CMCA-LEC-MIDTERM-Kyungmins-Reviewer PDF

CARE OF MOTHER, CHILD ADOLESCENT (LEC) INTRA – PARTAL CARE Lie LABOR, PARTURATION RELATED TERMINOLOGIES: relationship of the long axis of the fetus to the lo...

CARE OF MOTHER, CHILD ADOLESCENT (LEC) INTRA – PARTAL CARE Lie LABOR, PARTURATION RELATED TERMINOLOGIES: relationship of the long axis of the fetus to the long axis of the mother Pre – Term Lightening Before the fetus is mature. descent of the fetus towards the pelvic Post – Term inlet before the onset of labor. Delayed labor begins after fetus and Lochia placenta has pas the labor time. Vaginal discharge after birth. (Lochia: Amniotomy Rubra, Serosa, Alba) (Amniotic fluid - bag of water) artificial Molding rupture of the amniotic sac. shaping of the fetal head during Attitude movement through birth canal. Relationship of the fetal body parts to Position one another (flexion and extension) relationship of assigned area of the Bloody Show presenting part or landmark of the natural pelvis. has cervical mucus present and blood from the ruptured capillaries. Presentation Crowning fetal part that first enters the pelvis inlet. (Face presentation and occiput) appearance of the fetal head at the vaginal opening. (Malapit na sa 2nd Station stage) measurement of the fetal descent in Engagement relation to the ischial spine. the descent of the widest diameter of Sutures the fetal descending part of at least 0 or the level of the ischial spine. (Above 0 is membranous phases where bones of positive) the skull meet. Episiotomy Effacement surgical incision of the perineum. thinning of the cervical wall. Episiorrhaphy Dilation surgical repairing after delivery. enlargement of the external cervical OS (ischium - mouth of the cervix) Fontanel ATTITUDE: the intersection of suture connecting the Flexion - normal uterine attitude. fetal skull bones. Extension - tends to present larger fetal diameters. PRELIM 1 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) LIE: Longitudinal or Vertical Transverse or Horizontal PRESENTATION: portion of the fetus that enters the pelvic inlet first. Cephalic - head first. STATION: FOUR VARIATIONS OF CEPHALIC: 1. Vertex the measurement of the progress of 2. Military descent of the centimeters above or 3. Brow below the midplane from the presenting 4. Face part to the ischial part. Station 0 - at ischial spine. Breech - buttocks present first. Delivery by Minus station - above ischial spine. cesarean may be required. Plus, station - below ischial spine. COMPLETE VARIETIES: 1. Frank FOUR STAGES OF LABOR 2. Complete STAGE 1: DILATION STAGE INCOMPLETE VARIETIES: LATENT PHASE 1. Single footing 2. Double footing Longest for both nulliparous and 3. Footing frank multiparous. 4. Kneeling Mother is Talkative Shoulder - fetus is in transverse lie, arm back, CERVICAL DILATION: 1 – 4 CM abdomen or side could be present. Cesarean may be required. UTERINE CONTRACTIONS: 15 – 30 MINS Presenting part - the specific felt structure DURATION: 15 – 30 SECONDS lying nearest to the cervix. KEY INTERVENTION: POSITION: Encourage voiding every 1 to hours. relationship of assigned area of the Assist in comfort measures, changes in presenting part or landmark to the position and ambulation. maternal pelvis. ACTIVE PHASE CERVICAL DILATION: 4 – 7 CM UTERINE CONTRACTIONS: 3 – 5 MINS DURATION: 30 – 60 SECONDS PRELIM 2 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) KEY INTERVENTION: KEY INTERVENTION: Promote comforts with back rubs, sacral Examine placenta for cotyledons and pressure, pillow support and position membranes to verify it is intact. changes Assess for shivering. Provide warmth and comfort. TRANSITION PHASE Promote mother and child bonding. Mother becomes tired, restless, irritable STAGE 4: POSTPARTUM STAGE and feels out of control. Period of time from 1 – 4 hours after CERVICAL DILATION: 8 – 10 cm delivery. UTERINE CONTRACTIONS: 2 – 3 min Fundus remains firm and contracted. Vital signs return to pre labor level DURATION: 45 – 90 seconds Lochia is moderate or scant and red. KEY INTERVENTION: KEY INTERVENTION: Wake mother at the beginning of the Assessment q15 x hr then q30 x 1hr and contraction so she can begin breathing 1 x hrs. pattern. Apply ice packs to lower abdominal Assess the amniotic fluid. area. STAGE 2: DELIVERY OR BIRTH STAGE Support breast feeding. Increase bloody show. MECHANISM OF LABOR: Mother feels urge to bear down. ENGAGEMENT CERVICAL DILATION: Complete. Progress of (Lightening or dropping) is the Labor mechanism whereby the fetus nestles UTERINE CONTRACTIONS: 2 – 3 mins. into the pelvis. Strong intensity. DESCENT DURATION: 60 – 70 seconds Is the process that the fetal head KEY INTERVENTION: undergoes as it begins its journey through the pelvis. Assessment every 5 mins. (FHR) Prepare for birth. FLEXION STAGE 3: PLACENTAL STAGE Is the process of the fetal head’s nodding forward toward the fetal chest. Birth of placenta 5 – 30 minutes after birth of the baby. INTERNAL ROTATION Uterine fundus remains firm, located 2 finger breaths below the umbilicus Occurs most commonly from the occiput transverse position, assumed at PLACENTAL MECHANISM: engagement into the pelvis, to the occipitoanterior while continuously Schultze Mechanism - shiny part. descending Separation is center to the side. Duncan Mechanism - dirty side. Separation is side to the center. PRELIM 3 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) EXTENSION INDUCTION Enables the head to emerge when the An irritation of the uterine contraction fetus is in cephalic position. that may stimulates labor may be It begins after the head crowns if accomplished by oxytocin (PITOCIN) cephalic position and completes when FORCEPS DELIVERY the head passes under symphysis pubis to the perineum. VACUUM EXTRACTION RESTITUTION LABOR LABOR Realignment of the fetal head with the body after the head emerges. Process by which the mature product of conception is expelled from the uterus EXTERNAL ROTATION through the birth canal. Shoulders externally rotate after the Dry Labor head emerges and restitution occurs, so False Labor that the shoulders are in the True Labor anteroposterior diameter of the pelvis. Induce Labor EXPULSION Precipitate Labor Premature Labor Is the birth of the entire body Prolonged Labor OBSTETRICAL PROCEDURES Spontaneous Labor BISHOPS SCORE: THEORIES OF LABOR ONSET: Uterine Stretch or Mechanical distention Theory. Any hallow organ when stretched to capacity will necessarily contract and empty. Result from prostaglandin release. AMNIOTOMY Mechanical Irritation Theory. (Amniotic fluid - bag of water) artificial Pressure on the nerve endings on the rupture of the amniotic sac. cervix from the presenting part causes EPISIOTOMY labor pains. surgical incision of the perineum Oxytocin Theory MIDLINE INCISION Oxytocin released by the pituitary gland MIDIOLATERAL INCISION. initiates contraction. CERVICAL RIPENING Progesterone Deprivation Theory To ripen (soften) the cervix Change in ratio of estrogen and prostaglandins medication that may be progesterone – decreasing used to caused cervical ripening. progesterone stimulates uterine Dinoprostone (Cervidil, Prepidil, Prostin) contraction. PRELIM 4 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) Placental Age – Triggering contractions. CHANGE WITH MOVEMENT: Contractions may stop when walking or Prostaglandin Theory resting or they may stop with a change A precursor from the fetal adrenal of position. glands is conjugated in the placenta into STRENGTH OF CONTRACTIONS: estrogen. Usually weak and do not get much As it reaches a high level, prostaglandin stronger, or may start strong and get precursor is converted into weaker. prostaglandin which then acted on the PAIN OF CONTRACTIONS: Usually felt myometrium to contract only in the front. REMEMBER: Once membranes has ruptured: LABOR CONTRACTION: Labor is inevitable and will set in within TIMING OF CONTRACTIONS: Come at 24 hours. regular times and get closer together Infection can easily set in over time. Each last about 30 to 70 Occurrence of umbilical cord seconds. compression or prolapsed. CHANGE WITH MOVEMENT: Contractions continue despite PRELIMINARY SIGN OF LABOR: movement or resting. STRENGTH OF CONTRACTIONS: Get LIGHTENING steadily stronger. Occurs approximately 10 to 14 days PAIN OF CONTRACTIONS: Usually before the labor begins. starts in the back and moves to the Primiparas occurs early front. Multiparas - usually occurs on the day of RIPENING OF THE CERVIX the labor or eve after her labor has begun. seen only on pelvic examination. Goodell’s sign - at term, it can be SIGNS: described as butter-soft. a) Increase in abdominal pressure SIGNS OF TRUE LABOR b) Shooting leg pains c) Increased amounts of vaginal discharge UTERINE CONTRACTIONS d) Urinary frequency the surest sign that labor has begun is INCREASED LEVEL OF ACTIVITIES the initiation of effective, productive, involuntary uterine contractions. due to an increase in epinephrine release that is initiated by a decrease in TYPES OF UTERINE CONTRACTIONS: progesterone produced by the placenta a) Typical - 2-5 minutes; lasts 30-90 to prepare the woman’s body for the seconds work of labor ahead. b) Hypotonic - during contraction the BRAXTON HICKS CONTRACTION: pressure is evident 10mmHg c) Hypertonic - 40-50mmHg, does not TIMING OF CONTRACTIONS: Does allow the uterus to rest between not come regularly and do not get closer contraction together. PRELIM 5 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) SHOW ASSESSMENT OF UTERINE CONTRACTIONS: Mucus Plug vs. Bloody Show To determine the beginning of RUPTURES OF MEMBRANES contraction without a monitor, rest a may be experienced as either a sudden hand on the woman’s abdomen at the gush or scanty, slow seeping of clear fundus of the uterus very gently to fluid from the vagina. sense the gradual tensing and upward Will induce after 24 hours if labor has rising of the fundus that accompanies a not occurred. contracting. Low = Risk POSSIBLE COMPLICATIONS: ASSESS CONTRACTIONS: Intrauterine Infection Prolapsed of the Umbilical Cord 30 mins = latent phase Cord compression 15 to 30 mins = active phase 15 mins = transition phase UTERINE CHANGES CONTRACTION CYCLE Upper Uterine Segment: becomes thick and active in order to expel fetus. THREE (3) PHASES OF CONTRACTION: Lower Uterine Segment: becomes a. Increment contraction - begins at the thin-walled, supple and passive so that fundus and spread throughout the fetus can be pushed out so easily. uterus. FETAL RESPONSE b. Acme or Peak - contraction is most intense. PLACENTAL CIRCULATION: c. Decrement - uterine relaxation. Maternal blood supply to the placenta - INTENSITY OF CONTRACTIONS: intermittently stops during strong contraction. a) Mild - the uterus is contracting but does Fetal Hgb - are more readily to take in not become more than minimally tense. oxygen and releases carbon dioxide. Described as like tip of the nose. b) Moderate- the uterus feels firm. Placental Exchange - occurs during Described as like the chin. intervals c) Strong - the contraction to intense the CARDIOVASCULAR: uterus feels as hard as a wooden board at the peak of contraction. Described as Increase fetal heart rate ranging from like the forehead. 110-160 bpm at term. FETAL ASSESSMENT DURING LABOR: PULMONARY: Auscultation of Fetal Heart Sounds Decrease fetal lung fluid and increase absorption. Fetal Heart Sounds - are transmitted through the convex portion of the fetus, because that is the part lying in close contact with the uterine wall. PRELIM 6 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) Electronic Monitoring PERIODIC PATTERNS IN FETAL HEART RATE: FHR - is screened at least for a short time in early labor by an external Acceleration monitoring system. refers to temporary increase in the FHR The Monitoring - is left in place for that peaks at least 15 bpm above the continuous monitoring on women who baseline and lasts at least 15 seconds are categorized as high risk for any Often occurs with fetal movements reason or who have oxytocin Usually, a sign that fetus has stimulation. responsible CNS and is not in acidosis. Internal Electronic Monitoring Deceleration called “direct monitoring”. Invasive are temporary drops in the fetal heart procedure that uses a spiral electrode rate. attached to the presenting part. Determines fetal response to uterine THREE TYPES: contractions, measures intrauterine pressure, frequency, duration, baseline a. Early Deceleration - lowest point in the strength and the peak contractions. FHR that occurs with the peak of contraction. Fetal Heart Rate Patterns - Increase ICP from fetal head compression causes a decrease in FHR involves valuating 3 parameters: the by the vagus nerve baseline rate, variability in the baseline - Occurs as the fetal head is pressed rate (long term and short term), and against the woman’s pelvis or soft periodic changes in the rate tissue. (acceleration and deceleration) b. Late Deceleration - occur after the Fetal Bradycardia - occurs when FHR contraction begins often near the peak is below 120 for 10 minutes. o May result from uteroplacental Moderate Bradycardia - of 100 to 119 insufficiency. is not considered serious and is c. Variable Deceleration - results from probably due to a vaginal response reduce blood flow through the umbilical elicited by the fetal head being cord. compressed during labor. - FHR fail or rise abruptly (within 30 Marked Bradycardia - (under 100) is a seconds) with the onset and relief of sign of hypoxia is considered cord compression. dangerous. Fetal Tachycardia - occurs when the VARIABILITY rate is 160 beats or more per minute (for Baseline Variability - is a variation or a 10-minute period) differing rhythmicity in the heart rate Moderate Tachycardia - is 161 to 180 over time and is reflected on the FHR bpm. tracing as a slight irregularity or “jitter” to Marked Fetal Tachycardia - is more the wave than 180 bpm. This may be due to fetal Describes fluctuation in the baseline hypoxia, maternal fever, fetal arrhythmia FHR. or maternal anemia or hyperthyroidism. PRELIM 7 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) TYPES: FETAL RESPONSE TO LABOR: Short-term variability (STV) NEUROLOGIC SYSTEM changes in the FHR from one beat to increase intracranial pressure the next beat. Heart rate decreases by as much as 5 Difference between successive bpm during contraction (strength of 40 heartbeat, usually 3 to 5. mmHg) and shown as an early deceleration pattern. Long-term variability (LTV CARDIOVASCULAR: broader fluctuation that are apparent over 1 minute interval. Reduced placental nutrients and oxygen Fluctuation in the FHR of 6 to 10 beats exchange (slight fetal hypoxia) occurring 3 to 10 times per minute. Increased intracranial pressure from uterine pressure on the fetal head CAUSES: severe to keep circulation from failing Fetal sleep below normal during the duration of a contraction. Narcotics or sedatives such as MgSO4 Alcohol INTEGUMENTARY SYSTEM: Fetal Tachycardia Minimal petechiae or ecchymotic areas AOG less than 28 weeks of the fetus. Fetal anomalies e.g., anencephaly Edema of the presenting part (caput Severe hypoxia succedaneum) Abnormalities in CNS Maternal acidemia or hypoxemia MUSCULOSKELETAL SYSTEM: TECHNIQUES USED IN ASSESSMENT OF The force of uterine contractions tends FETAL ACIDOSIS: to push fetus into a position of full flexion. A fully flexed position is the most Fetal Blood Sampling advantageous for birth because it can minute amount of blood is extracted at speed labor. the scalp. Done only to high-risk fetus. RESPIRATORY SYSTEM: (N - 7.25 to 7.35). The process of labor appears to aid in Scalp Stimulation maturation of surfactant production by pressure is applied to the fetal scalp alveoli in the fetal lung. through dilated cervix. Tactile response The pressure applied to the chest from is assessed that will momentarily contractions and passage through the accelerate FHR (acceleration of 15 bpm birth canal clears it of lung fluid. for at least 15 seconds suggests normal oxygenation and acid-base balance) PRELIM 8 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) DELIVERY BIRTH: ❖ Assist the patient into a lithotomy Crowning position and attend to the patient’s needs and comfort. the fetal head distends the labial and ❖ Places patient hand on hand grip and perineal tissues. The anus is stretched explain the procedure. wide, and it is not unusual to see the ❖ Perform the perineal preparation. women’s anterior rectal wall at this time. ❖ Perform surgical Handwashing. Any feces expelled are wiped posteriorly ❖ Donn sterile gown and gloves (double to avoid contaminating the vulva. The gloving). attendant (physician or nurse-midwife) is ❖ Drape the client properly apply leggings not holding the fetal head back but and towels. rather controlling its exit by using gentle ❖ Instruct the client to bear down properly, pressure on the fetal occiput coaches to take deep breath as soon as the contraction begins. Ritgen Maneuver ❖ Encourage to push her flexed knee pressure is applied to the fetal chi against the stirrups. through the perineum at the same time ❖ Performs Ritgen’s Maneuver properly pressure is applied to the occiput of the (support the perineum) fetal head. This action aids the MANUAL SUPPORT OF PERINEUM: mechanism of extension as the fetal head comes under the symphysis. 1. Manual support of perineum with straight fingers, support against the Birth of the Head perineum. as the head emerges, the attendant 2. Manual support of perineum with prepares to suction the nose and mouth bended fingers, collecting the tissue to avoid aspiration of secretions when when support. the infant takes the first breath. 3. Manual support of perineum with thumb and index fingers the three other fingers Restrictions and External supports the chin (Modified Ritgen’s after the head emerges, it realigns with Maneuver) the shoulders (restitution). External DONNING STERILE GOWN AND GLOVES rotation occurs as the fetal shoulders (DOUBLE GLOVING) internally rotate, aligning their transverse diameter with the 1. Put on scrubs anteroposterior diameter of the pelvic 2. Put on shoe covers / trauma boots outlet. 3. Wash hands 4. Put on N95 Birth of the Anterior Shoulder 5. Put on cap the attendant gently gushes the fetal 6. Put on surgical mask head toward the woman’s perineum to 7. Put on goggle allow the anterior shoulder to slip under 8. Scrub her symphysis. The bluish skin color of 9. Put on gown the fetus is normal at this, it becomes 10. Put on surgical gloves pink as the infant begins air breathing. 11. Put on double surgical gloves PRELIM 9 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) Birth of the Posterior Shoulder ❖ Remove the wet cloth. ❖ Initiate skin-to-skin contact by placing the attendant now pushes the fetal head the baby on the mother’s abdomen or upward toward the woman’s symphysis between her breasts. to allow the posterior shoulder to slip ❖ Cover the baby’s head with bonnet. over perineum. ❖ Use the second linen to cover the Completion of the Birth baby’s back. ❖ Wipe eyes with separate piece of dry attendant supports the fetus during clean cloth and put a small amount of expulsion. Note that fetus has excellent eye ointment on the inside the baby's muscle tone, as evidenced by facial lower eye lid. grinding and flexion of the arms and ❖ Remove the first pair of gloves. hands. ❖ Do not cut the cord immediately. Allow Cord Clamping pulsation to stop without milking the cord. while the infant in skin-to-skin contacts ❖ Clamp the cord at 2cm from from on the mother’s abdomen, the attendant umbilical base and then apply the 2nd doubly clamps the umbilical cord. The clamp at 5cm from the base of the cord is then cut between the two umbilicus. clamps. Samples of cord blood are ❖ Cut the ties with a sterile equipment. collected after it is cut. Use cord clamp if available. Observe for Birth of the Placenta oozing of blood. o If blood oozes, place a second tie the attendant applies gentle reaction on between the skin and first time. The the cord to aid expulsion of the placenta. baby receives needed blood from the This placenta is expelled in the more placenta I the first minutes, to tie and cut common Schultze mechanism, with the the cord if the baby is receiving routine care and the mother has no bleeding shiny fetal surface and membranes problem. emerging. Note the fetal membranes o Do not apply any substance to stump. that surround the fetus and amniotic ❖ Do not bind or bandage stump fluid during pregnancy. The chorionic ❖ Leave stump uncovered. vessels that branch from the umbilical ❖ Inject 10 “IU” into the mother’s arms cord are readily visible on the fetal (depending on Doctor’s order). surface of the placenta. ❖ Leave the baby between the mother’s ESSENTIAL NEWBORN CARE: breast to start skin to skin care. ❖ Once the baby is out, pronounce the ACTIVE MANAGEMENT ON THIRD STAGE time of birth and ask assistant to record. OF LABOR: ❖ Use the fist linen/towel to dry the baby ❖ While maintaining skin to skin contact, for 30 seconds. check the mother’s condition while ❖ Do a rapid assessment while you dry delivering the placenta. the newborn ❖ Deliver the placenta when signs of ❖ Assess the baby’s breathing placental separation are not using CCT ❖ Resuscitation equipment should always (counter cord traction) correctly. be close to where the baby is being. It should be ready for use. PRELIM 10 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) ❖ Note the time of placental delivery and TWO (2) MECHANISMS OF PLACENTAL presentation and check the number of SEPARATION: cotyledons. (Schultz / Duncan) Schultze’s Mechanism - if the placenta ❖ Check the mount and characteristics of separates first from the center and last bleeding and examine the perineum, at the edges, appears as shiny and vagina and vulva for tears. glistening on the vaginal opening (Fetal ❖ Provide comfort to mother by applying Side) adult diaper and change soiled gown. ❖ Place an identity label on the baby and Duncan Mechanism - placenta mother. separates first on its edges and appears ❖ Encourage the initiation of breastfeeding raw, red and irregular (maternal surface) within 1 hour, when the baby is ready. Fetal side = (Schultze) o Signs of readiness to breastfeed are Maternal Side = (Duncan) baby looking around/moving, mouth Placental Expulsion open, searching. o Keep the mother and baby together placenta is delivered either by natural for as long as possible after delivery. bearing down effort of the mother or o A baby’s first breastfeed of gentle pressure on the contracted colostrum is very important because uterine fundus by the physician or it helps protect form many common diseases and contains many midwife (Crede’s Maneuver) important growth factors which help Pressure must never be applied to to develop the gut, the brain and uterus in non-contracted state otherwise nerves and the eyes. it may evert hemorrhage. ❖ Assist IW (institutional worker) to transfer manual removal can be done if it cannot patient from DR table to stretcher. be delivered spontaneously. ❖ Evaluate patient’s condition and health status. METHODS OF PLACENTAL SEPARATION: ❖ Document patient's postpartum and record Modified Crede’s Method pertinent data on chart accurately. 2 PHASES a process of delivery of the placenta from lower uterine segment or vagina by Placental separation a downward pressure along the axis of birth canal applied on the contacting active bleeding on the maternal surface fundus using it as a piston which of the placenta. simultaneously tracking the cord. After complete separation the placenta sinks into the lower uterine segment or Brandt-Andrews Method the upper vagina. expelling the separated placenta, I SIGNS: which the umbilical cord is held taut with left hand and the right hand placed over Lengthening of the umbilical cord. the lower abdomen then pressure is Sudden gush of vaginal blood exerted on the lower abdomen then Change in the shape of the uterus. pressure is exerted on the lower uterine segment down the vulva while simultaneously tracking the cord. PRELIM 11 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) Original Crede’s Method Shortening the duration of the third stage by expelling the placenta as soon delivering the placenta in which the signs of placental separation appears. body of the uterus vigorously squeezed Preventing the occurrence of laceration to produce a placental separation. - Administration of oxytocic. EXAMINATION OF THE MEMBRANES, OXYTOCIC PLACENTA AND UMBILICAL CORD: substance which stimulates contraction 1. Membrane carefully examined for the of the uterine musculature and is following: therefore useful in the prevention and Completeness - the state o membrane control of bleeding must be properly recorded in the chart Syntocinon - synthetic oxytocin as either complete, incomplete or (Methylergonovine Maleate) ragged - refers to torn out apparently complete membrane. Methergin - a semi synthetic derivatives of Ergonovine Presence of blood vessels in the membrane CONDITIONS THAT REQUIRE REFERRAL Site of rupture of the membrane - refers TO THE PHYSICIAN: to hole in the membrane through which the baby was born. Profuse bleeding before placental 2. Placenta both maternal and fetal separation surface area examined. Profuse bleeding from vaginal or 3. Umbilical Cord - the following are perineal laceration noted: Retained placenta Length of the cord Uterine atony Number of arteries (2) and vein (1) Retained placental Any abnormalities like presence of knots cotyledons/membrane Multiple perineal vaginal lacerations POST – PARTAL CARE Inversion of uterus due to strong POSTPARTUM tractions to umbilical cord Postpartum Increase or decrease vital signs Period when the reproductive tract Dyspnea returns to the normal, nonpregnant Convulsion state. PHYSIOLOGICAL MATERNAL CHANGES: The postpartum period starts immediately after delivery and is usually INVOLUTION completed by week 6 following delivery. is the rapid decrease in the size of the INTERVENTION TO PREVENT BLEEDING uterus as it returns to the nonpregnant DURING THIRD STAGE OF LABOR: state. Slow delivery of the shoulder and body ASSESSMENT: of the baby - to allow the uterus to By 10 days postpartum, the uterus contract and retract its diminishing cannot be palpate abdominally. content. After pain decreases in frequency after the first few days. PRELIM 12 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) LOCHIA Monitor amount, color and odor of lochia discharges discharge from the uterus that consist of Assess breast for engorgement blood from the vessels of the placental Monitor perineum for swelling or site and debris from the decidua. discoloration ASSESSMENT: Monitor episiotomy for healing Assess incisions or dressings of RUBRA - is bright red discharge that cesarean birth client occurs from delivery to day 3 Monitor bowel status SEROSA - brownish pink discharge that occurs from days 4-10. Monitor intake and output. Encourage frequent voiding ALBA - is white discharge that occurs from day 10-14. The discharge should Assess extremities for thrombophlebitis smell like normal menstruation. Assess bonding with the newborn infant and emotional status CERVIX POSTPARTUM DISCOMFORTS: Cervical involution occurs and after 1 week the muscles begin to regenerate After Birth Pains VAGINA occurs as a result of contractions of the uterus Vaginal distention decreases, although muscle tone is never restored Perineal Discomforts: completely to the pregravid state. apply icepacks to the perineum for the URINARY TRACT first 24 hrs. Warm sitz bath after 24 hours. Diuresis usually begins within the first 12 hours after delivery. EPISIOTOMY: GASTROINTESTINAL TRACT Instruct perineal care after voiding Administer analgesic as prescribed Constipation can occur, with bowel movement (soft, formed stool) by CONSTIPATION: second or third postpartum day. Encourage adequate fluid intake Hemorrhoids are common. Encourage high fiber diets VITAL SIGNS: Encourage ambulation Postpartum Blues - a condition caused Bradycardia - is common during the first by physiological and emotional stress. week, with a range of 50 - 70 bpm. May progressed to post-partum Blood remains unchanged. depression If unresolved. POSTPARTUM INTERVENTION: Verbalization or ventilation of feelings Monitor Vital Signs. Assess pain level Assess height consistency and location of the fundus PRELIM 13 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) NURSING CARE DURING PUERPERIUM: PHYSIOLOGY: Personal hygiene 1. Decrease estrogen and progesterone Early Ambulation - encouraged 8 2. Stimulation of anterior Pituitary to hours after delivery. secrete prolactin Monitoring of vital signs 3. Acts on acinar cells to produce foremilk Nutrition - should contain stored in collecting tubules approximately 2,600 to 2,800 calories 4. Sucking movement of infant daily. A diet in proteins, vitamins and 5. Production of oxytocin by Pituitary minerals is essential. Gland 6. Contraction of smooth muscle of RUBIN’S POSTPARTUM PHASES OF collecting tubules REGENERATION: 7. Milk ejection Taking in Phase: (First 3 days) 8. Let-down Reflex and hind milk production Mother focuses on her own primary needs (sleep and food) INTERVENTIONS: This phase is not an optimum time to Be kind and supportive teach the mother about baby care. Help her not to worry Taking Hold Phase: (Days 3-10) Reassure her that she can breastfeed Initiates infant’s reflexes (rooting, The woman is more control of sucking and swallowing) independence. Assume task of motherhood. CARE OF THE NEW BORN This phase is an optimum time to teach ASSESSMENT: the mother about baby care. Observe or assess with the initiation of Letting Go Phase: respiration. Assess for APGAR Score Mother may feel deep loss over Observe newborn for hypothermia separation of the baby from part of the body. INTERVENTIONS: Maybe in dependent or independent Suction mouth, then nares with bulb role. syringe. Breast Care: Establish Successful Lactation Dry newborn and stimulate crying by rubbing Colostrum Keep the newborn with mother to a thin milky fluid that is secreted by the facilitate bonding. Encouraged mammary gland. It contains more breastfeeding. Kept warm and thermo- protein and minerals but less in sugar regulated. and fat. Also contains maternal Ensures newborn’s proper identification antibodies. Let-down Reflex actual secretion and ejection of milk from the breasts. PRELIM 14 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) APGAR: flexor tone at rest that precedes in a centripetal direction with lower APPEARANCE (SKIN COLOR) extremities slightly ahead of upper 0 = cyanotic / pale all over extremities. 1 = peripheral cyanosis only Term newborn (flexed posture) and 2 = pink Preterm newborn (extended posture) PULSE (HEART RATE) Square Window: assessing the flexibility of the wrist. 0 = no pulse 1 = 100 BPM extensor stretching and responsibility for the resulting angle of flexion at the wrist. GRIMACE (REFLEX IRRITABILITY) The examiner strengthens the infant’s 0 = no response to stimulation fingers and applies gentle pressure on the dorsum of the hand, close to the 1 = grimace or weak cry when fingers. From extremely preterm ot post stimulated term, the resulting angle between the 2 = cry when stimulated palm of the infant’s hand and forearm is ACTIVITY (TONE) gradually diminished 0 = floppy Arm Recoil: examines the passive flexor tone 1 = some flexion of the biceps muscles by measuring the angle 2 = well flexed and resisting extension of recoil following very brief extensions of the upper extremity. RESPIRATION With the infant lying supine, the 0 = Apneic examiner places one hand beneath the 1 = Slow, irregular breathing infant’s elbow for support taking the 2 = Strong cry infant’s hand, the examiner briefly sets APGAR SCORE INTERPRETATION: the elbow in flexion, then momentarily extends the arm before releasing it. The 8 - 10 = No intervention is required angle of recoil, to which the forearm 4 - 7 = gently stimulate; rub newborn’s springs back into flexion is noted. back; administer O2 to the newborn Popliteal Angle: this maneuver assesses the 0 - 3 = infant requires resuscitation maturation of passive flexor tone of the knee OTHER SCORING TOOL: extensor muscles by testing for resistance to extension of the lower extremity. Ballard’s Scoring System: Neuromuscular Maturity and Physical With the neonate lying supine, the thigh Maturity is placed gently on the abdomen of the knee fully flexed. THE NEUROMUSCULAR CRITERIA: The examiner gently grasps the foot at Posture: Muscle Tone - is reflected I the the sides with one hand while infants preferred posture at rest. supporting the side of the thigh with the other. Care is taken not to exert As maturation progresses, the fetus pressure on the hamstrings. The leg is gradually assumes increasing passive PRELIM 15 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) extended until a definite resistance to BODY MEASUREMENT: extension is appreciated. LENGTH: 45-55 cm (18 to 22 inches) At this point the angle formed at the WEIGHT: 2,500 to 4,300 g (5.5 to 9.5 knee by the upper and lower leg is lb) measured. HEAD AND CHEST CIRCUMFERENCE Scarf Sign: it is tests the passive tone of the flexors about the shoulder girdle. HEAD: With the infant lying supine, the Bones of the skull are not infused examiner adjusts the infant’s head to the Sutures are palpable and may be midline and supports the infant’s hand overlapping because of head molding across the upper chest with one hand. but not widened. The thumb of the examiner’s other hand Caput Succedaneum - is edema of the is placed on the infant's elbow. The soft tissue over bone, subsides of over a examiner tries to pull the elbow gently few days. across the chest, feeling for the resistance. EYES: Heel to Ear: this measures the passive flexor Slate gray (light skin), dark blue, or tone of the posterior hip flexor muscles. brown - gray (dark skin) Symmetrical and clear The infant is placed supine and the Pupils equal, round, react to light and by flexed lower extremity is brought to accommodation Reston the cot. The examiner supports the infant’s thigh EARS: laterally alongside the body with the Top of pinna on or above the line drawn palm of one hand. The other hand is from outer canthus of the eye. used to grasp the infant’s foot at the sides and to pull it towards the ipsilateral NOSE: ear. Nares are patent and should flare The examiner feels for the resistance of Flat, broad, in center of face extension of the posterior pelvic girdle flexors and notes the location of the heel MOUTH: where significant resistance is appreciated. Assess for thrush (candida Albicans) white patchy areas evident on tongue or INITIAL PHYSICAL EXAMINATION: gums that cannot be removed with a wash cloth. VITAL SIGNS: Epstein's pearl (small, white cyst) may HEART RATE: (resting) 100-160 bpm be present on hard palate. (apical) for full 1 minute NECK: RESPIRATORY RATE: 30-60 breaths/min assess for 1 full minute Assess for torticollis AXILLARY TEMPERATURE: 96.8F to Good range of motion and ability to flex 99F and extend. BLOOD PRESSURE: 73/55 mmHg PRELIM 16 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) CHEST: Transitional stool - the second type of stool excrete by the newborn, is Nipples prominent and often greenish brown and of looser edematous; milky secretion (witch’s consistency than meconium. milk) common. Seedy, yellow tools - are noted in Circular appearance because breast fed newborns. anteroposterior and lateral diameter are about equal REFLEXES: SKIN: Sucking and Rooting Reflex: Pinkish-red (light skinned newborn) to Touch the newborn’s lip, cheek, or pinking - brown or pinkish - yellow (dark- corner of the mouth with a nipple. skinned newborn) Newborn’s head will turn toward the Vernix Caseosa - cheesy white nipple. substance, can be seen, especially on Swallowing Reflex: back. Milia - small white sebaceous glands, Newborn swallows in coordination with appearing on forehead, nose and chin. sucking without gagging, coughing or Dark red color - common in premature vomiting. newborns Tonic or Fencing Reflex: Cyanosis - common with hypothermia, injection, cardiac, respiratory, neurologic As the newborn face the left side, the problem. left arm and left led extend outward, Acrocyanosis - (peripheral cyanosis) while the right arm and right leg flex. normal for first few hours after birth and As the newborn face the right side, the then may be noted intermittently for next right arm and right leg extend outward, 7 to 10 days. while the left arm and left leg flex. Harlequin sign Palmar Plantar Grasp Reflex: Birthmarks Place a finger in the palm of newborn’s ABDOMEN: hand and then place a finger at the base Umbilical Cord should have 3 vessels: of the toes. (2) Arteries; (1) Vein Moro-Startle Reflex: Cord should be clamped for at least the first 24 hours Place a newborn on a flat surface and strike the surface to make it sound, or GASTROINTESTINAL: the examiner will make a loud noise or Monitor bowel sounds, which should claps hands to elicit response. occur within 1-2 hours after birth. The newborn symmetrically abducts and Monitor meconium extends the arms. The newborn fans the Meconium - which is greenish-black fingers out and forms a “C” with the with thick, sticky, star-like consistency, thumb and forefinger. Somehow the usually is passe within the first 24 hours hands stay clenched. in life. PRELIM 17 | 1  CARE OF MOTHER, CHILD ADOLESCENT (LEC) The Moro Reflex is present at birth; Keeps small articles away from the complete response may occur up to 8 reach of the infant weeks. Wipes feces on the perineum with The Startle Reflex should disappear cotton balls before bath within 4 months. Undress and wraps the baby in the towel Pulling to Sit Response Reflex: Cleanse the eyes with water using Pull the newborn up from the wrist while cotton balls, starting from the inner to the newborn is in supine position. outer canthus of the eye. One cotton The head will lag until the newborn is in ball each an upright position, and the head will be Washes baby’s face, neck, and ears level with the chest and shoulder and pat to dry. momentarily before falling forward. The Cleans the inside of the ear with head will lift for a few minutes. damped wisp of rolled cotton balls in gently rotating manner Babinski Sign: Plantar Reflex: Hold the baby in a football position over The reflex will disappear after the basin newborn is one year old. Absence of Lather scallop using mild soap and this reflex indicates the need for a massage it fingers tips, soft bristle brush neurological examination. or baby comb Beginning at the heel of the foot, gently Rinse and dry scalp well stroke upward along the lateral aspect Places baby lying on his back of the sole, and then move the finger Soaps, rinses and drive arms and hands along the ball of the foot. The toes particularly in axilla hyperextend while the big toes dorsiflex. Soaps, rinses and dries baby’s chest Stepping or Walking Reflex: and abdomen (keeps baby covered between soap and rinsing) hold the newborn in a vertical position, Soaps, rinses and dries baby’s leg and allowing the foot to touch a table surface feet exposing one leg at a time and stimulates walking. Alternately particularly the areas between the toes flexing and extending the feet. Reflexes Turns the baby on his side, and soaps, present for 3-4 months. rinses and dries his back Crawling Reflex: Cleans and dries the perineal area (anterior) from font to back Place the abdomen on the newborn. Soaps, rinses and dries the posterior The newborn begins making crawling perineum and buttocks movement. Usually disappears after Applies drops of alcohol at the base of about 6 weeks. the cord NEWBORN BATH: Puts on a clean clothing and diaper Keeps the baby warm and comfortable Washes hands before the procedure. Assembles all necessary equipment’s Makes sure the room is free from the drafts by closing the windows. PRELIM 18 | 1