Professional Documents
Culture Documents
Ignacio RN MAN
Primary Goal of MCHN: promotion and maintenance of optimal family health to ensure cycles of
optimal childbearing and childrearing
FSH >> Estrogen
LH >> Progesterone
Reproductive parts of the female
I.
External
a. Majora- external covering
b. Minora- inside the majora sensitive
i. Clitoris very sensitive; seat of sexual stimulation
1. Avoid stimulating the clitoris in patient with PIH >> seizure
2. Prepuce- protection of clitoris
c. Mons- cushioning
d. PBE: lower boundary of clitoris Fourchette- very thin layer of skin, when stretch
napupunit during delivery; portion before the perineum and anus
i. First degree perineal laceration- Fourchette- okay lang; suture for aesthetic
ii. 2nd perineum there are muscles and BV >> bleeding
iii. 3rd- anal sphincter
iv. 4rd degree entire rectum
v. 1 and 2 walang scar
vi. 4- at risk for incontinence of bowel
1. Res Ipsa Loquitor
vii. Para hindi mapunit Ritgens maneuver Perineal support\
viii. Episiotomy way to prevent extension to the sphincter
1. Medio-lateral malayo sa sphincter
ix. When will the MD cut: peak of a contraction- smooth muscle relaxation less
muscles
1. Pudendal nerve block or local infiltration no feeling in the perineum
a. Extended the pain free area including the perineum
x. Wound is too deep 3-4 week for complete healing
1. More risk for infection up to 4 week
xi. Only dorsal lithotomy position will always end up with a laceration
1. Perineal muscles will be fully relaxed
2. Why choose DL:
a. He can cut episiotomy
b. For forcep delivery open wide legs
c. For breech baby
II.
Internal
a. Vagina important passageway
i. Menstruation
ii. Penis
iii. Baby and birth product- placenta
iv. Why is capable of stretching? With rugae- muscle folds that stretches every
time child passess through
1. Rugae was flattened by the baby after the delivery
2. To restore the rugae Kegals exercise that uses the pubo-coccygeal
muscles or perineal muscles
a. As if trying to control mictuterine prolapseurition or urination contract for 4 counts, 1 count for relaxation
b. Done anytime anyday whenever she reminds to do it
c. For the vagina to restore after 6 weeks
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b. Pregnant: placenta
2. DM
3. Oral contraceptive use
a. Combination of hormone abnormal level of
hormones
4. Use of systemic antibiotics
a. Decrease normal flora due to antibiotics
Moniliasis or yeast infection
Can occur in mouth, vagina and diaper area of infant
White plaques on erythematous base if found in mouth
Looks like milk curd
Note: do not scrape away if in mouth magdudugo
Management
1. Systemic Fluconazole
a. Effective; not used in first trimester
teratogenic
2. Local Miconazole (Monistat)
a. Vaginal suppository
b. Best time at night before going to sleep
i. It will melt during the night > drug
stays in the vagina longer
ii. More discharge normal- drug has
taken effect
b. Uterus
i. Fundus- area that will contract; active segment of uterus
1. What hormones the uterus to contract
a. Oxytocin*** - oxytocin theory
b. Prostaglandin increased***- prostaglandin deprivation theory
i. Kapag nagddysmenorrhea take prostaglandin inhibiting
drugs
1. Take at the start of the pain
c. P + O sobrang sakit
d. Progesterone relaxation
e. Decrease progesterone >>> increase oxytocin >>> contraction
f. Braxton Hicks false labor >> decrease progesterone
i. Make her walk should stop
ii. Walking- intensify true labor
g. 2 weeks before EDC woman is releasing prostaglandin; semen
has prostaglandin
i. PROSTAGLANDIN CASCADE THEORY
h. Stretch theory not contract because of natural protection
i. Twins are always premature births
ii. Uterine rupture if there is obstruction in babys passage
1. How will you know:
i. Separates the active and passive normal physiologic
retraction ring
i. Palpable*
j. Bandls ring pathological ring
i. Visual or visible distinction
ii. Check the bladder bladder is distended
1. Empty bladder every two hours >> catheterize if
did not void after 4 hours
iii. CPD cephalopelvic disproportion
1. Call the MD
2. Anticipate CS or emergency deliver
f.
g.
h.
i.
j.
i.
c. Post menopause
6. Menstrual Cycle
a. Estrogen is the opposite of progesterone
b. Estrogen
i. Retains Na responsible for water retention; during
pregnancy, stimulates increase BV
ii. Decrease resistance in peripheral vessels vasodilator
iii. Increase fibrinogen or clotting
1. At risk for clot formed- lower legs
2. Change position every 2 hours, elevate the legs
iv. BBT- core body temperature, at rest
1. Decrease with estrogen
v. On mucus watery
vi. No effect on behavior
vii. Hypertrophy of the myometrium stickening of the
myometrium
c. Progesterone
i. Decrease sodium stimulate the RAA- increase
aldosterone anti diuretic hormone
ii. Vasoconstriction
iii. No effect on clotting
iv. Increase temperature
v. Mucus- sticky cervical closes
vi. Neuro endocrine effect on behavior of women
vii. Relaxation of myometrium
d. Myoma big tumor in uterus
e. PIH typical of imbalance of P and E
i. At risk of primipara
f. Ovulation drops then increase BBT
g. Extreme hormone changes separation of placenta
DEPRESSED post partum blues; menopause madrama.
h. Involved in the cycle
i. Hypothalamus gives GnRh
ii. Anterior Pituitary Gland for FSH and LH
1. FSH stimulates follicle maturation
a. Primordial to graffial
Edema- both
Hemorrhoids both
If suspected pregnancy count as a gravid
If not indicated that it is preterm, consider it as a full term
Ectopic and H mole count in gravida, not in para, consider in abortion
Abortion- termination of pregnancy until age of viability, any cause
Abnormal fertilization egg cell could be empty; sperm can still fertilize egg >> Hmole
With chorion source of HCG; no amnion
o Attachment of the uterus upper central; posterior in the uterus
Development
Chorion develops the primary villi/ chorionic villi >> release enzymes
to allow to open or tap maternal vessles >> LACUNAE (Blood Lake)
>> cotyledons are formed (16-20 cotyledons) >> placenta
Bigger placenta syphilis and placenta previa (poor vascularity)
6-8 days implantation
Placentation 3rd week nagfoform na
Completed on 3rd month
16 weeks functioning
o Kapag wala pang placenta endometrium from progesterone and estrogen
P and E corpus luteum
o Messenger of CV- HCG- to stimulate the CL to stay viable until the placenta is
working
o HCG prevents involution of corpus luteum
Present in maternal blood 8 to 10 days after fertilization (as soon as
implantation occurs)
Pregnancy Test first voided urine midstream clean catch urine
Doubles every 48 hours
o Ectopic pregnancy low levels of HCG
o Placenta provides P and E
3rd month HCG will decrease to its low level
HCG persistent level of HCG
Manifestation vomiting, diarrhea and diarrhea in the morning; and morning
sickness sick in the stomach in the morning only
NVD- hormonal in cause; no irritating foods, no spice and fats, bland
food
Morning sickness hypoglycemia and HCG
o Glucose is needed for brain development
o Hyperemesis Gravidarum
Too much HCG
Possible H mole
Hyperemesis after 1st trimester?
o Placenta ORGANS of the baby
Organ >> o2 >> umbilical vein
>> excretion of deoxygenated blood >> 1 umbilical arteries
o Endocrine hormones given by placenta
HCG
E and P
HPL fetal growth hormone
2 trimester
o Rapid growth of baby- 3rd trimester
Diabetes Mellitus
o Increase HCG, E and P, HPL insulin antagonist
^ insulin resistance
o HPL, E, P >> poor glucose metabolism because you dont use all insulin +
insulinase >> goes to baby >> immature pancreas >> fetal macrosomia >> PP =
hyperinsulinism
o
Amniocentesis aspiration of AF
Full term 800-1000ml
400 will remain; 600 is recycled
o Oligohydramnios less than 400ml
Kidney anomaly- small or missing kidney Downs Syndrome
o Polyhydramnios more than 200ml
May be the baby does not swallow
Tracheo-esophageal fistula
o pH = alkaline; 7-7.25
Litmus Paper Nitrazine test (LITHMUS)
ROM blue reaction- alkaline
o Early ROM early in labor; before transition
At risk for dry labor
Latent 0-4
Active- 4-7
Transition 7-10cm- normal ROM
o PROM premature baby; even before baby reaches term
Risk of infection
Treat with preventive AB: antimicrobials
If leaking continuous deliver the baby
If not delivered: chorioamnionitis infection of C and A
infects both mom and baby
o Color: slightly yellow because of vernix caseosa and shedding of the skin
Straw colored
If with cloudiness
Green meconium fetal distress and breech position(expected)
At risk for aspiration PNM suction very well
Portwine color abruptio placenta
o With characteristic odor but not foul
o Function
Maintains steady temperature warm
Kangaroo hold
Presumptive- subjective
o NV
o Urinary frequency
o Breast changes
o Quickening
o Skin changes
o Fatigue
o Amenorrhea
o GI symptoms
Probable objective signs
o Isthmus - Hegars
o Cervix- goodells
o Vagina chadwicks
Increase vascularity
o Ballottement internal
Gloved hand in the cervix 2 digits
Could also be a tumor
o Positive pregnancy test
o Braxton Hicks
o Enlargement of the abdomen
o
o
Positive
o Fetal heart sounds
o Outline
7 weeks sac
9th week- UTZ- fetus
o Movements felt by the examiners
Souffl high pitched sound that pass through a vessel
From UC Funic - FHT
Mother- uterine same with PR of mother
o FHT
Doppler 11 weeks/ 3 months
Stethoscope 16-20 weeks
120-160 bpm
o EDC
LMP; -3 +7 + 1; first day of LMP Naegels rule
No LMP- Bartholomews rule of 4
Xiphoid- 8th month- 9
Umbilicus- 5th month
Pubis
4 quadrants above and lower umbilicus
Each quadrant, one month
Engagement 9th month- lightening
Never accurate
Quickening
Primi 5 months
o Can give birth 2 weeks after or before
o +4(month) +20(date)
Multi- 4 months
o +5 (month) +4 (date)
o AOG
Mc Donalds Rule
Fundic Height in cm X 8; divide by 7 = AOG in weeks
Always the higher number
Normal weight gain in pregnancy
o 25 pounds or 12 kg = FT
o First trimester 1-3 months 1 lb per month
o 2nd-3rd trimester 1 lb per week
o Previous wt 137; previous 120
20 weeks gestation
Excessive: Normal should be only 11 lbs
Sample: LMP: November 30 Dec 3
o EDC: September 6, 2010
o LMP Spetember 25, 2009
AOG: if there is no date of visit consider date of exam
28 -29 weeks
Stages of intrauterine development
o Pre embryonic 1st 14 days after fertilization
50% are aborted blighted ovum
o Embryonic day 15 until about the 8 th week or until the embryo reaches a crown to
rump length of 3cm; organogenesis (most susceptible to teratogens)
First trimester
2nd week heart
Fetal
Cervix
Softens - Goodells
Mucus plug operculum
o Bloody show during labor
Vagina
Increased vascularity bluish blue Chadwicks
Decreased ph acidic
Increased secretion leucorrhea
Safe to have sex during pregnancy but not 2 weeks before EDC
No nipple stimulation and oral-genital sex
o Risk of air embolism if man blows air in the vagina
No douching with introduction of air air embolism
Cardiovascular
Expanded BV 30-50% - increased SV and CO
Cellular content just the same
Decreased HCT ( physiologic/ pseudoanemia and hemodilution)
Iron treatment increase RB 30%
No Iron treatment RBC 15%
Baby will store the iron first 6 months of life
Mother loses 75% of the iron to her baby
Iron supplement 2nd trimester
100% increase in previous dose
36mg/day OD
Best time to absorb needs acid
Pregnant: after meals to prevent gastric irritation to prevent
stimulation
WBC is increased, increased coagulation potential for thrombolytic
complication
Blood flow to the uterus and placenta improves when the patient is in left
side lying position >> Supine Hypotension Syndrome
Inferior - LE > baby
Superior sudden hypotension
CS: wedge the right side of shoulder
Bp decrease during the 2nd trimester, return to normal during the third
2nd trimester- vasodilation
If with sudden increase 20-24 weeks AOG PIH
Rate increases by 10 bpm 2nd trimester
Easy fatigability
Mother feels tired all the time
Increase workload for the heart
Swimming, walking anything that uses larger muscles weight
bearing exercises
o Regular hours: 40 minutes of active exercise - 10 minutes warm
up; 10 minutes cool down
o Last trimester 1 hour; divide.
Respiratory
Increased vascularity of mucuous membrane pharyngeal congestion
Diaphragm displaced causing DOB- raise HOB
Never lower down the head 7 month onwards
Best position: modified trendelenburg
Renal system
ABORTION
- Abortion termination before age of viability
- Early abortion before 16 weeks
- Late abortion between 16-24 weeks
- Spontaneous natural cause
- Complete abortion placenta and baby early abortion
- IUFD- late abortion missed abortion
- Late abortion
o Infection related to syphilis
- Rubella- 16 weeks only
- Causes
o Genetic -60%
o Endocrine factors
o Infection
Systemic disorders
PIH and DM poor placental perfusion late abortion
o Psychological factors
o Incompetent cervix most frequent cause of habitual abortion 3 or more
consecutive abortion; no intervening full term pregnancy
Defect in cervical os
Induced abortion illegal
Therapeutic pregnancy to save life of pregnancy ectopic pregnancy
Age of viability 20 -24 weeks
o In USA 24 weeks human; legally speaking, the fetus has a right
Incompetent cervix dilates without uterine contraction; cervix is very weak
o Causes or reasons
Congenital problem of cervix
Endocrine factor hormonal imbalance DM- abnormal hormonal release
Trauma to the cervix precipitate delivery too fast delivery
Kapag napunit na yung cervix, it cannot restore the cervix na nakasara
na
Abortion dilate the cervix
o Laminarium painless dilatation of the cervix
o To protect the cervix: cerclage
Temporary: Mc Donalds Procedure suturing is done about 12-14 weeks
AOG; temporary sutures to close the cervix
Permanent- Shirodkar procedure
CS birth from then on
NR: risk for infection - Mc Donalds
Types
o Spontaneous
Threatened abortion(spotting, painless, closed cervix)- baby is still intact;
uterus not in labor; should go immediately in the hospital for evaluation; see
MD ASAP
CBR without BP for 2 days
o If with bleeding maybe inevitable
Soft diet to prevent constipation straining on her stools
No invasive treatments or procedures
After two days, if fine- send home; home care restrictions in the
hospital should continue for 2 weeks
When will I be able to resume previous activities: 2 weeks
Sexual activity can be resumed after 2 weeks of last episode of
bleeding
Inevitable profuse bleeding, painful and cervix is dilated Imminent
abortion
With uterine contractions painful
Incomplete- placenta retained; fetus expelled
o Hysterometer
o Scraping is a blind procedure D and C
Sharp curette
Complete all products of conception expelled
Missed- fetus dies in the utero and is retained
o Laminarium piece of seaweed to dilate the cervix; dried
seaweed, sterilized, long, inserted in the cervical os and left
there for 24 hours
o
o
o
Unknown cause
Predisposing factors
o Oriental
o Clomiphene (Clomid) for fertility stimulates women to ovulate
o Age - <18 years old ; >35 years old
o CHON deficiency
First evidence: bleeding on second trimester
Signs and symptoms
o Dark red bleeding after the 12th week
o Disproportionate uterine size
o No fetal heart outline, quickening
o Hyperemesis
o Passage of vesicle
o Symptoms of PIH
o Anemia
o Ultrasound shows a snowstorm pattern
Intervention
o Curettage
o Hysterectomy
o Vacuum extraction
o Follow up protocol
Monitor HCG normal is zero; elevated- H mole
Schedule of titer testing regular, until 1 year
Magugulo ung MD kung mabuntis ulit
No pregnancy for 1 year
Oral contraception to prevent another pregnancy and to suppress
endogenous pituitary LH
HCG titers when elevated possible choriocarcinoma
Chest X ray common area of metastasis
Every month until HCG titers are negative then every 2 months for 1
year for surveillance and monitoring
Choriocarcinoma Methotrexate- Folic Acid antagonist
Give free folic acid diet- green leafy vegetable- do not give!
PLACENTA PREVIA
- Low implantation that it overlays some or all of the internal os
- Risk factors
o High altitude increase pressure
o Fraternal twins one will accommodate the upper part
o Multiparity
o Tumor
o Male baby
o Smoking
- Opening of the maternal venous sinuses in the placental site >> bleeding >> bright red
bleeding
- Uterus is not contracting >> no pain- painless
- Low lying- near the os
- Partial 50% of the cervix
- Complete total blockage
- Do not IE can cause rupture of the placenta
- UTZ- most practical way for placental attachment; non invasive
- Cesarean Section- birth
- Double set up
o CS and NSD
o Operating room
o 2 OB
- Risk of previa: hemorrhage or bleeding
- Lower segment does not contract bleeding always longitudinal muscles
o Transfusion of blood
- Baby will come out premature, but not in distress
ABRUPTIO PLACENTA
- Sudden separation of a normally implanted placenta
- Causes
o Short umbilical cord
o PIH ischemia to a part detachment
o Twins same placenta- identical
CS dapat
o Cocaine use vasoconstriction ischemia
o Smoking
o Trauma or accident domestic abuse
- Types:
o Concealed- hidden bleeding schultze
Couvalaier board like distended uterus due to covert bleeding
o Apparent seen duncans
Mix amniotic fluid >> portwine fluid
- Placenta separation
o Schultze- from inside to out shiny; fetal side exposed abruptio
o Duncan- from out to in maternal side dirty duncan
- Surgical intervention: CS premature and in distress
BLEEDING
- To warm client if she has lost considerable amount of blood- cover her with several layers
of blanket
- 1/3 of pads 10 ml
- Full soaked of pads 30ml
- NAME first in orientation
PIH
-
1g =1ml
Rh (-) - universal blood donor
Fetal compromise 2-3L
o In emergency, no need for order
Maternal compromise 4-6L
Maternal fetal compromise- 10L
Make sure IV fluid line big needle possible BT
NPO unless ordered possible surgery
Nursing assessments
o Blood loss with baseline assessment every 15 minutes PR- FHT
o I and O should have indwelling catheter- hourly assessment of UO
o LOC
o Emotional component of care
Acceptance of nursing care grieving acceptance
Stages
o Pre-ecclampsia- before the convulsion
Mild
140/90
+3- finger and face
24 hour urine collection = 2grams/L or less
Avoid strenuous activities
High CHON diet replace what is lost
Low sodium diet
Low fat diet
Slightly increase CHO- to spare CHON
Clinic visits low risk patient
o Every month 7
o Every 2 weeks- 8
o Every week 9
o At least twice the previous schedule if pre-ecclampsia
o Non compliance >> knowledge deficit
Severe
160/110 or higher
+4 - anasarca
24 hour urine collection = more than 2g/L
Can convulse anytime
Management
o Nursing diagnosis priority altered sensory and perceptual
function risk for convulsion
2- altered perfusion
o Quiet non stimulating environment
o Side rails restrictive and protective device
3rd rail restraint
4th full restraint
Both upper- protective
Sleeping- all rails up
Fully awake put down restraints
o CBR no BRP
Left side lying position
o Side rails up
o Limit visitors only during regular visiting hours lunch and
dinner
o Magnesium sulfate
Check DTR CNS depressant
RR
BP
FHR
UO per hour- decrease kidney that is no longer
functioning very well
To know enough dose of MgSO4 serum level 4-8mg/dl;
therapeutic level
Greater toxicity if continue giving respiratory
depression
Antidote: calcium gluconate
o Hydralazine titrated- lower BP >turn off