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OB Notes
OB Notes
4. Prostaglandin Theory
● Leg pains
● Muscle spasms
CANDAC
✓ Discomfort @ abdomen
✓ Absence of show
TRUE LABOR
CUPPAD
✓ Presence of show
LENGTH OF LABOR
STAGE OF LABOR
PRIMI (VIRGIN)
MULTI (DIS-VIRGIN)
1ST STAGE
10 – 12 HOURS
6 – 8 HOURS
2ND STAGE
30 MINS – 2 HOURS
Ave: 50 mins
20 – 90 MINS
Ave: 20 mins
3RD STAGE
5 – 20 MINS
5 – 20 MINS
4TH STAGE
2 – 4 HOURS
2 – 4 HOURS
1. Passages
2. Power
3. Passenger
4. Person
5. Position
PASSAGES
○ Serves as birthcanal
TYPES (GAPA)
DIVISION OF PELVIS
1. Diagonal Conjugate – midpoint of sacral promontory to the lower margin of symphysis pubis (12.5 cm)
2. Obstetric Conjugate – midpoint of sacral promontory to the midline of symphysis pubis (11 cm)
3. True Conjugate – midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)
POWERS 3I’s
2. Acme/Apex – “go”
3. Decrement/Decrescendo – “stop”
- measured from the beginning of a contraction to the beginning of the next contraction
- measured from the beginning of a contraction to the end of the same contraction
⦿ INTERVAL – measured from the end of contraction to the beginning of the next contraction
PASSENGER
⦿ HEAD (BOTu)
1 sphenoid bone
1 ethmoid bone
⦿ SUTURE LINES – allow skull bones to overlap (molding) and for further brain development (SFC La)
- 3 x 4 cm
● Posterior Fontanel or Lambda – intersection of Sla- triangular shaped, closes b/n 2 – 3 months
● Occipitofrontal – head partially extended and presenting part is the anterior fontanel
⦿ FETAL LIE – relationship of the long axis of the fetus to the long axis of the mother
⦿ Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.
LIE
PRESENTATION
ATTITUDE
A. Longitudinal Lie
1. Cephalic (head)
2. Breech (butt)
B. Transverse Lie
Causes:
2. placenta previa
Face presentation
Chin presentation
Complete breech - feet & legs flexed on the thighs and the thighs are flexed on the abdomen
Shoulder Presentation – fetus is lying perpendicular to the long axis of the mother
*Compound Presentation – when there is prolapsed of the fetal hand alongside the vertex, breech or
shoulder.
Complete flexion
Moderate flexion
Extension
Hyperextended
Good flexion
Moderate flexion
Flexion
POSITION
- fetus usually accommodates itself on the left because the placement of the bladder is at the right
⦿ STATION - relationship of the presenting part of the fetus to the ischial spine of the mother.
● Zero (0) station – presenting part is at the level of the ischial spine
● Positive (+) station – presenting part is below the level of the ischial spine
⦿ THE PERSON
● Coping skills
● Past experiences
STAGES OF LABOR
● Starts from first true uterine contraction until the cervix is completely effaced and dilated.
○ Effacement – thinning to 1- 2 cm
2. Fetal head and intact BOW serves as a wedge to dilate the cervix
1. PIPIT PEPA HF
3. Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the client feels it
Techniques:
- do it during relaxation
○ Blue – ruptured
● Gray/Cloudy – infection
2. maternal hypotension
3. administer oxygen
2. give 02 at 8 – 10 lpm
1. LATENT PHASE
○ Cervical Dilation: 0 – 4 cm
Interval: 3 – 5 mins
Multis – 4 – 5 hours
○ Nsg Responsibilties:TGC
1. Teach breathing techniques
2. Give instructions
2. ACTIVE PHASE
○ Cervical Dilation: 4 – 7 cm
Multis – 2 hours
○ Attitude of mother:prefer to stay in bed, withdraws from her environment and self – focused
3. Instruct woman to remain in bed, minimize noise, raise side rails, NPO
3. TRANSITION PHASE
○ Cervical Dilatation: 8 – 10 cm
Interval: 2 -3 mins
○ Attitude of mother: feel discouraged, ask midwife/nurse repeatedly when labor will end, not in control
of her emotions and sensations, irritated, may not want to be touched
⦿ CARE OF THE BLADDER – encourage the woman to void q 2 hrs to: DIPC
○ Predispose to UTI
○ Squatting is ideal position – directs presenting part towards the cervix promoting dilatation
⦿ AMBULATION – during the latent phase to shorten the first stage, to decrease the need for analgesia,
FHT abnormalities & to promote comfort
⦿ PERINEAL PREP
○ Prevent infection
○ CONTRAINDICATIONS: NIRVAA
● Rupture of BOW
● Vaginal bleeding
● Engagement
● Descent – entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet
● Flexion – the chin of the fetus touches his chest enabling the smallest diameter (suboccipitobregmatic)
to be presented to the pelvis for delivery
● Internal Rotation – when the head reach the level of the ischial spine, it rotates from transverse
diameter to AP diameter so that its largest diameter is presented to the largest diameter of the outlet.
This movement allows the head to pass through the outlet.
● Extension – the head of the fetus extend towards the vaginal opening. As the head extend, the chin is
lifted up and then it is born.
● External Rotation – when the head comes out, the shoulder which enters the pelvis in transverse
position turns to anteroposterior position for it become in line with the anteroposterior diameter of the
outlet & pass through the pelvis.
● Expulsion – when the head is born, the shoulder & the rest of the body follows without much
difficulties.
● Duration of Second Stage: Primis – 50 mins
Multis – 20 mins
● Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high risk cases if not yet
delivered
Delivery Position
2. Dorsal Recumbent – head of the bed is 35 – 45˚ elevated, knees are flexed & feet flat on bed. This
position facilitates the pushing effort of the mother.
3. Dorsiflex the affected foot and straigthen the leg until the cramps disappear
4. Perform ironing on vaginal orifice if the presenting part moves towards the outlet
7. Just after delivery, immediately wipe the nose & mouth of secretions then suction.
9. After the delivery of the baby, place the newborn in dependent position to facilitate drainage of
secretions.
10. Place the infant over the mother’s abdomen to help contract the uterus.
● Clamp the cord twice and cut in between 8 – 10 inches from umbilicus
MANAGEMENT:
1. Watchful waiting.
b) Rest a hand over the fundus to make sure the uterus remains firm
• Calkin’s sign – uterus is firm, globular & rising to the level of umbilicus
MANAGEMENT:
1. Repair of lacerations.
Second Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body
Third Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body & anal
sphincter
Fourth Degree - fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body, anal
sphincter & mucous membrane of rectum
2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from stirrups at
the same time.
3. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours until
stable.
HYPEREMESIS GRAVIDARUM
Causes:(UTEP)
1. Unknown
2. Thyroid dysfunction
3. Elevated HCG
4. Psychological stress
S/Sx:
2. Signs of dehydration (thirst, dry skin, weight loss, concentrated and scanty urine)
Management:
1. Differential diagnosis (liver & thyroid function studies, urinalysis, Hct/Hgb and WBC)
2. Conservative management
- dry crackers
- small frequent feedings & sips of water (gastric distention – trigger vomiting reflex)
c. take vitamin supplement to correct nutritional deficiencies from decreased food intake
- Promethazine (Phenergan)
- Prochlorperazine (Compazine)
- Ondansentron (Zofran)
- Droperidol (Inapsine)
- Metoclorpramide (Reglan)
- Diphenhydramine (Benadryl)
- Meclizine (Antivert)
b. Vitamin supplementation
5. Complementary therapies
c. vitamin supplementation
ABORTION
Definition of Terms:
1. Abortion – most common bleeding d/o of early pregnancy (before 20 weeks/fetus weighs 500 grams)
5. Occult Pregnancy – zygotes that were aborted before pregnancy is diagnosed or recognized
9. Fetus Compressus – fetus compressed upon itself and desiccated with dried amniotic fluid
12. Immature Infant – having a birth weight b/n 500 – 1000 grams
Types of Abortion:
1. Developmental anomalies
Complications of Abortion:
1. Hemorrhage
S/Sx:
Management:
1. Assess for:
- LMP
- abdominal pain
2. Conservative management
3. Educate mothers.
Management:
1. Monitor V/S
2. monitor closely for bleeding or signs of infection
5. may experience intermittent menstrual-like flow and cramps (next menstrual period occurs after 4 – 5
weeks)
6. Reassure patient that her next pregnancy is likely to last to term if she is young and has no other risk
factors. (no pregnancy for the next 3 months)
S/Sx:
4. rupture of membranes
Management:
1. Hospitalization
2. D&C
2. On examination:
- closed cervix
4. Incomplete Abortion – “expulsion of some parts and retention of other parts of conceptus in utero”
S/Sx:
3. open cervix
4. passage of tissue
Management:
1. D&C
S/Sx:
1. Absence of FHT
- no FHT
Management:
2. Insert 20mg Dinoprostone (Prostaglandin E) suppository into the vagina q 3 or 4 hours PRN (<28 weeks
gestation)
Causes:
1. incompetent cervix
2. IUGR
Management:
e. correction of defects
Causative Organisms:
1. E. Coli
2. Enterobacter Aerogenes
3. Proteus Vulgaris
4. Hemolytic Streptococci
5. Staphylococci
S/Sx:
2. uterine cramping
Management:
1. Treat abortion
2. high dose IV antibiotic therapy (Penicillin – gram negative, Clindamycin/Tobramycin – gram positive)
Causes:
- salphingitis
- peritubal adhesions
- developmental abnormalities
2. Functional Factors
- menstrual reflux
3. Assisted Reproduction
- ovulation induction(Clomid)
- in vitro fertilization
- ovum transfer
4. Failed contraception
1. Tubal - >95%
b. Isthmic (25%)
c. Fimbrial (17%)
d. Interstitial (2%)
e. Bilateral (very rare)
8. Tubo – Ovarian (partly implanted in the tub and partly in the ovary)
S/Sx:
4. Before rupture
- brief amenorrhea
a. pain
c. Cullen’s Sign or bluish discoloration of the umbilicus due to the presence of blood in the peritoneal
cavity
d. Hard or boardlike abdomen
e. Signs of shock
6. Diagnosis
b. Serial HCG
c. Pregnancy Test
d. Culdocentesis
f. Uterine Curettage
g. Colpotomy
h. Laparoscopy
i. CBC
j. Elevated WBC
Management:
a. Methotrexate Therapy
Nursing Interventions:
3. Post – op interventions:
- monitor v/s
5. Prevention
- S/Sx of STDs
HYDATIDIFORM MOLE
- benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo.
Types:
Risk Factors/Incidence:
1. Geography
2. High in women below 18 and above 40 years old
S/Sx:
Management:
1. D&C
2. Methotrexate (Choriocarcinoma)
- HCG should be negative 2-8 weeks after removal of mole (every 2 weeks)
5. Hysterectomy
Complications of H – Mole:
- conversion of chorionic villi into cancer cells that erode blood vessels and uterine muscles.
- “lungs”
c. Placental Site Trophoblastic Tumor – composes of cytotrophoblastic cells arising from the site of the
placenta.
INCOMPETENT CERVIX
Diagnosis:
1. Pelvic examination or IE
- “funneling”
Predisposing Factors/Causes:
3. Hormonal influences
4. Congenitally short cervix
5. Forced D&C
6. Uterine anomalies
S/Sx:
1. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)
Management:
- intact membranes
- restrict activities after application for the next 2 weeks including coitus
ABRUPTIO PLACENTA
1. Maternal hypertension
8. Behavioral factors:
1. Grade 0 – no symptoms
2. Grade 1 – some external bleeding, uterine tetany and tenderness, absence of fetal distress and shock
3. Grade 2 – external bleeding, uterine tetany, uterine tenderness and fetal distress
4. Grade 3 – internal bleeding and external bleeding (>1000ccc), uterine tetany, maternal shock,
probably fetal death and DIC
- entire placental separation (maternal shock, fetal death, severe pain and possible DIC
S/Sx:
2. Abdominal pain
• Sudden and knife-sharp pain, localized and diffused over the abdomen (severe AP)
3. Board like abdomen – accumulation of blood behind the placenta with fetal parts hard to palpate.
4. Signs of shock and fetal distress if bleeding are severe.
Management:
1. Hospitalization is a must
a. manage @ prolonging pregnancy with the hope of improving fetal maturity if:
- NPO status
- observe & record bleeding q 30 mins or more (saturated perineal pad can absorb approx 60 – 100ml of
blood)
- monitor V/S
• “clot test”
• Coagulation studies (fibrinogen level, prothrombin time (PT), partial prothrombin time (PTT), CBC,
anticoagulant factor and electrolytes)
- delivery
• VD – fetus is dead, maternal bleeding is mild and if the mother is in stable condition
PLACENTA PREVIA
4. Low Lying PP – implants near the internal os with its margin located about 2cm – 5 cm from the
internal os
Frequency:
Predisposing Factors/Causes:
1. Unknown
- multiparity
- endometritis
- age (above 35 y/o)
-previous CS
- abortion
- repeated D&C
6. Large placenta
Complications:
1. Hemorrhage
2. Infection
3. Prematurity
5. DIC
7. Renal failure may occur r/t shock caused from hemorrhage or DIC
8. Anemia
9. More lacerations
S/Sx:
1. Sudden painless vaginal bleeding (24 – 30 weeks)
2. Bright red bleeding occurs in gushes and is rarely continuous (usually @ night with the patient
awakening and finding herself lying in a pool of blood)
Management:
1. IE by MD only under double set up (done in the OR – patient is prepped and draped)
● Vital signs
● Tilt Test (woman bleeds profusely but has normal blood pressure and pulse in recumbent position will
develop hypotension and tachycardia when placed in sitting position)
● Urine flow
Nursing Interventions:
a) Monitor:
✓ Vaginal bleeding
✓ Uterine contractions
✓ Maternal V/S
✓ Maternal I&O
b) Woman in CBR (if no bleeding after 48 hours, mother is allowed bathroom privileges)
e) Betamethasone (Celestone)is given to hasten fetal lung maturity (12mg IM q 12 hrs for 2 doses)
4. Outpatient management
a. live close to the hospital (within 5 – 10 minutes) and 24 hours transportation availability and close
supervision by family or friends @ home
- regular NST
- biophysical profile
- fetus is mature
- persistent hemorrhage
- intrauterine infection
- rupture of membranes
b. method of delivery
c. Nursing Care:
• Ultrasound
• CBC, blood type and cross match for at least 2 units of whole blood, DIC panel, PTT, PT and electrolytes.
H/H may order every 12 hours.
• Keep on NPO
➢ Position
• Trendelenburg Position
✓ No IE
✓ Assess I&O
✓ WOF hemorrhage
● Surgical management such as ligation of the hypogastric arteries (internal iliac) or hysterectomy
✓ Puerperal infection
➢ Anemia
TRIAD SYMPTOMS:
- proteinuria
*specifically albuminuria
Predisposing Factors:
5. Familial tendency
2 Types:
Causes:
1. Unknown
2. Genetic predisposition
5. Endothelin theory
PREECLAMPSIA
EFFECT
Decreased blood supply to kidney and hemoconcentration stimulates release of aldosterone, ADH and
angiotensin
Vasospasm cause damage to the endothelium promotes coagulation and increase sensitivity to pressor
agents.
Elevated platelets
Patient’s renal perfusion is affected. Decreased blood supply to kidneys resulting in decreased GFR.
Efficiency of the kidney to remove metabolic waste is impaired. Decreased renal perfusion results in
damage to kidney structures allowing passage of large molecules
Serum levels of BUN, creatinine and uric acid rise leading to acidosis and decreased urine output.
Proteinuria
Convulsions
IUGR
Continuous vasospasm cause diminished blood supply resulting in damage to blood vessels and tissues
in the placenta and decidua
Abruptio Placenta
Signs/Symptoms
Mild Preeclampsia
Severe Preeclampsia
Blood Pressure
Proteinuria
+1 - +2 by dipsticks
+2 - +4
Liver enzymes
Slightly elevated
Markedly elevated
Laboratory studies
No IUGR
IUGR present
Edema
Generalized edema
Weight Gain
1 – 2 lb/week
Urinary Output
Cerebral Disturbances
Occasional headache
Severe frontal headache, photophobia, blurring, spots before the eyes (scomata), n/v
Reflexes
Normal to 3+
Hyperreflexia, 4+
Epigastric Pain
Absent
S/Sx of Eclampsia:
3. Oliguria
4. Pulmonary edema
Management:
Ambulatory Management:
• BP is 140/90 or below
• Low proteinuria
4. Home management also include phone calls and home visits by the N – M
a. Dietary modifications
✓ High in protein
✓ Avoid salty foods, such as canned foods, soda, chips and pickles
b. Monitor her own health condition and report to health care provider immediately if the following
occur:
Hospital Management:
• Proteinuria of 3+ or 4+
• Oliguria
• Visual disturbances
b. Expectant management
c. Fluid therapy
d. Medications
● Magnesium Sulfate
✓ Reduce edema
✓ Reduce BP
Nursing Considerations:
✓ RR above 14cpm
✓ UO at least 100ml/4hr
Antihypertensives
Hydralazine (Apresoline)
Safety measures
Stages of Convulsion:
1. Stage of Invasion or Aura – facial twitching, rolling of the eyes to one side, staring fixedly in space,
sudden severe headache, screaming and epigastric pain
2. Tonic Phase – rigid body, eyes protrude, arms are flexed with legs inverted, hands are clenched,
woman stop breathing lasts for 15 – 20 seconds.
3. Clonic Phase – jaws and eyelids close and open violently, foaming of the mouth, face becomes
congested and purple, muscles of the body contract and relaxes alternately last for about 1 minute.
Nursing Responsibilities:
✓ Two main resp: maintenance of patient airway and protection of patient from self injury
After convulsion:
• Take v/s
HEMOLYTIC DISEASE
Incidence:
ABO Incompatibility:
● Occurs when maternal blood type is O and fetus is:
Type AB – rare
Rh Incompatibility:
1. Rh Factor
Rh Sensitization/Isoimmunization:
● Occurs during placental separation (0.5 ml fetal Rh positive blood can produce massive production of
antibodies during the first 72 hours of life)
• Anemia
• Hyperbilirubinemia
• Hydrops fetalis
• Stillbirth
Prevention:
1. Prenatal screening
a. History
b. Screening test
• Anti-Rho(D) Gamma Globulin (RhoGRAM) @ 28 weeks and within 72 hours after delivery
• Untypeable pregnancies
S/Sx:
1. No signs and symptoms unless the baby dies in the utero and is not born right away.
Management: