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

5.1Corpus (body)- upper portion with a triangular part called fundus

5.2Isthmus – area between corpus and cervix which forms part of the lower uterine
segment

5.3Cervix – 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:

2.1Inlet – 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.

2.2Cavity – 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.
 2.3Outlet – 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

5.1Amenorrhea – temporary cessation of menstrual flow.

5.2Oligomenorrhea – markedly diminished menstrual flow, nearing amenorrhea

5.3Menorrhagia – excessive bleeding during regular menstruation.

 5.4Metrorhagia – bleeding at completely irregular intervals.

5.5Polymenorrhea – frequent menstruation occurring at intervals of less than 3

weeks.

5.6Oligomenorrhea – markedly diminished menstrual flow.

6. Body structures involved

6.1Hypothalamus

6.2Anterior pituitary gland

6.3Ovary

6.4Uterus

7. Hormones which regulate cyclic activities

7.1Follicle-stimulating hormone (FSH)

7.2Luteinizing hormone (LH)

8. Effects of estrogen in the body

8.1Inhibits production of FSH

8.2Causes hypertrophy of the myometrium

8.3Stimulates growth of the ductile structures of the breasts.

8.4Increases 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

9.1Inhibits production of LH

9.2Increases endomentrial tortuosity

9.3Increases endometrial secretions

9.4Inhibits uterine motility

9.5Decreases muscle tone of gastrointestinal and urinary tracts

 9.6Increases musculoskeletal motility

9.7Facilitates transport of the fertilized ovum through the Fallopian tubes

9.8Decreases renal threshold of lactose and dextrose

9.9Increases 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 14 th 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
post-ovulatory 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 14 th 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 includes
individual, achievement of personal independence and maturation of cognitive
reasoning skills.

C. Thelarche – budding of the breasts

 D. Adrenarche – development of axillary and pubic hair

II. SEXUAL DEVELOPMENT (Table 1)

Criteria Males Females

1. Start of growth spurt Around 13 years old After onset of menses,

around 10-12 years old

2. Growth rate Rapid early growth Sharp decrease after

menses occur

3. Growth cessation Early cessation 1-2 years after onset of

menses

4. Order of sexual 6 months later than 6 months earlier than

maturation females Completed in 5 males
years
Completed in 3 years
4.1 Darkening and
thinning of scrotum 4.1 Breast budding -
and enlargement of first visible sign
testes and scrotum – 4.2 Increased size of
first visible sign pelvis
4.2 Appearance of body 4.3 Appearance of body
hair hair
4.2.1 Pubic area 4.3.1 Pubic area
4.2.2 Axilla 4.3.2 Axilla
4.2.3 Upper lip 4.4 Menstruation
4.2.4 Face 4.5 Ovulation
4.3 Penis grows,
enlarges

4.4 Nocturnal emissions

(wet dreams) - male
 counterpart of
menstruation

4.5 Spermatogenesis

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 Males Females

I Childhood size of penis, testes, Prepubertal, no breast

scrotum tissue

II Enlargement of testes and scrotum Appearance of breast bud

III Lengthening of the penis Enlargement of the breasts

and areola
Further enlargement of testes and
scrotum

Deepening pigmentation of scrotal

skin

IV Widening and further lengthening Areola and nipple form a

of penis mound atop underlying
breast tissues
 Further enlargement of testes and
scrotum

Deepening pigmentation of scrotal

skin

V Adult configuration and size of Adult configuration and

genitalia size of genitalia

Areola and breasts have

smooth contour

Table 2. Tanner Stages of Pubertal Development: Thelarche & Genitalia

Stages Males Females

I Prepubertal, no pubic hair - same -

II Sparse, downy hair at the base of At the medial aspect of the

the phallus labia majora

III Darkening, coarsening, curling of - same -

hair which extend upward and
laterally

IV Hair of adult consistency limited - same -

to the mons pubis

V Hair spreads to the medial aspect - same -

of the thighs

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 X-carrying 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

B. From 15th day up to the 8th week = embryo

C. From 8th week up to the time of birth = fetus

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
trimester of pregnancy.
B. Syncytial layer – gives rise to 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

2. Chorion – together with the deciduas basalis, gives rise to the placenta, which
  Estrogen and Progesterone

2.6 Protective barrier – inhibits the passage of same bacteria and large
molecules

Table 4. Outline of Trophoblast Differentiation

IV. FETAL DEVELOPMENT

A. First Lunar Month

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. Third Lunar Month

1. Kidneys are able to function – urine is formed by the 12th week.

2. Buds of milk teeth form

3. Beginning bone ossification

4. fetus swallows amniotic fluid

5. Feto-placental circulation is established by selective osmosis; no direct exchange between

fetal and maternal blood.

D. Fourth Lunar Month

1. Lanugo appears

2. Buds of permanent teeth form

3. Heart beats maybe audible with fetoscope

E. Fifth Lunar Month

1. Vernix caseosa appears

2. Lanugo covers entire body

3. Quickening (fetal movements) felt

4. 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. Eighth Lunar Month

1. Fetus is viable

2. Lanugo begins to disappear

3. Nails extend to ends of fingers

4. 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 Increse exercise

 2.3.4 Avoid enemas

2.3.5 Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are
better

2.3.6 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 7lbs.
Placenta 1 lb.
Amniotic fluid 1 ½ lbs.
Increased weight of uterus 2 lbs.
Increased weight of the breasts 1/1 – 3 lbs.
Weight of additional fluid 2 lbs.
Fat and fluid accumulation 4-6 lbs.
Characteristics of pregnancy
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 poorly-controlled 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 Presumptive Probable Positive

First Trimester Amenorrhea Chadwick’s sign Ultrasound

evidence
Morning sickness Goodell’s sign

Breast changes Hegar’s sign

Urinary Positive HCG

frequency
Elevation of BBT
Enlarging uterus

Second Trimester Quickening Enlarged Fetal heart tones

abdomen
Skin Fetal movements
pigmentation Braxton Hicks felt by examiner
(chloasma and
Ballotement Fetal outline on
 linea nigra) x-ray

Striae
gravidarum

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

 2.1 Gravida – number of pregnancies a woman has had.

2.2 Para – number of viable pregnancies, regardless of number and outcome

2.3 TPAL score (_ _ _ _) number of full term babies (T, premature (P) babies,
abortion (A), living children (L)

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?

2.5 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)?
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)

2.1 Internal exam (IE) to determine Hegar’s, Chadwick’s, and Goodell’s

2.2 Ballotement – fetus will bounce when lower uterine segment is tapped
sharply (on 5th month of pregnancy)

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

2.2.4 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)
 2.3 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

2.5 Urine examinations

2.5.1 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

2.5.2 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.

2.5.3 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 Non-Pregnant Pregnant

Women

Calories (kcal) 2000 +300-400

Proteins (Gm) 46 +30

Vitamin A (IU) 4000 +1000

Vitamin D (IU) 400 +0

Vitamin E (IU) 12 +3

Ascorbic acid/Vitamin C 45 +15

(mg)
400 +400
Folic acid (mg)
13 +2
Niacin (mg)
1.2 +0.3
Riboflavin (mg)
1.0 +0.3
Thiamine (mg)
3.0 +1.0
Vitamin B12 (ug)
2.0 +0.5
Vitamin B6 (mg)
800 +400
Calcium (mg)
800 +400
Phosphorus (mg)
100 +25
Iodine (ug)
18 +18
Iron (mg)
300 +150
Magnesium (mg)

Active Non-Pregnant
Food Pregnant Women
Women

Meat 2 servings of meat, fowl 2-3 servings of meat,

or fish/day; 3-5 fowl or fish/day; 1
eggs/week egg/day

Vegetables specially 1 serving/day (at least 1 serving/day

dark green and deep 3/week)
yellow

Fruits: Citrus and others 2 or more servings/day 2-3 servings/day

Breads 1 serving/day 1 servings/day

Milk 4 or more servings/day 4 servings/day

Additional fluid 1 pint (6-8 oz. glasses 1 quart (2-6

/day) 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 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.

4.5.3 Counsel the couple to look for more comfortable positions. Definitely, the
missionary (man-on-top) position is not advisable

4.5.4 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 stimulus-response

conditioning. To be effective, full concentration on breathing exercises
during labor should be observed (Implication: Nurse should not interrupt
the couple doing breathing exercises.)

4.10Tetanus 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.

4.11Clinic 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. Sphenoid

2. Ethmoid

3. Temporal

4. Frontal

5. Occipital

6. 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. increase in urinary frequency

2. relief of abdominal tightness and diaphragmatic pressure

3. shooting pains down the legs because of pressure on the sciatic nerve

4. 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 TRUE LABOR PAINS

1. Remain irregular 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
2. Generally confined to the in a girdle-like fashion.
abdomen
5. Increase in duration, frequency
and intensity.
3. No increase in duration, 6. Continue no matter what the
frequency and intensity woman;s level of activity is.
4. Often disappears if the women 7. Accompanied by cervical
ambulates effacement and dilatation (the
5. Absent cervical changes 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.1Hospital admission – provide privacy and reassurance from the very start

III.1.1Personal data – name, age, address, civil status

III.1.2Obstetrical data – determine EDC; obstetrical score (gravida, para, TPAL);

amount and character of show; and whether or not membranes have ruptured.

III.2General physical examination, internal exam and Leopold’s maneuvers are done to
determine:

III.2.1Effacement and dilatation

III.2.2Station – 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.2.3Presentation – 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

3.3Monitoring 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 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)

3.3.3 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

3.4Emotional 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.

3.5.10Abdominal breathing – advised for contractions during the first stage in order
to reduce tension and prevent hyperventilation

FIGURE 16. Supine Hypotensive Syndrome

3.6Administer 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

3.7Assist 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

3.8A 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

1.1If 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

1.2Show becomes more prominent.

1.3There 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.

1.4Nausea and vomiting is a reflex reaction due to decreased gastric motility and
absorption.

1.5In primis, baby is delivered with 20 contractions (40 minutes); in multis, after 10
contractions (20 minutes).

2. Nursing actions are primarily comfort measures

2.1Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves
discomfort from contractions

2.2Proper bearing down techniques: push with contractions

2.3Controlled chest (costal) breathing during contractions

2.4Emotional 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)

3.1Descent – may be preceded by engagement.

3.2Flexion- as descent occurs, pressure from the pelvic floor causes the chin to bend
forward onto the chest.

3.3Internal Rotation – from AP to transverse, the AP to AP

3.4Extension – 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.

3.5External Rotation (also called restitution) – anterior shoulder rotates externally to the
AP position.

3.6Expulsion – delivery of the rest of the body.

3. Nursing Care

3.1When positioning legs on lithotomy, put them up at the same time to prevent injury
to the uterine ligaments

3.2As 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.

3.3Assist 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

3.4Apply 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

3.5Immediately 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
 3.6The 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.

3.7Wrap the baby in a sterile towel to keep him warm. Remember: Chilling increase the
body’s need for oxygen

3.8Put the baby on the mother’s abdomen. The weight of the baby will help contract
the uterus.

3.9Cutting 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

1.1Uterus becoming round and firm again, rising high to the level of the umbilicus
(Calkin’s sign) – the earliest sign of placental separation

1.2Sudden gush of blood from the vagina

1.3Lengthening of the cord

2. Types of placental delivery

2.1Schultz – 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.

2.2Duncan – 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
3.1Do 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.

3.2Tract 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.

3.3Take 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.

3.4Inspect for completeness of cotyledons; any placental fragment retained can also
cause severe bleeding and possible death.

3.5Palpate 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.

3.6Inject 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.

3.7Inspect 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.K May 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

1.1Fundus – 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.

1.2Lochia – 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.

1.3Bladder – 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.

1.4Perineum – is normally tender, discolored and edematous. It should be clean, with

intact sutures.
 1.5Blood 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

1.1The 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.

1.2While blood cell (WBC) count increases to 20,000 – 30,000/mm 3. implication: the
WBC count, therefore, cannot be used as a indicationor sign of postpartum
infection
 1.3Thre 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

2.1Kegal and abdominal breathing on postpartum day one (PPD1).

2.2Chin – to – chest – on PPD2 to tighten and firm up abdominal muscles

2.3Knee – to – abdomen – when perineum has healed, to strengthen abdominal and

gluteal muscles.

1.3.3 Massage is contraindicated

1.4All blood values are back to prenatal levels by the 3rd or 4th week postpartum

2. Genital Changes

2.1Uterine 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.

2.2To encourage the return of the uterus to its usual anteflexed position, prone and
knee chest positions are advised.

2.3Afterpains/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

2.4Lochia – 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

2.5Pain 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

2.6Sexual 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.

2.7Menstruation – 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).

2.8Postpartum check – up – should be done after the 6th week postpartum to assess
involution.

3. Urinary Changes

3.1There is marked diuresis within 12 hours postpartum to eliminate excess tissue

fluid accumulation during pregnancy.

3.2Some 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:

4.1Decreased muscle tone

4.2Lack of food + enema during labor

4.3Dehydration

4.4Fear of pain from perineal tenderness due to episotomy, lacerations or hemorroids

5. Vital Signs

5.1Temperature 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.
 5.2Bradycardia (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

1.1Regardless of the mother’s physical condition, method of delivery, or breast

size/condition, milk will be produced.

1.2Lactation does not occur during pregnancy because estrogen and progesterone are
present and therefore inhibit prolactin production.

1.3Lactation – suppressing agents are to be given immediately after placental delivery

to be effective.

1.4Oral contraceptives are contraindicated in lactating mother because they contain

estrogen and progesterone, thereby decreasing milk supply.

1.5Afterpains are felt more by breastfeeding women because of oxytocin production;

they also have less lochia and experience more rapid involution.

1.6In 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

2.1For 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

2.2For 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

3.1Hygiene

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.

3.2.2 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.

3.3 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 5th day of the menstrual cycle,
after which it is discontinued and then resumed on the 5 th 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

 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

1.2.1 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.

1.2.2 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
 1.2.3 Condom

 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.

1.3 Chemical methods – are spermicidals (kill sperms) E.g., jellies, creams,
foaming tablet, and suppositories.

1.4 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.)

2. Natural

2.1 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 32

18 11
 8 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 Exogenous sources – pathogens introduced from external sources. (Most

common is anaerobic streptococci). Common exogenous sources:

1.2.1 Hospital personnel

1.2.2 Excessive obstetric manipulations

1.2.3 Breaks in aseptic techniques – faulty handwashing, unsterile

equipments and supplies

1.2.4 Coitus in late pregnancy

1.2.5 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 24 th 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 oligo-hydramios

 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

week of gestation

A. Preeclampsia

1. Mile

2. Severe

B. Eclampsia

II. Chronic hypertension with pregnancy

III. Unclassified
 Table 14. Classification of Toxemia

PERIPHERAL ARTERIOLAR VASOCONSTRICTION

Blood supply & oxygen HYPERTENSION

perfusion to vital

KIDNEYS LIVER PLACENTA

Glomerular Glomerular Tissue ischemia Tissue

degeneration Filtiration ischemia

Glomerular permebility Tubular Vascular

reabsorption stasis
of sodium
release
Albumin& globulin Water retention Epigastric thromboplasti
cross pain n
into the urine like
substances
PROTEINU
RIA EDEMA OLIGURI
A Premature
placental
Fluid diffuses from deterioration
circulatory system to Fetal Abruptio
extracellular spaces nutrient placenta
Generalized
water
retention
LUNGS BRAIN

Fetal
Distress
Pulmonary cyanosis Cerebral hypoxia
edema edema
Premature
Labor and
CHF Cerebral Delivery
irritability

1.1.2 Generalized vasoconstriction

CONVULSIO and associated microangiopathy
NS
disease of capillaries

1.1.3 Abnormal retention of sodium and water by body tissues

1.2 Medical complications

1.2.1 Cerebrovascular hemorrhage

 1.2.2 Acute pulmonary edema

1.2.3 Acute renal failure

1.3 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

 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.
 6.2 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

V. 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.

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

VI. 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 Inappropriate use of analgesics

1.2 Pelvic bone contraction

1.3 Poor fetal position

1.4 Overdistention – due to multiparity, multiple pregnancy, polyhydramnios

or excessively large baby

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.

B. 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.

C. 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

D. 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

E. 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 2 nd
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

1.110 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

1.2Amniotomy will be done when cervical dilatation reaches 4 cm. Check

FHR and quality of fluid after amniotomy

1.3Nurisng 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.