Maternal-and-Child-Nursing.pdf

Maternal and Child Nursing OVERVIEW OF THE REPRODUCTIVE SYSTEM  Imperforate FEMALE o May lead to Breast...

Maternal and Child Nursing OVERVIEW OF THE REPRODUCTIVE SYSTEM  Imperforate FEMALE o May lead to Breast Pseudoamenorrhea/Cryptomenorrhea  Dependent on the ovary for hormones o Management is surgery; put to sleep to prevent  During menopause  stop supply of hormones  prone to damage to vagina cancer  Rigid Mons Pubis o Problem with intercourse Labia o Management is surgery  Serves as a covering  Carunculae Myrtiformes - remnants of hymen after tearing  Majora and minora  Minora - has erectile tissues (clitoris) Doderlein’s bacillus  Normal flora - Clitoris  Bacteria that protects the woman from bacterial infection  Anterior  Makes vagina acidic  Basis for catheterization  Candida albicans (candidiasis) (moniliasis)- most common  Avoid touching the clitoris when inserting the infection in the woman catheter – may cause convulsion in precclamptic o Yeast infection patients o Color (#1 assessment) - Yellowish creamy color - Fourchette o Consistency of discharge: thicker  Posterior of minora o Smell: no smell  Stretch during delivery napupunit o Pruritus  Ritgen’s Maneuver o Vaginal suppository (MICONAZOLE, MONISTAT) o Perineal support  Local effect only o Protect the are from overstretching  Best time to insert the vaginal  Episiotomy suppository: night time  patient not o Prevents laceration upright  drug is dissolved in vagina o Cut during peak of contraction  all the  6 hours for drug to take effect muscles are pulled up and no muscles are  Should report MORE discharge; drug cut and infection (only 1 day) o Should have anesthesia  Only needs a single dose o How many strong contractions before o Effect on Baby: infection on baby’s MOUTH (Oral episiotomy: 3 moniliasis) o Mediolateral- hindi mag eextend to anus but many layers of tissues are affected  Trichomonas vaginalis (Most common incision made) o SMELLY!!!!!!!!! o Median- used for immediate delivery, may o Greenish grayish frothy extend to anus  Gonorrheal - Vestibule o Effect on baby: eyes o Triangle  Chlamydial o Two important openings- 2 (urethra and o Effect on baby: eyes vagina) Cervical Mucus o All openings- 6  From cervical glands - Spinbarkeitt Urethra  Endocervical gland in cervix  Urethral canal is very short  at risk for infection 2 hormones that affects the cervix o 8-10 glasses of fluid / 50% should be plain water  Estrogen  UTI- increase fluids because no matter how much you do  Progesterone perineal care, the proximity of the urethra to still predisposes it to infection Estrogen Progesterone -Dilates the cervix -Closes the cervix *Because of hormone change, pregnant is more at risk for infection -Released before ovulation: -Released on the 16th day  progesterone  decreased renal threshold of sugar  small 14th day -Mucus is decreased in amount, amount leak out  sugar in vagina is good medium for bacterial -Mucus is watery, clear, sticky, cloudy growth stretchy -Spinnbarkheit: 3 cm -Spinnbarkheit: 6-12 cm -Safe Period Vagina -Unsafe period -Ph: 6  Discharge: Fleshy smelling (Normal: 6-8 soaked napkin = -13th day of the 28th day -Hormone that protects the 30ml of blood) cycle baby  More than 2000ml = shock -For 3-5 days -Dec. progesterone (AP) = Inc.  Organ for copulation -Ph: 8 oxytocin (PPG)  During birth passage no ruggae (less resistance) for easier passage of the baby Operculum  Has ruggae (folds of muscles) which allow to stretch  Mucus that plugs the cervix  Kegel’s exercise- to promote formation of ruggae  More discharge  formation of mucus plug o Pubo-coccygeal muscle  Protects the baby from possible entry of infection o Contract the muscle to hold the urine, then  “Show”- sign of cervical dilation release the muscle  Cervical dilation- indication that the woman has started o Done as much as she wants labor Hymen  Pag nastretch ang vagina, stretch din ang hymen University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing Uterus  Baby suckes stimulation of prolactin  Estrogen- thickens the muscle (hypertrophy) and oxytocin  Progesterone- relaxes the uterus, maintains the pregnancy  Baby suckles  stimulation of anterior  Upper Segment(Fundus) pituitary (estrogen and prolactin) o most active segment of the uterus  Only 1 or the other can be o Muscles are found in all directions ”figure of 8” released o Upper central and posterior segment- best site  Estrogen stimulates ovulation so during for implantation of placenta breastfeeding prolactin I released  Placenta previa- bigger placenta instead of estrogen o Placenta obstruct the passage way  Prolactin  increase production of milk, o Bleeding from the placenta insulin antagonist  Painless  Oxytocin  ejection of the milk, uterine  Last trimester contraction, released during labor  Lower Segment  8 times of feeding o Passive segment  6 times daytime o Longitudinal muscles  2 times at night  During contraction, same shape of uterus (globular  at 6 months, introduction of other foods shaped) to baby  decreased breastfeeding   Physiologic retraction ring (normal) estrogen instead of prolactin released o Imaginary line that separates the upper and the o Is there a difference between menstrual and lower segment of the uterus during labor lochial discharge? o Not seen but palpable  *Menstrual blood: NEVER CLOTS  Pathologic retraction ring (Bandle’s ring)  Color: SAME o There is an overstretching of the uterus  Smell: SAME o Visible separation of the upper and lower  Amount: DIFFERENT (more on lochia) segment of the uterus  Menstruation: 30-50 ml (max o There is an obstruction of the baby’s 80 ml) passageway  Lochia: difficult to estimate  Distended bladder  #of days of menstrual flow: 2-6 days  Make sure the patient voids o Lochia every 2 hour intervals  Rubra: 3 days  Straight catheter  Actual bleeding  Cephalo-pelvic disproportion  Presence of clots: report  Perimetrium  Serosa: at least 1 week  Myometrium  Alba: 3 weeks or more (3-5 weeks)  Endometrium  Braxton Hicks o 1.5 cm thick due to influence of estrogen and o Started at 4 months progesterone (supplied by the ovary) (release o Contractions more significant at 7th month estrogen and progesterone simultaneously) o Decreasing level o progesterone at the last o During pregnancy  6 cm thick trimester  increase frequency of contraction  Protective mechanism of the hormones  Labor to maintain the lining for the o Decrease progesterone  release of oxytocin  DECIDUA- endometrium during o Prostaglandin theory pregnancy  Hormone release by the when the  Estrogen and progesterone released at body is stressed the same time  Acts on the muscles  Hormones in the ovary are at rest,  From the placenta, uterus, fetus PLACENTA takes over supply of  Sudden increase in prostaglandin hormones  Mefenamic acid- prostaglandin  3 months before the woman starts inhibiting drug menstruating again  Take on the day before you  Decidua Basalis – where menstruate or at the onset of placenta is attached; E and P menstruation maintain it o Zona basalis – o Uterine Stretch theory remains when  When uterine is stretch to its max decidua is shed; new capability and capacity, it will naturally endometrium for contract and expel its contents next pregnancy  Natural protective capacity of the  Decidua Vera organ  Decidua Capsularis o *Conditions will stretch early  Lochia – shedding of the deciduas  Twins (needs delivery; will deliver earlier)  Alba and serosa are odorless 2 weeks earlier  Menstruation – shedding of the lining  polyhydramnios o Breastfeeding  macrosomic baby  Form of birth control *Safe ang Sex even during pregnancy  Only up to 6 months  Safe up to 34th week of pregnancy  Suppress the activity of the ovary o Semen contains prostaglandin  increase prostaglandin  early onset of labor University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing Fallopian Tube Bulbourethral gland (Couper’s)  As long as fallopian tube is healthy, fertilized egg can pass  Stimulated only during sexual arousal through  Cleans the urethra  Isthmus Ejaculate o Ligated in tubal ligation  2.5-5ml o Estrogen – propel by rhythmic movements  at least 50,000,000/ml o Progesterone – nourishment of the zygote  Low sperm count: less than 20,000,000/ml  Ampulla  300,000,000 per ejaculate o Fertilization- outer 3rd of the ampulla (distal  Pre-ejaculation: portion)  Irregardless of number, only 1 sperm can get a woman  Fibrae pregnant  Cause of ectopic pregnancy  If sperm is mature, can enter the woman’s uterus 80 o Surgery from tubal ligation (most common seconds!!!! cause) (1% chance that it will recanalized)  Characteristic of the Sperm o Pelvic inflammatory disease o Small head with long tail o Recurrent UTI infections o Length of the tail is 10x the length of the head  Development of the reproductibe organ- estrogen o Neck- gives energy to tail o Transport of baby through the tub (average of 1 o Head- gives chromosomes week) o Tail- propels the sperm  Never earlier than 7 (7-10) o Unidirectional- paakyat! o Rhythmic contraction of the fallopian tube  Progesterone MENSTRUAL CYCLE o Nourishment of the baby in the tube  the start of every cycle is the menstrual cycle Ovary/Ovulation Hormones  Primordial ova (at birth): 300,000-400,000  Hypothalamus: GnRh – stimulates APG o Immature follicle  Anterior Pituitary Gland: FSH, LH o Some die before they mature o FSH- stimulates development of graafian follicle  By age 7: reduce to ½ in number o Leutenizing Hormone (LT) or Interstitial Cell  Number that reach maturation: around 400 (200/day) Stimulating Hormone - stimulates ovulation and  Menarche: 9-17 years old development of ovary  Reproductive period: 35 years o The time the FSH stopped is the time of the  Menopause sudden increase in LH o Perimenopause  Ovary: Estrogen, Progesterone  2-10 years before menopause; o Estradiol – from the ovary hormone imbalance o Estriol – from the placenta  34-60 years of age o Progestin – progesterone form ovary and  Vasomotor instability, irregular periods, placenta sleep trouble, irritability  Corpus luteum- 2 weeks o Menopause  Albicans- dead corpus luteum  End of menstruation/Cessation of  Corpus luteum degenerates  corpus albicans menses decreased estrogen and progesterone (ischemic)   Possibility that 1 or 2 egg cells are still in shedding of endometrium  Bleeding (Menstrual) – start the ovary; risk of having a baby with of the cycle chromosomal defects  Low levels of E and P  stimulate hypothalamus: GnRh  o Post Menopause stimulate anterior pituitary gland  release of FSH   1 year after menopause; very low level stimulates the follicle to mature  Graafian Follicle of estrogen (increased ESTROGEN)  Endometrium Thickens (Proliferative)  Increased LH  Ovulation  Corpus luteum progesterone  further thickens at endometrium, more vascular  ready for implantation (Secretory) MALE FSH LH Scrotum - protects the testes from temperature Penis - organ of copulation Estrogen Progesterone Urethra  Releases urine and semen  Menstrual phase- degeneration of the endometrium  Glans penis- with an angle so it could reach the posterior  Ischemic phase- corpus albicans of the vagina  Menopause Testes o Fsh is forever increased  Where sperm s produces  Effect of combined birth control pills on ovary Epididymis o Prevent ovulation  Store house of sperms  Menstruation Vas Deferens o Degeneration of corpus luteum  Conduit between the epididymis and ejaculatory dock  Activity of ovary during Pregnancy Seminal fluid with fructose o No ovulation Prostate gland  Best hormonal requirement for ovulation  Add volume of fluid o Increased FSH and LH  Makes sperm alkaline  Suckling -> prolactin -> dec. estrogen University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing  Average mentstrual blood loss = 30-50ml  If one is pull down- unusual  Normal span = 21-28 days, at maximum 35 days heaviness  Oligomennorhea- prolonged intervals between menses  Put your hand on your waist and lean  Polymenorrhea- short intervals between menses forward  Metrorrhagia – intercyclic bleeding  Must point at the same  Hypomenorrhea- scanty flow of bleeding, caused by direction nutrient deficiency or hormonal imbalance  Palpate (person should raise the hand  Hypermenorrhea/Menorrhea- excessive menstrual flow, at the back of the head caused by endocrine imbalance, infection  Circular  Primary Amennorhea  Tail method/Tail of Spencer o Failure to begin to menstruate by 16 years of age (outer quadrant going to inner o If absence of breast development or pubic hair, quadrant) then consider Turner’s syndrome (female with  Feel for any lumps only one X chromosome)  Squeeze the nipple between thumb o No development of secondary sex and forefinger to observe for any characteristics discharge; abn if w/ secretion Menopause  Osteoporosis  Mammogram o Estrogen o Procedure to detect for any abnormal growth o Absorption of calcium o Starts at age 40-50 years; done every 2 years o Retention of calcium  decreased in o 51 and above: yearly menopause o Women of low risk category o Signs in Of Osteoporosis o Women of high risk category  Dowager hump (kyphosis)  From age 40, every year  Decrease in height  With family history of breast cancer  More prone to spontaneous fractures  Menopause after 50 (wrist fracture common)  Nulliparous  Pelvic fracture- dangerous  History of benign growth on the breast  Weight is on the area of the (fibroadenoma) pelvis  bone unable to support  Heart Disease (atherosclerosis) o Management o 1 year after menopause  start to increase  Walking devices cholesterol levels  Allendronate (Fosamax) – prevents o Peaks at 5 years bone resorption o Estrogen increases HDL decrease estrogen at  Take in the morning with menopause  decrease HDL  increase LDL plenty of water, 30 mins o Prevention: before eating  Diet - reduce intake of fatty foods  Stay upright for 30 mins after  Exercise talking to avoid reflux and  Stress Reduction other GI symptoms  Lifestyle change  Calcitonin – allows calcium to go to the  Exercise bones  Diet o Preventive Measures  Increase calcium in diet  Pap Smear  1500-1800 mg/day o First papaniculao smear  Exercise using the bigger bones/ weight o Age:21 bearing exercise o Earlier if sexually active (3 years after the first  Walking sexual activity)  Stair climbing o Then annually until 3 consecutive negative Paps  Dancing  I – normal cells  Avoid injurious activities  II – abnormal cells but not malignant,  Sports with bouncing or suggests infection jogging  III – abnormal cells, suggests  Bone Density Scan once a year malignancy, do cervical biopsy  Breast Cancer  IV – abnormal cells, malignancy (no o 1 out of 7,000,000 biopsy) o Prolonging the life the woman if diagnosed early   Breast Self-Exam FAMILY PLANNING o Schedule: 1 week after menstruation when  After intercourse, diaphragm should be in place for 6 estrogen can’t influence breast tissue hours o Menopause: breast self-exam at the same date  3 year spacing of children; mandated by WHO every month o Breastfeeding: same date of each month Major Program Policies of the Philippine Family Planning Program o Steps  Improvement of family welfare with the main focus on  Face the mirror women’s health, safe motherhood and child survival  Raise both hands  Promotion of family solidarity and responsible parenthood  Should pull up at the same  Nurses as EDUCATOR and FACILITATOR time  How many methods: 6 University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing Methods of Family Planning  Woman is not capable of protecting 1. Behavioral the vaginal wall o Coitus Reservatus - no sexual activity o Delivery bases o Coitus Withdrawal/Interruptus - with sexual  Cream,jelly activity  Foam  Sperm is not released inside the  Film woman’s body  Suppositories – mostly used in the PH  Not an accidental pregnancy   Foaming tablets unwanted o Common chemical agents  Never taught  Nonoxynol-9 (N-9) – kills sperm, virus, 2. Natural Family Planning and bacteria - Principles:  menfegol o The human ovum is susceptible to fertilization  benzalkonium chloride (BZK) only for 18 to 24 hours 4. Local barrier o The sperms deposited in the vagina are capable o Diaphragm of fertilizing the ovum for no more than 72 hours  Dome shaped; mustbe fitted by MD o Present methods of determining ovulation are  No protection from infection not exact by about 48 hours  Inserted up to 2 hours before intercourse and removed 6 hours o Calendar Method after intercourse to kills all sperms  Ogino-knaus formula  Should be fitted exactly  Regular- same interval each time  Covers cervix and posterior portion of  Subtract 12 from the number the vagina of days of the menstrual cycle  Can be tilted during intercourse to determine day ovulation  Spermicide should cover inner  Abstinence starts 5 days portion, outer portion and rim of the before ovulation and lasts up diaphragm to 3 days after ovulation o Cervical Cap  Important: 1st day of the last  No protection from infection menstrual cycle  Harder to place but one size fits all  9 days of abstinence – Rule of  The contraceptive sponge is 9’s moistened well with water and  Irregular- data of shortest cycle and inserted into the vagina with the data of longest cycle; for 6 months concave portion positioned over the  Subtract 18 from the short cervix; may stick to the cervix cycle and subtract 11 from  Wash hands thoroughly before the long cycle inserting the cap  13 days abstinence  Wear it while upright placing one leg  Answer of shortest to answer on on a stool to feel the cervix longest  abstinence  24-48 hours- time you can keep it  While waiting for 6 months, she can  Longer than 48 hours  develop use other natural family planning infection  toxic shock syndrome method  Might develop cervicitis Menstrual interval o Condom  Interval between the first day of menstruation from the  Made of latex - allergenic next menstrual cycle o Female Condom o Basal Body Temperature  30% effective  Any route for temp  Pre-ovulatory temperature is low 5. Hormonal (Anovulatory menstruation) because of high estrogen level o Prevent pregnancy by inhibiting the  Post-ovulatory temperature rise is due hypothalamus and anterior pituitary so that to high progesterone level ovulation does not occur  How many will you abstain from day o Injectable of change of temp: 3 days (egg cell  Depo-provera can survive for only 24 hours, 2 days  Depo-medroxyprogesterone – no leeway) estrogen, interfere with insulin use; o Symptothermal Method not given to diabetics  Combination of mucus and temp  3 month injectable contraceptive method containing 150 mg of synthetic  More conclusive since it has 2 progestin parameters  Increase (excessive) thickness of the o Billings/Cervical Mucus Method endometrium o Lactational Amennorhea Method  Avoid massaging the area  immediate absorption  effectivity 3. Chemical less than 3 months o Use of spermicides  Don’t move site/arm – increase o Makes the vagina more acidic absorption o Common side effect: vaginitis University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing  Slow gentle wrist motion- prevent  Undiagnosed vaginal bubbles to give complete dose bleeding prescribe  Thromboembolic disorders  Cost effective; given every 3 months;  Pregnancy – terratogenic not readily reversible  Liver disease  Mixed slowly  Coronary artery or o Implant cerebrovascular disease  Norplant; Non-absorbable  Heavy cigarette smoking –  Synthetic progestin effect on vessels  Implanted on the upper arm  Breastfeeding – suppress  Should be felt but not seen estrogen  Suppresses ovulation for 5 years  6 capsules of progestin are inserted SQ in the woman’s upper arm; INTRAUTERINE DEVICE (IUD) contraceptive effective lasts up to 5  A small, usually flexible appliance inserted into the uterine years cavity  2 years- 98-99%  Inserted only when the woman is menstruating  Every year minus 1% o To be also sure that woman is not pregnant o Oral o Only time cervix can open  Oral contraceptive pill; reversible  Disrupts normal uterine environment; abnormal lining  Available in 21 and 28 day  MD insert instrument to measure length of uterine cavity  preparation insert IUD as he pulls applicator  7 placebo- iron supplement  String is cut  Must be taken according to the  Inhibits implantation through: arrow o Local inflammatory response  1st day of menstruation- start intake of o Loal production of prostaglandins pill (28 day prep) o Interfere with enzymatic and hormonal activity  5th day of menstruation- start of o Increase motility of ovum in fallopian tube intake of pills (21 day prep)  It immobilizes the sperms as they pass through the uterus  Take pill with food (after a meal)-  ABORTIFACIENT prevent gastric irritation  Tell patient to check her string once a week for the first  Whatever time is convenient- best month time to take the pill  CHECK HER String once a week after insertion/once a  If forgot to take the pill in the month after menstruation morning- take pill now then take pill  Inserted during menstruation the time she regularly takes it the  If string not felt, go to doctor! next day  Progesterone-coated- changed every year  If she forgot the day before- take  Copper T- every 10 years, spermicide double dose and continue regular schedule *Pelvic Inflammatory disease  2 days missed dose, double dose  Complication of IUD for 10 years today and tomorrow then return to  If woman with PID is still with IUD in place normal schedule o Treat infection (antimicrobial) first before  3 days missed – stop taking and start removal of IUD and new one and use another  Danger Signs method o P- period late or skipped period  Side effect: o A- abdominal pain (severe)  Nausea o I- increased temperature, chills  Breast tenderness o N- noticeable vaginal discharge; foul-smelling  Weight gain- 5 lbs. every year discharge  Breakthrough bleeding o S- spotting, bleeding, heavy periods, clots  Adverse effect:  A- abdominal pain (severe), 6. Surgical due to hepatotoxicity o Vasectomy  C- chest pain (severe) or  Local infiltration__> incision  shortness of breath separate vas deferens pull out   H- headaches (severe) tie  cut  E- eye problems (blurred  A minor surgery vision, loss of vision), inc. BP  Scrotal area will be swollen within 2-3  S- severe leg pain (calf or days thigh) DVT  Can resume intercourse as soon as  Mini pill the inflammation subsides  Progestin only  Wear a condom (1 month)  Morning after pill a. 2-3 times per week  Patients who are raped  Sperms are already produced  Damage the development of  2-20- ejaculations needed to remove the ovum all ejaculation  Contains a lot of estrogen  Contraindications University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing  After 1 month, get sperm count if  Positive pregnancy test, Goodell’s, ballotment, negative  wait for another month Chadwick’s, Hegger’s, inc. abdominal sign, Braxton hicks  get sperm count again contraction  (-) (-)- OK na Positive  3rd sperm count- 1 year after  Diagnostic vasectomy  Fetal heart (low pitch) - funic soufflé (high pitch)  Sperms that are newly developed  Fetal outline and cannot be released is  Palpation of fetal parts by the examiner through Leopold’s REABSORBED by the body maneuver  64 days – production of new sperm cells Estrogen Both Progesterone  Vasodilating  Varicosity-  Constipation o Ligation (BTL) effect: Hegar’s, weakening of  Vasoconstriction  May equated to sterilization Chadwick’s vessels and effect  Woman signs the consent but  Hormone that vasodilating  Salt losing HUSBAND agrees to the procedure retains sodium; inc effects hormone  Who should be present when MD blood volume  Hemorrhoids  Weakening of discusses the procedure: BOTH the  Inc. in T4: gamma  Edema- primarily muscles couple globulin estrogen but  Inc activity of  After delivery- Best time to perform  Genital changes; later on ducts; secretary because uterus is found in the growth of breasts, progesterone function abdominal cavity hypertrophy of the (too much salt  Decreased clotting  Easier to access the fallopian gums was lost  factors tube  Skin changes- stimulation of  Weakens the  Laparoscopic- introduction of air  stimulate RAAS-- > increase vessel walls at risk for air embolism melanocyte sodium  Affects the mood;  A 3 cm abdominal incision is made  stimulating  Breast changes- neuroendocrine through which the tubes are hormone  skin primarily effect on behavior tied/cauterized/cut changes estrogen  Interval mini-lap – done during  Decrease o Progesterone- the first 7 days of the peripheral changes in the menstrual cycle vascular breast  Post-partum mini-lap – done resistance within the first 8 weeks after a normal delivery Neither *For DM patient  Waddling Gait-Relaxin- hormone from ovary  Unsafe ang pills  affects insulin o In mobility of the joints, abnormal gait of  Use barrier pregnancy  Contraindicated to  Morning sickness- Hcg o DVT o Pregnant Gravida- pregnancy o Thromboembolic disorders Para - delivered - must be considered viable- greater than 20 weeks o Liver disease Term - 38 -40 weeks o Coronary artery disease Preterm - 20-37 weeks o Breastfeeding Abortion - below 20 weeks  Don’t use pills that contain estrogen Living - living as of now (depo-provera is OK) Multiple pregnancies – G,P,T counted as one, only in L is counted  Estrogen shuts down prolactin Ectopic - counted in gravida and abortion o Heavy cigarette smoking Stillbirth - Not counted in H Hmole - Counted in gravida not in para PREGNANCY GP TAL (6 DIGIT DISTRIBUTION) G TAL (5 DIGIT DISTRIBUTION) Heartburn – pyrosis Suspecting of pregnancy - considered as pregnancy Chloasma – face-mask of pregnancy Segundi-2 Melasma – other parts – areola, linea nigra, axilla, groin Grand multi-5 and above Striae – Due to separation of underlying connective tissue Striae gravidarum – dark Leopold’s Maneuver Striae albicantes – white  Systematic palpation of the pregnant women’s abdomen Goodell’s sign – Cervical change to determine several data  Explain what you will do to the pregnant women Presumptive  To make sure that the results are accurate- tell the patient  Subjective data to void  Patient complaints  Position: Dorsal recumbent  Leucorrhea, pica, pyrosis, morning sickness, quickening,  Draping Procedure: horizontal urinary frequency, constipation  Warm hands before palpation; Cold hands stimulate Probable uterine contraction  Objective  When to do Leopold’s Maneuver: can be done at 5 months but best at 7-9 months  L1 University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing o Part of the fetus located at the fundus: cephalic o encapsularis or breech  Placenta  Soft angulated, nonballotable – o Protective barrier buttocks  Cytotrophoblast and  Hard, round, ballotable - head syncitiotrophoblast  L2  Present o Flat plain (back), nodular/irregular several  Prevents crossing of masses (fetal parts) treponemapallidum o Fetal lie/ Fetal back  2nd trimester- syncitiotrophoblast o Longitudinal and transverse remains only  Long axis of fetus and mother o Organ of the baby in utero  Location of fetal heart  Normal temperature of baby in utero:  L3 25-28⁰C o Engagement  Endocrine/Metabolic activities –  If floating, not engaged provides hormones of pregnancy –  If not floating and fixed, engaged E,P,Hcg, hPL (fetal growth hormone) o Presentation: Head, buttocks, shoulder  Transport function – nutrients,m stores  L4 iron for 6 months o Fetal habitus/Attitude – occiput is the indication  Endocrine function of position  Immunologic – IgG from mother at 34  A relationship of the baby’s parts to weeks (9 months, passive natural each other; degree of flexion immunity, all diseases)  Flexion- normal attitude  Milk have IgA; protection from  Extension diarrheal diseases  Sincciput- head and hand  Protective barrier against harmful presented substances (drugs and microorganisms) o Position However, viruses may enter  Face the foot part  place her fingers 2 inches above the  Give only tetanus toxoid inguinal are  glide downward  find the occiput  Oxygenation  Nonballotable mass- buttocks  Excretory organ  Wastes by baby excreted by Pregnancy maternal liver and kidney Fertilization  Umbilical arteries – waste  Union of a matured ovum and sperm products  Each gamete has a haploid number of chromosomes  Umbilical vein – oxygenated  The sperm carries and X or Y sex chromosome blood  22 pairs- autosomes o Result of the union of the chorion and the o Genotype – genetic material decidua basalis o Phenotype – physical trait o Chorion - source of the primary villi  1 pair- sex chromosomes; determinant of sex o Chorion chorionic villi  release enzymes  o XXY – Klinefelter’s Syntrome; male and female attach to maternal vessel and get blood  o XO – Turner’s Syndrome – no development of blood goes to space called lacunae (blood female sex characeristics lake)  several lacunae will form  cotyledon   Zygote- outcome of fertilization more cotyledon will form placenta (15-20  Father determines sex of the child cotyledons)  Fertilization- sex of the baby is determined o 1 week after fertilization (after implantation)-  2nd month or 8th week- formation of genitals Start of placental formation  12th week- differentiated o 3rd week- circulation starts  (4th month) After 12th week- ultrasound to establish the o 3rd lunar month- complete its formation baby’s sex o Grows until 20 weeks covering about ½ of the  Y sperm - Move really fast but die fast internal surface of the uterus  X sperm - Slow but sure o Corpus luteum  Zygote mitosis blastomeremorula (round, mulberry in  Kept alive by hCG shape, found at the end of the fallopian tube)  enters  Maintain the endometrium to nourish the uterus  blastocyst  (ready to implant)  inner and the baby outer portion o HCG will rise up to the 3rd month o Embryoblast  Prevents involution of the corpus luteum  Inner  Basis for pregnancy tests  Fetal portion  Present in maternal blood 8-10 days o Trophoblast after fertilization (as soon as  Outer will become placenta and fetal implantation occurs) membranes  Level doubles every 2 days  Amnion- fetal membrane  Nauseated  morning sickness  Chorion- placental portion  3rd month, placenta takes over E and P  Decidua  decrease hCG  degeneration of o Basalis corpus luteum; morning sickness  Basalis subsides  Placental portion o Vera University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing  Hyperemesis Gravidarum  Cord Prolapse o Excessive vomiting beyond 1st trimester o Concealed – inside the vagina; elevate the hip o Can be seen in H-mole o Apparent – outside the vagina o Pernicious vomiting – interferes with eating o Baby is not yet engaged  Vomits without food intake o Gold Standard Answer: CHECK THE FETAL HEART  Metabolic alkalosis o Ask mother to lie down  check baby’s heart  Ectopic Pregnancy rate o Level of hCG will not increase above 3 months o Insert a gloved finger into the mother’s vagina to o Management: check for cord prolapse  Methotrexate- stop development of o Position mother to knee chest cells o Trendelenburg is not advisable  compression of  Completed if hCG levels will decrease diaphragm  Abortion o Left side lying- put pillows on the hip to elevate it o Normal hCG then it dropped – assessed through o Apparent serum hCG  Never reposition the cord   H-mole compressed more o Fertilization of an empty ovum  Make sure cord will not shrink o Only placental portion is forming (chorion)  Cover with sterile gauze with warm NSS o No amnion to vasodilate and prevent atrophy o Human Chorionic Gonadotropin  Continuous irrigation  Establish pregnancy through urine  CS- only means of delivery o 7th or 8th week- presence of gestational without a o Emergency Situation baby  A clean cloth is OK o Ultrasound at 1st trimester  Pregnancy testing Amniotic Sac and Amniotic Fluid o She missed her period today, when can she take  Functions the test: TODAY o Cushions fetus against mechanical injury o Done in the morning o Maintains a steady temperature in utero (most o First void important) o Midstream collection o Allows freedom of movement -> change in o Done again a week later if negative at first position of fetus -> musculoskeletal development  IgG- 2 weeks before delivery passed to baby  16-18- multipara  Heparin- safe for pregnancy  18-20- primipara o Cannot cross placenta o Prevents drying of skin  Coumadin- can cross placenta o Permits symmetrical growth of the baby  Anything that happens to the placenta facts the baby o Prevents adherence to the amnion of the fetus  You save the placenta until the MD orders it to be o Source of oral fluid for fetus; of 1000ml, 400 will disposed remain, 600 recycled o Excretion – collection system Placental Aging Theory  Kidney’s start making urine around the 2nd-3rd month  When the placenta degenerates  stimulation of labor  Continuously produced by amnion and fetal urine  Ultrasound- determines the placental age  4th month- increased production because of fully matured o By the amount of calcification or amount of are kidneys that is calcified o Quickening = enough amount of fluid o Grade 3- fully matured placenta (38-40 weeks)  Primi – 5 months o Placenta premature degeneration  Multi 4 months  Blood going to the placenta is  98% H20 and 2% Salt decreased  placenta degenerates  800-1000 ml- normal volume of amniotic fluid o 42 weeks- maximum weeks the baby can stay at  600ml is recycled, 400ml remain the placenta  7-7.25 – pH (alkaline) Umbilical Cord  Oligohydramnios  length of the cord is estimated to be the same length as o Less than 400 ml the baby o Decreased urine production  50-55cm (48-52 for Filipinos)  1 kidney (anomaly); Very small kidneys  Short- might develop abruption placenta  Suggestive of Down’s syndrome  Long- at risk for cord coiling  Polyhydramnios  Haase’s rule o Greater than 2000 ml o 1-5 months = Month2 o Decreased capability to swallow o 6-10 months = Month x 5 (Tracheoesophageal atresia)  A-V-A o Diabetic frequently  Vein carries the 02 blood (placenta to baby) o Multiple pregnancy  Arteries (baby to placenta)  Color  Wharton’s Jelly o Slightly yellow in color, cloudy o Fluid filled connective tissue to connect the baby o Not deep yellow- bilirubin mixed in the fluid to the placenta  Erythroblastosis fetalis o It has fluid to prevent compression of arteries and  Xanthochromic – RH incompatibility; vein in the umbilical cord yellow fluid University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing o Deep yellow – bilirubin staining – Rh - Social drugs – cross addition; withdrawal symptom; get 1st Incompatibility urine sampling o Pink/Red wine color – abruption placenta - Smoking – SGA due to vasoconstriction o Green tinged- meconium stained - Thallidomide (antiemetic) – phocomelia  Needs suctioning to prevent aspiration - Lithium, Streptomycin,Kanamycin – damage to 8th cranial pneumonia nerve: deafness  May cause lung collapse - Tetracycline – staining of permanent teeth of baby  Because of fetal distress (cephalic) - Valium – can lead to cleft palate defect  CS- management  Fluid is also swallowed by the Intrauterine development baby  Pre-embryonic  Suctioning o Ovum zygote embro  Because of breech presentation o 0-2nd week (normal)  Embryonic  Abdomen descends  o 3-8th week increase pressure  o Important period defecation of meconium  Organogenesis o Red wine - mixed with blood  Fetal  Abruptio placenta o 8th week onward  CS- management  2 weeks- heart (beats on the 25th day)  Nitrazine Test  3 weeks- brain/CNS development (B9/folic Acid, glucose) o Lithmus paper test  2 months o Blue- positive rupture of membrane o Separation of GI and respiratory tract  Premature Rupture of Membrane o Sex organ develops o No option to continue the pregnancy  might o Meconium in the intestine lead to chorio-amnionitis o Respiratory structure are not yet formed o Fatal  Rubella- most dangerous o Infection of mother and baby o Can damage structures of the baby developing o Leaking fluid from the vagina at that time o Management o Underdeveloped structures (microcephaly,  IV antibiotics glaucoma, cataract, defect in 8th cranial nerve,  CS mental retardation) o Preterm premature rupture of membrane o 1-3 months- 60% chance of damage  Not in labor yet + pre-term baby o 4th month- 10% chance  Early Rupture  5th month- no chance of harming the o Membrane ruptured before transitional phase baby o Latent period- 3cm dilation o Vaccine NOT safe to be given  give o Active- 4-7 cm GAMMAGLOBULIN o Transitional- 8-10m o After deliverycan have vaccine o Cod Prolapse  Cannot get pregnant for 3 months o May cause Infection and caput succedanum o Best time for rupture: during transitional labor  Chicken Pox o Prolonged Labor o Women in the first 7 months of pregnancy have  Pressure exerted from the placenta a very high immunity for chicken pox helps the cervix dilate o After the 7th month (last trimester)  at risk for  Will cleanse the vaginal wall chicken pox o Dry Labor o If with chicken pox during delivery, after  Amniotic fluid makes the vagina more delivering the baby separate first mother and slippery baby to prevent transmission  Management: use KY jelly o Can have chicken pox vaccine after delivery o Nursing care: but cant get pregnant for 1 month  Check FHT – if abnormal = left side lying position  3rd month (fetal period)  Rupture without prolapse = check o Growth in size and weight temperature frequently – q20 o Sex is well differentiated  Anticipate antibiotic treatment and o Ossification- bone formation and development possible oxytocin augmentation to  Increase intake of calcium enhance contraction to decrease  800 mg (2 servings) – 2 glasses of milk + length of labor. 400 mg for the baby  Ballottement  If decreased calcium intake  baby o Insert gloved fingers into the vagina  tap the will get calcium from mother’s bones  cervix  bouncing movement of baby decreased bone integrity of the mother  loses her teeth FETAL DEVELOPMENT o Sources of calcium - Zygote – first 2 weeks  Dairy - Embryo – 3 to 8th week  Green leafy vegetables o Period of organogenesis  Fish bone (sardines) - Fetus – after the 8th week until delivery  Egg yolk (2 eggs per week) o Period of rapid growth o End of the 3rd month: ideal time from UTZ University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing  Genetic testing (early part of  4th month pregnancy) o Amniotic fluid is recycled as urine  Hemolytic Diseases (middle) o Quickening  Pulmonary Maturity (late) – L:S ratio o Vernix/Lanugo  Sex o Can do amniocentesis o Alpha-feto protein (early)  Enzyme only elevated when there is a  5th month break in the neural tube o Fetal heart rate  Spina bifida  Can be heard as early as 3 months  Elevated- Spina bifida (neural tube (Doppler) defect)  4th month (fetoscope)  Very low- Down syndrome  4-5th month (steth)  Can get from maternal serum  120-160 bpm (maternal serum alpha-feto protein) o Quickening (Primi: 18-20 weeks; multi: 16-18  Good result but not weeks) conclusive o Ballottement  Only a screening test  From amniotic fluid = direct result, done  6 month if maternal AFP shows abnormal values. o Regular sleep wake cycle  98% percent tested positive result but  Neurological functioning has began only 1% is with defect  20 hours a day o Hemolytic Disease  Awake- at night (hungry); at morning  Color of amniotic fluid when mother eats (30 minutes; increase o Pulmonary Maturity (organ maturity) supply of glucose to baby)  Check baby’s lung maturity and kidney  Fetal movement count function  First movement is the start of  High level of creatinine- kidneys are the time functioning  10-12 movements/hour  High level of bilirubin- liver problems (Cardiff Protocol) o Done first with ultrasound: FULL BLADDER  Must eat first before counting o Amniocentesis: EMPTY BLADDER  Empower mother to know the o MOST IMPORTANT: Check signed consent condition of the baby o What will the nurse prepare before  Less than 4 movements in 24 amniocentesis: ultrasound hours- danger sign; do o Abdominal- full bladder (more common) 1 ½-2 biophysical scoring glasses of water o Non Stress Test o Vaginal ultrasound- empty bladder o Ultrasound o After obtaining ultrasound  empty bladder to o Vernix caseosa – for temp regulation facilitate amniocentesis  7th month o Sterilize area  use sterile needle o alveoli opens (surfactants are present) – start of o Use local infiltration lung maturity o 5-10ml is aspirated o No surfactant o Aspirate; should not be exposed to direct light o Fat deposits under the skin o Area of puncture should have adhesive o Weight is doubled o Position on her back but not flat (semi-fowlers) o Red and plethoric  Pillow on right side – Right lateral tilt  8th month  Because uterus could go to the left and cause vena cava AOG L/S Ratio Lung Maturity compression 26-27 Secretion into alveolar Viability o BP and FHT q30 wks space begins attained o Normal side effect  Slight leaking of fluid in the area of 30-32 1:2:1 puncture wks  Baby moves more frequently than 35 wks 2:1 Maturity normal attained  Slightly increase in fetal heart rate  BP of mother slightly increased oPhosphatidyl glycerol  For 2 hours only  Phospholipid only noted when the fetal  Greater than 2 hours- admit to lungs are mature (most important and hospital best indicator) o Abnormal Side effect:  Amniocentesis  Leaking fluid from the vagina  o Test to establish lung maturity and maturity of premature rupture of membrane; early other organs labor – check for pH (REFER) o Not a routine procedure – performed on 2nd  Abortion 1;200 (early) trimester  Early labor (late) o Invasive, needs written consent, UTZ guided. o Can lead to possible abortion o Gives information on fetal: University of Santo Tomas – College of Nursing / JSV  Maternal and Child Nursing Determining EDC o Pre-colostrum - If known LMP, use Nagel’s Rule = -3 +7 +1  Present at 4th month (16th week) - If not known, use Bartholomew’s Rule – abdomen is  Not the real milk but a precursor of milk divided into quadrants  Yellow - McDonald’s Rule – get the fundic height (cm) x 8/7 = AOG  How many days will it take to empty the in weeks breast of colostrum: at least 3 days for - Kung ano yung sa situation, yun yung AOG. multipara - DO not get the lower number  Up to 5 days for primipara o Immediately after delivery  put the baby on Johnson’s Rule – Fh (cm) – n x 155 = g. the breast (without airway obstruction) - N = 11 – if the part is not engaged o CS- slightly delayed breastfeeding (4 hours after - N = 12 – if the part is engaged pa pwede) o Wear bra support Maternal Changes during Pregnancy  Strap supports  Head o Nursing Bra o Hair- grows faster and longer  Thick strap  Stimulated by estrogen  With opening for easier breastfeeding  Old hair that is growing fast  Abdomen  6 months postpartum- lose old hair o Darkening of the LiniaNigra  Don’t use hair treatments  goes to the o Abdominal Striae (stretch marks) baby  Gravidarum- dark brown  Chloasma  Albicantes- whitish o Bony prominences exposed to the sun  Postpartum o Mask of pregnancy o Diastasis Recti Abdominis o Freckles  Overstretching of the rectus abdominis o Dark people - darker areas are on the creases muscle o Only temporary  Abdominal exercise up to 5 months  Melasma  Beyond 4 months- left side lying position o Other parts darkens o Bartholomew’s rule of 4 o Not noticeable in multipara  Determine age gestation fundic height  Nose  5 months- umbilicus o Nasal congestion  Lightening- lowering of the uterus  Increased vascularity  Engagement- lowering of the head of  At risk for epistaxis, advise to open the baby mouth o McDonald’s rule  Gums  Using tape measure to get fundic o Hypertrophied height in cm x 8 / 7  Use soft-bristled toothbrush  = AOG in weeks o Advise to check-up with dentist  Yung given na cm, malapit dun yung o At risk for losing teeth  can never have tooth aog extraction because of anesthesia  Usually higher o Pagnatanggalanng teeth strep might go inside o LMP gums teratogenic  Jan-march o Increased salivation  G  Chew fruits  April-Dec  More acidic  -3 +7 +1  Tooth erosion  Vagina  Frequent use of mouth o Mucus plug- operculum  Decrease bacteria in the o Less acidic- more prone to infection mouth  Legs o Edema  Pica  Poor venous return (too much pressure o Craving for nonfood or nonnourishing food on the lower part of the body) o Decreased nutrition for the baby  Low salt diet o Provide protein to the diet  Management: o Treatment for anemia  Elevate- up to 3 pillows o Nonfood  Edema on nondependent areas is  Clay abnormal  Charcoal  Lower lid and fingers (+3)  Toothpaste o Weight gain o Chemical mother ingest can be dangerous for  1-3 months- 1 lb. per month the baby  4th month and above- 1 lb per week o Refer to psych  Filipino: up to 12 kgs or 25 lbs o Varicosity  Breast