MATERNAL AND CHILD HEALTH NURSING

Definition:
It involves care of the woman and family throughout pregnancy and childbirth and the health promotion and illness care for the children and families.

I. PHILOSOPHY OF MATERNAL AND CHILD NURSING

PHILOSOPHY OF MCN
1. 2. 3. 4. 5. 6. 7. 8. Family centered Community centered Research oriented Based on nursing theory Protects the rights of the family members Uses a high degree of independent functioning Places importance on health promotion Based on the belief that pregnancy or childhood illness are stressful because they are crises 9. Based on the belief that personal cultural and religious attitudes and beliefs influence the meaning of illness and its impact on the family 10.A challenging role for the nurse 11. A major factor in promoting high level wellness in families

PRINCIPLES OF MCN
1. The family is the basic unit of the society. It is the structural unit of the society. 2. Families represent racial, ethnic, cultural and socio-economic diversity. 3. Children grow both individually as a part of the family.

PHASES OF HEALTH CARE IN MCN

1. Health Promotion educating the client to be aware of healthy living through teaching and role modeling. 2. Health Restoration promptly diagnosing and treating illness using interventions that will turn client to wellness most rapidly. 3. Health Maintenance intervening to maintain health when risk of illness is present. 4. Health Rehabilitation - preventing further complications from an illness bringing ill client back to optimal state of wellness for helping the client accept inevitable death.

TRENDS IN MATERNAL AND CHILD HEALTH CARE

a) Families are smaller in size than in previous decades. b) Single parents are increasing in number. c) An increasing number of mothers work outside the home. d) Families are more mobile than previously. e) Abuse is a more common than ever before. f) Families are more health conscious than previously. g) Health care must respect cost containment.

II. NURSING CARE OF THE CHILD BEARING FAMILY

A. REVIEW OF THE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

MALE REPRODUCTIVE SYSTEM

1. EXTERNAL ORGANS
a. PENIS a. the male organ of copulation and urination b. has the following parts: i. shaft or body ii. glans penis the most sensitive part iii. prepuce a fo9ld of retractable skin covering the glans and which is removes during circumcision. iv. urethral meatus a slit-like opening located at the tips of the penis which serves as a passageway of both sperm and urine. b. SCROTUM is a sack-like structure containing the testes that hang behind the penis; keeps the sperm viable.

2. INTERNAL

ORGANS

a. TESTES
a. are oval shaped organs lying within the abdominal cavity in the early fetal life and descend to the scrotum after 34-38 weeks of gestation. b. male gonads (testicles) made up of loops of 900 coiled seminiferous tubules. c. principal function of the TESTES i. Hormone Production ii. Spermatogenesis production of sperm. b. EPIDIDYMIS is a long coiled tube, approximately 20 feet long at which the sperm travels for 12 20 days c. VAS DEFERENS the contractile power of this part of the duct system propels the spermatozoa to the urethra during ejaculation. d. EJACULATORY DUCT connects the seminal vesicle to the urethra

e. ACCESSORY GLANDS
1. SEMINAL VESICLE the pouch like organs that lie
behind the bladder and in front or the rectum. PROSTATE GLAND main responsible in the production of semen. a conical body lying below the bladder which secretes an alkaline fluid. size, a small gland located below the prostate that secretes an alkaline fluid which helps neutralize the acidic nature of the semen. SEMINAL FLUID/SEMEN are secretions from the seminal vesicle, prostate gland, Cowpers gland, ejaculatory duct and spermatozoa. can be assessed by examining the semen.

2.

3. COWPERS / BULBOURETHRAL GLAND pea

4.

5. MALE FERTILITY TEST/SPERM ANALYSIS

Characteristics of the semen which are analyzed for fertility are:

a. VOLUME- 2.5 6 ml (average is 3.5 ml) after 3 days abstention. b. SPERM COUNT normal sperm count is 120 million sperms per ml (1 teaspoon) after 3 days abstention. c. SPERM MOTILITY 3 Grading System 1. Grade 1 a. sperm tends to remain only in one spot exhibiting motion only of the tail 2. Grade 2 a. sperm move rapidly across microscopic field. 3. Grade 3 a. 60 % of sperm motility which is normal. d. SPERM MORPHOLOGY abnormal forms may be 2 headed sperms, abnormally shaped heads and abnormal tails.

FEMALE REPRODUCTIVE ORGAN

1. EXTERNAL ORGANS
a) MONS PUBIS/MONS VENERIS lies over the symphysis
pubis covered by the skin and at puber5ty by short hairs; protects the surrounding delicate tissues from trauma. b) LABIA MAJORA two folds of skin with fat underneath; contain Bartholins glands c) LABIA MINORA two thin folds of delicate tissues; form an upper fold encircling the clitoris (called the PREPUCE) and unite posteriorly (called the FOURCHETTE). d) GLANS CLITORIS small erectile structure at the anterior junction of the labia minora, which is comparable to the penis in its being sensitive. e) VESTIBULE narrow space seen when the labia minora are separated. f) URETHRAL MEATUS located on the anterior edge of the vestibule and surrounded by the SKENES GLAND or the paraurethral ducts which corresponds 6to the prostate in the male.

g) VAGINAL ORIFICE / INTROITUS external

opening of the vagina covered by a thin membrane (HYMEN) h) PERINEUM (vulva) area between the mons pubis, buttocks and the thigh externally. Perineal muscles are the bulbocavernosus, ischiocavernosus, sphincter of the urethra, superficial and deep transverse perineal muscles and the external sphincter of the anus.

2. INTERNAL ORGANS
a) VAGINA a 3-4 inches long dilatable canal located between
the bladder and the rectum; contains rugae; organ of copulation; passageway for menstrual discharges. b) BARTHOLINS GLAND these are located beneath the vestibule on either side of the vagina and open at the lateral border of the vagina. c) UTERUS hollow pear shaped fibromuscular organ, 3 inches long, 2 inches wide, 1 inch thick, and weighing 50 grams in a non-pr5egnant woman; organ of menstruation and implantation; nourishes the products of conception. d) FALLOPIAN TUBES/OVIDUCT/UTERINE TUBES 4 inches long from each side of the fundus; widest part (called AMPULLA) spreads into finger like projections; fertilization takes place in its outer third or outer half. e) OVARIES almond shaped, dull white sex glands near the fimbrae, kept in place by ligaments.

OTHER STRUCTURES:
Bones composing the bony pelvis:
1. 2. 3. 4. 5. Ilium Ischium Pubis Sacrum Coccyx

FOUR TYPES OF PELVIS

a) GYNECOID female pelvis shaped found in approximately 50 % of women; the anteroposterior and the transverse diameters are relatively equal, with straight pelvic sidewalls; the ischial spines are not usually prominent. Shape: transversely rounded b) ANDROID male pelvic shape; characterized by convergent sidewalls, prominent ischial spines, and a narrow pubic arch. Shape: wedge shape or angulated c) ANTHROPOID heart-shaped pelvic characterized by the anteroposterior diameter being greater than the transverse diameter. Shape: heart or oval shape d) PLATYPELLOID is characterized by the transverse diameter being greater than the anteroposterior diameter, with wide sidewalls. Shape: flat in shape but with oval inlet.

CONJUGATES found in pelvic inlet

a) OBSTETRIC CONJUGATE shortest
anteroposterior diameter between the sacral promontory and the symphysis pubis; it can only be measured radio graphically; 11 cm b) DIAGONAL CONJUGATE the distance between the sacral promontory of the sacrum and the lower margin of the symphysis pubis; 12.5 cm c) TRUE CONJUGATE conjugate vera; distance between the sacral promontory of the sacrum to the upper margin of the symphysis pubis; 11.5 cm

OTHER RELATED STRUCTURES LIGAMENTS OF THE UTERUS

1. BROAD LIGAMENTS extend from the lateral margin of the
uterus to the pelvis; the uterine vessels and the uterus are contained within the base of the broad ligaments. 2. ROUND LIGAMENT connective tissue that extend from the lateral uterine fundus to the upper portion of the labia majora. 3. UTEROSACRAL LIGAMENT connective tissue that extends from the inferior and posterior portion of the uterus and attach to the fascia over the sacrum. 4. CARDINAL LIGAMENTS connective tissue located at the base of the broad ligament; provide most of the support to the uterus.

B. COMPONENTS OF HUMAN SEXUALITY

PUBERTY
encompasses the physiologic changes leading to the development of adult reproductive capacity; the process includes maturation of the hypothalamus, pituitary glands and gonads.

ADOLESCENCE
- encompasses the physiologic, social and cognitive changes leading to the development of adult identity.

THELARCHE
- budding of the breast.

ADRENARCHE
- development of axillary and pubic hair

SEX
- act of copulation, coitus

SEXUALITY
- the sum of the physical, functional and psychological attributes that are expressed by ones gender identity and sexual behavior, whether or not related to the sex organs or to procreation.

BIOLOGIC GENDER
- term used to denote a persons chromosomal sex.

GENDER/SEXUAL IDENTITY
- is the inner sense a person has of being male or female.

GENDER ROLE
- the expression of a persons gender identity; the image that a person presents to both himself/herself and others demonstrating maleness/femaleness.

SEXUAL DEVELOPMENT (HUMAN SEXUAL CYCLE)

1. EXCITEMENT
vaginal lubrication and vasocongestion of the genitalia penile erection due to vasocongestion physical and psychological stimulus stimulation of the penis arterial dilation and venous constriction in the genital area

2. PLATEAU
Formation of orgasmic platform due to prominent vasocongestion Generalized muscle tension, hyperventilation, increase BP, tachycardia in the late plateau phase Reached first before orgasm WOMEN formation of orgasmic platform, increased nipple engorgement MEN full distension of the penis; pre-ejaculatory phase of life spermatozoa

3. ORGASM
Strong rhythmic contractions of vagina and uterus In males, vas deferens, seminal vesicle, ejaculatory duct and prostate contract 3-4 times over a few seconds causing pooling of seminal fluid in the prostatic urethra Rhythmic contractions in males occur at 0.8 seconds Discharge of accumulated sexual tension Shortest stage

4. RESOLUTION
Rapid decline in pelvic vasocongestion External and internal organs return to an unaroused state Generally takes 30 minutes

5. REFRACTORY PHASE
Only in males, the period during which no amount of stimulation can cause another erection Not manifested in females because females are multi-orgasmic This phase lengthens with age

TANNER STAGING
M - utual C - onsent F - oreplay A - rousal P - lateau C - oitus O - rgasm R - esolution R - efractory

SEXUAL STIMULATION
1. 2. physical/Foreplay or Actual Psychological Stimulation

C. MENSTRUAL CYCLE AND FAMILY PLANNING METHODS

HORMONES ENVOLVED
GnRH - Gonadotropin Releasing Hormone (APG- Anterior Pituitary Gland)
- initiates the menstrual cycle.

FSH (Follicle Stimulating Hormone)

- stimulates the development of the primordial follicle (immature follicle) into Graafian follicle (mature) follicles

LH- Luteinizing Hormone (ICSH)

- stimulates ovulation and development of corpus luteum (yellow body); corpus albican (white body) - thickens the endometrium

ESTROGEN
- hormone of women - secondary sex characteristics - female cervical mucus

- maintains the endometrium - stimulates uttering contraction - inhibits the production of FSH - causes hypertrophy of myometrium - stimulates the development of ductile structures of the breast - increases the pH and the quantity of the cervical mucus

PROGESTERONE
- hormone of mothers - prepares the endometrium - relaxes the myometrium - increases the basal body temperature - infertile mucus - maintains pregnancy - increases the fibrinogen, hematocrit and hemoglobin - Inhibits the production of LH - transport to the fertilized ovum (zygote) into the uterus - increase uterine motility

PHASES OF THE MENSTRUAL CYCLE

A. MENSTRUAL PHASE (1-5 DAYS)

Extends from the first day of menstruation to the fifth day The first day of menses is considered the first day of the cycle Characterized by desquamation of the superficial layers of the endometrium caused by corpus luteum regression and the consequent withdrawal of the progesterone and estrogen About 2/3 of endometrium is shed off every menstrual period

B. PROLIFERATIVE PHASE (6-14 DAYS)

From the 6th to day 15 of a 28 day cycle The very low estrogen level stimulates the hypothalamus to secrete follicle stimulating hormone releasing factor (FSHRH). In a 28 day cycle, estrogen level is lowest on the 3rd day before ovulation FSHRF stimulates the anterior pituitary gland to secrete follicle stimulating hormone FSH stimulates the primordial follicle to develop into graafian follicle As the graafian follicle develops, it produces large amount of estrogen, while at the same time an ovum is maturing inside Estrogen promotes regeneration and proliferation of the cells of endometrium and formation of new capillaries Also called: ESTROGENIC PHASE FOLLICULAR PHASE POST-MENSTRUAL PHASE

C. SECRETORY PHASE (15-23 DAYS)

From the 14th day to the 24th day or from the day of ovulation until about 3-4 days before the next menstruation The rising pituitary gland to secrete FSH, the very low progesterone level triggers the hypothalamus to release LHRF LHRF stimulates the anterior pituitary gland to secrete Luteinizing Hormone (LH) LH promotes ovulation. As the graafian follicles becomes overly distended, with follicle fluid, it finally ruptures releasing the mature ovum After ovulation, the graafian follicle will be called corpus luteum The corpus luteum produce large amount of progesterone Progesterone is said to cause opening of the uterus: as this hormone further decreases the vascularity of endometrium and stimulates endometrial glands to secrete mucin, nutrient and glycogen. As a result, the lining of the uterus becomes soft, spongy and edematous, this occurs in preparation for implantation and pregnancy

The corpus luteum has an average lifespan of about 8 days. If no fertilization occurs at this time, it regresses resulting in withdrawal of estrogen and progesterone. If no fertilization occurs, the fertilized ovum or zygote implant between 7-10 days after fertilization, the time when the corpus luteum is suppose to atrophy The secretion of human chorionic gonadotropin (HCG) by the trophoblast cells of the zygote will prolong the life of the corpus luteum. The corpus luteum then will continue to produce estrogen and progesterone until the third time or 12th week of pregnancy when the placenta is mature enough to take over the function of hormone production The corpus luteum having accomplished its role after 12 weeks will now atrophy The secretory phase is the endometrial phase that proceeds nidation or implantation Also called: PROGESTATIONAL PHASE OVULATORY PHASE LUTEAL PHASE

D. ISCHEMIC/PREMENSTRUAL PHASE (24-28 DAYS)

As mentioned earlier, the life of the corpus luteum is only 810 days, if fertilization does not take place, the corpus luteum shrivels Degeneration of the corpus luteum in withdrawal of estrogen and progesterone Absence of progesterone results in arteriolar spasm and vasoconstriction. Blood supply, then, to endometrium is cut off. Lack of blood vessels and endometrial sloughing The desquamated cells are discharge, thus menstruation occurs The onset of menstruation signals the beginning of another menstrual cycle Also called: POST-OVULATORY PHASE PREMENSTRUAL PERIOD

FAMILY PLANNING METHOD

A. Natural Family Planning Methods

1. Techniques including checking the body temperature or cervical mucus daily and recording menstrual cycles on a calendar to determine the days when the body is most fertile. 2. Effectiveness 81% 3. Accepted by religions and inexpensive.

B. Artificial Family Planning Methods

1. Spermicides
Chemicals in the form of foams, creams, jellies or suppositories that are inserted into the vagina to kill the sperm before they can enter the uterus. Typical effectiveness 70% Available over the counter and can be used with other methods to improve effectiveness

2. Condoms
Male condom is a sheath of latex or animal tissue placed on erect penis Female condom is a plastic sac with a ring on each end inserted into the vagina. Both may be used with a spermicide

3. Birth Control Pills

Prescription drugs that contains the female hormones (estrogen). One pill is taken daily to prevent ovaries from releasing eggs and thickens the cervical mucus to prevent sperm reaching egg.

4. Diaphragm
Shallow latex cup with flexible rim inserted into vagina over cervix to prevent sperm from entering uterus with spermicide.

5. Intrauterine Device
small device inserted by a health care professional into the uterus and prevents eggs from being fertilized and implanting in uterus.

6. Cervical Cap
Thimble-shaped latex cap inserted into a vagina over cervix to prevent sperm from entering uterus used with spermicide.

7. Hormonal Injection (Depo-Provera)

injection given by a health care professional in the arm or buttocks every 12 weeks to prevent ovaries from releasing an egg of thickened cervical mucus to keep sperm from reaching the egg.

8. Hormonal Implant (Norplant)

Six small capsules inserted by a health care professional under the skin of the upper arm that deliver small amounts of hormone to prevent ovaries from releasing eggs.

C. Permanent Methods of Reproductive Life Planning

1. Tubal Ligation
surgical procedure to permanently block womans fallopian tubes to prevent eggs from reaching by sperm.

2. Vasectomy
surgical procedure to permanently block the males vas deferens to prevent sperm from reaching eggs.

DIFFERENT MENSTRUAL CONCERNS

AMENORRHEA absence of menses DYSMENORRHEA painful, difficult menstruation

METRORRHAGIA bleeding in between menses

MENORRHAGIA excessive bleeding during regular menstruation MENOPAUSE cessation of menstruation OLIGOMENORRHEA markedly diminished menstrual flow, nearing amenorrhea POLYMENORRHEA frequent menstruation occurring at intervals of less than 3 weeks

OVULATION monthly growth and release of mature, non-fertilized ovum; usually occur in the middle of the menstrual cycle; the interval between ovulation and menstruation is approximately 14 days.

D. CONCEPTION AND FETAL DEVELOPMENT

Terminologies:

Fertilization- union of the sperm and the mature ovum in the outer third or outer half of the fallopian Tube.

Implantation/ Nidation immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place.

Zonapellucida- inner layer of zygote

The thick, transparent, non-cellular membrane that encloses the mammalian ovum. It is secreted by the ovum during its development in the ovary and is retained until nnear the time of implantation.

Corona Radiata- outer layer of zygote

An aggregate of cells that surrounds the zona pellucid of the ovum

Morula- a solid, spherical mass od cells resulting from the cleavage of the
fertilized ovum in the early stages of embryonic development - Represents an intermediate stage between the zygote and the blastocyst.

Blastocyst- corpus luteum - The embryonic form that follows the morula in human development - A spheric mass of cells having a central, fluid filled cavity(blastocele) surrounded by two layers of cells. - The outer layer (trophoblast) later forms the placenta, the inner layer (embryoblast) later forms the embryo.

Trophoblast or Trophectoderm
- Fingerlike projections form around the blastocyst and this trophoblast are the ones which will implant high on the anterior or posterior surface of the uterus. - It is the layer of tissue that forms the wall of the blastocyst in the uterine wall and in supplying nutrients to the embryo. - At implantation the cells differentiate into two layers, the inner cytotrophoblast, which forms the chorion and the syncitiotrophoblast, which developd into the outer layer of the placenta.

Terms to Denote Fetal Growth

Ovum- female germ cell extruded from the ovary at ovulation. Zygote- the developing ovum from the time it is fertilized until, as
blastocyst, it is implanted in the Uterus.

Embryo (chick)- the stage of prenatal development between the time of

implantation of the fertilized ovum about 2 weeks after conception until the end of the 7th or 8th week. -The period is characterized by rapid growth, differentiation of the major organ systems, and development of the main external features.

Fetus- the human being in utero after the embryonic period and the
beginning of the development of the major structural features, usually from the 8th week fertilization until birth.

Conceptus- the product of conception; the fertilized ovum and its

enclosing membranes at all stages of intrauterine development, from implantation to birth.

STAGES OF HUMAN PRENATAL DEVELOPMENT

Zygote first 12-14 days

Embryo- from 15th day up to the 8th week

Fetus- from 8th week up to time of birth

DEVELOPMENT OF EMBRYONIC AND FETAL STRUCTURES

MILESTONES OF FETAL GROWTH AND DEVELOPMENT

First Lunar Month

Germ layers differentiate by the 2nd week Fetal membranes appear by the 2nd week Nervous system develops rapidly by the 3rd week FHR begins to form as early as the 16th day of life. Digestive and respiratory tract exist as a single tube until 3rd week of life when they start to separate

Second Lunar Month

All vital organs are formed by the 3rd week; placenta fully developed Sex organs are formed by the 8th week Meconium are formed in the intestines by the 5th 8th week

Third Lunar Month

Kidneys are able to function- urine is formed by the 12th week. Buds of milk teeth form Beginning of bone ossification. Fetal swallows amniotic fluid

Fourth Lunar Month

LANUGO appears fine tiny hairs Buds of permanent teeth form. FHR maybe audible with Fetoscope .

Fifth Lunar Month

VERNIX CASEOSA appears Lanugo covers entire body QUICKENING felt.

Sixth Lunar Month

Skin markedly wrinkled Attains proportions of full-termed baby

Seventh Lunar Month

Alveoli begins to form (28 weeks AOG)

Eight Lunar Month

FETUS is viable LANUGO begins to disappear Nails extend to end of fingers Subcutaneous fat deposition begins

Ninth Lunar month

LANUGO and VERNIX CASEOSA disappear Amniotic fluid volume somewhat decreases

Tenth lunar month

All characteristics of the normal newborn

ASSESMENT OF FETAL GROWTH DEVELOPMENT

1. Age of gestation (AOG)

A. NAGALES RULE
Calculation of expected date of confinement (EDC) Count back 3 months from the first day of the LMP then add 7days. Substitute number for month for easy computation For example: September 0 = 9 0 mo 0 (JUNE) = 0 + 7 days 10 = EDC JUNE 10

B. MCDONALDS METHOD
Determine AOG by measuring from the fundus to the symphysis pubis (in cm) then divide by 4-AOG in months Example = Fundic height of 10cm / 4=4 months AOG= 10 weeks AOG

2. Measuring fundic Height

A. BARTHOLOMEWS RULE
Estimate AOG by the relative position of the uterus in the abdominal cavity By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis On the 5th lunar month the fundus is at the level of the umbilicus On the 9th month, the fundus id below the xiphoid process

B. HAASES RULE
Determines the length of the fetus in centimeters During the first half of pregnancy, square the number if the month (e.g. 1st lunar month 1x1 = 1cm) During the second half of the pregnancy, multiply the month by 5 (e.g. 6th lunar month: 6x5 = 30 cm)

C. JOHNSONS RULE
Estimates the weight of the fetus in GRAMS FORMULA: fundic height in cm. n x k K is a constant, it is always 155 n is = 12(if fetus is engaged) = 11(if fetus is not yet engaged)

FOCUS OF FETAL DEVELOPMENT

1ST Trimester Period of organogenesis. 2nd Trimester Period of continued fetal growth and development, rapid increase in fetal length.

3rd Trimester Period of most rapid growth and development because of rapid deposition of subcutaneous fat

TERATOGENS

Maternal Risk factors:

1. German measles (Rubella)

The risk of maternal & fetal or congenital infection is related to the trimester of placental infection Maternal infection during the first 8 weeks of gestation carries the highest rate of maternal & fetal infection

2. Sexually transmitted diseases

Syphilis
My cross the placenta Usually leads to spontaneous abortions Incidence & mental abnormality

Genital herpes
May cross placenta Fetus contaminated after membranes rupture or with vaginal delivery

Gonorrhea
The fetus is contaminated at the time of delivery May result to postpartum infection Pneumonia Sepsis

Human Immunodeficiency Virus (HIV) The virus is transmitted through blood, blood products, & other bodily fluids such as urine, semen & vaginal fluid.

3. Substance Abuse
Many substances cross the placenta; therefore no drugs, including over the counter medications should be taken unless prescribed by the physician Substances commonly abused include alcohol, cocaine, crack, marijuana, amphetamines, barbiturates, & heroin Substances abuse threatens normal fetal growth & successful term completion of the pregnancy Substance abuse places the pregnancy at risk for fetal growth retardation abruption placenta, & fetal bradycardia. Physical signs of drug abuse include dilated or constricted pupils, fatigue, trace marks, skin abscesses, and inflamed nasal mucosa. Alcohol during pregnancy may lead to fetal alcohol syndrome & can cause jitteriness, physical abnormalities, congenital anomalies, & growth deficits Smoking causes vasoconstriction leading to low birth weight babies, a higher incidence of birth defects & stillbirths

Drinking in moderation is not contra indicated but when excessive can cause transient respiratory depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories. Drugs dangerous to fetus especially during the first trimester when the placental barrier is till incomplete and the different body organs are developing Thalidomide causes Amelia or phocomelia Steroids can cause cleft palate and even abortion Iodine causes enlargement of the fetal thyroid gland, leading to tracheal ecompressin and dyspnea at birth Vitamin k causes hemolysis and hyperbilirubinemia ASA and Phenobarbital causes bleeding disorders. Streptomycin and Quinine cause damage to the 8th cranial nerve Tetracycline cause staining and tooth enamel

ADOLESCENT PREGNANCY

Factors that result in adolescent pregnancy include:

a.) The early onset of menarche b.) changing sexual behaviors in this age group c.) faulty family development d.) poverty e.) lack of knowledge of reproduction & birth control

The major concerns related t adolescent pregnancy includes:

1. Poor nutritional status 2. Emotional and behavioral difficulties 3. Lack of support systems 4. Increased risk of still birth 5. Increased risk of maternal complications: such as hypertension, anemia, prolonge labor & infections 6. Low birth weight newborn infants 7. Fetal mortality 8. cephalopelvic disproportion

CAPACITATION property of the sperm cell to transform for fertilizing ovum Hyalorunidase dissolves the corona radiate ACROSIN sperm cell enters the ovum and nucleus 2 sex cells fertilization

FETAL CIRCULATION

Fetal Circulation
O2 unbilical vein ductusvenosus Inferior vena cava atrum forameovale atrium ventricle ascending Aorta superior vena cava RAtrum pulmonary artery ductusarteriosisus aorta hypograstie artery placenta

STRUCTURE 1. Placenta 2. umbilical arteries 3. umbilical veins 4. foramen ovale

LOCATION attached to interus two arteries in a cord one vein in cord opening in interatrial septum

5. ductusvenosus

6. ductusarteriosus

accessory vein connecting Umbilical vein into fetal Liver & IVC connection between
Fetal lungs & aorta & directly into aorta

FUNCTION gas exchange during fetal life carry in oxygenated Blood from fetus carry oxygenated Blood in fetus shunt blood from rhatrium supply blood to liver

shunting larger portion blood away from lungs

AFTER BIRTH* 1. FO connects atrium L+R 2. U.U O2 blood fr. Placenta 3. UA - unoxygenated blood Fr. Fetus to placenta 4. DV O2 blood from UV to IVC 5. DA O2 blood from PA to aorta fossa ovalis ligamentumteres umbilical ligament

ligamentumvenosum ligamentumarteriosum

Medication

OXYTOTIC MED.
Description: smooth muscle stimulant promotes contraction to uterus. Uses: use to induce labor to promote milk let down A/E: contradiction: initially hypotension leading to rebound HPN

ERGOT ALKALOIDS
Ergonovine (ergotrate) Methylergovine (methergine) -after delivery placenta Description: Forces & frequency uterine contraction Use: it prevents post partrum hemorrhage A/E: HPN / bradycardia Input: monitor BP & HR

UTERINE RELAXANT (tocolytics)

Ritodrvine (yutopar) Terbutaline sulfate Description: it relaxes uteine muscles Use: Tx for preferm labor A/E: maternal tachycardia Implication: monitor HR mother if 1306pm stop ritodrine

PROSTAGLANDINS
Misoprostol (cytotec) Dinoprostone (cervidil) Description: promotes cervical dilatation if enhances at 2nd stage of labor Applied as gel

Mg SO4
Description: CNS depressant, uterine relaxant laxative effect Use: DOC for DIH (pregnancy include HPN) A/E: toxicity calcium lactate Antidote: calcium gluconate Imp.: monitor Mg level, normal 4-7 mg/dl, monitor BP, UO, RR & patellar reflex Pre elampsia- BP, edema Eclampsia- BP, anasarca(generalize edema), convulsion

MEPERIDINE HCL (Demerol)

- Narcotic analgesic Use: pain using labor A/E: respiratory depression Antidote: naloxone HCl / narcan Implication: monitor RR Teratogenicity cigarettes Envtl teratogens

E. SIGNS OF PREGNANCY

DIAGNOSIS OF PREGNANCY:
Presumptive Signs subjective evidence Probable Signs objective evidence Positive Signs absolute evidence

First Trimester

PRESUMPTIVE Amenorrhea Morning Sickness Urinary Frequency Enlargement of Uterus

PROBABLE Chadwicks sign Goodells sign Hegars sign Positive HCG Elevation of BBT

POSITIVE Ultrasound evidence 12 weeks by Doppler

Second Trimester
PRESUMPTIVE PROBABLE POSITIVE
Fetal Heart Tone 18-20 weeks by auscultation Fetal movements felt by the Examiner at 20 weeks Fetal outline on X-ray or Sonography

Quickening ( fetal Kick ) Enlarged abdomen skin pigmentation Braxton Hicks (chloasma and linea nigra Contraction ( false labor, Striae Gravidarum a painless uterine contraction) Ballotement

F. PHYSIOLOGICAL CHANGES OF PREGNANCY

A. Reproductive Tract Changes:

UTERUS Weight increase to about 1000 grams at full term Hegars sign softening of uterine segment Operculum mucus plugs in the cervix that are produced to seal out bacteria Goodells sign - softening of the cervix VAGINA Chadwicks sign - bluish discoloration of the vagina Leukorrhea increase estrogen leads to vaginal discharge Alkaline vaginal pH: 2 microorganisms which thrive in alkaline environment Trichomonas Candida Albicans OVARIES No changes No ovulation Placenta take over the function which supervises estrogen and progesterone

B. INTEGUMENTARY CHANGES:
Linea Nigra line running from navel to symphysis Melasma or Chloasma Mask of Pregnancy Abdominal Wall Striae Gravidarum pink or reddish streaks

C. BREAST CHANGES:
COLOSTRUM IS FORMED (4th Month) Feeling of fullness and tingling sensation in size and nipples more erect Montgomery gland become more bigger and protuberant Areola becomes more darker and diameter Skin surrounding areola turns dark

D. SYSTEMIC CHANGES: Circulatory or Cardiovascular Easy fatigability and SOB Undue bleeding due to fibrinogen Slight hypertrophy of the Heart Systolic murmurs are common Epistaxis, palpitation, bipedal edema Vulva and rectal varicosities
E. GI CHANGES: Morning Sickness Hemorrhoids Heartburn or Pyrosis Constipation and flatulence F. RESPIRATORY CHANGES: Shortness of Breath

G. URINARY CHANGES Urinary frequency 1st Trimester d/t blood supply to the kidneys and uterus rising out of the pelvic cavity. 3rd Trimester d/t pressure of enlarged uterus on the bladder.
H. MUSCULOSKELETAL CHANGES: Lordosis Pride of Pregnancy I. ENDOCRINE CHANGES Placenta take over lactogen Slight hypertrophy / enlargement of Parathyroid Gland to supply child calcium Slight of the thyroid gland leads to activity of adrenal cortex and production of cortisol anti-diuretic hormone leads to hyperglycemia.

G. PSYCHOLOGICAL TASKS OF PREGNANCY

First Trimester Accepting the Pregnancy The Fetus is unidentified concept with great future implications but without tangible evidence of reality Second Trimester Accepting the baby Fetus is perceived as a separate entity

Third Trimester Preparing for parenthood Has personal identification with a real baby about to be born and realistic plan for future childcare responsibilities Let pregnant woman listen to the fetal heart sounds

H. NURSING CARE DURING PREGNANCY

Health Assessment During First Prenatal Visit:

GRAVIDA a pregnant woman
Nulligravida = who has never been pregnant Primigravida = first time pregnancy Multigravida = 2 or more pregnancies Grandmultigravida = 5 or more pregnancies

PARTURIENT woman in labor

PARTURITION/CONFINEMENT process of labor and
delivery

VIABLE capable of living, such as fetus that has reached a

stage of development, usually 20-28 weeks, which will permit to live outside the uterus; dependent on level of technology

PARITY the number of pregnancies in which the fetus have

reached viability, whether the fetus is born alive or its stillborn after viability is reached does not affect parity

Nullipara = a woman who has not completed a pregnancy with a fetus that has reached the age of viability Primipara = a woman who has completed one pregnancy with a fetus that has reached the age of viability Multipara = a woman who has completed two or more pregnancy with a fetus to the stage of viability Grandmultipara = a woman who has completed at least four pregnancies

OB SCORE:
G number of pregnancies P number of pregnancies that reached the age of viability T number of babies born at term P number of preterm babies A number of abortions L number of children currently living M number of multiple pregnancies PRE-NATAL = before birth PERINATAL = 20th or 28th week of gestation through the end of the 28th day after birth POST-NATAL = after birth PREPARTUM = before delivery INTRAPARTUM = labor and delivery

THE PRENATAL CLINIC:

Consists of care and supervision given to the woman throughout pregnancy to ensure the health and wellbeing of both the mother and the baby by: Ascertaining the patients general physical condition at the beginning of the pregnancy. Preparing the patient psychologically for pregnancy, labor, delivery and infant care. The term antepartal has been used by some to refer to the mother and antenatal or prenatal to refer more specifically to the fetus.
Prenatal Visits are Scheduled: Once a month up to the 6th month (28th weeks) Every two weeks from the 7th or 8th months (28-32 weeks) Once a week from the 9th month until delivery.

INITIAL PRENATAL VISIT

It includes both the diagnosis or verification of pregnancy and the establishmenteof the data base for ongoing prenatal care.

A. INTERVIEW
Probability of pregnancy with symptoms noted Menstrual History Menarche Duration and amount of flow LMP Obstetric History OB Scoring Estimation of AOG based on LMP Fundic Height Ultrasonography Computation of EDC Outcomes of previous pregnancies Contraceptive History Previous major illness Current health problems and all medications being used Reaction to pregnancy

FETAL HEART TONE

Cephalic presentations, fetal heart sounds are heard loudest midway between the umbilicus and the anterior superior iliac spine. In LOA and LOP positions they are heard loudest in the Left Lower Quadrant; and in ROA and ROP positions they are heard loudest in the Right Lower Quadrant. In breech presentation, the fetal heart sounds are heard loudest at the level of the umbilicus or above. The normal fetal heart rate is 120 160 bpm regular.

PELVIC EXAMINATION
Its purpose is to permit visual and digital examination of the internal and external genitalia and the pelvic contour. Nursing Responsibilities: Give psychological care. Help the mother relax during the procedure. Maintain woman in Lithotomy Position. Drape her accordingly and avoid unnecessary exposure. When the examination is complete, assist the mother into sitting position and then stand. Provide wipes for the removal of lubricant.

PELVIC MEASUREMENTS
Done only two weeks before EDC X ray Pelvimetry is the most effective method of diagnosing Cephalopelvic Disproportion (CPD)

URINE EXAMINATIONS
Routine Analysis to determine pyuria. Pregnancy test Analysis for glucose albumin Heat and Acetic acid test to determine albuminuria. Albumin in the urine should be reported immediately because it is a sign of toxemia. Benedicts Test glycosuria, a sign of possible gestational diabetes.

BLOOD STUDIES
Hemoglobin and hematocrit Venereal Disease Research Lab (VDRL) or Rapid Plasma Reagin Test (RPR) Blood typing and Rhesus factor Antibody titer for Rubella Blood sugar

PAPANICOLAU SMEARS (CYTOLOGIC EXAMINATION)

To detect abnormalities of cell growth by examining cells and secretions from the cervix and vagina and to diagnose Cervical Carcinoma/ Classification of Findings: Class 1 absence of atypical or abnormal cells Class 2 atypical or abnormal cytology but no evidence of malignancy Class 3 cytology suggestive malignancy Class 4 cytology strongly suggestive malignancy Class 5 conclusive of malignancy CLINICAL STAGES: Reflect localization or spread of malignant and cervical changes Stage 1 CA confined to cervix Stage 2 CA extends beyond the cervix into the vagina, but not into the pelvic wall or l lower 1/3 of the vagina. Stage 3 metastasis to the pelvic wall Stage 4 metastasis beyond pelvic wall into the bladder and rectum. Speculum placement

PHYSICAL EXAMINATION
Vital Signs Height and Weight Breast examination Abdominal examination Contour of uterus, fundal height Leopolds Maneuver Fetal Heart Rate, if applicable Vaginal or bimanual examination for changes consistent with pregnancy Paps smear done during 1st prenatal visit and 1st postpartum visit.

LABORATORY TEST
Pregnancy test CBC Urine exams for glucose and protein

DANGER SIGNS TO BE REPORTED IMMEDIATELY:

Vaginal Bleeding Swelling of the face, fingers and legs Severe continuous headache Dizziness or blurring of vision Flashes of light or dots before eyes Abdominal or chest pain Persistent vomiting Chills and fever Sudden escape of vaginal fluids

COMMON DIAGNOSTIC PROCEDURES IN MCN

1. Assessment of Lochia To detect the presence of infection and bleeding (side-lying position). The normal color of lochia is as follows: Lochia Rubra (Reddish) 1 to 3 days postpartum Lochia Serosa (Brownish) 4 to 10 days Lochia Alba (Whitish) 10 to 14 days The longest possible time for the patient to have lochial discharge can be up to 3 weeks to sixty days postpartum. 2. Alpha Protein Levels Assesses presence of neural tube defects and Dawns Syndrome. 3. Amniocentesis Assesses fetal growth and maturity, determine genetic disorders and sex of fetus. 4. APGAR Scoring Appearance, pulse, grimace, activity and respiration. At first, it detects the cardiorespiratory nervous functioning, and the second is used for planning nursing care. 0 3 Poor ( needs resuscitation ) 4 6 Fair (needs suctioning and oxygenation ) 7 10 Good ( needs only admission care )

5. Chorionic Villi Sampling Determine some genetic aberrations.

6. Contraction Stress Test ( Oxytocin Challenge Test ) Indicates uteroplacental insufficiency and identifies pregnancies at risk NEGATIVE RESULT indicates absence of abnormal deceleration with all contractions. POSITIVE RESULT indicates FHR abnormal deceleration with all contractions.

7. Non Stress Test (NST) Assess fetal activity and well being . Types: Reactive Test acceleration of FHR > 15 bpm lasting for 15 seconds and more. Non Reactive Test acceleration of FHR < 15 bpm may indicate fetal jeopardy.
8. Coombs Test Direct used to test antibodies on patients erythrocytes. Indirect used to test antibodies on patients serum.

9. FHR Monitoring Assess FHR abnormalities. Early Decelerations indicate fetal head compression, reflects mirror image in the monitor and no treatment required. Late Decelerations placental insufficiency, reverse mirror image in the monitor Tx: Administer oxygen. Variable Decelerations cord compression, reflects V/W shape image in the monitor. Tx: Change the patients position to Left Lateral Recumbent Position and Administer oxygen. 10. Guthrie Capillary Blood Test Used to screen Phenylketonuria or PKU Normal level is 2mg/dl Provide the patient a high protein diet, 24 48 hours before the test. 11. Hysterosalpingography Determines patency of the fallopian tube and to detect pathology in the uterine cavity. 12. Laparoscopy Evaluates pelvic pain and infertility, and treats endometriosis lesions. NPO before the procedure.

13. Mammography Detects the presence of breast tumor. 14. Self Breast Exam Best done a week after the menstruation. 15. Pelvic Ultrasound Detects abnormalities of the organs in the abdomen. The patient should Oral Fluid Intake 30 mins. 1 hour before the test to distent the bladder to promote visualization of organs. 16. Percutaneous Umbilical Cord Blood Sampling (PUBS) Cardiocentesis or Funicentesis Removal of blood from Umbilical vein using an amniocentesis technique for analysis RhoGam is given to Rh negative women to prevent sensitization, since there is a possibility that the fetal blood could enter the maternal circulation. The fetus is monitored by NST before and after the procedure.

CONDITIONS ASSOCIATED WITH FIRST TRIMESTER BLEEDING

A. Spontaneous Miscarriage
Spontaneous interruption of pregnancy Early Miscarriage before week 16 of pregnancy Late Miscarriage between week 16 24 TYPES: Threatened Miscarriage Imminent Miscarriage Complete Miscarriage Incomplete Miscarriage Missed Miscarriage Early pregnancy failure: Recurrent Pregnancy Loss d/t Defective Spermatozoa or Ova Endocrine Factors Deviations of the Uterus Infection and autoimmune disorders

B. PREGNANCY
Implantation occurs outside the uterine cavity. The most common site is in the Fallopian Tube. Causes: Obstruction PID Smoking Use of IUD

C. Abdominal Pregnancy

The placenta continues to grow in the fallopian tube, spreading perhaps into the uterus for a better blood supply, or it may escape into the pelvic cavity and implant on an organ such as intestine.

CONDITIONS ASSOCIATED WITH SECOND TRIMESTER BLEEDING

A. Gestational Trophoblastic Disease/ Hydatidiform Mole

Abnormal proliferation and degeneration of the trophoblastic villi.

B. Premature Cervical Dilatation

Incompetent cervix Refers to a cervix that dilates prematurely and therefore cannot hold a fetus until term.

CONDITIONS ASSOCIATED WITH THIRD TRIMESTER BLEEDING

A. Placenta Previa
Low implantation of the placenta, a painless vaginal bleeding. Low-lying Placenta implantation on the lower rather than in the upper portion of the uterus. Marginal Implantation the placenta edge approaches that of the cervical os. Partial Placenta Previa implantation that occludes a portion of the cervical os. Total Placenta Previa implantation that totally obstructs the cervical os. Causes: Parity Advanced maternal age Past cs birth Past uterine curettage Multiple gestation

B. Abruptio Placenta

Detachment of placenta from the uterus and a painful vaginal bleeding. Apparent Hemorrhage partial separation Concealed Hemorrhage complete separation

C. Disseminated Intravascular Coagulation ( DIC )

An acquired disorder of blood clotting in which the fibrinogen level fails to below effective limits. It occurs when there is such a extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that not enough are left in the rest of the body fur further clotting. The high thrombin level continues to encourage anticoagulation.

PROMOTION OF NUTRITIONAL HEALTH DURING PREGNANCY

Nutrition Women who need special attention Pregnant teenagers Extremes in weighing scale low pregnant weight and obese Low income women Successive pregnancies Vegetarians

Nutritional Assessment is based on taking a diet history first:

Food preferences or eating habits Cultural or Religious Influences Educational or Occupational

Computation of Caloric Equivalents:

CHO x 4 CHON x 4 Fats x 9

Food Sources:
Protein Rich Foods Vitamin A Vitamin D Vitamin E Vitamin C Vitamin B Folic Acid Calcium or Phosphorus Iron

Weight Gain during Pregnancy:

1st Trimester 1.5 3 lbs is normal 2nd and 3rd Trimester 10 11 lbs per Trimester is recommended Total allowable weight gain during entire pregnancy 20- 25 lbs ( 10 12 kgs )

Distribution of Weight Gain during Pregnancy:

Fetus Placenta Amniotic Fluid Uterine weight Blood Volume Breast weight Additional Fluid Fat and Fluid Accumulation TOTAL - 7 lbs - 1lb - 1 lb - 2 lbs - 1 lb - 1 - 3 lbs - 2 lbs - 4 - 6 lbs = 20 25 lbs

MALNUTRITION
Results in prematurity; pre-eclampsias, absorption, low birth weight babies, congenital defects or even stillbirths.

Normal Pre-pregnancy BMI:

Underweight = under 18.5 Normal weight = 18.5 24.9 Overweight = 25 29.9 Obese = above 30

COMMON DISCOMFORTS IN PREGNANCY:

First Trimester
Breast Tenderness Palmar Erythema Constipation Nausea, vomiting, and pyrosis Fatigue Muscle cramps Hypotension Varicosities Hemorrhoids Palpitations Frequent urination Abdominal discomfort Leukorrhea

Second and Third Trimester

Backache Headache Dyspnea Ankle edema Braxton Hicks Contraction

HEALTH PROMOTION DURING PREGNANCY

Self-care needs:
Dental care Perineal care sexual activity Exercise such as Kaegels Exercise Taylor Sitting

Preparations for Childbirth and Parenting:

Gate Control of Pain

Premises: -Discomforts during labor can be minimized if the woman comes into labor informed about what is happening and prepared with breathing exercises to use during labor. - Discomforts during labor can be minimized if the womans abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall during contractions.

Major approaches to Prepared Childbirth

Grantly Dick Read Method - Fear leads to tension and tension leads to pain - Breathing techniques Lamaze Psychoprophylactic Childbirth Based on stimulus response conditioning. To be effective, full concentration on breathing exercises during labor should be observed, mouthing silently words or songs with rhythmical tapping of fingers. Leboyer Method the contrast of uterine environment and the external world causes infant to suffer psychological shock at the time of delivery relaxing the craniosacral axis.

I. LABOR AND DELIVERY

Theories of Labor Onset

Uterine Stretch Theory any hollow body organ when stretched to capacity will necessarily contract and empty. Oxytocin Theory labor, being considered a stressful event stimulates the hypophysis to produce oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the smooth muscles of the body. Progesterone Deprivation Theory progesterone, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases labor pain occurs. Prostaglandin Theory initiation of labor is said to result from the release of arachidonic acid produced by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis, which in turn causes uterine contractions. Theory of Aging Placenta because of the decrease in blood supply, the uterus contracts.

SIGNS OF LABOR

Preliminary Signs/ Prodromal Signs of Labor

1. Lightening refers to the settling of the fetal head into the pelvic brim. It results in increase in urinary frequency, relief of abdominal tightness and diaphragmatic pressure, shooting pains down the legs because of pressure on the sciatic nerve. 2. Engagement occurs when the presenting part has descended into the pelvic inlet. 3. Increase activity level 4. Loss of weight 5. Braxton Hicks Contraction painless, irregular practice contractions. 6. Ripening of the Cervix from Goodells sign, the cervix becomes butter- soft. 7. Rupture of the Membranes BOW ruptured, integrity of the uterus is already destroyed. 8. Show due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucus membrane of the cervix. It is only Pinkish Vaginal Discharge.

Uterine Contractions
The surest sign that labor has begun is the initiation of effective, productive uterine contractions Phases: INCREMENT first phase which the intensity of contraction increase, also known as CRESCENDO. ACME the height of the uterine contraction; also known as APEX DECREMENT last phase during which intensity of contraction decreases; also known as DECRESCENDO.

Differences between False and True Labor Pains

False Labor Pains 1. Remain irregular of uterine contraction. 2. Generally confined to the abdomen. 3. No increase in duration, frequently and intensity 4. Often disappears if the woman ambulates/walking. 5. Absent cervical changes True Labors 1. Maybe slightly irregular at first but become regular and predictable in a matter of hours. (3-4 contraction every 2hours) 2. First felt in the lower back and sweep around to the abdomen in a girdle-like fashion.(circle movement) 3. Increase in duration, frequency and intensity.

4. Continue no matter what the womans level of activity is being done. 5. Accompanied by cervical effacement and dilatation. (thinning of the cervical)

Effacement Shortening and thinning of the cervical canal as district from the uterus. Dilatation Enlargement of the external cervical os up to 10cm primarily as a result of uterine contractions and secondarily as a result of pressure of the presenting part and the BOW.

Length of Normal Labor

Stage of Labor First Stage Second Stage 12 hours 80 minutes Primis 7 hours, 20 30 minutes Multis

Third Stage
TOTAL

10 minutes
14 minutes

10 minutes
8 hours

COMPONENTS OF LABOR
Passage Passenger Power

STAGES OF LABOR

A. First Stage (Stage of Dilatation)

begins with true labor pains and ends with complete dilatation of the cervix. Power/ Forces: involuntary uterine contractions 3 PHASES (LAT) Latent early in time labor Cervix dilates only 3-4cm. Contractions are of short duration and occur regularly 5-10 minutes apart. Active/ Accelerated Cervical Dilatation reaches 4-8cm. Rapid increase n duration, frequency and intensity of constractions. Transition Period When the mood of the women suddenly changes and the nature of the contractions intensify.

B. Second Stage (Stage of Expulsion)

Begins with complete dilatation of the cervix and ends with the delivery of the baby. Power/ Forces: Involuntary uterine contractions and contraction of the diaphragmatic and abdominal muscles. Mechanisms of Labor/ Fetal Position Changes (ED FIRE ERE) Engagement Descent maybe preceded by engagement. Flexion as descent occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest. Internal Rotation from AP to transverse, then AP to AP. Extension as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear. External Rotation (also called as the Restitution) anterior shoulder rotates externally to the AP position. Expulsion delivery of the rest of the body.

C. Third Stage (Placental Stage) begins with the delivery of the baby and ends with the delivery of the placenta.
Signs of Placental Separation Calkins Sign the earliest sign of placental separation. Sudden gush of blood from the vagina. Lengthening of the cord. Types of Placental Delivery Schultz if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny (SHINY for SCHULTZ), 80% of placentas separate in this manner. Duncan if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface, which is raw, red, beefy and dirty (DIRTY for DUNCAN). Only about 20% placentas separate this way.

D. FOURTH STAGE
First 1 2 hours after delivery, which is said to be the most critical stage for the mother because of unstable VS.(Blood Pressure)

First Stage
Station relationship of the fetal presenting part to the level of the ischial spines Station 0 at the level of the ischial spines, synonymous to engagement Station -1 presenting part above the level of the ischial spines. Station +1 presenting part below the level of the ischial spines. Station +3 or +4 synonymous to crowning encircling of the largest diameter of the fetal head by the vulvar ring.

PRESENTATION
Relationship of the long axis of the mother to the long axis of the fetus; Also known as LIE 1. VERTICAL Cephalic head is the presenting part Vertex head is sharply flexed, making the parietal bones the presenting parts. In poor flexion face, brow, chin (MENTUM) Breech buttocks are the presenting parts. Complete thighs are flexed on the abdomen and legs are on the thighs. Frank thighs are flexed and legs are extended, resting on the anterior surface of the body.
Footling Single one leg unflexed and extended; one foot presenting. Double legs unflexed and extended; feet are presenting.

2. HORIZONTAL
Transverse Lie Shoulder Presentation

POSITION
Relationship of the fetal presenting part to a specific quadrant in the mothers pelvis.

Possible Fetal Positions

Vertex LOA left oxipitoanterior most favorable LOP left oxipitoposterior LOT left oxipitotransverse ROA right oxipitoanterior ROP right oxipitoposterior ROT right oxipitotransverse
BREECH LSA left sacroanterior RSA right sacroanterior LSP left sacroposterior RSP right sacroposterior LST left sacrotransverse RST right sacrotransverse

FACE LMA left mentoanterior LMP left mentoposterior LMT left mentotransverse RMA right mentoanterior RMP right mentoposterior RMT right mentotransverse
SHOULDER LADA left acromiodorsoanterior LADP left acromiodorsoposterior RADA right acromiodorsoanterior RADP right acromiodorsoposterior

NURSING CARE DURING LABOR

Monitoring and evaluating important aspects like uterine contraction (duration, interval, frequency and intensity), BP, FHT. Emotional support is provided for the women in labor. Health Teachings Bath, Ambulation, NPO, Enema Encourage the mother to void every 2 3 hours by offering the bedpan. Perineal prep done aseptically and perineal shave. Encourage Sims Position. Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage. Abdominal Breathing Administer analgesics as ordered. Assist in administration of original anesthesia.

Transition Period
Nursing Actions are primarily comfort measures. Sacral Pressure relieves discomfort from contractions. Proper bearing techniques. Controlled chest breathing during contractions. Emotional support.

Second Stage
When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine ligaments. As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid and shallow breathing to prevent rapid expulsion of the baby). Assist in episiotomy (incision made in the perineum primarily to prevent lacerations).

Types of Episiotomy
Median from middle portion of the lower vaginal border directed toward the anus. Mediolateral begun in the midline but directed laterally away from the anus. Often done because it prevents 4th degree laceration should it occur despite episiotomy. Natural Anesthesia Apply the Modified Ritgens Maneuver Immediately after delivery, the newborn should be held below the level of the mothers vulva for a few minutes to encourage flow of blood from the placenta to the baby. The infant is held with his head in a dependent position to allow for drainage of secretions. Wrap the baby in a sterile towel to keep him warm. Chilling increases the bodys need for oxygen. Put the baby on the mothers abdomen. The weight of the baby will help contract the uterus. Cutting the cord is postponed until the pulsations have stopped because it is believed that 50 100ml. of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart and then cut in between. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse.

Third Stage
Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus, a method called BRANDT ANDREWS MANEUVER. Take note of the time of placental delivery. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death. Palpate the uterus to determine degree of contraction. Inject oxytocin (Methergin=0.2mg/ ml or Syntocinon=10U/ ml) IM to maintain uterine contractions, thus preventing hemorrhage. NOTE: OXYTOCIN are not given before placental delivery. Inspect the perineum for lacerations. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vaginal opening. Position the newly delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra abdominal pressure. The newly delivered mother may suddenly complain of chills due to decreased BP, fatigue or cold temperature in the delivery room. NSG. INTERVENTION: Provide addition blankets to keep her warm. May give initial nourishment. Allow patient to sleep in order o regain lost energy.

Fourth Stage
Assessment of the fundus, lochia, bladder, perineum, BP and PR. Lactation - suppressing agents, estrogen, androgen preparations given within the first hours postpartum to prevent breast milk production on mothers who will not breastfeed. Rooming In Concept (Giving the baby to the mother) Lochia Assessment

J. PUERPERIUM

Terminologies:
Puerperium/ Postpartum a) Refers to the 6 week after delivery of the baby. b) Involution return of the reproductive organs to their pregnant state. PHASES OF PUERPERIUM a) Taking in phase (2 3 days) Woman is largely passive Is a time reflection A time when the new parent review their pregnancy, labor and birth. b) Taking Hold Phase Woman initiates action c) Letting Go Phase The woman finally redefines her new role, she gives up the fantasized image of her child and accepts the real one. She gives up her old role of being childless

MATERNAL NEWBORN ATTACHMENT

Bonding breast feeding Mother claiming En face position Father engrossment Rooming In Sibling visitation A chance to visit the hospital and see the new baby and their mother, reduces feeling that their mother cares more about the new baby. It helps relieve from impact of separation.

MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD

Abandonment Disappointment Postpartum blues Labile mood and affect Crying spells Sadness Insomnia Anxiety

PHYSIOLOGIC CHANGES DURING PUERPERIUM 1. Systemic changes 2. Reproductive System Changes

a. Vascular Changes
30%-50% increase in cardiac volume for 5-10 minutes after placental delivery Activation of the clotting factors, which encourages THROMBOEMBOLIZATION *massage is not advisable

b. Genital Changes
Uterine involution- measure the fundus using fingerbreath Knee-chest position Afterpains/ afterbirth pain- abdominal pain for large baby, twin delivery, etc. For breastfeeding mothers, it last for not more than 3 days Heat packs- not advisable Lochia- blood, residues, bacteria, mucous -Increase activity= increase lochia - breastfeeding= decrease lochia Pattern of Lochia a) Lochia Rubra- red, 1-3 days, moderate amount b) Lochia Serosa- 4-6 days, lower amount than in lochia rubra c) Lochia Alba- 10-14 days or up to 6 weeks, minimal amount
Characteristics of Lochia: Pattern should not reverse. It should approximate menstrual flow. It should not have any offensive odor. It should not contain large clots. It should never be absent regardless of method of delivey. Pain in the perineal region may be relieved by Sims position.

c. Urinary Changes
Marked dieresis within 12 hours postpartum Frequent urination- small amount/ scanty d/t urinary retention overflow

d. GI Changes
Decreased muscle tone Lack of food + enema during labor Dehydration Fear of pain from perineal tenderness

e. Vital Signs
Temperature may be increased Bradychardia is common for 6-8 days Theres no change in the respiratory rate.

NURSING CARE DURING THE PUERPERIUM

Promote healing and return to normal (involution) of different parts of the body Provide emotional support Prevent postpartum complication

POSTPARTUM COMPLICATION: 1. PP Hemorrhage- blood loss of more than 500 cc during delivery *normal: 250-350 cc a.early- 1st 24 hours Causes: uterine atony, laceration, hypofibrinogenemia Uterine Atony- boggy/relaxed uterine CAUSES: 1. CS 2. Over distention of the uterus 3. Placental accidents 4. Prolonged/difficult labor NURSING ACTIONS: 1. Massage the fundus (milking massage) 2. Ice compress (abdominal area) 3. Oxytocin administration 4. Empty the bladder 5. Bimanual compression 6. Hysterectomy Hypofibrinogenemia- d/o of clotting factors *administer BT

2. PP Infection Establish successful lactation

K. IMMEDIATE CARE OF THE NEWBORN

Suctioning- 5-10 seconds to prevent hypoxia - mouth first before nose to prevent vagal stimulation that leads to bradychrdia Establish and Maintain Patency of Airway- cover nostril one at a time Positioning- slight trendelenburg, side lying but avoid prone position (promotes drainage,prevents increase ICP, promotes closure of foramen ovale and ductus arteriosus, prevents aspiration) *Signs of Increased ICP: High pitch, high shrill cry Spontaneous vomiting Bregma and Lambda are bulging and very dense Increased BP Decreased CR & RR Widening of pulse pressure Maintain Appropriate Temperature- normal temp is 36.4C 37.2C *Temperature is unstable but stabilizes in 6-8 hours

SECOND PERIOD OF REACTIVITY Immature hypothalamus Inadequate brown fat Shivering mechanism is underdeveloped *Babies are born wet (more heat loss) Evaporation Radiation Convection Conduction Nursing Care: Dry once Wrap Expose to drop light Encourage the mother to cuddle and embrace the baby
Complications: Hypoglycemia- d/t use of glucose Metabolic acidosis

FIRST PERIOD OF REACTIVITY Methods: 1. Breastfeeding- best method Other Purpose: i. Colostrum- first milk - high protein-LACTOGLOBULIN, high antibody-IgA, high WBC, macrophages and Lactoferin - these protect infant against bacterial and viral infections of the respiratory and GI systems - high levels of vitamins ABCDE, low levels of CHO and COOH ii. Promotes uterine contraction iii. Prevents physiologic jaundiceICTERUS NEONATORUM d/t stimulation of gastrocolic reflex *bilirubin- responsible for jaundice

a) b)

a) b)

Rooming-in: Complete- mother and child are together 24 hour a day Partial- infant remains in the womans room for most of the time (8AM-9PM) but he/she is taken to a small nursery near the womans room for the night 3. Senses stimulation: Touch and hearing- highly developed Sight and smell- least developed but one of the best methods to promote bonding

ASSESSMENT:
APGAR Scoring Test by Virginia Apgar Assess general condition of infant Done twice at 1 & 5 mins. Determine the degree of acidosis and the need for CPR To evaluate ability of the NB to adjust extrauterinely and the prognosis Score Interpretation 0-3: poor, serious or severely depressed; needs immediate CPR 4-6: fair, guarded or moderately depressed; needs further observation and suctioning 7-10: good of healthy **therefore: the higher the Apgar score, the better

IDENTIFICATION
Best accomplished before transfer to the nursery ( footprints, ID bands, birthmarks )

CARE OF THE NEWBORN IN THE NURSERY

Recheck ID Take the temperature initially- per rectum to determine anal patency (primary reason) Complications related to frequent rectal temperature taking: Perforation of the mucous membrane Vagal stimulation Special initial care: a. Initial bath- best done with temperature of the NB stable or at least 37C Water with non-alkaline soap- prevent the destruction of the acid mantle of the skin Oil- appropriate in case vernix caseosa is plenty Anti-microbial solution- most preferred in NB of mothers with infections in the vaginal canal: Trichomoniasis, Candidiasis, STD, Gonorrhea

b. Cord dressing Done with strict aseptic technique practices Include application of CORD CLAMP- prevent OMPHALANGIA (bleeding) Include application of ANTISEPTIC SOLUTIONS: Povidone Iodine- Betadine (prevents Tetanus Neonatorum Alcohol 70%- prevents Omphalitis Inspect the blood vessels (2 arteries and 1 vein), in case 1 of the arteries is absent indicates a congenital disorder of possibly the GIT, CV % GUT **Cord falls on 7th-10th day c. Credes Prophylaxis- Ophthalmic Ointment -Prevent or prophylactic treatment against OPHTHALMIA NEONATORUM

MEDICATIONS: Ophthalmic drops- Silver Nitrate 1% Ophthalmic ointment Teramycin- most common Erythromycin- Chlamydia infections, 4 days Vit. K injection- left vastus lateralis, prevent bleeding
PHYTONADIONE- Aquamephyton PHYTOMENADIONE- Konakion Full term- 1 mg Preterm- 0.5 mg Amt- 0.05-0.1 ml Route- IM Site- Vastus Lateralis (prevent injury to sciatic nerve that may lead to paralysis

ANTHROPOMETRIC MEASUREMENTS: Birth weight- normally 2.5 kg to 3.4 kg or 5.5 lbs to 7.8 lbs Birth length- normally 47.5 to 53.75 cm Like the BW the BL: Increases by 50% at age of 1 year Doubles at 2 years (length at 2 years is half of adult height) Average of 50 cm at birth ***Note: children under 24 mos- take the RECUMBENT HEIGHT in supine Children over 24 mos- take height in standing position Head circumference- 33-35 cm or 13-14 inches HC < 32 cm- Microcephaly HC > 37 cm- Macrocephaly No fetal skull- Anencephaly Chest circumference- 31-33 cm or 12-13 inches Abdominal circumference- 29-31 cm or 11-12 inches

PHYSICAL ASSESSMENT Vital signs- PR/CR & RR *RR: 30-60/min; 80/min at birth > rapid, irregular with normal physiologic apnea of less than 15 seconds Note: observe signs and symptoms of respiratory distress Tachypnea Bradypnea Nasal flaring Retractions Expiratory grunt *PR: 120-160/min; at birth- 180/min Characteristics: Rapid, irregular Increases with activity & as low as 100/min when asleep SITES: Apical pulse- most preferred for children under 3 y/o Brachial pulse- site to check pulsation in case CPR is necessary Femoral pulse Pedal pulse Radial pulse- common site for children over 3 y/o

*Temperature: at birth 36.4- 37.2C Characteristics: Unstable Stabilize between 6-8 hours known as the 2nd period of reactivity *Blood Pressure: at birth- 80/46 mmHg; at 10th day 100/50 mmHg Methods: Doppler Flush- normally 60 mmHg

Head- largest part of the body & of the total length. Assess the following: Fontanels (soft spot): normally 6 in number 2-paired: Anterolateral & Posterolateral 2 single: Anterior (Bregma) & Posterior (Lambdoid) a) Anterior- closes between 12 mos- 18 mos, diamond shaped, 3-4 cm long and 2-3 cm wide. *if >5cm: sign of Cretinism/ Congenital Hypothyroidism. b) Posterior- triangular shaped, center of the 3 sutures, closes between 6 weeks- 12 weeks or 3-4 months, measures 1x1 cm Assess further for: a) Bulging- increased ICP b) Depressed- dehydration c) Craniostenosis or Craniosynostosis Complications: Increase ICP Mental Retardation

Other Structures: Caput Succedaneum Affects both hemisphere Swelling of the sculp Disappears on or before 3rd day Cephalhematoma Collection of blood Caused by increase pressure of birth Rupture of periosteal capillaries Disappears in 3-4 weeks Craniotabes Localized softening of cranial bones Caused by early lightening (2wks for primis and 1 day for multis) Disappears in 6 wks Eyes- NB usually cry tearlessly, because their lacrimal ducts do not fully mature until about 3 months of age.

L. BREASTFEEDING

Physiology of Breastmilk Production

Estrogen and progesterone levels after placental delivery- stimulates APG to produce PROLACTINacts on acinar cells to produce foremilk- stored in collecting tubules. When infant sucks- PPG is stimulated to produce OXYTOCIN- causes contraction of smooth muscles of collecting tubules- milk ejected forward, LETDOWN /MILK EJECTION REFLEX- hindmilk is produced.

Patient teaching: Line bra with soft cotton, never use plastic lining. Let nipples air dry 5-15 mins before replacing bra Wash breasts with water, if soap is used, rinse completely Use well fitting supportive bra Avoid using harsh cleanser Use a breast pump A tingling sensation is often felt just before leakage begins. Well balanced diet It takes about two days for the infant to establish a sucking pattern. Colostrums will be secreted initially and the infant should be encouraged to take it. Milk appears 48-96 hours after delivery. Teach positions for burping the baby, upright, across lap, or on shoulder Fluid intake of at least 3000 ml/day Teach the mother to bring the infant to breast, not pulling the breast to the infant Teach mother to support the infants head while feeding such as the cradle or the football hold.

Associated Nursing Diagnosis Anxiety Breastfeeding, ineffective Infant feeding pattern, ineffective Knowledge deficit Breastfeeding, effective Nutrition: Less than body requirements, altered
Associated Problems Engorgement- feeling of tension on the breasts during the 3rd postpartum day sometimes accompanied by fever. Sore nipples Associated problems: Mastitis- localized pain, swelling and redness, lamps in the breast and milk becomes scanty. Nutrition Lactating mothers should take 3000 calories daily and should have larger amounts of CHON (96 g/day), Ca, Fe, Vit. A, B & C.

BREASTFEEDING Best for babies Reduces the incidence of allergies Economical Antibodies, greater immunity Stool inoffensive Temperature is always ideal Fresh milk never goes off Emotional bonding Easy once established Digested easily with 2-3 hours Immediately available- no mixing reqts Nutritionally optimal Gastroenteritis greatly reduced
Additional notes: Ambulation a) 4-8 hours after NSD b) 24 hours after CS Return of sexual activity: 3rd-4th week postpartum Menstruation returns: 8th week