PHYSIOLOGY MENSTRUATION periodic discharge of bloody fluid from uterus occurring at more or less regular intervals during the

life of a woman for puberty to menopause

y Menstruation
E and P low stim Hypo to release GnRH {FSHRF&LHRF}

release FSHRF triggers

APG-FSH

acts on follicles of ovary, but only one will grow and develop GF-growing and developing primoidial follicle called Graafian follicle

as GF grows and develop produces ESTROGEN

in response to increase estrogen

1. lining of uterus starts to thicken 2. cervical glands produce sticky, cloudy, flaky mucus discharge giving a woman sticky sensation around the vagina

as GF full matures

E is at its peak and man levels of estrogen

HYPO 1. 2. stop prod. FSHRF-APG-Stop FSH FSHRF-APGsimultaneously produce LHRF-APG- LH LHRF-APG-

acts on matured GF causing it to rupture and release

process called ovulation

the ruptured follicle becomes a yellow body called CORPUS LUTEUM

produces and release progesterone

supports further growth of endometrium becomes

spongy, very thick, rich in mucus and b.v (vascular and tortous) making is a perfect bed for possible implantation

P reach its peak and no fertilization

stimu. HYPO- to stop LHRF HYPO-

APG stops LH Causes the CL to degenerate in 14 days as its normal life span,a drop in Pragesterone causes the

Shedding or sloughing of endometrial lining= MENSTRUATION

yOvum

zygote embryo- fetus-

infant yRHU visit once each trimester / more frequent to higher risk yBHS/Hx center once for 1-6 mos
twice 7-8 th weekly 9th

Discomfort Associated with Pregnancy

Nausea and Vomiting 1st trimester Increased HCG levels Interventions: - Small, frequent, lowfats meals - Avoid fried foods - Avoid antiemetics during pregnancy

Heartburn
2nd and 3rd trimesters Displacement of the stomach, decreased intestinal motility and esophageal reflux Interventions: - Small frequent meals - Avoid fatty and spicy food - Remain upright for 30 minutes after meals - Use antacid only as directed by physician

Fatigue
1st and 3rd trimesters Hormonal changes Interventions: - Regular exercise - Frequent rest perionds - Avoid food and drinks containing stimulants

Varicose Veins
2nd and 3rd trimesters Venous congestion and weakening of the walls of the veins Interventions: - Elevate feet when sitting - Avoid leg crossing - Avoid long periods of standing - Avoid constrictive clothing

Constipation
2nd and 3rd trimesters Decreased intestinal motility and displacement of the intestine Interventions: - High fiber diet (fruits and vegetables) - Increase fluid intake - Regular exercise - Avoid laxatives

Backache
2nd and 3rd trimesters Increased lordosis due to enlarged uterus Interventions: - Observe proper posture and body mechanics - Wear low heeled shoes - Firm mattress - exercise

EFM toco/ USD toco/

y NST

non stress test fetal heart rate with fetal movement

y Normal: reactive
FHR 120-160 Increase 15 bpm for 15 sec

y Non reactive
y

Fetal distress

y CST

FHR with UC y A. nipple stimulation y B. oxytocin challenge test

y Normal finding: Negative
y

There should be no variable/late deceleration

Discomfort Associated with Pregnancy

Nausea and Vomiting 1st trimester Increased HCG levels Interventions: - Small, frequent, lowfats meals - Avoid fried foods - Avoid antiemetics during pregnancy

Heartburn
2nd and 3rd trimesters Displacement of the stomach, decreased intestinal motility and esophageal reflux Interventions: - Small frequent meals - Avoid fatty and spicy food - Remain upright for 30 minutes after meals - Use antacid only as directed by physician

Fatigue
1st and 3rd trimesters Hormonal changes Interventions: - Regular exercise - Frequent rest perionds - Avoid food and drinks containing stimulants

Varicose Veins
2nd and 3rd trimesters Venous congestion and weakening of the walls of the veins Interventions: - Elevate feet when sitting - Avoid leg crossing - Avoid long periods of standing - Avoid constrictive clothing

Constipation
2nd and 3rd trimesters Decreased intestinal motility and displacement of the intestine Interventions: - High fiber diet (fruits and vegetables) - Increase fluid intake - Regular exercise - Avoid laxatives

Backache
2nd and 3rd trimesters Increased lordosis due to enlarged uterus Interventions: - Observe proper posture and body mechanics - Wear low heeled shoes - Firm mattress - exercise

Gravida
Number of pregnancy regardless of the duration; includes present pregnancy Nulligravida: woman who has never been pregnant Primigravida: woman who is pregnant for the first time Multigravida: woman who is pregnant two or more times

Para
Number of times a woman has given birth (beyond 2o weeks) regardless of outcome Nullipara: woman who has never given birth Primipara: woman who has given birth for the first time Multipara: woman who has given two or more times

Naegele s Rule
Used for estimating the expected date of confinement (EDC) Formula: subtract: 3 from the month of the LMP add: 7 to the first day of the LMP Example: LMP April 2 4 3=1 2+7=9 EDC: January 9

Fetal Diagnostic Tests

Ultrasound uses: - Validation and dating of pregnancy - Assessment of fetal growth and viability - Measurement of fluid volume safe for fetus

Amniocentesis aspiration of amniotic fluid after the 14th week uses: - Identify chromosomal abnormalities - Determine fetal sex

Alpha-Fetoprotein Screening sample used: amniotic fluid done between 15 and 18 weeks uses: - To detect presence of neural tube defects and chromosomal abnormalities

Lecithin/Sphingomyelin Ratio (L/S Ratio) sample used: amniotic fluid use: to determine fetal lung maturity normal results at 35-36 weeks: 2:1 (low risk for developing respiratory distress syndrome)

Chorionic Villi Sampling use: to obtain tissue sample at implantation site fetal chromosomal, DNA or metabolic abnormalities transabdominal or transcervical earliest test possible on fetal cells between 9 12 weeks of gestation

Preliminary signs of Labor

1. lightening - setting of the presenting part to the pelvis 2. weight loss 3. increase in activity level 4. Braxton Hick s Contraction 5. Ripening of the cervix 6. Rupture of membranes --risk for infection 7. Show

Cord prolapse
Nsg care CBR 2. Check FHR 3. Amniotic Fluid
1.
Greenish / yellowish meconium b. Blood tinged uteroplacental insufficiency
a.

True labor
a. Uterine contraction regular, predictable b. Pains start at the back goes to the front c. Increase in duration, frequency and intensity d. Pain not relieved anymore e. Dilatation and effacement of cervix

Uterine contractions Increment Acme Decrement

Length of Normal Labor

1.

1.

1.

Dilatation P 12 and hrs M- 7 hrs and 20 mins Expulsion P 80 mins M- 30 mins Placental expulsion P and M- 10 mins 20 mins max

Stages of Labor
a. Dilatation TL to full dilatation of the

cervix b. Expulsion Dilatation to delivery of the baby c. Placental delivery of baby to placental delivery d. Postpartum/puerperium

DILATATION
PHASES LATENT ACTIVE TRANSI TIONAL Dilatatio n 1-3 cms 4-7 cms 8-10 cms
INTENSITY

ACTIVITY

Mild Moderate

talkative Fear of losing ctrl uncontrolla ble

Transitional
a. Sudden gush of amniotic fluid b. Show becomes prominent c. Uncontrollable urge to push d. n/v

NSG CARE: - massage sacral area -teach to bear down

HEALTH TEACHINGS
Hygiene NPO Enema Voiding Perineal Preparation Bearing down Administration of Analgesics demerol ****Do not give 1 hr before the delivery

EXPULSION
Mechanism: DFIrEErE Descent Flexion Internal Rotation Extension External rotation expulsion

Nsg care
1. 2. 3.

Proper positioning Breathing: fast and shallow ---panting Assist in episiotomy a. median b. R or L mediolateral 4. Modified ritgen s maneuver 5. Assist with the delivery of the baby

PLACENTAL
a. Calkin s sign uterus rises up in the umbilical level and becomes firm b. gushing of blood Cotyledons 15 to 20 c. lengthening of the cord Brandt- Andrews d. uterus becomes globular and firm Schultz Duncan

Nsg care
1. 2. 3. 4. 5. 6. 7.
1.

Never hurry the delivery of the placenta Check for completeness of cotyledons Time of placental delivery Palpate for contracted uterus Inspect for lacerations Assist in episiorrhaphy Give oxytocic drugs
Syntocinon and methergine - to constrict the cervix hypertensive drugs

POSTPARTUM
1 to 2 hrs after delivery 1. Vs monitoring 2. Palapate uterus 3. Lochia 4. Bladder voids continously 5. Perineum 6. Breastfeeding INVOLUTION process where reproductive organs return to normal functioning and size

a. Promote healing b. Prevent complications c. Successful lactation d. Family planning method e. Meds Antibiotics Analgesic Oxytocics

y LOCHIA

RUBRA
decidua)

- 1ST 3 DAYS POST PARTUM(shreds

SEROSA - 4th-10th day post partum(brownish

vag.discharge)

ALBA

-10th day- 6th wk (whitish

yellowish non foul smelly vaginal discharges

Phase of Maternal Adjustmet

y 1. Taking In - 1-2 days post partum - Predominance of mother s needs (sleep and food) - Help with daily activities as well as child care - Listen to the mother s experience during labor and

delivery - Not the best time to do teaching about care of the neonate

2. -

Taking Hold 3-10 days post partum Mother starts assuming the care of the neonate Emotional lability may be present Best time to teach about baby care Reassure the mother that she can perform the tasks of being a mother

3. -

Letting Go Fifth or sixth week postpartum New baby is included in new lifestyle Focus on entire family Mother may be overwhelmed by demands on her time and energy

Complications of Pregnancy
Abortion termination of pregnancy before the age of viability spontaneous or induced clinical presentation - Vaginal bleeding - Contractions - Passage of fetus/placental tissue

Type of Abortion
y Threatened contractions/bleeding, cervix closed, y y y y y

fetus not expelled Inevitable cervix open, heavier bleeding Complete all products of conception expelled Incomplete membrane or placental tissue retained Missed fetus dies in uterus but is not expelled Habitual three consecutive pregnancies ending in spontaneous abortion

y Nursing considerations - Maintain client on bed rest - IV fluids - Instruct client to keep all tissues passed - Prepare client for D & C or suction eveat

Incompetent Cervix Pailess dilatation of the cervix in the absence of uterine contractions; due to cervical trauma History of repeated abortions Management - Cerclage - Shirodkar Technique/ McDonals Procedure

y Nursing considerations - Bed rest - Monitor VS, fetal heart rate - Prepare for procedure - Monitor post-complications:

Rupture of membranes 2. Contractions 3. bleeding

1.

Ectopic Pregnancy y Pregnancy outside the uterine cavity y Fallopian tubes most frequent site; ruptures before the 12th week AOG y Clinical presentation - Bleeding - Hypotension - Abdominal pain and abnormal pelvic mass - Decreased hemoglobin and hematocrit; leucocytosis

y Management - surgery: salpingostomy; salpingectomy - Blood transfusion y Nursing considerations - Obtain vital signs - Monitor bleeding - Prepare patient for surgery - Allow client to express feelings about loss of pregnancy

Hyperemesis Gravidarum y Intractable nausea and vomiting that last beyod the first trimester y Most pronounced upon waking up y Clinical presentation - Persistent nausea and vomiting - Dehydration - Electrolyte imbalance - Weight loss

y Nursing considerations - Monitor vital signs, fetal heart rate and fetal activity - Monitor I&O, electrolytes and hematocrit - Small feedings - Dry diet, alternate liquids and solids - Weight patient daily - Assess fetal growth

Hydatidiform mole y Developmental anomaly of placenta y Grape-like clusters y Common in women over 40 y Clinical presentation - Increasing size of uterus - Increased levels of HCG - Vaginal bleeding - Absent fetal heart sounds - Ultrasound: snowstorm pattern

y Management - Evacuation of the uterus (suction curretage) - Hysterectomy - chemothearapy y Nursing considerations - Instruct patient to monitor HCG levels for 1 year - Teach patient how to use contraceptives to delay

pregnancy by at least a year

Prenancy-Induced Hypertension y Vasopastic hypertesion, edema and proteinuria y Onset: after 20th week of pregnancy y Classification: 1. Preecclampsia (mild or severe) 2. Eclampsia y Management: termination of pregnancy y Complication: HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)

Mild Preeclampsia y Onset: between 20th and 24th week of pregnancy y Hypertension of 15-30 mmHg above the baseline y Sudden weight gain (1 lb/wk), edema of the hands and face, (+1) protenuria y Nursing considerations: - Bed rest in left position - Monitor blood pressure, weight, deep tendon reflexes - Increase dietary carbohydrate and protein

Severe Preeclampsia y Blood pressure of 150/100 160/110 y Headache, epigastric pain, nausea and vomiting, visual disturbance y (+4) protenuria, oliguria, hyperreflexia y Management: magnesium SO4, hydralazine y Nursing considerations: - Daily funduscopic examinations; monitor reflexes - Seizure precautions - Continue to monitor 24 -48 hours post partum

Eclampsia y C0nvulsions, coma, cyanosis, fetal distress y Bp > 160/110, severe edema, 4+ proteinuria y Nursing considerations: - Administer oxyden - Minimize all stimuli - Seizure precautions - Monitor vital signs - Prepare for C section

Placenta Previa y Abnormal implantation of the placenta in the lower uterine segment y Classification 1. Complete (total, central) 2. Partial 3. Marginal (low lying)

y Clinical presentation - Painless vaginal bleeding (third trimester) - Abnormal fetal position - anemia y Management - Based on maternal and fetal condition

Conservative 2. Cesarian section

1.

y Nursing considerations - Bed rest - IV fluids - Blood transfusion as needed - Monitor vital signs, FHR, fetal activity - Avoid vaginal examinations - Prepare for ultrasound - Prepare for cesarian section

Abrputio Placenta y Premature separation of a normally implanted placenta y Risk factors - Maternal hypertension - Short umbilical cord - Abdominal trauma - Smoking/use of cocaine

y Clinical presentation - Vaginal bleeding - Abdominal and low back pain - Frequent contractions - Uterine tenderness - Hypotension, tachycardia, pallor - Concealed hemorrhage: abdominal rigidity, increase in

fundal height

y y -

Management Cesarian section Blood transfusion IV fluids O2 inhalation Nursing consideration Relieve pressure on the cord Elevation of the presenting part Oxygen at 8 10 LPM via face mask Cesarian section

Prolapsed Cord y Protusion of the umbilical cord into the vagina

y Risk factors - Ruptured membranes - Small fetus - Breech presentation - Transverse lie - Excessive amniotic fluid

y y -

Clinical presentation Visible cord at the vaginal opening Palpable cork on vaginal examination Fetal bradycardia Management Relieve pressure on the cord Elevation of the presenting part Oxygen at 8-10 LPM via face mask Cesarian section

y Nursing considerations - knee-chest or Trendelenberg position - Monitor fetal heart tones - Avoid palpatation or handling of the cork - Prepare client for surgery - Allay client s anxiety

Uterine Rupture
y Tear in the uterine wall y Most serious complication of labor y Risk factors

Previous cesarian section 2. Mulitiparity 3. Intense uterine contractions

1.

y Clinical presentation 1. -

Complete rupture sudden, severe abdominal pain Abdominal rigidity Cessation of contractions Absence of FHR Shock

2. Incomplete rupture - Abdominal pain with contractions - Slight vaginal bleeding - Failure of cervical dilatation - Absence of FHR

y Management - Surgery (c section, hysterotomy, hysteretomy) - Blood trasfusion as needed y Nursing consideration - Monitor maternal vital signs and FHR - Watch out for signs and symptoms of shock - Prepare client for surgery - Provide emtional support for the client

Obstetrical Procedure
Episiotomy
y Incision made into the

perineum to enlarge the opening y Prevents perineal laceration y Types: 1. Midline (median) 2. Mediolateral

y Nursing considerations - Apply ice packs for the 24 hours - Hot sitz bath to promote healing - Check for signs of bleeding/infection - Instruct client about perineal hygiene

Forcep Delivery
y Indication: to shorten y Nursing considerations - Explain procedure - Reassure patient - Monitor mother and

second stage of labor Fetal distress Poor maternal effort Medical condition Maternal fatigue Large infant

fetus continuously - After delivery, check mother and fetus for injuries

Vacuum Extraction
y Used to assist delivery of the fetal head y Suction device applied to fetal head and traction y -

applied during contractions Nursing considerations Do not keep suction device longer than 25 minutes Continuous fetal monitoring Assess infant fro cerebral trauma

Cesarian Section
y Delivery of the fetus through an abdominal and y -

uterine incision Indications: Fetal distress Abnormal presentation (breech, face, shoulder) CPD Placental abnormalities Multiple gestation Previous CS Arrest in labor

y Nursing considerations - Obtain inform consent - Explain procedure to the mother - Monitor mother and fetus continuously - Prep abdomen and pubic area - Insert IV and catheter - Pain relief - Encourage turning, coughing and deep breathing - Monitor for signs of bleeding and infection