Human Sexuality

A.   Concepts

1.     A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to sexual self and eroticism.

2.     Sex – basic and dynamic aspect of life

3.     During reproductive years, the nurse performs as resource person on human sexuality.

B.    Definitions related to sexuality:

Gender identity – sense of femininity or masculinity

2-4 yrs/3 yrs gender identity develops.

Role identity – attitudes, behaviors and attributes that differentiate roles

Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.

- developed at the moment of conception.

II. Sexual Anatomy and Physiology

     A. Female Reproductive System

     1. External value or pretender

a. Mons pubis/veneris -  a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tannerscale tool - used to determine sexual maturity rating.

                        Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only

Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis

                        Stage 3 occurs between ages 12 and 13 – darker & curlier at labia

Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no  appear to the inner aspect of the upper thigh.

                        Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh .

     b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum

     c. Labia Minora – 2 sensitive structures

 clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key)

fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery.

Site – episiotomy.

     d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s glands.

1.     Urinary Meatus – small opening of urethra, serves for urination

2.     Skenes glands/or paraurethral gland – mucus secreting subs for lubrication

3.     hymen – covers vaginal orifice, membranous  tissue

4.     vaginal orifice – external opening of vagina

5.     bartholene’s glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs – secrets alkaline subs.

Alkaline – neutralizes acidity of vagina

Ph of vagina - acidic

                   Doderleins bacillus – responsible for acidity of vagina

                   Carumculae mystiformes-healing of torn hymen

          e. Perineum – muscular structure – loc – lower vagina & anus

Internal:

          A. vagina – female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long, dilated canal

Rugae – permits stretching without tearing

B.  uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights.

                   Size- 1x2x3

                   Shape: nonpregnant pear shaped / pregnant - ovoid

                   Weight - nonpregnant – 50 -60 kg- pregnant – 1,000g

                   Pregnant/ Involution of uterus:

                   4^th stage of labor                        - 1000g

                   2 weeks after delivery            - 500g

                   3 weeks after delivery            - 300 g

                   5-6 weeks after delivery        - returns to original, state 50 – 60

Three parts of the uterus

1.     fundus                 - upper cylindrical layer

2.     corpus/body        - upper triangular layer

3.     cervix                   - lower cylindrical layer

* Isthmus lower uterine segment during pregnancy

                             Cornua-junction between fundus & interstitial

Muscular compositions: there are three main muscle layers which make expansion possible in every direction.

1.     Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during menstruation.

Decidua- thick layer.

Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary.

          S/sx: dysmennorhea, low back pain.

          Dx: biopsy, laparoscopy

          Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation

                     2. Lupreulide (Lupron) –inhibit FSH/LH production

2.     Myometrium – largest part of the uterus, muscle layer for delivery process

·        Its smooth muscles are considered to be the living ligature of the body.

- Power of labor, resp- contraction of the uterus

3.     Perimetrium – protects entire uterus

C. ovaries – 2 female sex glands, almond shaped. Ext- vestibule int – ovaries

Function:    1. ovulation

                             2. Production of  hormones

d. Fallopian tubes – 2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus.

4 significant segments

1. Infundibulum – distal part of FT, trumpet or funnel shaped, swollen at ovulation

2. Ampulla – outer 3^rd or 2^nd half, site of fertilization

3. Isthmus – site of sterilization – bilateral tubal ligation

4. Interstitial – site of ectopic pregnancy – most dangerous

B. Male Reproductive System

1. External

penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis.

3 Cylindrical Layers

2 corpora cavernosa

1 corpus spongiosum

Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes.

-         cooling mechanism of testes

-      < 2 degrees C than body temp.

-      Leydig cell – release testosterone

2. Internal

Male and Female homologues

Male                    Female

Penile glans                  Clitoral glans

Penile shaft                   Clitorial shaft

Testes                            ovaries

Prostate                         Skene’s gands

Cowper’s Glands          Bartholin's glands

Scrotum                        Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1.     DNA – carries genetic code

2.     Chromosomes – threadlike strands composed of hereditary material – DNA

3.     Normal amount of ejaculated sperm 3 – 5 cc., 1 tsp

4.     Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation

5.     Sperm is viable within 48 – 72 hrs, 2-3 days

6.     Reproductive cells divides by the  process of meiosis (haploid)

Spermatogenesis – maturation of sperm

Oogenesis – process  - maturation of ovum

Gematogenesis – formation of 2 haploid into diploid 23 + 23 = 46 or diploid

7.     Age of Reproductivity – 15 – 44yo

8.     Menstruation-

Menstrual Cycle – beginning of mens to beginning of next mens

Average Menstrual Cycle – 28 days

Average Menstrual Period  - 3 – 5 days

Normal Blood loss – 50cc or ¼ cup

Related terminologies:

          Menarche – 1^st mens

          Dysmenorrhea – painful mens

Metrorrhagia – bleeding between mens

Menorhagia – excessive during mens

Amenorrhea – absence of mens

Menopause – cessation of mens/ average : 51 years old

9.     Functions of Estrogen and Progestin

* Estrogen “Hormone of the Woman” –

Primary function: development secondary sexual characteristic female.

Others:

1.     inhibit production of FSH  ( maturation of ovum)

2.     hypertrophy of myometrium

3.     Spinnbarkeit & Ferning ( billings method/ cervical)

4.     development ductile structure of breast

5.     increase osteoblast activities of long bones

6.     increase in height in female

7.     causes early closure of epiphysis of long bones

8.     causes sodium retention

9.     increase sexual desire

*Progestin “ Hormone of the Mother”

Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted)

Secondary Function: uterine contractility (favors pregnancy)

Others:                 1.inhibit prod of LH (hormone for ovulation)

2.inhibit motility of GIT

3. mammary gland development

4. increase permeability of kidney to lactose & dextrose causing (+) sugar

5. causes mood swings in moms

6. increase BBT

10. Menstrual Cycle

 4 phases of Menstrual Cycle

1. Phases of Menstrual Cycle:

1. Proliferative

2. Secretory

3. Ischemic

4. Menses

Parts of body responsible for mens:

1.     hypothalamus

2.     anterior pituitary gland – master clock of body

3.     ovaries

4.     uterus

Initial phase – 3^rd day – decreased estrogen

13^th day – peak estrogen, decrease progesterone

14^th day – Increase estrogen, increase progesterone

15^th day – Decrease estrogen, increase progesterone

I.         On the initial 3^rd phase of menstruation , the estrogen level is decreased, this level stimulates the   hypothalamus to release GnRH or FSHRF

II.                 GnRH/FSHRF – stimulates the anterior pituitary gland to release FSH

Functions of FSH:

1.     Stimulate ovaries to release estrogen

2.     Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen &  contains mature ovum.)

III.               Proliferative Phase – proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty.

-phase of increase estrogen.

Follicular Phase – causing irregularities  of mens

Postmenstrual Phase

Preovulatory Phase – phase increase estrogen

IV.              13^th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRF on LHRF

1.)  Mittelschmerz – slight abdominal pain on L or RQ of abdomen, marks ovulation day.

2.)  Change in BBT, mood swing

V.                GnRF/LHRF stimulates the ant pit gland to release LH.

Functions of LH:

1.     (13^th day-decreased progesterone) LH stimulates ovaries to release progesterone

2.     hormone for ovulation

        VI. 14^th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of     ovulation.

        VII. 15^th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone)

        VIII.     Secretory phase-

Lutheal Phase

Postovulatory PhaseIncreased progesterone

Premenstrual Phase

         IX. 24^th day if no fertilization, corpus luteum degenerate ( whitish – corpus albicans)

           X.    28^th day – if no sperm in ovum – endometrium begins to slough off to begin mens

Cornix- where sperm is deposited

Sperm- small head, long tail, pearly white

Phonones-vibration of head of sperm to determine location of ovum

Sperm should penetrate corona radiata and zona pellocida.

Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida.

11. Stages of Sexual Responses (EPOR)

Initial  responses:

          Vasocongestion – congestion of blood vessels

          Myotonia – increase muscle tension

1.     Excitement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – erotic stimuli cause increase sexual tension, lasts minutes to hours.

2.     Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30 seconds – 3 minutes.

3.     Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or psychologic release, immeasurable peak of sexual experience. May last 2 – 10 sec- most affected are is pelvic area.

4.     Resolution – (v/s return to normal, genitals return to pre-excitement phase)

Refractory Period – the only  period present in males, wherein he cannot be restimulated for about 10-15 minutes

A.    Fertilization

B.    Stages of Fetal Growth and Development

3-4 days travel of zygote – mitotic cell division begins

*Pre-embryonic Stage

     a. Zygote- fertilized ovum. Lifespan of zygote – from fertilization to 2 months

b. Morula – mulberry-like ball with 16 – 50 cells, 4 days free floating & multiplication

c. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. Blastocyst – covering of blastocys that later becomes placenta & trophoblast

     d. Implantation/ Nidation- occurs after fertilization 7 – 10 days.

Fetus- 2 months to birth.

placenta previa – implantation at low side of uterus

Signs of implantation:

1. slight pain

2. slight vaginal spotting

- if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed.

              3 processes of Implantation

                        1. Apposition

                        2. Adhesion

                        3. Invasion

C. Dicidua – thickened endometrium ( Latin – falling off)

* Basalis (base) part of endometrium located under fetus where placenta is delivered

* Capsularies – encapsulate the fetus

* Vera – remaining portion of endometrium.

C.    Chorionic Villi- 10 – 11^th day, finger life projections

3 vessels=

A – unoxygenated blood

V – O2 blood

A – unoxygenated blood

Wharton’s jelly – protects cord

Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes.

E. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6 months – life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis

F. Synsitiotrophoblast – synsitial layer – responsible production of hormone

          1. Amnion – inner most layer 

                   a. Umbilical Cord- FUNIS, whitish grey, 15 – 55cm, 20 – 21”. Short cord: abruptio placenta or inverted uterus.

                             Long cord:cord coil or cord prolapse

                   b. Amniotic Fluid – bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline.

                             *Function of Amniotic Fluid:

1. cushions fetus against sudden blows or trauma

2. facilitates musculo-skeletal development

3. maintains temp

4. prevent cord compression 

5. help in delivery process

Normal amt of amniotic fluid – 500 to 1000cc

polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid

oligohydramnios- decrease amt of fluid – kidney disease

Diagnostic Tests for Amniotic Fluid

A. Amniocentesis empty bladder before performing the procedure.

Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for:

1.     Genetic screening- maternal serum alpha feto-protein  test (MSAFP) – 1^st trimester

2.     Determination of fetal maturity primarily by evaluating factors indicative of lung maturity – 3^rd trimester

Testing time – 36 weeks

decreased MSAFP= down syndrome

increase MSAFP = spina bifida or open neural tube defect

Common complication of amniocenthesis – infection

Dangerous complications – spontaneous abortion

3^rd trimester- pre term labor

Important factor to consider for amniocentesis- needle insertion site

Aspiration of yellowish amniotic fluid – jaundice baby

Greenish – meconium

A.    Amnioscopy – direct visualization or exam to an intact fetal membrane.

B.     Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid)

C.    Nitrazine Paper Test – diff amniotic fluid & urine.

Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.

1.     Chorion – where placenta is developed

Lecithin Sphingomyelin L/S

Ratio- 2:1 signifies fetal lung maturity not capable for RDS

Shake test – amniotic + saline & shake

Foam test

Phosphatiglyceroli: PG+ definitive test to determine fetal lung maturity

a.     Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. Size: 500g or ½ kg 

-1 inch thick & 8” diameter

Functions of Placenta:

1.     Respiratory System – beginning of lung function after birth of baby. Simple diffusion

2.     GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic

3.     Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.

4.     Circulating system – achieved by selective osmosis

5.     Endocrine System – produces hormones

·        Human Chorionic Gonadrophin – maintains corpus luteum alive.

·        Human placental Lactogen or sommamommamotropin Hormone – for mammary gland development. Has a diabetogenic effect – serves as insulin antagonist

·        Relaxin Hormone- causes softening joints & bones

·        estrogen

·        progestin

6.     It serves as a protective barrier against some microorganisms – HIV,HBV

Fetal Stage “ Fetal Growth and Development”

Entire pregnancy days – 266 – 280 days    37 – 42 weeks

Differentiation of Primary Germ layers

* Endoderm

     1^st week endoderm – primary germ layer

Thyroid – for basal metabolism

Parathyroid - for calcium

Thymus – development of immunity

Liver – lining of upper RT & GIT

* Mesoderm – development of heart, musculoskeletal system, kidneys and repro organ

* Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth

First trimester:

1^st month -      Brain & heart development

GIT& resp Tract – remains as single tube        

1. Fetal heart tone begins – heart is the oldest part of the body

2. CNS develops – dizziness of mom due to hypoglycemic effect

                                  Food of brain – glucose        complex CHO – pregnant womans food (potato)

Second Month

1.     All vital organs formed, placenta developed

2.     Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2^nd month

3.     Sex organ formed

4.     Meconium is formed

Third Month

1.     Kidneys functional

2.     Buds of milk teeth appear

3.     Fetal heart tone heard – Doppler – 10 – 12 weeks

4.     Sex is distinguishable

Second Trimester: FOCUS – length of fetus

Fourth Month

1.     lanugo begins to appear

2.     fetal heart tone heard fetoscope, 18 – 20 weeks

3.     buds of permanent teeth appear

Fifth Month 

1.     lanugo covers body

2.     actively swallows amniotic  fluid

3.     19 – 25 cm fetus,

4.     Quickening- 1^st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi 

5.     fetal heart tone heard  with or without instrument

Sixth Month

1.     eyelids open

2.     wrinkled skin

3.     vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetus

Seventh Month – development of surfactant – lecithin

Eighth Month

1.     lanugo begin to disappear

2.     sub Q fats deposit

3.     Nails extend to fingers

Ninth Month 

1.     lanugo & vernix caseosa completely disappear

2.     Amniotic fluid decreases

Tenth Month – bone ossification of fetal skull

Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus

A.    Drugs:

Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8^th cranial nerve – poor hearing & deafness

Tetracycline – staining tooth enamel, inhibit growth of long bone

Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice

Iodides – enlargement of thyroid or goiter

Thalidomides – Amelia or pocomelia, absence of extremities

Steroids – cleft lip or palate

Lithium – congenital malformation

B.     Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly

C.    Smoking – low birth rate

D.    Caffeine – low birth rate

E.     Cocaine – low birth rate, abruption placenta

TORCH (Terratogenic) Infections – viruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.

T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat

O – others. Hepa A or infectious heap – oral/ fecal (hand washing)

                 Hepa B, HIV – blood & body fluids

                 Syphilis

R – rubella – German measles – congenital heart disease (1^st 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 terratogenic

C – cytomegalo virus

H – herpes simplex virus

VI.            Physiological Adaptation of the Mother to Pregnancy

A. Systemic Changes

          1. 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 Values

Hct    32 – 42%

Hgb  10.5 – 14g/dL

Criteria

1^st and 3^rd trimester.- pathologic anemia if lower

HCT should not be 33%, Hgb should not be < 11g/dL

2^nd trimester – Hct should not <32%

                   Hgb Shdn't < 10.5%  pathologic anemia if lower

Pathogenic Anemia

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

- Assessment reveals:

·        Pallor, constipation

·        Slowed capillary refill

·        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:

·        Iron from red meats is better absorbed iron form other sources

·        Iron is better absorbed when taken with  foods high in Vit C such as orange juice

·        Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs

Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level.

Varicosities – pressure of uterus

-         use support stockings, avoid wearing knee high socks

-         use elastic bandage – lower to upper

-          

Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position – side lying with pillow under hips or modified knee chest position

Thrombophlebitis – presence of thrombus at inflamed blood vessel

-         pregnant mom hyperfibrinogenemia

-         increase fibrinogen

-         increase clotting factor

-         thrombus formation candidate

outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion

milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens

Mgt:

1.)  Bed rest

2.)  Never massage

3.)  Assess + Homan sign once only might dislodge thrombus

4.)  Give anticoagulant to prevent additional clotting (thrombolytics will dilute)

5.)  Monitor APTT antidote for Heparin toxicity, protamine sulfate

6.)  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 – 1^st trimester change

·        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

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 constipating – veg – petchy, malungay.

- exercise

-mineral oil – excretion of fat soluble vitamins

* Flatulence – avoid gas forming food – cabbage

* 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

increase salivation – ptyalsim – mgt mouthwash

*Hemorrhoids – pressure of gravid uterus. Mgt; hot sitz bath for comfort

4.     Urinary System – frequency during 1^st & 3^rd trimester lateral expansion of lungs or side lying pos – mgt for nocturia

Acetyace test – albumin in urine

Benedicts test – sugar in urine

5.     Musculoskeletal

Lordosis – pride of pregnancy

Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones

Prone to accidental falls – wear low heeled shoes

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 Changes

Local change:  Vagina:

V – Chadwick’s sign – blue violet discoloration of vagina

C – Goodel's sign – change of consistency of cervix

I – 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 mom

Flagellated protozoa – wants alkaline

                            S&Sx:

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

Mgt:

FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1^st trimester

1.     treat dad also to prevent reinfection

2.     no  alcohol – has antibuse effect

VAGINAL DOUCHE – IQ 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:

Management – antifungal – Nistatin, genshan violet, cotrimaxole, canesten

Gonorrhea -Thick purulent discharge

Vaginal warts- condifoma acuminata due to papilloma virus

Mgt: cauterization

2. 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 3^rd 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:

1. 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 Pregnancy

A.    Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective

B.     Probable – signs observed by the members of health team. Objective

C.    Positive Signs – undeniable signs confirmed by the use of instrument.

Ballotment sign of myoma

* + HCG – sign of H mole

- trans vaginal ultrasound. Empty bladder

- ultrasound – full bladder

placental grading – rating/grade

o – immature

1 – slightly mature

2 – moderately mature

3 – placental maturity

What is deposited in placenta which signify maturity - there is calcium

Presumptive	Probable	Positive
Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Cloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening	Goodel's- change of consistency of cervix Chadwick’s- blue violet discoloration of vagina Hegar's- change of consistency of isthmus Elevated BBT – due to increased progesterone Positive HCG or (+)preg test Ballottement – bouncing of fetus when lower uterine is tapped sharply Enlarged abdomen Braxton Hicks contractions – painless irregular contractions	Ultrasound evidence (sonogram) full bladder Fetal heart tone Fetal movement Fetal outline Fetal parts palpable

VII.         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

VII. Pre-Natal Visit:

1.     Frequency of Visit:        1^st 7 months – 1x a month

8 – 9 months – 2 x a month

10 – once a week

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)

Address, civil status, religion, culture & beliefs with respect, non judgmental

Occupation – financial condition or occupational hazards, education background – level knowledge

3.     Diagnosis of Pregnancy

1.)  urine exam to detect HCG at 40 – 100^th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam.

2.)  Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days

3.)  Home preg kit – do it yourself

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

             Weight Monitoring

First 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 lbs

Optimal wt gain – 25 – 35 lbs

5.     Obstetrical Data:

nullipara – no pregnancy

a.     Gravida- # of pregnancy

b.     Para - # of viable pregnancy

Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.

age of viability - 20 – 24 wks  

Term 37 – 42 wks,

Preterm -20 – 37 weeks

abortion <20 weeks

Sample Cases:

1 – abortion        GTPAL

1 – 2^nd mo  2 0 01 0

G – 2

P – 0

1 – 40^th AOG                 GT P A L

1 – 36^th AOG                 6 1 2  2  4

2 – misc

1 – twins    35 AOG

1 – 4^th month       G6 P3

1 – 39^th week

1 – miscarriage                                          GP   GTPAL

1 – stillbirth 33 AOG (considered as para)                  4 2    4 11 1 1

1 – preg 3^rd wk

1 – 33  P

1  41^st  L

1 – abort A

1 – still 39                      GP    GTPAL

1 triplet 32                    6 4    6 2 2 15

1 4^th mon

c.      Important Estimates:

1.     Nagele’s Rule – use to determine expected date of delivery

Get LMP -3+ 7 +1 Apr-Dec                      LMP – Jan Feb Mar

                 M  D   Y                                     +9 +7 no year

LMP Jan 25, 04

+9 +7

10 / 32 / 04

     -  1

add 1 month to month

11/31/04 EDD

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

Fr sypmhisis pubis to fundus 24 X 7 =21 wks

                                        8

3.     Bartholomew’s Rule – to determine age of gestation by proper location of fundus at abdominal cavity.

3 months – above sym pub            

5 months – level of umbilicus

9 months – below zyphoid

10 months – level of 8 months due to lightening

4.     Haases rule – to determine length of the fetus in cm.

Formula: 1^st ½ of preg , square @ month

             2^nd ½ of preg, x @ month by 5

3mos x 3 = 9cm

4 mos x 4 = 16 cm   10 x 5 = 50 cm                1^st ½ of preg

5 x 5 = 25 cm

6 x 5 = 30 cm

7 x 5 = 35 cm         2^nd ½ of preg                     

8 x 5 = 40 cm

9 x 5 = 45 cm

d.     tetanus immunizations – prevents tetanus neonatum

-mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3

TT1 – any time during pregnancy

TT2 – 4 wks after TT1 – 3 yrs protection

TT3 – 6 months after TT2 – 5 yrs protection

TT4 – 1 yr after TT3 – 10 yrs protection

TT5 – yr after TT4 – lifetime protection

5.     Physical Examination:

A. Examine teeth: sign of infection

Danger signs of Pregnancy

C - chills/ fever - infection

      Cerebral disturbances ( headache – preeclampsia)

A – abdominal pain ( epigastric pain – aura of impending convulsions

B – boardlike abdomen – abruption placenta

Increase BP – HPN

Blurred vision – preeclampsia

Bleeding – 1^st trimester, abortion, ectopic pre/2^nd – H mole, incompetent cervix

3^rd – placental anomalies

S – sudden gush of fluid – PROM (premature rupture of membrane) prone to inf.

E – edema to upper ext. (preeclampsia)

6.     Pelvic Examination – internal exam

1.     empty bladder

2.     universal precaution

EXT OS of cervix – site for getting specimen

Site for cervical cancer

Pap Smear – cervical cancer

- composed of squamous columnar tissue

Result:

Class I - normal

Class IIA – acytology but no evidence of malignancy

             B – suggestive of infl.

Class III – cytology suggestive of malignancy

Class IV – cytology strongly suggestive of malignancy

Class V – cytology conclusive of malignancy

Stages of Cervical Cancer

Stage      0 – carcinoma insitu

          1 – cancer confined to cervix

          2 -  cancer extends to vagina

          3 – pelvis metastasis

          4 – affection to bladder & rectum

7. Leopold’s Maneuver

          Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone

- use palm! Warm palm.

Prep mom:

1.     Empty bladder

2.     Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)

Procedure:

1^st 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 presentation

2^nd 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 2^nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.

Uterine soufflé – maternal H rate

3^rd 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).

4^th 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.

When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting.

Attitude – relationship of fetus to a part – or degree of flexion

Full flexion – when the chin touches the chest

8.Assessment of Fetal Well-Being-

A.   Daily Fetal Movement Counting (DFMC) –begin 27 weeks

Mom- begin after meal - breakfast

a. Cardiff count to 10 method – one method currently available

(1)  Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs)

(2) Expected findings – 10 movements in 1 hour or less

3) Warning signs

          a.) more then 1 hour to reach 10 movements

          b.) less then 10 movements in 12 hours(non-reactive- fetal distress)

          c.) longer time to reach 10 FMs than on previous days

          d.) movement are becoming weaker, less vigorous

                   Movement alarm signals - < 3 FMs in 12 hours

4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP)

B.     Nonstress test – to determine the response of the fetal heart rate to activity

Indication – pregnancies at risk for placental insufficiency

          Postmaturity

a.)  pregnancy induced hypertension (PIH), diabetes

b.)  warning signs noted during DFMC

c.)   maternal history of smoking, inadequate nutrition

Procedure:

Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the “mark button”  on the electronic monitor when she feels fetal movement.

Attach external noninvasive fetal monitors

1.     tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)

2.     ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected

3.     monitor until at least 2 FMs are detected in 20 minutes

·        if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen

·        if no FM after 1 hour further testing may be indicated, such as a CST

Result:

Noncreative

Nonstress

Not Good

                             Reactive

                             Responsive is

                             Real Good

          Interpretation of results

i.                   reactive result

1.     Baseline FHR between 120 and 160 beats per minute

2.     At least  two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM

3.     Good variability – normal irregularity of cardiac rhythm representing  a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip.

4.     result indicates a healthy fetus with an intact nervous system

ii. Nonreactive result

1.     Stated criteria for a reactive result are not met

2.     Could be indicative of a compromised fetus.

       Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

9. Health teachings

     a. Nutrition – do nutritional assessment – daily food intake

High risk moms:

1.     Pregnant teenagers – low compliance to heath regimen.

2.     Extremes in wt – underweight, over wt – candidate for HPN, DM

3.     Low socio – economic status

4.     Vegetarian mom – decrease CHON – needs Vit B12 – cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect)

       How many Kcal CHO x4,CHON x4, fats x 9

Recommended Nutrient Requirement that increases During Pregnancy

Nutrients	Requirements	Food Source
Calories Essential to supply energy for -   increased metabolic rate -   utilization of nutrients -   protein sparing so it can be used for -   Growth of fetus -   Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth.	300 calories/day above the prepregnancy daily requirement to maintain ideal body weight and meet energy requirement to activity level -   Begin increase in second trimester -   Use weight – gain pattern as an indication of adequacy of calorie intake. -   Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage.	Caloric increase should reflect -   Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits) -   Variety of foods representing foods sources for the nutrients requiring during pregnancy -   No more than 30% fat
Protein Essential for: -   Fetal tissue growth -   Maternal tissue growth including uterus and breasts -   Development of essential pregnancy structures -   Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH)	60 mg/day or an increase of 10% above daily requirements for age group Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement	Protein increase should reflect -   Lean meat, poultry, fish -   Eggs, cheese, milk -   Dried beans, lentils, nuts -   Whole grains * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids
Calcium-Phosphorous Essential for -         Growth and development of fetal skeleton and tooth buds -         Maintenance of mineralization of maternal bones and teeth -         Current research is : Demonstrating an association  between adequate calcium intake and the prevention of pregnancy induce hypertension	Calcium increases of -   1200 mg/day representing an increase of 50% above prepregnancy daily requirement. -   1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous	Calcium increases should reflect: -   dairy products : milk, yogurt, ice cream, cheese, egg yolk -   whole grains, tofu -   green leafy vegetables -   canned salmon & sardines w/ bones -   Ca fortified foods such as orange juice -   Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood
Iron Essential for -   Expansion of blood volume and red blood cells formation -   Establishment of fetal iron stores for first few months of life	30 mg/day representing a doubling of the pregnant daily requirement -        Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet pregnancy requirement -        60 – 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia.  -        70 mg/day of vitamin C which enhances iron absorption -        inadequate iron intake results in maternal effects – anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and  birth -        fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy.	Iron increases should reflect -         liver, red meat, fish, poultry, eggs -         enriched, whole grain cereals and breads -         dark green leafy vegetables, legumes -         nuts, dried fruits -         vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes -         iron from food sources is more readily absorbed when served with foods high in vit C
Zinc Essential for * the formation of enzymes * maybe important in the prevention of congenital malformation of the fetus.	15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements.	Zinc increases should reflect -         liver, meats -         shell fish -         eggs, milk, cheese -         whole grains, legumes, nuts
Folic Acid, Folacin, Folate Essential for -         formation of red blood cells and prevention of anemia -         DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta	400 mcg/day representing an increase of more then 2 times the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency 4 servings of grains/day	Increases should reflect -         liver, kidney, lean beef, veal -         dark green leafy vegetables, broccoli, legumes. -         Whole grains, peanuts
Additional Requirements Minerals -         iodine -         Magnesium -         Selenium	175 mcg/day 320 mg/day 65 mcg/day	Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.
Vitamins E Thiamine Riborlavin Pyridoxine ( B6) B12 Niacin	10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day	Vit stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.

2.Sexual Activity

a.) should be done in moderation

b.)  should be done in private place

c.)   mom placed in comfy pos, sidelying or mom on top

d.)  avoided 6 weeks prior to EDD

e.)  avoid blowing or air during cunnilingus

f.)    changes in sexual desire of mom during preg- air embolism

Changes in sexual desire:

a.)  1^st tri – decrease desire – due to bodily changes

b.)  2^nd trimester – increased desire due to increase estrogen that enhances lubrication

c.)   3^rd trimester – decreased desire

Contraindication in sex:

1. vaginal spotting

          1^{st trimester} – threatened abortion

2^nd trimester– placenta previa

2. incompetent cervix

3. preterm labor

4. premature rupture of membrane

3.    Exercise – to strengthen muscles used during delivery process

-         principles of exercise

1.)  Done in moderation.  2.) Must be individualized

Walking – best exercise

Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor

Tailor Sitting – 1 leg in front of other leg ( Indian seat)

Raise buttocks 1^st before head to prevent postural hypotension – dizziness when changing position

-         shoulder circling exercise- strengthen chest muscles

-         pelvic rocking/pelvic tilt- exercise – relieves low back pain & maintain good posture

-         * arch back – standing or kneeling. Four extremities on floor

Kegel Exercise – strengthen pulococcygeal muscles

- as if hold urine, release 10x or muscle contraction

Abdominal Exercise – strengthens muscles of abdominal – done as if blowing candle

4. Childbirth Preparation:

Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical

1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based on imitation of nature.

Features:

1.) darkened rm

2.) quiet environment

3.) relaxation tech

4.) closed eye & appearance of sleep

2. Grantly Dick Read Method – fear leads to tension while tension leads to pain

b. Psychosexual

          1. Kitzinger method – preg, labor & birth & care of newborn is an impt turning pt in woman’s life cycle

- flow with contraction than struggle with contraction

c. Psychoprophylaxis – prevention of pain

1. Lamaze: Dr. Ferdinand Lamaze

req. disciple, conditioning & concentration. Husband is coach

Features:

1.     Conscious relaxation

2.     Cleansing breathe – inhale nose, exhale mouth

3.     Effleurage – gentle circular massage over abdominal to relieve pain

4.     imaging – sensate focus

5.                             Different Methods of delivery:

1.)  birthing chair – bed convertible to chair – semifowlers

2.)  birthing bed – dorsal recumbent pos

3.)  squatting – relives low back pain during labor pain

4.)  leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.

5.)  Birth under H20 – bathtub – labor & delivery – warm water, soft music.

IX. Intrapartal Notes – inside ER

A.      Admitting the laboring Mother:

                   Personal Data: name, age, address, etc

Baseline Data: v/s esppecially BP, weight

Obstetrical Data: gravida # preg, para- viable preg,  – 22 – 24 wks

Physical Exams,Pelvic Exams

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor

1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action

2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin

3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction

4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor

5.) theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

b.2. The 4 P’s of labor

1. Passenger

a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.

Bones – 6 bones  S – sphenoid      F – frontal - sinciput

                   E – ethmoid         O – occuputal - occiput

T – temporal        P – parietal  2 x

Measurement fetal head:

1.     transverse diameter – 9.25cm

-         biparietal – largest transverse

-         bitemporal 8 cm

2.     bimastoid 7cm smallest transverse

Sutures – intermembranous spaces that allow molding.

1.)  sagittal suture – connects 2 parietal bones ( sagitna)

2.)  coronal suture – connect parietal & frontal bone (crown)

3.)  lambdoidal suture – connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:

1.)  Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close

2.)  Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.

4.) Anteroposterior diameter -

suboccipitobregmatic 9.5 cm, complete flexion, smallest AP

occipitofrontal 12cm partial flexion

occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway

Mom          1.) < 4’9” tall

2.) < 18 years old

3.) Underwent pelvic dislocation

Pelvis

4 main pelvic types

1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy

2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow

3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow

4. Platypelloid – flat AP diameter – narrow, transverse – wider

b. Pelvis

2 hip bones – 2 innominate bones

          3 Parts of 2 Innominate Bones

                   Ileum – lateral side  of hips

- iliac crest – flaring superior border forming prominence of hips

Ischium – inferior portion

                             - ischial tuberosity where we sit – landmark to get external measurement of pelvis

Pubes – ant portion – symphisis pubis junction between 2 pubis

1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis

1 coccyx – 5 small bones compresses during vaginal delivery

Important Measurements

1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis.

          Measurement: 11.5 cm  - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm

3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.

Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.

3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor

a. Involuntary Contractions

b. Voluntary bearing down efforts

c. Characteristics: wave like

d. Timing: frequency, duration, intensity

4. Psyche/Person – psychological stress when the mother is fighting the labor experience

a. Cultural Interpretation

b. Preparation

c. Past Experience

d. 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 inlet

2. Braxton Hicks Contractions – painless irregular contractions

3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine

4. Ripening of the Cervix – butter soft

5. decreased body wt – 1.5 – 3 lbs

6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea

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 part

3.     Count pulsation of cord for FHT

4.     Prep mom for CS

Positioning – trendelenberg or knee chest position

              Emotional support

Prepare for Cesarean Section

 Difference Between True Labor and False Labor

False Labor	True Labor
Irregular contractions No increase in intensity Pain – confined to abdomen Pain – relived by walking No cervical changes	Contractions are regular Increased intensity Pain – begins lower back radiates to abdomen Pain – intensified by walking Cervical effacement & dilatation * major sx    of true labor.

Duration of Labor

Primipara – 14 hrs & not more than 20 hrs

Multipara – 8 hrs & not > 14 hrs

Effacement – softening  & thinning of cervix. Use % in unit of measurement

Dilation – widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

2 segments of the uterus

1. upper uterine  - fundus

2. lower uterine – isthmus

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

Latent Phase:

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

                             Frequency:  every 5 – 10 min

                                  Intensity mild

          Nursing Care: 

1.     Encourage walking - shorten 1^st stage of labor

2.     Encourage to void q 2 – 3 hrs – full bladder inhibit contractions

3.     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 ready

A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.

D – dry lips – oral care (ointment)

       dry linens

B – 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 – ires

I – nform of progress

R – estless support her breathing technique

E – ncourage and praise

D – iscomfort

Pelvic Exams

Effacement

Dilation

a. Station – landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if (-) floating

- 2 station = presenting part 2 cm above ischial spine if (-) floating

  0 station = level at ischial spine – engagement

+ 1 station = below 1 cm ischial spine

+3 to +5 = crowning – occurs at 2^nd stage of labor

b.  Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother

                             -spine of mom and spine of fetus

Two types:

b.1. Longitudinal Lie ( Parallel)

cephalic -   Vertex – complete flexion

                   Face

                   Brow Poor Flexion

                   Chin

Breech -     Complete Breech – thigh breast on abdomen, breast lie on thigh

                   Incomplete Breech – thigh rest on abdominal

                   Frank – legs extend to head

                   Footling – single, double

                   Kneeling

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.

Variety:

Occipito – LOA left occipito ant  (most common and favorable position)– side of maternal pelvis

LOP – left occipito posterior

LOP – most common mal position, most painful

ROP – squatting pos on mom

ROT

ROA

Breech- use sacrum                        LSA – left sacro anterior

- put stet above umbilicus              LST, LSP, RSA, RST, RSP

Shoulder/acromniodorso

LADA, LADT, LADP, RADA

Chin / Mento

LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions and Fetal heart Tone

Spread fingers lightly over fundus – to monitor contractions

Parts of contractions:

Increment or crescendo – beginning of contractions until it increases

Acme or apex – height of contraction

Decrement or decrescendo – from height of contractions until it decreases

Duration – beginning of contractions to end of same contraction

Interval – end of 1 contraction to beginning of next contraction

Frequency – beginning of 1 contraction to beginning of next contraction

Intensity - strength of contraction

Contraction – vasoconstriction

Increase BP, decrease FHT

Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve – 60 sec o2 for fetus during contractions

Duration of contractions shouldn’t >60 sec

Notify MD

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

Health teachings

1.) Ok to shower

2.)NPO – GIT stops function during labor if with food- will cause aspiration

3.)Enema administer during labor

a.)To cleanse bowel

b.)Prevent infection

c.)Sims position/side lying

12 – 18 inch – ht enema tubing

Check FHT after adm enema

Normal FHT= 120-160

Signs of fetal distress-

1.) <120 & >160

2.) mecomium stain amnion fluid

3.) fetal thrushing – hyperactive fetus due to lack O2

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 2^nd stage of labor.

Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula)

        Mediolateral – more bleeding & pain, hard to repair, slow to heal

-use local or pudendal anesthesia.

Ironing the perineum – to prevent laceration

Modified Ritgens maneuver – place towel at perineum

1.)To prevent laceration

2.) Will facilitate complete flexion  & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up.    Check time, identification of baby.

Mechanisms of labor

1.     Engagement -

2.     Descent

3.     Flexion

4.     Internal Rotation

5.     Extension

6.     External rotation

7.     Expulsion

Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider

                                 2. Cavity

Two Major Divisions of Pelvis

1.     True pelvis – below the pelvic inlet

2.     False pelvis – above the pelvic inlet; supports uterus during pregnancy

Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the  false and true pelvis.

Nursing Care:

To prevent puerperal sepsis - < 48 hours only – vaginal pack

Bolus of Ptocin can lead to hypotension.

3.    Third Stage: birth to expulsion of Placenta -placental stage    placenta has 15 – 28 cotyledons

Placenta delivered from 3-10 minutes

Signs of placental separation

1.     Fundus rises – becomes firm & globular “ Calkins sign”

2.     Lengthening of the cord

3.     Sudden gush of blood

Types of placental delivery

Shultz        “shiny” – begins to separate from center to edges presenting the fetal side shiny

Dunkan “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:

4.     Check completeness of placenta.

5.     Check fundus (if relaxed, massage uterus)

6.     Check bp

7.     Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives

8.     Monitor hpn (or give oxytocin IV)

9.     Check perineum for lacerations

10.Assist MD for episiorapy

11.Flat on bed

12.Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

4.     Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. Monitor v/s q 15 for 1 hr. 2^nd hr q 30 minutes.

Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus

1.)  Empty bladder to prevent uterine atony

2.)  Check lochia

a.     Maternal Observations – body system stabilizes

b.     Placement of the Fundus

c.      Lochia

d.     Perineum –

R - edness

E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation

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

e.     Bonding – interaction between mother and newborn – rooming in types

1.)  Straight rooming in baby: 24hrs with mom.

2.)  Partial rooming in: baby in morning , at night nursery

 

Complications of Labor

Dystocia – difficult labor related to:

Mechanical factor – due to uterine inertia – sluggishness of contraction

1.)  hypertonic or primary uterine inertia

-         intense excessive contractions resulting to ineffective pushing

-         MD administer sedative valium,/diazepam – muscle relaxant

2.)  hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.

Prolonged labor – normal length of labor in primi 14 – 20 hrs

                                                      Multi 10 -14 hrs

> 14 hrs in multi & > 20 hrs in primi

-         maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma

-         nsg care: monitor contractions and FHR

Precipitate Labor -  labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.

Earliest sign: tachycardia & restlessness

Late sign: hypotension

Outstanding Nursing dx: fluid volume deficit

Post of mom – modified trendelenberg

IV – fast drip due fluid volume def

Signs of Hypovolemic Shock:

Hypotension

Tachycardia

Tachypnea

Cold clammy skin

         

Inversion of the uterus – situation uterus is inside out.

MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus

1.)  short cord

2.)  hurrying of placental delivery

3.)  ineffective fundal pressure

Uterine Rupture

Causes: 1.)

1.)Previous classical CS

2.)Large baby

3.) Improper use of oxytocin (IV drip)

Sx:

a.)  sudden pain

b.)  profuse bleeding

c.)   hypovolemic shock

d.)  TAHBSO

Physiologic retraction ring

-         Boundary bet upper/lower uterine segment

BANDL’S pathologic ring – suprapubic depression

a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters natural circulation resulting to embolism

Sx:

dyspnea, chest pain & frothy sputum

prepare: suctioning

end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose, etc.

Trial Labor – measurement of  head & pelvis falls on borderline. Mom given 6 hrs of labor

Multi: 8 – 14, primi 14 – 20

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

Sx:

1. premature contractions q 10 min

2. effacement of 60 – 80%

3. dilation 2-3 cm

Home Mgt:

1. complete bed rest

2. avoid sex

3. empty bladder

4. drink 3 -4 glasses of water – full bladder inhibits contractions

5. consult MD if symptoms persist

Hosp:

1. 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.

X. Postpartal Period 5^th stage of labor

after 24hrs   :Normal increase WBC up to 30,000 cumm

Puerperium – covers 1^st 6 wks post partum

Involution – return of repro organ to its non  pregnant state.

Hyperfibrinogenia

- prone to thrombus formation

- early ambulation

Principles underlying puerperium

1. To return to Normal and Facilitate healing

A. Physiologic Changes

a.1. Systemic Changes

1. Cardiovascular System

- the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.

2. Genital tract

a. Cervix – cervical opening

b. Vaginal and Pelvic Floor

c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10^th day – no longer palpable due behind symphisis pubis

3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C

after,  birth pain:

1. position  prone

2. cold compress – to prevent bleeding

3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.

1. Ruba – red 1^st 3 days present, musty/mousy, moderate amt

2. Serosa – pink to brown 4 – 9^th day, limited amt

          3. Alba – créme white 10 – 21 days very decreased amt

dysuria

- urine collection

- alternate warm & cold compress

- stimulate bladder

3. Urinary tract:             Bladder – freq in urination after delivery- urinary retention with overflow

4. Colon:     Constipation – due NPO, fear of bearing down

5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress

                             sex- when perineum has healed

II. Provide Emotional Support – Reva Rubia

Psychological Responses:

a.     Taking in phase – dependent phase (1^st three days) mom – passive, cant make decisions, activity is to tell child birth experiences.

Nursing Care: - proper hygiene

b.     Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions

HT:

1.)  Care of newborn

2.)  Insert family planting method

common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic.

c.      Letting go – interdependent phase – 7 days & above. Mom  - redefines new roles may extend until child grows.

III. Prevent complications

1.     Hemorrhage – bleeding of  > 500cc

CS – 600 – 800 cc normal

NSD 500 cc

I.                    Early postpartum hemorrhage– bleeding within 1^st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock.

Mgt:

1.)  massage uterus until contracted

2.)  cold compress

3.)  modified trendelenberg

4.)  IV fast drip/ oxytocin IV drip

1^st degree laceration – affects vaginal skin & mucus membrane.

2^nd degree – 1^st degree + muscles of vagina

3^rd degree – 2^nd degree + external sphincter of rectum

4^th degree – 3^rd degree + mucus membrane of rectum

Breast feeding – post pit gland will release oxytocin so uterus will contract.

Well contracted uterus + bleeding = laceration

-         assess perineum for laceration

-         degree of laceration

-         mgt episiorapy

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.

-         bleeding to any part of body

-         hysterectomy if with abruption placenta

mgt: BT- cryoprecipitate or fresh frozen plasma

II.                  Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments

Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta,

Acreta – attached placenta to myometrium.

Increta – deeper attachment of placenta to myometrium                hysterectomy

Percreta – invasion of placenta to perimetrium

Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.

-         too much manipulation

-         large baby

-         pudendal anesthesia

Mgt:

1.)  cold compress every 30 minutes with rest period of 30 minutes for 24 hrs

2.)  shave

3.)  incision on site, scraping & suturing

Infection- sources of infection

1.)endogenous – from within body

2.) exogenous – from outside

1.)  anaerobic streptococci – most common - from members health team

2.)  unhealthy sexual practices

General signs of inflammation:

1.     Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)

2.     purulent discharges

3.     fever

Gen mgt:

1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for antibiotic

prolonged use of antibiotic lead to fungal infection

inflammation of perineum – see general signs of inflammation

2 to 3 stitches dislocated with purulent discharge

Mgt:

Removal of sutures & drainage, saline, between & resulting.

Endometriosis – inflammation of endometrial lining

Sx:

Abdominal tenderness, pos.

Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning

1.)  determine one’s own beliefs 1^st

2.)  never advice a permanent method of planning

3.) method of choice is an individuals choice.

Natural Method – the only method accepted by the Catholic Church

Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)

-         clear, watery, stretchable, elastic – long spinnbarkeit

Basal Body Temperature  13^th day temp goes down before ovulation – no sex

-         get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.

breast feeding- menstruation will come out 4 – 6 months

bottle fed 2 – 3 months

disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method – 1.) coitus interuptus/ withdrawal  - least effective method

2.     coitus reservatus – sex without ejaculation –

3.     coitus interfemora – “ipit”

4.     calendar method

OVULATION –count minus 14 days before next mens (14 days before next mens)

Origoknause formula –

-         monitor cycle for 1 year

-         -get short test & longest cycle from  Jan – Dec

-         shortest – 18

-         longest – 11

June 26        Dec 33

       - 18              -11

           8      -        22   unsafe days

21 day pill- start 5^th day of mens

28day pill- start 1^st day of mens

missed 1 pill – take 2 next day

Physiologic Method-

Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.

- if a new oral contraceptive is prescribed the mother should continue  taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.

- discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA  and subarachnoid hemorrhage.

Signs of hypertension

Immediate Discontinuation

A – abdominal pain
C – chest pain
H - headache
E – eye problems

S – severe leg cramps

If mom HPN – stop pills STAT!

Adverse effect: breakthrough bleeding

Contraindicated:

1.)  chain smoker

2.)  extreme obesity

3.)  HPN

4.)  DM

5.)  Thrombophlebitis or problems in clotting factors

-         if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.

DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation

          Depomedroxy progesterone acetate – IM q 3 months

- never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.

-         5 yrs – disadvantage if keloid skin

-         as soon as removed – can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation – affects motility of sperm & ovum

-         right time to insert is after delivery or during menstruation primary indication for use of IUD

-         parity or # of children, if 1 kid only don’t use IUD

HT:

1.)  Check for string daily

2.)  Monthly checkup

3.)  Regular pap smear

Alerts;

-         prevents implantation

-         most common complications: excessive menstrual flow and expulsion of the device (common problem)

-         others:

P eriod late (pregnancy suspected)

Abnormal spotting or bleeding

                   A bdominal pain or pain with intercourse

                   I nfection (abnormal vaginal discharge)

                   N ot feeling well, fever, chills

                   S trings lost, shorter or longer

                             Uterine inflammation, uterine perforation, ectopic pregnancy

Condom – latex inserted to erected penis or lubricated vagina

Adv; gives highest protection against STD – female condom

Alerts:

Disadvantage:

-         it lessen sexual satisfaction

-         it gives higher protection in the prevention of STDs

Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE Ht:

1.)  proper hygiene

2.)  check for holes before use

3.)  must stay in place 6 – 8 hrs after sex

4.)  must be refitted especially if without wt change 15 lbs

5.)  spermicide – chem. Barrier   ex. Foam (most effective), jellies, creams

S/effect: Toxic shock syndrome

Alerts:  Should be kept in place for about 6 – 8 hours

Cervical Cap – most durable than diaphragm no need to apply spermicide

C/I: abnormal pap smear

Foams, Jellies, Creams

Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects

Vasectomy – cut vas deferense.

HT: >30 ejaculations before safe sex

O – zero sperm count, safe

XI. High Risk Pregnancy

1.    Hemorrhagic Disorders

General Management

1.)  CBR

2.)  Avoid sex

3.)  Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)

4.)  Ultrasound to determine integrity of sac

5.)  Signs of Hypovolemic shock

6.)  Save discharges – for histopathology – to determine if product of conception has been expelled or not

First Trimester Bleeding – abortion or eptopic

A. Abortions – termination of pregnancy before age of viability (before 20 weeks)

Spontaneous Abortion- miscarriage

Cause:        1.) chromosomal alterations

2.) blighted ovum

3.) plasma germ defect

Classifications:

a.     Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed

b.     Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)

Types:

1.)  Complete – all products of conception are expelled. No mgt just emotional support!

2.)  Incomplete – Placental and membranes retained. Mgt: D&C

Incompetent cervix – abortion

McDonalds procedure – temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD

Sheridan – permanent surgery cervix. CS

c.    Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2^nd trimester

d.    Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding

Mgt:  induced labor with oxytocin or vacuum extraction

      5.)    Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil.

C.    Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site: tubal or ampular

Dangerous site – interstitial

Unruptured	Tubal rupture
-         missed period -         abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided) -         scant, dark brown, vaginal bleeding Nursing care: Vital signs Administer IV fluids Monitor for vaginal bleeding Monitor I & O	-         sudden , sharp, severe pain. Unilateral radiating to shoulder. shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve) + Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding syncope (fainting) Mgt: Surgery depending on side Ovary: oophrectomy Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Use: methotrexate to prevent choriocarcinoma

Assessment:

Early signs -        vesicles passed thru the vagina

                        Hyperemesis gravidarium increase HCG

                        Fundal height

Vaginal bleeding( scant or profuse)

Early in pregnancy

                   High levels of HCG

                   Preeclampsia at about 12 weeks

Late signs   hypertension before 20^th week

                   Vesicles look like a “ snowstorm” on sonogram

                   Anemia

                   Abdominal cramping

Serious complications           hyperthyroidism

                                      Pulmonary embolus

Nursing care:

          Prepare D&C

          Do not give oxytoxic drugs

          Teachings:

a.     Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma

b.     Avoid pregnancy for at least one year

Third Trimester Bleeding “Placenta Anomalies”

D.    Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.

-         candidate for CS

Sx: frank

Bright red

Painless bleeding

Dx:

Ultrasound

Avoid: sex, IE, enema – may lead to sudden fetal blood loss

Double set up: delivery room may be converted to OR

Assessment:

Engagement (usually has not occurred)

Fetal distress

Presentation ( usually abnormal)

          Surgeon – in charge of sign consent, RN as witness

-         MD explain to patient

complication: sudden fetal blood loss

Nursing Care

          NPO

Bed rest   

Prepare to induce labor if cervix is ripe

Administer IV

E.     Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:

Concealed bleeding (retroplacental)

Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.

Severe abdominal pain

Dropping coagulation factor (a potential for DIC)

Complications:

Sudden fetal blood loss

-placenta previa & vasa previa

Nursing Care:

Infuse IV, prepare to administer blood

Type and crossmatch

Monitor FHR

Insert Foley

Measure blood loss; count pads

Report s/sx of DIC

Monitor v/s for shock

Strict I&O

F.      Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut.

G.    Placenta Circumvalata – fetal side of placenta covered by chorion

H.   Placenta Marginata – fold side of chorion reaches just to the edge of placenta

I.        Battledore Placenta – cord inserted marginally rather then centrally

J.       Placenta Bipartita – placenta divides into 2 lobes

K.     Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta

L.      Vasa Previa – velamentous insertion of cord has implanted in cervical OS

2.    Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.)  Gestational hypertension - HPN without edema & protenuria    H without EP

2.)  Pre-eclampsia – HPN with edema & protenuria or albuminuria    HE P/A

3.)  HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension – HPN between 20 – 24 weeks

III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.

Three types of pre-eclampsia

1.) Mild preeclampsia – earliest sign of preeclampsia   

a.) increase wt due to edema

b.) BP 140/90

c.) protenuria +1 - +2

2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110  ,  protenuria +3 - +4

3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.

Cause of preeclampsia

1.)  idiopathic or unknown common in primi due to 1^st exposure to chorionic villi

2.)  common in multiple pre (twins) increase exposure to chorionic villi

3.)  common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:

P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.

P- prevent convulsions by nursing measures or seizure precaution

1.) dimly lit room . quiet calm environment

                             2.) minimal handling – planning procedure

                             3.) avoid jarring bed

P- prepare the following at bedside

                   - tongue depressor

                   - turning to side done AFTER seizure! Observe only! for safely.

E – ensure high protein intake ( 1g/kg/day)

                   - Na – in moderation

A – anti-hypertensive drug Hydralazine ( Apresoline)

C – convulsion, prevent – Mg So4 – CNS depressant

           E – valuate physical parameters for Magnesium sulfate

                            Magnesium SO4 Toxicity:

1.     BP decrease

2.     Urine output decrease

3.     Resp < 12

4.     Patella reflex absent – 1^st sigh Mg SO4 toxicity.  antidote – Ca gluconate

3.Diabetes Mellitus -  absence of insufficient insulin (Islet of Langerhans of pancreas)

Function: of insulin – facilitates transport of glucose to cell

Dx: 1 hr 50gr  glucose tolerance test   GTT

Normal glucose – 80 – 120 mg/dl            < 80 – hypoclycemic

                      ( euglycemia)             > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL

maternal effect DM

1.)  Hypo or hyperglycemia – 1^st trimester hypo, 2^nd – 3^rd trim – hyperglycemic

2.)  Frequent infection- moniliasis

3.)  Polyhydramnios

4.)  Dystocia-difficult birth due to abnormalities in fetus or mom.

5.)  Insulin requirement, decrease in insulin by 33% in 1^st tri; 50% increase insulin at 2nd – 3^rd trimester.

Post partum decrease 25% due placenta out.

Fetal effect

1.)  hyper & hypoglycemia

2.)  macrosomia – large gestational age – baby delivered > 400g or 4kg

3.)  preterm birth to prevent stillbirth

Newborn Effect : DM

1.)  hyperinsulinism

2.)  hypoglycemia

normal glucose in newborn 45 – 55 mg/dL

hypoglycemic < 40 mg/dL

Heel stick test – get blood at heel

Sx:

Hypoglycemia high pitch shrill cry tremors, administer dextrose

3.)  hypocalcemia - < 7mg%

Sx:

Calcemia tetany

Trousseau sign

Give calcium gluconate if decrease calcium

Recommendation

Therapeutic abortion

If  push through with pregnancy

1.)  antibiotic therapy- to prevent sub acute bacterial endocarditis

2.)  anticoagulant – heparin doesn’t cross placenta

Class I & II- good progress for vaginal delivery

Class  III & IV- poor prognosis, for vaginal delivery, not CS!

NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver

Regional anesthesia!

Low forcep delivery due to inability to push. It will shorten 2^nd stage of labor.

Heart disease

Moms with RHD at childhood

Class I – no limit to physical activity

Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II

1.)  sleep 10 hrs a day

2.)  rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort

Recommendation:

1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.

Recommendation: Therapeutic abortion

XII. Intrapartal complications

1.     Cesarean Delivery  Indications:

a.           Multiple gestation

b.           Diabetes

c.            Active herpes II

d.           Severe toxemia

e.           Placenta previa

f.             Abruptio placenta

g.           Prolapse of the cord

h.           CPD primary indication

i.              Breech presentation

j.              Transverse lie

Procedure:

a.     classical – vertical insertion. Once classical always classical

b.     Low segment – bikini line type – aesthetic use

VBAC – vaginal birth after CS

INFERTILITY -  inability to achieve pregnancy. Within a year of attempting it

-         Manageable

STERILITY - irreversible

Impotency – inability to have an erection

2 types of infertility

1.) primary – no pregnancy at all

2.) Secondary – 1^st pregnancy, no more next preg

test male 1^st

-         more practical & less complicated

-         need: sperm only

-         sterile bottle container ( not plastic has chem.)

-         Sims Huhner test – or post coital test. Procedure: sex 2 hours before test

mom – remains supine 15 min after ejaculation

Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm count

Best criteria- sperm motility for impotency

Factors: low sperm count

1.)  occupation- truck driver

2.)  chain smoker

administer: clomid ( chomephine citrate) to induce spermatogenesis

Mgt: GIFT= Gamete Intra Fallopian Transfer  for low sperm count

Implant sperm in ampula

1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia

Administer; parlodel ( Bromocryptice Mesylate)

Action; antihyper prolactineuria

Give mom clomid: action: to induce oogenesis or ovulation

S/E: multiple pregnancy

2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes

-         use of IUD

-         appendicitis (burst) & scarring

= dx: hysterosalphingography – used to determine tubal patency with use of radiopaque material

Mgt: IVF – invitrofertilization (test tube baby)

England 1^st test tube baby

To shorten 2^nd stage of labor!

1.)  fundal pressure

2.)  episiotomy

3.)  forcep delivery