Maternal and Child Nursing (1st Sem) PDF

CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENTS) Acronyms: EDC: Expected Date of Confinement EDD: Expected Date of Delivery AOG: Age of Gestation LMP: Last Menstrual Period Fetal Heart Rate Monitoring 120-160 4 Stages of Labor 1St stage: Dilatation of the cervix 2nd stage: Delivery of the ba...

CARE OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENTS) Acronyms: EDC: Expected Date of Confinement EDD: Expected Date of Delivery AOG: Age of Gestation LMP: Last Menstrual Period Fetal Heart Rate Monitoring 120-160 4 Stages of Labor 1St stage: Dilatation of the cervix 2nd stage: Delivery of the baby 3rd stage: Delivery of the placenta 4Th stage: First 2 hours of recovery (postpartum) Placental Examination Cotyledons – contents inside the placenta (15-20) Beware: 1. Spurt of blood 2. Placenta Cord – cut off Signs of Placental Separation 1. Uterine contraction (Calkin Sign) *globular and hard 2. The fundus of the uterus rises in the abdomen 3. Lengthening of the umbilical cord (most reliable) 4. An amount of blood suddenly escapes from the vagina *No indention (complete cotyledons) Internal Vaginal Examination Effacement (thickness): % Dilatation (opening): cm Bag of Water: BOW Station: (+)(-) Presentation: Cephalic/Breach Ex: 5cms, 60%, +BOW, Cephalic, strong regular contraction Documentation: Uterus firm and contracted. No presence of bleeding. Anthropometric Measurement Head: 33cm - 35cm Chest: 30.5cm - 33cm (measure at the level of the nipple) *less than 30 is a sign of prematurity Abdomen: 30.5cm - 33cm Length: 45cm – 55cm (head to heel, follow contours) 1 | Maternal and child nursing Late Deceleration: utero-placental insufficiency *strict monitoring; an emergency *Interventions:  Position the patient, left lateral  Change to plain IV if there is oxytocin drip  Put oxygen Variable Deceleration: cord prolapse (rupture of bad of water) *serious *Interventions:  Position the patient, left lateral  Change to plain IV if there is oxytocin drip  Put oxygen PUBERTAL DEVELOPMENT  Puberty is the stage of life at which secondary sex changes begin  Stimulated --- hypothalamus --- synthesized and releases --- gonadotropin-releasing hormone (GnRH) --- anterior pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH) GIRLS 1. Growth spurt 2. Increase in the transverse diameter of the pelvis 3. Breast development 4. Growth of pubic hair 5. Onset of menstruation 6. Growth of axillary hair 7. Vaginal secretions BOYS 1. Increase in weight 2. Growth of testes 3. Growth of face, axillary, and pubic hair 4. Voice changes 5. Penile growth 6. Increase in height 7. Spermatogenesis (production of sperm) REPRODUCTIVE DEVELOPMENT – VULVA The vulva is 5 organs making up the external genitalia of the female: 1. Mons Pubis – triangular-shaped pad of fatty tissue over the pubis bone, covered with pubic hair 2. Labia Majora – 2 large folds of adipose tissue on the sides of the vaginal opening 3. Labia Minora – 2 smaller folds of adipose tissue on the inside of the labia majora 4. Vestibule – area between labia with openings for the vagina, urethra, and two excretory ducts for Bartholin’s glands (produce lubricant) 5. Clitoris – sensitive fold of tissue partially covered by hood 2 | Maternal and child nursing   The perineum is the area located between the vaginal opening and the anus. It is a muscular sheet that can be torn during childbirth  Some doctors avoid uncontrolled tearing of the perineum by making a surgical incision called an episiotomy REPRODUCTIVE DEVELOPMENT – UTERUS  Uterus is a hollow, muscular, pear-shaped organ about the size of a woman’s clenched fist  Top is tipped forward in a normal ‘anteflexion’ position  Divided into the body or corpus, and the bottom cervix  Rounded top portion, above the Fallopian tubes, is called the fundus  The uterus wall has 3 layers: 1. Perimetrium – outside layer 2. Myometrium – muscular inside layer 3. Endometrium – mucous membrane lining the uterus  The uterus has 3 functions: 1. The endometrium sheds the lining of the uterus every 21 to 40 days by menstruation 2. It provides a place for the protection and nourishment of the fetus during pregnancy 3. It contracts during labor to expel the fetus REPRODUCTIVE DEVELOPMENT – FALLOPIAN TUBES  4-6 inches long. The egg, released from the ovary, is captured by the fimbria and brought into the Fallopian tube  The egg is moved along inside the tube by muscular contractions and the waving action of cilia  It takes an egg about 3-4 days to travel the length of the tube. If an egg is fertilized, ot occurs here REPRODUCTIVE DEVELOPMENT – OVARIES  The two ovaries are attached to each side of the uterus by a ligament. They are oval-shaped, about the size of a large olive, and lie close to the fimbria at the end of the Fallopian tubes  Each ovary is filled, already at birth, with egg-containing sacs called follicles. Each egg is called an ovum  Once every 21 days, one follicle in one ovary ripens. This mature follicle is a graafian follicle. The follicle ruptures in response to hormones from the pituitary gland, releasing the ovum/egg – OVULATION  After the follicle ruptures, it becomes a mass of yellow cells called the corpus luteum. This is a temporary, progesterone-producing structure REPRODUCTIVE DEVELOPMENT – BREASTS  The breasts are the mammary glands, varying in size according to age, heredity, and the amount of fatty tissue present  Each breast has 15-20 grandular lobes separated by connective tissue  After childbirth, the pituitary gland stimulates these lobules with the hormone prolactin and they produce milk  The dark-colored circle at the tip of the breast is called the areola. It contains sebaceous glands to keep the skin conditioned  In the center is the nipple, where ducts from the lobules open. The first secretion from the breast is not a true milk, but a thin yellowish substance called colostrum  Colostrum contains nutrients and the mother’s immunities that can protect baby MENSTRUAL CYCLE  The onset of the menstrual cycle, or menarche, begins at puberty and ceases at menopause  Hypothalamus – release of GnRH (also called luteinizing hormone-releasing hormone) initiates the menstrual cycle. When estrogen (produced by the ovaries) rises, release of the hormone is repressed, and menstrual cycles do not occur (the principle that birth control pills use to eliminate menstrual flow)  Pituitary Gland – (anterior lobe) produces 2 hormones that act on the ovaries to influence the menstrual cycle: a) FSH, responsible for maturation of the ovum b) LH, responsible for ovulation, or release of the mature egg cell from the ovary, and growth of the uterine lining during the second half of the menstrual cycle  FSH and LH are called gonadotropic hormones because they cause growth (trophy) in the gonads (ovaries), one of the ovaries primordial follicles is activated by FSH to begin to grow and mature  Cells produce a clear fluid (follicular fluid) that contains a high degree of estrogen (mainly estradiol) and some progesterone  At this state of maturation, is termed a graafian follicle  By day 14 the ovum has divided by mitotic division  LH from the pituitary, prostaglandins are released and the graafian follicle ruptures = ovulation  If conception (fertilization by a spermatozoa) occurs as the ovum proceeds down a Fallopian tube and the fertilized ovum implants on the endometrium of the uterus, the corpus luteum remains throughout the major portion of the pregnancy (approximately 16 to 20 weeks) 3 | Maternal and child nursing FIRST PHASE OF MENSTRUAL CYCLE (PROLIFERATIVE)  Immediately after a menstrual flow (which occurs during the first 4 or 5 days of a cycle), the endometrium, or lining of the uterus, is very thin half of a menstrual cycle is termed interchangeably the proliferative, estrogenic, follicular, or postmenstrual phase  Follicular Phase is characterized by menstruation, when the thickened lining of the endometrium is shed because no egg was fertilized or implanted. Just prior to this phase is a premenstrual period characterized by hormonal and physical changes SECOND PHASE OF MENSTRUAL CYCLE (SECRETORY)  Formation of progesterone in the corpus luteum (under the direction of LH) causes the glands of the uterine endometrium to become corkscrew or twisted in appearance of glycogen (an elementary sugar) and mucin (a protein)  Second phase of the menstrual cycle is termed the progestational, luteal, premenstrual, or secretory phase  Luteal Phase follows ovulation, and is characterized by the development of the corpus luteum, the secretion of progesterone, the preparation of the endometrium for implantation of a fertilized egg, and the formation of a thick mucous to block the cervix once the egg passes out of the Fallopian tube THIRD PHASE OF MENSTRUAL CYCLE (ISCHEMIC)  If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days. As it regresses, the production of progesterone and estrogen decreases  The capillaries rupture, with minute hemorrhages, and the endometrium sloughs off FOURTH PHASE OF MENSTRUAL CYCLE (MENSES)  Menses or the menstrual flow, is composed of: o Blood from the ruptured capillaries o Mucin from the glands o Fragments of endometrial tissue o The microscopic, atrophied, and unfertilized ovum PREGNANCY  At conception, a single sperm with 23 chromosomes (carrying genetic information from the father) penetrates/fertilizes a single egg with 23 chromosomes (carrying genetic information from the mother)  The resulting cell, a zygote, now has 47 chromosomes. The cell begins dividing and is also called a balstocyst. From week 2-8, it is called an embryo  The fertilized egg implants on the uterus. Progesterone production increases to signal a pregnancy; it can be detected in urine and blood  Embryo is suspended in an amniotic sac surrounded by fluid during the 280 day gestation period  Umbilical cord attached at the navel connects it to the placenta, where it gets nutrients and oxygen  The 1St trimester, all parts of the embryo are formed  Second trimester all parts start to function; during the last trimester the embryo is called a fetus and the main task is growth  Labor is muscle contractions, dilation (to 10cm) and effacement (thinning) of the cervix, and expulsion of the mucous plug that formed in the cervix, signals the onset of parturition, the childbirth process  Cephalic delivery, is the most common. Breech-backward presentation; Cesarian is delivery in the abdomen  The umbilical cord is cut and clamped, and placenta (afterbirth) is delivered following birth of the baby  The newborn my be covered with vernix caseosa (cheesy coating) or lanugo (downy hair) that protected the skin before birth  APGAR scale. Color, heartbeat, reflexes, muscle tone and breathing are scored on a scale of 0-10 FAMILY PLANNING  Choosing the number of children in a family and the length of time between their births PURPOSES  Delaying pregnancy until an appropriate time  Promoting a healthy and safe pregnancy  Ensuring healthy spacing to prevent maternal depletion and infant vulnerability TYPES OF FAMILY PLANNING  Natural Family Planning Method  Artificial Family Planning Method  Permanent Methods  Temporary Methods  NATURAL FAMILY PLANNING – also called Fertility Awareness/Rhythm Method relies on abstinence from sexual intercourse during the most fertile phase of a woman’s menstrual cycle 4 | Maternal and child nursing FERTILITY AWARNESS Day 1: the first day of your menstrual flow is the beginning of your cycle Day 7: by day seven your egg is preparing to be fertilized by sperm Day 11-21: (based in 28 day cycle) hormones in your body cause the egg to be released from the ovary, known as ovulation. The egg travels through the Fallopian tube towards the uterus and is only available to be fertilized for 12-24 hours during this window. If sperm penetrates the egg, the fertilized egg will attach to the lining of the uterus and begin to grow. If fertilization does not happen, the egg breaks apart Day 28: if the egg is not fertilized, hormone levels drop around this day, causing the lining of the uterus to be shed, known as menstruation 3 METHODS USED TO PREDICT OVULATION 1. Basal Body Temperature Method: a woman’s resting temperature rises between 0.4 F and 0.8 F on the day of ovulation and stays elevated until the next menstrual period. Using a special (Basal body) thermometer, a woman needs to take her temperature every morning before getting out of bed; illness, travel, and alcohol or drug-use can affect your temperature and lack of sleep 2. Cervical Mucus Method: right before ovulation, the mucus from the cervix changes from being cloudy and scanty to being clear and slippery. The consistency of ovulation mucus is like that of an egg white and it can be stretched between the fingers. After the ovulation, the mucus tends to dry up again 3. Calendar Tracking Method: the first day of your fertility window is determined by subtracting 18 days from the length of your shortest cycle. If your shortest menstrual cycle was 26 days, subtract 18 from 26, which gives you the number 8. This means that the first day of your fertility window starts on the 8Th day of your cycle ARTIFICIAL METHOD OF FAMILY PLANNING – In this method, the live sperm is prevented from entering the uterus either by killing them with spermicidal or by obstructing them through the use of condom and diaphragms SPERMICIDE – contains a chemical that kills sperm. It comes in the form of foam, jelly, cream or film that is placed inside the vagina before sex. Some types must be put in place 30 minutes ahead of time. Frequent use may cause tissue irritation, increasing the risk of infections and STDs. Spermicides are most often used along with other birth control methods Pros: easy to use, inexpensive Cons: may increase the risk of STDs, 29% get pregnant MALE CONDOM – the latex condom is the classic barrier method. It prevents sperm from entering the woman’s body, protecting against pregnancy and STDs. Of couples who rely only on male condoms, 15% get pregnant in a year Pros: widely available, protects against STDs, inexpensive Cons: only effective if used correctly every time. Can’t be reused FEMALE CONDOM – a thin plastic pouch that lines the vagina and can be put in place up to 8 hours before sex. Users grasp a flexible, plastic ring at the closed end to guide it into position. It’s somewhat less effective than the male condom Pros: widely available, some protection against STDs, conducts body heat better than the male condom Cons: can be noisy, 21% of users get pregnant, not reusable. Should not be used with a male condom to avoid breakage DIAPHRAGM – a rubber dome that is placed over the cervix before sex. It is used with a spermicide. Effectiveness compares to the male condom – 16% of average users get pregnant, including those who don’t use the device correctly every time Pros: inexpensive (a $15-$17 device lasts two years) Cons: must be fitted by a doctor, no STD protection. Can’t be used during your period due to a risk of toxic shock syndrome CERVICAL CAP – similar to a diaphragm, but smaller. The FemCap slips into place over the cervix, blocking entry to the uterus. It is used with a spermicide. The failure rate for the cervical cap is 15& for women who have never had children and 30% for those who have Pros: can stay in place for 48 hours, inexpensive Cons: must be fitted by a doctor, no protection BIRTH CONTROL SPONGE – sold as Today Sponge, is made of foam and contains spermicide. It is placed against the cervix up to 24 hours before sex. The sponge is about as effective as the cervical cap, with a failure rate of 16% for women who have never had children and 32% for those who have. But unlike the diaphragm or cervical cap, no fitting by a doctor is required Pros: no prescription, effective immediately Cons: difficult to insert correctly, no STD protection. Can’t be used during your period BIRTH CONTROL PILL – the most common type of birth control pill uses the hormones estrogen and progestin to prevent ovulation. When taken on schedule, the pill is highly effective. About 8% of typical users get pregnant, including those who miss doses. Like all hormonal contraceptives, the pill requires a prescription Pros: more regular, lighter periods, or no periods, depending on the type of pill. Less cramping Cons: cost ($15-$50 per month), no STD protection. May cause side effects, including breast tenderness, spotting, serious blood clots, and raises blood pressure. Some women should not use birth control pills 5 | Maternal and child nursing BIRTH CONTROL PATCH – women who have trouble remembering a daily pill may want to consider the birth control patch. The Ortho Evra patch is worn on the skin and changed only once a week for three weeks with a fourth week that is patch-free. The patch releases the same types of hormones as the birth control pill and is just as effective Pros: more regular, lighter periods, with less cramping, no need to remember a daily pill Cons: may cause skin irritation or other side effects similar to birth control pills. Doesn’t protect against STDs VAGINAL RING – the NuvoRing is a soft plastic ring that is worn inside the vagina. The ring releases the dame hormones as the pill and patch and is just as effective. But it only needs to be replaced once a month Pros: lighter, more regular periods, only replaced once per month Cons: cost ($30-$50), may cause vaginal irritation or other side effects similar to pills and the patch. Doesn’t protect against STDs BIRTH CONTROL SHOT – the birth control shot, known as Depo-Provera, is a hormonal injection that protects against pregnancy for three months. For the typical couple, it is more effective than the birth control pill – only 3% of users get pregnant in a year Pros: only injected four times per year, highly effective Cons: may cause spotting and other side effects. Doesn’t protect against STDs BIRTH CONTROL IMPLANT – the birth control implant (Implanon) is a matchstick-sized rod that is placed under the skin of the upper arm. It releases the same hormone that’s in the birth control shot, but the implant protects against pregnancy for 3 years. The failure rate is less than 1% Pros: lasts three years, highly effective Cons: more expensive upfront for exam, implant, and insertion, may cause side effects, including irregular bleeding. Doesn’t protect against STDs IUD – stands for intrauterine device, a T-shaped piece of plastic that is placed inside the uterus by a doctor. The copper IUD, ParaGard, works for as long as 12 years. The hormonal IUD, Mirena, must be replaced after 5 years. Both types make it more difficult for sperm to fertilize the egg. Fewer than eight in 1,000 women get pregnant Pros: long-lasting, low-maintenance Cons: irregular or heavier periods. More expensive upfront, may slip out, may cause side effects PERMANENT METHODS TUBAL LIGATION – the traditional method for women is called tubal ligation or “having your tubes tied.” A surgeon closes off the Fallopian tubes, preventing eggs from making their journey out of the ovaries Pros: permanent, nearly 100% effective Cons: requires surgery, may not be reversible, expensive. Doesn’t protect against STDs 6 | Maternal and child nursing VASECTOMY TUBAL IMPLANT – a newer procedure makes it possible to block the Fallopian tubes without surgery. Small implants of metal or silicone are placed inside each tube. Scar tissue eventually grows around the implants and blocks the tubes. Once an X-ray confirms the tubes are blocked, no other form of birth control is needed Pros: permanent, no surgery, almost 100% effective Cons: takes a few months to become effective. May raise the risk of pelvic infections, irreversible, expensive EMERGENCY CONTRACEPTION – emergency contraception works after sex to help avoid pregnancy. This is an option if no birth control was used or if a woman suspects her usual method failed. Plan B, Plan B Step-One, and a generic version of Plan B called Next Choice all contain a high dose of a hormone found in may birth control pills. No prescription is needed for women aged 17 and older. These types must be used within 72 hours. Ella uses a non-hormonal drug and requires a doctor’s prescription. It can be taken up to five days after sex  Not a form of everyday contraception  Taken only in case of birth control failure, rape, incest  Take up to five days after sexual contact  High dose of hormones  Ella, Next Choice or Plan B Options for Older Women Age and lifestyle are important factors in choosing a form of birth control. If you’re over 35 and smoke or are obese, the combination birth control pill, patch, and ring are not recommended. It’s best to consult your doctor about safe alternatives. Of you’re approaching the age of menopause, the birth control shot has an added benefit: it may relieve some of the symptoms of perimenopause WITHDRAWAL – nearly six in 10 American women report that a partner has used “pulling out,” the age-old method that relies on the man withdrawing his penis from the vagina before ejaculation. Newer reviews show that when it’s done correctly every time, about 4% of users get pregnant in a year. With more typical use, about 18% get pregnant Pros: free, no need for devices Least Effective Methods – without using any form of birth control, 85% of sexually active couples will get pregnant within a year. Even the least effective birth control options reduce that number considerably Most Effective Method – although barrier methods, such as the condom or diaphragm, are moderately effective with typical patterns of use, hormonal contraceptives have a better track record for effectiveness. There are also several options for couples that prefer the lowest possible odds of getting pregnant. Two of these are reversible – the IUD and hormonal implant. The only birth control method that is 100% effective is abstinence CALCULATION OF LMP, EDC, AOG Ex: LMP: December 20, 2019 -3 +7 +1 EDC: September 27, 2020 AOG: 29 weeks *for AOG, subtract the day of LMP to the number of days of that month, 31-20 = 11 then list all the months with all their number of days until the present date, then add, divide by 7 which is constant because we have seven days per week. December 11 January 31 February 28 March 31 April 30 May 31 June 30 July 11 (present date) Total 203 203/7= 29 weeks 7 | Maternal and child nursing RISK FACTORS IN PREGNANCY 8 | Maternal and child nursing Instrument Assisted Birth MOTHER’S RESPONSE TO PREGNANCY Ambivalence is a state of having simultaneous conflicting reactions, beliefs or feelings towards some object Mood changes – caused by physical stresses, fatigue, changes in your metabolism, or by the hormones estrogen and progesterone Introvert – someone who finds energy in alone time, isn’t the greatest at expressing emotions, and has small group of people they feel most comfortable around Changes in Body Image 1St Trimester: Accepting the Pregnancy – 50% of all pregnancies are unintended, unwanted or mistimed 9 | Maternal and child nursing FATHER’S RESPONSE TO PREGNANCY  Confused by partner’s mood swings  Feels left out  Resents changes in their relationship  Resents attention given to the woman  Needs to resolve conflicts about fathering PHYSIOLOGIC TASKS OF THE MOTHER  Ensuring safe passage through pregnancy, labor and birth  Seeking acceptance of this child by others  Seeking of commitment and acceptance of self as mother to the infant (binding in)  Learning to give to one’s self on behalf of one’s child 1St Trimester: Accepting the Pregnancy  50% of all pregnancies are unintended, unwanted or mistimed  Women sometimes experience disappointment, anxiety, or ambivalence  Partner may go through some changes also  Partner should give emotional support  May feel proud, happy, jealous or loss 2nd Trimester: Accepting the Baby  Second turning point is often quickening  Proof of child’s existence  Anticipatory role playing  May accept at conception, at birth or later  How well she follows prenatal instructions  Partner may feel left out, he may increase his work, he has misinformation  Educate both partners 3rd Trimester: Preparing for Parenthood  “nest building”  Attending prenatal classes or parenting classes  Reworking Developmental Tasks  Working through previous life experiences  Woman’s relationship with her parents, particularly her mother 3rd Trimester: Fear of Dying  Needs confidence in health care providers  Men may need to reconcile feelings toward fathers and learn a new pattern of behavior  Role-playing and Fantasizing  Second step in preparing for parenthood  Spend time with other mothers to learn how to be a mother. Needs good role models Signs of Pregnancy  Presumptive (subjective)  Probable (objective)  Positive (diagnostic) Presumptive Signs and Symptoms of Pregnancy  Are those signs and symptoms that are usually noted by the client, which impel her to seek council  These signs and symptoms are not proof of pregnancy but they will make the health provider and woman suspicious of pregnancy Presumptive Signs and Symptoms of Pregnancy 1. Amenorrhea (cessation of menstruation)  One of the earliest cues of pregnancy  Majority of clients have no periodic bleeding after the onset of pregnancy  At least 20% of women have some slight, painless spotting during early gestation for no apparent reason and a large majority of these continue to term and have normal infants 2. Nausea and Vomiting  Usually in early morning  Usually spontaneous and subsides in 6 to 8 weeks or by the twelfth to sixteenth week of pregnancy  Hyperemesis Gravidarum – as SEVERE nausea and vomiting lasts beyond the fourth month lf pregnancy, causes weight loss and upsets fluid and electrolyte balance of the mother  Nausea and vomiting are unreliable signs of pregnancy since they may result from other conditions such as: a) Gastrointestinal disorders (hiatal hernias, ulcers, and appendicitis) b) Infection (influenza and malaria) c) Emotional stress, upset (anxiety and anorexia nervosa) 10 | Maternal and child nursing  d) Indigestion 3. Frequency of Voiding  Frequent urination is caused by pressure of the expanding of the uterus ln the bladder  It subsides as pregnancy progresses and the uterus rises out of the pelvic cavity  The uterus returns during the last weeks of pregnancy as the head of the fetus presses against the bladder  Frequent urination is not a definite sign since other factors can be apparent (such as tension, diabetes, urinary tract infection, or tumors) 4. Breast Changes  In early pregnancy, changes start with a slight, temporary enlargement of the breasts causing a sensation of weight, fullness, and mild tingling  As pregnancy continues the patient may notice: a) Darkening of the areola – the brown part around the nipple b) Enlargement of Montgomery Glands – the tiny nodules of sebaceous glands within the areola c) Increased firmness or tenderness of the breasts d) More prominent and visible veins due to the increased blood supply e) Presence of colostrum (thin yellowish fluid that is the precursor of breast milk). This can be expressed during the second trimester and may even leak out in the latter part of the pregnancy 5. Vaginal Changes  CHADWICK’S SIGN: the vaginal walls have taken on a deeper colour caused by the increased vascularity because of increased hormones. It is noted at the sixth week when associated with pregnancy. It may also be noted with a rapidly growing uterine tumor or any cause of pelvic congestion 6. Vaginal Changes  LEUKORRHEA: this is an increase in the white or slightly gray mucoid discharge that has a faint musty odor. It due to hyperplasia of vaginal epithelial cells of the cervix because of increased hormone level from the pregnancy. Leukorrhea is also present in vaginal infections 7. Quickening (feeling of life)  This is the first perception of fetal movement within the uterus. It usually occurs toward the end of the fifth month because of spasmodic flutter a) A multigravida can feel quickening as early as 16 weeks b) A primigravida usually cannot feel quickening until 18 weeks  Once quickening has been established, the patient should be instructed to report any instance in which fetal movement is absent for a 24-hour period  Fetal movement early in pregnancy is frequently thought to be gas 8. Skin Changes  Straie Gravidarum – (stretch marks), noted on the abdomen and/or buttocks. May also be classified as a probable sign of pregnancy  Are caused by increased production or sensitivity to adrenocortical hormones during pregnancy, not just weigh gain  May be seen on a patient with Cushing’s disease or a patient with sudden weight gain 9. Skin Changes  Linea Nigra 11 | Maternal and child nursing   This is a black line in the midline of the abdomen that may run from the sternum or umbilicus to the symphysis pubis  Thus appears on the primigravida by the third month and keeps pace with the rising height of the fundus  The entire line may appear on the multigravida before the third month  This may be a probable sign if the patient has never been pregnant 10. Skin Changes  CHLOASMA – this is called the “Mask of Pregnancy.” It is a bronze type of facial coloration seen more on dark-haired women. It is seen after the sixteenth week of pregnancy  FINGERNAILS – some patient note marked thinning and softening by the sixth week 11. Fatigue  This is a common complaint by most patients during the first trimester. Fatigue may also be a result of anemia, infection, emotional stress, or malignant disease 12. Positive Home Test  These tests may not always be accurate; however, they can be very effective of they are performed properly Probable Signs of Pregnancy  Probable signs of pregnancy are those signs commonly noted by the health providers upon examination of the client. These signs include: uterine changes; abdominal changes; cervical changes; basal body temperature; a positive pregnancy test and fetal palpation POSITION: By the twelfth week, the uterus rises above the symphysis pubis and it should reach the xiphoid process by the 36Th week of pregnancy SIZE: The uterine increases in width and length approximately five times its normal size. Its weight increases from 50 grams to 1,000 grams UTERINE CHANGES HEGAR’S SIGN: This is softening of the lower uterine segment just above the cervix. Hegar’s sign is noted by the sixth to eighth week of pregnancy BALLOTTEMENT: This is demonstrated during the bimanual examination done at the 16 Th to 20Th week. The fetus floats upwards, then sinks back and a gentle tap is felt on the finger 12 | Maternal and child nursing ABDOMINAL CHANGES This corresponds to changes that occur om the uterus. As the uterus grows, the abdomen gets larger. Abdominal enlargement alone is not a sign of pregnancy. Enlargement may be due to uterine or ovarian tumors, or edema CERVICAL CHANGES GOODELL’S SIGN: The cervix is normally firm like the cartilage at the end of the nose. Goodell’s sign occurs when there is marked softening of the cervix. This is present at the 6Th week of pregnancy FORMATION OF A MUCOUS PLUG: This is due to hyperplasia of the cervical glands as a result of increased hormones. It serves to seal the cervix of the pregnant uterus and to protect it from contamination by bacteria in the vagina. The mucous is expelled at the end of pregnancy near or at the onset of labor BRAXTON-HICK’S CONTRACTION: This involves painless uterine contractions occurring throughout pregnancy. It usually begins at about the 12Th week of pregnancy and becomes progressively stronger. These contractions will, generally, cease with walking or other forms of exercise. Braxton-Hick’s contractions are distinct from contractions of true labor by the fact that they do not cause the cervix to dilate and can usually be stopped by walking BASAL BODY TEMPERATURE: This is a good indication if the patient has recorded her temperature over several previous cycles. A persistent temperature elevation spanning the 3 weeks from ovulation is noted as an indicator of pregnancy. Basal body temperature (BBT) if 97% accurate POSITIVE PREGNANCY TEST: This may be misread by doing it too early or too late. Even if the test is positive, it could be the result of ectopic pregnancy or a hydatidiform mole FETAL PALPATION: This is a probable sign in early pregnancy. The physician can palpate the abdomen and identify fetal parts. It is not always accurate POSITIVE SIGNS OF PREGNANCY Positive signs of pregnancy are those signs that are definitely confirmed as a pregnancy. They include fetal heart sounds, ultrasound scanning of the fetus, palpation of the entire fetus, palpation of fetal movements, X-ray, and actual delivery of an infant 13 | Maternal and child nursing FETAL HEART SOUNDS: The fetal heart begins beating by the 24 Th day following conception. It is audible with a Doppler by 10 weeks of pregnancy and with a fetoscope after the 16Th week. It is not to be confused with uterine souffle or the swish like tone from pulsating uterine arteries. The normal fetal heart rate is 120 to 160 beats ULTRASOUND SCANNING OF THE FETUS: Pregnancy ultrasound is a method of imaging the fetus and the female pelvic organs during pregnancy. The gestation sac can be seen  Pelvic ultrasound: ask the mother to drink a lot of water for the fetus to float  Transvaginal ultrasound: ask the mother to void to avoid urination once the probe is inserted into the vagina  Biophysical ultrasound: 5 Parameters o Fetal heart rate o Fetal movement o Fetal tone o Fetal breathing o Amniotic fluid Scoring: o 8-10: baby is fine, no problems o 4-7: another test is to be done for confirmation o 1-3: death Probable Signs of Pregnancy  Abdominal enlargement  McDonald’s sign  Uterine souffle  Braxton Hicks Contractions  Ballottement  Hegar’s Sign (uterus)  Goodell’s Sign (cervix)  Chadwick’s Sign (vagina)  Lines Nigra, Cholasma, Striae  Fetal Outline  Positive pregnancy test – early morning urine; made + because of HCG Positive Signs of Pregnancy Positive Signs Time Fetal heartbeat 10-12 weeks Fetal movement 20Th week Fetal outline by ultrasound 4-5 weeks gestation (2-3 weeks after conception) Fetal parts 8 weeks gestation DANGER SIGNS OF PREGNANCY The woman should report the following signs in pregnancy immediately Danger Sign Possible Cause Intervention Sudden gush of fluid from Premature rupture of membrane Get fetal heart rate of the vagina baby Do not let patient walk. Tell the patient to sit at a wheelchair then lie down to a stretcher Cord comes out of the vagina, stat CS No IE because of cord prolapse. If IE is performed by the doctor, the fingers should stay inside until the baby comes out to prevent distress of baby 14 | Maternal and child nursing Vaginal Bleeding Abruptio placenta, Placenta Complete bed rest without previa bathroom privileges Lesions of cervix or vagina “Bloody show” Abdominal Pain Premature labor, abruptio Complete bed rest placenta Stay away with worries and stress Temperature above 38.3°C Infection Slow IV of magnesium sulfate: (101°F) & chills 5mg=20cc each buttocks Dizziness, blurring of vision, Hypertension, preeclampsia double vision, spots before eyes Danger Sign Possible Cause Interventions Oliguria (scanty urine) Renal impairment, decreased fluid intake Dysuria (painful urine) Urinary Tract Infection Absence of fetal movement Maternal medication, obesity, Ask the mother to eat fetal death Encourage the mother to listen to music Placing a probe at the abdomen that produces a vibration-like sensation that will stimulate the baby DIAGNOSTICS AND LABORATORY FINDINGS 15 | Maternal and child nursing IMPORTANT:  VDRL  TB test  HB screening  HIV screening Pap Smear: candidate for menopause Amniocentesis: from the amniotic fluid; taken at bedside; done by inserting needle in the tummy Lecithin/Sphingomyelin ratio: 2:0; lecithin helps in breathing of the baby. If the ratio is low, it is injected to the mother going through the cord for absorption and delivered to the baby PRENATAL ASSESSMENT Prenatal Visit Focus:  Education about pregnancy  Screen for danger signs that might reveal:  Ectopic pregnancy  HTN  Hemorrhage  Embolism  Infection  Anesthesia-related complications (i.e. intrapartum cardiac arrest) Schedule of Visits  First 32 weeks: once/month  32-36 weeks: 2× a month (every 2 weeks)  36-40 weeks: 4× a month (every week) Prompt reporting of (+) danger signals of pregnancy – for evaluation A. Extensive Health Hx Initial Interview Purposes:  Establish rapport  Gain information about a woman’s physical and psychosocial health  Obtain basis for anticipatory guidance for the pregnancy Initial Interview  Completion of some of the forms by the client  Setting: private, quiet  Introduce self  Clarify your role  Ask how the client wants to be addressed  Good interview technique  Establish rapport Health History Components: 1. Demographic Data 2. Chief Concern  Ask:  LMP  Pregnancy test  Signs of early pregnancy  Discomforts of pregnancy  Danger signs of pregnancy 3. Family Profile 16 | Maternal and child nursing   Client’s age, occupation, educational level  Partner’s age, occupation educational level  Marital status  Available support people  House size, room location  Situations that can hinder acceptance of pregnancy 4. History of Past Illness  Heart and kidney diseases, UTI, HTN, DM, asthma, common infectious diseases, etc.  Immunizations  Allergies  Past surgical procedures 5. History of Family Illness  Cardiovascular  Renal  Cognitive  Blood disorders  Genetically inherited diseases  Congenital anomalies 6. Day History/Social Profile  Nutrition  Elimination  Sleep/rest, exercise  Recreation, hobbies  Interpersonal interactions  Habits  Involvement in abusive relationship  Medication Hx 7. Gynecologic History  Menarche  Usual menstrual cycle and discomforts  Monthly perineal self-examination  Past reproductive tract surgery  Hx of frequent D&C  FP methods  Sexual Hx  Stress incontinence 8. Obstetric History  Previous pregnancy  Previous miscarriages or therapeutic abortions  Blood transfusions  GTPALM o Gravida o Term o Preterm o Abortion o Living o Multiparity 9. Review of Systems Head: headache, injury, seizures, fainting Eyes: vision, glasses diplopia, infection, glaucoma, cataract, pain, recent changes Ears: infection, discharge, earache, hearing loss, tinnitus, vertigo Nose: epistaxis, colds, allergies, pastnasal discharge, sinus pain Mouth and Pharynx: dentures, teeth condition, toothache, bleeding gums, hoarseness, dysphagia, tonsillectomy, last dental exam Neck: stiffness Breasts: lumps, secretions, pain, tenderness Respiratory System: cough, wheezing, asthma, SOB, pain, TB, pneumonia Skin: rashes, acne, psoriasis B. P. E. INCLUDING PELVIC EXAMINATION 1. Baseline Height, Weight and V/S Measurement 2. Assessment of Systems  General appearance and mental status  Posture  Manner of dressing  Manner of speaking  Facial expression  Presence of bandages and dressings 17 | Maternal and child nursing  3. Measurement of Fundal Height & Fetal Heart Sounds 4. Internal Examination (IE) or Vaginal Examination Purposes:  Confirms the process of pregnancy  Cervix size  Pelvic abnormalities  Detects early pregnancy and gestations Chadwick’s, Goodell’s, and Hegar’s Sign  After 34 weeks: done to assess consistency of the cervix, length and dilatations, fetal presenting part, bony architecture of pelvis, anomalies of the vagina and perineum 5. Pelvic Examination and Estimating Pelvic Size  Done in the third trimester to determine CPD  Reveals information on the health of both external and internal reproductive organs  Pelvic Examination  External genitalia  HSV 2  Skene’s and Bartholin’s glands infection  Rectocele  Cystocele  Internal Genitalia  Position and color of cervix, pap smear  Signs of infection  Abnormal appearance  Position, contour, consistency, and tenderness of pelvic organs  Strength and irregularity of posterior vaginal wall  Estimating Pelvic Size Assessment of Pelvic Adequacy (clinical pelvimetry)  Diagonal conjugate  True conjugate or conjugate vera  Ischial tuberosity diameter C. LABORATORY ASSESSMENT a. Blood studies 1. CBC  Initial visit  Repeated at 28-32 weeks  To detect anemia 2. Genetic screening 3. Serologic test for syphilis 4. Blood typing (including RH factor) 5. Maternal serum for AFP (MSAFP)  Best done at 16-18 weeks of pregnancy o Increased AFP – neural tube or abdominal defect 18 | Maternal and child nursing  o Decreased AFP – chromosomal anomaly 6. Indirect Coomb’s Test 7. Antibody titers for Rubella and Hepatitis B (HBsAg) 8. HIV screening 9. Plasma glucose level b. Urinalysis  Microscopic examination  To test glycosuria, pyuria and proteinuria c. TB screening  Increases risk for miscarriage D. ULTRASONOGRAPHY  To observe FHR, movement, respirations, position and presentation, fetal death  Can detect:  A gestational sac as early as 5 to 6 weeks after the LMP  Heart activity by the 6 to 7 weeks  Fetal breathing movement by 10 to 11 weeks of pregnancy  Crown-to-rump measurements can be made to assess fetal age until the fetal head can be visualized clearly E. NON-STRESS TEST (NST)  Uses electronic fetal monitor  To assess fetal status:  Observe baseline variability and acceleration of FHR with movement  FHR accelerations – fetal central and autonomic nervous systems have not been affected by decreased oxygen to the fetus  Implication: Monitor HR and fetal movement Major Goals of Comprehensive Prenatal Assessment and Evaluation a) Define health status of mother and fetus b) Determine gestational age of fetus: estimate date of confinement c) Initiate a nursing care plan for continuing maternity care of both mother and fetus d) Detect early any high-risk condition PSYCHOLOGICAL RESPONSES TO PREGNANCY Mother’s Response to pregnancy: 1. Ambivalence – It is a state of having simultaneous conflicting reactions, beliefs, or feelings towards some object. 2. Mood Changes – Caused by physical stresses, fatigue, changes in your metabolism, or by the hormones estrogen and progesterone 3. Introvert- Someone whom finds energy in alone time, isn’t the greatest at expressing emotions, and has a small group of people they feel most comfortable around 4. Changes in body image 5. 1st Trimester: Accepting the pregnancy - 50% of all pregnancies are unintended, unwanted or mistimed. Father’s Response to pregnancy 1. Resents attention given to the woman 2. Needs to resolve conflicts about fathering 3. Resents changes in their relationship 4. Feels left out 5. Confused by partner’s mood swings PSYCHOLOGIC TASKS OF THE MOTHER  Ensuring safe passage through pregnancy, labor and birth  Seeking acceptance of this child by others  Seeking of commitment & acceptance of self as mother to the infant (binding in)  Learning to give of one’s self on behalf of one’s child 1ST TRIMESTER: Accepting the pregnancy  50% of all pregnancies are unintended, unwanted or mistimed.  Women sometimes experience disappointment, anxiety or ambivalence  Partner may go through some changes also  Partner should give emotional support 19 | Maternal and child nursing   May feel proud, happy, jealous or loss 2nd TRIMESTER: Accepting the baby  Second turning point is often quickening  Proof of the child’s existence  Anticipatory role playing  May accept at conception, at birth or later  How well she follows prenatal instructions  Partner may feel left out, he may increase his work, he has misinformation  Educate both partners 3 TRIMESTER: Preparing for Parenthood rd  “Nest building”  Attending prenatal classes or parenting classes  Reworking developmental tasks  Working through previous life experiences  Woman’s relationship with her parents, particularly her mother 3 TRIMESTER: Fear of dying rd  Needs confidence in health care providers  Men may need to reconcile feelings toward fathers and learn a new pattern of behavior  Role-playing and fantasizing  Second step in preparing of parenthood  Spend time with other mothers to learn how to be a mother. Needs good role models SIGNS OF PREGNANCY A. Presumptive (Subjective) B. Probable (Objective) C. Positive (Diagnostic) A. PRESUMPTIVE SIGNS OF PREGNANCY 1. Amenorrhea (Cessation of menstruation) - One of the earliest clues of pregnancy - Majority of clients have no periodic bleeding after the onset of pregnancy - At least 20% of women have some slight, painless spotting during early gestation for no apparent reason and a large majority of these continue to term and have normal infants 2. Nausea & Vomiting - Usually in early morning - Usually spontaneous and subsides in 6-8 weeks or by the 12th to 16th week of pregnancy Hyperemesis gravidarum – As severe nausea and vomiting and lasts beyond the 4th month of pregnancy, causes weight loss and upsets fluid and electrolyte balance of the mother - Nausea and vomiting are unreliable signs of pregnancy since they may result from other conditions such as: a. Gastrointestinal disorders: hiatal hernias, ulcers, and appendicitis b. Infection: influenza, malaria c. Emotional stress, upset: anxiety, anorexia nervosa d. Indigestion 3. Frequency of voiding - Frequent urination is caused by pressure of the expanding uterus on the bladder - It subsides as pregnancy progresses and the uterus rises out of the pelvic cavity - The uterus returns during the last weeks of pregnancy as the head of the fetus presses against the bladder - Frequent urination is not a definite sign since other factors can be apparent (such as tension, diabetes, UTI, or tumors) 4. Breast changes (With picture) - In early pregnancy, changes start with a slight, temporary enlargement of the breasts causing a sensation of weight, fullness, and mild tingling - As pregnancy continues the patient may notice: a. Darkening of the areola: the brown part around the nipple b. Enlargement of Montgomery glands: the tiny nodules or sebaceous glands within the areola c. Increased firmness or tenderness of the breasts d. More prominent and visible veins due to the increased blood supply e. Presence of colostrum (thin yellowish fluid that is the precursor of breast milk). This can be expressed during the 2nd trimester and may even leak out in the latter part of the pregnancy 5. Vaginal Changes I. CHADWICK’S SIGN - The vaginal walls have taken on a deeper color caused by the increased vascularity because of increased hormones. - It is noted at the 6th week when associated with pregnancy. 20 | Maternal and child nursing  - It may also be noted with a rapidly growing uterine tumor or any cause of pelvic congestion. 6. Vaginal Changes II. LEUKORRHEA - This is an increase in the white or slightly gray mucoid discharge that has a faint musty odor. It is due to hyperplasia of vaginal epithelial cells of the cervix because of increased hormone level from the pregnancy. - Leukorrhea is also present in vaginal infections 7. Quickening - This is the first perception of fetal movement within the uterus. - Occurs toward the end of 5th month because of spasmodic flutter a. A multigravida can feel quickening as early as 16 weeks b. A primigravida usually cannot feel quickening until after 18 weeks - Once quickening has been established, the patient should be instructed to report any instance in which fetal movement is absent for a 24-hour period - Fetal movement early in pregnancy is frequently thought to be gas 8. Skin Changes I. Stratum Gravidarum (Stretch marks) - Noted on the abdomen and/or buttocks. Striae gravidarum may also be classified as a probable sign of pregnancy - Caused by increased production or sensitivity to adrenocortical hormones during pregnancy, not just weight gain - May be seen on a patient with Cushing’s disease or a patient with sudden weight gain 9. Skin Changes II. Linea Nigra - This is a black line in the midline of the abdomen that may run from the sternum or umbilicus to the symphysis pubis. - This appears on the primigravida by the 3rd month and keeps pace with the rising height of the fundus - The entire line may appear on the multigravida before the 3 rd month - This may be a probable sign if the patient has never been pregnant 10. Skin Changes III. Cholosma Gravidarum (butterfly face, pigmentation) - This is called the Mask of pregnancy - It is a bronze type of facial coloration seen more on dark-haired women. - It is seen after the 16th week of pregnancy - IN FINGERNAILS, some patients note marked thinning and softening by the 6 th week 11. Fatigue - This is a common complaint by most patients during the first trimester. Fatigue may also be a result of anemia, infection, emotional stress, or malignant disease 12. Positive Home Test - These tests may not always be accurate; however, they can be very effective if they are performed properly B. PROBABLE SIGNS OF PREGNANCY - Probable signs are those signs commonly noted by the health providers upon examination of the client. - These signs include: uterine changes, abdominal changes, cervical changes, basal body temperature, a positive pregnancy test and fetal palpation 1. Uterine Changes I. Hegar’s Sign - This is softening of the lower uterine segment just above the cervix. Hegar’s sign is noted by the 6th week – 8th week of pregnancy Position:  12th week, uterus rises above the symphysis pubis and it should reach the xiphoid process by the 36th week of pregnancy Size:  Uterine increases in width and length approx. 5x its normal size. Its weight increases from 50g to 1000g. 2. Uterine Changes II. Ballottement - This is demonstrated during the bimanual examination done at the 16 th-20th week - The fetus floats upwards, then sinks back and a gentle tap is felt on the finger 3. Abdominal Changes (picture) - This corresponds to changes that occur in the uterus. 21 | Maternal and child nursing  - As the uterus grows, the abdomen gets larger. - Abdominal enlargement alone is not a sign of pregnancy - Enlargement may be due to uterine or ovarian tumors, or edema 4. Cervical Changes I. Goodell’s Sign - The cervix is normally firm, like the cartilage at the end of the nose. - Goodell’s sign occurs when there is marked softening of the cervix - Present at the 6th week of pregnancy 5. Cervical Changes II. Formation of a mucous plug - This is due to hyperplasia of the cervical glands as a result of increased hormones. - It serves to seal the cervix of the pregnant uterus and to protect it from contamination by bacteria in the vagina. - The mucous is expelled at the end of pregnancy near or at the onset of labor 6. Cervical Changes III. Braxton-Hick’s Contractions - This involves painless uterine contractions occurring throughout pregnancy. It usually begins at about the 12th week of pregnancy and becomes progressively stronger. - These contractions will, generally, cease with or other forms of exercise. - Braxton-Hick’s contractions are distinct from contractions of true labor by the fact that they do not cause the cervix to dilate and can usually be stopped by walking 7. Cervical Changes IV. Basal Body Temperature - This is a good indication if the patient has recorded her temperature over several previous cycles. - A persistent temperature elevation spanning the 3 weeks from ovulation is noted as an indicator of pregnancy. - Basal body temperature is 97% accurate 8. Cervical Changes V. Positive pregnancy test - This may be misread by doing it too early or too late. Even if the test is positive, it could be the result of ectopic pregnancy or a hydatidiform mole VI. Fetal Palpation - This is a probable sign in early pregnancy. The physician can palpate the abdomen and identify fetal parts. It is not always accurate. PROBABLE SIGNS OF PREGNANCY 1. Abdominal enlargement 2. McDonald’s sign 3. Uterine soufflé 4. Braxton Hick’s contractions 5. Ballotement 6. Hegar’s sign (uterus) 7. Goodell’s Sign (cervix) 8. Chadwick’s sign (vagina) 9. Linea nigra, cholosma, striae 10. Fetal outline 11. Positive pregnancy test – early morning urine; made + because of HCG C. POSITIVE SIGNS OF PREGNANCY - Positive signs of pregnancy are those signs that are definitely confirmed as a pregnancy. - They include fetal heart sounds, ultrasound scanning of the fetus, palpation of the entire fetus, palpation of fetal movements, x-ray, and actual delivery of an infant. 1. Fetal Heart Sounds - FHR begins beating by the 24th day following conception. It is audible with a Doppler by 10 weeks of pregnancy and with a fetoscope after 16th week. - It is not to be confused with uterine soufflé or the swish like tone from pulsating uterine arteries. - The normal FHR is 120-160 bpm 2. Ultrasound scanning of the fetus - Pregnancy ultrasound is a method of imaging the fetus and the female pelvic organs during pregnancy. - The gestation sac can be seen 22 | Maternal and child nursing  POSITIVE SIGNS OF PREGNANCY Positive Signs Time Fetal heartbeat 10-12 weeks Fetal movement 20th week Fetal outline by ultrasound 4-5 weeks gestation (2-3 weeks after conception) Fetal parts 8 weeks gestation DANGER SIGNS OF PREGNANCY - This woman should report the following signs in pregnancy immediately: DANGER SIGN POSSIBLE CAUSE Sudden gush of fluid from vagina  Premature rupture of membrane Vaginal bleeding  Abruptio placenta, placenta previa  Lesions of cervix or vagina “bloody show” Abdominal pain  Premature labor, abruption placenta Temp >38.3 C (101F) & chills  Infection Dizziness, blurring of vision, double vision, spots before  Hypertension, preeclampsia eyes Persistent vomiting  Hyperemesis gravidarum Severe headache  Hypertension, preeclampsia Edema of hands, face, legs, & feet  Preeclampsia Muscular irritability, convulsions  Preeclampsia, eclampsia Epigastric pain  Preeclampsia, ischemia in major abdominal vessel Oliguria  Renal impairment  Decreased fluid intake Dysuria  UTI Absence of fetal movement  Maternal meds, obesity, fetal death DIAGNOSTICS & LABORATORY FINDINGS 1ST TRIMESTER Blood type Determines risk for maternal-fetal blood Rh factor incompatibility Antibody screen Complete blood count (CBC) Determines anemia, infection, or cell abnormality Hemoglobin and hematocrit Detects anemia Veneral Disease Research Laboratory (VDRL) test or Syphilis screen Rapid Plasma Reagin (RPR) Rubella titer Determines immunity to rubella Tuberculosis test Screening test for exposure to TB Hepatitis B screening Identifies carriers for hepa B Human Immunodeficiency virus (HIV) screen Detects HIV infection Urinalysis & Culture Detects infection, renal disease, or diabetes Papanicolau (Pap) Test Screens for cervical cancer Vaginal or cervical culture Detects group B streptococci, bacterial vaginosis, or STI’s such as gonorrhea 23 | Maternal and child nursing  2ND TRIMESTER Blood glucose screen: 1 hr after ingesting 50g of Routine test done at 24-28 week gestation to identify glucose liquid gestational diabetes mellitus Result: >135 mg/dL requires medical follow up Serum-alpha-fetoprotein Optional routine test to identify neural tube or chromosomal tube defect in fetus Amniocentesis Performed at a 16-20 week gestation when high-risk problem is suspected or if the mother is over 35 y/o. 3RD TRIMESTER Ultrasound  Performed when problem is suspected  Identifies reduced amniotic fluid, which can result in fetal problem  Identifies excess amniotic fluid, which would indicate fetal anomaly or maternal problem  Confirms gestational age or CPD  Determines fetal lung maturity (lecithin / sphingomyelin ratio) with amniocentesis  Confirms presence of anomaly that may require fetal or neonatal surgery Cervical fibronectin assay Determines risk of preterm labor when problem is suspected PRENATAL VISIT Focus: - Education about pregnancy - Screen for danger signs that might reveal:  Ectopic pregnancy  HTN  Hemorrhage  Embolism  Infection  Anesthesia-related complications (i.e. intrapartum cardiac arrest) Schedule of visits: First 32 weeks: 1/month 32-36 weeks: 2x/month or every 2 weeks 36-40 weeks: 4x/month or every week - Promote reporting of (+) danger signals of pregnancy –for evaluation. Prenatal visit: A. Extensive Health History B. PE, Including pelvic examination C. Laboratory assessment INITIAL INTERVIEW OF PRENATAL VISIT Purpose:  Establish rapport  Gain info abt a woman’s physical and psychosocial health  Obtain basis for anticipatory guidance for the pregnancy 24 | Maternal and child nursing Initial Interview:  Completion of some of the forms by the client  Setting: Private & quiet  Introduce self  Clarify your role  Ask how the client wants to be addressed  Good interview technique  Establish rapport HEALTH HISTORY 1. Demographic data 2. Chief concern Ask:  LMP  Pregnancy test  Signs of early pregnancy  Discomforts of pregnancy  Danger signs of pregnancy 3. Family profile  Client’s age, occupation, educational level  Partner’s age, occupation, educ. Level  Marital status  Available support people  House size, room location  Situations that can hinder acceptance of pregnancy 4. HPI  Heart & kidney diseases, UTI, HTN, DM, asthma, common infectious diseases, etc.  Immunizations  Allergies  Past surgical procedures 5. History of family illness  Cardiovascular  Renal  Cognitive  Blood disorders  Genetically inherited diseases  Congenital anomalies 6. Day history/Social profile  Nutrition  Elimination  Sleep/rest, exercise  Recreation, hobbies  Interpersonal interactions  Habits  Involvement in abusive relationship  Medication Hx 7. Gynecologic history  Menarche  Usual menstrual cycle and discomforts  Monthly perineal self-examination  Past reproductive tract surgery  Hx of frequent D & C  FP methods  Sexual Hx  Stress incontinence 8. Obstetric history  Previous pregnancy  Previous miscarriages or therapeutic abortions  BT  GTPALM 9. Review of systems Head: Headache, injury, seizures, dizziness, fainting Eyes: Vision, glasses, diplopia, infection, glaucoma, cataract, pain, recent changes Ears: Infection, discharge, earache, hearing loss, tinnitus, vertigo Nose: Epistaxis, colds, allergies, postnasal discharge, sinus pain 25 | Maternal and child nursing  Mouth & Pharynx: Dentures, teeth conditions, tootache, bleeding gums, hoarseness, dysphagia, tonsillectomy, last dental exam Neck: stiffness Breasts: Lumps, secretion, pain tenderness Respiratory system: Cough, wheezing, asthma, SOB, pain, TB, pneumonia Skin: rashes, acne, psoriasis B. PHYSICAL EXAMINATION (Void prior to PE) 1. Baseline height, weight, V/S measurement 2. Assessment of systems 3. Measurement of fundal height & FH sounds 4. IE or vaginal examination 5. Pelvic examination & estimating pelvic size 1. BASELINE HEIGHT, WEIGHT, V/S MEASUREMENT 2. ASSESSMENT OF SYSTEMS  General appearance and mental status  Posture  Manner of dressing  Manner of speaking  Facial expression  Presence of bandages and dressings  Cephalocaudal assessment  Dry, sparse hair  Periorbital edema  Feeling of fullness  Nasal congestion  Cholasma / chloasma  Gingival hypertrophy cracked corners pinpoint lesions w/ erythematous base  Thyroid hyperthrophy  Functional murmurs, SOB  Breast changes  Lordosis  Palmar erythema, itching, subclinical jaundice  Slowed peristalsis  Hemorrhoids  Varicosities, pitting edema 3. MEASUREMENT OF FUNDAL HEIGHT AND FH SOUNDS  Mcdonald’s rule  Bartholomew’s rule  Haase’s rule  Leopold’s maneuver  Listening for FH sounds (10-12weeks, 18-20 weeks) 4. IE EXAMINATION Purpose:  Confirms the process of pregnancy  Cervix size  Pelvic abnormalities  Incompetent cervix  Detects early pregnancy and gestations, Chadwick’s, Goodell’s, & Hegar’s sign - After 34 weeks: done to assess consistency of cervix, length and dilatations, fetal presenting part, bony architecture of pelvis, anomalies of the vagina and perineum - Done in the 3rd trimester to determine CPD - Pelvic examination reveals information on the health of both external and internal reproductive organs External genitalia: HSV 2, skene’s & bartholin’s glands infections, rectocele, cystocele Internal genitalia:  Position and color of cervix, pap smear  Signs of infection  Abnormal appearance  Position, contour, consistency, and tenderness of pelvic organs  Strength and irregularity of vaginal wall 26 | Maternal and child nursing 5. PELVIC EXMAINATION AND ESTIMATING PELVIC SIZE Estimating Pelvic Size Assessment of pelvic adequacy (Clinical pelvimetry)  Diagonal conjugate  True conjugate or conjugate vera  Ischial tuberosity diameter C. LABORATORY ASSESSMENT A. Blood Studies 1. CBC  Initial visit  Repeated at 28-32 weeks  To detect anemia 2. Genetic screening 3. Serologic test for syphilis 4. Blood typing (Including RH factor) B. Urinalysis - Microscopic examination to test glycosuria, pyuria & proteinuria C. TB Screening - TB increases risk of miscarriage D. Ultrasonography Purposes:  Early identification of pregnancy (As early as the 5th week or 6th week after LMP)  Identification of more than one fetus  TO measure biparietal diameter  To detect fetal anomalies, hydramnios or oligohydramnios  To locate and grade the placenta - To observe FHR, movement, respirations, position and presentation, fetal death - Can detect:  A gestational sac as early as 5-6 weeks after the LMP  Heart activity by the 6-7 weeks  Fetal breathing movement by 10-11 weeks of pregnancy  Crown-to-rump measurements can be made to assess fetal age until the fetal head can be visualized clearly E. Non-Stress Test (NST) - Uses electronic fetal monitor - To assess fetal status:  Observe baseline variability and acceleration of fetal heart rate (FHR) with movement  FHR accelerations – fetal central & autonomic nervous systems have not been affected by decreased oxygen to the fetus  Implication: Monitor HR and fetal movement MAJOR GOALS OF COMPREHENSIVE PRENATAL ASSESSMENT & EVALUATION A. Define health status of mother and fetus B. Determine gestational age of fetus; estimate date of confinement C. Initiate an NCP for continuing maternity care of both mother and fetus D. Detect early any high risk condition Theories of Labor Onset All have in common: uterine contractions Uterine stretch  Any hollow organ such as the uterus tends to contract and empty itself when distended. Oxytocin  Helps in the myometrium  Also stops bleeding and hemorrhage after delivery Progesterone-deprivation  Increased progesterone= spotting or results to miscarriage; ectopic pregnancy also might occur= development of fetus outside the uterus Aging placenta  No more nutrient and oxygen needed by the baby  Deteriorates= before 36 weeks Prostaglandin 27 | Maternal and child nursing   Measurement of prostaglandin- normal 6-23 mcg/dL  Source of prostaglandins: amnion ad deciduas  Rising fetal cortisol level increases the formation of prostaglandin which stimulates contractions  Prostaglandin causes the smooth muscle contractions Preliminary/ premonitory signs of labor  Tell whether or not the patient is in labor Lightening  Primiparas- occur early; multi- on the day of labor or after day of labor  Venous stasis- blood clots in the veins o Deep vein thrombosis o Due to px is not moving  Descent of the fetal part into the pelvis  Uterus becomes lower and more anterior  Mother may experience the following: o Shooting leg pains o Increased vaginal secretions o Increased urinary frequency o Increased pelvic pressure o Increased venous stasis Braxton-Hick’s  May be alleviated when moving  Also called as false labors  Irregular, intermittent contractions  Felt in the abdomen or inguinal region and patients may mistake them for true labor Cervical Ripening  Strip: manual widening of the cervical opening  done for term patients  If there is history of bleeding, dystocia, or difficulty in delivering  Internal sign which can be determined only on pelvic examination  Cervix feels softer than normal (goodell’s sign); Get softer at term (butter soft) and tips forward Bloody show  Pink-tinged secretions signaling labor will begin within 24-48 hours  With the softening and effacement of cervix mucous plus is expelled= small amount of blood loss from the exposed cervical capillaries Rupture of Membranes  1st assess- check the fetal heart rate of the baby; fetal distress  2nd- color, amount, and odor  Clear/odorless- normal  Contains white specks (vernix caseosa) and lanugo  Yellow-green tinged amniotic fluid= infection or fetal passage of meconium o If meconium stained- give to the pediatrician o Signals need for further assessment and FHR monitoring o If engagement has not occurred: danger or prolapsed cord o Open pathway into the uterus increases risk of infection  Amniotic membranes rupture once labor is well established, either spontaneously or amniotomy Sudden burst of energy  24-48 hours of labor anxiety or energy levels are high  Increase activity= increase in epinephrine release  Prepares the woman’s body for the work of labor ahead. Other signs  Weight loss of 1 to 3 lbs  Diarrhea, nausea, and vomiting True labor pains  Involve uterine and cervical changes  Surest sign that labor has begun is progressive uterine contractions 28 | Maternal and child nursing Comparisons of true and false labor pains True labor False labor Pain usually begins in the lower back, radiating to Occurs in the lower abdomen the abdomen Intensity usually increases with change in activity Change of activity has no effect on contractions e.g. walking usually increases labor pain e.g. walking may lessen the pain  Frequency- beginning of 1st contraction to the beginning of the next  Duration- beginning to end of one contraction Components of Labor  6Ps of labor o Passage- birth canal o Passenger- fetus o Presenting part of the fetus and relationship of the maternal pelvis o Powers of labor o Position of the mother o Psyche/psychological outlook Passage  Route the fetus must travel (uterus-cervix-vagina-external perineum)  Must be adequate size  Two pelvic measurements important to determine the adequacy of the pelvic size o Diagonal conjugate (AP diameter of the inlet) o Transverse diameter of the outlet  Critical factors o Size of maternal pelvis (diameters of the pelvic inlet, midpelvis, and outlet) o Type of maternal pelvis  Gynecoid- best for delivery  Android- mostly in males  Anthropoid- for black women  Platypelloid- Transverse position of the baby o Ability of the cervix to dilate and efface o Ability of the vaginal canal and the introitus to distend  Introitus- an entrance to descent Passenger  Fetus  Movement of the fetus through the birth canal is determined by several interacting factors: o Fetal head, attitude, lie, presentation, and position  Fetal head- most important part of the fetus to be seen by OBs; largest part of the fetus, most frequent presenting part, and least compressible of all parts  The head is important in manipulating the baby o Has 7 bones: frontal-2, parietal-2, temporal-2, and occipital-1 o Sutures- spaces between cranial bones  Frontal- between 2 frontal bones  Coronal- between frontal and parietal bones  Sagittal- between 2 parietal bones (midline suture); Most important suture- overrides in labor (molding) decreasing biparietal diameter by 0.5 to 1 cm  Lamboidal- posterior suture; between parietal and occipital bones o Membrane-filled spaces called fontanelles are located where sutures intersect  Anterior, posterior, sphenoidal, and mastoid fontanelles  Anterior and posterior fontanelles are clinically useful along with the sutures in identifying the position of the fetal head in the pelvis and assessing the status of the new born after birth  Compresses to aid in molding of the fetal head o Landmarks of the fetal skull  Mentum- chin  Sinciput- upper part of the skull especially the anterior portion above and including the forehead  Bregma- large diamond-shaped anterior fontanelle  Vertex- area between posterior and anterior fontanelles  Posterior fontanelle  Occiput- area of the fetal skull occupied by the occipital bone o Submentobregmatic- 9.5 cm o Suboccipitobregmatic- 9.5 cm o Occipitofrontal- 12 cm o Occipitomental- 13.5 cm o Biparietal- 9.25 cm 29 | Maternal and child nursing  o Bitemporal- 8 cm  Fetal attitude/habitus o Relation of the fetal body parts to each other o Flexion- head flexed on chest o Extension- head extended, occiput touches the back o Types: complete flexion, moderate, flexion, poor flexion, hyperextension  Fetal lie o Relation of the long axis of the fetal body and the long axis of the mother’s body o Longitudinal/vertical lie- cephalic or breech o Transverse/horizontal lie- shoulder o Oblique lie- unstable and always becomes longitudinal or transverse during labor  Fetal presentation o Body part of the fetus that enters the pelvic inlet and leads through the birth canal during labor. o Determined by the combination of the fetal lie and degree of fetal flexion (attitude) o Cephalic- most frequent type of presentation o Head presents (vertex, sinciput, brow, and face) o Type of cephalic presentation  Vertex- occiput is the presenting part  Sinciput- fetal head is partially flexed, with the anterior fontanelle, or bregma presenting  Brow- fetal head is partially extended; sinciput (forehead) is the presenting part  Face- head is hyperextended; face is the presenting part o Breech- buttocks or feet is the presenting part  Complete—kneed and hips flexed, thighs on abdomen, and calves on posterior thighs, and feet present  Frank- hips flexed, knees extended, feet present  Footling- hips and legs extended  One-foot present- single footling  Both feet present- double footling o Shoulder- shoulder present (most frequent one of the shoulders) o Fetal hand, elbow, back, abdomen, or side may present in the maternal pelvis  Fetal position- relationship of the presenting part to a specific quadrant of the woman’s pelvis o 4 quadrants: (1) right anterior, (2) left anterior, (3) right posterior, and (4) left posterior o 4 parts of fetus as landmarks  Vertex presentation- occiput  Face presentation- chin (mentum)  Breech presentation- sacrum  Shoulder presentation- acromion process o Indicated by an abbreviation of three letters  1st letter- left or right (L or R)  2nd letter- denotes fetal landmark (O- occiput, M-mentum, SA- sacrum, and A-acromion process)  Last letter- anteriorly or posteriorly (A or P)  Right hand- right  Left hand- left  Anterior- facing away/ faces the mother  Posterior- facing towards/ faces towards  Engagement- settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spine o Can be determined by vaginal examination and leopold’s maneuver o Floating: dipping o Synclitism- occurs when the sagittal suture is midway between the symphysis pubis and sacral promontory o Asynclitism- occurs when the sagittal suture is directed towards either the symphysis pubis or the sacral promontory and feels misaligned  Station o Floating (-3)- presenting part above the inlet, in false pelvis o Dipping (-2) o Minus (-)- presenting part above the ischial spine o Fixed (-1) presenting part below the inlet, in true pelvis, no longer moving but not yet engaged o Station (-5)- presenting part at pelvic inlet o Engaged/ Station O- presenting part at the ischial spine o Plus (+) station- presenting part is below the ischial spine o (+4) crowning- presenting part at the perineum o Station (+5)- presenting part at the pelvic outlet  Powers of labor- involuntary and voluntary powers combine to expel the fetus, fetal membranes and the placenta from the uterus o Primary power/ primary force  Term used to describe uterine contractions during labor  Each contraction has three phases: increment(increase), acme(peak), and decrement(decrease)  Physiologic retraction ring 30 | Maternal and child nursing   Intensity  Mild- fundus indents easily and feels like the tip of your nose  Moderate- fundus indents less easily (firm fundus that is difficult to indent) and feels like a chin  Strong- fundus cannot be indented and feels like a forehead  Note: contractions that occurs more often than every two minutes and persistent contractions duration longer than 90 seconds may reduce fetal oxygen and should be reported  Responsible for the effacement and dilation of the cervix and descent of the fetus  Effacement- shortening and thinning of the cervix during the first stage of labor  Dilatation- enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun o Secondary power/ secondary force  Use of abdominal muscles to push during the second stage of labor  Voluntary bearing down efforts by the woman  As soon as the presenting part reaches the pelvic floor, contractions change in character and becomes expulsive  If cervix is not fully dilated, bearing down can cause cervical edema (which retards dilatation), possible tearing and bruising of the cervix, and maternal exhaustion  Position of the mother o Frequent changes in position relieve fatigue, increase comfort, and improve circulation o Laboring woman should be encouraged to find positions that are most comfortable to her  Upright  Lateral  Lithotomy  Semirecumbent  Sitting- uses gravity to help baby’s descent; allows rest between contractions  Kneeling- relieve back pain, helps baby rotate to favorable position(OA); relieves hemorrhoids  Squatting- uses gravity to help baby’s descent; open pelvis to provide more room  Walking, standing, and leaning- stimulate effective contractions; use of gravity to help baby’s descent  Powers of labor- woman’s psychological state or feelings that a woman brings into labor o A feeling of apprehension or fright and it includes a sense of excitement or awe Stages of Labor  Normal labor consists of: o Regular progression of uterine contractions o Effacement and progressive dilatation of the cervix o Progress in descent of the presenting part  First stage o Stages of dilatation o Begins with onset of regular uterine contractions and ends with complete dilatation of the cervix o Factors affecting the length of labor: analgesia, maternal and fetal position, woman’s body size, and the level of physical fitness o Latent(early), active, and transition phase  Latent/early phase  Duration: Nulliparas: 6 hours, multiparas: 4.5 hours  12 contractions/hour are considered a meaningful signal that spontaneous birth is beginning or imminent  Prolonged latent phase: exceeding 20 hours in nullipara and 14 hours in multipara  Best time to monitor the baby with the use of a stethoscope  Active phase  Cervical dilatation occurs more rapidly (1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas)  Fetal descent is progressive  Duration in nulliparas: 3 hrs; multiparas; 2 hrs  Spontaneous rupture of membranes may occur  Validate rupture of membranes though internal examination and nitro zine paper  Where amniotomy can be done  For faster delivery ask the mother to urinate or insert a straight catheter  Transition  By the end of this phase both full dilatation and effacement of the cervix has occurred  Does not last longer than 3 hours for nulliparas or longer than 1 hour for multiparas. Increased by approximately 1 hour is epidural anesthesia is used  Characteristics: o Restlessness o Increased apprehension and irritability o An inner focusing on her contractions o Sense of bewilderment, frustration, and anger at the contraction 31 | Maternal and child nursing  o Request for medication o Hiccupping, belching, nausea, and vomiting o Beads of perspiration on the upper lip or brow o Increasing rectal pressure and feeling the urge to bear down  For epidural anesthesia- but induction should be well timed. Do not give it on the early phase; patient will be sedated will only prolong phases. Give it on 8-9 cms.  Pudendal block anesthesia (using lidocaine 2%)- placed where the episiotomy is; has the same action as the lidocaine  Cord coil- fully dilated but cannot be delivered and baby retracts  Bulging occurs in the transitional phase  Second stage o Full dilatation and cervical effacement to birth of an infant o Completed within 3 hours after the full dilatation of the cervix for primigravidas; less than 1 hour and averages 15 minutes for multiparas o Crowning occurs o Cardinal movements of labor:  De-F-IR-E-R-ER-E  Descent- fetal head enters the maternal inlet in the occiput transverse or oblique position  Occurs because of 4 forces: (1) pressure of the amniotic fluid, (2) direct pressure of the uterine fundus on the breech, (3) contraction of the abdominal muscles, (4) extensions and straightening of the fetal body  Flexion- fetal chin flexes downward onto the chest  Allows smallest fetal diameter (suboccipitobregmatic diameter) to enter the maternal pelvis  Internal rotation- fetal head must rotate to fit the diameter of the pelvic cavity  Occiput usually rotated from left to right and the sagittal suture aligns in the anteroposterior pelvic diameter  Extension- head is born in extension as the occiput slides under the symphysis pubis  Face is directed towards the rectum  With this positional change, the occiput, then brow and face, emerge from the vagina  Restitution- once