Maternal Health PDF

MATERNAL Monday, August 22, 2022 23:10 Menstrual Cycle ○ Menarche = 9-17 yrs old; ave. = 12 yrs old ○ Cycle = 26-36 days; ave. = 28 days ○ Ovulation day = subtract 14 from the menstrual cycle (subtract 14 from the day of the next cycle) ○ Eg: 30 days cycle - 14 = 16th da...

MATERNAL Monday, August 22, 2022 23:10 Menstrual Cycle ○ Menarche = 9-17 yrs old; ave. = 12 yrs old ○ Cycle = 26-36 days; ave. = 28 days ○ Ovulation day = subtract 14 from the menstrual cycle (subtract 14 from the day of the next cycle) ○ Eg: 30 days cycle - 14 = 16th day is the ovulation day ○ Duration = 1-8 days; ave. = 3-5 days ○ Menstrual flow = 20-80mL; ave. = 30-50mL (1/8 to 1/4 of a cup) ○ Heavy flow = Menorrhagia 4 PHASES of the MENSTRUAL CYCLE: 1. Menses = shed endometrium 2. Proliferative phase = FSH and ESTROGEN ○ FSH causes an increase in Estrogen ○ Estrogen leads to Proliferation of Endometrium 3. Secretory Phase = LH and Progesterone ○ Progesterone promotes vascularization of endometrium 4. Ischemic Phase TRIGGER: START OF CYCLE = LOW Estrogen and LOW Progesterone due to absence of pregnancy Feedback is triggered = Hypothalamus is stimulated = releases FSHRH FSHRH stimulates APG to produce FSH FSH stimulates MATURATION of the Graafian Follicle --> Estrogen is produced ○ FSH and ESTROGEN are partners ○ LH and PROGESTERONE are partners Estrogen Production Leads to PROLIFERATION OF THE ENDOMETRIUM = PROLIFERATIVE PHASE FEEDBACK TO HYPOTHALAMUS = LHRH is produced --> triggers Anterior Pituitary Gland (APG) APG will release LH (peak levels) = OVULATION ○ LH is the hormone of ovulation ○ Egg is viable only for 24 hours LH also triggers the development of the Corpus Luteum --> INCREASES production of PROGESTERONE = SECRETORY PHASE  HORMONE OF PREGNANCY = PROGESTERONE  HORMONE OF OVULATION = LH Progesterone increases secretions and blood supply to endometrium in preparation for pregnancy ○ IF EVER FERTILIZATION HAPPENS = PREGNANCY ○ NO FERTILIZATION = ISCHEMIC PHASE = estrogen and progesterone decreases = ovum atrophies after 4-5days = DEGENERATION OF:  ENDOMETRIUM  CORPUS LUTEUM (YELLOW IN COLOR) becomes --> CORPUS ALBICANS  = SLOUGHING = MENSES first day of menstrual flow is used to mark the beginning day of a new menstrual cycle ○ FEEDBACK MECHANISM RESTARTS During OVULATION = Body temperature decreases and then increases by 0.5 °F to 1 °F around the time of ovulation OVULATION = DROP IN TEMP = due to DECREASE in PROGESTERONE ESTROGEN PROGESTERONE Producecd by Graafian follicle "Hormone of Pregnancy" Secreted by ovaries BEFORE ovulation Produced by corpus luteum Regulated by FSH Secreted by ovaries AFTER ovulation Thickens endometrium Regulated by LH For breast engorgement Maintains thickness of endometrium Formation of mammary gland  Amenorrhea = absence of menstruation ○ 18 yo and above without menarche = primary amenorrhea ○ 3 successive months without menstruation = amenorrhea = secondary amenorrhea ○ Pregnancy = most common cause of secondary amenorrhea ○ Eating disorders Dysmenorrhea ○ NSAIDS (Ibuprofen) = take with food, water only; NEVER take with milk or juice (reduces its analgesic effect) ○ #1 adverse effect = GI bleeding ○ Antispasmodic (Buscopan) ○ Yerba Buena = Peppermint = decoction Oligomenorrhea ○ Decreased frequency of menstruation Hypomenorrhea = LOW VOLUME (100mL) Metrorhaggia = INC Frequency Infertility = inability to conceive for 1 year without contraception and with regular sexual contact FERTILIZATION aka CONCEPTION aka FECUNDATION ○ Best site of FERTILIZATION is: AMPULLAR REGION OF FALLOPIAN TUBE  Sperm carries either X or Y chromosome  Egg only carries X chromosome ○ XX female ○ XY male  Genes = basic unit of heredity  Chromosomes = 46 total (23 pairs) = gene carriers ○ Genotype = actual genetic composition; "Not visible" ○ Phenotype = outward appearance; expression of the genes eg: hair color, skin color, eye color = "visible" Fallopian tubes = site of fertilization ○ Ampulla = common site of ectopic pregnancy ○ Clomiphene Citrate = "Clomid" = increases the RISK of MULTIPLE PREGNANCIES 1. Interstitial = first segment 2. Isthmus = narrowest site ○ Bilateral Tubal Ligation BEST SITE because it is narrowest ○ BTL is recommended >35yo (high risk pregnancy) ○ At least 3 kids ○ Consent of Married couple 3. Ampulla = site of fertilization 4. Infundibulum = contains finger-like structures (FIMBRIAE) = catches the egg during ovulation Uterus ○ Pre-pregnancy:  60 grams  Location: Pelvic cavity = hence vaginal ultrasound in 1st trimester  Organ of menstruation  Layers of uterus:  Endometrium = implantation  Myometrium = layer that responds to oxytocin and initiates contractions  Placenta acreta = deep implantation of placenta in myometrium  Perimetrium = outer lining ○ Pregnancy:  Ovoid  Weight = 1000 grams (from 60 grams)  Volume it can hold = 1000mL amniotic fluid  HEGAR'S SIGN = (+) SOFTENING OF THE LOWER SEGMENT OF THE UTERUS  Fundus = top part that contracts best during labor  Fingerpads = best instrument to check for contractions  Isthmus = part that stretches to accommodate growing baby  Cervix = softens in preparation for descent of baby = (+) GOODELL'S SIGN   (+) Ladin's sign is a clinical sign of pregnancy in which there is softening in the midline of the uterus anteriorly at the junction of the uterus and cervix  (+) Piskacek's sign consists noting a palpable lateral bulge or soft prominence one of the locations where the uterine tube meets the uterus Implantation or Nidation occurs in 7-10 days (ave. 1 week) Best location for implantation = endometrium of POSTERIOR FUNDUS; UPPER part ○ If lower = Placenta Previa esp in Multiple pregnancies (due to thinning of endometrium) ○ Deep implantation of placenta = placenta acreta = Massive hemorrhage during labor Zygote = single-cell structure formed after fertilization ○ Blastomere = 8-cell structure ○ Morula = 16-cell structure ○ Blastocyst = 32-cell structure = CAPABLE OF IMPLANTATION  Trophoblast will develop into placenta  Hydatidiform Mole = aka Gestational Trophoblastic Disease = fluid-filled grapelike structures ; proliferative and degenerative disorder of the trophoblast ○ In the first 7-14 days, the ovum is known as a blastocyst; it is called an embryo until the eighth week; the developing cells are then called a fetus from 8th week until birth.  Fertilization to implantation (ave 7 days) = Zygote  7-14 days = Blastocyst  Day 15 to 8th week = Embryo  8th week to birth = Fetus ENDOMETRIUM ○ Decidua Basalis = directly under embryo ○ Decidua Capsularis = stretches over trophoblast = envelopes growing baby = "CAPSULE" ○ Decidua Vera = remaining area in the endometrium Fetal Heart ○ 10th to 12th week = Doppler ○ 16th week = Fetoscope ○ 18th to 20th week = Auscultation with steth Fetal Sex ○ Visualized at 12th week AOG via UTZ FETAL STRUCTURES ○ Chorionic Villi = produces HCG  Part of placenta = increases surface area for absorption of nutrition  HCG = maintain the corpus luteum ○ Pattern of HCG production □ 30 days = HCG can be detected to determine pregnancy = 25 mIU/mL = detectable level = Urine = qualitative = pos or neg = can detect 12-15 days after ovulation = Blood = quantitative = exact □ 60 days = peak HCG production = Nausea and Vomiting □ 90 days = level slowly declines ○ Placenta = from the chorion  Present and functional at 10 to 12 weeks  15-20 cotyledons  15-20 cm in diameter  400-600 grams  Site of implantation: POSTERIOR FUNDUS  Basic life function of the baby  Separate Endocrine gland ○ HCG ○ Human Placental Lactogen = causes insulin resistance ○ Estrogen ○ Progesterone = hormone of PREGNANCY ○ GDM = insulin resistance that develops during pregnancy  Temporary but can develop Type 2 DM in 5-10 years  GDM screening begins at 24 to 28 weeks   Hormones of pregnancy (esp. HPL and HCG and progesterone) are insulin antagonists and cause insulin resistance = leading to GDM ○ Rebound Hypoglycemia in Neonates born to mother with GDM  Hypoglycemia is caused by hyperinsulinemia due to hyperplasia of fetal pancreatic beta cells consequent to maternal-fetal hyperglycemia. Because the continuous supply of glucose is stopped after birth, the neonate develops hypoglycemia becauseof excess insulin production and discontinuation of mother's blood supply (high in glucose) UMBILICAL CORD = "FUNIS" ○ 30 - 80 cms long, 2 cm diameter ○ 3 vessels = 2 arteries, 1 vein = "AVA"  2 vessel cord = renal agenesis = only 1 kidney  Less 1 blood vessel = congenital anomalies ○ Arteries carry deoxygenated blood away from fetus  Arteries AWAY (deoxy blood AWAY from Fetus) ○ Normal insertion site = CENTER  Lateral insertion = "Battledore placenta" = NO clinical significance Velamentous cord insertion is a complication of pregnancy where the umbilical cord is inserted in the fetal membranes. ○ It is a major cause of anterpartum hemorrhage that leads to loss of fetal blood and associated with high perinatal mortality WHARTON's JELLY = prevents the cord from getting compressed and prevents vasospasm = maintains adequate blood flow = protects blood vessels LEOPOLD'S MANEUVER ORDER: 1. LM1 - Fundus = Fundal grip - to determine Fetal Lie Normal = Longitudinal (Vertical) 2. LM2 - Sides of Abdomen = Lateral grip - to determine fetal position & structures (back of fetus vs anterior) If fetal back is on the right = Fetal position is right 3. LM3 - Above symphysis Pubis = Pawlik's grip - to determine presenting part (denoted by first fetal part that enters maternal pelvis) Normal = Occipital 4. LM4 - Abdominal midline going down = Pelvic grip - to determine Fetal Attitude (the relationship of the fetal parts (limbs/extremities to the fetal trunk) Normal = Complete flexion TRUE vs FALSE LABOR FALSE TRUE Contractions Irregularly spaced Regular, Rhythm is Latent = every 5-30 mins Duration, Frequency, Variable Increases and becomes closer and stronger Intensity over time = PROGRESSIVE Affect of position or activity Contractions lessen with activity Becomes stronger with ambulation or actiivty Location where felt Front = in the lower abdomen Back = starts in the back and radiates to abdomen Cervical change & presencee of "show" None Progressive effacement, dilation, (+) bloody show present Problems with LABOR and BIRTH Problems with Umbilical cord 1. SHORT CORD = 80 cms ○ Cord Prolapse = cord is presented first or along with the baby = can lead to VARIABLE DECELERATIONS IN FHT or BRADYCARDIA = First assess this Sign when PROM Occurs Severe fetal hypoxia = VIOLENT fetal activity first then SUDDENLY ceases = Tocolytic agents may be given to reduce uterine activity  A. OCCULT = cord is BESIDE but not past presenting part ○ Left Lateral position ○ Oxygenation for mother ○ Discontinue Oxytocin if in place = since C/S may be recommended ○ Allow labor progression if FHT within normal ○ Continue FHT monitoring B. OVERT = cord is BELOW presenting part ; ROM has occurred ○ Most COMMON i. RELIEVE COMPRESSION AND PREVENT VASOSPASM ○ Manual Elevation through maternal positioning = KNEE CHEST, MODIFIED TRENDELENBURG = priority intervention ○ Cord Reduction = done by doctor ○ Cover exposed cord with STERILE DRESSING SOAKED IN WARM SALINE if cord is exposed ○ Bladder Filling = 500-1000mL so pressure on cord is relieved ii. FETAL ASSESSMENT iii. PROMPT DELIVERY □ NSVD if CERVIX IS FULLY DILATED □ C/S = if slow labor progress C. FUNIC presentation = cord is BELOW presenting part with INTACT MEMBRANES  Aka Cord presentation  Same management as Occult but DELIVERY IS CS when TERM AMNIOTIC FLUID = cushions the fetus Contained in the amnion Volume of amniotic fluid ○ 12 weeks = 50 mL ○ 16 weeks = 200mL = AMNIOCENTESIS is done for further testing (chromosomal abnormalities) [15-30 mL is required; average of 20mL] ○ 20 weeks = 400 mL (increases due to fetal urine) ○ 36 to 38 weeks = 1000 to 1500 mL Functions:  Protective  Thermoregulation  Musculoskeletal development = baby can move around Production of amniotic fluid = Fetal urine and Lung secretions Clearance = fetal swallowing, membrane transfer Normal Amniotic Fluid index = 8-24 centimeters  Done via ultrasound  OLIGOHYDRAMNIOS = below 5 cm = kidney problems  POLYHYDRAMNIOS = greater than 24 cm = GIT problems Major method of absorption is through FETAL SWALLOWING ○ Fetus swallows amniotic fluid --> absorbed in fetal intestine --> blood stream --> umbilical arteries --> placenta Normal volume of AF = 800-1200mL ave 1000mL Problems with Amniotic Fluid EXCESS = POLYHYDRAMNIOS aka HYDRAMNIOS >1500mL or AFI >24 cms ○ Problems with FETAL GIT:  Esophageal atresia  Tracheoesophageal Fistula  Anencephaly ○ HIGHLY related to GDM and PIH  GDM = high glucose = causes osmotic shift of fluids into the uterus ○ POLYHYDRAMNIOS = HIGH RISK FOR PRETERM DELIVERY  Principle of "Uterine Stretch Theory"  Increased uterine pressure = PROM  Fetal malpresentation = baby can turn to transverse lie  S/Sx: Enlarged uterus, Increased Fundic height Increased Amniotic Fluid volume in USD Management ○ Rest = because mother is prone to preterm labor ○ Limit SODIUM intake ○ Treat or manage underlying problems = eg: GDM (diet and exercise) ○ Prepare and watch out for signs of labor LOW LEVEL = OLIGOHYDRAMNIOS 24 cms) or oligo (35 yo) ○ Done in 2nd Trimester (15-18 weeks) MARKERS: Sample = serum 1. AFP = produced in Liver High = NTD Low = TRISOMIES (eg: Down's Syndrome) 2. HCG = produced by placenta Remains elevated until after 2nd trimester (30-60-90 days) IF Constantly HIGH even after 2nd trimester = TRISOMY; H. MOLE 3. Unconjugated Estriol = produced by placenta LOW = TRISOMIES 4. Inhibin A = produced by placenta Increase (DOUBLE) with Trisomies COOMB'S TEST = checks for ANTIBODIES against PROTEINS attached to RBCs INDIRECT = uses patient SERUM or PLASMA (MOTHER) ○ Detects presence of antibodies in plasma (usually done for Rh neg mothers) ○ (+) = Agglutination when anti-human globulin reacts with anti-RBC antibody found in plasma ○ Rhogam given at 28 weeks AOG or within 72 hrs after birth; IM DIRECT = uses RBC sample from blood (BABY) ○ Detects mother's antibodies attached to baby's RBC = used to check: did mother Abs cross placenta? ○ (+) = checks for agglutination of anti-RBC antibody attached to RBC ○ Perform exchange transfusion = to replace RBCs with attached Abs = to prevent coagulation of baby's blood ○ Check Bilirubin levels ○ Blood type O mother = more prone to ABO incompatibilities if baby's blood type is not ORAL GLUCOSE CHALLENGE TEST ○ Done at 24-28 weeks to screen for GDM ○ Fasting: 8-14 hours; maintain normal carbohydrate intake at least 3 DAYS BEFORE TEST 50 g (non fasting) ○ Normal OGTT = less than 140 mg/dL ○ if sugar level is equal or more than 140 mg/dL proceed to 3 hour fasting OGTT (100 g) 100 g Fasting OGTT ○ Normal: (Less than) ○ Fasting = 95 mg/dL ○ 1 hr = 180 mg/dL ○ 2 hr = 155 mg/dL ○ 3 hr = 140 mg/dL  GDM = 2 values above are greater than or equal normal  If only 1 value is higher = repeat test after 2-4weeks Management:  diet, Calorie counting ( should not be below 1000 calories per day), Exercises  Oral hyperglycemics are TERATOGENIC = NOT GIVEN  Insulin may be given as a last resort but via SQ injection NON STRESS TEST Detect FETAL heart acceleration in response to movement FHT vs Fetal movement Done at 28 wks AOG Normal movement in 1 hour = 10-12 fetal movements  If baby is sleeping = use Sounds = BELL to stimulate movement  Let mother eat something sweet to stimulate baby INDICATIONS FOR NST:  Fetal distress  Hypoperfusion  Lack of movement RESULT: REACTIVE = GOOD! = FHT increases by 15 bpm sustained for about 10-15 secs for at least 2 movements in a 20 minute window CONTRACTION STRESS TEST FHT vs Uterine Contractions Done at 6-7months  Determines effect of uterine contractions on baby  To detect ability of baby to tolerate contractions in preparation for delivery  ASSESS ABILITY OF PLACENTA TO PERFUSE FETUS Stimulate Contractions = using NIPPLE STIMULATION or OXYTOCIN RESULT interpretation: ○ NEGATIVE = NO fetal Heart Rate Decelerations = GOOD (baby is okiedokie) ○ If Positive = BAD result = 50% of uterine contractions causes decelerations DECELERATIONS: ○ Early decel = Head compression  Not really alarming during descent, b/c the fetal head is compressed during labor  Alarming in early labor when head has not fully descended yet = indicates Cephalopelvic Disproportion (CPD) ○ Variable decel = Cord Compression, Cord prolapse  Irregular depression of FHT  Causes of variable decels:  Long or short cord  Multiple gestation  Maternal position  Trauma to mother ○ Late decel = Maternal Causes = UteroPlacental Insufficiency  LATE DECELS = Maternal conditions:  GDM = ineffective perfusion d/t viscous blood  Eclampsia  Maternal hemorrhage  FHT depressed after uterine contraction  Every time uterus contracts = placental perfusion is inadequate to supply baby = very bad = baby not okay :( First nursing intervention for Late and Variable decels: Reposition mother to left side lying HYPOTONIC LABOR = give 10 IU of Oxytocin is given if nipple stimulation does not work = to induce labor Remember! OXYTOCIN:  Prior to giving Oxytocin during labor = ensure that contractions are not less than 2 mins apart and not longer than 70 secs in duration  Monitor patient's FIO because prolonged Oxytocin infusion may cause SEVERE WATER INTOXICATION = Seizures, coma, death Contraindications to Oxytocin administration: ○ Any condition that may cause UTERINE RUPTURE   CPD  Abnormal Presentation  Fetal distress  Prematurity  Hydramnios = oxy leads to water intoxication = distended = rupture  Overdistention of uterus KICK COUNTS Done to check for fetal well-being NORMAL = 10-12/hour, Should NOT BE LESS THAN 3  LESS than 3 = Alarming Count on the same time each day, PREFERRABLY after meals Position = LEFT SIDE LYING SIGNS OF LABOR Lightening = descent of baby to birth canal = load is "lightened" on the chest = ease in breathing = usually 2 weeks before labor in PRIMIGRAVIDA ; in MULTI = sometimes at onset of labor already Backache = presenting part causes more pressure on coccyx and sacrum as baby goes down Weight loss = 0.5 to 1.5 kg Sudden surge of energy = Epinephrine/adrenaline increase Bloody Show = pinkish, mucoid = mucus plug is dislodged as cervix opens Cervical ripening = cervix softens in preparation for effacement & dilatation  Progressive Effacement = 100% & Dilatation = 10cm Possible Rupture of Membrane = 4-7cm = best time for bag of water to break = during ACTIVE LABOR  Preterm ROM = bag of water leaks before term  Premature ROM = bag of water breaks but not yet in active labor but baby is TERM If there is (+) PROM = but after 6-8 hrs baby is not yet delivered = HIGH risk for infection Amniotomy = artificial ROM; not recommended to reduce risk of infection  What will make FIRST STAGE of labor go FASTER? AMBULATION = best and then Amniotomy (2nd best) THE P's of LABOR Power Passageway Passenger Psyche Position 1. POWER A) Uterine Contractions = primary power of labor B) Abdominal Contractions = ability of mother to push WARNING Duration of more than 90 secs (may cause fetal distress = lessens perfusion to placenta) = monitor and report! : Normal duration = 60 secs Less than 30 sec Interval = short interval, does not allow baby to recover in between contractions = monitor and report! Mother should PUSH DURING CONTRACTIONS and when cervix is fully dilated  Cervix will become edematous if mother pushes without contractions = leads to arrest in dilatation  Fundal push can lead to Abruptio Placentae, Uterine inversion = not recommended Duration Interval Frequency 2. PASSAGEWAY Pelvis = GYNECOID is the best pelvis (Round) Ischial spine = used to determine STATION Coccyx is movable Types:  Gynecoid = round = female pelvis  Android = heart = male pelvis  Anthropoid = oval (vertical)  Platypelloid = Flat pelvis (oval) CPD = abnormal pelvic shapes Cervix  Effacement = 100% Full  Effacement happens first before Dilatation  Dilatation = 1 fingerbreadth = 1 cm = 10cm Full RATE of CERVICAL DILATATION = 1cm per hour (ACTIVE PHASE) Vagina 3. PASSENGER Fetal Presentation = Cephalic - Vertex (chin of baby touches the chest) = occiput = BEST 3 Passengers = membranes, baby, placenta ○ Head is favorable presenting part because it can undergo moulding (overlapping of cranial sutures) ○ Breech = any part of body except head  Complete = buttocks and feet  Incomplete = buttocks and a foot ○ Frank = buttocks only = NSVD not allowed ○ Footling ○ Transverse/Shoulder PELVIMETRY TRUE & DIAGONAL CONJUGATE ○ Estimated through IE ○ Anteroposterior diameters = sacrum to symphysis pubis (cms) ○ 12.5-13 cms Diagonal conjugate = NSVD okay  True Conjugate = equal to Diagonal Conj. minus 1.5cm = at least 11 cms = adequate Pelvis for NSVD  Diagonal conjugate = 12.5-13 cm  True conjugate = at least 11 cm Fetal Position = relationship of fetal part to a specific quadrant on mother's pelvis = Occiput-Anterior Position (LOA or ROA) = BEST bc of faster delivery & less painful  First letter =where is the Fetal back   2nd letter = what is the presenting part  3rd letter = where baby is facing (Anterior or Posterior) Fetal Station = relationship of fetus with the ischial spine  ENGAGEMENT = Station 0 = when the fetus is at the level of ischial spine  Above ischial spine = negative  Below ischial spine = positive  Eg: baby is at - station 2 = Floating = Allow mother to ambulate Eg: baby is at + station 2 = prepare for delivery Fetal Skull = Fetal skull is largest part of baby's body Molding allows head to be delivered by overlapping of cranial bones  Frontal, parietal, occipital bones = actively involved in delivery Caput Succedaneum = "cone heads" prolonged labor, resolves in 2-3 days Cephalohematoma = collection of blood in the scalp periosteum d/t rupture of capillaries, resolves in 2-3 weeks max of 6 weeks Which condition crosses the cranial suture lines? Caput Succedaneum (resolves quicker) Cephalohematoma is usually isolated in PARIETAL portion of the skull Fetal Lie = relationship of long axis of fetus and mother = Spine to spine relationship  Vertical or Longitudinal = BEST  Transverse  Oblique Fetal Attitude = relationship of fetal parts to one another = COMPLETE FLEXION = BEST/Most common Placental Delivery:  Duncan = "Dirty" = exposed cotyledons = more bloody = Maternal side  Placental issues = Duncan presentation  Schultze = "Shiny" = cotyledons are intact = Fetal 4. PSYCHE = feeling that patient brings into labor Preparation is important Patient education should be done prior to delivery = childbirth classes, breathing exercises Help ease pain by back rubs, change of position, breathing exercises, imagery High anxiety = distraction, massage, music, breathing exercises 5. POSITION Squatting & Lithotomy = BEST Epidural Anesthesia Done during active labor (4-7cm dilated)  If given too early = contractions may stop  Late = may cause Respiratory depression in baby ! Check BP ! = epidural may lead to hypotension  epidural block affects nerve fibers that control muscle contractions inside the blood vessels. This causes the blood vessels to relax, lowering blood pressure (WOF!) LABOR AND DELIVERY 4 Stages: 1. First Stage = Stage of Cervical Dilatation = longest; stage where primigravida vs multigravida differ From onset of true labor contractions to Full cervical dilatation LATENT ACTIVE TRANSITIONAL 4-6 hrs (up to 8hrs in primi) Dilatation & Effacement 0-3 cms ; 0-30% 4-7 cms ; 40-70% 8-10 cms ; 80-100% Mild Mod Strong Contractions  0-30 secs 30-60secs 60-90 secs 5-30 mins apart 3-5 mins apart 2-3 mins apart Attitude of Mother Irritable, Anxious Loss of control, panic Cooperative, excited with some degree of apprehension 3 Phases of contractions: 1. Increment = crescendo, increasing intensity 2. Acme = peak or apex 3. Decrement = decrescendo or relaxation 3 elements to note: 1. Duration = start to end of the same contraction 2. Frequency = start of the first contraction to the start of the next contraction 3. Interval = end of one contraction to the start of the next contractions  Be careful with interval. Do NOT count the duration of the contraction. Cervical dilation occurs more rapidly during the active phase ○ ACTIVE phase = progressive dilatation from 4 to 7 cm within 4 hours after ROM ○ Failure to fully dilate = Arrest of the Active phase of Stage 1 of labor  Prostaglandin Gel = promotes cervical ripening = leads to dilatation ○ PG gel is used in missed abortion ○ May also be used during Prolonged/Hypotonic labor First stage (Important Interventions): ONSET OF TRUE LABOR TO FULL CERVICAL DILATATION Common problems = hyperventilation & increasing anxiety, backache, abdominal cramps ○ To do:  Hygiene & Perineal Prep  Ambulation = do not ambulate anymore once (+) leaking BOW  Empty bladder  Breathing : ▪ Latent = Deep breathing ▪ Active = Accelerated breathing ▪ Transitional = Pursed lip = "HEE HEE HO"  If mother experiences hyperventilation = let them breathe through CUPPED HANDS or PAPER BAG  Bearing down techniques  Positioning for birth What is the most common position for childbirth? LITHOTOMY What is the best position anatomically? SQUATTING (pelvis opens up more)  Vital signs monitoring ▪ ! Take BP in between uterine contractions never during ▪ Take TEMP more often after bag of water breaks = to monitor infection closely ▪ Latent = Q1hr ▪ Active = Q30mins ▪ Transitional = Q15mins BP and FHT monitoring during this stage Best time to start analgesic in labor = ACTIVE PHASE (4-7cm dilated) = 4 cm Best Partograph = used at first stage ACTIVE PHASE 1. FHT = symbol used is "O" 2. Maternal V/S 3. Amniotic Fluid 4. Cervical Dilation = symbol used is "X" Two lines of surveillance (Partograph): 1. Action Line (horizontal line) = if beyond, provide immediate action 2. Alarm Line (Diagonal line) = if beyond, REFER TO OB-GYN  2. Second Stage = Stage of Expulsion = from full dilatation of cervix to delivery of baby = takes less than 1 hour = What will make second stage go faster? EPISIOTOMY = perineum is cut = Pudendal anesthesia may be used = Local = Epissiorraphy = repair = Pudendal anesthesia and absorbable sutures are used 2 types of Episiotomy 1. Median = easier to do and heals faster, but high risk of rectal involvement 2. Median-Lateral = MOST COMMONLY USED; slower healing but lower risk of rectal involvement Nx. Responsibilities:  Ritgen's maneuver = prevent lacerations of perineum  Establishing an effective airway  Check for cord coil ○ Nuchal = neck = do not pull baby out, loosen cord first ○ Truncal = body  Cutting and clamping of cord = wait for pulsations to stop before cutting to prevent fetal anemia  Record TIME of BIRTH "Unang Yakap" 1. Promotion of Immediate and thorough drying = prevents stress, stimulates crying 2. Skin to skin = best source of warmth is mom, baby is placed in prone position on mom's chest to drain secretions 3. Properly timed Cord Clamping 4. Promote early breastfeeding APGAR SCORE Criteria Assess 0 1 2 Pulse Cardiac rate Absent 100 (100 and above) Respiration Cry Absent Weak Strong, Lusty Activity Muscle tone Limp Some flexion Well Flexed Grimace Reflex/irritability No response Some grimace Cry, gag, cough Appearance Color Pale/blue all over Acrocyanosis Pink/Red all over (extremities are blue) INTERPRETATION (1st min and after 5 mins) 0-3 = Depressed = Poor, resuscitation may be required 4-6 = Mod Depressed = Fair, Close monitoring, suctioning 7-10 = Good, regular nursery care  1st minute = check response to labor  5th minute = check extrauterine adaptation Mechanisms of Labor & Delivery: EDFIrEErE A) Engagement = at level of ischial spine (station 0) B) Descent = fetal presenting part is beyond pelvic inlet (+1,+2) C) Flexion = fetal chin bends towards chest D) Internal rotation = baby aligns = longer if baby is in occipito-posterior position (anterior is best) E) Extension = head comes out F) External rotation = anterior shoulder rotates externally = pull down - pullup - baby out G) Expulsion = rest of body comes out BEQ : Description of mechanism of delivery & sequence Second stage of Labor management:  Transfer to DR  Assist in bearing down = risky for IICP, MI, Heart failure  Perineal preparation  Prepare for arrival of neonate 3. Third stage = Stage of Placental Expulsion = 5-30 minutes after baby is born 2 Types of Placental delivery 1. Schultz = "Shiny" = Fetal side = MORE COMMON (80%)  2. Duncan = "Dirty" = Maternal side 4 SIGNS OF PLACENTAL DELIVERY: 1. Sudden gush of blood 2. Lengthening of the cord 3. Calkin's sign = globular shape of uterus = BLOOD in vaginal vault causes fundus to rise 4. Uterus rises to umbilicus  AMTSL = Active Management of Thrid Stage of Labor  Fundal massage of boggy uterus  Delivery of placenta by CONTROLLED CORD TRACTION = Brandt-Andrews Maneuver  Nipple stimulation  Give uterotonic = oxytocin (10 IU) Parenteral (IM or IV) Important interventions: Brandt-Andrews maneuver = "CCT" Controlled Cord Traction Note for delivery time Check for completeness = bc retained fragments cause bleeding Keep uterus well-contracted = give oxytocin; massage uterus ○ methergine can cause hypertensive crisis = not recommended anymore Most common cause of postpartum hemorrhage = UTERINE ATONY 4. Fourth Stage = Recovery Period = first 4 hours Postpartum (to monitor complications mainly BLEEDING) Check V/S 1st hr = Q15mins Stable V/S Next 3hrs = Q30mins Keep uterus contracted Check perineal pad = Normal is pads not soaked within 5-10 mins Monitor bleeding POSTPARTUM CHECKS B - Bladder = keep empty (full bladder prevents uterine contraction) U - Uterus = should be Midline & contracted (when uterus deviates to the side = means bladder is full = empty bladder first and then massage uterus) B - Bowel = constipation = increase fiber & fluid and promote movement Uterine contractions & medications slow done peristalsis B - Breast = engorgement = breastfeed to relieve & apply warm compress/warm showers  May use cold cabbage (wtf haha) to relieve pain from breast engorgement FOR BOTTLEFED INFANTS L - Lochia ○ Rubra = Day 1-3 = Deep red to dark red with small clots ○ Serosa = Day 4-10 = Pink to brown ○ Alba = Day 10-14 = White E - Episiorrhaphy = check signs of infection (redness, foul odor) & healing H - Homan's sign = stirrups causes venous stasis = lower BOTH legs SLOWLY ○ (+) Homan's sign = must immobilize to prevent embolus ○ Prevent DVT = early ambulation = NSVD after 4-6hrs; C/S after anesthesia wears off = after 12-24 hrs (progressive movement) E - Emotions 1. Taking in = Day 1 to 2 = mom is tired and dependent on others = "self-centered" 2. Taking hold = mom starts to care for the baby, calls baby by name = assess initial signs of postpartum blues Begins on Day 3 to 10 and may last for 4-5 weeks 3. Letting go = mom is interdependent, acknowledging that baby is a separate entity Puerperium = 6th week postpartum = mother has undergone INVOLUTION = return of the body to pre-pregnant state (esp uterus) Return of Menses ○ 6 to 8 or 10 weeks non breastfeeding ○ 3 to 4 months or 4-6 months if breastfeeding  LAM = only effective if EBF (Q3hrs) Postpartum Check up = 1 week after discharge and 6 weeks after (check for involution) EMBRYONIC & FETAL STRUCTURES Decidua = high hCG secreted by trophoblast cells = causes endometrium to thicken & vascularize --> ENDOMETRIUM becomes DECIDUA 1. Decidua Basalis = under embryo (trophoblast-maternal circulation) 2. Decidua Capsularis = encapsulates trophoblast 3. Decidua Vera = remaining portion of uterine lining Chorionc Villi = contains trophoblast that forms PLACENTA ○ Synctiotrophoblast = OUTER = produces hCG, HPL, estrogen, progesterone ○ Cytotrophoblast aka Langhan's Layer= INNER = functions to protect fetus from infections in early pregnancy (disappears between 20th to 24th week AOG)  Protects fetus from syphilis = syphilis is not considered to have a high potential for fetal damage early in pregnancy, only after the point at which cytotrophoblast cells are no longer present (20th to 24th week = disappears = fetus is highly susceptible to infection) Placenta = arises from TROPHOBLAST ○ CIRCULATION = O2, nutrients, flucose, amino acids, fatty acids, vits & minerals, water OSMOSE from maternal blood through chorionic villi to the embryo at 3rd WEEK ○ DIFFUSION = O2, CO2, Sodium, Chloride ○ Facilitated Diffusion = moves more rapidly, there is a carrier = GLUCOSE ○ Active Transport = needs an enzyme = Essential amino acids, water-soluble vitamins ○ PINOCYTOSIS = absorption by the cellular membrane of microdroplets of plasma and dissolved substances ○ Gamma globulin, lipoproteins, and phospholipids ○ VIRUSES LEFT-SIDE LYING = increases uterine perfusion and placental circulation; lifts uterus away from inferior vena cava and prevent blood from being trapped in LOWER extremities If SUPINE = uterus compresses vena cava = reduced placental circulation = SUPINE HYPOTENSION ; POOR uterine circulation ENDOCRINE = Chorionic villi = hormone-producing hCG = first placental hormone produced; ensures that corpus luteum continues to produce estrogen & progesterone hCG production DECLINES after 30 days = since outer layer of placenta already produces progesterone ESTROGEN = contributes to mammary gland development; stimulates uterine growth PROGESTERONE = "Hormone of women/mothers" ; "Hormone of pregnancy" Maintains pregnancy Prevents premature labor HPL = promotes mammary gland growth ; can be detected in maternal serum and urine; regulates maternal glucose, protein, and fats AMNIOTIC FLUID = slightly alkaline at pH of 7.2 POLYHYDRAMNIOS >24 AFI ○ occurs in GDM (high blood glucose = fluid shifts into amniotic space) ○ Caused by defects in FETAL GIT = decreased swallowing = INC fluid OLIGOHYDRAMNIOS 20th week Prognosis: depends on amount of bleeding and AOG Management: Prevent hypovolemic shock  Monitor FHT (late decels), Maternal V/S  IVF, O2 therapy  Assess IO, amt of bleeding, CBC  Complete bed rest = to relieve pressure  Ultrasound to confirm  NEVER PERFORM IE pelvic and vaginal exams  NO NSVD = may lead to massive hemorrhage  Antenatal Steroid management = PP may increase preterm labor  Abruptio placenta = separation of placenta after 20 weeks AOG Causes: Hypertension, PIH, short umbilical cord, smoking, Cocaine use, trauma to abdomen Manifestations: Tenderness to severe constant pain Mild to moderate bleeding (dark red) Total separation: Tearing, Knifelike sensation Management:  Assess amount & control blood loss  Assess FHT and maternal VS, CBC  O2 sat & IVF therapy  Neonate may be hypoxic, hypoglycemic shock d/t blood loss  Prepare for emergency C/S Placenta previa Abruptio Placenta Low lying placenta Premature separation Painless vaginal bleeding Severe, sharp stabbing pain Bright red and abrupt Hard BOARD-LIKE abdomen Bleeding = (dark red bleeding) Pre-eclampsia, PIH Cause: Massive Vasospasm Factors: Age, gravida, Multiple pregnancies, Underlying medical conditions (HTN) S/S: High BP (2 elevated BP readings 2 separate occasions at least 6hrs apart), Proteinuria, Edema (Upper extremities) Check weight Check hands = for swelling Seizures = Eclampsia (d/t cerebral edema) Hydralazine & Methyldopa= safe antihypertensive medication for pregnant mom Diuretics = must use Potassium-sparing (Spironolactone)  Monitoring = V/S monitoring Q15mins  Environment = Non-stimulating environment to prevent eclampsia ○ No noise ○ Dim lights Gestational HPN MILD Preeclampsia SEVERE Preeclampsia ECLAMPSIA (after 20th week AOG) BP = 140/90; or BP = 140/90 BP = 160/100 or SEIZURE or COMA greater than Proteinuria +1 greater Severe Preeclampsia S/S 30mmHg SBP & (300mg/L) or 2+ Marked proteinuria +3 Toxemia 15mmHg DBP (1g/L) (5g/L) to 4+ from baseline Edema on upper EXTREME Edema Seizure is usually preceded NO proteinuria extremities or face (+) Oliguria of 400mL by: NO edema (MILD) Visual or cerebral  Headache Weight gain of disturbances  severe epigastric pain more than 2kg or Elevated Serum CREA =  Hyperreflexia 4.4 lbs per week greater than 1.2 mg/dL  hemoconcentrations (+) Hyperreflexia with possible ankle clonus HELLP Syndrome or Severe PIH  Hemolysis - leads to anemia  Elevated Liver enzymes - leads to epigastric pain  Low platelets - (+) petechiae, abnormal bleeding/clotting  Other S/S: proteinuria, edema, high BP, nausea, RUQ pain & general malaise (liver inflammation)  PRIORITY: Raise platelet count to normal by transfusing FFP or platelets  Eclampsia = Pre-eclampsia + Seizures Management: ○ CBR ○ LOW SODIUM ○ Avoid caffeine ○ Dark environment Meds: ○ MgSO4 = hold if RR is below 12cpm ○ MgSO4 DRUG OF CHOICE TO PREVENT ECLAMPSIA Magnesium Sulfate TOXICITY! S/S ○ absent DTR = early sign of MgSO4 TOXICITY (loss of patellar DTR) ○ Low RR = late sign of MgSO4 toxicity ○ Urine output = must be 30-60mL/hr = if urine output is low, withhold MgSO4 ○ Check BP  Antidote: Calcium Gluconate  Prevent toxicity by using an infusion pump  Before you administer magnesium sulfate, ensure that urine output is above 30 mL/hr, with a specific gravity of 1.010  Monitor Urine Output using Foley indwelling catheter to be more accurate  Respirations should be above 12 per minute  Before giving MgSO4 = make sure ankle clonus is minimal and DTR is present  ALWAYS ADMINISTER PIGGYBACK  may cause respiratory depression in the newborn if administered close to birth = prepare for possible resuscitation If seizure happens = give DIAZEPAM (Valium) LAMAZE = aka PSYCHOPROPHYLACTIC ○ If a woman can prevent fear from occurring, or break the chain between fear and tension or tension and pain, then she can reduce the pain of labor contractions ○ Focuses on preventing pain in labor through controlled breathing DICK-READ = fear leads to tension which leads to PAIN ○ If a woman can prevent fear from occurring, or break the chain between fear and tension or tension and pain, then she can reduce the pain of labor contractions ○ Education and relaxation = reduces pain BRADLEY = pregnancy is a joyful, enjoyable process ○ Partner plays an important role ○ Partner-coached method ○ She reduces pain in labor by abdominal breathing. In addition, she is encouraged to walk during labor and to use an internal focus point as a disassociation technique COMMON MATERNAL MEDICATIONS DRUG Mech of Action Adverse & WOF Nx.Responsibilities Contraindications TOCOLYTICS Relaxes uterus; halts Do not give: if Severe HYPOTENSION Monitor VS eg: nifedipine, labor AOG >37 weeks MIO terbutaline, ritodrine = prevents preterm 4cm or more cervical birth dilatation MAGNESIUM CNS depressant, anti- NEVER give just 2 hrs Respiratory Paralysis & Monitor TSL = 4-7.5 mEq/L SULFATE seizure before birth Cardiac arrest, Heart Monitor DTR Qhourly (normal is 2+ antidote: Calcium Do not give if UO is block to 3+) Gluconate inadequate LOSS OF DTR = TOXICITY! BETAMETHASONE & Increase production Decerease immune Infection, Monitor VS DEXAMETHASONE of SURFACTANT = response Hyperglycemia, Check lung sounds for pulmonary accelerates Fetal Lung Pulmonary edema = Pulmonary edema edema Maturity d/t Na & fluid Monitor WBC & glucose  - Given during preterm retention labor between 28-32 Elevated blood weeks AOG glucose PROSTAGLANDINS Ripens cervix = GI effects = diarrhea, UTERINE Monitor VS Eg: MISOPROSTOL stimulates dilation and NV, cramps TACHYSYSTOLE!!! VOID before giving prostaglandin effacement Hyperstimulation of Monitor BISHOP SCORE = given VAGINALLY Stimulates uterine uterus = MECONIUM 12 uterine contractions Treatment is discontinued when contractions STAINING in 20 minutes without the Bishop score is 8 or more an alteration in the (cervix ripens) or an effective fetal heart rate pattern contraction is established (3 or more contractions in a 10-minute period) OXYTOCIN For INDUCTION OF Adverse effects include UTERINE RUPTURE Monitor maternal VS (every 15 LABOR = increases the allergies, minutes), especially BP, HR, Wt, = Magnesium force, frequency, and dysrhythmias, changes WATER INTOXICATION FIO, LOC, Lung sosunds Sulfate needed at duration of uterine in blood pressure Monitor contractions bedside in case contractions Monitor FHR Q15 mins myometrium must be relaxed Methylergonovine Arterial C/I = CVD, PVD, Severe Hypertension Monitor BP, weight, LOC, lung Maleate vasoconstriction & Hypertension, MI, sounds (METHERGINE ) vasospasm bradycardia Assess for S/S of MI = chest pain, Produces firm, tetanic headache, dizziness contractions of uterus NEVER GIVE before = for POSTPARTUM delivery of placenta HEMORRHAGE OPIOID ANALGESICS Relieve pain May cause NALOXONE = antidote withdrawal S/S in Monitor V/S esp respiratory status newborn: Monitor FHR Irritability, tremors, Monitor characteristic of excessive crying, contractions diarrhea, seizures, Monitor bladder distention hyperactive reflexes 1. Hydromorphine & NOT given in early Respiratory Meperidine labor b/c it may slow depression, flaccidity, Hydrochloride labor process somolence, seizure, May cause RDS in coma, death newborns if given within 1-4 hrs of delivery 2. BUTORPHANOL & Use with CAUTION in NALBUPHINE client with PREEXISTING OPIOID DEPENDENCY = WITH DRAWAL OTHER MEDS RhoGam Given at 28 weeks of pregnancy and within 72 hrs after delivery IM Given to Rh NEG mothers with Rh POS babies Rubella SQ Given if Rubella titer is less than 1:8 DO NOT give to clients with hypersensitivity to eggs AVOID pregnancy for at least 3-6 months (better if 1 year) Eye Prophylaxis For N. gonnorhoeae & C. trachomatis (Erythromycin) Cleanse eyes before instilling meds (flush) Phytonadione (VIT K) IM at Left VASTUS LATERALIS Prophylactic for hemorrhagic disease of newborn  A/E = Hyperbilirubinemia Protect medication from light Monitor Jaundice Hepatitis B Administer IM in the lateral aspect of the middle third of the vastus lateralis muscle If MOTHER is POS for Hepa B surface antigen = give Hepatitis B immunoglobulin in addition to Hepa B vaccine