NCM 107: Care of Mother, Child, and Adolescent (Obstetrics - Finals) PDF

BICOL UNIVERSITY College of Nursing A.Y. 2023-2024 NCM 107: Care of Mother, Child, and Adolescent...

BICOL UNIVERSITY College of Nursing A.Y. 2023-2024 NCM 107: Care of Mother, Child, and Adolescent (Obstetrics - Finals) Name of Student: Miles Owen B. Valladolid, S.N. Block: BSN-2C Professor/Coach: Prof. Mary Joy B. Sande, RN, RM, MN, PhDNEd ANTEPARTUM/PRENATAL CARE Screening for diseases It is the monitoring and managing of a - HPN, Anemia, Syphilis, Diabetes, HIV, patient during pregnancy to: UTI - Prevent complications - Promote a healthy outcome for both the mother and infant Give PREVENTIVE MEASURES - Iron and folate supplementation Objectives of Prenatal Care - Tetanus immunization 1. Screening and Prevention of Diseases - In selected population which may complicate pregnancy ✓ Intermittent presumptive 2. Education of women on danger and treatment for malaria emergency signs and symptoms 3. Birth Preparedness & Complication ✓ Iodine supplementation in readiness of the woman and her family for severely iodine deficient areas childbirth - Health Education in Nutrition, Self-Care - Determine Signs of Labor BASIC EMERGENCY OBSTETRIC CARE ✓ A bloody, sticky discharge (BEmONC) APPROACH ✓ Painful contractions every 20 BEFORE mins or less High Risk Approach - waters have broken (BOW) Routine Antenatal Measurement - Danger Signals of Pregnancy - Maternal height to screen for CPD - Breastfeeding - Determining fetal position before 36 - Newborn Screening weeks - Family Planning - Testing for ankle edema to detect pre- - Determine: eclampsia ✓ EBD, AOG, FH, FM - Perform Leopold’s Maneuver NOW-Refocused Antenatal Care The elements of refocused antenatal care SKILLS NECESSARY DURING ANTENATAL are: CARE - At least 4 antenatal visits - Leopold’s Maneuver - Recognition and management of - Auscultation of Fetal Heart Tone complicated pregnancies - Determination of Fetal Movements - Screening for diseases that may FETAL MOVEMENT complicate pregnancy birth and - Vary emergency planning ✓ Depends on the sleep cycles of - Giving preventive measures the fetus and mother’s activity - The provision of adequate prenatal care during observation time - Identification and treatment of anemia - Quickening – 18th – 20th Week - Encouraging the mother to give birth in a - Sandovsky Method health facility with trained personnel ✓ Mother on left recumbent - Schedule of antenatal visits in the position after a meal and record absence of complications: how many fetal movements she ✓ First trimester feels over the next hour. ✓ 26 weeks ✓ 2x/10 min (ave. 10-12x/hour) ✓ 32 weeks ✓ Less than 5 (call health care ✓ 38 weeks providers)  - Cardiff Method ✓ Count-to-ten OBSTETRICAL SCORE ✓ Records the time interval it takes GTPAL or GTPALM for the mother to feel ten fetal movements G Remains the same ✓ Occurs within 60 mins P Is broken down T Number of full-Term infants born (at 37 TERMS RELATED TO PRENANCY STATUS weeks or after) Para (Parity) - the number of pregnancies P Number of Pre-term infants born (20-37 weeks) that reached viability, regardless of A Number of spontaneous or induced whether the infants were born alive or not Abortion Gravidity - the total number of L Number of Living children pregnancies M Multiple Pregnancies Viability - the ability of the fetus to live outside the uterus at the earliest possible T- Term (Full) SUMMARY gestational age; 20-24th weeks or 5-6 P – Preterm months A – Abortion L – Living Children Gravida - a woman who is or has been M – Multiple Pregnancies pregnant EXAMPLE: Primigravida - a woman who is pregnant G3 P20020 (G3P2) for the first time - 2 previous pregnancies and is currently Primipara - a woman who has given birth pregnant to one child past age viability - 2 term infants Multigravida - a woman who has been pregnant previously - No preterm abortion Multipara - a woman who has carried two - 2 living children or more pregnancies to viability - No multiple pregnancies Nulligravida - a woman who has never G3 P11031 (G3P2) been and is not currently pregnant - A woman who had twins, then 1 term and 1 preterm, no abortion and is now EXAMPLE: pregnant again G3 P2 - had two previous pregnancies and has G4 P21030 (G4P3) given birth to two term children and is - Pregnant woman with the following past again pregnant history: ✓ A boy born at 39 weeks gestation G3 PO - had 2 miscarriages at 12 weeks and now alive and well again pregnant ✓ A girl born at 40 weeks gestation now alive and well G1 PO ✓ A girl born at 33 weeks gestation - A woman is pregnant for the first time now alive and well SAMPLE QUESTIONS G2 P1 1. What is the gravida and para for each - A woman is pregnant for the first time of the following women, using the one with twins digit para and four digit para? G2 P2 a. Nancy is pregnant. Her first pregnancy - has had two pregnancies and two resulted in a still birth at 36 weeks of deliveries gestation and her second pregnancy resulted in the birth of her daughter at G2 P0 42 weeks of gestation. - has had two pregnancies, neither of which survived to a gestational age of 24 weeks  b. Marilyn is 6 weeks pregnant. Her previous pregnancies resulted in the live birth of a daughter at 40 weeks of gestation, the live birth of a son at 38 weeks of gestation, and a spontaneous abortion at 10 weeks of gestation. c. Linda is experiencing her fourth pregnancy. Her first pregnancy ended in a spontaneous abortion at 12 weeks, the second resulted in the live birth of twin boys at 32 weeks, and the third resulted in the live birth of a daughter. SAMPLE QUESTIONS (Get the Meaning) Assess the pregnant woman: Pregnancy a. G4 P(4)2204 Status, Birth and Emergency Plan b. G5 P(3)3013 - How old is patient? c. G1 P1 - It’s Linda’s ____ (1 or 3 ) Pregnancy st rd - Gravidity? Parity? - LMP? AOG? GENERAL RULE - History of previous pregnancies 1. Multiple Gestation (twins, triplets) is - Check for general danger signs counted as one in the number of - Perform abdominal examination pregnancy (Gravida) and is counted as one - Help woman decide on appropriate in the number of viable pregnancy (Para) place of birth 2. Stillbirth/Intrauterine Fetal Death - Prepare birth and emergency plan (IUFD)/ Fetal demise is counted as one viable pregnancy Check all women for: ✓ If it falls between 37-42 weeks it is - Pre-eclampsia counted under term pregnancy - Anemia ✓ If it falls less than 37 weeks but - Syphilis more than 20 weeks it is counted in - HIV Status preterm pregnancy - Diabetes Mellitus 3. If the product of conception was delivered before the age of viability (20-24 weeks) it Respond to Observed Signs and considered under abortion Volunteered Problems - No fetal movement DRILL - Ruptured membranes and no labor 1. Mrs. Jacob 2 months AOG visited a - Fever or burning urination doctor with an obstetrical history that reveals her first pregnancy resulted to - Vaginal discharge an abortion - Signs suggesting HIV infection 2. Mrs. Sanchez is again pregnant at 4 - Smoking, alcohol or drug abuse months AOG. She said that she gave - Cough or breathing difficulty birth to her first child at 40 weeks AOG, - Taking anti-TB drugs her second baby was aborted at 16 weeks, her third was a stillbirth delivered 36 weeks AOG 3. A prenatal visit was made by Mrs. ✓ RUPTURED MEMBRANES AND NO LABOR Orosco whose OB history revealed a - > 8 months baby boy delivered by the 39th week - No clear evidence of benefit of routine antibiotic AOG, her second pregnancy resulted to and steroid use. a miscarriage, her third pregnancy was a - < 8 months twin delivered at 35th week AOG and - Give antibiotic: ERYTHROMYCIN (B15). she is pregnant at 3rd month Alternative: Ampicillin - Give corticosteroid if no sign of infection o Betamethasone 12mg IM q 24 hrs. x 2 doses; OR o Dexamethasone 6mg IM 12 hrs. x 4 doses  Give Preventive Measures RECORD all findings, birth plan and - Tetanus toxoid immunization treatments given - Iron/ Folate Supplementation Record: - Mebendazole - Positive Findings - Anti-malaria - Birth Plan - Treatments given - Next Scheduled Visit Focused Antenatal Care - Reduced number of visits - Screening and prevention of diseases that may complicate pregnancy - Education - Birth Plan: Birth Preparedness and complication readiness 2ND PPT: DIAGNOSTIC TESTS At Antenatal Care: Check Immunization 1. ALPHA-FETOPROTEIN ANALYSIS (AFP) Status - a glycogen is produced by fetal liver - Not previously been vaccinated or - It is done to detect chromosomal or immunization status is unknown spinal cord disorder o Give 2 doses of TT/Td one o By 15th week of gestation- serum month apart before delivery test will be done - With 1-4 doses of Td in the past o If abnormal------amniotic fluid will o Give one of TT/Td (at least 2 be assesses of a sonogram will be weeks before delivery. done for confirmation - For the woman to be protected during ❖ increased value- spinal pregnancy, the last dose of tetanus cord disease toxoid must be given at least two ❖ decreased value- weeks prior delivery. chromosomal disorder - Two doses protection for 1-3 years (trisomy 21) - Five doses protection throughout the childbearing years - “NEEDED ANG TETANUS TOXOID PARA MAPREVENT ANG TETANUS” (Buagnin, 2023) Advise & counsel on nutrition, FP, labor signs, danger signs, follow-up visits DEVELOP A BIRTH and EMERGENCY PLAN Advise and Counsel on: - Nutrition - Self-care during pregnancy - Family Planning 2. CHORIONIC VILLI SAMPLING (CVS) - Routine and Follow-up visits - involves the retrieval and analysis of chorionic villi for chromosome analysis Develop a Birthing and Emergency Plan - commonly done at 8-10 weeks - Facility delivery vs home delivery with o chorion cells are located by skilled attendant ultrasound - Advise on signs of labor o a thin catheter is inserted - Advise on DANGER SIGNS ❖ vaginally - Discuss how to prepare for an ❖ abdominally emergency in pregnancy ❖ intravaginally - a number of chorionic cells are removed - Advise to avoid harmful practices for analysis - Advise on breastfeeding & newborn - has a risk of 2% or 4% for excessive screening bleeding - pregnancy loss  Coelocentesis 5. CONTRACTION STRESS TEST OR - a transvaginal aspiration of fluid from OXYTOCIN CHALLENGE TEST (OCT) the extraembryonic cavity is an - FHR is analyzed in conjunction with alternative method for fetal analysis contractions TECHNIQUE a. Oxytocin (Pitocin) ❖ IV infusion of dilute oxytocin until 3 contractions occur within 10 mins ❖ Start: 0.5-1.0 m “u”/min ❖ Titrate: increase 1 m “u” every 20 min ❖ Goal: 3 contractions/10 min b. Nipple stimulation ❖ Source of oxytocin is achieved by 3. AMNIOCENTESIS NIPPLE STIMULATION - Greek word AMNION – “SAC” and KENTESIS – “PUNCTURE” - FHR monitor is in place - The aspiration of amniotic fluid from the INTERPRETATION pregnant uterus for examination a. Positive Test - Done as early as the 12th to 13th week of ❖ presence of late decelerations pregnancy following 50% or more of the - Complications: contractions ❖ Hemorrhage ❖ indicates decreased fetal reserve ❖ Infection of amniotic fluid ❖ Puncture of the fetus and correlates with a 20-40% - sonogram will be done to determine the incidence of abnormal FHR position of the fetus, a pocket of patterns during labor amniotic fluid and placenta b. Negative Test - done to check the ❖ has no late or significant variable Lecithin/Sphingomyelin (L/S) ratio decelerations (lung maturity), phosphatidyl glycerol, bilirubin, chromosomal analysis, alpha- fetoprotein - An L:S ratio of greater than 2.0 to 2.5 is indicative of fetal lung maturity c. Equivocal-suspicious pattern ❖ consists of intermittent late or significant variable associated with abnormal FHR patterns in 4. ULTRASOUND - it is the response of soundwaves against labor, which are often related to objects cord compression due to - Intermittent soundwaves of high oligohydramnios frequency are projected towards the d. Unsatisfactory test ❖ tracing cannot be interpreted or uterus by a transducer placed on the contractions are fewer than 3 inn abdomen or in the vagina 10 mins - sound frequencies that bounce back can be displayed on an oscilloscope screen NOTE: Observe woman for 30 mins afterward to as a visual image see the contractions are quiet and preterm labor does not begin 6. DAILY FETAL MOVEMENT COUNTING b. Warning signs noted during daily (DFMC) frequency monitoring count - Also known as Fetal Kick Count or c. Maternal history of smoking, Cardiff Count-to-Ten Method inadequate nutrition - Test sensitive for fetal well-being at 27 weeks PROCEDURE: - Physiology of normal third trimester a. Done within 30 min wherein the mother is fetal movement placed in semi-fowler’s position (woman should not lie supine to prevent supine A. Fetus spends 10% of its time making hypotension syndrome) gross movements b. External monitors are applied to document ✓ Active fetal periods last 40 mins fetal activity ✓ Inactive fetal periods last 20 mins ❖ Tocotransducer over fundus to detect uterine contractions and B. fetal activity peaks with maternal fetal movements hypoglycemia ❖ Ultrasound transducer over the ✓ Usually occurs between 9pm-1 am abdominal site where more distinct ✓ Activity not increased after meals or fetal heart sounds are detected glucose load c. Mother activates the “mark button” on the electronic monitor when she feels fetal Technique movement a. mother self-monitors kick counts daily at d. Monitor until at least 2 fetal movements are home detected in 20 mins b. begin at the same time each day (usually ❖ If no FM after 40 mins provide woman after breakfast) with a light snack or gentle stimulate c. choose a time of the day that fetus is fetus through abdomen most active ❖ If no FM after 1-hour further testing d. consider performing after stimulating may be indicated, such as contraction activity like after walking or exercising stress test (CST) e. lie on left side in comfortable location f. count each fetal movement, noting how INTERPRETATION long it takes to count 10 fetal movements A. Reactive (Normal) (FMs) ❖ baseline FHT 120-160 bpm ❖ At least 2 accelerations of the Expected findings FHR of at least 15 bpm lasting at a. 10-12 movements in 1 hour or less than an least 15 sec in a 10-20 min period hour as a result of fetal movement b. Warning Signs ❖ Result indicates a healthy fetus ✓ more than 1 hour to reach 10 fetal with an intact nervous system movements B. Non-reactive ✓ less than 10 fetal movements in 12 ❖ monitoring for 2 20-min periods hours and neither period yield adequate ✓ longer time to reach 10 fetal accelerations movements than on previous days ❖ could be indicative of a ✓ movements are becoming weaker, compromised fetus less vigorous ✓ movement alarm signal: 36 weeks and lung maturity tests asphyxia positive (L/S ratio >2) 0-2 (likely asphyxia; continue CRITERIA monitoring for 2 hours; delivery is ❖ Anormal variable is assigned a score of two indicated) and an abnormal variable a score of zero: o The maximal score is 10/10 and MANAGING DISCOMFORTS OF PREGNANCY minimal score is 0/10 ❖ Amniotic fluid volume is based upon an A. MORNING SICKNESS (N/V OR PYROSIS) ultrasound-based objective measurement of - Eat dry crackers or toast before slowly the largest visible pocket: arising o The selected largest pocket must - Eat small frequent meals have a transverse diameter of at - Avoid greasy, highly seasoned food least 1 cm - Take adequate fluids between meals - Ice chips BIO-PRO COMPONENTS a. FETAL BODY MOVEMENTS B. BREAST TENDERNESS - > 3 episodes of either limb or trunk - Wear a well-fitted, supportive bra with movement (2) wide, adjustable straps - < 3 episodes during test (0) C. BACKACHE b. FETAL MUSCLE TONE - Maintain proper body alignment (pelvic - Extremities in flexion at rest and > 1 tilt) episode of extension of extremity, and or - Use good body mechanics (squat and not spine with return to flexion (2) bend when picking objects) - Extension at rest or no return to flexion - Use maternity girdle in selected after movement (0) situations - Wear comfortable shoes c. FETAL BREATHING MOVEMENT - Use proper mattress - Sustained FBM > 30 seconds (2) - Rest frequently - Do pelvic rock exercise, tailor sitting - Absence of FBM or short grasps only < 30 - Apply local heat seconds total (0) D. LEG CRAMPS d. AMNIOTIC FLUID VOLUME - Due to decrease in calcium and increase - Amniotic fluid index >5 or at least 1 in phosphorus pocket measuring 2 cm x 2 cm in - Interferes with circulation perpendicular planes (2) - Stretch involved muscles (e.g. extension - AFI 2 cm x 2 cm (0) of leg with dorsiflexion of the foot) - Maybe related to alteration in calcium, phosphorus) e. NON-STRESS TESTING - > Accelerations > 15 minutes above E. VARICOSE VEINS baseline during test lasting > 15 seconds - Elevate legs frequently when sitting or lying in 20 mins (2) down in bed - < 2 accelerations (0) - Avoid sitting or standing for prolonged periods of time or crossing legs at the knees  - Avoid tight or constricting hosiery or - Due to the circulatory adjustment garters (physician may suggest wearing necessary to accommodate the increase supportive hose) blood supply during pregnancy - Walk regularly - Slower movement will minimize it occurrence F. HEMORRHOIDS - Apply warm compresses O. LEUKORRHEA - Upon recommendation of a physician, - Whitish vaginal discharge due to reinsert hemorrhoids (place client in side- increase amount of normal lying or knee-chest position, use gentle - vaginal secretions (increase in estrogen pressure and lubricant) level) - Avoid constipation - Daily bath or shower - Take sitz baths - Avoid douching - Use perineal pads G. CONSTIPATION - Wear cotton underwear - Due to pressure of the growing fetus - Avoid tight fitting pantyhose against bowel - Increase fluid intake (ideal 6-8 P. HEADACHE glasses/day) - Due to expanding blood volume which - Increase daily roughage in diet put pressure on - Develop good daily bowel movement - Cerebral arteries habits - Rest with cold towel on forehead - Exercise - If frequent and intense, refer to physician - Avoid eye strain H. CONSTIPATION - Change position, lie on left side HEALTH PROMOTION DURING PREGNANCY - Rest with legs and hips elevated (report 1. BATHING any edema in face and hands) - Before bath tubs/hot water douching are contraindicated (contaminated water I. UTERINE CONTRACTIONS (BRAXTON might enter the uterus) HICK’S) - Now it is recommended except during - Normal during late pregnancy the last month of pregnancy - Report if they progressively increase and - Shower bath/sponge bath is most are accompanied by signs of labor) recommended J. FAINTNESS 2. BATHING - Avoid staying in one position over a long - Wear firm, supportive bra period of time - Wash with water with no soap - Arise from bed from a lateral position (to - Dry by patting prevent supine hypotension) 3. DENTAL CARE K. SHORTNESS OF BREATH (DYSPNEA) - Good tooth brushing habit - Use proper posture when erect - Sleep with head elevated by several 4. PERINEAL HYGIENE pillows (left lateral position preferred) - Avoid douching (force irrigating fluid could cause it to enter the cervix and L. PALMAR ERYTHEMA (PALMAR PRURITUS) lead to infection and alters the pH of the - Calamine lotion vagina) M. FATIGUE 5. DRESSING - Due to increase in metabolic requirement - wear comfortable clothes - Increase your amount of sleep and rest - avoid garters, extremely firm girdles with - Maintain good nutrition) panty legs and knee-high stockings ▪ impede lower extremity circulation N. HEART PALPITATIONS - wear shoes with moderate to low heel - Natural Occurrence (minimize pelvic tilt and possible backache) 6. SEXUAL ACTIVITY C. TAILOR SITTING: place 1 leg in front of - Principles the other (same purpose as squatting) a. Should be done in moderation and in D. KEGEL EXERCISE: strengthen private place pubococcygeal muscle b. Mother should be in a comfortable E. ABDOMINAL EXERCISE – strengthen position muscles of abdomen c. Must be avoided 6 weeks prior to EDD F. SHOULDER CIRCLING - strengthen (cervix is slightly dilated, operculum muscle of chest might be dislodged-prone to infection) G. PELVIC ROCKING OR PELVIC TILT - d. Avoid blowing of air during cunnilingus relieves low back pain and maintains to prevent air embolism good posture - Common myths: a. Coitus on the expected date of her period will initiate labor b. Orgasm will initiate labor, but participating in sexual relations without orgasm will not c. Coitus during the fertile days of a cycle will cause a second pregnancy or twins d. Coitus might cause rupture of the membranes - Contraindications: a. Women with history of spontaneous miscarriage b. Ruptures membrane c. Vaginal spotting d. Caution about male oral-female genital contact (accidental air embolism has 8. SLEEP been reported) - Rest period in PM / Afternoon - Modified sim’s position with top leg - Early pregnancy decreased desire for forward (good resting/sleeping coitus (increase estrogen level) position) - 2nd trimester increased (estrogen production) 9. WORK - 3rd trimester decreased (enlarged uterus) - Avoid heavy lifting - New positions for intercourse (side-by-side 10. TRAVEL position) - Early normal pregnancy (no restrictions) - Late pregnancy- Consider early labor 7. EXERCISE - Avoid uncooked fruits, vegetables and - Prevent circulatory stasis in lower meat or drinking unpurified water extremities - Strengthen muscles that will be used SUMMARY during the delivery process ▪ Antenatal care is also called as prenatal - Done in moderation and must be care individualized ▪ Skills required are Leopold’s maneuver, FH measurements, EDC and AOG EXERCISE DURING PREGNANCY computations, and Fetal movement A. WALKING: best form of exercise assessment B. SQUATTING: to strengthen perineal muscles ▪ Focused Antenatal care is the current and increase circulation to perineum (feet flat practice on floor) ▪ At least 4 visits to a health care facility - Do not stand abruptly (postural ▪ Follow the antenatal care process flow of hypotension) rather raise buttocks first the DOH and WHO before the head ▪ Diagnostic procedures are done  ▪ Health education on nutrition, self-care practices, the danger signs of pregnancy, and the birth and emergency plan 3RD PPT: DETERMINATION OF ESTIMATED BIRTHDATE EDC/EDD Naegele’s Rule - Standard method used to predict the length of pregnancy by determining the Last Menstrual Period (LMP) of the mother - From LMP you deduct 3 months plus 7 days McDonald’s Rule plus 1 year (April-December) - a method of determining AOG during - From LMP add 9 months and 7 days mid-pregnancy by measuring fundal (January-March) height - distance from the fundus to the symphysis pubis in cm is equal to PATIENT A | LMP: April 11, 2019 the week of gestation between the Less 3 months January 20th and 31st week of pregnancy Plus 7 days 18 Plus 1 year 2020 How to measure the Fundic Height EDC is January 18, 2020 Preparatory Steps PATIENT B | LMP: September 27, 2019 - Introduce yourself and identify your Less 3 months June client by getting her full name Plus 7 days 34 (Sept = 30 days) - Explain the procedure (Add one month to June and count remaining 4 days) - Provide client’s privacy Plus 1 year 2020 - Wash hands EDC is July 4, 2020 Implementation PATIENT C | LMP: January 10, 2019 - Let the woman void Add 9 months October - Assist her to lie in supine position Plus 7 days 17 - Drape the client exposing only the No need to add 1 2019 abdomen year EDC is October 17, 2019 PATIENT D | LMP: December 28, 2019 Less 3 months September Plus 7 days 35 (Dec. = 31 days) (Add one month to Sept. and count the remaining 4 days) Plus 1 year 2020 EDC is October 4, 2020 AOG Traditional Way Based on LMP - Adding the total number of days of the month from LMP up to the time of visit then divide by 7 to determine the AOG in weeks - EXPRESSED IN FRACTION Example: - AOG - 13 1/7 weeks - The woman is 13 weeks and 1 day pregnant - The fetus is 13 weeks and 1 day old  ❖ Using the fundic height measurement - 2x/10 min (ave 10-12x/hour) compute the AOG in weeks/months - Less than 5 (call health care - length of fundus in cm x 8/7 = AOG in provider) weeks s - length of fundus in cm x 2/7 = AOG in THE CARDIFF COUNT-TO-TEN CHART months - The patient records fetal movements during the course of usual daily ❖ Becomes inaccurate activity - during the 3rd trimester of pregnancy - WARNING SIGNAL: 12 Hours without (fetus is growing more in weight than at least 10 perceived movements: height) patient should be evaluated and - Patients who are obese or with fibroids or should undergo further testing e.g. myoma (abnormal growths in the uterus) NST. Implication ❖ FH greater than this standard suggests - Computed AOG is wrong - Multiple pregnancy - Polyhydramnios (too much amniotic fluid) - Molar Pregnancy (abnormal form of pregnancy) - Pregnancy with Myoma or Ovarian Tumor ❖ FH much less than suggests - Computed AOG is wrong 4th PPT: THE LABOR PROCESS - Baby is not growing well - Intra-uterine Theories of Labor growth restriction (IUGR) Components of Labor (4Ps) - Oligohydramnios LABOR BARTHOLOMEW’S RULE - Regular uterine contractions - To determine age of gestation by fundic - Painful uterine contractions location - Result in progressive cervical change a. 12 weeks (3 months) – over symphysis pubis b. 16 weeks (4 months) - midway between THEORIES OF LABOR symphysis pubis and umbilicus c. 20 weeks (5 months) – at the umbilicus UTERINE STRETCH THEORY d. 36 weeks (9 months) – just below - Any hollow organ once stretch to its xiphoid process maximum potential will always contract and expel its content FM (Fetal Movement) PROSTAGLANDIN THEORY - Vary - 1. A decrease in progesterone depends on the sleep cycles of fetus and - 2. Fetal membranes and uterine mother’s activity during observation decidua (lower part- forebag) - Quickening – 18th-20th week SADOVSKY METHOD - Mother on left recumbent position after a meal and record how many fetal movements she feels over the next hour PROSTAGLANDIN THEORY True Pelvis - The portion below the linea terminalis - The bony passageway through which - The fetus must pass during delivery - Important landmarks of the true pelvis include ✓ Inlet (entrance to the true pelvis) ✓ Mid-pelvis THEORY OF AGING PLACENTA ✓ Outlet (exit point) OXYTOCIN STIMULATION THEORY PELVIC DIMENSIONS (IMPORTANT MEASUREMENTS) COMPONENTS OF LABOR PASSAGE - Woman’s pelvis of adequate size and contour Conjugate vera (11 cm) - Refers to the route the fetus must travel - The most important measurement of from the uterus through the cervix and the inlet (cannot be measured vagina to the external perineum directly; therefore, the health care provider must estimate the size) - Measures between the anterior PELVIC BONES surface of the sacral promontory and superior margin of the symphysis Ileum-lateral/sides of the pubis hips - Diagonal conjugate minus 1.5 Ischium- inferior portion equals the true conjugate Pubes- anterior portion - It is the smallest diameter of the inlet Sacrum- posterior portion through which the fetus must pass Coccyx- posterior portion Obstetrical Conjugate vera (10 cm) - It is the smallest AP diameter of the pelvis False Pelvis - The flared upper portion Diagonal Conjugate (11.5-12.5 cm) - Not considered part of the bony - Extends from the symphysis pubis to passageway the sacral promontory  ❖ OCCIPITAL FONTANEL (LAMBDA) - Lies at the junction of the lambdoidal and sagittal sutures - Triangular in shape ▪ smaller than the anterior fontanelle (2 cm across its widest part) - Closes at 2-3 months NOTE: - The shape and dimensions of the inlet cannot be determined by the size of the woman - A woman might be small in stature but have a roomy gynecoid pelvis - A larger woman may have a small, contracted platypelloid or android pelvis PASSENGER Complete Flexion – Suboccipitobregmatic (9.5cm) Partial Flexion – Occipitofrontal (12cm) Hyperextension Flexion – Occipitomental (9.5cm) Sinciput – the area over the frontal bone Occiput – the area over the occipital bone FETAL PRESENTATION AND POSITION Suture Lines ❖ ATTITUDE - Where the bones of the skull meet - Describes the degree of flexion the Coronal Suture: The line of junction of the 2 fetus assumes during labor frontals bones and the 2 parietal bones - The relation of the fetal parts to each Sagittal Suture: A membranous interspace other that joins the two parietal bones of the skull NOTE: It is the common line of the Coronal ❖ DEGREE OF FLEXION and Lamboid Suture - AP diameter of the fetal head must fit Lamboid Sutures: The line of junction of the through the transverse diameter of occipital bone and the 2 parietal bones the pelvic inlet---12.4– 13.5 cm - Outlet----9.5 to 11.5 cm Molding COMPLETE FLEXION (FULL FLEXION) - overlapping of the sutures of the skull to - Head flexes so sharply that the chin permit passage of the head to the pelvis rests on the thorax - the smallest AP diameter is Fontanelles SUBOCCIPITOBREGMATIC - Significant membrane- covered spaces presentation found at the junction of the main suture - a fetus in good lines attitude ✓ Spinal column is bowed ❖ FRONTAL FONTANEL (BREGMA) forward - lies at the junction of the coronal and ✓ Head flexed forward (chin sagittal sutures touches the sternum) - diamond-shaped (AP diameter 3-4 cm; ✓ Arms are flexed and Transverse diameter 2-3cm) folded on the chest - closes at 12 - 18 mos  ✓ Thighs are flexed onto the abdomen FETAL LIE ✓ Calves are pressed against the posterior - The relationship between the long ✓ Aspect of the thighs axis (cephalocaudal) of the fetal MODERATE FLEXION (MILITARY FLEXION) body and the long axis of the - The chin is not touching the woman’s body chest but is in an alert or “military position” ❖ Vertical/ longitudinal/parallel - Causes the next-widest - 99% of the anteroposterior diameter, fetuses a. cephalic the occipital frontal (head) diameter to present to the b. breech birth canal c. buttocks - Does not interfere with labor (part of descent and ❖ Horizontal/transverse/perpendicular flexion) causes fetus to flex head freely - Fetus is lying horizontally PARTIAL FLEXION ✓long axis is perpendicular to that - Presents the “brow” of the mother - Shoulder presentation represents 1% of the head to the birth canal” of all deliveries - Presenting part usually becomes one POOR FLEXION of the Back is arched a. shoulders - neck is extended (acromion - fetus is in complete process) extension presenting the b. an iliac crest c. a hand OCCIPITOMENTAL d. an elbow DIAMETER of the head to the birth canal FETAL PRESENTATION - face presentation - denotes the body part that will first ✓ an unusual position contact the cervix or deliver first ✓ presents too wide a - determined by fetal lie and degree of diameter to the birth canal for normal birth flexion (attitude) - ✓ reflect neurologic abnormality causing spasticity STATION - refers to the relationship of the presenting part of the fetus to the level of the ischial spines - denoted in cm -1 cm to -4 cm - presenting part is above the spines (described and measured as minus stations) 0 cm - at the level of the ischial spine (engaged) +1 to +4 cm - presenting part below the ischial spines (stated as plus stations) NOTE: CROWNING (+3 OR +4) - presenting part is at the perineum (can be seen in the vulva) POSITIONS - The relationship of the presenting part to a specific quadrant of the woman’s pelvis - Maternal pelvis is divided into 4 quadrants a. right anterior b. left anterior c. right posterior d. left posterior 4 METHODS USED TO DETERMINE FETAL POSITION, PRESENTATION AND LIE: 1. Combined abdominal inspection and palpation- Leopold’s Maneuver 2. Vaginal examination – Internal Exam. 3. Auscultation of fetal heart tones 4. Sonography - Ultrasound POWERS OF LABOR The forces acting to expel fetus and placenta ✓fundus of the uterus LANDMARKS: ✓Abdominal muscles (after full dilation - Occiput: Vertex Presentation of the cervix) - Chin (Mentum): Face Presentation - Sacrum: Breech Presentation - Scapula/Acromion Process: Shoulder Presentation -- marked by abbreviations of 3 letters Description Example 1st Letter defines whether L the landmark is Strength/degree of contractions (50-100 pointing to the mmHg): mother’s right or MILD uterus is contracting but does left not become more than minimally 2nd Letter denotes fetal O tense landmark MODERATE uterus feel firm O - OCCIPUT STRONG - so intense M - MENTUM - uterus feels as hard as a Sa - SACRUM wooden board at the peak of A - ACROMION contraction PROCESS - you cannot indent the uterus 3rd Letter defines whether A with your fingertips the landmark points anteriorly (A), posteriorly (P) or transversely (T) LOA – Left Occiput Anteriorly  PSYCHE Refers to psychological state or feelings that women bring into labor with them 1. Maternal response to uterine contractions 2. Cultural influences and perceptions about labor and delivery 3. Antepartal and/or childbirth education 4. Ability to communicate feelings to significant others and staff 5. Support system Feeling of apprehension or fright Excitement or awe - encourage women to ask questions at prenatal visits - “debriefing time” (encouraging them to share their experience after labor) ANSWERS TO THE GRAVIDA AND PARITY SAMPLE QUESTIONS a. G3 P2 / P1101 b. G4 P2 / P2012 c. G4 P2/ P1213 Reference https://www.scribd.com/document/478844262/Gravida-and-Parity-Practice-Questions-docx ANSWERS TO DRILL 1. G2 P0 / P0010; She is called multigravida, nullipara 2. G4 P2 / P1111; Stillbirth – counted as 1 para as it is viable 3. G4 P2/ P11131; Reference https://classroom.google.com/c/NjE4MTU0MDY4MzM5/m/NTMwNjkyNTk0ODY2/details