Cont. (Jan 24, 2024) A.

MISCARRIAGE/ ABORTION

HIGH RISK PREGNANCY: The Woman 1. Spontaneous Abortion

who develops a Complication of
pregnancy.  Abortion - any interruption of
pregnancy before age of
A. Bleeding during Pregnancy: viability

- vaginal bleeding is a deviation from - when pregnancy is medically

the hormal that may occur at any time or surgically interrupted
during pregnancy
 Miscarriage - when the
- signs of hypovolemic shock occurs interruption occurs
when 10% of blood volume or spontaneously
approximately two units of blood, have
been lost; fetal distress occurs when  Stage of Viability - a stage
25% of blood volume is lost when the fetus is capable of
surviving outside the uterus,
more than 20- 24 weeks

Signs and symptoms of Hypovolemic - occurs in 15% to 30% of all

Shock pregnancies and occurs from natural
causes
1. increased pulse rate
- a spontaneous miscarriage is an
2. decreased blood pressure
early miscarriage if it occurs week 16
3. increased respiratory rate of pregnancy and a late miscarriage if
it occurs between weeks 16 and 24.
4. cold, clammy skin
- its presenting symptoms is almost
5. decreased urine output always vaginal spotting

6. dizziness or decreased level of

consciousness
Causes:
7. decreased central venous pressure
- the most frequent cause of
miscarriage in the first trimester of
pregnancy is abnormal fetal formation,
CONDITIONS ASSOCIATED WITH
due to either to a teratogenic factor or
FIRST- TRIMESTER BLEEDING:
to chromosomal aberration
- two most common causes of
- implantation abnormalities.
bleeding during the first trimester are
Approximately 50% of zygotes are
Abortion and Ectopic Pregnancy
never implanted

- corpus luteum fails to produce

enough progesterone to maintain the
deciduas basalis
- infection (i.e rubella, syphilis, complication such as infection
poliomyelitis, cytomegalovirus and
toxoplasmosis infections readily cross - after D & C the woman is advised to
the placenta and possibly causing record the number of pads used to
fetal death assess for heavy bleeding

- ingestion of teratogenic drug

4. Complete Abortion

2. Threatened Abortion - the entire products of conception

(fetus,membranes and placenta) are
- is manifested by vaginal bleeding, expelled spontaneously without any
initially beginning as scant bleeding assistance
and usually bright red. There may be
slight cramping, but no cervical - the bleeding usually slows within 2
dilatation is present on vaginal hours and then ceases within a few
examination. days after passage of he products of
conception
- limiting activity to no strenuous
activity for 24-48 hours is the key
intervention to stop vaginal bleeding. 5. Incomplete Abortion
Complete bed rest is usually not
indicated - part of the conceptus (usually the
fetus)is expelled, but the membranes
- coitus is usually restricted for 2 or placenta is retained in the uterus
weeks after the bleeding episode to
prevent infection and to avoid inducing - the physician will usually perform a
further bleeding D&C or a Suction Curettage to
evacuate the remainder of the
pregnancy from the uterus
3. Imminent (Inevitable) Abortion

- it happens with uterine contraction, 6. Missed Abortion

cramping and cervical dilatation
- commonly referred to as early
- the loss of the products of pregnancy failure, the fetus dies in the
conception cannot be halted because utero but is not expelled
of cervical dilatation
- a sonogram can establish that the
- instruct the mother to save tissue fetus is dead. Often the embryo
fragments that has passed and bring actually died 4-6 weeks before the
to the clinic to be examined onset of miscarriage symptoms. After
- the physician may perform D & C the sonogram, a D&C most commonly
(Dilatation and Curettage) to ensure will be done
that all products of conception are - if the pregnancy is over 14 weeks,
removed, preventing further labor may be induced by a
prostaglandin suppository or detect possible hypovolemic shock
Misoprostol (Cytotec) to dilate the
cervix, followed by oxytocin ✓ a BT may be necessary to replace
administration blood loss

- DIC (Disseminated Intravascular ✓ instruct the woman on how much

Coagulation), coagulation defect, may bleeding is abnormal (more than one
develop if the dead fetus remains too sanitary pad per hour is excessive),
long in utero what color changes she thould expect
in bleeding (gradually changing to a
dark color and then to the color of
serous fluid) and any unusual odor or
7. Recurrent Pregnancy Loss passage of large clots is also
- commonly referred to as habitual abnormal
abortion

- 3 or more consecutive pregnancies 2. Infection

result in niscarriage usually related to
incompetent cervix. - the possibility of infection is minimal
when pregnancy loss occurs a short
Δ Management (suture of cervix) period, bleeding is self limiting and
• McDonald procedure instrumentation is limited

- Cervical Cerclage ✓ educate the woman about the

danger signs of infection,such as fever,
 Temporary Circlage abdominal pain or tenderness and a
foul smelling discharge
 Side effect - infection
✓ organism responsible for infection
 May have NSD
after miscarriage is usually
• Shirodkar Escherichia Coli (E Coli)

 CS delivery ✓ caution the woman to wipe the

perineal area from front to back after
voiding and particularly after
defecation to prevent the spread of
COMPLICATIONS:
bacteria from rectal area
1. Hemorrhage
✓ caution the woman not to use
- a woman who develops DIC has a tampons to control vaginal discharge
major possibility for hemorrhage because stasis of any blood increases
the risk of infection
✓ if excessive vaginal bleeding is
occurring, immediately position e
woman flat and massage the uterine
3. Isoimmunization
fundus to aid contraction
- happens when the mother's blood is
✓ monitor vital signs for changes to
Rh negative, while the fetus is Rh - local anesthesia of the cervix is
positive. needed

- after spontaneous abortion or D & C.

some Rh positive fetal blood may
enter the maternal circulation and B. Dilatation and Curettage
mother will develops antibodies ✓ aka. Dilatation and Evacuation
against Rh positive fetus blood.
✓ dilation of cervix followed by gentle
- during the succeeding pregnancies scraping of the uterine walls to
when the fetus is Rh positive again, remove products of conception
those antibodies would attempt to
destroy the fetus RBC ✓ Used for first-trimester abortions
and to remove all products of
- so after miscarriage, because the conception after spontaneous
blood of the fetus is not known, all abartions
women with Rh negative blood should
receive Rhogam (Rh Immune Globulin) ✓ Greater risk of cervical or uterine
to prevent the build up of Rh trauma and excessive blood loss
antibodies
✓ Local anesthesia or general
anesthesia is needed

4. Powerlessness

- sadness and grief over the loss or a Nursing Care of Clients with Abortion
feeling that she has lost control of her
1. Document the amount and
life is to be expected
character of bleeding and saves
- emotional support tissues or clots for evaluation.

2. Check the bleeding and vitals signs

to identify hypovalemic shock
Procedures Used in Pregnancy resulting from blood loss
Termination
3. After vacuum aspiration or
A. Vacuum Curettage curettage, the amount of vaginal
- aka. Vacuum aspiration bleeding is observed

- cervical dilation followed by 4. Provide home health teaching after

controlled suction through a plastic curettage such as:
cannula to remove all products of  report increase bleeding
conception
 take temperature every 4 hours
- used for first trimester abortions, for 3 days
also used to remove remaining
products of conception after  take an oral iron supplement if
spontaneous abortion prescribed
  resume sexual activity as Risk Factors:
recommended by the health
care provider ✓ increase incidence in women who
have PID (Pelvic Inflammatory
 return to the health care Disease) which leads to tubal scarring
provider at the recommended
time for a check up. ✓ occurs more frequently in women
who smoke
5. Check laboratory test such as
hemoglobin level and hematocrit ✓ occurs more frequently in women
who douche, possibly due to risk of
6. Promote expression of grief by introducing an infection
providing privacy, allowing support
persons to help in pregnancy loss ✓ used of IUD (intrauterine device) for
contraception

B. ECTOPIC PREGNANCY
Signs and Symptoms:
- is one in which implantation occurs
outside the uterine cavity. Before Rupture

- the most common site is in a ✓ no menstrual flow occurs

fallopian tube. ✓ nausea and vomiting
• Of these fallopian tube sites, ✓ positive pregnancy test for HCG
 approximately 80% occur in the  Abdominal pain within 3- 5wks
ampullar portion of missed period (maybe
 12% occur in the isthmus and generalized or one sided)

 8% in interstitial  Scant, dark brown vaginal

bleeding

During Rupture

✓ sharp, stabbing pain in one of the

lower abdominal quadrants at the time
of rupture, followed by scant vaginal
bleeding

✓ lightheadedness, rapid pulse and

signs of shock (rapid thread pulse,
rapid respirations and falling blood
pressure)

✓ rigid abdomen from peritoneal

irritation (Board-like abdomen)

✓ Cullen's sign (bluish tinged

umbilicus) - because blood seeping
into the peritoneal cavity

✓ dull, excruciating pain on the

abdomen that may radiate on the
shoulder caused by irritation of the
phrenic nerve

Diagnostics:

1. Transvaginal UTZ will demonstrate

ruptured tube Management:

2. insertion a needle through the post- 1. an ectopic pregnancy ruptures, it is

vaginal fornix into the cul-de-sac under an emergency situation and the
the sterile conditions to see whether woman's conditions must be
blood that has collected there from evaluated quickly
internal bleeding can be aspirated
2. therapy for a ruptured ectopic
(Culdocentesis)
pregnancy is laparoscopy
3. Laparoscopy Culdoscopy can be
3. women with Rh negative blood
used to visualize the fallopian tube
should receive Rh immune globulin
(Rhogam) after an ectopic pregnancy
for isoimmunization protection in
future childbearing

Management:

1. treated medically by the oral

administration of Methotrexate

 a folic acid antagonist

chemotherapeutic agent,
attacks and destroys fast
growing cells. Because
trophoblast and zygote growth
is rapid, the drug is drawn to
the site of ectopic pregnancy

2. Hysterosalphingogram performed
after chemotherapy to assess the
patency of the tube

3. provide emotional support

CONDITIONS ASSOCIATED WITH Causes:
SECOND-TRIMESTER BLEEDING
- UNKNOWN

Risk Factors:
A. GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE OR - occurs most often in women who
H- MOLE) have a low protein intake

- is proliferation and degeneration of - in young women (under age 18 years)

the trophoblastic villi, which becomes - in older women older than 35 years
filled with fluid and appear as grape-
sized vesicles

- Incidence is approximately 1 in every Types:

2,000 pregnancies
- there are two distinct types of
hydatidiform mole

1. Complete mole - all trophoblastic

villi swell and become cystic.

- embryo dies early at only 1 to 2 mm

in size with no fetal blood present in
the villi

- on chromosomal analysis, although

the karyotype is a pormal 46XX or
46XY, this chromosome component
was contributed only by the father or
an "empty ovum'"was fertilized and the
chromosome material was duplicated

- this type usually lead to

choriocarcinoma

2. Partial mole - some of the villi form

normally

- although no embryo is present, fetal

blood may be present in the villi

- has 69 chromosomes (a triploid

formation in which there are three
chromosomes instead of two for eyery
pair, one set supplied by an ovum that
was fertilized by two sperm or an complications)
ovum fertilized by one Isperm in which
meiosis or reduction division did not ✓ prophylactic course of Methotrexate
occur) is the drug of choice for
choriocarcinoma. This must be weigh
carefully because It interferes with
WBC formation which can lead to
Signs and Symptoms: leucopenia
✓ uterus tends to expand than ✓ observe for bleeding and
normally hypovolemic shock
✓ no Fetal heart sounds are heard
because there is no viable fetus
B.REMATURE CERVICAL DILATATION
✓ hCG serum levels are abnormally
high - previously termed as "Incompetent
cervix"
✓ severe nausea and vomiting
- refers to a cervix that dilates
✓ symptoms of hypertension of prematurely and therefore cannot hold
pregnancy is present before week 20 a fetus until term
of pregnancy
- commonly occurs at approximately
✓ a sonogram/UTZ will show dense week 20 of pregnancy
growth (typically a "snowstorm"
pattern) but no fetal growth in the Causes:
uterus
- UNKNOWN
✓ Vaginal spotting of dark brown
blood Risk factors:

✓ Discharge of the clear fluid filled 1. associated with increased maternal

vesicles age, congenital structural defects and
trauma to the cervix such as might
occurred with biopsy or repeated D & C

Management:

✓ suction curettage to evacuate the Signs and Symptoms:

mole
1) often the first symptom is show (a
✓ after extraction, women should have pinkstained vaginal discharge) or
a baseline serum test for the beta increased pelvic pressure followed by
subunit of hCG rupture of membranes and discharge
of amniotic fluid
✓ educate on avoiding pregnancy for
at least one year hCGis analyzed every 2) painless cervical dilatation
2-4 weeks for 6-12 months (gradually
declining hCG suggest no 3) uterine contractions followed by
birth of fetus

Management:

1. bed rest in trendelenburg position

2. monitor FHT

3. observe for the rupture of BOW 4.

avoid coitus and limit activities 5.
avoid vaginal douche

6. Surgical Operation termed as

"Cervical Cerlage" is performed

- as soon as sonogram
confirms that the fetus of a
second pregnancy is healthy, at
approximately week 12-14,
pursing-string sutures are
placed in the cervix by vaginal
route under regional
anesthesia CONDITIONS ASSOCIATED WITH
THIRD - TRIMESTER BLEEDING

A. PLACENTA PREVIA
Types Cervical Cerlage:
 is low implantation of the
A. McDonald Procedure - nylon placenta
sutures are placed horizontally and
vertically across the cervix and pulled  it occurs in four degrees:
tight to reduce the cervical canal to a
few millimeters in diameter
1.Low- lying placenta
B. Shitodkar technique - sterile tape is
threaded in a purse-string manner - implantation in the lower rather than
under the sub mucosal layer of the in the upper portion of the uterus
cervix and sutured in place to achieve
a closed cervix

 sutures may be placed trans- 2. Partial placenta previa

abdominally
- implantation that occludes a portion
of the cervical OS
3. Marginal ✓ past uterine curettage

- placenta edge approaches the ✓ multiple gestation

cervical OS.Lower border is within 3
cm from internal cervical OS but does
not cover the OS Complication:

1. postpartum hemorrhage
4. Total placenta previa 2. hypovolemic shock
- implantation that totally obstructs the 3. preterm labor
cervical OS
4. fetal distress
 incidence is approximately 5
per 1000 pregnancies

Signs and symptoms:

1. sudden onset of painless bright red

vaginal bleeding (latter half of
pregnancy)

2. bleeding may be profuse or scanty

NOTE:

- site of bleeding: uterine deciduas

(maternal blodd) places the mother at
risk for hemorrhage

- bleeding may not occur until the

onset of cervical dilatation causing the
placenta to loosen from the uterus

Management:

1. Bleeding is an emergency. (fetal

oxygen may be compromised and
preterm birth may occur)

Risk Factors 2. Assess the amount of blood loss

(duration, time of bleeding began,
✓ increased parity accompanying pain, and color of the
blood)
✓ advanced maternal age
3. Bed rest with oxygenation
✓ past cesarean births
prescribed
4. Side-lying or trendelenburg position Causes:
(for 72 hours)
- UNKNOWN
5. NO internal exams (IE) or rectal
exams, may initiate massive Risk Factors:
hemorrhage (if necessary, must have ✓ high parity
double set up; OR/ DR)
✓ advanced maternal age
6. Keep IV line and have blood
available (X-matched and typed) ✓ short umbilical cord

7. Apt or Kleihauer- Betke test (test ✓ chfonic hypertensive disease

strip procedure to determine if blood is
✓ PIH
fetal or maternal in origin)
✓ direct trauma (from VA)

✓ cocaine or cigarette use

Fetal Assessment:
(Vasoconstrction)
1. monitor fetal status; heart tone and
movement
Complications:
2. Determine fetal lung maturity;
amniocentesis - L/S ratio 1. Fetal distress (altered HR)
3. Bethamethasone may be prescribed 2. Couvelaire uterus or Uteroplacental
(encourage maturity of fetal lungs; if apoplexy 3. disseminated
fetus is less than 34 weeks gestation) intravascular coagulation (DIC)

Signs and symptoms:

B. ABRUPTIO PLACENTA 1. Vaginal bleeding (may not reflect
the true amount of blood loss)
 premature separation of a
normally implanted placenta 2. Abdominal and low back pain (dull
either partial/marginal or or aching)
complete/total
3. Sharp stabbing pain high in the
 occurs after 20-24 weeks of fundus
pregnancy
4. Uterine irritability (frequent low
intensity contractions)

5. High uterine resting tone

6. Uterine tenderness
Degrees of Separation Grade criteria:

0 - no symptoms of separation. Slight

separation occurs after birth. When
placenta is examined, a segment
shows recent adherent clots

1 - minimal separation, enough to

cause bleeding and changes in vital
signs. However, there is no occurrence
of fetal distress and hemorrhagic
shock

2 - moderate separation. There is

evidence of fetal distress, and the
uterus is tense and painful on
palpation

3 - extreme separation, and maternal

shock or fetal death will result

Management:

1. Keep the client in lateral position,

not supine

2. Oxygen therapy (limit fetal anoxia)

3. Monitor FHT and record maternal

vital signs every5 to 15 minutes

4. Baseline fibrinogen(if bleeding is

extensive.Fibrinogen reserve may be
used up in the body's attempt to
accomplish effective clot formation)

5. NO IE or rectal exam. No Enema

6. Keep IV line open (possible BT)

Jan. 31

PRETERM LABOR b. Tocolytic agents (halt labor)

 aka. Premature Labor 1. Calcium channel blockers

 Labor that occurs after 20 - Beta adrenergic drugs

weeks and before the end
2. Indomethacin (prostaglandin
 Approximately 9-10% of all antagonist)
pregnancies
- Is usually used as an anti-
 Labor contractions that inflammatory medicine to treat
happens every 10-20 minutes arthritis

 Usualy leads to progressive - Blocks the production of certain

cervical dilatation of >2 cm and substances called prostaglandin which
effacement of >80% contribute to uterine contractions

3. Magnesium Sulfate

Management: - often the first drug used to halt

contractions
FOCUS:
 CNS depressant - halts uterine
- Prevention of the delivery of
contraction
premature fetus
4. Ritodrine Hydrochloride (Yutopar)
1. The woman should first
and Terbutaline (Brethine)
admitted to the hospital
- acts on entire beta 2 receptors sites
2. Place in Left lateral position
(uterine and brochial smooth muscles)
3. BEDREST to relieve the causing mild hypotension and
pressure of the fetus on the tachycardia effects, hypokalemia,
cervix hyperglycemia, pulmonary edema

4. Intravenous fluid therapy to  Side Effects:

promote hydration
✓ Headache (most common) -
5. Medical Management due to dilatation of cerebral
blood vessels
✓ Bethamethasone/Glucocortoids
✓ Nausea and vomiting
 steroids, given in an attempt to
hasten fetal lung maturity,

 given in 2 dose, 12mg IM 24 Nusing Responsibilities before

hours apart administration of Tocolytic Therapy:

1. Assess baseline blood data i.e. hct,

glucose, potassium, NaCl, ECG
(tachycardia)

2. Uterine and fetal monitoring

(external fetal monitors)

3. Mix/the drug with lactated Ringers

solution to prevent hyperglycemia
(piggyback administration, so that it
can be stop immediately if tachycardia
occurs)

4. Assess BP and pulse every 15

minutes and every 30 minutes until
contractions stop

5. Reports PR>120 bpm, BP < 90/60

chest pain, dyspnea, rales
Jan. 31 - Fear related to lack of preparation for
child care
PUERPERIUM
- Risk for deficient fluid volume related
Goal of nursing care in the immediate to postpartal hemorrhage
postpartum period is:

 to assist women and their

partners during their initial POSTPARTUM PERIOD
transition to parenting
Phases of Puerperium

1. Taking-in Phase
Puerperium
- a time of reflection
- refers to the 6-week period after
childbirth - first 2-3 days; woman is largely
passive due to physical discomfort,
- The woman is termed as a puerpera. uncertainty in caring her newborn, and
extreme exhaustion that follows
- a time for maternal changes that are childbirth
both retrogressive and progressive-
the period is popularly termed the 2. Taking-hold Phase
fourth trimester of pregnancy
- woman initiates her own action
- the physical care a woman receives
during the postpartal period can - may have expressed strong interest
influence her health for the rest of her - provide positive reinforcement
life.
3. Letting-Go Phase

- woman finally defines her new role-

Assessment: gives up the fantasized image of her
 Health interview child and accepts the real one

 physical exam - a woman who has reached this

phase is well into her new role
 analysis of laboratory data
 Rooming-In
 psychological adjustment
- the mother become better
acquainted with her child and
begin to feel more confident in
Nursing Diagnosis: her ability to care for him or her
- Health seeking behavior related to after discharge
care of newborn

- Risk for impaired parenting related to

disappointment in the sex of the child
Physiologic Changes of the within 2 weeks after childbirth.
Postpartal Period:

Involution - is the process whereby the

reproductive organs return to their
nonpregnant state. A woman is in
danger of hemorrhage from the
denuded surface of the uterus until
involution is completed.

Subinvolution - is the failure of the

uterus to return to a nonpregnant state.

- Return to the pelvis by about 2 weeks

I. ANATOMICAL CONSIDERATION
- Be at normal size by 6 weeks
UTERUS
✓ The weight changes of
- Immediately following delivery, the
uterus 1000grams immediately
uterus becomes firm and retract with
after birth (excluding the fetus)
alternate hardening and softening.
✓ Placenta, Membrane, and
- The uterus measures about 20 x 12 x
Amniotic Fluid 510 g, with a
7.5 cm (length, breadth and thickness)
diameter of 185 mm, 23 mm
and weighs about 1000 gm.
thickness, and an average
- At the end of 6 weeks, its volume of 500 ml.
measurement is almost similar to that
- the area where the placenta is
to the non-pregnant state and weighs
implanted is sealed off to prevent
about 60 gm.
bleeding
- The placental site contracts rapidly
- the organ is reduced to its
presenting a raised surface with
approximate pre-gestational size
measures about 7.5 cm and remains
elevated even at 6 weeks when it - the sealing of the placenta site is
measures about 1.5 cm. accomplished by rapid contraction
- By 24 hours postpartum the uterus is - uterus will never completely return to
about the same size it was at 20 its pre-pregnancy state
gestational weeks.
- uterus of a breastfeeding mother
- The fundus descends about 1-2cm may contract even more quickly
every 24 hours, and by the 6th
postpartum day, it is located halfway
between the symphysis pubis and the
umbilicus.

- The uterus lies in the true pelvis

Delayed uterine Involution: CERVIX

1. Multiple Birth - soft and malleable by the end of 7

days, the external os has narrowed to
2. Hydramnios the size of a pencil opening
3. Prolonged labor - The cervix contracts slowly, the
4. Grand multiparity external os admits two fingers for a
few days but by the end of first week,
5. Effects of analgesia narrows down to admit the tip of a
finger only.
6. Retained placental fragments
- The contour of the cervix takes a
7. Full bladder
longer time (6 weeks) to remain and
the external os never reverts back to
the nulliparous state.
Uterine Atony - a relaxed state of the
uterus which leads to rapid blood loss VAGINA
due to the absence of thrombi in the
- soft, with few rugae, and its diameter
placental site
is considerably greater than normal
Lochia- uterine flow consisting of
- the hymen is permanently torn and
blood, fragments of decidua, white
heals with small, separate tags of
blood cells, mucus, and some bacteria
tissue
- it takes approximately 6 weeks for
- if a woman practices Kegel
the placental implantation site to be
exercises,the strength and tone of the
cleansed and healed
vagina will increase more rapidly
Type of Color Postpartal Composition
Lochia Day
PERINEUM

Lochia Red 1-3 Blood - develops edema and generalized

rubra tenderness

Lochia Pink 3-10 Blood, - ecchymosis from ruptured capillaries

serosa mucus may be evident
and
leukocytes
Systemic Changes
Lochia White 10-14 Largely
alba (May mucus, 1. Hormonal System
last 6 increased
- pregnancy hormones begin to
wks) leukocyte
decrease as soon as the placenta is
count
no longer present

- levels of hCG and hPL are almost

neglible by 24 hours
 - bowel evacuation may be difficult
due to episiotomy sutures or
2. Urinary System hemorrhoids
- an extensive diuresis begins to take - Digestion and absorption begin to be
place almost immediately after birth active again soon after birth
- may have transient decrease in
bladder tone
5. Integumentary System
- Dilated ureters and renal pelvis return
to normal size within 8 weeks ✓ Striae gravidarum - stretch marks
on the woman's abdomen may even
- as the bladder fills, it displaces the gets prominent
uterus; uterine position is therefore a
good gauge of whether a bladder is ✓ Chloasma- excessive pigment on
full or empty the face and neck

✓ Linea nigra - excessive pigment on

the abdomen
3. Circulatory System

- the blood volume has returned to its

normal prepregnancy level by the first 6. Temperature
or second week after birth
- Show slight increase in temperature
- hematocrit, plasma fibrinogen, and
leukocytes - Occasionally, when a woman's breast
fill with milk on the 3rd or 4th
- Woman's pulse rate is usually slightly postpartum day,her temp. rises for a
slower than normal period of hours because of the
increased vascular activity involved
- Increased stroke volume reduces the
pulse rate to 60-70b/m

- By the end of 1st week, PR will return 7. Weight

to normal
Rapid diuresis and diaphoresis during
the 2nd to 5th days after birth result in
weight loss of 5 Ib. (2-4kg) ,in addition
4. Gastrointestinal System to approx. 12 Ib.(5.8kg)
- digestion and absorption begin to be - Lochia flow - 2 to 3lb. (1kg )loss
active again soon after birth
- Total weight loss - 19lb.
- woman feels hungry and thirsty
- Additional weight loss depend on
- hemorrhoids (distended rectal veins) amount of weight gain in pregnancy
that have been pushed out of the and active measures to reduce weight
rectum due to the effort of pelvic-
stage pushing often are present
8. Fluid Loss 6th week following delivery in about
40 %and by 12th week
- Net fluid loss of at least 2 liters
during 1st week - In non-lactating mothers ovulation
may occur as early as 4 weeks and in
- Additional 1.5 liters during the next lactating mothers about 10 weeks
5th weeks after delivery.

9. Blood Values

- diuresis evident between 2-5th day Pain Management During Labor

after birth
Etiology:
- Rapid reduction occurs, so that blood
volume returns to its pre pregnancy - normally, contractions of involuntary
state by 2nd week muscles (heart & stomach) do not
cause pain, this concept makes
- Cardiac output rises soon after uterine contractions unique because
delivery to about 60% above the pre- they do cause it during contractions,
labor value but gradually return to blood vessels constrict, reducing the
normal within a week blood supply to uterine and cervical
cells resulting anoxia to muscle fibers
also probably from stretching of the
CBC Volume and Hematocrit cervix and the perineum

- Returns to normal by the end of 1st

week
Comfort and Pain Relief Measures
- Leucocytosis to the extent of
30000/cu mm occurs following 1. Relaxation
delivery probably in response to labor 2.Guided imagery
- Platelet count decreases soon after 3.Breathing Techniques
the separation of the placenta but
secondary elevation occurs with 4.Herbal preparations
increase in platelet between 4-10days
5. Aroma therapy and Essential oils

6. Heat or Cold application

MENSTRUATION AND OVULATION
7. Bathing or hydrotherapy
- The onset of the first menstrual
period following delivery is very 8. Therapeutic touch
variable and depends on lactation. 9. Yoga
- If the woman does not breastfeed 10. Reflexology
her baby, the menstruation returns by
11. Hypnosis
12. TENS (Transcutaneous Electric oxygen and additional IV fluid
Electrical Nerve Stimulation) necessary to stabilize cardiovascular
status

Pharmacologic Pain Relief During

Labor

 Analgesia - which reduces or

decreases awareness of pain

 Anesthesia - which causes

partial or complete loss of
sensation

- virtually all medication given during

labor crosses the placenta and has
some effect on the fetus, which makes ✓ Spinal (Subarachnoid) Anesthesia
it important for a woman to receive as
- is used in emergency cases because
little systemic medication as possible.
the administration technique is
✓ Narcotic Analgesics simpler

- cause fetal CNS depression to some - A local anesthetic agent is injected

extent using lumbar puncture technique into
the subarachnoid space ath the 3rd
- not given for preterm labor and 4th lumbar interspace
- meperidine hydrochloride (Demerol) ✓ Local Infiltration
- morphine sulfate - injection of an anesthetic such as
- Nalbuphine (Nubain) lidocaine (Xylocaine) into the
superficial nerves of the perineum
✓ Regional Anesthesia Pudendal Nerve Block

- is the injection of a local anesthetic - for forceps delivery

to block specific nerve pathways

✓ Epidural Anesthesia (Peridural

Block)

- an anesthetic agent placed just

inside the ligamentum flavum

- spinal headaches occur rarely

apparently caused by leakage of CSF
or instillation of air into the CSF

- if hypotension does occur, raising the

woman's legs and administering