Maternal Nursing Lec

8/13/2019 Maternal Nursing Lec

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MATERNITY NURSING(Care Of Women With Problems In The Ante Partum Intra!artum

An" Post Partum Phase#

T$E PE%&IS

'alse Pel is) wide area above linea terminalis, supports the uterus duringpregnancy

True Pel is) narrow area below the linea terminalis, serves as birth canal

AREAS O' T$E TRUE PE%&IS

*+ IN%ET,-RIM,CO.ANE area bounded by sacral promontory, R & L ileopectineal lines, and

superior symphisis pubis AP dm- 11 cm ditane from superior symphiis pubis to sacral

promontory Transverse dm- 1 cm The greatest dm of the fetal head is AP dm 1!"#cm

/+ MI0PE%&IS Area bounded by the sacral wall, R & L ischial spine and P symphisis

pubis AP from s" pubis to sacral wall 1! cm Transverse dm R & L ischial spine 1$cm The AP dm of fetal head must occupy the AP dm of the cavity thru

internal rotation to allow the !nd descend, En1a1ement

2+ OUT%ET- Area bounded by cocy%, R & L ischial tuberosities and inferiorsymphisis pubis- AP dm- 1 cm if in labor, cm if not in labor- AP dm of the fetal head must occupy the AP dm of the outlet tofacilitate final descent called CROWNING

-ONES O' T$E PE%&IS'leum'schiumPubis(acrum)ocy%

TYPES O' PE%&IS*ynecoid

Android Anthropoid Platypelloid

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T$E P%ACENTA

P%ACENTA is formed from the chorionic villi and decidua basalis1! A+*, functionalwt #$$gm at term

- 1 -!$ cotyledons

Types./)A/( 0maternal side beefy red

()2L.T3 0fetal side glistening

FunctionsR- respiratory organ of the fetus4- 4%cretory organP- protection4- endocrine organ of mother and fetus

/- /utritive Abnormalities

*+ Multi!le !la3enta) 5ipartia- not completely ivided into ! lobes uple%- separated completely into ! parts!" Su33enturiate Pla3enta) has accessory lobe with blood vesselsconnected to it

" Cir3um allate Pla3enta) 6hen suh ftal surface present a centraldepression sorrounded by a thic7ened whitish-grayish ring which is doublelayer amnion and chorion with degenerated decidua and fibrin bet ! layers

8" Cir3ummar1inate Pla3enta) whitish-grayish ring is located at the marginof the placenta

T$E MEM-RANES

Chorioni3 membrane) originates from the portion of chorionic villinot involve in implantation" 't supports amniotic membrane" 't 9oins theplacenta Amnioti3 membrane) A smooth, thin, tough and translucentmembrane directly enclosing the fetus and the amniotic fluid" 't 9oins theumbilical cord

T$E AMNIOTIC '%UI0

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#$$-1#$$ ml amount- )ompose of #: water, mineral salts, uric acid, nutrients 0)2+/ ,lanugo, v"caseosa, epithilial cells- normal appearance- straw colored- *reen- meconium stained e%cept for brech presentation- *olden ;ellow- hemolytic disease 0A5+, Rh incompatibility- *ray- infection- p2


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Con3e!tus - products of conception

7 8ee4s) all system in rudementary formD beginning formations of eyes,nose, girtD heart chambers formedD heart beating 0 18days D with arm legbuds9 8ee4s B head large in proportion to body, neuromascular developmentDe%ternal genitalia appears*/ 8ee4s) placenta fully formedD functioning 7idneys developD secretesurineD center of ossification of most bonesD with suc7ing and swallowingD se%distinguishableD @2T detected by ultrasound 01$-1! w7s*: 8ee4s) more human appearance, =uic7ening- multigravidaD scalp hairdevelopsD formed eyes, ears, nose, @2T by stethoscope/; 8ee4s B with verni% caseosa and downy lanugo, =uic7ening forprimigravida/7 8ee4s B body well proportionedD s7in red and wrin7ledD eyebrows andeyelashes recogni>able when bornD may breathe but do not survive/9 8ee4s B!# cm, wt 11$$g, if born by this time, with e%pert care cansurvive2: 8ee4s B deposition of subcutaneous fat

Normal %en1th of Pre1nan35

aysE !


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wt"E $-1#$ lbs5elow $ lbsE malnutrition, goiter, T50c" anomaly ,abortionAbove 1#$ lbsE heart disease, ?, 2P/

ht"E less 8H1$0)(b" (tatusc" 4ducational Attainmentd" 4mployment

/+ 'amil5 $istor5) )" anomalies, mental retardation, twins, asthma, ?,*erman ?easles, .T'I2+ So3ial Status) ?ultiple se%ual partners, smo7ing, alcohol, drugdependency7+Obstetri3al histor5

8" +5 (core T-termP-prematureA-abortionL-livingeg"?rs (antos is w7s preg", she had 1 abortion, 1 2-mole,a child who iscurrently enrolled at ?ontessori born at # w7s A+*, a twin born at 8 w7sA+*, only 1 survived,and a 1 yGl child born at w7s A+*, find out her +5(core ANSWER= (*)/)/)2#

>+ Me"i3al $istor5) allergies, heart disease, ?, 2P/, .T', (urgeries:+ Assessment E 2ead to Toe

a" J( B 5PE unchange in 1 st trimesterdecresed at ! nd & rd increased during labor 0 $G1# and ! days after

labor2eadache-1 st sign of 2P/

b" Temp- elevated by "#-"C only in the 1 st trimesterc" PR B increased by 1$ bpmd" RR B unchanged but deeper to get more o%ygen

:+ Wt+ 1ain1 st trimester E !- lbs! nd trimester E 1$-1! lbs

rd trimester E 1$-1! lbs?+ %eo!ol"@s Maneu er a+ 'un"al Pal!ation presentation and lie b+ %ateral Pal!ation fetal bac7 and e%tremeties 3+ Pauli4s Pal!ation engagement "+ 0ee! Pel i3 Pal!ation fle%ionNs1 Inter ention E 'nform the client about the procedure

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4mpty the bladder orsal recumbent Provide privacy Palms should be warm

9+ Pa! Smear B cytological study of the cervi%one anually as early as age !$ in se%ually active women5est done 1 wee7 after menstration

'in"in1s =)lass ' B absence of atypical cells)lass ''- presence of atypical cell but not malignant)lass '''- atypical cells suggest malignant)lass 'J B atypical cells strongly suggest malignancy)lass J - atypical cell is conclusive of malignancy

Sta1es of Cer i3al Can3er

1 B )ancer cell are in situ! B )ancer cells invade vaginal wall

B invade the pelvic wall8 B invade bladder and rectum

B+ &a1inal E am done only on the initial visit to E assess for signs ofpregnancy and assess for vaginal discharge

*;+ $istor5 of Present Pre1nan35E00 - e%pected date of delivery%MP B last day of menstrationAOG) age of gestation

Im!ortant estimation of AOG D E00*+-artolome8@s Rule) 2t" of the fundus 1! 644K(Elevel at the symphisis pubis,1 644K(E halfway at symphisis pubis to umbilicus

!$ 644K(E level of umbilicus !8 644K(E ! fingers above the umbilicus $ 644K(E midway from umbilicus and %yphoid process 644K(E at the level of %yphoid process 8$ 644K(E ! fingers below umbilicus

/+ M3 0onal"@s Rule B it estimates A+* in lunar months by getting thefundic height in cm devided by 8

4%" 1 cm G 8 8 L?2+ $ase@s Rule B is used to determine the length of the fetus

1-# lunar month % the no" of month-1$ lunar month % #

7+ Nae1el@s Rule B most accurate estimate for A+* and 4 ) only if L?P is7nown

Add < days to the 1 st day of menstration and count bac7 months

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'f the woman forgot her L?P, as7 the date of =uic7ening, add !! w7sfor primi, add !8w7s for multi

Health Teachings E er3ise B strengthen the muscles used for labor and delivery

Promote circulation, prevent and relieve problems li7e varicosities andhemorrhoids

Relieve tension and an%iety'mprove posture and appetite'mproves metabolic efficiency)ontraindicated if the woman has P'2, twin pregnancy, '.*R, severe

heart disease

Em!lo5ment - can continue to wor7, avoid heavy lifting, standing, sitting forlong period of timeImmuni6ation - vaccine with live viruses is contraindicated 0 ?easles-Rubella, +PJ, ?umps !- months before pregnancy

2epa 5 vaccine is given only if ris7 factors are present TT vaccine is given by the +2 in all pregnant women TT1 B anytime during pregnancy TT! B 1 month after TT1 TT B months after TT! TT8 B 1 year after TT TT# B 1 year after TT8

Clothin1 - lightweight, non-constrictive and loose fitting, flat heeled shoes,wear supportive bra

-athin1 daily, tub is discouraged, can be allowed on swimming but nodiving, contraindicated when there is bleeding and when membranes haveruptured-reast Care nipple rolling, use water only in cleaning the breastTra el travel at ! nd trimester, avoid long trips at rd trimester, 1#-!$ min"rest period every ! hours, use seat beltsSe ual relations) contraindicated when PR+?, bleeding, incompetentcervi%, threatened abortionsAl3ohol refrain ta7ing alcoholsSmo4in1 stop smo7img

MINOR 0ISCOM'ORTS 0URING PREGNANCY

*+Nausea an" omitin1 B M morning sic7nessHa" 4at dry crac7ers before getting out of bedb" (mall fre=uent feeding

/ " 're uent urinationa" Limit fluid before bedtimeb" Kegel e%ercise

2+ 'ati1ue

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a" C hours of sleep at night and fre=uent rest periodsb" Avoid standing for long periods of timec" 4at well balanced diet

7+ %eu4orrheaa" Perineal hygiene

#" $eart -urn or P5rosis (mall meals 5end at 7nees not in waist when pic7ing ob9ects from the floor, avoidlying flat:+ &ari3ose eins Avoid long standing, massaging the legs, constricting garters 4levate the legs against the wall Rest with pillows under the hips ?odified 7nee chest Avoid constipation 2ot sit> bath

%A-OR

PRE%IMINARY SIGNS O' %A-OR

%i1thenin1) setting of the presenting part to the pelvic brim or inlet1$-18 days before labor onset

a" Relief of (+5b" increase urinationc" leg painsd" 'ncrease vaginal discharge

/+ In3rease" le el of a3ti it5) due to epinephrine that is initiated bydecreased Progesterone produced by the placenta2+ -ra ton $i34s Contra3tion - painless contraction to prepare themyometrium for labor7+ Ri!enin1 of the 3er i ) buttersoft>+ Wei1ht loss) !- days before labor woman losses 1-!lbs due todecreased progesterone level:+ 0iarrhea) due to increased peristalsis

SIGNS O' TRUE %A-OR Uterine 3ontra3tion) effective, productive, involuntary uterinecontraction, increase in duration and decreased in interval, ambulationintensify the pain, girdle li7e pain, pain starts from the bac7 radiating toabdomen (.R4(T ('*/ T2AT LA5+R 2A( 54*./ Sho8 - blood mi%ed mucus, pin7-tinge (.R4(T ('*/ +@ )4RJ')AL

'LATAT'+/ IE re eals 3er i3al "ilatation an" effa3ement) surest sign thatlabor is true

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Com!onents of %abor PASSEGE) 0womanIs pelvis route of the fetus must travel from theuterus through the cervi% and vagina to the e%ternal perineum PASSENGER) fetus, the head of the fetus is the most important partof its body

a" )ranial bones-1" one frontal bone!" two parietal bones

" two temporal bones8" one occipital bone#" one sphenoid

" one ethmoid

Sutures

Sa1ittal suture - membraneous interspace, 9oins the ! parietal bones/+ Coronal) line of unction of the frontal bones

2+ %amb"oi") line of 9unction of the occipital bone and ! parietal bone

7+ 'rontal suture) located between parietal and occipital bones(uture lines are important in birth because they allow the cranial

bones to move and overlap

'ontanelles) members covered spaces located between the intersection ofsuture lines 0position and presentation -re1ma (Anterior#) intersection of the sagittal, frontal and coronalsuture, diamond shape closes at 1!-1C mos %amb"a ( Posterior# -lies at the 9unction of the lambdoidal andsagittal suture, triangle shape closes at !- mos

0IAMETERS O' T$E 'ETA% SFU%%- The fetal head is wider in its anteroposterior dm" than its tranverse dm

*+Trans erse "m+a, 5iparietal iameter- most important transverse dm because it is the

greatest dm that must be presented to the pelvic inlet 0AP and outlet 0T!" AP "iameter

a" (uboccipitobregmatic- the smallest dm of the fetal head" "#cmfrominferior aspect of occiput toanterior fontanelle

b" +ccipitofrontal- 1! cm, bridge of the nose to the occiptalprominence

c" +ccipitomental- 1 "# cm, widest, from chin to the posterior

fontanelle

MO%0ING B change in shape of the fetal s7ull produced by the force ofuterine contractions passing the verte% against the not yet dilated cervi%

'ETA% POSITION D PRESENTATION ATTITU0E

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't is the degree of fle%ion of the fetus assume during labor or relation of thefetal parts to each other

Com!lete fle ion) good- spinal column is bowed forward, chin touches thesternum, arms fle%ed and folded on the chest, thighs fle%ed into abdomen

Mo"erate fle ion) chin is not touching the chest but is in alert or militaryposition

Partial fle ion) M5rowH bac7 is arched, nec7 e%tended, fetus is in completee%tension%IE

Relationship of the long a%is of the fetus to the long a%is of the mother

%on1itu"inal lie) a%is of the fetus is parallel to the long a%is of themother

/+ Tran erse lie the long a%is of the fetus is at right angle to the longa%is of the mother

2+ Obli ue lie) the fetus assuming this lie usually rotates to transverseor longitudinal lie in the course of labor

'ETA% PRESENTATION

Ce!hali3) head is contact with the cervi% 0 #: , verte%, brow,face,chin -ree3h) buttoc7s or feet, 0 : , complete, fran7 or footling Shoul"er) lying hori>ontally 01: hand, elbow, iliac crest Trans erse) perpendicularPOSITION- Relationship of the presenting part to a specific =uadrant of thewomanIs pelvis- ?ost common is L+A- L+PGR+P is painful due to the pressure at the sacral nerves causingsharp bac7 pains- 'mportant in labor because it influences the process and efficiency oflabor

MEC$ANISMS O' %A-OR

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E engagement,settling of the presenting part of the fetus far enough to thepelvis to be at the level of ischial spines0) descent, donward movement of the biparietal dm of the fetal head to within the pelvic inlet' - fle%ion, head bend forward onto the chestIr) internal rotationE) e%tension, bac7 of the nec7 stops beneath the pubic arch & acts as a pivotfor the rest of the headE) e%ternal rotationG RestitutionE) e%pulsion

POWERS O' %A-ORChara3teristi3s of Uterine Contra3tion 'nvoluntary- /ot within the control of parturient

a" 'ntermittent- alternate contraction and rela%ationb" 'nvolves discomfort- labor pains)ausesEa" compression of the nerve gangliab" (tretching of the cervi% during dilatationc" stretching of the peritoneum overlying the uterusd" hypo%ia of the concentrated myometriume" (tretching of ligaments

P$ASES O' UTERINE CONTRACTION

*+ In3rement OR Cresen"o) contraction is starting and intensity is buildingup, longest phase/+ A3me or A!e ) pea7 of contraction2+ 0e3rement or 0e3resen"o) when muscles start to rela%

'ntensity- strength of the uterine contraction ?ild contraction- slightly tense fundus that is easy to indent withfingertips ?oderate- firm fundus that is difficult to indent with fingertips (trong contraction- rigid board li7e fundus that is almost impossible toindent with fingertips

@re=uency- rate at which contraction are occuring, from beginning of acontraction to the beginning of the ne%t contraction

uration- Length of contraction" @rom beginning of one contraction to the endof same contraction'nterval- ?easured from the end of a contraction to the beginning of onecontraction

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Ph5siolo1i3 Retra3tion Rin1) upper portion becomes thic7er and active,lower segment becomes thin walled, passive so fetus can be pushed outeasily, boundery between the ! portions becomes mar7ed by a ridge on theinner surfacePatholo1i3 Retra3tion Rin1) in difficult labor, if fetus is larger than thebirth canal, the round ligaments of the uterus becomes tense duringdilatation and e%pulsion and maybe palpable on the abdomen" 't becomesprominent and observable as an abdominal indention" 't may signify possiblerupture of the lower uterine segment if obstruction is not relieve"

Cer i3al Chan1esEffa3ement) shortening and thinning of the cervical canal

0ilatation) enlargement of the cervical canal from an opening a fewmillimeters wide to one large enough to permit the passage of the fetus

STAGES O' %A-OR

@'R(T (TA*4 B from onset of true labor pains to the full dilatation of thecervi%

1! hours B primi 1"!cmGhr< hours - multi 1"#cmGhour mild 0.) , !$- $ sec 0duration , #-1$ min" 0interval , $- cm0) , hr for nullipara, 8"# hr multi

Pt"Is behavior- smiling, tal7ative or mute, tense or calm, ambulatory,controls the pain well, follows instruction readily

A3ti e Phase) labor is established, best time for admission, moderate tostrong 0.) , 8$-#$ sec", -#min", 8-< cm, hr for nullipara, !hr for multi

Pt"Is behavior- apprehensive, doubtful in the control of pain, has somedifficulty following instructionTransitional !hase) strong 0.) , $-


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2+ Che34 %ab+ E amination7+ Che34 Uterine Contra3tion- uration, intensity, fre=uency, interval- After each contraction, chec7 the fundus if it becomes soft to touch" 'tmeans that uterus has time to rela% and able to refill o%ygen for the placentato the fetus">+ Che34 fetal 8ell bein1 - @2T 1!$-1 $ bpm

Latent phase- = $ min, active = $ min", transitional = 1#min", second stage = # min

Normal '$T !attern5aseline rate- 1!$-1 $ bpm5aseline variability- # to 1# bpm fluctuation = min"5eat to beat variability- There is difference between successive heart

beats4arly deceleration- rate of @2T decreases at onset of uterine

contraction but return to normal before the end of contraction as a responseof the fetus to head compression during contraction

Acceleration- when the fetus moves, it is normal for the @2T toincrease

Abnormal '$T !attern

-ra"53ar"ia= 1$$-11 bpm- mo"erate below 1$$bpm B mar4e"Cause= @etal hypo%ia as a result of analgesia and anesthesia, maternal

hypotension and prolonged umbilical cord compressionMana1ement= Place the mother on the left side, assess for cord

prolapse, administer o%ygenTa3h53ar"ia= 1 1 to 1C$ bpm- moderate, above 1C$ bpm- mar7edCause= ?aternal fever, dehydration and drugs 0atrophine, vistaril,

ritrodrine and terbutaline , fetal distressMana1ement= Reduce maternal fever, increase fluids, monitor for

chorioamionitis

%ate "e3eleration rate of @2Tdecreases during uterine contractionand do not return to normal even after the said contraction is a sign ofuteroplacental insufficiency

Cause= 'ndicative of uteroplacental insufficiency caused by uterinetetany from o%ytocin administration, maternal supine hypotension,hypertensive disorder, ? and other chronic disorders

Mana1ement= iscontinue o%ytocin, position on the left side, o%ygenadministration O C-1C Lpm, prepare for birth if no improvement

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&ariable !attern) deceleration at unpridictable times of uterinecontraction

Cause= cord compressionMana1ement= Relieve pressure on the cord, 7nee-chest, e%agerated

sims, lateral position and o%ygen administration, prepare for )(

" Pro i"e Comfort Apply sacral pressure to minimi>e bac7ache +ffer ice chips to prevent crac7ing of the lips and drying of the mouth *ive perineal care and use sanitary pads to 7eep her drye discomfortContrain"i3ations= Ruptured 5+6 Possible placenta previa Premature labor ?alpresentation )ervical dilatation 8cm if the head is not engage

" En3oura1e ambulation)ontraindicationE P'2, (ame as enema

1$" Pro i"e emotional su!!ort 'nform her about the progress of labor Allow husband to stay with her" o not leave her alone

11" En3oura1e the 8oman to assume left sims !osition in be" To prevent vena cava compression Prevent supine hypotensive syndrome @avors internal rotation of the fetal head

1!" En3oura1e breathin1 e er3ises 8ith uterine 3ontra3tion to!re ent !remature !ushin1%e el I= if .) are mild, breathing e%ercise must be slow and shallow%e el II= if .) are moderate, breathing e%ercise must be rapid but shallow%e el III= if .) are strong & e%pulsive, and there is urge to push, breathing

techni=ue is pant blow%e el I&= if .c are strong & e%pulsive, cervi% is 1$cm, breath in with .) andpush

'f woman is hyperventilating to increase Pa)+!, minimi>e fetal acidosisand relieve symptoms of vertigo and syncope 5reathe into paper bag

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5reathe into cupped hands+ffer support, encouragement and praise as appropriate

iscourage bearing down effort if cervi% is not fully dilated

*2+ Assist in the a"ministration of anal1esia

Me!eri"ine $3l 0 emerol 'J route bet #- cm, 0anti spasmodic,)/( depression)hec7 5P and @2T before and immediately after the administration,

monitor the =uality of contractionAntedoteE /alo%one 0/arcan4piduralE O L -L8, it relieves pain contraction and numbs vagina and

perineum painless pushless delivery" ?ay cause hypotension but do notcause headache

PudendalE .sed at ! nd stage of labor of labor" Relieves perineal comfortand numbs area for episiotomy

*7+ Status of -OW

'f 5+6 rupture and the woman is wal7ing- P.T 24R '/ 54'f woman is in bed and 5+6 ruptures, )24)K @2T'f 5+6 ruptures and the woman remain undelivered for more than

hour ?+/'T+R T4?P" @+R ('*/( +@ (4P('(

*>+ Obser e if the 8oman is enterin1 the / n" sta1eProgressive increase in the amount of (2+6.rge to pushAnus is spoutingPerineum is bulging

SECON0 STAGE) full cervical dilatation to the e%pulsion of the fetusC$ min in primi- needs !$ strong contraction with the delivery of the

baby$ min in multi- 1$ strong contraction to push the baby out

Mana1ement= 4ncourage pushing only with uterine contraction 5ring her to R if fully dilated in primi, C-1$cm in multi Assist her to assume dorsal lithotomy position

(tirrups must be padded to prevent trauma to the veins resulting tothrombophlebitis

Legs must be placed O the same level to prevent damage to the

uterine ligament resulting to prolapse of uterus8" 'f fetal head is crowning, instruct the mother to pant blow to prevent s#"*et sterile towel to support the perineum0?odified RitgenIs ?aneuver

" As soon as the baby is out, wipe mucus, clear airway to preventaspiration " )hec7 nec7 for cord coil 0slip the cord over the shoulder or overthe head, delay clamping to prevent blood loss


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sudden e%pulsion of the fetal head resulting to lacerationC" As soon as the baby is out E )lear airway ry him immediately Place head lower than the body

Place over the motherIs s abdomen to promote .) and placentalseparation )lamp the cord only when the pulsation stops

" (how the baby to the mother to initiate bonding through eye to eyecontact, tell her the se% of the baby, time of delivery and start breastfeeding0 $ min" /( , 8hour )(

T$IR0 STAGE) from delivery of the baby and ends in the delivery of theplacenta

0uration #-!$ minSIGNS= )al7inIs sign C$:

sudden gush of bloodlengthening of the cord

Management eliver the placenta" )hec7 for completeness, AJA, !$ cotelydons .se 5rantIs AndrewIs ?aneuver to E Prevent placental fragments 'nversion of the uterus

" )hec7 the fundus, must be firm at the midline8" )hec7 5P#" Administer medication as orderedE

a+ Meth5ler1ono ine Malaete '? or 'JP- sustain .) for hour)ontraindicationE 2P/, 2eart isease

b+ O 5to3in) if given 'm or 'J, can sustain .) for $ min


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)hec7 J( = 1# min in the first hour and = $ min on the ne%t hour untilstable

5PE increased within 8C hours TempE elevated in the first !8 hoursPRE normally decreased- P2;('+L+*') 5RA ;)AR 'ARRE unchanged)hec7 the fundus, firm O the midline and normally palpable O the

level of umbilicus4ncourage early ambulation for 8 hours post delivery /( , C-1! hour

post )()hec7 perineum for bleeding and swelling" Apply cold compress only

for first !8 hour)hec7 for lochiaR.5RA- mainly blood , days PP(4R+(A- blood and mucus, 8- days PPAL5A- mainly mucus, yellowish to white, 1$ th to !! nd PP days

SIGNS TO REPORT

.terine cramping 'ncrease vaginal bleeding, passage of large clots /ausea and vomiting

COMMON COMP%ICATION POST PARTUM

Post Partum $emorrha1e)loss of #$$ml of blood or more during the first

!8 hour 0/( , 1$$$ml 0)(

Causes: .terine Atony & laceration Retained placenta & ') 0dessiminated intravascular coagulationdefects

Danger: (heehan (yndrome- necrosis of the pituitary gland Amenorrhea Loss of pubic hair 5reast shrin7 Loss of libido 2ypovolemia B decrease 5P, PR tachy, thready, RR increase depth,temp" decreased Renal failure

Causes: Uterine Aton5) loss of ability to maintain uterine contraction

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Causes= uterine over distension 0multipregnancy, polyhydramios, fetalmacrosomia , multiparity, prolonged or precipitate labor, anesthesia,o%ytocin, distended bladderSS & Sx: @undus- soft, boggy, flabby 5P decrease, PR increase Placenta 'ncomplete ar7 red vaginal bleeding

Management ?assage fundus gently 4mpty the bladder Apply ice cap Administer methergine as ordered

/+ %a3eration of the 3er i a1inal 8all an" Perineum

Causes= ! nd degree laceration, forceps delivery, large fetus, rapid deliverySS D S =a" @undus firmb" Perineal painc" 5right red vaginal bleedingMana1ement= Prepare for repair Apply ice cap first !8 hours 4ncourage 7egelIs e%ercise

2+ Retaine" Pla3ental !arts)Causes= ?ismanagement of the third stage, abnormally adherent placentaSS D S = fundus rela% Jaginal bleeding Placenta is incompleteMana1ement= Prepare for &) Assist in the administration of Pitocin drip )hec7 fundus and J( = $ in first !8 hours

7+ 0essiminate" Intra as3ular Coa1ulation inability of the plasma

clotting factor 0fibrin to form a permanent clot in the wound after !8 hours)ausesE 2ypofibrinogenemiaSS D S = @undus firm Jaginal bleeding- dar7 red 5lood test- hyperfibrogenemia

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Management: Assist in the administration of fro>en clotting factor-CRYOPRECIPITATE ?ust be thawed O room temp" o not sha7e

)onsumed within $ min

Puer!erual Se!sis'nfection of the genital tract within w7s after deliveryCauses = e%isting vaginitis, poor aseptic techni=ue, infected personnel, PR+?,precipitate deliverySS & Sx:- @ever after !8 hours- 5ody malaise- )hills- Anore%ia

Types*+En"ometritis) infection in the lining of the uterusS = foul odor lochia, sub- involuted uterus, abdominal tendernessManagement: 2igh fowlerIs position to facilitate drainage Jaginal discharge iet, increase )2+/, Jit" ), iron, moderate calorie Antibiotic theraphy

/+ Thrombo!hlebitis) inflamed wall of veins due to clot formationCauses = delayed ambulation, trauma to veins, varicosities

SS & Sx: 4dematous, pale & shiny leg- PhlegmasiaGAlbadolensG ?il7y leg Pelvic pain 2omanIs sign-Management: 4levate the affected leg o not massage Assist in heparin therapy2+ Mastitis) infected mammary glandCauses = crac7led nipple, infected mouth of /5, poor breastfeedingtechni=ue, poor breast hygieneManagement: Postponed breastfeeding on the affected breast 4mpty the breast regularly for continuous lactation 4%posed breast to heat lump 1#- $ minGday 2eatGcold application .se protective bra

PSYC$O%OGICA% C$ANGES in POST PARTUM PERIO0

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RU-IN@S POSTPARTUM P$ASE Ta4in1) In Phase

+ccurs !- days postpartum The woman focused on her own needs for rest , sleep, and dependent

on others

/+ Ta4in1 $ol" Phase) 2r"

/ 8ee4s@ocused on the ability to control body functions and ability to assumemothering role

@atigue and e%haustion is common at this phase2+ %ettin1 Go Phase)

?other thin7s that the infant is a separate individual and not part ofherself

4%periences a feeling of lossNursin1 Inter entions Ta4in1 In Phase

4ncourage verbali>ation of labor or birth e%perience

)omplement parents on how well they did4%plore feelings of disappoinment if any?eet dependency needs, comment on appearance, grooming4ncourage rooming in

/+ Ta4in1 $ol" Phaseiscuss self-care, psychologicalGphysiological changesemonstrate infant care

Let the mother to do return demonstration

-IO%OGICA% 'OUN0ATION O' POSTPARTA% PERIO0

Uterine In olution) uterus returns to pre-pregnant state

a" Contra3tions) after !ainsH@re=uency, intensity and discomforts after !8 hours)ommon in multipara, after birth of large baby, breastfeeding women

b" @ormation of new endometrium 8- wee7s until placental site is healed3+ Cer i

'mmediately after birth- bruised, small tears, admit 1 hand+ne w7 PP- admit ! fingers/ever return to pre-pregnant state

'un"usLocated midway between the umbilicus and symphisis pubis after

deliveryAfter 1! hours rises at the level of the umbilicus

escends 1 cmG dayAt 1$ th day, it cannot be palpated

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Nursing nter!ention

1" 5ed rest- 7nee chest, sims or left lateralRis7 for in9ury

!" ?onitor J( = !-8 hour if normal condition, @2T = 1, monitor the characterof amniotic fluid, uterine contraction

Ris7 for infection" Alleviate fears- inform progress of labor, let her listen to @2T

An%iety rGt outcome of pregnancy8" Provide comfort

(acral pressure, bac7 rub, fre=uent changes in position#" Administer prescribe medication and monitor patients response

" iscourage bearing down until cervi% is fully dilated

Premature %abor

5etween !$ w7s B < w7s A+* characteri>ed by regular contractionmore than $ seconds that results in cervical dilatation and effacement

*reatest cause of neonatal mortality and morbidityLow birth wt infants- less than !#$$ gJery low- less than 1#$$ g4%tremely low- less than 1$$$ gL*A- more than $ th : ran7(*A- below 1$ th : ran7

"is# o$ premature birth to in$ants Respiratory distress syndrome Pathologic apnea 'nfection )ongenital heart defects Thermoregulation problems @eeding difficulties /eurological disorders aundice 'ncrease susceptability to infection

Causes% etiology 2istory of premature labor 2istory of spontaneous abortion 4pidemiological factors- low socio economic,Q1C-N8$ yGo, smo7ing,cocaine, stressful living condition ?ultiparity .terine abnormalities ?aternal infections- (T

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)hronic 2P/, ? Poor nutrition PR+? )ongenital malformation of fetus and placenta

Management Regular prenatal chec7-up = !w7s if at ris7 Life style modification 'f preterm labor occurs, stop uterine contractions if Q ! w7s

bedrest- Left lateral2ydration/on-stress test

Tocolytics- if Q 8cm, intact membranes, fetus !#$$g)ontraindication- A" placenta, fetal distress, 2P/ eclampsia,

chorioamionitis8" /o coitus

T+)+L;T') R.*(

Ritrodine 2)L B ;utopar-2P/,tachycardia, arrythmiaAntidote- Propanolol

!" ?g (+8- effective in delaying delivery" Terbutaline- 5rethine

)ontraindicated to pt" with ?, cardiac disorder Tachycardia, hypotension, chest pain, dysrrythmias, nervousness,

/&J, headache8" Prostaglandin 'nhibitors 'ndomethacin- decrease concentration of )a 'so%suprine 2)l- Jasodilan, uvadilan (albutamol

POST TERM PREGNANCY

Management Assess fetal well being ?ethod of delivery based on fetal well being

Nursing nter!ention: ?onitor fetus for signs of hypo%ia and distress )olor of amniotic fluid After delivery of Post ?ature infantE (uctioning Assess for hypoglycemia Provide warm blan7et

$5"ramioN !$$$ ml

Causes:

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1"@etal abnormality anencephaly- absence of fetal s7ull, increase transudation of fluid frommeninges and e%cessive urination of fetus 4sophageal atresia- inability to swallow amniotic fluid (pinal bifida

2eart failure )ongenital infection

/+ Maternal 'a3tors ?ultiple pregnancy ?Signs and symptoms: 'ncrease uterine si>e out of proportion of A+* (+5 5ac7pain, varicosities, constipation, fre=uent urination, hemorrhoids .T3- increase amount of amniotic fluid

Management Complication Premature delivery Abruptio placenta Post partum hemorrhage )ord prolapse ?alpresentation

+L'*+2; RA?'+(

Less than #$$ ml

Causes:Renal anomalies of fetus and renal agenesis 0absence of 7idney PR+? 4%posure to A)4 inhibitors '.*R Post term

Signs and Symptoms: Lea7ing amniotic fluid ecrease amount of amniotic fluid on ultrasound (mall uterus

Management Assess fetal well being +bserve for complication- abortion, still birth, a" placenta, fetal growthretardation uring labor and delivery- )ord compression @etal hypo%ia Prolonged labor

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-%EE0ING IN PREGNANCY

A-ORTION) termination of pregnancy before the fetus sufficiently develop tosurvive before !$ th w7 or less than #$$g

tiology: A5 >ygote developmentG defective >ygote01 st trimester 'ncompetent cervi% 0! nd trimester

Types Threatene" Abortion) closed cervi%, slight vaginal bleeding, mildabdominal cramps

)5R for 8C hours(ave all pads for evaluation?onitor J(Progesterone supplement to maintain decidua/o '4, no coitus

/+ Ine itable) cervi% open, vaginal bleeding moderate, bac7ache, uterinecramps

Prepare for & )4motional support

S!ontaneous abortion is natures safe1uar" to !re ent the birth ofbabies 8ith multi!le anomaliesH

>+ $abitual) or more successive abortion%ea"in1 Cause= 'ncompetent cervi% B dilates before the !$ th w7 of pregnancy Parity of more than # )ervical laceration )ongenitalSigns and symptoms: Presence of show 5+6 ruptures .terine contraction4)T+P') PR4*/A/);

4%tra uterine gestation('T.E tubal0 ampulla-common, interstitial , cervical, ovarian

Causes Tumor in fallopian tube (car Adhesion 4ndometriosis- growth of endometrium in the tube '. P'F The tube ruptures between -1! th w7 of pregnancy

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Signs and symptoms: Fehr@s si1n) sharp stabbing pain on the lower outer =uadrant of theabdomen, radiates on shoulder Culler@s si1n) bluish umbilical area of the mother Rigid uterusG 'ncrease 65), temp /ormal, decreased 5P, rapid pulse '4 reveals presence of culdesac mass

Management: )ontrol of bleeding- laparotomy to ligate bleeders 5T T-berg position Provide warmth to decrease the demand for o%ygen

$Y0ATI0I'ORM MO%Eegeneration of chorionic villi resulting to proliferation forming a

cluster of vessels containing fluids, grape-li7e, maybe non-malignant or maycause cancer

4tiologyE .n7nown, age 1C below, low socio- economicstatus0 decrease )2+/ inta7e

Signs and Symptoms: preg" Test 2)*- millions .ndue enlargement of uterus 4arly P'2 before !$ th w7s 2yperemesis gravidarum Jaginal bleeding before or 8 th month, 1! th w7s Absence of fetal parts, outline and movements

Management: 4vacuation of 2-?ole Jaccuim aspiration & )

(ample of 2-mole is sent to laboratory for biopsy'f benign, the woman must undergo methotre%ate thepary to prevent

the growth of )A cells'f malignant, must undergo hysterectomy

!" Pregnancy is contraindicatedAfter 8$ days, 2)* must be absent to her urine)ontraception is necessary

P%ACENTA PRE&IALow lying placenta

Types: ?arginal- edge of placenta reaches the margin of the cervi% Partial- part of placenta covers cervical os

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)omplete or total- center of placenta covers cervical os

Signs and Symptoms: Painless uterine bleeding after !$ th w7 .terus remain soft- not always accompanied with fetal distress

Nursing Care .pon admission, )5R 8C hour, high fowlers ?onitor J( and @2T /o '4, enemas Prepare for sonogram to locate placenta @acilitate double set up, preparation for )( is completed before '4 at+R ?anage bleeding episodes ?aintain /P+ 'f bleeding stops, pregnancy is allowed upto Cw7s

A-RUPTIO P%ACENTAPremature separation of the implanted placenta

Causes: ecrease blood supply to placenta P'2 ? (hort umbilical cord Tetanic contraction isparity between placenta and its site 0PR+?Gbirth of the 1 st twin

Management Respond to symptoms Treat shoc7 symptoms Administer +%ygen by tight mas7 O -1$ LGmin 'ncrease 'J@ rate Administer blood- properly type and cross matched J( = 1#, @2R .rine output

" +bserve (s & (% of coagulation defects8" ?easure abdominal girth#" Remain with the client

" )ontinually monitor labor pattern if labor is allowed to continue


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Gestational $PN - 2P/ developed during pregnancy or after delivery whichis not accompanied with edema, proteinuria and convulsions and disappearswithin 1$ days after deliveryChroni3 $PN - presence of 2P/ or developed before the !$ th w7 gestation inthe absence of 2-mole and persist beyond post partum

'redisposing Factors: Primipara Q!$ yGo, N8$ yGo Low socio-economic status Previous 2P/ of pregnancy, 2-mole, ?, multiple pregnancy,polyhydramios, renal disease, heart disease 2eriditary

Classi$ication:

Gestational $PN - 5P 18$G $, no protienuria, no edema

Mil" !ree3lam!sia - 5P 18$G $0 ta7en in ! occasion O hours apart ,protienuria 1 ! 01gGl , edema Se ere !ree3lam!sia - 5P 1 $G11$, protienuria 8 0#gGl , edema

edema- puffiness face and hands, pitting edemaRings are tight or eyes are swollen at am

ecreased urine output(evere epigastric pain, /&J(+55lurred vision, severe headache?ar7ed hyper refle%ia and muscle clonus

7+ E3lam!sia - sei>ure all signs of severe preeclampsia

Complication: )erebral hemorrhage Renal failure @etal hypo%ia Abruptio placenta Premature labor

Nursing Diagnosis: 'neffective Tissue Perfusion rGt vasoconstriction of blood vessels @luid volume deficit rGt fluid loss to subcutaneous tissue Ris7 for in9ury rGt placental perfusion ! nd to vasospasm (ocial isolation rGt prescribe bed rest

Nursing nter!ention:

'or Mil" Pree3lam!sia= Promote best rest- lateral position

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Promote good nutrition, decreased /a in the diet Provide emotional support- verbali>ation of feelingsSe ere Pree3lam!sia 5est rest Provide =uite environment, limit visitor, avoid stress

?onitor fetal well being iet- moderate ti high )2+/, moderate /a Administer medication as ordered

$5"rala6ine (A!resoline# decreases 5P, can cause tachycardia M1SO7) bloc7s peripheral neuromascular transmission- lessenpossibility of sei>ure, reduces edema

)hec7 urine output $- $ mlG hrRR Q 1! bpm

TR

Classi$ication:$EART 0ISEASE

Pregnant women with heart disease should avoid infection, e%cessivewt" gain, edema and anemia because this conditions increase the wor7load ofthe heart

Signs and Symptoms: +5- dyspnea, orthopnea, nocturnal dyspnea cyanosis (yncope )hest pain )lubbing of fingers /ec7 vein distention ?urmurs )ardiomegaly Arrythmia Pulmonary 2P/

Complications: 2eart failure Abortion Premature labor '.*R

Management: Class &

1" Rest" C hours sleep and fre=uent rest period during the day" Lie downfor $ min" after each meal" Light wor7 only, no climbing of stairs and noe%haustion

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!" iet" 2igh 'ron, )2+/, minerals and vitamins, limit /a inta7e" ?onitorwt" *ain

" Avoid high altitudes, smo7ing areas, planes and crowded areas"8" Prevent infections#" Provide instructions on danger signs of heart failure- cough with rales,

increasing dyspnea, tachycardia, rales, edema" ?edicationsE

'ronigitalis to strengthen myocardial contraction and slow down heart

rate/itroglycerineAntibiotics

iuretics maybe prescribed in case of heart failure

ntrapartal Care

4arly hospitali>ation to promote rest and closed supervision (emi fowlerIs or lateral recumbent position"Lo lithotomy J( = 1# min 4pidural anesthesia- painless" /o pushing Poor candidate for )( due to increased ris7 for hemorrhage, infectionand throboembolism

'ostpartum Care

?onitor J( Promote rest" Limit visitors until cardiac status has estabili>ed 4arly but gradual ambulation to prevent thrombophlebitis ?edicationsE Antibiotics & (tool softeners 5reastfeeding is allowed if there are no signs of cardiacdecompensation during pregnancy, labor and puerperium

PREGESTATIONA% 0IA-ETES

ue to problems in the pancreatic 5eta cells

Gestational 0M) due to carbohydrate intolerance detected duringpregnancySi1ns= 4%cessive thirstG hunger 4%cessive fatigue @re=uent urination Recurrent monilial infections 'ncreased fundic ht" Polyhydramnios and suspected macrosomia 4levated blood sugar level, proteinuria

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$$ects o$ Diabetes:

*+ MotherpreeclampsiaG eclampsia, .T', candidiasis

ystociaPostpartum hemorrhage2ydramnios?aternal mortalityRetinopathy, nephrophathyPreterm delivery

/+ 'etus?acrosomiaPrematurity'.*R2ypoglycemia and hypocalcemiaPredisposition of ? in later lifeRespiratory distress

Classi$ications:()hite*s Classi$ication+

Class A+nset is at pregnancy)ontrolled by diet, insulin not re=uired'nfant Large for *estational age

Class -+nset at age !$, has the disease for less than 1$ yrs'nsulin dependent during pregnancy

Class C+nset between 1$-1 yGo'nsulin dependent before pregancy, insulin re=uirements increase

during pregnancy)omplication of preeclampsia and '.@

Class 0+nset before 1$ yGo6ith benign retinopathy, insulin dependent,(*A infants

'renatal Management

iagnosis- 2% of ?, une%plained repeated abortions, stillbirth, with

glycosuria, obese, 2% of large infants and congenital anomaly (creening test @5(- /P+ -C hours +*TT-

/P+ -C, fasting specimen in A? bloodG urineAdminister 1$$ gm of glucose dissolved 1 glass fruit 9uice or $$ gm

)2+1, !, , collection of blood sample'nterpretationE

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5lood rise after 1 *radually decrease at ! Almost normal at

-ene"i3ts Test - # ml of benedictIs soln", warm and add C-1$ gtts of urine,boil then let it cool

nterpretation:5lue - $5lue green - 1

;ellow - !+range - 5ric7 red - 8Aci test- aci test tablet)lini test- 1$ gtts of 2!+, # gtts of urine, clini test tablet0corrosive'nterpretation- 5, 5*, *, ;*, ;+, +range

" iet- #$: )2+, $: @ats, !$: )2+/)omple% )2+Proper e%ercise

8" 'nsulin therapy'ncreased 'nsulin re=uirement at ! nd & rd trimester+ral hypoglycemic drugs are contraindicated2umulin- drug of choice

#" ?onitor glucose level-

maternal age

/+ 0i651oti3 T8ins or fraternal t8ins) ! or more ova and sperm cells thatfertili>ed at the same time, may have different genetic traits, may not be thesame se% and always have ! placentas, ! chorions, ! amnions

Race

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2eredity- more common on maternal side2igh parity and advance maternal age.se of fertility drugs

Complications:

Abortion eath of one fetus Perinatal mortality Preterm labor Low birth wt" )ongenital malformation 2ydramnios ?aternal 2P/ Placenta previa and abruptio placenta '.*R )ord enlargement, prolapse, compression

?aternal anemia

Management: /utrition- additional $$ Kcal, 'ron $-1$$ mg, Jit", (i% small mealsGday Rest- more rest period to avoid premature labor ?anage discomforts Labor and elivery 'nstruct to come to the hospital if labor begins ?onitor J(, @2R, P+L

The cord is cut right after delivery of the first infant etect presentation of the second infant by leopoldIs or ultrasound /ormal interval is $ min of the second twin#" 6atch for post partum hemorrhage

n$ections in 'regnancy Tuber3ulosis) th cause of mortality and morbidity 0 +2 1 C

Rifampicin, '/2", P3A, 4thambutol5reastfeeding is not affected by the medications for T

/+ Malaria C th cause of morbidity'ncreased ris7 for anemia, death, spontaneous abortions, stillbirth,

premature delivery and low birth wt"Pro!h5la is= ! tab )hloro=uine phosphate !#$mgGtab = w7 for the

duration of pregnancy2+ -reastfee"in1 is contraindicated7+ $e!atitis -

1" 2epa 5 immuneglobulin at birth!" 2epa 5 vaccine at 1 w7, 1 month, months after delivery

>+ $I&) transmission thru placenta 0greatest near term , birth canal duringdelivery, breast mil7

" @ocus of care is to treat infections and reduce the ris7 of perinataltransmission

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8" I0O&U0INE initiated at 18- 8w7s A+* throughout the pregnancy,'J during labor and delivery, and neonatal dose after delivery

#" 5athe the neonate as soon as possible after delivery" All needle procedure is done after bath

:+ RU-E%%A ( German Measles#


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!1"?onitor fetal well being:+ Chorioni3 &illi Sam!lin1) a thin catheter is inserted into the uterus todetect genetic abberations

!!"'nstruct the client to drin7 water to fill the bladder to aid in theattainment of the desired position of the uterus

! "4%plain the ris7 involveE spontaneous abortion, infection, hematoma,intrauterine fetal death

Maternal Nursing Lec

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