TORCH (Terratogenic) Infections – virusesCHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and developmentTORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.T – toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meatO – others. Hepa A or infectious heap oral/ fecal (hand washing)

Hepa B, HIV – blood & body fluids SyphilisR – rubella – German measles congenital heart disease (1st month) normal rubella titer 1:10<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3 months. Vaccine is terratogenicC – cytomegalo virusH – herpes simplex virus

Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes1. Cardiovascular System

increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood

easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation,

Physiologic Anemia pseudo anemia of pregnant women.

Normal ValuesHct 32 – 42%Hgb 10.5 – 14g/dL

Criteria:1st and 3rd trimester pathologic anemia if lowerHCT should not be 33%, Hgb should not be < 11g/dL2nd trimester Hct should not <32%Hgb Shdn't < 10.5% pathologic anemia if lower

1. A. Pathogenic Anemia

Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.

Assessment reveals:o Pallor, constipationo Slowed capillary refillo Concave fingernails (late sign of progressive

anemia) due to chronic physio hypoxia

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 hrs after, black stool, constipation

Monitor for hemorrhage

Alert:o Iron from red meats is better absorbed iron

form other sourceso Iron is better absorbed when taken with foods

high in Vit C such as orange juiceo Higher iron intake is recommended since

circulating blood volume is increased and heme is required from production of RBCs.

1. B. Edema lower extremities due venous return is

constricted due to large belly, elevate legs above hip level.

1 .C. Varicosities pressure of uterus

use support stockings, avoid wearing knee high socks

use elastic bandage – lower to upper

1. D. Vulbar varicosities painful, pressure on gravid uterus, to relieve-

position side lying with pillow under hips or modified knee chest position

1. E. Thrombophlebitis presence of thrombus at inflamed blood vessel

pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate

outstanding sign – (+) Homan's sign milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Mgt: Bed rest Never massage Assess + Homan sign once only might dislodge

thrombus Give anticoagulant to prevent additional

clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity,

protamine sulfate Avoid aspirin! Might aggravate bleeding.

2. Respiratory system common problem SOB due to enlarged uterus &

increase O2 demand Position lateral expansion of lungs or side

lying position.

3. Gastrointestinal 1st trimester change

3. A. Morning Sickness Nausea & vomiting due to increase HCG. Eat dry

crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon small freq feeding.

Vomiting in preg emesisgravida. Metabolic alkalosis, F&E imbalance primary

med mgt – replace fluids, Monitor I&O.

3. B. constipation Progesterone resp for constipation. Increase

fluid intake, increase fiber diet (fruits: papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.) Except guava has

pectin that’s constipatin. Veg petchay, malungay.

exercise mineral oil excretion of fat soluble vitamins

3. C. Flatulence avoid gas forming food – cabbage

3. D. Heartburn or pyrosis reflux of stomach content to esophagus small frequent feeding, avoid 3 full meals, avoid

fatty & spicy food, sips of milk, proper body mechanical

3. E. increase salivation ptyalsim mgt mouthwash

3. F. Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for

comfort

4. Urinary System frequency during 1st & 3rd trimester lateral

expansion of lungs or side lying pos – mgt for nocturia

Acetyace test albumin in urineBenedicts test sugar in urine

5. Musculoskeletal5. A. Lordosis

pride of pregnancy

5. B. Waddling Gait wkward walking due to relaxation – causes

softening of joints & bones Prone to accidental falls wear low heeled

shoes

5. C. Leg Cramps causes: prolonged standing, over fatigue, Ca &

phosphorous imbalance (#1 cause while pregnant), chills, oversex,

pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus

Mgt:

Increase Ca diet-milk (Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.

Vit D for increased Ca absorption Dorsiflexion

B. Local ChangesLocal change: Vagina:V – Chadwick’s sign blue violet discoloration of vaginaC – Goodel's sign change of consistency of cervixI – Hegar's change of consistency of isthmus (lower uterine segment)

LEUKORRHEA (whitish gray, mousy odor discharge)ESTROGEN (hormone, resp for leucorrhea)OPERCULUM (mucus plug to seal out bacteria).PROGESTERONE (hormone responsible for operculum)PREGNANT (acidic to alkaline change to protect bacterial growth (vaginitis)

Problems Related to the Change of Vaginal Environment:a. Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant momFlagellated protozoa wants alkalineS&Sx:

o Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema

Mgt: FLAGYL – (metronidazole – antiprotozoa).

Carcinogenic drug so don’t give at 1st trimestero treat dad also to prevent reinfectiono no alcohol – has antibuse effect

VAGINAL DOUCHE H2O : 1 tbsp white vinegar

b. Moniliasis or candidiasis due to candida albecans, fungal infection.

Color white cheese like patches adheres to walls of vagina.Signs & Symptoms:

Managemen: antifungal – Nistatin, genshan violet, cotrimaxole,

canesten

Gonorrhea Thick purulent dischargeVaginal warts condifoma acuminata due to papilloma virusMgt: cauterization2. Abdominal Changes

striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue – avoid scratching, use coconut oil, umbilicus is protruding

3. Skin Changes brown pigmentation nose chin, cheeks – chloasma

melasma due to increased melanocytes. Brown pinkish line linea nigra- symphisis pubis to

umbilicus

4. Breast Changes increase hormones, color of areola & nipple

pre colostrums present by 6 weeks, colostrums at 3rd

trimester Breast self exam 7 days after mens supine

with pillow at back. quadrant B upper outer – common site of cancer.

Test to determine breast cancer: mammography 35 to 49 yrs once every 1 to 2 yrs

50 yrs and above – 1 x a yr

6. Ovaries rested during pregnancy

7. Signs & symptoms of PregnancyA. Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . SubjectiveB. Probable signs observed by the members of health team. ObjectiveC. Positive Signs undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma + HCG – sign of H mole trans vaginal ultrasound. Empty

Presumptive Probable Positiveo Breast

changeso Urinary freqo Fatigueo Amenorrheao Morning

sicknesso Enlarged

uteruso Cloasmao Linea negrao Increased skin

pigmentationo Striae

gravidariumo Quickening

o Goodel's- change of consistency of cervix

o Chadwick’s- blue violet discoloration of vagina

o Hegar's- change of consistency of isthmus

o Elevated BBT – due to increased progesterone

o Positive HCG or (+)preg test

o Ultrasound evidence

o (sonogram) full bladder

o Fetal heart tone

o Fetal movement

o Fetal outlineo Fetal parts

palpable

o Ballottement – bouncing of fetus when lower uterine is tapped sharply

o Enlarged abdomen

o Braxton Hicks contractions – painless irregular contractions

Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)

First Trimester: No tanginal signs & sx, surprise, ambivalence, denial

– sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy

Focus: bodily changes of preg, nutrition

Second Trimester tangible S&Sx. mom identifies fetus as a separate

entity due to presence of quickening, fantasy. Developmental

task accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus.

Third Trimester: mom has personal identification on appearance of

baby Development task: prepare of birth & parenting of

child. HT: responsible parenthood ‘baby’s Layette” – best time to do shopping.

Most common fear let mom listen to FHT to allay fear

Lamaze classes

Pre-Natal Visit:1. Frequency of Visit: 1st 7 months – 1x a month

o 8 – 9 months – 2 x a montho 10 – once a weeko post term 2 x a week

2. Personal data: name, age (high risk < 18 & >35 yrs old) record to determine high risk – HBMR. Home base mom’s record.Sex ( pseudocyesis or false pregnancy on men & women)Couvade syndrome dad experiences what mom goes through – lihi)3. Diagnosis of Pregnancya.) urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam.

b.) Elisa test test for preg detects beta sub unit of HCG as early as 7 – 10daysC.) Home preg kit do it yourself

4. Baseline Data: V/S esp. BP, monitor wt. ( increase wt – 1 s t sign preeclampsia)

Weight MonitoringFirst Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/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)

Minimum wt gain – 20 – 25 lbsOptimal wt gain – 25 – 35 lbs

5. Obstetrical Data:nullipara – no pregnancy

a. Gravida- # of pregnancyb. Para - # of viable pregnancy

age of viability: 20 – 24 wksTerm: 37 – 42 wks,Preterm: 20 – 37 weeksAbortion: <20 weeks

c. Important Estimates:1. Nagele’s Rule

use to determine expected date of delivery. Get LMP -3+ 7 +1

2. McDonald’s Rule to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8

3. Bartholomew’s Rule to determine age of gestation by proper

location of fundus at abdominal cavity.

3 months above sym pub5 months level of umbilicus9 months below zyphoid10 months level of 8 months due to lightening

4. Haases rule to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month

2nd ½ of preg, x @ month by 5

3mos x 3 = 9cm4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg 5 x 5 = 25 cm

6 x 5 = 30 cm7 x 5 = 35 cm 2nd ½ of preg8 x 5 = 40 cm9 x 5 = 45 cm

d. tetanus immunizations prevents tetanus neonatum

TT1: any time during pregnancyTT2: 4 wks after TT1 – 3 yrs protectionTT3: 6 months after TT2 – 5 yrs protectionTT4: 1 yr after TT3 – 10 yrs protectionTT5: yr after TT4 – lifetime protection

5. Physical Examination:

Danger Signs of Pregnancy:C - chills/ fever infection Cerebral disturbances ( headache – preeclampsia)A – abdominal pain ( epigastric pain aura of impending convulsionsB – boardlike abdomen abruption placentaIncrease BP – HPNBlurred vision – preeclampsiaBleeding – 1st trimester, abortion, ectopic pre/2nd – H mole, incompetent cervix3rd – placental anomalies

S – sudden gush of fluid PROM (premature rupture of membrane) prone to inf.E – edema to upper ext. (preeclampsia)

6. Leopold’s ManeuverPurpose: 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.

Prep mom:1. Empty bladder2. 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 to determine presentation2nd 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 FHT. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.Uterine soufflé – maternal H rate3rd Maneuver: using the right hand, grasp the symphis 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. To determine attitude – relationship of fetus to 1 another.

Intrapartal

Theories of the Onset of Labor1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin3.) prostaglandin theory stimulation of arachidonic acid – prostaglandin- contraction4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

The 4 P’s of labor1. Passengera. Fetal head is the largest presenting part – common presenting part – ¼ of its length.Bones – 6 bones S – sphenoid F – frontal - sinciputE – ethmoid O – occuputal - occiputT – temporal P – parietal 2 x

2. PassagewayMom 1.) < 4’9” tall2.) < 18 years old

3.) Underwent pelvic dislocation

Pelvis4 main pelvic types1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy2. Android heart shape “male pelvis”- anterior part pointed, posterior part shallow3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow4. Platypelloid flat AP diameter – narrow, transverse – wider

3. Power the force acting to expel the fetus and

placenta – myometrium – powers of labora. Involuntary Contractionsb. Voluntary bearing down effortsc. Characteristics: wave liked. Timing: frequency, duration, intensity

4. Psyche/Person psychological stress when the mother is

fighting the labor experiencea. Cultural Interpretationb. Preparationc. Past Experienced. Support System

Pre-eminent Signs of Labor

S&Sx:- shooting pain radiating to the legs- urinary freq.1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD* Engagement- setting of presenting part into pelvic inlet2. Braxton Hicks Contractions – painless irregular contractions3. Increase Activity of the Mother nesting instinct. Save energy, will be used for delivery. Increase epinephrine4. Ripening of the Cervix butter soft5. decreased body wt – 1.5 – 3 lbs6. Bloody Show pinkish vaginal discharge – blood & leucorrhealeukorrhea

7. Rupture of Membranes rupture of water. Check FHT

Premature Rupture of Membrane ( PROM)- do IE to check for cord prolapse Contraction drop in intensity even though

very painful Contraction drop in frequently Uterus tense and/or contracting between

contractions Abdominal palpations

Nursing Care; Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP –

most common malposition Bear down with contractions Adequate hydration prepare for CS Sedation as ordered Cesarean delivery may be required,

especially if fetal distress is noted

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. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy.2. Slip cord away from presenting part3. Count pulsation of cord for FHT4. Prep mom for CS

Difference Between True Labor and False LaborFALSE LABOR TRUE LABOR

Irregular contractions

No increase in intensity

Pain – confined to abdomen Pain – relived by

Contractions are regular

Increased intensity Pain – begins lower

back radiates to abdomen

Pain – intensified by

walking No cervical changes

walking Cervical effacement

& dilatation * major sx

of true labor.

Duration of LaborPrimipara 14 hrs & not more than 20 hrsMultipara 8 hrs & not > 14 hrs

Effacement softening & thinning of cervix. Use % in unit of measurementDilation widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor2 segments of the uterus1. upper uterine - fundus2. lower uterine – isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix.

Latent Phase:Assessment:

Dilations: 0 – 3 cm mom excited, apprehensive, can communicate

Frequency: every 5 – 10 min Intensity mild

Nursing Care:1. Encourage walking shorten 1st stage of labor2. Encourage to void q 2 – 3 hrs full bladder inhibit contractions3. Breathing – chest breathing

Active Phase: Assessment: Dilations 4 -8 cm Intensity: moderate Mom fears losing

control of self Frequency: q 3-5 min lasting for 30 – 60

seconds

Nursing Care:M – edications – have meds readyA – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.D – dry lips – oral care (ointment)dry linensB – abdominal breathing

Transitional Phase: Intensity: strong Mom mood changes

with hyperesthesia Assessment: Dilations 8 – 10 cm Frequency q 2-3 min contractions Durations 45 – 90 seconds

Hyperesthesia increase sensitivity to touch, pain all over

Health Teaching : teach: sacral pressure on lower back to

inhibit transmission of pain keep informed of progress controlled chest breathing

Nursing Care:T – iresI – nform of progressR – estless support her breathing techniqueE – ncourage and praiseD – iscomfort

Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus to

monitor contractions

Increment or crescendo beginning of contractions until it increasesAcme or apex height of contractionDecrement or decrescendo from height of contractions until it decreasesDuration beginning of contractions to end of same contractionInterval end of 1 contraction to beginning of next contractionFrequency beginning of 1 contraction

Contraction vasoconstrictionIncrease BP, decrease FHTBest time to get BP & FHT just after a contraction or midway of contractionsPlacental reserve – 60 sec o2 for fetus during contractionsDuration of contractions shouldn’t >60 secNotify MD

Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD –preeclampsia

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 – 8 multi bring to delivery room 10cm primi bring to delivery room Lithotomy pos put legs same time up Bulging of perineum sure to come out Breathing panting ( teach mom) Assist doc in doing episiotomy to prevent

laceration, widen vaginal canal, shorten 2nd stage of labor.

Mechanisms of labor1. Engagement -2. Descent3. Flexion4. Internal Rotation5. Extension6. External rotation7. Expulsion

3. Third Stage: birth to expulsion of Placenta placental stage placenta has 15 – 28 cotyledonsPlacenta delivered from 3-10 minutes

Signs of placental separation1. Fundus rises becomes firm & globular “ Calkins sign”2. Lengthening of the cord3. Sudden gush of blood

Types of placental deliveryShultz “shiny” begins to separate from center to edges presenting the fetal side shinyDunkan “dirty” begin to separate form edges to center presenting natural side – beefy red or dirty

Slowly pull cord and wind to clamp –BRANDT ANDREWS MANEUVER

Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta: Check completeness of placenta. Check fundus (if relaxed, massage uterus)

Check bp Administer methergine IM

(Methylergonovine Maleate) “Ergotrate derivatives

Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. Blanket, give clear

liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

Fourth Stage: the first 1-2 hours after delivery of placenta – Recovery stage. Monitor v/s q 15 for 1 hr.

2nd hr q 30 minutes. Check placement of fundus at level of

umbilicus. If fundus above umbilicus, deviation of

funduso Empty bladder to prevent uterine atonyo Check lochia

a. Maternal Observations – body system stabilizesb. Placement of the Fundusc. Lochiad. Perineum –

R - ednessE- demaE - cchemosisD – ischargesA – approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc

Preterm Labor labor after 20 – 37 weeks) ( abortion <20

weeks)Sx:1. premature contractions q 10 min2. effacement of 60 – 80%3. dilation 2-3 cm

Home Mgt:1. complete bed rest2. avoid sex3. empty bladder

4. drink 3 -4 glasses of water – full bladder inhibits contractions5. consult MD if symptoms persist

Hosp: If cervix is closed 2 – 3 cm, dilation saved by

administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback.

Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles notify MD – pulmo edema –

administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil)

Terbuthaline (Bricanyl or Brethine) sustained tachycardia

Antidote – propranolol or inderal - beta-blocker

If cervix is open MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.

Postpartal Period 5th stage of labor after 24hrs :Normal

increase WBC up to 30,000 cu mm

Puerperium covers 1st 6 wks post partumInvolution return of repro organ to its non pregnant state.

Hyperfibrinogenia- prone to thrombus formation- early ambulation