Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
0he
mos
t
imp
orta
&t
topi
c i&
a
+re&
atal
+reme&strual
Sy&drome
6me&orrhea (e&orrha"i
a
(etrorrha"ia
16
MALE C-ND-MIUDD
/eHuires withdrawal of the pe&is
from the va"i&a before /elies
o& absti&e&ce from i&tercourse
duri&" fertile period-.dema of
lower e1tremities- +rimary-
-8le1ible device i&serted i&to the
uteri&e cavity
-!t alters uteri&e tra&sport of the
sperm so fertili2atio& do&Et
occur
,AN-$ SI-NS "O $PO"1
. Late or missed menstrual period
.Se#ere abdominal pain
.%e#er and chills
. %oul #a*inal dischar*e
.Spottin*3 bleedin*3 or hea#y
menstrual periods
. Spontaneous e@pulsion occur in
AB.9CB of users in the first
year
- /ubber sheath that fits
over the erect pe&is a&d
preve&ts sperm from
e&teri&" the va"i&a
- 5o&" polyuretha&e sheath
that is i&serted ma&ually
i&to va"i&a with a fle1ible
i&ter&al ri&" e1te&di&" to
cover the peri&eum
- 5ubricated with a
spermicide :&o&-o1y&ol-
A;
- !t ca& be i&serted up to =
hrs before i&tercourse
1. 1a%%ie% Met!o&s
)EMALE C-ND-M
:;AGINAL -UCH;
eaculatio&
- 6bdomi&al bloati&"
- %ei"ht "ai&
- 7eadache
--reast te&der&ess
- ?epressio&
- 3ryi&"
- 5oss of co&ce&tratio&
*o '&ow& cause
- Seco&dary-
(ay be caused by
D (easured by ta'i&" &
recordi&" e temperature rally
rectally each mor&i&" before
wa'i&" after at least 3 hours of
sleep
D ?rops before ovulatio& a&d
rises B#2 8-B#= 8
In (asal body temperature
method the patient should ta8e
her temperature e#ery mornin*
upon a)a8enin* and prior to any
acti#ity to a#oid the temperature
bein* influenced by other factors.
D ,ses the appeara&ce,
characteristics a&d amou&t of
cervical mucus to ide&tify
ovulatio&
)vulatory< cervical mucus is clear
a&d abu&da&t
+re-ovulatory / post ovulatory<
cervical mucus is yellowish,
less abu&da&t, a&d stic'y
:i&hibit sperm motility;
.
D
3ou
ple
ma'
es
use
of
com
bi&at
io&
of
cale
&dar,
--0
, a&d
cervi
cal
muc
us
meth
od to
deter
mi&e
fertil
e
perio
d
1$
tumor/i&flammatory co&ditio&s
C 1et<een menst%'al cyclesD some <omen e+$e%ience $ain
<!en t!e o(a%y %eleases e""
8i"ure 1-d 3o&dom
C
E
R
;
I
C
A
L
C
A
D
I
A
H
R
A
G
M
:
)
i
"
'
%
e
#
9
e
*
C
E
R
;
I
C
A
L
C
A
;
S
D
I
A
NCLE@ TISEE
T!e female con&om &'%in" se+
)i"'%e #9&
?uri&" se1 the pe&is is i&serted i&to the ce&ter of the ope& ri&" at the ope&i&" of the va"i&a# ,&til both
part&ers are familiar with the /eality co&dom, the pe&is should be "uided by ha&d i&to the ope& ri&"#
)therwise there is the cha&ce that the pe&is will be i&serted outside the co&dom i&to the va"i&a, thus
defeati&" the co&domIs purpose# ,se of the male co&dom with the female co&dom is &ot recomme&ded,
because rubbi&" the late1 male co&dom a"ai&st the polyuretha&e female co&dom creates frictio& that may
ma'e i&tercourse difficult#
Remo(in" t!e female con&om
0he female co&dom should be removed followi&" i&tercourse a&d before sta&di&" up# 0o remove, sHuee2e
a&d twist the outer ri&" to e&sure that seme& remai&s i&side the co&dom# 4e&tly pull the co&dom from the
va"i&a# ?iscard i& the trash# ?o &ot attempt to flush the co&dom dow& the toilet, as it may clo" the toilet or
sewer li&es# ?o &ot reuse#
Im$o%tant $oints to %emembe% <!en 'sin" t!e female con&om
- "he female condom )or8s only if you use it e#ery time you ha#e se@.
. Use a ne) condom each time you ha#e se@ual intercourse. Do not reuse the %e+ale condo+.
. 5ou can still become pre*nant and transmit or ac4uire a se@ually transmitted disease )hile usin* the
female condom. "he ris8 is less than if you do not use the condom3 but there still is a sli*ht ris8.
. Althou*h the eality condom is prelubricated3 it also comes )ith a tube of lubricant in the pac8a*e. 5ou
may )ish to add a fe) drops of lubricant to the openin* of the condom or to the penis. Lubricants reduce
friction and noise those results from friction.
. emo#e tampons before insertin* the female condom.
. Use caution to a#oid tearin* the female condom )ith a sharp fin*ernail3 rin*3 or other ?e)elry )hen
insertin* and remo#in* the condom#
1=
H
R
A
G
M
C
*ot &ecessary for
repeated coitus,se
every
coitus3o&ti&uous
protectio& 24 hours
re"ardless of the
&umber of times of
se1ual i&tercourse)&
two hours prior to
se1ual i&tercourse a&d
i& place for 6 hours
after=BC with typical
use
S+./(!3!?.
,S64.
*,55!+6/6J=BC
(50!+6/6J6BC
?.S3/!+0!)*
Small rubber plastic that fits
s&u"ly over cervi1
8le1ible ri&" covered with dome shape
rubber cap
8
it
t
e
d
b
y
h
e
a
lt
h
p
r
o
v
i
d
e
r
S
a
S!?. .88.30S
1A
m
e
,
r
e
f
it
t
e
d
a
f
t
e
r
b
i
r
t
h
a
&
d
w
e
i
"
h
t
l
o
s
s
o
f
1
5
l
b
s
3
y
s
ti
ti
s
,
c
r
a
m
p
s
,
r
e
2B
c
t
a
l
p
r
o
l
a
p
s
e
d
7
)
%
0
)
!
*
S
.
/
0
"
o
@
i
c
S
h
o
c
8
s
y
n
d
r
o
m
e
0
"
S
S
7
.
8
8
.
3
0
21
!
@
!
0
F
3ervicitis
?,/60!)*
*ot lo&"er tha& 4= hours *ot lo&"er tha& 24 hours
A diaphra*m should be left in the #a*ina
:.; hours after se@ual intercourse.
Dia,hrag+A should remai& i& place 6-= hours after se1 & maybe left for 24 hours#
AL6A5S C+$C= %O "$AS < +OL$SDDD
#ontraindicated %or" %re4uent U"I3 Prolapsed Cord < etro#erted Uterus3 cystocele < rectocele3 acute
cer#icitis
)i"'%e 1-e ?iaphra"m
C. !a%macolo"ic met!o&s
&ral #ontrace,tive Pill A sy&thetic estro"e& combi&ed with small amou&ts of sy&thetic pro"estero&e-
preve&ti&" ovulatio& by stoppi&" 8S7 & 57#
- Stops L+ < %S+
ST- I) ?ITH THE ))< :637.S;
- A. abdominal pain3 #- Chest pain3 *. +eadaches3 E. eye problems < S.se#ere le* cramps
- A""N1 Se#ere +eadaches maybe an indication of +ypertensionDDDD
C-NTRAINDICATEDA
9 "hromboembolism
A C&A3 +PN3 smo8in* < diabetics3,IC3 hyper#iscosity
#ontraindicated %or D)ABE.)#S. "he best for diabetics are (arrier Contracepti#es..Condom <
,iaphra*m
E$a+,les" ?emule& :.thi&yl .stradiol .thyl&odiol ; a mo&ophasic oral co&traceptive a"e&t.
If the patient for*ets to ta8e A tablets for the ne@t A days3 she should ta8e A tablets N$'" A ,A5SDDD
And use another contracepti#e method for the rest of the cycle.
If she misses E or more3 she should discard the remainin* tablets < use another contracepti#e
method for the rest of the cycle.
)/65 3)*0/3.+0!@.S(!*!+!55SS,-?./(65 !(+56*0SS,-3,06*.),S !*K.30!)*S,se to
preve&t co&ceptio& by i&hibiti&" ovulatio& :i&hibits release of 8S7 a&d 57;
3auses atrophic cha&"es i& the e&dometrium to preve&t impla&tatio& of e""
3auses thic'e&i&" of cervical mucus to i&hibit sperm travel
Under ideal conditions the sperm can reach the o#um 9 to F minutes after e?aculation.
3ombi&ed estro"e& a&d pro"estero&e preparatio& i& tablet form a&d are ta'e& daily with combi&atio&s of
hormo&es
22
Oral contracepti#es pre#ent pre*nancy by suppressin* %S+ 0follicle stimulatin* hormone7 and L+
0leuteni2in* hormone7 release from the pituitary *land thereby bloc8in* o#ulation.+ills co&tai& pro"esti& but &o
estro"e&
+ills must be ta'e& each day a&d preferably same time each day to achieve ma1imal effective&ess
0hi&s a&d atrophy e&dometrium a&d thic'e&s cervical mucous
6?@6*064.< ca& be use immediately postpartum if clie&t is &ot breastfeedi&" a&d 6 wee's if breastfeedi&"
6omen ta8in* the minipill ha#e a hi*her incidence of tubal and ectopic pre*nancies3 possibly because
pro*estin slo)s o#um transport throu*h the fallopian tubes. $ndometriosis3 female hypo*onadism3 and
premenstrual syndrome arenGt associated )ith pro*estin.only oral contracepti#es.Si1 soft sillastic rods filled
with sy&thetic pro"estero&e impla&ted i&to the woma&Es arm
+ro"estero&e lea's i&to the blood stream, i&hibiti&" impla&tatio& i&to e&dometrium
*orpla&t
!&serted subdermally i&to the midportio& of the upper arm about =-1Bcm above the elbow crease# 6 impla&table
capsules are i&serted at o&e time(edro1ypro"estero&e :?(+6 or ?.+)@./6;
Birth #ontrol Su++ar/ .a0le
-!/07 3)*0/)5 (.07)?6?@6*064./!SLS )/ +)SS!-5. +/)-5.(S
Spermicides< chemicals i& the form of
foams, creams, ellies, films, or
suppositories that are i&serted i&to the
va"i&a to 'ill sperm before they ca& e&ter
the uterus9 typical use effective&ess< $BC
M 6vailable over the cou&ter
M 3a& be used with other
methods to improve
effective&ess
M )&ly partially effective
a"ai&st se1ually tra&smitted
disease :S0?; tra&smissio&
M +ossible aller"ies or irritatio&
M *ot effective a"ai&st S0?
tra&smissio&M /eusable3ervical 3ap<
thimble-shaped late1 cap i&serted
i&to va"i&a over cervi1 to preve&t
sperm from e&teri&" uterus9 used
with spermicide9 typical use
effective&ess< =2CM *ot effective
a"ai&st S0? tra&smissio&M
/eusable3o&dom< male co&dom is a
sheath of late1 or a&imal tissue
placed o& erect pe&is9 female
co&dom is a plastic sac with a ri&"
o& each e&d i&serted i&to the va"i&a9
both may be used with a spermicide9
typical use effective&ess< =4C
:male; $AC :female;
M *eeds to be fitted by a health care
professio&al
M ?ifficult to fit wome& with a&
u&usual cervi1 si2e
M ?ifficult for some wome& to i&sert
M 3a& last for o&e to two years
C$&ICAL CAP< ca& be retai&ed upto 4=
hours# !t does &ot lea'# 3a&&ot be re-applied
a"ai& after use# (ay use spermicide before
use#
M .ffective a"ai&st S0?
tra&smissio&
M 6vailable over the cou&ter
M 3a& be used with other
methods to further protect
a"ai&st S0?
M +ossible aller"ies to late1 or
spermicide
M 5esse&s se&satio&
M (ay brea' duri&" i&tercourse
#A#oid usin* petroleum ?elly of
oil base productsH it can
cause INC$AS$ %IC"ION
)hich )ill lead to "$AIN-
O% "+$ LA"$' CON,OM#
23
M *eeds to be fitted by a health care
professio&al
M !&creased ris' of bladder i&fectio&
M +ossible aller"ies to late1 or
spermicide
M 3a& last for o&e to two years
-irth 3o&trol +ill< prescriptio& dru"
co&tai&i&" female hormo&es9 o&e pill ta'e&
daily preve&ts ovaries from releasi&" e""s
a&d/or thic'e&s cervical mucus to preve&t
sperm from reachi&" e""9 typical use
effective&ess< A4C?iaphra"m< shallow
late1 cup with fle1ible rim i&serted i&to
va"i&a over cervi1 to preve&t sperm from
e&teri&" uterus9 used with spermicide9
typical use effective&ess< =2C
M (ore re"ular periods
M *o actio& reHuired prior
to se1ual i&tercourse,
permits se1ual
spo&ta&eity
M Some protection a*ainst
o#arian and endometrial
cancer3 noncancerous
breast tumors3 o#arian
cysts
M *ot effective a"ai&st S0?
tra&smissio&
M are but dan*erous
complications3 includin*
blood clottin* and
hypertension3 particularly in
)omen o#er EF years )ho
smo8e
M (ust be ta'e& daily
7ormo&al !mpla&t :*orpla&t;< si1 small
capsules i&serted by a health care
professio&al u&der the s'i& of upper arm
that deliver small amou&ts of hormo&e to
preve&t ovaries from releasi&" e""9 typical
use effective&ess< AAC
M +rotects a"ai&st
pre"&a&cy for up to five
years
M *o actio& reHuired prior
to se1ual i&tercourse,
permits se1ual
spo&ta&eity
M Can be used )hile breast.
feedin* be*innin* si@
)ee8s after deli#erin*
baby
M *ot effective a"ai&st S0?
tra&smissio&
M +ossible scarri&" or, rarely,
i&fectio& at i&sertio& site
M Side effects i&clude irre"ular
bleedi&", headaches, &ausea,
depressio&
M *ot effective a"ai&st S0?
tra&smissio&M .ffective o&e to si1
years, depe&di&" o& type
used7ormo&al !&ectio& :?epo-
+rovera;< in?ection *i#en by a health
care professional in the arm or
buttoc8 e#ery 9A )ee8s to preve&t
ovaries from releasi&" a& e"" a&d/or
thic'e& cervical mucus to 'eep
sperm from reachi&" a& e""9 typical
use effective&ess< AAC
M (ay cause spotti&" betwee& periods a&d
lo&"er, heavier periods
M Increased ris8 of pel#ic inflammatory
disorder0PI,7 )ithin first four months
after insertion
M /are ris' of uteri&e perforatio&
M *o actio& reHuired prior to se1ual
i&tercourse, permits se1ual
spo&ta&eity
M +rotects a"ai&st
pre"&a&cy for 12 wee's
M *o actio& reHuired prior
to se1ual i&tercourse,
permits se1ual
spo&ta&eity
M Can be used )hile breast.
feedin* be*innin* si@
)ee8s after deli#erin*
baby
M +rotects a"ai&st ca&cer of
the uteri&e li&i&" a&d iro&
deficie&cy a&emia
M *ot effective a"ai&st S0?
tra&smissio&
M Side effects i&clude irre"ular
bleedi&", wei"ht "ai&,
headaches, depressio&,
abdomi&al pai&
M Side effects do &ot reverse
u&til medicatio& wears off
M (ay cause delay i& becomi&"
pre"&a&t after i&ectio&s are
stopped
M *ot effective a"ai&st S0?
tra&smissio&*atural 8amily +la&&i&"<
tech&iHues, i&cludi&" chec'i&" body
M +erma&e&t protectio&
from pre"&a&cy
M *o actio& reHuired prior
M *ot effective a"ai&st S0?
tra&smissio&
M /eactio&s to sur"ery may
24
temperature or cervical mucus daily or
recordi&" me&strual cycles o& a cale&dar, to
determi&e the days whe& body is most
fertile9 typical use effective&ess< =1CM *o
medical or hormo&al side effectsM *ot
effective a"ai&st S0? tra&smissio&M
+erma&e&t protectio& from pre"&a&cy0ubal
5i"atio&< sur"ical procedure to perma&e&tly
bloc' woma&Is 8allopia& tubes to preve&t
e""s from reachi&" sperm9 typical use
effective&ess< AAC!&trauteri&e ?evice
:!,?;< small device i&serted by a health
care professio&al i&to the uterus9 preve&ts
e""s from bei&" fertili2ed a&d/or impla&ti&"
i& uterus9 typical use effective&ess< A6C
M /eHuires strict record'eepi&"
M !ll&ess or lac' of sleep may affect body
temperature
M @a"i&al i&fectio&s a&d douches may affect
cervical mucus
M /eHuires absti&e&ce from se1ual
i&tercourse or alter&ative co&traceptio&
duri&" fertile days
M !&e1pe&sive
M 6ccepted by most reli"io&s
M /eactio&s to sur"ery may i&clude
i&fectio&, blood clot &ear testes,
bruisi&", swelli&", or te&der&ess of
scrotum
M !rreversible
M *o actio& reHuired prior to se1ual
i&tercourse, permits se1ual spo&ta&eity
"ubal li*ation1 isthmus part in the
fallopian tube is the usual part bein*
li*hted#
Intra.uterine ,e#ices 0IU,;- a
small plastic obect is i&serted i&to the
uterus where it remai&s i& place# !t
i&terferes with the ability of the ovum to
develop as it tra&sverses the fallopia&
tube#
Most %re4uent Side $ffect<
a# $@cessi#e Menstrual flo)
0menorrha*ia7 b. Spontaneous
$@pulsion of the de#ice1 Myometrium
irritability c. Crampin* < fe#er
Contraindications1
1# +istory of PI,1 a )oman usin* IU,
has FCB chance of *ettin* PI,.
A. $ctopic Pre*nancy3 AI,S
Ne#er use > *i#e IU, to NULLIPAOUS
to se1ual i&tercourse,
permits se1ual
spo&ta&eity
i&clude i&fectio&, bleedi&",
i&ury to i&testi&e, reactio& to
a&esthesia
M !&creased cha&ce of ectopic
pre"&a&cy
M !rreversible
25
6OM$NDDD
eturn to the clinic for e#aluation after
her 9
st
mensesDDD
8i"ure !&tra uteri&e device
:!,?;
@asectomy< sur"ical procedure to perma&e&tly bloc' the maleIs vas defere&s to preve&t sperm
from reachi&" e""s9 typical use effective&ess< AAC
Section II
Ante$a%t'm e%io&
I. Assessment of Ris2 )acto%s in t!e %enatal e%io&
Age o% Pregnant 1o+en 91$ below< 7ave a hi"her i&cide&ce of
1# +rematurity
2# +re"&a&cy !&duced 7yperte&sio&
3# 3ephalopelvic ?isproportio&
1o+en over 23 /ears old are at is4 %or"
1# 3hromosomal ?isorders i& i&fa&ts
2# +!7
3# 3esarea& ?elivery
%imi"%a(i&a 9 1st time +re"&a&cy
%imi$a%a 9 1
st
delivery of a live i&fa&t,
N'lli"%a(i&a 9 &ever bee& pre"&a&t
)n%ections" !se .&#*
T - 0o1oplasmosis
- - )ther i&fectio&s
R - /ubella
C - 3ytome"alovirus
H - 7erpes
6# 0o1oplasmosis :proto2oa;
+roduces symptoms of acute, flu-li'e i&fectio& i& mother
0ra&smitted throu"h raw meat or ha&dli&" cat litter of i&fected cats
S$ontaneo's abo%tion li2ely to occ'% ea%ly in $%e"nancy
-# /ubella
E$tre+el/ teratogenic in %irst tri+ester
#auses congenital de%ects o% e/es5 heart5 ears5 and 0rain
26
1o+en 6ith lo6 ru0ella titers should 0e vaccinated at least 2 +onths 0e%ore 0eco+ing ,regnant or %ollo6ing
a deliver/
N&.E" Any )oman in the first trimester of pre*nancy is at ris8 if e@posed to rubella. Con*enital %etal defects
often results from such an infection.
3# 3ytome"alovirus :3(@;
#+roduces flu-li'e or mo&o&ucleosis-li'e symptoms i& the mother
0ra&smitted throu"h the respiratory or se1ual route
(ay cause fetal death, retardatio&, heart defects, deaf&ess
*o effective treatme&t available
?# 7erpes Simples
6ffects the e1ter&al "e&italia, va"i&a, a&d cervi1
3auses drai&i&", ,ain%ul vesicles
?elivery of the fetus is usually by cesarea& sectio& active lesio&s are prese&t i& the va"i&a9 delivery may be
performed va"i&ally if the lesio&s are i& the a&al, peri&eal, or i&&er thi"h area :strict precautio&s are
&ecessary to protect the fetus duri&" delivery;
*o va"i&al e1ami&atio&s are do&e i& the prese&ce of active va"i&al herpetic lesio&s
7aintain #&N.A#. isolation ,rocedures during hos,itali8ation i% the disease is active
*eo&ate a&d mother may be se$a%ate& &'%in" t!e acti(e $e%io&, or other special precautio&ary measures
may be used to avoid tra&smissio& to &eo&ate
.eratogenic Drugs" BASA-&(code9
1 9 -arbiturates
A 9 6&ti-malarial
S 9 Salicylates
A 9 6&esthetic
- 9 -ral hypo"lycemics
Su0stance A0useA
Alcohol" causes lear&i&" disabilities, (o&"olism, fetal alcohol sy&drome
NicotineA i&creases vasoco&strictio&, retardatio&, S46 :small "estatio&al a"e;, low birth wei"ht
*eroin addictA babies are bor& with an $'A--$A"$,> +5P$AC"I&$ CNS > $%L$'$S or
CNS II"A(ILI"5.
#occaine" "he effect of cocaine in a labor and the fetus is preterm labor thus increased uterine
contractions3 intrauterine *ro)th retardation and the potential for a sic83 addicted infant
II. !ysiolo"ical #hanges in Pregnanc/
Inc%eases &'%in" $%e"nancy
!&crease 7eart /ate for 1B-15 beats/mi&ute
!&crease 3ardiac )utput for 2BC - 3BC duri&" 1
st
> 2
&d
trimester to meet i&crease tissue
dema&d
!&crease secretio& of su"ar :4lycosuria;
INC$AS$ PLAMA &OLUM$
!&crease ,ri&ary 8reHue&cy due to pressure to bladder#
2$
!&crease &ormal depe&de&t .dema :bilateral or a&'le edema; &ormal for 36 wee's "estatio&#
Dec%eases &'%in" $%e"nancy
?ecrease :sli"htly of blood pressure; i& the 2
&d
trimester due to decrease peripheral resista&ce
?ecrease 7emo"lobi& & 7ematocrit because of !ro& ?eficie&cy 0Pseudo. AN$MIA;
?ecrease "astroi&testi&al motility & peristalsis due to displaceme&t of the i&testi&e & compressio&
of the stomach# ---leadi&" to 3)*S0!+60!)*#
?ecrease ,ri&e Specific "ravity< a result of i&crease ,ri&ary )utput#
-t!e%sA
#hloas+a " Mas8 of pre*nancy
Leu4orrhea" )hitish #a*inal dischar*e )ithout si*ns of inflammation < itchin*.
&,erculu+" formation of mucus plu* in C$&I' to seal out bacteria.
Lordosis" the Pride of Pre*nancy
ela$in" responsible hormone for the softenin* of the pel#ic cartila*es. Produce by the corpus luteum3
contributes to the )addlin* *ait typically noted in pre*nancy.
Nor+al deliver/ 0lood loss" ECC I JCC ml of blood
#esarean Section" ;CC I 9CCC ml
II a. Ante$a%t'm Healt! %omotion
%enatal ;isit
Sc!e&'le of (isit if <it! no com$licationsA
a. E(e%y . <ee2sD '$ to 3, <ee2s
b. E(e%y , <ee2sD f%om 3,934 <ee2s :mo%e f%eF'ently if $%oblems e+ist*
c. E(e%y <ee2 f%om 349.8 <ee2s
Classifications of %e"nancy
GRA;IDA > &umber of times pre"&a&t, re"ardless of duratio&, i&cludi&" prese&t pre"&a&cy#
RIMIGRA;IDA > pre"&a&t for the first time#
ItGs important for the nurse to distin*uish bet)een a client )hoGs ha#in* her first baby and one )ho has already
had a baby. %or the client )hoGs pre*nant for the first time3 4uic8enin* occurs around AC to AA )ee8s. 6omen
)ho ha#e had children )ill feel 4uic8enin* earlier3 usually around 9; to AC )ee8s3 because they reco*ni2e the
sensations.
MULTIGRA;IDA > pre"&a&t for seco&d or subseHue&t time#
ARA > &umber of pre"&a&cies that lasted more tha& 2B wee's#
NULLIARA > a woma& who has &ot "ive& birth to a baby beyo&d 2B wee's "estatio&#
RIMIARA > a woma& who has "ive& birth to o&e baby more tha& 2B wee's "estatio&#
MULTIARA > a woma& who has had two or more births at more tha& 2B wee's "estatio&#
Note1 ")ins or triplets counted as 9 para#
PE.E7 I ne)born born before EK )ee8s of *estation.
TERM > &ewbor& bor& after 3$ wee's to 4B wee's of "estatio&#
-ST9TERM > &ewbor& bor& after 4B wee's of "estatio&#
a%ity :TAL*
T 9 *umber of terms births,
9 *umber of premature births,
A 9 *umber of 6bortio&s,
2=
L 9 *umber of livi&" childre&
NUTRITI-N
1
st
.ri+ester" A IJ lbs *ain > EC.EF calories>8*>day
2
nd
tri+ester" 9 lb per )ee8 > ACC calories>8*>day
2
rd
tri+ester" 9 lb per )ee8> ACC calories>8*>day
%e"nant ?omen nee&s 2:: e$tra calories PE DA; fo% a&eF'ate n't%ition.
A &iet of 23:: calories ,er da/
An inc%ease of abo't 3:: calories ,er da/ is nee&e& &'%in" LA#.A.)&N.
)ron De%icienc/ Ane+ia is a %es'lt of P)#A.
Diffe%ent ty$es of E+e%cises
Pelvic (loor #ontractions (Kegel<s E$ercise*A +romotes peri&eal heali&", i&crease se1ual
respo&sive&ess, press stress i&co&ti&e&ce# ?o&e 5B-1BB times# .1amples< 0i"hte&i&" &
stre&"the&i&" the muscles of the @a"i&a, rectum, peri&eum & the& rela1 after# .fficie&t for
,ri&ary 8reHue&cy & 7emorrhoids# !&crease elasticity of the Pubococcy*eus muscle#
A0do+inal +uscle #ontractionsA pre#ent constipation i& pre"&a&cy, do&e i& sta&di&" or lyi&" positio&,
stre&"the&i&" the abdomi&al muscles#
Pelvic oc4ingA elie#es bac8ache duri&" pre"&a&cy, do&e by ti"hte&i&" the buttoc's & flatte&s the
lower bac' a"ai&st the floor for o&e mi&ute#
DI))ERENT T=ES -) 1REATHING TECHNIGUES
6# 6bdomi&al breathi&" : duri&" late&t phase of Sta"e 1 5abor;
1# ,sed u&til labor is more adva&ced
2# 0he abdome& moves outward duri&" i&halatio& a&d dow&ward duri&" e1halatio&
3# 0he rate remai&s slow, with appro1imately si1 to &i&e breaths per mi&ute
-# +a&t-pa&t-blow: duri&" 0ra&sitio&al +hase of Sta"e 1 5abor;
1# ,sed i& adva&ced labor
2# 6 more rapid patter&, co&sisti&" of two short blows from the mouth followed by a lo&"er blow
3# 6ll e1halatio&s are a blowi&" motio&
III. )e%tili3ation to Conce$tion
)e%tili3ationA the u&io& of the ovum & sperm# 0he start of (itotic cell divisio& < fetal se@
determination.
N +rimary oocyte :immature ovum; co&tai&s ?iploid &umber of chromosomes :46;#
N )&e oocyte co&tai&s a haploid :23; &umber of chromosomes after divisio&#
N 4amete :mature ovum;< is a cell or ovum that has u&der"o&e (aturatio& & will be ready for
fertili2atio&#
N )&e "amete carries 23 chromosomes#
N 6 sperm carries 2 types of se1 chromosomes# O & F#
N 4BB millio& sperm cells i& o&e eaculatio&#
N 8u&ctio&al 5ife of spermato2oa is 4= hours
N OOJ female, OFJ male#
2A
)i"'%e #9) Mo%'la
%ocess of )e%tili3ationA
6fter ovulatio& ovum will be e1pelled from the 4raafia& follicles ovum will be surrou&ded by Lona
Pellucida :mucopolysaccharide fluid; & a circle of cells 0Corona adiata; which i&creases the bul' of the
)vum e1pelled from the 8allopia& 0ube by the 8imbriae :i&fu&dibulum;# Sperms move by fla"ella &
+e&etrate the & dissolve the cell wall of the ovum by releasi&" a proteolytic e&2yme
:+yaluronidase7 6fter pe&etratio& 8usio& will result to Ly*ote# Gy"ote mi"rate for 4 days i& the
body of the uterus :(itosis will ta'e place-3leava"e formatio& will be"i&; 6fter 16-5B cell formatio& from
mitosis, a mulberry & -umpy appeara&ce will follow morula 0%igure 1-(7 ---after 3-4 days, the structure will
be ball li'e i& appeara&ce which will be called (lastocyst# 3ells i& the outer ri&" are called "rophoblast :later it
forms the place&ta, respo&sible for the devEt of place&ta & fetal membra&e9 3ells i& the i&&er ri&" are called
$rythroblas t cells :which will be the embryo;#
Te%ms to %emembe%A
&vu+A 8rom ovulatio& to fertili2atio&
=/goteA 8rom fertili2atio& to impla&tatio&
E+0r/oA 8rom impla&tatio& to 5-= wee's#
(etus" 8rom 5-= wee's u&til term
"he o#um is said to be #iable for AJ.36 hours#
Sodium (icarbonate. the freHue&t medicatio& to alter the va"i&al ph, decrease the acidity of the
va"i&a so as to !*3/.6S. 07. ()0!5!0F )8 07. S+./(#
)i"'%e #9G )etal Memb%anes
)etal Memb%anes< membra&es that surrou&d the fetus, & "ive the place&ta the shi&y appeara&ce#
:)i"'%e #-4;
2 5ayers<
a. A+nion< shi&y membra&e o& the 2
&d
wee' of .mbryo&ic ?evelopme&t & e&closes the 6m&iotic
3avity
b. #horion1 )uter membra&e that supports the sac of the am&iotic fluid#
#horionic Villi1 fin*er li8e pro?ections from the chorion. "his is the place )here *ases3 nutrients and
)aste products bet)een the maternal < fetal blood ta8es place.
Amniotic )l'i&< surrou&ds the embryo, co&tai&s fetal uri&e, la&u"o from fetal s'i& & epithelial cells#
+h is $# 2# Specific 4ravity< 1#BB5 > 1#B25
Normal Amount1 FCC I 9CCC ml.
Oli*ohydramnios. less than ECC ml.
Polyhydramnios. more than ACCC ml. obser#e for ,o)n syndrome < con*enital defects
8u&ctio&s of 6m&iotic 8luid<
a# +rotects the fetus from cha&"es i& the temperature & cushio& a"ai&st i&ury#
b# +rotects the umbilical cord from pressure, the fetus dri&'s & breaths the fluid
i&to the lu&"s#
Amniotic )l'i& Colo%s< *ormal color< tra&spare&t, clear, with white ti&y spec's
,ar8 amber or yello)< )mi&ous si"& of prese&ce of -ilirubi&, hemolytic disease
Port 6ine Colored< 6bruptio +lace&ta
-reenish1 (eco&ium Stai&ed / 8.065 ?!S0/.SS< always "o for Cesarian SectionP 6lso if ph is
less than K.A
If )ith odor< deliver withi& 24 hours, may i&dicate i&fectio&#
3B
Umbilical Co%&A 21 i&ches i& le&"th & 2 cm i& thic' &ess, circulatory commu&icatio& of the fetus to the
mother# 3)*06!*S 2 6/0./!.S & 1 @.!*# 3overed by a "elati&ous mucopolysaccharide called
6hartons ?elly.
!mpla&tatio& occurs at the e&d of the 1st wee' after fertili2atio&, whe& the blastocyst attaches to the
e&dometrium# ?uri&" the 2&d wee' :14 days after impla&tatio&;, impla&tatio& pro"resses a&d two "erm layers,
cavities, a&d cell layers develop# ?uri&" the 3rd wee' of developme&t :21 days after impla&tatio&;, the
embryo&ic dis' evolves i&to three layers, a&d three &ew structures Q the primitive strea', &otochord, a&d
alla&tois Q form# .arly duri&" the 4th wee' :2= days after impla&tatio&;, cellular differe&tiatio& a&d
or"a&i2atio& occur#
)i"'%e #9H )e%tili3ation Cycle
0able Summary from 8ertili2atio& to !mpla&tatio& :8i"ure 1-7;
III.a -RIGIN -) 1-D= TISSUE
.issue La/er Bod/ Portion (or+ed
.30)?./( *ervous system, mucus membra&es, a&us & mouth
(esoderm 3o&&ective 0issue, /eproductive, circulatory & upper
,ri&ary system, bo&es, cartilla"e
.&doderm li&i&" of the 4! tract, /espiratory 0ract, bladder & urethra
MULTILE REGNANCIES
Dou0le ovu+ Single &vu+
?i2y"otic/frater&al twi&s (o&o2y"otic/ide&tical twi&s
)va from same or differe&t ovaries u&io& of a si&"le ovum & a si&"le sperm
Same or differe&t se1 same se1 o&e place&ta
2 place&tas but maybe fused
2 chorio&s & 2 am&io&s o&e chorio& & 2 am&io&s
Genetics"
!enoty$eA !&dividualEs outward appeara&ce
Genoty$e< !&dividuals 4e&etic (a'e up
Ha%yoty$eA +ictorial a&alysis of i&dividualEs chromosomes
Se%oty$eA a&ti"e&ic character R6-)S
31
+/.-8./0!5!G60!)*
630!@!0!.S
)vum moves to amulla of
fallopia& tubes
3apacitatio&
6crosome reactio&
3)*3.+0!)*
Go&a reactio&
Gy"ote :fertili2ed ovum9
about 24-4= hrs, divides9
cleava"e divides, travels to
the uterus
!(+56*060!)*
(orula :after 3-4
days impla&tatio&;
-lastocyst
:trophoblast9
embryolast;
!mpla&ts complete
w/& $-1B days
Genetic Disorders"
Autoso+al ecessive DisordersA both me& & wome& are at eHual ris' because the ?.8.30!@. 4.*.
is a& 6,0)S)(.< o&e of 22 pairs of &o&-se1 chromosomes# )ffspri&" of each pre"&a&cy
has a 25C cha&ce of bei&" affected a&d 5BC cha&ce of bei&" a carrier#
E$a+,les are" P=U 0 phenyl8etenuria7 3 "ay . Sachs ,isease3 Cystic %ibrosis3 "hallasemia3
and Sic8le Cell Anemia
Autoso+al Do+inantA a& affected offspri&" has a& affected pare&t#
E$a+,les are" +untinton/s Chorea and Marfan/s Syndrome 0Arachnodactyly7
>-lin4ed do+inant?ecessive Diso%&e%s< ab&ormal "e&e is fou&d o& the O chromosome because me&
have o&ly o&e O chromosome, they always e1press the disorder#
E$a+,les are1 +emophillia and ,uchenne Muscular ,ystrophy
I;. )ETAL DE;EL-MENT
)i"'%e #9 H, )etal De(elo$ment
+lace&
tal
tra&sp
ort of
substa
&ces
: 5
wee's
;
0he
fetus is 2$-31 mm
a&d wei"hs 2-4
"rams
8etus s
mar'edly be&t
7ead
is
disproportio&ately
lar"e due to brai&
developme&t
3e&ter
s of bo&e be"i& to
ossify
4a&"li
o&ic cells :5
th
to
12
th
wee's;
+lace&ta a&d meco&ium
.mbryo is 4-5 mm le&"th
0rophoblasts embedded i& deciduas
8ou&datio&s for &ervous system, "e&itouri&ary system, s'i&, bo&es, a&d
lu&"s are formed
/udime&ts of eyes, ears, &ose appear
Cardio#ascular system functionin*3 heart be*innin* to beat3 be*innin* of heart circulation.
Placenta de#/t.
32
are prese&t, with facial features
1 mo/ 4 wee's
3 mos#/A-12 w's
2 mo/ 5-= wee's
C&S done 0; 9A )ee8s7 e#ery or*an present3 +ead *reatly enlar*ed
6vera"e le&"th is 5B-55 mm a&d wei"hs 45 "ms#
8i&"ers a&d toes are disti&ct#
+lace&ta is complete#
/udime&tary 'id&eys secrete uri&e#
8etal circulatio& is complete#
.1ter&al "e&italia show defi&ite characteristics#
4a&"lio&ic cells
S$' IS &ISUALL5 $CO-NILA(L$# +eart is audible in a ,oppler 0 99
th
)ee87
8etus swallows# %ith &ails# Lid&eys able to secrete#
4 mos# /13-16 wee's A4-14B mm le&"th a&d wei"hs A$-2BB "ms#
7ead is erected, lower limbs are well developed#
7eartbeat is prese&t
*asal septum a&d palate close
8i&"erpri&ts are set
LANU-O APP$AS IN "+$ (O,5
=
mos# /
3B-34
wee's
5e&"t
h
2=B-
32B
mm#
wei"h
t
1$BB-
25BB
"ms#$
mos# /
26-2A
wee's
5e&"t
h
25B-
2$59
wei"h
t A1B-
15BB
"ms#2
8etus is 15B-1AB mm# !& le&"th a&d wei"hs appro1imately 26B-46B
"ms#
5a&u"o covers e&tire body#
.yebrows a&d scalp hair is prese&t#
+eart sounds are perceptible by auscultation.
&erni@ caseosa co#ers s8in#
+eartbeat can be heard in the fetoscope 0 9; )ee8sMAC )ee8s7. Li#er is already pancreas
functionin*.
Quic8enin* felt by a mother. S8eleton be*ins to de#elop.
(ro)n %ats be*in to form. +eart sounds in the stethoscope
Can be heard 0 9K. AC )ee8s7
NO"$1 .here is a ,lacental 0arrier to s/,hilis until the 1@
th
6ee4 o% ,regnanc/.
)% the +other is treated 0e%ore 1@
th
6ee45 the 0a0/ 6ill +ost li4el/ not 0e
a%%ected.
33
1-25
%..
LST
)5?
(6*
Es
863.
5
mos# /
1$-2B
wee's
0oe&ails become
visible
Steady wei"ht
"ai& occurs
@i"orous fetal
moveme&t occurs#
LANU-O ,ISAPP$AS
are fully de#eloped.
A)are
of
sounds
outside
the
body.
Assum
es the
deli#er
y
positio
n.
Increa
sed
chance
of
sur#i#
al.
S'i& red
/hythmic
breathi&" occurs
+upillary
membra&e
disappears from
eyes#
8etus ofte&
survives if bor&
prematurely
(rain de#elops
rapidly. Lecithin. Sphin*omyelin 0L>S
ratio is already A197
(rains fully de#eloped. If born3
34
neonate may sur#i#e.
5e&"th 2BB-24B
mm# %t# 4A5-A1B
"ms#
S'i& appears
wri&'led a&d pi&'
to red#
/.( be"i&s
.yebrows a&d
fi&"er&ails
develop#
&$NI' CO&$S "+$ $N"I$
(O,5. +as the ability to hear.
Production of lun* surfactants.
Passi#e Antibody transfer
0 placental immuno*lobulin -7
Su
stained
)ei*ht
*ain
occurs.
A mos# /35-3$ wee's6
mos# /21-25 wee's
5e&"th 33B-36B mm# wei"ht 2$BB-34BB "ms#
8ace a&d body has a loose wri&'led appeara&ce because of
subcuta&eous fat deposit#
-ody is usually lump a&d la&u"o disappears
*ails reach fi&"ertip ed"e
6m&iotic fluid decreases#
Increase ,e#elopment. Sole of the foot ha#e already
creases. -ood chance of sur#i#al.
.
a
r
l
i
e
s
t
t
e
s
t
p
o
s
s
i
b
l
e
o
1B mos# / 3=-4B wee's 5e&"th 36B mm#9 %ei"ht 34BB-36BB
"ms#
S'i& is smooth, chest is promi&e&t
.yes are u&iformly slate colored
-o&es of s'ull are ossified a&d are
&early to"ether at sutures#
"estes are in scrotum.
Optimum "ime for sur#i#al.
%ull term. Li*htenin* is present.
35
&
f
e
t
a
l
c
e
l
l
s
9
s
a
m
p
l
e
o
b
t
a
i
&
e
d
b
y
s
l
e
&
d
e
r
c
a
t
h
e
t
e
r
36
p
a
s
s
e
d
t
h
r
o
u
"
h
c
e
r
v
i
1
t
o
i
m
p
l
a
&
t
a
t
i
o
&
s
i
t
e
#
#
h
3$
o
r
i
o
n
i
c
V
i
l
l
i
S
a
+
,
l
i
n
g
<
r
e
m
o
v
a
l
o
f
a
s
m
a
l
l
p
i
e
c
e
o
f
3
h
o
r
i
o
&
i
3=
c
v
i
l
l
i
s
a
m
p
l
i
&
"
t
o
d
e
t
e
c
t
t
h
e
f
f
<
f
e
t
a
l
c
h
r
o
m
o
s
o
m
e
,
e
&
2
y
m
e
,
?
*
6
&
3A
b
i
o
c
h
e
m
i
c
a
l
a
b
&
o
r
m
a
l
i
t
i
e
s
#
+
e
r
f
o
r
m
e
d
b
e
t
w
e
e
&
t
h
e
=
th
>
1
1
th
w
e
e
'
s
4B
o
f
"
e
s
t
a
t
i
o
&
#
3
a
&
d
e
t
e
c
t
t
h
e
f
f
9
4
e
&
e
t
i
c
?
e
f
e
c
t
s
<
c
/
s
t
i
c
%
i
0
r
o
s
41
i
s
5
t
r
i
s
o
+
/
2
1
5
.
a
/
S
a
c
h
s
5
s
i
c
4
l
e
c
e
l
l
a
n
e
+
i
a
5
t
h
a
l
l
a
s
e
+
i
a
5
D
u
42
c
h
e
n
n
e
+
u
s
c
u
l
a
r
d
/
s
t
r
o
,
h
/
A
h
e
+
o
,
h
i
l
i
a
.
(
o
s
t
c
o
m
m
o
&
i
&
d
i
c
43
a
t
i
o
&
<
a
d
v
a
&
c
e
m
a
t
e
r
&
a
l
a
"
e
<
i
&
c
r
e
a
s
e
s
r
i
s
'
o
f
c
h
r
o
m
o
s
o
m
a
l
d
a
m
44
a
"
e
f
r
o
m
a
"
i
&
"
o
f
o
o
c
y
t
e
#
4
r
e
a
t
e
s
t
6
d
v
a
&
t
a
"
e
o
v
e
r
6
m
&
i
o
c
e
&
t
45
e
s
i
s
<
+
.
/
8
)
/
(
.
?
?
,
/
!
*
4
0
7
.
8
!
/
S
0
0
/
!
(
.
S
0
.
/
#
:
1
6
t
h
-
2
B
t
h
w
e
e
46
'
o
f
"
e
s
t
a
t
i
o
&
;
#
#
5
a
b
o
r
a
t
o
r
y
r
e
s
u
l
t
s
a
r
e
o
b
t
a
i
&
e
d
i
&
1
-
$
d
4$
a
y
s
c
o
m
p
a
r
e
d
t
o
2
B
-
2
=
d
a
y
s
f
o
r
a
&
a
m
&
i
o
c
e
&
t
e
s
i
s
#
D
i
s
a
&
(
a
n
t
a
4=
"
e
s
A
1#
2#
3#
4A
4#
5#
5B
A
f
t
e
%
a
n
R
!
9
n
e
"
a
t
i
(
e
$
a
t
i
e
n
t
'
n
&
e
%
"
o
e
51
s
a
m
n
i
o
c
e
n
t
e
s
i
s
o
%
C
;
S
D
t
h
e
n
u
r
s
e
s
h
o
u
l
d
a
d
+
i
n
i
s
t
e
r
h
(
D
9
52
i
+
+
u
n
e
g
l
o
0
u
l
i
n
(
h
o
G
A
7
9
5
t
o
,
r
e
v
e
n
t
h
s
e
s
n
s
i
t
i
8
a
t
i
o
n
D
a
&
53
a
&
t
i
"
e
&
a
&
t
i
b
o
d
y
i
m
m
u
&
o
l
o
"
i
c
r
e
a
c
t
i
o
&
t
h
a
t
s
o
m
e
t
i
m
e
s
o
c
c
u
r
54
s
w
h
e
&
a
&
/
h
&
e
"
a
t
i
v
e
m
o
t
h
e
r
c
a
r
r
i
e
s
a
&
/
h
U
f
e
t
u
s
#
T
!
e
$
a
55
t
i
e
n
t
&
o
e
s
n
o
t
%
e
F
'
i
%
e
c
o
m
$
l
e
t
e
b
e
&
%
e
s
t
a
f
t
e
%
C
;
S
-
-
-
S
*
E
S
*
&
56
!
L
D
E
(
A
)
N
(
&
7
S
E
>
!
A
L
)
N
.
E
#
&
!
S
E
A
N
D
P
*
;
S
)
#
A
L
A
#
.
)
V
)
.
5$
;
(
&
B
@
h
o
u
r
s
.
6
s
m
a
l
l
a
m
o
u
&
t
o
f
s
p
o
t
t
i
&
"
i
s
&
o
r
m
a
l
f
o
r
t
h
e
9
s
5=
t
A
J
.
J
;
h
o
u
r
s
.
,50/6S),*?
*o '&ow& ris'
5A
;
.
)
e
t
a
l
C
i
%
c
'
l
a
ti
o
n
earl
y as
3
wee
' of
i&tra
-
uteri
&e
life,
fetal
bloo
d is
alre
ady
is
circ
ulati
&",
spec
ifica
lly
ther
e is
alre
ady
e1ch
a&"e
of
&utri
e&ts
with
the
6B
mat
er&a
l
circ
ulati
o&
i&
the
chor
io&i
c
villi#
N
6rte
ries
carr
y
,*
)O
F4
.*
60.
?
-5
))
?#
@.!
*S
carr
y
)O
F4
.*
60.
?
-5
))
?#
N
8eta
l
3irc
ulati
o&
-yp
ass<
%h
y<
?,
.
0)
*)
*-
8,
*3
61
0!)
*!*
4
5,
*4
S<
-----
?uc
tus
arter
ious
us
:bet
wee
&
pul
mo&
ary
arter
y &
6ort
a,
)+.
*S
60
-!/
07
&
35
)S.
S 24
>4=
hour
s
after
deli
very
#;
C
N"A
INS
a
mi@t
ure
of
arte
rial
<
#en
ous
bloo
d
-----
8ora
62
me&
)va
le <
bet
wee
&
ri"ht
&
left
atriu
m
?,. 0)
*)
*-
8,
*3
0!)
*!*
4
5!@
./<
-----
?uc
tus
@e&
osus
:by
pass
the
liver
,
clos
es at
birth
9 a&
umb
ilica
l
vei&
that
carri
es
7i"
h
o1y
"e&
fro
m
the
plac
e&ta#
63
)
i
"
'
%
e
I
.
i
C
!
a
n
"
e
s
i
n
)
e
t
a
l
c
i
%
c
'
l
a
t
i
o
n
:
%
e
n
a
t
a
l
t
o
o
s
64
t
n
a
t
a
l
C
i
%
c
'
l
a
t
i
o
n
*
@
#
a
M
e
a
s
'
%
i
n
"
A
"
e
o
f
G
e
s
t
a
t
i
o
n
)
i
"
'
%
e
65
I
.
>
)
'
n
&
i
c
H
e
i
"
!
t
#. Estimate&
Date of
Confinement
:EDC*
mo&ths U$
days
?ecember
,. McDonal&s
)o%m'la :a"e of
"estation*
8u&dic ht i& cm 1
2 divided by $ J
6)4 i& mo&ths
21 cm 1
2 $ J
24 wee's
3.
:HaaseIs R'le*
1 > 5 mo&ths -
Jmo&ths :sHuared;
6
-
5
6
7
;I.
66
#8
##
12
37
13
14
15
6
5
+
7
6
-
8
.
0
)
+
/
)
0
.
!
*
S
3
/
.
.
*
!
*
4
(
a
t
e
r
&
a
l
s
e
r
u
m
s
c
r
e
6(*!)3.*0.S!S
5ocatio& a&d aspiratio& of am&iotic fluid for
e1ami&atio&9 $ossible afte% t!e #.
t!
<ee2 whe&
sufficie&t amou&ts are prese&t9 used to ide&tify
chromosomal aberratio&, se1 of fetus, levels of
alpha-fetoprotei& a&d other chemicals i&dicative of
&eural tube defects a&d i&bor& error of metabolism,
"estatio&al a"e, /7 factor#
I.&. anesthesia isnGt *i#en for amniocentesis. "he
client should be supine durin* the procedureH
after)ard3 she should be placed on her left side
to a#oid supine hypotension3 promote #enous
return3 and ensure ade4uate cardiac output.
c# A+niocentesisA i&vasive procedure for am&iotic
fluid a&alysis, & fetal lu&" maturity#
%oce&'%eA ,ltrasou&d 1
st
< the ratio&ale< to locate
the +lace&ta# "he patient MUS" $MP"5 "+$
(LA,,$ "O $,UC$ "+$ SIL$ O% "+$
(LA,,$# @ital si"&s are assessed every 15
mi&utes#
0ypically performed o& the E
rd
trimester to assess
L$CI"+IN.SP+IN-OM5$LIN /60!) !* 07.
6(*!)0!3 85,!? :this ratio i&dicates fetal
lu&" maturity;, which is commo&ly delayed i& a
diabetic client3 3esarea& ?elivery should not
be done, u&less the fetal lu&"s are matured#
ositionA S'$ine.
PLAC$ A %OL,$, "O6$L ON +$ I-+"
(U""OC=S "O "IP +$ SLI-+"L5 "O "+$
L$%" < MO&$ "+$ U"$US O%% "+$ &$NA
CA&A "O P$&$N" SUPIN$ +5PO"$NSION
S5N,OM$.
A(,OMINAL P$P IS ,ON$, the&, &eedle
i&sertio& i& a 2B-22 "au"e spi&al &eedle,
withdrawi&" am&iotic fluid#
*)/(65 5/S /60!) :lecithi&/sphi&"omyeli&;<
2<1 J &ormal fetal lu&" maturity ratio
7ost i+,ortant %actor a%%ecting A+niocentesisA
*..?5. !*S./0!)*-because of the ris' of
pu&cture or dama"e to the place&ta, fetus,
umbilical cord, bladder & uteri&e arteries#
Disa&(anta"esA
is4 %or"
6$
e
&
s
f
o
r
o
p
e
&
&
e
u
r
a
l
t
u
b
e
d
e
f
e
c
t
s
#
!
t
i
s
a
"
l
u
c
o
p
r
o
t
e
i
&
p
r
o
d
u
c
e
d
b
y
f
9. Maternal hemorrha*e
A. Infection
E. h immuni2ation
J. abruptio placenta
F. Amniotic fluid embolism
#ALL .*E P*;S)#)AN (& .*E ((1 Chills3
fe#er3 lea8a*e of fluid3 decrease fetal mo#ement
or uterine contractions.
After amniocentesis3 the patient is monitored
for uterine contractions3 fetal heart rate
chan*es and lea8a*e of amniotic fluid from the
puncture site. ,urin* this period3 the patient
isn/t ambulated.
6=
e
t
a
l
y
o
l
'
s
a
c
,
4
!
t
r
a
c
t
a
&
d
l
i
v
e
r#
0
e
s
t
d
o
&
e
b
e
t
w
e
e
&
9
:
a
n
d
9
;
)
e
e
6A
8
s
*
e
s
t
a
t
i
o
n
#
3
a
&
b
e
u
s
e
d
l
a
t
e
i
&
p
r
e
"
&
a
&
c
y
:
a
f
t
e
r
o
s
$B
s
i
f
i
c
a
t
i
o
&
o
f
f
e
t
a
l
b
o
&
e
s
;
t
o
c
o
&
f
i
r
m
p
o
s
i
t
i
o
&
a
&
$1
d
p
r
e
s
e
&
t
a
t
i
o
&
9
&
o
t
u
s
e
d
i
&
e
a
r
l
y
p
r
e
"
&
a
&
c
y
t
o
a
$2
v
o
i
d
p
o
s
s
i
b
i
l
i
t
y
o
f
c
a
u
s
i
&
"
d
a
m
a
"
e
t
o
f
e
t
u
s
a
&
d
m
$3
o
t
h
e
r
#
,
s
e
o
f
s
o
u
&
d
a
&
d
r
e
t
u
r
&
i
&
"
e
c
h
o
p
a
t
t
e
r
&
s
t
o
$4
i
d
e
&
t
i
f
y
i
&
t
r
a
b
o
d
y
s
t
r
u
c
t
u
r
e
s
9
u
s
e
f
u
l
e
a
r
l
y
i
&
$5
p
r
e
"
&
a
&
c
y
t
o
i
d
e
&
t
i
f
y
"
e
s
t
a
t
i
o
&
a
l
s
a
c
s
9
l
a
t
e
r
u
s
e
$6
s
i
&
c
l
u
d
e
a
s
s
e
s
s
m
e
&
t
o
f
f
e
t
a
l
v
i
a
b
i
l
i
t
y
,
"
r
o
w
t
h
p
a
t
t
$$
e
r
&
s
,
a
&
o
m
a
l
i
e
s
,
f
l
u
i
d
v
o
l
u
m
e
,
u
t
e
r
i
&
e
a
&
o
m
a
l
i
e
s
a
&
$=
d
a
d
&
e
1
a
l
m
a
s
s
e
s
#
,
s
e
a
d
u
&
c
t
t
o
a
m
&
i
o
c
e
&
t
e
s
i
s
9
s
a
f
$A
e
f
o
r
f
e
t
u
s
:
&
o
i
o
&
i
2
i
&
"
r
a
d
i
a
t
i
o
&
;
A
l$
!
a
)
et
o
$
%
ot
ei
nA
P
)
N
#)
=B
PA
L
S
#
E
E
N)
N
G
.
E
S.
D
&
.
*
E
D
E
.
E
#
.)
&
N
&
(
N
E
!
A
L
.
!
B
E
D
E
(
E
#
.S
:sp
i&a
bif
ida
,
hy
dr
oc
ep
hal
us-
=1
ca
&
be
red
uc
ed
thr
ou
"h
i&c
rea
se
fol
ic
aci
d-
B#4
m"
/da
y
i&
the
1
tri
me
ste
r;
N
(
at
er
&
al
bl
o
o
d
sa
m
pl
i&
"
b
et
w
ee
&
1
6-
2
B
w
ee
's
#
=2
5
)
%
<
c
hr
o
m
os
o
m
al
d
ef
ec
ts
:
?
o
w
&s
s
y
&
dr
o
m
e;
+
I
-
+
1
0
*
r
e
a
t
e
r
t
h
a
n
9
C
m
*
>
d
l
=3
7
N
e
u
r
a
l
t
u
b
e
d
e
f
e
c
t
s
3
a
n
e
n
c
e
p
h
a
l
y
<
t
h
e
a
b
s
e
n
c
e
o
f
#
e
n
t
r
a
l
a
b
d
o
m
=4
i
n
a
l
)
a
l
l
3
p
r
e
m
a
t
u
r
e
d
e
l
i
#
e
r
y
3
t
o
@
e
m
i
a
<
f
e
t
a
l
d
i
s
t
r
e
s
s
<
h
=5
i
m
m
u
n
i
2
a
t
i
o
n
#
U
l
t
%
a
s
o
'
n
&
A
d
o
&
e
1
=
-
4
B
w
e
e
'
s
f
o
r
f
e
t
a
l
a
b
&
o
r
m
a
=6
l
i
t
i
e
s
3
.
*
E
B
E
S
.
.
E
S
.
(
&
E
#
.
&
P
)
#
P
E
G
N
A
N
#
)
E
S
*
o
&
-
i
&
v
a
=$
s
i
v
e
p
r
o
c
e
d
u
r
e
w
i
t
h
h
i
"
h
f
r
e
H
u
e
&
c
y
s
o
u
&
d
w
a
v
e
s
t
o
o
b
t
a
i
&
o
u
t
l
i
&
e
o
==
f
t
h
e
f
e
t
u
s
,
p
l
a
c
e
&
t
a
&
u
t
e
r
i
&
e
c
a
v
i
t
i
e
s
a
&
d
t
o
c
o
&
f
i
r
m
"
e
s
t
a
t
i
o
=A
&
a
l
a
"
e
&
.
?
?
#
N
$
$
,
S
A
%
U
L
L
(
L
A
,
,
$
"
O
O
(
"
A
I
N
A
(
$
"
"
$
I
M
A
AB
-
$
0
d
r
i
n
8
a
f
u
l
l
*
l
a
s
s
e
#
e
r
y
9
F
m
i
n
u
t
e
s
b
e
*
i
n
n
i
n
*
a
n
h
o
u
r
<
h
a
A1
l
f
t
h
e
p
r
o
c
e
d
u
r
e
7
C
O
M
M
O
N
M
$
"
+
O
,
I
N
L
O
C
A
"
I
N
-
"
+
$
P
$
C
I
S
$
P
O
A2
S
I
"
I
O
N
O
%
"
+
$
%
$
"
U
S
<
P
L
A
C
$
N
"
A
(
$
%
O
$
A
M
N
I
O
C
$
N
"
$
S
I
S
.
-
*o '&ow&
A3
-
-
-
-
-
-
-
-
8
o
u
&
d
i
&
a
m
&
i
o
t
i
c
f
l
u
i
d
a
f
t
e
r
3
5
w
e
e
'
s
#
!
&
c
o
&
u
&
c
t
i
o
&
w
i
5/S /60!) ,ses am&iotic fluid to ascertai& fetal lu&" maturity
throu"h measureme&t of prese&ce a&d amou&ts of
the lu&" surfacta&ts lecithi& a&d sphi&"omyeli&# 6t
35-36 wee's9 ratio is 2<1 i&dicative of mature levels#
A4
t
h
t
h
e
5
/
S
r
a
t
i
o
9
i
t
c
o
&
t
r
i
b
u
t
e
s
t
o
i
&
c
r
e
a
s
e
d
r
e
l
i
a
b
i
l
i
t
y
o
f
f
e
t
a
A5
l
l
u
&
"
m
a
t
u
r
i
t
y
t
e
s
t
i
&
"
#
(
a
y
b
e
d
o
&
e
i
&
l
a
b
o
r
a
t
o
r
y
#
O
-
/
6
F
!
o
s
$
!
A6
a
t
i
&
y
l
G
l
y
c
e
%
o
l
:
G
;
<
w
h
e
&
p
r
e
s
e
&
t
i
&
t
h
e
a
m
&
i
o
t
i
c
f
l
u
i
d
,
i
t
c
a
&
b
e
A$
p
r
e
d
i
c
t
e
d
t
h
a
t
r
e
s
p
i
r
a
t
o
r
y
d
i
s
t
r
e
s
s
s
w
i
l
l
&
o
t
o
c
c
u
r
,
o
r
/
?
S
w
i
l
l
A=
&
o
t
o
c
c
u
r#
5
e
v
e
l
-
h
i
"
h
e
a
r
l
y
i
&
p
r
e
"
&
a
&
c
y
9
&
%
o
$
s
a
f
t
e
%
3
4
<
e
e
2
s
"
e
s
3/.60!*!*. 5.@.5 .stimates fetal re&al maturity a&d fu&ctio&, uses
am&iotic fluid#
AA
t
a
t
i
o
n
9
u
s
e
s
a
m
&
i
o
t
i
c
f
l
u
i
d
#
+
7
)
S
+
7
6
0
!
?
F
5
4
5
3
.
/
)
5
"
h
e
y
e
l
l
1BB
o
)
c
o
l
o
r
i
s
t
h
e
r
e
s
u
l
t
o
f
f
e
t
a
l
a
n
e
m
i
a
a
n
d
b
i
l
i
r
u
b
i
n
.
1B1
E
A.
No
0
o
c
o
d
y
&
a
m
o
m
e
t
e
r
r
e
c
o
r
d
s
f
e
t
a
l
m
o
v
e
m
e
&
t
s
a
&
d
8.065 ()@.(.*0 3),*0
1B2
?
o
p
p
l
e
r
u
l
t
r
a
s
o
u
&
d
m
e
a
s
u
r
e
s
9
)
b
s
e
r
v
a
t
i
o
&
o
f
f
e
t
a
l
h
e
a
r
t
r
1B3
a
t
e
r
e
l
a
t
e
d
t
o
f
e
t
a
l
m
o
v
e
m
e
&
t
#
%
e
t
a
l
)
e
l
l
.
b
e
i
n
*
#
$.
!&dicate
d
for<
ass
ess
pla
ce&
tal
fu&
1B4
cti
o&
&
o1
y"e
&at
io&
,
fet
al
wel
l
bei
&",
eva
lua
tes
fet
al
hea
rt
rat
e i&
res
po
&se
to
fet
al
mo
ve
me
&t
esp
eci
all
y
for<
Ma
ter
nal
Pr
obl
em
s
suc
h
as
chr
oni
c
hy
per
ten
sio
n3
1B5
dia
bet
es
an
d
Pr
e.
ecl
am
psi
a3
*i#
en
aft
er
the
EA
d
)e
e8
RE
A
RA
TI
-
NA
atie
&t
sho
uld
eat
s&a
c's
#
osition
Semi.
%o)ler
s or left
lateral
positio
ns
mother
may
as' tom
press
the
butto&
every
time
1B6
she
feels
fetal
movem
e&ts9
the
mo&itor
records
a mar'
at each
poi&t of
fetal
movem
e&t#
=.
L.
RESUL
TS
A
9.
eactive
A.
E.
J.
Non-
1B$
F.
*)0.<
CO
ON
P$
%
O
$,
ON
A(
1B=
$N
($
CA
US
O%
"+
C
$A
%O
S"I
M.
Co
O.
%oma& i&
(o&itor for
a.
1BA
0.
c.
11B
-SITI;
E
R
E
S
U
L
T
<
5
a
t
e
d
e
c
e
l
e
r
a
t
i
o
&
s
w
i
t
h
a
t
l
e
a
s
t
5
B
C
o
f
c
o
&
t
r
a
c
111
t
i
o
&
s
#
+
o
t
e
&
t
i
a
l
r
i
s
'
s
t
o
t
h
e
f
e
t
u
s
,
w
h
i
c
h
m
a
y
&
e
c
e
s
s
i
t
a
t
e
t
o
3
-
s
e
112
c
t
i
o
&
#
Abno%
ma
l
an
&
2n
o<
n
as
J
osi
ti(
e
<i
n&
o<
C.
Ab
no
rm
al1
NP
osi
ti#
e
6i
nd
o)
O1
0P
7
LA
"$
,
$C
$L
$
A"
IO
NS
O
%
%
+
)it
h
thr
ee
113
co
ntr
act
ion
s a
9C
mi
nut
e
int
er#
al.
In
dic
ate
s
Ut
ero
pla
ce
nta
l
Ins
uff
ici
en
cy.
+.
NEGATI
;
E
R
E
S
U
L
T
S
<
*
o
l
a
t
e
d
e
c
e
l
e
r
a
t
114
i
o
&
s
w
i
t
h
a
m
i
&
i
m
u
m
o
f
3
c
o
&
t
r
a
c
t
i
o
&
s
l
a
s
t
i
&
"
4
B
-
6
B
s
e
c
o
&
d
s
i
&
1
B
m
115
i
&
u
t
e
s
p
e
r
i
o
d
#
N
o
%
m
a
l
1
N
N
e
*
a
t
i
#
e
6
i
n
d
o
)
O
1
0
.
7
L
A
"
$
,
$
C
$
L
$
A
"
I
O
116
N
S
O
%
%
+
)
i
t
h
t
h
r
e
e
c
o
n
t
r
a
c
t
i
o
n
s
a
9
C
m
m
i
n
u
t
e
i
n
t
e
r
#
a
l
o.
11$
,.
D.
s.
#.
e1cretio&<
measures place&tal
fu&ctio&i&"
throu"h uri&e test#
11=
11A
Est%iolA
estro"e
&ic
hormo&
e,
sy&thesi
2ed by
the
place&t
a &
adre&al
"la&d
of the
fetus
which
secreted
by the
ovaries
h
)
n
c
o
+
,
a
t
i
0
i
l
i
t
/
.
e
s
t
12B
A
'
%
$
o
s
e
A
a
#
t
o
d
i
s
c
o
v
e
r
p
r
e
s
e
&
c
e
o
f
a
&
t
i
b
o
d
i
e
s
p
r
e
s
e
&
t
i
&
/
h
-
121
&
e
"
a
t
i
v
e
m
o
t
h
e
r
E
s
b
l
o
o
d
#
1#
122
2#
3#
123
N
i
t
r
a
8
i
n
e
.
e
s
t
A
u
s
e
124
o
f
&
i
t
r
a
2
i
&
s
t
r
i
p
t
o
d
e
t
e
c
t
t
h
e
p
r
e
s
e
&
c
e
o
f
a
m
&
i
o
t
i
c
f
l
u
i
125
d
#
Kic4s
c
o
u
n
t
<
f
e
t
a
l
m
o
v
e
m
e
&
t
c
o
u
&
t
i
&
"
m
o
t
h
e
r
s
i
t
s
H
u
i
126
e
t
l
y
o
&
t
h
e
5
.
8
0
S
!
?
.
f
o
r
1
h
o
u
r
a
f
t
e
r
m
e
a
l
s
&
c
o
u
&
t
f
e
t
a
12$
l
'
i
c
'
s
f
o
r
3
B
m
i
&
u
t
e
s
#
*
o
t
i
f
y
t
h
e
p
h
y
s
i
c
i
a
&
o
r
h
e
a
l
t
h
c
a
r
12=
e
p
r
o
v
i
d
e
r
i
f
8
.
%
.
/
0
7
6
*
3
L
!
3
L
S
#
12A
/esult<
a
$
a
n
i
c
o
l
a
'
T
e
s
t
13B
A
c
y
t
o
l
o
"
i
c
t
e
s
t
f
o
r
c
a
&
c
e
r
?
e
t
e
c
t
p
r
e
c
a
&
c
e
r
o
u
s
l
e
s
i
o
&
s
&
,
d
e
131
t
e
c
t
t
h
e
r
e
c
u
r
r
e
&
c
e
o
f
3
a
&
c
e
r#
.
H
y
s
t
e
%
o
s
a
l
$
!
i
n
"
o
"
%
a
m
A
C
O
M
P
132
L
$
"
$
$
&
A
L
U
A
"
I
O
N
O
%
A
L
L
P
$
L
&
I
C
O
-
A
N
S
I
N
%
$
M
A
L
$
S
N
.
@
6
5
133
,
6
0
.
S
0
,
-
6
5
+
6
0
.
*
3
F
&
+
/
)
-
5
.
(
S
!
*
8
.
/
0
!
5
!
0
F
#
N
!f
the
tub
es
are
pat
e&t
,
the
134
dy
e
ca
&
be
vis
ual
i2e
d
pas
si&
"
out
the
fi
mb
tria
ted
e&
d
&
of
the
fall
opi
a&
tub
es#
&.
R'
bin
s
Tes
t9
det
er
mi
&es
tub
al
pat
e&c
y
of
the
fall
opi
a&
tub
es#
3)
2 is
pas
sed
135
thr
ou
"h
the
cer
vi1
to
the
ute
rus
#
136
13$
e.
Si
ms
H'
!n
e%
Tes
t
:o
st
Coi
tal
Tes
t*A
wit
hi&
1 >
2
day
s, a
spe
cim
e&
of
se
mi
&al
flui
d
fro
m
the
pos
teri
or
for
&i1
&
cer
vic
13=
al
ca&
al
is
asp
irat
ed
2 >
4
hou
rs
afte
r
coit
us#
'
%
$
o
s
e
A
t
e
s
t
f
o
r
i
&
c
o
m
p
a
t
i
b
i
l
i
t
y
o
f
s
p
e
r
m
s
13A
w
i
t
h
c
e
r
v
i
c
a
l
m
u
c
u
s
#
9
.
A
d
a
y
s
i
s
t
h
e
b
e
s
t
t
i
m
e
t
o
e
#
a
l
u
a
t
e
f
e
r
14B
t
i
l
i
t
y
b
e
c
a
u
s
e
t
h
e
r
e
i
s
i
n
c
r
e
a
s
e
e
s
t
r
o
*
e
n
#
i.
;III.
6
u
s
c
u
l
t
6me&orrhea *ausea/@omiti&"
-reast se&sitivity a&d i&creased si2e 8ati"ue 6bdomi&al e&lar"eme&t
S'i& pi"me&tatio& cha&"es
:(elasma chloasma, li&ea &i"ra- a brow& li&e ru&&i&" from the umbilicus to the symphysis pubis
Stretch mar8s )ill e#entually fade to a sil#ery )hite color3 but it is hi*hly unli8ely that they )ill completely
disappear.
141
a
t
i
o
&
o
f
f
e
t
a
l
h
e
a
r
t
b
y
w
e
e
'
=
0
e
a
c
h
m
o
t
h
e
r
t
o
c
o
u
&
-reast cha&"es- i&crease i& full&ess, dar'er areola# DVuic'e&i&"< first fetal movEt# D,ri&ary 8reHue&cy
D (elasma #
142
t
2
-
3
t
i
m
e
s
d
a
i
l
y
,
3
B
-
6
B
m
i
&
u
t
e
s
e
a
c
h
t
i
m
e
,
s
h
o
u
l
d
143
f
e
e
l
5
-
6
m
o
v
e
m
e
&
t
s
p
e
r
c
o
u
&
t
i
&
"
t
i
m
e
9
m
o
t
h
e
r
s
h
o
u
l
d
144
&
o
t
i
f
y
c
a
r
e
"
i
v
e
r
i
m
m
e
d
i
a
t
e
l
y
o
f
a
b
r
u
p
t
c
h
a
&
"
e
o
r
&
145
o
m
o
v
e
m
e
&
t
#
,
l
t
r
a
s
o
u
&
d
i
m
a
"
i
&
"
o
f
f
e
t
a
l
h
e
a
r
t
m
o
t
i
o
&
b
y
w
e
e
'
$
,
146
l
t
r
a
s
o
u
&
d
c
o
&
f
i
r
m
a
t
i
o
&
o
f
"
e
s
t
a
t
i
o
&
a
l
s
a
c
b
y
w
e
e
'
6
U
l
t
r
a
s
o
u
n
d
1
14$
:
)
e
e
8
s
c
a
n
a
u
s
c
u
l
t
a
t
e
t
h
e
f
e
t
a
l
h
e
a
r
t
.
8
e
t
a
l
m
o
v
e
m
e
&
t
s
p
a
l
p
a
t
14=
e
d
b
y
t
h
e
p
r
o
v
i
d
e
r
b
y
w
e
e
'
2
B
#
"
h
e
m
o
s
t
o
b
?
e
c
t
i
#
e
s
i
*
n
o
f
p
r
e
*
n
a
n
c
14A
y
i
s
f
e
t
a
l
m
o
#
e
m
e
n
t
f
e
l
t
b
y
t
h
e
e
@
a
m
i
n
e
r
.
%e"nancy test :$%esence of HCG* Softenin" of t!e 'te%ine ist!m's :He"a%Is si"n* Ce%(ical softenin"
:Goo&ellIs si"n*
!O# Disco+%orts in Pregnanc/
Discomfo%t T%imeste% N'%sin" Meas'%e
*ausea & @omiti&" e&ds o& the 1
st
trimester
N dry crac'ers & eat small freHue&t
feedi&"s
,ri&ary 8reHue&cy e&ds o& the 1
st
trimester Le"elEs e1ercise,
(ay start o& the 3
rd
trimester also
-reast te&der&ess all trimester phases N wear supportive well fitti&" bra
& .&"or"eme&t N avoid soap< to preve&t dryi&"
7eartbur& 2
&d
- 3rd N smaller meals, shorter i&tervals
N 6void fatty foods & *a -icarbo&ate
N ?ri&' mil' betwee& meals
N !&crease water :=-12 "lasses; - to
15B
mi&imi2e re"ur"itatio&
(uscle & 5e" cramps 3
rd
N le" e1te&sio& & feet dorsifle1io&
relief- &ursi&" i&terve&tio&
N .levate the le"s with a pillow
:+reve&tio&;
@aricosities 3
rd
%ear supportive hose# *)0 L*..
7!47 7)S.
-ach aches 3
rd
N %ear low heeled shoes# Sitti&" &
+elvic /oc'i&"
Supi&e 7ypote&sive 3
rd
N 5eft 5ateral side lyi&" positio&<
Sy&drome relieve i&ferior ve&a cava sy&drome
5eu'orrhea 3rd N 6void ?ouche# 7y"ie&e#
(atigue 2
nd
N due to )ron De%icienc/ Ane+ia
"he dia*nosis of iron.deficiency
anemia is made on the basis of a
hemo*lobin concentration #alue of
9C *>dl blood or less and a
hematocrit #alue of ECB or less.
(reDuent rest ,eriods A give dar4
lea%/ vegeta0les
#onsti,ation 2
n-
-2
rd
Prevention" *igh %i0er
)ntervention" )ncrease (luid
N&.E" Bul4 and %luid hel, increase
,eristalsis. La$atives and su,,ositories
should not 0e used routinel/ in
,regnanc/. Prevention is +ore
desira0le than treat+ent.
O# S=CH-L-GICAL CHANGES IN REGNANC=
TTRIMESTER
6
c
c
e
p
t
i
&
"
t
)i%st
"he benefits of dru* therapy out)ei*h the ris8s to the patient/s nausea is to control in a first trimester
patient/s nausea.
151
h
e
p
r
e
"
&
a
&
c
y
+
S
F
3
7
)
5
)
4
!
3
3
7
6
*
4
.
S
J
,
u
r
i
n
*
t
h
e
f
i
r
s
t
t
r
i
m
e
152
s
t
e
r
3
t
h
e
m
o
t
h
e
r
c
o
p
e
s
)
i
t
h
t
h
e
c
o
m
m
o
n
d
i
s
c
o
m
f
o
r
t
s
a
n
d
c
h
a
n
*
e
s
153
A
c
c
e
$
t
i
n
"
t
!
e
b
a
b
y
J
A
1
A
1
=
I
S
G
R
-
?
I
N
G
I
N
S
I
D
E
M
E
K
A
m
b
i
(
a
l
e
n
c
e
Secon&
"he second trimester of pre*nancy3 )omen *enerally feels their best.
154
.
D
u
r
i
n
g
t
h
e
s
e
c
o
n
d
t
r
i
+
e
s
t
e
r
5
,
s
/
c
h
o
s
o
c
i
a
l
t
a
s
4
s
i
n
c
l
u
d
e
+
o
t
155
h
e
r
-
i
+
a
g
e
d
e
v
e
l
o
,
+
e
n
t
5
c
o
,
i
n
g
6
i
t
h
0
o
d
/
i
+
a
g
e
a
n
d
s
e
$
u
a
l
i
t
/
c
156
h
a
n
g
e
s
5
a
n
d
,
r
e
n
a
t
a
l
0
o
n
d
i
n
g
.
8
e
a
r
8
a
&
t
a
s
i
e
s
a
b
o
u
t
m
o
t
h
e
r
h
o
o
d
a
15$
&
d
a
b
o
u
t
h
a
v
i
&
"
a
W
d
r
e
a
m
c
h
i
l
d
E
#
+
o
s
s
i
b
l
e
d
e
c
r
e
a
s
e
i
&
s
e
1
d
r
i
v
e
#
15=
T!i%&Alte%nate feelin"s of
emotional <ell9bein"
an& liability.
6ccepta&ce of pre"&a&cy#
+ossible i&crease i& se1#
6dustme&t to cha&"e i& body
ima"e#
8eeli&"s of aw'ward&ess a&d
clumsi&ess#
/e&ewed fears a&d te&sio&s
about labor#
Spurt of e&er"y duri&" last
mo&th#
.
+repari&" for pare&thood#
JI AM A M-THERK
,urin* the third trimester3 a 8ey
psychosocial tas8 is to o#ercome fears
the )oman may ha#e about the
un8no)n3 labor pain3 loss of self.
esteem3 loss of control3 and death.
"he emotions and fears that are
usually felt durin* the third trimester
are feelin*s of Nu*linessO3 alterations
in body self.ima*e and an@iety about
the comin* labor and deli#ery.
A. MATERNAL ADATATI-NS DURING REGNANC= / <it! 1I-L-GICAL TASHS -)
REGNANC=
)i%st T%imeste%A 6(-!@65.*3.- about pre"&a&cy< pre"&a&t woma& focus o&ly to self#
I am pre*nant. QAccept the biolo*ical fact of pre*nancy
Secon& T%imeste%A 633.+06*3.---of the ide&tificatio& of motherhood & aware&ess & i&terest i& the fetus#
I am *oin* to ha#e a babyQ Accept the *ro)in* fetus as distinct from self < as person to care for
T!i%& T%imeste%A .()0!)*65 56-!5!0F- assumi&" already the mother, fears & fa&tasies & dreams about
labor
I am *oin* to be a motherQPrepare realistically for birth < parentin*
1. ATERNAL ADAATATI-NS / REACTI-NS T- REGNANC=
#&!VADE S;ND&7E1 identification of the motherH ambi#alence < an@iety about the role chan*e
EEAL&!S; S.AGE" increase interest in mothers care.
SEL(-#&N#EP. #*ANGE" acti#e in#ol#ement in the fears < death of the fetus.
SECTI-N III
6*0.+6/065 3)(+5!360!)*S
A. Abo%tion
-termination of pre*nancy before the fetus is #iable (2: 6ee4s or a 6eight o% 3:: *7
15A
6-)/0!)*
0herapeutic Spo&ta&eous
!&evitable 0hreate&ed
)i". ... 0yp e s o f 6b o r t i o &
0F+.
S
?.8!*!0!)
*
S/S *,/S!*4
!*0./@.*0!)*
0hrea
te&ed
loss
that
ca&
be
preve
&ted9
aborti
ve
proce
ss is
"oi&"
o&-l
eedi&
" a&d
cervi
cal
dilati
o&Sa
ve
tissue
fra"
me&t
s3#
3om
plete
+rod
ucts
of
co&ce
ptio&
are
totall
y
e1pel
led(
i&ima
0he
co&ti&uatio&
of the
pre"&a&cy is
i& doubt
-leedi&"
or
spotti&"
closed
cervi1
-edrest, /estrictive
activity, Sedatio&, 6void
coitus for 2 wee's
followi&" last evide&ce
of bleedi&"
ho*am indicated )hen
a youn* patient has a
threatened abortion in
the first trimester and a
laboratory studies
re#eal an h ne*ati#e
and the husband is h
positi#e
16B
3omplete !&complete (issed 7abitual
l
bleed
i&"3
o&ti&
uous
mo&it
ori&"
1#
0hrea
te&ed
/ete&
tio&
of the
produ
cts of
co&ce
ptio&
after
fetal
death
!&ter
mitte
&t
bleed
i&"9
abse&
ce of
uteri&
e
"rowt
h.va
cuati
o&, ?
&
34#
!&co
mplet
e2#
!&evit
able
Some
fra"me&ts
are retai&ed
i&side the
uteri&e
cavity
+rofuse
bleedi&"
?ilatatio& & 3uretta"e9
,se of o1ytoci&<
O@ytocin nasal spray
should be administered
)hile the client is
sittin* )ith her head in
a #ertical position. A
nasal preparation must
not be administered
)ith the client lyin*
do)n or the head tilted
bac8 because this could
cause aspiration.
.vacuatio&
S
i
"
&
s
a
6#7abitual / /ecurre&t
161
&
d
S
y
m
p
t
o
m
s
?
i
a
"
&
o
s
t
i
c
0
e
s
t
s
(
a
&
a
"
e
m
e
&
t
+
r
o
v
i
d
e
!
@
,
(
o
&
162
i
t
o
r
b
l
e
e
d
i
&
"
,
3
o
u
&
t
p
e
r
i
&
e
a
l
p
a
d
s
,
p
s
y
c
h
o
l
o
"
i
c
a
l
s
u
p
p
o
r
t
5
#
(
i
s
163
s
e
d
1
?
e
s
c
ri
p
ti
o
&
<
6
p
r
e
"
&
a
&
c
y
t
h
a
t
o
c
c
164
u
r
s
i
&
a
&
o
t
h
e
r
t
h
a
&
u
t
e
ri
&
e
s
it
e
,
w
it
h
i
m
p
l
a
&
t
a
ti
o
&
u
s
u
a
ll
y
o
c
c
165
u
r
ri
&
"
i
&
f
a
ll
o
p
i
a
&
t
u
b
e
s
6
r
u
p
t
u
r
e
d
e
c
t
o
p
i
c
p
r
e
"
&
a
&
c
y
i
s
a
m
e
166
d
i
c
a
l
e
m
e
r
"
e
&
c
y
d
u
e
t
o
t
h
e
l
a
r
"
e
H
u
a
&
t
i
t
y
o
f
b
l
o
o
d
t
h
a
t
m
a
y
b
e
l
o
s
t
i
16$
&
t
h
e
p
e
l
v
i
c
a
&
d
a
b
d
o
m
i
&
a
l
c
a
v
i
t
i
e
s
#
S
h
o
c
'
m
a
y
d
e
v
e
l
o
p
f
r
o
m
b
l
o
o
d
16=
l
o
s
s
,
a
&
d
l
a
r
"
e
H
u
a
&
t
i
t
i
e
s
o
f
!
#
@
#
f
l
u
i
d
s
a
r
e
&
e
e
d
e
d
t
o
r
e
s
t
o
r
e
i
&
t
16A
r
a
v
a
s
c
u
l
a
r
v
o
l
u
m
e
u
&
t
i
l
t
h
e
b
l
e
e
d
i
&
"
i
s
s
u
r
"
i
c
a
l
l
y
c
o
&
t
r
o
l
l
e
d
#
+
1$B
a
i
&
m
a
y
b
e
c
a
u
s
e
d
b
y
a
r
u
p
t
u
r
e
d
o
r
d
i
s
t
e
&
d
e
d
f
a
l
l
o
p
i
a
&
t
u
b
e
o
r
b
l
o
o
d
1$1
i
&
t
h
e
p
e
r
i
t
o
&
e
a
l
c
a
v
i
t
y
#
3
a
u
s
e
s
N
O
"
$
1
B
e
c
a
u
s
e
s
,
o
n
t
a
n
e
o
u
s
a
0
1$2
o
r
t
i
o
n
i
s
t
h
r
e
a
t
e
n
i
n
g
5
a
l
l
,
e
r
i
n
e
a
l
,
a
d
s
+
u
s
t
0
e
i
n
s
,
e
c
t
e
d
%
o
r
1$3
t
h
e
,
r
o
d
u
c
t
s
o
%
c
o
n
c
e
,
t
i
o
n
.
%
l
u
i
d
r
e
p
l
a
c
e
m
e
n
t
i
s
n
e
c
e
s
s
a
r
y
b
e
c
a
1$4
u
s
e
o
f
b
l
o
o
d
l
o
s
s
3
sp
o&
ta
&e
ou
s
ab
ort
io
&s
oc
cu
rri
&"
su
cc
es
siv
el
y
-*arrowi&" of
tube
-+elvic i&fectio&
-.&dometriosis
-Smo'i&"
.+istory of IU,
usa*e
.
-@a"i&al -leedi&"
-=nife.li8e abdominal pain
-eferred pain on the ri*ht
shoulder
-Symptoms of Shoc8< decreased -+
i&creased //, fast but thready
pulse# "his is the number 9
complication.
-+elvic pressure of pelvic full&ess
-3ulle&Es si"&
-Pain unilaterally3 )ith crampin*
and tenderness
. Mass in the adne@al or cul.de.
sac
- Sli"ht, dar' va"i&al bleedi&"
- +rofou&d shoc' if rupture occurs
-3uldoce&tesis
-3uldoscopy
-/adioimmu&oassay of
elevated serum Hualitative
--eta-734
-6bdomi&al ,ltrasou&d
--lood samples of 7"b
a&d 7ct9 blood type a&d
"roup
(o&itor amou&t of
bleedi&"
6ssess vital si"&s
6ssess abdomi&al pai&
-lood tra&sfusio&
Sur"ery< Salpi&"ostomy
6dmi&ister /ho"am for
/h :-; clie&t
.he F1 #o+,lication o% Ecto,ic Pregnanc/ is *e+orrhagic Shoc4.
1$5
C. Hy&ati&ifo%m mole / T%o$!oblastic Disease / Mola% Disease
- 4estatio&al trophoblastic &eoplasm that arise from the chorio&9 characteri2ed
by the proliferatio& a&d de"e&eratio& of the chorio&ic or trophoblastic villi#
A patient )ith +ydatidiform mole has a positi#e si*ns of pre*nancy but is not pre*nant.
"he R9 Complication is #horiocarcino+a
"he "hree + of +.mole
9.*yper . emesis *ra#idarum
A. increase *c*
E. increase incidence for pi*
+/.?!S+)S!*4
8630)/S
0F+.S (6*!8.S060!)*S ?!64*)S0!3
0.S0S
(6*64.(.*0
1# INCOMP$"$N"
C$&I'S/non/+sD/s%unctional
cervi$Predis,osing?#ontri0uting
(actors"e,eated dilatation o% the cervi$5
+aternal DES ( Dieth/lstil0estrol9
E$,osure5 .rau+atic inGuries to the
cervi$. #ongenital ano+al/.he F1
#o+,lication o% *-+ole is
choriocarcino+a7olar evacuation ?
DA#Lo6 socioecono+ic status
2# 0rauma to the cervi1 :sur"ery / birth;
3# ,teri&e a&omaly
4# 7abitual abortio&
5# +re-term labor
1.
ii. D. Incom$etent ce%(i+
- +ai&less premature dilatatio& of the cervi1
:usually i& the 9:
th
to AC
th
)ee87
1# 3omplete/ classical parts of the villi are affected
2# !&complete/ partial- some parts are &ormal
1# @a"i&al bleedi&"
2# .1cessive */@
E. apid enlar*ement of the uterus
J. 0P7 Pre*nancy test
5# +ossible +!7
6# 6bdomi&al cramps
$# 6bse&t 87/
=# .levated 734 titer< 1-2 millio& !,9 *ormal level< 4BB,BBB !,
1$6
INC-METENT CER;I@
8i"ure 1A
2. 3hemotherapy
B. (o&itor 734 levels
3. ?elay childbeari&" pla&s for a year
H. +eri&eal pad cou&ts
I. !&struct the couple to have @64!*65 /.S0
: &o se1; for 1 year#
1# %ome& below 1= or above 35
2# !&ta'e of 3lomid :3lomiphe&e 3itrate;
3# %ome& of asia& herita"e
!&itial Si"&s734 titer determi&atio&
9. Ultrasound
2# O-ray of the abdome&
:. Sho) 0a pin8.stained #a*inal dischar*e7
$# F1 Sign1 upture of membranes and dischar*e
of amniotic fluid
1# 0he cervi1 dilates pai&lessly i& the
seco&d trimester of pre"&a&cy#
-loody show5ate si"&s<
2#+/)(
3#+ai&less dilatatio&
=# -irth of dead/&o&-viable fetus
A# +ressure or heavi&ess o& the lower abdome&#
1B# ,ltraso&o"raphy-est maor sur"ery<3ervical
3ercla"e, (c?o&ald 3ercla"eScree&i&" or
i&itial dia"&ostic
test<3ardi&al/+atho"&omo&ic/maor si"&<
11# ,ltrasou&d
+ossible sur"ical complicatio&<3o&formity test< 12# Sterility, rupture of the cervi1 premature
delivery, pelvic bleedi&" a&d i&fectio&#
Side lyi&" positio&?isease
complicatio&
+ro&e positio&
13# X9 +emorrha*e, .ctopic pre"&a&cy, birth
defects, viruses a&d pre"&a&cy diseases,
diabetes i& pre"&a&cy, 7+*
14# 4.S060!)*65 ?!6-.0.SDefinitionA t/,e
o% Dia0etes 6here onl/ ,regnant 6o+en gets
6here her 0lood sugar rate elevates 0ut never
had a high 0lood sugar rate 0e%ore
,regnanc/.SynonymsDiabetes &'%in"
%e"nancy *ursi&" ?ia"&osis3ervical
!&compete&ce*ursi&" !&terve&tio& Pre.
op1 $ncoura*e patient to maintain bed
rest(est side e4uipment(est position
before and after sur*ery
(Pillitteri5 7aternal and #hild Nursing5
,.2J1-J29
E. DIA1ETES MELLITUS
Suctio&
1$$
4estatio&al diabetes mellitus :pre"&a&cy
i&duced;
A pre*nant3 insulin.dependent diabetic is at
ris8 for sudden h/,ogl/ce+ia because insulin
needs and metabolism are affected b pre*nancy3
ma8in* sudden hypo*lycemic episodes more
common for diabetics.
3ha&"es i& the "lucose-i&suli& mecha&ism<
o .arly i& pre"&a&cy<
6# !&crease productio& of
i&suli&
-# (ater&al "lucose is
co&sumed by fetus
o 5ate i& pre"&a&cy<
6# (other develops
i&suli& resista&ce
-# 0he prese&ce of
place&tal i&suli&ase
brea's dow& i&suli&
rapidly
-# ?escriptio& of
?iabetes i& +re"&a&cy
)
1=A
2#
+
r
e
&
a
t
a
l
v
i
s
i
t
s
b
i
m
o
&
t
h
l
y
f
o
r
6
m
o
&
t
h
s
a
&
1AB
d
w
e
e
'
l
y
t
h
e
r
e
a
f
t
e
r
#
3#
#
a
l
o
r
i
e
s
i
n
d
i
e
t
s
h
o
u
l
d
c
o
1A1
n
s
i
s
t
o
%
3
:
K
t
o
H
:
K
c
a
r
0
o
h
/
d
r
a
t
e
s
5
1
2
K
t
o
2
:
K
,
1A2
r
o
t
e
i
n
5
a
n
d
2
:
K
t
o
2
:
K
%
a
t
4#
)
b
s
e
r
v
e
c
l
i
e
&
t
c
l
o
s
1A3
e
l
y
f
o
r
a
&
i
&
s
u
l
i
&
s
i
&
c
e
a
p
r
e
c
i
p
i
t
o
u
s
d
r
o
p
i
&
1A4
i
&
s
u
l
i
&
r
e
H
u
i
r
e
d
i
s
u
s
u
a
l
5#
(
o
&i
to
r
fo
r
si
"
&
s
of
i&
fe
ct
io
&
or
p
o
st
1A5
h
e
m
or
rh
a
"
e
6# If
a
p
r
e
*
n
a
n
t
d
i
a
b
e
t
i
c
i
s
i
n
l
a
b
o
r
3
h
e
r
b
l
o
o
d
1A6
*
l
u
c
o
s
e
s
h
o
u
l
d
b
e
m
o
n
i
t
o
r
e
d
h
o
u
r
l
y
.
"he
p
r
e
f
e
r
r
e
d
m
e
t
h
o
d
o
1A$
f
a
d
m
i
n
i
s
t
r
a
t
i
o
n
i
f
i
n
s
u
l
i
n
i
s
r
e
4
u
i
r
e
d
d
u
r
i
n
*
l
a
b
o
r
i
s
1A=
i
n
t
r
a
#
e
n
o
u
s
)07
.
/
!
(
+
)
/
0
6
*
0
(
6
*
6
4
.
(
.
*
0<
,
r
i
&
e
t
e
s
t
i
&
"
-
l
o
o
d
1AA
"
l
u
c
o
s
e
d
e
t
e
r
m
i
&
a
t
i
o
&
!
&
s
u
l
i
&
a
d
m
i
&
i
s
t
r
a
t
i
o
&
?
i
e
t
a
r
y
m
a
&
a
"
2BB
e
m
e
&
t
.
1
e
r
c
i
s
e
(
e
t
a
l
s
u
r
v
e
i
l
l
a
n
c
e
"
(
L
N
o
n
-
s
t
r
e
s
s
t
e
s
t
L
c
o
n
t
2B1
r
a
c
t
i
o
n
s
t
r
e
s
s
t
e
s
t
L
a
+
n
i
o
c
e
n
t
e
s
i
s
9
!
m
ba
la
&c
ed
&
ut
rit
io
&
re
la
te
d
to
i
m
ba
2B2
la
&c
ed
of
i&
su
li
&,
fo
o
d
a&
d
p
h
ys
ic
al
ac
ti
vi
ty
+o
te
&t
ia
l
he
at
h
ca
re
de
fi
ci
t
re
la
te
d
to
p
h
ys
ic
al
i
m
pr
o
ve
m
e&
ts
or
so
2B3
ci
al
fa
ct
or
s##
!&
su
li
&
.
H
ui
p
m
e&
t
F
1
E
te
r
n
al
E
le
ct
r
o
ni
c
(
et
al
*
e
a
rt
at
e
+
o
ni
to
ri
n
g
22.
)
et
al
D
ia
b
et
2B4
ic
C
o
m
$l
ic
at
io
ns
A
7
a
c
r
o
s
o
+
i
a
P
r
e
-
e
c
l
a
+
,
s
i
a
*
/
d
r
a
+
n
i
o
s
#
o
n
g
e
n
i
t
a
l
a
n
o
2B5
+
a
l
i
e
s
N
Strict ?iabetic ?iet
PEGNAN#; )ND!#ED *;PE.ENS)&N (.&>E7)A &( PEGNAN#;9
*6(. )8 07.
?!S.6S.
+/.-.356(+S!6 .356(+S!6
S
y
&
o
&
y
m
:
+
/
.
4
*
6
*
3
F
-
!
*
?
,
3
.
?
7
F
+
.
/
0
.
*
S
!
)
(!5? S.
@.
/.
2B6
*
;
+
r
e
d
i
s
p
o
s
i
&
"
/
3
o
&
t
r
i
b
u
t
i
&
"
f
a
c
t
o
r
s
-
P
r
i
+
i
,
a
r
a
s
/
o
u
n
g
e
r
2B$
t
h
a
n
a
g
e
2
:
/
e
a
r
s
o
r
o
l
d
e
r
t
h
a
n
B
:
/
e
a
r
s
'
6
o
+
e
n
%
r
o
+
2B=
l
o
6
s
o
c
i
o
e
c
o
n
o
+
i
c
0
a
c
4
g
r
o
u
n
d
0
e
c
a
u
s
e
o
%
,
o
o
r
n
u
t
r
i
t
i
o
2BA
n
'
6
o
+
e
n
o
%
c
o
l
o
r
'
6
o
+
e
n
6
i
t
h
h
e
a
r
t
d
i
s
e
a
s
e
5
d
i
a
0
e
t
e
s
6
21B
i
t
h
v
e
s
s
e
l
o
r
r
e
n
a
l
i
n
v
o
l
v
e
+
e
n
t
5
a
n
d
e
s
s
e
n
t
i
a
l
h
/
,
e
r
t
e
n
s
211
i
o
n
'
,
o
o
r
c
a
l
c
i
u
+
a
n
d
+
a
g
n
e
s
i
u
+
i
n
t
a
4
e
(
P
i
l
l
i
t
t
e
r
i
5
A
.
1
J
212
J
J
,
.
2
J
2
9
h
/
d
a
t
i
d
i
%
o
r
+
+
o
l
e
'
+
u
l
t
i
,
l
e
g
e
s
t
a
t
i
o
n
5
,
o
l
/
h
/
d
213
r
a
+
n
i
o
s
5
,
r
e
-
e
$
i
s
t
i
n
g
v
a
s
c
u
l
a
r
d
i
s
e
a
s
e
(
.
h
e
L
i
,
,
i
n
c
o
t
t
7
214
a
n
u
a
l
o
%
N
u
r
s
i
n
g
P
r
a
c
t
i
c
e
5
I
t
h
e
d
.
5
2
:
:
1
.
,
.
1
1
J
:
;
-
A
*
e
.
r
e
l
a
215
t
e
d
c
o
n
c
e
r
n
1
a
d
o
l
e
s
c
e
n
t
s
a
n
d
p
r
i
m
i
p
a
r
a
s
o
#
e
r
a
*
e
E
F
a
r
216
e
a
t
h
i
*
h
e
r
r
i
s
8
f
o
r
p
r
e
e
c
l
a
m
p
s
i
a
.
0
N
u
r
s
e
s
/
E
m
i
n
u
t
e
s
21$
c
l
i
n
i
c
a
l
p
a
*
e
J
J
A
.
J
J
E
A
u
t
h
o
r
1
-
l
o
r
i
a
%
,
o
n
n
e
l
l
y
M
.
P
h
d
21=
c
r
e
e
n
i
n
g
?
)
n
i
t
i
a
l
d
i
a
g
n
o
s
t
i
c
t
e
s
t
B
l
o
o
d
,
r
e
s
s
u
r
e
o
v
e
r
1
B
:
?
J
!&itial Si"& BM1B:?J: ++Gh on at least t6o occasion M H hours a,art (.he 5ippi&cott
(a&ual of *ursi&" +ractice $
th
ed#,2BB1#p#11AB; protei&uria of 1-2U o& a
ra&dom sample9 wei"ht "ai& over 2 lbs per wee' i& seco&d trimester a&d 1 l0
,er 645 third trimester9 mild edema i& upper e1tremities or face :+illitteri, a#,
1AAA#p#3A5;
BP
M1H
:?1
1:
++
*g
or
dias
toli
c
,re
ssu
reM
11:
++
*g
on
t6o
occ
asio
ns
at
leas
t H
hou
rs
a,a
rt
6it
h
the
,ati
ent
on
0ed
rest
'
,rot
ein
uri
a
M3
0?2
B h
or
2N
to
BN
on
Hual
itati
ve
asse
ssm
e&t
:uri
21A
:
5
o
r
i
n
c
r
e
a
s
e
o
%
2
:
+
+
s
/
s
t
o
l
i
c
5
1
3
+
+
d
i
a
s
t
o
l
i
c
o
v
e
r
,
r
e
-
,
r
e
&e
dips
tic'
;
:0h
e
5ip
pi&c
ott
(a
&ual
of
&urs
i&"
+rac
tice
$
th
ed#2
BB1#
p#11
AB;
e$tr
e+e
ede
+a
in
han
ds
and
%ac
e?C
,u%%
ines
sC
:+ill
itter
i,6#,
1AA
A#p#
3A6
;
22B
g
n
a
n
c
/
l
e
v
e
l
.
(
P
i
l
l
i
t
t
e
r
i
5
A
.
1
J
J
J
.
,
.
2
J
3
9
7
a
i
n
t
a
i
n
i
n
g
(
l
u
i
d
221
B
a
l
a
n
c
e
(
l
u
i
d
v
o
l
u
+
e
e
$
c
e
s
s
r
e
l
a
t
e
d
t
o
,
a
t
h
o
,
h
/
s
i
o
l
o
g
i
c
c
h
a
222
n
g
e
s
o
%
P
)
*
a
n
d
i
n
c
r
e
a
s
e
d
r
i
s
4
o
%
%
l
u
i
d
o
v
e
r
l
o
a
d
.
*
/
,
e
r
t
e
n
s
223
i
o
n
a
n
d
,
r
o
t
e
i
n
u
r
i
a
a
r
e
t
h
e
+
o
s
t
s
i
g
n
i
%
i
c
a
n
t
.
E
d
e
+
a
i
s
s
i
g
n
i
224
%
i
c
a
n
t
o
n
l
/
i
%
h
/
,
e
r
t
e
n
s
i
o
n
a
n
d
,
r
o
t
e
i
n
u
r
i
a
o
r
s
i
g
n
s
o
%
+
u
l
t
i
225
-
o
r
g
a
n
s
/
s
t
e
+
i
n
v
o
l
v
e
+
e
n
t
a
r
e
,
r
e
s
e
n
t
.
(
P
i
l
l
i
t
t
e
r
i
5
A
.
5
1
J
J
J
226
.
,
.
2
J
B
9
N
u
r
s
i
n
g
D
i
a
g
n
o
s
i
s
a
n
d
N
u
r
s
i
n
g
)
n
t
e
r
v
e
n
t
i
o
n
s
D
u
r
i
n
g
22$
,
r
e
g
n
a
n
c
/
5
0
l
u
r
r
e
d
v
i
s
i
o
n
+
a
/
0
e
a
d
a
n
g
e
r
s
i
g
n
o
%
,
r
e
e
c
l
a
+
,
22=
s
i
a
o
r
e
c
l
a
+
,
s
i
a
5
c
o
+
,
l
i
c
a
t
i
o
n
s
t
h
a
t
r
e
D
u
i
r
e
i
+
+
e
d
i
a
t
e
a
t
t
e
n
t
i
22A
o
n
0
e
c
a
u
s
e
t
h
e
/
c
a
n
c
a
u
s
e
s
e
v
e
r
e
+
a
t
e
r
n
a
l
a
n
d
%
e
t
a
l
c
o
n
s
e
D
u
e
n
23B
c
e
s
.
#
a
r
d
i
n
a
l
?
P
a
t
h
o
g
n
o
+
o
n
i
c
?
7
a
G
o
r
S
i
g
n
&
l
i
g
a
u
r
i
a
O
B
:
:
t
o
3
231
:
:
+
l
?
2
B
h
'
c
e
r
e
0
r
a
l
o
r
v
i
s
u
a
l
d
i
s
t
u
r
0
a
n
c
e
s
(
a
l
t
e
r
e
d
l
e
v
e
l
o
%
c
232
o
n
s
c
i
o
u
s
n
e
s
s
5
h
e
a
d
a
c
h
e
5
s
c
o
t
o
+
a
t
a
5
o
r
0
l
u
r
r
e
d
v
i
s
i
o
n
9
'
e
,
i
g
a
s
233
t
r
i
c
,
a
i
n
o
r
!
P
,
a
i
n
5
,
u
l
+
o
n
a
r
/
e
d
e
+
a
o
r
c
/
a
n
o
s
i
s
'
i
+
,
a
i
r
e
d
234
l
i
v
e
r
%
u
n
c
t
i
o
n
o
%
u
n
c
l
e
a
r
e
t
i
o
l
o
g
/
'
t
h
r
o
+
0
o
c
/
t
o
,
e
n
i
a
(
,
l
a
t
e
235
l
e
t
c
o
u
n
t
Q
1
3
:
5
:
:
:
9
'
d
e
v
e
l
o
,
+
e
n
t
o
%
e
c
l
a
+
,
s
i
a
:
0
h
e
5
i
p
p
i
&
c
o
tt
(
a
236
&
u
a
l
o
f
*
u
r
s
i
&
"
+
r
a
c
ti
c
e
,
$
th
e
d
#
2
B
B
1
#
p
#
1
1
A
B
;
e
l
e
v
a
t
e
d
s
e
r
u
m
c
r
e
a
23$
ti
&
i
&
e
N
1
#
2
m
"
/
d
l9
c
a
r
d
i
a
c
i
&
v
o
l
v
e
m
e
&
t9
e
1
t
e
&
s
i
v
e
p
e
r
'
i
p
h
e
r
a
l
e
d
e
m
23=
a
:
+
il
li
tt
e
r
i,
a
#,
1
A
A
A
#
p
#
3
A
5
;
5
a
t
e
S
i
"
&
S
i
*
n
s
o
f
6
o
r
s
e
n
i
n
*
P
I
+
o
r
I
m
23A
p
e
n
d
i
n
*
S
e
i
2
u
r
e
s
1# 3
o
&
t
r
o
l
!
@
i
&
t
a
'
e
u
s
i
&
"
a
c
o
&
t
i
&
u
o
u
s
i
&
f
24B
u
s
i
o
&
p
u
m
p
#
2# (
o
&
i
t
o
r
i
&
p
u
t
a
&
d
o
u
t
p
u
t
s
t
r
i
c
t
l
y
9
&
o
t
i
f
y
h
e
a
241
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
i
f
u
r
i
&
e
o
u
t
p
u
t
i
s
Y
3
B
m
l
/
h
#
3# (
o
&
i
t
o
r
h
e
242
m
a
t
o
c
r
i
t
l
e
v
e
l
s
t
o
e
v
a
l
u
a
t
e
i
&
t
r
a
v
a
s
c
u
l
a
r
f
l
u
i
d
s
t
a
t
u
s
#
4# (
243
o
&
i
t
o
r
v
i
t
a
l
s
i
"
&
s
e
v
e
r
y
h
o
u
r
#
5# 6
u
s
c
u
l
t
a
t
e
b
r
e
a
t
h
s
o
u
&
d
s
244
e
v
e
r
y
2
h
o
u
r
s
,
a
&
d
r
e
p
o
r
t
s
i
"
&
s
o
f
p
u
l
m
o
&
a
r
y
e
d
e
m
a
:
w
h
245
e
e
2
i
&
"
,
c
r
a
c
'
l
e
s
,
s
h
o
r
t
&
e
s
s
o
f
b
r
e
a
t
h
,
i
&
c
r
e
a
s
e
d
p
u
l
s
e
246
r
a
t
e
,
i
&
c
r
e
a
s
e
d
r
e
s
p
i
r
a
t
o
r
y
r
a
t
e
;
#
+romoti
&"
6de
Huat
0iss
ue
+erf
usio
1#
+
2#
(
3#
.
24$
4#
!
5#
6#
+
!
&
s
t
r
u
c
t
o
&
t
h
e
i
m
p
o
r
t
a
&
c
e
o
f
r
e
p
o
r
t
i
&
"
h
e
a
d
a
c
h
e
24=
s
,
v
i
s
u
a
l
c
h
a
&
"
e
s
,
d
i
2
2
i
&
e
s
s
,
a
&
d
e
p
i
"
a
s
t
r
i
c
p
a
i
&
#
!
&
s
t
r
u
24A
c
t
t
o
l
i
e
d
o
w
&
o
&
l
e
f
t
s
i
d
e
i
f
s
y
m
p
t
o
m
s
a
r
e
p
r
e
s
e
&
t
#
L
e
e
p
25B
t
h
e
e
&
v
i
r
o
&
m
e
&
t
H
u
i
e
t
a
&
d
a
s
c
a
l
m
a
s
p
o
s
s
i
b
l
e
#
!
f
p
a
t
i
e
&
251
t
i
s
h
o
s
p
i
t
a
l
i
2
e
d
,
s
i
d
e
r
a
i
l
s
s
h
o
u
l
d
b
e
p
a
d
d
e
d
a
&
d
r
e
m
a
i
252
&
u
p
t
o
p
r
e
v
e
&
t
i
&
u
r
y
i
f
s
e
i
2
u
r
e
o
c
c
u
r
s
#
H.
*)
(ai&tai
&i&"
3ar
diac
)ut
put
1#
(
253
2#
(
3#
(
4#
6
5#
(
6#
$#
:
6
l
t
e
r
e
d
t
i
s
s
u
e
p
e
254
r
f
u
s
i
o
&
,
8
e
t
a
l
c
a
r
d
i
a
c
a
&
d
c
e
r
e
r
a
l
,
r
e
l
a
t
e
d
t
o
a
l
255
t
e
r
e
d
p
l
a
c
e
&
t
a
l
b
l
o
o
d
f
l
o
w
c
a
u
s
e
d
b
y
v
a
s
o
s
p
a
s
m
256
a
&
d
t
h
o
m
b
o
s
i
s
#
/
i
s
'
f
o
r
i
&
u
r
y
r
e
l
a
t
e
d
t
o
c
o
&
25$
v
u
l
s
i
o
&
s
#
?
e
c
r
e
a
s
e
d
c
a
r
d
i
a
c
o
u
t
p
u
t
r
e
l
a
t
e
d
t
o
25=
d
e
c
r
e
a
s
e
d
p
r
e
l
o
a
d
o
r
a
&
t
i
h
y
p
e
r
t
e
&
s
i
v
e
t
h
e
r
a
p
y
#
25A
(
26B
P
9
:
C
>
9
9
C
m
m
+
*
o
r
a
b
o
#
e
$
p
i
*
a
s
t
r
i
c
p
a
i
n
,
e
c
r
e
a
s
e
d
261
u
r
i
n
a
r
y
o
u
t
p
u
t
&
i
s
u
a
l
c
h
a
n
*
e
s
+
e
a
d
a
c
h
e
.
h
e
6
o
+
a
n
n
e
e
3o&firmatory 0est 2B-hour urine %or ,rotein o% 2:: +g or greater' elevated seru+ B!N and
creatinine' increased dee, tendon re%le$es and clonus' 0lood ,ressure
changes +eeting criteria %or diagnosis :0he 5ippi&cott (a&ual of *ursi&"
+ractice,$
th
ed#, 2BB1#p#11AB;
262
d
s
a
+
o
d
e
r
a
t
e
t
o
h
i
g
h
-
,
r
o
t
e
i
n
5
+
o
d
e
r
a
t
e
-
s
o
d
i
u
+
d
i
e
t
t
o
263
c
o
+
,
e
n
s
a
t
e
%
o
r
t
h
e
,
r
o
t
e
i
n
s
h
e
i
s
l
o
s
i
n
g
.
(
P
i
l
l
i
t
t
e
r
r
i
5
A
264
.
5
1
J
J
J
.
,
.
2
J
@
9
S
i
g
n
s
a
n
d
s
/
+
,
t
o
+
s
o
%
s
e
v
e
r
e
,
r
e
-
e
c
l
a
+
,
s
i
a
265
5
,
.
2
J
3
'
t
e
+
,
e
r
a
t
u
r
e
r
i
s
e
s
s
h
a
r
,
l
/
t
o
2
J
.
B
R
#
o
r
B
:
S
#
(
1
266
:
2
S
(
t
o
1
:
B
S
(
9
%
r
o
+
i
n
c
r
e
a
s
e
d
c
e
r
e
0
r
a
l
e
d
e
+
a
'
r
e
%
l
e
$
e
s
26$
0
e
c
o
+
e
h
y
p
e
r
a
c
t
i
v
e
p
#
3
A
A
,
p
r
e
m
o
&
i
t
i
o
&
t
h
a
t
R
s
o
m
e
t
h
i
&
"
i
s
26=
h
a
,
,
e
n
i
n
g
C
'
e
,
i
g
a
s
t
r
i
c
,
a
i
n
a
n
d
n
a
u
s
e
a
'
u
r
i
n
a
r
/
o
u
t
,
u
26A
t
l
e
s
s
t
h
a
n
2
:
+
l
?
h
p
#
4
B
B
:
+
i
l
l
i
t
t
e
r
i
,
6
#
,
1
A
A
A
;
-
e
s
t
?
i
e
?isease 3omplicatio&s A0ru,tio ,lacentae (+ypertension in PI+ leads to #asopasm. "his in turn
causes the placenta to tear a)ay from the uterine )all 0abrupto placentae7
0Mosby/s Comprehensi#e e#e) of Nursin* for NCL$'. N p. AA:7
disse+inated intravascular coagulation' *ELLP s/ndro+e' ,re+aturit/'
intrauterine gro6th restriction ()!G9 from decreased place&tal perfusio&9
mater&al/fetal death9 hyperte&sive crisis9 acute re&al failure9 hemorrha"e9
2$B
t cerebrovascular accide&t9 bli&d&ess9 hypo"lycemia9 hepatic rupture :0he
5ippi&cott (a&ual of *ursi&" +ractice,$
th
ed#, 2BB1#pp#11A2;
-est +ositio& SEVEE PE#LA7PS)A" Lateral recu+0ent ,osition
(Pillitteri5A.51JJJ.,.2JI9 E#LA7PS)A" to ,revent as,iration5 turn the 6o+an
on her side to allo6 secretions to drain %ro+ her +outh.
(Pillitteri5A.51JJJ.,.B::9
-eside .Huipme&t !&fusio& pump9 pulse o1imeter :0he 5ippi&cott (a&ual of *ursi&" +ractice,$
th
ed#,2BB1#pp#11A2-11A3;
A
.
Se(
e%el
y
$ai
nf'
l
.
He
a(y
ble
e&i
n"
</c
ma
ybe
$a%
tiall
yLc
om
$let
ely
!i&
&en
.
Ri"
i&
:bo
a%&
li2e
*D
ten
&e%
'te
%'s
$os
sibl
e </
con
1est D%'" M"nesi'm s'lfateA .94 loa&in" &ose of 08M "i(e
I; o(e% #0938 mins follo<e& by a maintenance
&ose :secon&a%y inf'sion* of #9. "/! o% IM
inNection o% #8 " :0 " in eac! b'ttoc2* as a
loa&in" &ose follo<e& by 0 " e(e%y . !o'%s :T!e
Li$$incott Man'al of N'%sin" %acticeD5
t!
e&.D
,88#.$$.##78*s
Ad+inister antih/,ertensives such as h/drala8ine
(A,resoline9 as ,rescri0ed5 to ,revent a
cere0rovascular accident
2$1
t%a
ctio
ns
.
S!o
c2
see
min
" to
be
o't
of
$%o
$o%
tion
.
Si"
ns
of
feta
l
&ist
%ess
.
ainl
ess
.
Hea(
y
blee&
in"
. SoftD
non
ten&e
%D
%ela+
e&
'te%'
s </
no%m
al
tone
.
S!oc
2 in
$%o$
o%tio
n to
2$2
obse%
(e&
bloo
&
loss
.
Si"ns
of
fetal
&ist%
ess
's'al
ly
not
$%ese
nt
G
lacentaA
c
o
n
t
a
i
n
s
,
8
c
o
t
y
l
e
&
o
n
s
D
2$3
<
e
i
"
!
s
.
8
8
9
4
8
8
"
%
a
m
s
.
D
e
(
e
l
o
$
s
o
n
t
!
e
3
%
&
m
o
n
t
!
.
)
o
%
m
f
%
o
m
C
!
o
2$4
%
i
o
n
i
c
(
i
l
l
i
&
&
e
c
i
&
'
a
s
b
a
s
a
l
i
s
.
D
e
c
i
&
'
a
s
:
m
e
a
n
i
n
"
e
n
&
o
m
e
t
%
i
a
2$5
l
c
!
a
n
"
e
s
&
"
%
o
<
t
!
*
)'nctionsA
M
a
i
n
s
o
'
%
c
e
o
f
n
o
'
%
i
s
!
m
e
n
t
&
a
c
t
s
a
t
%
a
n
s
2$6
f
e
%
o
%
"
a
n
f
o
%
m
e
t
a
b
o
l
i
c
$
'
%
$
o
s
e
s
f
o
%
t
!
e
f
e
t
'
s
.
lacental %oblem
lace
ntal
se$a%
ation
is
c!a%a
cte%i3
e& by
a
2$$
s'&&e
n
"'s!
o%
t%ic2l
e of
bloo&
f%om
t!e
(a"in
aD
f'%t!e
%
$%ot%
'sion
of t!e
'mbil
ical
co%&
f%om
t!e
(a"in
aD a
"lob'l
a%9
s!a$e
&
'te%'
sD an&
an
inc%ea
se in
f'n&a
l
!ei"!t
. ?it!
ce%(ic
al o%
(a"in
al
lace%a
tionD
t!e
n'%se
notes
a
consis
tent
flo<
of
b%i"!t
%e&
bloo&
f%om
t!e
(a"in
2$=
a.
?it!
$ost$
a%t'm
!emo
%%!a"
eD
's'all
y
ca'se
& by
'te%in
e
atonyD
t!e
'te%'
s isnOt
"lob'l
a%.
Ute%i
ne
in(ol'
tion
canOt
be"in
'ntil
t!e
$lace
nta
!as
been
&eli(e
%e&.
lace
nta
%e(i
a :lo<
im$la
ntatio
n*
St
N
2$A
#
S
M
N
)
N
?
A
R
Si
T
SIDE
E))E
CT
F1
#o+,
licatio
n o%
2=B
7gS
&B
is "
es,i
rator/
De,re
ssion
%e&is$osin" )acto%sANat'%e of t!e D%'"
D (ultiparityD 6dva&ci&" mater&al a"e, D (ultiple
"estatio&D 6lteratio& i& the uteri&e structures
%e&is$osin" )acto%sA
D 3hro&ic 7yperte&sive diseaseD history of a short cord D
(ulti"ravida D trauma
+563.*06
+/.@!6N'%sin"
Consi&e%ationsA
. 3lie&t is hospitali2ed a&d
put o& bed rest
# 3o&ti&ually mo&itor fetal
well- bei&"
# 3aesarea& delivery
i&dicate
# (easure blood loss
throu"h peri&eal pad cou&ts
# *) va"i&al e1ams
# +rovide emotio&al support
N'%sin" Consi&e%ationsA
# -ed rest i& wed"e positio& too preve&t supi&e hypote&sio&
.
# 3o&ti&ually mo&itor fetal well- bei&"
# 0reat si"&s of shoc' a&d hemorrha"e
# +rovide emotio&al support
# +repare for delivery
?efi&itio&
LACENTA RE;IA
8i"ure 2B a
N !mproperly impla&ted place&ta i& the lower uteri&e se"me&t &ear or over
the i&ter&al cervical os
N 0otal< the i&ter&al os is e&tirely covered by the place&ta whe& cervi1 is fully
dilated
N (ar"i&al< o&ly a& ed"e of the place&ta e1te&ds to the i&ter&al os
N 5ow-lyi&" place&ta< impla&ted i& the lower uteri&e se"me&t but does &ot
reach the os :Sau&ders pa"e 2AA;
+redisposi&" 8actor N (ater&al a"e
N +arity :&o# )f pre"&a&cy;
N +revious uteri&e sur"ery
3ardi&al (a&ifestatio& N +ai&less bleedi&" as early as $ mo&ths :mild to hemorrha"e;
N Soft uterus
N 6bdomi&al fetal positio& of breech or tra&sverse lie
N ,teri&e co&tractio&s
N 6&emic
3omplicatio& N a&emia, X1hemorrha*e, X2shoc8, re&al failure, X3 disseminated
intra#ascular coa*ulation, cerebral ischemia, mater&al a&d fetal death
:*ursi&" 6lert p#41=;
0herapeutic !&terve&tio&s N ,ltraso&o"raphy to co&firm the pressure of place&ta previa#
N ?epe&ds o& locatio& of place&ta, amou&t of bleedi&" a&d status of the
fetus#
N 7ome mo&itori&" with repeated ultrasou&ds may be possible with type !-
low lyi&"
N 3o&trol bleedi&"
N /eplace blood loss if e1cessive
N 3esarea& birth if &ecessary
N -etamethaso&e is i&dicated to i&crease fetal lu&" maturity# :(osby,
2=1
3omprehe&sive p# 2B3;
*ursi&" ?ia"&osis with
*ursi&" !&terve&tio&
F1 N!S)NG D)AGN&S)S" Potential %luid volu+e de%icit
N (ai&tai& bed rest
N F1 Assess+ent - 7onitor +aternal vital signs5 (*5 and %etal activit/
N 6ssess bleedi&" :amou&t a&d Huality;
N (o&itor a&d treat si"&s of shoc'
N 6void va"i&al e1ami&atio& if bleedi&" is occurri&"
N +repare for premature birth or cesarea& sectio&
N 6dmi&ister !@ fluids as ordered
N 6dmi&ister iro& suppleme&ts or blood tra&sfusio& as ordered :mai&tai&
hematocrit level;
N +repare to admi&ister /h immu&e "lobuli&
-.S0+)S!0!)* .he ,atient 6ith ,lacenta ,revia should 0e +aintained on 0ed rest5
,re%era0l/ in a side-l/ing ,osition. Additional ,ressure %ro+ an u,right
,osition +a/ cause %urther tearing o% the ,lacenta %ro+ the uterine lining.
A+0ulating 6ould there%ore 0e indicated %or this ,atient. Per%or+ing a
vaginal e$a+ination and a,,l/ing internal scal, electrode could also cause
the ,lacenta to 0e %urther torn %ro+ the uterine lining.
2=2
A
A
1
R
U
T
I
-
L
A
C
E
N
T
A
E
8
i
"
u
r
e
2
1
3o&firmatory 0est N ,ltrasou&d for place&ta locali2atio&
*)0.<
Manual pel#ic e@aminations are contraindicated
)hen #a*inal bleedin* is apparent in the third
trimester unit a dia*nosis is made and placenta
pre#ia is ruled out. ,i*ital e@amination of the
cer#i@ can lead to maternal and fetal
hemorrha*e. A dia*nosis of placenta pre#ia is
made by ultrasound. "he hemo*lobin and
hematocrit le#els are monitored and e@ternal
electronic fetal heart rate monitorin* is initiated.
$lectronic fetal monitorin* 0e@ternal7 is crucial
in e#aluatin* the status of the fetus )ho is at ris8
for se#ere hypo@ia. 0Saunders Comprehensi#e
ACCA $dition3 p. ECJ7
2=3
+
r
e
d
i
s
p
o
s
i
&
"
8
a
c
t
o
r
N
(
a
t
e
?efi&itio& +remature separatio& of the place&ta from the
uteri&e wall after the 2B
th
wee' of "estatio& a&d
before the fetus is delivered :Sau&ders pa"e 2AA-
3BB;
2=4
r
&
a
l
a
"
e
N
+
l
a
c
e
&
t
a
l
a
b
r
u
p
t
i
o
&
-
e
s
t
+
o
s
i
t
i
o
&
N
+
a
r
i
t
y
N
2=5
+
r
e
v
i
o
u
s
a
b
r
u
p
t
i
o
p
l
a
c
e
&
t
a
e
,
m
u
l
t
i
f
e
t
a
l
"
e
s
t
a
t
i
o
&
N
7
y
p
e
r
t
2=6
e
&
s
i
o
&
*
)
0
.
<
A
b
r
u
p
t
i
o
p
l
a
c
e
n
t
a
e
i
s
a
s
s
o
c
i
a
t
e
d
)
i
t
h
c
o
n
d
i
t
2=$
i
o
n
s
c
h
a
r
a
c
t
e
r
i
2
e
d
b
y
p
o
o
r
u
t
e
r
o
p
l
a
c
e
n
t
a
l
c
i
r
c
u
l
a
t
i
o
n
3
s
u
2==
c
h
a
s
h
y
p
e
r
t
e
n
s
i
o
n
3
s
m
o
8
i
n
*
a
n
d
a
l
c
o
h
o
l
o
r
c
o
c
a
i
n
e
a
b
u
s
e
.
2=A
I
t
i
s
a
l
s
o
a
s
s
o
c
i
a
t
e
d
)
i
t
h
p
h
y
s
i
c
a
l
a
n
d
m
e
c
h
a
n
i
c
a
l
f
a
c
t
o
2AB
r
s
s
u
c
h
a
s
o
#
e
r
d
i
s
t
e
n
s
i
o
n
o
f
t
h
e
u
t
e
r
u
s
t
h
a
t
o
c
c
u
r
s
)
i
t
2A1
h
m
u
l
t
i
p
l
e
*
e
s
t
a
t
i
o
n
o
r
p
o
l
y
h
y
d
r
a
n
i
o
n
s
.
I
n
a
d
d
i
t
i
o
n
3
a
s
h
o
2A2
r
t
u
m
b
i
l
i
c
a
l
c
o
r
d
3
p
h
y
s
i
c
a
l
t
r
a
u
m
a
3
a
n
d
i
n
c
r
e
a
s
e
d
m
a
t
e
r
n
a
l
2A3
a
*
e
a
n
d
p
a
r
i
t
y
a
r
e
r
i
s
8
f
a
c
t
o
r
s
.
0
S
a
u
n
d
e
r
s
C
o
m
p
r
e
h
e
n
s
i
#
e
2A4
A
C
C
A
$
d
i
t
i
o
n
3
p
.
E
C
F
7
N
+
r
e
m
a
t
u
r
e
s
e
p
a
r
a
t
i
o
&
o
f
p
l
a
c
2A5
e
&
t
a
S
y
&
o
&
y
m
s
Pathophysiolo*y S Spontaneous rupture of blood #essels at the
placental bed may due to lac8 of resiliency or to
abnormal chan*es in uterine #asculature.
S May be complicated by hypertension or by an
enlar*ed uterus that can/t contract sufficiently to
seal off the torn #essels
S Conse4uently3 bleedin* continues unchec8ed3
possibly shearin* off the placenta partially or
completely. 0Nursin* Alert p.J7
(a&ifestatio& N +ai&ful va"i&al bleedi&"
N 7yperto&ic to teta&ic, e&lar"ed uterus
N Board-li4e rigidit/ o% a0do+en (#ullen Sign9
N 6b&ormal/abse&t fetal heart to&es
N +allor
N 3ool, moist s'i&
N -loody am&iotic fluid
N /isi&" fu&dal hei"ht from blood trapped behi&d
the place&ta
N Si"&s of shoc'
N (a&ifestatio& of coa"ulopathy
NO"$1
Uterine tenderness accompanies placental
abruption3 especially )ith a central abruption and
trapped blood behind the placenta. "he abdomen
)ill feel hard and boardli8e upon palpation as the
blood penetrates the myometrium and causes uterine
irritability. Obser#ation of the fetal monitorin* often
re#eals increased uterine restin* tone3 caused by
failure of the uterus to rela@ in an attempt to
constrict blood #essels and control bleedin*.
0Saunders Comprehensi#e ACCA $dition3 p. ECJ7
3omplicatio& S +emorrha*e3 shoc83 renal failure3 disseminated
intra#ascular coa*ulation3 maternal death3
fetal death0Nursin* Alert p.J7
"herapeutic Inter#entions N /eplaceme&t of blood loss#
N %ith moderate or severe separatio& or mater&al or
fetal distress< emer"e&cy childbirth#
*)0.<
.he goal o% +anage+ent in a0ru,tion
,lacentae is to control the he+orrhage and
deliver the %etus as soon as ,ossi0le. Deliver/
is the treat+ent o% choic i% the %etus is at ter+
gestation or i% the 0leeding is +oderate to
severe and +other or %etus is in Geo,ard/.
(Saunders #o+,rehensive 2::2 Edition5 ,.
2:B9
N %ith mild separatio& without fetal distress a&d i&
the prese&ce of some cervical effaceme&t a&d
*u
rsi
&"
?ia
"&
osi
s
wit
h
!&t
erv
e&t
io&
2A6
dilatatio&< i&ductio& of labor may be attempted
N)1y"e& if &ecessary
N (ai&te&a&ce of fluid a&d electrolytes bala&ce#
:(osby, 3omprehe&sive p# 2B4;
X1 *,/S!*4 ?!64*)S!S< /is' for fluid volume deficit3o&firmatory 0estN ,ltrasou&d detects
retro-place&tal bleedi&"
;ENA CA;A S=NDR-ME
?efi&itio& 0he ve&ous retur& to the heart is impaired by the wei"ht
of uterus#
Sy&o&ym Supi&e 7ypote&sive
Sy&drome
+redisposi&" factors 0hrombophlebitis
*)0.<
3o&tribute to clot
formatio& motio&
i&clude
i&activity,reduced
cordiac output,
compressio& of the
vie&s i& pelvis or
le"s
"he most li8ely
cause of supine
hypotension is
feelin* di22y3 short
of breath and
clammy )hen lyin*
bac8 for lon*
periods of time in
patients :
th
month of
pre*nancy.
"he cause of
supine hypotension
durin* pre*nancy
is the )ei*ht of the
uterus compresses
the inferior #ena
ca#a3 decreasin*
the return of blood
to the heart3 thus
decreasin* cardiac
output3 )hich
lo)ers the blood
pressure
!&itial si"& 8atiHue, pro1ymal
&octur&al dysp&ea,
orthop&ea, hypo1ia,
cya&osis
5ate Si"& /educe re&al
perfectio&, ?ecrease
"lomerular filtratio&
3ardi&al si"& shoc' such as
2A$
tachycardia
*)0.<
3aused by reduced
cardiac output,
respiratory
distress, fatal
distress
!&itial / Scree&i&" test 870 mo&itor
*)0.<
6bove 16B or
below 12B beats
per mi&utes, 8etal
+7 below $#5
3o&firmatory test 6m&iotomy<
*)0.<
6bove 'eepi&" the
si"&ifica&t other
improved of the
pro"ress of care,
the fatal status
would he the
priority
*ursi&" ?ia"&osis 6ltered tissue
perfectio&
related to
decrease blood
circulatio&
/is' for altered
7ealth
mai&te&a&ce
related to
i&sufficie&t
'&owled"e of
treatme&ts, dru"
therapies, home
care
ma&a"eme&t a&d
preve&tio& of
future i&fectio&
6ltered comfort
related to
maladaptive
copi&"
*ursi&" !&terve&tio& 3losely mo&itor
for shoc' a&d
decreasi&"
blood# +ressure,
tachycardia,
coal, clammy
S'i&
(ai&tai& patie&t
o& bed rest to
reduce )1y"e&
dema&ds a&d
ris' for bleedi&"#
2A=
(o&itor
prescribed
medicatio& "ive&
to preserve ri"ht
@e&tricular
felli&" pressure
a&d i&crease
blood pressure
!&struct patie&t
i& self > care
activities
+rovide
i&formatio&
about a&ti
smo'i&"
strate"ies a&d
allow patie&t
time to retur&
demo&stratio& of
treatme&t to the
do&e at home
6ssess physical
complai&ts
matters of facts
without
emphasi2i&"
co&cer&# ,se
deep > breathi&",
muscle
rela1atio&, a&d
ima"ery to
relieve
discomfort#
.1press a cari&"
attitude
-est maor Sur"ery 3aesaria& Sectio& >
&ote if cervi1 is
i&complete deleted#
-est dirt for pre-
operative
8ood a&d fluid are
withheld before
i&vasive procedure is
&ot resumed u&til the
clie&t is stable a&d
free of &ausea &
vomiti&"#
-est diet for ?isease 7ypoaller"e&ic !o&ic diet 3alcium i&creased
+ossible Sur"ical
3omplicatio&
!&terruptio& of ve&a
cava, which reduce
cha&&el si2e#
3omplicatio& of ?isease N -leedi&" as a result of treatme&t
*)0.<
)bservatio& of the fetal mo&itori&" ofte& reveal
i&crease uteri&e rustli&" to&e, caused by failure of the
uterus to rela1 i& a& attempt to co&strict blood vesicle
a&d co&trol bleedi&"
2AA
N /espiratory failure#
-est positio& pre-operative Sims +ositio&
*)0.<
.urning to the le%t side to shi%t right o% the %etus o%%
the in%erior vena cava#
-ed Side .Huipme&t )1y"e& obtai& eHuipme&t for e1ter&al electro&ic fetal
heart rate mo&itori&" )1y"e& with 3a&&ula
Disse+inated
)ntravascular
coagulation7istory of
?isease
6&"i&a, myocardial i&farctio&
3ool&ess a&d
mottli&" of
e1tremities9 pai&9
dysp&ea9 ab&ormal
bleedi&"+redisposi&
" / 3o&tributi&"
8actors
*ame of the ?isease
)verwhelmi&" i&fectio&s particularly bacterial sepsis9 F1 a0ru,tion ,lacenta'
ecla+,sia' am&iotic fluid embolism9 !,8?:!&tra-uteri&e fetal death; or
rete&tio& of dead fetus9 bur&9 trauma9 fractures9 maor sur"ery9 fat embolism9
soc'9 hemolytic tra&sfusio& reactio&9 mali"&a&cies particularly of lu&", colo&,
stomach, a&d pa&creas
NO"$1
,isseminated intra#ascular coa*ulation 0,IC7 is a state of diffuse clottin* in
)hich clottin* factors are consumed. "his leads to )idespread bleedin*.
Platelet are decreased because they are consumed by the process3 coa*ulation
studies sho) no clot formation 0and are thus normal to prolon*ed7H and fibrin
plu*s may clo* the micro#asculature diffusely3 oo2in* from in?ection sites3 and
presence of hematuria are si*ns associated )ith the presence of ,IC. S)ellin*
and pain in the calf of one le* are more li8ely to be associated )ith
thrompophlebitis. 0Saunders Comprehensi#e ACCA $dition3 p. ECJ7
5ate Si"&!&itial Si"& 6ltered me&tal status9 acute re&al failure
*ursi&" ?ia"&osis & !&terve&tio& /is' for i&ury related to bleedi&" due to
thrombocytope&ia
6ltered tissue perfusio& :all tissues; related
to ischemia due to microthrombi formatio&
(i&imi2i&" -leedi&"
1# !&stitute -leedi&" precautio&s
2# (o&itor pad cou&t/amou&t of saturatio& duri&" me&ses9 admi&ister or teach self-admi&istratio& of hormo&es to
suppress me&struatio& as prescribed#
3# 6dmi&ister blood products as ordered# (o&itor for si"&s a&d symptoms of aller"ic reactio&s, a&aphyla1is, a&d
volume overload#
4# 6void dislod"i&" costs# 6pply pressure to sites of bleedi&" for at least 2B mi&s, use topical hemostatic a"e&ts#
,se tape cautiously#
5# (ai&tai& bed rest duri&" bleedi&" episode#
6# !f i&ter&al bleedi&" is suspected, assess bowel sou&ds a&d abdomi&al "irth#
$# .valuate fluid status a&d bleedi&" by freHue&t measureme&t fo vital si"&s, ce&tral ve&ous pressure, i&ta'e a&d
output#
=#
A# +romoti&" 0issue +erfusio&
1# Leep patie&t warm
2# 6void vasoco&strictive a"e&ts :systemic or topical;#
3# 3ha&"e patie&tEs positio& freHue&tly a&d perform /)( e1ercises#
4# (o&itor electrocardio"ram a&d laboratory test for dysfu&ctio& of vital or"a&s casued by ischemia >
arrhythmias, ab&ormal arterial blood "ases, i&creased blood urea &itro"e& a&d creati&i&e#
5# (o&itor for si"&s of vascular occlusio& a&d report immediately#
a# -rai& > decreased level of co&scious&ess, se&sory a&d motor deficits, sei2ures, coma#
b# .yes > @isual deficits#
c# -o&e > +ai&
d# +ulmo&ary vasculature > chest pai&, short&ess of breath, tachycardia#
e# .1tremities > cold, mottli&", &umb&ess#
f# 3oro&ary arteries > chest pai&, arrhythmias#
"# -owel > pai&, te&der&ess, decreased bowel sou&ds#
3BB
h#
i#
#
?ecreased 8ibri&o"e&
level9 i&creased fibri&
split products9 decreased
a&ti-thrombi& !!!
level-eside
.Huipme&t.349
3@+Scree&i&" or !&itial
?ia"&ostic 0est
+09 +009 +latelet cou&t :Smelt2er, S#3# & -are, -#4#, 1AA2#p#=11;
6&ticoa"ula&t/efere&ce
sSmelt2er,S#3#& -are,
-#4# 1AA2# -ru&&er a&d
SuddarthEs 0e1boo' of
(edical-Sur"ical
*ursi&", $
th
ed# K#-#
5ippi&cott compa&y<
+hiladelphia, ,S6#-est
?ru"3o&firmative 0est
0he 5ippi&cott (a&ual
of *ursi&" +ractice, $
th
ed#, 2BB1#
5ippi&cott %illiams
& wil'i&s<
+hiladelphia, ,S6#
+p#==$-===#
7epari& i&hibits clotti&" compo&e&ts of ?!3
Nat'%e of t!e D%'"
Hy$e%emesis "%a(i&a%'m
7yperemesis "ravidarum is persiste&t, u&co&trolled vomiti&" that be"i&s i& #the first wee's of pre"&a&cy a&d
may co&ti&ue throu"hout pre"&a&cy# ,&li'e Rmor&i&" sic'&ess,S hyperemesis ca& have serious complicatio&s,
i&cludi&" severe wei"ht loss, dehydratio&, a&d electrolyte imbala&ce#
N&.E" .he de%ining %actor %or h/,ere+esis gravidaru+ should 0e the ti+e o% occurrence T and that is the
2nd tri+ester5 usuall/ the 1B T 1H
th
6ee4. )% this is on the 1
st
tri+ester5 usuall/ this is +orning sic4ness.
Ca'ses
4o&adotropi&e productio&
+sycholo"ical factors
0rophoblastic activity
Assessment )in&in"s
3o&ti&uous, severe &ausea a&d vomiti&"
?ehydratio&
?ry s'i& a&d mucous membra&es
.lectrolyte imbala&ce
(etabolic acidosis
*o&-elastic s'i& tur"or
)li"uria
3B1
Dia"nostic Test Res'lt
6rterial blood "as a&d a&alysis reveals al'alosis#
7b level a&d 730 are elevated#
Serum potassium level reveals hypo'alemia
,ri&e 'eto&e levels are elevated#
,ri&e specific "ravity is i&creased#
N'%sin" Dia"noses
8luid volume deficit
6ltered &utritio&9 less tha& body reHuireme&ts
+ai&
T%eatment
0otal pare&teral &utritio& :0+*;
/estoratio& of fluid a&d electrolyte bala&ce
D%'" T!e%a$y
6&ti-emetics, as &ecessary for vomiti&", for e1ample +lasil , 7ydro1y2i&e a&d +rochlorpera2i&e
Inte%(ention an& Rationales
(o&itor vital si"&s a&d fluid i&ta'e a&d output to assess for fluid volume deficit#
)btai& blood samples a&d uri&e specime&s for laboratory tests, i&cludi&" 7b level, 730, uri&alysis,
a&d electrolyte levels#
+rovide small freHue&t meals to mai&tai& adeHuate &utritio&#
(ai&tai& !#@# fluid replaceme&t a&d 0+* to reduce fluid deficit a&d p7 imbala&ce#
+rovide emBotio&al support to help the patie&t cope with her co&ditio&#
"eachin* "opics
,si&" salt o& foods to replace sodium lost by vomiti&"#
8rom< Spri&"house, pa"es 4=3-4=4
I;. INTRAARTUM CARE
Int%a$a%t'm $e%io& e1te&ds from the be"i&&i&" of co&tractio&s that cause cervical dilatio& to the first 1-4
hours after delivery of the &ewbor& a&d place&ta#
Int%a$a%t'm ca%e refers to the medical a&d &ursi&" care "ive& to a pre"&a&t woma& a&d her family duri&"
labor a&d delivery#
5abor versus 5abor
1# 5abor< 3oordi&ated seHue&ce of i&volu&tary uteri&e co&tractio&s or a result i& the effaceme&t a&d dilatio&
of the cervi1, followed by e1pulsio& of the products of co&ceptio&#
2# ?elivery< 6ctual eve&t of birth
3B2
A. )acto%s Affectin" Labo%
)ACT-RS A))ECTING LA1-R
+6SS64.%6F +6SS.*4./ +)%./S +563.*065
8630)/S
+SF37.
?iscomfort-e"i&s at
lower bac' a&d
radiates arou&d
abdome&+rimarily o&
the lower abdome& &
"roi&!rre"ular0/,.865S
.3o&tractio&s/e"ular4y&
ecoid
,&cha&"ed
,&cha&"ed or decrease i&
freHue&cy a&d i&te&sity
-ecome more freHue&t
4radual i&crease i&
duratio& a&d i&te&sity /
pro"ressive freHue&cy &
i&te&sity
I ASSAGE?A=
-refers to the adeHuacy of the
pelvis a&d birth ca&al i&
allowi&" the fetal desce&t9
factors i&clude<
6# 0ype of pelvis
-# structure of the pelvis
:true versus false pelvis;
3# pelvic i&let diameters
?# ability of the uteri&e
se"me&t & va"i&al ca&al to
diste&d, the cervi1 to dilate
A))ECTED 1= THE
)-LL-?ING )ACT-RSA
A. Ty$es of St%'ct'%e
PartsA ischium, iluim, coccy1#
Eoints" Sacroiliac, Sacrococcy"eal, symphysis
pubis :all softe& duri&" pre"&a&cy;
8etal bo&es
Suture li&es
8o&ta&els head
measureme&ts
8etal lie
8etal attitude
8etal prese&tatio&
8etal positio&
8etal statio&
+76S.S
N !&creme&t
N 6cme
N ?ecreme&t
6SS.SS(.*0
8reHue&cy
?uratio&
!&terval
!&te&sity
6bruptio
place&ta
+lace&ta
previa
+lace&ta
acreta
+lace&ta
media
3B3
#lassi%ications or ./,es o% Pelvis"
a# Gynecoi&A *ormal 8emale +elvis<
/ou&ded )val#
b#
(AV&ABLE (&
S!##ESS(!L LAB& A
B).*.
c# An&%oi&A *ormal (ale +elvis<
8u&&el Shape
d# Ant!%o$oi&A oval
e# laty$elloi&A flatte&ed, tra&sverse
oval
f#
B. St%'ct'%e of t!e el(is :<it!
$el(ic inlet & o'tlet
&iamete%s*
#.
D.
E.
(.
G.
*. )ALSE EL;IS
). 6bove the li&ea
termi&alis, across the top
of symphysis pubis# !t
supports the e&lar"e
uterus i& the
abdomi&al cavity
M Shallow upper basi& of
the pelvis
M Supports the e&lar"i&"
uterus but &ot importa&t
obstetrically
M LINEA TERMINALIS
3B4
M +la&e dividi&" upper or
false pelvis from lower or
true pelvis
M TRUE EL;IS
M 5ies below the
li&ea termi&alis, the bo&y
pelvis throu"h which the
baby pass
M %idest diameter
:tra&sverse;
M *arrowest
diameter :a&terior >
posterior;
M 3o&sists of the pelvic
i&let, pelvic cavity, a&d
pelvic outlet#
M -o&y ca&al throu"h which
the i&fa&t pass#
M (easureme&ts of true
pelvis i&flue&ce the
co&duct a&d pro"ress of
labor a&d delivery#
M MIDLANE
M +elvic cavity
M
M
M
M
M -UTLET
M ?i&est &iamete%A
6&terior posterior
diameter :reHuires the
i&ter&al /elatio&ship of
fetal head for e&try;
M Na%%o<est &iamete%<
0ra&sverse !&tertuberous
?iameter :facilitates
delivery i& )ccipital
6&terior +osterior;
M
M
M 1#. el(ic meas'%ements
M a. T%'e
conN'"ate o% conN'"ate
(e%a
M - measured from upper
mar"i& of symphysis
pubis to sacral
promo&tory9 should be at
least 11 cm#
M - may
be obtai&ed by 1-ray or
,/S
M b.
T'be%9isc!ial &iamete%/
Inte%t'be%o's &iamete%
3B5
M 9
(easures the outlet
betwee& the i&&er borders
of ischial tuberosities,
should be at least
=-A cm#
M -
estimated o& pelvic e1am
M c.
-bstet%ical ConN'"ate
M -
?ista&ce betwee& the
i&&er surfaces of the
symphysis pubis a&d
sacral promo&tory
M
M
M II. ASSENGER :T!e
)et's*
M Refe%s
to t!e fet's an& its
ability to mo(e t!%o'"!
t!e $assa"e<ay.
M A))ECTED 1= THE
)-LL-?ING
)ACT-RS<
M
M a#
Attit'&e
M
M 1# 0he relatio&ship of the
fetal body parts to o&e
a&other or, a&other word
is fetal posture
M
M 2# Nor+al intrauterine
attitude is %le$ion, i& which
the fetal bac' is rou&ded, the
head is forward o& the chest,
a&d the arms a&d le"s are
folded i& a"ai&st the body
M
M - Lie
M - /elatio&ship of the spi&e
of the fetus to the spi&e of
the mother
M
M .ransverse lie is an
indication for cesarean
deli#ery. Se#eral
maternal and fetal
conditions ma8e cesarean
deliver/ necessary ."he
3B6
commonly accepted
indications include
complete placenta pre#ia3
trans#erse lie at term3
cephalopel#ic
disproportion3 abruptio
placentae3 acti#e *enital
herpes3 umbilical cord
prolapse3 failure to
pro*ress in labor3 pro#en
fetal distress3 beni*n and
mali*nant tumors that
bloc8 the birth canal3 and
cer#ical cercla*e. Other
reasons for a cesarean
deli#ery are more
contra#ersial3 such as
breech presentation3
pre#ious cesarean birth3
ma?or con*enital
anomalies3 and se#ere
isoimmuni2ation. ")ins
can sometimes be
deli#ered #a*inally3
especially )hen the
lo)ermost t)in is in a
#erte@ presentation.
M
M
M 1### Lon"it'&inal o%
(e%tical
M a# 8etal spi&e is parallel to
the motherIs spi&e
M b# 8etus is either cephalic
or breech prese&tatio&
M 2### T%ans(e%se o%
!o%i3ontal
M a# 8etal spi&e is at a ri"ht
a&"le, or perpe&dicular, to
the motherIs spi&e
M b# +rese&ti&" part is the
shoulder
M c# ?elivery by cesarea&
sectio&
M 3... -bliF'e
M a# 8etal spi&e is at a sli"ht
a&"le from a true
hori2o&tal lie
M b# ?elivery is by cesarea&
sectio& if u&correctable
M
M 3
%esentati
on
3B$
M 9 the relatio&ship of a particular
refere&ce poi&t of the prese&ti&" part a&d
the mater&al pelvis described with a series
of 3 letters or presentation refers to the
part of the fetus at the cer#ical os
M
M +rese&ti&" part< +ortio& of
the fetus that e&ters the pelvis
first
M 1# 3ephalic
M a# 0he
most commo&
prese&tatio&
M b# 8etal
head prese&ts first
M 2 -reech
M a# -uttoc's
prese&t first
M b# ?elivery by
cesarea& sectio& may be
reHuired, althou"h it is ofte&
possible to deliver va"i&ally
M 3 Shoulders
M a# 8etus is i& a
tra&sverse lie, or the arm, bac',
abdome&, or side could prese&t
M b# !f the fetus does &ot
spo&ta&eously rotate or if it is
&ot possible to tur& the fetus
ma&ually, a cesarea& sectio& may
be performed
M
M *)0.< "he nurse )ould
auscultate abo#e the umbilicus if
the fetus is in breech
presentation has the bac8 abo#e
or at the umbilical area. %etal
heart tones are ausculated best
in the left lo)er abdomen )hen
the fetus is in a left
occipitoanterior position. %or
the heart tones to be located
belo) the umbilicus3 the fetus
)ould be in a cephalic position.
%etal heart tones are heard best
in the ri*ht lateral abdomen
)hen the fetus is in a ri*ht
occipitoposterior position.
M ?# osition
M /elatio&ship of assi"&ed area
of the prese&ti&" part or
la&dmar' to the mater&al
pelvis or the relationship of
the fetusGs presentin* part to
3B=
the motherGs pel#is
M
M LE--LDOS
MANEU;ERS
M
M It is a systematic )ay to
e#aluate the presentation3
position and attitude of
the fetusH the location of
the best place to
auscultate the fetal heart
soundsH and the
en*a*ement status of the
presentin* part. .he/
don<t accuratel/
deter+ine ho6 large the
%etus is5 6hich is 0est
deter+ined 0/
ultrasound.
M
M +
r
e
p
a
r
a
ti
o
&
M
M 1# 6s' the mother to
empty the bladder
M 2# %arm ha&ds a&d apply
them to the abdome& with
firm a&d "e&tle pressure
M
M +/)3.?,/.
M
M .he %irst +aneuver
deter+ines 6hat %etal
,art is in the %undal
,ortion o% the uterus. )n
this case5 the so%t5 %ir+
+ass indicated the %etal
0uttoc4s are in the
%undus5 re%lecting a
verte$ ,resentation. .he
second +aneuver
docu+ents the location
o% the %etal 0ac4. .he
side o% the uterus 6here
the 0ac4 is located is
s+ooth and conve$ to the
touch5 and the o,,osite
side has areas o%
3BA
indentation. .he third
+aneuver con%ir+s that
6as 6hat ,al,ated in the
%undus is correct and
also deter+ines 6hether
the ,resenting ,art is
engaged. )n this case5
the hard5 round5 +ova0le
o0Gect in the ,u0ic area is
the %etal head. .he
%ourth +aneuver
deter+ines id the %etal
head is %le$ed or
e$tended.
M
M (etal Position
M
M /)6< /i"ht occiput
a&terior
M 5)6< 5eft occiput
a&terior (the 0est %etal ,osition9
M /)+< /i"ht occiput
posterior
M /(6< /i"ht me&tum
a&terior
M /(+< /i"ht me&tum
a&terior
M 5)+< 5eft occiput
posterior
M 5(6< 5eft me&tum
a&terior
M /)0< /i"ht occiput
tra&sverse
M 5)0< 5eft occiput
tra&sverse
M /(+< /i"ht me&tum
posterior
M 5S6< 5eft sacrum
a&terior
M 5S+< 5eft sacrum
posterior
M
M Se#ere bac8 pain durin*
labor maybe related to a
fetus in an OCCIPI"O.
POS"$IO POSI"ION.
"his means that the fetal
head presses a*ainst the
client/s sacrum3 )hich
causes mar8ed discomfort
durin* contractions.
epositionin* the client
and pro#idin* sacral bac8
rubs may help alle#iate
the discomfort.
31B
"rans#erse3 obli4ue and
occiput positions do not
cause pressure on the
sacrum.
M
M 0. )etal Lie 9 refers to the
relationship of the fetal
lon* a@is to that of the
motherGs lon* a@is.
M a# CEHALIC P verte1,
face, brow
M b# 1REECH > fra&',
footli&", complete
M c# SH-ULDER >
tra&sverse lie
M
M N&.E1 Adolescent
clients maturation are
usually not yet complete3
therefore they are #ery
common for
cephalopel#ic
disproportion.
M
M N&.EA 5ie :spi&e to
spi&e; may be
lo&"itudi&al :parallel;,
tra&sverse :ri"ht a&"les;,
obliHue :sli"ht a&"le off
true tra&sverse lie;#
M
M )ETAL RE)ERENCE
-INT :RESENTING
ART*
M
M 6# )33!+,0 :);
M -# S63/,( :S;
M 3# S36+,56 :Sc;
M ?# (.*0,( :(;
M
M MATERNAL
RE)ERENCE -INT
M
M 1# S!?. )8
(60./*65 +.5@!S
M 6# 5eft :5;
M -# /i"ht :/;
M 3# 0ra&sverse :0;
M
M 2# +6/0 )8 07.
(60./*65 +.5@!S
M 6# 6&terior :6;
M -# +osterior :+;
M
M
M
311
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M 1%eec!
RESENTATI-NS
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
312
M )RANH 1REECH
)ULL /
C-MLETE
1REEC
H
RESEN
TATI-N
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
SH-ULDER
1REECH
M
M
)--TLING
RESENTATI-N
M III. -?ER
M
M 9 /efers to the freHue&cy,
duratio&, a&d stre&"th of
313
uteri&e co&tractio&s to
cause complete cervical
effaceme&t a&d dilatio&#
M
M 0he forces acti&"
to e1pel the fetus
1# EffacementA Shorte&i&" a&d
thi&&i&" of the cervi1 duri&"
the first sta"e of labor
2# Dilation< .&lar"eme&t of
cervical os a&d cervical
ca&al duri&" first sta"e
3#
.. LA1-R C-NTRACTI-NS
5#
4. THREE HASES -)
C-NTRACTI-N
5.
1# INCREMENT- steep
cresce&t slope from
be"i&&i&" of the
co&tractio& u&til
its pea'#
2. ACME/EAH >
stro&"est i&te&sity#
2. DECREMENT >
dimi&ishi&" i&te&sity#
B.
3. CHARACTERISTICS
-) C-NTRACTI-NS
H.
I. )REGUENC= >
be"i&&i&" of o&e
co&tractio& to be"i&&i&"
of o&e co&tractio&# 5ess
tha& 2 mi&utes should be
reported#
@. DURATI-N >
be"i&&i&" of o&e
co&tractio& u&til its
completio&#
(ore
tha& AB seco&ds should be
reported because of
uteri&e rupture or fetal
distress#
J. INTENSIT= > the
stre&"th of co&tractio& at
its pea' may be mild,
moderate or stro&"#
1:.
11.
12. I;. LACENTAL
)ACT-RS
12. - /efers to the site of
314
place&tal i&sertio&#
1B.
13.
1H. ;. S=CHE
1I. - /efers to the clie&tEs
psycholo"ical state,
available support systems,
preparatio& for birth,
e1perie&ces, a&d copi&"
strate"ies#
1@.
1J.
2:. 1. LA1-R
21. #. Si"ns of
im$en&in" labo%
22. ,. Com$a%ison
of T%'e Labo% f%om
)alse Labo%
22. 3. Sta"es of
labo%
2B. 3. a. station of
t!e $%esentin" $a%t
23. .. N'%sin"
Inte%(entions &'%in"
labo% & &eli(e%y
2H. 0. Assessin" t!e
)etal Hea%t Rate
2I.
2@.
2J. SIGNS -)
IMENDING LA1-R
2:.
21.
22. 5i"hte&i&" -ra1to&Es-
7ic's co&tractio&
4astroi&testi&al upset
-urst of e&er"y
-lood show
22.
2B.
F1 sign o% la0or
u,tured 0ag o% 6ater
23.
2H.
2I.
2@. #. REM-NIT-R=
SIGNS -) LA1-R
#. 5!470.*!*4
,. - ?esce&t of the fetus
a&d uterus i&to pelvic
cavity before labor
o&set#
3. -)ccurs 2-3 wee's
earlier i& primipara#
.. - !& multipara, may
&ot occur u&til labor
315
be"i&s#
0. 2# 3./@!365
376*4.S
4. a# E))ACEMENT
5. - +ro"ressive
softe&i&" Rripe&i&"S a&d
thi&&i&" of the cervi1#
6. - R-5))?F
S7)%S :e1pulsio& of
mucous plu";
7. b# DILATI-N
#8. - )pe&i&" of
cervical os duri&" labor#
##. 3# /e"ular -ra1to& 7ic'sE
co&tractio&s#
#,. 4# /upture of am&iotic
membra&es#
#3. 5# *.S05!*4
-.76@!)/S
#.. 6# %ei"ht loss of about 1-
3 lbs 2-3 days before
labor o&set#
#0.
#4. ,. C-MARIS-N -)
TRUE AND )ALSE
LA1-R
#5.
#6. 376/630./!S0!3S
6&thropoid
6&droid
+latypelloid
.ffects of wal'i&"Stress factors
5eadi&" to hypoto&ia
3o&tractio&s are
i&te&sified
5esse&ed or &ot
affected
3ervical cha&"es +ro"ressive dilatio& a&d
effaceme&t
*o cha&"e
+ai& does&Et
disappear+ai&
disappears?uri&"
Sedatio&3o&tractio&s
does&Et stop3o&tractio&s
stopsShow
+rese&t *ot prese&t
?uri&" sleep
3. STAGES -) LA1-R
1
S0
S064.
2
*?
S064.
316
3o&trac
tio& to
dilatio&
%e$a%
ato%y
&i(ision
A
1;
5ate&t
phase B-
3 cm
?urat
io&< 3B
> 45
seco&ds
*)0.<
Pushin*
durin*
the first
sta*e of
labor
)hen
the ur*e
is felt
but the
cer#i@
is not
yet fully
dilated
may
produce
cer#ical
s)ellin
* and
ma8es
labor
more
difficult
. "he
client
should
be
encoura
*ed to
PAN"
(LO6
or
(LO6.
(LO6
pattern
of
breathi
n* to
help
o#erco
me the
8ull cervical dilatatio& to delivery
31$
ur*e to
push.
2;
6ctive
phase 4-
$ cm
D'%atio
nA .09
48
secon&s
3;
0ra&siti
o&al
phase =-
1B cm
?uratio
& < 6B-
AB
seco&ds
)IRST STAGE -) LA1-R
:-NSET -) REGULAR C-NTRACTI-NS T- )ULL CER;ICAL DILATI-N
.ANS).)&N P*ASE
0!(.< +/!(!+6/6 :1hour;
(,50!+6/6 :1B > 15 mi&utes;
3./@!O<
.8863.(.*0 - 1BBC
?!560!)* - =-1B cm
3)*0/630!)*S
8/.V,.*3F - 2-3 mi&utes
?,/60!)* - 6B-AB seco&ds
(6*!8.S060!)*S<
3lie&t may be irritable a&d pa&ic'y9 (ay lose co&trol9 6m&esic betwee& co&tractio&s9 +erspiri&",
&auseous a&d vomiti&" commo&9 0rembli&" of le"s9 +ressure o& bladder a&d rectum9 -ac'ache9 !&creased
show9 3ircumoral pallor
NO"$1 If the client is in acti#e labor and there is no chan*e in dilation after A hours3 the nurse should suspect
cephalopel#ic disproportion. "he client is not e@periencin* a prolon*ed latent phase 0C.E cm73 prolon*ed
transitional phase 0pushin*73 and contraction pattern.
NO"$1&a*inal $@amination
31=
"o determine if the client is fully dilated3 the nurse performs a #a*inal e@amination. "o assess the
suture most readily felt3 the nurse )ould determine the position of the cranial suture termed.SA-I"ALL
SU"U$.
STATI-N
/efer to the level of prese&ti&" part of fetus i& relatio& to ima"i&ary li&e betwee& ischial spi&es :2ero
statio&; i& mid pelvis of mother#
- 0he measureme&t of the pro"ress of desce&t i& ce&timeters above or below the midpla&e from the
prese&ti&" part to the ischial spi&e
Min's stationA abo(e isc!ial s$ine
90 to P# in&icates a $%esentin" $a%t abo(e 3e%o station :93)L-ATINGD 9# DIING*
Station 8A at isc!ial s$ine
: +eans ENGAGE7EN.
l's stationA belo< isc!ial s$ine
Q # T- Q 0 in&icates a $%esentin" $a%t belo< 3e%o station
Q3 #&1N)NG
NMy baby is comin*O3 the R9 nursin* inter#ention is to loo8 for perineal bul*in* 0cro)nin*7. If the
perineum is bul*in*3 the patient should be coached to pant )ith her contractions so that she doesn/t
push. %etal heart rate is focus on the labor process or potential fetal cord compression and meconium
stained complications
SEC-ND STAGE -) LA1-R
:C-MLETE CER;ICAL DILATI-N T- 1IRTH -) NE?1-RN*
0!(.
+/!(!+6/6 :3B-5B mi&utes ;
(,50!+6/6 :2B mi&utes;
3)*0/630!)*S
8/.V,.*3F - 2-3 mi&utes
?,/60!)* - 6B-AB seco&ds
31A
!*0.*S!0F
@./F 76/?< 1BB mm 7"
(6*!8.S060!)*S<
?ecrease i& pai& from tra&sitio&al level9 i&creased bloody show9 .1cited ea"er a&d i& co&trol#
THIRD STAGE -) LA1-R
:DELI;ER= -) NE?1-RN T- DELI;ER= -) LACENTA*
0!(.< 5-3B mi&utes
3)*0/630!)*S
Stro&" a&d well-co&tracted uterus cha&"i&" to "lobular shape
(6*!8.S060!)*S<
Increased *ush of blood
Uterus becomin* *lobular )ith fundus risin* in the abdomen
Apparent len*thenin* of cord
)-URTH STAGE -) LA1-R
:DELI;ER= -) LACENTA T- H-ME-STASIS*
0!(.
,sually defi&ed as the first hour postpartum# 0his sta"e lasts from 1-4 hours after birth#
,0./,S
0he uterus co&tracts i& the midli&e of the abdome& with the fu&dus midway betwee& the umbilicus a&d
symphysis pubis#
(6*!8.S060!)*S<
5ochia rubra
.1ploratio& of &ewbor&
+are&t-i&fa&t bo&di&" be"i&s
*ewbor& alert a&d respo&sive
8irst period of reactivity
NURSING INTER;ENTI-NS DURING LA1-R AND DELI;ER=
M ?uri&" labor, mo&itor 87/#
M +rovide patie&t comfort#
M 6dmi&ister a&al"esics as i&dicated#
M +repare for delivery#
M !mmediate &ewbor& care at delivery#
- .stablish airway#
- )bserve 6p"ar score at 1 a&d 5 mi&utes i&terval#
- 3lamp umbilical cord#
- (ai&tai& warmth#
- 6ssess the &ewbor&Es "estatio&al a"e#
- 6dmi&ister prophylactic eye drops a&d vitami& L#
- +lace ide&tificatio& ba&d o& baby a&d mother#
32B
NURSING CARE DURING LA1-R
Nursin* care for the client durin* the second sta*e of labor should include assistin* the mother )ith pushin*3 helpin* position her le*s for ma@imum pushin* effecti#eness3 and monitorin* the fetal heart rate
321
Mec!anisms of Labo% En"a"ement o% Ca%&inal mo(ements by t!e )et's
Definition< (echa&ism by which the fetus &estles i&to the pelvis# 6 co&ti&uous process from the time of
e&"a"eme&t u&til birth, a&d is assessed by the measureme&t called statio&
Descent
6lso termed li"hte&i&" or droppi&" ?esce&t
0he process that the fetal head u&der"oes as be"i&s its our&ey throu"h the pelvis
322
)le+ion +rocess of the fetal headIs &oddi&" forward toward the fetal chest
Su0occi,oto0reg+aticA the diameter that prese&ts to the mater&al pelvis duri&" COMPL$"$ %L$'ION#
Inte%nal Rotation
!&ter&al rotatio& of the fetus9 most commo&ly from the occipital tra&sverse positio&, assumed at e&"a"eme&t
i&to the pelvis, to the occipital a&terior positio& while co&ti&uously desce&di&"
E+tension
.&ables the head to emer"e whe& the fetus is i& a cephalic positio&
-e"i&s after the head crow&s !s complete whe& the head passes u&der the pubis a&d occipital, a&d the a&terior
fo&ta&el, brow, face, a&d chi& pass over the sacrum a&d coccy1 are over the peri&eum
/estitutio&
/eali"&me&t of the fetal head with the body after that head emer"es
E+te%nal Rotation
0he shoulders e1ter&ally rotate after the head emer"es a&d restitutio& occurs, so that the shoulders are
a&teroposterior diameter of the pelvis
E+$'lsion
0he delivery baby
CARDINAL M-;EMENTS -) THE )ETUS
?esce&t 8le1io& !&ter&al /otatio& .1te&sio& .1ter&al /otatio&
.1pulsio&
8i"ure 1= 3ardi&al (oveme&ts or (echa&ism of labor
;II. ANESTHESIA
N-TEA Analgesia ad+inistered during the second stage o% la0or includes continuation o% the lu+0ar
e,idural 0loc45 ,udendal 0loc45 and local in%iltration o% the ,erineu+. Narcotic analgesics and ,ericervical
0loc4 are ad+inistered during the active ,hase o% la0or. A s,inal 0loc4 is given during the active ,hase o%
the %irst stage o% la0or. Sedative h/,notics5 i% ad+inistered5 are given 6hen the ,atient is in earl/ latent la0or
to encourage rest. A s,inal 0loc4 is given during the active ,hase o% the %irst stage o% la0or.
323
?.S3.*0 85.O!)* !*0./*65
/)060!)*
.O0./*65
/)060!)*
.O0.*S!)*
.O+,5S!)*
N&.E" *)0.< "he chief concepts of La+a8e teaching include conditioned responses to stimuli throu*h use of
a focal point. An emotionally satisfyin* e@perience is promoted rather than discoura*in* use of anal*esia and
anesthesia.
6# 5ocal a&esthesia
1# ,sed for bloc'i&" pai& duri&" episiotomy
2# 6dmi&istered ust before the birth of baby
3# *o effect o& the fetus
-# +aracervical bloc'
1# ,sed i& the first sta"e of labor
2# +rovides a rapid bloc' of uteri&e pai&
3# *o effect o& the peri&eal area
4# *o effect o& the ability to bear dow&
5# (ay cause fetal bradycardia
3# +ude&dal bloc'
1# 6dmi&istered ust before the birth of the baby
2# !&ectio& site at pude&dal &erve throu"h a tra&sva"i&al route
3# -loc's peri&eal area for episiotomy
4# .ffect lasts about 3B mi&utes
5# *o effect o& co&tractio&s or fetus
*)0.< Pudendal (loc8 Anesthesia
"he R9 purpose is to relie#e pain primarily in the perineum and #a*ina. It does not relie#e pain primarily
in the perineum and #a*ina. Pudendal bloc8 is ade4uate for episiotomy and its repair.
"he fetus should be assessed for (A,5CA,IA )hich is a potential complication of pudendal bloc8
anesthesia. ,ecrease mo#ements3 increase #ariability and meconium stained are NO" associated.
Maternal Ad#erse effects are the follo)in*1 hypotonia3 reduced responsi#eness and sei2ures.
?# .pidural bloc'
1# !&ectio& site i& epidural space at 53-54
2# 6dmi&istered after labor is established or ust before a scheduled cesarea& birth
3# /elieves pai& from co&tractio&s a&d &umbs va"i&a a&d peri&eum
4# (ay cause hypote&sio&
5# Does not cause headache 0ecause the dura +ater is not ,enetrated
6# 6ssess mater&al blood pressure
$# (ai&tai& the mother i& side-lyi&" positio& or place a rolled bla&'et be&eath the ri"ht hip to displace the
uterus from the ve&a cava
=# 6dmi&ister !@ fluids as prescribed A# !&crease fluids as prescribed if hypote&sio& occurs
A# 0he maor complicatio& of epidural a&esthesia is mater&al hypote&sio&#
N&.E" "o minimi2e the hypertensi#e effects of epidural anesthesia prior to the procedure ade4uately
hydrate the patient and position the patient side lyin* to the left.
After epidural anesthesia the #ital si*ns should be monitored e#ery 9.A minutes for the first 9F minutes.
.he assess+ent should 0e a high ,riorit/ a%ter a ,atient has received an e,idural is 0lood ,ressure
0ecause an e,idural can cause h/,otension and its 0loc4s the autono+ic nervous s/ste+.
324
A patient )ho is about to recei#e epidural anesthesia should empty her bladder before the procedure
because an epidural )ill lessen the sensation to #oid so #oidin* no) may decrease the need for
catheteri2ation later.
*)0.<
A co++on adverse e%%ect o% e,idural anesthesia is h/,otension5 6hich 6ould cause i+,aired gas
e$change in the %etus. .o ,revent h/,otension5 the ,atient receives a 0olus o% 3:: to 15::: +l o% ).V.
%luid 0e%ore the ,rocedure. .he ,atient isn<t a%%ected 0/ these ,ro0le+s 0ecause she didn<t receive the
e,idural anesthesia.
*)0.< "he patient plans to recei#e an epidural anesthetic for pain relief durin* labor3 it )on/t be
administered until the patient is dilated J to F cm.
.# Spi&al bloc'
1# !&ectio& site i& spi&al subarach&oid space at 53-55
2# 6dmi&istered ust before birth
3# /elieves uteri&e a&d peri&eal pai& a&d &umbs va"i&a, peri&eum, a&d lower e1tremities
4# (ay cause mater&al hypote&sio&
5# (ay cause postpartum headache
6# 0he mother must lie flat = to 12 hours followi&" spi&al i&ectio&
$# +lace a rolled bla&'et u&der the ri"ht hip to displace the uterus from the ve&a cava
=# 6dmi&ister !@ fluids as prescribed
8# 4e&eral a&esthesia
1# (ay be used for some sur"ical i&terve&tio&s
2# 0he mother is &ot awa'e
3# +rese&ts a da&"er of respiratory depressio& vomiti&"
-1STETRICAL R-CEDURES
6# )1ytoci& !&ductio&
1# 6 deliberate i&itiatio& of uteri&e co&tractio&s this stimulates labor
2# .lective i&ductio& may be accomplished ! o1ytoci& :+itoci&; i&fusio&
3# )btai& baseli&e traci&" of uteri&e co&tractio&s a&d 87/
4# !&crease !@ dosa"e of o1ytoci& as prescribed o&ly after assessi&" co&tractio&s, 87/, a&d mater&al blood
pressure a&d pulse
5# ,o not increase rate of o@ytocin once the desired contraction pattern is obtained 0contraction fre4uency
of A to E minutes and lastin* :C seconds7
6# ,iscontinue o@ytocin as prescribed contraction fre4uency is less than A minutes or duration more than TC
seconds3 or if fetal distress is note
*)0.< )1ytoci& :!&ductio& of 5abor;
(efore the induction of Labor3 the nurse should obtain a baseline measurement of the fetal heart rate. If
the fetal heart rate pattern sho)s fetal distress3 the client is not a candidate or if contractions occur less
than A minutes apart or last lon*er than :C seconds
325
3# Amniotomy
1# 6rtificial rupture of membra&es :6/)(;9 performe by the physicia& to stimulate labor
2# +erformed if the fetus is at ZBZ or ZUZ statio&
3# !&creases ris' of prolapsed cord a&d i&fectic
4# (o&itor 87/ before a&d after 6/)(
5# /ecord time of 6/)(, 87/, a&d characteristic of fluid
6# (eco&ium-stai&ed am&iotic fluid may be associated with fetal distress
$# -loody am&iotic fluid may i&dicate abrupt place&tae or fetal trauma
=# 6& u&pleasa&t odor to am&iotic fluid is associated with i&fectio&
A# +olyhydram&ios is associated with mater&al diabetes a&d certai& co&"e&ital disorders
1B# )li"ohydram&ios is associated with i&trauteri&e "rowth retardatio& :!,4/; a&d co&"e&ital
disorders
? #E+te%nal (e%sion
1# .1ter&al ma&ipulatio& of the fetus from a& ab&ormal positio& i&to a &ormal prese&tatio&
2# !&dicated for a& ab&ormal prese&tatio& that e1ists after the 34th wee'
3# (o&itor vital si"&s
4# !f the mother is /h-&e"ative, e&sure that /7 immu&e "lobuli& was "ive& at 2= wee's "estatio&
5# +repare for &o&stress test to evaluate fetal well-bei&"
6# !@ fluids a&d tocolytic therapy may be admi&istered to rela1 the uterus a&d permit easier ma&ipulatio& of
fetus
$# ,ltrasou&d is used duri&" the procedure to evaluate fetal positio& a&d place&tal placeme&t a&d "uide
directio& to the fetus
=# 6bdomi&al wall is ma&ipulated to direct fetus i&to a cephalic prese&tatio& if possible
A# (o&itor blood pressure to ide&tify ve&a cava compressio&
1B# (o&itor for u&usual pai&
11# 8ollowi&" the procedure
a# +erform &o&stress test to evaluate fetal well-bei&"
b# #(o&itor for uteri&e activity, bleedi&", ruptured membra&es, a&d decreased fetal activity
c# %ith /h-&e"ative clie&ts, perform Lleihauer -et'e test as prescribed to detect the prese&ce a&d
amou&t of fetal blood i& the mater&al circulatio& a&d to ide&tify clie&ts who &eed additio&al /h
immu&e "lobuli&
i# E$isiotomy
J "he purpose of episiotomy is to shorten the A
nd
sta*e of labor3 substitutes a clean sur*ical incision for
a tear and decreases undue stretchin* of perineal muscles. An episiotomy helps pre#ent tearin* of the
rectum but does not necessarily relie#e pressure on the rectum. An episiotomy does not pre#ent perineal
edema3 ensure 4uic8 deli#ery of the placenta or cause enlar*in* the pel#ic inlet.
1# !&cisio& made i&to peri&eum to e&lar"e va"i&al outlet a&d facilitate delivery
2# 3hec' episiotomy site
3# !&stitute measures to relieve pai&
4# +rovide ice pac' duri&" the first 24 hours
5# !&struct the clie&t i& the use of sit2 baths
6# 6pply a&al"esic spray or oi&tme&t as prescribed
326
$# +rovide peri&eal care, usi&" clea& tech&iHue
=# !&struct the clie&t i& the proper care of the i&cisio&
A# !&struct the clie&t to dry the peri&eal area from fro&t to bac' a&d to blot the area rather tha& wipe it
1B# !&struct the clie&t to shower rather tha& bathe i& a tub
11# 6pply a peripad without touchi&" the i&side surface of the pad
12# /eport a&y bleedi&" or dischar"e to the physicia&
13# "he ad#anta*e of an episiotomy is that it facilitates the deli#ery of the fetus3 it pre#ents tearin* of the
perineum3 and it pre#ents undo stretchin* of the perineal muscles.
8# )o%ce$s &eli(e%y
1# 0wo double-crossed, spoo& li'e articulated blades that are used to assist# i& the delivery of the fetal head
2# /eassure the mother a&d e1plai& the &eed for forceps
3# (o&itor mother a&d fetus duri&" delivery possible i&ury
5# 6ssist with repair of a&y laceratio&s
4# ;ac''m e+t%action
1# 6 cap li'e suctio& device is applied to the fetal head to facilitate e1tractio&
2# Suctio& is used to assist i& delivery of the fetal head
3# 0ractio& is applied duri&" uteri&e co&tractio&s u&til desce&t of the fetal head is achieved
4# 0he suctio& device should &ot be 'ept i& place a&y lo&"er tha& 25 mi&utes
5# (o&itor 87/ every 5 mi&utes if e1ter&al fetal mo&itori&" is &ot used
6# 6ssess &ewbor& i&fa&t at birth a&d throu"hout postpartum period for si"&s of cerebral trauma
$# (o&itor for developi&" cephalohematoma
=# 3aput succeda&eum is &ormal a&d will resolve i& 24 hours
7# Cesa%ean &eli(e%y
1# ?elivery of the fetus usually throu"h a tra&s-abdomi&al, low-se"me&t i&cisio& of the uterus
2# +reoperative
a# !f pla&&ed, prepare the mother a&d part&er
b# !f a& emer"e&cy, Huic'ly e1plai& the &eed a&d procedure to the mother a&d part&er
c# )btai& i&formed co&se&t
d# (a'e sure that the preoperative dia"&ostic tests are do&e, i&cludi&" the /h factor
e# +repare to i&sert a& !@ li&e a&d a 8oley catheter
f# +repare the abdome& as prescribed
"# (o&itor the mother a&d fetus co&ti&uously for si"&s of labor
h# +rovide emotio&al support
i# 6dmi&ister preoperative medicatio&s as prescribed
3# +ostoperative
a# (o&itor vital si"&s
b# +rovide pai& relief
c# .&coura"e tur&i&", cou"hi&", a&d deep breathi&"
32$
d# .&coura"e ambulatio&
e# (o&itor for si"&s of i&fectio& a&d bleedi&"
f# -ur&i&" a&d pai& o& uri&atio& may i&dicate a bladder i&fectio&
"# 6 te&der uterus a&d foul-smelli&" lochia may i&dicate e&dometritis
h# 6 productive cou"h or chills may i&dicate
p&eumo&ia
C-MLICATI-NS -) LA1-R AND DELI;ER=
%ete%m Labo%
+reterm labor is labor that be"i&s after 2B wee's "estatio& a&d before 3$ wee's "estatio&#
)btai& thorou"h obstetric
history5ow bac' pai&.0!)5)4F
)btai& specime& for 3-3 & ,/6
?etermi&e freHue&cy, duratio& &
i&te&sity of uteri&e co&tractio&s
?etermi&e cervical dilatatio&s a&d
effaceme&t
6ssess status of membra&es a&d
bloody show
.valuate fetus for distress, si2e
a&d maturity
Suprapubic pressure
@a"i&al pressure
/hythmic uteri&e co&tractio&s :2
uteri&e co&tractio&s lasti&" 3B
seco&ds withi& 15 mi&utes;
3ervical dilatatio& Y4 cm &
effaceme&t 5BC or less
.1pulsio& of cervical mucus plus
-loody dhow
S!4*S /SF(+0)(S 6SS.SS(.*0
+/)(
(6*64.(.*0+erform measures to ma&a"e or
stop +reterm labor(6*64.(.*0
R-M :%emat'%e R'$t'%e of Memb%ane*
- Spo&ta&eous rupture of am&iotic membra&es prior to
o&set of labor, maybe preterm :before 3= wee's
"estatio&; or term
6SS.SS(.*0
+lace o& 3-/ i& side-lyi&" positio&
+repare fro possible ultrasou&d, am&ioce&tesis,
tocolytic a&d steroid therapy
6dmi&ister meds as prescribed
6ssess S/. such as hypote&sio&, dysp&ea, chest
pai& a&d 87/ e1ceedi&" 1=B b#p#m#
*,/S!*4 (6*64.(.*0
32=
,yspnea on e@ertion and increased #a*inal
mucus are common discomforts caused by
the physiolo*ic chan*es of pre*nancy.
+rovide adeHuate hydratio&
+rovide emotio&al support
3)*0/!-,0!*4 8630)/ 4oal<
+/.@.*0!)* )8 +/.0./( ?.5!@./F
1# !&compete&t cervi1
2# 0rauma
3# !&fectio&
S!4*S 6*? SF(+0)(S
1# 5ea'a"e of am&iotic fluid
2# p7 hi"her tha& 6#5
3# *itra2i&e paper reactio& J blue
/!SL 8)/<
1# +rolapsed cord
2# !&fectio&
3# /?S
3o&servative 0reatme&t<
-ed rest i& lateral positio&
7ydratio& w/ !@8 a&d co&ti&uous fetal a&d uteri&e
co&tractio& mo&itori&"
0ocolytic 0herapy<
-eta mimetic a"e&ts< /itodri&e :Futopar;
Use of ritodrine can lead to pulmonary edema.
"herefore3 the nurse should assess for crac8les and
dyspnea. (lood *lucose le#els may temporarily rise3
not fall3 )ith ritodrine. itodrine may cause
tachycardia3 not bradycardia. itodrine may also
cause hypo8alemia3 not hyper8alemia.
itodrine 05utopar7 can cause tremor and ?ittery
feelin*s3 so it must be assessed )hether the feelin*s
are from the medication or from the Preterm labor
Steroid therapy
(6*64.(.*0<
1# %ith i&fectio&< a&tibiotics a&d delivery of i&fa&t
2# %ithout i&fectio&<
34-36 wee's of "estatio&J delay birth,
am&ioce&tesis a&d mo&itor 5S ratio of the
baby
2=-32 wee's of "estatio&J delay birth,
admi&ister steroids to haste& maturity of the
lu&"s a&d decreased /?S
"he *ood indicator of fetal lun* maturity in a
pre*nant diabetic is presence of phosphatid*lycerol in
the amniotic fluid.
6# ,mbilical cord prolapse
If the fetus is at IA station and the membranes rupture3 the patient is at ris8 for prolapsed cord.
5ou can determine if a prolapsed cord e@ists if you perform a #a*inal e@am.
R-LASE UM1ILICAL C-RD
8i"ure 23
32A
+/)56+S. ,(-!5!365 3)/?
?efi&itio& 0he umbilical cord is displaced, either betwee& the prese&ti&" post
a&d the am&io& or protrudi&" throu"h the cervi1#
Sy&o&yms 3ord +rolapse
+redisposi&" 8actors
%etal Position other than cephalic presentations
+rematurity<
*)0.< Small fetus allows more space arou&d prese&ti&" part#
+olyhydram&ios
Multiple fetal *estation
8eto+elvic disproportio&
6b&ormally lo&" umbilical cord#
Placenta Pre#ia
Intrauterine tumors that pre#ent the presentin* part from en*a*in*
N -reech prese&tatio&, 0ra&sverse lie, ,&e&"a"ed prese&ti&" part, 0wi&
"estatio&, 7ydram&ios
Small fetus
3a
0
h
e
c
o
r
d
m
a
y
t
h
e
&
p
r
e
s
e
&
t
/
v
i
s
i
b
l
e
!&itial Si"& 3ord +rolapse<
*)0." %irst discovered 6hen there is varia0le decelerated ,attern
87/ patter& variable< ?eceleratio&s with co&tractio&s or betwee&
co&tractio& or fetal bradycardia prese&t
+ersiste&t &o& reassuri&" fetal heart rate > fetal distress
6trophy of the umbilical cord & cord protrudi&" from va"i&a
3ord may be palpated i& cervi1/va"i&a
/efle1 co&strictio& whe& cord is e1posed to air
33B
[
t
h
e
v
u
l
v
a
#
N
o
t
e
"
D
o
n
o
t
a
t
t
e
+
,
t
t
o
,
u
s
h
t
h
e
c
o
r
d
i
n
t
o
t
h
e
331
u
t
e
r
u
s
#
?
y
s
t
o
c
i
a
3o&firmatory 0est5ate Si"& 6m&iotomy< /upture of (embra&es
F1 7aternal A
(etal )n%ection -
#ausing
co+,ression o% the
cord and
co+,ro+ising %etal
circulation-est
(aor Sur"ery
)07./S< +rematurity,
7ypo1ia, (eco&ium
aspiratio&,8etal death if
delayed or u&dia"&osed
Cesarian Section if the cer#i@ incompletely dilated.
%ast #a*inal deli#ery )ith forceps
7istory of the
?isease8etal
&utrie&ts
supply7epari& !@
-est ?ru".ter&al
.lectro&ic 8etal
7eart /ate
mo&itori&"-est
+ositio& ?isease
3omplicatio&
3ompressio& of the
umbilical cord
0o co&trol i&travascular
coa"ulatio& i& the
pulmo&ary circulatio&
*ature of the
dru"
)1y"e& with face-
mas'#
Sterile ha&d "love
.rendelen0erg<s ,osition or Knee #hest ,osition -6hich causes the
,resenting ,art to %all 0ac4 %ro+ the cord.
0ur& side to side -7elps may be elevated to shift to fetal prese&ti&"
toward diaphra"m#
332
H=ERT-NIC LA1-R
ATTERNS :%ima%y
ine%tia*H=-T-NIC LA1-R
ATTERNS :Secon&a%y
ine%tia**ursi&"
?ia"&osis-edside
eHuipme&t
(Pillitteri5 7aternal and #hild
Nursing5 ,.2::9
(Pillitteri5 7aternal and #hild
Nursing5 ,.3I@-3IJ9
). Dystocia
G.
7# - ?ifficult,
pai&ful, ab&ormal pro"ress of
labor of more tha& 24 hours
!#
1# +owers/ uteri&e i&ertia/
co&tractio&
2#
3#
8luid volume deficit related
to active hemorrha"e
6ltered tissue perfusio&
related to mater&al vital
or"a& a&d fetal related to
hypovolemia
/is' for i&fectio& related
traumati2e tissue
*ur
si&"
!&te
rve&
tio&
7anage+ent"N!S)NG
)N.EVEN.)&NPredis,osing
(actors"#A!SESEarl/ analgesia&$/tocin and
a+nionit/.EA.7EN.est and
sedation&##!EN#EN&.E" .he nurse<s F1
,riorit/ action to a ,rola,se cord is to assess the %etal
heart rate. A ,rola,sed cord interru,ts the o$/gen
and nutrient %lo6 to the %etus. )% the %etus doesn<t
receive adeDuate o$/gen5 h/,o$ia develo,s5 6hich
can lead to central nervous s/ste+ da+age in the
%etus.
1# (o&itor clie&t a&d fetus closely
2# +ossibly admi&ister tocolytic a"e&ts
3# +repare for emer"e&cy birth
1# (ultiparity
2# 7istory of rapid labor
3# +remature or small fetus
4# 5ar"e bo&y pelvis
5#
6# /is's<
1# +eri&eal laceratio&s & 7emorrha"e
A. 6hen deli#erin* the neonate3 you should
deli#er the head bet)een contractions. "his
)ill pre#ent the head from bein* deli#ered
too suddenly3 thuds pre#entin* a possible
tearin* of the perineum.
E.
4# 3# 8etal 3erebral trauma
4# +assa"eway
a# 3o&tracted pelvis
b# ,&favorable pelvic shapes
5ate&t phase of labor
333
c#
d# (a&a"eme&t<
i# .valuate pelvic diameters
ii# 3o&ti&ue labor with careful mo&itori&"
iii# +erform assisted va"i&al or caesarea&
delivery
iv#
5# +syche
a# 8ear, a&1iety ad te&sio& i&crease stress
a&d decrease uteri&e co&tractility
b# Stress i&terferes with the clie&ts ability
with her co&tractio&s
c# Stress i&crease fati"ue
d#
e# (a&a"eme&t<
i# (o&itor clie&ts psycholo"ic respo&se to
labor
ii# ?etermi&es clie&ts level of stress
iii# +rovide support
iv# .&coura"ed rela1atio&
(.
(i.
vii#
(iii. D. Infection
i+.
@. "he infant is at ris8 to de#elop
thrush if the pre*nant )oman has
monillial infection at the time of
#a*inal deli#ery
+i.
+ii.
+iii.
1iv#
1v#
1vi#
1vii#
1viii#
1i1# 3lamydia
4o&orrhea
Syphilis 6!?S
0)/37
11#
11i#
11ii#
11iii#
11iv#
++(. ACGUIRED
IMMUN-DE)ICIENC=
S=NDR-ME :AIDS*
a# 0ra&smissio&
6# 6cross the place&tal barrier
-# ?uri&" the process of labor a&d delivery
334
Infection
3# @ia breast mil'
-7!@ ca& cross some membra&es such as the place&tal
barrier, the blood-brai& barrier, va"i&al mucosa, a&d
:i& the &eo&ate; the walls of the "astroi&testi&al tract
-+re&atal tra&smissio& from i&fected mother to fetus or
&ewbor& via tra&splace&tal tra&smissio&, via
co&tami&atio& with mater&al blood duri&" birth, or
throu"h breast mil'
b# *ursi&" (a&a"eme&t
6void procedures that i&crease the ris' of pre&atal
tra&smissio&, such as am&ioce&tesis a&d fetal scalp
sampli&"
Note that i% the %etus has not 0een e$,osed to *)V in
utero5 the highest ris4 e$ists during deliver/ through
the 0irth canal
*ever use scalp electrodes
6void episiotomy to decrease the amou&t of mater&al
blood i& a&d arou&d the birth ca&al
+romptly remove the &eo&ate from the motherIs blood
followi&" delivery
*)0.< *)V has 0een %ound to 0e
trans+itted through the 0reast +il4 %ro+ +other
to 0a0/. .here%ore5 0reast %eeding isn<t
reco++ended %or a +other 6ho is *)V-,ositive.
1hile trans+ission rates o% *)V in%ection %ro+
+other to in%ant range %ro+ 2:K to I3K5
,ro%essionals esti+ate the actual trans+ission rate
at a0out B:K to 3:K. .he A)DS virus is ,assed
trans,lacentall/5 so cesarean deliver/ 6ill not
,revent in%ection o% the neonate. )n o,tions 25
trans+ission %ro+ +other to %etusUchild can occur
trans,lacentall/ throughout ,regnanc/5 trough
contact 6ith the +other<s 0lood and vaginal
secretions at deliver/ and through ingestion o%
0rea4 +il4. )n the o,tion B5 a ne60orn can 0e
s/+,to+-%ree at 0irth and still develo, A)DS. A
true diagnostic o% *)V in%ection in neonates
cannot actuall/ 0e +ade until around 13 +onths
o% age.
G# %eci$itate &eli(e%y
6SS.SS(.*0
-owel or bladder diste&tio&
(ultiple "estatio&
5ar"e fetus
7ydram&ios
4ra&dmultiparity
3esarea& sectio& if labor does &ot resume
8etal mo&itori&"
.he ,ri+ar/ goal 6ith a ,rola,sed o% the u+0ilical
cord is to re+ove the ,ressure %ro+ the cord.
#hanging the +aternal ,osition is the %irst
intervention. Acce,ta0le ,ositions include 4nee-
chest5 side-l/ing and elevation o% the hi,s. .he nurse
+a/ also ,er%or+ a vaginal e$a+ination and atte+,t
to ,ush the ,resenting ,art o%% the cord.
Ad+inistering the o$/gen 0ene%its the %etus onl/ i%
circulation through the cord has 0een reesta0lished.
Start or mai&tai& a& !@ as prescribed# ,se of
lar"e-"au"e catheter whe& starti&" the !@ for
blood a&d lar"e Hua&tities of fluid i&ta'e#
6dmi&ister o1y"e& by face >mas' to provide hi"h
o1y"e& co&ce&tratio& at = >1B5/mi&#
!&struct patie&t to clea&se from the fro&t to the
bac'#
.1plai& the importa&ce of ha&d washi&" before
a&d after peri&eal care#
)07./ (6*64.(.*0<
/epositio& clie&t to tre&dele&bur" or '&ee-
chest positio&
)1y"e&
+ush prese&ti&" part upward
6pply moiste&ed sterile towels
?elivery as soo& as possible
A
34$
.. Doc'ment all
abno%mal fin&in"s
#. -bse%(e o%
assist <it! initiation
of %es$i%ations
,. Assess A$"a%
sco%e
3. Note
c!a%acte%istics of c%y
.. Monito% fo%
nasal fla%in"D
"%'ntin"D
%et%actionsD
abno%mal
%es$i%ations
0. -btain (ital
si"ns
4. -bse%(e
ne<bo%n fo%
si"ns of
!y$ot!e%mia
o%
!y$e%t!e%mia
5. Assess fo% "%oss
anomalies
,. Im$lementation
#. S'ction
mo't!D t!en na%esD <it!
b'lb sy%in"e
,. D%y ne<bo%n
an& stim'late c%yin" by
%'bbin"
3. Maintain
tem$e%at'%e
stabilityR <%a$
ne<bo%n in
<a%m blan2ets
an& $lace a
stoc2inette ca$
on ne<bo%nOs
!ea&
N-TEA
Tem$e%at'%e ta2in"
.he 0est site
6ithout
co+,lications
is the ta4ing it
in a$illa. )t is
not advisa0le to
34=
,ut it in the
+outh5 anus or
ear since all o%
the+ are
sensitive.
.. Hee$ ne<bo%n
<it! mot!e% to
facilitate
bon&in"
0. lace
ne<bo%n at
mot!e%Os
b%east if
b%eastfee&in"
is $lanne&D o%
$lace on
mot!e%Os
ab&omen
4. lace
ne<bo%n in <a%me%
5. osition
ne<bo%n on
si&e o%
ab&omen o% in
mo&ifie&
T%en&elenb'%"
$osition to
facilitate
&%aina"e of
m'c's
6. Ens'%e
ne<bo%nOs $%o$e%
i&entification
7. )oot$%int
ne<bo%n an&
fin"e%$%int
mot!e% on
i&entification
s!eetD $e%
a"ency $olicies
an& $%oce&'%es
#8. lace
matc!in" i&entification
b%acelets on mot!e% an&
ne<bo%n
N-TEA Con(ectionD
Con&'ctionD Ra&iation
an& E(a$o%ation
34A
Eva,oration occurs 6hen
6et sur%aces such as
neonate<s s4in are e$,osed
to air.
#onduction o% heat a6a/
%ro+ the 0od/ +a/ occur
6hen the neonate co+es
in direct contact 6ith cold
sur%aces such as scale or
cold stethosco,e.
adiation is the trans%er o
heat to cooler o0Gects that
are not in direct contact
6ith the neonate.
#onvection- 4ee,ing a6a/
the neonate %ro+ the air
conditioning or cooling
ducts ,revents heat loss
3. ;ital si"ns
6+46/ 3/!0./!6
6+46/ S3)/.
Symptoms of
depressio& plus
delusio&s
6uditory
halluci&atio&s
7yperactivity
-+ytocin
Anal"esics
Maintain !y"iene
Semi9fo<le%s
$ositions
;ital si"ns
Ea%ly amb'lations
Assess loc!ia
Bright red 0lood is a
nor+al lochial
%inding in the %irst
2B hours a%ter
deliver/. Lochia
should never
contain large clots5
tissue %rag+ents5 or
+e+0ranes. A %oul
odor +a/ signal
in%ection5 as +a/
a0sence o% lochia.
35B
*o respo&se4rimace
@i"orous cry7.6/0
/60.
6bse&t 5ess tha& 1BB b#p#m# )ver 1BB b#p#m#
(,S35. 0)*./.85.O
!//!06-!5!0F
5imp Some fle1io& 6ctively moves
/.S+!/60)/F .88)/0 6bse&t Slow, irre"ular 4ood cry
"he components of Ap*ar scorin* system are tone3 color3 irritability3 respiration and heart rate.
1# +erform a&d record the 6p"ar score at 1 mi&ute a&d at 5 mi&utes
2# !f the score is less tha& $ at 5 mi&utes, the 6p"ar score should be performed at 1B mi&utes
3# 6ssess each of five items to be scored, a&d assi"& value of C :very poor; to 2 :e1celle&t; for each item
4# 6dd the poi&ts to determi&e the &ewbor&Es total score
a# 6 score of $ to 1B i&dicates a health
-in&icates t!at t!e ne<bo%n is &oin" <ell.
b# 6 score of 3 to 6 is co&sidered moderately depressed
c# 6 score of B to 2 is severely depressed
- in&icates t!at t!e ne<bo%n nee&s assistance.
1# 7eart rate< 1BB to 1$B beats per mi&ute :apical;9 assess for a full mi&ute because of irre"ularities
afterbirth
2# /espiratio&s< 3B to =B breaths per mi&ute9 assess or a full mi&ute
3# 61illary temperature< A6#= to AA^ 8
4# -lood pressure< $3/55 mm 7"
.. 1o&y meas'%ements
1# 5e&"th< 45 to 55 cm :1= to 22 i&ches;
2# %ei"ht< 25BB to 43BB " :5#5 to A#5 pou&ds;
3# 7ead circumfere&ce< 33 to 35#5 cm :13 to 14 i&ches;
4# 3hest circumfere&ce< 3B to 33 cm :12 to 13 i&ches; a&d should be eHual to or 2 to 3 cm less tha& the head
circumfere&ce
*)0.< Neonates +ead #ersus Chest circumference
At birth3 the neonates head circumference is about Acm LA-$ "+AN "+$ C+$S"
CICUM%$$NC$. "he A#era*e +ead circumference is 9E .9J inches 0EE.EF cm7 3 a#era*e Chest
circumference is 9A.F to 9J inches 0 E9.EF cm7
1 . Hea& to Toe Ne<bo%n Assessment
351
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
,ri&e prese&t i& the bladder at birth but *- may &ot void doe 1
st
12-24 hours
5ater patter& is 6-1B voidi&"s/ day > i&dicative of sufficie&t fluid i&ta'e
,ri&e is pale a&d straw colored > i&itial voidi&"s may leave bric'-red spots o&
diaper : d/t passa"e of uric acid crystals i& uri&e;
!&fa&t u&able to co&ce&trate uri&e for the 1
st
3 mo&ths
352
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
!((60,/. 36/?!63
S+7!*30./ > may allow reflu1 of
food, burped, /.4,/4!060.-
placed *- ri"ht side after feedi&"
*ewbor& ca&Et move food from lips
to phary&1# !&sert &ipple well to
mouth
8..?!*4 +600./S vary
- *ewbor&s may &urse vi"orously
immediately afterbirth or may &eed
as lo&" as several days to suc'
effectively
- +rovide support a&d e&coura"eme&t
to &ew mothers duri&" this time as
i&fa&t feedi&" is very emotio&al
doe most mothers
NO"$1 ,istin*uishin* Neonatal
&omitin* from e*ur*itation
&omitin* is usually sour3 loo8s li8e
curdled mil8 due to +CL3 )ith a sour
odor3 )hile re*ur*itation has no sour
odor or curdlin* of mil83 or occurs
durin* or immediately after feedin*.
!(+)/06*0 3)*S!?./60!)*S<
(reastfeedin* can usually
be*in immediately after birthH
bottle.fed ne)borns may be
offered fe) milliliters of
sterile )ater or FB de@trose 9
to J hours after birth prior to
a feedin* )ith formula
353
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
5iver respo&sible for cha&"i&" 7"b i&to co&u"ated bilirubi&, which is further
cha&"ed i&to co&u"ated :water soluble; bilirubi& that ca& be e1creted
.1cess u&co&u"ated bilirubi& ca& permeate the sclera a&d the s'i&, "ivi&" a
au&diced or yellow appeara&ce to these tissues
HEAT R-DUCTI-N i& &ewbor& accomplished by<
a# (etabolism of R -/)%* 860S
- 6 special structure i& *- is a source of heat
- !&creased metabolic rate a&d activity
61illary temperature< A6#= to AA8
*ewbor& ca&Et shiver as a& adult does to release heat
*ewbor&s are u&able to mai&tai& a stable body temperature because they have a&
immature vasomotor ce&ter, a&d u&able to shiver to i&crease body heat#
*-Es body temperature drops Huic'ly after birth > after stress occurs
easily
-ody stabili2es temperature i& =-1B hours if u&stressed
Cold stress increases oA consumption I may lead to metabolic acidosis
and respiratory distress
N( de#elops o)n antibodies durin* 9
st
E months but at ris8 for infection durin* the
first : )ee8s
6bility to develop a&tibodies develops seHue&tially
-irth wei"htJ25BB-4BB "rams :5 lbs# =o2# > = lbs# 13 o2#;
354
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
*ose breathers for first few mo&ths of life
355
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
Short a&d wea' with deep fold of s'i&
3haracteri2ed by cyli&drical thora1 a&d fle1ible ribs
*)0.<
appears circular si&ce a&teroposterior a&d lateral diameters are about eHual
/espiratio&s appear diaphra"matic
*ipples promi&e&t a&d ofte& edematous
7il4/ secretion (6itchWs +il49 co++on ( e%%ect o% estrogen9
356
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
35$
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
35=
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
35A
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
36B
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
361
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
362
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
363
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
364
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
Should be strai"ht a&d flat
6&us should be pate&t without a&y fissure
?impli&" at the base is associated with spi&a bifida
A degree o% h/,otonicit/ or h/,ertonicit/ is indicative o% central nervous s/ste+ (#NS
da+age
Assess+ent %or
Eaundice
.he F1
techniDue is to
0lanch the s4in
over the 0on/
,ro+inence such
as the %orehead5
chest or ti, o%
the nose.
N-TEA
starts at the head
first3 spreads to
the chest3 then the
abdomen3 then the
arms and le*s3
follo)ed by the
hands and feet3
)hich are the last
to be ?aundiced.
!aundice in the
first AJ hours
after the birth is
a cause for
concern that
re4uires further
assess+ent.
C.GESTATI-NAL
ASSESSMENT
+6/6(.0./
*,/S!*4 630!)*
365
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
Possi0le causes
o% earl/
Gaundice are
0lood
inco+,ati0ilit/5
o$/tocin
induction5 and
severe
he+ol/tic
,rocess
Acrocyanosis of
the hands and
feet is normal3
resultin* from
slu**ish
peripheral
circulation
Mon*olian Spots
-ary3 blue or
blac8 mar8s that
are fre4uently
found on the
sacral area3
buttoc8s3 arms
shoulders or
other areas.
+arle4uins Si*n
Occurs on one
side of the body
turns deep red
color. It occurs
)hen blood
#essels on one
366
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
side constrict3
)hile those on
the other side of
the body dilate.
Acrocyanosis
#ersus Central
Cyanosis
Acrocyanosis
in#ol#es the
e@tremities of the
neonate3 for
e@ample bluish
hands and feet
due to neonates
bein* cold or
poor perfusion of
the blood to the
periphery of the
body.
6hile central
cyanosis3 )hich
in#ol#es the lips3
ton*ue and trun8
indicatin*
+5PO'IA )hich
needs further
assessment by the
nurse.
.
E,stein<s ,earls
are small3 )hite
cysts on the hard
palate or *ums of
36$
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
the ne)born.
"hey are nor
abnormal and
)ill disappear
shortly after
birth.
7ilia are
bloc8ed
sebaceous
*lands located
on the chin and
the nose of the
infant.
+eman*iomas >
&ascular "umors
Ne#i flammeus or
port )ine stains
&$NI'
CAS$OASA
Should not be
remo#ed by oil or
hand lotion3
because it is a
protecti#e layer
of the neonate
after birth3 and it
disappears after
birth 0 pa*e 9TT
lippincot7 Ne#er
remo#e it )ith
alcohol or cotton
balls3 unless
36=
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
meconium
s8inned.
*)0.<
@er&i1 3aseosa
.rythema
to1icum
&eo&aturum
0ela&"iectasia
+ort wi&e stai&
:&evus flamus;
Strawberry
hema&"ioma
+eman*ioma is
beni*n #ascular
tumor that may
be present on the
ne)born
8i"ure 24
7ema&"ioma
8i"ure 25
.rythema
to1icum
&eo&aturum a&d
(ilia
8old the pi&&a
:auricle; forward
Pinna recoils 0sprin*s
bac87
Pinna opens slo)ly or stays folded
in #ery premature infants
36A
,(-!5!365 @.!* a&d ?,30,S @.*)S,S co&strict after cord id clamped
?,30,S 6/0./!)S,S co&strict with establishme&t of respiratory fu&ctio&
8)/6(.* )@65. closes fu&ctio&ally as respiratio&s established, but
a&atomic or perma&e&t closure may ta'e several mo&ths
7.6/0 /60. avera"es 14B b#p#m#
-+ $3/55 mm7"
+./!+7./65 3!/3,560!)* acrocya&osis withi& 24 hours
/-3 hi"h immediately after birth9 falls after 1
st
wee'
6-S.*3./ *)/(65 85)/6 !*0.S0!*. @itami& L
(easure it E mm Less than E mm
)bserve Labia ma?ora co#er
labia minora
Labia minora are more prominentH
#a*inal openin* can be seen
)bserve $@tend A>E of the )ay
from the toes to the heel
Soles are smoother3 creases e@tend
less than A>E of the )ay from the
toes to the heel
D.NE?1-RN RE)LE@ES
0he rooti&" refle1 is elicited by stro'i&" the &eo&ateIs chee' or stro'i&" &ear the cor&er of the &eo&ateIs mouth#
0he &eo&ate tur&s the head i& the directio& of the stro'i&", loo'i&" for food# 0his refle1 disappears by 6 wee's#
)ther optio&s refer to other refle1es see& i& &eo&ates< 0he palmar "rasp refle1 is elicited by placi&" a& obect i&
the palm of a &eo&ate9 the &eo&ateIs fi&"ers close arou&d it# 0his refle1 disappears betwee& a"es 6 a&d A
mo&ths# 0he -abi&s'i refle1 is elicited by stro'i&" the &eo&ateIs foot, o& the side of the sole, from the heel
toward the toes# 6 &eo&ate will fa& his toes, produci&" a positive -abi&s'i si"&, u&til about a"e 3 mo&ths# 0he
suc'i&" refle1 is see& whe& the &eo&ateIs lips are touched a&d lasts for about 6 mo&ths#
/ooti&" a&d suc'i&"
refle1 usually
disappears after 3-4
mo&ths but may
persists for up to 1
year+65(6/
4/6S+ /.85.O
*ewbor&Es fi&"ers curl arou&d the e1ami&erEs fi&"ers a&d the &ewbor&Es toes curl
dow&ward#
+almar respo&se lesse&s withi& 3-4 mo&ths
+almar respo&se lesse&s withi& = mo&ths
-e"i&&i&
" at the
heel of
the foot,
"e&tly
Symmetric & bilateral abductio& & e1te&sio& of arms a&d ha&ds
0humb & forefi&"er form a 3
R.(-/63.S refle1
+rese&t at birth, complete respo&se may occur up to = wee's
6 persiste&t respo&se lasti&" more tha& 6 mo&ths may i&dicate the occurre&ce of
3$B
stro'e
upward
alo&" the
lateral
aspect of
the sole9
the& the
e1ami&er
moves
the
fi&"ers
alo&" the
ball of
the
foot()/
)
/.85.O
/))0!*
4
/.85.O
.he ne60orn<s
toes
h/,ere$tend
6hile the 0ig
toe dorsi%le$es
e%le$
disa,,ears
a%ter the
ne60orn is 1
/ear old
6bse&ce of this
refle1 i&dicates
the &eed for a
&eurolo"ical
e1ami&atio&
brai& dama"e duri&" pre"&a&cy
A normal refle@ in a youn* infant caused by a sudden loud noise. It results in dra)in*
up the le*s3 an embracin* position of the arms3 and usually a short cry.
8i"ure 26 (oro /efle1 or .mbrace /efle1
%hile the
&ewbor&
is falli&"
asleep or
sleepi&",
"e&tly
a&d
Huic'ly
tur& the
head to
o&e
sideS0.+
+!*4 )/
0he &ewbor& simulates wal'i&", alter&ately fle1i&" a&d e1te&di&"
the feet
0he refle1 is usually prese&t 3-4 mo&ths
3$1
%65L!*
4
/.85.O
-6-!*S
L!E S!4*
6s the
&ewbor&
faces the left
side, the left
arm & le"
e1te&d
outward
while the
ri"ht arm &
le" fle1
%he& the
head is
tur&ed to the
ri"ht side,
the ri"ht arm
& le" e1te&d
outward
while the left
arm & le"
fle1
,sually
disappears
withi& 3-4
mo&ths
3/6%5!*40)*!
3 *.3L
/.85.O
a# +lace the &ewbor& o& the abdome&
b# 0he &ewbor& be"i&s ma'i&" crawli&" moveme&ts with the arms a&d le"s
c# .he re%le$ usuall/ disa,,ears a%ter a0out H 6ee4s
E. 1ASIC TEACHING NEEDS -) NE? ARENTS
+/
.
0.
/
(
!*
86
*
3)/? 36/. 3lea&se the cord with alcohol a&d sometimes triple dye o&ce a day
Leep the area clea& a&d dry
Leep the &ewbor&Es diaper below the cord to preve&t irritatio&
Si"&s of i&fectio&< red&ess, drai&a"e, swelli&", odor
*otify physicia& for si"&s of i&fectio&
*)0.<
Note any bleedin* or draina*e from the cord
"riple dye may be applied for initial cord care because it
minimi2es microor*anisms and promotes dryin*H use a cotton.
3$2
0
-
)
*
?!
*
4
.&
co
ur
a"
e
pa
re
&t
to
tal
'
to,
ho
ld,
a&
d
si&
"
to
i&f
a&t
)b
ser
ve
for
ble
edi
&"
,
fir
st
uri
&at
io
&
6
&e
o&
ate
tipped applicator to paint the dye3 one time3 on the cord on 9 inch
of surroundin* s8in
Application of KCB isopropyl alcohol to the cord )ith each
diaper chan*e and at least t)o r three times a day to minimi2e
microor*anisms and promote dryin*.
*)0.< "he s8in is surrounded )ith alcohol )hich promotes dryin* and
cleans the area. "he umbilical cord dries and falls off about 9J days.
Pero@ide and lanolin promote moisture3 )hich can inhibit dryin* and
allo) *ro)th of bacteria. 6ater doesn/t promote dryin*.
It is best to care for the neonate/s umbilical cord area by cleanin* it )ith
cotton pled*ets moistened )ith alcohol. "he alcohol promotes dryin* and
helps decrease the ris8 of infection. An antibiotic ointment maybe used
instead of alcohol3 because there are a lot of bacteria )hich is resistant
a*ainst some bacteria. Other a*ents such as )ipes3 sterile )ater and soap
< )ater are not as effecti#e as alcohol.
3$3
bo
r&
be
for
e
3=
we
e'
s
a"
e
of
"e
sta
tio
&
8i"
ure
2$
+re
ma
tur
e
i&f
a&t
s
sol
e
cre
ase
s,
ear
lob
e
a&d
pre
ma
tur
e
fe
ma
le
"e&
ital
ia
3$4
R
E
TE
R
M
IN
)A
NT
?efi&itio&
+romo
tes
s'i&-
to-s'i&
co&tact
betwee
&
pare&t
a&d
i&fa&t
8eedi&
"s are
opport
u&ities
for
pare&t-
i&fa&t
bo&di&
"
*otify
physici
a& for
si"&s
of
i&fecti
o&
N
&.E"
Sense
o%
.ouch
3$5
.h
e +ost
highl/
develo
,ed
sense
at
0irth
that is
6h/5
neona
tes
res,on
ds 6ell
to
touch.
6ppl
y
diape
r
loosel
y to
preve
&t
irritat
io&
*otif
y
physi
cia&
for
si"&s
of
i&fect
io&
3!/3,(
3!S!)*
36/.
Sy&o&ym
Lo) birth )ei*ht
0Mosby/s Comprehensi#e e#ie) of Nursin* for NCL$'.N pa*e A9F7
3o&tributi&" factors 5ow socioeco&omic level
+oor &utritio&al status
5ac' of pre &atal care
(ultiple pre"&a&cy
+rior previous early birth
/ace :&o& whites have a hi"her i&cide&ce of prematurity tha&
whites;
3i"arette smo'i&"
0he a"e of the mother : the hi"hest i&cide&ce is i& motherEs
you&"er tha& a"e 2B#;
3$6
)rder of birth : early termi&atio& is hi"hest i& first pre"&a&cies
a&d i& those beyo&d the forth ;
3losely spaced pre"&a&cies
6b&ormalities of the reproductive system such as i&trauteri&e
septum
!&fectio&s : specially uri&ary tract i&fectio&s;
)bstetric complicatio&s such as premature rupture of membra&es
or premature separatio& of the place&ta
.arly i&ductio& of labor
.lective cesaria& birth
3ardi&al si"&s 6ppears small a&d u&derdeveloped
0he head is disproportio&ately lar"e : 3 cm or more "reater tha&
chest si2e;
S'i& is thi& with visible blood vessel a&d mi&imal subcuta&eous
fat pads
@er&i1 caseosa is abse&t
-oth a&terior a&d posterior fo&ta&elles are small
/e
su
sci
tat
io
&
*
)
0
.<
res
us
cit
ati
on
0e
co
+e
s
i+
,o
rta
nt
%or
in%
an
t
6h
o
%ai
ls
to
ta4
e
6b&ormal laboratory values ?ecreased /-3Es
?ecreased serum "lucose
!&creased co&ce&tratio& of i&direct bilirubi&
?ecreased serum albumi&
*)0.< .he nor+al range o% urine out,ut %or a ,reter+
0a0/ is 1 to 2+l?4g?da/. .he nor+al s,eci%ic gravit/ %or a
,reter+ 0a0/ is 1.:2:. .he nor+al range %or 0lood glucose
level in a ,reter+ 0a0/ is B: to H: +g?dl.
3$$
%ir
st
0r
eat
h
or
di%
%ic
ult
/
+a
int
ai
ni
ng
ad
eD
ua
te
res
,ir
ato
r/
+o
ve
+e
nts
on
his
o6
n.
Su
cti
o&i
&"
*)
0.
<
all
o6
s
re
+o
vin
g
+
uc
us
an
d
,r
ev
ent
s
as
3$=
,ir
ati
on
o%
an
/
+
uc
us
an
d
a+
ni
oti
c
%lu
id
,r
ese
nt
in
the
+o
ut
h
an
d
no
se
o%
the
ne
60
or
n
to
est
a0l
ish
cle
ar
air
6a
/.
!&t
uba
tio
&s
*)
0.<
he
ad
o%
the
in%
3$A
ant
in
ne
utr
al
,os
itio
n
6it
h
to
6el
un
der
sh
oul
der
.
-est
procedure
-est positio& +ositio&i&" the i&fa&t o& the bac' with the head of the mattress
elevated appro1imately 15 de"rees to allow abdomi&al co&te&ts to
fall away from the diaphra"m affordi&" optimal breathi&" space#
-est positio& for suctio&i&"<
!&fa&t o& the bac' a&d slide a folded towel or pad u&der shoulders
to rise, head is i& &eutral positio&#
3omplicatio&s 6&emia of prematurity
7yperbilirubi&emia/ 'er&icterus
+ersiste&t pate&t ductus arteriosus
+erive&tricular / i&trave&tricular hemorrha"e
/espiratory distress sy&drome
etino,ath/ o% ,re+aturit/
etrolental fibroplasias are a complication that occurs if the infant is
o#ere@posed to hi*h o@y*en le#els.
Necroti8ing enterocolitis
7ost
severe
%or+
o%
s,ina
0i%ida .
( ,.
@J@5
.e$t0o
o4 o%
Basic
Nursin
g
Li,,in
cott H
th
ed.9&n
e o% the
%ete%m si3e
la%yn"osco$e
ET t'be
S'ction cat!ete% <it!
synt!etic s'%factant
Isolettes :inc'bato%*
D%'" st'&y
3=B
+enin
ges
(the
S,inal
cord
coverin
g9
,rotru
des or
herniat
ed
throug
h
o,enin
g in
verte0r
al
colu+
n. (,.
@J@5
.e$t0o
o4 o%
Basic
Nursin
g
Li,,in
cott H
th
ed.9Des
c%i$tio
n)s an
o,enin
g in
the
verte0r
al
colu+
n 6ith
no
a,,are
nt
reason.
( ,.
@J@5
.e$t0o
o4 o%
Basic
Nursin
g
Li,,in
cott H
th
ed.9S,i
na
0i%ida
occulta
7enin
gocele
3=1
7/elo
+enin
gocele
./,esS
,ina
0i%ida
occulta
S/non/
+sS,in
al
D/sra,
hia
e%ers
to
+al%or
+ation
o%
s,ine
in
6hich
the
,osteri
or
,ortion
o% the
la+ina
e o% the
verte0r
ae %ails
to
close.N
ursing
interve
ntions1
.
Nursin
g
diagno
ses1.
)ne%%ec
tive
air6a/
0reathi
ng
Positio
ning
the
in%ant
on the
0ac4
6ith
the
head
o% the
+attres
s
3=2
elevate
d
a,,ro$
i+atel/
13
degree
s to
allo6
a0do+i
nal
content
sA0nor
+al
la0orat
or/
values)
ncreas
ed total
no. o%
B#<s
#lassic
signs)n
trauter
ine
6eight
loss5
deh/dr
ations
and
chroni
c
h/,o$i
a Vold
+an
%aces<
Nursin
g
interve
ntion.
he
nurse<s
%irst
,riorit/
in
,re,ari
ng a
sa%e
enviro
n+ent
%or a
,reter
+
ne60or
n 6ith
lo6
A,gar
3=3
scores
is to
,re,ar
e
res,ira
tor/
resusci
tation
eDui,+
ent.
Air6a/
+ainte
nance
is the
%irst
,riorit/
.Nursi
ng
diagno
sis)+,
aired
gas
e$chan
ge
related
to
i++at
ure
,ul+o
nar/
%unctio
ning
%ot%
'sion
of t!e
s$inal
co%&
$%ot%'
&es
t!%o'"
! t!e
bac2.
Sacs
a%e
co(e%e
& by
t!in
memb%
ane &
ne%(e
a%e
e+$ose
&
Ne'%o
lo"ical
3=4
&eficits
a%e
e(i&ent
Menin
"es o%
$%otect
i(e
co(e%i
n"
a%o'n&
t!e
s$inal
co%&
!as
$'s!e&
o't
t!%o'"
! t!e
o$enin
" in
t!e
(e%teb
%ae in
a sac.
S$inal
co%&
intact
Ne'%o
lo"ical
&eficit
a%e
's'ally
N-T
RES
ENT
Can
be
%e$ai%e
& </
little o%
no
&ama"
e to t!e
ne%(e
$at!<
ays.
7ost
co++o
n site
o%
inGur/
T
lu+0os
acral
area
3=5
( 7os0
/<s
#o+,r
ehensi
ve
revie6
o%
Nursin
g %or
N#LE
>-N
,. 22H9
: menin"omyel
ocele*
Menin"oc
ele
Myelome
nin"ocele
o
-
A.
RESIR
AT-R=
DISTRE
SS
S=NDR-
ME
9
D
9
C
9
A
9
9 N
-
T
E
"
7
or
e
3=6
c
o
+
+
o
n
in
n
e
o
n
at
es
d
el
iv
er
e
d
0
/
ce
sa
re
a
n
se
ct
io
n
th
a
n
in
th
os
e
d
el
iv
er
e
d
v
a
gi
n
al
l/
.
9
9 C
-
M
M
-
3=$
N
SI
G
N
S
9
ya
n
os
isD
&
ys
$
ne
aD
st
e%
n
al
a
n
&/
o%
co
st
al
%e
t%
ac
ti
o
ns
D
ta
c!
y
$
ne
aD
"%
'
nt
in
"D
a
n
&
n
as
al
fl
a%
in
"D
%l
ar
3==
in
g
n
ar
es
5
E
$
,i
ra
to
r/
gr
u
nt
in
g
9
9 M
A
N
A
G
E
M
E
N
T
9
ai
nt
ai
n
a
$
at
en
t
ai
%
<
ay
D
$l
ac
e
t!
e
in
fa
nt
in
a
<
a%
m
3=A
is
ol
le
te
<i
t!
o+
y"
en
D
a
&
m
in
ist
e%
a
nt
ib
io
ti
cs
as
$%
es
c%
ib
e&
a
n
&
co
%%
ec
t
ac
i&
os
is
9
1.
HEM-L
=TIC
DISEAS
E
9
A
9
9 C-M
M-N
SIGN
S
9
E
3AB
9
9
9 RE;
ENTI
-N
INDI
RECT
C--
M1IS
TEST
9
T
9
9
9 RESU
LTSA
9
If
9
R
9
If
9
9 DIRE
CT
C--
M1IS
TEST
9
T
9
9 RESU
LTS
9
If
9
N
9
R
9
C.
H=E
R1IL
IRU1
3A1
INEM
IA
9
Se
9
A
9 E
(a
l'
at
io
n
is
in
&i
ca
te
&
<
!e
n
se
%'
m
A
o
ve
r
1
2
+
g?
d
L
in
th
e
te
r
+
n
e
6
0
or
n
9 T
!e
%a
$
y
is
3A2
ai
m
e&
at
$%
e(
en
ti
n
"
%e
s'
lts
in
$e
%
m
a
ne
nt
ne
'%
ol
o"
ic
al
&
a
m
a"
in
"
f%
o
m
t!
e
&e
$
os
iti
o
n
of
bi
li%
'
bi
n
3A3
in
ce
lls
9
9
T
9
9
T
9
9
9
9
N
9
9
9
9
9
E+$ose as
m'c! of
t!e
ne<bo%nOs
s2in as
$ossible
#over the
genital
area5 and
+onitor
genital
area %or
s4in
irritation
or
0rea4do6
n
( ,ria,is+
+a/
3A4
occur9
#over the
ne60ornWs
e/es 6ith
e/e shields
or
,atches'
+a4e sure
e/elids are
closed
6hen
shields or
,atches
are
a,,lied
e+ove
the shields
or ,atches
at least
once ,er
shi%t to
ins,ect the
e/es %or
in%ection
or
irritation
and to
allo6 e/e
contact
. Meas'%e
t!e
F'antity
of li"!t
e(e%y 6
!o'%s
Monito%
s2in
tem$e%at'
%e closely
)ncrease
%luids to
co+,ensat
e %or 6ater
loss
3A5
E$,ect
loose
green
stools and
green
urine
7onitor
the
ne60ornWs
s4in color
6ith the
%lorescent
light
turned o%%5
ever/ B to
@ hours
7onitor
the s4in
%or 0ron8e
0a0/
s/ndro+e5
a gra/ish
0ro6n
discolorati
on o% the
s4in
e,osition
ne60orn
ever/ 2
hours
R!
anti"e
ns
f%om
t!e
babyOs
bloo&
3A6
ente%
t!e
mate%
nal
bloo&s
t%eam
Dest%
'ction
of
R1Cs
t!ose
%es'lt
s f%om
an
anti"e
n
antibo
&y
%eacti
on
E+c!a
n"e of
fetal
an&
mate%
nal
bloo&
ta2es
$lace
$%ima
%ily
<!en
t!e
$lacen
ta
se$a%
ates at
bi%t!
T!e
mot!e
%
$%o&'
ces
anti9
R!
antibo
&ies
a"ains
t t!e
3A$
fetal
bloo&
cells
Antib
o&ies
a%e
!a%ml
ess to
t!e
mot!e
% b't
attac!
to t!e
e%yt!%
ocytes
in t!e
fet's
an&
ca'se
!emol
ysis
Sensit
i3atio
n is
%a%e
<it!
t!e
fi%st
$%e"n
ancy
AB&
inco+
,ati0il
it/ is
usuall
/ less
severe
1.
Assess
ment
#.
!y$e%
bili%'
binem
ia &
!emol
ytic
anemi
3A=
a
,.
Eaund
ice
that
develo
,s
ra,idl
/ a%ter
0irth
and
0e%ore
2B
hours
(PA.
*&L
&G)#
AL
EA!N
D)#E
9
C.
Im$le
menta
tion
1. A&ministe
% R!o:D*
imm'ne
"lob'lin to
t!e
mot!e%
&'%in" t!e
fi%st 5,
!o'%s
afte%
&eli(e%y if
t!e R!9
ne"ati(e
mot!e%
&eli(e%s
an R!9
$ositi(e
fet's b't
%emains
'nsensiti3
e&
2. T!e
babyOs
bloo& is
3AA
%e$lace&
<it! R!9
ne"ati(e
bloo& to
sto$ t!e
&est%'ctio
n of t!e
babyOs %e&
bloo&
cellsR t!e
R!9
ne"ati(e
bloo& is
%e$lace&
<it! t!e
babyOs
o<n bloo&
"%a&'ally
2.
B. N-TEA
.he *
negative
+other
6ho has
no titer
(negative
#oo+0s<
test
results5
non
sensiti8ed9
and 6ho
has
delivered
an *
,ositive
%etus is
given an
intra
+uscular
inGection
o% anti-*
(D9
(*oGA
79.
Paternal
0lood t/,e
+ight 0e
deter+ine
d %or the
,regnant
*
negative
4BB
6o+an in
order to
hel,
deter+ine
%etal 0lood
t/,e..
3.
H. *oGA7
0loc4s
anti0od/
,roduction
0/
attaching
to %etal
*
,ositive
0lood cells
in the
+aternal
circulation
0e%ore an
i++unolo
gical
res,onse
is
initiated.
I.
@. *oGA7
+ust 0e
ad+inister
ed to
unsensiti8
ed
,ost,artu
+ 6o+en
a%ter the
0irth o%
each *
,ositive
in%ant to
,revent
,roduction
o%
anti0odies.
)% the
%ather o%
%uture
%etuses is
*
,ositive
hetero8/go
us5 there is
a 3:K
chance o%
an *
negative
4B1
in%ant' i%
he is *
,ositive
ho+o8/go
us5 all
in%ants
6ill 0e *
,ositive.
J.
1:.
11. THE
ADDICT
ED
NE?1-R
N
N-TED
)EATURESA
Short
,al,e0r
al
%issures5
*/,o,la
stic
,hiltru
+D
short5
u,turne
dnose5
)lat
mi&face
T!in '$$e% li$D
Lo< nasal 0ridge5
Abno%mal $alma%
c%easesD
Res$i%ato%y
&ist%ess Sa$neaD
cyanosis*D
Con"enital !ea%t
&iso%&e%sD
)rrita0ilit/5
h/,ersensitivit/ to
sti+uli5 .re+ors
Poor
%eeding5
Sei3'%es
.
N&.E"
.hese
4B2
are
signs o%
*eroine
6ithdra
6al
usuall/
occurs
6ithin
2B to B@
hours o%
0irth.
.he
ne60or
n +a/
0e Gitter/
and
h/,eract
ive. .he
cr/ is
o%ten
shrill
and
,ersiste
nt 6ith
/a6ning
and
snee8ing
. .endon
re%le$es
are
increase
d5 and
7oro<s
re%le$ is
decrease
d.
N-TEA
*eroin
6ithdra6al
neonates
*igh
,itch
cr/5
increase
)#P5
h/,ogl/
ce+ia5
loud
and
lust/ cr/
NURSING
INTER;ENTI
-NA
4B3
#. 7onitor
%or
res,irator/
distress
,. osition
ne<bo%n on
si&e to
facilitate
&%aina"e of
sec%etions
3. Hee$
%es'scitatio
n
eF'i$ment
at t!e
be&si&e
.. 7onitor
%or
h/,ogl/ce+
ia
0. Assess
s'c2 an&
s<allo<
%efle+
4.
A&ministe%
small
fee&in"s
an& b'%$
<ell
5. S'ction
as
necessa%y
6.
Monito% I
& 8
7. 7onitor
6eight and
head
circu+%eren
ce (#hec4
%or )ncrease
)#P9
#8.
Dec%ease
en(i%onmen
tal stim'li
##. .he
use o%
narcotic
antagon
ists to
4B4
reverse
res,irat
or/
de,ressi
on in
the drug
addicted
neonate
is
contrain
dicated
0ecause
these
drugs
+a/
,reci,it
ate
acute
6ithdra
6al in
the
neonate.
NE? 1-RN
-)
DIA1ETIC
M-THER
A. Desc%i$tion
Neonate
bo%n to an
ins'lin9
&e$en&ent
mot!e% o%
"estationa
l &iabetic
mot!e%
an& <it!
!i"!
inci&ence
of
con"enital
anomalies.
C-M
LIC
ATI
-N
SA
*ig
h
inci
den
4B5
ces
o%
h/,
ogl/
ce+
ia5
res,
irat
or/
dist
ress
5
h/,
ocal
ce+
ia5
and
h/,
er0i
liru
0ine
+ia
1. Assessment
7A#
&S&
7)A
A
LGA
as a
result
o%
e$cess
%at
and
gl/cog
en in
tissue
s
E&em
a o%
$'ffin
ess in
t!e
face
an&
c!ee2
s
Signs
o%
h/,og
l/ce+i
a5
4B6
such
as
t6itch
ing5
di%%icu
lt/ in
%eedin
g5
lethar
g/5
a,nea
5
sei8ur
es5
and
c/ano
sis
Hy$e%
bili%'
binem
ia
Signs
o%
res,ir
ator/
distres
s5
such
as
tach/
,nea5
c/ano
sis5
retrac
tions5
grunti
ng5
and
nasal
%larin
g
N-
TE
)-
R
CH
AR
AC
TE
RIS
TIC
S
4B$
-)
H=
-
GL
=C
EM
IAA
Abno%
mally
lo<
le(el
of
"l'cos
e :less
t!an
38
m"/&
L in
t!e
fi%st
5,
!o'%
.0
m"/&
L
afte%
t!e
fi%st 3
&ays
of life
N ,.
No%m
al
bloo&
"l'cos
e le(el
is .8
to a #9
&ay9
ol&
neona
te an&
08 to
78
neona
te
ol&e%
t!an #
&ay
)ncre
ased
res,ir
ator/
rate
.6itc
4B=
hing5
nervo
usnes
s5 or
tre+o
rs
!nsta
0le
te+,e
rature
#/ano
sis
NURS
IN
G
INT
ER
;E
NTI
-N
A
#.
Mo
nito
%
fo%
si"n
s of
%es
$i%a
to%y
&ist
%ess
,.
Mo
nito
%
bili
%'b
in
an&
blo
o&
"l'c
ose
le(e
ls
3.
Mo
nito
%
<ei
"!t
..
4BA
(ee
d
earl
/5
6it
h
1:
K
glu
cos
e in
6at
er5
0re
ast
+il
45
or
%or
+ul
a as
,re
scri
0ed
0.
Ad
+in
iste
r )V
glu
cos
e to
trea
t
nec
ess
ar/
and
as
,re
scri
0ed
4.
Monito%
fo%
e&ema
5.
Moni
41B
to%
fo%
t%emo
%s &
sei3'%
es
SMALL )-R
GESTATI-N
AL AGE
A.
Desc%i
$tionA
A
neona
te
<!o is
$lotte
& at
o%
belo<
t!e
#-t!
$e%ce
ntile
on t!e
int%a'
te%ine
"%o<t
!
c'%(e
N&.
E" F1
Predis
,osin
g
%actor
is
7ater
nal
S+o4i
ng
1.
Assess
ment
411
#.
)etal
&ist%e
ss
,.
Gestat
ional
a"e
an&
$!ysic
al
mat'%
ity
3.
Lo<e%
e& o%
ele(at
e&
bo&y
tem$e
%at'%e
..
!ysic
al
abno%
maliti
es
0.
Hy$o
"lyce
mia
4.
Si"ns
of
$olycy
t!emi
aA
a.
R'&&y
a$$ea%a
nce
b.
Cyanosi
s
c.
>a'n&ic
e
412
5.
Si"ns
of
infecti
on
6.
Si"ns
of
as$i%a
tion of
mecon
i'm
N&.
E"
&0tai
ning a
0lood
sa+,l
e to
deter
+ine
glucos
e level
6ould
have
the
highe
st
,riorit
/ to
on
SGA.
A
co++
on
co+,l
icatio
n o%
the
SGA
ne60o
rn
i++e
diatel
/ a%ter
0irth
is
h/,og
l/ce+i
a
413
0ecau
se o%
the
increa
sed
+eta0
olic
rate in
res,o
nse to
heat
loss
and
,oor
he,ati
c
gl/cog
en
stores.
.he
SGA
ne60o
rn
+a/
also
have
su%%er
ed
intrau
terine
h/,o$
ia5
6hich
de,let
es
glucos
e.
C.
Im$le
menta
tion
#.
Maintai
n
ai%<ay
,.
Maintai
n bo&y
tem$e%a
t'%e
3.
-bse%(e
fo%
414
si"ns of
%es$i%at
o%y
&ist%ess
..
Monito%
fo%
infectio
n an&
initiate
meas'%e
s to
$%e(ent
se$sis
0.
Monito%
bloo&
"l'cose
le(els
an& fo%
si"ns of
!y$o"ly
cemia
4.
Initiate
ea%ly
fee&in"s
an&
monito%
fo%
si"ns of
as$i%ati
on
5.
%o(i&e
stim'lat
ionD
s'c! as
to'c!
an&
c'&&lin
"
A. NER;-US
S=STEM
AN-MALIES
9
M
415
9
9
9
9
S
9
9
9
D
Assess
ne<bo
%nIs
%es$i%
ato%y
%ateD
&e$t!
an&
%!yt!
m.
A'sc'
ltate
l'n"
so'n&
.
NoteA
7econi
u+
stained
s/ndro
+e o%
P&S.
7A.!
E
neonat
es
As,irat
ion o%
+econi
u+ is
0est
,revent
ed 0/
suction
ing the
neonat
e<s
naso,h
ar/n$
416
i++edi
atelt
a%ter
the
head is
delivere
d and
0e%ore
the
shoulde
rs and
chest
are
delivere
d. As
long as
the
chest is
co+,re
ssed in
the
vagina5
the
in%ant
6ill not
inhale
and
as,irat
e
+econi
u+ in
the
u,,er
res,irat
or/
tract.
7econi
u+
as,irati
on
0loc4s
the air
%lo6 to
the
alveoli5
leading
to
,otenti
all/ li%e
threate
ning
res,irat
or/
co+,lic
ations.
41$
S'ctio
n
e(e%y
,
!o'%s
o%
mo%e
often
as
necess
a%y
ositi
on
ne<bo
%n on
si&e
o%
bac2
<it!
t!e
nec2
sli"!tl
y
e+ten
&e&
A&mi
niste%
-,D
antici
$ate
t!e
nee&
fo%
CA
o%
EE
Conti
n'e to
assess
t!e
ne<bo
%nIs
%es$i%
ato%y
stat's
closel
y.
Enco'
%a"e
as
m'c!
$a%en
tal
$a%tic
i$atio
41=
n in
t!e
ne<bo
%nIs
ca%e
as
con&it
ion
allo<s
,.
A&mi
niste%
I;
fl'i&s
afte%
bi%t!
to
$%o(i
&e
Gl'co
se to
$%e(e
nt
!y$o"
lycemi
aD
monit
o%
closel
y t!e
inf'si
on
%ate.
He$t
t!e
infant
'n&e%
a
%a&ia
nt
!eat
<a%m
e% to
$%ese%
(e
ene%"
y
Monit
o%
babyIs
<ei"!
tD
se%'m
elect%
41A
olytes
an&
ens'%
e
a&eF'
ate
fl'i&
inta2e
Meas
'%e
'%ine
o't$'
t by
<ei"!i
n"
&ia$e%
s
C!ec2
fo%
bloo&
stools
to
e(al'a
te fo%
$ossib
le
blee&i
n"
f%om
intesti
nal
t%act.
Hee$
a
%estf'l
en(i%o
nment
.
3.
Antici
$ate
t!e
infant
s nee&
to be
b%east
fee&
Demo
nst%at
e
tec!ni
F'e
fo%
42B
fee&in
" to
mot!e
%D note
$%o$e
%
$ositi
onin"
of t!e
infant
D
Jlatc!
in"
onK
tec!ni
F'eD
%ate
of
&eli(e
%y of
fee&in
" an&
f%eF'e
ncy of
b'%$i
n"
%o(i
&e a
%ela+e
&
en(i%o
nment
&'%in
"
fee&in
"
A&N's
t
f%eF'e
ncy
an&
amo'
nt of
fee&in
"
acco%
&in"
to
infant
s
%es$o
nse
Alte%n
ate
fee&in
"
421
$%oce
&'%e
:ni$$l
e an&
"a(a"
e
fee&in
"*
acco%
&in"
to
infant
s
ability
.
Monit
o%
mot!e
%Is
effo%tD
$%o(i
&e
fee&b
ac2
an&
assista
nce as
nee&e
&
S'""e
st
mot!e
% to
monit
o%
infant
s
<ei"!
t
$e%io&
ically
,.
Ris2 fo%
fl'i& (ol'me
&eficit
%elate& to
insensible
<ate% loss at
bi%t!
3.
Ineffecti(e
infant
fee&in"
$atte%n
422
#.
;itam
in H
:AF'a
me$!
yton*
Use
fo%
$%o$!
yla+is
to
t%eat
!emo%
%!a"ic
&iseas
e of
t!e
ne<bo
%n
Si&e
effectsA
Hy$e%
bili%'
bin'%i
a
,. Eye
$%o$!
yla+is
3. :E%yt
!%omycin
8.0M
IlotycinD
Tet%acycli
ne #M
Sil(e%
Nit%ate
#M
%o$!
ylactic
meas'
%e to
$%otec
t
a"ains
t
Neisse
%ia
"ono%
%!oea
e an&
C!la
my&ia
t%ac!o
423
matis
Si&e
effectsA
Sil(e%
nit%at
e can
ca'se
c!emi
cal
conN'
cti(iti
s
D%'"
st'&y
ET
t'be
S'ctio
n
cat!et
e%
1e&si
&e
eF'i$
ment
Meco
ni'm
as$i%a
tion
syn&%
ome
Res$i
%ato%y
&ist%e
ss
syn&%
ome
N-TEA
Post +ature
neonates
have
di%%icult/
+aintainin
g glucose
reserves.
&ther
co++on
,ro0le+s
include
7econiu+
as,iration
s/ndro+e5
424
,ol/c/the+i
a5
congenital
ano+alies5
sei8ure
activit/ and
cold stress.
N&.
E" .he
in%ant 6ho
are
e$,osed to
high
0lood-
glucose
levels in
utero +a/
e$,erience
ra,id and
,ro%ound
h/,ogl/ce
+ia a%ter
0irth
0ecause o%
the
cessation
o% a high
in-utero
glucose
load. .he
s+all-%or-
gestational
-age
in%ant has
use u,
gl/cogen
stores as a
result o%
intrauterin
e
+alnutriti
on and
has
0lunted
he,atic
en8/+atic
res,onse
6ith
6hich to
carr/ out
gluconeog
enesis.
N-T
425
EA .he
,atient
6ith ,ost-
ter+
,regnanc/
is at high
ris4 %or
decreased
,lacental
%unctionin
g5
there%ore
increasing
the ris4 o%
inadeDuat
e o$/gen
circulation
to the
%etus
Com$
licatio
ns
1est
$ositi
on
Res's
citatio
n
N-T
EA
%es's
citati
on
beco
mes
im$o
%tant
fo%
infan
t <!o
fails
to
ta2e
fi%st
b%eat
! o%
&iffic
'lty
main
taini
n"
a&eF
'ate
426
%es$i
%ato%
y
mo(e
ment
s on
!is
o<n.
S'ctio
nin"
N-T
EA
all
o<
s
%e
mo
(in
"
m
'c
's
an
&
$%
e(
ent
s
as
$i%
ati
on
of
an
y
m
'c
's
an
&
am
nio
tic
fl'
i&
$%
ese
nt
in
t!e
mo
't
42$
!
an
&
no
se
of
t!e
ne
<b
o%
n.
To
est
abl
is!
cle
a%
ai%
<a
y.
Int'b
ations
N-T
EA
!e
a&
of
t!
e
inf
an
t
in
ne
't
%al
$o
sit
io
n
<i
t!
to
<e
l
'n
&e
%
s!
o'
l&
e%.
42=
1est
$%oce
&'%e
Sono"
%am
Sc%ee
nin"
test
Inc%ea
se&
!emat
oc%it
le(el
Dec%e
ase&
se%'m
"l'cos
e
Long
A thin
6ith
crac4
ed
s4in
6hich
is
loose5
6rin4l
ed
and
strain
ed
greeni
sh
/ello6
5 6ith
no
verni$
nor
lanug
o
Long
nails
6ith
%ir+
s4ull
1ide
e/ed
alertn
ess o%
one
+onth
old
42A
0a0/
Mate%
nal &
c!il&
n'%sin
"R a
&e(elo
$ment
al
a$$%o
ac! to
com$%
e!ensi
(e
c"fns
an&
ncle+
%e(ie
<R 0
t!
e&.
a"e
#3#
Lo<
socioe
cono
mic
le(el
oo%
n't%iti
onal
stat's
Lac2
of $%e
natal
ca%e
M'lti
$a%o'
s
mot!e
%Is
Ci"a%
ette
smo2i
n"
T!e
a"e of
t!e
mot!e
% :t!e
!i"!es
t
inci&e
nce is
43B
in
mot!e
%Is
yo'n"
e%
t!an
a"e
,8.*
Mot!e
%Is
<it!
&iabet
es
mellit
's
Con"e
nital
abno%
maliti
es
s'c!
as
om$!
alocel
e.
1o&y
is
co(e%e
& <it!
lan'"
o
-l&
man
facies
Cont%
ib'tin
"
facto%
s
-ST
TER
M
IN)A
NT
A
neona
te
bo%n
afte%
.,
<ee2s
a"e of
"estati
on
431
-ST
TER
M
IN)A
NT
)i"'%
e ,6
Defini
tion
Give
the
+othe
r
o$/ge
n 0/
+as4
durin
g the
0irth
to
,rovid
e the
,reter
+
in%ant
6ith
o,ti+
al
o$/ge
n
satura
tion at
0irth (
@3-
J:K9.
Kee,i
ng
+ater
nal
analg
esia
and
anest
432
hesia
to a
+ini+
u+
also
o%%ers
the
in%ant
the
0est
chanc
e o%
initiat
ing
e%%ecti
ve
res,ir
ation.
Bedsi
de
larng/
osco,
e5
endotr
achea
l tu0e5
suctio
n
cateth
ers
and
s/nthe
tic
sur%ac
tant to
0e
ad+in
istere
d 0/
the
endotr
achea
l tu0e.
)n%ant
+ust
0e
4e,t
6ar+
durin
g
resusc
itation
,roce
dures
so he
or she
433
is not
e$,en
ding
e$tra
energ
/ to
increa
se the
+eta0
olic
rate to
+aint
ain
0od/
te+,e
rature
.
&0ser
ve %or
chang
es in
res,ir
ations
5 color
and
vital
signs
#hec4
e%%ica
c/ o%
)solett
e"
+aint
ain
heat5
hu+id
it/
and
o$/ge
n
conce
ntrati
on5
ad+in
ister
o$/ge
n onl/
i%
necess
ar/
7aint
ain
ase,ti
c
techni
434
Due to
,reve
nt
in%ecti
on
Adher
e to
the
techni
Dues
o%
gavag
e
%eedin
g %or
sa%et/
o%
in%ant
&0ser
ve
6eigh
t-gain
,atter
ns
Deter
+ine
0lood
gases
%reDue
ntl/ to
,reve
nt
acidos
is.
)nstit
ute
,hotot
hera,
/
6hen
h/,er
0iliru
0ine+
ia
occur
s
Su,,o
rt
,arent
s 0/
letting
the+
ver0al
i8e
and
435
as4
Duesti
ons to
reliev
e
an$iet
/.
Provi
de
li0eral
visitin
g
hours
%or
,arent
s5
allo6
the+
to
,artici
,ate
in
care.
Arran
ge
%ollo6
-u,
0e%ore
and
a%ter
discha
rge 0/
a
visitin
g
nurse.
(7os0
/<s
#o+,rehe
nsive
evie6 o%
Nursing
%or
N#LE>-
N ,age
21H9
1. is4
%or
%luid
volu
+e
de%ici
t
relate
d to
436
insen
si0le
6ater
loss
at
0irth
and
s+all
sto+
ach
ca,a
cit/
2. is4
%or
as,ir
ation
relate
d to
6ea4
or
a0se
nt
gag
re%le
$ a
nd?or
ad+i
nistr
ation
o%
tu0e
%eedi
ngs
2. */,o
ther
+ia
relate
d to
lac4
o%
su0c
utane
ous
and
0ro6
n %at
de,os
its5
inade
Duate
shive
r
res,o
nse5
i++a
ture
43$
ther
+ore
gulat
ion
cente
r5
large
0od/
sur%a
ce
area
in
relati
on to
0od/
6eig
ht5
and?o
r
lac4
o%
%le$io
n o%
e$tre
+itie
s
to6ar
d the
0od/.
B. is4
%or
in%ect
ion
relate
d to
i++a
ture
i++
une
res,o
nse5
stasis
o%
res,i
rator
/
secre
tions5
and?
or
as,ir
ation
3. )+0a
lance
d
nutrit
43=
ion"
less
than
0od/
reDui
re+e
nts
relate
d to
lac4
o%
energ
/ to
suc4
and?o
r
6ea4
or
a0se
nt
suc4i
ng
re%le
$.
( 7o
s0/<s
#o+
,rehe
nsive
evie
6 o%
Nursi
ng
%or
N#L
E>-
N
,age
21H9
1e&si&e
eF'i$ment
%e&is$osin" )acto%#hild undergoes a gro6th s,urt during ,u0ert/. (,. @J@5 .e$t0oo4 o% Basic Nursing
Li,,incott H
th
ed.9!n4no6n 0ut generall/ thought to result %ro+ triggered environ+ent.N&.E" sa+e 6?
+enigocele #linical 7ani%estationDi+,le is ,resent over the 0ac40one. (,. @J@5 .e$t0oo4 o% Basic Nursing
Li,,incott H
th
ed.9E$ternal c/st de%ect in the s,inal cord usuall/ at the +idline 7eningitis T in%la++ation o%
the +eninges covering the s,inal cord.Screening ? Diagnostic .est>-ra/ (s+all tu%t o% hair or ,ort urine
strain is so+eti+es ,resent in the verte0ral are9 ( ,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9Neurologic E$a+ination-indicate loss o% neurologic %unctions 0elo6 the de%ect.Note" sa+e 6ith
+eningocele7aGor Surger/Surger/ i% necessar/ (,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9La+inecto+/La+inecto+/Pur,ose o% Surger/.o ,revent %urther deterioration o% neural %unction..o
,revent %urther co+,lications.Post-&,erative Nursing care7easure head si8e to deter+ine i% h/roce,halus is
develo,ing7easure head si8e to deter+ine i% h/roce,halus is develo,ingPossi0le surgical
co+,lication*/droce,halus*/droce,halusBest Position (or Pre-o,?Post-o, A dseNote" Sa+e 6?
7eningceleDisease #o+,lication7eningitis-i% sac 6ill ru,tured then in%ection 6ill occurDrugs"Anti0iotics-
to ,revent in%ectionNote" Sa+e 6? 7eningceleNursing Diagnosis and )ntervention)+,aired s4in )ntegrit/
related to i+,aired +otor A sensor/ %unction.Note" Sa+e 6? 7eningcele
43A
#
#
Nursing alert"
1. Prevent %urther da+age.
2. 7ost co++on ,ro0le+ is loss o% sensation in the legs (,rotect child against ,ossi0le leg inGur/.
2. S4in e$a+ination" ,ressure areas and tight clothing.
B. #hange dia,ers i% necessar/ a%ter voiding and de%ecating.
3. Patient is e$tre+el/ sensitive to late$. .he nurse +ust +a4e sure the/ do not co+e in contact 6ith
ite+s such as tourniDuets5 catheters5 ru00er 0ands5 gloves5 0alloons5 various tu0es +ade o% late$.
H. (olic acid (%olate9 ta4es during ,regnanc/ to reduce the severit/.
I. (,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9
@.
J.
1:.
Ris2 fo% Infection %elate& to contamination
N'%sin" Inte%(entionsA %otectin" t!e s2in inte"%ity
#. Avoid ,ositioning on the in%antWs 0ac4 to ,revent ,ressure on the sac.
,. Do not $lace any co(e%in" &i%ectly o(e% t!e sac.
3. -bse%(e sac fo% e(i&ence of i%%itation o% lea2a"e of CS)
.. !se ,rone ,osition 6? hi,s slightl/ %le$ed to decrease tension on the sac.
0. Place a %oa+ ru00er ,ad? s+all ,illo6 or roll dia,er 0et6een the in%ant<s legs to +aintain hi,s in
a0duction A to ,revent or counteract su0lu$ation.
4. %o(i&e s2in ca%e es$ecially an2lesD 2neesD ti$ of noseD c!ee2s & c!in.
5. %o(i&e $assi(e %an"e of motion e+e%cise.
6. Use foam o% fleece $a& to %e&'ce $%ess'%e of t!e matt%ess a"ainst t!e s2in.
7. A(oi& to'c!in" t!e sac.
44B
%e(entin" Infection
#. Hee$ a%ea clean f%om '%ine an& feces
,. Hee$ t!e infant clean es$. b'ttoc2s & "enitalia
3. A$$ly ste%ile "a'3e /moistene& to<el an& <atc! fo% any si"ns of infection.: fe(e%D i%%itabilityD
let!a%"yD oo3in" of fl'i& o% $'s f%om t!e sac*
%one9 to minimi3e t!e tension on t!e sac/%is2 fo% t%a'ma :RationaleATo $%e(ent $%ess'%e on t!e
incision*
*i, slightl/ %le$ed and a0ducted
(eet hanging5 %ree o% +attress and slight trendelen0urg ( reduce s,inal %luid9 (,.22H5 7os0/<s
#o+,rehensive evie6 %or Nursing N#LE> N9
Paral/sis5 hi, destruction5 4nee %le$ion contracture5 sensor/ loss (,. 2HH5 Ph/sical 7edicine A
eha0ilitation Basic5 Garrison9
)n%ection (,atient is o,en catheteri8ed9. (,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9
Monito% fo% si"n of inc%ease int%ac%annial $%ess'%e
A(oi& s$inal co%& &ama"e
ange o% +otion (,assive and active9 ( ,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9
%enatal Sc%eenin":#
st
T%imeste%*
1loo& test Jt%i$le sc%eenK
- Inc%ease& se%'m al$!a $%otein.
%enatal 'lt%aso'n&
Amniocentesis
Elective a0ortion ( ,. @J@5 .e$t0oo4 o% Basic Nursing Li,,incott H
th
ed.9
441
Afte% bi%t!
S$ine @9%ay %e(eals t!at e+act e+tent & location of t!e &efect.
S$ine Ult%aso'n& to &ete%mine s$inal co%& abno%malities.
CT scan/ MRI
1# *alo1o&e :*arca&;
2# *ature of the dru"<
*arcotic a&ta"o&ist
Side effects<
7yperte&sio&, irritability, tachycardia
2. Sur%actan ( Survanta9
B. Nature o% the drug"
Lung sur%actant to i+,rove lung co+,liance
Side e%%ect"
.ransient 0rad/cardia5 rales
5# @itami& L :6Huamephyto&;
,se for prophyla1is to treat hemorrha"ic disease of the &ewbor&#
Side effects<
7yperbilirubi&uria
6# .ye prophyla1is
$# :.rythromyci& B#5C !lotyci&, 0etracycli&e 1C
=# Silver Nitrate 1K ( not alread/ used T causes che+ical conGunctivitis;
+rophylactic measure to protect a"ai&st *eisseria "o&orrhoeae a&d 3hlamydia trachomatis
Side effects<
Silver &itrate ca& cause chemical co&uctivitis
Chad)ic8/s si*n is a bluish colorin* of the #a*inal mucosal that occurs as early
as : )ee8s *estation. ationale1 due to increase #ascularity < blood #essel
en*or*ement.
Increase si2e of the uterus
W P Pre*nancy "est
S Secretion of +C- in the urine 0%ro* "est7. ,etectable 9C days after the missed
period
. "he fetal heartbeat typically can be heard and fetal rebound is possible bet)een
9; and AA )ee8s. "he fetal outline becomes palpable and the fetus is hi*hly
443
mobile bet)een A; and E9 )ee8s. (ra@ton +ic8s contractions increase in
fre4uency and intensity bet)een EA and EF )ee8s.
Sur*ical sterili2ation of the male in#ol#es cuttin* the ductus deferens.
&asectomy1 &as ,eferens is cut. "he man can resume se@ after one )ee8 or )hen the sperm count
indicates C count or A ne*ati#e sperm count ha#e been e@amined.
4e&erally it reHuires 6 > 36 eaculatio&s to re&der &e"# sperm cou&t
In order to *et for semen analysis3 collect them in a clean *lass not plastic3 because it may affect the
spermato2oa. No se@ for E days before the semen collection < no drin8in* of alcohol for 9 day. "he first
portion of the semen has a hi*h ration of sperm.