Professional Documents
Culture Documents
Maternal and Child - Pre Intensive
Maternal and Child - Pre Intensive
◦Gonadotrophic - target the gonads (increase the size and produce sex hormones)
‣ FSH - stimulate the follicle and for MATURATION —>
‣ LSH - responsible for OVULATION
◦Sex Hormones
‣ Estrogen (hormone of women) - secondary sex characteristics
• result of estrogen to FSH —> assist FSH in maturation
• If estrogen reach limit it sends negative feedback to FSH and causing decrease or
suppressed FSH
• Thickening of the uterus (there is contraction happen) if estrogen is highly elevated it
is not fully thickened
‣ Progesterone - hormones of mothers or pregnancy
• Maintains pregnancy - by relaxation (thats why constipation is common) Relaxsphincter
• Produce by the corpus luteum
• Increases the basal body temperature (a day after ovulation)
CYLE
• Ovarian Cycle - changes happens in ovary Menstrual ( )
• Endometrial Cycle - changes happens in endometrium
◦Menstrual Phase v
Hypothalamus
‣ decrease estrogen and decrease progesterone
‣ Blood loss is 50cc (more than —> menorrhagia) v
Anterior Pituitary Gland
◦Proliferative Phase
‣ Estrogen was addressed
‣ ovulation happens at the end of proliferative FSH LSH
◦Secretory Phase on a on
‣ Progesterone was addressed Ovary Corpus Luteum
( Progesterone)
v
MENSTRUAL DISORDERS Estrogen
• PMS
◦Signs and Symptoms:
‣ Headache - Increase OFI, NSAIDS (take every 6hrs), paracetamol
‣ Breast tenderness - Bromocryptine Mesylate (Parlodel)
‣ Edema - elevate the legs
‣ Bloating - exercise
‣ Mood swings - listening
‣ irritability - listening
FAMILY PLANNING
1. Natural Method
2. Artificial Method
3. Surgical Method
NATURAL METHOD
◦Abstinence
‣ for Teenagers and NOT to adult
◦Coitus Interruptus (Withdrawal method)
‣ Not recommended to sexual worker
◦Lactation Amenorrhea Method
‣ Lactation: EXCLUSIVE breastfeeding, DIRECT latching (maximum 6months)
‣ Amenorrhea - not ovulating
◦Rhythm Method
‣ Calendar Method
‣ Signs of ovulation: teach to client
• Increase BBT
• Mittlescmerz (discomfort at Left or right lower quadrant)
• Cervical Mucus Changes (Spinnbarkeit)
• (+) Ferning Pattern
◦Non pregnant: signs of ovulating.
◦if client is Pregnant: Signs of ruptured membrane
ARTIFICIAL METHOD
◦Barrier
‣ Condoms
• Contraindicated to Allergy of Latex: Check history of foods: banana, papaya
‣ Cervical Cap and Diaphragm - difference is the time it is inserted
• Cervical Cap - 30 mins prior to Sex (half fill the cap of spermicide) Maximum 48hours
• Diaphragm - 2 hours prior (put spermicide gel with lubricant effect) Maximum 6-8 hours
• If it is not took out beyond the maximum—> TOXIC SHOCK SYNDROME
‣ IUD - can be barrier and hormonal
• Fever, Foul discharges - possible infection
• If string is not there —> notify MD
• CHECK every month
◦Hormonal
‣ Oral
• Combination oral contraceptives (COC)
◦Yellow pills (21)+7 placebo (ferrous)
◦Take the same time of the day
◦1 missed pill —> take the missed pill ASAP
◦2 missed pill —> take 1 missed pill ASAP —> 2 pills the ff day —> 1 week barrier method
◦3 missed pill —> discard
◦Contraindicated: (B.D.C.D.S)
‣ Breastfeeding
‣ Diabetes
‣ Cardiovascular Disorders, Blood vessels and Hx
‣ Dx Migraine
‣ Smoking
• Progesterone only Pills
◦Expected: UGLY
◦28 pills (no placebo)
‣ Injectable
• every 12 weeks or 3 months
• Alters Cycle
• If wanting to pregnant stop injectable or 2 years not using
• Injectable Progestin (Depo Provera)
‣ Implants
• 3-5 years
• Side effects: 1 month using common
◦GERD
◦Headache
◦Patchy hair loss
◦irritability
PRESUMPTIVE SIGNS
◦least indicative signs of pregnancy
◦Subjective manner
◦Starts: Amenorrhea/Missed periods —> might secondary to stress or Anemia
◦Nausea and Vomiting (morning sickness) - secondary to HCG (peaked in early morning) —> could sec. Ulcer
◦Increase Urinary Frequency —> could sec. to UTI
◦Chloasma (other skin changes: linea nigra, Striae gravidarum)
◦Quickening (movement perceived) —> could sec. to Gas
PROBABLE SIGNS
◦Objective manner
◦(+) pregnancy test - 3-5 drops of urine (High levels of Hormone: HCG)
‣ Could be pregnant
‣ Could be H.mole
‣ Could be Cancer
◦Chadwicks - bluish discoloration
◦Godels - Softening of the cervix
◦Hegars - soft lower uterine segment
◦Braun Von Fernwald
◦Piscacek’s sign
◦Ballotement - gently tap the uterine segment and the content goes up and down
POSITIVE SIGNS
◦FHR —> through ultrasound
‣ Heart rate through doopler —> might be uterine bruit
◦Visualization —> ultrasound
‣ Transvaginal Ultrasound - early part
‣ Trans-abdominal Ultrasound - later part
◦Fetal Movement felt by the examiner
EmONC
• Goal: patient nga kaya maalagaan ug endorse to appropriate facility ang pt nga di kaya maalagaan
—> ALL PATIENT ARE AT RISK
• Skilled attendant - underwent training of EmONC and professionals
• REQUIREMENT: Liscensed and Training
◦Refers to Skilled professional
ANTEPARTUM
• Prenatal Visit
◦Lunar months: 10 months
◦Calendar months: 9 months
◦40 weeks
◦WHO - at least 4 prenatal visits
• Obstetrics History - GTPAL
◦Gravida
‣ # of pregnancies regardless of outcome and # of fetus
◦Term
‣ at least 37 weeks
◦Pre-Term
‣ Age of viability 20 weeks - 36 weeks
◦Abortion
‣ below 20 weeks
◦Living
‣ Count ALL the Baby that is BUHI
• Estimates
◦EDD/EDC
‣ LMP - Naegels Rule
‣ AOG - fundal height (cm)
• Lunar Months: FH (cm) x 2/7
• weeks: FH(cm) x 8/7
‣ Ultrasound - confirmation
◦Fetal Length
‣ Haese’s rule
• Lunar months: 1-5(multiply own number) 6-10 (multiply 5)
• Screening
◦Vital signs
‣ Temp: elevated possible infection—> CemONC
‣ PR, RR - elevated (HF or Anemia) —> Transfer
‣ BP - elevated —> transfer CemONC
◦Height and Weight
‣ below 5ft patient —> transfer
‣ Overweight or underweight —> high risk —> transfer
◦Health History of Patient
‣ Hypertension
‣ Asthma
‣ DM
◦Laboratory
‣ Blood Typing with RH Factor
• For possible BT
• Rh factor - high risk if there is RH incompatibility (Rh -) —> Transfer
‣ CBC
• RBC
• Hematocrit
• Hemoglobin - 11-16 g/dL
◦Increase in 40-60% —> pseudoanemia
◦Low hemoglobin —> transfer
◦Ferrous Sulfate or Ferrous gluconate 30-60 mg/day
‣ For better absorption: with citrus juice
◦Folic Acid 400 mcg/day
‣ MOST IMPORTANT
‣ Decrease folic Acid —> neural tube defects
‣ Hx of NTD (multiply dosage to 3= 1200 mcg)
◦Calcium 1200 mg or 2 glasses of milk per day or cheese
• WBC (5-10,000 mm3)
◦elevated —> infection (more than 10,000) —> transfer
◦UTI —> spontaneous abortion = CRANBERYY JUICE or Buko Juice
◦if pregnant (upto 12,000: normal)
• Platelet (150-450,000)
◦decrease —> bleeding —> transfer
‣ Urinalysis
• Protein - (+) indication of PIH (20 wks and above AOG)
• (+) Glucose (GDM)
• (+) pus or (+) bacteria
• Good catch urine: minimal or zero epithelial cells (increase —> retest)
‣ Ultrasound
• Early Pregnancy = Transvaginal
• Preparation:
◦EMPTY THE BLADDER
• Late pregnancy = Trans-abdominal
• Preparation:
◦DRINK WATER
◦Put roll towel
COMMON DISCOMFORTS
◦Fatigue - rest and eliminate stressors
◦Hunger
◦Nausea and Vomiting (morning sickness) - dry crackers
◦Heartburn
‣ Small frequent feedings every 2hrs
◦Urinary Frequency
‣ Kegels Exercise
◦Constipation
‣ increase fluid intake and increase fiber
DANGER SIGNS
◦Bleeding or spotting
◦Severe cramps/pain
‣ 1st trimester
‣ 3rd trimester
◦Dysuria
◦Fever & Chills
◦leaking of fluid from vagina —> possible PROM
◦Increase BP
◦Edema (especially hands and face) —> pos. PIH
◦Severe persistent Headache —> pos Pre-eclampsia
COMPLICATIONS OF ANTEPARTUM
◦Abruptio Placenta
‣ early separation of placenta (hidden bleeding)
‣ ALWAYS EMERGENCY
‣ Decrease BS to placenta
• due to hypertension
• Cocaine
• Trauma & Accident
• Short umbilical cord
‣ Signs and Symptoms:
• painful bleedings (dark red or brownish) OLD BLOOD
• Rigid board like abdomen
‣ Management:
• EMERGENCY CS
‣ Complication:
• SHOCK
• DIC (NEVER DO CS) (S/Sx: Rashes, explode vessels)
• Covvelaire Uterus (do not contract uterus) —> HYSTERECTOMY
RH INCOMPATIBILITY
◦Mother is Rh (-) developed antibodies with baby of (+)
◦FIRST PREGNANCY: mixture of blood with mother and baby —> give RHOGAM (for PREVENTION of Rh
positive antibody formation) Before 72hrs or within 2 days
‣ Rh (-) mother —> INDIRECT COOMBS (maternal blood) - looking for Rh +AB —> RESULT: NEGATIVE —>
GIVE RHOGAM
‣ Rh (-) mother —> Indirect Coombs (maternal blood) - looking for Rh +AB —> RESULT: POSITIVE —>
DIRECT COOMBS (fetal blood through umbilical ARTERY) —> RESULT: NEGATIVE (Rh(-) = NO PROBLEM
‣ Rh (-) mother —> Indirect Coombs (maternal blood) - looking for Rh +AB —> RESULT: POSITIVE —>
DIRECT COOMBS (fetal blood through umbilical ARTERY) —> RESULT: POSITIVE Rh(+) —> RH
INCOMPATIBILITY —> Amniocentesis (amniotic fluid = baby’s urine) = increase Protein —> Intrauterine
Blood transfusion or else baby die
‣ If not increase protein —> wait until delivery
PRE-EXISTING/CO-EXISTING PROBLEMS
PREGNANCY- INDUCED HYPERTENSION —> transfer
◦Screening - starts @20 weeks
◦Criteria:
‣ @20 weeks
‣ Hypertension
‣ Proteinuria
◦less than 20 weeks: Hypertension
◦NO PROTEINURIA: Gestational hypertension
◦Normal BP with Proteinuria: Gestational Proteinuria
PRE-ECLAMPSIA
◦Mild
‣ +30 SBP , +15 DBP
‣ hands
‣ 1-2 protein
◦Severe
‣ 160/100 (at least) —> seizure precautions (decrease stimulation)
‣ Generalized edema and Puffy Face
‣ Severe persistent headache
‣ 3-5 protein
◦Management:
‣ *apresoline (hydralazine) not used —> LUPUS
‣ Magnesium sulfate initial loading dose: 4-6 grams in the buttocks , + 1-2g/hr
‣ Watch Out: TOXICITY —> put at bedside: Antidote (Calcium Gluconate)
• BP - decrease
• UO - decrease
• RR
• (-) Patellar Reflex
‣ Seizure precautions
• Assess for impending Seizure: AURA —> insert padded tongue depressor
• Decreased stimulation
• Dim light
• Bed is in lowest position with SIDE RAILS UP
• let the pt and monitor what type of seizure
• Side lying patient —> to prevent aspiration
‣ After Seizures: Diazepam (valium) 10mg
‣ TREATMENT: Termination of Pregnancy (deliver the pregnancy NOW) via emergency CS)
‣ PIH mothers —> Baby is SMALL FOR GESTATIONAL AGE (no RDS/good lungs)
◦ECLAMPSIA
CARDIAC DISEASE
◦Goal: Decrease workload of the heart
◦Classifications:
‣ Class I:
• diagnosed with heart condition but no (-) s/sx
• VAGINAL delivery with DOUBLE set-up
‣ Class II
• (+) s/sx with heavy physical activity
• VAGINAL delivery with DOUBLE set-up
‣ Class III
• (+) s/sx Normal physical Activity
• CAESAREAN SECTION
‣ Class IV
• (+) s/sx @ Rest
• CAESAREAN SECTION
◦Management:
‣ Digitalis/Digoxin —> TOXICITY —> Antidote: DIGIBIND
• Bradycardia - assess baseline
• Anorexia
• N/V
• Diarrhea
• Abd. cramps
• Vision changes (halos - yellow or green)
‣ Penicillin
• to maintain
• Presence of Damage: lifetime
‣ Stress Reduction
‣ Increase Iron in the DIET —> ask pt what she usually eats
‣ ENOUGH sleep 8 hours (night) + 2 hours (day)
‣ Cardiac Mothers —> SGA
GDM
◦Screening - starts @ 24 weeks
◦increase glucose —> To Baby —> MACROSOMIA
◦decrease production of phosphatidyl glyceral (responsible for surfactant) —> RDS
◦Signs and Symptoms:
‣ Polyuria
‣ Polydipsia - thirst mechanism
‣ Polyphagia - cell hunger
◦Management:
‣ Proper screening
• Oral Glucose Tolerance Test(OGTT): @24 weeks
◦(4 times blood extraction every hour for 4hrs)
◦Fasting 8-10hrs
‣ Insulin (GDM, TYPE I, TYPE II)
• Insulin Requirement:
◦First trimester: Normal or Decrease (if both is presence —> DECREASE)
◦Late: Increase
◦Delivery: Insulin back to normal
◦Breast feeding: Insulin reqs is Zero
INTRAPARTUM
COMPONENTS OF LABOR
Passage
• PELVIS
◦Gynecoid - NORMAL
◦Anthropoid - oval shaped
‣ Possible for vaginal deliver
◦Platypelloid - reversed oval shaped
‣ Possible for NSVD —> difficult
◦Android - heart shaped
‣ CPD —> Caearean section
Passenger
• Head measurements
◦Biparietal = 9.25 cm
‣ one parietal bone to another
‣ Smallest
◦Suoccipitobregmatic = 9.5 cm
‣ Full flexed position
‣ IDEAL
◦Occipitofrontal = 11.75
‣ from occiput to the frontal bone
‣ Neutral neck position
◦Occipitomental = 13.5 cm
‣ From the occiput to the mentum (chin)
‣ Head is extended —> face presentation
• Fetal Lie
◦LONG AXIS (Spine)
‣ Longitudinal
• cephalic
• breech
‣ Transverse
• shoulder presentation
• Fetal attitude
◦DEGREE OF FLEXION
‣ Good flexion
• the chin is touch the chest
‣ Moderate Flexion
• Neck is in neutral
‣ Poor flexion
• extension
• Fetal station
◦ISCHIAL SPINE
‣ Station 0 - ENGAGED
• cm below ischial spine is POSITIVE
• NO AMBULATION
‣ Floating is NEGATIVE
• cm above the ischial spine
• Fetal presentation
◦Fetal part presenting to the cervix
‣ Cephalic
• IDEAL —>95%
• Presenting part: Occiput or head
• Moulding: head is adjusting
• VARIATIONS:
◦Vertex
‣ head is fully flexed
‣ ONLY performed the CARDINAL MOVEMENTS
‣ Engaged
‣ Descent
‣ Flexion (9.5cm)
‣ IR (internal rotation)
‣ Extension (9.25cm)
‣ ER (external flexion)
‣ Expulsion
◦Military
‣ Moderate flexion
‣ Occipitofrontal (11.75cm)
◦Face
‣ Occipitomental (13.5cm)
‣ Poor flexion or hyper extended
◦Brow
‣ Head is partially extended and unstable
‣ Presenting part: Brow
‣ CAN MANIPULATE —> can partly flexed
‣ Breech
• Presenting part: Butt or sacrum
• Leopold’s Maneuver —> help know the presenting part and position
◦Empty the bladder
◦Position the supine leg is slightly flexed
◦Put a roller towel
◦WARM HANDS
• BEmONC - eminent BREECH
• External Version
◦Assisted ultrasound
◦Turn breech to Cephalic
◦Bladder empty
◦Make sure the umbilical cord is not short
‣ Frank Breech
• Legs is extended and BUTTOCKS ONLY
• Most ideal in breech
• Common complication: DDH
‣ Complete breech
• BOTH legs is flexed “indian sit”
‣ Incomplete breech
• one leg is flexed and one leg is extended
‣ Footling breech
• “the grudge” position
• In pushing the foot will be the presenting part
‣ Shoulder
• Presenting part: acromion process or shoulder
• NO NSVD
• CAESAREAN SECTION
• Fetal position Bet
◦3 LETTERS
◦FIRST and LAST LETTER a
◦Fetal presenting part with the Maternal Pelvic Quadrant Ex:
‣ 1. R or L ROP
‣ 2. O M (cephalic) S (breech) AC (shoulde)
‣ 3. Land Mark Points A (anterior) P (posterior) T (transverse)
◦ROP
‣ Most painful
‣ BACK MASSAGE
Power
◦Primary Power: Contraction
PARTOGRAPH
◦Secondary power: Mother’s ability to push
sosecs
minutes nosecs
◦Increment: beginning of contraction
410
◦Acme: Peak
◦Decrement: starts to go down NY macosecs
◦Frequency
‣ Beginning of one contraction to the beginning of the next
‣ In minutes
◦Duration
‣ In seconds
‣ Beginning of one contraction to the end of the SAME contraction
◦Interval or Resting Periods
‣ End of one contraction to the beginning of the next
‣ INTENDED FOR INTERVENTION OR ASSESSMENT
• PSYCHE
◦Relaxed
‣ Good labor
◦Anxiety
‣ Prolong Labor
◦Preparation of Labor and delivery
‣ 1. Bradley
• HUSBAND coached birth
‣ 2. Dick - Read
• BREATHING
• Active labor - (breath and blow)
• Transitioning - (Pant blow)
‣ 3. Le Boyer
• ENVIRONMENT
‣ 4. Lamaze
• Psychoprophylaxis (NO MEDS)
TRUE LABOR FALSE LABOR
◦(+) cervical dilatation (MARKER) ◦(-) cervical dilatation
◦ Effects of Ambulation: increase ◦Effects of ambulation: Decrease
duration and frequency pain
◦Location of pain: Lower back radiating ◦Location of pain: abdominal pain
to abdomen (braxton or pooping)
PARTOGRAPH
• Informations include:
◦Progress of Labor
◦Fetal Status
◦Maternal Status
• Starts at 4 cm
• Cervical Dilatation: put x
• T: write
• PR: dot
• BP: Line or arrow
• Urine: put check or 0
• IE: every 4hrs (w/ AB evey 2hrs)
• If it crosess alert: ASSESS and prepare for possible transfer
• If it crosses action line: TRANSFER
UNANG YAKAP
• Preparation:
◦3 pairs of surgical sterile gloves
‣ 2 of which use by the OB (double gloving)
‣ 1 use for pediatrician
◦2 warm blankets
‣ 1 for the drying
‣ 1 for the baby and mother
◦1 bonnet
◦cord care sets
‣ scissors
‣ 1 metal clamp
‣ 1 umbilical cord clamp
◦oxytocin 10 iu IM (inject mother to preven uterine atony)
◦Vitamin K (right)
◦Erythromycin
◦Hep B (left)
• Note the time of birth the doctor will say
• Immediate and thorough drying (minimum of 30 seconds)
◦Rapid assessment:
‣ crying related to BREATHING
‣ Tone (if flaccid stop unang yakap and do the recuscitate)
◦Do not wipe of vernix
◦Do not bath the baby for the first 6 hours
◦newborns are OBLIGATORY NOSE breathers
◦If neccessary: suction
‣ 1. mouth - risk for aspiration pneumonia
‣ 2. nose - (baby- periods of apnea without cyanosis)
• Initiate skin to skin contact (promote bonding)
◦placing prone to the mother’s abdomen or between the breast
CEmONC
10 Principles:
1. Parenteral Antibiotics (initial leading dose)
2. Parenteral Oxytocin (3rd stage of labor)
3. Parenteral Anticonvulsant for pre-eclampsia/eclampsia
4. Placenta (manual removal) - controlled cord traction with counteraction
5. Retained Fragments - Manually removed
6. IMMINENT Breech
7. Corticosteroids
8. Unang Yakap
9. BT
10. Caesarean Section
INTRAPARTUM (ABNORMAL)
TESTS:
Non-stress Test (Stress - contraction)
◦post mature
◦hx still birth
◦DM
• Monitor the fetal movement and fetal heart rate
• Give mother buzzer (instruct to press the bell if the baby move)
• Duration of procedure: 20 mins
• Watch 3-5 movements = increase beat of 15bpm per movement
◦Record: REACTIVE NST (pwedi mag induced ug labor)
• If no change in HR (sometimes decrease) and fetal movement
◦Record: NON-REACTIVE NST
‣ perform another test —> CONTRACTION STRESS TEST (Oxytocin Challenge Test) - trial contraction
‣ Hook 1 IV and diluted Oxytocin
• Look for: Late deceleration
• If deceleration is on PEAK = Early deceleration
◦Documeent: NEGATIVE of deceleration
◦Good for induction
• If late deceleration;
◦Document: POSITIVE
◦Caesarean Section
4 ps —> DYSTOCIA
◦Anthropoid, Platypelloid, android
◦Malposition or Malpresentation
◦Hypertonic Labor Pattern
‣ During LATENT PHASE
‣ not effective in dilatation and PAINFUL (PRIORITIZE) —> Analgesia
◦Hypotonic Labor Pattern
‣ During ACTIVE
‣ Due to full bladder and early analgesia (SHOULD GIVE DURING ACTIVE PHASE instead of latent)
‣ EMPTY the BLADDER (stimulation = sound of flowing water) or (alternative warm and tap water)
‣ Give Oxytocin (monitor BP)
• it can decrease bp
• Methergine = can increase BP
• Complain the Severe Pain due to Titanic Contractio
◦STOP THE INFUSION and Call the Doctor
◦Precipitate Labor
‣ Assess patient
‣ Fast Labor
‣ Risk:
• Grand-multiparity
• Large pelvis
• Small pelvis
‣ Focus: PREVENTION
• 1. Injury
• 2. Perineal Laceration —> mgt: EPISIOTOMY
◦Vaginal Laceration
◦Not need suture
◦Stop bleeding through balloon catheter and inflate or vaginal packing
• 3. Baby Injury
‣ Management
• EPISIOTOMY
• Pant-blow breathing
◦Pre-Term Labor
‣ S/Sx:
• Cervical Dilatation (4cm)
• Active contractions
‣ Management:
• Corticosteroids (prioritize) - for lung surfactant
◦Test to determine lung maturity
‣ 1 mL of _____
‣ Bubbles: mature
‣ Viscosity: Unmature
‣ L/S N - 2:1
‣ Common Problem:
• 1. RDS
• 2. Necrotizing enterocolitis
• 3. Patent Ductus arteriosus
• 4. Intraventricular Hemorrhage —> Hydrocephalus
• 5. Blindness
• 6. Anemia
◦Due to pre-term or blood sample
AfterPains
◦NEVER apply heat or warm compress
◦May give NSAIDS
POST-PARTUM BLUES
◦70% Experienced
◦secondary to: hormonal change
◦Therapeutic communication —> Listening
◦Extended taking in phase (last for 6 months)
◦Assess after 6 months —> postpartum depression
POST-PARTUM DEPRESSION
◦25%
◦First 6 months
◦NO LONGER OUR CARE
◦REFERRAL
POST-PARTUM PSYCHOSIS
◦Hx of mentally unstable
◦within first month
◦Priority: SAFETY
‣ separate the baby from the mother
◦Psychotherapy