MCN DAY 2 (ANTEPARTUM) - Won’t move even with rhythm, and sound.

- Moves but can’t reach 15 bpm

Amniocentesis (2nd trimester)
- 15-18 weeks?
- Can be done as early as 9 weeks Nsg mgt.
- Solution for polyhydramnios - Left side lying position to prevent inferior
- Guided with ultrasound vena cava syndrome
- Monitor patient after procedure - Oxygenate mother
- Refer mother
Chorionic Villus Sampling
- 8-10 weeks of pregnancy Non- reactive, non-reassuring
- 1st trimester - Doctor validates if baby is really in distress
- Contraction stress test (oxytocin challenge
3 types of visualization test)
- Indirect - With oxytocin drip, do titration meaning you
o Gram or Graphy have no exact flow rate but you increase
 Ex chest x-ray the dose gradually until you get the desired
 CT scan contractions
- Direct - Uterine contraction DECREASES fetal
o Scope heart tone
 Fetoscopy - Early deceleration results to fetal head
 Colonoscopy compression during contraction is NORMAL
- Transformed and negative
o EEG, ECG - Continue to monitor the fetus and mother
- Late deceleration means Uteroplacental
Fetoscopy Insufficiency, need to intervene with left
- Determine fetus problems side lying, oxygenate, refer
- Variable deceleration means Umbilical Cord
2 types of surfactants Compression, need to intervene with
- Lecithin Trendelenburg or Knee Chest. If cord
- Sphingomyelin prolapse, cover the exposed cord with wet
2:1 ratio sterile gauze.
- If normal results, continue to monitor the
Procedures that concern assessment of fetal health mother every week until age of viability (20
weeks)
Electronic Fetal Monitoring
- Uterus must contract for 90 seconds only.
Non-Stress Test More than 90 and uterine rupture is
- Fetal monitoring to determine fetal heart possible.
tone
- N (-) R Reassuring (normal)
- When fetus moves, heart rate accelerates
up to 15 bpm for 15 seconds
- To wake up baby, use Vibroacoustic
Stimulation Test with high decibel sounds
place into the abdomen of the mother

Signs of fetal distress during stress test:

- P (+) non-Reassuring
 b. Uterus contracts

LABOR
- Series of events in which products of
conception are expelled from the uterus

Premonitory Signs of Labor

- Lightening/Engagement
Bio Physical Scoring/Bio Physical Profile - Increase in the level of activity
- Decrease in weight 3-4 lbs.; 1-2 days
5 Basic Criterion: before labor begins
1. Fetal breathing movement - Exaggerated Braxton Hicks contraction
2. Gross body movement
3. Fetal tone Characteristics of Uterine Contraction
4. Qualitative amniotic fluid - Involuntary
5. Non stress test - Intermittent
- Regular
PRN
- >Discomfort: Intensity; frequency and
- Placental Grading
duration
7-10 score no aggressive nursing management
Cervix
6 aggressive nursing management
Dilation 10 cm
4 emergency CS
Effacement 100%
Post-Consultation
Primigravida
1. Nutrition
- Dilates at 1.2cm per hour
2. Smoking
Multigravida
a. Baby is small for gestational age
3. Alcoholism - Dilates at 1.8cm per hour
a. 3 oz. or 90 mL a day can be
teratogenic for baby 4P’s of labor
b. Fetal Alcohol Syndrome - Power
c. Alters proper metabolism of - Passenger
nutrients causing mental - Passageway
retardation - Position
d. Acetaldehyde byproduct of alcohol
causing congenital anomalies Power
e. Alcohol is an empty calorie drink Primary Power- Involuntary
4. Clothing
a. Should be loose and light, black Theories
shoes 1. Biologic theory
5. Employment - Placenta degeneration theory (aging
6. Bathing placenta)
7. Exercises - Fetal development and fetal hormones – 9
a. Kegel’s mos.
b. Tailor sitting 2. Mechanical theory
c. Squatting - Uterine stretch – full organ will empty
d. Pelvic Rock - Uterine over distention – release
8. Travelling - Oxytocin
9. Sexual Positions 3. Hormonal theory
a. Contraindicated if bleeding
 Breech Presentation
Secondary Power- Voluntary - Footling
Maternal Pushing/Bearing Down - Frank
- Complete
Passengers - Incomplete
- Blood
- Amniotic Fluid Transverse Presentation
- Fetus - Shoulder presentation
- Placenta
Fetal Station
- EROM or PROM, complete bed rest without - Refer to the relationship of the presenting
toilet privileges to prevent cord prolapse part of the fetus to the level of the ischial
spines.
- If ruptured amniotic fluid, check temp to - If primigravida, must move down 1 cm per
monitor for infection hour
- If multigravida, must move down 2 cm per
hour
Fetus
Protraction
Fetal Lie - Disorder in descent or dilation
Types To promote dilatation/contraction
- Longitudinal - Fundal massage
- Transverse - Walking mother
- Oblique - Nipple stimulation
Fetal Presentation Arrest disorder
- 2 hours or more still wont go down fetal
Likelihood
station or dilatation
- 96% Cepahlic presentation
- 3% Breech presentation Passageway
- 1% Transverse presentation
Pelvis has 2 parts, true and false upper half and
Cephalic presentation lower
- Vertex - Divided by linea terminalis
- Sinciput
- Brow True parts
- Chin/Face - Inlet
- Cavity
Fetal Attitude - Outlet
- Flexion
o Complete/Full Types of Pelvis
o Slight/Military Attitude - Gynecoid (preferable for females)
- Extension - Android (only pelvis for men)
o Slight - Anthropoid
o Complete - Platypelloid

Antero-Posterior Diameter of the Skull CPD (Cephalopelvic Disproportion)

PSYCHE o Intensity mild
- Physical prep for childbirth o Duration 20-40 sec.
- Culture heritage o Station: -2 -0
- Previous experience o Nulliparas 6h
- Support system o Multiparas 4-5h
- Self-esteem
- Psyche disorders Active Phase (Serious)
- More rapid dilation of cervix and descent of
presenting part
- Effacement: 50-75%
Psychological Preparation - Dilation: 4-7 cm
Methods of pain management - Contraction:
- Bradley Method (Husband-Coached) o F every 3-5 mins
- Psychosexual Method o I moderate
- Dick-Read Method o D 40-60 sec
o Fear-Tension-Pain - Station -1 -0
- The Lamaze Method (Psychoprophylaxis) - Primi: 3h
o Asked to attend antepartum - Multi: 2h
classes (5 sessions) - Division: Acceleration (4-5cm) Max slope
o Preventing pain with the use of: (5?)
 Mind
 Breathing exercise Transitional Phase (Irritable)
 Effleurage - Transition (8-10 cm)- contractions may be
every 1.5 to 2 min and last 60-90 sec.
Stages of Labor - Effacement: 75-100%
- First stage - Dilation: 8-10 cm
o Contractions and cervix dilate - Contraction:
- Second stage o F every 2 mins
o The woman pushes giving birth to o I strong
baby o D 60-90 sec
- Third Stage o Station: 0- +1
o Expels your placenta
o Should not be more than 3h for
- Fourth Stage nulliparas
o Postpartum period o 0.5-1h for multiparas
First Stage (Dilating stage) No more home deliveries
- From onset of regular contractions to full
dilation Stage II- Fetal Expulsion
- Averages 13-18h for nulliparas Normal Mechanism of Fetal Delivery
- 8-9h for multiparas - Descent
- Flexion
Latent Phase (Excited) - Internal Rotation
- Cervix begins effacing and dilating and o Baby should rotate 90 degrees
contractions become increasingly stronger ROA or LOA is normal
and more frequent o Not ROA or LOA, baby’s head
- Effacement: 0-50%
rotates 135 degrees
- Dilation: 0-3 cm Persistent Occiput Posterior
- Contraction: o If baby’s head does not rotate
o Frequency 5-10 mins
 o Occiput is pointed towards sacrum Breast
o Patient will feel backache, nurse - Soft first two days
should massage - Third day engorged
- Extension - Breastfeed within 30 mins.
o Ritgen’s maneuver to avoid - APH stimulates prolactin
laceration by supporting perineum - Oxytocin acts on acinar cell
and baby’s head - Let down reflex or milk ejection
o Crowning Uterus
o Feel the neck for cord coiling - By 9th or 10th day, you could not feel fundus
- External Rotation - 1 fingerbreadth per day from the umbilicus
- Expulsion going down
- On 3rd day, 3 fingerbreadth you will locate
fundus
- If fundus does not go down, sub-involution
of uterus may be suspected. Probable for
Transverse diameter of the skull infection or bleeding
Biparietal (9.25cm) - If fundus deviates to the right, might be full
Bitemporal (8cm) bladder. Ask patient to void
Bimastoid (7cm) Bladder
- Common problem is distention
Stage III- Placental Delivery - After giving birth, mother should void within
- Brandt Andrews maneuver 4-6 hours. If unable to void, refer patient to
o Signs of placental separation doctor for straight catheterization
 Calkins signs (uterus Bowel
becomes globular) - Common problem constipation from
 Fundus rises up in the anesthesia
abdomen - Normal Spontaneous Delivery local
 Sudden gush of blood anesthesia or pudendal block has no effect
 Lengthening of the cord on bowels or peristalsis
- If you pull when uterus is relaxed, inversion - Encourage high fiber diet after giving birth
of uterus happens - 3 days mother not defecating is okay. 4th
day should defecate.
Nursing Care Lochia
- Check for completeness - Lochia Rubra
- Uterus- firm/contracted o 1-3 days
- VS o Red
- Time of Placental Delivery o Some clots
- Mechanism of placental delivery - Lochia Serosa
o 4-9 days
Stage IV- 1st 2 hours after placental expulsion o Pinkish brownish
Nursing Care
o No clot
- Vital signs
- Lochia Alba
- Fundal check q15min
o 10-14 days
- Comfort
o Yellowish white
o Position
o No clot
o Perineal care
Should follow this pattern. If pattern from alba goes
back to rubra, maybe sign of retained placental
Postpartum/Puerperium Period
fragments
Episiotomy - Lack of well-equipped facilities
- Assess
o Redness ADMINISTRATIVE ORDER 2008-0029
o Ecchymosis
o Edema Every day around 800 women die due to pregnancy
o Discharge or childbirth related causes
o Approximation of the edges
- First Degree Perineal Tear Causes of maternal death are preventable
o Perineal tear only - Hemorrhage
- Pre-eclampsia
- Second Degree Perineal Tear
o Perineal muscles torn - Infection
- Unsafe abortions
- Third Degree Perineal Tear
- Obstructed labour
o Perineal muscles and anal
sphincter torn
Antenatal Care
- Fourth Degree Perineal Tear
- At least 4 antenatal visits with a skilled
o Perineal muscles, anal sphincter,
health provider
and rectum torn
- Should be properly distributed:
o First visit- pregnancy is suspected
Skin
(sexually active + regular menses
- Skin changes caused by pregnancy begin
+ missed period) or once in three
to recede. First 24-hour period, mother
months
might experience diaphoresis,
o Second- on the next three months
diuresis/polyuria, dehydration.
– 4th – 6th
Homan Sign o Third- on th----?
- (+) thrombophlebitis o Fourth- -------?
- Post NSD, mother can ambulate within 3-4
hours. CS within 24 hours To detect disease which may complicate pregnancy

Emotional Response Prevent by screening

- Three phases - Anemia (By CBC)
o Taking in/dependent - Pre-eclampsia
o Taking o Proteinuria
hold/dependent/independent o Hypertension
 Best time to teach mom o Must be above 20 weeks AOG, if
 Occurs day 3-10 symptoms persist below 20 weeks,
o Letting go/interdependent might be H-mole instead of pre-
eclampsia
Essential Intrapartum Newborn Care - Diabetes mellitus
o Oral Glucose Challenge Test (1
- For the Philippines, the target is to reduce blood extraction)
the MMR from 209 to 52 deaths/100,000 o 50g glucose load is ingested
live birth o 140mg/dL must not exceed
otherwise has Gestational
Maternal and Neonatal Deaths Diabetes Mellitus
- Fragmented MCN programs o Oral Glucose Tolerance Test (4
- Newborns most neglected blood extraction)
- Failure to integrate nutrition - Syphilis
- Lack of skilled health professionals
Detect - Controlled cord traction with countertraction
- Preterm Labor Rupture of the Membrane - Uterine massage after placental delivery
o Use litmus paper to determine
- Preterm Labor Oxytocin is given a minute after delivery to make
sure that there is not another baby inside the fundus
Prevent
- Ferrous and folic acid supplementation Practices during immediate postpartum
- Tetanus toxoid immunization Recommended:
- Corticosteroids for preterm labor - Routine inspection of the birth canal for
o Betamethasone 12mg OD for two lacerations
days IM - Inspect placenta and completeness
o Dexamethasone 6mg q12h for 2 - Early resumption of feeding
days - Massaging the uterus
o Even one dose is very important - Prophylactic antibiotics for women with a 3rd
for the mother and beneficial or 4th degree perineal tear
Treat - Early post-partum discharge
- Ferrous sulfate for anemia
- Antihypertensive meds and magnesium Not Recommended:
sulfate 250mg/mL for severe pre-eclampsia - Manual exploration of uterus
o For magnesium sulfate, check - Routine use of icepacks over the
deep tendon reflex, RR, urine hypogastrium
output - Routine oral methergine
o Prepare antidote calcium
gluconate
- Refer

Recommended Practices during labor

- Admit only when the patient is in active
phase
- Continuous maternal support
- Upright position during first stage of labor
- Routine use of WHO partograph to monitor
progress of labor
- Limit total number of IE to 5 or less

Not recommended during labor

- Routine perineal shaving on admission
- Routine enema
- Routine NPO
- Routine IVF
- Routine vaginal douching
- Routine amniotomy
- Routine oxytocin augmentation

Practices recommended during delivery

- Upright position during delivery
- Selective episiotomy
- Use of prophylactic oxytocin
- Delayed cord clamping