Maternal and Child Health Nursing Reviewer-Complete

FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY I.

THE EXTERNAL REPRODUCTIVE ORGANS A. Mons pubis or mons veneris – pad of fat which lies over the symphysis pubis covered by skin and at puberty by short hairs; protects the surrounding delicate tissues from trauma. B. Labia majora – two folds of skin with fat underneath; contain Bartholin’s glands which are believed to secrete a yellowish mucus which acts as a lubricant during sexual intercourse. The openings of the Bartholin;s glands are located posteriorly on either side of the vaginal orifice. C. Labia minora – two thin folds of delicate tissues; form an upper fold encircling the clitoris )called the prepuce) and unite posteriorly (called the fourchette) which is highly sensitive to manipulation and trauma that is why it is often torn during a woman’s delivery. D. Glans clitoris - small erectile structure at the anterior junction of the labia minora, which is comparable to the penis in its being extremely sensitive. E. Vestibule – narrow speace seen when the labia minora are separated. F. Urethral meatus – external opening of the urethra: slightly behind and to the side are the openings of the Skene’s glands (which are often involved in infections of the external genitalia). G. Vaginal orifice or Introitus – external opening of the vagina covered by a thin membrance (called hymen) in virgins. H. Perinuem – area from the lower border of the vaginal orifice to the anus; contains the muscles (e.g., pubococcoygeal and levator ani muscles) which support the pelvic organs, the arteries that supply blood to the external genitalia and the pudendal nerves which are important during delivery under anesthesia.

II.

THE INTERNAL RERODUCTIVE ORGANS (Figure 2) A. Vagina – a 3-4 inch long dilatable canal located between the bladder and the rectum; contains rugae (which permit considerable stretching without tearing); organ of copulation; passageway for menstrual discharges and fetus. B. Uterus 1. Hollow pear-shaped fibromuscular organ 3 inches lone, 2 inches wide, 1 inch thick and weighing 50-60 gms. In a non-pregnant woman 2. Held in place by broad ligaments (from sides of uterus to pelvic walls; also hold Fallopian tubes and ovaries in place) and round ligaments (from sides of the uterus to the mons pubis) 3. Abundant blood supply from uterine and ovarian arteries 4. Composed of 3 muscle layers: perimetrium, myometrium and endometrium 5. Consists of three parts 5.1 Corpus (body)- upper portion with a triangular part called fundus 5.2 Isthmus – area between corpus and cervix which forms part of the lower uterine segment 5.3 Cervix – lower cylindrical portion.

6. Organ of menstruation; site of implantation, retainment and nourishment of the products of conception. C. Fallopian Tubes – 4 inches long from each side of the fundus; widest part (called ampulla) spreadsinto fingerlike projections (called fimbriae). Responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half. D. Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in plact by ligaments. Produce, mature and expel ova and manufacture estrogen and progesterone. III. THE PELVIS (Figure 3) – although not a part of the female reproductive system but of the skeletal system, it is a very important body part of pregnant women. A. Structure 1. Two os coxae/innominate bones – made up of: 1.1 Ilium – upper extended part; curved upper border is the iliac crest. 1.2 Ischium – under part; when sitting, the body rests on the ischial tuberosities; ischial spines are important landmarks. 1.3 Pubes – front part; join to form an articulation of the pelvis called the symphysis pubis. 2. Sacrum – wedge-shaped, forms the back part of the pelvis. Consists of 5 fused vertebrae, the first having a prominent upper margin called the sacral promontory. 3. Coccyx – lowest part of the spine; degree of movement between sacrum and coccyx made possible by the third articulation of the pelvis called sacroccygeal joint which allows room for delivery of the fetal head. B. Divisions – set apart by the linea terminalis, an imaginary line from the sacral promontory to the ilia on both sides to the superior portion of the symphysis pubis. 1. False pelvis – superior half formed by the ilia. Offers landmarks for pelvic measurements; supports the growing uterus during pregnancy; and directs the fetus into the true pelvis near the end of gestation. 2. True pelvis – inferior half formed by the pubes in front, the iliac and the ischia on the sides and the sacrum and coccyx behind. Made up of three parts: 2.1 Inlet – entranceway to the true pelvis. Its transverse diameter is wider than its anterosposteior diameter. Thus: 2.1.1 Transverse diameter = 13.5 cm. 2.1.2 Anteroposterior diameter (AP) = 11 cm. 2.1.3 Right and left oblique diameter = 12.75 cm. 2.2 Cavity – space between the inlet and the outlet. Contains the bladder and the rectum, with the uterus between them in an anteflexed position towards the bladder. 2.3 Outlet – inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch. Its AP diameter is wider than its transverse diameter.

C. Types/Variations 1. Gynecoid – “normal” female pelvis. Inlet is well rounded forward and back. Most ideal for childbirth. 2. Anthropoid – transverse diameter is narrow, AP diameter is lager than normal. 3. Platypelloid – inlet is oval, AP diameter is shallow 4. Android – “male” pelvis. Intel has a narrow, shallow posterior portion and pointed anterior portion. D. Measurements 1. External – suggestive only of pelvic size: 1.1 Intercristal diameter – distance between the middle points of the iliac crests. Average = 28 cm. 1.2 Interspinous diameter – distance between the anterosuperior iliac spines. Average = 25 cm. 1.3 Intertrochanteric diameter – distance between the trochanters of the femur. Average = 31 cm. 1.4 External conjugate/Baudelocque’s diameter – distance between the anterior aspect of the symphysis pubis and depression below L5. Average = 18-20 cm. 2. Internal – give the actual diameters of the inlet and outlet 2.1 Diagonal conjugate – distance between the sacral promontory and inferior margin of the symphysis pubis. Average = 12.5 cm. 2.2 Important measurement because it is the diameter of the pelvic inlet. Average = 10.5 – 11 cm. 2.3 Bi-ischial diameter/tuberischii – transverse diameter of the pelvic outlet. Is measured at the level of the anus. Average = 11 cm. Figure 3. The Pelvis IV. FEEDBACK MECHANISM OF MENSTRUATION A. General Considerations 1. 300, 000 – 400, 000 immature oocytes per ovary are present at birth (were formed during the first 5 months of intrauterine life, a process called oogenesis); many of these oocytes, however, degenerate and atrophy (a process called atresia). Only about 300-400 mature during the entire reproductive cycle of women. 2. Ushered in by the menarche (very first menstruation in girls) and ends with menopause (permanent cessation of menstruation, i.e., there are no more functioning oocytes in the ovaries); age of onset and termination vary widely depending on heredity, racial background, nutrition and even climate.

3. Normal period (days when there is menstrual flow) lasts for 3-6 days; menstrual cycle (from first day of menstrual period up to the first day of next menstruation period) may be anywhere from 25-35 days, but accepted average length is 28 days. 4. Anovulatory states after menarche are not unusual because of immaturity of feedback mechanism. Anovulatory states also occur in pregnancy, lactation and related disease conditions. 5. Associated terms 5.1 Amenorrhea – temporary cessation of menstrual flow. 5.2 Oligomenorrhea – markedly diminished menstrual flow, nearing amenorrhea 5.3 Menorrhagia – excessive bleeding during regular menstruation. 5.4 Metrorhagia – bleeding at completely irregular intervals. 5.5 Polymenorrhea – frequent menstruation occurring at intervals of less than 3 weeks. 5.6 Oligomenorrhea – markedly diminished menstrual flow. 6. Body structures involved 6.1 Hypothalamus 6.2 Anterior pituitary gland 6.3 Ovary 6.4 Uterus 7. Hormones which regulate cyclic activities 7.1 Follicle-stimulating hormone (FSH) 7.2 Luteinizing hormone (LH) 8. Effects of estrogen in the body 8.1 Inhibits production of FSH 8.2 Causes hypertrophy of the myometrium 8.3 Stimulates growth of the ductile structures of the breasts. 8.4 Increases quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of 10-13 cm. (Spinnbarkheit test of ovulation). 9. Effects of progesterone in the body 9.1 Inhibits production of LH 9.2 Increases endomentrial tortuosity 9.3 Increases endometrial secretions 9.4 Inhibits uterine motility 9.5 Decreases muscle tone of gastrointestinal and urinary tracts 9.6 Increases musculoskeletal motility 9.7 Facilitates transport of the fertilized ovum through the Fallopian tubes 9.8 Decreases renal threshold of lactose and dextrose 9.9 Increases fibrinogen levels; decreases hemoglobin and hematocrit 9.10 Increases body temperature after ovulation. Just before ovulation basal body temperature decreases slightly (because of low progesterone level in the blood) and then increases slightly a day after ovulation (because of the presence of progesterone)

B. Sequential steps of the menstrual cycle 1. On the third day of the menstrual cycle, serum estrogen level is at its lowest. This low estrogen level serves as the stimulus for the hypothalamus to produce the Follicle-Stimulating Hormone Releasing Factor (FSHRF). 2. FSHRF is the one responsible for stimulating the Anterior Pituitary Gland (APG) to produce the first of two hormones which regulate cyclic activities, the Follicle-Stimulating Hormone (FSH). 3. FSH, in turn, will stimulate the growth of an immature oocytes inside a primordial follicle by stimulating production of estrogen by the ovary. Once estrogen is produced, the primordial follicle is now termed as Graafian follicle (The Graafian follicle, therefore, is the structure which contains high amounts of estrogen). 4. Estrogen in the Graafian follicle will cause the cells in the uterine endothelium to proliferate (grow very rapidly), thereby increasing its thickness to about eightfold. This particular phase in the uterine cycle, therefore, is called proliferative phase. In view of the change from primordial to Graafian follicle, it is also called follicular phase. Because of the predominance of estrogen, it is also called the estrogenic phase. And since it comes right after the menstrual period, it is also called postmenstrual phase. And it is also called the pre-ovulatory phase. 5. On the 13th day of the menstrual cycle, there is now a very low level of progesterone in the blood. This low serum progesterone level is the stimulus for the Hypothalamus to produce the Luteinzing Hormone Releasing Factor (LHRF). 6. LHRF is responsible for stimulating the APG to produce the second hormone which regulates cyclic activity, the Luteininzing Hormone (LH). 7. The LH, in turn, is responsible for stimulating the ovary to produce the second hormone produced by the ovaries, progesterone. 8. The increased amounts of both estrogen and progesterone push the new mature ovum to the surface of the ovary until, on the following day (the 14th day of the menstrual cycle), the Graafian follicle ruptures and releases the mature ovum, a process called ovulation. 9. Once ovulation has taken place, the Graafian follicle, because it now contains increasing amounts of progesterone, giving it its yellowish appearance, is termed Corpus Luteum. (Therefore, the structure which contains high amounts of progesterone is the Corpus Luteum). 10. Progesterone causes the glands of the uterine endothelium to become corkscrew or twisted in appearance because of the increasing amount of capillaries. Progesterone, therefore, is said to be the hormone designed to promote pregnancy because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place, that is why this phase in the uterine cycle, that is why this phase in the uterine cycle is what we call progestational

phase. This phase in the uterine cycle is also called secretory phase because it secretes the most important hormone in pregnancy. In view of the change from Graafian follicle to corpus Luteum, it is called luteal phase. Because it occurs just after ovulation, it is also called the postovulatory phase. And, it is also called the pre-menstrual phase. 11. Up until the 24th day of the menstrual cycle, if the mature ovum is not fertilized by a sperm, the amounts of hormones in the corpus Luteum will start to decrease. The corpus Luteum turning white is now called the corpus albicans and in 3-4 days, the thickened lining of the uterus produced by estrogen starts to degenerate and slough off and capillaries rupture. And thus begins another menstrual period. C. Additional Information 1. When the ovary releases the mature ovum on the day of ovulation, sometimes a certain degree of pain in either the right or left lower quadrants is felt by the woman. This sensation is normal and termed mittelschmerz. 2. The first 14 days of the menstrual cycle is a very variable period. The last 14 days of the menstrual cycle is a fixed period – exactly 2 weeks after ovulation, menstruation will occur (unless a pregnancy has taken place) because the corpus Luteum has a life span of only 2 weeks. Implications: when given options regarding the exact date of ovulation, choose two weeks before menstruation. 3. In a 28-day cycle, ovulation takes place on the 14th day. In a 32-day cycle, ovulation takes place on the 18th day. In a 26-day cycle, ovulation takes place on the 12th day (Subtract 14 days from the cycle). 4. Menstruation does not occur during pregnancy because progesterone does not decrease in amount. Corpus Luteum continues to produce progesterone until the placenta takes over production of hormones by the 8th week of pregnancy. 5. Menstruation can occur even without ovulation (as in women taking oral contraceptives). Ovulation can likewise occur even without menstruation (as in lactating mothers).

HUMAN SEXUALITY I. DEFINITION OF TERMS A. Puberty – encompasses the physiologic changes leading to the development of adult reproductive capacity; the process includes maturation of the hypothalamus, pituitary gland and gonads. The role of the anterior pituitary gland. The pituitary secretion of gonadotropin initiates growth and maturation. It occurs initially during sleep and later in puberty throughout wakefulness. B. Adolescence – encompasses the physiologic, social, and cognitive changes leading to the development of adult identity. The process

C. D.

includes individual, achievement of personal independence and maturation of cognitive reasoning skills. Thelarche – budding of the breasts Adrenarche – development of axillary and pubic hair

II. SEXUAL DEVELOPMENT (Table 1) Criteria 1. Start of growth spurt

Males Around 13 years old

2. Growth rate

Rapid early growth

3. Growth cessation

Early cessation

4. Order maturation

of

sexual 6 months later than females Completed in 5 years 4.1 Darkening and thinning of scrotum and enlargement of testes and scrotum – first visible sign 4.2 Appearance of body hair 4.2.1 Pubic area 4.2.2 Axilla 4.2.3 Upper lip 4.2.4 Face 4.3 Penis grows, enlarges 4.4 Nocturnal emissions (wet dreams) - male counterpart of menstruation 4.5 Spermatogenesis

Females After onset of menses, around 10-12 years old Sharp decrease after menses occur 1-2 years after onset of menses 6 months earlier than males Completed in 3 years 4.1 Breast budding - first visible sign 4.2 Increased size of pelvis 4.3 Appearance of body hair 4.3.1 Pubic area 4.3.2 Axilla 4.4 Menstruation 4.5 Ovulation

Table 1. Sexual Development III. TANNER STAGING (Table 2 and Table 3) A. A rating system for pubertal development B. It is the biologic marker of maturity C. It is based on the orderly progressive development of: 1. Breasts and pubic hair – in females 2. Genitalia and pubic hair – in males Stages I II III

Males Childhood size of penis, testes, scrotum Enlargement of testes and scrotum Lengthening of the penis Further enlargement of testes and

Females Prepubertal, no breast tissue Appearance of breast bud Enlargement of the breasts and areola

scrotum Deepening pigmentation of scrotal skin Widening and further lengthening of penis Further enlargement of testes and scrotum Deepening pigmentation of scrotal skin Adult configuration and size of genitalia

IV

V

Areola and nipple form a mound atop underlying breast tissues

Adult configuration and size of genitalia Areola and breasts have smooth contour

Table 2. Tanner Stages of Pubertal Development: Thelarche & Genitalia Stages I II III IV V

Males Prepubertal, no pubic hair Sparse, downy hair at the base of the phallus Darkening, coarsening, curling of hair which extend upward and laterally Hair of adult consistency limited to the mons pubis Hair spreads to the medial aspect of the thighs

Females - same At the medial aspect of the labia majora - same - same - same -

Table 3. Tanner Stages of Pubertal Development: Adrenarche IV. HUMAN SEXUAL CYCLE A. Excitement 1. Vaginal lubrication and vasocongestion of the genitalia. 2. Penile erection due to vasocongestion B. Plateau 1. Formation of orgasmic platform due to prominent vasocongestion. 2. Generalized muscle tension, hyperventilation, increased BP, tachycardia in the late plateau phase. 3. Pre-ejaculatory phase with live spermatozoa C. Orgasmic 1. Strong rhythmic contractions of vagina and uterus. 2. In males, vas deferens, seminal vesicle, ejaculatory duct and prostate contract 3-4 times over a few seconds causing pooling of seminal fluid in the prostatic urethra. Rhythmic contractions in males occur at 0.8 seconds interval that assist in the propulsion process D. Resolution – rapid decline in pelvic vasocongestion. All organs return to previous position

E. Refractory phase – only in males; the period during which no amount of stimulation can cause another erection. Not manifested in females because females are multi-orgasmic. This phase lengthens with age.

PREGNANCY AND PRENATAL CARE I. FERTILIZATION A. Definition: the union of the sperm and the mature ovum in the outer third or outer half of the Fallopian tube. B. General considerations 1. Normal amount of semen per ejaculation = 3-5 cc. = 1 teaspoon. 2. Number of sperms in an ejaculate = 120-150 million/cc 3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are capable of fertilizing even for 3-4 days after ejaculation. 4. Normal life span of sperms = 7 days 5. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after deposition. 6. Reproductive cells, during gametogenosis, divide by meiosis (haploid umber of daughter cells); therefore, they contain only 23 chromosomes (the rest of the body cells contain 46 chromosomes). Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome. The union of an Xcarrying sperm and mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum results in a baby boy (XY). Important: Only fathers, therefore, determine the sex of their children. II. IMPLANTATION A. Implementation after fertilization, the fertilization ovum or zygote stays in the Fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place. The developing cells are now called blastomere and when there are already about 16 blastomeres, it is now termed a morula. In this morula for, it will start to ravel (by ciliary action and peristaltic contractions of the Fallopian tube) to the uterus where it will stay for another 3-4 days. When there is already a cavity formed in the morula, it is now called a blastocyst. Fingerlike projections, called trophoblasts (Table 4), form around the blastocyst and these trophoblasts are the ones which will implant high on the anterior or posterior surface of the uterus. Thus, implantation, also called nidation, takes place about a week after fertilization. B. General Considerations 1. Once implantation has taken place, the uterine endothelium is now termed decidua. 2. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts = implantation bleeding. Implication: this should not be mistaken for the Last Menstrual Period (LMP) III. STAGES OF HUMAN PRENATAL DEVELOPMENT A. First 12-14 days = zygote

I. Cytotrophoblast – the inner layer. II. Syncytiotrophoblast – the outer layer containing fingerlike projections called chorionic villi, which differentiate into: A. Langhan’s layer – believed to protect the fetus against Treponema Pallidum (etiologic agent of syphilis). Present only during the second B. From 15th trimester day up to of thepregnancy. 8th week = embryo C. FromB.8th week up to layer the time of birth Syncytial – gives rise =tofetus the fetal membranes: 1. Amnion – inner membrane which gives rise to 1.1 Umbilical cord/funis – contains two arteries and one vein, which are supported by the Wharton’s jelly. 1.2 Amniotic fluid  Clear, albuminous fluid in which the baby floats.  Begins to form at 11-15 weeks gestation.  Approximates water in specific gravity (1.007-1.025) and is neutral to slightly alkaline (pH = 7.0-7.25). Note: the higher the pH, the more alkaline; the lower the pH, the more acidic  Near term is clear, colorless, containing little white specks of vernix caseosa and other solid particles.  Produced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid rate. By the 4th lunar month, urine is added to the amount of amniotic fluid. Amniotic fluid, therefore, is derived chiefly from maternal serum and fetal urine. Implication: a case of polyhydramnios )=more than 1500 ml of amniotic fluid) stems from the inability of the fetus to swallow amniotic rapidly, as in tracheoesophageal fistula; while oligohydramnios )=amniotic fluid less than 500 ml) is due to the inability of the kidneys to add urine to the amniotic fluid, as in congenital renal anomaly.  Also known as bag of water (BOW), it serves the following purposes:  Protestion – shields the fetus against blows or pressures on the mother’s abdomen; against sudden changes in temperature because liquid changes temperature more slowly than air; and from infections  Diagnosis – as in amniocentesis; meconium-stained amniotic fluid means fetal distress  Aids in descent of the fetus during active labor  Estrogen and Progesterone 2. Chorion – together with the deciduas basalis, gives rise to the placenta, which starts to form at 8th week gestation. Develops 15-20 call 2.6 Protective barrier – inhibits the passage of sameinto bacteria andsubdivisions large molecules cotyledons. Placenta serves the following purposes: 2.1 Respiratory system – exchange of gases takes place in the placenta, not in Table 4. of Trophoblast Differentiation theOutline fetal lungs 2.2 Renal system – waste products are being excreted through the placenta (Note: it is the mother;s liver which detoxifies the fetal waste products). IV. FETAL DEVELOPMENT 2.3 Gastrointestinal system – nutrients pass to the fetus via the placenta by A. First Lunar Monththrough the placental tissues diffusion 2.4 Circulatory system – feto-placental circulation is established by selective osmosis 2.5 Endocrine system – it produces the following important hormones (before 8 weeks gestation, the corpus luteum is the one producing these hormones):  Human chorionic gonadotropin (HCG) “orders” the corpus luteum to keep on producing estrogen and progesterone, that is why menstruation

1. Germ layers differentiat by the 2nd week: (in cases of multiple congenital anomalies, the structures that will be affected are those that arise out of the same germ layer). 1.1 Entoderm – develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra 1.2 Mesoderm – forms into the supporting structures of the body (connective tissues, cartilagem muscles and tendons); heart, circulatory system, blood cells, reproductive system, kidneys and ureters 1.3 Ectoderm – responsible for the formation of the nervous system, the skin, hair and nails, and the mucous membrane of the anus and mouth. 2. Fetal membranes (amnion and chorion) appear by the second week. 3. Nervous system very rapidly develops by the 3rd week. (Dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in the latter). 4. Fetal heart begins to form as early as the 16th day of life. (To the question, “When does the fetal heart begin to beat?”, the answer is first lunar month. But to the question, “When can fetal heart tones to first heard?” the answer is fifth month.) 5. The digestive and respiratory tracts exist as a single tube until the 3rd week of life when they start to separate. B. Second Lunar Month 1. All vital organs are formed by the 8th week; placenta develops fully 2. Sex organs (ovaries and testes) are formed by the 8th week. (To the question, “When is sex determined?” the answer is “At the time f conception”). 3. Meconium (first stools) are formed in the instestines by the 5th – 8th week. C. 1. 2. 3. 4. 5.

Third Lunar Month Kidneys are able to function – urine is formed by the 12th week. Buds of milk teeth form Beginning bone ossification fetus swallows amniotic fluid Feto-placental circulation is established by selective osmosis; no direct exchange between fetal and maternal blood.

D. 1. 2. 3.

Fourth Lunar Month Lanugo appears Buds of permanent teeth form Heart beats maybe audible with fetoscope

E. 1. 2. 3. 4.

Fifth Lunar Month Vernix caseosa appears Lanugo covers entire body Quickening (fetal movements) felt Fetal heart beats very audible

F. Sixth Lunar Month 1. Skin markedly wrinkled 2. Attains proportions of fullterm baby G. Seventh Lunar Month – alveoli begin to form (28th weeks of gestation is said to be the lower limit of prematurity because if baby is delivered at this time, will cry and breathe but usually dies) H. 1. 2. 3. 4.

Eighth Lunar Month Fetus is viable Lanugo begins to disappear Nails extend to ends of fingers Subcutaneous fat deposition begins

I. Ninth Lunar Month 1. Lanugo and vernix disappear 2. Amniotic fluid volume somewhat decreases J. Tenth Lunar Month – all characteristics of the normal newborn. V.

FOCUS OF FETAL DEVELOPMENT A. First trimester – period of organogenesis B. Second trimester – period of continued fetal growth and development; rapid increase in fetal length C. Third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fat

VI.

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 1. Circulatory/Cardiovascular 1.1 Beginning the end of the first trimester there is a gradual increase of about 30% - 50% in the total cardiac volume, reaching its peak during the 6th month. This causes a drop in hemoglobin and hematocrit values since the increase is only in the plasma volume = physiologic anemia of pregnancy. Consequences of increased total cardiac volume are: 1.1.1 Easily fatigability and shortness of breath because of increased workload of the heart 1.1.2 Slight hypertrophy of the heart, causing it to be displaced to the left, resulting in torsion on the great vessels (the aorta and pulmonary artery). 1.1.3 Systolic murmurs are common due to lowered blood viscosity 1.1.4 Nosebleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses.

1.2 Palpitations are due to: 1.2.1 Sympathetic nervous system stimulation during the first half of pregnancy 1.2.2 Increased pressure of uterus against the diaphragm during second hald of pregnancy 1.3 Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities: 1.3.1. Edema of the lower extremities occurs. Management legs above hip level. Important: Edema of the lower extremities is normal during pregnancy; it is not a sign of toxemia 1.3.2. Varicosities of the lower extremities can also occur. Management:  Use/wear support hose or elastic stockings to promote venous flow, thus preventing stasis in lower extremities  Apply elastic bandage – start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap toes so as to be able to determine adequacy of circulation (Principle behind bandaging: blod flow through tissues is decreased by applying excessive pressure on blood vessels)  Avoid use of constricting garters, e.g., knee-high socks 1.4 Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid uterus, varicosities of the vulva and rectum can occur. Management: side-lying position with hips elevated on pillow and modified knee-chest position. 1.5 There is increased level of circulating fibrogen, that is why pregnant women are normally safeguarded against undue bleeding. However, this also predisposes them to formation of blood clots (thrombi). The implication is that pregnant women should not be massaged since blood clots can be released and cause thromboembolism. 2. Gastrointestinal changes 2.1 Morning sickness – nausea and vomiting during the first trimester is due to increased human chorionic gonadotropin (HCG). It may also be due to increased acidity or even to emotional factors. Management: Eat dry toast or crackers 30 minutes before arising in the morning (or dry, high carbohydrate, low fat and low spices in the diet). 2.2 Hyperemesis gravidarum = excessive nausea and vomiting which persists beyond 3 months; results in dehydration, starvation and acidosis. Management: D10NSS 300 ml in 24 hours is the priority treatment; complete bed rest is also important. 2.3 Constipation and flatulence are due to displacement of the stomach and intestines, thus slowing peristalsis and gastric emptying time. May also be due to increased progesterone during pregnancy. Management: 2.3.1 Increase fluids and roughage in the diet 2.3.2 Establish regular elimination time

2.3.3 2.3.4 2.3.5 2.3.6

Increse exercise Avoid enemas Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better Mineral oil should not be taken because it interferes with absorption of fat-soluble vitamins.

2.4 Hemorrhoids are due to pressure of enlarged uterus. Management: cold compress with witch hazel or Epsom salts. 2.5 Heartburn, especially during the last trimester, is due to increased progesterone which decreases gastric motility, thereby causing reverse peristaltic waves which lead to regurgitation of stomach contents through the cardiac sphincter into the esophagus, causing irritation. Management: 2.5.1 Pats or butter before meals 2.5.2 Avoid fried, fatty foods 2.5.3 Sips of milk at frequent intervals 2.5.4 Small, frequent meals taken slowly 2.5.5 Bend at the knees, not at the waist 2.5.6 Take antacids (e.g. milk of Magnesia) but never sodium bicarbonate (e.g. Alka Seltzer or baking soda) because it promotes fluid retention. 3. Respiratory changes – shortness of breath 3.1 Causes 3.1.1 Increased oxygen consumption and production of carbon dioxide during the first trimester. 3.1.2 Increased uterine size causes diaphragm to be pushed or displaced, thus crowding the chest cavity. 3.2 Management: Lateral expansion of the chest to compensate for shortness of breath increases oxygen supply and vital lung capacity. 4. Urinary changes 4.1 Urinary frequency, the only sign in pregnancy seen during the first trimester disappears during the second and reappears during the third trimester. Early in pregnancy is due to increased blood supply to the kidneys and to the uterus rising out of the pelvic cavity; in the last trimester is due to pressure of enlarged uterus on the bladder, especially with lightning (descent of the fetus into the pelvic brim). 4.2 Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; also an effect of the increased progesterone. (implication: it would be difficult to diagnose diabetes in pregnancy based on the urine sample alone because a pregnant women have sugar in their urine.) 5. Muscoloskeletal changes

5.1 Because of the pregnant woman’s attempt to change her center of gravity, she makes ambulation easier by standing more straight and taller, resulting in a lordotic position (“pride of pregnancy”) 5.2 Due to increased production of the hormone relaxin, pelvic bones become more supple and movable, increasing the incidence of accidental falls due to the wobbly gait. Implication: Advise use of low-heeled shoes after the first trimester 5.3 Leg cramps 5.3.1 Causes  Increased pressure of gravid uterus on lower extremities  Fatigue  Chills  Muscle tenseness  Low calcium, high phosphorus intake 5.3.2 Management  Frequent rest periods with feet elevated  Wear warm, more confortable clothing  Increase calcium intake (calcium tablets and diet)  Do not massage – blood clots can cause embolism.  Most effective treatment: Press knee of the affected leg and dorsiflex the foot. 6. Temperature – slight increase in basal temperature due to increased progesterone, but the body adapts after the 4th month 7. Endocrine changes 7.1 Addition of the placenta as an endocrine organ, producing large amounts of HCG, HPL, estrogen and progesterone. 7.2 Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and increased vascularity. Could also be due to increased basal metabolic rate to as much as +25% because of the metabolic activity of the products of conception. 7.3 Increased size of the parathyroid, probably to satisfy the increased need of the fetus for calcium. 7.4 Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortiso,, aldosterone and ADH, all of which affect carbohydrate and fat metabolism, causing hyperglycemia. 7.5 Gradual increase in insulin production but the body’s sensitivity to insulin is decreased during pregnancy. 8. Weight (Table 5) 8.1 During the first trimester, weight gain of 1.5-3 lbs is normal 8.2 On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is recommended. 8.3 Total allowable weight gain during entire period of pregnancy, therefore, is 20-25 pounds (10-12 kgs). 8.4 Pattern of weight gain is more important than the amount of weight gained.

Fetus Placenta Amniotic fluid Increased weight of uterus Increased weight of the breasts Weight of additional fluid Fat and fluid accumulation Characteristics of pregnancy

7lbs. 1 lb. 1 ½ lbs. 2 lbs. 1/1 – 3 lbs. 2 lbs. 4-6 lbs. Total

20-25 lbs.

Table 5. Distribution of Weight Gain During Pregnancy 9. Emotional responses 9.1 First trimester. The fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, disbelief, even depression. (Implication: when giving health teachings, emphasize the bodily changes in pregnancy). 9.2 Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the baby. 9.3 Third trimester: has personal identification with a real baby about to be born and realistic plans for future childcare responsibilities. Best time to talk about layette and infant feeding method. Fear of death, though is prominent (To allay fears, let pregnant woman listen to the fetal heart sounds.) B. Local Changes (Table 6) 1. Uterus 1.1 Weight increases to about 1000 grams at full tern; due to increase in the amount of fibrous and elastic tissues. 1.2 Change in shape from pear-like to ovoid; enormous change in consistency of lower uterine segment causes extreme softening, known as Hegar’s sign, seen at about the 6th week 1.3 Mucous plugs in the cervix, called operculum, are produced to seal out bacteria. 1.4 Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as Goodell’s sign. 2. Vagina 2.1 Increased vascularity causes change in color from light pink to deep purple or violet known as Chadwick’s sign. 2.1.1 To prevent confusion as to pregnancy signs, arrange the body parts from “out to in” and the different signs alphabetically. Thus: Vagina – Chadwick’s sign Cervix – Goodell’s sign Uterus – Hegar’s sign

2.1.2

Due to increased estrogen, activity of the epithelial cell increases, thus increasing amount of vaginal discharges called leucorrhea. As long as the discharges are not excessive, green/yellow in color, foul-smelling or irritatingly itchy, it is normal. Management: maintain or increase cleanliness by taking twice daily shower baths using cool water.

2.2 The pH of the vagina changes from normally acidic (because of the presence of Dederlein bacillie) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to protect against bacterial infection; however, there are two microorganisms which thrive in an alkaline environment. 2.2.1 Trichomonas, a protozoa or flagellate. The condition is called trichomonas vaginalis or trichomonas vaginitis or trichomoniasis.  Signs and symptoms of Trichomoniasis  Frothy, cream-colored, irritatingly itchy, foul-smelling discharges  Vulvar edema and hyperemia due to irritation from the discharges  Management  Flagyl for 10 days p.o. or vaginal suppositories of trichomonicidal compounds. (e.g., Tricofuron, Vagisec or Devegan). o Is carcinogenic during the first trimester o Treat male partner also with Flagyl. o Avoid alcoholic drinks when taking Flagyl – can cause Antabuse – like reactions: vomiting, flushed face and abdominal cramps. o Dark brown urine a minor side effect – no need to discontinue the drug.  Acidic vaginal douche (1 tbsp. white vinegar in 1 quart of water or 15 ml. white vinegar in 1000 ml. of water) to counteract alkaline – preferred environment of the protozoa.  Avoid intercourse to prevent reinfection 2.2.2

Candida albicans, a fungus or yeast. The condition is called Moniliasis or Candidiasis. Fungus also thrives in an environment rich in carbohydrates (that is why it is common among poorlycontrolled diabetics) and in those on steroid or antibiotic therapy when acidic environment is altered. Moniliasis is seen as oral thrush in the newborn when transmitted during delivery through the birth canal of the infected mother.  Symptoms

White, patchy, cheese-like particles that adhere to vaginal walls  Irritatingly itchy and foul-smelling vaginal discharges  Management  Mycostatin/Nystatin p.o. or vaginal suppositories/peccaries (100,000 U) twice a day for 15 days  Gentian violet swab to vagina (use panty shields to prevent staining of clothes or underwear)  Correct diabetes  Avoid intercourse  Acidic vaginal douche 

3. Abdominal Wall 3.1 Striae gravidarum – increase uterine size results in rupture and atrophy of connective tissue layers, seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent diastasis) 3.2 Umbilicus pushed out 4. Skin 4.1 Linea nigra – brown line running from umbilicus to symphais pubis 4.2 Melasma or chloasma – extra pigmentation on cheeks and across the nose due to increased production of melanocytes by the pituitary gland 4.3 Sweat glands unduly activated 5. Breasts – all changes due to increased estrogen 5.1 Increase in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support with well-fitting brassiere necessary to prevent sagging 5.2 Feeling of fullness and tingling sensation in the breasts 5.3 Nipples more erect. For mothers who intend to breastfeed, advise: 5.3.1 Nipple rolling 5.3.2 Drying nipples with rough towel to help toughen the nipples. 5.3.3 Not to use soap or alcohol as this can cause drying which could lead to sore nipples. 5.4 Montgomery glands become bigger and more protruberant 5.5 Areola becomes darker and diameter increases 5.6 Skin surrounding areolae turns dark 5.7 By the fourth month, a thin, watery, high protein fluid, called colostrums, is formed. It is the precursor of breast milk. 6. Ovaries – no activity whatsoever since ovulation does not take place during pregnancy. Progesterone and estrogen are being produced by the placenta. Stage First Trimester

Presumptive Amenorrhea Morning sickness

Probable Chadwick’s sign Goodell’s sign

Positive Ultrasound evidence

Second Trimester

Breast changes Urinary frequency Enlarging uterus Quickening Skin pigmentation (chloasma and linea nigra) Striae gravidarum

Hegar’s sign Positive HCG Elevation of BBT Enlarged abdomen Braxton Hicks Ballotement

Fetal heart tones Fetal movements felt by examiner Fetal outline on xray

Table 6. Signs of Pregnancy VII. THE PRENATAL VISIT A. The provision of prenatal care is the primary factor in the improvement of maternal and infant morbidity and mortality statistics. To ensure the success of the prenatal care programs, it should be remembered that the patient’s understanding of the modalities of care is basic to cooperative action. B. The duration of a normal pregnancy is 266-280 days, or 38-42 weeks (average is 40 weeks), or 9 calendar months or 10 lunar months. Any baby, therefore, who is born before the 38th week of gestation is called pre-term and a baby born after the 42nd week of gestation is said to be post-term. C. Diagnosis of Pregnancy. Urine examination – human chorionic gonadotropin (HCG) in the urine is the basis for pregnancy tests. It is present from the 40th day through the 100th day, reaching a peak level on the 60th day. HCG, therefore, is most correct 6 weeks after the last menstrual period (LMP). If more than 1 hour would lapse before being tested, refrigerate specimen because HCG is unstable under room temperature. Biological tests (e.g., frog tests) are no longer done. Immunodiagnostic tests (antigen-antibody reaction) are widely used at present because results are obtained faster and do not involve the sacrifice of an animal. E.g., Gravindex, Pregnex, Prognosticon. D. Components of a Prenatal Visit 1. History-taking 1.1 Personal data – patient’s name, age, address, civil status, (an unwed pregnancy is a risk pregnancy) and family history (With whom does she live? Are there familial diseases that could possibly affect the pregnancy?) 1.2 Obstetrical data 1.2.1 Gravida – number of pregnancies a woman has had. 1.2.2 Para – number of viable pregnancies, regardless of number and outcome 1.2.3 TPAL score (_ _ _ _) number of full term babies (T, premature (P) babies, abortion (A), living children (L) 1.2.4 Past pregnancies  Method of delivery – normal spontaneous vaginal? Caesarion section (CS)? Indication for past CS?  Where – At home? In the hospital?

 Risks involved – Prematurity? Toxemia? Present pregnancy  Chief concern – is there nausea and vomiting?  Danger signals  Vaginal bleeding, no matter how slight  Swelling of face and fingers  Severe, continuous headache  Dimness or blurring vision  Flashes of light or dots before eyes  Pain in the abdomen  Persistent vomiting  Chills and fever  Sudden escape of fluids from the vagina  Absence of fetal heart sounds after they have been initially auscultated n the 4th or 5th month 1.3 Medical data – is there a history of kidney, cardiac or liver disease; hypertension; tuberculosis; sexually-transmitted diseases (STDs)? 1.2.5

2. Assessment 2.1 Physical examination – review of systems is indicated, including inspection of the teeth because they are common foci of infection. 2.2 Pelvic examination (Cardinal rule: Empty the bladder first) 2.2.1 Internal exam (IE) to determine Hegar’s, Chadwick’s, and Goodell’s 2.2.2 Ballotement – fetus will bounce when lower uterine segment is tapped sharply (on 5th month of pregnancy) 2.2.3 Papanicolau (Pap smear) – cytological examination to diagnose cervical carcinoma.  Classification of findings  Class 1 – absence of a typical or abnormal cells (normal)  Class 2 – atypical/abnormal cytology but no evidence of malignancy  Class 3 – cytology suggestive of malignancy  Class 4 – cytology strongly suggestive of malignancy  Class 5 – conclusive for malignancy  Clinical stages that reflect localization or spread of malignant cervical changes.  Stage 1 – CA confined to the cervix  Stage 2 – CA extends beyond the cervix into the vagina, but not into the pelvic wall or lower 1/3 of the vagina  Stage 3 – Metastasis to the pelvic wall  Stage 4 – Metastasis beyond pelvic wall into the bladder and rectum

Pelvic measurements are preferably done after the 6th lunar month. X-ray pelvimetry (several flat plate X-ray pictures of the pelvis taken from different angles) is the most effective method of diagnosing cephalopelvic disproportion (CPD). But since X-rays are teratogenic, the procedure can be done only 2 weeks before EDC. 2.2.5 Leopold’s maneuvers  Purposes  To determine presentation, position, and gratitude  Estimate fetal size  Locate fetal parts  Preparatory steps  Palpate with warm hands; cold hands cause abdominal muscles to contract  Use palms, not fingertips  Position patient on supine with knees flexed slightly (dorsal recumbent position) so as to relax abdominal muscles.  Apply gentle but firm motions  Procedure  First manever: Facing head part of pregnant woman, palpate for fetal part found in the fundus to determine presentation (a hard, smooth, ballotable mass at the fundus means the fetus is in breech presentation  Second maneuver: Palpate sides of the uterus to determine the location of fetal back (best place to hear fetal heart tones) and small fetal parts  Third maneuver: Grasp lower portion off abdomen just above the symphysis pubis to find out degree of engagement.  Fourth maneuver: Facing the feet part of the patient, press fingers downward on both sides of the uterus above the inguinal ligaments to determine attitude (degree of flexion of fetal head) 2.2.4

2.5

2.3 Vital signs – temperature, pulse and respiratory rates are important especially during the initial prenatal visit. More important, however, are the weight and blood pressure as baseline data to determine any significant increases. 2.4 Blood studies 2.4.1 Blood Typing 2.4.2 Complete blood count, including Hgb and Hct, to determine anemia 2.4.3 Serological tests (VDRL and Kahn Wasserman) to diagnose for syphilis Urine examinations

2.5.1 2.5.2 2.5.3

Heat and acetic acid test to determine albuminuria. Any sign of albumin in the urine should be reported immediately because it is a sign of toxemia Benedict’s test for glycosuria, a sign of possible gestational diabetes. Urine should be collected before breakfast to avoid false positive results. Should not be more than +1 sugar. Determination of pyura. Urinary tract infection has been found to be a common cause of premature delivery.

3. Important Estimates 3.1 Age of Gestation (AOG) 3.1.1 Nagele’s Rule – calculation of expected date of confinement (EDC). Count back three months from the first day of the last menstrual period (LMP) then add 7 days. Substitute number for month for easy computation. E.g., LMP is September 6 September is the 9th month of the year – 3 = 6 (June) Add 7 days to 6 = 13 EDC – June 13 3.1.2 McDonald’s Method – determine age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months. E.G., fundic height of 16 cm. divided by 4 = 4 months AOG = 16 weeks AOG. 3.1.3 Bartholomew’s Rule – estimate AOG by the relative position of the uterus in the abdominal cavity (Figure 4).  By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis  On the 5th lunar month, the fundus is at the level of the umbilicus  On the 9th lunar month, the fundus is below the xiphoid process Bartholomew’s Rule 3.2 Haase’s Rule – determines the length of the fetus in centimeters. 3.2.1 During the first half of pregnancy, square the number of the month (E.g., first lunar month: 1 x 1 = 1 cm.) 3.2.2 During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar month: 6 x 5 = 30 cm) 3.3 Johnson’ss Rule – estimates the weight of the fetus in grams. Formula: fundic height in cm. – n x k “k” is a constant, it is always 155 “n” is = 12 (if fetus is engaged) = 11 (if fetus is not yet engaged) 4. Health Teachings 4.1 Nutrition – most important aspect (Table 7 and 8) 4.1.1 Women who need special attention  Pregnant teenagers

 Extremes in weighing scale – low prepregnant weight and the obese  Low income women  Successive pregnancies  Vegetarians – although with high vitamin intake, are low in proteins and minerals because there are many essential amino acids that can be found only in animal sources 4.1.2

Nutritional assessment is based on taking a diet history first  Food preferences/eating habits  Cultural/religious influences  Educational/occupational level

4.1.3

Computation of caloric equivalents  Carbohydrates x 4  Proteins x 4  Fats x 9

4.1.4

Food sources  Protein-rich foods – meat, fish, eggs, milk, poultry, cheese, beans, mongo  Vitamin A – eggs, carrots, squash, all green and leafy vegetables  Vitamin D – fish, liver, eggs, milk, (Caution: excess Vit. D during pregnancy can lead to fetal cardiac problems)  Vitamin E – green leafy vegetables, fish  Vitamin C – tomatoes, guava, papaya  Folic acid – especially needed to prevent megaloblastic anemia, abruption placenta and prematurity because, together with iron, folic acid is needed for hemoglobin formation. E.g., asparagus  Vitamin B – food rich in protein  Calcium/phosphorus – milk, cheese  Iron  Especially important during the last trimester when the pregnant woman is going to transfer her iron stores from herself to her fetus so that the baby has enough iron stores during the first three months of life when all he takes is milk (which is deficient in iron).  Iron has very low absorpotion rate; only 10% of iron intake can be absorbed by the body. Thus, for optimum absorpotion, give Vitamin C.  Iron should be given after meals because it is irritating to the gastric mucosa.  Foods rich in iron: liver and other internal organs, camote tops, kangkong, egg yolk, amplaya, amlunggay.

4.1.5

Malnutrition during pregnancy can result in prematurity; preeclampsia, absorption, low birth weight babies, congenital defects or even stillbirths.

Nutrients Calories (kcal) Proteins (Gm) Vitamin A (IU) Vitamin D (IU) Vitamin E (IU) Ascorbic acid/Vitamin C (mg) Folic acid (mg) Niacin (mg) Riboflavin (mg) Thiamine (mg) Vitamin B12 (ug) Vitamin B6 (mg) Calcium (mg) Phosphorus (mg) Iodine (ug) Iron (mg) Magnesium (mg)

Food Meat Vegetables specially dark green and deep yellow Fruits: Citrus and others Breads Milk Additional fluid

Non-Pregnant Women 2000 46 4000 400 12 45 400 13 1.2 1.0 3.0 2.0 800 800 100 18 300

Active Non-Pregnant Women 2 servings of meat, fowl or fish/day; 3-5 eggs/week 1 serving/day (at least 3/week) 2 or more servings/day 1 serving/day 4 or more servings/day 1 pint (6-8 oz. glasses /day)

Pregnant +300-400 +30 +1000 +0 +3 +15 +400 +2 +0.3 +0.3 +1.0 +0.5 +400 +400 +25 +18 +150

Pregnant Women 2-3 servings of meat, fowl or fish/day; 1 egg/day 1 serving/day 2-3 servings/day 1 servings/day 4 servings/day 1 quart (2-6 glasses/day)

4.2 Smoking – causes vasoconstriction, leading to low birth weight babies and, therefore, is contraindicated during pregnancy 4.3 Drinking – in moderation is not contraindicated but when excessive can cause transient respiratory depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories. 4.4 Drugs – dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the different body organs are

developing. Are teratogenic (can cause congenital defects) and, therefore contraindicated unless prescribed by the doctor. 4.4.1 Thalidomide – auses Amelia or phocomelia (short or no extremeties) 4.4.2 Steroids – can cause cleft palate and even abortion 4.4.3 Iodine – contained in many over-the-counter cough suppressants, cause enlargement of the fetal thyroid gland, leading to tracheal compression and dyspnea at birth 4.4.4 Vitamin K – causes hemolysis and hyperbilirubinemia 4.4.5 Aspirin and Phenobarbital – cause bleeding disorder 4.4.6 Streptomycin and quinine – cause damage to the 8th cranial nerve (nerve deafness) 4.4.7 Tetracycline – causes staining of tooth enamel and inhibits growth of long bones (not given also to children below 8 years for the same reasons) 4.5 Sexual activity 4.5.1 Sexual desires continue throughout pregnancy, but levels change  During the first trimester, there is a decreased in sexual desire because the woman is more preoccupied with the changes in her body  During the second trimester, there is another decrease in sexual desire because the woman is afraid of hurting the fetus 4.5.2 4.5.3 4.5.4

Sex in moderation is permitted during pregnancy but not during the last 6 weeks since there is increased incidence of postpartum infection in women who engage in sex during the last 6 weeks. Counsel the couple to look for more comfortable positions. Definitely, the missionary (man-on-top) position is not advisable Sex is contraindicated in the following situations  Spotting or bleeding  Ruptured BOW  Incompetent cervical os  Deeply-engaged presenting part

4.6 Employment – as long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive physical or emotional strain, there is no contraindication to working. Advise pregnant women to walk about every few hours of her work day long periods of standing or sitting to promote circulation. 4.7 Traveling – no travel restrictions but postpone a trip during the last trimester. On long rides, 15-20 minute rest periods every 2-3 hours to walk about or empty the bladder is advisable. 4.8 Exercises 4.8.1 Chief aim: To strengthen the muscles used in labor and delivery 4.8.2 Should be done in moderation

4.8.3

Should be individualized: according to age, physical condition, customary amount of exercises (swimming or tennis not contraindicated unless done for the first time) and the stage of pregnancy) 4.8.4 Recommended exercises  Squatting (Figure 5) and Tailor Sitting (Figure 6) – to stretch and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable. When standing from squatting position, raise buttocks first before raising the head to prevent postural hypotension.  Pelvic rock – maintains good posture; relieved pressure abdominal pressure and low backache; strengthens abdominal muscles following delivery  Modified knee-chest position - relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from hemorrhoids  Shoulder-circling – strengthens muscles of the chest  Walking – said to be the best exercises  Kegel – relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles 4.9 Prepared Childbirth/Childbirth Education – preparing the pregnant couple for childbearing 4.9.1 Operates basically on the “Gate Control Theory” of pain: pain is controlled in the spinal cord. To ease pain in one body part, the “gate” to this pain should be “closed”. 4.9.2 Premises  Discomfort during labor can be minimized if the woman comes into labor informed about what is happening and prepared with breathing exercises to use during labor  Discomfort during labor can be minimized if the woman’s abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall during contractions. 4.9.3

Major approaches to prepared childbirth –pregnant couples are taught about anatomy, pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet comfort measures  Grantly – Dick Read Method fear leads to tension and tension leads to pain.  Lamaze – psychoprohylactic method; based on stimulusresponse conditioning. To be effective, full concentration on breathing exercises during labor should be observed (Implication: Nurse should not interrupt the couple doing breathing exercises.)

4.10 Tetanus immunization – given 0.5 ml IM (deltoid region of the upper arm) to all pregnant women anytime during pregnancy. It shall be given in two doses at least 4

weeks apart, with the second dose at least 3 weeks before delivery. Booster doses shall be given during succeeding pregnancies regardless of the interval. Three booster doses will confer lifelong immunity. 4.11 Clinic appointments 4.11.1 First 7 lunar month – every month 4.11.2 On 8th and 9th lunar month – every other week or twice a month 4.11.3 On 10th lunar month – every week until labor pains set in

LABOR AND DELIVERY I.

THE FETAL SKULL (Figure 10) A. Importance: From an obstetrical point of view the fetal skull is the most important part of the fetus because it is the: 1. largest part of the body 2. most frequent presenting part 3. least compressible of all parts B. Cranial bones - the first 3 are not important part of the fetus because it is the: 1. 2. 3. 4. 5. 6.

Sphenoid Ethmoid Temporal Frontal Occipital parietal

C. Membrane space – suture lines are important because they allow the bones to move and overlap, changing the shape of the fetal head in order to fit through the birth canal, a process called molding. 1. Sagittal suture line – the membranous interspace which joins the parietal bones 2. Coronal suture line – the membranous interspace which joins the frontal bone and the parietal bones 3. Lambdoid suture line – the membranous interspace which joins the occiput and the parietals. D. Fontanels – membrance – covered spaces at the junction of the main suture lines 1. Anterior fontanel – the larger, diamond-shaped fontanel which closes beween 12-18 months in an infant 2. Posterior fontanel – the smaller, triangular shaped fontanel which closes between 2-3 months in the infant

E. Measurements – the shape of the fetal skull causes it to be wider in its anteroposterior (AP) diameter than in its transverse diameter 1. Transverse diameters of the fetal skull 1.1 Biparietal = 9.25 cm. 1.2 Bitemporal = 8 cm. 1.3 Bimastoid = 7 cm. 2. Anteroposterior diameters (Figure 11) 2.1 Suboccipitobregmatic (A) – from below the occiput to the anterior fontanel = 9.5 cm. (the narrowest AP diameter) 2.2 Occipitofrontal (B) – from the occiput to the mid-frontal boe = 12 cm. 2.3 Occipitomental © - from the occiput to the chin = 13.5 cm (the widest AP diameter) Anteroposterior Diameters of the Fetal Skull Which one of these diameters is presented at the birth canal depends on the degree of flexion (known as attitude) the fetal head assumes prior to delivery. In full flexion (very good attitude when the chin is flexed on the chest), the smalles suboccipitobregmatic diameter (A) is the one presented at the birth canal. If in poor flexion, the widest occipitomental diameter (D) will be the one presented and will give mother and the baby more problems. II. THEORIES OF LABOR ONSET A. Uterine Stretch Theory – any hallow body organ when stretched to capacity will necessarily contract and empty. B. Oxytocin theory – labor, being considered a stressful event, stimulates the hypophysis to produce oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the smooth muscles of the body, e.g., uterine muscles. C. Progesterone Deprivation theory – progesterone, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases, labor pains occur. D. Prostaglandin theory – initiation of labor is said to result from the release of arachidonic acid produced by steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which, in turn, causes uterine contractions. E. Theory of Aging Placenta – because of the decrease in blood supply, the uterus contracts. III. PRELIMINARY/PRODROMAL SIGNS OF LABOR A. Lightening – the settling of the fetal head into the pelvic brim. In primis, it occurs 2 weeks before EDC; in multis, on or before labor onset. Lightening should not be confused with engagement; engagement occurs when the presenting part had descended into the pelvic inlet. Lightening results in:

1. 2. 3. 4.

increase in urinary frequency relief of abdominal tightness and diaphragmatic pressure shooting pains down the legs because of pressure on the sciatic nerve increace in the amount of vaginal discharges

B. Increased activity evel – due to increased epinephrine secreted to prepare the body for the coming “work” ahead. Advise the preganant woman no to use this increased energy for doing household chores. C. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset; probably due to decrease in progesterone production leading to decrease in fluid retention. D. Braxton Hicks contractions – painless, irregular practice contractions. E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “butter-soft” F. Rupture of the membranes – it is important to remember that one membranes (BOW) have ruptures: 1. Labor is inevitable. It will occur within 24 hours. 2. The integrity of the uterus has been destroyed. Infection, therefore, can easily set in. That is why once membranes have rupture: 2.1 Aseptic techniques should be observed in all procedures 2.2 Doctors do less obstetric manipulations (e.g. IE) 2.3 Enema is no longer ordered 2.4 Temperature should be taken regularly so that fever, a sign of infection, can be detected. 3. Umbilical cord compression and/or cord prolapsed can occur (especially in breech presentation). Nursing action depends on the specific situation: 3.1 A woman in labor seeking admission to the hospital and saying that her BOW has rupture should be put to bed immediately, and the fetal heart tones taken consequently 3.2 If a women in Labor Room says that her membranes have rupture, the initial nursing action is to take the fetal heart tones. 3.3 she feels a loop of the cord coming out of the vagina (cord prolapse), the first nursing

FALSE LABOR PAINS 1. Remain irregular 2. Generally confined to the abdomen 3. No increase in duration, frequency and intensity 4. Often disappears if the women

TRUE LABOR PAINS 3. May be slightly irregular at first but become regular and predictable in a matter of hours. 4. First felt in the lower back and sweep aroung to the abdomen in a girdlelike fashion. 5. Increase in duration, frequency and intensity.

ambulates 5. Absent cervical changes

6. Continue no matter what the woman;s level of activity is. 7. Accompanied by cervical effacement and dilatation (the most important differenc)

Differences Between False and True Labor Pains G. Effacement – shortening and thinning of the cervical canal as distinct from the uterus. It is expressed in percentage. H. Dilatation – enlargement of the external cervical os up to 10 cm primarily as a result of uterine contractions and secondarily as a result of pressure of the presenting part and the BOW. I. Uterine Changes 1. The uterus is gradually differentiated into two distinct portions 4.1. Upper uterine segment – becomes thick and active to expel out fetus 4.2. Lower uterine segment – become thin-walled, supple and passive so that fetus can be pushed out easily. 5. Physiological retraction ring is formed at the boundary of the upper and lower uterine segments. In difficult labor when the fetus is larger than the birth canal, the round ligaments of the uterus become tense during dilatation and expulsion, causing an abdominal indentation called Bandl’s pathological retraction ring, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not relieved. 6. Nursing Care III.1 Hospital admission – provide privacy and reassurance from the very start III.1.1 Personal data – name, age, address, civil status III.1.2 Obstetrical data – determine EDC; obstetrical score (gravida, para, TPAL); amount and character of show; and whether or not membranes have ruptured. III.2 General physical examination, internal exam and Leopold’s maneuvers are done to determine: III.2.1 Effacement and dilatation III.2.2 Station – relationship of the fetal presenting part to the level of the ischial spine (Figure 14)  Station 0 – at the level of the ischial spines; synonymous to engagement  Station -1 – presenting part above the level of the ischial spines  Station +1 – presenting part below the level of the ischial spines  Station +3 or +4 – synonymous to crowning (encircling of the largest diameter of the fetal head by the vulvar ring) III.2.3 Presentation – relationship of the long axis of the mother to the long axis of the fetus; also known as lie. Presenting part if the fetal part which enters the pelvis first and covers the internal cervical os

I. VERTICAL A. Cephalic – head is the presenting part 1. Vertex – head sharply flexed, making the parietal bones the presenting parts 2. If in poor flexion 2.1 Face 2.2 Brow 2.3 Chin B. Breech – buttocks are the presenting parts 1. Complete – thighs flexed on the abdomen and legs are on the thighs 2. Frank – thighs are flexed and legs are extended, resting on the anterior surface of the body C. Footling 1. Single – one leg unflexed and extended; one foot presenting 2. Double – legs unflexed and extended; feet are presenting II. HORIZONTAL = Transverse lie = Shoulder presentation  In vertex presentation, FHS are usually located in either the left or right lower quadrant (LLQ or RLQ); in breech presentation, at or above the level of the umbilicus, either left or right upper quadrant (LUQ or RUQ)  Hazards of breech delivery  Cord compression  Abruptio placenta  Erb – Duchenne paralysis  Horizontal lie is very rare (1%) and maybe due to a relazed abdominal wall because of multiparity, pelvic contraction or placenta previa 3.2.4. Position – relationship of the fetal presenting part to a specific quadrant in the mother’s pelvis  The pelvis is divided into four quadrants  Right anterior  Left anterior  Right posterior  Left posterior o Posterior positions result in more backaches because of pressure of the fetal presenting part on the maternal sacrum  Points of direction in the fetus  Occiput – in vertex presentations  Chin (mentum) – in face presentations  Sacrum – in breech presentations  Scapula (acromio) – in horizontal presentations  Possible fetal positions

Vertex o LOA – left occipitoanterior (most common and favorable position at birth) o LOP – left occipitoposterior o LOT – left occipitotransverse o ROA – right occipitoanterior o ROP – right occipitoposterior o ROT – right occipitotransverse  Breech o LSA – left sacroanterior o LSP – left sacroposterior o LST – left sacrotransverse o RSA – right sacroanterior o RSP – right sacroposterior o RST – right sacrotransverse  Face o LMA – left mentoanterior o LMP – left mentoposterior o LMT – left mentotransverse o RMA – right mentoanterior o RMP – right mentoposterior o RMT – right mentotransverse  Shoulder o LADA – left acromiodorsoanterior o LADP – left acromiodorsoposterior o RADA – right acromiodorsoanterior o RADP – right acromiodorsoposterior 3.3 Monitoring and evaluating important aspects 3.3.1 Uterine contractions – fingers should be spread lightly over the fundus. (Figure 15)  Duration – from the beginning of one contraction to the end of the same contraction (A to B)  Interval – from the end of one contraction to the beginning of the next contraction (B to C)  Interval early in labor – 40 – 45 minutes  Interval late in labor – 2 – 3 minutes  Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C). Observe 3 – 4 contractions to have a good picture of the frequency of contractions  Intensity – the strength of contraction; maybe mild, moderate or strong. Intensity is measured by the consistency of the fundus at the acme of the contraction. When estimating intensity, check fundus at the end of contraction to determine whether it relaxes. 

___________ A

__________ B C

___________ D

Figure 15. Aspects of Contraction 3.3.2

3.3.3

Blood Pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions.  BP readings should be taken at least every half hour during active labor  When a woman in labor complains of a headache, the first nursing action is to take BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia) Fetal heart rate (FHR) – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate)  Normally 120 to 160 per minute  Should not be taken during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, causes bradycardia  Should be taken every hour during the latent phase of labor, every half hour during the active phase and every 15 minutes during the transition period  For any abnormality in FHR, the initial nursing action is to change the mother’s position  Signs of fetal distress  Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute)  Meconium – stained amniotic fluid in non – breech presentation  Fetal thrahing – hyperactivity of the fetus as it struggles for more oxygen

3.4 Emotional support is provided for the woman in labor by keeping her constantly informed of the progress labor 3.5 -------------------------------------------3.5.3 Solid or liquid foods are to be avoided because  Digestion is delayed during labor  A full stomach interferes with proper bearing down  May vomit and cause aspiration 3.5.4 Enema – not a routine procedure  Purposes  A full bowel hinders the progress of labor – effectiveness of enema in labor can be determined by evaluating change in uterine tone and the amount of show

Expulsion of feces during second stage of labor predisposes mother and baby to infection  Full bowel predisposes to postpartum discomfort  Procedure of enema administration  Enema solution may either be soap suds or Fleet enema (contraindicated in patients with toxemia because of its sodium content)  Optimum temperature of the solution – 105°F to 115°F (40.5 °C – 46.1°C)  Patient on side – lying position  When there is resistance while inserting rectal catheter, withdraw the tube slightly while letting a small amount of solution enter  Clamp rectal tube during a contraction  Important nursing action: Check FHR after enema administration to determine fetal distress  Contraindications to enema in labor  Vaginal Bleeding  Premature labor  Abnormal fetal presentation or position  Ruptured membranes  Crowning 3.5.5 Encourage the mother to void every 2 – 3 hours by offering the bedpan because  A full bladder retards fetal descent  Urinary stasis can lead to urinary tract infection  A full bladder can be traumatized during delivery 3.5.6 Perineal prep – done aseptically. Use “No. 7” method, always from front to back 3.5.7 Perineal shave – not a routine procedure; maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth 3.5.8 Encourage Sim’s position because it:  Favors anterior rotation of the fetal head  Promotes relaxation between contractions  Prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel which brings unoxygenated blood back to the heart); pressure results in Supine Hypotensive Syndrome, also called Vena Cava Syndrome (Figure 16). Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP. 3.5.9 Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the first stage because  It leads to unnecessary exhaustion 

 Repeated strong pounding of the fetus against the pelvic floor will lead to ce4rvical edema, thus interfering with dilatation and prolonging length of labor. 3.5.10 Abdominal breathing – advised for contractions during the first stage in order to reduce tension and prevent hyperventilation FIGURE 16. Supine Hypotensive Syndrome 3.6 Administer analgesics as ordered. The dosage is based on the patient’s weight, status of labor and age of gestation. 3.6.1 Narcotics are the most commonly used, specifically Demerol.  Pharmacologic effect: depresses the sensory portion of the cerebral cortex. It is not only a potent analgesic, it is also a sedative and an antispasmodic.  It is not given early in labor because it can retard, progress (is an antispasmodic), but cannot also be given if delivery is only one hour away because it causes respiratory depression in the newborn (that is why it can be given only if cervical dilatation is 6 – 8 cm.)  Given 25 – 100 mg., depending on body weight  Takes effect in 20 minutes – patient experiences a sense of well – being and euphoria  Narcotic antagonist (e.g. Narcan, Nalline) are given to counteract any toxic effects of Demerol 3.7 Assist in administration of regional anesthesia – preferred over any other form of anesthesia because it does not enter maternal circulation and so does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved. 3.7.1 Xylocaine is the anesthetic of choice 3.7.2 Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose aids in proper functioning of the fetus 3.7.3 Types of Anesthesia  (purplish discoloration of the skin due to blood in subcutaneous tissues) area or hematoma in the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling 3.7.4 Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second – stage pushing. 3.7.5 Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management: Flat on bed for 12 hours and increase fluid intake 3.7.6 Common side effects  Hypotension – because Xylocaine is vasodilator. Management – turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered.  Fetal bradycardia

 Decreased maternal respirations 3.8 A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported from the Labor Room to the Delivery Room when the cervix is fully dilated or when there is bulging of the perineum. Mutiparas, on the other hand, are transported when cervical dilataton iis 7 – 8 cm. B Transition Period – when the mood of the woman suddenly changes and the nature of contractions intensify 1. Characteristics 1.1 If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid to drain) is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes. Amniotomy, however, can not be done if station is still “minus”, as this can lead to cord compression 1.2 Show becomes more prominent. 1.3 There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen. 1.4 Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption. 1.5 In primis, baby is delivered with 20 contractions (40 minutes); in multis, after 10 contractions (20 minutes). 2. Nursing actions are primarily comfort measures 2.1 Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves discomfort from contractions 2.2 Proper bearing down techniques: push with contractions 2.3 Controlled chest (costal) breathing during contractions 2.4 Emotional support C Second Stage (Stage of expulsion) – begins with complete dilatation of the cervix and ends with the delivery of the baby. 1. Powers/forces: involuntary uterine contractions and contractions of the diaphragmatic and abdominal muscles 2. Mechanisms of labor/Fetal Position Changes (D FIRE ERE) 3.1 Descent – may be preceded by engagement. 3.2 Flexion- as descent occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest. 3.3 Internal Rotation – from AP to transverse, the AP to AP 3.4 Extension – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin upper. 3.5 External Rotation (also called restitution) – anterior shoulder rotates externally to the AP position. 3.6 Expulsion – delivery of the rest of the body. 3. Nursing Care

3.1 When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine ligaments 3.2 As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid and shallow breathing to prevent rapid expulsion of the baby). If panting is deep and rapid, called hyperventilation, the patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms because of respiratory alkalosis. Management: let the patient breathe into a brown paper bag to recover lost carbon dioxide; a cupped hand over the mouth and nose will serve the same purpose. 3.3 Assist in episiotomy (incision made in the perineum primarily to prevent lacerations). 3.3.1 Other purposes  Prevent prolonged severe stretching of muscles supporting the bladder or rectum  Reduce duration of second stage when there is hypertension or fetal distress  Enlarge outlet, as in breech presentation or forceps delivery 3.3.2 Types of episiotomy  Median – from middle portion of the lower vaginal border directed towards the anus  Mediolateral – begun in the midline but directed laterally away from the anus. Often done because it prevents 4th degree laceration should it occur despite episiotomy. 3.3.3 Natural Anesthesia jis used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened 3.4 Apply the Modified Ritgen’s Maneuver 3.4.1 Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the smallest suboccipitobregmatic diameter of the fetal head is presented. 3.4.2 Ease the head out and immediately wipe the nose and mouth of secretions to establish a patent airway (remember: the first and most important principle in the care of the newborn is establish and maintain a patent airway). The head should be delivered in between contractions. 3.4.3 Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuichal cord). If so, but loose, slip it down the shoulders or up over the head; but if tight, clamp the cord twice, an inch apart, and then cut it in between. 3.4.4 As the head rotates, deliver the anterior shoulder by exerting a gentle 3.5 Immediately after delivery, the newborn should be held below the level of the mother’s vulva for a few minutes to encourage flow of blood from the placenta to the baby

3.6 The infant is held with is head in a dependent position (head lower thatn the rest of the body) to allow for drainage of secretions. Remember: never stimulate a baby to cry unless you have drained him out of his secretions. 3.7 Wrap the baby in a sterile towel to keep him warm. Remember: Chilling increase the body’s need for oxygen 3.8 Put the baby on the mother’s abdomen. The weight of the baby will help contract the uterus. 3.9 Cutting the cord is postponed until the pulsations have stopped because it is believe that 50 – 100 ml. of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart and then cut in between. 3.10 Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse. D Third Stage (Placental Stage) – begins with the delivery of the baby and ends with delivery of placenta. 1. Signs of placental separation 1.1 Uterus becoming round and firm again, rising high to the level of the umbilicus (Calkin’s sign) – the earliest sign of placental separation 1.2 Sudden gush of blood from the vagina 1.3 Lengthening of the cord 2. Types of placental delivery 2.1 Schultz – if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny (“Shiny” for Schultz); 80% of placentas separate in this manner. 2.2 Duncan – if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, and irregular and “dirty” (“Dirty” for Duncan). Only about 20% of placentas separate this way. 3. Nursing Care 3.1 Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation. 3.2 Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus, a method called Brandt – Andrews maneuver. 3.3 Take note of the time of placental delivery. It should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother. 3.4 Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death. 3.5 Palpate the uterus to determine degree of contraction. If relaxed boggy or non contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction.

3.6 Inject oxytocin (Methergin = 0.2 mg./ml. or Syntocinon = 10U/ml) IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery. 3.7 Inspect the perineum for lacerations. Any time the uterus is firm following placental delivery, yet bright red vaginal bleeding is gushing forth from the vaginal opening, suspect lacerations (tend to heal more slowly because of ragged edges) 3.7.1 Categories of lacerations  First degree – involves the vaginal mucous membranes and perineal skin  Second degree – involves not only the muscles, vaginal mucous membranes and skin, but also the muscles.  Third degree – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the rectum  Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the m mucous membranes of the rectum. 3.7.2 Assist the doctor in doing episiorrhaphy 9repair of episiotomy or lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: Vaginal packs have to be removed after 24 – 48 hours 3.H Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vaginal opening. Soiled napkins should be removed from front to back. 3.I Position the newly – delivered mother flat on bed without pillows to prevent dizziness due to decrease in intraabdominal pressure. 3.J The newly – delivered mother may suddenly complain of chills due to decreased blood pressure, fatique or cold temperature in the delivery room. Management: provide additional blankets to keep her warm. 3.KMay give initial nourishment; e.g., milk, coffee or tea 3.L Allow patient to sleep in order to regain lost of energy. E Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs. 1. Assessment 1.1 Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline, and during the first 12 hours postpartum, is a little above the umbilicus. First nursing action for a non- contracted uterus: massage. 1.2 Lochia – shuld be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes. If saturated in 15 minutes or earlier, may mean hemorrhage. 1.3 Bladder – a full bladder is evidenced by a fundus which is to the right of the midline and dark – red bleeding with some clots. Will prevent adequate uterine contraction.

1.4 Perineum – is normally tender, discolored and edematous. It should be clean, with intact sutures. 1.5 Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery, but normalize within one hour. 2. Lactation – suppressing agents – estrogen – androgen preparations given within the first hours postpartum to prevent breast milk production in mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol, TACE, Parlodel and deladumone. These drugs tend to increase uterine bleeding and retard menstrual return 3. Rooming – in concept – mother and baby are together while in the hospital. The concept of a family, therefore, is felt from the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn (maternal – infant bonding). Eye – to – eye contact is immediately established, releasing the maternal caretaking responses.

PUERPERUM I.

DEFINITION OF TERMS A. Puerperium/Postpartum – refers to the six – week period after delivery of the baby B. Involution - return of the reproductive organs to their prepregnant state

II.

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 1.1 The 30% - 50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation with 5 – 10 minutes after placental delivery. Implication: the first 5 – 10 minutes after placental delivery is crucial to gravidocardiacs because the weak heart may not be able to handle such workload. 1.2 While blood cell (WBC) count increases to 20,000 – 30,000/mm3. implication: the WBC count, therefore, cannot be used as a indicationor sign of postpartum infection 1.3 Thre is extensive activation of the clothing factors, which encourages thromboembolization. This is the reason why: 1.3.1 Ambulationis done early – 4 – 8 hours after normal vaginal delivery. When ambulating the newly – delivered patient for the first time, the nurse should hold on to the patient’s arm. 1.3.2 Recommended exercises 2.1 Kegal and abdominal breathing on postpartum day one (PPD1). 2.2 Chin – to – chest – on PPD2 to tighten and firm up abdominal muscles 2.3 Knee – to – abdomen – when perineum has healed, to strengthen abdominal and gluteal muscles. 1.3.3 Massage is contraindicated 1.4 All blood values are back to prenatal levels by the 3rd or 4th week postpartum 2. Genital Changes 2.1 Uterine involution is assessed by measuring the fundus by fingerbreadth (=1 cm.). on PPD1, fundus is 1 finger breadth below the umbilicus; on PPD2, 2 fingerbreaths below and so forth until on PPD10, it can no longer be palpated because it is already behind the symphysis pubis. Subinvoluted uterus is aa uterus larger than normal and vaginal bleeding with clots since blood cltos are good media for bacteria, it is , therefore, a sign of puerperal sepsis. 2.2 To encourage the return of the uterus to its usual anteflexed position, prone and knee chest positions are advised. 2.3 Afterpains/afterbirth pains – strong uterine contractions felt more particularly by multis, those who delivered large babies or twins and those who breastfeed. It is normal and rarely lasts for more than 3 days. Management:

2.3.1 Never apply heat on the abdomen 2.3.2 Give analgesics as ordered 2.4 Lochia – uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria. 2.4.1 Pattern  Rubra – first 3 days postpartum; red and moderate in amount  Serosa – net 4 – 9 days; pink or brownish and decreased in amount  Alba – from 10th day up to 3 – 6 weeks postpartum; colorless and minimal in amount 2.4.2 Characteristics  Pattern should not reverse  It should approximate menstrual flow. However, it increases with activity and decreases with breastfeeding.  It should not have any offensive odor. It has the same fleshy odor as menstrual blood. If fol smelling, may mean either poor hygiene or infection  It should not contain large clots.  It should never be absent, regardless of method of delivery. Lochia has the same pattern and amount, whether CS or normal vaginal delivery 2.5 Pain in perineal region may be relieved by: 2.5.1 Sim’s Position – minimizes strain on the suture line 2.5.2 Perineal heat lamp or warm Sitz baths twice a day – vasodilatation increases blood supply and, therefore, promotes healing 2.5.3 Application of topical analgesics or administration of mild oral analgesics as ordered 2.6 Sexual activity – maybe resumed by the 3rd or 4th week postpartum if bleeding has stopped and episiorrhappy has healed. Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of hormonal changes and emotional factors. 2.7 Menstruation – if not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery. If breastfeeding, menstrual return is expected in 3-4 months; in some women, no menstruation occurs during the entire lactation period. (important: amenorrhea during lactation is no guarantee that the woman will not become pregnant. She may be ovulating the absence of menstruation may her body’s way of conserving fluids for lactation. Implication: she should be protected against a subsequent pregnancy by observing a method of contraception, except the pill). 2.8 Postpartum check – up – should be done after the 6th week postpartum to assess involution. 3. Urinary Changes 3.1 There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation during pregnancy. 3.2 Some newly delivered mothers may complain of frequent urinatin in small amounts; explain that this is due to urinary retention with overflow.

Other, on the other hand, may have difficulty voiding because of decreased abdominal pressure or trauma to the trigone of the bladder. Voiding may be initiated by: 3.2.1 Pouring warm and cold water alternately over the vulva 3.2.2 Encouraging the client to go the comfort room 3.2.3 Let her listen to the sound of running water 3.2.4 If these measures fail, catheterization, done gently and aseptically, is the last resort on doctor’s order. (if there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again). 4. Gastrointestinal changes – delayed bowel evacuation postpartally may be due to: 4.1 Decreased muscle tone 4.2 Lack of food + enema during labor 4.3 Dehydration 4.4 Fear of pain from perineal tenderness due to episotomy, lacerations or hemorroids 5. Vital Signs 5.1 Temperature may increase because of the dehydrating effects of labor. Implication: any increase in body temperature during the first 24 hours postpartum is not necessarily a sign of postpartum infection. 5.2 Bradycardia (heart rate of 50 – 70 per minute) is common for 6 – 8 days B. Provide emotional support – the psychological phases during the postpartum period are: 1. Taking – in phase – first 1 – 2 days postpartum when mother is passive and relies on others to care for her and her newborn. She keeps on verbalizing her feelings regarding the recent delivery for her to be able ot integrate the experience into herself. 2. Taking hold phase – begins to initiate action and make decisions. Postpartum blues (an overwhelming feeling of sadness that cannot be accounted for) may be observed. Could be due to hormonal changes, fatigue or feeling of inadequacy in taking care of a new baby. Management: explain that it is normal; crying is therapeutic, in fact. C. Prevent postpartum complications 1. Hemorrhage (see page 68-69) 2. Infection D. Establish successful lactation (Table 12)0 Estrogen and progesterone levels after placental delivery Stimulates anterior pituitary gland to produce proclatin acts on Acinar cells to produce foremilk stored in collecting tubules. When infant sucks posterior pituitary gland is stimulated to Produced oxytocin causes contraction of smooth muscles of Collecting tubules milk ejected forward let – down or milk ejection Reflex hindmilk is produced

Table 12. Physiology of Breastmilk Production 1. Implications of physiology of Breastmilk production 1.1 Regardless of the mother’s physical condition, method of delivery, or breast size/condition, milk will be produced. 1.2 Lactation does not occur during pregnancy because estrogen and progesterone are present and therefore inhibit prolactin production. 1.3 Lactation – suppressing agents are to be given immediately after placental delivery to be effective. 1.4 Oral contraceptives are contraindicated in lactating mother because they contain estrogen and progesterone, thereby decreasing milk supply. 1.5 Afterpains are felt more by breastfeeding women because of oxytocin production; they also have less lochia and experience more rapid involution. 1.6 In an emergency delivery; 1.6.1 Determine the EDC, whether the woman in labor is a primi or a multi, and the stage of labor. 1.6.2 If no sterile equipment is available to cut the cord, wrap the baby and placenta together; never cut the cord unless sterile equipment is are available. 1.6.3 If the uterus fails to contract after delivery, put the infant to the breast; the sucking of the infant produces oxytocin which causes uterine contraction 2. Advantages of Breastfeeding 2.1 For mother 2.1.1 Economical in terms of time, money and effort 2.1.2 More rapid involution 2.1.3 Less incidence of cancer of the breast, according to some studies 2.2 For the baby 2.2.1 Closer mother – infant relationship 2.2.2 Contains antibodies that protect against common illnesses 2.2.3 Less incidence of gastrointestinal diseases 2.2.4 Always available at the right temperature 3. Health Teachings 3.1 Hygiene 3.1.1

Wash breasts daily at bath or shower time. 3.1.2 Soap or alcohol should never be used on the breasts as they tend to dry and crack the nipples and cause sore nipples. 3.1.3 Wash hands before and after every feeding. 3.1.4 Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharge. 3.2 Method – as suggested by the La Leche League 3.2.1 Side-lying position with a pillow under the mother’s head while holding the bulk of breast tissues away from the infant’s nose.

3.3

3.2.2 Stimulate the baby to open his mouth to grasp the nipples by mans of the rooting reflex. 3.2.3 Infant should grasp not only the nipple but also the areola for effective sucking motion. Effectiveness is ensured when the:  baby’s mouth parts “hike well up” into areola  mother feels after pains as the baby sucks  other nipple flows with milk while baby is feeding on other breast 3.2.4 To prevent nipples from becoming sore and cracked, infant should be introduced to the breast gradually. The baby should be fed for only 5 minutes at each breast during each feeding on the first day, increasing the time at each breast by 1 minute per day until the infant is nursing for 10 minutes at each breast, making a total feeding time of twenty minutes per feeding. 3.2.5 For continuous milk production, at each feeding, the infant should be placed first on the breast he fed last in the previous feeding. This ensures that each breast will be completely emptied at every other feeding. If breasts are completely emptied, they completely refill; if only half-emptied will also half-refill and after some time, will become insufficient. 3.2.6 To break away from the closed suction at the breast after feeding, insert a clean little finger in the corner of the infant’s mouth to release the suction, then pull the chin down. This also helps prevent sore nipples. 3.2.7 Feed as often as the baby is hungry, especially during the first few days, because he is receiving colostrums which is not very filling; however, it contains gamma globulin (antibodies), the only group of substances that can never be replicated by any artificial formula. 3.2.8 Advise the mother to learn how to relax during feedings because tension prevents good let-down. Associated problems 3.3.1 Engorgement – feeling of tension in the breasts during the third postpartum day sometimes accompanied by an increase in temperature (milk fever). The breasts become full, feel tense and hot, with throbbing pain. It lasts for about 24 hours and is due to increased lymphatic and venous circulation. Management: Advise use of firm-fitting brassiere for good support. It will not only decrease the discomfort from breast engorgement but will also prevent contamination of the nipples and areolae. Cold compress is applied if the mother does not intend to breastfeed; warm compress is applied if she will breastfeed. Breast pump should not be used and breast massage should not done if the mother is not going to breastfeed, since either will stimulate milk production. 3.3.2 Sore nipples – not contraindications to breastfeeding. Management:  Do not use plastic liners that are found in some nursing bras because they prevent air from circulating around the breasts.  Use nipple shield. 3.3.3 Mastitis – inflammation of the breasts

 Symptoms  Localized pain, swelling and redness in breast tissues  Lumps in the breasts  Milk becomes scantly  Management  Antibiotics as ordered  Ice compress  Proper breast support  Discontinue breastfeeding in affected breast 3.4 Nutrition – lactating mothers should take 3000 calories daily and should have larger amounts of proteins (96 Gms per day), calcium, iron Vitamins A, B and C. Non-breastfeeding women can have the same requirements as in pregnancy. 3.5 Contraindications 3.5.1 Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines. (Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are generally not contraindicated. Therefore, diabetics and those with asthma can breastfeed.) 3.5.2 Certain disease conditions, specifically tuberculosis, because of the close contact between mother and baby during feeding. (However, mothers may use masks to prevent droplet spread) TB germs, however, are not transmitted thru breast milk. E. Motivate use of family planning methods – the success of the family planning program depends to a large extent on the motivation of both husband and wife. 1. Artificial Methods 1.1 Physiological method – oral contraceptive. 1.1.1 Action: Suppresses the pituitary gland, thus inhibiting ovulation. 1.1.2 Types  Combined – estrogen and progesterone in the same dosage each day for 20 days, starting on the 5 th day of the menstrual cycle, after which it is discontinued and then resumed on the 5th day of the next menstrual cycle.  Sequential – estrogen alone for 15 days, then estrogen and progesterone for the next 5 days.  Mini-pill – taken continuously. 1.1.3 Side effects – same complaints of pregnant women because of estrogen and progesterone  Nausea and vomiting  Headache and weight gain - due to fluid retention because of progesterone  Breast tenderness  Dizziness  Breakthrough bleeding/spotting between periods  Chloasma 1.1.4 Contraindications  Breastfeeding  Certain diseases

1.2.1

1.2.2

1.2.3

 Thromboembolism – because there is increased tendency towards clotting in the presence of estrogen  Diabetes mellitus and liver disease because estrogen tends to interfere with carbohydrate metabolism  Migraine; epilepsy; varicosities  Cancer; renal disease; recent hepatitis  Women who smoke more than 2 packs of cigarettes per day  Strong family history of heart attack 1.1.5 Should the woman forget to take the pill on the scheduled time, she should take one as soon as she remembers and take the next ill on its regular taking time. If she still fails to do so, withdrawal bleeding will occur because of the sudden decrease in hormonal levels. 1.2 Mechanical methods Intrauterine device (IUD)  Specific action: Prevent implantation by setting up a non-specific cell inflammatory reaction to the device  Inserted during menstruation to ensure that the woman is not pregnant; septic abortion can result if she is pregnant  Side effects  Increased menstrual flow  Spotting or uterine cramps during the first 2 weeks after insertion  Increased risk of infection  When pregnancy occurs with the IUD in place, it need not be removed since it stays outside the membranes and, therefore, will not in any harm the fetus. Diaphragm  Specific action: A circular rubber disc that fits over the cervix and forms a barrier against the entrance of sperms  Is initially inserted by the doctor who determines the depth of the vagina  May be coated with spermicide jelly or cream for double protection  Maybe washed with soap and water after use; us reusable  Sperms remain viable in vagina for 6 hours, so the device should be kept in place during such time, but should not stay for more than 24 hours because stasis of semen can lead to infection Condom

1.3 1.4

2. 2.1

 Specific action: Sperms are deposited at the tip of the rubber sheath, which has been placed on an erect penis prior to coitus. Has the added potential of lessening the chance of contracting sexually-transmitted diseases (STDs, esp. AIDS)  Most common complaint of users: it interrupts the sexual act to apply. Chemical methods – are spermicidals (kill sperms) E.g., jellies, creams, foaming tablet, and suppositories. Surgical method 1.4.1 Tubal ligation – the Fallopian tubes are ligated in order to prevent passage of sperms. Menstruation and ovulation continue 1.4.2 Vasectomy – small incision made into each side of the scrotum and the vas deferens is cut and tied, blocking the passage of sperms. Sperm production continues, only passage into the exterior is prevented. (Sperms in the vas deferens at the time of surgery remain viable for as long as 6 months. Implication: Couple should still observe a form of contraception during this time to ensure protection against subsequent pregnancy.) Natural Biological method – Rhythm/Calendar/Ogino-Knause Formula 2.1.1 Specific action: the couple abstains on days that the woman is fertile 2.1.2 Procedure  The woman charts her menstrual cycles for 12 continuous months in order to determine the shortest and the longest cycles 26 18 8

32 11 21

2.1.3 Rhythm/Calendar/Ogino-Knause – a woman can discern her fertile and infertile days based on her sensory and visual observations of the cervical mucus (when it becomes thin and watery – spinnbarkheit). Intercourse is avoided 4 days prior to and 3 days after the spinnbarkheit. 2.1.4 Billings method/cervical mucus – when cervical discharges are thin and watery, couple resumes sexual intercourse 3-4 days after 2.1.5 Symptothermal method/Basal Body Temperature (BBT) – involves daily observation of the temperature of the woman at rest, free from any factor that may cause it to fluctuate (immediately upon waking up, before brushing teeth, drinking, etc.). Only 3-4 days after the temperature drops slightly and then increases (which means ovulation has taken place), can sexual intercourse be resumed. Fertile and infertile days are determined after having established an accurate record of the six

immediately preceding menstrual cycles then watching out for BBT fluctuations 2.2 Social methods 2.2.1 Abstinence 2.2.2 Withdrawal/Coitus Interruptus

RISK CONDITIONS I.

INFECTIONS A. Syphilis 1. Cause: Treponema pallidum – a spirochete which enters the body during coitus or through cuts and breaks in the skin or mucous membrane 2. Treatment: 2.4-4.8 million units of Penicillin (if allergic, 30-40 gms. erythrocin) will usually prevent congenital syphilis in the newborn because penicillin readily crosses the placenta. If untreated, syphilis can cause midtrimester abortion, CNS lesions in the newborn or even death. 3. The newborn with congenital syphilis 3.1 Signs and symptoms 3.1.1 Jaundice at 2 weeks of life – first sign of the disease 3.1.2 Anemia and hepatosplenomegaly 3.1.3 “Snuffles” (persistent rhinorrhea); coppery rashes on palms and soles; mucous patches; condylomas; pseudoparalysis due to bone inflammation 3.1.4 If untreated, can progress on to deformed bones, teeth, nose, joints and CNS syphilis 3.2 Management: Penicillin IM for 10 days or one long-acting Penicillin (Penadur LA) B. Rubella/German Measles 1. Incidence 1.1 Mother – the earlier the mother contracted the disease, the greater the likelihood that the baby will be affected. The rubella virus slows down division of infected cells during organogenesis, thus causing congenital defects 1.2 Newborn – can carry and transmit the virus for as long as 12-24 months after birth 2. Signs and symptoms of Congenital Rubella Syndrome 2.1 Low birth weight; jaundice; petechiae; anemia; thrombocytopenia; hepatosplenomegaly 2.2 Classic seequelae 2.2.1 Eyes: chorioretinitis, cataract, glaucoma 2.2.2 Heart: Patent Ductus Arteriousus, stenosis, coarctations 2.2.3 Ear: Nerve deafness 2.2.4 Dental and facial clefts C. Postpartum Infection 1. Sources 1.1 Endogenous (primary) sources – bacteria in the normal flora become virulent when tissues are traumatized and general resistance is lowered.

1 2

4 5

1.2 Exogenous sources – pathogens introduced from external sources. (Most common is anaerobic streptococci). Common exogenous sources: Hospital personnel Excessive obstetric manipulations 1.2.3 Breaks in aseptic techniques – faulty handwashing, unsterile equipments and supplies Coitus in late pregnancy Premature rupture of the membranes 2. General symptoms: malaise anorexia, fever, chills and headache 3. General management 3.1 Complete bed rest (CBR) 3.2 Proper nutrition 3.3 Increased fluid intake 3.4 Analgesics 3.5 Antipyretics and antibiotics, as ordered 4. Types of infection 4.1 Infection of the perineum 4.1.1 Specific symptoms  Pain, heat and feeling of pressure in the perineum  Inflammation of the suture line, with 1 or 2 stitches sloughed off  With or without elevated temperature 4.1.2 Specific management  Doctor removes sutures to drain area and resutures  Hot sitz bath or warm compress 4.2 Endometritis 4.2.1 Specific symptoms  Abdominal tenderness  Uterus not contracted and painful to touch  Dark brown, foul-smelling lochia 4.2.2 Specific management  Oxytocin administration  Fowler’s position to drain out lochia and prevent pooling of infected discharge 4.3 Thrombophlebitis – infection of the lining of a blood vessel with formation of clots; usually an extension of endometritis 4.3.1 Specific symptoms  Pain, stiffness and redness in the affected part of the leg  Leg begins to swell below the lesion because venous circulation has been blocked  Skin is stretched to a point of shiny whiteness, called milk leg or phlegmasia alba dolens  Positive Homan’s sign – pain in the calf when the foot is dorsiflexed 4.3.2 Specific management  Bed rest with affected leg elevated

 Anticoagulants, e.g., Dicumarol or Heparin, to prevent further clot formation or extension of a thrombus o Analgesics are given but never Aspirin because it inhibits prothrombin formation therefore causes hemorrhage 4.4 Mastitis – inflammation of breast tissues 4.4.1 Pathophysiology – local inflammatory response to bacterial invasion; suppuration may occur; organism can be recovered from breast milk. 4.4.2 Etiology – most common: Staphylococcus aureus 4.4.3 Assessment  Signs of infection (may occur several weeks postpartum).  Fever  Chills  Tachycardia  Malaise  Abdominal pain  Breast  Reddened areas  Localized/generalized swelling  Heat, tenderness, palpable mass. 4.4.4 Nursing care – goal: prevent infection. Health teaching in early postpartum  Handwashing  Breast care  Wash with warm water only (no soap)  Let breast milk dry on nipples to prevent drying of tissue.  Clean bra (with no plastic pads or liners) to support breasts, reduce friction, minimize exposure to microorganisms.  Good breastfeeding techniques II. BLEEDING/HEMORRHAGE A. Bleeding in pregnancy (Table 13) I. First Trimester Bleeding A. Abortion 1. Spontaneous 1.1 Threatened 1.2 Imminent 1.2.1 Complete 1.2.2 Incomplete 2. Induced 3. Missed B. Ectopic pregnancy 1. Tubal – most common

2. Cervical 3. Ovarian II. Second Trimester Bleeding A. Hydatidiform Mole B. Incompetent Cervical Os III. Third Trimester Bleeding A. Placenta Previa B. Abruptio Placenta Table 13. Bleeding in Pregnancy

1. Abortion – any interruption in pregnancy before the age of viability 1.1 Spontaneous 1.1.1 Natural causes  Blighted ovum/germ plasma defect = most common cause. It is nature’s way of eliminating the birth of a congenitally defective baby  Implantation or hormonal abnormality  Following trauma, infection (e.g., rubella, influenza) or emotional problems 1.1.2 Types  Threatened  Symptom: bright red vaginal bleeding which is moderate in amount  Management o Complete bed rest for 24-48 hours; if bleeding will stop it usually stops within this time o Coitus is restricted for 2 weeks after bleeding has stopped in order to prevent further bleeding or infection o Endocrine/hormonal therapy o Advise patient to save all pads, clots and expelled tissues  Imminent/inevitable  Symptom: Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatation. Loss of the products of conception is inevitable.  Management – depends on whether it is: o Complete abortion – all products of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed. o Incomplete abortion – part of the conceptus (usually the fetus) is expelled, but membranes or

placental fragments are retained. D & C is indicated as management. 1.2 Induced abortion – is never allowed in the Philippines 1.2.1 Therapeutic – performed by a doctor in a controlled hospital or clinic setting for a medical or a legal reason. Also known as medical, planned or legal abortion. 1.3 Missed abortion – fetus dies in utero but is not expelled. Usually discovered at a prenatal visit when fundal height is measured and no increase is demonstrated or when previously heard fetal heart tones are no longer present. In two weeks’ time, signs of abortion should occur; otherwise, labor will have to be induced to prevent hypofibrinoginemia or sepsis. 2. Ecotopic Pregnancy – any gestation located outside the uterine cavity. 2.1 Signs and symptoms – since the wall of the Fallopian tube is not sufficiently elastic, it ruptures within the first 12 weeks of gestation as it can no longer give way for growing fetus 2.1.1 Severe, sharp, knife-like stabbing pain either the right or left lower quadrant (in bleeding wherein there is no exit or egress of blood from the body, pain is the outstanding symptom; this pain differentiates Ectopic pregnancy from abortion) 2.1.2 Rigid abdomen 2.1.3 (+) Cullen’s sign – bluish umbilicus 2.1.4 Excruciating pain when cervix is moved on IE 2.1.5 Signs of shock: falling BP, PR more than 100/minute, rapid RR, lightheadedness 2.2 Management – ruptured Ectopic pregnancy is an emergency situation. 2.2.1 Salpingosomy – if Fallopian tube can still be replaced and preserved, 3. Hydatidiform Mole – developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi 3.1 Incidence: Is the most common lesion anteceding choriocarcinoma. It occurs most often in women: 3.1.1 From low socioeconomic backgrounds with low protein intake 3.1.2 Over 35 years and under 18 years of age. 3.2 Signs and symptoms – Because of rapid proliferation of the placental tissues and, therefore, high levels of HCG 3.2.1 Highly positive urine test for pregnancy (that is why a positive pregnancy test cannot be considered a positive sign of pregnancy) 3.2.2 Nausea and vomiting is usually marked 3.2.3 Rapid increase in fundic height. Rapid increase in weight 3.2.4 Toxemia signs and symptoms appear before the 24th week of gestation 3.2.5 No fetal heart tones 3.2.6 Vaginal bleeding seen as clear, fluid-filled, grape-sized vesicles

3.3 Management 3.3.1 D & C to evacuate the mole 3.3.2 Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma 3.3.3 Urine testing for one year to find out if new villi are developing. Contraceptives (but not the pills) have to be used so as not to confuse the results 4. Incompetent Cervical Os – one that dilates prematurely. It is the chief cause of habitual abortion (3 or more consecutive abortions). 4.1 Causes 4.1.1 Congenital developmental factors 4.1.2 Endocrine factors 4.1.3 Trauma to the cervix 4.2 Signs and symptoms 4.2.1 Presence of show and uterine contractions 4.2.2 Rupture of membranes 4.2.3 Painless cervical dilatation 4.3 Management: McDonald/Shirodkar-Barter procedure – a cerclage procedure wherein purse string sutures are placed around the cervix on the 14th - 18th week of gestation. These are removed during vaginal delivery (if McDonald’s method, since sutures are temporary) or the patient delivers by cesarean section (if Shirodkar method, since sutures are permanent). 5. Placenta Previa – low implantation of the placenta so that it is in the way of the presenting part. 5.1 Predisposing factors 5.1.1 Increasing parity 5.1.2 Advanced maternal age 5.1.3 Rapid succession of pregnancies 5.2 Types 5.2.1 Low lying 5.2.2 Partial 5.2.3 Complete 5.3 Diagnosis – made by means of symptoms and ultrasound (also known as Ultrasonic Echo Sounding or Sonar. Uses intermittent waves of very high frequency/above audible range in order to “picture the fetus”. Sound waves are projected towards the mother’s abdomen, are reflected back and converted into electrical impulses and recorded on a permanent graph paper). 5.3.1 Preparation for ultra sound  Explain the procedure to the patient, informing her that it is painless and there are no known ill effects  Empty the bladder but ask the patient to take 6 glasses of water afterwards in order to dilate the bladder. A full bladder displaces a gas filled bowel and, therefore, permits better visualization of the pelvis and its contents. 5.3.2 Clinical uses of ultra sound  Diagnose pregnancy as early as 5-6 weeks gestational age

 Can establish that the fetus is increasing in size and, therefore, can predict EDC  Can determine gestational age by measuring the biparietal diameter of the fetal skull (if it is more than 8.5 cm., it is more than 2500 gms); therefore, can diagnose intrauterine growth retardation, hydrocephaly, microcephaly and anencephaly  Can demonstrate size and growth rate of the amniotic sac; therefore; can identify poly- or oligohydramios  Can confirm presence, size and location of the placenta; therefore, is valuable before amniocentesis  Can diagnose multiple pregnancy  Can visualize ascites, polycystic kidneys, ovarian cysts, etc.  Can determine baby’s sec (during third trimester and if in cephalic presentation) 5.4 Signs and Symptoms – first and most constant: painless, bright red vaginal bleeding due to tearing of placental attachment as a consequence of dilatation of the internal cervical os 5.5 Management 5.5.1 Complete bed rest 5.5.2 Monitor vital signs of the mother and the fetal heart rate 5.5.3 Prepare oxygen and blood 5.5.4 Internal examination (IE) is not done. If ever it is to be done, it has to be a double set-up (done in the operating room wherein the patient has already signed the consent form, preop medication have been given, abdominal prep has been done, etc., so that if ever placenta is accidentally detached CS, can be done immediately. 5.6 Complications 5.6.1 Hemorrhage 5.6.2 Infection 5.6.3 Prematurity 6. Abruptio Placenta – premature separation of the placenta 6.1 Predisposing factors 6.1.1 Maternal hypertension or toxemia 6.1.2 Increasing parity and maternal age 6.1.3 Sudden release of amniotic fluid 6.1.4 Short umbilical cord 6.1.5 Direct trauma 6.1.6 Hypofibrinoginemia 6.2 Signs and symptoms 6.2.1 Severe, sharp, knife-like, stabbing pain high in the fundus 6.2.2 Hard, boardlike uterus; rigid abdomen 6.2.3 Signs of shock 6.2.4 Concealed bleeding, if extensive, causes uterus to lose its ability to contract. It becomes ecchymotic and copper-colored, called Couvelaire uterus, causing severe

bleeding. Since the uterus no longer has the ability to contract, hysterectomy will have to be done. B. Postpartum Hemorrhage 2.1.1 Uterine Atony – uterus is not contracted, relaxed or boggy; most frequent cause  Predisposing factors  Overdistention of the uterus – e.g., multiple pregnancy, multiparity, excessively large baby, polyhydramnios  Caesarian section  Placental accidents (previa or abruptio)  Prolonged and difficult labor  Management  Massage – first nursing action  Ice compress  Oxytocin administration  Empty the bladder  Bimanual compression to explore retained placental fragments  Hysterectomy – last resort 2.1.2 Lacerations 2.1.3 Hypofibrinoginemia – a clothing defect, Management: blood transfusion 2.2 Late postpartum hemorrhage 2.2.1 Retained placental fragments – management: dilatation and curettage (D & C) 2.2.2 Hematoma – due to injury to blood vessels in the perineum during delivery  Incidence: Commonly seen in precipitate delivery and those with perineal varicosities  Treatment  Ice compress during first 24 hours  Oral analgesics, as ordered  Site is incised and bleeding vessel is ligated

III. TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) - a vascular disease of unknown cause which occurs anytime after the 24th week of gestation up to two weeks postpartum. A. Triad of symptoms 1. Hypertension 2. Edema 3. Proteinuria (specifically albumiuria). B. Predisposing factors 1. Age – primis under 20 and over 30 years 2. Gravida – 5 or more pregnancies 3. Low socioeconomic status (SES) 4. Multiple pregnancy 5. With underlying medical conditions, e.g., heart disease, hypertension or diabetes

C. Classification (Table 14) D. Pathogenesis: (Figure 17) E. Diagnosis: roll-over test – assesses the probability of developing toxemia when performed between the 28th and 32nd week of pregnancy. 1. Procedure 1.1 Patient lies in lateral recumbent position for 15 minutes until BP has stabilized 1.2 Then rolls over to supine position 1.3 BP is taken at 1 minute and 5 minutes after having rolled over. 2. Interpretation: if diastolic increases 20 mm Hg or more, patient is prone to toxemia.

I. Acute toxemia – symptoms appear after the 24th Blood supply & oxygen perfusion to vital

KIDNEYS Glomerular degeneration

week of gestation HYPERTENSION A. Preeclampsia 1. Mile 2. Severe B. Eclampsia II. Chronic hypertension with pregnancy LIVER PLACENTA III. Unclassified

Table 14. Classification of Toxemia

Tubular reabsorption of sodium

Glomerular permebility

Tissue ischemia

Glomerular Filtiration Tissue ischemia

Vascular stasis

PERIPHERAL ARTERIOLAR VASOCONSTRICTION Albumin& globulin cross into the urine

PROTEINURIA

Water retention

EDEMA

Epigastric pain

release thromboplastin like substances

OLIGURIA Premature placental deterioration

Fluid diffuses from circulatory system to extracellular spaces

Fetal nutrient

Abruptio placenta

Generalized water retention LUNGS

BRAIN Fetal Distress

Pulmonary edema

CHF

cyanosis

Cerebral edema Cerebral irritability

CONVULSIONS

hypoxia Premature Labor and Delivery

1.1.2 1.2

1.3

Generalized vasoconstriction and associated microangiopathy disease of capillaries 1.1.3 Abnormal retention of sodium and water by body tissues Medical complications 1.2.1 Cerebrovascular hemorrhage 1.2.2 Acute pulmonary edema 1.2.3 Acute renal failure Types 1.3.1 Mild preeclampsia – signs and symptoms  Sudden, excessive weight gain of 1-5 lbs. per week (earliest sign of preeclampsia) due to edema which is persistent and found in the upper half of the body (e.g. inability to wear the wedding ring)  Systolic BP of 140, or an increase of 30mm. Hg. or more and a diastolic of 90, or a rise of 15 mm. Hg. or more, taken twice 6 hours apart.  Proteinuria of 0.5 gms/liter or more 1.3.2 Severe preeclampsia – signs and symptoms  BP of 160/110 mm Hg.  Proteinuria of 5 gm/liter or more in 24 hours  Oliguria of 400 ml. or less in 24 hours (normal urine output/day = 1500 ml).  Cerebral or visual disturbances  Pulmonary edema and cyanosis

 Epigastric pain (considered an “aura” to the development of convulsions) 2. Eclampsia – the main difference between preeclampsia and Eclampsia is the presence of convulsion in eclampsia. Signs and symptoms as in preeclampsia plus: 2.1 increased BUN 2.2 increased uric acid 2.3 decreased CO2 combining power

F. Management 1. Complete bed rest – sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of vasoconstriction and decreased blood flow that diminishes the amount of nutrients and oxygen in cells. In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling. 2. Diet 2.1 For mild preeclampsia – high protein, high carbohydrate, moderate salt restriction (no added table salt, including “bagoong”, “patis”, “tuyo”, canned goods, bottled drinks, preserved foods and cold cuts) 2.2 For severe preeclampsia – high protein, high calorie and salt-poor (3 gms of salt per day)

3. Medications 3.1 Diuretics – e.g., chlorthiazide/Diuril. Hourly urine output should be at least 20-30 ml. (normally 50-60 ml. per hour) 3.1.1 Pharmacologic effect: decreased reabsorption of sodium and chloride at the proximal tubules, thereby increasing renal excretion of sodium, chloride and water, including potassium. 3.1.2 Side effects: fatigue and muscle weakness due to fluid and electrolyte imbalance 3.1.3 Nursing care: closely monitor intake and output 3.2 Digitalis – if with heart failure. 3.2.1 Pharmacologic action: Increase the force of contraction of heart, thereby decreasing heart rate. 3.2.2 Important: Should not be given, therefore, if heart rate is below 60/minute. 3.2.3 Implication: take the heart rate before giving the drug. 3.3 Potassium supplements – patients receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the heart to the effects of digitalis. Potassium supplements (e.g., banana) must be given tot prevent cardiac arrhythmias. 3.4 Barbiturates – sedation by means of CNS depression 3.5 Analgesics; antihypertensives; antibiotics; anticonvulsants; sedatives 3.6 Magnesium sulfate – the drug of choice

3.6.1

Actions  CNS depressant – lessen the possibility of convulsions  Vasodilator – decreases the BP  Cathartic causes a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted. 3.6.2 Dosage: 10 gms. initially, either by slow IV push over 5-10 minutes, or deep IM, 5 gms/buttock, then IV drip of 1 gm. per hour (1 gm/100 ml. D10W) IF:  Deep tendon reflexes are present  Respiratory rate is at least 12 per minute  Urine output is at least 100 ml. in 6 hours 3.6.3 Antidote for magnesium sulfate toxicity: Calcium gluconate, 10% IV, to maintain cardiac and vascular tone. 3.6.4 Earliest sign of magnetism sulfate toxicity: disappearance of the knee jerk/patellar reflex. 4. Method of delivery – preferably vaginal, but if not possible, CS will have to be done. G. Prognosis: the danger of convulsions is present until 48 hours postpartum. IV.

DIABETES MELLITUS – chronic hereditary disease which is characterized by hyperglycemia due to relative insufficient or lack of insulin from the pancreas which, in turn, leads to abnormalities in the metabolism of carbohydrates, proteins and fats. A. Diabetogenic effects of pregnancy – many women who have had no evidence of diabetes in the past develop abnormalities in glucose tolerance 1. Decrease renal threshold for sugar because of increased estrogen; that is why it is common to find dextrose and lactose in the urine of pregnant women 2. increased production of adenocorticoids, anterior pituitary hormones and thyroxin, which affect carbohydrate concentration in blood (hyperglycemia) 3. rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased, i.e., insulin does not seem to be normally effective during pregnancy B. Attendant risks 1. Toxemia 2. Infection 3. Hemorrhage 4. Polyhydramnios 5. Spontaneous abortion – because of vascular complications which affect placental circulation 6. Acidosis – because of nausea and vomiting. It is the chief threat to the fetus in utero 7. Dystocia – due to excessively large baby C. Diagnosis – made on the basis of the glucose Tolerance Test (GTT) 1. Procedure 1.1 NPO after midnight 2.3 If more than 120 mg% - overt gestational diabetes

D. Categories – to predict the outcome of pregnancy 1. Class A – GTT is only slightly abnormal; minimal dietary restriction; insulin not need; fetal survival is high 2. Classes C to E – have 25% perinatal mortality 3. Class F – therapeutic abortion (in other countries may be justified, not in the Philippines) E. Management 1. Diet – highly individualized. Adequate glucose intake (1800-2200 calories) to prevent intraurine growth retardation. 2. Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones are more pronounced during the 2nd and 3rd trimesters there is increased need for insulin. 2.1 Insulin is regulated to keep urine +1 for sugar (minimal glycosuria is necessary to prevent acidosis) but negative for acetone. 2.2 Long-acting insulin (Ultralente) will have to be changed to regular insulin (Lente) during the last few weeks of pregnancy. 3. Often delivered by CS 3.1 Baby is typically larger or maybe in distress because of placental insufficiency. 3.2 Severe metabolic imbalances in vaginal delivery can occur because of depletion of glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during labor. 4. Maximum difficulty in controlling diabetes is during the early postpartum period because of the drastic changes in hormonal levels. F. Infant of the Diabetic Mother (IDM) 1. Is typically longer and weighs more because of: 1.1 excessive supply of glucose from the mother 1.2 increased production of growth hormones from the maternal pituitary gland 1.3 increased secretion of insulin from the fetal pancreas 1.4 increased action of adrenocortical hormones that favor passage of glucose from mother to fetus 2. Congenital anomalies are often seen 3. Cushingoid appearance (puffy, but limp and lethargic) 4. More often born premature, so respiratory distress syndrome is common 5. Lose a greater proportion of weight than normal newborns because of loss of extra fluid 6. Are prone to the following complications 6.1 Hypoglycemia – blood sugar level less than 30 mg%. It is the most common complication to watch for 6.1.1 Cause: while inside the uterus, the fetus tends to be hyperglycemic because of maternal hyperglycemia. The fetal pancreas thus responded to the high glucose level by producing matching high levels of insulin. Following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high levels of insulin, hypoglycemia develops. 6.1.2 Clinical signs of hypoglycemia  Shrill, high-pitched cry

6.2

V.

 Listlessness/jitteriness/tremors  Lethargy; poor suck  Apnea; cyanosis  convulsions 6.1.3 Consequences: hypoglycemia, if not treated, can lead to brain damage and even death 6.1.4 Management: feed with glucose water earlier than usual, or administer IV of glucose. Hypocalcemia – serum calcium level of less than 7 mg%. 6.2.1 Signs: same as hypoglycemia 6.2.2 Sequela: Same as that of hypoglycemia 6.2.3 Management: Calcium gluconate to prevent bypocalcemic tetany

HEART DISEASE A. Classification 1. Class I – no limitation physical activity 2. Class II – slight limitation of physical activity; ordinary activity causes fatigue; palpitation, dyspnea or angina 3. Class III – moderate to marked limitation of physical activity; less than ordinary activity causes fatigue, etc. 4. Class IV – unable to carry on any activity without experiencing discomfort B. Prognosis 1. Classes I and II – normal pregnancy and delivery 2. Classes III and IV – poor candidates C. Signs and symptoms 1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed 2. Cardiac output may become so decreased that vital organs are not perfused adequately; oxygen and nutritional requirements, therefore, are not met. 3. Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign. 4. Liver and other organs become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or ascites. 5. Congestive heart failure is a high probability also because of the increased cardiac pain on exertion, and cyanosis of nailbeds are obvious. D. Management – consider the functional capacity of the heart 1. Bed rest – especially after the 30th week of gestation to ensure that pregnancy is carried to term or at least 36 weeks gestation 2. Diet – should gain enough, but not too much as it would add to the workload of the heart 3. Medications 3.1 Digitalis 3.2 Iron preparations, e.g., Fer-in-sol or Feosol – anemia should be prevented because the body compensates by increasing cardiac output, thus further increasing cardiac workload.

VI.

4. Classes III and IV are not placed in lithotomy position during delivery to avoid increasing venous return. The semi-sitting position is preferred to facilitate easy respirations. 5. Anesthetic of choice is caudal anesthesia for effortless, pushless and painless delivery. Remember: Gravidocardiacs are not allowed to push with contractions (to prevent Valsalva maneuver which increases venous return to an already weak, damaged heart). Low forceps, therefore, is the best method of delivery. 6. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives are contraindicated because they cause fluid retention and promote thromboembolization. 7. Most critical period – the period immediately following delivery because the 30% - 500 MULTIPLE PREGNANCY (Twin Pregnancy) A. Classification 1. Monozygotic/Identical – twins begin with a single ovum and sperm, but in the process of fusion or in one of the first cell divisions, the zygote divides into two identical but separate individuals. 1.1 Characteristics 1.1.1 Always of the same sex 1.1.2 With 2 amnions, 1 chorion, 2 umbilical cords and 2 placentas fused as one. 1.2 Incidence – a chance occurrence 1.2.1 More frequent among non-whites 1.2.2 More frequent among young primis and old multis 2. Dizygotic/Fraternal – two separate ova are fertilized by 2 separate sperms. They are actually sibling growing at the same time in utero. 2.1 Characteristics 2.1.1 May or may not be of the same sex 2.1.2 With 2 amnions, 2 chorions, 2 placentas and 2 umbilical cords 2.2 Incidence – familial maternal pattern of inheritence B. Suspect multiple pregnancy if: 1. faster rate of increase in uterine size 2. on quickening, there are several flurries of action in different abdominal positions 3. on auscultation, 2 sets of fetal heart tones are heard 4. there is marked weight gain, not due to toxemia or obesity C. complications 1. Toxemia 4. Abruptio placenta 2. Polyhydramnios 5. Prematurity 3. Anemia 6. Postpartum hemorrhage

VII. BLOOD INCOMPABILITY – an antigen-antibody reaction which causes excessive destruction of fetal red blood cells A. Mother is Rh negative and the fetus is Rh positive (because the father is either a homozygous or a heterozygous Rh positive) B. Mother is Type O and the fetus is either Type A or Type B (because the father is either Type A or Type B) VIII. DYSTOCIA – broad term for abnormal or difficult labor and delivery A. Uterine Inertia – sluggishness of contractions

1. Causes 1.1 1.2 1.3 1.4

B.

C.

D.

E.

Inappropriate use of analgesics Pelvic bone contraction Poor fetal position Overdistention – due to multiparity, polyhydramnios or excessively large baby

multiple

pregnancy,

2. Types 2.1 Primary (hypertonic) Uterine Dysfunction – relaxation are inadequate and mild, thus are ineffective. Since uterine muscles are in a state of greater than normal tension, latent phase of the first stage of labor is prolonged. Treatment: sedate patient. 2.2 Secondary (hypertonic) Uterine Dysfunction – contractions have been good but gradually become infrequent and of poor quality and cervical dilatation stops. Treatment: stimulation of labor either by Oxytocin administration or amniotomy. Precipitate Delivery – labor and delivery that is completed in less than 3 hours after the onset of true labor pains. Probably due to multiparity or following Oxytocin administration or amniotomy. Can lead to: 1. extensive lacerations 2. abruptio placenta 3. hemorrhage due to sudden release of pressure, leading to shock. Prolonged Labor – in primis, labor lasting more than 18 hours and in multis, more than 12 hours. Can lead to: 1. maternal exhaustion 2. uterine atony 3. caput succedaneum Uterine Rupture – occurs when the uterus undergoes more straining than it is capable of sustaining. 1. Causes 1.1 Scar from a previous classic Cesarean section (CS) 1.2 Unwise use of oxytocins 1.3 Overdistention 1.4 Faulty presentation 1.5 Prolonged labor 2. Signs and symptoms 2.1 Sudden, severe pain 2.2 Hemorrhage and clinical signs of shock (restlessness, pallor, decreasing BP, increasing respiratory and pulse rates) 2.3 Change in abdominal contour, with two swellings on the abdomen: the retracted uterus and the extrauterine fetus 3. management: hysterectomy Uterine Inversion – fundus is forced through the cervix so that the uterus is turned inside out. 1. Causes 1.1 Insertion of placenta at the fundus, so that as fetus is rapidly delivered, especially if unsupported, the fundus is pulled down 1.2 Strong fundal push when mother fails to bear down properly during 2nd stage of labor 1.3 Attempts to deliver the placenta before signs of placental separation appear 2. Management: hysterectomy

F. Amniotic Fluid Embolism – occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli. 1. Signs and symptoms – are dramatic 1.1 Woman in labor suddenly sits up and grasps her chest because of inability to breathe and sharp chest pain 1.2 Turns pale and then the typical bluish-gray color associated with pulmonary embolism 1.3 Death may occur in a few minutes 2. Management 2.1 Emergency measures to maintain life: IV, oxygen, CPR 2.2 Provide intensive care in the ICU 2.3 Keep family informed 2.4 Provide emotional support G. Trial Labor – if a woman has borderline (just adequate) pelvic measurements but fetal position and presentation are good. Maybe continued for as long as there is progressive fetal descent of the presenting part and the cervix continues to dilate actively. Management: 1. Monitor FHRs and uterine contractions 2. Keep bladder empty to allow all available space to be used by the fetus 3. Emotional support 1.1 Ethyl alcohol (Ethanol) IV – blocks the release of Oxytocin. Side effects: nausea and vomiting, mental confusion, etc. (same side effects when alcohol is taken orally in excessive amounts) 1.2 Vasodilan IV – a vasodilator. Side effects: hypotension and tachycardia 1.3 Ritodrine – a muscle relaxant given orally 1.4 Bricanyl – a known bronchodilator 2. If premature uterine contractions are accompanied by progressive fetal descent and cervical dilatation, premature delivery is inevitable. 2.1 May not necessarily be shorter than full term labor 2.2 Pain medications are kept to a minimum because analgesics are known to cause respiratory depression. As it is, premature babies already have enough difficulty breathing on their own; giving analgesics, therefore, would add up to the problem. Implication: give emotional support to the mother such that she focuses her attention not on her own needs but those of her baby. 2.3 Steroids (glucocorticoids) are given to the mother to help in the maturation of the fetal lungs by hastening production of surfactants 2.4 Caudal, spinal or infiltration anesthesia is preferred because it does not compromise fetal respiration. 2.5 Episiotomy is not necessary smaller than in full term deliveries; may even be larger so that the preemie can be delivered at the shortest possible time, since excessive pressure on the fragile preemie’s head can cause subarachnoid hemorrhage that could be fatal 2.6 Forceps may be applied gently 2.7 Cord is cut immediately, rather than waiting for pulsations to stop, because preemies have difficult time excreting large amounts of bilirubin that will be formed from the extra amount of blood.

IX.

INDUCED LABOR – to bring about labor either by amniotomy or drugs (Oxytocin, prostaglandins) before the time when it would have occurred spontaneously or because it does not occur spontaneously. A. Indications 1. Maternal 1.1 Toxemia 1.2 Placental accidents 1.3 Premature rupture of the BOW 2. Fetal 2.1 Diabetes – terminated about 37 weeks AOG if indicated 2.2 Blood incompatibility with rising titer 2.3 Excessive size 2.4 Postmaturity B. Prerequisites 1. No CPD 2. Fetus is viable – survival is decreased if below 32 weeks AOG 3. Single fetus in longitudinal lie and is engaged 4. Ripe cervix – fully or partially effaced; dilated at least 1-2 cm. C. Procedure 1. Oxytocin administration 1.1 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 gtts/minute given initially. If no fetal distress is observed in 30 minutes, infusion rate is increased 16-20 drops/minute 1.2 Amniotomy will be done when cervical dilatation reaches 4 cm. Check FHR and quality of fluid after amniotomy 1.3 Nurisng Care 1.3.1 Primary concern: monitor intensity of uterine contractions. If uterine contractions are unduly sustained, uterine rupture can occur. 1.3.2 Monitor flow rate regularly 1.3.3 Turn off IV drip if with abnormalities in FHR or uterine contractions.