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Maternal/Ob Notes: "Above Success There Is Excellence Beyond Impossible. " Skei Nursing Review & Enhancement
Maternal/Ob Notes: "Above Success There Is Excellence Beyond Impossible. " Skei Nursing Review & Enhancement
Maternal/Ob Notes: "Above Success There Is Excellence Beyond Impossible. " Skei Nursing Review & Enhancement
MATERNAL/OB NOTES
Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes
emotions and preferences that are related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on
human sexuality.
B. Definitions related to sexuality:
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity
life long dynamic change.
- developed at the moment of conception.
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fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to
manipulation, torn during delivery.
Site – episiotomy.
d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice
and bartholene’s glands.
C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int – ovaries
Function: 1. ovulation
2. Production of hormones
d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from
the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum
from the ampulla to the uterus.
4 significant segments
1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at
ovulation
2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – site of ectopic pregnancy – most dangerous
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum – a pouch hanging below the pendulous penis, with a medial septum
dividing into two sacs, each of which contains a testes.
- cooling mechanism of testes
- < 2 degrees C than body temp.
- Leydig cell – release testosterone
2. Internal
Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholin's glands
Scrotum Labia Majora
VII. 15th day, after ovulation day, graafian follicle starts to degenerate
yellowish known as corpus luteum (secrets large amount of progesterone)
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2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing
orgasm. Lasts 30 seconds – 3 minutes.
3. Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release
of sexual tension with physiologic or psychologic release, immeasurable peak
of sexual experience. May last 2 – 10 sec- most affected are is pelvic area.
A. Fertilization
B. Stages of Fetal Growth and Development
3-4 days travel of zygote – mitotic cell division begins
*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote – from fertilization to 2 months
b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating &
multiplication
c. Blastocyst – enlarging cells that forms a cavity that later becomes the
embryo. Blastocyst – covering of blastocys that later becomes placenta &
trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 – 10 days.
Fetus- 2 months to birth.
placenta previa – implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization – corpus luteum continues to function & become
source of estrogen & progesterone while placenta is not developed.
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
Chorionic villi sampling (CVS) – removal of tissue sample from the fetal
portion of the developing placenta for genetic screening. Done early in
pregnancy. Common complication fetal limb defect. Ex missing digits/toes.
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6. It serves as a protective barrier against some microorganisms – HIV,HBV
Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life
span – end of 2nd month
3. Sex organ formed
4. Meconium is formed
Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard – Doppler – 10 – 12 weeks
4. Sex is distinguishable
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 – 20 weeks
3. buds of permanent teeth appear
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Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi
5. fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Eighth Month
1. lanugo begin to disappear
2. sub Q fats deposit
3. Nails extend to fingers
Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases
A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th
cranial nerve – poor hearing & deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia or pocomelia, absence of extremities
A. Systemic Changes
1. Cardiovascular System – increase blood volume of mom (plasma blood) 30
– 50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight
hypertrophy of ventricles, epistaxis – due to hyperemia of
nasal membrane palpitation,
Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL
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Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects
toughly 20% of pregnant women.
- Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic
physio hypoxia
Nursing Care:
Nutritional instruction – kangkong, liver due to ferridin content, green leafy
vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly
administered, hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1
hr before meals or 2 hrs after, black stool, constipation
Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vit C such as orange
juice
Higher iron intake is recommended since circulating blood volume is
increased and heme is required from production of RBCs
Edema – lower extremities due venous return is constricted due to large belly,
elevate legs above hip level.
Morning Sickness – nausea & vomiting due to increase HCG. Eat dry
crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon -
small freq feeding. Vomiting in preg – emesisgravida.
Metabolic alkalosis, F&E imbalance – primary med mgt – replace fluids.
Monitor I&O
*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort
4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of
lungs or side lying pos – mgt for nocturia
Acetyace test – albumin in urine
Benedicts test – sugar in urine
5. Musculoskeletal
B. Local Changes
Local change: Vagina:
V – Chadwick’s sign – blue violet discoloration of vagina
C – Goodel's sign – change of consistency of cervix
I – Hegar's – change of consistency of isthmus (lower uterine segment)
S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling
odor with vaginal edema
Mgt:
FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t
give at 1st trimester
1. treat dad also to prevent reinfection
2. no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar
Breast self exam- 7 days after mens –– supine with pillow at back
quadrant B – upper outer – common site of cancer
Second Trimester – tangible S&Sx. mom identifies fetus as a separate entity – due
to presence of quickening, fantasy. Developmental task – accept growing fetus as
baby to be nurtured.
Health teaching: growth & development of fetus.
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3. Diagnosis of Pregnancy
1.)urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6
weeks after LMP- best to get urine exam.
2.)Elisa test – test for preg detects beta subunit of HCG as early as 7 –
10days
3.)Home preg kit – do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1st sign preeclampsia)
Weight Monitoring
First Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month)
Second trimester: normal weight gain 10 – 12 lbs(4 lbs/month) (1
lb/wk)
Third trimester: normal weight gain 10 – 12 lbs(4 lbs/ month) ( 1lb/wk)
Minimum wt gain – 20 – 25 lbs
Optimal wt gain – 25 – 35 lbs
5. Obstetrical Data:
nullipara – no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability – the ability of the fetus to live outside the uterus at the earliest possible
gestational age.
age of viability - 20 – 24 wks
Term 37 – 42 wks,
Preterm -20 – 37 weeks
abortion <20 weeks
Sample Cases:
1 – abortion GTPAL
1 – 2 mo 2 0 01 0
nd
G–2
P–0
1 – 40th AOG GT P A L
1 – 36 AOG
th
612 2 4
2 – misc
1 – twins 35 AOG
1 – 4th month G6 P3
1 – 39th week
1 – miscarriage GP GTPAL
1 – stillbirth 33 AOG (considered as para) 42 4 11 1 1
1 – preg 3 wk
rd
1 – 33 P
1 41st L
1 – abort A
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1 – still 39 GP GTPAL
1 triplet 32 6 4 6 2 2 15
1 4 mon
th
c. Important Estimates:
6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache – preeclampsia)
Result:
Class I - normal
Class IIA – acytology but no evidence of malignancy
B – suggestive of infl.
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy
7. Leopold’s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting
part, degree of descent, an estimate of the size, and number of fetuses, position,
fetal back & fetal heart tone
- use palm! Warm palm.
Prep mom:
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent – to relax
abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put towel
under head and right hip; with both hands palpate upper abdomen and fundus.
Assess size, shape, movement and firmness of the part to determine presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus ( to
hear fetal heart sound) where the ball of the stethoscope is placed to determine
FHT. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine
soufflé.
Uterine soufflé – maternal H rate
3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and
fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis )Alert : if the head is
engaged it will not be movable).
4th Maneuver: the Examiner changes the position by facing the patient’s feet. With
two hands, assess the descent of the presenting part by locating the cephalic
prominence or brow. To determine attitude – relationship of fetus to 1 another.
When the brow is on the same side as the back, the head is extended. When the
brow is on the same side as the small parts, the head will be flexed and vertex
presenting.
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a. Cardiff count to 10 method – one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and
count each fetal movement, noting how long it takes to count 10 fetal movements
(FMs)
(2) Expected findings – 10 movements in 1 hour or less
3) Warning signs
a.) more then 1 hour to reach 10 movements
b.) less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to healthcare provider immediately; often
require further testing. Examples: nonstress test (NST), biographical profile (BPP)
B. Nonstress test – to determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Postmaturity
a.)pregnancy induced hypertension (PIH), diabetes
b.)warning signs noted during DFMC
c.)maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal
monitor); external monitor is applied to document fetal activity; mother activates
the “mark button” on the electronic monitor when she feels fetal movement.
Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
i. reactive result
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1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute,
lasting at least 15 seconds in a 10 to 20 minute period as a result of FM
3. Good variability – normal irregularity of cardiac rhythm representing a
balanced interaction between the parasympathetic (decreases FHR) and
sympathetic (increase FHR) nervous system; noted as an uneven line on
the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system
9. Health teachings
a. Nutrition – do nutritional assessment – daily food intake
High risk moms:
1. Pregnant teenagers – low compliance to heath regimen.
2. Extremes in wt – underweight, over wt – candidate for HPN, DM
3. Low socio – economic status
4. Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin –
formation of folic acid – needed for cell DNA & RBC formation. (Decrease
folic acid – spina bifida/open neural tube defect)
How many Kcal CHO x4,CHON x4, fats x 9
2.Sexual Activity
a.)should be done in moderation
b.)should be done in private place
c.)mom placed in comfy pos, sidelying or mom on top
d.)avoided 6 weeks prior to EDD
e.)avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:
a.)1st tri – decrease desire – due to bodily changes
b.)2nd trimester – increased desire due to increase estrogen that enhances
lubrication
c.)3rd trimester – decreased desire
Contraindication in sex:
1. vaginal spotting
1st trimester – threatened abortion
2nd trimester– placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
Raise buttocks 1st before head to prevent postural hypotension – dizziness when
changing position
4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting
wellness behavior that can be used by parents and family thus, helping them
achieved a satisfying and enjoying childbirth experience.
a. Psychophysical
1. Bradley Method – Dr. Robert Bradley – advocated active participation of
husband at delivery process. Based on imitation of nature.
Features:
1.) darkened rm
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method – fear leads to tension while tension leads to pain
b. Psychosexual
1. Kitzinger method – preg, labor & birth & care of newborn is an impt
turning pt in woman’s life cycle
- flow with contraction than struggle with contraction
1. Passenger
a. Fetal head – is the largest presenting part – common presenting part – ¼ of its
length.
Bones – 6 bones S – sphenoid F – frontal - sinciput
E – ethmoid O – occuputal - occiput
T – temporal P – parietal 2 x
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Measurement fetal head:
1. transverse diameter – 9.25cm
- biparietal – largest transverse
- bitemporal 8 cm
2. bimastoid 7cm smallest transverse
Moldings: the overlapping of the sutures of the skull to permit passage of the head
to the pelvis
Fontanels:
1.)Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm –
hydrocephalus), 12 – 18 months after birth- close
2.)Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3
months.
4.) Anteroposterior diameter -
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation
2. Passageway
Mom 1.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for
pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part
shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider
transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider
b. Pelvis
2 hip bones – 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum – lateral side of hips
- iliac crest – flaring superior border forming prominence of hips
Ischium – inferior portion
- ischial tuberosity where we sit – landmark to get external
measurement of pelvis
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Pubes – ant portion – symphisis pubis junction between 2 pubis
1 sacrum – post portion – sacral prominence – landmark to get internal
measurement of pelvis
1 coccyx – 5 small bones compresses during vaginal delivery
Important Measurements
3. Power – the force acting to expel the fetus and placenta – myometrium – powers
of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person – psychological stress when the mother is fighting the labor
experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP – most common malposition
Bear down with contractions
Adequate hydration – prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted
Cord Prolapse – a complication when the umbilical cord falls or is washed through
the cervix into the vagina.
Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina
Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord
will remain slippery & prevent cord compression causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment: Dilations: 0 – 3 cm mom – excited, apprehensive, can
communicate
Frequency: every 5 – 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
3. Breathing – chest breathing
Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears
losing control of self
Frequency q 3-5 min lasting for 30 – 60 seconds
Nursing Care:
M – edications – have meds ready
A – ssessment include: vital signs, cervical dilation and effacement, fetal
monitor, etc.
D – dry lips – oral care (ointment)
dry linens
B – abdominal breathing
Pelvic Exams
Effacement
Dilation
a. Station – landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning – occurs at 2nd stage of labor
b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the
long axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex – complete flexion
Face
BrowPoor Flexion
Chin
Breech - Complete Breech – thigh breast on abdomen, breast lie on thigh
Incomplete Breech – thigh rest on abdominal
Frank – legs extend to head
Footling – single, double
Kneeling
Variety:
Occipito – LOA left occipito ant (most common and favorable position)– side of
maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
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ROP – squatting pos on mom
ROT
ROA
Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP
Parts of contractions:
Increment or crescendo – beginning of contractions until it increases
Acme or apex – height of contraction
Decrement or decrescendo – from height of contractions until it decreases
Duration – beginning of contractions to end of same contraction
Interval – end of 1 contraction to beginning of next contraction
Frequency – beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction
Contraction – vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions
Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify
MD -preeclampsia
Health teachings
1.) Ok to shower
2.)NPO – GIT stops function during labor if with food- will cause aspiration
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 – 18 inch – ht enema tubing
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Signs of fetal distress-
1.) <120 & >160
2.) mecomium stain amnion fluid
3.) fetal thrushing – hyperactive fetus due to lack O2
Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis
that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only – vaginal pack
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Bolus of Ptocin can lead to hypotension.
4. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery
stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
d. Perineum –
R - edness
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E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation
Complications of Labor
Dystocia – difficult labor related to:
Mechanical factor – due to uterine inertia – sluggishness of contraction
1.)hypertonic or primary uterine inertia
- intense excessive contractions resulting to ineffective pushing
- MD administer sedative valium,/diazepam – muscle relaxant
2.)hypotonic – secondary uterine inertia- slow irregular contraction resulting to
ineffective pushing. Give oxytocin.
Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.)sudden pain
b.)profuse bleeding
c.)hypovolemic shock
d.)TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDL’S pathologic ring – suprapubic depression
a.) sign of impending uterine rupture
Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs
of labor
Multi: 8 – 14, primi 14 – 20
Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water – full bladder inhibits contractions
5. consult MD if symptoms persist
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Hosp:
1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents-
halts preterm contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes
before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
Antidote – propranolol or inderal - beta-blocker
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers because
the increased in plasma volume return to its normal state and thus adding to the
workload of the heart. This is critical especially to gravidocardiac mothers.
2. Genital tract
a. Cervix – cervical opening
b. Vaginal and Pelvic Floor
c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until
10th day – no longer palpable due behind symphisis pubis
3 days after post partum: sub involuted uterus – delayed healing uterus with big
clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C
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after, birth pain:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid
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I. Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed
uterus & profuse bleeding – uterine atony. Complications: hypovolemic
shock.
Mgt:
1.)massage uterus until contracted
2.)cold compress
3.)modified trendelenberg
4.)IV fast drip/ oxytocin IV drip
Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy
Gen mgt:
1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol,
VITC, culture & sensitivity – for antibiotic
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Social Method – 1.) coitus interuptus/ withdrawal - least effective method
2. coitus reservatus – sex without ejaculation –
3. coitus interfemora – “ipit”
4. calendar method
OVULATION –count minus 14 days before next mens (14 days before next
mens)
Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
Physiologic Method-
-in case a mother who is taking an oral contraceptive for almost long time plans to
have a baby, she would wait for at least 3 months before attempting to conceive to
provide time for the estrogen and progesterone levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the
previously prescribed contraceptive and begin taking the new one on the first day of
the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an
indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A – abdominal pain
C – chest pain
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H - headache
E – eye problems
S – severe leg cramps
If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.)chain smoker
2.)extreme obesity
3.)HPN
4.)DM
5.)Thrombophlebitis or problems in clotting factors
- if forgotten for one day, immediately take the forgotten tablet plus the tablet
scheduled that day. If forgotten for two consecutive days, or more days, use
another method for the rest of the cycle and the start again.
HT:
1.)Check for string daily
2.)Monthly checkup
3.)Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the
device (common problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
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A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom – latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD – female condom
Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs
Ht:
1.)proper hygiene
2.)check for holes before use
3.)must stay in place 6 – 8 hrs after sex
4.)must be refitted especially if without wt change 15 lbs
5.)spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance.
HT: avoid lifting heavy objects
Vasectomy – cut vas deferense.
HT: >30 ejaculations before safe sex
O – zero sperm count, safe
1. Hemorrhagic Disorders
General Management
1.)CBR
2.)Avoid sex
3.)Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.)Ultrasound to determine integrity of sac
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5.)Signs of Hypovolemic shock
6.)Save discharges – for histopathology – to determine if product of conception
has been expelled or not
Classifications:
5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect
choose between lesser evil.
Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon – in charge of sign consent, RN as witness
- MD explain to patient
complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of
uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a
blood vessel may lead to retained placental fragments if vessel is cut.
G. Placenta Circumvalata – fetal side of placenta covered by chorion
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H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta – cord inserted marginally rather then centrally
J. Placenta Bipartita – placenta divides into 2 lobes
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters
the placenta
L. Vasa Previa – velamentous insertion of cord has implanted in cervical OS
2. Hypertensive Disorders
3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.
Cause of preeclampsia
1.)idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.)common in multiple pre (twins) increase exposure to chorionic villi
3.)common to mom with low socioeconomic status due to decrease intake of
CHON
Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion,
water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
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1.) dimly lit room . quiet calm environment
2.) minimal handling – planning procedure
3.) avoid jarring bed
Fetal effect
1.)hyper & hypoglycemia
2.)macrosomia – large gestational age – baby delivered > 400g or 4kg
3.)preterm birth to prevent stillbirth
Newborn Effect : DM
1.)hyperinsulinism
2.)hypoglycemia
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normal glucose in newborn 45 – 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test – get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.)hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium
Recommendation
Therapeutic abortion
If push through with pregnancy
1.)antibiotic therapy- to prevent sub acute bacterial endocarditis
2.)anticoagulant – heparin doesn’t cross placenta
Heart disease
Moms with RHD at childhood
Class I – no limit to physical activity
Class II – slight limitation of activity. Ordinary activity causes fatigue &
discomfort.
Class IV. marked limitation of physical activity. Even at rest there is fatigue &
discomfort.
Recommendation: Therapeutic abortion
Procedure:
a. classical – vertical insertion. Once classical always classical
b. Low segment – bikini line type – aesthetic use
2 types of infertility
1.) primary – no pregnancy at all
2.) Secondary – 1st pregnancy, no more next preg
test male 1st
- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test – or post coital test. Procedure: sex 2 hours before test
mom – remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 –
low sperm count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.)occupation- truck driver
2.)chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count
Implant sperm in ampula
2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes
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- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography – used to determine tubal patency with use of
radiopaque material
Mgt: IVF – invitrofertilization (test tube baby)
England 1st test tube baby
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