FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY I. The External Reproductive Organs A.
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Mons Pubis or Veneris \u2013 pad of fat which lies over the symphysis pubis covered by skin and at puberty, by short hairs; protects the surrounding delicate tissues from trauma. Labia Majora \u2013 two folds of skin with fat underneath; conta Bartholin\u2019s glands (believed to secrete a yellowish mucus which acts as a lubricant during sexual intercourse. The openings of the Bartholin\u2019s glands are located posteriorly on either side of the vagina orifice. Labia Minora \u2013 two thin folds of delicate tissues; form an upper fol encircling the clitoris (called the prepuce) and unite posteriorly (called the fourchetes, which is highly sensitive to manipulation and trauma that is why it is often torn during a woman\u2019s delivery.) Clitoris \u2013 small, erectile structure at the anterior junction of the lab minora, which is comparable to the penis in its being extremely sensitive. Landmark for catheterization Vestibule \u2013 narrow space seen when the labia minora are separated. Urethral Meatus \u2013 external opening of the urethra; slightly behind a to the side are the openings of the Skene\u2019s glands (which are often involved in infections of the external genitalia). Vaginal orifice/Introitus \u2013 external opening of the vagina, covered by a thin membrane (called hymen) in virgins. Myrtiform caruncle Perineum \u2013 area from the lower border of the vaginal orifice to anus; contains the muscles (e.g., pubococcygeal and levator ani) which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia.
II. The Internal Reproductive Organs A.
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Vagina \u2013 a 3-4 inch long dilatable canal located between the bladde and the rectum; contains rugae (which permit considerable stretching without tearing); passageway for menstrual discharges, copulation and fetus. CBQ Uterus \u2013 hollow pear-shaped fibromuscular organ 3 inches long, 2 inches wide, 1 inch thick, and weighing 50-60 grams in a non-pregnant woman; hold in place by broad ligaments (from sides of the uterus to pelvic wall; also hold Fallopian tubes and ovaries in place) and round ligaments (from sides of uterus to mons pubis); abundant blood supply from uterine and ovarian arteries; composed of three muscle layers (perimetrium, myometrium, and endometrium). Consists of three parts: corpus (body) \u2013 upper portion with triangular part called fundus; isthmus \u2013 area between corpus and cervix which forms part of the lower uterine segment; and, - cylindrical portion.Organ of
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menstruation, site of implantation and retainment and nourishment of the products of conception. Main support comes from cardinal ligaments Fallopian Tubes \u2013 4 inches long from each side of the fundus; wide part (called ampulla) spreads into fingerlike projections (called fimbriae). Responsible for transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half. Ovaries \u2013 almond-shaped, dull white sex glands near the fimbriae kept in place by ligaments. Produce, mature and expel ova and manufacture estrogen and progesterone.
III. The Pelvis - although not a part of the Female Reproductive Organs but of the skeletal system, is a very important body part of pregnant women. A. Structure 1. 2 Os Coxae/Innominate bones \u2013 made up of: a. Ilium \u2013 upper, extended part; curved upper border is the iliac crest. b. Ischium \u2013 under part; when sitting, the body rests on the ischial tuberosities; ischial spines are important landmarks. c. Pubes \u2013 front part; join to form an articulation of th pelvis called the symphysis pubis. 2. Sacrum \u2013 wedge-shaped, form the back part of the pelvis. Consists of 5 fused vertebrae, the first having a prominent under margin called the sacral promontory. Articulates with the ilium, the sacroiliac joint. 3. Coccyx \u2013 lowest part of the spine; degree of movement between sacrum and coccyx, made possible by the third articulation of the pelvis called sacrococcygeal joint which allows room for delivery of the fetal head. B.
Divisions \u2013 set apart by the linea terminalis, (pelvic brim, ileopectinea line) and imaginary line from the sacral promontory to the ilia on both side to the superior portion of the symphysis pubic. 1. False pelvis \u2013 superior half formed byOffers the ilia. landmarks for pelvic measurements; supports the growing uterus during pregnancy; and directs the fetus into the true pelvis near the end of gestation. 2. True pelvis \u2013 inferior half formed by the pubis in front, the and the ischia on the sides and the sacrum and coccyx behind. Made up of three parts: a. Inlet \u2013 entranceway to the true pelvis. Its transverse diameter is wider than its anteroposterior diameter. Thus: Transverse diameter = 13.5 cm
Anteroposterior diameter = 11 cm Right and left oblique diameters = 12.75 cm b. Cavity \u2013 space between the inlet and outlet c. Outlet \u2013 inferior portion of the pelvis bounded in the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch. Its anteroposterior (AP) diameter is wider than its transverse diameter.
C. Types/Variations 1. Gynecoid \u2013 \u201cnormal female pelvis. Inlet is well rounded and back. Most ideal for childbirth. 2. Anthropoid \u2013 transverse diameter is narrow, AP diameter is larger than normal. 3. Platypelloid \u2013 inlet is oval, AP diameter is shallow 4. Android \u2013 \u201cmale\u201d pelvis. Inlet has a narrow, shallow portion and pointed anterior portion. D. Measurements 1. External \u2013 suggestive only of pelvic site. a. Intercristal \u2013 distance between the middle points of the iliac crests. Average = 28 cm. b. Interspinous \u2013 distance between the anterosuperior iliac spines. Average = 25 cm. c. Intertrochanteric \u2013 distance between the trochanters of the femur. Average = 31 cm. d. External conjugate/Daudelocque\u2019s \u2013 the distance between the anterior aspect of the symphysis pubis and depression below L5. Average = 18-20 cm. 2. Internal \u2013 give the actual diameters of the inlet and outlet a. Diagonal conjugate \u2013 distance between sacral promontory and inferior margin of the symphysis pubis. Average = 12.5 cm. b. True conjugate/conjugata vera \u2013 distance between the anterior surface of the sacral promontory and the superior margin of the symphysis pubis. Very important measurement because it is the diameter of the pelvic inlet. Average = 10.5 11 cm. c. Bi-ischial diameter/tuberischial \u2013 transverse diameter of the pelvic outlet. Is measured at the level of the anus. Average = 11 cm IV. Feedback Mechanism of Menstruation A. General Considerations
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300,000 – 400,000 immature oocytes per ovary are present at birth (ware formed during the first 5 months of intrauterine life); many, however, degenerate and atrophy (process called atresia). About 300 – 400 mature during the entire reproductive cycle of women. Ushered in by the menarche, (first menstruation in girls) and ends with menopause (permanent cessation of menstruation; no more functioning oocytes in the ovaries). Age of onset and termination vary widely, depending on heredity, racial background, nutrition and climate. Normal period (days when there is menstrual flow) lasts for 3-6 days; menstrual cycle (from first day of menstrual period to first day of next menstrual period) maybe anywhere from 25-35 days, but accepted average length in 28 days. Anovulatory states after menarche not unusual because of immaturity of feedback mechanism (anovulatory states occur also in pregnancy, lactation and related disease conditions). Associated terms: a. Amenorrhea – temporary cessation of menstrual flow b. Oligomenorrhea – markedly diminished menstrual flow, nearing amenorrhea c. Menorrhagia – excessive bleeding during regular menstruation d. Metrorrhagia – bleeding at completely irregular intervals e. Polymenorrhea – frequent menstruation occurring at intervals of less than three weeks Body structures involved: a. Hypothalamus b. Anterior pituitary gland c. Ovary d. Uterus Hormones which regulate cyclic activities: a. Follicle-stimulation hormone (FSH) b. Luteinizing hormone (LH) Effects of estrogen in the body: a. Inhibits production of FSH b. Causes hypertrophy of the endometrium c. Stimulates growth of the ductile structures of the breasts d. Increases quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of 10-13 cm. (Spinnbarkeit test of ovulation) Effects of progesterone in the body: a. Inhibits production of LH b. Increases endometrial tortuosity c. Increases endometrial secretions d. Inhibits uterine motility
e. Decreases muscle tone of gastrointestinal and urinary tracts f. Increases musculoskeletal motility g. Facilitates transport of the fertilized ovum through the Fallopian tubes h. Decreases renal threshold for lactose and dextrose i. Increases fibrinogen levels; decreases hemoglobin and hematocrit j. Increases body temperature after ovulation. Just before ovulation, basal body temperature decreases slightly (because of low progesterone level in the blood) and then increases slightly a day after ovulation (because of the presence of progesterone). B. Sequential Steps in the Menstrual Cycle 1. On the third day of the menstrual cycle, serum estrogen level is at its lowest. This low estrogen level serves as the stimulus for the hypothalamus to produce the Follicle-Stimulating Hormone Releasing Factor (FSHRF). 2. FSHRF is responsible for stimulating the Anterior Pituitary Gland (APG) to produce the first of 2 hormones which regulate cyclic activities, the Follicle-Stimulating Hormone (FSH). 3. FSH, in turn, will stimulate the growth of an immature oocyte inside a primordial follicle by stimulating production of estrogen by the ovary. Once estrogen is produced, the primordial follicle is not termed Graafian follicle (The Graafian follicle, therefore, is the structure which contains high amounts of estrogen). 4. Estrogen in the Graafian follicle will cause the cells in the uterine endothelium to proliferate (grew very rapidly), thereby increasing its thickness to about eightfold. This particular phase in the uterine cycle, therefore, is called proliferative phase. In view of the change from primordial to Graafian follicle, it is also called the follicular phase. Because of the predominance of estrogen, it is also called the estrogenic phase. And since it comes right after the menstrual period, it is also called postmenstrual phase. And, it is also called the pre-ovulatory phase. th 5. On the 13 day of the menstrual cycle, there is now a very low level of progesterone in the blood. This low serum progesterone level is then the stimulus for the Hypothalamus to produce the Luteinizing Hormone Releasing Factor (LHRF). 6. LHRF is responsible for stimulating the APG to produce the second hormone which regulates cyclic activity, the Luteinizing Hormone (LH). 7. LH, in turn, is responsible for stimulating the ovary to produce the second hormone produced by the ovaries, progesterone.
The increased amounts of both estrogen and progesterone pushes the now mature ovum to the surface of the ovary until, on the following day (the 14th day of the menstrual cycle), the Graafian follicle ruptures and releases the mature ovum, a process called ovulation. 9. Once ovulation is taken place, the Graafian follicle, because it now contains increasing amounts of progesterone is the Corpus Luteum. 10. Progesterone causes the glands of the uterine endothelium to become corkscrew or twisted in appearance because of the increasing amount of capillaries. Progesterone, therefore, is said to be the hormone designed to promote pregnancy because it makes the uterus nutritionally abundant with blood in order for the fertilize zygote to survive should conception take place. That is why this phase in the uterine cycle is what we call progestational phase. This phase in the uterine cycle is also called the secretory phase because it secretes the most important hormone in pregnancy. In view of the change from Graafian follicle, to Corpus Luteum, it is also called the luteal phase. Because it occurs just after ovulation, it is also called the post-ovulatory phase. And, it is also called the premenstrual phase. th 11. Up until the 24 day of the menstrual cycle, if the mature ovum is not fertilized by a sperm, the amounts of hormones in the Corpus Luteum will start to decrease. The Corpus Luteum, turning white, is now called the corpus albicans and after 3-4 days, the thickened lining of the uterus produced by estrogen starts to degenerate and slough off and the capillaries rupture. And thus begins another menstrual period. 8.
C. Additional Information 1. When the ovary releases the mature ovum on the day of ovulation, sometimes a certain degree of pain in either the right or left lower quadrant is felt by the woman. This sensation is normal and is termed mittelschmerz. 2. The first 14 days of the menstrual cycle is a very variable period. The last 14 days of the menstrual cycle is a fixed period exactly 2 weeks after ovulation, menstruation will occur (unless a pregnancy has taken place) because the corpus luteum has a life span of only 2 weeks. Implication: when given options regarding the exact date of ovulation, choose two weeks before menstruation. th 3. In a 28-day cycle, ovulation takes place on the 14 day. In a 32th day cycle, ovulation takes place on the 18 day. In a 26-day cycle, ovulation takes place or the 12 th day (Subtract 14 days from the cycle).
4. Menstruation can occur even without ovulation (as in women taking oral contraceptives). Ovulation can likewise occur even without menstruation (as in lactating mothers). PREGNANCY AND PRENATAL CARE I. Obstetric Terms in Statistical Data A. Birth rate – the number of births per 1,000 population B. Fetal death rate – the number of total deaths per 1,000 births. (both live births and stillbirths) C. Perinatal mortality rate – the number of deaths occurring between 28 weeks gestation until 6 days after birth D. Neonatal mortality rate – the number of neonatal (first 28 days of life) deaths per 1,000 live births E. Infant mortality rate – the number of infant (first 12 months of life) deaths per 1,000 live births F. Maternal mortality rate – the number of deaths that occur as the direct result of the reproductive process per 10,000 live births II. Fertilization A. Definition: the union of the sperm and the mature ovum in the outer third or outer half of the Fallopian tube.
B. General considerations: 1. Normal amount of semen per ejaculation = 3 – 5 cc = 1 teaspoon 2. Number of sperms in an ejaculate = 120 – 150 million/cc 3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are capable of fertilizing even for 3-4 days after ejaculation 4. Normal life span of sperms = 7 days 5. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after deposition. 6. Reproductive cells, during gametogenosis, divide by meiosis (haploid number of daughter cells); therefore, they contain only 23 chromosomes (the rest of the body cells have 46 chromosomes). Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome; ova contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum results in a baby boy (XY). Important: Only fathers determine the sex of their children. III. Implantation
Immediately after fertilization, the fertilized ovum or zygote stays in the Fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place. The developing cells are now called blastomere and when there are already 16 blastomeres, it is now terms a morula. In this morula form, it will start to travel (by ciliary action and peristaltic contractions of the Fallopian tube) to the
uterus where it will stay for another 3-4 days. When there is already a cavity formed in the morula, it is now called blastocyst. Fingerlike projections, called trophoblasts, form around the blastocyst and these trophoblast are the once which will implant high on trophoblasts or posterior surface of the uterus. Thus, implantation, also called nidation, takes place about a week after fertilization. General Consideration: A. Once implantation has taken place, the uterine endothelium is now termed decidua B. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting throphoblasts = implantation bleeding. Implication: this should not be mistaken for the Last Menstrual Period (LMP). Table 1. Outline of Trophoblast Differentiation Cytotrophoblast – the inner layer II. Syncytiotrophoblast – the outer layer containing fingerlike projections called chorionic villi: A. Langhan’s layer – believed to protect the fetus against Treponema Pallidum (etiologic agent of syphilis). Present only during the second trimester of pregnancy. B. Syncytial layer – gives rise to the fetal membranes: 1. Amnion – inner layer which gives rise to: a. Umbilical cord/funis – contains 2 arteries and one vein, which are supported by the Wharton’s jelly b. Amniotic fluid – clear, albuminous fluid in which the baby floats. Begins to form at 11-15 weeks gestation. Approximates water in specific gravity (1.007-1.025) and is neutral to slightly alkaline (pH=7.0-7.25. Note: the higher the pH, the more alkaline; the lower the pH, the more acidic). Near term, is clear, colorless, containing little white specks of vernix caseosa and other solid particles. Produced at a rate of 500 ml in 24 hours and fetus swallows it at an equally rapid rate. By the 4 th lunar month, urine is added to the amount of amniotic fluid. It is, therefore, derived chiefly from maternal serum and fetal urine. (Implication: a case of polyh ydramni os = more than 1500 ml of aminiotic fluid, stems from inability of the fetus to swallow amniotic rapidly, as in Tracheoesophageal fistuli; while oligo-hydramnios = amniotic fluid less than 500 ml, results when kidneys are not functioning normally, as in congenital renal anomaly.) Also know as bag of waters (BOW), it serves the following purposes: • Protection: I.
* Shields the fetus against blows or pressure on the mother’s abdomen * Protects the fetus against sudden change sin temperature because liquid changes temperature more slowly than air * Protects the fetus against certain infections • Diagnosis: * As in amniocentesis * Meconium-stained amniotic fluid means fetal distress • Aids in descent of the fetus during active labor 2. Chorion – together with the deciduas basalis gives rise to the placenta, which starts to form on the 8th week of gestation. Develops into 15-20 subdivision called cot yledons. Placenta serves the following purposes: a. Respiratory system – exchange of gases takes place in the placenta, not in the fetal lungs b. Renal system – waste products are being excreted through the placenta (Note: it is the mother’s liver which detoxifies the fetal waste products). c. Gastrointestinal system – nutrients pass to the fetus via the placenta by diffusion through the placental tissues. d. Circulatory system – feto-placental circulation is established by selective osmosis e. Endocrine system – it produces the following hormones (before 8 weeks gestation, the corpus luteum is the one producing these hormones): Human chronionic gonadotropin (HCG) – “order’s the corpus luteum to keep on producing estrogen and progesterone that is why menstruation does not ta ke place during pregnancy. It is also the basis for pregnancy test. placental lactogen (HPL)/human chronionic Human somatomammotropin – promotes growth of the mammary glands necessary for lactation. Also has growth-stimulating properties Estrogen Progesterone f. Protective barrier – inhibit passage of some bacteria and large molecules. 3. Stage of human prenatal development: a. First 12-14 days = zygote b. From 15th day up to the 8th week = embryo c. From 8th week up to the time of birth = fetus
IV. Fetal Development A. First Lunar Month 1. Germ layers differentiate by the 2nd week (In cases of multiple congenital anomalies, the structures that will be affected are those that arise out of the same germ layer.) a. Entoderm – develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus glands (for development of immunity), bladder and urethra b. Mesoderm – forms into the supporting structures of the body (connective tissues, bones, cartilage, muscles and tendons), heart, circulatory system, blood cells, reproductive system, kidneys and ureters c. Ectoderm – responsible for the formation of the nervous system, the skin, hair and nails, the sense organs and mucous membrane of the anus and mouth. 2. Fetal membranes (amnion and chorion) appear by the second week 3. Nervous system very rapidly develops by the 3rd week (Dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in the latter) 4. Fetal heart begins to form as early as the 16 th day of life (To the question, “When does the fetal heart begin to beat?”, the answer is the first lunar month. But to the question “When can fetal heart tones be first heard?”, the answer is fifth month.) 5. The digestive and respiratory tracts exist as a single tube until the 3rd week of life when they start to separate. B. Second Lunar Month 1. All vital organs are formed by the end of the 8th week. 2. Placenta develops fully. 3. Sex organs (ovaries and testes) are formed by the 8 th week. (To the question, “When is sex determined?”, the answer is at the time of conception.) 4. Meconium (first stools) are formed in the intestines by the 5 th-8th week. C. Third Lunar Month 1. Kidneys are able to function – urine formed by the 12th week 2. Buds of milk teeth form 3. Beginning bone ossification 4. Fetus swallows amniotic fluid 5. Feto-placental circulation is established by selective osmosis; no direct exchange between fetal and maternal blood D. Fourth Lunar Month 1. Lanugo appears 2. Buds of permanent teeth form
3. Hearth beats audible with fetoscope E. Fifth Lunar Month 1. Vernix caseosa appears 2. Lanugo covers entire body 3. Quickening (fetal movements) felt 4. Fetal heart beats very audible F. Sixth Lunar Month 1. Skin markedly wrinkled 2. Attains proportions of full term baby G. Seventh Lunar Month 1. Alveoli begin to form (28th weeks gestation is said to be the lower limit of prematurity; if born, cries, breathes, but usually dies) H. Eighth Lunar Month 1. Fetus is viable 2. Lanugo begins to disappear 3. Nails extend to ends of fingers 4. Subcutaneous fat deposition begins I. Night Lunar Month 1. Lanugo and vernix disappear 2. Amniotic fluid volume somewhat decreases J. Tenth Lunar Month – all characteristics of the normal newborn V. Focus of Fetal Development
A. First trimester - organogenesis B. Second trimester – period of continued fetal growth and development; rapid increase in fetal length C. Third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fat VI. Normal Adaptation in Pregnancy A. Systemic Changes 1. Circulatory/Cardiovascular a. Beginning the end of the first trimester, there is gradual increase of about 30%-50% in total cardiac volume, reaching its peak during the 6th month. This causes a drop in hemoglobin and hematocrit values since the increase is only in the plasma volume=physiologic anemia of pregnancy. Consequences of increased total cardiac volume are: Easy fatigability and shortness of breath because of increased workload of the heart Slight hypertrophy of the heart, causing it to be displaced to the left, resulting in torsion on the great vessels (the aorta and pulmonary artery) Systolic murmurs are common due to lowered blood viscosity
Nosebleeds may occur because of marked congestion of the nasopharynx as pregnancy progresses b. Palpitations due to: Sympathetic nervous system stimulation during first half of pregnancy Increased pressure of uterus against the diaphragm during 2 nd half of pregnancy c. Because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities: Edema of the lower extremities occurs. Management: raise legs above hip level Important: Edema of the lower extremities is NOT a sign of toxemia. Varicosities of the lower extremities can also occur. Management: • Use/wear support hose or elastic stocking to promote venous flow, thus preventive stasis in the lower extremities • Apply elastic bandage – start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap toes so as to be able to determine the adequacy of circulation (Principle behind bandaging: blood flow thru tissues is decreased by applying excessive pressure on blood vessels) • Avoid use of constricting garters, e.g., knee-high socks d. Because of poor circulation in the blood vessels of the genitalia due to pressure of the gravid uterus, varicosities of the vulva and rectum can occur. Management: Side-lying position with hips elevated on pillows Advise modified knee-chest position e. There is increased level of circulating fibrinogen, that is why pregnant women are normally safeguarded against undue bleeding. However, this also predisposes them to formation of blood clots (thrombi). The implication is that pregnant women should not be massaged since blood clots can be released an cause thromboembolism. 2. Gastrointestinal changes a. Morning sickness (-nausea and vomiting during the first trimester) is due to increased human chorionic genadotropin (HCC). It may also be due to increased acidity or even to emotional factors. Management:
Eat dry toast or crackers 30 minutes before arising in the morning (or dry, high carbohydrate, low fat and low spices in the diet). Hyperemesis gravidarum – excessive nausea and vomiting which persists beyond 3 months; will result in dehydration, starvation and acidosis. Management • D10 NSS 3000 ml in 24 hours is the priority of treatment • Complete bed rest is also an important b. Constipation and flatulence are due to the displacement of the stomach and intestines, thus slowing peristalsis and gastricemptying time; may also be due to increased progesterone during pregnancy. Management: Increase fluids and roughage in the diet Establish regular elimination time Increase exercise Avoid enemas Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace, are better Mineral oil should not be taken because it interferes with absorption of fat-soluble vitamins c. Hemorrhoids are due to pressure of enlarged uterus. Management: Cold compress with witch hazel or Epsom salts. d. Heartburn, especially during the last trimester, is due to increased progesterone which decreases gastric motility, thereby causing reverse peristaltic waves which lead to regurgitation of stomach contents through the cardiac sphincter into the esophagus, causing irritation. Management: Pats of butter before meals Avoid fried, fatty foods Sips of milk at frequent intervals Small, frequent meals taken slowly Bend at the knees, not at the waist Take antacids (e.g. Milk of Magnesia) but NEVER sodium bicarbonate (e.g. Alka Seltzer or baking soda) because it promotes fluid retention. 3. Respiratory changes – there is shortness of breath a. Causes Increased oxygen consumption and production of carbon dioxide during the first trimester Increased uterine size causes diaphragm to be pushed or displaced, thus crowding chest cavity
b. Management: Lateral expansion of the chest to compensate for shortness of breath increases oxygen supply and vital lung capacity. 4. Urinary changes a. Urinary frequency, the only sign in pregnancy seen during the first trimester, disappear during the second and reappear during the third trimester, is due to increased blood supply in the kidneys and to the uterus rising out of the pelvic cavity; on the last trimester, is due to pressure of enlarged uterus on the bladder, especially with lightening. b. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; also an effect of the increase in progesterone. (Implication: It would be difficult to diagnose diabetes in pregnancy based on the urine sample alone because all pregnant women have sugar in their urine) 5. Musculoskeletal changes a. Because of the pregnant woman’s attempt to change her center of gravity, she makes ambulation easier by standing more straight and taller, resulting in a lordotic position (“pride of pregnancy”) b. Due to increased production of the hormone relaxin, pelvic bones become more supple and movable, increasing the incidence of accidental falls due to the wobbly gait. Implication: Advise use of low-heeled shoes after the first trimester. c. Leg cramps are caused by: Increased pressure of gravid uterus on lower extremities Fatigue Chills Muscle tenseness Low calcium high phosphorus intake Management: Frequent rest periods with feet elevated Wear warm, more comfortable clothing Increase calcium intake (calcium tablets and diet) Do not massage – blood clots can cause embolism Most effective relief: Press knee of the affected leg and dorsiflex the foot 6. Temperature – slight increase in body temperature due to increased progesterone, but the body adapts after the 4th month 7. Endocrine changes a. Addition of the placenta as an endocrine organ, producing large amounts of estrogen, progesterone, HCG and HPL
b. Moderate enlargement of the thyroid gland due to hyperplasia of the glandular tissues and increased vascularity. Could also be due to increased basal metabolic activity of the products of conception. c. Increased size of the parathyroids, probably to satisfy the increased need of the fetus for calcium d. Increased size and activity of the adrenal cortex, thus increasing the amount of circulating cortisol, aldosterone and ADH, all of which affect carbohydrate and fat metabolism e. Gradual increase in insulin production but the body’s sensitivity to insulin is decreased during pregnancy 8. Weight a. During first trimester, weight gain of 1.5 – 3 lbs b. On 2nd trimester and 3rd trimesters, weight gain of 10-11 pounds per trimester is recommended c. Total allowable weight gain during entire period of pregnancy is 20 - 25 lbs ( = 10 – 12 kgs) d. Pattern of weight gain is more important than the amount of weight gained e. Distribution of weight gain during pregnancy: Fetus 7 lbs Placenta 1 lb Amniotic fluid 1 ½ lbs Increased weight of uterus 2 lbs Increased blood volume 1 lb Increased weight of the breast 1 ½ - 3 lbs Weight of additional fluid 2 lbs Fat fluid accumulation 4 – 6 lbs Characteristic of pregnancy _________
TOTAL =
20 – 25 lbs
9. Emotional responses a. First trimester: the fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, denial and disbelief, even repression. (Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy) b. Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the baby c. Third trimester: has personal identification with a real baby about to be born and realistic plans for future child care responsibilities. Best time to talk about preparation of layette and infant feeding method. Fear of death, though, is prominent
(To allay fears, let pregnant woman listen to the fetal heart tones). B. Local Changes 1. Uterus a. Weight in crease to about 1,000 grams at full term; due to increase in the amount of fibrous and elastic tissues. b. Change in shape from pear-like to ovoid c. Change in consistency of the lower uterine segment causes extreme softening, known as Hegar’s sign, seen at about the 6 th week d. Mucous plugs in the cervix, called operculum, are produced to seal out bacteria e. Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as Goodell’s sign. 2. Vagina a. Increased vascularity causes change in color from light pink to deep purple or violet known as Chadwick’s sign To prevent confusion as to pregnancy signs arrange the body “out to xxx” and the different signs alphabetically. Thus: Vagina - Chadwick’s sign Cervix - Goodell’s sign Uterus - Hegar’s sign b. Due to increase estrogen, activity of the epithelial cells increases, thus increasing amount of vaginal discharges called leukorrhea. As long as the discharges are not smelling or irritatingly itchy, it is normal. Management: Maintain or increase cleanliness by taking twice daily shower baths using cool water. c. pH of vagina changes from the normally acidic (because of the presence of the Doderlein bacilli) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to protect against bacterial infection, however, there are two microorganisms which love to thrive in an alkaline environment:
Trichomonas, a protozoa or flagellate. The condition is called trichomonas vaginalis or trichomonas vaginitis or trichomoniasis. Symptoms are: Frothy, cream-colored, irritatingly itchy, foul-smelling discharges Vulvar edema and hyperemia due to irritation from the discharges Treatment: Flagyl for 10 days p.o. or vaginal suppositories of Trichomonicidal compounds (e.g., Tricefuron, Vagisec, Devegan). Note: Is carcinogenic during the first trimester. Treat male partner also, with Flagyl. (Important: avoid
alcoholic drinks when taking Flagyl – can cause Antabuse-like reactions: vomiting, flushed face and abdominal cramps.) Dark brown urine a minor side effectno need to discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar to 1 quart of water or 15 ml white vinegar in 1000 ml water) to counteract alkaline-preferred environment of the protozoa. Avoid intercourse to prevent re-infection. Monilia, a fungus called Candida albicans. The condition is called Moniliasis or Candidiasis. Fungus also lives to thrive in environment right in carbohydrates (that is why it is common among poorly-controlled diabetics) and in those on steroid and antibiotic therapy when acidic environment is altered. Symptoms: White, patchy, cheese-like particles that adhere to vaginal walls. Irritatingly itchy and foul-smelling vaginal discharges Treatment: vaginal Mycostatin/Nystatin p.o. or suppositories/pessaries (100,000 U) twice a day for 15 days Gentian violet swab to vagina (use panty shields to prevent staining of clothes or underwear) Correct diabetes Avoid intercourse Acidic vaginal douche Moniliasis is seen as oral thrush in the newborn when transmitted during delivery through the birth canal of the infected mother. 3. Abdominal Wall a. Striae gravidarum – increased uterine size results in rupture and atrophy of the connective tissue layers, seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent diastasis) b. Umbilicus pushed out 4. Skin a. Linea nigra – brown line running from umbilicus to symphysis pubis b. Melasma or chloasma – extra pigmentation on cheeks and across the nose due to the increased production of melanocytes by the pituitary gland c. Sweat glands unduly activated
5. Breasts a. All changes due to increased estrogen b. Increase in size due to hyperplasia of mammary alveoli and fat deposits. Proper breast support with well-fitting brassiere necessary to prevent sagging c. Feeling of fullness and tingling sensation in the breasts d. Nipples more erect (For mothers who intend to breastfeed, advise nipple rolling, drying nipples with rough towel to help toughen the nipples and not to use soap or alcohol so as to prevent drying which could lead to sore nipples). e. Montgomery glands become bigger and more protruberant f. Areolae become darker and diameter increase g. Skin surrounding areolas turns dark h. By the fourth month, a thin, watery, high-protein fluid, called colostrums, is formed. It is the precursor of breast milk. 6. Ovaries – no activity whatsoever, since ovulation does not take place during pregnancy and progesterone and estrogen are being produced by the placenta. Table 2. Signs Of Pregnancy STAGE
First Trimester
Second Trimester
PRESUMPTIVE
Amenorrhea Morning sickness Breast changes Fatigue Urinary frequency Enlarging uterus Quickening Increased skin pigmentation: Chloasma Linea nigra Striae gravidarum
PROBABLE
Chadwick’s Goodell’s Hegar’s Positive HCG Elevation of basal body temperature Enlarged abdomen Braxton Hicks Ballotement
POSITIVE
Ultrasound evidence
Fetal heart tones Fetal movements Fetal outline on X-ray
VII. The Prenatal Visit
The provision of prenatal care is the primary factor in the improvement of maternal morbidity and mortality statistics. To ensure the success of the prenatal care programs, it should be remembered that the patient’s understanding of the modalities of care is basic to cooperative action. The duration of normal pregnancy is 266-280 days or 38-42 weeks (average is 40 weeks) or 9 calendar months or 10 lunar months. Any baby,
therefore, who is born before the 38 th week of gestation is called preterm and a baby born after the 42nd week of gestation is said to be post term. A. Diagnosis of Pregnancy 1. Urine examination – human chorionic gonadotropin (HCG) in the urine is the basis for pregnancy tests. It is present from the 40th day through the 100th day, reaching a peak level on the 60th day. HCG, therefore, is most correct 6 weeks after the LMP. When collecting urine for pregnancy testing: a. No water taken after 8 PM the night before urine collection in order to concentrate urine b. First morning urine, midstream, should be collected in a clean, dry jar c. If more than 1 hour would lapse before being tested, refrigerate specimen because HCG is unstable under room temperature d. Types of urine exams for pregnancy: Biological tests – presence of HCG will produce hemorrhagic changes in the ovaries/testes of the animal when the urine of a pregnant woman is injected. E.g. Ascheim-Zondek – mice; Freidman – rabbit; Frank Berman – rat; Hogben – toad; male frog. Is actually obsolete. Immunodiagnostic tests – antigen-antibody reaction. Widely used at present because results are obtained faster and do not involved the sacrifice of an animal. E.g. Gravindex; Pregnex; Prognosticon 2. Progesterone Withdrawal Test – also a test to diagnose pregnancy. A contraceptive pill is taken by the woman three times a day for 3 days pregnancy test pill (Gestex) is taken once. If menstruation occurs within 10-15 days after, the woman is not pregnant. If pregnant, there will be no menstruation because the corpus luteum produces enough hormones to neutralize the effect of withdrawn synthetic progesterone. B. Components of a prenatal visit 1. History-taking a. Personal data – patient’s name, age, address, civil status (an unwed pregnancy is a risk pregnancy) and family history (with whom does she live? Are there familial disease that could possible affect the pregnancy?) b. Obstetrical data Gravida – number of pregnancies a woman has had Para – number of viable deliveries, regardless of number and outcome TPAL score – (_ _ _ _) – number of full term babies; premature babies; abortions; living children
Past pregnancies Method of delivery – normal spontaneous Cesarean section (CS)? Indication for past CS? o Where – At home? In the hospital? o Risks involved – Prematurity? Toxemia? o
vaginal?
Present pregnancy o Chief concern – Is there nausea and vomiting? o Danger signals: Vaginal bleeding, no matter how slight Swelling of face or fingers Severe continuous headache Dimness or blurring of vision Flashes of light or dots before the eyes Pain in the abdomen Persistent vomiting Chills and fever Sudden escape of fluids from the vagina Absence of fetal heart sounds after they have been initially auscultated on the 4th or 5th month c. Medical data – Is there a history of kidney, cardiac or liver disease; hypertension; tuberculosis; sexually-transmitted disease (STDs)? 2. Assessment a. Physical examination – a review of systems is indicated, including inspection of the teeth because they are common foci of infection b. Pelvic examination (Cardinal rule: Empty the bladder first) Internal Exam (IE) to determine Hegar’s, Chadwick’s and Goodell’s Ballotement – fetus will bounce when lower uterine segment is tapped sharply (on 5th month of pregnancy) Papanicolau smear (Pap smear) – cytological examination to diagnose cervical carcinoma. Classification of findings: Class 1 – absence of atypical or abnormal cells (normal) Class 2 – atypical cytology but no evidence of malignancy Class 3 – cytology suggestive of malignancy Class 4 – cytology strongly suggestive of malignancy Class 5 – conclusive for malignancy Clinical stages that reflects localization or spread of malignant changes: Stage 1 – CA confined to the cervix Stage 2 – CA extends beyond cervix into the vagina, but not into pelvic wall or lower 1/3 of the vagina Stage 3 – metastasis to the pelvic wall
Stage 4 – metastasis beyond pelvic wall into the bladder and rectum Pelvic measurements are preferably done after 6th lunar month. X-ray pelvimetry (several flat plate X-ray pictures of the pelvis are taken from different angels), however, is the most effective method of diagnosing cephalopelvic disproportion (CPD). But since X-rays are teratogenic, the procedure can be done only 2 weeks before EDC. Leopold’s maneuvers – to determine presentation, position and attitude; estimate fetal size and locate fetal parts. o Preparatory steps: Palpate with warm hands xxx cold hands cause abdominal muscles to contract Use palms not fingertips Position patient on supine, with knees flexed slightly (-dorsal recumbent position) so as to relax abdominal muscles Use gentle but firm motions o Procedure: First maneuver: Facing head part of pregnant woman, palpate for the fetal part found in the fundus to determine presentation (a hard, smooth, round, ballotable mass at the fundus means the fetus is in breech presentation Second maneuver: Palpate sides of the uterus to determine the location of the fetal back and the small fetal parts Third maneuver: Grasp lower portion of abdomen just above the symphysis pubis to find out degree of engagement Fourth maneuver: Facing the feet part of the patient, press fingers downward on both sides of the uterus above the inguinal ligaments to determine attitude (-degree of flexion of fetal head) c. Vital signs – temperature and pulse and respiratory rates are important especially during the initial prenatal visit. But certainly more important are the weight and blood pressure as baseline data to determine any significant increases. d. Blood studies Blood typing Complete blood count, including Hgb and Hct, to determine anemia Serological tests (VDRL and Kahn & Wasserman) to diagnose for syphilis e. Urine examinations
Heat and acetic acid test to determine albuminuria. Any sign of albumin in the urine should be reported immediately because it is a serious sign of toxemia Benedict’s test for glycosuria, a sign of possible gestational diabetes. Specimen should be taken before breakfast to avoid false positive results. Should not be more than +1 sugar. Determination of pyuria. Urinary tract infection has been found to be a common cause of premature delivery. 3. Important Estimates a. Estimates of age of gestation (AOG): Naegele’s Rule – calculation of expected date of confinement (EDC). Count back three months from the first day of the last menstrual period (LMP) then add 7 days. Substitute number for month for easy computation. McDonald’s Method – determines age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months. E.g., fundic height of 16 cm. divided by 4 = 4 months AOG = 16 weeks AOG. Bartholomew’s Rule – estimates AOG by the relative position of the uterus in the abdominal cavity. o By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis o On the 5th lunar month, the fundus is at the level of the umbilicus o On the 9th lunar month, the fundus is below the xiphoid process b. Arey’s Rule – determines the length of the fetus in centimeters. During the first half of pregnancy, square the number of the month (E.g., first lunar month: 1 x 1 = 1 cm.) During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar month: 6 x 5 = 30 cm.) o Vitamin D – fish, liver, eggs, milk (excess Vit. D during pregnancy can lead to fetal cardiac problems o Vitamin E – green leafy vegetables, fish o Vitamin C – tomatoes, guava, papaya o Vitamin B – foods rich in proteins o Calcium/phosphorus – milk, cheese o Iron – especially important during the last trimester when the pregnant woman is going to transfer her iron stores from herself to her fetus so that the baby has enough iron stores during the first 3 months of life when all he takes is milk (which is deficient in iron). Iron has a very low absorption rate; only 10% of the iron intake can be absorbed by the body. Thus, for optimum absorption,
give Vitamin C. Iron should be given after meals because it is irritating to the gastric mucosa. Sources: liver and other internal organs camote tops, kangkong, egg yolk, ampalaya.
Table 4. Quantities of Food Necessary During Pregnancy NUTRIENTS
ACTIVE NON-PREGNANT
Meat
Vegetables: Dark deep yellow
2 servings of meat, fowl fish/day; 3-5 eggs per week
green
or 1 serving (at least 3/week)
Other vegetables
2 or more servings
Fruits: Citrus Other fruits
1 serving 1 serving
Breads and cereal
4 or more servings
Milk
1 pint (8 oz. glasses)
Additional fluid
Ad libitum
PREGNANT
or2-3 servings of meat, fowl or fish/day; 1 egg daily 1 serving daily 2-3 servings 1 serving 1 serving 4 servings 1 quart (4, 8 oz. glasses) At least 2 glasses daily
* Malnutrition during pregnancy can result in prematurity, preeclampsia, abortion, low birth weight babies, congenital defects or even stillbirths. b. Smoking – causes vasoconstriction, leading to low birth weight babies and, therefore, is contraindicated during pregnancy c. Drinking – in moderation is not contraindicated but when excessive can cause transient respiratory depression in the newborn and fetal withdrawal syndrome; besides, alcohol supplies only empty calories. d. Drugs – dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the different body organs are developing. Are teratogenic (can cause congenital defects) and, therefore, contraindicated unless prescribed by the doctor. Thalidomide – causes amelia or phocomelia Steroids – can cause cleft palate and even abortion Iodides – (contained in many over-the-counter cough suppressants) – cause enlargement of the fetal thyroid gland, leading to tracheal decompression and dyspnea at birth Vitamin K – causes hemolysis and hyperbilirubinemia
Aspirin/Phenobarbital – causes bleeding disorders Tetracycline – causes staining of long bones (not given also to children below 8 years for the same reasons) e. Sexual activity Sexual desires continue throughout pregnancy, but levels change: o During the first trimester, there is a decrease in sexual desires because the woman is more preoccupied with the changes in her body o During the second trimester, there is an improvement in sexual desires because the woman has adapted to the growing fetus o During the third trimester, there is another decrease in sexual desires because the woman is afraid of hurting the fetus Sex in moderation is permitted during pregnancy but not during the last 6 weeks of pregnancy because it has been found out that there is increased incidence of postpartum infection in women who engage in sex during the last 6 weeks. Counsel the couple to look for more comfortable positions. Sex is contraindicated in the following situations: o Spotting or bleeding o Incompetent cervical os o Ruptured BOW o Deeply engaged presenting part f. Employment – as long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive physical or emotional strain, there is no contraindication to working. Advise pregnant women to walk about every few hours of her work day during long periods of standing or sitting to promote circulation. g. Traveling – no travel restrictions, but postpone a trip during the last trimester. On long rides, 15-20 minute rest periods every 2-3 hours to walk about or empty the bladder is advisable. h. Exercises Chief aim: To strengthen the muscles used in labor and delivery Should be done in moderation Should be individualized: according to age, physical condition, customary amount of exercise (swimming or tennis not contraindicated unless done for the first time) and the stage of pregnancy Recommended exercises: o Squatting and tailor-sitting – help stretch and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable. When standing from the
squatting position, raise buttocks first before raising the head to prevent postural hypotension. o Pelvic rock – maintain good posture; relieves abdominal pressure and low backaches; strengthens abdominal muscles following delivery o Modified knee-chest position – relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from hemorrhoids o Shoulder-circling – strengthens muscles of the chest o Walking – said to be the best exercise o Kegel – relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles i. Prepared Childbirth/Childbirth Education – preparing the pregnant couple for child-bearing Operates basically on the “Gate Control Theory” of pain: Pain is controlled in the spinal cord. To ease pain in one body part, the “gate” to this pain should be “closed”. Premises: o Discomfort during labor can be minimized if the woman comes into labor informed about what is happening and prepared with breathing exercises to use during labor o Discomfort during labor can be minimized if the woman’s abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. Major approaches to prepared childbirth-pregnant couples are taught about anatomy, pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet, comfort measures: o Grantly-Dick Read Method: Fear leads to tension and tension leads to pain. o Lamaze – psychoprophylactic method; based on the stimulus-response conditioning. To be effective, full concentration on breathing exercises during labor should be observed. (Implication: Nurse should not interrupt the couple doing breathing exercises.) j. Tetanus immunization – given 0.5 ml IM (deltoid region of the upper arm) to all pregnant women any time during pregnancy. It shall be given in two doses at least 4 weeks apart, with the second dose at least 3 weeks before delivery. Booster doses shall be given during succeeding pregnancies regardless of the interval. Three booster doses will confer a lifelong immunity. k. Clinic appointments: First 7 lunar months – every month On 8th and 9th lunar months – every other week – twice a month On 10th lunar month – every week until labor pains set in
LABOR AND DELIVERY I. The Fetal Skull
A. Importance – From an obstetrical point of view the fetal skull is the most important part of the fetus because: 1. It is the largest part of the body 2. It is the most frequent presenting part 3. It is the least compressible of all parts B. Cranial bones – the first 3 are not important because they lie at the base of the cranium and, therefore, are never the presenting parts: 1. Sphenoid 2. Ethmoid 3. Temporal 4. Frontal 5. Occipital 6. Parietal C. Membrane spaces – suture lines are important because they allow the bones to move and overlap; changing the shape of the fetal head in order to fit through the birth canal, a process called molding: 1. Sagittal suture line – the membranous interspace which joins the 2 parietal bones 2. Coronal suture line – the membranous inter-space which joins the frontal bone and the parietal bones 3. Lambdoid suture line – the membranous inter-space which joins the occiput and the parietals D.
Fontanelles – membrane-covered spaces at the junction of the main suture lines: 1. Anterior fontanelle – the larger, diamond-shaped fontanelle which closes between 12-18 months in an infant 2. Posterior fontanelle – the smaller, triangular shaped fontanelle which closes between 2-3 months in the infant E. Measurements – the shape of the fetal skull causes it to be wider in its anteroposterior (AP) diameter that in its transverse diameter: 1. Transverse diameters of the fetal skull: a. Biparietal = 9.25 cm. b. Bitemporal = 8 cm. c. Bimastoid = 7 cm.
2. Anteroposterior diameter: a. Suboccipitobregmatic – from below the occiput to the anterior fontanelle = 9.5 cm (the narrowest AP diameter) b. Occipitofrontal – from the occiput to the mid-frontal bone = 12 cm. c. Occipitomental – from the occiput to the chin = 13.5 cm (the widest AP diameter) Which one of these diameters is presented at the birth canal depends on the degree of flexion (known as attitude) the fetal head assumes prior to delivery. In full flexion (very good attitude when the chin is flexed on the chest), the smallest suboccipitobregmatic diameter is the one presented at the birth canal. If in poor flexion, the widest occipitomental diameter will be the one presented and will give mother and baby more problems II. Theories of Labor Onset A. Uterine Stretch Theory – any hollow body organ when stretched to capacity will necessarily contract and empty.
B. Oxytocin theory – labor, being considered a stressful event, stimulate s the hypophysis to produce oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the smooth muscles of the body, e.g., uterine muscles. C.
Progesterone Deprivation theory – progesterone, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases, labor pains can occur.
D. Prostaglandin theory – initiation of labor is said to result from the release of arachidonic an acid produced by steroid action on lipid precursors. Arachidonic acid, is said to increase prostaglandin synthesis which, in turn, causes uterine contractions. E. Theory of Aging Placenta – because of the decreased blood supply, the uterus contracts. III. Preliminary/prodromal Signs of Labor
A. Lightening – the settling of the fetal head into the pelvic brim. In primis, it occur 2 weeks before EDC; in multis, on or before labor onset. Results of lightening: 1. Increase in urinary frequency 2. Relief of abdominal tightness and diaphragmatic pressure 3. Shooting pains down to legs because of pressure on the sciatic nerve 4. Increase in the amount of vaginal discharges.
5. B.
Lightening should not be confused with engagement. Engagement occurs when the presenting part has descended into the pelvic inlet.
Increased Activity Level – due to increase in epinephrine secreted to prepare the body for the coming “work” ahead. Advise the pregnant woman not to use this increased energy for doing household chores.
C. Loss of weight – of about 2-3 lbs 1 to 2 days before labor onset, probably due to decrease in progesterone production, leading to decrease in fluid retention. D. Braxton Hicks contractions – painless, irregular practice contractions E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “buttersoft”. F. Rupture of the membranes – it is IMPORTANT to remember that once membranes that once membranes (BOW) have ruptured: 1. Labor is inevitable. It will occur within 24 hours 2. The integrity of the uterus has been destroyed. Infection, therefore, can easily set in. That is why once membranes have ruptured, aseptic techniques should be observed in al procedures, doctors do less obstetric manipulations (e.g., IE) and enema is no longer ordered. 3. Umbilical cord compression and/or cord prolapse can occur (especially in breech presentation). Nursing action depends on the specific situation. a. A woman in labor seeking admission to the hospital and saying that her BOW has ruptured should be put to bed immediately and the fetal heart tones taken consequently. b. If a woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tones. c. If a woman in labor says that she feels a loop of the cord coming out of the vagina (cord prolapse), the first nursing action is to put her on Trendelenburg position (lower the head of the bed) in order to reduce pressure on the cord (REMEMBER: Only 5 minutes of cord compression can already lead to irreversible brain damage or even death). In addition, apply a warm saline-saturated OS on the prolapsed cord to prevent drying of the cord. G. Show – due to pressure of the descending presenting part of the fetus which causes rupture of minute capillaries in the mucous membrane of the cervix. Blood mixes with mucus when operculum is released. Show, therefore, is only a pinkish vaginal discharge. IV. Signs of True Labor
A. Uterine Contractions – the surest sign that labor has begun is the initiation of effective, productive uterine contractions. 1. Pain in uterine contractions results from: a. Contraction of uterine muscles when in an ischemic state b. Pressure on nerve ganglia in the cervix and lower uterine segment c. Stretching of ligaments adjacent to the uterus and in the pelvic joints d. Stretching and displacement of the tissues of the vulva and perineum 2. Phases of uterine contractions a. Increment – first phase during which the intensity of contraction increases; also known as crescendo b. Acme – the height of the uterine contraction; also know as apex c. Decrement – last phase during which intensity of contraction decreases; also known as decrescendo Table 5. Differences Between False and True Labor Pains FALSE LABOR PAINS 1. Remain irregular
TRUE LABOR PAINS 1. May be slightly irregular at first but become regular and predictable in a matter of hours.
2. Generally confined to the abdomen 2. First felt in the lower back and sweep around to the abdomen in a girdle-like fashion 3. No increase in duration, frequency 3. Increase in duration, frequency and and intensity intensity 4. Often disappears if the woman4. Continue no matter what the ambulates woman’s level of activity is. 5. Absent cervical changes
5. Accompanied by effacement & dilatation
cervical
B. Effacement – shortening and thinning of the cervical canal from 1-2 cm. to one in which no canal as distinct from the uterus exists. It is expressed in percentage. C. Dilatation – enlargement of the external cervical os to 10 cm. primarily as a result of uterine contractions and, secondarily, as a result of pressure of the presenting part and the BOW.
D. Uterine Changes – the uterus is gradually differentiated into 2 distinct portions: 1. Upper uterine segment – becomes thick and active to expel out fetus 2. Lower uterine segment – becomes thin-walled, supple and passive so that fetus can be pushed out easily. Physiological retraction ring is formed at the boundary of the upper and lower uterine segments. In difficult labor when fetus is larger than the birth canal, the round ligaments of the uterus become tense during dilatation and expulsion, causing an abdominal indentation called Bandl’s pathological retraction ring, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not relieved. V. Length of Normal Labor
Primis First Stage Second Stage Third Stage Total =
12 ½ hours 80 minutes 10 minutes _________ 14 hours
Multis 7 hours, 20 minutes 30 minutes 10 minutes _________ 8 hours
VI. Stages of Labor A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete dilatation of the cervix. 1. Power/Forces: Involuntary uterine contractions 2. Phases: a. Latent – early time in labor Cervical dilatation is minimal because effacement is occurring Cervix dilates 3-4 cm. only Contractions are of short duration and occur regularly 5-10 minutes apart (during which time the pregnant woman may seek admission to the hospital) Mother is excited, with some degree of apprehension but still with ability to communicated Takes up 8 of the 12-hour first stage b. Active/accelerated Cervical dilatation reaches 4-8 cm. Rapid increase in duration, frequency and intensity of contractions Mother fears losing control of herself 2. Nursing Care a. Hospital admission – provide privacy and reassurance from the very start Personal data – name, age, address, civil status
Obstetrical data – determine EDC; obstetrical score; amount and character of show; and whether or not membranes have ruptured b. General physical examination, internal exam and Leopold’s maneuvers are done to determine: Effacement and dilatation Station – relationship of the fetal presenting part to the level of the ischial spines Station 0 – at the level of the ischial spines; synonymous to engagement Station -1 – presenting part above the level of the ischial spines Station +1 – presenting part below the level of the ischial spines Station +3 or +4 – synonymous to crowning (= encirclement of the largest diameter of the fetal had by the vulvar ring) Presentation – relationship of the long axis of the fetus to the long axis of the mother; also known as lie Presenting part – the fetal part which enter the pelvis first and covers the internal cervical os Table 6. Types of Presentation
I. VERTICAL A. Cephalic – he is the presenting part 1. Vertex – head sharply flexed, making the parietal bone the presenting part 2. Face) 3. Brow) if in poor flexion 4. Chin ) B. Breech – buttocks are the presenting parts 1. Complete – thighs flexed on the abdomen and legs are on thighs 2. Frank – thighs are flexed and legs are extended, resting on the anterior surface of the body 3. Footling a. Single – one leg unflexed and extended; one foot presenting b. Double – legs unflexed and extended; feet are presenting II. HORIZONTAL – Transverse lie – Shoulder presentation
In vertex and breech presentations, fetal heart sounds are best heard, at the area of the fetal back; in face presentations, at the area of the fetal chest
In vertex presentations, FHS are usually located in either the left or right lower quadrant (RLQ or LLQ); in breech presentation, at or above the level of the umbilicus (RUQ or LUQ) Hazards of breech delivery: o Cord compression o Abruptio placenta o Erb-duchenne paralysis
Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal wall because of multiparity, pelvic contraction or placenta previa Position – relationship of the fetal presenting part to a specific quadrant of the mother’s pelvis The pelvis is divided into four quadrants o Right anterior o Right posterior o Left anterior o Left posterior o Posteriors positions result in more backaches because of pressure fetal presenting part on the maternal sacrum Points of direction in the fetus: o Occiput – in vertex presentations o Chin (mentum) – in face presentations o Buttocks/feet – in breech presentations o Scapula (acromic) – in horizontal presentation Possible fetal positions o Vertex LOA – left occipitoancetior (most common and favorable position at birth) LOP – left occipitoposterior LOT – left occipitoetransverse ROA – right occipitoanterior ROP – right occipitoposterior ROT – right occipitotransverse o Breech LSA – left sacroanterior LSP – left sacroposterior LST – left sacrotransverse RSA – right sacroanterior RSP – right sacroposterior RST – right sacrotransverse o Face LMA – left mentoanterior LMP – left mentoposterior LMT – left mentotransverse RMA – right mentoanterior RMP – right mentoposterior
o
RMT – right mentotransverse Shoulder LADA – left acromiodorsoanterior LADP – left acromiodorsoposterior RADA – right acromiodorsoanterior RADP – right acromiodorsotransverse
c. Monitoring and evaluation of important aspects Uterine contractions – fingers should be spread lightly over the fundus o Duration – from the beginning of one contraction to the end of the same contraction (A to B) Duration during early labor – 20-30 seconds Duration late in labor – 60 to 70 seconds (SHOULD NEVER BE LONGER) o Interval – from the end of one contraction to the beginning of the next contraction (B to C) Interval early in labor – 40-45 minutes Interval late in labor – 2-3 minutes o Frequency – from the beginning of one contraction to the beginning of the next contraction (A to C) Time 3-4 contractions to have a good picture of the frequency of contractions o Intensity – strength of contractions. May be mild, moderate or string. Intensity is measured by the consistency of the fundus at the acme of the contraction. When estimating intensity, check fundus at the end of contractions to determine whether it relaxes. o Blood pressure – should not be taken during a contraction as it tends to increase. Because no blood supply goes to the placenta during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions. BP readings should be taken at least every half hour during active labor When a woman in labor complains of a headache, the first nursing action is to take the BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of toxemia) o Fetal heart rate – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate) Normally 120-160 per minute Should not be taken also during a uterine contraction because it tends to decrease. Compression of the fetal head when the uterus contracts stimulates the vagal reflex which, in turn, caused bradycardia Should be taken every hour during the latest phase of labor; every half hour during the active phase and every 15 minutes during the transition phase
For any abnormality in FHR, the initial nursing action is to change the mother’s position. Signs of fetal distress: o Bradycardia (= FHR less than 100/minute) or tachycardia (=FHR more than 180/minute) o Meconium-stained amniotic fluid in non-breech presentation o Fetal thrashing – hyperactivity of the fetus as it struggles for more oxygen d. Emotional support is provided for the woman in labor by keeping her constantly informed of the progress in labor. e. Healthy Teachings Bath – is advisable if contractions are tolerable or not too close to one another. Will make the mother feel more comfortable Ambulation – during the latent phase of labor helps shorten the first stage of labor. But definitely not allowed anymore if membranes have ruptured. Solid or liquid foods are to be avoided because: o Digestion is delayed during labor o A full stomach interferes with proper bearing down o May vomit and cause aspiration Enema – NOT a routine procedure o Purposes:
o
o
A full bowel hinders the progress of labor- effectiveness of enema in labor is shown by evaluating change in uterine tone and amount of show Expulsion of feces during second stage of labor predisposes mother and baby to infection. Full bowel predisposes to post-partum discomfort Procedure of enema administration
Enema solution may either be soap suds or fleet enema Optimal temperature of the enema solution – 105 oF to 115oF ( 40.5oC – 46.1oC) Patient on side-lying position When there is resistance while inserting the rectal catheter, withdraw the tube slightly while letting a small amount of solution enter Clamp rectal tube during s contraction Important nursing action: Check FHR after enema administration to determine fetal distress Contraindications to enema in labor : Vaginal bleeding Premature labor
Abnormal fetal presentation or position Ruptured membranes Crowning Encourage the mother bedpan because:
to
void
very
2-3
hours
by
offering
the
A full bladder retards fetal descent Urinary stasis can lead to urinary tract infection A full bladder can be traumatized during delivery
Perineal Prep – done aseptically Use “No.7” method, always from front to back. Perineal shave – maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept taut and razor moved along the direction of hair growth Encourage Sim’s position because : It favors anterior rotation of the fetal head It promotes relaxation between contractions It prevents continual pressure of the gravid uterus on the inferior vena cava ( the blood vessel which brings unoxygenated blood back to the heart), pressure results in Supine Hypotensive Syndrome, also called Vena Cava Syndrome. Hypotension is due to the reduced venous return resulting in decreased cardiac output and therefore, a fall in arterial BP.
Woman in labor should not be allowed to push or unnecessarily during contractions of the first stage because:
bear
down
It leads to unnecessary exhaustion Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema, thus interfering with dilatation Abdominal breathing – is advised for contractions during the first stage in order to reduce tension and prevent hyperventilation. f. Administer analgesics as ordered. The dosage is based on the patient’s weight, status of labor and size and stage of gestation. Narcotics are the most commonly used, specifically Demerol. Pharmacologic effect: Depresses the sensory portion of the cerebral cortex. It is not only a potent analgesic, it is also a sedative and an antispasmodic. It is not given early in labor because it can retard labor progress ( is an antispasmodic), but cannot also be given if delivery is only one hour away because it causes respiratory depression in the newborn ( that is why it can be given only if cervical dilatation is 6-8cm.)
Given 25-100mg.,depending on the body weight Takes effect in 20 minutes – patient experiences a sense of well-being and euphoria Narcotic antagonists (e.g. Narcan or Nalline) are given to counteract the toxic effects of Demerol g. Assist in administration of regional anesthesia – preferred over any other form of anesthesia because it does not enter maternal circulation and thus does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved. Xylocaine is anesthesia of choice Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucose aids uterine muscles in proper functioning. Types of Anesthesia: Paracervical – transvaginal injection into either side of the cervix. Patient on lithotomy position. Coupled with a local anesthetic, results in “painless childbirth” ( uterine contractions are not felt by mother) Pudendal – through the sacro-spinous ligament into the posterior areolar tissues to reduce perception of pain during second stage and make mother comfortable. Patient on lithotomy. Side effect : an ecchymotic (purplish discoloration of the skin due to blood in the subcutaneous tissues) area or hematoma in the right of the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling
Low Spinal Epidural – injection of local anesthetic at the lumbar level outside the dura mater th Saddle block – injection into the 5 lumbar space, causing anesthesia into the parts of the body that come in contact with a saddle (perineum, upper thighs and lower pelvis). Blocks nerves that transmit pain of first stage of labor. In sitting or side-lying position, with back flexed.
Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination in second-stage pushing Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time of needle insertion. Management : Flat on bed for 12 hours and increase fluid intake
Common side-effects: Hypotension – because Xylocaine is a vasodilator. Management : turn to side; prompt elevation of legs; administration of vasopressor and oxygen, as ordered Fetal bradycardia Decreased maternal respirations h. A sure sign that the baby is about to be born is the bulging of the perineum. In general, primigravidas are transported from LR to the DR when the cervix is fully dilated or when there is bulging of the perineum; multiparas are transported at 7-8cm cervical dilatation. B. Transition Period – when the mood of the woman suddenly changes and the nature of the contractions intensify. 1. Characteristics : a) If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is pushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOW with a sterile pointed instrument e.g. Kelly or Allis forceps or amniohook to allow amniotic fluid to drain), is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetal position changes. Amniotomy, however cannot be if station is still “minus” as this (can lead to cord compression). b) Show becomes prominent. c) There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor. Profuse perspiration and distention of neck veins are seen. d) Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption. e) In primis, baby is delivered within 20 contractions (=40 minutes); in multis, in 10 contractions (=20 mintues) 2. Nursing actions are primarily comfort measures: a) Sacral pressure ( applying pressure with the heel of the hand on the sacrum) relieves discomfort from contractions b) Proper bearing down techniques: push with contractions c) Controlled chest ( costal) breathing during contractions d) Emotional support C. Second Stage ( stage of Expulsion) – begins with complete dilatation of the cervix and ends with delivery of the baby. 1. Power/forces : In voluntary uterine contractions and contractions of the diaphragmatic and abdominal muscles 2. Mechanisms of Labor/ Fetal Position Changes : (D FIRE ERE) a. Descent ( may be preceded by engagement)
b. Flexion – as descant occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest c. Internal Rotation – from AP to transverse, then AP to AP d. Extension – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin appear e. External Rotation ( also called restitution - anterior shoulder rotates externally to the AP position f. Expulsion – delivery of the rest of the body 3. Nursing Care a. When positioning legs or lithotomy, put them up at the same time to prevent injury to the uterine ligaments b. As soon as the fetal head crowns, instruct mother not to push, but to pant instead ( rapid and shallow breathing) to prevent rapid expulsion of the baby. If panting is deep and rapid, called hyperventilation the patient will experience lightheadedness and tingling sensation of the fingers leading to carpopedal spasms, because of respiratory alkalosis. Management: let the patient breath into brown paper bag to recover lost carbon dioxide; a cupped hand will serve the same purpose. c. Assist in episiotomy – incision made in the perineum primarily to prevent lacerations. Other purpose of episiotomy: o Prevent prolonged and severe stretching of muscles supporting bladder or rectum o Reduce duration of second stage when there is hypertension or fetal distress o Enlarge outlet, as in breech presentation or forceps delivery Types of episiotomy: o Median – from middle portion of the lower vaginal border directed towards the anus o Mediolateral – begun in the midline but directed laterally away from the anus Natural anesthesia is used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that nerve endings for pain are momentarily deadened. d. Apply the Modified Ritgen’s Maneuver: Cover the anus with sterile towel and exert upward and forward pressure on the fetal chin, while exerting gentle pressure with two fingers on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the
smallest sub-occipitobregmatic diameter of the fetal head is presented. Ease the head out and immediately wipe the nose and mouth of secretions to establish and maintain a patent airway (REMEMBER: the first principle in the care of the newborn is establish and maintain a patent airway). (The head should be delivered in between contractions.) Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuchal cord). If so, but loose, slip it down the shoulders or up over the head; but if tight; clamp cord twice, an inch apart, and then cut in between. As the head rotates, deliver the anterior shoulder by exerting a gentle downward push and then slowly give an upward lift to deliver the posterior shoulder While supporting the head and the neck, deliver the rest of the body. Take note of the exact time of delivery of the baby. e. Immediately after delivery, newborn should be held below the level of the mother’s vulva for a few minutes to encourage flow of blood from the placenta to the baby. f. The infant is held with his head in a dependent position (-head lower than the rest of the body) to allow for drainage of secretions. REMEMBER: Never stimulate a baby to cry unless you have drained him out of his secretions first. g. Wrap the bay in a sterile diaper to keep him warm. REMEMBER: Chilling increases the body’s need for oxygen. h. Put the bay on the mother’s abdomen. The weight of the baby will help contract the uterus. i. Cutting of the cord is postponed until the pulsations have stopped because it is believe that 50 – 100 ml of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart, and then cut in between j. Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse. D. Third Stage (Placental Stage) – begins with the delivery of the baby and ends with the delivery of the placenta. 1. Signs of placental separation: a. Uterus becoming round and firm again, rising high to the level of the umbilicus (Calkin’s sign) – the earliest sign of placental separation b. Sudden gush of blood from the vagina c. Lengthening of the cord from the vagina 2. Types of placental delivery:
a. Schu ltz – if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the fetal surface which is shiny. 80% of placentas separate in this manner (“Shiny” for Schultz) b. Duncan – if placenta separates first at its edges, it slides along the uterine surface and presents with the maternal surface which is raw, red, beefy, irregular and “dirty”. Only about 20% of placentas separate this way. (”Dirty” of Duncan) 3. Nursing Care a. Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal push as this can cause uterine inversion. Just watch for the signs of placental separation. b. Tract the cord slowly, winding it around the clamp until placenta spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus, a method called Brandt-Andrews maneuver. c. Take not of the time of placental delivery; it should be delivered within 20 minutes after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause severe bleeding in the mother. d. Inspect for completeness of cotyledons; any placental fragment retained can also cause severe bleeding and possible death e. Palpate the uterus to determine degree of contraction. If relaxed, boggy or non-contracted, first nursing action is to massage gently and properly. An ice cap over the abdomen will also help contract the uterus since cold causes vasoconstriction. f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10 U/ml) – IM to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before placental delivery because placental entrapment can occur. Categories of lacerations (tend to heal more slowly because of ragged edges): o First degree – involves the vaginal mucous membranes and skin o Second degree – involves not only the vaginal mucous membranes and skin, but also the muscles o Third degree – involves not only the muscles, vaginal mucous membranes and skin, but also the external sphincter of the rectum o Fourth degree – involves not only the external sphincter of the rectum, the muscles, vaginal mucous
membranes and skin, but also the mucous membranes of the rectum Assist the doctor in doing episiorrhaphy (- repair of episiotomy or lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure on the suture line, thus prevent further bleeding. Note: Vaginal packs have to be removed after 24 – 48 hours g. Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vagina. Soiled napkins should be removed from front to back. h. Position the newly-delivered mother flat on bed without pillows to prevent dizziness due to decrease in intra-abdominal pressure. i. The newly-delivered mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold temperature in the delivery room. Management: Provide additional blankets to keep her warm. j. May give initial nourishment, e.g., milk, coffee, or tea k. Allow patient to sleep in order to regain lost energy E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs. 1. Assessment: a. Fundus – should be checked every 15 minutes for 1 hour then every 30 minutes for the next 4 hours. Fundus should be firm, in the midline and, during the first 12 hours postpartum, is a little above the umbilicus. First nursing action for a non-contracted uterus: massage. b. Lochia – should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after 30 minutes. c. Bladder – a full bladder is evidenced by a fundus which is to the right of the midline, dark-red bleeding with some clots. d. Perineum – is normally tender, discolored and edematous. It should be clean, with intact sutures. e. Blood pressure and pulse rate – may be slightly increased from excitement and effort of delivery, but normalize within one hour. 2. Lactation-suppressing agents – estrogen-androgen preparation given within the first hours postpartum to prevent breastmilk production in mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol, TACE or deladumone. These drugs tend to increase uterine bleeding and retard menstrual return. 3. Rooming-in concept – mother and baby are together while in the hospital. The concept of a family, therefore, is felt at the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents
and newborn. Eye-to-eye contact is immediately established, releasing maternal caretaking responses. VII. Dystocia – bread term for abnormal or difficult labor and delivery. A. Uterine Inertia – sluggishness of contractions. 1. Causes: a. Inappropriate use of analgesics b. Pelvic bone contraction c. Poor fetal position d. Overdistention – due to multiparity, multiple pregnancy, polyhydramnios or excessively large fetus 2. Types: a. Primary (hypertonic) Uterine Dysfunction relaxations are inadequate and mild, this are ineffective. Since uterine muscles are in a state of greater than normal tension, latest phase of the first stage of labor is prolonged. Treatment: secure the patient b. Secondary (hypotonic) Uterine Dysfunction – contractions have been good but gradually become infrequent and of poor quality and dilatation steps. Treatment: stimulation of labor either by oxytocin administration or amniotomy. B. Precipitate Delivery – labor and delivery that is completed in less than 3 hours after the onset of true labor pains. Probably due to multiparity or following oxytocin administration or aminiotomy. Dangers imposed by precipitate delivery: Extensive lacerations; abruptio placenta; or hemorrhage due to sudden release of pressure, leading to shock. C. Prolonged Labor – in primis, labor more than 18 hours and in multis, more than 12 hours. Dangers: maternal exhaustion, uterine atony or caput succedaneum. D. Uterine Rupture – occurs when the uterus undergoes more strain that it is capable of sustaining. 1. Causes: a. Scar from a previous classic Cesarean Section (CS) b. Unwise use of oxytocins c. Overdistention d. Faulty presentation or prolonged labor 2. Signs and symptoms: a. Sudden, severe pain b. Hemorrhage and clinical signs of shock (restlessness, pallor, decreasing BP, increasing respiratory and pulse rates)
c. Changing abdominal contour, with two swellings on the abdomen, the retracted uterus and the extrauterine fetus 3. Management: hysterectomy E. Uterine Inversion – fundus is forced through the cervix so that the uterus is turned inside out 1. Causes: a. Insertion of placenta at the fundus, so that as fetus is rapidly delivered, especially if unsupported, the fundus is pulled down b. Strong fundal push when mother fails to bear down properly c. Attempts to deliver the placenta before signs of placental separation appear. 2. Management: hysterectomy F. Amniotic Fluid Embolism – occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter the maternal circulation and reach the lungs as emboli. 1. Signs and symptoms – are dramatic: a. Woman in labor suddenly sits up and grasps her chest because of inability to breathe and sharp pain b. Turns pale and then the typical bluish-gray color associated with pulmonary embolism c. Death may occur in few minutes 2. Management: a. Emergency measures to maintain life: IV, oxygen, CPR b. Provide intensive care in the ICU c. Keep family informed and provide emotional support G. Trial Labor – if a woman has borderline (just adequate) pelvic measurements but fetal position and presentation are good. Maybe continued for as long as there is progressive fetal descent of the presenting part and cervical dilatation. 1. Management: a. Monitor FHRs and uterine contractions b. Keep bladder empty to allow all available space to be used by the fetus c. Emotional support H. Premature Labor and Delivery – if uterine contractions occur before the 38th week of gestation 1. If there is no bleeding and cervical dilatation and fetal heart sounds are good, premature uterine contractions can be stopped by drugs:
a. Ethyl alcohol (ethanol) IV – blocks the release of oxytocin. Side effects: Nausea and vomiting, mental confusion, etc. (same side effects when alcohol is taken orally in excessive amounts) b. Vasodilan IV – a vasodilator. Side effects: hypotension and tachycardia c. Ritodrine – a muscle relaxant given orally d. Bricanyl – a known bronchodilator 2. If premature uterine contractions are accompanied by progressive fetal descent and cervical dilatation, premature delivery is inevitable. a. Not necessarily shorter than full term labor b. Pain medications are kept to a minimum because analgesics are know to cause respiratory depression. As it is, premature babies already have enough difficulty breathing on their own; giving analgesics, therefore, would add up to the problem. Implication: give emotional support to the mother such that she focuses her attention not on her own need, but those of her baby. c. Steroids (glucocorticoids) are given to the mother to help in maturation of fetal lungs by hastening production of surfactants. d. Caudal, spinal or infiltration anesthesia is preferred because it does not compromise fetal respiration. e. Episiotomy may not necessarily be smaller than in full-term deliveries; may even be larger so that the preemie can be delivered the shortest possible time, since excessive pressure on the fragile preemie’s had can cause subarachnoid hemorrhage that could be fatal. f. Forceps may be applied gently. g. Cord is cut immediately, rather than waiting for pulsations to stop, because preemies have difficult time excreting large amount of bilirubin that will be formed from the extra amount of blood.
PUERPERIUM I. Definitions
A. Puerperium/Postpartum – refers to the six-week period after delivery of the baby B. Involution – the return of the reproductive organs to their prepregnant state II. Principles of Postpartum Care
A. Promote healing and return to normal (involution) of the different parts of the body. 1. Vascular Changes a. The 30 – 50% increase in total cardiac volume during pregnancy will be reabsorbed into the general circulation within 5-10 minutes after placental delivery. Implication: the first 5-10 minutes after placental delivery is crucial to gravido-cardiacs because the weak heart may not be able to handle such workload. b. White blood cell (WBC) count increases to 20,000-30,000/rm3. Implication: WBC count, therefore, cannot be sued as an indicator of postpartum infection. c. There is extensive activation of the clotting factors, which encourages thrombo-embolization. This is the reason why: • Ambulation is done early – after 4-8 hours in normal vaginal delivery. When ambulating the newly-delivered patient for the first time, the nurse should hold on to the patient’s arm. • Exercises are recommended: • Kegel and abdominal breathing on postpartum day 1 (PPD 1) • Chin-to-chest – on second day to tight on and firm up abdominal muscles • Knee-to-abdomen – when perineum has healed, to strengthen abdominal and gluteal muscles. • Massage is contraindicated d. All blood values are back to prenatal levels by the third or fourth week postpartum 2. Genital changes a. Uterine involution is assessed by measuring the fundus by fingerbreadths (= 1 cm). On PPD 1 – fundus is one fingerbreadth below the umbilicus; on PPD 2, 2 fingerbreadths below umbilicus and so forth until on the 10 th day postpartum, it can no longer be palpated because it is already behind the symphysis pubis.
Subinvoluted uterus – a big uterus and vaginal bleeding with clots. Since blood clots are good media for bacteria, it is, therefore, a sign of puerperal sepsis. b. To encourage return of the uterus to its usual anteflexed position, prone and knee-chest positions are advised. c. Afterpains/after birth pains – strong uterine contractions felt more particularly by multis, those who delivered large babies or twins and those who breastfeed. • Management: • NEVER apply heat on abdomen • Give analgesics, as ordered • Explain that it is normal and rarely lasts for more than 3 days d. Lochia – uterine discharge consisting of blood, decidua, WBC mucus and some bacteria • Pattern: • Rubra – first 3 days postpartum; red and moderate in amount • Serosa – next 4-9 days; pink or brownish and decreased in amount th • Alba – from 10 day up to 3-6 weeks; colorless and minimal in amount • Characteristics: • Pattern should not reverse • It should approximate menstrual flow (However, it increases with activity and decreases with breastfeeding) • It should not have any offensive odor. It has the same fleshy odor as menstrual blood. Otherwise, it means either poor hygiene or infection • It should not contain large clots • It should never be absent, regardless of method of delivery. Lochia has the same pattern and amount, whether CS or normal vaginal delivery. e. Pain in perineal region may be relieved by: • Sim’s position – minimizes strain on the suture line • Perineal heat lamp or warm Sitz baths twice a day – vasodilatation increases blood supply and, therefore, promotes healing • Application of topical analgesics or administration of mild oral analgesics, as ordered f. Sexual activity – maybe resumed by the third or fourth week postpartum if bleeding has stopped and episiorrhaphy has haled. Decreased physiologic reactions to sexual stimulation are expected for the first 3 months and emotional factors •
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g. Menstruation – if not breastfeeding, return of menstrual flow is expected within 8 weeks after delivery.If breastfeeding, menstrual return is expected in 3-4 months; in some women, no menstruation occurs during the entire lactation period (IMPORTANT: Amenorrhea during lactation is no guarantee that the woman will not become pregnant. She may be ovulating and the absence of menstruation may be her body’s way of conserving fluids for lactation. Implication: She should be protected against a subsequent pregnancy by observing a method of contraception but not the pill.) h. Postpartum check-up – should be done after the 6th week postpartum to assess involution. Urinary changes a. There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid accumulation during pregnancy. b. Some newly delivered mothers may complain of frequent urination in small amounts; explain that it is due to urinary retention with overflow. Others, on the other hand, may have difficulty voiding because of decreased abdominal pressure or trauma to the trigone of the bladder. Voiding maybe initiated by pouring warm and cold water alternately over the vulva, encouraging patient to go to the comfort room and let her listen to the sound of running water. If these measures fail, catheterization, done gently and aseptically, is the last resort on doctor’s order. (If there is resistance to the catheter when it reaches the internal sphincter, ask patient to breathe through the mouth while rotating the catheter before moving it inward again.) Gastrointestinal changes – delayed bowel evacuation postpartally may be due to: a. Decrease muscle tone b. Lack of food + enema during labor c. Dehydration d. Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids Vital Signs a. Temperature may increase because of the dehydrating effects of labor. Implication: Any increase in body temperature during the first 24 hours postpartum is not necessarily a sign of postpartum infection. b. Bradycardia ( = heart rate of 50-70 per minute) is common for 68 days postpartum. c. There is no change in respiratory rate. Weight – there is an immediate weight loss of 10-12 lbs representing the weights of the fetus, placenta, amniotic fluid and blood. Further weight loss will occur during the next days due to diaphoresis.
7. Psychologic phases B. Provide emotional support – the psychological phases during the postpartum period are: 1.Taking-in phase – first 1-2 days postpartum when mother is passive and relies on others to care for her and her newborn. She keeps on verbalizing her feelings regarding the recent delivery for her to be able to integrate the experience into herself. 2. Taking-hold phase – begins to initiate action and make decisions. Postpartum blues ( - an overwhelming feeling of sadness that cannot be accounted for) may be observed. Could be due to hormonal changes, fatigue or feelings of inadequacy in taking care of a new baby. Management: Explain that it is normal and that crying is therapeutic, in fact. C. Prevent postpartum complications 1. Hemorrhage – blood loss of more than 500 cc. (normal blood loss during labor and delivery is 250-350 cc); leading cause of maternal mortality associated with childbearing Table 7. Classification of Postpartum Hemorrhage
I. Early postpartum hemorrhage – occurs during he first 24 hours postpartum A. Uterine Atony – uterus is not well contracted, relaxed or boggy; most frequent cause 1. Predisposing factors: a. Overdistention of the uterus – e.g., multiple pregnancy, multiparity, excessively large baby, polyhydramnios b. Cesarean section c. Placental accidents (previa or abruptio) d. Prolonged and difficult labor 2. Management: a. Massage – first nursing action b. Ice compress c. Oxytocin administration d. Emptying the bladder e. Bimanual compression to explore retained placental fragments f. Hysterectomy – last resort B. Lacerations C. Hypofibrinoginemia – a clotting defect II. Late postpartum hemorrhage A. Retained placental fragments – Management: dilatation and curettage (D&C) B. Hematoma – due injury to blood vessels during delivery
1. Incidence: Commonly seen in precipitate delivery and those with perineal varicosities 2. Treatment: a. Ice compress during the first 24 hours b. Oral analgesic, as ordered c. Site is incised and bleeding vessel is ligated 2. Infection a. Sources: • Endogenous (primary) sources – bacteria in the normal flora become virulent when tissues are traumatized and general resistance is lowered • Exogenous sources – pathogens introduced from external sources. Organism most frequently responsible for postpartum infections: Anaerobic streptococci. • Common exogenous sources: • Hospital personnel • Excessive obstetric manipulations • Breaks in aseptic techniques – faulty hand washing, unsterile equipments and supplies • Coitus in late pregnancy • Premature rupture of the membranes b. General symptoms: malaise, anorexia, fever, chills and headache c. General management: complete bed rest (CBR), proper nutrition, increased fluid intake, analgesics, antipyretics and antibiotics, as ordered d. Types of infection: A. Infection of the perineum • Specific symptoms: • Pain, heat and feeling of pressure in the perineum • Inflammation of the suture line, with 1 or 2 stitches sloughed off • With or without elevated temperature • Specific management: • Doctor removes sutures to drain area and re-sutures • Hot Sitz bath or warm compress B. Endometritis – inflammation/infection of the lining of the uterus • Specific symptoms: • Oxytocin • Fowler’s position to drain out lochia and prevent pooling of infected discharge C. Thrombophlebitis – infection of the lining of a blood vessel with formation of clots; usually an extension of endometritis
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Specific symptoms: • Pain, stiffness and redness in the affected part of the leg • Leg beings to swell below the lesion because venous circulation has been blocked • Skin is stretched to a point to shiny whiteness, called milk leg – phlegmasia alba dolens • Positive Homan’s Sign – pain in the calf when the foot is dorsiflexed Specific management: • Bed rest with affected leg elevated • Anticoagulants, e.g., Dicumarol or Heparin, to prevent further clot formation or extension of a thrombus Side effects: hematuria & increased lochia • Considerations: • Discontinue breastfeeding • Monitor prothrombin time • Always have Protamin sulfate or Vitamin at bedside to counteract toxicity • Analgesics are given but NEVER Aspirin because it inhibits prothrombin formation; since patient is already receiving an anticoagulant, bleeding may occur
D. Establish successful lactation Table 8. Physiology of Breastmilk Production
DECREASED ESTROGEN AND PROGESTERONE levels after the delivery of the placenta ---------------------stimulates anterior pituitary gland to produce prolactin ------------------- acts on acinar cells to produce foremilk -----------------stored in collecting tubules. WHEN INFANT SUCKS ----------------- posterior pituitary gland is stimulated to produce oxytocin --------------- causes contraction of smooth muscles of collecting tubules ---------- milk ejected forward --------------LET-DOWN or MILK EJECTION REFLEX --------------hindmilk is produced 1. Implications of physiology of breastmilk production: a. Regardless of the mother’s physical condition, method of delivery or breast size, condition, milk will be produced. b. Lactation does not occur during pregnancy because estrogen and progesterone are present and therefore, inhibit prolactin production. c. Lactation-suppressing agents are to be given immediately after placental delivery to be effective
d. Oral contraceptives are contraindicated in lactating mothers because they decrease milk supply e. After pains are felt more by breastfeeding women because of oxytocin production; they also have less lochia and experience more rapid involution f. If emergency delivery when the uterus does not contract, put the infant to the breast. • During initial contact in emergency delivery, determine whether the woman in labor is a primi or a multi, the EDC and also assess the stage of labor. And if not sterile equipment is available to cut the cord, wrap the baby and the placenta together; never cut the cord unless sterile equipments are available. 2. Advantages of breastfeeding a. For mother: • Economical in terms of time, money and effort • More rapid involution • Less incidence of cancer of the breast, according to some studies b. For the baby: • Closer mother-infant relationship • Contains antibodies that protect against common illnesses • Less incidence of gastrointestinal diseases • Always available at the right temperature 3. Health Teachings a. Hygiene • Wash breasts daily at bath or shower time • Soap or alcohol should never be used on the breasts as they tend to dry and crack the nipples and cause sore nipples • Wash hands before and after every feeding • Insert clean OS squares or piece of cloth in the brassiere to absorb moisture when there is considerable breast discharge b. Method – as suggested by the La Leche League • Side-lying position with a pillow under the mother’s head while holding the bulk of breast tissues way from the infant’s nose • Stimulate the baby to open his mouth to grasp the nipples by means of the rooting reflex • Infant should grasp not only the nipple but also the areola for effective sucking motion. Effectiveness is ensured when: • The baby’s mouth parts “make well up” into the areola
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The mother feels after pain as the baby sucks The other nipple flows with milk while baby is feeding on the other breast To prevent nipples from becoming sore and cracked, infant should be introduced to the beast gradually. The baby should be fed for only 5 minutes at each beast at each feeding on the first day, increasing the time at each beast by 1 minute per day until the infant is nursing for 10 minutes at each breast each feeding, making a total feeding time of twenty minutes per feeding. For continuous milk production, at each feeding, the infant should be placed first on the breast he fed last in the previous feeding. This ensures that each breast will be completely emptied at every other feeding. If breasts are completely emptied, they completely refill again; if only half-emptied, will half-refill and after some time, will become insufficient. To break away from the closed suction at the breast after feeding, insert a clean finger in the corner of the infant’s mouth to release the suction, then pull the chin down. This also helps prevent sore nipples. Feed as often as the baby is hungry, especially during the first few days, because he is receiving colostrums, which is not very filling; however, it contains the only group of substances that can never be replicated by any artificial formula, the gamma globulins (antibodies).
Advise the mother to learn how to relax during feedings because tension prevents good let-down. c. Engorgement – feeling of tension in the breasts during the third postpartum day, sometimes accompanied by an increase in temperature (- milk fever). The breasts become full, feel tense and hot, with throbbing pain. It lasts for about 24 hours and is due to increased lymphatic and venous circulation. •
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Management: • Advise use of firm-fitting brassiere for good support. It will not only decrease the discomfort from breast engorgement but also prevents contamination of the nipples and the areolae. •
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Cold compress is applied if mother does not intend to breastfeed; warm compress is applied if she will breastfeed Breast pump is not used more breast massage doe if mother is not going to breastfeed, since either will only stimulate milk production.
Sore nipples – are not contraindications to breastfeeding • Management: • Expose nipples to air by leaving bra unsnapped for 10 to 15 minutes after a feeding • When normal air drying is not effective, exposure to a 20-watt bulb place 12-18 inches away will cause vasodilatation, increase circulation and promote healing • Do not use plastic liners that are found in some nursing bras because they prevent air from circulating around the breasts • Use nipple shield • Mastitis – inflammation of the breasts • Symptoms: • Localized pain, swelling and redness in breast tissues • Lumps in the breast • Milk becomes scanty • Management: • Antibiotics, as ordered • Ice compress • Proper breast support • Discontinue breastfeeding in affected breast d. Nutrition – lactating mothers should take 3000 calories daily and should have larger amounts of proteins (=96 gms per day), calcium, iron, Vitamins A, B, and C. Non-breastfeeding women can have the same requirements as in pregnancy e. Contraindications • Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines. Insulin (diabetes, therefore, is not contraindicated), epinephrine, most antibiotics, antidiarrheal and antihistamines are generally not contraindicated. •
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Certain disease conditions, specifically tuberculosis because of the close contact between mother and baby during feeding. No TB germs, however, are every transmitted thru breast milk.
E. Motivate use of family planning methods – the success of the family planning program depends to a great extent on the motivation of both husband and wife. 1. Physiological methods – the oral contraceptives. a. Action: Suppresses the pituitary gland, thus inhibiting ovulation. b. Types:
Combined – estrogen and progesterone in the same dosage each day for 20 days, starting on the fifth day of the menstrual cycle, after which it is discontinued and then resumed on the fifth day of the next menstrual period. • Sequential – estrogen alone for 15 days, then estrogen and progesterone for 5 days. • Mini-pill – taken continuously c. Side effects – same complaints of pregnant women because of estrogen and progesterone: • Nausea and vomiting • Headache and weight gain – both due to fluid retention because of progesterone • Breast tenderness • Dizziness • Breakthrough bleeding/spotting between periods • Chloasma d. Contraindications: • Breastfeeding • Certain diseases • Thromboembolism – because there is increased tendency towards clotting in the presence of estrogen • Diabetes mellitus and liver disease – because estrogen tends to interfere with carbohydrate metabolism • Migraine; epilepsy; varicosities • Cancer; renal disease; recent hepatitis • Women who smoke more than 2 packs of cigarettes per day • Strong family history of heart attack 2. Mechanical methods a. Intrauterine device (IUD) • Specific action: Prevents implantation by setting up a non-specific cell inflammatory reaction to the device • Inserted during a menstruation to ensure that the woman is not pregnant; septic abortion can result if she is pregnant. • Side effects: • Increased menstrual flow • Spotting or uterine cramps during the first 2 weeks after insertion •
•
Increased risk of infection
When pregnancy occurs with the device in place, it need not be removed since it stays outside the membranes, and, therefore, will not in any way harm the fetus b. Diaphragm • Specific action: A circular rubber disc that fits over the cervix and forma a barrier against the entrance of sperms • Is initially inserted by a doctor who determines the depth of the vagina • May be coated with a spermicidal jelly or cream for double protection • Maybe washed with soap and water after use • Sperms remain viable in the vagina for 6 hours, so the device should be kept in place during such time, but should not stay for more than 24 hours because stasis of semen can lead to infection. c. Condom • Specific action: Sperms are deposited in the tip of the rubber sheath placed over an erect penis prior to coitus. Has the added potential of lessening the change of contacting sexually-transmitted disease (STDs) • Most common complaint of users: it interrupts the sexual act to apply 3. Chemical methods – are spermicidals (kill sperms). E.g., jellies, creams, foaming tablets, suppositories 4. Biological method – Rhythm/Calental/Ogino-Knause Formula a. Specific action: the couple abstains on days that the woman is fertile b. Procedure • The woman charts her menstrual cycles for 12 continuous months in order to determine the shortest and the longest cycles • The first fertile day is determined by subtracting “18” from the shortest menstrual cycle; the last fertile day is determined by subtracting “11” from the longest menstrual cycle. •
•
E.g., if a woman’s shortest menstrual cycle is 26 days and her longest is 32 days,
26 - 18 8
32 - 11 21
her fertile period would be from the 8 th to the 21st day of her cycle, i.e., she should not have sexual intercourse during these days
5. Natural Family Planning (NFF) – periods abstinence: a. Cervical mucus/Billing method • Basis: the flow of mucus from the cervix of the uterus • Method: a woman can discern her fertile and infertile days based on her sensory and visual observations of the cervical mucus (when it becomes thin and watery – spinnbarkeit), intercourse is avoided 4 days prior to and 3 days after the spinnbarkeit b. Basal Body Temperature (BBT) involves observing the temperature of the • Method: woman at rest, free from any factor that may cause it to fluctuate (immediately upon waking up, before doing anything else). As soon as the temperature drops slightly and then increases (which means ovulation has taken place), she counts 3-4 days, after which sexual intercourse may be resumed. c. Sympto-Thermal method – fertile and infertile days are determined after having established an accurate record of the six immediately preceding menstrual cycles and then watching out for BBT fluctuations. 6. Surgical methods a. Tubal ligation – the Fallopian tubes are ligated in order to prevent passage of sperms. Menstruation and ovulation continue b. Vasectomy – small incision made into each side of the scrotum and the vas deferens is and cut and tied, blocking passage of sperms. Sperm production continues, only passage into the exterior is prevented. (Sperms in the vas deferens at the time of surgery may remain viable for as long as 6 months. Implication: couple should still observe a form of contraception during this time to ensure protection against a subsequent pregnancy.) 7. Social methods a. Abstinence b. Withdrawal or coitus interruptus
RISK PREGNANCY I. BLEEDING IN PREGNANCY Table 9. Outline of Classification
I. First Trimester Bleeding A. Abortion 1. Spontaneous a. Threatened b. Imminent • Complete • Incomplete 2. Induced a. Therapeutic b. Illegal B. Ectopic Pregnancy 1. Tubal – most common 2. Cervical 3. Ovarian 4. Abdominal II. Second Trimester Bleeding A. Hydatidiform Mole B. Incompetent Cervical Os III. Third Trimester Bleeding A. Placenta previa B. Abruptio placenta A. ABORTION – any interruption in pregnancy before the age of viability. 1. Spontaneous – occurs from natural causes, blighted ovum/germ plasma defect (most common cause – it is nature’s way of eliminating the birth of a congenitally defective baby);
implantation or hormonal abnormality; following trauma, infection (e.g., rubella, influenza) or emotional problems a. Threatened • Symptom: bright red vaginal bleeding which is moderate in amount • Management: • Complete bed rest for 24-48 hours; if bleeding will stop it usually steps within this time • Coitus is restricted for 2 weeks after bleeding has stopped in order to prevent further bleeding or infection • Endocrine/hormonal therapy • Advise patient to save all pads, clots and expelled tissues b. Imminent/inevitable • Symptom: Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatation. Loss of the products of conception is inevitable. • Management: depends on whether it is • Complete abortion – all products of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed. • Incomplete abortion – part of the conceptus, usually the fetus, is expelled, but membranes or placental fragments are retained. D & C is indicated as management. c. Missed abortion – fetus dies in utero but is not expelled. Usually discovered at a prenatal visit when fundic height is measure and no increase is demonstrated or when previously heard fetal heart tones are no longer present. In 2 weeks’ time, signs of abortion should occur; otherwise, labor will have to be induced to prevent hypofibrinoginemia or sepsis. 2. Induced – is never allowed in the Philippines a. Therapeutic – performed by a doctor in a controlled hospital or clinic setting for a medical or a legal reason. Also known as medical, planned or legal abortion. b. Illegal B. ECTOPIC PREGNANCY – any gestation located outside the uterine cavity. 1. Signs and symptoms – since the wall of the Fallopian tube is not sufficiently elastic, it ruptures within the first 12 weeks of gestation as it can no longer give way for the growing fetus:
a. peri-umbilical colicky pain which mimics appendicitis (in bleeding wherein there is no exit or egress of blood from the body, pain is the outstanding symptom; this pain differentiates ectopic pregnancy from abortion). b. may radiate to shoulder & neck if internal bleeding reach level of diaphragm c. (+) xxxxxxxxx sign – xxxxxxxxxxxxxxxxx d. Excruciating pain when cervix is moved on IE e. Signs of shock: falling BP, tachycardia, lightheadedness • Ruptured ectopic pregnancy is an emergency situation. 2. Diagnosis: a. Pelvic exam-reveal adnexae or cul de sac mass/cul de sac of Douglas b. Culdocentesis-aspirate fluid c. Culdotomy d. Laparoscopy e. D&C 3. Management: a. Laparotomy – if Fallopian tube can still be repaired and preserved, but the pregnancy has to be terminated b. Salpingectomy + blood transfusion c. Salphingo-oopherectomy 3. Nursing care – combat shock: a. Elevate foot of the bed b. Maintain body heat by hot water bottles and blankets C. HYDATIDIFORM MOLE – developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi 1. Incidence: it is the most common lesion anteceding choriocarcinoma. It occurs most often in women: a. From low socioeconomic backgrounds with low protein intake b. Over 35 years and under 18 years of age 2. Signs and symptoms: a. Because of rapid proliferation of placental tissues and, therefore, high levels of HCG: • Highly positive urine test for pregnancy (that is why a positive pregnancy test cannot be considered a positive sign of pregnancy) • Nausea and vomiting is usually marked • Rapid increase in fundic height b. Toxemia signs and symptoms appear before the 24 th week of gestation c. No fetal heart tones d. Vaginal bleeding seen as clear, fluid-filled grape-sized vesicles 4. Management:
a. D & C to evacuate the mole b. Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma c. Urine testing for one year to find out if new villi are developing. Contraceptives (but not the pills) have to used to as not to confuse the results. D. INCOMPETENT CERVICAL OS – cervix dilates prematurely. It is the chief cause of habitual abortion (=3 or more consecutive abortions) 1. Causes: a. Congenital developmental factors b. Endocrine factors c. Trauma to the cervix 2. Signs and symptoms: a. Presence of show and uterine contractions b. Rupture of membrane c. Painless cervical dilatation 3. Management: McDonal/Shirodkar-Barter procedure – a cerclage procedure wherein purse-string sutures are place around the cervix on the 14 th-18th week of gestation. These are removed during vaginal delivery (if McDonald’s method, since sutures are temporary), or the patient delivers by Cesarean section (if Shirodkar method, since sutures are permanent). E. PLACENTA PREVIA – low implantation of the placenta so that it is in the way of the presenting part. 1. Predisposing factors: a. Increasing parity b. Advanced maternal age c. Rapid succession of pregnancies 2. Types: a. Low lying b. Partial c. Complete 3. Diagnosis – made by means of symptoms and ultrasound – also known as Ultrasonic Echo Sounding or Sonar, uses intermittent waves of very high frequency (above audible range) to “picture the fetus”. Sound waves are projected towards the mother’s abdomen, are reflected back and converted into electrical impulses and recorded on a permanent graph paper. a. Preparation: • Explain the procedure to the patient, informing her that it is painless and there are no known ill effects
Empty the bladder BUT ask the patient to take 6 glasses of water afterwards in order to dilate the bladder. A full bladder displaces the bowel and, therefore, permits better visualization of the pelvis and its contents. b. Clinical uses: • Diagnose pregnancy as early as 5-6 weeks gestational age • Can establish that the fetus is increasing in size and, therefore, can predict EDC • Can determine gestational age by measuring the biparietal diameter of the fetal skill (if it is more than 8.5 cm, it more or less weighs more than 2500 gms); therefore, can diagnose intrauterine growth retardation, hydrocephaly, microcephaly and anencephaly • Can demonstrate size and growth rate of the amniotic sac; therefore, can identify polyhydramnic, oligohydramnios • Can confirm presence, size and location of the placenta; therefore, is valuable in diagnosing previa and H-mole • Can diagnose multiple pregnancy • Can visualize ascites, polycystic kidneys, ovarian cysts, etc. • Can determine baby’s sex (during third trimester and if in cephalic presentation) 4. First and most constant symptom: painless bright red vaginal bleeding due to tearing of placental attachment as a consequence of the dilatation of the internal os 5. Management: a. Complete bed rest b. Monitor vital signs of the mother and the fetal heart rate c. Prepare oxygen and blood d. No attempt is made at doing internal exam. If ever it is to be done, it is done in a double set-up (done in the operating room wherein the patient has already signed the consent form, preop medications have been given, abdominal prep has been done, etc., so that if the placenta is accidentally detached because of the IE, CS can be done immediately). 6. Complications: a. Hemorrhage b. Infection c. Prematurity •
F. ABRUPTIO PLACENTA – premature separation of the placenta. 1. Predisposing factors: a. Maternal hypertension or toxemia
b. Increasing parity and maternal age c. Sudden release of amniotic fluid d. Short umbilical cord e. Hypofibrinoginemia 2. Signs and symptoms: a. Severe, sharp, knife-like, stabbing pain high in the fundus b. Hard, beardlike uterus; rigid abdomen c. Signs of shock d. Concealed bleeding, if extensive, causes the uterus to lose its ability to contract. It becomes ecchymotic and coppercolored, called Couvelaire uterus, causing severe bleeding. Since the uterus no longer has the ability to contract, hysterectomy will have to be done. II. TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) – a vascular disease of unknown cause which occurs anytime after the 24 th week of gestation up to 2 weeks post-partum. It has the following triad of symptoms: hypertension, edema and proteinuria (specifically albuminuria). A. Predisposing factors: 1. Age – primis under 20 and over 30 years 2. Gravida – 5 or more pregnancies 3. Low socioeconomic status (SES) 4. Multiple pregnancy 5. With underlying medical conditions, e.g., heart disease, hypertension or diabetes. B. Pathogenesis: C. Diagnosis: roll-over test – assess the probability of developing toxemia when performed between the 28th and 32nd week of pregnancy. 1. Procedure: a. Patient lies in lateral recumbent position for 15 minutes until BP has stabilized b. Then rolls over to back position c. BP is taken at 1 minute and 5 minutes after having rolled over. 2. Interpretation: if diastolic increases 20 mm Hg, or more, patient is prone to toxemia. Table 10. Classification
I. Acute toxemia – symptoms appear after 24th week of gestation A. Preeclampsia: 1. Mild 2. Severe B. Eclampsia II. Chronic Hypertension with pregnancy
III. Unclassified D. Details: 1. Preeclampsia a. Underlying causes: • Insufficient production of blood and platelets vasoconstriction and associated • Generalized microangiopathy (-disease of capillaries) • Abnormal retention of sodium and water by body tissues b. Medical complications: • Cerebrovascular hemorrhage • Acute pulmonary edema • Acute renal failure c. Types: • Mild preeclampsia • Signs and symptoms: • Sudden, excessive weight gain of 1-5 lbs per week (earliest sing of preeclampsia) due to edema which is persistent and found in the upper half of the body (e.g., inability to wear the wedding ring) • Systolic BP of 140, or an increase of 30 mmHg, or more and a diastolic of 90, or a rise of 15 mmHg or more, taken twice, 6 hours apart • Proteinuria of 0.5 gm/liter or more • Severe preeclampsia • Signs and symptoms • BP of 160/110 mmHg • Proteinuria of 5 gm/liter or more in 24 hours • Oliguria of 400 ml or less in 24 hours (normal urine output in 24 hours = 1560 ml) • Cerebral or visual disturbances • Pulmonary edema and cyanosis • Epigastric pain (considered an aura to the development of convulsions) • Anarsavea/pitting edema; dependent type • Headache • Blurred vision • Oliguria • Epigastric pain (Aura) 2. Eclampsia – the main difference between preeclampsia and eclampsia is the presence of convulsions in eclampsia. a. Signs and symptoms – as in preeclampsia plus: • Increased BUN
• •
Increased uric acid Decreased CO2 combining power
E. Management: 1. Complete bed rest – sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of vasoconstriction and decreased blood flow that diminishes the amount of nutrients and oxygen in the cells. In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling. 2. Diet: a. For mile preeclampsia – high protein, high carbohydrate, moderate salt restriction (no added table salt, (including “bagoong”, “patis” and “toyo”), dired fish (e.g., “daing” and “tuyo”), canned goods, bottled drinks, preserved foods and cold cuts) b. For severe preeclampsia – highprotein, high carbohydrate and salt-poor (3 gms of salt per day) 3. Medications: a. Diuretics – hourly urine output should be at least 20-30 ml (normally 50-60 ml per hour). E.g., chlorothiazide/Diuril. • Pharmacologic effect: decrease reabsorption of sodium and chloride at the proximal tubules, thereby increasing renal excretion of sodium, chloride and water, including potassium. • Side effects: fatigue and muscle weakness due to fluid and electrolyte imbalance • Nursing care: closely monitor intake and output b. Digitalis – if with heart failure • Pharmacologic action: Increase the force and contraction of the heart, thereby decreasing heart rate. Should not be given, therefore, if heart rate is below 60/minute. (Implication: take the heart rate before giving the drug.) c. Potassium supplements – any patient receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the patient to the effects of digitalis. Potassium supplements (e.g. banana) must be given to prevent cardiac arrhythmias. d. Barbiturates – sedation by means of CNS depression e. Analgesics: antihypertensives; antibiotics; anticonvulsants f. Magnesium sulfate – drug of choice •
Actions:
CNS depressant – lessens possibility of convulsions • Vasodilator – decreases the BP • Cathartic – it reduces edema by causing a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 Gms initially, either by slow IV push over 5-10 minutes, or deep IM, 5 Gms/buttock; then IV drip of 1 Gm/hour (1 GM/100 ml D1 xxxxx) IF: • Deep tendon reflexes are present • Respiratory rate is at least 12 per minute • Urine output is at least 100 ml •
•
Antidote for Magnesium sulfate toxicity: Calcium gluconate 10% IV to maintain cardiac and vascular tone • Earliest sing of Magnesium sulfate toxicity: disappearance of the knee jerk/patellar reflex 4. Methods of Delivery – preferably vaginal, but it not possible, CS will have to be done Prognosis: the danger of convulsions is present until 48 hours postpartum. •
F. III.
DIABETES MELLITUS – chronic hereditary disease which is characterized by hyperglycemia due to a relative insufficiency or lack of insulin from the pancreas which, in turn, leads to abnormalities in the metabolism of carbohydrates, proteins and fats. A. Diabetogenic effects of pregnancy – many women who had no evidence of diabetes in the past develop abnormalities in glucose tolerance: 1. Decreased renal threshold for sugar that is why it is not unusual to find sugar in the urine of pregnant women 2. Increased production of adrenocorticoids, anterior pituitary hormones and thyroxins which affect carbohydrate and lipoid metabolism, thus increasing carbohydrate concentration in the blood (- hyperglycemia). 3. Rate of insulin secretion is increased BUT sensitivity of the pregnant body to insulin is decreased, i.e., insulin does not seem to be normally effective during pregnancy. B. Attendant risks: 1. Toxemia 2. Infection 3. Hemorrhage 4. Polyhydramnios 5. Spontaneous abortion – because of vascular complication which affect placental circulation 6. Acidosis – because of nausea and vomiting. Is the chief threat to the fetus in utero.
C.
D.
E.
F.
7. Dystocia – due to excessively large baby Diagnosis – made on the basis of the Glucose Tolerance Test 1. Procedure: a. NPO after midnight b. 2 ml of 50% glucose/3 kg of pre-pregnant body weight is given IV (oral tablet not advisable because of known decreased gastric motility and delayed absorption of sugar during pregnancy) 2. Interpretation of results: a. If less than 100 mg – normal b. If 100-120 mg% - possible gestational diabetes c. If more than 120 mg% - overt gestational diabetes Categories – to predict the outcome of pregnancy 1. Class A – GTT is only slightly abnormal; minimal dietary restriction; insulin not needed; fetal survival is high 2. Class C to E – have 25 % prenatal mortality 3. Class F – therapeutic abortion (in other countries) may be justified Management: 1. Diet – highly individualized. Adequate glucose intake (18002200 calories) is necessary to prevent intrauterine growth retardation 2. Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones are more pronounced during the second half of pregnancy, the insulin requirements during the 2 nd and 3rd trimesters are, therefore, greater. a. Insulin is regulated to keep urine +1 for sugar (minimal) glycosuria is necessary to prevent acidosis, but negative for acetone b. Long-acting insulin (Ultralente) will have to be change to regular insulin (Lente) during the last few weeks of pregnancy. 3. Often delivered by CS because: a. Baby is typically larger or maybe in distress because of placental insufficiency b. Severe metabolic imbalances in vaginal delivery can occur because of depletion of glycogen reserved in the liver and skeletal muscles by strenuous muscular exertion during labor 4. Maximum difficulty in controlling diabetes is during the early postpartum period because of the drastic changes in hormonal levels. Infant of the Diabetic Mother (IDM) 1. Is typically longer and weighs more because of: a. Excessive supply of glucose from the mother
2. 3. 4. 5. 6.
b. Increased production of growth hormones from the maternal pituitary c. Increased secretion of insulin from the fetal pancreas d. Increased action of adrenocortical hormones that favor passage of glucose from mother to fetus Congenital anomalies are more often seen Cushingoid appearance (puffy, but limp and lethargic) More often born premature, so respiratory distress syndrome is common Lose a greater proportion of weight than normal newborns because of loss of extra fluid Are prone to the following complications: a. Hypoglycemia – blood sugar level less than 30 mgs. It is the most common complication to watch for • Cause: while inside the uterus, the fetus tends to be hyperglycemic because of maternal hyperglycemia. The fetal pancreas thus responds to the high glucose level of insulin. Following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high levels of insulin, hypoglycemia develops. • Clinical signs: • Shrill, high-pitched cry • Listlessness/jitterness/tremors • Lethargy; poor suck • Apnea; cyanosis • Hypotonia; hypothermia • Convulsions Consequence: hypoglycemia, if not treated, can lead to brain damage and even death • Management: feed with glucose water earlier than usual or administer IV of glucose b. Hypocalcemia – serum calcium level of less 7 mg%. • Signs: same as hypelycemia Calcium gluconate to prevent • Management: hypocalcemic tetany •
IV.
HEART DISEASE A. Classification: 1. Class I – no limitation of physical activity 2. Class II – slight limitation of physical activity; ordinary activity causes fatigue, palpitation, dyspnea or angina 3. Class III – moderate to marked limitation of physical activity; less than ordinary activity causes fatigue, etc.
4. Class IV – unable to carry on any activity without experiencing discomfort B. Prognosis: 1. Class I and II – normal pregnancy and delivery 2. Class III and IV – poor candidates C. Signs and symptoms: 1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed. 2. Cardiac output may become so decreased that vital organs are not perfused adequately; oxygen and nutritional requirements are not met. 3. Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign. 4. Liver and the other organs become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or ascites. 5. Congestive heart failure is a high probability also because of the increased cardiac output during pregnancy: dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of nailbeds are obvious D. Management: 1. Bed rest – especially after the 30 th week of gestation to ensure that pregnancy is carried to term or at least 36 weeks 2. Diet – should gain enough, but not to much as it would add to the workload of the heart 3. Medications: a. Digitalis b. Iron preparations, e.g., Fer-in-sol or Feosol – anemia should be prevented because the body compensates by increasing cardiac output, thus further increasing cardiac workload. 4. Classes III and IV are not put on lithotomy position during delivery to avoid increasing venous return. The semi-sitting position is preferred to facilitate easy respirations. 5. Anesthetic of choice is caudal anesthesia for effortless, pushless and painless delivery. Remember: Gravidocardiacs are not allowed to push with contractions (to prevent Valsalva maneuver which increase venous return to an already weak, damaged heart). Low forceps, therefore, is the best method of delivery. 6. Ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives are contraindicated because they cause fluid retention and promote thromboembolization. 7. Most critical period – the period immediately foll0owing delivery because the 30%-50% increase in blood volume during
pregnancy will be reabsorbed into the mother’s circulation in a matter of 5-10 minutes and the weak heart must make rapid adjustment to this change. VI. MULTIPLE PREGNANCY (Twin Pregnancy) A. Classification: 1. Monozygotic/Identical – twins begin with a single ovum and sperm, but in the process of fusion or in one of the first cell divisions, the zygote divides into two identical individuals. a. Characteristics: • Always of the same sex • With 2 amnions, 2 chorion, 2 umbilical cords and 2 placentas fused as one b. Incidence – a chance occurrence: • More frequent among non-whites • More frequent among young primis and old multis 2. Dizygotic/Fraternal – two separate ova are fertilized by 2 different sperms. They are actually siblings growing at the same time in utero a. Characteristics: • May or may not be of the same sex • With 2 amnions, 2 chorions, 2 placentas, and 2 umbilical cords b. Incidence – familial maternal patterns of inheritance B. Suspect multiple pregnancy if: 1. Faster rate of increase uterine size 2. On quickening, there are several flurries of action in different abdominal positions 3. On auscultation, 2 sets of fetal heart tones are heard 4. There is marked weight gain, not due to toxemia or obesity C. Compications: 1. Toxemia 2. Polyhydramnios 3. Anemia 4. Abruptic placenta 5. Prematurity 6. Postpartum hemorrhage VII. INSTRUMENTAL DELIVERIES A. Forceps Delivery – use of metal instruments (e.g., Simpson, Elliot, Piper for breech presentation) in order to extract the fetus from the birth canal. Forceps are applied when the fetal head is at the perineum (+3 or +4station) and the sagittal
suture line is in an anteroposterior position in relation to the outlet. 1. Purposes: a. Shorten second stage of labor – primary purpose because of: • Fetal distress • Maternal exhaustion • Maternal disease – cardiac, pulmonary complications, hemorrhage • Ineffective pushing due to anesthesia b. Prevent excessive pounding of fetal head against the perineum (e.g., low forceps for preemies) c. Poor uterine contractions or rigid perineum 2. Prerequisites: prolonged and severe stretching a. Pelvic xxxxxxxxxxxxxxxxxxxxxxxxxxx b. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx c. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx d. Membranes have ruptured e. Vertical presentation has been established f. Rectum and bladder are empty g. Anesthesia is given for sufficient perineal relaxation and to prevent pain 3. Types: a. Low b. Mid 4. Complications: a. Forceps marks –are normal and noticeable only for 24-48 hours b. Bladder or rectal injury, facial paralysis, ptosis, seizures, epilepsy, cerebral palsy are actually rare B. Cesarean Section (CS) 1. Indications: a. Cephalopelvic disproportion (CPD) – most common reason b. Severe toxemia, placental accidents, fetal distress c. Previous classic CS – selective CS – done prior to onset of labor pains 2. Types: a. Low segment – the method of choice. Incision is made in the lower uterine segment which is the thinnest and most passive part during active labor. • Advantages: • Minimal blood loss • Incision is easier to repair • Lower incidence of postpartum infection • No possibility of uterine rupture b. Classic – vertical incision. Recommended in:
Bladder or lower uterine segment adhesions resulting from previous operations • Anterior placenta previa • Transverse lie 3. Preoperative care – patient for CS is both a surgical and an obstetrical patient: a. Check vital signs, uterine contractions and fetal heart rate b. Physical examination; routine laboratory tests, blood typing and cross-matching c. Abdominal is shaved from the level of the xiphoid process/below the nipple line, extending out to the flanks on both sides up to the upper thirds of the thighs. d. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site. e. Preoperative medication is usually only Atropine sulfate. No narcotics are given in order to prevent respiratory depression in the newborn. 4. Postoperative care: a. Deep breathing, coughing exercises; turning from side to side b. Ambulate after 12 hours c. Monitor vital signs d. Watch for signs of hemorrhage – inspect lochia; feel fundus (when boggy, massage with proper abdominal splinting and give analgesics as ordered). e. Breastfeeding, if desired, should be started 24 hours after delivery (anestheti9c can be transmitted through breastmilk) 5. Most common complication: pelvic thrombosis •
VIII. INDUCED LABOR – to bring out labor either by amniotomy or drugs (oxytocin or prostaglandins) before the time when it would have occurred spontaneously or because it does not occur spontaneously. A. Indications: 1. Maternal a. Toxemia b. Placental accidents c. Premature rupture of the BOW 2. Fetal a. Diabetes – terminated about 37 weeks GA if indicated b. Blood incompatibility with rising titer c. Excessive size d. Postmaturity B. Prerequisites: 1. No CPD 2. Fetus is viable – survival is decreased if below 32 weeks CA 3. Single fetus is longitudinal lie and is engaged
4. Ripe cervix – fully or partially effaced; dilated at least 1 – 2 cm C. Procedure 1. Oxytocin administration: a. 10 IU of Pitocin in 1000 ml of D 5W at a slow rate of 8 gtts/minute given initially. If no fetal distress is observed in 30 minutes, infusion rate is increased 16-20 drops per minute. b. Amniotomy will be done when cervical dilatation reaches 4 cm. Check FHR and quality of fluid after amniotomy. c. Nursing care • Primary concern: monitor intensity of uterine contractions. Remember: if uterine contractions are unduly sustained uterine rupture can occur. • Monitor flow rate regularly • Turn off IV drip if with abnormalities in FHR or uterine contractions • Watch out for: • Hypertension – oxytocin is a vasoconstrictor • Antidiuresis leading to water intoxication Headache and vomiting • Convulsions, coma, even death 2. Prostaglandin administration: a. Route: Either oral or IV, never IM, because it causes tissue irritation b. Effect: compared to oxytocin, the onset of contraction is slower. •
IX.
INFECTIONS A. Syphilis 1. Cause: Treponema pallidum – a spirochete which enters the body during coitus or through cuts and other breaks in the skin or mucous membrane. 2. Treatment: 2.4 – 4.8 million units of Penicillin (if allergic, 30 – 40 gms. of erythrocin) will usually prevent congenital syphilis in the newborn because Penicillin readily crosses the placenta. If untreated, syphilis can cause midtrimester abortion, CNS lesions in the newborn or even death. 3. The newborn with congenital syphilis a. Signs and symptoms: • Jaundice at 2 weeks of life – first signs of the disease • Anemia and hepatosplonomegaly • “snuffles” (persistent rhinorrhea); coppery rashes on plams and soles; mucous patches; condylomas; pseudoparalysis due to bone inflammation
If untreated, can progress on to deformed bones, teeth, nose, joints and CNS syphilis b. Management: Penicillin IM for 10 days or one long-acting Penicillin (Penadur LA) •
B. Rubella/German Measles 1. Incidence: a. Mother – the earlier the mother contacted the disease, the greater the likelihood that the baby will be affected. The rubella virus slows down division of infected cells during organogenesis. b. Newborn – can carry and transmit the virus for as long as 1224 months after birth 2. Signs and symptoms of Congenital Rubella Syndrome: a. Low birth weight; jaundice; petechiae; anemia; thrombocytopenia; hepatosplenomegaly b. Classes sequelae; • Eyes: choricretinitis, cataract, glaucoma • Heart: Patent Ductus arteriosus, stenosis, coarctations • Xxxx nerve deafness • Dental and facial clefts X.
BLOOD INCOMPATIBILITY – excessive destruction of fetal red blood cells which occurs when the: A. Mother is Rh negative and the fetus is Rh positive (because the father is either a homozygous or a heterozygous Rh positive) B. Mother is Type O and the fetus is either Type A or Type B (because the father is either Type A or B)
XI.
MISCELLANEOUS RISK FACTORS A. Age – maternal and infant mortality rates tend to be high in cases in which the mother is younger than 15 or older than 40. 1. Adolescent pregnancy – is a high-risk pregnancy from both a physical and a psychosocial standpoint. Physical, because of rapid growth of both the pregnant adolescent and her fetus, causing possible depletion of nutritional reserves. Psychosocial, because adolescence is a crisis period by itself, compounded by the situational crisis of pregnancy, plus the fact that most pregnant adolescents are unwed adolescents. a. Most common problems of pregnant adolescents: • Toxemia • Iron-deficiency anemia 2. Advanced age – is a precipitating factor in: a. Placental accidents b. Toxemia c. Uterine atony or inertia
d. Varicosities; hemorrhoids e. Low birth weight babies f. Chromosomal abnormalities, e.g., Down’s syndrome/Trisomy 21/Mongolism, commonly associated with menopause: • Mechanism – a transitional phase, called the elimacterie, heralds the onset of menopause. During this 1-2 year period, the monthly menstrual flow occurs less frequently, is irregular and diminished in amount. Ovulatory and anovulatory periods, however, occur (that is why contraceptive methods are advised until the menses have been absent for at least six continuous months). After there have been periods for one year, menopause is said to have occurred. •
Classic signs: • Vasomotor changes due to hormonal imbalances: • Hot flushes (head, neck, upper thorax) • Excessive sweating especially at night
changes – insomnia, headache, Emotional palpitations, nervousness, apprehension, depression • Tendency to gain weight more rapidly • Tendency to lose height because of osteoporosis (“dowager hump”) • Arthralgias and muscle pains • Loss of skin elasticity and subcutaneous fat in labial folds • Artificial menopause/surgically-induced menopause – results from: • Ocphorectomy or irradiation of ovaries • Panhysterectomy (more hysterectomy will not lead to menopause since ovaries are still intact; only menstruation will be absent) B. Parity – first pregnancy is the period of highest risk. Risk increases steadily from gravida 5 and above, especially when the mother is over 40 years of age. C. Birth interval – a subsequent pregnancy within 3 months of a previous delivery is high risk, as much as a birth interval of more than 5 years. D. Weight 1. A pre-pregnant weight of less than 70 lbs or more than 180 lbs is a risk factor 2. A weight gain during pregnancy of less than 10 lbs can lead to low birth weight babies, prematurity, abortion, stillbirth and toxemia. A weight gain of more than 30 lbs during pregnancy maybe a sign of toxemia, diabetes, poly-hydramnios, H-mole or multiple pregnancy. •
E. Height – a primi of short stature (less than 4 feet, 10 inches) could mean a contracted pelvis or cephalopelvic disproportion.
THE NEONATES DEFINITION: The first 28 days of life. PRINCIPLES OF NEWBORN CARE
I.
Establish and maintain patent airway. A. Never stimulate a baby to cry unless secretions have been drained out. B. The position should be one that promotes drainage of secretions (head lower than the rest of the body) EXCEPT when there are signs of increased intracranial pressure (vomiting: bulging, tense fontanelles; abnormally large head; increased BP, decreased PR and RR and widening pulse pressure; shrill, high pitched cry), in which case, the head should be higher than the rest of the body. C. Suction the newborn properly: 1. Turn the baby’s head to one side 2. Suction gently and quickly – prolonged and deep suctioning of the nasopharynx during the first 5-10 minutes of life will stimulate the vagus nerve (located in the esophagus) and cause bradycardia. 3. Suction the mouth first before the nose – when suctioning the nose, the stimulation of the nasal mucosa will cause reflex inhalation of pharyngeal material into the trachea and bronchi, causing aspiration.
4. To test for patency of the airway, occlude one nostril at a time (REMEMBER: Newborns are nasal breathers). If the newborn struggles when a nostril has been occluded, additional suctioning is indicated. II.
III.
Maintain appropriate body temperature. Chilling will increase the body’s need for oxygen. The newborn suffers large losses of heat (cold stress) because he is wet at birth, the delivery room is cold, he does not have enough adipose tissues and does not know how to shiver. Effect of cold stress: • Metabolic acidosis – one of the ways by which heat is produced in the newborn is by increasing metabolism. When this occurs, fatty acids accumulate because of the breakdown of brown fat (seen only in newborns). • Hypoglycemia – due to the use of glucose stored as glycogen A. Dry the newborn immediately B. Wrap him warmly C. Put him under a droplight
Immediate assessment of the newborn A. Apgar score – standardized evaluation of the newborn’s condition. Done at one minute after birth to determine the general condition and then at 5 minutes to determine how well the newborn is adjusting to extra uterine life. Table 11. Apgar Score
SIGN
0
1
2
1. Hear rate *
Absent Absent Limp, flaccid No response Pale, blue
100 Weak cry Some flexion of extremities Grimace; weak cry Extremities blue, body pink
100 Good, strong cry Well-flexed extremities Sneeze; good strong cry Pink all over
2. 3. 4. 5.
Respiratory effort Muscle tone ** Reflex Color
* Most critical observation ** The general attitudes of the baby at birth is that of flexion 1. Interpretation of results: a. 0 – 3 - the baby is in serious danger and needs immediate resuscitation b. 4 – 6 - condition is guarded and may need more extensive clearing of the airway c. 7 – 10 - baby is in the best possible health
B. Assessment of gestational age 1. Methods of estimating gestational age: a. Mother’s LMP (Naegele’s Rule) b. Fundic height (McDonald’s method) c. Bartholomew’s rule d. Time quickening is first felt e. Time fetal heart tones are first heard f. Ultrasound g. Assessment of newborn at birth Table 12. Clinical Criteria for Gestational Age Assessment SIGN
Till 36 weeks
37 – 38 weeks
39 weeks
Anterior transverse Occasional creases, Sole covered with creases crease only anterior two-thirds 2 mm 4 mm 2. Breast nodule diameter 7 mm 1. Sole creases
3. Scalp hair
Fine & fuzzy
4. Earlobe
Pliable no cartilage Some cartilage
5. Testes and scrotum
Testes in scrotal sac
C.
Fine & fuzzy
lower Intermediate
Coarse & silky Stiffened by thick cartilage Testes pendulum scrotum with extensive rugae
Cephalometry – measurement of diameters of the skull: subeccipitobregmatic, bipatrietal, occipitofrontal, occipitomental, bitemporal
IV. Proper Identification – of the newborn must be done in the delivery room before bringing to the Nursery. Footprints are said to be the best way which identify newborns. V. Nursery Care A. Check identification band B. Take anthropometric measurements: 1. Length – average: 50 cm (20 in.) = 19 - 21 ½ inches (47.553.75 cm.) 2. Head circumference = 33 – 35 cm. 3. Chest circumference = 31 – 33 cm. 4. Abdominal circumference = 31 – 33 cm. C. Take the temperature – at birth is 37.2oC or 99oF, but because of evaporation from the moist skin and the cool delivery room, will stabilize in 8 hours time and must be maintained at 35.5 oC – 36.5oC (97oF – 99oF) so as to prevent hypoglycemia and acidosis due to hypothermia. Axillary and rectal temperatures are approximately the
same immediately following birth but the rectal route is preferred in order to check patency of the anus. D. Specific nursing actions: 1. Give initial oil bath to cleanse the baby of blood, mucus and vernix 2. Dress the umbilical cord. Inspect for the presence of 2 arteries and 1 vein. Suspect a congenital anomaly if blood vessels are not complete; a more thorough physical assessment is indicated and closer observation in an ICU is done. 3. Crede’s prophylaxis – prophylactic treatment of the newborn’s eyes against gonorrheal conjunctivitis (ophthalmic neonatorum) which the baby acquires as he passes through the birth canal of his mother who has untreated gonorrhea: a. Wipe and face dry. b. Shade the eyes from light and open one eye at a time by exerting gentle pressure on the upper and lower lids. c. 2 drops of 1% silver nitrate are instilled one at a time into the lower conjunctival sac. (Be careful not to drop on the cheeks because parents may worry about the stain) d. Wash silver nitrate away with sterile NSS after 1 minute to prevent chemical conjunctivitis (inflammation, edema, purulent discharge) e. Penicillin/chloromycetin/terramycin ophthalmic ointment may be used since it does not irritate the eyes (although the baby may develop sensitivity at an early age). Apply from the inner to the outer canthus of the eye. 4. Vitamin K administration a. Rationale: Vitamin K facilitates production of the clotting factor, thus preventing bleeding. But Vitamin K is synthesized in the presence of normal bacterial flora in the intestines. Since the newborn’s intestines are still relatively sterile, therefore, they will not be able to synthesize Vitamin K; that is why synthetic Vitamin K is given to prevent hemorrhage.) 1 mg. Aquamephyton (generic name is b. Method: phytonadione) is injected IM into the lateral anterior thigh (vastus lateralis). In children below 12 months of age how have not yet learned how to walk, this is the preferred site of injection because gluteal muscles are not yet fully developed. 5. Weight-taking a. Average birth weight = 6 ½ - 7.5 lbs = 3 – 3.4 kgs = 300 – 3400 gms. b. Arbitrary lower limit – below which the newborn is said to be of low birth weight: 5.5 lbs = 2.5 kgs = 2500 gms.
c. Ideal procedure • Weigh the clothes first • Put on the baby’s clothes • Weigh the baby with his clothes on • Subtract the weight of the clothes from the total weight of the baby and his clothes d. Physiologic weight loss of 5 – 10% of birth weight (6-10 oz) during the first 10 days of life because the newborn: • Is no longer under the influence of maternal hormones • Voids and passes out stools • Has limited intake • Has beginning difficulty establishing sucking 6. Feeding a. Initial feeding – is a test feeding consisting of an ounce of sterile water (glucose water has been found to irritating to the lungs if aspirated) is given to find if the newborn can swallow without aspirating. b. Subsequent feedings – preferably given by demand E. Physical Assessment 1. Pulse – normally irregular and 120-140 per minute. Apical pulse (stethoscope below the left nipple) is recommended since radial pulses are not ordinarily palpable (if prominent, in fact, may b ea sign of congenital heart anomaly). 2. Respirations – are gentle, quiet, rapid but shallow; normally 3060 per minute. Largely diaphragmatic and abdominal (watch for the rise and fall of the chest and abdomen). 3. Blood pressure – not routinely measured in newborns unless coarctation of the aorta is suspected. a. Normal values: • At birth – 80/46 mm Hg • After 15 days – 100/50 mm Hg b. Size of cuff in children: Must not be more than 2/3 the size of the extremity (will result in false low BP) nor less than ½ the length of the extremity (will result in false high BP). c. Procedure – flush method: • Cuff is applied to an extremity • Extremity is elevated and an elastic bandage is wrapped around the distal portion of the extremity • Slowly inflate the cuff up to 100 mm Hg, then remove the bandage (extremity is expectedly pale) • As soon as the extremity turns pink (flushes), read the manometer.
•
Only one reading can be obtained, the average between the diastolic and the systolic pressures, called flush pressure (therefore, is normally 60).
4. Skin a. Color – normally ruddy because of the increased concentration of RBCs and the decreased amount of subcutaneous fat • Acrocynosis – body pink, extremities blue. Normal during the first 24-48 hours of life. • Generalized mottling is common due to an immature circulatory system • Pallor – due to anemia which results from excessive blood loss when cord is cut, inadequate blood flow from cord to infant at birth, inadequate iron stores because of poor maternal nutrition. May also be due to blood incompatibility. • Gray color – indicated infection • Jaundice – yellowish discoloration of the skin sclerae: • Cause: Inability of the newborn to conjugate bilirubin. • Normal Values • Total bilirubin = 15 mg% • Direct bilirubin = 1.7 • Indirect bilirubin = 13.3 •
•
•
•
•
•
Most accurate method of assessing presence of jaundice: Use natural light and blanch skin on the chest or tip of the nose Physiologic jaundice – from the 2nd to the 7th day of life. • Breastfed babies, however, have longer physiologic jaundice because human milk has pregnanediol which depresses the action of glucose xxxxxxxxxxxxxxx (the enzyme responsible for converting indirect bilirubin to direct bilirubin) Harlequin Sign – because of immaturity of circulation, an infant who ahs been lying on his side will appear red on the dependent side and pale on the upper side. Mongolian spots – slate-gray patches seen across the sacrum/buttocks and consist of collections of pigment cells (melanocytes). Disappear by school age. Seen only among Southern European, Asian and African children. Lanugo – fine, downy hair that covers the shoulders, back and upper arms. Desquamation – drying of newborn’s skin
Cephalhematoma – due to increased intravascular pressure during delivery • Milia – unopened sebaceous glands found on the nose, chin and cheeks; disappear spontaneously by 24 weeks. 5. Head – largest part of the infant’s body (1/4 of his total length). a. Forehead is large and prominent b. Chin is receding and quivers when startled or crying c. Fontanelles are neither sunken (a sign of dehydration) nor bulging (a sign of increased intracranial pressure) d. Suture lines should neither be separated nor fontanelles prematurely closed (-craniosynostosis; leads to mental retardation) e. Craniotabes – localized softening of the cranial bones can be indented by pressure of a finger. Corrects itself without treatment after some months. More common among firstborns because of early lightening. •
Table 13. Comparison between Caput and Cephalhematoma INDICATORS
CAPUT SUCCEDANEUM
CEPHALHEMATOMA
Location
Presenting part of the head
Between periosteum of skill bone and the bone itself
Extent of Involvement
Both hemispheres
Confined to an individual bone; does not cross suture lines
Cause
Pressure (as in prolonged labor) Rupture of capillaries due to pressure
Definition
Edema of the scalp
Period of absorption significant differences)
(most On or about the third day None
Treatment
Collection of blood
Takes several weeks None; support the anxious parents
6. Eyes a. Method of assessment: Put infant on upright position b. Characteristics: •
• •
Cry tearlessly during first 2 months because of immature lacrimal ducts Cornea should be round and adult-sized Pupils should be round, not key-holed (- coloboma).
7. Ears – level of top part of external (should be in line with outer canthus of the eye. If set lower, maybe a sign of kidney malfunction or Down’s syndrome 8. Nose – may appear large for the face; there should be no septal deviation 9. Mouth a. Should open evenly when crying; if not, suspect cranial nerve injury b. Tongue appears large c. Palate should be intact; no break on the lips d. Epstein’s pearls – 1 or 2 small, round, glistening cysts seen on the palate; due to extra load of calcium while in utero e. A tooth may be seen; if loose, should be extracted to prevent aspiration when feeding. f. Oral thrush – white or gray patches on the tongue and side of the cheeks due to Candida albicans acquired during passage of the baby through the birth canal of the mother with untreated Moniliasis; also known as oral moniliasis. 10. Neck a. Thyroid gland is not palpable b. Appears soft and chubby and creased with skin folds c. Head should rotate freely on the neck and flex forward and back 11. Chest – as large as, or smaller than, the head: a. Should be symmetrical b. Breasts maybe engorged, a result of the influence of maternal hormones c. Witch’s milk – thin, watery fluid also due to maternal hormones 12. Abdomen: a. Liver, spleen and kidneys are palpable at birth. Liver is about 1-2 cm below the right costal margin b. Normally dome-shaped; if scaphoid, suspect Diaphragmatic Hernia 13. Anogenital area a. Take note of the time meconium is first passed (it should be within the first 24 hours of life) b. Female genitalia: may have swollen labia and drops of blood due to maternal hormones c. Male genitalia: • Scrotum maybe edematous – also due to maternal hormones • Foreskin should be retracted to test for phimosis (-tight foreskin)
Testes should be present; if not descended, the condition is called crypto-orchidism (repair of undescended testes is called orchidopexy). • Circumcision – maybe done prior to discharge from the nursery, preferably by the end of the first week. • Procedure: • Vitamin E injected IM • Infant is restrained; penis is cleansed with soap and water • Yellen clamp is used • Petrolatum gauze dressing is applied to prevent adherence of circumcised site to the diaper while applying pressure to prevent bleeding • Nursing care: • Check hourly for bleeding (most common complication) during the first day. If small amount of bright red blood is observed, apply gentle pressure to the area with a sterile gauze pad • Do not attempt to remove exudate which persists for 2-3 days. Just wash with warm water • Diaper must be pinned loosely during first 2-3 days when the base of the penis is tender 14. Back – on prone, appears flat (curves start to form only when sitting or waling has been achieved). 15. Extremities a. Arms and legs are short; hands are plump and clenched into fists b. Should move symmetrically c. Abnormalities: • Erb-Duchenne paralysis/Brachial plexus injury • Causes: • Lateral traction exerted on head and neck during delivery of the shoulder in vertex presentation • Excessive traction on the shoulders during breech extraction, especially when the arms are extended over the head • Signs and symptoms: • Inability to abduct arm from the shoulder, rotate arm externally or supinate forearm • Absent Moro reflex on affected arm • Some sensory impairment in the outer aspect of affected arm • Management: Abduct the affected arm in external rotation position with the elbow flexed •
•
Congenital hip dislocation/dysplasia • Signs and symptoms: • Assist in replacing head of the femur into the acetabulum of the hip bone by using 3 diapers instead of one, or by putting a pillow between the thighs to maintain abduction of the thighs and flexion of the hip and knee joints • Infant preferably carried astride mother’s hip • Hip spica cast is applied at a later age, before the infant starts to walk. Cast extends from the waistline to below the knee of the affected leg and above the knee of the unaffected leg. If treatment is delayed (after the baby has already learned how to walk), the child will become xxxxxxxxx walk with xxxxxxxxxxxxx at a later age.
F. Systemic Evaluation 1. Cardiovascular System a. Major Differences in fetal circulation: • Exchange of oxygen and carbon dioxide takes place in the placenta, not in the fetal lungs • Because little blood goes to the fetal lungs, pressure in the left side of the fetal heart is less than the pressure in the right side of the fetal heart. • Presence of fetal accessory structures: • Foramen ovale – bypasses the pulmonary circulatory system since it is the opening between the right and left atria • Ductus arteriosus – communication between the pulmonary artery and the aorta • Ductus venosus – communication which bypasses the liver • Umbilical vein – carries the most highly oxygenated blood • Umbilical arteries – carry deoxygenated blood b. Neonatal/adult circulation – as soon as breathing has been initiated, oxygenation now takes place in the newborn’s lungs. The change from fetal to neonatal circulation is, therefore, associated with lung expansion, causing pressure in the left side of the newborn’s heart to become higher compared to pressure in the right side of the newborn’s heart. •
Increased pressure on the left side of the newborn’s heart results in: • Closure of the foramen ovale
Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum) • The decreased pressure on the right side of the newborn’s heart causes the ductus venosus to become a mere ligament (ligamentum venosum) • Since no more blood goes through the umbilical vein and arteries, these blood vessels atrophy and degenerate. c. Blood values – are all high in their newborn period as a response to the pulmonary circulation: 3 • Red blood cells – 6 millon/ml • Hemoglobin – 17-18 Gms % • Hematocrit – 52% 3 • White blood cells – 15,000 – 45,000 per ml . A high WBC count during the newborn period, therefore, is not a sign of infection; with or without infection all newborns have high WBC count. 2. Gastrointestinal tract – differences in stools: a. Colostrum – xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx formed from mucus, vernix, lanugo, hormones and carbohydrates that accumulated while in utero b. Transitional – on the 2nd to the 10th day of life in response to the feeding pattern; are xxxx, green and loose, resembling diarrhea to the untrained eye c. Breastfed – golden yellow, xxxxx, more frequent (3-4 times/day) and sweet-smelling because breast is high in lactic acid which reduces the amount of putrefactive organisms d. Bottlefed – pale yellow, firm, less frequent (2-3 times/day) and with a more noticeable odor 3. Urinary system – newborns should avoid within the first 24 hours of life a. Female newborn – form a strong stream when voiding b. Male newborn – form a small produced arc when voiding. If not, suspect a defect in the urethral meatus: • Epispadia – urethral meatus located in the ventral (under) surface of the penis • Hypospadia – urethral opening located in the dorsal (above) surface of the penis • Management: • Inspect for cryptoorchidism often found associated with hypo-/epispadias • Meatotomy is done to establish better urinary function • When the child is older (12-18 months), adherent chordae (-fibrous bands that cause the penis to curve •
downward) may be released surgically. If repair will be extensive, surgery might be delayed until 3-4 years old. • Child should not be circumcised because at the time of repair, the surgeon may wish to use a portion of the foreskin • Surgical correction is done before school age so that the child appears normal to his schoolmates 4. Autoimmune system a. Type of immunity transferred from mother to newborn: passive natural immunity b. Newborns have antibodies from the mother against poliomyelitis, diphtheria, tetanus, pertussis, rubella and measles (present in the infant for one year). But little or no immunity against chickenpox (that is why chickenpox is often fatal in the newborn). c. Newborns have difficulty forming antibodies until 2 months of age (that is why immunizations are started at 2 months). 5. Neuromuscular system a. Blink reflex – rapid eyelid closure when strong light is shone; always present b. Feeding reflexes: • Rooting reflex – head will turn to the direction where cheek is stroked near the corner of the mouth; will help infant find food; disappears by 6 weeks of age when infant is already capable of seeing things past the visual midline. • Sucking reflex – anything placed between the lips will be sucked; disappears by 6 months. IMPORTANT: Sucking reflex disappears immediately if not stimulated regularly. IMPLICATION: Any infant who will be put on NPO should be given a pacifier not only for psychological reasons, but also to prevent premature disappearance of the sucking reflex. • Extrusion reflex – anything placed on the anterior portion of the tongue will be spit out; disappears by 4 months of age when infant is about ready for semi-solid foods. • Swallowing reflex – anything place at the back of the tongue will be swallowed and will never disappear. c. Tonic neck reflex – (TNR)/Fencing reflex/boxer reflex – when on his back, the infant’s arm and leg are extended on the side where the head is turned, while the arm and the leg on the opposite side are flexed; disappears by 2-3 months d. Babinski reflex – when side of the sole is stroked with a “j” from heel upward, the infant will fan out his toes; starts to disappear by 3 months of age. (If the adult’s sole is stroked, the adult will curve in his toes). e. Landau reflex – when on prone, the newborn should demonstrate some muscle tone; a test of spinal cord integrity
f. Palmar or plantar grasp/step-in-place reflexes – accessory reflexes. g. Moro reflex – singular most important reflex indicative of neurological status. If he bassinet is jarred or the infant’s head is allowed to drop backward in supine position (change infant’s equilibrium), the infant will abduct and then adduct his arms. Disappears by 4-5 months. 6. Senses – all are functional at birth: a. Sight – all newborns can see at birth, although they cannot see objects past the visual midline (not until 6-8 weeks). The visual field is 20-22 cm or 9 inches b. Hearing – as soon as amniotic fluid has been absorbed, the newborn can already hear c. Taste – as soon as secretions have been suctioned, newborns can already taste d. Smell – as soon as the nose has been cleared of mucous and fluid, newborns can smell e. Touch – the most developed of all the senses G. Discharge Instructions 1. Bathing – maybe given anytime convenient for the parents as long as it is not within 30 minutes after a feeding because the increased handling during bathing can cause regurgitation. Sponge baths are done until the cord falls off (7th-14th day). 2. Cord care a. Fold down diapers so that cord does not get wet during voiding b. Dab rubbing alcohol (10%) once or twice a day c. Small, pink granulating area may be clean on the day of the cord falls off. If remains moist for a week, advise mother to bring baby to the doctor’s clinic where cautery with silver nitrate stick will be done to speed healing. 3. Nutrition a. Recommended Daily Allowances • Calories – 120 cal/kg body weight (KBW) = 50-55 cal/lb body weight = more or less 3000 cal/day • Proteins = 96 Gms/KBW/day • Fluids = 16-20 cc/KBW = 2.5 – 3 oz per lb body weight = more or less 20 oz/day • Vitamins – Vitamins A, C and D are recommended for both bottlefed and breastfed babies during the entire first year of life. NUTRIENTS Protein
HUMAN MILK 8%
COW’S MILK 20%
Fats Carbohydrates Sodium Potassium Calcium Phosphorus Chloride
50% 42% 7 mEq/liter 14 mEq/liter 12 mEq/liter 9 mEq/liter 12 mEq/liter
50% 30% 25 mEq/liter 36 mEq/liter 61 mEq/liter 53 mEq/liter 34 mEq/liter
Table 14. Comparison Between Human Milk and Cow’s Milk c. Differences between human milk and cow’s milk • Human milk contains less proteins. Cow’s milk has more proteins but the newborn’s kidneys become overwhelmed with the higher protein content of cow’s milk that is why cow’s milk need to be diluted. The main protein in human milk is lactalbumin; the main protein in cow’s milk is casein. Since the curd tension in milk is related to the amount of casein, the curd in cow’s milk is therefore larger, tougher and more difficult to digest (that is why bottlefed babies have frequent constipation). Heating reduces the curd, that is why cow’s milk must be sterilized or pasteurized so newborns can digest it. •
•
Human milk and cow’s milk have similar fat content; but, fatty acid, which is necessary for growth and skin integrity, is three times higher in human milk than in cow’s milk. Besides, human milk has larger fat globules. Human milk contains more carbohydrates. Moreover, lactose in human milk appears to be the most easily digestible of all the sugars; it also improves calcium absorption and aids in nitrogen retention.
Cow’s milk has more minerals but, again, newborn’s kidneys become overwhelmed with the high mineral content of cow’s milk that is why it has to be diluted first. d. Similarities between human milk and cow’s milk • Both of them should be given by demand feeding • Both bottlefed and breastfed babies should be burped at least twice during a feeding – midway and after the feeding • Both have the same energy value = xxxxxxxxxxxxxx • Both are deficient in iron 4. Common health problems a. Constipation – more common among bottlefed infants. Management: • Add more fluids or carbohydrates/sugar • If due to an unusually tight anal sphincter, dilate twice or thrice a day by means of a gloved little finger •
b. Loose stools – careful history should be taken; management depends on cause c. Colic – paroxysmal abdominal pain common in infants below 3 months of age • Causes: • Overfeeding • Gas distention • Too much carbohydrates • Tense and unsure mother Management: • Feed by self-demand. It is the best schedule because it meets the individual needs of the newborn • Tell mother to burp the infant at least twice during a feeding • Feed baby in upright position • May need to change formula, as per doctor’s order • Reduce energy content of formula d. Spitting up – due to poorly developed cardiac sphincter; more common among bottlefed infants. Will disappear when coordination with swallowing is achieved and digestion improves. Management: • Feed in upright position because gravity will aid in gastric emptying • Position on right side after feeding • Bubble/burp more frequently e. Skin irritation – maybe due either to poor hygiene or irritation from urine, feces and some laundry products. Management: •
Expose to air – most important • Careful washing and rinsing away of irritating soap from the skin • Starch bath, if a case of measles (ruboela) f. Occasional “crossed eyes” – normal in many babies because the eye muscles of coordination have not yet fully developed will disappear spontaneously g. Cradle cap – involves the sebaceous glands; due to poor hygiene. Management: apply mineral oil or Vaseline on the scalp at night before giving shampoo in the morning 5. Clothing the newborn – rule of thumb: if the mother feels warm, keep the baby cool; if the mother feels cold, keep the baby warm. 6. Sleep patterns – babies sleep 16-20 hours a day. •
RISK NEWBORNS
I. Premature Babies – born before the 38th week of gestation A. Terminologies 1. Small-for-gestation age (SGA) – birth weight is less than expected for the specific gestational age. E.g., a baby born on the 38th week of gestation who weighs 5 lbs. 2. Appropriate-for-gestational age (AGA) – birth weight expected for the specific gestational age. E.g., a baby born on the 34 th week of gestation who weighs 5 lbs. 3. Large-for-gestational age (LGA) – birth weight more than expected for the specific gestational age. E.g., a baby born on the 36 th week of gestation who weighs 8 lbs. B. Characteristics 1. Have underdeveloped subcutaneous tissues and less fat to act as insulation. Are thin-skinned. This is the reason why rapid drying and warming inside incubators are important. In incubator care: a. Temperature = 92o – 94oF (33.3o – 34.4oC) b. Humidity = 55 – 65% c. Frequent positioning on the right side will favor closure of the foramen ovale because of the increased pressure of the left ventricle Are poikilothermic (- easily take on the temperature of the 2. environment). Temperature stabilizes at a lower rate: 35 o – 36oC. Take the axillary, not the rectal temperature before crying will mean increased energy expenditure. (Important: A special consideration in the care of premature babies is conservation of energy for growth and development.) 3. Physiologic weight loss is exaggerated. 4. General activity is more feeble and weak; they often assume frog-like position; extremities have less muscle tone (scarf sign – elbow passes the midline of the body; square window wrist – wrist at a 90 o angle). 5. CNS centers for respiration are underdeveloped, which results in irregular breathing with short periods of apnea. Oxygen administered should never be more than 40% because it can lead to retrolental fibroplasias (- an overgrowth of retinal blood vessels causing blindness). 6. Nutritional requirements – are high in order to maintain rapid growth appropriate for the developmental stage. Birth weight, kidney and GIT functioning should be considered in determining nutritional requirements of the preemies. a. Method of feeding – basically by NGT. • Rationale • Prematures often have ineffective sucking which is not coordinated with swallowing and, therefore, may aspirate.
Minimal handling is necessary in order to conserve energy. Procedure • Determine the distance to which the NGT is to be inserted by measuring from the ear lobe to the nose to the distal end of the sternum • Mummify (restrain) the baby as the NGT is being inserted • Check location after NGT has been inserted: • Submerge tip of the NGT in a glass of water; if bubbles appear, it is inside the lungs • Inject 5 cc. of air, then auscultate. If no sound is heard as air is injected, it means that the NGT is not in the stomach but in the lungs • Aspirate contents; if acids are aspirated, the NGT is in the stomach • Determine amount of residual milk or undigested milk and subtract the same amount from the next feeding because this means that the baby is not able to digest all the milk that is given to him. Be sure to put back the residual milk since it contains acids and the baby can develop metabolic alkalosis if not give back to the baby. •
•
•
•
•
Keep the NGT always closed to avoid abdominal distention Fill syringe with formula before opening NGT; let formula flow by gravity Feed with sterile water after the formula in order to prevent clogging the NGT.
C. Special Problems 1. Hyperbilirubiremia – because of immaturity of the liver, kernicterus (-staining of brain cells with bilirubin, causing brain damage or even death) appears to occur at a lower bilirubin level. Management: phototherapy – photooxidation by the use of artificial blue light in order to convert bilirubin into an excretable form. Nursing responsibilities in phototherapy care: a. Expose all areas of the body to light by turning the infant every 2 hours b. Cover eyes and genitalia c. Give plenty of fluids to prevent dehydration d. Check for loose stools and increased body temperature •
Hypoxia increases capillary permeability, causing effusion from the pulmonary capillaries into the alveoli and terminal bronchioles
Hyalin-like membrane forms around the alveoli and bronchioles, causing further hypoxia • Atelectasis, the chief lesion of RDS, thus occurs. b. Signs and symptoms: • Expiratory grunting – major symptom • Increased respiratory rate • Flaring alae nasi • Cyanosis; retractions; rales • Respiratory acidosis • Blood values: • Low pH level (normal = 7.35 – 7.45) • Low pO2 level (normal = 40 – 60 mm Hg) • High pCO2 level (normal = 35 - 45) c. Management: • Monitor vital signs, arterial blood gases, skin color, muscle tone • Proper positioning; NPG; IV; NGT care • Oxygen; high humidity; warmth; CPAP • Suction PRN • Prevent complications • Sodium bicarbonate – for acidosis •
II. Postterm/Postmature Babies – born after the 42nd week of gestation
A.
Classic signs – “old man faces”; evidence intrauterine weight loss, dehydration and chronic hypoxia. 1. Long and thin 2. Cracked skin which is loose, wrinkled and stained greenish-yellow, with no vernix nor lanugo 3. Long nails; firm skull 4. Wide-eyed alertness of a one month old baby B. Management: 1. Monitor vital signs 2. IV, as ordered C. Outlook: reasonable III. Tracheoesophageal Fistula A. Definitions 1. Esophageal atresia – failure of the esophagus to form a continuous passage from the pharynx to the stomach 2. Tracheoesophageal fistula – abnormal sinus connection between the esophagus and the trachea. B. Type
1. Type I/A – upper and lower segments of the esophagus are blind; no connection to the trachea 2. II/B – upper end of esophagus opens in the trachea; blind lower segment 3. III/C – upper end is blind, lower end connect into the trachea. Most common type (85%) 4. IV/D – both upper and lower ends of the esophagus open into the trachea by a fistula 5. Type V/E – “H” type; no esophageal atresia but with fistula; rare type 6. Type VI/F – stenosis occurs 2/3 of the way down the esophagus. Obstruction may be partial or complete. C. Clinical manifestations 1. Excessive amount of secretions – outstanding symptom which occurs soon after birth: a. Constant drooling b. Large amounts of secretions from the nose 2. Intermittent cyanosis – due to aspiration from the blind upper pouch 3. Abdominal distention – air from trachea passes through the fistula into the stomach 4. When fed, infant responds violently after first or second swallow: a. Coughs and chokes b. Fluid returns through nose and mouth c. Infant struggles 5. Inability to pass catheter through the nose or mouth into the stomach D. Diagnostic evaluation 1. Maternal history of polyhydramnios – helpful clue 2. Flat plate X-ray of abdomen and chest reveals presence of gas in the stomach and chest 3. X-ray with radiopaque catheter; radiopaque contrast medium never used because of aspiration E. Preoperative nursing care 1. Position newborn with the head and chest elevated 20 o-30o to prevent reflux of gastric juices into the tracheobronchial tree 2. Regular suctioning 3. Put in incubator with high humidity to aid in liquefying secretions and thick mucus 4. Administer oxygen PRN 5. Assist in bougie treatment (elongation of proximal pouch using a mercury weighted dilator or firm catheters inserted briefly each day) 6. Give antibiotics as ordered to prevent or treat associated pneumonitis 7. Monitor IV or hyperalimentation 8. Observe closely for: a. Vital signs; respiratory behavior b. Amount of secretions c. Abdominal distention d. Skin color
F. Surgery 1. Primary repair – esophageal anastomosis and division of fistula 2. Gastrostomy and cervical esophagestomy, temporarily until infant gains weight. Staging (-repeated operations separated by periods of time, waiting for growth) is the accepted philosophy of treatment. G. Postoperative care 1. Observe for signs of stricture at the anastomosis site; refusal to feed; pronounced coughing; dysphagia; atelectasis; pneumonia 2. Maintain patent airway: a. Suction PRN – mark catheter to determine how far it can be inserted without disturbing anastomosis site b. Change position frequently and stimulate baby to cry but avoid hyperextension of the neck to prevent tension on the suture line c. Continued use of incubator 3. Maintain adequate nutrition – oral feeding started 6-14 days postop a. Low residue diet to keep stools soft b. Feed slowly in upright position to allow time for swallowing 4. Oral hygiene to prevent bacterial growth 5. Allow infant to suck on a pacifier to meet psychological and physiologic needs 6. Encourage parental participation to promote strong parental-infant bonding IV. Chalasia A. Pathophysiology: On the 3rd to the 10th day of life, the cardiac sphincter muscles fail to function, causing it to be relaxed and constantly patent. B. Characteristics: Unknown cause; self-limiting – disappears spontaneously within 3 months C. Signs and symptoms 1. Prolonged, repeated non-projectile vomiting which is more pronounced when patient is lying flat on his back 2. Often hungry after each vomiting episode 3. Aspiration may occur 4. Pressure on abdomen causes reflux of stomach contents into the esophagus D. Management: 1. Thickened feedings (formula + cereals) – because they are less easily vomited 2. Put on upright position for 30 minutes after every feeding V. Imperforate Anus A. Unknown etiology – arrest in embryologic development at 8 weeks of intrauterine life B. Types C. Signs and symptoms 1. Normal opening
2. No meconium 3. Green-tinged urine – due to fistula 4. Inability to insert rectal thermometer 5. Abdominal distention D. Diagnosis: xxxxxxxxxxx xxxxx method – infant is held upside down while abdomen is filmed to determine distance from rectum to anal dimple E. Management: 1. NPO; IV xxxxx gastric xxxxxxxxxxx 2. Temporary colostomy – if poor surgical risk (very young baby, malnourished; high agenetic or stretic type 3. Surgery: a. Anoplasty b. Abdominoperineal pull-through 4. Postoperative care: a. Expose perineum to air by putting infant on supine with legs suspended straight up or on prone position b. Check bowel sounds frequently c. NGT for gastric decompression d. Change position from side to side to decrease tension on suture line e. Oral feedings resumed 1-2 days postop, when peristalsis has resumed (fluids are retained; stools/flatus passed) VI. Spina Bidifa – congenital problem in which there is a defective closure of the spinal column. A. Classification 1. Occulta – posterior laminae are usually affected, with no protrusion of spinal contents. Skin over the defect may reveal a dimple, a small fatty mass or a tuft of hair. 2. xxxxxxx a. Meningocele b. Myelomeningocele – congenital failure of the arches of one or more vertebrae to unite at the center of the back; so that the bony wall normally surrounding the spinal canal at that place is missing. There is external protrusion, through a transparent sac, containing spinal fluid meninges, spinal cord and/or nerve roots. It is the most severe of the spinal deformities. c. Encephalocele- a cranial meningocele or meningomyelocele occurring at occipital area of the skull but may occur as a nasal or nasopharyngeal defect. B.
Associated clinical problems – depend on the location; all body parts below the session are affected 1. Motor function: a. Feet maybe deformed
2. 3. 4.
5.
b. Joints of ankles, knees or hips may be immobile c. Variable degrees of weakness in the lower extremities d. Spontaneous and induced movements are decreased or absent Sensory function: a. Sensations usually absent below the level of the defect b. Ulcerations of the skin are common Impaired functioning of the autonomic nervous system: a. Skin is dry and cool b. Sweating ability is impaired Urinary and bowel problem: a. Inefficient bladder causes constant urinary dribbling b. Stasis of urine causes UTI c. Possible renal destruction d. Fecal incontinence or retention due to poor innervation of the anal sphincter and bowel musculature Hydrocephalus – occurs in 65% of children; usually develops within the first 6 weeks of life.
C. Preoperative management/conservative treatment: 1. Careful handling to avoid rupture, pressure, irritation or leakage from the protruding mass by putting child on prone position, with the hips abducted 2. Meticulous hygiene to prevent irritation-sterile donut ring over the lesion 3. Watch for signs of increased intracranial pressure: a. Anterior fontanelle for tenseness, fullness and bulging b. Shrill, high-pitched cry c. Measure head circumference daily for any significant increase d. Vomiting, irritability e. Increasing BP, decreasing PR and RR and widening pulse pressure 4. Passive range of motion (ROM) exercises to impaired lower extremities D. Surgical correction 1. Early excision of the sac if it is small and then primary closure is done 2. If base of the defect is too large for primary closure, conservative treatment is carried out first while waiting for epithelization to take place and then closure is done at a later time. E. Postoperative care 1. Keep on prone position 2. Monitor urine output – bladder injury is a high possibilityin operations involving the spinal column 3. Measure head circumference daily 4. Monitor movement of lower extremities
F. Complications 1. Meningitis 2. Severe neurologic deficits 3. Hydrocephalus a. Types: • Noncommunicating – blockage within the ventricles which prevents CSF from entering the subarachnoid space • Communication – obstruction in the subarachnoid cistern at the base of the brain and/or within the subarachnoid space b. Management • 1.5 – 2 Gms. Mannitol 20%/KBW over 10 -15 minutes – since Mannitol is a diuretic, an indwelling, catheter should be inserted for accurate recording of intake and output • Ventriculo-peritoneal/ventriculo-atrial shunt – to bring the CSF to an area from where it can be excreted from the body. After the procedure, the child should be positioned on the side where the shunt is to prevent sudden decrease in intracranial pressure.
