Maternity

1. No ovulation during pregnancy

2. Vagina: estrogenic hormone induces during leucohhrea (↑ in estrogen causes ↑ in discharge)
3. Blood volume ↑ by 50% to meet demands of pregnancy (maternity causes that)
 Pregnant women experience an increase in total blood volume to meet the increased oxygen demand
and nutritional needs of the growing fetus and maternal tissues.
 The increase in plasma volume is greater than the increase in red blood cells, creating a hemo
diluted state termed physiologic anemia of pregnancy
4. Progesterone relaxes smooth muscles ( relaxes stomach muscles too + GERD and constipation)
5. WBC increases in pregnancy up to 15 k (5-10K)
6. Greater tendency to coagulate = DVT = can lead to embolism
7. BP may reduce due to first trimester and should not rise during last half of pregnancy. HR ↑ and
palpitations possible
8. Blood flow to placenta is maximized in side lying position (LEFT) VCC = vena cava compression
9. Presence of protein is not expected component of maternal urine ( indicates possible renal diseases or
pregnancy induced HT) = proteinuria
10. N&V in first trimester due to increase HCG
11. Constipation because water is reabsorbed from large increase (↑50%)
12. Emptying time for the gall bladder increases prone to gall bladder stones ( stones due to longer period of
urinary stasis)
13. FSH and LH greatly decreased during pregnancy
14. Oxytocin secretes at the time of labour (let down reflex)
15. Progesterone secreted by corpus leutem until formation of of placenta
16. Priniciple source of estrogen is placenta
17. Slight increase in thyroid activity and BMR
18. First trimester: mother feels ambivalence
19. Second trimester: fantasies about unborn child
20. Third trimester: nesting activity: desired to finish delivery, anxiety over safe passage of child and
herself.

G - gravida indicates the number of pregnancies, delivered or undelivered

T - term deliveries are from 37 wk and beyond
P - preterm deliveries are from 20 wk to 36 wk gestation
A - abortions (spontaneous or elective) occur prior to 20 wk gestation
L - living children are counted individually regardless of multiple birth status.

a) Gravida: number of times pregnant regardless of duration, primigravid first line, multigravida, 2 or more.
b) Para: # of pregnancies that last for greater than 20 weeks regardless of outcome
Nullipara: who has not given birth to anyone above 20 weeks
Primpara: who gives birth to anyone greater than 20 weeks

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Signs and Symptoms of Pregnancy

Pregnancy Signs
Presumptive Signs Amenorrhea (4-6 weeks)
Breast enlargement/tenderness (3-4 weeks)
Fatigue (12 weeks)
Nausea and vomiting (4-14 weeks)
Quickening (first movement of fetus) (16-20 weeks)
Urinary frequency
Probable Signs Ballottement (fetal movement in response to tapping lower uterus/cervix)
Braxton Hicks contractions - @ 16 weeks - painless contractions
Chadwick’s sign (light pink-deep violet vaginal wall colour) ( 6-8 weeks)
Hegar’s sign (softening of cervix)
Positive pregnancy test
Abdominal + uterine enlargement
Positive Signs Fetal heartbeat
Fetal movement
Ultrasound findings

Prenatal Care: Time Frame

a) First visit: As soon as the mother finds out she is pregnant with probable & positive signs
b) Subsequent visits : Visit MD every 4 weeks for first 28-32 weeks, every 2 weeks from 32-36 weeks,
and every week from 36-40 wks

Fundal Height:
Measured to evaluate gestational age of fetus
*In 2nd and 3rd trimester: fundal height in cm = fetal age in wks +/- 2 cm
Priority: 1. Monitor for supine hypotension when placing pt in supine position

Prenatal tests
1. Glucose screening: 24- 28 weeks
2. Antibody screening: 28 weeks
3. STD/other infection: 9th month

Important preconception education topics

 Folic acid supplementation at least 400 mcg per day reduce the incidence of neural tube defects.
Fortified grain products (e.g., cereals, bread, pasta) and green, leafy vegetables; alternate sources include
beans, rice, peanut butter
 Appropriate dental care and vaccinations. Periodontal disease is associated with adverse pregnancy
outcomes, including preterm birth and low birth weight
 Avoidance of alcohol, smoking, and illicit drugs. Smoking is associated with fetal growth restriction
 Clients who are not immune to rubella should be vaccinated and avoid pregnancy for at least 4 weeks
after vaccination
 Clients should also attempt to achieve normal weight (BMI of 18.5-24.9 kg/m2) before conceiving to
improve outcomes. Obesity (BMI >30 kg/m2) during pregnancy is associated with increased risk for
fetal/maternal complications (eg, birth defects, gestational diabetes, pregnancy-related hypertension,
fetal macrosomia).

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 Discomforts during
pregnancy
Prevention/Interventions:
Nausea/Vomiting occurs in 1st month, subsides by Eat dry crackers before arising, avoid brushing teeth right
after arising, eat small frequent meals, drink in between
3rd month
meals, avoid fried/spicy food
Syncope st
occurs in 1 trimester, supine Elevate feet when sitting, change positions slowly
hypotension in 2nd and 3rd trimester
Urinary Urgency occurs in 1st + 3rd trimester due to 2L fluid restriction, void regularly, side lying sleep
uterus pushing on bladder position, Kegel exercises

Breast tenderness 1st-3rd trimester Wear supportive bra, avoid soap on nipples
Vaginal discharge 1st-3rd trimester Proper cleansing, cotton underwear, avoid douching
Fatigue 1st and 3rd trimesters Frequent rest periods, regular exercise
Heartburn 2nd and 3rd trimesters Small frequent meals, sit up right 30 mins post-meal, drink
milk between meals, avoid fatty/spicy food
Ankle edema 2nd and 3rd trimesters Elevate legs BID, side lying sleep position, supportive
stockings, avoid sitting/standing in one position for long
Varicose veins 2nd and 3rd trimesters Wear supportive stocking, elevate legs when sitting, lay
with feet elevated, avoid crossing legs
Hemorrhoids 2nd and 3rd trimesters Soak in warm sitz bath, sit on soft pillow, high fiber foods +
fluid intake, increase exercise

Weight gain: approximate 25 lbs.

Calories: additional 300 kcal/day (not less than 1800 kcal/day)

Special concerns
a) Religious, cultural food preferences
b) PICA – eating non-nutritional substances due to iron and calcium deficiency
c) Vegan vegetarian: needs b12 supplements - no milk or meat/egg products, eats only vegetables
d) Heavy smoking, alcohol consumption and drugs (no safe level for smoking or alcohol)

Amniocentesis: usually after 14 weeks when sufficient amount of amniotic fluid is present
 sex of the foetus
 level of alpha fetoprotein (To check neural tube defect)
 chromosomal variations
 RH factor
 Gestational age

Oligohydramnios
 a condition characterized by low amniotic fluid volume
 Amniotic fluid is produced by the fetal kidney and serves two major purposes - to prevent cord
compression and promote lung development.
 Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal
outline that is easily palpated through the maternal abdomen should raise suspicion for
oligohydramnios. Ultrasound confirms the diagnosis.

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 Major complications of oligohydramnios are:
1. Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic
fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible
resuscitation
2. Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to
monitor for variable decelerations

X-ray: use late in pregnancy to avoid possibility causing foetal damage

Alpha-fetoprotein: it is the glucoprotein produced by fetal yolk sac, GI tract, liver; test done between 15-18
weeks.
 ↑ AFP: renal tube defect, renal abnormality
 low AFP: chromosomal trisomy (down syndrome)

L/S Ratio: The lecithin–sphingomyelin ratio (a.k.a. L-S or L/S ratio) is a test of fetal amniotic fluid to assess for
fetal lung immaturity. Lungs require surfactant, a soap-like substance, to lower the surface pressure of the alveoli
in the lungs.

Foetal Movement: Teach mother, count movement daily 2-3 times for 1 hour; 5-6 movements ( or minimum 3
movements is normal) if any gross change or no movement immediately call MRP

PUBS: percutaneous umbilical blood sampling: uses US to locate umbilical cord and cord blood sample is
aspirated and test is done in second and third trimester (to check for congenital abnormalities)
Fundal Height:
 12 weeks: above pubic symphysis
 20 weeks: at the level of umbilicus
 30 weeks: between umbilicus and xiphoid-sternum
 36 weeks: highest level contact with xiphoid-sternum
 38 weeks: lightening sinks down or after 20 weeks 1 cm above umbilicus per week until 36 – 38 weeks
then fundus descends
Nonstress Test Stress
Test
Noninvasive test measuring fetal heart accelerations in Test triggers contractions and predicts how baby will react
response to fetal movement during labour
Done between 32-34 weeks gestation If fetal HR slows during contraction = positive result.
Nonreactive result = further testing is needed to determine Fetus may be experiencing stress during contractions
if the result indicates fetal hypoxia or if result is due to (cannot tolerate contractions) Further testing may be
sleep pattern, or maternal prescription drugs needed
Reactive result = normal. Indicates that blood flow and If fetal HR doesn’t slow down during contraction = normal
oxygen to fetus is adequate result. Indicates that the fetus is reacting properly to stress
of contractions

Biophysical profile: uses to evaluate foetus, to check risk for asphyxia, score of 0-2 given to each and physician
calculates score

1. Foetal Breathing: 2 3. Foetal HR: 2 5. Amniotic fluid: 2

2. Foetal movements: 2 4. Muscle tone: 2

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Danger signals of Pregnancy
 Any bleeding from vagina  swelling in upper body: Face and fingers
 gush of fluid from vagina ( amniotic fluid)  regular contraction occurring before due date
 severe headache and changes in vision  change in foetal activity
(frontal)  fever, STD, other infection
 epigastric pain

Ectopic Pregnancy
 most common in fallopian tubes, only 1:1 chances in peritoneum
 usually ruptures before 12 weeks or pregnancy
 infection which diminishes the tubes; lumen many predispose the tubal pregnancy
 Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness,
and referred shoulder pain. Shoulder pain results from irritation of the diaphragm by intra-abdominal
blood.
 A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention.

Signs and Symptoms of Ectopic Pregnancy

 severe pain in one side of the abdomen (spasmodic pain)
 rigid, tender abdomen
 bleeding is severe and leads to s&s of shock
 HCG titer is usually lower than uterine pregnancy

Nursing intervention
1. Prepare the client for surgery
2. treat shock
3. express feeling and loss of pregnancy for future pregnancy
4. chemical therapies to salvage fallopian tube ex: methotrexate

IMPORTANT: sharp lower or left abdomen pain radiation to shoulder (phrenic nerve irritated) *symptom of
shock

Hydatidiformmole (Gestational Troppblastic disease)

 embryo dies
 chronic villi change into a mass of clear fluid filled grapelike vessels
 cause is unknown
 common over 40 years of age
 In clients with hydatid
 iform mole or "molar pregnancy," the fetus is replaced by edematous, cystic chorionic villi. Clients
experiencing molar pregnancy should anticipate intermittent, dark brown vaginal discharge until the
pregnancy is evacuated.

S&S
 sign of uterus disproportionate to length of pregnancy
 HCG level high, excessive nausea and vomiting
 sign and symptoms of pre-eclampsia before usual time (20 weeks)
 No FHR, no foetal movement , no foetal part on palpation

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  US shows no fetal skeletal
Management
 suction curettage is done
 delay pregnancy for 1 year
 check for choriocarcinoma (uterus affected)
 emotional support and teach future pregnancy

Hyperemesis Gravidum: excessive vomiting = metabolic acidosis

1. Excessive vomiting leads to metabolic acidosis
2. Normally HCG levels begins to increase during 6th week of pregnancy and peak at 12 weeks then start to
decrease again.
3. Sickness should subside during later pregnancy but sometimes it can continue
4. Urine is concentrated with dehydration, indicated by increased specific gravity
(>1.030). Ketonuria indicates that the body is breaking down fat to use for energy due to the
client's starvation state
5. Low blood pressure would be expected due to hypovolemia.

S&S: severe N&V, dehydration, weight loss

Nursing Mgmt: NPO, I/V fluid, monitor I//O, mouth care, provide TPN in severe cases.

Placenta Previa: Placenta implants close to cervix

 C section after 36 weeks gestation
 can be managed outpatient
 return to hospital if bleeding occurs
 As pregnancy progresses, the placenta grows in size and can potentially migrate away from the cervical
opening, resulting in complete resolution of the previa.
 additional ultrasound 36 weeks gestation
 placed on pelvic rest
 decrease any physical activity that could cause contractions
 low implantation of placenta
 Persistent placenta previa or hemorrhage require caesarean birth.
 The nurse should initiate electronic fetal monitoring and pad counts, draw a type and screen, and initiate
large-bore IV access. Digital vaginal examinations are contraindicated.
 At risk for hemorrhage; vaginal examinations are contraindicated, and pelvic rest is recommended to
prevent disruption of placental vessels.
 A caesarean birth is planned prior to onset of labor.
 marginal, partial or complete
◦ causes: unknown, fibroid or multiple pregnancies
 Dx: before 30 weeks of pregnancy with sonogram

S&S:
 bright red painless vaginal bleeding after 7th month
 lower uterine segment soft
 no vaginal examination

Txt:
 complete bed rest

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  double set up procedure
 continue to monitor maternal VS and FHR
 high fowlers sitting position

Abruption Placenta
 separation of placenta from normal implant
 painful bleeding
 bleeding is usually old
 occurs after 20th week
 common in women with: HT, smoking, multiparity, abdominal trauma, previous history of abruptive
placenta

S&S:
 painful vaginal bleeding
 tender board like abdomen
 foetal bradycardia
 later deceleration * very dangerous
 s/s of shock
Txt:
 bed rest
 i/v infusion, blood transfusion, check foetal and maternal vital signs
 prepare for surgery
 emotional support.

PIH(Pregnancy induced HTN)

1. Gestational HTN
2. Preeclampsia
Mild pre-eclampsia
Severe Pre-eclampsia
3. Eclampsia
4. General characteristics: edema, HTN, proteinuria, age below 17 and above 35 years old; after 20th week of
pregnancy.
5. Risk factor: women with HTN, DM, multiple pregnancies, trophoblastic diseases

Clinical Manifestations: Gestational HTN:

 ↑ BP during pregnancy and resolve after 6 weeks of delivery
 no edema
 no proteinuria

Clinical Manifestations: Mild Preeclampsia

 BP ↑ systolic and diastotic 15 mmHg or 140/90
 proteinuria (+1)
 upper body edema, face and digit fingers
 excessive weight gain

Clinical Manifestations: Severe Preeclampsia

 BP: 160/110 or above, taken one or two reading after 6 hours period

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  proteinuria of +3 or +4 in 24 hours
 extensive edema, puffiness of face and digits
 hyper-reflexia 4+ with clonus (hands bending inside)
Eclampsia
1. seizures
2. coma
3. edema
4. proteinuria
5. foetus in great jeopardy
6. only known cure is delivery

HELLP syndrome: hemolysis, elevated liver enzyme, low platelet count

1. R upper quadrant pain (Liver)
2. proteinuria present
3. liver enzymes are elevated
4. platelet and RBC low

Medical and Nursing Mgmt.:

1. Gestational HTN:
 Rest
 Dietary management with fluid
 Symptomatic treatment
2. Mild eclampsia
 bed rest side lying position
 well balanced diet; adequate protein and roughage
 no salt restriction, high calories
 close follow up weekly or twice weekly
3. Severe Eclampsia
 Magnesium Sulfate (MgSO4) – resp. Depression is one of the main side effects
 monitor Resp, BP, reflexes frequently (due to severe hyperreflexion)
 Antidote: Calcium Gluconate for MgSO4
 Bed Rest
 Maternal and foetal vital signs
 Take daily weight

Institute seizure precautions:

 restricted visitors
 minimal stimuli
 monitor hyperreflexia
 sedatives as ordered
 continue to monitor for 72 hours after delivery
 administer vasodilator – hydralazine/apresoline for HTN

Important: MgSO4 causes bradypnea and weak patellar reflexes

Hematocrit levels increases by hem concentration caused by decreased plasma volume

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4. Eclampsia: same as severe pre-eclampsia
 MgSO4
 seizure precautions
 prepare for C-section

Endocrine conditions: Diabetic Mellitus

1. Maternal insulin level need to be carefully monitored during pregnancy
2. careful blood and urine testing (ac/pc breakfast)
3. dose may drop during 1st trimester and rise during 2nd and 3rd trimester
4. 1 hour GTT for all women of DM, 24-28 weeks
5. 3 hours GTT for those whose GTT>140 mg/dl
6. The accurate test is blood testing not urine test because in pregnancy urine threshold is decreased

AIDS and pregnancy

1. Transmission through blood, semen and breast milk
2. During delivery or C-section
3. Breast feeding contraindicated
4. Treatment with AZT(zidovudine) was administered during prenatal period, intratal period to reduce
transmission; postnatal given to the infant as well.
5. Infant should be screened for HIV infection when either parent is HIV positive or at high risk for AIDS
6. symptoms are usually not present at birth

TORCH
1. Toxoplasmosis: can be acquired by eating under cooked meat, cat litter, organism crossing the placenta,
severity of infection related to gestational age can cause: hydrocephalus and intracranial calcification
2. Other infections:
1. Syphilis: Treponema palladium (spirochete): crosses placenta after 16 weeks of pregnancy
Signs and Symptoms
▪ initial- plainness chancre (cardinal sign- lesions on the vagina; painless)
▪ lymphadenopathy, may disappear after 4-6 weeks without treatment
▪ Secondary signs and symptoms: rash, malaise, alopecia, and may disappear after
several weeks without treatment.
▪ Tertiary signs: affect cardiovascular and neuralgic system, foetus can be infected in
the stage
 Diagnosed by dark field exam and VDRL
Treatment
 Penicillin is the choice of drug; if allergic use erythromycin or tetracycline
 probenecid is given to delay the excretion of penicillin
 use of condoms
 identify prior contacts
 teach the client sexual activity until test is negative

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Gonorrhea
1. Neisseria gonorrhoea
2. initially client remain asymptomatic and mirror symptoms appear and disappears itself but client became
carrier

Sign and Symptoms: dysuria, joint pain, purulent discharge vaginal or penile fever
Diagnosis
 Uretheral or endo-cervical smear positive for gonococcus
 culture from urethra, endocervix and pharynx
 if left untreated – sterility, prostatic, birth defect, miscarriage
 pass to fetus at time of birth, causing opthalmia (which is why the baby receives eye drops at
birth as a prophylactic measure)
 All contacts must be treated as soon as possible to prevent recurrence.
 Drug of choice: Penicillin

Herpes: painful vesicles, no cure

 Painful genital lesions can be indicative of an outbreak; are a priority assessment finding to report to the
health care provider.
 Active herpes lesions that are present at the onset of labor indicate the need for cesarean birth.
 S&S: unilateral clustered skin vesicles along peripheral sensory nerve on the face, thorax, trunk, fever
burning and neuralgia, purulent discharge
 NSG Mgmt: Isolate, standard precaution, acetic acid compress antiviral, analgesic, anti-anxiety, steroid,
keep cool environment, and prevent scratching
 Drug: Zovirex (Acyclovir) can halt progression

Important
 latex condoms help prevent the transmission of germs
 high rate of cervical cancer in patients with herpes genital or PAP smear every year
 untreated herpes genitals during delivery infant may acquire the herpes infection from vaginal birth
putting the infant at risk for systemic infection herpes which has very high mortality rate

Measles-mumps-rubella (MMR)
 Is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk
of contracting the disease from the vaccine.
 Maternal rubella infection can be teratogenic for the fetus.
 The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects
(patent ductus arteriosus), and cerebral palsy.
 The best time to administer an MMR vaccine to a nonimmune client is in the postpartum period just
prior to discharge
 Can safely be administered to breastfeeding clients.
 Pregnancy should be avoided for at least 1-3 months after immunization.

Rubella (German measles)

1. Viral diseases causing lymphadenopathy and pink maculopapule

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 2. very mild disease, no specific care is needed
3. complication: Arthralgia, arthritis if occurs in young adults

Important
 Greater danger: if pregnant mother contracts the disease, its a serious complication, congenital
malformation of foetus
◦ cataract
◦ deafness
◦ cardiac abnormalities (first 12 weeks)

Cytomegalovirus: pregnant women usually asymptomatic, it is sexually transmitted diseases

Sign and Symptoms:
 hemolytic anemia
 hydrocephalus
 microcephalus (IUGR)

Adolescence and Pregnancy

1. Pregnancy is a physical and psychological burden and risk
2. adolescent are always undernourished and not fully matured
3. Toxemia and low birth weight are most common complications

Substance Abuse and Pregnancy

Alcohol
a) elevates mood and depresses CNS
b) no safe level of maternal alcohol use in pregnancy has been established
c) foetal effects: IUGR, CNS depression, cranial facial abnormalities (foetal alcohol syndrome), mental
retardation feeding difficulty, cardiac SGA, facial abnormalities, large space between the eyes
d) Signs and symptoms: increased temperature, hyperirritability, hyperactivity, vomiting and diarrhea, high
pitched cry

Treatment: decrease stimulus, handle with minimal movement, swaddle and handle close to the body.

Cocaine
a) powerful stimulate, very addictive
b) causes vasoconstriction, increase BP and may cause seizures
c) complication: absorption, malformation, neural tube defect, abruption placenta
Newborn: irritability, hyper toxicity, poor feeding pattern, increased risk of SIDS

Opiates
 Produces analgesia, euphoria, resp. Depression
 newborns experience withdrawal within 24-72 hours after delivery; s&s: high pitched cry, restlessness,
poor feeding pattern

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Five factors of Labour (5Ps)

Passenger:
 Foetus: Foetal head – largest part of the body
 Moulding: overlapping of cranial bones
 Anterior fontanelle: largest diamond shaped closes about 1.5 years
 Posterior fontanelle: smaller, triangular, closes at 1- 3 months

Presentation: the part of the fetus which enters the birth canal
 cephalic
 breach
 shoulder

Position: fetal presenting part to maternal bony pelvis; favourable position: LOA (left occipital anterior)

Leopold’s Maneuvers:
Palpating to determine presentation + position
Head = hard, round, movable
Buttocks = irregular shape, more difficult to move
Back = smooth, hard surface (should be felt on 1 side of abdomen)

Passageway:
1. Engagement:
◦ 2 weeks before labour in primigravida
◦ at the beginning of labour in multigravida
2. Station:
◦ at ischial spine: Station is 0
◦ above the ischial spine station is -1
◦ below the ischial spine station is +1

Power: frequency, duration, intensity

 Frequency: time from beginning of contraction to the beginning of next contraction

 Duration: length of contractions, contraction lasting more than 90 seconds without subsequent of
relaxation should be informed immediately.
 Intensity: is how strong the contraction is

Placenta: usually in the fundus; if its low lying, it requires medical attention.
Normal mechanism of labour: engagement, decent (lightening), flexion, internal rotation, extension, external
rotation

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Stages of labour:

Stages of Labour
First Stage Onset of true labour – complete dilation of cervix Lasts anywhere from 2-18 hours
3 phases:
Latent phase – cervix dilated 0-3 cm, irregular contraction, cervical effacement almost complete
Active phase – cervix dilated 4-7 cm, contractions 5-8 minutes apart, cervical effacement
complete
Transitional phase – cervix dilated 8-10 cm, contractions 1-2 minutes apart + lasting 60-90
seconds
Assessment:
 check contraction freequency, intensity, duration
 membranes intact or rupture, color of fluid
 cervical changes
 FHR q15min and immediately after membrane rupture
 temp, q2h (s&s of infection)
 void q2h

Second Stage Complete dilation of cervix – delivery

Usually lasts ~40 minutes
Assess: FHR, check for bulging of perineum
Third Stage Delivery – expulsion of placenta
Usually lasts 5-30 minutes
 Assess: placenta separation, lengthening of the cord, gush of blood, globular shape of
uterus
Fourth Stage Maternal-neonatal bonding period
Usually lasts 1-4 hours
Assessment:
 increased temperature and pulse due to dehydration or blood loss is normal; if this stays
for more than 2 hours it will indicate infection; inform MRP and start with abx
 low BP
 physiological bradycardia due to fatigue during labor
 boggy uterus: massage to prevent bleeding
 deviated uterus: empty the bladder
 vaginal hematoma or episiotomy care: give ice pack for first 24 hours
 perineal care from to back to prevent infections
 Cleaning of perineal area from front to back

Lochia
- Rubra: bright red, no odour, first 3 days is normal
- Serosa: 2 pink to pinkish brown, 4-7 days, fishy odour
- Alba – creamy yellow or brown, 1-3 weeks, no odour

True Labor False Labor

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Regular contractions that become stronger, last longer, and Contractions are irregular, without progression
occur closer together No dilation, effacement, or descent
Cervical dilation + effacement progress Activity (e.g. walking) relieves false labor
Fetus becomes engaged in pelvis and begins to descend
Post-partum: 6 weeks involution – this is the process in which uterus returns to normal size, shape and
consistency in 3 weeks

Fundal height
 Immediately after delivery: between symphysis pubis and umbilicus
 First day: above the level of umbilicus
 after this fundus descends 1 cm everyday
 on 9th and 10th day, in the pelvis and cannot be palpated

Ovulation/Menstruation after delivery

 first cycle is usually involuntary
 for lactating mothers menses less predictable, may resume in 12-24 weeks

Breasts: Non Lactating

 prolactin level falls rapidly
 engorgement of breast tissue lasts for 24-36 hours, usually resolves spontaneously
 client should wear tight bra and cold compress

Breasts: Lactating mother

 High prolactin level
 initial secretion is colostrum: true breast milk appears between 48-96 hours
 let down reflex caused by oxytocin which is released by the sucking motion
 prolactin helps in production in milk with frequent contact with using baby

IMPORTANT
 Normal blood loss during normal delivery is 500 ml and C section is 1000 ml
 WBC count increased upto 20k in pregnancies (normal is 4-11k)
 clotting factor increases during delivery and remain increased for several weeks and leaving the women
at risk for thrombi
 Marked diuresis with 12 hours of delivery to reduce edema
 Lacto urea may present in nursing mothers

Tips for breast feeding mothers

 wear well-fitted bra, use absorbent pads without plastic coating if leaking occurs
 uterine cramping during feeding is normal
 Additional calories 400-600 kcal per day, 2-3 litres of fluid per day.
 Avoid medicine excreted in milk, check with a doctor
 avoid birth control pills (minipress can be given)
 don't use soap on nipples aerola, expose nipples to air to toughen them, use lanolin or fresh milk on
cracked nipples
 psychological readiness of mother is a major factor in successful breast feedings
 6-8 feeding in 24 hours and 6-8 wet diapers in week of life

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 Advantages of breast-feeding
 closeness, enhances bonding, optimal nutrition
 greater immunity to infection
 develop facial muscle, jaw, nasal passage
 assist in involution of uterus
 decreases incidence of otitis media

Important: storing EBM (expressed breast milk) in plastic bottles not in glass bottles because of immunoglobin
B adheres to glass bottles, EBM can be stored in 48 hours in fridge and 6 months in freezer.

Contraindication of breast-feeding
 Active TB, HIV positive, cancer patient taking chemotherapy, cardiac patients
 extensive surgery, renal disease, narcotic addiction, cleft lip or palate

Important: Unmodified regular cow’s milk, liquid or reconstituted is not appropriate for infants before 12
months of age.

Breast feeding schedule

1. Self-demand schedule is desirable, usually 2-3 hours
2. length of feeding time is usually 20 minutes, 10 minutes on each breastfeed
3. Burp and bubble infant between each breast while feedings
4. WHO recommends breast feeding for atleast 6 months

APGAR score

2 points 1 point 0 points

Appearance All pink Pink and blue Blue/pale
Pulse >100 <100 Absent
Grimace Cough Grimace No response
Activity Flexed Flaccid Limp
Respiration Strong cry Weak cry Absent
Score of 7-10 is excellent, 4-6 indicates moderate depression, and 0-3 is severely depressed
(resuscitation needed)

Post Partum hemorrhage: bleeding more than 500 ml in normal delivery and bleeding more than 1L in C-section
 Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition.
 Characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early
PPH (occurring ≤24 hours after birth).
 Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a
long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes).
 The nurse should first assess the fundus and massage it if boggy. The nurse should also assess the
client's vital signs and should never leave the client alone.

Risk factors for PPH include:

 History of PPH in prior pregnancy
 Uterine distension due to:
o Multiple gestation

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 o Polyhydramnios (i.e., excessive amniotic fluid)
o Macrosomic infant (≥8 lb 13 oz [4000 g])
 Uterine fatigue (labor lasting >24 hours)
 High parity
 Use of certain medications:
o Magnesium sulfate
o Prolonged use of oxytocin during labor
o Inhaled anesthesia (ie, general anesthesia)
S&S Causes
Boggy uterus uterine atony (may lead to excessive blood loss and clots)
Atonic uterus Retained Placenta
Laceration
Vaginal hematoma Penetration of placenta in myometrium
All signs and symptoms of shock come with PPH

Uterine Atony:
 Excessive postpartum bleeding is most commonly caused by uterine atony.
 Fundus is elevated above the umbilicus and deviated to the right, indicating a distended bladder.
 Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous
placental site. The client should be assisted to void to correct the bladder distension then perform fundal
massage.

Nursing Interventions for PPH:

 monitor fundus q15 min for 2 hours  FIRM fundal massage
 monitor VS for indications of shock  if fundal massage causes uterus to
 administer medication and IV as become firm nurse should check
ordered every 15 minutes for first hour after
 I/O measurement birth
 keep client warm  if fundal massage does not work
 prepare for surgery as needed oxytocin may be necessary

Thrombophlebitis: causes a blood clot to form and block one or more veins, usually in your legs
 may result from injury or infection
 increase in clotting factors is normal during pregnancy to prevent DVT

S&S
 pain, edema, redness over affected area (legs mostly, or pelvic region)
 positive homan sign = dorsiflexion of foot
Treatment
 pain management
 no massage
 heparin
 no knee gatch (no pillow under knee)
 observe for pulmonary embolism
Important: Encourage mother to ambulate shortly after delivery, there is extensive activation of blood clotting
factor. This together with immobility, trauma or sepsis encourages formation of thrombosis (which can be
prevented through activity)

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Mastitis
1. infection of breast; usually unilateral
2. frequently caused by cracked nipples
3. cause: Strep H
4. if left untreated: can lead to breast abscess

S&S:
 redness, hardness in breast
 fever, chills, tachycardia

Txt:
 handwashing, before touching the breast
 abx
 apply ice between feedings
 empty breast regularly, always breast feed until 6 months atleast

New Born Physiology

1. HR: 120-160 bpm, BP: 70/42 mmHg, RR-30-60 min
2. acrocynosis for 24 hours is normal
3. RBC – count is high immediately after birth (causes – jaundice)
4. absence of normal flora in intestine of new born results in low vitamin K; it is given on 1st day IM
5. Adequate LS ratio is 2:1 which prevents RDS
6. New borns are nose breathers
7. Voiding 12-24 hours is normal; then 6-8 void / day
8. Kidneys are immature and unable to concentrate urine
9. full cheeks and well developed sucking pads
10. white area on palate (Epstein’s pearl) are normal
11. immature cardiac sphincter, causes regurgitation, needs frequent burping
12. first stool passed within 12-24 hours, meconium, change color after 3 days
13. Liver is responsible for changing hemoglobin from breakdown of RBC into unconjugated bilirubin to
conjugate bilirubin (water-soluble) that can be excreted.
14. Excess unconjugated bilirubin can penetrate the sclera and the skin giving a jaundiced or yellow color to
the tissues
15. physiological jaundice is considered normal after 24 hours usually appears 48-72 hours
16. Temperature is maintained by using brown fat, newborn cannot shiver cold stress. Increased oxygen
demand leads to metabolic acidosis and RDS
17. newborns acquire immunity from mothers during pregnancy and colostrum; at risk for infection for first
6 weeks
18. 1-2 hours of delivery; start feeding to form good sucking reflexes
19. hearing fully developed at birth
20. weight: 6-8 lb = normal at birth; loss 10% during first 7-10 days. Regained in 2 weeks, double at 6
months, triple at 1 year
21. at birth, head circumference is 33-35 cm, chest is 32-34 cm
22. intervention in delivery room:

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 ◦ apgar score: 1-5 mins
◦ overall rapid physical and neurological examination to examine the obvious abnormalities, cord,
vessels, birth injuries
◦ prevent heat loss: dry, wrap, cover head, place on warm surface
23. Intervention in nursery:
Maintain temperature, respiration
Medication to prevent opthalmia in neonates, administer 0.5 erythromycin or 1% tetracycline
Vitamin K
24. Milia: usually on nose and chin are essentially normal
25. Eyes: strabismus (crossed eyes) occasionally normal; wide space between eyes is a sign of foetal alcohol
syndrome
26. ears: lack of cartilage in premature low set ears: kidney failure and down syndrome
27. pseudo menstruation: normal; it is a red spot in the new born’s diaper (more common in female child)

Reflexes present at birth: PARM

 Palm grasp: place finger in palm of baby’s hand, baby encircle the finger with his palm.
 Atonic/fencing reflex turn head to one side, leg and arm is also flexed of the same side
 Rooting reflex
 Moro reflex
 Babinski reflex

Complication in newborn

Caput Succedaneum:
- is present at birth
- may cross suture line
- tend to grow less
- disappear within 36 hours
- is diffused, pit on pressure
- a double caput is unilateral
- it is serosangunious infiltration into the fetal skull

Cephalohematoma
- appears after 12 hours
- never crosses the suture line; tends to grow larger
- persists for weeks
- do not pit
- a double cephalatoma usually bilateral
- it is blood under the skull lining
- new born may suffer from hyperbilirubinemia(due to high breakdown of RBC)

Hyperbilirubinemia
- RH or ABO incompatibility
- within 23 hours of birth
- mixing of blood during abruptive placenta or during delivery

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 - RBC destruction in fetus marked hemolytic anemic
- Rhogham at 28 weeks within 72 hours of delivery
- coombs test is done to monitor compatibility

Fetal Heart Rate: Decelerations

Early:

- Gradual (onset to lowest point > 30 seconds) decrease then return to baseline
- Caused by transient fetal head compression during UCs,
- NORMAL AND BENIGN finding, no intervention necessary
Late:
- visually apparent gradual decrease in an return to baseline FHR associated with UCs,
- deceleration begins after contraction has started and nadir of deceleration occurs after peak of
contraction, usually doesn't return to baseline until contraction is over,
- R/T UTEROPLACENTAL INSUFFICIENCY/DECREASED OXYGEN SUPPLY TO FETUS,
ominous sign when associated with absent or minimal variability,
- INTERVENTIONS (change maternal position to lateral, correct maternal hypotension by
elevating legs, increase rate of IV solution, palpate uterus, discontinue oxytocin if infusing,
administer oxygen by nonrebreather face mask, notify HCP, consider internal fetal monitoring,
assist with birth if pattern cannot be corrected)
Variable:
- visually abrupt (onset to nadir < 30 seconds) decrease in FHR below baseline, 15bpm at least
below baseline/lasts at least 15 seconds/return to baseline in less than 2 minutes,
- COMPRESSION OF UMBILICAL CORD, INTERVENTIONS (change maternal position to
side-to-side/knee to chest, discontinue oxytocin if infusing, administer oxygen by nonrebreather
face mask, notify HCP, assist with vaginal exam, assist with amniofusion (isotonic fluid into
amniotic cavity) and birth if pattern cannot be corrected)

Spontaneous Rupture of Membranes

-sterile gloves
-nitrazine pH test strip: positive for amniotic fluid if blue color present on strip

Systemic Analgesia for Labor Pain

-given in stage 1 active labor ONLY
-do not give to opioid dependent women
-more than 3 doses not recommended d/t ceiling effect
-ex. Stadol & Nubain

*give at peak of contraction for best absorption

Oxytocin/Pitocin: STIMULATES UTERINE CONTRACTIONS

 Used to induce or augment labor and to stop postpartum hemorrhage by promoting uterine contractions.
 Oxytocin must be administered via infusion pump and requires continuous electronic fetal monitoring as
it is a high-alert medication.
 The nurse assesses and documents the fetal heart rate and contraction pattern every 15 minutes during
the first stage of labor with oxytocin.
 Tachysystole (i.e., ≥5 contractions in 10 minutes) is a potential adverse effect of oxytocin.
 Excessive uterine contractions can decrease placental blood flow and compromise fetal oxygenation.

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  Treatment of tachysystole may include decreasing or stopping oxytocin infusion and administering IV
fluid bolus

RISKS
-late deceleration, bradycardia
-emergency C-section
-postpartum hemorrhage
-water intoxication
-uterine tachysystole (>5 contractions in 10 minutes)

TXT
-monitor every 15 minutes in first hour
-contractions should be 2-3 minutes apart
-electronic IV pump
-continuous monitoring
-monitor mother's fluid intake
-secondary IV line
-titrated based on rate and intensity of contractions

MAGNESIUM SULFATE TOXICITY

-nausea, headache, hyporeflexia, cardiac arrest
-TXT: stop magnesium sulfate therapy & use IV calcium gluconate to reverse

Shoulder Dystocia
-obstetrical emergency
-"turtle sign": fetal head retracting back into mother's perineum
-usually secondary to gestational diabetes causing macrosomia
-apply suprapubic pressure and sharp pressure of maternal thighs towards abdomen

Medications to Avoid During Pregnancy

 NSAIDs  valproate
 ace inhibitors (PRIL)  isotretinoin
 phenytoin  methotrexate
 lithium  warfarin

Pyrosis: HEARTBURN
-teaching: keep head elevated at night using pillows, sit upright after meals, eat small frequent meals,
avoid tight fitting clothing, eliminate fried/fatty foods, caffeine, citrus, chocolate, spicy foods,
carbonated drinks)
Folic Acid: ESSENTIAL DURING PREGNANCY
-women planning to become pregnant should take in 400-800 mcg per day
-fortified foods & green leafy vegetables are good source for folic acid

Foods containing large amount of folic acid

-asparagus
-fortified breakfast cereal
-cooked dried beans
-liver

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Treating Constipation during Pregnancy
-high fiber diet
-high fluid intake
-regular exercise
-bulk forming fiber supplements
*laxatives not recommended during pregnancy

Breast Engorgement: SUGGEST TO MOTHER'S NOT PLANNING TO BREAST FEED

-Use cold cabbage
-ice packs
-anti-inflammatory meds
-maintain breast support

Normal Newborn Assessment

-plantar creases (the more creases the more mature the neonate)
-Babinski reflex (toes fan out when sole of foot is stroked) until 1 year of age
-Epstein's pearls (white pearl like cysts) are benign and should disappear in a few weeks
-opaque/whitish blue umbilical cord with 2 arteries & 1 vein (should turn black then detach from body in
2 weeks—do not use alcohol to clean)
-acrocyanosis: bluish color of hands and feet, place skin to skin with mother, normal during first 24
hours
-Mongolian spots: benign discoloration of skin that fades in 1-2 years of life, document size and location
-2-6 wet diapers expected first 24 hours, by 3-4 days 6-8 wet diapers
-positive Moro reflex (startle)
-swollen labia with thin white discharge
-Milia: pinpoint papules
-diamond shaped anterior fontanel
-triangular shaped posterior fontanel smaller than anterior
-rales d/t transitioning to extra uterine life

Abnormal Newborn Assessment

-jaundice (<24 hours of life is pathological, >24 hours referred to as physiological)
-cold stress: decreased temp, irritability, lethargy, bradycardia, tachypnea at first, emesis, hypoglycemia,
weak cry
-hypotonia
-sacral dimple
-weight loss since birth > 7%
-small tuft of hair at base of spine

Sudden infant death syndrome (SIDS): UNEXPLAINED DEATH <1 YEAR OLD
PREVENTION
-supine position when sleeping
-breastfeeding
-pacifier during sleep
-up to date vaccines
-appropriate clothing (sleep sack)
-firm sleep surface
-removal of loose items from bed
-smoking cessation

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 Phototherapy: JAUNDICE TREATMENT
-Fully exposed except for diaper
-Can be fed during therapy
-No lotions or ointments
-Change dirty diapers immediately

Naegle's Rule: DETERMINES ESTIMATED DELIVERY DATE

-pregnancy on average is 40 weeks/280 days starting with first day of last normal menstrual period as day 1
Steps:
1. determine first day of last menstrual period
2. Go back 3 months from that date
3. Add one year + 7 days
-dates may have to be adjusted for longer or shorter menstrual cycles and confirmed with ultrasounds

Late Pregnancy Bleeding

Placenta Previa Abruptio
Placentae
Placenta implanted low in uterus or over cervical os Premature separation of placenta from wall
S/S: sudden painless, bright red bleeding S/S: painful dark red bleeding, uterine pain, uterine rigidity,
abdo pain
Priority: 1. Ultrasound to confirm 2. Avoid vaginal exam 3. Priority: 1. Trendelenburg 2. Monitor bleeding 3. O2, IV
Side lying position 4. Monitor amount of blood 5. IV fluids fluids, blood products 4. Prepare for delivery ASAP
and blood products 6. C-section may be needed
RH factor:
The Rh factor is transmitted in the genes of chromosomes of both ovum and sperm
 If both parents are negative = fetus is also negative
 if both parents are positive = fetus is positive
 If one parents is positive and other is negative – fetus is positive(always a higher likelihood)
If Rh-negative mother has Rh-positive fetus in utero then it is a possibility that fetus RH antigen on RBC will
enter maternal blood. Normally maternal blood and fetal blood does not mix during pregnancy but only on these
occasions:
 partial placental separation
 abortion
 amniocentesis
 Antepartum hemorrhage

Coombs test: done with infant’s cord blood

 Screens for Rh sensitization in Rh-negative mothers. If the test results are positive, the fetus and
subsequent pregnancies are at risk for serious complications.
 Rh immune globulin (e.g., RhoGAM) is given at 28 weeks gestation and within 72 hours postpartum as
well as any time there is maternal trauma. RhoGAM is not effective once sensitization has occurred.

Infertility and Sterility

Infertility: inability on the part of couple to conceive after consistent attempt for 1-year period
Primary: never been pregnant
Secondary: pregnant once, then unable to conceive or carry again

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Test for infertility
 Basal body temperature and cervical mucus
 Hormone analysis
 Rubin test tubal patency
 For males: sperm analysis: Assess composition, volume, motility and agglutination

IUD complication PID

Surgical sterilization: bilateral ligation of tubes in females to prevent passage of ova (tubectomy)
Vasectomy: In the male to prevent, the passage of sperm, male must take additional measures for 6
weeks. USE EXTRA CONTRCEPTIVES

Menstrual disorder
Menarche: first period 11-14 years
Menopause: 52 years
Dysmenorrhea: painful periods, or menstrual cramps, is pain during menstruation. Its usual onset
occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is
usually in the pelvis or lower abdomen; due to high levels of prostaglandins found in the menstrual flow
Amenorrhea: absence of menstruation; causes: endocrine issues, rapid weight gain, strenuous exercise,
Menorrhagia: excessive menstrual flow.
Metrorrrhegia: inter cyclic bleeding

Endometriosis
 growth of endometrial cells in areas outside the uterus attached to the ovaries, colon and round ligaments
 Endometrial tissues react to the endocrine stimulation as in the intrauterine endometrium; causes pain,
inflammation and fibrosis

Risk Factors:
- Heavy menses > 7 days - Maternal inheritance - 3-10X risk if 1st
- Autoimmune disease degree maternal relative (mother or sister)
- Race has/had it
- Early menarche - Short menstrual cycle (<27 days)
S&S
-may be asymptomatic
-Dysmenorrhea (painful menstruation)
-Dyspareunia (painful vaginal penetration/sex)
-Dyschesia (painful bowel movements)
-Dysuria (painful urination)
- Also pain may be in form of : back pain, Acute abdomen pain, Intense premenstrual syndrome,
Bleeding, Menorrhagia, cyclic hematuria during menstruation, Infertility

Treatment: Oral contraceptive to minimize endometrial build up or medications to suppress

menstruation, pregnancy and lactation may also be recommended to suppress menstruation

Osteoporosis
Decrease in bone substance so the bone can no longer maintain the skeletal structure
Increase porosity of bones with increased incidence of spontaneous fracture
Causes:

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  low level of estrogen as it plays a part in absorption of calcium and the stimulation of
osteoclasts(which are new bone forming cells)
 other causes: inactivity, insufficient Ca intake or absorption, hyperparathyroidism, acromegaly,
cushing syndrome
S&S:
 backache, kyphosis, loss of height due to compression of vertebrae, pathological fractures
 major cause of hip fracture in elderly with subsequent mobility impairment, possible decrease in
self-care
Txt:
 HRT (hormonal replacement therapy)
 Calcium – 1 gm
 2-3 L of water to prevent formation of kidney stones
 regular exercises

Prevention of osteoporosis:
 no smoking
 Ca and Vitamin D
 Regular weight bearing exercises
 minimal use of exclusion of alcohol

Breast Cancer
- Most common neoplasm in women and leading cause of death in 40-44 years.
S&S:
- Palpation of lump is the first sign, - Skin of breast dimpled
common site is upper quadrant -asymmetry
- Nipple discharge -surgical biopsy: definitive diagnosis

Nursing Txt:
-assess breasts for early identification and treatment
-support client through recommended/chosen treatment
-prepare client for mastectomy if needed

Medical management
-Surgical excision; simple lobectomy
-simple mastectomy
-modified radical mastectomy

Nursing Txt. - post op

- elevate client’s arm on operative side on pillow to minimize edema and promote lymph drainage
-DO not use arm on affected side for blood pressure measurement IVs and injections
Position: Turn only to back and unaffected side-to-side
-monitor for bleeding; under the back
-begin ROM immediately on unaffected side
-start with simple movements on effected side; fingers and hand first
-teach client about any life style changes, BSE on remaining breast
-encourage/arrange visit from support group members

Cervical Cancer

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 -early sexual activities
-multiple sexual partners
-females exposed to DES in utero increase the risk of cervical cancer
-strong associated with HPV
S&S:
-back pain, leg pain, vaginal discharge, lengthening of menstrual period
Test: PAP smear is conclusive for cervical Ca.
Txt:
Gardasil – vaccine for prevention of genital warts; given between 9-26 years
Annual PAP smear for early detection of cervical cancer.
Confirmation: a cervical biopsy may be required to confirm or rule out cancer from suspicious cervical
tissue
Emotional Changes
Postpartum Blue Postpartum Depression Postpartum Psychosis
Anger, anxiety, cries easily, let- Anxiety, change in appetite, cries, difficulty Break with reality, confusion,
down feeling, fatigue, headache, making decisions, fatigue, guilty, irritable, lacks delirium, delusions,
insomnia, restless, sad energy, less responsive to baby, loss of pleasure in hallucinations, panic
normal
activities, suicidal thoughts

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