Professional Documents
Culture Documents
Human Sexuality
A. Concepts
1. A persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to
sexual self and eroticism.
2. Sex basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:
Gender identity sense of femininity or masculinity
2-4 yrs/3 yrs gender identity develops.
Role identity attitudes, behaviors and attributes that differentiate roles
Sex biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.
- developed at the moment of conception.
II. Sexual Anatomy and Physiology
A. Female Reproductive System
1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by
pubic hair that serves as cushion or protection to the symphysis pubis.
Stages of Pubic Hair Development
Tannerscale tool - used to determine sexual maturity rating.
Stage 1 Pre-adolescence. No pubic hair. Fine body hair only
Stage 2 Occurs between ages 11 and 12 sparse, long, slightly pigmented & curly hair at pubis
symphysis
Stage 3 occurs between ages 12 and 13 darker & curlier at labia
Stage 4 occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so
thick and does no appear to the inner aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh .
b. Labia Majora - large lips longitudinal fold, extends symphisis pubis to perineum
c. Labia Minora 2 sensitive structures
clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of sexual arousal (Greek-key)
fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery.
Site episiotomy.
d. Vestibule an almond shaped area that contains the hymen, vaginal orifice and bartholenes glands.
1.
2.
3.
4.
5.
2. Internal
The Process of Spermatogenesis maturation of sperm
Hypothalamus
GnRH
Vas Deferens conduit for
spermatozoa or pathway of sperm
Ant Pit
Gland
FSH
Fx:
Sperm
Maturation
LF
Fx: Hormones
for
Testosterone
Production
Female
Clitoral glans
Clitorial shaft
ovaries
Skenes gands
Bartholin's glands
Labia Majora
IV.
V.
PhaseIncreased progesterone
IX. 24th day if no fertilization, corpus luteum degenerate ( whitish corpus albicans)
X.
28th day if no sperm in ovum endometrium begins to slough off to begin mens
Excitement Phase (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) erotic stimuli
cause increase sexual tension, lasts minutes to hours.
2.
3.
Plateau Phase (accelerated V/S) increasing & sustained tension nearing orgasm. Lasts 30 seconds 3 minutes.
Orgasm (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic or
psychologic release, immeasurable peak of sexual experience. May last 2 10 sec- most affected are is pelvic area.
A. Fertilization
B. Stages of Fetal Growth and Development
3-4 days travel of zygote mitotic cell division begins
*Pre-embryonic Stage
a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months
b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication
c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of blastocys that later
becomes placenta & trophoblast
d. Implantation/ Nidation- occurs after fertilization 7 10 days.
Fetus- 2 months to birth.
placenta previa implantation at low side of uterus
Signs of implantation:
1. slight pain
2. slight vaginal spotting
- if with fertilization corpus luteum continues to function & become source of estrogen & progesterone while
placenta is not developed.
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
C. Dicidua thickened endometrium ( Latin falling off)
* Basalis (base) part of endometrium located under fetus where placenta is delivered
* Capsularies encapsulate the fetus
* Vera remaining portion of endometrium.
C. Chorionic Villi- 10 11th day, finger life projections
3 vessels=
A unoxygenated blood
V O2 blood
A unoxygenated blood
Whartons jelly protects cord
Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing placenta for genetic
screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes.
E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span of langhans layer
increase. Before 24 weeks critical, might get infected syphilis
F. Synsitiotrophoblast synsitial layer responsible production of hormone
1. Amnion inner most layer
a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21. Short cord: abruptio placenta or inverted uterus.
Long cord:cord coil or cord prolapse
b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline.
*Function of Amniotic Fluid:
1. cushions fetus against sudden blows or trauma
2. facilitates musculo-skeletal development
3. maintains temp
4. prevent cord compression
5. help in delivery process
normal amt of amniotic fluid 500 to 1000cc
polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid
oligohydramnios- decrease amt of fluid kidney disease
Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g or kg
-1 inch thick & 8 diameter
Functions of Placenta:
1.
Respiratory System beginning of lung function after birth of baby. Simple diffusion
2.
GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic,
fetus hypoglycemic
3.
Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.
4.
5.
6.
Fourth Month
lanugo begins to appear
fetal heart tone heard fetoscope, 18 20 weeks
buds of permanent teeth appear
1.
2.
3.
4.
5.
Fifth Month
lanugo covers body
actively swallows amniotic fluid
19 25 cm fetus,
Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks multi
fetal heart tone heard with or without instrument
1.
2.
3.
Sixth Month
eyelids open
wrinkled skin
vernix caseosa present
Eighth Month
lanugo begin to disappear
sub Q fats deposit
Nails extend to fingers
1.
2.
Ninth Month
lanugo & vernix caseosa completely disappear
Amniotic fluid decreases
Tenth Month bone ossification of fetal skull
Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs:
Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing & deafness
Tetracycline staining tooth enamel, inhibit growth of long bone
Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides enlargement of thyroid or goiter
Thalidomides Amelia or pocomelia, absence of extremities
B.
C.
D.
E.
A. Systemic Changes
1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood
- easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to
hyperemia of nasal membrane palpitation,
Physiologic Anemia pseudo anemia of pregnant women
Normal Values
Hct
32 42%
Hgb
10.5 14g/dL
Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL
2nd trimester Hct should not <32%
Hgb Shdn't < 10.5% pathologic anemia if lower
Pathogenic Anemia
- iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.
- Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia
Nursing Care:
Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay,
horseradish, ampalaya
Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool,
constipation
Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vit C such as orange juice
Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of
RBCs
Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level.
Varicosities pressure of uterus
- use support stockings, avoid wearing knee high socks
- use elastic bandage lower to upper
Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest
position
Thrombophlebitis presence of thrombus at inflamed blood vessel
- pregnant mom hyperfibrinogenemia
- increase fibrinogen
- increase clotting factor
- thrombus formation candidate
outstanding sign (+) Homan's sign pain on cuff during dorsiflexion
milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens
Mgt:
1.)
2.)
3.)
4.)
5.)
6.)
Bed rest
Never massage
Assess + Homan sign once only might dislodge thrombus
Give anticoagulant to prevent additional clotting (thrombolytics will dilute)
Monitor APTT antidote for Heparin toxicity, protamine sulfate
Avoid aspirin! Might aggravate bleeding.
2. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand
Position- lateral expansion of lungs or side lying position.
3.
Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising
bed. Nausea afternoon - small freq feeding. Vomiting in preg emesisgravida.
Metabolic alkalosis, F&E imbalance primary med mgt replace fluids.
Monitor I&O
constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet
- fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
Except guava has pectin thats constipating veg petchy, malungay.
- exercise
-mineral oil excretion of fat soluble vitamins
* Flatulence avoid gas forming food cabbage
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Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos mgt for nocturia
Acetyace test albumin in urine
Benedicts test sugar in urine
5.
Musculoskeletal
2. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue avoid scratching,
use coconut oil, umbilicus is protruding
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3.
Skin Changes brown pigmentation nose chin, cheeks chloasma melasma due to increased melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus
7.
A.
B.
C.
Positive
Ultrasound evidence
(sonogram) full bladder
Fetal heart tone
Fetal movement
Fetal outline
Fetal parts palpable
VII.
Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory)
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial sign of maladaptation to pregnancy. Developmental task is to
accept biological facts of pregnancy
Focus: bodily changes of preg, nutrition
Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of quickening, fantasy. Developmental
task accept growing fetus as baby to be nurtured.
Health teaching: growth & development of fetus.
Third Trimester: - mom has personal identification on appearance of baby
Development task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette best time to do
shopping.
Most common fear let mom listen to FHT to allay fear
Lamaze classes
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4.
Diagnosis of Pregnancy
1.) urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get urine exam.
2.) Elisa test test for preg detects beta subunit of HCG as early as 7 10days
3.) Home preg kit do it yourself
Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st sign preeclampsia)
Weight Monitoring
First Trimester: Normal Weight gain
Second trimester: normal weight gain
Third trimester: normal weight gain
Minimum wt gain 20 25 lbs
Optimal wt gain 25 35 lbs
1.5 3 lbs
10 12 lbs
10 12 lbs
(.5 1lb/month)
(4 lbs/month) (1 lb/wk)
(4 lbs/ month) ( 1lb/wk)
5. Obstetrical Data:
nullipara no pregnancy
a. Gravida- # of pregnancy
b. Para - # of viable pregnancy
Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age.
age of viability - 20 24 wks
Term 37 42 wks,
Preterm -20 37 weeks
abortion <20 weeks
Sample Cases:
1 abortion
GTPAL
1 2nd mo
2 0 01 0
G2
P0
1 40th AOG
1 36th AOG
2 misc
1 twins
1 4th month
GT P A L
612 2 4
35 AOG
G6 P3
1 39th week
1 miscarriage
1 stillbirth 33 AOG (considered as para)
1 preg 3rd wk
1 33 P
1 41st L
1 abort A
1 still 39
1 triplet 32
1 4th mon
c. Important Estimates:
GP GTPAL
4 2 4 11 1 1
GP GTPAL
6 4 6 2 2 15
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M D Y
+9 +7 no year
2nd of preg
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6.
Empty bladder
Position of mom-supine with knee flex (dorsal recumbent to relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate
upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the
stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic souffl (FHR) & uterine souffl.
Uterine souffl maternal H rate
3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable).
4th Maneuver: the Examiner changes the position by facing the patients feet. With two hands, assess the descent of the presenting
part by locating the cephalic prominence or brow. To determine attitude relationship of fetus to 1 another.
When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head
will be flexed and vertex presenting.
Attitude relationship of fetus to a part or degree of flexion
Full flexion when the chin touches the chest
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8.Assessment of Fetal Well-BeingA. Daily Fetal Movement Counting (DFMC) begin 27 weeks
Mom- begin after meal - breakfast
a. Cardiff count to 10 method one method currently available
(1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes
to count 10 fetal movements (FMs)
(2) Expected findings 10 movements in 1 hour or less
3) Warning signs
a.) more then 1 hour to reach 10 movements
b.) less then 10 movements in 12 hours(non-reactive- fetal distress)
c.) longer time to reach 10 FMs than on previous days
d.) movement are becoming weaker, less vigorous
Movement alarm signals - < 3 FMs in 12 hours
4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST),
biographical profile (BPP)
B. Nonstress test to determine the response of the fetal heart rate to activity
Indication pregnancies at risk for placental insufficiency
Postmaturity
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition
Procedure:
Done within 30 minutes wherein the mother is in semi-fowlers position (w/ fetal monitor); external monitor is applied to document
fetal activity; mother activates the mark button on the electronic monitor when she feels fetal movement.
Attach external noninvasive fetal monitors
1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen
if no FM after 1 hour further testing may be indicated, such as a CST
Result:
Noncreative
Nonstress
Not Good
Reactive
Responsive is
Real Good
i.
Interpretation of results
reactive result
1. Baseline FHR between 120 and 160 beats per minute
2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute
period as a result of FM
3. Good variability normal irregularity of cardiac rhythm representing a balanced interaction between the
parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the
rhythm strip.
4. result indicates a healthy fetus with an intact nervous system
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Protein
Essential for:
- Fetal tissue growth
- Maternal tissue growth including
uterus and breasts
- Development of essential pregnancy
structures
- Formation of red blood cells and
plasma proteins
* Inadequate protein intake has been
associated with onset of pregnancy induces
hypertension (PIH)
Calcium-Phosphorous
Essential for
- Growth and development of fetal
skeleton and tooth buds
- Maintenance of mineralization of
maternal bones and teeth
- Current research is :
Demonstrating an association between
adequate calcium intake and the prevention
of pregnancy induce hypertension
Calcium increases of
- 1200 mg/day representing an
increase of 50% above
prepregnancy daily requirement.
- 1600 mg/day is recommended for
the adolescent. 10 mcg/day of
vitamin D is required since it
enhances absorption of both
calcium and phosphorous
Iron
Essential for
- Expansion of blood volume and red
blood cells formation
- Establishment of fetal iron stores for
first few months of life
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deficiency anemia.
70 mg/day of vitamin C which
enhances iron absorption
- inadequate iron intake results in
maternal effects anemia
depletion of iron stores, decreased
energy and appetite, cardiac stress
especially labor and birth
- fetal effects decreased availability
of oxygen thereby affecting fetal
growth
* iron deficiency anemia is the most
common nutritional disorder of
pregnancy.
15mcg/day representing an increase of
3 mg/day over prepreganant daily
requirements.
Zinc
Essential for
* the formation of enzymes
* maybe important in the prevention of
congenital malformation of the fetus.
Folic Acid, Folacin, Folate
Essential for
- formation of red blood cells and
prevention of anemia
- DNA synthesis and cell
formation; may play a role in the
prevention of neutral tube defects
(spina bifida), abortion,
abruption placenta
Additional Requirements
Minerals
- iodine
- Magnesium
- Selenium
Vitamins
E
Thiamine
Riborlavin
Pyridoxine ( B6)
B12
Niacin
175 mcg/day
320 mg/day
65 mcg/day
10 mg/day
1.5 mg/day
1.6 mg/day
2.2 mg/day
2.2 mg day
17 mg/day
2.Sexual Activity
a.) should be done in moderation
b.) should be done in private place
c.) mom placed in comfy pos, sidelying or mom on top
d.) avoided 6 weeks prior to EDD
e.) avoid blowing or air during cunnilingus
f.) changes in sexual desire of mom during preg- air embolism
Changes in sexual desire:
a.) 1st tri decrease desire due to bodily changes
b.) 2nd trimester increased desire due to increase estrogen that enhances lubrication
c.) 3rd trimester decreased desire
Contraindication in sex:
1. vaginal spotting
1st trimester threatened abortion
2nd trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
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3.
-
19
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1 sacrum post portion sacral prominence landmark to get internal measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery
Important Measurements
1. 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.
3. Power the force acting to expel the fetus and placenta myometrium powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Pre-eminent Signs of Labor
S&Sx:
- shooting pain radiating to the legs
- urinary freq.
1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine
4. Ripening of the Cervix butter soft
5. decreased body wt 1.5 3 lbs
6. Bloody Show pinkish vaginal discharge blood & leukorrhea
7. Rupture of Membranes rupture of water. Check FHT
Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP most common malposition
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.
Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
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Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression
causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
Positioning trendelenberg or knee chest position
Emotional support
Prepare for Cesarean Section
Difference Between True Labor and False Labor
False Labor
True Labor
Irregular contractions
Contractions are regular
No increase in intensity
Increased intensity
Pain confined to abdomen Pain begins lower back radiates to abdomen
Pain relived by walking
Pain intensified by walking
No cervical changes
Cervical effacement & dilatation * major sx
of true labor.
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.
Nursing Interventions in Each Stage of Labor
2 segments of the uterus
1. upper uterine - fundus
2. lower uterine isthmus
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment:
Dilations: 0 3 cm mom excited, apprehensive, can communicate
Frequency: every 5 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 3 hrs full bladder inhibit contractions
3. Breathing chest breathing
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
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
Transitional Phase:
Assessment: Dilations 8 10 cm
Frequency q 2-3 min contractions
Durations 45 90 seconds
intensity: strong
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Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP
Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus to monitor contractions
Parts of contractions:
Increment or crescendo beginning of contractions until it increases
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2. Cavity
Two Major Divisions of Pelvis
1. True pelvis below the pelvic inlet
2. False pelvis above the pelvic inlet; supports uterus during pregnancy
Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack
Bolus of Ptocin can lead to hypotension.
3.
Perineum
R - edness
E- dema
E - cchemosis
D ischarges
A approximation of blood loss. Count pad & saturation
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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
- MD administer sedative valium,/diazepam muscle relaxant
2.) hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.
Prolonged labor normal length of labor in primi 14 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
- maternal effect exhaustion. Fetal effect fetal distress, caput succedaneum or cephal hematoma
- nsg care: monitor contractions and FHR
Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom modified trendelenberg
IV fast drip due fluid volume def
Signs of Hypovolemic Shock:
Hypotension
Tachycardia
Tachypnea
Cold clammy skin
Inversion of the uterus situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.
Factors leading to inversion of uterus
1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure
Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
d.) TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDLS pathologic ring suprapubic depression
a.) sign of impending uterine rupture
Amniotic Fluid Embolism or placental embolism amniotic fluid or fragments of placenta enters natural circulation resulting to
embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body eyes, nose, etc.
Trial Labor measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
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27
Letting go interdependent phase 7 days & above. Mom - redefines new roles may extend until child grows.
I.
Mgt:
1.)
2.)
3.)
4.)
Breast feeding post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy
DIC Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.
- bleeding to any part of body
- hysterectomy if with abruption placenta
mgt: BT- cryoprecipitate or fresh frozen plasma
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II.
Late Postpartum hemorrhage bleeding after 24 hrs retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta,
Acreta attached placenta to myometrium.
Increta deeper attachment of placenta to myometrium
Percreta invasion of placenta to perimetrium
hysterectomy
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4.
calendar method
OVULATION count minus 14 days before next mens (14 days before next mens)
Origoknause formula
- monitor cycle for 1 year
- -get short test & longest cycle from Jan Dec
- shortest 18
- longest 11
June 26
- 18
8
-
Dec 33
-11
22 unsafe days
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.
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proper hygiene
check for holes before use
must stay in place 6 8 hrs after sex
must be refitted especially if without wt change 15 lbs
spermicide chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
Hemorrhagic Disorders
General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)
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Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed
Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete all products of conception are expelled. No mgt just emotional support!
2.) Incomplete Placental and membranes retained. Mgt: D&C
Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan permanent surgery cervix. CS
c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester
d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty
dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.)
Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser evil.
C. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or ampular
Dangerous site - interstitial
Unruptured
Tubal rupture
- missed period
- sudden , sharp, severe pain. Unilateral radiating to
- abdominal pain within 3 -5 weeks of missed period
shoulder.
(maybe generalized or one sided)
shoulder pain (indicative of intraperitoneal bleeding that extends
- scant, dark brown, vaginal bleeding
to diaphragm and phrenic nerve)
+ Cullens Sign bluish tinged umbilicus signifies intra
Nursing care:
peritoneal bleeding
Vital signs
syncope (fainting)
Administer IV fluids
Mgt:
Monitor for vaginal bleeding
Surgery depending on side
Monitor I & O
Ovary: oophrectomy
Uterus : hysterectomy
Second trimester bleeding
C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization. Progressive degeneration of
chorionic villi. Recurs.
- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form 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.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs
vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
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D. Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the
cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:
E. Abruptio Placenta it is the premature separation of the placenta form the implantation site. It usually occurs after the
twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
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G.
H.
I.
J.
K.
L.
Strict I&O
Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental
fragments if vessel is cut.
Placenta Circumvalata fetal side of placenta covered by chorion
Placenta Marginata fold side of chorion reaches just to the edge of placenta
Battledore Placenta cord inserted marginally rather then centrally
Placenta Bipartita placenta divides into 2 lobes
Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
Vasa Previa velamentous insertion of cord has implanted in cervical OS
2.
Hypertensive Disorders
F.
I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.
1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome hemolysis with elevated liver enzymes & low platelet count
II. Transissional Hypertension HPN between 20 24 weeks
III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending
convulsion. BP 160/110 , protenuria +3 - +4
3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety.
Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling planning procedure
3.) avoid jarring bed
P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E ensure high protein intake ( 1g/kg/day)
- Na in moderation
A anti-hypertensive drug Hydralazine ( Apresoline)
C convulsion, prevent Mg So4 CNS depressant
E valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent 1st sigh Mg SO4 toxicity. antidote Ca gluconate
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