Prenatal Care & Tests PDF

## PRE: Empty bladder ### AOG | Location ------- | -------- 12-14 weeks | Symphysis level 16 weeks | Midway between the umbilicus and symphysis pubis 20 weeks | Umbilicus or 20 cm above symphysis pubis 21 weeks - 36 weeks| Increase 1 cm per week 36 weeks | Xyphoid process >37 weeks | Goes down be...

## PRE: Empty bladder ### AOG | Location ------- | -------- 12-14 weeks | Symphysis level 16 weeks | Midway between the umbilicus and symphysis pubis 20 weeks | Umbilicus or 20 cm above symphysis pubis 21 weeks - 36 weeks| Increase 1 cm per week 36 weeks | Xyphoid process >37 weeks | Goes down beginning of engagement - **Engagement:** lowering of the head of the baby - **McDonald's rule:** Using tape measure to get fundic height in cm x 8/7 = AOG in weeks ### Fetal Heart Rate - indicator of fetal well-being ### AOG | Equipment ------- | -------- 10 weeks | Doppler 16 weeks | Fetoscope 18-20 weeks | Stethoscope ### Internal Examination (IE) or Vaginal Examination Purposes: - Confirms the process of pregnancy - Cervix size - Pelvic abnormalities - Detects early pregnancy and gestations Chadwick's, Goodell's, and Hegar's Sign - After 34 weeks: done to assess consistency of the cervix, length and dilatations, fetal presenting part, bony architecture of pelvis, anomalies of the vagina and perineum ### Pelvic Examination and Estimating Pelvic Size - Done in the third trimester to determine CPD - Reveals information on the health of both external and internal reproductive organs - **External genitalia:** HSV 2, Skene's and Bartholin's glands infection, Rectocele, Cystocele - **Internal Genitalia:** Position and color of cervix, pap smear, signs of infection, position, contour, consistency, and tenderness of pelvic organs, strength and irregularity of posterior vaginal wall ### LABORATORY ASSESSMENT - Fetal well-being test - Initial visit - Repeated at 28-32 weeks - To detect anemia ## Blood typing (including RH factor) - Indirect Coomb's Test - Antibody titers for Rubella and Hepatitis B (HBsAg) - HIV screening - Plasma glucose level ## Amniocentesis - Color - Color of water; late in pregnancy, slightly yellow tinge (normally clear-pale). - L/S ratio- 2:1 for lung maturity. - Phosphatidyl glycerol and desaturated phosphatidylcholine- presence indicate lung maturity. - Bilirubin determination- for blood incompatibility. - Chromosome analysis- for karyotyping. - Fetal fibronectin- damage to fetal membranes releases the substance; can signal preterm labor. - Inborn errors of metabolism- enzymes are present in the amniotic fluid. - Alpha-fetoprotein ## Rhythm Strip testing - Assessment of fetal heart rate - Woman in semi-Fowler's position - External fetal heart rate and uterine contraction monitors are attached - FHR is recorded for 20 minutes ## Chorionic Villi Sampling - Uses a catheter to get a sample - Done: 1st trimester (8 to 10 weeks) - Purpose: detection of genetic defects - Pre: consent, full bladder - Intra: Monitor Maternal VS, FHR ## Fetoscopy - Visualization of the fetus by inspection through a fetoscope - To confirm the intactness of the fetus - To obtain biopsy samples of the fetus - To perform elemental surgery - Can be performed as early as the 16th or 17th week ## Ultrasonography - To observe FHR, movement, respirations, position and presentation, fetal death - Can detect: - A gestational sac as early as 5 to 6 weeks after the LMP - Heart activity by the 6 to 7 weeks - Fetal breathing movement by 10 to 11 weeks of pregnancy - Crown-to-rump measurements can be made to assess fetal age until the fetal head can be visualized clearly. ## Urinalysis - Microscopic examination - To test glycosuria, pyuria and proteinuria ## MRI - Has the potential to replace or complement ultrasound - Most helpful in diagnosing complications like ectopic pregnancy and trophoblastic disease ## Maternal Serum alpha-fetoprotein (MSAFP) - Protein produced by liver of unborn baby - Best done at 16-18 weeks of pregnancy - Normal value: 2.5 Mom (multiple of mean) - Increased AFP - neural tube or abdominal defect - Decreased AFP - chromosomal anomaly down syndrome ## Vibroacoustic stimulation - Health teaching: Increase folic acid (400-800 mcg) - Acoustic stimulator is applied to the mother's abdomen to produce a sharp sound to startle and wake the fetus ## Amnioscopy - Visual inspection of amniotic fluid through cervix and membranes - To detect meconium staining ## Triple Screening - Analysis of 3 indicators: MSAFP, unconjugated estriol of HCG ## TB screening - Requires a simple venipuncture - Increases risk for miscarriage. ## Biophysical Profile Scoring ### Assessment using Sonogram #### Criteria for score of 2: - **Fetal breathing:** Presence of 1 episode of 30 seconds of sustained breathing movements in a period of 30 minutes - **Fetal Movement:** 3 separate episodes of fetal limb or trunk movement in a period of 30 minutes - **Fetal tone:** Fetus must show extension and then flexion of the extremities or spine at least once in a period of 30 minutes - **Amniotic Fluid Volume:** Presence of pocket of amniotic fluid that measures more than 1cm in vertical diameter. ### Assessment using non-stress test - **Fetal heart reactivity:** 2 or more FHR accelerations of at least 15 beats/min above baseline and of 15 sec duration with fetal movement in 20-minute period. ### Assessment | Nonstress | Contraction ------- | -------- | -------- **Criterion for measurement** | **Effect of fetal movement to FHR** | **Effect of uterine contractions produced by nipple stimulation on FHR** **Normal Findings** | Presence of 2 or more accelerations of FHR of 15 beats/min for 15 sec or more occurring after fetal movements in a period of 20 min | No late deceleration with contractions ## FETAL GROWTH AND DEVELOPMENT ### Stages of development - **Zygote:** Conception to 2 weeks - **Embryo:** 2 weeks to 2months - **Fetus:** 2 months to term ### Emphasis on development - **1st tri:** Organogenesis - **2nd tri:** Fetal length - **3rd tri:** Rapid G&D ### Months | Description of development ------- | -------- 1st month | - Germ layer formation: Ectoderm, Mesoderm, Endoderm | - Brain or nervous system development | - Fetal heart beat not audible | - Development of trachea and esophagus 2nd month | - Organogenesis is complete | - Development of the placenta | - Development of sex organs 3rd month | - Complete placenta and barrier | - Production of amniotic fluid | - Audible FHT by Doppler | - Bone formation 4th month | - Audible FHT by fetoscope | - Visualization of skeletal outline | - Human face appearance | - Development of external genitalia | - Lanugo: fine 5th month | - Quickening 0 fist fetal movement felt by mother | - Vernix | - Audible FHT by stethoscope 6th month | - Term size | - Scalp hair | - Pinkish, wrinkled skin (premature) 7th month | - Development of alveoli | - Production of surfactant 8th month | - Decreased lanugo and vernix caseosa | - Rapid fat deposition | - Viable for delivery 9th month | - Disappearance and vernix caseosa disappearance | - Amniotic fluid decreases | - Birth position assumed | - Lightening ## Fetal Circulation ### Structure | Location | Function ------- | -------- | -------- **Placenta** | Attached to uterus | Gas exchange during fetal life **Umbilical Arteries** | Two arteries in the cord | Carry unoxygenated blood from the fetus (descending aorta) to the placenta. **Umbilical Vein** | One vein in the cord | Carry oxygenated blood to the fetus **Foramen Ovale** | Opening in the interatrial septum (between the right and left atrium) | To shunt blood from the right atrium to the left atrium so that blood can be supplied to brain, heart and kidney **Ductus Venosus** | Accessory vein connecting umbilical vein into fetal liver and inferior vena cava | To supply blood to liver. A bypass to the fetal liver. **Ductus Arteriosus** | Connection between fetal lungs and the aorta | Shunting of the larger portion of the blood away from the lungs and directly into the aorta. ## INTRAPARTUM (PROCESS OF LABOR & DELIVERY) - A.Κ.Α. Childbirth/Parturition: Series of events by which uterine contractions & abdominal pressure expel a fetus & placenta from a woman's body. - EUTOCIA: Normal labor ## THEORIES OF LABOR ONSET ### Theory | Description ------- | -------- Uterine Stretch Theory | Any hollow organ such as uterus tends to contract and empty itself when distended. Oxytocin Theory | Oxytocin increases before pregnancy comes to term size and initiates labor due to its contraction in the myometrium. Oxytocin stimulates contraction which facilitates sealing of rupture capillaries which then stops the bleeding. Progesterone Deprivation Theory | Decreased amount of progesterone inhibits the relaxation effect of prostaglandin. Aging placenta Theory | Aging placenta cannot anymore support the growing fetus Prostaglandin Theory | Sources of prostaglandin: amnion & deciduas Rising fetal cortisol level increases the formation of prostaglandin which stimulates contraction. Prostaglandin causes the smooth muscles contractions. ## Preliminary/Premonitory Signs of Labor ### Signs | Description ------- | -------- Lightening | Descent of the fetal presenting part into the pelvis. Uterus becomes lower and more anterior. May experience shooting leg pains and increased venous stasis and increased vaginal secretions, urinary frequency, and pelvic pressure. Braxton Hicks Contraction | Irregular, intermittent contractions Cervical Ripening | Felt in the abdomen or inguinal region and patients may mistake them for true labor Internal sign which can be determined only on pelvic examination Throughout pregnancy, the cervix feels softer than normal (goodell's sign). At term, the cervix becomes still softer (describe as butter soft) and it tips forward. Bloody show | Pink - tinged secretions and the mucous plug is often expelled, resulting in a small amount of blood loss from the exposed cervical capillaries. Rupture of Membranes | Clear/odorless and contains white specks (vernix caseosa) and lanugo Yellow-green tinged amniotic fluid infection or fetal passage of meconium → give to the pediatrician → Signals need for further assessment and FHR monitoring Amniotic membranes rupture once labor is well established, either spontaneously or amniotomy Sudden Burst of energy | Burst of energy approximately 24-28 hours before labor. Prepares a woman's body for the work of labor ahead. ## Comparisons of true and false labor pains ### True Labor | False Labor ------- | -------- **Contractions** | Regular; Contractions do not decrease with rest or warm tub bath | Irregular; Rest and warm tub bath lessen contractions **Intervals** | Shortened | Long **Intensity** | Increases with change in activity | No change and walking may lessen the pain **Dilatation/effacement** | Progressive | No changes in the cervix **Discomfort** | Lower back radiating to the abdomen | Lower abdomen ## Causes of Labor onset 1. Decreased placental function due to aging placenta 2. Increases prostaglandins 3. Decreased progesterone 4. Increased oxytocin 5. Increased uterine stretch ## COMPONENTS OF LABOR 1. The passage (birth canal) 2. The passenger (fetus) 3. The relationship between the maternal pelvis and presenting part of the fetus 4. The powers of Labor 5. Position of the mother 6. Psyche/psychological outlook ## PASSAGE - The route a fetus must travel from the uterus through the cervix & vagina to the external perineum - Must be of adequate size ## Two pelvic measurements important to determine the adequacy of the pelvic size: 1. Diagonal conjugate (the AP diameter of the inlet) 2. Transverse diameter of the outlet ### Critical factors: - Size of maternal pelvis (diameters of the pelvic inlet, midpelvis, and outlet) - Type of maternal pelvis (Gynecoid, Android, anthropoid, platypelloid) - Ability of the cervix to dilate and efface - Ability of the vaginal canal and introitus to distend ## PASSENGER "The FETUS" - The movement of the fetus, through the birth canal is determined by several interacting factors: ### Presentation | Assessment of the passenger | Attitude ------- | -------- | -------- **Part of the fetus in the lower pole of the uterus overlying the pelvic brim.** Cephalic, vertex, breech | Posture of the fetus Flexion, deflexion, extension | **Lie** Relation of the long axis of the fetus to the mother Normal: Longitudinal lie | **Position** Relationship of the presenting part to the mother's pelvis Expressed by referring to the position of one area of the presenting part ## FETAL HEAD - **Sutures:** spaces between cranial bones - Frontal - between 2 frontal bones - Coronal - between frontal & parietal bones - Sagittal - between 2 parietal bones (midline suture) most important suture - overrides in labor (molding) decreasing biparietal diameter by 0.5 to 1 cm. - Lambdoidal - posterior suture; between parietal & occipital bones. - **Fontanelles:** Membrane-filled spaces called fontanels/fontanelles are located where the sutures intersect. - Posterior fontanelle - Anterior fontanelle - **ANTERIOR & POSTERIOR FONTANELLES** are clinically useful along with the **SUTURES** in identifying the position of the fetal head in the pelvis and in assessing the status of the newborn after birth. Fontanelle spaces compress during childbirth to aid in **MOLDING** of the fetal head. ## FETAL ATTITUDE/HABITUS - degree of flexion - Relation of the fetal body parts to each other - **FLEXION:** head flexed on chest - **EXTENSION:** head extended; occiput touches the back ### TYPES: 1. **Complete flexion:** A 2. **Moderate flexion:** B 3. **Poor flexion:** C 4. **Hyperextension:** D ## FETAL LIE - It is the relation of the long axis of the fetal body and the long axis of the mother body. - **Longitudinal/vertical lie:** cephalic or breech - parallel - **Transverse/horizontal lie:** shoulder - perpendicular - **Oblique lie:** becomes longitudinal or transverse during labor. ### Types of cephalic presentation 1. **Vertex** - occiput is the presenting part 2. **Sinciput** - fetal head is partially flexed, with the anterior fontanel, or bregma, presenting 3. **Brow** - fetal head is partially extended; the sinciput (forehead) is the presenting part. 4. **face** - fetal head is hyperextended; the face is the presenting part. ## Types of Breech Presentation 1. **Complete** - both legs are flex 2. **Incomplete** - 1 leg is flexed, the other leg is extended 3. **Frank**-both legs are extended 4. **Footing**-1 foot ## FETAL POSITION - The relationship of the presenting part to a specific quadrant of the woman's pelvis. ### 4 quadrants of maternal pelvis 1. Right anterior 2. Left anterior 3. Right posterior 4. Left posterior - **Indicated by an abbreviation of three letters.** - First letter defines whether the landmark is pointing to the mother's right (R) or (L) - Middle letter denotes the fetal landmark (O) for OCCIPUT, M for MENTUM OR CHIN, Sa for SACRUM & A for acromion process. - Last letter defines whether the landmark points anteriorly (A), posteriorly(P) or transversely (T) ### Four parts of fetus as landmarks: 1. Vertex presentation - occiput 2. Face presentation - chin (mentum) 3. Breech presentation - sacrum 4. Shoulder presentation - acromion process ## STATION It is relationship of presenting part to the level of the ischial spine (IS) and measure of the degree of descent of the presenting part of the fetus through the birth canal. - Floating (-3)- presenting part above the inlet, in false pelvis - Dipping (-2) - Minus (-) - presenting part above the IS - Fixed (-1) - presenting part below the inlet, in true pelvis, no longer moving but not yet engaged. - Station (-5) - presenting part at pelvic inlet - **ENGAGED/STATION 0-PRESENTING PART AT IS** - Plus (+) station - presenting part below IS - (+4) - crowning - presenting part at perineum - Station (+5) - presenting part at pelvic outlet ## Leopold's Maneuver - Systematic method of observation and palpation to determine fetal position. ### Nursing Responsibilities 1. Ask patient to empty the bladder 2. Position patient in supine position with her knees flexed slightly so abdomen is relaxed. 3. Warm hands to avoid contraction of abdominal muscles. 4. Gentle but firm touch ### First Maneuver (Fundal Grip) | Purpose ------- | -------- | Fetal Presentation ### Second Maneuver (Umbilical Grip) | Purpose ------- | -------- | Fetal Back | FHR | Fetal Lie ### Third Maneuver (Pawlick's Grip) | Purpose ------- | -------- | Fetal Engagement ### Fourth Maneuver (Pelvic Grip) | Purpose ------- | -------- | Fetal attitude ## POWERS OF LABOR - Involuntary and voluntary powers combine to expel the fetus, the fetal membranes and the placenta from the uterus ### Primary power/primary force - 3 phases of contraction: - Increment - Acme - Decrement - **DURATION:** beginning to end of one contraction - **FREQUENCY:** beginning of one contraction to the beginning of the next contraction. - **INTENSITY:** - Mild intensity fundus indents easily & feels like a tip of your nose. - Moderate intensity fundus indents less easily (firm fundus that is difficult to indent) and feels like chin. - Strong intensity fundus cannot be indented & feels like a forehead. - **WOF:** Contractions occurring more often than every two minutes and persistent contraction duration longer than 90 seconds may reduce fetal oxygen supply - Responsible for the effacement and dilation or the cervix and descent of the fetus - **Effacement:** shortening and thinning of the cervix during the first stage of labor. - **dilation/dilatation:** enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun. ### Secondary power/ secondary force 1. Use of abdominal muscles to push during the second stage of labor. 2. The voluntary bearing down the efforts by the woman 3. As soon as the presenting part reaches the pelvic floor, the contractions change in character and become expulsive. 4. If the cervix is not fully dilated, bearing down can cause cervical edema (which retard dilatation) possible tearing and bruising of the cervix, and maternal exhaustion. ### Positions: - Upright position - Lateral position - Lithotomy position - Semi recumbent position - Sitting position - kneeling or squatting position ## STAGES OF LABOR - I-onset of true labor up to full cervical dilatation - II- full cervical dilatation up to the birth of the baby (pushing stage) - III- birth of the baby up to placental delivery - IV - puerperium (up to 6 weeks post-partum) ### First stage #### Latant | Active | Transitional ------- | -------- | -------- **Dilatation** | 0-3 cm | 4-7 cm | 8 to 10 cm **Frequency** | Every 5-10 minutes | Every 3 -5 minutes | Every 2-3 minutes **Duration** | 20-40 seconds | 40-60 seconds | 60-90 seconds **Intensity** | Mild | Moderate-severe | Severe ## FHR VARIABILITIES ### FHR PATTERN | Description | Cause | Nursing Interventions ------- | -------- | -------- | -------- Early deceleration | Decrease FHR at the onset of uterine contractions (UC) then returns to baseline at the END of UC | Head compression | Continue monitoring maternal VS FHR Late Deceleration | Decrease in FHR after the onset of UC, continues beyond the end of the UC | Placental Insufficiency due to IVC compression on RL part | L side lying position Give oxygen Increase fluids Variable Deceleration | Decrease FHR is unpredictable times in relation to UC | Cord compression and cord prolapse | Knee chest position Trendelenburg Give Oxygen Increase Fluids ### Nursing responsibilities: 1. Assessment - mother - VS; baby = FHT 2. Nutrition - ice chips, yogurt but determine the presentation - ONLY for cephalic 3. Position - semi or high-fowlers with both legs flexed 4. Sacral pressure - relieves low back pain - Effleurage - light massage (abdomen/thigh) - Breathing technique: - LATENT - chest breathing - ACTIVE - Abdominal breathing - TRANSITIONAL - pant pant blow 5. Encourage voiding to allow more space for contraction. Avoid rupture of bladder. ## SECOND STAGE - Intrapartal care - Full dilatation and cervical effacement to birth of an infant - Cardinal movements of labor (De-F-IR-E-R-ER-E) 1. **Descent:**-fetal head enters the maternal inlet in the occiput transverse or oblique position 2. **Flexion:**- fetal chin flexes downward onto the chest. 3. **Internal rotation:**- Occiput usually rotated from left to right and the sagittal suture aligns in the anteroposterior pelvic diameter. 4. **Extension:**- head is born in extension as the occiput slides under the symphysis pubis. 5. **Restitution:**- once the head is born and free from pelvic resistance, the neck untwists, turning the head to one side and aligns with the position of the back of the birth canal. 6. **External rotation:**- head rotates back to the diagonal or transverse position. This brings the shoulders into an anteroposterior position. 7. **Expulsion:**- Anterior and posterior shoulders are born, quickly followed by the rest of the body ### Medications given: 1. **Analgesic:** - DOC: Nalbuphin HCl (nubain) /Meperidine *Demerol - given 2 to 3 hours before delivery (time to reach fetal blood) - WOF: respiratory depression - Contraindicated: Pre-term labor due to immaturities of fetus - Antidote: Naloxone # 2. Anesthesia - Pudendal block for episiotomy - Epidural - side lying position - WOF Hypotension; Give: Ephedrine, side-lying, O2 and fluids, (+) leg compression - Spinal - sitting with back arch - WOF Headache, hypotension - same management but flat on bed for 10-12 hours (X) pillow ### Nursing Responsibilities 1. Sterile vaginal examinations 2. Monitor BP q30, FHT q15mins 3. Provide support, reassurance, and clear directions for the woman to follow. Provide information regarding the process of her labor 4. When contraction beings, the nurse tells the woman to take two breaths, then to take a thirdbreath and hold it while pulling back on her knees and pushing down with her abdominal muscles 5. Assist woman into a comfortable position for pushing 6. Assess the level of pain 7. Positions: Dorsal recumbent/lithotomy 8. Assist in episiotomy ## THIRD STAGE - the placental stage - Placental separation/expulsion/delivery - Begins with the birth of the infant and ends with the delivery of the placenta ### Phases - Placental separation - Sudden gush of blood from the vagina - Lengthening of the umbilical cord - Calkin's sign: change in uterus shape - Firm contraction of uterus - Appearance of the placenta at the vaginal opening - Placental expulsion/delivery ### Techniques used to facilitate delivery - Brandt-andrews: placing fingers of one hand at lower uterine segment and uterus is pushed upwards in to the abdomen at the same time maintaining gentle traction on clamped umbilical cord - Modified crede's- gentle pressure is applied on the fundus of the contracted uterus, separated placenta is pushed downward to the vagina. Uterine fundus is grasped with 4 fingers at the back and the thumb anteriorly - Schultze- placenta separates from the inside to the outer margins, and it is delivered with the fetal side presenting first and most common method of placental expulsion ### Presentation 1. Shiny Schultze - side: fetal; separation: center 2. Dirty Duncan - side: maternal; separation: edges ## Placental Examination - *No indention = complete 15 - 20 cotyledons* ### Nursing Responsibilities: 1. Placental delivery may take 5 to 10 minutes (maximum 20 minutes). Either by Duncan (dirty presentation of uterus) or Schultze (shiny and glistering). 2. Evaluate placental completeness (up to 30 cotyledons, weighing about 400 to 600 grams (11b) and is 1/6 of fetal weight. 3. Observe for signs of placental separation (appear 5 mins after birth ) 4. Palpate uterus for ballooning 5. Vagina and cervix are inspected for lacerations and any necessary repairs are made, take BP - Degrees of perineal lacerations - 1st degree- limited to the fourchette and superficial perineal skin or vaginal mucosa - 2nd degree- beyond fourchette, perineal skin and vaginal mucosa to perineal muscles and fascia, but not the anal sphincter - 3rd stage- fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter aretorn - 4th degree- fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are torn. 6. Give oxytocin as ordered. Oxytocin (Pitocin) 10-20 u may be added to an IV infusion or 10 units IM 7. Assess and record BP before and after administration of oxytocin and assess the amount of bleeding ## FOURTH STAGE - 6 weeks after childbirth; mother's reproductive organ returns to normal prepregnancy state ### Nursing Responsibilities 1. Places clean absorbent pad beneath her and apply maternity pads. 3. Apply cold pack over the perineum 4. Palpate uterus q15 for first 1-2 hrs. Monitor VS q15. 5. Inspect the lochia 6. A heated bath blanket/warm drink 7. Encourage to rest 8. Systemic medications ## SUMMARY ### 1 st | Dilation | Intensity | Duration | Frequency | Nullipara | Multip ara ------- | -------- | -------- | -------- | -------- | --------| -------- Latent | 0-3 cms | Mild to moderate | 20-30 secs | 10-30 mins | 6 hrs | 4-5 hrs Active phase | 4-7 cms | Moderately strong | 40-60 secs | 5-7 mins | 3 hrs | 2 hrs Transition phase | 8-10 cms | Strong | 60-90 secs | 2-3 mins | 3 hrs | ▷ 1 hr Average 15 mins ## 2ND | PHASE | STATION | CONTRACTION ------- | -------- | -------- | -------- | Phase I | 0 to +2 | 2 to 3 minutes apart | Phase II | +2 to +4 | 2 to 2.5 mins. Apart with urgency to bear down | Phase III | +4 to birth | To 2 mins apart; fetal head is visible | Placental Delivery | | Puerperium | ## Psychological Adaptation ### Stage | Duration | Feature | Management ------- | -------- | -------- | -------- Taking in | 1-3 days | FOCUS: self Passive dependent | FOCUS: mother Assist with ADL's Taking hold | 4-10 days | FOCUS: baby Readiness to learn | FOCUS: NB teaching (BF and cord care) letting-go | >10 days | FOCUS: New Role | Support guidance Family planning ### Postpartum blues | Postpartum depression | Postpartum psychosis ------- | -------- | -------- **Incidence** | 50%-85% | 10%-15% | 0.1%-0.2% **Duration** | 2-3 days, resolves within 10 | 2 weeks to 12 months | Variable (typically 4-6 weeks postpartum) ### Symptoms | Tearfulness, fatigue, depressed effect, and irritability | Depressed effect, anxiety, symptoms worsen at night, poor concentration, decreased libido | Delusions, confusion, sleep disturbances, unusual behavior, emotional liability ### Treatment | Reassurance, watchful waiting, 20% of patients will develop postpartum depression within one year | Antidepressants, psychotherapy | Antipsychotic, antidepressant, possibly in-patient hospitalization ## Physiologic changes of the post-partal period ### Reproductive system - Fundus of the uterus may be palpated through the abdominal wall, halfway between the symphysis pubis and umbilicus within a few minutes after birth - One hour later, it will have risen to the level of the umbilicus, where it remains for approximately the next 24 hours - Decreases 1 finger breadth per day on the first postpartal day, it will be palpable 1 fingerbreadth below the umbilicus - On the second day, 2 fingerbreadths below the umbilicus - 9th-10th day uterus will have contracted so much that it is withdrawn to the pelvis and can no longer be palpated in the abdomen - Uterus will never completely return to its prepregnancy state but its reduction in size is simply dramatic - 500 gms prepregnancy weight - Decreases one fingerbreadth a day in size ### Involution of the uterus: - The process whereby the reproductive organs return to their nonpregnant state - Weight of the uterus: 500g ### Conditions that might delay involution: - Retained placenta or membranes - Full bladder - Well contracted fundus- firm; can be compared with a grapefruit in size and tenseness or consistency - Poor contracted fundus- boggy (soft or flabby) - Birth of multiple fetuses - Hydramnios- too much amniotic fluid - Exhaustion from prolonged labor or difficult birth - Grand multiparity - Physiologic effects of excessive analgesia ## Lochia - Sloughing process by the means of uterine flow consisting of blood, fragments of deciduas, white blood cells, mucus, and some bacteria ### Type | Color | Duration | Composition ------- | -------- | -------- | -------- Rubra | Dark Red | 1-3 days | Blood fragments, deciduas, mucus Serosa | Pink to brownish | 3-10 days | Blood, mucus, leukocytes (healing) Alba | Yellow to white | 10-14 (may last 6 weeks) | Largely mucus, leukocyte count is high ## POST-PARTAL PROBLEMS ## A. Early first 24 hours ### Type | Description | Management ------- | -------- | -------- Uterine Atony | Lack of tonicity Most common cause of post-partal bleeding Risk factors: deep anesthesia/analgesia, prolonged labor, full bladder, age >35 years | 1. Empty Bladder at least every 4 hours 2. Uterine massage until uterus becomes firm → increase risk for relaxation permanent due to fatigue 3. Pitocin/methergine 4. Hysterectomy (for extreme bleeding) ### Types | Description | Management ------- | -------- | -------- Laceration | 1. Cervical 2. Vaginal 3. Perineal | Cervical - repair Vaginal - repair and vaginal packing Perineal - mgt repair, increase fluids, stools softeners, avoid enema, suppository, rectal temp Uterine Inversion | Cause: incomplete placental separation | 1. Inform MD/midwife 2. Anesthesia, antibiotic, tocolytics 3. Oxygen 4. IV fluids/BT 5. CS for future pregnancies ## BREAST DISCOMFORTS ### Discomfort | Assessment | Management ------- | -------- | -------- Engorgement | Pain, fullness | BF: regular breastfeeding pump, Warm compress, massage, supportive bra (X) sports bra Non-BF: Cold compress, tight bra/binder Sore Nipples | Cracked | Position baby slightly different per feeding Use mild soap and water Air dry Vitamin E lotion, drops of milk and massage ## SCHEDULE OF RETURN PRE-PREGNANCY STATE ### Onset | Breastfeeding mother | Non-BF ------- | -------- | -------- Ovulation | 6 months | 6-8 weeks Menstruation | 3-4 months | 6-8 weeks Contraception | No pills - estrogen decreases milk production | Pills Abstinence | 3-4 weeks to (X) cervical and vaginal infection Even post CS | ## TERATOGENIC VACCINES 1. MMR 2. HPV 3. Polio ## TERATOGENIC DRUGS - Warfarin - Ace inhibitors - Lithium - Thalidomide - anti emetic - Steroids, streptomycin, statin - Valproic acid - Iodides - Rogaine (hair grower) - Tetracycline - Isotretinoin (for acne) - OHA - oral hypoglycemic agents ## TORCH INFECTIONS ### TOXOPLASMOSIS - Others (HIV, Hepatitis, Syphilis) ### Rubella - Cytomegalovirus → causes neurologically challenge ### Herpes --) active Lesions ## Toxoplasmosis ### Cause | parasite/protozoa (protozoan toxoplasma gondii) ------- | -------- ### Transmission | Can be ingested - Infected meat of animals (not well cooked) From droppings of animals - Droppings of cat feces ### Manifestations | Maternal: May cause repeated abortion Fetal effects: 1. Fetal hydrocephaly 2. Chorioretinitis 3. Cerebral calcification CNS signs: Microcephaly, seizures, severe mental retardation ## Diagnosis | Congenital heart defects: patent ductus arteriosus Auditory: high incidence of delayed hearing loss Prepregnancy serum analysis Amniocentesis ------- | -------- ## Medical | Antibiotics - Sulfadiazine with pyrimethamine drug ------- | -------- ## Treatment | Abortion is an option ------- | -------- ## Prevention | 1. Removing unhealthy cat from the home during pregnancy. Do not touch cat litter 2. Eat only well-cooked meat. 3. Reinforce proper hand washing after handling uncooked meat ------- | -------- ## NOTES