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Pregnancy: is a period of health. There are numerous changes associated with pregnancy with increase abdominal size as the most evident

Purpose: (1)support fetal growth, (2)support and maintain maternal health, (3)prepare the body for childbirth, & (4)prepare the body for lactation

THE DIAGNOSIS OF PREGNANCY
- Pregnancy is officially diagnosed on the basis of the SYMPTOMS reported by the woman and the SIGNS elicited by the healthcare team.
- Serves to date the diagnosis of birth and helps predict the existence of a high-risk status.
- The feeling/ experience of pregnancy highly depends if it has been planned or not

3 Classification of "Pregnancy sign"

1. Presumptive: HIGHLY SUBJECTIVE. Ex. breast changes (earliest sign)

2. Probable: CAN BE DOCUMENTED BY HEALTHCARE PROVIDER. Ex. Pregnancy test

3. Positive: UNDENIABLE SIGN BY THE USE OF INSTRUMENT. Ex. Fetal heart movement

Additional NOTES:

2 types of pregnancy test: (1) Laboratory test- detect presence of HCG in blood/urine, (2) Home pregnancy test- 97% accuracy if followed properly

Quickening- fetal movement felt by woman (16-20 weeks)

Melasma- dark line pigmentation

Striae gravidarum- red streaks on the abdomen

Chadwick's sign- change of color of the vagina. PINK to VIOLET

Goodel's sign- softening of the cervix

Hegar's sign- softening of the LUS

Ballotement- fetus can be felt to rise against the abdominal wall

Braxton-Hicks contraction- periodic uterine tightening

Doppler UTZ- fetal heart is audible at 10-12 weeks

Ordinary stethoscope- fetal heart is audible at 18-20 weeks

PHYSIOLOGIC CHANGES IN PREGNANCY

*THE CULPRIT: HORMONES- new hormones are being produced by an organ that is present only during pregnancy– the placenta

Can be categorized as:

LOCAL- confined to the reproductive organs

SYSTEMIC- affecting the entire body

LOCAL CHANGES
A. Uterus: predictable rate of growth.
- size: length, depth, width, weight, wall thickness and volume. steadily increases and is predictable
- measured from top of the symphysis to the top of the uterine fundus
- uterine blood flow increases from 50ml/minute to 1L/minute or more at term
B. Amenorrhea
- occurs because of suppression of FSH
C. Cervical changes
- more vascular and edematous
- coating of mucus fills the cervical canal called the Operculum or the mucus plug (prevents infection)
D. Ovarian changes
- ovulation stops (halt FSH and LH production)
E. Vaginal changes
- presence of white vaginal discharge (Leukorrhea)
- dangerous if it requires you to change underwear frequently
F. Breast changes
- first physiologic change in pregnancy
- Colostrum is a clear yellowish fluid, the earliest breastmilk produced by the 12th-18th week of pregnancy

SYSTEMIC CHANGES
A. Integumentary System
- striaegravidarum→striae albicans
- appearance of skin pigmentations, vascular spiders
- umbilicus becomes stretched and protrudes
B. Respiratory System

RR: ↑by 1 or 2/minute

Tidal volume: ↑ by 30-40%

Vital capacity: no change

Residual Volume: ↓ by 20%

Plasma pCO2: ↓ by 27-32 mmHg

Plasma pH: ↑ to 7.40-7.45

Plasma pO2: ↑ to 104-108 mmHg

C. Cardiovascular System
- may cause Pseudoanemia

Blood Volume: ↑ by 30% - 50% during the end of 3rd trimester up to 28th 32nd week

Iron needs: ↑ by 350-400 mg, RBC- 400 mg

Heart: CO ↑ by 25%-50%, HR by 10 bpm

Blood pressure: ↓ slightly during the second trimester→ rises again to 1st trimester levels

Peripheral Blood Flow: ↓ blood flow to extremities→ edema and varicosities of  vulva, rectum and legs

Blood Constitution: ↑ up to to 50%

D. Gastrointestinal
- ↓ intestinal peristalsis and stomach emptying time→ heartburn, constipation and flatulence
- “morning sickness” (subsides after 3 months)
- (+) hemorrhoids, heartburn, generalized itching, tooth decay
E. Urinary System

Fluid retention: ↑ to 7.5L

Ureter and Bladder changes: ↑ in diameter of ureters; bladder capacity to 1500 L

Renal function: these includes the ff.

1. Glomerular Filtration Rate: ↑ by 50%

2. Renal plasma Flow: ↑ by 25%-80%

3. Blood Urea Nitrogen: ↓ by 25%

4. Plasma Creatinine level: ↓ by 25%

5. Renal threshold for sugar: ↓ to allow slight spillage

6. Bladder Capacity:↑ by 1,000mL

7. Diameter of ureters: ↑ by 25%

8. Frequency of Urination: ↑ 1st trimester, last 2 weeks of pregnancy to 10-12 times/day

F. Endocrine System

Presence of placenta: increases concentration of prostaglandins in the female reproductive tract

Pituitary gland: ↑progesterone & estrogen, ↑production of growth hormone & melanoctye stimulating hormone

Thyroid and parathyroid glands: enlarged thyroid gland, ↑BMR by 20%, iodine & thyroxine in blood serum

Adrenal glands: ↑activity, corticosteriods & aldosterone production

Pancreas: ↑Insulin level but is LESS effective

G. Immune System
- ↓Immunologic Competency, ↓IgG production
- ↑ WBC
H. Skeletal System
- ↑calcium & phosphorus needs, ↑progesterone and presence of relaxin, ↑ in pliability of pelvic joints & ligaments

ADDITINAL NOTES - HORMONES -

Estrogen - prevents ovulation/FSH changes in reproductive organs and in development of your mammary gland

Progesterone - prevents ovulation/LH; maintains the uterine lining, decrease progesterone leads to contraction = start labor

HPL (Human Placental Lactogen) - similar to GH, makes INSULIN less effective -> makes glucose more available for fetal use

HCG - during the start of pregnancy because it maintains your CL (corpus luteum) -> beginning of pregnancy

Relaxin - relaxes smooth muscles/ligaments

Progesterone - same as relaxin

MSH - GH, lung maturity and may lead to hyperpigmentation

Prolactin - lactation/milk production

Oxytocin - uterine contraction, milk-let down

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Psychological Changes during Pregnancy (

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Psychological Changes during Pregnancy (

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Psychological Changes
: increased responsibility associated with welcoming a new and completely dependent person into a family

A. Social Influences
* PAST

9-month long illness

alone to a physician’s office for care

Time of birth: separated from her family and

admitted to a hospital

* PRESENT

a TIME OF HEALTH

bring their families during prenatal care

participate actively in the experience

Couples viewed pregnancy:

related to their cultural background

their personal experiences, and the experiences of friends and relatives as taught by childbirth educators

People's opinion have changed MARKEDLY:

Teenage pregnancy affects about 6% of Filipino girls

the second highest rate in Southeast Asia based on Save the Children’s Global Childhood Report from 2019

an estimated 538 babies are born to Filipino teenage mothers EVERY SINGLE DAY, according to the Philippine Statistical Authority from 2017

B. Cultural influences

ask at prenatal visits if there is anything they believe should or should not be done

Supporting these beliefs shows respect for the individuality of a woman and her knowledge of good health

C. Family Influences
* POSITIVE INFLUENCES

if she and her siblings were loved & seen as the pleasant outcome of a happy marriage

pregnancy is natural and simple

* NEGATIVE INFLUENCES

if she and her siblings were seen as intruders or were blamed for the breakup of a marriage

women with disabilities may have specific concerns

D. Individual Influences

ability to cope with or adapt to stress

relationship with people around

“brides” as young, “mother” as old

COMMON PSYCHOSOCIAL CHANGES/ TASKS THAT OCCUR WITH PREGNANCY

1. 1st Trimester TASK: Accepting the Pregnancy – Ambivalence: feeling both pleased and not pleased about the pregnancy

2. 2nd Trimester TASK: Accepting the Baby – Narcissism and introversion: as they concentrate on what it will feel like to be a parent

3. 3rd Trimester TASK: Preparing for the Baby and End of Pregnancy - Preparing for Parenthood: Being ready for birth

EMOTIONAL RESPONSES TO PREGNANCY

1. Ambivalence: Interwoven feelings of wanting & not wanting that can exist at high levels

2. Grief: Not just a daughter anymore, a wife, a friend but a mother

3. Narcissism: self-centeredness (early reaction)

4. Introversion vs Extroversion: turning inward to concentrate on oneself and one’s body VS more active, appear healthier than ever before and more
outgoing

5. Body Image: way body appears to oneself

6. Body Boundary: zone of separation perceive between oneself and objects

7. Stress: difficult for a woman to make decisions, be as aware of her surroundings as usual or maintain time management

8. Couvade Syndrome: men are experiencing physical symptoms like N & V, backache to some degree or more
intensely than partner

9. Emotional Lability: (1) Mood changes- manifestation of narcissism, (2) Mood swings- beginning with early pregnancy

Changes in sexual desire:

1. 1st trimester: Decrease in libido due to nausea, fatigue and breast tenderness

2. 2nd trimester: As blood flow to pelvic area increases to supply the placenta, libido and sexual enjoyment rise markedly

3. 3rd trimester: Sexual desire remain high or may decrease

Changes in Expectant Family- Reassure preschool and school age children periodically during pregnancy

Emotional Changes- the birth of your baby and the postnatal period, changes in the hormones in your body will have an effect on your emotions.

Anger in Pregnancy- You might also be troubled by the changes in your body shape and might worry that you look unattractive.

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STAGES OF FETAL DEVELOPMENT

1. Pre-embryonic Period (the OVUM): first 2 weeks, beginning with fertilization

2. Embryonic Period: weeks 3 through 8

3. Fetal Period: from week 8 through birth

Terms Used to Denote Fetal Growth

Ovum: From ovulation to fertilization

Zygote: From fertilization to implantation

Embryo: From implantation to 5–8 weeks

Fetus: From 5–8 weeks until term

Conceptus: Developing embryo or fetus and placental structures throughout pregnancy

Age of viability: Earliest age at which fetuses could survive

Fertilization: beginning of pregnancy
- conception and impregnation (72 hrs: 48 hours before ovulation + 24 hours afterward)
- never a certain occurrence. It depends on at least three separate factors:

1. equal maturation of both sperm and ovum

2. the ability of the sperm to reach the ovum

3. the ability of the sperm to penetrate the zona pellucida and cell membrane and achieve fertilization

Generalized acrosomal process

sperm makes contact with egg

acrosome reacts with zona pellucida

acrosome reacts with perivitelline

plasma membranes of egg and sprem fuse

sperm nucleus enters egg

cortical granules fuse with egg plasma membrane, which renders the vitelline layer impenetrable to sperm

NOTE:
(1) THE FUNCTIONAL LIFE OF A SPERMATOZOON IS ALSO ABOUT 48 HOURS, POSSIBLY AS LONG AS 72 HOURS
(2) WHEN MATURE OVUM IS RELEASED, FERTILIZATION MUST OCCUR FAIRLY QUICKLY BECAUSE AN OVUM IS CAPABLE OF FERTILIZATION FOR ONLY 24 HOURS (48 HOURS AT THE MOST)

Capacitation: final process that sperm must undergo to be ready for fertilization

Hyalurodinase: a proteolytic enzyme

1. The oocyte and sperm meet in the ampulla of uterine tube

Oocyte: an immature egg, usually undergo miosis

Ampulla: widest part of fallopian tube

2. The capacitated sperm enzymatically breakdown the zona pellucida

Zona pellucida: membrane of ovum

3. A single sperm penetrates the ovum. Conception has occurred.
4. Zygote now contains 23 chromosomes from oocyte and 23 chromosomes from sperm

Zygote: fertilized ovum

5. Mitosis occurs to replicate cells of this new individual = cleavage

Morula: solid ball of cells resulting from division of zygote

6. Blastocoel develops pushing cells into an outer shell

Blastocoel: fluid filled activity that causes the inner and outer form

Blastocyst: fluid cavity in which differentiation of the cells

XX: X- carrying spermatozoon entered the ovum, resulting child will have 2 X chromosomes will be female
XY: Y- carrying spermatozoon fertilized the ovum, resulting child will have an X and Y chromosomes and will be male

Implantation
Day 1: first cleavage
Day 2: 2-cell stage
Day 3-4: 4-cell stage; 8-cell uncompcated morula
Day 4: 8 cell compacted morula
Day 5: early blastocytes
Day 6-7: late-stage blastocytes (hatching)
Day 8-9: implantation of the blastocytes ( attaches to the uterine endometrium)
MORULA: (from the Latin word morus, meaning “mulberry”) bumpy outward appearance
- late blastocyst implants in the wall of the
uterus (by day 14)

Embryonic and Fetal structures: lies directly under the embryo (or the portion where the trophoblast cells establish communication with maternal blood vessels

Decidua capsularis: stretches/encapsulates the surface of the trophoblast

Decidua vari: remaining portion of the uterine lining

Decidua: the Latin word for “falling off”

Layer of Trophoblast Cells

syncytiotrophoblast, or the syncytial layer: outer of the two covering layers

cytotrophoblast or Langhans’ layer: middle layer

Placenta: "pancake" 15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the surface area of the internal uterus at term
- At term: the placental circulatory network has grown so extensively that a placenta weighs 400 to 600 g (1 lb)
- If a placenta is smaller: circulation to the fetus may have been inadequate
- If placenta is larger: circulation to the fetus was threatened

Placental Circulation

Metabolic gas exchange begins at 4 weeks

Funic souffle soft blowing heard over umbilical cord: synchronous with fetal heartbeat, hearing bloodflow through vessel

Uterine souffle heard just above mother’s pelvis: synchronous with maternal pulse

Mechanisms by which nutrients cross the placenta

Diffusion: area of higher concentration to the area of lower concentration

Facilitated Diffusion: ensure that a fetus receives sufficient concentrations of necessary nutrients, some substances cross the placenta

Active Transport: process requires the action of an enzyme to facilitate transport

Pinocytosis: absorption by the cellular membrane of microdroplets of plasma and dissolved substances

Functions of the Placenta

1. Forms a barrier between mother and embryo (blood is not exchanged)

2. Delivers nutrients and oxygen

3. Removes waste from embryonic blood

4. Becomes an endocrine organ (produce hormones)

1. Endocrine Function

Human Chorionic Gonadotropin: first placental hormone produced; can be found in maternal blood and urine as early as the first missed menstrual period. Act as a fail-safe measure to ensure that the corpus luteum of the ovary continues to produce progesterone & estrogen

Estrogen: referred to as the “hormone of women”

Progesterone: the “hormone of mothers”

Human Placental Lactogen (Human Chorionic Somatomammotropin): hormone with both growth-promoting and lactogenic (milk-producing) properties

2. Placental Proteins
: The function of these has not been well documented, but it is thought that they may contribute to decreasing the immunologic impact of the growing placenta through being part of the complement cascade

Amniotic Membranes: membranes, with Embryo Lying within Amniotic Sac

Embryonic Membranes

Chorion: Outer most membrane; Fingerlike projections, “villi”

Amnion: Thin protective membrane; Contains amniotic fluid

Amniotic Fluid: constantly being newly formed and reabsorbed by the amniotic membrane, so it never becomes stagnant

HYDRAMNIOS : Excessive amniotic fluid

OLIGOHYDRAMNIOS : Reduction in the amount of amniotic fluid

Functions/Purpose

Protection

Temperature regulation

Protects the umbilical cord from pressure

Protecting the fetal oxygen supply

Aids in muscular development gives freedom of movement

Umbilical Cord: formed from the fetal membranes (amnion and chorion)
and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta
Function:

to transport oxygen and nutrients to the fetus

- 1% to 5% of infants are born with only a single vein and artery
- chromosomal disorders or congenital anomalies, particularly of the kidney and heart
- Assess and record the number of vein and arteries in the cord at birth
- rate of blood flow through an umbilical cord is rapid (350 mL/min at term)
- 20% of all births, a loose loop of cord is found around the fetal neck (nuchal cord) at birth
- walls of the umbilical cord arteries are
lined with smooth muscle

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STEM CELLS

TOTIPOTENT STEM CELLS
• cells that are so undifferentiated they have the
PLURIPOTENT STEM CELLS
• cells begin to show differentiation and lose their
MULTIPOTENT
• Cells grow so specific that they Mare set a sure Course toward the body organ they will create
REPRODUCTIVE CLONING
• an infant who is identification adult
donor
THERAPEUTIC CLONING
• pluripotent stem cells are removed and allowed to grow in the laboratory, these have the potential to be able to supply a type of body cell needed by the adult donor

ZYGOTE GROWTH: development proceeds in a cephalocaudal (head-to-tail)
direction

YOLK SAC: to provide a source of red blood cells until the embryo's hematopoietic system is mature enough to perform this function (at about the 12th week of intrauterine life)

ORIGIN OF THE BODY TISSUE
Ectoderm, Mesoderm, Endoderm

8 WEEKS GESTATION
• the end of the embryonic period

CARDIOVASCULAR SYSTEM

One of the first systems to become functional in intrauterine life

16th day of life: simple blood cells joined to the walls of the yolk sac progress to become a network of blood vessels and a single heart

24th day: Heart beats

6th or 7th week: septum that divides the heart into chambers develops

7th week: heart valves begin to develop

10th to 12th week: heartbeat may be heard with a Doppler instrument

11th week: an electrocardiogram (ECG) may be recorded on a fetus

FETAL CIRCULATION: 3rd week of intrauterine life –fetal blood begins to exchange nutrients with the maternal circulation across the chorionic villi
UMBILICAL CIRCULATION: Facilitates gas and nutrient exchange between maternal and fetal blood. The blood itself does not mix
THE PLACENTA: Facilitates gas and nutrient exchange between maternal
and fetal blood

THREE SHUNTS IN THE FETAL CIRCULATION

1. DUCTUS ARTERIOSUS: protects lungs against circulatory overload

2. DUCTUS VENOSUS: fetal blood vessel connecting the umbilical vein to the IVC

3. FORAMEN OVALE: shunts highly oxygenated blood from right atrium to left atrium

RESPIRATORY SYSTEM

3rd week of intrauterine life: the respiratory and digestive tracts exist as a single tube

end of the 4th week: septum begins to divide the esophagus from the trachea

Until the 7th week of life: the diaphragm does not completely divide the thoracic cavity from the abdomen

SURFACTANT: a phospholipid substance, is formed and excreted by the alveolar cells at about the 24th week of pregnancy
RESPIRATORY DISTRESS SYNDROME: severe breathing disorder, can develop if there is lack of surfactant or it has not changed to its mature form at birth

NERVOUS SYSTEM

begins to develop extremely early in pregnancy 3rd and 4th weeks of intrauterine life

neural plate (a thickened portion of the ectoderm) is apparent by the 3rd week of gestation

By 24 weeks, the ear is capable of responding to sound; the eyes exhibit a pupillary reaction, indicating that sight is present

Brain waves can be detected on an electroencephalogram (EEG) by the 8th week

Spinal cord disorders such as meningocele

ENDOCRINE SYSTEM

fetal adrenal glands : supply a precursor necessary for estrogen synthesis by the placenta

fetal pancreas: produces insulin needed by the fetus

thyroid and parathyroid glands: play vital roles in fetal metabolic function and calcium balance

DIGESTIVE SYSTEM

digestive tract separates from the respiratory tract at about the 4th week of intrauterine life and, after that, begins to grow extremely rapidly.

ATRESIA: (blockage) or stenosis (narrowing) can develop if either the
first or second canalization does not occur
MECONIUM: collection of cellular wastes, bile, fats, mucoproteins, mucopolysaccharides, and portions of the vernix caseosa
VITAMIN K: gastrointestinal tract is sterile before birth

MUSCULOSKELETAL SYSTEM

first 2 weeks of fetal life, cartilage prototypes provide position and support

Ossification of this cartilage into bone begins at about the 12th week

REPRODUCTIVE SYSTEM

child’s sex is determined at the moment of conception by a spermatozoon carrying an X or a Y chromosome and  can be ascertained as early as 8 weeks by chromosomal analysis

6th week of life, the gonads (ovaries or testes) form

URINARY SYSTEM

rudimentary kidneys are present as early as the end of the 4th week of intrauterine life,

Urine is formed by the 12th week and is excreted into the amniotic fluid by the 16th week of gestation.

INTEGUMENTARY SYSTEM

skin of a fetus appears thin and almost translucent until subcutaneous fat begins to be deposited at about 36 weeks

IMMUNE SYSTEM

Immunoglobulin G ((gG) maternal antibodies cross the placenta into the fetus as early as the 20th week and certainly by the 24th week of intrauterine life to give a fetus temporary passive immunity against diseases for which the mother has antibodies

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LABOR

The Process by which the Products of Conception will be expelled from the body

THEORIES OF LABOR ONSET
CONTRACTION = Decrease in progesterone, release of oxytocin, production of prostaglandins

PRELIMINARY SIGNS OF LABOR

1. Lightening- descent of the fetal presenting part into the pelvis; occurs 10-14 days before labor begins

2. Braxton-Hicks Contractions- begin and remain irregular; Felt first abdominally & remain confined to the abdomen & groin

3. Nesting Instinct- increase in epinephrine release – prepares a woman’s body for the work of labor ahead

4. Ripening of the cervix- an internal sign seen only on pelvic examination: Goodell’s sign – all throughout pregnancy, cervix has the same consistency as the earlobe (( at term it becomes still softer & described as “butter-soft”))

5. Weight loss

6. Bloody show

7. Rupture of membranes

PRELIMINARY SIGNS
• SUBTLE SIGNS
• INDICATES IMMINENT LABOR
• MUST EDUCATE PATIENTS FOR THEM TO DETECT THESE SIGNS

DURATION OF LABOR:

Primipara: 14 hours-20 hours

Multipara: 8-14 hours

EFFACEMENT: The softening and thinning of cervical canal recorded in percentage.
DILATION: The widening of the external cervical os to 10 cm

Primipara: 1st effacement then dilation

Multipara: Both processes occur at the same time

COMPONENTS OF LABOR

1. The Passage or the woman’s pelvis: should be adequate in size & contour

2. The Passenger or the fetus: should be appropriate in size & in an advantageous position presentation

3. The Powers of labor or uterine factors: should be adequate

4. A woman’s Psyche is preserved: should be preserved, so that afterward labor can be viewed as

PELVIC SHAPE: Gynecoid
TRUE PELVIS: The bony passageway through which the fetus must pass during delivery

OBSTETRIC/TRUE CONJUGATE: The most important measurement of the inlet because it has the smallest diameter (N-11cm)

MOLDING: CHANGE IN CONTOUR OF FETAL HEAD DUE TO
UTERINE FORCE WITH UNDILATED CERVIX

FETAL PRESENTATION: Refers to the foremost part of the fetus that enters the pelvic inlet.

CEPHALIC: most frequent type, 95%; 4 types: vertex, face, brow & mentum presentation

BREECH: buttocks or feet are the first body parts that will contact the cervix, 3% of births; 3 types: complete, frank, footling.

SHOULDER: fetus lie horizontally (transverse) in the pelvis – longest fetal axis is perpendicular to that of the mother, 1% of births

FETAL LIE: Relationship between the spine of the fetus to the spine of the mother; whether the fetus is lying in a horizontal

FETAL DEGREE/ DEGREE OF FLEXION: Relationship of the fetal body parts to one another.

GOOD ATTITUDE: advantageous for birth because it helps the fetus present the smallest AP diameter of the skull to the pelvis

COMPLETE FLEXION: The most common attitude; most favorable for vaginal birth; Skull smallest diameter to the bony pelvis: Sub-occiptobregmatic

FETAL STATION: How far the presenting part descended into the pelvis.

Ischial spines→ 0 station “engaged”

Above ischial spines→ negative

Below ischial spines→ positive

+3-+4 crowning

ENGAGEMENT: SETTLING OF THE PRESENTING PART INTO THE PELVIS (LEVEL OF ISCHIAL SPINES)

FETAL POSITION: Relationship of reference point on fetal presenting part to maternal specific pelvic quadrant.

LOA: most common and favorable for birthing position

MECHANISMS OF LABOR (D-F-IR-E-ER-E)

DESCENT: A continuous process from engagement until birth

FLEXION: Nodding of the fetal head toward the chest.

INTERNAL ROTATION: Occipitotransverse to the occipito anterior position while descending

EXTENSION: Begins when the head crowns to head passing under the symphysis pubis

EXTERNAL ROTATION (RESTITUTION): Realignment of the fetal head with the body after the head emerges.

EXTERNAL ROTATION (SHOULDER ROTATION): Shoulders externally rotate after the head emerges and restitution occurs

EXPULSION: Birth of the entire body

UTERINE CONTRACTION (CONTOUR CHANGES): As labor contraction progresses Uterus differentiates into
two distinct functional areas:

1. UPPER PORTION: becomes thicker & active, preparing to exert strength to expel the fetus when the expulsion phase is reached.

2. LOWER PORTION: becomes thin-walled, supple & passive to easily push the fetus out of the uterus.

STAGES OF LABOR

1. FIRST: active labor to full cervical dilation

2. SECOND: full cervical dilation to delivery of infant

3. THIRD: delivery of infant to delivery of placenta

4. FOURTH: delivery of placenta to 1-4 hours

NURSING MANAGEMENT

Modified Ritgen’s

Support the head & (suction secretions?)

Dry the baby

Initiate skin to skin interaction

Wait for pulsation to stop

When there is still birth, let the mother see the baby

PLACENTAL SEPARATION
• LENGTHENING OF THE UMBILICAL CORD
PLACENTAL EXPULSION
• NATURAL (BEARING-DOWN)

COMPONENTS OF LABOR (4 PS OF LABOR)
EFFECTIVE POWERS OF LABOR: second important requirements for a successful labor

MAJOR POWERS OF LABOR

1. Involuntary Uterine Contractions or Primary Powers: Muscular contractions which lead to dilation and effacement in the First Stage of Labor

2. Voluntary Uterine Contractions or Secondary Powers: Abdominal muscles assist in the Second Stage with pushing.

POWERS

Uterine contractions: primary force moving fetus thru maternal pelvis during 1st stage of labor

Maternal Efforts: woman adds voluntary pushing force to force of contractions during 2nd stage of labor to propel fetus thru pelvis

UTERINE CONTRACTION: involuntary and cannot be controlled by the experiencing
women

THREE PHASES OF CONTRACTION

1. INCREMENT: building up of the contraction

2. ACME: peak or highest intensity

3. DECREMENT: descent or relaxation of the uterine muscle fibers

PHASES OF CONTRACTION

CONTRACTION: exhibits a wavelike pattern that begins slowly climbing (increment) to a peak (acme), and decreases (decrement)

DURATION: beginning of one contraction to the end of the same contraction (from 20 to 30 sec to a range of 60 to 90 sec)

FREQUENCY: from beginning of one contraction to the beginning of another contraction

INTERVAL: Resting time between contractions for placental perfusion, from 10 minutes early in labor to only 2 to 3 minutes

PARAMETERS OF UTERINE CONTRACTION

INTERVAL: early labor: 10 to 20 minutes between contractions; late labor: 3 to 5 minutes between contractions

DURATION: early labor: 20 second long contraction; late labor: 40 to 80 second long contraction

QUALITY: early labor: Uterus can be dented (poor quality); late labor: Uterus is hard (good quality)

CONTOUR: uterus gradually differentiates itself into two distinct functioning areas

HYDROSTATIC FORCE
• power that facilitates the process of labor and birth
INTRA-ABDOMINAL FORCE
• the final power for labor & birth

FIRST STAGE

Onset of true labor to complete dilation = 10 cm.

primipara: 6-18 hrs (12H)

multipara: 2-10 hrs (7H)

3 phases: latent, active, transition

LATENT PHASE

latent or preparatory phase

begins at the onset of regularly perceived uterine contractions and ends when rapid cervical dilatation begins

Contractions: mild and short, irregular, lasting 20 to 40

seconds

ACTIVE PHASE

Contractions: more rapidly, stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes

Cervical effacement: cervix dilates from 4 to 7 cm

TRANSITION PHASE

contractions reach their peak of intensity

Contractions: every 2 to 3 minutes with a duration of 60 to 90 seconds

Cervical effacement: maximum cervical dilatation of 8 to 10 cm

CARE OF A WOMAN DURING THE FIRST STAGE OF LABOR
-SIX MAJOR CONCEPTS TO MAKE LABOR AND BIRTH AS NATURAL-

1. Labor should begin on its own, not be artificially induced

2. Women should be able to move about freely throughout labor, not be confined to bed.

3. Women should receive continuous support during labor

4. No interventions such as intravenous fluid should be used routinely.

5. Women should be allowed to assume a non-supine (e.g.,upright, side-lying) position for birth.

6. Mother and baby should be together after the birth, with unlimited opportunity for breastfeeding

* RESPECT CONTRACTION TIME- Do not interrupt in the middle of breathing exercises

BREATHING TECHNIQUES

Slow chest: 6-12 “easy” breaths/min. Used in early labor.

Combination: quicker, lighter breaths Used during active

labor; one slow breath in beginning & quicker breaths to follow.

Pant-Blow: 3 - 4 quick breaths, with forceful exhalation.

Used @ end of 1st stage when contractions strongest

SECOND STAGE: BIRTHING OF BABY

period from full dilatation and cervical effacement to birth of the infant

Primipara: up to 1 hr. (50 min) or ~ 20 contractions

Multipara: 20 min. or ~ 10 contractions

Cardinal movements

Most difficult & uncomfortable part of labor

Crowning occurs at +4 -+5 station

CARE OF A WOMAN DURING THE SECOND STAGE OF LABOR
• Assess fetal heart sounds at the beginning of the second stage of labor to be certain that the start of the baby’s passage into the birth canal is not occluding the cord and interfering with fetal circulation

PREPARING THE PLACE OF BIRTH

Multipara: convert a birthing room into a birth room by opening the sterile packs of supplies on waiting tables when the cervix has dilated to 9 to 10 cm.

Primipara: can be delayed until the head has crowned to the size of a quarter or half-dollar

BABY CARE: open the partition at the end of the room to reveal the “baby island,” or newborn care area

POSITIONING FOR BIRTH

1. lateral or Sims’ position

2. dorsal recumbent position (on the back with knees flexed)

3. semi-sitting

4. squatting

PROMOTING EFFECTIVE SECOND-STAGE PUSHING
• woman should wait to feel the urge to push even though a
pelvic examination has revealed that she is fully dilated
PERINEAL CLEANING
• clean with warmed antiseptic such as Iodophor (cold
solution causes cramping) and then rinse it with a
designated solution before birth, according to the policy of
the physician, nurse midwife, or agency
EPISIOTOMY
• surgical incision of the perineum that is made both to prevent tearing of the perineum and to release pressure on
the fetal head with birth

CUTTING AND CLAMPING THE CORD: Delaying the cutting until pulsation ceases and maintaining the infant at a uterine level allows as much as 100 mL of blood to pass from the placenta into the fetus

THIRD STAGE

begins with the birth of the infant and ends with the delivery of the placenta

5 - 30 min (if not: uterine atony)

TWO PHASES:

1. placental separation

2. placental expulsion

SIGNS OF PLACENTAL SEPARATION ((CALKIN'S SIGN))

Normal: 300 to 500 mL.

Up to 30 minutes for placental separation

BRANDT-ANDREW MANEUVER

Dirty: Duncan

Shiny: shultze

OXYTOCIN: Once the placenta is delivered, oxytocin is usually ordered to be administered intramuscularly or intravenously to the mother

CARBOPROST TROMETHAMINE (HEMABATE): may be administered if the woman has excess bleeding with poor uterine contraction

PERINEAL REPAIR
• important to be sensitive to the mother’s needs at this time

FOURTH STAGE

Placenta out; mother recovers in “LDR” “Labor, delivery, & recovery”

Lasts ~ 1 hr. unless complications arise

Then pt. transferred to PP unit

AFTERCARE

uterus may be so exhausted from labor that it cannot

maintain contraction, there is a high risk for hemorrhageduring this time

woman often is so exhausted that she may be unable toassess her own condition or report any changes

specific assessments done during this time are continued throughout the postpartal period

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LESSON 1: Care of the Family with a Newborn (Midterm)

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LESSON 1: Care of the Family with a Newborn (Midterm)

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> Newborns undergo profound changes at birth
> Warm, snug, dark, liquid - filled environment -> Chilly, unbounded, brightly lit, gravity-based world
> SUSTAINED LIFE: Within minutes after birth, must initiate respiration, within 24 hours, all physiologic functions must be operating competent

Profile of a Newborn
1. Vital Statistics
Weight – 2.5 to 3.4 kg (5.5 to 7.5 lbs)

Plotted in conjunction with height and head circumference to highlight disproportionate measurements

A newborn loses 5% to 10% of birth weight (6-10 oz) during first few days after birth because

Length – 46 to 54 cm
Head Circumference – 34 to 35 cm (2 cm larger than chest)

Measured using a tape measure drawn across the center of the forehead around the occiput

Chest circumference – 32 to 33 cm

usually about 2 cm less than head circumference and is measured at the level of the nipples

Temperature – 97.60F - 98.60F axillary

Newborns lose heat by 4 mechanisms

1. Convection – flow of heat from newborn’s body surface to cooler surrounding air

2. Conduction – transfer of body heat to cooler solid object in contact with the baby

3. Radiation – transfer of body heat to cooler solid object not in contact with the baby

4. Evaporation – loss of heat through conversion of a liquid to vapor

> Newborns has difficulty in conserving heat by insulation because they have little subcutaneous fats

> They conserve heat by: – Constricting blood vessels – Increasing metabolism (utilizing brown fats) – Kangaroo care

> Increased Metabolism -> Increased O2 demand -> (without O2) Anaerobic catabolism will occur -> Acidosis

Pulse - 120-160 bpm

irregular, transient murmurs, coarctation of aorta

Respiration – 30 – 60 breaths per minute

Rate may be irregular, with short periods of apnea

Blood Pressure – 80/46 mm Hg to 100/50 mm Hg

2. Physiologic Function

Cardiovascular System – Circulatory events at birth

1. Drying or clamping of umbilical cord and stimulation of cold receptors

2. Increased PCO2 and decreased PO2 And increasing acidosis

First Breath
Increased PO2 <- Decreased pulmonary artery pressure -> Closure of Foramen Ovale
-> Closure of Ductus arteriosus --> Closure of ductus venosus and umbilical vein and arteries

Blood values

BV: 80-110 ml per kg of BW (300 ml)

NB: increased erythrocyte count, increased hemoglobin and hematocrit; increased erythrocyte count, increased hemoglobin and hematocrit; increased WBC in response to the trauma of birth and is nonpathogenic

Blood coagulation

newborn’ s intestine is sterile at birth, it has no flora needed to synthesize Vitamin K; Vitamin K is administered intramuscularly

Respiratory System

Within 10 minutes after birth, newborns have established good residual volume;

10-12 hours: vital capacity is established

Gastrointestinal System

NB: GI tract is sterile ; limited ability to digest fat and starch because of deficient pancreatic enzymes

immature cardiac sphincter -> causing regurgitation

Stools : meconium within 24 hours, transitional stool by 2nd -3 rd day of life

NOTE: Breast fed – light yellow, sweet smelling stool, Fed on formula – bright yellow with more noticeable odor, Clay colored stool, Black tarry stool, Loose watery stool

Urinary System

NB: voids within 24 hours after birth; 15 ml/single voiding; Daily urine output in first 1 -2 days is about 30-60 ml. By week 1, total volume rises to about 300 mL

urine light colored and odorless

Immune System

They have passive antibody from the mother (IgG) that crossed the placenta

Neuromuscular System

REFLEXES: Blink, Rooting, Rooting, Sucking, Swallowing, Extrusion, Palmar Grasp, Step – in Place, Placing, Plantar Grasp, Tonic Neck, More, Babinski, Landau, and Deep Tendo

The Senses

1. Hearing – able to hear even before birth

2. Vision – see as soon as they are born

3. Touch – well developed at birth

4. Taste – taste buds developed and functioning at birth

5. Smell – present as soon as nose is clear of mucus

Physiologic Adjustment to Extrauterine Life

> Periods of reactivity: occurs in the first 6 hours of life before newborn’s body systems stabilize

> First Periods of Reactivity – lasts for half an hour : Baby is alert, exhibits exploring, searching activity.

Resting Period – 90 minutes: Baby sleeps

Second Period of Reactivity – 2 to 6 hours of life: Baby wakes again, alert and responsive to surroundings

Appearance of a Newborn

1. Skin

Color – Term baby has ruddy complexion

Cyanosis, mottling of skin is common

Acrocyanosis – blueness of hands and feet (24-48 hrs)

Central cyanosis – indicates decreased oxygenation

Hyperbilirubinemia – leads to jaundice; RBC breakdown

1. Physiologic jaundice – 2nd to 3rd day of life

2. Pathologic jaundice - first 24 hrs (DANGEROUS)

Cephalhematoma - collection of blood under the periosteum of the bone

Kernicterus - permanent neurologic damage caused by build up of indirect bilirubin (MGT: phototherapy)

(-) Pallor - Maybe caused by excessive blood loss, inadequate perfusion, fetal –maternal transfusion, low iron stores, blood incompatibility

(-) Harlequin sign - nb who has been lying on his side appears red on the dependent side and pale on the upper side

2. Birthmarks

Hemangiomas- dilated cappilaries; vascular tumors of skin

TYPES:

Nevus flammeus – macular purple/dark red lesion

1. Port-wine stain – tend to fade

2. stork’s beak marks - do not fade

Strawberry hemangiomas - elevated immature capillaries and endothelial cells

Cavernous Hemangiomas – dilated vascular spaces; they do not disappear

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Mongolian spots - Collection of melanocytes that appear slate gray patches in sacrum or buttocks

Vernix caseosa - White cream cheese like substance that serves as lubricant

Lanugo – fine downy hair, disappears by 2 weeks of age

Desquamation – Newborn’s skin becomes
extremely dry.

Milia – A pinpoint white papule

Erythema Toxicum (Flea bite rash) - Caused by newborn’s eosinophils reacting to the environment as the immune

Forceps Mark – A circular or linear contusion matching the rim of the blade of the forcepssystem matures

Skin Turgor - Newborn’s skin should feel resilient and elastic

3. Head: Disproportionately large (1/4 of the body length); Forehead is large and prominent

Fontannels

1. Anterior – diamond shaped, closes at 12-18 mos.

2. Posterior – triangular, closes by end of 2nd month

3. Indented fontannel – a sign of dehydration

4. Bulging fontannel – a sign of increased ICP

Sutures – The separating lines of the skull

1. Wide separation – suggests hydrocephalus, subdural bleeding

2. Fused suture lines – prevents head growth expansion

Molding – The part of the infant’s head that engages the cervix is molded to fit the cervix contours

Caput Succedaneum – Edema of the scalp at the presenting part of the head

Cephalhematoma – Collection of blood between the periosteum of a skull bone and the bone itself

Craniotabes – Localized softening of the cranial bones caused by pressure of fetal skull

4. Eyes: Newborns cry tearlessly because their lacrimal ducts do not fully mature until 3 months of age
Other conditions to note

1. (-) Ophthalmia neonatorum (gonorrheal conjunctivitis)

2. (-) Subconjunctival hemorrhage

3. (-) Periorbital edema

4. (-) Congenital glaucoma

5. (-) Congenital cataract

5. Ears: Pinna tends to bend easily but strong enough to recoil
6. Nose: Tends to appear large for the face
7. Mouth: Should open evenly

Tongue appears large and prominent in the mouth

The frenulum membrane is attached close to the tip of the tongue

Epstein’s pearls – small round, glistening, well

circumscribed cysts as a result of extra load of Calcium deposited in utero

Thrush – a Candida infection

Natal teeth

8. Neck: neck of newborn is short and often chubby; With creased skin folds

Congenital torticollis – injury to the sternocleido mastoid muscle

Nuchal rigidity – suggests meningitis

9. Chest: look smaller (by 2 inches) because the head is large in proportion

Retractions – drawing in of the chest wall w/ inspiration

Rhonchi – air passing over mucus

Grunting – suggests respiratory distress syndrome

Crowing – suggests stridor or immature trachea

10. Abdomen: Slightly protuberant

Scaphoid / sunken – suggests missing abdominal contents or diaphragmatic hernia

Bowel sounds present within 1 hour

Liver must be palpable 1-2 cm below right costal margin

Spleen must be felt 1-2 cm below left costal margin

Right kidney is located lower than the left; Umbilical stump must have 1 vein, 2 arteries

11. Anogenital area: Imperforate anus – infant should first passes
1. Male genitalia: Scrotum is edematous and has rugae; Both testes should be present in scrotum meconium in 24 hours after birth

Cryptorchidsm - undescended testes

Agenesis – absence of an organ

Ectopic testes – testes cannot enter scrotum because the opening in scrotal sac is closed

2. Female Genitalia : Pseudomenstruation - some female newborns have mucus vaginal secretion caused by maternal hormone

12. Cremasteric Reflex: Tests integrity of spinal nerve T8 – T10.

Epispadias – urethral opening is on the dorsal surface of the glans

Hypospadias – urethral opening is on the ventral surface of the glans

13. Back: The spine of newborn should lie flat in
the lumbar and sacral areas
14. Extremities: They appear short, hands are plump and clenched into fists

Hips- Both can be flexed and abducted 180 degrees

1. Hip subluxation- shallow and poorly formed acetabulum

2. Ortolani’s Sign - can be heard

3. Barlow’s sign – can be felt

Assessment for Well-Being
1. Apgar Scoring Chart

< 4 – needs resuscitation

4 – 6 - guarded, clear airway, O2 support

7-10 - good

2. Silverman-Andersen Index – grading neonatal respiratory distress

0 – no resp. distress

4-6 –moderate

7-10 – severe

3. Physical Assessment

Height and weight- Weighed nude once a day, same time everyday

4. Laboratory Studies

Heel stick tests - Anemia, ploycythemia, hypoglycemia (<40mg / 100 ml)

Assessment for Gestational Age
Clinical Criteria for Gestational Age

1. Ballard’s Physical Maturity Assessment

2. Ballard’s Neuromuscular Maturity Assessment

Care of a Newborn

Necessary equipment includes: Radiant heat table, warmer bassinet, warm soft blanket, equipment for O2 administration, resuscitation, suction, eye care, identification and weighing of newborn

Newborn Identification and registration: ID band with permanent locks and built in sensor

Birth record documentation

Immediate Newborn Care

Keep newborn warm

Promote adequate breathing pattern and prevent aspiration

Record the first cry

Inspect and care for umbilical cord

Administer eye care

General infection precautions

Nursing Care of a Newborn and Family in Post Partal Period

Initial feeding - Do best on demand schedule

Bathing - In hospitals, nb receive a complete bath to wash away vernix caseosa in an hour after birth ; Pattern should be from cleanest to most soiled areas – eyes, face – trunk – extremities – diaper area (“football hold”)

Sleeping Position : Sudden Infant death syndrome (SIDS) – cause is unknown. But placing infants in supine position has decreased the incidence of the syndrome.

Diaper Area Care – To prevent diaper dermatitis, wash area with clean water and dry well

Metabolic Screening Tests - Tests PKU, hypothyroidsm, cystic fibrosis, galactosemia

Hepatitis B vaccination – Given in 12 hours after birth, then after a month, then at 6 months (0-1-6)

Vitamin K Administration – NB are risk for bleeding, vitamin K is administered intramuscularly

Circumcision – Is the surgical removal of the foreskin of the penis

Indications:
Phimosis – severe constriction of foreskin that it obstructs the urinary meatal opening of the penisoval of the foreskin of the penis
Contraindications: Hypospadias / epispadias Bleeding history

Assessment of Family’s Readiness to Care for a Newborn at Home

Daily home care - Parents should offer a degree of consistency ; Satisfy the infant

Sleep patterns - Infant sleeps 16 hours of every 24 hours, average 4 hours at a time. By 4 months, sleeps 15 hours through the night

Crying – Infants typically cry for 2 hours of every 24 hours

Parental concerns related to breathing – Stuffy nose, snoring noises, sneeze frequently, periods of apnea are all normal for newborns

Continued health maintenance for a newborn – Make appointments with primary care provider (2-6 wks)

Car safety – Child placed in car seat, at the back seat facing the back of the car

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LESSON 1: Promoting Maternal and & Fetal Health

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LESSON 1: Promoting Maternal and & Fetal Health

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PART 1: Promoting Health and Comfort

1. Bath

MISCONCEPTIONS: Tub bath are restricted because water can enter the vagina and cervix and contaminate the uterine contents; It may also initiate labor

FACT: Daily baths are recommended to cleanse the mother from excessive perspiration and vaginal discharge

CAUTION: WOF risk of slipping due to difficulty in maintaining balance; Not recommended when there is vaginal bleeding or ROM

HEALTH EDUCATION: Change to sponge bath/showering if with problem in balance

2. Breast Care

FACT: A woman should wear a firm, supportive bra with wide strap to spread the weight across the shoulders

CAUTION: Constant moisture next to the nipple can cause nipple excoriation, pain and fissuring;  Place gauze pad or breast pad inside the bra if necessary

HE: Inform that colostrums may be discharged from the breast at 16 week; Instruct to wash breasts with clear tap water daily then dry nipple by patting

3. Dental Care

MISCONCEPTIONS: Dental care is not part of prenatal care

FACT: Gingival tissue tends to hypertrophy during pregnancy; Dentist should be seen for routine examination and cleaning

CAUTION: X-ray for dental purposes can be done as long as the woman wears a lead apron

HE: Encourage the woman to brush teeth regularly; Encourage to snack on nutritious food such as fresh fruits and vegetables; If sweets are unavoidable, ask to eat sweets that can easily dissolve in the mouth

4. Perineal Hygiene

FACT: Douching is not recommended because it can enter the cervix and lead to infection; Douching alters the vaginal pH

5. Dressing

FACT: Women should avoid garters, extremely firm girdles with panty legs and knee high stockings because these may impede LE circulation

HE: Encourage to wear shoes with a moderate to low heel to minimize pelvic tilt and possible backache

6. Sexual Activity

MISCONCEPTIONS: Coitus on expected date of her period will initiate labor; Orgasm will initiate labor but participating in sexual relations without orgasm will not; Coitus during the fertile days of a cycle will cause a second pregnancy or twins; Coitus might cause ROM

CAUTION: Women with history of miscarriages;Women with ROM and vaginal bleeding; Oral-genital sex could cause air embolism

HE: Assure that coitus is not harming the child;A side by side or woman in a superior position may be comfortable; Use of water soluble lubricant maybe necessary

7. Exercise

MISCONCEPTIONS: Exercise is contraindicated in pregnancy

FACT: important to prevent circulatory stasis in the LE.; Offer well-being

CAUTION: For HR pregnant women, they need to be cautioned to restrict; Make sure the woman has consulted her physician

HE: A woman should exercise everyday for 30 consecutive minutes with 5-min warm up 20- min active and 5-min cool-down; Exercise that focus on large muscle groups such as walking is recommended

8. Sleep

FACT: Women need enough sleep during pregnancy for fetal growth and because of increased BMR

CAUTION: Avoid lying flat on bed or with knees sharply bent

HE: Advise to drink a glass of milk if there is difficulty of sleeping; Relaxation exercises may also be effective; Modified Sim’s position is a good resting position

9. Employment

MISCONCEPTIONS: Women should not work during pregnancy

FACT: Only women who are exposed to work hazards that might affect pregnancy should not continue work (toxic substances, lifting, etc)

CAUTION: Preterm birth may occur more frequently in women who work at strenuous jobs or those who stand for a prolonged period

HE: Counsel women to reserve periods during the day for rest and to eat a healthy diet than telling them to resign from their jobs

10. Travel

FACT: There are no restrictions early in pregnancy; Pregnant women can drive as long as they are comfortable and use seat belts

CAUTION: Regardless of the AOG, the pregnant woman must be familiar with the nearest health care facility; Vaccines may be necessary if traveling

HE: Educate not to eat raw fruits, vegetables and meat or drink unpurified water;Advise a woman taking a long trip by automobile to plan for frequent rest or stretch periods every hour or 2 hours

Discomforts of Early Pregnancy

Breast Tenderness

Encourage to wear bra that provides support

Dress warmly

Rule out other conditions if persistent

Palmar Erythema

Explain Calamine lotion may be soothing

Constipation

Discuss preventive measures

Reinforce the need for Iron even if it may cause constipation

Advise not to use mineral oil

Recommend avoiding gasforming food

Avoid enema and use of laxatives

Nausea, Vomiting Pyrosis

Advise to side-lying eat dry crackers

Dry CHO diet

Wait 30 minutes before arising from bed

Fatigue

Relieve by rest and sleep

Advise one short rest period per day

Advise to elevate legs

Muscle Cramps

Advise to lie on the back momentarily, extend the leg and dorsiflex the foot

May also advise to decrease milk intake

Hypotension

Assume left to side-lying

Varicosities

Assume the Sim’s position or on the back with legs raised against a wall or elevated on a footstool for 15-20 minutes

Caution not to cross legs

Avoid wearing knee-high hose/garters

Apply TEDS

Walk break 2x/day

Exercise

Vitamin C and fruits

Hemorrhoids

Daily bowel evacuation

Resting in modified Sim’s position

Assume a knee-chest position for 10- 15minutes

Cold compress

Gentle finger pressure

Stool softeners

PREVENTION

Heart Palpitations

Reassure that it is normal

Report if they occur very frequently or continuously or if accompanied by pain

Advise gradual/slow movements

Frequent Urination

Decrease coffee intake

Explain that voiding frequently is normal

Advise to perform Kegels’ exercises to decreases stress incontinence and strengthen perineal muscles

Abdominal discomforts

Advise to rise slowly

Evaluate description of the pain carefully

Leukhorrhea

Advise daily bath/shower

Wearing cotton underwear and sleeping at night w/o one

May wear perineal pads but not tampons

Advise to consult when there are changes in discharge

Advise not to douche

Avoid tight underpants and pantyhose

Discomforts of Middle to Late Pregnancy

Backache

Advise to wear lowheeled shoes to reduce the amount of spinal curvature

Encourage to walk with pelvis tilted forward

Apply local heat

Advise to squat rather than bend to pick up objects

Hold objects close to the body when lifting

Perform pelvic tilt/rocking

Detailed account of women’s symptoms

Caution not to self medicate

Headache

Resting with cold towels on forehead

Taking usual dose of acetaminophen

Caution that if HA is unusually intense or continuous, they should report it; It may be a danger sign of high BP

Dyspnea

Advise to sleep upright

May require 2 or more pillows

Caution to limit her activities during the day

Ankle Edema

Advise to assume left-lateral position

Sitting with legs elevated 2x/day for 30 min

Avoid wearing constrictive clothing

Reassure

Assess for other signs of PIH

Braxton-Hicks contraction

Educate about these types of contraction

Some women might be anxious

Report to the primary care provider for evaluation

Observe for rhythmic pattern of even very light contractions

PRELIMINARY SIGNS OF LABOR

1. LIGHTENING: Settling of the fetal head into the inlet of the true pelvis

2. EXCESS ENERGY: Feeling extremely energetic

3. UTERINE CONTRACTIONS: True contractions

4. SHOW: beginning of cervical dilatation

5. RUPTURE OF THE MEMBRANE: Sudden gush of clear fluid from the vagina

PART 2 - Danger Signs & Exposure Risks

Danger signs of Pregnancy

1. Vaginal Bleeding

2. Sudden Escape of clear fluid from the vagina

3. Persistent vomiting

4. Abdominal or chest pain

5. Pregnancy-induced HTN

6. Increase/decrease Fetal movement

7. Chills and Fever

Teratogenic Maternal Infection

Can either be sexually transmitted or systemic infections

Organisms cause the placental barrier (viral, bacterial, protozoan)

Maybe subclinical but still injure a fetus

Common diseases that cross the placenta and cause fetal harm: – TORCH (Toxoplasmosis, Other Infections, Rubella, Cytomegalovirus, Herpes Simplex virus)

1. TOXOPLASMOSIS

MOT: Handling raw meat, cat litter, or soil contaminated with cat feces; Eating inadequately prepared meat and animal products; Eating inadequately washed vegetables that have come in contact with contaminated soil

EFFECT: CNS damage, hydrocephalus, microcephaly, intracerebral calcification, retinal deformities

2. OTHER INFECTIONS: (HEPATITS A and B, HIV, SYPHILIS, RUBELLA)

3. RUBELLA

EFFECTS: Deafness, mental and motor challenges, cardiac defects, dental and facial clefts

4. CYTOMEGALOVIRUS

MOT: By contact with contaminated saliva, respiratory secretions, urine, semen, breastmilk, blood, cervical-vaginal secretions

EFFECTS: Hemolytic anemia, jaundice, hydrocephalymicrocephaly, pneumonitis, mental retardation

5. HERPES SIMPLEX

MOT: Contact with contaminated genital secretions; Transplacentally especially during a primary infection; Contact with active lesions and contaminated secretions during passage

EFFECTS: 1st trimester: severe congenital anomalies or spontaneous miscarriages; 2nd-3rd trimester: premature labor, intrauterine growth restrictions, and continuation of infection

OTHER VIRAL DISEASES
SYPHILIS

EFFECTS: Congenital anomalies, extreme rhinitis, syphilitic rash; Presence of Hutchinson teeth (oddly shaped)

LYME DISEASES

MOT: Tick bites

EFFECTS: Spontaneous miscarriage or severe congenital anomalies

CAUSE ILLNESS AT BIRTH (Gonorrhea, candidiasis, chlamydia, streptococcus B and hepatitis B)

MOT: Not teratogenic to fetus but are harmful at birth

Teratogenic Vaccines

Live virus vaccines cannot be administered during pregnancy

They may transmit viral infection to a fetus

Live virus vaccines include:
– Measles
– Mumps
– Rubella
– Poliomyelitis

Teratogenic drugs

Women should be cautious in taking any type of drug, whether it be over-the-counter, herbal or prescription drugs

Recommendations: – Women (pregnant or child-bearing age) should not take any drugs or supplements not specifically prescribed or approved by their physician

A common teratogenic drug is THALIDOMIDE. can cause amelia/phocomelia when taken between 34th -45th day of pregnancy

Recreational drugs are also harmful for fetus:
– Narcotics and heroin: causes intrauterine growth
restriction
– Marijuana: unstudied
– Cocaine: compromises fetal blood flow, spontaneous
miscarriage, preterm labor, meconium staining and
intrauterine growth restriction
– Inhalants: limit oxygen supply

CATEGORY

A: Risk during 1st trimester; No evidence for risk in last trimester. (Ex: Thyroid hormone)

B: Adverse effect on fetus on animal studies but not on pregnant women. (Ex: Insulin)

C: Adverse effect on the fetus on animals but not on humans. No adequate studies. Unknown pregnancy risk. (Ex: Docusate sodium (Colace))

D: There is evidence risk to human fetus but maybe acceptable because of potential benefits. (Ex: Lithium citrate)

X: Show abnormalities in humans and animals. Risk outweighs the benefits. (Ex: Isotretinoin (Accutane))

Teratogenicity of Alcohol

Alcohol from the mother is passed on to the fetus through the placenta

Fetus cannot remove breakdown products of alcohol→ causes Vitamin B deficiency→ neurologic damage

Can cause fetal alcohol syndrome→ baby becomes SGA and may be cognitively challenged

The infant is characterized by craniofacial deformity

Teratogenicity of Cigarettes

Fetus experiences growth restriction

Infants are at greater risk for sudden infant death syndrome and they are born with LBW due to limited blood supply to the fetus during pregnancy

Environmental Teratogens

Women are exposed to this at home or at work

Can be classified into:
– Metal and chemical hazards: includes pesticides, carbon monoxide, lead, paints, etc
– Radiation: destroys rapidly growing cells; all women should only be exposed to x-ray during the first 10 days of menstruation; pregnancy test should be done before x-ray
– Hyperthermia & hypothermia: It interferes with cell
metabolism

Teratogenic Maternal Stress

Emotionally disturbed pregnant woman can cause physiologic changes through its effect on sympathetic division of the Autonomic Nervous System

It may cause constriction

It is not caused though by normal anxiety but by long-term, extreme stress

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LESSON 3: Genetic Assessment & Counseling

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LESSON 3: Genetic Assessment & Counseling

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GENETIC ASSESSMENT
> begins with careful study of the pattern of inheritance in a family.
#1 Elicit History
#2 Perform physical examination
#3 Inform/ assist during diagnostic procedures
#4 Present reproductive alternatives

LEGAL & ETHICAL ASPECTS

Elective participation

Signed informed consent

Results must be interpreted correctly yet provided as quickly as possible

Confidentiality of results

Free and individual decision on action to be taken

ASSESSMENT
> measures for genetic disorders: detailed family history, preferably of three generations; physical examination of both the parents and any affected children; and an ever-growing series of laboratory assays of blood, amniotic fluid, and maternal and fetal cells.
> Chorionic villi sampling (CVS) and amniocentesis are
follow-up techniques that may be offered to women who are older than 35 years of age, or to those whose MSAFP level
is abnormal, to further screen for genetic disorders.
>>>  consists of a health history, physical examination, and diagnostic studies such as chorionic villi sampling, amniocentesis, and maternal serum levels of alpha-fetoprotein analysis.

Thalassemia: a blood dyscrasia, occurs most frequently in families of Greek or Italian heritage
Sickle cell anemia: occurs most often in African Americans.
Tay-Sachs disease: occurs most often in people of Jewish
ancestry.

GENETIC COUNSELING
> PROVIDE INFORMATION/ EDUCATE → clients feel well and guilt-free
> can be a role for nurses with advanced preparation and education.

REMEMBER!
> Allelles are different forms of a gene
> We inherit one allele from each parent

GENETIC DISORDERS
> Inherited or genetic disorders are disorders that can be
passed from one generation to the next.
> 5% to 6% of newborns.

Genetics: study of the way such disorders occur
Cytogenetics: study of chromosomes by light microscopy and the method by which chromosomal aberrations are identified
Genetic disorders: occur at the moment an ovum and
sperm fuse

NATURE OF INHERITANCE
> Genes are the basic units of heredity that determine both
the physical and cognitive characteristics of people.
> Sperm and ovum, contains 46 chromosomes (22 pair of autosomes and 1 pair of sex chromosomes)
> Spermatozoa and ova each carry only half of the chromosome number, or 23 chromosomes
> One chromosome in which this does not occur is the
chromosome for determining gender
> both type X: Female
> X and Y: Male

***22 autosomes & 1 sex chromosome (Mother) + 22 autosomes & 1 sex chromosome (Father) → Genotype (46 xx or 46 xy) expressed as phenotype

Phenotype: appearance or the expression of genes.
Genotype: actual gene composition

> person’s genome is the complete set of genes (about 50,000 to 100,000)
> normal genome is abbreviated as 46XX or 46XY

MENDELIAN INHERITANCE: DOMINANT AND
RECESSIVE PATTERNS
> discovered and described by Gregor Mendel, an Austrian naturalist; known as mendelian laws.
> can predict the likely y incidence of recessive
or dominant diseases in children

Homozygous: two like genes for a trait
Heterozygous: genes differ

> When paired with nondominant (recessive) genes, dominant genes are always expressed in preference to the recessive genes. An individual with two homozygous genes for a dominant trait is said to be homozygous dominant; an
individual with two genes for a recessive trait is homozygous recessive.

INHERITED DISORDERS

Autosomal

X-linked

MULTIFACTORIAL INHERITANCE
> Diseases caused by multiple factors this way do not follow
Mendelian laws because more than a single gene or HLA is involved

AUTOSOMAL DISORDERS

Dominant

Recessive

AUTOSOMAL DOMINANT CONDITION
> either a person has two unhealthy genes (is homozygous dominant) or is heterozygous, with the gene causing the disease stronger than the corresponding healthy recessive gene for the same trait.

Huntington’s Disease

Osteogenesis Imperfecta

Marfan Syndrome

Achondroplasia

Retinoblastoma

AUTOSOMAL RECESSIVE DISORDERS
> Such diseases do not occur unless two genes for the disease are present

Cystic Fibrosis

Sickle Cell Anemia

Fancone’s Anemia

Galactosemia

Phenylketonuria

Albinism

Limb –girdle Muscular Dystrophy

Adrenogenital Syndrome

Rh-factor Incompatibility

Tay Sach’s Disease

BIG IDEA!
> Both parents must be a carrier for the disease to be transmitted
> There must be 2 recessive diseased genes for the disease to be manifested

X-LINKED DOMINANT DISORDERS
> Some genes for disorders are located on, and therefore
transmitted only by, the female sex chromosome (the X chromosome).

Alport’s syndrome

X-LINKED RECESSIVE DISORDERS
> majority of X-linked inherited disorders are not dominant, but recessive. When the inheritance of a recessive gene comes from both parents
> females who inherit the affected gene will be
heterozygous; the expression of the disease will be blocked.
> manifested in any male
children who receive the affected gene from their mother.
Hemophilia A

Christmas Disease

Color Blindness

Baldness

Duchenne Muscular Dystrophy

Fragile X syndrome

BIG IDEA!
> Females can only be carriers & only males will have the disorder
> Sons of affected man are unaffected
> The parents of affected children don’t have the disease

CHROMOSOMAL ABNORMALITIES (CYTOGENIC DISORDERS)
-CHROMOSOMAL

1. Numerical

2. Deletion

-NUMERICAL: Additional or missing chromosome

1. Monosomy

2. Trisomy

3. Tetrasomy

CHROMOSOMAL ABNORMALITIES
> fault in the number or structure of chromosomes which results in missing or distorted genes.

Karyotype: chromosomes are photographed and displayed

1.) DOWN’S SYNDROME (TRISOMY 21): Trisomy 21, the most frequently occurring chromosomal abnormality, occurs in about 1 in 800 pregnancies.
2.) EDWARD’S OR TRISOMY 18 SYNDROME (47XY18 OR
47XX18): three copies of chromosome 18
3.) PATAU SYNDROME: extra chromosome 13; abnormal genitalia are present.
4.) KLINEFELTER SYNDROME: e males with an extra X
chromosome; small testes that produce ineffective sperm
5.) TURNER SYNDROME: only one functional X chromosome; small and nonfunctional ovaries
6.) DELETION: chromosome breaks during cell division; normal number of chromosomes plus or minus
7.) CRI-DU-CHAT (46XY5Q-): missing portion of
chromosome 5; abnormal cry

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PPD

6 week period after birth; Considered as the fourth trimester

Time for maternal changes (retrogressive and progressive)

Changes during PPD (BUBBLESHE+V)
B—reast
U—terus
B—owel
B—ladder
L—ochia
E—pisiorrhapy/ episiotony
S—kin
H—oman’s sign/hemorrhage
E—motions
V—ital signs

BREAST CHANGES

Formation of breast milk (lactation)→increase breast tissue

2nd day: SOFT AND NON TENDER

Primary engorgement: On the 3rd day, breast feels tender, fuller

Breast may appear reddened: MASTITIS- appear on 1 side of the breast

Nursing Consideration:

Assess woman’s breasts: Inspect & palpate for breast size, shape & color

Note for a firm nodule. Take note of location & report

UTERUS CHANGES

Undergoes INVOLUTION: contraction of uterus to go back to pre-pregnancy state

Uterine contraction begins immediately after birth

After 24 hrs: FIRM. MIDLINE, AT THE LEVEL OF UMBILICUS

Nursing Consideration:

Position the patient supine: Assess for contour, striae & diastasis; measure width & length in fingerbreadths

Ask the patient to empty bladder

If the uterus is boggy/not contracted: Massage gently

BLADDER CHANGES

Extensive diuresis & urine output increases to 3,000mL (2nd-5th PPD)

Transient loss of bladder tone+ edema surrounding the urethra (4 weeks) + effect of anesthesia= decrease ability to sense fullness of bladder

Nursing Consideration:

Assess the bladder for fullness frequently & encourage regular voiding habits

Full bladder may cause uncontracted uterus

BOWEL CHANGES

Bowel sounds are active

The woman feels hungry & thirsty immediately after giving birth

Hemorrhoids are often present

(+) constipation: presence of relaxin & pain d/t episiotomy or hemorrhoids

Nursing Consideration:

Stool softeners, suppositories or an

enema given as ordered.

Bowel movements do not occur for a few days (2-3 days PP)

LOCHIA

Composed of blood, fragments of decidua, white blood cells, mucus & some bacteria

It takes 6 weeks for the placental implantation site to be cleansed & healed

Nursing Consideration:

Check perineal pad and evaluate lochia for character, amount, color, odor, and presence of any clots

Perineal pad soaked within 1 hr: COULD BE DANGEROUS

Instruct on hygiene

X tampons

TYPE OF LOCHIA

1. Lochia rubra: red; 1-3 PPD; Blood, fragments of decidua & mucus

2. Lochia serosa: pink/brownish; 3-10 PPD; Blood, mucus & invading leukocytes

3. Lochia alba: white; 10-14--6 wks; Largely mucus, leukocyte count is high

Assessing Post-Partum Lochia

Small amount: <4 inch stain on peripad

Moderate amount: <6 inch stain on peripad

Heavy amount: saturated pad within 1hr (could be DANGEROUS)

EPISIOTOMY

Ask the woman to turn on her side (Sim’s position)

Labia majora & minora remain atophic & softened

R-ednessE-demaE-pisorapphyD-ischargedA-approximation

Usually 1-2 inches long: inspect for laceration & clotted lochia

SKIN CHANGES

Striae lightens or becomes slightly darker (reddened) over 3-6 months

Chloasma and linea nigra will be barely detectable in 6 weeks

Diastasis recti will appear as slight indentation or a bluish area

HOMAN’S SIGN

Same high level of fibrinogen during the 1st postpartal weeks

Pain on dorsiflexion

EMOTIONS

1. Taking In Phase (DEPENDENT PHASE): time for reflection where the woman is largely PASSIVE; Encourage to talk about the birth

2. Taking Hold (DEPENDENT TO INDEPENDENT PHASE): Begins to initiate action; Give brief demonstration of baby care & praise efforts

3. Letting Go (INTERDEPENDENT PHASE): new role and gives up old role; Extended and continues during the child’s growing years

Maternal concerns & feelings

ABANDONMENT: Feeling less important/jealous; Allow verbalization of feelings

DISAPPOINTMENT: Difficult for parents to feel positive immediately about the child (does not meet their expectations); should handle the child warmly and comment on the child’s good points

POST PARTAL BLUES: burst into tears easily/feel let down/irritable; Reassure the woman and family and allow to verbalize feelings & low to make decisions --> can lead to postpartal depression (overwhelmed feeling of sadness that extends beyond 2 wks)

Effects of retrogressive changes

Exhaustion: sleep hunger

Weight loss: 5lbs for diuresis + 2-3 lb for lochial flow + 12 lb at birth= 19 lbs

VITAL SIGNS CHANGES

Temperature: slight increase 1st 24 hours

Increased in Temp = infection

Pulse: Usually slightly slower

(+) Thready & rapid pulse, decreased in BP, hypotension, tachypnea = could be signs of hemorrhage

Blood Pressure: monitor for increased & decreased

ADD notes:

PROLACTIN – stimulates milk Production

OXYTOCIN – initiates the let-down reflex with milk ejection as the baby suckles

Menstruation – 6 weeks after birth in non-nursing moms; 24 weeks in nursing moms