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OVERVIEW

I.          Estimation of Date of Birth

  • Use the Niagele rule:

                      1.         Start with the last day of menstrual period
                      2.         Subtract 3 months.
                      3.         Add 7 days.

  • Use the Fundal Height – a very gross estimate of DOB by using a measuring tape from just above the pubic symphysis to the top of the funds

                      1.         If tape is at the level of the pubic symphysis – about 12 – 14 weeks.
                      2.         If tape is at the umbilicus – about 20 weeks.
                      3.         From the umbilicus, top of fundus rises every 1cm / week, up until 36 weeks.        

  • Use of ultrasonography.

         1.         Abdominal sound waves show fetal image.
         2.         Encourage patient to drink fluids before the procedure in order to provide better clarify of image.

II.         Classification of Pregnancy

  • Gravida – means the total number of pregnancies regardless of duration and it includes the current pregnancy

                     i.          Nulligravida – a woman that has never been pregnant.           

  • Para – total number of pregnancies that went beyond the period of viability.

                     i.          Primipara – a woman who has one pregnancy

  • Term – an infant born from 38 weeks to end of 42nd week
  • Abortion – a fetus that terminates before the period of viability, which is 20 weeks.

                                 
                       
III.       Changes that may appear or experienced by a pregnant woman

  • Uterus – increase in size beginning 12- 14 weeks.
  • Skin

                     a.  Appearance of striae (stretch marks due to additional fatty deposits) on abdomen, breasts, buttocks, or thighs. Strias eventually fade and become
less prominent.
                     b.  Chloasma – appearance of blotches or pigmentation on the face
                     c.   Linea nigra – a dark line that appears on the abdomen, usually from the umbilicus to the pubic symhysis.
                     d.  Appearance of vascular spiders

  • Breasts – gets enlarge and tender
  • Cardiac Ouput – increases by aobut 750ml/minute
  • Cervix – softens, appearance of mucus plug in the canal and may appear blue (Chadwick’s sign)
  • Digestion – decrease in peristalsis
  • Frequent urination
  • Umbilicus – may protrude outward by 7th month
  • Endocrine changes

                     a.   Elevation of estrogen and progesterone; suppression of Lutenizing hormone and FSH
                     b.   Placenta also produces human chorionic gonadotrophin (hCG) and human placental lactogen (hPL) other than estrogen and progesteronew

  • Weight gain

                     a.   Ideal weight gain during pregnancy is about 24 – 28 pounds
                                 i.          First trimester   2 – 4 lbs
                                 ii.         Second trimester          12- 14 lbs
                                 iii.        Third trimester 8 – 12 lbs

  • Discomforts that may be associated to a pregnant woman and what nurses can advise their patients.

Discomforts

Nursing Actions

Morning Sickness - with nausea and / or vomiting

Offer dry crackers in the morning

 

Encourage to eat smaller meals througout the day

Hemorrhoids or Constipation

Encourage fiber and fluid intake

Breast tenderness

Use of well fiting bra

Backache

Ask patient to wear flat or well cushioned shoes

 

Tell patient not to do any heavy lifting

 

Encourage proper posture

Leg Cramping

Encourage to increase calcium intake

 

Apply heat pad

Vertigo or lightheadedness

Ask patient to lie on left side

(The Vena Cava syndrome)

 

Frequent Urination

Encourage Kegel exercise

 

Ask patient not to take fluids at night

 

 

                                                                               

 IV     Actual Way to Verify Pregnancy
            A.     Subjective – changes a woman feels.
                                    Morning sickness – nausea and vomiting; breast sensitivity, frequent urination 
            B.         Objective – changes observed by an examiner
Uterine enlargement, Chadwicks sign, Hegars sign (softening of the isthmus of the uterus), soufflé (soft blowing sounds heard over the uterus and it occurs at the same rate as the maternal pulse)
            C.         Diagnostic – definitive signs of being pregnant
                                    a.   Fetal heart rate is present – 110 – 160 beats / minute
                                                i.          Tachycardia – greater than 160 bpm that lasts longer than 10 minutes; an early sign of fetal hypoxia
                                                            Not a good sign if associated with late deceleration, severe variable decelerations or absence of variability
                                               
                                                ii.         Bradycardia – less than 110 bpm that las longer than 10 minutes; a late sign of fetal hypoxia
                                               
                                                iii.        Vaiability – irregular FHR fluctuations of at least 2 cycles per minute or greater.
                                    NOTE:            Absence or decreased heart rate may mean fetal sleep. If it lasts longer than 30 minutes, it is an indictor of fetal distress.

                                    b.   Fetal movement – at least 10 movements within 30 – 2 hours. Anything fewer than 3 movements in an hour should be checked into.
                                    c.   Outline of fetus on sonogram or Xray
                       
V.        Diagnostic Tests
            A.        Alpha-fetal protein tests
                                    1.         Done to predict neural tube defects but has a high false positive result.
                                    2.         Done between 16 – 18 weeks.
                                    3.         May be done in conjunction with check for acetylcholinesterase,
            B.         Chorionic villus sampling
                                    1.         Done earlier before amniocentisis, thus, it can’t detect neural tube defect
                                    2.         Done to test for PKU, sickle cell anemia, Downs syndrome Duchenne muscular dystrophy
                                    3.         Done before 10th week
                                    4.         Rh negative mother should receive Rhogam after the tests in order to prevent Rh isoimmunization 
            C.         Amniocentisis
                                    1.         A procedure where amniotic fluid is aspirated with a needle inserted through the abdominal wall
                                    2.         Done some time at about 16th week to determine certain genetic disorders such as Downs syndrome
                                    3.         Can be done at the 30th week in order to determine the L/S ratio (see topic below), to determine lung maturity.
                                    4.         Make sure patient empties her bladder before the procedure
                                    5.         Encourage patient to increase fluid intake after the procedure in order to replace the amniotic fluid
                                    6.         Encourage patient to  report decrease in fetal movement, any contractions or abdominal discomfort
            D.        Ultrasound – Encourage patient to take fluids before the procedure in order to provide better clarity in the image
            E.         Non-Stress test (NST)
                                    1.         Used to assess if fetus is well oxygenated and has intact CNS
                                    2.         A procedure where a tocodynamometer records fetal movements.
                                    3.         There is good fetal movement if there is accelerations in the FHR of 15 bpm that last 15 seconds over a 20 minute window.
            F.         Contraction Stress test (CST)
                                    1.         A test to evaluate how the fetus responds to the stress of labor by nipple stimulation of oxytocin stimulation
                                    2.         The patient should be on a semi—Fowler or side lying position.
                                    3.         A positive CST means there is repetitive late deceleration of more than 50% of the contractions. THIS NOT the DESIRABLE result.
                                    4.         A negative CST – there is no late deceleration

VI.       Labor and Delivery
            A.        Characteristics
                        a.         Lightening – a subjective sense of relief as the fetus descends into the pelvic area.
                                    i.          Primipara – may occur 2 weeks before delivery
                                    ii.         Multipara – may not occur until actual labor
                        b.         Mucus plug show – expulsion of the mucus plug
                        c.         Cervical changes
                                    i.          Thinning and softening of the cervix
                                    ii.         Cervix dilates during labor
                        d.         Rupture of Membrane (ROM) – “my water broke” experience as the amniotic sac ruptures
                                    i.          Nurse ought to check for fetal heart tones and for any fetal heart distress
                                    ii.         Check for prolapsed cord       
                                 1.         Check for protruding cord
                                 2.         Call for help, put patient in Trendelenburg position or knee high position, push against the presenting part to avoid the cord from pulling.

            B.         Different Factors that affect labor
                        a.         Lie – looks at the spine of the fetus in relation to the mother’s spine
                                                Can be parallel, transverse, oblique
                        b.         Presentation – the part of the fetus that enters the pelvic inlet
                                                1.         Cephalic – head first
                                                2.         Breech
                                                                        i.          Frank – the most common; flexion of hips and extension of knees
                                                                        ii.         Complete – flexion of hips and knees
                                                                        iii.        Footing – extension of hips and knees
                                                3.         Shoulder (transverse lie)
                        c.         Position – looks at the fetus in relation to the mothers pelvis
                                                1.         Fetal reference point – either vertex, breech or shoulder presentation
                                                2.         Maternal pelvis – either right / left and anterior / posterior
                                                3.         Expressed as a 3 letter abbreviation (see diagram below)
                                                            a.         LOA – the most common position; left occiput anterior
                                                            b.         LOP -  left occiput posterior
                                                            c.         ROA – right occiput anterior
                                                            d.         ROP – right occiput posterior
                                                            e.         LSA – left sacrum anterior
                                                            f.          RSA – right sacrum anterior

d.         Station – left at which the fetus in relation to the ischial spine (the imaginary line) and the pelvis of mother
                       

e.         Contractions
                                                1.         Phases
                                                                        i.          Increment – beginning of contraction
                                                                        ii.         Acme or peak – very strong intensity
                                                                        iii.        Decrement -     intensity is decreasing
                                                2.         Characteristics
                                                                        i.          Frequency –     beginning of one contraction to the beginning of the next contraction
                                                                                                            Measured from peak of the contraction to the peak of the next contraction
                                                                                                            Report any frequency less than two minutes.
                                                                        ii.         Duration -        Anything more than 90 second may mean fetal distress or rupture of uterine and therefore must be reported.
                                                                        iii.        Intensity -        This may be subjective to each woman
                                                                                                             
                        f.          Diameter of pelvis
                        g.         How much the uterus can be stretched.
                                      
            C.         Labor
                       
                        a.         Stages of Labor                                              

 

Phase 1

Phase 2

Phase 3

Stage 1

Latent

Active

Transition

 

0 - 3 cm cervix

4 - 7 cm cervix

8 -10 cm cervix

 

10 - 30 sec contractions

30 - 40 sec contractions

45 - 90 sec contractions

Stage 2

0 - +2 Station

+2 - +4 Station

+ 4 - birth

 

 

 

 

Stage 3

Delivery of Placenta

 

 

                        b.         Comparison of True and False Labor
                                                         


True Labor

False Labor

Discomfort starts from back and radiates to the abdomen

Discomfort is usually on abodmen

Pain increases when walking

 Walking has no effect; may lessen contractions

Contractions are regular intervals

Contractions are irregular

Progressive dilation of cervix

No change in cervix

 

            D.        Fetal Heart Rate
                        a.         Accelerations
                        b          Decelerations –a fall below the base line and may last for 15 seconds or more and a return to baseline
                                    i.          Early deceleration – before the peak of contraction; associated with head compression or in pushing in second stage
                                                            No nursing intervention necessary. This is a reassuring pattern
                                    ii.         Late deceleration – occurs after contraction with slow return to baseline; may mean fetal hypoxia
Immediately position mother on her left side . If no change noted on tracing, reposition to the other side or put on Trendelenburg or knee high position.
                                                            Give oxygen 7 – 10 liters
                                                            Start an IV or increase the flow rate and Stop the oxytocin if given
iii.        Variable deceleration – occurs any time during uterine contraction for more than 15 bpm and may last for 15 second and returns to baseline in less than 2 minutes; may mean cord compression
                                                            This is bad if it occurs repetitively and the nurse ought to do the same interventions noted above for late deceleration.
 
            E.         Key Fetal Development

    • 4 weeks
      Able to hear the heart beat
    • 8 weeks
      Most body organs are formed
    • 16 weeks
      Baby’s sex can be seen
      Intestines begin to collect meconium, lanugo present on body, transparent skin with visible blood vessels SO, one can tell if boy or girl and hear heart sounds
    • 20 weeks
      Fetus can suck and weigh about 11 ounces
      Mother feels movement (quickening)
      Vernix protects the body and lanugo (fine hair) keep oil on skin
    • 24 weeks
      Could weigh about 1lb 10 oz
      Increase in fetal activity
      Fetal respiratory movement begins
    • 28 weeks
      Baby can breathe at this time
      Surfactant, needed for breathing at birth, is formed
      Eyes may begin to open and close
    • 32 weeks
      Baby may have fingernails and toenails
    • 38 plus weeks
      Baby fills the uterus and gets antibodies from the mother
      Lungs have definitive shape so breathe of fetus can be heard.

VII.      Anesthesia
            A.        Inhaled anesthetics
                        1.         Nitrous oxide and oxygen
                                                - good since patient can cooperate in bearing down
                                                - If more then 20 minutes, it can cause neonatal depression
            B.         Regional Blocks – the mother remains awake but this can cause maternal hypotension or fetal bradycardia
                        1.         Subarachnoid block or saddle block
                                                - given S1 – S4
                                                - given with woman in sitting position for up to 2 minutes.
                        2.         Spinal block – mainly used before cesarean delivery
                        3.         Lumbar epidural block 
                                                - administered at T10 to S5.
                                                - Mother stays in a side-lying position.
                                               
VIII      Common Labor Complications
            A.        Ectopic Pregnancy – Pregnancy that occurs in the fallopian tubes and this is life threatening to the mother due to hemorrhage (bleeding)
                                    Prepare mother for surgery
                                    Bleeding occurs into the abdomen, so the belly should be rigid and tender and pain occurs in the lower quadrant after 4 to 6 weeks.
                                    Low hematocrit and loc hCG levels in the urine and blood. So, monitor for shock.
                                    Concerns about future pregnancy can be an issue. Prepare patient for loss of pregnancy.

            B.         Pregnancy Induced Hypertension (PIH)
                                    Common to with large fetuses;  Older women (over 35 years) or younger women (less than17 years); First time mothers; Poor nutrition; those with Hydatidiform mole;
obese and overweight women; family history of HTN, renal issues or diabetes
                                   
                                    1.         Mild Pre-eclempsia
                                                            Blood pressure is about 140 / 90 or an increase or about 30/ 15 mm Hg
                                                            Protenuria +2 - +3
                                                            Occurs about 5 months into pregnancy
                                                            Put patient in left lateral position and should be on bed rest. Weigh patient daily to see if patient is retaining fluids.
                                    2.         Severe Pre-eclempsia
                                                            Blood pressure is about 150 – 160 / 100 – 110 mm Hg
                                                            Proteinura +4
                                                            May have epigastric pain, which is a dangerous sign that the patient might get convulsions
                                                            Patient is on bed rest; Monitor I/O and vital signs and fetal heart rate
                                                            Vasodilators and other anti-hypertensive medications are safe for pregnancy.
                                                            Magnesium sulfate may be given to prevent HTN and convulsion. Monitor patient for reflexes when given magnesium.
                                    3.         Eclempsia
                                                            Hypertension, Protenuria, Convulsions, Coma may happen if nothing is done
                                                           
            C.         Placenta Previa
                                    Occurs when the placenta is implanted in the lower part of the uterus.
                                    Painless bleeding occurs as oppose to painful vaginal bleeding (abruption placenta0
                                    Bed rest is encouraged and in Trendelenburg position for at least 72 hours.
                                    Ultrasound is done to locate the placenta. Monitor fetal heart rate
                                    DO NOT do any vaginal or rectal exams and if necessary only do in OR under sterile conditions. Cesarean delivery may be necessary.
                                    Amniocentisis may be done to check for lung maturity (see L/S topic) below.
                                   
                                    Tell patient to minimize activity. Avoid any douching, enema or coitus.
                                    Do a NST (see topic below) every 2 weeks to assess FHR variability
                                    Assses kick count of baby to determine fetal movement.

            D.        Abruptio Placenta (Premature separation of the placenta)
                                    Painful vaginal bleeding as oppose to painless vaginal bleeding (placenta previa)
                                    Associated with maternal HTN and cocaine abuse.
                                    This is an emergency since the patient may be bleeding inside and one only sees minimal vaginal bleeding.  In other words, loss of blood does not match what is seen.
                                    One should be ready for immediate delivery since the placenta is already detached.
                                    Maintain fluid and electrolyte balance.

            E.         Diabetes:
                                    Either a Type I, Type II or Gestational diabetes (GDM)
                                    Who are at risk:     Age 25 or older, Obese patient, has a family history
                                    All women in their 24 – 28th weeks should be tested for Glucose tolerance test.
                                    Oral hypoglycemics are NOT given because they are teratogenic.
                                    Hispanic, African American, Native American or Asian Americans are at risk
                                    Patient with diabetes is at risk for PIH, Hydramnios (greater than 20000 ml of amniotic fluid)
                                    Risk for fetus that is Macrosomia (large for gestational age / greater than 6 – 9 lbs or 4000 grams); but with immature organ systems.  
                                    Fetus is at risk for Respiratory Distress Syndrome (RDS) since the fetus is big and the lungs may be undeveloped.
                                   
            F.         Hydatidiform Mole
                                    An abnormality of the chorionic villi  
                                    Uterine appears bigger than what is expected and there can be passage of red/brown blood that appears like a cluster of grapes.
                                    hCG level are elevated and this causes one to have nausea and vomiting. The hcG levels has to be monitored for one year.  
                                    There is NO FHR and no fetus in ultrasound.
                                    Complete curettage should be done in order remove all unwanted tissue that can be malignant.
                                    The patient is Discouraged to be pregnant for a year since she is susceptible to cancer.
                                   
                                   
            G.        Pre-term Labor
                                    Any time between 20 week (the benchmark for viability) and 37 weeks (one week before full term)
                                    Patient is on bed rest, side lying
                                    Patient is usually given medication:
                                                Terbutaline – used for airway diseases such as asthma or COPD but unlabelled use is for preterm labor
                                                Yutopan – to treat premature labor by relaxing the uterine

            I.          Inducing Labor
                                    Done  because of reasons such as too large baby, breached baby (mature fetus must have a vertex presentation), head is engaged and cervix has to be ripened.
                                    Done also if fetus is Post maturity (usually over 42 weeks) or if mother has PIH, Diabetes,
                                    Prepare patient for amniotony (rupture of membrane)
                                    Begin Oxytocin (Pitocin), piggybacked to the main IV line. Start out at 0.8 – 1 ml and increase to 1 0 2 ml/min until contraction pattern is 2 -3 minutes and last for 90 seconds or less.
                                                Stop Pitocin if fetal distress is determined – a contraction lasting greater than 90 seconds and occurs every 2 minutes.

            J.          Cesarean Section
                                    Often done if pt has previous cesarean, breech, fetal distress, active maternal gonorrhea or herpes infection, prolapsed cord, PIH, Placenta previa, abruption placenta, fetal abnormalities
                                    Monitor for hemorrhage after delivery
                                    Routine post op care; splint the incision and encourage deep breathing exercises

            K.        Delivery outside the hospital or clinic setting
                                    First thing, DON’T leave the patient alone
                                    Try to prepare a sterile environment
                                    Support the infant’s head and rotate infant as head emerges; slip the nuchal cord, if present.
                                    Establish airway for baby upon delivery and dry baby
                                    Wrap baby and put on mothers breast  

A. PRE-NATAL ISSUES / TOPICS

Abruptio Placenta (Premature Separation of Placenta)

  • Painful vaginal bleeding as oppose to painless vaginal bleeding (placenta previa).
  • Associated with maternal HTN and cocaine abuse.
  • This is an emergency since the patient may be bleeding inside and one only sees minimal vaginal bleeding.  In other words, loss of blood does not match what is seen.
  • One should be ready for immediate delivery since the placenta is already detached.
  • Maintain fluid and electrolyte balance.

 

Amniocentisis

  • A procedure where amniotic fluid is aspirated with a needle inserted through the abdominal wall
  • Done some time at about 16th week to determine certain genetic disorders such as Downs syndrome
  • Can be done at the 30th week in order to determine the L/S ratio (see topic below), to determine lung maturity.
  • Make sure patient empties her bladder before the procedure.
  • Encourage patient to increase fluid intake after the procedure in order to replace the amniotic fluid.
  • Encourage patient to  report decrease in fetal movement, any contractions or abdominal discomfort

 

Amniotic Fluid

  • Should be straw colored and odorless.
  • Green tinged indicates meconium staining and could mean fetal distress.

Alpha Fetoprotein

  • Used to detect neural tube defects like spina bifida.
  • Done between 16 – 18 weeks.
  • Test has a high false positive result

Abortion
1.    Missed Abortion

  • Fetus dies in utero and is not expelled.
  • Would require induction of labor and Prostin E, a form of prostaglandin, is used to soften the cervix.

2.    Complete Abortion

  • All products of conception are expelled.

3.    Incomplete Abortion

  • Some products of conception are retained, usually the placenta.

Alcohol

  • A mother that drinks alcohol during pregnancy can give birth to a preterm or small for gestational age baby.

Breech

  • Put a FHR monitor on the mother. Fetus in breech position if FHR (Fetal Heart Rate) is heard on the upper right of abdomen.
  • May need to prepare the mother for caesarean delivery.

Cesarean Section

  • Often done if pt has previous cesarean, breech, fetal distress, active maternal gonorrhea or herpes infection, prolapsed cord, PIH, Placenta previa, abruption placenta, fetal abnormalities.
  • Monitor for hemorrhage after delivery.
  • Routine post op care; splint the incision and encourage deep breathing exercises

 

Chadwick’s sign

  • Appearance of bluish color of the cervix when a woman begins her pregnancy

Constipation

  • Usually due to progesterone production which slows down the bowel; coupled with iron supplement and lack of exercise and low intake of water.

Contractions

  • Measured from beginning of the contraction until the end of the same contraction.

Contraction Stress Test (CST)

  • A test to evaluate how the fetus responds to the stress of labor by nipple stimulation of oxytocin stimulation.
  • The patient should be on a semi—Fowler or side lying position.
  • A positive CST means there is repetitive late deceleration of more than 50% of the contractions. THIS NOT the DESIRABLE result.
  • A negative CST – there is no late deceleration

Corpus Luteum 

  • Responsible for the production of progesterone especially during the first trimester until the placenta assumes the production throughout the rest of the pregnancy.

 Down Syndrome

  • Age of mother is a factor.
  • Patient will have broad hands, epicanthal folds, transpalmar creases.

Decelerations

  • Decelerations on the second stage of labor may mean fetal head compression.

Diabetes

  • Either a Type I, Type II or Gestational diabetes (GDM).
  • Who are at risk:     Age 25 or older, Obese patient, has a family history.
  • All women in their 24 – 28th weeks should be tested for Glucose tolerance test.
  • Oral hypoglycemics are NOT given because they are teratogenic.
  • Hispanic, African American, Native American or Asian Americans are at risk.
  • Patient at risk for PIH, Hydramnios (greater than 20000 ml of amniotic fluid).
  • Risk for fetus that is Macrosomia (large for gestational age / greater than 6 – 9 lbs or 4000 grams); but with immature organ systems.
  • Fetus is at risk for Respiratory Distress Syndrome (RDS) since the fetus is big and the lungs may be undeveloped. A mother with a history of diabetes may potentially give birth to a large for gestational age baby. These babies usually do not have enough surfactant to help in the breathing process, therefore, cause respiratory distress.

Ectopic Pregnancy

  • Pregnancy that occurs outside the uterus often in the fallopian tubes. Prepare patient for surgery.
  • A main symptom is the sudden stabbing pain on the lower quadrant with the pain radiating to the leg and chest.
  • Unilateral dull pain may be ectopic pregnancy while vaginal bleeding with cramping can be threatened abortion

Effacement

  • Effacement is caused by the pressure of the baby as it descends.

Epidural Anaesthesia

  • Check for signs of shock every 5 – 15 minutes.
  • It decreases the urge to void. It can lead to less sensation to the bladder. So, one can ask  the patient to void regularly or the patient may also need a catheter.
  • Epidural causes vasodilation that can lead to hypotension especially if given via IV. If patient gets hypotensive, decrease the infusion rate and put patient  on her left side with an oxygen via nasal cannula. Do not put the patient in supine because the anesthesia can move to the respiratory center.
  • Have Adrenalin ready in case of emergency.
  • Don’t give analgesics during the transition phase.
  • Epidural - causes relaxation and therefore leads to vasodilation and maternal hypertension.
  • It can also decrease uterine perfusion and FHR. If epidural is too high on the woman’s spine, it can cause respiratory distress.

Estimated Date of Birth (DOB)

  • Use the Niagele rule:
              1.    Start with the last day of menstrual period
              2.    Subtract 3 months.
              3.     Add 7 days.
  • Use the Fundal Height – a very gross estimate of DOB by using a measuring tape from just above the pubic symphysis to the top of the funds
              1.    If tape is at the level of the pubic symphysis – about 12 – 14 weeks.
              2.    If tape is at the umbilicus – about 20 weeks.
              3.    From the umbilicus, top of fundus rises every 1cm / week, up until 36 weeks.
            
  • Use of ultrasonography.
              1.   Abdominal sound waves show fetal image.
              2    Encourage patient to drink fluids before the procedure in order to provide better clarify of image.

 Fetal Heart Rate (FHR)

  • Normal is 110 – 160 beats per minute (bpm)
  • If bradycardia occurs, turn the mother to be to her side.

Fetal Position – based on FHR
1.    Breech - if heard on upper right of abdomen.
2.    Sacral position – if heard on Center of the abdomen.
3.    Right Occipital Anterior position – if heard on Right lower quadrant.
4.    Left Occipital Transverse position – if heard on left lower of abdomen.

Fetal Presentation

  • Determined by which part of the fetus presents itself in the pelvic passage
    1.    Cephalic
    Fetal head presents itself
    97% of birth are cephalic

    2.    Breech 
    Fetal hips and knees present themselves first.

    3.    Shoulder or Traverse
    The shoulder of the fetus is presented first.

Gestational Diabetes

  • Occurs during pregnancy where extra glucose produced can cross the placenta and cause the baby pancreas to produce additional insulin but can lead to a large baby (macrosomia). After birth, the baby may be hypoglycemic because it continues to creates its own insulin without the mother’s additional glucose.
  • The baby is prone to develop Diabetes 2 later on in life.
  • Glucose test done with FBS (Fasting Blood Sugar, also referred to as Fasting Plasma Glucose); normal should be at least 80 -100mg/ dL
  • HbA1c can also be done; it is the measure of glucose level for the past 3 months. Normal is about 6%  – 8 %.

Gonorrhea

  • Mother has positive culture for vaginal secretions.
  • As a prophylactic, a baby’s eyes upon delivery is given an antibiotic ointment. 

Hegars Sign

  • Softening of the isthmus of the uterus

Human Chorionic Gonadotropin

  • Secreted by the trophoblast and chorionic villi.
  • Human chorionic gonadotropin increases insulin need.

Hydramnios 

  • Greater than 2000ml of amniotic fluid.

Inducing Labor  

  • Done because of reasons such as too large baby, breached baby (mature fetus must have a vertex presentation), head is engaged and cervix has to be ripened.
  • Done also if fetus is Post maturity (usually over 42 weeks) or if mother has PIH, Diabetes.
  • Prepare patient for amniotony (rupture of membrane).
  • Begin Oxytocin (Pitocin), piggybacked to the main IV line. Start out at 0.8 – 1 ml and increase to 1 0 2 ml/min until contraction pattern is 2 -3 minutes and last for 90 seconds or less.
  • Stop Pitocin if fetal distress is determined – a contraction lasting greater than 90 seconds and occurs every 2 minutes.

    

Insulin Use

  • Human chorionic gonadotropin increases insulin need.
  • Insulin requirement may increase in FIRST TRIMESTER and NOT increase in 3rd trimester.

Labor

  • A patient who is in labor and complains of "not being able to hold urine" --  check PH value of urine to determine if amniotic fluid (Alkaline) or urine (acidic); CK for dilation and effacement if BOW ruptures
  • Effacement is caused by the pressure of the baby as it descends.
  • Usually, fetal movement decreases with the onset of labor.

Late Deceleration

  • Place the mother to her left side and give oxygen.
  • Persistent late deceleration correlates with uteroplacental deficiency which is shown in the drop in the fetal heart rate to about 30bpm from beginning to the end of contraction.

Leopold Maneuver

  • Use fingers to palpate fundus NOT your palms.

Lutenizing Hormone

  • An increase in the lutenizing hormone is responsible for ovulation or for a woman’s ability to conceive.
  • Increase in estrogen increase stimulates the release of the lutenizing hormone.

Low Birth Weight

  • Smoking is a factor. Smoking also causes growth retardation.

Large for Gestational Age

  • Diabetic mothers. The newborn will be hypoglycemic because of the absence of the mother’s glucose.
  • A mother with a history of diabetes may potentially give birth to a large for gestational age baby. These babies usually do not have enough surfactant to help in the breathing process, therefore, cause respiratory distress.

Lecithin Sphingomyelin Ratio (L:S ratio)

  • These are the two components of surfactant and the ratio is used to determine fetus’ lung maturity.
  • Early in pregnancy S > L and at 32 weeks, S begins to fall and L increases.
  • At 35 weeks, L/S ratio should be 2:1, which indicates low risk for respiratory distress syndrome (RDS). Anything less would lead to respiratory distress at birth.

Macrosomia

  • Large for gestational age but with immature organ systems.
  • Greater than 9 lbs or 4000 grams NOTE: Normal is 6 – 9 lbs. or 2700 – 4000 grams

MAGNESIUM

  • Reduces respiration and reflexes.
  • Expected outcomes: Patients gets sleepy, develop hot flashes and get lethargic.
  • Toxicity outcome: Patient urinary output decreases, no knee jerk reflex, and decreased respiration.
  • The patient on magnesium sulfate should have a foley catheter.

Maternal Hypotension

  • Put mother in left lateral position and give oxygen.
  • If left lateral position does not seem to resolve the condition of the mother, place patient on Trendelenburg position.
  • Always monitor the maternal BP and FHR.

Morning sickness

  • To minimize eat crackers or toast upon arising in the morning.

MRI

  • Not for pregnant ladies because radioactive isotopes are used.

Non-stress Test (NST)

  • To evaluate the movement of the fetus and to assess if fetus is well oxygenated and has intact CNS.
  • A procedure where a tocodynamometer records fetal movements.
  • There is good fetal movement if there is accelerations in the FHR of 15 bpm that last 15 seconds over a 20 minute window.

           

Nutrition

  • 300 additional Calories recommended for fetal growth

Paracentisis

  • Encourage patient to void before the procedure and avoid additional liquid intake to prevent any accidental trauma to the bladder.
  • Make sure to have BP cuff on to check for shock which may occur after removal of fluid.

Phases of Labor

1.    Early or Latent – 1 – 3 cm dilation.
2.    Active – 4 -7 cm dilation. 
3.    Transition – 8 – 10 cm dilation.  Patient may not be able to concentrate especially when being touched because of the intense contractions. Don’t give analgesics during the transition phase
.

PITOCIN

  • Monitor for decelerations;           NOTE: Pitocin increase cervical effacement in pregnant mothers and therefore increase contractions.
  • Also used to control bleeding at post partum. Given post partum to help firm the uterus and lessen the chance of hemorrhage.

Placenta Previa

  • Occurs when the placenta is implanted in the lower part of the uterus.
  • Painless vaginal bleeding as oppose to painful vaginal bleeding (abruption placenta)
  • Initial action should be to check the FHR. May have to do NST every two week to assess FHR.
  • Do not do a cervical check for dilation which can increase the bleeding nor rectal exams. If necessary, it has to be done in OR under sterile environment.
  • Can check for uterine firmness.
  • Assess for fetal movement.
  •  
  • Tell patient to minimize activity. Avoid any douching, enema or coitus.
  • Amniocentisis may be done to check for lung maturity (see L/S topic) below.                                   

Preeclempsia (see PIH below)

  • Pedal edema is natural.
  • Nosebleed and be a sign of high blood pressure.

Pregnancy induced hypertension (PIH)

  • Best to put the mother on her left side to relieve pressure from vena cava, thus, providing oxygenation to the fetus.
  • Commont to those with large fetuses; Older women (over 35 years) or younger women (less than17 years); First time mothers; Poor nutrition;  those with Hydatidiform mole; obese and overweight women;  or those with family history of HTN, renal issues or  diabetes.

                        1.         Mild Pre-eclempsia
                                                Blood pressure is about 140 / 90 or an increase or about 30/ 15 mm Hg
                                                Protenuria +2 - +3
                                                Occurs about 5 months into pregnancy
                                                Put patient in left lateral position and should be on bed rest. Weigh patient daily to see if patient is retaining fluids.
                        2.         Severe Pre-eclempsia
                                                Blood pressure is about 150 – 160 / 100 – 110 mm Hg
                                                Proteinura +4
                                                May have epigastric pain, which is a dangerous sign that the patient might get convulsions
                                                Patient is on bed rest; Monitor I/O and vital signs and fetal heart rate
                                                Vasodilators and other anti-hypertensive medications are safe for pregnancy.
                                                Magnesium sulfate may be given to prevent HTN and convulsion. Monitor patient for reflexes when given magnesium.
                        3.         Eclempsia
                                                Hypertension, Protenuria, Convulsions, Coma may happen if nothing is done

Prolapsed Cord

  • If one notices the umbilical cord protruding, prolapse cord have occurred.
  • Best  to put the patient in knee chest position or Trendelendburg posiition and immediately bring the patient to emergency.
  • Apply pressure against the presenting cord to lessen the pulling pressure that may cause strangulation on the fetus.
  • Give oxygen to patient and start an IV line.

Rupture of membrane

  • Will cause a temporary drop in FHR that should return back to normal.

RHOGAM

  • Given within 72 hours.
  • Given to prevent formation of Rh antibodies.

Scanty Bloody Discharge

  • Normal because of frequent urination and uterine contractions

Syphilis

  • If a risk, do a blood test VDRL. Usually acquired sexually or congenitally.
  • One may see lesios (chancre) on the internal or external genital area.
  • Penicillins are administered which crosses the placenta and therefore treats the fetus.  

Uteroplacental Insufficiency

  • If the fetal heart monitor indicates late deceleration with a FHR of about 165 – 175 bpm with a variability of 0-2 bpm, the likely explanation could be uteroplacental insufficiency.

Ultrasonography

  • Mother should take as much fluids

Variable Deceleration

  • If observed, reposition the patient initially and then give oxygen.

 
Viability

  • The ability of the fetus to survive outside the uterus
  • Defined as the fetus after 20 weeks of gestation or if baby weighs greater than 500 grams, regardless of whether baby infant was born alive or dead
B. OVERVIEW OF POST PARTUM

I.          Immediate Actions after delivery
            A.        What to do to newborn
                        1.         Ensure airway on newborn.
                        2.         Check the APGAR score at 1 and 5 minutes.
                        3.         Properly identify (ID Bands) newborn.
                        4.         Clamp umbilical cord.
           
            B.         What to do to mother
                        1.         Check the vital signs Q15mins until stable.
                                                If the BP is low, it may be a sign of hemorrhage.
                                                If the BP is elevated, it may be due to oxytocin or Pregnancy Induced Hypertension (PIH)
                        2.         Bonding should be encouraged by touching and eye contact.
                        3.         Check FUNDUS Q15 mins.
                                                For the first 12 hours, the fundus should be about 1 cm/finger breadth above the umbilicus and descends by 1 finger breadth each day after.
                                                Fundus should be located in the center and can be displaced by a full bladder.
                        4.         Check for LOCHIA Q15 mins.
                                                Color changes of Lochia: progresses from rubra  -  serosa  -  yellow/ white
                                                            1 – 3 day after delivery – color should be rubra (bloody) and may have a fleshy odor
                                                            4 – 9 days – serosa (pinkinsh brown) color with fleshy odor
                                                            10 and over – yellow to white color

                                                If the peri-pad appears to be soaked with more than 100 cc of blood, then bleeding may be occurring.
                                                There should be NO foul odor. If so, it may indicate infection.
                                               
                        5.         Measure the first urine void to check for urine retention. Encourage Kegel exercises and to avoid diuretics like caffeine.
                        6.         If applicable, check episiotomy for infection. Check perineum also for infection. Avoid intercourse until episiotomy is healed and the lochia has ceased.

II.         Lactation Issues
                        1.         Non-nursing woman
                                                Encourage to wear tight fitting bra, use of ice packs and minimize and kind of breast stimulation
                        2.         Nursing woman
                                                Most medications make it into the breast milk. So check with your physician before taking any medication.
                                                Avoid soap to prevent dryness.
                                                Milk delivery (letdown) is dependent on infant sucking. Warm showers or warm compress can stimulate letdown.
                                                To prevent breast engorgement, nurse frequently (every 3 hours).  Engorgement can be due to plugged ducts. Use warm compresses and light massages before feeding.
                                                Breast pump can be used to collect milk, but makes sure to refrigerate the milk no more than 48 hours or frozen for than 2 weeks or deep freeze for more than a month to ensure the stability of the milk. DO NOT thaw milk in microwave.
                                                Offer both breasts for feeding and have the infant’s mouth cover the large portion of the areola. About 5 minutes on each breast.
                                                Infants’ mouth can be released by inserting a finger in order to stop the sucking of the newborn.
 

III.       Some Postpartum Complications
            A.        Postpartum Hemorrhage
                                    Occurs usually if placenta fragments are left inside; overdistended uterus either due to multiple pregnancies or prolonged labor, or any lacerations. 
                                    Lochia is reverting back from previous color, serosa or white, back to reddish color
                                    Uterus becomes boggy or spongy; massage the uterus if not firm
           
            B.         Postpartum Infection
                                    Watch for a termperature 100 F or higher on two consecutive postpartum, except the first 24 hours, along with any chills and tachycardia
                                    Check for any foul smelling lochia
                                    Patient may have abdominal or perineal pain
                                    WBC may be elevated and cultures of blood, lochia and urine may be done.
                                    To prevent infection, encourage patient to ambulate, change peripads often, have adequate nutrition and fluid intake

            C.         Postpartum depression
                                    The baby blues feeling may be due to decrease in estrogen and progesterone and the depression may occur within 3 – 7 days after delivery
                                    It is usually a normal occurrence but a patient may have a roller coaster of emotions with appetite and sleep disturbances
                                    Encourage verbalization of feelings and assess for suicide.    
                                   

                                    

POST PARTUM ISSUES / TOPICS
  • Immediately after delivery, ice pack may be used for a day or so after, but a sitz bath will be more beneficial in relieving swelling.

Birth Contol

  • Birth control pill actually suppresses milk production.

Bleeding

  • Small clots size of dime / quarter is normal after delivery but golf size ball clot is an indication of bleeding. Pitocin is used to decrease any bleeding. If Pitocin is not able to control the bleeding, Methergine is used.

          NOTE: Pitocin increases cervical effacement in pregnant mothers and therefore increase contractions.

  • Early post partum hemorrhage is often caused by uterine atony.
  • Late post partum hemorrhage is usually caused by placental fragments left in the uterus. Hemorrahge is more common with multiparous patients.

Breastfeeding

  • Check physician before taking any medications since most cross into the breast milk
  • Not for HIV positive mothers
  • Warm showers or warm compresses are good to facilitate “letdown.”

Clostridium Botulism

  • Do not give honey to an infant under 2 years of age.

Engorgement

  • To prevent, nurse often (about every 3 hours).
  • Can be due to plugged ducts, use warm compresses and light massages before feeding.
  • Breast pump can be used to collect the milk. Make sure not to store milk for more than 48 hours nor freeze them for more than 2 weeks or deep freeze for more than 1 month to ensure milk stability.

Fundus

  • Fundus is about 1 fingerbreaths above the umbilicus within an hour of birth and is about 3 fingerbreaths below the umbilicus on the 3rd day post partum.
  • A uterine that deviates is an indication that the bladder is full. Fundus should be located in the center.

Lochia

  • If the peri-pad appears to be soaked with more than 100cc of blood, bleeding may be occurring.
  • There should be NO foul odor. If so, it may indicate infection.
  • Color changes:

          1 – 3 day after delivery – color should be rubra (bloody) and may have a fleshy odor
          4 -  9 days – serosa (pinkinsh brown) color with fleshy odor
            10 and over – yellow to white color
 

Uterine Inversion

  • Protrusion of large red mass after delivery is an indication of UTERINE INVERSION, the most common obstetrical emergency. It  occurs if the doctor pulls on the umbilical cord before the placenta has separated.

 

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