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I. Human Sexuality

a. Concepts
1. A person’s sexuality encompasses the complex behaviors,
attitudes and emotions and preferences that is related to sexual
self and eroticism
2. Sex is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource
person on human sexuality
15 – 44 y.o. – age of reproductivity CBQ

b. Definitions related to sexuality

Gender Identity – sense of feminity and masculinity – developed
@age 3 or 2 -4 y.o.
Role Identity – attitudes, behaviours and attitudes that differentiate
roles
Sex – biologic male or female status. sometimes referred to as specific
sexual behavior such as sexual intercourse
Sexuality - behavior of being a girl or boy and is identity subject to a
lifelong dynamic change

II. Sexual Anatomy and Physiology

a. Female Reproductive System

1. External – Vulva/ Pudenda
a. Mons pubis/ veneris – mountain of venus, a pad of fatty
tissues that lies over the symphysis pubis covered by skin
and at puberty covered by pubic hair that serves as a cushion
or protection to the symphysis pubis

Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/

Sexual Maturity Rating)

Stage 1 – Pre adolescence

• no pubic hair, fine body hair
Stage 2 – Occurs bet. 11 – 12 y.o
• sparse, long, slightly pigmented and curly that
develop along labia
Stage 3 – Occurs bet. 12 – 13 y.o.
• hairs become darker and curlier develops along pubis
symphysis
Stage 4 – 13 – 14 y.o.
• hair ssumes normal appearance of an adult but is
not so thick and does not appear to the inner aspect
of the upper thigh
Stage 5 – Sexual Maturity
• assumes the normal appearance of an adult, appears
at the inner aspect of thigh

b. Labia Majora – large lips latin, longitudinal fold from

perenium to pubis symphysis
c. Labia Minora – aka Nymphae, soft and thin longitudinal fold
created between labia majora
 • Clitoris – “key”, pea – shaped erectile tissue composed
of sensitive nerve endings; sight of sexual arousal in
females
• Fourchet – tapers posteriorly of the labia majora. Site
for episotomy
- sensitive to manipulation, torn during pregnancy
d. Vestibule – almond shaped area that contains the hymen,
vaginal orifice and batholene’s gland
• Urinary Meatus – small opening of urethra/ opening
for urination
• Skene’s Gland – aka Paraurethral Gland, 2 small
mucus secreting glands for
lubrication
• Hymen – membranous tissue that covers the vaginal
orifice
• Vaginal Orifice – external opening of the vagina
• Bartholene’s Gland – paravaginal gland, secretes
alkaline substance, neutralizes acidity of the vagina
o Doderleins Bacillus – responsible for vaginal
acidity
o Parumculae Mystiformes – healing of a
hymen
e. Perenium – muscular structure in between lower vagina and
anus

2. Internal
a. Vagina – female organ for ovulation, passageway of
menstruation, ¾ inches 8 – 10 cm long containing rugae
o Rugae – permits considerable stretching withouit
tearing during delivery CBQ
b. Uterus – hollow muscular organ, varies in size, weight and
shape, organ of menstruation
Size : 1 x 2 x 3
Shape : pear shaped, pregnant - ovoid
Weight : Uterine involution CBQ
Non pregnant : 50 – 60 g
Preganant : 1000 g
4th stage of Labor : 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery : 300 g
5 – 6 Weeks after delivery: 50 – 60 g
Three Parts of Uterus
• Fundus – upper cylindrical layer
• Corpus/ Body – upper triangular layer
• Cervix – lower cylindrical layer
Isthmus – lower uterine segment during pregnancy

Muscular Composition: 3 main Muscles making possible expansion in

all direction
a. Endometrium
muscle layer for menses
o Lines the non-pregnant uterus
o Volumes the non pregnant uterus
o Decidua – slouching off of endometrium during
menstruation
o Endometriosis
 Ectopic Endometrium
  Common site is ovaries
 Proliferation of abnormal growth of lining of
outer part
 Persistent dysmenorrhea, low back pain
 Dx Exam: biopsy,laparoscopy
 Tx: Lupron (luprolide)
inhibits FSH & LH
 Tx: Danazol (Danacrine) DOC
1. Inhibits ovulation
2. stop menstruation
b. Myometrium
o Power of labor
o Smooth muscles is considered to be LIVING
LIGATURE (muscles of delivery, capable of
closing) of the body
o Largest portion of the uterus
c. Peremetrium
o Protects the entire uterus
c. Ovaries
• 2 female sex gland
• almond shape
• Fxn: Ovulation,production of 2 hormones( estrogen and
progesterone)
d. Fallopian Tube
• 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
o Infundibulum – most distal part, trumpet shape,
has fimbrae
o Ampulla – outer 3rd or 2nd half, site of fertilization,
common site for ectopic preg.
o Isthmus – site for sterilization, site for BTL
o Interstitial – most dangerous site for ectopic
pregnancy

b. Male Reproductive System

1. External
• Penis
• The male organ of copulation and urination
• Contains of a body or shaft consisting of 3 cylindrical
layers and erectile tissues
o 2 corpora cavernosa
o 1 corpus spongiosum
• At the tip is the most sensitive area comparable to clitoris
= glans penis
• Scrotum
• Pouch hanging below the pendulous penis, with medial
septum deviding into 2 sacs each containing testes
• Requires 2 degrees celcius for continuous spermatogenesis
• Cooling mechanism of testes
2. Internal
The Process of Spermatogenesis
 Testes
(900 coiled seminiferous tubules)
↓
epididymis
(site of maturation of sperm 6 m)
↓
Vas Deferens
(conduit pathway of sperm)
↓
Seminal Vesicle
(secreted: fructose form of glucose, nutritative value
Prostaglandin: causes reverse contraction of uterus)
↓
Ejaculatory Duct
(conduit of semesn)
↓
Prostate Gland
(release alkaline substances)
↓
Cowpers Gland
(release alkaline substance)
↓
Urethra
Hypothalamus GNRH
↓
APG
↓
FSH – maturation of sperm
LH – testosterone production
Leydig Cells – releases testosterone

Male & female Homologues

Male Female
Penile Glans Clitoris
Penile Shaft Clitoral shaft
Testes Ovaries
Prostate Skene’s gland
Cowper’s Glands Bartholin’s Gland
Scrotum Labia Majora

III. Basic Knowledge on Genetics and Obstetrics

1. DNA – Deoxyribonucleic Acid – carries genetic code

2. Chromosomes – threadlike structure of hereditary material known as the
DNA
3. Normal amount of ejaculated sperm – 3 – 5 cc/ 1 teaspoon
4. Ovum is capable of being fertilized within 24 – 36 hours after ovulation.
5. Sperm 48 – 72 days viability
6. Reproductive cells divide by the process of MEIOSIS (haploid number)
• Spermatogenesis – process of maturation of sperm
• Oogenesis – process of maturation of ovum
o 30 weeks AOG – 6 million immature ovum
o @ birth – 1 million immature oocytes
o @ puberty – 300 – 400 immature oocytes
 o @ 13 y/o – 300 – 400 mature oocytes
o @ 23 y/o – 180 – 280 mature ovum
o @ 33 y/o – 60 – 160 mature ovum
o @ 36 y/o – 24 – 124 mature ovum
o @46 y/o – 4 mature ovum
• Gametogenesis – process of formation of two haploid into diploid
7. Age of reproductivity – 15 – 44 y/o childbearing age – 20 – 35
y/o
High risk
<18 & >35 y.o. With Risk
18 – 20; 30 – 35
8. Menstruation
• Menstrual Cycle – beginning of menstruation to the beginning of
the next menstruation
• Average menstrual cycle – 28 days
• Average menstrual period – 5 days
• Normal blood loss – 50 cc/ ¼ cup accompanied by
FIBRINOLYSIS – prevents clot formation
• Related terminologies
o Menarche – 1st menstruation
o Dysmenorrhea – painful menstruation
o Metrorrhagia – bleeding in between menstruation
o Menorrhagia – Excessive bleeding during menstruation
o Amenorrhea – absence of menstruation
o Menopause – cessation of menstruation (Average Age- 51
y.o.)
 Tofu – has isoflavone – estrogen of plant that mimics
the estrogen with a woman
9. Functions of Estrogen and Progestin
• ESTROGEN – hormone of woman
o Primary function
 Responsible for the development of secondary
characteristics in females
 inhibit production of FSH
o Other function
 Hypertrophy of the myometrium
 Spinnbarkeit and Ferning Pattern (Billings Method)
 Ductile structure of the breast
 Osteoblastic bone activity (causes increased in height)
 Early closure of the epiphysis of the bone
 Sodium retention
 Increased sexual desire
 Responsible for vaginal lubrication
• PROGESTERONE – Hormone of the mother
o Primary function – prepares the endometrium for
implantation making it thick and tortous
o Secondary Function – inhibit uterine contractibility
o Others
 Inhibit LH (hormone of ovulation) production
 ↓ GI motility
 ↑ Permeability of kidneys to lactose and dextrose
causing + 1 sugar in urine
 Mammary gland development
 ↑ BBT
 Mood swings

10. Menstrual Cycle

 4 phases of menstrual cycle
1. Proliferative
2. Secretory
3. Ischemic
4. Menses

1. On the initial phase of menstruation, the estrogen level is ↓, this level

stimulates the hypothalamus to release GnRH/ FSHRF
2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH
• FSH Function
o Stimulate ovaries to release estrogen
o Facilitate the growth of primary follicle to become
GRAAFIAN FOLLICE
structure that secretes large
amount of estrogen that contain
mature ovum
3. Proliferative Phase (↑estrogen)
Follicular Phase – responsible for the variation and irregularity of
mense
Postmenstrual Period – after menstruation
Preovulatory Phase – happen before menstruation
4. 13th day of menstruation, estrogen level is PEAK while progesterone is
↓, these stimulates the hypothalamus to release GnRH/ LHRF
5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH
• Functions of LH
o Stimulates the release of progesterone
o Hormone for ovulation
6. 14 day estrogen level is ↑ while progesterone level is ↑
th

• S/S
o Rupture of the graafian follicle -
OVULATION
o Mittelschsmerz – slight abdominal pain
lower right quadrant
th
7. 15 day, after ovulation day, graafian follicle starts to degenerate,
estrogen level ↓, progesterone ↑, causing degeneration of the graafian
follicle becoming yellowinsh known as CORPUS LUTEUM – secretes
large amount of progesterone
8. Secretory Phase
Lutheal Phase ↑progesterone)
(↑
Postovulatory phase
Premenstrual Phase
9. 24th day – Corpus Albicans (whitish) corpus luteum degenerates and
becomes white
10. 28th day – if no sperm united the ovum, the uterine begins to slough
off to have the next menstruation
Note:
• if there is no fertilization, corpus luteum continues functioning
• Ovarian Cycle – from primary follicle – corpus albicans
• Stages:
o 1 – 5 days – menses
o 6 – 14 – proliferative
o 15 – 26 – secretory
o 27 – 28 – ischemic

11. Stages of Human Sexual Response

Initial Response:
 VASOCONGESTION – constriction of blood vessels
MYOTONIA – increased muscle tension
• Excitement Phase
• ↑ muscle tension, moderate VS
• erotic stimuli causing ↑ sexual tension, may last from
minutes to hours
• Plateu Phase
• ↑ and sustained tension near orgasm
• may last 30 sec – 30 minutes
• Orgasm
• Involuntary release of sexual tension accompanied by
physiologic and psychologic release,
• immeasurable peak of experience 2 – 3 seconds
• Resolution
• Return to normal state
• VS return to normal

REFRACTORY PERIOD – only period present in male, wherein he cannot

restimulated for about 10 – 15 minutes

IV. Wonders of Fertilization

a. Fertilization
1. Phonones – song of sperm
2. Capacitation – ability of sperm to release proteolytic enzyme
and penetrate the ovum
b. Stages of Fetal Growth and Development
1. Pre Embryonic Stage
I. Zygote
fertilized ovum (3 – 4 days travel, 4 days floating)> from
fertilization
II. Morula
mulberry-liked ball containing 16 – 50 cells
III. Blastocyst
enlarging cell forming a cavity that later becomes the
embryo covered by thropoblast which later becomes the placenta and
membrane
IV. Implantation
7 – 10 days after fertilization
• Thropoblast – covering of blastocyst that become
placenta
• S/Sx of Implantation
Slight pain, Slight Vaginal
Spotting
• 3 Processes
o Apposition
o Adhesion
o Invasion
2. Embryonic Stage
Zygote – fertilization to 14 days
Embryo – 15th – 2 mos/ 8 weeks
Fetus – 2 mos to birth
c. Decidua – thickened endometrium, latin word for “falling off”
1. Basalis – located directly under the fetus where placenta
developed
2. Caspularis – encapsulates the fetus
3. Vera – remaining portion of and endometrium
d. Chorionic Villi – 10 – 11 weeks
1. Chorionic Villi Sampling (CVS) – removal of tissue from the
fetal postion of the developing placenta
• For genetic screening
• Fetal limb defects, missing digits of toes
 e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the
fetus against syphilis (24 weeks/ 6 months)
f. Synsitiotrophoblast – syncitial layer – responsible for hormone
production
1. Amnion – inner most layer 2. Chorion
I. Umbilical cord (Funis) – whitish gray (50 – 60 cm)
• Short
abruptio placenta, uterine inversion
• Long
cord prolapse, cord coil
• 3 vessels (AVA) – Artery Vein Artery
• Wharton’s Jelly – protects the umbilical cord
II. Amniotic fluid
bag of water
clear color, musty/mousy odor
• With crystallized forming pattern, slightly alkaline
• 500- 1000 cc Normal
o Oligohydramnios – kidney malformation
o Hydramnios – GIT , TEF/ TEA
• Functions
o Cushion the fetus against sudden blow or
trauma
o Maintains temperature
o Facilitate muscuskeletal development
o Prevents cord compression
o Helps in development process

Diagnostic Test for Amniotic Fluid
Amniocentesis

• Purpose: obtain sample of amniotic fluid by inserting a needle hrough
the abdomen into the amniotic sac
• Fluid is tested for:
• Genetic screening
• Determination of fetal maturity primarily by evaluating factors
indicative of lung maturity
• Done with empty bladder
• Complication
> Most common side effect : INFECTION
> Late : pre term labor
> Early : spontaneous abortion
• Indication for Amniocentesis:
> Early in Pregnancy
Advance Maternal Age
> Later in Pregnancy
Diabetic Mothers
• ↑ - down syndrome
• ↓ - neural tube defect, spina befida
• L/S ratio : 2:1 (Lecitin/ Spingomyelin)
• Definitive test = Phosphatiglycerol: PG +
best Answer
• Greenish – Meconium Stains (Fetal Distress)
• Yellowish – jaundice, hyperbilirubinemia
• Cloudy – Infection
• Most Important Consideration
Needle insertion site
• Amnioscopy – direct examination through intact fetal membrane via
ultrasound
• Fern Test – a test determining if bag of water has rupture or not
• Nitrazine Paper Test – differentiate amniotic fluid and urine Blue geen

+ rupture of bag of H2O

2. Chorion – outermost layer

a. Placenta – AKA Secundines
chorionic Villi and basalis
• Pancake in latin
• 500 grams in weight
 • 15 – 28 cotyledons
• 15 – 20 cm in diameter and 2 – 3 cm in depth
• Functions
o Respiratory
02 – CO2 exchange via simple
diffusion
o GIT
glucose transport via facilitated
diffusion
o Excretory
via 2 arteries, carries
unoxygenated blood then detoxify
by maternal liver
o Circulatory
fetoplacental circulation by
SELECTIVE OSMOSIS
o Endocrine
 HCG – primary maintain corpus luteum/
secondary basis of pregnancy test
 Human Placental Lactogen – aka
Somatomammothrophin
• Responsible for the development
of mammary gland
• Diabetogenic Effect – insulin
antagonist
 Relaxin – softening of maternal joints
and bones
o Serves as protective barrier against some
microorganism
 Can pass: HIV CMV Rubella
 PINOCYTOSIS – transport of virus

Pregnancy – 266 – 288 days/ 37 – 42 weeks

FETAL STAGE: Fetal Growth and Development

First Trimester : Period of organogenesis, most critical period

First Month
FHT, CNS Develops, GIT and Respi Tract remains as single tube
Differentiation of Primary Germ Layer
• Endoderm
o Thyroid – responsible for basal metabolism
o Thymus – immunity
o Liver
o GIT
o Linings of Upper GI Tract
• Mesoderm
o Heart
o Musculoskeletal
o Reproductive Organ
o Kidney
• Ectoderm
o Brain
o CNS
o Skin
o 5 senses
o Hair, nails
o Anus
o Mouth
Second Month
 • Life span of corpus luteum ends
• All vital organs are formed
• Placenta is developed
• Sex organ is developed
• Meconium is present
Third Month
• Placenta is complete
• Kidneys are functional
• Fetus begins to swallow amniotic fluid
• Buds of milk appear
• Sex is distinguishable
• FHT audible via dopples @ 10 – 12 weeks
Terratogens – any drug or irradiation, the exposure to which may cause
damage to the fetus
• DRUGS
o Streptomycin – anti – TB – (quinine) damage to the 8th cranial
nerve
poor learning and deafness/ ototoxic
o Tetracycline – stoning the tooth enamel, inhibits long bone growth
o Vitamin K – hemolysis, destruction of RBC, jaundice,
hyperbilirubenemia
o Iodides – enlargement of thyroid and goiter
o Thalidomides – anti-emetics
Amelia or Pocomelia
absence of
distal part of extremities
o Steroids – cleft lip or palate and even abortion
o Lithium – congenital maformation
• ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly)
• SMOKING – LBW
• CAFFEINE – LBW
• COCCAINE – LBW, abruptio placenta
• TORCH – group of infections that can cross the placenta or ascend through
the birth canal and adversely effect fetal growth
o Toxoplasmosis – cat lovers
o Others - Hepa AB, HIV, Syphillis
o Rubella – CHD,
 Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify
doctor
 Rubella vaccine after delivery for 3 mos. No pregnancy for 3
mos.
o Cytomegalo virus
o Herpes Simplex virus

Second Trimester : continuous growth and development (focus

lengh of fetus)
Fourth Month
• Lanugo begins to appear
• Buds of permanent teeth appear
• FHT audible via Fetuscope @ 18 – 20 weeks
Fifth Month
• Quickening : 1st fetal movement Primi: 18 – 20, Nulli - 16 - 18
• Lanugo covers the body
• FHT audible via stethoscope or w/out instrument
• Actively swallow amniotic fluid
• Fetus : 19 – 25 cm
Sixth Month
• Skin is red and wrinkled
• Vernix caseosa covers the skin
 • Eyelids open
• Exhibits startle reflex
3rd Trimester : period of most rapid growth and development
Focus: weight
Seventh Month
• Surfactant development
• Male: the testes begins to descent into the scrotal sac
• Female : clitoris is prominent and labia majora are small doesn’t
cover the minora
Eight Month
• Active moro reflex
• Lanugo begins to disappear
• Sub q fats deposits, steady weight gain, nails to fingers
Ninth Month
• Lanugos and vernix caseosa is evident in body fold
• Birth position assumed
• Amniotic fluid somewhat decrease
• Sole of the foot has few creases
Tenth Month
• Bone ossification in the fetal skull
• Vernix caseosa is evident in body

PHYSIOLOGIC ADAPTATION TO PREGNANCY

Systemic Changes
1. Cardiovascular System
• ↑ blood volume 30 – 50%
• 1500 cc; additional 500 cc for multiple pregnancy
• ↑ plasma volume
• ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy
• Epistaxis due to hyperemia of nasal membrane
• Palpitation due to SNS stimulation
• Physiologic Anemia/ pseudoanemia in pregnacy
o Normal Value
Hct : 32 – 42%
Hgb: 10.5 – 14 g/dl
o Criteria
1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl
2nd Trimester : Hct > 32% Hgb > 10.5 g/dl
o Pathologic Anemia
 Iron Defficiency Anemia is the most common
hematologic disorder. It affects 20% of pregnant women
 Assesment reveals:
• Pallor
• Slowed capillary refill = Normal = 2 – 3 sec
• Concave fingernails (late sign of progressive
anemia) – clubbing = chronic tissue hypoxia
• constipation
 Nursing care
• Nutritional instruction
o Source of iron
 Kangkong
 Liver = best source due to FERRIDIN
Content
 Red and lean meat
 Green Leafy Vegetables
 • Parenteral Iron (Imferon)
o Z tract IM
o incorrect causes hematoma
o best given 1 hour before meals (causes GI
irritation)
o Maybe given 2 hours after meal (results to
poor absorption)
 Given with orange juice to ↑ absorption
• Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a
day)
• Monitor for hemorrhage
 Alert
• Iron from red meat is better absorbed iron from
other sources
• Iron is better absorbed when taken with foods high
in Vitamin C such as orange juice
• Higher iron intake is recommended since
circulating blood volume is increased and heme is
required from production of RBCs
• Edema
o Impeded venous return due to the gravid uterus
o Nursing Intervention
 Elevate legs above the hips level
• Varicosities
o Wear support stockings
o Elevate legs
• Vulvar Varicosities
o D/t pressure of gravid uterus
o Side –lying with pillow under the hips
o Modified knee – chest position
• Thrombophlebitis
o Presence of thrombus in inflamed blood vessels
o + Homan’s Sign – pain on the calf upon dorsiflexion
o Medical Management
 Anticoagulant/ HEPARIN
• Does not cross the placental barrier
• Monitor APTT
• Antidote: PROTAMINE SULFATE
• No aspirin
• Milk Leg/ Plagmasia Alba Dolens
o Shiny white legs due to stretching of skin &
hyperfibrinogenemia
o Nursing intervention
 Check dorsalis pedis pulse (compare both)
 Never massage
 Assess for Homan’s sign only once

2. Respiratory System
• Shortness of Breath d/t gravid uterus
• Nursing intervention: Side-lying – lateral expansion of the lungs

3. Gastrointestinal System
• Nausea and vomiting
• Morning Sickness
o Due to ↑ HCG levels
o Crackers 30 min before arising
 o AM – Carb diet 30 mins
o PM – small frequent meal
• Constipation
o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT
motility
o Nursing intervention
• ↑ Fluid
• ↑ Fiber
• Exercise
• Flatulence
o Due to increased progesterone
o Avoid gas forming foods
• Heartburn (pyrosis)
o Reflux of stomach content into esophagus
o Nursing Intervention
• Small frequent meals
• Sips of milk
• Avoid fatty and spicy foods
• Proper body mechanics
o Waist Above – Acid
o Waist Below – Base
• Hemorrhoids
o Due to gravid uterus
o Hot sitz bath for comfort
• Ptyalism
o ↑ salivation
o Mouthwashes to relieve
4. Urinary System
• Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST
• First Trimester - Frequency
• Second Trimester - normal
• Third Trimester - Frequency
5. Muscoloskeletal
• Calcium sources
o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day
o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli
• Lordosis
o Pride of Pregnacy
• Waddling Gait
o Awkward gait while walking due to relaxin
o Prone to accidental falls
 Wear low healed shoes
• Leg Cramps
o Ca – P Imbalance during pregnancy
o Lumbo-sacral nerves by pressure of gravid uterus during labor
o Over sex
o Dorsiflex the foot affected
o 3-4 servings/ 4 cups/day sa milk, sardines, dilis

A. Local Chnages

• Vagina
o Chadwick’s Sign – bluish discoloration
o Leukorrhea – whitish gray, moderate in amount, mousy odor
• Cervix
o Goodel’s Sign – change in consistency of uterus
 o Operculum – mucus plug to seal bacteria/ progesterone
• Uterus
o Hegar’s Sign – change in consistency

Vagina Chadwick’s
Cervix Goodel’s
Uterus Hegar’s

Problems related to the changes of Vaginal Environment

a. Vaginitis - AVOCADO
• Trichomonas Vaginalis
o Flagellated protoxzoan, Loves alakaline environment
• Signs and Symptoms
o Greenish, cream, colored, frothy, irritably itchy, foul smelling
vaginal discharge
o Vaginal edema
• Management
o Drug of choice: METRONIDAZOLE (Flagyl)
 Antiprotozoan
 Carcinogenic
 Not given in 1st trimester
• vaginal douche as substitue
o 1 qt Water = 1 tbsp white vinegar
o Treat partner as well to prevent reinfection
o No alcohol – due to antabuse effect
b. Moniliasis - CHEESE
• Candida Albicans
• Transvaginal transfer in fetus – Oral Trush
• Signs and Symptoms
o White Cheeselike patches that adheres to the walls of the
vagina
• Management
o Antifungals
 Mycostatin
 Contrimazole – Canisten
 Gentian Violet

1. Abdominal Changes
• Striae Gravidarum
o Due to destruction of the subcutaneous tissue by the enlarge
uterus

2. Skin Changes
• Melasma/ Chloasma
o White light brown pigmentation related to ↑ melanocytes
• Linea Nigra
o Brown pinkish line from symphysis pubis to umbilicus

3. Breast Changes
• Due to hormonal changes
• Change in color and size of nipple and areola
• Precolostrum – 6 weeks
• Colustrum – 3rd trimester
• Supine with pillow under the back
4. Ovaries – rest period, no ovulation
5. Signs and Symptoms of Pregnancy
 Presumptive Probable Positive
S/sx felt and observed Signs observed Undeniable signs
by the mother but by the confirmed by the use
does not confirm the members of the of instrument
diagnosis of pregnancy health care
team
First Breast changes Goodel’s sign Ultrasound Evidence
trimester Urinary changes Chadwick’s sign
Fatigue Hegar’s sign
Amenorrhea Elevated BBT
Morning sickness Positive HCG
Enlarge uterus
Second Chloasma Ballotement
Trimester Linea Nigra Enlarge etal Heart Tone
Increase Skin Abdomen etal movement
Pigmentation Braxton Hicks etal outline
Striae gravidarum Contraction etal parts
Quickening palpable

CBQ Cancer of the Breast
quadrant B

Mamography 35 and above
1/ year
Ballotement
bouncing of the fetus

may be present in uterine myoma
Transvaginal Ultrasound – empty bladder
Abdoiminal ulrasound – full bladder

Placenta Grading System

• Grade 0 – immature
• Grade 1 – slightly mature
• Grade 2 – moderately mature
• Grade 3 – fully mature
• What is deposited?
calcium

VI. Psychological Adaptation to Pregnancy – Reva Rubin

First Trimester
• No tangible s/sx
• Feeling of surprise
• Ambivalence
• Denial of pregnancy
maladaptation
• Developmental Task: Accept biological facts of pregnancy
• Health Teaching: Body changes of pregnancy and Nutrition

Second Trimester
• Tangible s/sx
• Mother identifies fetus as separate entity due to quickening
• Fantasy
• Developmental Task: Accept growing fetus as a baby to nurture
• Health Teaching: Growth and development of fetus

Third Trimester
• Mother has personally identifies with the appearance of the baby
• Developmental Task: Prepare child birth and parenting the child
• Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze
Class
• Address Mother’s fear
let she hear the FHT
VII. Pre – Natal Visit

Basic Consideration
1. Frequency of Visit
• 1 – 7th mos.
once a month
• 8 – 9th mos.
twice per month
• 10th month
every week
2. Personal Data
• Home Based Mother’s Record/ HBMR
determines high risk
pregnancy
• Pseudocyesis
false pregnancy
appearance of presumptive &
probable signs
• Comade Syndrome
psycosomatic disorder, father experience
what the mother goes through
3. Diagnosis of Pregnancy
• Urine Exam
HCG
40 – 100th day; peak 60 – 70th day
• ELISA
beta subunits of HCG is detected as early as 7 – 10th day
• RIA
beta subunits of HCG is detected as early as 8th day
• Home Pregnancy Kit
4. Baseline Data
• Roll – Over Test
test of pre-eclampsia by the use of BP
• Weight monitoring
Normal Weight Gain
1st Trimester = 1.5 – 3 lbs
1 lb/ mo
2nd Trimester = 10 – 12 lbs
4 lbs/mo
3rd Trimester = 10 – 12 lbs
4 lbs/mo

Minimum allowable weight gain
20 – 25 lbs

Optimal weight gain
25 – 35 lbs

5. Obstetrical Data

a. Gravida
no. of pregnancy

b. Para
no. of viable pregnancy

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

1 abortion 1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo.

preg
1 pregnancy 3rd mos. G4P2 G4 T1 P1 A1 L1

G2P0 G2 T0 P0 A1 L0

c. Important Estimates
1. Nagele’s Rule
• Use to determine expected date of delivery
• Jan – Mar
+9 months +7 days
• Apr – Dec
-3 months +7 days + 1 year

2. McDonald’s Rule
• Determines age of gestation in weeks
 • Fundic Height x 7/8 = AOG in weeks
3. Bartholomew’s Rule
• Determines age of gestations
o 3 mos – above pubis symphysis
o 5 mos – level of umbilicus
o 9 mos – below xiphoid process
o 10 mos – level of 8th mos

4. Haases Rule
• Determines the length of fetus in cm.
• 1st half
square each month
• 2nd half
month x 5

d. Tetanus Immunization
• TT1 – anytime or early during pregnancy
• TT2 – 1 month after TT1
3 years protection
• TT3 – 6 months after TT2 – 5 years of protection
• TT4 – 1 year after TT3
10 years of protection
• TT5 – 1 year after TT4
lifetime protection

5. Physical Examinations
a. Danger Signs of Pregnancy
Chills & Fever
Cerebral Disturbances
Abdominal Pain
epigastric pain
auro of impending convulsion
Boardlike Abdomen
Abruptio placenta
Blurred Vission
pre eclampsia
Bleeding
abortion/ ectopic pregnancy – 1st trimester

H Mole/ Incompetent Cervix – 2nd trimester

Placental Anomalies – 3rd Trimester
BP ↑
Swelling
Scotoma – spots in the eye
Sudden gush of fluid – PROM – premature rupture of membrane

6. Pelvic Examination
 Pelvic examination or IE – empty bladder, precaution
 1st visit – Chadwicks, Goodle’s sign, etc.
 Position : dorsal recumbent, lithotomy
 Pap smear – done 1st visit
 Cytological exam – determine presence of cancer cells.
 Result :
o Class I – normal
o Class II A – cytology without evidence of malignancy
B – suggestive of inflammation
o Class III – cytology suggestive of malignancy
o Class IV – cytology suggestive og malignancy
o Class V – conclusive for malignancy
 Most common cancer report organ : cervical cancer
 Most common site for pap smear – external OS of cervix (squamocolumnar
tissue)
 Common site of cervical cancer. maternal – speculum (open)
 Stages of cervical cancer
o 0 – carcinoma in situ
o 1 – Ca strictly confined to cervix
o 2 – from cervix extends to the vagina
 o 3 – pelvic metastasis
o 4 – affectation to bladder & rectum

7. Leopolds Maneuver
 Purpose: Done to determine the attitude, fetal presentation, lie,
presenting part, degree of descent an estimate of the size, and no. of
fetuses
 Procedure
1. 1st maneuver
o place patient in supine position with knees slightly flexed. Put towel
under head and right hip. With both hands palpate uppe4r abdomen
and fundus. Assess size, shape, movement and firmness of the part
o determine the presenting parts:
2. 2nd maneuver
o with both hands moving down, identify the back of the fetus where
the ball of the stethoscope is placed to determine FHT.
o PR of mother : uterine soufflé – MHR
o fundic soufflé – FHR
3. 3rd maneuver
o using the right hand, grasp the symphysis pubis part using the
thumb and fingers.
o Assess whether the presenting part is engaged in the pelvis.
o Alert! If the head is engaged it will not be movable
4. 4th maneuver
o 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.
o 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 8is flexed and vertex presenting.
 Attitude – relationship of fetus to one another.
 Full Flexion – when the chin touches the chest

8. Assessment of Fetal Well-being

a. Daily fetal Movement Counting (DFMC)

 Done starting 27th week
 Consideration
 fetal sleep wake pattern
 maternal food intake
 drug-nicotine use
 environmental stimuli
 maternal dose
 Cardiff count to 10 method – one method currently available
o 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)
o expected findings – 10 movements in 1hrs or less
o warning signs – 10-12 movements in 1hr or less
 more than 1hr to reach 10 movements
 less than 10 movements in 12hrs
 longer time to reach 10 FMs than on previous days.
 movements are becoming weaker, less vigorous
 movement alarm signal <3 FMs in 12hrs
 o warning signs should be reported to healthcare provider
immediately; often require further testing. Eg. Non stress test
(NST), biophysical profile (BPP)

b. Nonstress Test
o to determine the response of the fetal heart rate to the stress to
activity.
o Indications – pregnancies at risk for
o placental insufficiency
o Postmaturity
• pregnancy induced hypertension (PIH), diabetes
• warning signs noted during DFMC
• maternal history of smoking, inadequate nutrition
o Procedure :
• Done within 30mins wherein the mother is in semifowlers
position; 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
• tocotransducer over fundus to detect uterine contractions and
fetal movements (FMs)
• ultrasound transducer over abdominal site where most distinct
fetal heart sounds are detected
• monitor until at least 2 FMs are detected in 20mins.
o if no FM after 40mins provide women with a light snack or gently
stimulate fetus through abdomen
o If no FM after 1hr further testing may be indicated, such as a CST
o Result :
• Noncreative Nonstress Not Good
• Reactive Response is Real Good
o Interpretation of results
• Reactive result – real good
 baseline FHR between traction beteen 120 and 160 beats
per min.
 at least two accelerations of the FHR of at least 15 beats
per min., lasting at least 15secs in a 10 to 20 min period
as a result of FM
 good variability – normal irregularity of cardiac rhythm
representing a balanced interaction between the
parasympathetic (↓ FHR) and sympathetic (↑ FHR) nervous
system; noted as an uneven line on the rhythm strip
 result indicates a healthy fetus with an intact nervous
system
o Nonreactive result – not good
 stated criteria for a reative result are not met
 could be indicative of a compromised fetus requires further
evaluation with another NST, biophysical profile, (BPP) or
contraction stress test (CST)

9. Health Teachings
o do nutritional assessment
o daily food intake
o determine habit
o if ↓ folic acid – lead to spina bifida/open neural tube defect
o HIGH RISK MOTHERS
• pregnant teenagers – poor compliance to health regimen
 • extremes in wt – underwt – eg. Elite models overwt – eg.
DM/HPN
• low social economic status. Refer to OSWD
• vegetarian mothers because ↓ intake of vit B12
(Cyanocobalamin) – formation of folic acid (cell DNA & RNA
formation)
• types :
 strict vegetarian – prone to develop anemia
 lacto vegetarian – milk
 lacto-ovo vegetarian – milk & egg

a. Recommended Nutrient Requirement that Increases During Pregnancy

Nutrients Requirements Food sources
Calories
Essential to supply 300 calories/day above Caloric ↑ should reflect
energy for the prepregnancy daily foods of high nutrient
• ↑ metabolic rate requirement to maintain value such as protein,
• Utilization of nutrients ideal body weight and complex carbohydrates
• Protein sparing so it meet energy requirement (whole grains,
can be used for : of activity level vegetables, fruits)
nd
o growth of fetus begin ↑ in 2 variety of foods
o development of Trimester representing food sources
structures use wt-gain pattern for the nutrients required
requires for as an indication of during pregnancy
pregnancy adequacy of calories no more than 30%
including intake fat
placenta, amniotic failure to meet
fluid, tissue caloric requirements Na – 3gms/day – eat in
growth can lead to ketosis as moderation
fat & protein are used CHON x 4K Cal
for energy, ketosis has CHO x 4K Cal
been associated with Fats x 9K Cal
fetal damage.

Non pregnant: 2200

calories
Pregnant: 2500 calories
2200+500 @
lactation=2700 cal
Protein
Essential for 60mg/day or an ↑ of 10% Protein ↑ should reflect
• fetal tissue growth above daily requirements Lean meat, poultry,
• maternal tissue growth for age group fish
including uterus and Eggs, cheese, milk
breasts. Adolescents have a Dried beans, lentils,
• Development of higher protein nuts
essential pregnancy requirement than mature Whole grains
structures women since adolescents
• Formation of RBC and must supply protein for Vegetarians must take
plasma proteins their own growth as well note of the amino acid
as protein to meet the content of CHON foods
Inadequate protein intake pregnancy requirement consumed to ensure
has been associated with ingestion of sufficient
onset of pregnancy quantities of all amino
induced hypertension acids
(PIH)
Calcium-Phosphorous
Essential for Calcium ↑ of Calcium ↑ should reflect
• Growth and • 1200mg/day Dairy products, milk,
development of fetal representing an ↑ of yogurt, ice cream,
skeleton and tooth 50% above pre cheese, egg yolk
buds pregnancy daily Whole grain, tofu
• Maintenance of requirement Green leafy
mineralization of • 1600mg/day is vegetables
maternal bones and recommended for Canned salmon &
teeth adolescent sardines with bones
• Current research is • 10mcg/day of vitamin D Ca fortified foods
demonstrating an is required since it such as orange juice
association between enhances absorption of Vitamin D sources
adequate calcium both calcium and fortified milk, margarine,
intake and the phosphorous egg yolk, butter, liver,
prevention of seafood
pregnancy induced
hypertension

Iron
Essential for Non Pregnat:15mg/day
Expansion of blood Pregnant : 30mg/day Iron ↑ should reflect
volume & RBC formation - representing a • liver, red meat, fish,
Establishment of fetal doubling of the poultry, eggs
iron stores for first few prepregnant daily • enriched, whole grain
months of life requirement cereals & breads
• Begin supplementation • dark green leafy
at 30mg/day in second vegetables, legumes
trimester, since diet • nuts, dries fruits
alone is unable to meet • vitamin C sources:
pregnancy requirement citrus fruits & juices,
• 60 – 120mg/day along strawberries,
with copper and zinc cantaloupe, tomatoes,
supplementation for green peppers, broccoli
women who have low or cabbage, potatoes
Hgb values prior to • iron form food sources
pregnancy or who have is more readily
iron deficiency anemia absorbed when served
• 70mg/day of vitamin C with foods high in vit C
which enhances iron
absortion
o Inadequate iron
intake results in
maternal effects
anemia, depletion of
iron stores, ↓ energy
and appetite, cardiac
stress especially
during labor & birth
o fetal effects ↓
availability of oxygen
thereby affecting
fetal growth
• iron deficiency anemia
is the most common
nutritional disorder of
 pregnancy
Zinc
Essential for 15 g/day representing an Zinc ↑ should reflect
• the formation of ↑ of 3mg/day over liver, meats
enzymes prepregnant daily shell fish
• maybe be important in requirement grains, legumes,
the prevention of nuts
congenital
malformation of the
fetus
Folic acids, folacin,
folate 400mcg/day representing ↑ should reflect
Essential for an ↑ of more than 2x the • Liver. Kidney, lean
• Formation of RBC & daily prepregnant beek, veal
prevention of anemia requirement • Dark, green leafy
• DNA synthesis & cell vegetables, broccoli,
formation; may play a 300mcg/day supplement asparagus, artichokes,
role in the prevention for women with low folate legumes
of neural tube defects levels or dietary • Whole grains, preanuts
(spina bifida), deficiency
abortion, abruption
placenta
Additional requirements
Minerals ↑ requirements of
Iodine 175mcg/day pregnancy can easily be
Magnesium 320mg/day met with a balanced diet
selenium 65mcg/day that meets the
requirement for calories
and includes food sources
high in the other
nutrients needed during
pregnancy
Vitamins
E 10mg/day
Thiamine 1.5mg/day
Riboflavin 1.6mg/day
Pyridoxine (B6) 2.2mg/day
B12 2.2mcg/day
Niacin 17mg/day

b. Sexual Activity
• Principles of sex in Pregnancy
o Should be done in moderation
o Should be done in a private place
o That the mother should be placed in a comfortable position
o It must be avoided 6 weeks prior to EDD
o Avoid blowing of air during cunnilingus
• Contraindication in sex:
o vaginal spotting – 1st tri
o incompetent cervix – 2nd tri
o placenta previa, abruption placenta – 3rd tri
o pre-term labor R: prostaglandin – oxytocin – contraction
o PROM – infection
• Changes in sexual appetite during pregnancy:
o 1st tri - ↓
o 2nd tri - ↑
 o 3rd tri - ↓

c. Exercise
• strengthen muscle to be used during the delivery process
• Walking – best form of exercise
• Squatting – strengthen perineum & ↑circulation to the perineum (raise the
buttocks before head to prevent postural hypotension)
• Tailor sitting – same purpose with squatting
• Kegel exercise – strengthen pubococcygeal muscle
• Abdominal exercise – muscle of the abdomen ( done as if blowing a
candle)
• Shoulder circling exercise – strengthen muscle of the chest
• Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain
good posture (arching back for 3 sec)
• Principles of exercise
o must be done in moderation
o must be individualized

d. Childbirth Preparation
• Overall goal: To prepare patents physically & psychologically while
promoting wellness behavior that can be used by parents & family thus,
helping them achieved a satisfying & enjoying childbirth experiences.

• Psychological
o Bradley Method – Dr. Robert Bradley – discoverer
 advocated active participation of husband during labor &
delivery to serve as coach, based on “imitation of nature”
 Features:
• darkened room
• quiet & calm environment
• relaxation technique
• close eyes
o Grantly Dick Read Method
 fear can lead to tension while tension can lead to pain. (break
cycle by removing the fear-by abdominal breathing exercises &
relaxation technique)
• Psychosexual
o Kitzinger Method – Dr. Shiella Kitzinger
 pregnancy, labor & birth & the care of the newborn is an
important turning point in a woman’s life cycle. “flowing with
contractions rather than struggle with contractions”
• Psychoprophylaxis
o Lamaze – Dr. Ferdinand Lamaze
 Prevention of pain thru mind & requires discipline, conditioning
& concentration with the husband’s help.
 Features:
• conscious relaxation
• cleansing breathe – inhaling thru nose & exhaling thru
mouth
• effleurage – gentle circular massage
• over abdomen to relieve pain
• imaging
• Different methods of delivery
o birthing chain – semi-fowlers – mother
o bathing bed – dorsal recumbent
 o squatting – position relieve on back pain & maintain good posture
o Leboyer’s method
 features :
• darkly lighted room
• quiet & calm environment
• room temp.
• soft music
o Birth under water

IX. INTRAPARTAL NOTES

A. Admitting the laboring Mother
• Personal data
• Baseline data
• Obstetrical data
• Physical exams
• Pelvic exams
B. Basic knowledge in intrapartum
• Theories of the Onset of Labor
o Uterine Stretch Theory – any hollow organ once stretched to its
maximum potential will always contract & expel its content
o Oxytocin Theory – released by PPG, contraction effect
o Prostaglandin Theory – stimulation by Arachidonic acid, causes
contraction of uterus
o Aging Placenta – 42wks (lifespan) by 36wks placenta begins to
degenerate causes contraction
o Progesterone deprivation theory - ↓ level of progesterone will
facilitate contraction of the uterus
• The 4 Ps of Labor
o Passenger – fetus
 fetal head
• is the largest presenting part
• ¼ of its length
• Bones – 6 bones (sphenoid, temporal, ethmoid) Frontal,
occipital & 2 parietal bones
• Sutures/intermembranous spaces – allows molding
• Molding – the overlapping of the sutures of the skull to
permit passage of the head to the pelvis
o Sagittal bones – connect to parietal bones
o Cororontal bones – connect to parietal & frontal
bones
o Lambdoidal bones – connect to parietal &
occipital bones
• Fontanels
o 6 fontanels only 2 palpable
 anterior fontanel/Bregma
• diamond in shape
• 3cm x 4cm size
• close 12-18 mos post delivery
• ↑ 5cm – hydrocephalus
 posterior fontanel/lambda
• triangular in shape
• 1 x 1cm size
• close 2-3mos post delivery
• Measurements of fetal head :
o transverse diameter
 Bi-parietal - largest transverse diameter-
9.25cm
 Bi-temporal - 8cm
 Bi-mastoid - smallest transverse diameter -
7cm
o AP diameter
 Suboccipitobregmatic – complete flexion
 Occipitofrontal – partial flexion - 12cm
 Occipitotemporal – largest AP diameter;
hyperextended (13.5cm)
 Submentobrgmatic - face presentation;
poor flexio
o Passageway – vagina & pelvis
 Pelvis
• 4 main pelvic types
o gynecoid – round, wide, deeper, most suitable for
pregnancy
o android – heart shape “male pelvis” – anterior
pointed post part – shallow
o Anthropoid – oval “ape-like pelvis“ AP wider
transverse narrow
o Platypelloid – flat transverse oval AP narrow
transverse – wider – c/s for delivery
• Problem :
o mother who encounter accident
o ↓ 4’9”
o ↓ 18y/o – R: pelvis not achieve its full pelvic growth
 Bones of pelvis
• 4bones
o 2 hips (2 innominate bones)
 3parts of 2 innominate bones
• Ileum – lateral/side of hips
o Iliac crest – flaring superior
border that forms prominence of
hips; common site for bone
marrow aspiration
• Ischium – inferior portion
o Ischial tuberosities of the area
where we
o Sit; basis in getting external
measurement of pelvis
• Pubis – anterior portion
o Symphysis pubis – junction in
between
o sacrum – posterior portion
 Sacral prominence – basis internal
measurement of pelvis
o 1 coccyx - 4 small bones that compresses during
vaginal delivery
• universal precaution in measurement of pelvis is to
empty bladder first
• Important Measurements
o Diagonal Conjugate
 measure between Sacral promontory &
inferior margin of the symphysis pubis
 Measurement 11.5-12.5 cm
  Basis in getting the true conjugate.
o True Conjugate/Conjugate Vera
 Measure between the anterior surface of the
sacral promontory & superior margin of the
symphysis pubis.
 Measurement: 11.0 cm
 Diagonal conjugate: 1.5 cm = true conjugate.
o Obstetrical Conjugate
 smallest AP diameter of the pelvis measuring
10cm or more.
o Tuberoischii Diameter
 transverse diameter of the pelvic outlet.
 Approx by a fist- 8cm & above.
o Power
 the forces acting to expel the fetus & placenta
• involuntary contractions
• voluntary bearing down efforts
• characteristics: wave like
• timing: frequency, duration, intensity
 myometrium – power of labor
o Psyche/person
 psychological stress exist when the mother is fighting the labor
experience.
• cultural interpretation preparation
• past experience
• support system
• Pre-eminent signs of labor
o Preeminent Signs
 lightening
• settling of the presenting part into the pelvis brim
(shooting pain radiating to the legs, urinary frequency)
• primi- early 2 weeks prior to EDD
• engagement – settling of presenting part into pelvic inlet
(not signs of labor)
 Braxton Hicks Contractions – painless irregular contractions
 Increase Activity of the Mother – Nesting
• Instinct (mgt: save energy)
• epinephrine production (hormone that ↑ the activity of
the mother)
 Ripening of the cervix –butter softness
 Decrease in weight – 1.5-3 lbs.
 Bloody show
• pinkish vaginal discharge (blood + leucorrhea +
operculum = pink in color)
 Rupture of membranes
• check FHT
• IE check for cord prolapse
• after several hrs – check temp.
o Premature Rupture of Membranes (PROM)
 contraction drop in intensity even though very painful
 contraction drop in frequency
 uterus tense &/or contracting between contractions
 abdominal palpitations
 Nursing Care:
• administer analgesics (morphine)
• attempt manual rotation for ROP or LOP
 • bear down with contractions
• adequate hydration
• sedation as ordered
• cesarean delivery may be required, especially if fetal
distress is noted
o 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 from vagina – cerebral palsy – ↑ 5 mins.,
irreversible brain damage mgt: CS
 Nursing Care
• Positioning – knee chest or trendelenberg, place wet
sterile gauze R: to make it slippery
• Observe for fetal distress
• Provide emotional support
• Prepare for cesarean section

• Difference Between True and False Contraction

True
• No in intensity
• Pain confined in the
abdomen
• Pain is relieved by walking
• No cervical changes
• effacement (thinning of
False
• There is an in intensity
• Pain begins @ the lower
back to abdomen
• Pain is intensified by
walking Cervical
the cervix, measured
thru %) & dilatation
(widening of the cervix,
measurement thru cm)
*best/major sign of true
labor

• Duration of Labor
o Primipara – 14 hrs but not more than 120 hrs
o Multipara – 8 hrs but not more than 14 hrs
• Nursing Interventions in Each Stage of Labor
o First Stage: onset of contractions to full dilatation & effacement of
the cervix
o stage of effacement & dilatation
 Latent Phase:
• Assessment:
o Dilatations 0-3 cm
o Frequency 5-10 mins
o Duration 20-40 mins
o Intensity mild
o Mother is excited, apprehensive but can
communicate
• Nursing Care:
o Encourage walking : shortens 1st stage of labor
o Encourage to void q 2-3 hrs : full bladder inhibits
uterine contraction
o breathing (chest breathing technique)
  Active Phase:
• Assessment:
o Dilatations 4-8 cm
o Frequency q 3-5 mins lasting for 30-60 secs
o Duration 30-60 secs
o Intensity moderate
• Nursing Care:
o M – edications – have meds ready
o A – ssessment include: v/s, cervical dilatation &
effacement, fetal monitor, etc
o D – ry lips – oral care (ointment), dry linens
o Breathing – abdominal breathing
 Transitional Phase:
• Assessment:
o Dilatations 8-10cm
o Frequency q 2-3 mins contractions
o Duration 45-90 sec
o Intensity strong
o Mood of mother suddenly change accompanied by
hyperesthesia (hypersensitivity of mother to touch)
of the skin
• Management
o sacral pressure, cold compress
• Nursing care:
o T – tires
o I – inform of progress (to relieve emotional
support)
o R – restless support her breathing technique
o E – encourage & praise
o D – discomfort
o Pelvic Exams
 Effacement & Dilatation
• Station – relationship of the presenting part to the
ischial spine
o 5 - -1 = the presenting part is above the ischial
spine
o Engagement 10 = the presenting part is in line with
the ischial spine
o (-) fetus is floating
o (+) below the ischial spine
• Presentation
o the relationship of the long axis of the fetus to the
long axis of the mother.
o spine relationship of the spine of the mother & the
spine of the fetus

o Two Types
 Longitudinal Lie (Parallel)/ Vertical
• Cephalic – when the fetus is
completely flexed
o Vertex
o Face
o Brow
o Chin
 • Breech
o Complete breech – thigh rest
on abdomen while legs rest on
thigh
o Incomplete breech
 Frank – thigh resting on
abdomen while legs extend
to the head
 Footling
 Kneeling
 Transverse Lie
(Perpendicular)/Horizontal lie
• Position – relationship of the fetal
presenting part to specific quadrant of
the mother’s pelvis.
o ROA/LOA
 left occipito anterior
 most common & favorable
position
o ROT/LOT – left occipito
transverse
o ROP/LOP – left occipito
posterior

o L/R- side of maternal pelvis

o Middle – presenting part

o ROP/ROT – most common

malposition
o ROP/LOP – most painful mgt:
pelvis squatting

o Breech – sacro
 place the stethoscope
above the umbilicus
o Chin – mentum
o Shoulder – acromnio dorso
 Monitoring the contractions & fetal heart tone
• spread the finger lightly over the fundus to monitor the
contraction
• Increment/Cresendro - beginning of contraction until
it increases
• Apex/Acne – height of contraction
• Decrement/Decresendro – from height of contraction
until it decreases
• Duration – beginning of contraction to the end of the
same contraction
• Interval – from end of contraction to the beginning of
the next contraction
• Frequency – from the beginning of 1 contraction to the
beginning of next contraction
• Intensity – strength of contraction
• if contract – blood vessel constricts; the fetus will get the
oxygen on the placenta reserve which is capable of giving
oxygen to the fetus up to 1min.
• Duration of placenta to the fetus should not exceed 1min.
 • Significance During active phase, if ↑ to 1min should
notify the AMD
• ↑ BP; ↓ FHT : best time to get BO & FHT just after a
contraction

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR

 Bath is necessary
 Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
 NPO
o Prevent aspiration
chemical pneuminitis
 Enema (per hospital policy)
o Purpose
 Cleanse the bowel
 Prevent infection
o 12 – 18 inches normal length of tube
o 18 inches optimal length
o Lateral sims position
o If there is contraction
clump the tube
o If there is resistance
slowly remove
o Before and after administration: check FHT (120 – 160) and
contractions
 Encourage mother to void
 Perennial preparation (rule of 7)
 Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
 If membrane doesn’t rupture
amniotomy
 FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen
 For Pain
o Systemic analgesic
 DEMEROL (Meperidine HCl)
• Narcotic and antispasmonic
• Don’t give during latent phase
• Given @ 6-8 cm dilated
• WOF : Respiratory depression
• Narcan (Naloxone, nalorfan, nalline)
o Antidote for toxicity
o Injected on the baby
 Epidural Anesthesia
• WOF : Hypotension
• Prehydrate the client to prevent hypotension
• In case of Hypotension
o Elevate leg
o Fast Drip IV

SECOND STAGE OF LABOR (FETAL STAGE)

 Complete dilatation and effacement to birth
 Crowning occurs
 PRIMI – transfer to DR @ 10 cm dilatation
 MULTI – transfer to DR @ 7 – 8 cm dilatation
 Position in lithotomy both legs at the same time
 BULGING OF PERENIUM
surest sign of delivery initiation
 PANT & BLOW Breathing, fetal pushing should be done on an open glottis
 Respiratory alkalosis
o Due to incorrect breathing
 o Hyperventilation
o S/sx
 ↑ RR
 Lightheadedness
 Tingling sensation
 Carpopedal spasm
 Circumoral numbness

Episiotomy
 Prevent laceration
 Widen the vaginal canal
 Shortens the 2nd stage of labor
 2 types
o MEDIAN
 Less bleeding
 Less pain
 Easy repair
 Possible urethroanal fistula
major disadvantage
o MEDIOLATERAL
 More bleeding
 More pain
 Hard to repair and slow healing
 Ironing the Perenium
prevent laceration

Mechanism of Labor (ED FIRE ERE)

 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

PELVIS
 3 Parts
o Inlet – AP diameter narrow, transverse wider
o Cavity – between inner and outer
o Outlet – AP diameter wider, transverse narrow
 LINEA TERMINALES

Nursing Care

 MODIFIED RIGEN’S MANEUVER

o Done by supporting the perenium with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
 First intervention: Support the head and suction secretion
 Do not milk the cord, wait for pulsation to stop before cutting
o Milking may cause too much blood going to the baby that may cause
cardiac overload
 When there is still birth, let the mother see the baby to accept the finality
of death

THIRD STAGE OF LABOR (PLACENTAL STAGE)

 3 – 10 minutes after child birth
 1st sign
Fundus rises
CALKIN’S SIGN
  Signs of Placental Separation
o Fundus becomes globular and rises
calkin’s sign
o Lengthening of the cord
o Sudden gush of blood
 BRANT – ANDREW’S MANEUVER
o slowly pulling the cord and wind at the clamp
o rapidly
may cause uterine inversion

Types Placental Delivery

 SHULTZ (Shiny)
o From center to the edges
o Presenting fetal side
 DUNCAN (Dirty)
o Form edges to center
o Presenting the maternal side

Nursing Considerations during placental delivery

 Check placental completeness
o Should be 500 g
 Check Fundus – Massage if Boggy
 BP Check
 Methergine, methylergonovine mallate (IM)
 Oxytocin (IV) if methergine is not present
 Check perenium for lacerations
 Assist in episioraphy
 Vaginoplasty/ Vaginal Landscape – Virgin again

FOURT STAGE OF LABOR (Recovery Stage)

 First 1 – 2 hours after delivery of placenta
 Maternal observation – body system stabilize
o 1st hour – q15 min 2nd hour - q 30 min
 Placement of fundus
o In between umbilicus and pubis symphysis
o Check bladder, assist in voiding, May lead to uterine atony

hemorrhage
 Lochia
 Perineum
o Check REEDA
 R edness
 E dema
 E cchymosis
 D ischarge
 A pproximation
o Fully saturated – 30 – 40 cc
o Weighing – 1 cc = 1 gram Common Board Question

Nursing Consideration during Recovery

 Flat on bed to prevent dizziness
 If with Chills
give blanket due to dehydration
 Give nourishment (progression of meal)
o Clear liquids – gatorade, ginger juice, gelatins
o Full liquid – milk, ice cream
o Soft diet
o Regular diet
 Check VS/ Pain
 Pychic State
  Bonding – interaction between mother and newborn
o Strict – 24 hours with mother
o Partial – morning with mother, night nursery

COMPLICATIONS OF LABOR

Dystocia
 Difficult labor related to mechanical factor
 Primary cause is Uterine Inertia

Uterine Inertia
 Sluggishness of contraction
 Types
o Primary/ Hypertonic
 Intense contraction resulting to ineffective pushing
 Management : Sedation
o Secondary/ Hypotonic
 Slow, irregular contraction resulting to ineffective pushing
 Management : Oxytocin Augmentation
Prolonged Labor
 > 20 H for primi
 > 14 H for multi
 proper pushing should be encourage if inappropriate:
o may cause fetal distress
o caput succedaneum
o cephalhematoma
o maternal exhaustion
 monitor contractions and FHT

Precipitate Labor
 labor less than 3 hours
 causes excessive laceration leading to profuse bleeding
hypovolemic
shock
 s/sx of hypovolemic shock HYPO TACHY TACHY
o HYPOtension
o TACHYpnea
o TACHYcardia
o Cold clammy skin
o Management
 Modified trendelenburg
 Fast Drip IV

Inversion of Uterus
 Situation in which uterus is turn inside out due to:
o Short cord
o Hurrying of placental delivery
o Ineffective fundal push
 Cause profuse bleeding
hypovolemic
 Hysterectomy

Uterine Rupture
 Rupture of uterus
 Caused by
o Previous classical CS
o Very large baby
o Improper use of oxytocin
  S/sx
o Sudden pain
o Profuse bleeding
 Prepare fore TAHBSO
Physiologic Retraction Ring
boundary between upper and lower uterine
segment
Bandl’sPathologic Ring
suprapubic depression sign of uterine rupture

Amniotic Fluid/ Placental Embolism

 Anaphylactic syndrome of pregnancy
 Situation in which placental fragment and amniotic fluid enters maternal
circulation
 S/Sx
o Dyspnea
o Chest Pain
o Frothy Sputum
o End Stage – DIC
 Prepare for CPR, Suction and emergency etc

Trial Labor
 Fetal head measurement = measurement of pelvis
 6 hours labor allowance given to mother
 monitor FHT and contractions

Preterm Labor
 labor after 20 weeks and before 37 weeks
 Triad signs
o Premature conditions every 10 minuets
o Effacement of 60 – 80%
o Dilatation of 2 – 3 cm
 Home Management
o CBR
o Avoid Sex
o Empty bladder
o Drink 3 – 4 Glasses of H2O
 Full bladder inhibit contraction
 Hospital Management
o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated
only)
 2 – 3 cm dilated, pregnancy can be saved
 Tocolytic Therapy
• Yutupar (Ritodine HCl)
o Side effect maternal BP < 90/60
o Check Impt. Presence of crackles
• Brethine (terbutaline) Bricanyl
o DOC
o Side effect: sustained tachycardia
o Antidote: propanolol/ inderal
• Mg SO4
o If cervix is dilated ( > 4cm)
 Give steroid dexamethasone
• Promote surfactant maturation
• Immediately cut the cord after delivery to prevent
jaundice/ hyperbilirubinemia

POSTPARTAL PERIOD
Puerperium – 5th stage of labor, 1st 6 weeks post partum
Characterize by involution
Involution - return to the normal stage of reproductive organ after pregnancy

Return to Normal Healing

Physiologic Changes
Systemic Changes
 Cardiovascular System
o ↑plasma volume
o sudden ↓ in blood volume
o elevated WBC’s up to 30, 000 mm3
o hyperfibrinogenemia
o orthostatic hypertension can be possible
o early ambulation prevents thrombos formation
 steps in ambulation
• Flat
• Semifowlers
• Fowlers with dangling
• Walk with assist

 Genital Tract
o Fundus
 goes down 1 finger breadth a day
 10th day – non palpable behind the symphysis pubis
 Subinvolution
• delayed healing of uterus containing quarters or clots of
blood
• may lead to puerperal sepsis
• Management : D&C
o After Pains
 After birth pains
 Multiparous breastfeeding – most common to develop
 Position = prone
 Cold compress
 Mefenamic acid
o Lochia
 Components
• Blood
• Deciduas
• WBC
• Microorg
 3 types
• Rubra – 1 – 3 days, musty, moderate amount
• Serosa – 4 – 10th day, pink or brown
• Alba – 10 – 21th day, crème white, ↓ amount

 Urinary Tract
o Urinary Frequency – due to urinary retention with overflow
o Dysuria
 Damage to trigone of the bladder
 Urine collection for culture and sensitivity
 Stimulate navel to urinate
 Palpate bladder
 Running water listening
 Pull pubic hair - stimulate cremasteric reflex
  Colon
o Constipation
 Due to NPO
 Bearing down may cause pain
 Perenium
o Pain relieved by sim’s position
o Cold compress 1st 24 hours if there is pain at episioraphy followed by
warm

EMOTIONAL SUPPORT

1. Taking phase
• 1st 3 days
• dependent phase
• passive, can’t make decision
• tells about childbirth experience
• focus on: Hygiene
2. Taking Hold
• 4 – 7th day
• dependent to independent phase
• active, decides actively
• focus: care of newborn
• health teaching : Family planning
3. Letting Go
• Interdependent phase
• Redefines goals, new roles as parents
• May extend till the child grows

Post Partum Blues

• 4th – 5th days
• overwhelming feeling of depression, inability of sleep and lack of appetite
• 50 – 80% incidence rate
• cause by sudden hormaonal change – progesterone suddenly decreases
• allow crying: therapeutic
• may lead to postpartum psychosis/ depression

Postpartal Complications

Hemorrhage
 bleeding within 24 hours postpartum

Early Pospartal Hemorrhage

1. Uterine Atony
 boggy fundus
 profuse bleeding
 interventions
o massage the uterus
o cold compress
o modified trendelenburg
o fast drip IV
o breastfeeding – to release oxytocin

2. Laceration
 well contracted uterus with profuse bleeding
  assess perenium for laceration
 degrees of laceration
o 1st degree – vaginal skin and mucus membrane
o 2nd degree – 1st degree + muscles
o 3rd degree – 2nd degree + external sphincter of rectum
o 4th degree – 3rd degree + mucus membrane of rectum

3. Hematoma
 bluish discoloration of subQ tissues of vagina or perenium
 candidates
o delivery of very large babies
o pudendal block
o excessive manipulation due to excessive IE
 intervention
o cold compress 10 – 20 min then allow 30 minutes rest period for 24
h

4. DIC – disseminated intravascular coagulation

 Consumption of pregnancy (otherterm)
 Failure to coagulate
 Bleeding in the eyes, ears, nose
 Oozing blood
 Seen in cases with
o Abruptio placenta
o Still birth / IUFD
 Management
o Blood transfusion of cryoprecipitate or fresh frozen plasma
o hysterectomy

Late Postpartum Hemorrhage

Retained placental fragments

 manual extraction of fragments is done
 uterine massage
 D&C except for cases of
o Placenta Acreta – umusual attachment of the placenta to the
myometrium
o Placenta Increta – deeper attachment of placemat to the
myometrium
o Placenta Percreta – invasion of placenta to the perimetrium
 Candidates of these disorders are
• Grand multiparous
• Post CS
 All these requires hysterectomy

Infection
 Sources
o Endogenous – from normal flora of the body
o Exogenous – from the health care team
 Most common – Anaerobic Streptococci
 Management
o Supportive care
o ↑ Fluid intake
o TSB if there is fever/ cold compress + paracetamol may also be given
o Analgesics
 Given on time to achieve maximum effect
 o Culture and sensitivity

Perenial Infection
 Same s/ sx with infection
 2 – 3 stitches are dislodges
 with purulent drainage
 Tx – resuturing

Endometritis
 Inflammation of the endometrium
 Gen s/sx of infection + abdominal tenderness
 Management
o High fowler’s – facilitates drainage & localize infection
o Administer oxytocin

FAMILY PLANNING METHOD

Guiding Principles
1. determine your own beliefs first
2. never advise a permanent method of family planning
3. informed concent
4. the method is an individual decision

Natural Method – accepted by the church

Billing’s/ Cervical Mucus/ Spinnbarkeit

• clear watery & stretchable
th
• 13 day – longest due to estrogen
Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of
progesterone
LAM – Lactational Amenorrhea Method
 prolactin – inhibits ovulation
 breastfeeding – 4 – 6 months no menstrual cycle
 bottle fed – 2 – 3 months
Sympthothermal – combination of Billings and BBT – most effective method

Social Methods

Coitus Interuptus
 withdrawal
 least effective method
Coitus Reservatus
 sex w/o ejaculation
Coitus interfemora
 between femor
Calendar Method
 14 days before menstrual cycle – ovulation day (regular)
 - 4, + 4 days – unsafe period
Origoknause Formula ( irregular menstrual cycle)
 get the longest and shortest cycle
 subtract 18 to shortest
 11 to the longest
 the difference is the unsafe period
PILLS
 combined oral contraceptives preventovulation by inhibiting the anterior
pituitary gland roduction of FSH and LH which are essential for he
maturation and rupture of a follicle.
 Estrogen inhibit FSH which is responsible in the mturation of ovum.
Progesterone inhibit LH which is responsible for ovulation.
 contains estrogen that inhibits FSH and progesterone that inhibit LH
 99.9% effective
 21 day feel on the 5th day of mense start taking
 28 day – 1st day of mense
 if forgotten, take 2 tablets the following day
 adverse effect : breakthrough bleeding
 if mother wants to get pregnant
o wait 3 monts
o another 3 months if unsuucessful before consulting gyne
 contraindications
o chain smoking
o Hypertension
o DM
o Extreme obesity
o Thrombophlebitis
 Side effects (ressembles Hypertension)/ Immediate
Discontinuation
o Abdominal paon
o Chest pain
o Headache
o Eye problem
o Severe leg cramp
 Alerts on oral contraceptives :
o In case a Mother who is taking an oral contraceptive for almost a
long time and plans to have a baby, she would wait for at least 3mos
before attempting to conceive to provide time for estrogen and
progesterone levels to return to normal. If after 6months the mother
did not get pregnant, consult AMD.
o 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.
o Discontinue oral contraceptive if there is signs of severe headache as
this are an indication of hypertension associated with increase
incidence of CVA and subarachnoid hemorrhage.
o If forget to drink pill for 1 day, take 2 pills the next day. If forget to
drink pills for 2days, stop the pill and wait for the next mens.
 Adverse reaction : breakthrough bleeding

DMPA – Depoprovera
 Contains progesterone
 Depomedroxy progesterone Acetate
 IM q 3 months – never massage the site
may decrease effectiveness

NORPLANT
 6 match stick like capsules/ rod
 contain progesterone
 sub Q planted
 good for 5 years
Mechanical Device
IUD
 prevent implantation
 alters mobility of sperm and ovum
 99.7% effective
 best inserted after delivery and during menstruation
 Common complication – EXCESSIVE MENSTRUAL FLOW
 Common problem – EXPULSION OF THE DEVICE
 No protection against STD
 Side effects include
o Uterine infection
o Uterine perforation
o Ectopic pregnacy
 Major indication for the use is PARITY
 HT: monthly check up and regular pap smear

CONDOM
 Made up of latex
 Put in erected penis or lubricated vagina
 Prevents sperm to enter the uterus
 FEMALE CONDOM – higher protection than that of male

DIAPRAGHM
 Dome shaped rubberied material inserted at the cervix to prevent sperm
getting inside the uterus
 Reusable
 HT : Proper hygiene
o Check for holes
o Must be refitted in case of weight gain of 15 lbs - - board question
o Kept in place for about 6-8 Hours – Board question
 Contraindicated to
o Frequent UTI

CERVICAL CAP
 More durable than the diaphram
 Could stay on place for more than 24 hours
 No need to apply spermicides
 Contraindicated to – abnormal papsmear

CHEMICAL
SPERMICIDES
 FOAMS – most effective
 Jellies
 Creams
 These may cause toxic shock syndrome

SURGICAL METHOD
 Bilateral tubal Ligation
o @ isthmus
o 20% probability of reversal
 Vasectomy
o Vas deferens is cut
o More than 30 x or 0 sperm count or 2 x negative sperm count before
it could be consider safe sex
HIGH RISK PREGNANCY
HEMORRHAGIC DISORDERS

General management
 CBR
 Avoid sex
 Prepare ultrasound – determine the sac integrity
 Assess bleeding and approximation
 Assess hypovolemia
 Save discharge for histopathology
o Determine whether the product of labor has been expelled

First Trimester Bleeding

Abortion – termination of labor before age of viability
 SPONTANEOUS
o AKA miscarriage
o Causes
1. Chromosomal aberrations due to advanced maternal age
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatened
• pregnancy is jeopardized by bleeding and cramping but
the cervix is closed and can be saved.
2. Inevitable
• moderate bleeding, cramping, tissue protrudes from the
cervix and the cervix is open.
o Types :
1. Complete
• all products of conception are expelled.
• Mgt : emotional support
2. Incomplete
• placenta and membranes retained.
• Mgt : D&C
 HABITUAL
o 3 or more consecutive pregnancies result in abortion usually related
to incompetent cervix.
o Management (suture of cervix)
1. McDonald procedure
• Temporary circlage
• Side effect – infection
• May have NSD
2. Shirodkar
• CS delivery
 MISSED
o fetus dies; product of conception remain in uterus 4 weeks or longer
o signs of pregnancy cease
1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
o Mgt : induction of labor/ vacuum extraction
  INDUCED
o Therapeutic abortion
principle of 2 fold effect
1. Done when mother has class 4 heart disease

Ectopic Pregnancy
• occurs when gestation is location
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial
Unruptured
• Missed period
• Abdominal pain within 3-
5wks of missed period
(maybe generalized of one
sided)
• Scant, dark brown vaginal
bleeding
• Vague discomfort
outside the uterine cavity
Ruptured
• sudden, sharp severe
unilateral pain, knife like
• shoulder pain (indicative of
intraperitoneal bleeding that
extends to diaphragm &
phrenic nerve)
• (+) Cullen’s sign – bluish
tinged umbilicus
• syncope/fainting

• Nursing Care :
o vital signs
o administer IV fluids
o monitor for vaginal bleeding
o monitor I&O
o prepare for culdocentesis to determine
o hemoperitoneum
• Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING

Hydatidiform Mole / “bunch of grapes”
• Gestational Trophoblastic Disease – progressive degeneration of Chorionic
Villi
• gestational anomaly of the placenta consisting of a bunch of clear vesicles.
This neoplasm is formed from the swelling of the chronic villi and lost
nucleus of the fertilized egg. The nucleus of the sperm duplicates,
producing a diploid number 46xx. It grows and enlarges the uterus very
rapidly.
• Cause : Unknown
• Assessment :
o Early signs
 vesicles passed thru the vagina
 Hyperemesis gravidarum due to ↑ HCG
 Fundal height
 Vaginal bleeding (scant or profuse)
o Early in pregnancy
 high levels of HCG
 Pre ecclampsia at about 12wks
 Vesicles look like a “snowstorm” on sonogram
 Anemia
 Abdominal cramping
o Serious late complications
 Hyperthyroidism
 Pulmonary embolus
• Nursing care :
o prepare for D&C
o do not give oxytocin drugs due to proneness to embolism
 o Health Teaching:
 return for pelvic exams as scheduled for one year to monitor
HCG and assess for enlarged uterus and rising titer could be
indicative of choriocarcinoma
 Avoid pregnancy for at least one year
 Methotrexate therapy

Incompetent Cervix Management:

• McDonald procedure
o temporary circlage of incompetent cervix.
o Delivery : NSVD
o SE: infection
o Health teaching
 observe for signs of infection
 signs of labor
• Shhirodkar procedure
o permanent procedure.
o Delivery : caesarian section required.

THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES”

Placenta Previa
• it occurs when the placenta is improperly implanted in the lower uterine
segment, sometime covering the cervical os.
• Assessment
o Outstanding sign : frank, bright red, painless bleeding
o enlargement (usually has not occurred)
o fetal distress
o abnormal presentation
• Nursing care :
o Initial mgt : NPO candidate for CS
o Bedrest
o prepare to induce labor if cervix is ripe
o administer IV
o No IE, No Sex, No enema – complication : Sudden fetal blood loss
o prepare Mother for double set –up –DR is converted to OR

Abruptio Placenta
• it is the premature separation of the placenta from the implantation site.
• It usually occurs after the twentieth week of pregnancy
• Cause:
o Cocaine user
o Severe PIH
o Accident
• Assessment:
o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-)
contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
o sx : bleeding to any part of the body. Mgt : for hysterectomy
• General Nursing care :
o infuse IV, prepare to administer blood
 • type and crossmatch
o monitor FHR
o insert Foley catheter
o measure bllod loss; count pads
o report s/s of DIC
o monitor v/s for shock
o strict I&O

Placental Succenturiata – 1 or 2 lobes connected to the placenta by a blood

vessel
Placenta Bipartita – placenta divided into 2 lobes

HYPERTENSIVE DISORDER

Pregnancy Induced Hypertension

o HPN after 24wks resolved 6wks postpartum which cause pregnancy.
o Types :
o Gestational HPN
 HPN without edema & proteinuria.
 Mgt : monitor BP
o Pre-eclampsia – triad
o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which
cause is unknown or idiopathic but multifactoral
 primis d/t 1st exposure to chorionic villi
 multiple pregnancies due to ↑ exposure to chorionic villi
 Mothers of low socio-economic status due to ↓ protein intake
 Teenagers d/t low compliance to protein intake
o HELLP syndrome – hemolysis with elevated liver enzymes & low
platelet count

Transitional Hypertension – HPN between 20-24wks

Chronic or Pre-existing Hypertension
o HPN before the 20th wk not resolved 6wks postpartum
o 3 types of pre-eclampsia
o Sign of pre-eclampsia :
o > 30mmHg systolic
o > 15mmHg diastolic
o Roll over test
 10-15min side lying
 Then supine
 Then take BP
o mild pre-ecclampsia
 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt,
inability to wear wedding ring due to developing edema
 Signs present
• cerebral & visual disturbances, epigastric pain to liver
edema and oliguria usually indicates an impending
convulsion
• Before convulsion : if you see sign of epigastric pain, 1º
mgt is to place tongue depressor and put the side rales
up
• During convulsion : observe the Mother for safety
• After convulsion – turn to side to facilitate drainage
o Severe pre-ecclampsia
 160/110, +3 or +4, proteinuria, visual disturbances
  Nursing care
 P – promote bedrest
 Prevent convulsions by nursing measures
• to ↑ O2 demand & facilitate Na excretion
• Management: quiet & calm environment, minimal
handling, avoid moving the bed
• Heat Acetic Acid – determine protein in the urine
• Prepare the following at bedside
o tongue depressor, Suction machine & O2 tank
 E – ensure high protein intake (1g/kg/day)
• Na in moderation
 A – antihypertensive drug with hydraluzine
 C – CNS depressant with Mg Sulfate for anti-convulsion
• Mgt : evaluate for hypermagnesiumenimia
 E – evaluate physical parameters for Magnesium Sulfate
toxicity :
• B – BP ↓
• U – Urine output ↓
• R – RR ↓
• P – Patellar reflex is absent
• Antidote : Ca gluconate
o Eclampsia – with seizure
 ↑ BUN – sign of glumerular damage
Diabetes Mellitus
o cause by absent & lack of Insulin
o Action of Insulin is to facilitate transfer of glucose into the cell
o Dx test : 50gm 1hr Glucose Tolerance Test
o ↑ 130 – hyperglycemia
o ↓ 70 – hypoglycemia
o 80-120 – euglycemia
o if > 130mg/dl, the Mother needs to undergo a 3hr GTT
o Maternal Effects :
o hypoglycemia during the 1st trimester development of the brain
sinisipsip ng fetus yung glucose ng nanay.
o Hyperglycemia during the 2nd & 3rd trimester
 HPL effect Mgt : give insulin. OHA are teratogenic.
 1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum
– drop suddenly
 Frequent infections eg. Moniliasis
 Polyhydramnios
 Dystocia
o Fetal Effects :
o hypoglycemia during the 1st trimester and Hyperglycemia during the
2nd & 3rd trimester thru facilitated diffusion
o Macrosomia/LGA .4000gms
o IUGR due to prolonged DM
o Preterm birth promote still birth
o Newborn Effects :
o Hyperinsulinism and Hypoglycemia
 40mg/dl
 Normal : 45-55mg/dl
 Borderline : 40mg/dl
 Sx : ↑ pitched shrill cry, tremors, jitteriness
 Dx test : heel stick test to check glucose levels
o Hypocalcemia
 < 7mg/dl
 Calcemic tetany
 Tx : Ca gluconate

Heart Disease
o Classification :
o I – no limitation
o II – Slight limitation, ordinary activity causes fatigue
 good prognosis can deliver vaginally
 Mgt : sleep of 10hrs/day, rest 30mins after meals
o III – moderate limitation, less than ordinary activity causes
discomfort
 poor prognosis. Good for vaginal delivery
  Mgt : early hospitalization by 7-8mos
o IV – marked limitation of physical activity for even at rest there is
fatigue
 poor prognosis. Good for vaginal delivery only with regional
anesthesia.
 Low forceps delivery when unable to push & to shorten the
stage of labor
 Mgt :
• therapeutic abortion, high semi- fowlers position, left side
lying, no valsalva maneuver - may trigger cardiac arrest,
heparin therapy required, antibiotic therapy for
prevention of sub acute bacterial endocarditis

INTRAPARTAL COMPLICATIONS

Cesarean Delivery
• Indications
a. multiple gestation
b. diabetes
c. active herpes II
d. severe toxemia
e. placental previa
f. abruption placenta
g. prolapse of the cord
h. cephalo pelvic disproportion and primary indication
i. breech presentation
j. transverse lie
• procedure :
o classical – vertical incision
o low segment – “bikini”, for aesthetic purposes. Can have vaginal
birth after c/s

Genotype – genetic make-up

Phenotype – Physical appearance
Karyotype – pictorial analysis of individual chromosome for detecting
chromosomal abnormalities
Autosomal Dominant
• huntington’s chorea
• retinoblastoma
• achondroplasia
• polydactyl
Autosomal Recessive
• sickle cell
• Cystic fibrosis
• Celiac
• PKU
• Galactosemia
X- Linked Recessive
• Hemophilia
• Duchenne’s muscular dystrophy
• Color blindness
X – Linked Dominant
• Rickette’s