Professional Documents
Culture Documents
NURSING
• Duration – 4 to 7 days
ischemic phase (some sources group this with secretory phase) 27–28
MENSTRUAL CYCLE
Endometrial changes
Proliferative (Follicular) phase
depends on ESTROGEN produced by
GRANULOSA CELLS of the ovarian
follicles under the stimulation of FSH
Secretory (Luteal) phase
depends on PROGESTERONE produced
by the LUTEAL CELLS of the CORPUS
LUTEUM
Endometrial changes
Menstrual phase
depends on withdrawal of PROGESTERONE
assuming pregnancy does not occur
the entire endometrial zona functionalis layer
sheds
Understanding…
• Menstrual Cycle
• ..\..\..\OTHERS\Menstrual Cycle.s
NORMAL
Regular frequency
Normal amount and duration
MENORRHAGIA
Regular frequency
Increased in amount and duration
Cycle 21-35 days
HYPOMENORRHEA
Regular frequency
Decreased in amount and duration
Cycle 21-35 days
POLYMENORRHEA
Regular frequency
Normal amount and duration
Cycle<21 days
OLIGOMENORRHEA
Regular frequency
Normal amount and duration
Cycle>35 days
METRORRHAGIA
Menstrual bleeeding between
normal cycles
MENOMETRORRHAGIA
Irregular frequency
Increased in amount and duration
At what age does menstruation
typically begin?
• Average age of 12
• However, girls can begin menstruating as
early as 8 years of age or as late as 16 years
of age
• Women stop menstruating at menopause,
which occurs at about the age of 50
What are some of the symptoms
of a normal menstruation?
Moodiness
Trouble sleeping
Food cravings
Development of cramps
Bloating
Tenderness in the breasts
What symptoms may indicate a
need to contact my doctor about my
period?
You have not started menstruating by the age of
16
Your period stops suddenly
You are bleeding for more days than usual
You are bleeding more heavily than usual
What symptoms may indicate a
need to contact my doctor about my
period?
You have bleeding between periods that is
more than just a few drops
You suddenly feel sick after using tampons
You think you might be pregnant—for
example, you have had sex and your period is
at least five days late
FERTILIZATION
• Per ejaculation the average of 2.5 ml of
seminal fluid contains 50-200 million
spermatozoa per ml or 400 million per
ejaculation
• Occurs in the outer third of fallopian
tube
• Upon fertilization, the resulting structure
is called the ZYGOTE!
IMPLANTATION
• It takes 3-4 days for the ZYGOTE to journey to
the uterus(where implantation takes place) and
during such journey mitotic division occurs.
• Zygote free floats for the next 3-4 days, the
morula grows to become a BLASTOCYTES
with TROPOBLAST.
• Implantation occurs at high and posterior
portion of the uterus.
• Structure is called EMBRYO until 5-8 weeks
when it begin to be referred to as FETUS.
Fetus
PROBABLE SIGNS
POSITIVE SIGNS
DANGER SIGNS
PRESUMPTIVE SIGNS &
SYMPTOMS OF PREGNANCY:
• M – MORNING SICKNESS
• A- AMENORRHEA
• C-CHANGE IN BREAST
• F- FATIQUE
• L-LASSITUDE (fatigue)
• U-URINARY FREQUENCY
• Q-QUICKENING
• S-SKIN CHANGES
PROBABLE SIGNS:
• C – CHADWICKS
• H – HEGAR
• U- UTERINE ENLARGEMENT
• P- POSITIVE PREGNANCY TEST
• B – BALLOTEMENT
• O-OUTLINING OF FETAL BODY
• G- GOODELLS
• S- SOUFFLE CONTRACTION
AND BRAXTON HICKS
DANGER SIGNS
(1) Pelvic complaints
• Vaginal bleeding
– Which could signify spontaneous
abortion, placenta previa, or abruptio
placenta
• Vaginal leakage of fluid
– Which could signify rupture of
membranes
DANGER SIGNS
(2) Abdominal complaints
• Epigastric pain
– Occurs in women who have severe
preeclampsia
• Uterine cramping
– Occur in women undergoing preterm
labor
DANGER SIGNS
(2) Abdominal complaints
• Decreased fetal movements
– Occurs when the fetus is in
jeopardy
• Persistent vomiting
– In cases of hyperemesis
gravidarum
DANGER SIGNS
(3) Swelling
• Dizziness
• Mental confusion
• Visual disturbances
DANGER SIGNS
(4) Cerebral disturbances
• Persistent headache
• Occurs in women who have severe
preeclampsia
DANGER SIGNS
(5) Urinary complaints
• Painful urination
• Decreased urine output
• May signify cystitis or pyelonephritis
DANGER SIGNS
• A. Time Frame
1. First Visit:
– may be made as soon as woman suspects she
is pregnant; frequently after first missed
period.
Interventions
2. Subsequent Visits:
– Every month until the 8th month, every 2 weeks during
the 8th month, and weekly during the 9th month; more
frequent visits are scheduled if problems arise.
6. Gallbladder
emptying time
biliary cholesterol saturation inc risk
of gallstone formation
Alimentary Tract
7. Nausea and vomiting
onset: 4 – 8 weeks AOG lasting 14 – 16
weeks
caused by stomach tone and hCG
supportive treatment
frequent small meals
Respiratory system
TV, but all lung volumes decrease
Vital Capacity, but other lung
capacities remain unchanged
“dyspnea of pregnancy” Oxygen
consumption
Skin
1. Vascular changes Estrogen levels
Spider angioma face, thorax, and arms
Palmar erythema skin blood flow to the
hands
1. Striae gravidarum normal stretching of the
skin (pink purple silvery white)
2. Pigmentation changes MSH stimulated
by Estrogen and Progesterone
Urinary system
1. Kidney
size of renal pelvis physiologic
hydronephrosis
1. Ureter
Dilates hydroureter and urinary stasis
1. Consequence
risk pyelonephritis
Urinary system
GFR by 50%
creatinine clearance
creatinine and urea by 25%
Glucosuria common in normal
pregnancy risk of UTI
Proteinuria NOT normal in pregnancy
Cardiovascular system
By 20 weeks AOG CO by 35%
CO is dependent on maternal position
Optimal CO left lateral position (the
IVC is not compressed by the uterus)
Hematologic changes
Plasma volume 50% by term
RBC mass 30% by term
Physiologic anemia hemoglobin
value that results from a smaller in
RBC than in plasma volume
Hematologic changes
Pregnancy is a hypercoagulable state
clotting factors
Venous stasis thromboembolism
Vessel wall injury
Endocrine and Metabolic
changes
size of the thyroid gland
Thyroid-binding globulin (TBG)
from estrogen stimulation, T3 and T4
Note: Active unbound hormone forms
remain unchanged (free T3 andT4)
Musculo – skeletal changes
Relaxin increased ligamental
laxity, contributing to back pain
Shift in posture with exaggerated
lumbar lordosis
• CAUSES OF BLEEDING
DURING PREGNANCY
ABORTION
• The expulsion or removal of an embryo or
fetus from the uterus at a stage of pregnancy
when it is incapable of independent survival.
Missed Abortion
Threatened Abortion
Inevitable Abortion
Incomplete Abortion
Complete Abortion
Septic Abortion
MISSED ABORTION
• Diagnosed if there is
sonographic evidence of a
nonviable pregnancy without
bleeding or cramping
MISSED ABORTION
• Abnormal sonographic findings
• Management
– Scheduled suction
dilatation and
curettage (D&C)
THREATENED ABORTION
• Diagnostic criteria
– Expectant observation
– Bed rest
– SAVE ALL PADS
– NO COITUS UPTO 2 WEEKS AFTER
BLEEDING STOPPED
– Tocolytic agents
Tocolytic Agents
B – Adrenergic Agonist
Magnesium Sulfate
Prostaglandin Synthesis
Inhibitors
Calcium Channel
Blockers
INEVITALBE ABORTION
• diagnostic criteria
• Management
– HOSPITALIZATION
– D AND C
– OXYTOCIN AFTER D AND C
– EMOTIONAL SUPPORT
INCOMPLETE ABORTION
• diagnostic criteria
• Management
supportive
SEPTIC ABORTION
(+) fever
EXERCISE
MISSED
THREATENED
IMMINENT
INEVITABLE
INCOMPLETE
COMPLETE
SEPTIC
TYPES VariabilitBleeding Cervix BOW Tissue Febrile?
y passed?
MISSED NO NO CLOSED ( -) NO NO
• Before Rupture
abdominal pain & tenderness
amenorrhea
abnormal vaginal bleeding.
palpable pelvic mass
• Rupture
exacerbation of pain
• After Rupture
faintness / dizziness
referred shoulder pain
signs of shock
Diagnosis
Pelvic exam
Blood tests
Ultrasound
Culdocentesis
Laparoscopy
Medical Management
METHOTREXATE
A folic acid antagonist that is
metabolized in the liver and
excreted in the kidney
Salpingectomy
Salpingotomy
Salpingostomy
INCOMPETENT CERVIX
presence of uterine
contractions of sufficient
frequency and intensity to
effect progressive
effacement and dilation of
the cervix prior to term
gestation
ETIOLOGY
Hx of tears or lacerations in
cervix during childbirth
Forceful D&C
Exposure of mother to
diethylstilbestrol (DES)
Short cervix
Uterine abnormalities
Hx of early cervical dilation in
previous pregnancies
Cervical surgery
Signs and symptoms
Cerclage
Shirodkar method
McDonald procedure
McDonald cerclage
The Shirodkar
Gestational Trophoblastic
Neoplasia (GTN)
• Hydatidiform moles (H – mole)
Benign
Consists of a nonviable embryo which implants
and proliferates within the uterus
Presence of multiple grape – like vesicles filling
the uterus
• Gestational trophoblastic tumor (GTT)
Malignant
Complete hydatidiform mole
chromosomal problems
poor nutrition
problem w/ the ovaries
or the uterus
placental fragments
following miscarriage or
childbirth
Risk Factors
HCG levels
Histologic examination
Ultrasonography
(+) grapelike clusters
snowstorm pattern
Doppler ultrasonography
(−) fetal heart tones
Surgical Treatment
Hysterectomy
- ovaries usually are not
removed
Medical Treatment
Chemotherapeutic
agents
Weekly B-hCG titers
until they are negative for
3 weeks
Monthly titers until
they are negative for 12
months
Abruptio Placenta
• Placenta Previa…
Placenta Previa
• Abnormal
implantation of
placenta in lower
uterine segment
Risk factors
• Increased parity
• Advanced maternal age
• Past caesarian births
• Past uterine curettage
• Multiple gestations
Degrees of Placenta Previa
• Partial
– Placenta partially covers the
internal cervical os.
• Complete
– Placenta totally covers the cervical
os (caesarian birth necessary)
• Low-lying or marginal
– Placenta encroaches on margin of
internal cervical os.
Degrees of Placenta Previa
• Ultrasound
The passive lower uterine segment
stretches and thins, which alters
the lower uterine segment
implantation site of the placenta.
✦ HYDRALAZINE
✦ direct arteriolar vasodilator
✦ lowers the blood pressure
✦LABETOLOL
✦ non selective B blocker
✦ lowers the blood pressure
Magnesium Sulfate
✦ Prevention of convulsion
✦ Loading dose of 5g IV over 20
minutes
✦ Maintenance infusion at 2g/hr
✦ WOF clinical evidence of
magnesium toxicity
✦ Absence of toxicity is ensured as
long as DTR are obtainable
Magnesium Sulfate
DOSE EFFECT
paralysis
25 mg/dL Cardiac arrest
✦What is the antidote for
Magnesium toxicity?
What is the antidote for
Magnesium toxicity?
✦CALCIUM GLUCONATE
✦ 1g IV push
GRAVIDO CARDIACS
Severe or progressive
dyspnea
Paroxysmal nocturnal dyspnea
Progressive orthopnea
Syncope with exertion
Chest pain related to effort or
emotion
PRINCIPLES of Prenatal
Mgt
Fluid retention should
be avoided
Strenuous activity
should be avoided
Anemia should be
avoided
PRINCIPLES of Intrapartum
Mgt
Reassurance and sedation
Use of epidural analgesia
Left Lateral position
Forceps delivery
PRINCIPLES of Postpartum
Mgt
Close observation for
volume overload
A condition of abnormal
glucose metabolism that arises
during pregnancy
There is progressive
resistance to the efforts of
insulin
Diabetogenic effect of human
placental lactogen (hPL)
• Abnormal lie
– Transverse Lie
– Oblique Lie
(unstable lie)
FETAL PRESENTATION
• Presentation: Breech (Head is not
presenting part)
• Engagement
Refers to
presenting part
meeting pelvic floor
Occurs at 0 station
FETAL ATTITUDE
• Degree of flexion or
extension of fetal head
• Most common
subcategory: Vertex
– Complete flexion
– Chin against the chest
– Suboccipito-bregmatic
FETAL ATTITUDE
Normal Attitude:
Fetus is in full flexion
Every fetal joint is
flexed
Smallest fetal head
diameter:
Suboccipito-
bregmatic
Diameter is 9.5 cm.
FETAL ATTITUDE
• Sinciput Presentation
– Occipito-frontal
– Diameter is 12. 5 cm
FETAL ATTITUDE
Abnormal presentations: Extended
Attitude
General
• Abnormal Attitude: Fetal head is
extended
• Results in largest head diameter:
Occipito-mental (Brow)
• Diameter is 13.5 cm.
• May results in Failure to progress
FETAL ATTITUDE
• Face Presentation
– Submento-bregmatic
– Diameter is 9.5 cm
– Fetal head is hyper extended
CONTRACTION
• Frequency
• Duration
• Interval
Labor and Delivery
TRUE versus FALSE LABOR
TRUE FALSE
CONTRACTION • Regular • Irregular
• Increasing • No change in
frequency, duration, frequency,
and intensity duration, and
• Shortening of intensity
interval
1. Latent
2. Active
3. Transitional
Latent phase
Early part in labor characterized by:
Cervical dilatation of about 2-3 cm.
Mild, regular uterine contractions
Intervals of 5-10 minutes apart
Duration of 30 seconds
Mother becomes talkative, alert, excited
but in control
Active phase
Characterized by:
Cervical dilatation of 4-8 cm.
Frequency of 3-5 minutes
Rapid increase in duration of 45-60 seconds
Intensity becomes moderate
Mother less talkative, more anxious, restless
and fears losing control
Transition phase
Nursing Care and Management
during the First Stage of Labor
• Admit the patient
• Check the vital signs and FHT
• Physical examinations
• Perineal preparation
• Monitor and assess uterine contraction
• Avoid giving food
Nursing Care and Management
during the First Stage of Labor
• Encourage the parturient to void at least
within 2 hours.
• Woman during labor may ambulate
• Monitor danger signs
• Comfort measures
• Transfer to DR table
Second stage of labor
Duncan’s mechanism
20% of all deliveries
Begins at the edges / periphery
Nursing Care and Management
during the Third Stage of Labor
• Careful management of placental expulsion
• Watch for the signs of placental separation
• Deliver the placenta with Brandt Andrews
method
• Note the time the placenta is delivered
Nursing Care and Management
during the Third Stage of Labor
• Check for the completeness of the placenta
• Check and evaluate the blood pressure
• Administer oxytocin medicine after the placenta
has been completely expelled to prevent and
control hemorrhage
• Inspect perineum, vagina and cervix for
laceration, extension of the episiotomy or
hematomas.
Types of Laceration:
First degree
vaginal mucous membranes and the skin of the perineum
Second degree
levator ani and perineal body
Third degree
entire perineum and external sphincter of the rectum
Fourth degree
entire perineum, rectal sphincter and mucous membrane of
the rectum
Episiotomy
Nursing Care and Management
during the Third Stage of Labor
Carefully examine the uterine cavity manually
Assist the physician in episiorrhaphy
Note down vaginal packing if any:
the number of vaginal pack in placed
the time of removal (endorse) at least within 24-
48 hours.
Cleanse the vulva with sterile water.
Nursing Care and Management
during the Third Stage of Labor
• Apply perineal pad (application should be from
front to back).
• Lower legs of the woman simultaneously from the
stirrup to avoid injury to the uterine ligaments.
• Change the woman’s gown.
• Transfer the newly delivered mother to the ward.
Fourth stage of labor
BTL
Vasectomy
FOLK METHOD
Coitus interruptus
Withdrawal of the penis from the
vagina prior to ejaculation
Post coital douching
Water, vinegar, or other products
theoretically flush semen out of the
vagina. (spermicidal properties)
MALE CONDOM
A sheath that is placed on the
erect penis, preventing sperm
deposition into the vagina
Most widely used mechanical
contraception
MALE CONDOM
ADVANTAGES
Inexpensive, readily available,
and convenient
Provide major protection
against STD
One size fits all
DISADVANTAGES
Reduction of penile sensation
Sexual spontaneity is lost
Breakage is possible
Male controlled
FEMALE CONDOM
Contains polyurethane
pouch with two flexible rings
Blind pouch end fits over
the cervix, the open rests
outside the vagina on the
vulva
FEMALE CONDOM
FEMALE CONDOM
FEMALE CONDOM
Advantages
Provide protection against STD
Female controlled
Disadvantages
Bulkiness and awkwardness
Relatively expensive
VAGINAL DIAPHRAGM
A mechanical and spermicidal
barrier placed between the
posterior vaginal fornix and the
symphysis pubis
Containing spermicidal jelly
against the external cervical os
VAGINAL DIAPHRAGM
VAGINAL DIAPHRAGM
VAGINAL DIAPHRAGM
Placement may occur up to 2
hours before intercourse
Removal may be delayed for at
least 6 hours after ejaculation
Prevent some STD
Female controlled
DISADVANTAGES
Individual fitting
Placement must occur before
penile insertion
Risk for infection (TSS)
Reapplication of spermicide is
required for repeated
intercourse
CERVICAL CAP
A cup – like
diaphragm that
is placed tightly
over the cervix
without
spermicide
CERVICAL CAP
Insertion may occur from 30 minutes
to 48 hours before intercourse
Left in place for a prolonged period
May prevent some STD
Female controlled
DISADVANTAGE
Individualfitting is required
Many women cannot feel their
own cervix
VAGINAL
CONTRACEPTIVE
SPONGE
A spermicide – impregnated
polyurethane disk that is placed
in the proximal vagina
Spermicide is released when the
sponge is moistened and by the
action of the intercourse
VAGINAL
CONTRACEPTIVE
SPONGE
VAGINAL
CONTRACEPTIVE
SPONGE
Insertion may occur up to 24
hours before intercourse
Prevent some common STD
No need to re-apply spermicide
for repeated intercourse
Female controlled
Size fits all
VAGINAL
CONTRACEPTIVE
SPONGE
The sponge offers continuous
protection for up to 24 hours after
insertion, no matter how many
times you have sex.
Left in place for at least 6 hours
after intercourse
Sold over-the-counter, without a
prescription.
STEROID HORMONE –
BASED METHOD
ORAL AGENTS
Most commonly used methods of
reversible contraception
Estrogen – progestin combination
and Progestin only forms (mini-
pill)
ADVANTAGES
Contraceptive protection is
continuous when taken correctly
Contraceptive effect is readily
reversible when the pills are
discontinued
Non-contraceptive health
benefits
Non – contraceptive
health benefits
incidence of dysmenorrhea
decreased strength of menstrual
contractions from prostaglandin
suppression
incidence of benign breast
disease
decreased hormonal stimulation
DISADVANTAGE
Must be remembered and taken
daily
Intermenstrual bleeding and
headaches
Weight gain may be noted
ACHES
INTRAMUSCULAR
AGENT
Depomedroxyprogesterone
acetate (DMPA)
A progestin only formulation
DMPA
IM injections (150mg) must be
repeated every 3 months
Return of regular ovulation and
normal menses may be delayed up
to 12 months after discontinuation
(usually 6 months)
Irregular bleeding, fluid retention,
and weight gain
SUBCUTANEOUS DEPOT
METHODS
Norplant
L – norgestrel, which is contained in six
Silastic capsules
Implanted beneath the upper arm skin
Effective within 24 hours of insertion if
placed within 7 days of the onset of a
woman's menstruation
NORPLANT
NORPLANT
Replaced only every 5 years
SE: Irregular bleeding, fluid
retention, weight gain
IUD
Progesterone – impregnated
IUD
Copper IUD
Altered tubal motility for both
sperm and egg transport
IUD
When is an IUD inserted?
A. Before menstruation
B. During menstruation
C. After menstruation
D. Anytime the patient wants to
COMPLICATIONS
Uterine perforation
Septic abortion
PID
STERILIZATION
Men Vasectomy
Women Bilateral tubal
ligation
BTL
Minilaparotomy
Laparoscopy
MINILAPAROTOMY
Defined as a laparotomy with an
incision size smaller than 5 cm.
The operation can be performed
through a suprapubic incision in
the interval after pregnancy and
through a subumbilical incision
within the first 48 hours after
delivery.
LAPAROSCOPY
Small incisions
Rapid access to the oviducts
Rapid recovery
Limited ability to inspect
intraperitoneal organs
VASECTOMY
Objective criteria for a
successful vasectomy
is AZOSPERMIA on a
semen after 12 weeks
or 20 ejaculations
VASECTOMY
VASECTOMY
Make a small incisions, or cuts, in the
skin of the scrotum, which has been
numbed with a local anesthetic.
The vas is cut, and a small piece may
be removed.
The doctor ties the cut ends and sews
up the scrotal incision.
The entire procedure is then repeated
on the other side.
END
Thank you
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