Maternal and Child Health I
Maternal and Child Health I
Maternal and Child Health I
delivery
2. Android Pelvis
Wide
HEART-SHAPED
This is the typical MALE PELVIS
3. Anthropoid
Pelvis
Wide
Narrow
This is the typical
APE PELVIS
4. Platypelloid Pelvis
Opposite of Anthropoid Pelvis
Wide
Narrow
A. Diagonal conjugate – 12.5 cm or greater is
adequate size, evaluated by examiner
◦ OC = DC – 1.5 or 2.0 cm
Diagonal Conjugate
Distance from posterior surface of
clinically
Normal value is 11.5 cm to 12.5 cm.
A. Mons veneris – protects symphysis
B. Labia majora – covers, protects labia minora
C. Labia minora – two located within labia
majora
D. Clitoris – small erectile tissue
E. Hymen – thin membrane at opening of
vagina
F. Urinary meatus – opening of urethra
G. Bartholins glands – producer of alkaline
secretions that enhances sperm motility,
viability.
Vagina – outlet for menstrual flow, depository
of semen, lower birth canal
Cervix – cone-shaped neck of the uterus that
protrudes into the vagina
OVARY
Ovulation is the
most important
function of the
ovary
Production of the
female hormone
Situated
retroperitoneally
Contained in the
OVARIAN FOSSA
In times of
abdominal new
growth in the ovary
– these are always
detected late due to
anatomical location
Example:
◦ Ovarian carcinoma
◦ Ovarian
malignancy
Not easily palpable
UTERUS
Changes occurring
during pregnancy
Endometrium lining
during pregnancy
becomes deciduas (lining
of the pregnant uterus)
Endometrium is the
Fallopian Tube
Composed of the
(endometrium) is proliferating
Elevated Hormones
Anterior Pituitary INCREASES SECRETION OF
FOLLICLE STIMULATING HORMONE
◦ Therefore, the follicle in the ovary ENLARGES
◦ As it enlarges, it becomes more mature
GRAAFIAN FOLLICLE
◦ Most mature of all follicles
◦ With cavity
◦ With ovum ready to be extruded
◦ With clear fluid rich in ESTROGEN
◦ Only one (1) follicle matures per menstrual cycle
Approximate number of growing follicles:
◦ At twenty-eight (28) weeks Age of Gestation
6,000,000
◦ At Term
1,000,000
◦ At menarche
400,000
◦ At forty (40) years of age
8,000
Thickens the uterine lining
Usually eight-fold of previous
PREGNANCY
If ovum degenerates,
◦ LH and Progesterone no longer needed
◦ Therefore, there is menstruation
If there is coitus and fertilization
Corpus Luteum must persist up to twelve
NORMAL
If the menstrual period is short (i.e. 21
2005
Menstrual Cycle is 35 days
January 2005
01 02 03 04 05 06 07
08 09 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
February 2005
xx xx xx 01 02 03 04
05 06 07 08 09 10 11
The LAST MENSTRUAL PERIOD or LMP is the
FIRST DAY OF THE PERIOD
◦ Therefore, counting of the MENSTRUAL CYCLE,
starts from this same date
◦ Thus, February 4, 2005
Is the 35th day
Is the expected start of the next cycle
Is the LMP of the next cycle
Thus, February 3, 2005
Is the 34th day
Is the end of the cycle that started on
January 1, 2005
This is WHERE YOU START COUNTING
BACK FOURTEEN DAYS TO GET THE DAY
OF OVULATION
Therefore, count fourteen (14) days, starting
February 3 going backward
Thus, the expected OVULATION DAY is
February 21, 2005
If the cycle is irregular, do not do this
procedure
If the Menstrual Cycle is not given, it is
delivery
VIABILITY
A fetus can be delivered
Capable of living outside utero
Period of Viability is TWENTY (20) WEEKS
AND ABOVE
GRAVIDA
Number of pregnancies REGARDLESS OF
THE OUTCOME
PREGNANT WOMAN
d. Nulligravida – never been pregnant
e. Primigravida – first pregnancy
f. Multigravida – a woman with a second or
later pregnancy
PARITY
Number of pregnancies THAT REACH THE
(after 6 week)
Increased basal body temperature
Probable signs - examiner’s objective findings
positive pregnancy test
Enlargement of abdomen/uterus
Reproductive organ changes (after six
week)
3. Changes in Urination
Urinary frequency
◦ Primigravida
Mostly manifests this
Peaks at FIRST TRIMESTER
◦ At two (2) to three (3) months of pregnancy
◦ At eight (8) to twelve (12) weeks of pregnancy
Provide:
Dry unsalted crackers
Ice chips
Small, frequent feedings
Six (6) times a day
This is the best among all the options
Split food into two halves and give meals after every
two (2) hours
Less fatty foods in diet
Do not lie supine after eating
Encourage ambulation
Progesterone decreases gastric emptying!
If nausea and vomiting is severe consider
◦ Hydration
◦ Vomiting
◦ Hypokalemia, presenting as generalized
weakness
◦ Electrolyte Balance
Therefore, client needs to be admitted
5. Fatigue
Diaphragm does not descend upon
inspiration
6. Skin Changes
Brought about by hormonal changes -
ESTROGEN
◦ Cloasma
Mask of pregnancy
Visible at the cheek
◦ Melasma
Darkening of the neck
◦ Linea Negra
From the symphysis pubis to the umbilicus
◦ Striae Gravidarum
Silvery in color
Due to distention of the collagen of the abdomen as
the uterus enlarges
PROBABLE SIGNS
More of the signs
1. Abdominal Enlargement
Symmetrical and globular
High risk
Less than eighteen (18) weeks
See different Landmarks:If uterus is at the
level of the symphysis pubis
◦ Age of Gestation = 12 weeks
If uterus is midway between umbilicus and
symphysis pubis
Age of Gestation = 16 weeks
If uterus is at the level of the umbilicus
◦ Age of Gestation = 20 weeks
Then, increase of one centimeter (1 cm) in
FUNDIC HEIGHT = Additional Four (4) weeks
in Age of Gestation
◦ 1 cm above the umbilicus = 24 wks
◦ 2 cm above the umbilicus = 28 wks
◦ 3 cm above the umbilicus = 32 wks
◦ 4 cm above the umbilicus = 36 wks
At the LEVEL OF THE XIPHOID PROCESS, Age
of Gestation is 36 weeks
If one centimeter (1cm) below the xiphoid
and progesterone
purple hue in vulvar/ vaginal area.
Increase in acidity of vaginal pH due to
lactobacillus acidophilus
Lactobacillus acidophilus protects the
be detected
Peak of level of HCG is ten (10) weeks Age
of Gestation or 2½ months
Then it goes down
Therefore, yield of positivity of pregnancy
◦ 280 days
- 40 weeks
- 10 lunar month
s
1. WEIGHT GAIN
Twenty-five (25) to thirty-five (35) pounds
First Trimester
pregnancy
Additional ten grams (10 g) of protein per
◦ Add to diet
◦ A little increase in fat in the diet is necessary
Iron supplementation in pregnancy is
DOUBLED
In pre-pregnancy
consist of:
◦ Inspection
◦ Palpation
◦ Auscultation
NO PERCUSSION
2.3) FOCUS ON ABDOMEN
Inspection
◦ Look for striae
◦ Look for hernia of umbilicus
Palpate
◦ Take the fundic height
◦ Supine position with both legs flexed
◦ Use centimeter scale of tape measure
◦ Place at TIP OF SYMPHYSIS PUBIS up to the level
of FUNDUS AND NOTE THE MEASUREMENT
2.4) PERFORM LEOPOLD’S MANEUVER
Purpose of Leopold’s Maneuver
of the uterus?
FUNDAL GRIP
How is Leopold’s 1 done?
Use both hands
Palpate the fundus of the uterus in a
circular manner
Locate if the fundus has:
◦ HEAD
Round
Hard
Ballottable mass
◦ BREECH (buttocks)
Soft
Irregular
With nodulations
(coccyx, bilateral aspect of buttocks)
Question:
What Leopold’s maneuver will you use to
pelvic inlet
PAWLIK’S GRIP
How is Leopold’s 3 done?
Use dominant hand
Grasp area just above the symphysis pubis
If you grasp the head
◦ Round
◦ Hard
◦ Ballotable mass
If breech
◦ Soft
◦ Irregular
◦ With nodulations
(coccyx, bilateral aspect of buttocks)
You will ALSO KNOW if PRESENTING PART IS
ENGAGED or NOT ENGAGED
If head is engaged,
◦ If head is already descended, you will not feel the
head
◦ If head has not descended fully to the pelvic inlet
(partial descent), you can feel for the shoulders of
the baby
◦ If head is unengaged, you can grasp head and
you can move it sideways
FETAL PRESENTATION is best determined by
LEOPOLD’S 3 because IT IS DIRECT.
LEOPOLD’S 1 is INDIRECT
LEOPOLD’S 4
Performed to know. . .
What is the ATTITUDE of the fetus?
FETAL ATTITUDE
◦ This is the degree of flexion of the baby in utero
Types of Fetal Attitude
Flexed
Suboccipitobregmatic
diameter is presented
Approximately nine centimeters (9cm)
pelvis
Head Size is greater than the Pelvis
B) Fetal Posture or Attitude
If in complete extension, labor will not
progress
C) Fetal Lie
If fetus is in TRANSVERSE LIE, DILATATION
DELIVERY
E) Fetal Position
Relationship of the four (4) quadrants of the
SPINES
If head of baby descends in the pelvis, the
PELVIS
Below the linea terminalis is the TRUE
PELVIS
If engaged, head is not necessarily at
STATION ZERO
From STATION –3, the head is ALREADY
ENGAGED!!!
Below the Ischial spine, the reckoning is
POSITIVE
1 cm below ischial spine = +1
2 cm below ischial spine = +2
3 cm below ischial spine = +3
4 cm below ischial spine = +4
At station +4, head is already CROWNING or
SHOWING AT THE INTROITUS
3. FETAL HEAD
Fontanelles
the uterus
In the United States, the mother is hooked
to an external monitor
Example:
Contraction starts 7:00 AM
Lasts 60 seconds 7:01 AM
Second contraction 7:04 AM
Duration is 60 secs 7:05 AM
Third contraction 7:08 AM
Interval
◦ From end of first contraction to the beginning of
the next contraction
◦ 7:01 AM to 7:04 AM
◦ Therefore, three (3) minutes
Frequency
◦ Beginning of one contraction to beginning of next
contraction
◦ 7:00 AM to 7:04
◦ Therefore, four (4) minutes
Duration
◦ From the beginning to end of one contraction
◦ 7:00 AM to 7:01 AM
◦ Therefore, one (1) minute
Intensity
◦ This is a subjective term
◦ May be classified as:
Mild Contraction
Examining finger can be indented but uterus is still
contracting
Moderate Contraction
Examining finger can be indented but uterine
contraction is more than in mild
◦ Strong Contraction
You cannot indent examining finger because the
abdomen is board-like in consistency (hard)
1. LIGHTENING
In Primigravida
hours
For Multigravida (in normal circumstances)
First Stage lasts for six (6) to eight (8) hours
In Precipitate Labor
Entire labor is through within three (3)
hours
PHASE 1
LATENT PHASE OF FIRST STAGE OF
LABOR
Cervical Dilatation
OF LABOR
Cervical Dilatation
mechanisms of labor
DELIVERY OF BABY TO DELIVERY OF
PLACENTA
Lasts for five (5) to ten (10) minutes
Maximum waiting time is thirty (30) minutes
Beyond thirty (30) minutes is ALREADY
ABNORMAL
1. Calkins’s Sign
◦ Uterus becomes firm and globular
2. Lengthening of the Cord
3. Sudden Gush of Blood
placenta
Massive contraction of the uterus traps
placenta inside
Therefore, do not give before placental
expulsion
2. OXYTOCIN
Given prior to expulsion of placenta to add
to contraction
Given at minimal amounts
Normally at a rate of eleven to twelve drops
gonadotropin hormone
Sonogram is done to assessed viability of
fetus.
Avoiding strenuous activity for 24 to 48
isthmus, 8% fimbria.
2nd most common cause of bleeding in early
pregnancy
Can be abdominal pregnancy
TENDERNESS
◦ Usually lower abdomen
CLINICAL MANIFESTATIONS OF
ECTOPIC PREGNANCY
Severe, sharp knife-like abdominal pain
◦ Unilateral pain
Abdominal rigidity
◦ Bleeding inside
◦ Hemoperitoneum
◦ Peritonitis
Positive (+) for Cullen’s Sign
◦ Ecchymosis around the umbilicus due to
hemoperitoneum
◦ Sign of peritoneal irritation
Decreased Blood Pressure
◦ About 80 / 50
Excruciating Pain when the cervix is moved
In ectopic pregnancy, blood goes to the
peritoneum
◦ Blood ruptures and pools at CUL DE SAC or the
POUCH OF DOUGLAS or URETERORECTAL POUCH
When internal examination is done and cul
de sac is palpated, WRIGGLING SENSATION
arises
DIAGNOSIS FOR ECTOPIC PREGNANCY
CULDOCENTESIS
You get something from the cul de sac
How is Culdocentesis done?
Consent
Lithotomy position
Prepare Perineum
Speculum introduced
◦ Held in place
To visualize the cervix
◦ No anesthetic is given
Spinal needle directed towards posterior
portion of the cervix
Aspirate
If blood is present in the cul de sac, it is a
RUPTURED ECTOPIC PREGNANCY
If there is blood. . .
centimeter (3 cm))
“binubutas, tinatanggal”
Left to heal
Salphingotomy
Limited to UNRUPTURED
“binubutas, tinatanggal”
Sutured
Salphingectomy
For a ruptured ectopic pregnancy
Conditions Associated with second-
Trimester bleeding
Hydatidiform mole (H-MOLE)
Predisposing Factors:
chorionic villi
Vesicle-like structure is formed instead of
placenta
May be antecedent to choriocarcinoma
Genetic base of complete mole (sperm
enters empty egg and its chromosomes
replicates; 23 pairs of chromosomes are all
paternal).
More common in women over 45 years of
opening
◦ Purpose is to make the cervix tense
Done if products of conception IS LESS
THAN TWELVE (12) WEEKS OLD
Mother is allowed to deliver by NORMAL
◦ Modified Trendelenberg
◦ Lumbar area is elevated and feet are lowered
Coitus is temporarily restricted
Tocolytic therapy is employed if there is
contraction
◦ RITODRIN, TERBUTALLINE is administered to STOP
CONTRACTION
Conditions Associated with Third-
Trimester bleeding
PLACENTA PREVIA
Important Concept!
All previa types are CAESARIAN
DELIVERIES !!!
FOUR (4) TYPES OF PLACENTA PREVIA
1. Low Lying Placenta Previa;
Example: Gravida 7
Predisposing Factors
Multiparity, Advanced maternal age, past
INTERNAL OS
3. Partial Placenta Previa
Part of placenta is OBSCURING THE
INTERNAL OS
4. Total Placenta Previa
Also called Placenta Previa Totalis
Placenta TOTALLY COVERS THE INTERNAL
OS
◦ Definitely a Caesarian Section!
Localization of Placenta
◦ Done on the second / third trimester
PLACENTAL MIGRATION
Placenta moves and may move up
Can occur up to thirty-two (32) weeks
Establish that the placenta is NOT PREVIA in
ALL INSTANCES OF SECOND OR THIRD
TRIMESTER BLEEDING
◦ Wait for the ULTRASOUND result
DO NOT DO INTERNAL EXAMINATION!!!
DOUBLE SET-UP
Client with placenta previa
signs
CENTRAL SEPARATION
More dangerous
Blood does not seep off through the
Myometrium
Uterus remains soft and boggy
◦ Uterine Atony
Therefore, HYSTERECTOMY IS DONE
Called COUVELAIRE
Uterus is COPPER-COLORED or BLUISH in
7. Vaginal spotting
LABOR
No contractions yet
PROBLEMS IN PREMATURE RUPTURE
OF MEMBRANES
1. INFECTION
Gold Standard is twenty-four (24) hours
If more than twenty-four hours, there will be
SEPSIS
2. CORD PROLAPSE
Umbilical cord goes out
Position the client to TRENDELENBERG
POSITION
◦ Lower the head part
◦ NICHE’S POSITION
Do not reinsert!!!
Moisten OS with NSS and cover
Push the PRESENTING PART BACK and NOT
THE CORD
Transport client to the OPERATING ROOM
Provide oxygenation
Get Fetal Heart Tone
Then Caesarian Section is started
Never Normal Spontaneous Delivery
MANAGEMENT OF PREMATURE
RUPTURE OF MEMBRANES
Pregnancy can still be prolonged if PRE-
TERM PREMATURE RUPTURE OF
MEMBRANES (PPROM)
◦ Pre-term Premature Rupture of Membranes (i.e.
35 weeks)
Problems are:
◦ Infection
◦ Cord Prolapse
◦ Prematurity
Provided
◦ There is no maternal infection
◦ There is no fetal distress
◦ Mother is not in labor
Termination of Pregnancy
◦ Caesarian Section
◦ Normal Spontaneous Delivery
PREMATURE LABOR
Most common cause of neonatal morbidity
and mortality
◦ Eighty five percent (85%)
Preventable
◦ How?
Modify lifestyle of the mother
Resolve on-going infection
Ascending infection affects fetus, uterus (goes into
contraction)
Management is similar to Placenta Previa
Except coitus restriction throughout
POST TERM LABOR
Pregnancy extends beyond forty-two (42)
weeks
1. Cephalopelvic Disproportion (CPD)
This leads to babies with
◦ Long nails
◦ Wrinkled Skin
2. Oligohydramnios
Amniotic fluid is less than 1,000 ml
Polyhydramnios is amniotic fluid level
CONSTRICTIONS ON BODY
3. Inadequate blood supply to the baby due
to calcification of the placenta
Placenta tends to harden
There are whitish specks instead of black
specks
4. Meconium Staining
Due to distress
Meconium Aspiration Syndrome
PRECIPITATE LABOR
Course of labor is ABRUPT
Labor lasts for LESS THAN THREE (3) HOURS
DANGERS OF PRECIPITATE LABOR
Non-institutionalized Delivery
◦ Single Footling
Double Footling
MAIN PROBLEM
Cord Prolapse
a. meconium stained
b. FHR irregularies
3. Maternal vital signs
4. Emotional status
Medical management:
2. Shorting acting barbiturates – to
encourage rest, relaxation.
3. Intravenous fluids – to restore/maintain
hydration and fluid-electrolyte balance.
4. If CPD, cesarean birth.
Nursing management:
2. Emotional support – assist coping with
fear, pain, discouragement
a. encourage verbalization of anxiety, fear
concern.
b. explain all procedure
c. reassure, keep couple informed of
progress.
2. Comfort measure
a. position: sidelying – to promote
relaxation and placental perfusion.
b. bath, back rub, linen change, clean
environment
c. environment: quiet, darkened room – to
minimize stimuli and encourage relaxation
and warmth.
d. encourage voiding – to relieve bladder
distension; to test urine for ketones.
Hypotonic dysfunction during labor
After normal labor at onset, contractions
block/spinal block)
CPD
Overdistention (polyhydramnios, fetal
Rh isoimmunization,or decrease
uteroplacental perfusion
Etiology
Maternal:
1. preeclampsia/eclampsia, PIH
2. heart disease
3. diabetes
4. Rh or ABO incompatibility
5. insuffient uteroplacental/cord circulation due
to:
a. maternal hypotension/hypertension.
b. cord compression
1. prolapsed
2. knotted
c. hemorrhage; anemia
Placental Problem;
1. malformation of the placenta/cord
2. premature “ aging” of placenta
3. Placental infarcts
4. abruptio placentae
5. placenta previa
Prolapsed umbilical cord
Cord descent in advance of presenting part;
positive
Therefore, client has increased chance of
◦ To conserve oxygen
◦ Due to constriction of vessels
Limit intake of salty foods
◦ Up to three (3) grams per day
Closer follow-up
◦ Weekly check-up
Severe Pre-eclampsia
Blood Pressure
◦ 160/110 or more
Proteinuria
Five (5) grams per liter
Measured in twenty-four (24) hour urine
output
Edema
Other signs and symptoms:
◦ Severe headache
◦ Blurring vision due to retention of water going
up to optic discs
◦ Fundoscopic examination
Looking for papilledema
◦ Pulmonary edema
Crackles
Cough
◦ Oliguria
Urine Output
Less than four-hundred milliliters (< 400 ml) in a day
Less than thirty thirty milliliters (< 30 ml) in an hour
◦ Epigastric pain
Aura of an impending seizure
◦ Reason for Presence of Epigastric Pain
Distention of capsule of liver due to edema
Necrosis of pancreas
Enzymes release digesting contents of intestine
◦ Vomiting
Due to increased
intracranial pressure (▲ICP)
Management of Severe Pre-eclampsia
Prevention of seizures
PHARMACOLOGIC MANAGEMENT
Give Magnesium Sulfate (MgSO4)
◦ Drug of choice
◦ Can also cause decrease in Blood Pressure
◦ (Hydralazine is drug of choice for hypertension)
◦ Check deep tendon reflex
◦ Knee jerk
If no reflex, hold magnesium sulfate
Hyporeflexia
◦ Magnesium sulfate causes depression
◦ Check Respiratory Rate
If less than twelve (12) to fourteen (14) respirations
per minute, HOLD
Magnesium sulfate causes INCREASED RESPIRATORY
DEPRESSION
◦ Check Urine Output
Magnesium Sulfate is eliminated through the urine
If urine output is low, Magnesium sulfate cannot be
eliminated
Loading Dose of Magnesium Sulfate
Fourteen grams (14 g)
Four grams (4 g) via I.V. infusion pump
Given for a duration of thirty (30) minutes
This is painful to the blood vessels
Ten grams (10 g) via I.M. injection
Five grams (5 g) on each buttock / gluteus
◦ Maintenance Dose
Give at one to two grams (1 – 2 g) in one to two
hours (1 hr. – 2 hrs.)
Given via I.V. drip
Continue forty-eight (48) hours after delivery
Because there is post partum pre-eclampsia
◦ Antidote
Calcium Gluconate
One gram (1 g) via direct I.V.
Provide dim light room
Limit Visitors
Put up side rails
Suction machine by bedside
Don’t put anything in mouth if there is
seizure
Open collar
Turn patient to side to eliminate saliva
Concern is safety
ECLAMPSIA
Positive for seizures
Give additional medications:
◦ Diuretics
Furosemide is the drug of choice
◦ Digitalis (digoxin)
To promote contractility of heart without increasing
heart rate
Inotropic
Check pulse rate
◦ In Adults:
If pulse rate is less than sixty beats per minute (< 60
BPM) – HOLD THE MEDICATION
◦ In children less than ten (10) years old
If pulse rate is less than eighty beats per
minute
(< 80 BPM) – HOLD THE MEDICATION
In both cases, patient will go into BRADYCARDIA IF
MEDICATION IS NOT WITHHELD
◦ Potassium (K+)
Prevents DIGITALIS TOXICITY
And USE OF POTASSIUM WASTING
FUROSEMIDE
Before giving Potassium (K+)
◦ Before I.V. is in the vein, test for backflow
◦ Subcutaneous tissue necrosis
◦ Tissues get burned due to Potassium (K+)
Barbiturates
Fast acting sedatives
To arrest seizure
Hydralazine
For hypertension
HELLP SYNDROME
HEMOLYSIS, ELEVATED LIVER ENZYMES,
LOW PLATELET
Due to necrosis of the liver
Disseminated Intravascular Coagulopathy
Because of increased pressure in the blood
vessels
GESTATIONAL DIABETIS MELLITUS
Two (2) values elevated in OGTT
DIET
◦ Maintain daily calorie intake of 1,800 to 2,200
kcal/day
◦ Refrain from eating simple sugars and
saturated fats
EXERCISE
◦ Appropriate for Age of Gestation
PHARMACOLOGIC THERAPY
◦ Insulin
Drug of Choice
◦ Oral hypoglycemic agent is teratogenic
Insulin given is based on the weight of the
client
If client is sixty kilograms (60 kg)
◦ Give 1ų / kg / day
◦ Therefore, give sixty units
In a B.I.D. dosing
◦ Bigger portion is given in the morning
◦ 2/3 of 60 units = 40 units
Smaller portion is given in the evening
◦ 1/3 of 60 units = 20 units
The bigger portion – 2/3 portion or 40 units
is composed of
◦ Regular Insulin
Brief onset
For immediate need
Thirty (30) minutes to one (1) hour onset of action
Comprises 1/3 of 40 units
◦ Intermediate Insulin
For later need
Comprises 2/3 of the 40 units
Note: The bigger portion is given thirty (30)
minutes prior to breakfast
For the smaller portion – 1/3 portion or 20
units
◦ 1 : 1 ratio of the regular : intermediate for 20
units
10 units for regular
10 units for intermediate
In drawing insulin
Vacuum air
First introduced to regular (clear)
◦ A vaginal delivery
EPIDURAL ANESTHESIA
Upon active labor (3 cm)
Check Blood Pressure
Side effect is hypotension
No Oxytocin
No Methergine
No augmentation of labor
All natural labor
General Anesthesia only given when
crowning occurs
◦ If given early, this crosses the placenta and the
effect is a decrease in the APGAR SCORE
POSITION OF CHOICE DURING LABOR
Will deliver at these positions:
Semi-sitting
Semi-Fowler’s position
◦ Not lithotomy
Femoral vessels are obstructed
DELIVERY OF CHOICE
Outlet forceps extraction – Vaginal
In Caesarian Section
◦ Achieve INVOLUTION
Return of reproductive organs to pre-pregnancy
state
Usually achieved after six (6) weeks
PRINCIPLES
1. PROMOTE HEALING
Uterus
◦ At level of umbilicus
◦ After the delivery of the placenta
One (1) day after
◦ One (1) finger breadth below the umbilicus
Two (2) days after
◦ Two (2) finger breadths below the umbilicus
Three (3) days after
◦ Three (3) finger breadths below the umbilicus
Four (4) days after
◦ Four (4) finger breadths below the umbilicus
Five (5) days after
◦ Five (5) finger breadths below the umbilicus
Six (6) days after
◦ Six (6) finger breadths below the umbilicus
Seven (7) days after
◦ Seven (7) finger breadths below the umbilicus
Eight (8) days after
◦ Eight (8) finger breadths below the umbilicus
Nine (9) days after
◦ Nine (9) finger breadths below the umbilicus
Ten (10) days after
◦ Ten (10) finger breadths below the umbilicus or at
the level of the symphysis pubis
Eleven (11) days after
- Uterus at the pelvic cavity
After six (6) weeks, upon Internal
Examination. . .
◦ If Uterus is midway between the umbilicus and
symphysis pubis, this is ABNORMAL
This means that there is something left inside
SUB-INVOLUTION or POST PARTUM
HEMORRHAGE
Uterus has not gone back to original size
Caused by retained placental fragment
Rubra
Day one (1) to day three (3)
Day two (2) to day three (3)
Bright red in color
Serosa
Day three (3) to day ten (10)
Pinkish in color
Actually, brown in color
Alba
Day ten (10) until third (3rd) week up to
cause
Inherent clotting disorders occur:
Thrombocytopenia
Leukopenia
Late post-partum hemorrhage
◦ Occurs after first twenty-four hours of delivery
Common causes:
◦ Primary Cause
Retained placental fragment/s
◦ Secondary Cause
Hematoma (vaginal)
3.2) INFECTION
Endogenous infection
Normal flora causes infection
These travel up the uterus
3.3) PERINEAL INFECTION
On site of episiotomy
◦ Semi-Fowler’s position
Oxytocin is given
◦ Promotes contractions
◦ Promotes release of secretion
ENDOMETRITIS is a PRELUDE to
THROMBOPHLEBITIS
3.5) THROMBOPHLEBITIS
Most common site are the vessels of the
LOWER EXTREMITIES
Positive (+) for HOMAN’S SIGN
How is Homan’s Sign elicited?
◦ Ask patient to dorsiflex foot
◦ Upon lying supine, legs extended
◦ Stretching of the blood vessels causes pain on
calf muscle (gastrocnemius muscle)
Management of Thrombophlebitis
◦ Antibiotics
◦ Anticoagulant
Heparin
Larger molecule than warfarin
Less likely to enter breast milk
Discontinue breastfeeding whether heparin
or warfarin is administered
Antidotes
◦ For Heparin
Protamine Sulfate
◦ For Warfarin
Vitamin K
ESTABLISHMENT OF SUCCESSFUL
LACTATION
La leche Method
the baby
Day 1
Start breastfeeding for five (5) minutes on
each breast
Day 2
Provide breastfeeding for six (6) minutes on
each breast
Day 3
Provide breastfeeding for seven (7) minutes
on each breast
Day 4
Provide breastfeeding for eight (8) minutes
on each breast
Day 5
Provide breastfeeding for nine (9) minutes
on each breast
Day 6
Provide breastfeeding for ten (10) minutes
on each breast
Stop and maintain ten (10) minute feeding
per breast
This would give a total of twenty (20)
minutes of breastfeeding time
Important Concept!
Breastfeeding is done on a per demand
basis
1. CARDIOVASCULAR SYSTEM
HEART
As diaphragm rises, the heart is displaced
laterally
Point of Maximum Impulse
◦ Normally located at Fifth Intercostal Space Mid-
clavicular Line on the Left Side {5th ICS-MCL (L)}
◦ This shifts to Fourth Intercostal Space Lateral
Axillary Line on the Left Side {4th ICS-LAL (L)}
◦ Exaggeration of first and second heart sounds
{S1 (Lub) and S2 (Dub)} due to INCREASED
CARDIAC OUTPUT
Appreciation of S3 (third heart sound;
ventricular filling) due to INCREASED
CARDIAC OUTPUT
Appreciation of a MURMUR, which is almost
always SYSTOLIC (all pathologic) in
natureInnocent in nature
◦ As soon as mother delivers placenta, excess fluid
is absorbed or excreted, then the MURMUR
DISAPPEARS
Blood Volume is INCREASED due to
INCREASE IN WATER RETENTION
HIGHEST CARDIAC OUTPUT IN
PREGNANCY
Twenty-eight to thirty-two weeks (28-32
cardiac patient
Supine Hypotensive Syndrome
◦ When mother assumes supine position, she
develops hypotension
◦ Weight of uterus presses on the VENA CAVA
This results into DECREASED VENOUS RETURN
This results into DECREASED CARDIAC OUTPUT
End result is HYPOTENSION
Therefore, SUPINE POSITION IN PREGNANCY
IS NOT ALLOWABLE (particularly in the
second and third trimester)
POSITION OF CHOICE
◦ Side-lying Left (so as not to impede the Vena
Cava
◦ Left Lateral Position
◦ Sim’s Left Position
With arm flexed
Leg flexed
Weight of uterus would be ON THE BED
2. HEMATOLOGIC CHANGES
HEMODILUTION
Due to increase in PLASMA VOLUME
CHANGES IN PLATELET
Expected during Postpartum
Due to blood loss, there is TRANSIENT
platelet aggregation
This would then predispose to EMBOLISM
Therefore, EARLY AMBULATION is NEEDED
WHITE BLOOD CELL LEVELS INCREASE
(particularly in labor)
LEUKOCYTOSIS is STRESS-INDUCED
ESTROGEN
Therefore, CONTINUE TO USE SOFT BRISTLE
TOOTHBRUSH
4.3) ESOPHAGUS
Progesterone is a relaxant of smooth
muscle
◦ Effect is on lower esophageal sphincter
◦ It is more relaxed
Pressure of Lower Esophageal Sphincter
(LES) is less than pressure on Cardiac
Sphincter (CS)
◦ If LES pressure is > CS pressure
No regurgitation
◦ If LES pressure is < CS pressure
◦ There is HEARTBURN OR PYROSIS;
SUBSTERNAL PAIN related to eating
Most common surgical complication of
pregnancy is ACUTE APPENDICITIS!
Right Upper Quadrant pain is not expressed
ureter
Therefore, URINE STAGNATION occurs in the
URETER (no longer peristaltic)
Therefore, the PATIENT IS PRONE TO
URINARY TRACT INFECTION
5.2) Glomerular Filtration Rate in
Pregnancy
Increased Cardiac Output
Increased Glomerular Filtration Rate
But absorptive capacity of nephrons is not
pregnancy
The following are normal during pregnancy:
◦ Blurring of vision
Headache
8. MUSCULOSKELETAL SYSTEM
8.1) PLACENTA IS CAPABLE OF
PRODUCING RELAXIN
Relaxes pelvic joints
Therefore, the pelvis is more movable
8.2) DIASTASIS RECTI
Separation of rectus abdominis muscle
Only fascia remains in between
This is normal
Rectus abdominis muscle goes back after
pregnancy (coarctate)
8.3) PHYSIOLOGIC LORDOSIS
Known as the PRIDE OF PREGNANCY
Increased outward curvature
◦ In Fetal Circulation
Nutrient exchange occurs
NO PORTAL CIRCULATION EXISTS
Liver is bypassed as METABOLISM (by the liver) is
NOT NEEDED
E is for:
ENDOCRINOLOGIC
normally removed
◦ Ductus Venosus
◦ Foramen ovale
Two (2) types of Closure
Functional Closure
Anatomic Closure
FORAMEN OVALE
Closed functionally immediately after birth
Indomethacin
◦ Not advisable
◦ Causes premature closure of the Ductus Arteriosus
◦ Not compatible with life
◦ No supply to the lower half of the body of the fetus
PARACETAMOL IS ALLOWED
ASPIRIN
Causes persistence of Ductus Arteriosus
Arteriosus
Important Concept!
EXAMINATION
1.1) First thing to ask is the LAST
MENSTRUAL PERIOD
Purpose is to IDENTIFY THE AGE OF
GESTATION
1.2) What are History of Previous
Pregnancy:
NSAID?
Postpartum complication?
Infection?
1.3) Past Medical History
Diabetes Mellitus?
Gestational Diabetes?
Hypertension?
2. FETAL HEART TONE
Easiest method to assess for fetal well-
being
Very reliable indicator of oxygenation of the
fetus
If FHT is heard
◦ Fetus is alive
◦ THIS IS AN ALL OR NONE RESPONSE
NORMAL
◦ 120 –160 beats per minute
If greater than 160
◦ Tachycardia
If less than 120
◦ Bradycardia
Be able to assess that sound you hear in
the mother is the FHT
In the mother’s abdomen, you can hear:
◦ BORBORYGMIC SOUNDS
Hunger sounds
◦ UMBILICAL SOUFFLE
When the blood in the placenta enters the umbilical
vein, this coincides with the Fetal Heart Tone
But FHT should be DISTINCT
Fetal Heart Tone sound
TUG – TUG – TUG
Umbilical Souffle Sound
SHHH – SHHH – SHHH
This is the sound of the gush of blood
◦ UTERINE SOUFFLE
Sound heard when blood enters uterine artery
This coincides with the heartbeat of the mother
IDEAL WAY TO TAKE THE FETAL HEART
TONE
Use the bell of the stethoscope
distress
POLYHYDRAMNIOS
Amniotic fluid greater than 2,000 ml
◦ A teratogenic effect
Therefore, remove part of amniotic fluid
IDENTIFICATION OF GENETIC OR
CHROMOSOMAL PROBLEM
HOW TO PREPARE THE CLIENT FOR
AMNIOCENTESIS
Explain what to do to the client
Get Consent
Remember, CONSENT IS NEEDED as this
procedure is INVASIVE!
Client must have I. V. fluid
Age of Gestation
Fifteen to Twenty (15 – 20) weeks Age of
Gestation is the IDEAL TIME FOR MS AFP or
during the SECOND (2nd) TRIMESTER, not
on the First or the Third Trimesters
If early high result
◦ Yolk sac and liver gives false elevated result
If late low result
◦ Liver only gives false low result
CHORIONIC VILLUS SAMPLING (CVS)
Get part of chorionic villi from the placenta
Done at nine to twelve (9 – 12) weeks Age
of Gestation
Approach is INTRAVAGINAL
Ultrasound-guided
A part of chorionic villi near maternal
attachment will be suctioned to the catheter
for KARYOTYPING and GENETIC ANAL
Purpose of this procedure is for detection of
genetic and chromosomal problems
Nursing Responsibility
only),
Repeat NST after two (2) to three (3) hours
If NST is NON-REACTIVE, it is ABNORMAL
CONTRACTION STRESS TEST (CST)
Best done when mother is at thirty-eight (38)
weeks Age of Gestation
Done when NST is NON-REACTIVE
Then, proceed with Contraction Stress Test
If CST could not be withstood by baby, IT NEEDS
IMMEDIATE DELIVERY
Introduce a STRESSOR – CONTRACTION if
ABNORMAL CST
OXYTOCIN CHALLENGE TEST
Rub nipples
used instead)
History of problem in the placenta
(placentation)
NIPPLE STIMULATION
◦ Give warm pack / warm soaks for ten (10)
minutes prior to stimulation to increase circulation
/ vascularity
◦ Explain procedure
◦ Start
◦ Four (4) cycles per stimulation
◦ 1, 2, 3, 4 stimulations REST x4
First Cycle
◦ If after these and there are NO CONTRACTIONS
◦ Stop and rest for two (2) to four (4) minutes
◦ Then stimulate
Up to four (4) cycles
◦ If NO CONTRACTIONS AFTER THE FOURTH (4th)
CYCLE
Stop stimulation
Proceed with Oxytocin Challenge Test
OXYTOCIN CHALLENGE TEST
Give diluted form of oxytocin
of Gestation
◦ Ask client to come back every four (4) weeks
At twenty-eight to thirty-six weeks (28 – 36)
Age of Gestation
◦ Ask client to come back every two (2) weeks
At thirty-six (36) weeks onwards
Ask client to come back every week
DOH RECOMMENDATION
One (1) pre-natal check-up per TRIMESTER
Three (3) pre-natal check-ups during the
◦ Type A, B, O
◦ A or B antigens
Rh Typing
◦ Rh (C, D, E)
◦ Three antigens
C
D
E
◦ In incompatibility, the concern is the D antigen
Rh
Mother is Rh- Father is Rh+
No D antigens ▼▼▼
Rh- or Rh0 ▼▼▼
(zero for D) ▼▼▼
▼▼▼▼▼▼▼▼▼▼▼▼▼
Baby is Rh+ or Rh(D)
Antigen D is present in the blood
The first pregnancy is spared
The first baby is born
Blood enters mother’s circulation
Therefore, mother PRODUCES ANTI-D
antibody
Interaction
During time of delivery when the placenta
in the uterus
Ancillary Procedures like AMNIOCENTESIS
Interaction of blood of baby entering
circulation
COOMB’S TEST
Two (2) types
Direct Coomb’s Test
Indirect Coomb’s Test
DIRECT COOMB’S TEST
Concerns the Baby
Identify if RBC of baby has hemolysis and
mother
INDIRECT COOMB’S TEST
Concerns the mother
Identify for titer of antibody
hemolysis
If Rh+ is given
A. 12 hours c. 36 hours
B. 24 hours d. 48 hours
45. The process of implantation takes place
in:
A. uterus c. ampulla
B. ovaries d. tunica albuginea
46. The non pregnant uterus is lined by the:
c. Urinary frequency
d. Dyspnea
e. Heartburn
f. constipation
Answer: A
Lightening or descent of the fetus puts added
pressure on the bladder, causing frequency.
5. A client is in active labor, the baby’s head
is crowning, the client is bearing down,
and delivery appears imminent. The nurse
should: