Obstetric Nursing - Intrapartal Period

Nursing lectures is proud to share with you a comprehensive review about the Intrapartal period. Included in this lecture are the following

1. A. Admitting the laboring Mother:
   • Personal Data: name, age, address, etc
   • Baseline Data: v/s especially BP, weight
2. • Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks
   • Physical Exams,Pelvic Exams
3. B. Basic knowledge in Intrapartum .
4. A. Theories of the Onset of Labor
   • 1.) uterine stretch theory
   • -( any hollow organ when stretched, will always contract & expel its content).
   • – contraction action.
5. • 2.) Oxytocin Theory
   • – post pit gland releases oxytocin. Hypothalamus produces oxytocin
6. • 3.) Prostaglandin Theory
   • – stimulation of arachidonic acid.
   • – prostaglandin- contraction
7. • 4.) progesterone theory
   • – before labor, decrease progesterone will stimulate contractions & labor.
8. • 5.) Theory of Aging placenta
   • – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).
9. B. The 4 P’s of labor
   • Passenger
   • a. Fetal head
   • – is the largest presenting part
   • – common presenting part
   • ¼ of its length.
11. • Bones – 6 bones
    • S–sphenoidF –frontal –sinciput
    • E–ethmoid O–occipital–occiput
    • T–temporal P– parietal 2 x
12. Measurement fetal head:
    • transverse diameter – 9.25cm
    • biparietal – 9.5cm
    • largest transverse
    • bitemporal 8 cm
13. • Sutures
    • – intermembranous spaces that allow molding.
14. • 1.Sagittal Suture
    • – connects 2 parietal bones .
15. • 2.Coronal suture
    • – connects parietal & frontal bone (crown).
16. • 3.Lambdoidal suture
    • – connects occipital & parietal bone.
17. • Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis
19. Fontanels:
    • 1.Anterior fontanel
    • – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close.
20. • 2.Posterior fontanel or lambda
    • – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
21. • 4. Anteroposterior diameter
    • - suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
22. • occipitofrontal 12cm partial flexion
    • occipitomental – 13.5 cm hyper extension submentobregmatic-face presentation
24. 2. Passageway
    • Mom
    • 1.) <>
    • 2.) <>
    • 3.) Underwent pelvic dislocation
25. Pelvis
26. 4 Main Pelvic Types
    • Gynecoid
    • – round, wide, deeper most suitable (normal female pelvis) for pregnancy.
28. • 2. Android
    • – heart shape “male pelvis”- anterior part pointed, posterior part shallow.
30. • 3. Anthropoid
    • – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
32. • 4. Plattypelloid
    • – flat AP diameter – narrow, transverse – wider
35. • 2 hip bones –2 innominate bones
37. 3 Parts of 2 Innominate Bones
38. • Ileum
    • – lateral side of hips
    • -iliac crest
    • – flaring superior border forming prominence of hips.
39. • Ischium
    • – inferior portion
    • - ischial tuberosity where we sit
    • – landmark to get external measurement of pelvis
40. • Pubes
    • – ant portion – symphysis pubis junction between 2 pubes
41. • 1 sacrum
    • – post portion – sacral prominence – landmark to get internal measurement of pelvis
    • 1 coccyx
    • – 5 small bones compresses during vaginal delivery
42. Important Measurements
43. • Diagonal Conjugate
    • – measure between sacral promontory and inferior margin of the symphysis pubis.
45. • Measurement: 11.5 cm - 12.5 cm
    • - basis in getting true conjugate. (DC – 11.5 cm=true conjugate)
46. • 2. True conjugate/conjugate vera
    • – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm.
47. • 3. Obstetrical conjugate
    • – smallest AP diameter. Pelvis at 10 cm or more.
48. • Tuberoischi Diameter
    • – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.
50. 3. Power
    • – the force acting to expel the fetus and placenta – myometrium – powers of labor.
51. 4. Psyche/Person
    • – psychological stress when the mother is fighting the labor experience.
52. • Cultural Interpretation
    • b. Preparation
    • c. Past Experience
    • d. Support System
53. Pre-eminent Signs of Labor
54. S&Sx
    • 1.Lightening
    • – setting of presenting part into pelvic brim - 2 weeks prior to EDD
    • -shooting pain radiating to the legs
    • -urinary freq.
55. • 2.* Engagement- setting of presenting part into pelvic inlet
    • 3.Braxton Hicks Contractions
    • – painless irregular contractions.
56. • 4. Increase Activity of the Mother
    • 5. Ripening of the Cervix
    • – butter soft.
57. • 6. Decreased body wt
    • – 1.5 – 3 lbs
    • 7. Bloody Show
    • – pinkish vaginal discharge – blood & leukorrhea
59. • 8. Rupture of Membranes
    • – rupture of water.
60. • Premature Rupture of Membrane ( PROM)
    • check for cord prolapse.
61. • Contraction drops in intensity even though very painful
    • Contraction drops in frequently
    • Uterus is tensed and/or contracting between contractions
62. Nursing Care
63. • Administer Analgesics
    • Attempt manual rotation for ROP or LOP
    • Bear down with contractions
64. • Adequate hydration – prepare for CS
    • Sedation as ordered
    • Cesarean delivery may be required, especially if fetal distress is noted
65. • Cord Prolapse
    • – a complication when the umbilical cord falls or is washed through the cervix into the vagina
66. Danger signs
    • PROM
    • Presenting part has not yet engaged
    • Fetal distress
    • Protruding cord form vagina
67. Nursing care
68. • Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy
69. • Slip cord away from presenting part
    • Count pulsation of cord for FHT
    • Prep mom for CS
70. • Positioning – trendelenberg or knee chest position
    • Emotional support
71. • Difference Between True Labor and False Labor
72. • False Labor
    • Irregular contractions
    • No increase in intensity
    • confined to abdomen
    • relived by walking
    • No cervical changes
73. • True Labor Contractions
    • are regular
    • Increased intensity
    • Pain – begins lower back radiates to abdomen
    • Pain – intensified by walking
    • Cervical effacement & dilatation * major sx of true labor.
76. Duration of Labor
    • Primipara
    • – 14 hrs & not more than 20 hrs
    • Multipara
    • – 8 hrs & not > 14 hrs
77. • Effacement – softening & thinning of cervix. Use % in unit of measurement
    • Dilation – widening of cervix. Unit used is cm
78. Nursing Interventions in Each Stage of Labor
79. • First Stage
    • onset of true contractions to full dilation and effacement of cervix.
80. Latent Phase
    • Assessment:
    • a. Dilations
    • 0 – 3 cm
81. • Frequency
    • every 5 – 10 min Intensity mild.
82. Nursing Care
    • 1.Encourage walking
    • 2.Encourage to void q 2 – 3 hrs
    • 3.Breathing – chest breathing
83. Active Phase
    • Assessment:
    • Dilations 4 -8 cm
    • Intensity: moderate
    • Mom- fears losing control of self
84. • Frequency
    • q 3-5 min lasting for 30 – 60 seconds.
85. Nursing Care
86. • M –edications
    • – have meds ready
    • A –ssessment
    • include: vital signs, cervical dilation and effacement, fetal monitor, etc.
87. • D – dry lips
    • – oral care (ointment)
    • dry linens.
    • B – abdominal breathing
88. Transitional Phase
    • Assessment :
    • Dilations
    • - 8 – 10 cm
    • Frequency
    • -q 2-3 min contractions
89. • Durations
    • -45 – 90 seconds
    • Intensity
    • -strong
    • Mom – mood changes
90. • Hyperesthesia
    • – increase sensitivity to touch, pain all over.
91. Health Teaching
    • teach: sacral pressure on lower back
    • keep informed of the progress
    • controlled chest breathing
92. Nursing Care
    • T – ires
    • I – nform of progress
    • R – estless support her breathing technique
    • E – ncourage and praise
    • D – iscomfort
93. Pelvic Exams
    • Effacement
    • Dilation
94. • Station
    • – landmark used: ischial spine.
95. • - 1 station = presenting part 1cm above ischial spine if (-) floating
    • -2 station = presenting part 2 cm above ischial spine if (-) floating
96. • 0 station = level at ischial spine – engagement
    • + 1 station = below 1 cm ischial spine
    • +3 to +5 = crowning – occurs at 2nd stage of labor
98. • Presentation/lie
    • – the relationship of the long axis (spine) of the fetus to the long axis of the mother.
    • -spine of mom and spine of fetus.
99. Two types
    • Longitudinal Lie ( Parallel)
    • cephalic:
    • Vertex – complete flexion
    • Face
    • Brow
    • Chin
100. • Breech :
     • a. Complete Breech
     • – thigh breast on abdomen, breast lie on thigh
101. • Incomplete Breech
     • – thigh rest on abdominal
102. • Frank – legs extend to head
     • Footling – single, double
104. • 2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation
105. • c. Position
     • – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.
106. Variety
     • Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis
     • LOP – left occipito posterior
107. • LOP – most common mal position, most painful
     • ROP – squatting pos on mom
     • ROT
     • ROA
116. • *Breech
     • - use sacrum
     • - put stethoscope above umbilicus
     • LSA – left sacro anterior
     • LST, LSP, RSA, RST, RSP
     • *Shoulder/acromniodorso
     • LADA, LADT, LADP, RADA
117. • Chin / Mento
     • LMA, LMT, LMP, RMP, RMA, RMT, RMP
118. Monitoring the Contractions and Fetal heart Tone
     • Spread fingers lightly over fundus – to monitor contractions
120. Parts of contractions
     • Increment or crescendo
     • – beginning of contractions until it increases.
     • Acme or apex
     • – height of contraction.
121. • Decrement or decrescendo – from height of contractions until it decreases
     • Duration – beginning of contractions to end of same contraction
     • Interval – end of 1 contraction to beginning of next contraction
122. • Frequency – beginning of 1 contraction to beginning of next contraction
     • Intensity - strength of contraction
123. • Contraction – vasoconstriction
     • Increase BP, decrease FHT
     • Best time to get BP & FHT just after a contraction or midway of contractions
124. • Duration of contractions shouldn’t >60 sec
     • Notify MD
126. • 5. Fetal Heart Patterns
     • a. Early Decelerations – head compression
     • 1. begins early in contraction
     • 2. ominous
     • 3. continue monitoring
127. • b. Late decelerations – uteroplacental insufficiency
     • 1. begins late in contraction
     • 2. ominous
     • 3. turn mother to the left lateral recumbent
     • 4. administer oxygen
     • 5. d/c oxytocin
128. • c. Variable decelerations – umbilical cord compression
     • 1. not related to contractions
     • 2. not ominous, but requires interventions
     • 3. change maternal position
     • 4. administer oxygen
     • 5. assess for prolapsed cord
129. • Mom has headache – check BP, if same BP, let mom rest. If BP increases , notify MD -preeclampsia
130. Health teachings
     • 1.) Ok to shower
     • 2.)NPO – GIT stops function during labor if with food- will cause aspiration
131. • 3.)Enema administer during labor
     • a.) To cleanse bowel
     • b.) Prevent infection
     • c.) Sims position/side lying
     • 12 – 18 inch – ht enema tubing.
132. • Check FHT after adm enema
     • Normal FHT= 120-160
133. Signs of fetal distress
     • 1.) <120>160
     • 2.) meconium stained- amniotic fluid
     • 3.) fetal thrashing – hyperactive fetus due to lack O2
134. • 2. Second Stage
     • - fetal stage, complete dilation and effacement to birth
135. • 7 – 8 multi – bring to delivery room.
     • 10cm primi – bring to delivery room
     • Lithotomy pos – put legs at the same time
136. • Bulging of perineum
     • – sure to come out
     • Breathing
     • – panting ( teach mom)
137. • Assist doc in doing episiotomy
138. • Episiotomy
     • – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (urethroanal fistula).
141. • Mediolateral
     • – more bleeding & pain, hard to repair, slow to heal
     • -use local or pudendal anesthesia.
142. • Modified Ritgens maneuver
     • – place towel at perineum
     • 1.)To prevent laceration
143. • 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.
144. Mechanisms of labor
     • Engagement
     • Descent
     • Flexion
     • Internal Rotation
     • Extension
     • External rotation
     • Expulsion
145. Parts of Pelvis
     • 1. Inlet
     • – AP diameter narrow, transverse diameter wider
     • 2. Cavity
146. Two Major Divisions of Pelvis
     • True pelvis
     • – below the pelvic inlet
     • False pelvis
     • – above the pelvic inlet; supports uterus during pregnancy.
148. • Linea Terminalis
     • -diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
149. Nursing Care:
     • To prevent puerperal sepsis
     • - <>
     • Bolus of Pitocin can lead to hypotension.
150. • Third Stage
     • Birth to expulsion of Placenta
     • -placental stage placenta has 15 – 28 cotyledons. Placenta delivered from 3-10 minutes.
151. Signs of placental separation
     • 1.Fundus rises – becomes firm & globular “ Calkins sign ”
     • 2.Lengthening of the cord
     • 3.Sudden gush of blood
152. Types of placental delivery
154. • a. Shultze “shiny”
     • – begins to separate from center to edges presenting the fetal side shiny
155. • b. Duncan “dirty”
     • – begin to separate form edges to center presenting natural side – beefy red or dirty.
156. • Slowly pull cord and wind to clamp.
     • – BRANDT ANDREWS MANEUVER.
157. Nursing care for placenta
     • Check completeness of placenta.
     • Check fundus
     • Check bp
158. • Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives
     • Monitor hpn (or give oxytocin IV)
     • Check perineum for lacerations
159. • Assist MD for episiorrhapy
     • Flat on bed
     • Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.
160. • Fourth Stage
     • -the first 1-2 hours after delivery of placenta.
     • – recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
     • Check placement of fundus at level of umbilicus.
161. If fundus above umbilicus, deviation of fundus
     • Empty bladder to prevent uterine atony
     • Check lochia
     • a.Maternal Observations – body system stabilizes
162. • b. Placement of the Fundus
     • c. Lochia
163. • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
164. • d.Perineum
     • R - edness
     • E- dema
     • E – cchymosis
     • D – ischarges
     • A – approximation of blood loss. Count pad & saturation
165. • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
166. • e. Bonding – interaction between mother and newborn – rooming in types
     • 1.Straight rooming in baby: 24hrs with mom.
     • 2.Partial rooming in: baby in morning , at night nursery.
169. Complications of Labor
170. • Dystocia
     • – difficult labor related to:
     • Mechanical factor
     • – due to uterine inertia
     • – sluggishness of contraction
171. • 1.hypertonic or primary uterine inertia
     • Intense excessive contractions resulting to ineffective pushing
172. • Interventions with Hypertonic Dysfunction
     • Short-acting barbiturates
     • IV fluids
     • If CPD – c/s.
     • Provide emotional support.
     • Provide comfort measures.
     • Prevent infection
     • Prepare patient for c/s if needed.
173. • 2. hypotonic secondary uterine inertia
     • Slow irregular contraction resulting to ineffective pushing.
     • Give oxytocin.
174. • Management:
     • Amniotomy (artificial ROM).
     • Oxytocin augmentation of labor.
     • If CPD, prepare for c/s.
     • Emotional support, comfort measures, prevent infection.
175. Normal length of Labor
     • Primi 14 – 20 hrs
     • Multi 10 -14 hrs
176. Prolonged Labor
     • > 14 hrs in multi &
     • > 20 hrs in primi
     • Maternal effect – exhaustion.
     • Fetal effect – fetal distress, caput succedaneum or cephalhematoma
177. Precipitate Labor
     • Labor of <>
     • extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
178. • Outstanding Nursing dx: fluid volume deficit
     • IV: fast drip due to fluid volume def
179. Signs of Hypovolemic Shock:
     • Hypotension
     • Tachycardia
     • Tachypnea
     • Cold clammy skin
180. Inversion of the uterus
     • Situation: uterus is inside out.
181. Factors leading to inversion of uterus
     • short cord
     • hurrying of placental delivery
     • ineffective fundal pressure
182. Uterine Rupture
     • Causes:
     • 1.)Previous classical CS
     • 2.)Large baby
     • 3.) Improper use of oxytocin (IV drip)
183. Uterine Rupture
     • Sx:
     • Sudden pain
     • Profuse bleeding
     • Hypovolemic shock
     • TAHBSO
184. Physiologic retraction ring
     • Boundary bet upper/lower uterine segment
     • BANDL’S pathologic ring – suprapubic depression
185. Amniotic Fluid Embolism or Placental Embolism
     • Amniotic fluid or fragments of placenta enters natural circulation resulting to embolism
186. Amniotic Fluid Embolism or Placental Embolism
     • Sx:
     • dyspnea, chest pain & frothy sputum
187. Trial Labor
     • Measurement of head & pelvis falls on borderline.
     • Mom given 6 hrs of labor
     • Multi: 8 – 14, primi 14 – 20
188. Preterm Labor
     • Labor Abortion: <20>
189. Preterm Labor
     • Sx:
     • 1. premature contractions q 10 min
     • 2. effacement of 60 – 80%
     • 3. dilation of 2-3 cm
190. Preterm Labor
     • Home Mgt:
     • 1. complete bed rest
     • 2. avoid sex
     • 3. empty bladder
     • 4. drink 3 -4 glasses of water
     • 5. consult MD if symptoms persist
191. Preterm Labor
     • Hosp:
     • 1. If cervix is closed
     • dilation is saved by administering Tocolytic agents
     • halts preterm contractions. Ritodrine HCl (Yutopar)
     • 150mg incorporated 500cc Dextrose piggyback.
     • Terbutaline (Brethine)
192. Preterm Labor
     • If cervix is open : MD  steroid dexamethazone (betamethazone)
     • Preterm: Cut cord ASAP
193. Postpartal Period : 5th stage of labor
     • After 24hrs: Normal increase WBC up to 30,000 mm3
     • Puerperium  covers 1st 6 wks post partum
     • Hyperfibrinogenemia
     •  prone to thrombus formation
     •  early ambulation
194. Principles underlying PUERPERIUM
     • To return to Normal and Facilitate healing
     • Systemic changes
195. Cardiovascular System
     • The first few minutes after delivery is the most critical period in mothers
196. Genital tract
     • a. Cervix – cervical opening
     • b. Vaginal and Pelvic Floor
     • c. Uterus – return to normal 6 – 8 wks.
197. Genital tract
     • Birth pain:
     • 1. position prone
     • 2. cold compress – to prevent bleeding
     • 3. mefenamic acid
198. Genital tract
     • Lochia  bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
     • 1. Rubra  red 1st 3 days present, musty/mousy, moderate amt
     • 2. Serosa  pink to brown 4 – 9th day, limited amt
     • 3. Alba  créme white 10 – 21 days very decreased amt
199. Genital tract
     • Dysuria
     • - urine collection
     • - alternate warm & cold compress
     • - stimulate bladder
200. Urinary tract
     • Freq in urination after delivery
     • Urinary retention with overflow
201. Colon
     • Constipation due to:
     • NPO
     • Fear of bearing down
202. Perineal Area
     • Painful – episiotomy site
     • Sex  when perineum has healed
203. Provide Emotional Support – Reva Rubin
     • Psychological Responses:
     • Taking in phase
     • Taking hold phase
     • Letting go
204. Taking hold phase
     • Dependent to independent phase (4 to 7 days).
     • Mom  active, can make decisions
205. Letting go phase
     • Interdependent phase – 7 days & above.
206. Complication: HEMORRHAGE
     • Bleeding of > 500cc
     • CS – 600 – 800 cc normal
     • NSD 500 cc
207. Early postpartum hemorrhage
     • Bleeding within 1st 24 hrs.
208. Early postpartum hemorrhage
     • Complications :
     • Hypovolemic shock.
209. Early postpartum hemorrhage
     • Breast feeding – post pit gland will release oxytocin so uterus will contract.
     • Well contracted uterus + bleeding = laceration
211. LACERATION
     • 1st degree laceration – affects vaginal skin & mucus membrane.
     • 2nd degree – 1st degree + muscles of vagina
     • 3rd degree – 2nd degree + external sphincter of rectum
     • 4th degree – 3rd degree + mucus membrane of rectum
213. DIC
     • Disseminated Intravascular Coagulopathy. Hypofibrinogen  failure to coagulate.
214. Late Postpartum hemorrhage
     • Bleeding after 24 hrs  retained placental fragments
215. Late Postpartum hemorrhage
     • Accreta
     • Increta
     • Percreta
     • Hematoma
216. Late Postpartum hemorrhage
     • too much manipulation
     • large baby
     • pudendal anesthesia
217. Infection
     • Sources of infection
     • 1.) endogenous
     • 2.) exogenous
     • Anaerobic streptococci
218. Infection
     • General signs of inflammation:
     • Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
     • Purulent discharges
     • Fever
219. INFECTION
     • Gen mgt:
     • supportive care
     • inflammation of perineum
     • 2 to 3 stitches dislocated with purulent discharge
220. INFECTION
     • Mgt:
     • Removal of sutures & drainage, saline, between & resulting.
     • Endometriosis – inflammation of endometrial lining
221. INFECTION
     • Sx:
     • Abdominal tenderness,
223. Family Planning
     • determine one’s own beliefs 1st
     • never advise a permanent method of planning
     • method of choice is an individual’s choice.
224. Family Planning
     • Natural Method – the only method accepted by the Catholic Church
     • Billings / Cervical mucus – test spinnbarkeit & ferning (estrogen)
     • clear, watery, stretchable, elastic – long spinnbarkeit
225. • Basal Body Temperature 13th day temp goes down before ovulation – no sex
     • get before arising in bed
227. Family Planning
     • LAM – lactation amenorrhea method – hormone that inhibits ovulation is prolactin.
228. Family Planning
     • Symptothermal – combination of BBT & cervical. Best method
     • Social Method – 1.) coitus interruptus/ withdrawal - least effective method
     • coitus reservatus – sex without ejaculation –
     • calendar method
229. OVULATION
     • count minus 14 days before next mens (14 days before next mens)
     • Origoknause formula – monitor cycle for 1 year
     • get shortest & longest cycle from Jan – Dec
     • shortest – 18
     • longest – 11
230. OVULATION
     • June 26 Dec 33
     • - 18 - 11
     • 8 - 22 unsafe days
     • 21 day pill- start 5th day of mens
     • 28day pill- start 1st day of mens
     • missed 1 pill – take 2 next day
231. Pills
     • Combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle.
     • 99.9% effective.
232. OCP Alert
     • If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.
233. Pills
     • Signs of hypertension
     • Immediate Discontinuation
     • A – abdominal pain C – chest pain H - headache E – eye problems
     • S – severe leg cramps
     • If mom HPN – stop pills STAT!
     • Adverse effect: breakthrough bleeding
234. Pills
     • If forgotten for one day , immediately take the forgotten tablet plus the tablet scheduled that day.
     • If forgotten for two consecutive days , or more days, use another method for the rest of the cycle and the start again.
235. DMPA
     • Depoprovera – has progesterone inhibits LH – inhibits ovulation
     • Depomedroxy progesterone acetate – IM q 3 months
     • Never massage injected site, it will shorten duration
236. DMPA
     • Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
237. Mechanism and Chemical Barriers
     • IUD
     • Condom
     • Diaphragm
     • Cervical cap
     • Foams, Jellies, Creams
238. Intrauterine Device (IUD)
     • Action: prevents implantation – affects motility of sperm & ovum
     • right time to insert is after delivery or during menstruation
     • primary indication for use of IUD
     • parity or # of children, if 1 kid only don’t use IUD
240. Intrauterine Device (IUD)
     • ALERTS:
     • prevents implantation
     • most common complications: excessive menstrual flow and expulsion of the device (common problem)
241. Intrauterine Device (IUD)
     • OTHERS:
     • P eriod late (pregnancy suspected)
     • Abnormal spotting or bleeding
     • A bdominal pain or pain with intercourse
     • I nfection (abnormal vaginal discharge)
     • N ot feeling well, fever, chills
     • S trings lost, shorter or longer
     • Uterine inflammation, uterine perforation,ectopic pregnancy
242. CONDOM
     • – latex inserted to erected penis or lubricated vagina
     • Adv: gives highest protection against STD – female condom
     • Alerts:
245. Diaphragm
     • – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSIBLE
     • S/effect: Toxic shock syndrome
     • Alerts: Should be kept in place for about 6 – 8 hours
248. Cervical Cap
     • – more durable than diaphragm no need to apply spermicide
     • C/I: abnormal pap smear
     • Foams, Jellies, Creams
249. Surgical Method
     • BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects
     • Vasectomy – cut vas deferens.
     • HT: >30 ejaculations before safe sex
     • O – zero sperm count , safe
250. • High Risk Pregnancy
251. Hemorrhagic Disorders
     • General Management
     • CBR
     • Avoid sex
     • Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
252. • Ultrasound to determine integrity of sac
     • Signs of Hypovolemic shock
     • Save discharges – for histopathology
253. First Trimester Bleeding
     • Abortion
     • Ectopic pregnancy
254. Abortion
     • – termination of pregnancy before age of viability (before 20 weeks)
     • Spontaneous Abortion- miscarriage
     • Causes:
     • 1.) chromosomal alterations
     • 2.) blighted ovum
     • 3.) plasma germ defect
255. Classifications:
     • Threatened
     • Inevitable
     • Complete
     • Incomplete
     • Habitual
     • Missed
     • Induced Abortion
256. Threatened
     • – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
257. Inevitable
     • Moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
258. Complete – all products of conception are expelled. No mgt just emotional support! Incomplete – Placental and membranes retained. Mgt: D&C
259. Habitual
     • 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
     • Present: 2nd trimester
260. Missed
     • fetus dies ; product of conception remain in uterus 4 weeks or longer; signs of pregnancy ceases; (-) preg test; scanty dark brown bleeding
     • Mgt: induced labor with oxytocin or vacuum extraction
261. Induced Abortion
     • – Therapeutic abortion to save life of mom.
262. Ectopic Pregnancy
     • – occurs when gestation is located outside the uterine cavity.
     • Common site: tubal or ampular
     • Dangerous site - interstitial
264. Unruptured
     • missed period
     • abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
     • scant, dark brown, vaginal bleeding
265. • Nursing care:
     • Vital signs
     • Administer IV fluids
     • Monitor for vaginal bleeding
     • Monitor I & O
266. Tubal rupture
     • sudden , sharp, severe pain . Unilateral radiating to shoulder.
     • + Cullen’s Sign
     • syncope (fainting)
267. • Mgt:
     • Surgery depending on side
     • Ovary: oophorectomy
     • Uterus : hysterectomy
268. Second trimester bleeding
     • Hydatidiform Mole
     • Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
269. Second trimester bleeding
     • Hydatidiform Mole
     • This neoplasm is formed from the selling of the chronic villi and lost nucleus of the fertilized egg.
     • The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.
271. Hydatidiform
     • Use: methotrexate to prevent choriocarcinoma
272. Hydatidiform
     • Early in pregnancy
     • High levels of HCG
     • Preeclampsia at about 12 weeks
     • Late signs:
     • hypertension before 20th week
     • Vesicles look like a “ snowstorm” on sonogram
     • Anemia
     • Abdominal cramping
273. Hydatidiform
     • Nursing care:
     • Prepare D&C
     • Do not give oxytoxic drugs
274. • 2 . Incompetent Cervix – cervical dilation without uterine contractions
     • Assessment:
     • 1. Hx of previous abortions
     • 2. Cervical dilatation/effacement
     • 3. Membrane present in cervical os
     • Interventions
     • 1. bedrest
     • 2. cervical cerclage
276. • McDonalds procedure – temporary cerclage on cervix
     • S/E: infection. During delivery, cerclage is removed. NSD
     • Sheridan – permanent surgery cervix. CS
277. • Third Trimester Bleeding “Placenta Anomalies”
278. Placenta Previa
     • Abnormal lower implantation of placenta .
     • Candidate for CS
     • Sx:
     • Bright red
     • Painless bleeding
280. Placenta Previa
     • Dx:
     • Ultrasound
     • Avoid: sex, IE, enema – may lead to sudden fetal blood loss
     • Double set up: delivery room may be converted to OR
281. Placenta Previa
     • Assessment:
     • Engagement (usually has not occurred)
     • Fetal distress
     • Presentation ( usually abnormal)
     • Surgeon – in charge of sign consent, RN as witness
     • MD explain to patient
282. Placenta Previa
     • Nursing Care
     • NPO
     • Bed rest
     • Prepare to induce labor if cervix is ripe
     • Administer IV
284. Abruptio Placenta
     • Outstanding Sx: dark red, painful bleeding , board like or rigid uterus.
285. Abruptio Placenta
     • Assessment:
     • Concealed bleeding
     • Couvelaire uterus (caused by bleeding into the myometrium) Dropping coagulation factor (a potential for DIC)
286. Abruptio Placenta
     • Complications:
     • Sudden fetal blood loss
     • Placenta previa & vasa previa
287. Abruptio Placenta
     • Nursing Care:
     • Infuse IV, prepare to administer blood
     • Type and crossmatch
     • Monitor FHR
     • Insert Foley cath
     • Measure blood loss; count pads
     • Report s/sx of DIC
     • Monitor v/s for shock
     • Strict I&O
288. • Placenta succenturiata
     • Placenta Circumvallata
     • Placenta Marginata
     • Battledore Placenta
289. • Placenta Bipartita
     • Velamentous Insertion of cord
     • Vasa Previa
290. Hypertensive Disorders
     • I. Pregnancy Induced Hypertension (PIH )
291. Pregnancy Induced Hypertension (PIH )
     •  HPN after 20 wks of pregnancy, solved 6 weeks post partum.
     • Gestational hypertension - HPN without edema & proteinuria
     • Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
     • HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count
292. Chronic or pre-existing Hypertension
     • – HPN before 20 weeks not solved 6 weeks post partum.
293. Three types of pre-eclampsia
     • Mild preeclampsia – earliest sign of preeclampsia
     • a.) increase wt due to edema
     • b.) BP 140/90
     • c.) proteinuria +1 - +2
294. Three types of pre-eclampsia
     • Severe preeclampsia
     • Signs present: cerebral and visual disturbances, epigastric pain and oliguria
     • BP 160/110
     • Proteinuria +3 - +4
295. Three types of pre-eclampsia
     • Eclampsia – with seizure!
     • Increase BUN – glomerular damage.
     • Provide safety.
296. Cause of preeclampsia
     • Idiopathic or unknown common in primi
     • Common in multiple pregnancy (twins)
     • Common to mom with low socioeconomic status
297. Nursing care: PPPEACE
     • P – romote bed rest
     • P – prevent convulsions by nursing measures or seizure precaution
298. Nursing care: PPPEACE
     • turning to side is done AFTER seizure! Observe only!
     • E – ensure high protein intake ( 1g/kg/day)
     • Na – in moderation
     • A – anti-hypertensive drug Hydralazine (Apresoline)
299. Nursing care: PPPEACE
     • C – convulsion, prevent! – give Mg So4 – CNS depressant
     • E – evaluate physical parameters for Magnesium sulfate
300. • DIABETES MELLITUS
301. Diabetes Mellitus
     • Absence of insulin (Islet of Langerhans of pancreas)
     • is an endocrine disorder in which the PANCREAS cannot produce adequate insulin to regulate body glucose levels
302. • Classifications of Diabetes Mellitus ( American Diabetes Association)
     • Type 1 Insulin-dependent DM
     • Type 2 Non-insulin- dependent DM
     • Gestational Diabetes
     • Impaired Glucose Homeostasis -A state between normal and diabetes
303. • Dx: 1 hr 50gr glucose tolerance test GTT
     • Normal glucose  80 – 120 mg/dl;
     • <>
     • > 120  hyperglycemia
     • 3 degrees GTT of > 130 mg/dL
304. • 3 hour oral glucose tolerance test
     • 100 g oral glucose solution
     • fasting 95mg/dL
     • 1 hour 180mg/dL
     • 2 hour 155mg/dL
     • 3 hour 140mg/dL
305. Diabetes Mellitus
     • Maternal effect DM
     • Hypo or hyperglycemia
     • Frequent infection
     • Polyhydramnios
     • Dystocia
306. • Hyperglycemia- fatigue , flushed hot skin, dry mouth, excessive thirst, frequent urination, rapid deep respirations, fruity odor, depressed reflexes, drowsiness, headache
307. • Hypoglycemia-
     • shakiness, dizziness, sweating, pallor, cold clammy skin, disorientation, irritability, headache, hunger, blurred vision, nervousness, weakness, fatigue, shallow respirations, normal PR
308. Diabetes Mellitus
     • Insulin requirement: decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd trimester.
     • Post partum decrease 25%
309. Fetal effect: DM
     • hyper & hypoglycemia
     • macrosomia – large gestational age – baby delivered > 4000g or 4kg
     • preterm birth to prevent stillbirth
310. Newborn Effect : DM
     • hyperinsulinism
     • hypoglycemia
     • hypoglycemic <>
     • Heel stick test – get blood at heel
311. Newborn Effect : DM
     • Hypoglycemia: high pitch shrill cry tremors, administer dextrose
     • Hypocalcemia - <>
     • Calcemia tetany
     • Trousseau sign
     • Give calcium gluconate if decrease calcium
312. • HEART DISEASE
314. Heart disease
     • Class I – no limit to physical activity
     • Class II – slight limitation of activity.
315. Heart disease
     • Class III - moderate limitation of physical activity.
     • Class IV - marked limitation of physical activity.
316. Recommendation
     • Therapeutic abortion
     • If push through with pregnancy
     • Antibiotic therapy
     • Anticoagulant
317. Recommendation
     • Class I & II- good progress for vaginal delivery
     • Class III & IV- poor prognosis, for vaginal delivery, not CS!
318. • RH INCOMPATIBILITY (ISOIMMUNIZATION)
     • Occurs when an Rh-negative mother (one negative for a D antigen or one with a dd genotype) is CARRYING A FETUS WITH AN Rh-positive blood type (DD or Dd genotype).
319. • Subsequent exposure to Rh-positive blood can cause a serious reaction that results in agglutination and hemolysis of red blood cells
     • * A fetus can become so deficient in red blood cells that sufficient O2 transport to the body cannot be maintained=HEMOLYTIC DISEASE OF THE NEWBORN or ERYHTROBLASTOSIS FETALIS
320. • CAUSES:
     • 1. SEPARATION OF PLACENTA
     • 2. AMNIOCENTESIS
     • 3. PERCUTANEOUS UMBILICAL BLOOD SAMPLING
322. • ANTIBODY SCREENING TEST (indirect Coomb’s test)
     • -done on the mother’s blood to measure the number of Rh-positive antibodies
323. • DIRECT COOMBS’ TEST
     • -done on the infant’s blood to detect antibody-coated Rh-positive RBC’s
325. ASSISTED BIRTH
326. • Cesarean Delivery
     • Indications:
     • Multiple gestation
     • Diabetes
     • Active genital herpes II
     • Severe toxemia
     • Complete Placenta previa
     • Abruptio placenta
     • Prolapse of the cord
327. • UTERINE INCISIONS
     • a. kerr
     • b. sellheim- vertical incision in the lower uterine segment
     • c. classic
329. • FORCEPS DELIVERY
     • 3 Categories
     • Outlet forceps
     • Low forceps
     • midforceps
     • 
       
331. • INDICATIONS:
     • Heart dse
     • Pulmonary edema
     • Infection
     • Exhaustion
     • Premature placental separation
     • Fetal nonreassuring status
332. • Conditions before forceps delivery:
     • Cervical dilatation is complete
     • Membranes must be ruptured
     • Type of pelvis should be known
     • Maternal bladder should be empty and adequate anesthesia given
     • No degree of CPD can be present
333. • VACUUM- ASSISTED BIRTH
     • used to facilitate the birth of a fetus by applying suction to the fetal head
     • Composed of soft suction cup attached to a suction bottle (pump) by tubing
     • Suction cup is placed against the fetal occiput.
336. INFERTILITY
     • Inability to achieve pregnancy. Within a year of attempting it
     • Manageable
337. • In order to get pregnant:
     • 1. A woman must release an egg from one of her ovaries (ovulation).
     • 2. The egg must go through a fallopian tube toward the uterus (womb).
     • 3. A man's sperm must join with (fertilize) the egg along the way.
     • 4. The fertilized egg must attach to the inside of the uterus (implantation).
338. • Is infertility a common problem?
339. • Is infertility just a woman's problem?
340. • NO
341. • What causes infertility in men?
342. • Infertility in men is most often caused by:
     • problems making sperm -
     • problems with the sperm's ability to reach the egg and fertilize it
     • Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury.
343. • What increases a man's risk of infertility?
     • The number and quality of a man's sperm can be affected by his overall health and lifestyle.
344. • What causes infertility in women?
345. • Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized.
346. • Less common causes of fertility problems in women include:
     • blocked fallopian tubes physical problems with the uterus
     • uterine fibroids
347. • What things increase a woman's risk of infertility?
     • Many things can affect a woman's ability to have a baby. These include:
     • 1.age
     • 2.stress
     • 3.poor diet
     • 4.athletic training
348. • How long should women try to get pregnant before calling their doctors?
349. • Some health issues also increase the risk of fertility problems. So women with the following issues should speak to their doctors as soon as possible :
     • irregular periods or no menstrual periods
     • very painful periods
     • endometriosis
     • pelvic inflammatory disease
     • more than one miscarriage
350. • How will doctors find out if a woman and her partner have fertility problems?
351. • For a woman, the first step in testing is to find out if she is ovulating each month.
352. • Some common tests of fertility in women include :
     • Hysterosalpingography : In this test, doctors use x-rays to check for physical problems of the uterus and fallopian tubes.
353. • Laparoscopy:
     • During this surgery doctors use a tool called a laparoscope to see inside the abdomen.
354. • How do doctors treat infertility?
     • Infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive technology.
355. • Doctors often treat infertility in men in the following ways:
     • Sexual problems: Behavioral therapy and/or medicines can be used in these cases.
     • Too few sperm:, doctors can surgically remove sperm from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.
356. • Intrauterine insemination (IUI) - is known by most people as artificial insemination.
     • IUI is often used to treat:
     • mild male factor infertility
     • women who have problems with their cervical mucus
     • couples with unexplained infertility
357. • What medicines are used to treat infertility in women?
358. • Some common medicines used to treat infertility in women include:
     • 1.Clomiphene citrate ( Clomid ): This medicine causes ovulation by acting on the pituitary gland.
     • 2.Human menopausal gonadotropin or hMG ( Repronex, Pergonal ): This medicine is often used for women who don't ovulate due to problems with their pituitary gland.
359. • 3.Follicle-stimulating hormone or FSH ( Gonal-F, Follistim ): FSH works much like hMG..
     • 4.Gonadotropin-releasing hormone (Gn-RH) analog : These medicines are often used for women who don't ovulate regularly each month.
360. • 5. Metformin ( Glucophage ): Doctors use this medicine for women who have insulin resistance and/or Polycystic Ovarian Syndrome (PCOS) . This drug helps lower the high levels of male hormones in women with these conditions.
     • 6. Bromocriptine ( Parlodel ): This medicine is used for women with ovulation problems due to high levels of prolactin.
361. • Many fertility drugs increase a woman's chance of having twins, triplets or other multiples.
362. • What is assisted reproductive technology (ART)?
     • Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples.
363. • How often is assisted reproductive technology (ART) successful?
     • age of the partners
     • reason for infertility
     • clinic
     • type of ART
     • if the egg is fresh or frozen
     • if the embryo is fresh or frozen
364. • What are the different types of assisted reproductive technology (ART)?
365. • Common methods of ART include:
     • 1. In vitro fertilization (IVF) . Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
366. • 2. Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer - Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus.
367. • 3.Gamete intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube.
368. • 4. Intracytoplasmic sperm injection (ICSI)
     • In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.
372. 2 types of infertility
     • 1.) primary
     • 2.) Secondary
     • Sims Huhner test
373. Infertility
     • Normal: cervical mucus must be stretchable 8 – 10 cm
     • Best criteria- sperm motility for impotency
374. Infertility
     • Mgt:
     • GIFT= Gamete Intra Fallopian Transfer for low sperm count
375. • Mom: anovulation – no ovulation
     • hyperprolactinemia
376. • Tubal Occlusion – tubal blockage
     • = dx: hysterosalphingography
     • Mgt: IVF – invitrofertilization
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