COURSE OUTLINE

TOPICS (MIDTERMS to FINALS)

ANTEPARTUM/PREGNANCY

Anatomy and Physiology of the Reproductive System

Menstrual Cycle
Process of Conception
Fetal Circulation
Milestones of Fetal Development
Common Teratogens and their Side Effects
Assessment of Pregnancy/ Normal Changes in Pregnancy
Danger Signs of Pregnancy
Prenatal Exercises/ Childbirth Preparation
INTRAPARTUM
Theories of Labor Onset
Factors Affecting Labor and Delivery
Common Signs of Labor
Stages of Labor
Care of the Paturient in the Phases of Labor
POSTPARTUM/ PURPERIUM

Principles of Puerperium/Phases of Puerperium

Perineal Lacerations
Postpartum Complications
MEDICAL CONDITIONS IN PREGNANCY

Urinary Tract Infection

Iron Deficiency Anemia
Gestational Diabetes Mellitus
Pregnancy Induced Hypertension
Hyperemesis Gravidarum
Incompetent Cervix
Isoimmunization
Infections during pregnancy
Cardiac Disorders
Abortion
Intrauterine Growth Restriction
Preterm Labor
Premature Rupture of Membranes
Chorioamnionitis
Intrauterine Fetal Death
NURSING CARE OF NEWBORN

Apgar Scoring
Common Complications
ENC
PEDIATRIC GROWTH AND DEVELOPMENT

1. Basic Divisions of Life

2. Principles of Growth and Development
3. Theories of Growth and Development

l Psychosexual Theory
l Psychosocial Theory
l Cognitive Theory
l Moral Theory
4. Developmental Milestones
5. Cardiac Disorders
6. Respiratory Disorders
7. Integumentary Disorders
8. Hematologic Disorders
9. Chromosomal and Genetic Abnormalities

Anatomy and Physiology of the Reproductive System

Overview of the Anatomy and Physiology of Reproductive System

 FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

 
l  THE EXTERNAL REPRODUCTIVE ORGANS

ü  Mons pubis or mons 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.

ü  Labia majora – two folds of skin with fat underneath; contain Bartholin’s glands which are 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 vaginal orifice.

ü  Labia minora – two thin folds of delicate tissues; form an upper fold encircling the clitoris )called the prepuce)  and
unite posteriorly (called the fourchette) which is highly sensitive to manipulation and trauma that is why it is often torn
during a woman’s delivery.

ü  Glans clitoris  - small erectile structure at the anterior junction of the labia minora, which is comparable to the penis
in its being extremely sensitive.

ü  Vestibule – narrow speace seen when the labia minora are separated.

ü  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).

ü  Vaginal orifice or Introitus – external opening of the vagina covered by a thin membrane (called hymen) in virgins.

ü  Perinuem – area from the lower border of the vaginal orifice to the anus; contains the muscles (e.g., pubococcoygeal
and levator ani muscles) which support the pelvic organs, the arteries that supply blood to the external genitalia and the
pudendal nerves which are important during delivery under anesthesia.

l  THE INTERNAL RERODUCTIVE ORGANS

ü  Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum; contains rugae (which permit
considerable stretching without tearing); organ of copulation; passageway for menstrual discharges and fetus.
ü  Uterus

u  Hollow pear-shaped fibromuscular organ 3 inches lone, 2 inches wide, 1 inch thick and weighing 50-60 gms.

u  Held in place by broad ligaments (from sides of uterus to pelvic walls; also hold Fallopian tubes and ovaries in place)
and round ligaments (from sides of the uterus to the mons pubis)

u  Abundant blood supply from uterine and ovarian arteries

u  Composed of 3 muscle layers: perimetrium, myometrium and endometrium

u  Consists of three parts

Fundus - upper portion; site of implantation

Corpus (body)- middle portion

Isthmus – ower uterine segment; adjacent to Cervix – lower cylindrical portion

u  Organ of menstruation; site of implantation, retainment and nourishment of the products of conception.

ü  Fallopian Tubes – 4 inches long from each side of the fundus; widest part (called ampulla) spreads into finger-like
projections (called fimbriae).  Responsible for transport of mature ovum from ovary to uterus; fertilization takes place in
its outer third or outer half

Parts:   infundibulum : adjacent to uterus;

Ampulla : Widest part; site of fertilization

Interstitial: narrowest portion; most dangerous site of ectopic pregnancy

ü  Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in plact by ligaments.  Produce, mature and
expel ova and manufacture estrogen and progesterone.
 

THE PELVIS – although not a part of the female reproductive system but of the skeletal system, it is a very important
body part of pregnant women.

   

A. Structure

l  Two os coxae/innominate bones – made up of:

Ø  Ilium – upper extended part; curved upper border is the iliac crest.

Ø  Ischium – under part; when sitting, the body rests on the ischial tuberosities; ischial spines are important landmarks.

Ø  Pubes – front part; join to form an articulation of the pelvis called the symphysis pubis.

Ø  Sacrum – wedge-shaped, forms the back part of the pelvis.  Consists of 5 fused vertebrae, the first having a prominent
upper margin called the sacral promontory.

Ø  Coccyx – lowest part of the spine; degree of movement between sacrum and coccyx made possible by the third
articulation of the pelvis called sacroccygeal joint which allows room for delivery of the fetal head.

B. Divisions – set apart by the linea terminalis, an imaginary line from the sacral promontory to the ilia on both sides to
the superior portion of the symphysis pubis.

n  False pelvis – superior half formed by the ilia.  Offers landmarks for pelvic measurements; supports the growing uterus
during pregnancy; and directs the fetus into the true pelvis near the end of gestation.

n  True pelvis – inferior half formed by the pubes in front, the iliac and the ischia on the sides and the sacrum and coccyx
behind.  Made up of three parts:

u     Inlet – entranceway to the true pelvis.  Its transverse diameter is wider than its anterosposteior diameter.  Thus:
Transverse diameter = 13.5 cm.

Anteroposterior diameter (AP) = 11 cm.

Right and left oblique diameter = 12.75 cm.

u     Cavity – space between the inlet and the outlet.  Contains the bladder and the rectum, with the uterus between them
in an anteflexed position towards the bladder.

u     Outlet – inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by the ischial tuberosities and
in front by the inferior aspect of the symphysis pubis and the pubic arch.  Its AP diameter is wider than its transverse
diameter.

C. Types/Variations

v  Gynecoid – “normal” female pelvis.  Inlet is well rounded forward and back.  Most ideal for childbirth.

v  Anthropoid – transverse diameter is narrow, AP diameter is lager than normal.

v  Platypelloid – inlet is oval, AP diameter is shallow

v  Android – “male” pelvis.  Intel has a narrow, shallow posterior portion and pointed anterior portion.

D. Measurements

u  External – suggestive only of pelvic size:

Ø  Intercristal diameter – distance between the middle points of the iliac crests.

Average = 28 cm.

Ø      Interspinous diameter – distance between the anterosuperior iliac spines.

Average = 25 cm.
Ø      Intertrochanteric diameter – distance between the trochanters of the femur.

Average = 31 cm.

Ø      External conjugate/Baudelocque’s diameter – distance between the anterior aspect of the symphysis pubis and
depression below L5. 

Average = 18-20 cm.

u  Internal – give the actual diameters of the inlet and outlet

Ø  Diagonal conjugate – distance between the sacral promontory and inferior margin of the symphysis pubis.  Average =
12.5 cm.

- Important measurement because it is the diameter of the pelvic inlet.  Average = 10.5 – 11 cm.

Ø     Bi-ischial diameter/tuberischii – transverse diameter of the pelvic outlet.  Is measured at the level of the anus. 
Average = 11 cm.

Diagram 1.2 Female Reproductive System

l  THE MAMMARY GLANDS

External structures

1. Nipple or Papillae - located on the surface of each breast

2. Areola - surrounds the nipple; pigmented

3. Montgomery Tubercles - glands that secrete oily substance to lubricate areola and nipples

Internal structures

          1. Lobes:  15 to 20 lobes/breast

          2. Lobules: composed of acini cells

          3. Acini cells: secretes milk d/t prolactin

4. Lactiferous Ducts: stimulates development of the ductile structures of the breast

5. Lactiferous Sinus:  reservoir of milk.

 MALE REPRODUCTIVE SYSTEM

Ø  External organs

1. Penis: consists of two corposa cavernosa and one corposa spongiosum

- organ of copulation

- urination

          PARTS:
                  

2. Scrotum: hanging sac-like structure; contains testes

Ø  Internal organs

1. Testes : descends in the scrotum after 28 weeks AOG

- produces testosterone (spermatogenesis)

PARTS:

A. Seminiferous tubules: site of spermatogenesis (176 sperm/day)

B. Leydig/Interstitial cells: produce testosterone

C. Sertoli Cells: supports sperm transport

Common Disorders:

*Cryptorchidism: undescended testes; remains in the abdominal cavity

   - non-palpable testes in the scrotum

   - Mgt: Surgery > orchiopexy - physician stitches the testes into the scrotum

   - Post - op mgt:

2. Epididyms: passageway of sperm

3. Vas deferens: propels sperm during ejaculation

4. Ejaculatory Duct- it connects the seminal vesicles to the urethra.

Diagram 1.2. Male Reproductive System

ACCESSORY ORGANS

·         Seminal Vesicle

·         Prostate Gland                            secretes alkaline fluid

·         Cowper’s/Boulburethral Gland

*Seminal Fluid or Semen-mixture of secretions from the seminal

vesicles, prostate gland,Cowper’s gland, ejaculatory duct and
sperm cells.
Diagram 1.3 The Sperm Cell        

Menstrual Cycle

- is a cyclic uterine bleeding in response to hormonal changes; start counting from the first day of your last menstruation
up to the first day of the next menstruation

Purpose: To bring an ovum to maturity

 To prepare uterus for pregnancy

Terminologies:

Menarche - first mentrual period

Thelarche - budding of the breasts

Adrenarche - development of body hair

Menopause/ Climacteric - cessation of menstruation (45-55 years of age)

 
Structures involved:

·         Hypothalamus

·         Anterior Pituitary Gland

·         Ovaries

·         Uterus

Table 1.2. Hormones and its Functions

HORMONES FUNCTION/ PURPOSE

GnRh Signals pituitary to release FSH and LH

(Hypothalamus)
FSH For follicle maturation

(A. Pituitary Gland) Causes hypertrophy of myometrium

Triggered by a decrease in estrogen

↓Estrogen = ↑FSH ; ↑Estrogen = ↓FSH

LH Stimulates ovulation

(APG) Suppressed by Progesterone

Develops the corpus luteum

Estrogen Secreted by Graafian follicles

  Takes over proliferative phase

 Thickens the endometrium

Responsible for secondary sex

characteristics

Hormone of women
Progesterone Corpus Luteum hormone

Prepares uterus for implantation

Hormone of pregnancy

Most important hormone during the

secretory phase

PHASES OF THE MENSTRUAL CYCLE (28-day cycle)

1. MENSTRUAL PHASE

          -day 1-5

          -shedding of endometrium (2/3)

          -uterus lining is in its thinnest

          -total blood loss:30-80 ml (Average: 50 ml)

- iron loss: 12 to 29mg

- estrogen is LOW; cervical mucus is opaque and viscous

2. PROLIFERATIVE PHASE (follicular, postmenstrual and estrogenic phase)

          -day 6-13 (Lasts 8-10 days)

-stimulated by ↓ estrogen = APG releases FSH

          -↑ FSH = maturation occurs: from Primordial follicle to Graafian follicle

-Graafian follicle produces increasing amount of follicular fluid that is high in ESTROGEN

***Estrogen increases = thickening of endometrium

- ↑ estrogen = ↓ FSH

3. SECRETORY PHASE

          -day 13-25

-↑ estrogen, ↓FSH

-↓ progesterone = hypothalamus releases LHRF to stimulate APG to release LH

-↑ LH = ovulation (ovum can only lasts for 24-48 hrs)

-Graafian follicle becomes the corpus luteum

          -after ovulation, Graafian follicle is now the Corpus Luteum (life span: 10-12 days)

          -endometrium appears spongy

**following ovulation, estrogen drops sharply

4. ISCHEMIC PHASE

-release of prostaglandins =arteriolar spasm →necrosis→rupture of blood vessels

-uterine cramping occurs

-beginning of another cycle

OVULATION

-14th day of a 28-day cycle

-estimate day of ovulation by subtracting 14 from your regular cycle

Signs of Ovulation

·         Mittelschmerz: unilateral pain felt on either side of the abdomen

·         Spinnbarkeit: stretchy, thin, transparent and watery mucus secretion

·         Sudden increase in body temp: 1 F

OVARIAN PHASE:

1. FOLLICULAR PHASE (DAYS 10-14)

- a primordial follicle matures under the influence of FSH and LH up to the time of ovulation

2. LUTEAL PHASE (DAYS 15-28)

- Mature ovum leaves the graafian follicle

- the empty cavity will become corpus luteum

Fetal Circulation

Shunts: Ductus Venosus: between umbilical vein and vena cava, bypasses liver
Ductus Arteriosus: between pulmonary artery and aorta

Foramen Ovale: between two atria

**PLACENTA works as RESPIRATORY SYSTEM

**shunts are closed during the first breath/cry**

Ductus Venosus = Ligamentum Venosum

Ductus Arteriosus = Ligamentum Arteriosum

Foramen Ovale = Fossa Ovale

Fetal Milestones

A. First Lunar Month

1. Germ layers differentiat by the 2nd week: (in cases of multiple congenital anomalies, the structures that will be
affected are those that arise out of the same germ layer).
1.1   Entoderm – develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal metabolism),
parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra

1.2   Mesoderm – forms into the supporting structures of the body (connective tissues, cartilagem muscles and tendons);
heart, circulatory system, blood cells, reproductive system, kidneys and ureters

1.3   Ectoderm – responsible for the formation of the nervous system, the skin, hair and nails,  and the mucous
membrane of the anus and mouth.

2. Fetal membranes (amnion and chorion) appear by the second week.

3. Nervous system very rapidly develops by the 3rd week.  (Dizziness is said to be the earliest sign of pregnancy
because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in
the latter).
4. Fetal heart begins to form as early as the 16th day of life.  (To the question, “When does the fetal heart begin to
beat?”, the answer is first lunar month.  But to the question, “When can fetal heart tones to first heard?” the answer
is fifth month.)
5. The digestive and respiratory tracts exist as a single tube until the 3 rd week of life when they start to separate.

B. Second Lunar Month

1. All vital organs are formed by the 8th week; placenta develops fully
2. Sex organs (ovaries and testes) are formed by the 8th week. (To the question, “When is sex determined?” the answer
is “At the time f conception”).
3. Meconium (first stools) are formed in the instestines by the 5 th – 8th week.

C. Third Lunar Month

1. Kidneys are able to function – urine is formed by the 12th week.

2. Buds of milk teeth form
3. Beginning bone ossification
4. fetus swallows amniotic fluid
5. Feto-placental circulation is established by selective osmosis; no direct exchange between fetal and maternal blood.
 

D. Fourth Lunar Month

1. Lanugo appears
2. Buds of permanent teeth form
3. Heart beats maybe audible with fetoscope

E. Fifth Lunar Month

1. Vernix caseosa appears

2. Lanugo covers entire body
3. Quickening (fetal movements) felt
4. Fetal heart beats very audible

F. Sixth Lunar Month

1. Skin markedly wrinkled

2. Attains proportions of fullterm baby

G. Seventh Lunar Month – alveoli begin to form (28th weeks of gestation is said to be the lower limit of prematurity
because if baby is delivered at this time, will cry and breathe but usually dies)

H. Eighth Lunar Month

1. Fetus is viable
2. Lanugo begins to disappear
3. Nails extend to ends of fingers
4. Subcutaneous fat deposition begins
 

I. Ninth Lunar Month

1. Lanugo and vernix disappear

2. Amniotic fluid volume somewhat decreases

J. Tenth Lunar Month – all characteristics of the normal newborn.

FOCUS OF FETAL DEVELOPMENT

A. First trimester – period of organogenesis

B. Second trimester – period of continued fetal growth and development; rapid increase in fetal length
C. Third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fat

Teratogens

 Toxoplasmosis: protozoan infection; spread through uncooked meat or contaminated soil or cat litter

S/sx: malaise, lymphadenopathy

: can cause CNS damage to infant

Mngt: SULFONAMIDES (Pyrimethamine)

 Rubella: most dangerous; can cause microcephaly, glaucoma, cataract and mental retardation

: advice mother to get vaccinated but NO PREGNANCY within 3 months

 Cytomegalovirus: herpes virus; causes CNS damage

 Herpes Simplex Virus: can cause severe congenital anomalies or abortion
 Chickenpox: HIGH IMMUNITY in the first 7 months; can have vaccine after delivery
Assessment of Pregnancy/Normal Changes in Pregnancy

l  PRENATAL CARE

COMPONENTS:

o   History taking

o   Physical examination

o   TT Immunization

o   Iron Supplementation

o   Health Education

o   Laboratory examination

o   Oral-dental examination

o   Referral when necessary

l  Nutrition

*Recommended weight gain: 25-35 lbs (ave 12kg)

1st tri: 1 lb per month

2nd and third tri: 1 lb per week

*Iron, Folic and Calcium supplementation

l  OBSTETRIC HISTORY

Gravida: # of pregnancies

Parity: # of pregnancies that have reached the age of viability (25 weeks)
Term: infants born @ 37 weeks AOG

Pre-term: infants born <37 weeks AOG

Abortion: miscarriage/ termination of pregnancy before 25 weeks

Living: number of alive children

Multiple gestation: # of pregnancies carrying twins or the like

          -Blood flow: increases from 20ml before pregnancy to 700-900 ml at the end of pregnancy

l  Determination of Age of Gestation

          Menstrual age/Gestation Age-measures from LMP

l  BARTHOLOMEW’S RULE (measures the location of fundus to determine AOG)

          -12 wks: at the level of the symphisis pubis

          -16 wks-halfway between symphisis pubis and umbilicus

          -20 wks-at the level of the umbilicus

          -24 wks-two fingers above umbilicus

          -30 wks- midway between umbilicus and xyphoid process

          -36 wks-at the level of xyphoid process

          -40 wks-two fingers below umbilicus, drops at 34 wks.level because of lightening.

l  Mc Donald’s Rule (AOG)

          - Fundic height (cm) X 2/7=AOG in lunar months

          - Fundic height (cm) X 8/7= AOG in weeks

l  Johnson’s Rule-use to calculate fetal weight in grams

          FH(cm) - N X K= fetal weight

                             K= 155(constant)

                             N= 12 if engaged

                             N= 11 if not yet engaged

l  Haase’s Rule to determine the length of the fetus

          a. during the first half of pregnancy, square the number of months

          b. during the second half of pregnancy, multiply the number of months by 5.

                             *Greater fundic height indicates:

                             - multiple pregnancy

                             -miscalculated due date

                             -polyhydramnios

                             -Hydatidiform mole

                             *Lesser Fundic height indicates

                             -fetal growth retardation

                             -fetal death

                             -error in estimating AOG

                             -oligohydramnios

l  Expected Date of delivery

            Naegele’s Rule

          ex.      April 3 2020

                   -3   +7   +1

EDC=January 10,2021

Note: BE SURE TO REMEMBER ALL FORMULAs

l  LEOPOLD’S MANEUVER

MANEUVER DESCRIPTION ASSESSMENT FOR BETTER

RETENTION :)
1ST (FUNDAL GRIP) -facing head of the -assess fetal part in  
mother the fundus
 
-place both hands *soft and round:
over the fundus buttocks (CEPHALIC  
position)
L1e
*hard and round:
head (BREECH
position)

*nodular: extremities
(TRANSVERSE
position)
2nd (UMBILICAL) -face head part of the - determines fetal  
mother back to assess FHT
 
-place one hand on Normal: 120-160 bpm
either side of the
 abdomen to stabilize  
it
B2ck
-use the other hand
to palpate
3  (PAWLIK’S GRIP) Use one hand to
rd
Engaged: NON-  
grasp the presenting Movable
part over the 3ngag3m3nt
symphysis pubis Engaged: MOVABLE
4  (PELVIC GRIP)
th
-face FOOT part of Tilt lightly  
mother
-Flexion 4ttitude
-move the presenting
part with both hands -Extension

PSYCHOLOGIC/EMOTIONAL ADAPTATIONS OF PREGNANCY

A. Systemic  Changes

1. Circulatory/Cardiovascular

1.1   Beginning the end of the first trimester there is a gradual increase of about 30% - 50% in the 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:

1.1.1     Easily fatigability and shortness of breath because of increased workload of the heart

1.1.2     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).

1.1.3     Systolic murmurs are common due to lowered blood viscosity

1.1.4     Nosebleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses.

                                                       
1.2   Palpitations are due to:

1.2.1     Sympathetic nervous system stimulation during the first half of pregnancy

1.2.2     Increased pressure of uterus against the diaphragm   during second hald of pregnancy

1.3   Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities:

1.3.1.   Edema of the lower extremities occurs.  Management legs above hip level.  Important: Edema of the lower
extremities is normal during pregnancy; it is not a sign of toxemia

1.3.2.   Varicosities of the lower extremities can also occur.  Management:

Ø  Use/wear support hose or elastic stockings to promote venous flow, thus preventing stasis in lower extremities

Ø  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 adequacy of circulation (Principle
behind bandaging: blod flow through tissues is decreased by applying excessive pressure on blood vessels)

Ø  Avoid use of constricting garters, e.g., knee-high socks

1.4   Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid uterus, varicosities
of the vulva and rectum can occur.  Management:  side-lying position with hips elevated on pillow and modified knee-
chest position.

1.5   There is increased level of circulating fibrogen, 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 and cause thromboembolism.

2. Gastrointestinal changes
2.1   Morning sickness – nausea and vomiting during the first trimester is due to increased human chorionic
gonadotropin (HCG).  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).

2.2   Hyperemesis gravidarum = excessive nausea and vomiting which persists beyond 3 months; results in dehydration,
starvation and acidosis.  Management: D10NSS 300 ml in 24 hours is the priority treatment; complete bed rest is also
important.

2.3   Constipation and flatulence are due to displacement of the stomach and intestines, thus slowing peristalsis and
gastric emptying time. May also be due to increased progesterone during pregnancy.  Management:

2.3.1     Increase fluids and roughage in the diet

2.3.2     Establish regular elimination time

2.3.3     Increse exercise

2.3.4     Avoid enemas

2.3.5     Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better

2.3.6     Mineral oil should not be taken because it interferes with absorption of fat-soluble vitamins.

2.4   Hemorrhoids are due to pressure of enlarged uterus.  Management: cold compress with witch hazel or Epsom salts.

2.5   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:

2.5.1     Pats or butter before meals

2.5.2     Avoid fried, fatty foods

2.5.3     Sips of milk at frequent intervals

2.5.4     Small, frequent meals taken slowly

2.5.5     Bend at the knees, not at the waist

2.5.6     Take antacids (e.g. milk of Magnesia) but never sodium bicarbonate (e.g. Alka Seltzer or baking soda) because it
promotes fluid retention.

3. Respiratory changes – shortness of breath

3.1   Causes

3.1.1     Increased oxygen consumption and production of carbon dioxide during the first trimester.

3.1.2     Increased uterine size causes diaphragm to be pushed or displaced, thus crowding the chest cavity.

3.2   Management: Lateral expansion of the chest to compensate for shortness of breath increases oxygen supply and vital
lung capacity.

4. Urinary changes

4.1   Urinary frequency, the only sign in pregnancy seen during the first trimester disappears during the second and
reappears during the third trimester.  Early in pregnancy is due to increased blood supply to the kidneys and to the
uterus rising out of the pelvic cavity;  in the last trimester is due to pressure of enlarged uterus on the bladder, especially
with lightning (descent of the fetus into the pelvic brim).

4.2   Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose
to spill into the urine; also an effect of the increased progesterone.  (implication: it would be difficult to diagnose diabetes
in pregnancy based on the urine sample alone because a pregnant women have sugar in their urine.)

5. Muscoloskeletal  changes

5.1   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”)
5.2   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

5.3   Leg cramps

5.3.1     Causes

Ø  Increased pressure of gravid uterus on lower extremities

Ø  Fatigue

Ø  Chills

Ø  Muscle tenseness

Ø  Low calcium, high phosphorus intake

5.3.2     Management

Ø  Frequent rest periods with feet elevated

Ø  Wear warm, more confortable clothing

Ø  Increase calcium intake (calcium tablets and diet)

Ø  Do not massage – blood clots can cause embolism.

Ø  Most effective treatment:  Press knee of the affected leg and dorsiflex the foot.

6. Temperature – slight increase in basal temperature due to increased progesterone, but the body adapts after the
4th month
7. Endocrine changes

7.1   Addition of the placenta as an endocrine organ,  producing large amounts of HCG, HPL, estrogen and progesterone.
7.2   Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and increased vascularity. 
Could also be due to increased basal metabolic rate to as much as +25% because of the metabolic activity of the products
of conception.

7.3   Increased size of the parathyroid, probably to satisfy the increased need of the fetus for calcium.

7.4   Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortiso,,  aldosterone and
ADH, all of which affect carbohydrate and fat metabolism, causing hyperglycemia.

7.5   Gradual increase in insulin production but the body’s sensitivity to insulin is decreased during pregnancy.

8. Weight (Table 5)

8.1   During the first trimester, weight gain of 1.5-3 lbs is normal

8.2   On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is recommended.

8.3   Total allowable weight gain during entire period of pregnancy, therefore, is 20-25 pounds (10-12 kgs).

8.4   Pattern of weight gain is more important than the amount of weight gained.

Fetus                                                     7lbs.

Placenta                                                 1 lb.

Amniotic fluid                                          1 ½ lbs.

Increased weight of uterus                        2 lbs.

Increased weight of the breasts                  1/1 – 3 lbs.

Weight of additional fluid                           2 lbs.

Fat and fluid accumulation                         4-6 lbs.

     Characteristics of pregnancy

                                                         Total       20-25 lbs.

Table 5.  Distribution of Weight Gain During Pregnancy

1. Emotional responses

1.1   First trimester.  The fetus is an unidentified concept with great future implications but without tangible evidence of
reality.  Some degree of rejection, disbelief, even depression.  (Implication: when giving health teachings, emphasize the
bodily changes in pregnancy).

1.2   Second trimester: fetus is perceived as a separate entity.  Fantasizes appearance of the baby.

1.3   Third trimester: has personal identification with a real baby about to be born and realistic plans for future childcare
responsibilities.  Best time to talk about layette and infant feeding method.  Fear of death, though is prominent (To allay
fears, let pregnant woman listen to the fetal heart sounds.)

A. Local Changes

1. Uterus

1.1   Weight increases to about 1000 grams at full tern; due to increase in the amount of fibrous and elastic tissues.

1.2   Change in shape from pear-like to ovoid; enormous change in consistency of lower uterine segment causes extreme
softening, known as Hegar’s sign, seen at about the 6th week

1.3   Mucous plugs in the cervix, called operculum, are produced to seal out bacteria.

1.4   Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as Goodell’s sign.
 

2. Vagina

2.1   Increased vascularity causes change in color from light pink to deep purple or violet known as Chadwick’s sign.

2.1.1     To prevent confusion as to pregnancy signs, arrange the body parts from “out to in” and the different signs
alphabetically.  Thus:

                        Vagina – Chadwick’s sign

                        Cervix – Goodell’s sign

                        Uterus – Hegar’s sign

2.1.2     Due to increased estrogen,  activity of the epithelial cell increases, thus increasing amount of vaginal discharges
called leucorrhea.  As long as the discharges are not excessive, green/yellow in color, foul-smelling or irritatingly itchy,  it
is normal.  Management: maintain or increase cleanliness by taking twice daily shower baths using cool water.

2.2   The pH of the vagina changes from normally acidic (because of the presence of Dederlein bacillie) to alkaline (because
of increased estrogen).  Alkaline vaginal environment is supposed to protect against bacterial infection; however, there are
two microorganisms which thrive in an alkaline environment.

2.2.1     Trichomonas, a protozoa or flagellate.  The condition is called trichomonas vaginalis or trichomonas vaginitis or
trichomoniasis.

Ø  Signs and symptoms of Trichomoniasis

§  Frothy, cream-colored, irritatingly itchy, foul-smelling discharges

§  Vulvar edema and hyperemia due to irritation from the discharges

Ø  Management

§  Flagyl for 10 days p.o. or vaginal suppositories of trichomonicidal compounds.  (e.g., Tricofuron, Vagisec or Devegan).
o   Is carcinogenic during the first trimester

o   Treat male partner also with Flagyl.

o   Avoid alcoholic drinks when taking Flagyl – can cause Antabuse – like reactions: vomiting, flushed face and abdominal
cramps.

o   Dark brown urine a minor side effect – no need to discontinue the drug.

§  Acidic vaginal douche (1 tbsp. white vinegar in 1 quart of water or 15 ml. white vinegar in 1000 ml. of water) to
counteract alkaline – preferred environment of the protozoa.

§  Avoid intercourse to prevent reinfection

2.2.2     Candida albicans, a fungus or yeast.  The condition is called Moniliasis or Candidiasis.  Fungus also thrives in an
environment rich in carbohydrates (that is why it is common among poorly-controlled diabetics) and in those on steroid or
antibiotic therapy when acidic environment is altered.  Moniliasis is seen as oral thrush in the newborn when transmitted
during delivery through the birth canal of the infected mother.

Ø  Symptoms

§  White, patchy, cheese-like particles that adhere to vaginal walls

§  Irritatingly itchy and foul-smelling vaginal discharges

Ø  Management

§  Mycostatin/Nystatin p.o. or vaginal  suppositories/peccaries (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

 

3. Abdominal Wall

3.1   Striae gravidarum – increase uterine size results in rupture and atrophy of connective tissue layers, seen as pink or
reddish streaks (gently rubbing oil on the skin helps prevent diastasis)

3.2   Umbilicus pushed out

4. Skin

4.1   Linea nigra – brown line running from umbilicus to symphais pubis

4.2   Melasma or chloasma – extra pigmentation on cheeks and across the nose due to increased production of
melanocytes by the pituitary gland

4.3   Sweat glands unduly activated

5. Breasts – all changes due to increased estrogen

5.1   Increase in size due to hyperplasia of mammary alveoli and fat deposits.  Proper breast support with well-fitting
brassiere necessary to prevent sagging

5.2   Feeling of fullness and tingling sensation in the breasts

5.3   Nipples more erect.  For mothers who intend to breastfeed, advise:

5.3.1     Nipple rolling

5.3.2     Drying nipples with rough towel to help toughen the nipples.

5.3.3     Not to use soap or alcohol as this can cause drying which could lead to sore nipples.

5.4   Montgomery glands become bigger and more protruberant

5.5   Areola becomes darker and diameter increases

5.6   Skin surrounding areolae turns dark

5.7     By the fourth month, a thin, watery, high protein fluid, called colostrums, is formed.  It is the precursor of breast
milk.

6. Ovaries – no activity whatsoever since ovulation does not take place during pregnancy.  Progesterone and estrogen
are being produced by the placenta

Emotional Adapation of Mothers during Pregnancy

1. Acceptance of Pregnancy (1st tri)

2. Acceptance of the Fetus (2nd tri)

3. Acceptance of motherhood (3rd  tri)

l  SIGNS AND SYMPTOMS OF PREGNANCY

Table 1.5. Signs and Symptoms of Pregnancy

PRESUMPTIVE PROBABLE SIGNS POSI+IVE SIGNS DANGER SIGNS

SIGNS (QUELNACS) (FUX F2)
(PUGO HUB) -refer
-subjective
-objective
Quickening Positive pregnancy FHT                       -vaginal bleeding of
test any amount
Urinary frequency Uterine growth UTZ                       -persistent vomiting

Easy fatigabilty Goodel’s sign X-ray -chills and fever

Leukorrhea Outline of the fetus   -sudden escape of

fluid from the vagina
Nausea and Vomiting   Funic Souffle
-swelling of face and
Amenorrhea Hegar’s sign Fetal movement felt fingers
by the examiner
Chadwick’s Sign Uterine souffle -visual disturbances

Skin changes Ballotement -painful urination or

dysuria

-abdominal pain

-severe or continuous
headache

l  LABORATORY TEST

1. Blood studies

Blood Typing

Complete blood count, including Hgb and Hct, to determine anemia

Serological tests (VDRL and Kahn Wasserman) to diagnose for syphilis

2. Urine examinations

- Heat and acetic acid test to determine albuminuria.  Any sign of albumin in the urine should be reported immediately
because it is a sign of toxemia

- Benedict’s test for glycosuria, a sign of possible gestational diabetes.  Urine should be collected before breakfast to avoid
false positive results.  Should not be more than +1 sugar.
- Determination of pyura. Urinary tract infection has been found to be a common cause of premature delivery.

PRENATAL HEALTH TEACHINGS

1. Schedule of Clinic Visit

          1st Tri: at least 1

2nd  tri: at least 1

3rd tri: every week starting 36 wks

2. Exercise

          -pelvic rocking

          -squatting and tailor sitting

          -Rib Cage Lifting

          -calf stretching

-kegel’s exercise

          -shoulder circling

          -abdominal muscle contractions

          -modified knee chest

1. Health Teachings

1.1   Nutrition – most important aspect (Table 7 and 8)

1.1.1     Women who need special attention

Ø  Pregnant teenagers

Ø  Extremes in weighing scale – low prepregnant weight and the obese

Ø  Low income women

Ø  Successive pregnancies

Ø  Vegetarians – although with high vitamin intake, are low in proteins and minerals because there are many essential
amino acids that can be found only in animal sources

1.1.2     Nutritional assessment is based on taking a diet history first

Ø  Food preferences/eating habits

Ø  Cultural/religious influences

Ø  Educational/occupational level

1.1.3     Computation of caloric equivalents

Ø  Carbohydrates x 4

Ø  Proteins x 4

Ø  Fats x 9

1.1.4     Food sources

Ø  Protein-rich foods – meat, fish, eggs, milk, poultry, cheese, beans, mongo

Ø  Vitamin A – eggs, carrots, squash, all green and leafy vegetables

Ø  Vitamin D – fish, liver, eggs, milk, (Caution: excess Vit. D during pregnancy can lead to fetal cardiac problems)

Ø  Vitamin E – green leafy vegetables, fish

Ø  Vitamin C – tomatoes, guava, papaya

Ø  Folic acid – especially needed to prevent megaloblastic anemia, abruption placenta and prematurity because, together
with iron, folic acid is needed for hemoglobin formation. E.g., asparagus

Ø  Vitamin B – food rich in protein

Ø  Calcium/phosphorus – milk, cheese

Ø  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 three months of life when all he takes is milk
(which is deficient in iron).

§  Iron has very low absorpotion rate; only 10% of iron intake can be absorbed by the body.  Thus, for optimum
absorpotion, give Vitamin C.

§  Iron should be given after meals because it is irritating to the gastric mucosa.

§  Foods rich in iron: liver and other internal organs, camote tops, kangkong, egg yolk, amplaya, amlunggay.

1.1.5     Malnutrition during pregnancy can result in prematurity; preeclampsia, absorption, low birth weight babies,
congenital defects or even stillbirths.

Nutrients Non-Pregnant Pregnant

Women
Calories (kcal) 2000 +300-400
Proteins (Gm) 46 +30

Vitamin A (IU) 4000 +1000

Vitamin D (IU) 400 +0

Vitamin E (IU) 12 +3

Ascorbic acid/Vitamin C (mg) 45 +15

Folic acid (mg) 400 +400

Niacin (mg) 13 +2

Riboflavin (mg) 1.2 +0.3

Thiamine (mg) 1.0 +0.3

Vitamin B12 (ug) 3.0 +1.0

Vitamin B6 (mg) 2.0 +0.5

Calcium (mg) 800 +400

Phosphorus (mg) 800 +400

Iodine (ug) 100 +25

Iron (mg) 18 +18

Magnesium (mg)  300 +150

Active Non-Pregnant
Food Pregnant Women
Women
Meat 2 servings of meat, fowl 2-3 servings of meat,
or fish/day; 3-5 fowl or fish/day; 1
eggs/week egg/day
Vegetables specially 1 serving/day (at least 1 serving/day
dark green and deep 3/week)
yellow
Fruits: Citrus and 2 or more servings/day 2-3 servings/day
others
Breads 1 serving/day 1 servings/day
Milk 4 or more servings/day 4 servings/day
Additional fluid 1 pint (6-8 oz. glasses 1 quart (2-6
/day) glasses/day)

1.1   Smoking – causes vasoconstriction, leading to low birth weight babies and, therefore, is contraindicated during
pregnancy

1.2   Drinking – in moderation is not contraindicated but when excessive can cause transient respiratory depression in
the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories.

1.3   Drugs – dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the
different body organs are developing.  Are teratogenic (can cause congenital defects) and, therefore contraindicated unless
prescribed by the doctor.

1.3.1     Thalidomide – auses Amelia or phocomelia (short or no extremeties)

1.3.2     Steroids – can cause cleft palate and even abortion

1.3.3     Iodine – contained in many over-the-counter cough suppressants, cause enlargement of the fetal thyroid gland,
leading to tracheal compression and dyspnea at birth

1.3.4     Vitamin K – causes hemolysis and hyperbilirubinemia                

1.3.5     Aspirin and Phenobarbital – cause bleeding disorder

1.3.6     Streptomycin and quinine – cause damage to the 8th cranial nerve (nerve deafness)

1.3.7     Tetracycline – causes staining of tooth enamel and inhibits growth of long bones (not given also to children below
8 years for the same reasons)

1.4   Sexual activity

1.4.1     Sexual desires continue throughout pregnancy, but levels change

Ø  During the first trimester, there is a decreased in sexual desire because the woman is more preoccupied with the
changes in her body

Ø  During the second trimester, there is another decrease in sexual desire because the woman is afraid of hurting the
fetus

1.4.2     Sex in moderation is permitted during pregnancy but not during the last 6 weeks since there is increased
incidence of postpartum infection in women who engage in sex during the last 6 weeks.

1.4.3     Counsel the couple to look for more comfortable positions. Definitely, the missionary (man-on-top)  position is not
advisable

1.4.4     Sex is contraindicated in the following situations

Ø  Spotting or bleeding

Ø  Ruptured BOW

Ø  Incompetent cervical os

Ø  Deeply-engaged presenting part

 
1.5   Employment – as long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive
physical or emotional strain, there is no contraindication to working.  Advise pregnant women to walk about every few
hours of her work day long periods of standing or sitting to promote circulation.

1.6   Traveling – no travel restrictions but postpone a trip during the last trimester.  On long rides, 15-20 minute rest
periods every 2-3 hours to walk about or empty the bladder is advisable.

1.7   Exercises

1.7.1     Chief aim: To strengthen the muscles used in labor and delivery

1.7.2     Should be done in moderation

1.7.3     Should be individualized: according to age, physical condition, customary amount of exercises (swimming or
tennis not contraindicated unless done for the first time) and the stage of pregnancy)

1.7.4     Recommended exercises

Ø  Squatting (Figure 5) and Tailor Sitting (Figure 6) – to stretch and strengthen perineal muscles; increase circulation in
the perineum; make pelvic joints more pliable.  When standing from squatting position, raise buttocks first before raising
the head to prevent postural hypotension.

Ø  Pelvic rock – maintains good posture; relieved pressure abdominal pressure and low backache; strengthens abdominal
muscles following delivery

Ø  Modified knee-chest position  - relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from
hemorrhoids

Ø  Shoulder-circling – strengthens muscles of the chest

Ø  Walking – said to be the best exercises

Ø  Kegel – relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles

ü  COMMON DISCOMFORTS

 
Table 1.6. Physical Discomforts of Pregnancy and its Management

S/SX CAUSE MANAGEMENT

FIRST TRIMESTER
N&V Hcg -offer dry crackers or toast

-no oily, greasy food

-drink fluids between meals

Urinary frequency Pressure of fundus Empty bladder as needed
Breast tenderness ↑ E and P Wear a well-fitting bra
Leukorrhea ↑ mucus production Keep it dry

Refer if infection is suspected

Ptyalism   Offer hard candy
SOB   Rise slowly; assume Semi-
Fowler’s position
SECOND TRIMESTER
Pyrosis D/t esophageal reflux -assume SF position

-refrain from lying down after

meals

-offer sips of warm water

-AVOID ANTACIDS
Ankle Edema D/t venous stasis Elevate legs

Left side lying position

Varicosities Weakening of faulty valves Elevate feet

Use support hose

Hemorrhoids/ D/t constipation Eat high fiber diet

↑ OFI
 Stool Softeners as prescribed
(Colace)
Backache Lumbosacral pressure Pelvic tilting
Leg cramps Losing Calcium Tailor sitting; dorsiflexion of
foot
Danger Signs of Pregnancy

1. Chills and fever - suspect for infection

2. Escape of fluid from vagina - PROM

3. Persistent vomiting beyond first trimester- Hyperemesis Gravidarum

4. Abdominal pain

Early pregnancy – crampy with bleeding – abortion

Low quadrant pain radiating to shoulder – ectopic pregnancy

Hard, boardlike painful abdomen – abruption placenta

Sudden, sharp abdominal pain – uterine rupture

5.  Vaginal bleeding

1st trimester – Abortion

3rd trimester – Placenta previa

6. Dysuria with burning sensation - UTI

7. Severe, persistent headache with vomiting

8. Swelling of hands and face

9. Dimness, blurring and doubling of vision

# 7, 8, and 9 = signs of PIH

10. Marked change in intensity & frequency of fetal movement or absence of movement (6-8 hours) after quickening – fetal
distress

Childbirth Preparations

METHOD DESCRIPTION
Bradley (Partner-coached) -husband plays an important role

-reduce labor pain by abdominal breathing

-woman does muscle-toning exercises

Psychosexual Method -developed by Sheila Kitzinger

-includes a program of conscious relaxation

and levels of progressive breathing
Dick-Read Method -fear leads to tension which in turn leads to
pain

-prevent fear thru prenatal classes

(aabdominal breathing)
Lamaze “psychoprophylactic”

-conscious relaxation -preventing pain in labor by using the

“mind”
-cleansing breath
-uses imagery to block incoming sensations
-controlled breathing

-effleurage

-Focusing/Imagery
Theories of Labor Onset
A.    Uterine Stretch Theory – any hallow body organ when stretched to capacity will necessarily contract and empty.

B.    Oxytocin theory – labor, being considered a stressful event, stimulates the hypophysis to produce oxytocin from the
posterior pituitary gland.  Oxytocin causes contraction of the smooth muscles of the body, e.g., uterine muscles.

C.    Progesterone Deprivation theory – progesterone, being the hormone designed to promote pregnancy, is believed to
inhibit uterine motility.  Thus, if its amount decreases, labor pains occur.

D.    Prostaglandin theory – initiation of labor is said to result from the release of arachidonic acid produced by steroid
action on lipid precursors.  Arachidonic acid is said to increase prostaglandin synthesis which, in turn, causes uterine
contractions.

E.    Theory of Aging Placenta – because of the decrease in blood supply, the uterus contracts.

Factors Affecting Labor

ESSENTIAL FACTORS OF LABOR (5Ps)

1. Passages
2. Power
3. Passenger
4. Person

5. Position

PASSAGES

FUNCTIONS (Sit Sit)

○        Serves as birthcanal

○        It proves attachment to muscles, fascia and ligaments

○        Supports uterus during pregnancy

○        It provides protection to the organs found within the pelvic cavity
TYPES (GAPA)

○        Gynecoid – normal female type of pelvis

              -  most ideal for childbirth

              - round shape, found in 50% of women

○        Android – male pelvis

              - presents the most difficulty during childbirth

              - found in 20% of women

○        Platypelloid – flat pelvis, rarest, occurs to 5% of women

○        Anthropoid – apelike pelvis, deepest type of pelvis found in 25% of women

DIVISION OF PELVIS

1.    False Pelvis – “provide and direct”

2.    True Pelvis – “the tunnel” IPO

○        Inlet or Pelvic Brim – entrance to true pelvis

ANTEROPOSTERIOR DIAMETER DOT

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)

○        Pelvic Canal – situated between inlet and outlet

                        - designed to control the speed of descent of the fetal head

○        Outlet – most important diameter of the outlet.

POWERS  (3I’s)

ž  Involuntary – not within the control of the parturient

ž  Intermittent – alternating contraction and relaxation

ž  Involves discomfort (compression, stretching and hypoxia)

ž  PHASES OF UTERINE CONTRACTIONS

          1. Increment/Crescendo – “ready, get set”

          2. Acme/Apex – “go”

          3. Decrement/Decrescendo – “stop”

ž  INTENSITY - strength of uterine contraction

○        Mild – slightly tensed fundus

○        Moderate – firm fundus

○        Strong – rigid, board like fundus

ž  FREQUENCY – rate of uterine contraction

                             - measured from the beginning of a contraction to the beginning of the next contraction

ž  DURATION – length of uterine contraction

                             - measured from the beginning of a contraction to the end of the same contraction

ž  INTERVAL – measured from the end of contraction to the beginning of the next contraction

PASSENGER

ž  HEAD (BOTu)

     - Biggest part of the fetal body

     - Olways the presenting part

     - Turn to present smallest diameter

ž  CRANIAL BONES       1 FOSE, 2 PaTe

              1 frontal bone          2 parietal bone

              1 occipital bone                  2 temporal bone

              1 sphenoid bone

              1 ethmoid bone

ž  SUTURE LINES – allow skull bones to overlap (molding) and for further brain development (SFC La)

—  Sagittal Suture – between 2 parietal bones

—  Frontal Suture – between 2 frontal bones

—  Coronal Suture – between frontal and parietal

—  Lamdiodal Suture – between parietal and occipital

ž  FONTANELS – intersection of suture lines

—  Anterior Fontanel or Bregma – intersection of SFC

                             - diamond shaped, closes b/n 12 – 18 months

                             - 3 x 4 cm

—  Posterior Fontanel or Lambda – triangular shaped, closes b/n 2 – 3 months

ž  DIAMETERS OF THE FETAL HEAD

AP > T (fetal head)

1.Tranverse Diameters  BBB

—  Biparietal – most important TD

                             - greatest diameter presented to the pelvic inlet’s AP and at the outlet’s TD

                             - average measurement is 9.5 cm

—  Bitemporal – average measurement is 8 cm

—  Bimastoid – average measurement is 7 cm

2. Anteroposterior Diameters   SOO

—  Suboccipitobregmatic – smallest APD

                                      - fully flexed (presenting part)

                                      - measured from the inferior aspect of occiput to the anterior fontanel

                                      - average measurement is 9.5 cm

—  Occipitofrontal – head partially extended and presenting part is the anterior fontanel

                                      - average size is 12. 5 cm

—  Occipitomental – head is extended and the presenting part is the face

                                      - measured from the chin to the posterior fontanel

                                      - average size is 13.5 cm

ž  FETAL LIE – relationship of the long axis of the fetus to the long axis of the mother

—  Longitudinal Lie – “parallel”

—  Transverse Lie – “right angle/lying crosswise”

—  Oblique Lie – “slanting”

ž  Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.
 

Diagram 4.2. Diameters of the Fetal Head

PRESENTATION AND PRESENTING PART

LIE PRESENTATION ATTITUDE

A.    Longitudinal Vertex – most ideal Complete flexion
Lie
            - suboccipitobregmatic is  
      1. Cephalic  presented (9.5 cm)
(head)  
 
   
Brow – occipitomental is presented (13.5
  cm) Moderate flexion

     

  Sinciput – occipitofrontal is presented Partial flexion (military

(12.5 cm) position)
 
    Extension

      2. Breech Face presentation  

(butt)
  Hyperextended
 
Chin presentation  
 
  Good flexion
 
Complete breech  - feet & legs flexed on  
  the thighs and the thighs are flexed on
the abdomen Moderate flexion
 
   
 
Frank breech -  hips flexed and legs  
  extended (MOST COMMON)
 
   
Very poor flexion
  Footling Breech – one or both feet are the
presenting parts  
 
   
 
Shoulder Presentation – fetus is lying Flexion
  perpendicular to the long axis of the
mother
B. Transverse Lie
              - vaginal delivery is NOT
     Causes: POSSIBLE

      1. relaxed  
abdominal wall
*Compound Presentation – when there is
      2. placenta prolapsed of the fetal hand alongside the
previa vertex, breech or shoulder.      
 

POSITION

ž  LOA (Left Occipitoanterior) – most favorable & common fetal position

              - fetus in vertex presentation (occiput)

              - fetus usually accommodates itself on the left because the placement of the bladder is at the right

ž  LOP/ROP – mother will suffer more back pains

ž  FHT Breech: Upper R or L Quadrant (above Umbilicus)

ž  FHT Vertex: Lower R or L Quadrant (below Umbilicus)

ž  STATION - relationship of the presenting part of the fetus to the ischial spine of the mother.

—  Minus (-) station – presenting part is above the ischial spine

—  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

—  FLOATING – head is movable above the pelvic inlet

—  +1 station – fetus is engaged

—  +2  station – fetus is in midpelvis

—  +4 station – perineum is bulging

ž  THE PERSON
 

FACTORS affecting labor   

—  Perception & meaning of childbirth

—  Readiness & preparation for childbirth

—  Coping skills

—  Past experiences

—  Cultural & social background

—  Presence of significant others and support system

Signs of Labor

 Weight Loss – 2-3 pounds (progesterone)

 Ripening of the Cervix – “soft”
 Increased Braxton Hicks – “irregular, painless”
 Show – “ruptured capillaries + operculum = pinkish color”
 Lightening – “the baby dropped”; settling of presenting part into the pelvic brim

                             -  2 weeks (primi) and before or during (multi)

—  Relief of respiratory discomfort

—  Increased frequency of urination

—  Leg pains

—  Muscle spasms

—  Increased vaginal discharge

—  Decreased fundal height

  Increased Level of Activity – large amount of epinephrine (AG)
 Rupture of Membranes – gush or steady trickle of clear fluid

FALSE LABOR

CANDAC

ü  Contraction disappear with ambulation

ü  Absence of cervical dilation

ü  No ↑ DIF (duration, intensity, frequency)

ü  Discomfort @ abdomen

ü  Absence of show

ü  Contraction stops when sedated

TRUE LABOR

CUPPAD

ü  Contraction persists when sedated

ü  Uterine contraction ↑ DIF (duration, intensity, frequency)

ü   Progressive cervical dilation

ü  Presence of show

ü  Ambulation increase contractions

Discomfort radiates to lumbosacraL

Stages of Labor

ž  STAGE 1 – DILATATION STAGE

—  Starts from first true uterine contraction until the cervix is completely effaced and dilated.

○        Dilatation – widening of cervical os to 10 cm

○        Effacement – thinning to 1- 2 cm

—  CAUSES:        1. Pergusion Reflex

                        2. Fetal head and intact BOW serves as a wedge to dilate the cervix

—  Maternal Assessment During Labor

ü  Check V/S q 4hrs during the first stage

                        - temp q hour if membranes are already ruptured (risk of infection)

                        - BP b/n contractions, in left lateral pos, q 15 – 20 mins after giving anesthesia

                        - a rapid pulse indicates hemorrhage & dehydration

ü  Uterine contraction

Manual: fingers over fundus, you feel it about 5 secs before the client feels it

Techniques:

                        1. assess contraction (DIIF)

                        2. check contraction q 15 – 30 mins during the first stage

                        3. refer immediately if:

                                  - duration more than 90 secs

                                  - interval less than 30 secs

                                  - uterus not relaxing completely after each contraction

ü  Show – slightly blood-tinged mucus discharge

ü  Internal Examination – to assess status of amniotic fluid, consistency of cervix, effacement/dilatation, presentation,
station and pelvic measurement.

              - do it during relaxation

              - less IE done once membrane have ruptured

              - start with middle finger then index finger

ü  Status of Amniotic Fluid (if ruptured)

—  Danger of cord prolapse if fetal head is not yet engaged.

—  Danger of serious intrauterine infection if delivery does not occur in 24 hours

NITRAZINE PAPER TEST

          - used to assess whether membrane ruptured or not.

—  Procedure: “Insert and Touch”

○        Yellow – intact BOW

○        Blue – ruptured

—  Normal Color of AF – clear, colorless to straw colored

—  Green tinged – meconium stain (fetal distress in non – breech presentation)

—  Yellow/Gold – hemolytic disease

—  Gray/Cloudy – infection
—  Pinkish/Red stained – bleeding

—  Brownish/Tea Colored/Coffee Colored – fetal death

OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID

ž  Ferning pattern of cervical mucus

           (“swab – dry – view”)

ž  Nile blue sulfate staining of fetal squammous cells

FETAL ASSESSMENT DURING LABOR    FHT Monitoring

—  Latent Phase – every hour

—  Active Phase – every 30 minutes

—  Second Stage of Labor – every 15 minutes

—  FHT is taken more frequently in high – risk cases

ž  Normal FHT Pattern

—  Baseline rate: 120 – 160 bpm

—  Early Deceleration –    FHT @ contraction, Normal @ end of contraction (head compression)

—  Acceleration -    FHT when fetus moves

ž  Abnormal FHT Pattern

—  Bradycardia – 100 – 119 bpm – moderate

                        - below 100 bpm – marked

     CAUSES:        1. fetal hypoxia (analgesia &          anesthesia)

                        2. maternal hypotension

                        3. prolonged cord compression

     MGT: 1. place mother on left side

                        2. assess for cord prolapse

                        3. administer oxygen

Tachycardia – 161 – 180 bpm – moderate

              - above 180 bpm – marked

CAUSES:   1. maternal fever, dehydration

              2. drugs (atrophine, terbutaline, ritodrine, etc.

MGT:       1. D/C oxytocin, position on LLP

              2. give 02 at 8 – 10 lpm

              3. prepare for birth if no improvement

—  Variable Pattern – deceleration at unpredictable times of uterine contraction

     CAUSE: sign of cord compression

     MGT: release pressure on the cord

—  Sinusoidal Pattern – no variability in FHT

     CAUSE: hypoxia, fetal anemia & prematurity

 
CARE OF THE PARTURIENT

1. LATENT PHASE

○        Cervical Dilation: 0 – 4 cm

○        Nature of Contraction:         Duration: < 30 secs

                                           Interval:  3 – 5 mins

○        Length of Latent Phase:      Primis – 6 hours

                                           Multis – 4 – 5 hours

○        Attitude of mother: feel comfortable, walking and sitting at this time

○        Nsg Responsibilties:         TGC

                        1. Teach breathing techniques

                        2. Give instructions

                        3. Conversation is possible (cooperative & focus mother)

2. ACTIVE PHASE

○        Cervical Dilation: 4 – 7 cm

○        Nature of contractions:        Duration: 30 – 50 secs

                                           Intensity: moderate to strong

○        Length of Active Phase:       Primis – 3 hours

                                           Multis – 2 hours

○        Attitude of mother:   prefer to stay in bed, withdraws from her environment and self – focused
○        Nsg Responsibilities:            CPIC

              1. Coach woman on breathing and relaxation techniques

              2. Prescribed analgesics given during active phase

              3. Instruct woman to remain in bed, minimize noise, raise side rails, NPO

              4. Check BP 30 mins after giving analgesics          (hypotension)

3. TRANSITION PHASE

○        Cervical Dilatation:  8 – 10 cm

○        Nature of Contractions:       Duration: 50 – 60 secs

                                           Interval: 2 -3 mins

                                           Intensity: moderate to strong

○        Length of Transition Phase:

     Primis – 1 hour (baby delivered within 10 contractions or 20 mins)

     Multis – 30 mins (baby delivered within 10 contractions or 20 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

○        Nsg Responsibilities:   RRE

              1. Reassure woman that labor is nearing end & baby will be born soon

              2. Reinforce breathing and relaxation techniques

              3. Encourage fast-blow breathing to remove the urge to bear down

ž  CARE OF THE BLADDER – encourage the woman to void q 2 hrs to: DIPC
○        Delay fetal descent

○        Increases the discomfort of labor

○        Predispose to UTI

○        Can be traumatized during labor

ž  FOODS & FLUIDS – NPO on active phase

○        Clear fluids on latent phase

ž  POSITIONING – LLP - best position bcoz J RIPES

○        Relieves pressure – IVC

○        Improves urinary function

○        Prevent hypotensive syndrome

○        Encourage anterior rotation of the fetal head

○        Squatting is ideal position – directs presenting part towards the cervix promoting dilatation

ž  AMBULATION – during the latent phase to shorten the first stage, to decrease the need for analgesia,   FHT
abnormalities & to promote comfort    

○        NO WALKING IF BOW IS RUPTURED

ž  IV FLUIDS – reasons:   PLUA

○        Prevent dehydration/fluid & electrolyte imbalances

○        Life – line for emergencies

○        Usually required before administration of A/A

○        Administration of oxytocin after delivery to prevent atony

ž  PERINEAL PREP

○        Clean & disinfect the external genitalia

○        Provide better visualization of the perineum

ž  ENEMA – emptying the colon of fecal matters to:

○        Prevent infection

○        Facilitate descent of fetus

○        Stimulate uterine contractions

○        CONTRAINDICATIONS: NIRVAA

—  Not given during active phase

—  If premature labor bcoz of danger of cord prolapse

—  Rupture of BOW

—  Vaginal bleeding

—  Abnormal fetal presentation & position

—  Abnormal fetal heart rate pattern

SECOND STAGE – EXPULSIVE STAGE

          MECHANISM OF LABOR: EDFIRE ERE

—  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

—  Transfer to the DR:   Primis – cervix fully dilated

                                                Multis – cervix is 8 cm dilated

Delivery Position

1.    Lithotomy – used when forcep delivery & episiotomy are to be performed.

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.    Left Lateral Position – indicated for woman with heart disease.

ž  ASSISTING THE MOTHER IN THE DR

1.    Coach the mother to push effectively

2.    Instruct the woman to pant

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

5.    When the head is crowning, instruct the mother to pant.

6.    Perform Ritgen’s Maneuver while delivering the fetal head to:

1.    Slows down delivery of the head

2.    Lets the smallest diameter of the head to be born

3.    Facilitates extension of the head

7.    Just after delivery, immediately wipe the nose & mouth of secretions then suction.

8. Take note of the exact time of baby’s birth

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.

11. Clamping the cord:

—  After the pulsation stops

—  Clamp the cord twice and cut in between 8 – 10 inches from umbilicus

—  After cutting the cord, look for 2 arteries & 1 vein

12. Wrap the infant & bring to the nursery

THIRD STAGE – PLACENTAL DELIVERY

METHODS OF PLACENTAL SEPARATION:

1. Schultz Mechanism – separation of the placenta starts from the center

              - the shiny & smooth fetal side is delivered first

              - 80% of placental separation

2. Duncan Mechanism – separation begins from the edges of placenta

              - the dirty maternal side is delivered first

              - 20% of placental separation

MANAGEMENT:

1. Watchful waiting.

a)    Do not hurry placental delivery. Tract the cord slowly, winding it around the clamp until the placenta spontaneously
comes out, slowly rotating it so that no membranes are left inside the uterus, a method called Brandt – Andrews
maneuver.

b)   Rest a hand over the fundus to make sure the uterus remains firm

c)    Wait for signs of placental delivery

·         Calkin’s sign – uterus is firm, globular & rising to the level of umbilicus; earliest sign of placental separation

·         Sudden gush of blood from vagina

·         Lengthening of the cord

2. Manage the uterus to keep it contracted.

3. Administer methergine (0.2 mg./ml. or Syntocinon = 10U/m) as prescribed.

4. Never leave the client unattended.

5. Oxygen & emergency equipment made available.

THE FOURTH STAGE – PUERPERIUM

MANAGEMENT:

1. Repair of lacerations.

              CLASSIFICATION OF PERINEAL  LACERATIONS

            

Ø  First degree – involves the vaginal mucous membranes and perineal skin

Ø  Second degree – involves not only the muscles, vaginal mucous membranes and skin, but also the muscles.

Ø  Third degree – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the
rectum

Ø  Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and
skin, but also the m mucous membranes of the 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.

4. Check uterus & bladder q 15 mins.

Perineal Lacerations

MANAGEMENT:

1. Repair of lacerations.
              CLASSIFICATION OF PERINEAL  LACERATIONS

            

Ø  First degree – involves the vaginal mucous membranes and perineal skin

Ø  Second degree – involves not only the muscles, vaginal mucous membranes and skin, but also the muscles.

Ø  Third degree – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the
rectum

Ø  Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and
skin, but also the m mucous membranes of the 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.

4. Check uterus & bladder q 15 mins.

Postpartum Complications

1. HEMORRHAGE

- Bleeding of >500 cc  (NSD 500 cc normal, CS 600-800 cc)

A. Early postpartum hemorrhage - bleeding within 1st 24 hours;

- baggy or relaxed uterus, profuse bleeding (UTERINE ATONY)

Mngt: massage uterus until contracted

- cold compress

- modified T.berg position

- IV drip: OXYTOCIN

u   Lacerations:

1st degree: vaginal skin and mucus membrane

2nd degree: 1st degree + muscles of vagina

3rd degree: 2nd degree + external sphincter of rectum

4th degree: 3rd degree + mucus membrane of rectum

l  DISSEMINATED INTRAVASCULAR COAGULATION

- bleeding occurs to any part of the body

- hysterectomy if with abruptio placenta (BT as mngt)

Diagram 4.3. Types of Lacerations

LATE POSTPARTUM HEMORRHAGE - bleeding  occurs after 24 hrs d/t retained placental fragments

Mngt: D&C

Acreta

Increta              HYSTERECTOMY

Percreta
 

l  INFECTION

General signs of inflammation: heat, redness, pain, swelling, discharges

Mngt: Supportive care: CBR, hydration, TSB, antipyretics, cold compress, antibiotic as prescribed

UTI, IDA, GDM, PIH

l  URINARY TRACT INFECTION

                                                - occurs more frequently in pregnancy and puerperium

- most common complication

- d/t decreased urinary stasis

- risk for acute cystitis, pyelonephritis and possible PROM

-Mngt: amoxicillin (first line)

: increase OFI

: void at regular regular intervals

l  IRON DEFICIENCY ANEMIA

- iron requirement: 1000 mg/ fetus

- causes: inadequate intake, malabsorption, bleeding, multiple gestation, concurrent antacid use

                                      - diagnostics: CBC

- mngt: dietary iron (30 mg iron/day) for all women; 200 mg/day if anemic

- alternate activity and rest

- take green leafy vegetables

l  GESTATIONAL DIABETES MELLITUS

HORMONES THAT ANTAGONIZE INSULIN

1.    Human Placantal Lactogen (HPL): counteract effect of insulin

2.    Estrogen and progesterone: antagonist of insulin

3.    Placental insulinase: enhances degradation of insulin

4.    Placental insufficiency: maternal insulin utilization

EFFECTS

1.    EFFECT ON BABY

1.1 MACROSOMNIA: wide shoulder, fractured clavicle; BEST DELIVERED C/S

1.2  ORGANOMEGALY: heart, liver

1.3  Preterm delivery

1.4 HYPOGLYCEMIA (Serious): After birth; due to hyperinsulinism inside the mother

2.    EFFECT ON THE MOTHER

2.1 More prone to infection: UTI sugar is increase in urine; Also Vaginal Candidiasis

2.2  Grater incidence of PIH and eclampsia

2.3  Increase incidence of hydramnios

2.4  DICTOCIA: CS MGT

2.5  ATONY of the uterus after delivery-hemorrhage

3.    DX:

u  Not diagnosed in the 1st trimester

u  Diagnosed in the 2nd trimester- 5th month (20-24 weeks)

u  OGTT (glucose challenge)

u  First step: FBS in the morning (8 hours of Fasting before test); If high FBS: Diabetic, No need for OGTT

u  Second step: OGTT given Oral Glucose comprising of 50 g or oral glucose; One hr check the blood; The result: Normal:
Less than 7.8 mmol,140 mg/dl or less 7.8mmol of less –normal)

u  Step 3: If positive for step 2100gms of oral glucose: Check 3 out of 2 values: you become positive and she has GDM

4.    MANAGEMENT

3.1 Only insulin is given: 2nd trimester: Later half of pre-pregnancy more insulin requirement
3.2 No OHA: Tolbutamides; Crosses placental barrier, teratogenic; Further aggravate insulin production in baby

3.3  INSULIN

-       Last trimester (increase demand)

-       LABOR- will have insulin pump

-       POST-PARTUM: at risk of hypoglycemia; 6 weeks, diabetes should be resolve

o BLOOD GLUCOSE MONITORING: in 3 months with HBA1C

•      Diet: 6 meals – to prevent hypoglycemia; Equally distributed into 3 meals and snacks; Weight Gain desirable at term
is 22-27 lbs

o 200 calories additional in GDM , in normal 300 cal

§      45%-CHO

§      30%- protein-delays absorption of glucose

§      25 %–fat: Good oil; Fish Oil

§      eat a light meal before exercising *Mangoes: Only one slice only

*Fruits with covers (Apple): Have Lower glycemic Index

•      returns to pre-pregnancy state after 6 WEEKS

•
 

*MOTHER AND BABY: monitor for Hypoglycemia *+300 Calories + Normal Calories; for normal weight

l  PREGNANCY INDUCED HYPERTENSION (PIH)

                          -after the 24th week gestation – 2 weeks postpartum

TRIAD SYMPTOMS: REMEMBER HEP!

                          - Hypertension (2 successive BP of 140/90 and above taken 4 - 6 hours apart)

                          - Edema (upper part of the body – hands and face)

                          - Proteinuria (Albuminuria)

ü  Causes:

1.    Age (<20y/o & >35y/o)

2.    multigravida – >5

3.    Low socio-economic status

4.    macrosomia

5.    Family history

ü  2 Types:

1. Preeclampsia : H.E.P
2. Eclampsia : with convulsions
Table 3.1 Signs and Symptoms of Eclampsia

Signs/Symptoms Mild Preeclampsia Severe Preeclampsia

Blood Pressure 140/90, diastolic BP is more than Diastolic is 110mmHg or higher
100mmHg
Proteinuria +1 - +2 by dipsticks +2 - +4

300mg/24 hour urine collection 5g/24 hour urine collection

Liver enzymes Slightly elevated Markedly elevated
Laboratory studies Normal hematocrit, uric acid, creatinine Increased Hct, Crea and UA;
thrombocytopenia may be present
Fetus No IUGR IUGR present
Edema Digital edema, dependent edema Pitting edema (4+)

Generalized edema
Weight Gain 1 – 2 lb/week More rapid weight gain
Urinary Output Not less than 400ml/24 hours Less than 400 ml/24 hours
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 RUQ pain (aura to convulsion) d/t
swelling of hepatic capsule
S/Sx of Eclampsia:

1. All the S/Sx of preeclampsia

2. Convulsion followed by coma
3. Oliguria
4. Pulmonary edema

Management:

Diet: LS, LF, HIGH CHON, moderate CHO

Exercise: Alternate rest and activity; no strenuous activities

Environment: Dim; cluster nursing care; non-stimulating

Medications: MgSO4 (Anticonvulsant, CNS Depressant);  Hydralazine (anti-hypertensive)

Nursing considerations: Check VS and DTR

Table 3.2. Magnesium Sulfate Toxicity

MgSO4 Toxicity Antidote

 DECREASED: Give CALCIUM GLUCONATE

Blood pressure  

Urinary Output WOF:

Respiratory Rate Cardiac dysrhythmias

Patellar Reflex (Deep Tendon Reflex) Tetany

   

Checkpoint Question:

What equipment should be at the bedside

in case these adverse reactions occur?

Seizure management:

- WOF: AURA

- Padded side rails

- lower the bed

- remove sharp and slippery objects

-monitor FHT

Ø  During seizures: Note time and duration

Protect the head

PRIORITY: SAFETY

Ø  Post-ictal: Side lying position

Ensure patent airway

Reorient the patient

Hyperemesis Gravidarum,Abortion, Incompetent Cervix, Isoimmunization

l  HYPEREMESIS GRAVIDARUM

      Causes:    (UTEP)

                     1. Unknown

                     2. Thyroid dysfunction

                     3. Elevated HCG

                     4. Psychological stress

                        S/Sx:  

ü  Excessive N/V – persist beyond 12 weeks

ü  Signs of dehydration (thirst, dry skin, weight loss, concentrated and scanty urine)

                   Dx:

                                      Differential diagnosis (liver & thyroid function studies, urinalysis, Hct/Hgb and WBC)
          

           Management:

n  Conservative management

A. dry, low fat, high carbohydrate and bland diet

                     - dry crackers

                     - small frequent feedings & sips of water (gastric distention – trigger vomiting reflex)

                     - avoid very hot or very cold food & beverages

B. avoid noxious stimuli

                     - motion and pressure around the stomach (tight waistbands)

                     - temporary cessation of iron supplement (gastric upset)

                     - avoid highly seasoned and spicy foods

                     - avoid strong odors (perfumes)

                     - avoid loud noises, bright and blinking lights

C. take vitamin supplement to correct nutritional deficiencies from decreased food intake

D. have enough relaxation & rest

E. take prescribed medications

                     - Promethazine (Phenergan)

                     - Prochlorperazine (Compazine)

                     - Ondansentron (Zofran)

                     - Droperidol (Inapsine)

                     - Metoclorpramide (Reglan)

                     - Diphenhydramine (Benadryl)

                     - Meclizine (Antivert)

n  Hospitalization (correct dehydration and F&E imbalances)

           a. IV fluids (lactated ringers)

           b. Vitamin supplementation

           c. NPO for 24 – 48 hours (rest GIT)

           d. Oral fluid intake after hydrated and nausea subside

e. when patient begins oral intake of foods:

                     - administer antiemetics ac

                     - introduce food gradually starting with clear liquids

                     - small frequent feedings

                     - X odorous, spicy & greasy foods

n  Complementary therapies

           a. acupressure (pericardium 6 or P6)

           b. herbal remedy (ginger – carminative effect/aroma)

           c. vitamin supplementation

n  Provide emotional support

           a. show sincere concern for the women’s welfare

           b. empower patient with knowledge & encouragement

           c. provide necessary referrals (counseling)

l  ABORTION

Terminologies:

1. Abortion – termination pregnancy before 20 weeks and fetus is <500g

2. Early Abortion – <12 weeks
3. Late Abortion – > 20 weeks
4. Abortus – aborted fetus
5. Occult Pregnancy – zygotes that were aborted before pregnancy is diagnosed or recognized
6. Clinical Pregnancy – pregnancies that were diagnosed
7. Blighted Ovum – small macerated fetus, sometimes there is no fetus, surrounded by a fluid inside an open sac.
8. Carneous Mole – zygote that is surrounded by a capsule of clotted blood
9. Fetus Compressus – fetus compressed upon itself and desiccated with dried amniotic fluid
10. Fetus Papyraceous – fetus that is so dry that it resembles a parchment

11. Lithopedion – a calcified embryo

12. Immature Infant – having a birth weight b/n 500 – 1000 grams

Ø  Types of Abortion:

1. Elective/Therapeutic Abortion “-”deliberate”
a. EA – initiated by personal choice
b. TA – recommended by the healthcare provider
2. Spontaneous Abortion – “due to natural causes”

ü  Causes of Spontaneous Abortion:

A.    Fetal Causes (chromosomal)

B.    Maternal Causes
1.    Advanced maternal age (>35 y/o)

2.    Structural abnormalities of the reproductive tract

3.    Inadequate progesterone

4.    Maternal infections (TORCH)

5.    Substance abuse

Table 3.3 Types of Spontaneous Abortion:

TYPE
Threatened Imminent/Inevitab Complete Incomplete Missed Habitual Septic
le
S/sx
*(+) *Moderate to profuse *bleeding *heavy bleeding *(-)FHT 3 or more *foul-smelling discharge
bleeding (brigh bleeding and miscarriages
t) cramping *abdomin *severe crampin *no uterine ; usually *uterine cramping
al pain g enlargement   inevitable
* (-) cervical *open cervix *fever, chills and
dilatation *passage *open cervix *s/sx of pregnancy peritonitis
*ROM of tissue disappear
*mild uterine *passage of *WBC ↑
cramping *no tissue passed *closed tissue
cervix
          *retained
*empty products upon
uterus utz
on utz

 
Management
-monitor vs -avoid complications -D&C -D&C to prevent Causes: -Treat abortion
of infection and DIC
-monitor heavy bleeding -inspect fundus frequently - -high dose IV antibiotic
bleeding and -Insert incompetent therapy (Penicillin –
infection -admit pt -monitor blood loss 20mg Dinoproston cervix gram negative,
e (Prostaglandin Clindamycin/Tobramyci
-complete bed -D&C -inspect perineal pads (60- E) suppository into -genetic n – gram positive)
rest 100 ml) vagina q 3-4 hours abnormalitie
-give oxytocin after s -D&C if accompanied
-no coitus for D&C -monitor VS -Oxytocin IV
2 weeks -treat cause
-provide emotional -monitor I&O
-diet: ↑ iron support *cerclage
(WOF: oliguria - shock)
-no douching *fertility
-Encourage verbalization drugs
-determine Rh of feelings (EVOF)
factor *aspirin

WOF:  

-heavy  
bleeding

-hyperthermia

l  INCOMPETENT CERVIX

Causes:

1. DES exposure
2. Cervical trauma (forcep deliveries)
3. Hormonal
4. short cervix
5. Forced D&C
6. Uterine anomalies

Dx:
 1. Pelvic examination or IE
2. Ultrasonography – “funneling”

S/Sx:

1. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)
2. ROM

Management:

1. Cervical cerclage @ 14 weeks (“earlier the better”)

2. Prerequisites of cervical cerclage:

- cervix not dilated >3 cm

                   - intact membranes

                   - (-) bleeding and cramping

ü  Types of cervical cerclage:

—  Shirodkar  – “permanent suture”

—  Mc Donald – “temporary suture”

- 38 – 39 weeks removal of suture

4. After suture:

                   - bedrest for 24 hours – several days

                   - monitor bleeding, contraction and rupture

                   - report passage of fluid or signs of PROM

                   -  if uterine contracts, give RITODRINE

                   - restrict activities after application for the next 2 weeks including coitus

Diagram 3.1. Cervical Cerclage

l  ISOIMMUNIZATION

❏ antibodies produced against a specific RBC antigen as a result of antigenic stimulation with RBC of another individual

❏ occurs when mother is Rh (-) and baby is Rh (+)

Pathogenesis

❏ maternal-fetal circulation normally separated by placental barrier

❏ upon first exposure, initially IgM and then IgG antibodies are produced; IgG antibodies cross the placental barrier

❏ sensitization routes

    - ncompatible blood transfusion

    - previous fetal-maternal transplacental hemorrhage

    - invasive procedure (amniocentesis, chorionic villi sampling)

     - therapeutic abortion, D&C, amniocentesis ❏ complications

Complications:

     fetal hemolysis, fetal anemia, CHF, edema, and ascites

    severe cases can lead to fetal hydrops (total body edema), or erythroblastosis fetalis

Diagnosis

❏ routine screening = Ab titres < 1:16 considered benign

❏ Ab titres > 1:16 necessitates amniocentesis (correlation exists between amount of biliary pigment in amniotic fluid and
severity of fetal anemia) from 24 weeks onwards

❏ Liley curve is used to determine bilirubin level and appropriate management

❏ Kleihauer-Betke test can be used to determine extent of fetomaternal hemorrhage

Management

❏ Rhogam must be given to all Rh negative women

     - at 28 weeks

     - within 48 hours of the birth of an Rh positive fetus

     - positive Kleihauer-Betke test

     - with any invasive procedure in pregnancy

     - in the case of ectopic pregnancy

     - antepartum hemorrhage

Infections During Pregnancy

TORCH Infection

v  TOXOPLASMOSIS

•      Etiology: protozoan Toxoplasma gondii

•      Risk factors: eating raw or undercooked meat

                                                              : drinking unpasteurized goat’s milk

                                                              : contact w/ feces of infected cats

•      Fetal-Neonatal Risks

Fetal Hydrocephaly; Chorioretinitis; Cerebral Calcification

Ø     inflammation of the retina, blindness, deafness, severe retardation

Ø     severe disorders = convulsions, coma, microcephaly, hydrocephalus

•       Diagnostic Test:

1. IgG and IgM fluorescent antibody  tests (IFA)

2. Indirect hemagglutination test (IHAT)

3. Sabin-Feldman dye test

4. Ultrasound to detect fetal infection

•       Treatment (mother):

Ø     combination of antiparasitic drugs Sulfadiazine and Pyrimethamine (penicillin and Erythromycin are acceptable for
pregant): Teratogenic effects

Ø     Spiramycin in Europe

•       Treatment (newborn):

Ø     combination of Sulfadiazine, Pyrimethmine, Leucovorin for 1yr

v RUBELLA (German Measles)

•      Best Therapy is PREVENTION

•      Prenatal laboratory screening -- Hemagglutination inhibition (HAI) test (the presence of positive titer 1:16 or greater
is evidence of immunity while a negative titer less than 1:8 indicates susceptibility to rubella)

•      Clinical Therapy:
 

GIVEN Gammaglobulin: for immunity to the pathogen

Rubella Titer test: to determine if she has antibodies against rubella; has Greater than 1:8 (PROTECTED)

All women of childbearing age who receive the rubella vaccine should carefully avoid pregnancy for at least 3 MONTHS

Ø             Vaccine is made with attenuated virus thus pregnant women are NOT vaccinated.

•      Fetal-Neonatal Risks: period of greatest risk for the teratogenic effects of rubella on the fetus is the

•      First Trimester

Ø             CONGENITAL RUBELLA SYNDROME: Most common clinical signs of congenital infection: congenital
cataracts, galucoma, micorocephaly, mental retardation sensorineural deafness, congenital heart defects particularly PDA,
IUGR, cerebral palsy

Ø             Expanded Rubella Syndrome – relates to the effects that may develop for years after the infection (increased
incidence of insulin-dependent diabetes mellitus, sudden hearing loss, glaucoma, slow and progressive form of
encephalitis)

 
 

v  CYTOMEGALOVIRUS (CMV) Infects lower genital tract without symptoms

FETAL EFFECTS: Microcephaly; Cerebral Calcification; Chorioretinitis; Hepatosplenomegaly

Neonatal Period: Early Jaundice; hematemesis; melena; Hematuria; Death

•      CMV belongs to the herpes virus group and causes both congenital and acquired infections referred to as cytomegalic
inclusion disease (CID)

•      Transmission: placenta, cervical route during birth, through body fluids; between human by any close contact e.g.
kissing, breastfeeding, and sexual intercourse

•      Accurate Dx in pregnant women: depends on presence of CMV in the urine, rise in IgM levels and identification of the
CMV antibodies w/in the serum IgM fraction

v  HERPES SIMPLEX VIRUS (HSV-1 or HSV-2)

1: Oral

2: Genital; Dangerous for baby

2: Painful vesicles in thevulva and perianal area; Transmistted intrapartum causing fatal congenital herpes (C/S Delivery
Indicated); Mother is treated with Acyclovir (ZiroVax:
 

Gibven more for 3rd Trimester)

•      Fetal-Neonatal Risks:

Ø     Primary infection – spontaneous abortion, LBW, preterm birth

Ø     If antiviral therapy is not used, SEVERE infection – microcephaly, mental retardation, seizures, retinal dysplasia,
apnea, coma

Ø     Infected infant is often asymptomatic at birth but develops – fever (or hypothermia), jaundice, seizures, poor
feeding after an incubation period of 2-12 days

•      Treatment: Acyclovir, Valacyclovir, Famciclovir (Acyclovir has been shown to be effective and safe during pregnancy,
but NOT well absorbed as the other two drugs)

•    Mode of Delivery: NSD (if no evidence of genital infection), CS (active genital lesions or presence of prodromal
symptoms of infection

v SYPHILIS

•      Causative organism: spirochete Treponema pallidum

 
•      MOT: transplacental inoculation (fetus)

•    Signs and symptoms:

Ø     Stage I – Primary: chancre appears (lasts about 4 weeks then disappears), w/ slight fever, weight loss, malaise

Ø     Stage II – Secondary: condylomata lata

(wartlike plaques), acute arthritis, enlargement of liver and spleen, nontender

enlarged lymph nodes, chronic sore throat with hoarseness

•    Diagnostic Tests:

1.    Blood tests – VDRL, RPR, FTA, ABS

2.    Dark-field examination of spirochetes

•    Treatment:

Ø       for pregnant and nonpregnant w/ Syphilis of less than 1yr: 2.4 million units of Benzathine penicillin G IM in single
dose

Ø       for Syphilis of more than 1 year duration:

2.4 million units of Benzathine penicillin G IM once a wk for 3wks

•    Fetal-Neonatal Risks:

Ø       Can be passed transplacentally to the fetus. If untreated, one of the following can occur: 2 nd trimester abortion,
stillborn infant at term, congenitally infected infant, uninfected live infant
 

v  BACTERIAL VAGINOSIS

•      A.K.A nonspecific vaginitis or Gardnerella vaginalis

•      Causative organism: Gardnerella, mycoplasmas, anaerobes

•      Contributing factors: tissue trauma, sexual intercourse

•      Symptoms:

Ø       excessive amount of thin, watery, white or gray vaginal discharge with a foul odor (“fishy”), vaginal pH is usually
>4.5

Ø       wet-mount preparation reveals “clue cells”, application of potassium hydroxide (KOH) to a specimen of vaginal
secretions produces a pronounced fishy odor

•      Treatment: oral Metronidazole or oral Clindamycin

v  VULVOVAGINAL CANDIDIASIS

•      Also called moniliasis or yeast infection

•      Causative organism: Candida albicans

•      Contributing factors: oral contraceptives, immunosuppressants, antibiotics, frequent douching, pregnancy, DM

•    Symptoms:

Ø     thick, curdy vaginal discharge, severe itching, dysuria, dyspareunia

•    On Physical Exam: labia may be swollen, speculum exam reveals thick, white tenacious cheeselike patches adhering
to the vaginal mucosa

•    Treatment (pregnant):

Ø     intravaginal insertion of Miconazole, Butoconazole or other topical azole preparations for 7days

Ø     Clotrimazole suppositories at bedtime for 1 week

Ø     Cream may be prescribed for topical application to the vulva if necessary

•     Fetal-Neonatal Risks: thrush if delivered vaginally

v  TRICHOMONIASIS

•      Causative organism:  Trichomonas vaginalis

•      Most infections are acquired through sexual intimacy

•    Symptoms:
Ø     yellow-green frothy, odorous discharge frequently accompanied by inflammation of the vagina and cervix, vulvar
itching, dysuria, dyspareunia

Ø     strawberry patches may be visible on vaginal walls or cervix

•    Treatment: single 2g dose of Metronidazole orally

•    Implications for Pregnancy:

Ø     Increased risk for PROM, preterm birth, and LBW

v  GONORRHEA

•      Causative organism:  Neisseria gonorrhoeae

•      Majority of women are asymptomatic

•      Symptoms:

Ø          purulent, greenish yellow vaginal discharge, dysuria, urinary frequency, inflammation and swelling of the vulva

•      Treatment :

1.    Nonpregnant women –Cefixime orally or Ceftriaxone IM plus Doxycycline

2.    Pregnant women -- Ceftriaxone IM or Cefixime orally combined w/ Erythromycin or Azithromycin to address risk of
co-infection w/ chlamydia

•      Fetal-Neonatal Risks: Infection at time of birth may cause ophthalmia neonatorum in the newborn

v  CHLAMYDIAL INFECTION

•      Causative organism: Chlamydia trachomatis

•      Symptoms: thin, purulent discharge, burning and frequency of urination, and lower abdominal pain

•      Laboratory detection: antigen detection, DNA probe assays, polymerase chain reaction (PCR) tests

•      TREATMENT: Erythromycin or Amoxicillin followed by repeat culture in 3 weeks

Implications for pregnancy: if untreated, infant may develop newborn conjunctivitis which is treated with Erythromycin
ointment, chlamydial pneumonia, fetal death

v  HUMAN PAPILLOMA VIRUS

•      Condylomata acuminata is a relatively common sexually trasmitted condition

•      Also called venereal warts

•      Signs and symptoms:

 

Ø       Soft, grayish pink lesions on the vulva, vagina, cervix, or anus

•      Treatment: based on client preference, available resources, and experience of healthcare provider

•      Client-applied therapies: Podofilox solution or gel or Imiquimod cream (not used during pregnancy)

•      Provider-administered therapies: Cryotherapy w/ liquid nitrogen or cryoprobe, topical podophyllin, trichloroacetic

acid (TCA), bichloroacetic acid (BCA), intralesional interferon, surgical removal by tangential scissor excision, shave
excision, curettage, electrosurgery, laser surgery

•      Implications for pregnancy: Large doses of Podophyllin have been associated with fetal death

v  HEPATITIS B

·         Causative organism: Hepa B virus

·         Predisposing factors: illegal IV drug users, homosexuals, prostitutes, multiple sex partners, occupational exposure
to blood

·         Treatment: Hepa B immune globulin soon after birth (newborn)

v  HERPES SIMPLEX VIRUS (HSV-1 or HSV-2)

·             Oral

·             Genital; Dangerous for baby

·             Painful vesicles in thevulva and perianal area; Transmistted intrapartum causing fatal congenital herpes (C/S
Delivery Indicated); Mother is treated with Acyclovir (ZiroVax: Given more for 3rd Trimester)

·             Fetal-Neonatal Risks:

Primary infection – spontaneous abortion, LBW, preterm birth

Ø  If antiviral therapy is not used, SEVERE infection – microcephaly, mental retardation, seizures, retinal dysplasia,
apnea, coma

Ø  Infected infant is often asymptomatic at birth but develops – fever (or hypothermia), jaundice, seizures, poor feeding
after an incubation period of 2-12 days

Ø  Treatment: Acyclovir, Valacyclovir, Famciclovir (Acyclovir has been shown to be effective and safe during pregnancy,
but NOT well absorbed as the other two drugs)

Ø  Mode of Delivery: NSD (if no evidence of genital infection), CS (active genital lesions or presence of prodromal
symptoms of infection)

Principles Underlying Puerperium

1. To return to normal and facilitate healing

A. Physiologic Changes

Ø  Uterus: return to normal after 6-8 weeks; fundus goes down 1cm/day until 10 th day

: Sub-involuted uterus: can cause puerperal sepsis; mngt is D&C

Ø  Lochia (RSA) : puerperal discharge; mixture of blood, deciduas

1. Rubra - red (1-3 days); musty, moderate amount

2. Serosa- pink to brown (4-9 dyas); limited amount

3. Alba - cream white (10-21 days); minimal amount

Ø  Perineal area: Painful d/t episiotomy

Mngt: Sim’s position, cold compress after 24 hrs, no sex until fully healed

2. Provide Emotional Support - Reva Rubin

Psychological Responses

A. Taking in phase

- dependent phase; cant make decisions, encourage verbalization of feelings

- encourage proper hygiene

B. Taking Hold phase

- independent phase; mother is active and can make decisions already

- task: care of the newborn

-postpartum blues occur: overwhelming feeling of depression characterized by crying, insomnia

C. Letting Go: interdependent phase; redefining new roles

Cardiac Diseases,IUGR,Preterm Labor

-       3rd trimester- risk of CHF

-       Decreased blood to the baby: premature by size and age

-       If employed, advise to be shifted at day shift: best time to sleep at night; during sleeping, increase growth hormones

 
-       Effects of Pregnancy on a Client with Cardiac Disease

-       Cardiac output increases by 30-50% CR increased by10bmp

-       Progesterone stimulates the respiratory center causing dyspnea

-       Increase blood volume may precipitate CHF

-       CLASSES

1.    CLASS 1

1.1  Asymptomatic

1.2  Rest between activities

2.    CLASS 2

2.1  Asymptomatic at rest

2.2  Exertion produces symptom

2.3  Rest between activities

2.4 1 day complete bed rest per week: Allows the heart on day to recover Last trimester- CBR

3.    CLASS 3

3.1  Less than ordinary activities produce symptom

3.2 Diet: minimal carb and protein intake, low fat, low sodium

4.    CLASS 4
4.1  Symptomatic even at rest

4.2  X for pregnancy

4.3 Candidates for ligation Managed like 3rd classification Delivery: forceps assisted

-       Decompensation: Tachycardia à cardiac arrest

-       Compensation: Bradycardia

-       Effects of cardiac disease on pregnancy

•      LBW baby due to decrease placental perfusion

•      If taking anticoagulant: could be teratogenic

•      May cause premature labor and delivery

-       MANAGEMENT

•      Digitalis

•      Propanolol

•      Spironolactone: need potassium for heart contractility

•      Penicillin: Prophylaxis for upper respiratory tract infection caused by GABHS à sequela is rheumatic heart disease

•      Delivery: CS or NSD(epidural anesthesia): Best: forceps!! Like PIH

•      Most critical time: 1st 24 hours: w/o for tachycardia

v  INTRA-UTERINE GROWTH RESTRICTION

❏ infants whose weight is < 10th percentile for a particular GA

❏ weight not associated with any constitutional or familial cause

❏ prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia, and mental retardation

❏ greater risk of perinatal morbidity and mortality

Risk Factors:

·         maternal causes

    poor nutrition, cigarette smoking, drug abuse, alcoholism, cyanotic heart disease, severe DM, SLE, pulmonary
insufficiency

·         maternal-fetal

    any disease which causes placental insufficiency (PIH, chronic HTN, chronic renal disease)

l  fetal causes

    TORCH infections, multiple gestation, congenital anomalies

Clinical Features

❏ symmetric/Type I (20%)
l  occurs early in pregnancy; inadequate growth of the head and body

❏asymmetric/Type II (80%)

l  occurs late in pregnancy

l  brain is spared therefore the head:abdomen ratio is increased

l  usually associated with placental insufficiency

l  more favorable prognosis than Type I

Management

❏ prevention via risk modification prior to pregnancy ideal

❏ most important consideration is accurate menstrual history and GA in which to assess the above data

❏ modify controllable factors: smoking, alcohol, nutrition ❏ bed rest (in LLD position)

v  PRETERM LABOUR

❏ labour occurring between 20 and 37 weeks gestation ❏ complicates about 10% of pregnancies

❏ prematurity is the leading cause of perinatal morbidity and mortality

   at 30 weeks or 1500 g = 90% survival

   at 33 weeks or 2000 g = 99% survival

❏ major causes of morbidity = asphyxia, sepsis, RDS

❏ intrapartum asphyxia may lead to cerebral hemorrhage

 

Causes

❏ idiopathic (most common)

❏ maternal

   prior history of premature delivery (recurrence risk of 17-40%)

   preeclampsia/hypertension

   placenta previa or abruption

   uncontrolled diabetes

   recurrent pyelonephritis and untreated bacteriuria

   maternal genital tract infection

   chorioamnionitis

    other medical illness (heart disease, renal disease, severe anemia, systemic infection, chronic vascular disease)

   maternal age < 18 years or > 40 years

   fibroids or other uterine anomalies

   incompetent cervix

   history of abortions or stillbirths

❏ maternal-fetal

    PPROM (a common cause)

    polyhydramnios
❏ fetal

    multiple gestation

    congenital abnormalities of fetus

Requirements for Consideration of Labour Suppression (Tocolysis)

❏ live fetus

❏ fetal immaturity ❏ intact membranes

❏ cervical dilatation of 4 cm or less

❏ absence of maternal or fetal contraindications (see below)

❏ availability of necessary personnel and equipment to assess mother and fetus during labour and care for baby of the
predicted GA if therapy fails

Maternal Contraindications to Tocolysis

❏ bleeding (placenta previa or abruption)

❏ maternal disease (hypertension, diabetes, heart disease) ❏ preeclampsia or eclampsia

❏ chorioamnionitis

Fetal Contraindications to Tocolysis

❏ erythroblastosis fetalis

❏ severe congenital anomalies ❏ fetal distress/demise

❏ IUGR, multiple gestation (relative)

Diagnosis

❏ regular contractions (2 in 10 minutes)

❏ cervix > 2 cm dilated or 80% effaced OR documented change in cervix

Prevention

❏ good prenatal care

❏ identify pregnancies at risk

❏ treat silent vaginal infection or UTI ❏ patient education

❏ the following may help but evidence for their effectiveness is lacking

     rest, time off work, stress reduction

     improved nutrition

     U/S measurement of cervical length or frequent vaginal exams to assess cervix; this would catch PTL earlier so
tocolysis would be more effective

Management
❏ initial

ütransfer to appropriate facility

ühydration (NS @ 150 mL/hour)

übed rest in left lateral decubitus position

üsedation (morphine)

üavoid repeated pelvic exams (increased infection risk)

üU/S examination of fetus (for GA, BPP, position)

ü  prophylactic antibiotics; controversial but may help delay delivery

❏ tocolytic agents -if no contraindications present

übeta-mimetics: ritodrine, terbutaline

ümagnesium sulphate (if diabetes or cardiovascular disease present)

ücalcium channel blockers: nifedipine

ü  PG synthesis inhibitors (2nd line agent): indomethacin

Rupture of Membranes Problems, Chorioamnionitis, Intrauterine Fetal Death

RUPTURE OF MEMBRANES

Premature ROM

❏ rupture of membranes prior to the onset of labour at any GA

 

Prolonged ROM

❏ if 24 hours elapse between rupture of membranes and onset of labour

Preterm ROM

❏ ROM occurring before 37 weeks gestation (associated with PTL)

PPROM

❏ preterm premature rupture of membranes (not in labour)

Associated Conditions

❏ congenital anomaly ❏ infection

Causes

❏ idiopathic (most common) ❏ frequently associated with

   multiparity

   cervical incompetence

   infection: cervicitis, vaginitis, STD, UTI

   multiple gestation
   family history of PROM

   low socioeconomic class/poor nutrition

   and other risk factors associated with PTL (see above)

Complications

❏ cord prolapse

❏ intrauterine infection (chorioamnionitis) ❏ premature delivery

Diagnosis

❏ history of fluid gush or continued leakage

❏ avoid introducing infection with examinations (do not do a digital pelvic exam)

❏ sterile speculum exam

   - pooling of fluid in the posterior fornix

   - may observe fluid leaking out of cervix on valsalva

❏ amniotic fluid turns nitrazine paper blue (low specificity as can be blood, urine or semen)

❏ ferning (high salt content of amniotic fluid evaporates and looks like ferns under microscope)

❏ U/S

Management
❏ cultures (cervix for GC, lower vagina for GBS)

❏ dependent upon gestational age; must weigh degree of prematurity vs risk of amnionitis and sepsis by remaining in
utero

❏ assess fetal lung maturity by L/S ratio of amniotic fluid

❏ consider administration of betamethasone valerate (Celestone) to accelerate maturity

❏ if not in labour or labour not indicated, consider antibiotics (controversial)

❏ admit and monitor vitals q4h, daily BPP and WBC count

ü  < 24 weeks consider termination (poor outlook due to pulmonary hypoplasia)

ü  26-34 weeks: expectant management as prematurity complications significant

ü  34-36 weeks: “grey zone" where risk of death from RDS and neonatal sepsis is the same

> 36 weeks

ü  CHORIOAMNIONITIS

❏  infection of the chorion, amnion and amniotic fluid

❏ risk factors: prolonged ROM, long labour, multiple vaginal exams during labour, internal monitoring, bacterial
vaginosis and other vaginal infections

❏ s/sx: maternal fever, maternal or fetal tachycardia, uterine tenderness, foul cervical discharge, leukocytosis, presence
of leukocytes or bacteria in amniotic fluid

❏ management: blood and amniotic fluid cultures, IV antibiotics (ampicillin and gentamycin)

❏ expedient delivery regardless of gestational age

 
v  INTRAUTERINE FETAL DEATH

❏ incidence = 1% of pregnancies

Causes

❏ unknown in 50%

❏ hypertension, DM

❏ erythroblastosis fetalis

❏ congenital anomalies

❏ umbilical cord or placental complications ❏ intrauterine infection

❏ antiphospholipid Ab’s

S/sx

❏ history

ü  decreased perception of fetal movement by mother

ü  FH and maternal weight not increasing

ü  absent fetal heart tones (not diagnostic)

ü  (-) cardiac activity and fetal movement on U/S required for diagnosis

ü  high maternal serum AFP

Management

❏ labour induction (see Abnormal Labour Section)

❏ must monitor for maternal coagulopathy (10% risk of DIC)

❏ psychologic aspects of fetal loss

❏ investigations to determine cause ❏ subsequent pregnancies high risk

: cal lasts for up to 5 years

Immediate Care of Newborn

 1st days of life:

1.    Initiation and maintenance of respiration

2.    Establishment of extra uterine circulation

3.    Control of  body temp

4.    Establishment of waste elimination

5.    Intake of adequate nourishment

6.    Prevention of infection

7.    Establishment of an infant-parent relationship

8.    Dev’t care that balances rest & stimulation or mental dev’t

1.) Initiation and Maintenance of Respiration

 
              2nd stage of labor- initial airway

              -initiation of a /w is a crucial adjustment

              -most neonatal deaths w/n 24 h caused by inability to initiate a/w

              -lung function begins after birth only

How to initiate a/w :

a. Remove secretions bulb syringe

       b. Catheter Suctioning

     1.) Place head to side to facilitate drainage of secretions

     2.) Suction mouth 1st before nose

                        -neonates are nasal breathers

     3.) Period of time

              5-10 sec suctioning, gentle and quick

Prolonged & deep suctioning can lead to :  Hypoxia

                                                Laryngospasm, Bradycardia

                                       d/t stimulation of vagal nerve--near esophagus & anus

 
          4.) Evaluate for patency

                   -cover nostril & baby struggles there’s a need for additional suctioning

c. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted
and oxygen can be administered by (+) pressure bag and mask with 100% oxygen at 40-60b/m.

       Nsg alert In O2 Administration:

          1. No smoking to prevent combustion

          2. Always humidify to prevent drying of mucosa

          3. Over dosage of oxygen can lead to scarring of retina leading to blindness

                   (Retro Lentalfibrolasia or Retinopathy of Prematurity) ROP  --- prone to: SGA, LBW, Preterm

          4. When meconium stained (greenish) never administer oxygen with pressure

                    (O2 pressure will push mecomium inside)------Atelectasis

2.) Establishing Extra-Uterine Circulation

          *Circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.

Feto Placental Circulation

* Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liver-ductus venousus- IVC- RT
atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricle- aorta-lower extremities.

-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition)--vasoconstriction of lungs pushes
blood to ductus arteriousus to aorta to supply upper extremities.

                             *3 SHUNTS*

       SHUNTS-shortcuts

1. Ductus Venosus- -shunts from liver to IVF   (umbilical vein to inferior vena cava)

2. Foramen Ovale- shunts bet 2 atrias

3. Ductus Arteriosus- from pulmonary artery to aorta

What will sustain 1st breath- decreased artery pressure

What will initiate lung circulation-lung expansion

What will complete circulation- cutting of cord

4.) 2 Ways to facilitate closure of Foramen Ovale

 
       a.) Tangential Footslap- slap foot of baby----slap---cry---lung expansion

                   -never stimulate baby to cry if secretions not fully drained to prevent aspiration

                   -check characteristic of cry

          *Normal cry- strong, vigorous and lusty cry                            *Normal cry of baby boy: lower

                   cri-du-chat syndrome-chromosomal obliteration cat like cry  (meow)

b.) Proper position : Right side lying pos.

                   -will increase pressure on left and foramen ovale will close

                   *Foramen Ovale and Ductus arteriosus will begin to close within 24h

                  

Obliteration-complete closure

Table 4.3. Fetal shunts

Structure Appropriate Time Structure Remaining Failure to Close

of Obliteration
Foramen Ovale Begins 24 hrs, 1yr Fossa Ovalis Atrial Septal Defect
Ductus Begins 24 hrs., 1 Ligamentum  Arteriosum Patent Ductus
Arteriosus month Arteriosus
Ductus Venosus 2 months Ligamentum venosum  
    1.) Lateral umbilical Ligament  

Umbilical artery 2-3 months 2.) Interior iliac artery

Umbilical vein 2-3 months Ligamentum Teres ( round  
ligament of liver)
*Position of infant immediately after birth:

                                      NSD-Trendelenberg/ T position for drainage

                                                contraindication of  Trendelenberg position -  increase ICP

                                      CS- Supine or crib level position

3. Control of Body Temperature  :    Temp Regulation

-          *Goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)

-          Maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to hypothermia or
cold stress

A.    Factors Leading to Dev’t of HYPOTHERMIA

1.    Preterms are born PoiKilothermic- cold blooded

·         Babies easily adapt to temp of environment d/t immaturity of thermo regulating system of body.  >Hypothalamus

2.    Inadequate SQ tissue fats

3.    Baby is not capable of shivering                              *Earliest sign of hypothermia- increase in RR

4.    Babies are born wet

PROCESS OF HEAT LOSS

                      1. Evaporation-------  body to air (TSB)

                      2. Conduction-------   body to cold solid object (cold compress)

                      3. Convection-------   body to cooler surrounding air (aircon)

                      4. Radiation-  --------  body to cold object not in contact with body

                              

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal   ( 40- borderline)    d/t utilization of glucose

2.) Metabolic acidosis- catabolism of brown fats (best insulator of newborns body)

                      will form ketones  ( found in chest/back)

3.) High risk for kernicterus- bilirubin in brain leading to cerebral palsy

4.) Additional fatigue to allergy stressful heart

To Prevent Hypothermia:

1.    Dry and wrap baby

2.    Mechanical pressure – radiant warmer   (incubator)    *Pre-heat first isolette (or square acrylic sided incubator)

3.    Prevent an necessary exposure – cover baby

4.    Cover baby with tin foil or plastic

5.    Embrace the baby- kangaroo care  (skin to skin contact)

4. Establish Adequate Nutritional Intake

*Advantages of Breastfeeding                                       *Store milk- plastic storage container

1. Economical                                           >good for 6 mon. from freezer/ at  rm. temp. don’t heat
2. Always available
3. Promotes Bonding
4. Breastfed babies have higher IQ than bottle fed babies.
 5. It facilitates rapid involution
6. Decrease incidence of breast cancer.
7. Contents of BREAST MILK:       

a. Antibodies- IgA

b. Lactobacillius bifidus- interferes w/ attack of pathogenic bacteria in GIT

c.Macrophages

d. Lactoferrin - iron bindig protein

e. Lyzozymes - breastmilk enzyme that destroys bacteria by lyzing or disolving cell membrane

f. Interferons - it inhibits viral growth

g. Immunoglobulins

STORED IN STERILE PLASTIC CONTAINER *

Disadvantages:

1. Possibility of transfer HEP B, HIV ( 30%-39%), cytomegalovirus virus.

2. No iron content -----prone to IDA
3. Father can’t feed & bond as well

5. Prevention of Infection:

Health Teachings:

1. Proper hygiene- proper hand washing

Care of breast - cotton balls with warmwarm water (inner to outer)

Caked colostrums- dry milk on breast

2. Best position in breastfeeding – upright sitting LEAST POSITION - SIDE LYING

-avoid tension!—if w/ tension breast will not properly empty

3.Evaluate and stimulae feeding reflexes

a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6
weeks baby can focus. Reflex will be gone

- Purpose rooting- to look for food.

b.) Sucking – when you touch middle of lips then baby will suck

- Disappears by 6 months

- When not stimulated sucking will stop.

c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed NEVER DISAPPEAR

d.) Extrusion/ Protrusion reflex

-when food touches anterior portion of tongue thenit will be automatically extruded or protruded.

                             Purpose: to prevent from poisoning

                             Disappear by 4 months & baby can already spit out by 4 months.

Criteria for Effective Sucking:

a.)  Baby’s mouth is hiked well up to areola

b.)  That the mother experiences after pain.

c.)  That the other nipple is also flowing with milk.

To prevent from crack nipples & initiate proper production of oxytocin.

- begin 2-3 mins per breast ( 5 – 7 min other authors)

to initiate production of oxytocin

- increase 1 min/ day – until reaching 10 mins per breast or 20 to 30 mins/ feeding.

For proper emptying & continuous milk production / feeding

-feed baby alternately on last breast that you feed him/her with. if not alternately - will cause mastitis

Involution of breast - 4 weeks

Problems Experienced in Breastfeeding :

1st day post-partum:  Breast soft and non tender

3RD day changes in breast post partum:

a.)Engorged- feeling of fullness & tension in the breast.

- sometimes accompanied by fever known  as MILK FEVER-continue BF

Mgt:            Warm compress- for breastfeeding mom

Cold compress – for bottle feeding & wear snug fitting, supportive brassiere.

b.) Sore nipple – cracked, wet and  painful nipple. not contraindication to breast feeding.

                             Mgt:    Exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb
                                      (12-18 inches away)

                      - avoid wearing plastic liner bra

c.) Mastitis- inflammation of breast : staphylococcus aureus (common)

Factors:

1. Improper breast emptying

2. Unhealthy sexual practices

-contraindicated for breast feeding

- manually express inflamed breast-----  feed on unaffected breast

- give antibiotics – can still feed on unaffected breast

Contraindications in Breast Feeding:

a. Maternal Conditions:                                    b. Newborn Condition:

>HIV                                                  Inborn errors of metabolism

>CMV                                                 Erythroblastosis Fetalis – Rh incompatibility

> Coumadin                                         Hydrops fetalis

> use of warfarin                         Phenylketonuria, Galactosemia

         

6. Establish Waste Elimination

A. Different  Stools

1. Meconium -  physiologic stool

- blackish green, sticky, tar like, odorless (Sterile intestine)(no bacteria) will pass w/in 24 – 48 hrs

*Failure to pass mecomium after 24h- GIT obstruction

ex.      Hirschsprungs disease

                                                                                                Imperforate anus

                                                                                                Mecomium ileus – due to Cystic Fibrosis

2. Transitional Stool -  (4-14 days)

- green loose & shiny, like diarrhea to the untrained eye (primipara mother)

3. Breastfed Stool -  golden yellow or orange-yellow , soft, mushy with sour milk smell odor, frequently passed occuring
almost nearly every after feeding

- recur every feeding  (orange-yellow)

4. Bottlefed Stool - pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day

5. Supplementary - with food added -brown & odorous

Indication of Stool Changes:       Jaundice baby –                   light stool

Under phototherapy –          bright green

Mucus mixed with stool -      milk allergy

Clay colored stool –             obstruction to bile duct

Chalk clay stool –                after barium enema                                 Black stool –                        GIT bleeding
(melena)                  Blood flecked stool -           anal fissure.                                             *Currant jelly stool –           
intussuseptio                             *Ribbon like stool –              hirschsprung disease

*Steatorrhea stool –              fatty, bulky foul smelling odor stool

Assessment for Well Being

A. APGAR SCORE – Dr. Virginia Apgar

Special Considerations:        1st 1 min        – determine general condition of baby

Next 5 min- determine baby’s capabilities to adjust extra uterinely                                            (most important)

                                                                            Next 15 min – (optional) dependent on the 5 min

A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.

P- pulse rate – apical pulse – left lower nipple

G- grimace – reflex irritability-  (1)  tangential foot slap, (2) catheter insertion

A – activity – degree of flexion or muscle tone

R – respiration

Baby cry – within 30 secs

Failure to cry after 30 secs – asphyxia neonatorum

                             Resp. depression – d/t mom given Demerol. Administer Naloxone

                                  

 Table 4.4. APGAR Scoring Chart

  0 1 2
HR  (most Absent <100 >100
important)
Respiratory Absent Slow, irregular, Good strong
Effort weak cry
Muscle Tone Flaccid Some flexion Well flexed
extremities
  No Response Grimace Cough, sneeze

Reflex Irritability
    Acrocyanosis Pinkish

Color Blue/pale (body- pink

extremities-blue)

APGAR Result:

0 – 3 = severely depressed, need CPR, admission NICU

4 – 6 = moderately depressed, needs add’l suctioning & O2 administration

7 - 10 =good/ healthy

CPR – cardio pulmonary resuscitation or CPR

          New: Cardio pulmonary cerebral resuscitation (CPCR)

 

l  5 min no O2 – irreversible brain damage

                   a/w     1. shake, no resp, call for help

                             2. flat on head, use cardiac board

                             3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway

shake, if no response, call for help

Do 1minite cpr before calling flat on bed , use cardiac board  head tilt chin lift maneuver

l  Breathing ( ventilating the lungs)

1. check for breathlessness

          if breathless, give 2 breaths- ambu bag

          > 1 yr old- mouth to mouth, pinch nose to create a seal

          < 1 yr – mouth to nose

Force – different between baby & child

          infant – puff

l  Circulation :        Check for pulselessness :     carotid- adult

Table 4.5. Respiratory Assessment

 Criteria 0 1 2
Chest movement synchronized Lag on See - saw
respiration
Intercostal No  Just visible Marked
retraction retraction
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet Heard on naked
only ear

Brachial – infants

l  CPR – breathless/pulseless

l  Compression –for infant:  1 finger breath below nipple line or 2 finger breaths or thumb

CPR : Infant  1:5

Adults    2:30

B. Respiration Evaluation

1. Assessment tool that determines respiration of baby :

Silvermann Anderson Scale

Lowest score – best

Interpretation result:

0 -3 – normal, no RDS

4 – 6 – moderate RDS

7 – 10 – severe RDS

C. Assessment of Gestational Age

           1. Clinical Criteria:        

Table 4.6 Ballards & Dobowitz

Findings Less 36 weeks (Preterm) 37 - 38 39 and up

Sole creases Anterior transverse crease Occasional creases 2/3 Covered with creases
only in
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and  testes in lower canal Some intermediate Testes pendulus
Scrotum
Scrotum – small few rugae Scrotum fully covered w/
rugae

*2. Signs of Preterm Babies

> Born after 20 weeks &  before 37 weeks

>Frog leg or lax position

>Hypotonic muscle tone- prone resp problem

>Scarf sign – elbow passes midline pos.

>Square window wrist – 90 degree angle of wrist

>Heel to ear sign                                            Complications:  RDS, Hypothermia, ROP

>Abundant lanugo

*Type of Feeding Pre-Term:  Gavage Feeding –to prevent aspiration –d/t absence of gag & swallowing reflex

*3. Signs of Post term babies:

> 42 weeks

>Classic sign – old man’s face

>Desquamation – peeling of skin

*Long brittle finger nails

>Wide & alert eyes

Neonates in Nursery

1. Special & Immediate Interventions:

a. Nsg responsibility upon receiving baby- proper identification

- Foot printing, affixing mother thumb print

b. Take anthropometric measurement

normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm

head circumference 33- 35 cm or 13 – 14 “

Hydrocephalus - >14”

Chest 31 – 33 cm or 12 – 13”  (Average 32 cm)

Abdomen   31 – 33 cm or 12 – 13”

c. Bathing

>Oil bath – initial : To cleanse baby & spread vernix caseosa

Fx of vernix caseosa :         1. Insulator

2. Bacterio- static

* Babies of HIV + mom – immediately give full bath to lessen transmission of HIV

 (13 – 39% possibly of  transmission of HIV

*Full bath – safely given when cord fall     *Dressing the Umbilical Cord: strict asepsis to prevent tetanus

d. Dressing the Umbilical Cord

1. * 3 Cleans in community

1. Clean hand

2. Clean cord

3. Clean surface

Betadine or Povidone Iodine – to clean cord

 

2. Check AVA, then draw 3 vessel cord--- if 2 vessel cord—suspect absence of kidneys

- leave about 1 inch”  of cord

- if BT or IV infusion – leave 8” of cord

*Best site of blood nerve access: umbilical cord

3. Check cord  every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood----hemorrhage

*Excessive  bleeding of cord – Omphalagia  – suspect hemophilia or blood dyscrasias

*Cord turns black on 3rd day & fall 7 – 10 days

*Failure to fall after 2 weeks- Umbilical granulation (w/o foul smelling odor, pinkish)

Mgt: silver nitrate or cautery

-          clean with normal saline solution not alcohol

-          don’t use bigkis – air

-          persistent moisture-urine, suspect patent uracus – fistula bet bladder & normal umbilicus

Dx:    Nitrazine paper test – if yellow – urine ---if blue – amniotic fluid
 - if reddish -- Omphalitis

Mgt: Surgery

e. Credes Prophylaxis – Dr. Crede

Purpose: prevent opthalmia neonatorum or gonorrheal conjunctivitis

* how transmitted – mom with gonorrhea or chlamydia

Drug: erythromycin ophthalmic ointment- inner to outer

Silver nitrate (used before) – 2 drops lower conjunctiva (not used now)

                                                -causes staining of skin, chemical conjunctivitis

                                                - does not give protection against STDs

f. Administer Vit-K

– to prevent hemorrhage R/T physiologic hypoprothrombinemia

- Aquamephyton, phytomenadione or konakion

- .5 – 1.5 mg IM, vastus lateral or lateral ant thigh

- 5 mg preterm baby

*Vit K – synthesized by normal flora of intestine

Vit K – meds is synthetic d/t  intestine is sterile

 
g. Weight-taking

> Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 -     7.5 lbs

> Arbitrary lower limit 2500 gm

> Low birth wt baby delivered < 2500g

> Small for gestational age (SGA) < 10th % rank or born small

> Large for gestational age > 90th % rank or macrosomia  >4000 g

> Appropriate for GA – within 2 standard deviation of mean (AGA)

> Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90

Principles of Growth and Development

I. Growth & Development

*Growth - Increase in physical size of a structure or whole.

  - Quantitative change.

Two parameters of Growth

1.    Weight- Most sensitive measure of growth, especially low birth rate.

                             6 months-----BW doubles

                   12 months----BW triples

                   2-2 ½ yrs-----BW quadrupled

       2. Height   - Increase by 1”/mo during 1st 6 months, 7-12 months by 1 ½ inch.

              - Average increase in height -  1st year = 50%

                    Stoppage of ht coincide with eruption of wisdom tooth.

*Development  - Increase skills or capability to function

-          Qualitative

How to measure development:

1.  Observe child doing specific task.

2.  Role description of child’s progress

3.  DDST- Denver development screening test except mental, its I.Q. Test

                         MMDST (Phil) Metro Manila Developmental Screening Test.

                                                4 Main Rated Categories of DDST

                             1. Language communication

                             2. Personal social-interaction

                             3. Fine motor adapting- prehensile ability to use hand movement

                             4. Gross motor skills- large body movement

*Maturation- same with development “readiness”

*Cognitive Development –ability to learn and understand from experience, to acquire and retain knowledge, to respond
to a new situation and to solve problems.                           *Learning---change of behavior

IQ Test- test to determine cognitive development                             * Average IQ – 90-100

       Formula:       Mental age      x 100 = IQ                         * Gifted child- > 130 IQ

                        Chronological age

II. Basic Divisions of Life

1.    Prenatal stage from conception- birth

2.    Period of Infancy

a.       Neonate- 1st 28 days or 1st 4 weeks of life

b.      Formal infancy- 29 day – 1 year

3.    Early Childhood

a.       Toddler – 1-3 yrs

b.      Pre school 4-6 years

4.    Middle Childhood

a.    School age- 7 – 12 yrs

5.    Late Childhood

a.        Pre adolescent 11 – 13 yrs

b.       Adolescent 12 - 18 – 21

III. Principles of G & D

1.     G&D is a continuous process that begins from conception- ends in death--“ Womb to Tomb principle”

2.     Not all parts of the body grow at the same time or at same rate.-------------“Asynchronous Growth principle”

         Patterns of G&D:

a.     Renal, GIT, musculoskeletal, circulatory----grows rapidly during childhood

b.     Neuromuscular tissue (CNS, brain, S. cord)---grow rapidly 1-2 years of life

o    Brain achieved its adult proportion by 5 years.

o    1-2 y/o- very important yrs---if with severe malnutrition--mild mental retardation

c. Lymphatic system- lymph nodes, spleen, tonsils---grows rapidly- infancy and childhood

     -protection against infection

·          tonsil adult proportion by 5 years

d. Reproductive system- grows rapidly at puberty

 
   Rates of G&D:

a.        Fetal and Infancy – period of most rapid G&D -----*prone to develop anemia

b.       Adolescent-  period of rapid G&D Toddler- slow growth period

c.        Toddler and preschool- alternating rapid and slow

d.       School age- slower growth

3.     Each child is unique

2 Primary Factors Affecting G&D :

                   A. Heredity:                   R – race                                    F- born less in length than M by 1 inch.

                                                         I – intelligence                   F- born less in wt. than M by 1 lb.

                                                         S – sex

                                                         N -  nationality

                   B. Environment:            Q – quality of nutrition

                                                         S – socio eco. status

                                                         H – health

                                                      O – ordinal position in family                   Eldest-  ability in comm. & social skills

                                                         P – parent child relationship                    youngest- more toilet trained

1.     G&D occurs in a regular direction reflecting a definitive & predictable patterns or trends.

A. Directional Trends- occur in a regular direction reflecting the development of neuromuscular function. These apply to
physical, mental, social and emotional development and includes.
                   1. Cephalo-caudal--- “head to toe”

·         Occurs along body’s long axis in w/c control over head, mouth & eye movements & precedes control over upper
body torso and legs.

              2. Proximo- distal---- “Centro distal”

·         From center of body to extremities.

              3. Symmetrical----side of body develop on same direction at same time at same rate.

                  4. Mass Specific “Differentiation” - Learns simple operations before complex function, from broad general
pattern of behavior to a refined pattern.

            B. Sequential-  involves a predictable sequence of G&D to w/c the child normally passes.

                             1. Locomotion- creep, crawls, sit then stand.

                             2. Socio & Language skills- solitary games, parallel games

                 C. Secular- worldwide trend of maturing earlier & growing larger as compared to succeeding generations.

2.     Behavior--most compressive indicator  of developmental status.             

3.     Universal language of child- play                                                                                       2nd sound-cooing

4.     Great deal of skill and behavior is learned by practice. Practice makes perfect.    

5.     Neonatal reflexes must be lost 1st  before dev’t  can proceed.                           *1st play-solitary

              -Plantar reflex shld. disappear before baby can walk

              -Moro reflex shld. disappear before baby can roll

              *Persistent primitive infantile reflexes- case of cerebral palsy

Theories of Growth and Development

Developmental Tasks- different from chronological age

Ø  skill or growth responsibility arising at a particular time in the individual’s life.

Ø  The successful achievement of w/c will provide a foundation for the accomplishments of future tasks.

         Theorists

1. SIGMUND FREUD: (1856-1939) Austrian neurologists----- Founder of Psychoanalysis

                             - offered personality development, Psychosexual theory

         *Phases of Psychosexual Theory*

       a.) Oral Phase------------- 0-18 months

                             - Mouth: site of gratification

                             -Activity of infant- biting, sucking crying.

                             -Why do babies suck?- enjoyment & release of tension.

                             -Provide oral stimulation even if baby on NPO.

                             -Pacifier.

                             -Never discourage thumb sucking.

 
       b.) Anal Phase------------- 18 months-3 years

                             -Anus: site of gratification

                             -Activity- elimination, retention or defecation of feces must take place

                             - Principle of holding on or letting go.

                             -Mother wins or child wins

                             -Child wins- stubborn, hardheaded anti social (anak pupu na, child holds pupu, child wins)

                             -Mother wins- obedient, kind, perfectionist, meticulous---------     OC-anal phase

                             -Help child achieve bowel & bladder control even if child is hospitalized.

       c.) Phallic Phase----------- 3-6 years

                             - Genitals: site of gratification      

                             - Activity- may show exhibitionism

                             - Increase knowledge of a sexes

                             - Accept child fondling his/her own genitalia as normal exploration

                             - Answer child’s question directly.

                             - Right age to introduce sexuality – preschool

       d.) Latent Phase---------- 7-12 years

                             -Period of suppression- no obvious development.

                             -Child’s libido or energy is diverted to more concrete type of thinking

                             -Help child achieve (+) experience, ready to face conflict of adolescence

       e.) Genital Phase--------- 12-18 years

                             -Genitals: site of gratification         

                             -Achieve sexual maturity

                             -Learns to establish relationships with opposite sex.

                             -Give an opportunity to relate to opposite sex.

2. ERIC ERICKSON-  Psychoanalysis theory

                      -stresses important of culture & society to the development of ones personality

                      -environment , culture

            *Stages of Psychosocial Theory of Development*

a.)  Trust vs. Mistrust – 0-18 months.

                        -foundations of all psychosocial task

                        -to give & receive is the psychosocial theme

                        -know to develop trust baby

              1. Satisfy needs on time

                        - breastfeed

              2. Care must be consistent & adequate

                        -both parents- 1st 1 year of life

              3. Give an experience that will add to security- touch, eye to eye contact, soft music.

b.)  Autonomy vs. Shame & Doubt---- 18-3 years

            - Independence /self gov’t

              - Develop autonomy on toddler  ---1. Give an opportunity of decision making, offer choices.

                                                              2. Encourage to make decision rather than judge.

                                                              3. Set limits

  c. Initiative vs. Guilt------------------------ 4-6 years

              -Learns how to do basic things

              -Let explore new places & events

            -activity recommended- modeling clay, finger painting--enhance imagination & creativity

                                                                                & facilitate fine motor dev’t

  d. Industry vs. Inferiority------------------- 7-12 yrs

              -Child learns how to do things well

              -Give short assignments & projects

 
  e. Identity vs. Role Confusion or Diffusion 12-18 yrs

              -Learns who he/she is, what kind of person he/ she will become by adjusting to new body image and seeking
emancipation from parents

              -Freedom from parents.

  f. Intimacy vs. Isolation-----------------------18-25 yrs. Up to 30 y/o

              -looking for a lifetime partner and career focus

  g. Generatively vs. Stagnation------------ 30-45 y/o

              - well-established career

   h. Ego Integrity vs. Despair---------------65 & above

3. JEAN PIAGET- Swiss psychologists , pioneer work on dev.t of intelligence in children

                                  -develop reasoning power

*Stages Of Cognitive Development*

A. Sensory Motor------ 0-2 y/o

-“Practical Intelligence”- words & symbols not yet available baby communicates thru senses & reflexes.

 
Table 5.1. Types of Reactions According to age Groups

Schema (Subdivision) Age Behavior

1. Neonate Reflex
2. Primary Circular Reaction
3. Secondary Circular Reaction
1 month All reflexes
1-4 -Activity related to body
months
-Repetition of behavior  (ex. thumb sucking)
4-8 -Activity not related to body
months
-Discover object & person’s permanence

-Memory traces present

-Anticipate familiar events.

4. Coordination of Secondary Reaction 8-12 -Exhibit goal directed behavior
months
-       of permanence & separateness (search of lost toy, knows mom,
throw & retrieve)
5. Tertiary Circular Reaction 12-18 -Use trial & error to discover places & events
months
-“ invention of new means”
(1-1
1/2yrs.) -capable of space & time perception

(hits fork, spoon on table or drops fork)

6. Invention of new means thu mental 18-24 -Transitional phase to the pre operational thought process.
combination---“Symbolic months
Representation”
B.       Preoperational Thought---- 2-7 y/o

Table 5.2.  Preoperational Stage Schema

Schema Age Behavior

1. Preconceptua 2-4 -Thinking basically complete literal & static
l yrs
-Egocentric- unable to view others viewpoint
 -Concept of dying is only now

-Concept of distance is only as far as they can see.

-Concept of Animism: inanimate object is alive

(-) reversibility concept- in every action there’s an opposite

reaction or cause & effect
2. Initiative 4-7 Beginning of Causation
yrs

C. Concrete Operational Thought------ 7-12 years

1.    Can find solution to everyday problems with systematic reasoning.

2.    *Aware concept of reversibility- cause & effect

3.    Concept of Conservation – constancy  despite of transformation.

4.    Activity recommended- collecting & classifying: stamps, stationeries, dolls, rubber band markers.

D. Formal Operational Thought--------- 12 and up.

1.    Cognition achieved its final form

2.    Can deal with past present & future

3.    Have abstract & mature thoughts & formal reasoning.

4.    Can find solutions to hypothetical problems with scientific reasoning.

5.    Activity: talk time:-- will sort out opinions  & current events.

 
4. KOHLBERG  (1984) 

- recognized the theory of moral dev’t as considered to closely approximate cognitive stages of dev’t

*Stages of Moral Development*

A. Infancy – “Amoral, Pre-religious or pre-moral stage

Table 5.3. Moral Development

Age Stage Description

1. Pre- Level 1  
conventional
       2-3 yrs 1 -*Punishment/ obedience
oriented (heteronymous morality) child does right
cause a parent tells him or her to & to avoid
punishment
       4-7 2 -Individualism. Instrumental purpose &
exchange. Carries out action to satisfy own needs
rather than society.

-Will do something for another if that person

does something for the child.
2. Conventional Level  
       7-10 3 -Orientation to interpersonal relations of
mutuality. Child follows rules cause of a need to
be a “good” person  in own eyes

& eyes of others.

      10-12 4 -Maintenance of social order fixed rules &
authority. Child finds ff. rules satisfying. Follows
rules of authority figures.
3. Post- Level III  
conventional
       Above 12 5 -Social contract, utilitarian level making
yrs perspectives. Follows standards of society fro the
good of the people.
  6 Universal ethical principle orientation. Follows
internalized standards of conduct.
Developmental Milestones

DEVELOPMENTAL MILESTONES

-Major markers of growth and dev’t

1. Period of Infancy:       

       *Universal  language of child----- Play

       a. Play- Solitary plays  (non-interactive)

                   Priority : Safety  (toys: age appropriate)

                   Main goal: Facilitate motor  & sensory dev’t

                   Ex.  mobile, teeter, music box, rattle

       b. Fear- Stranger anxiety begin 7-8 months: peak 8 months diminishes 9 months

         c. Milestones:   

Ø  Neonate:           >Complete head lag

             >Largely reflex visual fixation for human race

           > Hands fisted with thumbs in

             > Cries w/o tears d/t undeveloped lacrimal glands

 
Ø  1 month:     > Dance reflex disappears looks at mobile

                                                     > Alert to sound, regards face, may smile

                                                     >Looks at mobile, follows to midline

Ø  2 months:   >Holds head up when in prone

                                                     >Social smile, cries with tears, baby coos “doing sound”

                                                     >Closure of Frontal Fontanel ( 2-3 months)

                                          >Head lag when pulled to sitting position.

                                          >No longer clenches fist tightly

                                          > Follows object past midline

                                          > Recognizes

Ø  3 months:   >Holds head & chest up when prone

                                                     > Holds hand, open at rest

                                          >Hand regards, follows object past midline

                                          > Grasp & tonic-neck reflexes are fading

                                          > Reaches for familiar people & object

                                          > Anticipates feeding

 
Ø  4 months:   >Head control complete

                                                     >Turns front to back, needs space to turn

                                          > Laugh aloud, bubbling sounds

Ø  5 months:  > Turn both ways “roll over”

                                          >Teething rings, handles rattle well

                                          >Moro reflex disappears ( 4-5 months)

                                          > Enjoys looking around environment

Ø  6 months:   >Reaches out in anticipatory of being picked up

                                                     *>Sits with support

                                          >Uses palmar grasp, handles bottle well

                                          >Eruption of 1st temporary teeth:  6-8 months: 2 lower incisors

                                           >Say vowel sounds “ah”, “oh”

                                          > Sucking reflex disappears

                                          >Recognizes strangers (6-7 months) peak 8 months, diminishes 9 months

Ø  7 months:   >Transfer object  from hand to hand

                                          >Likes  object that are good size for transferring

                                         

Ø  8 months:   >Sits without support

                                                     >Peak of stranger anxiety   

                                          >Planters reflex disappears 8-9 months in prep. for walking

Ø  9 months:  > Creeps or crawls, needs space for creeping

                                          >Neat finger grasp reflex, probes with forefinger (finger feeds)

                                          >Combine 2 syllables “mama” & “dada”

Ø  10 months: >Pull self to stand

                                          >Understands “no”

                                          >Responds to own name

                                          >Activity: peak a boo, pat a cake, can clap

Ø  11 months: >Cruises

                                          >Stands with assistance

                                          >Walking while holding to crib’s handle

                                          > One word other than mama & dada

                                
Ø  12 months: >Stands alone, take 1st step

                                          >Walk with assistance

                                          >Drink from cup, cooperate in  dressing

                                          >Says 2 words mama & dada

                                          >Pots & pans, pull toys, nursery rhymes

                                          >Imitates action, comes when called

                                          >Uses mature pincer grasp, throws object

                                 > Follows one-step with gesture

         2. Toddler:

          a. Play: Parallel play- 2 toddlers playing separately

                   -Provide with similar toys

                   Ex. squeaky frog to squeeze, waddling duck to pull, trucks to push-push pull toy, building blocks, pounding
peg, toys to ride on

          b. Fear: Separation Anxiety:  begin 9 months,  peak 18 months

                             3 Phases Of Separation Anxiety (in order)

                                      P-   protect

                                      D-  despair

                                       D-  denial
                             -don’t prolong goodbye

                             -say goodbye firmly to develop trust- say when you will be back

                  

            c. Milestones

Ø  15 months: >Plateau stage

                                                >Walks alone        *Lateness in walking---mild mental retardation

                                                          >Puts small pellets into small bowl

                                                          >Holds spoon well

                                                          >Seats self on chair, creeps up stairs

                                                          >Scribbles voluntarily, say 4 - 6 words

Ø  18 months:  >Height of possessiveness

                                                     >Favorite word- “mine”

                                                     >Bowel control achieved (bowel 1st before bladder)

                                                     >No longer rotates spoon

                                                     >Can run & jump in place

                                                     >Walks up & down stairs holding railing or persons hand

                                                     >1-20 words

                                                     >Names 1 body part

                                                     >Puts both feet on 1 step before advancing.

Ø  24 months:               >Terrible two’s

                                                     >Can open doors by turning door knobs

                                                     > Turn pages one at a time, removes shoes & pants

                                                     >Unscrew lids

                                                     >Can walk upstairs alone –using both feet on same step at same time

                                                     >50-200 words  ( 2 words sentences), knows 5 body parts

                                                     >Daytime bladder control achieved (daytime 1st,then night time bladder)

                                                     > Bring to MD (2-3) or when temporary teeth complete

Ø  30 months or 2 ½ year:

                                                                   >Makes simple lines or stroke for crosses with a pencil

                                                     >Can jump down from chairs

                                                     >Knows full name

                                                     >Copy a circle

                                                      >Holds up finger to show age

                                                      >Temporary teeth complete (deciduous teeth -20)

                                                  *Posterior Molar- last temporary teeth to appear

                                                          >Beginning of toothbrush – 2-2 ½ yrs

                                                          >Tooth brushing with little assistance 3 yrs , brushing alone – 6 yrs

                                                          > The right time to bring to dentist- when temp teeth complete

Ø  36 months or 3 yrs:           >Trusting 3

                                                     >Unbutton buttons (unbutton before learn to button)

                                                     >Draw a +, learns how to share

                                                     >Knows full name & sex (gender identity)

                                                >Speaks fluently, 300-900 words

                                                >Nighttime bladder control achieved

                                                >Ride a tricycle

                        d. Characteristic Traits of Toddler

                      1. Negativistic- “NO!”  -way to search for independence

            >Limit questions

            >Modify questions to a statement

                                      2. Rigid, ritualistic & stereotype

                                                >Ritualism- to gain mastery

                                      3. Temper Tantrums  (most common)

                                                >Head banging, screaming, stamping feet, holds breath

            >Ignore behavior

*Protruding abdomen-d/t underdeveloped abdominal muscles

*Physiologic anorexia- d/t preoccupation with environment- food fads, short period of time

            >Loves rough & tumbling play

            >Loves toilet training

            >Failure of toilet training- unreadiness

*Clues For Toilet Readiness:

1.)         can stand, squat walk alone

2.)         can communicate toilet needs

3.)         can maintain dryness for 2 hours

        

3. Pre-Schoolers:

                   a. Play : Associative or Cooperative Play                                    

                        >bahay-bahayan – play house       >Role playing                             

              b. Fear : Body Mutilation or Castration                                                          

                        >Fear of dark places, witches                          

                        >Fear of thunder & lightning                                                          

                        >Fear of ghosts                                                                                        

              c. Milestones

Ø  *4 years old:> Furious 4 , noisy, aggressive, stormy

                                                  > Can button buttons

                                                  > Copy a square

                                                  > Jumps & skips                *Laces shoes

                                                  > Vocabulary 1,500

                                                  > Knows 4 basic colors

                                                  > Say songs or poem from memory

Ø  5 years old:         > Frustrating 5

                                                  > Copy a triangle

                                                  > Draw a 6 part man

                                                  > Imaginary playmates

                                                  > 2,100 words         > Jumps over low objects

                        d. Character Traits of Pre-Schooler:

          1. Curious, creative imaginative, imitative

          2. Favorite words- “why & how”

          3. Complexes- identification to parent of same sex & attachment to parent of

                             opposite sex

                        Ex. Oedipal complex- girl to dad/boy to mom

                          Electra complex- identification to mother (daughter-mother), attachment to father

                                           >Cause of incest marital discord

                     e. Behavior Problems

                        1. Telling tall tales d/t over imagination

                        2. Imaginary friend- to release tension & anxieties

                        3. Sibling rivalry- jealousy to newly delivered baby.

                        4. Regression- going back to early stage

                                  Sx: >thumb sucking (should be oral stage only)

                                        >baby talk, bed wetting, fetal position

                        5. Masturbation- sign of boredom

                                  -divert attention, offer a toy

            4. School Age:

                   a. Play:  Competitive play

                                      Ex. Tug of war, track and field, basket ball

                   b. Fear.  1. School Phobia

                                      -orient to new environment

                                        2. Displacement from school

                                      -teacher and peer of same sex

                                        3. Loss of Privacy

                                      -wants bra

                                       4. Fear of Death:  thinks death is reversible as sleep               

*7-9yrs death is personified, death as permanent loss of life

                   c. Significant Person:  Teacher, peer of same sex

                   d. Significant Development

          -boys prone to bone fracture

          - mature vision 20/20

                   e. Milestones

Ø  6 years old:        >Temporary  teeth begin to fall

                                                >Perm teeth appear- 1st molar

                                                          1st temp teeth- 5 months

                                                          1st perm teeth- 6 yrs

                                                >Year of constant motion

                                                > Common: green-stick fracture

                                                >Recognize all shapes

                                                >1st grade teacher becomes authority figure

                                                >Nail biting

                                                >Begin interest in God.

Ø  7 years old;  Age of Assimilation

                                                >Copy a diamond

                                                >Enjoys teasing and playing alone

                                                >Quieting down period

Ø  8 years old:        Expansive age

                                                >Smoother movement

                                                >Loves to collect objects

                                                >Count backwards

                                                > Normal homosexual

Ø  9 years old:        >Coordination improves

                                                >Tells time correctly

                                                >Hero worship

                                                >Stealing & lying are common

                                                >Takes care of body needs completely

                                                >Teacher finds this group difficult to handle

Ø  10 years old: >Age of Special Talent

                                                >Writes legibly

                                                >Ready for competitive games

                                                >More considerate & cooperative

                                                >Joins orgs.

                                                >Well mannered with adult

                                                >Critical of adults

Ø  11-12 y/o:         >Pre-adolescents

                                                >Full of energy & constantly active

                                                >Secret language are common

                                                >Share with friends secrets

                                                >Sense of humor present

                                                >Social & cooperative

                   f. Character Traits of School Age:

 

                                       1. Industrious

                                      2. Modest

                                      3. Can’t bear to lose- will cheat

                                      4. Love collections- stamps

*SIGNS OF SEXUAL MATURITY*

Table 5.4. Development of Secondary Sex Characteristics

   

Girls Boys

 
I-inc size breast & genitalia  (thelarche- A-appearance  axillary &  Pubic hair
1st sign sexual at.

 
W- widening of hips D-deepening  of voice

 
A- appearance axillary & pubic hair D- development of muscles
( adrenarche)
 
 
M- menarche- last sign sexual mat. Girls I—increase  in testes and penis size
( 1st sign sexual mat)

 
  P- production of viable sperm ( last sign
 sexual maturity)

 
5. Adolescent :

                   a. Fear :

                             1. Obesity

                             2. Acne

                             3. Homosexuality

                             4. Death

                             5. Replacement from friends

                   b. Significant Person: Peer of Opposite Sex

                   c. Significant Developmen

                             1. experiences conflict bet. his needs for sexual satisfaction & societies expectation

                             *Core Concern:  Change of body image & acceptance of opposite sex

                             * Hallmark of Adolescence: Nocturnal Emission  (wet dreams)

                             2. Distinctive odor  d/t stimulation  of apocrine glands

                             3. Sperm is viable by 17 y/o

                             4. Testes & scrotum increase until age 17

                             5. Breast & female genitalia increase until age 18

                   d. Personality Traits Adolescents:

                                     1. Idealistic 

                                     2. Very conscious with body image

                                     3. Rebellious

                                     4. Reformers, adventuresome

         

                   e. Problems:

1.    Vehicular accident

2.    Smoking

3.    Alcoholism

4.    Drug addiction

5.    Pre-marital sex

Large GA > (more) 90

Reflexes

A.             BLINK REFLEX

- Rapid eyelid closure when strong light is shown

B.             PALMAR GRASP REFLEX

- With solid object, baby will grasp object

- Cling to mother for safety

- 6 weeks to 3 months to disappear

C.             STEP IN/WALK-IN REFLEX

- Neonate placed on a vertical position with their feet touching a hard surface will take a few quick, alternating steps.

* PACING REFLEX

– Almost the same with step in place reflex only that you are touching the anterior surface of a newborn’s leg

D.             PLANTAR GRASP REFLEX

– When an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the
fingers do.

E.             TONIC-CLONIC REFLEX

– When newborns lie on their backs, their heads usually turn to one side or the other. The arm on the leg on the side to
which the head turns extend, and the opposite arm and leg contract.

F.             MORO REFLEX

– Letter “C” position

- Disappears 4-5 months

- Test for neuro integrity

 
G.             MAGNET REFLEX

– when there is pressure on the sole of the foot he pushes back against the pressure

H.            CROSSED EXTENSION REFLEX

– When the sole of the foot is stimulated by a sharp object, it causes the foot to rise and the other foot extend

I.              TRUNK INCURVATION REFLEX

– While in prone position & the paravertical area is stimulated, it causes flexion of the trunk and swing his pelvis towards
the touch

J.              LANDAU REFLEX

– While in prone position and the trunk is supported, the baby exhibit some muscle tone

K.             PARACHUTE REACTION

 – While on ventral suspension, with the sudden change of equilibrium, it causes extension of the hand and legs

L.             BABINSKI REFLEX

–When the sole of the foot is stimulated by an inverted “J”, it causes fanning of the toes

Cardiac Disorders

A. Important Considerations:
1.  if client is new born, cover areas not being examined to prevent hypothermia

2.  if client is infant – the 1st yr of life  - get VS – take RR 1st

              - begin from least intrusive to the most intrusive area

3. if client is a toddler and preschool, let them handle an instrument  like:

- play syringe or stet,  security blanket – favorite article.

Let baby hold it, allow bedtime rituals

4. Explain procedure & respect their modesty - school age & adolescent

              - by wearing your complete uniform

                   *Security Blanket--- a transitional object as representation of the parents

B. Components:

A. V/S: 

Temp: rectal- newborn – to rule out imperforate anus/assess patency of anus

take it once only, 1 inch insertion

*Imperforate anus

1.    Atretic – no anal opening               more dangerous

2.    Agenetic – no anal opening

3.     Stenos – has opening                       but narrow opening

4.    Membranous – has opening

Earliest sign:
1. No mecomium

                   2. Abdominal destention

                   3. Foul odor breath

                   4. Vomitous of fecal matter

                 5. Can aspirate – resp problem may arise d/t aspiration of intestinal    contents----atelectasis

Mngt:  Surgery with temporary colostomy

Cardiac rate: 120 – 160 bpm newborn

Apical pulse – left lower nipple

Radial pulse – normally absent. If present PDA   (+) radial pulse

Femoral pulse – normal present.  If absent- COA -  coartation of aorta

Congenital Heart Diseases:

*Common in girls – PDA, ASD , Atrial Septal  (Acyanotic HD)

*Common in boys –  TOGA ( Transposition of great arteries)

                                                                TA – Tronchus arteriosus                                            Cyanotic HD

                                                                TOF – Tetralogy of Fallot

*Causes:

1.    Familial
2.    Exposure to rubella – 1st month of pregnancy

3.    Failure of  heart structure to progress

2 Major Types:  “AL CR”

1. Acyanotic L to R : Left to Right shunting

2. Cyanotic R to  L  : Right to Left shunting

I. ACYANOTIC HEART DEFECTS L to R    --------         ( 8  Types)

*With increased pulmonary blood flow

1.    Ventricular Septal Defect (VSD) - opening between 2 ventricles

S&Sx:   

a. Systolic murmurs at lower border of sternum  and no other significant sign

b. Cardiac catheterization reveals increased o2 saturation @ R side of heart

c. ECG reveals hypertrophy of R side of heart

Nsg Care:

Cardiac catheterization: site – Right femoral vein

1.NPO 6 hrs before procedure

2.Protect site of catheterization. Avoid flexion of joints proximal to site.

3.Assess for complication – infection, thrombus formation – check pedal pulses

Mgt.
1.)         *Long term antibiotic – to prevent subacute bacterial endocarditis

2.)          Open heart surgery

2.) Atrial Septal Defect (ASD) – Failure of foramen ovale to close

S & Sx:

1.      Systolic murmur @ upper border of sternum

2. Result of cardiac catheterization & ECG same with VSD--  O2 sat & hypertrophy

Mgt: Open heart surgery

3.) Endocardial Cushion Defects (ECD) - atrium ventricular - affects both tricuspid & mitral valve

Dx      : Confirmed by cardiac catheterization

Mgt:    : Open heart surgery

Antibiotics to prevent subacute bacterial endocarditis

4.) Patent Ductus Arteriosus - Failure of ductus arteriosus to close

- should close within 24 h -complete close – 1 month

S & Sx :

1.    Continuous machinery like murmurs > outstanding sign of acyanotic HD

2.     Prominent radial pulse

3.     ECG- hypertrophy Left ventricle

Drug:
1.    Indomethacin – prostaglandin inhibitor - facilitate closing of PDA

2.    Ligation of PDA by 3-4 y/o  via thoracotomy procedure- prone position

*With decrease Pulmonary Blood Flow

5.) Pulmonary Stenosis- narrowing of  valve of pulmonary artery    

S &Sx:        

1. Typical systolic ejection murmur---d/t congestion at the right side of heart

2.  S2 sound widely split

3.  ECG- R. ventricular hypertrophy

*Normal: Pulmonary Artery  = size with aorta*

6.) Aortic Stenosis – narrowing of valve of aorta                           

S & Sx:

1. If inactive, sx same with angina-like symptoms

                             2. Typical murmur

                             3. Rough systolic sound and thrill

                             4. ECG- Left ventricular hypertrophy

Cardiac catheterization-

Mgt. For  Pulmonary Stenosis & Aortic Stenosis---ECMO>Extra Corporeal Membrane Oxygenation    

                                      -a lung & heart machine

                                      - return to activity: 3 wks.

1.)  Balloon Stenotomy

2.)  Surgery

7. Duplication of Aortic Arch- doubling of arch of aorta causing compression to

trachea & esophagus

S & Sx :

 1. Dysphagia

                                       2. Dyspnea

 3. left ventricular hypertrophy

Mgt:  Close heart surgery

8. Coarctation of Aorta – narrowing of arch of aorta

- *Outstanding Sx : Absent Femoral Pulse

                                                         - BP increased on upper extremities & decreased on lower extremities

ECG – hypertrophy Left ventricle    ------EPISTAXIS

Mgt: close heart surgery

                                                       Monitor BP on 4 extremities

II. CYANOTIC HEART DEFECTS R to L (6)

*With increase Pulmonary Blood Flow

1. Transportation of Great Arteries (TOGA)

- aorta arising from  Rt  ventricle, pulmo artery arising form Lt ventricle
- direct from RV to aorta w/o oxygenation

          Outstanding Sx:            1. Cyanosis after 1st cry (due no oxygenation)

2. *Polycythemia – increased RBC =compensatory d/t O2 supply=viscous blood

*Complications: Thrombus = Embolus = Stroke

3. ECG – cardiomegaly

4. Cardiac cath – decreased O2 saturation

5. Palliative repair – rash kind procedure

6. Complete repair – mustard repair

2.) Total Anomalous Pulmonary Venous Return

– pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC

- Increased pressure on Rt so blood goes to Left

Outstanding Sx: Open Foramen Ovale  -------so blood L to R

>Mild to moderate cyanosis

>Polycythemia = thrombus = embolus = stroke

 >Asplenia- absent spleen

Mgt: Restructuring of heart

3.) Truncus Arteriousus

- aorta & pulmo artery is arising from 1 single vessel or common trunk with VSD
S & Sx     1. Cyanosis

2. Polycythemia – thrombus = embolus = stroke

Mgt: Heart transplant

4.) Hypoplastic Left Heart Syndrome – a non- functioning Left ventricle

S & Sx:

1. Cyanosis

2. Polycythemia – thrombosis, embolus, stroke

Mgt: Heart Transplant

*With decrease Pulmonary Blood Flow

5.) Tricuspid Atresia – Failure of tricuspid valve to open

S&SX:

1. Open Foramen Ovale-----pressure increase in right so open FO

(R to L shunting – goes to Lt atrium)

2. Cyanosis, Polycythemia

Mgt: Fontan procedure – to open tricuspid valve

6.) Tetralogy Of Fallot  (TOF)

P – pulmonary stenosis

V – ventricular SD

O – overriding or dextroposition of aorta

R – Rt ventricular hypertrophy

S &Sx:

1.     Rt ventricular hypertrophy

2.     High degree of cyanosis

3.     Polycythemia

4.     Severe dyspnea – squatting position – relief , inhibit venous return, facilitate lung expansion.

5.      Growth retardation – due no O2------ Mental retardation –d/t       O2 in brain

6.     Tet spell or blue spells  - short episodes of hypoxia—blue baby esp. when crying

7.     Syncope

8.     Clubbing of fingernails – due to chronic tissue hypoxia

9.     Boot shaped heart – revealed by x-ray

Mgt:

1.    O2 administration after 1 month old—to wait for the complete closure of the ductus arteriosus

2.    No valsalva maneuver , fiber diet laxative

3.    Morphine – hypoxia  ,  Propanolol – decrease heart spasms

4.    Palliative repair – BLT  >Blalock taussig procedure

ACQUIRED HEART DISEASES

1.  Rheumatic Heart Disease  (RHD)

- inflammation disease ff an infection acquired by group A Beta hemolytic streptococcus

                                                                   (GABHS)

a. Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary

b. Suspect : Sorethroat before RHD -----candidate babies---eating lots of sweets

c. Aschoff – rounded nodules with nucleated cells & fibroblasts – stays that occludes mitral valve.

d. To Diagnose RHD uses the Jones Criteria

Table 5.5 *Jones Criteria*

Major Minor
1. Polyarthritis – multi joint pain 1. Arthralgia – joint pain
2. Chorea – Sydenhamms Chores or  St. Vitous 2. Low grade fever
Dance

                       -purposeless involuntary hand and

shoulder with grimace
3. Carditis – characterized by tachycardia 3. All Dx Test & Lab
results
 

4. Erythema marginatum - macular rashes

         antibody

5. SQ nodules        C reactive protein

       ESR

       Anti streptolysin O

 titer (ASO)
*Criteria: Presence of 2 major, or 1 major & 2 minor + history of sore throat will confirm the dx.

Mngt: Supportive only

Nsg Care:

1. CBR , avoid contact sports

2. Throat swab – culture & sensitivity for antibiotic therapy
3. *Antibiotic mgt – to prevent recurrence
4. Aspirin ( ASA therapy)– anti-inflammatory. Low grade fever – don’t give aspirin.

S/E of aspirin: if given to children continuously w/ bacterial infection:

*Reye’s syndrome – encephalopathy- fatty infiltration of organs such as liver & brain

Respiratory Disorders

Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea  w/o cyanosis.

If < 15 secs – normal apnea –newborn

Resp Check:       Newborn – 40 – 90 bpm

1 yr  - 20 – 40

2-3yr 20 – 30

5 yrs 20 – 25

10 yrs 17 – 22

15 & above 12- 20

1. Asthma
Pathognomonic Sign: Expiratory wheezing

Pet – fish.  Sport – swimming

Drugs – Aminophylline – monitor BP, may lead to hypotension

                             Allergens: dust

                             Food allergens:        seafood, chocolate,

                             Climate Changes

2. Respiratory Distress Syndrome (RDS) or Hyaline Membrane

Cause- lack of surfactant – for lung expansion ----------------end stage: Atelectasis

Hypotonia, Post surgery, Common to preterm

Fibrine Hyaline : Sx----definite with in  1st  4  hrs. of life ---d/t lack of surfactant

Tachypnea with  retraction -------earliest sign

*Inspiratory Grunting – Pathognomonic Sx

> 7 – 10 severe RDS (Silverman Anderson Index), respiratory acidosis

end stage: Cyanosis d/t atelectasis        *Chromolin Sodium---prevents asthmatic attack

                                                        

                        > if with asthma attack ----bronchodilator---Aminophylline—monitor BP

Mgt:
1.    Surfactant replacement and rescue

2.    Pos- head elevated

3.    Proper suctioning

4.    O2 with increase humidity- to prevent drying  of mucosa

5.    Monitor V/S skin color , ABG------Radial artery

6.    *CPAP- continuous (+) a/w pressure

7.    PEEP - + end expiratory pressure

Purpose of #6-7- to maintain alveoli partially open & alveoli collapse

3. LaryngoTracheo Bronchitis (LTB)

Pathognomonic Sign: Inspiratory Stridor 

LTB – most common Croup -viral infection of larynx, trachea & bronchi

Outstanding  Sx : Croupy cough or barking

-          Labored respiration

-          Respiratory acidosis

-          End stage – death

Lab:

1.    ABG
2.    Neck and throat culture

3.    Dx- neck x-ray to rule out epiglotitis

4.    CBC- to determine leukocytosis

Nsg Mgt:

1. Bronchodilators

2. Humidified oxygen

3. Prepare tracheostomy set

4. Corticosteroids

4. Broncholitis

Inflammation of bronchioles  characterized by production of thick, tenacious mucus

*Causative agent – RSV - Resp sincytial virus

Sx:      Flu-like sx

                                       Increased RR---Monitor: Tachypnea of >90 bpm =RDS

Drug:  Antiviral – Ribavirin

End stage – epiglotitis

5. Epiglotittis

Inflammation of epiglottis

*Emergency: Condition of URTI

Sx:    *Sudden onset

*Tripod Position – leaning forward with tongue protrusion

*Never use tongue depressor

>Prepare tracheostomy set

*< 5 y/o – unable to cough out, put on mist tent (humidifier o2) or croupe tie

Nsg Care:      Check edges tucked on mist tent

Provide washable plastic material

No toys with friction due O2 on

No hairy toys – due moist environment medium for bacterial growth

No smoking

Integumentary Disorders

1. BIRTHMARKS:

1.    Mongolian Spots:  stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks d/t
accumulation of melanocytes.

Disappear by 1 yr old  or 5 y/o pre-schooler

2.    Milia – plugged or unopened sebaceous gland, white pin point patches on nose, chin or cheek.

3.    Lanugo – fine, downy hair – common preterm

4.    Desquamation – peeling of newborn, extreme dryness that begin sole and palm.

5.    Stork bites (Telangiectasis nevi) – pink patches nape of neck

- hair will grow as child grows old

6.    Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically &  unpredictably as to time & place.

7.    Harlequin Sign – dependent part is pink, independent part is blue

                     (side lying – bottom part is dependent pink)

8.    Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.

9.    Hemangiomas  – vascular tumors of the skin

3 Types of  Hemangiomas

a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh.

NEVER disappear. Can be removed surgically

b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges,
disappears at 10 y/o.

c.) Cavernous hemangiomas – comm. network of venules in SQ tissue that never disappear with age.

MOST DANGERIOUS – intestinal hemorrhage

10. Vernix Caseosa – white cheese like for lubrication, insulator

Skin Color & its significance: Blue – cyanosis or hypoxia   Ringworm Infestation:

                                   White – edema                                                  Tinea Pedia : foot  (athelte’s foot)

                                   Grey – infection                                                  Tinea Capites:  head

                                   Yellow – jaundice , carotinemia                    Tinea Cruris: singit

                                   Pale – anemia                                                              Tinea Corporalis – body

                  

2. ATOPIC DERMATITIS - Infantile eczema (hika ng balat) (asthma of the skin)

Papillovesicular erythematus lesions with weeping & crusting

Usual Cause : Food allergies: milk, citrus juice, eggs, tomatoes, wheat

Sx:

> Extreme pruritus---linear excoriation----weeping crusting----- scaly shiny & white  to -----Lichenification

Goal of Care:         1. Decrease pruritus – avoid food allergen  

        2. Diet: Prosobi or Isomil

                                                     3. Hydrate skin w/ burrow solution

           4. Topical Steroids ---1% hydrocortisone cream

5. Prevent infection – proper hand washing, trim nails/cut short

3. IMPETIGO- skin disease.

Causative agent – Grp. A beta Hemolytic streptococcus (GABHS), possibly staphylococcus

> Papulovesicular surrounded by localized erythema

becomes purulent & oozes a honey       colored crust

 
4. PEDICULOSIS CAPITIS –“KUTO”  

Mgt:    proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment

*Can lead to acute glomerulonephritis AGN ---common to children with this type

5. ACNE- adolescent problem

>Self limiting inflammatory disease – sebaceous gland

*Comedones – sebum causing white heads

*Sebum- lipids of cholesterol causing acne bulgaris

Mgt: Proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

                                              Liver clearance before using Retin a: C/I to pregnant women

Blood/ Hemolytic Disorders

Anemia   -pallor

Causes:

1.) Early cutting of cord – preterm – cut umbilical cord ASAP

Full term – cut umbilical cord when pulsation stops

2.) Bleeding disorders – blood dyscrasias

                   Ex.

a. Hemophilia – deficiency of clotting factor.

Pattern of Inheritance : X linked recessive

Usual carrier : mother   (with X chromosome carrying the disease)

Usually affected children:  Son

If mom – carrier, son – affected                                   

If father carrier- transmitted to daughter

          3 Types:      

Hemophilia A – Deficiency of coagulation component factor 8 (classic/most common)                                     

Hemophilia B –or Christmas disease, deficiency of clotting factor 9 

Hemophilia C – deficiency of clotting factor 11

Assessment:

>Omphalagia – earliest sign  >30cc in newborn

>Newborn receive maternal clotting factor –reason why late Dx of hemophilia

>Newborn growing – sudden bruising on bump area- marks earliest sign

>Continuous bleeding – Hemarthrosis

>damage or repeated bleeding of synovial membrane

Dx test :

PTT = Partial thromboplastin time – reveals deficiency in clotting factor

*Long Term Goal- prevention of injury

Nsg Dx:  Increase risk of injury

HT:   avoid contact sport, swimming only, don’t stop immunization – change gauge of needle

Falls –1st  splint then immobilized , elevate affected part, apply pressure-not more then 10 min

Of cold compress  to prevent necrosis

> Determine case before doing invasive procedure

> No Aspirin

> BT : Fresh  frozen plasma or cryoprecipitate

> Long-Term Goal: Prevention of Injury

Hemolytic Disorders:                                          Hemolysis = destruction of RBC

a.    Rh Incompatibility

> “Rhesus” means foreign body

> mother (-), fetus & father (+)

> 4th baby severely affected

> if (-) or no antigen : CHON factor

>    (+) has antigen    : CHON factor

            *Erythroblastosis Fetalis = hemolysis or destruction of RBC d/t         O2 carrying capacity

                   S & Sx:          Intrauterine growth retardation w/ pathologic jaundice w/in 24 hrs.

 
                 b. ABO Incompatibility

Most common incompatibility – ( mom) O – ( fetus) A

Most severe incompatibility         (Mom) O– (Fetus) B

                                      Assessment:  Can affect 1st pregnancy

                                                RBC  - 120 days lifespan

                                                O = universal donor

                                                AB = universal recipient

            Dx: Coomb’s Test

                             Indirect: mother ----- normal result is (-)

                             Direct : from baby---normal result is initially (-)

Drug Of Choice: Rhogam Vaccine given to mothers (-) w/in 72 hrs. post-exposure to fetal RBCs to destroy fetal RBC’s,
then preventing Rh sensitization or antibody formation

                                                > given only w/in 72 hrs. once only 1st pregnancy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term                  

*Normal Value:  0-3 mg/dL

-  bilirubin  encephalopathy

Kernicterus - > 20 mg/dL among full term & >12 mg /dl of indirect  for pre-term----lead to cerebral palsy

 
*Physiologic Jaundice –(Icterus Neonatorum) jaundice within 48 -72 h (2-3 days)------     
NORMAL 

-- just expose to morning sunlight

*Pathologic Jaundice – (Icterus Gravis) jaundice w/n 24h or Jaundice during delivery

d/t  small Rh/edematous ABO

                    *Breastfeeding Jaundice—caused by pregnanediole (6-7th day)

Assessment of Jaundice :

*1. Blanching neonates forehead, nose or sternum  (use 2 thumbs to separate skin folds)

- yellow skin & sclerae

- color of stool – light stool

- color of urine – dark urine

Mgt: Phototherapy or photo oxygenation  (Normal HT: 18-20 inch.)

Nsg Resp:

1. Cover eyes – prevent retinal damage

2. Cover genitals – prevent Priapism –  a painful continuous erection
3. Change position regularly – even exposure to light
4. Increase fluid intake – prone to dehydration
5. Monitor I&O – weigh baby            diaper – 1 g= 1cc
 6. Monitor V/S – avoid use of oil or lotion due- heat at phototherapy

>  Bronze baby syndrome------transient S/E of phototherapy

Chromosal Aberrations/ Congenital Problems

Cause: Advance maternal age  >35 y/o

1.NONDISJUNCTION = Uneven division of chromosome

a. TRISOMY 21 or “DOWN SYNDROME”

= Extra #21 chromosome

= Related to advance paternal age:  47xx + 21 

Sx:

Low set ears

Mongolian slant

Broad, flat nose

Epicanthal Fold      = extra fold of eyelids

Brushfield’s Spot    = black & white specks in the iris

Pectum Excavatum = sunken sternum

Puppy’s neck

Hypotonic  =       muscle tone prone to URTI

Simian crease  = a single transverse line on palm.

                                      Alert:
                                                          Always check PR for tachycardia d/t hypotonia

                                                          Check for respiration

                                                          Check for mental retardation----educable

a.    TRISOMY 18  or  “ENDVARD SYNDROME”

- Affecting more girls than three times as boys.

- Caused by the presence of an extra number 18 chromosome

                                                Sx:

                                                          Pecan Carinatum (protruding sternum)

                                                         Small Jaw (micrognathia)

                                                          Hypoplastic (underdeveloped) fingernails

*OTITIS MEDIA = Inflammation of middle ear

Common to children d/t wider & shorter Eustachian tube

Causes :

1. Bottle propping w/c may also lead to dental carries

2. Cleft lip/ cleft palate

Sx:    During Otoscopic Exam:

Bulging tympanic membrane

Absence of light reflex

Observe for passage of milky, purulent foul smelling odor discharge

Observe for URTI

Nsg Care:

1.    Position: Side-lying on affected aside – to facilitate drainage

2.    Supportive Care- Bed rest, increase fluid intake

3.    Massive dosage antibiotic to prevent complication  of Bacterial Meningitis

4.    Apply ear ointment

5.    Mucolytics

How?   School age : Pull pinna  up & down

< 3 y/o = down & back

> 3 y/o = up & back

Small child = down & back ( no age)

6.    Surgery :

Myringotomy w/ Tympanostomy Tube Insertion:

       Prevents permanent hearing loss

Nsg. Care:

Post surgery: Position on affected  side for drainage

             When taking a bath put ear plugs on both ears

                    If tympanous tube falls – healed already- usually 6 months

ü  TRACHEOESOPHAGEAL FISTULA/ATRESIA  ( TEF /TEA)

                        - TEF – there is a thin connection bet. the esophagus & stomach

                   - TEA – there is no connection bet. the esophagus & stomach

Outstanding Sx:    4 C’s

        Coughing

        Choking

        Continuous drooling

        Cyanosis

Mgt:    Emergency surgery

ü  ORAL MONILIASIS or ORAL THRUSH “Oral Candidiasis”

- White cheese-like substances & curd like patches that coats tongue

CA: Candida Albicans

Nsg Care:
 Do not remove, wash mouth with cold boiled water

 Administer meds:  Nystatin / Mycostatin: Antifungal

ü  *KAWASAKI DISEASE or “Mucocutaneous Lymphnode Syndrome”

- A Strawberry tongue, originated in Korea

- Dr. Kawasaki discovered it

- Common in Japan

                   Criteria For Diagnosis Of Kawasaki Disease

1. Fever lasting more than 5 days

2. Bilateral Conjunctivitis

3. Changes of lips & oral cavity

- Dry, red fissure of lips

- Strawberry tongue

- Diffuse erythema of hands & feet

                                                4. Changes of Peripheral Extremities

- Erythema of the hands & soles

- Indurative edema of the hands & feet

- Membranous desquamation from fingertips

                                                5. Polymorphous rash

6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter

                             Complication:  Myocardial Infarction in Children ( only MI in children)

Mgt:    Administer Drug: Aspirin

                                                                        Gamma Globulin

ü  LIPS

a. *CLEFT LIP

- Failure of median maxillary nasal processes  to fuse by 5-8 wks of pregnancy

- Common to boys

- Unilateral

b. *CLEFT PALATE

- Failed palate to fuse by 9 – 12 wks of pregnancy

- Common to girls

- Unilateral or bilateral
Sx:

1.    Evident at birth

2.    Milk escapes to nostril during feeding

3.    Frequent colic & otitis media or URTI

Nsg Care:

                 1. Provide soft & large nipples---cross cut    

                  2. Burp baby often

Mgt:

1. Surgery : Depends on the Rule of 10

                   10 wks. Old

                   10 grams HgB

                   10 lbs. weight

a. Cleft Lip Repair  = Cheiloplasty

- Done 1-3 months to save sucking reflex (lost in 6 months )

b. Cleft Palate Repair = Uranoplasty

- Done 4-6 months to save speech

Pre- Operative Care:

 
1. Provide emotional support especially to mom

2.  Provide Proper nutrition to prevent colic

Feeding : Upright seating position

Burp frequently :

2x at middle & after feeding in a prone position& in a lower to upper tap

3. Orient parents to type of feeding

Rubber tipped syringe = Post-cheiloplasty

Paper cup/ soup spoon/ plastic cup  = Post-uranoplasty

4. Apply restraints; Elbow restraints pre-opt so baby can adjust post op & decrease movement

5. 7-8 years after: Velopharyngeal Flap Operation: To fix nostril & pharynx

·         ALL Operation for mouth (adenoidectomy, tonsillectomy):

MOST IMPORTANT DIAGNOSTIC TEST TO CHECK: CLOTTING TIME

·         Condition that warrants suspension of operation:

COLDS & PHARYNGITIS = can lead to generalized infection TO SEPTICEMIA

Post Operative Nsg Care:

 
1. Airway:

Position post-cheilopasty : Side lying to facilitate drainage

Post-uranoplasty (tonsillectomy): Prone position to increase mucus secretion

Avoid using straw,spoon,fork

2. Assess for RDS & signs of bleeding

3. Assess for bleeding: Frequent swallowing 6-7 days after surgery  indicates bleeding

4. Proper nutrition

          Post-NPO: Children- offer first sterile water before clear liquid

Clear liquids:  Gelatin except red or brown color it may mask bleeding

(Popsicle- not ice cream)

Full liquid

Soft diet

Regular diet

5. Maintain integrity of suture line such as:

Logan bar – wash ½ strength Hydrogen Peroxide & saline solution:

Bubbling effect traps microorganism

                                      Prevent crusting & scarring by putting sterile gauze + NSS

- Prevent baby form crying give analgesic for pain

 

ü  CONGENITAL CRETINISM

- Absence or non functioning thyroid glands or Hypothyroidism

Reasons for Delayed Dx:

1.    Thyroid glands covered by sternocleidomastoid muscles in newborn

2.    Baby received maternal thyroxin

3.    Baby sleeps 16 – 20 hrs a day

Earliest Sign:

1.   Change in Sucking -1st

2.    Change in Crying – 2nd –decrease sound

3.    Sleep excessively

4.    Constipation d/t decrease peristalsis

5.    Edema – moon face

       Late Sign:

1.    Mental Retardation

Prognosis: Mental retardation preventable when Dx is early

New Born Screening: it is included in the 6 diseases to be tested

Dx:
1.    PBI- Protein Bound Iodine

2.    RIA - Radioimmunoassay Test

3.    Radioactive Iodine Uptake

Mgt:

Synthroid  (Sodium Levothyrosin) = Synthetic thyroid given lifetime

Check PR before giving synthroid

Tachycardia = Sx of Hyperthyroidism

GI Disorders

ü  GASTRIC MOTILITY DISORDER:  (Lower GIT Obstruction)

a. HIRSCHPRUNGS DISEASE

- Congenital aganglionic megacolon

- Aganglionic: Absence of ganglion cells needed for peristalsis

Earliest Sign in Neonate:

1.         Failure/Delayed passage of  mecomium after 24h

2.         Abdominal distension

3.         Vomitus of fecal material ---lead to aspiration----Atelectasis

4.         Foul-smelling breath

Signs in Early Childhood:

1. Ribbon like stool

                        2. Foul smelling stool

                        3. Constipations

4. Diarrhea

Dx:

1. Barium Enema – Reveals narrowed portion of bowel 

2. Rectal Biopsy – Reveals absence of ganglionic cells

3. Abdominal X-ray – Reveals dilated loops on intestine

4. Rectal manometry – Reveals failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1.               NGT feeding:

 Measure tube from nose to ear to midline of xyphoid  & umbilicus

2.               Surgery

a.)             Temporary colostomy

b. Anastomosis &  pull through procedure

Pre-opt:           Provide Enema everyday

           Use NSS: Isotonic   ( 1 tsp. sugar + 500 cc of H20)

           Not tap water: Hypotonic

          Can be absorbed by the cells----Circulatory Overload

3. Diet:

Increase CHON

Increase calories

Decrease residue  Ex. Offer pasta, spaghetti, chicken

                   No corn, raisins ---may lead to aspiration

ü  OBSTRUCTIVE DISORDERS

a. PYLORIC STENOSIS

– Hypertrophy of the muscles of pylorus causing narrowing  & obstruction

- Progressive thickening of the muscular layer of the pylorus

                   Assessment:

1.) Outstanding Sx: Projectile vomiting  d/t  pressure from narrowed pylorus

                   Nursing Alerts:

                   a. Vomiting is an Initial Sign of Upper GI obstruction

b. Vomitus of upper GI can be blood tinged not bile streaked. (with blood)

c. Vomitus of lower GI is bilous ( with pupu)

d. Projectile vomiting – increase ICP or GI obstruction

e. Abdominal distension – Major Sign of Lower GIT Obstruction

2.) Metabolic Alkalosis

3.) Failure to gain weight

4.) Olive shaped mass – On palpation  (almond-shaped mass)

5.) Peristaltic wave visible from L to R across epigastrum

6.) Always hungry, irritable

Dx:

 1. Ultrasound

2.  X-ray of upper abdomen with barium swallow reveals a “STRING SIGN”

Mgt:

1.Pyloromyotomy  - incision of the pyloric muscle

2.Fredret-Ramstedt Procedure – separation of hypertrophied muscle w/o incision

Nsg Care:

1.  Serum electrolyte: Increase Na & K, Decrease chloride

                                      2. If on enteral feeding, provide pacifier

                                      Pre-Opt:                  Thickened feedings   (regular formula + Cereal)

                                      Post-Opt:      Monitor feedings      (Clear liquid 24 hrs.)

                                                                                   (Diluted Formula)

A.   INSTUSSUSCEPTION

- Invagination or telescoping of position of bowel to another

- Common Site: Ilio-Cecal junction (Junction bet. the small intestine)

                                                         Cecum is bigger than the ileum

- Not congenital

Prone People:         Person who eats too fast

Too much activities involving the movement of the stomach

Complication:         Invagination  

Sx:

1.)  Persistent paroxysmal abdominal pain

2.)  Vomiting

3.)  Currant Jelly Stool: d/t bleeding & inflammation

4.)  Palpable sausage shaped mass

Dx:

          1.) X-ray with Barium Enema – reveals “Staircase Sign” (coiled spring)

Mgt:

1.)  Hydrostatic Reduction with barium enema

2.)  Anastomosis & pull thru procedure

Inborn Errors of Metabolism

- Due to deficient liver enzymes

a. PHENYLKETONURIA (PKU)                          
            - Genetic disorder that is characterized by an inability of the body to utilize the essential amino acid,
phenylalanine d/t deficiency of liver enzymes (PHT) 

Phenylalaninehydroxylase Transferase :   The liver enzyme that converts Phenylalanine to tyroxine or CHON to amino
acid 

Sx:

a.        Fair complexion

b.        Blond hair

c.        Blue eyes

thyroxin: – decrease basal metabolism

-Accumulation of Phenyl Pyruvic acid leads to:

      a. Atopic dermatitis

b. Musty / mousy odor urine

c. Seizure: Mental retardation

Dx:

1. GUTHRIE TEST: Use blood as specimen

Preparation: Increase CHON intake

- Test if CHON will convert to amino acid

Nsg Care:

DIET:

Low phenylalanine diet:

Food C/I  : Meats, chicken, milk, legumes, cheese, peanuts

Give Lofenalac: Milk with synthetic protein

GALACTOSEMIA

- Deficiency of liver enzyme GUPT: Galactose Urovil Phosphatetranferase

Converts galactose to phosphate tranferase glucose

          Galactose will destroy brain cells if untreated – death within 3 days

Dx:

1. Beutler Test  = Get blood after 1st feeding

Presence of glucose in blood: Sign of galactosemia

Nsg Care:

1. Diet:  Galactose free diet for lifetime

2. Give Neutramigen : Milk formula

CELIAC DISEASE

- Gluten enteropathy

Assessment:

Early Sx:
a.    Diarrhea: Failure to gain weight following diarrheal episodes

b.    Constipation

c.   Vomiting

d. Abdominal Pain: Protuberant abdomen even if with muscle wasting

e. Steatorrhea

Late Sx:

1.    Behavioral changes: Irritability & Apathy

2.    Muscle wasting & loss of subcutaneous fats

Celiac Crisis: Exaggerated vomiting with bowel inflammation

Dx:

1.     Laboratory Studies : Stool analysis

2.     Serum Antigliadin & Antireticulin Antibodies: Confirmatory Dx of the disease

3.     Sweat Test

Nsg Care:

1. Gluten-free diet for lifetime

2. All brow food not allowed: Intolerance

        Common Gluten food:

B- barley
R- rye

O- oat

W- wheat

3. Allowed to eat rice & corn

Mgt:

1.    Vitamin supplements

2.    Mineral supplements

3.   Steroids

Assessment of the Back/Extremities

1. Check for flatness & symmetry

*Spina Bifida – From L5 to S1

NOTE FOR:

a. OPEN NEURAL TUBE DEFECT

- Decreased Folic Acid intake of mother & those during pregnancy undergoes steam bath/spa

2 Types:

1. SPINA BIFIDA OCCULTA

- Failure of post laminae of vertebrae to fuse

Sx:

Dimpling of the back

Abnormal tufts of hair

2. SPINA BIFIDA CYSTICA

- Failure of post laminae of vertebrae to fuse with a sac

Types:

1.* MENINGOCELE

- Protrusion of CSF & Meninges

- No alteration in function

2. MYELOMENINGOCELE

- Protrusion of CSF & Meninges & Spinal Cord

- Most dangerous type

- On the back : under illumination shows a half glow

3. ENCEPHALOCELE

- CNS complication : Hydrocephalus--Cranial meningocele or Myelomeningocele

Most Common Problem :

Rupture of sac

Prone position

Sterile wet dressing

Most Common Complication:  Infection

1. For Myelomeningocele : Genitourinary & Fecal Incontinence

2. Orthopedic complication: Paralysis of lower extremities

Sx:

a. Weakness, paralysis of lower extremities

b. Cold to touch

c. Ulceration

d. Absence of spontaneous movement

e. Bladder – dribbling of urine

g. Bowel – no control

Dx:

1. During pregnancy thru MAFEP

Mgt:

Surgery just to prevent infection, will not cure

Pre-opt – Protect the sac, use sterile doughnut ring

Post op – prone position

 

Nsg Care:

Always check diaper

SCOLIOSIS

- Lateral curvature of the spine

- Common to adolescence

2 Types:

1. Structural   – d/t Wry neck

2. Postural     – d/t  improper posture or heavy bags

Sx:

-Uneven hemline

- Bend forward & 1 hip higher

- 1 shoulder blade more prominent than the other

Nsg care:

1. Conservative            – Avoid obesity, exercise

2. Preventive               – Milwaukee brace : Worn 23 h a day

3. Corrective surgery     – Insert Harrington rod

                                                  Post operative- How to move : Log Rolling- move client as 1 unit

Assessment of the EXTREMITIES:

              1. Assess for the # of digits = 20

NOTE FOR:

SYNDACTYLY       - Webbing of digits (ginger-like foot)

POLYDACTYLY     - Extra digits

OLIDACTYLY        - Lack of digits

AMELIA                  - Total absence of digits

POCOMELIA           - Absence of distal part of extremities

Both d/t use of anti-emetic in Pregnancy or  Thalidomides