Maternity and Gynecological Nursing PDF - Ain Shams University, 2018-2019

y Maternity and Gynecological Nursing Prepared by Prof Dr/ Sabah Metwally Mohamed Professor of Maternity & Gynecological Nursing Dr/ Amal Fatthy Mohamed Lecturer of Maternity & Gynecological Nursing...

y Maternity and Gynecological Nursing Prepared by Prof Dr/ Sabah Metwally Mohamed Professor of Maternity & Gynecological Nursing Dr/ Amal Fatthy Mohamed Lecturer of Maternity & Gynecological Nursing Faculty of Nursing, Ain Shams University Medical Reviewer Dr. Ahmed Mohammed Abbas Lecturer of Obs.& Gyn. Faculty of medicine Ain shams university Second Year 2018-2019  Acknowledgments This two-year curriculum was developed through a participatory and collaborative approach between the Academic faculty staff affiliated to Egyptian Universities as Alexandria University, Ain Shams University, Cairo University, Mansoura University, Al-Azhar University, Tanta University, Beni Souef University, Port Said University, Suez Canal University and MTI University and the Ministry of Health and Population(General Directorate of Technical Health Education (THE). The design of this course draws on rich discussions through workshops. The outcome of the workshop was course specification with Indented learning outcomes and the course contents, which served as a guide to the initial design. We would like to thank Prof.Sabah Al- Sharkawi the General Coordinator of General Directorate of Technical Health Education, Dr. Azza Dosoky the Head of Central Administration of HR Development, Dr. Seada Farghly the General Director of THE and all share persons working at General Administration of the THE for their time and critical feedback during the development of this course. Special thanks to the Minister of Health and Population Dr. Hala Zayed and Former Minister of Health Dr. Ahmed Emad Edin Rady for their decision to recognize and professionalize health education by issuing a decree to develop and strengthen the technical health education curriculum for pre-service training within the technical health  Course Description This course is designed for students to appreciate the concepts and principles of maternity nursing and helps them to acquire knowledge and develop attitude and beginning skills in rendering nursing care to normal and high risk pregnant women during antenatal, natal and postnatal periods in hospital. Also focuses on the role of the nurse in meeting the physiological, psychosocial, cultural needs of women during normal and abnormal aspects of the maternity cycle. These course includes reproductive biology , antepartum, labor, and postpartum care, complications of pregnancy ,labor, postpartum and newborn care, it focus on the application of the basic knowledge, skills and attitude required for nursing management of women during normal and abnormal aspects of the maternity cycle in the form of Modules. Each Module contains normal and abnormal and its related practice and application of the nursing process as integrated course.  Contents Part I Theoretical part Reproductive Biology - Female reproductive system Module One - Menstrual cycle - Reproductive health Normal & Abnormal pregnancy - Physiological changes during pregnancy Module Two - Nursing care during pregnancy - Hypertensive Disorders - Hemorrhagic Disorders in Pregnancy Childbirth & Birth complications Module three - Labor and Birth Processes - Nursing Care During Labor and Birth - Labor emergencies Normal & Abnormal Postpartum Period - Postpartum physiological changes Module four - Nursing care during postpartum Period - Post-partum hemorrhage - Puerperal sepsis Module five Family planning Part II Practical part 22 References Course overview  Lab /hospital Assignment Field Work Interactive Research ID Topics Lecture Class s Module One: Reproductive biology Female reproductive system 1 2.5 0.5 Menstrual cycle 2 2.5 0.5 Reproductive health 3 2.5 0.5 Module Two: Normal & Abnormal Pregnancy Physiological changes during pregnancy 0.5 9 4 2.5 Nursing care during pregnancy 0.5 9 5 2.5 Hypertensive Disorders 1.5 0.5 6 Hemorrhagic Disorders in Pregnancy 1.5 0.5 9 7 Module three: Child Birth & Birth complications Labor and Birth Processes 18 8 2.5 0.5 Nursing Care During Labor and Birth 0.5 18 9 2 Labor emergencies 2 1 18 10 Module Four: Normal & Abnormal Postpartum Postpartum physiological changes 2 0.5 18 11 Nursing care during postpartum Period 2.5 0.5 9 12 Post-partum hemorrhage 1.5 0.5 13 Puerperal sepsis 1.5 0.5 14 Family planning 1.5 0.5 9 15 TOTAL HOURS 39 +117 31 8 117 ‫ وصاسج انصحه وانسكان‬: ‫جامعح‬ ً‫ االداسج انعامه نهرعهيم انفىً انصح‬: ‫كهيح‬  ‫ شعثح انرمشيض‬: ‫قسم‬ ً‫ذىصيف مقشس دساس‬ ‫ تياواخ انمقشس‬-1 ٌ‫انفشقح\انمسرى‬ maternity Nursing ‫اسم انمقشس‬ NUR :‫انشمض انكىدي‬ ‫انفصم انذساسً االول‬ ‫انفشقه انثاويه‬ : : ً‫ عمه‬9 + ‫ وظشي‬3 :‫انرخصص‬ maternity Nursing : ‫ هذف انمقشس‬-2 This course focuses on providing the necessary cognitive, intellectual, practical skills to the students for acquiring the basic body of knowledge about maternity nursing : ‫ انمسرهذف مه ذذسيس انمقشس‬-3. ‫ انمعهىماخ‬-‫أ‬ A.1. Identify the normal anatomical structure of female and male :‫وانمفاهيم‬ reproductive system and it’s significant for nursing. A.2.Explain physiological adaptation to pregnancy and normal prenatal care A.3.Describe the physiology of labor and clinical features of each stage of labor A.4.Recognize principle of nursing intervention for parturient woman. A.5.Identify the significant aspects of immediate newborn resuscitation. A.6.Describe maternal physiological changes, needs and management of puerperium. A.7.Explain common physical complication of pregnancy, labor and puerperium and appropriate nursing management. B.1. Formulates effective nursing care plan based on women health ‫ انمهاساخ انزهىيح‬-‫ب‬ condition & illness according to needs priority. : B.2. Detect the woman at risk during pregnancy, labor & puerperuiml B.3.Use health education & counseling for pregnant, laboring & postpartum mothers  ‫ انمهاساخ انمهىيح‬-‫ج‬ C.1. Use assessment techniques to identify all health problems and : ‫انخاصه تانمقشس‬ needs. For women during the maternity cycle. C.2. Provide care to women during normal & abnormal condition of pregnancy, labor & postnatal according to nursing process. C.3. Use health education, instruction &counseling methods for common women concerns requiring during pregnancy, labor & postpartum events. C.4. Perform nursing procedures considered essential care for the scope of maternity nursing practice during pregnancy, labor & postnatal. ‫د‬-: ‫انمهاساخ انعامه‬ D.1. Work within team of health care providers in different women health care settings effectively. D.2. Mange time effectively during applying nursing intervention for women in pregnancy, labor & postpartum. D.3. Use appropriate learning resources including texts, internet and consultation with peers D.4. Use problem solving skills within the nursing process in maternity nursing. Theoretical part: :‫ محرىي انمقشس‬-4 - Human Reproductive Biology - Normal pregnancy - Normal labor - Normal puerperium - High risk Pregnancy - Abnormal labor - Puerperium complications. - Care of Newborn Practical skills : - Antenatal skills - Labor skills - Postnatal skills - Modified Lectures ‫ اسانية انرعهيم‬-5 ‫وانرعهم‬: - Group discussion - Brain storming - Clinical in lab and in hospital through demonstration and redemonstration - Self-learning. ‫ اسانية انرعهيم‬-6 - Referral to the academic advisor. ‫وانرعهم نهطالب روي‬ - Personal activities (office hours, group discussion, more re- : ‫انقذساخ انمحذودج‬ demonstration, and films). : ‫ ذقىيم انطالب‬-7 - Quiz 1: to assess knowledge in writing exam ‫ االسانية انمسرخذمح‬-‫أ‬ - Mid-term exam: to assess accumulative knowledge in writing exam. - Clinical practice to assess the practical level through the semester - Final written exam: to assess accumulative knowledge in writing exam. - Final clinical exam to assess the accumulative practice Assessment I (Quiz) Week 3 ‫ انرىقيد‬-‫ب‬ Mid-term exam Week6 Final exam Week 14 - Quiz 5 ‫ ذىصيع انذسجاخ‬-‫ج‬ - Midterm exam 10 - Case study 5 - Clinical practice 60 - Final clinical exam 20 - Final written exam 100 - Total 200 : ‫ قائمح انكرة انذساسيح وانمشاجع‬-8 ‫ مزكشاخ‬-‫أ‬ ‫ كرة مقرشحه‬-‫ب‬ - Robert Durham, Linda Chapman, (2014): Maternal- Newborn Nursing: The Critical Components of Nursing  Care, 2nd ed., F.A Davis Company, USA - Shannon E. Perry, Marilyn J. Hockenberry, Deitra Leonard Lowdermilk, David Wilson (2014): Maternal & Child Nursing Care, Mosby & Elsevier Inc., Canada  Module one: Reproductive Biology Objective: At the end of this module; each student should be able to: - Identify component of internal and external female genitalia - Explain Structure and function of internal and external genital tract of male genitalia - Define menstrual cycle. - Discuss nursing role during menstrual cycle - Define Reproductive health - Identify women's reproductive health needs. - Define family planning. - Identify methods of family planning - Discuss client instruction for using each method. Female reproductive system  External genitalia The vulva refers to those parts that are outwardly visible which includes: Mons pubis Labia majora Labia minora Clitoris The vestibule: (Urethral opening &Vaginal opening) Perineum 1-Mons Pubis:  Also called Mons veneris, The triangular mound of fatty tissue that covers the pubic bone  During adolescence sex hormones trigger the growth of pubic hair on the Mons pubis  Hair varies in coarseness, curliness, amount, color and thickness 10   The function of Mons pubis is to protect the pelvic bones, especially during sexual intercourse. 2-Labia Majora ( Outer& greater lips):  These are two rounded, fleshy folds of fat and areolar tissue that extend from the mons pubis to the perineum  They have a darker pigmentation  They Are covered with hair and sebaceous glands  Tend to be smooth and moist  The chief function of is to protect the structure lying between them. 2-Labia Minora ( Inner& lesser lips):  These are paired of erectile tissue folds that darkens and swells during sexual arousal  Located inside the labia majora  They are more sensitive and responsive to touch than the labia majora 3- Clitoris:  At the apex of labia minora is a hooded body composed of erectile tissue called clitoris.  It is very rich in blood and nerve supplies and allows the women to experience sexual pleasure & orgasm during sexual stimulation. 4- The vestibule: - This is the area enclosed by the labia minora in which are situated the openings of the urethera, parauretheral (skene's ) glands, vaginal opening or introitus and bartholin's glands. It is boat shape. *The Urethral orifice:  This orifice lies 2.5cm posterior to the clitoris. its long is 4cmc  On either side lie the openings of skene‘s ducts, two small blind-ended tubules 0.5 cm long running within the 11  uretheral wall. Their secretions lubricate the vaginal vestibule to facilitate sexual intercourse. *The vaginal orifice:  This is also known as introitus of the vagina and occupies the posterior two thirds of the vestibule.  The orifice is partially closed by the hymen, a thin elastic membrane that tears during sexual intercourse or during the birth of the first child.  The hymen is a vascular & it varies in shape from woman to woman. * Bartholin’s glands (vulvovaginal glands):  There are two small glands that open on the either side of the vaginal orifice and lies in the posterior part of the labia majora.  These glands secrete mucus that is clear and thick mucus with an alkaline pH that enhances the viability and motility of the sperm deposited in the vaginal vestibule. 5- Perineum:  The muscle and tissue located between the vaginal opening and anal canal  It supports and surrounds the lower parts of the urinary and digestive tracts  The perinium contains an abundance of nerve endings that make it sensitive to touch  An episiotomy is an incision of the perinium used during childbirth for widening the vaginal opening  Internal genitalia :  Vagina 12   Cervix  Uterus  Fallopian Tubes  Ovaries 1-Vagina:  The vagina connects the cervix to the external genitals  It is located between the bladder and rectum  Its length: (Anterior wall is 8-9 cm &Posterior wall is 10 -11 cm) Its functions:  As a passageway for the menstrual flow  For uterine secretions to pass down through the introitus  As the birth canal during labor  With the help of two Bartholin‘s glands becomes lubricated during sexual intercourse 2-Ccervix:  The cervix connects the uterus to the vagina  The cervical opening to the vagina is small  This acts as a safety precaution against foreign bodies entering the uterus  During childbirth, the cervix dilates to accommodate the passage of the fetus  This dilation is a sign that labor has begun 3-Uterus:  Commonly referred to as the womb  A pear shaped organ about the size of a clenched fist 13   It is made up of the endometrium, myometrium and perimetrium  Consists of blood-enriched tissue that sloughs off each month during menstrual cycle  The powerful muscles of the uterus expand to accommodate a growing fetus and push it through the birth canal  Size: 7.5 long, 5cm wide, 2.5cm thick and weight about 60gms. Divisions: - The cervix: Froms the lower third of the uterus. The isthmus: Is the narrowed construction about 7mm thick lying between body of uterus and cervix. - The corpus or body: Forms the upper two thirds of the uterus and is that portion of organ lying above the cervix. - The cornua: Are the areas of uterus where fallopian tubes are inserted the lumen of this tubes opens into the uterine cavity. - The fundus: It‘s the portion lies above and between the cornuae. - The cavity: Is a triangular hollow shape in the center of the uterus. The wall of the uterus normally lie in opposition. 4-Fallopian tube:  Serve as a pathway for the ovum to the uterus  Are the site of fertilization by the male sperm  Often referred to as the oviducts or uterine tubes  Fertilized egg takes approximately 6 to 10 days to travel through the fallopian tube to implant in the uterine lining  It consists of 4 parts : 14  - Interstitial part: Lies within the wall of the uterus and is 2.5cm in length. - Isthmus : Is also 2.5cm in length. It is the narrowest portion of the tube and acts as reservoir for spermatozoa because the temperature is lower there than in the rest of the tube. - Ampulla :Is the widened lateral area of the tube where fertilization normally occurs. It is 5cm in length. - Infundibulum (2 cm): trumpet shaped outer end opens into the peritoneal cavity by the tubal ostium. 5- Ovaries:  The female gonads or sex glands  They develop and expel an ovum each month  A woman is born with approximately 400,000 immature eggs called follicles  During a lifetime a woman release 400 to 500 fully matured eggs for fertilization  The follicles in the ovaries produce the female sex hormones, progesterone and estrogen  These hormones prepare the uterus for implantation of the fertilized egg. 15 Menstrual cycle Definition: Menarche:, the onset of menstruation signals the bodily changes that transform a female body Menstrual cycle: Cyclic changes in the endometrium caused by estrogen and progesterone Average age is 12.8 Amount of bleeding varies from woman to woman Expulsion of blood clots Blood color can vary from bright red to dark maroon Usually occurs every 25 to 32 days Women can experience fluid retention, cramping, mood swings, weight gain, breast tenderness, diarrhea, and constipation Menstrual cycle: control by hormones It is a hypothalamus pituitary ovarian axis hypothalamus releases GnRH that stimulates pituitary pituitary produces:  Follicle-stimulating hormone (FSH): Ovum maturation in follicles inside ovaries Estrogen production in ovaries  Luteinizing hormone (LH): Stimulates release of mature ovum Stimulates development of corpus luteum, the progesterone- secreting part of the follicle that remains after egg is released. Negative feedback mechanism – Each hormone is secreted until the organ it acts upon is stimulated--then that organ secretes a hormone that reduces secretion of the first hormone. 16 Component of female reproductive cycle  Menstrual cycle  Ovarian cycle Menstrual cycle Cyclic changes in the endometrium caused by estrogen and progesterone 1-Menstrual Phase Starts with 1st day of menstrual cycle Lasts for 4-5 days Functional layer of uterine wall is sloughed off and discarded with the menstrual flow Blood discharge from vagina is combined with small pieces of endometrial tissue Cyclic changes of the Endometrium Decidua functional is: 2/3 superficial, proliferate and shed each cycle Decidua basalis: deepest region, source of endometrial regeneration after each menses 2-Proliferative phase Is a phase of repair and proliferation Lasts for 9 days Controlled by estrogen secreted by follicles 2-3 mm increase in thickness of endometrium The glands increase in number and length and the spiral arteries elongate 17  Glandular epithelium secrete glycogen rich material Endometrium thickens under the influence of estrogen and progesterone 3-Secretory Phase It begins with ovulation and end with menstruation Spiral arteries grow into the superficial layer Arteries become increasingly coiled Large venous network develops If Fertilization Occurs Fertilized ovum implants in endometrium on about 6th day of this phase HCG hormone secreted by syncytiotrophoblast keeps the corpus luteum secreting estrogen and progesterone If Fertilization Doesn’t Occur No HCG Corpus luteum degenerates Estrogen and progesterone levels fall Secretory endometrium enters an ischemic phase Menstruation occurs 4-Ischemic Phase Decreased levels of estrogen & progesterone Stoppage of glandular secretion Loss of interstitial fluid Marked shrinking of endometrium Spiral arteries become constricted Venous stasis & Ischemic necrosis Rupture of damaged vessel wall Blood seeps into the surrounding connective tissues 2 days before menses: dramatic increases in PMN migrate from vascular system Lasting about 13 days 18 Ovulation It occurs around mid-cycle about 14 days in a 28 day menstrual cycle Ovarian follicle undergoes sudden growth spurt (burst) under the influence of FSH & LH These hormones prepare endometrium for implantation of Fertilized Ovum (Blastocyst) OVARIAN CYCLE FSH and LH produce cyclic changes in ovaries. 1. Follicular phase the primordial follicles start to grow under the effect of FSH. Only one reaches the maturity and called Graafian follicle. the grown follicle secrete steroidal 2. Ovulatory phase Ovulation is outward expulsion of a mature ovum from a ruptured Graafian follicle. Where it is picked up by the fimbirial end of the tube. It occurs about 14 th day of menstrual cycle 3. luteal phase Ruptured Graafian follicle are termed corpus luteum It secretes Progesterone and little estrogen These hormones prepare endometrium for implantation of Fertilized Ovum (Blastocyst) If the oocyte is fertilized the corpus luteum enlarges & remains active for first 20 weeks of pregnancy If the oocyte is not fertilized the corpus luteum degenerates in 10-12 days 19 Nursing role during menstrual cycle: Nurse must provide health teaching about the following items: Sanitary pads and tampons: - Wash hands before and after giving self perineal care. - Washing or wiping the perineum should be always done from front to back. - Reduce use of tampons by substitute sanitary pads part of the time especially at night. - Apply perineal pad snugly enough so it won't slide back and forth with her movements. - Do not touch the side of the perineal pad that will come in contact with the perineum. - Frequently take warm bath to maintain personal hygiene. Diet: - Decrease intake of caffeine (tea, coffee, coals, chocolate) to reduce anxiety. - Decrease intake of simple sugars. - Decrease intake of salty food to reduce fluid retention. - Eat six small meals a day to prevent hypoglycemia. - Increase fluid intake. - Avoid alcohol which aggravates depression. Nutritional self-care: - Vitamin B complex neutralizes the excessive amounts of estrogen produced by the ovaries thus reduce nervousness that sometimes occur premenstrual. It is present in lean meats, whole grains, and dark green leafy vegetables. - Vitamin B6 can relive the heavy bloated puffy feeling that is often experienced before the period. 20  - Vitamin E is a mild prostaglandin inhibitor similar to aspirin but without the side effects. It improves circulation; reduce muscular spasm and pain by reducing the uterus need for O2. It is present the yeast, wheat germ. - Iron is needed to prevent depletion of the female iron stores. - Calcium may also provide relief from menstrual symptoms, it is present in yogurt and cheese. Exercise: - Daily exercise can prevent cramps, relieves constipation. - Deep breathing brings more O2 to the blood which relaxes the uterus. - Aerobic activities as jogging or walking alleviate irritability and tension. Heat and massage - Using any form of warm application may be beneficial during painful periods. - Massage can also sooth aching muscles, promote relaxation and blood flow. 21 Reproductive Health Definition: - Reproductive health is a status of complete physical, mental and social wellbeing and not merely the absence of disease or disability in all matters relating to the reproductive system and to its function and processes. - Being able to choose when to get pregnant, apart from being health issue, greatly influences population growth, and environmental conditions. - Increasing contraceptive choices and access leads to fewer unsafe abortions-arguably the most easily avoidable cause of maternal death. - Life-saving care for complications from abortion is an excellent opportunity to provide contraception, avoiding another unwanted pregnancy. - Reducing pregnancy-related deaths and illness in mothers increases newborn and child survival, and improves productivity. - Reducing maternal deaths depends on a functioning death system. Strengthening the system to improve maternal health benefits in many other areas of death. Basic elements of reproductive health: - Employment of women. - Woman's nutrition. - Care of adolescent. - Safe sexual behavior. - Safe motherhood. - Widely available family planning services. - Elimination of unsafe abortion. - Prevention of unwanted pregnancy. - Prevention and management of infertility. - Male involvement. - Prevention and treatment of malignancies and post menopausal care. - Women's and men's reproductive health needs Women's reproductive health needs are: - A continuum from sexual health. - Prevention and management of infertility. - Fertility by choice, not by chance. - Pre-conceptional care. - Keeping labour normal. - Pregnancy and child birth, postnatal care. - In addition, it covers menopausal and postmenopausal health care. - Women's reproductive health needs include: 1. Sexuality. 2. Protection against sexually transmitted infectious. 3. Infertility prevention and management and fertility regulation. 4. Protection against prostatic hypertrophy and prostatic cancer is another concern 22 Reproductive health rights: - Right to be free from all forms of discrimination. - Right to life, liberty and security. - Right to marry and found a family. - Right to education and information. - Right to benefit from scientific progress. - The right of sexual equality. - Right to health and health care. - The Egyptian women work law. - Right of adolescents to meet their needs. 23  Module Two: Normal and abnormal Pregnancy Objectives At the end of this module, the student will be able to: – Discuss the progression of the fertilized egg from conception to birth. – Explain Stages Of fetal development – Differentiate between presumptive, probable, and positive signs of pregnancy. – Discuss nursing interventions during pregnancy – Define the concept of high risk pregnancy. – Identify the classification of hypertensive disorders of pregnancy. – Explain nursing interventions for pregnancy induced hypertension – Identify causes of bleeding in early pregnancy – Discuss nursing interventions for early and late bleeding during pregnancy – Describe the gestational diabetes and its risk factors. – Discuss the nursing management for pregnant women with diabetes mellitus Physiological changes during pregnancy Related definitions:  Ante: means before.  Natal: means delivery.  Antenatal: means before delivery.  Antenatal care: comprehensive health supervision of a pregnant woman before delivery.  Prenatal : time before delivery.  Gravida : any pregnancy, regardless of duration. It includes the present pregnancy.  Para : number of births after 20 weeks' gestation regardless of whether the infants were born alive or dead.  Primigravida : a woman pregnant for the first time.  Multigravida: a woman who is in her second or a subsequent pregnancy.  Nuligravida : a woman who has not given birth at more than 20 weeks' gestation. Primipara : a woman who has given birth to a fetus ( dead or alive ) that has reached 20 weeks' gestation.  Multipara : a woman who has given birth two or more times at more than 20 weeks' gestation.  Stillbirth : A fetus born dead after 20 weeks' gestation.  LMP: Last menstrual period. Pregnancies are dated from the first day of the LMP 24  EDC: Estimated date of confinement (EDD: estimated date of delivery) For a rough estimate: Add 7 days to 1st day of LMP, then add 9 months. (Nagele rule)  Linea Nigra: This is a dark line that runs from the umbilicus to the symphysis pubis and may extend as high as the sternum. It is a hormone- induced pigmentation. Noted in some women during the later months of pregnancy (after 20 weeks).  Striae Gravidarum (Stretch Marks). Fine pinkish white or gray lines resulting from streching of skin during pregnancy. They generally appear on the woma's abdomen,breats ,thighs and buttocks. Usually appears in the second half of pregnancy ( between 6 to 12 wks)  Cholosma --- brownish pigmentation of the face during pregnancy; also called ―mask of pregnancy‖Or it is a butterfly pigmentation may appear on cheeks and nose,it disappear after delivery  Braxton Hicks contraction:- Irregular, mild ,painless uterine contractions that occur throughout pregnancy; they become stronger in the last trimester  Hegar’s sign -- A softening of the lower segment of the uterus found upon palpation in the second or third month of pregnancy suggesting pregnancy. It occurs between 6 to 12 wks (bimanual examination)  Goodell’s sign --- softening of the cervix, uterus and vagina during pregnancy.  Chadwick’s sign-- bluish discoloration of the cervix, vagina, and labia during pregnancy as a result of vascular congestion  Palmer sign: Intermittent uterine contraction early in pregnancy detected by bimanual examination.  Leucorrhea: it is colorless, non effective normal vaginal discharge due to hormonal changes occur during pregnancy  Amenorrhea: Absence of menstruation  Quickening: It‘s the first time at which the mother feels fetal movements. 25  o PG: usually occurs between the 18th and 20th week o MG: usually occurs between the 16th and 18th week.  Ptyalism: increase of saliva. Ballottement: It refers to the fetal movement in the amniotic flui Presumptive signs: 1. Amenorrhea. 2. Nausea& vomiting. 3. Fatigue 4. Urinary frequency. 5. Breast& skin changes. 6. Quickenin Positive signs of pregnancy: 1. Visualization of fetal sac by ultrasound 2. Hearing FHS by Doppler or stethoscope 3. Felt fetal movement 4. Palpate fetal parts Physiological changes in pregnancy 1-Reproductive system: A. the uterus:  Size: increase to20 times of its non pregnant size.  weight:increase from 60gm-1000gm. This enlargement due to hypertrophy " increase the size of preexisting muscle cells" and hyperplasia " formation of the new cells"  Capacity :increase to 5000ml and has sufficient capacity for the fetus –placenta-amniotic fluid.  As the pregnancy advanced the uterus divided into upper and lower uterine segment the lower uterine segment composed of lower part of uterus and the upper cervix composed mainly from connective tissue because of this the lower uterine segment becomes stretched in late pregnancy.  The endometrial layer increased in thickness and called deciduas  By the 12 weeks' gestation the uterus can be felt above the symphysis pubis , and at 24 weeks the fundus is at the umbilical 26  level. By 36 weeks the fundus is at the xiphoid process. By 40 weeks the fetus descend, with the fetus head entering into pelvis. B. Ovaries:  Stop producing ova during pregnancy  Progesterone and estrogen continues produce until 10th _ 12th weeks of gestation to maintain pregnancy until the placenta develops and can take over adequate hormone production C. Cervix:  The cervix becomes softer and swollen in pregnancy  Prostaglandins and collagenase especially in last weeks of pregnancy act on collagen fiber make cervix more softer.  Chadwicks sign :it is bluish color of the vagina and labia due to increase the level of estrogen which is one of the earliest signs of pregnancy.  Goodell sign :it is a softening of the cervical tip.  The secretion from cervical gland Form the mucus plug in the cervical canal that acts as a barrier to prevent organisms from entering the uterus.  the mucus plug is usually expelled from the vagina during labor D. Vagina :  Increased vascularity prominently affects the vagina resulting in the violet color characteristic of (chadwick sign).  Considerable increase in the thickness of the vaginal mucosa, loosening of the connective tissue, hypertrophy of smooth muscle cells.  Vaginal secretion increase ( thick ,white and acidic) acidity help to prevent bacterial infection  In end of pregnancy the vagina & perineal body are sufficiently relaxed to permit of the infant E-breasts and lactation:  There are changes in both size & appearance due to 'effect of estrogen& progesterone'.  The earliest changes is a swelling of the breast tissue.  The nipple increase in size &become larger& more pigmented.  Yellowish breast fluid 'colostrums' is present in greater or lesser amounts throughout pregnancy especially in 3rd trimester. 2-Cardiovascular system:  Cardiac hypertrophy from increased blood volume and cardiac output 27   Progressive increase in blood volume, peaking in the third trimester at 30% to 50 % of prepregnancy levels.  Increased heart rate and Increased cardiac output to meet demands of enlarging uterus & fetal oxygenation.  Smooth-muscle relaxation and arteriole dilation, resulting in vasodilatation due to increase in progesterone level.  Supine hypotension due to the enlarging uterus compresses both the inferior vena cava and the lower aorta when the woman lies in supine position. This reduces venous return to the heart this condition happen in 10% of pregnant women  Increased levels of blood coagulation factors &White cell count  Decrase in Red cell count. hemoglobin concentration., haematocrit, Platelets & blood pressure. 3-Respiratory system:  Increased vascularization of the respiratory tract caused by increased estrogen levels  Shortening of the lungs caused by the enlarging uterus  Upward displacement of the diaphragm by the uterus  Breathlessness due to hyperventilation and elevation of diaphragm  Increased tidal volume, causing slight hyperventilation  Increased chest circumference (by about 2:%" [6 cm))  Altered breathing, with abdominal breathing replacing thoracic breathing as pregnancy progresses  Slight increase (2 breaths/minute) in respiratory rate  Increase O2 demand by 20 %. 4-Central nervous system:  Pregnant women frequently decreased attention, concentration& memory during & shortly after pregnancy.  Some women are sleepy&depressed, other may be irritable& suffer from insomnia. 5-urinary system:  Decreased bladder capacity and bladder tone.  Frequency of micturition is a common symptom of early pregnancy due to pressure on bladder by uterus and again at term due to pressure of presenting part on bladder when engages. 6-Gastrointestinal system:  Morning sickness: means nausea and vomiting are common during the first trimester in response to increasing level of human gonadotropin 28   Heartburn: is common &is caused by reflux of acidic secretions into lower esophagus & decreased tone of sphincter and relaxation of smooth muscle & high progesterone levels of pregnancy  Reduced motility of large intestine lead to increase time for water absorption to induce constipation 7-Endocrine system:  Parathyroid Gland: This gland increases in size slightly. It meets the increased requirements for calcium needed for fetal growth.  Posterior Pituitary. Near the end of term, the posterior pituitary will begin to secrete oxytocin that was produced in the hypothalamus and stored there. It will serve to initiate labor.  Anterior Pituitary. At birth, the anterior pituitary will begin to secrete prolactin. This stimulates the production of breast milk.  Placenta. The placenta acts as a temporary endocrine gland during pregnancy. It produces large amounts of estrogen and progesterone by 10 to 12 weeks of pregnancy. It serves to maintain the growth of the uterus, helps to control uterine activity, and is responsible for many of the maternal changes in the body 8- Integumentary system: (skin changes):  Hair growth (abdomen and face)  Linea nigra  Striae gravidarum  Cholasma  Hyperpigmentation (esp. linea nigra)  Rashes and acne relatively common 29  Nursing Care during Pregnancy Definition of antenatal Care: It refers to the care that given to an expected mother from time of conception is confirmed until the begging of labor. Significance of prenatal care:  To reduce maternal and prenatal mortality and morbidityrates.  To improve the physical and mental health of women andchildren.  To ensure that the pregnant woman and her fetus are in the best possible health.  To prepare the woman for labor, lactation and care of her infant.  To detect early and treat properly complicated conditions that could endanger the life or impair the health of the mother or the fetus.  Promotion of health for both maternal & fetal well being. Elements of antenatal care: 1. Complete history taking(personal history, menstrual history, family history, past history of previous pregnancy, obstetric history, present complain 2. Physical examination (general and local) 3. Laboratory investigation 4. Health education 5. General examination Schedule of Antenatal Care Visits: Regular antenatal care can detect anemia, hypertensive disease, infections and other existing conditions and diseases that lead to high-risk pregnancy. Antenatal visits should take place:  Before 28th weeks gestation (every 4 weeks)  From 28th-36th weeks (every 2 weeks)  Thereafter (every week)  In a normal pregnancy, with no complications, a minimum of three antenatal visits is acceptable in the first 20 weeks. 30 Prenatal Visits: Initial Visit 1- Taking history 2- Physical Ex. ( general& local ) 3- Investigations ( urine, stool & blood ) 1- History taking: Should be taken carefully and thedetails should be recorded in the relevant section in theMaternal Health record which includes the following. a-Personal and social history  The woman's name and address should be filled out clearly.  Other personal details should be recorded such as age, educatio, marital status, duration of marriage, and occupation of both partners..  Religion may give an indication of particular attitudes, beliefs or practices associated with childbirth and lifestyle such as dietary taboos.  Nationality and language should also be recorded. b-Medical and surgical history: Certain diseases may have an adverse effect on pregnancy, so a note is made about details regarding:  Childhood illnesses and any serious, chronic diseases such as: diabetes mellitus, hypertension, urinary tract troubles, heart diseases,  Allergies, radiation exposure, blood transfusions, and current medications.  Previous operations such as cesarean section, genital repair, and cervical cerclage.  Recent surgery, particularly on the genital tract.  Accidents involving injury of the bony pelvis. 31 c-Obstetrical history: Details of previous pregnancies such as: -Length, outcome, and problems of each pregnancy. - Date of last abortion. - Details of previous labors such as:  Sex and weight of each infant.  Whether live or stillborn.  Whether breast or artificially feed.  Prematurity and neonatal death.  Complications of previous labors.  Date of last delivery. Details of previous postpartum such as:  Contraceptive history.  Complications such as postpartum hemorrhage. d-Menstrual history:  Age of menarche.  Regularity and frequency of menstrual cycle.  Duration and nature of menstrual flow.  Any previous treatment of menstrual problems or infertility.  Date and character of last menstrual period (LMP.) **Expected date of delivery (EDD) is calculated as follows: - 1 day of LMP + 7 days + 9 months. st e-Family history: - Some families have genetic pre-dispositions to certain diseases especially if the parents are close relatives. - Prevalence of any of the following within the families of both parents should be noted; diabetes mellitus, essentialhypertension, cardiac disease, mental illness, multiple pregnancy,congenital abnormalities, allergic conditions such as ( 32  asthma, eczema ). Sickle cell anemia and thalassemia are common in particular races, F- History of present pregnancy:  Symptoms of pregnancy,  Main complaint, duration of complaint,  Any associated complication: pre-eclampsia.  Fetal movement ,self care practice  Investigation done. 4-Physical Examinations a-General Examination: ►It should be started from the moment the pregnant womanwalks into the examination room. ►A general examination should be done systematically. Start by looking at the woman's face, then progress downwards to finish with aninspection of her legs and feet. ►Examine general appearance: Observe the woman for stature or body build and gait. Check the hair of woman to assess her health. The hairof a healthy womanis shiny and glossy. Look at the woman's face to assess her health. The face is observed for skin color as pallor and pigmentation as chloasma. Observe the eyes for edema of the eyelids and color of conjunctiva. Healthy eyes are bright and clear. 33 ►Observe the mouth for:  Dryness or cyanosis of the lips.  Gingivitis of the gums.  Septic focus or caries of the teeth  Observe the neck for enlarged thyroid gland and scars of previous operations. ►Examine height:  Height of over 150 cm and shoe size above 3 give an indication of an average-sized pelvis ►Weight:  The approximate weight gain during pregnancy is 12 kg.; 2 kg in the first 20 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term).  Little or no maternal weight gain leads to fetal jeopardy.  Obesity (more than 20 kg above the weight-height formula) leads to an increased risk of gestationaldiabetes, pregnancy-induced hypertension and thromboembolic disorders.  Underweight (less than 20 kg below the weight-height formula) also puts the pregnant woman at great risk. ► Blood pressure: It is taken to ascertain normality and provide a baselinereading for a comparison throughout the pregnancy. If the blood pressure is elevated because the woman is nervous and anxious, take it again when the woman is more relaxed. In late pregnancy, raised systolic pressure of 30 mm Hg or raised diastolic pressure of 15 mm Hg above the baseline values on at least two occasions of 6 or more hours apart indicates toxemia. ►Breast examination: The breast should be gently palpated to feel any lump. The nipple should be drawn forward to see if it isprotractile. The breast should be observed for pregnancy changes. 34 ►Elimination: Ask the woman about her bowel habits. Carry out routine urine analysis. Check the presence of dysuria and frequency of micturition. ►Vaginal discharge: Ask the woman about any increase or change of vaginal discharge. Report to the obstetrician any mucoid loss before the 37th week of pregnancy. ►Vaginal bleeding: Vaginal bleeding at any time during pregnancy should be reported to the obstetrician to investigate its origin. ►Legs: Legs should be noted for edema. They should be observed for varicose veins which predispose to deep vein thrombosis. The calf must be observed for reddened areas which may be caused by phlebitis and white areas which could be caused by deep vein thrombosis. Ask the woman to report tenderness during examination. The legs should be observed for unequal length or muscle wasting which may be an indication of pelvic abnormalities. b-Local Abdominal Examination:  Inspection  Palpation  Auscultation 1) Inspection: The nurse should look at the following: Skin changes such as linea nigra, striae gravidarum andscars of previous operations. 35  The size of the abdomen is inspected for: * Height of the fundus, which determines the period of gestation. * Multiple pregnancy and polyhydramnios will enlargeboth the length and breadth of the uterus. * A large fetus increases only the length of the uterus. The shape of the abdomen is inspected for : * Fetal lie and position. * The abdomen is longer if the fetal lie is longitudinal as occurs in 99.5% of cases. * The abdomen is lower and broad if the lie is transverse. * Contour of the abdominal wall is observed for pendulous abdomen, lightening protrusion of umbilicus and fullbladder. * Fetal movements are inspected as evidence of fetal lifeand position. * The abdomen is also inspected for edema and varicoseveins. 2) Palpation The uterus will be palpable per abdomen after the 12'h weekof gestation Abdominal palpation includes: * Estimation of the period of gestation. This is done bydetermination of fundal height. * The uterus may be higher than expected due to large fetus, multiple pregnancy, polyhydrammnios or mistaken date of last menstrual period. * The uterus may be lower than expected due to small fetus, intrauterine growth retardation, oligohydramnios or mistaken date of last menstrual period. Fundal palpation is performed to determine: Whether itcontains the breech or the head. This will help to diagnosethe fetal lie and presentation. 36  Pelvic palpation is done to determine: Fetal position and presentation. Engagement of fetal head. Disproportion between head and pelvis. Pawlik's maneuver is sometimes used to: * Locate the round, hard head. * Judge the size flexion and mobility of the head. 3) Auscultation: * Fetal heart sound is heard by sonicaid as early as 10th weekof pregnancy. * Fetal heart sound is heard by pinard's fetal stethoscope after the 20th week of pregnancy. * The normal fetal heart rate is 120-160 beats/minute. *Fetal heart sound has been described as the ticking of a watch under the pillow. 5-investigations ** urineis testedfor protein, glucose, and ketones. **Stool analysis for ova and parasites. **Complete blood picture: results in ►Hemodilution of blood during pregnancy results in lowered hemoglobin level (11- 12 g/dl), hermatocrit, & red blood cell count (normal range is 3.600.000-4.7000/mm3 ). ►White blood cells are increased especially neutrophils (more than 70% ), which enhances the. blood phagocytotic and bactericidal properties. ►Coagulation time changes from 12 to 8 minutes. This increased capacity for clotting results in higher risk of thrornbosis and embolisrn. ►Screening for sickle cell anemia, thalassemia and hepatitis may be necessary for some women. ► Testing for rubella antibodies if the pregnant woman comes in contact with the disease is required. 37  ►ABO blood group and Rhesus factor ( Rh ) ►Random blood glucose (80-120 mg/100ml). ►Venereal disease tests should be performed. ►Toxoplasmosis. ►Ultrasound scanning is used to assess the fetal growth and wellbeing. Subsequent Prenatal Visits: 1-History : ** Of any new problems and worries. 2- Measurement of weight, assessment of edema and bloodpressure. 3-Local abdominal examinations such as : **Fundal level, fetalsize, lie, presentation and fetal heart rate. 4-Investigations: ** Urine should be tested for sugar, ketones, and protein. ** Hemoglobin will be repeated: At 36 weeks of gestation. Every 4 weeks if Hb is < 9 g/dl. If there is any other clinical reason. 5-Fetal kick count: ** The pregnant woman reports at least 10 movements in 12 hours. ** Absence of fetal movements precedes intrauterine fetal death by 48 hours. Education for self care & home care during pregnancy: Physiological changes: * The changes that affect all systems during pregnancy should be explained to the pregnant woman in a simple way. * Enlargement of the abdomen. * Skin pigmentation as chloasma, striae gravidarum and linea nigra. * Vascular spiders. 38 Weight gain: *During the 1st trimester, the pregnant woman gains about 1-2 kg. * During the 2 A trimester, the pregnant woman gains about 6-7 kg. * During the3 rd trimester, the pregnant woman gainsabout 3-4 kg. Rest and sleep: **The pregnant woman should lie down to relax or sleep for one or two hours during the afternoon. **At least 8 hours sleep should be obtained every night and increased towards term. Diet : **Diet is important for the health of the pregnant woman, her developing fetus, and the alleviation of minor disorders of pregnancy. **Diet should be contained protein, fat and carbohydrates, fibers, vitamins and minerals. **The prime sources of bodybuilding foods are meat, fish and cheese, but cheaper sources may be advised such as peas, beans and lentils, milk and eggs. **Calcium and iron are vital in pregnancy, calcium is found in milk and eggs. Iron is found in red meat and offal, and to a lesser extent in green vegetables and red fruits. **Pregnant women should be encouraged to consume a good quantity of fresh fruit and vegetables because they contain vitamin C that helps the absorption of iron and contributes to the fiber content which helps to prevent constipation. Other high fiber foods include wholemeal bread, cereals and pulses. **A certain amount of carbohydrates and fats is required to provide heat and energy, but high sugar and fat intake should be avoided and starches are taken instead because they are absorbed more slowly. **Salt should be restricted in case of edema. 39 **Lemon or vinegar is allowed in case of excessive sweating ** In the latter part of the second trimester when the fetus starts to store iron in the liver, the woman is advised to take an iron concentrate. Exercises and relaxation: * Exercise should be simple, mild exercise out of doors, in the fresh air. Walking is ideal, but long periods of walking should be avoided. * The pregnant woman should avoid lifting heavy weights such as mattresses furniture or large, heavy shopping bags, as it may lead to abortion. * The pregnant woman should avoid long period of standing because it predisposes her to varicose veins. * She should avoid sitting with legs crossed because it will impede circulation. Clothing: * Suitable clothes are a necessity not a luxury. Loose, light clothes are the most comfortable. * The pregnant woman should avoid wearing tight clothes such as belts or corset and constricting bands on the legs. * A suitable larger bra with wide shoulder straps should be used in order to give good support to the heavy breasts.It should be light and not tight enough to depress the nipples. * Shoes need to be comfortable. High heels, flat shoes and thin soles should be avoided. Hygiene: * Daily all-over wash is necessary because it is stimulating, refreshing and relaxing. * Warm showers or sponge baths are better than tub baths * Hot baths should be avoided because they may cause fainting. 40 * Regular and frequent washing of genital area, axilla and breasts due to increased discharge and sweating. * Vaginal douches should not be allowed except in case of excessive secretions or infections. *Perineal care should be done due to frequency of urinationand increased discharge Teeth: * The teeth should be brushed carefully in the morning, after each meal and at night. * The pregnant woman should visit the dentist twice during pregnancy. Bladder and bowel: * Regular habit of defecation should be maintained. * Bowels should move without using laxatives. * Adequate fluid should be taken, a glass of warm water in the morning should be taken to avoid constipation.strong tea is avoided * Plenty of roughage should be included in the diet to avoid constipation. Sexual intercourse: * Sexual intercourse is allowed with moderation, is absolutely safe and normal unless specific problem exists. * If a woman has a history of abortion, she should avoid sexual intercourse in the early months of pregnancy. * If the pregnant woman has a history of preterm labor, she should avoid sexual intercourse in the late months of pregnancy. Smoking: * Pregnant women who are heavy smokers should stop smoking or reduce the number of cigarettes to less than 4 each day. * Smoking may lead to ptyalism, nervousness and hyperemesis and make pregnant women at increased risk of chest infections and thrombo-embolic disorders. Medication * Pregnant women should avoid all unnecessary drugs because many drugs are known to have an adverse effect on pregnancy. * Minor complaints should be managed without drugs on pregnancy. 41 Infection * Pregnant woman should be avoid contact with infectious diseases especially rubella or ( German measles ) because it has deleterious effects on the fetus. Immunization: * All pregnant women should be fully immunized with tetanus toxoid vaccine in order to prevent neonatal tetanus. * If TT vaccine is not given before, it should be given during pregnancy in the form of 2 doses, 4 weeks apart starting from the third month. *Remaining TT doses should be completed lateraccording to the approved schedule. Irradiation * Pregnant women should avoid exposure to x-ray or irradiation because of possible teratogenic effects on the fetus such as birth defects or childhood leukemia. Occupational & environmental hazards * Pollutants, radioactive substances & chemicals such as ethylene oxide, lead, mercury and benzene that workers can carry home on skin or clothes may cause reproductive problems. Travel *Long unbroken rail or car journey should not be undertaken because jarring and excitement may induce abortion in susceptible women. * Airlines ask for a doctor's certificate stating that a pregnant woman is fit to travel and do not permit pregnant women to fly after the 32nd week. * If traveling is essential, it is allowed when comfortable. Taking extra fluids and taking breaks can case any discomfort. Follow up *The pregnant woman should visits the antenatal clinic monthly, during the first & second trimester. * During the second trimester pregnant woman should visits the antenatal 42 clinic Every 2 weeks during the 7th to 8th months (from 28th - 36th week(. * Every week during the 9th month (from 36th - 40th week). Danger signs during pregnancy: Pregnant women should be encouraged to report andseek advice as soon as any of the following occurs:  Persistent vomiting.  Severe persistent abdominal pain.  Vaginal bleeding.  Vaginal discharge with odor or itching  Chills or fever.  Marked changes of fetal movements.  Dysuria or burning sensation.  Severe headache.  Sudden swelling of face, fingers and feet.  Blurring of vision..  Sudden enlargement of the abdomen.  Premature onset of contractions.  Sudden escape of fluid from the vagina.  Dysuria, oliguria or anuria. Delivery: ** The woman should be encouraged to deliver in the hospital. ** She should be taught the signs and symptoms of early labor, when to go to the hospital and what to take with her. 43  High risk pregnancy Hypertensive Disorders During Pregnancy Introduction Hypertensive disorders of pregnancy are multisystem affection unique to human female pregnancy. Hypertensive disorders of pregnancy are the third leading cause of maternal mortality and morbidity and also major causes for perinatal mortality and morbidity. In Egypt it is reported to be the 2nd leading direct cause of maternal mortality and estimated to be 13% of all maternal deaths Classifications: 1- Gestational hypertension (transient hypertension): it is defined as new hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or both) presenting at or after 20 weeks gestation without proteinuria or other features of preeclampsia. 2-Chronic hypertension: This is known hypertension before pregnancy of a rise in blood pressure > 140/90mmhg before 20wks gestation, and persisting 6wks after delivery 3- Pregnancy induced hypertension (PIH): It is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation it includes two types' pre elampsia & eclampsia) Pre-eclampsia: It is a condition that can develop during pregnancy characterized by high blood pressure (hypertension) and protein in the urine (proteinuria) after the 20th week of pregnancy and can even occur in the days following birth. Incidence: It constitute about 75% of cases of hypertensive disorder of pregnancy and Eclampsia complicates 5-7% of all pregnancies.. Risk factors: - Chronic hypertension. - Chronic nephritis. - Past history - Family history. - Obesity.Polyhydramnios. - Diabetes mellitus. - Nulliparity. - Teenage Pregnancy. - Multiple pregnancies - Smoking& stress. a)Signs 1- Hypertension: It is diagnosed when the systolic blood pressure is a rise to 140/90 mmHg 2- Proteinuria: It is a late sign. It is due to glomerular damage allowing a leak of protein. Proteinuria in pregnancy is described as the presence of ≥ 300 mg or more of urinary protein per 24hrs. 3-Edema: It may be Manifest in the feet and ankle may be physiological due to pressure of the pregnant uterus on pelvic veins. Or Occult edema; in the internal organs. It is observed by sudden increase in body weight more than 1kg/week or >3kg/month, or the presence of generalized edema affecting the vulva, lower abdominal wall, face and hands. B) Symptoms: 1- Headache due to hypertension, often frontal but may be occipital. 2- Blurring of vision 3- Epigastria pain 4- Oliguria and anuria dye to kidney pathology 44  5- May be nausea and vomiting Classifications of preeclampsia: 1- Mild preeclampsia  Hypertension, but not reaching 160/110 mmHg after 20 weeks gestation.  Proteinuria 1+ dipsticks (300 mg / 24 hrs)  Manifestation disappearing < 12 weeks postpartum. 2-Severe preeclampsia  Bp ≥ 160 / 110 mmHg, plus one or more of the following criteria.  Proteinuria ≥ +2 or +3 dipstick (2 gms or 5gms / 24 hrs).  Serum creatinine ≥ 1.2 mg / dl unless known to be previously elevated.  Persistent headache, visual disturbance and persistent epigastria pain.  Oliguria or anuria.  Pulmonary edema. Complications or prognosis of pre eclampsia:  Maternal:  Convulsions and coma (eclampsia 1-2% of cases).  Cerebral hemorrhage.  Renal failure.  Liver failure..  Abruption placenta.  Residual chronic hypertension in about 1/3 of cases.  Recurrent pre-eclampsia in next pregnancies.  Retinal detachment  hemolytic anemia  HELLP Syndrome  Fetal:  Intrauterine growth retardation (IUGR).  Intrauterine fetal death.  Prematurity and its complications as respiratory distress, hge and infection in the newborn. HELLP syndrome: It is a group of symptoms that occur in pregnant women who have:  H -- hemolysis (the breakdown of red blood cells)  EL -- elevated liver enzymes  LP -- low platelet count HELLP occur in 10-20% of pregnant women with severe preeclampsia or eclampsia. Symptoms  Fatigue or feeling unwell  Fluid retention and excess weight gain  Headache  Nausea and vomiting that continues to get worse  Epigastric pain  Seizures or convulsions (rare) 45 Management of mild preeclampsia The only way to cure preeclampsia is to deliver the baby.  If baby is developed enough (usually 37 weeks or later),. Pregnant women may receive medicines to help trigger labor, or may need a c-section.  If baby is not fully developed and women have mild preeclampsia, the disease can often be managed at home until baby has a good chance of surviving after delivery. The nurse should instruct the women about:  Decrease activities and promote bed rest  Lie in left lateral position  Remain quiet and calm – restrict visitors and phone calls  Weigh daily at the same time  Keep record of fetal movement - kick counts  Check urine for Protein  Frequent doctor visits to make sure women and her baby are doing well  Medicines to lower blood pressure (sometimes)  Sedative drugs  Dietary modifications  increase protein intake to 70 - 80 g/day  Caffeine avoidance  Drinking plenty of water  Eating less salt Nursing management at the hospital may include:  Provide for a Quiet Environment and Rest  Explain plans and provide Emotional Support  Bed rest in left or right lateral position  Close monitoring of the mother and baby  Check B / P frequently.  Assess Reflexes  Assess Subjective Symptoms "headache, visual disturbance"  Check hourly output  Count fetal movement  Dipstick for Protein  Weigh dailyGive Antihypertensive Drugs  Administer anticonvulsant Magnesium Sulfate  Administer Sedative -- Diazepam (Valium)  Steroid injections (after 24 weeks) to help speed up the development of the baby's lungs  Keep Emergency Supplies Available Management of severe preeclampsia: Hospitalization:  Prevention of eclampsia.  Termination of pregnancy 46 a) Prevention of eclamptic seizures: Seizures can be prevented by the use of magnesium sulfate & potent antihypertensive Magnesium sulfate:  Dosage:  A loading dose: of 4 to 6 gm diluted in 100 ml of 5% glucose and injected I.V. over 15-20 minutes.  Maintenance dosage: Infusion of 2 gm/hour as a continuous infusion ( diluted in glucose 5 %)  Measure serum magnesium levels every 4-6 hrs. This is indicated when there is oligouria.  Maintenance dose of Mag. sulfate can be given I.M. every 4 hrs give 5 gm of 50% solution (one 10 ml ampule) 2. Eclampsia A life-threatening complication of pregnancy, it is characterized by high blood pressure and protein in the urine, seizures or coma. Incidence: Less than one in 1000 women with preeclampsia will develop eclampsia or (convulsions or seizures) or coma. Stages of eclampsia ( 4 stages): 1-Premonitory stage (1/2 minute):  Eye rolled up.  Twitches of the face and hands. 2-Tonic stage (1/2 minute):  Generalized tonic spasm with  Cyanosis.  Tongue may be bitten between the clenched teeth. 3-Clonic stage (1-2 minutes):  Convulsions.  Tongue may be bitten.  Face is congested and cyanosed.  conjunctival congestion.  Blood stained froth from the mouth.  Stertorous breathing,  Temperature may rise.  Involuntary passage of urine or stool.  Gradually convulsions stop. 47  4-Coma:  Variable duration due to respiratory and metabolic acidosis.  Deep coma may occur (cerebral hemorrhage).  Labor usually starts shortly after the fit.  Sometimes labor does not start and convulsions recur again the so called ‗intercurrent eclampsia‘ and carries a bad prognosis. Complications of eclampsia:  Maternal complications:  Respiratory distress syndrome from aspiration pneumonia, inhalation of blood, saliva and vomitous, airway obstruction by the tongue andpulmonary edema.  Heart failure.  Hypovolemic shock from placental abruption circulatory collapse post partum.  Cerebral hge.  Acute renal failure.  Liver failure.  HELLP syndrome.  Fetal hypoxia may also result.  Fetal complication.  The prenatal mortality is about 10-15% due to  Fetal hypoxia due to placental infarctions, premature separation of the placenta by accidental hemorrhage and maternal hypoxia during convulsion.  Prematurity and it is complications. Management of Eclampsia: The treatment of patient that has got one or more eclamptic seizures comprises the following:  General measurements and nursing care of a patient with seizures.  Medical measurements for Control of seizure by:  Parenteral administration of Mag. Sulfate,  Parenteral administration of antihypertensive  Delivery and Prevention and treatment of complications of eclampsia. 1) General measurements and nursing care of a patient with seizers:  Airway and respiratory management  Place patient in left lateral decubitus position  Suction oral secretions  Anesthesia at bedside for possible intubation  Consider Oral Airway  Supplemental Oxygen  Arterial Blood Gas  Prevent injury  Padding on side rails of bed  Other post-Seizure measures  Foley Catheter to monitor urinary out put  Internal fetal monitor (Internal Scalp electrode)  Consider central venous pressure catheter 48   Fluid administration needed to be monitored by central venous pressure (CVP) monitoring  Continuous hourly monitoring of patient's plus, temperature B.p, respiration rate and fluid intake and output. 2) Medical measurements a) Magnesium sulfate treatment b) Parenteral anti-hypertensive drugs to prevent cerebral hge and left ventricular heart failure. c) Delivery: Eclampsia frequently precipitates preterm labor.  If the patient in not in labor within few hours (3-4) after the last seizure, labor should be induced by pitocin drip.  C.S. should not be a routine for all eclamptic patients. 49 Hemorrhagic Disorders in Pregnancy Bleeding in early pregnancy Definition: it means bleeding before 20 weeks of gestation) Causes 1- Abortion. 2- Vesicular mole. 3- Ectopic pregnancy. 4- Local lesions — cervical polyps — cervical cancer. 1- Abortion Definition: It is the termination of pregnancy before 24 weeks, or products of conception weighing below 500 grams. It occurs in 10-15% of pregnancy , 80% of them occur in the first trimester. Causes:  Fetal: - Chromosomal anomalies. - Diseases of the fertilized ovum. - Hypoxia.  Maternal: - Infections e.g. influenza, malaria, syphilis ,HIV. - Disease such as chronic nephritis,TB. - Drug intake during pregnancy. - Rh and ABO incompatibility. - Incompetent cervix. - Uterine malformation. - Acquired uteine defect as uterine fibroid or adhesions - Trauma - criminal interference, - Endocrinal disorder as hypothyrodism , daibetes mellitus Types of abortion: - Spontaneous abortion - Threatened abortion 50  - Missed abortion - Inevitable abortion - Complete abortion - Incomplete abortion - Habitual abortion - Therapeutic abortion - Criminal abortion - Septic abortion 1- Threatened abortion: It is an attempt of uterus to get rid of its contents Signs & symptoms: - Vaginal bleeding, mild & bright red in color - Abdominal pain and backache may or may not be present. - Cervical os is closed. - Membranes are intact. Nursing management: - Complete bed rest - Avoid, heavy work enema &constipation - no sexual intercourse - Administration of prescribed drugs 2- Inevitable abortion Bleeding is excessive (more than 10 days). Blood is red in color with clots. Severe colicky lower abdominal pain. Cervical os is dilated and rupture of membranes has occurred. There is severe blood loss and the woman becomes shocked. 51 Nursing management: - Hospitalization - Antisock measure: - Fluid infusion - Bl. transfusion if indicate - O2/mask 6-8L/m - Warmth - Sedative ; 10mg morphia - If no heart beats are detected a dilute solution of oxcytocin may be given as the doctor orders to help in the expulsion of the contents of the uterus. - Dilatation and curettage should be done. 3-Missed abortion: Fetus is dead and retained inside the uterus Signs & symtomes: - Some signs of pregnancy disappear. - Pregnancy test will be negative. - Fundal height does not increase in size. - The breasts may secrete milk due to hormonal changes - FHR are absent. - No fetal movement. - A sonar test confirms fetal death. - Some brownish vaginal discharge Management - Wait about 2-4 weeks aiming spontaneous expulsion & follow up by coagulation profile - Evacuation 4- Septic abortion: Definition; any type of abortion complicated by infections e.g., missed or criminal abortion Signs & symptoms:  Tender and painful uterus.  Offensive vaginal bleeding.  High temperature.Rapid pulse..Unstable blood pressure.  Shock. 52 Nursing management: - Isolation. - Complete bed rest → in fowler's position - Monitoring for vital signs & fluid chart. - Fluid infusion (5% glucose + saline) to maintain urine flow >30 ml/hr - Clinical bacteriological to identify the infectious organisms. - Administration of antibiotics, Antipyretic &Analgesic as doctor orders. - The soiled pads should be properly collected and burned 5- Incomplete abortion Signs & symptoms: - Severe bleeding. - Cervical is partly closed. - No uterine involution. - Pain may or may not be present. - Uterus is soft and smaller than the expected period of pregnancy. 6-Complete abortion: Signs & symptoms: - There is minimal bleeding. - Pain stops. - Uterus is hard and much smaller - The cervix is closed - Rh incompatibility. Treatment: of the cause such as cervical incompetence or treatment of causative diseases as syphilis, DM, etc. Nursing Management of Abortion Prevention measures should be taken to avoid risk of a spontaneous abortion: A nutritional diet. Avoiding smoking or drinking. Receiving available immunizations against infectious diseases. Treatment of vaginal or pelvic infections. 53 2-Hydatidiform Mole (Vesicular Mole) Definition: is a gross malformation of the trophoblast in which the chorionic villi proliferate and become avascular. Causes: The exact cause is unknown. Risk factors are: Maternal age above 40 years or below 19 years. Malnutrition Types partial mole complete mole Signs and Symptoms Excessive frequent vomiting. Over distension of the uterus and larger than expected for weeks of gestation. Some vaginal bleeding may occur plus vesicles. No fetal movements ,No fetal parts Positive pregnancy test result in highly diluted urine 1:500. Complications: Hemorrhage. shock perforation Uterine sepsis. Choriocarcinoma Nursing management: Admit the woman into hospital. Evacuation of the uterus under general anesthesia. Health education on the following: Need for monitoring HCG levels for two years (monthly for the first 3 months, then every three months for one year). Birth spacing methods to prevent pregnancy for two years. 54  If HCG levels remain more than five international units per liter eight weeks postpartum, prophylactic chemotherapy is indicated. 3-Ectopic Pregnancy Definition : pregnancy occurring outside the normal uterine cavity.it usually occurs 99% of cases in the uterine tube. Tubal Pregnancy Causes: Impaired tubal cilliary action. Impaired tubal contractility. Decreased sperm mobility. The use of intrauterine contraceptive device. Risk Factors: Pelvic inflammatory disease. History of previous pelvic operations such as D and C, ovarian surgery. Signs and Symptoms Short periods of amenorrhea. Sudden/recurrent severe, colicky abdominal pain in one iliac fossa or entire lower abdomen. Blood stained vaginal discharge. Signs of shock. Dyspareunia. Management: Surgical Especially in undisturbed ectopic. Evacuated immediately. Salpingectomy is performed. Provide emotional support. Follow-up is needed. 55 Medical  When undisturbed.  B-HCG less than 10000  Mthotrexate is used and follow up of B-HCG titre is a must. Bleeding late in pregnancy Definition: It is defined as bleeding from the genital tract between 28th week of pregnancy and onset of labor. Classification: Placenta previa Abruptio placenta Vasa previa 1-Placenta Previa Abnormal situated placenta in lower uterine segment. Signs & Symptoms:  Vaginal bleeding bright red, painless, recurrent  Soft, pain free uterus  Easy to feel fetus & hear FHR Degrees 1.Complete "Centralis";placenta completely covers the internal os even when it is fully dilated. 2. Incomplete "Partials";placenta covers the internal os when it is closed, but covers it partially when it is fully dilated. 3. Lateralis:placenta on LUS but does not reach internal os. 4. Marginalis:placenta reaches internal os but does not cover it Nursing management: Bed rest and restriction of physical activity for at least 24 hours after admission. Avoid constipation, enemas, and vaginal and rectal examinations Follow strict aseptic technique to avoid infection. 56  Continuous observation of bleeding and signs of shock. listening FHR every 4 hours. accurate recording of intake and output. I.V fluids & o2 mask 2-Abruptio Placenta: Premature separation of normally situated placenta. Signs & Symptoms  Abdominal pain  Dark red vaginal bleeding  Tender uterus  Fetal parts hard to feel  No fetal heart is heard Types Revealed: almost all the blood expelled through the cervix. Concealed: almost all the blood is retained inside the uterus. Combined: some blood is retained inside the uterus and some is expelled through the cervix. Nursing management:  Continuous observation of patient‘s general condition, blood pressure, vital signs, bleeding and signs of shock. Continuous observation of fetal condition. Initiation and continuous observation of IV transfusion. Give medications accurately, especially for hypotension and shock if present. Regular urine analysis for proteinuria. Assessment and recording of intake and output. Assist in vaginal delivery, Provide pre-operative care & post-operative care. 57 Module Three: Childbirth and Birth Complications Objectives At the end of this module each student should be able to: - Define criteria of normal labor correctly - Describe the structure and diameters of bony pelvis, fetal head and distinguish between the anterior and posterior fontanels - Describe the structure and diameters of Describe premonitory and sure signs of labor - Identify the stages of labor - Describe nursing care for each stage of labor - Identify problems in passage and passenger. - Discuss nursing management for abnormal labor - Identify obstetric emergencies accurately. - Explain nursing management for emergencies according to priority of care. Child Birth Introduction: During late pregnancy the woman and fetus prepare for the labor process. The fetus has grown and developed in preparation for extrauterine life. The woman has undergone various physiologic adaptations during pregnancy that prepare her for birth and motherhood. Labor and birth represent the end of pregnancy, the beginning of extrauterine life for the newborn, and a change in the lives of the family. Terminology Primipara: The woman who delivers for the first time. Multipara: The woman that delivers several times before. Nulli para: The woman that hasn‘t past delivery. Para X+O: X: number of deliveries. O: number of abortions. Normal labor (eutocia): It is expulsion of mature viable fetus, presenting by vertex through the birth canal, spontaneously within reasonable time (24 hrs) without interference & without fetal or maternal complications. Immature labor: Termination of pregnancy between 20-28 wks (fetal weight 500-1000). Premature labor: Termination of pregnancy between 28-38 weeks and fetal weight between (1000-2500gm). Post maturity: Prolongation of pregnancy 2 weeks or more over the E.D.D 58  Show: It is a blood stained cervical mucous (cervical mucus plug which close the cervical canal during pregnancy to prevent infection and noticed at the start of labor when cervix starts to dilate). Lie: It is the relationship of the long axis of the fetus to the long axis of the mother (Normally is longitudinal lie 99.5%), but may be transverse or oblique 0.5%. Attitude: It is the relationship of the fetal parts to each other; normally the fetus is in an attitude of generalization or complete flexion. Presentation: It refers to the first part of the fetus which enters the pelvic brim or inlet and felt by vaginal examination and it may be: (Cephalic: 96% / Breech: 3.5% / Shoulder: 0.5%) Denominator: It is the landmark on the presenting part by which the position of the fetus is known;  Vertex presentation, the dominator is the occiput.  Face presentation, the dominator is the chin (mentum).  Brow presentation, the dominator is the frontal bone.  Breech presentation, the dominator is the sacrum.  Shoulder presentation, the dominator is the scapula. Position: It is the relationship of a certain point on the presenting part of the fetus to the back of the mother. - Vertex presentation, the positions (R.O.A, R.O.P, L.O.A, L.O.P). - Breech presentation, the positions (R.S.A, R.S.P, L.S.A, L.S.P). Crowning: It is distention of the vulva by the largest diameter of the fetal skull bone (biparietal diameter) and not return again after the end of uterine Contraction. 59  Station: It is the relationship between the spines of the maternal pelvis (-2, -1, 0, presenting part of the fetus and the imaginary +1, +2). line between the two ischial 60  Maternity Nursing Moulding: It is decrease of the fetal head in size and shape by overlapping of fetal skull bones to pass through the maternal pelvis. Degrees: (0) = Bones are separated and sutures can be felt easily. (+1) = Bones are just touching each other. (+2) = Bones are overlapping each other but separate by genital pressure. (+3) = Bones are severely overlapping each other but not separate by pressure and may make intracranial pressure. 19. Effacement: It is the shortening or taking up of the cervical canal. Lightening: It is descend of the fundal level of the uterus at 32 wks level due to engagement of the fetal head in the maternal pelvis, (occur in PG at 2 weeks before labor and MG at onset of labor) and this leads to:  Relief of dyspnea and palpitation.  Complain of frequency of micturation.  Complain of heaviness in the pelvis and difficulty in walking. Engagement: It is passage of biparietal diameter of fetal head through pelvic brim. PG at 38 wks & MG at onset of labor or at 2nd stage of labor. Apgar score: It is the newborn observational check list that includes five parameters (heart rate, respiration, color, muscle tone and reflexes) and it is recorded at 1 min and 5 min after delivery. Partogram: It is a graphic analysis tool to follow the progress of labor (for cervical dilatation in the time spent in labor) and includes all events occur during labor to the mother and fetus. Episiotomy: A surgically incision on the perineum and posterior vaginal wall during the second stage of labor to widen the vaginal orifice to facilitate passage of the fetus from the vagina. Caput succedaneum:Accumulation of fluid under fetal scalp due to compression during labor of the fetal head , it usually not require medical intervention as it resolve normally after one to two days after birth Criteria of normal labor:  Mature viable fetus  Vertex presentation  Through birth canal  Spontaneously  Within reasonable time  Without interference except episiotomy  Without complication for the mother and fetus Premonitory S&S of labor:  Lightening.  Greet pressure below.  Frequency of micturation.  False labor pain. 61  Maternity Nursing ngng Sure S&S of labor:  True labor pain.  Show is present.  Cervical dilatation. Factors Affecting Labor (5 Ps):  Passage: (Bony pelvis & Soft tissue (Birth canal).  Passenger: ( Fetus& Placenta & membranes).  Power: (Primary (uterine contraction) & Secondary (Bearing down).  Prejudice (place & personnel)  Psychological aspect 1-Passage: It is composed of the mother‘s bony pelvis and the soft tissues of uterus, the cervix, the vagina and the perineum Pelvis is divided into halves: 1)The false pelvis: it lies above the pelvic brim and is formed by the wings of the ileum. It has no major clinical significance for labor. 2)The true pelvis: it lies below the linea terminalis. It is a bony basin and form the canal through which the fetus passes. It is composed of an inlet, a cavity and an outlet.  The pelvic inlet (Pelvic brim): It is that plane which separates the false pelvis a above from the true pelvis below, it is heartly shaped bounded by the sacrum posteriorly, the linea terminalis laterally, and the symphysis pubis anteriorly.  The pelvic cavity (midpelvis): is a curved passage with a short anterior wall and a much longer posterior wall.  The pelvic outlet: Is the lower border of the true pelvis viewed from below , it is ovoid, somewhat diamond shaped. Normal Female Pelvis 62  Maternity Nursing 2-PASSENGER: It includes the placenta, membranes and fetus. a)The Placenta & membranes: Shape: it is a round flat mass, about 20cm in diameter and 2.5cm thick at its center. Size: It weighs one-eight of the infant's weight at term. Structure: It consists of 15-20 lobesand it hastwo surface:  The Maternal Surface: it is dark red in color.  The Fetal Surface: it a white, shiny appearance. b)The Umbilical Cord: -It extends from the fetus to the placenta and transmits two umbilical arteries and one vein. - The length of the cord is about 50cm. c)Fetus: Fetal Skull: It includes bones and fontanels. The skull is composed of:  Vault: the large & more compressible area.  Face: smaller & incompressible.  Base of the skull: it is composed of 2 parietal bones, 2 temporal bones, 2 frontal bones, one occipital bone. The fontanels: Structure of placenta It is spaces filled membranes located where the sutures intersect". The two most important fontanels are: A-Anterior fontanel: it is diamond shaped, is about 3 cm by 2 cm, and lies at the junction of the coronal & sagital sutures. It closes by 12-18 months after birth. B- Posterior fontanel: it is at the junction between the sagittal suture & lambdoidal suture. It is triangular in shape, and is about 1 cm by 2 cm. It is closed at full term. Fetal skull. 63  Maternity Nursing ngng Fetal disposition includes: 1-Presentation. 3-Lie. 2-Attitude. 4-Position. 3-Power: A) Primary involuntary power (uterine contraction) The contraction wave of the uterus begins in the fundus, which contains the greatest concentration of myometrial cells and moves downward through out the entire myometrium. Description of uterine contraction: Frequency: it refers to number of uterine contraction contractions per 10 minutes Interval: itrefers to the period of time between the end of one contraction to the beginning of the next contraction. Duration: it refers to the length of time a contraction lasts. Intensity: it refers to the strength of the uterine contraction, (mild, moderate, severe). Normal criteria of contraction  Frequency 3-5/10min  Duration not more than 90 sec.  Interval not less than 60 sec. B)-Secondary voluntary power (Bearing Down) Factors affecting bearing down:  Maternal condition (Fatigue, severe pain).  Fear & anxiety: lead to muscle tension…..general fatigue….. increase perception of pain.  Child births education (labor preparation).  Motivation of child bearing (unwanted pregnancy- intra uterine fetal death). Advantages of bearing down during 2nd stage of labor:  Help in pushing down of the fetus  Help in facilitate descend of the head  Aids in cervical dilatation  Facilitate labor  Shortening of the 2nd stage of labor. Disadvantage of bearing down during 1st stage of labor:  Weakness of pelvic muscles  Genital or cord prolapsed  Edema of the cervix  Placental insufficiency  Exhausted mother 4-Psychological factors affecting labor:  Social support  Past experience  Knowledge  Beliefs, values, culture 5- Prejudice:  Personnel; number & skills  Place of delivery; facilities 64  Maternity Nursing Stages of normal labor :  1st stage (Dilatation): begins with true labor pain & ends with fully cervical dilatation (10cm). PG: 16 hrs. MP: 8 hrs.  2nd stage (Birth): begins with fully cervical dilatation & ends with complete delivery of the baby. PG: 45 min-1 hour hrs. MP: 15-30 min.  3rdstage(Delivery of placenta): begins with complete delivery of the baby & ends with complete delivery of the placenta. PG: 10-20 min. MP: 10-20 min.  4th stage (Recovery): It is the first 2-4 hours immediate after delivery of the placenta. 1- First stage of labor (Dilatation): Phases of 1st stage:  Latent phase: (0-3 cm)  Contractions become comes every 10-15 minutes and least 2/10 min with each lasting > 20 seconds, moderately strong and are quite well tolerated without analgesia  Active phase: (4-10 cm)  Contraction comes every 3-5 minutes and at least 3 / 10 min, with each lasting > 40 seconds.  Normal rate of CD in active phase is 1.2cm/hour in PG and 1.5cm/hour in MP. Differentiate between true labor pain & false labor pain: True Labor contractions False labor pain (Braxton Hicks Contraction) *Regular *irregular *increase in frequency, duration & intensity *does not increase in frequency, duration & *Interval between contraction gradually shorten intensity *not relieved by analgesic *Usually no change *Spasmodic colicky pain begins in the lower back & radiates around to abdomen *relieved by analgesic *Productive:associated with stretching & *pain usually in the abdomen dilatation of cervix *Intensity increases with walking *not productive * not increased with walking 2- Second stage (Birth): Criteria of 2nd stage of labor:  Full dilatation, complete effacement of cervix.  Strong uterine contraction.  Spontaneous rupture of membranes  Urge to bear down.  Appearance of presenting part from the vulva.  Plugging of perineum.  Flushing of the face.  Changing in woman voice begin to cry. 65  Maternity Nursing ngng Mechanism of normal labor: 1. Descent 2. Engagement 3. Flexion 4. Internal rotation 5. Extension 6. Restitution 7. External rotation 8. Delivery of shoulder Mechanism of normal labor 3-Third stage of labor: (Delivery of placenta): Signs of placental separation: 1. The uterus becomes smaller, harder, higher, and more globular. 2. A suprapubic bulge appears due to presence of the placenta in the lower uterine segment. 3. The passage of gush of blood per vagina. 4. Elongation the umbilical cord. 5. Loss of pulsation in the cord. 6. Methods of placental separation: Shultze method Duncan’s method - 97% of cases. - 3% of cases. - Separation started at the center then at - The edges of placenta separated first. the edges as an inverted umbrella. - Less liability for bleeding. - More liability for bleeding - Less retention of membranes. - Retention of membranes. 4-The fourth stage (Recovery) :It is that the immediate postpartum period, as it is the 1st 2-4 hrs after delivery of the placenta. Nursing management of normal labor Nursing care during the first stage of labor: 1- Assessment at admission: It is divided into:  Initial assessment  Ongoing assessment  Initial assessments: When the woman arrives to peirnatal unite. Assessment is the top priority of nursing care.it includes history taking, physical examination and investigation.. 1- History taking: ( subjective data) A maternal health history should include:  Personal history, which involves (name, age and address).  Mother life-style; such as (Housing condition, daily living activities, personal hygiene, nutrition and habits.  Medical history; chronic diseases such as cardiac disease, liver disease & renal disease)  Family history; such as (twin pregnancies, diabetes mellitus, hypertension and history of congenital malformation, any operations, receiving blood transfusion and a