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HUMAN SEXUALITY
Concepts
A person’s sexuality encompasses the complex behaviors, attitudes and emotions and
preferences that is related to sexual self and eroticism
Sex is basic and dynamic aspect of life
During reproductive years, the nurse performs as resource person on human sexuality
15 – 44 y.o. – age of reproductivity CBQ
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
SEXUAL ANATOMY AND PHYSIOLOGY
FEMALE REPRODUCTIVE SYSTEM
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
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
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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. 14th day estrogen level is ↑ while progesterone level is ↑
• S/S
o Rupture of the graafian follicle - OVULATION
o Mittelschsmerz – slight abdominal pain lower right
quadrant
7. 15th 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
Stages of Human Sexual Response
Initial Response:
VASOCONGESTION – constriction of blood vessels
MYOTONIA – increased muscle tension
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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
Wonders of Fertilization
Fertilization
Phonones – song of sperm
Capacitation – ability of sperm to release proteolytic enzyme and penetrate the ovum
Stages of Fetal Growth and Development
Pre Embryonic Stage
Zygote fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilization
Morula mulberry-liked ball containing 16 – 50 cells
Blastocyst enlarging cell forming a cavity that later becomes the embryo covered by thropoblast which later
becomes the placenta and membrane
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
Embryonic Stage
Zygote – fertilization to 14 days
Embryo – 15th – 2 mos/ 8 weeks
Fetus – 2 mos to birth
Decidua – thickened endometrium, latin word for “falling off”
Basalis – located directly under the fetus where placenta developed
Caspularis – encapsulates the fetus
Vera – remaining portion of and endometrium
Chorionic Villi – 10 – 11 weeks
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
Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis (24 weeks/ 6
months)
Synsitiotrophoblast – syncitial layer – responsible for hormone production
Amnion – inner most layer 2. Chorion
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
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
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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
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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
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• 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
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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
•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 by the Signs observed by the Undeniable signs confirmed by
mother but does not confirm the members of the health the use of instrument
diagnosis of pregnancy care team
First trimester Breast changes Goodel’s sign Ultrasound Evidence
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 Abdomen etal Heart Tone
Increase Skin Pigmentation Braxton Hicks etal movement
Striae gravidarum Contraction etal outline
Quickening etal parts 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
Abdominal 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
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5. Obstetrical Data
Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age
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
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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
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• 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 energy for 300 calories/day above the Caloric ↑ should reflect
↑metabolic rate prepregnancy daily requirement to • foods of high nutrient value such
Utilization of nutrients maintain ideal body weight and as protein, complex carbohydrates
meet energy requirement of activity (whole grains, vegetables, fruits)
• Protein sparing so it can be
level • variety of foods representing food
used for :
growth of fetus • begin ↑ in 2nd
Trimester sources for the nutrients required
o development of • use wt-gain pattern as an during pregnancy
structures requires for
indication of adequacy of • no more than 30% fat
calories intake
pregnancy including
placenta, amniotic fluid, • failure to meet caloric Na – 3gms/day – eat in moderation
tissue growth requirements can lead to ketosis CHON x 4K Cal
as fat & protein are used for CHO x 4K Cal
energy, ketosis has been Fats x 9K Cal
associated with fetal damage.
• 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
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• 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 FALSE
• No in intensity • There is an in intensity
• Pain confined in the abdomen • Pain begins @ the lower back to
• Pain is relieved by walking abdomen
• No cervical changes • Pain is intensified by walking
Cervical effacement (thinning of
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
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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
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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
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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
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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
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• 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
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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
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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 outside the uterine cavity
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial
UNRUPTURED RUPTURED
• Missed period • sudden, sharp severe unilateral pain, knife
• Abdominal pain within 3- 5wks of like
missed period (maybe generalized of • shoulder pain (indicative of intraperitoneal
one sided) bleeding that extends to diaphragm &
• Scant, dark brown vaginal bleeding phrenic nerve)
• Vague discomfort • (+) 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
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• 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
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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
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Heart Disease
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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