Guide to Obstetrics: Understanding the Menstrual Cycle, Fertility, and Pregnancy, Study notes of Nursing

Download Guide to Obstetrics: Understanding the Menstrual Cycle, Fertility, and Pregnancy and more Study notes Nursing in PDF only on Docsity! 1 Women health ob-note-taking-guide OBSTETRICS _ THE MENSTRUAL CYCLE - cyclic uterine bleeding in response to hormonal changes Average days for Menstrual Cycle: 28 days Average days for Menstrual Period: 5-6 days Average blood loss: ¼ of a cup/ around 60 mL. maximum of 80mL The menstrual blood is a little thicker than normal bleeding. 1-6= bleeding, 7-14= thickening, 15-26= preparation for implantation, 27-28= vasoconstriction in preparation for another menstrual cycle Menstrual Blood Color Bright red= most likely present at the beginning of the period Dark red= usually darkens over the course of the period Pink = common at the very beginning or end. Indicates light flow The menstrual cycle starts when the uterus bleeds 1-6=Bleeding 7-14=Thickening 14=Ovulation = released of mature ovum 15-26= Preparation for Implantation 27-28= Vasoconstriction Normal menstrual cycle ✓ Having a cycle anywhere from 24-38 days ✓ Bleeding anywhere from 4 -7 days at a time ✓ Losing 5-80 mL over the course of menstrual period When to see a doctor ✓ Not bleeding for more than 3 months ✓ A change from regular to irregular periods ✓ Bleeding for more than 7 days at a time or between periods ✓ Bleeding so heavily ✓ Severe pain during your period ✓ Getting a fever Body Parts Involved 1. UTERUS (endometrium-innermost, layer for menstruation, regenerating layer, layer of implantation) 2. HYPOTHALAMUS produces GnRH (Gonadotropin Releasing Hormone) that stimulates 3. APG (Anterior Pituitary Hormone) releases a. FSH= follicle stimulating hormone= responsible for maturation of ovum which is active on the first half of menstrual cycle (active on 1-14th day) 2 Primordial follicle (immature or primary follicle contains the immature ovum) becomes Graafian follicle (mature follicle containing the mature ovum) b. LH=luteinizing hormone= responsible for ovulation and active from 15- 28(second half) LAST Ovulation- monthly release of the mature ovum by the Graafian follicle. Occurs 14 days before the next cycle . august1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 #Irregularities in the menstrual Cycle= culprit hormone #FSH To check for fertile periods for a woman having irregular cycle Formula= count the shortest and longest cycle of the woman for 6 consecutive months Example January= 26 days, February=24 days, March= 33 days, April =28 days, May =29 days, June =30 days Shortest cycle minus 18 days, longest cycle minus 11 days 24-18= 6 33-11= 22 Her fertile days start on Day 6 of menstrual cycle up to day 22. Her safe days/ infertile days= Day 23 of the cycle to day 5 of the next menstrual cycle. 4. OVARIES produce a. ESTROGEN (estrone, estradiol= for puberty, estriol= for preg)- hormone of the Woman (development of secondary sexual characteristics, specifically ESTRADIOL) Fat distribution in the hips and legs= widening of the hips T- helarche = breast development A- drenarche = formation of axillary hair M- enarche= first menstruation A- drenarche = formation of pubic hair Estrogen is the hormone responsible for HEIGHT INCREASE. Estrogen is also the hormone responsible for CLOSURE OF EPIPHYSEAL LINES OF LONG BONES. #At puberty, GIRLS are taller. At maturity BOYS are taller Hormone responsible for fertile cervical mucus (thin, clear, watery, alkaline, slippery, abundant, stretchy OR SPINNBARKEIT, +ferning OR FERNLIKE PATTERN SEEN IN MICROSCOPE, wet) 5 Zygote TYPES OF SPERM (small head, long tail/flagella, pearly white in color, motile, can reach the cervix for 80 sec. after ejaculation) minimum sperm count considered normal = 20 million per mL or 60 million per ejaculation 6 MALE SPERM Y, dies in acid, fast moving, short-lived sperm FEMALE SPERM X, acid resistant, slow moving, long-lived sperm The ovum survives for 24-36 hours the sperm survives for 48-72 hours. The ovum must be fertilized in 24 hours #What is Infertility?= no pregnancy after 0ne year of unprotected sex Most common causes: To man =low sperm count= mgt. is GIFT (gamete intrafallopian transfer) to woman= anovulation/ absence of ovulation- Mgt= fertility/ovulatory drug (clomid/clomiphene citrate, pregnyl, pergonal) WHAT IF... 2 sperm cells entered the ovum has no genetic material FRATERNA L TWINS= more common IDENTICAL TWINS / Monozygotic twins= same sex Types 1. DICHORIONIC DIAMNIONIC= most common type 2 placentas, 2 amniotic sacs, 2 fetuses - If splitting occurs on the first 3 days after fertilization. 2. MONOCHORIONIC DIAMNIONIC 1 placenta, 2 amniotic sacs. 2 fetuses If splitting occurs on 4th-7th day 3. MONOCHORIONIC MONOAMNIONIC 1 placenta, 1 amniotic sac, 2 fetuses If splitting occurs on 8th-13th day 4. CONJOINED TWINS = cleavage is incomplete If splitting occurs more than 13 days Dispermy Triploid karyotype Xxx xyy xxy 69 anucleat e d ovum at risk=40 years old and above Or Dizygotic twins 2 zygotes 2 fetus Abnormal Partial H- mole Abnormal Complet e H- mole 2 sperms fertilize two different ova. 2 placentas May be different or same sex 2 BOW IMPLANTATION / NIDATION SIGNS OF IMPLANTATION: Vaginal spotting and slight pain 3 processes of implantation 1. Apposition- when the trophoblast begins to brush the endometrium 2. Adhesion= attach 3. Invasion= blastocyst settles SITE- posterior fundus of the uterus (uppermost portion of the uterus) WHEN= 7-10 days after fertilization FETAL GROWTH AND DEVELOPMENT ZYGOTE (fertilized ovum)----CLEAVAGE----BLASTOMERES---- After 3-4 days--- 7 MORULA(16-50 cells, moving structure, mulberrylike structure)---after 3-4 days ----BLASTOCYST (reorganized morula, implanted structure)----EMBRYO (2weeks – 8weeks)----FETUS (8th week to term) 10 4th week All systems in the rudimentary form. HEART chambers formed (first functional organ). Heart beating (as early as 14 days) Beginning formation of eyes, ears nose With arms and leg buds 8th week Head is large Rapid BRAIN development Neuromuscular development External genitalia is formed 12th week Placenta is complete, FHT is audible by Doppler #SEX is distinguishable, Fetus begins to swallow AF. Kidneys begin to excrete urine. 16th week QUICKENING ( for MULTI)= first fetal movement felt by the mother. DFMC= daily fetal movement count Normal count= 10-12 FMs in one hour How to stimulate movements= 1. Food 2. Exercise 3. Activity 4. Sounds (6th mo. and above) Less than 10 FMs in one hour= extend one hour Less than 10 FMs in 2 hours= report Formed eyes ears nose. Scalp hair develops, FHT by Fetoscope, lanugo begins to appear Meconium in bowels 20th week Lanugo completely appears, QUICKENING (PRIMI) FHT by STETHOSCOPE (bell), Bones hardening Age of Viability= is the ability of the fetus to survive outside the uterus (5th mo) 24th week Body well proportioned. Skin is red and wrinkled Eyebrows and eyelashes appear, vernix caseosa appears HEARING ESTABLISHED 28th week Surfactant develops, clitoris is prominent and large Body is less wrinkled NAILS APPEAR 32th week SUBCU8TANEOUS FAT deposits, iron deposits, calcium deposits, skin is smooth and pink Birth position assumes- leopold’s maneuver can be done 36th week Nails firm, with definite sleep and wake pattern, lanugo disappearing Lecithin (most abundant phospholipid) and sphingomyelin ratio (L/S) is 2:1= LUNGS ARE MATURE (35 WEEKS) presence of phosphatidyl glycerol(second most abundant) (PG) confirms lung maturity (36 WEEKS) lung maturity occurs late in pregnancy Side knowledge (antenatal corticosteroids=drugs enhancing lung maturity) tocolytics= drugs to stop contraction 40th week Little lanugo, if male, testes descend with good muscle tone and reflexes at birth- Undescended testes= mostly preterm 11 temporarily Betamethasone 12 mg IM every 24 hours x 2 Dexamethasone 6 mg IM every 12 hours x 4 12 Side Knowledge: At birth, if the newborn has… More lanugo preterm Absent lanugo Post term Little lanugo term Wrinkled skin Pre term Dry and desquamating Post term Smooth skin term Soft nails Pre term Long nails Post term Firm nails term AMNIOTIC FLUID/ BAG OF WATER/ AMNIOTIC SAC AOG VOLUME OF AMNIOTIC FLUID (ULTRASOUND) 10 WEEKS 30 ml 20 WEEKS 350 ml AFTER 20 WEEKS The fetus actively swallows 1. amniotic fluid at 5 mos. 2. 3. Fetus swallows 600ml each day 4. and 400ml flows out of the lungs each day. The major sources of amniotic fluid after 20 weeks are the FETAL KIDNEYS The amniotic fluid contains albumin, urea, uric acid, fats, fructose, bilirubin, leukocytes, lecithin, sphingomyelin, protein and lanugo Normal color- CLEAR/ slightest yellow color or pale yellow FUNCTIONS OF AMNIOTIC FLUID 1.protection from trauma 2.maintains temperature 3.prevents cord compression 4.helps in delivery 5. fetal drink 6. for musculoskeletal development Normal Volume: 500-1000ml or 700-1000ml or 800-1200ml #Less than 500 ml AFTER 20 WEEKS= oligohydramnios Indication= FETAL KIDNEY PROBLEMS #More than 1500ml AFTER 20 WEEKS= polyhydramnios Indication= 1. FETAL GIT PROBLEMS (TRACHEOESOPHAGEAL ATRESIA= closed esophagus, TRACHEOESOPHAGEAL FISTULA= the closed esophagus is connected to trachea) 2. GDM, 3. Multiple Pregnancy pH= 7-7.25- neutral to slightly alkaline NITRAZINE PAPER TEST= pH paper BLUE/GREEN = alkaline= amniotic fluid YELLOW = acidic= urine GREEN AMNIOTIC FLUID= MECONEUM STAINING. Report if the presentation is cephalic and transverse. Consider it normal if the presentation is breech. GOLDEN YELLOW AMNIOTIC FLUID= due to destruction of fetal RBCs= BILIRUBIN (erythroblastosis fetalis) SK- RH INCOMPATIBILITY- Mother is RH negative and Fetus is RH positive NOTES: If the mother and the fetus are both RH Negative= COMPATIBLE If the Mother and the fetus are both RH positive= COMPATIBLE If the mother is RH positive and the fetus is RH negative = COMPATIBLE On 28th week Rhogam will be given as prophylaxis. Within 48-72 hours after placental delivery, Rhogam will be given to prevent antibody formation, rh sensitization. Before giving Rhogam, Check INDIRECT COOMBS TEST If the result is ( - indirect ) no antibody formation yet=give Rhogam If the result is ( + indirect ) with antibody formation= do 15 4. Velamentous Cord Insertion- the umbilical cord inserts into fetal membrane. The vessels of the umbilical cord are improperly inserted in chorioamniotic membrane. The expose vessels are not protected by Wharton’s Jelly, hence are vulnerable to damage or rupture and blood vessel compression decreasing the blood supply to the fetus. Risk Factor= nulliparity Complication= Vasa Previa (vessels in the way, before the baby). Fetal vessels running or crossing in close proximity to the inner cervical os. Management= CS at 35 weeks. ABNORMAL IMPLANTATION OF THE PLACENTA = CRETAS. Cretas occur due to incompletely developed fibrinoid Nitabuch Layer- SPECIALIZED LAYER ON THE FUNDUS PREVENTING IMPLANTATION TO MYOMETRIUM Risk factors 1. Previous CS 2. Placenta Previa 3. Other uterine surgery 4. Advanced maternal health 5. High gravidity 5 OR MORE 6. Previous curettage Placenta Accreta Implantation of placenta into the myometrium. Placenta Increta Deeper implantation to myometrium. Placental villi penetrate the uterine muscle. Placenta Percreta Invasion to perimetrium. The placental villi penetrate the myometrium to uterine serosa/PERIMETRIUM. NOTE: Placenta Cretas cannot be diagnosed during pregnancy. PLACENTAL HORMONES FUNCTIONS and EFFECTS HCG- human chorionic 1. prolongs the life of corpus luteum for the 1st 6-8 weeks gonadotropin 2. basis for pregnancy= PROBABLE SIGN Gradually increase until around 10 weeks 60,000 to 140,000 m IU / ML then declines sharply PRODUCED BY SYNCYTIOTROPHOBLAS T 2. HPL- human placental lactogen HUMAN CHORIONIC SOMATOMAMMOTROPIN Function- anti insulin hormone. During pregnancy, the needs of the fetus increase glucose production by the maternal liver. The placental hormones increase insulin resistance. Since the pancreas cannot produce enough insulin, hyperglycemia develops. This delicate balance in carbohydrate metabolism during pregnancy puts a stress on the pancreas known as the diabetogenic effect of pregnancy. All placental hormones are anti-insulin. insulin utilization during pregnancy- DECREASES 16 3. RELAXIN It increases joint mobility. The gait of a pregnant woman is waddling gait. Too much relaxin production can be a factor for the development of congenital hip dysplasia to the fetus. 4. ESTROGEN VASCULARIZATION =increase in blood supply a. Uterine Soufflé= sound created due to the rush of blood to dilated uterine arteries. 28 weeks, maternal pulse b. Funic Soufflé= sound created due to the rush of blood to umbilical arteries. Synchronous to the fetal heart beat. 28 weeks. It guarantees fetal life c. CHADWICK’S SIGN- bluish discoloration of vagina, cervix, vulva and perineum due to vasocongestion #starts on 4th week or 6th week d. NASAL CONGESTION/stuffiness, GUM PAIN, PALMAR ERYTHEMA EXPANSION OF BLOOD/ INCREASED BLOOD VOLUME starting on last week of first tri ENLARGEMENT OF UTERUS= hypertrophy to myometrium Non pregnant weight= 50-60 grams non pregnant shape: pear shape/inverted avocado Pregnant weight = 1000-1100 grams containing a maximum of 5kgs . SECRETIONS = LEUCORRHEA (whitish vaginal discharge due to WBC increase) OPERCULUM (cervical mucus plug) due to hyperplasia to mucosal glands of the cervix. It has BACTERIOSTATIC EFFECT EXCESSIVE SALIVATION (PTYALISM) mgt. MOUTHWASH SOFTENING OF CERVIX GOODELL’S SIGN DUE TO EDEMA FORMATION ON CERVIX starts on 6 WEEKS SOFTENING OF LOWER UTERINE SEGMENT= HEGAR’S starts on 8TH WEEK #SK ON LABOR The Cervix will not dilate if it is FIRM. The Isthmus on labor RELAXES because of Hegar’s sign. 5.PROGESTERONE Muscle relaxant Decreases peristalsis. For mammary gland development (as early as 3-4 months, colostrum production begins) Fluid retaining hormone Increases BBT= normalizes on 4th month COMMON DISCOMFORTS OF PREGNANCY DISCOMFORT RELIEF MEASURES 1. Morning Sickness common on first tri Eat dry crackers 30 minutes before arising, suck on popsicles, 17 due to hcg eat small frequent meals separate liquids from solids alternate every 2-3 hours ginger tea/ale 2. Heartburn / Chalasia due to relaxin or progesterone Maintain on upright position after eating. Avoid highly seasoned food. Avoid sweets. Avoid fatty and fried foods 3. Flatulence due to Progesterone Avoid gas forming food (root crops etc), . Avoid sweets. 4. Urinary Frequency (first tri and 3rd tri) due to uterine enlargement Limit caffeine because they are bladder irritants (less than 200 mg per day. This is equal to about one 12oz. cup of coffee) High levels of caffeine in pregnancy can result in babies having LBW. 5. Fatigue due to increased metabolic requirements Increase amount of rest and sleep. Go to bed earlier. 6. Constipation due to progesterone( muscle relaxant) Increase fluid and fiber, no laxatives and enemas, mild stool softeners are allowed as prescribed for intermittent constipation 7. Supine Hypotension due to enlarged uterus Lie on left side 8. #Leg cramps due to Low Calcium Increase calcium 1000-1200mg/day. Increase Vit. D for calcium absorption with sun exposure and dorsiflexion – to stretch the muscles affected (immediate relief) 9. Varicose veins Due to enlarged uterus Elevate the legs higher than the heart. Ambulation, panty hose. Don stockings before standing. Do not use knee-high hose 10.#Back pain Due to enlarged uterus Sleep on #Firm mattress, pelvic rocking exercise 11. Pedal edema= N Due to enlarged uterus and low protein due to fetal consumption Increase protein 60 grams per day 12. Shortness of Breath Due to enlarged uterus Maintain proper posture when sitting, elevate the head when lying down 13.#Hemorrhoids Due to enlarged uterus Warm sitz bath and #cold compress to reduce swelling, push by gentle finger pressure, lie with legs elevated 14. Increased vaginal discharge Bathe daily, wear cotton underwear, avoid douching, nylon panties and panty hose 15. Breast tenderness due to E and P Wear a well-fitting bra 16. Vena-caval syndrome Avoid lying flat on the back, elevate head of the bed, place a small pillow under the right hip to prevent hypotension when woman needs to be in a back- lying position. 17. Difficulty sleeping Drink a warm caffeine-free beverage before bedtime, relaxation techniques. 20 FHT 1. CEPHALIC Below the umbilicus 2. BREECH Above the umbilicus 3. TRANSVERSE Near the umbilicus ANTEPARTAL PERIOD: Duration of pregnancy Days= 267-280 days Weeks= 37-42 weeks 21 Calendar months= 9 Lunar months= 10 ESTIMATING the EXPECTED DATE OF BIRTH 1. Frequency of Prenatal Visit: 1st tri =1 (BEFORE 4 MOS) 2nd tri = 1 (6TH MONTH) 3rd tri = 2 (8TH MONTH AND 9TH MONTH) ESTIMATING the AGE OF GESTATION= LUNAR MONTH RULE FORMULA 1. BARTHOLOMEW’S RULE ✓ Starts on 3rd month ✓ Rule of 4 ✓ Position of the woman= Dorsal Recumbent 2. MC DONALD’S RULE ✓ Starts on 5TH MO ✓ Instruct the mother to void. just below xiphoid process= 36 weeks 2 fingers below the xiphoid process= 40 weeks due to LIGHTENING At the level of Umbilicus= 20 weeks Midway between SP and U= 16 weeks Just above the symphysis pubis= 12 weeks AOG in weeks= FH in cm x 8/7 AOG in months= FH in cm x 2/7 3. FUNDIC HT in CENTIMETERS Starts on 5TH MO 20-36cm = 20-36 weeks of pregnancy Affecting Factors 1. Obesity 2. Volume of amniotic fluid 3. Multiple pregnancy 4. GDM ESTIMATING the FETAL LENGTH in CENTIMETERS RULE FORMULA HAASE’S RULE First 5 lunar months = MONTH X MONTH= EFL in cm 6-10 lunar months = month x 5= EFL in cm Estimated Fetal Weight Weeks Weight RULE FORMULA MOST POPULAR RULE= NAEGELE’S RULE #LMP= FIRST DAY OF LAST MENSTRUAL PERIOD If LMP is January to March= =+9mos +7days +the same year If LMP is from April to December= -3mos +7days +1year Example: the last day of LMP of client was Feb. 14. And her period lasted for 5 days. When do u expect her to give birth? NOVEMBER 17 2. if LMP is unknown? Use the DATE OF QUICKENING PRIMI= Date of QUICKENING (5TH MO) + 4 months= EDB MULTI= Date of QUICKENING (4TH MO) + 5 months= EDB 22 12 weeks 45 grams 20 weeks 1 lb / 435 g 24 weeks 1.5 lbs / 680 g 28 weeks 2.5 lbs / 1200 g 36 weeks 5 to 6 lbs / 1800-2800g 40 weeks 6.5 to 8lbs / 3000- 3600g 2500- 4000g= Normal >4000g= Large <2500= Small <1500g= very small OBSTETRICAL NOTATION NULLI= never PRIMI=one or first MULTI= 2 or more GRANDMULTI= 5 or more CASES GRAVIDA PARA Ectopic pregnancy H mole Abortion Yes Yes Yes No No No Stillbirth- a fetus born 20 wks. and above without life. Yes Yes Present pregnancy Yes No Twins, triplets yes Counted as 1 after delivery T-erm infant- born 37 weeks and above dead or alive P-reterm infant born 20 weeks -36 weeks dead or alive A-bortion- termination of Pregnancy less than 20 weeks. Miscarriages, ectopic pregnancy and molar pregnancies are included here. L-iving M- ultiple pregnancy Sample Exercises: 1. A pregnant client reveals two pregnancies delivered prematurely, both living, one pregnancy aborted, one pregnancy delivered term, living. And one stillbirth at 43 weeks. What is the GP TPALM score? G6 P4, T2 P2 A1 L3 Mpreg 0 2. The woman is pregnant for the second time. Her first pregnancy was the birth of her twins at 35 weeks living. G2 P1 T0 P2 A0 L2 Mpreg1 #WEIGHT GAIN DURING PREGNANCY Para = total number of births 20 weeks and above, irrespective of outcome Gravida = total number of pregnancies, irrespective of outcome, regardless of AOG 25 Hematocrit decreases, to prevent drop Increase Iron. Physiologic Anemia of Pregnancy or Pseudoanemia/ false anemia Increase in WBC count on pregnancy is NORMAL due to Estrogen Increase in WBC count on the first 24 hours after delivery is NORMAL Increase in the Heart Rate during pregnancy NORMAL Mild Tachycardia during pregnancy is NORMAL During Pregnancy, there is also an increase in platelet and fibrinogen clotting factors of the mother CLASSIFICATION OF CARDIAC PROBLEMS CLASS 1 =no limitations. PREGANCY IS ALLOWED, NSVD IS ALSO ALLOWED CLASS 2 =slight limitations. PREGANCY IS ALLOWED, PUSHING IS NOT ALLOWED CLASS 3 =marked limitation. No Pregnancy CLASS 4 =marked limitation. No pregnancy Respiratory System The mother changes from being abdominal breather to thoracic breather The lungs adjust to provide increased amount of oxygen. The lungs expand laterally; ribs flare out slightly Increase tidal volume (30-40%) due to progesterone, increase partial oxygen. Increase inspiratory capacity. Decrease partial carbon dioxide. Decrease expiratory capacity. ##The pregnant woman has respiratory alkalosis. Diaphragm is displaced upward RR increases Total oxygen consumption increases by 20 % to meet fetal needs Nasal congestion due to ESTROGEN. Tendency to hyperventilate. Skin- All skin changes are presumptive starting on 5TH MONTH Phlegmasia alba dolens known as MILK LEG is most often seen during 3RD TRI resulting from compression of the left iliac vein against the pelvic rim by the ENLARGED UTERUS. Linea Nigra, Chloasma, Striae Gravidarum GIT System A hypotonic gastrointestinal tract. DUE TO PROGESTERONE The smooth muscle of stomach and intestines relaxes due to PROGESTERONE The stomach is compressed upward and backward. Delayed emptying. Decrease hydrochloric acid. Gall bladder is influenced by Estrogen and become hypotonic. Increased concentration of bile which can lead to gallstones. Urinary- Kidneys increase renal plasma flow by 30-50% Glomerular filtration rate by 50% Urine output 25% Increased urination (1st tri and 3rd tri) Increased bladder capacity and decrease the tone due to the influence of PROGESTERONE (2nd tri), dilated ureters, decrease glucose threshold due to increased renal blood flow = +1 glycosuria despite normal sugar during pregnancy 26 Musculoskeletal- The hormones RELAXIN and PROGESTERONE soften and relax the ligaments and joints of the pelvis. (WADDLING GAIT) The enlarging uterus may cause diastasis recti, the separation of the rectus muscles of the abdominal wall. This may persist in the postpartum period until the muscle tone of the abdomen is regained. Lordosis (LIYAD), low back pain, waddling gait, leg cramps Reproductive System The uterus increases 20 times The cervix softens, more vascular, and produces increased mucus= Estrogen Mucus plug seals the cervix Egg production stops in the ovaries= due to suppression of FSH and LH The vagina increases vascularity, mucosa thickens Vaginal secretions become more acidic 3-4pH= due to estrogen Contraindications to Exercise during pregnancy 1. Incompetent cervix 2. Intrauterine growth restrictions 3. Pre-eclampsia 4. PROM 5. History of preterm labor 6. Persistent second and third trimester bleeding 7. Multiple gestation 8. No exercise should be performed in a supine position after the third month. 9. Valsalva maneuver is to be avoided TRIMESTERS OF PREGNANCY 1ST TRI (1-14 weeks) 2ND TRI (15th-28th week) 3RD TRI (29th- 42nd week) TASKS Acceptance of pregnancy Ambivalence – 2 opposing feelings Acceptance of the baby Quickening Childbirth preparation Nesting period MOST critical comfortable Rapid growth FOCUS organogenesis Fetal length Fetal weight gaining Estrogen LEVEL increasing increasing increasing Progesterone LEVEL increasing increasing Decreasing slowly in preparation for LABOR BP LEVEL Pre-pregnant level Decreases slightly due to vasodilation Increased BP before 20 weeks- H-mole Increased BP after 20 weeks- PIH Returns to baseline or Pre-pregnant level WT. GAIN- SINGLETON PREG. 1 lb. per mo 1 lb. per week 1 lb. per week URINARY FREQUENCY Increase due to enlarged uterus normal Increase due to lightening / baby drop(settling of presenting part) 27 SEXUAL DESIRES Decrease due to bodily increase Decrease due to very changes large uterus BLEEDING DISORDERS Ectopic Pregnancy Incompetent cervix Placenta Previa Abortion H mole Abruptio Placenta PREGNANCY INDUCED HYPERTENSION CAUSE= vasoconstriction of unknown etiology WHEN= after 20 weeks FORMER NAME= Toxemia TYPES • Gestational HPN- HPN after 20 weeks • Pre-Eclampsia- with edema and proteinuria • Eclampsia – with convulsion (tonic-clonic seizure) 3 MAJOR SYMPTOMS P roteinuria I dima H PN MAJOR BODY PARTS affected B- rain (CNS irritation and HYPERREFLEXIA) U- terus (Uteroplacental insufficiency which can lead to, IUGR, Fetal distress, LBW, Malnutrition, Abruptio placenta) K- idneys (Oliguria and Proteinuria) MILD PRE ECLAMPSIA SEVERE PRE ECLAMPSIA BP 140/90 Or +30 Systolic +15 Diastolic 160/110 Or +50 Systolic +30 Diastolic proteinuria +1 +2 +3 +4 Edema digital periorbital weight gain= first sign 2 lbs./week 5 lbs./week urine output More than 500 cc in 24 hours Less than 500 cc in 24 hours visual disturbances none Scotomata- spots before the eyes Blurring of vision halos epigastric pain none Aura for convulsion headache Occasional Persistent COMPLICATIONS H- 30 hours BUT NOT MORE THAN 14 HOURS. FBS= 105mg/dl One hour= 190 mg/dl 2-hour= 165mg/dl 3-hour = 145mg/dl 31 FBS will be taken The mother will take 100g oral glucose solution then blood glucose will be monitored at 1, 2, 3 hours. BASIS GDM is positive if 2 or MORE values met or exceeded GDM is borderline abnormal if only ONE value met or exceeded GDM is negative if NO value met. EXAMPLE Mrs. A= has GDM FBS= 100. Mrs. B= is borderline abnormal (repeat the test after 1 month) FBS= 90 1hr= 200 2hr= 150 3hr=135 Mrs. C= has NO GDM FBS=90 1Hr= 170 2hr= 151 3hr= 120 The therapy for GDM is= DIET DISTRIBUTION OF CALORIES 45% CARBOHYDRATES 20% PROTEIN 35% FAT If diet is inadequate = insulin Oral diabetogenic (metformin) drugs during pregnancy are not allowed! PERINATAL INSULIN NEEDS FIRST TRI= decreased due to inhibition of anterior pituitary hormones, growth of the embryo, decreased maternal intake. SECOND TRI= gradually increases due to insulin-resistant properties of placental hormones. THIRD TRI=continue to increase until 36 weeks then may decrease slightly as placental functioning diminishes. LABOR AND DELIVERY=decreases during active labor (4cm- 7cm) due to increased metabolism. The only type on insulin that can be used during labor is regular 1h= 210. 2hr= 190. 3hr= 152. 32 insulin POSTPARTUM=rapidly decreases because of the loss of placental hormones. BREASTFEEDING=decreased because of carbohydrate use in milk production. 35 2. snowstorm pattern seen in UTZ 3. passage of vesicles 4.excessive hcg 5.hyperemesis gravidarum 6.HPN before 20 weeks 36 7.no fetal heart tone 8.ovarian enlargement 9.prune juice/ brown bleeding (usually intermittent or continuous but not profuse). When molar tissues start separating from the uterus, bright red bleeding may result 10. a partial mole may present with signs of incomplete or missed abortion which include irregular vaginal bleeding and no FHR. TYPES OF H-MOLE PARTIAL H-MOLE COMPLETE H-MOLE Localized areas of chorionic villi become hyperplastic and avascular 69, (XXY, XXX, XYY) Triploid karyotype, One set of chromosomes of maternal in origin and 2 sets of paternal in origin (Dispermy) There is an embryo/fetus and an amniotic sac with multiple congenital anomalies and never matures Generalized areas of the chorionic villi become hyperplastic and avascular 46, Diploid karyotype, A sperm fertilizes an ovum with no genetic material Androgenesis (duplication of paternal set of chromosomes) History of clomid, No embryo. No Fetus, No amniotic sac High risk for choriocarcinoma= after surgical evacuation of a complete H-mole, there is 20 percent risk for developing cancer. Diagnostic test: transvaginal ultrasound and serum hCG MANAGEMENT Remove the moles = suction evacuation/D and C. Oxytocin after evacuation. Do not give oxytocin before surgery because of the increased risk for trophoblastic embolization follow up visits= 1. check hcg levels monthly for 6 months 2. regular chest X-ray 3. regular pelvic examinations anti-cancer drugs. Actinomycin D or Methotrexate Other considerations • No pregnancy for at least 1 year. Recommend to use contraception. • Abdominal Hysterectomy if no plans of future pregnancies. INCOMPETENT CERVIX- if the cervix shortens below 37 20mm T= a normal cervix without any funneling 40 AMNIOCENTESIS- insertion of ultrasound guided needle through the maternal abdomen into the uterine cavity to obtain a sample of amniotic fluid. Invasive= CONSENT. Full bladder before Ultrasound FOR BETTER VISUALIZATION Empty the bladder before amniocentesis TO PREVENT BLADDER PUNCTURE Position= SEMI FOWLER’S OR LEFT SIDE TO PREVENT HYPOTENSION. Can detect NEURAL TUBE DEFECT (SPINA BIFIDA) on 16-18 weeks of pregnancy. Increased AFP (ALPHA FETOPROTEIN) = NTD. To prevent NTDs = FOLIC ACID Low AFP= Down Syndrome AFP determination should be done BEFORE 20 WEEKS for accurate results. IF DONE AFTER 20 WEEKS= FALSE HIGH AFP Amniocentesis can detect Lung Maturity on 35-36 weeks of pregnancy. (L/S RATIO and PG determination) ULTRASOUND- uses high frequency sound waves to visualize the fetus, placenta, umbilical cord, and amniotic fluid, gestational age, fetal growth, fetal abnormalities, number of fetuses, umbilical artery blood flow. Non- invasive For Abdominal UTZ= full bladder for transvaginal Ultrasound= Empty the bladder NON STRESS TEST- measures the response of the FHR to fetal movements, non-invasive, done on 28 weeks and above, done usually after breakfast. Position= Semi Fowler’s TO PREVENT HYPOTENSION Goal- 2 FMs in 20 minutes Interpretations Reactive- good/normal result. an increase of 15 bpm or more to the baseline FHR lasting for 15 seconds in each FM in a 20-minute period. (EXAMPLE= Baseline FHR + 15 bpm lasting for 15 seconds). No need for CST Non-Reactive- Abnormal result, Needs Contraction stress test If the fetus didn’t move= uninterpretable. CONTRACTION STRESS TEST – measures the response of the fetal heart rate to controlled contractions. Invasive, needs consent, Done on 32 weeks and above, done in a hospital setting. Other Terms: BSST= Breast Self Stimulation Test/ Oxytocin Challenge test invasive Position= Semi Fowler’s Goal- 3 contractions in 10 minutes Interpretations Negative= absence of late decelerations, normal, good sign. The fetus can withstand the stress of contraction Positive= presence of late decelerations (presence of uniform image), Abnormal, bad sign, the fetus cannot withstand the stress of contraction, poor O2, the baby will be delivered via CS. Contraindications= Previous Classical CS, History of Abruptio placenta, History of PROM, History of Preterm Labor, Current Placenta Previa and Multiple pregnancy Reactive NST= no need for CST, good Oxygenation, NSD allowed Non reactive NST= needs CST Non reactive NST + Positive CST= CS, NSD not allowed Non reactive NST + Negative CST= NSD is allowed BIOPHYSICAL PROFILE= utilizing ultrasound to check Fetal O2 in 20-30 minutes. Done 28 weeks and above, non invasive 5 variables (1-4- needs UTZ, except NST) 1. Fetal breathing movement- at least one episode of 30 seconds fetal breathing movement 2. Gross fetal movement- 3 or more discreet movements 3. Fetal tone- at least one episode of flexion and extension 41 4. Amniotic fluid volume- one or more pockets 5. NST- reactive Total Score 8-10 = Normal 6= Equivocal 4 and below= deliver ASAP, diminished O2 THE INTRAPARTAL PERIOD REAL CAUSE: unknown The woman in labor is called: Parturient- laboring woman Theories of Labor 1.Uterine stretch Theory/ Uterine Myometrial Irritability = most acceptable due to estrogen 2.Prostaglandin Theory= arachidonic acid 3. Progesterone Deprivation Theory 42 4.Aging Placenta starting on 36 weeks 5.Oxytocin Theory due to stimulation of PPG Preliminary signs of labor LIGHTENING/BABY DROP Signs- increase urinary frequency, shooting pain radiating to legs (pressure to sciatic nerve), relief of dyspnea,(no more pressure to diaphragm) increase vaginal discharges. It occurs 2 weeks before labor for PRIMI and 0ne day for MULTI. Braxton hick’s contraction- Tightening/pulling sensation over the pubic bone sensation Mgt- walk weight loss 1-2 weeks before labor 1-2 lbs due to loss of progesterone ripe cervix Buttersoft means the cervix is ready to dilate. increasing energy due to epinephrine ROM Occasional sign SIGNS OF TRUE AND FALSE LABOR CRITERIA TRUE LABOR FALSE LABOR contraction 3 contractions in 10 minutes, increasing decreasing discomfort Increasing (starts from the back and radiates to abdomen) decreasing cervix with changes DILATATION- widening of external os. Most essential sign of true labor. Do IE every 4 hours starting on active phase/4cm, cervical dilatation is one cm per hour. EFFACEMENT- thinning of the cervical canal (original length is 2cm) 2cm=0 % 1.5cm= 25 % 1cm= 50% .5cm=75% Paper thin=100% MULTI=D and E occur simultaneously PRIMI= Effacement first before dilatation. Precipitate Labor= labor and delivery in less than 3 hours Common to MULTIPARA At risk= laceration, cephalhematoma Mgt. Panting techniques= blowing in each exhale to no changes 45 minus ruptured No 0 +1 +2 ruptured Yes 0 +1 +2 intact Yes +3 +4 +5 ruptured/ intact No DECELERATIONS TYPES COMMON CAUSE And Management EARLY Normal Contraction- Head compression- stimulates vagal nerve- decrease FHR. Mirror image. NO need to reposition the mother. Continue monitoring LATE Abnormal Utero placental insufficiency. Uniform image. Reposition the mother to LEFT SIDE to improve venous return Seen to patient with Abruptio Placenta and PIH VARIABLE Abnormal Cord compression. Unpredictable image. Reposition the mother to MODIFIED TRENDELENBURG to decompress the cord. Seen to patient with placenta previa SIGNS OF FETAL DISTRESS less than 120 FHR or more than 160 FHR hyperactive fetus due to lack of O2 meconium staining except for Breech UNNECESSARY INTERVENTIONS TO THE MOTHER Pubic hair shaving IV infusion Amniotomy= artificial rupture of membrane NPO Oxytocin Augmentation Fundal push Enema Episiotiomy = 3 indications 1. Tight perineum 2. Large baby 3. Forceps delivery Two types 1. Median= is only indicated if the perineum is long. less pain, less bleeding, heals faster, easier to repair 2. Mediolateral= more common. more pain, more bleeding, slow to heal, difficult to repair strict supine position= Upright position is recommended STAGES OF LABOR 1ST STAGE OF LABOR/ CERVICAL DILATATION STAGE LATENT ACTIVE TRANSITION DILATATION 0-3 cm 4-7cm 8-10cm DURATION 20-40 sec 40-60 sec 60-90 sec FREQUENCY Every 5-10 minutes Every 3-5 minutes Every 2-3 minutes INTENSITY Mild moderate strong BEHAVIOR excited Fear of losing control Resistance to touch 46 CONSIDERATIONS Give instructions Give analgesia/pain relievers Do not give during latent phase= it will prolong labor reassurance Do not give it on transition phase= no value to the mother What is UTERINE TETANY = contraction of 2 minutes. At risk for fetal distress 2ND STAGE OF LABOR= FETAL EXPULSION STAGE temperature of delivery room 25-28 degree Celsius transfer to delivery room Primipara 10cm Multipara= 7-8cm wear double sterile gloves wash hands just before delivery most common birthing position lithotomy but at risk for hypotension best birthing position dorsal recumbent surest sign that the baby is about to be delivered bulging of the perineum= check the perineum when to push during contractions, fully dilated cervix when not to push not fully dilated cervix, intervals, delivery of the head MECHANISMS OF LABOR o engagement o Descent (because of fundal contraction) o Flexion (from moderate flexion to complete flexion) o Internal rotation o Extension= delivery of the head (do not push) the best time to deliver the head is at interval o External rotation o Expulsion (anterior shoulder delivers first) UNANG YAKAP (ENC) Time bound interventions Non immediate interventions Unnecessary interventions 1. Dry= first 30 seconds of life to prevent hypothermia 2. Skin to skin contact= first 30 seconds to prevent hypothermia 3. Properly-timed cord clamping= between 1-3 minutes. To prevent anemia 4. Non separation Vitamin K to prevent bleeding. Crede’s Prophylaxis to prevent opthalmia neonatorum or gonorrheal conjunctivitis. Bathing not earlier than 6 hours. Removal of the Vernix not earlier than 6 hours Turning upside down Slapping Hanging Chest compression Cord milking Cord bandaging Routine Separation Suctioning Putting alcohol and betadine on the cord Foot printing 47 Side Knowledge If newborn skin is pink and amniotic fluid is green= acute hypoxia If newborn skin is green and amniotic fluid is green= chronic hypoxia= seen to post term babies If newborn skin is pink on the first day and turns yellowish on second day=normal, physiologic jaundice Time bound interventions Non immediate interventions Unnecessary interventions 1. Dry= first 30 seconds of life to prevent hypothermia 2. Skin to skin contact= first 30 seconds to prevent hypothermia 3. Properly-timed cord clamping= between 1-3 minutes. To prevent anemia 4. Non separation Vitamin K to prevent bleeding. Crede’s Prophylaxis to prevent opthalmia neonatorum or gonorrheal conjunctivitis. Bathing not earlier than 6 hours. Removal of the Vernix not earlier than 6 hours Turning upside down Slapping Hanging Chest compression Cord milking Cord bandaging Routine Separation Suctioning Putting alcohol and betadine on the cord Foot printing 50 Taking-hold (4th to 6th day) Active independent phase Health teaching on newborn care Letting go (7th day and above) Collaborative phase Interdependent phase Health teaching on responsible parenting/family planning. OTHER NOTES 1. the placental site is healed by 6 weeks 2. a new endometrium is formed 3 weeks after delivery 3. lochia is heavier in the morning 4. Lochia rubra (1-3 days, moderate in amount, red in color) 5. lochia serosa (day 4- day 9), 456= pink, 789=brown 6. lochia alba (day 10-21) whitish in color 7. sex can be resumed when lochia flow has stopped and episiorrhaphy is healed. 8. cervix after delivery= transverse slit 9. the use of old diaphragm and old cervical cap after delivery is not allowed 10. vagina returns to pre pregnant state by 6 weeks 11. for non- lactating mother, ovulation resumes after 6-8 weeks 12. for lactating mother, ovulation resumes after 6 months because prolactin inhibits ovulation. 13. Lactation Amenorrhea Method is only effective on the first 6 months 14. All contraception with estrogen are not allowed for Lactating Mothers. 15. Progesterone Only Pill (POP) is safe for lactating mothers. 16. WBC is increase if labor is prolonged 17. hunger will start to increase 2-3 hours after birth 18. first bowel movement normally occurs by 2-3 days postpartum. 19. immediate weight loss after delivery 12-15 lbs 20. weight loss in the 1st week 5 lbs 21. loss in the next 6 weeks 10 lbs 22. most women return to their pre-pregnant weight by 6 mos. 23. the best schedule for breastfeeding per demand 24. the protein found in breast milk is lactalbumin 25. the protein found in cow’s milk is casein 26. What are the 3 Es of Breastfeeding EARLY, EXCLUSIVE, EXTENDED? 27.#the best breastfeeding hold for a term infant born vaginally. CRADLE 28.#the best breastfeeding hold for a preterm infant born vaginally. CROSS CADLE 29.#the best breastfeeding hold for an infant born CS CLUTH/FOOTBALL 30.#the best breastfeeding hold for twins FOOTBALL 31.#the best breastfeeding hold for a woman with large breast FOOTBALL 32.#the best breastfeeding hold for a woman recovering from a difficult delivery SIDE LYING 33. the most intimate breastfeeding hold is KOALA 34. is Mastitis a contraindication for Breastfeeding? NO 35. Is Breast engorgement a contraindication for breastfeeding? NO 36. Burp the baby MIDDLE AND END of feeding 37. Best hold for burping SHOULDER HOLD 38. Breastmilk at room temperature should be consumed 8-19 HOURS 39. Refrigerated Breastmilk should be consumed 24-48 HOURS 40. Breastmilk on freezer can be consumed up to 3 MONTHS 41. Breastmilk on deep freezer can be consumed up to 6 MONTHS 42. The universal language of infant CRYING 43. Capacity of infant’s stomach = Age in months + 2 ounces. 1 OUNCE IS EQUIVALENT TO 30 ML. 51 Let GOD write your story… Congratulations! 52