risks Factors during Pregnancy
Human Sexual Responses
Hydatidiform or Vesicular Mole
Inflammatory Bowel Disease during Pregnancy
Leopold's Maneuver
Mechanisms of Labor (EDFIERRE)
Menstruation Cycle
Pain Management during Childbirthing Process
Pelvic Inflammatory Diseases
Pregnancy - Induced Hypertension
Preterm or Premature Labor
Placenta Previa
Puerperium
Rheumatic Disorders during Pregnancy
Stages and Five P's of Labor
Signs and Developmental Task of Pregnancy
Signs of Beginning Labor and Placental Separation
TORCH Complex in Pregnancy
Types of Pelvis
ABORTION AND MISCARRIAGE
ABORTION
- the termination of pregnancy before fetus is viable
- fetus is "viable" - defined as fetus of 20 weeks AOG, weighing below 350 gram
- abortion may be elective (planned, medical termination of pregnancy) or reproductive
problem
1. Chromosomal defect
2. Teratogenic factor
3. Immunologic (anti-phospolipid antibody)
4. Faulty placental development
5. Infection
6. Hyperemesis
7. Trauma
8. Severe stress
9. Disease
10. Incompetent cervical os
Types of Abortion
D&C
oxytocin
IV/Blood transfusion
observe
may be given oxytocin
bedrest
no intercourse
monitor bleeding
Manifestations of Abortion
ABDOMINAL PREGNANCY
- The placenta is usually located posterior to the uterus on the intestine or in Douglas' cul-
de-sac, which can infiltrate and erode major blood vessel in the abdomen leading to
hemorrhage or peritonitis.
- Fetal outline is difficult to palpate; woman may feel no fetal movement or experience
painful fetal movements
- Past history of the woman includes previous uterine surgery or ectopic pregnancy.
- If reaches term, the infant has an increased incidence of fetal deformity and is delivered
by laparotomy
- Methotrexate is the drug of choice for abdominal pregnancy to destroy placental cells.
ABRUPTIO PLACENTA
3. Anxiety
- expresses fears and concerns
ADOLESCENT PREGNANCY
- It is an early pregnancy in client under age 17
1. poverty
2. faulty family processes
3. sexual revolution
4. early onset of menarche
5. inadequate knowledge about reproductive health
Teenage pregnancy or early pregnancy increases the risk of:
stillbirth
low birth weight infants
cephalopelvic disproportion
fetal deaths
hypertension
anemia
prolonged or premature labor
hemorrhage and infections.
Adolescents should gain the usual 11 to 13 kg (25 to 30 lbs) recommended for all
pregnant women, thus need to be reminded always of their nutritional needs.
peer companionship a great consideration for planning their activities and rest
child birthing
plans for the baby
nutrition
post partal care
Assessed with single maternal blood sample drawn at 15-18 weeks gestation.
Amenorrhea
- Absence of menstruation or no menstruation
1. Primary Amenorrhea
- client never menstruated before, absence of menses by age 16 if secondary sexual
characteristic is present. Absence of menses by age 14 if secondary sexual characteristic
is absent.
- Turner's syndrome (no X chromosome) is the most common cause of primary
amenorrhea.
2. Secondary Amenorrhea
- client did have menses previously. Absence of menses for more than 3 cycles
- can be due to stress, excessive exercise, anorexia nervosa, post pill (last for 6 months),
drugs (antipsychotic, antidepressant, benzodiazepine), pituitary failure, pituitary
neoplasms.
- Pregnancy is the most common cause of secondary amenorrhea.
AMNIOCENTESIS
- the aspiration of amniotic fluid from the pregnant uterus for examination to determine
genetic disorders, sex and fetal maturity; done from 14th weeks onwards.
maternal hemorrhage
infection
Rh isoimmunization
abruptio placenta
labor
fetal death (0.3-0.5% risk)
injury from needle
Nursing Responsibilities for Amniocentesis
1. informed consent
2. have clients empty bladder before amniocentesis
3. baseline vital signs and FHR, then check every 15 minutes
4. Position supine with abdominal scrub
5. encourage bedrest and avoidance of strenuous activities
6. instruct client to report any side effects, chills, fever, fluid leakage, decreased fetal
movement and uterine contractions
a) color
- normally, the color of water. Yellow tinge suggest blood incompatibility. A green color
suggests meconium staining
b) Lecithin/Sphingomyelin Ration
- they are protein component of the lung enzyme surfactant that the alveoli begin to form
about the 22-24 weeks of pregnancy
- normal ratio is 2:1 or greater which signifies lung maturity
c) bilirubin determination
- normally, should be negative for blood or should have no false-positive reading
d) Chromosome Analysis
- chromosomal study of fetal tissues should be free of disease
f) Alpha fetoprotein
Amniotic Fluid and Membranes
The chorionic villi on the medial surface thins and becomes double lined membranes -
the chorionic membrane, the outermost fetal membrane which supports the sac containing
amniotic fluid, and the amniotic membrane or amnion, which contains and produces the
amniotic fluid itself and phospolipids that initiate production of prostaglandin.
- Fetal urine is present by 10th week
- Average amount of amniotic fluid is 1,000 ml at term
Hydramnios a excessive amniotic fluid (more than 2,000 ml) due to inability of the fetus
to swallow it. Normal volume is 500 to 1,00 ml.
M - maternal diabetes
I - infant with esophageal atresia
M - monozygotic twins
I - infant with neural tube defect
L - large placenta
maintain bed rest to reduce pressure on cervix and to prevent premature labor
monitor for rupture or uterine contraction
avoid constipation (will increase intrauterine pressure) by bulk in the diet
amniocentesis (slow to prevent premature separation of the placenta) guided by
ultrasound
Oligohydramnios a reduction in the amount of amniotic fluid (300 ml) due to disturbed
fetal kidney function
ANEMIA IN PREGNANCY
- decrease in RBC's (in the blood) leading to a decrease in oxygen carrying capacity of
blood
Types of Anemia
b) Megaloblastic/Folic acid anemia - RBC is enlarged due to low level of folic acid;
responsible for physical defects, early abortion or abruptio placenta
fatigue
shortness of breath
activity intolerance
pallor
Iron deficiency anemia - 300 mg/day TID, Hgb rises 0.3 to 1.0 g per week
Folic acid anemia - 0.4 to 0.8-1.0 mg folic acid. Sources are lettuce, asparagus,
broccoli, lima beans, lemons, melon, bananas
If secondary to parasites - management of the root cause
Nurses Implications for Anemia in Pregnancy
explain the side effects of iron preparations, emphasize that they are dose related
iron supplements can be taken with meals or reduce dose at tolerable level
taking the iron with meals can decrease absorption
ideally, between meals doses are preperable
foods that reduce iron absorption are: oregano, cereals, cheese, coffee, milk, tea,
whole grain breads, yogurt
foods that enhance iron absorption are those rich in Vitamin C
APGAR SCORING
The Apgar scoring provides a valuable index for evaluation of the newborn infant's
condition at birth. It is based on the five signs ranked in order of importance as follows:
Heart Rate
Respiratory Effort
Muscle Tone
Reflex Irritability
Color
Apgar scoring is done at one (1) minute of life and repeated again in five (5) minutes.
Each sign is evaluated according to the degree to which it present and is given a score of
0, 1, or 2. Then the score is added together to get the total scores (10 is the highest).
BREASTFEEDING
Breastfeeding
- Lactation is established when oxytocin is released from posterior pituitary and cause let
down reflex
as soon as both mother and baby is stable, even if its on delivery table
regular and sustained sucking at the breast is 8-10 times a day
gradually increase time of breastfeeding for each breast with subsequent feedings
baby will develop their own schedule of feeding
Advantages of Breast (Human) Milk
a) Engorgement
b) Retracted Nipples
c) Cracked Nipple
1. LEft-Sided CHF
2. Right-Sided CHF
3. General Manifestations
fatigue, anxiety, chest pain - bed rest; assist ADLs. Quiet, relaxed environment.
Oxygen; nitrates if ordered
Risk increases to Class I to Class IV; Class I and II may carry to term, Class III and IV
may require therapeutic abortion
CESAREAN BIRTH
- the birth through an abdominal incision into the uterus.
CPD
severe PIH
genital herpes or papilloma
previous C/S (history)
placenta previa
abruptio placenta
transverse fetal lie
breech presentation
extreme low birth weight
fetal distress
large fetus
low transverse
classic
low vertical
informed consent
overall hygiene
skin prep
GIT prep
monitoring of intake and output
hydration
pre-op meds
role of support system
breathing exercise
early ambulation
Vital signs monitoring
hydration
adequate rest
analgesics and antibiotics
promote mother-infant bonding
CHILDBIRTH EDUCATION
Manifestations of Cystitis
DISCOMFORTS OF PREGNANCY
Nausea and Vomiting - it is due to elevated HCG levels and changes in CHO
metabolism. Nursing interventions are dry crackers before arising, small frequent and low
fat meal during the day, liquids between meal and avoid anti-emetics.
Urinary Urgency and Frequency - it is due to pressure of the gravid uterus on urinary
bladder. Interventions are: sleep on side at night, limit fluid intake during evening, and
bladder training.
Ankle Edema - due to venous stasis. Pregnant should elevate legs at least twice a day,
sleep on left side, and avoid use of diuretics.
Headaches - from changes in vascular tone and blood volume. Pregnant should change
position slowly, cold compress, avoid use of NSAIDs or tranquilizers, and use tylenol
(acetaminophen).
Varicose Veins - from faulty valves or weakened vessel walls. Nursing interventions
includes elevating feet when sitting, use support hose, avoid pressure on lower thighs
Hemorrhoids - due to increase venous pressure and constipation. Use warm sitz bath, sit
on soft pillows, high fiber diet with increased fluid intake, use local hemorrhoidal
ointment like anusol
Skin Changes - due to increased hormonal level. Pregnant woman should use basic skin
care.
Backache - from exaggerated lumbosacral curving during pregnancy. Interventions are
back exercises, wear low-heeled shoes, avoid heavy lifting, avoid NSAIDs or codeine,
use tylenol sparingly.
Leg Cramps - due to low calcium level and pressure of uterus on nerves. Nursing
interventions are regular exercise like walking, elevate feet and dorsiflex while rest
increase milk intake.
GESTATIONAL DIABETES
uteroplacental
insufficiency
risk of dystocia
hydramnios
Effects on Pregnancy
If FBS is more than 90 mg/dl and at 1 hour post glucose loading is more than 140 mg/dl,
DIABETIC!
Normal Findings:
3. Glycosylated Hemoglobin
careful monitoring
DIET: 20% of calories from protein; 50% from carbohydrates; 30% from fats.
Increased dietary fibers, should not less than 1800 calories per day
exercise to lower blood glucose
stress management
insulin requirements will be increasing in the 2nd and 3rd trimester in relation to
human-placental lactogen (HPL)
Infection prevention
sugar evaluation of fetal status.
White's Classification of DM
Second is Follow-up.
It should be schedule at 4-6 weeks. Report any signs of fever, chilling, increased lochia
and depressed behaviors.
Third is Hygiene.
Clean the perineal area from front to back, center to sides. No douching for one month or
until there's postpartum check-up.
Fourth is Work
Avoid heavy lifting for at least 3 weeks.
Fifth is Coitus
An be done if episiotomy is healed already and lochia returns to alba (about 3 weeks).
Dystocia is a difficult labor and delivery due to problems with one of the "five P's"
(Passenger, Passageway, Powers, Person, Psychological response)
leading to maternal exhaustion, infection, trauma, and fetal injury and death.
vaginal exam
pelvimetry
ultrasound
Leopold's maneuver.
The Main Nursing Diagnoses for Dystocia are Pain and Anxiety.
Episiotomy is an incision made into the perineum to enlarge vaginal outlet and facilitate
delivery.
R - redness
E - edema
E - ecchymosis
D - discharge
A - approxiamtion, hematomas, and pain.
Nursing Care for episiotomy includes pain measures, peri-care, and incision care
Exercise during pregnancy helps in managing discomforts of labor by strengthening
pelvic and abdominal muscles.
Exercise during pregnancy must have a specific time and duration.
1. tailor sitting
2. squatting
3. pelvic floor exercise/kegel's exercise
4. abdominal muscle contraction exercise: blowing candle exercise
5. pelvic rocking
FAMILY PLANNING
Sexual adjustment: Sex is resumed as soon as wound healing occurs, bleeding stops,
and client feels comfortable with it. Fatigue, body image, and hormonal changes can
influence desires.
- Health Teachings
: daily body temperature recording plots of ovulation: usually 14 days before next
menses.
: abstinence recommended from day 6 to day 14 for an average 28 day cycle
: Cervical mucus becomes stretchable at ovulation (spinnbarkeit)
Oral Contraception
inhibits ovulation
effective, reversible method
should be taken everyday
alters cervical mucus
Health Teachings
Side Effects:
irregular vaginal bleeding, missed period, upset stomach
Health Teachings
: six selastic capsules containing a progestin are implanted in the patient's arm
: side effects are spotting, irregular bleeding, amenorrhea, weight gain, headache,
depression
Health Teachings
: procedures are theoretically reversible but permanency of effect should be emphasized
: Vasectomy- ligation of the vas deferens: pain and swelling on the incision site during
the first week is common. Takes 4-6 weeks and upt to 36 ejaculations to clear sperm from
vas deferens. Follow-up semen count is necessary
: Tubal Ligation- interruption of tubal patency by coagulation, ligation, or banding.
Complications include hemorrhage, infection, bowel perforation
Vasectomy
permanent
no effect on sexual performance
fully effective only after 20 ejaculations or 3 months. The man should use
condom or his partner should use another method
common complications: pain in the scrotum, swelling, bruising, brief feeling of
faintness after the procedure
Health Teachings
: sheath placed over the erected penis before intercourse to collect semen
: affords some protection against STDs
: side effects are perineal or vaginal irritation
IUD
Action
: destroy sperm or neutralize vaginal secretions
- Health Teachings
: effectiveness increases if used with a condom
: report local tissue irritation
Cervical secretions: avoid unprotected sex from the first day of any cervical secretions
or feelings of vaginal wetness until the 4th day after the peak day of slippery secretions
Basal Body temperature (BBT): avoid unprotected sex from the first day of menstrual
bleeding until body temperature has risen and stayed up for 3 full days
Calendar or rhythm: determine the fertile time through calendar calculations. Avoid
unprotected sex between the first and last days of the estimated fertile time
Cervical Secretions + BBT: avoid unprotected sex from the first day of cervical
secretions until both the 4th day after the peak of slippery secretions and the 3rd full day
after the rise in body temperature
temporary
based on breastfeeding
can be used when (1) the woman breastfeeds often both day and night (2)
menstruation have not returned (3) baby is less than 6 months
effective for up to 6 months after childbirth
an ideal pattern of breastfeeding for LAM is at least 8-10 times a day including at
least once a night
External Genitalia
Mons pubis - a pad of adipose tissue over symphysis pubis, covered by curly
hair, for protection against trauma.
Glans clitoris - a small rounded organ (approximately 1-2 cm) of erectile tissue at
the forward junction of the labia minora, covered by prepuce
Urethra meatus - urethral opening
Labia majora - two folds of adipose tissue covered by loose majora: serves as
protection for external genitalia
Labia minora - posterior to mons veneris are two folds of connective tissues
Hymen - tough but elastic semicircle of tissue that covers the opening to the
vagina in childhood
Fourchette - the ridge of tissue formed by the posterior joining of the two labia
minora and labia majora
Perineum - perineal muscles posterior to the fourchette; stretchable during
childbirth
Internal Genitalia
In fetal circulation, the placenta is responsible for metabolism (fetal digestive tract),
endocrine secretions, and transfer (fetal pulmonary and renal system).
The umbilical cord has two arteries and one vein.
1. Placenta
Location: attached to the uterus
Function: gas exchange during fetal life
2. Umbilical Arteries
Location: two arteries in the cord
Function: carry unoxygenated blood from the fetus (descending aorta) to placenta
3. Umbilical Vein
4. Foramen ovale
Location: an opening between right and left atria of heart bypassing lungs
Function: to shunt blood from the right atrium to the left atrium so that blood can be
supplied to brain, heart and kidney
5. Ductus arteriosus
Location: connects pulmonary artery and aorta, bypassing lungs.
Function: shunting of the larger portion of the blood away from the lungs and directly
into the aorta
6. Ductus venosus
Location: connects umbilical vein and inferior vena cava, bypassing liver
Function: to supply blood to liver
Fetal Heart Tone (FHR) should be 120-160 beats per minute throughout the pregnancy.
It can be heard as early as 11th week by the use of an ultrasonic doppler technique
1. Rhythm Strip Testing - Fetal Heart Tone is assessed in terms of baseline and long-and-
short term variability.
- baseline reading means the average rate of the fetal heart beat per minute
- short term variability denotes the small changes in rate that occur from second to second
- long term variability denotes the difference in heart rate that occurs over a 10 or 20
minute time period
2. Non-Stress Testing
- done in 10 minutes to note the response of FHR to fetal movement
- as fetus moves, FHR should be increased by 15 beats per minute and remain elevated
for 15 seconds, then return to its pattern as the fetus quiets
- the test is reactive if 2 accelerations of fetal heart rate lasting for 15 seconds occur
following movement within 10 minutes period.
- the test is non-reactive if no accelerations occur with fetal movements. Amniocentesis is
indicated to check lung maturity
- if 10 minute period passed without fetal movement, it means that the fetus is sleeping.
Give the mother oral carbohydrate snack to increase the glucose level and stimulate fetal
movement.
3. Vibroacoustic Stimulation
- the application of an instrument to produce a sharp sound to the mother's abdomen to
startle and wake the fetus.
Fetal Monitoring During Labor and Delivery
3) External Monitoring:
a. External Mode
b. Internal Mode
4) Fetal scalp sampling - a small sample of fetal blood is taken from a punctured wound
made into the fetal scalp to test for the presence of fetal acidosis.
- Laboratory analysis of fetal pH is done; Normal value ranges from 7.25 to 7.35. A
reported value of 7.20 or below means fetal acidosis.
FETAL MOVEMENT
- Fetal movement can be felt by the mother beginning 18th to 20th weeks of pregnancy
and reaches a peak at 29th to 38th weeks.
Normally, 2 times every ten minutes that it can be counted to move 10-12 times an hour.
Any fetal movement fewer than 5 (half the normal number) in a chosen hour of
observation should be reported.
Cardift's count of ten means that having less than 10 counts in 10 hours calls for further
evaluation.
Placental insufficiency will greatly decrease the fetal movement. Maternal intake of
depressant drugs, alcohol and smoking can reduce its movement, too.
Fetal movements are not usually present in sleeping fetus.
FETAL HEART RATE
- Two double-crossed spoon like articulated blades are used to assist in delivery of fetal
head.
- Prerequisites are fully dilated cervix, engaged head, vertex or face presentation, absence
of CPD, empty bladder and bowel.
perineal lacerations
damage to facial nerve of fetus
fetal death
postpartal hemorrhage
cystocele
rectocele
uterine prolapse
Main Nursing Diagnosis for Forceps Delivery is Fear and risk of injury to both fetus
and mother.
Nursing Implications for Forceps Delivery is closely monitoring both fetus and mother
during delivery with continual assessment.
The life of woman and fetus has significantly increased risk of disability or death. The
importance of early detection: Better maternal-fetal neonatal outcome when the factors
contributing to risky pregnancy are identified and intervened.
Maternal mortality rate is 1 per 1,000 live births.
1. low income
2. lack of prenatal care
3. age-height less than 145 cm (4'9")
4. parity >5
5. marital status
6. residence
7. ethnicity
It is more common for those with Asian heritage, older gravida, and after
induction of ovulation with Clomiphene therapy.
Uterus is larger than AOG, soft and full lower segment on palpation
brown vaginal discharges during 12th week onwards
persistent bleeding
Client needs to have HCG testing every month for a year while using a reliable
contraceptive.
Ulcerative colitis is the inflammation of the distal colon. Both may be caused by
autoimmune response characterized by exacerbation and remissions.The predominant
symptom is rectal bleeding.
The bowel develops shallow ulcers; the woman experiences chronic diarrhea (4-24x/day),
weight loss, occult blood in stool, and nausea and vomiting.
vitamin B12
folic acid,
iron, calcium
fats
vitamins ADEK.
Complications
nutritional deficiencies
toxic megacolon and other extraintestinal manifestations (arthritis, ankylosing
spondylitis, clubbing of fingers, anemia)
Colon cancer is common.
- woman who emptied her bladder should lie in supine position with her knees flexed
slightly so abdomen is relaxed.
1. First Maneuver
- to determine presenting part at the fundus
- head is more firm, hard and round that moves independently of the body
- Breech is less well defined that moves only in conjunction with the body
2. Second Maneuver
- to determine fetal back
- one hand: will feel smooth, hard resistant surface (the back)
- the opposite side, a number of angular nodulation (knees and elbows of fetus)
3. Third Maneuver
- to determine position and mobility of presenting part by grasping the lower portion of
the abdomen (just above the symphysis pubis).
- if the presenting part moves upward so the examiner's hand can be pressed together,
then presenting part is not engaged
4. Fourth Maneuver
- to determine fetal descent
- fingers are pressed in both side of the uterus approximately 2 inches above the inguinal
ligaments, then press upward and inward.
- the fingers of the hand that do not meet obstruction palpates the fetal neck, as the
fingers of the other hand meet an obstruction above the ligaments palpates the fetal brow.
- Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows
and knees.
- Poor attitude if examining fingers will meet an obstruction on the same side as fetal
back (hyperextended head).
- also palpates infant's anteroposterior position. If brow is very easily palpated, fetus is at
posterior position (occiput pointing towards woman's back).
MECHANISM OF LABOR
We can follow the Gate Control Theory in pain management during giving birth to a
child.
1. cutaneous stimulation
2. distraction
3. reduction of anxiety
the cleansing breath - breaths in deeply and exhales deeply to begin any breathing
exercises
conscious relaxation - deliberately contracts and relaxes body portions from head
to toe
consciously controlled breathing - chest breathing following these pattern: slow >
shallow > pant blow > shallow chest panting
effleurage - light abdominal massage
focusing/imaging
PELVIC INFLAMMATORY DISEASES
gonococci
staphylococcus
streptococci
other pus forming organisms
acute, sharp, severe aching pain on both sides of the abdomen or pelvis
occasional vaginal bleeding
generalized infection
malaise
fever
chills
anorexia
nausea and vomiting
tachycardia
pelvic abscess
chronic PID
septic shock
history of acute lower UTI during menses (gonococcal PID) or between periods
(non-gonococcal PID)
sexual patterns
contraceptives (esp. IUD)
laboratory test including multiple cultures
Treatment of Pelvic inflammatory diseases
laparotomy
antibiotic therapy
pain management
avoid sex and douching and observe perineal care
bed rest for acute stage
proteinuria
edema
hypertension
I. PRE-ECLAMPSIA
1. Mild Pre-eclampsia
BP of 160/110
severe hypertension, 30-40 mmHg while on bedrest
massive anasarca and weight gain
3 - +4 proteinuria (5 grams/24 hrs urine collection)
less than 500 ml output in 24 hrs (Oliguria)
dizziness, headache, blurring or with spots on vision, nausea and vomiting,
epigastric pain, and irritabilty)
managed in the hospital
II. ECLAMPSIA
III. HELLP
characterized by RBC hemolysis, elevated liver enzymes and low platelet count
related to severe vasospasm leading to disseminated intravascular coagulation
(DIC)
platelet and RBC transfusion often are administered, coagulation factors are
monitored
labor is induced if AOG is more than 32 weeks, cesarean if less than 32 weeks.
IV. DIC
a) closely monitoring of maternal vital signs (esp. BP) and weight, FHR
b) bedrest most of the day; side-lying position; 8-12 hours
c) high protein (60-70 gram/day), low sodium diet, calcium (1,200 mg), magnesium, 2-6
g of zinc, vit. C and E
d) health teachings for symptoms of mild and severe pre-eclampsia
e) administration of magnesium sulfate. Corticosteroids and antihypertensives as ordered.
HPN drugs are excreted in breast milk
f) drug of choice is Magnesium Sulfate (MgSO4) - monitor for magnesium sulfate
toxicity
- normal MgSO4 serum level is 1.5 - 3 mEq/L - maintenance dose 4 - 7 mEq/L - at 8-10
mEq/L, respiratory rate starts to diminish - at 10-14 mEq/L, deep tendon reflex is absent
g) blood replacements
h) monitor for seizure activity and protection from injury
i) administer O2 as needed
j) prepare mother and her family for early induction of labor. Vaginal delivery is
preferred over cesarean
k) health teachings on contraception
PREMATURE LABOR
Preterm or Premature labor is a labor occurring after 20th week but before 37th. It
may cause fetal death if delivered low birth weight but there's a good chance of survival
if delivered 35th weeks onwards.
M - multiple gestation
E - emotional and physical stress
N - nutritional deficiency
Focus: prevention of the delivery of premature fetus
Conditions to halt labor: membrane are intact, good FHT, no evidence of bleeding,
cervix not dilated more than 3 - 4 cm, effacement not more than 50% (if any of these
condition is not present, delivery, regardless of fetal age, is inevitable).
Nursing Implications
PLACENTA PREVIA
ultrasound
identification of fetal position
hemoglobin and hematocrit count
Post partum period begins after delivery towards when reproductive tract returns to
normal non-pregnant state.
Involution is the time when uterus returns to non-pregnant state.
3. Breast
4. Urinary Tract
urinary retention may be experienced as a result of loss of elasticity and tone and
loss of sensation from drugs, trauma or loss of privacy
diuresis will be experienced within first 12 hours after delivery
kidney function returns to normal easily
5. Gastrointestinal
6. Vascular System
WBC increases during labor and delivery, as well as early post partum period;
then return to normal after few days
Hemoglobin and RBC decreased and return to normal value after a week
elevated fibrinogen levels during first week postpartum and contribute to
thrombophlebitis
blood volume is back by third week
7. Vital Signs
temperature may be elevated to 100.4 F (38 C) during first 24 hours after delivery
without pathologic condition
bradycardia is usual for a week about 50-70
blood pressure must be unchanged
basic and primary needs of mothers are their own - food, water, clothing, sleep
mother becomes attention seeker: she always talk about her experience during
labor and delivery. The nurse should be good listener in interpreting these events
not good time for health teachings
2. Taking-hold phase - usually for 3 days to 2 weeks but it varies in every women
mothers may grieve over the separation of the baby from her body
may display dependent-independent behaviors where she wanted to feel secure
while making decisions
time when post-partum blues may develop
time when bonding process is facilitated and parenting skills are enhanced
RHEUMATIC DISORDERS DURING PREGNANCY
- most marked characteristic is the erythematous "butterfly shaped" rash on the face.
- most serious kidney change is the fibrin deposits that blocks glomeruli leading to
necrosis and scarring, expect renal failure. Thickening collagen tissues in the vascular
system pose life threatening situation.
- clients with SLE has antophospolipid antibodies which increases tendency for thrombi
formation.
- SLE is associated to infants small for gestational age, abortion, premature birth, and
anemia.
STAGES OF LABOR
2. Second Stage of Labor - from full dilation to delivery of the fetus (30-60 mins for
primigravida and 20 mins for multipara)
1. transfer to delivery room for 8-9 cm dilation for multigravidas and full dilation for
primiparas
2. monitor V/S and FHR
3. prepare perineal area
4. encourage pushing with contractions
5. immediate newborn care
5 - 30 mins
sudden gush of blood
lengthening of the cord
rising of the fundus
globular uterus
4. Fourth Stage of Labor - time from delivery of placenta to homeostasis (first 4 hours
after delivery of the placenta)
Attitude - relationship of fetal body parts to each other, normal uterine posture is
completely flexed
Lie - relationship of fetal spine to maternal spine. Longitudinal or vertical is when
fetus is parallel to mother's spine, transverse or horizontal if fetus is at right angle
to mother's spine.
Presentation - portion of fetus that enters pelvis first: presenting part could be
cephalic or breech (frank, footling)
Position - relationship of fetal reference point to one or four quadrants or sides of
mother's pelvis. Maternal pelvis side: L-left, R-right; Fetal Reference points:
O-occiput, M-mentum, B-brow, S-sacrum; Maternal Pelvis Quadrant: A-
anterior, T-transverse, P-posterior
Station - degree of engagement from presenting part to ischial spine; Station 0
means at ischial spine, minus station means above spine, and plus station is below
the spine.
B. Passageways
Pelvis
Soft tissues - lower uterine segment, cervix, vagina, and introitus
C. Powers
- forces acting to expel fetus; primarily by involuntary uterine contractions, secondarily
by voluntary bearing down.
- functions of uterine contraction are effacement and dilation
D. Person
E. Psychological Response
- response to contraction, perceptions and beliefs, pre-natal care and education, support
systems and communication skills.
SIGNS OF PREGNANCY
uterine enlargement
hegar's sign - softening of the lower segment of the uterus
goodells's sign - softening of the cervix due to increased blood supply
chadwick's sign - purplish discoloration of the vaginal mucosa
ballottment - when fetus rebounds against examiner's fingers during palpation
braxton hick's contraction
positive pregnancy test: HCG, reliable by 90 - 98%
Tip: To arrange Hegar's Goodel's and Chadwick's signs, arrange them anatomically from
external to internal organ, then mathc them with alphabetized sequence, wher
Chadwicks is to vagina, Goodels is to cervix, and Hegar is uterus (because of alphabetical
sequence C-G-H and organ order of vagina-cervix-uterus.
3. Positive Signs - definitive signs of pregnancy
fetal heart tone (FHT) can be heard: 12 weeks by doppler; 18-20 weeks by
auscultation
X-ray or ultrasound of fetus (by 6-8 weeks)
palpable fetal movements - felt by examiner usually 20 weeks
"DO SCREAM"
D - descent of fetus into pelvic inlet (Lightening), may not occur in multiparas but 2
weeks prior in primiparas
O - opening cervical OS (Dilatation)
S - softening of cervix
C - contraction of uterus. From the back and sweep across the abdomen, increasing
frequency and intensity
R - rupture of membrane. Sudden gush of clear fluid from the vagina
E - effacement (progressive thinning and shortening of cervix)
A - apprehension. Sometimes with feeling of extreme energetic
M - mucous plug expulsion (SHOW)
T - toxoplasmosis
O - other
R - rubella
C - cytomegalovirus
H - herpes
Toxoplasmosis protozoa is transmitted through raw meat handling litter of infected cats.
- Symptoms is flu-like: organisms passes placenta can result spontaneous abortion.
- Diagnosis by serologic tests, such as the Sabin-Feldman dye test.
- Treated with sulfadiazine and pyrimethamine. If toxoplasmosis is diagnosed before 20
weeks of gestation, damage to the fetus is more severe than if the disease is acquired
later.
- The incidence of abortion, stillbirths, neonatal deaths, and severe congenital anomalies
is high.
Other includes streptococcal infections, syphilis, gonorrhea, hepatitis; increased risk for
spontaneous abortion and still birth.
Rubella is highly teratogenic in first semester: cross placenta, death is usually the result
if acquired during the third and seventh weeks. I it occurs in the second trimester,
permanent hearing impairment is usually the result.
- The best therapy for women is prevention. Women with titers should be vaccinated at
least 2 months before becoming pregnant. Live attenuated vaccine is available and should
be given to all children.
Cytomegalovirus (CMV) belongs to the herpesvirus group and causes both congenital
and acquired infections referred to as cytomegalic incluusion disease.
- it is flu-like, mononucleosis like transmitted through sexual or respiratory route; may
either cross placenta or infect thru vaginal canal.
- May cause fetal death, retardation, heart defects and deafness.
Herpes Simplex virus type 2 is an STD with painful blister on genitalia; vaginal and
urethral discharge, which may be copious and foul smelling. Begins with reddened
papules which becomes itchy, pustular vesicles that break and form painful wet ulcers,
which then dry and develop crusts.
- Treatment is toward relieving the woman's vulvar pain. Bacterial infection may be
treated with cream containing sulfonamide.
- When infection is suspected in pregnant woman, amniocentesis can be performed to
determine if there is fetal involvement. If present, cesarean delivery should not be
performed.
TYPES OF PELVIS
Pelvis serves to both support and protect the reproductive and other support organs. Its
bones are ilium, ischium, pubis, sacrum, and coccyx.
1. False pelvis - the superior half, supports the uterus during late months of
pregnancy and aids in directing fetus to the true pelvis.
2. True pelvis - the inferior half, facilitates true delivery of fetus.
3. Inlet - the entrance to true pelvis or the upper ring of the bone through which the
infant must passed to deliver vaginally.
4. Outlet - the inferior portion of the pelvis, bounded in the back by the coccyx,
greatest diameter is the antero-posterior part.
5. Pelvic cavity - the space between the inlet and outlet. Its curve slows and controls
the speed of birth.
1. Diagonal conjugate - the distance between the anterior surface of the sacral
prominence and the anterior surface of the inferior margin of the symphysis pubis;
suggestive of antero-posterior diameter of inlet; it should be 12.5 cm to be
adequate.
2. True conjugate/Conjugate vera - the distance between the anterior surface of
sacral prominence and posterior surface of the inferior margin of symphysis
pubis; to get this, just subtract the usual depth of symphysis pubis from diagonal
conjugate. It should be 10.5 - 11.0 cm.
3. Ischial tuberosity diameter - the distance between ischial tuberosities or the
transverse diameter of the outlet; 11.0 measurement is adequate.
Types of Pelvis