SAINT GABRIEL COLLEGE KALIBO, AKLAN 2013-2014 MATERNAL AND CHILD NURSING MR. HARLEY L.

DELA CRUZ RN MAN Instructor

SYSTEMIC CHANGES DURING PREGNANCY

1. CARDIOVASCULAR SYSTEM HEART As diaphragm rises, the heart is displaced laterally Point of Maximum Impulse o Normally located at Fifth Intercostal Space Mid-clavicular Line on the Left Side {5th ICS-MCL (L)} o This shifts to Fourth Intercostal Space Lateral Axillary Line on the Left Side {4th ICS-LAL (L)} Exaggeration of first and second heart sounds {S1 (Lub) and S2 (Dub)} due to INCREASED CARDIAC OUTPUT Appreciation of S3 (third heart sound; ventricular filling) due to INCREASED CARDIAC OUTPUT Appreciation of a MURMUR, which is almost always SYSTOLIC (all pathologic) in nature o Innocent in nature o As soon as mother delivers placenta, excess fluid is absorbed or excreted, then the MURMUR DISAPPEARS Blood Volume is INCREASED due to INCREASE IN WATER RETENTION HIGHEST CARDIAC OUTPUT IN PREGNANCY Twenty-eight to thirty-two weeks (28-32 wks) Age of Gestation During labor and delivery Immediately postpartum Therefore, be careful and monitor pregnant cardiac patient Supine Hypotensive Syndrome o When mother assumes supine position, she develops hypotension o Weight of uterus presses on the VENA CAVA This results into DECREASED VENOUS RETURN This results into DECREASED CARDIAC OUTPUT End result is HYPOTENSION Therefore, SUPINE POSITION IN PREGNANCY IS NOT ALLOWABLE (particularly in the second and third trimester) POSITION OF CHOICE o Side-lying Left (so as not to impede the Vena Cava) o Left Lateral Position o Sims Left Position With arm flexed Leg flexed Weight of uterus would be ON THE BED 2. HEMATOLOGIC CHANGES 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,

Physiologic Anemia pseudo anemia of pregnant women 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 2nd trimester Hct should not <32%

HgbShdn't< 10.5% pathologic anemia if lower PHYSIOLOGIC ANEMIA Due to increase in plasma value o Dilutes circulating Red Blood Cells o Therefore, take the Complete Blood Count in the initial assessment to get the blood picture of the client Give iron supplementation o Do this is the second trimester because this is the time when iron stores are depleted o Best taken at night o Metallic taste is nauseus o Give with food o A gastric irritant o Followed by orange juice o Acidic environment provides greater absorption o Advise that client will have black stool o Client taking iron is constipated o Therefore, increase oral fluid intake and iron

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 HEMODILUTION Due to increase in PLASMA VOLUME

CHANGES IN PLATELET Expected during Postpartum Due to blood loss, there is TRANSIENT INCREASE IN PLATELET COUNT This predisposes to THROMBOSIS due to platelet aggregation This would then predispose to EMBOLISM Therefore, EARLY AMBULATION is NEEDED Important Concept! WHITE BLOOD CELL LEVELS INCREASE (particularly in labor) LEUKOCYTOSIS is STRESS-INDUCED o Increased by 20K to 30K Therefore, DO NOT CORRELATE THIS TO INFECTION NO FEVER NO abdominal / uterine infection 3. RESPIRATORY SYSTEM Diaphragm is prevented from descending in inspiration on second and third trimester Tidal Volume is increased o Lungs are easily filled o Client tends to hyperventilate o Therefore, RESPIRATORY ALKALOSIS OCCURS

This is manifested by: o Tingling sensation on the lower ends of extremities o Lightheadedness Nursing Management o Breathe through a paper bag or through cupped hands Important Concepts! During labor, there is increase in oxygen consumption by three-hundred percent (300%) o When exhaling, pursed lip breathing is practiced during labor Swelling of mucosa during estrogen o Prone to epistaxis o Therefore, caution in picking nose! 4. GASTROINTESTINAL TRACT- 1st trimester change PICA Craving for food Unedible (i.e. rice grains) No reason for this May be due to hypersalivation If not checked, this causes vomiting EPULIS OF PREGNANCY Effect on gums Swelling of gums due to INCREASED ESTROGEN Therefore, CONTINUE TO USE SOFT BRISTLE TOOTHBRUSH ESOPHAGUS Progesterone is a relaxant of smooth muscle o Effect is on lower esophageal sphincter o It is more relaxed Pressure of Lower Esophageal Sphincter (LES) is less than pressure on Cardiac Sphincter (CS) o If LES pressure is > CS pressure No regurgitation o If LES pressure is < CS pressure o There is HEARTBURN OR PYROSIS; SUBSTERNAL PAIN related to eating Nausea and Vomiting Human Chorionic Gonadotropin o Primigravida Mostly manifests this Peaks at FIRST TRIMESTER o At two (2) to three (3) months of pregnancy o At eight (8) to twelve (12) weeks of pregnancy Nursing Responsibility o Provide: Dry unsalted crackers Ice chips Small, frequent feedings Six (6) times a day This is the best among all the options Split food into two halves and give meals after every two (2) hours Less fatty foods in diet Do not lie supine after eating Encourage ambulation 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 Constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava has pectin thats constipating veg petchy, malungay. - exercise -mineral oil excretion of fat soluble vitamins Flatulence avoid gas forming food cabbage Heartburn or pyrosis reflux of stomach content to esophagus

- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical Increase salivation ptyalsim mgt mouthwash Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort Interjected Concept! Most common surgical complication of pregnancy is ACUTE APPENDICITIS! Right Upper Quadrant pain is not expressed during pregnancy or on flank as the appendix rises in pregnancy Nursing Management Do not assume supine position after eating Gradual ambulation Small Frequent feeding Important Concepts! Due Progesterones relaxing effect on smooth muscles, there IS INCREASED GASTRIC EMPTYING TIME o Water and electrolytes absorbed by walls o This gives rise to hard stools o This eventually leads to constipation Management o Increase fluid intake o Provide high fiber diet Tendency is to do valsalva maneuver o This leads to hemorrhoids Progesterone also decreases stretchability of vessels. o This also causes hemorrhoids 5. RENAL OR EXCRETORY SYSTEM 5.1) Due to Progesterone There is relaxation of renal pelvis and the ureter Therefore, URINE STAGNATION occurs in the URETER (no longer peristaltic) Therefore, the PATIENT IS PRONE TO URINARY TRACT INFECTION 5.2) Glomerular Filtration Rate in Pregnancy Increased Cardiac Output Increased Glomerular Filtration Rate But absorptive capacity of nephrons is not increased (NO CHANGE IN ABSORPTION) Therefore, the following will be spilled in the urine: o Sugar o Carbohydrates o Protein Changes in Urination Urinary frequency o Present in First and Third Trimester o No Urgency Second Trimester o This disappears o Uterus starting to enlarge in First Trimester o Uterus becomes abdominal organ in the second trimester o This releases pressure on the bladder Third Trimester o Uterus enlarges and presses again against the bladder in the Third Trimester 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

Important Concepts! Carbohydrates in the urine is NORMAL Acceptable level of Carbohydrates in the urine o Qualitative analysis o Trace = +1 sugar

Protein in the urine is NORMAL Acceptable level of Proteins in the urine o Trace = +1 Protein o Or less than 250 mg / dl If Protein level in the urine is greater than 250 mg / dl, CONSIDER PREGNANCY INDUCED HYPERTENSION

Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Important Concepts! If you LOSE PROTEIN and RETAIN WATER, this leads to EDEMA o This is Physiologic Edema o This type of edema is normal and expected in pregnancy

TYPE OF EDEMA LOCATION OF EDEMA TIME OF OCCURRENCE

PHYSIOLOGIC

PATHOLOGIC

Dependent portion of the Independent portion; Upper extremities, body; leg or lower face, arms extremity Afternoon or PM Althroughout the day but evident in the morning Ring cannot be removed

Important Concepts! No management for PHYSIOLOGIC EDEMA o Supportive o Leg raises For Pathologic Edema o Identify the cause of the edema o Most common cause is PREGNANCY INDUCED HYPERTENSION

6. ENDOCRINE SYSTEM Hypertrophy is present in most of the endocrine system organs Thyroid Gland is hyperthrophied Increased production of thyroid hormones Therefore, there is RISK FOR HYPERTHYROIDISM o Patient may die when in labor with hyperthyroidism o Thyroid Storm leads to arrhythmia o Arrhythmia leads to DEATH Therefore, monitor so that client goes EUTHYROID (with normal thyroid hormonal level) 7. NEUROLOGIC SYSTEM This is the only system UNAFFECTED during pregnancy The following are normal during pregnancy: o Blurring of vision Headache 8. MUSCULOSKELETAL SYSTEM PLACENTA IS CAPABLE OF PRODUCING RELAXIN Relaxes pelvic joints Therefore, the pelvis is more movable DIASTASIS RECTI Separation of rectus abdominis muscle Only fascia remains in between This is normal Rectus abdominis muscle goes back after pregnancy (coarctate) PHYSIOLOGIC LORDOSIS

Known as the PRIDE OF PREGNANCY Increased outward curvature o There is back pain Nursing Management o Do PELVIC ROCKING Place direct pressure on lumbar area o Prevent supine position Increases pressure on the spine o No analgesics Waddling Gait Awkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes Leg Cramps Causes: prolonged standing, over fatigue, Ca& phosphorous imbalance(#1 cause while pregnant), chills, oversex, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: o Increase Ca diet-milk(IncCa&Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab. Vit D for increased Ca absorption dorsiflexion 9. Skin Changes Brought about by hormonal changes - ESTROGEN o Cloasma Mask of pregnancy Brown pigmentation of nose, chin, cheeks o Melasma Darkening of the neck o Linea Negra From the symphysis pubis to the umbilicus; brown pinkish line o Striae Gravidarum Silvery in color Due to distention of the collagen of the abdomen as the uterus enlarges

Varicosities pressure of uterus - use support stockings, avoid wearing knee high socks - use elastic bandage lower to upper Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest position 10. Problems Related to the Change of Vaginal Environment: a. Vaginitits trichomonasvaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa wants alkaline S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont 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

b. Moniliasis or candidiasis due to candida albicans, fungal infection. Color white cheese like patches adheres to walls of vagina. Management antifungal Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifomaacuminata due to papilloma virus o Mgt: cauterization 11. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue avoid scratching, use coconut oil, umbilicus is protruding 12. Breast Changes increase hormones, color of areola & nipple

precolostrums present by 6 weeks, colostrums at 3rd trimester Breast self exam- 7 days after mens supine with pillow at back Quadrant B upper outer common site of cancer

Test to determine breast cancer: 20-39 years old women-monthly BSE and CBE every 3 years women 40 years and older- annual mammogram, monthly BSE and yearly CBE NOTE: Ovaries rested during pregnancy 1. Pelvic Examination internal exam 1. empty bladder 2. universal precaution EXT OS of cervix site for getting specimen Site for cervical cancer Pap Smear cervical cancer - composed of squamous columnar tissue 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 Stages of Cervical Cancer Stage 0 carcinoma insitu 1 cancer confined to cervix 2 - cancer extends to vagina 3 pelvis metastasis 4 affection to bladder & rectum

Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory) First Trimester: No tanginal signs &sx, surprise, ambivalence, denial sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg, nutrition 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. Third Trimester: - mom has personal identification on appearance of baby Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette best time to do shopping. Most common fear let mom listen to FHT to allay fear Lamaze classes

Pre-Natal Visit: 1. Frequency of Visit:

1st 7 months 1x a month 8 9 months 2 x a month 10 once a week post term 2 x a week 2. Personal data name, age (high risk < 18 &>35 yrs old) record to determine high risk HBMR. Home base moms record. Sex ( pseudocyesis or false pregnancy on men & women) Couvade syndrome dad experiences what mom goes through lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation financial condition or occupational hazards, education background level knowledge 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 Second trimester: normal weight gain Third trimester: normal weight gain Minimum wt gain 20 25 lbs Optimal wt gain 25 35 lbs 1.5 3 lbs 10 12 lbs 10 12 lbs (.5 1lb/month) (4 lbs/month) (1 lb/wk) (4 lbs/ month) ( 1lb/wk)

Danger signs of Pregnancy C - chills/ fever - infection Cerebral disturbances ( headache preeclampsia) A abdominal pain ( epigastric pain aura of impending convulsions B boardlike abdomen abruption placenta Increase BP HPN Blurred vision preeclampsia Bleeding 1st trimester, abortion, ectopic pre/2nd H mole, incompetent cervix 3rd placental anomalies S sudden gush of fluid PROM (premature rupture of membrane) prone to inf. E edema to upper ext. (preeclampsia)

FETAL CIRCULATION PLACENTA Functions of the Placenta Mnemonic is NIMEE N is for: NUTRITION or NIDATION o Supplying nutritional requirements of the fetus o Nutrients and oxygen exchanged o THE BLOOD IS NOT EXCHANGED o Modes of Exchange Active transport from mother to baby Diffusion Pinocytosis I is for: IMMUNOLOGIC o If not pregnant, all foreign matter antigens are rejected o Baby is a foreign matter o But immunologic function of the placenta removes the MAJOR HISTOCOMPANITIBILITY COMPLEX TYPE 2 (MHC TYPE 2) o This is responsible for rejecting the foreign body M is for: METABOLIC FUNCTION o In Fetal Circulation Nutrient exchange occurs NO PORTAL CIRCULATION EXISTS Liver is bypassed as METABOLISM (by the liver) is NOT NEEDED E is for: ENDOCRINOLOGIC o Hormones are secreted only during pregnancy: Human Placental Lactogen Human Chorionic Gonadotropin Relaxin E is for:

EXCRETORY Metabolites excreted by Placenta and NOT BY THE KIDNEY NOR THE LIVER

Question: In the fetal circulation, which part has the higher pressure? Answer: Right Side Important Concepts!!! There is ONE-WAY flow of blood from the RIGHT ATRIUM to the LEFT ATRIUM Therefore, Right AtriumPressure > Left AtriumPressure SHUNTS When the baby is delivered, the shunts are normally removed o Ductus Venosus o Foramen ovale Two (2) types of Closure Functional Closure Anatomic Closure FORAMEN OVALE Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED Anatomically, it can persist up to one (1) year after delivery Important Concept! o Therefore, in auscultation in twenty-eight (28) day old baby There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR o A PHYSIOLOGIC MURMUR IN NEONATES DUCTUS ARTERIOSUS Functional Closure o Ten to ninety-six hours (10 96 hrs) after birth or approximately four (4) days Anatomically o Two to three months (2 3 mos.)

DRUGS TAKEN DURING PREGNANCY NSAIDs

Indomethacin o Not advisable o Causes premature closure of the Ductus Arteriosus o Not compatible with life o No supply to the lower half of the body of the fetus PARACETAMOL IS ALLOWED

ASPIRIN
Causes persistence of Ductus Arteriosus even after delivery No functional / anatomic delivery of Ductus Arteriosus Important Concept! o Stop taking about four (4) weeks prior to confinement

ANESTHESIA OF CHOICE EPIDURAL ANESTHESIA Upon active labor (3 cm) Check Blood Pressure Side effect is hypotension Important Concepts! No Oxytocin No Methergine No augmentation of labor All natural labor

General Anesthesia only given when crowning occurs o If given early, this crosses the placenta and the effect is a decrease in the APGAR SCORE

POSITION OF CHOICE DURING LABOR Will deliver at these positions: Semi-sitting Semi-Fowlers position o Not lithotomy Femoral vessels are obstructed DELIVERY OF CHOICE Outlet forceps extraction Vaginal In Normal Spontaneous Delivery o Normal blood loss is 500 ml o 500 ml blood loss is hemorrhage In Caesarian Section o Normal blood loss is 800 1,000 ml o 1,000 ml blood loss is hemorrhage TIME OF LAST MEAL / DRINK For Caesarian Section o It should be NPO For aspiration if CS or NSD o It limits use of anesthesia if patient had a meal Normal Spontaneous Delivery (NSD) o Normal anesthesia: General Anesthesia via I.V. or sedation (not given with a full stomach) o If client had a meal and has a full stomach, client will gag and aspirate o Therefore, use REGIONAL or LOCAL ANESTHESIA Medications: o Alcoholic mothers Sedation takes a longer time to take effect

NOTE: FIRST STAGE OF LABOR Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus to monitor contractions 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 Placental reserve 60 sec o2 for fetus during contractions Duration of contractions shouldnt >60 sec Notify MD Main Nursing Problem during the FIRST STAGE OF LABOR o To ALLEVIATE PAIN or DISCOMFORT of client

Common Board Question! Which of the following phases in the first stage of labor does the client feel most pain and discomfort? Answer: TRANSITIONAL PHASE

Rationale: Client loses sense of control in this most uncomfortable phase of the first stage of labor In Latent Phase o Client is still able to smile In Active Phase o Client is unable to smile In Transitional Phase o Mother is now frowning o Remove fingers from the uterus o This gives additional pain to the mother o Mother loses sense of time Mom has headache check BP, if same BP, let mom rest. If BP increase, notify MD pre-eclampsia

Health teachings: Ok to shower NPO GIT stops function during labor if with food- will cause aspiration Enema administer during labor To cleanse bowel Prevent infection Sims position/side lying 12 18 inch ht enema tubing Check FHT after adm enema Normal FHT= 120-160

Signs of fetal distress: Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute) mecomium stain amnion fluid- stained amniotic fluid in non breech presentation fetal thrushing hyperactive fetus due to lack O2; hyperactivity of the fetus as it struggles for more oxygen Emotional support is provided for the woman in labor by keeping her constantly informed of the progress labor Solid or liquid foods are to be avoided because Digestion is delayed during labor A full stomach interferes with proper bearing down May vomit and cause aspiration Enema not a routine procedure Purposes A full bowel hinders the progress of labor effectiveness of enema in labor can be determined by evaluating change in uterine tone and the amount of show Expulsion of feces during second stage of labor predisposes mother and baby to infection Full bowel predisposes to postpartum discomfort Procedure of enema administration Enema solution may either be soap suds or Fleet enema (contraindicated in patients with toxemia because of its sodium content) Optimum temperature of the solution 105F to 115F (40.5 C 46.1C) Patient on side lying position When there is resistance while inserting rectal catheter, withdraw the tube slightly while letting a small amount of solution enter Clamp rectal tube during a contraction Important nursing action: Check FHR after enema administration to determine fetal distress Contraindications to enema in labor Vaginal Bleeding Premature labor Abnormal fetal presentation or position Ruptured membranes Crowning Encourage the mother to void every 2 3 hours by offering the bedpan because A full bladder retards fetal descent Urinary stasis can lead to urinary tract infection A full bladder can be traumatized during delivery Perineal prep done aseptically. Use No. 7 method, always from front to back

Perineal shave not a routine procedure; maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth Encourage Sims position because it: Favors anterior rotation of the fetal head Promotes relaxation between contractions Prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel which brings unoxygenated blood back to the heart); pressure results in Supine Hypotensive Syndrome, also called Vena Cava Syndrome (Figure 16). Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP. Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage because It leads to unnecessary exhaustion Repeated strong pounding of the fetus against the pelvic floor will lead to ce4rvical edema, thus interfering with dilatation and prolonging length of labor. Abdominal breathing advised for contractions during the first stage in order to reduce tension and prevent hyperventilation Supine Hypotensive Syndrome Administer analgesics as ordered. The dosage is based on the patients weight, status of labor and age of gestation. Narcotics are the most commonly used, specifically Demerol. Pharmacologic effect: depresses the sensory portion of the cerebral cortex. It is not only a potent analgesic, it is also a sedative and an antispasmodic. It is not given early in labor because it can retard, progress (is an antispasmodic), but cannot also be given if delivery is only one hour away because it causes respiratory depression in the newborn (that is why it can be given only if cervical dilatation is 6 8 cm.) Given 25 100 mg., depending on body weight Takes effect in 20 minutes patient experiences a sense of well being and euphoria Narcotic antagonist (e.g. Narcan, Nalline) are given to counteract any toxic effects of Demerol Assist in administration of regional anesthesia preferred over any other form of anesthesia because it does not enter maternal circulation and so does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved. Xylocaine is the anesthetic of choice Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose aids in proper functioning of the fetus (purplish discoloration of the skin due to blood in subcutaneous tissues) area or hematoma in the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second stage pushing. Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management: Flat on bed for 12 hours and increase fluid intake Common side effects Hypotension because Xylocaine is vasodilator. Management turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered. Fetal bradycardia Decreased maternal respirations A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported from the Labor Room to the Delivery Room when the cervix is fully dilated or when there is bulging of the perineum. Mutiparas, on the other hand, are transported when cervical dilatatoniis 7 8 cm. NOTE: SECOND STAGE OF LABOR FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS In Primigravida o One (1) to four (4) hours long In Multigravida o Twenty (20) to forty-five (45) minutes only Main Problem in Second Stage of Labor is STILL PAIN

 Nursing management is focused on the ALLEVIATION OF PAIN!!! Transition Period when the mood of the woman suddenly changes and the nature of contractions intensify 1. Characteristics 1.1 If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid to drain) is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes. Amniotomy, however, cannot be done if station is still minus, as this can lead to cord compression 1.2 Show becomes more prominent. 1.3 There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen. 1.4 Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption. 1.5 In primis, baby is delivered with 20 contractions (40 minutes); in multis, after 10 contractions (20 minutes). 2. Nursing actions are primarily comfort measures 2.1 Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves discomfort from contractions 2.2 Proper bearing down techniques: push with contractions 2.3 Controlled chest (costal) breathing during contractions 2.4 Emotional support

MAL-PRESENTATIONS: 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 Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. Occipito LOA left occipitoant (most common and favorable position) side of maternal pelvis LOP left occipito posterior LOP most common mal position, most painful ROP squatting pos on mom Breech- use sacrum - put stet above umbilicus Shoulder/acromniodorso LADA, LADT, LADP, RADA Chin / Mento LMA, LMT, LMP, RMP, RMA, RMT, RMP IN SECOND STAGE: 7 8 multi bring to delivery room 10cm primi bring to delivery room Lithotomy position put legs same time up Bulging of perineum sure to come out Breathing panting ( teach mom) Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor. Episiotomy median less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula) Mediolateral more bleeding & pain, hard to repair, slow to heal -use local or pudendal anesthesia. Ironing the perineum to prevent laceration Modified Ritgens maneuver place towel at perineum 1.)To prevent laceration 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby. LSA left sacro anterior LST, LSP, RSA, RST, RSP

Nursing Care: When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine ligaments

 As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid and shallow breathing to prevent rapid expulsion of the baby). If panting is deep and rapid, called hyperventilation, the patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms because of respiratory alkalosis. Management: let the patient breathe into a brown paper bag to recover lost carbon dioxide; a cupped hand over the mouth and nose will serve the same purpose. Assist in episiotomy (incision made in the perineum primarily to prevent lacerations). o Other purposes Prevent prolonged severe stretching of muscles supporting the bladder or rectum Reduce duration of second stage when there is hypertension or fetal distress Enlarge outlet, as in breech presentation or forceps delivery

NOTE: THIRD STAGE OF LABOR DELIVERY OF BABY TO DELIVERY OF PLACENTA Lasts for five (5) to ten (10) minutes Maximum waiting time is thirty (30) minutes Beyond thirty (30) minutes is ALREADY ABNORMAL SIGNS OF PLACENTAL EXPULSION: 1. Calkinss Sign Uterus becomes firm and globular 2. Lengthening of the Cord 3. Sudden Gush of Blood 4. Rising of the Uterus into the Abdomen Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus after the delivery of the placenta Drugs for Third Stage of Labor These drugs cause contraction of the uterus 1. ERGOTRATES Includes METHERGINE I.V. or I.M. Best given immediately after delivery of placenta Massive contraction of the uterus traps placenta inside Therefore, do not give before placental expulsion 2. OXYTOCIN Given prior to expulsion of placenta to add to contraction Given at minimal amounts Normally at a rate of eleven to twelve drops per minute (11-12 gtts / min) After delivery of placenta, give oxytocin at GREATER AMOUNTS

Important Nursing Considerations! Methergine o Prior to administration, check blood pressure o If BP is greater than 140/90, WITHHOLD METHERGINE Oxytocin o Never given in direct bolus o Never push o Causes UTERINE HYPERTONUS Tetanic contractions of the uterus or UTERINE ATONY o Always dripped Ten (10) units with one (1) liter o Duration and Interval of Contraction in Uterine Atony / Hypertonus o Duration of Contraction Greater than seventy seconds (>70 secs) In Transitional Phase of First Stage of Labor, duration of contraction is about sixty (60) seconds o Interval Less than two (2) minutes This means that rest period is decreased Maximum interval must be maintained at two (2) to three (3) minutes

Therefore, STOP INFUSION OF OXYTOCIN AS SOON AS POSSIBLE DO PROCEDURES IN LATE DECELERATION

Additional Important Concepts! Oxytocin o A potent vasoconstrictor o Side effect Initially is HYPERTENSION o If given in bolus Hypertension will be REVERSED TO HYPOTENSION Therefore, DO NOT GIVE OXYTOCIN IN BOLUS Also causes WATER INTOXICATION o Therefore, assess lungs of client o Crackles will be present due to pulmonary edema due to water retention by oxytocin Primary Problem in Third Stage of Labor Bleeding or Hemorrhage Important Concepts! Uterus must be at level of umbilicus or about one centimeter (1 cm) above If it is three centimeters (3 cm) above the umbilicus, UTERUS IS NOT CONTRACTED o There would be BLEEDING First thing to do: o Massage the uterus to attempt contraction o Increase the rate of oxytocin drip Nurse does this Rate is increased from ten drops per minute (10 gtt/min) to twelve to fifteen drops per minute (12 15 gtt/min) o Place icepack over the abdomen Remove compress every ten minutes and replace This prevents necrosis and blackening of the tissues Inspect Perineum o How to measure amount of bleeding? o Utilize the PADS Count and Weigh Guide: One gram is equivalent to one milliliter (1 g = 1 ml) o Qualitative Approach Mild Bleeding One (1) pad saturated in one (1) hour Moderate Bleeding One (1) pad saturated in thirty (30) minutes Heavy Bleeding One (1) pad saturated in fifteen (15) minutes Heavy Bleeding Perineal pads saturated at one (1) hour and if blood clots are present Palpate Abdomen Uterus contracted Perineum has bleeding Bleeding from episiotomy (done if there is crowning or +4 station) Laceration not appraised Bleeding from cervical laceration Most common cause of bleeding Vaginal wall bleeding

o o

Important Concept! DO NOT ENCOURAGE PUSHING IF CERVIX IS NOT FULLY DILATED Question When is the best time to ask client to push? Answer Second Stage of Labor Important Concepts! Main purpose of pushing o To shorten the Second Stage of Labor Ask client to PANT-BREATHE if there is an urge to push This prevents VALSALVA MANEUVER

Remember, FIRST STAGE PUSHING IS NOT ADVISABLE In the Third Stage of Labor, the NURSING RESPONSIBILITY is to PROVIDE MEASURES TO PREVENT HEMORRHAGE

Other Causes of Bleeding Bladder Distention o Therefore, MOTHER MUST VOID AFTER GIVING BIRTH o Offer bedpan every hour or accompany the mother to the bathroom (patient has HYPOTENSION) o First twelve (12) hours post partum It is NORMAL for mother to go into DIURESIS Absorbed water must be eliminated o After twelve (12) hours, there is difficulty in voiding due to FATIGUE of TRIGONE of BLADDER because of CONSTANT PRESSURE EXERTED BY CONTRACTING UTERUS This results to a DISTENDED BLADDER Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY This causes UTERINE ATONY (Uterus is deflected either to the LEFT or to the RIGHT) Therefore, assure voiding so uterus stays at center Place warm water in container o Do not place warm water in abdomen or at the hypogastric area o This will cause bleeding Nursing Responsibility o Do alternate pouring of warm and cold water over the perineum to promote uterine contraction FOURTH STAGE OF LABOR FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA Crucial Problem or Main Problem at this stage o BLEEDING All the retained water retained previously will be reabsorbed into the circulation o Increase in Cardiac Output o Increase in Oxygen Consumption Therefore, it is the most detrimental or difficult stage of labor in GRAVIDOCARDIAC PATIENTS!!!

EPISIOTOMY Episiotomy is performed at the PERINEUM Perineum is the muscular portion between the vagina and the rectum Episiotomy is performed to o Prevent laceration (secondary) o Shorten the duration of the second stage of labor (this is the MOST IMPORTANT PURPOSE) as the head of the fetus will emerge quickly Two (2) ways of EPISIOTOMY Median Episiotomy o Cut is made from the vagina direct to the anus Mediolateral Episiotomy o To the right or left Advantages of Median Episiotomy Has lesser blood loss because area cut has more fibrous tissue Less pain due to less nerves Disadvantages of Median Episiotomy Promotes extension to the rectum Therefore, there is greater degree of laceration Therefore, this is used most of the time This is the more common cut among the two types Advantages of Mediolateral Episiotomy Cut is done on the side of the perineal body This prevents extension (of the cut) into the rectum Therefore, there is less degree of laceration Important Concepts! For Meconium staining Use NITRAZINE TEST

o To determine whether fluid is amniotic fluid or urine pH Nitrazine paper is placed in contact with vaginal secretion Amniotic Fluid is ALKALINE o If pH nitrazine paper turns GREEN (ANY TINGE OF GREEN), IT IS AMNIOTIC FLUID Urine is ACIDIC o If pH nitrazine paper turns RED (ANY TINGE OF RED / ORANGE)

Important Concept! Note the time when Rupture of Membrane occurs (ROM) Golden Period is twenty-four (24) hours If membrane has ruptured for greater than twenty-four hours (and STILL NO BIRTHING FROM LABOR), INFECTION WILL OCCUR. Therefore, a CAESARIAN SECTION IS NEEDED

DEGREES OF LACERATION First Degree Laceration Skin Fourchette Posterior portion of vagina Posterior tip Subcutaneous tissues Second Degree of Laceration First three structures (mentioned in First degree laceration) plus PERINEAL MUSCLES Third Degree Laceration All of the structures in the second degree laceration plus RECTAL SPHINCTER Fourth Degree Laceration All the structures in the third degree laceration plus RECTAL MUCOSA Important Concept! The greater the severity of the laceration, the longer recovery period is needed, the greater the chances for obtaining infections PUERPERIUM Main Responsibility o Achieve INVOLUTION Return of reproductive organs to pre-pregnancy state Usually achieved after six (6) weeks PRINCIPLES 1. PROMOTE HEALING Uterus o At level of umbilicus o After the delivery of the placenta One (1) day after o One (1) finger breadth below the umbilicus Two (2) days after o Two (2) finger breadths below the umbilicus Three (3) days after o Three (3) finger breadths below the umbilicus Four (4) days after o Four (4) finger breadths below the umbilicus Five (5) days after o Five (5) finger breadths below the umbilicus Six (6) days after o Six (6) finger breadths below the umbilicus Seven (7) days after o Seven (7) finger breadths below the umbilicus Eight (8) days after o Eight (8) finger breadths below the umbilicus Nine (9) days after o Nine (9) finger breadths below the umbilicus Ten (10) days after

o Ten (10) finger breadths below the umbilicus or at the level of the symphysis pubis Eleven (11) days after o Uterus at the pelvic cavity Important Concept! After six (6) weeks, upon Internal Examination. . . o If Uterus is midway between the umbilicus and symphysis pubis, this is ABNORMAL This means that there is something left inside SUB-INVOLUTION or POST PARTUM HEMORRHAGE Uterus has not gone back to original size Caused by retained placental fragment LOCHIA Rubra Day one (1) to day three (3) Day two (2) to day three (3) Bright red in color Serosa Day three (3) to day ten (10) Pinkish in color Actually, brown in color Alba

Day ten (10) until third (3rd) week up to sixth (6th) week post-partum

Important Concept! After six (6) weeks, THERE IS NO MORE LOCHIA CHARACTERISTICS OF NORMAL LOCHIA Normal Odor o Musty but not FOUL SMELLING o Foul smell indicates infection Color o Should not be YELLOWISH o Yellowish color indicates infection Order of Appearance o Should never be reversed o Reversal in appearance indicates RETAINED PLACENTAL FRAGMENTS LACTATIONAL AMENORRHEA Lactating Fully Not ovulating Six (6) months effectivity TO BE EFFECTIVE There must be complete emptying of the breast without supplementation (baby receives no bottle feeding) Four (4) to six (6) months Start Supplementation Important Concepts! Normally, after eight (8) weeks or two (2) months, MENSTRUATION RETURNS If the mother is breastfeeding, it would take six (6) months BEFORE MENSTRUATION RETURNS After three (3) to four (4) weeks, COITUS IS ALLOWABLE 2. PROVIDE EMOTIONAL SUPPORT a. TAKING IN First two (2) days post-partum

 Mother is very dependent for care for self and the newborn Rejecting rooming-in is NORMAL b. TAKING HOLD After second day o Mother is now independent of self care and newborn care o Time of evidence of POST PARTUM BLUES / DEPRESSION IS OVERT o If poor support system is present, this predisposes to POST PARTUM BLUES / DEPRESSION / PSYCHOSIS o Brief Psychotic episode lasts for three (3) months c. LETTING GO Completely accepted role as a new mother 3. PREVENTION OF POST-PARTUM. . . 3.1) MATERNAL HEMORRHAGE Early post-partum hemorrhage Occurs within the first twenty-four (24) hours after delivery Uterine atony is most common cause Lacerations are the second most common cause Inherent clotting disorders occur: o Thrombocytopenia o Leukopenia Late post-partum hemorrhage o Occurs after first twenty-four hours of delivery Common causes: o Primary Cause Retained placental fragment/s o Secondary Cause Hematoma (vaginal)

3.2) INFECTION Endogenous infection Normal flora causes infection These travel up the uterus

TORCHES (Teratogenic) Infections viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCHES: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus, SYPHILIS T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O others. Hepa A or infectious heap oral/ fecal (hand washing) Hepa B, HIV blood & body fluids Syphilis R rubella German measles congenital heart disease (1st month) normal rubella titer 1:10 <1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant for 3 months. Vaccine is teratogenic C cytomegalo virus H herpes simplex virus S- YPHILIS 3.3) PERINEAL INFECTION On site of episiotomy o Management involves antibiotic therapy Surgical Management o Remove suture o Drain pus Position in Semi-Fowlers position

3.4) ENDOMETRITIS Infection of the lining of the uterus o With maternal fever > 38 C (37.5C is common due to dehydration) o With foul-smelling vaginal discharge With uterine or abdominal tenderness Management for Endometritis Antibiotics Position o Semi-Fowlers position Oxytocin is given o Promotes contractions o Promotes release of secretion Important Concept! ENDOMETRITIS is a PRELUDE to THROMBOPHLEBITIS 3.5) THROMBOPHLEBITIS Most common site are the vessels of the LOWER EXTREMITIES Positive (+) for HOMANS SIGN How is Homans Sign elicited? o Ask patient to dorsiflex foot o Upon lying supine, legs extended o Stretching of the blood vessels causes pain on calf muscle (gastrocnemius muscle) Management of Thrombophlebitis o Antibiotics o Anticoagulant Heparin Larger molecule than warfarin Less likely to enter breast milk Important Concepts! Discontinue breastfeeding whether heparin or warfarin is administered Antidotes o For Heparin Protamine Sulfate o For Warfarin Vitamin K

HEART DISEASE IN PREGNANCY Four (4) Functional Classifications of Heart Disease Class I o Heart Disease is present o But uncompromised Class II o Heart Disease is present o Slightly compromised Class III o Heart Disease is present o Markedly compromised Class IV o Heart Disease is present Severely compromised Important Concepts! If you belong to Class I and Class II o You can go through normal pregnancy If you belong to Class III and Class IV o You cannot go through normal pregnancy o You are not a good candidate Heart Disease In Pregnancy Labor and delivery should be:

Effortless Painless Pushless o A vaginal delivery

ASSESSMENT OF FETAL MATURITY AND WELL-BEING

1. MATERNAL HISTORY AND PHYSICAL EXAMINATION

1.1) First thing to ask is the LAST MENSTRUAL PERIOD

Purpose is to IDENTIFY THE AGE OF GESTATION

1.2) What are History of Previous Pregnancy:

NSAID? Postpartum complication? Infection? 1.3) Past Medical History Diabetes Mellitus? Gestational Diabetes? Hypertension? 2. FETAL HEART TONE Easiest method to assess for fetal well-being Very reliable indicator of oxygenation of the fetus If FHT is heard o Fetus is alive o THIS IS AN ALL OR NONE RESPONSE NORMAL o 120 160 beats per minute If greater than 160 o Tachycardia If less than 120 o Bradycardia Be able to assess that sound you hear in the mother is the FHT In the mothers abdomen, you can hear: o BORBORYGMIC SOUNDS Hunger sounds o UMBILICAL SOUFFLE When the blood in the placenta enters the umbilical vein, this coincides with the Fetal Heart Tone But FHT should be DISTINCT Fetal Heart Tone sound TUG TUG TUG Umbilical Souffle Sound SHHH SHHH SHHH This is the sound of the gush of blood o UTERINE SOUFFLE Sound heard when blood enters uterine artery This coincides with the heartbeat of the mother

IDEAL WAY TO TAKE THE FETAL HEART TONE

 Use the bell of the stethoscope o Purpose is for greater amplification Hand / Dominant Hand o On area being auscultated Non-Dominant Hand o Palpates radial pulses for the mother Therefore, you can correlate o FETAL HEART TONE IS DISTINCT TUG TUG TUG TUG o Radial pulse of the Mother is Tug - - - - - - Tug - - - - - - Tug

FETAL MOVEMENT
Two (2) schools of thought o Cardiff Count to Ten o Sandovsky Method

CARDIFF COUNT TO TEN

Normal Fetal Movement o At least one (1) movement every five (5) to six (6) minutes o About ten (10) to twelve (12) movements per hour First Instruction o Instruct the client to eat LIGHT MEAL one (1) hour before monitoring for fetal movement Have short walk or massage abdomen as baby may be asleep or is hungry Ask mother to assume left lateral position A clock must be at the bedside with pencil and paper Dominant hand of mother palpates most prominent part of abdomen Note for any fetal movement FETAL MOVEMENT SHOULD BE ASSESSED WHEN THERE IS QUICKENING (AT TWENTY-FOUR MONTHS AGE OF GESTATION ONWARDS) Mother notes for ten (10) fetal movements and NOTES THE TIME THAT THE TEN (10) FETAL MOVEMENTS HAVE BEEN COMPLETED o Should be completed in one (1) hour o Approximately five (5) movements in thirty (30) minutes You MUST get at LEAST ONE HALF OF NORMAL Therefore, AT LEAST FIVE (5) FETAL MOVEMENTS PER HOUR IS ACCEPTABLE

Important Concepts!
Approximate number of growing follicles: o At twenty-eight (28) weeks Age of Gestation 6,000,000 o At Term 1,000,000 o At menarche 400,000 o At forty (40) years of age 8,000

SANDOVSKY METHOD
Same procedure as in Cardiff Count to Ten Mother monitors fetal movement three (3) times a day These are done: o After breakfast o After lunch o After dinner Normal You should appreciate two (2) to three (3) fetal movements in one hour OTHER WAYS TO ASSESS: DIAGNOSTICS

AMNIOCENTESIS Best done at sixteen to eighteen (16 18) weeks Age of Gestation or during second (2nd) trimester This is the time when the baby is SMALL and there is MUCH AMNIOTIC FLUID

Information Obtained: A) FETAL LUNG MATURITY

Analyzed for lung surfactant: Dipalmytoyl Phosphatidylcholine L : S Ratio o Lecithin : Sphingomyelin Ratio Lecithin is a specific component of lung surfactant o Lecithin should be greater than Spinglomyelin o Normal Ratio is 2L : 1S If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable

PHOSPHATIDYL GLYCEROL (PG)

Most potent of all lung surfactants Usually appreciated at amniotic fluid at THIRTY-FOUR to THIRTY SIX (34 36) WEEKS AGE OF GESTATION Therefore, it is safe to deliver fetus if Phosphatidyl Glycerol is present There is decreased risk of respiratory distress

POLYHYDRAMNIOS
Amniotic fluid greater than 2,000 ml o A teratogenic effect Therefore, remove part of amniotic fluid

IDENTIFICATION OF GENETIC OR CHROMOSOMAL PROBLEM HOW TO PREPARE THE CLIENT FOR AMNIOCENTESIS
Explain what to do to the client Get Consent Remember, CONSENT IS NEEDED as this procedure is INVASIVE! Client must have I. V. fluid o Plain Normal Saline Solution o Side drip of Tocolytic to relax the uterus Ask client to void before the procedure so as not to puncture bladder o Ultrasound-guided procedure o Needle should not puncture the placenta Abdomen is prepared aseptically Specific Site o Pocket of abdomen containing highest amount of Amniotic Fluid o Done by OBSTETRIC SONOLOGIST Needle Inserted o Local anesthesia o Abdominal wall through the uterus to amniotic sac

Post Procedure o Check Vital Signs (every fifteen (15) minutes) o Check Blood Pressure o Check Fetal Heart Tone o Client then rests for two (2) to three (3) hours o Mother is then sent home DISCHARGE INSTRUCTIONS o Note for UTERINE TONE o Note for Fetal Activity o Client may be: Hyperactive In distress Hypoactive In distress o Note for vaginal bleeding or spotting o Vaginal spotting is acceptable

DANGER SIGNS
Persistent uterine contraction Hyper / Hypoactive

 Vaginal Spotting to Bleeding o Therefore, ask mother to come back if she observes any of the above signs

MATERNAL SERUM ALPHA FETOPROTEIN

A special kind of protein produced in the yolk sac of the liver of baby / fetus Specimen is blood Consent is needed Normal value of Maternal Serum Alpha Feto Protein (MS AFP) o 2.0 2.5 MOM (measurements of the mean) If MS AFP is higher than normal, THERE IS A NEURAL TUBE DEFECT: o Spina bifida o Meningocoel o Myelomeningocoel o Anencephaly If MS AFP is lower than normal, THERE IS DOWNS SYNDROME Therefore, you must be able to know exact Age of Gestation Fifteen to Twenty (15 20) weeks Age of Gestation is the IDEAL TIME FOR MS AFP or during the SECOND (2nd) TRIMESTER, not on the First or the Third Trimesters If early high result o Yolk sac and liver gives false elevated result If late low result o Liver only gives false low result

CHORIONIC VILLUS SAMPLING (CVS)

Get part of chorionic villi from the placenta Done at nine to twelve (9 12) weeks Age of Gestation Approach is INTRAVAGINAL Ultrasound-guided A part of chorionic villi near maternal attachment will be suctioned to the catheter for KARYOTYPING and GENETIC ANALYSIS Purpose of this procedure is for detection of genetic and chromosomal problems Nursing Responsibility o Bleeding is common in CVS o Instruct mother to observe SPOTTING to BLEEDING o Ask mother to come back if bleeding occurs Therefore, not much done; increases chance of abortion or fetal loss

PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS)

Also known as CORDOCENTESIS Get sample Ultrasound-guided Sonologist identifies umbilical vein o Vein has larger lumen than the artery Catheter is inserted Approach is through the abdomen Information obtained: o For identification of blood incompatibilities o For exchange transfusion o For isoimmunization Needed in instances of an Rh+ baby and an Rh- mother

ULTRASOUND
Types of Ultrasound Transabdominal Ultrasound Transvaginal Ultrasound

TRANSABDOMINAL ULTRASOUND
Ask the client to FILL BLADDER Full bladder will push uterus to pelvic cavity for better visualization at abdomen

ULTRASOUND IN FIRST TRIMESTER

Information obtained:

 Confirmation of Pregnancy o (+) cardiac movement o (+) yolk sac o (+) Fetal Heart Tone Identification of Ectopic Pregnancy o Fallopian tube is PERISTALTIC o Therefore, look at the uterus o If the uterus is empty and positive (+) for pregnancy test, then there is pregnancy outside or ECTOPIC PREGNANCY Identification of Intrauterine Device (IUD) in Place o Intrauterine Device Has 97% protection Has 3% failure rate o If IUD is in place and pregnancy occurs, advice the client to LET THE IUD STAY IN PLACE o IUD will attach to the fetal membrane o If taken out, there is greater chance of SPONTANEOUS ABORTION Identification of the H-MOLE o Ultrasound characteristic of H-Mole SNOW STORM APPEARANCE In a dark background there is a speck of white There are vesicles filled with fluid

ULTRASOUND IN THE SECOND AND THIRD TRIMESTER

Information obtained: Location of Placenta o Placental Localization Growth of the Fetus Amount of Amniotic Fluid Fetal Position and Fetal Presentation Sex / Gender of the baby o Determinable at sixteen (16) weeks of gestation o Ideal time is twenty-eight (28) weeks Congenital / Chromosomal Problems o Determined by three-dimensional (3D) ultrasound TRANSVAGINAL ULTRASOUND Ask client to void

BIOPHYSICAL SCORE
Has five (5) parameters (including Non-Stress Test or NST) Modified Biophysical Score o Has four parameters only Uses ULTRASOUND Criteria / Parameters observed o Fetal Breathing Two (2) is the highest score for this parameter o Fetal Movement Two (2) is the highest score for this parameter o Fetal Muscle Tone Flexion and extension in utero Two (2) is the highest score for this parameter o Amniotic Fluid Index Done for a period of thirty (30) minutes Babys breathing is not spontaneous Two (2) is the highest score for this parameter Perfect score is 8/8 o This means that the baby is in the best possible health Before, Biophysical Score includes the Non-Stress Test Non-Stress Test o For fetal heart activity o With this parameter added, the perfect score in BPS becomes 10/10

NON-STRESS TEST
Uses CARDIOTOGORAPH (CTG) TRACING No stressor on part of the baby

 Stressor is the contraction of the uterus There should be NO CONTRACTION Compare o Fetal Heart Tone and Fetal Movement If baby moves, FHT INCREASES! With two (2) transducers placed near FHT at fundus of uterus Leopolds maneuver Water soluble lubricant o KY jelly amplifies FHT TOCO o No lubricant at fundus of uterus So that it is verified There is no contraction FHT 150 140
BASELINE130

120 110 100

FLAT LINE (NO CONTRACTION)

UC
(MEASURED IN PRESSURE)

Push button o If mother feels fetal movement

CRITERIA TO SAY NST IS NORMAL

Period of Observation should be o Greater than or equal to twenty (20) minutes You must get at least two (2) accelerations in twenty (20) minutes Acceleration should be at least fifteen (15) beats above baseline Duration of acceleration should be o Greater than or equal to fifteen (15) seconds o One (1) small square = one (1) second Therefore, IF ALL CRITERIA ARE MET, NON-STRESS TEST IS NORMAL

KEY CONCEPT!!!
If NST is NORMAL IT IS REACTIVE Therefore, the chances of fetal survival is greater than 99% in the next week You can assure the mother If NOT ALL CRITERIA ARE MET (i.e. Criteria No.3 with 10 beats per minute only), Repeat NST after two (2) to three (3) hours FHT 150 140
BASELINE130

120 110

100

UC
(MEASURED IN PRESSURE)

Important Concept!
If NST is NON-REACTIVE, it is ABNORMAL CONTRACTION STRESS TEST (CST)

Best done when mother is at thirty-eight (38) weeks Age of Gestation Done when NST is NON-REACTIVE Then, proceed with Contraction Stress Test If CST could not be withstood by baby, IT NEEDS IMMEDIATE DELIVERY Introduce a STRESSOR CONTRACTION if ABNORMAL CST

OXYTOCIN CHALLENGE TEST

Rub nipples o Nipple stimulation if uterus is NOT contracting When assessing o Hide your thumb o If you are a male so as not to be sued for sexual harassment NIPPLE STIMULATION o Give warm pack / warm soaks for ten (10) minutes prior to stimulation to increase circulation / vascularity o Explain procedure o Start o Four (4) cycles per stimulation o 1, 2, 3, 4 stimulations REST x4 First Cycle o If after these and there are NO CONTRACTIONS o Stop and rest for two (2) to four (4) minutes o Then stimulate o Up to four (4) cycles If NO CONTRACTIONS AFTER THE FOURTH (4th) CYCLE o Stop stimulation o Proceed with Oxytocin Challenge Test OXYTOCIN CHALLENGE TEST Give diluted form of oxytocin o Five units (5U) or ampule + 1 liter D5LR or D5H2O Give at a titrating dose Start at ten to twelve (10-12) drops per minute to a maximum of forty (40) drops per minute Observe for Uterine Contraction Wait for two (2) consecutive uterine contractions Stop Oxytocin Challenge Test if two (2) uterine contractions are obtained Now compare Uterine Contractions with Fetal Heart Tone FHT 150 140
BASELINE130

120 110 100

CST IS NORMAL OR NEGATIVE

UC

NEGATIVE o In the presence of uterine contraction, tracing is NEGATIVE FOR DECELERATION Vagus Nerve o Parasympathetic Stimulation gives rise to bradycardia Carotid Stimulation results into o Bradycardia o Hypotension

Important Concept!
Abnormal if POSITIVE (+) FOR DECELERATION FHT 150 140
BASELINE130

120 110 100

CST IS ABNORMAL

UC

Note for timing of deceleration in relationship to contraction o Deceleration is before contraction o Shape of deceleration is U-SHAPED o Deceleration has early recovery to baseline level

Important Concepts!
If (1), (2) and (3) above are present, it is called EARLY DECELERATION o The most NORMAL of all the ABNORMAL If mother is in TRANSITIONAL PHASE o Cervix is 8 10 cm dilated o Head / presenting part in vaginal vault In the dura of the brain is the innervation of the vagus nerve If head of baby is in the pelvis If vagus nerve is stimulated, there is BRADYCARDIA If head is released, there is normalization Therefore, EARLY DECELERATION is NOT PRESENT in the EARLY STAGE of the FIRST STAGE of LABOR If NORMAL, DO NOTHING!!!! o JUST OBSERVE o This is NORMAL!

Second type of Deceleration

FHT 150 140

130
BASELINE120

110 100

UC

Deceleration o Occurs anytime (variable) during contraction o W-shaped Deceleration o Decrease in baseline from 130 to 125 Therefore, TYPICAL VARIABLE DECELERATION Significance: o Signifies CORD COMPRESSION but not necessarily Cord Prolapse o Therefore, INTERVENE IF THERE IS CORD COMPRESSION

INTERVENTIONS
If in labor: Turn client to left lateral position Stop oxytocin immediately o No contractions are wanted Give oxygen to mother o Rate is 8 10 liters per minute Hydrate with plain water o No incorporation of oxytocin to increase circulating blood volume o Mother is on NPO during labor and there could be DEHYDRATION ADH secretion is increased to conserve water o ADH is released from the posterior pituitary o Oxytocin is released from the posterior pituitary o Cross reaction of ADH and Oxytocin in the Uterus o ADH binds in OXYTOCIN RECEPTORS in Uterus resulting to CONTRACTION o Therefore, hydrate so as not to increase ADH secretion If variable deceleration is >10 minutes, then CAESARIAN SECTION may be NECESSARY

Third Type of Deceleration

FHT 150 140
BASELINE130

120 110 100

UC

LATE DECELERATION Occurs before contraction ends Has a late recovery Baseline is changed Lower than original baseline Significance: o UTEROPLACENTAL INSUFFICIENCY is present Management o Hydrate o Give oxygen o Stop oxytocin Placenta and Uterus are compromised o Therefore, this is an indication for OUTRIGHT ABDOMINAL DELIVERY o Do outright Caesarian Section

PRE-NATAL ASSESSMENT
In the Ideal Setting: At zero to twenty-eight weeks (0 28) Age of Gestation o Ask client to come back every four (4) weeks At twenty-eight to thirty-six weeks (28 36) Age of Gestation o Ask client to come back every two (2) weeks At thirty-six (36) weeks onwards Ask client to come back every week

DOH RECOMMENDATION
One (1) pre-natal check-up per TRIMESTER Three (3) pre-natal check-ups during the entire course of pregnancy If high risk Below 18 years old Above 35 years old Greater than Gravida 5 o Due to higher chances of maternal bleeding after delivery Problem in placentation (location) History of Maternal illness o Hypertension o Diabetes mellitus o Cardiac Problems Clinical check-up should be performed every week!

Important Concepts!
Auscultate the lungs on the first visit Nursing history has physical examination o This is done by the nurses o Not weigh o Baby is sleeping contentedly o Baby will cry Changes in heart rate NO IPPA IN PEDIATRIC PATIENTS Get Maternal History of Client Laboratory Examinations

COMPLETE BLOOD COUNT

Hemoglobin Hematocrit Platelet

 Rh and ABO blood typing

Important Concepts!
Asians NOT COMMONLY Rh Caucasians are COMMONLY Rh-

BLOOD NOMENCLATURE
ABO Typing o Type A, B, O o A or B antigens Rh Typing o Rh (C, D, E) o Three antigens C D E o In incompatibility, the concern is the D antigen

Rh
Mother is RhNo D antigens Rh- or Rh0 (zero for D) Father is Rh+

Baby is Rh+ or Rh(D) Antigen D is present in the blood

Important Concept!
The first pregnancy is spared The first baby is born Blood enters mothers circulation Therefore, mother PRODUCES ANTI-D antibody

Interaction
During time of delivery when the placenta starts to detach from maternal attachment Abortion / Dilatation and Curettage Some fragments of placenta are retained in the uterus Ancillary Procedures like AMNIOCENTESIS Interaction of blood of baby entering mother occurs and stimulates antigen-antibody reaction

Second Pregnancy
Anti-D antibody of mother hemolyzes the Antigen D of second baby o This results into erythroblastosis fetalis or death of the RED BLOOD CELLS o Second baby would have SEVERE ANEMIA HEART FAILURE ANASARCOUSDEATH

RHOGAM
Gamma globulin A pre-formed antibody Given within seventy-two (72) hours If to undergo amniocentesis o Rhogam is given before the procedure If mother undergoes abortion o Rhogam is given within seventy-two (72) hours after abortion If pregnant now o Give at twenty-eight to thirty-two (28 32) weeks Age of Gestation o to Rh- mother REGARDLESS OF Rh of Baby

Important Concept!
Rhogam is repeated prior to term at forty (40) weeks Rhogam has a half life Rhogam may be out of circulation

COOMBS TEST
Two (2) types Direct Coombs Test Indirect Coombs Test

DIRECT COOMBS TEST

Concerns the Baby PUBS Identify if RBC of baby has hemolysis and has attached antibody Therefore, sensitization has occurred on the mother

INDIRECT COOMBS TEST

Concerns the mother Identify for titer of antibody o Get blood sample o Identify titer of Anti-D o Zero titer if Rh+ o If Rh- individual 1 : 8 or 1 : 16 If titer is less than 1 : 8 this means that MOTHER IS NOT YET SENSITIZED o Therefore, blood of the mother is FREE OF ANTI-D antibody o There is a need for Rhogam If titer is greater than 1 : 16 this means that there is SENSITIZATION o It has ANTI-D antibody o Then, Rhogam is NOT needed o Rhogam CANNOT REVERSE SENSITIZATION

Interjected Concepts
G3P2 Cervix is 9 cm dilated EEFM

TWO (2) ABSOLUTE CONTRAINDICATIONS FOR CONTRACTION STRESS TEST

If client is premature (Biophysical Score is used instead) History of problem in the placenta (placentation)

Situation
Mother is Type O Rh Baby is Type A Rh+

Question
What type of blood do you give?

Answer
Give type A blood

Rationale
Hemolysis is present Baby has anti-D that is why there is hemolysis If Rh+ is given o There is continuous antibody given there is confirmed hemolysis o Therefore, give Rh-

KEY CONCEPT!
ALWAYS GIVE THE BLOOD TYPE OF THE MOTHER (as far as Rh is concerned)

Important Concept!
If mother is Rh+ and father is Rh+, then the baby is Rh+ and there is no problem

ABO BLOOD GROUPS

Blood Type A B AB O Antigen A B A and B None Antibody Anti-B Anti-A None Anti-A and Anti-B

Important Concepts!
Type O blood causes hemolysis If baby is type A, B, AB

Question
What type of blood in mother will cause hemolysis in ABO?

Answer
Type O

Question
What type of blood will be given to the baby if there is ABO incompatibility?

Answer
Blood type of mother

Important Concepts!
Most common cause of PATHOLOGIC JAUNDICE is ABO INCOMPATIBILITY Pathologic Jaundice is prolonged jaundice Normal Value of Bilirubin o 15 mg / dl If greater than 15 mg / dl, transformation is needed ABO INCOMPATIBILITY is protective against Rh INCOMPATIBILITY o If Mother is type O o If Baby is type A RBC carries Rh(D) o RBC of baby contains D antigen o Since hemolysis has already occurred, Anti-D of mother will no longer hemolyze any RBC with Anti-D

URINALYSIS
Note for infection White Blood Cells o Pus Cells o Common minute amount of pus cells o Normal Value is 5 / hpf (high power field) o In Females 5 / hpf means there is INFECTION < 5 / hpf means NO INFECTION o In males 5 / hpf is SIGNIFICANT

URINE SAMPLES
Wash perineum Dry perineum Let first stream pass out o This is done to flush bacteria outside urethra Get midstream void Given sterile container with pack with iodine

GLUCOSE CONTENT OF BLOOD

Glomerular Filtration Rate is increased Normal to see trace and +1 Glucose Normal to see trace and +1 protein or < 250 mg / dl

GLUCOSE TESTING IN BLOOD

Screening Procedure

GLUCOSE CHALLENGE TEST

For diagnosis of GESTATIONAL DIABETES MELLITUS Best timing is twenty-four to twenty-eight (24 28) weeks Age of Gestation This is the PEAK PERIOD FOR INSULIN RESISTANCE No need for fasting Give mother concentrated glucose solution (orange juice) o 50 grams per orem Wait for one (1) hour Blood sample is drawn from the mother Two (2) probable results: o Glucose level < 140 mg / dl Normal Therefore, STOP There is remote risk of GESTATIONAL DIABETES MELLITUS o Glucose level > 140 mg / dl Abnormal There are chances of developing GESTATIONAL DIABETES MELLITUS Therefore, PROCEED WITH ORAL GLUCOSE TOLERANCE TEST

ORAL GLUCOSE TOLERANCE TEST (OGTT)

Fasting is needed for 8 10 hours or 8 12 hours Example: o NPO by 12 midnight o Be at clinic by 8:00 AM Draw specimen for Fasting Blood Sugar (FBS) Give concentrated glucose solution o 100 grams per orem Wait for one (1) hour Draw blood sample Wait for another hour Draw another blood sample Wait for another hour Draw another blood sample o Therefore, four (4) drawings of blood 1 FBS 2 1st Hour Normal <95 mg/dl Normal <180 mg/dl Normal <155 mg/dl 3 2nd Hour 4 3rd Hour Normal <140 mg/dl

Important Concept!
If client has TWO VALUES ELEVATED OUT OF THE FOUR, CONCLUSION IS THAT CLIENT HAS GESTATIONAL DIABETES MELLITUS INFECTION

1. VENEREAL DISEASE RESEARCH LABORATORY (VDRL) Test for syphilis Baby will get STD if delivered normally

2. HbSAg(+) Surface Antigen

Mandatory on first pre-natal check-up If mother is HbS+ (reactive); she carries the virus o Health care provider requests for HbP protocol HbE antigen o If positive, therefore INFECTIVE and can infect baby

 HbSAg(+) and HbE(+) o Give vaccination to the baby o Active Hepatitis B vaccine 0.5 ml via I.M. Within 24 hours of delivery o Passive Hepatitis B immunoglobulin 0.5 ml I.M. Within 24 hours after delivery o Site of Choice Vastus lateralis

Vitamin K
Best site for administration o Rectus femoris Do not give vaccination on medial nerve (sciatic nerve) will be hit Do not give on gluteus o Not developed o This is developed only when baby has begun to sit Do not give at deltoid o Deltoid is not developed Rectus femoris is the anterior muscle of the thigh

Question
HbSAg(+) mother Can she breastfeed?

Answer
Yes, provided baby should have received BOTH ACTIVE and PASSIVE VACCINATION PRIOR TO BREASTFEEDING