Maternal and Child Nursing

Maternal and Child Nursing
OVERVIEW OF THE REPRODUCTIVE SYSTEM 

FEMALE
Breast
 Dependent on the ovary for hormones Go forth and set the Wo
 During menopause  stop supply of hormones  prone to
cancer
Mons Pubis
Labia
 Serves as a covering
 Majora and minora
 Minora - has erectile tissues (clitoris)
- Clitoris
 Anterior
 Basis for catheterization
 Avoid touching the clitoris when inserting the
catheter – may cause convulsion in
precclamptic patients
- Fourchette
 Posterior of minora
 Stretch during delivery napupunit
 Ritgen’s Maneuver
o Perineal support
o Protect the are from overstretching
 Episiotomy
o Prevents laceration
o Cut during peak of contraction  all the
muscles are pulled up and no muscles are
cut
o Should have anesthesia
o How many strong contractions before
episiotomy: 3
o Mediolateral- hindi mag eextend to anus
but many layers of tissues are affected
(Most common incision made)
o Median- used for immediate delivery, may
extend to anus
- Vestibule
o Triangle
o Two important openings- 2 (urethra
and vagina)
o All openings- 6
Urethra
 Urethral canal is very short  at risk for infection
o 8-10 glasses of fluid / 50% should be plain water
 UTI- increase fluids because no matter how much you do
perineal care, the proximity of the urethra to still
predisposes it to infection
*Because of hormone change, pregnant is more at risk for infection

 progesterone  decreased renal threshold of sugar  small
amount leak out  sugar in vagina is good medium for bacterial
growth
Vagina
 Discharge: Fleshy smelling (Normal: 6-8 soaked napkin =
30ml of blood)
 More than 2000ml = shock
 Organ for copulation
 During birth passage no ruggae (less resistance)
for easier passage of the baby
 Has ruggae (folds of muscles) which allow to stretch
 Kegel’s exercise- to promote formation of ruggae
o Pubo-coccygeal muscle
o Contract the muscle to hold the urine, then
release the muscle
o Done as much as she wants
Hymen
 Pag nastretch ang vagina, stretch din ang hymen
MCN
Imperforate  Cervical dilation- indication that the woman has started
o May lead to labor
Pseudoamenorrhea/Cryptome
norrhea
o Management is surgery; put to sleep to
prevent damage to vagina
 Rigid
o Problem with intercourse
o Management is surgery
 Carunculae Myrtiformes - remnants of hymen after tearing
Doderlein’s bacillus
 Normal flora
 Bacteria that protects the woman from bacterial
infection
 Makes vagina acidic
 Candida albicans (candidiasis) (moniliasis)- most
common infection in the woman
o Yeast infection
o Color (#1 assessment) - Yellowish creamy color
o Consistency of discharge: thicker
o Smell: no smell
o Pruritus
o Vaginal suppository (MICONAZOLE, MONISTAT)
 Local effect only
 Best time to insert the vaginal
suppository: night time 
patient not upright  drug is
dissolved in vagina
 6 hours for drug to take effect
 Should report MORE
discharge; drug and infection
(only 1 day)
 Only needs a single dose
o Effect on Baby: infection on baby’s
MOUTH (Oral moniliasis)
 Trichomonas vaginalis
o SMELLY!!!!!!!!!
o Greenish grayish frothy
 Gonorrheal
o Effect on baby: eyes
 Chlamydial
o Effect on baby: eyes
Cervical Mucus
 From cervical glands - Spinbarkeitt
 Endocervical gland in cervix
2 hormones that affects the cervix
 Estrogen
 Progesterone
Estrogen Progesterone
-Dilates the cervix -Closes the cervix
-Released before ovulation: -Released on the 16th day
14th day -Mucus is decreased in amount,
-Mucus is watery, sticky, cloudy
clear, stretchy -Spinnbarkheit: 3 cm
-Spinnbarkheit: 6-12 cm -Safe Period
-Unsafe period -Ph: 6
-13th day of the 28th -Hormone that protects the
day cycle baby
-For 3-5 days -Dec. progesterone (AP) =
-Ph: 8 Inc. oxytocin (PPG)
Operculum
 Mucus that plugs the cervix
 More discharge  formation of mucus plug
 Protects the baby from possible entry of infection
 “Show”- sign of cervical dilation
MCN
Uterus Baby suckes stimulation of prolactin and oxytocin
 Estrogen- thickens the muscle (hypertrophy)  Baby suckles  stimulation of
 Progesterone- relaxes the uterus, maintains the pregnancy anterior pituitary (estrogen and
 Upper Segment(Fundus) prolactin)
o most active segment of the uterus  Only 1 or the other can
o Muscles are found in all directions ”figure of 8” be released
o Upper central and posterior segment- best site  Estrogen stimulates ovulation so
for implantation of placenta during breastfeeding prolactin I
 Placenta previa- bigger placenta released instead of estrogen
o Placenta obstruct the passage way  Prolactin  increase production of milk,
o Bleeding from the placenta insulin antagonist
 Painless  Oxytocin  ejection of the milk,
 Last trimester uterine contraction, released during
 Lower Segment labor
o Passive segment  8 times of feeding
o Longitudinal muscles  6 times daytime
 During contraction, same shape of uterus (globular  2 times at night
shaped)  at 6 months, introduction of other
 Physiologic retraction ring (normal) foods to baby  decreased
o Imaginary line that separates the upper and breastfeeding  estrogen instead of
the lower segment of the uterus during labor prolactin released
o Not seen but palpable o Is there a difference between menstrual and
 Pathologic retraction ring (Bandle’s ring) lochial discharge?
o There is an overstretching of the uterus  *Menstrual blood: NEVER CLOTS
o Visible separation of the upper and lower  Color: SAME
segment of the uterus  Smell: SAME
o There is an obstruction of the  Amount: DIFFERENT (more on lochia)
baby’s passageway  Menstruation: 30-50 ml (max
 Distended bladder 80 ml)
 Make sure the patient voids  Lochia: difficult to estimate
every 2 hour intervals  #of days of menstrual flow: 2-6 days
 Straight catheter o Lochia
 Cephalo-pelvic disproportion  Rubra: 3 days
 Perimetrium  Actual bleeding
 Myometrium  Presence of clots: report
 Endometrium  Serosa: at least 1 week
o 1.5 cm thick due to influence of estrogen and  Alba: 3 weeks or more (3-5 weeks)
progesterone (supplied by the ovary) (release  Braxton Hicks
estrogen and progesterone simultaneously) o Started at 4 months
o During pregnancy  6 cm thick o Contractions more significant at 7th month
 Protective mechanism of the hormones o Decreasing level o progesterone at the last
to maintain the lining for the trimester  increase frequency of contraction
 DECIDUA- endometrium  Labor
during pregnancy o Decrease progesterone  release of oxytocin
 Estrogen and progesterone released at o Prostaglandin theory
the same time  Hormone release by the when the
 Hormones in the ovary are at body is stressed
rest, PLACENTA takes over supply  Acts on the muscles
of hormones  From the placenta, uterus, fetus
 3 months before the woman  Sudden increase in prostaglandin
starts menstruating again  Mefenamic acid- prostaglandin
 Decidua Basalis – where inhibiting drug
placenta is attached; E and  Take on the day before you
P maintain it menstruate or at the onset
o Zona basalis – of menstruation
remains when
decidua is shed; new o Uterine Stretch theory
endometrium for  When uterine is stretch to its max
next pregnancy capability and capacity, it will naturally
 Decidua Vera contract and expel its contents
 Decidua Capsularis  Natural protective capacity of
 Lochia – shedding of the deciduas the organ
 Alba and serosa are odorless o *Conditions will stretch early
 Menstruation – shedding of the lining  Twins (needs delivery; will deliver earlier)
o Breastfeeding 2 weeks earlier
 Form of birth control  polyhydramnios
 Only up to 6 months  macrosomic baby
 Suppress the activity of the ovary *Safe ang Sex even during pregnancy
  Safe up to 34th week of pregnancy
o Semen contains prostaglandin  increase
MCN
When you are a nurse, you know that everyday you touch a life, or a life will touch yours
prostaglandin  early onset of
labor
MCN
Fallopian Tube Bulbourethral gland (Couper’s)
 As long as fallopian tube is healthy, fertilized egg can pass  Stimulated only during sexual arousal
through  Cleans the urethra
 Isthmus Ejaculate
o Ligated in tubal ligation  2.5-5ml
o Estrogen – propel by rhythmic movements  at least 50,000,000/ml
o Progesterone – nourishment of the zygote  Low sperm count: less than 20,000,000/ml
 Ampulla  300,000,000 per ejaculate
o Fertilization- outer 3rd of the ampulla  Pre-ejaculation:
(distal portion)  Irregardless of number, only 1 sperm can get a
 Fibrae woman pregnant
 Cause of ectopic pregnancy  If sperm is mature, can enter the woman’s uterus
o Surgery from tubal ligation (most common 80 seconds!!!!
cause) (1% chance that it will recanalized)  Characteristic of the Sperm
o Pelvic inflammatory disease o Small head with long tail
o Recurrent UTI infections o Length of the tail is 10x the length of the head
 Development of the reproductibe organ- estrogen o Neck- gives energy to tail
o Transport of baby through the tub (average of 1 o Head- gives chromosomes
week) o Tail- propels the sperm
 Never earlier than 7 (7-10) o Unidirectional- paakyat!
o Rhythmic contraction of the fallopian tube
 Progesterone MENSTRUAL CYCLE
o Nourishment of the baby in the tube  the start of every cycle is the menstrual cycle
Ovary/Ovulation Hormones
 Primordial ova (at birth): 300,000-400,000  Hypothalamus: GnRh – stimulates APG
o Immature follicle  Anterior Pituitary Gland: FSH, LH
o Some die before they mature o FSH- stimulates development of graafian follicle
 By age 7: reduce to ½ in number o Leutenizing Hormone (LT) or Interstitial Cell
 Number that reach maturation: around 400 (200/day) Stimulating Hormone - stimulates ovulation
 Menarche: 9-17 years old and development of ovary
 Reproductive period: 35 years o The time the FSH stopped is the time of
 Menopause the sudden increase in LH
o Perimenopause  Ovary: Estrogen, Progesterone
 2-10 years before menopause; o Estradiol – from the ovary
hormone imbalance o Estriol – from the placenta
 34-60 years of age o Progestin – progesterone form ovary and
 Vasomotor instability, irregular periods, placenta
sleep trouble, irritability  Corpus luteum- 2 weeks
o Menopause  Albicans- dead corpus luteum
 End of menstruation/Cessation of  Corpus luteum degenerates  corpus albicans
menses decreased estrogen and progesterone (ischemic) 
 Possibility that 1 or 2 egg cells are still in shedding of endometrium  Bleeding (Menstrual) – start
the ovary; risk of having a baby with of the cycle
chromosomal defects  Low levels of E and P  stimulate hypothalamus: GnRh
o Post Menopause  stimulate anterior pituitary gland  release of FSH 
 1 year after menopause; very low stimulates the follicle to mature  Graafian Follicle
level of estrogen (increased ESTROGEN)  Endometrium Thickens
(Proliferative)
 Increased LH  Ovulation  Corpus luteum
progesterone  further thickens at endometrium, more
vascular  ready for implantation (Secretory)
MALE
Scrotum - protects the testes from temperature FSH LH
Penis - organ of copulation
Urethra Estrogen Progesterone
 Releases urine and semen
 Glans penis- with an angle so it could reach the posterior  Menstrual phase- degeneration of the endometrium
of the vagina  Ischemic phase- corpus albicans
Testes  Menopause
 Where sperm s produces o Fsh is forever increased
Epididymis  Effect of combined birth control pills on ovary
 Store house of sperms o Prevent ovulation
Vas Deferens  Menstruation
 Conduit between the epididymis and ejaculatory o Degeneration of corpus luteum
dock Seminal fluid with fructose  Activity of ovary during Pregnancy
Prostate gland o No ovulation
 Add volume of fluid  Best hormonal requirement for ovulation
 Makes sperm alkaline o Increased FSH and LH
 Suckling -> prolactin -> dec. estrogen
MCN
 Average mentstrual blood loss = 30-50ml  If one is pull down-
 Normal span = 21-28 days, at maximum 35 days unusual heaviness
 Oligomennorhea- prolonged intervals between menses  Put your hand on your waist and lean
 Polymenorrhea- short intervals between menses forward
 Metrorrhagia – intercyclic bleeding  Must point at the same
 Hypomenorrhea- scanty flow of bleeding, caused direction
by nutrient deficiency or hormonal imbalance  Palpate (person should raise the hand
 Hypermenorrhea/Menorrhea- excessive menstrual flow, at the back of the head
caused by endocrine imbalance, infection  Circular
 Primary Amennorhea  Tail method/Tail of Spencer
o Failure to begin to menstruate by 16 years of age (outer quadrant going to inner
o If absence of breast development or pubic quadrant)
hair, then consider Turner’s syndrome (female  Feel for any lumps
with only one X chromosome)  Squeeze the nipple between
o No development of secondary thumb and forefinger to observe for
sex characteristics any discharge; abn if w/ secretion
Menopause time
 Osteoporosis
o Estrogen
o Absorption of calcium
o Retention of calcium  decreased
in menopause
o Signs in Of Osteoporosis
 Dowager hump (kyphosis)
 Decrease in height
 More prone to spontaneous fractures
(wrist fracture common)
 Pelvic fracture- dangerous
 Weight is on the area of the
pelvis  bone unable to
support
o Management
 Walking devices
 Allendronate (Fosamax) – prevents
bone resorption
 Take in the morning
with plenty of water, 30
mins before eating
 Stay upright for 30 mins after
talking to avoid reflux and
other GI symptoms
 Calcitonin – allows calcium to go to
the bones
o Preventive Measures
 Increase calcium in diet
 1500-1800 mg/day
 Exercise using the bigger bones/ weight
bearing exercise
 Walking
 Stair climbing
 Dancing
 Avoid injurious activities
 Sports with bouncing
or jogging
 Bone Density Scan once a year
 Breast Cancer
o 1 out of 7,000,000
o Prolonging the life the woman if diagnosed early
 Breast Self-Exam
o Schedule: 1 week after menstruation
when estrogen can’t influence breast
tissue
o Menopause: breast self-exam at the same date
every month
o Breastfeeding: same date of each month
o Steps
 Face the mirror
 Raise both hands
 Should pull up at the same
MCN
 Mammogram
o Procedure to detect for any abnormal growth
o Starts at age 40-50 years; done every 2 years
o 51 and above: yearly
o Women of low risk category
o Women of high risk category
 From age 40, every year
 With family history of breast cancer
 Menopause after 50
 Nulliparous
 History of benign growth on
the breast (fibroadenoma)
 Heart Disease (atherosclerosis)

o 1 year after menopause  start to
increase cholesterol levels
o Peaks at 5 years
o Estrogen increases HDL decrease
estrogen at menopause  decrease
HDL  increase LDL
o Prevention:
 Diet - reduce intake of fatty foods
 Exercise
 Stress Reduction
 Lifestyle change
 Exercise
 Diet
 Pap Smear
o First papaniculao smear
o Age:21
o Earlier if sexually active (3 years after
the first sexual activity)
o Then annually until 3 consecutive negative Paps
 I – normal cells
 II – abnormal cells but not
malignant, suggests infection
 III – abnormal cells,
suggests malignancy,
do cervical biopsy
 IV – abnormal cells,
malignancy (no biopsy)

FAMILY PLANNING
 After intercourse, diaphragm should be in
place for 6 hours
 3 year spacing of children; mandated by WHO
Major Program Policies of the Philippine Family Planning Program

 Improvement of family welfare with the main
focus on women’s health, safe motherhood
and child survival
 Promotion of family solidarity and responsible parenthood
 Nurses as EDUCATOR and FACILITATOR
 How many methods: 6
MCN
Methods of Family Planning o Common side effect: vaginitis
1. Behavioral
o Coitus Reservatus - no sexual activity
o Coitus Withdrawal/Interruptus - with sexual
activity
 Sperm is not released inside
the woman’s body
 Not an accidental pregnancy 
unwanted
 Never taught
2. Natural Family Planning
- Principles:
o The human ovum is susceptible to
fertilization only for 18 to 24 hours
o The sperms deposited in the vagina are
capable of fertilizing the ovum for no more than
72 hours
o Present methods of determining ovulation are
not exact by about 48 hours
o Calendar Method
 Ogino-knaus formula
 Regular- same interval each time
 Subtract 12 from the number
of days of the menstrual cycle
to determine day ovulation
 Abstinence starts 5 days
before ovulation and lasts up
to 3 days after ovulation
 Important: 1st day of the
last menstrual cycle
 9 days of abstinence – Rule of
9’s
 Irregular- data of shortest cycle and
data of longest cycle; for 6 months
 Subtract 18 from the short
cycle and subtract 11 from
the long cycle
 13 days abstinence
 Answer of shortest to answer
on longest  abstinence
 While waiting for 6 months, she
can use other natural family
planning method
Menstrual interval
 Interval between the first day of menstruation from
the next menstrual cycle
o Basal Body Temperature
 Any route for temp
 Pre-ovulatory temperature is
low because of high estrogen
level
 Post-ovulatory temperature rise is
due to high progesterone level
 How many will you abstain from day
of change of temp: 3 days (egg
cell can survive for only 24 hours, 2
days leeway)
o Symptothermal Method
 Combination of mucus and
temp method
 More conclusive since it has 2
parameters
o Billings/Cervical Mucus Method
o Lactational Amennorhea Method
3. Chemical
o Use of spermicides
o Makes the vagina more acidic
MCN
 Woman is not capable of increase absorption
protecting the vaginal wall
o Delivery bases
 Cream,jelly
 Foam
 Film
 Suppositories – mostly used in the PH
 Foaming tablets
o Common chemical agents
 Nonoxynol-9 (N-9) – kills sperm,
virus, and bacteria
 menfegol
 benzalkonium chloride (BZK)
4. Local barrier
o Diaphragm
 Dome shaped; mustbe fitted by MD
 No protection from infection
 Inserted up to 2 hours before
intercourse and removed 6
hours after intercourse to kills
all sperms
 Should be fitted exactly
 Covers cervix and posterior portion
of the vagina
 Can be tilted during intercourse
 Spermicide should cover inner
portion, outer portion and rim of
the diaphragm
o Cervical Cap
 No protection from infection
 Harder to place but one size fits all
 The contraceptive sponge is
moistened well with water and
inserted into the vagina with the
concave portion positioned over
the cervix; may stick to the cervix
 Wash hands thoroughly
before inserting the cap
 Wear it while upright placing one
leg on a stool to feel the cervix
 24-48 hours- time you can keep it
 Longer than 48 hours 
develop infection  toxic
shock syndrome
 Might develop cervicitis
o Condom
 Made of latex - allergenic
o Female Condom
 30% effective
5. Hormonal (Anovulatory menstruation)

o Prevent pregnancy by inhibiting the
hypothalamus and anterior pituitary so
that ovulation does not occur
o Injectable
 Depo-provera
 Depo-medroxyprogesterone –
no estrogen, interfere with
insulin use; not given to
diabetics
 3 month injectable
contraceptive containing 150
mg of synthetic progestin
 Increase (excessive) thickness of
the endometrium
 Avoid massaging the area 
immediate absorption 
effectivity less than 3 months
 Don’t move site/arm –
MCN
 Slow gentle wrist motion-  Undiagnosed vaginal
prevent bubbles to give bleeding
complete dose prescribe  Thromboembolic disorders
 Cost effective; given every 3  Pregnancy – terratogenic
months; not readily reversible  Liver disease
 Mixed slowly  Coronary artery or
o Implant cerebrovascular disease
 Norplant; Non-absorbable  Heavy cigarette smoking –
 Synthetic progestin effect on vessels
 Implanted on the upper arm  Breastfeeding – suppress
 Should be felt but not seen INTRAUTERINE DEVICE (IUD) estrogen
 Suppresses ovulation for 5 years
 6 capsules of progestin are
inserted SQ in the woman’s upper
arm;
contraceptive effective lasts up to 5  Contains a lot of estrogen
years  Contraindications
 2 years- 98-99%
o Oral  Every year minus 1%
 Oral contraceptive pill; reversible

 Available in 21 and 28 day
preparation
 7 placebo- iron supplement
 Must be taken according to
the arrow
 1st day of menstruation- start intake
of pill (28 day prep)
 5th day of menstruation- start
of intake of pills (21 day prep)
 Take pill with food (after a
meal)- prevent gastric irritation
 Whatever time is convenient- best
time to take the pill
 If forgot to take the pill in the
morning- take pill now then take
pill the time she regularly takes it
the next day
 If she forgot the day before- take
double dose and continue
regular schedule
 2 days missed dose, double dose
today and tomorrow then return to
normal schedule
 3 days missed – stop taking and
start and new one and use another
method
 Side effect:
 Nausea
 Breast tenderness
 Weight gain- 5 lbs. every year
 Breakthrough bleeding
 Adverse effect:
 A- abdominal pain (severe),
due to hepatotoxicity
 C- chest pain (severe)
or shortness of breath
 H- headaches (severe)
 E- eye problems (blurred
vision, loss of vision), inc.
BP
 S- severe leg pain (calf
or thigh) DVT
 Mini pill
 Progestin only
 Morning after pill
 Patients who are raped
 Damage the development of
the ovum
MCN
 A n open
sm  Disrupts normal uterine 6. Surgical
all, environment; abnormal lining o Vasectomy
us  MD insert instrument to  Local infiltration > incision 
ual measure length of uterine separate vas deferens pull out 
ly cavity  tie  cut
fle insert IUD as he pulls applicator  A minor surgery
xib  String is cut  Scrotal area will be swollen within 2-
le  Inhibits implantation through: 3 days
ap o Local inflammatory  Can resume intercourse as soon as
pli response the inflammation subsides
an o Loal production of  Wear a condom (1 month)
ce prostaglandins a. 2-3 times per week
ins o Interfere with  Sperms are already produced
ert enzymatic and  2-20- ejaculations needed to
ed hormonal activity remove all ejaculation
int o Increase motility of
o ovum in fallopian
th tube
e  It immobilizes the sperms as
ut they pass through the uterus
eri  ABORTIFACIENT
ne  Tell patient to check
ca her string once a
vit week for the first
y month
 Inserted  CHECK HER String
only when once a week after
the insertion/once a
woman is month after
menstruati menstruation
ng  Inserted during menstruation
o T  If string not felt, go to doctor!
o  Progesterone-coated-
b changed every year
e  Copper T- every 10 years,
al spermicide
so
su *Pelvic Inflammatory disease
re  Complication of IUD for 10
th years
at  If woman with PID is still with
w IUD in place
o o Treat
m infecti
on
a
(anti
n micro
is bial)
n first
ot before
pr remov
e al of
g IUD
n  Danger Signs
a o P- period late or
nt skipped period
o O o A- abdominal pain
nl (severe)
y o I- increased
ti temperature, chills
m o N-
e noticeable
c vaginal
discharge;
er
foul-
vi smelling
x discharge
c o S- spotting, bleeding,
a heavy periods, clots
MCN
 After 1 month, get sperm count if  Positive pregnancy test, Goodell’s, ballotment,
negative  wait for another month Chadwick’s, Hegger’s, inc. abdominal sign, Braxton hicks
 get sperm count again contraction
 (-) (-)- OK na Positive
 3rd sperm count- 1 year  Diagnostic
after vasectomy  Fetal heart (low pitch) - funic soufflé (high pitch)
 Sperms that are newly developed  Fetal outline
and cannot be released is  Palpation of fetal parts by the examiner through Leopold’s
REABSORBED by the body maneuver
 64 days – production of new sperm
cells Estrogen Both Progesterone
 Vasodilating  Varicosity-  Constipation
o Ligation (BTL) effect: Hegar’s, weakening of  Vasoconstriction
 May equated to sterilization Chadwick’s vessels and effect
 Woman signs the consent but  Hormone that vasodilating  Salt losing
HUSBAND agrees to the procedure retains sodium; inc effects hormone
 Who should be present when MD blood volume  Hemorrhoids  Weakening of
discusses the procedure: BOTH  Inc. in T4:  Edema- primarily muscles
the couple gamma globulin estrogen but  Inc activity of
 After delivery- Best time to perform  Genital changes; later on ducts; secretary
because uterus is found in the growth of breasts, progesterone function
abdominal cavity hypertrophy of the (too much salt  Decreased clotting
 Easier to access the fallopian gums was lost  factors
tube  Skin changes- stimulation of  Weakens the
 Laparoscopic- introduction of air  stimulate RAAS-- > increase vessel walls
at risk for air embolism melanocyte sodium  Affects the mood;
 A 3 cm abdominal incision is  stimulating  Breast changes- neuroendocrine
made through which the tubes are hormone  primarily effect on
tied/cauterized/cut skin changes estrogen behavior
 Interval mini-lap – done  Decrease oProgesterone-
during the first 7 days of the peripheral changes in the
menstrual cycle vascular breast
 Post-partum mini-lap – done resistance
within the first 8 weeks after a
normal delivery Neither
*For DM patient  Waddling Gait-Relaxin- hormone from ovary
 Unsafe ang pills  affects insulin o In mobility of the joints, abnormal gait
 Use barrier of pregnancy
 Contraindicated to  Morning sickness- Hcg
o DVT
o Pregnant Gravida- pregnancy
o Thromboembolic disorders Para - delivered - must be considered viable- greater than 20 weeks
o Liver disease Term - 38 -40 weeks
o Coronary artery disease Preterm - 20-37 weeks
o Breastfeeding Abortion - below 20
 Don’t use pills that contain estrogen weeks Living - living as of
(depo-provera is OK) now
 Estrogen shuts down prolactin Multiple pregnancies – G,P,T counted as one, only in L is counted
o Heavy cigarette smoking Ectopic - counted in gravida and abortion
Stillbirth - Not counted in H
PREGNANCY Hmole - Counted in gravida not in
para GP TAL (6 DIGIT DISTRIBUTION)
Heartburn – pyrosis G TAL (5 DIGIT DISTRIBUTION)
Chloasma – face-mask of pregnancy Suspecting of pregnancy - considered as
Melasma – other parts – areola, linea nigra, axilla, groin pregnancy Segundi-2
Striae – Due to separation of underlying connective tissue Grand multi-5 and above
Striae gravidarum – dark
Striae albicantes – white Leopold’s Maneuver
Goodell’s sign – Cervical change  Systematic palpation of the pregnant women’s
abdomen to determine several data
Presumptive  Explain what you will do to the pregnant women
 Subjective data  To make sure that the results are accurate- tell the
 Patient complaints patient to void
 Leucorrhea, pica, pyrosis, morning sickness,  Position: Dorsal recumbent
quickening, urinary frequency, constipation  Draping Procedure: horizontal
Probable  Warm hands before palpation; Cold hands stimulate
 Objective uterine contraction
 When to do Leopold’s Maneuver: can be done at
5 months but best at 7-9 months
MCN
 L1
MCN
o Part of the fetus located at the fundus: cephalic o encapsularis
or breech  Placenta
 Soft angulated, nonballotable – o Protective barrier
buttocks  Cytotrophoblast and
 L  Hard, round, ballotable - head syncitiotrophoblast
2  Present
o Flat plain (back), nodular/irregular  Prevents crossing of
several masses (fetal parts) treponemapallidum
o Fetal lie/ Fetal back  nd
2 trimester- syncitiotrophoblast
o Longitudinal and transverse remains only
 Long axis of fetus and mother o Organ of the baby in utero
 L  Location of fetal heart  Normal temperature of baby in utero:
3 25-28⁰C
o Engagement  Endocrine/Metabolic activities –
 If floating, not engaged provides hormones of pregnancy –
 If not floating and fixed, engaged E,P,Hcg, hPL (fetal growth
 L o Presentation: Head, buttocks, shoulder hormone)
4  Transport function – nutrients,m stores
o Fetal habitus/Attitude – occiput is the indication iron for 6 months
of position  Endocrine function
 A relationship of the baby’s parts to  Immunologic – IgG from mother at
each other; degree of flexion 34 weeks (9 months, passive natural
 Flexion- normal attitude immunity, all diseases)
 Extension  Milk have IgA; protection
 Sincciput- head and from diarrheal diseases
hand presented  Protective barrier against harmful
o Position substances (drugs and microorganisms)
However, viruses may enter
 Face the foot part  place her fingers 2 inches above  Placental portion
the inguinal are  glide downward  find the occiput o Vera
 Nonballotable mass- buttocks
Pregnancy
Fertilization
 Union of a matured ovum and sperm
 Each gamete has a haploid number of chromosomes
 The sperm carries and X or Y sex chromosome
 22 pairs- autosomes
o Genotype – genetic material
o Phenotype – physical trait
 1 pair- sex chromosomes; determinant of sex
o XXY – Klinefelter’s Syntrome; male and female
o XO – Turner’s Syndrome – no development
of female sex characeristics
 Zygote- outcome of fertilization
 Father determines sex of the child
 Fertilization- sex of the baby is determined
 2nd month or 8th week- formation of genitals
 12th week- differentiated
 (4th month) After 12th week- ultrasound to establish
the baby’s sex
 Y sperm - Move really fast but die fast
 X sperm - Slow but sure
 Zygote mitosis blastomeremorula (round, mulberry
in shape, found at the end of the fallopian tube) 
enters the uterus  blastocyst  (ready to implant) 
inner and outer portion
o Embryoblast
 Inner
 Fetal portion
o Trophoblast
 Outer will become placenta and fetal
membranes
 Amnion- fetal membrane
 Chorion- placental portion
 Decidua
o Basalis
 Basalis
MCN
 Give only tetanus toxoid
 Oxygenation
 Excretory organ
 Wastes by baby excreted by
maternal liver and kidney
 Umbilical arteries – waste
products
 Umbilical vein – oxygenated blood
o Result of the union of the chorion and the
decidua basalis
o Chorion - source of the primary villi
o Chorion chorionic villi  release enzymes  attach
to maternal vessel and get blood  blood goes to
space called lacunae (blood lake)  several lacunae
will form  cotyledon  more cotyledon will form
placenta (15-20 cotyledons)
o 1 week after fertilization (after implantation)-
Start of placental formation
o 3rd week- circulation starts
o 3rd lunar month- complete its formation
o Grows until 20 weeks covering about ½ of the
internal surface of the uterus
o Corpus luteum
 Kept alive by hCG
 Maintain the endometrium to nourish the
baby
o HCG will rise up to the 3rd month
 Prevents involution of the corpus luteum
 Basis for pregnancy tests
 Present in maternal blood 8-10 days after
fertilization (as soon as implantation
occurs)
 Level doubles every 2 days
 Nauseated  morning sickness
 3rd month, placenta takes over E and P
 decrease hCG  degeneration of
corpus luteum; morning sickness subsides
MCN
 Hyperemesis Gravidarum  Cord Prolapse
o Excessive vomiting beyond 1st trimester o Concealed – inside the vagina; elevate the hip
o Can be seen in H-mole o Apparent – outside the vagina
o Pernicious vomiting – interferes with eating o Baby is not yet engaged
 Vomits without food intake o Gold Standard Answer: CHECK THE FETAL HEART
 Metabolic alkalosis o Ask mother to lie down  check baby’s
 Ectopic Pregnancy heart rate
o Level of hCG will not increase above 3 months o Insert a gloved finger into the mother’s vagina
o Management: to check for cord prolapse
 Methotrexate- stop development of o Position mother to knee chest
cells o Trendelenburg is not advisable  compression of
 Completed if hCG levels will decrease diaphragm
 Abortion o Left side lying- put pillows on the hip to elevate it
o Normal hCG then it dropped – assessed through o Apparent
serum hCG  Never reposition the cord 
 H-mole compressed more
o Fertilization of an empty ovum  Make sure cord will not shrink
o Only placental portion is forming (chorion)  Cover with sterile gauze with warm
o No amnion NSS to vasodilate and prevent
o Human Chorionic Gonadotropin atrophy
 Establish pregnancy through urine  Continuous irrigation
o 7th or 8th week- presence of gestational without  CS- only means of delivery
a baby o Emergency Situation
o Ultrasound at 1st trimester  A clean cloth is OK
 Pregnancy testing
o She missed her period today, when can she take Amniotic Sac and Amniotic Fluid
the test: TODAY  Functions
o Done in the morning o Cushions fetus against mechanical injury
o First void o Maintains a steady temperature in utero (most
o Midstream collection important)
o Done again a week later if negative at first o Allows freedom of movement -> change in
 IgG- 2 weeks before delivery passed to baby position of fetus -> musculoskeletal
 Heparin- safe for pregnancy development
o Cannot cross placenta  16-18- multipara
 Coumadin- can cross placenta  18-20- primipara
 Anything that happens to the placenta facts the baby o Prevents drying of skin
 You save the placenta until the MD orders it to be o Permits symmetrical growth of the baby
disposed o Prevents adherence to the amnion of the fetus
o Source of oral fluid for fetus; of 1000ml, 400 will
Placental Aging Theory remain, 600 recycled
 When the placenta degenerates  stimulation of labor o Excretion – collection system
 Ultrasound- determines the placental age  Kidney’s start making urine around the 2nd-3rd month
 Continuously produced by amnion and fetal urine
o By the amount of calcification or amount of
are that is calcified  4th month- increased production because of fully
o Grade 3- fully matured placenta (38-40 weeks) matured kidneys
o Placenta premature degeneration o Quickening = enough amount of fluid
 Blood going to the placenta is  Primi – 5 months
decreased  placenta degenerates  Multi 4 months
o 42 weeks- maximum weeks the baby can stay at  98% H20 and 2% Salt
the placenta  800-1000 ml- normal volume of amniotic fluid
 600ml is recycled, 400ml remain
Umbilical Cord  7-7.25 – pH (alkaline)
 length of the cord is estimated to be the same length as
the baby  Oligohydramnios
 50-55cm (48-52 for Filipinos) o Less than 400 ml
 Short- might develop abruption placenta o Decreased urine production
 Long- at risk for cord coiling  1 kidney (anomaly); Very small kidneys
 Haase’s rule  Suggestive of Down’s syndrome
o 1-5 months = Month2  Polyhydramnios
o 6-10 months = Month x 5 o Greater than 2000 ml
 A-V-A o Decreased capability to
 Vein carries the 02 blood (placenta to baby) swallow (Tracheoesophageal
 Arteries (baby to placenta) atresia)
 Wharton’s Jelly o Diabetic frequently
o Fluid filled connective tissue to connect the o Multiple pregnancy
baby to the placenta  Color
o It has fluid to prevent compression of arteries o Slightly yellow in color, cloudy
and vein in the umbilical cord o Not deep yellow- bilirubin mixed in the fluid
 Erythroblastosis fetalis
MCN
 Xanthochromic – RH
incompatibility; yellow fluid
MCN
o Deep yellow – bilirubin staining – o Period of rapid growth
Rh Incompatibility
o Pink/Red wine color – abruption placenta
o Green tinged- meconium stained
 Needs suctioning to prevent aspiration
pneumonia
 May cause lung collapse
 Because of fetal distress (cephalic)
 CS- management
 Fluid is also swallowed by
the baby
 Suctioning
 Because of breech
presentation (normal)
 Abdomen descends 
increase pressure 
defecation of meconium
o Red wine - mixed with blood
 Abruptio placenta
 CS- management
 Nitrazine Test
o Lithmus paper test
o Blue- positive rupture of membrane
 Premature Rupture of Membrane
o No option to continue the pregnancy 
might lead to chorio-amnionitis
o Fatal
o Infection of mother and baby
o Leaking fluid from the vagina
o Management
 IV antibiotics
 CS
o Preterm premature rupture of membrane
 Not in labor yet + pre-term baby
 Early Rupture
o Membrane ruptured before transitional phase
o Latent period- 3cm dilation
o Active- 4-7 cm
o Transitional- 8-10m
o Cod Prolapse
o May cause Infection and caput succedanum
o Best time for rupture: during transitional labor
o Prolonged Labor
 Pressure exerted from the placenta
helps the cervix dilate
 Will cleanse the vaginal wall
o Dry Labor
 Amniotic fluid makes the vagina more
slippery
 Management: use KY jelly
o Nursing care:
 Check FHT – if abnormal = left side
lying position
 Rupture without prolapse = check
temperature frequently – q20
 Anticipate antibiotic treatment
and possible oxytocin
augmentation to enhance
contraction to decrease length of
labor.
 Ballottement
o Insert gloved fingers into the vagina  tap
the cervix  bouncing movement of baby
FETAL DEVELOPMENT
- Zygote – first 2 weeks
- Embryo – 3 to 8th week
o Period of organogenesis
- Fetus – after the 8th week until delivery
MCN
- Social drugs – cross addition; withdrawal  loses her teeth
symptom; get 1st urine sampling o Sources of calcium
- Smoking – SGA due to vasoconstriction  Dairy
- Thallidomide (antiemetic) – phocomelia  Green leafy vegetables
- Lithium, Streptomycin,Kanamycin – damage to  Fish bone (sardines)
8th cranial nerve: deafness  Egg yolk (2 eggs per week)
- Tetracycline – staining of permanent teeth of baby o End of the 3rd month: ideal time from UTZ
- Valium – can lead to cleft palate defect
Intrauterine development
 Pre-embryonic
o Ovum zygote embro
o 0-2nd week
 Embryonic
o 3-8th week
o Important period
 Organogenesis
 Fetal
o 8th week onward
 2 weeks- heart (beats on the 25th day)
 3 weeks- brain/CNS development (B9/folic Acid, glucose)
 2 months
o Separation of GI and respiratory tract
o Sex organ develops
o Meconium in the intestine
o Respiratory structure are not yet formed
 Rubella- most dangerous
o Can damage structures of the baby
developing at that time
o Underdeveloped structures
(microcephaly, glaucoma, cataract,
defect in 8th cranial nerve, mental
retardation)
o 1-3 months- 60% chance of damage
o 4th month- 10% chance
 5th month- no chance of
harming the baby
o Vaccine NOT safe to be
given  give
GAMMAGLOBULIN
o After deliverycan have vaccine
 Cannot get pregnant for 3 months
 Chicken Pox
o Women in the first 7 months of
pregnancy have a very high immunity
for chicken pox
o After the 7th month (last trimester) 
at risk for chicken pox
o If with chicken pox during delivery,
after delivering the baby separate
first mother and baby to prevent
transmission
o Can have chicken pox vaccine after
delivery but cant get pregnant for 1
month
 3rd month (fetal period)

o Growth in size and weight
o Sex is well differentiated
o Ossification- bone formation and development
 Increase intake of calcium
 800 mg (2 servings) – 2 glasses of milk +
400 mg for the baby
 If decreased calcium intake 
baby will get calcium from
mother’s bones  decreased
bone integrity of the mother
MCN
 Genetic testing (early part of pregnancy)
 4th month  Hemolytic Diseases (middle)
o Amniotic fluid is recycled as urine  Pulmonary Maturity (late) – L:S ratio
o Quickening  Sex
o Vernix/Lanugo o Alpha-feto protein (early)
o Can do amniocentesis  Enzyme only elevated when there is a
break in the neural tube
 Spina bifida
 5th month
 Elevated- Spina bifida (neural tube
o Fetal heart rate
defect)
 Can be heard as early as 3 months
 Very low- Down syndrome
(Doppler)
 Can get from maternal serum
 4th month (fetoscope) (maternal serum alpha-feto protein)
 4-5th month (steth)  Good result but not
 120-160 bpm conclusive
o Quickening (Primi: 18-20 weeks; multi: 16-  Only a screening test
18 weeks)  From amniotic fluid = direct result,
o Ballottement done if maternal AFP shows abnormal
values.
 6 month  98% percent tested positive result but
o Regular sleep wake cycle only 1% is with defect
 Neurological functioning has began o Hemolytic Disease
 20 hours a day  Color of amniotic fluid
 Awake- at night (hungry); at morning o Pulmonary Maturity (organ maturity)
when mother eats (30 minutes;  Check baby’s lung maturity and kidney
increase supply of glucose to baby) function
 Fetal movement count  High level of creatinine- kidneys
 First movement is the start of are functioning
the time  High level of bilirubin- liver problems
 10-12 movements/hour o Done first with ultrasound: FULL BLADDER
(Cardiff Protocol) o Amniocentesis: EMPTY BLADDER
 Must eat first before counting o MOST IMPORTANT: Check signed consent
 Empower mother to know the o What will the nurse prepare before
condition of the baby amniocentesis: ultrasound
 Less than 4 movements in 24 o Abdominal- full bladder (more common) 1 ½-2
hours- danger sign; do glasses of water
biophysical scoring o Vaginal ultrasound- empty bladder
o Non Stress Test o After obtaining ultrasound  empty bladder to
o Ultrasound facilitate amniocentesis
o Vernix caseosa – for temp regulation o Sterilize area  use sterile needle
 7th month o Use local infiltration
o alveoli opens (surfactants are present) – start o 5-10ml is aspirated
of lung maturity o Aspirate; should not be exposed to direct light
o No surfactant o Area of puncture should have adhesive
o Fat deposits under the skin o Position on her back but not flat (semi-fowlers)
o Weight is doubled  Pillow on right side – Right lateral tilt
o Red and plethoric  Because uterus could go to
 8th month the left and cause vena cava
compression
AOG L/S Ratio Lung Maturity o BP and FHT q30
26-27 Secretion into alveolar Viability o Normal side effect
wks space begins attained  Slight leaking of fluid in the area
30-32 1:2:1 of puncture
wks  Baby moves more frequently than
35 wks 2:1 Maturity normal
o Phosphatidyl glycerol attained  Slightly increase in fetal heart rate
 Phospholipid only noted when the fetal  BP of mother slightly increased
lungs are mature (most important and  For 2 hours only
best indicator)  Greater than 2 hours- admit
 Amniocentesis to hospital
o Test to establish lung maturity and maturity of o Abnormal Side effect:
other organs  Leaking fluid from the vagina 
o Not a routine procedure – performed on premature rupture of membrane; early
2nd trimester labor – check for pH (REFER)
o Invasive, needs written consent, UTZ guided.  Abortion 1;200 (early)
o Can lead to possible abortion  Early labor (late)
o Gives information on fetal:
MCN
Determining EDC o Pre-colostrum
- If known LMP, use Nagel’s Rule = -3 +7 +1  Present at 4th month (16th week)
- If not known, use Bartholomew’s Rule – abdomen  Not the real milk but a precursor of milk
is divided into quadrants  Yellow
- McDonald’s Rule – get the fundic height (cm) x 8/7 = AOG  How many days will it take to empty
in weeks the breast of colostrum: at least 3 days
- Kung ano yung sa situation, yun yung AOG. for multipara
- DO not get the lower number  Up to 5 days for primipara
o Immediately after delivery  put the baby
Johnson’s Rule – Fh (cm) – n x 155 = g. on the breast (without airway obstruction)
- N = 11 – if the part is not engaged o CS- slightly delayed breastfeeding (4 hours
- N = 12 – if the part is engaged after pa pwede)
o Wear bra support
Maternal Changes during Pregnancy  Strap supports
 Head o Nursing Bra
o Hair- grows faster and longer  Thick strap
 Stimulated by estrogen  With opening for easier breastfeeding
 Old hair that is growing fast  Abdomen
 6 months postpartum- lose old hair o Darkening of the LiniaNigra
 Don’t use hair treatments  goes to o Abdominal Striae (stretch marks)
the baby  Gravidarum- dark brown
 Chloasma  Albicantes- whitish
o Bony prominences exposed to the sun  Postpartum
o Mask of pregnancy o Diastasis Recti Abdominis
o Freckles  Overstretching of the rectus abdominis
o Dark people - darker areas are on the creases muscle
o Only temporary  Abdominal exercise up to 5 months
 Melasma  Beyond 4 months- left side lying position
o Other parts darkens o Bartholomew’s rule of 4
o Not noticeable in multipara  Determine age gestation fundic height
 Nose  5 months- umbilicus
o Nasal congestion  Lightening- lowering of the uterus
 Increased vascularity  Engagement- lowering of the head
 At risk for epistaxis, advise to open of the baby
mouth o McDonald’s rule
 Gums  Using tape measure to get fundic
o Hypertrophied height in cm x 8 / 7
 Use soft-bristled toothbrush  = AOG in weeks
o Advise to check-up with dentist  Yung given na cm, malapit dun
o At risk for losing teeth  can never have yung aog
tooth extraction because of anesthesia  Usually higher
o Pagnatanggalanng teeth strep might go o LMP
inside gums teratogenic  Jan-march
o Increased salivation  G
 Chew fruits  April-Dec
 More acidic  -3 +7 +1
 Tooth erosion  Vagina
 Frequent use of mouth o Mucus plug- operculum
 Decrease bacteria in o Less acidic- more prone to infection
the mouth  Legs
o Edema
 Pica  Poor venous return (too much
o Craving for nonfood or nonnourishing food pressure on the lower part of the
o Decreased nutrition for the baby body)
o Provide protein to the diet  Low salt diet
o Treatment for anemia  Management:
o Nonfood  Elevate- up to 3 pillows
 Clay  Edema on nondependent areas
 Charcoal is abnormal
 Toothpaste  Lower lid and fingers (+3)
o Chemical mother ingest can be dangerous o Weight gain
for the baby  1-3 months- 1 lb. per month
o Refer to psych
 4th month and above- 1 lb per week
 Filipino: up to 12 kgs or 25 lbs
o Varicosity
 Breast gland of the breast
o Enlarges
 Estrogen stimulates ductile structures
 Progesterone stimulates secretory
MCN
 Due to weakening of the blood vessels and
vasodilation
 Pressure of the uterus
 Avoid prolonged sitting or standing
 Elevate with pillows (up to 2)
MCN
o Vulvar varicosity  Exercise:
 Put pillow on hips to elevate  Whatever she did before is safe
 To decease risk of rupture  except contact sports
put sanitary pad (at least 1
layer)
o Sexual Activity
 Safe during pregnancy
 Don’t do nipple stimulation during
foreplay  stimulation of oxytocin
 No oral-genital stimulation (not to blow
air inside the vagina) pressure is
introduced  can rupture and open
up the vessel  air embolism
 No douching  air embolism
o Cramps
 Calcium-phosphorus imbalance
 Lightening and engagement pressure
on the sciatic nerve  cramps
 No prevention
 Just stretch and dorsiflex
the foot
 No massage (might dislodge thrombus)
 Stretch and dorsiflex the foot (safest)
 Place warm compress only if there is
no varicosity
 Scenario: foot is on the stirrups 
cramps  take the leg off the
stirrups then dorsiflex
 Scenario: crowning of the baby 
keep leg on the stirrups dorsiflex the
foot
o Relaxation of smooth vessel walls

causes increased tendency for
varicosities
 Stockings: best to prevent venous
dilation (but is not always the
answer, depends on the situation)
 Sit every 2 hours, stand up and walk
for 15 minutes
 Nutrition
o Pregnant: 1700, Additional 300 calories
o Breastfeeding: additional 500 cal, addt’l protein
SYSTEMIC EFFECTS OF PREGNANCY
Cardiovascular
 Sudden increase in blood volume
o 45-50% (plasma only) – because of increased
fetal demand
o Up 30% during 2nd trimester, and up 50% during
3rd trimester
 With iron treatment - Can increase cellular
component by 30%
 No iron treatment - 10%
 Iron treatment - 2nd trimester to prevent
deficiency in 3rd trimester
 Sources of iron: Organ meats, dark colored
preserved fruits (raisins), green leafy
vegetables
 Iron supplement
o Best taken with empty stomach
(acidic)
o With meals + foods high in
citric acid
 Prone to infection
 Easy fatigability, shortness of breath,
palpitation
MCN
 No weights greater than Propanolol
5lbs may cause valsalva o Any steroid is not safe during pregnancy!
maneuver  Prone to hyperventilation = deep breathing
 No sauna – o Blow through a brown bag or cupped hand
teratogenic if too  Nasal congestion
much heat  Difficulty of breathing
 Floor exercise such as
curl ups = side lying on
the left
 Pelvic rocking and tailor
sitting for backache
 NO CONTACT SPORTS
o Decreased hematocrit- physiologic or pseudoanemia
o Cardiac rate- increased by 10 beats per minute
o Increased WBC
 Slight elevation
 Not a significant sign
 Significant if accompanied
by other symptoms of
infection
 Increased coagulation
 BP decrease during the second trimester, return to
normal during the 3rd
o Vasodilation due to estrogen – PIH at 20-24 wks
o HR increases by 10 BPM on 2nd trimester
 Advised pregnant woman to wear seat belt, no
driving pag 7 months na
 Traveling by plane is not safe in the last trimester
 Boat rides not safe during 1st trimester
 Iron deficiency anemia:
o Mother provides baby’s requirements
o Baby stores Iron for 6 months
Uterus
 As uterus grows in size goes into the abdomen 
woman lying on back  uterus pushed to the right
side  pressure on vena cava uteroplacental
insufficiency  fetal heart (distressed)
 Shape changes from pear to oval shape
 Rises out of the pelvic cavity by the tenth week
 Non-pregnant uterus- needs 15 ml/min of blood
 Pregnant uterus- 500ml/min
 Upright- uterus will find a space in the abdomen
o Side sitting and side lying safe
 Raising right part paramatiltyug left 
prevent hypotension
 Angiotensin gene T235- will not allow you to
respond to estrogen normally (afro-americans)
Pregnancy-Induced Hypertension
 At risk for PIH:
o Old
o Smoker
o With T235 gene
 Test:
o Roll over position
 One on flat and one od side lying
 Get BP
 >20 diastolic – (+) hypertension
Respiratory System
 Inc CO2 level > effect of progesterone and fetal
waste – effect depends on patient
 TEATMENT OF CHOICE IN ASTHMATIC
PREGNANT: B- adrenergic agonist – Bricanyl
– same drug used in premature labor,
tocolytic
o Risk for arrhythmia – use beta blocker;
MCN
Renal System  N/V
 Pressure on the bladder (first and third tri) >
 Inc renal perfusion > Increased glomerular filtration rate
> inc output (low specific gravity)
 Glucose threshold drops (due to progesterone)and more
glucose likely to be expelled thru kidneys thus will see an
increase in insulin demand after 24th week
 To check for GDM – use serum glucose because urine will
always have glucose during pregnancy
 Enlarging of the uterus add pressure to the bladder
o Frequency
 Beginning of pregnancy because
of pressure to the bladder
 Later during the lightening because of
the descend of the uterus
o Urgency
 If there is discomfort  possible UTI irritable bladder
syndrome  premature labor
 Aldosterone production increases
o Increase in sodium and fluid retention
 If with kidney failure
o Both can be used as long it is
consistently monitored because both are
at risk
 Urine sample is good within 2 hours
 Benedict’s test – for glucose in the urine – blue is
negative (-)
 Heat and Acetic acid test
o Get urine 2/3 full  heat
 If clear- ok
 If cloudy  put acetic acid
 If clear- possibly due to increased
protein intake the day before
 If cloudy  albumin determination
(24 hour urine collection)
Musculoskeletal
 Changes ion center of gravity as pregnancy progresses
 Lordosis - back pain – pride of pregnancy
 Prevent back pain
o Maintain postural alignment of the spine
 Sit on the floor (tailor sitting position)
(Indian sitting)
 If with back pain: Pelvic rocking position
 Cramping in calf from hypocalcemia or hypercalcemia
 Progressive softening of the cartilage
 Waddling Gait (inc mobility of pelvic joints) due to
RELAXIN form ovary
 Walking – assisted
 For back pain – do pelvic rocking exercises
 Shoes
o Any shoes that are low heeled
o Wedge
o Rubberized
 Can they use bath tub: yes
o Somebody should assist her in getting in and
out of the tub
o Should be rubberized
 1st trimester – no boat ride because of nausea/vomiting
 3rd trimester – no airplane since change in pressure may
sti contraction
 Safest: Automobile, must ambulate every 2 hours
for circulation for 15 mins
Neurological
 Pressure on the sciatic nerve in third trimester
o Cramps
Gastrointestinal
 Bleeding gums
MCN
 First trimester due to increased hcg labor and delivery
 Cravings/increased appetite  Ovaries secrete relaxin
 Smooth muscle relaxation o Increased flexibility of joints
(Progesterone) > decreased  Increased thyroid hormone, thyroxine (T4)
peristalsis o Increased BMR
 Heartburn or Pyrosis  Increased demand for insulin from pancreas
o Eat slowly (chew 10  Production of relaxin
times before
swallowing)
o Eat small frequent feedings
(especially in the last trimester)
o Avoid fats and spices
o Fiber should be cooked
o Can be given antacids
 Aluminum
magnesium
combination
 Prevent GI complaints
 Maalox - only antacid that
is lowest sodium
 Abdominal cramps
 Decreased peristalsis due to progesterone
o Gas constipation
o Heartburn
 Constipation and gas
o Never laxatives since it will
stimulate the uterus to contract
o No oil based preparation since it
hinders fat soluble vitamin
absorption
o Stool softeners are ok (Colace)
 Morning Sickness
o Phenomena only in the morning
 hCG
 Because of
Hypoglycemia (baby
used up all her glucose
 Eat crackers before
getting out of bed
 N/V (hyperemesis)
o Pernicious vomiting
 Vomiting that ffects food intake
 All throughout the day
 Met.Alkalosis
o Persistent vomiting
 Exceeds first trimester
o Starvation vomiting
 Met.acidosis
o Causes
 H-mole – remove the mole
 Psychological cause -
Level of maturity
should be assessed
 AGE IS
IMPORTAN
T FACTOR
o Cracker-water combination
 Give cracker, wait for an
hour, if ok, give sips of
water, the if ok repeat
every hour
o 2 days NPO 3rd day water-
cracker  soft diet  full diet
Endocrine
 Anterior pituitary gland:
o decreased FSH
o ncreased LSH
o Increased oxytocin secretion during
MCN
o Hormone that permits relaxation of hip joints  Late abortion- after 16 weeks AOG
in preparation for child birth o More dangerous
 PTU o Possible DIC
o low dose – safe during pregnancy  Spontaneous Abortion
o high dose – dwarfism and cretinism o Also known as miscarriage; 15-30% of
 Hyperthyroidism may lead to thyroid crisis abortion
and hypothyroidism may cause infertility.  Chromosomal abnormality
Psychosocial Task  Infection that damages organs of
 Maturational Crisis the baby
 Situational Crisis  Endocrine disturbance (Hyperthyroid)
 First Trimester  Trauma
o Period of ambivalence  Incompetent cervix – dilates
o TASK: Acceptance of pregnancy (assess w/o uterine contraction
maternal feelings, support)  Induced Abortion/Therapeutic
 Second Trimester o Performed to save the mother
o Acceptance and fantasy o Ectopic pregnancy
o Fantasy about the baby  Habitual Abortion - 3 consecutive times or more abortions
o Might have an ideal child in her head   Incomplete Abortion
might have a different child o Fetus is expelled
o o Placenta retained
o TASK: Fetal Embodiment (accepting the baby as o Management- D&C, suction curretage
separate from self  Complete Abortion
 Last Trimester o All products of conception expelled
o Fear of delivery o Mgt: methergine, antibiotic
o TASK: Preparing for child birth or fetal separation (pennicillins), pain meds (mefenamic)
 Introduce childbirth classes  Threatened Abortion
 Lamaze – psychoprophylaxis o Painless spotting with not effect on fetus
(conditioned response) o 2 weeks rest: Complete bed rest; soft
 Bradley – natural childbirth; diet given sedatives to prevent stimulus
husband coached; no medication; for contractions; sex resume after 2
oxytocin released through nipple weeks
stimulation  Missed Abortion
 Dick Read - hypnosis o Fetus dies in utero and is retained
 Fatherhood o No caesarean section
o Mittleiden- “to hatch” observes behaviors o Drugs to contract the uterus
and “taboos” associated with pregnancy o Laminaria – dried seaweed that is
o Couvade- means “suffering along” sterilized, absorb the fluids, expand and
 Psychosomatic symptoms felt by the painlessly expand, then given misoprostol
husband while the woman is free from (Cytotec) intravaginally and Oxytocin
the same (Pitocin) per IV
o D&C to remove the placenta
 Toddler
o Relay news of pregnancy when there are signs  Signs and Symptoms:
of pregnancy o Threatened Abortion- cervix is still closed
 School Age and Adolescent  Vaginal bleeding/spotting
o Relay the news as soon as pregnancy is  Painless
confirmed o Inevitable/ Imminent
 Fetus and clot expelled
High Risk Factors  Vaginal bleeding may be heavy, pain
- Age = 18 and below; 35 and above on abdominal area and radiates to
- Height = 4’10 the back
- Weight – less or more than 20% of ideal body weight  Contractions
- Parity = Primi; G5 above  Cervix dilated
- Nutrition deficiency: CHON deficiency  Management
- Low socioeconomic level o Complete bed rest
History o Soft diet: Prevent constipation  prevent
- Medical = DM, HPN, Heart disease straining
- Gyne: STI, infertility o Sedatives - stress can predispose
- Surgery: abdominal the abortion of baby
- OB: Bleeding, PIH o Admission in hospital only for
observation to observe for further
bleeding
BLEEDING COMPLICATIONS o Cerclage
 McDonald’s- temporary (12-14
First Trimester Second Trimester Third Trimester weeks) (NSD)
Ectopic H mole Placenta previa  Shirodkar-bar- permanent
Abortion Abruptio placenta  Purse String
 Delivery by CS
Abortion
MCN
 Loss of pregnancy before fetus is viable (<20 o D&C
weeks)  Safe all the tissue that passes out
 Early Abortion- before 16 weeks AOG for histopathology
MCN
 Might scar endometrium possible o May go to shock
placenta previa on the next o Manifestations
pregnancy  Cullen’s Sign
o Help cervix dilate (induction of Labor)
 Laminaria- seaweed introduced into side with ruptured
the cervix; will swell if absorbed
water cervical dilation
 Misoprostol (Cytotec)- prostaglandin
that increases blood supply to the
cervix (more dilatable)  softening of
the cervix
 Oxytocin (Pitocin/Syntocinon) -
contraction of uterus
 Dead baby can be expelled
 Placenta removed through D&C
 Possible DIC to mother
 Home Management
o Restriction at home for 2 weeks
o Can have sex after 2 weeks
o Can go back to work after 2 weeks
 50% of threatened abortions lose their babies
 Causes
o Genetic defect in the baby
o Endocrine factors
 Hyperthyroidism
 DM (rare)
o Infection
o Systemic disorders
o Psychological factors
 Medications can be terratogenic
o Incompetent cervix
 Can be managed surgically
 Dilates without uterine contraction
 Frequent dilation- D and C
 Habitual Abortion
 Complication: Missed Abortion - DIC
 Classical CS incision - forever CS
Medical Therapeutic for Spontaneous Abortion

1. Ultrasound
2. Bed rest
3. Intravenous fluids
4. Possible blood transfustions
5. D&C
6. RhoGAM given within 72 hours post-delivery,
post amniocentesis and after D&C
ECTOPIC PREGNANCY
 Pregnancy outside the uterus
 Sites
o Fallopian
 If in isthmus - more bloody (closer to
uterus); can be expelled vaginally
 70% tubal
 If in ampulla- chronic bleeding (more
dangerous)
 Acute – on the isthmus;
bleeding form rupture may go
to the uterus and manifest
outside
 Chronic – on the ampulla;
bleeding form rupture goes
back and goes to the cul-
de- sac (Cullen’s Sign)
o May compress
phrenic nerve;
shoulder pain upon
respiration; same
MCN
 Bluish discoloration  Risk Factors
in the umbilicus – o Extremes of age - very young and very old
hematoma because o Genetic - Asian women
of the bleeding o Low protein diet
underneath the
peritoneum
 Cul-de-sac mass
 Normally it is hollow
 Shoulder pain
 Referred pain
 Compression of the
phrenic nerve
 Side of implantation
 Unilateral, lower quadrant, on
and of colicky pain (not
ruptured), sharp one- sided
pain (rupture)
o Ovarian Ectopic
 Rhythmic contractions of the
fallopian tube pushes the
zygote backward to the ovary
o Cervical Ectopic
 Hypermotility of the
zygote then implants
itself in the cervix - IUD
 Cervix has low blood supply
 cannot fully nourish the
baby
 Remove the portion of with
the fetus then cerclage is
done
o Abdominal
 Laparotomy done to get the baby
 Placenta is retained in the
attached organ
 Will naturally degenerated
 Medical Treatment for Ectopic Pregnancy
o Administration of methotrexate IM
(prevent multiplication)
o Surgical treatment –
salphingostomy via laparoscope
 Risk Factors:
o History of PID
o IUD
o Abnormal tube
o Endometriosis
 Abnormal thickening of
the endometrium due
to hormonal imbalance
 Estrogen
 Management-
androgen (male
hormones)
 Can damage the liver
 Given Depo-provera
 40% of young women are at risk
HYATIDIFORM MOLE/MOLAR PREGNANCY

 Gestational trophoblastic disease -
proliferation of the trophoblasts (bigger than
age of gestation); no embryoblast
 Trophoblast > formation of amniotic fluid > elevated HCG
 Benign - precursor of choriocarcinoma (malignancy)
 Inc. FH, No FHT, hyperemesis, red or brownish
vaginal bleeding which may also include
vesicles (diagnostic!)
 Degeneration of the chorion into the fluid-filled
grape like chorionic epithelioma
 NO KNOWN CAUSE
MCN
o Use of Clomid – stimulate excretion of egg cell  Double set-up: NSD and CS
that is empty (fertility drug)  Complication
 Manifestations o NSD (marginal and low lying)
o Increase in fundic height
o Increased hCG
o Hyperemesis
o No fetal heart tones
o Red, brown vaginal discharge
o Ultrasound reveals mass without fetal skeleton
 Snowstorm pattern
 Management
o Suction evacuation of the mole
 hCG monitored after
o Curettage - if she still wants to become pregnant
 Labs drawn – serial hCG monitoring
(blood)
 CXR – to establish if metastasis is seen
 Birth control for minimum of one year
 If mole is cancerous – chemotherapy
(methotrexate)
o Hysterectomy
o Monitor level of hCG for 1 year after surgery
o Teach the patient to delay pregnancy for 1
year
o Follow up for choriocarcinoma
o Provide emotional support
o Methotrexate- drug of choice
for choriocarcinoma
 Since it is folic acid antagonist,
free from folic acid diet since it will
neutralize the effect
o Chest x-ray
 To determine if there was metastasis
to another area
 Lungs- most lymphatic organ
o Use birth control (Combined birth control)
PLACENTA PREVIA
 Low lying placenta/ attachment in the lower uterine
segment
 Risk Factors
o Uterine abnormalities
o No invasive History of uterine surgery
 Causes:
o Unfavorable deciduas
o Multiparity
o Twins (dizygotic/fraternal) – different placenta
 kung sino unang kumapit, sya
yung nauna
 Manifestations: Painless, bright red bleeding from
the placenta, soft uterus
 Dx : Ultrasound
 Types
o Low lying - placenta is very near the cervix but
does not cover it
 May be NSD, may have minimal
bleeding, double set up when
bleeding occurs
o Marginal - 1 cm before you touch the placenta
o Partial – placenta covers 50% of the cervical ox
o Complete/Total - placenta covers the entire
cervical O
 Excessive bright red bleeding with no
pain, not in bleeding
 Directly CS
 Management
o No IE in suspected previa
o treatments
o Only through CS (partial and total)
MCN
o Bleeding because area of
attachment (lower part of uterus)
does not contract
ABRUPTIO PLACENTA
 Sudden complete/partial separation of a
normally implanted placenta after 20th
weeks AOG
 OBSTETRIC EMERGENCY
 Risk Factors
o HPN
o History of placental abruption
o Multipara
o Substance Abuse
 Types
o Partially or Completely Separate
o Concealed
 Separation at the middle
 More dangerous
 Blood will not b able to come
out  sink into muscles 
board-like rigidity (internal
bleeding)
 Shultz, Couveaire
o Apparent – separation from
marginal area where blood mixes
with amniotic fluid
 Assessment
o Sharp like abdominal pain
o Board-like abdominal pain (Couvelaire)
o Changes in the shape of the uterus
o Usually w/ vaginal bleeding - Dark red
(not fresh blood)
o Middle of pad- scant
o Fully saturated pad- 30 ml of blood
o 1/3 pad- 10 ml
o S/Sx of shock fetal distress (bradycardia)
o Assess abnormal coagulation
o 99% of babies die
 Management
o Position on modified trendelenburg Environment is the priority, Nursing Interventions must primary be dir
 Blood from the extremity will go
to more important organs
o Keep patient warm
 Cover her with several layers of sheets
o Monitor CVP
 Right pressure of the heart
 If increased- slow down the IVF to KVO
o Fluid volume deficit
 Priority nursing intervention
 Then altered perfusion
Previa Abruptio
Low implantation Sudden separation
Bright red With or without bleeding
Painless Painful
Soft uterus Couvelaire uterus
Emergency Implementation for Bleeding in Pregnancy

- Alert the health team to provide maximum
coordination of care
- Place woman on modified trendelenberg or left
side lying (minimal bleeding)
MCN
- Begin IV with a gauge 18-19 needle in anticipation of
blood infusion  Management
- NPO in anticipation of surgery o Mild
- Administer oxygen PRN at 2-4 L/min to provide adequate  Bed rest on left side
fetal oxygenation despite decreasing circulating  Diet alterations: High protein, low
volume of blood fat, low salt
- Assess blood loss (weigh pads), FHR, VS, I and O, Uterine  Normal CHO to avoid use of protein for
contractions energy
- Omit vaginal or rectal exam  Monitor fetal status – times two
- Order type and cross match 2 “U” whole blood to restore of normal visit
maternal circulating blood  Twice a week on the last
- Assist with placement of CVP (assess pressure of month
blood that goes to the heart) o Severe
Pulmonary wedge pressure (pressure that leaves the  Altered perfusion
heart)  Altered sensory and perceptual
o Rise in CVP – put to KVO function (priority) – promote quiet,
o Low in CVP – hasten delivery non- stimulating environment
- Set aside 5 ml of blood in a test tube and observe if it  Room of patient is 20 feet
will clot in 5 mins. If it did not clot, suspect DIC away from the nurses
- Maintain a positive attitude towards fetal outcome station
to maintain bonding  Limit visitors to visiting time
to promote rest and sleep
Stages of fetal Death  No TV and close eye work
 Macerated – Generalized softening of skin  High protein, low salt, low fat
 Mummification – death-like  Bed rest anticonvulsant medications
 Lithopedian – calficied bones  Fluid and electrolyte replacement
 Corticosteroids are given:
PREGNANCY INDUCED HYPERTENSION / TOXEMIA bethamethasone
 Anti HTN meds
PIH Chronic HPN
Seen on 20-24 weeks Seen before 20 weeks  Magnesium Sulfate (TL: 4-8 mg/dl)
Accompanying symptoms No proteinuria  Anticonvulsant
are hypertension, edema,  IM bolus, Buttocks, Deep IM, Z-
and proteinuria track
Eclampsia - convulsions No convulsions  Check DTR,RR, BP, FHR,
BP will be normal after BP will remain elevated I&O(released through the
6 weeks after 6 weeks kidneys; monitor I&O; maintain
30 ml before giving next dose)
 Noted in the second trimester before giving first dose
 Risk  Prepare calcium gluconate;
o Primipara - highest max of 8 hours
o Young and old  May be replaced by
o (+) HPN in hypertension Hydralazine (vasodilator)
o Low socioeconomic group  Potassium sparing (non-
o Low protein diet thiazine) because loss of
 Manifestation potassium can affect
o Edema – generalized anasarca the heart
o Proteinuria  12 gms- respiratory distress
o HTN  >12 gms- circulatory collapse
o Has convulsion  If IV- use soluset - over
 Corrected within 6 weeks after delivery a period of 20 minutes
 Cause is unknown; due to hormonal change  Stinging to the tissue -
 Stages lidocaine is added to
o Stage 1 (Pre-ecclampisia) decrease pain
 Magnesium sulfate first
Mild (Home before lidocaine
Severe (Hospitalized)
Management)
BP 140/90 BP 160/110 or above  Corticosteroids
Edema of finger and face Anasarca – third spacing  Stimulates Surfactant
edema production for the
Proteinuria +1 (<2g/day) – Proteinuria + 3 or 4 (more baby
less than 2 g of than 2g/day)  Given for possible
protein per liter preterm birth
Epigastric pain (aura)  Injection within 2 days
Visual disturbances – inc before birth
ICP  Betamethasone – better but
Altered sensory and expensive ( 2 injections)
perceptual function  Dexamethasone – cheaper
(4 doses)
MCN
 Epigastric Pain (aura for seizure) o Organomegaly – heart, liver
 Grand mal o Preterm delivery
 With loss of consciousness o Hypoglycemia – due to hyperinsulinism inside
 Tonic-clonic the mother
o Delivery: CS - Effect on mother
o Given epidural if NSD to anesthesize prevent o More prone to infection; UTI – sugar is increase
seizures in urine
o Greatest risk for convulsion o Greater incidence of PIH and eclampsia
 1st 24 hours after delivery because o Inc incidence of hydramnios
ECLAMPSIA of loss of fluid  increased BP to o Distocia – CS management
compensate for the fluid loss o Atony of uterus after delivery - hemorrhage
 Dx:
 Grand mal (generalized tonic clonic seizure w/ loss of o Macrosomia – wide shoulders, fractured clavicle
consciousness)
 Stages
o Invasion
 When VS is fluctuating, restless
o Aura (warning) – epigastric pain! (may signal
HELLPS – hemolysis, elevated liver enzymes (DIC),
decreased platelet)
 Protect the tongue
 Side-lying position (DO THIS FIRST!)
 Tongue depressor is NOT safe,
use mouth gag
 Tongue blade (rubber)
o Tonic-clonic / Contraction
 20 sec tonus (muscle contraction)
before clonus (alternate
contraction and relaxation)
 Prevent self-inflicted injuries: Time the
duration of seizure  to know how
much time brain lost oxygenation
 Lock jaw
 Prepare for safe environment; padded
side rails
 Do not restrain or stop
o Post-ictal
 Coma/Resuscitation
 Oxygen first before suction
 Reorient the client to prevent anxiety
which may cause another seizure
 Antianxiety medication (Valium)
*Status epilipticus – may cause death
 Nursing Care
o Mild preeclampsia
 Bed rest on the left side
 Diet alteration
 Monitor for fetal status
o Sever preeclampsia
 Bed rest
 Anticonvulsant medication
 Fluid and electrolyte replacement
 Corticosteroids are given:
bethamethasone to
increase surfactant
production
 antiHPN meds
o Mgt: Forceps assisted, analgesia to prevent
stimulation
GESTATIONAL DIABETES
- Human placental lactogen (HPL) – counteract effect
of insulin
- Estrogen and progesterone – antagonist of insulin
- Placental insulinase – enhances degradation of insulin
- Placental insufficiency – Maternal insulin utilization
- Effect on baby
MCN
Not diagnosed in the 1st trimester
o
Diagnosed in 2nd trimester- 5th month
o
o
OGTT (glucose challenge)
 Ability to use glucose in the body
 Get FBS – baseline; if
abnormal, patient is diabetic
 Intake of 50 gms of oral glucose
 Check blood glucose 1 hour after
 <7.8mmol, 140 mg/dl or less
7.8 mmol of less - normal
 >7.8, 140- abnormal
 If abnormal, ingest 100
gms of oral glucose
 Check blood glucose 3 times
for every hour
 2 positive- (+) for GDM
 Management
o Only INSULIN is given – 2nd trimester
 Later half of pregnancy
more insulin requirement
o No OHA
 Crosses placental barrier, teratogenic
 Further aggravate insulin
production in baby
o Insulin
 Last trimester (increased demand)
 Labor- will have insulin pump
 Postpartum- at risk for hypoglycemia
o Postpartum- 6 weeks, diabetes should resolve
 Diet: 6 meals- because of insulin to prevent

hypoglycemia
o 200 calories additional in GDM, in normal 300cal
 45- CHO
 35- protein - delays
absorption of glucose
 20- fat
 Eat a light meal before exercising
 Returns to pre-pregnancy state after 6 months
CARDIAC DISEASES IN PREGNANCY

 3rd trimester- risk of CHF
 Decreased blood to the baby  premature by
size and age
 If employed, advise to be shifted at day shift
best time to sleep at night  during sleeping,
increase growth hormones
Effects of Pregnancy on a Client with Cardiac Disease

 Cardiac output increases by 30-50% CR
increased by 10bmp
 Progesterone stimulates the respiratory center
causing dyspnea
 Increase blood volume may precipitate CHF
Classes
 Class 1
o Asymptomatic
o Rest between activities
MCN
 Class 2 RUBELLA
o Asymptomatic at rest - Congenital rubella syndrome
o Exertion produces symptom o Congenital cataract
o Rest between activities o Glaucoma
o 1 day complete bed rest per week o Microcephaly
 Allows the heart on day to recover o Mental retardation
o Last trimester- CBR o PDA
 Class 3 o Deafness – damage to 8th cranial nerve
o Less than ordinary activities produce symptom o IUGR
o Diet: minimal carb and protein intake, low - Vaccine not given in pregnancy
fat, low sodium - Greater than 1:8 – has antibodies to rubella; has immunity
 Class 4 - Give gamma globulin; not the vaccine
o Symptomatic even at rest
o X for pregnancy CYTOMEGALOVIRUS
o Candidates for ligation  Infection of the genital tract without symptoms
o Managed like 3rd classification  Infects baby’s brain and damage developing
o Delivery: forceps assisted bone structures
 Decompensation – Tachycardia – cardiac arrest  Fetal effects:
 Compensation - Bradycardia o Microcephaly
o Cerebral calcification
Effects of cardiac disease on pregnancy o Chorioretinitis
 LBW baby due to decrease placental perfusion o Hepatosplenomegaly – possible bleeding
 If taking anticoagulant could be teratogenic internally
 May cause premature labor and delivery  Neonatal period
o Early jauncie
Management o Hematemesis
 Digitalis o Melena
 Propanolol o Hematuria
 Spironolactone o Death
o Need potassium for heart contractility  Management
 Penicillin o Antiviral (Zovirax)
o Prophylaxis for upper respiratory tract infection  Not safe in early part of pregnancy
caused by GABHS sequela is rheumatic heart (teratogenic)
disease  Prevention
 Delivery: CS or NSD(epidural anesthesia) o Avoid having sex with a possible contaminated
o Best: forceps!! Like PIH partner
 Most critical time: 1st 24 hours o Have a monogamous relationship
o w/o for tachycardia
TORCH INFECTIONS HERPES

TOXOPLASMOSIS  Painful vesicles in the vulva and peri-anal area
 Caused by parasite/protozoa  Zoster - chickenplox
 Can be ingested - Infected meat of animals (not  Simplex
well cooked) o Herpes Simplex 1 - Oral
 From droppings of animals - Droppings of cat feces o Herpes Simplex 2 - Genital-dangerous for
 From unpasteurized milk baby (anal and genital)
 Fetal effects:  Resembles same lesion as syphilis (chancre-painless-
o Fetal hydrocephaly syphilis)
o Chorioretinitis  Cauliflower like lesion that is PAINFUL
o Cebrebral calcification  Has periods of remission and exacerbation
o May cause repeated abortion  Complications – shedding the virus: direct transmission
 Management of virus to baby
o Cook food very well  Management: CS delivery
o Antibiotics – Sulfa drug (terratogenic
effects noted after treatment is given) LABOR AND DELIVERY
o Abortion is an option
 Complication Labor - series of events whereby the products are expelled
o Can infect brain of mom and baby Powers of Labor
 Prevention - Primary power - uterine contrations (involuntary)
o Eat only well cooked meat, do not touch o Protaglandin cascade
cat litter o Oxytocin
o Progesterone deprivation
OTHERS o Uterine stretched theory
 Chickenpox - Secondary power – intra-abdominal pressure
 Hepatitis B o Needed in 2nd and 3rd stage of labor
o Transferred through placenta or breastfeeding
o Mommy can breastfeed because there are Early postpartum – 24 hours postpartum
immunoglobulins that can be given to Late postpartum – 6 months
baby before feeding
MCN
Factors that Affect  Brow (sinciput) - moderately
Labor Passage flexed head
 Pelvis (more important)  Face - exaggerated extension of
o Assessed through pelvimetry the head
o Hip bones (innominate bones)  Mentum – chin presentation
 Ilium, ischium and pubis, o Breech
coccyx, sacrum  Complete
o False Pelvis- where the uterus is  Flexed at thighs and flexed at
o Linea terminalis- separates false pelvis from true knees
pelvis  Squatting position
o True Pelvis  Buttocks and legs are
o Diagonal Conjugate presented
 DIstrance of anterior margin of  Difficult to deliver because it
the pubic to the sacrum (pelvic has 2 presenting parts
inlet) (compound presentation) -
 Widest anteroposterior diameter CS delivery
 11.5-12.5cm  Frank
o True Conjugate (Vera)  Flexed at the thighs and
 From lower margin of pubis to sacrum extended at the knees
 Less than 1.5 or 2 cm from the  Head cannot flex on its way
diagonal conjugate out  Mariceu’s Maneuver
o Ischial Diameter (bi-ischial/inter-tuberous) – attempt to flex the head
 Outlet (transverse diameter) in a breech delivery
 Always greater than 8 cm  Use of Piper’s forceps –
o Gynecoid forceps on the chin to flex
 Round-shaped; most ideal  Incomplete/Footling
 Wide antero-posterior diameter  Legs are extended
o Anthropoid  Single or Double footling
 Wide inlet, narrow outlet o Shoulder
 Allows vaginal delivery through forceps  Baby is on a transverse lie
o Platypelloid
 Oval o Persistent Occiput Posterior/ Back Labor
 Wide transverse, narrow AP diameter  Arrested after 45 degrees
 Wide inlet, narrow outlet  Position: side-lying
 CS delivery  Back rub/ sacral massage
o Android  Delivery position: side lying
 Pelvis that is narrow on all sides  Fetal Station – degree of descent on the ischial spine,
 We are all android before relationship of the presenting part to the level of the
 Bone of women thins  widens ischial spine
 Height less than 4”10 o (-) – floating
o Linea Terminalis o 0 – at the level of ischial spines
 Imaginary line that separates the o (+) – engaged
false from the true pelvis o +3 – crowning
o Cephalopelvic Disproportion  Seen at the vulva
 Baby’s head size is not in proportion o Primi – 1 hour per station
to the maternal pelvic size o Multigravida – 30 mins per station
 Soft tissues
The relationship between the passage and fetus
Passenger  Ischial Spine
 Size of the fetal head – presenting part  Stations
o AP diameter
o Occipitomentum- 13.5 Powers (Physiologic forces)
o Occipitofrontal- 12  Primary: Uterine Contraction - involuntary; contracts
o Suboccipitobragmatic- 9.5 due to
o Biparietal- 9 o Hormone release
o Bi-temporal- 8 o Uterine Stretch theory
o Bimastoid- 7  Secondary: Intra-abdominal Pressure – voluntary
o Small amount of pushing
 Fetal attitude/habitus - degree of flexion of a part o Done on second and third stage
 Fetal position – relation of the point of reference
(denominator) to the quadrants of the pelvic inlet, where Duration – start to end of contraction A-C
the occiput (cephalic), buttocks (breech), or shoulder Interval – space between two contraction C-D
blade(acromio) is facing Frequency – start to start of each contraction A-D
 Fetal lie – relationship of fetal long axis and long axis Intensity – hardness of the abdomen
of mother o Assessed using tocodynamometer
 Fetal presentation – part seen first the fetus that is lying in Frequency and duration increases are labor progresses
the inlet or at the cervical os Interval becomes shorter as labor progresses
o Cephalic
 Vertex (occiput) - well flexed head
MCN
Psychosocial Considerations Phases of First Stage
 Fear + Anxiety = Pain Latent Active Transition
o Reduce fear and anxiety 0-3 cm 4-7 8-10
o Gate Control Theory Intervals: 5-30 3-5 minutes 2-3 minutes
 Substantiagelatinosa minutes
 Open gate- pain Duration: 30 sec 45-60 60-80
 Close- no pain Calm, walking Irritable, Behavioral change,
o To close the gate: diversion/distract the mother Narcissistic may lose control
 Birth Center - relatives can be with the mother
 LDR Room - labor delivery recovery  Latent Phase
 Water Birth - Baby is a good swimmer  adjustment o Time when woman is most comfortable; not
is faster in pain
o Multipara- go to the hospital agad
o Primipara had lightening, after 2 weeks goes
Position into labor
- Described the relation of the point of reference o Multipara had lightening, labor the same day
(denominator) to the quadrants of the pelvic inlet
o Nsg Dx: Anxiety and knowledge deficit;
update her of the status
3 Reasons for Lithotomy Position o Interventions:
- Use forceps
 Upright position to make the baby
- Physician intends suture
descend faster, deep breathing
- Baby is in breech position exercise, clear liquid diet, BP q1,
FHT q30
Signs of True Labor vs. False 
1. Location – abdomen radiating to the back  Active Phase
2. Positional changes – intensifies the pain (if relieved o When the patient can’t handle the pain,
by walking, false) give pain meds
3. Rhythm – regular  Demerol (meperidine hydrochloride)
4. Cervix – dilated  Antidote: naloxone
o Phenergan- reduce secretion
STAGES OF LABOR AND DELIVERY  Potentiates the effect of Demerol
Stage 1: Cervical Dilation and Effacement  Get RR and FHR
 Begins with true labor and ends with cervical dilatation o Nsg Dx: Acute pain
and effacement o Interventions:
 Effacement first before dilation  Breathing: Pursed-lip
o Fully effaced- both internal and external os meet breathing/accelerated breathing
 Multipara- almost the same time for dilation and  Massage (effleurage) - light stroking
effacement of the abdomen
 Duration: 12-18 hours for primi; 6-8 hours for multi  Pain relief (Demerol, Nubain) – given
 Prolonged Labor at 5 to 6 cm
o Greater than 18 hours in a primi  Antidote: Narcan/Naloxone
o Greater than 12 hours in a multi  Change position
 Precipitate labor  Acupressure
o faster than 3 hours  Hoku acupressure point-
o danger of laceration and head injury improve contraction but
o May be given tocolytic (Bricanyl) can be not increase the pain
given for women who are: grand multi,  NPO with IVF
premature babies in good position, overuse of  Left side lying
oxytocin, large pelvis  Activity: None
 BR on her side
HYPOTONIC HYPERTONIC  FHT q 15, BP q30
Decreased intensity when Strong intensity at the start of
woman has entered labor (latent phase) o Fetal Monitoring
Active phase There 2 sources of contraction  Early deceleration (before acme)
Cervix will not dilate  head compression,
Cause fetal distress  no variability
At risk = multi At risk = primi  continue monitoring
Tx: oxytocin Tx: Morphine  Late deceleration
For every hour Causes respiratory distress  Uteroplacental insufficiency
oxytocin, there should -labor can progress  Fetal distress
be 1 cm cervical  Nsg care:
dilation Why not tocolytic?? Uterus o Turn off pitocin
might not contract o Side-lying
If not responding  CS o Start oxygen
o Call the
 Pacemaker- start of contraction doctor(anticipate
o Fundus CS)
 Oxytocin stress test
MCN
o As if woman is  Bonding
in labor o Claiming – identified features that are her’s
o 3x in 20 mins
o 45-60 seconds
o Reactive – NO
LATE
DECELERATION
 Variable deceleration
 Unstable flow of blood
to baby
 Cord compression due
to prolapse
 Beat to beat variability
 Nsg care:
o Stop pitocin
o Oxygen before CS
 Transition Phase
o Ready to give birth
o Primi = 1 hour; multi 10-15 mins
o Fear of losing control
o Accompanying symptoms of n/v, trembling of
legs, pressure on bladder and rectum,
circumoral pallor
o Nsg Dx: Fear of losing control
o Breathing: Panting and Blowing
o Stirrups
 Put legs on the stirrup at the same
time to prevent over stretching of
ligament, changing pressure inside the
uterus
 Adjust height of stirrup when she sits up
for bearing down
o 6 strokes in perineal prep – pubis, leg, leg, labia
,labia, center
 Use betadine, assess allergy to protein
o Intervention: help regain control, prepare
delivery
Stage 2 Fetal Stages

 Starts when cervix is fully dilated and effaced ends on
expulsion
 6 Cardinal Movements/ 7 Mechanisms of Fetal Movement
o *Engagement
o Descent
o Flexion
o Internal Rotation
o Extension
o External Rotation
o *Restitution
o Expulsion
 Best position: Where mother is comfortable
 Sterile drapes - 4 sterile drapes
 Instruments
o Needle holder
o Kelly straight clamp (2)
o Mayo Scissor (Not part of the basic set since it
is a sharp)
o Needles
 Cutting- pass through areas of great
resistance
 Round
o *Tissue forceps (not part of the basic set)
o Thumb forceps
o Sterile basin – receptacle for placenta
 Crowning- support lower part of the head (Ritgen’s
Maneuver)
 Put your finger between the neck to check of there is
cord coiling
 Deliver the body of the baby
MCN
o Identification – identifies features that cephalhematoma
are the baby’s
o Attachment
 Rooming - in to promote bonding
 For stillbirth and baby’s with defect
o Relay news immediately
o Tell mother the positive first then the negative
o Break it to me gently
 Cord Coil or Nuchal Cord

o Wait until pulsations stop
o First clamp 2cm from base (plastic)
o Second clamp 3cm away from the first (forcep)
o Third clamp 5cm away from the first (forcep)
o Cut as close to the edge of the plastic
clamp as possible
o Multiple coil – clamp and cut
o Single coil - loosen
Stage 3: Placental Delivery

- 5-30 mins
- Placental time (duration) - starts when fetus is
expelled and ends with placental expulsion
Signs of Separation
1. Uterus fundus rises in the abdomen and forms a
globular- shaped uterus (Calkin’s sign) – 1st sign
2. Sudden trickle or gush of blood
3. Umbilical cord lengthens
 After delivery, check the uterus if it is contract
 To stimulate contraction
o Massage the uterus
o Direct stimulation of the pacemaker
o After, ice
o Then ergot prep (methergine)
 Acts like an oxytocin
 Works in 15 minutes
 Increase in BP
 Brandt Andrew’s technique - remove placenta
 Crede’s Maneuver – remove placenta
with fundal push
Placenta accreta
- Deep attachment of the placenta to the
uterine myometrium
- Hysterectomy or treatment with methotrexate to
destroy the still-attached tissue may be
necessary
o Placenta increta – deep in the
myometrium; muscles of uterus
o Placenta percreta – in the perimetrium;
beyond the muscle
Battledore Placenta
- cord is marginally not centrally; no
problem with oxygenation; fragile
Forceps Delivery
- Two double crossed spoon like articulated
blades are used to assist in the delivery of the
fetal head
- Check neonate and mother after delivery for any
possible injury
- May have facial nerve damage, Bell’s Palsy
Vacuum Suction
- A cap-like suction device is applied to the
fetal heat to facilitate obstruction
- Assess for cerebral trauma and developing
MCN
Stage 4: Postpartum (involution)
 Critical 24 hours is called IMMEDIATE POSTPARTUM  In 10 days, uterus is not palpable
o Patient might bleed
 Lasts for about 6 weeks but may vary involution
 Puerperium
 Assessment in first 24 hours
o VS q15 minutes for the 1st hour
 Q30 for the 2nd and 3rd hour
 Q1 until 24 hours have passed or
until stable
o Change in BP- potential for bleeding (low)
o Check fundus ever 15 mins – check for
atony; massage intermittently
o Check the condition of the uterus every 15
 Atony is the common cause
of bleeding the first 24 hours
 Lacerations- if not atony
 Laceration of uterine artery
 Bleeding is bright red
 Comes out in spurts (with
pressure)
 Do immediate repair
 Laceration in Vagina
 Bright red bleeding
 Slow trickle
 Use pressure dressing
cherries insert catheter
 Cherries only for 24 hours-
prevent toxic shock syndrome
 Laceration in Perineum
 1st degree- skin
 2nd- all the way to the
perennial area (muscle)
 3rd- anal area
affected (external)
 4th- rectum included
 Late: retained
placental tissue;
puerperal sepsis
o Assess blood loss
 1000ml = normal for cesarean
 200-400ml = normal for NSD
 More than 500 = hemorrhage
 Causes in early postpartum:
atony, laceration
o Check bladder for distention – a distended
bladder pushes the uterus out of place which
may prevent contraction
 Uterus must be like at the level of 5
months pregnancy which is midway
between umbilicus and symphisis
BUBBLE-HE/8-Point Assessment Tool

 Breast
o 3rd day woman will start to release
milk (colostrum)
o Engorgement in 2-3 days in multipari; primi in 5
days
o First time – 7 mins max (primi)/ 12 mins max
(multi)
o Marmet’s technique - gently pull the nipple twice
if inverted nipple
o Football hold - benefits CS  no pressure
in abdomen
o Uterus decends 1-2cm fingerbreaths per day
MCN
 Uterus by 2015 Administrative Order 2008-0029
o Firm and contracted (DOH)
o Fundus - AO 2008-2009 – Implementing Health Reforms
 After birth, midway towards Rapid Reduction in Maternal and Neonatal
between the umbilicus Mortality
and pubis
 Fundus goes down by
1-2cm
(fingerbreadths) a
day
 About 1oth day, uterus is not
palpable anymore
 Bladder
o First 24 hours urine = 2500-3000ml
o May have dehydration; inc temp
 Bowel
o Give full meal even with IV
o IV is only for dehydration
o 2 days after delivery, resume of BM
 if not able to defecate
(constipation) laxative or
suppository
 Lochia
Type Color Duration Components

Rubra Red, fleshy 1-3 days Blood, fragments of
with clots deciduas, mucus
Seros Pink/brown, 7 days Blood, mucus,
a odorless invading leukocytes
Alba White,odorle 1-3 wks Largely mucus,
ss leukocyte count
high
 Episiotomy
o R – redness
o E- edema
o E – ecchymosis
o D – discharge
o A – approximation
o Needs order form MD, perineal prep,
must be 12 inches away
8Major sign of sepsis – low grade fever/chills
 Homan’s Sign
 Emotions
Reva Rubin’s Assessment
Taking in Taking hold Letting go

Mother’s Interests, shifts to infant Bursting out
needs and infant’s needs Socializing
predominate Post partum blues (they Back to work
I cannot do it, want babies, but they
you do it are afraid); less than 1
week
Post partum depression
– psychosis; more than 1
week
Dependent Independent Interdependent
1-2 days
Maternal and Child Care
- Millennium development deceleration in 2000

- Goals: reduce disease and poverty
MCN
- AO 2009-0025 – Adopting new policies and protocol on
essential newborn care Criteria for Lying in/ Home Delivery
- AO 2010-0001 – Policies and Guidelines for the - 18-35 years old
Philippine National Blood Services (PNBS) and the Blood - Full term, cephalic, NO CPD
Services Networks (BSN) - Growth appropriate for age
- AO 2010-0010 – Revised Policy on Micronutrient - Gravida 2-4
Supplementation to Support Achievement of 2015 MDG - No medical disorders for complications
Targets to Reduce Under-Five and Maternal Deaths and - Newborn Emergency Functions
Address Micronutrient Needs of Other Population Groups
- AO 2010-0014 – Administration of the saving drugs
and medicine by midwives to rapidly reduce Partograph
maternal and neonatal morbidity and mortality Important Instructions
- Birth registration
3 Levels of MNCHN Sense Delivery Network (SDN) - Importance of BF
- NB screening test
1. Community Level Providers - Cord care
- Outpatient clinics of RHU, BHS, private clinics - Post-partum visits
with health staff and volunteer health workers  1st visit – 1st week postpartum
- Tasks  2nd visit – 6 weeks postpartum
1. Navigation – health risks, access to 1. Newborn Resuscitation
critical health services and financing 2. Treatment of neonatal sepsis
resources 3. Oxygen support
2. Basic Service Delivery Functions – birth 4. Low birth weights of protein
spacing, family planning, counseling, 5. Other specialized newborn services
and other health issues - Can be private or public secondary or tertiary hospital
capable of performing CS and emergency NB care
2. BEmONC Capable Network of Facilities and Providers - Can serve high volume providers for IUD and VSC
(Basic Emergency Obstetric and Newborn Care) services (BTL and no scalpel vasectomy)
- Services - Ideally is less than 2 hours from the residence of
1. Parenteral antibiotics priority population or referring facility
2. Parenteral oxytocic drug
3. Parenteral anticonvulsant Breastfeeding Campaign
4. Removal or retained products - Breastfeeding: The 1st Step to Raising a
5. Manual removal of the placenta Child Unique Characteristics of Breastmilk
6. Assisted vaginal delivery – vacuum - B – best for baby
or forceps - R – reduced allergic reaction
- If the BEmONC is hospital based-blood - E – economical
transfusion services may or may not - A – always available
include collection and screening - S – safe
- Operates on 24 hours basis with skilled - T – temperature always right
health professional - F – fresh always
- 1:125,000 - E – emotional bonding
- E – easily established
3. CEmONC Capable Facility or Network Facilities – end - D – digestible
referral facilities - I – immunity
- Complicated deliveries and - N – nutritious
newborn emergencies - G – GIT disorder decreased
- OB function
1. 6 Basic Functions Under BEmONC Promoting Breastfeeding
2. Blood Banking and Transfusion - Laws
3. Cesarean Delivery o RA 7600 – Rooming-In and Breastfeeding Act
of 1992
All Pregnancies to be at risk o E.O. 51 – milk code
- OLD Approach – screening - Health Education
- NEW Approach – should all deliver with o Advantages for
assistance from skilled health breastfeeding Reflexes Involved in
professionals Breastfeeding
- Best intra-partum strategy – deliver in health - Prolactin reflex
center with midwives as the main providers - Letdown reflex
but not with others
Technique of Breastfeeding
Maternal Health Programs: Essential Health Packages Positions for Breastfeeding
A. Ante-natal Registration - Cradle hold (Madonna)
B. Tetanus Toxoid Immunization - Football hold
C. Micronutrient Supplementation - Side-lying
D. Treatment of diseases and other conditions
E. Clean and safe delivery
F. Support for breastfeeding
G. Family planning counseling
MCN

Maternal and Child Nursing

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Maternal and Child Nursing

OVERVIEW OF THE REPRODUCTIVE SYSTEM 

*Because of hormone change, pregnant is more at risk for infection

 Heart Disease (atherosclerosis)

Major Program Policies of the Philippine Family Planning Program

5. Hormonal (Anovulatory menstruation)

 Oral contraceptive pill; reversible

 3rd month (fetal period)

o Relaxation of smooth vessel walls

SYSTEMIC EFFECTS OF PREGNANCY

Medical Therapeutic for Spontaneous Abortion

HYATIDIFORM MOLE/MOLAR PREGNANCY

Emergency Implementation for Bleeding in Pregnancy

 Diet: 6 meals- because of insulin to prevent

CARDIAC DISEASES IN PREGNANCY

Effects of Pregnancy on a Client with Cardiac Disease

TORCH INFECTIONS HERPES

Stage 2 Fetal Stages

 Cord Coil or Nuchal Cord

Stage 3: Placental Delivery

BUBBLE-HE/8-Point Assessment Tool

Type Color Duration Components

Reva Rubin’s Assessment

Taking in Taking hold Letting go

Maternal and Child Care

- Millennium development deceleration in 2000

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