handouts obstetric nursing

Maternal and Child Nursing

1 Maria Nazarethe A. Sulit| ©2009

THE FEMALE REPRODUCTIVE SYSTEM

I. External Genitalia

a. Mons pubis

b. Labia majora

Nulliparous:

multiparous:

c. Labia minora

d. Clitoris

Sensitive to touch & temperature

2 erectile tissue: corpus cavernosa

Sexual intercourse:

Clitoral congestion & erection

Produce cheese-like secretion:

e. Vestibule

a.

b.

c.

d.

e.

II. Internal Genitalia

a. Vagina

8-12 cm long

Before puberty

After puberty

b. Uterus

Organ of:

Layers:

Parts:

2.5-3 inches long

2 inches wide

50-70 gms

Supporting ligaments:

1. Broad

2. Round

3. Posterior

c. Fallopian Tube

Parts:

Interstitial

Isthmus

Ampulla

Infundibulum

d. Ovaries

6-19 gms, 1.5-3cm wide, 2-5 cm long



III. Accessory Structures

a. Mammary glands

S- W- D-

Parts:

o Acini cells

o Lactiferous duct

o Lactiferous sinus

Dilated portion behind the nipple

Reservoir of milk

o Nipples

o Areola

Montgomery tubercles

Hormones

o Estrogen

Stimulates dev’t of the ductile structures of the breast

o Progesterone

Stimulates the dev’t of acinar structures of the breast

o Human Placental Lactogen

Promotes breast dev’t during pregnancy

o Prolactin

Stimulates milk production

inhibited by estrogen

o Oxytocin

Let down reflex

inhibited by progesterone

THE MALE REPRODUCTIVE SYSTEM

I. External Genitalia

a. Penis

b. Scrotum

II. Internal Genitalia

a. Testes

Descends in the scrotum at 28 week gestation

4-5 cm long

Parts

o Seminiferous tubules

where spermatogenesis takes place

o Leydig’s/ interstitial cells

Found around the semineferous tubules

o Sertoli cells

b. Epididymis

Appx 20 feet long

Passageway for the traveling sperm for 12-20 days



c. Vas deferens

Passageway of the sperm from the epdidymis in the testes to the urethra

d. Ejaculatory duct

The Process of Spermatogenesis

Testes

epididymis

Vas Deferens

Seminal Vesicle (secreted: fructose form of glucose, nutritative value)

Ejaculatory Duct

Prostate Gland

Cowpers Gland

Urethra

III. Accessory structures

a. Seminal vesicles

b. Prostate gland

c. Bulbourethral gland

The Analogous

Male Female

Spermatozoa

Glans clitoris

Scrotum

Vagina

Testes

Fallopian tube

Prostate gland

Bartholin’s gland



THE EVOLUTION OF LIFE

I. Prefertilization

a. Ovum moves to the ampulla by means of peristaltic movement

b. Sperm moves into the ampulla by means of their tail

c. Before sperm can penetrate the ovum, the cap must be removed

Capacitation- physiologic removal of the acrosome

d. Acrosome reaction-

Hyaluronidase- proteolytic enzyme released

Zona pellucid-protective covering of the ovum

Corona radiate-cells that encircle the zona pellucida

II. Conception/Fertilization

Zona reaction- ovum becomes impenetrable to other sperms

Zygote

Blastomere

Morula

Blastocyst

Embryo

Fetus

III. Implantation

Trophoblast

o Placenta

o Fetal membrane

o Umbilical cord

o Amniotic fluid

Embryoblast

o Germ Layers

Ectoderm

mucus membrane, acessories, nervous system

Entoderm

bladder, GIT, tonsils, thyroid gland, respiratory system

Mesoderm

kidneys, musculoskeletal, reproductive, cardiovascular

Embryonic Membrane

a. Chorion - Outer membrane

b. Amnion - Inner membrane

c. Amniotic fluid

Slightly yellow

d. Placenta

Contains 30 separate (cotyledons)



2 Functions:

a. Metabolic exchange

produces nutrients needed by the embryo

systhesis of glycogen, cholesterol & fatty acids

b. Endocrine Function

HCG

HPL

o Human chorionic somatomammotropin

o Promotes normal nutrition & growth of the fetus

Estrogen

Progesterone

e. Umbilical cord

IV. Fetal Development

1 month

2 months

3 months

4 months

5 months

6 months

7 months

8 months

9 months

10 months

ANTEPARTUM

I. Schedule of Visits

II. Classification of Pregnancy

Gravida

Para

TPALM

III. Determination of Pregnancy

Presumptive Sign

o Amenorrhea

o Breast changes

o Skin changes

o Quickening

o Chadwick’s Sign

Probable Sign

o Goodell

o Hegar

o Piskacek



Positive Sign

o

o

o

IV. Physiologic Changes of Pregnancy

a. Breast

Increase in size & nodularity

Enlarged Montgomery’s tubercles

Veins become prominent

Colostrum

b. Uterus

Increase in vascularity

Presence of Hegar’s sign

c. Cervix

Formation of mucus plug or operculum

Presence of Goodell’s sign

d. Vagina

e. Gastrointestinal system

Constipation

Heartburn

Hemorrhoids

Morning sickiness

f. Urinary system

g. Musculoskeletal system

h. Intergumentary system

Chloasma

Linea nigra

Striae gravidarum

i. Endocrine system

Increase activity & hormone production

V. Antepartum Assessment

a. Nagele’s Rule

b. Fundal Height



c. Leopold’s Maneuver

VI. Evaluation of Fetal Well Being

Fundic Souffle

o Caused by blood rushing through the umbilical arteries. Synchronous with the

FHR.

Uterine Souffle

o Caused by the sound of blood passing through the uterine vessels. Synchronous

with the maternal pulse.

Amniocentesis

o TEST RESULTS: within 2-4 weeks

o Complication: Premature labor, Infection, Rh isoimmunization

Electronic Fetal Heart Rate Monitoring

a. NST

o Tocodynamometer records fetal movements and Doppler ultrasound measures

fetal heart rate to assess fetal well-being after 28 weeks.

o 2 or more FHR accelerations of 15 seconds over a 20 minute interval, and return

of FHR to normal baseline.

b. Contraction Stress Test

o Late decelerations with at least 50% of contractions

o No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in

10 minute period.

Fetal Activity

o Daily recording of fetal movements

o 3 or more movements felt in 1 hour

VII. Psychosocial Adaptation to Pregnancy

a. 1st Trimester

o acceptance of the biological fact of pregnancy

b. 2nd Trimester

o acceptance of the fetus as a distinct individual and a person to care for

c. 3rd Trimester

o prepare realistically for the birth and parenting of the child

INTRAPARTUM

I. Theories of Labor

a. Uterine Stretch Theory

b. Oxytocin Theory

c. Progesterone Deprivation Theory

d. Prostaglandin Theory

e. Theory of the Aging Placenta



II. Factors Affecting Labor

A. Passageway

o Diagonal Conjugate- from lower border of symphysis pubis to sacral promontory

o Obstetric conjugate- distance between inner surface of symphysis pubis & sacral

promontory

o True conjugate or conjugate vera

o Tuber-ischial diameter/ Intertuberous diameter- measures the outlet between

the inner borders of ischial tuberosities

Pelvic Divisions

o False

o True- Consists of the pelvic inlet, pelvic cavity, and pelvic outlet

o Linea Terminalis

Types of Pelvis

Android

Anthropoid

Gynecoid

Platypelloid



B. Passenger

a. Fetal Attitude

b. Fetal Presentation

c. Fetal Lie

d. Fetal Positions

C. Power- refers to the frequency, duration, and strength of uterine contractions to cause

complete cervical effacement and dilation

D. Placental factors

E. Psyche

III. Premonitory Signs of Labor

a. Lightening

b. Cervical changes

Effacement

Dilation

c. Regular Braxton Hick’s Contraction

d. Rupture of amniotic membrane

e. Nestling behaviors

f. Weight loss

IV. True vs False Labor

True Labor False Labor

Regular contractions

Decrease in frequency & intensity

Shorter intervals bet. contractions

Activity such as walking either has

no effect or decreases contraction

Activity such as walking, increases

contractions

Disappear while sleeping

No appreciable change in the cervix

V. Labor Contractions

VI. Fetal Monitoring

Variability

o Irregular fluctuations in the baseline of FHR of 2 cycles per minute or greater

Accelerations

o 15 bpm rise above baseline followed by a return to baseline



Decelerations-

o Fall below baseline lasting 15 seconds or more followed by a return to baseline

a. Type 1

b. Type 2

c. Type 3

VII. Labor

a. Stage 1

Latent Active Transition

Time

Cervix

Contraction

Intensity

Manifestations

b. Stage 2

Cardinal Movement of Labor (Even Donna Failed In Easy English Exam)

c. Stage 3



d. Stage 4

VIII. APGAR

A

P

G

A

R

POSTPARTUM

I. Uterine involution

II. Lochia

a. Rubra

b. Serosa

c. Alba

III. Post Partum Psychosocial Adaptation

a. Taking In

b. Taking Hold

c. Letting Go

TERATOGENS

– any drug or irradiation, the exposure to which may cause damage to the fetus

a. Streptomycin/Anti – TB –

b. Tetracycline

c. Vitamin K –

d. Iodides –

e. Thalidomides –

f. Steroids –

g. Lithium –

Substances Effects to Fetus

a. Alcohol LBW

b. Cigarette LBW

c. Caffeine LBW

d. Cocaine LBW



TORCH – group of infections that can cross the placenta or ascend through the birth

canal and adversely affect fetal growth

T-

O-

R-

C-

H-

ANTEPARTUM COMPLICATIONS

I. Ectopic Pregnancy

Causes:

a.

b.

c.

Assessment Findings:

Complications:

Hemorrhage/shock

Peritonitis

Diagnostics:

Culdocentesis

Ultrasound

Management:

II. Abortion



Causes:

a.

b.

c.


Management:

III. Hydatidiform Mole

Types:

a. Complete

b. Partial


Management:

IV. Incompetent Cervix


Management:

V. Hyperemesis Gravidarum

VI. Anemia

VII. Placenta Previa

Perdisposong Factors:




VIII. Abruptio Placenta

Risk Factors:

Uterine anomalies

Multiparity

Trauma to the abdomen

Previous 3rd trimester bleeding

Abnormally large placenta

Types:


CHARACTERISTCS ABRUPTIO PLACENTA PLACENTA PREVIA

Onset 3rd Trimester 3rd Trimester

Bleeding

Pain & Uterine Tenderness

FHR

Presenting Part

Shock Moderate to severe Usually not present

Delivery Immediate delivery, usually

by CS

Delivery maybe delayed,



IX. Pregnancy Induced Hypertension

Incidence:

Severe nutritional deficiencies

< 15 years or > 35 years of age

Common Types:

Gestational HTN

Preeclampsia

Eclampsia




a) Mild Pre-Eclampsia

Increase systole > 30 mmhg (3 measurements)

Increase diastolic 15 mmhg

b) Severe Pre-Eclampsia

>160/110 mmhg or higher (2 occasions)

Proteinuria 3-4+

c) Eclampsia

Presence of convulsions

Coma

Management:

Hydralazie (Apresoline)

Magnesium sulfate

Magnesium sulfate

Diazepam

Phenobarbital

Phenytoin



X. Gestational Diabetes Mellitus


Diagnostics:

FBS

HbA 1cv

Oral Glucose Tolerance Test

Management:

XI. RH Incompatibility

Management:

Blood test early pregnancy



XII. Multiple Gestation

Types:

Monozygotic Twins

Dizygotic Twins


Uterine size is greater than expected

Palpation of three or more large parts

Different FHT

Complications:

Fetal malpresentation

Uterine dysfunction due to over stretching

Twin to twin transfusion

Management:

Prenatal care

Balanced diet

Rest periods

Anticipatory guidance & support

INTRAPARTUM COMPLICATIONS

I. Premature Rupture of Membranes

Amniotic fluid gushing from the vagina in the absence of contraction

Contributing Factors:

Amniotic sac with weak structure

Recent sexual intercourse

Diagnostics:

Nitrazine test tape

Management:

Monitored : infection / spontaneous labor

Bed rest

Tocolytic therapy

Betamethasone (Celestone)

II. Cord Prolapse



Etiology:

Rupture of membranes with the fetal presenting part unengaged

Hydramios


Cord protruding from the vagina

Cord palpated in the vagina or cervix

Fetal distress

Management:

O2 therapy

Push presenting part forward

Deliver ASAP

III. Preterm Labor

Etiology:

Incompetent cervix

Placenta previa/Abruptio placenta

Previous preterm labor

Management:

Tocolytic therapy not needed if contractions stops

Fetal and uterine contraction monitoring

Ritodrine HCl (Yutopar)

Terbutaline sulfate (Brethine)

Magnesium Sulfate

NSAIDS

Indomethacin (Indocin)

Betamethasone

IV. Post Term Labor


Weight loss and decreased uterine size

Management:

Provide emotional and physical support

V. Induction of Labor

a. Amniotomy

- Initiated when the cervix is soft, partially effaced, slightly dilated,

presenting part is engaged

b. Prostaglandin



- 8-12 hours after Prostaglandin E2 administration, pump infusion of

Oxytocin (Pitocin)

c. Oxytocin

Dinoprostone (Prepidil)

Prostin E2 suppository or gel

OXYTOCIN (Pitocin, Syntocinon)

VI. Precipitate Labor

Complications:

a. mother

b. infant

Management:

- Support and guide fetal head through birth canal when birth occurs

VII. Uterine Rupture

Causes:

Rupture of the scar from a previous CS

Forceps delivery

Use of oxytocin

Fundal push

Management:

IVF

maintain patent airway

VIII. Episiotomy




R-

E-

E-

D-

A-

Management:

Apply ice packs to perineal area for the first 12-24 hours after delivery.

Sitz bath with either warm or cool water

IX. Lacerations

1st Degree

2nd Degree

3rd Degree

4th Degree

X. Forceps Delivery

Purpose:

Prevents excessive pounding of the fetal head against the perineum

Prevents exhaustion from a woman’s pushing effect


Cervix fully dilated before use of forceps

Fetus in vertex presentation

Bowel and bladder empty

XI. Cesarean Section



Types:

a. Classical

Advantage

Simple and rapid to perform

Disadvantage

Potential for rupture of the scar with subsequent pregnancy

b. Pfannenstiel’s incision

Advantages

Less chance of rupture of uterine scar during future deliveries

Fewer postpartum complications

Disadvantages

Longer to perform than classic incision

XII. Uterine Inversion

Types:

a. Forced Inversion

Cause : excessive pulling of the cord , vigorous manual expression of the placenta or

clots from an atonic uterus

b. Spontaneous Inversion

Cause: due to increased abdominal pressure from bearing down, coughing, or sudden

abdominal muscle contraction

Predisposing Factors:

Straining after delivery of the placenta

Vigorous kneading of the fundus to expel the placenta

Manual separation and extraction of the placenta


Extrusion of the inner uterine lining into the vagina

Management:

Restore the uterus to its normal position

use of general anesthesia and tocolytic therapy

POSTPARTUM COMPLICATIONS

I. Post Partum Hemorrhage

Management:

Monitor BP and PR Q5-15 minutes

Prepared for a possible D&C

IV infusion, oxytocin, and BT



Oxytoxic methylergonovine maleate (Methergine)

II. Subinvolution

Delayed return of the enlarged uterus to normal size and function


Larger than normal uterus

Prolonged lochial discharge

Management:

Massage uterus, facilitate voiding

Administer prescribed medications

III. Puerperal Infection

IV. Mastitis

Inflammation of the breast tissue caused by infection or stasis of milk in the ducts

Management:

Administer antibiotics

Breast feed frequently

V. Post Partum Mood Disorders

Postpartum Blues

Postpartum Depression

Postpartum Psychosis

FAMILY PLANNING

Natural Method

Abstinence Coitus interruptus (withdrawal)

80% effective with typical use

Rhythm (Calendar method) Ovulation occurs 14 days (plus or minus 2 days) prior to next menses sperm viable for 5 days ovum is capable of being fertilized for 24 hours fertile period = shortest cycle minus 18 days and longest cycle minus 11 days 91% effective with perfect use; 75% effective with typical use



Basal body temperature (BBT) Temperature drops just prior to ovulation, rises and fluctuates at higher

level until 2-4 days prior to next menses basal thermometer – shows tenths of a degree get temperature each AM prior to getting out of bed avoid intercourse on the day temperature drops and for 3 days thereafter 97% effective with perfect use; 75% effective with typical use

Cervical Mucus method (Billing’s, Ovulation)

Luteal Phase - infertile period - dominant hormone: progesterone - vaginal characteristics:dry - cervical mucus characteristics:

scant

cloudy, white to yellow

beading – on microscope

Follicular phase – ovulation - fertile period - dominant hormone: estrogen - vaginal characteristics: wet - cervical mucus characteristics:

profuse, clear

thin, watery, slippery

stretchable (spinnbarkheit)

ferning – on microscope assess cervical mucus daily avoid intercourse when cervical mucus is first noted to become more

clear, stretchable and slippery and for about 4 days effectiveness the same as basal body temperature

Symptothermal Method

o Ovulation o Menstrual calendar o Effectiveness: 98% (perfect use), 75% (typical use)



Mechanical Methods

Male condom Latex, plastic or natural membranes effectiveness: 97% (perfect use); 86% (typical use)

Female condom

Thin polyurethane sheath with flexible rings at each end Cover the cervix, lines the vagina and partially shields the perineum May be inserted up to 8 hours before intercourse Effectiveness: 95% (perfect use); 79% (typical use)

Spermicides

Kill spermatozoa before it reaches cervix Make vaginal pH strongly acidic Helps prevent STDs Active ingredient: nonoxynol Forms:

a. contraceptive foam b. creams and jellies c. spermicidal vaginal tablet d. spermicidal condom e. film

allergic reaction is possible must be applied with each act of intercourse onset of action varies

Diaphragm

Circular rubber disc fitted over cervix to prevent entrance of sperm cells into uterus

Of different sizes Fitted by an obstetrician during:

a. first time of use b. after every delivery/abortion c. weight loss of at least 10lbs

largest size that fits is chosen inspect for tears and holes by holding against the light can be inserted 2 hours before intercourse but left for 6 hours after

intercourse do not leave more than 24 hours complication: toxic shock syndrome

a. elevation of temperature b. diarrhea and vomiting c. weakness and faintness d. muscle aches e. sore throat f. sunburn type rash

effectiveness: 94% (perfect use), 80% (typical use)



Cervical Cap Resembles a diaphragm but smaller with taller dome Insert at least 20 minutes but no longer than 4 hours prior to intercourse May be left in place for 48 hours

Hormonal Methods

Contraceptive Pills Consist of estrogen and progesterone inhibit ovulation by suppressing FSH and LH cause thickening of cervical mucus alter motility of fallopian tubes 2 types of packets:

a. 21 day pill – rest day of 7 days b. 28 day pill – last 7 pills either iron supplement or lactose

Forms of OCP a. Combination Oral Contraceptives

- contain both an estrogen and a progestin - formulations:

1. monophasic contains fixed amount estrogen and progestin e.g.: cyproterone/ethinylestradiol,

Desogestrel/ethinylestradiol 2. biphasic

fixed or variable amount of estrogen progestin increases in the 2nd half of the cycle e.g.: desogestrel/Ethinyldestradiol 7 tabs 25 mcg progestin/40mcg estrogen 15 tabs 125mcg progestin/30mcg estrogen

3. Triphasic amount of estrogen may be fixed or variable while amount

of progestin increases in 3 equal phases e.g., Levonorgestrel/Ethinyldestradiol 6 tabs 30 mcg progestin/50mcg estrogen 5 tabs 40 mcg progestin/75mcg estrogen 10 tabs 30mcg progestin/75mcg estrogen

- effectiveness: 99.1% (perfect use), 95% (typical use) b. progestin-only pills (POPs)

- “mini-pills” - contain low doses of progestins - considered in women seeking a highly effective, reversible and

coitally independent method of contraception - action:

a. prevents ovulation b. thickens cervical mucus and suppresses the endometrium

- effectiveness with perfect use: 95.5% - with typical use: 95%



- warning signs and symptoms

(ACHES)

A – abdominal pain

C – chest pain,cough

H – headache, dizziness

Norplant (Subdermal Implant) - six silastic capsules containing progestin - implanted subdermally - upper inner arm - first 7 days of menstrual cycle - action:

a. prevent ovulation b. stimulate production of thick cervical mucus

Long Acting Progestin Injections

- medroxyprogesterone acetate (Depo-Provera) 150mg IM every 3 months starting with 1st 5-7 days of the menstrual cycle

- blocks LH surge - action:

a. suppress ovulation b. thickens cervical mucus

- effectiveness: 97.7%

Combination transdermal contraceptive patch - Norelgestromin/ethinylestradiol - 150mcg/20mcg per 24 hr patch - apply 1 patch weekly x 3 weeks followed by 1 week patch free period. - Women >90kg may find patch less effective - Patch applied to clean, dry, hair-free skin on: buttock, abdomen, upper outer

arm or upper torso - Avoid irritated or broken skin, breasts or skin in contact with tight

clothing/cosmetic

INTRAUTERINE DEVICE - Contraception achieved by immobilizing sperm and impeding travel from cervix

to fallopian tube - Types:

a. Progesterone T (progestasert) for women allergic to copper

b. Copper T380A (ParaGard)

for women with at least 1 child can be left in place x 10 years

c. Levonorgestrel Suited for women with heavy menstruation Inserted in uterus during 1st 7 days of menstrual cycle Effective x 5 years



- warning signs & symptoms (PAINS)

P – period late, abnormal spotting

A – abdominal pain, pain with

intercourse

I – Infection exposure abnormal

Discharges

N – not feeling well, fever

S – string missing

Surgical Methods

a. vasectomy b. tubal ligation

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