Sei sulla pagina 1di 49

The Royal Pentagon Review Specialist, Inc.

Maternity Nursing

Human Sexuality
a. Concepts
1. A persons sexuality encompasses the complex behaviors, attitudes and
emotions and preferences that is related to sexual self and eroticism
2. Sex is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human
15 44 y.o. age of reproductivity CBQ
b. Definitions related to sexuality
Gender Identity sense of feminity and masculinity developed @age 3 or 2 -4 y.o.
Role Identity
attitudes, behaviours and attitudes that differentiate roles
Sex biologic male or female status. sometimes referred to as specific sexual behavior
such as sexual intercourse
Sexuality - behavior of being a girl or boy and is identity subject to a lifelong dynamic

Sexual Anatomy and Physiology

a. Female Reproductive System
1. External Vulva/ Pudenda
a. Mons pubis/ veneris mountain of venus, a pad of fatty tissues that lies
over the symphysis pubis covered by skin and at puberty covered by pubic
hair that serves as a cushion or protection to the symphysis pubis
Stages of Pubic Hair Development (Tool Used: Tanners Scale/ Sexual Maturity Rating)
Stage 1 Pre adolescence
no pubic hair, fine body hair
Stage 2 Occurs bet. 11 12 y.o
sparse, long, slightly pigmented and curly that develop along labia
Stage 3 Occurs bet. 12 13 y.o.
hairs become darker and curlier develops along pubis symphysis
Stage 4 13 14 y.o.
hair ssumes normal appearance of an adult but is not so thick and
does not appear to the inner aspect of the upper thigh
Stage 5 Sexual Maturity
assumes the normal appearance of an adult, appears at the inner
aspect of thigh
b. Labia Majora large lips latin, longitudinal fold from perenium to pubis
c. Labia Minora aka Nymphae, soft and thin longitudinal fold created between
labia majora
Clitoris key, pea shaped erectile tissue composed of sensitive
nerve endings; sight of sexual arousal in females
Fourchet tapers posteriorly of the labia majora. Site for episotomy
- sensitive to manipulation, torn during pregnancy
d. Vestibule almond shaped area that contains the hymen, vaginal orifice and
batholenes gland

Urinary Meatus small opening of urethra/ opening for urination

Skenes Gland aka Paraurethral Gland, 2 small mucus secreting
glands for
Hymen membranous tissue that covers the vaginal orifice
Vaginal Orifice external opening of the vagina
Bartholenes Gland paravaginal gland, secretes alkaline
substance, neutralizes acidity of the vagina
o Doderleins Bacillus responsible for vaginal acidity
o Parumculae Mystiformes healing of a hymen
e. Perenium muscular structure in between lower vagina and anus
2. Internal
a. Vagina female organ for ovulation, passageway of menstruation, inches
8 10 cm long containing rugae
o Rugae permits considerable stretching withouit tearing
during delivery CBQ
b. Uterus hollow muscular organ, varies in size, weight and shape, organ of
Size : 1 x 2 x 3
Shape : pear shaped, pregnant - ovoid
Weight :
Uterine involution CBQ
Non pregnant
: 50 60 g
: 1000 g
4 stage of Labor
: 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery
: 300 g
5 6 Weeks after delivery: 50 60 g
Three Parts of Uterus
Fundus upper cylindrical layer
Corpus/ Body upper triangular layer
Cervix lower cylindrical layer
Isthmus lower uterine segment during pregnancy
Muscular Composition: 3 main Muscles making possible expansion in all direction
a. Endometrium muscle layer for menses
o Lines the non-pregnant uterus
o Volumes the non pregnant uterus
o Decidua slouching off of endometrium during menstruation
o Endometriosis

Ectopic Endometrium

Common site is ovaries

Proliferation of abnormal growth of lining of outer part

Persistent dysmenorrhea, low back pain

Dx Exam: biopsy,laparoscopy

Tx: Lupron (luprolide) inhibits FSH & LH

Tx: Danazol (Danacrine) DOC

1. Inhibits ovulation
2. stop menstruation
b. Myometrium
o Power of labor
o Smooth muscles is considered to be LIVING LIGATURE
(muscles of delivery, capable of closing) of the body

o Largest portion of the uterus

c. Peremetrium
o Protects the entire uterus
c. Ovaries
2 female sex gland
almond shape
Fxn: Ovulation,production of 2 hormones( estrogen and progesterone)
d. Fallopian Tube
2 3 inches long that serves as a passageway of the sperm from the
uterus to the ampulla or the passageway of the mature ovum or fertilized
ovum from the ampulla to the uterus
4 significant segments
o Infundibulum most distal part, trumpet shape, has fimbrae
o Ampulla outer 3rd or 2nd half, site of fertilization, common site for
ectopic preg.
o Isthmus site for sterilization, site for BTL
o Interstitial most dangerous site for ectopic pregnancy
b. Male Reproductive System
1. External
The male organ of copulation and urination
Contains of a body or shaft consisting of 3 cylindrical layers and erectile
o 2 corpora cavernosa
o 1 corpus spongiosum
At the tip is the most sensitive area comparable to clitoris = glans penis
Pouch hanging below the pendulous penis, with medial septum deviding
into 2 sacs each containing testes
Requires 2 degrees celcius for continuous spermatogenesis
Cooling mechanism of testes
2. Internal
The Process of Spermatogenesis
(900 coiled seminiferous tubules)

(site of maturation of sperm 6 m)

Vas Deferens
(conduit pathway of sperm)

Seminal Vesicle
(secreted: fructose form of glucose, nutritative value
Prostaglandin: causes reverse contraction of uterus)

Ejaculatory Duct
(conduit of semesn)

Prostate Gland
(release alkaline substances)

Cowpers Gland
(release alkaline substance)

Hypothalamus GNRH


FSH maturation of sperm

LH testosterone production
Leydig Cells releases testosterone
Male & female Homologues
Penile Glans
Penile Shaft
Clitoral shaft
Skenes gland
Cowpers Glands
Bartholins Gland
Labia Majora
III. Basic Knowledge on Genetics and Obstetrics

DNA Deoxyribonucleic Acid carries genetic code

Chromosomes threadlike structure of hereditary material known as the DNA
Normal amount of ejaculated sperm 3 5 cc/ 1 teaspoon
Ovum is capable of being fertilized within 24 36 hours after ovulation.
Sperm 48 72 days viability
Reproductive cells divide by the process of MEIOSIS (haploid number)
Spermatogenesis process of maturation of sperm
Oogenesis process of maturation of ovum
o 30 weeks AOG 6 million immature ovum
o @ birth 1 million immature oocytes
o @ puberty 300 400 immature oocytes
o @ 13 y/o 300 400 mature oocytes
o @ 23 y/o 180 280 mature ovum
o @ 33 y/o 60 160 mature ovum
o @ 36 y/o 24 124 mature ovum
o @46 y/o 4 mature ovum
Gametogenesis process of formation of two haploid into diploid
7. Age of reproductivity 15 44 y/o childbearing age 20 35 y/o
High risk <18 & >35 y.o. With Risk 18 20; 30 35
8. Menstruation
Menstrual Cycle beginning of menstruation to the beginning of the next
Average menstrual cycle 28 days
Average menstrual period 5 days

Normal blood loss 50 cc/ cup accompanied by FIBRINOLYSIS prevents

clot formation
Related terminologies
o Menarche 1st menstruation
o Dysmenorrhea painful menstruation
o Metrorrhagia bleeding in between menstruation
o Menorrhagia Excessive bleeding during menstruation
o Amenorrhea absence of menstruation
o Menopause cessation of menstruation (Average Age- 51 y.o.)
Tofu has isoflavone estrogen of plant that mimics the estrogen
with a woman
9. Functions of Estrogen and Progestin
ESTROGEN hormone of woman
o Primary function
Responsible for the development of secondary characteristics in
inhibit production of FSH
o Other function
Hypertrophy of the myometrium
Spinnbarkeit and Ferning Pattern (Billings Method)
Ductile structure of the breast
Osteoblastic bone activity (causes increased in height)
Early closure of the epiphysis of the bone
Sodium retention
Increased sexual desire
Responsible for vaginal lubrication
PROGESTERONE Hormone of the mother
o Primary function prepares the endometrium for implantation making it
thick and tortous
o Secondary Function inhibit uterine contractibility
o Others
Inhibit LH (hormone of ovulation) production
GI motility
Permeability of kidneys to lactose and dextrose causing + 1 sugar
in urine
Mammary gland development
Mood swings
10. Menstrual Cycle
4 phases of menstrual cycle
1. Proliferative
2. Secretory
3. Ischemic
4. Menses
1. On the initial phase of menstruation, the estrogen level is , this level stimulates the
hypothalamus to release GnRH/ FSHRF
2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH
FSH Function
o Stimulate ovaries to release estrogen

Facilitate the growth of primary follicle to become

GRAAFIAN FOLLICE structure that secretes large amount of
estrogen that contain mature ovum
3. Proliferative Phase (estrogen)
Follicular Phase responsible for the variation and irregularity of mense
Postmenstrual Period after menstruation
Preovulatory Phase happen before menstruation
4. 13th day of menstruation, estrogen level is PEAK while progesterone is , these
stimulates the hypothalamus to release GnRH/ LHRF
5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH
Functions of LH
o Stimulates the release of progesterone
o Hormone for ovulation
6. 14th day estrogen level is while progesterone level is
o Rupture of the graafian follicle - OVULATION
o Mittelschsmerz slight abdominal pain lower right
7. 15 day, after ovulation day, graafian follicle starts to degenerate, estrogen level ,
progesterone , causing degeneration of the graafian follicle becoming yellowinsh
known as CORPUS LUTEUM secretes large amount of progesterone
8. Secretory Phase
Lutheal Phase
Postovulatory phase
Premenstrual Phase
9. 24th day Corpus Albicans (whitish) corpus luteum degenerates and becomes white
10. 28th day if no sperm united the ovum, the uterine begins to slough off to have the next
if there is no fertilization, corpus luteum continues functioning
Ovarian Cycle from primary follicle corpus albicans
o 1 5 days menses
o 6 14 proliferative
o 15 26 secretory
o 27 28 ischemic

11. Stages of Human Sexual Response

Initial Response:
VASOCONGESTION constriction of blood vessels
MYOTONIA increased muscle tension
Excitement Phase
muscle tension, moderate VS
erotic stimuli causing sexual tension, may last from minutes to hours
Plateu Phase
and sustained tension near orgasm
may last 30 sec 30 minutes
Involuntary release of sexual tension accompanied by physiologic and
psychologic release,

immeasurable peak of experience 2 3 seconds

Return to normal state
VS return to normal

REFRACTORY PERIOD only period present in male, wherein he cannot restimulated for
about 10 15 minutes




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

o Hydramnios GIT , TEF/ TEA

o Cushion the fetus against sudden blow or trauma
o Maintains temperature
o Facilitate muscuskeletal development
o Prevents cord compression
o Helps in development process

Diagnostic Test for Amniotic Fluid Amniocentesis

Purpose: obtain sample of amniotic fluid by inserting a needle hrough the abdomen into
the amniotic sac
Fluid is tested for:
Genetic screening
Determination of fetal maturity primarily by evaluating factors indicative of lung
Done with empty bladder
> Most common side effect : INFECTION
> Late : pre term labor
> Early : spontaneous abortion
Indication for Amniocentesis:
> Early in Pregnancy Advance Maternal Age
> Later in Pregnancy Diabetic Mothers
- down syndrome
- neural tube defect, spina befida
L/S ratio : 2:1 (Lecitin/ Spingomyelin)
Definitive test = Phosphatiglycerol: PG + best Answer
Greenish Meconium Stains (Fetal Distress)
Yellowish jaundice, hyperbilirubinemia
Cloudy Infection
Most Important Consideration Needle insertion site
Amnioscopy direct examination through intact fetal membrane via ultrasound
Fern Test a test determining if bag of water has rupture or not
Nitrazine Paper Test differentiate amniotic fluid and urine Blue geen + rupture of bag
of H2O
2. Chorion outermost layer
a. Placenta AKA Secundines chorionic Villi and basalis
Pancake in latin
500 grams in weight
15 28 cotyledons
15 20 cm in diameter and 2 3 cm in depth
o Respiratory 02 CO2 exchange via simple diffusion
o GIT glucose transport via facilitated diffusion
o Excretory via 2 arteries, carries unoxygenated blood
then detoxify by maternal liver
o Circulatory fetoplacental circulation by SELECTIVE
o Endocrine

HCG primary maintain corpus luteum/

secondary basis of pregnancy test
Human Placental Lactogen aka
Responsible for the development of
mammary gland
Diabetogenic Effect insulin antagonist
Relaxin softening of maternal joints and bones
Serves as protective barrier against some microorganism
Can pass: HIV CMV Rubella
PINOCYTOSIS transport of virus

Pregnancy 266 288 days/ 37 42 weeks

FETAL STAGE: Fetal Growth and Development
First Trimester : Period of organogenesis, most critical period
First Month
FHT, CNS Develops, GIT and Respi Tract remains as single tube
Differentiation of Primary Germ Layer
o Thyroid responsible for basal metabolism
o Thymus immunity
o Liver
o Linings of Upper GI Tract
o Heart
o Musculoskeletal
o Reproductive Organ
o Kidney
o Brain
o Skin
o 5 senses
o Hair, nails
o Anus
o Mouth
Second Month
Life span of corpus luteum ends
All vital organs are formed
Placenta is developed
Sex organ is developed
Meconium is present
Third Month
Placenta is complete
Kidneys are functional
Fetus begins to swallow amniotic fluid
Buds of milk appear
Sex is distinguishable

FHT audible via dopples @ 10 12 weeks

Terratogens any drug or irradiation, the exposure to which may cause damage to the fetus
o Streptomycin anti TB (quinine) damage to the 8th cranial nerve poor learning
and deafness/ ototoxic
o Tetracycline stoning the tooth enamel, inhibits long bone growth
o Vitamin K hemolysis, destruction of RBC, jaundice, hyperbilirubenemia
o Iodides enlargement of thyroid and goiter
o Thalidomides anti-emetics Amelia or Pocomelia absence of distal part of
o Steroids cleft lip or palate and even abortion
o Lithium congenital maformation
ALCOHOL LBW, fetal alcohol syndrome ( characterized by microcephaly)
COCCAINE LBW, abruptio placenta
TORCH group of infections that can cross the placenta or ascend through the birth canal
and adversely effect fetal growth
o Toxoplasmosis cat lovers
o Others - Hepa AB, HIV, Syphillis
o Rubella CHD,
Rubella Titer N @ 1:10 or = immunity to rubella = notify doctor
Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos.
o Cytomegalo virus
o Herpes Simplex virus
Second Trimester : continuous growth and development (focus lengh of fetus)
Fourth Month
Lanugo begins to appear
Buds of permanent teeth appear
FHT audible via Fetuscope @ 18 20 weeks
Fifth Month
Quickening : 1st fetal movement Primi: 18 20, Nulli - 16 - 18
Lanugo covers the body
FHT audible via stethoscope or w/out instrument
Actively swallow amniotic fluid
Fetus : 19 25 cm
Sixth Month
Skin is red and wrinkled
Vernix caseosa covers the skin
Eyelids open
Exhibits startle reflex
3 Trimester : period of most rapid growth and development Focus: weight
Seventh Month
Surfactant development
Male: the testes begins to descent into the scrotal sac
Female : clitoris is prominent and labia majora are small doesnt cover the minora
Eight Month
Active moro reflex
Lanugo begins to disappear


Sub q fats deposits, steady weight gain, nails to fingers

Ninth Month
Lanugos and vernix caseosa is evident in body fold
Birth position assumed
Amniotic fluid somewhat decrease
Sole of the foot has few creases
Tenth Month
Bone ossification in the fetal skull
Vernix caseosa is evident in body
Systemic Changes
1. Cardiovascular System
blood volume 30 50%
1500 cc; additional 500 cc for multiple pregnancy
plasma volume
cardiac workload easy fatigability/ slight ventricular hypertrophy
Epistaxis due to hyperemia of nasal membrane
Palpitation due to SNS stimulation
Physiologic Anemia/ pseudoanemia in pregnacy
o Normal Value
Hct : 32 42%
Hgb: 10.5 14 g/dl
o Criteria
1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl
2nd Trimester
: Hct > 32% Hgb > 10.5 g/dl
o Pathologic Anemia
Iron Defficiency Anemia is the most common hematologic disorder. It
affects 20% of pregnant women
Assesment reveals:
Slowed capillary refill = Normal = 2 3 sec
Concave fingernails (late sign of progressive anemia) clubbing
= chronic tissue hypoxia
Nursing care
Nutritional instruction
o Source of iron
Liver = best source due to FERRIDIN Content
Red and lean meat
Green Leafy Vegetables
Parenteral Iron (Imferon)
o Z tract IM
o incorrect causes hematoma
o best given 1 hour before meals (causes GI irritation)
o Maybe given 2 hours after meal (results to poor
Given with orange juice to absorption
Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day)



Monitor for hemorrhage

Iron from red meat is better absorbed iron from other sources
Iron is better absorbed when taken with foods high in Vitamin C
such as orange juice
Higher iron intake is recommended since circulating blood
volume is increased and heme is required from production of

o Impeded venous return due to the gravid uterus
o Nursing Intervention
Elevate legs above the hips level
o Wear support stockings
o Elevate legs
Vulvar Varicosities
o D/t pressure of gravid uterus
o Side lying with pillow under the hips
o Modified knee chest position
o Presence of thrombus in inflamed blood vessels
o + Homans Sign pain on the calf upon dorsiflexion
o Medical Management
Anticoagulant/ HEPARIN
Does not cross the placental barrier
Monitor APTT
No aspirin
Milk Leg/ Plagmasia Alba Dolens
o Shiny white legs due to stretching of skin & hyperfibrinogenemia
o Nursing intervention
Check dorsalis pedis pulse (compare both)
Never massage
Assess for Homans sign only once

2. Respiratory System
Shortness of Breath d/t gravid uterus
Nursing intervention: Side-lying lateral expansion of the lungs
3. Gastrointestinal System
Nausea and vomiting
Morning Sickness
o Due to HCG levels
o Crackers 30 min before arising
o AM Carb diet 30 mins
o PM small frequent meal
o Due to PROGESTERONE = fluid reabsorption due to GIT motility
o Nursing intervention


o Due to increased progesterone
o Avoid gas forming foods
Heartburn (pyrosis)
o Reflux of stomach content into esophagus
o Nursing Intervention
Small frequent meals
Sips of milk
Avoid fatty and spicy foods
Proper body mechanics
o Waist Above Acid
o Waist Below Base
o Due to gravid uterus
o Hot sitz bath for comfort
o salivation
o Mouthwashes to relieve
4. Urinary System
Normal = + 1 sugar due to Progesterone via BENEDICTS TEST
First Trimester - Frequency
Second Trimester - normal
Third Trimester - Frequency
5. Muscoloskeletal
Calcium sources
o Milk - Ca P 1 pint/ day or 3 4 servings/ day
o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli
o Pride of Pregnacy
Waddling Gait
o Awkward gait while walking due to relaxin
o Prone to accidental falls
Wear low healed shoes
Leg Cramps
o Ca P Imbalance during pregnancy
o Lumbo-sacral nerves by pressure of gravid uterus during labor
o Over sex
o Dorsiflex the foot affected
o 3-4 servings/ 4 cups/day sa milk, sardines, dilis
1. Local Chnages

o Chadwicks Sign bluish discoloration
o Leukorrhea whitish gray, moderate in amount, mousy odor
o Goodels Sign change in consistency of uterus
o Operculum mucus plug to seal bacteria/ progesterone


o Hegars Sign change in consistency


Problems related to the changes of Vaginal Environment

a. Vaginitis - AVOCADO
Trichomonas Vaginalis
o Flagellated protoxzoan, Loves alakaline environment
Signs and Symptoms
o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge
o Vaginal edema
o Drug of choice: METRONIDAZOLE (Flagyl)
Not given in 1st trimester
vaginal douche as substitue
o 1 qt Water = 1 tbsp white vinegar
o Treat partner as well to prevent reinfection
o No alcohol due to antabuse effect
b. Moniliasis - CHEESE
Candida Albicans
Transvaginal transfer in fetus Oral Trush
Signs and Symptoms
o White Cheeselike patches that adheres to the walls of the vagina
o Antifungals
Contrimazole Canisten
Gentian Violet
1. Abdominal Changes
Striae Gravidarum
o Due to destruction of the subcutaneous tissue by the enlarge uterus
2. Skin Changes
Melasma/ Chloasma
o White light brown pigmentation related to melanocytes
Linea Nigra
o Brown pinkish line from symphysis pubis to umbilicus
3. Breast Changes
Due to hormonal changes
Change in color and size of nipple and areola
Precolostrum 6 weeks
Colustrum 3rd trimester
Supine with pillow under the back
4. Ovaries rest period, no ovulation


5. Signs and Symptoms of Pregnancy

S/sx felt and observed by the
mother but does not confirm
the diagnosis of pregnancy
Breast changes
Urinary changes
Morning sickness
Enlarge uterus
Linea Nigra
Increase Skin Pigmentation
Striae gravidarum

Signs observed by
the members of the
health care team
Goodels sign
Chadwicks sign
Hegars sign
Elevated BBT
Positive HCG
Enlarge Abdomen
Braxton Hicks

Undeniable signs confirmed
by the use of instrument
Ultrasound Evidence

etal Heart Tone

etal movement
etal outline
etal parts palpable

CBQ Cancer of the Breast quadrant B

Mamography 35 and above 1/ year
Ballotement bouncing of the fetus
may be present in uterine myoma
Transvaginal Ultrasound empty bladder
Abdoiminal ulrasound full bladder
Placenta Grading System
Grade 0 immature
Grade 1 slightly mature
Grade 2 moderately mature
Grade 3 fully mature
What is deposited? calcium
VI. Psychological Adaptation to Pregnancy Reva Rubin
First Trimester
No tangible s/sx
Feeling of surprise
Denial of pregnancy maladaptation
Developmental Task: Accept biological facts of pregnancy
Health Teaching: Body changes of pregnancy and Nutrition
Second Trimester
Tangible s/sx
Mother identifies fetus as separate entity due to quickening
Developmental Task: Accept growing fetus as a baby to nurture
Health Teaching: Growth and development of fetus
Third Trimester
Mother has personally identifies with the appearance of the baby
Developmental Task: Prepare child birth and parenting the child
Health Teaching: responsible parenthood, prepare babys layette, Lamaze Class


Address Mothers fear let she hear the FHT

VII. Pre Natal Visit

Basic Consideration
1. Frequency of Visit
1 7th mos. once a month
8 9th mos. twice per month
10th month every week
2. Personal Data
Home Based Mothers Record/ HBMR determines high risk pregnancy
Pseudocyesis false pregnancy appearance of presumptive & probable signs
Comade Syndrome psycosomatic disorder, father experience what the mother
goes through
3. Diagnosis of Pregnancy
Urine Exam HCG 40 100th day; peak 60 70th day
ELISA beta subunits of HCG is detected as early as 7 10th day
RIA beta subunits of HCG is detected as early as 8th day
Home Pregnancy Kit
4. Baseline Data
Roll Over Test test of pre-eclampsia by the use of BP
Weight monitoring
Normal Weight Gain
1st Trimester = 1.5 3 lbs 1 lb/ mo
2nd Trimester = 10 12 lbs 4 lbs/mo
3rd Trimester = 10 12 lbs 4 lbs/mo
Minimum allowable weight gain 20 25 lbs
Optimal weight gain 25 35 lbs
5. Obstetrical Data
a. Gravida no. of pregnancy
b. Para no. of viable pregnancy
Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age
1 abortion
1 pregnancy 3rd mos.

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

G4P2 G4 T1 P1 A1 L1

G2P0 G2 T0 P0 A1 L0
c. Important Estimates
1. Nageles Rule
Use to determine expected date of delivery
Jan Mar +9 months +7 days
Apr Dec -3 months +7 days + 1 year
2. McDonalds Rule


Determines age of gestation in weeks

Fundic Height x 7/8 = AOG in weeks
3. Bartholomews Rule
Determines age of gestations
o 3 mos above pubis symphysis
o 5 mos level of umbilicus
o 9 mos below xiphoid process
o 10 mos level of 8th mos
4. Haases Rule
Determines the length of fetus in cm.
1st half square each month
2nd half month x 5
d. Tetanus Immunization
TT1 anytime or early during pregnancy
TT2 1 month after TT1 3 years protection
TT3 6 months after TT2 5 years of protection
TT4 1 year after TT3 10 years of protection
TT5 1 year after TT4 lifetime protection
5. Physical Examinations
a. Danger Signs of Pregnancy
Chills & Fever
Cerebral Disturbances
Abdominal Pain epigastric pain auro of impending convulsion
Boardlike Abdomen Abruptio placenta
Blurred Vission pre eclampsia
Bleeding abortion/ ectopic pregnancy 1st trimester
H Mole/ Incompetent Cervix 2nd trimester
Placental Anomalies 3rd Trimester
Scotoma spots in the eye
Sudden gush of fluid PROM premature rupture of membrane
6. Pelvic Examination
Pelvic examination or IE empty bladder, precaution
1st visit Chadwicks, Goodles sign, etc.
Position : dorsal recumbent, lithotomy
Pap smear done 1st visit
Cytological exam determine presence of cancer cells.
Result :
o Class I normal
o Class II A cytology without evidence of malignancy
B suggestive of inflammation
o Class III cytology suggestive of malignancy
o Class IV cytology suggestive og malignancy
o Class V conclusive for malignancy
Most common cancer report organ : cervical cancer
Most common site for pap smear external OS of cervix (squamocolumnar tissue)


Common site of cervical cancer. maternal speculum (open)

Stages of cervical cancer
o 0 carcinoma in situ
o 1 Ca strictly confined to cervix
o 2 from cervix extends to the vagina
o 3 pelvic metastasis
o 4 affectation to bladder & rectum

7. Leopolds Maneuver
Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of
descent an estimate of the size, and no. of fetuses
1. 1st maneuver
o place patient in supine position with knees slightly flexed. Put towel under head and
right hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape,
movement and firmness of the part
o determine the presenting parts:
2. 2nd maneuver
o with both hands moving down, identify the back of the fetus where the ball of the
stethoscope is placed to determine FHT.
o PR of mother : uterine souffl MHR
o fundic souffl FHR
3. 3rd maneuver
o using the right hand, grasp the symphysis pubis part using the thumb and fingers.
o Assess whether the presenting part is engaged in the pelvis.
o Alert! If the head is engaged it will not be movable
4. 4th maneuver
o the examiner changes the position by facing the patients feet. With two hands, assess
the descent of the presenting part by locating the cephalic prominence or brow.
o When the brow is on the same side as the back, the head is extended. When the brow
is on the same side as the small parts, the head 8is flexed and vertex presenting.
Attitude relationship of fetus to one another.
Full Flexion when the chin touches the chest
8. Assessment of Fetal Well-being
a. Daily fetal Movement Counting (DFMC)
Done starting 27th week
fetal sleep wake pattern
maternal food intake
drug-nicotine use
environmental stimuli
maternal dose
Cardiff count to 10 method one method currently available
o begin at the same time each day (usually in the morning after breakfast ) and
count each fetal movement, noting how long it takes to count 10 fetal
movements (FMs)
o expected findings 10 movements in 1hrs or less
o warning signs 10-12 movements in 1hr or less
more than 1hr to reach 10 movements
less than 10 movements in 12hrs


longer time to reach 10 FMs than on previous days.

movements are becoming weaker, less vigorous
movement alarm signal <3 FMs in 12hrs
warning signs should be reported to healthcare provider immediately; often
require further testing. Eg. Non stress test (NST), biophysical profile (BPP)

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


pregnant teenagers poor compliance to health regimen

extremes in wt underwt eg. Elite models overwt eg. DM/HPN
low social economic status. Refer to OSWD
vegetarian mothers because intake of vit B12 (Cyanocobalamin) formation
of folic acid (cell DNA & RNA formation)
types :
strict vegetarian prone to develop anemia
lacto vegetarian milk
lacto-ovo vegetarian milk & egg

a. Recommended Nutrient Requirement that Increases During Pregnancy

Food sources
Essential to supply energy for
300 calories/day above the
Caloric should reflect
metabolic rate
foods of high nutrient value
to maintain ideal body weight
such as protein, complex
Utilization of nutrients
carbohydrates (whole grains,
Protein sparing so it can be
vegetables, fruits)
used for :

variety of foods representing
o growth of fetus
food sources for the nutrients
o development of
required during pregnancy
structures requires
no more than 30% fat
for pregnancy
failure to meet caloric
including placenta,
requirements can lead to
Na 3gms/day eat in
amniotic fluid, tissue
used for energy, ketosis has
CHON x 4K Cal
been associated with fetal
CHO x 4K Cal
Fats x 9K Cal
Non pregnant: 2200 calories
Pregnant: 2500 calories
2200+500 @ lactation=2700 cal
Essential for
fetal tissue growth
maternal tissue growth
including uterus and
Development of essential
pregnancy structures
Formation of RBC and
plasma proteins
Inadequate protein intake has
been associated with onset of
pregnancy induced
hypertension (PIH)
Essential for
Growth and development of
fetal skeleton and tooth
Maintenance of

60mg/day or an of 10%
above daily requirements for
age group
Adolescents have a higher
protein requirement than mature
women since adolescents must
supply protein for their own
growth as well as protein to
meet the pregnancy

Calcium of
1200mg/day representing an
of 50% above pre
pregnancy daily requirement
1600mg/day is recommended

Protein should reflect

Lean meat, poultry, fish
Eggs, cheese, milk
Dried beans, lentils, nuts
Whole grains
Vegetarians must take note of
the amino acid content of
CHON foods consumed to
ensure ingestion of sufficient
quantities of all amino acids

Calcium should reflect

Dairy products, milk, yogurt,
ice cream, cheese, egg yolk
Whole grain, tofu


mineralization of maternal
bones and teeth
Current research is
demonstrating an
association between
adequate calcium intake
and the prevention of
pregnancy induced
Essential for
Expansion of blood volume &
RBC formation
Establishment of fetal iron
stores for first few months of life

Essential for
the formation of enzymes
maybe be important in the
prevention of congenital
malformation of the fetus
Folic acids, folacin, folate
Essential for
Formation of RBC &

for adolescent
10mcg/day of vitamin D is
required since it enhances
absorption of both calcium
and phosphorous

Non Pregnat:15mg/day
Pregnant : 30mg/day
- representing a doubling
of the prepregnant daily
Begin supplementation at
30mg/day in second
trimester, since diet alone is
unable to meet pregnancy
60 120mg/day along with
copper and zinc
supplementation for women
who have low Hgb values
prior to pregnancy or who
have iron deficiency anemia
70mg/day of vitamin C which
enhances iron absortion
o Inadequate iron intake
results in maternal effects
anemia, depletion of iron
stores, energy and
appetite, cardiac stress
especially during labor &
o fetal effects availability
of oxygen thereby
affecting fetal growth
iron deficiency anemia is the
most common nutritional
disorder of pregnancy

Green leafy vegetables

Canned salmon & sardines
with bones
Ca fortified foods such as
orange juice
Vitamin D sources fortified
milk, margarine, egg yolk,
butter, liver, seafood

Iron should reflect

liver, red meat, fish, poultry,
enriched, whole grain cereals
& breads
dark green leafy vegetables,
nuts, dries fruits
vitamin C sources: citrus
fruits & juices, strawberries,
cantaloupe, tomatoes, green
peppers, broccoli or
cabbage, potatoes
iron form food sources is
more readily absorbed when
served with foods high in vit

15 g/day representing an of
3mg/day over prepregnant daily

Zinc should reflect

liver, meats
shell fish
grains, legumes, nuts

400mcg/day representing an
of more than 2x the daily
prepregnant requirement

should reflect
Liver. Kidney, lean beek, veal


prevention of anemia
DNA synthesis & cell
formation; may play a role in
the prevention of neural
tube defects (spina bifida),
abortion, abruption placenta
Additional requirements

Pyridoxine (B6)

300mcg/day supplement for

women with low folate levels or
dietary deficiency


Dark, green leafy vegetables,

broccoli, asparagus,
artichokes, legumes
Whole grains, preanuts

requirements of pregnancy
can easily be met with a
balanced diet that meets the
requirement for calories and
includes food sources high in
the other nutrients needed
during pregnancy


b. Sexual Activity
Principles of sex in Pregnancy
o Should be done in moderation
o Should be done in a private place
o That the mother should be placed in a comfortable position
o It must be avoided 6 weeks prior to EDD
o Avoid blowing of air during cunnilingus
Contraindication in sex:
o vaginal spotting 1st tri
o incompetent cervix 2nd tri
o placenta previa, abruption placenta 3rd tri
o pre-term labor R: prostaglandin oxytocin contraction
o PROM infection
Changes in sexual appetite during pregnancy:
o 1st tri -
o 2nd tri -
o 3rd tri -
c. Exercise
strengthen muscle to be used during the delivery process
Walking best form of exercise
Squatting strengthen perineum & circulation to the perineum (raise the buttocks before head
to prevent postural hypotension)
Tailor sitting same purpose with squatting
Kegel exercise strengthen pubococcygeal muscle
Abdominal exercise muscle of the abdomen ( done as if blowing a candle)
Shoulder circling exercise strengthen muscle of the chest
Pelvic rocking exercise or pelvic tilt relieve low back pain & maintain good posture (arching
back for 3 sec)


Principles of exercise
o must be done in moderation
o must be individualized
d. Childbirth Preparation
Overall goal: To prepare patents physically & psychologically while promoting wellness
behavior that can be used by parents & family thus, helping them achieved a satisfying &
enjoying childbirth experiences.
o Bradley Method Dr. Robert Bradley discoverer
advocated active participation of husband during labor & delivery to serve as
coach, based on imitation of nature
darkened room
quiet & calm environment
relaxation technique
close eyes
o Grantly Dick Read Method
fear can lead to tension while tension can lead to pain. (break cycle by
removing the fear-by abdominal breathing exercises & relaxation technique)
o Kitzinger Method Dr. Shiella Kitzinger
pregnancy, labor & birth & the care of the newborn is an important turning point
in a womans life cycle. flowing with contractions rather than struggle with
o Lamaze Dr. Ferdinand Lamaze
Prevention of pain thru mind & requires discipline, conditioning & concentration
with the husbands help.
conscious relaxation
cleansing breathe inhaling thru nose & exhaling thru mouth
effleurage gentle circular massage
over abdomen to relieve pain
Different methods of delivery
o birthing chain semi-fowlers mother
o bathing bed dorsal recumbent
o squatting position relieve on back pain & maintain good posture
o Leboyers method
features :
darkly lighted room
quiet & calm environment
room temp.
soft music
o Birth under water
A. Admitting the laboring Mother
Personal data


Baseline data
Obstetrical data
Physical exams
Pelvic exams
B. Basic knowledge in intrapartum
Theories of the Onset of Labor
o Uterine Stretch Theory any hollow organ once stretched to its maximum potential
will always contract & expel its content
o Oxytocin Theory released by PPG, contraction effect
o Prostaglandin Theory stimulation by Arachidonic acid, causes contraction of uterus
o Aging Placenta 42wks (lifespan) by 36wks placenta begins to degenerate causes
o Progesterone deprivation theory - level of progesterone will facilitate contraction of
the uterus
The 4 Ps of Labor
o Passenger fetus
fetal head
is the largest presenting part
of its length
Bones 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2
parietal bones
Sutures/intermembranous spaces allows molding
Molding the overlapping of the sutures of the skull to permit passage
of the head to the pelvis
o Sagittal bones connect to parietal bones
o Cororontal bones connect to parietal & frontal bones
o Lambdoidal bones connect to parietal & occipital bones
o 6 fontanels only 2 palpable
anterior fontanel/Bregma
diamond in shape
3cm x 4cm size
close 12-18 mos post delivery
5cm hydrocephalus
posterior fontanel/lambda
triangular in shape
1 x 1cm size
close 2-3mos post delivery
Measurements of fetal head :
o transverse diameter
Bi-parietal - largest transverse diameter- 9.25cm
Bi-temporal - 8cm
Bi-mastoid - smallest transverse diameter - 7cm
o AP diameter
Suboccipitobregmatic complete flexion
Occipitofrontal partial flexion - 12cm
Occipitotemporal largest AP diameter; hyperextended
Submentobrgmatic - face presentation; poor flexio
o Passageway vagina & pelvis


4 main pelvic types
o gynecoid round, wide, deeper, most suitable for pregnancy
o android heart shape male pelvis anterior pointed post part
o Anthropoid oval ape-like pelvis AP wider transverse narrow
o Platypelloid flat transverse oval AP narrow transverse wider
c/s for delivery
Problem :
o mother who encounter accident
o 49
o 18y/o R: pelvis not achieve its full pelvic growth
Bones of pelvis
o 2 hips (2 innominate bones)
3parts of 2 innominate bones
Ileum lateral/side of hips
o Iliac crest flaring superior border that
forms prominence of hips; common site
for bone marrow aspiration
Ischium inferior portion
o Ischial tuberosities of the area where we
o Sit; basis in getting external measurement
of pelvis
Pubis anterior portion
o Symphysis pubis junction in between
o sacrum posterior portion
Sacral prominence basis internal measurement of
o 1 coccyx - 4 small bones that compresses during vaginal
universal precaution in measurement of pelvis is to empty bladder first
Important Measurements
o Diagonal Conjugate
measure between Sacral promontory & inferior margin of
the symphysis pubis
Measurement 11.5-12.5 cm
Basis in getting the true conjugate.
o True Conjugate/Conjugate Vera
Measure between the anterior surface of the sacral
promontory & superior margin of the symphysis pubis.
Measurement: 11.0 cm
Diagonal conjugate: 1.5 cm = true conjugate.
o Obstetrical Conjugate
smallest AP diameter of the pelvis measuring 10cm or
o Tuberoischii Diameter
transverse diameter of the pelvic outlet.
Approx by a fist- 8cm & above.

the forces acting to expel the fetus & placenta


involuntary contractions
voluntary bearing down efforts
characteristics: wave like
timing: frequency, duration, intensity
myometrium power of labor
o Psyche/person
psychological stress exist when the mother is fighting the labor experience.
cultural interpretation preparation
past experience
support system
Pre-eminent signs of labor
o Preeminent Signs
settling of the presenting part into the pelvis brim (shooting pain
radiating to the legs, urinary frequency)
primi- early 2 weeks prior to EDD
engagement settling of presenting part into pelvic inlet (not signs of
Braxton Hicks Contractions painless irregular contractions
Increase Activity of the Mother Nesting
Instinct (mgt: save energy)
epinephrine production (hormone that the activity of the mother)
Ripening of the cervix butter softness
Decrease in weight 1.5-3 lbs.
Bloody show
pinkish vaginal discharge (blood + leucorrhea + operculum = pink in
Rupture of membranes
check FHT
IE check for cord prolapse
after several hrs check temp.
o Premature Rupture of Membranes (PROM)
contraction drop in intensity even though very painful
contraction drop in frequency
uterus tense &/or contracting between contractions
abdominal palpitations
Nursing Care:
administer analgesics (morphine)
attempt manual rotation for ROP or LOP
bear down with contractions
adequate hydration
sedation as ordered
cesarean delivery may be required, especially if fetal distress is noted
o Cord Prolapse
a complication when the umbilical cord falls or is washed through the cervix
into the vagina.
Danger Signs:
Presenting part has not yet engaged
Fetal distress


Protruding cord from vagina cerebral palsy 5 mins., irreversible

brain damage mgt: CS
Nursing Care
Positioning knee chest or trendelenberg, place wet sterile gauze R: to
make it slippery
Observe for fetal distress
Provide emotional support
Prepare for cesarean section

Difference Between True and False Contraction

No in intensity

Pain confined in the abdomen

Pain is relieved by walking

No cervical changes

There is an in intensity
Pain begins @ the lower back
to abdomen
Pain is intensified by walking
Cervical effacement (thinning of
the cervix, measured thru %) &
dilatation (widening of the
cervix, measurement thru cm)
*best/major sign of true labor

Duration of Labor
o Primipara 14 hrs but not more than 120 hrs
o Multipara 8 hrs but not more than 14 hrs
Nursing Interventions in Each Stage of Labor
o First Stage: onset of contractions to full dilatation & effacement of the cervix
o stage of effacement & dilatation
Latent Phase:
o Dilatations 0-3 cm
o Frequency 5-10 mins
o Duration 20-40 mins
o Intensity mild
o Mother is excited, apprehensive but can communicate
Nursing Care:
o Encourage walking : shortens 1st stage of labor
o Encourage to void q 2-3 hrs : full bladder inhibits uterine
o breathing (chest breathing technique)
Active Phase:
o Dilatations 4-8 cm
o Frequency q 3-5 mins lasting for 30-60 secs
o Duration 30-60 secs
o Intensity moderate
Nursing Care:
o M edications have meds ready
o A ssessment include: v/s, cervical dilatation & effacement,
fetal monitor, etc
o D ry lips oral care (ointment), dry linens
o Breathing abdominal breathing


Transitional Phase:
o Dilatations 8-10cm
o Frequency q 2-3 mins contractions
o Duration 45-90 sec
o Intensity strong
o Mood of mother suddenly change accompanied by
hyperesthesia (hypersensitivity of mother to touch) of the skin
o sacral pressure, cold compress
Nursing care:
o T tires
o I inform of progress (to relieve emotional support)
o R restless support her breathing technique
o E encourage & praise
o D discomfort
Pelvic Exams
Effacement & Dilatation
Station relationship of the presenting part to the ischial spine
o 5 - -1 = the presenting part is above the ischial spine
o Engagement 10 = the presenting part is in line with the ischial
o (-) fetus is floating
o (+) below the ischial spine
o the relationship of the long axis of the fetus to the long axis of
the mother.
o spine relationship of the spine of the mother & the spine of the

Two Types
Longitudinal Lie (Parallel)/ Vertical
Cephalic when the fetus is completely flexed
o Vertex
o Face
o Brow
o Chin
o Complete breech thigh rest on
abdomen while legs rest on thigh
o Incomplete breech
Frank thigh resting on abdomen
while legs extend to the head
Transverse Lie (Perpendicular)/Horizontal lie
Position relationship of the fetal presenting part
to specific quadrant of the mothers pelvis.



left occipito anterior

most common & favorable position
ROT/LOT left occipito transverse
ROP/LOP left occipito posterior


L/R- side of maternal pelvis

Middle presenting part


ROP/ROT most common malposition

ROP/LOP most painful mgt: pelvis

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


Bath is necessary
Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
o Prevent aspiration chemical pneuminitis
Enema (per hospital policy)
o Purpose
Cleanse the bowel
Prevent infection
o 12 18 inches normal length of tube
o 18 inches optimal length
o Lateral sims position
o If there is contraction clump the tube
o If there is resistance slowly remove


o Before and after administration: check FHT (120 160) and contractions
Encourage mother to void
Perennial preparation (rule of 7)
Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
If membrane doesnt rupture amniotomy
FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen
For Pain
o Systemic analgesic
DEMEROL (Meperidine HCl)
Narcotic and antispasmonic
Dont give during latent phase
Given @ 6-8 cm dilated
WOF : Respiratory depression
Narcan (Naloxone, nalorfan, nalline)
o Antidote for toxicity
o Injected on the baby
Epidural Anesthesia
WOF : Hypotension
Prehydrate the client to prevent hypotension
In case of Hypotension
o Elevate leg
o Fast Drip IV
Complete dilatation and effacement to birth
Crowning occurs
PRIMI transfer to DR @ 10 cm dilatation
MULTI transfer to DR @ 7 8 cm dilatation
Position in lithotomy both legs at the same time
BULGING OF PERENIUM surest sign of delivery initiation
PANT & BLOW Breathing, fetal pushing should be done on an open glottis
Respiratory alkalosis
o Due to incorrect breathing
o Hyperventilation
o S/sx
Tingling sensation
Carpopedal spasm
Circumoral numbness
Prevent laceration
Widen the vaginal canal
Shortens the 2nd stage of labor
2 types
Less bleeding
Less pain
Easy repair


Possible urethroanal fistula major disadvantage

More bleeding
More pain
Hard to repair and slow healing
Ironing the Perenium prevent laceration

Mechanism of Labor (ED FIRE ERE)

Internal Rotation
External Rotation
3 Parts
o Inlet AP diameter narrow, transverse wider
o Cavity between inner and outer
o Outlet AP diameter wider, transverse narrow
Nursing Care
o Done by supporting the perenium with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
First intervention: Support the head and suction secretion
Do not milk the cord, wait for pulsation to stop before cutting
o Milking may cause too much blood going to the baby that may cause cardiac overload
When there is still birth, let the mother see the baby to accept the finality of death
3 10 minutes after child birth
1st sign Fundus rises CALKINS SIGN
Signs of Placental Separation
o Fundus becomes globular and rises calkins sign
o Lengthening of the cord
o Sudden gush of blood
o slowly pulling the cord and wind at the clamp
o rapidly may cause uterine inversion
Types Placental Delivery
SHULTZ (Shiny)
o From center to the edges
o Presenting fetal side
DUNCAN (Dirty)
o Form edges to center
o Presenting the maternal side


Nursing Considerations during placental delivery

Check placental completeness
o Should be 500 g
Check Fundus Massage if Boggy
BP Check
Methergine, methylergonovine mallate (IM)
Oxytocin (IV) if methergine is not present
Check perenium for lacerations
Assist in episioraphy
Vaginoplasty/ Vaginal Landscape Virgin again
First 1 2 hours after delivery of placenta
Maternal observation body system stabilize
o 1st hour q15 min 2nd hour - q 30 min
Placement of fundus
o In between umbilicus and pubis symphysis
o Check bladder, assist in voiding, May lead to uterine atony hemorrhage
o Check REEDA
R edness
E dema
E cchymosis
D ischarge
A pproximation
o Fully saturated 30 40 cc
o Weighing 1 cc = 1 gram Common Board Question
Nursing Consideration during Recovery
Flat on bed to prevent dizziness
If with Chills give blanket due to dehydration
Give nourishment (progression of meal)
o Clear liquids gatorade, ginger juice, gelatins
o Full liquid milk, ice cream
o Soft diet
o Regular diet
Check VS/ Pain
Pychic State
Bonding interaction between mother and newborn
o Strict 24 hours with mother
o Partial morning with mother, night nursery
Difficult labor related to mechanical factor
Primary cause is Uterine Inertia
Uterine Inertia
Sluggishness of contraction


o Primary/ Hypertonic
Intense contraction resulting to ineffective pushing
Management : Sedation
o Secondary/ Hypotonic
Slow, irregular contraction resulting to ineffective pushing
Management : Oxytocin Augmentation
Prolonged Labor
> 20 H for primi
> 14 H for multi
proper pushing should be encourage if inappropriate:
o may cause fetal distress
o caput succedaneum
o cephalhematoma
o maternal exhaustion
monitor contractions and FHT
Precipitate Labor
labor less than 3 hours
causes excessive laceration leading to profuse bleeding hypovolemic shock
s/sx of hypovolemic shock HYPO TACHY TACHY
o HYPOtension
o TACHYpnea
o TACHYcardia
o Cold clammy skin
o Management
Modified trendelenburg
Fast Drip IV
Inversion of Uterus
Situation in which uterus is turn inside out due to:
o Short cord
o Hurrying of placental delivery
o Ineffective fundal push
Cause profuse bleeding hypovolemic
Uterine Rupture
Rupture of uterus
Caused by
o Previous classical CS
o Very large baby
o Improper use of oxytocin
o Sudden pain
o Profuse bleeding
Prepare fore TAHBSO
Physiologic Retraction Ring boundary between upper and lower uterine segment
BandlsPathologic Ring suprapubic depression sign of uterine rupture
Amniotic Fluid/ Placental Embolism


Anaphylactic syndrome of pregnancy

Situation in which placental fragment and amniotic fluid enters maternal circulation
o Dyspnea
o Chest Pain
o Frothy Sputum
o End Stage DIC
Prepare for CPR, Suction and emergency etc
Trial Labor
Fetal head measurement = measurement of pelvis
6 hours labor allowance given to mother
monitor FHT and contractions
Preterm Labor
labor after 20 weeks and before 37 weeks
Triad signs
o Premature conditions every 10 minuets
o Effacement of 60 80%
o Dilatation of 2 3 cm
Home Management
o Avoid Sex
o Empty bladder
o Drink 3 4 Glasses of H2O
Full bladder inhibit contraction
Hospital Management
o If Cervix Close (Criteria: cervix is closed if it is 2 3 cm dilated only)
2 3 cm dilated, pregnancy can be saved
Tocolytic Therapy
Yutupar (Ritodine HCl)
o Side effect maternal BP < 90/60
o Check Impt. Presence of crackles
Brethine (terbutaline) Bricanyl
o Side effect: sustained tachycardia
o Antidote: propanolol/ inderal
Mg SO4
o If cervix is dilated ( > 4cm)
Give steroid dexamethasone
Promote surfactant maturation
Immediately cut the cord after delivery to prevent jaundice/
Puerperium 5th stage of labor, 1st 6 weeks post partum
Characterize by involution
Involution - return to the normal stage of reproductive organ after pregnancy
Return to Normal Healing
Physiologic Changes


Systemic Changes
Cardiovascular System
o plasma volume
o sudden in blood volume
o elevated WBCs up to 30, 000 mm3
o hyperfibrinogenemia
o orthostatic hypertension can be possible
o early ambulation prevents thrombos formation
steps in ambulation
Fowlers with dangling
Walk with assist
Genital Tract
o Fundus
goes down 1 finger breadth a day
10th day non palpable behind the symphysis pubis
delayed healing of uterus containing quarters or clots of blood
may lead to puerperal sepsis
Management : D&C
o After Pains
After birth pains
Multiparous breastfeeding most common to develop
Position = prone
Cold compress
Mefenamic acid
o Lochia
3 types
Rubra 1 3 days, musty, moderate amount
Serosa 4 10th day, pink or brown
Alba 10 21th day, crme white, amount
Urinary Tract
o Urinary Frequency due to urinary retention with overflow
o Dysuria
Damage to trigone of the bladder
Urine collection for culture and sensitivity
Stimulate navel to urinate
Palpate bladder
Running water listening
Pull pubic hair - stimulate cremasteric reflex


Due to NPO
Bearing down may cause pain
o Pain relieved by sims position
o Cold compress 1st 24 hours if there is pain at episioraphy followed by warm

1. Taking phase
1st 3 days
dependent phase
passive, cant make decision
tells about childbirth experience
focus on: Hygiene
2. Taking Hold
4 7th day
dependent to independent phase
active, decides actively
focus: care of newborn
health teaching : Family planning
3. Letting Go
Interdependent phase
Redefines goals, new roles as parents
May extend till the child grows
Post Partum Blues
4th 5th days
overwhelming feeling of depression, inability of sleep and lack of appetite
50 80% incidence rate
cause by sudden hormaonal change progesterone suddenly decreases
allow crying: therapeutic
may lead to postpartum psychosis/ depression
Postpartal Complications
bleeding within 24 hours postpartum
Early Pospartal Hemorrhage
1. Uterine Atony
boggy fundus
profuse bleeding
o massage the uterus
o cold compress
o modified trendelenburg
o fast drip IV
o breastfeeding to release oxytocin


2. Laceration
well contracted uterus with profuse bleeding
assess perenium for laceration
degrees of laceration
o 1st degree vaginal skin and mucus membrane
o 2nd degree 1st degree + muscles
o 3rd degree 2nd degree + external sphincter of rectum
o 4th degree 3rd degree + mucus membrane of rectum
3. Hematoma
bluish discoloration of subQ tissues of vagina or perenium
o delivery of very large babies
o pudendal block
o excessive manipulation due to excessive IE
o cold compress 10 20 min then allow 30 minutes rest period for 24 h
4. DIC disseminated intravascular coagulation
Consumption of pregnancy (otherterm)
Failure to coagulate
Bleeding in the eyes, ears, nose
Oozing blood
Seen in cases with
o Abruptio placenta
o Still birth / IUFD
o Blood transfusion of cryoprecipitate or fresh frozen plasma
o hysterectomy
Late Postpartum Hemorrhage
Retained placental fragments
manual extraction of fragments is done
uterine massage
D&C except for cases of
o Placenta Acreta umusual attachment of the placenta to the myometrium
o Placenta Increta deeper attachment of placemat to the myometrium
o Placenta Percreta invasion of placenta to the perimetrium
Candidates of these disorders are
Grand multiparous
Post CS
All these requires hysterectomy
o Endogenous from normal flora of the body
o Exogenous from the health care team
Most common Anaerobic Streptococci
o Supportive care



Fluid intake
TSB if there is fever/ cold compress + paracetamol may also be given
Given on time to achieve maximum effect
Culture and sensitivity

Perenial Infection
Same s/ sx with infection
2 3 stitches are dislodges
with purulent drainage
Tx resuturing
Inflammation of the endometrium
Gen s/sx of infection + abdominal tenderness
o High fowlers facilitates drainage & localize infection
o Administer oxytocin
Guiding Principles
1. determine your own beliefs first
2. never advise a permanent method of family planning
3. informed concent
4. the method is an individual decision
Natural Method accepted by the church
Billings/ Cervical Mucus/ Spinnbarkeit
clear watery & stretchable
13th day longest due to estrogen
Basal Body Temp in the morning before arising/ 13th 14th day due to peak of progesterone
LAM Lactational Amenorrhea Method
prolactin inhibits ovulation
breastfeeding 4 6 months no menstrual cycle
bottle fed 2 3 months
Sympthothermal combination of Billings and BBT most effective method
Social Methods
Coitus Interuptus
least effective method
Coitus Reservatus
sex w/o ejaculation
Coitus interfemora
between femor
Calendar Method
14 days before menstrual cycle ovulation day (regular)
- 4, + 4 days unsafe period
Origoknause Formula ( irregular menstrual cycle)
get the longest and shortest cycle


subtract 18 to shortest
11 to the longest
the difference is the unsafe period
combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland
roduction of FSH and LH which are essential for he maturation and rupture of a follicle.
Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH
which is responsible for ovulation.
contains estrogen that inhibits FSH and progesterone that inhibit LH
99.9% effective
21 day feel on the 5th day of mense start taking
28 day 1st day of mense
if forgotten, take 2 tablets the following day
adverse effect : breakthrough bleeding
if mother wants to get pregnant
o wait 3 monts
o another 3 months if unsuucessful before consulting gyne
o chain smoking
o Hypertension
o DM
o Extreme obesity
o Thrombophlebitis
Side effects (ressembles Hypertension)/ Immediate Discontinuation
o Abdominal paon
o Chest pain
o Headache
o Eye problem
o Severe leg cramp
Alerts on oral contraceptives :
o In case a Mother who is taking an oral contraceptive for almost a long time and plans
to have a baby, she would wait for at least 3mos before attempting to conceive to
provide time for estrogen and progesterone levels to return to normal. If after 6months
the mother did not get pregnant, consult AMD.
o If a new oral contraceptive is prescribed, the mother should continue taking the
previously prescribed contraceptive and begin taking the new one on the first day of
the next menses.
o Discontinue oral contraceptive if there is signs of severe headache as this are an
indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
o If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days,
stop the pill and wait for the next mens.
Adverse reaction : breakthrough bleeding
DMPA Depoprovera
Contains progesterone
Depomedroxy progesterone Acetate
IM q 3 months never massage the site may decrease effectiveness


6 match stick like capsules/ rod
contain progesterone
sub Q planted
good for 5 years
Mechanical Device
prevent implantation
alters mobility of sperm and ovum
99.7% effective
best inserted after delivery and during menstruation
No protection against STD
Side effects include
o Uterine infection
o Uterine perforation
o Ectopic pregnacy
Major indication for the use is PARITY
HT: monthly check up and regular pap smear
Made up of latex
Put in erected penis or lubricated vagina
Prevents sperm to enter the uterus
FEMALE CONDOM higher protection than that of male
Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the
HT : Proper hygiene
o Check for holes
o Must be refitted in case of weight gain of 15 lbs - - board question
o Kept in place for about 6-8 Hours Board question
Contraindicated to
o Frequent UTI
More durable than the diaphram
Could stay on place for more than 24 hours
No need to apply spermicides
Contraindicated to abnormal papsmear
FOAMS most effective
These may cause toxic shock syndrome


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


General management
Avoid sex
Prepare ultrasound determine the sac integrity
Assess bleeding and approximation
Assess hypovolemia
Save discharge for histopathology
o Determine whether the product of labor has been expelled
First Trimester Bleeding
Abortion termination of labor before age of viability
o AKA miscarriage
o Causes
1. Chromosomal aberrations due to advanced maternal age
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatened
pregnancy is jeopardized by bleeding and cramping but the cervix is
closed and can be saved.
2. Inevitable
moderate bleeding, cramping, tissue protrudes from the cervix and the
cervix is open.
o Types :
1. Complete
all products of conception are expelled.
Mgt : emotional support
2. Incomplete
placenta and membranes retained.
Mgt : D&C
o 3 or more consecutive pregnancies result in abortion usually related to incompetent
o Management (suture of cervix)


1. McDonald procedure
Temporary circlage
Side effect infection
May have NSD
2. Shirodkar
CS delivery
o fetus dies; product of conception remain in uterus 4 weeks or longer
o signs of pregnancy cease
1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
o Mgt : induction of labor/ vacuum extraction
o Therapeutic abortion principle of 2 fold effect
1. Done when mother has class 4 heart disease
Ectopic Pregnancy
occurs when gestation is location outside the uterine cavity
Common site : Ampulla or Tubal
Dangerous site: Interstitial
Missed period
sudden, sharp severe unilateral
pain, knife like
Abdominal pain within 3- 5wks of

shoulder pain (indicative of

missed period (maybe generalized
of one sided)
intraperitoneal bleeding that extends
to diaphragm & phrenic nerve)
Scant, dark brown vaginal bleeding

(+) Cullens sign bluish tinged

Vague discomfort

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


Hydatidiform Mole / bunch of grapes
Gestational Trophoblastic Disease progressive degeneration of Chorionic Villi
gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is
formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus
of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus
very rapidly.
Cause : Unknown
Assessment :
o Early signs


vesicles passed thru the vagina

Hyperemesis gravidarum due to HCG
Fundal height
Vaginal bleeding (scant or profuse)
o Early in pregnancy
high levels of HCG
Pre ecclampsia at about 12wks
Vesicles look like a snowstorm on sonogram
Abdominal cramping
o Serious late complications
Pulmonary embolus
Nursing care :
o prepare for D&C
o do not give oxytocin drugs due to proneness to embolism
o Health Teaching:
return for pelvic exams as scheduled for one year to monitor HCG and assess
for enlarged uterus and rising titer could be indicative of choriocarcinoma
Avoid pregnancy for at least one year
Methotrexate therapy

Incompetent Cervix Management:

McDonald procedure
o temporary circlage of incompetent cervix.
o Delivery : NSVD
o SE: infection
o Health teaching
observe for signs of infection
signs of labor
Shhirodkar procedure
o permanent procedure.
o Delivery : caesarian section required.
Placenta Previa
it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
o Outstanding sign : frank, bright red, painless bleeding
o enlargement (usually has not occurred)
o fetal distress
o abnormal presentation
Nursing care :
o Initial mgt : NPO candidate for CS
o Bedrest
o prepare to induce labor if cervix is ripe
o administer IV
o No IE, No Sex, No enema complication : Sudden fetal blood loss
o prepare Mother for double set up DR is converted to OR


Abruptio Placenta
it is the premature separation of the placenta from the implantation site.
It usually occurs after the twentieth week of pregnancy
o Cocaine user
o Severe PIH
o Accident
o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
o sx : bleeding to any part of the body. Mgt : for hysterectomy
General Nursing care :
o infuse IV, prepare to administer blood
type and crossmatch
o monitor FHR
o insert Foley catheter
o measure bllod loss; count pads
o report s/s of DIC
o monitor v/s for shock
o strict I&O
Placental Succenturiata 1 or 2 lobes connected to the placenta by a blood vessel
Placenta Bipartita placenta divided into 2 lobes
Pregnancy Induced Hypertension
o HPN after 24wks resolved 6wks postpartum which cause pregnancy.
o Types :
o Gestational HPN
HPN without edema & proteinuria.
Mgt : monitor BP
o Pre-eclampsia triad
o sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or
idiopathic but multifactoral
primis d/t 1st exposure to chorionic villi
multiple pregnancies due to exposure to chorionic villi
Mothers of low socio-economic status due to protein intake
Teenagers d/t low compliance to protein intake
o HELLP syndrome hemolysis with elevated liver enzymes & low platelet count
Transitional Hypertension HPN between 20-24wks
Chronic or Pre-existing Hypertension
o HPN before the 20th wk not resolved 6wks postpartum
o 3 types of pre-eclampsia


Sign of pre-eclampsia :
o > 30mmHg systolic
o > 15mmHg diastolic
o Roll over test
10-15min side lying
Then supine
Then take BP
o mild pre-ecclampsia
140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : wt, inability to wear
wedding ring due to developing edema
Signs present
cerebral & visual disturbances, epigastric pain to liver edema and
oliguria usually indicates an impending convulsion
Before convulsion : if you see sign of epigastric pain, 1 mgt is to place
tongue depressor and put the side rales up
During convulsion : observe the Mother for safety
After convulsion turn to side to facilitate drainage
o Severe pre-ecclampsia
160/110, +3 or +4, proteinuria, visual disturbances
Nursing care
P promote bedrest
Prevent convulsions by nursing measures
to O2 demand & facilitate Na excretion
Management: quiet & calm environment, minimal handling, avoid
moving the bed
Heat Acetic Acid determine protein in the urine
Prepare the following at bedside
o tongue depressor, Suction machine & O2 tank
E ensure high protein intake (1g/kg/day)
Na in moderation
A antihypertensive drug with hydraluzine
C CNS depressant with Mg Sulfate for anti-convulsion
Mgt : evaluate for hypermagnesiumenimia
E evaluate physical parameters for Magnesium Sulfate toxicity :
U Urine output
P Patellar reflex is absent
Antidote : Ca gluconate
o Eclampsia with seizure
BUN sign of glumerular damage



Diabetes Mellitus
o cause by absent & lack of Insulin
o Action of Insulin is to facilitate transfer of glucose into the cell
o Dx test : 50gm 1hr Glucose Tolerance Test
o 130 hyperglycemia
o 70 hypoglycemia
o 80-120 euglycemia
o if > 130mg/dl, the Mother needs to undergo a 3hr GTT
o Maternal Effects :
o hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus
yung glucose ng nanay.
o Hyperglycemia during the 2nd & 3rd trimester
HPL effect Mgt : give insulin. OHA are teratogenic.
1st trimester - insulin, 2nd trimester - insulin, post partum drop suddenly
Frequent infections eg. Moniliasis
o Fetal Effects :
o hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd
trimester thru facilitated diffusion
o Macrosomia/LGA .4000gms
o IUGR due to prolonged DM
o Preterm birth promote still birth
o Newborn Effects :
o Hyperinsulinism and Hypoglycemia
Normal : 45-55mg/dl
Borderline : 40mg/dl
Sx : pitched shrill cry, tremors, jitteriness
Dx test : heel stick test to check glucose levels
o Hypocalcemia
< 7mg/dl
Calcemic tetany
Tx : Ca gluconate
Heart Disease
o Classification :
o I no limitation
o II Slight limitation, ordinary activity causes fatigue


good prognosis can deliver vaginally

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

Cesarean Delivery
a. multiple gestation
b. diabetes
c. active herpes II
d. severe toxemia
e. placental previa
f. abruption placenta
g. prolapse of the cord
h. cephalo pelvic disproportion and primary indication
i. breech presentation
j. transverse lie
procedure :
o classical vertical incision
o low segment bikini, for aesthetic purposes. Can have vaginal birth after c/s
Genotype genetic make-up
Phenotype Physical appearance
Karyotype pictorial analysis of individual chromosome for detecting chromosomal abnormalities
Autosomal Dominant
huntingtons chorea
Autosomal Recessive
sickle cell
Cystic fibrosis
X- Linked Recessive
Duchennes muscular dystrophy
Color blindness
X Linked Dominant