Ob Penta Notes
Ob Penta Notes
I. Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes, emotions and preferences
that are related to sexual self and eroticism.
2. Sex – is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:
Gender identity – sense of femininity or masculinity
2 - 4 years / 3 years gender identity develops.
Role identity – attitudes, behaviors and attributes that differentiate roles.
Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as
sexual intercourse.
Sexuality - behavior of being boy or girl, male or female; man or woman.
- It is an entity subject to a life long dynamic change.
- developed at the moment of conception.
II. Sexual Anatomy and Physiology
A. Female Reproductive System
1. External - vulva or pudendum
a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by
skin and at puberty covered by short pubic hair that serves as cushion or protection to the
symphysis pubis and surrounding delicate tissues from trauma.
Tannerscale - tool used to determine sexual maturity rating.
Stages of Pubic Hair Development
Stage 1 – Pre-adolescence - No pubic hair except for fine body hair only
Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly
hair along the labia .
Stage 3 - occurs between ages 12 and 13 – hair becomes darker & curly hair that
develops along symphysis pubis.
Stage 4 – occurs between ages 13 and 14. Hair assumes the normal appearance of
an adult but is not so thick and does no appear to the inner aspect of the
upper thigh.
Stage 5 - sexual maturity - normal adult - appear to the inner aspect of thigh.
b. Labia Majora – means “large lips” - a longitudinal fold, that extends from the symphysis
pubis to the perineum; Two folds of skin with fat underneath; contain Bartholene’s glands
c. Labia Minora – means “nymphae” – a soft and thin longitudinal fold that is located in
between the labia majora; two thin folds of delicate tissues; form an upper fold encircling
the clitoris called the prepuce and unite posteriorly called the fourchette.
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2 sensitive structures of labia minora:
c.1. clitoris – means “key”- anterior, pea shaped erectile tissue composed of so many
nerve endings which is the sight of sexual arousal in female. (Greek-key)
c.2. fourchette - Posterior, tapers posteriorly of the labia minora
- very sensitive to manipulation, oftenly torn during vaginal delivery.
- common site – episiotomy.
d. Vestibule – an almond shaped, narrow space area seen when the labia minora are separated,
that contains the hymen, vaginal orifice and bartholene’s glands.
i. Urinary Meatus – small opening of urethra that serves for urination; external opening of
the urethra; slightly behind and to the side are the openings of the Skene’s Glands.
ii. Skenes Glands/or Paraurethral Gland – two small mucous secreting substances that
serve for lubrication; often involved in infections of the external genitalia.
iii. Hymen – a membranous tissue that covers vaginal orifice, membranous tissue
* Carumculae mystiforms - healing of a torn hymen
iv. Vaginal Orifice – external opening of vagina
v. Bartholene’s Glands/or Paravaginal Gland or Vulvo Gland - 2 small mucus secreting
substance that secrets alkaline substances- responsible for the acidity of the vagina.
( Believed to secrete a yellowish mucous which acts as a lubricant during sexual
intercourse. The openings are located posteriorly on either side of the vaginal orifice)
Alkaline – neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus – responsible for acidity of vagina
e. Perineum – a muscular structure that is located in between the lower vagina & anus;
contains muscles which support the pelvic organs, the arteries that supply blood and the
pudendal nerves which are important during delivery under anesthesia.
2. Internal:
A. Vagina – female organ of copulation; passageway of menstruation & fetus
- it is 3 – 4 inches or 8 – 10 cm long of dilated canal located between the bladder and
the rectum. Contains* Rugae – permits considerable amount of stretching without tearing
B. Uterus - Organ of menstruation, site of implantation and retainment and nourishment of
the products of conception. It is a hollow, thick walled muscular organ. It varies
in size, shape and weights.
Size - 1 inch thick; 2 inches wide; 3 inches long
Shape: non pregnant = pear shaped or inverted avocado
Pregnant = ovoid
Weight : Non pregnant: – 50 - 60 grams
Pregnant: - 1000 grams
4th stage of labor - 1000 grams
2 weeks after delivery - 500 grams
3 weeks after delivery - 300 grams
Normal State - 5 - 6 weeks after delivery - 50 – 60 grams
Entire Process is “Involution of Uterus”
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Three parts of the uterus
1. fundus - upper cylindrical layer
2. corpus/body - upper triangular layer
3. cervix - lower cylindrical layer
* Isthmus – known at the lower uterine segment during pregnancy
* Cornua - junction between fundus & interstitial
Muscular compositions: there are three main muscle layers which make expansion possible in
every direction.
1. Endometrium - inside uterus, in lines the nonpregnant uterus. Muscle layer for
menstruation. Sloughs off during menstruation.
* Decidua - thick layer; Once implantation has taken place, the uterine endothelium is
termed decidua. 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 LMP(Last Menstrual Period)
*Endometriosis – “ectopic endometrium” abnormal proliferation of endometrial
lining outside uterus.
Common site: ovary.
Signs/symptoms: persistent dysmennorhea and low back pain.
Diagnostic test: biopsy, laparoscopy
Drug of choice: 1. Danazole (Danocrene)
Action: a. to stop menstruation
b. inhibit ovulation
2. Lupreulide (Lupron)
Action: a. inhibit FSH/LH production
2. Myometrium – largest part of the uterus
- it is the muscle layer responsible for delivery process
- it is a smooth muscles considered to be the living ligature of the body.
- power of labor, responsible for the contraction of the uterus
3. Perimetrium – muscle layer that protects entire uterus
C. Ovaries – Almond shape, dull white sex glands near the fimbrae, kept in place by ligaments.
2 female sex glands that serves for two functions:
1. ovulation
2. Production of two hormones
D. Fallopian tubes – 2 - 3 inches long that serves as a passageway of the sperm from the uterus to
the ampulla of the passageway of the mature ovum of fertilized ovum from the
ampulla to the uterus. Widest part (ampulla) spreads into fingerlike projections
called (fimbrae) responsible for the transport of mature ovum from ovary to
uterus; fertilization takes place in its outer third or outer half.
4 significant segments
1. Infundibulum – most distal part of Fallopian Tube, trumpet or funnel shaped, swollen
at ovulation
2. Ampulla – outer 3rd or 2nd half, site of fertilization
3. Isthmus – site of sterilization – bilateral tubal ligation
4. Interstitial – most dangerous site of ectopic pregnancy
* Cortex of the ovary – releases the matured ovum
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B. Male Reproductive System
1. External
Penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of
3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to
that of the clitoris in the female – the glands penis.
3 Cylindrical Layers
2 corpora cavernosa
1 corpus spongiosum
Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into
two sacs, each of which contains a testes. It is the cooling mechanism of testes
- < 2 degrees C than body temperature
Leydigs cell – release testosterone
* pure sperm plus secreting substance equals SEMEN*
2. Internal
The Process of Spermatogenesis – maturation of sperm
Hypothalamus
will release Epididymis – 6 meters coiled
tubules site for maturation of sperm
GnRH
Gonadotropin
releasing hormone Vas Deferens – conduit for
spermatozoa or pathway of sperm
Entry of pure sperm
Urethra
Final link from anterior to posterior
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Male and Female homologues
Male Female
Penile glans Clitoral glans
Penile shaft Clitoral shaft
Testes Ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholene's glands
Scrotum Labia Majora
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May last from 2 – 10 sec- most affected are is pelvic area.
4. Resolution – (vital sign return to normal, genitals return to pre-excitement phase)
Refractory Period – the only period present in males, wherein he cannot be restimulated for about
10 - 15 minutes
IV. Wonders of Fertilization
Fornix - where sperm is deposited
Sperm - small head, long tail, pearly white
Phonones -vibration of head of sperm to determine location of ovum
Sperm should penetrate corona radiata and zona pellocida.
Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and
zona pellocida.
A. Fertilization – union of the sperm and the mature ovum in the outer third or outer half of the
Fallopian Tube.
General Consideration:
1. Normal amount of semen per ejaculation - 3 – 5 cc = 1 teaspoon
2. Number of sperms in an ejaculate = 120 – 150 million/cc
3. Mature ovum is capable of being fertilized for 24 – 36 hours after ovulation.
4. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation
5. Sperm is viable within 48 – 72 hours or 2 – 3 days
6. Normal lifespan of sperm = 7 days
7. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after
deposition.
8. Reproductive cells, during gametogenesis, divide by meiosis (haploid number of daughter cells);
therefore, they contain only 23 chromosomes ( the rest of the body cells have 46 chromosomes ).
Sperms have 22 autosomes and 1 X sex chromosomes or 1 Y sex chromosome; Ovum contain 22
autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results
in a baby girl (XX); the union of a Y-carrying sperm and mature ovum results in a baby boy (XY).
Important: Only “fathers” determine the sex of their children
B. Stages of Fetal Growth and Development
3 - 4 days travel of zygote → during the travel → mitotic cell division begins
*Pre-embryonic Stage
a. Zygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months
fetus - 2 months to birth
b. Morula – mulberry-like ball with 16 – 50 cells, start to travel by ciliary action and
peristaltic contractions of fallopian tube to the uterus where it will stay for 4 days
free floating & multiplication
c. Blastocyst – enlarging cells that forms a cavity in the morulla, that later becomes the embryo.
Trophoblast – fingerlike projections covering around the blastocyst that later becomes
placenta and membrane.
d. Implantation other term Nidation - occurs after fertilization 7 – 10 days.
Placenta previa – implantation at the lower side of the uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization – corpus luteum continues to function & become source of estrogen
& progesterone while placenta is not developed.
* 3 processes of Implantation
1. Apposition – blastocysts begin to brush the endothelial lining
2. Adhesion – blastocysts begin to attached the endothelial lining
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3. Invasion – blastocysts begin to settle down
“Proteolytic enzyme” – for dissolving endothelial lining allowing implantation
* Embryonic Stage
C. Decidua – thickened endometrium (Greek word – falling off); implantation has taken place
Kinds of decidua:
* Basalis (base) part of endometrium located directly beneath or under the implanted ovum/fetus
where placenta is developed.
* Capsularies – encapsulate or co the fetus
* Vera – remaining portion of endometrium.
D. Chorionic Villi - 10 – 11th day of pregnancy; fingerlike projections
3 vessels = two arteries, one vein
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood
Wharton’s jelly – protects cord
Chorionic Villi Sampling (CVS) – removal of tissue sample from the fetal portion of the developing
placenta for genetic screening. Done early in pregnancy.
Common dangerous side effects: fetal limb defect such as missing digits/toes.
Advance Maternal Age – candidate for amniocentesis
E. Cytotrophoblast – inner layer or langhans layer of the trophoblast that gives rise to the outer
surface and villi of the chorion.
- protects fetus against syphilis, however it can be capable of living
for 24 weeks/6 months
- life span of langhans layer increase.
* Before 24 weeks critical, might get infected syphilis
F. Syncytiotrophoblast – syncytial layer or outer layer . It erodes the uterine wall during implantation and
give rise to the villi of the placenta. It is responsible production of hormones. It is
also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast
Two structures developed:
1. Amnion – innermost layer. It is a membrane, continuous with and covering the fetal side of
the placenta that forms the outer surface of the umbilical cord.
2 structures progress:
a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis, a flexible
structure connecting the umbilicus with the placenta in the gravid uterus and giving
passage to the umbilical arteries and vein; whitish grey, “15 – 55 cm, 20 – 21”.
*Importance of determining the length of the cord:
Short cord: abruptio placenta or inverted uterus.
Long cord: cord coil or cord prolapse
Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of
pregnancy; it contains the yolk sac and the body stalk with enclosed allatois.
b. Amniotic Fluid , also known as (BOW) bag of water, clear, odor mousy/musty, with
crystallized forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo - skeletal development and symmetrical growth
3. maintains temperature
4. prevent cord compression
5. help in delivery process
normal amount of amniotic fluid – 500 to 1000cc
polyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia
/(TEF) Tracheoesophageal Fistula, increased amount of fluid
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oligohydramnios- decrease amount of fluid – kidney disease; “inom → absorbed → ihi”
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5. Endocrine System – produces hormones
• Human Chorionic Gonadrophin – maintains corpus luteum alive; basis of
pregnancy test
• Human placental Lactogen or sommamommamotropin Hormone – for
mammary gland development. Has a diabetogenic effect – serves as insulin
antagonist
• Relaxin Hormone- causes softening joints & bones
• estrogen
• progestin
6. It serves as a protective barrier against some microorganisms – HIV,HBV
Entire pregnancy days – 266 – 280 days 37 – 42 weeks
280 divided by 28 = 10 lunar months
280 divided by 31 days = 9.7 days (calendar months)
1st week counted “zero”
Fetal Stage “ Fetal Growth and Development”
First trimester: period of organogenesis; most critical period
First Month - Brain & heart development
GIT & respiratory Tract – remains as single tube
1. Fetal heart tone begins – heart is the oldest part of the body
2. CNS develops – dizziness of mother due to hypoglycemic effect
Food of brain – glucose complex CHO – pregnant woman’s food (potato)
Differentiation of Primary Germ layers
* Endoderm
1st week endoderm – primary germ layer
Thyroid – for basal metabolism; respiratory
Parathyroid - for calcium metabolism
Thymus – development of immunity
Liver
Lining of upper Respiratory Tract & Gastro Intestinal Tract
* Mesoderm – development of heart, musculoskeletal system, kidneys and
reproductive organ
* Ectoderm – development of brain CNS, skin and 5 senses, hair, nails,
mucous membrane of anus & mouth
Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month
3. Sex organ formed
4. Meconium is formed
Third Month
1. Kidneys functional
2. Fetus begin to swallow amniotic fluid
3. Buds of milk teeth appear
4. Fetal heart tone heard – Doppler – 10 – 12 weeks
5. Sex is distinguishable
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Second Trimester: FOCUS – length of fetus
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 – 20 weeks
3. buds of permanent teeth appear
Fifth Month
1. lanugo covers body
2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks – multi
5. fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
Third trimester: Period of most rapid growth. FOCUS: weight of fetus
Seventh Month
– development of surfactant – lecithin
Eighth Month
1. lanugo begin to disappear
2. subcutaneous fats deposit
3. Nails extend to fingers
Ninth Month
1. lanugo & vernix caseosa completely disappear
2. Amniotic fluid decreases
Tenth Month
– bone ossification of fetal skull
Teratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor
hearing & deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – lead to hemolysis (destruction of RBC); hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia – totally no extremities
Pocomelia - absence of distal part of extremities
Steroids – cleft lip or cleft palate or even abortion
Lithium – congenital malformation
B. Alcohol – low birth weight (vasoconstriction on mother), fetal alcohol withdrawal syndrome
charterized by microcephaly
C. Smoking – low birth weight
D. Caffeine – low birth weight abruption placenta
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E. Cocaine – low birth weight
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Nursing Care:
• Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetable-
alugbati, saluyot, malunggay, horseradish, ampalaya
• Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered,
hematoma.
• Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before
meals or 2 hours after, black stool, constipation
• Monitor for hemorrhage
Alert:
• Iron from red meats is better absorbed iron form other sources
• Iron is better absorbed when taken with foods high in Vitamin C such as orange juice
• Higher iron intake is recommended since circulating blood volume is increased and
hemoglobin is required from production of RBCs
Edema – occurs because of poor circulation resulting from pressure of the gravid uterus on
the blood vessels of the lower extremities due venous return is constricted due to
large belly.
Management: elevate / raise legs above hip level.
Varicosities – pressure of uterus
Management: - use support stockings, avoid wearing knee high socks
- use elastic bandage – lower to upper
Vulbar varicosities - painful, pressure on gravid uterus,
Management: to relieve- position – side lying with pillow under hips or
modified knee chest position
Thrombophlebitis – presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate
outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion
milk leg – skinny white legs due to stretching of skin caused by inflammation or
phlagmasia albadolens
Management:
1.) Complete Bed rest
2.) Never massage
3.) Assess + Homan sign once only might dislodge thrombus
4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
5.) Monitor APTT - Heparin toxicity : protamine sulfate(antidote for heparin)
6.) Avoid aspirin! Might aggravate bleeding.
2. Respiratory system – common problem Shortness Of Breathing due to enlarged uterus &
increase O2 demand
Management: Position: lateral expansion of lungs or side lying position.
3. Gastrointestinal – 1st trimester change
* Morning Sickness – nausea & vomiting due to increase HCG.
Management:
• Eat dry crackers or dry CHO diet 30 minutes before arising bed.
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• Nausea afternoon - small frequent feeding.
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b. Moniliasis or Candidiasis – caused by Candida Albicans also called Candidiasis,
fungal infestation.
Signs & Symptoms:
Color – white cheeselike patches adheres to the walls of vagina, extreme pruritus
Management :
antifungal – Nistatin, gentian violet, cotrimaxole, canesten
Gonorrhea - Thick purulent discharge
Vaginal warts - condifoma acuminata due to papilloma virus
Management: cauterization
2. Abdominal Changes
* striae gravidarium (stretch marks) due to enlarging uterus brought
by destruction of subcutaneous tissue.
Nursing Care: Instruct to avoid scratching and application of oil
* umbilicus is protruding
3. Skin Changes
* Chloasma/ Melasma – white or light brown pigmentation in the nose, chin, cheeks
due to increased melanocytes.
* Linea Nigra – brown pinkish line running from symphisis pubis to umbilicus
4. Breast Changes – all breast changes are related to change and increase in hormones
- size and color of areola & nipple change
pre colostrums present by 6 weeks, colostrums at 3rd trimester
BSE (Breast self exam) - one week or 7 days after menstruation
Position: supine with pillow at back
quadrant B – upper outer – common site of cancer
Test to determine breast cancer:
Mammography – 35 to 49 years old should submit to mammography once every 2 years
50 years old and above – once a year
5. Ovaries – rested during pregnancy; no significant changes
6. Signs & symptoms of Pregnancy
A. Presumptive – signs and symptoms felt and observed by the mother but does not confirm
positive diagnosis of pregnancy : Subjective
B. Probable – signs observed by the members of health team: Objective
C. Positive Signs – undeniable signs confirmed by the use of instrument.
Ballotement sign of myoma
* + HCG – sign of H mole
- trans vaginal ultrasound. Empty balder
- ultrasound – full bladder
placental grading – rating/grade
0 – immature
1 – slightly mature
2 – moderately mature
3 – placental maturity
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What is deposited in placenta which signify maturity - there is calcium
VI. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)
First Trimester:
• No tanginal signs & symptoms, surprise, ambivalence, denial
• Sign of mal adaptation to pregnancy
Developmental task: is to accept biological parts of pregnancy
Health Teaching: bodily changes of pregnancy,
Focus: nutrition and on growth and development
Second Trimester
• tangible Signs & Symptoms: mother identifies fetus as a separate entity due to presence
of quickening, fantasy.
Developmental task: to accept growing fetus as baby to be nurtured.
Focus: growth & development of fetus.
2. Personal data:
Name: for identification
Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old)
(HBMR) Home Base Mother’s Record – tool used to determine high risk pregnancy
Sex: PSEUDOCYESIS – false pregnancy common to male
COUVADE SYNDROME – psychosomatic reaction wherein the father experiences the
mother goes through; the father is the one to vomits,etc – (lihi)
Religion: for their culture & beliefs with respect, non judgmental
Occupation: financial condition or occupational hazards
Education Background: to determine level knowledge
Address; civil status
3. Diagnosis of Pregnancy
1.) urine exam to determine HCG - 6 weeks after Last Menstrual Period , 40 – 100th day but
peak 60 – 70 day best to get urine exam.
2.) Elisa test – test to detect beta subunit of HCG as early as 7 – 10 days
3.) Home pregnancy kit – do it yourself
4. Baseline Data:
Vital Signs especially Blood Pressure
Monitor weight (increase weightt – 1st sign preeclampsia), pattern of weight gain/loss is
important
Weight Monitoring
First Trimester: Normal Weight gain 1.5 – 3 lbs ( .5 – 1 lb/month )
Second trimester: Normal Weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: Normal Weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)
Average weight gain – 20 – 25 lbs
Optimal weight gain – 25 – 35 lbs
5. Obstetrical Data:
nullipara – no pregnancy
a. Gravida - number of pregnancies, 2 children G2
b. Para - number of viable pregnancies, 2 viable P2
Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
Age of Viability - 20 – 24 weeks
Term - 37 – 42 weeks
Preterm - 20 – 37 weeks
Abortion < 20 weeks
Sample Cases:
a. 1 – abortion G2T0P0A1L0
1 – 2nd month pregnant G2P0
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1 – 4th month pregnant
c. 1 – 39th week
1 – miscarriage
1 – stillbirth 33 AOG (considered as para) G4P2
1 – pregnant 3rd wk G4T1P1A1L1
d. 1 – 33rd P
1 - 41st L
1 – abortion A
1 – stillbirth 39th G6T2P2A1L5
1 - triplet 32nd G6P4
1 - 4th month pregnant
e. 1 – 39th AOG
1 – miscarriage G4P1
1 – stillbirth 33rd AOG G4T1P1A1L1
1 – 3rd month pregnant
f. 1 – 40th AOG
1 – Abortion G4P2
1 – twin 37th AOG G4T1P1A1L3
1 – 4th month pregnant
g. 1 – 38th AOG 1 – Triplets 30th AOG
1 – 37th AOG 1 – 32nd AOG G6P5
1 – Abortion 1 – Stillbirth 42nd AOG G6T3P2A1L6
c. Important Estimates:
1. Nagele’s Rule – used of determine expected date of delivery
January, February and March - +9+7 while
April to December - -3+7+1
Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar
M D Y +9 +7 no year
Example: a. LMP January 03, 2005
01 03 05
+ 09 07___
10-10-05= Expected Date of Confinement October 10, 2005
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Fundic Ht X 7 = AOG in weeks
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From symphysis pubis to fundus 24 X 7 =21 wks
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6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ of preg
8 x 5 = 40 cm
9 x 5 = 45 cm
d. Tetanus Immunizations – prevents tetanus neonatum
- mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3
TT1 – any time during pregnancy
TT2 – 4 weeks after TT1 – 3 yrs protection
TT3 – 6 months after TT2 – 5 yrs protection
TT4 – 1 year after TT3 – 10 yrs protection
TT5 – year after TT4 – lifetime protection
Note: if the mother received 3 doses of DPT during childhood, she will be given TT3.
5. Physical Examination: Cephalocaudal including the teeth
* Examine teeth: sign of infection
Danger signs of Pregnancy:
C - chills/ fever - infection
- Cerebral disturbances ( headache – preeclampsia)
A – abdominal pain ( epigastric pain) – aura/alert of impending convulsions
B – boardlike abdomen – sign of abruption placenta
Increase BP – HPN(hypertension)
Blurred vision – pre eclampsia
Bleeding :
1st trimester - abortion, ectopic pregnancy
2nd trimester – H mole, incompetent cervix
3rd trimester – any placental anomalies such as abruption placenta,
placenta previa
S – sudden gush of fluid – PROM (premature rupture of membrane) prone to infection.
- swelling/edema of upper extremities (pre eclampsia)
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6. Pelvic Examination : Internal Examination
Preparation: 1. empty bladder
2. universal precaution
On the first visit the mother will examined internally in order to determine the presence of
probable signs such as Chadwick, Goodels and Hegar’s sign.
Pap Smear – cytological examination to determine the presence of cancer cells
External OS of cervix – site for getting specimen ; composed of squamous
columnar tissue; Site for cervical cancer
Vaginal Speculum will be needed, to avoid contact from other organ
Result:
Class I - normal
Class IIA – suggestive of inflammation
B - acytology but no evidence of malignancy
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy
Stages of Cervical Cancer
Stage 0 – carcinoma insitu
1 – cancer confined to cervix
2 - cancer extends to vagina
3 – pelvis metastasis
4 – affectation to bladder & rectum
7. Leopold’s Maneuver
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree
of descent, an estimate of the size, and number of fetuses, position, fetal back &
fetal heart tone; use palm! Warm palm.
Preparation for mothers:
1. Empty bladder
2. Position of mom-supine with knee flex
(dorsal recumbent – to relax abdominal muscles)
Procedure:
1st maneuver: Place patient in supine position with knees slightly flexed; Put towel under head
and right hip; With both hands palpate upper abdomen and fundus. Assess size, shape,
movement and firmness of the part. In dorsal recumbent position – to relax the abdominal
muscles. To determine presentation parts.
2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart
sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone. Get Vital
Signs (before 2nd maneuver) Pulse Rate to differentiate fundic soufflé (Fetal Heart Rate) &
uterine soufflé (Maternal Heart Rate). To determine fetal back.
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3rd Maneuver: using the right hand, grasp the symphysis pubis part using thumb and fingers.
To determine degree of engagement. (Assess whether the presenting part is engaged in the
pelvis ) Alert : if the head is engaged it will not be movable.
4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands,
assess the descent of the presenting part by locating the cephalic prominence or brow.
When the brow is on the same side as the back, the head is extended. When the brow is on the
same side as the small parts, the head will be flexed and vertex presenting. To determine
attitude – relationship of fetus to 1 another.
Attitude – refers to the relationship of fetus to each part into one another ( degree of flexion )
Full flexion – when the chin touches the chest
8. Assessment of Fetal Well-Being-
A. Daily Fetal Movement Counting (DFMC) – begin 27 weeks
Mother - begin after meal – breakfast
a. Cardiff count to 10 method – one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and count
each fetal movement, noting how long it takes to count 10 fetal movements (FMs)
(2) Expected findings – 10 movements in 1 hour or less
(3) Warning signs
a.) more than 1 hour to reach 10 movements
b.) less than 10 movements in 12 hours (non-reactive- fetal distress)
c.) longer time to reach 10 (FMs) fetal movements than on previous days
d.) movement are becoming weaker, less vigorous
* Movement alarm signals - < 3 FMs in 12 hours
(4.) Warning signs should be reported to healthcare provider immediately; often require
further testing. Examples: non stress test (NST), biophysical profile (BPP)
b. Nonstress test – to determine the response of the fetal heart rate to activity
Indication – pregnancies at risk for placental insufficiency
Postmaturity
a.) Pregnancy Induced Hypertension (PIH), diabetes
b.) Warning signs noted during DFMC
c.) Maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal
monitor);external monitor is applied to document fetal activity; mother activates the
“mark button” on the electronic monitor when she feels fetal movement.
Attach external noninvasive fetal monitors
1. Tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
2. Ultrasound Transducer over abdominal site where most distinct fetal heart sounds
are detected
3. Monitor until at least 2 FMs are detected in 20 minutes
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• if no FM after 40 minutes provide woman with a light snack or gently
stimulate fetus through abdomen
• if no FM after 1 hour further testing may be indicated, such as a CST
Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
i. Reactive Result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at
least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement
3. Good variability – normal irregularity of cardiac rhythm representing a balanced
interaction between the parasympathetic (decreases FHR) and sympathetic
(increase FHR) nervous system; noted as an uneven line on the rhythm strip.
4. result indicates a healthy fetus with an intact nervous system
ii. Nonreactive Result
1. Stated criteria for a reactive result are not met
2. Could be indicative of a compromised fetus.
Requires further evaluation with another nonstress test NST, biophysical profile,
(BPP) or Contraction Stress Test (CST)
9. Health Teachings : do nutritional assessment
a. Nutrition – daily food intake
High risk mothers:
1. Pregnant teenagers – very long compliance to health regimen.
2. Extreme weight
Underweight: malnourished like elite model
Over weight : candidate for HPN, DM
3. Mothers with low socio – economic status – refer to DSWD
4. Vegetarian mothers – decrease CHON – needs Vitamin B12/folic acid –
cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation.
(Decrease folic acid – spina bifida/open neural tube defect, meningocele umphalocele)
Types of Vegetarian:
1. Strict Vegetarian – vegetables only ( with rigid personality)
2. Lactovegetarian – vegetables/milk
3. Lactoovovegetarian – vegetables/milk/egg
How many calorie : CHO x 4, CHON x 4, FATS x 9
Daily Calorie Intake : Non Pregnant – 2,200
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Add - 300
Pregnant – 2,500
During Lactation Add - 500
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abruption placenta
Additional Requirements Increased requirements of pregnancy
Minerals can easily be met with a balanced diet
- iodine 175 mcg/day that meets the requirement for calories
- Magnesium 320 mg/day and includes food sources high in the
- Selenium 65 mcg/day other nutrients needed during
pregnancy.
Vitamins
E 10 mg/day Vitamin stored in body. Taking it not
Thiamine 1.5 mg/day needed – fat soluble vitamins. Hard to
Riboflavin 1.6 mg/day excrete.
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day
4. Childbirth Preparation:
Overall goal: to prepare parents physically and psychologically while promoting wellness behavior
that can be used by parents and family thus, helping them achieved a satisfying and
enjoying childbirth experience.
a. Psychophysical
1. Bradley Method – discovered by Dr. Robert Bradley , advocated active participation of
husband during delivery process to serve as a coach. Based on imitation
of nature.
Features:
1.) darkened room
2.) quiet environment
3.) relaxation tech
4.) closed eye & appearance of sleep
2. Grantly Dick Read Method – that fear leads to tension while tension leads to pain
- to remove fear by relaxation technique and abdominal
exercises
b. Psychosexual
1. Kitzinger Method – discovered by Dr. Shiela Kitzinger , that pregnancy, labor, birth & the
care of the newborn is an important turning point in a woman’s life
cycle
- for a mother to achieve the satisfying childbirth experiences, flow with
contraction rather than struggling with contraction
c. Psychoprophylaxis – prevention of pain
1. Lamaze – discovered by Dr. Ferdinand Lamaze
- prevention of pain in the brain
Features: discipline, conditioning & concentration with the help of the Husband
1. Conscious relaxation
2. Cleansing breathe – inhaling through the nose and exhaling through the mouth
3. Effleurage – gentle circular massage over abdomen to relieve pain
4. Imaging – sensate focus
5. Different Methods of delivery:
1.) Birthing Chair – bed convertible to chair – “semifowlers” position
2.) Birthing Bed – “dorsal recumbent” position
3.) Squatting Position – position that facilitates descent and relieves low back pain during labor pain
4.) Leboyers Method – features: warm, quiet, darkened room, calm and comfortable environment,
room temperature, soft music.
- After delivery, baby gets warm bath.
5.) Birth Under Water – warm water in a bathtub – labor & delivery – warm water, soft music.
- After delivery the baby should be kept warmth, prepare for bathing
IX. Intrapartal Notes – inside Emergency Room
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A. Admitting the laboring Mother:
* Personal Data: name, age, address, etc
* Baseline Data: v/s especially BP, weight
* Obstetrical Data: gravida # pregnancy, para- viable pregnancy – 22 – 24 weeks
* Physical Examination
* Pelvic Examination
4. Psyche/Person – (mother) psychological stress exist when the mother is fighting the
labor experience ( effective pushing )
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
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Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix
into the vagina.
Danger signs:
* PROM
* Presenting part has not yet engaged
* Fetal distress
* Protruding cord form vagina
Nursing care:
1. Slip cord away from presenting part
2. Count pulsation of cord for Fetal Heart Tone
3. Positioning – trendelenberg or knee chest position
4. Observe for fetal distress
5. provide emotional support
6. Prepare mother for Cesarean Section
• Cover cord with sterile gauze with saline solution - to prevent drying of cord so
cord will remain slippery.
* NOTE: five minutes cord compression can lead to irreversible brain damage such
as cerebral palsy.
b.4. Difference Between True Labor and False Labor
False Labor True Labor
* Irregular contractions * Contractions are regular
* No increase in intensity * Increased intensity
* Pain – confined on abdomen * Pain – begins lower back radiates to abdomen
* Pain – relived by walking * Pain – intensified by walking
* No cervical changes * Cervical effacement & dilatation
- major symptom of true labor.
Effacement – softening & thinning of cervix. Use % in unit of measurement
Dilatation – widening of cervix. Unit used is cm.
b.5 Duration of Labor
Primipara – 14 hours not more than 20 hours
Multipara – 8 hours not more than 14 hours
b.6 Nursing Interventions in Each Stage of Labor
2 segments of the uterus
1. upper uterine - fundus
2. lower uterine – isthmus
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase: ( The mother is excited but apprehensive and can communicate)
Assessment: Dilatations: 0 – 3 cm
Frequency: every 5 – 10 min
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Intensity : mild
Nursing Care:
1. Encourage walking - to shorten the 1st stage of labor
2. Encourage to void every 2 – 3 hours – full bladder inhibit uterine contractions
3. Breathing – chest breathing
Assessment: Dilatations: 8 – 10 cm
Frequency : every 2 - 3 minutes contractions
Durations : 45 – 90 seconds
Intensity: Strong
Hyperesthesia – increase sensitivity to touch, pain all over
Nursing Care:
T – tires
I – inform of progress- best way to give emotional support to the mother
R – restless, support her to do breathing technique (chest breathing)
E – encourage and praise
D – discomfort – due to sacral pressure
Health Teaching :
* teach the father about sacral pressure technique on lower back to inhibit transmission
of pain
* keep informed of progress
* controlled chest breathing
Contractions:
Increment/ Crescendo – beginning of contraction until it increases
Acme/ Apex – height of contraction
Decrement/ Decresendo – from height of contraction until it decreases
* Pelvic Exams
Effacement: – softening & thinning of cervix.
Dilatation: - widening of cervix.
a. Station – relationship of the presenting part to the ischial spine
landmark used: ischial spine
Floating – negative station
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
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- 0 station = level at ischial spine – engagement
+ 1 station = below 1 cm ischial spine
+3 ,+4, +5 = crowning – occurs at 2nd stage of labor
b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the
long axis of the mother - spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
Cephalic - Vertex – when the fetus is completely flex
Face
Brow Poor Flexion
Chin
Breech - Complete Breech – thigh rest on abdomen, while leg rest on thigh
Incomplete Breech
Frank – thigh rest on abdomen while leg rest on the head
Footling – presenting part – foot : single, double
Kneeling – presenting part - knees
b.2. Transverse Lie (Perpendicular) or Perpendicular lie.
- Shoulder presentation is very rare – 1 %
c. Position – relationship of the fatal presenting part to specific quadrant of the
mother’s pelvis.
Variety:
Occipito/ Occiput
LOA left occipito anterior (most common and favorable position)
– side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
ROP – squatting pos on mom
ROT
ROA
A – Anterior
L – Left – side of maternal pelvis
O – Occipito – denominator
ROP; LOP : most painful position; best – squatting position
LOA – most favorable position
FACE – Mentum LMA, LMT, LMP, RMA, RMT, RMP
Shoulder – Acromio Dorso – LADA, LADT, LADP, RADA, RADT, RADP
Breech- SACRO - LSA – left sacro anterior LST, LSP, RSA, RST, RSP
Shoulder/acromniodorso: LADA, LADT, LADP, RADP
Chin / Mento: LMA, LMT, LMP, RMP, RMA, RMT, RMP
• In cases of breech presentation –place the stethoscope above the umbilicus
Sign of fetal distress:
34
• < 120 or > 160 bpm
• meconium stain
• fetal trushing – hyperactivity of fetus due to lack of oxygen.
35
• Pain during labor – can give Meperidine HCL ( Demerol ) – narcotic antispasmodic
( during active phase 6 – 8 cm )
Toxic Effect: respiratory depression
Antidote : Narcan ( Naloxone )
Note:
Amniotomy – artificial rupture of the membrane
Respiratory Alkalosis – signs and symptoms ( increase RR, Tingling sensation,
light headedness,
• Precipitate Labor - labor of < 3 hours. extensive lacerations to mother that leads to
profuse bleeding → hypovolemic shock → hypotension, Tachypnea, Tachycardia,
cold clammy skin
Note: Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing diagnosis: fluid volume deficit
Position of mother: Modified Trendelenberg
IV – fast drip due fluid volume deficit
Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin
• Inversion of the Uterus – uterus is turned inside out due to the following factors:
a. hurrying pull out of the placenta
b. ineffective fundal pressure
c. short cord
Management: MD will push uterus back inside or not hysterectomy.
• Uterine Rupture – Possible causes:
1.) Previous classical Cesarean Section
2.) Large baby
3.) Improper use of oxytocin (IV drip)
Symptoms:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Note: Physiologic Retraction – boundary between upper and lower uterine segment
Suprapubic Depression – sign of impending rupture of the uterus
Bandl’s Pathologic Ring – bleeding that leads to hypovolemic to TABHBSO
• Pre Term Labor – labor after 24 weeks before the 37th week
Triad of Preterm Symptoms:
1. Premature contractions every 10 minutes
2. Effacement of 60 – 80 %
3. Dilatation of 2 - 3 cm
Home Management:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 - 4 glasses of water – full bladder inhibits contractions
5. consult MD if symptoms persist
Hospital Management:
1. If cervix is closed (2 – 3 cm), dilation saved by administer
Tocolytic agents- to halts the preterm contractions of the uterus.
(YUTOPAR - Yutopar Hcl) 150 mg incorporated 500 cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - < 90/60
Crackles – notify MD
Pulmonary edema – administer oral yutopar 30 minutes before d/c IV
PreTerm: Magnesium Sulfate
• Before delivery mother will be given :
DEXAMETHASONE –to facilitate surfactant maturation.
• Tocolytic (Phil)
• Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
• Antidote – propranolol or inderal - beta-blocker
Note : * If cervix is open – MD – steroid dexamethsone (betamethazone) to
facilitate surfactant maturation preventing Respiratory Distress Syndrome
* Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.
* Term – suction at once
X. Postpartal Period 5th stage of labor
after 24hours: Normal increase WBC up to 30,000 mm3
Puerperium – covers 1st 6 wks post partum
Involution – return of reproductive organ to its non pregnant or normal state.
Hyperfibrinogenia
- prone to thrombus formation
40
- early ambulation
42
b. Laceration - Contracted uterus but with profuse bleeding
Nursing Action: assess episiotomy
assess perineum for laceration
degree of laceration
Management: Episiorapy
1st degree laceration – affects vaginal skin & mucus membrane.
2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum
Immediate Discontinuation
A – abdominal pain
C – chest pain
H - headache
E – eye problems
S – severe leg cramps
ACHES – signs of hypertension hence if the Blood Pressure of the mother is
increased – stop the pills STAT!
• if forgotten for one day, immediately take the forgotten tablet plus the tablet
scheduled that day. If forgotten for two consecutive days, or more days, use another
method for the rest of the cycle and the start again.
Adversed Effect: breakthrough bleeding
Contraindicated:
chain smoker
extreme obesity
Hypertension
Diabetes Mellitus
Thrombophlebitis or problems in clotting factors
Health Teaching:
a. Check for string daily
b. Monthly checkup
c. Regular pap smear
Alerts:
prevents implantation
inserted during menstruation and after delivery because the cervix is open
most common complications: excessive menstrual flow
most common problem: expulsion of the device
others complications – uterine infection uterine perforation and ectopic pregnancy
Period late (pregnancy suspected) Abnormal spotting or bleeding
Abdominal pain or pain with intercourse
Infection (abnormal vaginal discharge)
Not feeling well, fever, chills
Strings lost, shorter or longer
49
Assessment:
Outstanding signs and symptoms:
FRANKBRIGHT RED PLEEDING, PAINLESS BLEEDING
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal )
Complications:
Internal examination
Sudden fetal blood loss
Diagnostic Examination:
Ultrasound
Note: Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Nursing Care:
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
Note Alert : Surgeon – in charge of sign consent, RN as witness
MD explain to patient
E. Abruptio Placenta - it is the premature separation of the placenta form the implantation
site.
- It usually occurs after the twentieth week of pregnancy.
• (due to use of cocaine ) – PIH
Assessment:
dark red, painful bleeding
board like or rigid uterus/abdomen
Concealed bleeding/hemorrhage (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to
contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
placenta previa & vasa previa
General Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report signs and symptoms of DIC
Monitor v/s for shock
Strict I & O
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F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel
which may lead to retained placental fragments if vessel is cut.
G. Placenta Circumvalata – fetal side of placenta covered by chorion
H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta – cord inserted marginally rather then centrally
J. Placenta Bipartita – placenta divides into 2 lobes
K. Placenta Tripartita – placenta divides into 3 lobes
L. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
M. Vasa Previa – velamentous insertion of cord has implanted in cervical OS
2. Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)
• Hypertension after 24 wks of pregnancy, solved 6 weeks post partum.
1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HEP/A
- idiopathic
3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count
- common in primi because of increase exposure to chronic villi
- multiple pregnancy
- Mother low socio-economic status
- Increase sensitivity to Angiotensin II
↓ main effect
peripheral vascular vasospasm
↓
decrease Oxygen supply → Hypertension
( main denominator )
↓
KIDNEYS
↓
↓ ↓
↓ ↓
EYES Glomerular Degeneration Glomerular Filtration Placenta
↓ ↓ ↓ ↓
Retinal vassoconstriction increase permeability increase sodium absorption IUGR
↓ ↓ ↓ (intrauterine growth retardation)
Blurred Vision proteinuria increase water retention
↓ └ EDEMA ┘
SCOTOMA ↓
↓ ANASARCA
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↓ PRE TERM LABOR
BLINDNESS ↓ ↓
BRAIN LUNGS
↓ ↓
LIVER – Tissue Ischemia Cerebral Edema Pulmonary Edema
↓ ↓
Liver Edema HEART ( CHF )
↓ ↓
Epigastric Pain CONVULSION
56