MATERNAL AND CHILD

(NCLEX – RN)

Table of Content

Abortion or Miscarriage Abdominal Pregnancy Abruptio Placenta Adolescent or Teen-age Pregnancy Alpha-fetoprotein Screening (AFP) Amenorrhea Amniocentesis Amniotic Fluid and Membranes Anemia in Pregnancy Apgar Scoring Breastfeeding Cardiac Diseases during Pregnancy Cesarean Birth Childbirth Health Education Cystitis after Delivery Danger Signs and Discomfort of Pregnancy Diabetes Mellitus during Pregnancy (Gestational DM) Discharge Instructions (Postpartum) Dystocia during Pregnancy Ectopic Pregnancy Episiotomy in Assisting Delivery Exercise during Pregnancy Family Planning Female Reproductive Anatomy Fetal Blood Circulation Fetal Heart Tone Fetal Monitoring Fetal Movement and Fetal Heart Rate Patterns Forceps Delivery High Risks Factors during Pregnancy

Human Sexual Responses Hydatidiform or Vesicular Mole Inflammatory Bowel Disease during Pregnancy Leopold's Maneuver Mechanisms of Labor (EDFIERRE) Menstruation Cycle Pain Management during Childbirthing Process Pelvic Inflammatory Diseases Pregnancy - Induced Hypertension Preterm or Premature Labor Placenta Previa Puerperium Rheumatic Disorders during Pregnancy Stages and Five P's of Labor Signs and Developmental Task of Pregnancy Signs of Beginning Labor and Placental Separation TORCH Complex in Pregnancy Types of Pelvis

ABORTION AND MISCARRIAGE

ABORTION - the termination of pregnancy before fetus is viable - fetus is "viable" - defined as fetus of 20 weeks AOG, weighing below 350 gram - abortion may be elective (planned, medical termination of pregnancy) or reproductive problem Predisposing/precipitating factors of Abortion are: 1. Chromosomal defect 2. Teratogenic factor 3. Immunologic (anti-phospolipid antibody) 4. Faulty placental development 5. Infection 6. Hyperemesis 7. Trauma 8. Severe stress 9. Disease 10. Incompetent cervical os Types of Abortion 1. Spontaneous - pregnancy ends of natural cause 2. Induced - therapeutic or elective reasons for terminating pregnancy 3. Inevitable - threatened loss that cannot be prevented

save and count pads monitor hemorrhage emotional support

4. Incomplete - loss of some products of conception and retention of others

D & C oxytocin IV/Blood transfusion

5. Complete - loss of all products of conception in utero after fetal death

observe may be given oxytocin

6. Missed - retention of products of conception in utero after fetal death

D & C monitor for infection DIC (disseminated intravascular coagulation)

7. Habitual - spontaneous abortions in three or more successive pregnancies

cerclage (encircling the cervix with suture) shirodkar and McDonald technique

8. Septic - abortion due to infection 9. Threatened - bleeding, cramping and softening of uterus with CLOSED CERVIX

bedrest no intercourse monitor bleeding

Manifestations of Abortion Types of Abortion - Abdominal Pain - Vaginal Bleeding - Others - Threatened ------ Mild ------------ Mild ---------- Closed Cervix - Inevitable ------Mild to moderate - moderate ----- open cervix - Complete ------ minimal --------- complete -- passage of fetus and placenta - Incomplete ---- severe ----------- severe --------- open cervix - Missed -------- mild to moderate - spotting ----- no uterine contraction - Septic --------- severe --------- mild to severe -- fever, foul vaginal discharge - Habitual ------ mild to moderate --intermittent; fetal discharge ABDOMINAL PREGNANCY - The placenta is usually located posterior to the uterus on the intestine or in Douglas' cul-de-sac, which can infiltrate and erode major blood vessel in the abdomen leading to hemorrhage or peritonitis. - Fetal outline is difficult to palpate; woman may feel no fetal movement or experience painful fetal movements - Past history of the woman includes previous uterine surgery or ectopic pregnancy. - If reaches term, the infant has an increased incidence of fetal deformity and is delivered by laparotomy - Methotrexate is the drug of choice for abdominal pregnancy to destroy placental cells.

ABRUPTIO PLACENTA - Premature separation of placenta from the uterine wall - Abruptio placenta is common in older gravidas, hypertensives with previous history of experienced direct trauma, and with fibrin defects - Occurs after 20 - 24 weeks of pregnancy

PAINFUL (sharp and stabbing), vaginal bleeding abdomen is tender, painful, and tense (board-like) fetal distress (altered FHR) may lead to Couvelaire uterus (blood infiltrating the uterine musculate) forming a

hard, board-like uterus without apparent bleeding. complications of abruptio placenta include shock and coagulopathy (DIC)

In Concealed Abruptio Placenta

bleeding, signs of hypovolemia beyond observed blood loss increase in abdominal girth and fundic height

Degrees of Separation in Abruptio Placenta

Grade 0 - no symptoms of separation were apparent from maternal or fetal sign; the diagnosis that a slight separation did occur is made after delivery when the placenta is examined and a segment of the placenta showed a recent adherent clot on the maternal side

Grade 1 - this is minimal separation, but enough to cause vaginal bleeding and changes in the maternal vital signs; no fetal distress or hemorrhagic shock occurs

Grade 2 - this is moderate degree of abruptio placenta Grade 3 - this is extreme separation; without immediate interventions, maternal

shock and fetal death will result

Nursing Diagnoses and Expected Outcome about Abruptio Placenta : 1. Alteration in maternal tissue perfusion - improved vital signs, improved clotting, no anemia, decreased blood loss, no hypovolemia, improved comfort level 2.Altered fetal oxygenation and tissue perfusion - normal fetal heart rate and variability 3. Anxiety - expresses fears and concerns 4. High risk for infection due to decreased in hemoglobin - blood is replaced, temperature on normal level Nursing Care Plan for Abruptio Placenta

keep woman in lateral (not supine) position oxygenation (to limit fetal anoxia) FHT monitoring, vital signs monitoring baseline fibrinogen (if bleeding is extensive, fibrinogen reserve may be used up in

body's attempt to accomplish effective clot formation) NO IE or rectal examination, NO enema keep IV open for possible blood transfusion

ADOLESCENT PREGNANCY - It is an early pregnancy in client under age 17 Predisposing factors of Teenage Pregnancy

1. poverty 2. faulty family processes 3. sexual revolution 4. early onset of menarche 5. inadequate knowledge about reproductive health

Teenage pregnancy or early pregnancy increases the risk of:

stillbirth low birth weight infants cephalopelvic disproportion fetal deaths

Teenage pregnancy or early pregnancy also increases risk for maternal complications such as:

hypertension anemia prolonged or premature labor hemorrhage and infections.

Developmental tasks of adolescents which superimposed that of pregnancy are:

1. establish sense of worth and a value system 2. establish a lasting relationship 3. parental independence 4. choosing a vocation

Approach of prenatal health teachings in teenage pregnancy or early pregnancy should be directed and emphasized to their own health more than to that of the fetus inside them. Adolescents should gain the usual 11 to 13 kg (25 to 30 lbs) recommended for all pregnant women, thus need to be reminded always of their nutritional needs. Adolescents have strong need for:

peer companionship a great consideration for planning their activities and rest child birthing plans for the baby nutrition post partal care

Pelvic measurement should be taken early and carefully in teenage pregnancy.

Alpha-fetoprotein Screening (AFP) Alpha-fetoprotein Screening measures the quantity of fetal serum proteins. An elevated result of Alpha-fetoprotein Screening is associated with open neural tube defects. A significantly decreased amount of Alpha-fetoprotein Screening means chromosomal defects such as Down's syndrome. Assessed with single maternal blood sample drawn at 15-18 weeks gestation. If Alpha-fetoprotein Screening increased in less than 18 week gestation, a second sample is drawn. Level 2 ultrasound is also performed to rule out fetal abnormality, multiple gestation, or fetal death. Amenorrhea - Absence of menstruation or no menstruation 1. Primary Amenorrhea - client never menstruated before, absence of menses by age 16 if secondary sexual characteristic is present. Absence of menses by age 14 if secondary sexual characteristic is absent. - Turner's syndrome (no X chromosome) is the most common cause of primary amenorrhea. 2. Secondary Amenorrhea - client did have menses previously. Absence of menses for more than 3 cycles - can be due to stress, excessive exercise, anorexia nervosa, post pill (last for 6 months), drugs (antipsychotic, antidepressant, benzodiazepine), pituitary failure, pituitary neoplasms. - Pregnancy is the most common cause of secondary amenorrhea.

AMNIOCENTESIS - the aspiration of amniotic fluid from the pregnant uterus for examination to determine genetic disorders, sex and fetal maturity; done from 14th weeks onwards.

Timing of amniocentesis procedures: Reason for Procedure ----------- Timing in Weeks - Chromosomal determination ------- 14-16 - Rh isoimmunization in Rh ---------- 20-28 negative mothers - Maturity determination ------------ 34-42 - Assessment of fetal ----------------- 34-42 well being Risk of Amniocentesis to client include:

maternal hemorrhage infection Rh isoimmunization abruptio placenta labor fetal death (0.3-0.5% risk) injury from needle

Nursing Responsibilities for Amniocentesis 1. informed consent 2. have clients empty bladder before amniocentesis 3. baseline vital signs and FHR, then check every 15 minutes 4. Position supine with abdominal scrub 5. encourage bedrest and avoidance of strenuous activities 6. instruct client to report any side effects, chills, fever, fluid leakage, decreased fetal movement and uterine contractions Information from Amniocentesis a) color - normally, the color of water. Yellow tinge suggest blood incompatibility. A green color suggests meconium staining b) Lecithin/Sphingomyelin Ration - they are protein component of the lung enzyme surfactant that the alveoli begin to form about the 22-24 weeks of pregnancy - normal ratio is 2:1 or greater which signifies lung maturity c) bilirubin determination - normally, should be negative for blood or should have no false-positive reading d) Chromosome Analysis - chromosomal study of fetal tissues should be free of disease e) Inborn error of Metabolism - the enzyme defect must be present in the amniotic fluid as early as 14-16th weeks to have a diagnosis f) Alpha fetoprotein

Amniotic Fluid and Membranes The chorionic villi on the medial surface thins and becomes double lined membranes - the chorionic membrane, the outermost fetal membrane which supports the sac containing amniotic fluid, and the amniotic membrane or amnion, which contains and produces the amniotic fluid itself and phospolipids that initiate production of prostaglandin. - Fetal urine is present by 10th week - Average amount of amniotic fluid is 1,000 ml at term Hydramnios a excessive amniotic fluid (more than 2,000 ml) due to inability of the fetus to swallow it. Normal volume is 500 to 1,00 ml.

rapid enlargement of the uterus increase weight difficult to palpate and to auscultate fetus due to excessive fluid shortness of breath because of compression of the diaphragm

Risk Factors of Hydramnios M - maternal diabetes I - infant with esophageal atresia M - monozygotic twins I - infant with neural tube defect L - large placenta Nursing Care Plan for Hydramnios

maintain bed rest to reduce pressure on cervix and to prevent premature labor monitor for rupture or uterine contraction avoid constipation (will increase intrauterine pressure) by bulk in the diet amniocentesis (slow to prevent premature separation of the placenta) guided by

ultrasound

Oligohydramnios a reduction in the amount of amniotic fluid (300 ml) due to disturbed fetal kidney function Functions of Amniotic Fluid:

1. Shock absorber from external pressure 2. Protects fetus from changes in temperature 3. Medium of excretion 4. Protect the umbilical cord from pressure protecting fetal oxygenation 5. Specimen

Amniotic Fluid Characteristics:

pH is 7.2 slightly alkaline specific gravity is 1.005 to 1.025, slightly heavier than water clear, color is same as water green-tinged in non breech is a sign of fetal distress, golden discoloration may be

found to those with hemolytic disease

ANEMIA IN PREGNANCY - decrease in RBC's (in the blood) leading to a decrease in oxygen carrying capacity of blood Types of Anemia a) Iron deficiency - a characteristically microcystic (small-sized RBC), hypochromic (less hemoglobin than the average RBC) anemia when iron is unavailable; usually associated with low fetal birth weight and premature delivery b) Megaloblastic/Folic acid anemia - RBC is enlarged due to low level of folic acid; responsible for physical defects, early abortion or abruptio placenta c) Sickle cell anemia - a recessively inherited hemolytic anemia. RBC is irregularly shaped and does not carry much hemoglobin. - the RBC clumps, infarcts and blockes vessels which hemolyzes eventually - may cause fetal death, maternal repiratory infection, asymptomatic bacteriuria resulting to pyelonephritis. Anemia in pregnancy is most common in adolescent pregnancies Clinical Manifestations for Anemia in Pregnancy includes

fatigue shortness of breath activity intolerance pallor

Diet to be observed for Anemia in Pregnacy:

Iron deficiency anemia - 300 mg/day TID, Hgb rises 0.3 to 1.0 g per week Folic acid anemia - 0.4 to 0.8-1.0 mg folic acid. Sources are lettuce, asparagus,

broccoli, lima beans, lemons, melon, bananas If secondary to parasites - management of the root cause

Nurses Implications for Anemia in Pregnancy

explain the side effects of iron preparations, emphasize that they are dose related iron supplements can be taken with meals or reduce dose at tolerable level taking the iron with meals can decrease absorption ideally, between meals doses are preperable foods that reduce iron absorption are: oregano, cereals, cheese, coffee, milk, tea,

whole grain breads, yogurt foods that enhance iron absorption are those rich in Vitamin C

APGAR SCORING

The Apgar scoring provides a valuable index for evaluation of the newborn infant's condition at birth. It is based on the five signs ranked in order of importance as follows:

Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color

Apgar scoring is done at one (1) minute of life and repeated again in five (5) minutes. Each sign is evaluated according to the degree to which it present and is given a score of 0, 1, or 2. Then the score is added together to get the total scores (10 is the highest).

BREASTFEEDING

Breastfeeding - Prolactin is released from anterior pituitary gland - Lactation is established when oxytocin is released from posterior pituitary and cause let down reflex - Colostrum is secreted by 2-3 days post partum General Principles in Breastfeeding

oxytocin cause uterus to contract and uterine cramps may be experienced wash breast daily without using soaps with flat nipples, nipple rolling is done avoid medications and gas-forming foods calories should be increased to 3,000 per day of additional 500 to normal caloric

needs per day and with 1,000 ml additional fluids baby stool will be water, frequent and light yellow in color start with breast used on last feeding stimulate rooting to start and finish each session by burping the baby

Schedule for Breastfeeding

as soon as both mother and baby is stable, even if its on delivery table regular and sustained sucking at the breast is 8-10 times a day gradually increase time of breastfeeding for each breast with subsequent feedings baby will develop their own schedule of feeding

Advantages of Breast (Human) Milk 1. it contains necessary nutrients in proper quality and quantity 2. growth rates of breastfed are better during 3 to 4 months of life 3. anti-infective properties (colostrum contains plenty of anti-bodies 2-4 days postpartum) 4. more protein (globulin); more vitamins (vit. A); more salt (sodium and potassium); more immune bodies (IgA); less fat ans sugar than mature milk; high lactose content stimulates growth of lactobacillus bifidus (acidify the intestinal content and inhibits the growth of pathogenic bacteria during diarrhea); antibodies to e-coli (most common cause of diarrhea in newborn); large amounts of lactoferrin which binds iron, inhibits growth of e-coli, staphylococci and candida albicans; lysozyme is bacteriostatic against enterobacteriaceae and staph species; anti-staphylococcus factor (inhibits systemic staph. infection which causes diarrhea, pneumonia, abscesses and sepsis); secretory IgA protects intestinal mucosae; contains cellular components (macrophages, lymphocytes, neutrophils, and epithelial cells) which provides immunological protection. 5. prevents hypersensitivity and allergy 6. lactational amenorrhea method of family planning 7. maternal and child bonding is fostered 8. protective effect against necrotizing enterocolitis 9. less otitis media due to position assumed during breastfeeding 10. decreased incidence of dental caries 11. safe, always the right temperature, convenient, no pathogenic organism, and always available

Breastfeeding problems and Immediate Interventions: a) Engorgement

more frequent breastfeeding apply warm packs before feeding and ice pack between feeding

b) Retracted Nipples

nipple-rolling before feeding wear breast shield before feeding, which would act as a vacuum when baby suck

and consequently pull nipple out

c) Cracked Nipple

lubricate nipple with A & D ointment after feeding rotate feeding position expose nipples to air for 10-20 minutes every after feeding

d) No milk or inadequate supply increase frequency of feeding and make the interval longer

CARDIAC DISEASES DURING PREGNANCY - inability to cope with added volume and increased cardiac output with outstanding signs of CHF. CHF manifestations and Intervention: 1. LEft-Sided CHF

Dyspnea/Orthopnea - fowler's or semi-fowler's position; humidified oxygen Cheyne-stoke respiration - ensure airway patency. Monitor ABGs; avoid sedatives Cough; rales - assess lung sound; give lasix Oliguria - strict monitoring of intake and output; monitor BUN and creatinine

2. Right-Sided CHF

edema of lower extremities - protect from thermal mechanical injury; elevate periodically

sacral edema - turn every 2 hours jugular vein distention (JVD) - assess for other signs of fluid retention and need

for Lasix, digoxin, and sodium restrictions abdominal ascites/hepatomegaly - measure girth and weight; know all drugs and

effect to liver function; serum digoxin level abdominal pain, anorexia, nausea and vomiting - avoid gas-forming foods, serve

small, frequent feeding. Oral care; antiemetics

3. General Manifestations

fatigue, anxiety, chest pain - bed rest; assist ADLs. Quiet, relaxed environment. Oxygen; nitrates if ordered

Functional Classification of Organic Heart Disease a. Class I - no symptoms of insufficiency, no limits of physical activity, no anginal pain b. Class II - slight limitations of activity, dyspnea, fatigue, palpitations, and angina with ordinary activity c. Class III - considerable limitation of activity less than normal activity produces symptoms d. Class IV - inability to perform any physical activity without discomfort; symptoms of insufficiency present at rest Risk increases to Class I to Class IV; Class I and II may carry to term, Class III and IV may require therapeutic abortion Main Nursing Diagnosis: Impaired air exchange related to pulmonary edema

Nursing Care for CHF during Pregnancy

continuing and careful prenatal care adequate stress free rest infection precaution avoiding anemia close monitoring of maternal and fetal well-being sodium and fluid restriction antibiotic therapy

CESAREAN BIRTH - the birth through an abdominal incision into the uterus.

Indications of Cesarean Birth

CPD severe PIH genital herpes or papilloma previous C/S (history) placenta previa abruptio placenta transverse fetal lie breech presentation extreme low birth weight fetal distress large fetus

Types of Cesarean Birth

low transverse classic low vertical

Preoperative Care of Cesarean Birth

informed consent overall hygiene skin prep

GIT prep monitoring of intake and output hydration pre-op meds role of support system

Post-operative vital signs to be reported immediately: fall in blood pressure (5-10 mmHg), pulse more than 110 bpm, RR more than 20 cpm -- signs of hemorrhage. Nursing Care for Cesarean Birth

breathing exercise early ambulation Vital signs monitoring hydration adequate rest analgesics and antibiotics promote mother-infant bonding

CHILDBIRTH EDUCATION The goal of childbirth education is to prepare expectant parents emotionally and physically for childbirth while promoting wellness behaviors in family processes. It should make the expectant couple a knowledgeable consumer of Obstetric care, help them reduce or manage pain with no or little pharmacologic intervention and increase their over all enjoyment and satisfaction with the childbirth experience. Must begin with the expectant base knowledge and ideally done in an interactive group format. Contents of Childbirth Education are:

1. Review of physiologic changes of pregnancy and fetal growth 2. Personal care during pregnancy ; nutrition, hygiene, exercise and rest 3. Emotional changes during pregnancy 4. Labor and delivery ; birth process, exercise and breathing technique, medications

in labor 5. The post partum period 6. Infant care nutrition and hygiene 7. Plans of birth and birth setting available, supplies to take to birth settings, tour to

the birth setting 8. Reproductive life planning

CYSTITIS AFTER DELIVERY

Cystitis is an infection of bladder from trauma during delivery, catheterization, and temporary loss of bladder tone. Manifestations of Cystitis

urinary frquency, urgency and retention dysuria nocturia hematuria tenderness fever

Main nursing diagnosis for cystitis: Pain and knowledge deficit Nursing care for cystitis includes:

1. observe closely for bladder function 2. forcing fluids to 3000 ml/day 3. antibiotics 4. perineal care 5. infection precautions

DISCOMFORTS OF PREGNANCY Nausea and Vomiting - it is due to elevated HCG levels and changes in CHO metabolism. Nursing interventions are dry crackers before arising, small frequent and low fat meal during the day, liquids between meal and avoid anti-emetics. Urinary Urgency and Frequency - it is due to pressure of the gravid uterus on urinary bladder. Interventions are: sleep on side at night, limit fluid intake during evening, and bladder training. Breast Tenderness - due to increased level of estrogen and progesterone. Pregnant women should wear well fitted bra, and warm compress. Increased Vaginal Discharges - due to hyperplasia of mucosa and increase mucus production. Intervention includes consult physician if infection is suspected, wash carefully and keep it dry, use yogurt for vulvular itch.

Nasal Stuffiness and Epistaxis - it is due to elevated estrogen levels. Pregnant women should direct pressure to the nasal area, and avoid blowing of nose. Fatigue - from hormonal changes. Interventions are: get regular exercise, sleep as much as needed, and avoid stimulants. Heartburn - from esophageal reflux. Interventions includes drinking milk between meals, small and frequent meals, avoid antacids such as gavinscon, baking-soda, and histamin-receptor antagonist such as tagamet. Can use Maalox or mylanta occasionally. Ankle Edema - due to venous stasis. Pregnant should elevate legs at least twice a day, sleep on left side, and avoid use of diuretics. Headaches - from changes in vascular tone and blood volume. Pregnant should change position slowly, cold compress, avoid use of NSAIDs or tranquilizers, and use tylenol (acetaminophen). Varicose Veins - from faulty valves or weakened vessel walls. Nursing interventions includes elevating feet when sitting, use support hose, avoid pressure on lower thighs Hemorrhoids - due to increase venous pressure and constipation. Use warm sitz bath, sit on soft pillows, high fiber diet with increased fluid intake, use local hemorrhoidal ointment like anusol Constipation - from displaced intestines and iron supplements. Interventions include high-roughage food, increased fluid intake with exercise regimen, avoid mineral oil or Castor oil during pregnancy, use metamucil, senokot or 1 teaspoon milk of magnesia sparingly. Skin Changes - due to increased hormonal level. Pregnant woman should use basic skin care. Backache - from exaggerated lumbosacral curving during pregnancy. Interventions are back exercises, wear low-heeled shoes, avoid heavy lifting, avoid NSAIDs or codeine, use tylenol sparingly. Leg Cramps - due to low calcium level and pressure of uterus on nerves. Nursing interventions are regular exercise like walking, elevate feet and dorsiflex while rest increase milk intake. Orthostatic Changes - due to abdominal pressure from enlarging uterus. Pregnant should sit with feet up, change position slowly, avoid alcohol. Shortness of Breath - from pressure on diaphragm. Nursing interventions include sleep with feet elevated or on side, no overexertion, get rest periods regularly.

DANGER SIGNS OF PREGNANCY (SHAVVVE)

S - swelling of face, finger, legs: possibly due to hypertension of pregnancy, thrombophlebitis (for leg swelling. H - headache, continuous and severe: possibly caused by hypertension of pregnancy. A - abdominal or chest pain: possibly due to ectopic pregnancy, uterine rupture, pulmonary embolism V - vaginal bleeding: possibly caused by placental problems (previa, abruptio, premature separation). V - vomiting, persistent: possibly caused by infection (also with fever and chills), hyperemesis gravidarum V - visual changes: possibly due to hypertension of pregnancy E - escape of vaginal fluids: possibly due to premature rupture of membranes Danger Signs of Pregnancy Induced Hypertension

swelling of the face or fingers flashes of lights or dots before the eyes dimness or blurring of vision severe, continuous headache

Fetal Danger Signs:

high or low FHR meconium staining hyperactivity fetal acidosis determined through scalp capillary technique (result is below 7.2

pH)

GESTATIONAL DIABETES Diabetes is an inherited metabolic disorder caused by insulin deficiency or excessive resistance to insulin. Gestational diabetes: a diabetic manifestations occurring whenever the woman gets pregnant with eventual symptom fading at the completion of pregnancy. There is presence of indications of hyperglycemia and hypoglycemia, hydramnios, infection, and pre-eclampsia. Oral hypoglycemic is contraindicated during pregnancy and early delivery is anticipated because it passes to placental barrier and can be teratogenic. Maternal Effects Gestational diabetes

uteroplacental insufficiency risk of dystocia hydramnios

Fetal Effects of Gestational diabetes

increased fetal mortality risk of congenital abnormalities increased hypoxia large for gestational age infant neonatal hypoglycemia

Effects on Pregnancy

high insulin resistance changing insulin needs difficulty controlling blood sugar insulin shock

Diagnostic Exams of Gestational diabetes 1. Glucose Screening Test

8 hour fasting for FBS given 50g glucose load blood sample for sugar 1 hour after

If FBS is more than 90 mg/dl and at 1 hour post glucose loading is more than 140 mg/dl, DIABETIC! 2. Three Hour Glucose Tolerance Test Normal Findings:

FBS - 80 - 100 mg/dl 1 hour - <190 mg/dl 2 hours - <165 mg/dl 3 hours - <145 mg/dl

3. Glycosylated Hemoglobin

measures control after 3 months. Upper normal level is 6% of total hemoglobin

Main Nursing Diagnoses 1. Altered nutrition greater than body requirements 2. High risk for infection Nursing Care for Gestational Diabetes

careful monitoring DIET: 20% of calories from protein; 50% from carbohydrates; 30% from fats.

Increased dietary fibers, should not less than 1800 calories per day exercise to lower blood glucose stress management insulin requirements will be increasing in the 2nd and 3rd trimester in relation to

human-placental lactogen (HPL) Infection prevention sugar evaluation of fetal status.

White's Classification of DM

1. Class A - Gestational diabetes, abnormal glucose tolerance test, diet controlled, insulin may be needed.

2. Class B - onset after age 20, 0-9 years duration, no vascular disease 3. Class C - onset between ages 10 and 19, 10-19 years duration, no vascular disease 4. Class D - onset under age 10, 20 years or more duration, with vascular disease

(retinitis and calcification in legs), hypertension is present 5. Class E - calcified pelvic vessels 6. Class F - characteristic of class E plus retinopathy and nephropathy

DISCHARGE INSTRUCTIONS AFTER DELIVERY (Postpartum) The first discharge instruction after delivery is Rest. It should be at least one rest period a day. Second is Follow-up. It should be schedule at 4-6 weeks. Report any signs of fever, chilling, increased lochia and depressed behaviors. Third is Hygiene. Clean the perineal area from front to back, center to sides. No douching for one month or until there's postpartum check-up. Fourth is Work Avoid heavy lifting for at least 3 weeks. Fifth is Coitus An be done if episiotomy is healed already and lochia returns to alba (about 3 weeks). Sixth discharge instructions after delivery is Contraception. Begins after or when coitus is initiated.

DYSTOCIA DURING PREGNANCY

Dystocia is a difficult labor and delivery due to problems with one of the "five P's" (Passenger, Passageway, Powers, Person, Psychological response) leading to maternal exhaustion, infection, trauma, and fetal injury and death. Diagnostic exams for dystocia:

vaginal exam pelvimetry ultrasound Leopold's maneuver.

The Main Nursing Diagnoses for Dystocia are Pain and Anxiety. Management for Dystocia:

sedation for hypertonicity stimulation of labor for hypotonicity C/S prophylactic antibiotic constant monitoring of fetal and maternal vital signs provide rest monitor presence of cord prolapse or rupture of membranes regularly assess fatigue and pain.

ECTOPIC PREGNANCY

Ectopic Pregnancy is a pregnancy that occur in extrauterine area with implantation usually occurring in ampulla of the fallopian tubes outer third portion. Ectopic pregnancy may result to maternal and fetal death and infertility. Manifestations of ectopic pregnancy

Amenorrhea, with positve pregnancy test unilateral lower quadrant (abdominal or pelvic pain) rigid, tender abdomen upon palpation vaginal spotting or bleeding presence of bloody fluid in culdocentesis (aspiration of the cul-de-sac of Douglas) visualization of pelvic organ throug culdoscopy gestational sac in tube in ultrasound

Diagnosis of ectopic pregnancy is made by laparoscopy and ultrasound. Nursing management for ectopic pregnancy

preventive measures for shock prepare for surgery provide emotional support for the grieving process administration of antibiotics and Rhogam as needed.

EPISIOTOMY

Episiotomy is an incision made into the perineum to enlarge vaginal outlet and facilitate delivery. Different Types of Episiotomy: 1. median - commonly used, safer and less painful. 2. mediolateral - has no risk of extending to rectum but with greater blood loss, difficult to repair, and healing is painful. Assessment After Episiotomy: R - redness E - edema E - ecchymosis D - discharge A - approxiamtion, hematomas, and pain. Main nursing diagnosis for episiotomy is Pain Nursing Care for episiotomy includes pain measures, peri-care, and incision care

Exercise during pregnancy helps in managing discomforts of labor by strengthening pelvic and abdominal muscles. Exercise during pregnancy must have a specific time and duration. The Safety Precautions include:

1. never exercise to a point of exhaustion or if there are danger signs of pregnancy 2. always rise from the floor slowly to prevent orthostatic hypotension 3. to rise from the floor, roll over to the side first and then push up to avoid strain on

the abdominal muscles 4. never point the toes to prevent leg cramps 5. do not hyperextend the lower back to prevent muscle strain 6. do not hold your breath while exercising because this increases intra-abdominal

and intrauterine pressure 7. do not practice second-stage pushing. This may increase intrauterine pressure and

rupture of membrane

Exercise during pregnancy designs include:

1. tailor sitting 2. squatting 3. pelvic floor exercise/kegel's exercise 4. abdominal muscle contraction exercise: blowing candle exercise 5. pelvic rocking

FAMILY PLANNING

Ineffective methods of family planning are Coitus interruptus and breastfeeding. Sexual adjustment: Sex is resumed as soon as wound healing occurs, bleeding stops, and client feels comfortable with it. Fatigue, body image, and hormonal changes can influence desires. Natural Family Planning - avoidance of coitus during fertile period - Health Teachings : daily body temperature recording plots of ovulation: usually 14 days before next menses. : abstinence recommended from day 6 to day 14 for an average 28 day cycle : Cervical mucus becomes stretchable at ovulation (spinnbarkeit)

Oral Contraception

inhibits ovulation effective, reversible method should be taken everyday alters cervical mucus

Health Teachings

pills must be taken according to schedule teach patient to report side effects headache, edema, hypertension, amenorrhea, breakthrough bleeding protect against certain cancers, anemia and other conditions not recommended for breastfeeding women because it can reduce milk supply can be used for emergency contraception after unprotected sex

Side Effects: irregular vaginal bleeding, missed period, upset stomach

DMPA (Depot-medroxyprogesterone acetate)

effective and safe changes in vaginal bleeding are normal weight gain may occur do not prevent STD's do not contain estrogen

Long-acting progestin implants (norplant) - inhibit ovulation

capsules are placed under the skin of a woman's upper arm can prevent pregnancy for at least 5 years effective within 24 hours after insertion

Health Teachings : six selastic capsules containing a progestin are implanted in the patient's arm : side effects are spotting, irregular bleeding, amenorrhea, weight gain, headache, depression Tubal Ligation - permanent interruption of reproductive capacity

helps protect against ovarian cancer reversal surgery is difficult

preparation of the patient for minilaparotomy or laparoscopy

Before: NPO for 8 hours, no medications After: rest for 2-3 days, avoid heavy lifting for a week, take paracetamol, avoid sex for at least 1 week Reportable sign and symptoms: high fever in the first 4 weeks, pain, pus, abdominal pain, diarrhea, fainting, dizziness Health Teachings : procedures are theoretically reversible but permanency of effect should be emphasized : Vasectomy- ligation of the vas deferens: pain and swelling on the incision site during the first week is common. Takes 4-6 weeks and upt to 36 ejaculations to clear sperm from vas deferens. Follow-up semen count is necessary : Tubal Ligation- interruption of tubal patency by coagulation, ligation, or banding. Complications include hemorrhage, infection, bowel perforation Vasectomy

permanent no effect on sexual performance fully effective only after 20 ejaculations or 3 months. The man should use

condom or his partner should use another method common complications: pain in the scrotum, swelling, bruising, brief feeling of

faintness after the procedure

Condom - barrier method

interrupts sex, reduces sensation comes in different sizes, shapes, colors and textures the only contraindication: LATEX allergy (severe redness, itching, swelling)

Health Teachings : sheath placed over the erected penis before intercourse to collect semen

: affords some protection against STDs : side effects are perineal or vaginal irritation IUD

small flexible plastic frame it is inserted into a woman's uterus through her vagina a provider can remove the IUD by pulling gently on the strings with forceps common side effects: menstrual changes (longer, heavier menstrual periods,

bleeding and spotting, cramps or pain during periods) check IUD once a week during the first month after insertion, after each menstrual

period, if possible after noticing any possible symptoms of serious problems to check the IUD, a woman should: wash her hands, sit in a squatting position,

insert 1 or 2 fingers into her vagina as far as she can until she feels the strings. Do not pull on the strings

instruct the patient to return for a visit 3-6 weeks after IUD insertion

Vaginal Methods (spermicide, diaphragm, cervical cap) - methods that women control and can be used when needed - help protect against some STD's - insert spermicide up to 1 hour before sex. Place it high in the vagina. Insert foaming tablets, films, and suppositories at least 10 minutes before sex. Do not douche for at least 6 hours after sex - insert a diaphragm or cervical cap ahead of time when you might have sex. After sex leave the diaphragm or cap in place and do not douche for at least 6 hours Action

: destroy sperm or neutralize vaginal secretions - Health Teachings : effectiveness increases if used with a condom : report local tissue irritation Fertility awareness-based methods : Remember the Rules: Cervical secretions: avoid unprotected sex from the first day of any cervical secretions or feelings of vaginal wetness until the 4th day after the peak day of slippery secretions Basal Body temperature (BBT): avoid unprotected sex from the first day of menstrual bleeding until body temperature has risen and stayed up for 3 full days Calendar or rhythm: determine the fertile time through calendar calculations. Avoid unprotected sex between the first and last days of the estimated fertile time Cervical Secretions + BBT: avoid unprotected sex from the first day of cervical secretions until both the 4th day after the peak of slippery secretions and the 3rd full day after the rise in body temperature LAM (Lactation Amennorhea method)

temporary based on breastfeeding can be used when (1) the woman breastfeeds often both day and night (2)

menstruation have not returned (3) baby is less than 6 months effective for up to 6 months after childbirth an ideal pattern of breastfeeding for LAM is at least 8-10 times a day including at

least once a night

FEMALE REPRODUCTIVE ANATOMY

The female reproductive anatomy composes of External and internal genitalia. External Genitalia

Mons pubis - a pad of adipose tissue over symphysis pubis, covered by curly hair, for protection against trauma.

Glans clitoris - a small rounded organ (approximately 1-2 cm) of erectile tissue at the forward junction of the labia minora, covered by prepuce

Urethra meatus - urethral opening Labia majora - two folds of adipose tissue covered by loose majora: serves as

protection for external genitalia Labia minora - posterior to mons veneris are two folds of connective tissues Hymen - tough but elastic semicircle of tissue that covers the opening to the

vagina in childhood Fourchette - the ridge of tissue formed by the posterior joining of the two labia

minora and labia majora Perineum - perineal muscles posterior to the fourchette; stretchable during

childbirth

Internal Genitalia

Vestibule - a flattened, smooth surface inside the labia Bartholin's gland - vulvovaginal gland, just lateral to the vaginal opening of both

sides, lubricates the external vagina during coitus Skene's gland - a paraurethral gland located just lateral to the urinary meatus on

both sides; lubricates the external vagina during coitus Vagina - muscular organ that extends from the vulva to the uterine cervix; act as

the organ of intercourse and conveys sperm to the cervix approximately 6-7 cm long

Cervix - the lowest portion of uterus; about 2-5 cm long: cavity is termed cervical canal, junction of the canal at isthmus is internal cervical os and distal opening to the vagina is external cervical os

Uterus - about 5-7 cm long, 5 cm wide and 2-5 cm deep in its widest upper part; receives ova, provides a place for implantation and nourishment during fetal growth, furnishes protection to a growing fetus and at the maturity of the fetus, expel it from the woman's body. The three divisions are: a) the body or corpus b) the isthmus, and c) the cervix

Fallopian tubes - 8-14 cm muscular tubes that extend laterally from the cornua of the uterus convey ova from ovaries to uterus. Segments are interstitial, isthmus, ampulla, and infundibulum

Ovaries - function is to produce, mature and discharge egg cells. Consist of ovarian cortex which is responsible to maturation of ova and production of large amount of estrogen and progesterone, and ovarian medulla contains connective tissue and the blood supply to the ovary.

FETAL BLOOD CIRCULATION

In fetal circulation, the placenta is responsible for metabolism (fetal digestive tract), endocrine secretions, and transfer (fetal pulmonary and renal system). The umbilical cord has two arteries and one vein.

Structures in Fetal Circulation are: 1. Placenta Location: attached to the uterus Function: gas exchange during fetal life

2. Umbilical Arteries Location: two arteries in the cord Function: carry unoxygenated blood from the fetus (descending aorta) to placenta

3. Umbilical Vein

Location: one vein in the cord Function: carry oxygenated blood to the fetus 4. Foramen ovale Location: an opening between right and left atria of heart bypassing lungs Function: to shunt blood from the right atrium to the left atrium so that blood can be supplied to brain, heart and kidney

5. Ductus arteriosus Location: connects pulmonary artery and aorta, bypassing lungs. Function: shunting of the larger portion of the blood away from the lungs and directly into the aorta 6. Ductus venosus Location: connects umbilical vein and inferior vena cava, bypassing liver Function: to supply blood to liver

FETAL HEART TONE

Fetal Heart Tone (FHR) should be 120-160 beats per minute throughout the pregnancy. It can be heard as early as 11th week by the use of an ultrasonic doppler technique Variability of Fetal Heart Tone:

a) Decreased Variability - CNS depression (often due to meds) b) Late Deceleration - a fetal hypoxia and distress due to pre-eclampsia, maternal hypotension, excessive uterine contraction c) Early Deceleration - not caused by hypoxia nor can result to poor fetal outcome

Assessment of Fetal Heart Tone can be done through: 1. Rhythm Strip Testing - Fetal Heart Tone is assessed in terms of baseline and long-and-short term variability. - baseline reading means the average rate of the fetal heart beat per minute - short term variability denotes the small changes in rate that occur from second to second - long term variability denotes the difference in heart rate that occurs over a 10 or 20 minute time period 2. Non-Stress Testing - done in 10 minutes to note the response of FHR to fetal movement - as fetus moves, FHR should be increased by 15 beats per minute and remain elevated for 15 seconds, then return to its pattern as the fetus quiets - the test is reactive if 2 accelerations of fetal heart rate lasting for 15 seconds occur following movement within 10 minutes period. - the test is non-reactive if no accelerations occur with fetal movements. Amniocentesis is indicated to check lung maturity - if 10 minute period passed without fetal movement, it means that the fetus is sleeping. Give the mother oral carbohydrate snack to increase the glucose level and stimulate fetal movement. 3. Vibroacoustic Stimulation - the application of an instrument to produce a sharp sound to the mother's abdomen to startle and wake the fetus.

Fetal Monitoring During Labor and Delivery 1) Periodic auscultation - per minute basis 2) FHR - baseline without contraction should be 120-160 bpm. Baseline variability is dependent on fetal sleep wake states, medications, hypoxia. Marked acceleration (more than 180 bpm) may be related to prematurity, maternal fever, hypoxia, fetal infection, and drugs. 3) External Monitoring: a. External Mode

Tocotransducer - pressure-sensing device applied to maternal abdomen to monitor frequency and duration of contraction

Ultrasound Transducer - continous monitor of FHR, which can be interpreted in relation to contraction

Phonotransducer and abdominal electrodes - fetal electrocardiogram

b. Internal Mode

Spiral electrode - applied to fetal presenting part; provides continuous measurement of FHR, baseline variability, and periodic changes

Intrauterine catheter - pressure transducer inserted beyond presenting part; measures frequency, duration, and intensity of contractions

4) Fetal scalp sampling - a small sample of fetal blood is taken from a punctured wound made into the fetal scalp to test for the presence of fetal acidosis. - Laboratory analysis of fetal pH is done; Normal value ranges from 7.25 to 7.35. A reported value of 7.20 or below means fetal acidosis. Stress Test or OCT Stress Test or OCT determines fetal well being and fetal ability to withstand stress of labor, done for abnormal NST or at risk fetus assesses placental function. Monitoring requires indirect fetal external monitor, and positioning is fowler's position; same as NST but with the use of oxytocin. Baseline and frequent maternal BP readings are taken, test takes 1-3 hours with close monitoring until there's contractions.

RESULTS:

1. Negative (normal) - absence of late decelarations of FHR with each of 3 contractions: negative window

2. Positive (abnormal) - presence of late decelarations of FHR with 3 contractions during 10-minute period: positive window

3. Equivocal or suspicious - absence of positive or negative window 4. Unsatisfactory - inadequate contractions of tracing 5. High risk pregnancies continue with weekly negative test

FETAL MOVEMENT - Fetal movement can be felt by the mother beginning 18th to 20th weeks of pregnancy and reaches a peak at 29th to 38th weeks. Normally, 2 times every ten minutes that it can be counted to move 10-12 times an hour. Any fetal movement fewer than 5 (half the normal number) in a chosen hour of observation should be reported. Cardift's count of ten means that having less than 10 counts in 10 hours calls for further evaluation. Placental insufficiency will greatly decrease the fetal movement. Maternal intake of depressant drugs, alcohol and smoking can reduce its movement, too. Fetal movements are not usually present in sleeping fetus.

FETAL HEART RATE

Type I (early deceleration)

caused by head compression - nursing responsibility: continuing FHR monitoring normal pattern were onset of FHR deceleration begins as uterus contracts, and before peak of

contraction, and ends as contraction ends, with return to baseline.

Type II (late deceleration)

caused by uteroplacental insufficiency - nursing responsibility: turn patient to left lateral position. Give oxygen at 6-10 L/min via mask. Discontinue oxytocin if in use. Notify physician.

begins after contraction, and continues after contraction is over with a gradual return to baseline.

Type III (variable deceleration)

caused by umbilical cord compression nursing responsibility: change patient position. Give O2 @ 6-10 L/min via mask.

Notify physician. abrupt, transitory, and variable in duration, intensity, and timing includes rapid return to baseline with possible acceleration

FORCEPS DELIVERY - Two double-crossed spoon like articulated blades are used to assist in delivery of fetal head. - Prerequisites are fully dilated cervix, engaged head, vertex or face presentation, absence of CPD, empty bladder and bowel. Types of Forceps Delivery 1. High forceps - biparietal dimension of vertex above ischial spine 2. Midforceps - vertex at ischial tuberosities 3. Low forceps - vertex distending introitus, use to control and guide head easiest to deliver Complications of Forceps Delivery

perineal lacerations damage to facial nerve of fetus fetal death postpartal hemorrhage cystocele rectocele uterine prolapse

Main Nursing Diagnosis for Forceps Delivery is Fear and risk of injury to both fetus and mother. Nursing Implications for Forceps Delivery is closely monitoring both fetus and mother during delivery with continual assessment.

HIGH RISKS FACTORS DURING PREGNANCY The life of woman and fetus has significantly increased risk of disability or death. The importance of early detection: Better maternal-fetal neonatal outcome when the factors contributing to risky pregnancy are identified and intervened. Maternal mortality rate is 1 per 1,000 live births. Generally, these are:

1. abnormal fetal position or presentation 2. age 35 years, or younger than age 15 years

3. bleeding during pregnancy 4. drug or alcohol dependent 5. hydramnios 6. hypertension of pregnancy 7. infection in mother 8. maternal illness 9. past history of difficult delivery 10. post cesarean birth 11. potential for blood incompatibility

Medical history and current problems include:

1. obstetrical history, current status 2. psychosocial risks, maternal behaviors, and adverse lifestyle 3. smoking 4. caffeine: 3 or more cups of coffee 5. alcohol: no safe dose 6. drugs 7. abuse and violence 8. psychologic status: intrapsychic disturbance, family dissolution/disruption, stress 9. working more than 10 hours, heavy lifting, standing for more than 4 hours

Socio-demographic risks are:

1. low income 2. lack of prenatal care 3. age-height less than 145 cm (4'9") 4. parity >5 5. marital status 6. residence 7. ethnicity

Environmental risks are:

1. infection: viral, bacterial, fungal, protozoan 2. radiation 3. chemicals 4. physical: extreme heat >38.9C, noise, vibration, atmospheric pressure

HYDATIDIFORM MOLE Hydatidiform mole (Vesicular Mole) -it is an abnormal development of placental villi into grapelike cysts filled with viscid material.

It is more common for those with Asian heritage, older gravida, and after induction of ovulation with Clomiphene therapy.

Uterus is larger than AOG, soft and full lower segment on palpation brown vaginal discharges during 12th week onwards persistent bleeding

Diagnosis of Hydatidiform (Vesicular) Mole

high HCG level no FHR or palpable fetal parts ultrasound shows no fetal skeleton. increased nausea and vomiting

Management for Hydatidiform (Vesicular) Mole

monitoring and management of shock by blood transfusion or IV therapy mole is removes by vacuum aspiration or curettage educate on avoiding pregnancy for at least one year educate on the need to monitor HCG for 1 year if there is rise in HCG, further treatment (hysterectomy or chemotherapy) is

required

Client needs to have HCG testing every month for a year while using a reliable contraceptive.

Methotrexate is the drug of choice for prophylaxis.

INFLAMMATORY BOWEL DISEASE DURING PREGNANCY

Crohn's disease is the inflammation of the terminal ileus. Ulcerative colitis is the inflammation of the distal colon. Both may be caused by autoimmune response characterized by exacerbation and remissions.The predominant symptom is rectal bleeding. The bowel develops shallow ulcers; the woman experiences chronic diarrhea (4-24x/day), weight loss, occult blood in stool, and nausea and vomiting. In Crohn's Disease, there is Malabsorption of:

vitamin B12 folic acid, iron, calcium fats vitamins ADEK.

Complications

nutritional deficiencies toxic megacolon and other extraintestinal manifestations (arthritis, ankylosing

spondylitis, clubbing of fingers, anemia) Colon cancer is common.

Therapy is total GIT rest by administration of TPN; Sulfasalazine maybe continued without fetal injury. Specific goals of nursing care for inflammatory bowel disease:

maintain and correct nutritional and fluid status relieve discomfort diarrhea prevent complications provide physical rest and comfort relieve pain restore blood volume provide emotional support

LEOPOLD’S MANEUVER

- are a systematic method of observation and palpation to determine fetal position, presentation, lie and attitude which helps in predicting course of labor. - woman who emptied her bladder should lie in supine position with her knees flexed slightly so abdomen is relaxed. - Warm hands to avoid contraction of abdominal muscles. - gentle but firm touch Keen observation of abdomen should give data about

1. longest diameter in appearance 2. location of apparent fetal movement

The four Leopold's maneuver are: 1. First Maneuver - to determine presenting part at the fundus - head is more firm, hard and round that moves independently of the body - Breech is less well defined that moves only in conjunction with the body 2. Second Maneuver - to determine fetal back - one hand: will feel smooth, hard resistant surface (the back) - the opposite side, a number of angular nodulation (knees and elbows of fetus)

3. Third Maneuver - to determine position and mobility of presenting part by grasping the lower portion of the abdomen (just above the symphysis pubis). - if the presenting part moves upward so the examiner's hand can be pressed together, then presenting part is not engaged 4. Fourth Maneuver - to determine fetal descent - fingers are pressed in both side of the uterus approximately 2 inches above the inguinal ligaments, then press upward and inward. - the fingers of the hand that do not meet obstruction palpates the fetal neck, as the fingers of the other hand meet an obstruction above the ligaments palpates the fetal brow. - Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows and knees. - Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). - also palpates infant's anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman's back).

MECHANISM OF LABOR

The mechanisms of labor (memorize EDFIERRE) comprises of the following: Engagement - presenting part of the fetus is fixed in true pelvis Descent - presenting part progresses through pelvis; level os station

Flexion - descending head meets pelvic floor; chin is brought down to chest

Internal Rotation - fetal head rotates from transverse diameter to anteroposterior diameter to facilitate movement through pelvis

Extension - once fetal head reaches perineum, it extends to be born

Restitution - after delivery of the head, it rotates back to position prior to engagement External Rotation - shoulder engage and move similarly to head

Expulsion - entire infant emerges from mother

PAIN MANAGEMENT DURING LABOR

We can follow the Gate Control Theory in pain management during giving birth to a child. The three techniques to help gating mechanisms are:

1. cutaneous stimulation 2. distraction 3. reduction of anxiety

The methods include: 1. The Bradley Method by Robert Bradley

stresses on the role of husband muscle toning exercise

diet contains no animal fats, preservatives or high salts walking is encouraged during labor and use of internal focus point as

disassociation technique

2. The Psychosexual method by Sheila Kitzinger

a program of conscientious relaxation and levels of progressive breathing to go with the flow of contractions

3. The Dick Method by Grantly Dick

eliminates fear to reduce tension and eventually pain sensation done with relaxation exercises and abdominal breathing during labor

4. The Lamaze Method by Ferdinand Lamaze a) follows the concept of stimulus - response conditioning: Preventing pain in labor by use of the mind as guided by the premise:

pain does not have to occur during contraction sensation such as uterine contraction can be inhibited from reaching the brain

cortex and registering as pain conditioned reflexes are positive action use to replace pain sensations of labor

b) this method is for those whose AOG is at least 26 weeks only c) typical exercises include:

the cleansing breath - breaths in deeply and exhales deeply to begin any breathing exercises

conscious relaxation - deliberately contracts and relaxes body portions from head to toe

consciously controlled breathing - chest breathing following these pattern: slow > shallow > pant blow > shallow chest panting

effleurage - light abdominal massage focusing/imaging

PELVIC INFLAMMATORY DISEASES

Causes of Pelvic inflammatory diseases

gonococci staphylococcus streptococci other pus forming organisms

Signs and Symptoms of Pelvic inflammatory diseases

acute, sharp, severe aching pain on both sides of the abdomen or pelvis occasional vaginal bleeding generalized infection malaise fever chills anorexia nausea and vomiting tachycardia

Complications of Pelvic inflammatory diseases

pelvic abscess chronic PID septic shock

Diagnosis of Pelvic inflammatory diseases

history of acute lower UTI during menses (gonococcal PID) or between periods (non-gonococcal PID)

sexual patterns contraceptives (esp. IUD) laboratory test including multiple cultures

Treatment of Pelvic inflammatory diseases

laparotomy antibiotic therapy pain management avoid sex and douching and observe perineal care bed rest for acute stage

PREGNANCY INDUCED – HYPERTENSION

Pregnancy-Induced Hypertension is a group of disorders characterized by the presence of hypertension beginning 20 weeks AOG or greater. It is the 2nd cause of maternal mortality in the country (Philippines). Pregnancy-Induced Hypertension is common in those with age below 17 years or more than 35 years, protein malnutrition, pimiparity, diabetes, little or no prenatal care, low socioeconomic status, previous history of hypertension. Basic Manifestations of Pregnancy-Induced Hypertension

proteinuria edema hypertension

Types of Pregnancy-Induced Hypertension 1. Toxemia - pre-eclampsia and eclampsia 2. Chronic Essential Hypertension - present during non-pregnant state and combines with pre-eclampsia. I. PRE-ECLAMPSIA 1. Mild Pre-eclampsia

increased BP 20/15 mmHg above baseline (Roll Over Test) weight gain of 1 lb or more per week in last trimester mild generalized edema +1 proteinuria (<300-500> maybe managed at home

2. Severe Pre-eclampsia

BP of 160/110 severe hypertension, 30-40 mmHg while on bedrest massive anasarca and weight gain 3 - +4 proteinuria (5 grams/24 hrs urine collection) less than 500 ml output in 24 hrs (Oliguria) dizziness, headache, blurring or with spots on vision, nausea and vomiting,

epigastric pain, and irritabilty) managed in the hospital

II. ECLAMPSIA

changes from pre-eclampsia with tonic-clonic seizure attacks to comatose state. Pre-monitoring signs: aura,

epigastric pain hypertensive crisis coma death is from hemorrhage, circulatory collapse, or renal failure obstetrical emergency!!!

III. HELLP

characterized by RBC hemolysis, elevated liver enzymes and low platelet count related to severe vasospasm leading to disseminated intravascular coagulation (DIC)

platelet and RBC transfusion often are administered, coagulation factors are monitored

labor is induced if AOG is more than 32 weeks, cesarean if less than 32 weeks.

IV. DIC

clinical manifestations include varying degree of bleeding from oozing to generalized hemorrhage, purpura, and petechiae as a result of overstimulation of coagulation factors

coagulation factors are closely monitored and replaced treatment of underlying cause (ie. abruptio placenta, fetal death in utero, PIH)

resolves its pathology the only cure is to end the pregnancy

Nursing Care for Pregnancy-Induced Hypertension a) closely monitoring of maternal vital signs (esp. BP) and weight, FHR b) bedrest most of the day; side-lying position; 8-12 hours c) high protein (60-70 gram/day), low sodium diet, calcium (1,200 mg), magnesium, 2-6 g of zinc, vit. C and E

d) health teachings for symptoms of mild and severe pre-eclampsia e) administration of magnesium sulfate. Corticosteroids and antihypertensives as ordered. HPN drugs are excreted in breast milk f) drug of choice is Magnesium Sulfate (MgSO4) - monitor for magnesium sulfate toxicity

B - blood pressure is decreased U - urine output less than 30 cc/hour R - respiratory rate less than 12 cycles/min (1st to diminish) P - patellar reflex

- normal MgSO4 serum level is 1.5 - 3 mEq/L - maintenance dose 4 - 7 mEq/L - at 8-10 mEq/L, respiratory rate starts to diminish - at 10-14 mEq/L, deep tendon reflex is absent g) blood replacements h) monitor for seizure activity and protection from injury i) administer O2 as needed j) prepare mother and her family for early induction of labor. Vaginal delivery is preferred over cesarean k) health teachings on contraception

PREMATURE LABOR

Preterm or Premature labor is a labor occurring after 20th week but before 37th. It may cause fetal death if delivered low birth weight but there's a good chance of survival if delivered 35th weeks onwards. If labor occurs before 20 weeks of gestation, it is abortion; if beyond 37 weeks, it is a mature fetus. Risk Factors of Preterm/Premature Labor P - previous preterm labor A - abdominal surgery Y - younger than 17 O - older than 35 L - low socio-economic class A - abnornality of fetus or placenta M - multiple gestation E - emotional and physical stress N - nutritional deficiency

Focus: prevention of the delivery of premature fetus Conditions to halt labor: membrane are intact, good FHT, no evidence of bleeding, cervix not dilated more than 3 - 4 cm, effacement not more than 50% (if any of these condition is not present, delivery, regardless of fetal age, is inevitable). Maternal Complications requiring delivery of preterm infants are:

1. placental separation with uncontrolled hemorrhage 2. severe pre-eclampsia or eclampsia 3. uncontrolled renal or CVD 4. premature rupture of membrane 5. chorioamnionitis

Main Nursing Diagnosis: Fear Nursing Implications

bed rest in less stimulating environment at left lateral recumbent position adequate hydration use of steroids to prevent respiratory distress syndrome for infants prepare for delivery administer tocolytic agents (vasodilan, ritodrine, terbutaline, magnesium sulfate)

as ordered, but prepare calcium gluconate as an antidote for MgSO4 toxicity.

PLACENTA PREVIA

Placenta previa is an improperly implanted placenta in lower uterine segment caused by multiparity, presence of myomas, previous CS, uterine abnormalities.

spotting (during first and second trimester) bleeding that is PAINLESS, profuse and sudden (during third trimester or at the

end of second trimester). NOTE: bleeding may not occur until onset of cervical dilatation causing the placenta to loosened from the uterus. Total placenta previa has more earlier profuse bleeding.

ultrasound showing the location and degree of obstruction

Classification of Placenta Previa

complete (total or central) partial (implantation occludes a portion of the cervical os) marginal (placenta edge approaches cervical os) low lying (lower rather than upper implantation)

Diagnosis for Placenta Previa

ultrasound identification of fetal position hemoglobin and hematocrit count

Nursing Implications for Placenta Previa

BLEEDING IS AN EMERGENCY! (Fetal oxygen supply may be compromised and premature labor may begin

strict bed rest with oxygen if prescribed close monitoring of bleeding and maternal and fetal well-being determine fetal lung maturity by amniocentesis - L/S ration preventive shock measures positioning: sidelying or trendelenburg for 72 hrs (some advocate sitting position) NO IE OR RECTAL exam - it may initiate massive hemorrhage! (if necessary

MUST be done in the OR with double set up) keep IV line and make blood available

NOTE: greater risk for post-partum hemorrhage. Endometritis is also common.

PUERPERIUM

Post partum period begins after delivery towards when reproductive tract returns to normal non-pregnant state. Involution is the time when uterus returns to non-pregnant state.

weight of uterus reduced from 2 lbs to 2 oz endometrium regenerates fundus descends into pelvis; fundal height decreases about 1 cm per day; by 10th

day post partumly, fundus cannot be palpated abdominally.

Other Events during Puerperium 1. Cervix and Vagina

the muscles of cervix after a week regenerates external os remains wider internal os is closed after a week vaginal distention decreases vaginal rugae reappeared by third week lacerations or episiotomy suture line gradually heal

2. Ovarian function and Menstruation

dependent on how pituitary functions menses returns within 8 weeks to non-breastfeeding women and 3-4 months for

breastfeeding mothers breastfeeding mothers may experience amenorrhea woman may ovulate without menstruating

3. Breast

continue to secrete colostrum breasts become distended with milk on third day engorgement 48-72 hours in non-breastfeeding clients

4. Urinary Tract

urinary retention may be experienced as a result of loss of elasticity and tone and loss of sensation from drugs, trauma or loss of privacy

diuresis will be experienced within first 12 hours after delivery kidney function returns to normal easily

5. Gastrointestinal

client will feel extremely starve after delivery constipation is occurring due to loss of tone and perineal tenderness hemorrhoids are common but eventually subsides

6. Vascular System

WBC increases during labor and delivery, as well as early post partum period; then return to normal after few days

Hemoglobin and RBC decreased and return to normal value after a week elevated fibrinogen levels during first week postpartum and contribute to

thrombophlebitis blood volume is back by third week

7. Vital Signs

temperature may be elevated to 100.4 F (38 C) during first 24 hours after delivery without pathologic condition

bradycardia is usual for a week about 50-70 blood pressure must be unchanged

Rubin's Postpartum Emotional Phases 1. Taking-in phase - for 2-3 days

basic and primary needs of mothers are their own - food, water, clothing, sleep mother becomes attention seeker: she always talk about her experience during

labor and delivery. The nurse should be good listener in interpreting these events not good time for health teachings

2. Taking-hold phase - usually for 3 days to 2 weeks but it varies in every women

mother is sensitive in doing the "mothering" role right mother is more in control of her emotions best time for health teachings

3. Letting-go phase - varied

mothers may grieve over the separation of the baby from her body may display dependent-independent behaviors where she wanted to feel secure

while making decisions time when post-partum blues may develop time when bonding process is facilitated and parenting skills are enhanced

RHEUMATIC DISORDERS DURING PREGNANCY

Juvenile Rheumatoid Arthritis - it is a disease of connective tissue (synovial membrane destruction) with joint inflammation and contractures. - the symptoms improved during pregnancy because of increased circulating corticosteroids in the maternal bloodstream which recur during postpartum. - with corticosteroid and salicylate threapy, prolonged pregnancy results. Salicylate interferes prostaglandin synthesis that inhibits labor process. - due to salicylates, infant can have bleeding defects and premature closure of ductus arteriosus, Also, women should not breastfeed. salicylates dose must be decreased 2 weeks before term. Systemic Lupus Erythematosus (SLE)

- it is a multisystem chronic degenerative disease of connective tissues. Symptoms are controlled during pregnancy and exacerbates during delivery. - most marked characteristic is the erythematous "butterfly shaped" rash on the face. - most serious kidney change is the fibrin deposits that blocks glomeruli leading to necrosis and scarring, expect renal failure. Thickening collagen tissues in the vascular system pose life threatening situation. - clients with SLE has antophospolipid antibodies which increases tendency for thrombi formation. - SLE is associated to infants small for gestational age, abortion, premature birth, and anemia.

STAGES OF LABOR 1. First Stage - onset of regular contraction to full dilation

Phase One (LATENT) - dilatation is 0 - 3 cm; duration is 10 - 30 sec; interval is 5 - 30 mins; intensity is mild to moderate

Phase Two (ACTIVE) - dilatation is 4 - 7 cm; duration is 30 - 40 sec; interval is 3 -5 mins; intensity is moderate to strong

Phase Three (TRANSITION) - dilatation is 8 - 10 cm; duration is 45 - 90 sec; interval is 2 - 3 mins; intensity is strong

Nursing Care for First Stage of Labor

1. monitor V/S and FHR every 15 mins 2. bed rest for ruptured membrane 3. empty the bladder 4. pain relief 5. teach breathing techniques 6. maintain safety

2. Second Stage of Labor - from full dilation to delivery of the fetus (30-60 mins for primigravida and 20 mins for multipara)

Phase One - station is 0 to +2; contraction is 2 to 3 mins apart Phase Two - station is +2 to +4; contraction is 2 to 2.5 mins apart with urgency

to bear down Phase Three - station is +4 to birth; contraction is 1 to 2 mins apart;fetal head

visible, increased urgency to bear down

Nursing Care for Second Stage of Labor

1. transfer to delivery room for 8-9 cm dilation for multigravidas and full dilation for primiparas

2. monitor V/S and FHR 3. prepare perineal area 4. encourage pushing with contractions 5. immediate newborn care

3. Third Stage of Labor - from delivery of infant to delivery of placenta

5 - 30 mins sudden gush of blood lengthening of the cord rising of the fundus globular uterus

Nursing Care for Third Stage of Labor

1. assess for placental separation 2. inspection of placenta 3. monitor V/S 4. initiate breastfeeding

5. administer oxytoxin and antilactation agents as ordered 6. sending cord blood to laboratory if mother is O-positive or Rh-negative 7. allow bonding

4. Fourth Stage of Labor - time from delivery of placenta to homeostasis (first 4 hours after delivery of the placenta) Nursing Care for Fourth Stage of Labor

1. monitor V/S every 15 mins 2. take fundal height, position and consistency 3. assess for lochia 4. check perineum 5. perform perineal care from front to back 6. post partum care

FIVE P’s OF LABOR A. Passenger: the fetus

Attitude - relationship of fetal body parts to each other, normal uterine posture is completely flexed

Lie - relationship of fetal spine to maternal spine. Longitudinal or vertical is when fetus is parallel to mother's spine, transverse or horizontal if fetus is at right angle to mother's spine.

Presentation - portion of fetus that enters pelvis first: presenting part could be cephalic or breech (frank, footling)

Position - relationship of fetal reference point to one or four quadrants or sides of mother's pelvis. Maternal pelvis side: L-left, R-right; Fetal Reference points: O-occiput, M-mentum, B-brow, S-sacrum; Maternal Pelvis Quadrant: A-anterior, T-transverse, P-posterior

Station - degree of engagement from presenting part to ischial spine; Station 0 means at ischial spine, minus station means above spine, and plus station is below the spine.

B. Passageways

Pelvis Soft tissues - lower uterine segment, cervix, vagina, and introitus

C. Powers - forces acting to expel fetus; primarily by involuntary uterine contractions, secondarily by voluntary bearing down. - functions of uterine contraction are effacement and dilation D. Person E. Psychological Response - response to contraction, perceptions and beliefs, pre-natal care and education, support systems and communication skills.

SIGNS OF PREGNANCY 1. Presumptive Signs - it is the changes felt by the woman

Amenorrhea - absence of menses; ovulation inhibited by increased progesterone and estrogen level

nausea and vomiting increased breast sensitivity and breast changes - from increasing estrogen level integumentary changes - increased pigmentation in localized areas constipation frequent urination - due to increased renal blood and plasma flow; increased GFR quickening (18th - 20th weeks) abdominal enlargement

2. Probable Signs - changes observed by examiner

uterine enlargement hegar's sign - softening of the lower segment of the uterus goodells's sign - softening of the cervix due to increased blood supply chadwick's sign - purplish discoloration of the vaginal mucosa ballottment - when fetus rebounds against examiner's fingers during palpation braxton hick's contraction positive pregnancy test: HCG, reliable by 90 - 98%

Tip: To arrange Hegar's Goodel's and Chadwick's signs, arrange them anatomically from external to internal organ, then mathc them with alphabetized sequence, wher Chadwicks is to vagina, Goodels is to cervix, and Hegar is uterus (because of alphabetical sequence C-G-H and organ order of vagina-cervix-uterus.

3. Positive Signs - definitive signs of pregnancy

fetal heart tone (FHT) can be heard: 12 weeks by doppler; 18-20 weeks by auscultation

X-ray or ultrasound of fetus (by 6-8 weeks) palpable fetal movements - felt by examiner usually 20 weeks

Developmental Tasks of Pregnancy 1. Validation: observed during the first trimester Psychological Task: Accepting the Pregnancy

Ambivalence, shock or denial may be experienced at the time of knowing occurrence of pregnancy

Introvert manifestation is usual with weight gain and other outward signs of pregnancy

2. Fetal Embodiment: second trimester Psychological Task: Accepting the Baby

fetus is viewed as part of self role adjustments - time of emotional maturity gains "inner" strength with the condition

3. Fetal Distinction: common when pregnancy reached 5th lunar month

fetus is viewed as separate to herself quickening encourages this feeling woman daydreaming on her role as mother and the future of the baby

4. Role Transition: third trimester Psychological Task: Preparing for Parenthood

woman becomes irritable and wanted to end the pregnancy with concrete plans about herself and the baby

SIGNS OF BEGINNING OF LABOR

Onset of labor is due to oxytocin stimulation, estrogen stimulation, progesterone withdrawal, and prostaglandin secretion, fetal secretion of cortical steroids, aging of placenta and increasing uterine pressure. Women in labor: "DO SCREAM"

"DO SCREAM"

D - descent of fetus into pelvic inlet (Lightening), may not occur in multiparas but 2 weeks prior in primiparas O - opening cervical OS (Dilatation) S - softening of cervix C - contraction of uterus. From the back and sweep across the abdomen, increasing frequency and intensity R - rupture of membrane. Sudden gush of clear fluid from the vagina E - effacement (progressive thinning and shortening of cervix) A - apprehension. Sometimes with feeling of extreme energetic M - mucous plug expulsion (SHOW) Signs of Placental Separation

1. uterus becomes firm and globular 2. sudden gush of blood from the vagina 3. umbilical cord lengthens outside vulva 4. uterine fundus rises in the abdomen

TORCH COMPLEX OF PREGNANCY

T - toxoplasmosis O - other R - rubella C - cytomegalovirus H - herpes Toxoplasmosis protozoa is transmitted through raw meat handling litter of infected cats. - Symptoms is flu-like: organisms passes placenta can result spontaneous abortion. - Diagnosis by serologic tests, such as the Sabin-Feldman dye test. - Treated with sulfadiazine and pyrimethamine. If toxoplasmosis is diagnosed before 20 weeks of gestation, damage to the fetus is more severe than if the disease is acquired later. - The incidence of abortion, stillbirths, neonatal deaths, and severe congenital anomalies is high. Other includes streptococcal infections, syphilis, gonorrhea, hepatitis; increased risk for spontaneous abortion and still birth. Rubella is highly teratogenic in first semester: cross placenta, death is usually the result if acquired during the third and seventh weeks. I it occurs in the second trimester, permanent hearing impairment is usually the result. - The best therapy for women is prevention. Women with titers should be vaccinated at least 2 months before becoming pregnant. Live attenuated vaccine is available and should be given to all children. Cytomegalovirus (CMV) belongs to the herpesvirus group and causes both congenital and acquired infections referred to as cytomegalic incluusion disease. - it is flu-like, mononucleosis like transmitted through sexual or respiratory route; may either cross placenta or infect thru vaginal canal. - May cause fetal death, retardation, heart defects and deafness. Herpes Simplex virus type 2 is an STD with painful blister on genitalia; vaginal and urethral discharge, which may be copious and foul smelling. Begins with reddened papules which becomes itchy, pustular vesicles that break and form painful wet ulcers, which then dry and develop crusts. - Treatment is toward relieving the woman's vulvar pain. Bacterial infection may be treated with cream containing sulfonamide. - When infection is suspected in pregnant woman, amniocentesis can be performed to determine if there is fetal involvement. If present, cesarean delivery should not be performed.

TYPES OF PELVIS

Pelvis serves to both support and protect the reproductive and other support organs. Its bones are ilium, ischium, pubis, sacrum, and coccyx. The subdivisions for obstetrical purpose are:

1. False pelvis - the superior half, supports the uterus during late months of pregnancy and aids in directing fetus to the true pelvis.

2. True pelvis - the inferior half, facilitates true delivery of fetus. 3. Inlet - the entrance to true pelvis or the upper ring of the bone through which the

infant must passed to deliver vaginally. 4. Outlet - the inferior portion of the pelvis, bounded in the back by the coccyx,

greatest diameter is the antero-posterior part. 5. Pelvic cavity - the space between the inlet and outlet. Its curve slows and controls

the speed of birth.

Internal Measurement of Pelvis are:

1. Diagonal conjugate - the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis; suggestive of antero-posterior diameter of inlet; it should be 12.5 cm to be adequate.

2. True conjugate/Conjugate vera - the distance between the anterior surface of sacral prominence and posterior surface of the inferior margin of symphysis pubis; to get this, just subtract the usual depth of symphysis pubis from diagonal conjugate. It should be 10.5 - 11.0 cm.

3. Ischial tuberosity diameter - the distance between ischial tuberosities or the transverse diameter of the outlet; 11.0 measurement is adequate.

Types of Pelvis

Gynecoid - transversely rounded and slightly ovoid Android - angulated, resembles male pelvis, heart shaped Anthropoid - oval, wider anteroposterior diameter Platypelloid - flat anteroposterior diameter, wide transversely

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