OB Nursing Review PDF

INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM MATERNAL NURSING o If conception occurs and the fertilized ovum...

INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM MATERNAL NURSING o If conception occurs and the fertilized ovum implants in the uterus, corpus luteum will ! GOOD TO KNOW ! remain throughout the major portion of the pregnancy (16-20 weeks). Average length of pregnancy: 40 weeks o If conception does not occur, the unfertilized Range: 38-42 weeks egg atrophies after 4-5 days and corpus Pospartum is 6 weeks luteum remain for 8-10 days → as corpus o Involution: return of uterus to its pre- luteum regresses, it is gradually replaced by pregnant state white fibrous tissue → corpus albicans → o Subinvolution: failure of the uterus to return decrease progesterone and estrogen → to its pre-pregnant state. ISCHEMIC PHASE → degeneration of the lining, mucus, blood, and egg (happens for 1 OVARIAN / MENSTRUAL CYCLE to 3 days) → MENSES → discharge of the lining, mucus, blood, and egg. ⇒ Average: 28 days The cells of the follicles remain during the rupture of GF - Range: 23-35 days → the follicles become empty → LH will act on the left follicle to produce lutein and fill it–– a bright yellow ! TERMS ! liquid → corpus luteum → high in progesterone (but low Menarche –– first menstruation which may occur for in estrogen) → LUTEAL / SECRETORY PHASE → women who are 9-16 years old. progesterone function by: Fertilization –– also known as conception and o Thickening the lining impregnation. o Thickening the mucus to prevent any o This is the process of the fusion of an egg microorganism to harm the pregnancy and sperm. o Keeping the lining intact to maintain o Zygote –– union of an egg and sperm. pregnancy and prevent miscarriage Progesterone –– hormone of pregnancy. o Relaxing the uterus to prevent contraction Estrogen –– hormone of menstrual cycle. and labor o Produced by the adrenal gland during childhood. COMMON PHYSIOLOGIC CHANGES DURING Luteinizing hormone (LH) –– hormone of ovulation PREGNANCY Follicle-stimulating hormone (FSH) –– hormone of maturation and development of follicles. PRESUMPTIVE Ejaculation is 1ml in amount which contains 4-20 ⇒ Subjective (sumbong ni mother) ; lowest level of confirmatory million sperm cells. PAIN DURING childhood, estrogen is low. However, it needs to go up A. Legs during puberty. Normal - Estrogen is produced by the adrenal gland during - Cramps due to low calcium and phosphorus childhood. o Prevention: - The amount is minimal because of the overall hormonal " Calcium supplement (1g/day) balance and the inactivity of the hypothalamus- " Magnesium lactate / Citrate BID (AM pituitary-gonadal axis. and PM) " No extension of foot and tip toe PART 1 o Management: The low estrogen during puberty triggers the start of the " Dorsiflex the foot with the knee menstrual cycle → hypothalamus is informed to release extended. Gonadotropin releasing hormone (GnRH) → this act as trigger to stimulate APG to secrete follicle-stimulation hormone (FSH) Abnormal → will activate 1 oocyte and its surrounding follicle––primordial - Clot due to uterine pressure (primary; young) follicle to grow and mature with the help of o Prevention: ↑circulation some additional stimulation → graafian follicles (GF) → contains " Ambulate –– BEST!! follicular fluid that is high in estrogen (but low in progesterone) " Elevate legs → ESTROGENIC / FOLLICULAR / PROLIFERATIVE PHASE " Elastic (anti-embolic) stockings → endometrial cells that are attached in the uterus lining ○ Should be worn before proliferates to prepare for the possible implantation for getting out of bed in the pregnancy. morning. IF she ambulated already, let her lie down for PART 2 30 minutes, then wear it to The high estrogen is detected by the APG → APG releases the patient. luteinizing hormone (LH) → this triggers the rupture of GF and ○ Length should be release of egg → OVULATION → pantyhose. The egg will travel toward the fallopian tube " ↑OFI (infundibulum) and wait for the egg to be fertilized for 24 to 48 hours. YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM " Assess for Homan’s sign by dorsiflexing the $Citrus / cabbage (gas- foot and extending the knee. forming food) ○ If (+) calf pain, (+) Homan’s sign → % Magnesium and aluminum REPORT / NOTIFY MD! hydroxide This may indicate venous % H2 blockers thrombosis and % Maalox thrombophlebitis––signs: #pain, #fever, #redness, D. Head #warmth, and #swelling. Normal - New onset or new type ! MANAGEMENT OF THROMBOPHLEBITIS: ! o Should be mild and occasional. ABCD o Management: %Paracetamol " AVOID HAM: $ Hot compress → should be moist heat! Abnormal $ Ambulation - Severe, continuous; unrelieved by paracetamol; visual $ Massage changes –– these three are seen in HTN. " Bed rest for awhile o Management: "REPORT! " Call MD " Doppler ultrasound: confirmatory test " Drugs: anticoagulant before thrombolytics RESPIRATORY CHANGES % Heparin - Stuffiness of nose (nasal congestion) caused by % Thrombolytics estrogen. !! No warfarin because it damages fetal kidney !! - Shortness of breath, especially on the 3rd trimester, due to uterus enlargement. o Relieved by engagement (descent) of the B. Back baby on the last 2 weeks of pregnancy, which - Normal: Lower back pain due to progesterone and causes lightening effect on the mother. relaxin (P-R) that soften and relaxes the pelvic joints to - Speedy breaths (tachypnea) due to enlarged uterus. prepare the baby o Aggravated by lordosis (pride of pregnancy) ENLARGEMENT OF BREASTS o Prevention: Encourage Normal: BREAST " Stand straight - Blue veins appearance due to increased vascularity " Support pillow in the back caused by estrogen. " Squatting - Readies for lactation " Shoes should be low-heeled. o Hormones that prepare for lactation are o Management: progesterone and human placental lactogen " Pelvic rocking to strengthen lumbar (HPL; human chorionic somatomammotropin) spine. - Enlarged due to estrogen. ○ Relaxed and hollowed - Areolar darkening due to estrogen. ○ Hold for a minute - Secretes colostrum –– high in IgA. o Starts at 16 weeks of gestation. C. Chest o Colostrum lasts for 2-3 days, then true milk - Normal: Burning sensation (heartburn / pyrosis) appears. because of: o Produced by prolactin and ejected by 1. Relaxed sphincter caused by P-R leading to oxytocin. decreased motility in GI resulting in o Bilateral tenderness of the breasts due to milk constipation and flatulence. filling is called engorgement. 2. Stomach is pushed upward caused by § Management: Address the pain enlarged uterus before continue breastfeeding (BF) " Cold compress for pain o Management: " Warm compress for edema " Small, frequent feeding or swelling " Slow chewing % Analgesic " Should wait 2-3 hours after eating " Continue BF before lying down. - Tubercles becomes prominent. " Sleep on the left " Support with 2 pillows Abnormal " Avoid ABTFC: - Dry, crack breast → MASTITIS (unilateral) $ Alka seltzer o Management: $ Baking soda % Antibiotics $ Tomato % Analgesic $ Fatty food " Continue BF. Stop only when there is abscess. YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM SKIN CHANGES: SKIN " Dry toast or cracker is given upon waking up - Striae gravidarum because it is easily converted to glucose. o Management for pruritus: ○ Has baking soda, which contains % Cocoa butter lotion bicarbonate, that fights the acidity. - Kloasma / Chloasma / Melasma –– mask of pregnancy; " Delay breakfast cheeks and nose " Call the Doctor if this is more than 1x daily, > - Increased pigmentation 1 trimester, and causes dehydration → - Line Nigra –– vertical, thin line mid abdomen SEVERE → hyperemesis gravidarum. !! All of these may fade after giving birth !! ○ The mother and the baby are prone to fluid and electrolyte imbalance. URINARY FREQUENCY: IHI - Increased bladder pressure MENSES CESSATION: AMENORRHEA o 1st tri: mild - Due to continuously high estrogen → negative o 2nd tri: absent feedback of FSH and LH o 3rd tri: stronger, especially on the last 2 weeks o High estrogen levels stop only after placental (10-12x/day) due to the fetus’ engagement. delivery - High hormones - Return of menses: o hCG: o Non-BF: 6-10 weeks § 1st tri: increased o BF (lactational amenorrhea): 3-4 months and Due to trophoblast cells more that produces hCG § Preserve fluids. § 2nd tri: decreased o Aldosterone: retains water and sodium ! LACTATIONAL AMENORRHEA METHOD ! § Pregnancy needs fluid retention to 1. Pure breastfeeding increase blood volume 2. Never menstruated - Increased GFR 3. Maximum of 6 months due to solid food introduction MOVEMENT PALMAR EYTHEMA Fetal Movement - Due to estrogen - Quickening: first movement felt by the mother - Management: %Calamine lotion o When: 20 weeks § Primi: 18-20 weeks TIREDNESS § Multi: 16 weeks - 1st tri: decreased glucose, increased metabolic o Peak: 28 weeks until 38 weeks or demands (organogenesis), nausea and vomiting engagement - 2nd tri: peak increased of blood volume - Assess fetal well-being: KICK COUNT o 1st to increased: Plasma o Frequency: OD o Seems down (decreased): RBC (responsible o Position: left recumbent to increase fetal for oxygen transport) circulation § Physiologic anemia or pseudo o Time: after meal for 1 hour anemia o Rate: 10-12/hour - 3rd tri: heaviest uterus; deprived sleep due to SOB and § If less than, ambulate. increased fetal movement § If ambulation is contraindicated, give - Management: REST food–– snack or juice. " Relaxation !! if there is still no movement, REPORT !! " ↑Recommended dietary allowance (RDA): +300 calories/day. MORNING SICKNESS (NAUSEA AND VOMITING) § Increased weight: normal 25-35 lbs - Cause: PHEG 1. Increased progesterone 1st tri: 1kg or 1lb/month 2. Increased hCG (1st trimester) 2nd tri: 1 with extra 3. Increased estrogen allowance 2 lbs/week 4. Decreased glucose 3rd tri: 1 lb/week - Management: SAD § If there is lack or excess in weight " Snack before bed gain per week or months, REPORT " Small, frequent feeding to the MD! ○ Sour ball, sips of carbonated drinks " Enough sleep or sparkling water § Give extra pillow " Avoid: 4s § modify environment $ Spicy " Short nap during the day $ Seasoned " Take breaks $ Sebo (fatty food) " Take Iron (at least 800 mg––500 mg: mother; $ Sudden movement 300 mg: baby) to prevent pseudo anemia § Foods high in iron: " Acupressure band: wrist Meats " Acupuncture YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM Green leafy vegetables § During labor: CS Legumes (Nuts) § If acquired by baby thru NSD due to § Supplement: 27mg (if there is no infected birth canal, ophthalmia exact 27mg, find 15-30mg) neonatorum may result which may § Side effects: lead to blindness. ↑GI upset –– NC: "take it o Management: good perineal care with meals and vitamin C; " Front to back "avoid: $calcium (milk) " Cotton, clean underwear and $magnesium as it " Perineal pads to absorb secretions decreases absorption–– 2- " Avoid tampons as it causes hour window allowance infection. before taking it. Constipation –– NC: VARICOSE VEINS - Development of tortuous leg veins–– wherein there is "↑fiber and OFI; blood pooling and vessel dilation, caused by uterine "mobilization; "give pressure COLACE (docusate - Management: VEINS sodium; stool softener); " Vitamin CAB and "avoid: $laxatives, ○ Vitamin C has the highest impact. $enema, and $mineral " Elevate legs (footstool, wall–– with small oils as it stimulates the GI towel or rolled towel on the right hip) to reduce and causes contraction of blood pooling uterus–– which may lead to " Increased mobilization pre-term labor. " No crossing of legs and constrictive knee high Stool: blackish, dark green stockings § Given during the 2nd trimester until " Sim’s position postpartum to recover blood loss. § BEST GIVEN: before pregnancy. Hemorrhoids –– varicosities of the anus caused by uterine If not given before pressure. pregnancy, give it during - Management: CoCo MILK the 2nd trimester (due to " Constipation management peak ↑ of blood volume) " Cold compress until end of postpartum (to " Modified Sim’s position recover blood loss). " Insert gently using fingers Not given during the 1st " Lotion: witch hazel –– has cooling effect; trimester as it may promote perineal healing aggravate nausea and " Knee-chest position for 10-15 min/day vomiting. § Best indicator to detect if the patient ! KEGEL’S EXERCISE: PELVIC FLOOR ! is taking iron religiously: CBC–– CONTRACTION ↑RBC. Purposes " Take folic acid (Vitamin B9) to prevent pseudo 1. Perineal strength (tailor sitting, squatting) anemia and neural tube defects (problem: 2. Perineal healing failure of spinal cord to fuse). 3. Bowel / bladder incontinence § RDA: 400 mcg/day 4. Sexual return –– tightens vagina. 5. Premature ejaculation INCREASED SALIVATION (PTYALISM) - Cause by estrogen ENLARGEMENT OF THE UTERUS / ABDOMEN - Pica –– craving of weird or abnormal non-food - (+) pregnant can approximate AOG: substances (such as powder, wood, paper, or etc.) o McDonald’s Rule: estimation of AOG in o Can be caused by psychological factors, and months and weeks by fundic height ↓iron and zinc. measurement o Concern: § 1cm = 1 week § Nutrition due to low nutritional value § Tip of the tape measure is placed on § Fetus due to the intake of harmful the symphysis pubis to the fundus. substances. § Best accuracy: 20-31 weeks of AOG § Investigate parasitism. VAGINAL CHANGES ! MCDONALD’S RULE FORMULAS ! !"#$%& ()%*+, (&.) 0 1 - Leukorrhea: ↑secretions (white, colorless; odorless) Formula (AOG in MONTHS): 2 caused by estrogen Example: Fundic Height is 21 cm. 13 &. 0 1 = 6 %&'(ℎ* " Monitor for infection: 2 § 1st tri: anomalies and abortion !"#$%& ()%*+, (&.)0 4 § 2nd-3rd tri: preterm labor Formula (AOG in WEEKS): 2 YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM 13 &. 0 4 Example: Fundic Height is 21 cm. = 24 -../* What: to check if head or buttocks 2 Why: presentation (presenting part) o Bartholomew’s Rule: SUX o Ideal presentation: cephalic presentation § Symphysis pubis: 3 months (occiput [vertex presentation) § Umbilicus: 5 months o Ideal lie: longitudinal (cephalic presentation) § Xiphoid: 9 months ! FETAL PRESENTATION, LIE AND ATTITUDE ! FETAL PRESENTATION ! NAEGELE’S RULE ! 1. Cephalic: head first - Best parameter to determine EDD. Fetal Attitude - Ask the when is the first day of the last menstrual a. Occiput (vertex) –– most ideal; full flexion period. b. Sinciput (military) –– moderate / partial flexion c. Brow –– partial extension; CS Month Day Year d. Face –– poor flexion, complete extension; Jan-Mar +9 +7 CS Apr-Dec –3 +7 +1 PROBABLE ⇒ Objective; observed by the examiner or nurse POSITIVE SERUM PREGNANCY TEST - Hormone: hCG - Created by: chorionic villi (trophoblast cells) Vertex Sinciput Brow Face - Accuracy: 95-98% - Present: 2. Breech: buttocks first o 7-9 days after fertilization a. Frank –– feet are extended on the face. o 1-2 days after implantation b. Complete –– cross legs - Increases: 1st trimester → abortion may result when c. Footling –– can be single or double. hCG is low - Decreases: 2nd trimester → hydatidiform mole may result when hCG is high. - Absent: 1-2 weeks after delivery → if still present, there is retained placenta. POSITIVE URINE PREGNANCY TEST - Reported by the patient, nurse, midwife, medtech - Highest accuracy rate: 99% Frank Complete Footling - Considerations: ABCDE o Avoid late reading → may lead to false (+) 3. Shoulder –– CS result o Best done in 1st urine o Concentrated urine o Do not take methadone and chlordiazepoxide → may lead to false (+) result o Expiration date → may lead to false (+) result FETAL LIE OUTLINE FELT BY THE EXAMINER 1. Longitudinal –– vertical - When: 2nd trimester 2. Transverse –– horizontal; CS - Why only probable: the outline may be tumors with 3. Diagonal (oblique) –– 45 degrees; may rotate to calcium deposits longitudinal. LEOPOLD’S MANEUVER - Observation + palpation - Purpose: to determine if the process of labor is easy or difficult delivery - When: late third trimester - Nursing considerations: " Instruct the patient to empty the bladder before doing the procedure. " The hands should be warm. ① 1st Grip: Fundal Grip Longitudinal Oblique Transverse Where: superior of fundus YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM ② 2nd Grip: Umbilical Grip § Dilation of cervix is perfect Where: side of uterus § Molding of head –– overlapping of How: top to bottom suture lines What: fetal back (broad and hard) § Cord prolapse prevented Why: position o Ideal position: occiput anterior (of the BALLOTEMENT mother)–– whether left (LOA; most common) - When: 2nd trimester (4-5 months) or right (ROA) - Why only probable: this is also present in ascites § If ROP/LOP: painful, prolonged - Balloter: to quake delivery - Bimanual palpation o One hand: top of the cervix o Other hand: abdomen - Bouncing of the baby (passive movement) - Baby against amniotic fluid BRAXTON HICKS CONTRACTIONS - Painless to painful episode: false labor - Present throughout pregnancy o Starts at 12 weeks o Noticed by the patient at 2nd trimester o Strongest at 3rd trimester - Placental perfusion - Practice of preparation Steps BLUISH VAGINA: CHADWICK’S SIGN 1. Chosen point - Normally, vagina is pink § Sacrum: breech - This is due to increased vascularity caused by § Mentum: face estrogen. § Occiput: vertex - Violet or purplish § Acromion: shoulder 2. Left or right of the mother. LOWER UTERINE (ISTHMUS) SOFTENING: HEGAR’S SIGN 3. Anterior, posterior, or transverse - When: 6 weeks AOG, second missed period - Soft and paper thin due to PR ③ 3rd Grip: Pawlick’s Grip Goodell’s Sign Where: above symphysis - Softening of the cervix How: grasps between thumb and fingers - 1st trimester: cervix start to soften What: movement and consistency - 2nd trimester: soft cervix o Movable: not engaged - 3rd trimester: ripen cervix o Fixed or not movable: engaged Why: engagement and confirm presentation EVIDENT SAC o Engagement is the descent of the fetus to the - What: characteristic ring in UTZ pelvic inlet of the mother o If this is seen in UTZ, needs to return after a § Landmark of engagement: ischial week or two to confirm if there is fetus. spine–– two pelvic bone (station 0) - When: appears on the UTZ on the 4th to 6th week of Station (-): above the pregnancy ischial spine o Then return on the 8th to 10th week → visible o -3 to -4: floating presence of fetus in UTZ → confirms o pregnancy! Station (+): below the ischial spine POSITIVE o +3 to +4: crowning ⇒ Confirmatory of pregnancy § Best indicator if the fetus has descended: Internal / vaginal / PRESENCE OF HEARTBEAT OF FETUS digital exam–– Two fingers (middle & - Seen and heard index finger), gloved, and lubricated. - Use to assess fetal wellbeing - Normal HR of fetus: 110-160 bpm ④ 4th Grip: Pelvic Grip - Earliest heard: 1st trimester (3rd month; 10th to 12th For cephalic presentation only week) Where: both above inguinal ligaments - Point of maximum impulse (PMI): fetal’s upper back How: press downward-inward o If cephalic: LLQ What: flexion or extension o If breech: LUQ Why: attitude o Ideal attitude: full flexion (vertex): Dila MoCo YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM OUTLINE OF FETUS IN UTZ § It has 3 blood vessels (AVA), - When: 8-10 weeks (earliest) wherein the only vein is responsible giving the oxygenated, nutrient-rich Ultrasonography blood from the placenta to the fetus. - Routine transabdominal or pelvic UTZ 3. Nutrients o Transvaginal UTZ may be utilized during the 4. Barrier 1st trimester or early pregnancy. § However, it cannot block drugs and § Nursing considerations: viruses––TORCH: " A probe is inserted in the 1. Toxoplasmosis vagina, and it is covered 2. Rubella with a sterile sheath 3. Cytomegalovirus (usually a condom). 4. Herpes simplex. " Instruct the patient to 5. IgG empty the bladder. 6. Hormones to sustain pregnancy. - Preparations: " Educate (nurse can educate since it is not an MOVEMENTS FELT BY THE EXAMINER invasive procedure) - When: 20-24 weeks ○ Sound waves is used and does not - Rate: 10-12 movements/hr cause harm to both the mother and baby. SKELETON IN XRAY ○ Transducer is placed on the - Formed: starts on the 12th week or 3rd month abdomen. - Seen: 4th month ○ Visualize pregnancy in monitor. - Mineral needed: calcium (1g/day) –– given on the 2nd " Physical trimester; and avoid giving it simultaneously with iron, ○ Full abdomen to stabilize uterus. wait for 2 hours. 1 glass q15 for 90 minutes - Vitamin needed: Vitamin D (600IU/day; fat soluble) (1 hour and 30 minutes) - X-ray is avoided during the 1st trimester because it is Instruct the mother to not the period of organogenesis, hence procedures that void. may emit teratogenic effects to the fetus should be ○ Position: supine with pillow or towel avoided. on her right hip or buttocks ○ UTZ gel should be in room FETAL DEVELOPMENT temperature or warmer. - Purpose: ⇒ 40 weeks; 10 lunar months o 1st trimester: confirm and diagnose o 2nd trimester: detect congenital anomalies FIRST TRIMESTER and gender, placenta, amniotic fluid. ⇒ From 1st to 3rd month: 1st to 12th week o 3rd trimester: optional and not routine § Maturity: biparietal diameter, head FIRST LUNAR MONTH (1st to 4th week) circumference, femoral length Four (4) weeks old § Presentation Implanted (embedded) embryo § Position o Average: 8-10 days o Only 50% are implanted Amniotic Fluid Rudimentary heart –– not yet functioning. - Purpose: Spinal cord fusion 1. Cushion (protection) o CNS starts to form at 3 weeks 2. Thermoregulation o Folic acid is crucial in the fusion of spinal cord. 3. Fluid to drink Three germ layers: EME 4. Facilitate movement o Ectoderm (outside): ECTO - Normohydramnios: ~500-1000ml (28 weeks and more) § Ear, eyes, nose o During the 4th month, the fetus starts to § CNS urinate. § Touch, taste - Oligohydramnios: < 200ml → fetal problem: § Openings musculoskeletal problems, renal agenesis o Mesoderm (middle): MESO - Polyhydramnios: > 2000ml → fetal problem: § Muscles, muscular esophageal atresia § Enamel of teeth § Skeletal Placenta § Organs: - When: 2nd trimester Circulatory - Location: upper - Purpose: Reproductive 1. Blood supply Upper urinary tract: 2. Oxygen kidneys, ureters o Endoderm: 4Ls YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM § Lower urinary tract: bladder, urethra ○ Amniotic leak § Linings ○ Bleeding § Lalamunang may TT-TT ○ Contraction Tonsil, thyroid ○ Fetal heart rate Thymus, trachea ○ Infection signs–– WOF: § Lungs fever and chills ○ Rh (-) mother –– give SECOND LUNAR MONTH (5th to 8th week) RhoGAM. Sac –– probable sign Extremities INSTRUMENTS USED TO HEAR HEART SOUNDS Contraction of heart is seen in UTZ Doppler: 3 mos Organogenesis is completed → FETUS (8 weeks until Fetoscope: 4 mos delivery) Stethoscope: 5 mos Noticeable face Developing digestive system: starts to swallow FIFTH LUNAR MONTH (17th to 20th week) amniotic fluid Fetal movements IgG transfer THIRD LUNAR MONTH (9th to 12th week) Vernix caseosa–– whitish, cheese-like substance in Tooth buds + bone ossification skin Hear the heart sound o Purpose: Ihi (urine) formation § Protection o Amniotic fluid is scanty (small) in amount from § Provide heat (thermoregulation)–– maternal serum through osmosis and delay bath for 24 hours; helps the diffusion. baby to adjust from extrauterine life § Invasive procedure to check fetal o Decreases overtime well-being or genetic/chromosomes § Term: decreased (karyotyping): chorionic villi sample § Post term: absent → desquamation (CVS) of skin. Chorion (placenta) and amnion (baby and amniotic SIXTH LUNAR MONTH: SPECIAL (21st to 24th week) sac) have the same origin Scalp hair Reflex: Babinski –– first reflex. Sound Doppler technology to her the heart sound Surfactant: produced by the lungs to prevent alveolar collapse SECOND TRIMESTER o To determine fetal lung maturity: lecithin (L): ⇒ From 4th to 6th month: 13th to 24th week sphingomyelin (S) ratio § L:S ratio is 2:1 FOURTH LUNAR MONTH (13th to 16th week) If < 35 weeks, S > L. Fetoscope § Amniotic fluid sample is taken to Fine, downy hair (lanugo) determine L:S ratio o Decreases overtime: Survival: age of viability § Term: decreased o Official age of viability: 20-24 weeks, thanks § Pre-term: increased to technology! § Post term: absent o The fetus should weigh more than > 500g Ordinary stethoscope (~550g) to survive 24 weeks o Best used in 5 months THIRD TRIMESTER Urinate o Starts at 4 months → increased amniotic fluid ⇒ From 7th to 10th month: 25th to 40th week → may perform amniocentesis Reveal gender: 4 months SEVENTH LUNAR MONTH (25th to 28th week) Scrotum has descended due to heat ! GOOD TO KNOW ! Eyes are delicate CVS VS. AMNIOCENTESIS Vessels in the retina are forming CVS AMNIOCENTESIS Eye blinking peaks When 1st trimester 2nd trimester Ninety percent (90%) survival 5 weeks; usually Earliest 14-16 weeks Lack of surfactant may result to respiratory distress 8-10 weeks Sample Chorionic villi Amniotic fluid syndrome (RDS) → intervention: increase O2 concentration → too much concentration → blindness. " Informed consent Prepare " Empty bladder EIGHTH LUNAR MONTH (29th to 32nd week) " UTZ at bedside Extends when startled: Moro reflex Monitor " At least 30 minutes: ABCFIT Iron stores in liver YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM o Used up to 6 months of life o If there is presence of edema on the face or o 6th month old baby: start food introduction–– at the start of the day → URINALYSIS–– has CERELAC! traces of protein! Grows faster Hermit face is now gone (old man’s face MEDICAL MANAGEMENT disappearance) Pharmacological: Lab Ni Hyd Tips of nails is equal on the fingertip % Labetalol –– first choice % Nifedipine NINTH LUNAR MONTH (33rd to 36th week) % Hydralazine (apresoline) –– potent vasodilator Near term !! DO NOT GIVE %ACE INHIBITORS → FETAL KIDNEY Increased fats DAMAGE !! Nearly 100% survival Turn around NURSING MANAGEMENT Head down: cephalic " Monitor BP and PR TENTH LUNAR MONTH (37th to 40th week) PRE-ECLAMPSIA Term (10 months = 40 week; ~38-42 weeks) - Complication of HTN o Best: 39-40 weeks - Happens before seizure Engagement - HTN + proteinuria, then edema. o Primi: 38 weeks o Multi: different times # Proteinuria Nearing birth # Renal involvement o If > 42 weeks, POST TERM # Edema (generalized) → cerebral edema → cerebral § Decreased placental functioning irritated → seizure → ECLAMPSIA. § IMMEDIATE DELIVERY!! " Eliminate triggers of seizures: bright light and sudden GESTATIONAL HYPERTENSION noise. ○ Private room ⇒ Hypotension is normal during pregnancy but only in the 2nd ○ Dim light trimester. This is to give way to the growing placenta. " Convulsion prevention by (see L or PRE-ECLAMPSIA) " Lowering the BP: ESSENTIAL / CHRONIC HYPERTENSION % Labetalol - Happens even before pregnancy. % Nifedipine % Hydralazine PREGNANCY-INDUCED HYPERTENSION " Assess vital signs hourly, especially the BP, and DTRs. - Only happens during pregnancy ○ BP of 160/110: severe - Due to ↑ blood volume (peak: 2nd trimester) ○ DTRs: hyperreflexia o Some arteries (relaxed during pregnancy due % Magnesium sulfate (CNS depressant): DOC to P-R) cannot tolerate the pressure → vessel ○ Prevent seizure. damage → vasospasm → ↑pressure → PIH. " Protein intake: o All organs are affected → first organ involved: ○ Mild features: regular kidneys → proteinuria → hypoalbuminemia → ○ Severe features: high protein fluid shifting due to imbalance in the oncotic " Sodium intake: moderate; limit salt pressure (decreased) and hydrostatic ○ Low sodium diet is not indicated because the pressure→ generalized edema → PRE- high aldosterone (retention of sodium and ECLAMPSIA. water) in pregnancy → double its effort which may stimulate RAAS → REBOUND HTN ASSESSMENT " Intake and output should not be 30. o (+) PIH requirement: ○ Oliguria may indicate: § BP of 140/90 and beyond Severe pre-eclampsia § Systolic (pre-pregnancy): + 30 At risk of toxicity magnesium toxicity 56 7 86 316 Example: 96 = 96 Sign of magnesium sulfate toxicity § Diastolic (pre-pregnancy): +15 " Assess FHR 56 56 Example: 96 7 3: = 2: ! MAGNESIUM SULFATE: CNS DEPRESSANT ! !! At least 2x, 6 hours apart !! AND MUSCLE RELAXANT Since all organs are affected, assess the face for Narrow therapeutic range: 5-8 mg/dL edema. o Check magnesium every 6-8 hours. o Normal edema: lower extremity due to Urine output: > 30 ml/hr uterine pressure. DTR: +2 § Normal at the end of the day o WOF: hyporeflexia–– 1st sign of toxicity § Abnormal at the start of the day RR: >12 cpm YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM Antidote: calcium gluconate CAUSES: DIM TOXICITY 1. Development: exposure to teratogenicity or 8-10 mg/dL Hyporeflexia 0, +1 chromosomal aberrations → destroys organogenesis Respiratory o Examples: 15-20 mg/dl < 12 cpm § Drug: Thalidomide → Amelia–– depression > 25 mg/dl Cardiac arrest → death absence of extremities § Radiation, chemicals ECLAMPSIA § Virus such as TORCH § Diabetes mellitus - Most severe gestational hypertensive disorder 2. Implantation –– implantation abnormality, ↓ - Tonic-clonic seizure progesterone - 20% mortality rate 3. Maintenance –– infections, immunologic " Ensure safety DIAGNOSTICS: HUH ○ Padded rails up hCG level ○ Lowest bed position Ultrasound ○ If the patient is on the floor during seizure, remove items or furniture nearby that can Heartbeat (absence of heartbeat in doppler or UTZ) injure patient. " Convulsion drugs MANAGEMENT " Prevent bleeding of the mother % Diazepam (Valium) IV !! The longer the seizure, the more ↓cerebral blood flow!! " Prevent infections " Left side to drain secretions ○ Bothe might lead to hypovolemic shock and septic shock " Assess fetus % Magnesium sulfate continued Pharmacological " Progress to labore due to high BP Late abortion (2nd trimester): MOM " SpO2 check: % Misoprostol ○ Emergency: 8-10 LPM via facemask ○ Prostaglandin E1 analog that promote: " Instruct NPO Contraction ○ Baby should be delivered within 12-24 hours Cervical ripening whether CS or NSD % Oxytocin NSD: GIT is ↓ and sphincter is ○ Stimulates uterine contractions. relaxed. % Mifepristone Prone to aspiration ○ A progesterone antagonist (vomiting) !! Dilates cervix and expel products of conception !! Not all mother who are subject for NSD may Surgical delivery normally, there Early abortion (1st trimester): DDS may are emergency & Dilation and curettage (D&C) situations that may lead to CS. & Dilation and evacuation (D&E) & Suction curettage " Assess for signs of bleeding every 15 minutes. ○ Petechiae !! Dilates cervix and remove products of conception !! ○ Bleeding gums ○ Ecchymosis ! TYPES OF ABORTION ! There is liver involvement. THREATENED Patient may complain 50-50 chance epigastric pain. " Abruption placenta Assessment ○ Check perineum and vagina for bleeding Cramping because high blood pressure may cause the Bleeding detachment of the placenta (premature Closed cervix separation). Nursing Management BLEEDING IN PREGNANCY " Complete bed rest (CBR) is not indicated as it can cause vaginal blood pooling → vaginal bleeding ⇒ No matter how small the amount is, bleeding in pregnancy " Avoid: S2S2T must be REPORTED to the physician. $ Strenuous activities for 2 days - Implantation bleeding should also be reported. $ Sex for 2 weeks $ Tampons FIRST TRIMESTRIAL BLEEDING ABORTION IMMINENT - Loss or interruption of pregnancy before the age of Inevitable viability (20-24 weeks) YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM Assessment CLASSIC TRIAD: APV Cramping # Amenorrhea: missed periods Bleeding # Pain Open cervix ○ Lower abdominal ○ Unilateral Nursing Management ○ Sharp pain " Save pads, clots, and tissue to rule out H mole # Vaginal bleeding –– scanty ○ H mole has 25% chance to develop a choriocarcinoma–– invasive type of WATCH OUT FOR placental cancer. ' Shock: HYPO TACHY TACHY " Assess bleeding ' Peritonitis ○ Rigid abdomen with tenderness COMPLETE ○ Pain Assessment Assess all products of conception that are expelled: DIAGNOSIS ○ Fetus UTZ to confirm if the implantation is outside the uterus. ○ Placenta ○ Membrane MANAGEMENT Bleeding slows in 2 hours and stops in days. " Spontaneously ended and reabsorb. Nursing Management Pharmacological " REPORT heavy bleeding % Methotrexate ○ 1 pad: 1 hour saturation of pad. ○ Antineoplastic ○ Can detect and stop rapidly growing cells like INCOMPLETE tumors, cells, and fetus. Not all products of conception are expelled Surgical Management & Emergency laparotomy if ruptured. " Surgical or pharmacological SECOND TRIMESTRIAL BLEEDING o WOF: hyporeflexia–– 1st sign of toxicity HYDATIDIFORM MOLE (H MOLE) - Gestational trophoblastic disease (GTD) MISSED - Pregnancy disorder Early pregnancy failure - Trophoblasts cells produces hCG o hCG should decline during second semester Assessment o However in H mole, there is abnormal Assess: 5S proliferation and degeneration ○ Silent symptoms o Fetus has 46 chromosomes, 23 from mother ○ Slight cramping and father respectively. ○ Spotting § 22 autosomes; 1 sex chromosome ○ Stopped signs and symptoms of pregnancy § In H mole, all of the 46 ○ Stopped development and heartbeat of the chromosomes are from the father. baby § There is fetus however the proliferation of trophoblasts hinder RECURRENT the growth of the fetus. AKA habitual abortion ASSESSMENT: 4Fs and 4Ps Assessment Fundic height is larger Assess 3 consecutive abortion Fast fresh flow Four months (16 weeks) is the start of bleeding Causes Fluid-filled clear vesicles (grape-sized) 1. Autoimmune, abortion Prune-juice like bleeding 2. Blood flow resistance in the uterine artery or uterus Peaked hCG levels 3. Chorioamnionitis Pattern: snowflake without fetal 4. Defective sperm or ova PIH starts earlier 5. Endocrine factors MANAGEMENT ECTOPIC PREGNANCY " Suction curettage - Implantation outside the uterine cavity. ( WOF: bleeding - 95% of ectopic pregnancy is tubal pregnancy - First to rule out before abortion. Teaching: HeTo NaMan PaPaPan-Cn (H2 NM1 PPPC)–– to - Risk: rupture that can cause bleeding know if cancerous " hCG level baseline YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM " Should be done every 2 weeks until normal. " Above 30% (if near the cervix area): CS " Monthly check up. " Under 30% (if a bit further from cervix area): NSD " hCG level should be normal for 1 year. " Vaginal exam ONLY IF: 3Ds " Prevent pregnancy to avoid disruption of hCG o Doctor monitoring, hence the use of pills. o Delivery " If the level of hCG is still high, it is choriocarcinoma. o Double set up § NSD CERVICAL INSUFFICIENCY § CS - Premature cervical dilatation or incompetent cervix - Happens during mid-pregnancy: 20 weeks ABRUPTIO PLACENTA - Premature separation of a normally situated placenta CAUSES 1. Advanced age > 40 years ASSESSMENT 2. Biopsies Painful because of irritated myometrium 3. Cervical trauma (D&C) 4. Defects Advanced age due to weak attachment of placenta Brown or dark bleeding (covert bleeding) ASSESSMENT Rigid uterus Painless dilatation (around 5 months and beyond) Uterus tenderness in the upper area (fundal) which is Pink show classified as sharp to dull. o Mucus plug (operculum) in the cervix that o Pain between contractions prevents invasion of microorganism Premature separation Pressure (contractions) (Hyper)Tension, trauma Premature rupture of membranes Disseminated Intravascular Coagulation (DIC) Progress of labor o The body tries to reattempt to reattach the placenta. MANAGEMENT o Increased clotting = embolism " Cerclage –– suture o Increased bleeding ○ Can be McDonald or Shirodkar Occult/hidden bleeding ○ Placed 12 weeks after UTZ No IE, rectal exam, and Leopold’s maneuver or ○ Removed 37 weeks or delivery (if elective or abdominal palpations as these may prompt the CS) detachment of placenta ○ Contraindication: ABC $ Amniotic bag rupture –– prone to PRETERM LABOR AND BIRTH infection - 4000g RISK FACTORS o Initiate breastfeeding if baby is hypoglycemic. 1. Defects 2. Race: Asian, Hispanic, Native American DIAGNOSTICS 3. IUFD, stillbirth Screening: 1 Hour Glucose Tolerance Test 4. PCOS - When: 2nd trimester (24-28 weeks or 6-7 months) 5. Obesity - How: 6. LGA baby before 1. Fasting 7. Age: > 25 year old 2. Give 50g glucose concentrate 8. Relative § Should be tolerated within 1 hour YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S. BACANI, RN, RM 3. Check blood sugar level after 1 hour " Few days later: pre-pregnancy insulin requirements § Should be 140 mg/dL " Breastfeeding: less due to risk of hypoglycemia § If positive screening, confirmatory test! ABO AND RH INCOMPATIBILITY Confirmation: 3 Hour Glucose Tolerance Test ABO INCOMPATIBILITY - How: - More common but less severe 1. Fasting: FBS of 95 mg/dL - 60% of the fetus blood type comes from the father. 2. Give 100g glucose concentrate 3. Check blood sugar level after 1 hour (1st hour): 180 mg/dl 4. Check blood sugar level after 1 hour (2nd hour): 155 mg/dl 5. Check blood sugar level after 1 hour (3rd hour): 140 mg/dl - Interpretation: 2 abnormal results MANAGEMENT Diet " 3 meals + 3 snacks " 20% from protein " 40-50% from complex carbohydrates (grains) to prevent hyperglycemia and hypoglycemia " 30% from low saturated fat because the body breaks down the fat if the body cannot get any carbohydrates. If the mother is type O and baby is type A. The mother has naturally occurring anti-A and B Exercise: GALAW agglutinins–– these two antibodies are mainly IgM and " Glucose regulation better does not cross placenta. " Avoid extreme exercises, especially if uncontrolled If by any chance that there is a fetal blood escape into glucose level the maternal circulation, immune antibodies (IgM) are " Lasts > 12 hours effect formed in response to the entry of the A antigen bearing fetal RBC. Hence, this sensitization may lead to a mild " Aerobic exercise: or moderate immune response but less severe. ○ Walking for 30 minutes: daily o However, if the mother has been previously sensitized to these antigens, IgG antibodies Insulin: INSULIN (less common) may also be produced against " If uncontrolled with diet + exercise A or B antigens of the fetus. " NPH + regular-acting (mixed) o 2/3rd NPH; 1/3rd Regular RH INCOMPATIBILITY o Subcutaneous § Give 2/3 in AM - Less common but severe § Give 1/3 in PM - With antigen D: Rh + - With no antigen D: Rh – " Short-acting (alone) If mother is Rh – and baby is Rh + " Use one site in pregnancy due to sensitive regulation If fetal blood escape into the maternal circulation, the in pregnancy mother’s immune system will produce IgG antibodies " Less insulin in 1st trimester because of risk of against Rh antigen (Rh sensitization or hypoglycemia due to increased metabolic rate, isoimmunization). organogenesis, and vomiting o During the first pregnancy, the mother is not " Increased insulin in 2nd to 3rd trimester usually sensitized to the Rh antigen because " Nourishments or snacks she has not been exposed to SIGNIFICANT ○ Complex carbohydrates with protein (milk) amounts of Rh+ blood and small exposure to ○ If hypoglycemia occurs after exercise, give Rh+ is not enough to trigger strong immune milk. response. o Since IgG antibodies are more effective at Postpartum crossing the placenta, it can potentially target GDM and attack the Rh+ RBC of a subsequent Rh+ - Normalized by 24 hours fetus is future pregnancies. Hence, this ○ If not, possible DM Type II may result. sensitization may lead to mild to severe fetal " Check 1-2 hours post meal to regulate insulin during effects, such as adjustment period. 1. Hemolysis 2. Anemia DM Type I and II 3. Decreased albumin = edema - Immediate postpartum: none 4. Hydrops fetalis YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23  INTENSIVE: MATERNAL AND CHILD NURSING LECTURER: HAYDEE S.BACANI, RN, RM ! FETAL BLOOD ESCAPES HAPPENS DURING: ! 3Ps 1. Pregnancy end or loss 2. Placental problems: previa, abruption 3. Procedures of OB that are invasive MANAGEMENT " Rhogam: ○ Passive Rh (D) antibodies ○ Prevent Rh isoimmunization ○ When: 28 weeks (Rh-mothers) Again: within first 72 hours or 3 days after birth If not given, Rh isoimmunization. ○ Duration: 2 weeks to 2 months (effectivity) YOU ARE GOING TO MAKE IT: TRUST ME. PSALM 23