MCN NOTES

INTERNAL REPRODUCTIVE SYSTEM

UTERUS
• A muscular, pear-shaped cavity in which the fetus develops
• the cavity from which menstruation occurs
• Has three layers
a) perimetrium
b) myometrium
c) endometrium

WEIGHT OF THE UTERUS:

non pregnant uterus - 60 – 70 grams
Full term uterus - 1000 grams
1 week postpartum - 500 grams
6 weeks postpartum - pre-pregnant state which is 60 – 70 grams

POSITIONAL DEVIATIONS OF THE UTERUS

• ANTEVERSION – A condition in which the fundus is tipped forward
• RETROVERSION – A condition in which the fundus is tipped back
• ANTEFLEXION – A condition in which the body of the uterus is bent sharply forward at
the junction with the cervix
• RETROFLEXION - A condition in which the body is bent sharply back just above the
cervix.

CERVIX
• Internal cervical os opens into the uterus
• external cervical os opens into the vagina
• cervical canal is located between the internal os and the external os

CLASSIFICATION OF PAP SMEARS

CLASS I – Normal
CLASS II – Slightly suspicious for malignancy
CLASS III – Moderately suspicious for malignancy
CLASS IV – Highly suspicious
CLASS V – Diagnostic for malignancy

FALLOPIAN TUBES
• Also called as oviducts
• tubes that propel the ova from the ovaries to the uterus
• Has four parts:
a) fimbriae
b) ampulla
c) isthmus
d) interstitial portion

OVARIES

• formation and expulsion of ova

• secretion of estrogen, progesterone and relaxin.
• An almond shaped organ

Has two parts:

a) medulla or the inner
b) cortex or the outer

VAGINA
• Known as the birth canal
• The organ for copulation
• passageway for menstrual blood flow
• passageway for fetus

MENSTRUATION

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Body structures involved:

a. Hypothalamus
b. Anterior Pituitary gland
c. Ovary
d. Uterus

Decrease level of serum estrogen

Hypothalamus to produce FSHRF

FSHRF

APG to produce FSH

FSH

Primordial follicle

Estrogen in the graafian follicle will stimulate the uterine endothelium to proliferate

Estrogen + progesterone – pushes the mature ovum to the surface of the ovary

Graafian follicle- rupture and release the mature ovum on the 14th day of
menstrual cycle ( process of ovulation).

Empty shell of GRAAFIAN FOLLICLE becomes the CORPUS LUTEUM

CORPUS LUTEUM is the yellow body of the ovary

CORPUS LUTEUM releases two hormones; Estrogen and Progesterone

PROGESTERONE cause the gland of the uterine endothelium to become corkscrew or twisted in
appearance because of the amount of capillaries

24TH day of menstrual cycle- if the mature ovum is not fertilized by sperm, the corpus luteum will
degenerate. It will turn to white appearance- CORPUS ALBICANS.

Corpus Albicans is the white body of the ovary

• 3-4 days- the thickened lining of the uterus produced by the estrogen starts to
degenerate and slough and the capillaries rupture

CHARACTERISTICS OF NORMAL MENSTRUAL CYCLE

 Average age of onset, 12 or 13 years; average range of 9 – 17 years
 Average interval between cycles is 28 days; cycles of 23 to 35 days not unusual
 Average flow 2 – 7 days; ranges of 1 – 9 days not abnormal
 Average amount 30 to 80 ml per menstrual period; saturating pad in less than an hour is
heavy bleeding
 Color is dark red; a combination of blood, mucus, and endometrial cells
 Odor is similar of that of marigolds

TEACHING ABOUT MENSTRUAL HEALTH

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 It’s good to continue moderate exercise during menses because it increases abdominal
tone. Sustained excessive exercise, such as professional athletes, can cause
amenorrhea.
 Sexual relations not contraindicated during menses ( the male should wear a condom to
prevent exposure to body fluids.) Orgasm may increase menstrual flow.
 Activities of daily life is not contraindicated (many people believe incorrectly that things
like washing hair are harmful)
 Mild analgesic is helpful. Prostaglandin inhibitors such as ibuprofen are specific for
menstrual pain. Applying local heat may also be helpful.
 More rest may be helpful if dysmenorrhea interferes with sleep at night.
 Many women need iron supplementation to replace iron lost in menses. Eating pickles or
cold food does not cause dysmenorrhea.

FERTILIZATION
• takes place when sperm and ovum unite
• occurs in the ampulla of the fallopian tubes
• Once fertilized, the membrane of the ovum undergoes changes that prevents the entry of
other sperm
• The sperm carries the hormone HYALURONIDASE
• The ovum has two coverings; Zona Pellucida and Corona Radiata

IMPLANTATION
• Zygote is propelled toward the uterus
• zygote implants 7 to 10 days after ovulation
• blastocyst secretes choronic gonadotropin to ensure that the corpus luteum remains
viable and secretes estrogen and progesterone for the first 2 to 3 months of gestation.

AMNION
• encloses the amniotic cavity
• is the inner membrane that forms about the second week of embryonic development
• forms a fluid-filled sac that surrounds the embryo and later the fetus

CHORION
• is the outer membrane
• becomes vascularized and forms the fetal part of the placenta

DECIDUA
• Is the specialized endometrium of pregnancy.
a) Decidua Basalis
b) Decidua Capsularis
c) Decidua Vera

PLACENTA
• Is the organ that sustains and nourishes the growing pregnancy.
• Begins to develop during the 5th week after fertilization at the site of implantation.
• Made up of many lobes or sections, called cotyledons.
• Is the exchange site for nutrients and wastes between the fetal and maternal circulatory
systems.
• Weight at term is 400 – 600 grams

Six Functions of the placenta:

a) Oxygenation / Respiration
b) Nutrition
c) Storage
d) Excretion
e) Protection
f) Endocrine

Hormones Released by the Placenta

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  Estrogen
 Progesterone
 Human Chorionic Gonadotropin (HCG)
 Human Placental Lactogen (hPL) also called as Human Chorionic Somatomammotropin

 ESTROGEN functions to provide a rich blood supply to the decidua and placenta.
 PROGESTERONE is necessary to maintain the nutrient-rich decidua. It also functions to
keep the myometrium quiet, so that contractions do not occur prematurely.
 HCG sustains the corpus luteum at the beginning of the pregnancy. This hormone is also
responsible for the POSITIVE PREGNANCY TEST.
 hPL regulates the glucose that is available for the fetus.

Two Anatomical Parts of the Placenta

1. Fetal side
 white, shiny, with blood vessels

2. Maternal side
 Red, rough, with cotyledons

Two Mechanisms of Placental Delivery

1. Schultze’s mechanism
 fetal part appears first
 White, shiny, with blood vessels
 most common, occurs to 80% of deliveries.
2. Duncan’s mechanism
 Maternal part appears first
 Red, rough, with cotyledons
 Less common, occurs to 20% of deliveries

MECHANISMS BY WHICH NUTRIENTS CROSS THE PLACENTA

DIFFUSION
Ex: Oxygen, Carbon dioxide, Sodium and Chloride
FACILITATED DIFFUSION
Ex: Glucose
ACTIVE TRANSPORT
Ex: Essential amino acids and Water soluble vitamins
PINOCYTOSIS
Ex. Gamma globulins, Lipoproteins, phospholipids, viruses

ANATOMICAL VARIATIONS OF THE PLACENTA AND THE CORD

• SUCCENTURIATE LOBE OF PLACENTA
A small extra lobe is present, separate from the main placenta, and joined to it by
blood vessels which run through the membranes to reach it.
• CIRCUMVALLATE PLACENTA
In this situation an opaque ring is seen on the fetal surface
 BATTLEDORE INSERTION OF THE CORD.
The cord is attached at the very edge of the placenta in the manner of a table
tennis bat
 VELAMENTOUS INSERTION OF THE CORD
The cord is inserted into the membranes some distance from the edge of the
placenta
 BIPARTITE PLACENTA
Two complete and separate lobes are present, each with a cord leaving it

COMMON CAUSES OF IUGR

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  Chromosomal abnormalities
 Fetal infection
 Placental infarcts
 Maternal nutritional deficiencies
 Maternal hypertension
 PIH
 Maternal renal disease
 Maternal smoking
 Maternal illegal drug use
 Toxin/teratogen exposure
 Multifetal pregnancy

AMNIOTIC FLUID
Functions:
 Physical protection
 Temperature regulation
 Provision of unrestricted movement
 provision of symmetrical growth
 pH is 7.2, alkaline
 clear
 Sometimes with white specks
 Normal amount is 800 to 1200 cc

AMNIOCENTESIS

Definition:
- is the withdrawal of amniotic fluid through the abdominal wall for analysis at the 14th to
16th week of pregnancy.
The procedure can be done at the physician’s office or an ambulatory clinic.

Nursing Consideration:
 Ask the woman to void before the procedure (to reduce the size of the bladder, thus
preventing in advertent puncture).
 During the procedure and for the 30 mins afterward, assess the fetal heart rate monitor
and uterine contraction monitor to be certain the fetal heart rate remains normal and no
uterine contractions are occuring.
 If the woman has Rh – negative blood, Rho (D) immune globulin (RhoGAM) may be
administered after the procedure to prevent fetal isoimmunization.

INFORMATION ABOUT FETAL WELL BEING OBTAINED THROUGH

AMNIOCENTESIS

COLOR:
Normal amniotic fluid is the color of water.
A strong yellow color suggests a blood incompatibility (the yellow results from the presence of
bilirubin released with the hemolysis of red blood cells)
A green color suggests meconium staining, a phenomenon associated with fetal distress.

ALPHA-FETOPROTEIN
Is a substance produced by the fetal liver that is present in amniotic fluid and maternal
serum.
• The level is abnormally high if the fetus has an open spinal defect (such as neural tube
defects) because the open defect allows more alpha-fetoprotein to appear.
• The level is low if the fetus has a chromosomal defect, such as Down syndrome.

LECITHIN/SPHINGOMYELIN RATIO

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Lecithin and sphingomyelin are the protein components of the lung enzyme surfactant that the
alveoli begin to form about the 22nd to 24th weeks of pregnancy.
A ratio of 2:1 is traditionally accepted as lung maturity.
Mature lung profiles are usually found after 35 weeks gestation.

COMPLICATIONS:
 Premature labor
 Infection
 Rh isoimmunization
 Fetal deaths
Complications can be prevented if amniocentesis is done by an experienced
obstetrician with the aid of ultrasound.

Patients advised to undergo amniocentesis

 Maternal age of 35 years or older.
 History of a chromosomal abnormality in either parent or another child.
 Parent known to be a carrier for a diagnosable metabolic disease
 Prior delivery of a child with a neural tube defect.
 Parent has a neural tube defect
 Elevated maternal serum Alpha Fetoprotein level
 Women with unexplained hydramnios

UMBILICAL CORD

 Average length is 50 – 55 cm
 contains two arteries and one vein
 Arteries carry deoxygenated blood and waste products from the fetus
 vein carries oxygenated blood and provides oxygen and nutrients to the fetus
 Wharton’s jelly – clear gelatinous substance that gives support to the cord and helps
prevent compression of the cord.

GERM LAYERS AND BODY PORTIONS FORMED

ECTODERM
• CNS
• PERIPHERAL NERVOUS SYSTEM
• SKIN, HAIR AND NAILS
• SEBACEOUS ORGANS
• SENSE ORGANS
• MUCOUS MEMBRANES OF THE ANUS, MOUTH AND NOSE
• MAMMARY GLANDS

MESODERM
o Supporting structures of the body (connective tissues, bones, cartilage, muscle,
ligaments and tendons)
o Dentin of teeth
o Upper portion of the urinary system (kidneys and ureters)
o Reproductive system
o Heart
o Circulatory system
o Blood cells; Lymph vessels

ENTODERM /ENDODERM
 Lining of the pericardial, pleura, and peritoneal cavities
 Lining of the GIT, Resp. tract, tonsils, parathyroid, thyroid, thymus gland
 Lower Urinary system (bladder and urethra)

ORGANOGENESIS

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  Organ formation
 Will be completed at 8 weeks gestation

TERATOGENS
 Teratogens are substance that cause birth defects.
 The severity of the defect depends upon when during the development the conceptus is
exposed to the teratogen and the particular teratogenic agent to which the fetus is
exposed
 Exposure to a teratogen during the embryonic stage produces the greatest damaging
effects than exposure during the fetal stage.

COMMON TERATOGENS AND ASSOCIATED EFFECTS

Medications:
 Dilantin Cleft palate

 Chemotherapy agents Major congenital malformations, especially of the

CNS

 Tetracycline Damage to developing dental and osseous tissue

 Alcohol Fetal alcohol syndrome (FAS) with facial defects, low

birth
weight.

INFECTIOUS AGENTS:
Varicella Fetal Varicella syndrome, which ranges in severity from

generalized multiorgan damage to isolated defects, such

as incomplete limb, development of skin scarring

 Rubella (German Measles) Cataracts, deafness, and cardiac malformations

ENVIRONMENTAL AGENTS:
 Mercury Neurologic damage, blindness

 Radiation Congenital malformations, mental retardation

FETAL ORGANS

CARDIOVASCULAR SYSTEM
 The first system to be functioning
 Heart beating will start on the 24th day from fertilization
 can be heard with the use of doppler at 10th to 12th week gestation
 Can be heard with the use of stethoscope at 18th to 20th week gestation
 Normal FHR is 120 – 160 beats per minute

FETAL CIRCULATION BYPASS

• Fetal circulation bypass is present because of nonfunctioning lungs

• Bypasses must close following birth to allow blood to flow through the lungs and the liver
• ductus arteriosus connects the pulmonary artery to the aorta, bypassing the lungs
• ductus venosus connects the umbilical vein and the inferior vena cava, bypassing the
liver
• foramen ovale is the opening between right and left atriums of the heart, bypassing the
lungs

RESPIRATORY SYSTEM:
 Alveoli and capillaries begin to form at 24th to 28th week gestation
 SURFACTANT is a phospholipid substance formed and excreted by the alveolar cells at
about 24th week of pregnancy

NERVOUS SYSTEM

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  Anoxia
 Hypoxia

DIGESTIVE SYSTEM:
 Meconium is present at GIT on the 16th week

MUSCULOSKELETAL SYSTEM:
 Quickening is the first fetal movement felt by the mother
 quickening is on the 20th week gestation

INTEGUMENTARY SYSTEM:
 Lanugo are fine downy hair
 Vernix caseosa is the white cheezy substance found on the skin of the baby, secreted by
the sebaceous glands of the skin

MILESTONE OF DEVELOPMENT
 END OF 8 WEEKS GESTATION
 Organogenesis is complete
 Heart is beating rhythmically
 Sonogram shows a gestational sac
 END OF 12 WEEKS
 Sex is distinguishable
 Kidney secretion has begun
 END OF 16 WEEKS
 FHR are audible with an ordinary stethoscope
 Lanugo is well formed
 Liver and pancreas are functioning
 END OF 20 WEEKS
 Fetal movement can be sensed by the mother
 Meconium is present in the upper intestine
 Vernix Caseosa begins to form
 Sleeping and activity patterns are distinguishable
 End of 24 weeks
 Active production of lung surfactant begins
 Eyelids open
 Pupils are capable of reacting to light
 End of 28 weeks
 Lung alveoli begin to mature
 Testes begin to descend into the scrotal sac
 End of 32 weeks
 Subcutaneous fat begins to be deposited
 Delivery position may be assumed
 Fingernails grow to reach the end of fingertips
 End of 36 weeks
 Amount of lanugo present begins to diminish

 End of 40 weeks
 Fingernails extend over the fingertips
 Creases on the soles of the feet cover at least two thirds of the surface

ESTIMATING THE EXPECTED DATE OF CONFINEMENT (EDC)

Nagele’s rule:
Count back 3 months then add 7 days from the first day of the last
menstrual period.

Mc Donald’s Rule:
The fundal height in cm is equal to the age of gestation between 20 - 31 weeks
of pregnancy

NON STRESS TESTING

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NST is the assessment of the Fetal Heart Rate in relation to Fetal Movement
Preparation:
Patient should eat snacks.
RESULT:
REACTIVE ( NORMAL)
FHR should increase of 15 beats from the baseline that will last for 15 seconds,
when the baby moves.

NON REACTIVE (ABNORMAL)

CONTRACTION STRESS TESTING

CST is the assessment of the fetal heart rate in relation to uterine contraction

 There must be at least three uterine contraction that will last for 40 seconds or more.
RESULT:
 NEGATIVE (NORMAL)
- there are no late decelerations after any of the contractions
 POSITIVE (abnormal)

Late deceleration – are decelerations that occur after the contraction

BIOPHYSICAL PROFILE SCORING

1. FETAL BREATHING
instrument used: sonogram
criteria for a score of 2:
At least one episode of 30 secs of sustained fetal breathing movements
with in 30 mins of observation

2. FETAL MOVEMENTS:
INSTRUMENT USED: Sonogram
CRITERIA FOR A SCORE OF 2:
At least 3 separate episodes of fetal limb or trunk movement within a 30 mins
observation
3. FETAL TONE
INSTRUMENT USED: Sonogram
CRITERIA FOR A SCORE OF 2:
The fetus must extend & then flex the extremities or spine at least once in 30
mins.

4. AMNIOTIC FLUID VOLUME:

INSTRUMENT USED: Sonogram
CRITERIA FOR A SCORE OF 2:
A pocket of amniotic fluid measuring more than 1 cm in vertical diameter must be
present

5. PLACENTAL GRADE
INSTRUMENT USED: Sonogram
CRITERIA FOR A SCORE OF 2:
Placenta is grade 3. Grading is based on structure & amount of calcium present.

6. FETAL HEART REACTIVITY

INSTRUMENT USED: Non stress test
CRITERIA FOR A SCORE OF 2:
- Two or more FHR accelerations of at least 15 bpm above baseline & of 15 secs
duration occur with fetal movement.

INTERPRETATION (COMPLETE PROFILE:

8 – 12 : FETUS IS DOING WELL
4 – 6 : DENOTES THE FETUS IS IN JEOPARDY

DIAGNOSIS OF PREGNANCY

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I. PRESUMPTIVE SIGNS
o Breast changes
o Nausea, vomiting
o Amenorrhea
o Frequent urination
o Fatigue
o Uterine Enlargement
o Quickening
o Linea Nigra
o Melasma / Chloasma
o Striae gravidarum

 PROBABLE SIGNS
o Serum Lab Test
o Goodell’s sign
o Hegar’s sign
o Chadwick’s sign
o Sonographic evidence of gestational sac
o Ballotement
o Braxton Hicks
o Fetal outline felt by examiner

POSITIVE SIGNS
o Sonographic evidence of fetal outline
o Fetal heart audible
o Fetal movement felt by examiner

PSYCHOLOGICAL TASKS OF PREGNANCY

First trimester – accepting the pregnancy

Second trimester – accepting the baby

Third trimester – preparing for parenthood

PHYSIOLOGICAL CHANGES OF PREGNANCY

 UTERUS
a) Lightening
- the presenting part settled into the pelvic cavity
- the baby has “dropped”

b) Hegars sign
c) Ballotement
Ballotement occurs when the examiner pushes up on the uterine wall
during a pelvic examination, then feels the fetus bounce back against the
examiner’s fingers.
d) Braxton Hicks Contractions
 Amenorrhea
 Cervical changes
a) Mucus plug
- tenacious coating of mucus
b) Goodel’s sign

 Vaginal Changes
a) Leukorrhea
b) chadwick’s sign
c) vaginal pH changes from 7 or above to 4 or 5 (acidic)
d) favors candida albicans which will cause oral thrush or oral moniliasis

 Ovarian changes
no ovulation

 Breast changes

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 a) increase in size, darkened and enlarged areola, fullness
b) colostrum will be seen on the 16th week AOG

 Skin
a) Striae gravidarum
b) melasma
c) Linea Nigra

 Cardiovascular system (CVS)

a) physiologic anemia (pseudoanemia)
b) Drop of BP commonly on the 2nd trimester
c) Supine Hypotension

SIGNS AND SYMPTOMS OF SUPINE HYPOTENSION

• Dizziness
• Sweating
• Lightheadedness
• Fetal distress
MANAGEMENT:
 turn the patient to the left.

 GIT
a) slow peristalsis
b) Nausea and vomiting
c) hyperptyalism
d) hypertrophy of the gumlines

 Skeletal system
a) Lordosis - “pride of pregnancy”
- lordosis causes back pains
- Pelvic rocking or pelvic tilting -management of back pains caused by lordosis.

USUAL SCHEDULE FOR PRENATAL VISITS

• every 4 weeks for first 28 to 32 weeks
• every 2 weeks from 32 to 36 weeks
• every week from 36 to 40 weeks

OBSTETRICAL HISTORY
GRAVIDA (G) is the number of pregnancies.

PARA (P) is the number of pregnancies that reaches a period of viability.

- number of deliveries.

WEIGHT GAIN OF PREGNANCY

Recommended TOTAL WEIGHT GAIN of pregnancy is 25 – 35 lbs (12 - 15 kg)
Distribution:
First trimester – one pound per month
Second trimester - one pound per week
Third trimester - one pound per week

RELIEVING THE COMMON DISCOMFORTS OF PREGNANCY

 Breast tenderness
wear supportive bra.

 Constipation
have a regular time for bowel movements.
Increase fiber in the diet
drink additional fluids.

 Nausea and Vomiting or “morning sickness”

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 eat six small meals per day rather than three.
Eat a piece of dry toast or some crackers before getting out of bed.

 Pyrosis or Heartburn
eat small, frequent meals each day.
Avoid overeating, as well as spicy, fatty, and fried foods.
Avoid bending or lying after eating.
Avoid carbonated drinks.

 Fatigue
schedule rest period daily
Have a regular bedtime routine.
Use extra pillows for comfort.

 Muscle cramps
avoid pointing your toes.
Straighten your leg and dorsiflex ankle.
Increase calcium intake

 Varicosities
walk regularly.
Rest with feet elevated.
wear a well support stockings
avoid constricting stockings

 Hemorrhoids
Avoid constipation and straining with a bowel movement.
Take a sitz bath.

 Leukorrhea
wear cotton underwear.
Bathe daily.
Avoid tight pantyhose.

 Ankle edema
rest with feet elevated.
Avoid standing for long periods and avoid restrictive clothings.

CRAVINGS AND PICA

Craving is the desire for certain foods
Pica is the desire to eat unnatural substances

EXERCISE FOR PREGNANT MOTHERS

1. Tailor sitting
2. Kegel’s exercise
3. Squatting
4. Pelvic rocking

Danger Signs of Pregnancy

! Fever or severe vomiting
! Persistent headache
! Blurred vision or spots before the eyes
! Epigastric pain
! Sudden weight gain
! Sudden onset of edema in the hands and face
! Vaginal bleeding
! Painful urination
! Sudden, constant, or uncontrollable leaking of fluid from the vagina
! Decreased or excessive fetal movement
! Signs of premature labor

SIGNS OF APPROACHING LABOR

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  Lightening
 Frequently occuring braxton hicks
 Increased level of activity
 Ripening of the cervix

TRUE LABOR FALSE LABOR

Cervical Changes Progressive dilatation No change

& effacement

Membranes May bulge or rupture Remain intact

spontaneously

Bloody show Present Absent

Contraction Regular Irregular

pattern

Pain Starts in the back and radiates Confined to the abdomen

Characteristics to the lower abdomen

Effects of walking Continue and become May eliminate the

Stronger contraction

COMPONENTS OF LABOR

4 P’s of Labor
P – Passenger
P – Passage
P - Power
P - Psyche

PASSAGE
1. Vaginal Canal
2. Cervix
a) Cervical dilatation
10 cm is the fully dilated cervix
b) Cervical effacement
100% is the fully effaced cervix.

3. Pelvic bone

4 Types of pelvis
 ANDROID
• Narrow, heart-shaped
• - Male type pelvis
 ANTHROPOID
• Narrow, oval shaped;
• - resembles ape pelvis
 Gynecoid
• Classic female pelvis
• Suitable for vaginal delivery
• Wide and round in all directions
 PLATYPELLOID
• Flattened, oval, transverse shape
• Broad pelvis with shortened AP diameter

PASSENGER

FETAL SKULL:
 Occipital bone
 Frontal bone
 Parietal bones
 Temporal bones

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SUTURES are fibrous joints of the fetal skull

Types of suture:
Coronal suture – the joint between the frontal bones and the parietal bones
SAgittal suture – the joint between the two parietal bones.
Lambdoidal suture – the joint between the two parietal bones and the occipital bones

ATTITUDE
- the degree of flexion of the fetus
- the relationship of the fetal parts towards each other.

STATION:
is the relationship of the presenting part to the ischial spines of the maternal’s pelvis

FETAL LIE
is the relationship between the long axis of the mother to the long axis of the fetus.

Types:
Longitudinal
Transverse
Oblique

PRESENTATION
Is the part of the fetus that is first in contact with the cervix.

TYPES:
1. Cephalic
2. Breech
3. Shoulder

TYPES OF CEPHALIC PRESENTATION

1.VERTEX
- The head is sharply flexed, making the parietal bones or the space between the
fontanelles (the vertex)the presenting part.

2. BROW
- Because the head is only moderately flexed the brow or the sinciput becomes
the presenting part
3. FACE
- The fetus has extended his head to make the face the presenting part.
4. Mentum
The fetus has completely hyperextended the head to present the chin.

TYPES OF BREECH PRESENTATION

1. COMPLETE
- The fetus has thighs tightly flexed on the abdomen; both the buttocks and the
tightly flexed feet present to the cervix.

2. FRANK
- Attitude is moderate because the hips are flexed but the knees are extended to
rest on the chest. The buttocks alone present to the cervix.

3. FOOTLING
- Neither the thighs nor lower legs are flexed. If one foot presents, it is a single
footling breech; if both presents, it is a double footling breech.

POSITION
is the relationship of the presenting part to the 4 quadrants of the maternal’s pelvis

FETAL REFERENCE POINT (PRESENTING PART)

 OCCIPUT (O)
 SACRUM (S)
 SCAPULA (Sc)
 MENTUM (M)
MECHANISMS OF LABOR

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D – Descent
F - Flexion
I - Internal Rotation
R
E - Extension
E – External Rotaion (Restitution)
R
E - Expulsion

POWER

Two sources of power:

1. Involuntary muscular contraction of the uterus.
2. Voluntary muscle contraction of the maternal abdome

3 PHASES OF UTERINE CONTRACTION:

1. Increment
2. Acme
3. Decrement

COMPONENTS OF UTERINE CONTRACTION:

 Frequency
measured by counting the time interval from the beginning of one contraction to the
beginning of the following contraction.
 Duration
is the interval from the beginning of a contraction to its end.
 Interval
or the period of relaxation.
Measured from the end of one contraction to the start of the next contraction.
 Intensity
refers to the strength of the contraction and is documented as MILD, MODERATE or
STRONG.

STAGES OF LABOR

1.FIRST STAGE - Is cervical dilatation stage.

Starts with the signs of true labor and ends with a fully dilated cervix

a) Latent phase
 1 – 3 cm cervical dilatation
 uterine contractions lasts from 20 – 40 seconds
 Mild uterine contractions
 MANIFESTATIONS: Abdominal cramps; backache; Client generally excited, alert,
talkative and in control; may rupture membranes
b) ACTIVE PHASE
 4 – 7 cm cervical dilatation
 uterine contraction will last from 40 – 60 seconds
 Uterine contractions – moderate in intensity
 Manifestations: Moderate increase in pain; Client more apprehensive, fear of
losing control; focusing on self; skin warm and flushed

c) TRANSITIONAL PHASE
 8 – 10 cms cervical dilatation
 uterine contractions will last from 60 to 90 seconds
 Strong uterine contractions
 Manifestations: Client may be irritable and panicky; may lose control; Perspiring;
Nauseous and vomiting is common; Trembling of legs; Pressure on bladder and
rectum; backache; increased show

2) SECOND STAGE
also called as the FETAL EXPULSION STAGE.
It starts with a fully dilated cervix and ends with the delivery of the fetus.

3) THIRD STAGE or the PLACENTAL EXPULSION STAGE

It starts with the delivery of the fetus and ends with the delivery of the placenta.

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Signs of placental separation:
• Increased gush of blood
• Uterus becoming globular with fundus rising in the abdomen
• Apparent lengthening of cord

4. FOURTH STAGE OF LABOR

is the first 4 hours postpartum

UTERUS:
The uterus contracts in the midline of the abdomen with the fundus midway between the
umbilicus and symphysis pubis.

MANIFESTATIONS:
• Lochia rubra
• Exploration of newborn
• Parent-infant bonding begins
• Newborn alert and responsive

FETAL MONITORING DURING LABOR AND DELIVERY

VARIABILITY
 Irregular fluctuations in the baseline of FHR.
 Absent or decreased with fetal sleep or fetal maturity.
 Drugs (anesthetics)
 Hypoxia (acidosis)
 If persists longer than 30 minutes – indicator of fetal distress.

TACHYCARDIA
 More than 160 bpm lasting longer than 10 minutes
 Early signs of hypoxia
 Associated with maternal fever, fetal anemia, fetal or maternal infection.
 Maternal hyperthyroidism, heart failure
 Not reassuring when associated with late decelerations, severe variable deceleration, or
absence of variability
BRADYCARDIA
 Less than 110 bpm lasting longer than 10 minutes
 Late signs of hypoxia
 Associated with maternal drugs (anesthetics), maternal supine hypotensive syndrome
 Prolonged cord compression
 Not reassuring when associated with loss of variability and late decelerations

ACCELERATIONS:
 15 bpm rise above baseline followed by a return to baseline
 Usually in response to fetal movement or uterine contractions
 Indicates fetal well being

TYPE I (EARLY DECELERATIONS)

 CAUSE: Fetal head compression
 FHR decreases with onset of contraction and mirrors the pattern of contractions
 Range of drop in FHR within normal parameters
 Nursing Implications: Continue observation

TYPE 2 (LATE DECELERATIONS)

 CAUSE: Uteroplacental insufficiency causing fetal hypoxia
 FHR decreases after the onset of contraction.
 FHR deceleration persists beyond completion of contraction
 Range of drop in FHR within normal
 Nursing implications: Turn client to left side, give oxygen and summon physician

TYPE 3 (VARIABLE DECELERATIONS)

 CAUSE: Umbilical Cord Compression
 FHR decreases at any point during or between contractions
 Decelerations may be jagged V or U shape
 Range of drop in FHR is large and extends beyond normal
 Nursing Implications: Turn client to left side; Give oxygen and summon physician

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EPISIOTOMY is a surgical incision made into the perineum to enlarge the vaginal opening just
before the baby is born.

SITUATIONS IN WHICH AN EPISIOTOMY MAY BE INDICATED:

• Shoulder dystocia
• Persistent occiput posterior
• Breech presentation
• Forceps or vacuum-assisted delivery is used to shorten the second stage of labor.

Two Types of Episiotomy:

1. Midline episiotomy
2. Mediolateral episiotomy

DANGER SIGNS OF LABOR

 Increasing or decreasing fetal heart rate
 Meconium staining
 Hyperactivity
 Fetal acidosis (Scalp capillary technique pH below 7.2 – acidosis)
 Increasing or decreasing maternal BP
 Increasing maternal pulse rate
 Prolonged or inadequate contraction

POST PARTUM (PUERPERIUM)

Postpartum (Puerperium) is the first 6 weeks after delivery

PHASES:
1. Taking – in: 1 to 2 days
2. Taking hold: 3 days to 8 weeks
3. Letting go

POSTPARTUM BLUES
 Experienced by 50% to 70% of postpartum mothers
 Sometimes called the “baby blues”
 Usually begins on the 3rd day and lasts for 2 to 3 days
 the woman may be tearful, have difficulty sleeping and eating, and feel generally let down
 This is a normal reaction; however, if the depression lasts for more than several days, or
if the symptoms become severe, further psychological evaluation is needed.

INVOLUTION
Involution is the return of the pregnant reproductive system to its non pregnant state.

UTERUS:
Immediately after birth weighs 1000 g
One week postpartum estimated as 500g
At the end of 6 weeks postpartum, will return to its pre pregnant weight which is 50 – 70g

LOCHIA
1. Lochia rubra
 Red
 Present on the 1st to 3rd day postpartum
2. Lochia serosa
 Pink or brown
 Present on the 4th to 10th day PP
3. Lochia Alba
 White
 Present on the 10th day up to the 14th

B-U-B-B-L-E-E

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B – Breast
U – Uterus
B – Bowel
B - Bladder
L – Lochia
E – Extremeties
E - Episiotomy

ANTEPARTUM COMPLICATIONS
ECTOPIC PREGNANCY:

 is the implantation of products of conception in a site other than the uterine

cavity.( fallopian tube, ovary, cervix, peritoneal cavity)

ASSESSMENT for ECTOPIC PREGNANCY

Mild manifestations initially
little or no bleeding
lower abdominal pain that radiates to the shoulder
When tube ruptures:
Sharp abdominal pain
signs of shock

COMPLICATIONS:
Hemorrhage
Shock
Peritonitis

DIAGNOSTIC EVALUATION
Culdocentesis:
Aspiration of fluid from the cul-de-sac of Douglas
Presence of bloody fluid indicates peritoneal bleeding
Culdoscopy:
visualization of the pelvic organs thru the punctured posterior fornix.
Ultrasound
Confirm extrauterine pregnancy

THERAPEUTIC INTERVENTIONS
• Diagnosis confirmed by ultrasound examination, laparoscopy, or culdocentesis.
• Immediate blood replacement if blood loss is severe.
• Surgical repair or removal of ruptured fallopian tube may be attempted.
• Chemical therapies to salvage fallopian tube ( e.g.Methotrexate, Leucovorin.

NURSING INTERVENTIONS
• Assess continuously for signs of shock.
• Administer blood transfusion if ordered for excessive blood loss.
• Administer analgesics as ordered for pain.
• Provide emotional support.
• Administer RhoGAM to Rh negative client

HYDATIDIFORM MOLE

TYPES:
1. Complete Mole
chromosomes are either 46XX or 46XY but are contributed by only one parent and the
chromosome material duplicated
this type usually leads to chriocarcinoma

2. Partial Mole
has 69 chromosomes. There are 3 chromosomes for every pair instead of 2.
this type rarely leads to choriocarcinoma

ASSESSMENT FOR H-MOLE:

 Vaginal bleeding containing grapelike tissue
 Uterus larger than expected of the pregnancy
 S/Sx of preeclampsia before 20 wks’ gestation ( BP elevated earlier than 24 weeks’
gestation)

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  Severe nausea and vomiting
 Absence of fetal heart tones

LABORATORY AND DIAGNOSTIC STUDIES

• HCG serum levels are abnormally high
• U/S reveals characteristic appearance of molar growth.

NURSING MANAGEMENT

• Prepare for suction curettage evacuation of the mole.

• Frequent PE X 1 year
• HCG levels monitored for one year
• Pregnancy is discouraged for one year.
• Oral contraceptives and IUD are not recommended

ABORTION

NURSING INTERVENTION
 amount and type of bleeding. Save and count number of pads.
 fundus for firmness after products of conception are expelled.
 for hypovolemia, shock and infection.

• Prepare for D&C if indicated.

• RhoGAM

INCOMPETENT CERVIX

THERAPEUTIC INTERVENTIONS:
Cerclage

A. Permanent suture (Shirodkar Procedure)

B. Temporary Purse String (McDonald Procedure)

PRETERM LABOR

Preterm labor is labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation.

ASSESSMENT:
 Low back pain
 Suprapubic pressure
 Vaginal pressure
 Rhythmic uterine contractions
 Cervical dilation and effacement
 Possible rupture of membranes

CONSERVATIVE TREATMENT:
 Bedrest
 Hydration
 Tocolytic Therapy (not needed if contraction stops)
 Discharge planning includes:
Complete bedrest
Stress management
Promotion of nutrition
Increased fluid intake
No sexual activity

NURSING ASSESSMENT DURING TOCOLYTIC THERAPY

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Evaluate the following:
 Fetal status
 Respiratory status
 Muscular tremors
 Contractions pattern
 Palpitation
 Hypotension
 Dizziness

PREGNANCY INDUCED HYPERTENSION

GESTATIONAL HYPERTENSION
Increased BP during pregnancy that resolves within 6 weeks after birth
No edema or proteinuria is present

MILD PREECLAMPSIA
elevated bp – BP of above 140/90
Weight gain
Edema
Proteinuria + 1 or +2
Hypereflexia + 3

THE PATELLAR REFLEX IS SCORED AS:

0 - No response; hypoactive; abnormal
1+ - somewhat diminished response but not abnormal
2+ - average response
3+ - Brisker than average but not abnormal.
4+ - hyperactive; very brisk; abnormal

SEVERE PREECLAMPSIA
Elevated BP - ≥ 160/110
Edema
Proteinuria - +3 or + 4
Hypereflexia +4
Oliguria

ECLAMPSIA
All changes associated with preeclampsia, plus tonic and clonic convulsions (grand mal seizure),
cerebral hemorrhage, liver rupture, and coma.

GUIDELINES FOR PREVENTION OF PIH

• Increase CHON to 60 g daily in the 2nd and 3rd trimesters.
Caloric intake increased by 10% during pregnancy. Severe
caloric restriction harmful during pregnancy
• Restriction of Na is harmful during pregnancy, can result in
fld.and electrolyte imbalance. (reduced circulatory vol.)

PIH TREATMENT
Bedrest in the left lateral recumbent position
High-protein diet.
Ambulatory care; frequent visits to obstetrician.
Frequent rest periods with feet elevated.
Sedatives to ensure rest and sleep.
Administer magnesium sulfate.

MAGNESIUM SULFATE
ACTION:

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 Is a central nervous system depressant that acts to block neuromuscular transmission to
halt convulsions.

THERAPEUTIC RANGE: 5 to 7 mg/ 100ml

PATELLAR REFLEX DISAPPEARS:
8 – 10 mg/ml

RESPIRATORY DEPRESSION OCCURS:

15 to 20 mg. ml
ADVERSE EFFECT:
- Flushing thirst
- with toxicity, absence of deep tendon reflec (DTR), respiratory depression,
cardiac arrest, and decreased urine output.

NURSING IMPLICATIONS:
 Administer continuos infusion “piggybacked” into a main IV line so it can be
discontinued immediately without interfering with fluid administration.
 Assess maternal blood pressure and FHR continuously.
 Assess DTR every 4 hours during continuos infusion
 Monitor I and O every hour . Urine output should be 30 ml / hr.
 Assess client’s level of consciousness
 Stop infusion if DTR are absent or if RR is less than 14 or urine output is less than 30
ml/hr.
 may cause depression in the NB.

PLACENTA PREVIA

Implantation of the placenta at the lower uterine segment

Types:
Type I or LOW LYING PLACENTA PREVIA
TYPE II Placenta Previa or Marginal Placenta Previa
TYPE III Placenta Previa
or PARTIAL PLACENTA PREVIA
TYPE IV Placenta Previa or Total Placenta Previa or sometimes called as Complete Placenta
Previa

ABRUPTIO PLACENTA

Abruptio Placenta is the early separation of a normally implanted placenta

Types:
1. Concealed hemorrhage – placental separation starts at the center.
Signs and symptoms:
 Rigid / board like abdomen
 Decreasing Bp and Increasing Pulse Rate
 Couvelaire Uterus or the bronze colored uterus
 Uterine Apoplexy
 Abnormal or absent FHR
2. Revealed or apparent hemorrhage – placental separation starts at the edge
Signs and symptoms:
 Same as concealed
 Vaginal bleeding

3. Mixed hemorrhage
- placental separation both at the edge and center.
Signs and symptoms:
 Same as revealed hemorrhage

DISORDERS OF AMNIOTIC FLUID

1. Polyhydramnios

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 Excessive amount of amniotic fluid
more than 1,500 ml to 3000ml
Types:
a)Chronic – gradual
b) Acute – sudden (very rare.
Possible causes:
 Esophageal atresia
 Multiple pregnancy
 diabetes

2. Oligohydramnios
Scanty amount of amniotic fluid.
300 ml or less

Causes:
Kidney malfunction

Complication:
Compression deformity

GESTATIONAL DIABETES

PREGNANCY RELATED COMPLICATIONS OF DIABETES

INCREASED RISK FOR THE DEVELOPMENT OF THE FOLLOWING COMPLICATIONS:

• SPONTANEOUS ABORTIONS
• HYPERTENSIVE DISORDERS (PIH)
• PRETERM LABOR
• INFECTIONS (MONILIASIS)
• BIRTH COMPLICATIONS: POSTPARTUM HEMORRHAGE

SCREENS FOR FETAL COMPLICATION

• Maternal serum alpha-fetoprotein level
• Ultrasound
• Nonstress test (as early as 30 weeks), contraction stress test, and biophysical
profile
• Lung Maturity Studies (Amniocentesis

NURSING MANAGEMENT:
CARE OF THE MOTHER
Stress importance of ongoing, regular, and more frequent antepartal care
Strict adherence to prescribe dietary regimen and insulin requirements. Record results.
Regulate insulin dose as prescribed by blood glucose levels not by urine tests. Expect altered
requirements in intrapartal and postpartal periods.
Promote good personal hygiene to prevent infection.
Assure that she will be able to breastfeed her infant if she wishes.
Reinforce importance of various tests to assess fetal well-being such as U/S, stress and
non-stress tests, amniocentesis, L/S ratio.

CARE OF THE NEONATE

Admit infant to neonatal intensive care unit if necessary.
Keep infant warm. (poor control mechanisms)
Provide glucose water feeding or initiate feedings to prevent acidosis.(With poor sucking reflex,
glucose should be given parenterally).
Observe for congenital anomalies.
Promote early infant and mother interaction.
Observe for signs for hypoglycemia
jitteriness, irregular RR, cyanosis, weak, high-pitched cry, lethargy, twitching, eye-rolling,
seizures, poor sucking reflex

INTRAPARTUM COMPLICATIONS
DYSTOCIA – difficult labor

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I. PROBLEMS OF THE POWER:
1. Inertia – sluggishness of uterine contractions
- also called as dysfunctional labor
Common causes:
a) Hypotonic uterine contractions
usually happens during the active phase of labor
Management: Oxytocin
b) Hypertonic uterine contractions
usually happens during the latent phase of labor
Management: Sedative

DYSFUNCTION OF THE FIRST STAGE

Prolonged Latent Phase:
> 20 Hours in Primi, > 14 hours in multi
Protracted active phase
> 12 hours in primi, > 6 hours in multi
Secondary Arrest of Dilatation
No progress of cervical dilatation for more than 2 hours
Prolonged Descent
< 1 cm/hour in primi; < 2 cm/hr in multi

DYSFUNCTION OF THE SECOND STAGE

Arrest of Descent
No descent for 1 hour in multi; 2 hours in primi

2. PRECIPITATE LABOR
Rapid labor and birth of less than 2-hour duration.
Hazards to mother are perineal laceration and postpartum hemorrhage.
Hazards to infants are anoxia and intracranial hemorrhage.

ASSESSMENT
Rapid cervical dilation
Accelerated fetal descent
History of rapid labor
Rapid uterine contractions with decreased periods of relaxation between contractions

NURSING MANAGEMENT
Remain with mother and monitor closely.
Keep mother and partner informed throughout process of labor and birth
Support and guide fetal head through birth canal when birth occurs

• Spontaneous or traumatic rupture of the uterus.

• Classified into 2 types: complete and incomplete rupture
• Diagnosis: based on the presenting symptoms

UTERINE RUPTURE
CAUSES

• Rupture of the scar from a previous cesarean delivery or hysterectomy

• Prolonged or obstructed labor (shoulder dystocia)
• Forceps delivery of fetus with abnormalities (hydrocephalus)
• Application of forceps and extraction before cervical os has completely dilated
• Injudicious use of oxytocin
• Excessive manual pressure applied to the fundus during delivery
• Violent, bearing down

ASSESSMENT COMPLETE RUPTURE

• Sudden sharp abdominal pain during contractions
• Cessation of contractions
• Bleeding into the abdominal cavity and sometimes into the vagina
• FHT cease
• Signs of shock
ASSESSMENT INCOMPLETE RUPTURE
• Abdominal pain during contractions
• Contractions continue, but cervix fail to dilate
• Vaginal bleeding may be present

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 • Rising pulse rate and skin pallor
• Loss of fetal heart tones

UTERINE INVERSION

Uterus turns completely or partially inside out during 3rd stage of labor.
Occurs immediately following delivery of the placenta or in the immediate postpartum period.

TYPES
FORCED INVERSION
caused by excessive pulling of the cord or vigorous manual expression of the placenta or clots
from an atonic uterus.
SPONTANEOUS INVERSION
due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle
contraction.

PREDISPOSING FACTORS
Straining after delivery of the placenta
Vigorous kneading of the fundus to expel the placenta
Manual separation and extraction of the placenta
Rapid release of excessive amniotic fluid

CLINICAL MANIFESTATIONS
Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina
Extrusion of the inner uterine lining into the vagina or extending past the vaginal introitus
Vaginal bleeding

MEDICAL MANAGEMENT
GOAL:
Restore the uterus to its normal position.
Often involves the use of general anesthesia and tocolytic therapy (use of terbutaline, ritodrine,
or magnesium sulfate).
Blood replacement to correct shock.
After the uterus has been restored to its normal position, oxytocin is given to contract the uterus.

NURSING MANAGEMENT
Recognize signs of impending inversion and immediately notify physician and call for
assistance.
Immediate manual replacement of the uterus at the time of inversion. (prevent cervical
entrapment of the uterus)
If reinversion not performed, rapid blood loss may occur. (Hypovolemic shock)

II. PROBLEMS OF THE PASSENGER

1. Prolapse of the umbilical cord

loop of umbilical cord slips down in front of the presenting part.

ASSESSMENT
Cord may be protruding from the vagina
Cord may be palpated in the vaginal canal or cervix
Fetal distress may occur as the cord is compressed between the presenting part and the bony
prominence
FHR pattern may show variable decelerations with contractions or between contractions
Fetal bradycardia present
If the cord is exposed to the cold air, there may be reflex constriction of the umbilical vessels
(restricts O2 flow to fetus)

MEDICAL MANAGEMENT
• Delivery of the fetus as soon as possible

NURSING MANAGEMENT
If prolapsed cord is identified, notify the physician and prepare for emergency cesarean birth.
If the client is fully dilated, the most emergent delivery route may be vaginal. Encourage the
client to push and assist with delivery.
Lower the head of the bed and elevate the client’s hips on pillow, or place the client in knee-chest
position (minimize pressure on the cord.)
Administer O2 at 10-12 L/min

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Apply firm upward manual pressure to the presenting part of the fetus with sterile gloved hand
(elevate the fetus and relieve pressure on the cord.
Gently wrap gauze soaked in sterile normal saline solution the prolapsed cord.

PROBLEMS OF THE PASSAGE

I. Inlet Contraction
Anteroposterior diameter is < 11 cm
Transverse diameter is < 12 cm
II. Outlet Contraction
Transverse diameter < 11 cm

Management could be forceps delivery

RH INCOMPATIBILITY
Also called as Isoimmunization
Two types:
Rh – ( negative of D-antigen)
Rh + ( positive of D - antigen

Coombs test
to test the presence antibodies against D

Two types:
Indirect Coombs test – blood sample is of the mother
Direct Coombs test – blood sample is of the fetus

Negative Coombs test:

No antibody
Give Rhogam
Positive Coombs test:
Positive with antibody
Do not give Rhogam

Rhogam
Is given to prevent development of antibodies.
Given only to Rh – mothers
Indications for Rhogam:
On the 28th gestation of an Rh – mother pregnant with Rh + baby
Every after ectopic pregnancy
After amniocentesis
Every after abortion
72 hours postpartum

POSTPARTUM COMPLICATIONS

4 Common Abnormalities of the Postpartum:

1. Postpartal hemorrhage
2. Puerperal Infection
3. Thrombophlebitis
4. Mastitis

Postpartum Hemorrhage
any blood loss from the uterus greater than 500 ml within a 24 hour period (some
agencies – 1,000ml)
Types:
a) Early PP hemorrhage – first 24 hours
b) Late PP hemorrhage – after 24 hours to 6 weeks PP.
Causes:
1. Uterine Atony – the most frequent cause
2. Lacerations
3. Retained placental fragments
4. Disseminated intravascular coagulation

ASSESSMENT:
Vaginal bleeding
Signs of impending shock

NURSING MANAGEMENT

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Massage the uterus, facilitate voiding and report blood loss.
Monitor blood pressure and pulse rate every 5-15 minutes.
Prepare for IV infusion, oxytocin, and blood transfusion if needed
Administer medications and oxygen as prescribed. (Oxytoxic methylergonovine maleate (IM, PO,
IV)
Measure and record fluid intake and output.
Be prepared for a possible D&C.

PUERPERAL INFECTION

Assessment:
Puerperal morbidity is marked by a temperature of 38ºC (100.4ºF) or higher after the first 24
hours postpartum;

NURSING MANAGEMENT
Inspect the perineum for redness, edema ecchymosis, and discharge
Evaluate for abdominal pain, fever, malaise, tachycardia, and foul-smelling lochia
Obtain specimens for lab. analysis and report findings.
Offer a balanced diet, frequent fluids and early ambulation
Administer prescribed antibiotics or medications and document patient response
Stress careful perineal hygiene and handwashing

THROMBOPHLEBITIS
Thrombophlebitis is the inflammation of the lining of a blood vessel with the formation of blood
clots.
Women most prone are:
 Obese
 With varicosities
 With previous thrombophlebitis
 Above 30 years old
 High parity

PREVENTION OF THROMBOPHLEBITIS:
 Early ambulation
 Limiting the time in obstetrics stirrups
 Padded stirrups
 Wearing support stockings for the first 2 weeks PP especially if the woman has
varicosities.

MEDICAL MANAGEMENT
• Strict bedrest.
• Anticoagulant therapy
Heparin therapy given continuously for 7-10 days
Dicumarol/ Warfarin Na (Coumadin) administration follows Heparin therapy
Antibiotics
• Maintain hydration

MASTITIS

ASSESSMENT:
Symptoms usually don’t appear until the third or fourth postpartum week (or even months later)

Elevated temperature, chills, general aching, malaise and localized pain

Increased pulse rate
Engorgement, hardness, and reddening of the breasts
Nipple soreness and fissures
Swollen and tender axillary lymph nodes

NURSING MANAGEMENT
Administer antibiotics and complete antibiotic regimen.
Offer comfort measures such as:
Suggest supportive bra
Apply cold or heat application over localized abscess.
Breast feed frequently.
Perform adequate breast and nipple care.
Avoidance of harsh cleansing agents and decrusting the nipple.
Frequent breast pad changes.

26
Intermittent exposure of nipples to the air.
Observe for signs of infection
Elevated temperature, chills, tachycardia, headache, pain and tenderness, firmness and
redness of the breast.

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