Maternal-Lecture-Notes (1).docx

Maternal Child Nursing

ANATOMY AND PHYSIOLOGY

FEMALE EXTERNAL GENITALIA

1. MONS PUBIS- AKA Mountain of Venus, a fat pad above symphisis pubis
2. LABIA MAJORA- Large Lips, two thick folds of adipose tissue originating from the mons and terminating in the perineum
3. LABIA MINORA- AKA Nymphae, two thin folds of connective tissue that joins anteriorly to form the prepuce and posteriorly to form the fourchette
4. CLITORIS- a highly sensitive and erectile tissue situated under the prepuce of the labia minora. Sight of sexual arousal in females.
5. FOSSA NAVICULARIS- refers to the space between the fourchette and the vaginal introitus
6. VESTIBULE- triangular space located between the labia minora
7. BARTHOLIN’S GLANDS- located at each inner side of the vagina
8. SKENE’S GLANDS- pair of glands situated at each inner side of the urethral meatus
9. VAGINAL ORIFICE- external opening of the vagina
10. HYMEN- thin circular membrane made of elastic tissue situated at the vaginal opening.
11. URETHRAL MEATUS- external opening of the female urethra

THE FEMALE INTERNAL ORGANS

1.VAGINA- a hollow, membranous and muscular canal about 8 to 12 cm long.

FUNCTIONS

-organ of copulation

-discharges menstrual flow

-birth canal

-VAGINAL pH- before puberty is 6.8 to 7.2, after puberty vainal pH goes down to 4-5

2.UTERUS- hallow muscular organ canal resembling an inverted pear which is situated in the true pelvis

FUNCTIONS

-organ of reproduction

-organ of menstruation

-uterine contraction

PARTS OF THE UTERUS

FUNDUS- the upper most portion located between the insertion of the fallopian tubes

CORNUA- the portion at which the fallopian tubes are inserted

ISTHMUS-the upper third of the cervix which is very thin and which forms the lower uterine segment delivery

CORPUS- makes up two-third of the said organ.

CERVIX- the neck of the uterus is about 2.5 cm long and has a diameter of 2.5 cm, too.

LAYERS OF THE UTERUS

1. Perimetrium- the outermost serosal layer attached to the broad ligaments

2. Myometrium- the middle muscular layer responsible for uterine contractions during labor.

3. Endometrium- the innermost ciliated mucosal layer containing numerous uterine glands.

TWO LAYERS OF THE ENDOMETRIUM

a. Glandular Layer- composed of columnar epithelium

b. Basal Layer- layer adjacent to the myometrium

3. FALLOPIAN TUBES(OVIDUCTS)-pair of tube-like structures originating from the cornua of the uterus with the distal ends located near the ovaries.

FUNCTIONS

-transport ovum from ovary to the uterus

-the site of fertilization

-provides nourishment to the ovum during its journey

PARTS OF THE FALLOPIAN TUBE

1. Interstitial/ Intramural-thick walled, located inside the uterus, about 1 cm long

2. Isthmus-narrowest portion of the uterus and about 1 cm long

3. Ampulla- middle portion and the widest part.

4. Infundibulum- most distal portion. It has fingerlike projections called fimbria.

4.OVARIES- almond-shape glandular organs located on either side of the uterus. Each ovary weighs between 6 to 19 g, 1.5 to 3 cm wide and 2 to 5 cm long.

FUNCTIONS

-oogenesis

-ovulation

-hormone production

LAYERS OF THE OVARY

• Tunica Albuginea- the outermost protective layer.
• Cortex- functional layer which is the site of ovum formation and maturation.

THE MALE REPRODUCTIVE SYSTEM

EXTERNAL ORGANS

1. Penis- composed of three longitudinal erectile tissue: two corposa cavernosa and one corposa spongiosum

FUNCTIONS

-organ of copulation and of urination

PARTS

Shaft or body

Glans Penis-most sensitive part

Prepuce/Foreskin-fold of retractable skin coverig the glans

Urethral Meatus- a slitlike openig located at the tip of the penis

2.Scrotum-sac-like structure containing the testes and hangs behind the penis

INTERNAL ORGANS

1.Testes- two oval shape glandular organs lying within the abdominal cavity in early fetal life and descend to the scrotum after 28 weeks gestation.

FUNCTIONS

-hormone production-testosterone

-spermaogenesis-production and maturation of sperm cell begins at puberty and continue until old age

PARTS

Seminiferous tubules- long coiled tube where spermatogenesis take place, the testes produce about 176 sperm cells a day

Leydig/Interstitial cells-produce testosterone, found around seminiferous tubules

Sertoli Cells- suppporting cells which plays a role in sperm transport.

2.Epididyms- long coiled tube approximtely 20 feet long at which the sperm travels for 12 to 20 days after it leaves the testis.

3. Vas deferens- contractile power of this part of the duct system propels the spermatozoa to the urethra during ejaculation.

4. Ejaculatory Duct- it connects the seminal vesicles to the urethra.

ACCESORY ORGANS

• Seminal Vesicle- a two-pouch like organs consisting of many saclike structures located behind the bladder and in front of the rectum
• Prostate Gland- a walnut-shape(conical) body lying below the bladder
• Cowper’s/Boulburethral Gland- two small glands located below the prostate that secrete alkaline fluid before ejaculation.
• Seminal Fluid or Semen-mixture of secretions from the seminal vesicles, prostate gland,Cowper’s gland, ejaculatory duct and sperm cells.

THE MENSTRUAL CYCLE

• Hypothalamus-ultimate initiator. Secretes gonadotropin releasing hormones.
• Anterior Pituitary Gland-releases the gonadotropin hormones(FSH,LH).
• Ovaries- site ovulation,source of estrogen and progesterone.
• Uterus-it is where menstrual discharged is formed.

HORMONES INVOLVED IN THE MENSTRUAL CYCLE

1.FSHRF-produced by the hypothalamus,stimulates APG to release FSH

2.FSH-stimulates production of several Graafian Follicles

3.Estrogen- “hormone of women”.Produced by the Graafian Follicles.

THREE TYPES OF ESTROGEN

-estradiol

-estrone

-estriol

EFFECTS OF ESTROGEN

-inhibit FSH

-stimulates deposition of fat in subcutaneous tissues that gives a female shape and development of secondary characteristics.

-stimulates growth of vagina and uterus, thickening of the endometrium

-causes mucus to be thin, highly stretchable

-stimulates the growth of the ductile structures of the breasts

-menarche and menstruation

-premenstrual water retention

4. LHRF-produced by the hypothalamus, stimulates APG to release LH.

5.Progesterone- hormone for mothers.Produced by the corpus luteum.

EFFECTS OF PROGESTERONE

-Thermogenic effect

-relaxes uterine muscles

-promotes growth of acini cells of the breasts

-causes fluid retention

-cause of PMS (Premenstrual Syndrome)

-prepares endometrium for implantation

-causes tingling sensation and feelling of fullness in the breast during menstruation

PHASES OF THE MESTRUAL CYCLE

1.MENSTRUAL PHASE

-day 1-5 of a 28 day menstrual cycle

-begins on the first day of menses,lasts 2-7 days

-because of progesterone withdrawal

-desquamation of the layer of the endometrium

-2/3 of the endometrium is shed off

-uterus lining is in its thinnest

-total blood loss-30-80 ml, iron loss-11 to 29mg

-saturating a pad or tampons more than an hour is a heavy flow

2.PROLIFERATIVE PHASE

-from day 6-13 of a 28 day cycle. Lasts 8-10 days

-low estrogen stimulates FSHRF which in turn stimulater APG to secrete FSH

-Primordial follicle to Graafian follicle

-estrogen is on its highest causing endometrium to be highly vascular,thickness increasing up to 8^th folds

-genital tract is prepared for sperm migration,cervical secretion becomes abundant- called follicular, postmenstrual and estrogenic phase

3. SECRETORY PHASE

-13^th to 25^th day

-rise in estrogen inhibits the APG to secrete FSH. Suppression of FSH, high estrogen, low progesterone triggers hypothalamus to release LHRF which stimulates APG to secrete LH that promotes ovulation

-after ovulation, Graafian follicle is now the Corpus Luteum.

-Corpus lutuem produces large amounts of progesterone

- progesterone increases vascularity of the endometrium and stimulates endometrial glansds to produce mucin and glycogen

-endometrium becomes very soft, spongy and edematous

-corpus luteum has a lifespan of 7-8 days. If fertilization occurs, it regresses and becomes non-functional 10-12 days after ovulation resulting in withdrawal of progesterone and estrogen.

-if fertilization occurs:the fertlized ovum will implant in 7-8 days after fertilization

4.ISCHEMIC PHASE-progesterone withdrawal results in formation and release of prostaglandins

-arteriolar spasms cuts off blood supply that causes necrosis and rupture of blood vessels that would cause endometrial sloughing

-onset of dysmennorhea may signal the beginning of another menstrual cycle

OVULATION

-midpoint of the cycle,the very high level of estrogen and very low level of progesterone triggers the release of LH which is the hormone that promotes ovulation

-occurs 14 days before menstruation

SIGNS OF OVULATION

• Mittelschmerz-lower abdominal pain felt at the side of the ovary that released the ovum.
• Spinnbarkheit-signals that a woman is nearing ovulation or is ovulating.Cervical mucus is thin, watery or transparent, abundant and highly strechable
• Increased basal body temperature-due to progesterone

Peak blood level of LH.

Example: First day of menstruation is January 30

January 30-14=16

ovulation occured on January 16

MENSTRUAL PROBLEMS

• Dysmenorrhea- painful menstruation

a. Primary dysmenorrhea- no known cause

-discomfort begis 1-2 days before onset of menses then subsides by the second day

-nausea, vomiting,diarrhea,syncope, leg pain

Intervention: sedatives,narcotic analgesics, oral contraceptive is contraception is desired

b. Secondary dysmenorrhea- has underlying disease condition

causes: PID Pelvic Inflammatory Disease

-Endometriosis

-Adenomyosis

-Uterine prolapse

-Uterine myomas and polyps

-Intervention:treat the cause

2. Amenorrhea-absence of menses. May be due to pregnancy, lactation, abnormality of the endocrine system, rapid weight loss, anorexia nervosa or strenous exercise.

3. Oligomenorrhea- decreased menstrual flow

4. Menorrhagia-heavy and prolonged menses. May be due to endocrine imbalance, infection and uterine tumors.

5. Metrorrhagia- bleeding in between menses

6. Polymenorrhea- bleeding at frequent intervals. Frequently due to a disease process.

MENOPAUSE

SIGNS AND SYMPTOMS OF MENOPAUSE

a. hot flushes

b. loss of breast mass and firmness, and atrophy of reproductive organs

c. dyspareunia

d. musculoskeletal symptoms.

MANAGEMENT:

1. Estrogen replacement therapy(ERT) to relieve hot flushes, mood instability and for prevention and treatment of osteoporosis.

2. Provide information regarding contraception.

3. Calcium (1g/day at HS) and vitamin D supplementation.

4. Increase fluid intake

5. Teach how to manage hot flushes

6.Role of the nurse-midwife

-encourage woman to engage in regular exercise

-instruct on proper use of water-soluble vaginal lubricant for painful intercourse

-provide emotional support and sympathetic understanding

-refer for counselling as the need arise

-instruct to avoid smoking and alcohol

-regular physical examination

FERTILIZATION PROCESS

ZYGOTE

-fertilized ovum

-journeys from the fallopian tube and to the uterus in 3-4 days

-24 hrs after fertilization, it undergoes the first cell division(blastomere)

-after 22 hrs. it becomes a morula that travels into the uterus and becomes a blastocyst.

BLASTOCYST

-called embryonic disc/blastocoel

-on its outer layer is the trophoblast/trophoderm.

-trophoblast gives rise to the placenta, fetal membranes, umbilicus cord and amniotic fluid

-important functions of the trophoblasts: are to absorb nutrients from the endometrium and secrete HCG

-the embryonic disc gives rise to the three primary germ layers:

a. Ectoderm-gives rise to the skin, hair, nails, sense organs, nervous system, mucous membrane of the mouth and the anus

b. Mesoderm- gives rise to the kidney, musculoskeletal system, reproductive system nand the cardiovascular system

c. Entoderm- gives rise to the bladder, lining of the GIT, tonsils, thyroid gland and respiratory system.

IMPLANTATION

-blastocyst remains free floating in the uterine cavity for 3-4 days

-blastocyst implants in the endometrium approximately 6-7 days after fertilization

-site of implantation is the fuNdal portion

TROPHOBLAST

-differenttiates in two distinc layers after 3 wks.

a. Cytotrophobast/langhan’s layer-first layer that develops. Protects the fetus against treponema pallidum/syphilis until 2^nd trimester of pregnancy.

b. Syncytiotrophoblast-outer layer. It produces hormones

AMNIOTIC FLUID

- volume: 500 to 1200ml, average is 1000 ml

-composition: 99% water and 1% solid particles, contains albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, ilirubin and vernix caseosa

-early pregnancy it is chiefly composed of maternal serum

-at 10^th wk. of pregnancy, the fetus urinates and contributes to the volume of the amniotic fluid

-appearance;clear and colorless to straw colored

- pH- 7.0-7.25

-specific gravity-1.005 to 1.025

FUNCTION OF THE AMNIOTIC FLUID

P-protects the fetus

A-allows freedom of movement

S-secretion and excretion system of the fetus

M-maintain constant temperature

O-oral fluid as source

P-prevents pressure on the cord

A-aids in fetal descent during labor

UMBILICAL CORD/FUNIS

-main function is to carry oxygen and nutrients from the placenta

-contains 2 arteries and 1 vein (AVA)

-one artery & one vein: TWO VESSEL CORD/SINGLE UMBILICAL ARTERY.

-length: 50-55 cm long, 2 cm in diameter

-Protects the umbilical cord: Wharton’s Jelly found inside the cord

PLACENTA

- reaches maturity at 12 weeks gestation

-weight: 500 grams, diameter of 15-20 cm and about 3 cm thick

-occupies about ¼ of the uterine cavity

-MATERNAL SIDE: faces the mother, 15-20 cotyledons

-FETAL SIDE: faces the fetus, the amnion covers it

FUNCTIONS OF THE PLACENTA- GRECE

G-gastrointestinal system

R-respiratory system

E-endocrine system

C-circulatory system

E-endi kalimutan renal system

ABNORMALITIES OF THE PLACENTA

• Placenta Bipartita- placenta not divided in two lobes
• Placenta Duplex- placenta is separated completely into two parts
• Placenta Succenturiata- has an accessory lobe with blood vessels connected to it.
• Ring-shaped placenta- associated with fetal growth retardation,postpartum and antepartum bleeding
• Fenestrated Placenta- the central portion of the maternal side of the placenta is missing.
• Placenta Circumvallata- central depression surrounded by a thickened white-greyish ring .
• Circummarginate placenta- when the white-greyish ring is located at the margin of the placenta
• Placenta accreta- deeply implanted placenta
• Large placenta- encountered in syphilis and erythroblastosis fetalis

PSYCHOLOGICAL/EMOTIONAL ADAPTATIONS OF PREGNANCY

1. Acceptance of Pregnancy (first trimester)

-”I am pregnant”

2. Acceptance of the Fetus as a separate individual

-”I am going to have a baby”

-she begin to fantasize about the child’s sex and appearance

-she gives the fetus identity

3. Acceptance of motherhood (third trimester)

-’I am going to be a mother”

-she plans about her baby

SIGNS AND SYMPTOMS OF PREGNANCY

PRESUMPTIVE SIGNS (PRESUME)

P-Period Absent (Amenorrhea)

R-Really tired

E-Enlarged breast

S-Sore breasts

U-Urination Frequency Increased

M-Movement Perceived (Quickening)

Emesis and Nausea

PROBABLE SIGNS (PROBABLE)

P-Positive Preganancy Test

R-Return fetus when tapped

O-Outline of the fetus palpable

B-Braxton Hicks contractions

A- A softening of the cervix (Goodell’s sign)

B-Bluish color of the cervix (Chadwick’s sign)

L- Lower uterine segment softens (Hegar’s sign)

E-Enlarged Uterus

POSITIVE SIGNS (FETUS)

F-Fetal movement felt by Health Care Provider

E- Electronic device detects fetal heart sounds

T-The delivery of fetus

U-Ultrasound detects the fetus

S-See movement of the fetus by Health Care Provider

LEOPLODS MANUEVER

1. First manuever (fundal grip)

-to determine fetal part lying in the fundus

-round,smooth- HEAD

-soft, angular- BUTTOCKS

2. Second Manuever (Umbilical grip)

-to identify location of the fetal back

-fetal back feels smooth and hard

3. Third Manuever (Pawlik’s Grip)

-to determine engagement of the presenting part

-movable-not yet engaged

4. Fourth Manuever (Pelvic Grip)

-to determine degree of flexion

-if descended deeply, only a small portion of the fetal head can be palpated

HEALTH TEACHINGS

1. Schedule of Clinic Visit

-diagnosis of preg.to 28 wks-every month

-28 wks to 36 wks. every two weeks

-36 wks. until delivery- evry week

2. Exercise

-pelvic rocking

-squatting and tailor sitting

-Rib Cage Lifting

-calf stretching

-shoulder circling

-abdominal muscle contractions

-modified knee chest

ADVANTAGES OF EXERCISE DURING PREGNANCY

-strengthen muscles

- promote circulation

-relieves tension and anxiety

-improves posture and appetite

-improves metabolic efficiency

3. Dental Care

-dental carries should be treated

-alkaline mouthwash can be used to counteract the acidic saliva during pregnancy

4. Clothing

-light-weight, non-constrictive

-absorbent and reasonably priced

-flat heeled shoes

5. Bathing

-daily bath

-no tub bath

-swimming is ok, but no to diving

-no bathing if there is vaginal bleeding and if BOW is ruptured.

6. Breast Care

-well fitting and larger size brassiere

-wash breast with water only

7.Immunizations

-no to Rubella vaccine,Mumps vaccine, Oral Poliomyelitis Vaccine

-Hep B and Typhoid fever vaccine can be given only if risk factors are present.

-TT immunizations

8. Employment

-no lifting of heavy objects

-no sitting and standing for a long time

-no excessive physical and emotional strain

-no to exposure of toxic substances

9. Travel

-Avoid long trips on the third trimester

-best time to travel-second trimester

-when travelling:

-15-20 minute rest period every 2 hours on a long ride

-use shoulder and lap belts

-the place should be pressurized

10. Sexual Relations

-first trimester- decreased sexual desire

-second trimester-increased sexual desire

-third trimester-decreased sexual desire

CONTRAINDICATION OF SEXUAL INTERCOURSE

-deeply presenting part

-rupture of bag of water

-vaginal bleeding or spotting

-incompetent cervix

11. Alcohol- no to alcohol during pregnancy

12. Caffeine

-not more than 4 cups a day

Effects of Caffeine

-diuretic

-feeling satisfaction without being nutritious

-causes mood swings and sleep disturbances

-interfere with iron absorption

-baby may develop diabetes later in life

13. Drugs -they should not take any drug nor prescribed by a physician.

FAMILY PLANNING

Guiding Principles

1. determine your own beliefs first

2. never advise a permanent method of family planning

3. informed consent

4. the method is an individual decision

Natural Method – accepted by the church

1. Billing’s/ Cervical Mucus/ Spinnbarkeit

• clear watery & stretchable

• 13th day – longest due to estrogen

2. Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of progesterone

3. LAM – Lactational Amenorrhea Method

> prolactin – inhibits ovulation

> breastfeeding – 4 – 6 months no menstrual cycle

> bottle fed – 2 – 3 months

4. Symptothermal – combination of Billings and BBT – most effective method

Social Methods

1. Coitus Interuptus

> withdrawal

> least effective method

2. Coitus Reservatus

> sex w/o ejaculation

3. Calendar Method

> 14 days before menstrual cycle – ovulation day (regular)

> - 4, + 4 days – unsafe period

4. PILLS

-combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland

roduction of FSH and LH which are essential for he maturation and rupture of a follicle.

-Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH

which is responsible for ovulation.

5. DMPA – Depoprovera

> Contains progesterone

> Depomedroxy progesterone Acetate

> IM q 3 months – never massage the site may decrease effectiveness

6. NORPLANT

> 6 match stick like capsules

> contain progesterone

> sub Q planted under the skin of a woman’s inner upper arm.

> good for 5 years

Mechanical Device

1. IUD- IntraUterine Device

> prevent implantation

> alters mobility of sperm and ovum

> 99.7% effective

>best inserted after delivery and during menstruation

> Common complication – EXCESSIVE MENSTRUAL FLOW

>Common problem – EXPULSION OF THE DEVICE

> No protection against STD

Side effects include

• Uterine infection
• Uterine perforation
• Ectopic pregnacy

Health Teaching: monthly check up and regular pap smear

2. CONDOM

> Made up of latex

> Put in erected penis or lubricated vagina

> Prevents sperm to enter the uterus

> FEMALE CONDOM – higher protection than that of male

3. DIAPHRAGM BIRTH CONTROL

> Dome shaped rubberized material inserted at the cervix to prevent sperm getting inside the

uterus

> Reusable

Health Teachings:

1. Proper hygiene
2. Check for holes
3. Must be refitted in case of weight gain of 15 lbs- board question
4. Kept in place for about 6-8 Hours- board question

Contraindicated to: Frequent UTI

4. CERVICAL CAP

• More durable than the diaphram
• Could stay on place for more than 24 hours
• No need to apply spermicides
• Contraindicated to – abnormal papsmear

SURGICAL METHOD

1. Bilateral tubal Ligation

• @ isthmus
• 20% probability of reversal

2. Vasectomy

• Vas deferens is cut
• More than 30 x or 0 sperm count or 2 x negative sperm count before it could be

consider safe sex

• 20 ejaculation following the vasectomy to make sure it’s “free of sperm”

HIGH RISK PREGNANCY HEMORRHAGIC DISORDERS

First Trimester Bleeding

A. ABORTION – termination of labor before age of viability

1. SPONTANEOUS

• AKA miscarriage
• Causes:

>Chromosomal aberrations due to advanced maternal age

>Blighted ovum

>Germ plasm defect

Classifications:

1. Threatened

• pregnancy is jeopardized by bleeding and cramping but the cervix is

closed and can be saved.

2. Inevitable

• moderate bleeding, cramping, tissue protrudes from the cervix and the

cervix is open.

Types :

1. Complete

• all products of conception are expelled.
• Mgt : emotional support

2. Incomplete

• placenta and membranes retained.
• Mgt : D&C Dilation and Curettage

B. HABITUAL

• 3 or more consecutive pregnancies result in abortion usually related to incompetent

cervix.

Management (suture of cervix)

1. McDonald procedure

• Temporary circlage

• Side effect – infection

• May have NSD

2. Shirodkar

• CS delivery

C. MISSED

• fetus dies; product of conception remain in uterus 4 weeks or longer

Signs of pregnancy cease(huminto)

1. (-) pregnancy test

2. Dark brown

3. Scanty bleeding

Mgt :

1. induction of labor (medicine: Oxytocin: Pitocin)
2. vacuum extraction(aka: Ventouse) is a method to assist delivery of a baby using a vacuum device.

D. INDUCED

-Therapeutic abortion principle of 2 fold effect

-Done when mother has class 4 heart disease

Ectopic Pregnancy

• occurs when gestation is location outside the uterine cavity
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial

UNRUPTURED

• Abdominal pain within 3- 5wks of missed period (maybe generalized of one sided)
• Scant, dark brown vaginal bleeding
• Vague discomfort

RUPTURED

• sudden, sharp severe unilateral pain, knife like
• shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm & phrenic

nerve)

• (+) Cullen’s sign – bluish tinged umbilicus
• syncope/fainting

Nursing Care :

• vital signs
• administer IV fluids
• monitor for vaginal bleeding
• monitor I&O

• Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING

Hydatidiform Mole / “bunch of grapes”

• Cause : Unknown

• Assessment :

Early signs

• vesicles passed thru the vagina
• Hyperemesis gravidarum due to ↑ HCG
• Vaginal bleeding (scant or profuse)

Early in pregnancy

• high levels of HCG
• Pre ecclampsia at about 12wks
• Vesicles look like a “snowstorm” on sonogram
• Anemia
• Abdominal cramping

Serious late complications

• Hyperthyroidism
• Pulmonary embolus

Nursing care :

• prepare for D&C
• do not give oxytocin drugs due to proneness to embolism

Health Teaching:

• return for pelvic exams as scheduled for one year to monitor HCG and assess

for enlarged uterus and rising titer could be indicative of choriocarcinoma

• Avoid pregnancy for at least one year
• Methotrexate therapy

Incompetent Cervix Management:

• McDonald procedure

• temporary circlage of incompetent cervix.
• Delivery : NSVD
• SE: infection
• Health teaching

-observe for signs of infection

-signs of labor

• Shhirodkar procedure

• permanent procedure.
• Delivery : caesarian section required.

THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES”

Placenta Previa

• It occurs when the placenta is improperly implanted in the lower uterine segment.

Assessment:

• Outstanding sign : frank, bright red, painless bleeding
• enlargement (usually has not occurred)
• fetal distress
• abnormal presentation

Nursing care :

• Initial mgt : NPO candidate for CS
• Bedrest
• prepare to induce labor if cervix is ripe
• administer IV
• No IE, No Sex, No enema – complication : Sudden fetal blood loss
• prepare Mother for double set –up –DR is converted to OR

Abruptio Placenta

• It is the premature separation of the placenta from the implantation site.
• It usually occurs after the twentieth week of pregnancy

Cause:

• Cocaine user
• Severe PIH
• Accident

Assessment:

• Outstanding sign : dark red & painful bleeding
• concealed hemorrhage (retroplacental)
• couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
• rigid boardlike abdomen
• severe abdominal pain
• dropping coagulation factor (a potential for DIC)
• sx : bleeding to any part of the body. Mgt : for hysterectomy

General Nursing care :

• infuse IV, prepare to administer blood type and crossmatch
• monitor FHR
• insert Foley catheter
• measure blood loss; count pads
• report s/s of DIC (Disseminated Intravascular Coagulation)
• monitor v/s for shock
• strict I&O

Placental Succenturiata – 1 or 2 lobes connected to the placenta by a blood vessel

Placenta Bipartita – placenta divided into 2 lobes

HYPERTENSIVE DISORDER

Pregnancy Induced Hypertension

• HPN after 24wks resolved 6wks postpartum which cause pregnancy.

Types :

1. Gestational HPN

• HPN without edema & proteinuria.
• Mgt : monitor BP

1. Pre-eclampsia – triad

• sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or

idiopathic but multifactoral

• primis d/t 1st exposure to chorionic villi
• multiple pregnancies due to ↑ exposure to chorionic villi
• Mothers of low socio-economic status due to ↓ protein intake
• Teenagers d/t low compliance to protein intake

1. HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

Chronic or Pre-existing Hypertension

• HPN before the 20th wk not resolved 6wks postpartum

Signs of pre-eclampsia :

• > 30mmHg systolic
• > 15mmHg diastolic

3 types of pre-eclampsia

1. Roll over test

• 10-15min side lying
• Then supine
• Then take BP

1. mild pre-ecclampsia

• 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear

wedding ring due to developing edema

Signs present:

• cerebral & visual disturbances, epigastric pain to liver edema and

oliguria usually indicates an impending convulsion

• Before convulsion : if you see sign of epigastric pain, put the side rales up
• During convulsion : observe the Mother for safety
• After convulsion – turn to side to facilitate drainage

1. Severe pre-ecclampsia

• 160/110, +3 or +4, proteinuria, visual disturbances

Nursing care: PEACE

P- promote bedrest

prevent convulsions by nursing measures:

• to ↑ O2 demand & facilitate Na excretion
• Management: quiet & calm environment, minimal handling, avoid

moving the bed

• Heat Acetic Acid – determine protein in the urine
• Prepare the following at bedside: tongue depressor, Suction machine & O2 tank

E- ensure high protein intake (1g/kg/day)

• Na in moderation

A- antihypertensive drug with hydralazine(vasodilators) ex: Aprezine

C- CNS depressant with Mg Sulfate for anti-convulsion: Antidote: Calcium Gluconate

Mgt : evaluate for hypermagnesiumenimia

E- evaluate physical parameters for Magnesium Sulfate toxicity :

B – BP ↓

U – Urine output ↓

R – RR ↓

P – Patellar reflex is absent

Eclampsia – with seizure

• ↑ BUN – sign of glumerular damage

Diabetes Mellitus

• cause by absent & lack of Insulin
• Action of Insulin is to facilitate transfer of glucose into the cell
• Dx test : 50gm 1hr Glucose Tolerance Test

↑ 130 – hyperglycemia

↓ 70 – hypoglycemia

80-120 – euglycemia

if > 130mg/dl, the Mother needs to undergo a 3hr GTT

Maternal Effects :

• hypoglycemia during the 1st trimester development of the brain- sinisipsip ng fetus

yung glucose ng nanay.

• Hyperglycemia during the 2nd & 3rd trimester
• HPL effect Mgt : give insulin. OHA are teratogenic.
• 1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly
• Frequent infections eg. Moniliasis
• Polyhydramnios
• Dystocia

Fetal Effects :

• hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd

trimester thru facilitated diffusion

• Macrosomia/LGA .4000gms
• Intrauterine Growth Restriction due to prolonged DM
• Preterm birth -> promote still birth

Newborn Effects :

• Hyperinsulinism and Hypoglycemia

-40mg/dl

-Normal : 45-55mg/dl

-Borderline : 40mg/dl

-Sx : ↑ pitched shrill cry, tremors, jitteriness

-Dx test : heel stick test to check glucose levels

- Hypocalcemia

-< 7mg/dl

-Calcemic tetany

-Tx : Ca gluconate