1 OBSTETRIC NURSING ANATOMY OF FEMALE REPRODUCTIVE SYSTEM I. FEMALE REPRODUCTIVE SYSTEM A. The External Genitalia 1.

Mons Pubis or Veneris- a pad of fat which lies over the symphysis pubis covered by skin and at puberty, by short hairs; it protects the surrounding delicate tissues from trauma. 2. Labia Majora- two fold of skin with fat underneath containing Bartholins glands that secrete a yellow mucus which acts as a lubricant during sexual intercourse; the openings of the Bartholins glands are located posteriorly on either side of the vaginal orifice. 3. Labia Minora- two thin folds of delicate tissues forming an upper fold encircling the clitoris (called the Prepuce) and unite posteriorly (called the Fourchette which is highly sensitive to manipulation and trauma that is why it is often torn during delivery). 4. Glans Clitoris- a small, erectile structure at the anterior junction of the labia minora which is comparable to the penis in its extremely sensitive. 5. Vestibule- a narrow space seen when the labia minora are separated. 6. Urethral Meatus- an external opening of the urethra that is slightly behind and to the sides are the openings of the Skenes glands (which are often involved in infections of the external genitalia). 7. Vaginal Orifice or Introitus- an external opening of the vagina covered by a thin membrane (called Hymen) in virgins. 8. Perineum- an area from the lower border of the vaginal orifice to the anus that contains the muscles which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia.

2 B. The Internal Genitalia 1. Vagina- a 3-4 inch long dilatable canal located between the bladder and the rectum that contains rugae which permit considerable stretching without tearing; it is also a passageway for menstrual discharges, copulation and fetus. 2. Uterus- a hollow pear-shaped fibromuscular organ which measures 3 inches long, 2 inches wide, 1 inch thick and weighing 50-60 grams in a non-pregnant woman; it is held in place by broad ligaments from the sides to the pelvic walls and fallopian tubes and ovaries in place and by round ligament from sides of uterus to mons pubis; it has abundant blood supply from uterine and ovarian arteries; It is composed of three muscle layers: a. Peritoneum b. Myometrium c. Endometrium It is also consists of three parts: a. Corpus (body)- upper portion with triangular part called Fundus b. Isthmus- an area between corpus and cervix which forms part of the lower uterine segment c. Cervix- lower cylindrical portion; organ of menstruation, site of implantation and retainment and nourishment of the products of conception 3. Fallopian Tubes- 4 inches long from each side of the fundus with its widest part called Ampulla spreads into fingerlike projections called Fimbriae; it is responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half 4. Ovaries- an almond-shaped, dull white sex glands near the fimbriae kept in place by ligaments; it produces, matures and expels ova and manufacture estrogen and progesterone. II. THE PELVIS A. Structures 1. Two Os Coxae or Innominate Bones- it is made up of: a. Ilium- is the upper, extended part which has a curved upper border called Iliac Crest. b. Ischium- is the under part which when sitting, the body rests on the ischial tuberosities and an important landmark is the ischial spines. c. Pubis- is the front part that joins to form an articulation of the pelvis called the Symphysis Pubis. 2. Sacrum- a wedge-shaped that forms the back part of the pelvis that consists of 5 fused vertebrae, the first having a prominent upper margin called the Sacral Promontory; it articulates with the ilium and sacroiliac joint. 3. Coccyx- is the lowest part of the spine with a degree of movement between the sacrum and coccyx which is made possible by the third articulation of the pelvis called Sacrococcygeal joint which allows room for delivery of the fetal head

3 B. Divisions 1. False Pelvis- the superior half formed by the ilia offers landmarks for pelvic measurements; it supports the growing uterus during pregnancy and directs the fetus into the true pelvis near the end of gestation. 2. True Pelvis- the inferior half formed by the pubes in front, the ilia and the ischia on the sides and the sacrum and coccyx behind; it is made up of three parts: a. Inlet- the entrance way to the true pelvis wherein its transverse diameter is wider than its anteroposterior diameter, thus Transverse diameter = 13.5 cm Antero-posterior diameter = 11 cm Right and left oblique diameter = 12.75 cm b. Cavity- the space between the inlet and outlet c. Outlet- the inferior portion of the pelvis bounded in the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch; its anteroposterior diameter is wider than its transverse diameter C. Types 1. Gynecoid- normal female pelvis where inlet is well rounded forward and back; it is most ideal for childbirth. 2. Anthropoid- transverse diameter is narrow, AP diameter is larger than normal. 3. Platypelloid- inlet is oval, AP diameter is shallow. 4. Android- male pelvis where inlet has a narrow, shallow posterior portion and pointed anterior portion D. Measurements 1. External- suggestive only of pelvic size a. Intercristal- distance between the middle points of the iliac crests with an average= 28 cm. b. Interspinous- distance between the anterosuperior iliac spines with an average= 25 cm. c. Intertrochanteric- distance between the trochanters of the femur with an average= 31 cm. d. External Conjugate or Baudelocques- the distance between the anterior aspect of the symphysis pubis and depression below L5 with an average= 18-20 cm. 2. Internal- gives the actual diameter of the inlet and outlet a. Diagonal Conjugate- distance between the sacral promontory and inferior margin of the symphysis pubis with an average= 12.5 cm. b. True Conjugate or Conjugata Vera- distance between the anterior surface of the sacral promontory and the superior margin of the symphysis pubis; it is very important measurement because it is the diameter of the pelvic inlet with an average=10.5-11 cm. c. Bi-ischial diameter or Tuberischii- transverse diameter of the pelvic outlet and measured at the level of the anus with an average= 11 cm.

4 MDRN 7th Batch October 15, 2005/8-12 Mrs. Elena Ramirez, RN, MAN PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM FEEDBACK MECHANISM of MENSTRUATION Menstruation: the periodic sloughing off of the endometrium which occurs every 28 days and usually last 3-5 days General Considerations 1. 300, 000- 400, 000 immature oocytes per ovary are present at birth formed during the first 5 months of intrauterine life; 300-400 mature only after degeneration and atrophy called Atresia during the entire reproductive cycle of a woman 2. Menarche- first menstruation in girls Menopause- permanent cessation of menstruation and no more functioning oocytes in the ovaries; age of onset and termination vary widely depending on heredity, racial background, nutrition and climate. 3. Menstrual cycle- from first day of menstrual period to the first day of the next menstrual period with an accepted average length is 28 days. Board Question: Is rhythm method reliable? Answer: Yes, granting she knows her menstrual cycle 1st Day of Mense Example: Oct 15 Sept 15 Aug 17 July 17 Days of Month 31 30 31 31 Menstrual Cycle 30 days 29 days 31 days

July 31-17= 14 + Aug 17= 31 days= longest cycle considered regular Aug 31-17= 14 + Sept 15= 29 days= shortest cycle Sept 30-15= 15 + Oct 15= 30 days If 33-45 day cycle, considered irregular because 8 days longer from shortest to longest day cycle 4. Associated terms: a. Amenorrhea- temporary cessation of menstrual flow b. Oligomenorrhea- markedly diminished menstrual flow nearing amenorrhea c. Menorrhagia- excessive bleeding during regular menstruation d. Metrorrhagia- bleeding at completely irregular intervals e. Polymenorrhea- frequent menstruation occurring at intervals of les than 3 weeks

5 5. Three Major Phases of Menstruation: a. Uterine Cycle- Proliferative Phase, Secretory Phase, Menstrual Phase b. Ovarian Cycle- Follicular Phase , Luteal Phase , Menstrual Phase Proliferative /Follicular /Estrogen/Postmenstrual/Pre-Ovulatory Phase 3rd Day of Menstruation- serum level of Estrogen is at lowest Stimulates the hypothalamus to produce FSHRF (Follicle Stimulating Hormone Releasing Factor) Stimulates the Anterior Pituitary Gland (APG) to produce Follicle Stimulating Hormone (FSH) Stimulates the OVARY to produce ESTROGEN Stimulates growth of an immature oocyte inside a primordial follicle, GRAAFIAN FOLLICLE Secretory/Luteal/Progestational/Postovulatory/Pre-menstrual Phase 13th Day of Menstrual Cycle- serum level of Progesterone is low Stimulates the hypothalamus to produce LHRF (Luteinizing Hormone Releasing Factor) Stimulates the APG to produce Luteinizing Hormone (LH) Stimulates the OVARY to produce PROGESTERONE The increased amounts of both estrogen and progesterone pushes the now mature ovum to the surface of the ovary until on the following day (14th day of MC), the graafian follicle ruptures and releases the mature ovum, a process called Ovulation. Board Question: What is the time when graafian follicle will be release? Answer: 14th day of menstrual cycle Example: Oct 15- 14 days= Oct 01 ovulation 29-31 day cycle, 5 days before 29 and 5 days after 31, -14-14 15-17 days of ovulation

6 Signs of Ovulation: 1. Breast tenderness, heaviness and fullness 2. Mood changes 3. Increase basal body temperature (BBT) Route: oral Temperature drop & rises=.1 or .2 degrees centigrade Board Question: Natural parenthood CGFNS: Artificial 4. Right or left iliac pain- Mittleschmerz 5. Changes in cervical mucus- Spinnbarkheit Methods used: 1) Billings method- clear and stretchable Board Question: How long? Answer: 10-12 cm 2) Board Question: BBT + Billings method Answer: Sympto Thermal Device Once ovulation has taken place, the graafian follicle that contains increasing amounts of progesterone gives a yellowish color, called Corpus Luteum. Menstrual Phase 24th Day of Menstrual Cycle- amounts of hormone decrease Corpus Luteum turns white, Corpus albicans Degeneration of the lining of uterus Sloughing Off of the Endometrium MENSTRUATION (Approx. amount of blood loss: 20-80 cc with an average of 50 cc/cycle) Functions of Estrogen: 1. Responsible for the development of secondary sex chromosomes 2. Responsible for changes in cervical mucus 3. Responsible for control of proliferative phase 4. Responsible for maturation of the immature oocytes which are contained in the graafian follicle, in turn, contains the mature ovum. Effects of Estrogen in the Body: 1. Inhibits production of FSH 2. Causes hypertrophy of the myometrium 3. Stimulates growth of the ductile structures of the breasts 4. Increases quantity and pH of cervical mucus causing it to become thin and watery and can be stretched to a distance of 10-13 cm (Spinnbarkheit Test of ovulations)

7 Functions of Progesterone: 1. It increases Basal Body Temperature (BBT) 2. It prepares the uterus for pregnancy because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place 3. It maintains pregnancy because it relaxes the uterine muscles 4. It decreases peristaltic activity of the intestines Effects of Progesterone in the body: 1. Inhibits production of LH 2. Increases endometrial tortousity 3. Increases endometrial secretions 4. Inhibits uterine motility 5. Decreases muscle tone of gastrointestinal and urinary tracts 6. Increases musculoskeletal motility 7. Facilitates transport of the fertilized ovum through the fallopian tubes 8. Decreases renal threshold for lactose and dextrose 9. Increases fibrinogen levels but decreases hemoglobin and hematocrit 10. Increases body temperature after ovulation where basal body temperature decreases slightly (because of low progesterone level in the blood) and increases slightly a day after ovulation (because of the presence of progesterone). Additional Information 1. When the ovary releases the mature ovum on the day of ovulation sometimes a certain degree of pain in either the right or left lower quadrant is felt by the woman. This sensation is normal and is termed Mittleschmerz. 2. The first 14 days of MC is a very variable period. The last 14 days of the MC is a fixed period exactly 2 weeks after ovulation, menstruation will occur because the corpus luteum has a life span of only 2 weeks. IMPLICATION: When given options regarding the exact date of ovulation, choose 2 weeks before menstruation. 3. In a 28 day cycle, ovulation takes place on the 14th day. In a 32 day cycle, ovulation takes place on the 18th day. In a 26 day cycle, ovulation takes place on the 12th day. (Subtract 14 days from the cycle). 4. Menstruation can occur even without ovulation (as in women taking oral contraceptives). Ovulation can likewise occur even without menstruation (as in lactating mothers).

8 STAGES of FETAL DEVELOPMENT I. Fertilization Definition: the union of the sperm and the mature ovum in the outer third or outer half of the FT General Considerations: 1. Normal amount of semen per ejaculation=3-5 cc or 1 teaspoon 2. # of sperms in an ejaculate=120-150 million/cc or 300- 400 million/ejaculation Board Question: Out of the million, how many sperm can be fertilized? Answer: one complete sperm consisting of head, neck and one long, motile tail 3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are capable of fertilizing even for 2-3 days after ejaculation Board Question: In a 28 day cycle, when is fertilization to take place Answer: 28-14= 14th day ovulation, within 24 hours following ovulation 4. Normal life span of sperms=7 days; ovum= 24-48 hours 5. Sperms once deposited in the vagina will generally reach the cervix within 90 seconds after deposition 6. Reproductive cells during gametogenesis divide by Meiosis (haploid # of daughter cells) therefore they contain only 23 chromosomes (the rest of the body cells have 46 chromosomes). Sperms have 22 autosomes and 1 X sex chromosome maybe or 1 Y sex chromosome; ova contain 22 autosomes and 1 X sex chromosome. The union of an X carrying sperm and a mature ovum results in a baby girl (XX); the union of a Y carrying sperm and a mature ovum results in a baby boy (XY). IMPORTANT: Only fathers determine the sex of their children. Fertilized Ovum: ZYGOTE- gametes or sex cells (Sperm and Ova) (46 Chromosomes) MEIOSIS 2 haploid cells (23 Chromosomes- 22 autosomes and 1 sex chromosome) Board Question: Female =X Male = X or Y Answer: Male give sex determinants XX= BG XY= BB

9 II. Implantation Definition: Immediately after fertilization, the fertilized ovum or zygote stays in the FT for 3 days during which time rapid cell division (Mitosis) is taking place. The developing cells are now called blastomeres and when there are already 16 blastomere it is now termed a Morula. In this morula form, it will start to travel (by ciliary action and peristalsis contractions of the FT) to the uterus where it will stay for another 3-4 days. When there is already a cavity formed in the morula, it is now called a Blastocyst. Fingerlike projections called Trophoblasts form around the blastocyst and those trophoblasts are the ones which will implant high on the anterior or posterior surface of the uterus. Thus IMPLANTATION also called NIDATION, takes place about a week after fertilization. Occassionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts= implantation bleeding. IMPLICATION: This should not be mistaken for the LMP Rapid cell division-MITOSIS 2 Blastomeres 16 Blastomers MORULA (ball like structure) Blastocyst (Free in the uterus for another day or 2) Trophoblast (Blastocysts goes to the cellular wall) Functions: 1. It contains the primary chorionic villi which become the source of nutrients and oxygen of fetus when the placenta develop 2. It has the power to produce, proteolytic/cytolytic enzymes that help trophoblast to burrow each way to the endometrium Implantation (occurs at the fundus 7-10 days after fertilization) NIDATION III. Once implantation has taken place, the uterine implantation is now termed Decidua divided into 3 parts: 1. D. basalis- part of the endometrium lying directly under the embryo and where trophoblast cells are establishing communication with maternal BV; future placenta 2. D. capsularis- stretches or encapsulates the surface of the trophoblast 3. D. vera- the remaining portion of the uterine lining

10 IV. Trophoblastic Differentiation A. Cyto trophoblast- inner layer B. Syncytiotrophoblast- the outer layer containing fingerlike projections called chorionic villi. 1. Langhans layer- believed to protect the fetus against Treponema pallidum (Etiologic Agent: Syphilis) that is present only during the 2nd trimester of pregnancy. 2. Syncytial layer- gives rise to the fetal membranes: a. Chorion-develop from trophoblast containing villi on the surface that later gives rise to placenta which starts on 8th week of gestation. It develops into 15-20 subdivisions called cotyledons and has two surfaces: maternal and fetal surface. Placenta serves the following purposes: 1) Exchange of gases takes place in the placenta 2) Waste products are being excreted through the placenta 3) Nutrients pass to the fetus via the placenta by diffusion through the placental tissues 4) Feto-placental circulation is established by selective osmosis 5) Corpus Luteum (CL) produces hormones: a) HCG- Human chorionic gonadotropin orders the CL to keep producing estrogen and progesterone that is why menstruation does not take place during pregnancy; it is also the basis for (+) pregnancy test b) HPL- human placental lactogen or human chorionic somatomammotropin promotes growth of the mammary glands necessary for lactation c) Estrogen d) Progesterone 6) Inhibits passage of some bacteria and large molecules Processes involved in Placental Exchange: 1) Simple Diffusion- for oxygen and carbon dioxide, fat soluble vitamins, liquids including narcotics, anesthetics and barbiturates 2) Facilitated Diffusion- glucose 3) Active Transport- amino acids, calcium, iron, water soluble vitamins 4) Pinocytosis- cations, large molecules such as globulins, viruses and anaerobes b. Amnion- develops from the inner cells of the blastocysts Board Question: 2 fetal structures arising from the amnion? Answer: Umbilical cord/funis and Amniotic fluid 1) Umbilical cord/funis- contains 2 arteries (Unoxygenated) and 1 vein (Oxygenated blood) which are supported by Whartons jelly Board Question: How many arteries and veins in the UC? Answer: 2 arteries and 1 vein

11 Board Question: What period of pregnancy is at higher risk? Answer: First Trimester because placental barrier is incomplete and organogenesis occurs 2) Amniotic Fluid- clear, albuminous fluid in which the baby floats that begins to form at 11-15 weeks gestation. Board Question: Sources of AF? Answer: Amniotic cells, fetal urine, secretions from the lungs and skin of the fetus Specific gravity- 1.007- 1.025 pH- 7.0- 7.25 Rate of production- 500 ml in 24 hours Functions: a) Cushions/protects fetus against injury b) Equalizes pressure inside c) Prevents adhesions of the sticky secretion and umbilical cord compression d) Fetal movement e) Thermoregulation f) Oral source 3) 5 Structures of Fetal Circulation: a) Umbilical vein- carries oxygenated blood from the placenta to the inferior vena cava b) Ductus venosus- goes to inferior vena cava and shower blood to the liver c) Foramen ovale- directed blood from right to left atrium d) Ductus arteriosus- directs blood from pulmonary arteries going to aorta e) Umbilical arteries- carries unoxygenated blood going to the placenta for oxygenation; bypass the lungs Summary of Stages of Fetal Development 1. Ovum/Zygote - fertilization= 2 weeks 2. Embryonic - 2 weeks to 2 months= period of organogenesis- 3 Germ layers 3. Fetal Stage - 2months up to birth= fetus

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FETAL DEVELOPMENT A. First Lunar Month (4 weeks) 1. 3 Germ layers differentiate by the 2nd week- Board Questions (*) Germ Layers Organs & Tissues Derived From Ectoderm *Central Nervous System- brain & SC *Peripheral Nervous System Sensory epithelial cells of Sense Organs Mesoderm *Heart Supporting structures of the body Circulatory & Reproductive System Kidneys and Ureters Endoderm and Entoderm *Inner linings of GI Tract and Respiratory Liver, Pancreas, Bladder and Urethra 2. Fetal Membranes (amnion and chorion) appear by the 2nd week 3. Nervous System develops rapidly by the 3rd week 4. Fetal heart begins to form as early as 16th day of life Board Question #1: When does fetal heart begin to beat? Answer: First lunar month Board Question #2: When can fetal HT be first heard? Answer: 5th month 5. Digestive and respiratory tracts start to separate until 3rd week B. Second Lunar Month (8 weeks) 1. Embryo rapidly growing within the embryonic sac 2. Limbs and fingers form and start to appear 3. Ears, nose mouth present 4. Eyes forms but eyelids are closed 5. Heart beat active and visible C. Third Lunar Month (12 weeks) 1. Embryo is called Fetus 2. Swallowing starts 3. Kidneys are able to function- urine passes 4. More coordinated limb movement 5. FHT may be examined through ultrasound 6. External genitalia show definite characteristics 7. CR length: 11 cm and fetal weight: 14 gms D. Fourth Lunar Month (16 weeks) 1. Placenta is completely formed 2. Head now in better proportion with the body 3. Face resembles the human face 4. Quickening: first movement felt by the mother- common among multi mother 5. HB audible by fetoscope

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E. Fifth Lunar Month (20 weeks) 1. Lanugo appear and covers the entire body 2. Fetus moves freely in the amniotic sac 3. Movements are more vigorous 4. External genitalia and sex can be identified through ultrasound 5. CR length: 16 cm and fetal weight: 30 gms F. Sixth Lunar Month (24 weeks) 1. Vernix caseosa ( cheesy white, sebaceous secretion) covers the skin of fetus 2. Head better with the body 3. Skin red and wrinkled G. Seventh Lunar Month (28 weeks) 1. High survival rate 2. Lungs are already developing #1 problem of babies-Hyaline Membrane Disease MD does amniocentesis and request for Lecithin/Sphingomyelin ratio=2:1 Treatment for lung immaturity: Steroids (Bethamethasone/Dexamethasone) 2 doses Termination of pregnancy H. Eight Lunar Month (32 weeks) 1. Lanugo hair disappears 2. Start of fat deposition under the skin for thermoregulation for preterm babies (<32 weeks) babies are placed in the incubator, radiant warmer or droplight I. Ninth Lunar Month (36 weeks) 1. Vernix disappears 2. Amniotic fluid decreasing in amount J. Tenth Lunar Month (40 weeks) Head move further downward into the lower part of the utero to engage in the bony pelvis FOCUS OF FETAL DEVELOPMENT A. First Trimester - organogenesis B. Second Trimester- period of continued fetal growth & development; - rapid increase in fetal length C. Third Trimester - period of most rapid growth & development because of rapid deposition of subcutaneous fat

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NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 1. Cardiovascular Change a. Beginning the end of 1st Trimester, there is a gradual increase of 30-50% in total cardiac volume, reaching its peak during the 6th month. This causes a drop in hemoglobin and hematocrit values resulting to Physiologic Anemia of Pregnancy. Health Teachings: 1) Increase iron supplement by eating iron rich food such as green leafy vegetables and liver rich in Folic Acid= deficiency results to neural tube defect. 2) Take Folic acid after breakfast and stools are colored black 3) Increase in iron supplement may lead to constipation so advise increase in fluid intake and roughage Consequences of increased total cardiac volume: a) Easy fatigability because of increase workload of the heart Health Teaching: Advised rest not CBR b) Slight cardiomegaly displacing it to the left resulting in torsion on the great vessels such as aorta and pulmonary artery c) Systolic murmur common due to lowered blood viscosity d) Nosebleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses b. Consequences of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities: 1) Edema (physiologic) of the lower extremities occur Health Teachings: Raise legs above hip level for <15 minutes 2) Varicosities of the lower extremities can also occur Health Teachings: a) Use or wear support hose to promote venous flow thus preventing stasis in the lower extremities b) Apply elastic bandage so that blood flow thru tissues is decreased by applying excessive pressure on blood vessels c. Varicosities of the vulva and rectum can occur due to poor circulation in blood vessels of the genitalia due to pressure of the gravid uterus Health Teachings: 1) Side lying position with hips elevated on pillows 2) Advise modified knee-chest position 2. Respiratory Changes- there is shortness of breathing (SOB) caused by: a. Increase oxygen consumption and production of carbon dioxide during the 1st trimester b. Increase uterine size causes diaphragm to be pushed or displaced thus crowding the chest cavity Health Teachings: Side lying position (L) and elevation of the head part increases oxygen supply and vital lung capacity

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3. Gastro-intestinal Changes a. Nausea and vomiting during the 1st trimester (100 days or 3 months) is due to increased HCG (NV: 400.000 IU in 24 hours). It may also be due to increased acidity or emotional factors. Health Teachings: 1) Advise to eat dry toast or crackers 30 minutes before arising in the morning (or dry, high carbohydrate, low fat and low spices in the diet) 2) Ice chips 3) Small, frequent feedings 4) Mental tube feedings- psychological factors: divert attention If nausea and vomiting persists beyond 3-5 months, it is termed a hyperemesis gravidarum which result in dehydration, starvation and acidosis Health Teachings: a) Complete bed rest b) D10NSS 3000 ml in 24 hours is the priority b. Constipation and flatulence are due to the displacement of the stomach and intestines thus slowing peristalsis and gastric emptying time. It is also due to progesterone during pregnancy. Health Teachings: 1) Increase fluids except at night time and roughage in the diet 2) Establish regular elimination 3) Increase exercise- walking c. Heartburn during the last trimester is due to increased progesterone which decreases gastric motility, thereby causing reverse peristaltic waves which lead to regurgitation of the stomach contents through the cardiac sphincter into the esophagus causing irritation. Health Teachings: 1) Pats of butter before meals 2) Avoid fried, fatty foods 3) Sips of milk at frequent intervals 4) Small, frequent meals taken slowly 5) Upright position 6) Bend at the knees and not at the waist 7) Ambulation 8) Take antacids such as Milk of Magnesia and never Sodium bicarbonate because it promotes fluid retention (alka seltzer or baking soda) d. Hemorrhoids are due to pressure of enlarged uterus Health Teaching: Cold compress with witch hazel or enema salts

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October 17, 2005/8-12 Mrs. Elena Ramirez, RN, MAN Continuation of Normal Adaptations in Pregnancy 4. Urinary Changes a. Urinary frequency- seen during the 1st due to increased blood supply in the kidneys and to the uterus rising out of the pelvic cavity and 3 rd trimester due to pressure of enlarged uterus on the bladder. Health Teaching: 1) Basic perineal care=from front to back stroke 2) Increase fluid intake 3) Wear cotton panties 4) Void before intercourse b. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine. 5. Musculoskeletal Changes a. Lordotic position- due to a change in the center of gravity, ambulation is made by standing straight and taller (pride of pregnancy). b. Wobbly Gait- due to increased production of the hormone relaxin that cause pelvic bones become more supple and movable. Health Teaching: Advise use of low heeled shoes after the 1st trimester c. Leg Cramps- are caused by calcium-phosphorus imbalance (low calcium, high phosphorus intake) Health Teachings: Calcium intake of 1,200 mg/day by drinking milk 6. Weight Gains: 1st Trimester = 1.5- 3 lbs 2nd & 3rd = 10- 11 lbs Total = 20- 25 lbs or 10-12 kg 1 lb/month 1 lb/week

B. Local Changes 1. Uterus- houses the growing fetus a. Hegars sign seen at about the 6th week is softening of the lower uterine segment particularly the isthmus b. Goodels sign- softening of the cervix (operculum-mucus plug in the cervix) 2. Breast a. Increase in size is due to hyperplasia of mammary alveoli and fat deposits b. Colostrum- a thin, watery, high protein fluid is formed by the 4th month 3. Vagina a. Chadwicks sign is a change in color of vagina from light pink to deep purple or violet due to increase vascularity b. Leukorrhea is an increased amount of whitish, mucoid vaginal discharges due to increase in epithelial cells activity cause by estrogen c. pH of vagina becomes alkaline because of increased estrogen

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4. Skin a. Melasma or chloasma- extra pigmentation on cheeks and across the nose due to increase production of melanocytes by the pituitary gland b. Linea nigra- brown line running from umbilicus to symphysis pubis c. Striae gravidarum- pink or reddish streaks in the abdominal wall due to rupture and atrophy of the connective tissue layers caused by increased uterine size SIGNS and SYMPTOMS OF PREGNANCY Stage First Trimester Presumptive Amenorrhea N and V Easy fatigability Urinary frequency Breast changes Skin changes Enlarging uterus Quickening Chloasma Linea nigra Striae gravidarum Probable Positive Chadwicks sign Ultrasound Goodels sign Hegars sign (+) preganancy test Increased BBT Enlarged abdomen Braxton Hicks Ballotement FHT Fetal movements Fetal outline on XR

Second Trimester

ANTEPARTUM/PRENATAL CARE- from conception up to birth Nursing Consideration: 1) Frequency of visits: first 7 months =monthly 8 months =every other week 9 months =weekly 2) Danger Signs: vaginal bleeding, abdominal pain, fever & chills, edema of face & finger, severe HA & dizziness, severe N & V, passage of watery vaginal discharge and absence of fetal movement 3 Phases/Components of Prenatal Visit: I. Pre-consultation Phase A. Rapport B. History Taking 1. Personal data- name, age (<15 and >35), civil status (unwed/married), occupation, education and religion 2. Medical history 3. Family history 4. Obstetric data: a. Gravida- # of pregnancies a woman has had b. Parity - # of viable deliveries regardless of # and outcome TPAL score (_,_,_,_) # of FT, Premature, Abortion, Living

18 Board Question: Sofia is expecting a 3rd child, she has 2 living-age 2 and 4. Last year she delivered a twin baby fraternal by CS at 19 weeks. Answer: G4P2 (1,1,1,2) c. Computation of AOG/EDC 1) Naegeles Rule LMP known subtract 3 months and add 7 days if the LMP is on the first 3 months of the year: add 9 months & 7 days Example: LMP- Feb 14= 2 14 2 14 +9 +07 -3 +07 EDC= 11 21 -1 21 2) Bartholomews Method LMP unknown 3 landmarks of the abdomen: Xiphoid Umbilicus = 20-22 weeks Symphysis pubis= >12-16 weeks 3) McDonalds Rule Fundic height in cm x 2/7 = age in months Fundic height in cm x 8/7 = age in weeks Example: FH= 20 cms AOG = 20 weeks 20 cm x 8/7 = 22-23 weeks 4) Quickening Primi = 20 weeks/5 months Example: Sept 30 = + 4 months + 20 days 9 30 Multi = 16 weeks/4 months +5 +4 = + 5 months + 4 days ------------14 34 - 12 -28 -------------2 06 5) Haases Rule determines the length of the fetus in centimeters AOG first months = square the age in months AOG 6-10 months= multiply age by 5 Board Question: AOG 2 months = 20 AOG 6 months = 30 Board Question: 48 cms, what is the AOG? Answer: 9- 45 (3), 10- 50 (2) 6) Johnsons Rule estimates the weight of the fetus in grams Formula: FH in cms- n (12- if engaged or 11- if not engaged) x k (155) Example: 20 cm floating= 20-11 x 155= 1,395 grams= viable

19 C. Assessment 1. Physical examination- ROS is indicated including inspection of teeth because they are common foci of infection 2. Pelvic examination a. Cardinal Rule: Empty the bladder first b. Internal examination- to determine hegars, chadwicks and goodels sign c. Ballotment- fetus bounce when uterine segment is tapped sharply (5th month) d. Pap smear: Classification of finding: Clinical Stages of Spread Class 1- normal Stage 1- ca at cervix Class 2- atypical cytology Stage 2- ca beyond cervix to vagina Class 3- suggestive of malignancy Stage 3- metastasis to pelvic wall Class 4- strongly suggest malignancy Stage 4- metastasis beyond pelvic Class 5- conclusive of malignancy wall, bladder and rectum th e. XR pelvimetry done after 6 lunar month to diagnose Cephalopelvic Disproportion (CPD) or 2 weeks before EDC f. Leopolds Maneuver to determine presentation, position and attitude as well as estimate fetal size and locate fetal parts-Board Question First maneuver- Facing head part of mother, palpate for feta part found in the fundus to determine presentation Second maneuver- Palpate sides of uterus to determine the location of the fetal back and small fetal parts Third maneuver- Grasp lower portion of abdomen just above the symphysis pubis to find out degree of engagement Fourth maneuver- Facing the feet part of the patient, press fingers downward on both sides of the uterus above the inguinal ligament to determine attitude II. Consultation Phase A. Rapport B. High Risk Pregnancy past pregnancies:

1. Methods of delivery- NSD or CS (indication for CS) 2. Where- at home? In the hospital? 3. Risk involved- Prematurity? Toxemia? present pregnancy: 1. Chief concern 2. Danger signals 3. Medical data C. Laboratory Examinations Blood Studies:1. Complete Blood Cell Count including Hgb and Hct 2. Blood Typing- ABO incompatibility 3. Serological Tests- Rubella and Syphilis Urine examinations: 1. Heat and acetic acid test- albuminuria= toxemia 2. Benedicts test- glycosuria= gestational diabetes 3. UTI- pyuria= premature delivery

20 D. Procedures that concerns Assessment of Fetal Health 1. Fetal Movements- <10 FM in 12 hours, lack of movement for 8 hours and sudden increase in violent movements especially if followed by reduced movement Nursing Care: a. Left lateral position b. Oxygen preparation c. Refer to MD 2. Biochemical Assessment- triple analyte screening to identify birth defects and chromosomal anomalies a. Levels of unconjugated estriol b. Level of HCG c. AFP 3. Amniocentesis- done at 15-18 weeks of pregnancy with a guide of ultrasound Nursing Care: a. Puncture site for possible leakage of amniotic fluid through the site and vagina b. Preterm labor c. Infection d. Fetal compromise 4. Chorionic Villus Sampling- done at 10-12 weeks of pregnancy 5. Electric Fetal Monitoring- non stress test and in a semi-sitting position a. Reactive - stimulate baby by making sound or drink juice; - HB: 15 beats/min for 15 secs b. Non reactive- no change in HB, with change but not 15 beats/15 secs or with change but 15 beats but not 15 secs 6. Contraction Stress Test: Oxytocin Challenge Test baby withstand the stress of labor mother will do the nipple stimulation do fundal massage oxytocin drip or pitocin drip which is best given by infusion pump 10-15 min period 2 or 3 uterine contraction that last for about 30-45 secs 3 types of FHT: a. Early- reactive; normal; (+) head compression b. Late- non reactive c. Variable 3 Phases of uterine contraction: a. Start- increment b. Peak- acme c. End- decrement If HB decelerates after- late but if decelerates before- early Maximum duration for a uterus to contract- 90 sec, more than 90 seconds considered abnormal 7. Biophysical Screening- Fetal breathing, gross body movements, fetal tone, reactive FHR and qualitative AF volume Normally, 8-10 AF index

21 III. Post consultation Phase (Health Teachings) A. Nutrition- most important aspect 1. Women who need special attention: a. Pregnant teenagers b. Extremes in weighing scale- low pre-pregnant weight & obese c. Low income women d. Successive pregnancies e. Vegetarians- high vitamin intake, low in proteins and minerals 2. Nutritional assessment is based on taking a diet history first: a. Food preferences/eating habits b. Cultural/religious influences c. Educational/Occupational level 3. Proteins- 75 gms/day for brain development B. Smoking- causes vasoconstriction leading to low birth weight babies (Small Gestational Age) C. Alcoholism- supplies empty calories causing transient respiratory depression in NB and fetal withdrawal syndrome D. Clothing- loose and light with flat shoes E. Employment-make sure to have periods of rest F. Bathing- discourage in bath tubs to prevent fall and public pools for possible infection G. Exercises- to strengthen the muscles used in labor and delivery Recommended Exercises: 1. Squatting (Flat on floor) and tailor sitting (Indian sit)-help stretch & strengthen perineal muscles 2. Pelvic rock (hands on floor and knee bended)-maintains good posture & relieves abdominal pressure & low backaches 3. Modified knee-chest position- relieves pelvic pressure and cramps in the thighs or buttocks and relieves discomfort from hemorrhoids 4. Shoulder-circling- strengthens muscles of the chest 5. Walking 6. Kegal- relieves congestion and discomfort in pelvic region and tones up pelvic floor muscles H. Traveling- seatbelt not to compress the abdomen Board Question: Seatbelts? Answer: over the lap I. Sexual Activity- permitted but not during the last 6 weeks of pregnancy because there is increase incidence of postpartum infection Contraindication: 1. Bleeding or Spotting 2. Incompetent cervical os 3. Ruptured BOW 4. Deeply engaged presenting part

22 LABOR and DELIVERY I. FETAL SKULL A. Importance: From an obstetrical point of view, the fetal skull is the most important part of the fetus because: 1. It is the largest part of the body 2. It is the most frequent presenting part 3. It is the least compressible of all parts B. Cranial Bones: The first 3 are not important because they lie at the base of the cranium and therefore are never the presenting parts: 1. Sphenoid 2. Ethmoid 3. Temporal 4. Frontal 5. Occipital 6. Parietal C. Membrane Spaces: Suture lines are important because they allow the bones to move and overlap changing the shape of the fetal head in order to fit through the birth canal, a process called Molding: 1. Sagittal suture line- the membranous interspace which joins the 2 parietal bones 2. Coronal suture line- the membranous interspace which joins the frontal bone and the parietal bones 3. Lambdoid suture line- the membranous interspace which joins the occiput and the parietal bones D. Fontanelles: Membrane-covered spaces at the junction of the main suture lines: 1. Anterior Fontanelle- the larger, diamond shaped fontanelle which closes between 12-18 months in infants 2. Posterior Fontanelle- the smaller, triangular shaped fontanelle which closes between 2-3 months in the infant E. Measurements: The shape of the fetal skull causes it to be wider in its anteroposterior (AP) diameter than in its transverse diameter: 1. Transverse diameter of the the fetal skull: a. a. Biparietal = 9.25 cm b. b. Bitemporal = 8 cm c. c. Bimastoid = 7 cm 2. Anteroposterior diameters: a. Suboccipitobregmatic-from the below the occiput to the anterior fontanelle (the narrowest AP diameter) = 9.5 cm b. Occipitofrontal- from the occiput to the mid-frontal bone = 12 cm c. Occipitomental-from the occiput to the chin (the widest AP diameter)=13.5 cm

23 LABOR-series of events in which products of conception are expelled from the uterus II. PRELIMINARY/PRODROMAL/PREMONITORY SIGNS of LABOR: A. Lightening- is the settling of the fetal head into the pelvic brim which occurs 2 weeks before EDC in PRIMIS and on or before labor onset in MULTIS, while Engagement occurs when the presenting part has descended into the pelvic inlet. Results of Lightening: 1. Increase in urinary frequency 2. Relief of abdominal tightness and diaphragmatic pressure 3. Shooting pains down the legs because of pressure on the sciatic nerve 4. Increase in the amount of vaginal discharges B. Increase in the Level of Activity- is due to an increase in epinephrine secretion to prepare the body for the coming work ahead. RN Consideration: Advise the pregnant woman to preserve this energy. C. Loss of weight- of about 3-4 lbs 1-2 days before labor onset probably due to a decrease in progesterone production causing a decrease in fluid retention. D. Braxton Hicks Contractions- are painless, irregular uterine contractions E. Ripening of the Cervix- when the cervix becomes butter soft, Goodels sign F. Rupture of the Membranes- it is important to remember that once BOW has ruptured: 1. Labor is inevitable because it will occur within 24 hours 2. The integrity of the uterus has been destroyed and infection can easily set it so aseptic techniques should be observed-less IE and no enema 3. Umbilical cord compression/prolapse can occur therefore: Nursing Considerations: a. A woman should be admitted, put to bed and monitor FHT b. A woman in the labor room, take FHT c. A woman says a loop of cord coming out of her vagina, put her in Trendelenberg position (lower the head of the bed) to reduce pressure on the cord and apply a warm saline saturated OS on the prolapsed cord to prevent drying of the cord. G. Show- a pinkish vaginal discharge consists of blood mixed with mucus that is release when minute capillaries in the mucous membrane of the cervix rupture due to pressure of the descending presenting part of the fetus

24 III. SIGNS OF TRUE LABOR A. Uterine Contractions- an effective, productive uterine contraction is the surest sign that labor has begun 1. Pain in uterine contractions results from: a. Contraction of uterine muscles when in an ischemic state b. Pressure on nerve ganglia in the cervix and lower uterine segment c. Stretching of ligaments adjacent to the uterus and in the pelvic joints d. Stretching and displacement of the tissues of the vulva and perineum 2. Phases of uterine contractions: a. Increment- first phase during which the intensity of contraction increases, also called crescendo b. Acme- the height of the uterine contraction, also called apex c. Decrement- last phase during which intensity of contraction decreases, also called decrescendo 3. Difference between true and false labor: TRUE FALSE Location of Pain Lumbosacral radiating at Lower abdomen without the back to front radiation Walking Intensifies the pain Relieves the pain Enema Intensifies the pain Relieves the pain Show Present Absent Uterine Contraction: Duration Longer Shorter Frequency Shorter Longer Intensity Cervical change Accompanied by Effacement Absent changes and dilatation B. Cervical Changes: 1. Effacement- is the shortening and thinning of the cervical canal from 1-2 cm expressed in % 2. Dilatation- is enlargement of the external cervical os to 10 cm primarily as a result of uterine contraction and secondarily as a result of pressure of the presenting part and BOW C. Uterine Changes: 1. Upper uterine segment- becomes thick and active to expel out fetus 2. Lower uterine segment- becomes thin-walled, supple and passive so that fetus can be pushed out easily Physiological retraction ring is formed at the boundary of the upper and lower uterine segments. In difficult labor where fetus is larger than the birth canal, the round ligament of the uterus become tense during dilatation and expulsion causing an abdominal indentation called Bandls Pathological Retraction Ring= a danger sign of labor signifying an impending rupture of the uterus if the obstruction is not relieved.

25 IV. LENGTH OF NORMAL LABOR First Stage Second Stage Third Stage TOTAL V. THEORIES OF LABOR A. Uterine Stretch Theory- any hollow body organ when stretched to full capacity will necessarily contract and empty. B. Oxytocin Theory- labor is being considered a stressful event which stimulates the hypophysis to produce oxytocin from the Posterior Pituitary Gland causes contraction of the smooth muscles of the body. C. Progesterone Deprivation Theory- progesterone being the hormone designed to promote pregnancy, it is also believed to inhibit uterine motility thus if its amount decreases, labor pains can occur. D. Prostaglandin Theory- initiation of labor is said to result from the release of arachidonic acid which increases prostaglandin synthesis causing uterine contraction. E. Theory of Aging Placenta- impaired blood flow causes uterus to contract. VI. FOUR PS of LABOR: I. Power A. Primary Power (Involuntary)-upper 2/3 of the uterus contracts actively lower 3rd and the cervix are passive B. Secondary Power (Voluntary)-bearing down height of contraction and full dilatation II. Passengers A. Blood B. Amniotic Fluid- BOW ruptures spontaneously during active phase of labor. If not in active phase=PROM, if in active phase but does not rupture then may do amnitomy= artificial rupturing of BOW. Ideal Time: when the cervix is fully dilated which is 10 cm, the MD will rupture the BOW to induce labor. Nursing Responsibilities: 1. Check FHR 2. Keep mother on bed to prevent cord compression or prolapse 3. Assess the amount and color = clear, colorless or straw, = greenish- meconium staine 4. Perineal sterile technique 5. Monitor closely the temperature PRIMIS 12 hours 80 minutes 10 minutes 14 hours MULTIS 7 hours & 20 minutes 30 minutes 10 minutes 8 hours

26 C. Fetus Fetal head is the largest part of the body to pass= 1-2 cm, if more than 2 cm= hydropcephalus. Refer to Fetal Skull- sutures, bones and fontanelles; transverse diameters of the skull. Adaptive Mechanism of Labor: 1. Fetal Lie- relationship of the long axis of the fetus to the long axis of the mother. 3 Types: a. Longitudinal- parallel to the mother b. Transverse - perpendicular to the mother c. Oblique - obliquely to the spines of the mother 2. Fetal Presentation- the fetal part that is felt by the examining finger 3 Types: a. Cephalic- head is the presenting part; 96% NSD; 1) Vertex- head is sharply flexed making the parietal bone the presenting part; AP diameter of the skull 2) Sinciput 3) Brow 4) Face/chin b. Breech- buttocks are the presenting part; 3% CS; 1) Complete- thighs flexed on the abdomen and legs are on thighs 2) Frank- thighs flexed and legs are extended resting on the anterior surface of the body 3) Footling: a) Single- one leg unflexed and extended; one foot present b) Double- legs unflexed and extended; feet are presenting c. Transverse- shoulder presentation; 1% CS 3. Fetal Attitude- relationship of the fetal part to one another 3 Types: a. Flexion - Complete/Full - Vertex- NSD - Slight Flexion - Sinciput b. Extension - Complete/Slight - Brow and Face/Chin 4. Fetal Position- relationship of the presenting part of the fetus to a specific quadrant of the mothers pelvis (4 quadrants- RA, RP, LA and LP) Presenting Part Vertex Face/Chin Breech Shoulder Fetal Points of Reference Occipital (O) Mentum (M) Sacrum (S) Scapula (Sc) Maternal Relationship AP diameter & Posterior R & Left Side Transverse

27 Quadrants of Pelvis: Sc M O S Sc M O S Posterior ! ! ! ! L ! ! ! ! L ! Anterior Ss M O S Sc M O S A P L O T S

M R O T S

Summary:

Vertex =6 Cephalic =6 Breech =6 Shoulder =4 ----------------------= 22 Fetal Positions

5. Fetal Station- relationship of the presenting parts of fetus to the level of ischial spines: Station 0 - at the level of the ischial spine= engagement Station -1 - presenting part above the level of the ischial spines Station +1 - presenting part below the level of the ischial spines Station +3 or +4- synonymous to crowning= encirclement of the largest diameter of the fetal head by the vulvar ring. RN Responsibilities: MD does IE to mother so RN takes note of the time of IE and findings. If at 10:00 Station 0, 11:00 Station 0 and 12:00 still Station 0, there is an arrest disorder in descent related to CPD, so assess bladder and do catheterization if full using straight catheter. Descent for PRIMI= 1 cm/hour; MULTI= 2 cms/hour III. Passageway A. Structures of Pelvis- 2 innominate bones made up of 3 bones B. Divisions of Pelvis 1. False- superior half that supports uterus during pregnancy 2. True- inferior half made up of 3 parts: a) Pelvic inlet- main door of the pelvis b) Pelvic cavity c) Pelvic outlet

28 3. Measurements- actual diameters of inlet and outlet usually done by MDs: a. Diagonal Conjugate- anterior surface of sacral promontory to anterior margin of symphysis pubis b. True Conjugate- anterior surface of sacral promontory to posterior margin of the symphysis pubis c. Obstetric Conjugate- center portion; narrowest diameter of inlet where fetal needs to pas through= 10 cms or more Board Question: 12.5 cm done by MD, 1.5-2 cm from the measurement of diagonal conjugate= 12.5-2 cm Answer: 10.5 cm 4. Types of Pelvis: a. Android- male pelvis b. Anthropoid- oval c. Gynecoid- round; most suitable d. Platypelloid- flat IV. Psychological Preparation Methods of Pain Management: 1. Bradley method (Husband coached)- childbirth is a joyful, natural process but stressful so the presence of the husband is important during pregnancy while woman is performing muscle toning exercises, walking and breathing techniques 2. Psychosexual method 3. Dick Read method- breaking the chain between fear and tension that leads to pain 4. Lamaze method- psychoprophylaxis method; a. Preventing pain in labor with the use of: 1) decrease tension during contraction 2) concentrate or focusing and imagery 3) conditioned reflexes b. Breathing exercises c. Effleurage d. Focusing and imagery

29 October 18, 2005/8-12 Mrs. Elena Ramirez, RN, MAN STAGES OF LABOR First Stage (Stage of Dilatation) begins with true labor pains and ends with complete dilatation of the cervix with contractions only 1. Power/Forces: Involuntary uterine contractions-duration, frequency & intensity 2. Phases: a. Latent early time in labor cervical dilatation is minimal because effacement is occurring cervix dilates 3-4 cm only contractions are of short duration & occur regularly 5-10 minutes apart mother is excited with some degree of apprehension but still with ability to communicate takes up 8 of the 12 hour first stage b. Active/Accelerated cervical dilatation reaches 4-8 cm rapid increase in duration, frequency & intensity of contractions mother fears losing control of herself 3 Phases 1) Cervical dilatation 2) Fetal station 3) Contraction Duration Frequency Intensity 4) Mothers reaction Latent 3-4 -1-0 30-45 secs 5-10 mins mild Talkative Active 4-7 +1 45-60 secs 3-5 mins moderate Less talkative Transitional 8-10 +2 or +3 60-90 secs 2-3 mins severe Irritable

3. Nursing Care If dilated 5-6 cm, may give Demerol but nurse needs to check BP first

30

Transitional Period period when the mood of the woman suddenly changes & the nature of the contractions intensify if tetanic contraction occurs, the mother will develop rupture of uterus while the fetus will develop respiratory distress (>90 minutes) 1. Characteristics: A. 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, Ex. 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 is station is still minus as this lead to cord compression. B. Show becomes more prominent C. 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 D. Nausea and vomiting is a reflex reaction due to decrease gastric motility and absorption E. In primis, baby is delivered within 20 contractions (in 40 minutes) In multis, baby is delivered in 10 contractions (in 20 minutes). 2. Nursing actions are primarily comfort measures: A. Refer to MD B. Put pregnant woman to left lateral position C. Monitor vital signs: Latent - every hour Active - every 30 minutes Transitional - every 15 minutes D. Explain procedures especially IE and dilatation E. Monitor fetal heart tone F. Encourage the pregnant woman to void at least every 2 hours G. Proper bearing down techniques and push with contractions H. Advise her to do Pant Blow Exercises or do controlled chest breathing during contractions I. Emotional Support 3. Three Signs of Incoming Second Stage of Labor: a. Bulging of the perineum b. Urge to push- spontaneous push c. Urge to defecate due to rectal pressure Nursing Responsibilities: Place patient in lithotomy position by making use of stir-ups or leggings if available Board Question: When to prepare patient in labor? Answer: If primi, transfer pregnant woman if 3 signs of incoming 2nd stage are present If multi, transfer pregnant woman the moment she enters the Transitional phase

31

Second Stage (Stage of Expulsion) begins with complete dilatation of the cervix and ends with the delivery of the baby. 1. Powers/Forces: involuntary uterine contraction and contractions of the diaphragmatic and abdominal muscles. 2. Normal Mechanisms of Labor/Fetal Delivery: (D FIRE ERE) A. Descent- may be preceded by engagement B. Flexion- as descent occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest C. Internal Rotation- from AP to transverse then AP to AP ( an arch of 90-135 degrees); if does not rotate, mother complains of severe backache D. Extension- as head comes out, the back of the neck steps beneath the pubic arch, the head extends and the forehead, nose, mouth and chin appear. Nursing Responsibilities: Wipe mouth and nose of secretions and feel the nape to determine cord coiling to prevent strangulation E. External Rotation- also called restitution where anterior shoulder rotates externally to the AP position. F. Expulsion- delivery of the rest of the body Nursing Responsibilities: 1) Establish Fetal Airway- position the baby where head is lower the body to drain secretions and prevent aspiration 2) Thermoregulation to help baby warm 3) Cut the cord using two clamps- wait for the cord pulsation (blood rushing to towards the baby) to stop first then 8-10 inches distance longer from the baby and 3-4 inches from the mother 4) ID (name tags & footprints) of the baby as soon as they are in the delivery room Board Question and Answer: Engagement, Descent and Flexion 3. Nursing Care: A. When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine ligaments B. As soon as the fetal head crowns, instruct mother not to push but to pant (rapid and shallow breathing) instead to prevent rapid expulsion of the baby. If panting is deep and rapid it is called hyperventilation where the patient will experience light headedness and tingling sensations 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 C. Purposes of Episiotomy: 1. To shorten the second stage of labor especially when there is HPN or fetal distress; 2. Incision made in the perineum primarily to prevent lacerations; 3. Prevent prolonged and severe stretching of muscles supporting bladder or rectum; 4. Enlarge outlet as in breech presentation or forceps delivery

32

Types of Episiotomy: a) Median- from middle portion of the lower vaginal border directed towards the anus; b) Mediolateral- begun in the midline but directed laterally away from the anus D. Apply the Modified Ritgens Maneuver: 1. Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum thus preventing lacerations but will also favor flexion so that the smallest suboccipitobregmatic diameter of the fetal head is presented. 2. Base the head out and immediately wipe the nose and mouth of secretions to establish a patent airway. 3. Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck. If loosen, slip it down the shoulders or up over the head but if tight, clamp cord twice an inch apart and then cut in between. 4. As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and then slowly give an upward lift to deliver the posterior shoulder. 5. While supporting the head and neck, deliver the rest of the body. Take note of the exact time of delivery of the baby E. Immediately after delivery, newborn should be held below the level of the mothers vulva for a few minutes to encourage flow of blood from the placenta to the baby F. The infant is held with his head in a dependent position (head lower than the rest of the body) to allow for drainage of secretions. REMEMBER: Never stimulate a baby cry unless you have drained him out of his secretions first G. Wrap the baby in a sterile diaper to keep him warm. REMEMBER: Chilling increases the bodys need for oxygen H. Put the baby on the mothers abdomen. The weight of the baby will help contract the uterus I. Cutting of the cord is postponed until the pulsations have stopped because it is believed that 50-100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart and then cut in between J. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse.

33

Third Stage (Placental Expulsion/Delivery) begins with the delivery of the baby and ends with the delivery of the placenta. 1. Signs of Placental Separation: a. Uterus becoming round and firm (CULKENS SIGN)- the earliest sign of placental separation= Board Question b. Fundus rises up at the level of the umbilicus c. Sudden gush of blood from the vagina d. Lengthening of the cord from the vagina If the signs of placental separation are not visible during separation, the RN should consider inversion of the uterus. Board Question: If the membranes of placenta are out, take out the clamp and use it to pull out the membranes. 2. Types of Placental Delivery: a. SCHULTZ- if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny, smooth and glistening with BV and appears in grayish white in color; 80% of placentas separate in this manner. b. DUNCAN- if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, meaty, dirty, rough, red beefy in color with cotyledons of 15-20 pieces, irregular and dirty; only 20% of placentas separate this way. 3. Nursing Care: a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. b. Tract the cord slowly, winding it around the clamp until placenta spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus a method called BRANDT-ANDREWS MANEUVER. c. Take note of the time of placental delivery; it should be delivered within 20 minutes after delivery of the baby; otherwise refer immediately to the doctor as this can cause severe bleeding in the mother; while referring to MD, RN may stimulate nipple or baby may suck to allow uterine contraction d. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death. e. Palpate the uterus to determine degree of contraction; if relaxed boggy or non contracted, first nursing action is to massage gently and properly; an ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction f. Inject Oxytocin (Methergin=0.2 mg/ml or Syntocinon=10 U/ml) IM to maintain uterine contractions thus preventing hemorrhage. NOTE: Before giving Oxytocin, check BP first= uterine atony.

34 g. Inspect the perineum for lacerations; anytime the uterus is firm following placental delivery, yet bright red vaginal bleeding is gushing forth from the vaginal opening, suspect lacerations. Categories of Lacerations (tend to heal more slowly because of ragged edges): First Degree-involves the vaginal mucous membranes and skin Second Degree-involves not only the vaginal mucous membranes and skin but also the muscles Third Degree-involves not only the muscles, vaginal mucous membranes & skin but also the external sphincter of the rectum Fourth Degree-involves not only the external sphincter of the rectum, muscles, vaginal mucous membranes and skin but also the mucous membranes of the rectum Assist the doctor in doing episiorrhaphy (repair of episiotomy or lacerations); in vaginal episiorrhaphy, packing is done to maintain pressure on the suture line thus preventing further bleeding. NOTE: vaginal packs have to be removed after 24-48 hours h. Make mother comfortable by perineal care and apply clean sanitary napkin snugly to prevent its moving forward from the anus to the vagina. Soiled napkins should be removed from the front to back i. Position the newly delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure j. The newly delivered mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold temperature in the delivery room. NURSING CARE: Provide additional blankets to keep her warm k. May give initial nourishment such as milk, coffee or tea l. Allow patient to sleep in order to regain the lost energy. Fourth Stage first 1-2 hours after placental expulsion which is said to be the most critical stage for the mother because of possible complications and unstable vital signs. 1. Assessment: a. Fundus should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline & during the first 12 hours postpartum is a little above the umbilicus. FIRST NURSING CARE: massage the non contracted uterus. b. Lochia should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes c. A full bladder is evidenced by a fundus which is to the right of the midline, dark red bleeding with some clots. d. Perineum is normally tender, discolored and edematous. It should be clean with intact sutures.

35 e. Vital signs should be checked every 15 minutes. Blood pressure & pulse rate may be slightly increased from excitement & effort of delivery but should normalize within 1 hour. f. Provide comfort to the patient by positioning properly. 2. Lactation-suppressing agents: Estrogen-androgen preparations given within the first hours postpartum to prevent breast milk production in mothers who will not (or cannot) breastfeed. Example: Diethylstilbestrol, TACE or Deladumone- these drugs tend to increase uterine bleeding & retard menstrual return 3. Rooming-In Concept: Mother & baby are together while in the hospital. The concept of a family therefore is felt at the very beginning because parents have the baby with them thus providing opportunities for developing a positive relationship between parents and newborn. Eye to eye contact is immediately established releasing maternal caretaking responses. DYSTOCIA- is defined as abnormal or difficult labor and delivery A. Uterine Inertia- sluggishness of contractions 1. Causes: a. Inappropriate use of analgesia b. Pelvic bone contraction c. Poor fetal position d. Over distention due to multiparity, multiple pregnancy, polyhydramnios and excessive large fetus 2. Types: a. Primary (Hypertonic) Uterine Dysfunction- relaxations are inadequate and mild thus are ineffective. Uterine muscles are in a state of greater than normal tension, latent phase of the first stage of labor is prolonged. TREATMENT: Sedate the patient b. Secondary (Hypotonic) Uterine Dysfunction- contractions have been good but gradually become infrequent and of poor quality and dilatation steps TREATMENT: Stimulation of labor either by oxytocin administration or Amniotomy B. Precipitate Delivery- labor and delivery that is completed in less than 3 hours after the onset of true labor pains probably due to multiparity or following oxytocin administration or amniotomy Dangers imposed by precipitate delivery: Excessive lacerations Abruption placenta Hemorrhage & Shock C. Prolonged Labor- in primis, labor more than 18 hours while in multis, labor more than 12 hours. Dangers: Maternal exhaustion, Uterine atony or Caput succedaneum

36

D. Uterine Rupture- occurs when the uterus undergoes more strain than it is capable of sustaining. Causes: 1) Scar from a previous CS 2) Unwise use of oxytocins 3) Over distention 4) Faulty presentation or prolonged labor Signs & Symptoms: 1) Sudden, severe pain 2) Hemorrhage and clinical signs of shock (such as restlessness, pallor, decrease BP, increase RR and PR) 3) Change in abdominal contour with 2 swellings on the abdomen, the retracted uterus & extrauterine fetus Management: Hysterectomy E. Uterine Inversion-fundus is forced through the cervix so that the uterus is turned inside out Causes: 1) Insertion of placenta at the fundus so that the fetus is rapidly delivered especially if unsupported thus fundus is pulled down. 2) Strong fundal push when mother fails to bear down properly 3) Attempts to deliver the placenta before signs of placental separation appear Management: Hysterectomy F. Amniotic Fluid Embolism- occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter the maternal circulation and reach the lungs as emboli. Signs and Symptoms: 1) Woman in labor suddenly sits up and grasps her chest because of inability to breathe and sharp pain 2) Turns pale and then the typical bluish gray color associated with pulmonary embolism 3) Death may occur in few minutes Management: 1) Emergency measures to maintain life: IV, Oxygen and CPR 2) Provide intensive care in the ICU 3) Keep family informed and provide emotional support G. Trial Labor- is a woman has borderline pelvic measurement but fetal position and presentation are good. Maybe continued for as long as there is progressive fetal descent of the presenting part and cervical dilatation. Management: 1) Monitor FHR and uterine contractions

37 2) Keep bladder empty to allow all available space to be used by the fetus 3) Emotional Support H. Premature Labor and Delivery- if uterine contractions occur before the 38th week of gestation 1. If there is no bleeding and cervical dilatation and FH sounds are good, premature uterine contractions can be stopped by drugs: a) Ethyl alcohol (Ethanol) IV- blocks the release of oxytocin Side Effects: Nausea & vomiting and mental confusion b) Vasodilan IV- a vasodilator Side Effects: Hypotension and Tachycardia c) Ritedrine- a muscle relaxant given orally d) Bricanyl- a known bronchodilator 2. If premature uterine contractions are accompanied by progressive fetal descent and cervical dilatation, premature delivery is inevitable. a. Not necessarily shorter than full term labor b. Pain medications are kept to a minimum because analgesics are known to cause respiratory depression. As it is, premature babies already have enough difficulty breathing on their own; giving analgesics, therefore, would add up to the problem. Implication: Give emotional support to the mother such that she focuses her attention not on her own needs, but those of her baby c. Steroids (Glucocorticoids) are given to the mother to help in maturation of fetal lungs by hastening production of surfactants d. Caudal, spinal or infiltration anesthesia is preferred because it does not compromise fetal respiration e. Episiotomy may not necessarily be smaller than in full term deliveries; may even be larger so that the preemies can be delivered the shortest possible time, since excessive pressure on the fragile preemies head can cause subarachnoid hemorrhage that could be fatal f. Forceps may be applied gently g. Cord is cut immediately, rather than waiting for pulsations to stop, because preemies have difficult time excreting large amounts of bilirubin that will be formed from the extra amount of blood

38

POSTPARTUM/PUERPERIUM PERIOD Definitions: A. Puerperium/Postpartum- refers to 6-8 week period after delivery of the baby B. Involution- refers to the return of the reproductive organs to its pre-pregnant state Principles of Postpartum Care: Nursing Concern- BUBBLE SHE Assessment I. Breast On the 3rd stage of Labor: Placental deliverystimulates low estrogen & progesterone level that stimulates the anterior pituitary gland to produce the hormone, PROLACTIN, that acts on acinar cells to produce milk stored in collecting tubules, thus the breast engorged. Further, when the baby suck, the posterior pituitary gland is stimulated to produce another hormone, OXYTOCIN, that cause contraction of smooth muscles of collecting tubules, thus milk ejected forward causing let down or milk ejection reflex uterus and breast stimulated. POST PARTUM DISCOMFORTS are caused by uterine contraction, multi mothers and overstretching of uterus. Latching-In: Mother breastfeed baby and baby learn to suck establishing bonding Breastfeeding should be done as soon as possible, initially 1 minute/breast and gradually increase feeding up to 10-20 minutes/breast on demand basis Assurance of mother that baby is being breastfed properly: a. baby was breastfed 8X or more/day b. 20 minutes duration c. baby voided 6X or more/day Signal for mother to breastfeed baby: a. Check on the babys fontanel b. There is engorgement of breast c. # of times baby voids 2-3X PLACENTAL DELIVERY Decrease Estrogen and Progesterone Anterior Pituitary Gland Prolactin Breastfeeding (SUCK) Posterior Pituitary Gland Oxytocin / \ Uterus Breast (acinar cells) Board Question Let Down Reflex

39 Milk Ejection II. Uterus Assess contractions or consistency- it should be firm and contracted Assess location- it should be in the midline; if fundus goes to the R or above the umbilicus= full bladder, thus uterus cant contract well and its more at risk to bleed Fundic height measurement- is important to assess uterine involution which is 1 finger breaths each day; on PPD 1 fundus is 1 fingerbreaths below the umbilicus; on PPD 2, 2 fingerbreaths below the umbilicus and so forth; until on the 9-10 day postpartum, uterus can no longer be palpable because it is already behind the symphysis pubis. SUBINVOLUTION uterus is a big uterus and vaginal bleeding with clots, a sign of Puerperal Sepsis, caused by: infection, placental fragments and endometritis Health Teaching: Advise prone and knee chest positions to encourage return of uterus to its anteflexed position III. Bladder/Bowel Factors that influence both urinary and bowel elimination: 1. Trauma from delivery 2. Residual hormonal levels 3. Anesthesia 4. Fluid shift In NSD, mother voids after 4-8 hours after delivery while in post CS, mother voids upon removal of catheter Perineal Care: wash with warm water allowing it to flow while urinating Bowel elimination is delayed due to: a. decreased muscle tone b. lack of food and enema during labor c. dehydration d. fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids In NSD, mother eliminates once fully awake while in CS, mother lies flat on bed for 4-6 hours & has low peristalsis. RN Concern: to turn mother from side to side to prevent adhesions and hypostatic pneumonia. If mother is in pain, give pain relievers first, after 15-20 minutes, turn mother from side to side Nursing Diagnosis: Urinary retention related to periurethral edema from delivery Constipation related to anesthesia, diet, medication or pain

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IV. Lochia Uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria 3 Types/Patterns of Lochia: RUBRA SEROSA ALBA Color Red Pinkish-brownish Yellowish-whitish Length First 3 days 4-9 days (Book:4-10 days) 10-14 days Clots Few small clots no clot no clot Amount of Lochia: scant < 2 cm stain on a perineal pad light < 10 cm moderate < 15 cm heavy - 1 saturated pad in 1 hour (BQ) excessive - 1 saturated pad in 15 mins. Possible Complications: bleeding secondary to retained placental fragments V. Episiotomy Pain in perineal region may be relieved by: a. Sims position to minimize strain on the suture line b. Perineal heat lamp or warm Sitz baths 2X/day because vasodilatation increases blood supply and promote healing c. Application of topical analgesics or administration of oral analgesics as ordered VI. Skin Skin changes caused by pregnancy such as chloasma, striae gravidarum, hyperpigmentation of nipples begin to recede Diaphoresis, diuresis, polyuria results to dehydration; fever of 24 hours postpartum is considered physiologic or normal response to postpartum VII. Homans Sign If mother dorsiflex her foot and complains of calf pain= (+) homans sign Thrombophlebitis, infection of the lining of a blood vessel with formation of clots Symptoms: a) pain, stiffness and redness on the affected part of the leg b) leg swell below lesion because venous circulation has been blocked c) skin is stretched to a point of shiny whiteness, milk leg= phlegmasia alba dolens Management: a) Bed rest with affected leg elevated b) Anticoagulants ex. Dicumarol or Heparin to prevent clot formation or thrombus

41 Side Effect: hematuria & increased lochia Nursing Considerations: 1) Discontinue breastfeeding 2) Monitor prothrombin time 3) Have protamine sulfate or vitamin K c) Analgesics but never aspirin because it inhibits prothrombin formation Nursing Care: Encourage early ambulation for NSD mothers to prevent thrombophlebitis For CS mothers, early ambulation may be done within 24 hours postpartum with MDs orders VIII. Emotional Response The psychological phases during the postpartum period are: 1. Taking-in Phase/Dependent Phase First 1-2 days postpartum and not more than 3 days when mother is passive and completely relies on others to care for her and her baby. She keeps on verbalizing her feelings regarding the recent delivery for her to be able to integrate the experience into herself. 2. Taking hold Phase/Dependent & Independent Phase From 3days- 2 weeks postpartum and mother begins to care for self and baby Postpartum blues= an overwhelming feeling of sadness which could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby. RN Care: Explain that it is normal and crying is therapeutic- offer empathy. Once the RN sympathizes, depression sets in- suicide. 3. Letting go Phase/Interdependent Phase Once postpartum blues are resolved, mother moves on towards the family Weight- there is an immediate weight loss of 10-12 lbs representing the weights of the fetus, placenta, amniotic fluid and blood. Further weight loss will occur during the next day due to diaphoresis. Sexual Activity- maybe resumed by the 3rd or 4th week postpartum if bleeding has stopped and episiorrhaphy has healed. Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of hormonal changes and emotional factors. Menstruation- if not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery; if breastfeeding, menstrual return is expected in 3-4 months Postpartum Check up- should be done after the 6th week postpartum to assess involution

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COMPLICATIONS IN PREGNANCY BLEEDING DISORDERS I. FIRST Trimester Bleeding: A. ABORTION expulsion of the fetus (abortus) before the age of viability viability is the ability to live outside the uterus based on the AOG (20 weeks) or maybe the period of conception below 500 gms.- abortus 501- 1001 gms.- immature 1001- 2,500 gms.- preterm > 2, 500 gms.- fullterm CR: crown rump of <16.5 cmc length Fetal Causes: Board Question 1. Defective germ plasma-imperfect ova and defective sperm (abnormal fetal formationmost frequent cause) manifested by spot bleeding & abdominal cramps 2. Implantation abnormality- inadequate placental circulation Maternal Causes: 1. Decrease progesterone production by the corpus luteum 2. Incompetent cervix 3. Acute infection- rubella, toxoplasmosis and UTI 4. Maternal Malnutrition 5. Abnormal reproductive organ- infantile uterus and inverted uterus 6. Over fatigue/over exhaustion 7. Heart failure- CHF 8. Pelvic Fracture Pathophysiology of Abortion: Failure of Growth of the Fetus Decrease Estrogen and Progesterone production Endometrial Sloughing Release of Prostaglandin Uterine Contraction and Cervical Dilatation

43 ABORTION

General Classification of Abortion: A. Spontaneous- occurs from natural causes and also called miscarriage 1. Threatened a. Can be prevented if treated immediately b. S/Sxs: vaginal bleeding- bright red, scanty to moderate in amount uterine cramping- none or slight cervical dilation none c. Mgt: 1) Complete bed rest for 24-48 hours 2) Sexual intercourse is restricted for 2 weeks after bleeding 3) Hormonal (Tocolytics) Therapy- Duvadilan, Bricanyl or Terbutaline d. RN Concern: Monitor uterine contraction and heart beat 2. Inevitable/Imminent a. Can not be prevented b. S/Sxs: vaginal bleeding- became profuse uterine cramping- increased cervical dilation- present c. Mgt: Complete - BUBBLE assessment Incomplete - D & C 3. Missed/Still birth/IUFD/Fetal Demise a. Fetus dies in utero but is not expelled b. S/Sxs: No increase in abdominal size; no FHT; no fetal parts on palpation; mother maybe anorexia, with nausea and vomiting, with brownish vaginal discharge and later with weight loss c. If mother did not come for check up for 2 weeks, she may suffer from hypofibrinoginemia or sepsis d. Degenerative Changes in Fetus: CGFNS Question 1) Maceration- softening, amniotic fluid is greenish-brownish and thick; fetus could be 1-2 weeks dead 2) Mummification- fetus becomes leather-like in appearance; fetus could be about 2-4 weeks dead 3) Womb Stone- Lithopedion, very stony in appearance; fetus could be dead for more than a month e. Mgt: Cytotec for dilation of the cervix with Pitocin drip and do D & C Emotional reassurance because it is a wanted pregnancy B. Induced- Habitual Recurrent 1. Abortion more than 3 successive times 2. Most commonly caused by incompetent cervix=cervix that dilates prematurely, unable to hold fetus till term, dilation is painless 3. Mgt: Cervical cerclage done at 14-18 weeks a) McDonalds- temporary; removed at 38-39 weeks to allow vaginal delivery

44 b) Shirodkar-Barter- permanent; baby delivered by CS

B. ECTOPIC PREGNANCY pregnancy outside the uterus: ovary, cervix, FT and intestines 95% tubal in nature Causes: 1. Narrowing, constriction of the tubes due to inflammation (salpingitis), kinking or congenital narrowing of the tubes 2. PID Sign and Symptoms: 1. Early- amenorrhea, normal signs of pregnancy; If detected early medical treatment is Methotrexate followed by Leukoonia to destroy fast growing cells until HCG is negative 2. Late (6-8 wks)- growing zygote rupture causing severe intraperitoneal bleeding & pain a) Pain is described as severe sharp, knife-like stabbing in the right or left lower quadrant radiating to the neck and shoulder (BQ) b) Cervical pain during IE- do culdocentesis to confirm further the presence of ectopic pregnancy c) Bleeding- vaginal spotting only; intraperitoneal bleeding causing CULLENS SIGN (blue-tinged umbilicus); bleeding into the cul-de-sac Management: 1. First Nursing Care- Combat Shock by 1) Keeping warm 2) Elevate lower extremities 3) IVF with large needle for possible BT 2. Surgical intervention PRN: a) Salphingotomy - removal of pregnancy and preserving tubes b) Salphingectomy - removal of pregnancy and the tubes c) Salphingectomy with oophorectomy- removal of pregnancy, tubes & ovary II. SECOND Trimester Bleeding A. HYDATIDIFORM MOLE also known as Gestational Trophoblastic Disease developmental anomaly of the placenta resulting in proliferation & degeneration of chorionic villi it is a benign neoplasm of the chorion= chorionic villi and trophoblast degenerates and turn into transparent vesicles containing fluid resembling grape-like clusters. Embryo fails to develop therefore, pregnancy test is still positive Types: a. Complete - 46XY, cystic, no embryo b. Partial - 9 weeks gestation with 69 chromosomes Signs and Symptoms: 1. Initially, normal symptoms of pregnancy which is a positive pregnancy test because of rapid proliferation of placental tissues, therefore, high levels of HCG. 2. Large abdominal size not proportional to AOG (too big), abdomen is soft & spongy

45 3. 4. 5. 6. Brownish vaginal bleeding with some moles passed out Edema, proteinuria, hypertension (PIH) on the first trimester Absence of quickening, no FHT, no fetal parts on Leopolds maneuver Very high HCG that will not go down throughout pregnancy Normal HCG Level: First Trimester = 400, 000-500, 000 IU declines 100 days from conception Second Trimester = 10, 000- 25, 000 IU/24 hours Third Trimester = 5,000- 15, 000 IU/24 hours Management: 1. Evacuation with Laminaria ( seaweed dried, sterilized and inserted in the cervix to cause dilation) or Laminary Tents followed by D & C 2. HCG monitoring 3. Prophylactic chemotherapy using Methotrexate to prevent choriocarcinoma 4. Regular check up (CXR and mammography) to detect metastasis 5. Emotional reassurance B. INCOMPETENT CERVICAL OS cervix dilates prematurely; it is the chief cause of habitual abortion Causes: a. Congenital development factors b. Endocrine factors c. Trauma to the cervix Signs and Symptoms: a. Presence of show and uterine contractions b. Rupture of membranes c. Painless cervical dilatation Management: McDonald/Shirodkar-Barter procedure= a cerclage procedure wherein pursestring sutures are placed around the cervix on the 14th-18th weeks of gestation. These are removed on vaginal delivery (if McDonalds method) or the patient delivers CS (if Shirodkar method). III. THIRD Trimester Bleeding A. PLACENTA PREVIA low implantation of the placenta so that it is in the way of the presenting part Predisposing Factors: 1. Increase parity 2. Advanced maternal age 3. Rapid succession of pregnancies Types: 1. Low lying implantation 2. Partial Placenta Previa- partially blocking the cervical os 3. Total/Complete PP - completely blocking the os Diagnosis: It is made by means of symptoms and ultrasound known as Ultrasonic Echo Sounding or Sonar, which uses intermittent waves of very high frequency to picture the fetus. Sound waves are projected towards the mothers abdomen that are reflected back and converted into electrical impulses and recorder on a permanent graph paper. 1. Preparation

46 Explain the procedure to the patient informing her that it is painless and has no known ill effects. Empty the bladder but ask the patient to take 6 glasses of water afterwards in order to dilate the bladder. A full bladder displaces the bowel and permits better visualization of the pelvis and its contents.

2. Clinical Uses Diagnose pregnancy as early as 5-6 weeks gestational age Can establish that the fetus is increasing in size and can predict EDC Can determine gestational age by measuring bi-parietal diameter of the fetal skull to identify intrauterine growth retardation, hydrocephaly microcephaly and anencephaly Can demonstrate size and growth rate of amniotic sac to identify polyhydramnios and oligohydramnios Can confirm presence, size and location of the placenta to identify H-mole and previa Can diagnose multiple pregnancy Can visualize ascites, polycystic kidneys and ovarian cysts Can determine babys sex Symptom: painless bright red vaginal bleeding which is always overt and external Management: 1. Complete bed rest 2. Monitor VS of mother and FHR 3. Prepare oxygen and blood 4. No IE, if ever, it should be done in a double set-up (in OR) 5. No sexual activity Complications: 1. Hemorrhage 2. Infection 3. Prematurity B. ABRUPTIO PLACENTA/PLACENTA APOPLEXY premature separation of a normally implanted placenta Predisposing Factors: 1. Maternal Hypertension (Chronic or PIH) 2. Direct trauma 3. Pressure by the enlarging uterus 4. PROM causing sudden release of pressure 5. Increasing parity and maternal age 6. Short umbilical cord 7. Hyperfibrinoginemia Sign and Symptoms: 1. Severe, sharp, knife-like, stabbing pain in the fundus 2. Hard, board-like uterus, rigid abdomen 3. Signs of shock 4. Concealed bleeding causes the uterus to lose its ability to contract becoming ecchymotic and copper colored called COUVALAIRE UTERUS. Types:

47 1. Marginal - there is overt bleeding 2. Central - blood is trapped between the cord and wall thus bleeding is internal, covert and concealed Management: 1. Emergency situation- hospital admission 2. IVF with large gauge needle 3. Oxygen preparation 4. Monitor bleeding Placenta Previa Abnormal implantation Painless Always external No change in uterus Classical CS Abruptio Placenta Normal implantation Severe pain External/Internal Boardlike uterus Low Transverse Incision

October 24, 2005/8-12 Mrs. Elena Ramirez, RN, MAN Continuation of Complications in Pregnancy TOXEMIA/PREGNANCY INDUCED HYPERTENSION is a vascular disease of unknown cause which occurs anytime after the 24th week of gestation up to 2 weeks postpartum. It has the following triad of symptoms: 1. Hypertension 2. Edema 3. Proteinuria (albuminuria) Predisposing Factors: 1. Age- primis under 15 and over 35 years 2. Gravida- 5 or more pregnancies 3. Low socioeconomic status 4. Multiple pregnancy 5. W/ underlying medical conditions such as heart disease, hypertension or diabetes Diagnosis: Roll Over Test assess the probability of developing toxemia when performed between the 28th and 32nd week of pregnancy. a. Procedure: 1) Patient lies on lateral recumbent position for 15 minutes until BP has stabilized 2) Then rolls over to back position 3) BP is taken at 1 minute and 5 minutes after having rolled over b. Interpretation: If diastolic increases 20 mm Hg or more, patient is prone to toxemia Classification: I. Acute Toxemia- symptoms appear after 24th week of gestations A. Pre eclampsia

48 Underlying Causes: 1. Insufficient production of blood & platelets 2. Generalized vasoconstriction & associated microangiopathy (disease of capillaries) 3. Abnormal retention of sodium & water by body tissues Medical Complications: 1. Cerebrovascular hemorrhage 2. Acute pulmonary edema 3. Acute renal failure Types: 1. Mild-Signs and Symptoms: a. Sudden excessive weight gain of 1-5 lbs/week (earliest sign of pre-eclampsia) due to edema which is persistent and found in the upper half of the body b. Systolic BP of 140 or an increase of 30 mm Hg or more & a diastolic of 90 or a rise of 15 mm Hg or more, taken twice, 6 hours apart c. Proteinuria of 0.3 gm/liter or more 2. Severe-Signs and Symptoms: a. BP of 160/110 mm Hg b. Proteinuria of 5 gm/liter or more in 24 hours c. Oliguria of 400 ml or less in 24 hours (Normal Urine Output in 24 hours= 1,500 ml) d. Cerebral or visual disturbances e. Pulmonary edema and cyanosis f. Epigastric pain B. Eclampsia- the main difference between preeclampsia and eclampsia is the presence of convulsions in eclampsia. Signs and Symptoms: 1. All in Preeclampsia Plus: 2. Increased BUN 3. Increased uric acid 4. Decreased CO2 combining power II. Chronic Hypertension with Pregnancy III. Unclassified Management: 1. Complete Bed Rest-sodium tends to be excreted rapidly if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension is the result of vasoconstriction and decreased blood flow that diminishes the amount of nutrients and oxygen in the cells. 2. Diet a. Mild preeclampsia- high protein, high carbohydrate, moderate salt restriction b. Severe preeclampsia- high protein, high carbohydrate and salt poor 3. Medications a. Diuretics

49 Action: Decrease reabsorption of sodium and chloride at the proximal tubules thereby increases renal excretion of sodium, chloride and water including potassium Side Effects: Fatigue and muscle weakness Nursing Care: Closely monitor urine intake and output Normal Urine/hour: 50-60 ml b. Digitalis Action: Increase the force of contraction of the heart thereby decreasing heart Rate (Note: It should not be given if HR is below 60/minute) Nursing Care: Take the heart rate before giving the drug c. Potassium supplements should be given to prevent cardiac arrhythmias Side Effects: Causes hypokalemia d. Barbiturates sedation by means of CNS depression e. Analgesics f. Magnesium sulfate Action: 1) CNS depressant- lessens possibility of convulsions 2) Vasodilator- decreases the BP 3) Cathartic- reduces edema by causing a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 grams initially, either by slow IV push over 5-10 minutes or deep IM, 5 grams/buttock, then IV drip of 1 gram/hour (1 gram/100 ml D10W) if: deep tendon reflexes are present RR is at least 12/minute UO is at least 100 ml in 6 hours Antidote for toxicity: Calcium gluconate 10% IV to maintain cardiac and vascular tone Earliest Sign of toxicity: Disappearance of the knee jerk/patellar reflex 4. Method of Delivery- preferably vaginal but if not possible CS; Prognosis: The danger of convulsions is present until 48 hours postpartum TORCH INFECTIONS 1. Toxoplasmosis: caused by protozoa resulting to mental retardation, microcephaly, chorioretinitis and choreoretinitis; 10-15% mortality 2. Others: Syphilis, AIDS, Hepatitis Cause: Treponema pallidum Treatment: 2.4-4.8 M units of Penicillin (or 30-40 gms of Erythrocin) The NB with Congenital Syphilis a. Signs and Symptoms: 1) Jaundice at 2 weeks of life 2) Anemia and hepatosplenomegaly 3) Snuffles (persistent rhinorrhea), coppery rashes on palms and soles, mucous patches, condylomas, pseudoparlysis due to bone inflammation

50 4) If untreated, progressed to deformed bones, teeth, nose, joints and CNS b. Management: Penicillin IM for 10 days or one long acting Penicillin (Penadur LA)

3. Rubella/German Measles a. Incidence 1) Mother- the earlier the mother contracted the disease, the greater the likelihood that the baby will be affected 2) NB- can carry and transmit the virus for as long as 12-24 months after birth b. Signs and Symptoms 1) Lower birth weight, jaundice, petechiae, anemia, thrombocytopenia, hepatoslenomegaly 2) Classic Sequelae Eyes: chorioretinitis, cataract, glaucoma Heart: patent ductus arteriosus, stenosis, coarctations Nerve Deafness, Dental and facial clefts 4. Cytomegalovirus: permanent damage to fetus; causes abortion 5. Herpes Simplex II: neonatal infection; mental retardation, microcephaly DIABETES MELLITUS chronic hereditary disease which characterized by hyperglycemia due to a relative insufficiency or lack of insulin from the pancreas, which leads to abnormalities in the metabolism of carbohydrates, proteins and fats. Diabetogenic Effects of pregnancy: 1. renal threshold for sugar (+) sugar in urine 2. production of adrenocorticoids, anterior pituitary hormones & thyroxin affecting carbohydrates & lipid metabolism ing carbohydrate concentration in the blood hyperglycemia 3. Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased (insulin is not effective during pregnancy) Attendant Risks: 1. Toxemia 2. Infection 3. Hemorrhage 4. Polyhydramnios 5. Spontaneous abortion because of vascular complications which affect placental circulation 6. Acidosis because of nausea & vomiting chief threat to the fetus in utero 7. Dystocia due to excessively large baby

51 Diagnosis: Glucose Tolerance Test 1. Procedure: NPO after midnight; 2 ml of 50% glucose/3 kg of pre-pregnant body weight is given IV 2. Interpretation of results: < 100 mg% normal 100-200 mg% possible gestational diabetes > 120 mg% overt gestational diabetes Categories: to predict the outcome of pregnancy 1. Class A- GTT is only slightly abnormal; minimal dietary restriction; insulin not needed; fetal survival is high 2. Class C to E- 25% perinatal mortality 3. Class F- therapeutic abortion maybe justified (in other countries) Management: 1. Diet: 1,800-2,200 calories adequate glucose intake is necessary to prevent intrauterine growth retardation 2. Insulin requirements: higher in 2nd & 3rd trimesters a. Insulin is regulated to keep urine +1 for sugar but negative for acetone b. Long acting insulin (Ultralente) will have to be changed to regular insulin (Lente) during the last few weeks of pregnancy 3. Delivered by CS because: a. Baby is typically larger or in distress due to placental insufficiency b. Severe metabolic imbalances because of depletion of glycogen reserve in the liver & skeletal muscles by strenuous muscular exertion during labor Infant of the Diabetic Mother (IDM): 1. Baby longer and weighs more because of: a. Excessive supply of glucose from the mother b. Increased production of growth hormones from the maternal pituitary c. Increased secretion of insulin from the fetal pancreas d. Increased action of adrenocortical hormones that favor passage of glucose from mother to fetus 2. Congenital anomalies are more often seen 3. Cushingoid appearance-puffy, limp & lethargic 4. Born premature so with respiratory distress syndrome is common 5. Lose weight because of loss of extra fluid 6. Prone to complications: a. Hypoglycemia-most common complication where blood sugar < 30 mg% Cause: While in the uterus, the fetus tends to be hyperglycemic because of maternal hyperglycemia. The fetal pancreas responds to glucose level by producing matching levels of insulin. After delivery, the glucose level begins to fall because the baby has been severed from the mother hypoglycemia develops Clinical Signs: Shrill high pitched cry, listlessness, lethargy, poor suck, apnea, cyanosis, hypotonia, hypothermia & convulsions Consequence: leads to brain damage & death

52 Management: feed with glucose water through IV b. Hypocalcemia- serum calcium level < 7 mg%, treated by calcium gluconate to prevent tetany

HEART DISEASE Classification: 1. Class I-no limitation of physical activity 2. Class II-slight limitation of physical activity, ordinary activity causes fatigue, palpitation, dyspnea or angina 3. Class III-moderate to marked limitation of physical activity, less than ordinary activity causes fatigue, etc. 4. Class IV-unable to carry on any activity without experiencing discomfort Prognosis: 1. Classes I and II-normal pregnancy and delivery 2. Classes III and IV-poor candidates Signs and Symptoms: 1. Heart murmurs are observed because of total cardiac volume during pregnancy 2. Cardiac output may become so vital organs are not perfused adequately hypoxia 3. When the left side of the heart is not able to empty the pulmonary vessels adequately, it become engorged causing pulmonary edema & HPN moist cough is a danger sign 4. Liver & other organs become congested because blood returning to the heart may not be handled adequately venous pressure fluid escapes through the walls of engorged capillaries & cause edema or ascites 5. CHF is a high probability because of cardiac output dyspnea, exhaustion, edema, ascites, pulse irregularities, chest pain on exertion & cyanosis of nail beds Management: Consider the functional capacity of the heart 1. Bed rest after the 30th week of gestation to ensure that pregnancy is carried to term 2. Diet should gain enough 3. Medications: a. Digitalis b. Iron preparations to prevent anemia because body compensates by ing cardiac output and further ing cardiac workload 4. Classes III and IV are placed on semi-sitting position during delivery to facilitate easy respirations 5. Anesthetic of choice is caudal anesthesia for effortless, push less & painless delivery. Remember: Gravidocardiacs are not allowed to push with contractions to prevent Valsalva maneuver which increases venous return to an already weak & damaged heart. Low forceps method is the best method of delivery 6. Ergotrate & other oxytocins, scopolamine, diethylstilbestrol & oral contraceptives are contraindicated because they cause fluid retention and promote thrombo-embolization

53 7. The period immediately following delivery is most critical period because the 3050% increase in blood volume during pregnancy will be re-absorbed into the mothers circulation in a matter of 5-10 minutes and the weak heart must make rapid adjustment to this change.

MULTIPLE (TWIN) PREGNANCY Classification: 1. Monozygotic/Identical-twins begin with a single ovum & sperm but in the process of fusion or in one of the first cell divisions, the zygote divides into two identical individuals a. Characteristics: always of the same sex; with 2 amnions, 1 chorion, 2 placentas fused in one and 2 umbilical cords b. Incidence: a chance occurrence-more frequent among non whites and among young primis and old multis 2. Dizygotic/Fraternala. Characteristics: may or may not be of the same sex; with 2 amnions, 2 chorions, 2 placentas & 2 umbilical cords b. Incidence: familial maternal pattern of inheritance Multiple pregnancy is suspected if: 1. Faster rate of increase in uterine size 2. On quickening, there are several flurries of action in different abdominal positions 3. On auscultation, 2 sets of fetal heart tones are heard 4. There is marked weight gain, not due to toxemia or obesity Complications: 1. Toxemia 2. Polyhydramnios 3. Anemia 4. Abruptio Placenta 5. Prematurity 6. Postpartum hemorrhage

54