Professional Documents
Culture Documents
Maternal Ob Notes
Maternal Ob Notes
I. Human Sexuality
A.
Concepts
1.
A person s sexuality encompasses the complex behaviors, attitudes, emotions and
preferences that are related to sexual self and eroticism.
2.
Sex is basic and dynamic aspect of life
3.
During reproductive years, the nurse performs as resource person on human sexual
ity.
B.
Definitions related to sexuality:
Gender identity sense of femininity or masculinity
2 - 4 years / 3 years gender identity develops.
Weight :
Non pregnant: 50 - 60 grams
Pregnant: - 1000 grams
4th stage of labor - 1000 grams
2 weeks after delivery - 500 grams
3 weeks after delivery - 300 grams
Scrotum a pouch hanging below the pendulous penis, with a medial septum dividing
into
two sacs, each of which contains a testes. It is the cooling mechanism of testes
CONSTIPATION
3. responsible for the development of mammary gland
4. responsible for the increase permeability of kidney to lactose & dextrose cau
sing (+) sugar
5. responsible for mood swings in woman
6. responsible for the increase Basal Body Temperature
10. Menstrual Cycle: average 28 days
4 phases of Menstrual Cycle
1.1. Proliferative
1.2. Secretory
1.3. Ischemic
1.4. Menses
Parts of body responsible for menstruation:
1.
hypothalamus
2.
anterior pituitary gland masterclock of the body
3.
ovaries
4.
uterus
I. Initial phase of menstruation, the estrogen level is . , this level stimulate
s the hypothalamus to release
GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Rele
asing Factor)
3rd day Decreased estrogen
13th day Peak estrogen, Decrease progesterone
14th day Increase estrogen, Increase progesterone
15th day Decrease estrogen, Increase progesterone
II. GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone
Releasing
Factor) stimulates the anterior pituitary gland to release FSH (Follicle Stimula
ting Hormone)
Functions of FSH:
A.
Stimulate ovaries to release estrogen
B.
Facilitate growth primary follicle to become graffian follicle
(structures that secrets large amount of estrogen & contains mature ovum.)
III. Proliferative Phase contains mature ovum (ovulation)
proliferation of tissue . follicular phase . post menstrual phase . Preovularoty
Phase
Follicular Phase causing irregularities or variations of menstruation; 14th days
Postmenstrual Phase occurs after menstruation day
Preovulatory Phase happens before menstruation day
all phases increase ESTROGEN
IV.
13th day of menstruation, estrogen level is peak while the progesterone level is
down, these
stimulates the hypothalamus to release GnRH or LHRF (Luteinizing Hormone Releasi
ng Factor)
V.
GnRH/LHRF stimulates the anterior pituitary gland to release LH(Luteinizing Horm
one)
Functions of LH:
1. LH stimulates ovaries to release progesterone
2. hormone for ovulation
VI.
14th day estrogen level is increased while the progesterone level is increased c
ausing rupture
of graffian follicle on process of ovulation.
Signs and symptoms:
Mittelschmerz slight abdominal pain on Left or Right lower Quadrant of abdomen,
marks ovulation day.
2.) Change in Basal Body Temperature
3.) Mood Swing
4.) Constipation
VII.
15th day, after ovulation day, graafian follicle starts on degenerate becoming y
ellowish known as
corpus luteum (secretes large amount of progesterone)
VIII. Secretory phase
Lutheal Phase
Postovulatory
Increased progesterone
Premenstrual
Secretory Phase secretes the most important hormone in pregnancy which is the
progesterone because it makes the uterus nutritionally abundant with blood in or
der for the
fertilized zygote to survive should conception take place. It is also called pro
gestational
phase.
· Luteal Phase change from Graafian follicle to Corpus Luteum(yellowish appearan
ce)
· Postovulatory Phase occurs just after ovulation
Premenstrual Phase occurs after menstruation
IX. 24th day - no fertilization, corpus luteum degenerate turning white ( whitis
h corpus albicans)
X.
28th day no sperm in ovum endometrium begins to slough off to have the next mens
trual period
1st 7 days menstrual phase
7 14th days proliferative phase
14 28 days secretory phase
11. Stages of Sexual Responses (EPOR)
Initial responses:
Vasocongestion congestion of blood vessels
Myotonia increase muscle tension
1.
Excitement Phase (moderate vital signs : sign present in both sexes, moderate in
crease in
HR, RR,BP, sex flush, nipple erection) during this phase: erotic
stimuli increase sexual tension that may lasts from minutes to hours.
2.
Plateau Phase (accelerated Vital Signs) increasing & sustained tension nearing o
rgasm.
May lasts 30 seconds 3 minutes.
3.
Orgasm (involuntary spasm throughout the body, peak vital signs). This is the
involuntary release of sexual tension accompanied by physiologic and
psychologic release known as immeasurable peak of sexual experience .
May last from 2 10 sec- most affected are is pelvic area.
4.
Resolution (vital sign return to normal, genitals return to pre-excitement phase
)
Refractory Period the only period present in males, wherein he cannot be restimu
lated for about
10 - 15 minutes
IV. Wonders of Fertilization
Fornix - where sperm is deposited
Sperm - small head, long tail, pearly white
Phonones -vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation - ability of sperm to release proteolytic enzyme to penetrate coron
a radiata and
zona pellocida.
Fertilization union of the sperm and the mature ovum in the outer third or outer
half of the
Fallopian Tube.
General Consideration:
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 24 36 hours after ovulation.
4.
Sperms are capable of fertilizing even for 3 4 days after ejaculation
5.
Sperm is viable within 48 72 hours or 2 3 days
6.
Normal lifespan of sperm = 7 days
7.
Sperms, once deposited in the vagina, will generally reach the cervix within 90
seconds after
deposition.
8.
Reproductive cells, during gametogenesis, divide by meiosis (haploid number of d
aughter cells);
therefore, they contain only 23 chromosomes ( the rest of the body cells have 46
chromosomes ).
Sperms have 22 autosomes and 1 X sex chromosomes or 1 Y sex chromosome; Ovum con
tain 22
autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature
ovum results
in a baby girl (XX); the union of a Y-carrying sperm and mature ovum results in
a baby boy (XY).
Important: Only fathers determine the sex of their children
Stages of Fetal Growth and Development
3 - 4 days travel of zygote . during the travel . mitotic cell division begins
*Pre-embryonic Stage
a. Zygote - fertilized ovum. Lifespan of zygote from fertilization to 2 months
fetus -2 months to birth
b. Morula mulberry-like ball with 16 50 cells, start to travel by ciliary action
and
peristaltic contractions of fallopian tube to the uterus where it will stay for
4 days
free floating & multiplication
c. Blastocyst enlarging cells that forms a cavity in the morulla, that later bec
omes the embryo.
Trophoblast fingerlike projections covering around the blastocyst that later bec
omes
placenta and membrane.
d. Implantation other term Nidation - occurs after fertilization 7 10 days.
Placenta previa implantation at the lower side of the uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization corpus luteum continues to function & become source of e
strogen
& progesterone while placenta is not developed.
* 3 processes of Implantation
1. Apposition blastocysts begin to brush the endothelial lining
2. Adhesion blastocysts begin to attached the endothelial lining
3. Invasion blastocysts begin to settle down
Proteolytic enzyme for dissolving endothelial lining allowing implantation
* Embryonic Stage
C.
Decidua thickened endometrium (Greek word falling off); implantation has taken p
lace
Kinds of decidua:
* Basalis (base) part of endometrium located directly beneath or under the impla
nted ovum/fetus
where placenta is developed.
* Capsularies encapsulate or co the fetus
* Vera remaining portion of endometrium.
D.
Chorionic Villi -10 11th day of pregnancy; fingerlike projections
3 vessels = two arteries, one vein
A unoxygenated blood
V O2 blood
A unoxygenated blood
Wharton s jelly protects cord
Chorionic Villi Sampling (CVS) removal of tissue sample from the fetal portion o
f the developing
placenta for genetic screening. Done early in pregnancy.
Common dangerous side effects: fetal limb defect such as missing digits/toes.
Advance Maternal Age candidate for amniocentesis
E.
Cytotrophoblast inner layer or langhans layer of the trophoblast that gives rise
to the outer
surface and villi of the chorion.
- protects fetus against syphilis, however it can be capable of living
for 24 weeks/6 months
-life span of langhans layer increase.
* Before 24 weeks critical, might get infected syphilis
F.
Syncytiotrophoblast syncytial layer or outer layer . It erodes the uterine wall
during implantation and
give rise to the villi of the placenta. It is responsible production of hormones
. It is
also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast
Two structures developed:
1. Amnion innermost layer. It is a membrane, continuous with and covering the fe
tal side of
the placenta that forms the outer surface of the umbilical cord.
2 structures progress:
a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis, a
flexible
structure connecting the umbilicus with the placenta in the gravid uterus and gi
ving
passage to the umbilical arteries and vein; whitish grey, 15 55 cm, 20 21 .
*Importance of determining the length of the cord:
Short cord: abruptio placenta or inverted uterus.
Long cord: cord coil or cord prolapse
Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of
pregnancy; it contains the yolk sac and the body stalk with enclosed allatois.
b. Amniotic Fluid , also known as (BOW) bag of water, clear, odor mousy/musty, w
ith crystallized
forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo - skeletal development and symmetrical growth
3. maintains temperature
4. prevent cord compression
5. help in delivery process
normal amount of amniotic fluid 500 to 1000cc
polyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia /
(TEF) Tracheoesophageal Fistula, increased amount of fluid
oligohydramnios- decrease amount of fluid kidney disease; inom . absorbed . ihi
Diagnostic Tests for Amniotic Fluid
A. Amniocentesis aspiration of amniotic fluid
-empty bladder before performing the procedure.
Purpose obtain a sample of amniotic fluid by inserting a needle through the abdo
men
into the amniotic sac.
Fluid is tested for:
1.
Genetic screening / abnormality - maternal serum alpha feto-protein test (MSAFP)
1st trimester
2.
Determination of fetal lung maturity primarily by evaluating factors indicative
of
lung maturity 3rd trimester
2.1 Testing time 36 weeks
decreased MSAFP(maternal serum alpha feto-protein test) = down syndrome
increase MSAFP(maternal serum alpha feto-protein test) = spina bifida or open ne
ural
tube defect
Common infections amniocenthesis infection
Dangerous complications spontaneous abortion / bleeding
3rd trimester- pre term labor; indication of diabetic mother
Important factor to consider for amniocentesis - needle insertion site
Aspiration of yellowish amniotic fluid jaundice baby / hyperbilirubin
Greenish mecomium
A.
Amnioscopy direct examination thru an intact fetal membrane.
B.
Fern Test - determine if amniotic fluid has ruptured or not
(blue paper turns green/grey - + ruptured amniotic fluid)
C.
Nitrazine Paper Test diff amniotic fluid & urine.
Paper turns yellow- urine. Paper turns blue green/gray -(+) rupture of amniotic
fluid.
2. Chorion where placenta is developed outermost membrane
Lecithin Sphingomyelin L/S
Ratio - 2:1 signifies fetal lung maturity not capable for
RDS(Respiratory Distress Syndrome)
Test for Fetal Lung Maturity:
Shake test amniotic + saline & shake
Foam test amniotic + saline & shake
Phosphatiglycerol: PG+ definitive test to determine fetal lung maturity
a.
Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas b
asalis.
- Size: 500g or ½ kg
- 15 28 cotyledons
-1 inch thick & 8 diameter
Functions of Placenta:
1.
Respiratory System beginning of lung function after birth of baby. Simple diffus
ion
Higher Concentration to Lower Concentration
2.
GIT transport center, glucose transport is facilitated diffusion more rapid from
higher to lower. If mom hypoglycemic, fetus hypoglycemic
Higher to Lower Concentration but RAPID
3.
Excretory System- artery - carries waste products. Liver detoxifies waste produc
ts of
the fetus.
4.
Circulating system achieved by selective osmosis
5.
Endocrine System produces hormones
Human Chorionic Gonadrophin maintains corpus luteum alive; basis of
pregnancy test
Human placental Lactogen or sommamommamotropin Hormone for
mammary gland development. Has a diabetogenic effect serves as insulin
antagonist
Relaxin Hormone- causes softening joints & bones
estrogen
progestin
6.
It serves as a protective barrier against some microorganisms HIV,HBV
Entire pregnancy days 266 280 days 37 42 weeks
280 divided by 28 = 10 lunar months
280 divided by 31 days = 9.7 days (calendar months)
1st week counted zero
1. Fetal heart tone begins heart is the oldest part of the body
2. CNS develops dizziness of mother due to hypoglycemic effect
Food of brain glucose complex CHO pregnant woman s food (potato)
Differentiation of Primary Germ layers
* Endoderm
1st week endoderm primary germ layer
Thyroid for basal metabolism; respiratory
Parathyroid - for calcium metabolism
Thymus development of immunity
Liver
Lining of upper Respiratory Tract & Gastro Intestinal Tract
* Mesoderm development of heart, musculoskeletal system, kidneys and
reproductive organ
* Ectoderm development of brain CNS, skin and 5 senses, hair, nails,
mucous membrane of anus & mouth
Second Month
1.
All vital organs formed, placenta developed
2.
Corpus luteum source of estrogen & progesterone of infant life span end of 2nd m
onth
3.
Sex organ formed
4.
Meconium is formed
Third Month
1.
Kidneys functional
2.
Fetus begin to swallow amniotic fluid
3.
Buds of milk teeth appear
4.
Fetal heart tone heard Doppler 10 12 weeks
5.
Sex is distinguishable
Second Trimester: FOCUS length of fetus
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 20 weeks
3. buds of permanent teeth appear
Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks multi
5. fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month
Hct 32 42%
Hgb 10.5 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
Hct should not fall below 33%
Hgb should not fall below 11g/dL
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic physiologic
hypoxia
Nursing Care:
Nutritional instruction kangkong, liver due to ferridin content, green leafy veg
etablealugbati,
saluyot, malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly admini
stered,
hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr
before
meals or 2 hours after, black stool, constipation
Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vitamin C such as orange j
uice
Higher iron intake is recommended since circulating blood volume is increased an
d
hemoglobin is required from production of RBCs
Edema occurs because of poor circulation resulting from pressure of the gravid u
terus on
the blood vessels of the lower extremities due venous return is constricted due
to
large belly.
Management: elevate / raise legs above hip level.
Varicosities pressure of uterus
Management: -use support stockings, avoid wearing knee high socks
B. Local Changes
1. Vagina Chadwick s sign (color change of the vagina from pink to violet)
blue violet discoloration of vagina
Cervix Goodell's sign (softening of the cervix)
change of consistency of cervix
Uterus Hegar's sign (softening of the lower uterine segment)
change of consistency of isthmus (lower uterine segment)
LEUKORRHEA whitish gray, mousy odor discharge
ESTROGEN hormone, responsible for leukorrhea (remember the second letter of Leuk
orrhea)
OPERCULUM mucus plug to seal out bacteria.
PROGESTERONE hormone responsible for operculum
-Lamaze classes
VII. Pre-Natal Visit:
Basic Considerations:
1.
Frequency of Visit: 1st 7 months once a month
8 9 months twice a month
10 once a week (weekly)
post term - twice a week
2.
Personal data:
Name: for identification
Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old)
(HBMR) Home Base Mother s Record tool used to determine high risk pregnancy
Sex: PSEUDOCYESIS false pregnancy common to male
COUVADE SYNDROME psychosomatic reaction wherein the father experiences the
mother goes through; the father is the one to vomits,etc (lihi)
Religion: for their culture & beliefs with respect, non judgmental
Occupation: financial condition or occupational hazards
Education Background: to determine level knowledge
Address; civil status
3.
Diagnosis of Pregnancy
1.) urine exam to determine HCG - 6 weeks after Last Menstrual Period , 40 100th
day but
peak 60 70 day best to get urine exam.
2.) Elisa test test to detect beta subunit of HCG as early as 7 10 days
3.) Home pregnancy kit do it yourself
4.
Baseline Data:
Vital Signs especially Blood Pressure
Monitor weight (increase weightt 1st sign preeclampsia), pattern of weight gain/
loss is
important
Weight Monitoring
First Trimester:
Second trimester:
Third trimester:
Normal Weight gain 1.5 3 lbs
Normal Weight gain 10 12 lbs
Normal Weight gain 10 12 lbs
Average weight gain 20 25 lbs
Optimal weight gain 25 35 lbs
( .5 1 lb/month )
(4 lbs/month) (1 lb/wk)
(4 lbs/ month) ( 1lb/wk)
5. Obstetrical Data:
a.
b.
nullipara no pregnancy
Gravida -number of pregnancies, 2 children G2
Para - number of viable pregnancies, 2 viable P2
Viability the ability of the fetus to live outside the uterus at the earliest po
ssible gestational age.
Age of Viability -20 24 weeks
Term -37 42 weeks
Preterm -20 37 weeks
Abortion < 20 weeks
Sample Cases:
a.
1 abortion G2T0P0A1L0
1 2nd month pregnant G2P0
b.
1 40th AOG G6T1P2 A 2L4
1 36th AOG G6 P3
2 miscarriage
1 twins 35th AOG
1 4th month pregnant
c.
1 39th week
1 miscarriage
1 stillbirth 33 AOG (considered as para) G4P2
1 pregnant 3rd wk G4T1P1A1L1
d.
1 33rd P
1 -41st L
1 abortion A
1 stillbirth 39th G6T2P2A1L5
1 - triplet 32nd G6P4
1 - 4th month pregnant
e.
1 39th AOG
1 miscarriage G4P1
1 stillbirth 33rd AOG G4T1P1A1L1
1 3rd month pregnant
f.
1 40th AOG
1 Abortion G4P2
1 twin 37th AOG G4T1P1A1L3
1 4th month pregnant
g.
1 38th AOG 1 Triplets 30th AOG
1 37th AOG 1 32nd AOG G6P5
1 Abortion 1 Stillbirth 42nd AOG G6T3P2A1L6
c.
Important Estimates:
1. Nagele s Rule used of determine expected date of delivery
January, February and March - +9+7 while
April to December - -3+7+1
Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP Jan Feb Mar
M D Y +9 +7 no year
Example: a. LMP January 03, 2005
01 03 05
+ 09 07___
10-10-05= Expected Date of Confinement October 10, 2005
b. LMP August 04, 2005
08 04 05
-03+07+01
05-11-06= EDC May 11, 2006
2.
McDonald s Rule used to determine age of gestation IN WEEKS
Get the length in cm x 7/8 = AOG in weeks
FUNDIC HT X 7/8=AOG in weeks
Fundic Ht X 7 = AOG in weeks
8
From symphysis pubis to fundus 24 X 7 =21 wks
8
1st ½ of preg
5 x 5 = 25 cm
6 x 5 = 30 cm
7 x 5 = 35 cm
2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
d. Tetanus Immunizations prevents tetanus neonatum
- mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3
TT1 any time during pregnancy
TT2 4 weeks after TT1 3 yrs protection
TT3 6 months after TT2 5 yrs protection
TT4 1 year after TT3 10 yrs protection
TT5 year after TT4 lifetime protection
Note: if the mother received 3 doses of DPT during childhood, she will be given
TT3.
5. Physical Examination: Cephalocaudal including the teeth
* Examine teeth: sign of infection
Danger signs of Pregnancy:
C - chills/ fever - infection
- Cerebral disturbances ( headache preeclampsia)
A abdominal pain ( epigastric pain) aura/alert of impending convulsions
B boardlike abdomen sign of abruption placenta
Increase BP HPN(hypertension)
Blurred vision pre eclampsia
Bleeding :
Result:
Class I - normal
Class IIA suggestive of inflammation
7.
Leopold s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting p
art, degree
of descent, an estimate of the size, and number of fetuses, position, fetal back
&
fetal heart tone; use palm! Warm palm.
Preparation for mothers:
1. Empty bladder
2.
Position of mom-supine with knee flex
(dorsal recumbent to relax abdominal muscles)
Procedure:
1st maneuver: Place patient in supine position with knees slightly flexed; Put t
owel under head
and right hip; With both hands palpate upper abdomen and fundus. Assess size, sh
ape,
movement and firmness of the part. In dorsal recumbent position to relax the abd
ominal
muscles. To determine presentation parts.
2nd Maneuver: with both hands moving down, identify the back of the fetus (to h
ear fetal heart
sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone
. Get Vital
Signs (before 2nd maneuver) Pulse Rate to differentiate fundic soufflé (Fetal He
art Rate) &
uterine soufflé (Maternal Heart Rate). To determine fetal back.
3rd Maneuver: using the right hand, grasp the symphysis pubis part using thumb
and fingers.
To determine degree of engagement. (Assess whether the presenting part is engage
d in the
pelvis ) Alert : if the head is engaged it will not be movable.
4th Maneuver: the Examiner changes the position by facing the patient s feet. Wit
h two hands,
assess the descent of the presenting part by locating the cephalic prominence or
brow.
When the brow is on the same side as the back, the head is extended. When the br
ow is on the
same side as the small parts, the head will be flexed and vertex presenting. To
determine
attitude relationship of fetus to 1 another.
Attitude refers to the relationship of fetus to each part into one another ( deg
ree of flexion )
Full flexion when the chin touches the chest
8.
Assessment of Fetal Well-Being-
A.
Daily Fetal Movement Counting (DFMC) begin 27 weeks
Mother - begin after meal breakfast
a. Cardiff count to 10 method one method currently available
(1)
Begin at the same time each day (usually in the morning, after breakfast) and co
unt
each fetal movement, noting how long it takes to count 10 fetal movements (FMs)
(2)
Expected findings 10 movements in 1 hour or less
(3)
Warning signs
a.) more than 1 hour to reach 10 movements
b.) less than 10 movements in 12 hours (non-reactive- fetal distress)
c.) longer time to reach 10 (FMs) fetal movements than on previous days
d.) movement are becoming weaker, less vigorous
* Movement alarm signals - < 3 FMs in 12 hours
(4.) Warning signs should be reported to healthcare provider immediately; often
require
further testing. Examples: non stress test (NST), biophysical profile (BPP)
b. Nonstress test to determine the response of the fetal heart rate to activity
Indication pregnancies at risk for placental insufficiency
Postmaturity
a.) Pregnancy Induced Hypertension (PIH), diabetes
b.) Warning signs noted during DFMC
c.) Maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler s position (w/ fetal
monitor);external monitor is applied to document fetal activity; mother activate
s the
mark button on the electronic monitor when she feels fetal movement.
Attach external noninvasive fetal monitors
1.
Tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
2.
Ultrasound Transducer over abdominal site where most distinct fetal heart sounds
are detected
3.
Monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light snack or gently
stimulate fetus through abdomen
if no FM after 1 hour further testing may be indicated, such as a CST
Result:
Noncreative
Nonstress
Not Good
Interpretation of results
i. Reactive Result
Reactive
Responsive is
Real Good
1.
Baseline FHR between 120 and 160 beats per minute
2.
At least two accelerations of the FHR of at least 15 beats per minute, lasting a
t
least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement
3.
Good variability normal irregularity of cardiac rhythm representing a balanced
interaction between the parasympathetic (decreases FHR) and sympathetic
(increase FHR) nervous system; noted as an uneven line on the rhythm strip.
4.
result indicates a healthy fetus with an intact nervous system
ii. Nonreactive Result
1.
Stated criteria for a reactive result are not met
2.
Could be indicative of a compromised fetus.
Requires further evaluation with another nonstress test NST, biophysical profile
,
(BPP) or Contraction Stress Test (CST)
9.
Health Teachings : do nutritional assessment
a. Nutrition daily food intake
High risk mothers:
1.
Pregnant teenagers very long compliance to health regimen.
2.
Extreme weight
Underweight: malnourished like elite model
Over weight : candidate for HPN, DM
3.
Mothers with low socio economic status refer to DSWD
4. Vegetarian mothers decrease CHON needs Vitamin B12/folic acid
cyanocobalamin formation of folic acid needed for cell DNA & RBC formation.
(Decrease folic acid spina bifida/open neural tube defect, meningocele umphaloce
le)
Types of Vegetarian:
1.
Strict Vegetarian vegetables only ( with rigid personality)
2.
Lactovegetarian vegetables/milk
3.
Lactoovovegetarian vegetables/milk/egg
How many calorie : CHO x 4, CHON x 4, FATS x 9
Daily Calorie Intake : Non Pregnant 2,200
Add - 300
Pregnant 2,500
During Lactation Add - 500
VIII. Recommended Nutrient Requirement that increases During Pregnancy
Nutrients Requirements Food Source
Calories
Essential to supply energy for
-increased metabolic rate
-utilization of nutrients
-protein sparing so it can be
used for
-Growth of fetus
-Development of structures
required for pregnancy
including placenta, amniotic
fluid, and tissue growth.
300 calories/day above the pre-
pregnancy daily requirement to
maintain ideal body weight and
meet energy requirement to
activity level
-Begin increase in second
trimester
-Use weight gain pattern as
an indication of adequacy of
calorie intake.
-Failure to meet caloric
requirements can lead to
ketosis as fat and protein are
used for energy; ketosis has
been associated with fetal
damage.
Caloric increase should reflect
-Foods of high nutrient value such as
protein, complex carbohydrates
(whole grains, vegetables, fruits)
-Variety of foods representing foods
sources for the nutrients requiring
during pregnancy
-No more than 30% fat
Protein
Essential for:
-Fetal tissue growth
-Maternal tissue growth
including uterus and breasts
-Development of essential
pregnancy structures
-Formation of red blood cells
and plasma proteins
* Inadequate protein intake has
been associated with onset of
pregnancy induces hypertension
(PIH)
60 mg/day or an increase of 10%
above daily requirements for age
group
Adolescents have a higher protein
requirement then mature women
since adolescents must supply
protein for their own growth as
well as protein t meet the
pregnancy requirement
Protein increase should reflect
-Lean meat, poultry, fish
-Eggs, cheese, milk
-Dried beans, lentils, nuts
-Whole grins
* vegetarians must take note of the
amino acid content of CHON foods
consumed to ensure ingestion of
sufficient quantities of all amino acids
Calcium-Phosphorous
Essential for
-Growth and development
of fetal skeleton and tooth
buds
-Maintenance of
mineralization of maternal
bones and teeth
-Current research is :
Demonstrating an association
between adequate calcium intake
Calcium increases of
-1200 mg/day representing an
increase of 50% above pre-
pregnancy daily requirement.
-1600 mg/day is recommended
for the adolescent. 10
mcg/day of vitamin D is
required since it enhances
absorption of both calcium
and phosphorous
Calcium increases should reflect:
-dairy products : milk, yogurt, ice
cream, cheese, egg yolk
-whole grains, tofu
-green leafy vegetables
-canned salmon & sardines w/ bones
-Ca fortified foods such as orange
juice
-Vitamin D sources: fortified milk,
margarine, egg yolk, butter, liver,
seafood
and the prevention of pregnancy
induce hypertension
Iron
Essential for
-Expansion of blood volume
and red blood cells formation
-Establishment of fetal iron
stores for first few months of
life
30 mg/day representing a
doubling of the pregnant daily
requirement
-Begin supplementation at 30mg/
day in second trimester,
since diet alone is unable to
meet pregnancy requirement
-60 120 mg/day along with
copper and zinc
supplementation for women
who have low hemoglobin
values prior to pregnancy or
who have iron deficiency
anemia.
-70 mg/day of vitamin C
which enhances iron
absorption
-inadequate iron intake results
in maternal effects anemia
depletion of iron stores,
decreased energy and
appetite, cardiac stress
especially labor and birth
-fetal effects decreased
availability of oxygen thereby
affecting fetal growth
* iron deficiency anemia is the
most common nutritional
disorder of pregnancy.
Iron increases should reflect
-liver, red meat, fish, poultry,
eggs
-enriched, whole grain cereals
and breads
-dark green leafy vegetables,
legumes
-nuts, dried fruits
-vitamin C sources: citrus fruits
& juices, strawberries,
cantaloupe, broccoli or
cabbage, potatoes
-iron from food sources is more
readily absorbed when served
with foods high in Vitamin C
Zinc
Essential for
* the formation of enzymes
* may be important in the
prevention of congenital
malformation of the fetus.
15 mcg/day representing an
increase of 3 mg/day over pre-
pregnant daily requirements.
Zinc increases should reflect
-liver, meats
-shell fish
-eggs, milk, cheese
-whole grains, legumes, nuts
Folic Acid, Folacin, Folate
Essential for
-formation of red blood
cells and prevention of
anemia
-DNA synthesis and cell
formation; may play a
role in the prevention of
neutral tube defects
(spina bifida), abortion,
abruption placenta
400 mcg/day representing an
increase of more then 2 times the
daily pre-pregnant requirement.
300mcg/day supplement for
women with low folate levels or
dietary deficiency
4 servings of grains/day
Increases should reflect
-liver, kidney, lean beef, veal
-dark green leafy vegetables,
broccoli, legumes.
-Whole grains, peanuts
Additional Requirements
Minerals
Increased requirements of pregnancy
can easily be met with a balanced diet
-iodine
-Magnesium
-Selenium
175 mcg/day
320 mg/day
65 mcg/day
that meets the requirement for calories
and includes food sources high in the
other nutrients needed during
pregnancy.
Vitamins
E
Thiamine
Riboflavin
Pyridoxine ( B6)
B12
Niacin
10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day
Vitamin stored in body. Taking it not
needed fat soluble vitamins. Hard to
excrete.
Vitamin A,D,E,K - - - No need to take it daily ( FAT SOLUBLE )
2. Sexual Activity
should be done in moderation
should be done in private place
that the mother should be placed in comfortable position; sidelying or mother on
top
it must be avoided 6 weeks prior to Expected Date of Delivery
avoid blowing or air during cunnilingus to prevent air embolism
changes in sexual desire of mom during pregnancy
a.) 1st trimester decrease desire due to bodily changes
b.) 2nd trimester increased desire due to increase estrogen that enhances
lubrication
c.) 3rd trimester decreased desire due to bodily changes
Contraindication in sex:
1. vaginal spotting
1st trimester
threatened abortion
2nd trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane prone to infection
Exercise to strengthen muscles that will be used during delivery process
- it must be done in moderation
principles of exercise
- it must be individualized case to case basis
* Walking best exercise
* Squatting strengthen muscles of perineum and increase circulation to perineum.
Done
feet flat on floor
* Tailor Sitting same with squatting done by placing one leg in front of other l
eg ( Indian seat)
Raise buttocks 1st before head to prevent postural hypotension dizziness when
changing position
* Shoulder Circling Exercise to strengthen chest muscles
* Pelvic Rocking/Pelvic Tilt Exercise to relieve low back pain & maintain good p
osture
- can be used to Lordosis
* Arch Back standing or kneeling. Four extremities on floor
* Kegel Exercise to strengthen pubococcygeal muscles
-as if hold urine, release 10x or muscle contraction
* Abdominal Exercise to strengthen the muscles of the abdomen
done as if blowing candle
4.
Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting
wellness behavior
that can be used by parents and family thus, helping them achieved a satisfying
and
enjoying childbirth experience.
a.
Psychophysical
1. Bradley Method discovered by Dr. Robert Bradley , advocated active participat
ion of
husband during delivery process to serve as a coach. Based on imitation
of nature.
Features:
1.) darkened room
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method that fear leads to tension while tension leads to pa
in
-
to remove fear by relaxation technique and abdominal
exercises
b. Psychosexual
1. Kitzinger Method discovered by Dr. Shiela Kitzinger , that pregnancy, labor,
birth & the
care of the newborn is an important turning point in a woman s life
cycle
-
for a mother to achieve the satisfying childbirth experiences, flow with
contraction rather than struggling with contraction
c. Psychoprophylaxis prevention of pain
1.
Lamaze discovered by Dr. Ferdinand Lamaze
- prevention of pain in the brain
Features: discipline, conditioning & concentration with the help of the Husband
1. Conscious relaxation
2. Cleansing breathe inhaling through the nose and exhaling through the mouth
3. Effleurage gentle circular massage over abdomen to relieve pain
4. Imaging sensate focus
5.
Different Methods of delivery:
1.) Birthing Chair bed convertible to chair semifowlers position
2.) Birthing Bed dorsal recumbent position
3.) Squatting Position position that facilitates descent and relieves low back p
ain during labor pain
4.) Leboyers Method features: warm, quiet, darkened room, calm and comfortable e
nvironment,
room temperature, soft music.
- After delivery, baby gets warm bath.
5.) Birth Under Water warm water in a bathtub labor & delivery warm water, soft
music.
-After delivery the baby should be kept warmth, prepare for bathing
IX. Intrapartal Notes inside Emergency Room
A. Admitting the laboring Mother:
*
Personal Data: name, age, address, etc
*
Baseline Data: v/s especially BP, weight
* Obstetrical Data: gravida # pregnancy, para- viable pregnancy 22 24 weeks
* Physical Examination
* Pelvic Examination
B. Basic knowledge in Intrapartum.
b. 1 Theories of the Onset of Labor
1.) Uterine Stretch Theory -any hollow organ once stretched to its maximum poten
tial
will always contract & expel its content
contraction action
2.) Oxytocin Theory posterior pituitary gland releases oxytocin that produce by
hypothalamus.
3.) Prostaglandin Theory stimulation of Arachidonic Acid which causes contractio
n to the
onset of labor.
prostaglandin male
4.) Progesterone Theory before labor, decrease progesterone will stimulate contr
actions
and labor
5.) Theory of Aging Placenta lifespan of placenta is 42 weeks. By 36 weeks the p
lacenta
is beginning to degenerate hence causes the uterus to
contract to the onset of labor.
b.2. The 4 P s of Labor
1. Passenger - FETUS
a. Fetal head is the largest and common presenting part comprises of ¼ of its le
ngth.
Bones 6 fetal bones ( in all = 8 bones )
S sphenoid
F frontal - sinciput
E ethmoid
O occuputal - occiput
T temporal
P parietal 2 x
Important Measurement fetal head:
1. Transverse Diameter
Biparietal largest transverse 9.25cm
Bitemporal - 8 cm
Bimastoid - 7cm smallest transverse
2. Anterior Posterior Diameter (AP )
Suboccipitobregmatic from occiput to bregmatic ( smallest AP diameter)
- complete flexion
Occipito Frontal 12 cm partial flexion
Occipito Mental 13.5 cm hyperflexion ( largest AP )
Submentobregmatic ( face presentation )
Sutures intermembranous spaces that allow molding.
a) Sagittal Suture connects 2 parietal bones ( sagitna )
b) Coronal Suture connect parietal & frontal bone ( crown )
c) Lambdoidal Suture connects occipital & parietal bone
Moldings: the overlapping of the sutures of the skull to permit passage of the
Nursing Care:
1.
Encourage walking - to shorten the 1st stage of labor
32
2. Encourage to void every 2 3 hours full bladder inhibit uterine contractions
3. Breathing chest breathing
Active Phase: ( Mother feels losing control of herself )
Assessment: Dilatations: 4 - 8 cm
Intensity: moderate
Frequency : every 3 - 5 minutes lasting for 30 60 seconds
Nursing Care:
M medications have medicines ready
A assessment include: vital signs, cervical dilatation and effacement, fetal mon
itoring, etc.
D dry lips oral care (ointment)
* Pelvic Exams
Effacement: softening & thinning of cervix.
Dilatation: - widening of cervix.
a.
Station relationship of the presenting part to the ischial spine
landmark used: ischial spine
Floating negative station
-1 station = presenting part 1cm above ischial spine if (-) floating
-2 station = presenting part 2 cm above ischial spine if (-) floating
-0 station = level at ischial spine engagement
+ 1 station = below 1 cm ischial spine
+3 ,+4, +5 = crowning occurs at 2nd stage of labor
b.
Presentation/lie the relationship of the long axis (spine) of the fetus to the
long axis of the mother - spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
Cephalic - Vertex when the fetus is completely flex
Face
Brow
Poor Flexion
Chin
Breech -Complete Breech thigh rest on abdomen, while leg rest on thigh
Incomplete Breech
Frank thigh rest on abdomen while leg rest on the head
Footling presenting part foot : single, double
Kneeling presenting part - knees
b.2. Transverse Lie (Perpendicular) or Perpendicular lie.
-Shoulder presentation is very rare 1 %
c.
Position relationship of the fatal presenting part to specific quadrant of the
mother s pelvis.
Variety:
Occipito/ Occiput
LOA left occipito anterior (most common and favorable position)
Mom has Headache check BP, if same BP, let mom rest.
If BP increases, notify MD preeclampsia
· Hungry mother NPO - no meals GI is not functioning thus to prevent aspiration
· Bathe mother can bathe after the delivery
Enema optimum rectal tube 12 - 18 inches
a.) To cleanse bowel
b.) Prevent infection
c.) Sims position/side lying
Constipated mother slowly pulling the rectal tube
* During insertion of rectal tube contraction clamp after insertion
check the FHT after administration of enema
Normal FHT = 120-160 bpm
inserting 2 fingers.
Nursing Care:
c.
Lochia vaginal discharges after the delivery process
Rubra red, 1 - 3 days moderate
Serosa pink to brown, 4 9 days , decrease in amount, with musty odor
Alba creamy white, 10 days 3 weeks
d.
Perineum check the perineum for :
R - redness
E-edema
E - ecchymosis
D discharges
A approximation of blood loss.
* Count pad & saturation
* Fully soaked pad : 30 40 cc weigh pad. 1 gram = 1cc
e.
Bonding interaction between mother and newborn
Types of rooming:
1.) Strict rooming: 24 hours - baby stays with mother.
2.) Partial rooming in: baby stays with mother in the morning
and stays in the nursery at night .
Complications of Labor
Dystocia difficult labor related to mechanical factor
due to uterine inertia which means sluggishness of contraction
2 Types of uterine inertia:
1.) hypertonic or primary uterine inertia - intense excessive contractions
resulting to ineffective pushing
Management: sedation MD administer sedative
Valium/Diazepam muscle relaxant
2.) hypotonic secondary uterine inertia, slow irregular contraction
resulting to ineffective pushing.
Management: Administer Oxytocin
Inversion of the Uterus uterus is turned inside out due to the following factors
:
a.
hurrying pull out of the placenta
b.
ineffective fundal pressure
c. short cord
Management: MD will push uterus back inside or not hysterectomy.
Uterine Rupture Possible causes:
1.) Previous classical Cesarean Section
2.) Large baby
3.) Improper use of oxytocin (IV drip)
Symptoms:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Note:
Physiologic Retraction boundary between upper and lower uterine segment
Suprapubic Depression sign of impending rupture of the uterus
Bandl s Pathologic Ring bleeding that leads to hypovolemic to TABHBSO
Pre Term Labor labor after 24 weeks before the 37th week
Triad of Preterm Symptoms:
1. Premature contractions every 10 minutes
2. Effacement of 60 80 %
3. Dilatation of 2 - 3 cm
Home Management:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 - 4 glasses of water full bladder inhibits contractions
5. consult MD if symptoms persist
Hospital Management:
If cervix is closed (2 3 cm), dilation saved by administer
Tocolytic agents- to halts the preterm contractions of the uterus.
(YUTOPAR - Yutopar Hcl) 150 mg incorporated 500 cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - < 90/60
Crackles notify MD
Pulmonary edema administer oral yutopar 30 minutes before d/c IV
PreTerm: Magnesium Sulfate
1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid
d. Lochia - bld, wbc, deciduas, microorganism. NSD & C/S with lochia.
1. Ruba red 1st 3 days present, musty/mousy, moderate amount
2. Serosa pink to brown 4 9th day, limited amount
3. Alba creamy white 10 21 days very decreased amount
a.3. Urinary tract:
Bladder
Frequency in urination after delivery (postpartum)
- urinary retention with overflow
Dysuria trigone of bladder
Nursing Action:
- urine collection
- alternate warm & cold compress
- stimulate bladder
Colon:Constipation due to NPO, fear of bearing down; episiotomy
Perineal area: painful episiotomy site
Position: Sim s position
Cold compress for immediate pain after 24 hours,
Hot sitz bath, Hot compress for immediate pain after 24 hours
Sex Act - when perineum has healed
Classifications:
a.
Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is
closed; can give progesterone
b.
Inevitable moderate bleeding, cramping, tissue protrudes form the cervix
(Cervical dilation) cervix is open
Types:
b.1. Complete all products of conception are expelled.
Nursing Management: no need for D & C, just emotional support!
b.2 Incomplete Placenta and membranes retained.
Management:
for D& C
b.3
Habitual 3 or more consecutive pregnancies result in abortion usually
related to incompetent cervix. Present 2nd trimester
Incompetent cervix abortion
Surgery: a. McDonalds procedure temporary circlage on cervix
* During delivery, circlage is removed. NSD
Side Effects: infection.
b. Shirodkar permanent surgery on cervix. CS
b.4
Missed fetus dies; product of conception remain in uterus 4 weeks or
longer; signs of pregnancy cease. (-) pregnancy test, scanty, dark
brown bleeding
Management:
induced labor with oxytocin or vacuum extraction
c.
Induced Abortion therapeutic abortion to save life of mother based on the
principles of twofolds effect - choose between lesser evil.
Ectopic Pregnancy occurs when gestation is located outside the uterine cavity.
Common site : tubal or ampular
Dangerous site : interstitial
Unruptured Tubal rupture
o
missed period
o
abdominal pain within 3 -5 weeks of missed
period (maybe generalized or one sided)
o
scant, dark brown, vaginal bleeding
o
vague discomfort
o
sudden , sharp, severe pain.
Unilateral radiating to shoulder.
o
shoulder pain (indicative of intraperitoneal
bleeding that extends to diaphragm and phrenic
nerve)
o
+ Cullen s Sign bluish tinged umbilicus
signifies intra peritoneal bleeding
o
syncope (fainting)
Nursing Care: Surgery:
. Vital Signs * Fallopian - Salphingectomy
. Administer IV fluids * Abdominal - Exploratory Laparotomy
. Monitor for vaginal bleeding * Uterus - Hysterectomy
. Monitor I and O
Second trimester bleeding small and incompetent cervix
Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with ferti
lization.
-Progressive degeneration of chorionic villi. Recurs.
-Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
-This neoplasm is formed form the selling of the chronic villi and lost nucleus
of the
fertilized egg.
-The nucleus of the sperm duplicates, producing a diploid number 46 XX
-It grows & enlarges the uterus vary rapidly. ( progressive degeneration of cori
onic villi )
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs -vesicles passed thru the vagina
-Hyperemesis gravidarium due to increase HCG
-Fundal height
-Vaginal bleeding ( scant or profuse)
Early in pregnancy -High levels of HCG
-Pre eclampsia at about 12 weeks
Abruptio Placenta -it is the premature separation of the placenta form the impla
ntation site.
-It usually occurs after the twentieth week of pregnancy.
· (due to use of cocaine ) PIH
Assessment:
. dark red, painful bleeding
. board like or rigid uterus/abdomen
. Concealed bleeding/hemorrhage (retroplacental)
. Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus
to
contract due to hemorrhage.
. Severe abdominal pain
. Dropping coagulation factor (a potential for DIC)
Complications:
. Sudden fetal blood loss
. placenta previa & vasa previa
.
Epigastric Pain
CONVULSION
II. Transissional Hypertension HPN between 20 24 weeks
III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks
post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver ed
ema
and oliguria usually indicates an impending convulsion. BP 160/110, protenuria
+3 - +4
3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety.
Cause of pre eclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia large for gestational age
Heart disease
Mothers with RHD at childhood
Class I no limitation of physical activity
Class II slight limitation of physical activity.