Wednesday, February 18, 2009

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
        • Obstetrical Data: gravida # preg, para- viable preg, – 22 – 24 wks
        • Physical Exams,Pelvic Exams
  2. B. Basic knowledge in Intrapartum .
  3. A. Theories of the Onset of Labor
    • 1.) uterine stretch theory
    • -( any hollow organ when stretched, will always contract & expel its content).
    • – contraction action.
    • 2.) Oxytocin Theory
    • – post pit gland releases oxytocin. Hypothalamus produces oxytocin
    • 3.) Prostaglandin Theory
    • – stimulation of arachidonic acid.
    • – prostaglandin- contraction
    • 4.) progesterone theory
    • – before labor, decrease progesterone will stimulate contractions & labor.
    • 5.) Theory of Aging placenta
    • – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).
  4. B. The 4 P’s of labor
    • Passenger
    • a. Fetal head
    • – is the largest presenting part
    • – common presenting part
    • ¼ of its length.
    • Bones – 6 bones
    • S–sphenoidF –frontal –sinciput
    • E–ethmoid O–occipital–occiput
    • T–temporal P– parietal 2 x
  5. Measurement fetal head:
    • transverse diameter – 9.25cm
    • biparietal – 9.5cm
    • largest transverse
    • bitemporal 8 cm
    • Sutures
    • – intermembranous spaces that allow molding.
        • 1.Sagittal Suture
        • – connects 2 parietal bones .
    • 2.Coronal suture
    • – connects parietal & frontal bone (crown).
      • 3.Lambdoidal suture
      • – connects occipital & parietal bone.
    • Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis
  6. Fontanels:
    • 1.Anterior fontanel
    • – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close.
    • 2.Posterior fontanel or lambda
    • – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.
    • 4. Anteroposterior diameter
    • - suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
    • occipitofrontal 12cm partial flexion
    • occipitomental – 13.5 cm hyper extension submentobregmatic-face presentation
  7. 2. Passageway
    • Mom
    • 1.) <>
    • 2.) <>
    • 3.) Underwent pelvic dislocation
  8. Pelvis
  9. 4 Main Pelvic Types
    • Gynecoid
    • – round, wide, deeper most suitable (normal female pelvis) for pregnancy.
    • 2. Android
    • – heart shape “male pelvis”- anterior part pointed, posterior part shallow.
    • 3. Anthropoid
    • – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
    • 4. Plattypelloid
    • – flat AP diameter – narrow, transverse – wider
    • 2 hip bones –2 innominate bones
  10. 3 Parts of 2 Innominate Bones
    • Ileum
    • – lateral side of hips
    • -iliac crest
    • – flaring superior border forming prominence of hips.
    • Ischium
    • – inferior portion
    • - ischial tuberosity where we sit
    • – landmark to get external measurement of pelvis
    • Pubes
    • – ant portion – symphysis pubis junction between 2 pubes
    • 1 sacrum
    • – post portion – sacral prominence – landmark to get internal measurement of pelvis
    • 1 coccyx
    • – 5 small bones compresses during vaginal delivery
  11. Important Measurements
    • Diagonal Conjugate
    • – measure between sacral promontory and inferior margin of the symphysis pubis.
    • Measurement: 11.5 cm - 12.5 cm
    • - basis in getting true conjugate. (DC – 11.5 cm=true conjugate)
    • 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.
    • 3. Obstetrical conjugate
    • – smallest AP diameter. Pelvis at 10 cm or more.
    • Tuberoischi Diameter
    • – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.
  12. 3. Power
    • – the force acting to expel the fetus and placenta – myometrium – powers of labor.
  13. 4. Psyche/Person
    • – psychological stress when the mother is fighting the labor experience.
    • Cultural Interpretation
    • b. Preparation
    • c. Past Experience
    • d. Support System
  14. Pre-eminent Signs of Labor
  15. S&Sx
    • 1.Lightening
    • – setting of presenting part into pelvic brim - 2 weeks prior to EDD
    • -shooting pain radiating to the legs
    • -urinary freq.
    • 2.* Engagement- setting of presenting part into pelvic inlet
    • 3.Braxton Hicks Contractions
    • – painless irregular contractions.
    • 4. Increase Activity of the Mother
    • 5. Ripening of the Cervix
    • – butter soft.
    • 6. Decreased body wt
    • – 1.5 – 3 lbs
    • 7. Bloody Show
    • – pinkish vaginal discharge – blood & leukorrhea
    • 8. Rupture of Membranes
    • – rupture of water.
    • Premature Rupture of Membrane ( PROM)
    • check for cord prolapse.
    • Contraction drops in intensity even though very painful
    • Contraction drops in frequently
    • Uterus is tensed and/or contracting between contractions
  16. Nursing Care
    • Administer Analgesics
    • Attempt manual rotation for ROP or LOP
    • Bear down with contractions
    • Adequate hydration – prepare for CS
    • Sedation as ordered
    • Cesarean delivery may be required, especially if fetal distress is noted
    • Cord Prolapse
    • – a complication when the umbilical cord falls or is washed through the cervix into the vagina
  17. Danger signs
    • PROM
    • Presenting part has not yet engaged
    • Fetal distress
    • Protruding cord form vagina
  18. Nursing care
    • Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy
    • Slip cord away from presenting part
    • Count pulsation of cord for FHT
    • Prep mom for CS
    • Positioning – trendelenberg or knee chest position
    • Emotional support
    • Difference Between True Labor and False Labor
    • False Labor
    • Irregular contractions
    • No increase in intensity
    • confined to abdomen
    • relived by walking
    • No cervical changes
    • 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.
  19. Duration of Labor
    • Primipara
    • – 14 hrs & not more than 20 hrs
    • Multipara
    • – 8 hrs & not > 14 hrs
    • Effacement – softening & thinning of cervix. Use % in unit of measurement
    • Dilation – widening of cervix. Unit used is cm
  20. Nursing Interventions in Each Stage of Labor
    • First Stage
    • onset of true contractions to full dilation and effacement of cervix.
  21. Latent Phase
    • Assessment:
    • a. Dilations
    • 0 – 3 cm
        • Frequency
    • every 5 – 10 min Intensity mild.
  22. Nursing Care
      • 1.Encourage walking
      • 2.Encourage to void q 2 – 3 hrs
    • 3.Breathing – chest breathing
  23. Active Phase
    • Assessment:
    • Dilations 4 -8 cm
    • Intensity: moderate
    • Mom- fears losing control of self
    • Frequency
    • q 3-5 min lasting for 30 – 60 seconds.
  24. Nursing Care
    • M –edications
    • – have meds ready
    • A –ssessment
    • include: vital signs, cervical dilation and effacement, fetal monitor, etc.
    • D – dry lips
    • – oral care (ointment)
    • dry linens.
    • B – abdominal breathing
  25. Transitional Phase
    • Assessment :
    • Dilations
    • - 8 – 10 cm
    • Frequency
    • -q 2-3 min contractions
    • Durations
    • -45 – 90 seconds
    • Intensity
    • -strong
    • Mom – mood changes
    • Hyperesthesia
    • – increase sensitivity to touch, pain all over.
  26. Health Teaching
    • teach: sacral pressure on lower back
    • keep informed of the progress
    • controlled chest breathing
  27. Nursing Care
        • T – ires
        • I – nform of progress
        • R – estless support her breathing technique
        • E – ncourage and praise
        • D – iscomfort
  28. Pelvic Exams
    • Effacement
    • Dilation
    • Station
    • – landmark used: ischial spine.
    • - 1 station = presenting part 1cm above ischial spine if (-) floating
    • -2 station = presenting part 2 cm above ischial spine if (-) floating
    • 0 station = level at ischial spine – engagement
    • + 1 station = below 1 cm ischial spine
    • +3 to +5 = crowning – occurs at 2nd stage of labor
    • 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.
  29. Two types
    • Longitudinal Lie ( Parallel)
    • cephalic:
            • Vertex – complete flexion
    • Face
    • Brow
    • Chin
    • Breech :
        • a. Complete Breech
        • – thigh breast on abdomen, breast lie on thigh
        • Incomplete Breech
        • – thigh rest on abdominal
    • Frank – legs extend to head
    • Footling – single, double
    • 2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation
    • c. Position
    • – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.
  30. Variety
    • Occipito – LOA left occipito ant (most common and favorable position)– side of maternal pelvis
    • LOP – left occipito posterior
    • LOP – most common mal position, most painful
    • ROP – squatting pos on mom
    • ROT
    • ROA
    • *Breech
    • - use sacrum
    • - put stethoscope above umbilicus
    • LSA – left sacro anterior
    • LST, LSP, RSA, RST, RSP
    • *Shoulder/acromniodorso
    • LADA, LADT, LADP, RADA
    • Chin / Mento
    • LMA, LMT, LMP, RMP, RMA, RMT, RMP
  31. Monitoring the Contractions and Fetal heart Tone
    • Spread fingers lightly over fundus – to monitor contractions
  32. Parts of contractions
    • Increment or crescendo
    • – beginning of contractions until it increases.
    • Acme or apex
    • – height of contraction.
    • 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
    • Frequency – beginning of 1 contraction to beginning of next contraction
    • Intensity - strength of contraction
    • Contraction – vasoconstriction
    • Increase BP, decrease FHT
    • Best time to get BP & FHT just after a contraction or midway of contractions
    • Duration of contractions shouldn’t >60 sec
    • Notify MD
    • 5. Fetal Heart Patterns
    • a. Early Decelerations – head compression
    • 1. begins early in contraction
    • 2. ominous
    • 3. continue monitoring
    • 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
    • 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
    • Mom has headache – check BP, if same BP, let mom rest. If BP increases , notify MD -preeclampsia
  33. Health teachings
    • 1.) Ok to shower
    • 2.)NPO – GIT stops function during labor if with food- will cause aspiration
    • 3.)Enema administer during labor
    • a.) To cleanse bowel
    • b.) Prevent infection
    • c.) Sims position/side lying
    • 12 – 18 inch – ht enema tubing.
    • Check FHT after adm enema
    • Normal FHT= 120-160
  34. Signs of fetal distress
    • 1.) <120>160
    • 2.) meconium stained- amniotic fluid
    • 3.) fetal thrashing – hyperactive fetus due to lack O2
    • 2. Second Stage
    • - fetal stage, complete dilation and effacement to birth
    • 7 – 8 multi – bring to delivery room.
    • 10cm primi – bring to delivery room
    • Lithotomy pos – put legs at the same time
    • Bulging of perineum
    • – sure to come out
    • Breathing
    • – panting ( teach mom)
    • Assist doc in doing episiotomy
    • Episiotomy
    • – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (urethroanal fistula).
    • Mediolateral
    • – more bleeding & pain, hard to repair, slow to heal
    • -use local or pudendal anesthesia.
    • Modified Ritgens maneuver
    • – place towel at perineum
        • 1.)To prevent laceration
    • 2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.
  35. Mechanisms of labor
      • Engagement
      • Descent
      • Flexion
      • Internal Rotation
      • Extension
      • External rotation
      • Expulsion
  36. Parts of Pelvis
    • 1. Inlet
    • – AP diameter narrow, transverse diameter wider
    • 2. Cavity
  37. Two Major Divisions of Pelvis
    • True pelvis
    • – below the pelvic inlet
    • False pelvis
    • – above the pelvic inlet; supports uterus during pregnancy.
    • Linea Terminalis
    • -diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
  38. Nursing Care:
    • To prevent puerperal sepsis
    • - <>
    • Bolus of Pitocin can lead to hypotension.
    • Third Stage
    • Birth to expulsion of Placenta
    • -placental stage placenta has 15 – 28 cotyledons. Placenta delivered from 3-10 minutes.
  39. Signs of placental separation
    • 1.Fundus rises – becomes firm & globular “ Calkins sign ”
    • 2.Lengthening of the cord
    • 3.Sudden gush of blood
  40. Types of placental delivery
    • a. Shultze “shiny”
    • – begins to separate from center to edges presenting the fetal side shiny
    • b. Duncan “dirty”
    • – begin to separate form edges to center presenting natural side – beefy red or dirty.
    • Slowly pull cord and wind to clamp.
    • – BRANDT ANDREWS MANEUVER.
  41. Nursing care for placenta
      • Check completeness of placenta.
      • Check fundus
      • Check bp
      • Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives
      • Monitor hpn (or give oxytocin IV)
      • Check perineum for lacerations
      • 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.
    • 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.
  42. If fundus above umbilicus, deviation of fundus
    • Empty bladder to prevent uterine atony
    • Check lochia
    • a.Maternal Observations – body system stabilizes
    • b. Placement of the Fundus
    • c. Lochia
    • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
    • d.Perineum
    • R - edness
    • E- dema
    • E – cchymosis
    • D – ischarges
    • A – approximation of blood loss. Count pad & saturation
    • Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
    • 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.
  43. Complications of Labor
    • Dystocia
    • – difficult labor related to:
    • Mechanical factor
    • – due to uterine inertia
    • – sluggishness of contraction
    • 1.hypertonic or primary uterine inertia
      • Intense excessive contractions resulting to ineffective pushing
    • 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.
    • 2. hypotonic secondary uterine inertia
        • Slow irregular contraction resulting to ineffective pushing.
        • Give oxytocin.
    • Management:
      • Amniotomy (artificial ROM).
      • Oxytocin augmentation of labor.
      • If CPD, prepare for c/s.
      • Emotional support, comfort measures, prevent infection.
  44. Normal length of Labor
    • Primi 14 – 20 hrs
    • Multi 10 -14 hrs
  45. Prolonged Labor
    • > 14 hrs in multi &
    • > 20 hrs in primi
    • Maternal effect – exhaustion.
    • Fetal effect – fetal distress, caput succedaneum or cephalhematoma
  46. Precipitate Labor
    • Labor of <>
    • extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
    • Outstanding Nursing dx: fluid volume deficit
    • IV: fast drip due to fluid volume def
  47. Signs of Hypovolemic Shock:
    • Hypotension
    • Tachycardia
    • Tachypnea
    • Cold clammy skin
  48. Inversion of the uterus
    • Situation: uterus is inside out.
  49. Factors leading to inversion of uterus
        • short cord
        • hurrying of placental delivery
        • ineffective fundal pressure
  50. Uterine Rupture
    • Causes:
      • 1.)Previous classical CS
      • 2.)Large baby
      • 3.) Improper use of oxytocin (IV drip)
  51. Uterine Rupture
    • Sx:
      • Sudden pain
      • Profuse bleeding
      • Hypovolemic shock
      • TAHBSO
  52. Physiologic retraction ring
    • Boundary bet upper/lower uterine segment
    • BANDL’S pathologic ring – suprapubic depression
  53. Amniotic Fluid Embolism or Placental Embolism
    • Amniotic fluid or fragments of placenta enters natural circulation resulting to embolism
  54. Amniotic Fluid Embolism or Placental Embolism
    • Sx:
    • dyspnea, chest pain & frothy sputum
  55. Trial Labor
    • Measurement of head & pelvis falls on borderline.
    • Mom given 6 hrs of labor
    • Multi: 8 – 14, primi 14 – 20
  56. Preterm Labor
    • Labor Abortion: <20>
  57. Preterm Labor
    • Sx:
      • 1. premature contractions q 10 min
      • 2. effacement of 60 – 80%
      • 3. dilation of 2-3 cm
  58. 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
  59. 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)
  60. Preterm Labor
    • If cervix is open : MD  steroid dexamethazone (betamethazone)
    • Preterm: Cut cord ASAP
  61. 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
  62. Principles underlying PUERPERIUM
    • To return to Normal and Facilitate healing
    • Systemic changes
  63. Cardiovascular System
    • The first few minutes after delivery is the most critical period in mothers
  64. Genital tract
    • a. Cervix – cervical opening
    • b. Vaginal and Pelvic Floor
    • c. Uterus – return to normal 6 – 8 wks.
  65. Genital tract
    • Birth pain:
    • 1. position prone
    • 2. cold compress – to prevent bleeding
    • 3. mefenamic acid
  66. 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
  67. Genital tract
    • Dysuria
    • - urine collection
    • - alternate warm & cold compress
    • - stimulate bladder
  68. Urinary tract
    • Freq in urination after delivery
    • Urinary retention with overflow
  69. Colon
    • Constipation due to:
      • NPO
      • Fear of bearing down
  70. Perineal Area
    • Painful – episiotomy site
    • Sex  when perineum has healed
  71. Provide Emotional Support – Reva Rubin
    • Psychological Responses:
    • Taking in phase
    • Taking hold phase
    • Letting go
  72. Taking hold phase
    • Dependent to independent phase (4 to 7 days).
    • Mom  active, can make decisions
  73. Letting go phase
    • Interdependent phase – 7 days & above.
  74. Complication: HEMORRHAGE
    • Bleeding of > 500cc
    • CS – 600 – 800 cc normal
    • NSD 500 cc
  75. Early postpartum hemorrhage
    • Bleeding within 1st 24 hrs.
  76. Early postpartum hemorrhage
    • Complications :
    • Hypovolemic shock.
  77. Early postpartum hemorrhage
    • Breast feeding – post pit gland will release oxytocin so uterus will contract.
    • Well contracted uterus + bleeding = laceration
  78. 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
  79. DIC
    • Disseminated Intravascular Coagulopathy. Hypofibrinogen  failure to coagulate.
  80. Late Postpartum hemorrhage
    • Bleeding after 24 hrs  retained placental fragments
  81. Late Postpartum hemorrhage
    • Accreta
    • Increta
    • Percreta
    • Hematoma
  82. Late Postpartum hemorrhage
    • too much manipulation
    • large baby
    • pudendal anesthesia
  83. Infection
    • Sources of infection
    • 1.) endogenous
    • 2.) exogenous
    • Anaerobic streptococci
  84. Infection
    • General signs of inflammation:
      • Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
      • Purulent discharges
      • Fever
  85. INFECTION
    • Gen mgt:
    • supportive care
    • inflammation of perineum
    • 2 to 3 stitches dislocated with purulent discharge
  86. INFECTION
    • Mgt:
      • Removal of sutures & drainage, saline, between & resulting.
      • Endometriosis – inflammation of endometrial lining
  87. INFECTION
    • Sx:
      • Abdominal tenderness,
  88. Family Planning
    • determine one’s own beliefs 1st
    • never advise a permanent method of planning
    • method of choice is an individual’s choice.
  89. 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
    • Basal Body Temperature 13th day temp goes down before ovulation – no sex
    • get before arising in bed
  90. Family Planning
    • LAM – lactation amenorrhea method – hormone that inhibits ovulation is prolactin.
  91. 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
  92. 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
  93. 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
  94. 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.
  95. 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.
  96. 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
  97. 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.
  98. DMPA
    • Depoprovera – has progesterone inhibits LH – inhibits ovulation
    • Depomedroxy progesterone acetate – IM q 3 months
    • Never massage injected site, it will shorten duration
  99. DMPA
    • Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
  100. Mechanism and Chemical Barriers
    • IUD
    • Condom
    • Diaphragm
    • Cervical cap
    • Foams, Jellies, Creams
  101. 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
  102. Intrauterine Device (IUD)
    • ALERTS:
    • prevents implantation
    • most common complications: excessive menstrual flow and expulsion of the device (common problem)
  103. 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
  104. CONDOM
    • – latex inserted to erected penis or lubricated vagina
    • Adv: gives highest protection against STD – female condom
    • Alerts:
  105. 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
  106. Cervical Cap
    • – more durable than diaphragm no need to apply spermicide
    • C/I: abnormal pap smear
    • Foams, Jellies, Creams
  107. 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
    • High Risk Pregnancy
  108. Hemorrhagic Disorders
    • General Management
    • CBR
    • Avoid sex
    • Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
    • Ultrasound to determine integrity of sac
    • Signs of Hypovolemic shock
    • Save discharges – for histopathology
  109. First Trimester Bleeding
    • Abortion
    • Ectopic pregnancy
  110. 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
  111. Classifications:
    • Threatened
    • Inevitable
    • Complete
    • Incomplete
    • Habitual
    • Missed
    • Induced Abortion
  112. Threatened
    • – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
  113. Inevitable
    • Moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
  114. Complete – all products of conception are expelled. No mgt just emotional support! Incomplete – Placental and membranes retained. Mgt: D&C
  115. Habitual
    • 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.
    • Present: 2nd trimester
  116. 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
  117. Induced Abortion
    • – Therapeutic abortion to save life of mom.
  118. Ectopic Pregnancy
    • – occurs when gestation is located outside the uterine cavity.
    • Common site: tubal or ampular
    • Dangerous site - interstitial
  119. Unruptured
    • missed period
    • abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
    • scant, dark brown, vaginal bleeding
    • Nursing care:
    • Vital signs
    • Administer IV fluids
    • Monitor for vaginal bleeding
    • Monitor I & O
  120. Tubal rupture
    • sudden , sharp, severe pain . Unilateral radiating to shoulder.
    • + Cullen’s Sign
    • syncope (fainting)
    • Mgt:
    • Surgery depending on side
    • Ovary: oophorectomy
    • Uterus : hysterectomy
  121. Second trimester bleeding
    • Hydatidiform Mole
    • Gestational anomaly of the placenta consisting of a bunch of clear vesicles.
  122. 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.
  123. Hydatidiform
    • Use: methotrexate to prevent choriocarcinoma
  124. 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
  125. Hydatidiform
    • Nursing care:
      • Prepare D&C
      • Do not give oxytoxic drugs
    • 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
    • McDonalds procedure – temporary cerclage on cervix
    • S/E: infection. During delivery, cerclage is removed. NSD
    • Sheridan – permanent surgery cervix. CS
    • Third Trimester Bleeding “Placenta Anomalies”
  126. Placenta Previa
    • Abnormal lower implantation of placenta .
    • Candidate for CS
    • Sx:
      • Bright red
      • Painless bleeding
  127. 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
  128. 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
  129. Placenta Previa
    • Nursing Care
    • NPO
    • Bed rest
    • Prepare to induce labor if cervix is ripe
    • Administer IV
  130. Abruptio Placenta
    • Outstanding Sx: dark red, painful bleeding , board like or rigid uterus.
  131. Abruptio Placenta
    • Assessment:
    • Concealed bleeding
    • Couvelaire uterus (caused by bleeding into the myometrium) Dropping coagulation factor (a potential for DIC)
  132. Abruptio Placenta
    • Complications:
    • Sudden fetal blood loss
    • Placenta previa & vasa previa
  133. 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
    • Placenta succenturiata
    • Placenta Circumvallata
    • Placenta Marginata
    • Battledore Placenta
    • Placenta Bipartita
    • Velamentous Insertion of cord
    • Vasa Previa
  134. Hypertensive Disorders
    • I. Pregnancy Induced Hypertension (PIH )
  135. 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
  136. Chronic or pre-existing Hypertension
    • – HPN before 20 weeks not solved 6 weeks post partum.
  137. 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
  138. Three types of pre-eclampsia
    • Severe preeclampsia
    • Signs present: cerebral and visual disturbances, epigastric pain and oliguria
    • BP 160/110
    • Proteinuria +3 - +4
  139. Three types of pre-eclampsia
    • Eclampsia – with seizure!
    • Increase BUN – glomerular damage.
    • Provide safety.
  140. Cause of preeclampsia
    • Idiopathic or unknown common in primi
    • Common in multiple pregnancy (twins)
    • Common to mom with low socioeconomic status
  141. Nursing care: PPPEACE
    • P – romote bed rest
    • P – prevent convulsions by nursing measures or seizure precaution
  142. 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)
  143. Nursing care: PPPEACE
    • C – convulsion, prevent! – give Mg So4 – CNS depressant
    • E – evaluate physical parameters for Magnesium sulfate
    • DIABETES MELLITUS
  144. 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
    • 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
    • Dx: 1 hr 50gr glucose tolerance test GTT
    • Normal glucose  80 – 120 mg/dl;
    • <>
    • > 120  hyperglycemia
    • 3 degrees GTT of > 130 mg/dL
    • 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
  145. Diabetes Mellitus
    • Maternal effect DM
    • Hypo or hyperglycemia
    • Frequent infection
    • Polyhydramnios
    • Dystocia
    • Hyperglycemia- fatigue , flushed hot skin, dry mouth, excessive thirst, frequent urination, rapid deep respirations, fruity odor, depressed reflexes, drowsiness, headache
    • Hypoglycemia-
    • shakiness, dizziness, sweating, pallor, cold clammy skin, disorientation, irritability, headache, hunger, blurred vision, nervousness, weakness, fatigue, shallow respirations, normal PR
  146. Diabetes Mellitus
    • Insulin requirement: decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd trimester.
    • Post partum decrease 25%
  147. Fetal effect: DM
    • hyper & hypoglycemia
    • macrosomia – large gestational age – baby delivered > 4000g or 4kg
    • preterm birth to prevent stillbirth
  148. Newborn Effect : DM
    • hyperinsulinism
    • hypoglycemia
    • hypoglycemic <>
    • Heel stick test – get blood at heel
  149. Newborn Effect : DM
    • Hypoglycemia: high pitch shrill cry tremors, administer dextrose
    • Hypocalcemia - <>
      • Calcemia tetany
      • Trousseau sign
      • Give calcium gluconate if decrease calcium
    • HEART DISEASE
  150. Heart disease
    • Class I – no limit to physical activity
    • Class II – slight limitation of activity.
  151. Heart disease
    • Class III - moderate limitation of physical activity.
    • Class IV - marked limitation of physical activity.
  152. Recommendation
    • Therapeutic abortion
    • If push through with pregnancy
      • Antibiotic therapy
      • Anticoagulant
  153. Recommendation
    • Class I & II- good progress for vaginal delivery
    • Class III & IV- poor prognosis, for vaginal delivery, not CS!
    • 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).
    • 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
    • CAUSES:
    • 1. SEPARATION OF PLACENTA
    • 2. AMNIOCENTESIS
    • 3. PERCUTANEOUS UMBILICAL BLOOD SAMPLING
    • ANTIBODY SCREENING TEST (indirect Coomb’s test)
      • -done on the mother’s blood to measure the number of Rh-positive antibodies
    • DIRECT COOMBS’ TEST
      • -done on the infant’s blood to detect antibody-coated Rh-positive RBC’s
  154. ASSISTED BIRTH
    • Cesarean Delivery
    • Indications:
    • Multiple gestation
    • Diabetes
    • Active genital herpes II
    • Severe toxemia
    • Complete Placenta previa
    • Abruptio placenta
    • Prolapse of the cord
    • UTERINE INCISIONS
    • a. kerr
    • b. sellheim- vertical incision in the lower uterine segment
    • c. classic
    • FORCEPS DELIVERY
    • 3 Categories
    • Outlet forceps
    • Low forceps
    • midforceps

    • INDICATIONS:
    • Heart dse
    • Pulmonary edema
    • Infection
    • Exhaustion
    • Premature placental separation
    • Fetal nonreassuring status
    • 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
    • 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.
  155. INFERTILITY
    • Inability to achieve pregnancy. Within a year of attempting it
    • Manageable
    • 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).
    • Is infertility a common problem?
    • Is infertility just a woman's problem?
          • NO
    • What causes infertility in men?
    • 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.
    • 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.
    • What causes infertility in women?
    • Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized.
    • Less common causes of fertility problems in women include:
    • blocked fallopian tubes physical problems with the uterus
    • uterine fibroids
    • 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
    • How long should women try to get pregnant before calling their doctors?
    • 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
    • How will doctors find out if a woman and her partner have fertility problems?
    • For a woman, the first step in testing is to find out if she is ovulating each month.
    • 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.
    • Laparoscopy:
    • During this surgery doctors use a tool called a laparoscope to see inside the abdomen.
    • How do doctors treat infertility?
    • Infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive technology.
    • 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.
    • 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
    • What medicines are used to treat infertility in women?
    • 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.
    • 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.
    • 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.
    • Many fertility drugs increase a woman's chance of having twins, triplets or other multiples.
    • What is assisted reproductive technology (ART)?
    • Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples.
    • 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
    • What are the different types of assisted reproductive technology (ART)?
    • 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.
    • 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.
    • 3.Gamete intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube.
    • 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.
  156. 2 types of infertility
    • 1.) primary
    • 2.) Secondary
    • Sims Huhner test
  157. Infertility
    • Normal: cervical mucus must be stretchable 8 – 10 cm
    • Best criteria- sperm motility for impotency
  158. Infertility
    • Mgt:
    • GIFT= Gamete Intra Fallopian Transfer for low sperm count
    • Mom: anovulation – no ovulation
    • hyperprolactinemia
    • Tubal Occlusion – tubal blockage
    • = dx: hysterosalphingography
    • Mgt: IVF – invitrofertilization
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