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OBSTETRIC NURSING Part 1 (NORMALS) - NOVEMBER 2023 PNLE

Prof. Kenneth Arzadon, MAN(eu), RN (PH UK)

ANATOMY and PHYSIOLOGY

FALLOPIAN TUBE

UTERINE
ENDOMETRIUM

OVARY

MENSTRUAL CYCLE
Onset of Menarche: 9 – 17 years old
Interval of Menses: 23 – 35 days
Duration of Bleeding: 2 – 9 days
Amount: 30 – 80 ml
Odor: Marigold

PHYSIOLOGY OF MENSES

ESTROGEN

Hypothalamus

Follicular Stimulating Hormone Anterior Pituitary Gland Luteinizing Hormone

formation of
↑ production of corpus luteum
Thickens the follicular fluid
endometrium
Rupture of the
Graafian Follicle Maintains the
thickness of the
endometrium

Ovum will atrophy NO FERTILIZATION CL will remain for 10 days

Pregnancy FERTILIZATION CL will remain for 16 weeks

PHASES OF THE MENSTRUAL CYCLE

1st Phase: Follicular, Estrogenic, __________

2nd Phase: Luteal, Progestational, __________

3rd Phase: Ischemic (decreased progesterone and estrogen)

4th Phase: Menstrual Bleeding

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Date of Last Menstrual Bleeding:
1. First day of the next menstrual bleeding –
2. Day of Ovulation –
3. Date of Ovulation –
4. Fertile period –

Date of Last Menstrual Bleeding:

1. First day of the next menstrual bleeding –
2. Day of Ovulation –
3. Date of Ovulation –
4. Fertile period –

Date of Last Menstrual Bleeding:

1. First day of the next menstrual bleeding –
2. Day of Ovulation –
3. Date of Ovulation –
4. Fertile period –

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OVULATION
Fertile period: 3-4 days before and after ovulation

Signs and Symptoms of Ovulation:

✓ Increased body temperature (Cause: increased Progesterone)

✓ Mittelschmerz – unilateral lower abdominal discomfort

✓ (+) Spinbarkeit – elasticity of the cervical mucus
✓ (+) Ferning – palm leaf patter under the microscope

✓ Cervical Mucus

STAGES OF FETAL DEVELOPMENT

OVUM → Fertilization (within ________)

BLASTOCYST → Implantation (within ___________)

DECIDUA:

Basalis – in contact with blood vessels

Capsularis – encapsulates the blastocyst
Vera – remaining portion of endometrium

ZYGOTE

EMBRYO (5 – 8 weeks) – Period of ORGANOGENSIS

FETUS (8 weeks to TERM)

Note: LECITHIN-SPHYNGOMYELIN RATIO – indicates _________________________

EMBYONIC FETAL STRUCTURES

Placenta – serves a fetal lungs, kidneys, and GIT

Endocrine functions:
- Estrogen and Progesterone
- Human Chorionic Gonadotrophin

Umbilical Cord – 2 arteries, 1 vein (AVA)

Amniotic Fluid
- Protects the fetus from temperature and pressure changes
- Aids in muscular development
- Ensured adequate oxygenation for the fetus

Normal Amount:
Oligohydramnios:

Polyhydramnios:

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GRAVITY AND PARITY

Gravity: Number of pregnancies regardless of outcome of duration

Parity: Number of deliveries that reach the age of viability subsequently delivered; dead or alive

Principle in identifying parity:

1. Multiple pregnancy -
2. Abortion -
3. Stillbirth -

Examples:
1. Patient A is pregnant for the first time and carries a twin
2. Patient B delivered to an alive monozygotic twin
3. Patient C is now pregnant. Her pregnancy three years ago ended in abortion
4. Patient D has delivered an alive baby girl. Her pregnancy three years ago ended in abortion
5. Patient E pregnancy three years ago ended in abortion. She aborts for the second time;

GTPALM Scoring
Gravity
Term (37 weeks and above)
Preterm (36 weeks and below)
Abortion (Less than 20 weeks)
Living
Multiple Pregnancy

Example:
Patient X is experiencing her fourth pregnancy. Her first pregnancy ended in a spontaneous abortion at 8
weeks, the second resulted in the live birth of twin boys at 38 weeks, and the third resulted in the live
birth of a daughter at 34 weeks.

OBSTETRICAL FORMULA AND COMPUTATIONS:

NAEGELE’S RULE
To estimate: ESTIMATED DATE OF CONFINEMENT
Pre-requisite: Last Menstrual Period

Jan – Mar:
Apr – Dec:

BARTHOLOMEW’S METHOD

Xiphoid process (36 weeks)

Umbilicus (20 weeks)

Symphysis pubis (12 weeks)

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SIGNS AND SYMPTOMS OF PREGNANCY

PRESUMPTIVE
• Amenorrhea
• Nausea and vomiting
• Urinary Frequency
• Breast changes
• Uterine enlargement
• QUICKENING
• Melasma/Chloasma (face)
• Linea Nigra (Xiphoid process to Symphysis pubis)
• Striae Gravidarum (Lower abdomen)

PROBABLE

• Braxton Hicks contractions – painless contractions relieved by walking

• Ballottement – rebounding of the fetus

POSITIVE
• Fetal heart rate
• Fetal outline
• Fetal movement

COMMON DISCOMFORTS DURING PREGNANCY

Nausea and Vomiting

o Dry crackers / carbohydrates
o Small frequent feedings
o Avoid fried, fatty, and spicy foods
o Fluid in between meals

Heartburn (Pyrosis)
Manifestation: substernal chest pain
o Elevate head of bed 3 hours after meals
o Milk in between meals

Constipation
o Increase oral fluid intake
o High fiber diets
o STOOL SOFTENERS

Backache
o __________________ Exercise
o Sleep in a flat, firm surface

Lordosis (Pride of Pregnancy)

Waddling Gait (Duck walk)

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 Breast Tenderness
o Wearing a supportive bra
o Avoid using soap to prevent drying

Leg Varicosities and Pedal Edema

o Elevate the legs
o Anti-embolic stockings
o Avoid prolonged sitting and standing
o Avoid crossing the legs

Hemorrhoids
o Knee Chest position
o Modified sim’s position
o Cold Compress
o Warm sitz bath

LEUKORRHEA (Whitish non-foul vaginal discharge)

o Use cotton underpants / perineal pads

NOTE:

Leg Cramps
o Increase CA in the diet
o Dorsiflexion of the foot

Urinary Frequency
o Increase fluid intake
o Wipe perineum front to back

SUPINE HYPOTENSIVE SYNDROME

Cause: vena cava compression
Manifestation: Dizziness while lying supine

Management: ________________________

ROUND LIGAMENT PAIN

- Stabbing or jabbing pain in the lower abdomen aggravated by movement
- Management: ___________________

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 PHYSIOLOGIC CHANGES DURING PREGNANCY

Blood Volume
Cardiac output To support the growing fetus
Heart rate

Platelets and WBC – to prevent bleeding and infection

Lipids and Serum cholesterol – sources of energy

GFR and Creatinine Clearance

The pregnant woman’s kidneys eliminate the fetal waste products.
Urine Output

BUN and plasma creatinine

Vaginal pH To prevent infection

Protein – for fetal and placental development

IgG To prevent fetal rejection

Functional (innocent) heart murmurs

MILD __________________

NUTRITION IN PREGNANCY

Fats: difficult to digest

Proteins: for fetal and placental development

Carbohydrate (1st trimester): glucose is needed for fetal brain development

Carbohydrate (2nd trimester): ↑ Human Placental Lactogen = ↓ insulin

Normal Weight Gain in Pregnancy;

1st trimester

2nd Trimester

3rd trimester

Normal BMI:

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PREGNANCY AND SMOKING:

PSYCHOLOGICAL CHANGES IN PREGNANCY

1st Trimester: Accepting the Pregnancy
- Anxiety
- Ambivalence (2 opposing feelings)
- COUVADE Syndrome (husband experience signs and symptoms of pregnancy)

2nd Trimester: Accepting the Baby

- Narcissism / Introversion (woman)
- Extroversion (husband)

3rd Trimester: Prepare for delivery

- NEST building (naming the baby, preparing the room of the baby, buying stuffs for the baby)

OBSTETRICAL PROCEDURES

LEOPOLD’S MANEUVER

Client instruction: empty the bladder

Client Position: supine position/dorsal recumbent
Nursing Considerations: Use the PALMS

Position of the nurse:

Left-handed (Nurse): Left side of the woman
Right-handed (Nurse): Right side of the woman

First Maneuver
Hard, Round and Smooth (fetal head)
Soft and Glandular (fetal buttocks)

Second Maneuver
Hard and Smooth (fetal back)
Irregular and Bony (fetal extremities)

Third Maneuver
Movable (not engaged)
Not movable (engaged)

Fourth Maneuver
Degree of Flexion

FETAL MOVEMENT COUNT

SANDOVSKY METHOD:
✓ ________________
✓ ________________
✓ POSITION: ____________________
✓ Same time each day
✓ 2 attempts

NORMAL fetal movement count: SANDOVSKY Method –

CARDIFF Method –

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FETAL HEART TONE MONITORING
PRINCIPLES/Equipment used
Doppler:
Fetoscope:
Stethoscope:

PROMOTE BONDING: let the parents listen to the fetal heart beat

NORMAL Fetal Heart Rate: _____________________________

NON - STRESS Test – fetal heart rate in response to fetal movement

_______________ ↑ FHR of 15bpm in 15 seconds (2 episodes in 20 minutes)

_______________ NO ↑ FHR / less than 15bpm

CONTRACTION STRESS test – fetal heart rate in uterine contractions

FINDINGS AND INTERPRETATIONS (FHT monitoring)

EARLY DECELERATIONS
- occurs during the onset of contractions

LATE DECELERATIONS
- occurs during the end of contractions

VARIABLE DECELERATION
- occurs anytime during or in between contraction

AMNIOCENTESIS
Earliest time: _______________________
Client Position: Supine position
Site: between the umbilicus and symphysis pubis

Client instruction
Before: Empty the bladder
After: Avoid sexual intercourse and strenuous activities for 24 hours

Important Assessment:

PREGNANCY AND VACCINATION

T
H
I
R
D

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PREPARATION FOR CHILDBIRTH
Walking – _________________________
Squatting – increases blood supply to then uterus
Tailor Sitting – tightens the perineal muscles
Kegel’s exercise – strengthens the perineal muscles
Pelvic rocking – to prevent and manage _________

PREMONITORY / PRODROMAL SIGNS OF LABOR

LIGHTHENING (engagement) – relief of dyspnea
Primipara: 1 – 2 weeks before labor
Multipara: a day before labor

Increased BRAXTON HICKS CONTRACTIONS

- painless contractions relieved by walking

Bloody Show – Pink-tinged vaginal spot

Ripening of the cervix – as soft as a whipped butter

PSYCHOSOCIAL SIGN: ↑ MATERNAL ENERGY

TRUE LABOR Contractions

Decreasing INTERVALS
Regular
Increasing INTENSITY
Progressive Cervical Effacement and Dilation

Pain Characteristics:
radiating from the back to the abdomen

PELVIC MEASUREMENTS
DIAGONAL Conjugate OBSTETRIC Conjugate
- the only pelvic measurement obtained
thru vaginal / internal examination

Best Position for Delivery:

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6 MAJOR CONCEPTS OF NATURAL BITH
LEBOYER METHOD OF CHILDBIRTH
- Not artificially induced
- NO to IV fluids and analgesics
Birthing Room Temperature:
- Woman can move freely
- Woman is supported
Delivery of the Fetal Head:
- Upright or side lying position
- Immediate and unlimited breastfeeding
Cutting of the Cord:

STAGES OF LABOR
1ST STAGE OF LABOR (Onset of true contraction to full cervical dilation)
PRIMI: _____________________
MULTI: _____________________

PHASE Cervical Duration Frequency Intensity Nursing Considerations

Dilation
Latent

Active

Transition

FERGUSON’s REFLEX – uncontrollable urge to push

USUAL TIME FOR RUPTURE OF MEMBRANES

2ND STAGE OF LABOR (fetal expulsion)

PRIMI: ______________________
MULTI: ______________________

CARDINAL MOVEMENTS of LABOR

- To allow the smallest diameter of the fetal head to pass the maternal pelvis

Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

DURING EXTENSION: using one hand to pull the fetal chin from between the maternal anus and the coccyx,
and the other on the fetal occiput to control speed of delivery.

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3RD STAGE OF LABOR (placental expulsion)
Duration: ________________________

SIGNS OF PLACENTAL SEPARATION

Uterus becomes firm and globular
Sudden gush of fluid
Lengthening of the cord

Placental Separation

Duncan’s mechanism – separate at the edges (Maternal Side)

Shultz’s mechanism – separates at the center (Fetal side)

OXYTOCIN

ERGOMETRINE
METHYLERGONOVINE

ESSENTIAL IMMEDIATE NERBOWN CARE (EINC)

✓ Handwashing
✓ Double gloving

within 30 seconds within 3 minutes within 90 minutes within 6 hours

Stimulate breathing

Prevent: Prevent: Prevent: IMMUNIZATION:

• Hypothermia • Anemia • Ophthalmia
• Hypoglycemia Neonatorum
• Infection

Drying: Cord Clamping: BREASTFEEDING

Signs of good attachment:
Skin – to skin contact: ✓ Mouth wide open
✓ Lower lip turned out
✓ Chin touching the
Identification band: breast

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POST-PARTUM CARE
INVOLUTION – return of the reproductive organs to its pre-pregnant state
Promotion:
1. Massage the uterus
2. Administration of oxytocin
3. _____________________________

Location of fundus:
After fetal delivery: below umbilicus
After placental delivery: between umbilicus and symphysis pubis
One hour after delivery: at the level of below the level of the umbilicus

NOTE: Fundus goes down 1 cm/day

LOCHIA

Lochia Rubra

Lochia Serosa

Lochia Alba

EVALUATION: non-foul smelling

Normal amount: 4 – 8 pads per day

POST – PARTUM PSYCHOLOGICAL ADAPTATION

Taking in: Woman is passive and self-centered (DEPENDENT)

Taking hold: Strives to learn the tasks (STRIVES FOR INDEPENDENCE)

Letting Go: Resumes sexual intimacy (INDEPENDENCE)

RETURN OF MENSTRUAL FLOW:

Breastfeeding mother:

Non-breastfeeding mother:

Thank you. – Sir Ken

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