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Maternal and Child

Health Nursing

PART II
Maternal and Child
Health Nursing
Promoting Fetal
and Maternal Health

Mary Lourdes Nacel G.


Nursing Process
 Nursing Diagnosis
 Health-seeking behaviors
 Anxiety
 Risk for deficit fluid
 Constipation
 Disturbed body image
 Risk for altered sexuality patterns
 Disturbed sleep pattern
 Fatigue
 Risk for fetal injury
MARY LOURDES NACEL G. CELESTE, RN, MD 4
Health Promotion During Pregnancy
 Self-care needs
 Bathing
 Breast care
 Dental care
 Perineal hygiene
 Sexual activity
Exercise
Sleep
Employment
Travel
MARY LOURDES NACEL G. CELESTE, RN, MD 5
Health Promotion During Pregnancy
First-Trimester Discomforts

 Breast  Hypotension
tenderness  Varicosities
 Palmar erythema  Hemorrhoids
 Constipation  Heart
 Nausea, palpitations
vomiting and  Frequent
pyrosis urination
 Fatigue  Abdominal
 Muscle cramps discomfort
 Leukorrhea
MARY LOURDES NACEL G. CELESTE, RN, MD 6
Health Promotion During Pregnancy

 Middle to Late Pregnancy Discomforts


Backache
Headache
Dyspnea
Ankle edema
Braxton Hicks contractions

MARY LOURDES NACEL G. CELESTE, RN, MD 7


Discomforts associated with
pregnancy
1. First trimester
 Nausea and vomiting (“morning
sickness”) related to altered hormone
levels and metabolic changes; advise
small snacks of dry crackers before
arising, small feedings of bland food,
milk
 Urinary frequency and urgency without
dysuria; fluid intake should not be
restricted
 Increased vaginal discharge; manage
with good hygiene (but no douching)
and loose-fitting cotton underwear;
report signs or symptoms of vaginitis
MARY LOURDES NACEL G. CELESTE, RN, MD 8
 Breast soreness due to hormonal
changes; suggest wearing a well-
fitting, supportive brassiere
 Headache due to tension from
emotional and physical stresses at any
time during pregnancy; provide
reassurance, suggest relaxation
techniques; inform patient to report
persistent and/or severe episodes
MARY LOURDES NACEL G. CELESTE, RN, MD 9
Second and third
trimester
 Heartburn may be related to tension
and vomiting in early pregnancy,
progesterone-induced decreased
motility and relaxation of the cardiac
sphincter; displacement of the
stomach by the growing uterus;
encourage small, frequent meals and
discourage overeating, ingesting
fried/fatty foods, lying down soon after
eating, use of sodium bicarbonate
MARY LOURDES NACEL G. CELESTE, RN, MD 10
(would interfere with sodium balance)
 Constipation related to progesterone-induced
hypoperistalsis, compression/displacement of
the bowel by the enlarging uterus, poor food
choices, lack of fluids, and/or iron
supplementation; advise bulk foods, fruits
and vegetables, exercise, and generous fluid
intake; avoid laxatives

 Hemorrhoids due to pelvic congestion related


to pressure from enlarged uterus; suggest
regulation of bowel habits, gentle reinsertion
into rectum with use of lubricant, relief
measures, e.g., ice packs, topical ointments,
sitz baths, lying down with legs elevated

MARY LOURDES NACEL G. CELESTE, RN, MD 11


 Uterine contractions (Braxton-Hicks) due to
tension on the round ligaments as a result
of displacement of the uterus; instruct
patient to rest, change position or activity

 Backache due to increased spinal


curvature; educate the patient on the
importance good posture

 Faintness related to vasomotor lability or


postural hypotension; instruct the patient
to use slow, deliberate movements when
rising, avoid prolonged standing and warm,
stuffy environments; elastic hose may be
needed
MARY LOURDES NACEL G. CELESTE, RN, MD 12
 Leg cramps related to pressure on the
nerves supplying the lower extremities
aggravated by poor peripheral circulation or
fatigue; instruct the patient to increase
calcium and decrease phosphorus intake;
encourage dorsiflexion of feet

 Ankle edema related to decreased venous


return from lower extremities, instruct the
patient to avoid wearing anything that
constricts blood flow, elevate legs when
sitting or resting, and dorsiflex feet when
sitting or standing for any length of time;
medical management if edema persists in
AM, is pitting, involves the face, or
associated with elevated BP, proteinuria,
MARY LOURDES NACEL G. CELESTE, RN, MD 13

persistent headaches
 Varicosities of extremities or vulva
related to uterine compression of
venous return, increased vein wall
distensibility from progesterone-
initiated relaxation, or inherited
tendency; suggest elevating legs
frequently, avoid sitting with legs
crossed, standing/sitting for long
periods of time, or wearing constrictive
clothing; support/elastic stockings may
be helpful.
MARY LOURDES NACEL G. CELESTE, RN, MD 14
DISCOMFORTS OF PREGNANCY
Assessment Nursing Considerations
May occur any time of day
Nausea and vomiting (morning
Eat dry crackers on arising
sickness)
Eat small, frequent meals
Bulk foods, fiber
Constipation, hemorrhoids
Generous fluid intake
Increase calcium intake
Leg cramps
Flex feet, local heat
Well-fitting bra
Breast soreness
Bra may be worn at night
Emphasize posture
Backache Careful lifting
Good shoes
Small, frequent meals
Antacids – avoid those containing phosphorous
Heartburn
Decrease amount of fatty and salty foods

Slow, deliberate movements


Dizziness Support stockings

Vena cava or supine hypotensive syndrome


Vertigo, light-headedness
Turn on left side
Kegel exercises
Urinary frequency Decrease fluids before bed
Report signs of infection
MARY LOURDES NACEL G. CELESTE, RN, MD 15
 *Fetal heart rate (FHR)
 *Fetal movements (FM)
 *Leopold’s Maneuver

 Health Teachings
 Schedule of clinic visits
 Exercises
 Dental hygiene
 Clothing
 Traveling
 Bathing
 Employment
 Sexual relation
 Immunization

MARY LOURDES NACEL G. CELESTE, RN, MD 16


Tetanus toxoid
 T1 – anytime during pregnancy
 T2 – one month after T1 (3)
 T3 – six months after T2 (5)
 T4 - one year after T3 (10)
 T5 – One year after T4 (lifetime)

MARY LOURDES NACEL G. CELESTE, RN, MD 17


DANGER SIGNS OF PREGNANCY

SIGN POSSIBLE CAUSE

Swelling of face. fingers; legs Hypertension of pregnancy, thrombophlebitis


(for leg swelling)
Headache, continuous and severe Hypertension of pregnancy

Blurring of vision Hypertension of pregnancy

Abdominal/ chest pain Ectopic pregnancy, uterine rupture, pulmonary embolism

Vaginal bleeding Placental problems (previa, abruption, premature


separation)

Vomiting, persistent Infection (also with fever and chills), hyperemesis


Gravidarum

Visual changes Hypertension of pregnancy

Escape of vaginal fluids Premature rupture of membrane

Others: change or decrease in movements; dysuria


fetal
MARY LOURDES NACEL G. CELESTE, RN, MD 18
Danger Signs of Pregnancy

 Abdominal or  Vaginal bleeding


chest pain  Persistent
 Pregnancy- vomiting
induced  Chills and fever
hypertension  Ruptured
 Increase or membranes
decrease in fetal
movement

MARY LOURDES NACEL G. CELESTE, RN, MD 19


Teratogens
Any factor that adversely
affects fertilized ovum,
embryo or fetus

MARY LOURDES NACEL G. CELESTE, RN, MD 20


Teratogenic Fetal Exposure
 Maternal infections
 Toxoplasmosis
 Rubella
 Cytomegalovirus
 Herpes simplex virus
 Syphilis

MARY LOURDES NACEL G. CELESTE, RN, MD 21


Teratogenic Fetal Exposure
 Lyme disease
 Infections
 Vaccines
 Drugs
 Alcohol
 Cigarettes

MARY LOURDES NACEL G. CELESTE, RN, MD 22


Teratogenic Fetal Exposure
 Environmental
 Metal and chemical
 Radiation
 Hyperthermia and hypothermia
 Maternal stress

MARY LOURDES NACEL G. CELESTE, RN, MD 23


Preparing for
Labor
 Lightening
 Show

 Rupture of membranes

 Excess energy

 Uterine contractions

MARY LOURDES NACEL G. CELESTE, RN, MD 24


Promoting Nutritional
Health During
Pregnancy

Mary Lourdes Nacel G.


Celeste, R.N., M.D.
THE FOOD PYRAMID
MARY LOURDES NACEL G. CELESTE, RN, MD 26
Maternal Diet and Infant
Health
 Recommended weight gain
 Components of healthy nutrition

Calorie needs
Protein needs
Fat needs
Vitamin needs

MARY LOURDES NACEL G. CELESTE, RN, MD 27


Total desirable weight gain in pregnancy
(for average woman)
•about 23-28 lb (11-13 kg)
•3-4 lb (1.36-1.81 kg) during the first trimester,
followed by an average of slightly less than
one pound per week for the rest of the
pregnancy
1st trimester: 3-4 lbs
2nd trimester: 12-14 lbs
3rd trimester: 8-12 lbs

MARY LOURDES NACEL G. CELESTE, RN, MD 28


MARY LOURDES NACEL G. CELESTE, RN, MD 29
Maternal Diet and Infant
Health
 Components of healthy
nutrition
Mineral needs
 Calcium and phosphorus
 Iodine
 Iron
 Fluoride
 Sodium
 Zinc

MARY LOURDES NACEL G. CELESTE, RN, MD 30


Maternal Diet and Infant
Health
 Components of healthy nutrition
Fluid needs
Fiber needs
Foods to avoid
 Alcohol
 Caffeine
 Artificial
sweeteners
 Weight loss diets

MARY LOURDES NACEL G. CELESTE, RN, MD 31


 Nutritional status
1. Weight gain should be within expected parameters
2. increased nutrient requirements

a. Calories – 300 kcal/d; may need adjustment for prepregnant


under/overweight

b. There should be no attempt at weight reduction during


pregnancy

c. Carbohydrates – needed to prevent unsuitable use of


fats/proteins for added energy needs; important to avoid
“empty” calorie sources

d. Proteins to 60 g/d; additional increase for


adolescent/multiple pregnancies; efficient use of requires
complete protein (contains all essential amino acids; animal
sources) or complemented with other protein sources, e.g.,
legumes, grains, nuts
MARY LOURDES NACEL G. CELESTE, RN, MD 32
e. Iron – to a total of 30 mg/d of elemental iron;
usually requires supplement

f. Calcium to 1,200/d; best obtained from dairy


products; if milk is disliked or poorly tolerated, calcium
supplement may be necessary

g.Sodium – should not be restricted without serious


indication; excess should be discouraged

3. 24-h recall/diet diaries may be used to evaluate


high-risk woman

MARY LOURDES NACEL G. CELESTE, RN, MD 33


Assessment: Nutritional Health

MARY LOURDES NACEL G. CELESTE, RN, MD 34


Assessment: Nutritional Health

MARY LOURDES NACEL G. CELESTE, RN, MD 35


Preparation for
Childbirth and
Parenting

Mary Lourdes Nacel G.


MARY LOURDES NACEL G. CELESTE, RN, MD 37
Childbirth
Education
 Childbirth educators and
teaching methods
 Childbirth education
classes
 Cultural and
socioeconomic factors
MARY LOURDES NACEL G. CELESTE, RN, MD 38
Childbirth
Education
 Expectant parent classes
Sibling education classes

MARY LOURDES NACEL G. CELESTE, RN, MD 39


Childbirth
Education
Preparation

Perineal and abdominal
exercises
 Tailor sitting
 Squatting
 Kegel exercises
 Abdominal muscle contractions
 Pelvic rocking

MARY LOURDES NACEL G. CELESTE, RN, MD 40


CHILDBIRTH
PREPARATION CLASSES
Bradley
Dick-Read
Lamaze Method
Leboyer Method

MARY LOURDES NACEL G. CELESTE, RN, MD 41


CHILDBIRTH PREPARATION CLASSES
1. Bradley (Partner-Coached)
Method
 stresses the important role of the
husband during pregnancy, labor and
early newborn period
 woman uses muscle toning exercises
 limits or omits food that contain
preservatives, animal fat and high salt
content
 abdominal breathing exercise
 woman is encouraged to walk during
labor
 use of dissociation technique
MARY LOURDES NACEL G. CELESTE, RN, MD 42
2. Dick-Read Method
 tension (psychic and muscular) is aroused by fear
and anticipation of pain
 sympathetic stimulation brought about by fears
causes contraction of the circular muscle of the
cervix
 prenatal courses and training reduce fear,
educate and boost self-confidence
 Covers: fetal development and childbirth; pain
relief methods; muscle strengthening exercises;
breathing techniques; physical and emotional
health for children; mother gets emphatic
understanding from partner, nurse, physician
 fear >>> tension >>> pain
 abdominal breathing contraction
MARY LOURDES NACEL G. CELESTE, RN, MD 43
3. Lamaze Method
(Psychoprophylactic method)
 based on stimulus – response conditioning
(Pavlov Theory of Classical Conditioning)
where unfavorable responses are replaced by
favorable conditioned responses
 high level of activity can excite higher brain
centers to inhibit other stimuli as pain
 woman is taught to replace responses of
anxiety, fear and loss of control with more
useful activity

MARY LOURDES NACEL G. CELESTE, RN, MD 44


Conscious relaxation
Cleansing breath
Conscious controlled breathing
Effleurage
Focusing
Second-stage breathing

MARY LOURDES NACEL G. CELESTE, RN, MD 45


 Covers: practice of breathing techniques
during labor; controlled perception;
relaxation of involved muscles; mouthing
silently words or songs with rhythmical
tapping of fingers; supportive person nearby
in a calm environment
 Use 3 Gate Control Method of pain relief
 education and relaxation
 use of imagery and focusing

(breathing patterns)
 conditioned reflex

MARY LOURDES NACEL G. CELESTE, RN, MD 46


4. Leboyer Method
 The contrast of intrauterine environment and
the external world causes infant to suffer
psychological shock at the time of delivery
 Gentle controlled delivery
 Covers: Relaxing the craniosacral axis by
supporting the head, neck and sacrum
 Restoring body heat loss by warm bath
 Allowing infant to breathe spontaneously
 Delaving cutting of cord to permit placental
blood flow
 Bonding mother and infant by skin to skin
contact
MARY LOURDES NACEL G. CELESTE, RN, MD 47
 Conscious Relaxation – learning to relax
muscles deliberately
 Cleansing Breath – woman breathes in deeply
and exhales deeply
 Consciously Controlled Breathing (Set
breathing Patterns)
 Level 1 – full respiration, 6 – 12cpm, early
contraction
 Level 2 – lighter, 40cpm, 4-6cm dilated
 Level 3 – more shallow, 50 - 70cpm,
transition contraction
 Level 4 – pant blow pattern, 3-4 quick
breaths then forceful
expiration
 Level 5 – continuous chest panting
(60cpm), strong contraction
and 2nd stageMARY LOURDES NACEL G. CELESTE, RN, MD of labor 48
 Leboyer method
Birthing room is darkened
Soft music
Infant placed immediately into
a warm-water bath
 Hydrotherapy and water birth

MARY LOURDES NACEL G. CELESTE, RN, MD 49


MARY LOURDES NACEL G. CELESTE, RN, MD 50
The Birth Setting
 Appropriate setting
 Birth attendant and
support person
 Hospital births
Postpartal birth

MARY LOURDES NACEL G. CELESTE, RN, MD 51


MARY LOURDES NACEL G. CELESTE, RN, MD 52
The Birth Setting
 Alternative birthing centers
 Home birth
 Children attending the
birth

MARY LOURDES NACEL G. CELESTE, RN, MD 53


MARY LOURDES NACEL G. CELESTE, RN, MD 54
MARY LOURDES NACEL G. CELESTE, RN, MD 55
Mary Lourdes Nacel G.
Caring for a Woman
During Vaginal Birth

Mary Lourdes Nacel G. Celeste, R.N., M.D.


LABOR AND DELIVERY
 Labor is a process is a process
whereby with time regular uterine
contractions brings about progressive
effacement and dilatation of the
cervix, resulting in the delivery of the
fetus and expulsion of the placenta.

Critical factors affecting the process of


labor:
 Passage
 Passenger
 Power MARY LOURDES NACEL G. CELESTE, RN, MD 57
THEORIES OF LABOR ONSET

1. Uterine Stretch Theory – Any hollow


muscular organ when stretched to the
capacity will contract and empty

2. Oxytocin Theory – Increased


production of oxytocin by the anterior
pituitary increases as pregnancy nears
term while production of oxytinase by
the placenta decreases
MARY LOURDES NACEL G. CELESTE, RN, MD 58
3. Progesterone Deprivation Theory
– as pregnancy nears term,
progesterone level drops, hence
uterine contraction occurs
4. Prostaglandin Theory – when
pregnancy reaches term, the fetal
membranes produces high levels of
arachidonic acid
5. Theory of the aging Placenta – as
the placenta ages it becomes less
efficient
MARY LOURDES NACEL G. CELESTE, RN, MD 59
Components of
Labor
 Passage

 Passenger

 Power

MARY LOURDES NACEL G. CELESTE, RN, MD 60


I. Passage (maternal)
– size and type of pelvis, ability of the cervix to
efface and dilate, and distensibility of vagina
and introitus

 Pelvis – the bony ring through which the


fetus passes during labor and delivery;
consists of four united bones (two hip or
innominate bones, the sacrum, and the
coccyx) between the trunk and thighs

 Measurements – may be obtained by internal


and external pelvic examination (using
pelvimeter), x-ray pelvimetry (used rarely in
pregnancy and MARY only late
LOURDES NACEL in third
G. CELESTE, RN, MD trimester or 61
in labor), and ultrasound
Pelvic types:
 a. Gynecoid – classic female pelvis inlet,
well rounded (oval); ideal for delivery
 - most ideal for childbirth (50% of women)
 b. Android – resembling a male pelvis,
narrow and heart-shaped; usually requires
cesarean section or difficult forceps delivery
(20% of women)
 c. Platypelloid – flat, broad pelvis; usually
not adequate for vaginal delivery (5% of
women)
 d. Anthropoid – similar to pelvis of
anthropoid ape; long, deep, and narrow;
usually adequate for NACEL
MARY LOURDES vaginal
G. CELESTE,delivery
RN, MD (25% of 62
women)
MARY LOURDES NACEL G. CELESTE, RN, MD 63
II. Passenger (fetal)
 Size – primarily related to fetal
skull
 Fetopelvic relationships
 Lie – relationship of spine of fetus
of spine of mother;
 longitudinal (parallel)
 transverse (right angles)
 oblique (slight angle off a true
transverse lie)
MARY LOURDES NACEL G. CELESTE, RN, MD 64
MARY LOURDES NACEL G. CELESTE, RN, MD 65
Presentation
 part of fetus that presents to
(enters) maternal pelvic inlet
– Cephalic/vertex – head
presentation (>95% of labors)

MARY LOURDES NACEL G. CELESTE, RN, MD 66


MARY LOURDES NACEL G. CELESTE, RN, MD 67
Breech presentation
 Complete – flexion of hips and
knees
 Frank (most common) – flexion of
hips and extension of knees
 Footling/incomplete – extension of
hips and knees

MARY LOURDES NACEL G. CELESTE, RN, MD 68


MARY LOURDES NACEL G. CELESTE, RN, MD 69
Attitude/ habitus
 relationship of fetal parts to each
other; usually flexion of head and
extremities on chest and abdomen to
accommodate to shape of uterine
cavity
 Vertex – head is maximally flexed
 Military – head is partially flexed
 Brow – head is maximally extended
 Face – head is partially extended
MARY LOURDES NACEL G. CELESTE, RN, MD 70
MARY LOURDES NACEL G. CELESTE, RN, MD 71
Position
 relationship of fetal reference point to
mother’s pelvis

Fetal reference point


 Vertex presentation – dependent upon
degree of flexion of fetal head on chest; full
flexion–occiput (O); full extension–chin (M);
moderate extension–brow (B)
 Breech presentation – sacrum (S)
 Shoulder presentation – scapula (SC)

MARY LOURDES NACEL G. CELESTE, RN, MD 72


Position

Relation of the presenting part to a


specific quadrant of a woman’s pelvis
 Right anterior

 Left anterior

 Right posterior

 Left posterior

MARY LOURDES NACEL G. CELESTE, RN, MD 73


 Maternal pelvis is designated per her
right/left and anterior/posterior
– Expressed as standard three letter
abbreviation; e.g., LOA = left occiput
anterior, indicating vertex presentation
with fetal occiput on mother’s left side
toward the front of her pelvis

– Fetal position reflects the orientation of


the fetal head or butt within the birth
canal.

MARY LOURDES NACEL G. CELESTE, RN, MD 74


 Anterior Fontanel
The bones of the fetal scalp are soft and
meet at "suture lines." Over the forehead,
where the bones meet, is a gap, called the
"anterior fontanel," or "soft spot." This will
close as the baby grows during the 1st year
of life, but at birth, it is open.
 The anterior fontanel is an obstetrical
landmark because of its' distinctive diamond
shape. Feeling this fontanel on pelvic exam
tells you that the forehead is just beneath
your fingers.
 Early in labor, it is usually difficult (if not
impossible) to feel the anterior fontanel. After
the patient is nearly completely dilated, it
becomes easier to feel the fontanel.
 When attaching a fetal scalp electrode, it is
better to not attach it to the area of the
fontanel. MARY LOURDES NACEL G. CELESTE, RN, MD 75
 Posterior Fontanel
The occiput of the baby has a similar
obstetric landmark, the "posterior
fontanel."
 This  junction of suture lines in a Y
shape that is very different from the
anterior fontanel.
 In cases of fetal scalp swelling or
significant molding, these landmarks
may become obscured, but in most
cases, they can identify the fetal head
position as it is engaged in the birth
canal. MARY LOURDES NACEL G. CELESTE, RN, MD 76
MARY LOURDES NACEL G. CELESTE, RN, MD 77
Left occiput anterior
(LOA)

MARY LOURDES NACEL G. CELESTE, RN, MD 78


Right occiput anterior
(ROA)

MARY LOURDES NACEL G. CELESTE, RN, MD 79


Left occiput transverse
(LOT)

MARY LOURDES NACEL G. CELESTE, RN, MD 80


Right occiput
transverse
(ROT)

MARY LOURDES NACEL G. CELESTE, RN, MD 81


Occiput posterior
(OP)

MARY LOURDES NACEL G. CELESTE, RN, MD 82


Occiput Anterior
(OA)

MARY LOURDES NACEL G. CELESTE, RN, MD 83


Left occiput posterior
(LOP)

MARY LOURDES NACEL G. CELESTE, RN, MD 84


Right occiput posterior
(ROP)

MARY LOURDES NACEL G. CELESTE, RN, MD 85


MARY LOURDES NACEL G. CELESTE, RN, MD 86
FETAL POSITION

MARY LOURDES NACEL G. CELESTE, RN, MD 87


Station
 level of presenting part of fetus
in relation to imaginary line
between ischial spines (zero
station) in midpelvis of mother
– –5 to –1 indicates a presenting part
above zero station (floating); +1 to
+5, a presenting part below zero
station
– Engagement – when the presenting
part is at station zero
MARY LOURDES NACEL G. CELESTE, RN, MD 88
STATION or DEGREE OF ENGAGEMENT

MARY LOURDES NACEL G. CELESTE, RN, MD 89


III. Power – force
expelling the fetus and
placenta
1. Primary – involuntary uterine
contractions
 Three phases
 Increment – steep crescent slope
from beginning of a contraction
until its peak
 Acme/peak – strongest intensity
 Decrement – diminishing intensity

MARY LOURDES NACEL G. CELESTE, RN, MD 90


Characteristics of
contractions
 1. Frequency – time frame in minutes from
1. Frequency – time frame in minutes from
the beginning of one contraction to the
beginning of the next one; frequency of less
than every 2 min should be reported
 2. Duration – time frame in seconds from the
beginning of a contraction to its completion;
more than 90 s should be reported because
of potential risk of uterine rupture or fetal
distress
 3.Intensity – the strength of a contraction at
acme; may be assessed by subjective
description from the woman, palpation (mild
contraction would feel like the tip of the
nose, moderate like the chin, strong like the
forehead), or electronic intrauterine pressure
catheter (IUPC)
MARY LOURDES NACEL G. CELESTE, RN, MD 91
2. Secondary – voluntary bearing-down
efforts

 Psychological state of the woman – fear


and anxiety may lead to increased
perception of pain and impede progress
of labor; preparation and support for
childbirth may enhance coping efforts
 Preparation for childbirth education about
the birthing process and methods to
decrease discomfort and tension
 Relaxation of voluntary muscles
 Distraction, focal point, imagery
 Breathing techniques with each
contraction MARY LOURDES NACEL G. CELESTE, RN, MD 92
 a.Always begin and end with “cleansing”
or “relaxing” breath (inhale deeply
through nose and exhale passively
through relaxed, pursed lips)
 b.Hyperventilation – may cause maternal
respiratory alkalosis and compromise fetal
oxygenation; characterized by light-
headedness, dizziness, tingling of fingers
and/or circum-oral numbness; managed
by having woman breathe into her cupped
hands or a paper bag
 Support person/”coach” should be
involved in the formal preparation
MARY LOURDES NACEL G. CELESTE, RN, MD 93
 Position (maternal)
 Side-lying enhances blood flow to
the utero-feto-placental unit and
maternal kidneys
 Upright (standing, walking,
squatting) enlists gravity to aid in
fetal descent through the birth
canal
 Frequent changes relieve fatigue
and improve circulation
MARY LOURDES NACEL G. CELESTE, RN, MD 94
 Cardinal mechanisms/
movements of labor in
vertex presentation
 usually flow smoothly and often
overlap; failure to accomplish one
or more usually requires
obstetrical intervention

(ED FIrE ErE)


MARY LOURDES NACEL G. CELESTE, RN, MD 95
Cardinal mechanisms/
movements of labor in vertex
presentation
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 Restitution and external rotation
 Expulsion
MARY LOURDES NACEL G. CELESTE, RN, MD 96
 Engagement - movement of the presenting
part below the plane of the pelvic inlet
 Descent – progress through the maternal
pelvis; continuous throughout labor
 Flexion – as a result of resistance from
maternal pelvis and musculature, the head
flexes so that a smaller diameter enters
pelvis
 Internal rotation – head rotates from occiput
transverse or oblique position (usual position
as it enters the pelvis) to anterior/posterior
at pelvic outlet; head is under symphysis
pubis and neck is twisted
MARY LOURDES NACEL G. CELESTE, RN, MD 97
 Extension – the head is moved backward
as it proceeds under the symphysis pubis
and baby is born by extension over the
perineum
 Restitution and external rotation –
movement of head to align itself with
face and shoulders (restitution) and then
rotation bringing shoulders into
anteroposterior diameter appears as one
movement
 Expulsion – first the anterior shoulder
under the symphysis pubis, then the
posterior shoulder over the perineum,
followed rapidly by the rest of the body;
time of birth is recorded at this time
MARY LOURDES NACEL G. CELESTE, RN, MD 98
MECHANISM OF LABOR & CARDINAL MOVEMENTS OF A
FETUS

MARY LOURDES NACEL G. CELESTE, RN, MD 99

Mary Lourdes Nacel G. Celeste, R.N., M.D.


Signs of Labor
 Preliminary signs of labor
Lightening
Increase in level of activity
Braxton Hicks contractions
Ripening of the cervix

MARY LOURDES NACEL G. CELESTE, RN, MD 100


Signs of Labor
 Signs of true labor
Uterine contractions
Show
Rupture of membranes

MARY LOURDES NACEL G. CELESTE, RN, MD 101


Signs and symptoms
of labor:
 1. Impending – may begin several
weeks prior to labor
 Lightening “the baby dropped”
 settling of uterus and fetal presenting
part into pelvis
 sensation of decreased abdominal
distention
 Increase Braxton-Hicks
contractions
 mild, intermittent, irregular, abdominal
 contractions
MARY LOURDES NACEL G. CELESTE, RN, MD 102
  decrease/disappear with activity
 May be heightened anxiety, and
anticipation, fatigue
 Weight loss of about 2-3 lb 3-4 d
before onset of labor; related to
changes in estrogen and
progesterone levels
 Increased vaginal mucus
discharge
 Fetal movements may appear
less active
 May be episodes of false labor
MARY LOURDES NACEL G. CELESTE, RN, MD 103
2. Onset
 Expulsion of mucous plug; pink/brown-tinged
discharge (bloody show)
 Regular contraction increasing in frequency,
duration, and intensity
 Spontaneous rupture of membranes (SROM) may
occur before or during
 Check FHR by auscultation for 1 min and with next
contraction
 May be a gush or trickle; report strong/foul odor
(infection), meconium-stained (in vertex
presentation, may indicate fetal anoxia) or wine-
colored (indicative of premature separation of
placenta) MARY LOURDES NACEL G. CELESTE, RN, MD 104
 Questionable leakage of
amniotic fluids should be tested
for alkalinity to differentiate
from urine:
– Nitrazine tape turns
blue/gray/green (alkaline); urine
(acidic) does not change the yellow
color
– A mixture of cervical mucus and
amniotic fluid dried on a slide looks
like crystallized ferns by
microscopic examination
MARY LOURDES NACEL G. CELESTE, RN, MD 105
Cervical changes
 Effacement – thinning and
shortening of the cervix during
late pregnancy and/or labor;
measured in percentages (100%
is fully effaced)
 Dilation – opening and
enlargement of the cervical canal;
measured in centimeters 0-10 cm
(10 cm is fully dilated)
MARY LOURDES NACEL G. CELESTE, RN, MD 106
EFFACEMENT AND DILATION OF CERVIX

MARY LOURDES NACEL G. CELESTE, RN, MD 107


TRUE VERSUS FALSE
LABOR
True False
Contractions – Contractions –
regular with irregular with
increasing usually no change
frequency in frequency,
(shortened duration, or
intervals), intensity
duration, and
intensity
Discomfort Discomfort is
radiates from usually
back around the abdominal
abdomen
Contractions do Contractions may
not decrease lessen with
with rest activity or rest
Cervix Cervical changes
progressively do not occur
effaced and

MARY LOURDES NACEL G. CELESTE, RN, MD 108


DIVISIONS OF LABOR/ FRIEDMAN’S
CURVE

MARY LOURDES NACEL G. CELESTE, RN, MD 109


Stages of Labor
 First stage
Latent phase
Active phase
Transition phase

MARY LOURDES NACEL G. CELESTE, RN, MD 110


Stages of Labor
 Second stage
Period from full dilatation and
cervical effacement to birth of
the infant
 Third stage

Placental separation
Placental expulsion
MARY LOURDES NACEL G. CELESTE, RN, MD 111
Friedman’s Division of
Labor
 Stages of Labor:
 First stage (dilating/ Cervical stage) – from onset of
regular contraction to full cervical dilation
 AVE: 13-18 h for nulliparas
 8-9 h for multiparas

 A. Latent phase (0-4 cm) – the cervix begins


effacing and dilating and contractions become
increasingly stronger and more frequent
 DURATION: nulliparas 7-10 h
 multiparas 5-6 h

MARY LOURDES NACEL G. CELESTE, RN, MD 112


B. Active phase (5-7 cm) – more rapid dilation
of cervix and descent of presenting part
 DURATION: approximately 3-4 h for
both

C. Transition (8-10 cm) – contractions may be


every 1.5 to 2 min and last 60-90sec
 DURATION: should not > 3 h for
nulliparas
 1 h for
multiparas
MARY LOURDES NACEL G. CELESTE, RN, MD 113
 May be accompanied by irritability
and restlessness, hyperventilation,
and dark heavy show, as well as leg
cramps, nausea/vomiting, hiccups,
belching
 Possible rectal pressure creating a
desire to push; should discourage
before full dilation because it may
cause maternal exhaustion and
cervical and fetal trauma
MARY LOURDES NACEL G. CELESTE, RN, MD 114
 * Monitor vital signs and FHR
 *Provide comfort measures (ambulate
if tolerated and if BOW is not ruptured
yet; side lying is usually most
comfortable, sacral pressures, back
rubs)
 *Breathing technique during transition
phase: Take a deep breath and exhale
slowly and completely. At beginning of
contraction, take a fairly deep breath.
Then engage in shallow breathing. If
there is an urge to push, puff out every
3rd, 4th, or 5th breath. Take deep
breath at the end of contraction.
MARY LOURDES NACEL G. CELESTE, RN, MD 115
 2. Second stage (stage of
expulsion) – from complete
dilation of cervix to delivery of the
baby
 AVE: 2 h for nulliparas
 20 min for multiparas
 Contractions are now severe,
lasting 60-90sec at 1.5 to 3 min
intervals
MARY LOURDES NACEL G. CELESTE, RN, MD 116
 Bearing down/pushing increases intra-
abdominal pressure from voluntary
contraction of maternal abdominal
muscles and pushes the presenting
part against the pelvic floor, causing a
stretching, burning sensation and
bulging of the perineum; “crowning”
occurs when the presenting part
appears at the vaginal orifice,
distending the vulva
 Timing of transfer to delivery room
 Nulliparas – during second stage when
the presenting part begins to distend
the perineum
 Multiparas – at the end of first stage
when the cervix is dilated 8-9 cm
MARY LOURDES NACEL G. CELESTE, RN, MD 117
 Third stage (placental stage) –
from delivery of the baby to delivery
of the placenta; if more than 30 min,
placenta is considered retained
 AVE: < 30mins
 Separation of placenta from the
uterine wall evidenced by a change
in the fundus from discoid to globular
shape as it becomes firm and rises in
the abdomen, a sudden gush/trickle
of blood and lengthening of the
umbilical cord
 Expulsion of the placenta through the
vagina by uterine contractions and
pushing by mother or by gentle
traction on the umbilical cord
MARY LOURDES NACEL G. CELESTE, RN, MD 118
Placental delivery make take 5-10
minutes (maximum 30 minutes)
Either by
 Duncan – margin of the placenta
separates first and the dull, red,
rough maternal surface emerges
from from the vagina first (dirty
presentation)
 Schultze – center portion of the
placenta separates first and the
shiny and glistening fetal surface
emerges from the vagina
MARY LOURDES NACEL G. CELESTE, RN, MD 119
 *Crede’s maneuver – gentle pressure
on the contracted uterine fundus
(never on a noncontracted uterus;
uterus may evert and lead to
hemorrhage)

 Contraction of the uterus following


delivery controls uterine hemorrhage
and produces placental separation: if
necessary, Pitocin (oxytocin) or
Methergine (methylergonovine
maleate) may be administered to help
contract the uterus
MARY LOURDES NACEL G. CELESTE, RN, MD 120
 Fourth stage – immediate recovery
period from delivery of placenta to
stabilization of maternal systemic
responses and contraction of the
uterus
 DURATION: from 1 to 4 h
– Mother begins to readjust to non-
pregnant state
– Areas of concern include discomfort due
to contraction of uterus 9after pain)
and/or episiotomy, fatigue or exhaustion,
hunger, thirst, excessive bleeding,
bladder distention, parent-infant
interaction
MARY LOURDES NACEL G. CELESTE, RN, MD 121
STAGES OF LABOR
STAGE PHASE Dilatation Duration/Interval Intensity
First Phase1- 0-4 cm 10-30 sec/ 5-30 Mild to
Stage Latent min moderate
Phase 2- 5-7 cm 30-40 sec/ 3-5 Moderate
Active min to strong
Phase 3- 8-10 cm 45-90sec/ 2-3 min strong
Transition
Second From full cervical dilatation (10 cm) up to the
Stage expulsion of the fetus
-in the later phase of this stage, station becomes (+);
+4 to birth
-contraction becomes 1-2 minutes apart; fetal head
visible; increased urgency to bear down
3rd Placental Delivery- sudden gush of blood,
Stage lengthening of the cord, rising of the fundus,
globular uterus
4th First 4 hours after delivery of the placenta (monitor
Stage VS, fundus and lochia until stable)
MARY LOURDES NACEL G. CELESTE, RN, MD 122
Maternal and Fetal Responses to
Labor
 Danger signs of labor -
fetal
 Heartrate
 Meconium staining

 Hyperactivity

 Fetal acidosis

MARY LOURDES NACEL G. CELESTE, RN, MD 123


Maternal and Fetal Responses

 Dangersigns of labor -
maternal
 Blood pressure
 Abnormal pulse

 Inadequate or prolonged contractions

 Pathologic retraction ring

 Abnormal lower abdominal contour

 Apprehension
MARY LOURDES NACEL G. CELESTE, RN, MD 124
MARY LOURDES NACEL G. CELESTE, RN, MD 125
Maternal and Fetal Assessment

 Assessment of stage one


History
Physical exam
Leopold’s maneuvers
Rupture of membranes
Vaginal exam
Pelvic adequacy

MARY LOURDES NACEL G. CELESTE, RN, MD 126


Assessment
 Laboratory analysis
Blood
Urine
 Uterine contractions
Length
Intensity
Frequency

MARY LOURDES NACEL G. CELESTE, RN, MD 127


LOCATING FETAL HEART SOUNDS BY FETAL POSITION

MARY LOURDES NACEL G. CELESTE, RN, MD 128


Electronic
Monitoring
External and Internal Monitoring
Telemetry
FHR and uterine contractions
FHR patterns
Baseline FHR
Periodic changes

MARY LOURDES NACEL G. CELESTE, RN, MD 129


Assessment Techniques
 Scalp stimulation
 Fetal blood sampling

 Acoustic stimulation

MARY LOURDES NACEL G. CELESTE, RN, MD 130


Fetal Heart Monitoring
 Labor is stressful for the fetus;
therefore, continual assessment of
fetal well- being through fetal heart
rate monitoring is essential.
 Fetal well-being is determined by the
response of the fetal heart rate to
uterine contractions.
 Fetal anoxia resulting from stressful
labor must be avoided to prevent
intrauterine death or neurological
damage. MARY LOURDES NACEL G. CELESTE, RN, MD 131
NORMAL FHR: 120 – 160 bpm
 Fetal monitoring during labor and delivery

 Methods
 1. Periodic auscultation of the fetal heart by
fetoscope (stethoscope adapted to amplify sound or
Doptone (ultrasound stethoscope) during contractions
and for 30sec beyond; best heard over fetal back
 Electronic fetal monitoring (EFM) – continuous
monitoring providing audio and visual recordings as
well as tracing strips
 External – indirect, noninvasive method using a
lubricated (water-soluble gel) ultrasound transducer
attached to the abdomen
 Internal – small electrode attached to the fetal scalp;
indicated for high-risk maternity patient, problematic
labor, or with oxytocin use; requires ROM, cervical
dilation of at least 2 cm, and presenting part can be
reached
MARY LOURDES NACEL G. CELESTE, RN, MD 132
a. Alterations in fetal heart rate

 a. Normal – 120-160 BPM


 b. Tachycardia (>160 BPM) – associated
with prematurity, maternal fever, fetal
activity, or fetal hypoxia/infection, drugs; if
continued for an hour or more, or
accompanied by late deceleration, indicates
fetal distress
 c. Bradycardia (<120 BPM) – associated with
fetal hypoxia, maternal drugs/hypotension,
prolonged cord compression, congenital
heart lesions; persistent bradycardia or
persistent drop of 20 beats per min below
baseline mayMARYindicate
LOURDES NACELcord
G. CELESTE,compression
RN, MD or 133
separation of the placenta
Variability – beat-to-beat fluctuations;
measured by internal EFM only

 a. Normal (6-25 BPM) – significant indicator


of fetal well-being
 b. Absent (0-2 BPM) or decreased (3-5 BPM)
may be associated with fetal sleep state,
fetal prematurity, reaction to drugs,
congenital anomalies, hypoxia, acidosis; if
persists for more than 30 min is indicator of
fetal distress
 c. Increased (>25 BPM) – significance is not
known
 d. Loss of the baseline (beat-to-beat
variation) or “smoothing out” of the
baseline is often prelude to infant death 134
MARY LOURDES NACEL G. CELESTE, RN, MD
Periodic changes
 1.Accelerations – rise above baseline followed by a
return; usually in response to fetal movement or
contractions
 2.Decelerations – fall below baseline followed by a
return
 Early – occurs before peak contraction; most often
uniform mirror image of contraction on tracing;
associated with head compression, commonly in
second stage with pushing
 Late – onset after the peak with slow return to
baseline; indicative of fetal hypoxia because of
deficient placental perfusion
 Variable deceleration – transient U/V/M-shaped
reduction occurring at any time before, during, or
after contraction; indicative of cord compression,
which may be relieved by change in mother’s
position; ominous if repetitive,
MARY LOURDES NACEL G. CELESTE,prolonged,
RN, MD severe, or
135
has slow return to baseline
 Nursing interventions
– None for early decelerations
– For late decelerations (at the first sign of
abnormal tracing) – position mother left
side-lying (if no change, move to other
side, Trendelenburg or knee/chest
position); administer oxygen by mask,
start IV or increase flow rate, stop
oxytocin if appropriate; if the pattern
persists, fetal scalp blood sampling for
acidosis (pH >7.25 is normal, 7.20-7.24
is considered preacidotic – repeat in 10-
15 min; 7.2 or less indicates serious
acidosis; prepare for cesarean section)
MARY LOURDES NACEL G. CELESTE, RN, MD 136
Fetal Heart Rate Patterns Indicative of… Intervention
Tachycardia (>160 bpm) Maternal or fetal infection Depends on the cause
Fetal hypoxia (ominous
sign)
Bradycardia (<120 bpm) Fetal hypoxia or stress Place client on her left side
Maternal hypotension after Increase fluids to
epidural initiation counteract hypotension
Stop oxytocin (Pitocin) if in

use
Early deceleration Head compression :not None required
(deceleration begins and ominous
ends with uterine Vagal stimulation
contraction)
Late deceleration Fetal stress and hypoxia Change maternal position
(HR decreases after peak of Deficient placental Correct hypotention

contraction and recovers perfusion Increase IV fluid rate as


after contraction ends) Supine position ordered
Maternal hypotension Discontinue oxytocin

Uterine hyperstimulation Administer oxygen as

Variable deceleration Cord compression ordered


Change maternal position

(transient decrease in HR Hypoxia or hypercarbia Administer Oxygen


anytime during contraction
Decreased variability Fetalsleep cycle Depends on the cause
Depressant drugs

Hypoxia

CNS anomalies
MARY LOURDES NACEL G. CELESTE, RN, MD 137
Nursing Care: First Stage
 Respect contraction time
 Change positions

 Voiding and bladder care

 Support

 Pain management

MARY LOURDES NACEL G. CELESTE, RN, MD 138


Nursing Care: Second
Stage
 Preparing for birth
 Positioning for birth
 Pushing
 Perineal cleaning
 Episiotomy
 Birth
 Cutting and clamping the cord

MARY LOURDES NACEL G. CELESTE, RN, MD 139


Perineal cleaning

MARY LOURDES NACEL G. CELESTE, RN, MD 140


EPISIOTOMY

MARY LOURDES NACEL G. CELESTE, RN, MD 141


RITGEN’S MANEUVER

MARY LOURDES NACEL G. CELESTE, RN, MD 142


MARY LOURDES NACEL G. CELESTE, RN, MD 143
MARY LOURDES NACEL G. CELESTE, RN, MD 144
A child is considered born when the whole body is delivered.

MARY LOURDES NACEL G. CELESTE, RN, MD 145


UMBILICAL CORD CLAMP APPLIED TO
CORD

MARY LOURDES NACEL G. CELESTE, RN, MD 146


Providing Comfort
During Labor and
Birth
Mary Lourdes Nacel G. Celeste, R.N., M.D.
Intapartal nursing
management
 Stage 1
 Maternal
 Monitor vital signs, fluid and electrolyte balance,
frequency, duration, and intensity of uterine
contractions and degree of discomfort (hourly,
at minimum); urine protein and glucose with
every voiding; laboratory results; preparedness;
ROM
 Provide comfort measures – e.g., positioning,
back massage/effleurage (light abdominal
stroking in rhythm with breathing during a
contraction to ease mild/moderate discomfort),
warm/cold compresses, ice chips
MARY LOURDES NACEL G. CELESTE, RN, MD 148
1. Support coping measures – reassure,
explain procedures, reinforce/teach
breathing techniques, relaxation, focal
point
2. Assist support person
 Fetal – monitor status

MARY LOURDES NACEL G. CELESTE, RN, MD 149


 Stage 2
 Maternal
– Monitor physical status; assess progress of
labor, perineal and rectal bulging,
increased vaginal show
– Assist in techniques to foster expulsion –
encourage bearing down focus on vaginal
orifice (discourage breath holding for more
than 5sec), position squatting, side-lying,
Fowler’s as appropriate
– Provide comfort measures; support coping
measures; assist support person
MARY LOURDES NACEL G. CELESTE, RN, MD 150
 Fetus/neonate
 Monitor fetal heart rate and regularity
 Provide immediate neonatal care
– Assist M.D./nurse/midwife; neonate may be held at
above or below level of vagina until cord pulsations
cease, then cord is clamped and cut; mucus, is
removed by bulb syringe immediately after the
head is delivered (mouth before nose to avoid
aspiration)
– Record time of birth
– Hold neonate with head slightly lowered to
expedite drainage of amniotic fluid, mucus, and
blood
– Inspect cord for two arteries and one vein
– Dry and wrap neonate to prevent heat loss
MARY LOURDES NACEL G. CELESTE, RN, MD 151
 Stage 3
 Maternal – observe for signs and symptoms
of placental separation; assess amount of
blood loss; monitor blood pressure, pulse,
and fundus frequently
 Neonate
 Apgar scores at 1 and 5 min to evaluate
condition at birth
– Based on five signs: heartbeat, respiratory effort,
muscle tone, reflex irritability, color
– Each sign rated 0-2 2 is top score); all the scores
are added for total score
– 7-10 (good condition) should do well in normal
neonatal nursery; 4-6 (fair condition) may require
close observation; 0-3 (extremely poor condition)
resuscitation and intensive care are acquired

MARY LOURDES NACEL G. CELESTE, RN, MD 152


Assessment for Well-Being

 Apgar scoring
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

MARY LOURDES NACEL G. CELESTE, RN, MD 153


MARY LOURDES NACEL G. CELESTE, RN, MD 154
APGAR SCORE
0 1 2
Cardiac tone Absent Slow (<100 BPM) Normal (>100 BPM)
Respiration Absent Slow, irregular Good cry
Muscle tone Flaccid Some flexion Active
Reflexes No response Cry Vigorous cry
Color Blue, pale Body pink, Completely pink
extremities blue

MARY LOURDES NACEL G. CELESTE, RN, MD 155


 Maintain temperature – minimize
exposure to environmental heat loss
(evaporation, radiation, conduction,
convection); skin-to-skin with mother
or at 36.4°C skin temperature
 Weigh and measure infant
 Place identification band on infant;
footprint infant and fingerprint
mother
 Record time of first void and stool
(meconium) after delivery; monitor
physical status
MARY LOURDES NACEL G. CELESTE, RN, MD 156
 Initiate parent-child interaction
 Instill prophylactic eye
drops/ointment – legally required to
prevent conjunctival gonococcal
infection that could lead to blindness
in the neonate; 1% silver nitrate or
0.5% erythromycin
 Administer intramuscular vitamin K –
for first 34 d of life the neonate is
unable to synthesize vitamin K, which
is necessary for blood clotting and
MARY LOURDES NACEL G. CELESTE, RN, MD 157

coagulation
 Stage 4
 Monitor maternal blood pressure and
pulse; uterine contractility tone and
location; amount and color of lochia,
presence of clots; condition of
episiotomy every 15 min x 4
 Monitor bladder function
 Provide comfort
 Evaluate parenteral interaction
MARY LOURDES NACEL G. CELESTE, RN, MD 158
FOURTH STAGE OF LABOR
First 1-2 h Nursing Considerations
Vital signs (BP, pulse) q 15 min Follow protocol until stable
q 15 min Position – even to 1 cm/finger breadth above the
umbilicus for the first 12 h, then descends by one
Fundus
finger breadth each succeeding day, pelvic usually by
day 10
q 15 min Lochia (endometrial sloughing) – day 1-3 rubra (bloody
Lochia with fleshy odor; may be clots); day 4-9 serosa
(color, volume) (pink/brown with fleshy odor); day 10+ alba (yellow-
white); at no time should there be a foul odor
(indicates infection)
Urinary Measure first void May have urethral edema, urine retention
Bonding Encouraged interaction Emphasize touch, eye contact

MARY LOURDES NACEL G. CELESTE, RN, MD 159


Delivery
1. Normal spontaneous vaginal
delivery
 The mother is encouraged not to push
as the head is delivered; the infant
cries (or is encouraged to do so to
expand the lungs); if the cord is
encircling the neck (nuchal cord), it is
gently slipped over the head
 Episiotomy (a surgical incision of the
perineum) may be done at the end of
the second stage of labor to facilitate
delivery and to avoid laceration of the
MARY LOURDES NACEL G. CELESTE, RN, MD 160

perineum
Types of Episiotomy
 Median – rare faulty healing,
easier to make and repair
 Mediolateral – tearing in the anus
and rectum is rare

MARY LOURDES NACEL G. CELESTE, RN, MD 161


 Classification of Perineal
Laceration
 First Degree – involves the perineal
mucosa
 Second Degree – involves the muscle
of the perineal body but does not
involve the rectal sphincter
 Third Degree – involves the rectal
sphincter but not the rectal mucosa
 Fourth Degree – involves the rectal
mucosa
MARY LOURDES NACEL G. CELESTE, RN, MD 162
Mary Lourdes Nacel G. Celeste, R.N., M.D.
MARY LOURDES NACEL G. CELESTE, RN, MD 163
Operatives deliveries

2.Forceps delivery
forceps - two doubled-curved,
spoonlike articulated blades used to
extract the fetal head; indicated if
mother cannot push fetus out or
compromised maternal/fecal status in
late second stage; contraindicated in
cephalopelvic disproportion (CPD)

MARY LOURDES NACEL G. CELESTE, RN, MD 164


 Classification:
– Outlet – fetal head is on the pelvic
floor
– Low – fetal head is below station +2
but not reached the pelvic floor
– Mid – fetal head is below station 0
but not reached station +2
– High – fetal head is above station 0

MARY LOURDES NACEL G. CELESTE, RN, MD 165


Indications:
 Prolonged second stage (most
common)
 Non reassuring EFM strip
 Avoiding maternal pushing
 Breech presentation

Complications
 Maternal – lacerations
 fetal – neonatal – soft tissue
compression or cranial injury
MARY LOURDES NACEL G. CELESTE, RN, MD 166
MARY LOURDES NACEL G. CELESTE, RN, MD 167
2. Vacuum extractor – delivery with
use of suction device that is
applied to the fetal scalp for
traction; used in prolonged second
stage; contraindicated in CPD and
face/breech presentation
Indications:
 Prolonged second stage (most
common)
 Non reassuring EFM strip
 Avoiding maternal pushing
 Breech presentation
MARY LOURDES NACEL G. CELESTE, RN, MD 168
Complications
 Maternal – lacerations

 fetal – neonatal –
cephalhematoma and scalp
laceration, subgluteal hematoma
and intracranial hemorrhage
(>10min)

MARY LOURDES NACEL G. CELESTE, RN, MD 169


MARY LOURDES NACEL G. CELESTE, RN, MD 170
4. Cesarean delivery

MARY LOURDES NACEL G. CELESTE, RN, MD 171


Comfort and Pain Relief
 Support from doula or coach
 Alternative therapies

Relaxation
Focusing and imagery
Breathing
Herbal preparations

MARY LOURDES NACEL G. CELESTE, RN, MD 172


Comfort and Pain Relief
 Pharmacological Measures
Goals
Preparation
Narcotic analgesics
 Intrathecal

Regional anesthesia

MARY LOURDES NACEL G. CELESTE, RN, MD 173


Nursing Care: Promoting
Comfort
 Reducing anxiety
 Coping strategies

 Comfort measures

 Positioning

 Childbirth method

 Pharmacologic pain relief


MARY LOURDES NACEL G. CELESTE, RN, MD 174
Pharmacological control of
discomfort

 Principles of use – minimize pain


without increasing risk to mother
or fetus; type of pain relief is
influenced by length of gestation,
mother’s emotional status,
response to pain, previous history
with analgesics or anesthesia,
and general character of labor
process MARY LOURDES NACEL G. CELESTE, RN, MD 175
Analgesia – alleviation of the sensation
of pain or the elevation of one’s
thresshold for perception of pain

 Narcotic analgesics – effective for


relief of severe, persistent pain
- with no amnesic effect
- adverse effects: nausea and
vomiting, maternal respiratory
depression, neonatal CNS depression
(blocking nerve impulses to the brain)
requiring stimulation or resuscitation
at delivery
- cross the placental barrier and affect
the neonate
EX: Meperidine HCl (Demerol);
MARY LOURDES NACEL G. CELESTE, RN, MD 176

Morphine sulfate
Anesthesia- includes analgesia, amnesia,
and relaxation; abolishes pain
perception by CNS depression

 epidural block –most common; local


anesthetic such as lidocaine or
bupivocaine is injected into the
epidural space surrounding the spinal
cord; a catheter is placed for
continuous epidural anesthesia
- - if hypotension occurs, woman
should be placed on her left side; IV
rate should be accelerated as ordered;
oxygen support should be
administered if ordered and doctor
MARY LOURDES NACEL G. CELESTE, RN, MD 177
should be notified
Regional
Anesthesia
 Injection
of local
anesthesia to block specific
nerve pathways
Epidural anesthesia
 Nursingcare
 Administration

Spinal anesthesia
MARY LOURDES NACEL G. CELESTE, RN, MD 178
Medication for Pain Relief:
Birth
 Local anesthesia
Local infiltration
Pudendal nerve block
 General anesthesia
Preparation
Aspiration of vomitus
MARY LOURDES NACEL G. CELESTE, RN, MD 179
MARY LOURDES NACEL G. CELESTE, RN, MD 180
MARY LOURDES NACEL G. CELESTE, RN, MD 181
 Timing of administration
 1. Before 5 cm (latent phase) – may
retard or stop labor
 From 5 to 7 cm (early active phase) –
may aid relaxation
 After 8 cm (transition phase) – may
result in respiratory depression
requiring resuscitative measures in
sedated neonate
 - Because most medications cross the
placental barrier, FHR is taken
frequently before and after
administration of medication
MARY LOURDES NACEL G. CELESTE, RN, MD 182
 Obstetrical analgesia – functions
through alleviation of sensation of pain
or enhancement of threshold for pain
 Sedatives/hypnotics – used less
frequently than previously because of
incidence of side effects
 Narcotics
– Morphine sulfate – used rarely because of
adverse reactions
– Meperidine hydrochloride (Demerol) –
most commonly used; mother and infant
interaction may be limited in immediate
postpartum period because infant may still
be sluggish and less alert
– Alphaprodine (Nisentil) – may be given
IV/SC but never IM because of
unpredictability by this route
MARY LOURDES NACEL G. CELESTE, RN, MD 183
– Mixed narcotic agonist-antagonist
compounds (Stadol [IM/IV/SC], Talwin
[IV/IM] but not SC, which can cause severe
tissue damage) – analgesia while
decreasing side effects but can still
produce respiratory depression, nauseas
and vomiting, light-headedness
– Narcotic antagonist (Narcan) – counteracts
respiratory depressant effects; may be
administered to mother IM/IV 5-15 min
prior to delivery or to neonate IV via
umbilical vein immediately after birth
 Note: Narcotic antagonist given to a
woman who is addicted to narcotics
may cause immediate withdrawal
symptoms. MARY LOURDES NACEL G. CELESTE, RN, MD 184
 Analgesic potentiator/ataractic
(Phenergan, Largon, Vistaril,
Sparine) – tranquilizing effect,
decreasing apprehension and
anxiety as well as the nausea and
vomiting associated with many
analgesics; fetal and neonatal
problems are rare
MARY LOURDES NACEL G. CELESTE, RN, MD 185
 Anesthetics
 Inhalation
– Nitrous oxide and oxygen – used
intermittently with each
contraction; patient is able to
cooperate in bearing down;
increased danger of neonatal
depression with continued use
after 15-20 min
– Trilline/Penthine – self-
administered by mother with
inhaler (under supervision); may
cause maternal and fetal narcotic
depression
MARY LOURDES NACEL G. CELESTE, RN, MD 186
 Regional blocks – allow mother to be awake
and participate in process; can increase
incidence of maternal hypotension and fetal
bradycardia; need for forceps delivery,
prolonged labor or uterine atony, necessity
for catheterization, and sometimes post
spinal headache
1. Lumbar epidural block –affects the entire pelvis by
blocking impulses at level of T12 through S5; may
be administered continuously through tubing left in
place; incidence of maternal hypotension may be
minimized if 500-1000 ml of IV fluids is infused at a
rapid rate prior to administration and mother is
maintained in side-lying position
 There must be vigilant monitoring of maternal
BP and FHR every 1-2 min x 15 min and every
10-15 min thereafter
MARY LOURDES NACEL G. CELESTE, RN, MD 187
 Treatment of maternal hypotension includes
– Mild/Moderate – place mother in left
lateral position, increase the rate of IV
fluid; administer oxygen by mask
– Severe/prolonged – place mother in
Trendelenburg position for 2-3 min
2. Caudal – administered during second stage
just before delivery; not commonly used
3. Subarachnoid block/ “saddle block” (nerves
from S1 to S4) – anesthetizes perineum,
lower pelvis, and upper thighs; diminishes
pushing efforts; high incidence of maternal
hypotension and potential for fetal hypoxia

MARY LOURDES NACEL G. CELESTE, RN, MD 188


3. Spinal block – now used primarily
just prior to cesarean delivery
4. Paracervical block analgesics –
injection of an anesthetic solution
into region around cervical area to
relieve pain caused by cervical
dilation; thought to have a
depressing effect on infant’s
respiratory center
5. Intravenous anesthesia (Pentothal) –
rarely used, can cause fetal
depression, maternal laryngospasm,
vomiting and aspiration, postpartal
uterine atony

MARY LOURDES NACEL G. CELESTE, RN, MD 189


COMMON ANALGESICS AND ANESTHETICS OF LABOR AND DELIVERY
Medication Side Effects Nursing Considerations
Meperidine hydrochloride Hypotension Increases pain tolerance
(Demerol) Respiratory depression Do not administer within 2 h of
Gastric irritability expected delivery
Constipation
Bradycardia
Constricted pupils
Secobarbitol sodium (Seconal) Drowsiness Sedates
Lethargy Anxiety relief
Respiratory depression
Angioedema
Naloxone hydrochloride Tachycardia IV into umbilicus vein for neonates
(Narcan) Hypertension (0.01 mg/kg)
Tremors Reverses narcotic depression
Thiopental sodium (Sodium Respiratory depression Induction anesthesia for cesarean
pentothal) secretion
Tetraccaine hydrochloride Confusion If subarachnoid space used, keep
(Pontocaine; lidocaine) Tremors patient flat for 6-8 h
Restlessness Regional nerve block
Hypotension Relieves uterine or perineal pain
Dysrhythmias
Tinnitus
Blurred vision

MARY LOURDES NACEL G. CELESTE, RN, MD 190


Cesarean Birth

Mary Lourdes Nacel G. Celeste, R.N., M.D.


Nursing Care:
Anticipating a
Cesarean
Immediate preoperative care
 Informed consent
 Hygiene
 GI tract preparation
 Baseline intake and output
 Hydration
 Preoperative medication
 Checklist
 Transport
 Role of support person
MARY LOURDES NACEL G. CELESTE, RN, MD 192
Nursing Care:
Cesarean Birth
 Intraoperative care
Anesthesia
Skin preparation
Surgical incision
 Types of incisions
Birth

MARY LOURDES NACEL G. CELESTE, RN, MD 193


Nursing Care:
Cesarean Birth
 Postpartal care
Pain control
Fluid volume
Output
Circulation
Parenting
Infection

MARY LOURDES NACEL G. CELESTE, RN, MD 194


Cesarean Birth
 Birth accomplished through an
abdominal incision into the uterus
1970
 5.5% of births

Currently
 26% of births

MARY LOURDES NACEL G. CELESTE, RN, MD 195


MARY LOURDES NACEL G. CELESTE, RN, MD 196
Cesarean section
– fetus is delivered through an incision
in anterior abdominal and uterine
wall

Indications:
 Cephalopelvic disproportion
 Fetal malpresentation
 non reassuring EFM strip

MARY LOURDES NACEL G. CELESTE, RN, MD 197


 Complications:
 hemorrhage
 Infection

 Visceral injury

 Thrombosis

MARY LOURDES NACEL G. CELESTE, RN, MD 198


MARY LOURDES NACEL G. CELESTE, RN, MD 199
MARY LOURDES NACEL G. CELESTE, RN, MD 200
MARY LOURDES NACEL G. CELESTE, RN, MD 201
Uterine Incisions
2. Low segment Transverse
- incision is made in the non contractile
portion of the uterus
- low chance of uterine rupture, may
have trial of labor
- fetus must be in longitudinal lie
2. Classical
- incision is made in the contractile
portion of the uterus
- risk uterine rupture
- lower segment varicosities and
myomas can be bypassed
MARY LOURDES NACEL G. CELESTE, RN, MD 202
MARY LOURDES NACEL G. CELESTE, RN, MD 203
Anesthesia in C/S
Most popular:
 Regional block
 Epidural
 Spinal anesthesia
• Because the mother is awake and
aware of the birth of her infant
• When time is of the essence or when
an epidural or spinal cannot be used,
general anesthetic is used.
MARY LOURDES NACEL G. CELESTE, RN, MD 204
Scheduled or Unscheduled
C/S
 Scheduled Cesarean Birth
- If it is to be a repeat cesarean birth

(eg, cephalopelvic disproportion)


- If labor is contraindicated (eg,
complete placenta previa,
hydrocephaly)
- If labor cannot be induced and birth is
necessary
Clients have some time to prepare for
the cesarean birth
MARY LOURDES NACEL G. CELESTE, RN, MD 205
 Unscheduled/ Emergency Cesarean
Birth
- Usually a result of some difficulty in
the labor process/ failure to progress
in labor
- Placenta previa
- Abruptio placenta
- Fetal distress
MARY LOURDES NACEL G. CELESTE, RN, MD 206
 Vaginal Birth after Cesarean (VBAC)
- When the reason for the initial
cesarean is a nonrecurring situation
such as placenta previa, prolapsed
cord, or breech presentation, the client
may be able to have a vaginal birth
with the next pregnancy
- Low transverse uterine incision: trial of
labor is recommended
- Classic uterine incision: trial of labor is
CI MARY LOURDES NACEL G. CELESTE, RN, MD 207
Complications during
Labor and Birth

Mary Lourdes Nacel G.


Risks of Labor and
Delivery
 Preterm labor and Birth
 Premature Rupture of Membranes
 Dystocia
 Abnormal duration of labor
 Prolapsed Cord

MARY LOURDES NACEL G. CELESTE, RN, MD 209


 Preterm labor
- Onset of regular contractions of
the uterus that cause cervical
changes between 20 and 37
weeks of gestation

 Preterm birth
- Birth before the end of the 37th
week of gestation
MARY LOURDES NACEL G. CELESTE, RN, MD 210
 Factors predisposing to preterm
labor and birth
- History of preterm birth
- PROM premature rupture of
membranes
- Multiple gestation
- Bacterial vaginosis
- Intraamniotic infection
- Bleeding
- Uterine/ cervical abnormalities
MARY LOURDES NACEL G. CELESTE, RN, MD 211
 If contractions are continuing and
cervical changes are occurring,
tocolytic agents may be prescribed.
 Tocolytic agents – medications that
inhibit contractions
- Ritodrine, Terbutaline, Magnesium
sulfate
 Corticosteroid may also be given to
accelerate fetal lung maturation
 If contractions subside and cervical
dilatation and effacement remain the
same, client may be discharged with
instructions to limit activities and
medication to prevent labor.
MARY LOURDES NACEL G. CELESTE, RN, MD 212
 Premature Rupture of Membranes
- Spontaneous rupture of membranes
before the onset of labor characterized
by fluid leak in the cervix and pooling
in the posterior fornix of the vagina,
(+)nitrazine test, (+)ferning under
microscopic exam; possible protrusion
of membranes or presenting part,
prolapsed cord
MARY LOURDES NACEL G. CELESTE, RN, MD 213
 Prophylactic antibiotic therapy –
to decrease the occurrence of
chorioamnionitis
 Tocolysis
 corticosteroid

MARY LOURDES NACEL G. CELESTE, RN, MD 214


 Dystocia
- long, difficult or abnormal labor caused
by any of the 4 major variables that
affect labor:
 Dysfunctional labor: ineffective
contractions or maternal pushing
efforts (power)
 Pelvic structure variations (passage)
 Fetal variations (abnormal
presentation or position, very large
size or number of fetuses ,anomalies)
 Mother’s responses related to
preparation for childbirth, past
experiences, culture and support
persons MARY LOURDES NACEL G. CELESTE, RN, MD 215
 Abnormal duration of labor
- Prolonged labor
 labor progress in either the 1st or 2nd
stage may be prolonged or arrested
(stopped)
 Hypotonic contractions, CPD, abnormal
fetal presentation, or early use of
analgesics may cause prolonged labor

MARY LOURDES NACEL G. CELESTE, RN, MD 216


Precipitate labor
- Labor lasting <3 hours from the onset
of contractions
- Possible maternal complications: loss
of coping ability; risk of uterine
rupture, laceration of the cervix,
vagina and perineum; postpartum
hemorrhage
- Fetal complications – hypoxia, distress,
cerebral trauma
 Precipitate birth

- Birth occurring suddenly and


unexpectedly
MARY LOURDES NACEL G. CELESTE, RN, MD 217
 Prolapsed Cord
- When the umbilical cord lies below the
presenting part of the fetus; may be
hidden or visible
- A cord below the presenting part is
compressed between the fetus and the
mother’s pelvis resulting in decreased
blood flow to the fetus
- The fetus will have bradycardia with
variable decelerations during uterine
contractions
MARY LOURDES NACEL G. CELESTE, RN, MD 218
 Occurs in
- PROM
- Fetal presentation other than cephalic
- Placenta previa
- Intrauterine tumors
- Small fetus
- CPD
- Hydramnios
- Multiple gestation
MARY LOURDES NACEL G. CELESTE, RN, MD 219
MARY LOURDES NACEL G. CELESTE, RN, MD 220
 Relieve pressure on the cord to relieve
the compression of the cord and fetal
anoxia; done by placing a gloved hand
in the vagina and manually elevating
the fetal head off the cord
- Place the woman in a knee-chest or
Trendelenburg position which causes
the fetal head to fall back from the
cord
MARY LOURDES NACEL G. CELESTE, RN, MD 221
 Other complications
- Uterine rupture
- Uterine inversion
- Amniotic fluid embolism

MARY LOURDES NACEL G. CELESTE, RN, MD 222


Induction/
Augmentation of Labor
 Induction of Labor
 Augmentation of Labor

MARY LOURDES NACEL G. CELESTE, RN, MD 223


Induction of Labor
 Stimulation of uterine contractions
before they begin spontaneously
 By chemical and mechanical
methods
4. Oxytocin
5. Amniotomy
May be considered in situations of
preexisting maternal disease, PIH,
PROM, postterm gestation or fetal
demise
MARY LOURDES NACEL G. CELESTE, RN, MD 224
Augmentation of Labor
- Stimulation of uterine
contractions after spontaneously
beginning but the progress of
labor is unsatisfactory
- Intravenous oxytocin is used

MARY LOURDES NACEL G. CELESTE, RN, MD 225


Anomalies of the placenta and
cord
 Placenta
- Weighs approximately 500 g and is 15 – 20
cm in diameter, 1.5 – 3 cm thick
- Weight is 1/6 of the fetus
- Maternal and fetal sides

 Umbilical cord
- length:55 cm at term
- 1 vein (carries oxygenated blood to the fetus)
- 2 arteries (carry deoxygenated blood from
fetus to placenta)
- Wharton’s jelly, gelatinous substance
- Cord extends from the fetal surface of the
placenta to the fetal umbilicus
MARY LOURDES NACEL G. CELESTE, RN, MD 226
Placenta succenturiata
 Placenta has 1 or
more accessory
lobes connected
to the main
placenta by
blood vessels

MARY LOURDES NACEL G. CELESTE, RN, MD 227


Placenta circumvallata
 Ordinarily, chorion
membrane begins
at the edge of the
placenta; no chorion
covers the fetal side
of the placenta
 This kind- the fetal
side of the placenta
is covered with
chorion

MARY LOURDES NACEL G. CELESTE, RN, MD 228


Battledore placenta
 The cord is
inserted
marginally rather
than centrally

MARY LOURDES NACEL G. CELESTE, RN, MD 229


 Placeta increta- invasion of the
placenta into the myometrium
 Placenta percreta – penetration of
the placenta through the
myometrium to the serosa
 Vasa previa – placental vessels
crossing the cervical os

MARY LOURDES NACEL G. CELESTE, RN, MD 230


Velamentous insertion
of the cord
 The cord, instead of
entering the
placenta directly,
separates into small
vessels that reach
the placenta by
spreading across a
fold of amnion
 May be found in
multiple gestation
 May be associated
with fetal anomalies
MARY LOURDES NACEL G. CELESTE, RN, MD 231
Nursing Care of a
Postpartal Woman and
Family
MARY LOURDES NACEL G. CELESTE, RN, MD 233
Postpartum
FROM STAGE 4 UNTIL 6 WEEKS
AFTER DELIVERY
 Involution – (uterus reduced to prepregnant
size)
 Fundus – midline, firm
 Position – even to 1 cm/finger breadth above
the umbilicus for the first 12 h, then
descends by one finger breadth each
succeeding day, pelvic organ usually by day
10
 If with deviations, check bladder and have 234
MARY LOURDES NACEL G. CELESTE, RN, MD
patient void; if deviations continue, massage
MARY LOURDES NACEL G. CELESTE, RN, MD 235
MARY LOURDES NACEL G. CELESTE, RN, MD 236
 Lochia – (endometrial sloughing)
– day 1-3 rubra (bloody with fleshy
odor; may be clots)
– day 4-9 serosa (pink/brown with
fleshy odor)
– day 10+ alba (yellow-white); at no
time should there be a foul odor
(indicates infection)

MARY LOURDES NACEL G. CELESTE, RN, MD 237


MARY LOURDES NACEL G. CELESTE, RN, MD 238
 Perineum – possible discomfort, swelling,
and/or ecchymosis
 Managed with analgesics and/or topical
anesthetics, ice packs for first 12-24 h and
then 20 min sitz baths 3-4 times/d, tightening
buttocks before sitting
 Monitor episiotomy/laceration – teach
techniques to prevent infection, e.g., change
pads on regular basis, peri care (cleaning
from front to back using peri-bottle or
surgigator after each voiding and bowel
movement), and sitz baths

MARY LOURDES NACEL G. CELESTE, RN, MD 239


Breasts – progress from soft filling with
potential for engorgement (vascular
congestion related to increased blood and
lymph supply; breasts are larger, firmer, and
painful)
 Non-nursing woman – suppress lactation
 Mechanical methods – tight-fitting brassiere,
ice packs, minimize breast stimulation
 Nursing woman – successful lactation is
dependent on infant sucking and maternal
production and delivery of milk (letdown/milk
ejection reflex); monitor and teach
preventive measures for potential problems

MARY LOURDES NACEL G. CELESTE, RN, MD 240


Nipple – irritation/cracking
 Nipple care – clean with water, no
soap, and dry thoroughly; absorbent
breast pads if leaking occurs; expose
to air
 Position nipple so that infant’s mouth
covers a large portion of the areola
and release infant’s mouth from nipple
by inserting finger to break suction
 Rotate breastfeeding positions
MARY LOURDES NACEL G. CELESTE, RN, MD 241
Engorgement
 nurse frequently (every ½-3 h) and long
enough to empty breasts completely
(evidenced by sucking without swallowing)
 warm shower or compresses to stimulate
letdown
 alternate starting breast at each feeding
 mild analgesic 20 min before feeding and ice
packs between feedings for pronounced
discomfort

 Plugged ducts – area of tenderness and


lumpiness often associated with
engorgement; may be relieved by heat and
massage priorMARY
toLOURDES
feeding
NACEL G. CELESTE, RN, MD 242
Expression of breast milk
 to collect milk for supplemental
feedings
 to relieve breast fullness or to build
milk supply
 may be manually expressed or
pumped by a device and refrigerated
for no more than 48 h or frozen in
plastic bottles (to maintain stability of
all elements) in refrigerator freezer for
2 wk and deep freezer for 2 mo (do not
thaw in microwave or on stove)
 Medications – most drugs cross into
breast milk; check with physician
before taking any medication
MARY LOURDES NACEL G. CELESTE, RN, MD 243
LACTATION PRINCIPLES
Breast Care – Antepartum Initiating Breast Feeding
and Postpartum
Soap on nipples should be Relaxed position of mother is
avoided during bathing to essential – support
prevent dryness dependent arm with pillow
Nipples can be “prepared” Both breasts should be offered
antepartum by exposure to at each feeding
sun, air, and by wearing Five minutes on each breast is
loose clothing sufficient at first – teach
Redness or swelling can proper way to break suction
indicate infection and should Most of the areola should be
always be investigated infant’s mouth to ensure
proper sucking

MARY LOURDES NACEL G. CELESTE, RN, MD 244


 Elimination
 Urinary – increased output
(postpartum diuresis), urethral trauma,
decreased bladder sensation, and
inability to void in the recumbent
position may cause bladder distention,
incomplete emptying and/or urinary
stasis increasing the risk of uterine
relaxation and hemorrhage and/or UTI;
monitor I and O encourage voiding
every 24 h (early ambulation and
pouring warm water over perineum);
catheterization may be necessary if no
voiding after 8 h
MARY LOURDES NACEL G. CELESTE, RN, MD 245
 GI – bowel sluggishness,
decreased abdominal muscle
tone, perineal discomfort may
lead to constipation; managed by
early ambulation, increased
dietary fiber and hydration, stool
softeners

MARY LOURDES NACEL G. CELESTE, RN, MD 246


 After pains – cramps due to uterine
contractions lasting 2-3 d; more
common in multipara and with
nursing; may be relieved by lying on
abdomen with small pillow, heat,
ambulation, mild analgesic (if breast
feeding, 1 h before nursing)
 Rubella vaccine – for susceptible
woman; RhoGam as appropriate
MARY LOURDES NACEL G. CELESTE, RN, MD 247
 Psychosocial adjustment
 Attachment/bonding – influenced by
maternal psychosocial-cultural factors,
infant health status, temperament,
and behaviors, circumstances of the
prenatal, intrapartal, postpartal, and
neonatal course; evidenced initially by
touching and cuddling, naming, “en
face” positioning for direct eye
contact, later by reciprocity and
rhythmicity in maternal-infant
interaction
MARY LOURDES NACEL G. CELESTE, RN, MD 248
Psychological Changes
 Phases
Talking-in
Taking-hold
Letting-go

MARY LOURDES NACEL G. CELESTE, RN, MD 249


Phases of adjustment
 “Taking in”/dependency (day
1-2 after delivery) – preoccupied
with self and own needs (food and
sleep); talkative and passive;
follows directions and is hesitant
about making decisions; retells
perceptions of birth experience
MARY LOURDES NACEL G. CELESTE, RN, MD 250
 “Taking hold”/dependency-
independency (by day 3) –
performing self-care; expresses
concern for self and baby; open to
instructions

MARY LOURDES NACEL G. CELESTE, RN, MD 251


 “Letting go”/independence
(evident by weeks 5-6) –
assuming new role
responsibilities; may be grief for
relinquished roles; adjustment to
accommodate for infant in family

MARY LOURDES NACEL G. CELESTE, RN, MD 252


 “Postpartum blues” (day 3-7) –
normal occurrence of “roller
coaster” emotions, weeping, “let-
down feeling”; usually relieved
with emotional support and
rest/sleep; report if prolonged or
later onset

MARY LOURDES NACEL G. CELESTE, RN, MD 253


 Sexual activities – abstain from intercourse
until episiotomy is healed and lochia has
ceased (usually 3-4 wk); may be affected by
fatigue, fear of discomfort, leakage of breast
milk, concern about another pregnancy;
assess and discuss couple’s desire for and
understanding about contraceptive methods;
breastfeeding does not give adequate
protection, and oral contraceptives should
not be used during breastfeeding.

MARY LOURDES NACEL G. CELESTE, RN, MD 254


Pregnant
Adolescent
 Complications
Pregnancy-induced
hypertension
Iron-deficiency anemia
Preterm labor

MARY LOURDES NACEL G. CELESTE, RN, MD 255


Pregnant
Adolescent
 Complications and
concerns of labor, birth
and postpartum
Cephalopelvic disproportion
Postpartal hemorrhage
Inability to adapt
Lack of knowledge
MARY LOURDES NACEL G. CELESTE, RN, MD 256
MARY LOURDES NACEL G. CELESTE, RN, MD 257
Over Age 40
 Complications
Pregnancy-induced hypertension
 Complications and concerns of labor, birth
and postpartum
Failure to progress
Difficulty accepting event
Postpartal hemorrhage

MARY LOURDES NACEL G. CELESTE, RN, MD 258


MARY LOURDES NACEL G. CELESTE, RN, MD 259
Substance
Dependent
 Withdrawal symptoms following
discontinuation of the substance
Abandonment of important
activities
Spending increased time in
activities related to substance
use
Using substance for a longer
time than planned
MARY LOURDES NACEL G. CELESTE, RN, MD 260
Substance
Dependent
Drugs commonly used during pregnancy

Cocaine
Amphetamines
Marijuana and hashish
Phencyclidine
Narcotic agonists
Inhalants
Alcohol
MARY LOURDES NACEL G. CELESTE, RN, MD 261
MARY LOURDES NACEL G. CELESTE, RN, MD 262
CHILDBEARING –
MATERNAL
COMPLICATIONS

Mary Lourdes Nacel G.


Identifying the
High-Risk Pregnancy
 High-risk pregnancy
A concurrent disorder,
pregnancy-related
complication, or external factor
jeopardizes the health of the
mother, fetus or both

MARY LOURDES NACEL G. CELESTE, RN, MD 264


Factors associated with increased
risk
 lack of prenatal care

 age less than 18 or older than 35

 conception within two months of


previous delivery
 fifth or subsequent delivery

 prepregnant weight 20% more or


less than normal and/or minimal or
no weight gain
 fetal anomaly
MARY LOURDES NACEL G. CELESTE, RN, MD 265
Adolescence
 there may be interference with normal
physical growth and maturation
 lack of family acceptance or support

 isolation from peers

 delayed/ no prenatal care

 increased medical and obstetrical risks

*requires support for feelings, assistance


with decision-making, regular
monitoring of health status, instruction
in nutrition
MARY LOURDES NACEL G. CELESTE, RN, MD 266
 Substance use/abuse
 Drugs (including alcohol) – may be
increased risk of maternal nutritional
deficits, sexually transmitted diseases
(STDs), AIDS, delayed/no prenatal
care, withdrawal symptoms, and fetal
intrauterine growth retardation (IUGR),
anomalies, spontaneous abortions,
death, signs and symptoms of
withdrawal or addiction in neonate;
educate, reinforce, counsel, and/or
refer as necessary; emphasize that a
safe level of alcohol has not been
identified MARY LOURDES NACEL G. CELESTE, RN, MD 267
 Cigarettes – increased incidence
of intrauterine growth retardation
(IURG), preterm births, low Apgar
scores, spontaneous abortions,
SIDS; as with drugs

MARY LOURDES NACEL G. CELESTE, RN, MD 268


Infections
 Urinary tract infections (UTI's) –
characterized by urinary frequency
and urgency, dysuria, and sometimes
hematuria and manifested in upper
tract by fever, malaise, anorexia,
nausea, abdominal/back pain;
confirmed by >100,000/ml bacterial
colony count by clean catch urine;
sometimes asymptomatic; treated with
sulfa-based medications and ampicillin
MARY LOURDES NACEL G. CELESTE, RN, MD 269
 TORCH test series – group of
maternal systemic infections that
can be transmitted across the
placenta or by ascending
infection to the fetus; infection
early in pregnancy may produce
significant and devastating fetal
deformities, whereas later
infection may result in
overwhelming active systemic
disease and/or CNS involvement,
causing severe neurological
impairment or death of newborn
MARY LOURDES NACEL G. CELESTE, RN, MD 270
TORCH
Toxoplasmosis
– caused by protozoan Toxoplasma gondii
– Caused by eating raw or poorly coked
meat or by contact with the feces of
infected animals
– transplacental to fetus
– Asymptomatic or myalgia, malaise, rash,
splenomegaly, and posterior cervical
lymphadenopathy
– Damage to the fetus is worse if acquired
early in the pregnancy
– Dx: Sabin-Feldman dye test
– discourage eating undercooked meat and
handling cat litter box
– Tx: Sulfadiazine & Pyrimethamine
– Incidence of abortion, stillbirths, neonatal
death & severe congenital anomalies is
high MARY LOURDES NACEL G. CELESTE, RN, MD 271
Others
 1. Syphilis –
 2. Varicella/ shingles (transplacental to fetus
or droplet to newborn) – caution susceptible
woman about contact with the disease and
zoster immune globulin for exposure
 3. Group B beta – hemolytic Streptococcus
(direct or indirect to fetus during labor and
delivery) – treated with penicillin
 4. Hepatitis B (transplacental and contact
with secretions during delivery) – screen and
immunize maternal carriers; treat newborn
with HBIg
 5. AIDS (as with hepatitis) – titers in newborn
may be passive transfer of maternal
MARY LOURDES NACEL G. CELESTE, RN, MD 272
antibodies or active antibody formation
Rubella (transplacental) – prenatal testing
required by law; caution susceptible woman
about contact; vaccine is not given during
pregnancy
 Period of greatest risk for teratogenic effect:
 during the 1st trimester; between 3rd – 7th
weeks of pregnancy – damage usually results
in death
 2nd trimester – hearing impairment
 Leukemia in childhood noted
 Best Tx: PREVENTION!
 Live attenuated vaccine given to children
( not given during pregnancy)
MARY LOURDES NACEL G. CELESTE, RN, MD 273
Cytomegalovirus (CMV) – transmitted in
body fluids; detected by
antibody/serological testing
 Virus found in urine, saliva, cervical
mucus, semen & breast milk
 Principal organs affected: blood, brain
and liver
 Anemia, hyperbilirubinemia,
thrombocytopenia, (petecchiae,
ecchymosis), hepatosplenomegaly
 Encephalitis (lethargy, convulsions)
 Cerebral palsy may develop

MARY LOURDES NACEL G. CELESTE, RN, MD 274


Herpes type 2 (transplacental, ascending
infection within 4-6 h after ROM or contact
during delivery if active lesions)
 cesarean delivery if there are active lesions
 S/S: genital irritation and itching, vaginal or
urethral discharge- may be copious, foul-
smelling; enlarged tender lymph nodes;
dysuria begins as reddish papules>> itchy
pustular vesicles>> break and form painful
wet ulcers>> dry and develop crusts
 20 – 50% rate of spontaneous abortion if
infection occurs during the 1st trimester
 Infection after the 20th week leads to
incidence of premature birth and not to
teratogenic effects
 Survivors have permanent visual damage &
impaired psychomotor & intellectual
development MARY LOURDES NACEL G. CELESTE, RN, MD 275

 Tx: relieve woman’s vulvar pain ;


1st Trimester Bleeding
 Spontaneous miscarriage
Threatened
Imminent
Complete
Missed
Recurrent pregnancy loss

MARY LOURDES NACEL G. CELESTE, RN, MD 276


 ABORTION Early (before 20
wks)
- Any pregnancy that terminates
before the age of viability
 Spontaneous abortion
characterized by painless (may be
cramping) dark-bright red vaginal
bleeding
MARY LOURDES NACEL G. CELESTE, RN, MD 277
CLINICAL CLASSIFICATIONS OF SPONTANEOUS ABORTION
Type Assessment Nursing Considerations
Threatened Vaginal bleeding and Ultrasound for intrauterine sac, quantitative HCG
cramping Decrease activity for 24-48 h, avoid stress, no sexual
Soft uterus, cervix closed intercourse for 2 wk after bleeding stops
Monitor amount and character of bleeding; report
clots, tissue, foul odor
Inevitable, if Persistent symptoms, Monitor for hemorrhage (save and count pads) and
cervical dilation hemorrhage, moderate to infection; if persistent or increased symptoms, D
cannot be severe cramping and C
prevented Cervical dilatation and Emotional support for grief and loss
(Imminent) effacement
Incomplete Persistent symptoms, Administer IV/blood, oxytocin
expulsion of part of D and C or suction evacuation
products of conception
Complete As above, except no retained Possible oxytocin PO; no other treatment if no
tissue evidence of hemorrhage or infection
Missed – fetus dies May be none/some abating of D and C evacuation within 4-6 wk
in utero but is not above symptoms After 12 wk, dilate cervix with several applications of
expelled Cervix is closed prostaglandin gel or suppositories of laminaria
If retained >6 wk, increased (dried sterilized seaweed that expands with cervical
risk of infection, DIC, and secretions)
emotional distress
Habitual – 3 or May be incompetent cervix, Cerclage (encircling cervix with suture)
more infertility

MARY LOURDES NACEL G. CELESTE, RN, MD 278


1st Trimester Bleeding
 Ectopic pregnancy
Implantation occurs outside of
the uterine cavity

MARY LOURDES NACEL G. CELESTE, RN, MD 279


SITES AT WHICH ECTOPIC PREGNANCY CAN OCCUR

MARY LOURDES NACEL G. CELESTE, RN, MD 280


 Ectopic pregnancy
– implantation outside uterus (commonly in
fallopian tube)
- potentially life threatening to mother

- Characterized by:
 unilateral lower quadrant pain after 4-6
weeks of normal signs and symptoms of
pregnancy (amenorrhea, (+) pregnancy test
 bleeding may be gradual oozing to frank
bleeding
 may be palpable unilateral mass in adnexa
 low HCG levels
 rigid and tender abdomen
 signs and symptoms of hemorrhage
MARY LOURDES NACEL G. CELESTE, RN, MD 281
– Necessary to be alert for signs and symptoms
– investigate risk factors especially PID,
multiple sexual partners, recurrent episodes
of gonorrhea, infertility
Management
– prepare for surgery
– Shock monitoring and management
– postoperatively, monitor for infection and
paralytic ileus
– Provide support for emotional distress
– RhoGam for Rh- negative woman
– monitor Hgb and Hct
– ultrasound for adnexal mass/ gestational sac
in tube
– culdocentesis (indicated by nonclotting blood)
– laparoscopy and/or laparotomy
– adequate blood replacement (type and X
match, IV withMARYlarge-bore needle)
LOURDES NACEL G. CELESTE, RN, MD 282
2nd Trimester Bleeding

Premature cervical dilatation


Cannot hold the fetus until term
Cervical cerclage

MARY LOURDES NACEL G. CELESTE, RN, MD 283


Incompetent Cervix
 Painless dilatation of the cervix
usually in the 2nd trimester
 May lead to infection, premature
rupture of membranes, preterm
labor

MARY LOURDES NACEL G. CELESTE, RN, MD 284


SHIRODKAR SUTURE FOR CERVICAL CERCLAGE

MARY LOURDES NACEL G. CELESTE, RN, MD 285


2nd Trimester Bleeding
 Gestational trophoblastic disease
(hydatidiform mole)
Abnormal proliferation and
degeneration of the
trophoblastic villi

MARY LOURDES NACEL G. CELESTE, RN, MD 286


Hydatidiform mole – degenerative anomaly of the
placenta converting the chorionic villi into a mass
of clear vesicles
*characterized by
 elevated HCG levels
 uterine size greater than expected for gestational
age
 no FHR
 minimal dark red/brown vaginal bleeding with
passage of grapelike clusters
 no fetus by ultrasound
 possible increased nausea and vomiting and
associated pregnancy-induced hypertension
 treated with curettage to completely remove all
molar tissue, which can become malignant
 pregnancy is discouraged for 1 year, and HCG
levels are monitored during that time (if it
continues to be elevated, may require
hysterectomy and chemotherapy)
MARY LOURDES NACEL G. CELESTE, RN, MD 287
Gestational trophoblastic disease
(hydatidform mole)

MARY LOURDES NACEL G. CELESTE, RN, MD 288


3nd Trimester Bleeding
 Placenta previa
Low implantation of placenta
 Abruptio Placenta
Premature separation of placenta
Occurs suddenly

MARY LOURDES NACEL G. CELESTE, RN, MD 289


 Late in pregnancy
 Placenta previa – development of the
placenta in the lower uterine segment,
partially or completely covering the internal
cervical os
 Characterized by painless vaginal bleeding,
which is usually slight at first (spotting – 1st
and 2nd trimesters) and increases in
subsequent unpredictable episodes; usually
soft and non tender abdomen

4 Degrees of Placenta previa


6. Low-lying - in lower segment
7. Marginal - at border of internal cervical os
8. Partial – occludes a portion of the cervical os
9. Total - complete obstruction of the os

MARY LOURDES NACEL G. CELESTE, RN, MD 290


DEGREES OF PLACENTA PREVIA

LOW IMPLANTATION PARTIAL PLACENTA PREVIA TOTAL PLACENTA PREVIA

MARY LOURDES NACEL G. CELESTE, RN, MD 291


Management of PLACENTA PREVIA
 Hospitalization
 bed rest
 side-lying or Trendelenburg position for at least 72
hours
 ultrasound shows the location and degree of
obstruction
 no vaginal/ rectal exam unless delivery would not be
a problem
(if it becomes necessary, it must be done in OR
under sterile conditions)
 amniocentesis for lung maturity
 monitor for changes in bleeding and fetal status
 daily Hgb and Hct; keep IV line and make blood
available (blood typed and cross matched- 2 units)
 Delivery by cesarean if evidence of fetal maturity,
excessive bleeding, active labor, other complications
 Home - if bleeding ceases and pregnancy to be
maintained – limit activity;
MARY LOURDES NACEL no douching,
G. CELESTE, RN, MD enemas, 292
coitus; monitor FM; NST at least every 1-2 wk
 Abruptio placenta – premature
separation of normally implanted
placenta; may be marginal (near
edge) with dark red vaginal bleeding
or central (at center) with concealed
bleeding; life threatening to fetus
and mother
 Common among women with
hypertension, short umbilical cord
and alcohol use; also by direct
trauma MARY LOURDES NACEL G. CELESTE, RN, MD 293
 Characterized by:
- painful (sharp, stabbing) vaginal bleeding/
epigastric pain
- uterine rigidity and tenderness: abdomen is
tender, painful and tense (board-like)
- rapid signs and symptoms of maternal shock
and/or fetal distress (altered FHR)
- May lead to Couvelaire uterus (blood
infiltrating the uterine musculature) forming a
hard, board-like uterus without apparent
bleeding
- External bleeding may seem out of proportion
to symptoms (shock) displayed by the woman
MARY LOURDES NACEL G. CELESTE, RN, MD 294
PREMATURE SEPARATION OF THE PLACENTA

MARY LOURDES NACEL G. CELESTE, RN, MD 295


Abruptio placenta
 Manage signs and symptoms

- Keep woman in lateral position (not


supine)
- Oxygenation (to limit fetal anoxia)

- FHR monitoring; VS monitoring

- Baseline fibrinogen (if bleeding is


extensive, fibrinogen reserve may be
used up in the body’s attempt to
accomplish effective clot formation)
MARY LOURDES NACEL G. CELESTE, RN, MD 296
Abruptio placenta
- NO IE or rectal examination, No enema
- Keep IV open for possible blood
transfusion
 prepare for immediate delivery
usually, cesarean section

 Postoperatively monitor for


complications
– Infection
– Renal failure
– Disseminated intravascular
coagulation (DIC)
MARY LOURDES NACEL G. CELESTE, RN, MD 297
Disseminated Intravascular Coagulation
(DIC)
 Disorder of blood clotting
 Fibrinogen levels fall below effective limits
 Symptoms
 Bruising or bleeding
 massive hemorrhage initiates coagulation process
causing massive numbers of clots in peripheral
vessels (may result in tissue damage from multiple
thrombi), which in turn stimulate fibrolytic activity,
resulting in decreased platelet and fibrinogen
levels and
 signs and symptoms of local generalized bleeding
(increased vaginal blood flow, oozing IV site,
ecchymosis, hematuria, etc)
 monitor PT, PTT, and Hct, protect from injury; no IM
injections; early anticoagulant therapy is
controversial
MARY LOURDES NACEL G. CELESTE, RN, MD 298
Diabetes – interaction of
diabetes and pregnancy
may cause serious problems
for mother and
fetus/newborn

Classification
 Type I – insulin-dependent (IDDM)
 Type II – non insulin-dependent
(NIDDM)
 Gestational diabetes (GDM)
 Impaired glucose tolerance (IGT)
MARY LOURDES NACEL G. CELESTE, RN, MD 299
MARY LOURDES NACEL G. CELESTE, RN, MD 300
Effects of diabetes on pregnancy
 Maternal

 long-standing diabetes and/or poor


control before conception can increase
risk of maternal infections – monolilial
vaginitis, pyelonephritis, UTI
 Polyhydramnios (>2,000 ml amniotic
fluid)
 pregnancy-induced hypertension (PIH),
and consequent preterm labor
 Instrumental or cesarean delivery

 Postpartum bleeding

MARY LOURDES NACEL G. CELESTE, RN, MD 301


 Fetal and neonatal effects of gestational
diabetes
 Due to hyperglycemia – in more severe cases,
congenital anomalies- neural tube defect,
cardiac, GI and renal defects
 macrosomia (large for gestational age but may
have immature organ systems) and
 IUGR < prematurity
 Delayed lung maturity - respiratory distress
syndrome (RDS) in neonate
 Neonatal hypoglycemia
 Neonatal hyperbilirubinemia
 Neonatal polycythemia
 untreated ketoacidosis can cause coma and
death of mother and fetus
MARY LOURDES NACEL G. CELESTE, RN, MD 302
 Gestational diabetes
 Women who do not begin in pregnancy
with diabetes become diabetic during
pregnancy (approximately 2 – 3%)
 usually normal response to glucose
load before and after pregnancy
 abnormal response is usually noted
after 20 weeks, when insulin need
accelerates, bringing about symptoms;
some gravidas will need exogenous
insulin but majority are controlled by
diet; oral hypoglycemics must not be
used because they maybe teratogenic
and increase the risk of neonatal
hypoglycemia
MARY LOURDES NACEL G. CELESTE, RN, MD 303
 60 -70 % chance of GDM in the next
pregnancy
 40% of those with GDM may develop
DM
 Assessment
 Risk factors (GDM) – obesity, family
history of diabetes; patient history of
gestational diabetes, hypertension/PIH,
recurrent UTI's, monilial vaginitis,
polyhydramnios; previously large
infant (9 lb/4,000 g or more),
previously unexplained death/anomaly
or stillbirths; glycosuria, proteinuria on
two or more occasions
MARY LOURDES NACEL G. CELESTE, RN, MD 304
 Diabetes – at 24-28 wk for all gravidas
 Screen blood glucose level 1 hour after 50 g
concentrated glucose solution
 Three-hour glucose tolerance test
 OGTT 100 mg glucose
 normal findings:
 FBS: 80-100 mg/dL
 1 h: <190 mg/dL
 2 h: <165 mg/dL
 3 h: <145 mg/dL
 If two or more abnormal findings, significant
for diabetes
 Glycosylated hemoglobin (HbA1c) –
measures control over the past 3 mo;
elevations (>68%) in first trimester are
associated with increased risk of congenital
anomaly and spontaneous abortion; in the
last trimesterMARY
with macrosomia
LOURDES NACEL G. CELESTE, RN, MD 305
MARY LOURDES NACEL G. CELESTE, RN, MD 306
GDM Mx
 Polydipsia  Diet: 20% calories from
 Polyphagia protein; 50% from
carbohydrates; 30% from
 Polyuria fats; increased dietary
 Hyperglycemia fibers; not less than 1800
 Dizziness, if calories per day
hypoglycemic  Exercise: to lower blood

 Hydramnios glucose
 Stress Management
 Macrosomia (large  Try diet first; then Insulin:
fetus)
usually short acting
 Possible PIH, (regular) insulin combined
moniliasis with immediate acting
 NO ORAL HYPOGLYCEMIC
AGENT! –passes through the
placenta and can be
teratogenic
MARY LOURDES NACEL G. CELESTE, RN, MD 307
Hypertension disorders
 Preexisting hypertension (HTN) – diagnosed
and treated before pregnancy; requires strict
medical and obstetrical management
 Pregnancy-induced hypertension (PIH) – no
prior incidence, develops during pregnancy
and resolves during postpartum period
 Pre-eclampsia (synonymous with PIH) – may
progress from mild, which can usually be
managed as outpatient, to severe, which
requires hospitalization; triad of
symptomatology:
 Hypertension (vascular effect)
 Edema (interstitial effect)
 Proteinuria (kidney effect)
 Mild
 Severe
MARY LOURDES NACEL G. CELESTE, RN, MD 308
Pregnancy-Induced
Hypertension
 Vasospasm occurs during
pregnancy
 Symptoms

Hypertension
Proteinuria
Edema

MARY LOURDES NACEL G. CELESTE, RN, MD 309


Pregnancy-Induced Hypertension

Mild preeclampsia
Severe preeclampsia
Eclampsia
Gestational hypertension

MARY LOURDES NACEL G. CELESTE, RN, MD 310


MARY LOURDES NACEL G. CELESTE, RN, MD 311
Pregnancy-Induced
Hypertension
 HELLP syndrome
Hemolysis
Elevated Liver Enzymes
Low Platelets

MARY LOURDES NACEL G. CELESTE, RN, MD 312


 Mild Preeclampsia
– Elevated BP : 140/90 or
– Increase of +30/ +15 mmHg on two
consecutive occasions at least 6 hours
apart as compared to first-trimester BPs
– Edema: generalized edema that does not
clear overnight, or more significantly,
facial; sudden weight gain >2 lbs/wk (2nd
trimester); >1 lb/wk (3rd trimester)
– Proteinuria 1+ - 2+ in two consecutive
tests at least 6 hours apart or 300 mg/L in
a 24-h specimen
– May be managed at home
MARY LOURDES NACEL G. CELESTE, RN, MD 313
 Severe Preeclampsia
– BP 150-160/100-110, increased edema 3+
- 4+ proteinuria
– Oliguria (Urine output <500 ml/ 24 hours)
– Complaints of headache, visual changes,
epigastric pain, extreme irritability
– Hyperreflexia
– HELLP – hemolysis (significantly decreased
Hct), elevated liver enzymes (Hepatic
dysfunction- SGOT, SGPT), low platelet
count
– Managed in the hospital
MARY LOURDES NACEL G. CELESTE, RN, MD 314
 FOR PREECLAMPSIA
 Assess BP, protein level in urine,
changes in level of consciousness,
weight, FHT, vaginal bleeding, FHT
 Bedrest
 Left lateral recumbent position (to
avoid pressure on vena cava)
 High protein diet
 Seizure precautions (note headaches,
visual changes, dizziness and
epigastric pain)
MARY LOURDES NACEL G. CELESTE, RN, MD 315
 Eclampsia (obstetrical emergency!!!) - when
convulsions, coma, HTN crisis or shock occurs
 Hypertension
 Proteinuria
 Convulsions
 Coma
 Death is from cerebral hemorrhage, circulatory
collapse, or renal failure
 May be maternal recurrence, cerebral
hemorrhage, DIC, and fetal hypoxia – ensure
patent airway (suction and O2 as necessary);
monitor mother for signs and symptoms of
cerebral hemorrhage, placenta abruptio,
pulmonary edema; may require invasive
hemodynamic monitoring; IV with large-bore
needle, type and cross-match blood available for
emergency transfusion; monitor fetal status;
MgSO4 IV; immediate delivery if signs and
symptoms do notMARYsubside
LOURDES NACEL G. CELESTE, RN, MD 316
 FOR ECLAMPSIA
 Maintain IV line
 Keep Oxygen and airway equipment
available at bedside
 Minimize stimuli
 Medication as ordered (Magnesium
sulfate, Valium, Apresoline)
 Side rails up and padded
 Aspiration precaution post ictal phase

MARY LOURDES NACEL G. CELESTE, RN, MD 317


 Magnesium Sulfate
 Drug of choice for the prevention and
treatment of convulsion
 Therapeutic level is 4 – 7 mg/ 100 ml
 Given slowly piggy back IV but may be
irritating to vein or IM given Z tract method
 Monitor RR closely as respiration may be
depressed
 Poor urinary excretion may lead to toxicity.
Accurate I and O (catheterization)
 Monitor deep tendon reflex (DTR), absence
means increase in magnesium level
 Monitoring of maternal and fetal vital signs
 Antidote is Calcium gluconate
MARY LOURDES NACEL G. CELESTE, RN, MD 318
 Labor induction with IV oxytocin
(administered simultaneously with
MgSO4), or in severe cases, cesarean
delivery may be indicated
 In cases of severe hypertension,
seizures may still occur 24-48 h
postpartum; monitor MgSO4 or
hydralazine may be continued
postpartum
MARY LOURDES NACEL G. CELESTE, RN, MD 319
PHARMACOLOGICAL MANAGEMENT OF PREGNANCY-INDUCED
HYPERTENSION
Medications Side Effects Nursing Considerations
Magnesium sulfate Flushing, sweating CNS depressant, anticonvulsant
Symptoms of toxicity: Monitor BP, P, R, FHR at least every 15
sudden drop in BP, min; MgSO4 levels and DTR prior to
respirations <12/min, administration, mental status
urinary output <25-30 frequently; have resuscitation
ml/hr, equipment and calcium gluconate/
decreased/absent DTRs, chloride (antidote) in room
toxic serum levels
Hydralazine Tachycardia, palpitations Vasodilator
(Apresoline) Headache Maintain diastolic BP
Nausea and vomiting 90-100 mm Hg for adequate
Orthostatic hypotension uteroplacental flow;
monitor FHT and neonatal status
Diazepam Risk of neonatal Sedative, anticonvulsant
(Valium) depression if given Monitor FHT and neonatal status
within 24 h of delivery
Methyldopa May masks symptoms of Used for chronic HTN
(Aldomet) preeclampsia; Monitor maternal, fetal, and neonatal
risk of maternal vital signs
orthostatic Monitor maternal mental status
hypotension and
decreased pulse and BP
in neonate for 2-3 d
Hemolytic anemia
Propranolol Decreased heart rate, Take apical rate before giving
MARY LOURDES NACEL G. CELESTE, RN, MD 320
(Inderal) depression, Monitor BP, EKG
hypoglycemia
 Hydramnios – excessive amniotic
fluid (2,000 ml) exceeding the normal
volume of 500 – 1,000 ml AF
 Rapid enlargement of the uterus
 Increased weight
 Difficult to palpate and to auscultate
fetus due to excessive fluid
 Shortness of breath because of
compression of the diaphragm
 Ultrasound finding of excessive fluid
MARY LOURDES NACEL G. CELESTE, RN, MD 321
 Using ultrasound, we measure the
amniotic fluid index (AFI)
 The maternal abdomen is divided
into 4 quadrants; find the largest
vertical pocket of fluid in each
quadrant
 AFI < 5 : OLIGOHYDRAMNIOS
 AFI > 20 : POLYHYDRAMNIOS
MARY LOURDES NACEL G. CELESTE, RN, MD 322
Oligohydramnios
 In the absence of ROM is associated with 40x
increase in perinatal mortality
 Associated with congenital anomalies (renal
agenesis, polycystic kidney disease,
obstruction of the GU system) particularly of
the genitourinary system and growth
restriction
 Caused by chronic uteroplacental
insufficiency
 Pregnancies at term complicated with
oligohydramnios should be delivered

MARY LOURDES NACEL G. CELESTE, RN, MD 323


Polyhydramnios
 AFI > 20
 Associated with diabetes, multiple
gestation , hydrops and congenital
abnormalities
 Asssociated with neural tube defects,
obstruction of the alimentary canal
and hydrops
 Increased risk of malpresentation and
prolapsed cord
MARY LOURDES NACEL G. CELESTE, RN, MD 324
Hydramnios
Mx:
Risk Factors
 Maintain bedrest to
 Maternal diabetes
rdeuce pressure on
 Infant with
cervix and to prevent
esophageal atresia premature labor
 Monozygotic twins  Monitor for rupture or
 Infant with neural uterine contraction
tube defect  Avoid constipation by
 Large placenta bulk in the diet
 Amniocentesis guide by
ultasound (slow to
prevent premature
separation of placenta)
MARY LOURDES NACEL G. CELESTE, RN, MD 325
 PRECIPITOUS DELIVERY
Assessment
 Determine that transport to hospital/birthing center is
not possible
 Evaluate mother’s cognitive status and explain actions

Nursing management
 Remain with patient; do not attempt to prevent birth
 Prepare sterile or clean environment
 Support infant’s head; apply slight pressure to control
delivery
 Slip nuchal cord, if present, over head
 Deliver shoulders, trunk, holding head downward to
facilitate drainage
 Dry baby and place on mother’s abdomen
 Hold placenta as delivered
 Wrap infant in blanket and put to breast
 Check for bleeding and fundal tone
 Comfort mother and family; arrange transport to
hospital MARY LOURDES NACEL G. CELESTE, RN, MD 326
CARDIAC DISEASE
Assessment
 Monitor vital signs and do EKG as heart lesion
(especially those of the mitral valve) may become
aggravated by pregnancy
 Chest pain
 Dyspnea
 Treatment of heart disease in pregnancy is
determined by the functional capacity of the heart,
and type of delivery will be influenced by the
mother’s status and the condition of fetus

Nursing Management
 Encourage rest
 Encourage moderation in physical activity
 Explain importance of avoidance of upper
respiratory infections
 Be alert for signs of heart failure: increase of
dyspnea; tachycardia
 Monitor activity level
MARY LOURDES NACEL G. CELESTE, RN, MD 327
Cardiac Disease
 Left-sided heart
failure
 Right-side heart failure
 Dyspnea,
Orthopnea  Distended liver and
 Paroxysmal spleen
nocturnal dyspnea  Ascites
(PND)  Peripheral edema
 Rales, cough  hepatomegaly
 Chest pain, cardiac
arrhythmia,
syncope during or
after exertion
 Extreme fatigue,
pallor cyanosis
MARY LOURDES NACEL G. CELESTE, RN, MD 328
Common Nursing Diagnoses:
 Potential for decreased cardiac
output
 Activity intolerance

 Risk for infection

 Potential for fetal injury

MARY LOURDES NACEL G. CELESTE, RN, MD 329


Classifications of Cardiac
Disease
 CLASS I (shows no - No limitation of
CLASS I (shows no No limitation of
signs of cardiac activity
insufficiency)
 CLASS II (ordinary - Slight limitation of
physical activity may activity
result in discomfort
and signs of cardiac
insufficiency)
- Marked limitation of
 CLASS III (less than
ordinary activity activity
results in excessive
feelings of fatigue,
dyspnea) - Symptoms present
 CLASS IV (signs of at rest
cardiac insufficiency
may be experienced
even at rest; physicial *** Class I & II usually
activity increases the do well in
discomfort) pregnancy
MARY LOURDES NACEL G. CELESTE, RN, MD 330
CARE OF PREGNANT WOMEN WITH CARDIAC
DISEASE
 Reduce cardiac workload – promote rest,
infection prophylaxis, prevention of
anemia, provision of adequate calories/
fiber/ nutrients and no added salt (2.5
g/day); reduce streaa and anxiety; delivery
without bearing down (eg, forceps
assisted, pain relief)
 Strengthen cardiac function –administer
medication (eg, digoxin)
 Prevent volume overload

 Monitor fetal well-being


MARY LOURDES NACEL G. CELESTE, RN, MD 331
Isoimmunization
(Rh Incompatibility)
 Rh: major blood group antigen of
importance during pregnancy
 Rh (-) negative mother is carrying
a fetus with Rh (+) positive blood
 Incompatibility between the
mother’s Rh (-) and fetus’ Rh (+)
can lead to Hemolytic disease of
the newborn
MARY LOURDES NACEL G. CELESTE, RN, MD 332
 Rh Sensitization and Prevention
Rh- mother carries Rh+ fetus

Rh+ fetal blood may mix with Rh- maternal blood

Mother’s immune system produces Rh antibodies in


response to Rh+ fetal blood cells

Antibodies remain in maternal blood following


pregnancy

Maternal antibodies attack


Rh+ fetus in the next pregnancy,
resulting in hemolysis

Mother receives Rhogam to


prevent her immune system
from producing Rh
antibodies
so in a subsequent
pregnancy,
Rh+ fetal blood cells are
MARY LOURDES NACEL G. CELESTE, RN, MD 333
NOT
destroyed
 If a tear in the placenta occurs and
there was no treatment, the next Rh+
positive fetus will have RBCs destroyed
by the maternal Rh antibodies. This
causes hemolysis of fetal RBCs and
then -anemia which in turn causes
fetal edema – Hydrops fetalis or
Erythroblastosis fetalis (a syndrome
with a hyperdynamic state, heart
failure, diffuse edema, ascites and
pericardial effusion)
MARY LOURDES NACEL G. CELESTE, RN, MD 334
RhoGAM
 Rh immune globulin given to
gravidas who are Rh(-) if there is
suspicion of feto-maternal
bleeding (amniocentesis,
miscarriage, vaginal bleeding and
delivery), during any trimester,
after delivery and prophylactically
at 28 weeks

MARY LOURDES NACEL G. CELESTE, RN, MD 335


MATERNAL ANTIBODY FORMATION AGAINST THE RH ANTIGEN

MARY LOURDES NACEL G. CELESTE, RN, MD 336


ABO INCOMPATIBILITY
 The problem occurs when the maternal blood
enters fetal circulation.
 Most common: mother is Type O and the
fetus is either Type A, B, or AB
 The mother’s plasma naturally contains anti-
A and anti B antibodies
 With weaker hemolytic effect than Rh
antibodies and only affect mature RBC’s
 Number of antibodies is limited to the
amount of maternal blood that entered
circulation
 May affect fetus of the 1st pregnancy
 Affected newborn will become jaundiced in
the first 3 days of life
MARY LOURDES NACEL G. CELESTE, RN, MD 337
 Possible combinations for
ABO INCOMPATIBILITY

MOTHER FETUS
A B
B A
O A, B, AB

MARY LOURDES NACEL G. CELESTE, RN, MD 338


MARY LOURDES NACEL G. CELESTE, RN, MD 339
Infections in Pregnancy

Tuberculosis
 Neither the disease nor the treatment is
threatening to the mother or newborn
 Late afternoon fevers, nightsweats, weight
loss, malaise
 Sputum Microscopy / Chest X-ray with
abdomnal shield
 TB drugs : Rifampicin, Izoniazid,
Pyrazinamide, Ethambutol (RIPE)
 Breastfeeding is not affected by the
medications of TB
MARY LOURDES NACEL G. CELESTE, RN, MD 340
Rubella (German Measles)
 Virus crosses the placenta and had deleterious
effects on 50-90% of the fetus in the 1st trimester
(deafness, psychomotor prolems, microcephaly)
 S/S: 3-day rash which disappears upon pressure
on the skin; fever; lymphadenopathy
 Rubella immunization during childhood
 Women immunized should NOT be pregnant for at
least 3 months following vaccination
 Immune serum globulin for maternal symptoms;
does not alter fetal outcome
 Strict isolation during the disease
 May breastfeed after the disease

MARY LOURDES NACEL G. CELESTE, RN, MD 341


Syphilis
 Can cross the placenta at any time and can cause 100%
fetal infection if primary and secondary infection is
untreated and 6-14% fetal infection in latent syphilis
 2nd trimester infections cause spontaneous
abortion, preterm labor, stillbirth and congenital
anomalies
 3rd trimester infection causes enlarged liver,
spleen, skin rash and jaundice in a newborn
 Dx: (+) VDRL; presence of a chancre for 10 days
to 3 months if primary, low-grade fever 4-6 weeks
after the chancre; asymptomatic for 5-20 years
 Tx: Syphilis <1 year: Benzathine Penicillin G, 1
dose
>1 year: 3 doses of Benzathine
Penicillin Gl;
will prevent congenital syphilis
MARY LOURDES NACEL G. CELESTE, RN, MD 342
MARY LOURDES NACEL G. CELESTE, RN, MD 343
Herpes Simplex Virus Type 2
 Associated with infection in the newborn (almost half
exposed to herpes in vaginal delivery will become
infected)
 S/S: headache, generalized itching, malaise, low grade
fever and burning in the area where vesicles will appear,
inguinal and pelvic lymphadenopathy with pain, pain in
urination; vesicles in the labia, vaginal, perianal and
endocervical area for 2-6 weeks; recurrent lesions
 Presumptive dx done in pap smear, viral isolation from
the lesion
 Pregnancy considerations: Cesarean section- most
probable course for delivery; good handwashing;
cleaning of room using universal precautions
 Health teaching: NO sexual activity in the presence of
lesions and 10-14 days after lesions subsided; keep vulva
clean and dry in the presence of lesions; sitz bath; use
foley catheter if retention persists; povidone- iodine
douche and acyclovir NOT used during pregnancy
MARY LOURDES NACEL G. CELESTE, RN, MD
MARY LOURDES NACEL G. CELESTE, RN, MD 344
344
MARY LOURDES NACEL G. CELESTE, RN, MD 345
Gonorrhea
 S/S: profuse and purulent vaginal
discharge, itching of the vulva, painful
urination and (+) cervical smear
 Can cause spontaneous abortion, preterm
delivery or PROM; if present at the time of
delivery, it can cause gonoccocal
ophthalmia (associated with severe eye
infection and blindness)
 Tx: Ceftriaxone or Spectinomycin or Probenecid
with Amoxicillin
 0.5% Erythromycin or 1% Tetracycline ointment
for newborn babies
MARY LOURDES NACEL G. CELESTE, RN, MD 346
MARY LOURDES NACEL G. CELESTE, RN, MD 347
 HIV Infection
 Transmission through the placenta
(greatest near term); delivery due to
exposure in birth canal secretions and
blood(60%) and breast milk
 Focus of care: treat the infection; reduce
the risk of perinatal transmission through
maintenance or reduction of viral load
 Tx: oral Zidovudine initiated at 14-34
weeks AOG and continued throughout
pregnancy, IV dose during labor and
delivery and neonatal dose 8-12 hours
after delivery
 Suggested mode of delivery depends on
viral load: >1000 copies/ml, CS might
reduce transmission
 Bathe the newborn as soon as possible
after delivery; all needle procedures made
MARY LOURDES NACEL G. CELESTE, RN, MD 348
after the bath
Type Signs/Symptoms Diagnostic Tests Transmission and Nursing Considerations
Incubation
Painless chancre fades after 6 wk VDRL, RPR, FTA Mucous membrane or skin; Treat with penicillin G IM
Copper-colored rash on palms and congenital For PCN allergy – erythromycin for
soles 10-90 d 10-15 d
Low-grade fever Retest for cure
Syphilis Cardiac/CNS dysfunction
Congenital – “sniffles”
May result in blindness, pegged
notch permanent teeth
(Hutchinson teeth)
Thick discharge from vagina Culture of Mucous membrane or skin; IM ceftriaxone (Rocephin) 1 time
Frequently asymptomatic in discharge from congenital and PO doxycycline BID for 1
females cervix or urethra 2-7 d wk:
IM aqueous penicillin with PO
probenicid to delay penicillin
Gonorrhea urinary excretion
PO tetracycline or doxycycline is
used to treat chlamydia, which
coexists in 45% of cases
Monitor for complications, pelvic
inflammatory disease
Painful vesicular genital lesions Direct examination Mucous membrane of skin; Acyclovir (not cure)
Difficulty voiding of cells congenital Emotional support
Recurrence in times of stress, HSV antibodies Virus can survive on objects Sitz baths
Genital herpes infection, menses such as towels Local medication
(HSV-2) 3-14 d Client must notify sexual contacts
(simplex) Monitor Pap smears on regular
basis – increased incidence of
cancer of cervix
Precautions for vaginal delivery
Men – urethritis, dysuria Direct examination Mucous membrane; sexual Notification of contacts
Women – thick vaginal discharge of cells contact May cause sterility
Chlamydia
with acrid odor Enzyme-linked 1-3 wk Treat with tetracyclineor
doxycycline PO
MARY LOURDES NACEL G. CELESTE, RN, MD 349
Initially single, small Direct exam Mucous Curettage,
papillary lesion Biopsy membrane; cryotherapy with
spreads into large sexual liquid nitrogen or
cauliflowerlike contact; podophyllin resin
cluster on perineum congenital Keratolytic agents
and/or vagina or 1-3 mo Avoid intimate
penis; may be sexual contact
itching/burning until lesions are
Condylomata
healed
acuminata
Strong association
(venereal
with incidence of
warts)
genital dysplasia
and carcinoma
Atypical,
pigmented, or
persistent warts
should be
biopsied
Notify contacts
Human Generalized fatigue, Blood test - Sexual contact See section of HIV
immuno- recurrent fever, etc. ELISA with infected infection
deficiency persons
virus (HIV)
MARY LOURDES NACEL G. CELESTE, RN, MD 350
Problems of the
Reproductive Tract

Mary Lourdes Nacel G. Celeste, R.N., M.D.


PROBLEMS OF THE
FEMALE REPRODUCTIVE TRACT
Infectious processes
Vaginal
 Simple vaginitis – characterized by a yellow discharge,
itching, burning and edema; treated with dilute vinegar
douche, antibiotics, sitz baths

 Nonspecific vaginits (Gardnerella) – presumed to be


bacterial
 Gray-white discharge with foul/fishy odor; itching;
“clue” cells on saline wet slide
 May be treated locally with sulfa vaginal cream;
more commonly with oral metronidazole (Flagyl),
tetracycline (both of which are contraindicated in
pregnancy), or ampicillin

MARY LOURDES NACEL G. CELESTE, RN, MD 352


 Candida albicans – overgrowth of vaginal yeast
- Odorless, cheesy white discharge; itching, inflamed
vagina and perineum
- vaginal irritation, pruritus, with yeasty odor
dysuria, (+)KOH or saline wet mount

- The newborn has the risk of being infected upon


passage in the vaginal canal
 Clotrimazole type of antifungal agent for 7 days

Candidiasis
 Thrush in newborn

MARY LOURDES NACEL G. CELESTE, RN, MD 353


 Trichomonas vaginalis – protozoan infection
- Profuse green/yellow/white, malodorous, frothy
discharge, irritate genitalia, itching;
“strawberry” cervix
- positive motile protozoa in a saline wet mount

- Client and partner(s) are treated with


metronidazole (Flagyl) and advised to use a
condom during intercourse; concurrent alcohol
ingestion with metronidazole causes severe GI
symptoms

- Associated with preterm labor, premature


rupture of membranes and postcesarean
infection MARY LOURDES NACEL G. CELESTE, RN, MD 354
 Atrophic vaginitis – occurs after menopause
- Pale, thin, dry mucosa, itching, dyspareunia
- Treated with topical estrogen cream, water-
soluble vaginal lubricants, and sometimes
antibiotic vaginal suppositories and
ointments

MARY LOURDES NACEL G. CELESTE, RN, MD 355


 Toxic shock syndrome (TSS)
-Characterized by sudden onset of high
fever, vomiting, diarrhea, drop in systolic
blood pressure, diffuse sunburn like
macular red rash, later desquamation of
palms and soles; usually due to
Staphylococcus aureus

- Potential involvement of kidneys, CNS,


gastrointestinal system, hematological
system, and/or cardiovascular system;
therefore, early diagnosis and treatment
are important
MARY LOURDES NACEL G. CELESTE, RN, MD 356
Toxic Shock syndrome
 Reproductive age, near menses or postpartum period
 Due to Staphylococcus Aureus
 Related to use of tampons, cervical cap or diaphragm

Manifestations: fever, rash on trunk, desquamation of skin,


hypotension, dizziness, vomiting, diarrhea, myalgia,
inflamed mucous membranes

 Diagnostics:
Elevated BUN, Crea
Elevated AST, ALT, total bilirubin
Decreased platelets

Management:
IV fluids, fluid and electrolyte replacement
Antibiotics
renal dialysis
Client education – change tampons 3-6 hours, avoid tampons
6-8 wks after childbirth, do not
MARY LOURDES NACEL leave
G. CELESTE, RN, MDdiaphragms>48357

hours
 Pelvic inflammatory disease (PID)
– local infection, usually gonorrhea
and/or chlamydia, spreads/ ascends to
the fallopian tubes, ovaries, and other
organs
-Characterized by lower abdominal
pain and tenderness, malaise, fever,
leukocytosis, and purulent vaginal
discharge
-Potential to cause adhesions that
produce sterility and contribute to
ectopic pregnancy
-Management includes noting amount,
color, and odor of drainage; systemic
antibiotics; warm douches to increase
circulation and promote drainage; rest
and comfort measures; STD prevention
MARY LOURDES NACEL G. CELESTE, RN, MD 358
Chlamydia
 Increased yellowish vaginal discharge,
painful and frequent urination, bleeding
between periods, mucopurulent cervicitis,
(+) culture and antigen detection test
 Tx: erythromycin (tetracycline not used
during pregnancy)
 Associated with premature rupture of
membranes, preterm labor and
endometriosis, low birth weight and
perinatal mortality due to placental
transmission
 Can lead to infertility, ectopic pregnancy
and endometritis

MARY LOURDES NACEL G. CELESTE, RN, MD 359


 Problems related to breast
 Mastitis – infection of the breast (occurring
most often during lactation) caused by
inadequate cleanliness of the breast,
infection in the infant, blood-borne infections,
or plugged lactiferous ducts

-Characterized by reddened, inflamed, and


tender breast; exudates from the nipple;
fever, fatigue, leukocytosis; and pain from
stagnation of milk

-Management includes administering


systemic antibiotics, warm packs to promote
drainage, and instructing the patient to wear
a brassiere to support the breasts
MARY LOURDES NACEL G. CELESTE, RN, MD 360
 Fibrocystic disease
 Characterized by multiple soft, tender,
freely moving cysts that become
enlarged during menstruation and
subside during pregnancy, lactation, or
after menopause

-Management includes aspiration to


relieve discomfort and instructing the
patient to report to the physician any
changes in shape or size
MARY LOURDES NACEL G. CELESTE, RN, MD 361
Fibrocystic breast disease
 Most common benign condition of the breast
 20-50 years old
 Due to imbalance between hormones
 Rare in postmenopausal women not taking HRT
 Not risk for Ca except if patient has (+) family history
and with atypical cellular changes on biopsy
S/S: bilateral cyclic pain, tenderness, nipple discharge

Dx: mammography, sonography, FNA

Managementt: restrict Na, mild diuretic, Danazol


(hormone inhibitor), Bromocriptine and Tamoxifen (to
decrease symptoms)

MARY LOURDES NACEL G. CELESTE, RN, MD 362


Fibroadenoma
 2nd most common benign disorder
 Teens, early 30’s
 Not associated with breast Ca

S/S: freely movable, solid, well defined, sharply


delineated, rounded w/ a rubbery texture

Dx: USG, FNA

Mgmt: surgery of enlarged lesion

MARY LOURDES NACEL G. CELESTE, RN, MD 363


Intraductal Papilloma
 Tumors growing in terminal portion of
ducts
 Potentially malignant

S/S: unilateral mass/solitary nodule,


bloody discharge

Dx: ductogram followed by mammogram


biopsy

Mgmt: excision with follow up care


MARY LOURDES NACEL G. CELESTE, RN, MD 364
 Hypoplasia or hyperplasia of
the breast – may affect a
woman’s self-concept; cosmetic
surgery may be done to increase
or reduce breast size
 Augmentation mammoplasty –
inserts are placed under breast
tissue
 Reduction mammoplasty –
excessive tissue removed and the
MARY LOURDES NACEL G. CELESTE, RN, MD 365

nipple is relocated
 Cancer of the breast – rapidly
growing tumor
 Assessment – small, mobile,
painless lump; rash, or in more
advanced cases, change in color,
puckering or dimpling of skin,
pain and/or tenderness, nipple
retraction or discharge; axillary
adenopathy; detection by
mammography
MARY LOURDES NACEL G. CELESTE, RN, MD 366
Risk Factors:
Age, female, family hx, HRT > 5 yrs,
overweight after menopause, alcohol, no
history of pregnancy or 1st pregnancy after
age 30, never breastfeeding, early
menarche, late menopause, radiation, upper
socioeconomic areas, geographic location

Dx: mammography, FNA, USG, MRI


 May be managed by surgery, radiation
therapy, and/or chemotherapy
Tamoxifen (anti-estrogen)
Emotional responses
MARY LOURDES NACEL G. CELESTE, RN, MD 367
Types of mastectomies
 Partial (lumpectomy) – removal of involved
tissue while preserving contour and muscle
function; usually followed by radiation
 Subcutaneous (adenomastectomy) – removal
of breast tissue but skin and nipple remain
intact; used with premalignant lesions
 Simple – removal of the entire breast; a skin
flap may be left for cosmetic reconstruction
 Radical – removal of the breast as well as the
major and minor pectoral muscles, all lymph
nodes, fat, and fascia; a skin graft may be
used to cover the area
 Modified radical – the chest wall is resected,
as well as all of the above
 Superradical – the sternum is split and lymph
nodes are dissected from the mediastinum

MARY LOURDES NACEL G. CELESTE, RN, MD 368


Nursing care in addition to routine postop care:
 Inspect dressing and incision for bleeding
 To prevent lymphedema (pooling of lymph
circulation is involved arm), elevate it on a
pillow, turn patient to back and unaffected
side; avoid constricting clothing and using
the arm for blood pressure measurement,
IVs, injections
 To prevent muscle contractures, encourage
an exercise program with gradual
progression from those that do not stress the
incision to adduction and external rotation
 Promote acceptance of new body image by
providing emotional support

MARY LOURDES NACEL G. CELESTE, RN, MD 369


Problems of the uterus
1. Fibroid (leiomyomas) – benign tumors on the
myometrium
 Assessment – backache, constipation, pain
 Frequently asymptomatic
 Lower abdominal pain
 Fullness or pressure
 Menorrhagia
 Metrorhaggia
 dysmenorrhea

 May predispose to uterine cancer – but potential


for cancer is minimal
 40 yrs old
 Smooth muscle cells present in whorls and arise from
uterine muscle

MARY LOURDES NACEL G. CELESTE, RN, MD 370


 Dx: Ultrasonography
 Management includes:

Routine pelvic exam every 3-6 months


surgery
-hysterectomy (surgical removal of the
uterus) or myomectomy (partial
resection of the uterus)

MARY LOURDES NACEL G. CELESTE, RN, MD 371


 Uterine displacements – caused by
weakening of pelvic muscles; may be
retrograde (retroversion and/or
retroflexion) or forward displacement
(anteversion and/or anteflexion)
 Assessment – discomfort,
dysmenorrhea
 May contribute to infertility
 Management includes muscle-
strengthening exercises, insertion of a
pessary, or surgery to shorten the
muscles MARY LOURDES NACEL G. CELESTE, RN, MD 372
 Uterine prolapse – collapse of the uterus
into the vagina due to weakened pelvic
musculature

 Assessment – urinary incontinence, retention,


constipation, backache, and vaginal
discharge
-dragging sensation in groin, backache in
sacrum

 Management by insertion of a pessary or by


surgical removal of the uterus
MARY LOURDES NACEL G. CELESTE, RN, MD 373
 Cancer of the cervix –
malignant tumor cells invade the
cervix
 Assessment – often
asymptomatic; with invasion, the
primary sign is painless vaginal
bleeding, later a watery, foul-
smelling discharge progressively
becomes darker; irregular
menstrual bleeding, and
menorrhagia, confirmed positive
Pap smear and positive cervical
MARY LOURDES NACEL G. CELESTE, RN, MD 374
 Preventable

Risk Factors:
coitus at an early age
Multiple sexual partners
Sex partner with a history of numerous sexual
partners
Exposure to STD
HPV infections
Chemotherapy
Contraceptive use>5 yrs
Smoking
Antenatal exposure to DES
History of dysplasia
MARY LOURDES NACEL G. CELESTE, RN, MD 375
Diagnostics:
Pap smear
Colposcopy
Endocervical curettage

Management:
Surgery
 intravaginal radiation implants to deter
tumor growth and metastatic invasion
or hysterectomy

MARY LOURDES NACEL G. CELESTE, RN, MD 376


Types of hysterectomy
 Subtotal – removal of the fundus only
 Total – removal of the uterus (vagina
remains intact)
 Panhysterosalpingo-oophorectomy –
removal of the uterus, fallopian tubes,
and ovaries
 Radical – removal of the lymph nodes
in addition to the uterus, fallopian
tubes, and ovaries
 Nursing care – appropriate for internal
radiation therapy or routine
preoperation and postoperative care of
patient with malignancy

MARY LOURDES NACEL G. CELESTE, RN, MD 377


 Uterine (endometrial) cancer –
slowly growing malignancy most
often occurring postmenopausally
 Assessment – usually
asymptomatic during early
development; primary symptom
is postmenopausal vaginal
bleeding, followed by low pelvic
and lower back pain, palpable
uterine mass; diagnosis by
endometrial biopsy
MARY LOURDES NACEL G. CELESTE, RN, MD 378
Risk Factors:
Obesity
Multiparity
DM
HPN
Use of unopposed estrogen
High fat diet
Early menarche and late menopause
Use of tamoxifen
MARY LOURDES NACEL G. CELESTE, RN, MD 379
Diagnosis:
Pap smear
Endometrial biopsy
USG

Management:
TAHBSO
counseling
 Management includes internal and
sometimes external radiation therapy;
surgery; chemotherapy in advanced
cases
MARY LOURDES NACEL G. CELESTE, RN, MD 380
Problems related to the ovaries
 Benign Ovarian masses

Ovarian cysts – benign tumors (rare after menopause); may


or may not be painful; surgical removal may be
recommended during fertile years for cysts larger than 8
cm
– physiologic variations in menstrual cycle

 Dermoid cysts (cystic teratomas) – cartilage, bone, teeth,


skin or hair can be observed
 Endometriomas (chocolate cysts)

 Manifestations
 Sensation of fullness, cramping, dyspareunia, irregular
bleeding

Diagnostics:
USG

Management:
OCP to suppress ovarian function
MARY LOURDES NACEL G. CELESTE, RN, MD 381

Surgery
 Ovarian cancer – leading cause of death from female
reproductive malignancies because of rapid growth and
spread and lack of early symptoms
 Assessment – family history of ovarian cancer, client
history of breast, bowel, endometrial cancer, nulliparity,
infertility, heavy menses, palpation of abdominal mass
(late sign); diagnosis by ultrasound, CT, x-ray, IVP

Risk Factors:
Increased age (mean age 59 yrs old)
Fertility drugs
Early menarche or late menopause
Asbestos and talc exposure

S/S: abdominal swelling or inc abdominal girth, bloating,


pelvic pressure, mild constipation

 Management – surgical, chemotherapy, staging of tumor


after removal
 Nursing care – foster verbalization of feelings, continuity of
care, encourage support systems
MARY LOURDES NACEL G. CELESTE, RN, MD 382
Other alterations of female reproductive structures
 Endometriosis – proliferation of aberrant
endometrial tissue in the uterus, ovaries,
fallopian tubes, and within the abdominal cavity
and vagina
 Assessment – backache, menstrual irregularities,
and increasing dysmenorrhea
- Bleeding results to inflammation, scarring of
peritoneum and adhesions
 Cause unknown
 Common in 20-45 yrs old

Manifestations
 Pelvic pain – dull/cramping, related to
menstruation
 Dyspareunia
 Abnormal uterine bleeding
 Fixed tender retroverted uterus
MARY LOURDES NACEL G. CELESTE, RN, MD 383
 Palpable nodules in the cul de sac
Risk Factors
 Retrograde menstrual flow of
endometrium
 Physiologic disruption after
gynecologic surgery or cesarean birth
 Hereditary
 Possible immunologic effect

 May potentially cause adhesions,


which can result in sterility
 Management includes antiovulatory
drugs (ovulation is the stimulus for the
proliferation of tissue) and
encouraging early childbearing
because pregnancy helps to abate
symptoms MARY LOURDES NACEL G. CELESTE, RN, MD 384
Diagnostics:
Laparoscopy

 Management
 OCP-combination contraceptives to induce amenorrhea
 Analgesics
 NSAIDS
 Danazol – antiprogesterone; suppresses GnRH, low estrogen
and high androgens to suppress ovulation, promotes
amenorrhea and decreases endometrial support
 GnRH agonists ie leuprolide suppresses the menstrual cycle
through estrogen antagonism
 Progestins ie Medroxyprogesterone – antiendometrial effect

 Discuss condition, symptoms, treatment


 Avoid delay of pregnancy because of risk of infertility
 surgery

MARY LOURDES NACEL G. CELESTE, RN, MD 385


 Cystocele – protrusion of the bladder
through the vaginal wall
-Downward displacement of bladder,
which appears as a bulge in the anterior
vaginal wall
-Related to genetics, childbearing,
obesity, age
-S/S: incontinence (interference with
voiding and stress incontinence), vaginal
fullness

 Management includes Kegel’s exercises;


surgery (anterior colporrhaphy) to
MARY LOURDES NACEL G. CELESTE, RN, MD 386
surgically shorten the muscles that
Vaginal Cancer
 Upper 1/3 most common site

 S/S: painless vaginal bleeding and


discharge, urinary retention, bladder
spasm, hematuria, frequency of
urination, tenesmus, constipation,
blood in the stool
 Dx: pap smear, biopsy

 Mx: radiation, surgery


MARY LOURDES NACEL G. CELESTE, RN, MD 387
 Rectocele – protrusion of the rectum
through the vaginal wall characterized
by rectal pressure, heaviness, and
hemorrhoids

 Posterior vaginal wall is weakened


 Anterior wall of rectum sags forward
into the vagina
 S/S:constipation
 Mx: surgery
MARY LOURDES NACEL G. CELESTE, RN, MD 388
Thank you!

MARY LOURDES NACEL G. CELESTE, RN, MD 389