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OBSTETRICAL NURSING, Trinidad S.

Ignacio RN MAN
Primary Goal of MCHN: promotion and maintenance of optimal family health to ensure cycles of
optimal childbearing and childrearing
FSH >> Estrogen
LH >> Progesterone
Reproductive parts of the female
I.
External
a. Majora- external covering
b. Minora- inside the majora sensitive
i. Clitoris very sensitive; seat of sexual stimulation
1. Avoid stimulating the clitoris in patient with PIH >> seizure
2. Prepuce- protection of clitoris
c. Mons- cushioning
d. PBE: lower boundary of clitoris Fourchette- very thin layer of skin, when stretch
napupunit during delivery; portion before the perineum and anus
i. First degree perineal laceration- Fourchette- okay lang; suture for aesthetic
ii. 2nd perineum there are muscles and BV >> bleeding
iii. 3rd- anal sphincter
iv. 4rd degree entire rectum
v. 1 and 2 walang scar
vi. 4- at risk for incontinence of bowel
1. Res Ipsa Loquitor
vii. Para hindi mapunit Ritgens maneuver Perineal support\
viii. Episiotomy way to prevent extension to the sphincter
1. Medio-lateral malayo sa sphincter
ix. When will the MD cut: peak of a contraction- smooth muscle relaxation less
muscles
1. Pudendal nerve block or local infiltration no feeling in the perineum
a. Extended the pain free area including the perineum
x. Wound is too deep 3-4 week for complete healing
1. More risk for infection up to 4 week
xi. Only dorsal lithotomy position will always end up with a laceration
1. Perineal muscles will be fully relaxed
2. Why choose DL:
a. He can cut episiotomy
b. For forcep delivery open wide legs
c. For breech baby
II.
Internal
a. Vagina important passageway
i. Menstruation
ii. Penis
iii. Baby and birth product- placenta
iv. Why is capable of stretching? With rugae- muscle folds that stretches every
time child passess through
1. Rugae was flattened by the baby after the delivery
2. To restore the rugae Kegals exercise that uses the pubo-coccygeal
muscles or perineal muscles
a. As if trying to control mictuterine prolapseurition or urination contract for 4 counts, 1 count for relaxation
b. Done anytime anyday whenever she reminds to do it
c. For the vagina to restore after 6 weeks

v.

vi.
vii.

viii.

ix.
x.
xi.

xii.
xiii.

xiv.

i. Prolapse uterus is supported by three ligaments


1. Upper ligament support to keep in place
2. Middle support
3. Lower- no support
a. 1st degree- okay lang pessary donut ring
to hold the uterus to prevent more prolapsed
i. At risk for infection
3. PBE: Diaphragm fitting 6 weeks PP
i. Uterine inversion
Cystocoele protrusion of the urinary bladder anterior wall of the vagina
1. Stress incontinence kapag nag valsalva, naiihi na increase
abdominal pressure
a. Wear diapers
2. Perineorraphy - anterior
Kegels exercise matagal bago bumalik ang vaginal sa dati
Rectocoele protrusion of the rectum in the vagina due to laceration of
vagina posterior wall
1. Constipation obstipation obstructed constipation >> nasasakal
yung rectum; mas nakakatakot
2. Posterior perineorraphy
Lubrication of vagina
1. Bartholins gland outside; opening of vagina
a. Cyst- infection of the gland
2. Skenes or paraurethral sides of urethra
3. Cervical mucus - - comes from the glands of the cervical area
Day before ovulation lalabas ung vaginal secretions Spinnbarkeit
Needle point size cervix
Estrogen
1. Dilate cervix
2. Released before ovulation
3. Mid cycle 13-14th day
4. Mucus is clear, watery, stretchy (Spinnbarkheit 6-12cm)
a. Unsafe mucus in billings method
b. Vagina is no longer acidic alkaline na pH 8
i. Sperm can live only in neutral or basic
Life span ng egg cell 1 day; kapag namatay, increase progesterone
Progesterone
1. Closes the cervix
2. Released on the 16th day
3. Mucus is decreased in amount, sticky cloudy (Spinnbarkheit 3cm)
a. Napuputol na agad
b. Vagina is acidic ph:6
c. Safe to have sex
Normal flora of vagina
1. Doderleins bacillus makes the vagina acidic, protects vagina from
bacterial infection
a. Candidiasis Candida albican opportunistic organism- matagal
na sa vagina; kapag acidic, konti ang naiiwan; kapag alkaline
infection
i. Looks like a diaper rash
ii. Cottage cheesy discharge if in vagina
iii. May only see red, itchy vulva
iv. Risk factors alter the acidity
1. Pregnancy increase progesterone and estrogen
a. Non pregnant- source: ovary

v.
vi.
vii.
viii.
ix.
x.

b. Pregnant: placenta
2. DM
3. Oral contraceptive use
a. Combination of hormone abnormal level of
hormones
4. Use of systemic antibiotics
a. Decrease normal flora due to antibiotics
Moniliasis or yeast infection
Can occur in mouth, vagina and diaper area of infant
White plaques on erythematous base if found in mouth
Looks like milk curd
Note: do not scrape away if in mouth magdudugo
Management
1. Systemic Fluconazole
a. Effective; not used in first trimester
teratogenic
2. Local Miconazole (Monistat)
a. Vaginal suppository
b. Best time at night before going to sleep
i. It will melt during the night > drug
stays in the vagina longer
ii. More discharge normal- drug has
taken effect

b. Uterus
i. Fundus- area that will contract; active segment of uterus
1. What hormones the uterus to contract
a. Oxytocin*** - oxytocin theory
b. Prostaglandin increased***- prostaglandin deprivation theory
i. Kapag nagddysmenorrhea take prostaglandin inhibiting
drugs
1. Take at the start of the pain
c. P + O sobrang sakit
d. Progesterone relaxation
e. Decrease progesterone >>> increase oxytocin >>> contraction
f. Braxton Hicks false labor >> decrease progesterone
i. Make her walk should stop
ii. Walking- intensify true labor
g. 2 weeks before EDC woman is releasing prostaglandin; semen
has prostaglandin
i. PROSTAGLANDIN CASCADE THEORY
h. Stretch theory not contract because of natural protection
i. Twins are always premature births
ii. Uterine rupture if there is obstruction in babys passage
1. How will you know:
i. Separates the active and passive normal physiologic
retraction ring
i. Palpable*
j. Bandls ring pathological ring
i. Visual or visible distinction
ii. Check the bladder bladder is distended
1. Empty bladder every two hours >> catheterize if
did not void after 4 hours
iii. CPD cephalopelvic disproportion
1. Call the MD
2. Anticipate CS or emergency deliver

2. Immediate PP 5 month pregnancy uterine size umbilical area


3. After placental separation
a. Check uterine contraction >> assess blood loss >> maternal VS
b. If there is uterine atony massage then ice
ii. Corpus
iii. Isthmus
c. Fallopian tube
i. Area where fertilization occurs distal third of the ampulla;
1. Fertilization to implantation 6-8 days
2. Isthmus BTL
a. Connection between FT and uterus
b. Most vascular area
ii. Hormonal influences
1. Progesterone provides nourishment for the fertilized egg as it travels
the tube
d. Ovary
i. Menstrual cycle
1. Promordial ova (at birth): 300-400K
2. By age 7: reduced by half in number
3. Number that reach maturation: around 400 (200 per ovary)
a. Menstruation: alternating ovary
ii. Menopause cessation of menses; grand climacterium no reproductive
function
1. Age of menopause of mother >> same as daughter
2. Reproductive period 35 years average
3. Menarche 9-17 years old; earlier than 9- precocious puberty; after 17Turners syndrome genetic problem, missing X chromosome (44 XO)
4. Age 34-60
5. Phases
a. Peri-menopause start of hormonal imbalance, 2-10 years prior
to menopause
i. Hot flash and night sweats vasomotor instability FIRST
SIGN ***
ii. Changes in menstrual cycle irregular menses
iii. Moodiness psychosocial issues forgetfulness,
sleeplessness
b. Menopause- menstruation stops
i. not ended until 1 year after woman stops menstruation
lowest estrogen level
ii. problems life threatening
1. HPN and heart disease - CAD
a. Good level of estrogen, high level of HDL- low
level of LDL
b. Dec estrogen low HDL, ^LDL
c. Yearly cholesterol check
2. Osteoporosis
a. Loss of bone density or mass; brittle bones
b. Good estrogen calcium to be absorbed, and
retained- good calcium deposits
c. Loss estrogen with calcium absorption,
decrease retention of calcium- less calcium
in the bones
d. Non menopause: ca = 800mg/day
e. Menopause: 1500-1800 mg/day

f.
g.
h.
i.
j.

One glass 400mg


At risk for pelvic fracture
Wrist fracture- first sign
Kyphosis- Dowagers hump
Weight bearing exercises to exercise bones
i. Anything that using the legs
ii. Stair climbing, walking, squatting
iii. No jumping or bouncing too much
pressure on the bones
3. Breast cancer
a. BSE is compulsory; one week post
menstruation
b. For menopause same day every month
c. BF or lactating same day every month
i. She has to empty her BF; post NF
dapat
d. BSE
i. Standing never pantay; symmetrical
ii. Raise hand above head one is bigger
or heavier growth that pulls it
downward
iii. Head on waist and lean forward
where breast points; if push to the side
growth
iv. Abnormal symmetry
v. Palpate circular and tail method
>>using thumb, gently squeeze the
nipple, check for discharge from the
nipple growth
e. A sore that does not heal pimple Pagets
disease- cancer of ducts
f. Dimpling the skin growth that is retracting
or pulling the skin inward
g. Mammogram- 40 to 50 every 2 years; 51
and above every year
i. More common in menopausal women
due to sudden loss of estrogen
h. Cervical cancer
i. Paps Smear 21 years old; but
sexually active earlier 3 years after
first sexual activity
ii. No physical preparation
iii. Clean the area before insertion of
speculum
iv. No sexual activity the night before
baka may sperm pa
v. No douching within 48 hours before
Pap smear clean vagina inside alter
vaginal environment - inaccurate
vi. From one end roll to other end:
proper way to put the specimen in the

slide >> fixing solution >> examine


through the microscope
vii. Once a year - normal
viii. First visit then after 6 weeks PP
pregnant
ix. Every 3 months sex worker
x. I- negative for any abnormal cells
abnormal mens infection
xi. II- negative for cancer cells; with
atypical cells
xii. III- suggest malignancy >> biopsy
not conclusive
xiii. IV- highly suggest malignancy >>
biopsy
xiv. V- conclusive the earlier treated,
better
xv. Abnormality in the uterus and cervix
HPV- pre cancerous infection

i.
c. Post menopause
6. Menstrual Cycle
a. Estrogen is the opposite of progesterone
b. Estrogen
i. Retains Na responsible for water retention; during
pregnancy, stimulates increase BV
ii. Decrease resistance in peripheral vessels vasodilator
iii. Increase fibrinogen or clotting
1. At risk for clot formed- lower legs
2. Change position every 2 hours, elevate the legs
iv. BBT- core body temperature, at rest
1. Decrease with estrogen
v. On mucus watery
vi. No effect on behavior
vii. Hypertrophy of the myometrium stickening of the
myometrium
c. Progesterone
i. Decrease sodium stimulate the RAA- increase
aldosterone anti diuretic hormone
ii. Vasoconstriction
iii. No effect on clotting
iv. Increase temperature
v. Mucus- sticky cervical closes
vi. Neuro endocrine effect on behavior of women
vii. Relaxation of myometrium
d. Myoma big tumor in uterus
e. PIH typical of imbalance of P and E
i. At risk of primipara
f. Ovulation drops then increase BBT
g. Extreme hormone changes separation of placenta
DEPRESSED post partum blues; menopause madrama.
h. Involved in the cycle
i. Hypothalamus gives GnRh
ii. Anterior Pituitary Gland for FSH and LH
1. FSH stimulates follicle maturation
a. Primordial to graffial

b. Umaakyat ang estrogen - thickens


2. LH stimulation of ovulation and corpus luteum
iii. Ovary Estrogen and Progesterone
1. Estradiol from ovary; estriol from pregnancy,
placenta
2. Progestine help the uterus
iv. Uterus
1. Estrogen proliferative phase
2. Progesterone secretory phase
i. Where it started
i. Shedding Menstrual cycles
1. 3 to 6 days
ii. Proliferative- unusually longer or shorter; gives rise to
different intervals
1. Maiksi ang P- short cycle; vice versa
2. Normal or balance upto 2 weeks only
iii. Secretory
iv. Ischemic
j. Why menstruated?
i. Corpus luteum- main source of progesterone and some
estrogen
k. Degenerated corpus luteum (corpus albican) >>> dec estrogen
>>> endometrium shedding >>> menstruation
i. Decrease estrogen and progesterone >>> GNRH >>>
1. >>> FSH >>> follicular maturation >>> increase
estrogen >>> thickening of the endometrium
2. >>> LH >>> ovulation (hanggang dito ang
proliferative)
a. >>>
corpus
luteum(secretory)
>>>
progesterone >> Vascular (^blood supply)
>>> ready for implantation
l. Pregnancy is completed secretory phase
m. Corpus albicans- ischemic phase
n. In menopause - ^FSH, dec Estroegen = HRT
o. Pills decrease FSH and LH
p. LAM lactational amenorrhea
i. Prolactin >> stimulates production of milk
ii. ^prolactin, decrease estrogen
iii. Breast feeding 6x during the day, twice per night
iv. 6 months maximum
7. Abnormal Menstruation
-

Weight gain highest third trimester


Physiologic anemia increase in plasma volume- baby needs more blood from the mother
Gravida- number of pregnancy regardless of outcome
o Twins 1 gravida and para
Skin changes - estrogen
Constipation progesterone relaxation of smooth muscles
Breast changes both
Morning sickness none- HCG
Waddling gait- unstable movement of the joints due to relaxin - neither
Genital changes estrogen
Hypertrophy estrogen
Varicosity progesterone and estrogen

Edema- both
Hemorrhoids both
If suspected pregnancy count as a gravid
If not indicated that it is preterm, consider it as a full term
Ectopic and H mole count in gravida, not in para, consider in abortion
Abortion- termination of pregnancy until age of viability, any cause

PREGNANCY result of fertilization and implantation


- Lifespan of ovum and sperm
o Sperm can live up to 48-72 hours
o Eggs 24 hours
- Fertilization- distal third of FT
o Zygote- outcome of fertilization
o The carries an x or y chromosome
o Union of a matures ovum and sperm
o Genotype genetic trait
o Phenotype- physical trait
o 44 autosomes
o 2 sex chromosomes
XX - girl
XY boy
o X chromosome slow moving; longer life span
o Y fast, short Life span
o Zygote divides into two cells blastomeres >> morula >> blastocyst +
Endometrium lining of the uterus
Endometrium during the pregnancy deciduas
Basalis base; where placenta is attached chorion
o Chorion and basalis = placenta
o Maiiwan pagkatapos ng lahat ng lochial discharge zona basalis
gives rise to new endometrium PP
o Deeper layer
o Will be the lochia
Rubra
Serosa
Alba
Vera
Capsularis sac or membrane
Twinning 2 babies from a zygote monozygotic twins share everything
Fraternal 2 egg cells 2 sperms to fertilize- dizygotic different placentasthey share space
1st baby na makapag implant ng placenta sa taas more blood vessels
more vascular- good blood supply
2nd baby- lower- placenta previa
Morula at the end of FT
Blastocyst once entered in the uterus
Outer portion of blastocyst- trophoblast
Division of blastocyst
Embryoblast- fetus; nothing in H-mole
Trophoblast
o Chorion placenta
o Amnion- fetal membrane

Abnormal fertilization egg cell could be empty; sperm can still fertilize egg >> Hmole
With chorion source of HCG; no amnion
o Attachment of the uterus upper central; posterior in the uterus
Development
Chorion develops the primary villi/ chorionic villi >> release enzymes
to allow to open or tap maternal vessles >> LACUNAE (Blood Lake)
>> cotyledons are formed (16-20 cotyledons) >> placenta
Bigger placenta syphilis and placenta previa (poor vascularity)
6-8 days implantation
Placentation 3rd week nagfoform na
Completed on 3rd month
16 weeks functioning
o Kapag wala pang placenta endometrium from progesterone and estrogen
P and E corpus luteum
o Messenger of CV- HCG- to stimulate the CL to stay viable until the placenta is
working
o HCG prevents involution of corpus luteum
Present in maternal blood 8 to 10 days after fertilization (as soon as
implantation occurs)
Pregnancy Test first voided urine midstream clean catch urine
Doubles every 48 hours
o Ectopic pregnancy low levels of HCG
o Placenta provides P and E
3rd month HCG will decrease to its low level
HCG persistent level of HCG
Manifestation vomiting, diarrhea and diarrhea in the morning; and morning
sickness sick in the stomach in the morning only
NVD- hormonal in cause; no irritating foods, no spice and fats, bland
food
Morning sickness hypoglycemia and HCG
o Glucose is needed for brain development
o Hyperemesis Gravidarum
Too much HCG
Possible H mole
Hyperemesis after 1st trimester?
o Placenta ORGANS of the baby
Organ >> o2 >> umbilical vein
>> excretion of deoxygenated blood >> 1 umbilical arteries
o Endocrine hormones given by placenta
HCG
E and P
HPL fetal growth hormone
2 trimester
o Rapid growth of baby- 3rd trimester
Diabetes Mellitus
o Increase HCG, E and P, HPL insulin antagonist
^ insulin resistance
o HPL, E, P >> poor glucose metabolism because you dont use all insulin +
insulinase >> goes to baby >> immature pancreas >> fetal macrosomia >> PP =
hyperinsulinism
o

Macrosomic baby organomegaly; usual cause of death


Neonatal hypoglycemia after birth
Too viscous blood >> decrease blood flow to uterus >> placental
degeneration >> baby dies to uterus
CS and preterm
For check for degenerating placenta UTZ
o Amount of calcification of the placenta- placental age
Grade 3- matured
o Insulinase hastens degradation of insulin
o Effects on mother PIH due to poor circulation urine has glucose; small amount
okay lang, just the effect of progesterone; sugar in urine +1 or +2 good medium
for infections
Infections >> bladder irritability >> premature birth
Candidiasis
Cesarean
Infection: Atony due to over distention of uterus >> hemorrhage of PP
o DM because of placenta
DOC: Insulin Intermediate
Oral hypoglycemic teratogenic >> goes to the baby >> overstimulation in
the babys pancreas
o Insulin requirement in last trimester last trimester period of greatest stress
Insulin mixing last trimester
o Labor needs insulin; insulin pump
o PP: at risk for hypoglycemia both patient and baby
o After 6 weeks she will be back to non diabetic
More than 6 weeks diabetic talaga, not diagnosed before = type 2
o Critical baby for babay for hypoglycemia- 1st 24 hours
Immunologic Function
o IgG passive natural (2 weeks before delivery or 36-38 weeks AOG)
o Protective barrier (single cell membrane)
Cytotrophoblast- inner- naiiwan at risk for syphilis
Can be transferred in the 2nd trimester than in the first
VDRL- to check for syphilis
Can Wasserman Method
Penicillin safe drug to use for pregnant women. It will not damage
baby.
Syncytiotrophoblast- outer - papasok yung Treponema pallidum
Umbilical Cord same as the length of the baby
o Length of the cord HAASEs rule
1st five month month squared length in cm
6-10 month month times 5 cm
o Short cord- less than 40cm at full term
Abruption placenta**
Whartons Jelly- connective tissue
o Fluid filled open all the time
o Cord prolapse position the patient on a side lying position with legs elevated with
pillows; knee chest position
If exposed na cover it, moist with NSS- clean or sterile>> CS
Amniotic Fluid baby only
o Amnion- membrane of the baby
o Fetal urine
Sterile 98% water; 2% salt

Amniocentesis aspiration of AF
Full term 800-1000ml
400 will remain; 600 is recycled
o Oligohydramnios less than 400ml
Kidney anomaly- small or missing kidney Downs Syndrome
o Polyhydramnios more than 200ml
May be the baby does not swallow
Tracheo-esophageal fistula
o pH = alkaline; 7-7.25
Litmus Paper Nitrazine test (LITHMUS)
ROM blue reaction- alkaline
o Early ROM early in labor; before transition
At risk for dry labor
Latent 0-4
Active- 4-7
Transition 7-10cm- normal ROM
o PROM premature baby; even before baby reaches term
Risk of infection
Treat with preventive AB: antimicrobials
If leaking continuous deliver the baby
If not delivered: chorioamnionitis infection of C and A
infects both mom and baby
o Color: slightly yellow because of vernix caseosa and shedding of the skin
Straw colored
If with cloudiness
Green meconium fetal distress and breech position(expected)
At risk for aspiration PNM suction very well
Portwine color abruptio placenta
o With characteristic odor but not foul
o Function
Maintains steady temperature warm
Kangaroo hold
Presumptive- subjective
o NV
o Urinary frequency
o Breast changes
o Quickening
o Skin changes
o Fatigue
o Amenorrhea
o GI symptoms
Probable objective signs
o Isthmus - Hegars
o Cervix- goodells
o Vagina chadwicks
Increase vascularity
o Ballottement internal
Gloved hand in the cervix 2 digits
Could also be a tumor
o Positive pregnancy test
o Braxton Hicks
o Enlargement of the abdomen
o
o

Positive
o Fetal heart sounds
o Outline
7 weeks sac
9th week- UTZ- fetus
o Movements felt by the examiners
Souffl high pitched sound that pass through a vessel
From UC Funic - FHT
Mother- uterine same with PR of mother
o FHT
Doppler 11 weeks/ 3 months
Stethoscope 16-20 weeks
120-160 bpm
o EDC
LMP; -3 +7 + 1; first day of LMP Naegels rule
No LMP- Bartholomews rule of 4
Xiphoid- 8th month- 9
Umbilicus- 5th month
Pubis
4 quadrants above and lower umbilicus
Each quadrant, one month
Engagement 9th month- lightening
Never accurate
Quickening
Primi 5 months
o Can give birth 2 weeks after or before
o +4(month) +20(date)
Multi- 4 months
o +5 (month) +4 (date)
o AOG
Mc Donalds Rule
Fundic Height in cm X 8; divide by 7 = AOG in weeks
Always the higher number
Normal weight gain in pregnancy
o 25 pounds or 12 kg = FT
o First trimester 1-3 months 1 lb per month
o 2nd-3rd trimester 1 lb per week
o Previous wt 137; previous 120
20 weeks gestation
Excessive: Normal should be only 11 lbs
Sample: LMP: November 30 Dec 3
o EDC: September 6, 2010
o LMP Spetember 25, 2009
AOG: if there is no date of visit consider date of exam
28 -29 weeks
Stages of intrauterine development
o Pre embryonic 1st 14 days after fertilization
50% are aborted blighted ovum
o Embryonic day 15 until about the 8 th week or until the embryo reaches a crown to
rump length of 3cm; organogenesis (most susceptible to teratogens)
First trimester
2nd week heart

Fetal

o 24th day pumping


3rd brain and CNS
o Spina bifida- Folic Acid B9
Green leafy vegetables best source
Prenatal vitamins multi vitamins- can be bought OTC
Double in prenatal vitamins 800mg/day
nd
2 month genitals will form
o Penis and clitoris look the same cannot detect sex
o Separation of GI and respiratory tract
o Start of development of the bones
rd
3 month 12 weeks
o Real bone development ossification***
o Need a lot of calcium form the mother
Calcium is increased in the diet: 1200mg/day; increase of
50%
Insufficient: get calcium form her bones >>
osteoporosis
Best source: PBE: milk
o Soya > leafy green > fish sources sardines,
tawilis; include the bones
o Genitals fully formed can go for UTZ by next month to know for
sex month
4th month and onwards best time to have UTZ for detecting changes
end of the 8th week to end of pregnancy
Start of the third month until the baby is formed
16 weeks sex can be seen
Fetus looks like a baby*** PBE
Multi quickening
20 weeks
Quickening standard answer
Vernix and lanugo
o Decrease- 8 months
With fats deposits
Head hair, eyebrows, eyelashes
Hands can grasp
Baby has a regular schedule of sleeping, sucking and kicking
Stethoscope Fetal Heart
24 week
Respiratory movements begin
Fetal lung maturity
AOG 26-27 weeks
o Secfretion into alveolar space begins
o Viability attained
30-32 weeks
o 1.2:1 (L/S)
35 weeks
o 2:1 MATURITY ATTAINED
o Amniocentesis aspiration of amniotic fluid
Very invasive; not done routinely
For possible problems intrauterine
14-16 weeks genetic problems genetic tests

AFP ratio AF- enzyme released when there is a defect in


neural tube
Elevated NT defects
Low Downs syndrome or chromosomal
aberrations
Start with maternal serum AFP (MSAFP)
o Levels of AFP
o Screening test
Positive: test is done in amniotic fluid
o Required:
35 years old or above
History of delivery of baby with birth
defects
Done early in the pregnancy to continue pregnancy or
not if with defects
In the Philippines: to determine lung maturity 3 rd
trimester
Risk or complication: 1/200 pregnancies will abort or in
later pregnancy early labor / preterm
Make sure that a written consent to protect the MD and
hospital
Prerequisite before doing amniocentesis ULTRASOUND
Full bladder uterus to be pushed upward for
visualization
Empty bladder immediately before the puncture
possible urinary puncture
Lying back with pillow on head Semi Fowlers
Wedge the hips put small pillow on the right side of back
prevent IVC syndrome
Post amniocentesis
Maternal VS
FHR
You need to report immediately: sign of complication
leaking fluid from vagina sign of ROM >> early labor
38+ - baby gets antibodies from mother
32 baby has fingernail and toenails
28 eyes begin to open and close; surfactant is formed baby can breathe
Nervous system developed 28 weeks
Fetal movement count
o Sleep 20 hours of the day
o Wake 4 hours
o 11pm baby is hungry
o After breakfast - first fetal movement
o 30 minutes to 1 hour after a meal baby will start to move
rhythmic
10 movements per hour normal
o Cardiff Method of counting fetal movement- mother will
determine the fetal movement pattern for 2 days
o NST >> BPS >> ST fetal assessment
o Fetal movement count is abnormal NST screening test
Confirmatory BPS or Stress Test

Maternal changes during pregnancy


o Physical and psychological adaptation changes in pregnancy
o Hair grows faster- estrogen
Old hair that is growing fast; no new hair growth
Very healthy looking
She cannot have treatments for scalp >> dangerous >> can be absorbed by
the scalp >> teratogenic
o Face
Chloasma face mask of pregnancy; anything that is exposed to the skin cheeks, forehead, nose
Skin is extra sensitive to the sun
Have sunscreen or protection
o Cold 15 SPF ; Hot 75 SPF
Melasma- axilla, groin, buttock, neck, tuhod, siko lahat ng may kulubot
Brown discoloration- darkening of the skin
Temporary just because of estrogen
o Mouth
Gums are hypertrophied increased blood supply estrogen
Easily bleed use soft bristle toothbrush
Massage the gums
o More prone to gingivitis
NO MOUTH EXTRACTION 1st and third trimester just have pasta- to
protect tooth temporarily
Salivation / ptyalism
Increased estrogen
Stimulation of more saliva- protective
o Too much acidic- enamel destruction
Frequent mouth washing
No chewing of gums too much sugar could coat the enamel
Chew fruits- apples
o Breast

Estrogen increased stimulation on ductile structures for possible


breastfeeding
Progesterone stimulates activity of secretory glands
No prolactin no breastmilk in pregnancy
Pre colostrums- 16 weeks
Release all colostrums before breast milk will flow out
PP 3 days before breast milk flows out
3 days- release colostrums
4th day onward- breast engorgement
o Abdomen
Striae stretch marks
Gravidarum brown or dark colored
Albicantes white- PP permanent mark
o Fade in color
Stretching of the abdominal muscles DIASTASIS rectus abdominis
muscle making it weak and saggy lower abs na nakalawlaw puson
o Abdominal exercise sit ups to bring it back
Post CS 6 months
NSD- immediately after delivery
o Genitals

Cervix
Softens - Goodells
Mucus plug operculum
o Bloody show during labor
Vagina
Increased vascularity bluish blue Chadwicks
Decreased ph acidic
Increased secretion leucorrhea
Safe to have sex during pregnancy but not 2 weeks before EDC
No nipple stimulation and oral-genital sex
o Risk of air embolism if man blows air in the vagina
No douching with introduction of air air embolism
Cardiovascular
Expanded BV 30-50% - increased SV and CO
Cellular content just the same
Decreased HCT ( physiologic/ pseudoanemia and hemodilution)
Iron treatment increase RB 30%
No Iron treatment RBC 15%
Baby will store the iron first 6 months of life
Mother loses 75% of the iron to her baby
Iron supplement 2nd trimester
100% increase in previous dose
36mg/day OD
Best time to absorb needs acid
Pregnant: after meals to prevent gastric irritation to prevent
stimulation
WBC is increased, increased coagulation potential for thrombolytic
complication
Blood flow to the uterus and placenta improves when the patient is in left
side lying position >> Supine Hypotension Syndrome
Inferior - LE > baby
Superior sudden hypotension
CS: wedge the right side of shoulder
Bp decrease during the 2nd trimester, return to normal during the third
2nd trimester- vasodilation
If with sudden increase 20-24 weeks AOG PIH
Rate increases by 10 bpm 2nd trimester
Easy fatigability
Mother feels tired all the time
Increase workload for the heart
Swimming, walking anything that uses larger muscles weight
bearing exercises
o Regular hours: 40 minutes of active exercise - 10 minutes warm
up; 10 minutes cool down
o Last trimester 1 hour; divide.
Respiratory
Increased vascularity of mucuous membrane pharyngeal congestion
Diaphragm displaced causing DOB- raise HOB
Never lower down the head 7 month onwards
Best position: modified trendelenburg
Renal system

Increased GFR >> increased UO


Progesterone glucose threshold drops and more glucose likely to be
expelled thru kidneys thus will see an increase insulin demand after 24 th week
Enlarging uterus adds pressure to the bladder
Frequency 1st and third uterus puts pressure on bladder
o 2nd GDM
Frequency and dysuria UTI burning sensation at the end of urination
o Safe to treat- wag lang teratogenic drug
o Most teratogenic Kanamycin and Streptomycin damage to 8 th
CN - deafness
Aldosterone production increases increases in sodium and fluid retention
Diet: low sodium add a little bit of salt to give food a taste NO
NEGATIVE DIRECTIONS
Musculoskeletal
Lordosis back pain
Changes in the center of gravity as pregnancy progresses - lordosis
Cramping in calf from hypocalcemia or hypercalcemia
Progressive softening of the cartilage
Waddling gait by her position and movements of the joints relaxin by
ovaries
Best- one inch heels, wedge shaped, rubberized
Neurological system
Pressure on sciatic nerve in third trimester reason for cramps
While on labor remove in stirrups, dorsiflex
Cramps- hypocalcemia in first trimester
GI system
Bleeding of gums
NV (morning sickness) in the first trimester due to increased HCG
Hyperemesis gravidarum
o Beyond first trimester
o Excessive interferes with food intake
Pernicious vomiting- patient is not eating but she vomits
Alkalosis first phase
Acidosis- later stages
H mole
Psychological factor
o Pregnancy is not wanted
o Unprepared mother
o Age is an important factor teenager too much crises
o Treatment: Psychotherapy
Nurse supportive prevention of complications
o Rest from all kinds of stress- FIRST!
o NPO to provide rest in NPO
IV fluids only
o Replace what she loss slow introduction of food
Crackers and water first hour crackers then next hour,
sips of water = alternate feeding
o General liquids >> soft diet >> full diet
Not ready to eat bring back food to dietary department
> tell her to get new tray when she wants to eat
25% taken first time chart only

2nd time call the MD about the situation food


preferences
o 24 hour recall all foods preferences for a day with amount pattern
Craving / increased appetite pica
Craving for non food hindi pagkain- clay. Crayons, toothpaste
Craving for non nourishing- anything that is cold, ice cream, soda non
toxic
Effect on pregnancy IDA
Effect in baby small baby SGA
o Baby needs CHON- increase protein intake
If nontoxic- wag mo pigilan
If toxic - psychotherapist
Pyrosis heartburn
Slow peristalsis
Slow frequent feeding, low fat diet
DOC: Maalox- antacid combination of aluminum magnesium and LOW
SODIUM
o Last resort if with HB
o CONTENT
Aluminum constipation
Magnesium diarrhea
If with HB give water, sips of warm water >> if didnt work - antacid
Abdominal cramps
Decreased peristalsis due to progesterone gas constipation, heartburn
o Psychological
Situational >> maturational
Situational change her situation to accommodate baby
Maturational adjust to a new role; role adaptation
Husband: Situational look for extra jobs
M ordinal position in the family sibling rivalry
Eldest intellectually capability good, lampa
Middle child- emotionally inferior, intellectually superior competitive
for attention
Youngest emotionally stable
Share the experience with every one
Help to plan husband
Child birth classes
When do you share the news to your children:
If with signs of pregnancy
School age or adolescent As soon as pregnancy is confirmed
Adolescent- hardest to cope
o Period of latency confused with sexuality
o They can adjust just give them time
Motherhood Psychosocial Adaptation Reva Rubin nurse from Germany observed
client PP for 20 years; recovery of psychosocial adaptation
o Based on psychological task AKA maternal task
o First Trimester
Task acceptance of pregnancy
o 2nd trimester
Introversion fantasy imagined child

Rejection of NB > abused child abuse; special child- never wanted


Special parent- abused parent when he was a child
Special situation - Attribute to the death of a mother or a crisis
situation during the birth of the child
Task: acceptance of the baby fetal embodiment***
Separate baby as a separate being
o Third trimester
Afraid of delivery
Task: preparation for child birth or fetal separation
Lamaze psychoprophylaxis mind over body; gate control theory
breathing, massage, changing position- HOSPITAL SETTING
Dick Read- Hypnosis- trained in hypnosis- visual imagery
Bradley Method husband being the coach, natural child birth;
emphasized that things needed in delivery are seen at home does not
believe in episiotomy instead perineal massage; if at home- thumb
massages the vagina, everything natural sucking the breasts agadHOME BIRTH
o Post Partum
Taking In
Taking Hold
Letting Go
o Fatherhood
Mittleiden to hatch; observes behaviors and taboos associated with
pregnancy
Mga paniniwala
Blind following of every thing
Couvade- suffering along
Psychosomatic symptoms felt by the husband while the woman is free
from the same
Husband is naiinggit sa mother pregnancy; unintentional
Psychosomatic symptoms
The mind dictates it
Normal
Questions:
o Tranvasginal UTZ- empty bladder; transabdominal UTZ full bladder 1-1.5L
o Surfactant 28 weeks

ABORTION
- Abortion termination before age of viability
- Early abortion before 16 weeks
- Late abortion between 16-24 weeks
- Spontaneous natural cause
- Complete abortion placenta and baby early abortion
- IUFD- late abortion missed abortion
- Late abortion
o Infection related to syphilis
- Rubella- 16 weeks only
- Causes
o Genetic -60%
o Endocrine factors
o Infection

Systemic disorders
PIH and DM poor placental perfusion late abortion
o Psychological factors
o Incompetent cervix most frequent cause of habitual abortion 3 or more
consecutive abortion; no intervening full term pregnancy
Defect in cervical os
Induced abortion illegal
Therapeutic pregnancy to save life of pregnancy ectopic pregnancy
Age of viability 20 -24 weeks
o In USA 24 weeks human; legally speaking, the fetus has a right
Incompetent cervix dilates without uterine contraction; cervix is very weak
o Causes or reasons
Congenital problem of cervix
Endocrine factor hormonal imbalance DM- abnormal hormonal release
Trauma to the cervix precipitate delivery too fast delivery
Kapag napunit na yung cervix, it cannot restore the cervix na nakasara
na
Abortion dilate the cervix
o Laminarium painless dilatation of the cervix
o To protect the cervix: cerclage
Temporary: Mc Donalds Procedure suturing is done about 12-14 weeks
AOG; temporary sutures to close the cervix
Permanent- Shirodkar procedure
CS birth from then on
NR: risk for infection - Mc Donalds
Types
o Spontaneous
Threatened abortion(spotting, painless, closed cervix)- baby is still intact;
uterus not in labor; should go immediately in the hospital for evaluation; see
MD ASAP
CBR without BP for 2 days
o If with bleeding maybe inevitable
Soft diet to prevent constipation straining on her stools
No invasive treatments or procedures
After two days, if fine- send home; home care restrictions in the
hospital should continue for 2 weeks
When will I be able to resume previous activities: 2 weeks
Sexual activity can be resumed after 2 weeks of last episode of
bleeding
Inevitable profuse bleeding, painful and cervix is dilated Imminent
abortion
With uterine contractions painful
Incomplete- placenta retained; fetus expelled
o Hysterometer
o Scraping is a blind procedure D and C
Sharp curette
Complete all products of conception expelled
Missed- fetus dies in the utero and is retained
o Laminarium piece of seaweed to dilate the cervix; dried
seaweed, sterilized, long, inserted in the cervical os and left
there for 24 hours
o

Seaweed - Absorbs liquid >> swells >> increase in


diameter >> dilation
Pitcon synthetic oxytocin
Misoprostol synthetic form of prostaglandin (16-38weeks)
intravaginally or intramyometrial
Induce premature labor
Stimulates uterus to contract
Most abused drug
For ulcer
Hazards include convulsions, vomiting and cardiac arrest
Dead fetus in the womb at risk for DIC afibrinogenemia
Monitor for signs and symptoms for non clotting blood
Fetus >> toxins >> enter small capillaries >> fibrin clots
>> consumes fibrinogen >> non clotting blood
Non clotting cryoprecipitate and plasma expanders

o
o

ECTOPIC PREGNANCY any gestation outside the uterus


- Locations
o Fallopian tube- 70-90% - scarring in fallopian tube
Isthmic more chance of bleeding; highly vascular; closest to uterus >>
conceptus can pass out; better type of ectopic
Ampullar far from uterus; continuously bleeding >> accumulate in the cul
de sac (space)
Culdocentesis aspirate blood
Ultrasound is enough
Cullens sign peritoneal bleeding hematoma chronic rupture
Chronic rupture: Pressure on the phrenic nerve >> shoulder pain
o Cervix with IUD; unusual
o Ovary
o Abdomen
Can be attached to the liver- placenta
Ex laparotomy no attempt to remove placenta when it is attached to a vital
organ
Placenta- Methotrexate anti cancer drug to decompose placenta
- Signs and symptoms
o Lowe abdominal pain unilateral and knifelike
o Cullens sign- bluish umbilicus
o Cul de sac mass- blood accumulation
o Dark red bleeding
o Shoulder pain compression of the phrenic nerve
o Signs and symptoms of shock
- Management- salphingectomy (laparoscopic surgery)
o Complication: air embolism
H MOLE
- Gestational trophoblastic disease
- Clustered vesicles
- Growth in the uterus >> distention >> carrying a baby
- Hyaditiform mole
- Proliferation noted as a grape like cluster of vesicles
- May lead to choriocarcinoma cancer form
- Benign condition**

Unknown cause
Predisposing factors
o Oriental
o Clomiphene (Clomid) for fertility stimulates women to ovulate
o Age - <18 years old ; >35 years old
o CHON deficiency
First evidence: bleeding on second trimester
Signs and symptoms
o Dark red bleeding after the 12th week
o Disproportionate uterine size
o No fetal heart outline, quickening
o Hyperemesis
o Passage of vesicle
o Symptoms of PIH
o Anemia
o Ultrasound shows a snowstorm pattern
Intervention
o Curettage
o Hysterectomy
o Vacuum extraction
o Follow up protocol
Monitor HCG normal is zero; elevated- H mole
Schedule of titer testing regular, until 1 year
Magugulo ung MD kung mabuntis ulit
No pregnancy for 1 year
Oral contraception to prevent another pregnancy and to suppress
endogenous pituitary LH
HCG titers when elevated possible choriocarcinoma
Chest X ray common area of metastasis
Every month until HCG titers are negative then every 2 months for 1
year for surveillance and monitoring
Choriocarcinoma Methotrexate- Folic Acid antagonist
Give free folic acid diet- green leafy vegetable- do not give!

PLACENTA PREVIA
- Low implantation that it overlays some or all of the internal os
- Risk factors
o High altitude increase pressure
o Fraternal twins one will accommodate the upper part
o Multiparity
o Tumor
o Male baby
o Smoking
- Opening of the maternal venous sinuses in the placental site >> bleeding >> bright red
bleeding
- Uterus is not contracting >> no pain- painless
- Low lying- near the os
- Partial 50% of the cervix
- Complete total blockage
- Do not IE can cause rupture of the placenta
- UTZ- most practical way for placental attachment; non invasive
- Cesarean Section- birth
- Double set up
o CS and NSD
o Operating room
o 2 OB
- Risk of previa: hemorrhage or bleeding
- Lower segment does not contract bleeding always longitudinal muscles
o Transfusion of blood
- Baby will come out premature, but not in distress
ABRUPTIO PLACENTA
- Sudden separation of a normally implanted placenta
- Causes
o Short umbilical cord
o PIH ischemia to a part detachment
o Twins same placenta- identical
CS dapat
o Cocaine use vasoconstriction ischemia
o Smoking
o Trauma or accident domestic abuse
- Types:
o Concealed- hidden bleeding schultze
Couvalaier board like distended uterus due to covert bleeding
o Apparent seen duncans
Mix amniotic fluid >> portwine fluid
- Placenta separation
o Schultze- from inside to out shiny; fetal side exposed abruptio
o Duncan- from out to in maternal side dirty duncan
- Surgical intervention: CS premature and in distress
BLEEDING
- To warm client if she has lost considerable amount of blood- cover her with several layers
of blanket
- 1/3 of pads 10 ml
- Full soaked of pads 30ml
- NAME first in orientation

PIH
-

1g =1ml
Rh (-) - universal blood donor
Fetal compromise 2-3L
o In emergency, no need for order
Maternal compromise 4-6L
Maternal fetal compromise- 10L
Make sure IV fluid line big needle possible BT
NPO unless ordered possible surgery
Nursing assessments
o Blood loss with baseline assessment every 15 minutes PR- FHT
o I and O should have indwelling catheter- hourly assessment of UO
o LOC
o Emotional component of care
Acceptance of nursing care grieving acceptance

Previously called toxemia


PIH- proteinuria and edema
o Back to normal in 6 weeks
CH no proteinuria; may or may not have edema
o PP- elevated even after delivery
Possible roommate same condition or same management; same limitation, limit visitors
Epigastric pan aura to a convulsion
Matter of fact- statement of fact without interpretation
Reasons
o Estrogen and progesterone
o Prostaglandin
Prostocycline - VD
Thromboxane- VC
o >> VC and arteriospasm >> reduced perfusion in some organs >>
Kidney- decreased blood supply >> affect nephrons >> decreased UO /
oliguria, anuria
Increased capillarity permeability CHON- albumin= albuminuria
reverse A/G ratio >> edema generalized edema or anasarca
o Finger edema
o Puffiness in lower eyelids
o Third spacing cerebral edema, pulmonary edema, ascites
Pulmonary congestion >> CHF left sided failure
Headaches due to CNS irritability brought about by cerebral edema >>>
seizure
Less volume thick and viscous blood- sluggish possible problems in
clotting; less blood going to baby
Uteroplacental perfusion decreased = no oxygen and nourishment for
baby IUGR
o At risk for premature birth >> abruption >> fetal death
Liver affectation increased pressure in liver increased pressure in portal
circulation >> HELLP
H hemolysis
EL- elevated liver enzymes
LP- low platelet >> DIC
Worst
Pain on the epigastric area- aura to a convulsion- liver affectation

Stages
o Pre-ecclampsia- before the convulsion
Mild
140/90
+3- finger and face
24 hour urine collection = 2grams/L or less
Avoid strenuous activities
High CHON diet replace what is lost
Low sodium diet
Low fat diet
Slightly increase CHO- to spare CHON
Clinic visits low risk patient
o Every month 7
o Every 2 weeks- 8
o Every week 9
o At least twice the previous schedule if pre-ecclampsia
o Non compliance >> knowledge deficit
Severe
160/110 or higher
+4 - anasarca
24 hour urine collection = more than 2g/L
Can convulse anytime
Management
o Nursing diagnosis priority altered sensory and perceptual
function risk for convulsion
2- altered perfusion
o Quiet non stimulating environment
o Side rails restrictive and protective device
3rd rail restraint
4th full restraint
Both upper- protective
Sleeping- all rails up
Fully awake put down restraints
o CBR no BRP
Left side lying position
o Side rails up
o Limit visitors only during regular visiting hours lunch and
dinner
o Magnesium sulfate
Check DTR CNS depressant
RR
BP
FHR
UO per hour- decrease kidney that is no longer
functioning very well
To know enough dose of MgSO4 serum level 4-8mg/dl;
therapeutic level
Greater toxicity if continue giving respiratory
depression
Antidote: calcium gluconate
o Hydralazine titrated- lower BP >turn off

Only treatment Delivery


Baby may be too premature; more complications if
delivered too early
Mode of delivery: CS; epidural anesthesia; emergency if
with convulsive tendecy
Condition controlled can be on labor; pain medications,
analgesia at start of labor Forceps assisted delivery
Greatest risk for convulsion 1st 24 hours post partum
Too fast to eliminate extra blood volume
Seizure- Grand Mal
o Invasion
o Aura- preceding conlvusion
Dito palang, protect the tongue
prevent obstruction fitted mouth
piece, mouth gag- kinakagat na cloth
o Tonic clonic stage
Clonic- seizure can hurt herself- put
padding or pillow around; no restraint
can result to fracture; duration of
seizure = anoxic episode
o Post ictal stage post seizure
Coma
Exert every effort in resuscitating the
client
She wakes up >> she will be very
afraid, anxious, tense can be at risk
for bleeding; mentally disoriented: re
orient client to allay anxiety and order
drug to sleep
Status epilipticus intractable seizure

Increase Fluid intake


- Normal 6-8 glasses
- Pregnant 8-10
o 50%- water- 5-6 glasses
B12- only meat sources