MATERNAL AND CHILD HEALTH NURSING Maternal and Child Health Nursing involves car e of the woman and

family throughout pregnancy and child birth and the health pr omotion and illness care for the children and families. Primary Goal of MCN 1 Th e promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and child rearing I. ANATOMY & PHYSIOLOGY 1. Ovaries o Almond shap ed o Produce, mature and discharge ova o Initiate and regulate menstrual cycle o 4 cm long, 2 cm in diameter, 1.5 cm thick o Produce estrogen and progesterone E strogen: promotes breast devt & pubic hair distribution prevents osteoporosis kee ps cholesterol levels reduced & so limits effects of atherosclerosis Fallopian t ubes. . 1 2 3 4 Approximately 10 cm in length Conveys ova from ovaries to the ut erus Site of fertilization Parts: interstitial isthmus cut/sealed in BTL ampulla site of fertilization infundibulum most distal segment; covered with fimbria 2. Uterus 1 Hollow muscular pear shaped organ uterine wall layers: endometrium; myometrium; perimetrium 2 Organ of menstruation 3 Receives the ova 4 Provide pla ce for implantation & nourishment during fetal growth 5 Protects growing fetus 6 Expels fetus at maturity 7 Has 3 divisions: corpus fundus , isthmus (most commo nly cut during CS delivery) and cervix 3. 1 2 3 Uterine Wall Endometrial layer: formed by 2 layers of cells which are as follows: basal layer- closest to the ut erine wall glandular layer inner layer influenced by estrogen and progesterone; thickens and shed off as menstrual flow Myometrium composed of 3 interwoven laye rs of smooth muscle; fibers are arranged in longitudinal; transverse and oblique directions giving it extreme strength 4 Vagina Acts as organ of copulation Conveys sperm to the cervix Expands to serve as birth canal Wall contains many folds or rugae making it very elastic Fornices uterine end of the vagina; serve as a place for pooling of semen following coit us Bulbocavernosus circular muscle act as a voluntary sphincter at the external opening to the 4. 5 6 7 8

vagina (target of Kegels exercise) II. PUBERTAL DEVELOPMENT 1. Puberty: 1 2 3 the stage of life at which secondary sex changes begins the development and matu ration of reproductive organs which occurs in female 10-13 years old & male at 1 2-14 yrs old the hypothalamus serve as a gonadostat or regulation mechanism set to turn on gonad functioning at this age 2. Reproductive Development Readiness for child bearing 1 begins during intraute rine life 2 full functioning initiated at puberty -the hypothalamus releases the GnRF which triggers the APG to form and release FSH and LH. (FSH & LH initiates production of androgen and estrogen ---> 2 sexual characteristics Role of Androg en 1 Androgenic hormones are produced by the testes, ovaries and adrenal cortex which is responsible for: muscular development physical growth inc. sebaceous gl and secretions 1 testosterone primary androgenic hormone Related terms a. Adrenar che the development of pubic and axillary hair (due to androgen stimulation) b. Thelarche beginning of breast development c. Menarche first menstruation period in girls (early 9 y.o. or late 17 y.o.) d. Tanner Staging 2 It is a rating syste m for pubertal development 3 It is the biologic marker of maturity 4 It is based on the orderly progressive development of: 5 breasts and pubic hair in females 6 genitalia and pubic hair in males 3. Body Structures Involved 1 2 3 4 Hypothal amus Anterior Pituitary Gland Ovary Uterus 4. Menstrual Cycle 1 Female reproductive cycle wherein periodic uterine bleeding occurs in response to cyclic hormonal changes 2 Allows for conception and impla ntation of a new life 3 Its purpose it to bring an ovum to maturity; renew a ute rine bed that will be responsive to the growth of a fertilized ovum

5. Menstrual Phases First: 4-5 days after the menstrual flow; the endometrium is very thin, but begins to proliferate rapidly; thickness increase by 8 folds und er the influence of increase in estrogen level also known as: proliferative; est rogenic; follicular and postmentrual phase Secondary: after ovulation the corpus luteum produces progesterone which causes the endometrium become twisted in app earance and dilated; capillaries increase in amount (becomes rich, velvety and s pongy in appearance also known as: secretory; progestational; luteal and premens trual Third: if no fertilization occurs; corpus luteum regresses after 8 10 days causing decrease in progesterone and estrogen level leading to endometrial dege neration; capillaries rupture; endometrium sloughs off ; also known as: ishemic Final phase: end of the menstrual cycle; the first day mark the beginning of a n ew cycle; discharges contains blood from ruptured capillaries, mucin from glands , fragments of endometrial tissue and atrophied ovum. Physiology of Menstruation 1. About day 14 an upsurge of LH occurs and the graaf ian follicle ruptures and the ovum is released 2. After release of ovum and flui d filled follicle cells remain as an empty pit; FSH decrease in Amount; LH incre ase continues to act on follicle cells in ovary to produce lutein which is high in progesterone ( yellow fluid) thus the name corpus luteum or yellow body 3. Co rpus luteum persists for 16 20 weeks with pregnancy but with no fertilization ov um atropies in 4 5 days, corpus luteum remains for 8 -10 days regresses and repl aced by white fibrous tissue, corpus albicans Characteristics of Normal Menstrua tion Period 1. Menarche average onset 12 -13 years 2. Interval between cycles av erage 28 days 3. Cycles 23 35 days 4. Duration average 2 7 days; range 1 9 days 5. Amount average 30 80 ml ; heavy bleeding saturates pad in <1hour 6. Color dar k red; with blood; mucus; and endometrial cells Associated Terms 1. 2. 3. 4. 5. Amenorrhea - temporary cessation of menstrual flow Oligomenorrhea - markedly dim inished menstrual flow Menorrhagia - excessive bleeding during regular menstruat ion Metrorrhagia - bleeding at completely irregular intervals Polymenorrhea - fr equent menstruation occurring at intervals of less than 3 weeks Ovulation 1 Occurs approximately the 14th day before the onset of next cycle (2 weeks before) 2 If cycle is 20 days 14 days before the next cycle is the 6th day , so ovulation is day 6 3 If cycle is 44 days 14 days, ovulation is day 30. 4 Sl ight drop in BT (0.5 1.0 F) just before day of ovulation due to low progesterone level then rises 1F on the day following ovulation (spinnbarkheit; mittelschmerz) 5 If fertilization occurs, ovum proceeds down the fallopian tube and implants o n the endometrium Menopause

o o o o Mechanism- a transitional phase (period of 1 2 years) called climacteric, herald s the onset of menopause. Monthly menstrual period is less frequent, irregular a nd with diminished amount. Period may be ovulatory or unovulatory - advised to u se Family planning method until menses have been absent for 6 continuous months Menopause is has occurred if there had been no period for one year. Classical si gns: Vasomotor changes due to hormonal imbalance a. hot flushes b. excessive swe ating especially at night c. emotional changes d. insomnia e. headache f. palpit ations g. nervousness h. apprehension i. depression j. tendency to gain weight m ore rapidly k. tendency to lose height because of osteoporosis (dowager hump) l. arthralgias and muscle pains m. loss of skin elasticity and subcutaneous fat in labial folds Artificial menopause / surgically induced menopause a. oophorectom y or irradiation of ovaries b. panhysterectomy III. PROMOTE RESPONSIBLE PARENTHOOD ysiologic method: oral contraceptives chemical methods 4. surgical methods release of FSH no ovulation Combined FAMILY PLANNING A. Artificial Methods: 1. ph ; natural methods 2. mechanical methods 3. Oral contraceptive Action: Types: inhibits ; Sequential; Mini pill

Side Effects: due to estrogen and progesterone > nausea and vomiting > Headache and weight gain > breast tenderness > dizziness > breakthrough bleeding/spotting > chloasma Contraindications: a. Breastfeeding b. Certain diseases: o thromboem bolism o Diabetes Mellitus o Liver disease o migraine; epilepsy; varicosities o CA; renal disease;recent hepatitis c. Women who smoke more than 2 packs of cigar ette per day d. Strong family Hx of heart attack Note: If taking pill is missed on schedule, take one as soon as remembered and take next pill on schedule; if n ot done withdrawal bleeding occurs.

B. Natural Methods: a. Rhythm/Calendar/Ogino Knause Formula o Couple abstains on days that the woman is fertile o Menstrual cycles are observed and charted for 12 months first day of the beginning of one cycle to the first day of the Standard Formula: next cycle shortest cycle = minus 18 longest cycle = minus 11 Example: shortest cycle = 28 longest cycle = 35 Shortest cycle: Longest cycle: Fertile pd: 28 days 18 = 10 35 days 11 = 24 10th to 24th day of cycle = No sexual intercourse b. Billings Method / Cervical Mucus o woman is fertile when cervical mucus is th in and watery; may be extended o Sexual Intercourse may be resumed after 3 4 day s c. Symptothermal Method / BBT 1 the 2 3 4 morning or doing any activity to det ect time of ovulation Ovulation is indicated by a slight drop of temperature and then rises Resume Sexual intercourse after 3 4 days Recommended observation of BBT is 6 menstrual cycle to establish pattern of fluctuations Requires daily obs ervation and recording of body temperature before rising in C. Mechanical Methods 1. Intrauterine Device - prevents implantation by non-spec ific cell inflammatory reaction inserted during menstruation (cervix is dilated) SE: increased menstrual flow spotting or uterine cramps increased risk of infec tion Note: when pregnancy occurs, no need to remove IUD, will not harm fetus 2. o o o o o Diaphragm a disc that fits over the cervix forms a barrier against the entrance of sperms initially inserted by the doctor maybe washed with soap and water is reusable when used, must be kept in place because sperms remains viable for 6 hrs. in the vagina but must be removed within 24 hours (to decrease risk of toxic shock syndrome) Condom a rubber sheath where sperms are deposited it le ssens the chance of contracting STDs 3. 1 2

3 most common complaint of users interrupts sexual act when to apply D. Chemical Methods These are spermicidals (kills sperms) like jellies, creams, foaming tablets, suppositories E. Surgical Method a. Tubal Ligation: Fallopian t ubes are ligated to prevent passage of sperms Menstruation and ovulation continu e b. Vasectomy: Vas deferens is tied and cut blocking the passage of sperms Sper m production continues Sperms in the cut vas deferens remains viable for about 6 months hence needs to observe a form of contraception this time to prevent preg nancy couple IV. BEGINNING OF PREGNANCY A. Fertilization 1. Union of the ovum and spermatozoo n 2. Other terms: conception, impregnation or fecundation 3. Normal amount of se men/ejaculation= 3-5 cc = 1 tsp. 4. Number of sperms: 120-150 million/cc/ejacula tion 5. Mature ovum may be fertilized for 12 24 hrs after ovulation 6. Sperms are capable of fertilizing even for 3 4 days after ejaculation (life span of sperms 72 hrs) B. Implantation General Considerations: o Once implantation has taken p lace, the uterine endometrium is now termed decidua o Occasionally, a small amou nt of vaginal bleeding occurs with implantation due to breakage of capillaries o Immediately after fertilization, the fertilized ovum or zygote stays in the fal lopian tube for 3 days, during which time rapid cell division (mitosis) is takin g place. The developing cells now called blastomere and when about to have 16 bl astomere called morula. o Morula travels to uterus for another 3 4 days o When t here is already a cavity in the morula called blastocyt o finger like projection s called trophoblast form around the blastocyst, which implant on the uterus o I mplantation is also called nidation, takes place about a week after fertlization C. Stages of human prenatal development 1. 2. Cytotrophoblast inner layer Syncy tiotrophoblast the outer layer containing finger like projections called chorion ic villi which differentiates into: Langerhans layer protective against Treponema Pallidum, present only during the second trimester o

o Syncytial Layer gives rise to the fetal membranes, amnion and chorion D. Fetal Membranes 1. Amnion gives rise to umbilical cord/funis with 2 arteries and 1 vein supported by 2. Whartons jelly 3. Amniotic fluid: clear albuminous flu id, begins to form at 11 15th week of gestation, chiefly derived from maternal s erum and fetal urine, urine is added by the 4th lunar month, near term is clear, colorless, containing little white specks of vernix caseosa, produced at rate o f 500 ml/day. Known as BOW or Bag of Water E. Amniotic Fluid Purposes of Amnioti c Fluid Protection shield against pressure and temperature changes Can be used t o diagnose congenital abnormalities intrauterine amniocentesis Aid in the descent of fetus during active labor Implication: Polyhydramios = more than >1500 ml du e to inability of the fetus to swallow the fluid as in trachoesophageal fistula. Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine as in congenital renal anomaly F. Fetal Membranes Chorion - together with t he deciduas basalis gives rise to the placenta, start to form at 8th week of ges tation; develops 15 20 cotyledons Purpose of Placenta: respiratory; exchange of n utrients and oxygen Renal system Gastrointestinal system Circulatory system Endocrin e system: produces hormones (before 8th week-corpus luteum produces these hormon es) hCG keeps corpus luteum to continue producing estrogen and progesterone HPL o r human chorionic somatomammotropin which promotes growth of mammary glands for lactation Protective barrier: inhibits passage of some bacteria and large molecul es V. FETAL GROWTH AND DEVELOPMENT First lunar month Germ layers differentiate b y the 2nd week 1. endoderm gives rise to lining of GIT, Respiratory Tract, tonsi ls, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra 2. Mesoderm forms into the supporting structures of the body (connective tissues, cartilage, muscles a nd tendons); heart, circulatory system, blood cells, reproductive system, kidney s and ureters. 3. Ectoderm responsible for the formation of the nervous system, skin, hair and nails and the mucous membrane of the anus and mouth

1 month: 2nd week fetal membranes beats 16th day heart forms ; 4th week heart 2nd month: All vital organs and sex organs formed; placental fully developed; me conium formed (5th 8th wk) 3rd month: Kidneys function - 12th wk- urine formed ; Buds of milk teeth form ; begin bone ossification ; allows amniotic fluid ; esta blishment of feto-placental exchange 4th month: Lanugo appears; buds of permanen t teeth form; heart beat heard by fetoscope quickening; FHR audible with 5th month: Vernix appears; lanugo over entire body; stethoscope 6th month: Attains proportions of full term but has wrinkled skin 7th month: 28 weeks lower limit of prematurity; alveoli begins to form 8th month: 32 weeks fet us viable; lanugo disappears, subcutaneous fat deposition begins 9th month: Lanu go continue to disappear; vernix complete; amniotic volume decrease Focus of Fetal Development First Trimester period of organogenesis Second Trimes ter period of continued fetal growth and development; rapid increase in length T hird Trimester period of most rapid growth and development because of the deposi tion of subcutaneous fat

Assessing Fetal Well-being Fetal Movement: Quickening at 18 20 weeks , peaks at 29 -38 weeks Consistently felt until term a. Cardiff Method: Count to ten - record s time interval it takes for 10 - fetal movements to be felt usually occurs in 6 0 minutes Fetal Heart Rate (FHR) analyzed in conjunction with b. Contraction Stress Test: contractions Nipple stimulation done to induce gentle contractions ***3 contractions with 40 sec duration or more must be present in 10 minutes window Normal Result no fetal decelerations with contractions c. Non-stress Test: 20mins.) Measures response of FHR to fetal movement (10with fetal movement FHR increase by 15 beats and rem ain for 15 seconds then decrease to average rate (no increase means poor oxygen perfusion to fetus) d. Amniocentesis - done to determine fetal maturity: Identif y L/S ratio 16 wks detect genetic disorder 30 wks assess 1. Prior to the procedure, bladder should be emptied; ultrasonography is used to avoid trauma from the needle to the placenta, fetus 2. Complications include pr emature labor, infection, Rh isoimmunization 3. Monitor fetus electronically aft er procedure, monitor for uterine contractions 4. Teach client to report decreas ed fetal movement, contractions, or abdominal discomfort after procedure. e. Ult rasound transducer on abdomen transmits sound waves that show fetal image on scr een a. b. c. d. e. Done as early as five weeks to confirm pregnancy, gestational age Multiple purposes to determine position, number, measurement of fetus(es) a nd other structures (placenta) Client must drink fluid prior to test to have ful l bladder to assist in clarity of image No known harmful effects for fetus or mo ther Noninvasive procedure

VI. NORMAL ADAPTATIONS IN PREGNANCY 1. Cardiovascular/ Circulatory changes: a. P hysiologic anemia of pregnancy -30-50% gradual increase in total cardiac volume (peak 6th month) causing drop in Hemoglobin and Hematocrit values (inc only in p lasma volume) Consequences of increased cardiac volume: 1. easy fatigability & s hortness of breath due increase cardiac workload 2. slight hypertrophy of the he art 3. systolic murmurs due to lowered blood viscosity 4. nosebleeds may occur d ue to congestion of nasopharynx b. Palpitations caused by the SNS stimulation du ring early part of pregnancy; increased pressure of the uterus against the diaph ragm during the second half of pregnancy c Edema of the lower extremities & vari cosities due to poor circulation caused by the pressure of the gravid uterus on the blood vessels of the lower extremities d. Vaginal and rectal varicosities due to pressure on blood vessels of the genitalia Management: side lying hips el evated on pillow modified knee chest position e. Predisposition to blood clot fo rmation -due to increased level of circulating fibrinogen as a protection from b leeding implication: no massage 2. Gastrointestinal Changes a. Morning sickness 2 nausea and vomiting in the 1st trimester due to HCG or due to increased acidit y or emotional factors 3 Management: dry toast 30 mins before get up in AM b. Hy peremesis gravidarum 4 excessive nausea & vomiting which persists beyond 3 month s causing dehydration, starvation and acidosis 5 Management: hydration in 24 hrs ; complete bed room c. Constipation and Flatulence GI displacement slows perista lsis & gastric emptying time; inc progesterone d. Hemorrhoids 1 due pressure of enlarged uterus 2 Management: cold compress with witch hazel and Epsom salts e. Heartburn 1 due to increased progesterone and decreased gastric motility causing regurgitation through gastric sphincter 2 Management: pats off butter before me als avoid fried, fatty foods sips of milk at intervals

small, frequent meals taken slowly dont bend on waist take antacids (milk of magn esia) 3. Respiratory Changes a. Shortness of Breath due to inc. oxygen consumpti on and production of carbon dioxide during the 1st Trimester; and increased uter ine size pushing the diaphragm crowding chest cavity management: side lying posi tion to promote lateral chest expansion 4. Urinary Changes a. Urinary frequency felt during the 1st trimester due to the increase blood supply to the kidneys an d then on the 3rd trimester due to pressure on the bladder. b. Decreased renal t hreshold for sugar due to increased production of glucocorticoids which cause la ctose and dextrose to spill into the urine; and inc. progesterone 5. Musculoskel etal changes a. Pride of Pregnancy 1 due to need to change center of gravity res ult to lordotic position b. Waddling gait 1 due to increased production of hormo ne relaxin, pelvic bones becomes more movable 2 increasing incidence of falls c. Leg cramps 1 due to pressure of gravid uterus, fatigue, muscle tenseness, low c alcium and phosphorus intake 6. Endocrine Changes a. Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen and progesterone b. Moderate enlargement of the thyroid due to increased basal metabolic rate c. Increased size of the parathyroid to meet n eed of fetus for calcium d. Increased size and activity of adrenal cortex increa sing circulating cortisol, aldosterone, and ADH which affect CHO and fat metabol ism causing hyperglycemia. e. Gradual increase in insulin production but there i s decreased sensitivity to insulin during pregnancy 7. Weight Change a. First Tr imester 1.5 to 3 lbs normal weight gain b. 2nd and 3rd trimester 10 11 lbs per t rimester is recommended c. Total allowable weight gain during throughout pregnan ce is 20 25 lbs or 10 12 kgs. d. Pattern of weight gain is more important than t he amount of weight gained. 8. Emotional responses

a. b. c. 1st trimester: some degree of rejection, disbelief, even depression because of i ts future implication -> give health teachings on body changes and allow for exp ression of feelings 2nd trimester: fetus is perceived as a separate entity and f antasizes appearance 3rd trimester: best time to talk about layette, and infant feeding method. To allay fear of death let woman listen to the FHT. VII. COMMON EMOTIONAL RESPONSES DURING PREGNANCY Stress decrease in responsibilit y taking is the reaction to the stress of pregnancy not the pregnancy itself aff ects decision making abilities Couvade syndrome men experiencing nausea/vomiting , backache due to stress, anxiety and empathy for partner Emotional labile mood changes/swings occur frequently due to hormonal changes Change in Sexual Desire may increase or decrease as a loss of interest in sexual partner needs correct i nterpretation not VIII. LOCAL CHANGES DURING PREGNANCY 1. Uterus wt tissues a. b. c. d. increase t o about 1000 grams at full term due to increase in fibrous and elastic Becomes o void in shape Softening of lower uterine segment: Hegars sign seen at 6th week Op erculum mucus plug to seal out bacteria Goodells sign cervix becomes vascular and edematous giving it consistency of the earlobe 2. Vagina increased vascularity occurs a. Chadwicks sign purplish discoloration o f the vagina b. Leukorrhea increased amount of vaginal discharges due to increas ed activity of estrogen and of the epithelial cells. a. Must not be itchy, foul smelling, excessive, nor green/yellow in color. b. Management: good hygiene c. U nder the influence of estrogen, vaginal epithelium & underlying tissues hypertro phic & enriched with glycogen d. pH of vaginal secretions during pregnancy fall Microorganisms that thrive in an alkaline environment: a. Trichomonas causes tri chomonas vaginalis/vagnitis or trichomoniasis s/s: frothy, cream-colored, irrita tingly itchy, foul smelling discharges, vulvar edema Management : Flagyl 10 days p.o. or trichomonicidal cmpd suppositories (e.g. Tricofuron, Vagisec, Devegan) Management: 1. treat male partner also with Flagyl 2. avoid alcohol to prevent S E 3. dark brown urine expected 4. Acidic vaginal douche (1 tbsp vinegar:1 qt wat er or 15 ml: 1000 ml) 5. avoid intercourse to prevent reinfection a. Candida Alb icans - condition is called Moniliasis or Candidiasis 6 it thrives in an environ ment rich in CHO and those on steroid or antibiotic

7 8 walls, foul therapy seen as oral thrush in the NB when transmitted during delivery s/s: whit e, patchy, cheese-like particles that adhere to vaginal smelling discharges causing irritating itchiness Management : 1. Mycostatin/Nyst atin p.o. or vaginal suppositories 100,000 U BID x 15 days 2. Gentian violet swa b to vagina 3. Acidic vaginal douche 4. Avoid intercourse 3. Ovaries Inactive si nce ovulation does not take place during pregnancy. Placenta produces Progestero ne and Estrogen during pregnancy 4. Abdominal Wall 1 Striae Gravidarum due to ru pture and atrophy of connective tissue layers on the growing abdomen 2 Linea Nig ra 3 Umbilicus is pushed out 4 Melasma or Chloasma increased pigmentation due in creased production of melanocytes by the pitutitary 5 Unduly activated sweat gla nds IX. SIGNS OF PREGNANCY I. Pregnancy 1 2 3 4 5 Prenatal care is important for prevention of infant and maternal morbidity and mortality Care is a cooperative action based on clients understanding of treatment modalities Duration of normal pregnancy 266 280 days of 38 42 weeks or 9 calendar months or 10 lunar months. Infant born < 38 weeks pre-term & 42 post term) Diagnosis: Urine examination tes ts presence of HCG (present from 40th 100th day, peak 60 days) conduct test 6 wee ks after LMP 2. Prenatal Visit History Taking: personal data gravida TPAL present pregnancy: cc medical data: hx of diseases/illnesses 3. Danger Signals of Pregnancy 1. 2. 3 . 4. 5. 6. 7. 8. 9. 10. obstetrical data para past pregnancies LMP Vaginal bleeding (any amount) Swelling of face or fingers Severe, continuous hea dache Dimness or blurring of vision Flashes of light or dots before eyes Pain in the abdomen Persistent vomiting Chills and fever Sudden escape of fluids from t he vagina Absence of FHT after they have been initially heard on 4th or 5th mont h

4. Assessment a. Physical examination review of systems b. Pelvic examination (a sk client to void) c. IE determine Hegars, Goodells, Chadwicks d. Ballotement on 5t h month e. Pap Smear f. Pelvic measurements (done after 6th month or 2 wks befor e EDC) g. Leopolds Manuever: to determine fetal presentation, position, attitude, est. size and fetal parts h. Vital signs i. Blood studies: CBC Hgb, Hct , blood typing, serological tests j. Urinalysis: test for albumin, sugar & pyuria 5. Im portant Estimates: a. Age of Gestation: Nageles Rule: -3 calendar months and +7 d ays Ex. LMP= May 15, 2006 or LMP: Formula: EDC: 5 15 -3+ 7 2 22 or 5-15-06 February 22, 2007 McDonalds Rule: Ht fundus/4 (AOG wks) 1. Measure in cms the length from the symphysis to the level of fundus 2. Lunar months: Fundal Height (cms) x 2/7 3. Weeks of pregnancy: Fundal height (cms) x 8 /7 Ex. Fundal Height = 14 cms Lunar Month: 14cms x 2 = 28 / 7 = 4 months Weeks P regnant: 14 cms x 8 = 112 / 7 = 16 weeks AOG Bartholomews Rule: based on position of fundus in abdominal cavity 3rd month = ab ove symphysis 5th month = umbilical level 9th month = below xiphoid process) Fet al Length: 1 Haases Rule: 1st half of pregnancy square number of months Example : 2 months = 2x2 = 4 cm 2nd half of pregnancy number of months multiplied by 5 Ex ample: 7 months x 5 = 35 cm Fetal Weight: 1 Johnsons Rule: Fundic Ht n x k ( k=15 5; n = 11 not engaged/12 engaged) Example for a not engaged fetus Fundic Height given = 35 cms n = 11 (standard for not engaged fetus) k= 155 gms. (9 standard) Solution: 35 cms 11 = 24 x 155 =3,720 g b. c.

5. Health Teachings a. Smoking lead to LBW babies b. Drinking can cause respirat ory depression in the NB and fetal withdrawal syndrome if excessive; alcohol has empty calories c. Drugs may be teratogenic hence contraindicated unless prescri bed by Doctor d. Sexual activity allowed in moderation but not during last 6 wks - high incidence of post partum infection noted. counseling is important on chan ges in desire and positions contraindication: bleeding, ruptured BOW, incompeten t cervix, deeply engaged presenting part e. Prepared childbirth/Childbirth educa tion 1 Based on Gate Control Theory: pain is controlled in the spinal cord and t here is a gate that can be closed to ease pain felt. 2 Information and breathing techniques help minimize discomfort of labor experience 3 Discomfort can be les sened if abdomen is relaxed and allows uterus to rise freely against it during c ontractions Major Approaches to prepared childbirth 1 Teaching about anatomy, pr egnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene , diet and comfort measures Grant-Dick Read Method: Fear leads to tension and te nsion leads to pain Lamaze Method: Psychoprophylactic method ; based on S-R cond itioning; concentration on breathing is practiced f. Immunization: Tetanus Toxoi s (TT) = 0.5 ml IM for all pregnant women shall be given in 2 doses- 4 wks inter val with 2nd dose at least 3 wks before delivery = booster doses given during su cceeding pregnancies regardless of interval. = 3 booster doses is equal to lifet ime immunity g. Clinic Visits for Pre-natal check-up 2 First 7 lunar months ever y month 3 On 8th and 9th lunar month every week 4 On 10th lunar month every week until labor X. LABOR AND DELIVERY 1. THEORIES OF LABOR ONSET Uterine stretch th eory Oxytocin theory Progesterone Deprivation theory Prostaglandin theory 2. FOU R PS OF LABOR a. Power - the uterine contraction

b. Passenger the fetus c. Passageway the maternal pelvis d. Psyche the mental an d emotional aspect of the woman a. POWER - Uterine Contractions: a.1. Frequency the beginning of one contraction to the beginning of the next contraction a.2. I nterval pattern which increases in frequency and duration a.3. Duration the begi nning of one contraction to the end of the same contraction a.4. Intensity stren gth of contraction, measured through a monitor or through touch of a fingertip o n the fundus (mild, moderate or strong) b. PASSENGER - Fetus b.1. Fetal Skull: a . largest part of the fetus - most frequent presenting part; least compressible Bones: sphenoid, ethmoid, temporal, frontal, occipital, parietal Suture lines: s agittal/ coronal, lamboidal b.2. Fontanels - membrane covered spaces at the junc tion of the main suture lines anterior fontanel: larger, diamond shaped; closes at 12 18 months posterior fontanel: smaller, triangular shaped, closes at 2 3 mo nths b.3. Fetal Lie relationship of the cephalocaudal axis of the fetus to the c ephalocaudal axis of the mother. Measurements: b.4. Fetal Attitude fetal position Pelvis is divided into 6 areas: Anterior, Pos terior, Transverse Left, Transverse Right, Posterior Left, Posterior Right Fetal landmarks: Occiput (O); mentum (M), sacrum (S), and scapula (Sc) b.5. Presentat ion the part of the passenger that enters the pelvis is the presenting part a. Ce phalic Vertex (occiput) ; Brow (sinciput); Face (mentum) b. Breech Complete (sac rum) ; Frank; Footling c. Shoulder b.6. Movement of Passenger upon birth or desc ent: d. Descent e. Flexion f. Internal Rotation g. Extension h. External rotatio n/ restitution c. PASSAGEWAY maternal pelvis c.1. Divisions

a. b. -supports the growing uterus during pregnancy -directs the fetus into the true p elvis near the end of gestation True Pelvis: the bony canal through which the fe tus will pass during delivery formed by the pubis in front, the iliac and ischia on the sides and the sacrum and coccyx behind False Pelvis c.2. Significant Pelvic Measurements a. External Suggestive only of pelvic size > External Conjugate/ Baudelaocques Diameter - the distance between the anterior aspect of the symphysis pubis and the depression below lumbar 5 (Average: 18 20 cm) b. Internal the actual diameters of the pelvic inlet and outlet > Diagonal C onjugate - the distance between the sacral promontory and inferior/lower margin of the symphysis pubis - widest AP diameter at outlet estimated on vaginal/pelvi c exam (Average: 12.5 cm) >Obstetrical Conjugate - the distance from the inner b order of the symphysis pubis to the sacral prominence - most important pelvic me asurement - shortest AP diameter of the inlet through which the head must pass 1.5 to 2 cm or less than the diagonal conjugate >True Conjugate/Conjugate Vera - the distance between the anterior surface of the sacral promontory and superio r margin of the symphysis pubis - diameter of the pelvic inlet (10.5 -11 cm) >Bi -Ischial/ Tuberiischial Diameter - the distance between the ischial tuberosities - narrowest diameter of the outlet - transverse diameter of the outlet (Average : 11 cm) D. PSYCHEFactors 1 2 3 4 5 6 7 the emotions of the mother that may incr ease a womans chance of depression: History of depression or substance abuse Fami ly history of mental illness Little support from family and friends Anxiety abou t the fetus Problems with previous pregnancy or birth Marital or financial probl ems Young age (of mother Signs and Symptoms of Post-partum depression: 1 Feeling restless or irritable 2 Feeling sad, hopeless, and overwhelmed 3 Crying a lot 4 Having no energy or moti vation 5 Eating too little or too much 6 Sleeping too little or too much 7 Troub le focusing, remembering, or making decisions 8 Feeling worthless and guilty

9 Loss of interest or pleasure in activities 10 Withdrawal from friends and fami ly 11 Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow br eathing) 3.PRELIMINARY/PRODROMAL SIGNS OF LABOR a. b. c. d. e. f. g. h. i. j. k. Lightening Increased activity level- nesting behavior Loss of weight ( 2-3 lbs) B raxton Hicks Contractions Cervical Changes effacement - Goodells sign ripening of the cervix Increase in back discomfort Bloody Show - pinkish vaginal discharge R upture of Membranes labor expect in 24 hours Sudden burst of energy Diarrhea Regu lar Contractions - phases: increment,acme,decrement - characteristics: intensity , frequency, interval, duration False Labor Pains o1 Remain irregular o2 Confined to abdomen o3 No increase in d uration, frequency, intensity o4 Disappears on ambulation o5 No cervical changes True Labor Pains o6 Becomes regular and predictable o7 Radiates in girdle like f ashion o8 Increase in duration, frequency, intensity o9 Continue regardless of a ctivity o10 Effacement and dilatation occurs o11 Signs of True labor Effacement Dilatation 1 2 Uterine Changes upper and lower segments; physiologic retraction ring Bandls patho logic retraction ring- a danger sign of impending rupture of the uterus if obstr uction is not relieved 1. Nursing Interventions of Woman in Labor: a. Assessment history and physical a ssessment a.1. Personal data a.2. Obstetrical data 1 determine EDC 2 obstetrical score 3 amount/ character of show 4 status of the BOW 5 general physical examin ation 6 Leopolds Maneuver: presentation 7 Internal examination: effacement ; dila tation; station b. Monitoring and Evaluating Progress of Labor b.1. Blood pressu re b.2. Fetal Heart Tone b.3. Observe for signs of fetal distress

12 bradycardia 13 fetal thrashing 14 meconium stained amniotic fluid in non-bree ch presentation b.4. Monitor and inform patient of progress of labor b.5. Monito r progress fetal a) during labor check FHR b) manage fetal distress 5. Analgesia /anesthesia during childbirth 5.1. Analgesia relieves pain and its perception 5. 2. Anesthesia produces local or general loss of sensation ; - usually regional a nesthesia (e.g. spinal) o o o Relieve uterine and perineal pain Usually safe for the fetus (potential for maternal hypotension) Types of Anesthesia: a. Paracerv ical block b. Peridural block: Epidural/caudal c. Intradural: spinal/saddle bloc k d. Pudendal block e. Local anethesia Regional Anesthesia is mostly preferred b ecause it does not enter maternal circulation nor affect fetus Xylocaine is used (NPO with IV infusion) > allows to be awake and participate in process; > can i ncrease incidence of maternal hypotension and fetal bradycardia o o 5.3. Analgesics: 5.3.1 Narcotics o o o o (Demerol) produces sedation/relaxation depresses NBs respiration given in active labor Special Considerations: Demerol i s most commonly used Has sedative and antispasmodic effect Dose is usually 25 100 mg depends on body weight Not given early in labor due to possible effect on co ntractions Not given too late (1 hr before delivery) can cause respiratory depre ssion in the newborn Given if cervical dilatation is 6 8 cms. 5.3.2. Narcotic Antagonist: Narcan; Nalline 6. Nursing Care before administratio n of anesthesia/analgesia 1.1.Assess pain status 1.2.Explain the action of drugs 1.3.Check vital signs of mother and fetus 1.4.Observe safety measures Evaluate allergies Provide siderails have call bell ready NPO (anesthesia)

Check time last medication was given 1.5.Nursing Care after administration of an esthesia/analgesia 1.6.Monitor: vital signs BP and FHR (be alert for bradycardia ) 1.7.Record properly 1.8.Provide comfort measures 1.9.Remember that the use of Forceps is needed in delivery of patient under anesthesia due to loss of coordin ation in bearing down during 2nd stage 1.10. Side effects: a. postspinal headach es place flat on bed for 12 hrs and increase fluid intake b. common side effect is hypotension (xylocaine vasodilator): Nursing Intervention: turn to side elevat e legs administer vasopressor and oxygen as ordered Fetal bradycardia Decreased maternal respirations (Observe for bulging of the perineum) XI. STAGES OF LABOR 1. Stages of Labor Stage First Stage - the stage of true labor until the complet e cervical dilatation Characteristics Extent: Primigravida 3.3.-19.7 hrs Multigr avida 0.1 - 14.3 hrs a. Latent Phase 0-4 cms. cervical dilatation Interval: 15-20 mins interval Duration: 10-30 secon ds 5-7 cms. cervical dilatation Interval: 3-5 mins Duration: 30-60 seconds 8-10 cms cervical dilatation Interval: 2-3 mins. Duration: 50-90 seconds b. Active Phase c. Transitional Phase Second Stage - begins with complete dilatation of the cervix until the birth of the newborn Duration: Primigravida 30 mins. - 2 hrs. Multi-gravida- 20 mins 1 hr. Contractio ns- 2-3 mins for 50-90 secs Mother is exhausted and has urge to push Third Stage - from delivery of the newborn to the delivery of the placenta Still with mild contractions until the placenta is expelled. Usually, placenta i s expelled within 30 minutes.

Fourth Stage - the first hour after complete delivery until the woman becomes ph ysically stable Uterine cramping Rubra with small clots 2. Principles of Postpartum Care a. Promote healing and the process of involutio n b. Provide emotional support c. Prevent postpartum complications d. Establish successful lactation e. Promote responsible parenthood (FP) 3. Nursing Care of t he Woman in First & Second Stage Labor a. b. Monitor discomfort/exhaustion/pain control support client in choice of pain control Relaxation techniques taught du ring pregnancy where breathing is taught as a relaxed response to contraction Lo w back pain massage of sacral area Use different breathing techniques during the different phases of labor Encourage rest between contractions Keep couple infor med of progress Administer analgesic : side effects-may prolong labor; local/ bl ock/ general Care of Woman in the 3rd Stage of Labor Principle Of Watchful Waiti ng Use Brandt Andrews Maneuver Note Time Of Delivery (20 Minutes After Delivery Of The Baby) Check Bp; Injects Oxytocin (Methergin 0.2 Mg/Ml Or Syntocinon 10 U/ Ml Im) Inspect Cotyledons For Completeness Check Uterus For Contraction Check Pe rineum For Lacerations -Give perineal care; apply perineal pads Change gown Plac e flat on bed Keep warm provide extra warm blanket Give initial nourishment warm milk, tea Allow to rest/ sleep c. d. e. f. g. 4. Nursing a. b. c. d. e. f. g. h. i. j. k. l. 5. Nursing Care of Woman in Fourth Stage a. Lactation: promote lactation by enco uraging early breastfeeding to stimulate milk production *** Those mothers who c annot breastfeed: suppressing agents are given estrogen- androgen preparations g iven first hours post partum to prevent milk production. These drugs tend to inc rease uterine bleeding and retard involution. (e.g. diethylstilbestrol, Parlodel or deladumone) b. Rooming-in-concept provides opportunity for developing positi ve family relationship promotes maternal infant bonding releases maternal careta king responses c. Assess vital signs, fundus and flow every 15 minutes. d. Hydra tion and elimination e. May ambulate

Puerperium - the 6 weeks period following delivery Involution- time period for t he return of the reproductive organs to return to its prepregnant state 8. Categ ories of Lacerations 8.1. First degree involves vaginal mucous membrane and peri neal skin 8.2. Second degree involves the perineal muscles, vaginal mucous membr ane and perineal skin 8.3. Third degree involves all in the 2nd degree laceratio ns and the external sphincter of the rectum 8.4. Fourth degree involves all in 3 rd degree lacerations and the mucus membrane of the rectum XII. PROMOTING HEALIN G AND INVOLUTION DURING POST-PARTUM 1. Vascular Changes - Reabsorption of the 30 -50% increase in cardiac volume within 5 10 minutes after the third stage of lab or. - WBC increases to 20,000 30,000/mm - Activation of the clotting factor - All blood values are back to prenatal levels by 3rd or 4th week 2. Location of the Fundus - Uterine involution is measured by determining the level of the fundus i n relation to the umbilicus - Nursing care: Assess condition and level of the fu ndus Position in prone or knee chest 1 Occurrence of afterpains it is an indicat ion of uterine contractions and are normal. Usually lasts up to 3 days after bir th Nursing Care: Explain to client cause of pain Do not apply heat Administer analg esics as prescribed 3. Genital Changes/ Discharges - Presence of Lochia: uterine discharges consisting of blood, decidua, WBC and some bacteria - Characteristic s: pattern should not reverse 1-3 days rubra - - - bright red with no or minimal clots 4-9 days serosa- - - thinner, serous sanguinous blood 10- 3 to 6 wks pp a lba - - - whitish discharge same amount as menstrual flow, decreased if with bre astfeeding , increased with activity with fleshy odor; never foul smelling 4. Pe rineal Pain Nursing Care: Place in Sims position lessens strain on the suture lin e

Expose to dry heat or warm Sitz bath Application of topical analgesics or oral a nalgesics as ordered Provide/ encourage perineal care 5. Sexual Activity 1 sexua l stimulation may be decreased due to emotional factors and hormonal changes 2 i t may be resumed if bleeding has stopped and episiorrhaphy has healed by the 3rd or 4th week 6. Menstruation 1 Breastfeeding influences return of the menstrual flow. 2 Breastfeeding menses return in 3 4 months; o some do not menstruate thro ughout lactation period o ovulation is also possible with lactational amenorrhea 3 Non-Breastfeeding Mothers menstrual flow return within 8 weeks 7. Urinary Cha nges o marked diuresis occurs within 12 hours postpartum to eliminate excess tis sue fluids during pregnancy o frequent urination in small amounts may be experie nced by some o others have difficulty of urination Nursing Care: Explain cause o f urinary changes Assist to promote voiding utilizing appropriate measures (enco uraging voiding, let client listen to sound of flowing water, etc.) 8. Gastroint estinal Changes - Change is more on the delay of bowel evacuation; constipation - Cause: decreased muscle tone lack of food intake dehydration fear of pain -Nur sing Care: encourage early ambulation increase fluids increase fibers in the die t 9. Vital Signs o Temperature: may increase because of dehydration on the first 24 hours pp. o CR 50 70 beats/min (bradycardia) is common for 6 - 8 days pp. o RR no change is expected o Weight = 10 12 lbs is expected to be immediately lost . This corresponds to the weight of the fetus, placenta, amniotic fluid and bloo d. Diaphoresis will contribute to further weight loss 10. Provision of Emotional Support Post-partum Psychological Phases 1. Taking in : First 1 2 days; mother focuses on herself and her experience 2. Taking hold: mother starts to assume he r role 3. Letting go Postpartum Blues overwhelming sadness that cannot be accoun ted for. Could be due to hormonal changes, fatigue or feelings of inadequacy. Nu rsing Care: Encourage verbalization; crying is therapeutic, explain that it is n ormal 11. Establish Successful Lactation

Physiology of Lactation: Estrogen & progesterone levels stimulates APG to produc e Prolactin acts on acinar cells to produce foremilk stored in collecting tubule s -> infant sucking stimulates PPG to produce oxytocin causes contraction of smo oth muscles of collecting tubules milk ejected forward (milk ejection reflex or let down reflex hindmilk is produced Implications of lactation: 1 Breast milk wi ll be produced postpartum 2 Lactation do not occur during pregnancy due to level s of estrogen and progesterone 3 Lactation suppressing agents are to be given im mediately after placental delivery to be effective 4 Oral contraceptives decreas e milk supply and are contraindicated in lactating mothers 5 Afterpains are felt more by breastfeeding mothers due to oxytocin production; have less lochia and rapid involution 12. Advantages of Breastfeeding Mother: faster involution less incidence of CA economical- time, effort, cost Infant: bonding with the mother p rotection against common illness less incidence of GI diseases always available 13. Health Teachings a. Hygiene Wash breasts daily No soap; No Alcohol for clean ing Handwashing Insert clean OS squares/ absorbent cloth in brassiere for breast discharges b. Feeding Techniques c. Nutrition: 3000 calories daily; 96 grams pr otein d. Contraindications: Drugs oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines. Certain disease conditions TB becau se of close contact during feeding (TB germs are not transmitted thru breast mil k) XIII. ASSOCIATED PROBLEMS 1. Engorgement breast becomes full, tense and hot w ith throbbing pain expected to occur on the 3rd post partum day accompanied by f ever (milk fever)last for 240 due to increased lymphatic and venous circulation Nursing care: o encourage breastfeeding o advise use of firm-supportive brassier e o (if not going to breastfeed apply cold compress; no massage; no breast pump; apply breast binder)

2. Sore Nipples Nursing care: encourage to continue BF expose nipples to air for 10 15 minutes after feeding (alternative) exposure to 20 watt bulb placed 12 18 inches away promotes vasodilation and therefore promote healing do not use plas tic liners use nipple shield 3. Mastitis inflammation of the breast Signs & Symptoms: pain, swelling, redness, lumps in the breasts, milk becomes sc anty Nursing Care: Ice compress Supportive brassiere , empty breast with pump Di scontinue BF in affected breast Apply warm dressing to increase drainage Adminis ter antibiotics as prescribed *** Postpartum Check-up: 6th week postpartum to as sess involution XIII. HIGH RISK PREGNANCY CONDITIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. Infections Bleed ing / Hemorrhage/ PIH Diabetes Mellitus Heart Disease Multiple Pregnancy Blood I ncompability Dystocia Induced Labor Instrumental Deliveries 1. INFECTIONS 1.1. Syphilis Cause: intercourse Treatment: x 10 days Untreated: Treponema pallidum - a spirochete transmitted thru sexual 2.4 4.8 million units of Penicillin (or 30 40 gms Erythrocin) readily cross placenta thus prevent cong enital syphilis Cause mid-trimester abortion Cause CNS lesions Can cause death T 1.2. TORCH test series Oxoplasmosis (protozoa) avoid eating uncooked meat and handling cat litter box Rx Zoster Immune Globulin ,Penicillin O thers: Syphilis, Varicella/ Shingles Hepatitis B; Hepatitis A; AIDS Ubella R Effect: if contracted early, slows down cell division during organogenesis causi ng congenital defects NB can carry and transmit the virus for about 12 24 months after birth

C H Ytomegalovirus erpes type 2 (CMV) (DNA virus) Group of maternal systemic infections that can cross the placenta or by ascendin g infection (after rupture of membranes) to the fetus. Infection early in pregna ncy may produce fetal deformities, whereas late infections may result in active systemic disease and/or CNS involvement causing severe neurological impairment o r death of newborn Sources/ Cause: 1. Endogenous/primary sources - normal bacter ial flora 2. Exogenous sources - hospital personnel, excessive obstetric manipul ations breaks in aseptic techniques, coitus late in pregnancy premature rupture of membranes General symptoms: malaise, anorexia, fever, chills and headache Man agement: Complete Bedrest Proper Nutrition Increased Fluid Intake Analgesics Ant ipyretics and antibiotics as ordered 1.3. Infection of the perineum Signs & Symp toms: pain, heat, feeling of pressure, inflammation of suture line with 1 2 stitc hes sloughed off temperature elevation Management: drain area & resuturing ; sit z bath & warm compress 1.4. Endometritis - An infection/inflammation of the lini ng of the uterus Signs & Symptoms: Abdominal tenderness painful to touch Dark br own Management: Oxytocin administration Fowlers position to drain out lochia Prev ent pooling of discharges 1.5. Thrombophlebitis -infection of the lining of a bl ood vessel with formation of clots, usual an extension of endometritis Signs & S ymptoms: o1 Pain o2 Stiffness and redness in the affected part of the leg o3 Leg begins to swell below the lesion because venous circulation has been blocked Fo ul smelling lochia Uterus not contracted and

o4 Skin is stretched to a point of shiny whiteness, called milk leg of Phlegmasi a alba dolens o5 Positive Homans sign: calf pain on dorsi-flexing the foot Specif ic Management: 1 bed rest with affected leg elevated 2 anticoagulants (e.g. Dicu marol or Heparin) to prevent formation or extension of a thrombus Side effect of Anticoagulant: hematuria, increased lochia Considerations: 1 discontinue breast feeding 2 monitor prothrombin time 3 have Protamine Sulfate at bedside to counte r act severe bleeding 4 analgesics are given but not ASPIRIN because it prevents prothrombin formation which may lead to hemorrhage 2. HEMMORRHAGE/ BLEEDING Def inition: blood loss more than 500 cc. ( normal blood loss 250- 350 cc) *** Leadi ng cause of maternal mortality associated with childbearing 2.1. Early Post-partum hemorrhage first 24 hrs after delivery 2.2. Late Postpart um Hemorrhage Early Post-partum hemorrhage Cause Uterine Atony uterus is not well contracted, relaxed or boggy (most frequent cause) Lacerations Hypofibrinogenemia Clotting d efect Management Bleeding in Pregnancy blood transfusion Late Postpartum Hemorrhage Retained Placental Fragments D & C (Dilatation and Curettage Predisposing factor: Overdistension of the uterus (multiparity, large babies, po lyhydramnios, multiple pregnancies) Cesarean Section Placental accidents (previa or abruptio) Prolonged and difficult labor Management: Massage first nursing act ion Ice compress Oxytocin administration Empty bladder Bimanual compression to e xplore retained placental fragments Hysterectomy (last alternative)

2.3. Hematoma - Due to injury to blood vessels in the perineum during delivery I ncidence: Commnon in precipitate delivery and those with perineal varicosities T reatment: 1 Ice Compress in first 24 hours 2 Oral Analgesics as prescribed 3 Sit e is incised and bleeding vessel ligated 2.4. Pregnancy Induced Hypertension (PI H) - A vascular disease of unknown cause - Occurs anytime after the 24th wk of g estation up to 2 wks PP - Develops during pregnancy and resolves during postpart um period Predisposing Factors: a. large fetus b. Older than 35, younger than 17 c. primigravida d. multiple pregnancy or H mole e. poor nutrition f. Hx of DM, renal and vascular disease g. Morbid obesity or weight less than 100 lb h. Famil y history Diagnosis: Roll over test : Assess the probability of developing toxem ia when done between the 28th and 32nd week of pregnancy. Procedure of Roll-over test: 1 Patient in lateral recumbent position for 15 minutes until BP Stable 2 Rolls over to supine position 3 BP taken at 1 minute and 5 minutes after roll ov er 4 Interpretation: If diastolic pressure increases 20 mmHg or more, patient is prone to Toxemia Types of Pregnancy Induced Hypertension (PIH): a. Transient hy pertension - without proteinuria or edema b. Pre-eclampsia, mild o BP of 140/90 mmHg or increase of 30/15mmHg o 2+ to 3+ proteinuria o begins past 20th week o s light generalized edema may be present, weight gain of 1- 5 lbs/wk c. Pre-eclamp sia, severe o BP of 150-160/100-110 mmHg o 4+ proteinuria (5 gm/L or more in 24 hrs o Headache and epigastric pain(aura to convulsions) o Oliguria of 400 ml or less in 24 hrs. (normal UO/day 1500 ml) o Cerebral or visual disturbances d. Ecl ampsia - Obstetrical Emergency o HPN o Proteinuria o Convulsions o Coma

Immediate Intervention for Eclampsia: a. Maintain IV line with large-bore needle b. Monitor fluid balance c. Minimize stimuli d. Have airway and oxygen availabl e e. Give medications as ordered (e.g Magnesium sulfate, Apresoline, Valium) f. Prepare for possible delivery of fetus g. Monitor fetal status h. Type and cross match for blood i. Postpartum- monitor vital signs and watch for seizure Manage ment for Eclampsia: a. Digitalis (with Heart Failure) Increase the force of cont raction of the heart decrease heart rate Nursing Considerations: Check CR prior to administration ( do not give if CR <60/min) b. Potassium supplements prevent arrhythmias c. Barbiturates sedation by CNS depression d. Analgesics; antihypert ensives, antibiotics, anticonvulsants, sedatives e. Magnesium Sulfate drug of ch oice Action: CNS depressant ; Vasodilator Antidote: Calcium Gluconate- given 10% IV to maintain Cardiac and vascular tone Earliest sign of MgSO4 toxicity disapp earance of knee jerk/patellar reflex Method of delivery preferably Vaginal but i f not possible CS Prognosis: the danger of convulsions is present until 48 hrs p ostpartum f. Cathartic cause shift of fluid from the extra cellular spaces into the intestines from where the fluid can be excreted Dosage: 10 gms initially eith er by slow IV push over 5 10 minutes or deep IM, 5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 ml D10W), Check 1 2 3 first the ff. before administra tion: Deep tendon reflexes are present Respiratory rate = 12 / min UO = at least 100 ml / 6 hrs. Nursing Intervention: a. Advised bedrest, left lateral b. Encourage a well-balan ced diet c. Weigh daily, keep daily log d. Education on self assessment e. Diver sion f. Family support

e. Post-delivery PIH o with Disseminated Intravascular Coagulation anticoagulant therapy o Monitor blood pressure for 48 hours Diagnosis: Roll over test : Asses s the probability of developing toxemia when done between the 28th and 32nd week of pregnancy. Procedure on Roll-over test: 5 Patient in lateral recumbent posit ion for 15 minutes until BP Stable 6 Rolls over to supine position 7 BP taken at 1 minute and 5 minutes after roll over 8 Interpretation: If diastolic pressure increases 20 mmHg or more, patient is prone to Toxemia Management: a. Digitalis (with Heart Failure) Increase the force of contraction of the heart decrease hea rt rate Nursing Considerations: Check CR prior to administration ( do not give i f CR <60/min) b. Potassium supplements prevent arrhythmias c. Barbiturates sedat ion by CNS depression d. Analgesics; antihypertensives, antibiotics, anticonvuls ants, sedatives e. Magnesium Sulfate drug of choice Action: CNS depressant ; Vas odilator Antidote: Calcium Gluconate- given 10% IV to maintain Cardiac and vascu lar tone Earliest sign of MgSO4 toxicity disappearance of knee jerk/patellar ref lex Method of delivery preferably Vaginal but if not possible CS Prognosis: the danger of convulsions is present until 48 hrs postpartum f. Cathartic cause shif t of fluid from the extracellular spaces into the intestines from where the flui d can be excreted Dosage: deep IM, ml D10W), May administer if : 4 Deep tendon r eflexes are present 5 Respiratory rate = 12 / min 6 UO = at least 100 ml / 6 hrs . 3. DIABETES MELLITUS a. b. c. Chronic hereditary disease characterized by mark ed hyperglycemia Due to lack or absence of insulin abnormalities in CHO, fat and protein metabolism Effects of pregnancy may develop abnormalities in glucose to lerance decreased renal threshold for sugar due to increased estrogen, inc. prod uction of adenocorticoids, Anterior Pituitary hormones, and thyroxin which affec t CHO concentration in blood (hyperglycemia) Rate of insulin secretion is increa sed but sensitivity of the pregnant body to insulin is decreased 10 gms initiall y either by slow IV push over 5 10 minutes or 5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 d.

Pregnancy Risks: 1 2 3 4 5 6 7 Toxemia Infection Hemorrhage Polyhydramnios Spontaneous abortion because of vasc ular complications which affect placental circulation Acidosis because of nausea and vomiting Dystocia due to large baby Diagnosis : Glucose Tolerance Test (GTT) Procedure for GTT: NPO after midnight 2 ml of 50% glucose / 3 kg of pre-pregnant body weight given IV (oral glucose not advisable due to decreased gastric motility and delayed absorption of sugar dur ing pregnancy) Interpretation of Results: a. If less than 100 mg% = normal b. If 100 120 mg% possible GDM c. If more than 120 mg% - overt gestational diabetes M anagement: a. b. c. d. Diet - highly individualized- adequate glucose intake (1,800 2200 calories) to p revent intrauterine growth retardation Insulin requirements individualized; incr eased during 2nd and 3rd trimester because of more pronounced effect of hormones Method of Delivery Cesarian Section Postpartum Period more difficult to control Blood Glucose because of hormonal changes Effect on Infant: a. b. c. d. e. f. g. h. Typically longer and weighs more due to: excessive supply of glucose from the mo ther Increased production of growth hormone from maternal pituitary gland Increa sed secretion of insulin from the fetal pancreas Increased action of adrenocorti cal hormone that favor the passage of glucose from mother to fetus congenital an omalies are often seen Cushingoid appearance (puffy, but limp and lethargic) Bor n premature more often RDS common Greater weight loss because of loss of extra f luid Prone to hypoglycemia (BG <30 mg%) Signs and symptoms of Diabetic Babies/ Hypoglemic Infant: a. Shrill, high pitche d cry b. Listlessness/jitteriness/tremors c. Lethargy/poor suck d. Apnea/cyanosi s e. Hypotonia; hypothermia ***Consequence of hypoglycemia: untreated hypos brai n damage and even death ***Management: feed with glucose water earlier than usual, or administer IV of g lucose

4. HEART DISEASE Classification: Class I Class II Class III activity causes fatigue Class IV -unable to carry on any activity with out experiencing discomfort Prognosis: Classes I & II normal pregnancy & deliver y Classes III & IV poor candidates no physical limitation slight limitation of physical activity Ordinary activity causes fatigue, palpitation, dyspnea, or angina moderate to marked limitation of physical activity; less than ordinary Signs & Symptoms: Heart murmur due to increased total cardiac volume Cardiac out put decreased nutritional and oxygen requirements not met Pulmonary edema Incomp lete emptying of the left side of the heart and HPN (moist cough in Gravidocardi acs danger sign) Congestion of liver and other organs due to inadequate venous r eturn increased venous pressure fluid escapes through the walls of engorged capi llaries and cause edema and ascites CHF is a high probability due to increased C O during pregnancy dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of nailbeds are obvious Management: (depends on cardiac functional capacity) a. b. c. d. e. f. g. h. i. j. Bed rest especially after 30 th week of gestation Diet gain enough (consider effect on cardiac workload) Medi cations: Digitalis, Iron preparations Avoid lithotomy position to avoid increase in venous return, place in semisitting position Not allowed to bear down; Birth is via low forceps or Cesarean section Anesthetic choice caudal anesthesia Ergo trate and other oxytoxics, scopolamine, diethylstilbestrol and oral contraceptiv es contraindicated can cause fluid retention and promote thromboembolism Most cr itical period: immediate postpartum period when 30 50% increased blood volume is reabsorbed back in 5 10 minutes and the weak heart needs to adjust 5. MULTIPLE PREGNANCY Risks: Increased Blood Loss Small for Gestational Age Infa nts Premature Birth Dystocia Management: a. Monitor FHT, VS, weight b. Cesarean Section c. Health Teaching on importance of regular pre-natal check-up visits d. Educate regarding proper nutrition and exercise 6. BLOOD INCOMPATIBILITY - An a ntigen-antibody reaction which causes excessive destruction of fetal red blood c ells

Mother Rh- negative BloodType O 7. DYSTOCIA Fetus Rh Positive (Father is homozygous or heterozygous Rh positive) Either Type A or B (From father) broad term for abnormal or difficult labor and delivery Uterine Inertia sluggishness of contractions Cause: Inappropriate use of analges ics Pelvic bone contraction Poor fetal position Overdistention due to multiparit y, multiple pregnancy, polyhydrmanios or excessively large baby Management: Stim ulation of labor by oxytocin administration or amniotomy 7.1. Precipitate Delive ry - labor and delivery that is completed in < 3 hours due to multiparity or fol lowing oxytocin administration or amniotomy Effects: Extensive lacerations Abrup tio placenta Hemorrhage due to sudden Release of pressure shock 7.2. Prolonged L abor - Usually occurs in primi gravida - Labor lasting more than 18 hrs and in m ultigravidas, more than 12 hours Effects: Maternal exhaustion Uterine atony Capu t succedaneum 7.3. Uterine Inversion turned inside out fundus is forced through the cervix so that the uterus is - Insertion of placenta at the fundus, so that as fetus is rapidly delivered, fundus is pulled down - Strong fundal push, attem pts to deliver the placenta before signs of separation -Management: Hysterectomy 8. INDUCED LABOR - Stages of labor and birth occurs due to chemical or mechanic al means which is usually performed to save the mothe or fetusr from complicatio ns which may cause death Indications: Maternal toxemia Placental accidents Prema ture Rupture Of Membrane Fetal: DM terminated at about 37 wks AOG if indicated B lood incompatibility Excessive size Postmaturity Prerequisites to Induce Labor : No Cephalo- Pelvic Dislocation Fetus is already viable >32 weeks AOG Single fet us in longitudinal lie and is engaged

Ripe cervix fully or partially effaced; Cervical Dilatation at least 1=2 cm Proc edure for Induced labor: 1. Oxytocin Administration; 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 gtts/min given initially no fetal distress in 30 min utes rate 16 -20 gts/min 2. Amniotomy done with Cervical Dilatation = 4 cm ; Che ck FHR and quality of amniotic fluid Nursing Considerations: Monitor uterine con tractions potential for rupture Monitor flow rate regularly Turn off IV with any abnormality in FHR or contractions Watch out for complications: HPN, Antidiures is Prostaglandin administration: Route: oral or IV (never IM causes irritation); effect is slower than oxytocin 9. INSTRUMENTAL DELIVERIES a. Forceps Delivery Use of metal instruments to extract the fetus from the birth canal, when at +3 / +4 and sagittal suture line is in an AP position in relation to the outlet (e. g. Simpson, Elliot, Piper for breech presentation) Purposes: shorten second stag e of labor because of fetal distress; maternal exhaustion; maternal disease card iac, pulmonary complication ineffective pushing due to anesthesia prevent excess ive pounding of fetal head against perineum (low forceps for prematures) poor ut erine contraction or rigid perineum Prerequisites: Pelvis adequate, no dispropor tion Fetal head is deeply engaged Cervix is completely dilated and effaced Membr anes have ruptured Vertical presentation has been established The rectum and bla dder are empty Anesthesia is given for sufficient perineal Relaxation and to pre vent pain Types: Low or Mid Forceps Delivery Complications: Forceps marks noticeable only for 24 48 hrs Bladder or rectal inj ury Facial paralysis Ptosis Seizures Epilepsy Cerebral Palsy a. Cesarean Section birth through a surgical incision on the abdomen Indications: o Cephalo-pelvic disproportion (CPD)

o o o o Types: Severe Toxemia Placental Accidents Fetal Distress Previous classic CS done prior to onset of labor pains; scheduled birth 1. Low Segment the method of choice. Incision is made in the lower uterine segme nt, which is the thinnest and most passive Part during active labor. Advantages: Minimal blood loss Incision is easier to repair Lower incidence of post partum infection No possibility of uterine rupture 2. Lower vertical incision recommend ed in: Bladder or lower uterine segment Adhesions from Previous operations Anter ior Placenta Previa Transverse lie Preoperative Care a. The patient is both a su rgical and an OB patient b. Check vital signs, uterine contractions, and FHR c. Physical examination; routine laboratory tests; blood typing and cross matching d. Abdomen is shaved from the level of the xiphoid process below the nipple line , extending out to the flanks on both sides up to the upper thirds of the thighs e. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site f. Preoperative medication is usually only atropine sul fate. No narcotics are given causes respiratory depression in the NB Postoperati ve Care a. b. c. d. e. f. Deep breathing, coughing exercises, turning from side to side Ambulate after 12 hours Monitor vital signs Watch for signs of hemorrhage inspect lochia; feel fun dus (if boggy, massage with proper abdominal splinting and give analgesics as or dered) Breastfeeding should be started 24 hrs after delivery Most common complic ation: Pelvic thrombosis 10. OTHER RISK FACTORS: 10.1. Age: - Maternal and infant mortality rates tend to be high in age below 15 and older than 40 years Adolescent pregnancy Most commo n problems: Toxemia Advanced age A precipitating factor in: Placental accidents

Iron-deficiency anemia Toxemia Uterine atony or inertia Varicosities; hemorrhoids Low birth weight babi es Chromosomal Abnormalities like Downs Syndrome / Trisomy 21 (associated with me nopause) 10.2. Parity first pregnancy is the period of high risk Multiparity G5 and above and age is over 40 10.3. Birth Interval 3 months from previous delivery or more than 5 years 10.4. Weight Pre-pregnant weight < 70 lbs or > 180 lbs Weight gain < 10 lbs LBW babies Weight gain > 30 lbs = sign of toxemia; DM; H-mole; polyhyd ramnios; multiple pregnancy 10.5. Height Short stature < 4 feet, 10 inches = con tracted pelvis or CPD XIV. MATERNAL COMPLICATIONS 1. Spontaneous Abortion Termin ation of pregnancy spontaneously at any time before the fetus has attained viabi lity Assessment: 1. Persistent uterine bleeding and cramplike pain 2. Laboratory finding negatively or weakly positive urine pregnancy test 3. Obtain history, i ncluding last menstrual period 2. Ectopic Pregnancy - Any gestation outside the uterine cavity Causes of Ectopic Pregnancy: a. Pregnancy Induce Hypertension b. Previous tubal surgery c. Congenital anomalies of the fallopian tubes Signs & Sy mptoms: 1 2 3 4 5 Severe, sharp, knife-like stabbing pain Rigid abdomen Positive Cullens sign (blui sh umbilicus) Excruciating pain on IE Signs of shock Management: Ruptured Ectopic Pregnancy is an emergency requiring immediate inter vention Salpingostomy if Fallopian tube can still be replaced and preserved,preg nancy is terminated Saphingectomy removal of FT and BT Nursing Interventions: 1 Help woman to combat shock 2 Elevate foot of the bed 3 Maintain body heat 4 Prep are for surgery 5 Monitor for shock preoperatively and postoperatively 6 Provide emotional support and expression of grief 7 Administer Rhogam to Rh negative wo men

8 Discharge teaching 3. Hydatidiform Mole (H-Mole) -Degenerative anomaly of chorionic villi Signs & S ymptoms: 1. Elevated hCG levels marked nausea & vomiting 2. Uterine size greater than expected for dates 3. No FHR 4. Minimal dark red/brown vaginal bleeding wi th passage of grapelike clusters 5. No fetus by ultrasound 6. Increased nausea a nd vomiting and associated with PIH Management: 1. Curettage to completely remov e all molar tissue that can become malignant 2. Pregnancy is discouraged for 1 y ear 3. hCG levels are monitored for 1 year (if continue to be elevated, may requ ire hysterectomy and chemotherapy) 4. Contraception discussed; IUD not used 4. I ncompetent Cervical Os One that dilates prematurely Chief cause of habitual abor tion ( 3 or more) Causes: 1 Congenital Developmental Factors 2 Endocrine factors 3 Trauma to the cervix Signs & Sypmtoms: 1 Presence of show and uterine contrac tions 2 Rupture of membranes, Painless cervical dilatation 5. Incompetent Cervix 6. Placenta Previa the placenta is the presenting part 1. First and second trim ester spotting 2. Third trimester bleeding that is sudden, profuse, painless 3. Ultrasonography classified by degree of obstruction Management: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Hospitalization, initially Bedrest side-lying or Trendelenberg position for at l east 72 hrs. Ultrasound to locate placenta No vaginal, rectal exam unless delive ry would not be a problem (if necessary must be done in OR under sterile conditi ons) Amniocentesis for lung maturity; monitor for changes in bleeding and fetal status Daily Hgb and Hct Two units of crossmatched blood available Monitor amoun t of blood loss Send home if bleeding ceases and pregnancy is maintained Limit a ctivity No douching, enemas, coitus Monitor fetal movement NST at least every 1 2 weeks Monitor complications

15 7. Abruptio Placenta Delivery by cesarean if evidence of fetal maturity, excessive bleeding, active l abor, other complications Signs & Symptoms: 1. Painful vaginal bleeding 2. Abdomen (uterus) is tender, pai nful, tense (couvelaire uterus) 3. Possible fetal distress 4. Contractions (Occu rrence increased with maternal HPN and cocaine abuse; sudden release of amniotic fluid; short cord; advanced age; multiparity; direct trauma; hypofibroginemia) Management: a. Monitor maternal and fetal progress b. Blood loss seen may not ma tch symptom c. Could have rapid fetal distress d. Prepare for immediate delivery e. Monitor for post partal complications Predisposing Factors: b. Disseminated intravascular coagulation c. Pulmonary emboli d. Infection e. Renal failure f. T ransfusion hepatitis Nursing Intervention: Bedrest Vital signs, FHT Monitor inta ke and output Seizure precautions Medications (Magnesium sulfate, Apresoline, Va lium) 8. Uterine Rupture -occurs when the uterus undergoes more straining than i t is capable of sustaining Cause: Scar from previous CS Unwise use of oxytocins Overdistention Faulty presentation Prolonged labor Signs & Sypmtoms: Sudden seve re pain Hemorrhage and clinical signs of shock Change in abdominal contour (two swelling on the abdomen due to retracted uterus and the extrauterine fetus) Mana gement: Hysterectomy 9. Amniotic Fluid Embolism (Obstetric Emergency) occurs whe n amniotic fluid is forced into an open maternal uterine flood sinus through som e defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli Signs and symptoms: Dramatic Sudden inability to breathe, sits u p, grasps chest and sharp chest pain Turns pale then bluish gray color

Death may occur in a few minutes Management: Emergency measures to maintain life : IV, oxygen, CPR Provide intensive care in the ICU Keep family informed Provide emotional support XVI. PREMATURE LABOR AND DELIVERY - Uterine contractions occu r before 38th week of gestation Cause: a. Pre-eclampsia b. Placenta Previa c. Ag e: Adolescent or 40 yrs old above primigravids Management: o If no bleeding; no CD, Good FHT, medication is given Ethyl alcohol (Ethanol) IV blocks release of O xytocin Vasodilan IV vasodilator Ritodrine muscle relaxant per orem Bricanyl bro nchodilator o If premature delivery is evident pain meds are kept to a minimum t o prevent respiratory depression Steroids (glucocrticoids) for maturation of fet al lung surfactant production o o o o Anesthesia preferred caudal, spinal or infiltration do not affect the infant Res piration forceps may be applied gently Cord is cut immediately prevents transfer of extra amounts of blood because prematures have difficulty excreting large am ounts of bilirubin that will come the extra blood.