Signs & Symptoms of Pregnancy PDF

SIGNS & SYMPTOMS OF PREGNANCY PRESUMPTIVE, PROBABLE, POSITIVE, DANGER SIGNS & SYMPTOMS OF PREGNANCY PRESUMPTIVE SIGNS: (SUBJECTIVE SIGNS) 1. AMENORRHEA 2. MORNING SICKNESS ( NAUSEA & VOMITING) 3. EASY FATIGABILITY 4. URINARY FREQUENCY 5. STRIAE GRAVIDARUM 6. CHLOASMA, MELASMA OR “ MASK...

SIGNS & SYMPTOMS OF PREGNANCY PRESUMPTIVE, PROBABLE, POSITIVE, DANGER SIGNS & SYMPTOMS OF PREGNANCY PRESUMPTIVE SIGNS: (SUBJECTIVE SIGNS) 1. AMENORRHEA 2. MORNING SICKNESS ( NAUSEA & VOMITING) 3. EASY FATIGABILITY 4. URINARY FREQUENCY 5. STRIAE GRAVIDARUM 6. CHLOASMA, MELASMA OR “ MASK OF PREGNANCY” 7. LINEA NIGRA 8. LEUKORRHEA 9. QUICKENING FIRST FETAL MOVEMENT 4TH MONTH IN MULTIS 5TH MONTH IN PRIMIS PROBABLE SIGNS: ( OBJECTIVE SIGNS) 1. CHADWICK’S SIGN – PURPLISH DISCOLORATION OF THE VAGINA DUE TO HIGH VASCULARITY IN THE AREA 2. GOODEL’S SIGN – SOFTENING OF THE CERVIX 3. HEGAR’S SIGN – SOFTENING OF THE LOWER UTERINE SEGMENT. 4. BALLOTEMENT – BOUNCING OF THE BABY WHEN TAPPED BY AN EXAMINING FINGER. 5. BRAXTON HICK’S – PAINLESS UTERINE CONTRACTIONS 6. ( + ) PREGNANCY TEST POSITIVE SIGNS OF PREGNANCY: 1. PRESENCE OF FETAL HEART TONE 2. FETAL OUTLINE BY XRAY / ULTRASOUND 3. FETAL MOVEMENT FELT BY EXAMINER SYSTEMIC CHANGES IN PREGNANCY CAUSES & EFFECTS SYSTEMIC CHANGES CIRCULATORY / CARDIOVASCULAR: ** BEGINNING THE END OF THE FIRST TRIMESTER, THERE IS A GRADUAL INCREASE OF ABOUT 30%-50% IN TOTAL CARDIAC VOLUME. THIS CAUSES A DROP IN HgB & HcT VALUES SINCE THE INCREASE IS ONLY IN PLASMA. = PHYSIOLOGIC ANEMIA OF PREGNANCY CONSENQUENCES OF INCREASED CARDIAC VOLUME: ** EASY FATIGABILITY & SOB DUE TO INCREASED WORKLOAD OF THE HEART MX: REST ** SLIGHT HYPERTHOPHY OF THE HEART CAUSING IT TO BE DISPLACED TO THE LEFT ** SYSTOLIC MURMURS DUE TO LOWERED BLOOD VISCOSITY ** NOSEBLEEDS MAY OCCUR DUE TO MARKED CONGESTION OF THE NASOPHARYNX ** PALPITATIONS DUE TO INCREASED PRESSURE ON THE DIAGPHRAGM ** EDEMA OF LOWER EXTERMITIES OCCURS DUE TO POOR CIRCULATION RESULTING FROM PRESSURE OF THE GRAVID UTERUS ON THE BLOOD VESSELS MANAGEMENT: RAISE LEGS ABOVE HIP LEVEL AND AVOID PROLONGED STANDING & SITTING NOTE: EDEMA OF THE LE IS NOT A SIGN OF TOXEMIA CONSENQUENCES OF INCREASED CARDIAC VOLUME: ** VARICOSITIES COULD OCCUR DUE TO PRESSURE OF THE GRAVID UTERUS ON THE BLOOD VESSELS OF THE LE MANAGEMENT: DO NOT CROSS LEGS WHEN SITTING WEAR SUPPORT HOSE TO PROMOTE VENOUS FLOW THUS PREVENTING STASIS IN THE LOWER EXTREMITIES APPLY ELASTIC BANDAGE – START AT THE DISTAL END TOWARDS THE TRUNK TO AVOID CONGESTION & IMPAIRED CIRCULATION IN THE DISTAL PART AVOID USE OF KNEE HIGH SOCKS ** VARICOSITIES OF THE VULVA & RECTUM MANAGEMENT: SIDE LYING POSITION WITH HIPS ELEVATED ON PILLOWS MODIFIED KNEE CHEST POSITION CONSENQUENCES OF INCREASED CARDIAC VOLUME: ** THERE IS INCREASED CIRCULATING FIBRINOGEN (CLOTTING FACTOR) THAT IS WHY PREGNANT WOMEN ARE NORMALLY SAFEGUARDED AGAINST UNDUE BLEEDING. HOWEVER THIS ALSO PREDISPOSES THEM TO CLOT FORMATION (THROMBI) IMPLICATION: PREGNANT WOMEN SHOULD NOT BE MASSAGED SINCE BLOOD CLOTS CAN BE RELEASED & CAUSE THROMBOEMBOLISM. ** BP DECREASES SLIGHTLY IN THE 2ND TRIMESTER DUE TO LOWERED PERIPHERAL RESISTANCE TO CIRCULATION BUT ARISES IN THE 3RD TRIMESTER. ** DURING DELIVERY, THE ALLOWABLE BLOOD LOSS IS 250-450 ML (MAXIMUM 500 ML) FOR A SINGLE FETUS, 1000 ML FOR VAGINAL DELIVERY OF TWINS OR CESARIAN SECTION. CONSENQUENCES OF INCREASED CARDIAC VOLUME: ** SUPINE HYPOTENSION SYNDROME OR VENA CAVA SYNDROME = THE WEIGHT OF THE GRAVID UTERUS PRESSES ON THE VENA CAVA OBSTRUCTING BLOOD FLOW. THE WOMAN EXPERIENCES LIGHTHEADEDNESS, FAINTNESS & HEART PALPITATIONS. MANAGEMENT: LEFT SIDE LYING OR LEFT LATERAL SO AS NOT TO COMPRESS THE VENA CAVA ** PSEUDOANEMIA – AS THE BLOOD VOL. INCREASES, THE CONCENTRATION OF HGB MAY DECLINE. MX:> IRON SUPPLEMENT RESPIRATORY SYSTEM: ** SLIGHT DYSPNEA MAY OCCUR UNTIL LIGHTENING CAUSED BY INCREASED O2 CONSUMPTION & PRODUCTION OF CO2 GASTROINTESTINAL SYSTEM: ** MORNING SICKNESS MX: EAT DRY CRACKERS 30 MINUTES BEFORE ARISING IN THE MORNING. AVOID SPICY, FATTY FOODS HYPEREMESIS GRAVIDARUM = EXCESSIVE NAUSEA & VOMITING WHICH PERSISTS BEYOND 3 MONTHS THAT COULD RESULT TO DEHYDRATION, STARVATION, MALNUTRITION AND F & E IMBALANCE MX: D10NSS 3000 ML IN 24 HOURS IS THE PRIORITY OF TREATMENT > REST CONSTIPATION = DUE TO DISPLACEMENT OF THE STOMACH & INTESTINES; DUE TO INCREASED PROGESTERONE DURING PREGNANCY MANAGEMENT for Constipation INCREASE FLUID INTAKE HIGH FIBER DIET ESTABLISH REGULAR ELIMINATION PATTERN EXERCISE MINERAL OIL SHOULD NOT BE USED BECAUSE IT INTERFERES WITH ABSORPTION OF FAT SOLUBLE VITAMINS ( ADEK) HEARTBURN REFLUX OF STOMACH CONTENT INTO THE ESOPHAGUS DUE TO INCREASED PROGESTERONE WHICH DECREASES GASTRIC MOTILITY MANAGEMENT: PATS OF BUTTER BEFORE MEALS AVOID FRIED, FATTY FOODS BEND AT THE KNEES NOT AT THE WAIST TAKE ANTACIDS EX. MILK OF MAGNESIA BUT NEVER SODIUM NHCO3 ( ALKA SELTZER OR BAKING SODA) BECAUSE IT PROMOTES FLUID RETENTION PICA ABNORMAL CRAVING FOR NON NUTRITIOUS SUBSTANCES. THE MOST COMMON IS CRAVING FOR ICE CUBES. THERE COULD ALSO BE CRAVING FOR PAPER, ETC., OFTEN ACCOMPANIES IRON DEFICIENCY ANEMIA ENCOURAGE TO TAKE IRON SUPPLEMENTS MUSCULOSKELETAL SYSTEM GRADUAL SOFTENING OF PELVIC LIGAMENTS AND JOINTS TO FACILITATE PASSAGE OF THE BABY. LORDOSIS= FORWARD CURVATURE OF THE LUMBER SPINAL STANDING WITH THE SHOULDERS, BACK AND ABDOMEN FORWARD IN ORDER TO CHANGE CENTER OF GRAVITY AND MAKE AMBULATION EASIER. “THE PRIDE OF PREGNANCY” LEG CRAMPS MAY OCCUR FROM AN IMBALANCEOF CALCIUM PHOSPORUS RATIO IN THE BODY AND FROM PRESSURE OF THE UTERUS ON LOWER EXTREMITIES; FATIGUE; CHILLS MUSCLE TENSENESS; LOW CALCIUM. MANAGEMENT: FREQUENT REST PERIODS WITH FEET ELEVATED **WEAR WARM, COMFORTABLE CLOTHING **INCREASE CALCIUM INTAKE (CALCIUM TABLETS AND DIET) DO NOT MASSAGE= BLOOD CLOTS CAN CAUSE EMBOLISM MOST EFFECTIVE RELIEF: PRESS KNEE OF THE AFFECTED LEG AND DORSIFLEX THE FOOT. WEIGHT *DURING THE FIRST TRIMESTER, WEIGHT GAIN OF 1.5- 3LBS. *ON THE 2ND AND 3RD TRIMESTERS, WEIGHT GAIN OF 10-11 POUNDS PER TRIMESTER IS RECOMMENDED. *TOTAL ALLOWABLE WEIGHT GAIN DURING THE ENTIRE PERIOD OF PREGNANCY IS 20-25 LBS. ( 10-12 KGS.). MORE THAN 30 LBS OF WEIGHT GAIN IS A DANGER SIGN = POSSIBLE PREECLAMPSIA. ** PATTERN OF WEIGHT GAIN IS MORE IMPORTANT THAN THE AMOUNT OF WEIGHT GAINED. DISTRIBUTION OF WEIGHT GAIN DURING PREGNANCY: FETUS 7 LBS PLACENTA 1 LB AMNIOTIC FLUID 2 LBS INCREASED WT. OF UTERUS 2 LBS INCREASED BLOOD VOLUME 1 LB INCREASED WT. OF THE BREASTS 2-3 LBS WT. OF ADDITIONAL FLUID 2 LBS FAT & FLUID ACCUMULATION 4-6 LBS CHANGES IN SEXUAL DESIRE: A. FIRST TRIMESTER = SEXUAL DESIRE IS DECREASED AS CAUSED BY NAUSEA, FATIGUE & SLEEPINESS. B. SECOND TRIMESTER = SEXUAL DESIRE IS INCREASED DUE TO PELVIC CONGESTION & SENSE OF WELL BEING. C. THIRD TRIMESTER = SEXUAL DESIRE IS DECREASED DUE TO FATIGUE & PHYSICAL BULKINESS ** SEXUAL INTERCOURSE IS ALLOWED UNTIL THE LAST 6 WEEKS OF PREGNANCY ( BECAUSE IT HAS BEEN FOUND OUT THAT THERE IS INCREASED INCIDENCE OF POSTPARTUM INFECTION IN WOMEN WHO ENGAGE IN SEX DURING THE LAST 6 WEEKS) AS LONG AS THERE ARE NO CONTRAINDICATIONS LIKE THE FOLLOWING: 1. BLEEDING 2. INCOMPETENT CERVICAL OS 3. DEEPLY ENGAGED PRESENTING PART 4. RUPTURED BOW ** SEXUAL INTERCOURSE SHOULD BE DONE WITH THE WOMAN IN A COMFORTABLE POSITION: 1. SIDE LYING 2. WOMAN SUPERIOR – WOMAN ON TOP EMOTIONAL RESPONSES: FIRST TIMESTER AMBIVALENCE, REJECTION, DENIAL, DISBELIEF, REPRESSION THE FETUS IS AN UNIDENTIFIED CONCEPT WITH GREAT FUTURE IMPLICATIONS BUT WITHOUT TANGIBLE EVIDENCE OF REALITY IMPLICATION: WHEN GIVING HEALTH TEACHINGS, BE SURE TO EMPHASIZE THE BODILY CHANGES IN PREGNANCY B. SECOND TRIMESTER FETUS IS PERCEIVED AS A SEPARATE ENTITY. FANTASIZES APPEARANCE OF THE BABY ( 4-6 MONTHS) C. THIRD TRIMESTER HAS PERSONAL IDENTIFICATION WITH A REAL BABY ABOUT TO BE BORN & REALISTIC PLANS FOR FUTURE CHILD CARE RESPONSIBILITIES. BEST TIME TO TALK ABOUT PREPARATION OF LAYATTE & INFANT FEEDING METHOD. FEAR OF DEATH IS IMMINENT ( TO ALLAY FEARS , LET PREGNANT WOMAN LISTEN TO FETAL HEART TONES. THE PSYCHOLOGICAL TASKS OF PREGNANCY: A. FIRST TRIMESTER ACCEPTING THE PREGNACY – ACCEPTANCE OF REALITY & INCORPORATION OF FETUS INTO BODY IMAGE B. SECOND TRIMESTER ACCEPTING THE BABY – PREPARATION FROM PHYSICAL SEPARATION FROM FETUS C. THIRD TRIMESTER PREPARING FOR THE DELIVERY & PARENTHOOD – ATTAINMENT OF MATERNAL ROLE PATERNAL REACTIONS TO PREGNANCY: A. FIRST TRIMESTER AMBIVALENCE & ANXIETY ABOUT ROLE CHANGE; CONCERN FOR IDENTIFICATION WITH MOTHER’S DISCOMFORTS ( COUVADE SYNDROME) B. SECOND TRIMESTER INCREASED CONFIDENCE & INTERST IN MOTHER’S CARE; DIFFICULTY RELATING TO FETUS; “JEALOUSY” C. THIRD TRIMESTER CHANGING SELF CONCEPT; CONCERN ABOUT BODY CHANGES; ACTIVE INVOLVEMENT IN COMMON FEARS ABOUT DELIVERY, MUTILATION OR DEATH OF PARTNER OR FETUS SIBLING REACTIONS TO PREGNANCY: A. NORMAL RIVALRY DEPENDENT ON DEVELOPMMENTAL STAGE B. MAY NEED INCREASED AFFECTION & ATTENTION C. REGRESSION IN BEHAVIOR ( MAY APPEAR IN BEDWETTING & THUMSUCKING); REJECTION EMPLOYMENT AS LONG AS THE JOB DOES NOT ENTAIL HANDLING TOXIC SUBSTANCES OR LIFTING HEAVY OBJECTS , OR EXCESSIVE EMOTIONAL STRAIN, THERE IS NO CONTRAINDICATION TO WORKING. ADVISE PREGNANT WOMEN TO WALK ABOUT EVERY FEW HOURS OF HER WORKDAY DURING LONG PERIODS OF STANDING OR SITTING TO PROMOTE CIRCULATION THEREBY MINIMIZING VARICOSE VEINS. TRAVELLING NO TRAVEL RESTRICTIONS BUT POSTPONE A TRIP DURING THE LAST TRIMESTER. ON LONG RIDES , 15-20 MINUTE REST PERIODS EVERY 2-3 HOURS TO WALK ABOUT OR EMPTY THE BLADDER IS ADVISABLE. EXERCISE SHOULD BE DONE IN MODERATION; SHOULD BE INDIVIDUALIZED: ACCORDING TO AGE, PHYSICAL CONDITION, CUSTOMARY AMOUNT OF EXERCISE ( SWIMMING OR TENNIS) NOT CONTRAINDICATED UNLESS DONE FOR THE FIRST TIME ; & STAGE OF PREGNANCY BATHING: DUE TO INCREASED PERSPIRATION , THE PREGNANT WOMAN IS ENCOURAGED TO HAVE A DAILY BATH TO KEEP HER FRESH & CLEAN TUB BATH IS DISCOURAGED BECAUSE ALTERATION IN THE WOMAN’S BALANCE MAKES GETTING IN & OUT OF THE BATH TUB DIFFICULT, SHE MIGHT SLIP & FALL & HURT HERSELF SWIMMING IS OK BUT NO DIVING BREAST CARE: WELL FITTING & LARGER SIZED BRASSIERE ( WIDE STRAPS & DEEP CUPS TO PREVENT LOSS OF BREAST TONE.) WASH BREAST WITH WATER ONLY. NO SOAPS OR ALCOHOL SHOULD BE USED AS THESE CAUSES DRYING & CRACKING. DRINKING IN MODERATION IS NOT CONTRAINDICATED BUT WHEN EXCESSIVE, CAN CAUSE TRANSIENT RESPIRATORY DEPRESSION IN THE NEWBORN AND FETAL WITHDRAWAL SYNDROME: BESIDES, ALCOHOL SUPPLIES ONLY EMPTY CALORIES. DRUGS DANGEROUS TO FETUS ESPECIALLY DURING THE FIRST TRIMESTER WHEN THE PLACENTAL BARRIER IS STILL INCOMPLETE AND THE DIFFERENT BODY ORGANS ARE DEVELOPING. ARE TERATOGENIC (CAN CAUSE CONGENITAL DEFECTS)(AND THEREFORE, CONTRAINDICATED UNLESS PRESCRIBED BY THE DOCTOR) RECOMMENDED EXERCISES: CHIEF AIM: STRENGTHEN MUSCLES USED IN LABOR & DELIVERY. 1. TAILOR SITTING ( INDIAN SIT) = STRENGTHENS THE THIGH & STRETCHES THE PERINEAL MUSCLES. THE WOMAN SHOULD NOT PUT ONE ANKLE ON TOP OF THE OTHER BUT SHOULD PLACE ONE LEG IN FRONT OF THE OTHER GENTLY PUSHING HER KNEES ( PUSHING THEM TOWARDS THE FLOOR) UNTIL SHE FEELS HER PERINEUM “ STRETCH” 2. SQUATTING = HELPS TO STRETCH THE MUSCLES OF THE PELVIC FLOOR. IT SHOULD BE DONE FOR 15 MINUTES A DAY. THE WOMAN MUST KEEP HER FEET FLAT ON THE FLOOR TO BENEFIT FROM THE EXERCISE. 3. PELVIC FLOOR CONTRACTIONS ( KEGEL’S EXERCISE) = STRENGTHENS PERINEAL MUSCLES FOR LABOR & DELIVERY; PROMOTES PERINEAL HEALING; INCREASES SEXUAL RESPONSIVENESS AND PREVENTS STRESS INCONTINENCE. WHILE SITTING AT HER DESK OR WORKING AROUND THE HOUSE, THE WOMAN CAN TIGHTEN THE MUSCLES SURROUNDING HER VAGINA, THEN TIGHTENTHE MUSCLES SURROUNDING HER RECTUM, RELAX, THEN TIGHTEN HER PERINEUM. RELAX. IT CAN BE DONE 50-100 TIMES DAILY. 3. PELVIC ROCKING = HELPS RELIEVE BACKACHE DURING PREGNANCY. IT CAN BE DONE ON HANDS AND KNEES, LYING DOWN, SITTING OR STANDING. IF THE WOMAN LIES SUPINE, SHE TIGHTENS HER BUTTOCKS & FLATTENS HER LOWER BACK AGAINST THE FLOOR TRYING TO LENGTHEN HER SPINE. SHE HOLDS THE POSITION FOR 1 MINUTE THEN HALLOWS HER BACK OR RAISES THE LUMBAR SPINE IN THE FLOOR. 4. ABDOMINAL MUSCLE CONTRACTIONS = HELPS STRENGHTEN ABDOMINAL MUSCLES DURING PREGNANCY & PREVENTS CONSTIPATION IN THE POSTPARTAL PERIOD. IT CAN BE DONE IN A STANDINGOR LYING POSITION.THE WOMAN TIGHTENS HER ABDOMINAL MUSCLES, & THEN RELAXES & SHE CAN REPEAT THE EXERCISE AS OFTEN AS SHE WISHES IMPORTANT ESTIMATES IN PREGNANCY IMPORTANT ESTIMATES 1. NAEGELE’S RULE = CALCULATION OF EXPECTED DATE OF DELIVERY ( EDD) FORMULA: COUNT BACK 3 MONTHS FROM THE 1ST DAY OF THE MENSTRUAL PERIOD (LMP) THEN ADD 7 DAYS PLUS 1 YEAR. EXAMPLE: LMP APRIL 22, 1995 -3 +7 +1 JAN 29, 1996 2. MC DONALD’S RULE = ( ESTIMATION OF AOG IN MONTHS & WEEKS BY FUNDIC HEIGHT MEASUREMENT)= FORMULA : FUNDIC HEIGHT IN CMS X 2/7 EXAMP[LE: FUNDIC HEIGHT IS 21 CMS 21 CMS X 2 =42 42/ 7 = 6 ( AOG IN MONTHS) 6 MONTHS X 4 = 24 ( AOG IN WEEKS) HAASE’S RULE = ESTIMATION OF FETAL LENGTH RULE: **DURING THE FIRST HALF OF PREGNANCY, SQUARE THE NUMBER OF THE MONTH ( EX. FIRST LUNAR MONTH: 1X1 = 1CM. **DURING THE SECOND HALF OF PREGNANCY, MULTIPLY THE MONTH BY 5 ( EX. 6TH LUNAR MONTH: 6X5 = 30 CM.) FORMULA: 1 TO 5 MONTHS = MONTHS SQUARED EXAMPLES: 5 MONTHS X 5 = 25 CMS LENGTH 8 MONTHS X 5 = 40 CMS LENGTH JOHNSON’S RULE = ESTIMATATION OF WEIGHT IN GRAMS FORMULA: FUNDIC HEIGHT IN CM – N X K “K” IS CONSTANT, IT IS ALWAYS 155 “N” IS MINUS 11 IF PART IS NOT YET ENGAGED MINUS 12 IF PART IS ALREADY ENGAGED EXAMPLE: 21 CM, NOT ENGAGED 21 – 11 = 10 X 155 = 1,550 GMS BARTHOLOMEW’S RULE = ESTIMATION OF AOG BY THE RELATIVE POSITION OF THE UTERUS IN THE ABDOMINAL CAVITY. ** BY THE 3RD LUNAR MONTH, THE FUNDUS IS PALPABLE SLIGHTLY ABOVE THE SYMPHYSIS PUBIS ** ON THE 5TH LUNAR MONTH, THE FUNDUS IS AT THE LEVEL OF THE UMBILICUS ** ON THE 9TH LUNAR MONTH , THE FUNDUS IS BELOW THE LEVEL OF THE XIPHOID PROCESS DANGER SIGNS OF PREGNANCY DANGER SIGNS OF PREGNANCY 1. VAGINAL BLEEDING = VAGINAL BLEEDING SHOULD BE REPORTED IMMEDIATELY FOR FURTHER EVALUATION 2. PERSISTENT VOMITING ( HYPEREMESIS GRAVIDARUM) = NAUSEA & VOMITING THAT CONTINUES PAST THE 12 WEEK OF PREGNANCY IS EXTENDED VOMITING. IT DEPLETES THE NUTRITIONAL SUPPLY AVAILABLE TO THE FETUS. 3. CHILLS & FEVER = MAY BE EVIDENCE OF INTRAUTERINE INFECTION WHICH IS A SERIOUS COMPLICATION FOR BOTH THEWOMAN & THE BABY. 4. SUDDEN ESCAPE OF FLUID FROM THE VAGINA = MEANS THAT THE MEMBRANES HAVE RUPTURED. BOTH THE MOTHER & THE FETUS ARE THREATENED BECAUSE UTERINE CAVITY IS NO LONGER SEALED AGAINST INFECTION. ** IF FETUS IS SMALL & HIS HEAD DOES NOT FIT INTO THE CERVIX, THE UMBILICAL CORD MAY PROLAPSE WITH THE RUPTURED MEMBRANE , THE HEAD MAY BE COMPRESSED AGAINST THE CORD. ANOTHER DANGEROUS COMPLICATION IS ASCENDING INFECTION. 5. ABDOMINAL OR CHEST PAINS = ABDOMINAL PAINS MAY MEAN TUBAL PREGNANCY THAT HAVE RUPTURED, SEPARATION OF THE PLACENTA, PRETERM LABOR WHILE CHEST PAINS MAY INDICATE PULMONARY EMBOLUS THAT FOLLOWS THROMBOPHLEBITIS. 6. ABSENCE OF FETAL HEART SOUNDS AFTER THEY HAVE INITIALLY BEEN AUSCULTATED ON THE 4TH & 5TH MONTH (MAY INDICATE INTRAUTERINE FETAL DEATH - IUFD) 7. SWELLING OF THE FACE & FINGERS = EDEMA 8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA) 9. BLURRING OF VISION 10. SEVERE HEADACHE & DIZZINESS ** MAY MEAN SIGNS OF PREGNANCY INDUCED HYPERTENSION PRENATAL CARE (Antepartum Care) PRENATAL CARE ( ANTEPARTUM CARE) 3 PHASES: 1. PRE-CONSULTATION = HISTORY TAKING, FAMILY, MEDICAL, OB HISTORY) 2. CONSULTATION = PHYSICAL ASSESSMENT 3. POST CONSULTATION = HEALTH TEACHINGS A. PRENATAL CARE: SCHEDULE OF PRENATAL VISIT: A. ONCE EVERY 4 WEEKS , UP TO 32 WEEKS B. EVERY 2 WEEKS FROM 32 – 36 WEEKS ( MORE FREQUENTLY IF PROBLEM EXISTS) C. EVERY WEEK FROM 36 – 40 WEEKS COMPONENTS OF PRE NATAL VISIT: PERSONAL DATA: AGE, CIVIL STATUS, WEIGHT, HEIGHT 1. AGE : UNDER 17 OR ABOVE 35 (GREATER RISK IF OVER 40) ** PREGNANT ADOLESCENTS HAVE A HIGHER INCIDENCE OF PREMATURITY, PIH, CEPHALOPELVIC DISPROPORTION, POOR NUTRITION & INADEQUATE ANTEPARTAL CARE. ** WOMEN OVER 35 YEARS OLD ARE AT RISK FOR CHROMOSOMAL DISORDERS IN INFANTS, PIH & CESARIAN DELIVERY.  ** THE PROVISION OF PRENATAL CARE IS THE PRIMARY FACTOR IN THE IMPROVEMENT OF MATERNAL MORBIDITY & MORTALITY STATISTICS. “”  ** THE DURATION OF A NORMAL PREGNANCY IS 266 – 280 DAYS OR 38-42 WEEKS (AVERAGE IS 42 WEEKS) ; OR 9 CALENDAR MONTHS OR 10 LUNAR MONTHS. ** BOTH OVULATION & GESTATIONAL AGE ARE ALSO SOMETIMES MEASURED IN LUNAR MONTHS (4 WEEK PERIODS) OR IN TRIMESTERS (3 MONTH PERIOD) RATHER THAN IN WEEKS. IN LUNAR MONTHS, A PREGNANCY IS 10 MONTHS ( 40 WEEKS OR 280 DAYS) LONG; A FETUS GROWS IN UTERO 9.5 LUNAR MONTHS OR THREE FULL TRIMESTERS (38 WEEKS OR 266 DAYS) OBSTETRICAL DATA: MENSTRUAL HISTORY: INCLUDES MENARCHE, LENGTH & REGULARITY OF MENSES, INTERVAL BETWEEN PERIODS, AMOUNT OF FLOW, DYSMENORRHEA HISTORY OF PAST PREGNANCIES: GRAVIDA = ALL PREGNANCIES REGARDLESS OF DURATION OR OUTCOME PARA = PAST PREGNANCIES RESULTING IN VIABLE FETUS ( 20 WEEKS) WHETHER BORN DEAD OR ALIVE. ( TWINS, TRIPLETS ETC. CONSIDERED AS ONE). T= NUMBER OF FULL TERM BIRTHS P= NUMBER OF PREMATURE BIRTHS A= NUMBER OF ABORTIONS L= NUMBER OF LIVING CHILDREN PRIMIGRAVIDA = A WOMAN WHO IS PREGNANT FOR THE FIRST TIME PRIMIPARA = A WOMAN WHO HAS DELIVERED A VIABLE, ALIVE OR DEAD CHILD MULTIGRAVIDA = A WOMAN WHO HAS BEEN PREGNANT PREVIOUSLY NULLIGRAVIDA = A WOMAN WHO HAS NEVER BEEN & IS NOT CURRENTLY PREGNANT 2. CONSULTATION PHASE = PHYSICAL ASSESSMENT A. PHYSICAL EXAMINATION = A REVIEW OF SYSTEMS IS INDICATED, INCLUDING INSPECTION OF THE TEETH BECAUSE THEY ARE A COMMON CAUSE OF INFECTION. B. PELVIC EXAMINATION (CARDINAL RULE: EMPTY THE BLADDER FIRST) ** INTERNAL EXAMINATION (IE) = TO DETERMINE CHADWICK’S, GOODEL’S, HEGAR’S TT IMMUNIZATION: > TT1 GIVEN ANYTIME DURING PREGNANCY > TT2 ONE MONTH AFTER TT1 (3 YEARS PROTECTION) > TT3 SIX MONTHS AFTER TT2 (5 YEARS PROTECTION) > TT4 ONE YEAR AFTER TT3 ( 10 YRS) TT5 ONE YEAR AFTER TT4 OR NEXT PREGNANCY (LIFETIME PROTECTION) ** PAPANICOLAU SMEAR (PAP SMEAR) = CYTOLOGICAL EXAMINATION TO DIAGNOSE CERVICAL CARCINOMA ** CLASSIFICATION OF FINDINGS ** CLASS 1 = ABSENCE OF ATYPICAL OR ABNORMAL CELLS ** CLASS 2 = ATYPICAL CYTOLOGY BUT NO EVIDENCE OF MALIGNANCY  ** STAGE 3 = METASTASIS TO THE PELVIC WALL. ** STAGE 4 = METASTASIS BEYOND PELVIC WALL INTO THE BLADDER & RECTUM. ** PELVIC MEASUREMENTS ARE PREFERABLY DONE AFTER 6TH LUNAR MONTH. X-RAY PELVIMETRY ( SEVERAL FLAT PLATE X-RAY PICTURES OF THE PELVIS ARE TAKEN FROM DIFFERENT ANGLES) HOWEVER, IT IS THE MOST EFFECTIVE METHOD OF DIAGNOSING CEPHALOPELVIC DISPROPORTION (CPD). BUT SINCE X-RAYS ARE TERATOGENIC, THE PROCEDURE CAN ONLY BE DONE 2 WEEKS BEFORE DELIVERY. C. VITAL SIGNS = TEMPERATURE, PULSE AND RESPIRATORY RATES ARE IMPORTANT ESPECIALLY DURING THE INITIAL PHASE OF THE PRENATAL VISIT. BUT CERTAINLY MORE IMPORTANT ARE THE WEIGHT & BLOOD PRESSURE AS BASELINE DATA TO DETERMINE ANY SIGNIFICANT INCREASE. D. BLOOD STUDIES ** BLOOD TYPING ** CBC, INCLUDING HgB, & HcT TO DETERMINE ANEMIA E. URINE EXAMINATIONS: ** HEAT & ACETIC ACID TEST TO DETERMINE ALBUMINURIA. ANY SIGN OF ALBUMIN (PROTEIN) IN THE URINE SHOULD BE REPORTED IMMEDIATELY BECAUSE IT IS A SERIOUS SIGH OF TOXEMIA (PIH). ** BENEDICT’S TEST FOR GLYCOSURIA, A SIGN OF POSSIBLE GESTATIONAL DIABETES.SPECIMEN SHOULD BE TAKEN BEFORE BREAKFAST 3. POST-CONSULTATION PHASE = HEALTH TEACHINGS NUTRITION = MOST IMPORTANT ASPECT FOOD SOURCES: ** PROTEIN RICH FOODS = MEAT, FISH, EGGS, MILK, POULTRY, CHEESE, BEANS, MONGO ** VIT. A = EGGS, CARROTS, SQUASH, CHEESE, BEANS, VEGETABLES ** VIT. D = FISH, LIVER, EGGS, MILK (EXCESS VIT.D DURING PREGNANCY CAN LEAD TO FETAL CARDIAC PROBLEMS) **VITAMIN E = GREEN LEAFY VEGETABLES, FISH **VITAMIN C= TOMATOES, GUAVA, PAPAYA **VITAMIN B= PROTEIN RICH FOODS **CALCIUM/PHOSPHORUS=MILK, CHEESE **IRON= ESPECIALLY IMPORTANT DURING THE LAST TRIMESTER WHEN THE PREGNANT WOMAN IS GOING TO TRANSFER HER IRON STORES FROM HERSELF TO HER FETUS SO THAT THE BABY HAS ENOUGH IRON STORES DURING THE 1ST 3 MONTHS OF LIFE WHEN ALL HE TAKES IS MILK (WHICH IS DEFICIENT IRON). IRON HAS A VERY LOW ABSORPTION RATE: ONLY 10% OF THE IRON INTAKE CAN BE ABSORBED BY THE BODY. THUS, FOR THE OPTIMUM ABSORPTION, GIVE VITAMIN C. IRON SHOULD BE GIVEN AFTER MEALS BECAUSE IT IS IRRITATING TO THE GASTRIC MUCOSA. SOURCES: LIVER AND OTHER INTERNAL ORGANS, CAMOTE TOPS, KANGKONG, EGG YOLK, AMPALAYA. **MALNUTRITION DURING PREGNANCY CAN RESULT IN PREMATURITY, PREECLAMPSIA, ABORTION, LOW BIRTH WEIGHT BABIES, CONGENITAL DEFECTS OR EVEN STILL BIRTHS. **SMOKING= CAUSES VASOCONSTRICTION, LEADING TO LOW BIRTH WEIGHT BABIES AND THEREFORE IS CONTRAINDICATED DURING PREGNANCY. ** FOLIC ACID – TO PREVENT NEURAL TUBE DEFECTS ( SPINA BIFIDA, MENINGOCOELE) SOURCES: GREEN LEAFY VEGETABLES LEOPOLD’S MANEUVER  LEOPOLD’S MANEUVER = A SYSTEMATIC METHOD OF OBSERVATION & PALPATION TO DETERMINE THE PRESENTATION, FETAL POSITION, ATTITUDE, FETAL LIE & DEGREE OF ENGAGEMENT. THE WOMAN SHOULD BE IN SUPINE POSITION WITH HER KNEES FLEXED SLIGHTLY SO AS TO RELAX THE ABDOMINAL MUSCLES. PREPARATORY STEPS: ** INSTRUCT THE CLIENT TO VOID ** PALPATE WITH WARM HANDS. COLD HANDS CAUSE ABDOMINAL MUSCLES TO CONTRACT.  ** USE GENTLE BUT FIRM MOTIONS. PROCEDURE: 1. FIRST MANEUVER = ( DETERMINES THE FETAL PRESENTATION) ** FACING THE HEAD PART OF THE CLIENT, PALPATE THE SUPERIOR SURFACE OF THE FUNDUS.DETERMINE CONSISTENCY, SHAPE & MOBILITY. A HARD BALLOTABLE MASS AT THE FUNDUS MEANS THE FETUS IS IN BREECH PRESENTATION. 2. SECOND MANEUVER = ( DETERMINES THE FETAL BACK) **PALPATE THE SIDES OF THE UTERUS TO DETERMINE WHERE THE FETAL BACK IS FACING. THE LEFT HAND IS LEFT STATIONARY ON THE LEFT SIDE OF THE UTERUS WHILE THE RIGHT HAND PALPATES OPPOSITE SIDE OF THE UTERUS FROM TOP TO BOTTOM. DO ON THE OPPOSITE SIDE. 3. THIRD MANEUVER = ( DETERMINES DEGREE OF ENGAGEMENT) ** PALPATE TO DISCOVER THE PART OF THE FETUS AT THE INLET & ITS MOBILITY. GRASP THE LOWER PORTION OF THE ABDOMEN JUST ABOVE THE SYMPHYSIS PUBIS BETWEEN THE THUMB & INDEX FINGER. DETERMINE ANY MOVEMENT & WHETHER THE PART IS FIRM OR SOFT. IF THE PRESENTING PART MOVES UPWARD,SO AN EXAMINING FINGERS CAN BE PRESSED TOGETHER, THE PRESENTING PART IS NOT ENGAGED ( NOT FIRMLY SETTLED INTO THE PELVIS). IF THE PART IS FIRM , IT IS THE HEAD; IF SOFT THEN IT IS THE BREECH. 4. FOURTH MANEUVER = ( DETERMINES FETAL ATTITUDE & DEGREE OF FLEXION OR EXTENSION).NOTE: THIS SHOULD ONLY BE DONE IF THE FETUS IS IN CEPHALIC PRESENTATION. ** FACING THE FEET PART OF THE PATIENT, PLACE FINGERS ON BOTH SIDES OF THE OF THE UTERUS APPROXIMATELY 2 INCHES ABOVE THE INGUINAL CANAL PRESSING DOWNWARD & INWARD IN THE DIRECTION OF THE BIRTH CANAL. ALLOW FINGERS TO BE CARRIED DOWNWARD. IF THE FINGERS OF ONE HAND WILL SLIDE ALONG THE UTERINE CONTOUR & MEET NO OBSTRUCTION, IT INDICATES NECK OF THE FETAL BACK. THE OTHER HAND WILL MEET AN OBSTRUCTION AN INCH OR SO ABOVE THE LIGAMENT – THIS IS THE FETAL BROW. THE POSITION OF THE FETAL BROW SHOULD CORRESPOND TO THE SIDE OF THE UTERUS THAT CONTAINED THE ELBOWS & KNEES OF THE FETUS. IF THE FETUS IS IN A POOR ATTITUDE, THE EXAMINING FINGER WILL MEET AN OBSTRUCTION ON THE SAME SIDE AS THE FETAL BACK, THAT IS, THE FINGERS WILL TOUCH THE HYPEREXTENDED HEAD. STAGES OF FETAL DEVELOPMENT Fertilization and Implantation INTRAUTERINE LIFE STAGES OF FETAL DEVELOPMENT OVUM: 1. IT IS THE FEMALE SEX CELL OR GAMETE. 2. FOLLOWING OVULATION, AS THE OVUM IS EXTRUDED FROM THE GRAAFIAN FOLLICLE, IT IS SURROUNDED BY A RING OF FLUID “ ZONA PELLUCIDA”, & A CIRCLE OF CELLS CALLED “ CORONA RADIATA” ** ONLY ONE OVUM REACHES MATURITY EVERY MONTH. ** OVUM CAN STAY VIABLE & IS CAPABLE OF BEING FERTILIZED FOR 12-24 HOURS AFTER OVULATION BUT CAN LIVE UP TO 3-4 DAYS ** MATURED OVUM SPERM CELL: ** SPERMATOZOA DEPOSITED IN THE VAGINA REACHES THE WAITING EGG IN THE FALLOPIAN TUBE IN ABOUT 5 MINUTES ** THE FUNCTIONAL LIFE OF SPERMATOZOA IS 48-72 HRS (3DAYS) BUT CAN STAY ALIVE IN THE VAGINA FOR 5 -7 DAYS. ** ONLY ONE SPERMATOZOON IS ABLE TO PENETRATE THE CELL MEMBRANE OF THE OVUM AFTERWHICH CELL MEMBRANE BECOMES IMPERVIOUS TO OTHER SPERMATOZOA. ** REPRODUCTIVE CELLS, DURING GAMETOGENESIS DIVIDE BY MEIOSIS ( HAPLOID NUMBER OF DAUGHTER CELLS) ** (THE REST OF THE BODY CELLS HAVE 46 CHROMOSOMES) ** SPERMS CONTAIN ONLY 23 CHROMOSOMES, 22 AUTOSOMES & 1 X SEX CHROMOSOME OR 1 Y SEX CHROMOSOME. ** THE UNION OF AN X CARRYING SPERM (GYNOSPERM)& A MATURE OVUM RESULTS IN A BABY GIRL (XX) ** THE UNION OF A Y CARRYING SPERM(ANDROSPERM) & A MATURE OVUM RESULTS IN A BABY BOY (XY) ** ONLY FATHERS CAN DETERMINE THE SEX OF THEIR CHILDREN ** SEX OF A CHILD IS DETERMINED AT THE TIME OF FERTILIZATION ** SEX OF A CHILD CAN BE DISTINGUISHED THROUGH AN ULTRASOUND AT 3 MONTHS. FACTORS AFFECTING SPERM MOTILITY 1. ALCOHOLISM 2. CHAIN SMOKING 3. POOR RESISTANCE TO SMOKING 4. MEN WHO WEAR TIGHT JEANS A. FERTILIZATION ( CONCEPTION, FECUNDATION, IMPREGNATION) = IT IS THE UNION OF A MATURED EGG AND A SPERM & THE PRODUCT IS CALLED A CONCEPTUS OR ZYGOTE. = IT OCCURS AT THE DISTAL 3RD OF THE FALLOPIAN TUBE – THE AMPULLA TWO CHANGES THAT TAKE PLACE IN THE SPERM AS IT REACHES THE OVUM CAPACITATION – REMOVAL OF THE PROTECTIVE COATING OF THE SPERM ACROSOME REACTION = PERFORATION OF THE HEAD AND RELEASE OF ENZYMES (HYALURONIDASE) THEREBY DISSOLVING THE COVERING OF THE OVUM ( ZONA PELLUCIDA & CORONA RADIATA) ZYGOTE: - IS THE FIRST CELL FORMED FROM THE FERTILIZATION OF SPERM & OVUM. IT CONTAINS 46 CHROMOSOMES: 44 AUTOSOMES & EITHER XX CHROMOSOMES IF THE OFFSPRING IS A FEMALE, OR XY CHROMOSOME, IF THE OFFSPRING IS A MALE. - IT JOURNEYS FROM THE FALLOPIAN TUBE TO THE UTERUS FOR 3-5 DAYS - 16 HOURS AFTER FERTILIZATION, IT UNDERGOES ITS FIRST CELL DIVISION ,” BLASTOMERE” - WHEN THERE ARE ALREADY 16 OR MORE BLASTOMERES, THE ZYGOTE IS TERMED “MORULA”( MORUS – MULBERRY) - WHEN IT REACHES THE UTERUS IT IS TRANSFORMED INTO A “BLASTOCYST” – A BALL LIKE STRUCTURE COMPOSED OF AN INNER CELL MASS , CALLED EMBRYONIC DISC OR BLASTOCELE & AN OUTER LAYER OF RAPIDLY DEVELOPING CELLS CALLED TROPHOBLASTS OR TROPHODERM. - THE TROPHOBLASTS SECRETES A HORMONE CALLED “ HUMAN CHORIONIC GONADOTROPIN NECESSARY IN PROLONGING THE LIFE OF THE CORPUS LUTEUM. - THE BLASTOCELE OR EMBRYONIC DISC GIVES RISE TO THE THREE PRIMARY GERM LAYERS: ECTODERM, MESODERM, ENDODERM.  PRIMARY GERM LAYERS TISSUE LAYER BODY PORTIONS FORMED ECTODERM NERVOUS SYSTEM, SKIN, HAIR ( OUTER LAYER) NAILS, SENSE ORGANS, MUCUS MEMBRANES OF NOSE & MOUTH MESODERM CONNECTIVE TISSUE, BONES, ( MIDDLE LAYER) CARTILAGE, MUSCLES, TENDONS, KIDNEYS, URETERS, REPRODUCTIVE SYSTEM, HEART, CIRCULATORY SYSTEM, BLOOD CELLS  ENDODERM / ENTODERM LINING OF THE GI TRACT, ( INNER LAYER) RESPIRATORY TRACT, TONSILS, PARATHYROID, THYROID, THYMUS GLANDS, BLADDER, URETHRA IMPLANTATION / NIDATION: - THE BLASTOCYST REMAINS FREE FLOATING IN THE UTERINE CAVITY FOR 3-5 DAYS & IMPLANTS IN THE ENDOMETRIUM 6-7 DAYS AFTER FERTILIZATION. - AS IT ATTACHES ITSELF TO THE WALL OF THE UTERUS, ITS TROPHOBLAST CELLS RELEASE ENZYMES ALLOWING IT TO BURROW DEEP INTO THE ENDOMETRIUM RESULTING IN RUPTURE OF VESSELS & BLEEDING AT THE IMPLANTATION SITE. “ IMPLANTATION BLEEDING”. - IDEAL SITE OF IMPLANTATION IS THE FUNDAL PORTION. TROPHOBLASTS: AT ABOUT 3 WEEKS, THE TROPHOBLAST CELLS DIFFRENTIATE INTO TWO DISTINCT LAYERS: 1.CYTOTROPHOBLAST OR LANGHAN’S LAYER: - INNER LAYER THAT PROTECTS THE FETUS AGAINST SYPHILIS UNTIL THE 2ND TRIMESTER. 2.SYNCYTIOTROPHOBLAST OR SYNCYTIAL LAYER: - OUTER LAYER THAT PRODUCES HORMONES HCG, HPL. ESTROGEN & PROGESTERONE. CHORIONIC VILLI: - AS EARLY AS 12 DAYS AFTER FERTILIZATION,TINY PROJECTIONS AROUND THE ZYGOTE, CALLED VILLI, CAN BE SEEN. - THE CHORIONIC VILLI IN CONTACT WITH THE DECIDUA BASALIS PROLIFERATE VERY RAPIDLY BECAUSE THEY RECEIVE RICH BLOOD SUPPLY. IT WILL LATER ON FORM THE FETAL SIDE OF THE PLACENTA. DECIDUA: - AFTER IMPLANTATION, THE ENDOMETRIUM IS NOW REFERRED TO AS THE DECIDUA. LAYERS: 1. DECIDUA BASALIS –LAYER WHERE IMPLANTATION TAKES PLACE. IT WILL LATER ON FORM THE MATERNAL SIDE OF THE PLACENTA. 2. DECIDUA CAPSULARIS – LAYER WHICH ENCLOSES, ENVELOPES THE BLASTOCYST & BECOMES THE BAG OF WATER. 3. DECIDUA VERA – NO FUNCTION ** DECIDUA PARIETALIS – LOCATED UNDER THE DECIDUA BASALIS. MEMBRANES: 1. CHORION – TOGETHER WITH THE DECIDUA BASALIS BECOMES THE PLACENTA. 2. AMNION – SMOOTH, THIN, TOUGH & TRANSLUCENT MEMBRANE DIRECTLY ENCLOSING THE FETUS & THE AMNIOTIC FLUID. IT IS CONTINUOUS WITH THE UMBILICAL CORD & COVER THE FETAL SURFACE OF THE PLACENTA & UMBILICAL CORD. 3. DECIDUA VERA – NO FUNCTION ** DECIDUA PARIETALIS – LOCATED UNDER THE DECIDUA BASALIS. MEMBRANES: 1. CHORION – TOGETHER WITH THE DECIDUA BASALIS BECOMES THE PLACENTA. 2. AMNION – SMOOTH, THIN, TOUGH & TRANSLUCENT MEMBRANE DIRECTLY ENCLOSING THE FETUS & THE AMNIOTIC FLUID. IT IS CONTINUOUS WITH THE UMBILICAL CORD & COVER THE FETAL SURFACE OF THE PLACENTA & UMBILICAL CORD. ABNORMAL AMNIOTIC COLORS: 1. GREEN TINGES OR MECONIUM STAINED – SIGNIFIES FETAL DISTRESS 2. GOLD OR YELLOW – SIGNIFIES HEMOLYTIC DISEASE SUCH AS Rh OR ABO INCOMPATIBILITY 3. GRAY – INDICATES INFECTION 4. PINK – SIGNIFIES BLEEDING FUNCTIONS OF AMNIOTIC FLUID: 1. PROTECTS THE FETUS FROM TRAUMA 2. ALLOWS FREEDOM OF MOVEMENT WHICH PERMITS SYMMETRICAL GROWTH & DEVELOPMENT 3.MAINTAINS A CONSTANT TEMPERATURE. 4. SOURCE OF ORAL FLUID INTRAUTERINE. 5. AIDS IN DIAGNOSIS OF MATERNAL & FETAL COMPLICATIONS. 6. AIDS IN FETAL DESCENT DURING LABOR BY PROVIDING LUBRICATION IN THE BIRTH CANAL. UMBILICAL CORD / FUNIS - STRUCTURE THAT CONNECTS THE FETUS TO THE PLACENTA. MAIN FUNCTION IS TO CARRY O2 & NUTRIENTS FROM THE PLACENTA TO THE FETUS & RETURN THE UNOXYGENATED BLOOD & FETAL WASTE PRODUCTS TO THE PLACENTA. - 50 -55 CMS LONG. APPEARS DULL WHITE,MOIST & COVERED BY AMNION. - COMPOSED OF 2 ARTERIES & 1 VEIN ( AVA) - IF ONLY TWO BLOOD VESSELS, SUSPECT RENAL ANOMALIES. ** WHARTON’S JELLY – GELATINOUS SUBSTANCE THAT COVERS THE UMBILICAL CORD TO PREVENT KINKING, AND TRAUMA TO THE CORD. CORD INSERTION: * CENTRAL INSERTION – NORMALLY, THE CORD IS INSERTED AT THE CENTER OF THE FETAL SURFACE OF THE PLACENTA. * LATERAL INSERTION – WHEN THE CORD IS INSERTED AWAY FROM THE CENTER OF THE PLACENTA BUT NOT AT ITS EDGES. * VELAMENTOUS INSERTION – WHEN THE CORD IS INSERTED IN THE MEMBRANES ABOUT 5 TO 10 CM AWAY FROM THE EDGE OF THE PLACENTA. * BATTLEDORE INSERTION – WHEN THE CORD IS INSERTED AT THE EDGE OF THE PLACENTA  PLACENTA * THE PLACENTA IS FORMED FROM THE CHORIONIC VILLI AND DECIDUA BASALIS. * IT BECOMES FUNCTIONAL ON THE 2ND MONTH & IT REACHES MATURITY AT 12 WEEKS GESTATION AND CONTINUE TO FUNCTION EFFECTIVELY UNTIL THE 40 TO 41ST WEEK. IT BEGINS TO DEGENERATE AFTER THE 42ND WEEK MAKING IT DANGEROUS FOR THE FETUS TO REMAIN IN UTERO BEYOND 42 WEEKS GESTATION. FUNCTIONS OF THE PLACENTA 1. RESPIRATORY SYSTEM = EXCHANGE OF GASES TAKES PLACE IN THE PLACENTA, NOT IN THE FETAL LUNG. 2. RENAL SYSTEM = WASTE PRODUCTS ARE BEING EXCRETED THROUGH THE PLACENTA NOTE: IT IS THE MOTHER’S LIVER WHICH DETOXIFIES THE FETAL WASTE PRODUCTS 3. GASTROINTESTINAL SYSTEM = NUTRIENTS PASS TO THE FETUS VIA THE PLACENTA BY DIFFUSION THROUGH THE PLACENTAL TISSUES. 4. CIRCULATORY SYSTEM = FETO PLACENTAL CIRCULATION IS ESTABLISHED BY SELECTIVE OSMOSIS 5. PROTECTIVE BARRIER = INHIBITS PASSAGE OF CERTAIN BACTERIA & LARGE MOLECULES ** PROVIDES MATERNAL IMMUNOGLOBULIN G (IG G) THAT GIVES FETUS PASSIVE IMMUNITY TO CERTAIN DISEASES FOR THE FIRST FEW MONTHS AFTER BIRTH. 6. ENDOCRINE SYSTEM = PRODUCES HORMONES HCG, HPL ( HUMAN PLACENTAL LACTOGEN “ CHORIONIC SOMATOMAMMOTROPIN”, ESTROGEN , PROGESTERONE, RELAXIN Video Presentation Fertilization and Implantation FETAL GROWTH ANDDEVELOPMENT A. PRE-EMBRYONIC = FIRST 2 WEEKS BEGINNING WITH FERTILIZATION B. EMBRYONIC = WEEKS 3-8, CONSIDERED THE MOST CRITICAL IN FETAL STAGE BECAUSE Of ORGANOGENESIS. C. FETAL = WEEKS 8 TO BIRTH  NORMAL FETAL DEVELOPMENT FIRST TRIMESTER 4 WEEKS FORM OF EMBRYONIC DISC, NOT CLEARLY DEFINED FEATURES, SPINAL CORD IS FORMED; RUDIMEN TARY HEART APPEARS AS A PROMINENT BULGE ON THE ANTERIOR SURFACE, ARMS & LEGS BUD LIKE STRUCTURES, RUDIMENTARY EYES, EARS, & NOSE ARE DISCERNABLE 8 WEEKS ORGANOGENESIS IS COMPLETE, HEART BEATS RHYTHMICALLY, , FACIAL FEATURES ARE DISCERNABLE,EXTREMITIES HAVE DEVELOPED, , EXTERNAL GENITALIA PRESENT BUT NOT DISTINGUISHABLE PRIMITIVE TAIL IS REGRESSING, ABDOMEN APPEARS LARGE AS FETAL INTESTINES GROWS RAPIDLY, SONOGRAM SHOWS GESTATIONAL SAC ( DIAGNOSTIC OF PREGNACY) 12 WEEKS NAIL BEDS FORMING ON FINGERS & TOES, BONE OSSIFICATION BEGINS, RESENT, SEX OUTWARD APPEARANCE, KIDNEYS SECRETE, HEARTBEAT AUDIBLE BY A DOPPLER 16 WEEKS FETAL HEART SOUNDS AUDIBLE VIA FETOSCOPE, LANUGO IS WELL FORMED, LIVER & PANCREAS FUNCTIONING, FETUS SWALLOWS AMNIOTIC FLUID SHOWING AN INTACT BUT UNCOORDINATED SWALLOWING REFLEX, SEX CAN BE DETERMINED BY ULTRASOUND;QUICKENING FELT BY A MULTIGRAVIDA 20 WEEKS QUICKENING FELT BY A PRIMAGRAVIDA, ANTIBODY PRODUCTION IS POSSIBLE, HAIR FORMS INCLUDING EYEBROWS & HAIR ON HEAD, MECONIUM PRESENT IN UPPER INTESTINE, BROWN FAT ( AIDS IN TEMPERATURE REGULATION AT BIRTH) BEGINS TO BE FORMED BEHIND THE KIDNEYS, STERNUM, & POSTERIOR NECK, FETAL HEART AUDIBLE VIA STETHOSCOPE, VERNIX CASEOSA BEGINS TO FORM, 24 WEEKS PASSIVE ANTIBODY TRANSFER FROM EARLY AS 20 WEEKS BUT CERTAINLY AT 24 WEEKS. INFANTS BORN BEFORE ANTIBODY TRANSFER HAS TAKEN PLACE HAVE NO NATURAL IMMUNITY & NEED MORE THAN THE USUAL PROTECTION AGAINST INFECTIOUS DISEASE IN THE NEWBORN UNTIL THE INFANT’S OWN STORE OF IG’S CAN BUILD UP; MECONIUM IS PRESENT IN THE RECTUM; ACTIVE PRODUCTION OF LUNG SURFACTANT BEGINS; EYEBROWS & EYELASHES WELL DEFINED; EYELIDS NOW OPEN; PUPILS REACTIVE TO LIGHT; HEARS IN RESPONSE TO SUDDEN SOUND. 28 WEEKS LUNG ALVEOLI BEGINS TO MATURE; SURFACTANT PRESENT IN AMNIOTIC FLUID; BLOOD VESSELS OF THE RETINA EXTREMELY SUSCEPTIBLE TO DAMAGE FROM HIGH O2 CONCENTRATIONS; THE EYES OPEN 32 WEEKS SUBCUTANEOUS FAT BEGINS TO BE DEPOSITED ( THE FORMER “ STRINGY” OLD MAN APPEARANCE IS LOST); FETUS IS AWARE OF SOUNDS OUTSIDE THE MOTHERS BODY; ACTIVE MORO REFLEX PRESENT, BIRTH POSITION( VERTEX OR BREECH) MAY BE ASSUMED; IRON STORES THAT PROVIDE IRON FOR THE TIME THAT THE NEONATE WILL INGEST ONLY MILK AFTER BIRTH ARE BEGINNING TO BE DEVELOPED; FINGERNAILS GROW TO REACH END OF FINGERTIPS. 36 WEEK ADDITIONAL AMOUNTS OF SUBCATANEOUS FATS ARE DEPOSITED; SOLE OF THE FOOT HAS ONLY ONE OR TWO CRISSCROSS CREASES; LANUGO BEGINS TO DIMINISH; MOST BABIES TURN INTO A VERTEX OR HEAD-DOWN PRESENTATION DURING THIS MONTH 40 WEEKS FETUS KICKS ACTIVELY CAUSING DISCOMFORT TO THE MOTHER; VERNIX CASEOSA IS FULLY FORMED; FINGERTIPS EXTEND OVER THE FINGERTIPS ** IN PRIMIPARAS, THE FETUS OFTEN SINKS INTO THE BIRTH CANAL DURING THE LAST TWO WEEKS ( UP TO 4 WEEKS), GIVING THE MOTHER A FEELING THAT HER LOAD IS BEING LIGHTENED. THIS IS TERMED LIGHTENING. IT IS A FETAL ANNOUNCEMENT THAT THE THIRD TRIMESTER OF PREGNANCY HAS ENDED AND BIRTH IS AT HAND.** CHILDBIRTH PREPARATION CLASSES ** CHILDBIRTH PREPARATION CLASSES = NON PHARMACOLOGIC PAIN REDUCTION DURING LABOR. = TO DECREASE FEAR & ANXIETY 1. THE BRADLEY ( PARTNER COACHED) METHOD ** PAIN IS REDUCED BY ABDOMINAL BREATHING 2. PSYCHOSEXUAL METHOD = ** CONSCIENTIOUS RELAXATION & LEVELS OF PROGRESSIVE BREATHING THAT ENCOURAGES THE WOMAN TO “ FLOW WITH” RATHER THAN STRUGGLE WITH CONTRACTIONS. 3. DICK-READ METHOD ** FEAR LEADS TO TENSION, WHICH LEADS TO PAIN ** RELAXATION TECHNIQUES ** AVOIDANCE OF MEDICINES 4. LAMAZE METHOD ** USE CONTROLLED BREATHING & THEREFORE REDUCE PAIN DURING LABOR. ** PREVIOUSLY TERMED PSYCHOPROPHYLACTIC METHOD ( MEANING PREVENTING PAIN IN LABOR (PROPHYLAXIS) BY USE OF THE MIND (PSYCHE) ** CONSCIOUS APPLICATION OF CONDITIONED RESPONSES TO STIMULI ** CHEST BREATHING IN EARLY LABOR ** INCREASE RATE AS LABOR PROGRESSES LABOR & DELIVERY Management  LABOR AND DELIVERY LABOR = PHYSICAL & MECHANICAL PROCESS IN WHICH THE BABY, THE PLACENTA & FETAL MEMBRANES ARE PROPELLED THROUGH THE PELVIS & ARE EXPELLED FROM THE BIRTH CANAL. DELIVERY = ACTUAL EVENT OF BIRTH 5 P’S IN LABOR & DELIVERY ◆ 1. PASSENGER = THE FETUS ◆ 2. PASSAGEWAY = THE BIRTH CANAL ◆ 3. POWERS OF LABOR= FORCE OF UTERINE CONTRACTIONS ◆ 4. PLACENTAL IMPLANTATION ◆ 5. PSYCHOLOGICAL STATE OR FEELINGS THAT WOMEN BRING TO LABOR 1. THE FETAL SKULL = FROM AN OBSTETRICAL POINT OF VIEW, THE FETAL SKULL IS THE MOST IMPORTANT PART OF THE FETUS BECAUSE: A. IT IS THE LARGEST PART OF THE BODY B. IT IS THE MOST FREQUENT PRESENTING PART C. IT IS THE LEAST COMPRESSIBLE OF ALL PARTS A. CRANIAL BONES 1. SPHENOIDAL 2. FRONTAL 3. ETHMOIDAL 4. TEMPORAL 5. PARIETAL B.MEMBRANE SPACES = SUTURE LINES ARE IMPORTANT BECAUSE THEY ALLOW THE BONES TO MOVE AND OVERLAP, CHANGING THE SHAPE OF THE FETAL HEAD IN ORDER TO FIT THROUGH THE BIRTH CANAL, A PROCESS CALLED MOLDING. 1. SAGITTAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE 2 PARIETAL BONES. 2. CORONAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE FRONTAL BONE AND THE PARIETAL BONES. B.MEMBRANE SPACES = SUTURE LINES ARE IMPORTANT BECAUSE THEY ALLOW THE BONES TO MOVE AND OVERLAP, CHANGING THE SHAPE OF THE FETAL HEAD IN ORDER TO FIT THROUGH THE BIRTH CANAL, A PROCESS CALLED MOLDING. 1. SAGITTAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE 2 PARIETAL BONES. 2. CORONAL SUTURE LINE = THE MEMBRANOUS INTERSPACE WHICH JOINS THE FRONTAL BONE AND THE PARIETAL BONES.  3. LAMBDOIDAL SUTURE LINE C. FONTANELLES = MEMBRANE – COVERED SPACES AT THE JUNCTION OF THE MAIN SUTURE LINES: 1. ANTERIOR FONTANEL = THE LARGER, DIAMOND SHAPED FONTANEL WHICH CLOSES BETWEEN 12 TO 18 MONTHS IN AN INFANT  2. POSTERIOR FONTANEL = THE SMALLER TRIANGULAR SHAPED FONTANEL WHICH CLOSES BETWEEN 2-3 MONTHS IN THE INFANT. THE SPACE BETWEEN THE TWO FONTANELLES IS REFERRED TO AS THE VERTEX. D. MEASUREMENTS – THE SHAPE OF THE FETAL SKULL CAUSES IT TO BE WIDER IN ITS ANTEROPOSTERIOR (AP) DIAMETER THAN IN ITS TRANSVERSE DIAMETER. 1. TRANSVERSE DIAMETER OF THE FETAL SKULL: I. BIPARIETAL = 9.25CM TO 9.5 II. BITEMPORAL = 8 CM. III. BIMASTOID = 7 CM. 2. ANTEROPOSTERIOR DIAMETERS I. SUBOCCIPITOBREGMATIC = FROM BELOW THE OCCIPUT TO THE ANTEROIR FONTANELLE = 9.5 CM (THE NARROWEST AP DIAMETER)  II. OCCIPITOFRONTAL = FROM THE OCCIPITAL PROMINENCE TO THE BRIDGE OF THE NOSE = 12 CM. III. OCCIPITOMENTAL = FROM THE POSTERIOR FONTANELLE TO THE CHIN = 13.5 CM (THE WIDEST AP DIAMETER)  ** WHICH ONE OF THESE DIAMETERS IS PRESENTED AT THE BIRTH CANAL DEPENDS ON THE DEGREE OF FLEXION (ATTITUDE) THE FETAL HEAD ASSUMES PRIOR TO DELIVERY. IN FULL FLEXION, ( VERY GOOD ATTITUDE WHEN THE CHIN IS FLEXED ON THE CHEST), THE SMALLEST SUBOCCIPITOBREGMATIC DIAMETER IS THE ONE PRESENTED AT THE BIRTH CANAL. IF IN POOR FLEXION, THE WIDEST OCCIPITOMENTAL DIAMETER WILL BE THE ONE PRESENTED & WILL GIVE MOTHER & BABY MORE PROBLEMS. ENGAGEMENT = REFERS TO THE SETTLING OF THE PRESENTING PART OF THE FETUS FAR ENOUGH INTO THE PELVIS TO BE AT THE LEVEL OF THE ISCHIAL SPINES , A MIDPOINT OF THE PELVIS. DESCENT TO THIS POINT MEANS THAT THE WIDEST PART OF THE FETUS (THE BIPARIETAL DIAMETER IN A CEPHALIC PRESENTATION, THE INTERTROCHANTERIC DIAMETER IN A BREECH PRESENTATION) HAS PASSED THROUGH THE PELVIS OR THE PELVIC INLET HAS BEEN PROVEN ADEQUATE FOR BIRTH. IN A PRIMIPARA, NONENGAGEMENT OF THE HEAD AT THE BEGINNING OF LABOR INDICATES A POSSIBLE COMPLICATION SUCH AS ABNORMAL PRESENTATION OR POSITION, ABNORMALITY OF THE FETAL HEAD, OR CEPHALOPELVIC DISPROPORTION (CPD). IN PRIMIPARAS, ENGAGEMENT MAY OR MAY NOT BE PRESENT AT THE BEGINNING OF LABOR. A PRESENTING PART THAT IS NOT ENGAGED IS SAID TO BE “ FLOATING”. ONE THAT IS DESCENDING BUT HAS NOT YET REACHED THE ISCHIAL SPINES CAN BE SAID TO BE “ DIPPING”. THE DEGREE OF ENGAGEMENT IS ASSESSED BY VAGINAL & CERVICAL EXAMINATION. STATION = REFERS TO THE RELATIONSHIP OF THE PRESENTING PART OF THE FETUS TO THE LEVEL OF THE ISCHIAL SPINES. **STATION 0 = PRESENTING PART IS AT THE LEVEL OF THE ISCHIAL SPINES ( SYNONYMOUS TO ENGAGEMENT) ** STATION -1 = PRESENTING PART IS 1CM ABOVE THE ISCHIAL SPINES ** STATION +1 = PESENTING PART IS 1CM BELOW THE ISCHIAL SPINES  ** STATION +3 OR +4 = THE PRESENTING PART IS AT THE PERINEUM & CAN BE SEEN IF THE VULVA IS SEPARATED; SYNONYMOUS TO “CROWNING”. ( ENCIRCLING OF THE LARGEST DIAMETER OF THE FETAL HEAD BY THE VULVAR RING). FETAL LIE/ PRESENTATION = IS THE RELATIONSHIP BETWEEN THE LONG AXIS OF THE FETUS TO THE LONG AXIS OF THE MOTHER. PRESENTING PART = REFERS TO THE FETAL PART THAT FIRST ENTERS THE MATERNAL PELVIS & COVER THE INTERNAL OS. 2 KINDS OF LIE 1. LONGITUDINAL LIE = LONG AXIS OF THE FETUS IS PARALLEL TO THE LONG AXIS OF THE MOTHER. 2. TRANSVERSE LIE = LONG AXIS OF THE FETUS IS PERPENDICULAR TO THE LONG AXIS OF THE MOTHER  CAUSES OF TRANSVERSE LIE: 1.MULTIPARITY 2. CONTRACTED PELVIS 3. PLACENTA PREVIA  TYPES OF FETAL PRESENTATION A.VERTICAL/ LONGITUDINAL LIE: 1. CEPHALIC PRESENTATION (96%)= MEANS THAT THE HEAD IS THE BODY PART THAT FIRST CONTACTS THE CERVIX. a. VERTEX/ OCCIPUT ( MOST COMMON) = THE HEAD IS FULLY FLEXED ON THE CHEST MAKING THE PARIETAL BONES OR THE SPACE BETWEEN THE FONTANELLES, THE POSITION = REFERS TO THE RELATIONSHIP OF THE PRESENTING PART TO A SPECIFIC QUADRANT OF THE WOMAN’S PELVIS.  4 QUADRANTS OF THE MATERNAL PELVIS: A. RIGHT ANTERIOR B. LEFT ANTERIOR C. RIGHT POSTERIOR D. LEFT POSTERIOR E. TRANSVERSE 4 PARTS OF THE FETUS CHOSEN AS LANDMARKS: 1.OCCIPUT “O”- VERTEX PRESENTATION 2. MENTUM “M”(CHIN) –FACE PRESENTATION 3. SACRUM “ Sa”– IN BREECH PRESENTATION 4. SCAPULA “Sc”– IN SHOULDER PRESENTATION POSITION IS IMPORTANT BECAUSE IT INFLUENCES THE PROCESS & EFFICIENCY OF LABOR. TYPICALLY, A FETUS DELIVERS FASTEST FROM AN LOA – LEFT OCCIPITO ANTERIOR ( MOST COMMON) & ROA – RIGHT OCCIPITO ANTERIOR ( 2ND MOST COMMON). POSTERIOR POSITIONS MAY BE MORE PAINFUL FOR THE MOTHER BECAUSE THE ROTATION OF THE FETAL HEAD PUTS PRESSURE ON THE SACRAL NERVES, CAUSING SHARP BACK PAINS.(“ BACK LABOR”) II THE PASSAGEWAY/ THE BIRTH CANAL A.THE PELVIS TYPES OF PELVIS 1. GYNECOID = NORMAL FEMALE PELVIS; THE INLET IS WELL ROUNDED FORWARD & BACKWARD; THE PUBIC ARCH IS WIDE; THIS PELVIS IS IDEAL FOR CHILDBIRTH 2. ANDROID = “ MALE PELVIS”; THE PUBIC ARCH IN THIS PELVIS TYPE FORMS AN ACUTE ANGLE MAKING THE LOWER DIMENSIONS OF THE PELVIS NARROW. A FETUS MAY HAVE DIFFICULTY EXITING FROM THIS TYPE OF PELVIS. (LEAST FAVORABLE) 3. ANTHROPOID PELVIS = “ APE-LIKE PELVIS” ; THE TRANSVERSE DIAMETER IS NARROW & THE AP DIAMETER OF THE INLET IS LARGER THAN NORMAL. 4. PLATYPELLOID = “ FLATTENED PELVIS” THE INLET IS AN OVAL SMOOTHLY CURVED, BUT THE AP DIAMETER IS SHALLOW. A FETAL HEAD MIGHT NOT ABLE TO ROTATE TO MATCH THE CURVES OF THE PELVIC CAVITY. DIVISIONS: 1.FALSE PELVIS = “ SUPERIOR HALF”; SUPPORTS THE UTERUS DURING THE LATE MONTHS OF PREGNANCY & AIDS IN DIRECTING THE FETUS INTO THE TRUE PELVIS FOR BIRTH. 2.TRUE PELVIS = : INFERIOR HALF”; FORMED BY THE PUBES IN FRONT, THE ILIA & THE ISCHIA ON THE SIDES & THE SACRUM & COCCYX BEHIND. ** THE FALSE PELVIS IS DIVIDED FROM THE TRUE PELVIS ONLY BY AN IMAGINARY LINE: THE LINEA TERMINALIS DRAWN FROM THE SACRAL PROMINENCE AT THE BACK TO THE SUPERIOR ASPECT OF THE SYMPHYSIS PUBIS AT THE FRONT OF THE PELVIS. ** a.PELVIC INLET = ENTRANCE TO THE TRUE PELVIS, OR THE UPPER RING OF BONE THROUGH WHICH THE FETUS MUST FIRST PASS TO BE BORN VAGINALLY. ITS TRANSVERSE DIAMETER IS WIDER THAN ITS AP DIAMETER. THUS: ** TRANSVERSE DIAMETER = 13.5 CM ** AP DIAMETER = 11 CM b. MIDPELVIS/ PELVIC CAVITY = THE SPACE BETWEEN THE INLET & THE OUTLET. THIS IS NOT A STRAIGHT BUT A CURVED PASSAGE. c. PELVIC OUTLET = THE INFERIOR PORTION OF THE PELVIS. THE MOST IMPORTANT DIAMETER OF THE OUTLET IS ITS TRANSVERSE OR BI-ISCHIAL DIAMETER( DISTANCE BET THE TWO ISCHIAL TUBEROSITIES) WHICH IS ABOUT 11.5 CM > AP DIAMETER 9.5 TO 11.5 CM MEASUREMENTS: a. DIAGONAL CONJUGATE = DISTANCE BETWEEN THE MIDPOINT OF THE SACRAL PROMONTORY TO THE LOWER MARGIN OF THE SYMPHYSIS PUBIS. ( MEASURED BY INTERNAL EXAMINATION) AVERAGE = 12.5 TO 13 CMS B. TRUE CONJUGATE/ CONJUGATA VERA = THE DISTANCE BETWEEN THE MIDPOINT OF THE SACRAL PROMONTORY TO THE UPPER MARGIN OF THE SYMPHYSIS PUBIS. VERY IMPORTANT MEASUREMENT BECAUSE IT IS THE DIAMETER OF THE PELVIC INLET. AVERAGE = 11.5 CM. c. OBSTETRIC CONJUGATE = DISTANCE BETWEEN THE MIDPOINT OF SACRAL PROMONTORY TO THE MIDLINE OF THE SYMPHYSIS PUBIS WHICH IS ASCERTAINED BY SUBTRACTING 1 TO 1.5 CM FROM THE DIAGONAL CONJUGATE.. AVERAGE = 11 CM III POWERS a. INVOLUNTARY UTERINE CONTRACTIONS b. VOLUNTARY UTERINE CONTRACTIONS PHASES OF UTERINE CONTRACTIONS: 1.INCREMENT = WHEN THE INTENSITY OF THE CONTRACTIONS INCREASES 2. ACME = WHEN THE CONTRACTIONS ARE AT ITS STRONGEST 3. DECREMENT = WHEN THE INTENSITY DECREASES CHARACTERISTICS OF UTERINE CONTRACTIONS: 1. DURATION = REFERS TO THE LENGTH OF CONTRACTIONS STARTING FROM THE BEGINNING OF ONE CONTRACTION TO THE END OF SAME CONTRACTION. 2. FREQUENCY = STARTS FROM THE BEGINNING OF ONE CONTRACTION TO THE BEGINNING OF THE NEXT CONTRACTION. 3. INTERVAL = REFERS TO THE REGULARITY OF CONTRACTIONS. IT STARTS FROM THE END OF ONE CONTRACTION TO THE BEGINNING OF THE NEXT CONTRACTION. 4. INTENSITY = REFERS TO THE STRENGTH OF UTERINE CONTRACTIONS. a. MILD – IF THE FUNDUS IS SLIGHTLY TENSE & EASY TO INDENT WITH FINGERTIPS b. MODERATE – IF THE FUNDUS IS FIRM & IS DIFFICULT TO INDENT WITH FINGERTIPS c. STRONG – IF THE FUNDUS IS HARD & RIGID & ALMOST IMPOSSIBLE TO INDENT. ** AS LABOR CONTRACTIONS PROGRESS & BECOME REGULAR & STRONG, THE UTERUS GRADUALLY DIFFERENTIATES ITSELF INTO TWO DISTINCT FUNCTIONING AREAS. THE UPPER PORTION BECOMES THICKER & ACTIVE, PREPARING TO EXERT ITS STRENGTH NECESSARY TO EXPEL THE FETUS. THE LOWER PORTION BECOME THIN WALLED, SUPPLE & PASSIVE, SO THE FETUS CAN BE EXPELLED OUT EASILY.THE BOUNDARY BETWEEN THE TWO PORTIONS BECOMES MARKED BY A RIDGE CALLED “ PHYSIOLOGIC RETRACTION RING” IN A DIFFICULT LABOR , THE RING MAY BECOME PROMINENT & OBSERVABLE AS AN ABDOMINAL INDENTATION. THIS IS TERMED AS “PATHOLOGIC RETRACTION RING” OR “BANDL’S RING” A DANGER SIGN THAT SIGNIFIES IMPENDING RUPTURE OF THE LOWER UTERINE SEGMENT. CERVICAL CHANGES: - EVEN MORE MARKED THAN THE CHANGES IN THE BODY OF THE UTERUS ARE TWO CHANGES THAT OCCUR IN THE CERVIX: 1.EFFACEMENT = SHORTENING & THINNING OF THE CERVICAL CANAL. NORMALLY THE CANAL IS 1-2 CM LONG. WITH EFFACEMENT, THIS CANAL VIRTUALLY DISAPPEARS.THIS IS EXPRESSED IN PERCENTAGE ( % ) 2. DILATATION – REFERS TO THE ENLARGEMENT OF THE CERVICAL CANAL FROM AN OPENING A FEW MMLLIMETERS WIDE TO ONE LARGE ENOUGH ( APPROXIMATELY 10 CM) TO PERMIT PASSAGE OF THE FETUS. IV PLACENTAL IMPLANTATION a. IF THE PLACENTA HAS IMPLANTED NORMALLY IN THE FUNDAL PORTION OF THE UTERUS ( ANTERIOR OR POSTERIOR), IT RARELY CAUSE TROUBLE DURING LABOR & DELIVERY. b. WHEN MALIMPLANTATION OF THE PLACENTA OCCURS IN THE LOWER UTERINE SEGMENT, IT NECESSITATES MEDICAL OR SURGICAL INTERVENTION. PRELIMINARY/ PRODROMAL SIGNS OF LABOR A. LIGHTENING = THE SETTLING OF THE FETAL HEAD INTO THE PELVIC BRIM. IN PRIMIS, IT OCCURS 2 WEEKS BEFORE EDC ( 10-14 DAYS). IN MULTIS, ON OR BEFORE LABOR ONSET.  RESULTS OF LIGHTENING: 1.INCREASE IN URINARY FREQUENCY 2. RELIEF OF ABDOMINAL TIGHTNESS & DIAPRAGMATIC PRESSURE 3. SHOOTING PAINS DOWN THE LEGS DUE TO PRESSURE ON THE SCIATIC NERVE. 4. INCREASE IN THE AMOUNT OF VAGINAL DISCHARGES 6. LOSS OF WEIGHT OF ABOUT 2-3 LBS ONE TO TWO DAYS BEFORE LABOR ONSET = DECREASE IN PROGESTERONE THUS DECREASE IN FLUID RETENTION 7. RIPENING OF THE CERVIX = FROM GOODEL’S SIGN THE CERVIX BECOMES “BUTTER SOFT” IN ADDITION, APPLY A WARM SALINE SATURATED OS ON THE PROLAPSED CORD TO PREVENT DRYING OF THE CORD. B. SHOW – THIS IS DUE TO PRESSURE OF THE DESCENDING PRESENTING PART OF THE FETUS WHICH CAUSES RUPTURE OF MINUTE CAPILLARIES IN THE MUCUS MEMBRANE OF THE CERVIX.BLOOD MIXES WITH MUCUS WHEN OPERCULUM ( MUCUS PLUG) IS RELEASED.  SIGNS OF LABOR UTERINE CONTRACTIONS – THE SUREST SIGN THAT LABOR HAS BEGUN IS THE INITIATION OF EFFECTIVE PRODUCTIVE UTERINE CONTRACTIONS. DIFFERENCES BETWEEN TRUE LABOR & FALSE LABOR: FALSE LABOR TRUE LABOR 1.CONTRACTIONS 1. MAY BE SLIGHTLY REMAIN IRREGULAR IRREGULAR AT FIRST BUT BECOME REGULAR IN A MATTER OF HRS. 2. GENERALLY 2. FIRST FELT IN THE CONFINED TO LOWER BACK & SWEEP THE ABDOMEN AROUND TO THE ABDOMEN IN A GIRDLE LIKE FASHION. 3. NO INCREASE 3. INCREASE IN DURATION, INTENSITY INTENSITY DURATION & FREQUENCY & FREQUENCY 4. OFTEN 4. CONTINUE NO DISAPPEARS MATTER WHAT IF THE WOMAN THE WOMAN’S AMBULATES LEVEL OF ACTIVITY WALKING INTENSIFIES CONTRACTIONS. 5. ABSENT 5. ACCOMPANIED BY CERVICAL CERVICAL CHANGES. EFFACEMENT & DILATATION ( MOST IMPORTANT DIFFERENCE) 6. NO BLOOD 6. BLOOD SHOW SHOW 7.PROGRESSIVE FETAL DESCENT  THEORIES OF LABOR ONSET: 1.OXYTOCIN STIMULATION THEORY – AS PREGNANCY NEARS TERM, OXYTOCIN PRODUCTION BY THE PPG INCREASE & AS A RESULT , THE UTERUS BECOME INCREASINGLY SENSITIVE TO OXYTOCIN. OXYTOCIN STIMULATES UTERINE CONTRACTIONS. 2. UTERINE STRETCH THEORY = ANY HOLLOW MUSCULAR ORGAN WHEN STRETCHED TO CAPACITY WILL CONTRACT & EMPTY. 3. PROGESTERONE DEPRIVATION THEORY - PROGESTERONE MAINTAINS PREGNANCY BY ITS RELAXANT EFFECT ON THE SMOOTH MUSCLES OF THE UTERUS.AS PREGNANCY NEARS TERM, PROGESTERONE PRODUCTION DECREASE. WHEN PROGESTERONE LEVEL DROPS, UTERINE CONTRACTION OCCURS. 4. THEORY OF THE AGING PLACENTA - AS THE PLACENTA AGES, IT BECOMES LESS EFFICIENT & AS A RESULT , IT PRODUCES LESS & LESS AMOUNT OF PROGESTERONE & ALLOWS CONCENTRATION OF PROSTAGLANDIN & ESTROGEN TO RISE STEADILY WHICH RESULTS TO RHYTHMIC REGULAR & STRONG UTERINE CONTRACTIONS. 5. PROSTAGLANDIN THEORY - WHEN PREGNANCY REACHES TERM, THE FETAL MEMBRANE PRODUCE LARGE AMOUNTS OF ARACHIDONIC ACID WHICH IS CONVERTED BY MATERNAL DECIDUA INTO PROSTAGLANDIN, ANOTHER HORMONE THAT INITIATES UTERINE CONTRACTIONS.  LENGTH OF LABOR: STAGE PRIMIS MULTIS 1ST STAGE 10-12 HRS 6-8 HRS 2ND STAGE 30MIN.2 HRS 20 TO 90 MIN AVE. 50 MIN AVE. 20 MIN 3RD STAGE 5 TO 20 MIN 5 TO 20 MIN 4TH STAGE 2 TO 4 HRS 2 TO 4 HRS  STAGES OF LABOR A.FIRST STAGE OF LABOR ( STAGE OF DILATATION) – FROM THE ONSET OF TRUE LABOR PAINS & ENDS WITH COMPLETE DILATATION OF THE CERVIX. (10 CM). 1.LATENT PHASE – DILATATION: 0-3 CMS INTENSITY: MILD & SHORT CONTRACTIONS DURATION:20-40 SECONDS INTERVAL: 15 – 20 MINS ELECTRONIC FETAL MONITORING: 1.EXTERNAL OR INDIRECT MONITORING a. APPLIED WHEN MEMBRANES ARE STILL INTACT SUCH AS TOCODYNAMOMETER AND UTERINE TRANSDUCER. 2. INTERNAL OR DIRECT MONITORING A. APPLIED WHEN MEMBRANES HAVE RUPTURED & CERVIX HAS DILATED 2-3 CM. ** MOTHER IS EXCITED WITH SOME DEGREE OF APPREHENSION BUT STILL WITH ABILITY TO COMMUNICATE. ** TAKES UP 8 OF THE 12 HOUR FIRST STAGE. 2. ACTIVE PHASE – DILATATION: 4 – 7 CMS. INTENSITY: MODERATE DURATION: 40 – 60 SECONDS INTERVAL: 3 -5 MINUTES ** THIS PHASE LASTS APPROXIMATELY 3 HOURS IN A NULLIPARA & 2 HOURS IN A MULTIPARA. ** ANESTHESIA IS GIVEN DURING THIS PHASE AT 5-6 CM DILATATION.  TYPES OF ANESTHESIA a.PARACERVICAL – TRANSVAGINAL INJECTION INTO EITHER SIDE OF THE CERVIX. PATIENT ON LITHOTOMY POSITION. COUPLED WITH A LOCAL ANESTHETIC, RESULTS IN A PAINLESS CHILDBIRTH ( UTERINE CONTRACTIONS ARE NOT FELT BY THE MOTHER) b. PUDENDAL – INJECTION THROUGH THE SACROSPINOUS LIGAMENT INTO POSTERIOR AREOLAR TISSUES TO REDUCE PERCEPTION OF PAIN DURING SECOND STAGE & MAKE MOTHER COMFORTABLE. PATIENT IS ON LITHOTOMY POSITION. SIDE EFFECT: ECCHYMOSIS = PURPLISH DISCOLORATION OF THE SKIN DUE TO BLOOD IN THE SUBCUTANEOUS TISSUES NURSING CARE: APPLY ICE BAG TO THE AREA ON THE FIRST DAY WHICH COULD REDUCE SWELLING. c. EPIDURAL – INJECTION OF LOCAL ANESTHETIC AT THE LUMBAR LEVEL OUTSIDE THE DURA MATER ** POST SPINAL HEADACHES MAY BE DUE TO LEAKAGE OF ANESTHETICS INTO THE CSF OR INJECTION OF AIR AT TIME OF NEEDLE INSERTION. NURSING MX: ** FLAT ON BED FOR 12 HOURS & INCREASE FLUID INTAKE. NURSING MX: - TURN TO SIDE - PROMPT ELEVATION OF LEGS - ADMINISTRATION OF VASOPRESSOR & O2 AS ORDERED  *** A SURE SIGN THAT THE BABY IS ABOUT TO BE BORN IS THE BULGING OF THE PERINEUM. IN GENERAL, PRIMIGRAVIDAS ARE TRANSPORTED FROM LR TO DR WHEN THERE IS BULGING OF THE PERINEUM ( 10 CM); MULTIPARAS ARE TRANSPORTED AT 7-8 CM CERVICAL DILATATION OR AT +1+2*** 3. TRANSITION PHASE – DILATATION: 8 – 10 CM INTENSITY: STRONG DURATION: 60 – 90 SECONDS INTERVAL: 2-3 MINUTES STATION: +1 +2 **WHEN THE MOOD OF THE WOMAN SUDDENLY CHANGES & THE NATURE OF THE CONTRACTIONS INTENSIFY** CHARACTERISTICS: 1.IF THE MEMBRANES ARE STILL INTACT, THIS PERIOD IS MARKED BY A SUDDEN GUSH OF AMNIOTIC FLUID, AS FETUS IS PUSHED TO THE BIRTH CANAL. 2. IF SPONTANEOUS RUPTURE DOES NOT OCCUR, AMNIOTOMY ( SNIPPING OF BOW WITH A STERILE POINTED INSTRUMENT TO ALLOW AMNIOTIC FLUID TO DRAIN) IS DONE TO PREVENT FETUS FROM ASPIRATING THE AMNIOTIC FLUID AS IT MAKES ITS DIFFERENT POSITION CHANGES. AMNIOTOMY HOWEVER CANNOT BE DONE IF STATION IS STILL AT “ MINUS” AS THIS CAN LEAD TO CORD COMPRESSION. 3. THERE IS AN UNCONTROLLABLE URGE TO PUSH WITH CONTRACTIONS, A SIGN OF AN IMPENDING SECOND STAGE OF LABOR. 4. PERINEAL PREPARATION – THE PUBIC HAIR ON THE LOWER HALF OF THE VULVA & THE PERINEUM IS REMOVED BY SHAVING TO MAKE IT CLEAN & TAUT. REASONS FOR ADMINISTRATION OF ENEMA: a. TO PREVENT INFECTION TO BOTH THE MOTHER & THE FETUS. b. IT HELPS TO INCREASE UTERINE CONTRACTIONS. c. PREVENTS POSTPARTUM DISCOMFORT d. TO FACILITATE THE DESCENT OF THE FETUS TO THE BIRTH CANAL. CONTRAINDICATIONS OF ENEMA: a. MALPRESENTATION & POSITION b. VAGINAL BLEEDING c. RUPTURED BAG OF WATERS d. CROWNING e. PLACENTA PREVIA  NOTE: CHECKING THE BLOOD PRESSURE SHOULD BE DONE MIDWAY BETWEEN CONTRACTIONS BECAUSE IT NORMALLY INCREASES DURING A CONTRACTION. FHR SHOULD NOT BE TAKEN DURING UTERINE CONTRACTIONS SINCE IT TENDS TO SLOW DOWN AS INDUCED BY THE COMPRESSION OF THE FETAL HEAD DURING UTERINE CONTRACTION. NURSING ALERT:ANY CHANGE IN THE FHR, THE FIRST NURSING ACTION IS TO CHANGE THE POSITION OF THE MOTHER”. NURSING ACTIONS: ** PRIMARILY COMFORT MEASURES** a. SACRAL PRESSURE ( APPLYING PRESSURE WITH THE HEEL OF THE HAND ON THE SACRUM) RELIEVES DISCOMFORT FROM CONTRACTIONS. b. PROPER BEARING DOWN TECHNIQUE. c. CONTROLLED CHEST ( COSTAL) BREATHING DURING CONTRACTIONS. D. EMOTIONAL SUPPORT B. SECOND STAGE OF LABOR ( STAGE OF EXPULSION) = BEGINS WITH COMPLETE DILATATION ( 10 CM) & ENDS WITH THE DELIVERY OF THE BABY. = MOST CRITICAL STAGE ON THE PART OF THE FETUS 2. FLEXION = AS DESCENT OCCURS, PRESSURE FROM THE PELVIC FLOOR CAUSES THE FETAL HEAD TO BEND FORWARD ONTO THE CHEST. THIS PERMITS THE SMALLEST AP DIAMETER (SUBOCCIPITOBREGMATIC DIAMETER) TO PRESENT IN THE OUTLET. 3. INTERNAL ROTATION – OCCIPUT ROTATES UNTIL IT IS SUPERIOR, OR JUST BELOW THE SYMPHYSIS PUBIS SO THE SMALLEST DIAMETER IS PRESENTED TO THE PELVIC OUTLET. 4. EXTENSION = AS THE HEAD COMES OUT, THE BACK OF THE NECK STOPS AT THE PUBIC ARCH & ACTS AS A PIVOT FOR THE REST OF THE HEAD. THE HEAD EXTENDS & THE FOREHEAD, NOSE, MOUTH & FINALLY THE CHIN APPEAR. 5. EXTERNAL ROTATION =( RESTITUTION) - AS THE HEAD IS BORN IT ROTATES BRIEFLY FROM THE POSITION IT OCCUPIED WHEN IT WAS ENGAGED. ** WHEN THE BIPARIETAL DIAMETER OF THE FETAL HEAD HAS PASSED THE PELVIC INLET, THE PALPABLE PORTION OF THE FETAL HEAD IS APPROXIMATELY AT STATION +2). ONE SHOULDER, IS ANTERIOR TO THE SYMPHYSIS PUBIS & THE OTHER IS POSTERIOR TO THE PELVIC FLOOR.) 6.EXPULSION = WITH THE DELIVERY OF THE SHOULDERS, THE REST OF THE BABY IS BORN EASILY & SMOOTHLY BECAUSE OF ITS SMALLER SIZE & BIRTH IS COMPLETED. NURSING CARE: a.WHEN POSITIONING LEGS IN LITHOTOMY POSITION, PUT THEM UP AT THE SAME TIME TO PREVENT INJURY TO THE UTERINE LIGAMENTS. b. AS SOON AS THE FETAL HEAD CROWNS, INSTRUCT THE MOTHER NOT TO PUSH BUT TO PANT INSTEAD ( RAPID & SHALLOW BREATHING), TO PREVENT RAPID EXPULSION OF THE BABY. c. IF PANTING IS DEEP & RAPID, CALLED HYPERVENTILATION,THE PATIENT WILL EXPERIENCE LIGHTHEADEDNESS & TINGLING SENSATION OF THE FINGERS LEADING TO CARPOPEDAL SPASMS BECAUSE OF RESPIRATORY ALKALOSIS. MX: - LET THE PATIENT BREATHE INTO A PAPER BAG TO RECOVER LOST CARBON DIOXIDE.( A CUPPED HAND WILL SERVE THE SAME PURPOSE) d. ASSIST IN EPISIOTOMY – INCISION MADE IN THE PERINEUM PRIMARILY TO: 1. PREVENT LACERATIONS 2. PREVENT PROLONGED & SEVERE STRETCHING OF MUSCLES SUPPORTING BLADDER OR RECTUM 3. REDUCE DURATION OF SECOND STAGE OF LABOR WHEN THERE IS HYPERTENSION & FETAL DISTRESS 4. ENLARGE OUTLET, AS IN BREECH PRESENTATION OR FORCEPS DELIVERY  TYPES OF EPISIOTOMY 1. MEDIAN - FROM MIDDLE PORTION OF THE LOWER VAGINAL BORDER DIRECTED TOWARDS THE ANUS. 2. MEDIOLATERAL – BEGINS IN THE MIDLINE BUT DIRECTED LATERALLY AWAY FROM THE ANUS. ** NATURAL ANESTHESIA IS USED IN EPISIOTOMY – MEANING NO ANESTHETIC IS INJECTED BECAUSE PRESSURE OF THE FETAL PRESENTING PART AGAINST THE PERINEUM IS SO INTENSE THAT NERVE ENDINGS FOR PAIN ARE MOMENTARILY DEADENED. e. APPLY THE MODIFIED RITGEN’S MANEUVER ** COVER THE ANUS WITH STERILE TOWEL & EXERT UPWARD & FORWARD PRESSURE ON THE FETAL CHIN. WHILE EXERTING GENTLE PRESSURE WITH TWO FINGERS ON THE HEAD TO CONTROL EMERGING HEAD. THIS WILL NOT ONLY SUPPORT THE PERINEUM THUS PREVENTING LACERATIONS BUT WILL ALSO FAVOR FLEXION SO THAT THE SMALLEST SUBOCCIPITOBREGMATIC DIAMETER OF THE FETAL HEAD IS PRESENTED. ** EASE THE HEAD OUT IN-BETWEEN CONTRACTIONS & IMMEDIATELY WIPE THE NOSE & MOUTH OF SECRETIONS TO ESTABLISH A PATENT AIRWAY. REMEMBER: ** THE FIRST PRINCIPLE IN THE CARE OF THE NEWBORN IS TO ESTABLISH & MAINTAIN A PATENT AIRWAY.** - THE HEAD SHOULD BE DELIVERED IN BETWEEN CONTRACTIONS. ** INSERT TWO FINGERS INTO THE VAGINA SO AS TO FEEL FOR THE PRESENCE OF A CORD LOOPED AROUND THE NECK ( NUCHAL CORD ). IF SO, BUT LOOSE, SLIP IT DOWN THE SHOULDERS OR UP OVER THE HEAD; BUT IF TIGHT, CLAMP CORD TWICE AN INCH APART, AND THEN CUT IN-BETWEEN. ** AS THE HEAD ROTATES, DELIVER THE ANTERIOR SHOULDER BY EXERTING A GENTLE DOWNWARD PUSH & THEN SLOWLY GIVE AN UPWARD LIFT TO DELIVER THE POSTERIOR SHOULDER. 14. FORCEP DELIVERY Management C. THIRD STAGE OF LABOR = STAGE OF PLACENTAL EXPULSION - BEGINS WITH THE DELIVERY OF THE INFANT TO THE DELIVERY OF THE PLACENTA. SIGNS OF PLACENTAL SEPARATION 1. CALKIN’S SIGN – UTERUS BECOMING ROUND & FIRM & GLOBULAR AGAIN, RISING HIGH TO THE LEVEL OF THE UMBILICUS. ( EARLIEST SIGN OF PLACENTAL SEPARATION) 2. SUDDEN GUSH OF BLOOD FROM THE VAGINA 3. LENGTHENING OF THE CORD FROM THE VAGINA TYPES OF PLACENTAL SEPARATION: 1. SCHULTZ – IF THE PLACENTA SEPARATES FIRST AT ITS CENTER & LAST AT ITS EDGES, IT TENDS TO FOLD ON ITSELF LIKE AN UMBRELLA & PRESENTS THE FETAL SURFACE WHICH IS SHINY. 80% OF PLACENTAS SEPARATE THIS WAY. “ SHINY FOR SCHULTZ” 2. DUNCAN – IF THE PLACENTA SEPARATES FIRST AT ITS EDGES, IT SLIDES ALONG THE UTERINE SURFACE & PRESENTS AT THE VAGINA WITH THE MATERNAL SURFACE WHICH IS RAW, RED, & IRREGULAR WITH THE RIDGES OR COTYLEDONS THAT SEPARATE BLOOD COLLECTION SPACES SHOWING. ONLY ABOUT 20% OF PLACENTAS SEPARATE THIS WAY. “ DIRTY FOR DUNCAN” NURSING CARE: 1.DO NOT HURRY THE EXPULSION OF THE PLACENTA BY FORCEFULLY PULLING OUT THE CORD OR DOING VIGOROUS FUNDAL PUSH AS THIS CAN CAUSE UTERINE INVERSION. 2. TRACT THE CORD SLOWLY, WINDING IT AROUND THE CLAMP UNTIL THE PLACENTA SPONTANEOUSLY COMES OUT ,ROTATING IT SLOWLY SO THAT NO MEMBRANES ARE LEFT INSIDE THE UTERUS. A METHOD CALLED “ BRANDT ANDREW’S MANEUVER” 3. TAKE NOTE OF THE TIME OF PLACENTAL DELIVERY. IT SHOULD BE DELIVERED WITHIN 15 TO 20 MINUTES AFTER THE DELIVERY OF THE BABY, OTHERWISE REFER IMMEDIATELY TO THE PHYSICIAN AS THIS CAN CAUSE SEVERE BLEEDING IN THE MOTHER. ** IF BLEEDING OCCURS & THE PLACENTA CANNOT BE DELIVERED, MANUAL EXTRACTION OF THE PLACENTA IS INDICATED ** 4. INSPECT FOR COMPLETENESS OF COTYLEDONS; ANY PLACENTAL FRAGMENT RETAINED CAN ALSO CAUSE SEVERE BLEEDING & POSSIBLE DEATH. ( FIRST NURSING ACTION IN THE 3RD STAGE OF LABOR). 5. PALPATE THE UTERUS TO DETERMINE DEGREE OF CONTRACTION. IF RELAXED, BOGGY OR NON CONTRACTED; THE FIRST NURSING ACTION IS TO MASSAGE GENTLY & PROPERLY. AN ICE CAP OVER THE ABDOMEN WILL ALSO HELP CONTRACT THE UTERUS SINCE COLD CAUSES VASOCONSTRICTION. 6. INJECT OXYTOXICS, METHERGIN OR SYNTOCINON IM TO MAINTAIN UTERINE CONTRACTIONS, THUS PREVENT HEMORRHAGE. NOTE: OXYTOXICS ARE NOT GIVEN BEFORE PLACENTAL DELIVERY BECAUSE PLACENTAL ENTRAPMENT COULD OCCUR. DO NOT GIVE METHERGIN IF BP IS 130/100 OR ABOVE. 7. INSPECT THE PERINEUM FOR LACERATIONS. ANYTIME THE UTERUS IS FIRM FOLLOWING PLACENTAL DELIVERY, YET BRIGHT RED VAGINAL BLEEDING IS GUSHING FORTH FROM THE VAGINAL OPENING, SUSPECT LACERATIONS.  CATEGORIES OF LACERATIONS 1.FIRST DEGREE – INVOLVES THE VAGINAL MUCUS MEMBRANES & SKIN OF THE PERINEUM & THE FOURCHETTE. 2. SECOND DEGREE – INVOLVES NOT ONLY THE VAGINAL MUCUS MEMBRANES & SKIN BUT ALSO THE MUSCLES. 3. THIRD DEGREE – INVOLVES NOT ONLY THE RECTAL SPHINCTER OF THE RECTUM, MUSCLES, VAGINAL MUCUS MEMBRANES & SKIN BUT ALSO THE MUCUS MEMBRANES OF THE RECTUM. D. FOURTH STAGE OF LABOR – STAGE OF PUERPERIUM / STAGE OF VIGILANCE -SAID TO BE THE MOST CRITICAL FOR THE MOTHER BECAUSE OF UNSTABLE VITAL SIGNS. = STARTS IMMEDIATELY AFTER THE DELIVERY OF THE FETUS UP TO 4 HOURS & IS COMPLETED WHEN THE REPRODUCTIVE TRACT HAS RETURNED TO ITS NON PREGNANT CONDITION PUERPERIUM / POSTPARTUM STAGE PUERPERIUM / POSTPARTUM STAGE  = STARTS IMMEDIATELY AFTER THE DELIVERY OF THE FETUS UP TO 4 HOURS & IS COMPLETED WHEN THE REPRODUCTIVE TRACT HAS RETURNED TO ITS NON PREGNANT CONDITION PUERPERIUM / POSTPARTUM = REFERS TO THE SIX TO EIGHT WEEK PERIOD AFTER THE DELIVERY OF THE BABY. INVOLUTION = THE RETURN OF THE REPRODUCTIVE ORGANS TO THEIR PRE- PREGNANT STATE.( 6 WEEKS) ASSESSMENT: 1.FUNDUS - SHOULD BE CHECKED EVERY 15 MINUTES FOR 1 HOUR THEN EVERY 30 MINUTES FOR THE NEXT 4 HOURS. FUNDUS SHOULD BE FIRM, IN THE MIDLINE, & DURING THE FIRST 12 HOURS POST PARTUM, IS A LITTLE ABOVE THE UMBILICUS. 2. LOCHIA – UTERINE DISCHARGE CONSISTING OF BLOOD, DECIDUAS, WBC & MUCUS. SHOULD BE MODERATE IN AMOUNT.  PATTERN OF LOCHIA: 1.RUBRA = 0-3 DAYS , DARK RED & MODERATE IN AMOUNT, SMALL CLOTS, FLESHY STALE ODOR. 2. SEROSA = 4 -7 DAYS ; PINK OR BROWNISH IN COLOR, NO CLOTS, NO ODOR ( UNLESS POOR HYGIENE) 3. ALBA = 1 – 3 WEEKS; CREAM TO YELLOWISH IN COLOR; MINIMAL IN AMOUNT; NO ODOR; NO CLOTS NOTES ON LOCHIA: a.PATTERN SHOULD NOT REVERSE b. IT SHOULD APPROXIMATE MENSTRUAL FLOW c. IT HAS THE SAME FLESHY ODOR AS MENSTRUAL BLOOD. d. IT SHOULD NEVER BE ABSENT, REGARDLESS OF THE METHOD OF DELIVERY. ( NSD OR CS) 3. BLADDER = A FULL BLADDER IS EVIDENCED BY A FUNDUS WHICH IS RIGHT TO THE MIDLINE 4.PERINEUM – IS NORMALLY TENDER , DISCOLORED ( ECCHYMOTIC) & EDEMATOUS. ( APPLY ICE BAG TO THE PERINEUM IMMEDIATELY). IT SHOULD BE CLEAN WITH INTACT SUTURES. 5. ROOMING – IN CONCEPT – ( PRIMARILY TO PROMOTE BONDING). 4. BLOOD PRESSURE – TAKEN EVERY 15 MINUTES FOR 1ST HR; THEN EVERY 30 MINUTES DURING THE 2ND HOUR  *** IMMEDIATE MEDICAL INTERVENTION IS NECESSARY IF ANY OF THE FOLLOWING OCCURS: 1. MARKED BLEEDING PERSISTS – BLOOD SOAKS A PERINEAL PAD IN 15 MINUTES REGARDLESS OF WHETHER THE BLEEDING IS ACCOMPANIED BY A CHANGE IN VITAL SIGNS, MATERNAL COLOR OR BEHAVIOR. 2. COMPLAINTS OF LIGHTHEADEDNESS & BLURRING OF VISION. 3. ASHEN COLOR / PALLOR 4. EXHIBITS AIR HUNGER 5. COLD CLAMMY SKIN 6. RESTLESSNESS 7. DECREASED BLOOD PRESSURE 8. INCREASED BLOOD PRESSURE 9. INCREASED PR & RR EMERGENCY MX & INTERVENTION: 1. CALL FOR HELP 2. TURN WOMAN TO HER LEFT & CHECK FUNDUS OF THE UTERUS FOR FIRMNESS 3. INCREASE IV FLOW & ADD OXYTOCIN AS PER DOCTORS ORDER 4. ELEVATE THE FOOT PART OF THE BED TO ALLOW THE FAST RETURN OF THE BLOOD TO THE UPPER PART OF THE BODY 5. ADMINISTER OXYGEN 5. GENITAL CHANGES – UTERINE INVOLUTION IS ASSESSED BY MEASURING THE FUNDIC HEIGHT BY FINGERBREADTHS (=1 CM). ON POSTPARTUM DAY 1 ( PPD 1) = FUNDUS IS ONE FINGERBREADTH BELOW THE UMBILICUS; ON PPD 2, 2 FINGERBREADTHS BELOW THE UMBILICUS & SO FORTH UNTIL ON DAY 10, IT CAN NO LONGER BE PALPATED BECAUSE IT IS ALREADY BEHIND THE SYMPHYSIS PUBIS. ** TO ENCOURAGE RETURN OF THE UTERUS TO ITS USUAL ANTEFLEXED POSITION, PRONE & KNEE CHEST POSITIONS ARE ADVISED. 6. AFTERPAINS / AFTERBIRTH PAINS = STRONG UTERINE CONTRACTIONS FELT MORE PARTICULARLY BY MULTIS,THOSE WHO DELIVERED LARGE BABIES, & THOSE WHO BREASTFEED BECAUSE OF OXYTOCIN PRODUCTION. IT WILL BE RELIEVED IN 3 -4 DAYS. POSTPARTUM PSYCHOLOGICAL ADAPTATION: 1. TAKING- IN PHASE = 1 – 3 DAYS POSTPARTUM WHEN MOTHER RELIES ON OTHERS TO CARE FOR HER & HER NEWBORN.PREOCCIPIED WITH SELF & OWN NEEDS ( FOOD & SLEEP), CLIENT MAY VERBALIZE HER FEELINGS REGARDING RECENT DELIVERY. HESITANT ABOUT MAKING DECISIONS. 2. TAKING – HOLD PHASE = 4 – 7 DAYS POSTPARTUM WHEN MOTHER BEGINS TO INITIATE ACTIONS & DECISIONS;DEPENDENCY /INDEPENDENCY; READY FOR MOTHERING ROLE; POST- PARTUM BLUES – (AN OVERWHELMING FEELING OF SADNESS THAT CANNOT BE ACCOUNTED FOR) MAY BE OBSERVED. COULD BE DUE TO HORMONAL CHANGES, FATIGUE OR FEELINGS OF INADEQUACY IN TAKING CARE OF A NEW BABY. MX: - EXPLAIN THAT IT IS NORMAL & THAT CRYING COULD BE THERAPEUTIC. BUT IF POSTPARTUM BLUES EXTEND BEYOND TWO WEEKS, IT COULD LEAD TO POSTPARTUM DEPRESSION & POSTPARTUM PSYCHOSIS ;THEREFORE CONSTANT MONITORING SHOULD BE DONE TO THE MOTHER. IMPLICATION: PROVIDE PSYCHOLOGICAL SUPPORT. 1. LETTING –GO PHASE = 10 DAYS - WOMAN ATTAINS COMPLETE INDEPENDENCE; ASSUMING NEW ROLES AND RESPONSIBILITIES