Download Anatomy of the Male Reproductive System The importance of the

Anatomy of the Male Reproductive System
 The importance of the reproductive system is the production of off
spring & continued existence of the genetic code.
 The male reproductive system, like that of the female, consists of
those organs functioning to produce a new individual.
 The male organs are specialized to produce and maintain the male
sex cells, or sperm; to transport them, along with supporting fluids,
to the female reproductive system; and to secret the male hormone
testosterone.
 The Male reproductive organs include the two testes (Where the
sperm cells and testosterone are made), the penis, the scrotum, and
the Accessory organ (epididymis, vas deferens, seminal vesicles,
ejaculatory duct, urethra, bulbourethral glands, and prostate gland).
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Testes

They are located in the scrotum; one testis in each of the two
scrotal compartments.

The left testis is lower than the right one.

Each testis is composed of several lobules which contain
many seminiferous tubules and interstitial cells.

Seminiferous tubules in testis open into a series of efferent
ductules that emerge from the top of the organ & enter the
head of epididymis.

The functions of testes are:

Spermato genesis which is formation of mature male
gametes by seminiferous tubules (cells divide first by the
process of mitosis).

Secretion of hormone (testosterone) by interstitial cells.
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The genital Ducts

Epididymis:

Each one is formed of a single, coiled tube enclosed in a
fibrous tissue.

It lies along the top of testis & behind it.

Functions:

It is one of the ducts systems (they convey sperms to
the vas deferens)

Maturation of the sperm which stays 1-3 weeks in this
segment.


Secretion of a small part of the seminal fluid.
Vas deferens:

It's the extension of the tail of the epididymis.

It passes up in the inguinal canal to the top of the urinary
bladder, to join the the seminal duct, forming the
ejaculatory duct.

Function:

Ductal
system
connects
the
epididymis
with
ejaculatory duct.

The storage time is about 30 days & the sperm will
not loose their fertility power.

Ejaculatory duct:

Both ducts are short tubes.

Pass through the prostate gland to terminate in urethra
and they carry the spermatozoa and the seminal fluid.

Each is formed of the union of vas deferens & seminal
vesicle.

Urethra: is a tube for micturation & semen secretion.
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Accessory Reproductive Glands

Seminal vesicles:

They are two pouches, lies along the lower part of the
posterior surface of the bladder, directly in front of the
rectum.

Functions:

Secretion of an alkaline viscous liquid component of
the semen (it accounts for 60% of semen volume).

It contains fructose which is considered an energy
source for sperm motility after ejaculation.

Contains alkaline prostaglandin to help neutralize
semen pH.

Prostate gland:

It lies just below the bladder.

is a donut-shaped structure that encircles the urethra.

Functions:

It secretes a thin, milky, alkaline fluid that is rich in
zinc, citric acid, acid phosphatase, and calcium which
accounts for 30% of the seminal fluid.

Its alkalinity protects the sperm from the acidity of the
male urethra & female vagina.

Bulbourethral glands:

Cowper's glands are small peas in size & shape.

They are just below the prostate and around the penile
part of urethra.

Functions:

Secretion of an alkaline fluid.

Secretion of mucous which is lubricant for urethra.
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Supporting Structure

Scrotum:

It's a pouch covered by skin.

The main function of the scrotum is to provide the
optimum
temperature
for
testes
for
proper
spermatogenesis; it's about 3°C below normal body
temperature.

Penis:

It's formed of 3 cylindrical masses of erectile or
cavernous tissue, enclosed in separate fibrous
covering of skin.

The larger upper two are called corpora cavernosa
& the smaller lower one which contains the urethra
is called the corpus spongiosum.

The distal part of the corpus spongiosum overlaps
the terminal ends of the two corpora cavernosa
forming a slight bulging, called glans penis.

The skin is folder over it. It is called foreskin or
prepuce that's cut during circumcision.

The opening of urethra at the tip of glans penis is
called the external urinary meatus.

The
main
function
of
penis
is
erection
(enlargement & rigidity of the penis) by filling of
the cavernous tissue by blood for penetration of the
vagina to reach the semen deeply near the women’s
cervix.

Spermatic cord:

It's a fibrous covering of the vas deferens, blood
vessels, lymph vessels & nerves.
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
It extends from the top of the testis along the inguinal
canal, up to the internal inguinal ring.
Note:
a) Sperm count is 70 million per ml of semen.
b) Semen volume is 3-5 cm.
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Anatomy of the Female Reproductive System

The female reproductive system produces the female reproductive
cells (the eggs, or ova and contains an organ (uterus) in which
development of the fetus takes place.

The system includes the ovaries, uterus, uterine tubes, vagina,
vulva, pelvis & breast.
Female pelvic
a) Function
 Allows movement of the body, especially walking and
running.
 Helps in child bearing
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 Protect the pelvic organ.
b) Types of pelvic (will be discussed later)
 Gynecoid pelvis: The ideal pelvis for childbearing, its
rounded brim.
 Android pelvis: It resembles the male pelvis. Its brim is
heart- shaped (tri-angular).
 Anthropoid pelvis: It has a long oval brim.
 Platypelloid pelvis (Flat): Has a kidney shaped brim.
Characteristic inlets of the four types of pelvis.
 Pelvic floor
Function
 Responsible for voluntary control of micturition and
play an important part in sexual intercourse.
 Allows exit to the fetus
Ovaries

Both ovaries are nodular glands of uneven surface, like large
almonds in size & shape.
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
Attached to the posterior surface of the broad ligament.

The end of the uterine tube cup is over it without actual
attachment.

Functions:

Oogenesis (egg production).

Endocrine function: ovaries are the source of the female
sex hormones (estrogen & progesterone) which are
essential hormones in menstrual cycle & pregnancy.
Uterus

It is centrally located in the pelvic cavity between the
bladder (anteriorly) and rectum (posteriorly).

In unmarried woman, the uterus is pear shaped, measures
approximately 7.5 cm length, 5 cm in width, and 2.5 cm in
thickness.

The upper part is called the body, the bulging upper part of
the body is called the fundus & the lower part is called the
cervix (neck).
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
Uterine wall: consists of 3 layers:
I)
Endometrium: is the innermost layer

It is composed of three layers, and of these, two are
shed with each menses.
II)
Myometrium:

It's the thick middle layer.

The fundus has the thickest part of myometrium.

It is composed of layers of smooth muscle that
extend
transverse,
in
three
and
directions—longitudinal,
oblique.
The
tridirectional
formation of the muscular layers is important in
facilitating effective uterine contractions during
labor and birth.
III)
Parietal peritoneum:

It's the outermost layer.

It covers all the parts except the lower fourth of the
anterior surface & the cervix.

Uterine cavity:

The cavity is small because of the thick wall.

It's flat & triangular.

The base is upward & its apex is downward, constitutes
the internal os which opens into the cervical canal which
narrows on its lower end forming the external os which
opens into the vagina.

Blood supply of the uterus:

The uterine blood supply is generous.

The two uterine arteries are branches of the internal iliac
arteries.
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
The uterine & vaginal veins return to the internal iliac
veins.

Functions of the uterus:

Permits sperm to ascend toward the fallopian tubes.

Pregnancy site.

Nutritional source for the zygote until the placental
develops.

Provides a safe environment that protects and nurtures the
growing embryo/fetus

Labor.

Menstruation.
Uterine (Fallopian) Tubes

Each one is about 10 cm long, attached to the outer upper
angle of the uterus. The diameter of each tube is
approximately 6 mm.

The mucosa of it has free connection with the uterine cavity
medially & the peritoneal cavity laterally, so any infection in
the tube "salpingitis" may extend to the peritoneal region
caused peritonitis.

It consists of 3 divisions:

The isthmus: the closest part to the uterus. Tubal ligation
done here.

Ampulla: is the middle third, dilated part, passing over
the ovary. Mostly, ovum fertilization takes place here.

Infundibulum: Is the funnel-shaped portion located at the
distal end of the fallopian tube. It has a finger like
processes called fimbriae with an opening that receive
ovum.
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
Functions:

It is one of the ductal systems.

It is the site of fertilization.
Vagina

It's a collapsabel tube, 7-10 cm long.

It presents between the bladder & urethra (anteriorly) & the
rectum (posteriorly).

It connects the uterus with the perennial opening.

Functions:

Receives the sperms during the sexual intercourse.

Birth canal.

Transports tissue and blood during menses to the outside,
Vulva
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
It's the external genitalia which include mons pubis, labia
majora, labia minora, urethral meatus, vaginal orifice, and
bartholin's glands.

Mons pubis: is a skin – covered pad of fat over the
symphysis pubis.

Labia majora (large lip):

The two folds of tissue that lie lateral to the genitalia
and serve to protect the delicate tissues between them.

The external labia are covered with pubic hair while
the medial surfaces, which are moist and pink, are
without pubic hair.

It's formed mainly of connective tissue & fat with
numerous sweat & sebaceous glands.

Labia minora (small lip):

They are hairless folds of skin.

They contain a number of sebaceous glands that
provide lubrication and protective bacteriocidal
secretions

The area in between the labia minora is called the
vestibule.

Clitoris:

It's small erectile tissue and it’s sensitive during
sexual intercourse.

It presents just behind the anterior junction of the labia
minora.

Urinary meatus (urethral orifice): is a small opening of
the urethra, between clitoris & vaginal orifice.
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
Greater vestibular gland (bartholin's gland):

It's bean-shaped, one on each side of the vaginal
orifice.

Each opens by a long duct in a space between labia
minora & the hymen and they secrete mucus which
lubricates the vaginal opening.
Hymen

A small portion of tissue surrounds the opening of the
vagina.

It typically forms a border around the entrance of the
vagina in premenstrual girls.

Hymenal tissue does not completely cover or occlude
the vagina.

Ultimately the hymen becomes widened, sometimes
by tearing, which may be accompanied by bleeding.
Breast

Breasts lay over the pectoralis muscles, connected to
them by fibrous tissue and their size depend on the
amount of fat deposited.

At puberty, development of an adolescent’s breasts is
controlled
by
the
hormones
estrogen
and
progesterone.

Interestingly, in most women, the left breast is often
larger than the right.
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 Breast tissue is formed of two major organs:
1) Mammary systems: which include :
a) Lactating glands: which are formed of distal alveoli,
forming lobules, united to form lobes, arranged in
grape like clusters.
b) Ductal system: The ducts from the various lobules
unite forming a single lactiferous (milk carrying) duct
for each lobe, each enlarges slightly before reaching
the nipple into small lactiferous sinuses, each duct
terminates in a tiny opening on the surface of the
nipple, each nipple is bordered by a circular
pigmented area called areola, which contains many
sebacious glands.
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2) The connective tissue & fat: Which form the bulk of the
breast, it is made mainly of fat, and the skin is anchored
to the pectoral fascia by many fibrous suspensory
ligaments.
 Breast function:
 The function of the breast is lactation, the factors affecting milk
production are:
1) Estrogen hormones promote the ductal growth.
2) Progestrone stimulates the alveolar system.
3) Prolactin stimulates milk secretion.
4) Oxytocin stimulates milk ejection from the breast.
 Mechanisms of breast function:
 A high blood concentration of estrogen during pregnancy
inhibits anterior pituitary secretion of prolactin, so no milk
will be made during pregnancy.
 Shedding of placenta, after labor leads to marked decrease in
estrogen level in the blood that stimulates anterior pitutary to
secrete prolactin.
 Sucking movements of a baby stimulates the anterior
pituitary to secrete prolactin, and the posterior pituitary to
secrete oxytocin to increase milk ejection.
Female reproductive cycles
 There are many periodical changes in female during the years
between the onset of the menses (menarche) and their cessation
(menopause) on the level of endometrium, ovarian, myometrial &
gonadotropic cycle.
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1) Ovarian Cycle:
 Before birth, the ovarian tissue begins a meiosis division;
it reduces the number of chromosomes in the daughter
cell by half.

When a child is born, her ovaries contain many primary
follicles, each contains an oocytes that have temporarily
suspended the meiotic process before it's complete, once
each month, on about the first day of menstruation, the
oocytes within many primary follicles resume meiosis,
one of them matures & migrates to the surface of the
ovary, to be expelled from the ruptured wall of the
mature follicle during ovulation.
 Ovulation usually occurs 14 days before the next
menstrual period begins.
 Immediately after ovulation, cells of the ruptured follicle
enlarged & transformed into a golden colored body which
called corpus luteum.
 The corpus luteum which grows for 7-8 days, during this
period will secrete high amount of progesterone.
 Then the corpus luteum will be nonfunctioning white
scar, called corpus albicans which moves to the center of
the ovary & finally disappears.
2) Endometrial (menstrual) cycle:
 During menstruation, parts of compact & spongy layers
of the endometrium slough off, leaving denuded areas.
 After menstruation, this cell layer will proliferate causing
the endometrium to reach a thickness of 2-3 mm by the
time of ovulation.
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 Part of this is secreting a nutrient fluid during the time
between ovulation & the next menses.
 A day before menstruation starts again, a drop in
progesterone level causes contraction of the muscle layer
of the arteries that supply the glands, producing
endometrial ischemia, leading to the death of the tissue,
and sloughing of the endometrium (bleeding).
 So we can divide menstrual cycle into phases:
a) Menses: occurs on days 1-5 of a new cycle.
b) Postmenstrual phase (between the end of menses &
ovulation), so it can be described as " preovulatory
phase" it starts from the 6th to 13th day of a 28 dayscycle. This period is called estrogenic or follicular or
proliferative phase.
c) Ovulation: occurs on cycle day 14 in a 28- day cycle.
d) Premenstrual phase (postovulatory) between ovulation
& the onset of menses, it's secretory or luteal phase so
progesterone will be secreted, it takes from 14 days to
28 in a 28-day cycle.
3) Myometrial cycle:
 Myometrium contracts mildly but with increasing
frequency during the two weeks preceding ovulation, to
decrease or stop during ovulation & after that.
4) Gonadotropic cycle:
 The anterior pituitary gland secretes two hormones, LH
& FSH.
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 Control of female reproductive cycles:
 The menstrual cycle is hormonally mediated through events that
take place in the hypothalamus, anterior pituitary gland, and the
ovaries.
 The hypothalamus stimulates the anterior pituitary gland to
produce gonadotropin. FSH, one of these hormones, stimulates
the growthand development of the graafi an follicle, which
secretes estrogen.
 Estrogen stimulates proliferation of the endometrial lining of
the uterus.
 After ovulation, the anterior pituitary gland secretes LH, which
stimulates development of the corpus luteum.
 Progesterone secreted by the corpus luteum prompts further
development of the lining of the uterus in preparation for the
fertilized ovum.
 When pregnancy does not occur, the corpus luteum degenerates,
and the levels of estrogen and progesterone decline.
 The decreased levels of estrogen and progesterone cause the
uterus to shed its lining during menstruation.
 The decrease in estrogen and progesterone triggers a positive
feedback to the hypothalamus, which stimulates the anterior
pituitary gland to secrete FSH once again.
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 Increase of estrogen during the post menstrual phase
will cause:
a) Proliferation of the endometrium cells.
b) Growth of the endometrial glands.
c) Increase in endometrium water content.
d) Increase in myometrial contraction.
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 Increase of progesterone during the premenstrual
phase will cause:
a) Increase secretion by endometrial glands.
b) Increase in the endometrium water content.
c) Decrease in myometrial contraction.
 Importance of female reproductive cycles:
1) Production of ovum is the main role.
2) Preparing the uterine endometrium for suitable implantation, so
constant renewable of the endometrium makes successful
implantation.
Notes:
 Menarche: is the first flow of menstruation, at puberty, at about
the age of 13 years, with many variations.
21
 Menopause (climacteric) is the cessation of menstruation from
about the age 45-50 years.
 After
menopause,
estrogen
concentration
decreases
dramatically, which causes negative feedback response that
increases the gonadotropin levels.
 Notes:
 After ovulation, the ovum can be fertilized for 12-24 hours.
 After ejaculation, sperm can fertilize an egg for up to 48 hours.
 Less than 200 sperms actually reach the egg and only one will
fertilize it.
 Fertilization occurs in the ampullary portion of the fallopian
tube.
 The fertilized ovum reaches the uterine cavity approximately 23 days after fertilization
 Implantation begins 2-3 days after the fertilized ovum enters the
uterine cavity
 Human chorionic gonadotropin (hCG) is produced by the
conceptus at about the time of implantation.
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Menstrual disorders
Dysmenorrhea
 Dys= painful, menorrhea = normal menstrual flow
 Painful menstruation
 It has 2 types
1) Primary dysmenorrhea:
 Is painful menstruation that occurs in the absence of pelvic
pathologic finding.
 An ovulataroy cycles are not accompanied by dysmenorrhea,
so that it does not occur during the 6-12 months following the
onset of menarche.
 Symptoms of primary dysmenorrheal are associated with a
functioning corpus luteurn; premenstrual tension, uterine
cramping, occasionally headache, dizziness, vomiting and
diarrhea. Spasmodic pain starts with the menstrual flow and
lasts for 1 to 3 days.
 Intense myometrial contractions lead to uterine ischemia that
results in pain.
 Pregnancy increases vascularity and blood flow to the uterus,
so that following pregnancy, intense uterine contractions may
no longer lead to ischemia
 Prostaglandins have been implicated in primary
dysmenorrheal. Significantly elevated P rostaglandins have
been detected in the endometrium and menstrual fluid of
women with primary dysmenorrhea.
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2) Secondary dysmenorrhea
 Occurs in association with pathologic changes such as
endometriosis, pelvic inflammatory disease, cervical stenosis
or uterine or ovarian neoplasm.
 The presence of IUD may lead to secondary dysmenorrhea
 Management
 Mild analgesics
 Prostaglandin inhibitors.
 Contraceptive pills are effective for some women
 Regular exercises
 Emotional support and reassurance.
Premenstrual syndrome
 Is a condition related to neuroendocrine events within the
hypothalamus–pituitary axis that modulate neurotransmitters
function.
 It differs from dysmenorrhea in that it has no relation to
ovulation.
 Causes are unclear, but it may be due to heredity or
environmental factors
 Clinical manifestations
o Symptoms may begin 10 days or more prior to menstrual
flow onset, they diminish 1 to 2 days after menses begin. It
includes transitory edema, breast swelling and abdominal
distension due to increase water content tissues, behavioral
problems include irritability, sleep disturbances, depression,
headache and vertigo.
 Management
o Progesterone supplement
24
- Diuretices.
o Tranqulizers may be helpful
- Low sodium diet.
Amenorrhea
 Absence of menstrual flow.
 Primary amenorrhea. A girl 16-17 years old and has not
menstruated yet. Causes include congenital obstructions,
congenital absence of uterus, absence or imbalance of
hormones.
 Secondary amenorrhea: menstruation has begun but stops.
Causes include pregnancy, lactation, hormonal imbalance, poor
nutrition, ovarian lesions, stress, and use of contraceptive pills.
 Post pill amenorrhea: after discontinuing oral contraception,
there is usually a delay before ovulation and menstrual cycle
recur. However, amenorrhea exceeding 6 months should be
investigated.
 Management
o Find the cause and treat it.
Oligomenorrhea:
 Is markedly diminished menstrual flow nearing amenorrhea.
Monorrhagia:
 Is excessive bleeding during regular menses.
Metrorrhagia:
 Is bleeding from uterus between regular menstrual periods. It is
significant because it is usually a symptom of some diseases,
often benign or malignant tumor of uterus.
Ploymenorrhea:
 Is frequent menstruation occurring in intervals of less than 3
weeks.
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Menopause
 Is the stage of female life when there is physiologic cessation
of the menses along with progressive ovarian failure.
Climacteric is the transition period during which the woman's
reproductive function gradually diminishes and disappears. It
usually occurs between the age of 45 and 55 years
 Menopause can be surgically induced
 The age of onset may be influenced be nutritional, cultural, and
genetic factors.
 Menopause occurs when estrogen levels come so low.
 50% of women report symptoms of heat (hot flashes) arising
on the chest and spreading to the neck and face caused be
vasodilatation and last for 20-30 days
 Long range physical changes may include osteoporosis.
 Reproductive female system starts to atrophy.
 Menopausal women may need assistance in the form of
counseling to adjust successfully to this developmental stage of
life. The way of dealing depends on socio-cultural factors and
acceptance to menopause woman.
26
Preconception health and preconception counseling
 Preconception care produces healthier babies "every pregnant
woman has a 2-3% baseline risk of giving birth to a baby with birth
defects and/or mental retardation"
 Since the baby's major organs are formed during the first 2 months
of pregnancy, we need to start pregnancy care before conception.
 Despite the many advances in medicine and technology, women
still have higher rates of certain complications related to pregnancy
 Simple things like getting immunized for rubella or taking folic
acid supplements can play a major role in decreasing birth defects,
if it is done before conception. The fact is, the first prenatal visit,
traditionally done after a woman is pregnant is really too late.
 Proper nutrition:
o A well balanced diet is important, with special emphases on
three nutrient: calcium, iron and FOLIC ACID.
o The center for disease control (CDC) recommends that every
woman if childbearing age takes folic acid 0.4 mg before
conception to reduce her chance of having a baby with a
neural tube defect (NTD).
o N.B: consumption of folic acid should ideally start at least 1
month before conception.
 Exercise: Women who exercise regularly usually tolerate the
stresses the of labor better
 Immunization status: vaccination before pregnancy can prevent the
complication due to these infection.
o Physician will recommend waiting 3 months after receiving
these vaccines before conceiving .
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 Habits to break:
1. Tobacco:
Mothers who smoke during pregnancy increase the chances of
miscarriage, stillbirth and low birth weight babies. Also, sudden
infant death syndrome, asthma and breathing problems. If the
father smokes, he also has good reason to quit.
2. Alcohol:
Alcohol use during pregnancy can cause fetal alcohol syndrome or
related birth defect such as heart problems, microcephally and
mental retardation. No safe level of alcohol during pregnancy has
been determined.
3. Drugs:
Using illicit drugs such as marijuana, cocaine and heroin increase
chances for miscarriage, stillbirth and poor fetal development and
growth, or children are born with learning difficulties.
Some researchers believe that fathers use of drugs will affect their
children.
 Medical problems:
Cretin medical conditions need special attention before pregnancy.
If women are under treatment for conditions like hypertension,
diabetes or thyroid disease, it is important that these conditions to
be well controlled before pregnancy.
 Hazards at work and home:
Exposure to cretin chemicals such as lead, mercury, heat,
hypothermia may be teratogenic. There are also many
misconceptions concerning safety of home and work as hair dyes
or microwave ovens, which should be addressed.
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 Genetic screening:
A review of family history and ethnic background may show
predisposition to certain genetic disorders.
Other reasons to meet with a genetic counselor include family
history of a child with a birth defect or genetic disorder.
 Emotional and physical factors:
Stress, long hours, hard physical labor, prolonged standing,
domestic violence, all can affect pregnancy and fertility
 Financial Considerations:
The average cost of having a baby needs planning ahead for issues
related employment and health insurance.
 Stopping Birth Control:
When pregnancy is desired, there is usually a transition period
from contraception to conception. Knowing some general
principles makes the transition an easy one.
Reproductive Alternatives
1. In Vitro Fertilization : IVF
 Used when a women’s uterine tubes are damaged or obstructed, or
the husband doesn’t produce sufficient number of sperms.
 The woman is given drugs to stimulate ovulation.

The ovary is punctured via laparoscopy and mature follicles
(oocyte) are removed by suction.
 Each egg is placed in a mixture of salt, sugar and proteins
designated to simulate the maternal fluids found in the uterine
tubes.
 The oocytes are then combined with husband’s sperm in the
laboratory.
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 After fertilization, the normally developing embryos are placed in
the uterus
 Legal and ethical aspects:
 The first live birth with these technique “test-tube babies” was
in 1978.
 Several questions were raised concerning the possible disrespect
for human life, for example regarding fertilized eggs that are
discarded.
 Whether the personal and agency performing the procedure are
legally liable for defects if the child conceived by IVF is born
with physical or mental handicaps is questionable.
30
 Another ethical question concerns the relative cost of IVF. In
countries with limited medical resources available, decisions
need to be made regarding how funds should be sent.
2. Embryo Transplants
 Used when a woman is not capable of producing normal mature
follicles, but the male partner is fertile.
 Through hormonal therapy, the menstrual cycles of the donor
woman and the recipient woman are synchronized.
 The sperm of fertile husband is artificially inseminated in a fertile
donor woman following her normal ovulation.
 If fertilization occurs, several days later the fertilized egg is washed
from the donors woman uterus.
 The fertilized egg is then deposited in the uterus of the wife who
was incapable of producing a normal mature follicle. If successful,
implantation occurs soon afterward.
3. Artificial insemination:
 Injection of sperm cells into the vagina or uterus.
a) Homologous insemination (Artificial insemination by husband)
AIH, denotes the use of the husband semen.
 May be considered in pronounced hypospedias or with
abnormal cervical discharge.
 Semen may be frozen and stored in the early stages.
 The woman may be given drugs to stimulate ovulation before
insemination. Ultrasound and blood studies of varying
hormone levels are used to pinpoint the ovulation and best time
of insemination. Starting at 2-3 days before ovulation,
31
insemination may be repeated daily or every other day until 2
days after ovulation.
b) Heterologous insemination (artificial insemination by a donor)
AID, denotes the use of the semen of a donor other than the
husband.
 Used in case of the husband is sterile.
 The donor should have no family history of epilepsy, D.M. or
known genetic defects and should have negative test result for
syphilis and HIV.
 Precautions should be taken so that the donor is not known to
the reception and vice versa.
Religion views and Ethical concerns:
 Religion views AIH as a moral and good process to be done when
indicated
 Religion objections to AID voiced mainly by the Islamic religion,
the Catholic Church, conservative Protestant and Jewish
theologians. They are concerned mostly with the idea of adultery
and consider the resulting child is illegitimate.
 The couples must know, there is no guarantee of pregnancy.
4. Surrogate mother.
 Surrogate mothers contract to carry pregnancies for women who
are unable to carry a pregnancy due to an absent or anomalous
uterus or medical condition that would be life threatening during
pregnancy.
 A gestational carrier contracts to carry a pregnancy that is not
genetically her own offspring.
32
Notes:
A. During assessment you have to identify the religious and cultural
data related to infertility and its management.
B. We have to treat the causes of infertility such as infection, varicose
veins, malnutrition or psychosocial disorders " treat conditions
that are treatable"
C. Maintain client's self–esteem and sense of adequacy as woman or a
man.
D. Help client maintain control over his/her destiny through active
participation in the decision–making process.
33
Fertility Control
Family planning: the controlling of the number of children born in a
family and the time of their birth by the use of any of various
contraceptive.
Birth control: the use of various methods to limit the number of children
born, especially by preventing them from coming into begin.
Contraception: is the voluntary prevention of pregnancy.
Contraceptive: the act or practice of preventing sex from rustling in the
birth of a child, and/or all the methods for preventing this.
Basic principles:
1. The nurse should be familiar with the application, advantages and
disadvantages of the various methods of contraception available,
2. The most effective methods is the one a woman selects for herself
and will use consistently.
3. Male involvement and female empowerment should go hand in
hand and focus in social rather than only changing their knowledge
and practice of family planning.
Men can:
 Share in decisions about family planning size and use of
contraceptives.
 Take responsibility for using some methods.
 Support partners in using some methods
 Share responsibility for child rearing.
Family planning benefits couple/family:
1. Help limiting/spacing pregnancies.
2. Less emotional and economical strain.
3. More resources available for children.
4. Increase education opportunities for children.
5. More energy for husband activities.
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6. More energy for personal development and community activities.
Family Planning Benefits Community:
1- Reduce strain on environmental resources (land, food, and water…)
2- Reduce strain on community resources (health care, education…)
3- Greater participation by individuals in community affairs.
Contraception employs one or more of the following methods:1- Methods available to people without prescription
a) Natural family planning e.g. periodic abstinence.
b) Chemical barriers e.g. spermicidal creams, gels, vaginal
suppositories.
c) Mechanical barriers e.g. condom, diaphragms.
2- Methods that require periodic medical examination and
prescriptions.
a) Hormonal barriers e.g. oral contraceptives.
b) Mechanical barriers e.g. tubal occlusion.
c) Intrauterine devices (IUD).
3- Methods that require surgical interventions
a) Female sterilization e.g. tubal ligation.
b) Male sterilization e.g. vasectomy.
Note: failure rate (pregnancy is determined by the experience of 100
women for 1 years and this expressed as pregnancies/100.
1) Periodic abstinence “ natural family planning ”
Avoidance of intercourse during the presumed fertile days of the
menstrual cycle.
 Mode of action:
The human ovum can be fertilized no later than 24 to 48a hours
after ovulation. Motile sperm have been recovered from the uterus and
the oviducts as long as 60 hours after coitus.
35
However, their ability to fertilize the ovum probably lasts no
longer than 24 to 48 hours. Pregnancy is unlikely to occur if a couple
abstains from intercourse for 4 days before and 3 or 4 days after
ovulation (Fertile Period).
 The fertile period can be anticipated by:
1- Calculating the time at which ovulation is likely to occur, based on
the length of previous menstrual cycles (calendar methods).
N.B:- ovulation usually occurs 14 days before the onset of
menstruation.
2- Recording the rise in the basal body temperature (BBT)
(Temperature methods). "Thermogenic effect of progesterone".
3- Recognizing the changes in cervical mucus (ovulation or billings
methods).
 Abstaining for about 7 to 08 days
depends on the regularity
of the cycle.
 Effectiveness ranges between 73-97%
2) Coitus interrupts:
This is the withdrawal of the penis from the vagina when
ejaculation is imminent.
Indications: effective when mechanical devices are unavailable.
Contraindication: when males is not able to exert self-control.
Ineffective when premature ejaculation occurs.
Undesirable effects: failure rate is between 35-40% and psychological
ill effects for both male and female.
Subsequent prostatitis has been substantiated.
3) Condom:
Is a thin stretchable sheath to cover the penis.
Mode of action: Use correctly , condoms prevent sperm from entering
the cervix.
36
Spermicide- coated condoms cause ejaculated sperm to be
immobilized rapidly.
Advantage:
 Safe, without side effects and readily available.
 Easy to use
 May lessen premature ejaculation
 Protect against sexually transmitted diseases (STDs).
Disadvantages and side effect:
 May dull sensation somewhat for male and female.
 If use improperly, spillage of sperm can result in pregnancy.
 May cause contact dermatitis.
Effectiveness: in general the failure rate is 15 pregnancies/ woman years.
Nursing actions:
 Female and male partners benefit from discussion of their feeling.
 Use a medical model to demonstrate application and removal of the
device.
 Clients need to be alert to the mode of action, advantage,
disadvantage and side effects, and failure rate of this method.
N.B: " morning after pill " high estrogen may be used in case of ruptured
condom immediately.
4) Chemical barriers:
A vaginal spermicide is a physical to sperm penetration that also has a
chemical action.
Spermicides (creams, suppositories, and gel) provide physical and
chemical barriers that prevent viable sperm from entering the cervix.
The effect is local within the vagina.
Advantages:
 Easy of application
37
 Inexpensive
 Safe
 Available without prescription
 Aid in lubrication of vagina.
Disadvantages and side effect:
 Allergic response or irritation.
 Need 10-30 minutes before coitus
 Need reapplication of additional spermicide prior to repeat
intercourse.
Effectiveness: correct and regular use could be expected to have a
failure rate as low as 5 pregnancies/100 woman years.
Nursing actions:
 Encourage open communication with partners.
 Clients are offered the opportunity to see and handle a variety of
samples.
5) Hormonal contraception: (the pill)
Oral synthetic preparations of estrogens and progesterone's are used.
Mode of action:
Activation of the hypothalamus and pituitary to release FSH and LH is
dependent on fluctuation in the blood concentration of ovarian
estrogen and progesterone .The medication suppresses anterior
pituitary secretion of gondoatropins (FSH & LH). As a result of low
FSH &LH, ovulation will not occur. It is also has a direct effect on the
endometrium, so that from 1-4 days after the last tablet is taken, the
endometrium sloughs and bleeds as a result of hormone withdrawal.
The withdrawal bleeding usually is les profuse than that of normal
menstruation.
Some women have no bleeding at all.
38
Advantages:
 For motivated woman it is easy to take an oral contraceptive at
about the same time each day.
 May help regulate menstrual cycles and make it possible for
conception to occur at a later time.
 Women taking contraceptive are examined before the
medication is prescribed and yearly thereafter, medical
surveillance is valuable in the detection of non-contraception
related disorders as well.
Absolute contraindications include a history of: Thromboembolic disorders – cancer breast.
 Cerebrovascular or abnormal genital bleeding.
 Liver tumor.
 Known or suspected pregnancy.
 Migraine headaches.
 Sickle cell disease.
Relative contraindications include:
 Age of 40 years or older.
 D.M.
 Heavy smoking.
 Hypertension
 Gall-bladder diseases
Failure rate:
Nursing actions: There are many different preparations; the nurse needs to
review the prescribing information in the package insert with
the client.
 Directions for care after missing one or two tablets also vary.
39
 Before oral contraceptives are prescribed, the woman is alerted
to stop taking the pill and to report any of the following
symptoms to the physician immediately. The word ACHES
help in retention of this list :
A - Abdominal pain (may indicate a problem with liver)
C- Chest pain or shortness of breath (may indicate possible clot
problem)
H - Headache (sudden or persistent) may be caused by
cardiovascular accident or hypertension
E - Eye problems, may indicate vascular accident or hypertension
S - Sever leg pain, may indicate a thrompoembolic process (DVT).
Morning after pill:
It is a post coital method used as an emergency. It blocks the release
of progesterone and affects the lining of the uterus. If an egg is
fertilized, it will not be able to implant in the uterus. It may prevent
ovulation.
However, it will not abort pregnancy from earlier sexual experience
or later in the cycle.
 Tow tablets of oral contraceptive and two tablets 12 hours later
Effectiveness: 98% effective, its effectiveness decreases the longer
the delay.
Special considerations:
 Effectiveness decreases, if used repeatedly in one cycle.
 Should be taken as soon as possible after unprotected
intercourse. No points in taking it after 72 hours.
Depo prvera (injection):
 Deep injection is given every 3 months (150 mg IM).
40
 It contains progestin, which inhibits ovulation, thins lining of
the uterus, thickens cervical mucus and alter fallopian tube
movement.
Effectiveness: 99%
Advantages:
 No need to remember to take a pill.
 No need to interrupt intercourse.
 Highly effective.
 Reversible.
 Continuous protection.
Disadvantages and side effects:
 Menstrual irregularities as amenorrhea.
 Increased menstrual bleeding
 Bleeding at unusual times
 Delayed return to fertility.
Special considerations:
Contraindications: generally the same as oral pills.
Nor plant:
Hormonal contraceptive that lasts for 5 years. Six capsules are
inserted by a trained health professional in a minor surgical procedure,
Which take 20 minutes.
The progestin in capsules is released slowly. It inhibits ovulation,
thins the uterine wall, thickens cervical mucus, and slowly movement
of fallopian tubes. More recently the capsules have been reduced to
two capsules given the same amount of progesterone.
Effectiveness: extremely effective 100%
Advantages:
 Very safe
– Convenient
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 Reversible
- Estrogen free
 5 years effective
– Can be removed at any time
 Decreased incidence of anemia and inflammatory diseases
Disadvantages and side effects:
- Irregular bleeding
- Spotting between periods.
- NO periods
- Not readily available.
- Having continuous bleeding
- Although rare, some women may experience headaches, nausea,
nervousness, dizziness, skin inflammation, acne, change in appetite,
increased facial hair, and hair loss or breast tenderness.
Special considerations:
 Should not be used for people suffering from :
 Active thromboemebolic disorders.
 Undiagnosed abdominal or genital bleeding
 Breast cancer
 Some drugs reduce effectiveness of nor plant such as Rifampin,
phenobarbtione .
 Preventive checkups are recommended.
 Follow up within one month after insertion then at least every year
for 5 years.
6) Diaphragm:
The vaginal diaphragm is a shallow, dome-shaped rubber device with a
flexible wire rim that covers the cervix. The use of a contraceptive gel or
cream with the diaphragm offers both mechanical and chemical barriers
to pregnancy.
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Mode of action:
It is a mechanical barrier preventing the meeting of the sperm with the
ovum. The diaphragm holds the spermicide in place against the cervix for
the 6-8 hours it takes to destroy the sperms.
Insertion of diaphragm immediately prior to intercourse.
Advantages :
-No side effect from a well–fitted device.
Disadvantages & side effects:
-Reluctance of some women to insert or remove the diaphragm.
-Side effects may include irritation of tissues related to contact with
spermicides.
-High failure rate.
Effectiveness: approx. 83 – 90 %, highly motivated women may achieve
rates of 99%.
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Nursing action:
- The woman is informed that she needs annual gynecological
examination.
- Use the package insert for the diaphragm.
- Instruct the woman to retain it 6-8 hours after intercourse.
7) Intrautrine Device
The IUD is a device made of metal or plastic that inserted in the uterine
cavity. M
Mode of action: IUD alters the endometrium locally and there by
discourage implantation if fertilization occurs. Because the effect is local,
there is no disruption of the women’s ovulatory pattern.
Advantages:
 Very effective.
 Requires no daily activities.
 Reversible (when pregnancy is desired, the IUD can be removed).
 Low cost.
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 Used very successfully by most women.
 Doesn’t interrupt intercourse.
 Can remain in place for 4 years or more.
 Useful when hormones are contraindicated.
Disadvantages and side effects:
 The use of an IUD is contraindicated for women with a history of
pelvic inflammatory disease (PID).
 Some discomfort as cramping pain, increased menstrual flow,
spotting between periods.
 PID, perforation.
Effectiveness:
Very effective, average failure rate is 3 pregnancies/100 women/year
during the first year, effectiveness increases after the first year.
Special considerations:
 Requires trained practitioner to insert and to remove.
 Contraindicated for women with PID, pregnancy, uterine tumors,
and history of ectopic pregnancy.
 Not a method of choice for women with diabetes, STD, anemia,
dysmenorrhia.
 Must be inserted during menstruation or after abortion (if the client
is pregnant when an IUD is inserted, she might suffer septic
abortion and possibly fetal septicemia shock, hence the wisdom of
having the device inserted during menstruation)
8) Sterilization:
Refers to surgical procedures intended to render the person infertile.
Permanent contraceptive for men and women
a) Vasectomy: Tubes (vas deferens) that carry sperm are cut.
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b) Tubal ligation: fallopian tubes are cut or tied so eggs can’t reach the
uterus.
Effectiveness: 100%
Advantages: no worry about unwanted
Disadvantages: Reversal not very successful
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Conception and fetal Development
Genes and Chromosomes :
The genes are composed of tiny segments of DNA which enables them to
duplicate themselves during cell division.
-Each body cell contains 2 sets of genes arranged in a line to form larger
structures, the chromosomes within the cell nucleus.
- Each cell nucleus contains 2 sets of chromosomes consisting of 2
matching sets of genes, one set obtained from each parent during the
process of fertilization.
- When a pair of genes are alike and produce the same effect, they are
called homozygous,
When they are not alike and produce different effects they are said to be
heterozygous.
Cell Division
-Somatic cells divide by the process of mitosis in which the cell
components including the genetic material divide and are distributed
equally to the 2 newly formed cells. Each new cell contains the same
composition and genetic potential as the original cell .
-The process of cell division in the reproductive cells is called
gametogenesis.
Gametogenesis takes place by meiosis or reduction division to from
gametes.
Gametogenesis
Spermatogenesis:
-Meiosis in the male gonad is a continuous process that begins about the
time of puberty and lasts until senescence.
-Each normal sperm contains a haploid (23) complement of
chromosomes, 22 autosomes + X or Y chromosome.
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-The male supplies the genetic material (X or Y chromosome ) that
determine the sex of the child .
Oogenesis :
-Unlike spermatogenesis, the process of meiosis in the ovaries is not a
continuous process.
-Oogenesis begins during intrauterine life and the female gametes have
already enlarged and developed into primary oocytes at the time of birth.
Approx. 500,000 in number.
-Each normal ovum contains 22 autosomes and X chromosome.
-An ovum fertilized by bearing a Y chromosome results in a male zygote,
where as an ovum fertilized by X bearing sperm results in a female
zygote.
Conception "fertilization"
During sexual intercourse 2-5 ml of semen usually containing more than
300 million sperms are ejaculated into the female vagina.
By flagellar movement, the sperms make their way through the fluid of
the cervical mucus, across the endometrium and into the uterine tube to
meet the descending ovum in the ampulla of the tube .
Before fertilization the sperm undergo a physiologic change called
capicitation and a structural change called acrosome reaction.
Capicitation refers to the removal of a protective coating from the sperm
“enzymes of uterine tubes assist in this process"
The acrosome reaction refers to the small perforation that form in the
anterior head of the sperm through which a hyalurinadese enzyme escape
and digest a path through the ovum.
Only one sperm is required for actual fertilization.
Conception, the fusion of a sperm and an ovum (Oocyte) is a process that
requires about 24 hours.
48
At the moment that a sperm makes contact with eggs plasma membrane
the oocyte reacts, a zone reaction "as yet not understood " occurs
preventing the entry of more sperms.
When the sperm and ovum meet and from zygote, the diploid number of
chromosomes (44+2 sex) is restored.
Developmental Stages
The fusion of nucleus of the 2 gametes is called conception.
Fusion initiates the first of the three stage of human prenatal development
(Ovum, Embryo and fetus)
Ovum:
The conceptus is called an ovum during the period from conception until
primary vili appear 12-14 days after fertilization or about 4 weeks since
LMP. By the end of the period, implantation (Nidation) is complete, the
conceptus is totally within the endometrium and is covered by surface
epithelium.
Embryo :
From the end of the ovum stage until it measure approx. 3cm , normally
54-56 days (10 week since LMP), characterized by rapid cell division and
the most critical time in the development of an individual, all the
principle organ systems are being established and are highly vulnerable to
environmental agents e.g. teratogenes such as viruses , drugs, radiation or
infection.
Developmental interference during this time can result in major
congenital abnormalities.
Fetus:
Latin word = off spring
During the period from the end of embryo stage until the pregnancy is
terminated. Changes occurring during the fetal period, although
important, are not dramatic as those in the preceding period. During this
49
period the fetus is less vulnerable to the teratogenic effects of the drugs,
viruses…etc. however these agents may interrupt normal functional
development of organs specially the brain.
Viability
Is the capability of a fetus to survive outside the uterus at the earliest
gestational age?
-It was believed that viability was reached when the fetus weighted more
than 1000 gm and had reached at least 28 weeks gestational age.
Improvement in maternal and neonatal care now suggests that a new
standard of viability must be established.
Survival outside the uterus is dependent on 2 factors:
1-The maturity of fetal central nervous system for directing rhythmic
respirations and controlling body temperature.
2-The maturity of lungs.
The decidua
After conception, the vascularity of the uterine wall increases greatly
under the influence of the ovarian hormones principally progesterone.
After implantation, the endometrium is called the decidua which means
“to cast off" or “to discard" since this actually what happens after the
infant is born. The prepared lining of the endometrium is cast off in
vaginal discharge called lochia.
The decidua is divided to 3 areas:
1-Decidua Vera (Parietalis): is a part of the endometirum not directly
associated with the development of the embryo.
2-Decidua basalis: is the portion of the decidua vera where nidation take
place, that is the area where chorionic villi invade the maternal blood
vessels and develop into placenta.
3-Decidua capsularis: is the portion of the deciduas vera that cover the
blastocyst after nidation occurs, isolating it from other portion of the
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uterus, it appear to fuse with the chorion (a fetal membrane as pregnancy
advances).
Implantation "Nidation"
After conception, the zygote is propelled by ciliary action and irregular
peristaltic contractions. Then it starts to move through the uterine tube
into the uterine cavity . During a 3-4 days period, it takes to travel down
the uterine tube. The zygote goes into a process of rapid cell division
called Mitosis "CLEEVAGE"
-The initial division of zygote results in 2 blastomeres, which
subsequently divides into progressively smaller blastomereses.
-At the end of 3-4 days, the developing individual comprises about 16
blastomeres arranged in a ball-like structure called "MORULA".
-After the morula enters the uterus, a cavity formed within the dividing
cells changing the morula into a blastocyst.
-The blastocyst remains free in the uterus for 1-2 days then develops into
to masses:
a) trophoblast (which develops into the placenta) implant generally in the
endometrium of the anterior or posterior fundal region.
b) embryoblast: which develops into the embryo
-Cells of the attaching portion of the trophoblast secrete proteolytic and
cytolytic enzymes to help burrow their way into the compact layer of the
endometrium.
-This burrowing in the endometrium is called implantation or nidation.
-Slight bleeding called trophoblastic burrowing stops before it reaches the
myometrium .
-About 7-10 days elapse between fertilization and completion of
implantation.
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-Trophoblasts are vascular processes that have the power of cytolysis and
are able to tap maternal blood vessels as sources of nourishment and
oxygen for the embryo.
These villi are the 1st stage of the developing chorionic villi that secrete
HCG (Human Chorionic Gonadotropic Hormone) and synthesize protein
and glucose for approx. 12 weeks.
-By 12 weeks, the fetal liver can supply its own glucose and insulin.
-HCG stimulates continued secretion of progesterone and estrogen by the
corpus luteum, thus preventing ovulation and menstruation during
pregnancy.
-Chorionic villi invasion of the endometrium by enzymatic action
occasionally opens a maternal vein and artery causing lacunae (small
blood lakes) in the decidua basalis.
-This rich blood supply causes the adjacent villi to multiply rapidly.
These villi become the chorion fordosum or fetal portion of the future
placenta.
Placenta
Greek word = flat cake.
 The placenta develops after the third week of gestation.
 The growth of the thickness of placenta continues until 16-20
weeks.
 Placental circumference continues growing until later pregnancy.
 The fully developed placenta "after birth" is reddish, 15-20 cm
diameter, 2.5-3 cm thickness, 400-600gm or 1/6 wt. of the
newborn.
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Functions:Depends entirely on maternal circulation. Optimum circulation to the
placenta and fetus is possible when the women is lying on her left side.
1. Endocrine gland: HCG, Estrogen and progesterone, HPL (Human
Placental Lactogine).
2. Metabolic, respiratory and renal function: the placenta serves as
lung, kidneys, stomach and intestine for the fetus, maternal
nutrients and oxygen pass through the placenta to the fetus, waste
materials move from the fetus to the mother by way of the
placenta.
3. Immunologic function: helps in transfer of IgG and antibodies from
the mother to the fetus "passive natural immunity".
4. Protective barrier: the placenta serves as a protective barrier against
the harmful effects of certain drugs and microorganisms.
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Amniotic fluid
 Amniotic fluid volume increases at an average rate of 25 ml
per week during the first trimester and 50 ml per week
during second trimester.
 Full fetus is immersed in about 1000 ml (800-1200 ml) of
clear, slightly yellowish liquid.
 Specific gravity is (1.007-1.025).
 pH is neutral to slightly alkaline (7.0-7.25).
 It contains albumin, urea, uric acid, Creatinine, fat,
billirubin, inorganic salts, epithelial cells, few leukocytes,
and various enzymes and lanugo hair.
 Amniotic fluid replaced every 3 hours, in early pregnancy
originates from maternal serum then from fetal urine.
Functions:
1. Protects the fetus from direct trauma.
2. Separates the fetus from the fetal membrane.
3. Allows freedom of fetal movement and permits musculoskeletal
development.
4. Facilitates symmetric growth and development of the fetus.
5. Protects the fetus from loss of heat and maintains a relatively
constant fetal body temperature.
6. Serves as a source of oral fluid for the fetus (fetus swallow up to
400 ml/day).
 Amniocentesis: done to detect sex, state of health and
maturity of the fetus.
 If more than 2L: polyhydrammios (occurs if fetus has GI or
other disorders).
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 If less than 300 ml: oligohydrammnios (occurs if fetus has
renal disorders).
Umbalical Cord
Is the lifeline that links the embryo and the placenta
- 50 – 55 cm long . 2 cm diameters.
- Contains no pain receptors.
- Has 2 umbilical arteries and one umbilical vein.
- Vein carry oxygenated blood, arteries deoxygenated blood.
- Approx. 400 ml blood flows through the cord every minute.
- It is supported by a loose connective tissue containing a mucoid
material called Wharton’s jelly. This jelly prevents kinking of the
cord in the uterus and interference with the circulation to the fetus.
The high water content of this jelly causes the cord to shrink
quickly after birth beside prostaglandins, which has a
vasoconstrective effect that inhibits bleeding from the cord stump
when it is cut after birth.
Fetal membranes:
Two closely applied but separated, membranes surround the fetus,
which are
- Inner: amnion
- Outer: chorion
These membranes contain the fetus and amniotic fluid.
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Embryonic development and Fetal maturation
 Fetal maturation takes place in an orderly and predictable
pattern.
 There is a steady increase in overall growth, and organ system
develop from the 3 primary germ layers:
1. The Ectoderm (ecto= outside); which gives rise to such
tissues as the skin, nails, the nervous system and tooth
enamel.
2. The Endoderm (endo= inner); which develops into tissues
such as the connective tissues as epithelial inner linings of
gastrointestinal and respiratory tracts, endocrine glands and
auditory canal.
3. The Mesoderm (meso= middle); form tissues such as the
connective tissue, teeth (except enamel), muscles, blood and
vascular system.
 Cardiovascular System:
 The first system to function in the developing human is the CVS.
 Blood vessels formation begins early in the 3rd week.
 Note: the CVS must form early to bring nourishment and oxygen
from the mother to the embryo.
 The CVS is functional (heart beats) at 3 weeks since conception.
 Fetal Circulation:
 The single umbilical vein carries oxygen-enriched blood from the
placenta.
 The paired umbilical arteries return most of the mixed blood from
the descending aorta to the placenta.
 The pattern of blood flow is as follows:
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1. Placenta
Umbilical vein
Liver, sinusoids
Inferior venacava
Hepatic veins
Ductus venosus
2. Inferior venacava
Rt atrium
Lt ventricle
3. Inferior venacava
foramen ovale
Lt atrium
aorta.
Rt atrium
Rt ventricle
Pulmonary
artery
Small amounts to nonfunctional lungs but most of it through ductus
arteriosus
Aorta
Hypogastric arteies
umbilical arteries
Placenta.
Ductus venosus: is a vascular channel that connects the umbilical vein to
the inferior vena cava.
Foramen ovale: is an opening in the septum between the right and left
atrium.
Ductus arteriosus: a vascular channel between the pulmonary artery and
descending aorta.
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FHR and fetal hemoglobin
Following are a number of compensatory circulatory factors that benefit the
fetus
1. The fetal heart rate (FHR) is 120-160 BPM and cardiac output is
approx. 350-500 ml/kg/min.
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2- The hemoglobin of the fetus is primarily fetal hemoglobin (HgF)
which is capable of maintaining a high O2 saturation at a lower
pressure (PO2 ). It has been estimated that HgF can carry as much
as 20 – 30% more oxygen than can maternal hemoglobin.
3- The hemoglobin concentration of the fetus is about 50% higher
than that of the mother.
As a result, greater amounts of O2 can be transported to the fatal
tissues.
 Hematopoietic System:
Formation and development of blood cells begins in the liver about
the 6th week of gestation. Later, blood formation occurs in the
spleen, bone marrow and lymph nodes. Platelets are present in the
circulation by the 11th week of gestation.
Respiratory system:
 Fetal lungs don’t function until after delivery, the exchange of
oxygen and carbon dioxide in the fetus occurs through the placenta
by a process of simple diffusion.
 Pulmonary surfactants. Are produced in an increasing amount by
the 24th week of gestation by the alveolar cells. They are
substances of surface – active phospholipids that minimize surface
tension. Pulmonary surfactant which migrates from the lung’s
fluid, mixes with amniotic fluid and it is used as biochemical
marker for determining the degree of fetal lung maturity.
Lecithin sphingomyelin ( L\S ) ratio is used to determine lung
maturity. At 30- 23 weeks it will be 1.2\1.
At 35 weeks of gestation
2 \1
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maturity attained.
Renal system:
 The placenta is the major fetal excretory organ and effectively
eliminates waste products from fetal blood. It maintains fetal
water, electrolyte and acid – base balance.
 Kidneys are not necessary for fetal growth and development; renal
excretory function must begin immediately after birth.
 The kidneys appear in the 5th week. Urine is excreted into and
mixes with the amniotic fluid that the fetus swallows.
Neurologic System:
 The human brain only partially developed and functional at birth.
 Prenatal maternal anemia and malnutrition compromise fetal brain
development, if the fetus doesn’t receive adequate nutrition early in
development, there is a smaller number of cells developed, if the
fetus Continues to receive inadequate nutrition the existing cells are
smaller in size.
 Disease, trauma or unfavorable environmental factors may
irreparably alter the development of CNS.
 At 9 weeks the whole fetus moves in a jerky movement.
 By 16 weeks, fetal muscle movement is strong enough to activate
receptors on the maternal abdominal wall, the mother usually
interprets this as "the baby moving" and professionals refer it as
"quickening".
 The fetus is able to hear both internal and external sounds by the 5th
month of pregnancy.
Gastrointestinal system:
 The digestive system forms during the 4th week.
 Intrauterine nutrition and elimination occur through the placenta.
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 During the second trimester, the fetus begins to swallow amniotic
fluid.
 The fetus receives its glucose, its main source of energy from the
mother. Maternal insulin doesn't pass to the fetus, the fetus secretes
insulin. The fetus synthesizes glycogen and forms his own fat rather
than receiving these nutrients in these forms from the mother.
Meconium: is a sterile, dark greenish brown, semisolid residue of bile
and embryonic secretions plus cellular waste (epithelial tissue) and hair
swallowed in utero.
Note: the presence of meconium in amniotic fluid before delivery usually
indicates fetal hypoxia.
Hepatic system:
 Liver function begins at about 4th week of gestation.
 Hematopoiesis starts at about the 6th week of intrauterine life; this
activity is primarily responsible for the rapid growth and relatively
large size of the liver during the 2nd month of gestation.
 Metabolic and glycogen store organ, secretes bile.
 Full liver function is not achieved well until after delivery.
Endocrine system:
 The fetal adrenal cortex produces cortisol, which may be important in
the initiation of labor.
 The thyroid gland is the first endocrine gland to develop in the fetus.
By the 4th week, it can synthesize thyroxin.
 By the 12th week insulin can be extracted from the pancreas.
Reproductive system:
 By the end of the 9th week, male and female external genitalia appear
somewhat similar. At the 12th week, the external genitalia are well
developed enough to be easily distinguished.
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 The fetal ovary has many primordial follicles and produces small but
increasing amounts of estrogen. Withdrawal bleeding follows rapid
drop of maternal estrogen following birth.
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The Expectant Mother
Terminology:
 Gravida: a woman who is or has been pregnant without regard to
pregnancy outcome.
 Nulligravida: a woman who is not now and never has been pregnant.
 Primigravida: a woman pregnant for the first time.
 Multigravida: a woman who has been pregnant several times.

Para: refers to past pregnancies that have reached viability.
 Nullipara: a woman who has never completed a pregnancy to the
period of viability.
 Primipara: refers to a woman who had completed one pregnancy to the
period of viability regardless of the number of infants delivered i.e. the
birth of twins increases parity by 1(not by 2), and regardless of the
infant being live or stillborn.
 Multipara: a woman who has completed 2 or more pregnancies to the
period of viability.
Manifestations of Pregnancy
I. Presumptive signs and symptoms:
1- Cessation of menses: pregnancy is suspected if more than 10 days
have elapsed since the time of the expected menses onset.
2- Breast changes:
a. breasts enlarge and become tender with visible veins.
b. nipples become larger and more pigmented.
c. colostrums, a thin milky fluid (in the second half of pregnancy).
d. Montgomery glands (secrete a fatty substance that lubricates
and protects the nipple and areola during breastfeeding ) may
appear "small elevations in the aereolae"
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3- Chadwick's sign: a bluish purple discoloration that appears on the
cervix, vagina, and vulva.
Chadwick's sign
4- abdominal striae (striae gravidarum) sometime appear on the
breasts, abdomen and thighs because of stretching, rupture and
atrophy of the deep connective tissue of the skin.
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5- Nausea and vomiting (morning sickness), occurs mainly in the
morning, lasts and usually disappears near the end of the first
trimester.
6- Quickening (sensation of fetal movement in the abdomen), occurs
between 16th and 20th week after the onset of last menses.
7- Frequency of urination:
- caused by pressure of expanding uterus on bladder.
- decreases when the uterus rises out of the pelvis.
- reappear when the fetal head engages in the pelvis at the end of
pregnancy.
8-Fatigue: characteristic of early pregnancy.
II. Probable signs and symptoms:
1. Enlargement of the abdomen.
2. Changes in shape, size and consistency of the uterus.
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- uterus enlarges, elongates and decreases in thickness as
pregnancy progress.
- Hegar's sign, lower uterine segment softens at 6-8 weeks.
3. Changes in cervix:
- Goodell's sign: softening of the cervix at 6-8 weeks.
- with inflammation and carcinoma during pregnancy, the cervix
may remain firm.
4. Intermittent contractions of the uterus (Braxton Hick's
contraction): painless, palpable contractions occurring at irregular
intervals. May appear early at the 16th week.
5. Ballottement: a sinking and rebounding of the fetus in its
surrounding amniotic fluid in response to sudden tap on the uterus,
occurs near midpregnancy (16-28 weeks).
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6. positive hormonal tests for pregnancy, response of HCG in
maternal blood (4-12weeks) and urine (6-12 weeks).
III. Positive signs:
1. Fetal heart sounds by ultra sound (6 weeks) or fetal stethoscope at
20-24 weeks.
2. Visualization of the fetus by ultrasound at 6 weeks or X-ray at 16
weeks.
3. Fetal parts palpated at 24 weeks- Fetal movements are palpable at
22 weeks and visible are late pregnancy.
Physiological and psychological changes of pregnancy
“Maternal adaptations to pregnancy”
All changes in a mother’s body during pregnancy are due to:
1. The effects of specific hormones.
2. The growth of the fetus inside the uterus.
3. The mother’s physical adaptation to the changes that are occurring.
These changes enable the mother to nurture the fetus, prepare her
body for labor, develop her breasts and by down stores of fat to
provide calories for production of breast milk during puerperium. By
understanding the normal changes, the nurse can detect abnormality.
The woman’s psychological state is also affected by hormonal
changes.
The changes interact with other external factors and influence her
transition to motherhood.
Changes begin soon after fertilization.
Physiological changes in the reproductive system:
1. The uterus:
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 The uterus develops to provide a nutritive and protective
environment in which the fetus will develop and grow.
- Progesterone and estrogen initially produced by the corpus lutetium
cause the deciduas become thicker, richer and more vascular at the
fundus and in the upper body of the uterus. The deciduas provides a
glycogen- rich environment for the blastocyst until the trophoblastic
cells begin to form the placenta.
- Estrogen is responsible for the growth of uterine muscle.
- Enlargement during pregnancy involves muscle to accommodate its
contents.
- Increase in weight, from 60 g to 900-1100g.
- Increase in size from 7.5x5x2.5cm to 30x23x20 cm.
- Braxton–Hicks contractions are necessary for the uterus to strech,
usually painless, last approx. 60 seconds, begins at 8 weeks gestation,
continue throughout pregnancy and later changes in intensity to
became contractions of labor.
- Estrogen causes development of new blood vessels to meet the
needs of the functioning placenta.
- The uterus changes to a globular shape to anticipate fetal growth
and also to accommodate increasing amounts of liquid and
placental tissue. This causes pressure on other pelvic organs.
- At 12 weeks the fundus of the uterus may be palpated abdominally
above the symphysis pubis.
- By 20 weeks gestation, the fundus has reached the umbilicus.
- By 36 weeks, the fundus has reached the xiphoid.
- During the last 3 weeks, the uterus descends slightly because of
fetal descent into pelvis. Walls of the uterus become thinner.
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2. The cervix:
- It acts as an effective barrier against infection, it also retains
pregnancy.
- Under the influence of progesterone, endocervical cells secrete
mucus, which becomes thicker and more viscous during
pregnancy.
A clot of very thick mucus obstructs the cervical canal, which
provides protection from ascending infections.
Estrogen increases cervical vascularity and if viewed through a
speculum, the cervix looks purple.
- In late pregnancy softening of the cervix occurs in response to
increasing painless contractions. Progestron also play a role in
cervical softening in readiness for the onset of labor.
3. The vagina:
Estrogen causes muscle layer hypertrophy and changes the
surrounding connective tissue which allows the vagina to become
more elastic and enabling it to dilate during labor. The epithelium
has a marked desquamation of the superficial cells which increases
the amount of normal white vaginal discharge called leukorrhea.
The nurse should reassure the patient about the
normalcy of leukorrhea during pregnancy and instruct
her to call her health care provider if the discharge
appears thicker; becomes bloody or yellowish/green;
is accompanied by a foul odor; or if it causes itching,
irritation, or pain in the vulvar or vaginal area.
The vagina is more vascular, appearing reddish purple in color.
The pH of vaginal secretions is 3.5-6 because of increased
production of lactic acid from glycogen in the vaginal epithelium
by lactobacilus acidophilus which prevent infection but
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unfortunately, it increase the susceptibility of other infections such
as candida albicans.
4. The ovaries:
- Ovulation ceases during pregnancy, maturation of new follicles is
suspended.
- One corpus luteum functions during early pregnancy (first 8 weeks)
producing mainly progesterone.
Notes:
- The placenta blood flow 450-650 ml/min at term.
The blood flow to the uterus constitutes 2% of cardiac output in
nonpregnant woman and increases to 17% at term of pregnancy.
▪ Skin changes:
- Increased activity of the melanin- stimulation hormone causes deeper
pigmentation during pregnancy.
- Some develop deeper, patchy coloring on the face which resembles a
mask and is known as chloasma. (The heightened pigmentation fades
after pregnancy but can recur after exposure to the sun).
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- Many notice a pigmented line running from the pubis to the umbilicus
and sometimes higher, called the linea nigra.
- The perineum darkens in order to enable it to stretch during the birth of
the baby.
- In some women the areas of maximum stretch become thin and stretch
marks, striae gravidarum appear as red stripes during pregnancy. It
appears in the skin of the abdomen, breast and thighs.
- The increased blood supply to the skin leads to sweating. Women often
feel hotter in pregnancy. “This may be caused by a progesterone
induced vasodilation".
- Vascular spiders are tiny, branched, slightly raised and pulsatingend
arterioles, usually found on the neck, chest, face, and arms.
- Oily skin and acne may occur during pregnancy.
- Increased adrenal steroid levels cause the connective tissue to lose
strength and become more fragile. This change can cause striae
gravidarum, or “stretch marks” on the breasts, buttocks, thighs, and
abdomen. Striae appear as reddish, wavy, depressed streaks that will
fade to a silvery white color after birth but they do not usually
disappear completely.
▪ Breasts changes:
Estrogen and progesterone produce a number of changes in the mammary
glands. Breast enlargement, fullness, tingling, and increased sensitivity
occur during the early weeks of gestation. The superficial veins become
more prominent from the vascular relaxation effects of progesterone.
- They are tender and tingle in early pregnancy.
- Increase in size by the second month (hypertrophy of mammary
alveoli).
- Nipples become larger, more deeply pigmented and more erectile.
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- Colostrum may be expressed by the second trimester, colostrums has
more protein and minerals but less sugar and fat than that of mature milk.
Aereolae become broader and more deeply pigmented. This pre-milk
substance contains antibodies, essential proteins, and fat to nourish the
baby and prepare his intestines for digestion and elimination.
- Glands of Montgomery scattered through the aereolae a number of
small elevations (hypertrophic sebaceous glands).
▪ Changes in the cardiovascular system:
- Due to an increase in blood volume and increase in workload, the
heart may increase in size.
- The heart may be displaced upwards and to the left because of the
increasing pressure from the growing uterus.
- Blood volume increases by 40% to 45% and is due primarily to an
increase in plasma and erythrocyte volume.
- Most of the increased blood flow is directed to the uterus to nourish
the fetus.
- The increased need for oxygen requires the pregnant woman to
increase her iron intake.
- During pregnancy, the woman’s hematocrit values may appear low
due to the increase in total plasma volume (on average, 50%). Since
the plasma volume is greater than the increase in erythrocytes (30%).
This alteration is termed “physiological anemia of pregnancy” or
pseudoanemia.”
- The hemodilution effect is most apparent at 32 to 34 weeks. The mean
acceptable hemoglobin level in pregnancy is 11 to 12 g/dL of blood.
- The number of leukocytes also increases and the average white blood
cell count ranges from 5000 to 15,000 /mm3. During labor and
postpartum these levels may climb as high as 25,000/mm3.
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- Cardiac output increases, and peaks around the 20th to 24th week of
gestation at about 30% to 50% above pre-pregnancy levels. It remains
increased for the duration of the pregnancy.
- With the increased vascular volume and cardiac output, vasodilation
(related to progesterone-induced relaxation of the vascular smooth
muscle) prevents an elevation in blood pressure.
- The woman’s pulse rate frequently increases up to 10 to 15 beats per
minute to facilitate effective circulation of the increased blood
volume.
- Because of the relaxed vascular resistance and stasis of blood in the
lower extremities, there is an increased risk of varicose veins and
hemorrhoids.
- The nurse should instruct the woman to elevate her lower extremities
by lying on her left side with the feet higher than her heart for 15 to 20
minutes daily to improve venous return from the lower extremities.
- The pregnant woman may experience supine hypotension syndrome,
or vena caval syndrome (faintness related to bradycardia) if she lies
on her back. The pressure from the enlarged uterus exerted on the
vena cava decreases the amount of venous return from the lower
extremities and causes a marked decrease in blood pressure, with
accompanying dizziness, diaphoresis, and pallor.
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Changes in the respiratory system
- The tidal volume (amount of air breathed in each minute) increases
30% to 40%. This change is related to the elevated levels of estrogen
and progesterone. Estrogen prompts hypertrophy and hyperplasia of
the lung tissue. Progesterone decreases airway resistance by causing
relaxation of the smooth muscle of the bronchi, bronchioles, and
alveoli.
- These are necessary in order to maximize maternal oxygen intake and
provide efficient carbon dioxide excretion for the mother and through
her for the fetus.
- Diaphragm is elevated during pregnancy chiefly by enlarged uterus,
but chest circumference increases by 6 cm.
- Maternal oxygen requirements increase in response to increased
metabolic rate.
- Increased respiratory rate and reduced PCO2 probably induced by
progesterone and estrogen to a lesser on respiratory center.
- EYES Blurred vision, the most common visual complaint in pregnant
women, is caused by corneal thickening associated with fluid retention
and decreased intraocular pressure.
- NOSE An increase in mucus production results from the combined
effects of progesterone (increased blood flow to the mucus membranes
of the sinus and nasal passages) and estrogen (hypertrophy and
hyperplasia of the mucosa). Nasal stuffiness and congestion (rhinitis
of pregnancy) and epistaxix may occur.
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Changes in the gastrointestinal system:
- Gums may become hyperemic and softened and inflamed (gingivitis)
and may bleed easily under the effect of estrogen. Dental problems
occur because of leading to dietary changes and food cravings.
- Craving for unnatural substances such as coal is termed pica
- Progesterone relaxes smooth muscle; gastric emptying and peristalsis
are slowed in order to maximize the absorption of nutrients. More
water is reabsorbed from the bowel and bloating and constipation can
occur.
- Heartburn is common and is associated with gastric reflux due to the
relaxation of cardiac sphincter. (Eating small meals, avoiding lying
down after meals for at least 1 hour, and limited use of antacids can
alleviate some of these symptoms).
- Constipation is a result of sluggish gut motility .
- It can exacerbate hemorrhoids which may exist as a result of the
relaxing effect of progesterone’s action on the smooth muscle of vein
wall and the pressure exerted by the enlarged uterus on pelvic veins.
- Nausea and vomiting occur mainly during early pregnancy, possibly,
due to raised hCG levels and altered carbohydrate metabolism.
- Changes in taste and smell, due to alterations in the oral and nasal
mucosa, can further aggravate the gastrointestinal discomfort.
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- Patients should be encouraged to drink at least 8 to 10 glasses of water
each day, add fiber to their diets to produce bulk, and exercise to
encourage peristalsis. They should be taught to avoid straining with
bowel movements. Warm sitz baths may be helpful for hemorrhoid
discomfort.
Changes on urinary system
- During the first trimester, the bladder is compressed by the weight of
the growing uterus. The added pressure, along with progesteroneinduced relaxation of the urethra and sphincter musculature, leads to
urinary urgency, frequency, and nocturia.
- These signs and symptoms disappear during the second trimester and
most of the third trimester. They reappear in the last 2-3 weeks when
the presenting part of the fetus descends into the pelvis.
- Ascending infection (UTI) occur more frequently in pregnancy due to
relaxation of the smooth muscle of the bladder and urinary sphincter,
changes that allow bacterial ascent into the bladder.
- Ureters are dilated, glomarular filtration increased, glycosuria may be
evident, proteinuria doesn’t occur normally.
Skeletal changes:
- Progesterone and relaxin (a hormone produced by the placenta)
encourage relaxation of ligaments and muscles, reaching maximum
effect during the last weeks of pregnancy.
- This relaxation allows the pelvis to increase its capacity in readiness to
accommodate the fetal presenting part at the end of pregnancy and in
labor.
- Unstable pelvic joints result in the rolling gait sometimes seen in
pregnant women.
- Alteration in posture and walking due to an increase in weight which
result in back pain.
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Changes in the endocrine system:- - Human placental lactogen (hPL), placental hormone promotes
lipolysis , increases plasma free fatty acids and thereby provides
alternative fuel sources for the mother. HPL, estrogen and
progesterone produced by the placenta oppose the action of insulin
during pregnancy.
- Note this happens to elevate the maternal circulating blood glucose
level since the fetus is dependent on glucose for body and brain
growth.
- The anterior pituitary gland is enlarged. ACTH, melanocytestimulating and thyrotropic hormone increase their activity.
- FSH and LH are inhibited by progesterone and estrogen.
- Thyroid gland is moderately enlarged because of hyperplasia of
glandular tissue and increase vascularity leading to increased BMR.
- Adrenal gland secretions (corticosteroid) considerably increased and
may be one of the reasons for glycosuria in pregnancy.
- Excretion of sodium is increased in the presence of progesterone and
elevated level of aldosterone.
Metabolic changes:- Maternal weight:
Continuing weight increase in pregnancy is considered to be one
favorable indicator of maternal adaptation and fetal growth.
Expected increase:
1 Kg in first 20 weeks.
0.5 Kg per week until term.
12.0 Kg approximates total.
Many factors influence weight gain. The degree of maternal edema,
smoking, amount of amniotic fluid, and size of the fetus must all be taken
into account.
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Water metabolism:
-Average woman retains 6.5 liter of water during pregnancy. Production
of aldosterone increase which will increase water retention.
- Many woman experience edema of the legs at the end of pregnancy.
▪ Protein metabolism:
- At term, fetus and placenta contain 500g of protein.
- Approx. 500g more of protein are added to the uterus, breasts and
maternal blood in the form of hemoglobin and plasma proteins.
Total increase: 1000 grams.▪ Fat metabolism: increase in plasma concentrations of lipid and
lipoproteins.
▪ Carbohydrate metabolism:
- Pregnancy is potentially diabetogenic.
- Normal pregnancies induce a state of peripheral resistance to insulin by
hPL, estrogen and progesterone.
Duration of pregnancy:
- Average length is 280 days or 40 weeks from the first day of the last
normal menstrual period.
- Duration may also be divided into three equal parts or trimesters of
slightly more than 13 weeks or 3 calendar months each.
- Estimated date of confinement (EDC) is calculated according to Nagele
rule by adding 7 days to the date of the first day of the last menstrual
period and counting back 3 months.
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Antenatal (prenatal) Care
"Nursing care during pregnancy"
The prenatal period is a preparatory one, both physically in terms of fetal
growth and maternal adaptation and psychologically in terms of
parenthood. Prenatal is a time of intense learning for the parents and for
those close to them, as well as a time for development of family unity.
Regular prenatal visits ideally begin soon after the first missed menstrual
period, offer opportunities to ensure the health of the expectant mother
and her infant.
Aims of antenatal care:
1. To support and encourage a family's healthy psychological adjustment
to childbearing.
2. To promote an awareness of the sociological aspects of childbearing
and rearing and the influences that these may have on the family.
3. To monitor the progress of pregnancy in order to ensure maternal
health and normal fetal development and provide management or
treatment as required.
4. To recognize deviation from the normal and provide management or
treatment as required.
5. To ensure that the woman reaches the end of her pregnancy physically
and emotionally prepared for her delivery.
6. To help and support the mother in her choice of infant feeding to
promote breast feeding in a sensitive manner and give advice about
preparation for lactation when appropriate.
7. To offer the family advice on parenthood either in a planned program
or on an individual basis.
8. To build up a trusting relationship between the family and their
caregiver which will encourage them to participate in and make
informed choices about the care they receive.
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The initial visit (booking visit):
The visit should take place as soon as possible after pregnancy had been
confirmed. Advice should be given early because the fetal organs are
almost completely formed by the 12th week of pregnancy.
Objectives for the booking visit:
1. to assess levels of health by taking a detailed history and to employ
screening test appropriate.
2. To ascertain baseline recordings of weight, height, blood pressure
and hemoglobin level in order to assess normality. These findings
are used for comparison as the pregnancy progresses.
3. To identify risk factors by taking accurate details of past and
present obstetric and medical history.
4. To provide an opportunity for the woman and her family to express
any concerns they might have regarding this pregnancy or previous
obstetric experiences.
5. To give advice on general health matters and those pertaining to
pregnancy in order to maintain maternal health and healthy
development of the fetus.
6. To begin building a trusting relationship in which realistic plans of
care are discussed.
Nursing care follows the nursing process:
Assessment includes detailed health history, physical examination and
screening laboratory tests.
Health history
1. Personal or demographic information
o Client’s name and information
o Phone number
o Age: if over 35 years, risk factors for genetic and medical
problems increases.
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o Increased risk for hypertension (PIH), anemia, and
prematurity in young women.
o Education: is learning a problem. Is she able to follow
instructions.
o Usual responsibilities: what are her daily activities, who can
help her if there is a problem.
o Husband and family: husband name, do they have means of
transportation, how closely they are related (genetics)
2. Woman’s present obstetric history (current pregnancy):
o Gravidity and parity: one obstetric abbreviation commonly
employed in maternity centers is often more detailed. It
consists of 5 digits. The firs digit presents the total number
of pregnancies including the present one. The second digit
represents the total number of deliveries. The third indicates
the number of premature babies. The fourth identifies the
number of abortions. The fifth is the number of children
currently living. GTPAL
o Example: if the woman pregnant only once with twins
delivered at the 35th week and the babies survived. The
abbreviation that represents this information is 1-2-2-0-2.
o During her next pregnancy, the abbreviation is 1-2-2-0-2.
o Note: according to the 2 digits system, the abbreviation that
represent the information above will be 1-1, 2-1
o Date of last menstrual period. Estimated date of
confinement, signs and symptoms of pregnancy, rest and
sleep pattern (regularity of sleep)
o Activity and employment, plans for continued employment.
o Diet history, weight gain, eating patterns, social and cultural
dietary habits.
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o Psychosocial status, woman’s and family’s reaction to this
pregnancy, support system.
3. Woman’s menstrual history:
o Menarche
o Length and regularity of menstrual period.
4. Past obstetric history: for each previous pregnancy, record the
following information: you are looking for a pattern of problems or
non-problems to help you predict what may happen during the current
pregnancy.
a. Data of previous pregnancies.
i. Year: if within the last year, note the month
ii. Consider nutrition and recovery if recent or increased
number of birth
iii. Still breast feeding.
b. Gestational age: any known cause for abnormal gestation.
i. If stillbirth or abortion, document gestational age, if
genetics results were obtained.
c. Birth weight: appropriate for gestational age. Pattern of large
for gestational age (LGA) or small for gestational age
(SGA).
d. Duration of labor: spontaneous of induced
e. Abortions
f. Type of birth: vaginal or CS (why CS)
g. Place of birth: hospital, clinic or home.
h. Maternal and fetal complications
i. Received prenatal care, weight gain, infection, ….
j. Administration of anti D immunoglobulin to Rh negative
5. Medical history: in additional to the usual questions appropriate to
a health history, the following are specific to the pregnant woman.
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o Kidney: recurrent UTI (may lead to premature labor)
o CV: systolic ejection murmur common in pregnancy,
varicosities in legs, other areas, DVT.
o Essential hypertension (predispose pregnancy-induced
hypertension and increase the risk for antepartal
hemorrhage)
o Heart disease, blood transfusion.
o Diabetes: if previous large babies, consider blood sugar with
other prenatal blood tests in the initial blood visits.
o Infections
o Thyroid problems and medications.
o Transfusions. Previous transfusion may lead to HB virus or
HIV. Document any objection to transfusion.
o Operations. What, when and where.
o Surgery of reproductive organs
o Allergies, food, medication, bronchial asthma.
6. Family history
-Hypertension: sisters, mother, what is family pattern?
- Diabetes: prevalence in family, when diagnosed…
-Heart disease: who has it, what is it, age at diagnosis.
-Multiple births: fraternal or identical.
-Genetic disease: Sickle cell, Down syndrome, thalasemia.
-Family obstetric history: breech delivery.
Physical Examination and laboratory tests:
 Screening procedures play an important part in ascertaining
normality.
 Height of over than160 cm gives an indication of a normal-sized
pelvis.
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-Being tall or short not necessarily related to ease of birthing.
- May wish to document father’s height if significant .
- Woman who is short may come from a small- sized race or family
or she may be stunted because of poor nutrition in utero or in
childhood. If she continues to be poorly nourished, her fetus may
be growth retarded.
 Weight: obesity can lead to an increased risk of gestational
diabetes and PIH. To be accurate, weight should be measured using
the same scale and the woman is asked to wear similar clothing at
each visit.
 Blood pressure: is taken in order to ascertain normality and provide
a baseline reading for comparison throughout pregnancy.
 Adequate BP is required to maintain placental perfusion, but
systolic BP of 140 mmhg or diastolic of 90 mmhg at booking is
indicative of hypertension and could cause damage to the placenta.
Physical Examination: Ask the woman to empty her bladder before the examination so
that during abdominal and vaginal examination her uterus and
pelvic organs may be readily palpated.
 General appearance: woman who is anemic, depressed, tired or ill
appears lethargic and is not interested in her appearance.
 Examination of eyes, ears, and nose.
 Examination of mouth, teeth, and throat. Gums may be hyperemic
and softened because of increased progesterone.
 Inspection of breasts and nipples: may be linked to the discussion
of infant feeding. The breast should be gently palpated with the flat
of the hand to feel for any lump. Some women are distressed by the
increase in breast size.
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 Auscultation of the heart.
 Auscultation and percussion of the lungs .
 Abdominal examination.
 Should be performed at every visit.
 At the early booking visit, the nurse will observe for signs of
pregnancy.
Examination for scars, striae, or umbilical hernia.
 It is unlikely that the uterus will be palpable at the abdominal
cavity before the 12th week of gestation.
 Palpation of the abdomen for fetal outline and position during the
third trimester.
 Fetal heart tone checked” heard by fetoscope at 20-24 weeks of
gestation, earlier if a Doppler is used”.
 Fetal position, presentation and heart rate are recorded.
- Pelvic Examination: Woman in a lithotomy position.
 Vaginal examination done to rule out abnormalities of the
birth canal and to obtain cytological smear.
 Vaginal discharge increases during pregnancy. The woman
should be able to report any changes during the subsequent
visits as itching, offensive odor…
 Vaginal bleeding at any time during pregnancy should be
reported.
 Evaluation of the pelvic inlet- anteroposterior diameter.
 Evaluation of the mid pelvis- prominence of ischial spines.

Gynecoid: The gynecoid pelvic type is the typical,
traditional female pelvis (present in 50% of women) that is
best suited for childbirth. The anterior/posterior and lateral
85
measurements in the inlet, midpelvis, and outlet of the true
pelvis are largest in the gynecoid pelvis. The inlet is round to
oval-shaped laterally, a characteristic that improves its
adequacy for childbirth. The other pelvic structures can pose
problems for vaginal birth.
 Android: The android pelvis (found in 23% of women)
resembles a typical male pelvis. The inlet is triangular or
heart-shaped, and laterally narrow. Its characteristics can
cause difficulty during fetal descent.
 Anthropoid: The anthropoid pelvis (occurs in 24% of
women). Similar to the gynecoid pelvis, the anthropoid
pelvis is oval-shaped at the inlet, but in the anterior–
posterior, rather than lateral, plane. The subpubic arch may
be slightly narrowed. Fetal descent through an anthropoid
pelvis is more likely to be in a posterior (facing the woman’s
front) rather than anterior (facing the woman’s back)
presentation.
 Platypelloid: The platypelloid pelvis (found in 3% of
women) is broad and flat and bears no resemblance to a
lower mammal form. The pelvic inlet is wide laterally with a
flattened anterior–posterior plane and the sacrum and ischial
spines are prominent. The subpubic arch is generally wide.
Fetal descent through a platypelloid pelvis is usually in a
transverse presentation and will not allow for a vaginal birth.
 Evaluation of the pelvis outlet- distance between ischial
tubrosities.
 Rectovaginal exploration to identify hemorrhoids, fissures,
or masses.
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 Examination of the cervix for position, consistency and
appearance.
Extremities:
 Edema: is not likely to be in evidence during the booking visit, but
nurse must ensure that the observed edema is physiological and
not- excessive. This could be associated with pregnancy induced
hypertension.
 Is often associated with daily activities or hot weather.
 Occurs after rising in the morning and worsens during the day.
Blood tests: “At the initial visit”
 Complete blood count values (CBC)
 Blood type and Rh factor.
 Antibody screen texoplasmosis, Rh, rubella’’
 Rubella titer (if not Known).
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 VDRL (Venereal Disease Research Laboratory) test for syphilis.
 Hb electrophoresis, when indicated (to detect for sickle cell,
thalassemia).
 Hepatitis B virus screen.
Cervical cytology pap. Smear.
Follow- up antenatal visits (Subsequent visits):_
It has been stressed that all the information gathered will enable a
decision to be made about the subsequent care offered to the pregnant
woman and her family. The plan of care is suited to the needs of the
teaching and counseling the client and her family.
Schedule:
The gravid should be seen once each month until the 32nd week,
every 2 weeks until the 36th week, and each week thereafter until
delivery. More frequent visits may be required if there are
complications.
Purpose of continuing antenatal care:1. To continue observe for maternal health and freedom from
infection.
2. To assess fetal well- being.
3. To ascertain that the fetus has adopted a lie and presentation that
will allow vaginal delivery.
4. To ensure that the mother and family are confident to decide when
labor has commenced and that they have telephone numbers to use
if they wish to seek advice.
5. To offer an opportunity to express any fears or worries about
pregnancy and labor.
6. To discuss any views about the conduct of labor and formulate a
birth plan if required.
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Maternal assessment: Interview: General well being, complaints or problems, questions.
 Woman and her family’s needs for psychosocial support.
 Physical examinations:
1. Temperature, pulse, respiration’s.
2. Blood pressure (Woman sitting).
3. Weight and determination of whether gain is compatible
with overall plan for weight gain.
4. Abdominal examination:
a. Height of fundus above pubic symphsis.
 Fundus at symphysis pubis- 12 weeks gestation.
 Fundus at umbilicus = 20 weeks gestation.
 Fundus 28 cm from top of symphysis =28 weeks
gestation.
 Fundus at lower border of rib cage= 36 weeks
gestation.
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 Uterus becomes globular and drops= 40 weeks
gestation.
 A greater fundal height suggests:
- Multiple pregnancy
- miscalculated due date.
- polyhydramnios
- Hydatidiform (vesicular) mole.
 A lesser fundal height suggests:
- Intrauterine fetal growth retardation.
- Error in estimating gestation.
- Fetal or amniotic fluid abnormalities.
- Intrauterine fetal death.
b. Auscultation and counting of FHR (FHR may be heard
from weeks 8 through 12 using Doppler method.
c. Beginning at 32week, identification with aid of Leopold‘s
maneuvers of fetal presentation, position and station.
- A four-part clinical assessment method, to determine
the lie, presentation, and position of the fetus.
- The first maneuver determines which fetal body part
(e.g., head or buttocks) occupies the uterine fundus. The
examiner faces the patient’s head and places the hands on
the abdomen, using the palmar surface (not the
fingertips) of the hands to gently palpate the fundal
region of the uterus. The buttocks feel soft, broad, and
poorly defined. It moves with the trunk. The head feels
firm and round and moves independently of the trunk
- The second maneuver determines the location of the fetal
back or spine. Facing the maternal abdomen, the palmar
surface of one hand is placed on one side of the patient’s
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abdomen to provide support. The palmar surface of the
opposite hand is used to palpate the fetal spine, which
feels like a firm, continuous, smooth, convex structure.
An irregular shape or fetal kicks indicate that the back
is on the opposite side .
- The third maneuver (“Pawlik maneuver”) compares
the fetal part in the fundal region with the part in the
lower uterine segment, primarily to confirm that the
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fetus is in a cephalic (head) presentation. The hands
are placed just above the symphysis and the examiner
notes whether the palpated part feels like the fetal head
or the buttocks.
- For the fourth maneuver, the examiner uses the
fingertips of both hands. One hand is placed on each
side of the women’s lower abdomen with the palmar
surfaces down. The hands are moved gently down the
sides of the uterus toward the symphysis pubis as the
fingertips palpate the presenting part to determine
whether it is moveable (ballotable). If the presenting
part is moveable, engagement (when the largest
diameter of the presenting part reaches or passes
through the maternal pelvic inlet) has not occurred. If
the presenting part is fixed, engagement has occurred.
With the first pregnancy, engagement occurs around
37 weeks gestation; with subsequent pregnancies,
engagement may not occur until labor has begun
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d. Vaginal or rectal examination at anytime (unless gravid is
bleeding) to investigate lechorrhea and other important
finding.
 Lab tests- see discussion of lab tests at the initial visit.
Fetal assessment:

Fetal gestational age: in normal pregnancy, gestational age is
estimated by determining the duration of pregnancy and the
date of delivery. In some centers ultrasonography is used
with all pregnancies.
Note: calculation of fundal height according to
Macdonald’s rule:
(measure from the top of the symphysis pubis to fundus,
from approximately 24 to 34 weeks’ gestation) - for
example, at 28 weeks of gestation, the fundal height
should be approximately 28 cm and at 30 weeks’
gestation the fundal height should be 30 cm.
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
Fetal health status:
1) Fetal movement, the mother is instructed to note the
extent and timing of fetal movements and to report
immediately if the pattern changes or if movement
ceases.
2) FHR is checked on routine visits. Normal rate and
rhythm is another good indicator of fetal health.
3) Abnormal maternal or fetal symptoms: intensive
investigation of fetal health status is initiated if any
maternal or fetal complications arise e.g maternal
hypertension, premature rupture of membranes or
irregular or absent FHR..

Factors that indicate the need for intensified antenatal
care:1. Booking history:
 Age less than 18 years or over 35 years. (risk increase
with age to have a baby with down's Syndrome)
 Primigravide over 30 years.
 Vaginal bleeding at any time during pregnancy.
 Uncertain EDD.
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2. Past obstetric History:
 Stillbirth or neonatal death.
 Baby small or large for gestational age.
 Congenital abnormality.
 Rhesus iso- immunization.
 Pregnancy- induced hypertension (PIH)
 Premature labor.
 Two or more terminations of pregnancy.
 Spontaneous abortion twice or more.
 Previous cervical cerclage.
 Previous caesarian section.
 Ante- or postpartum hemorrhage.
 Precipitate labor.
3. Maternal Health:
 Previous history of DVT or pulmonary embolism.
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 Chronic illness.
 Hypertension.
 History of infertility.
 Uterine anomaly including fibroids.
 Smoking more than 10 cigarettes a day.
 Family history of diabetes.
4. Booking Examination:
 Blood pressure 140/90 or above.
 Maternal weight over 85 kg or less than 45 Kg.
 Maternal height less than 150 cm .
 Shoe size below 30 cm.
 Cardiac murmur detected.
 Other pelvic mass detected.
 Blood disorders.
Nursing Diagnoses:
1. Potential injury to mother or fetus related to knowledge deficit or
relevant symptomatology of pregnancy.
2. Problems related to physical alterations of pregnancy, fatigue,
discomfort, nutritional intake, urinary frequency, and
constipation…
3. Problems related to psychosocial and sexual factors of pregnancy,
body image, sexual functioning. Life- style changes, coping,
anxiety.
4. Knowledge deficit related to physical and psychosocial changes
of Pregnancy and preparation for parenthood.
5. Anxiety related to uncertainty about labor and delivery.
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Planning:
Planning care for clients during the prenatal is based on the
biopsychosocial assessment of the client and her family. For each
client a plan is developed that relates specifically to her clinical and
nursing problems.
Goals:
1. To alert clients to the symptoms those indicate deviations from
normal progress and the protocols for reporting them.
2. To detect deviations from the normal progress of pregnancy and to
initiate prompt remedial therapy.
3. To provide clients with pertinent knowledge of the adaptation of
maternal body to a developing fetus for understanding the rational
and necessity for modalities of care.
4. To provide clients with information and counseling including those
relating to nutritional needs, sexual needs, activities of daily living,
and discomforts pregnancy.
5. To encourage participation by clients and their families in their
care during pregnancy.
6. To provide support for clients and their families as they experience
stress during pregnancy.
7. To establish an environment that promotes an emotionally
satisfying pregnancy.
Implementation:
Nursing interventions: Health education
A) Dealing with physical, psychosocial and life- style changes.
1. Teach the woman reasons for fatigue and help her plan a
schedule for adequate rest.
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a. Fatigue in the first trimester is due to increased progesterone
and its effects on the sleep center.
b. Fatigue in the last trimester is due mainly to carrying
increased weight of the pregnancy.
c. About 8 hours of rest is needed at night.
d. Inability to sleep may be due to excessive fatigue during
day;
e. In the latter months of pregnancy, sleeping on the side with
small pillow under the abdomen may enhance comfort.
f. Frequent 15-30 minute rest periods during the day are
important to avoid over fatigue.
g. Whenever possible, the woman should work while sitting
with her legs elevated.
h. The woman should avoid standing for prolonged periods of
time especially during the third trimester.
2. Help the woman plan for adequate exercise and activities.
Sports that have a risk of bodily harm should be avoided.
3. Teach the woman about the importance of good nutrition for
herself and her fetus, have her plan good daily nutrition.
a. Pregnancy increases the need for protein, vitamins A, D, E
and B complex, calcium, phosphorus, and iron.
b. Daily caloric requirements are approx 400 calories in
addition to the pregnancy maintenance calories.
c. According to her life- style, culture, income and eating
patterns, have the woman plan daily menus that include.
 Protein foods.
 Milk or milk products.
 Grain products.
 Leafy green vegetables.
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 Vitamin C- rich fruits and vegetables.
 Other fruits and vegetables.
d. Carefully evaluate the dietary intake of overweight or
underweight woman.
e. Caffeine intake should be limited.
f. Smoking should be eliminated, risk of spontaneous abortion,
fetal death, birth of low- birth- weight infant and neonatal
death increase directly with increasing levels of maternal
smoking during pregnancy.
4. Discuss methods of achieving sexual satisfaction during
pregnancy, female superior or side- lying positions are often
more comfortable in the latter half of pregnancy.
5. Assist the woman in her employment planning.
a. Generally there is no reason to stop working unless
complications arise or there are hazards to the fetus in the
work place.
b. It is desirable to avoid severe physical strains and get
adequate periods of rest.
c. Use good body mechanics.
d. Avoid toxic substances and radioactive substances.
e. Begin childcare planning, if employment after birth is
planned.
B) minimizing common discomforts of pregnancy:
1. Morning sickness:
Nausea sometime accompanied by vomiting occurs frequently
in the morning but may occur at any time.
a) Cause: unknown, Hormonal changes believed to be a
causative factor. Duration of morning sickness mirrors
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duration of elevated hCG production. Emotional upset and
hypoglycemia also seen as contributing factors.
b) Eating dry carbohydrates such as toast or crackers often help.
c) Eating small, frequent meals is helpful.
d) Avoid hard to digest, greasy foods and odors.
2. Urinary frequency:
a) Cause: pressure of enlarging uterus on bladder.
b) Cause: usually subsides spontaneously by the second or third
month when the uterus rises into the abdominal cavity,
returns in the last weeks of pregnancy when the vertex drops
into the pelvic cavity engagement.
c) Prevention: not preventable. Kegal exercise will help to
strengthen pubococcygeal muscle. Limit fluid intake before
bedtime to ensure rest.
d) Treatment; same as prevention. Reassurance, wear pereneal
pads. Refer to physician for pain and burning sensation.
3. Heart burn;
a) Cause: Pressure on stomach from enlarged uterus and the
effect of progesterone which slows GI tract motility and
digestion, reflux to cardiac sphincter and delays emptying
time of stomach result in a reflux of stomach contents in
lower esophagus and a feeling of heartburn.
b) Smaller and more frequent meals of foods easy to digest are
helping. Sips of milk for temporary relief. Local antacids
soothe the mucosa and neutralize acid reflux.
c) Avoid NaHCO3 since it results in absorbtion of excessive
sodium and fluid retention.
d) Avoid or limit gas-producing foods and avoid fatty food.
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4. Backache:
Cause: relaxation of joints because of hormones. Pregnant
woman’s center of gravity changes, as a compensation she
walks with head and shoulder backward and chest forward. This
position may produce lordosis and back pain.
Management:
 Good posture, standing tall- good body mechanics.
 Avoid fatigue.
 Firm mattress.
 Wear comfortable, low-heeled (5-cm shoes with good
arch support).
 Reassure that the condition will go away 6 weeks or less
after delivery.
5. Constipation
Cause; GI tract motility slowed because of progesterone,
resulting in increased absorption of water and drying of stool
and because intestine is compressed by enlarged uterus.
Management:
 Additional fluids (6 glasses) and increasing green leafy
vegetables will help.
 Adequate daily exercise is an aid using relaxation
techniques and deep breathing. Establish regular pattern
of elimination.
 Don’t use stood softeners, laxatives, other drugs or
enemas without first consulting physicians.
 Never ingest mineral oil since this inhibits absorption of
fat-soluble vitamins.
6. Respiratory discomfort:
Cause: expansion of diaphragm limited by enlarged uterus.
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Management:
 Spontaneous relief occurs with lightening or with birth of
the baby.
 Provide relief by semifolwer’s position, sleep with extra
pillow.
 Some relief is obtained with good posture and standing
tall, or with exercise.
 Eating small amounts of frequent meals prevents
increased pressure from full stomach on the diaphragm.
 Stop smoking.
 Refer to physician if symptoms worsen to rule out anemia
and bronchial asthma.
7. Varicose veins
May affect lower extremities, vulva, pelvis, and anus.
Cause: hereditary predisposition, pressure of gravid uterus on
large veins, relaxation of smooth muscle walls of veins because
of hormones, prolonged standing or bearing sown for bowel
movements.
Prevention:
 Avoidance of obesity, length standing, or sitting,
constricting clothing and constipation and bearing down
with bowel movements.
 Moderate exercise.
Management:
 Same as prevention.
 Rest frequently by sitting or lying with legs elevated.
 Wear support stockings, applied before rising.
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 Hemorrhoids: avoid constipation, apply cold compresses
and avoid sitting or standing for prolonged periods of
time, rest lying down.
 Vulvar varicosities: rest periodically with small pillow
under buttocks to elevate pelvis.
 Varicosities are totally or greatly resolved after delivery.
8. Leg cramps:
Cause: compression of nerves supplying lower extremities
because of enlarging uterus, reduced level of diffusible serum
calcium or elevation of serum phosphorus.
Aggravating fatigue, poor peripheral circulation.
Management:
 Avoid fatigue and cold legs.
 Frequent rest periods with legs elevated may be helpful.
 Adequate calcium intake my decrease the incidence.
 Rule out blood clot by checking for Homan’s sign. If
negative, use massage and hear over affected muscle.
 For immediate relief, push toes upward while applying
pressure to the knee to straighten the leg.
9. Leg and ankle edema;
Nonpitting.
Cause: pressure of gravid uterus impeding venous and
lymphatic return.
Aggravated by long standing or sitting.
Management:
 Avoidance of prolonged standing or sitting.
 Avoid constrictive clothing.
 Rest frequently with legs elevated.
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 Refer to physician if generalized edema develops even if
other symptoms of preeclampsia are not found.
 Diuretics are contraindicated.
10.Vaginal discharge (Leukorrhea):
Cause: hormonally stimulated cervix becomes hypertrophic
and hyperactive, producing abundant amounts of mucus.
Management
 Don’t douche
 Personal hygiene
 Perineal pads
 Reassurance
 Refer to physician if accompanied by purities, foul odor,
or change in character of color. These signs indicate
infection or other complications.
11. Tender breast and nipple irritation:
Cause: hypertrophy of the mammary glandular tissue and
increase vascularization, pigmentation and size and prominence
of nipple and areola cause by hormone stimulation.
Management:
 Wear well supporting brassiere.
 Wash breasts and nipples with water only.
 Nipples rolling 3 times a day.
 Lanolin creams applied to nipples help minimize
irritation from colostrums and clothing.
C) Reducing anxiety and preparing for the upcoming labor.
1. Have the woman/couple discuss perceptions and expectations of
labor process, using birthing room, position of delivery.
2. Encourage the couple to attend child birth education classes.
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3. Discus value of breathing exercises as another tool for
composing with labor and encourage their practice.
4. Have the woman identify when to come to the birthing center or
hospital. (for Primigravida – when contractions are 5-10
minutes apart. For multigravida- when contractions have
established a regular pattern).
D)
Preparing for parenthood:
1. Have the woman/couple discus perceptions and expectations of
a new parenthood.
 Perception of their idealized child.
 Perceptions and expectations of infant’s sleeping, eating
and activity and response pattern.
 Expectations of returning to work and child care
arrangements.
2. Physical preparation for the newborn (crib, clothing, blankets,
bathing equipment, feeding equipment, etc…)
3. Help the woman/couple plan for time for themselves and each
other a part from the newborn.
Evaluation:
Evaluation is a continuous process. To be effective, evaluation
needs to be based on measurable criteria. The criteria reflect the
parameters used to measure the goals of care.
1. Understand reasons for fatigue, establish a schedule for
adequate rest.
2. Engages in prescribed program of exercise.
3. Understands the essentials of good nutrition during pregnancy.
4. Avoids potentially harmful substances.
5. Learns and practices means of dealing with physical discomfort
of pregnancy.
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6. Couple prepares for upcoming labor and delivery.
Maternal Nutrition
Maternal nutrition plays a significant role in fetal well being as well as in
the prevention and treatment of high-risk pregnancy. A 25% deficit in
needed calories and protein can interfere with the synthesis of DNA. As a
result during the first 2-3 months of pregnancy, a deficit in nutrients can
have teratogenic effect or lead to spontaneous loss.
After 2-3 months, a maternal nutritional deficit can impede fetal growth,
causing a small for gestational age infant or a small brain growth infant.
Specific maternal nutritional deficiencies can have deleterious effects on
the fetus.
Protein, 75-100g daily is important in supporting embryonic-fetal cell
growth, in promoting necessary increase maternal blood volume and
possibly in facilitating prevention of Pregnancy Induced Hypertension
(PIH).
To prevent maternal anemia which affect oxygenation and neonatal RBCs
mass, and adequate maternal intake of iron, folic acid, vit. B6 and B12 is
needed. Supplemental iron of at least 300mg in maternal stores is
necessary for the fetus to grow upon.
During pregnancy, the diet should contain 30-50mg of zinc each day.
Zinc is found in such foods as nuts, meats, whole grain and legumes. A
deficiency of zinc during pregnancy increases the risk of premature
rupture of membranes and preterm labor. This may be the result of a
related deficiency in the antimicrobial properties of the amniotic fluid as
well.
To meet the growing needs of the fetus, for maternal storage of fat and
protein, there should be an increase of 300-500 calories/ day above
normal caloric requirements.
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Social habits such as alcohol intake, smoking and drug abuse will
interfere with adequate of nutrients in the fetus and the mother.
Nutrition Risk factors in Pregnancy
Risk factors at the onset of pregnancy:
1. Adolescence:
pregnancy at this time superimposes metabolic
demands for nutrients on the dietary requirements for the
adolescent own growth. The pregnant adolescent need for
increased protein, calories and iron will exceed that of the pregnant
woman over 20 years of age.
2. frequent pregnancies: three or more pregnancies within two years
or multiparous woman who has progressed from one pregnancy
directly to another
depleted nutrient stress
compromise
maternal and fetal well being.
3. Economic deprivation: a need for programs that help on offering
food supplements.
4. Vegtarian diets: of particular concern the strict vegetarian (vegan)
who eliminates all products of animal origin including meat,
poultry. Vegetarianism may not receive adequate quantities of
essential nutrients e.g. protein, vit. B12…
5. Smoking,, drug addiction or alcoholism: there is always the
possibility that woman who uses cigarettes, drugs or alcohol may
not consume sufficient quantities of nutritious food beside its
effects on pregnancy.
6. Medical problems: such as anemia, thyroid dysfunction and
chronic gastrointestinal disorders may interfere with the digestion,
ingestion, absorption or utilization of nutrients. Drugs may also
affect nutrition.
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7. Bizarre food patterns: Pica regular and excessive ingestion of non
food items or food with limited nutritional value. Woman on
nutritionally inadequate diet.
Risk factors in Pregnancy:
1. Anemia:
- Mostly iron deficiency anemia.
- Iron supplementation will aid greatly in maintaining the Hb.
at normal level.
2. Pregnancy Induced Hypertension (PIH):
- Unknown cause.
- Characterized by increased B.P., proteinuria and increased
body weight.
- There is considerable controversy over the influence of
nutrition (Na, protein) on the development of PIH.
3. Inadequate weight gain:
The following are presumptive signs of maternal and fetal
malnutrition:
- failure to gain weight (less than 0.9 kg/month during 2 nd and
3rd trimester)
- Actual weight loss.
- Significant nausea and vomiting during 1 st trimester.
- Poor or delayed uterine fetal growth.
 Effect:
o Low birth weight infant.
o Intrauterine growth retardation.
4. Excessive weight gain:
- May be due to tissue fluid retention and may be associated
with (PIH), so the woman must be carefully assessed for this
condition.
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- Sources of calorically rich but nutritionally poor food should
be identified and eliminated.
- Weight reduction in pregnancy and lactation by dietary
manipulation
or
drug
administration
or
both
is
contraindicated.
5. Demands of lactation:
Storage of 2-3 kg of fat during pregnancy provide a reservoir of some
(14000-24000 kcal) for lactation needs, this is utilized for the first 4-6
months of lactation.
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Nutritional needs of Pregnancy
Non
Nutrition
Pregnant
Need
Protein
44g
Pregnant
Reasons for increase Needs in
Need
Pregnancy
74g
Food Sources
- Rapid fetal tissue growth
Milk, cheese,
- Amniotic fluid.
egg, meat,
- Placental growth and development
grains, legumes
- Increased Hb.
and nuts
- Increased plasma protein.
- Maternal storage reserves for labor and
lactation.
Calories
1200-
+ 300
2400
Increased BMR. Energy needs and protein CHO. Fats and
sparing.
proteins
Minerals
- Fetal skeleton formation.
Calcium
800mg
1200mg
and
Phosphorus
- Fetal tooth bud formation
Milk, cheese,
- Increased material calcium
whole grain,
- phosphorus metabolism
leafy
vegetables, egg
yolk.
Iron
18mg
- Increased maternal circulation blood
Liver, nuts,
+ (30–
volume and Hb.
meats leafy
60)mg
- increase liver storage of iron.
vegetables, egg,
- stored in neonate’s liver and used to
dried fruits and
supply him with iron during the first 3
whole grain.
months (to compensate for lack of iron in
breast milk).
110
Iodine
150mg
175mg
Increased BMR and thyroxin production
Iodized salt.
Vitamins
A
4000 IU
5000 IU
- Essential for cell development.
Butter, cream,
- Tooth and formation and bone growth.
green and
yellow,
vegetables.
D
200 IU
400 IU
- Absorption of calcium and phosphorus.
Fortified milk
- Mineralization of bone tissue.
and fortified
- Tooth buds.
margarine.
Sun exposure
E
8mg
10mg
alpha
Tissue growth cell wall and RBCs
Vegetable oils,
integrity.
cereals milk,
total vit.
meat, egg.
E activity
- Tissue formation and integrity.
C
60mg
80mg
Citrus fruit,
- Cement substance in connective vascular melons,
tissue.
tomatoes,
- Increased iron absorption.
potatoes and
green peppers.
Folic acid
400mg
800mg
- Prevention of megaloblastic anemia
Meat, Peanuts,
- Increased heme production for
beans, peas and
hemoglobin.
enriched grains.
- Production of nucleus material.
- Coenzyme in energy and protein
metabolism
Riboflavin
and
1.2mg
1.5mg
- Coenzyme in energy and protein
Milk, Liver and
metabolism
enriched grains.
Thiamin
111
B6
2mg
2.6mg
- Coenzyme in energy and protein
Liver, meat,
metabolism
wheat corns.
- Increased fetal growth requirements.
B12
3g
4mcg
- Coenzyme in energy and protein
Milk, egg,
metabolism
cheese, meat,
- DNA and RBCs formation
liver
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Normal labor
Labor is described as the process by which the fetus, placenta and
membranes are expelled through the birth canal. Normal labor occurs at
term and is spontaneous in onset with the fetus presenting by the vertex.
The process is completed within 18 hours and no complications arise.
 Initiation of labor:
The exact mechanism that initiates labor is unknown. Theories include
the following:
1. Uterine stretch theory: uterus becomes stretched, pressure increase
causing physiologic changes that initiate labor. stretching causes a
release of prostaglandins.
2. As pregnancy advances, the uterus becomes more sensitive to
oxytocin (pressure on cervix stimulate production of oxytocin).
3. As pregnancy advances, progesterone is less effective in
controlling rhythmic uterine contractions that occur normally
throughout pregnancy.
4. There is increased production of prostaglandins by fetal
membranes and uterine deciduas as pregnancy advances.
5. In later pregnancy, the fetus produces increased levels of cortisone
which inhibit progesterone production from the placenta.
6. Placental aging and deterioration triggers the initiation of
contractions.
 General terms:
1. Lie: a comparison of the long axis of the fetus with the long axis of
the mother. Fetal lie is either, longitudinal, transverse or oblique.
In longitudinal lie either the fetal head presents or the buttocks
present. In transverse lie, the shoulders present.
2. Presentation: the part of the fetus deepest in the birth canal.
Presentation may be vertex, face, brow, breech or shoulder.
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3. Presenting part: portion of the fetus deepest in the birth canal and
felt on vaginal examination.
4. Attitude: relationship of fetal parts to each other (normal flexion).
114
5. Position: Position refers to the location of a fi xed reference point
on the fetal presenting part in relation to a specific q uadrant of the
maternal pelvis. The presenting part can be right anterior, left
anterior, right posterior, and left posterior. These four quadrants
designate whether the presenting part is directed toward the front,
back, right, or left of the passageway.
It is the relationship of landmark on the fetal presenting part to the
front (anterior = A) back (posterior = P) or side (transverse = T) of
the mothers pelvis.
Landmarks on the fetal presenting parts
include head = occiput (O) buttocks = sacrum (S), shoulder =
scapula or acromion (A), face = chin of mentum (M).
Example: a fetus presenting by the vertex with his occipit on the left
anterior part of the woman’s pelvis would have his presentation and
position described as LOA or lift occiput anterior.
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 Factors affecting labor:
• Powers (physiological forces)
• Passageway (maternal pelvis)
• Passenger (fetus and placenta)
• Passageway _ Passenger and their relationship
(engagement, attitude, position)
• Psychosocial influences (previous experiences, emotional status)
Successful labor and delivery depend on adequate pelvic dimensions,
adequate
fetal
dimensions,
presentation
and
adequate
uterine
contractions.
A. Pelvic dimensions:
1. Adequate pelvic inlet. AP diameter, normal shape.
2. Adequate midpelvis: Ischia spines don’t protrude into bony
canal.
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3. Adequate outlet:
adequate distance between tubrosities and
coccyx.
B. Fetal dimensions:
Important fetal dimensions influenced by fetal size, posture, lie,
and presentation.
Fetal position is also an important factor in
successful labor.
C. Uterine contractions:
1. Uterine contractions are involuntary, occurring at regular
intervals and having adequate intensity.
2. During uterine contractions, the active upper portion becomes
thicker, while the lower uterine segment stretches and becomes
thinner.
True and false labor contractions
True labor contractions
false labor contractions
1. Result in progressive cervical Do
dilation and effacement.
2. Occur at regular intervals.
not
result
in
progressive
cervical dilation and effacement.
Occur at irregular intervals.
3. Intervals between contractions Intervals remain the same or
decrease.
increase.
4. Intensity increases.
Intensity decrease or remains the
same.
5. Location mainly in back and Location mainly in groin and
abdomen.
6. Generally
abdomen.
intensified
by Generally unaffected by walking.
walking.
7. Not affected by mild sedation. Generally relived by mild sedation.
8. Dilation and effacement of the There is no change in the cervix.
cervix are progressive.
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 Events preliminary to labor (Signs and symptoms of lablor):
Pre-labor is the term given to the last few weeks of pregnancy during
which time a number of changes occurring.
1. Lightening, the setting of the fetus in the lower uterine segment
occurs 2-3 weeks before the onset of labor in the primigravida and
later during labor in the multigravida.
a. The woman’s breathing becomes easier as the fetus falls away
from the diaphragm.
b. Lordosis of the spine is increased, walking is more difficult
because the pelvic joints are more mobile and relaxed, leg
cramping may increase Backache may increase.
c. Frequency of micturation occurs because of the pressure on the
bladder.
2. Vaginal secretions may increase.
3. Mucus plug is discharged from the cervix along with a small
amount of blood from surrounding capillaries, referred as SHOW
(bloody show). Its presence often indicates that labor will begin
within 24 to 48 hours.
4. Taking up of the cervix. The cervix is drawn up and gradually
merges into the lower uterine segment. The cervix becomes soft
and effaced “thinned”. This softening and thinning is called
cervical effacement
5. False labor contractions may occur.
6. Membranes may rupture.
7. As the pregnancy approaches term, most women become more
aware
of
irregular
contractions
called
Braxton-Hicks
contractions. As the contractions increase in frequency (they may
occur as often as every 10 to 20 minutes), they may be associated
with increased discomfort.
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Stages of labor
1. The 1st stage is that of dilation of the cervix. It begins with regular
rhythmic contractions and is complete when the cervix is fully
dilated 10 cm (takes most of the time)
2. The 2nd stage of labor is the expulsion of the fetus. It begins when
the cervix is fully dilated and is completed when the baby is
completely born.
3. The 3rd stage of labor includes separation and expulsion of placenta
and membranes.
It lasts from the birth of the baby until the
placenta and the membranes have been expelled. (about half an
hour)
4. The 4th stage lasts from delivery of the placenta until the
postpartum condition of the woman has become stabilized “usually
1-2 hour after delivery”
 Note: the 1st stage consists of 3 phases:
a. Latent phase: cervical dilation is 0-3 cm
Begins with the establishment of regular contractions (labor pains).
Labor pains are often initially felt as sensations similar to painful
menstrual cramping and are usually accompanied by low back
pain. Contractions during this phase are typically about 5 minutes
apart, last 30 to 45 seconds, and are considered to be mild. Usually,
woman is excited about labor and talkative. It takes up to 10-14
hours.
b. Active phase: cervical dilation is 4-7 cm.
The active phase of labor is characterized by more active
contractions. The contractions become more frequent (every 3 to 5
minutes), last longer (60 seconds), and are of a moderate to strong
intensity.
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Cervical dilation during this phase advances more quickly as the
contractions are often more efficient. While the length of the active
phase is variable, nulliparous women generally progress at an
average speed of 1 cm of dilation per hour and multiparas at 1.5 cm
of cervical dilation per hour.
c. Transitional phase: cervical dilation is 7-10 cm
The transition phase is the most intense phase of labor. Transition
is characterized by frequent, strong contractions that occur every 2
to 3 minutes and last 60 to 90 seconds on average.
Other sensations that a woman may feel during transition include
rectal pressure, an
increased urge to bear down, an increase in bloody show, and
spontaneous rupture of the membranes (if they have not already
ruptured).
Mechanism of labor
If the woman’s pelvis is adequate, size and position of the fetus are
adequate and uterine contractions are regular and of adequate intensity,
the fetus will move through the birth canal. The position and rotational
changes of the fetus as he/she moves down the birth canal will be affected
by resistance offered by the woman’s bony pelvis, cervix and surrounding
tissues
A. Engagement:
When biparietal diameter of fetal head has passed through pelvic inlet.
1. Primigravida: occurs up to 2 weeks before onset of labor
2. Multigravida: usually occurs with onset of labor.
3. Since biparietal diameter of fetal head and AP diameter is
narrowest of pelvic inlet, the fetal head usually enters pelvis in a
transverse position.
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The fetal head enters the maternal inlet in the occiput transverse or
the oblique position because the pelvic inlet is widest from side to
side.
B. Descent:
Occurs throughout labor and is essential for rotations of the fetus prior to
birth:
1. Accomplished by force of uterine contractions on fetal portion in
funds, during second stage of labor the bearing down increases
intra-abdominal pressure thus augmenting effects of uterine
contractions.
2. Degree of descent described as:
a. Floating: presenting part is not engaged in pelvic inlet.
b. Fixed presenting part has entered pelvis
c. Engagement: presenting part has passed pelvic inlet
d. Station O: presenting part has reached the level of ischial spine
e. Stations (-1,-2,-3,-4) presenting part in 1,2,3,4 cm above the
level of ischial spine.
f. Stations (+1, +2, +3, +4) presenting part in 1, 2, 3, 4 cm below
the level of ischial spine.
A station of +4 indicates that
presenting part is on pelvic floor.
C. Flexion
Resistance to descent causes head to flex so that the chin is close to the
chest. This cause the smallest fetal head diameter, subocciputobregmatic
(9.5 cm) to present through the canal.
D. Internal rotation:
In accommodating to the birth canal, the fetal occiput rotates interiorly
from its original position toward the symphysis pubis.
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E. Extension:
As the fetal head descends further, it meets resistance from the perineal
muscles and is forced to extend. The fetal head becomes visible at the
vulvovaginal ring. Its largest diameter is encircled (crowing) and the
head then emerges from the vagina.
The head is born in extension as the occiput slides under the symphysis
and the face is directed toward the rectum. The fetal brow, nose, and chin
then emerge.
F. External rotation:
When the head emerged, the shoulder are undergoing internal rotation to
accommodate to the birth canal, the head now born, rotates as the
shoulders undergo the internal rotation.
G. Expulsion
Following delivery of the infant’s head and internal rotation of the
shoulder, the anterior shoulder rest beneath the symphonies pubis. The
posterior shoulder is born followed by the anterior shoulder and the rest o
the body.
122
Nursing management during labor
Assessment:
When the woman present at the hospital, she will experience a mixture of
excitement and apprehension. She should ideally be welcomed and her
partner.
Skill in inspiring confidence and establishing a trusting
relationship with a woman is an integral part of good nursing care.
 History taking and baseline data:
1. Introduce yourself, ask for name of woman’s midwife or physician
and if he or she has been notified that the woman was coming to
the hospital or birth center.
123
2. Establish baseline information
a. Gravidity, parity, expected date of delivery.
b. When did contractions begin? How far apart are they? How long
do they last?
c. Have the membranes ruptured? Color? Consistency? Amount of
fluid?
d. Is there any bloody show?
e. How much discomfort is the woman experiencing?
f. What, if any problem has the woman had in this pregnancy?
Problems in past pregnancies?
g. Blood type and Rh?
3. Establish baseline vital signs.
a. Temperature elevations suggest infection
b. Blood pressure measure between contractions.
c. Pulse: some elevation of pulse, respiration and blood pressure may
be due to anxiety.
Blood pressure elevations of 140 mmHg
systolic and 90 mmHg diastolic suggest hypertensive disorder of
pregnancy.
d. Respiration.
Methods for determining fetal presentation
1. Leopold’s maneuvers: determined by abdominal palpation.
a. The 1st maneuver: to determine if fetal head or breech is in uterine
funds. Head feels hard and round, freely movable and ballotable
breech feels large, nodular and softer.
b. The 2nd maneuver to determine the position of fetal extremities the
fetal back and the anterior shoulder. Place hand on the abdomen to
identify the location of the back and small parts palpate down
sides of uterus, applying gentle but deep pressure onside of fetal
back along continuous structure will be felt, side with fetal
124
extremities will feel nodular, reflecting portions of fetal
extremities.
c. The 3rd maneuver: to determine is presenting and if engagement
has occurred. Grasp the lower uterine segment between the thumb
and fingers of one hand to feel. If presenting part is movable,
engagement has not occurred, if engagement has occurred fetal part
feels fixed in the pelvis
d. The 4th maneuver: to confirm the findings of the 3rd maneuver and
to determine the flexion of the vertex.
2. Vaginal examination:
Vaginal examination should preceded by abdominal examination and the
woman’s bladder must be empty.
 Indications:
- To make a positive diagnosis of labor.
- To make a positive identification of presentation.
- To determine whether the head is engaged in case of doubt.
- To ascertain whether the fore waters have ruptured or to rupture
them artificially.
- To exclude cord prolapsed after rupture of membranes.
- To assess progress or delay in labor.
- To apply a fetal scalp electrode.
- To confirm full dilation of the cervix.
 Notes:
- It is not always the only way of obtaining this information
- It should be avoided if there is any frank bleeding unless the
placenta is positively known to be in the upper uterine segment
- It is an aseptic procedure, sterile gloves are required.
- It usually increases frequency and intensity of uterine contractions.
3. Ultrasonography
125
4. X-ray rarely used today (replaced by ultrasonography)
Assessing uterine contractions
(Intensity, Frequency and Duration)
1. Place fingertips gently on the funds.
2. As contraction begins, tension will be felt under the fingertips.
Uterus will become harder, then slowly soften.
3. The intensity may be described as follows:
a. Mild: the uterine muscle is somewhat tense.
b. Moderate: the uterine muscle is moderately firm.
c. Strong:
the uterine muscle is so firm that it seems almost
board-like.
4. The frequency is measured in minutes, represents the time from the
beginning of one contraction until the beginning of the next.
5. Duration of contraction is timed from the moment the uterus first
begins to tighten until it relaxes again.
6. As labor progresses, the character of the contraction changes and
they last longer.
7. When the cervix becomes completely dilated, the contractions
become very strong, last for 60 seconds and occur at 2-3 minute
intervals.
Assessing fetal heart tones
1. Note location, rate and character.
2. Determine the position, presentation and lie of the fetus.
3. Place the fetal stethoscope on the abdomen over the back or chest
of the fetus.
126
4. Listen and count the beat for one minute.
5. Check the rate before, during, and after a contraction to detect
slowing or irregularities (120-160 BPM
normal)
6. Differentiate between FHT and other abdominal sounds.
a. FHT, very rapid, somewhat muffled ticking sound.
b. Uterine bruit, murmur, dilated uterine vessels, material pulse.
c. Fetal pulse (umbilical arteries) is synchronous with funic
soufflé.
7. Check FHR immediately following rupture of the membranes.
Sudden release of fluid may cause prolapsed of the umbilical cord.
Fetal monitoring
The purposes of continuous fetal monitoring during labor are:
1. To monitor the progress of a women’s contraction pattern.
2. To monitor the condition of the fetus in response to the stress of
uterine contractions.
Women’s reaction to being monitored varies:
1. Some women are reassured by hearing the continuous fetal heart
sound.
2. Some women \ couples use the printout of the contraction pattern
to assist them in using breathing techniques.
3. Some women experience discomfort because of the abdominal
straps & their interference with movement as well as difficulty
assuming a comfortable position.
 External monitoring (indirect):
- Separate transducers are secured to the women’s abdomen.
- A tokodynamometer translates abdominal tension.
- An ultrasound transducer translates fetal heart sound into electrical
signals that are recorded on a strip chart.
127
- The ultrasound transducer device should be applied over the
abdomen where the sharp fetal heart sound is heard .the transducer
needs to be adjusted when fetus changes position.
- The tokodynamometer recording uterine contraction will need to
be reapplied over the fundus as the fetus & uterus descend during
labor.
- The measurement by external monitoring of the intensity of uterine
contractions is not accurate.
 Internal monitoring (direct):
- A method of recording intrauterine pressure and FHR through
internal measurement.
- More accurate than external monitoring.
- Fetal electrocardiograph obtained by a small electrode clipped to
the presenting part.
128
 Note:
1. The membranes must be ruptured.
2. The cervix must be dilated 3-4 cm.
3. The station must be (-2) or lower.
- Uterine contractions are recorded by means of a catheter placed in
uterine cavity behind the presenting part.
- The catheter filled with distilled water and is connected to an
external transducer that converts pressure to electronic signals.
- Monitor strips record the quality of the uterine contractions and
fetal heart patterns simultaneously.
 Interpretation:
- FHR must be checked initially for rate in the absence of or in
between contraction.
- A change from the baseline is termed as fluctuation and is either
acceleration or deceleration.
129
- Acceleration or deceleration of the FHR are due to:
1. Mechanical effects or uterine pressure applied directly to the fetal
head and / or umbilical cord.
2. Uterine pressure applied directly to the intervillous space which
leads to decrease blood flow.
 Acceleration:
Of more than 60 BPM above the baseline is considered sever and
indicates fetal compromise e.g. fetal hypoxia , fetal immaturity or breech
presentation .
An acceleration is defined as an increase in the FHR of 15 bpm above the
fetal heart baseline that lasts for at least 15 to 30 seconds. Accelerations
are considered a sign of fetal well-being when they accompany fetal
movement.
130
Thus, when a fetus is active in utero, accelerations are normally present.
Consequently, when the fetus is sleeping or not moving, limited FHR
accelerations may be noted. When contractions are present, accelerations
are often noted as a response to the contraction.
Top. Fetal heart rate accelerations.
Bottom. Uterine contractions.
 Deceleration :
1. Early Deceleration.
- Wave-form approximates a mirror image of the pattern of
intrauterine pressure (contractions)
- Pattern is often uniform in appearance.
- Begins near the onset of contraction
- Lowest level of FHR occurs at the peak of the intrauterine pressure
(contraction).
- FHR does not fall below 100 BPM.
131
- Not usually cause change in acid-base balance.
- Caused by fetal head pressure (which cause vagal stimulation
which decrease in HR), May occur during vaginal examinations,
uterine contractions, and during placement of the internal mode of
fetal monitoring.
- Need no intervention.
Top. Early decelerations.
Bottom. Uterine contractions.
2. Late deceleration:
- Manifests a smooth uniform heart pattern.
- Begins later in contracting phase of uterus (as the contraction
reaches its peak) and resolved when the contraction ends.
- Usually less than 90 seconds in duration.
- Frequently associated with fetal tachycardia.
- Passage of meconium may occur.
132
- Associated with progressive fetal hypoxia and acidosis.
- Due to acute uteroplacental insufficiency as a result of a decreased
intervillous space blood flow (in this circumstance a decrease in
blood flow from the uterus to the placenta results in fetal hypoxia
and late decelerations).
- Should be reported immediately.
Late decelerations.
Bottom. Uterine contractions.
- Late deceleration can be avoided by:
a) Careful maintenance of maternal pressure within normal limits
b) Careful infusion of oxytocins and anesthetics .
- Late deceleration can be modified by :
a) Discontinue oxytocin if being given .
b) Chang the woman's position to the left side
c) Administer oxygen and IV fluid
d) Obtain fetal blood sample to measure degree of hypoxia and
acidosis
133
e) If persist, labor may be terminated by Cesarean or Forceps
delivery
3-Variable deceleration
- Decelerations are variable in terms of their onset, frequency,
duration, and intensity.
- The decrease in FHR below the baseline is 15 bpm or more, lasts at
least 15 seconds, and returns to the baseline in less than 2 minutes
from the time of onset.
- Due to umbilical cord compression
- Non uniform and has no relation to contractions
- In severe deceleration, FHR may fall by 70 BPM and last longer
than 60 seconds.
- Usually relieved by changing position of the woman to relieve
pressure on the cord When sever cord prolapse should be suspected
Top. Variable decelerations.
Bottom. Uterine contractions.
134
4-Combined deceleration : difficult to identify the FHR pattern
Tachycardia is generally defined as a sustained baseline fetal heart rate
greater than 160 beats
per minute for a duration of 10 minutes or longer. A number of conditions
are associated with fetal tachycardia:
• Fetal hypoxia
• Maternal fever
• Maternal medications
• Infection
• Fetal anemia
• Maternal hyperthyroidism
Bradycardia is defined as a sustained
(greater than 10 minutes) baseline FHR of less than 110 to 120 bpm. Fetal
bradycardia may be associated with:
• Late hypoxia
• Medications: (e.g., propanolol)
• Maternal hypotension
• Prolonged umbilical cord compression
• Bradyarrhythmias
135
Assessing woman's / couples expectations and concerns
1- What are their concerns?
2- How anxious are they?
3- What has been their preparation for labor?
4- What is their understanding of labor process?
5- What are their expectations of the labor and delivery process?
6- How will are they coping and how will are they communicating
with each other?
136
Nursing Diagnosis
1- Anxiety related to uncertainties/misconception of the labor and
birthing process, hospital, environment, fear for self and baby.
2- Pain and discomfort related to uterine contraction ,passage of the
fetus through the birth canal, possible tearing of the perineum
3- Potential for ineffective coping related to length and discomfort of
labor process, fatigue, decreased energy
4- Potential for blood loss related to complication
5- Potential for infection related to rupture membranes
Nursing Intervention
Reduce anxiety
- Monitor the woman's/couples concerns
- Keep the woman's/couple up to date on the woman's progress during
labor
- Explain any procedure that need to be performed or any unexpected
event that may occur
- If the woman is in true labor, the perineal area may be shaved to
promote cleanliness, to reduce postpartum infection and to make
episiotomy repair easier
- An enema may be necessary to increase the space available for passage
of the fetus and decrease fecal contamination of the field during labor
Reduce pain and discomfort, promote effective coping throughout
the state of labor as described in the following:
1st stage of labor
Latent phase (0-3cm).
1- Monitor progress of labor, take and record vital signs, contractions
(usually 5-10minutes apart, lasting 20-40second), fetal heart
sounds every1-2houre,temperature every 4hours unless elevated
137
2- Provide clear liquids if permitted
3- Allow the woman to walk about, provided presenting part is
engaged and membranes have not ruptured
4- Encourage diversionary activity such as reading or watching TV.
5- Evaluate and teach breathing techniques helpful in coping with
active and transitional phase of the 1st stage and breathing and
pushing techniques for 2nd stage.
6- Involve partner or support person in the woman's care such as
providing back massage and timing of contractions
7- Provide privacy for the couple between periods of giving care
8- Encourage the woman to void approximately every 2 hours to keep
bladder empty
Active phase (4-7cm)
Contractions are usually 2-5 minutes apart, lasting 30-50 seconds
1. Monitor progress of labor, take and record vital signs,
Contractions and fetal heart sounds every 30 minutes
2. Be aware that the woman may begin to feel unable to cope with
discomfort and may begin to lose control
3. Partner or nurse should help the woman to concentrate on
breathing and relaxation techniques with each contraction
4. Provide comfort measures:
- Side-lying position is usually more comfortable, remove
pressure of gravid uterus on inferior vena cava and increase
blood flow to the placenta
- Provide sacral hand pressure and backrest
- Change damp or soiled linen
- Assist with mouth care
- Sponge bathe face, neck and back
- Continue to provide encouragement and information
138
- Administer prescribed analgesia as prescribed
5. Maintain hydration and glucose level of woman. Low glucose level
decrease intensity of contractions (I.V) fluid may be necessary
Transitional phase (7-10cm).
A- Characteristics:
-
contractions are usually 2-3 minutes apart, lasting 50-60 seconds
-
This stage averages 10 contractions or 20 minutes for
multigravida, 20 contractions or 40 minutes for primigravida
- Generally it is the most difficult of the phase of the 1st stage
- Bloody show increases as more capillary vessels in the cervix
rupture
- Nausea and vomiting may occur because of reflex action as the
cervix stretches and begins to retract over the fetal head
- Woman may experience or have potential amnesia between
contractions, may be restless and cry during feelings
B- Nursing Interventions:
- Monitor progress of labor, vital signs, contractions and fetal heart
sounds every15 minutes
- Assist with controlled breathing as contractions occur
- Discourage the woman from bearing down until cervical dilatation
is complete
- Encourage the women to rest between contractions to conserve
energy
- Provide concise and brief explanations because woman is irritable
- Remind the woman that labor is nearing an end
- Prepare the woman for movement to the delivery room
139
2nd and 3rd stage of labor
A-Characteristics:
- Full cervical dilation occurs, infant is delivered
- Usually primigravida has an average of 20 contraction and
multigravida an average of 10 contraction
Possible nursing diagnoses
- Pain related to increasing frequency, duration, and intensity of
contractions.
- Knowledge deficit related to pain management techniques for
active labor.
- Anxiety related to the previous birth experience.
- Fatigue related to a prolonged latent phase labor.
- Risk for infection related to prolonged rupture of membranes.
B-Nursing Interventions
- Monitor F.H.R, contractions and blood pressure every 5 minutes
- Assist the woman into lithatomy position
- Coach for most effective pushing, only with contractions using
abdominal muscles
- If the partner or support person is present, have him to support
woman and see birth if desired
- Adjust delivery mirror, so the women can see birth if desired
- Cleanse vulva and perineal area
- Check equipment needed for infant resuscitation
- Keep the woman/couple informed of progress of delivery
- The woman may need to be catheterized, if bladder is full
- When the vulvovaginal ring encircles the head, an episiotomy may
be performed to prevent tearing of the perineum
140
- Episiotomy is a surgical incision of the perineum that is performed
to enlarge the vaginal orifice during the second stage of labor.
- When the head is delivered, mucus is wiped from face and
aspirated from the nose and mouth by bulb syringe.
- If loops of umbilical cord are around the infants neck, they are
loosened and slipped from around the neck. If unable to be
loosened the cord is clamped with two clamps and cut between
them. The nurse then places a plastic clamp on the umbilical cord
approximately 0.5 to 1 inch (1.2 to 2.5 cm) from the newborn’s
abdomen.
- When the baby is delivered, the infant is shown to the
mother/couple and then give to the nurse or pediatrician for normal
newborn care and finally returned to the mother
- Placenta usually separates and delivered within 15-20 minutes
following delivery of the baby.
- Vaginal canal and cervix are inspected for lacerations or injury, if
episiotomy has been performed, it is now sutured.
- The woman perineal area is cleansed and a sterile perineal pad
applied.
- The woman is assisted from delivery table to abed or stretcher; she
is moved with her newborn to the recovery room and accompanied
by support person.
- As the placenta separates from the uterine wall, it is important that
the uterus continues to contract. The contractions minimize the
bleeding that results from the open blood vessels left at the
placental attachment site. Failure of the uterus to contract
adequately with separation of the placenta can result in excessive
blood loss or hemorrhage.
141
- To enhance the uterine contractions after expulsion of the placenta,
oxytocin is often given (IV or IM).
- Once the placenta has been delivered, the nurse carefully examines
it to ensure that all cotyledons are intact. If any part of the placenta
is missing, the nurse immediately reports this finding to the
attending physician. Because retained placental fragments can
contribute to postpartum hemorrhage or infection, the physician
may perform a manual exploration of the uterus to remove any
remaining placental tissue.
- Initiate attachment between the mother and the newborn. The
infant is in a stage of alertness during the first hour after birth and
is responsive to voice, touch, and gaze. The nurse can facilitate
eye-to-eye contact between the patient and her neonate by dimming
the room lights. This occasion also provides an excellent time to
initiate breastfeeding if the mother wishes to do so.
Expected Outcomes:
- Manages anxiety, vital signs at acceptable levels
- Copes with pain, use breathing techniques
- Remains in control, absence of untoward bleeding
- No evidence of infection
4th stage of labor
- Considered to be the stage of recovery period but in the same time
it is a critical period for the mother and the newborn
- It is the first two hours post-birth, the mother starts readjustment to
the non-pregnant state and body systems begin to stabilize
- The primary danger for the mother is hemorrhage
- The safety of the mother depends on frequent assessment and
timely interventions of alert nurses
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- During is the first hour for physical assessment, all factors except
temperature are assessed every 15 minutes then every 30 minutes
during the second hour
Factors to be assessed :
- Blood pressure :slightly elevated
- Pulse: 50-70/minute (return within one hour)
- Fundus: firm and 2cm below or at level of umbilicus, but if it was
soft, message is done until firm
- Bladder
- Emotional status
- Lochia: if blood comes in spurts, cervical tear is suspected
- Perineum: assess sutures of episiotomy
- Discomfort (after pain): as a result of uterine contraction
Nursing Interventions:
Provide a quiet environment for the woman to promote as much rest as
possible for at least two hours
1) Potential for hemorrhage related to uterine atony and trauma
- The fundus remains firm with gentle massage
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- Massaging expels blood and clots (uterus contract)
- If uterus doesn't respond and bleeding continue, I.V Pitocin is
administered
- Lochia is bright red (scant, moderate, heavy)
- Assess the amount of bleeding by checking the perineal pads and
under buttocks
Note :
- Saturated pad (tail to tail) =100ml blood
- Loss of 100ml blood/15min is considered heavy
- Vital signs every 15minutes
- Notify the physician
2)
Potential for urinary retention related to child birth trauma, effect of
full bladder on the uterus (position, contraction)
- Hemorrhage (atony of bladder
retention)
- Warm water poured over the vulva to relax urethral sphincter
- Catheter may be prescribed
3) Alteration in comfort level related to after pain and childbirth trauma
- Uterine contractions (strong, painful; specially in multipara)
- Explain the normal physiology of after pains
- Encourage the mother to empty her bladder frequency
- Cover her abdomen with a warmed blanket
- Administer analgesics as prescribed
- Encourage self-relaxation techniques
For Episiotomy and Hemorrhoids:
- Encourage side lying position
- Apply ice packs for 2hours
- Administer analgesics as prescribed
- Encourage self- relaxation techniques
4) Self care deficit (bathing) related to fatigue and medications
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- Wash the mothers’ face and hands and place a warm blanket over
her
5) Potential for injury related to ambulating without assistance
- Bed rest for at least two hours
Note: rapid decrease in intra-abdominal pressure will lead to dilation of
blood vessels supplying the intestine (Splachnic engorgement) that will
lead to pooling of blood in the viscera and then to Orthostatic
hypotension
- Dangling her feet for five minutes
- Not to ambulate for the first time without assistance
6) Potential fluid volume deficit related to restriction during delivery
- Woman is thirsty and request fluid as soon as possible
- Clear fluids with moderate amount are permitted
- Drinking too much and too quickly
vomiting
- I.V infusion may be prescribed
- Accurate intake and output readings are maintained
- After the first hour alight diet is ordered
7) Potential distress of the human spirit related to lack of support person
8) Potential altered bonding related to fatigue and postpartum
discomfort
- Initial response of the mother: positive or negative (return by time and
bond with her baby)
- Immediate Care of the Newborn
The sequence of procedures may differ from one birth setting to another
In more traditional settings, the care is performed immediately after birth
In other settings, many aspects are performed after the parents have had
an hour or more to become acquainted with their newborn
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Assessment and Interventions:
1) Immediately after delivery, dry the infant “a wet small newborn
loses up to 200 calories/kg/minute in the delivery room through
evaporation, convection and radiation” drying the infant cuts this
heat loss in half.
2) Aspirate mucus from the mouth and pharynx with suction catheter.
3) Evaluate infant’s condition by Apgar Scoring System at 1-5
minutes after birth.
Apgar Scoring Chart
a) Infants scoring (7-10): are free of immediate stress
b) Infants scoring (4-6): are moderately depressed
c) Infants scoring (0-3): are severely depressed
4) Cord care: cord is tied off approximately 2.5cm from abdominal
wall using a cotton cord tie, plastic clamp or rubber band. Count
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the number of vessels, fewer than three vessels has been associated
with renal and cardiac anomalies
5) Eye care: prophylactic treatment against Ophthalmia Neonatorum
(Gonorrheal conjunctivitis). Two drops of 1% silver nitrate
solution or erythromycin is placed in the conjunctival sac of the
infants eye.
The infant of a mother with known gonorrheal disease should
receive penicillin intramuscularly.
6) Vitamin K: 1mg may be administered in the delivery room or
nursery.
The newborn has no intestinal flora to manufacture vitamin k
which is important in preventing hemorrhagic disease in the
newborn period.
7) Identification:
a) Apply ID band or bracelet to infants arm, include mothers
name, hospital number, infants sex and time and date of birth
b) Apply bracelet with the same information on the mothers wrist
c) After cleaning the soles of the infants feet, take footprints of the
infant and fingerprints of the mother
8) Weight and measure the infant
9) Assess the infant for gestational age and general wellbeing
Care of the Mother and Newborn during the Postpartum Period
The Puerperium:
Is the period beginning after delivery and ending when the woman's body
has returned closely as possible to its pre-pregnant state.
The period lasts approximately 6 weeks
Physiologic changes:
1) Uterine changes (Involution): uterus returns to pregravid status
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a) The fundus is usually midline and about at the level of the
umbilicus after delivery. The level of the fundus descends about
1cm each day until the 10th day, it has descent into the pelvic cavity
and can no longer be palpated
b) Post delivery Lochia (a vaginal discharge) consisting of fatty
epithelial cell, shreds of membranes, deciduas and blood is red
(Lochia Rubra) for about 2-3 days. It then progresses to a pallor or
brownish color (Lochia serosa ) followed by a whitish or yellowish
color (Lochia Alba) in the 7th-10th day. Lochia usually ceases by
three weeks and the placental site is completely healed by the 6 th
week.
2) The vaginal wall, uterine ligaments and the muscles of pelvic floor
and abdominal wall regain most of their tone during puerperium.
3) Postpartum diuresis occurs between the 2nd and 5th postpartum day as
extracellular water accumulated during pregnancy begins to be
excreted. Diuresis may also occur shortly after delivery if urinary
output was obstructed by presenting part or I.V fluids were given
during labor.
4) Breasts:
a) With loss of the placenta, circulating level of estrogen and
progesterone will decrease, while increase level of prolactine thus
initiating lactation in the postpartum woman.
b) Colostrum: a yellowish fluid containing more minerals and protein
but less sugar and fat than mature breast milk and having a laxative
effect on the infant is secreted for the first 2 day postpartum.
c) Mature milk secretion is usually present by the 3rd postpartum day
but may present earlier if a woman breast-feeds immediately after
delivery
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d) Breast engorgement with milk, venous and lymphatic stasis and
swollen, tense and tender breast tissue may occur between day 3
and 5 postpartum.
5) Ovulation: immediately after delivery, blood level of estrogen and
progesterone severely diminished, F.S.H level is still low for 7-10
days after delivery, F.S.H increase by the 3rd week, ovulation reoccur
in the non lactating woman by the 10th to 12th week, and she may
menstruate 6-8 weeks post delivery (usually there is no ovulation at
the first menstruation)
6) In the lactating woman ovulation and menstruation may not occur by 3
months or more.
It is important to educate patients that since ovulation can precede
menstruation, breastfeeding is not a reliable method of contraception.
7) Involution is a term that describes the process whereby the uterus
returns to the nonpregnant state. The uterus undergoes a dramatic
reduction in size although it will remain slightly larger than its size
before the first pregnancy.
Note : Involution of the uterus may be delayed by many causes as
infection and the term subinvolution is used .
Subinvolution is the failure of the uterus to return to the nonpregnant
state.
8) Cardiovascular system: immediately after delivery, the pulse rate will
be decreased around 50 beats per minute and restored after 48 hours
after delivery due to vagal stimulation. The intravascular blood
volume increased due to shifting of fluid to the blood vessels. Blood
volume returns to prepreganacny state by the end of the second week.
9) G.I.T increase tendency for constipation.
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10)
Skin: increase perspiration (diaphoresis) and diminished skin
discoloration.
Assessment
 Immediate postpartum assessment :
The first hour after delivery of the placenta (4th stage) is a critical period;
postpartum hemorrhage is most likely to occur at this time
1. Check fundus frequently.
2- Inspect perineum frequently for visible signs of bleeding
3. Evaluate V/S at frequent intervals
4. Avoid leaving the woman alone at this time since changes in
condition can occur precipitously
 Subsequent postpartum assessment:
1. Check firmness of the fundus at regular intervals
2. Inspect the perineum regularly for frank bleeding
a- Note color, amount and odor of the Lochia
b- Count the number of perineal pads that are saturated in each 8
hours period
3. Assess V/S at least once daily and more frequently if indicated.
Nursing Diagnosis :
1. Potential bleeding related to vaginal delivery, episiotomy, uterine
atony, complication…
2. Discomfort (backache, uterine cramping, breast engorgement…)
related to process of labor
3. Urinary retention related to bladder trauma
4. Constipation related to episiotomy, decreased muscle tone of
intestine
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5. Risk for infection related to prolonged labor, vaginal delivery,
laceration…
6. Knowledge deficit related to inadequate childbirth / parenting
preparation, lack of self-confidence.
7. Anxiety related to chronic fatigue, adapting anew family member,
inability to integrate that with labor experience.
Planning:
During planning goals are set in priority:
1. Saturate no more than one pad per hour.
2. Void within 6-8 hours Post delivery.
3. Verbalize acceptance of labor process after expressing concerns.
4. Verbalize increased comfort following initiation of comfort
measures.
5. No signs of infection will appear.
Implementation:
1. Prevention of hemorrhage:
 v/s should be within normal limits.
 Uterus must be palpated at frequent intervals to ascertain that
it is not filled with blood.
 Pads must be checked frequently to ensure that blood loss is
not excessive.
 Lochia may be described as light, moderate or heavy.
 Uterus, normally is firm or may be returned to a state of
firmness with gentle massage.
 Perineal pad that is soaked from tail to tail=100 ml of blood,
when hemorrhage is suspected, save all pads.
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 If pad is soaked within 15 minutes or blood is seen under
buttocks, check and observe vital signs and color of the
mother.
2. Prevention of bladder distension:
 Palpation of bladder comes with palpation of the fundus.
 The full bladder forces the uterus upward and to the right of
the midline
muscles
interfere with contractility of uterine
hemorrhage.
 Distention leads to atony of bladder
retention.
 Check the woman's voiding pattern, most women void with
sufficient amount within 8 hours of delivery.
 If the woman's meatus or bladder has been traumatized
during deliver, she may need to be catheterized, until the
urinary tract swelling has subsided.
 Teach the woman to void every several hours to keep her
bladder empty. This may help to reduce uterine cramping
and promote comfort
3. Maintain comfort:
 Mothers need to be in bed for at least 2 hours after delivery,
most mothers ambulate within 8-12 hours after delivery.
 When assisting the woman to ambulate for the first time,
have her sit on the edge of bed for 5 minutes then ambulate
with assistance to void falling because of fainting and
dizziness.
 Counsel the woman to avoid stair climbing as much as
possible for the first several days at home.
4. Breast care:
- Assess the condition of the woman’s breast and nipple.
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- Teach the woman to wash her breast with worm water to avoid
removing protective skin oil.
- Teach the woman to wear a brassier that provides good support
during the night and day time.
- Lactation suppressants such as estrogen or androgens may be given
to bottle-feeding mothers to suppress milk production and breast
engorgement.
- Check the breasts for signs of engorgement (swollen, tender, tense,
and shiny breast skin).
a. If the breasts engorged and the woman is breast feeding:
1. Allow worm to hot shower water to flow over the breasts to
improve comfort.
2. Hot compresses on the breast may improve comfort.
3. Express some milk manually or by breast pump to improve
comfort and allow nipples more available for infant feeding.
4. A mild analgesic may be used to improve comfort.
b. If the breasts engorged and the woman is bottle feeding:
1. Teach the woman to wear a supportive binder day and night.
2. Teach the woman to avoid handling her breast since this
stimulates more milk production.
3. Suggests ice bags to the breasts to provide comfort.
4. Moderately strong analgesics may be needed to provide
comfort.
5. Diet and elimination:
1. Review the woman’s dietary intake with her.
2. Emphasize foods high in iron, protein and vitamins to aid the
healing process. Foods such as fresh fruits and vegetables with
high fiber will help reestablish normal bowel habits.
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3. If the woman is breast-feeding, she should add between 500-900
additional calories daily for milk production.
4. She also needs 20 gm protein more than before she was pregnant
and additional calcium, phosphorus, vitamins (A, D, E, C, B1, B2,
and niacin), zinc and iodine.
6. Resuming of sex
1. Sexual intercourse may be resumed when perineal and uterine
wounds have healed.
2. Healing occurs within 2-4 weeks. However, evaluation by the
midwife or physician during the following up visit is necessary.
Therefore, methods of contraception should be reviewed.
For women who are bottle-feeding, menstruation usually returns
within 6-8 weeks after delivery (75% menstruate by the twelfth
postpartal week).
Note: nursing mothers may ovulate even if they are experiencing
amenorrhea and so a form of contraception should be used if
pregnancy is to be avoided.
7. Maintain cleanliness:
- Vulva is cleaned and sterile pad is applied.
- Linen is changed
- Teach the woman to carry out perineal care, warm water over the
perineum after voiding.
- Sitz baths may be used.
Evaluation:
- Evaluation of progress and out-comes is a continuous activity
through this stage.
- The nurse evaluates physiologic recovery from pregnancy and
labor and development of parent-infant relationships (attachment).
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- If the evaluation process identifies that results fall short of
achieving any goal, further assessment, planning, and
implementation are needed to be done.
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Physiology of the Newborn
The neonatal or newborn period is the first 28 days of life during which
the infant undergoes amazing growth and change.
Respiratory Changes :
During a vaginal birth, approximately one third of the fetal lung fluid is
expelled due to the “thoracic squeeze” that occurs during passage through
the birth canal.
Infants of cesarean births are at a higher risk for pulmonary transitional
difficulties because they do not receive the lung compression benefits
associated with a vaginal birth.
Lung expansion after birth stimulates the release of surfactant.
Initiation of respiration: a combination of physical, sensory and chemical
factors:
1. Chemical: ↓O2, ↓pH and ↑ CO2 level (stimulate the respiratory
center in the brain to initiate breathing).
2. Sensory: maximum effort is required to expand the lungs and fill
the collapsed alveoli. (When leaving a familiar, comfortable, warm
environment to enter into an extremely sensory overloaded one—
filled with visual and auditory stimuli. These sensory experiences
aid in the initiation of respirations).
3. Thermal factors The drastic change in temperature (from the warm
intrauterine [37º] to cooler environment outside the womb) helps to
stimulate the initiation of respirations. (to prevent cold stress and
respiratory depression, immediately dry the infant).
4. Mechanical factors: Removal of fluid from the lungs with the
subsequent replacement of air constitutes the primary mechanical
factors involved in the initiation of respirations.
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Several factors may interfere with the neonate’s ability to initiate
respirations (prematurity, birth asphyxia can be due to birth trauma,
maternal medications, and the mode of delivery) can interfere with
normal pulmonary transition.
Neonates less that 36 weeks gestation are subject to RDS.
Normal respiration :
- Irregular in depth, rate and rhythm.
- 40 - 60 breath \ minute
- Affected by such things like crying.
- Accomplished mainaly by the diaphragm and abdominal
muscles.
- Dyspnea or cyanosis may indicate anomaly or pathology.
The breathing pattern may include brief pauses that last 5 to 15
seconds. Termed periodic breathing, this pattern is usually not
associated with any change in skin color or heart rate and it has no
prognostic significance.
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Circulatory Changes:
 Anatomic changes :
- Umbilical arteries and vein contract and close.
- Ductus arteriosus close within 24 hours.
- Ductus arteriosus and ductus venosus are converted to fibrous
tissue
(ligaments ) within 2 - 3 months.
- When the pressure in the left atrium exceeds than that of right
atrium
Formen Ovale closes.
 Blood Volume for full term neonate: 80 - 90 ml \ kg at birth.
Holding the neonate below the level of the placenta and delaying the
clamping of the cord may allow up to a 100 mL/kg increase in the
neonate’s total blood volume. The increase in blood volume may
facilitate an improved transition due to enhanced pulmonary
perfusion and the gain of additional iron stores. A disadvantage of
this practice concerns the increased risk of jaundice due to the higher
volume of erythrocytes and possible resultant polycythemia.
 Peripheral Circulation: residual cyanosis in hands and feet.
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 Pulse Rate: 120 - 160 beat \ minute, apical rate is more accurate.
 Blood Pressure: 70\40 mmhg at birth, 100\50 mmhg by the 10th
day.
 Blood Elements : (Hb 16 - 22 gm/ Hb consists of fetal Hb and Adult
Hb. Fetal Hb has more affinity to oxygen than adult Hb), (average
leukocytes18,000 but range from 9,000- 30,000\ ml)
 Neonate’s RBC is higher than the adults but have a shorter lifespan
(60-70 days in full term) which leads later on for physiological
anemia (persist for 2-3 months)
 Blood Coagulation :
- Coagulability is temporarily diminished because of lack of
bacteria in the intestinal tract that contribute to the synthesis of
vitamin K.
- Coagulation time 3 – 4 minutes.
- Bleeding time 2 - 4 minutes.
- Prothrombin 50% decreasing to 20% - 30%.
Temperature Regulation:
At birth temperature is as mother’s temperature. The newborn has poor
ability to regulate his body temperature because of:
- He has little fat insulation.
- He has large body surface (but their normal position of flexion
facilitates maintenance of body heat).
- He has a relatively poor circulation.
- He doesn’t yet sweat or shiver.
When the infant is exposed to a cold environment, several
physiological adaptations help him to increase heat production.
These include increasing the basal metabolic rate and muscle activity
to generate heat, peripheral vasoconstriction to conserve heat, and
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nonshivering (or chemical) thermogenesis (NST) (heat production).
Unlike children and adults, newborns are unable to shiver to
generate heat.
Basal Metabolism:
- Surface area of the infant is large in comparison with body
surface.
- Basal metabolism per kg of body is higher than that of adult.
- Caloric requirements are high (117 calorise \ kg day).
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Renal Funcion:
- At birth the kidney’s function 30 % - 50% of the adult’s
capacity and are not yet mature enough to concentrate urine. With
a low GFR, the newborn’s kidneys are unable to dispose of fluid
rapidly and tend to reabsorb excess sodium.
Term newborns are unable to adequately concentrate urine
(reabsorb water back into the blood). This alteration may lead to
an inappropriate loss of substances such as amino acids and
glucose.
- Neonate usually voids immediately after birth or within few
hours, but it may take up to 24 hours.
- Anuria should be reported.
- Increase uric acid will stain in the diaper.
- Not functioning well yet in maintaining acid-base balance.
- GFR rapidly increases during the first 4 months, but reaches
adult’s function after 2 years.
Hepatic Function :
- Limited because of decrease of GIT activity and decrease blood
supply.
- Decrease ability to conjugate bilirubin will lead to jaundice.
This condition occurs in approximately 60% of full-term infants
and in up to 80% of preterm infants (becomes visible when the
total serum bilirubin level is greater than 5 mg to 7 mg/dL)
Physiologic jaundice may start 1-2 days after birth, peak at 5-7
days, & decline after 10-14 days.
Elevated blood levels of unconjugated bilirubin can be toxic and
result in kernicterus, a life-threatening condition caused by the
deposition of unconjugated bilirubin in the brain and spinal cord.
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- Decrease ability to regulate glucose will lead to hypoglycemia
(90% of the stored glycogen is converted to glucose in the first 3
hours). The serum blood glucose level drops during the first 3
hours of life and then gradually rises over the next 3 to 4 hours to
reach a steady state of 40 to 80 mg/dL.
The blood glucose of a term infant should be 70% to 80% of the
maternal blood glucose level.
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- Decrease production of prothrombin will lead to hemorrhage.
- Adequate maternal iron intake during pregnancy ensures that a
sufficient amount of iron is available in the infant to last up to 6
months of age. Beginning at 6 months, all infants should receive
iron supplements or iron-rich foods to prevent anemia
Endocrine Function:
Disturbances are most often realated to maternally provided hormones
which can cause the following:
- Vaginal discharage \ bleeding in famale infant.
- Enlargement of mammary glands in both sexes.
- Disturbance related to maternal endocrine pathology ( D. M )
GI system:
The neonate’s stomach capacity is approximately 6 mL/kg at birth
and by the end of the first week of life, the capacity has increased to
hold approximately 90 mL.
A decrease of pancreatic amylase makes it difficult for infants to
digest fats efficiently. Newborns also have a decreased production of
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pancreatic lipase and bile acids, which further limits their ability to
absorb fats.
No salivation for the first 3 months.
Cardiac sphincter is immature (leads to regurgitation)
Compared to size, small intestines are long which increase rate of
absorption.
Infants born at term generally pass their first meconium stool within
8 to 24 hours of life.
Absence of passage of a bowel movement by 72 hours of age may be
indicative of an obstructive bowel problem.
Immunological Adaptation
 IgG is the only immunoglobulin able to pass through the placenta
before birth. Placental transfer of IgG occurs primarily during the
third trimester. At birth, full-term infants have already acquired
immunity to tetanus, diphtheria, smallpox, measles, mumps,
poliomyelitis, and a host of other bacterial and viral diseases.
Preterm infants born before 34 weeks of gestation are at a greater
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risk for infection. Passive acquired immunity typically disappears
by 6 months of age.
 Colostrum and breast milk are important sources of IgA (which is
important in protecting the infant against gastrointestinal and
respiratory infections.
Physical Findings:
 Posture:
- Full term newborn assumes symmetric posture, face turned to
side, flexed extrermities, hands tightly fisted with thumb covered
by fingers.
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- Asymmetric posture may be caused by fracture of clavicle or
humerus or never injury.
Figure The full-term infant assumes a flexed position.
●
Length: 45 - 55 cm
 Birth weight: On average, a term newborn infant weighs 3400
grams, with a normal range of 2500 to 4300
 Skin:
- Hair distribution, lango hair over the back.
-
Color : ( cyanosis - acrocyanosis), (pallor - cold, anemia or
heartfailure), ( jaundice - physiologic )
- Turgor: full term should have good skin turgor.
- Dryness feeling: sign of post term.
- Vernix: in skin folds. (vernix caseosa, a whitish, cheesy
substance, present between skin folds)
- Milia: enlarged sebaceous glands on face, decreased by 2 weeks.
(small white papules or sebaceous cysts on the infant’s face that
resemble pimples)
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Mangolian spots: blue pigmentation on lower back, decreased by 4
years. (are areas that appear gray, dark blue, or purple and are most
commonly located on the back and buttocks, although they may
also be found on the shoulders, wrists, forearms, and ankles)
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- Petechiae: pinpoint hemorrhage, decreased within 24 - 48 hours.
- Edema: around eyes, face, legs, scrotum, labia and hands.
 Head :
- Caput succedaneum: swelling of soft tissue of the scalp.
- Cephalhematoma: subperiosteal hemorrhage.
- Molding: overlapping of skull bones.
- Examine symmetry of facial movement.
- Head circumference: 33 - 38 cm (2 cm larger than chest).
- Fontanels: (enlarged = increased intracranial pressure), (sunken =
dehydration).
- Size of fontanels : (posterior 2 – 3 months \ molding ), (
anterior 12- 18 months ).
 Face :
- Eyes: color, hemorrhage, lid edema, conjunctivitis, jaundice,
pupils.
-
Nose: patency and discharge (nasal breathing)
-
Ears : hearing, position, cartilage.
- Mouth: size, palate, size of the tongue, teeth, epestinpearls (white
nodules ), frenulum linguae, oral thrust.
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 Neck :
Mobility, lymph nodes, fractures.
- Skin folds: increased in trisomy 21.
- Stiffness: trauma or infection.
●
Chest :
-
Circumference : 30 - 33 cm.
- Breast enlargment.
● Abdomen :
- Protrudes slightly, moves with chest in respiration.
- Examine umbilical cord for number of vessels, signs of infection,
umbilical hernia, usually falls within 7 - 10 days.
 Genitalia:
- Female genitalia: vaginal discharge, labia majora cover labia
minora.
- Male genitalia: testes in scrotal sac, examine glans penis for
urethral open
(Open ventrally = hypospadias), ( open dorsally = epispadias)
 Back :
- Spinal column for normal curvature and closure.
- Anal area.
 Muscloskletal:
- Extremities for fractures.
- Fingers and toes for number (if extra digit: polydactyly) (if fused
digit: syndactyly).
- Hips for dislocation: clicking sounds.
Neurologic: muscle tone, head control and reflexes.
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Nursing Care of Newborn
In some hospitals the newborn infant is transferred from delivery room to
traansitional nursery for intensive observation. When stabilized, the infant
is admitted to a regular nursery or mother’s room. Infants designated as
high risk are admitted to an ICU. The immediate care of the newborn
infant after arrived in the nursery room:
1. Cleansing and assessment:
- Baby’s hair is frequently matted with dried blood; the body may
have areas with a heavy deposits of vernix caseosa.
- Just remove the excess of vernix and sponge away the dried
blood.
-
This called dry-skin care to reduce heat loss and potential
damage to delicate skin.
- General assessment beside axillary temperaure, respiration and
pulse are measured at this time.
- Prevent undue exposure, provide warn enviroment.
2. Weighing and measuring:
- The newborn is weighed after arrival to nursery.
- The scales are balanced with a protective paper on which the
naked infant is placed.
- Great care is taken to protect the infant from falling off the scales.
- Accuracy is vital, since it is a part of the baseline data.
- 5% - 10% weight loss is normal.
- After 3 – 5 days the baby begins to gain weight and reach their
birth weight after 2 weeks.
- Measurement of the head and chest cirumferences and length.
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3. Estimation gestational age:
- Ability to survive is affected by the maturity of the infant.
- Accurate assessment of gestational age is vital to effective care
planning.
- Ggestational age is determined by standarized measuremeants of
physical growth as: (preterm, term, post term), (SGA, AGA,
LGA).
The Ballard Gestational Age by Maturity Rating tool includes a
neuromuscular maturity and a physical maturity component
4. Cord care:
- About 2 inches (5cm) of umbilical cord usually is extending from
the abdomen with some type of clamp....
- In few days (7 - 10 days) the cord shrinks and falls off.
- Observe for signs of hemohrrge, other clamp may be used.
- Protect from infection.
- As a precaution against such an infection, the area around the
umbilicus stump is scrubbed and 70% alcohol may be applied.
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5. Clothing and cover:
- It is not desirable to constrict their movement with heavy clothes
or blankets.
6. Positioning and enviroment ;
- The baby is placed in a preheated incubator usually on the side
with head slightly lower than the rest of the body; this help drains
any remaining amniotic fluid or mucus from the stomach and
nasophrynx.
- Provide warm enviroment 24 – 27C◦.
- Never leave the infant alone.
- Extra oxygen is not administered unless indicated because
retrolental fibroplasia, a condition producing blindness, may
result from excessively high oxygen concentration.
7. Recording and identifying:
- All the observations, measurements and care given to the
newborn should be carefully recorded on the chart.
- It is important to label the incubator with a clearly marked card
having the mother’s name, room number, baby’s sex, birth time
and date and the physician’s name.
- It is customary to give the card to the mother when she takes her
baby home.
8. Feeding and rest:
- After birth the primary need is for rest, so infant is kept NPO for
4 – 6 hours.
- Test blood glucose, infant may be hypoglaycemic and require
feeding sooner than usual.
9. Discharge planning:
- The nurse takes the baby to the mother’s bedside.
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- The mother watches the nurse – cut off the baby’s ID. band and
together they check the number against the mother’s band.
- Give instructions about :
● Cord care.
● Follow up.
● Bathing, diapering.
● Breast and formula feeding.
● Measuring body temperature.
● Recogizing reportable signs and symptoms " pallor,
cyanosis, vomiting, diarrhea, abdominal respiration, fever,
hypothermia….".
- Encourage the parents to ask questions and participate in
discussion.
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Complications of pregnancy
Pregnancy is a normal function of the body, not a disease. Several factors
can complicate pregnancy. However including preexisting conditions
and those that develop during pregnancy. Pregnancy (s) that threaten the
health of the fetus or the mother need special care (before, during and
after delivery).
High Risk pregnancies :
□
Complications of previous pregnancies:
-
Prolonged labor.
- Cesarean birth
-
Bleeding
- Abnormal fetal position.
□
Anatomical abnormalities:
-
Small pelvis.
□
Metabolic and endocrinological disorders:
-
Diabetes.
□
Cardiovascular disorders:
-
Hypertension
□
Kidney disorders:
-
Acute pyelonephritis.
□
Hemoatological disorders:
-
Anemia.
□
other factors :
-
Age: under 16 or over 35 years.
-
Weight: less than 45 kg or over 90 kg.
-
Syphilis.
-
Tuberculosis.
-
Smoking.
-
Drug addiction.
-PIH
- Incompetent cervix.
- Thyroid disorders.
- Congenital heart disease.
- Acute cystitis.
- Sickle cell anemia.
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Preexisting medical conditions
Diabetes mellitus
Diabetes is an endocrine disorder characterized by high blood levels of
glucose in the urine. diabetes results from inadequate production or use of
insulin. Pregnancy imposes an additional physiological stress on a
diabetic woman. Successful delivery of a healthy infant requires much
teaching, support, adherence to dietary control and work of the entire
health care team.
Effects of pregnancy on diabetes:
1. Pregnancy is an insulin-resistant state.
2. Placental hormones (HPL[Human placental lactogen]) , Placental
insulinase) have anti-insulin effect result in increasing the
incidence of ketoacidosis {Spare glucose for fetal use while
mobilizing lipids for maternal energy use}.
3. Increase peripheral resistance to insulin.
4. Nausea and vomiting of pregnancy may further compound the
problem of blood glucose regulation.
5. Insulin dose increases (except in first trimester).
6. Oral hypoglycemic must not be used.
7. During labor and early postpartum period, insulin should be
stopped since HPL is decreased.
8. Glucosuria is common during pregnancy because of decreased
renal threshold or nephropathy.
Effects of Diabetes on Pregnancy:
1. Gestational diabetes: " 90% of all diabetics seen by obstetrician ".
2. Insulin-dependent Diabetes.
 Maternal problems:
1. Hypoglycemia: usually occurs in the first half of pregnancy
and needs to adjust insulin dose based on caloric intake.
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2. hyperglycemia : Tends to occur in second half of pregnancy.
3. Urinary tract and other infections:
- pregnancy predisposes to urinary tract colonization.
- Obtain urine cultures at first visit and at 32 weeks or if
symptoms develop.
4. Hypertension : diabetic woman are at higher risk for
hypertensive disorders of pregnancy.
5. Hydramnios: May occur in 10-20% of diabetic pregnancies
probably result of fetal polyuria resulting from fetal
glucosuria.
6. Retinopathy.
7. Postpartum hemorrhage.
 Infant problems:
1. Abortion: Frequency increased in patients with poor control.
2. Congenital anomalies: Threefold increase overall in anomaly rate.
3. Neonatal hypoglycemia: Monitor infant closely after delivery.
4. Macrosomia: usually defined as infants greater than 4000 or
4500g. High incidence of birth trauma.
5. Perinatal mortality.
6. Hypocalcemia.
7. Hyperbillirubinemia.
8. Respiratory distress.
Assessment:
 History:
- Family history.
- Obstetric history of preeolmpsia , abortion , congenital
anomalies or birth of over 4 kg babies.
 Screening for Diabetes during Pregnancy:
- High –risk patient: screen at the first visit.
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- All mothers: screen by end of second trimester (26 weeks).
 Screening Examination:
- 50g oral glucose load, plasma glucose checked 1 hour later.
- Less than 140mg/dl →normal.
- Greater than 140mg/dl → perform oral glucose tolerance test
(GTT).
- Greater than 200mg/dl → probably doesn't need GTT →
(positive).
 Glucose Tolerance Test:
- Begins after 3 days of good diet. (250 calories of
carbohydrate daily).
- Fast for 10 hours prior to test is ingested.
- 100 g oral glucose solution.
- Perform blood level tests at fasting, 1, 2 and 3 hours after
drinking solutions.
 Follow-up:
- Two or more abnormal values, define gestational diabetes.
- One abnormal value, repeat GTT in one month.
 Pregnancy Oral Glucose Tolerance Test by using a 100 gm
load:
Upper limits for Normal Glucose Levels (mg/dl)
Sample Fasting
1h
2h
3h
Blood
90
165
145
125
Plasma
105
190
165
145
- Assess the woman's ability to monitor blood sugar levels,
insulin regulation throughout pregnancy.
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- Urine test for glucosuria.
- Assess the woman's understanding of diabetes and changes
that may occur during pregnancy.
- Assess the woman's support system.
Interventions:
Diabetic woman needs continuous medical and nursing supervision
during pregnancy, therefore prenatal visits are scheduled every 1-2 weeks
for the first 32 weeks, then weekly until delivery.
 interventions are based on Identifying Problems as follow:
1. Dietary Regulation Need:
- Recommended diet is 35 calories/ kg of ideal body weight.
- 250 g of carbohydrates, 125 g protein , 60-80 g fat.
- Mother should not gain more than 1.3-1.6 kg /month.
2. Insulin Need:
- Insulin dosage is based on blood and urine glucose levels.
- Oral hypoglycemics are not used because they are fetotoxic
(teratogenic) and don't provide adequate control.
- Mothers need to learn how to test for glucose and administer
correct amount of insulin.
- They need to know the symptoms of hypoglycemia and
hyperglycemia and appropriate emergency management of
each.
3. Preeclampsia potential:
- there is a potential susceptibility to PIH.
- Monitor blood pressure frequently.
- If signs of PIH appear, treatment is begun at once.
4. Infection potential:
- vaginitis and UTI are common.
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- If symptoms appear , diagnosis and medical treatment are
begun at once.
5. Inadequate rest: Mothers need to lie down and rest frequently during
the day.
6. Hydramnios:
- Size of mother's uterus and signs of respiratory distress are
evaluated.
- Sometimes amniotony may be performed to remove
excessive fluid.
7. Labor Induction:
- At about 37 weeks if fetal lungs have mature enough , labor
may be induced . Blood glucose levels and fetal conditions
are monitored closely.
- To evaluate the fetal status , observe how FHR varies in
relation to fetal movement . Variations are limited in
prematurity or sedative taking but variations increase with
mature autonomic nervous system. Observation for 30
minutes by continuous F.H.M. after ingestion of 30 g
glucose.
8. Postpartum Considerations:
- The mother's insulin need is monitored closely.
- She is watched carefully for signs of hemorrhage caused by
uterine relaxation, which often follows hydramnios.
- If the infant was placed in a special care unit, efforts are
made to assist the parents with infant bonding.
- Postpartum Family Planning:
Usually recommend barrier contraception, IUD may also be a
good choice in selected patients. Low-dose oral contraception
pills may be used.
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Heart Disease
Every pregnancy places extra demands on the cardiovascular system
especially on the heart. Blood volume and cardiac output are increased
40%-45% and the rate is accelerated. The normal heart is well able to
compensate for the added work but the damaged or diseased one may
not.
The signs of Cardiac Decompensation are:
- Increasing fatigue and breathlessness with usual exertion.
- Episodes of murmures, palpitation and tachycardia.
- Hemoptysis.
- Progressive generalized edema.
Incidence:
o 0.5%-2% of pregnant woman.
o 4.5% these with rheumatic heart disease.
o 3% of these with congenital heart disease.
Classification:
Woman with heart disease are classified into 4 groups according to the
level of activity tolerated without symptoms. Medical and nursing care is
adjusted accordingly.
Class 1
No limitation of physical activity, no symptoms of cardiac insufficiency
or anginal pain with ordinary physical activity.
Class 2
Slight limitation of physical activity, comfortable at rest, excessive
fatigue, palpitation, dyspnea or anginal pain with heavy physical activity.
Class 3
Marked limitation of physical activity, comfortable at rest, excessive
fatigue, palpitation, dyspnea or anginal pain with less than ordinary
physical activity.
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Class 4
Inability to perform any physical activity without discomfort, cardiac
insufficiency signs possible at rest, discomfort increased with physical
activity.
Patients classified as NYHA I and II generally do well during pregnancy,
but those classified as III or IV have a significantly increased risk of
morbidity and mortality with pregnancy.
Effects of pregnancy on heart disease:
1. Increase volume of circulation 40-45%.
2. Increase cardiac output.
3. Increase body weight (edema).
4. Increase coagulation tendency.
5. Salt and water retention.
Effects of heart disease on pregnancy:
1. Prematurity.
2. IUGR.
3. Placental insufficiency.
4. Intrauterine fetal death.
Assessment:
- History.
- Cardiac status of women should be evaluated very early in
pregnancy if not before {chest X-ray, ECG}.
- Cardiac status and functional capacity are monitored carefully
throughout pregnancy.
- Monitor for signs of cardiac decompensation {cyanosis, dyspnea,
tachycardia, edema, hemoptysis, and cough…}.
Nursing diagnosis:
- Potential for fetal distress related to uteroplacental
insufficiency.
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- Potential for infection "endocarditis".
- Alteration of fluid volume "excess" related to hypervolemia.
- Alteration of comfort level.
- Fear and anxiety.
- Knowledge deficit.
Interventions:
1. Rest is most important; 10 hours sleep per night and rest
throughout the day.
2. Physical exertion is to be avoided since it is an important cause of
heart failure.
3. Emotional as well as physical stress is to be avoided.
4. Infection must be avoided and if contracted treat immediately.
5. A well balanced diet, high in protein, iron, vitamins and minerals is
recommended to prevent anemia.
6. Hospitalization prior to delivery is usual for women with classes 1
or 2 cardiac disease to evaluate cardiac status before labor; women
in class 3 are hospitalized somewhat earlier.
7. Any woman showing signs of cardiac failure during pregnancy is
hospitalized and may remain hospitalized for the duration of
pregnancy.
8. For classes 3 and 4 therapeutic abortion may be indicated,
sterilization surgery may be recommended for those who attempt
pregnancy of the 4th class, absolute bed rest, hospitalization and
intensive care are necessary.
9. During labor and delivery:
- The woman`s vital signs and fetal heart tones are monitored
continuously, don`t leave the woman alone and decrease anxiety.
- The woman may receive oxygen during the course of labor.
- Regional anesthesia may be used to reduce pain.
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- To avoid having the mother push, forceps delivery may be used.
o Cesarean delivery is avoided because of (grater blood loss, risk
of infection, risk of thromboemboism ).
- Second stage of labor is shortened to reduce stress on the
mother`s heart as much as possible.
10.During postpartum:
- Monitor carefully for postpartum hemorrhage, infection or
thromboemboism.
- Restrict visitors; promote rest and gradual resumption of
activities.
- Ambulate to avoid thromboemboism.
- Prophylactic antibiotic may be used to avoid infection.
- Methergin and estrogen are contraindicated because they increase
fluid retention and blood clotting.
- Diluted oxytocin may be administered continuously to shorten
second stage of labor and control postpartum bleeding.
- Stool softeners to prevent straining.
- Careful monitoring of vital signs.
- Preparation for discharge planning (care of the baby, bed rest,
medications, future pregnancy and contraception).
Note:
- If there is a need for anticoagulant, heparin is used, oral anticoagulants
are contraindicated.
- Breast-feeding is too strenuous and not recommended for class 3 & 4.
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Medical conditions associated with pregnancy
Anemia in pregnancy
Normal hematological events associated with pregnancy:
- During pregnancy there is an increase of 40 up to 45% in the blood
volume , the maximum is reached at 34 weeks gestation.
- The plasma volume increases 47-50% and the RBCs mass increases
only 17% and reaches its maximum at term.
- There is relative hemodilution throughout pregnancy, and this reaches
its maximum at 28-34 weeks.
- This dilution effect lowers the Hb, HCT and RBCs count; it causes no
change in the mean corpuscular volume (MCV) {the average red
blood cell volume that is reported as part of a standard complete blood
count} or in the mean Corpuscular Hb concentration (MCH).
Definition:
- Hb value below the lower limits of normal not explained by the state
of hydration.
- Anemia during pregnancy 11 or 10.5 g/dl . Anemia is defined as a
reduction in the total circulating red blood cell mass.
- 20-60% of prenatal patients will be found to be anemic at sometimes
during pregnancy.
Causes of anemia during pregnancy:
1. Acquired:
- Iron deficiency anemia.
- Anemia caused by acute blood loss.
- Anemia of inflammation or malignancy.
- Megaloblastic anemia.
- Acquired hemolytic anemia.
- Aplastic or hypoplastic anemia.
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Hereditary:
- Thalassemia.
- Sickle-cell hemoglobinopathies.
- Other hemoglobinopathies.
- Hereditary hemolytic anemia.
Red blood cell disorder during pregnancy:
1. Decreased erythrocyte production:
- Iron deficiency.
- Thalassemia.
- Chronic disease.
- Bone marrow failure.
- Folate deficiency.
- Malignancy.
- Inflammatory process.
- Vitamin B12 deficiency.
2. Increased erythrocyte loss:
– Parasites.
- Hemorrhage.
3. Increased erythrocyte destruction:
- Hemoglobinopathies.
- Hemolytic anemia.
- Chemical toxicity.
Clinical presentation:
Symptoms caused by anemia are those resulting from:
1. Tissue hypoxia: fatigue, lightheadness , weakness , pallor and
exertional dyspnea.
2. Cardiovascular system attempts to compensate for the anemia:
palpitation and tachycardia (hyperdynamic circulation).
3. An underlying disease:
- Chronic infection.
- Chronic liver disease.
- Chronic renal disease.
- Multiple pregnancies.
Note:
In obstetric patients anemia is discovered because CBC is obtained as
part of laboratory evaluation at the initial prenatal visit or at repeat
screening at 28-32 weeks.
Severe anemia is associated with:
o Congestive heart failure.
185
o Multi-organ failure.
o Tissue hypoxia.
Iron Deficiency Anemia
Is a hypochromic microcytic anemia that occurs when iron stores are
inadequate to support normal erythropoiesis.
WHO standard: anemia during pregnancy is defined as Hb < 11g/dl.
It is the most common nutritional anemia worldwide and accounts for
75% of all anemia diagnosed during pregnancy.
Almost all pregnancies are associated with some degree of iron depletion.
If iron depletion becomes severe; iron deficiency anemia occurs.
The major reason for poor iron stores is thought to be menstrual loss.
Pregnancy places large demands on iron balance and can`t be met with
usual diet. In absence of iron supplementation, iron deficiency develops.
High-risk Populations for Iron-Deficiency Anemia:
- Low socioeconomic status.
- Limited education.
- Women with a history of menorrhagia.
- Diet deficient in meat and ascorbic acid.
- Regular use of aspirin.
- Adolescent pregnancy.
- Multiple pregnancies.
- Successive pregnancies (less than 2 years a part).
Factors affecting Iron absorption:
1. Iron content of the meal.
2. The chemical form of iron (iron is absorbed in the ferrous state in the
duodenum and proximal small intestine).
3. The iron status of the individual.
4. Composition of ingested food.
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Effects of pregnancy on Iron Metabolism:
- Iron requirements increase throughout pregnancy.
- During the first half of pregnancy, iron requirements are minimally
elevated. During the last 20 weeks, requirements increase
dramatically.
On average 2.5 mg of iron are required to meet these demands per day. In
the third trimester the requirements may rise to as much as 7.5 mg per
day and dietary iron absorption increases each trimester to meet these
increased requirements. During the first trimester, approx 10% of the
dietary iron is absorbed; this increases to 25-30% in the second and in the
third trimester.
- Pregnancy complications such as hypermesis will compromise the
availability of iron absorption.
Effects of Iron Deficiency Anemia on Pregnancy:
1. Maternal effects:
- Symptoms associated with iron deficiency anemia include fatigue,
irritability, palpitations, dizziness, headaches, breathlessness, glossitis
and stomaitis.
- In severe cases, high output congestive heart failure.
- Pica: the ingestion of various substances that have no dietary value is
a striking manifestation of iron deficiency. { Pagophagia (ice),
geophagia (clay) and amyophagia ( starch) } are common examples of
pica. Pica is noted in over 50% of patients diagnosed with iron
deficiency anemia, mostly occur after 20 weeks of gestation.
- Maternal anemia has been associated with placental gigantism.
2. Fetal and neonatal effects:
- Controversy exists.
187
- An increase in the frequency of preterm delivery, low birth weight
infants and stillbirth. The outcome is related to the gestational age
when maternal iron deficiency is diagnosed.
- The fetus stores enough iron to meet requirements for 3-6 months after
birth.
Megaloblastic Anemia
Is the second most common nutritional anemia seen during pregnancy
Folate deficiency is the cause but a deficiency in vitamin B12 must be
considered.
Folate:
Folic acid, a water-soluble vitamin is widely available in diet. Folate is
absorbed in the proximal jejunum. Pancreatic conjugates reduce folate to
monoglutamate before its absorption. Conjugate activity is reduced by:
1. Anticonvulsants
2. Alcohol
3. Oral contraceptives
4. Sulfa drugs
Because adequate folate intake before and during the first weeks of
pregnancy may reduce the occurrence of neural tube defects, all women
considering to become pregnant should consume 400 mcg/day of folate.
Vitamin B12:
Abundantly available in the diet bond to animal proteins. Its absorption
requires HCL and pepsin to free the cobalamin molecule from protein.
Most of the vitamin B12 is stored in the liver and most people have a 2-3
years store available.
Diagnosis of Anemia:
- Anemia is not a diagnosis, but rather a sign as fever.
- Is the patient anemic?
- What is the morphology of the anemia? CBC and reticulocyte is
helpful.
- What is the mechanism of anemia?
188
- Is there an underlying disease?
- History.
- Family history.
- History of tonics.
- History of GI bleeding and melena.
- Exposure to oxidant drugs ( Risk of G6PD) e.g. sulfonamides, PASA.
- Peripheral blood smear.
- Serum iron value (less than 30 mcg/dl indicates IDA).
- The gold standard to determine iron stores is a bone marrow biopsy,
which is rarely indicated in pregnancy patients.
Treatment:
o Preventable by routine use of iron supplementation. When not given
supplemental iron, 80% of normal pregnant women will have Hb
value less than 11 g /dl at term.
o Correct the underlying cause.
Nursing intervention:
o To improve Nutritional status:
1. Provide a well-balanced diet high in iron.
2. Administer iron supplementation if prescribed.
3. With iron supplementation, increase intake of foods high in fiber and
fluids to prevent constipation. Increase intake of foods high in vitamin
C to enhance iron absorption.
4. For folic acid deficiency anemia, provide folic acid supplement and
diet high in animal protein and green leafy vegetables.
5. In severe anemia, IM iron or transfusion of packed RBCs may be
necessary.
o To improve Fetal Nutrition and Oxygenation:
1. Provide diet rich with vitamin and mineral supplementation.
2. Oxygenation to fetus can be improved by:
a. Improving maternal Hb level.
189
b. Avoidance of maternal infection, which increases BMR and
oxygen consumption.
190
Hyperemesis Gravidarum
Is exaggerated nausea and vomiting during pregnancy, persisting past the
1st trimester.
About 70-85% of all women experience a mild form of nausea in early
pregnancy called morning sickness usually disappear by about 12th week,
however vomiting persist causing serious dehydration and starvation.
Such a condition is called hyperemesis gravidarum which means
"excessive vomiting of pregnancy".
Causes:
1. Hormonal changes of pregnancy: increase hCG hormone level.
2. Emotional factors, insecurity, anxiety.
Risk Factors
 increased placental mass associated with multiple gestation
 a history of hyperemesis gravidarum in a previous pregnancy, and
a history of motion sickness or migraine headaches.
 Daughters and sisters of women who experienced hyperemesis
gravidarum
 women who are pregnant with a female child
Incidence: 3.5 in 1000 pregnancies.
Clinical manifestations:
- Begin with morning sickness and become increasingly severe.
- Frequent vomiting when mention, sight or smell food.
- Loss of weight (5% of the pre-pregnancy weight).
- Dehydration.
- Tachycardia.
- Thirst.
- Scanty concentrated urine.
- Jaundice caused by liver damage.
- Blindness caused by retinal hemorrhage.
191
- Convulsions.
- Death.
Note:
If the fetus dies and is expelled, nausea usually stops immediately but
damage to major organs of the mother may be permanent.
Nursing diagnosis:
- Alteration in comfort level…
- Impaired skin integrity…
- Alteration in nutritional status…
- Fluid volume deficit…
- Knowledge deficit…
- Potential for complication…
Nursing interventions:
- Treatment of hyperemesis gravidarum should begin before damage
occurs.
- Maintaining fluid and Electrolyte Balance:
1. If vomiting is severe, the woman is hospitalized and oral intake is
restricted for 24-48 hours. I.V. fluids are administered.
2. Oral liquid intake is resumed slowly, usually high in carbohydrate of
the type preferred by the woman.
3. Vitamin B complex to combat nausea.
4. Sedative and antiemetic as prescribed.
- Improve Nutritional Status:
1. Offer small and frequent meals, high in carbohydrates.
2. Avoid strong food odors.
3. Avoid greasy foods.
4. Give vitamin supplementation as prescribed.
- Developing Coping Abilities:
1. Have the woman discuss her perception of the problem.
192
2. Discuss possible resolutions to problems identified.
3. Hospitalization usually removes the woman from pressure.
4. Restriction of visitors usually relieves stress.
193
Hypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension (PIH):
The term Preeclampsia has replaced the term Toxemia. The hypertensive
disorders complicate 5% -10 of all pregnancies (the second leading cause
of maternal death in the United States). Delay of diagnosis and
uncertainty of treatment can lead to significant maternal and fetal
morbidity and mortality.
Hypertension:
Defined as blood pressure of at least 140/90 mmHg or a rise of 30 mmHg
diastolic. Blood pressure usually falls during second trimester.
Pregnancy induced Hypertension. (PIH) has two stages; Preeclampsia
and Eclampsia. In Preeclampsia hypertension, proteinuria and excessive
fluid retention develop with resultant edema and weight gain. Symptoms
may be mild or severe. In Eclampsia, convulsive seizures and coma
develop.
The only cure for PIH is termination of pregnancy.
Etiology:
1. Unknown: described in 1916 as “a disease of theories" and still true
today.
2. Theories include:
a) Uterine ischemia.
b) Autoimmune disease.
c) Deficiency of dietary protein.
d) Organism called "hydatoxi Lualba".
Risk Factors:
- Primigravida.
- Family history of Preeclampsia or Eclampsia.
- Obesity - Diabetes mellitus.
- Multiple gestations.
- Preexisting hypertensive vascular, autoimmune or renal disease.
- Extremes of maternal age (younger than 20 or older than 35 years).
194
- Hydatiform mole.
- Rh incompatibility
The incidence:
- PIH develops in the last 10 weeks of gestation, during labor or in the
first 12-48 hours after delivery.
- It occurs in 5% of all pregnancies.
- Adolescents, younger primiparas and low income women have 10%30% risk.
- Women who have had PIH or those who have chronic hypertension
have a chance of 25%-35%.
- In those who develop Preeclampsia, 5% go on to develop Eclampsia.
- Fetal death with Preeclampsia is about 10% and with Eclampsia 20%.
Preeclampsia
Preeclampsia is a pregnancy-specific systemic syndrome clinically
defined as an increase in blood pressure (140/90) after 20 weeks’
gestation accompanied by proteinuria.
Syndrome of pregnancy-induced hypertension accompanied by
proteinuria, edema and frequently other organ system disturbances.
Mild Preeclampsia
Is characterized by:
1. Hypertension: a rise of 30 mmHg systolic and 15 mmHg diastolic,
blood pressure : 140/90 mmHg.
2. Proteinuria: of +2 or 1 g/L.
3. Edema: generalized, facial, hands and fingers reflecting weight gain of
over than 0,7 kg/week.
Assessment:
- It is essential of prenatal assessment of all women is to establish a
baseline blood pressure.
195
- In each prenatal visit, blood pressure and other signs of hypertension
are assessed.
- Assessment includes urine testing for proteinuria.
- Weighting on the same scale.
- Assessing for edema, headache, epigastric pain…
- Assessment of fetal movement, non stress test and U/S.
Management:
- Initial management consists of rest and observation if patient is not a
candidate for delivery. Bed rest maximizes uteroplacental flow.
- Delivery should be accomplished by 38th week or sooner if the fetus is
mature.
Nursing intervention:
1. Diet: increase protein diet with moderate sodium intake.
2. Rest and activity: resting on the left lateral recumbent position is
beneficial by increasing renal blood flow, glomerular filtration rate
and placental perfusion. Complete bed rest may not be necessary,
reduced activity is beneficial.
3. Medical supervision: office visits are scheduled every 2 weeks or less
depending on the symptoms for assessment of signs of Preeclampsia.
4. Danger signs: mothers are instructed to report any sudden change in
their condition such as generalized edema, headache, fever, muscle
tremors or seizures and sudden increase of body weight.
196
197
Severe Preeclampsia
Criteria for severe Preeclamosia:
- Blood pressure: consistently > (160 mmHg systolic) or > (110 mmHg diastolic).
- New onset of proteinuria > (2 g in 24 hours urine collection) or > (3 g in a
randomly collected specimen).
- Oliguris: (less than 400 ml/ 24 hours) or increasing serum creatinine levels.
- Edema: generalized, weight gain of 0,9 kg over a period of one week or less.
- Platelet count: less than 100,000; hemolytic anemia and increase in lactic acid
dehydrogenase (LDH) and direct bilirubin levels.
- Headache, visual disturbances or other cerebral signs.
- Epigastric or right upper quadrant pain.
- Cardiac decompensation, pulmonary edema or cyanosis.
- Fetal growth retardation: due to reduction of intervillous perfusion.
Note: { HELLP variant (syndrome)}.
- Hemolysis (H): due to hypofibrogenemia.
- Elevated liver enzymes (EL).
- Low Platelet Count (LP).
Assessment:
1. Hospitalization is necessary.
2. The goal of care is to prevent seizures, lowering blood pressure, establishing an
adequate renal function and to continue the pregnancy until fetal maturity.
3. If the pregnancy is at the 34th week or more, labor is induced or cesarean birth is
performed.
4. Serial examinations recommended for Preeclamptic hospitalized patients
include:
 Mother:
- Blood pressure: four times daily.
198
- Assessment for proteinuria, edema, weight, hyperreflexia, headache, visual
disturbance, epigastric pain (daily).
- Hematocrit, platelet count (every 2 days).
- Serum uric acid and creatinine levels, 24 hours urine for total protein and
creatinine clearance (twice weekly).
- Liver function test (weekly).
- Urinary output (at each voiding or by catheterization, should be more than 700
ml/24 hours or 30 ml/hr).
 Fetus:
- Fetal movement (daily).
- Fetal heart rate (every 4 hours or continuously).
- Placental separation (hourly in case of severe Preeclampsia).
- Ultrasound for fetal growth (every 2 weeks).
- Non stress test (twice weekly).
Note:
Recommendation is to hospitalize patients from time of diagnosis to delivery.
Frequency of evaluations can be increased or decreased, depending on severity of
disease.
Management:
The goal of therapy is to reduce the risk of cerebral vascular accident, while
maintaining uteroplacental perfusion. A decrease in the diastolic pressure to less
than 90 mm Hg in the patient with severe hypertension will decrease placental
blood flow, often with a decrease in the fetal heart rate (FHR). Management is
directed at reducing the diastolic blood pressure to a value of less than 110 mm Hg,
but greater than 95 to 100 mm Hg.
1. Delivery is always the appropriate maternal therapy.
2. Fetal risk must be balanced against maternal risk.
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- Consider conservative management between 25-30 weeks.
- Delivery indicated for severe Preeclampsia, IUGR or fetal distress.
3. Treating Hypertension:
- Treat for greater than 160/110 mmHg.
- Goal is to lower diastolic to 95 to 110 mmHg.
- Drug therapy: Hydralazine, aldomine, nefidipine.
- Carefully monitor urinary output.
4. Preventing Convulsions:
- Drug of choice is Magnesium Sulfate.
- Treat all Preeclamptic patients during labor and 24 hours postpartum.
- Dosing.
 4 g I.V. load then 2-3 g/ hour.
 Keep serum magnesium 4-8 mg/dl.
 IM doses more painful.
 10 g load IM, then 5 g IM every 4 hours.
- Toxicity:
 Loss of patellar reflex.
 Respiratory depression, respiratory rate is less than 12 breath/min.
 Defective cardiac conduction.
 Treatment of toxicity: Calcium Gluconate 10% (1 g I.V. over 3 min).
Prognosis:
Typically resolves following delivery. Discharge is usually safe with blood
pressure less than 160/100 mmHg. Oral contraceptive
Acceptable, but wait until blood pressure normalizes.
Recurrence Rates:
- Mild disease in primigravida : rare.
- Severe Preeclampsia: 30%-50%.
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- Superimposed Preeclampsia: 70%.
Nursing Care:
1. Maternal and fetal compromise related to edema, proteinuria, hypertension.
The goal: to minimize the effects of edema, proteinuria and hypertension.
- Control amount of stimulation, place in quiet private room with dimmed
lighting, no phone or visitors.
- Maintain absolute bed rest with side rails up, disturb only for essential
procedures.
- Have the woman select the people she wishes to stay with her.
- Explain rational for care.
- Monitor: level of consciousness, headache, irritability and epigastric pain…
2. Potential for injury related to effects of Magnesium Sulfate.
3. Potential injury to mother and fetus related to undetected hemoconcentration,
clotting disturbances (DIC), hepatic problems.
- Send blood specimen for measurement of HCT, PLT and SGOT daily.
- Check results against normal values and report variations immediately.
4. Potential injury to fetus related to alteration in tissue perfusion of placenta.
- Prevent supine hypotension.
- Woman is placed on her left side.
5. Alteration in patterns of urinary elimination related to hypertension, proteinuria
and edema.
- Check urinary output every hour.
- Report urinary output of less than 100 ml/4 hours.
- Check input every 8 hours.
- Check urine for protein every 8 hours.
- Send blood specimen to laboratory for measurement of creatinine and check
results against normal values and report deviations immediately.
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6. Alteration in respiratory function related to edema and hypertension.
- Check for pulmonary edema, respiratory rate.
7. Ineffective individual and family coping related to stress of experiencing a major
complication of pregnancy.
- Assess restlessness, anxiety, response to support person and response to labor
contraction.
- Keep woman informed of progress.
8. Alteration in normal physiologic process related to type of delivery.
- Monitor woman for signs of progress in labor and for complications such as
prolapsed cord.
- Prepare for precipitous labor, have delivery pack available in room.
- Prepare for elective delivery if ordered.
Evaluation:
- Symptoms improve.
- FHR remains stable
- Woman doesn't develop complications.
- Respiratory functions within normal limits.
- Urinary elimination pattern remains within normal limit.
- Labor progresses normally.
Possible Complications of Preeclampsia:
 Eclampsia.
 Abruptio placenta.
 Pulmonary edema.
 Congestive heart failure.
 Cerebral edema.
 Retinal detachment.
 Renal damage.
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EcIampsia
Severe form of Preeclarnpsia with seizure or coma. The occurrence of one or more
convulsions not attributable to other cerebral disorders such as epilepsy or cerebral
hemorrhage in a patient with Preeclampsia. Convulsions usually preceded by
headaches, epigastric pain, hyperfiexia and hernoconcentration. It can occur before
labor in 50%, during labor in 25% and early postpartum in 25%.
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Incidence 0.2%.
Women in whom eclampsia develops exhibit a wide spectrum of signs and
symptoms, ranging from extremely high blood pressure, 4+ proteinuria,
generalized edema, and 4+ patellar reflexes to minimal blood pressure elevation,
no proteinuria or edema, and
normal reflexes.
Maternal complications of eclampsia include cerebral hemorrhage, aspiration
pneumonia, hypoxic encephalopathy, coma, thromboembolic events, and maternal
death (incidence 0.4% to 14%) (Poole, 2004b). The perinatal death rate in
pregnancies complicated by eclampsia is 9% to 23%.
Protocol for treating Eclampsia: {Management}
1. Turn, the woman on her side to prevent aspiration.
2. Establish airway and administer oxygen.
3. Administer 4-6 g of Magnesium Sulfate IV (over 10-15 minutes) followed by a
2g/hour maintenance dose; adjust dose later based on patellar reflexes, urine output
and serum magnesium level.
4. Obtain arterial blood gas measurement and chest X-ray film.
5. If convulsions are controlled and maternal condition is stable, initiate induction
or delivery within 3-6 hours.
6. Continue to administer Magnesium Sulfate for at least 24 hours after delivery or
last convulsion.
7. Obtain computed tomographic scan or magnetic resonance imaging if seizures
are atypical or coma is prolonged.
Nursing Interventions:
During the tonic phase of convulsions:
- Turn the woman to her side to allow saliva to drain from her mouth.
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- Inserting a padded tongue blade may prevent injury to the mouth; it can be done
without force.
- Side rails should be padded or a pillow placed between them and the woman.
- Call for assistance.
When clonic phase begins:
- Remain nearby and assist as an oral airway is inserted.
- Administer oxygen.
- Monitor maternal vital signs and FHR.
- Magnesium Sulfate, Diazepam, Lasix and other drugs may be administered as
prescribed.
- Keep the woman on her left side {left lateral position}.
- A decision about delivery is made based on maternal condition and fetal maturity.
- Signs and symptoms usually decrease rapidly after delivery; however dangers of
seizures don’t pass until 48 hours following delivery.
- Follow up care is necessary.
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Bleeding disorders
Any bleeding during pregnancy is abnormal. When bleeding occurs early in
pregnancy, the most common causes are abortion, ectopic pregnancy and vesicular
mole. When hemorrhage occurs late in pregnancy, the most common causes are
placenta previa and abruptio placenta.
Bleeding in Early Pregnancy
Vaginal bleeding occurs in 16% of all pregnant women during the first trimester.
The exact etiology of bleeding is not always known but there are identifiable
reasons in most instances.
Causes of bleeding in early pregnancy:
1. Abortion.
2. Ectopic pregnancy.
3. Hydatidiform (vesicular) mole.
Abortion
Abortion can be defined as the death or expulsion of the fetus either spontaneously
or by induction, before the 20th week of pregnancy, and weight less than 500g.
Abortus: Fetus lost before 20 weeks of gestation, less than 17.5 oz. (500 g), or less
than 9.8 inches (25 cm) in size.
Types of abortion
1. Spontaneous abortions “Miscarriage”: occur without planning.
2. Induced abortions: are performed deliberately for medical (therapeutic) or social
(elective) reasons.
Spontaneous Abortion (SAB)
Etiology:
The exact etiology is not always known, but there are some identifiable factors.
More than 80% of abortions occur in the first trimester.
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Chromosomal abnormalities present in 60°/ of first trimester losses, decrease to 7%
at 24th week.
Fetal factors:
 Chromosomal abnormalities (cause of about 60-80% of SAB).
 Faulty or defective germ plasm (a zone found in the cytoplasm of the egg
cell).
 Malformation of the trophoblast.
 Poor implantation of blastocyst.
Maternal factors:
1. General Conditions:
- Infections such as (e.g., bacteriuria and Chlamydia trachomatis)
- Chronic debilitating diseases such as hypertension or renal diseases.
- Endocrine abnormalities as uncontrolled diabetes and progesterone deficiency.
- Malnutrition.
- ABO and Rh incompatibility.
- Recreational drugs and environmental factors such as (Tobacco smoking, Alcohol
drinking, Caffeine consumption, Radiation exposure, Oral contraceptives and
environmental toxins)
- Aging gametes: insemination 4 days before or 3 days after ovulation.
- Laparatomy, especially nearer to pelvic organs
- Physical trauma.
- Psychological factors as stress and anxiety.
- Maternal anatomical defects, and immunological and endocrine factors
- Exposure to fetotoxic agents
2. Local disorders of the genital tract:
- Acquired uterine defects such as leiomyomas (a benign smooth muscle neoplasm
that is not premalignant), intrauterine adhesions or fibroid
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- A retroverted uterus (is a uterus that is tilted backwards instead of forwards)
- Cervical incompetence.
- Chronic debilitating diseases such as hypertension or renal diseases.
• Paternal factors:
Little is known but certainly, chromosomes translocation in sperm can lead to
zygote defect that result in abortion.
Assessment: - Signs and Symptoms:
1. Vaginal bleeding: the earliest sign of an impending abortion (blood stained
discharge, brown spotting or a bright red loss) which may be variable in
amount.
2. Pain and cramping: usually felt in a central position, low in the abdomen,
intermittent and accompanied by backache.
3. Decreased symptoms of pregnancy
4. Dilation of the cervix: present when abortion becomes inevitable.
5. hCG level will decrease.
- pregnancy test, vaginal examination, and other tests are indicated.
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Classification:
Abortions are classified according to various criteria:
1. Threatened Abortion: Any intrauterine bleeding before 20 weeks of gestation,
without dilation of the cervix or expulsion of any POC (products of conception).
Small to moderate amount of bleeding with a closed cervix.
2. Inevitable Abortion: No expulsion of products, but bleeding and dilation of the
cervix such that a pregnancy is unlikely.
Moderate to large amount of bleeding with uterine cramping with pain and cervical
dilation.
3. Complete Abortion: passage of all products of conception after which bleeding
stops. Cervical os is closed, uterus is small and no tenderness. No other symptoms
appear.
4. Incomplete Abortion: partial passage of products of conception. Continued,
heavy bleeding with discharge of pieces of tissue, severe uterine cramping and
open cervical os. The uterus is smaller than expected.
5. Missed Abortion: Death of the embryo or fetus before 20 weeks of gestation
with complete retention of the POC; these often proceed to a complete abortion
within 1 to 3 weeks but occasionally they are retained much longer.
No symptoms of abortion, but symptoms of pregnancy regress. Condition may
persist for many years as slight irregular bleeding.
5. Septic Abortion : infected conceptus with a soft tender uterus, odorous
discharge, persistent bleeding, fever and pain. It can progress to septic shock.
7. Recurrent (Habitual) Abortion:
Is defined as three or more successive spontaneous abortions.
Primary: no previous successful pregnancies.
Secondary: repetitive losses after live birth.
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Etiology
- Chrornosomal defects.
- Sub mucous myomas.
- Infections.
- Endocrine imbalance (Luteal phase deficiency) inadequate production or
response to progesterone.
- Incompetent cervix: premature cervical dilation in the 2nd trimester.
Painless and gradual with eventual expulsion of previable fetus, (the etiology may
be previous cervical trauma or congenital structural defects)
Assessment of patients with Recurrent Miscarriage:
1. History: unusual exposure to environmental toxins, drugs, infections, previous
gynecological disorder or surgery including dilation and Curettage (D & C: the
cervix
is dilated and a curette is inserted and used to scrape the uterine walls and remove
the uterine contents).
2. Physical examinations: abnormalities or pelvic examination, abnormal
cervix.
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3. Tests:
- Hysterosalpinography
- Luteal phase endometrial biopsy.
- Chromosome analysis.
- Ultrasound examination at 6 weeks of gestation in the next Pregnancy.
Treatment of Recurrent Miscarriage:
1. Treatment of possible causes.
2. Cervical Cerclage (Shirodkar or McDonald techniques) {placement of ligature
to close the cervix}:
- Usually vaginal under regional anesthesia.
- Prophylactic placement at end of the 1st trimester.
- Placement after cervical changes less effective.
- Remove cerclage at time of spontaneous rupture of membranes, labor.
- Elective removal after 37 weeks.
- Success rates 80% to 90%.
3. An unsensitized, Rh-negative woman should be given Rho(D) immune globulin
(RhoGAM) to prevent antibody formation.
Interventions: (Spontaneous Abortion )
The goal of interventions is to prevent damage to the mother and to save the
pregnancy.
Threatened Abortion:
- Bed rest with close observation of all vaginal discharge.
- Emotional support.
- Measures to promote relaxation in a quiet comfortable environment.
- Poor outcome predicted by: falling of hCG, progressive bleeding and cramping.
Inevitable and Incomplete Abortion:
- IV. hydration
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- Dilation and curettage (D & C) or suction curettage.
- Observe 4-6 hours after procedure.
- Rh negative clients should receive Rh immune globulin.
- Always check pathology to rule out mole.
- Analgesics and emotional support are provided
Complete Abortion:
- Rh negative clients should receive Rh immune globulin.
- Submit POC (Product of Conceptus) to pathology.
Missed Abortion: dilation and evacuation
Septic Abortion:
- Culture and sensitivity.
- Antibiotic therapy.
Therapeutic Abortion
Is the termination of pregnancy before the time of fetal viability for the purpose of
safeguarding the health of the mother, Religious and legal considerations are
always respected.
Indications.
1. When continuation of the pregnancy may threaten the life of the woman or
seriously impair her health.
2. When continuation of the pregnancy is likely to result in the birth of a child with
grave physical deformities or mental retardation.
Counseling before Elective Abortion:
- Reasons for the abortion should be identified and discussed.
- Discussion of possible resolutions of these reasons.
- Discussion of alternatives of abortion.
Nursing Diagnoses: (Following abortion)
I. Potential for hemorrhage related to abortion.
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2. Potential for infection related to surgical procedure.
3. Pain re1ated to uterine cramping.
4. Grieving related to lost pregnancy.
Dealing with Grieving
Grieving
Is a complex of somatic and psychological symptoms associated with some
extreme sorrow or loss specially the death of a loved one.
1. Denial and Isolation.
2. Anger
3. Bargaining.
4. Depression.
5. Acceptance.
Management:
- Determine if this was a planned pregnancy
- Assist the woman to discuss her feelings.
- Allow the woman time and opportunity to grieve.
- Don’t tell the woman she can get pregnant again.
- Contact Immam clergy as desire.
- Ensure that the physician talk with the woman / couple regarding her / their future
childbearing potential and any treatment that may be necessary to carry a
pregnancy to term.
Ectopic Pregnancy
Is any gestation located outside the uterine cavity. When a fertilized ovum implants
any place other than the endometrium of the uterus, the pregnancy is called ectopic
or extra uterine. Implantation may occur in the fallopian tube (99%), on the ovary,
the cervix, on the outside of the fallopian tube, the abdominal wall, or on the
bowel.
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Most common causes of maternal death in first half of pregnancy but, mortality is
decreasing.
Factors responsible for increasing incidence (diagnosis) of Ectopic Pregnancy:
- Improved diagnostics method
- Sensitive and specific hCG assays.
- High-resolution ultrasound.
- Diagnostic labaroscopy.
- Increase awareness.
Etiology
Ectopic implantation may be -tortuitous or result of a tubal abnormality, which
obstructs or delays the passage of the fertilized ovum as:
• History of sexually transmitted infections or pelvic inflammatory disease
• Prior ectopic pregnancy
• Previous tubal, pelvic, or abdominal surgery
• Endometriosis
• Current use of exogenous hormones (i.e., estrogen, progesterone)
• In vitro fertilization or other method of assisted reproduction
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• In utero diethylstilbestrol (DES) exposure with abnormalities of the reproductive
organs.
• Use of an intrauterine device.
Clinical Manifestations:
Vary with site of implantation and usually occur after tubal rupture.
Early Signs and Symptoms:
- Menstrual irregularities (irregular vaginal bleeding)
- Symptoms of early pregnancy.
- Dull pain on the affected side.
Signs and Symptoms of Tubal rupture:
- Pain: sudden, severe and unilateral, generalized and radiated to the shoulder and
neck due to phrenic nerve stimulation.
- Vaginal bleeding dark brown and scanty, about 25% of cases without vaginal
bleeding.
- Nausea, vomiting, fainting (signs of internal blood loss).
- Signs of shock.
- Normal or low temperature: Fever is important in distinguishing Ruptured tubal
pregnancy from Salpingitis.
- Tenderness over abdomen upon palpation.
- Pelvic mass posterior or lateral to uterus.
- Cervical pain during vaginal examination.
Differential Diagnoses:
- Threatened or Incomplete abortion.
- Ruptured corpus luteum.
- Salpingitis.
- Appendicitis.
- Adnexal torsion.
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- Perforated peptic ulcer.
Diagnostic Evaluation:
- Medical history. (e.g., unilateral, bilateral or diffuse abdominal pain, missed
period)
- Physical examination. (a palpable mass is present on bimanual examination in
approximately 50% of women)
- hCG that is low for gestational age (because an ectopic pregnancy has a poorly
implanted placenta, the level of a hCG does not double every 48 hours as in normal
implantation)
- WBC: can range from normal to 15,000/mm3.
- Transvaginal ultrasonography should be performed to confirm intrauterine or
tubal pregnancy
Treatment:
- Surgical management: Salpingostomy has replaced Salpingectomy except in case
of irreparable tubal rupture, tumor or hemorrhage.
- Medical management: Methotrexate (stops cell production and destroys
remaining
trophoblastic tissue).
- Blood transfusion for hemorrhage.
- Fluid correction to treat or prevent shock.
Nursing Diagnoses
1. Inadequate tissue perfusion (Shock XX) related to effects of rupture (pain,
blood loss..)
2. Potential fluid volume deficit related to blood loss.
3. Pain related to rupture and outpouring of blood into peritoneal cavity.
4. Anxiety related to uncertainty about condition arid potential loss of
childbearing capacity.
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Nursing Interventions:
• To Reduce Pain:
- Remain with the woman as much as possible and provide psychological support.
- Administer prescribed analgesics as needed.
- Explain procedures that needed to be performed to reduce anticipation of
additional discomfort.
• To Prevent/Treat Shock:
- Monitor vital signs, assess indications of impending shock.
- Start I.V. fluids/blood as prescribed.
- Provide constant monitoring, noting any changes in the woman’s condition.
- Inspect for vaginal bleeding.
- Prepare the woman for surgery.
- Postoperative care as any patient who had any abdominal Laparatorny.
• To Establish Fluid Volume:
- Monitor vital sighs.
- IV. fluids/blood.
- Intake and output.
• To Cope with anxiety :
- Listen to the woman’s account of what has happened.
- Ask the woman to explain her understanding of future childbearing potential,
correct misinformation and reinforce positive aspects.
• Reinforce physician’s decisions/expectations of future childbearing potential.
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Hydatidiform (Vesicular ) Mole
It is a developmental anomaly of the placenta and trophoblast in which the
fertilized ovum deteriorates and the chorionic villi convert into a mass of clear
grape-like vesicles.
It is one of the most common lesions anteceding choriocarcinoma, a malignant
tumor of the trophoblast with a tendency toward rapid and widespread metastasis.
Incidence:
- Occurs in about 1 of every 1500-2000 pregnancies.
- Previous molar gestation increases risk of developing a subsequent molar
gestation by 4 to 5 times.
- Frequency in woman over 45 years is 10 times higher than in woman aged 20-40
years.
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Etiology:
The cause is unknown, but factors contributed are:
- Maternal age: below 20 years old and above 45 years.
- Genetic factors.
- High parity and malnutrition.
Clinical classification:
Vesicular mole is classified into complete and partial moles according to the
presence or absence of a fetus or embryo and to its location or dissemination.
 A complete mole is characterized by trophoblastic proliferation and the
absence of fetal parts.
 Incomplete moles often appear with a coexistent fetus that has a triploid
genotype (69 chromosomes) and multiple anomalies. Most fetuses
associated with incomplete moles survive only several weeks in utero before
being spontaneously aborted. Incomplete moles are almost always benign
and have a much lower malignancy potential than complete moles.
 An invasive mole is similar to a complete mole but has invaded the
myometrium layer of the uterus. Invasive moles rarely metastasize.
 Choriocarcinoma is invasive, malignant trophoblastic disease that is usually
metastatic and can be fatal
Clinical manifestation:
1. Bleeding: the most common sign and vary from spotting to profuse,
continuous or intermittent, red or brownish bloody discharge, about the 12th
week of gestation, may also pass villi.
2. Enlargement of the uterus is out of proportion to what it normally is at a
specific time in pregnancy. Uterine enlargement results from the rapidly
proliferating trophoblastic tissue and the large accumulation of clotted blood.
3. Signs of preeclampsia or eclampsia earlier than 20 weeks gestation.
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4. Hyperemesis Gravidarum experienced by 30% of women with this condition
(due to uterine enlargement).
5. Pallor and dyspnea → anemia.
6. hCG titer is markedly increased beyond the 90th day of gestation when
normally expected to drop.
7. Anxiety and tremors → thyroid dysfunction due to high hCG.
8. Uterine discomfort due to over stretching.
9. Absent fetal heart tone.
10. Absent fetal parts (except in partial mole) found on ultrasound or X-ray.
Diagnostic Evaluation:
- Ultrasound is the diagnostic method of choice.
- A patient often presents with vaginal bleeding, uterine enlargement in absence of
fetal heart tone.
- CBC, Hb, HCT, and RBCs, are decreased.
- Blood chemistries: renal, liver and thyroid function test.
- Chest X-ray, for ? lung cancer metastasis.
- hCG titers are elevated up to 1 to 2 million IU in 24 hours.
- Notes: normal hCG at 10 weeks ? 400,000 IU.
Management:
1. Suction curettage has low complications rate with uterine size < 16 weeks.
Excessive uterine enlargement may predisposed to pulmonary complication as
preeclampsia and fluid overload.
2. Primary Hysterectomy:
- Patients who have completed childbearing and desire sterilization are good
candidates.
- Reduce malignant sequelae from 20% to 5%.
3. Prophylactic chemotherapy:
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- May reduce malignant sequelae in high-risk patient.
- Not routinely recommended in cases of uncomplicated mole.
4. Blood transfusion: to correct anemia and to replace blood loss.
Follow-up:
Follow-up supervision at least for 1 year includes the following:
1. hCG measurement as:
- Once weekly until titers are negative for 3 consecutive weeks, then:
- Once monthly for 6 month then.
- Every 2 months for 6 months and,
- Every 6 months.
2. Chest X-ray: to exclude and detect metastases are done every month until hCG
titers are negative, then every 2 months for 1 years.
3. Start contraception during surveillance (for 1 year).
Oral contraceptive are the best choice.
Prognosis:
- Favorable if hCG titers doesn't persist at elevated levels.
- Unfavorable if a malignant mole is discovered and untreated.
Nursing diagnosis:
1. Fluid volume deficit…
2. Knowledge deficit regarding this condition.
3. Grieving related to fetal loss.
4. Potential for infection..
5. Altered nutrition status related to nausea and vomiting.
6. Anxiety related to prognosis of the condition.
Nursing Intervention:
Preoperative and postoperative care:
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- Replace blood as prescribed.
- Prepare the woman for surgery, suction curettage or hysterectomy.
- Administer antimetabolite drugs as prescribed.
- Observe for complication e.g. hemorrhage or rupture uterus.
- Advice the woman for the one year follow-up care.
- Counsel the woman to avoid attempting pregnancy for 1 year to allow hCG to be
monitored carefully.
Promoting a healthy self concept:
- Encourage the woman to discuss her feelings regarding the condition.
- Determine the woman's understanding of what causes the abnormal development,
correct misinformation and reinforce the correct one.
- Help the woman to understand that the abnormal development was a "quirk of
nature" and not caused by her partner actions or genetic make up.
Bleeding in late pregnancy
Bleeding during 2nd half of pregnancy occurs in 3% to 4% of woman.
The most common causes are placenta previa and placental abruption. It is
potentially fatal to both mother and fetus.
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Placenta previa
Is the development of the placenta in the lower uterine segment, partially or
completely covering the internal cervical os.
Incidence:
- One of the major causes of bleeding during the last trimester.
- Occurs once in every 200 deliveries (1/200 births).
- It accounts for 20% of all antepartal hemorrhages.
- More common in parous woman (1/20 in grand multiparity).
Classification:
Traditionally categorized in to 3 types:
1. Complete, total or central previa: internal os entirely covered. It is associated
with the greatest amount of blood loss.
2. Partial placenta previa: internal os partially covered.
3. Marginal placenta previa: placenta reaches edge of the internal os.
Note: the term low-lying Implantation is used when the placenta situated in the
lower uterine segment but away from the os.
Etiology:
 Placenta previa may be associated with conditions that cause scarring of the
uterus such as a prior cesarean section, multiparity, or increased maternal
age.
 large placental mass as seen in multiple gestations.
 Smoking, cocaine use.
 Prior history of placenta previa
 Closely spaced pregnancies
 Maternal age greater than 35 years
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Clinical Manifestation:
- Usually presents as painless vaginal bleeding in the 3rd trimester, but can occur
as early as 20 weeks of gestation. Bleeding occurs without warning in the
absence of trauma.
- Blood loss from the first bleeding is rarely fatal; in each subsequent episode
bleeding is heavier.
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- Placenta previa may not cause bleeding until labor begins, or complete dilation
has occurred.
- Bleeding occurs earlier and is more profuse with total placenta previa.
Notes:
 There is a relationship between the site and size of the placenta because low
uterine segment is less favorable than that of the fundus, so placenta needs to
cover larger area for adequate efficiency.
 The site of placenta is close to the cervical os
more accessible to
ascending infection from the vagina. Hemorrhage and anemia increase the
risk of antenatal infection (placentitis) and purpraul sepsis.
 Blood loss may not cease with the delivery of the infant, blood loss may
continue because of the diminished muscle content of the lower uterine
segment, therefore, postpartum hemorrhage may occur even the fundus is
contracted firmly.
 If uterine bleeding can’t be controlled with ocytocics drugs, ligation of the
internal iliac arteries or even hysterectomy may be necessary.
 The major problem related to placenta previa is preterm delivery (about 60%
of neonates die).
 Maternal risks associated with placenta previa are shock, the potential for
emergency hysterectomy, and death.
Diagnostic evaluation:
 Painless vaginal bleeding is placenta previa until proven otherwise.
 Ultrasound is the diagnostic technique of choice (93% -97% accurate), some
difficulties can arise in:
o Obese patients.
o Posterior previa.
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o Over distended bladder.
 Transvaginal ultrasound may be preferred to transabdominal for initial
resolution.
- Definitive diagnosis by direct palpation of the placenta is not
recommended (risk of placental perforation).
- Leopold maneuvers often reveal the fetus to be in a breech or oblique
position or transverse lie because of the abnormal location of the
placenta.
Management:
1. Hospital admission
- Itravenous access
- vital signs.
- Blood typing and screening
2. Remote from term
- Maternal hemodynamic stability obviously a requirement.
- Preterm contractions/labor, Tocolytics have been used (MgSO4 is
tocolytic of choice) with no proven efficacy.
- Replace blood loss to keep HCT greater than 30%.
- Steroids have been shown to be beneficial to aid fetal lung maturity.
-
Serial ultrasound examinations every 2-3 weeks.
- Home care only under ideal circumstances.
o High motivated patient
o Location near a hospital
o Full understanding of the risk
o Ability to maintain bed rest.
o 24-hours transportation is available.
3. Delivery
 The ideal is a well-planned elective cesarean section at 36-37 weeks.
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 Amniocentesis is useful for timing of delivery.
 Vaginal approach considered in rare circumstances.
o Dead fetus.
o Major fetal anomalies.
o Previability.
o Active labor with engagement of fetal head.
Nursing intervention:
 To prevent premature delivery:
o Bed rest
o No vaginal or rectal examination
o Regular assessment of blood loss, uterine contractility, pain, FHR,
vital signs, and laboratory tests.
o Intravenous fluid.
o Two units of blood (cross matched) available for immediate
transfusion.
Abruptio Placenta
Premature separation of the normally implanted placenta. Separation occurs in the
area of deciduas basalis, most often in the third trimester, but can happen any time
after 20 weeks.
Incidence:
 Complicates approximately 1% of pregnancies.
 Is a serious disorder, account about 15% of all perinatal mortality "most
common cause of intrapartum fetal death".
 Permanent neurologic impairment in 14% of surviving infants.
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 Fetal mortality occurs in about 35% of all placental abruptions and can be as
high as 50% to 80% when associated with severe placental abruption. Death
results from hypoxia that is related to the decreased placental surface area
and maternal hemorrhage
Classification:
The 3 types of Abruptio Placenta are:
1. Convert: Placenta separates in the center and bleeding is concealed.
2. Overt: blood passes from under the placenta causing vaginal bleeding.
3. Placental prolapse: total separation of placenta with massive bleeding.
Etiology / Risk factors:
 Maternal hypertension.
 PIH.
 Cocaine induced.
 Maternal smoking.
 Short umbilical cord.
 Uterine anomalies.
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 Advanced maternal age.
 Physical work.
 Poor nutrition.
 Trauma.
 Amniotomy in patients with polyhydramnios.
Recurrent risk:
 Tenfold increase in second pregnancy over population risk.
 With 2 previous abruptions, 25% chance of third abruption.
Clinical Manifestations:
 Vaginal bleeding (80% of patients), blood remains concealed (20% of
patients).
 Other signs include uterine tenderness and abdominal or back pain, a
boardlike abdomen and no vaginal bleeding.
 Sudden onset of severe continuous abdominal pain and/ or low back pain.
 Uterine contractions with rigid, tender and irritable uterus.
 Amniotic fluid color may be dark red.
 If bleeding is severe, the myometrium may be infiltrated with blood and may
fail to contract following delivery (couvelair uterus).
 If bleeding is severe, hypofibrinogenemia may develop (Consumptive
coagulopathy).
 Fetal activity may be increased, because of fetal hypoxia. With severe
complete abruption fetal heart tones may not be heard (late decelerations,
bradycardia and lack of variability on the electronic fetal Monitor).
Complications: "accompany moderate to severe abruption"
1. Hypovolemic shock which may cause Renal failure.
Etiology: is unclear, probably from reduced renal perfusion.
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2. Fetal hypoxia or anoxia with possible fetal death.
3. Consumptive Coagulopathy → Hypofibrinogenemia → DIC.
4. Couvelair uterus: bleeding into the myometrium resulting in boardlike rigidity of the uterus.
5. Hepatitis post blood or fibrinogen transfusion.
Management:
Goals of therapy:
1. Maternal urine greater than 30ml/hr.
2. HCT greater than 30%.
 Close observation.
 Induction of labor: (48% will deliver vaginally).
o Evidence or concern regarding maternal or fetal compromise.
o Greater than 37 weeks gestation.
o No placenta previa.
o Perform vaginal examination and amniotomy.
o Oxytocin may be useful if labor doesn't progress.
 Cesarean section:
o Continued bleeding.
o Fetal distress.
o May be dangerous in setting of coagulation defect.
-Note: Hypofibrinogenemia is treated with plasma or
cryoprecipitate.
 Hemorrhagic shock:
o Wide- bore I.V in place.
o Blood products available.
o Repeat coagulation tests.
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o Fetal monitoring: distress develops in 60% of patient with
moderate abruption.
Nursing Diagnosis:
1.
Potential shock related to hemorrhage.
2.
Fluid volume deficit related to hemorrhage.
3.
Trauma to fetus related to hypoxia.
4.
Anxiety regarding safety of self and fetus.
Nursing Interventions:
A. Fluid Replacement:
1. Administer I.V fluids and whole blood to replace blood loss as
prescribed.
2. Monitor fibrinogen level.
3. Monitor vital signs and FHR to detect impending shock and to assess
fetal status.
4. Monitor vaginal bleeding and height of the fundus to detect increasing
concealed hemorrhage.
B. Ensuring Blood flow and Oxygen:
1. Administer fluids or blood as prescribed.
2. Monitor fetal heart tones continuously to assess fetal well-being.
3. Provide oxygen therapy as prescribed.
4. Maintain the women in a side lying position to keep uterus off vena cava,
therapy improving blood flow to intervillous spaces.
5. Prepare the women for immediate delivery (vaginal or cesarean).
C. Reducing Anxiety:
1. Keep the women /couple informed of what is happening and of the
plan of care.
2. Explain procedure that might be needed.
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3. Reinforce positive aspects of the woman condition without giving
false reassurance. Have the couple listen to fetal heart tones.
4. Don't leave the woman alone.
5. Following delivery:
-Provide nursing surveillance during the puerperium for early
detection of complications.
- Monitor vital signs and uterine muscle tones to detect uterine atony.
- Be alert for signs of postpartum infections, blood loss and shock
greatly reduce resistance to infection.
A comparison between Abruptio Placenta and Placenta Previa
Abruptio Placenta
Placenta Previa
Onset
Third trimester
Third trimester
Bleeding
May be concealed, external
External, small to profuse in
dark hemorrhage or bloody
amount, bright red
amniotic fluid
Pain and uterine Usually present, irritable
contraction
Usually absent, uterus soft
uterus progress to broad-like
consistency
Fetal heart tone
May be irregular or absent
Usually normal
Presenting part
May or may not be engaged
Usually not engaged
Shock
Moderate to severe depending Usually not present, unless
on extent of concealed or
bleeding is severe
external hemorrhage
Delivery
Immediate delivery usually
Delivery may be delayed
by cesarean
depending on gestational
age and amount of bleeding
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Teratology and drug use during pregnancy
Once it was believed that the placenta acted as a protective barrier, keeping
dangerous substances from reaching the fetus. This is not true. Substances that can
harm the fetus "teratogens" do pass through the placenta and can adversely affect
the developing fetus.
Principles of teratology:
1- Drugs ingested during pregnancy can affect the fetus:
- Should be used only when necessary.
- Risk-benefit ratio should justify the use of any drug.
2- Passage of drugs influenced by several factors:
- Lipid-soluble substances passed readily across the placenta.
- Water-soluble substances pass less well.
- Protein bound fraction
only free drugs can cross the placenta.
3- Development defects:
- Drug exposure responsible for 2% to 3%.
- Genetic factors about 25%.
- Unknown etiology in most cases.
FDA Categories:
Category A:
Adequate, well-controlled studies in pregnant women have not shown an increased
risk of fetal abnormalities to the fetus in any trimester of pregnancy.
Category B:
Animal studies have revealed no evidence of harm to the fetus; however, there are
no adequate and well-controlled studies in pregnant women.
OR
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Animal studies have shown as adverse effect, but adequate and well-controlled
studies in pregnant women have failed to demonstrate a risk to the fetus in any
trimester.
Category C:
Animal studies have shown an adverse effect and there are no adequate and wellcontrolled studies in pregnant women.
OR
No animal studies have been conducted and there are no adequate and wellcontrolled studies in pregnant women.
Category D:
Adequate well-controlled or observational studies in pregnant women have
demonstrated a risk to the fetus.
However, the benefits of therapy may outweigh the potential risk. For example, the
drug may be acceptable if needed in a life-threatening situation or serious disease
for which safer drugs cannot be used or are ineffective.
Positive evidence of human fetal risk exists, but benefits in certain situations
"e.g. life- threatening situations or serious diseases " may make use of the drug
acceptable despite its risks.
Category X:
Adequate well-controlled or observational studies in animals or pregnant women
have demonstrated positive evidence of fetal abnormalities or risks.
The use of the product is contraindicated in women who are or may become
pregnant.
Studies in animals or humans have demonstrated fetal abnormalities,
or there is evidence of fetal risk based on human experience, or both and the
risk clearly outweighs any possible benefit .
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Timing of teratogenesis:
Classic teratogenesis period extends from the second to the eighth week, which
is the critical period of organogenesis. This means that early exposure usually
results in all-or-none effect. Later exposure can result in problems.
Breasts milk secretion of drugs often pharmacologically insignificant.
After 11 weeks, the fetus becomes more resistant to damage from teratogens
because the organ systems have been established.
Effects of some therapeutic drugs:
Anticonvulsant:
 Infants of epileptic mothers have 5% risk of major malformations , and
2%to3% risk of epilepsy .
 Phenytoin decreases folate absorption
increased risk of neural tube
defects, microcephaly and developmental delay.
 Carbamazepine, valproic acid
1% risk of neural tube defects.
Anticoagulant:
 Heparin does not cross placenta but Coumadin does.
 Lithium
high rate of cardiovascular anomalies.
Thyroid and antithyroid drugs:
 Propylthiouracil
 Thyroxine
causes fetal goiter.
safe in pregnancy.
Antiemetic:
 Phenergan is effective and safe.
Analgesics:
 Aspirin:
 No teratogenic effect in the 1st trimester.
 Low dose use may be useful in preventing PIH in high-risk patients.
 Prolonged bleeding time.
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 Acamol: safe.
Antibiotics:
 Penicillins , Erythromycin , Isoniazid , Rifampin , Ethambutol and
Flagyl are safe in pregnancy.
 Sulfonamides: increase the risk of hyperbilirubinemia .
 Tetracyclines: inhibit bone growth, can affect enamel of decidual teeth.
Aminoglycosides:
 No teratogenicity in the 1st trimester.
 Increase the incidence of ototoxicity.
Antiasthmatics:
 Aminophylline: safe.
 Epinephrine: slight increase in minor malformations.
Cardiovascular drugs:
 Digoxin , Aldomet and Hydralazine are safe .
 Capoten: not recommended, can result in fetal renal failure, craniofacial
deformities and limb contractures.
Androgens:
 May masculinize a developing female fetus.
Radiation
 High levels of radiation during pregnancy may cause damage to
chromosomes and embryonic cells and can adversely affect fetal physical
growth and cause mental retardation. Consequences of radiation exposure
include stunted growth, deformities, abnormal brain function, or cancer
that may develop sometime later in life.
Social Drug Exposure
Maternal effects:
 Usually are malnourished, receive little or no prenatal care.
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 More susceptible to all types of infections e.g. AIDS, Hepatits, …
 Have a much higher risk of PIH, third trimester bleeding and puerperal
sepsis.
 Their ability to handle the stress of pregnancy is severely reduced.
 Psychosocial upset when the woman did not know that she is pregnant
e.g. guilty or fear.
 Bone marrow depression with an increased susceptibility to infection.
 Septic phlebitis.
 Psychosocial effects since these substances are expensive (crime).
Alcohol:
 Fetal alcohol syndrome (FAS).
 Gross retardation before or after birth.
 Facial anomalies: thin upper lip, retarded midfacial development,
epicanthric fold, flattened nasal bridge, short nose and/or low set,
unparalled ears.
 CNS dysfunction: microcephaly, mental retardation and attention deficit.
 FAS is one of the most common causes of mental retardation. Body
organs affected include the heart and the brain.
 Heavy drinking may cause spontaneous abortion and a low-birth-weight
infant
o No degree of drinking is known to be safe in pregnancy.
Smoking:
 Nicotine causes vasoconstriction of the uterine blood vessels, resulting in
a decreased blood flow and supply of nutrients and oxygen to the fetus.
 Smoking is associated with spontaneous abortion, low birth weight,
intrauterine growth restriction, preterm labor and birth, placenta previa,
placental abruption, and premature rupture of the membranes.
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Cocaine: CNS bleeding, urinary anomalies and learning disabilities.
Caffeine: no evidence of teratogenicity, IUGR, anemia and spontaneous
abortion.
Diazepam: hypotonia, hypothermia, poor suckling and respiratory depression.
Drug in Breast Milk
Rate of transfer depends on lipid solubility, molecular weight and ionization. Dose
to infant is usually 1% to 2% maternal dose.
Secretion into Colostrum is minimal. Generally medications should be taken after
breast-feeding and long-acting preparations should be avoided
Drugs contraindicated during breast-feeding :
 Drugs of abuse e.g. Cocaine, Heroin , marijuana, …
 Lithium, Antianxiety, Antipsychotic, Antidepressants.
 Radioactive isotopes.
Interventions:
Goal: to provide maximum health for the mother and her infant.
Assessment:
 General health status with particular attention to infection and nutrition.
 Obstetrical condition of mother and her fetus.
 Substance being used by the mother.
Diagnosis: is made according to specific teratogenic substance,
Planning: there should be a cooperation between the mother, physician, midwife,
social worker and other health professionals.
Implementation:
 Prescribed drugs: used with caution after consultation with physician or
pharmacist.
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 Prenatal health teaching, alcohol and smoking to be stopped.
 Neonates need intensive care and discharge planning with long term
rehabilitation.
Toxoplasmosis
Toxoplasma gondii, a single-celled parasite, is responsible for toxoplasmosis.
The majority of individuals who become infected with toxoplasmosis are
asymptomatic, although when present, symptoms are described as “flu-like”
and include glandular pain and enlargement (lymphadenopathy) and myalgia.
Severe infection may cause damage to the brain, eyes, or organs.
Toxoplasmosis is usually acquired by eating raw or poorly cooked meat
contaminated with Toxoplasma gondii. It may also be acquired through close
contact with feces from an infected animal (usually a cat) or from contact with
soil that has been contaminated with Toxoplasma gondii.
Once maternal infection occurs, the Toxoplasma gondii organism crosses the
placental membrane and infects the fetus, causing damage to the eyes and
brain. If the infection is acquired early in the gestation, there is an increased
risk of fetal death.
Blood Dyscrasias
Of special significance in obstetrics is the typing of blood according to the
inherited presence or absence of certain antigens. The two most important types are
the Rh and A and B antigens.
Rh factors:
 Several forms of Rh antigens exist. Those factors responsible for problems
are D, M, E, c, e & d.
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 The D antigen produces the strongest stimulus for antibody production in Rh
negative people. 85% of population is Rh positive. Rh hemolytic disease
occurs when Rh antigens pass through the placenta into the mother’s blood.
 In most situations, exposure of maternal blood to fetal blood occurs during
the third stage of labor at the time of placental separation. The woman’s first
child is usually unaffected because the maternal antibodies form after the
infant’s birth.
 The woman produces antibodies against the antigens (sensitization).
Sensitization also can occur whenever an Rh negative person receives an Rh
positive blood transfusion.
 The antibodies then pass back into the fetus circulation and destroy the
erythrocytes. The life span of the fetal or neonatal RBCs is shortened.
 The fetus attempts to make up for this destruction by producing increased
numbers of immature RBCs called erythroblast that are unable to carry
oxygen. This is called erythroblastosis.
 The severe hemolytic syndrome is known as erythroblastosis fetalis.
 If treatment is not begun, the anemia resulting from this disorder can cause
severe fetal edema called hydrops fetailis.
 Congestive heart failure may result and profound jaundice called icterus
gravis leading to neurological disorder (damage) called kernicterus.
Prenatal screening and assessment:
 At the first prenatal visit, a history is taken concerning prior blood
transfusions, abortions, and children born with jaundice and the presence of
medical diseases.
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 Blood typing (ABO), Rh factor and Rh antibody screening are done. If the
woman is Rh negative, the father of unborn child is assessed for Rh factor
and blood type.
 Indirect coombs test
for Rh negative woman to determine if she is
sensitized to the Rh antigen. “When baby is Rh positive" The test measures
the antibody amounts in the blood.
 Results are expressed as titer or proportion of antibody to serum.
o A titer of 1: 16 or less indicates that the fetus is not at risk. When
titers are higher than 1:16 a delta optical density ( OD) test of
amniotic fluid is performed at 26 weeks gestation to plan treatment .
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 This test a spectrophotometric (color) analysis test that determines the
amount of bilirubin in the amniotic fluid.

OD test results are indicated as zones:
o Zone I indicates a normal neonate (fetus) who can be delivered at term
with good prognosis anticipated.
o Zone II indicates an infant possibly at risk.
o Zone III indicates a seriously affected fetus who may require
intrauterine transfusions every 1-2 weeks until viability at about 32
weeks then cesarean birth is performed .
 Interventions:
o Prentally, if tests indicate a severely affected fetus, plans will be
made for an early delivery .
o Intrauterine transfusions of the fetus may be considered.
o Fresh packed RBCs are introduced through a catheter that passes
through the woman’s abdomen into her intrauterine space, then into
the fetal peritoneal cavity, in which diaphragmatic lymphatics absorb
these RBCs into fetal circulation.
o In the postpartum period, the Rh negative woman whose indirect
cooms titer is negative and who is delivered an Rh positive fetus is
given an IM injection of anti-D gamma globulin such as RhoGAM
within 72 hours.
o This is done so that she does not have time to produce antibodies to
fetal cells that entered her blood stream when the placenta is
separated. This is done to protect future babies if she becomes
pregnant again.
o RhoGAM is given to Rh-negative nonimmunized woman at 28 -32
weeks gestation (as a preventive measure to prevent formation of
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active antibodies during the remainder of pregnancy) as well as after
delivery.
o RhoGAM (anti-D) works by coating and destroying fetal cells in the
maternal circulation.
o (RhoGAM) must be given after the birth of every Rh(D)-positive
infant. If the infant is Rh(D) negative, no Rho(D) immune globulin is
necessary.
o RhoGAM is not useful in a woman who has Rh antibodies .
o RhoGAM should be given IM , not in fatty tissue or IV .
o RhoGAM never given to an infant or father .
ABO blood types:
 In the ABO system, there are 2 kinds of antigens A and B
 People who have neither are said to be O (zero).
 The rest of population has type A, B or AB.
 When the fetus inherits a blood type from the father that is different from
that of mother, fetal blood may cross the placenta and sensitize the mother to
antigens of foreign blood type.
 During subsequent pregnancy, another baby with same type as the first
infant might be affected by hostile antibodies in the blood of the mother.
 Note: ABO hemolytic problems almost exclusively A or B infants of O
mothers. The problem may appear in the first pregnancy as well as in the
subsequent ones.
 Kernicterus / anemia are rare.
 To date no immune globulin such as RhoGAM has been developed.
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Polyhydramnios
Is an excessive amount of amniotic fluid more than 2000 ml.
 The exact cause is unknown, it is associated with :
o Maternal disease as DM, renal disease.
o Multiple pregnancies.
o Fetal abnormalities that affect the swallowing mechanism.
 The condition leads to preterm delivery, malpresentations (because it
provides extra uterine space for the fetus to turn in), and cord prolapsed
(because the increased amount of fluid pushes the fetus high into the uterine
cavity) and abruption placenta, thus increasing maternal mortality.
Clinical manifestations:
 Excessive uterine enlargement, fundal height increases out of proportion to
gestational age.
 Difficulty in breathing.
 Difficult to hear FHR and to palpate the fetus.
 Difficult finding a comfortable sleeping position.
 Pain in abdomen, back and thighs due to increased pressure.
 Difficult ambulating.
 Varicosities.
 Nausea and vomiting.
Management:
 Hospitalization, if the mother is dyspnic or in pain.
 Transabdominal or vaginal amniocentesis with the aid of sonography and
careful monitoring of vital signs. Remove the fluid slowly to avoid abruptio
placenta.
 Offer support by explaining procedures.
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 Encourage the woman to rest on her left side in semi-recumbent position to
increase blood flow to uterus and fetus and to relief symptoms.
 Watch carefully for signs of abruption placenta , abnormal presentation and
post partum hemorrhage.
Oligohydramnios
 Is a small amount of amniotic fluid less than 300 ml.
 It is associated with:
a) Fetal renal abnormalities.
b) Poor placental perfusion, or
c) Premature rupture of the membranes.
 During labor, the absence of the amniotic fluid buffer may lead to cord
compression during contractions and decreased fetal blood flow as
evidenced by variable heart rate decelerations.
Clinical manifestations:
 Small uterine size.
 Labor may be premature.
 Uterine contractions may be ineffective and labor prolonged.
 Fetal hypoxia may occur because of cord compression.
Management:
 Monitor fetal status carefully during pregnancy and labor.
 Monitor the woman for labor complications
Pseudocyesis
 False pregnancy is usually seen in woman with a very strong desire to get or
to be pregnant.
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Clinical manifestations
a) Irregular menses or absent menses.
b) Morning sickness.
c) Uterus generally remains small; breasts may be enlarged with pigmentary
changes.
d) Intestinal gases or contractions may be interpreted as fetal movements.
Management:
1. Following physician diagnosis and discussion with the woman, evaluate
her understanding of the situation, reinforce the correct understanding
and facts, correct misunderstanding and provide additional information as
needed.
2. Help family members understand and accept situation.
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Complications of labor and birth
Premature Rupture of Membranes (PROM)
Is the spontaneous rupture of fetal membranes one hour or more before the onset of
labor.
Incidence: 10% of all pregnancies.
Causes: remains unknown in most cases.
Risk factors:
 Polyhydaminos
 Cerculage
 Amniocentesis
 Placental abruption.
 Infection
 More common in twins gestation.
 Seldom associated with trauma.
Complications:
1. Preterm delivery.
2. Maternal or fetal infections:
a. Chorioamniositis
b. endometrits
clinically persisting after delivery.
3. Fetal distress
a. Umbilical prolapsed more common in cases of PROM.
b. Increase rate of stillbirths in unmonitored patients.
Evaluating the patient with PROM
 Correct diagnosis is essential for future management.
 Sterile speculum examination:
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o Visualize pool of fluid in vaginal formix
o Leakage of fluid through cervix.
 pH of amniotic fluid is 7.1 to 7.3
 Normal vaginal pH is 4.5 to 6
 Nitrazine paper turns blue at pH > 6.5
Note: false positive rates (1% to 17%) by blood, semen, vaginal infection, alkaline
antiseptics or alkaline urine.
 Cervical dilation is assessed.
 Observe for prolapsed fetal part or umbilical cord.
 Collection of samples for culture.
 Collection of fluid for lung maturity studies (PG most reliable)
Note: don't perform digital intracervical examination in nonlaboring patient.
- Ultrasound is a final confirmatory step in some cases.
- Establish gestational age and fetal maturity (history, u/s, and other dating
criteria).
- Rule out infection: clinical manifestation e.g. fever and cultures.
- Rule out fetal distress: continuous fetal heart tone monitoring.
Management and interventions:
Term patients:
Immediate induction is suggested.
Preterm patients:
Survival rate with PROM after 26 weeks is close to 50%.
- If gestation is less than 34 weeks, efforts are directed toward maintaining
pregnancy. Tocolytic therapy may be attempted; its purpose is to delay labor
long enough for fetal lungs to mature with administration of corticosteroids.
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- Antibiotics therapy for patients colonized with microorganisms as group B
streptococci, it clearly reduces neonatal sepsis.
- Nurse monitors vital sings and describe the characters of the amniotic fluid,
uterine activity, fetal response to labor and hydration.
- Comfort measures and emotional support are provided as nurse prepares the
mother for delivery, cesarean birth, a preterm neonate and potential loss of the
fetus.
Preterm labor
Is defined as rhythmic uterine contractions that produce cervical changes prior to
completion of 37 weeks gestation.
Incidence:
- 7% to 10% of infants are born prematurely.
- Responsible for 75% of prenatal mortality and about 50% of neurological
deficits.
Etiology:
 Demographics:
- Upper and lower extremes of age.
- Lower socioeconomical status.
- Inadequate prenatal care.
- Race “increase in blacks"
 Lifestyle and employment:
- Smoking and drug abuse.
- Prolonged periods of standing.
- Fatigue and long hours at work.
- Heavy work and lifting.
 Reproductive history:
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- Previous preterm delivery.
- Incompetent cervix.
- Spontaneous or induced abortion.
 Uterine anomalies e.g. leiomyomata.
 Weight again: low weight or low weight gain may increase risk.
 Anemia: probably due to other risk factors.
 Uterine size and placental abnormalities:
- Multiple gestations.
– Polyhydramnios.
- Placenta previa.
– Abruption placenta.
 Premature rupture of membranes (most common cause).
 Vaginal bleeding.
 Surgery: abdominal procedure.
 Infection: UTI, pneumonia, malaria, typhoid fever syphilis, gonorrhea,
amniotic fluid infection, vaginitis.
 Other associations:
- Fetal gender (male fetuses have shorter gestation period).
- Low magnesium level.
Assessment:
 Cervical dilation.
 Membranes: ruptured or not.
 Presences of sever preeclampsia and hemorrhage.
 Ultrasonography: to determine fetal gestational age, condition and weight.
Management and intervention:
 Special prenatal care for high risk women.
a) Frequent visits for weeks 22 to32.
b) Urine culture at 24 weeks.
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c) Vaginal examination for pH.
d) Education on nutrition and preterm labor.
Signs and symptom reinforced:
a) Increased or change in vaginal discharge.
b) Uterine contractions.
c) Vaginal bleeding or leaking fluid.
 Bed rest and hydration: increase uterine blood flow.
 Continuous monitoring.
 Tocolytics:
- Now most frequently used agents are magnesium sulfate and beta mimetic
agents → acts on β2 receptors on myometrium.
- Maternal transport: tocolytic therapy may improve outcomes by delaying
delivery enough to facilitate transport.
Note : labor is not stopped if one or more of the following are present "exclusion
criteria for tocolytic therapy" :1. Advanced cervical dilation, usually > 6 cm.
2. PROM.
3. Abruption.
4. Fetal distresses or death.
5. Major fetal anomalies incompatible with life.
6. PIH with HELLP syndrome.
 Fetal maturation therapy: glucocorticord therapy.
Nursing care:
 If women is currently in premature labor, she is admitted to hospital and:
- Placed on bed rest, lying on her side.
- Uterine contractions are evaluated and monitored every 1-2 hr.
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- Continuous monitoring of FHR.
- Cervical consistency, dilation and effacement are evaluated.
- Symptoms are evaluated for progress “increasing or decreasing".
- I.V fluids started, intake and output are monitored.
 Once contraction have been stopped and women's condition has stabilized, she
may be discharged and the following done to prevent subsequent occurrence:
- Bed rest maintained.
- Nutritional status is improved with iron and vitamins supplement, especially
vitamin C.
- Usual activity level is evaluated and restricted if necessary.
- Chronic illnesses are monitored closely, acute illnesses are treated promptly.
- Oral medications may be continued at home.
- Prenatal visits are made weekly for remainder pregnancy.
Patient teaching:
1. Teach the symptoms of preterm labor such as uterine contractions in regular
pattern, low dull backache, changes in vaginal discharge and rupture of
membranes.
2. Teach the woman the importance of avoiding stresses and strenuous activity
and getting adequate rest.
3. Assist the woman to plan a nutritious diet.
4. Help the women make life style changes to prevent this condition.
 When preterm delivery can't be arrested, preparations are made for delivery:
1. Administer glucocorticoids as prescribed to help in fetal lung maturation.
2. Give emotional support to the couple, keeping them informed of the progress
of labor, treatment plan and status of their baby.
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Postdate (post term pregnancy or prolonged pregnancy)
Duration of pregnancy: 280 days or 40 weeks from the first day of the LMP or 266
days from ovulation, based on 28 day cycle.
Post term: pregnancy lasting more than 2 weeks beyond the expected date of
delivery “after day 294, 42 completed weeks or more"
Note: post mature, used to describe the infant with recognizable clinical features
indicating a pathologically prolonged pregnancy.
Incidence: 3 % - 12 %.
Etiology: most frequent cause is inaccurate dating of pregnancy.
The exact cause of postterm pregnancy is unknown. However, a possible cause
may be related to a deficiency of placental estrogen and the continued secretion of
progesterone. Low levels of estrogen may result in a decrease in prostaglandin
precursors and the reduced formation of
myometrial oxytocin receptors.
Rare causes:
- Fetal anencephaly, adrenal hypoplasia.
- Lake of cervical prostaglandin production.
Maternal problems:
1. Emotional stress.
2. Potential for delivery trauma.
3. Hemorrhage, infection, and labor abnormalities.
A. Infant problems : much more serious than those for this mother.
1. Oligohydramnios
associated with cord compression, acute fetal
hypoxia and sudden death.
2. Macrosomia
birth trauma, obstructive labor, shoulder
dystocia.
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3. Meconium aspiration
due to thick undiluted meconium as a result of
oligohydramnios.
4. Intraprtum fetal distress.
5. Dysmaturity: at 37 weeks, there is no further growth of the placenta. It ages
rapidly past the fortieth week of gestation; it becomes inefficient and cannot
adequately support the fetus. A decrease in oxygen and nutrients results in
fetal hypoxic episodes.
6. Neonatal problems may include asphyxia, meconium aspiration syndrome,
hypoglycemia, polycythemia, respiratory distress, and dysmaturity syndrome.
Management:
 Weekly vaginal examination, plan induction when cervix is favorable.
 Antepartum fetal heart monitoring, non stress test, ultrasound scans.
 Induction of labor, prostaglandins or oxytocin, forceps- or vacuum-assisted
birth and cesarean birth
 Fetal distress
emergency cesarean section sometimes required.
Precipitate labor
Is one that lasts less than 3 hours from the time of the first contraction to delivery
of baby.
Predisposition factors:
- Multiparity
- Large pelvic
- Small baby in good position.
- Lax and unresistant soft tissue, hyperactive uterine contraction.
- Induction of labor by rupture of membranes and oxytocin infusion.
- May result from hypertonic uterine contractions that are titanic in their
intensity.
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 Multiparous women with little soft tissue resistance are at the greatest risk
for this labor pattern. Patients often progress through the first stage of labor
with little or no pain and may present to the birth setting already advanced
into the second stage. Cervical dilation may occur as rapidly as 10 cm in 1
hour.
 In a nulliparous patient, cervical dilation that occurs faster than 5 cm per
hour is defined as precipitous labor.
Maternal problem:
- Laceration of birth canal.
– Rupture uterus.
- Amniotic fluid embolism.
– Postpartum hemorrhage.
Infant problem:
- Hypoxia from decreased periods of uterine relaxation.
- Intracranial hemorrhage from sudden release of pressure.
Assessment:
Women at risk for precipitate labor are those who have:
- A history of rapid labor.
- Accelerated cervical dilation and fetal descent.
- Uterine contractile patterns with no relaxation between contractions.
- Pain that seems out of the proportion to the contractions.
Patient problems / nursing diagnosis:
1. Trauma to mother and fetus from strong, frequent uterine contractions.
2. Maternal anxiety resulting from unexpected and unusual labor pattern.
Nursing intervention:
1. Prevention of maternal and fetal trauma:
 At risk women are monitored closely and attended constantly to provide rest
and comfort.
 The physician or midwife is kept informed of unusual contraction pattern.
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 Monitor FHR every 15 minutes to detect distress from fetal hypoxia.
 Anesthesia is sometimes used to decrease strength of contractions or to
prevent involuntary pushing during delivery. Watch for sings of impending
uterine rupture.
 Stop oxytocin immediately (if being administered).
 Turn the woman to her left side to promote blood supply to the uterus and
oxygen is started at once.
 If birth can't be halted, nurse must never hold a woman's legs together; such
action may damage the fetal head.
 Following birth, evaluate infant carefully for signs of injury.
 Examine the woman for cervical, vaginal or perineal laceration.
2. To reduce anxiety:
 Explain to couple what is happening.
 Assist women in retaining a sense of control over what is happening to her.
Provide her with as many choices in her care as she desires or is able to
handle.
 Following birth, have the woman hold her infant as soon as possible for
reassuring that all is well.
Dystocia
 Is defined as difficult birth as opposed to easy (normal) birth or eutocia.
 Dystocia, defined as a long, difficult or abnormal labor, is a term used to
identify poor labor progression.
Predisposing factors “Etiology"
 Dystocia may arise from any of the three major components of the labor
process—the powers (uterine contractions), the passenger (fetus), or the
passageway (maternal pelvis).
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- Hypertonic or hypotonic uterine contractions.
- Multiple gestations.
Contracted pelvic.
- Abnormal implantation site of the placenta. - Fetopelvic disproportion.
- Large baby.
- Malposition and malpresentation.
- Previous experience.
- Poor support system.
Types:
1. Mechanical dystocia:a) Maternal causes: contracted pelvis, obstructive tumor…
b) Fetal causes: malformation of the fetus as hydrocephalus or large
size baby, malpresentation as shoulder, face or breech.
2. Functional dystocia: (uterine dysfunction or inertia).
Condition in which uterine contractions deviate from the normal
contractions may be extremely forceful with a rapid and traumatic
labor,
more commonly, the contractions are ineffectual.
Hypotonic uterine contraction (inertia)
 Hypotonic labor is defined as less than 3 contractions of mild to moderate
intensity occurring in a 10 minutes period during the active phase of labor.
 The intrauterine pressure (IUP) is insufficient for the progression of cervical
effacement and dilation.
 Cervical dilation and descent of fetus slow greatly or stop.
Etiology:
 Such labor occurs when uterine fibers are overstretched from large baby,
twins, hydramnios, or multiparity.
 May also be caused by administration of sedations or narcotics.
 Bowel or bladder distention.
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Potential maternal effects:
- Exhaustion.
- Postpartum hemorrhage.
- Stress and psychological trauma.
- Infection.
Potential fetal effects:
- Fetal sepsis (Infection).
- Fetal and neonatal death.
Medical management:
 Walking and position changes in labor assist in fetal descent through the
maternal pelvis and therefore need to be encouraged.
 The use of relaxation techniques & massage can decrease the need for
pharmacological agents for pain.
 Oxytocic stimulation of labor or prostaglandin stimulation.
Nursing intervention:
 Pelvis is reevaluated for size.
 IV fluids are provided to maintain hydration and electrolyte balance.
 Oxytocin administration is started if pelvic size is adequate, fetal
position and presentation is normal.
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- Monitor FHR and contractions, if contractions last more than 60-70 seconds,
decrease or stop infusion to prevent rupture of uterus and premature
separation of the placenta and fetal hypoxia.
- Observe IV drip, be certain that infusion is running at the prescribed rate.
- Report any maternal or fetal distress immediately.
 Amniotomy may be performed to augment labor.
 Use anxiety-reducing measures to promote psychological and emotional
status.
Hypertonic uterine contraction
 Hypertonic labor usually occurs in the latent phase of labor, with an increase
in frequency of contractions and a decrease in their intensity.
 Contractions are strong and often painful but are ineffective in producing
cervical effacement and dilation.
 An increase in maternal catecholamine release (i.e., epinephrine,
norepinephrine) can result in poor uterine contractility. Uterine pacemakers
(the energy source of contractions located in the uterine wall) do not initiate a
good myometrial response needed for progressive cervical change. Instead,
irregular spasmodic episodes occur that do not result in effective contractions
or assist in bringing the fetus into a more favorable downward position
 Contraction may be uncoordinated and involve only portions of the uterus.
 Usually occurs before 4 cm dilation. The cause is not yet known, may be
related to fear or tension.
Potential maternal causes:
 Maternal anxiety (Primiparous labor, Loss of control, Sexual abuse, Lack of
support, Cultural differences, Fear of pain)
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Potential fetal causes:
 occiput–posterior malposition
Medical management:
 Analgesic (morphine, meperdine) if membranes are not ruptured and
fetopelvic disproportion isn't present.
 Natural labor with effective contractions often resumes after this simple
intervention.
 Nonpharmacological techniques to reduce anxiety such as relaxation
techniques, massage, a warm shower or tub bath, and increased emotional
support are also helpful for some women.
 For a woman whose fetus is in an occiput–posterior position, the major goal of
care is to facilitate rotation of the fetal head into a more favorable position
(walk and change positions frequently).
Nursing intervention:
 Provide bed rest with end of sedatives to promote relaxation and reduce pain.
 Provide fluids to maintain hydration and electrolyte balance.
 Observe for normal contractions when woman awakens.
 Oxytocin is not administered; it will increase the abnormal labor pattern.
 Check intake and output every 2 hr.
 Monitor vital signs and FHR.
 If the condition is prolonged, check for CPD and malpresentation, if excluded,
amniotomy and oxytocin infusion may be instituted.
 Reduce anxiety; give psychological and emotional support measures.
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Contracted pelvis
 A contracted pelvis is one in which the bony funnel of the woman’s pelvis is
too narrow at some point for the fetus to pass through.
 Term used with pelvic diameter 1 cm or more less than normal (except
transverse, diameter 2 cm). This may involve one or more diameters.
Causes:
- Growth retardation.
-Sever disease e.g. anemia.
- Growth disease e.g. T.B.
-Bone disease e.g. rickets.
 Before pregnancy, pelvic measurement can be identified using clinical and Xray pelvimetry.
 During pregnancy sonography is used to measure the fetal head in relation to
the pelvis.
 When measurements are minimal in one or more places, they are described as
marginal pelvis if the infant has a moderately small head, is in normal position
and contractions are forceful.
 When measurements are marginal, the physician may decide to allow a trial
labor for a few hours, vaginal delivery may be accomplished and the women
is spared a major surgery.
 If there is little or no progress in baby's descent, cesarean birth is performed.
 The couple needs support to cope with the stress of complicated labor and
participate in the decision regarding cesarean birth.
Cephalopelvic disproportion
 Is fetal head to maternal pelvis discrepancy.
 Fetopelvic disproportion term used with other than cephalic
presentation.
 When CPD is great, it is impossible for fetus to pass.
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 CPD is suspected when labor is prolonged, cervical dilatation and effacement
are slow and engagement of the presenting part is delayed.
 Contractions are monitored as well as FHR.
 Trial labor is allowed to continue only as long as dilation and descent
progress.
 If there is no progress, cesarean birth is performed.
 Nursing care as contracted pelvis and other complicated labors.
 Maternal complications of such labor include PROM, uterine rupture and
necrosis of maternal soft tissue from pressure of the fetal head.
 Fetal complications include cord prolapse, extreme molding of the skull with
possible fractures and intracranial hemorrhage.
Multiple pregnancies
Introduction of ovulation inducing agents in late 1960s and assisted reproductive
technologies (ART) in the 1970 caused increased number of multiple births.
Much of perinatal mortality and morbidity attributable to multiple births is due to
preterm delivery.
Twin gestation:
 1% all births.
 Represent a high-risk pregnancy.
Types of twining:
1) Monozygotic (identical): are identical because they develop from
fertilization of one ovum. "The same sex" occurs at random in about 3 to
4/1000. develop from one fertilized oocyte (zygote) that divides into equal
halves during an early cleavage phase (series of mitotic cell divisions) of
development.
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2) Dizygotic (fratermal): twining occurs more frequently in some families
"heredity is important on mother’s side".
- Occurs in response to greater levels of FSH.
- Increased in women greater than 35 years of age and in obese women.
- More common among Africans (10 to 40/1000).
- May be different sexes.
- Always have 2 chorions, 2 amnions.
- Result from fertilization of 2 separate ova.
- Fertility drug use associated with dizygotic twinning such as clomide and
pergonal.
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Note: Conjoined twins with shared organs occur as a monozygotic twins through
division of the fertilized ovum after the 13th day post conception.
Maternal complications:
 Greater increase in blood volume, pulse, cardiac output and weight gain.
 Increased rate of preterm labor, hypertension, abruption, anemia,
hydramnios, UTI, cesarean section and postpartum hemorrhage.
Infant complications:
 Prematurity –average age of delivery is 37 weeks.
 Discordance: defined as a difference of greater than 20% to 25% in weight.
Etiology:
- Difference in placental surface area.
- Donor twin→ small, pale, anemia.
- Recipient twin→ large, plethoric, polycythemia, hyperbilirubinemia.
 Fetal anomalies occur more often in multiple pregnancies.
Clinical manifestation:
1. Uterus larger than expected for length of gestation.
2. Two fetal heart tones can be counted simultaneously.
3. Abdominal palpation yields many small parts by 6-7 months.
4. U/S usually used to confirm the diagnosis.
5. Oversized uterus and increased abdominal pressure often lead to:
- Diagnosis difficulty
- Constipation
- Dyspnea
- Backache
- Hemorrhoids &other varicosities.
Triplets:
 Increasing frequency because of ART.
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 Average weight gains 45 to 50 pounds.
 Usual spontaneous time for delivery is 32-34 weeks.
 Average weight 1800-1900 grams.
 Most delivered by cesarean section.
Quadruplets or more:
 Most are a result of ART.
 Average weight gains 50 to 55 pounds.
 Average gestational age 30 to 31 weeks.
 Average weight 1200-1500 grams.
Multifetal reduction, has been shown to improve perinatal survival rate.
Assessment:
 Initial maternal assessment includes a family history of twinning or use of
fertility drugs.
 At each prenatal visit, assess fundal height, FHR, fetal development.
 U/S to confirm the diagnosis.
 Assessment of physical discomforts such as backache and dyspnea.
 Multiple pregnancies increase the incidence of PIH, prematurity, hydramnios,
abnormal fetal positions and presentations, uterine dysfunction, and
postpartum hemorrhage.
Nursing intervention:
To prevent premature delivery:
 Encourage the woman to keep appointments for more frequent checkups.
 Counsel the woman to rest frequently during the day especially in the third
trimester; assist the family to mobilize support system for this purpose.
 Teach the woman reportable signs and symptoms of premature labor.
 Diet high in protein, iron, calcium, 300 calories added to normal pregnancy.
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 Monitor for hypertensive disorders.
 During labor, mother and fetuses are monitored closely.
 Ideally, the largest fetus is delivered through vertex presentation and is the
first to be born. If the first is a breech presentation or the smaller one, delivery
is complicated.
 Cesarean birth is recommended if fetal distress, CPD, placenta previa, or sever
PIH is present or if prior cesarean birth have occurred.
 Following delivery, monitor the woman for postpartum hemorrhage due to
over distended uterus.
Health education:
 Rest frequently on her side.
 Sitting with leg elevated to help relief backache.
 Small frequent meals will aid digestion.
Malpositions and malpresentations
Even when the fetus is of normal size and birth canal is adequate, delivery may be
complicated if the baby's position in relation to the mother's pelvis is abnormal. In
9 of 10 deliveries the position of the baby at birth is occiputo anterior. That is the
face is toward the mother's back and the occipital bone is toward the mother's
pubis. Unless there are other problems of size or uterine power, this fetal position
allows the baby to pass through the irregular birth canal with least difficulty. Any
other position or presentation complicates delivery to some degree is termed as a
malpresentation or malposition.
Two positions of special concern are occiput posterior and breech presentation.
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Occiput posterior position
Is one of the most common obstetrical problems. When in this position, the fetus
must rotate 135 degrees to occiput anterior, as a result, labor is prolonged, dilation
and descent are slowed and the woman experiences intense back pain because the
fetal head presses on sacral nerve.
Management and nursing intervention:
1. Relief back pain as much as possible by sacral pressure, back rubs, frequent
change of position from side to side, this also may assist fetal head to rotate.
2. Observe uterine contractions and FHR closely.
3. IV fluids are used to prevent dehydration and to provide glucose needed for
effective contractions.
4. When cervix is completely dilated, fetal head may be rotated by physician.
Waiting may result in spontaneous rotation. Manual rotation to occiput
anterior. If there are signs of fetal distress or lack of progress → surgical
intervention by forceps or large mediolateral episiotomy.
5. Provide encouragement and reassurance to woman/couple throughout labor.
Complication:
- Prolonged labor.
- Dehydration.
Ketoacidosis.
- Fetal distress.
Perineal tear or laceration.
- Electrolyte imbalance.
-
Breech presentation
 Presentation in which buttocks and or feet are nearest the cervical opening
and are born first.
 Occurs approximately in 3 % of all deliveries.
 Cause is unknown but it seems to be related to inability of the fetus to move
freely within the uterus.
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 Breech presentation is associated with:
- Preterm labor.
- hydramnios.
- Multiple pregnancies.
- Fetal defect of cranium.
Diagnosis:
- Previous history.
– History of predisposing factors.
- Vaginal examination: buttocks, sacrum or lower extremities are found.
- Ultrasound.
– X-RAY.
Types:
1. Complete: buttocks is the presenting, legs are flexed against thighs and
thighs flexed against abdomen.
2. Frank: buttocks is the presenting part with the lower extremities hyper
extended.
3. Incomplete: foot extends below buttocks.
Management and nursing intervention:
 Labor may be longer, since in breech delivery the soft buttocks don't aid in
cervical dilation as well as head dose.
 Analgesia may be limited in order not to interfere with the mother's ability to
push effectively.
 Amniotomy is not done until breech is well engaged because there is a
greater danger of cord prolapse with footling presentation or breech that
doesn't fill the pelvic cavity.
 Breech presentation may be delivered spontaneously with strong
contractions particularly in multi-para.
 More aid is indicated (application of forceps) for the majority of women
especially primigravida.
 Cesarean delivery is a better approach than difficult extraction.
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 To prevent fetal and mother complications, version at 37 weeks gestation
may be attempted.
Types of version:
1. External (cephalic): is the use of external abdominal manipulation to rotate
the fetus from breech to transverse to cephalic at 37 weeks after tocolytic
drug has been given to relax the uterus and with continuous FHR
monitoring.
2. With internal version, the physician rotates the fetus by inserting a hand into
the uterus and changes the fetal presentation to cephalic (head) or podalic
(foot).
It is an emergency measure used to deliver a second twin, when the cord has
prolapsed or when immediate delivery is required.
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3. Combined: is the use of both internal and external version to trun a fetus into
most favorable position.
Complications of breech presentation:
To the fetus:
Complications associated with version include umbilical cord compression,
placental abruption, maternal hemorrhage, and fetal bradycardia.
To the mother.
- Prolonged labor, exhaustion, and dehydration.
- Perineal tear and laceration.
- Infection.
Uterine rupture
Uterine rupture is a spontaneous or traumatic rupture of the uterus.
Causes:
 Rupture of the scar from a previous cesarean delivery or hystrotomy.
 uterine trauma
 congenital uterine anomaly.
 Prolonged or obstructed labor.
 Forced delivery of fetus with abnormalities e.g. hydrocephalus.
 Internal of external version.
 Application of forceps and extraction before cervical os has completely
dilated.
 Injurious use of oxytocin.
 Excessive manual pressure applied to the fundus during delivery.
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Clinical manifestation:
1. Complete rupture:
- Sudden sharp abdominal pain during contractions.
- Abdominal tenderness.
– Cessation of contractions.
- Bleeding into abdominal cavity and sometimes into vagina.
- Fetal easily palpated, fetal heart tones cease.
- Signs of shock.
2. Incomplete rupture:
- Develops over a period of few hours.
- Abdominal pain during contractions.
- Contractions continue, but cervix fails to dilate.
- Vaginal bleeding may be present.
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- Tachycardia, pale skin.
- Loss of heart tones.
Management and nursing intervention:
- Emergency laparotomy is performed with complete rupture, usually the
uterus is removed and attempts are made to save the baby.
- Administer IV fluids and blood as directed.
- Administer oxygen to the woman.
- Prepare the woman for emergency surgery.
- Monitor maternal and fetal vital signs until surgery begins.
- Uterus may be repaired if rupture is not extensive, if extensive hysterectomy
is necessary.
Reduce fear and anxiety:
- Keep the woman informed about procedures being done.
- Answer her questions as positively and as realistically as possible.
- Fetal prognosis is very poor, unless delivery can be accomplished
immediately.
- Maternal prognosis is guarded, especially in uterine rupture of traumatic
origin (5-10 % mortality). If fetus doesn't survive, offer grief counseling. If
the uterus is spared, woman is advised to have cesarean birth with future
pregnancy.
Amniotic fluid embolism.
 Is the accidental infusion of amniotic fluid in to the mother's blood stream
under pressure from the contracting uterus. Amniotic fluid containing fetal
vernix, lanugo, meconium, and mucus enters maternal blood sinuses
through defect's in to the placental attachment, these particles become
emboli in the mother’s general circulation causing acute respiratory,
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circulatory collapse, hemorrhage and corpulmonale as they block the vessels
of her lungs.
 These particles stimulate abnormal coagulating, initiating DIC.
 Amniotic fluid embolism is rare and usually fatal (mortality rate is as high as
80% for mothers & approximately 50% of neonates)
Clinical manifestations:
- Sudden dyspnea and chest pain.
- Pulmonary edema.
– cyanosis.
– tachycardia.
– Prolonged shock due to:
1. Anaphylaxis, which cause vascular collapse.
2. Uterine bleeding with development of hypofibrinogenemia.
Management and nursing intervention:
Emergency measures are instituted immediately including, cardiopulmonary
resuscitation (CPR).
1. Improving tissue perfusion and cardiopulmonary function.
2. Administer O2 as soon as possible, when situation is recognized.
3. Provide assisted ventilation.
4. Maintaining fluid volume and correction of DIC.
5. Administer fresh whole blood and fibrinogen.
6. Administer IV fluids and plasma.
7. Provide continuous monitoring of maternal and fetal status.
8. Delivery of fetus.
9. Since fetus is in great danger, delivery is used.
10. Care for the neonate and provide family members with comfort and
information about the status of mother and infant.
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Prolapsed Umbilical Cord
Umbilical cord prolapse occurs when a loop of the umbilical cord slips down
below the presenting part of the fetus.
Types
1. Occult prolapse (hidden; not visible), occurs at any time during labor whether or
not the membranes have ruptured—the cord lies beside the presenting part in the
pelvic inlet.
2. Complete prolapse, the cord descends into the vagina, where it is felt as a
pulsating mass on vaginal examination. It may or may not be seen.
3. Frank (visible) prolapse most commonly occurs immediately after rupture of
membranes as gravity washes the cord in front of the presenting part.
Causes:
4. Rupture of membranes, when the presenting part is not engaged in the pelvis.
5. More common in shoulder & foot presentation.
6. Prematurely: small fetus allows more space around presenting part.
7. Hydramnios: causes greater amount of fluid to be related with greater force
when membranes rupture.
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8. Contracted pelvis.
9. Placenta previa.
Clinical Manifestation:
 Cord may be seen protruding from vagina, or can be palpated in the vaginal canal
cervix.
 Signs of fetal distress: the cord is compressed between the presenting part and
bony pelvis.
 If cord is exposed to cold room air, there may be reflex constriction of umbilical
vessels, restricting oxygen flow to fetus.
 Fetal heart rate pattern may be irregular with periodic fetal bradycardia.
Management & Nursing Interventions:
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Maintaining oxygen supply to fetus:
-Until the presenting part has engaged, all women whose membranes have ruptured
should remain on bed rest.
-At the time of spontaneous rupture or amniotomy, FHR is assessed continuously, if
bradycardia is noticed, assess for cord prolapse.
-Place the women in recovery or knee-chest position.
-Administer oxygen to the women.
-Place sterile gloved hand in vagina and push the fetal head up ward to relief
compression of the cord.
-Prepare of immediate vaginal delivery if cervix is dilated.
-Prepare of immediate cesarean delivery if cervix is not deleted.
-In home situation, cover-protruding cord with clean wet dressing. Elevate the woman's
hips and transports to hospital immediately.
Reducing Anxiety:
-Have the woman/couple hear fetal heart tones for reassurance.
-Keep the woman informed of procedure being performed.
-When infant is born and stabilized, have the woman/couple hold him as soon as possible
for reassurance.
Uterine Inversion
Uterine inversion (uterus is turned inside out) is a rare but potentially lifethreatening complication.
Possible causes:
Most common cause is excessive pulling on the umbilical cord in an attempt to
hasten the third stage of delivery. Other contributing factors include vigorous
fundal pressure, uterine atony, and abnormally adherent placental tissue.
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Clinical Manifestations:
When complete inversion occurs, a large, red, globular mass (that may contain the
still-attached placenta) protrudes 20 to 30 cm outside the vaginal introitus.
A partial or incomplete inversion is not visible; instead, a smooth mass is palpated
through the dilated cervix.
Maternal symptoms include pain, hemorrhage, and shock.
Management
Involves manual replacement of the fundus (under general anesthesia) by the
physician, followed by oxytocin to facilitate uterine contractions and antibiotic
therapy to prevent infection. Prevention (by not pulling strongly on the cord until
the placenta has fully separated) is the safest and most effective therapy.
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Operative Obstetrics
Operative obstetrics refer to a number of procedures (episiotomy, forceps delivery,
cesarean delivery) that may be used to assist the mother in labor and delivery.
Episiotomy
Is an incision made in the perineum to enlarge the vaginal outlet during the second
stage of labor. It serves the following purposes:
 Prevent tearing of the perineum. It substitutes a straight surgical incision for the
laceration that may otherwise occur.
 Facilitate repair of laceration and to promote healing.
 Minimize prolonged and severe stretching of the muscles supporting the
bladder or rectum which may later lead to stress incontinence or vaginal
prolapse.
 Shorten the second stage, which may be important for maternal reasons, as PIH
or fetal reasons as persistent bradycardia.
 Enlarges the vagina in case manipulation is needed to deliver an infant for
example in a breech presentation or for application of forceps.
Types of Episiotomies:
The type of Episiotomy is designated by site and direction of the incision.
1. Median:
- Is the one most commonly employed.
- It is effective, easily repaired and generally the least painful.
- Incision is made in the middle of the perineum and directed toward the
rectum.
- Is believed to heal with few complications, more comfortable for the
woman.
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- If a long and large incision is needed during delivery, it may necessitate
incision into anal sphincter.
2. Mediolateral:
- Incision is made laterally in the perineum to the 5 o’clock or 7 o’clock
position.
- This method avoids the anal sphincter if enlargement is needed.
- Women find it very uncomfortable during healing.
- The blood loss is grater, the repair is more difficult.
Note:
Because sutures used to repair episiotomy are of absorbable material they don't
need to be removed and no dressing is applied.
Assessment:
- The Episiotomy site is inspected every 15 minutes during the first hour after
delivery, then on a daily basis.
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- The site is assessed for redness, edema, ecchymosis, discharge, and
approximation (REEDA) and
- then document all findings.
Management and nursing interventions:
 Patient teaching:
- Explain reasons for episiotomy.
- Discuss methods to reduce discomfort and promote healing.
- Explain that with good hygienic measures, healing should be completely
reached in several weeks.
- Inspect area daily for signs of infection.
 Reduction of pain and discomfort:
- Apply ice packs after procedure to reduce edema and promote comfort during
the first 24 hours.
o The ice bag should be wrapped in a towel or disposable paper cover to
prevent a thermal injury. Application of cold provides local anesthesia and
promotes vasoconstriction while reducing edema and the incidence of
peripheral bleeding.
o Thereafter, warm sitz baths (3-4 times a day) and dry heat help increase
circulation to the area and promote healing.
- Use local analgesic sprays or oral analgesic to promote comfort.
Forceps Delivery
Obstetric forceps are made from two double-curved, spoon-like articulated blades.
Forceps are designed for rotating or extracting the fetal head.
Conditions Requiring Forceps Delivery:
1. Fetal conditions:
- Fetal distress.
- Cord prolapsed.
- Abruption placenta.
- Excess pressure on the fetal head from arrested descent.
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2. Maternal conditions:
- Eclampsia.
- Heart disease.
- Maternal hemorrhage.
- Maternal exhaustion.
- Failure of progress in the second stage because of poor uterine contractions
(dystocia).
Prerequisites for application of Forceps:
 Cervix must be completely dilated.
 Fetal head must be engaged, preferably deeply engaged.
 Vertex or face presentation. (Accurate diagnosis of position station).
 Pelvis should be adequate with no disproportion.
 Membranes should be ruptured.
 Some form of anesthesia should be used.
 Rectum and bladder should be empty to avoid laceration and fistula formation.
 Forceps are never applied to an unengaged presenting part.
Types of Forceps delivery:
1. Outlet forceps are used when the fetal scalp is visible on the maternal perineum
without manual separation of the labia.
2. Low Forceps: forceps are applied after the head has reached the perineal floor
(at a +2 station or more). This will be an easy forceps delivery.
3. Mid Forceps: are used when the fetal head is engaged but at less than a +2
station.
 Because birth trauma has been associated with the use of midforceps, this
procedure has been largely replaced by cesarean birth, which poses less
risk to the fetus.
Management and Nursing Intervention:
 Reducing any anxiety:
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- Explain needs for forceps delivery.
- Keep the woman informed of procedures progress.
- Focus on positive outcome of the birth.
 Reducing potential for trauma and subsequent complications:
- Assist the woman to relax between contractions.
- Have the woman empty her bladder.
- Monitor the woman for signs of complications following forceps delivery.
a) Laceration of vagina and cervix (bleeding, tachycardia, hypotension).
b) Rupture uterus (massive bleeding, shock).
c) Injury to bladder to rectum.
- Check and record FHR before forceps are applied.
 Examine the infant for complications following forceps delivery:
- Facial paralysis.
- Injury to eyes and skull.
- Abrasions of the face.
Vacuum Extraction (Vacuum Assisted-birth)
A vacuum extractor applies suction to the fetal head creating an artificial caput
within the suction cup, thus allowing adequate traction for delivery of the infant's
head.
Uses:
- Dysfunctional labor.
- Fetal distress.
- Abruptio placenta.
- When forceps are to be avoided.
- Maternal cardiopulmonary disease.
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- PIH.
Nursing Intervention:
1. Explain procedure to the woman and why it is needed.
- Help the woman relax during application of suction to fetal scalp.
- Coach the woman to push with contractions when needed.
2. Following delivery:
- Examine the infant's scalp for lacerations, cephalohematoma or intracranial
hemorrhage.
- Examine the woman for vaginal or cervical lacerations.
- Explain to the woman that fetal caput will regress in a few days.
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Cesarean Delivery
Is removal of the infant from the uterus through an incision made in the abdominal
wall and in the uterus.
Indications:
1. Cephalopelvic disproportion (CPD).
2. Uterine dysfunction, inertia, inability of the cervix to dilate.
3. Neoplasm obstruction birth canal or pelvis.
4. Malposition and malpresentation.
5. Previous uterine surgery (cesarean delivery, hysterotomy …).
6. Complete or partial placenta previa.
7. Abruption placenta.
8. Fetal distress.
9. Prolapsed umbilical cord.
The basic purpose of cesarean delivery is to preserve the life or health of the
mother and her fetus.
Types of Cesarean Delivery:
1. Low Segment (Operation of choice):
 Incision is made transversely in lower uterine segment, in the thinnest
portion so that blood loss is minimal and uterus is easier to open. Lower
uterine segment is also area of least uterine activity.
 Postoperative convalescence is more comfortable.
 Possibility of later rupture is lessened.
 Peritoneal flap is brought over uterine incision, preventing lochia from
entering peritoneal cavity.
 Incidence of postoperative adhesions and danger of intestinal obstruction are
reduced.
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2. Classic:
 Vertical incision is made directly into the wall of the body of uterus.
 Useful when bladder and lower uterine segment are involved in extensive
adhesions.
 Useful when fetus is in transverse lie.
 Selected when anterior placenta previa exist.
 Rarely used today, the classic cesarean incision is reserved for some cases of
shoulder presentation, placenta previa, and when birth must take place
immediately. Since this type of uterine incision is associated with
complications including considerable blood loss, infection, and uterine
rupture with subsequent pregnancies, women who undergo classic cesarean
births may not attempt future vaginal births.
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Nursing Intervention:
 Preparations for Emergency cesarean birth:
Standard preoperative measures include:
- Nothing by mouth (NPO).
- Abdominal and perineal shaved from nipple line to pubis.
- Indwelling catheter to dependent drainage.
- Signed operative permit.
- Two units of whole blood ready for administration.
- I.V. line in place.
- Preoperative medications (atropine), narcotics are avoided.
- Infant preparations: warmer, resuscitation and suction equipment, and
notification of the pediatrician.
 Promoting Coping Abilities:
- Have the woman discuss her perception of why the cesarean delivery is needed,
correct misinformation and provide further knowledge.
- Have the woman / couple listens to fetal heart sounds to reassure them of the
well being of the fetus.
- Explain postoperative care and procedures:
 Provide Postoperative Care similar to that following abdominal surgery:
- Observe for hemorrhage, inspect perineal pads and abdominal dressing, and
assess vital signs frequently.
- Administer oxytocics as prescribed.
- Check fundus for firmness.
- Continue IV fluid as prescribed.
- Check urinary output from indwelling catheter for amount and evidence of
bleeding.
- Provide medications to relief pain as prescribed.
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- Encourage woman to turn frequently from side to side, to breathe deeply and to
cough.
- Assist woman out of bed on first postoperative day.
- As soon as possible, have the woman hold and care for infant to reassure her of
infant's well being.
- Maintain cleanliness and prevent infection.
Note:
When a mother who has had cesarean birth wants to deliver vaginally, a trial labor
may be undertaken.
 She must be in a good health, her medical history should be available, and the
fetus should be in vertex position with no CPD or other complications.
 The birthing center must be able to provide fetal and maternal monitoring,
blood transfusions, anesthetic services and physician availability.
Induction of Labor
 Is the deliberate initiation of uterine contractions before their spontaneous
onset.
 Is the use of physical or chemical stimulants to initiate or intensify uterine
contractions.
 The need for initiating labor may arise from maternal or fetal sources. E.g. PIH,
postterm pregnancy , D.M, PROM, I.U.F.D….
 Elective induction may be indicated for the woman who has a history of
precipitate labor to avoid unexpected out of hospital birth.
 There are a number of medically approved methods to induce labor; they
include chemical induction with prostaglandins, oxytocin and mechanical as
rupture of membranes.
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Prostaglandins
- A prostaglandin gel for local application to the cervix has been formulated to
soften the cervix and induce labor.
- For those women whose cervix is unfavorable, induction using PGE is more
effective than using oxytocin.
- On admission, routine assessments are completed, dilation of cervix and
effacement are determined.
- A 30 minutes electronic monitoring of FHR and uterine contractions is done to
establish base line data.
- The physician instills 0.5 mg of PGE intracervically using a plastic catheter.
The catheter is then removed.
- The woman remains in bed for 30 minutes, then may ambulate.
- FHR, BP and pulse are monitored at least every 30 minutes.
- Contractions usually begins 1/2 hour after administration of gel, the time of
contraction is recorded.
- An amniotomy is performed at 4 cm of cervical dilation and internal fetal
monitoring is applied.
- Progress of labor is recorded.
- Any hypertonic contractions of the uterus are reported immediately.
- If the woman doesn`t deliver within 24 hours, the cervix is reassessed and an
induction using oxytocin is done if indicated.
- Because prostaglandin administration is effective, free of side effects and non
invasive, some authorities believe it will replace amniotomy and oxytocin as the
method of choice for induction of labor.
- The woman is kept informed of the progress of labor.
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Oxytocin
May be used either to induce the labor process or to augment a labor that is
progressing slowly because of inadequate uterine contraction, or to assess fetal
response to the stress of contractions (OCT).
Indications:
- Prolonged pregnancy.
- Preterm delivery in diabetic mother.
- Severe Preeclampsia, Abruptio placenta or I.U.F.D.
- Multigravida with a history of precipitate labor.
- Prolonged rupture of membrane.
- Management of abortions.
Contraindications:
- Fetopelvic disproportion .
- Fetal distress.
- Previous uterine surgery.
- Over distended uterus e.g. multiple pregnancy.
Hazards:
 Maternal: titanic contractions, Abruptio placenta, Postpartum hemorrhage,
infection, DIC, Amniotic fluid embolism, anxiety and fear.
 Fetal: Asphyxia, Hypoxia, physical injury and Prematurity.
 10 IU of oxytocin is added to 1L of 5% dextrose or saline solution.
 Initial dose 2 milliunits/minute via constant infusion pump.
 Dose is increased every 15-20 minutes until dose is 20 milliunits per minute.
 Monitor the woman's BP, P, respiratory rate, contractions and FHR every 15
minutes.
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 If FHR indicate distress or if contractions last 70 seconds or more, reduce or
discontinue administration immediately.
 Increase IV solution without oxytocin, give O2, turn on her left side and call the
physician.
 Satisfactory labor has usually been initiated when the woman has 3 contractions
in 10 minutes.
 Reduce anxiety.
Amniotomy
 Transcervical amniotomy or artificial rupture of membranes can be used to
stimulate labor.
 The cervix should be soft, partially effected and slightly dilated with presenting
part engaged.
 Vulva is cleansed.
 Simple rupture of the membranes using sharp instrument passes over a finger
into the cervix will allow the discharge of amniotic fluid.
 Procedure is explained to the woman, FHR recorded.
 Note and record amount and quality of fluid (clear, color, bloody,
meconium…).
 Artificial rupture of the membranes is often done to augment labor already in
progress, since the membranes serve as a barrier against infection.
 Delivery is usually accomplished soon after the membranes have been ruptured
artificially.
 Some obstetricians prefer to first stimulate the uterus with IV oxytocin and as
soon as good contractions are evident, rupture the membranes. Others prefer
merely to rupture the membranes.
 Reduce anxiety.
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Postpartum Complications
Puerperal Infection “Puerperal Sepsis”
 Is any clinical infection of the genital canal and breasts that occurs within 28
days after abortion or delivery.
 Postpartum infection of genital tract usually of the endometrium that may
remain localized or may extend to various parts of the body.
 Infections may result from bacteria commonly found in the vagina
(endogenous) or from the induction of pathogens from outside the vagina
(exogenous).
 The most common microorganisms are Streptococci, E. coli, Staphylococci,
Sexually Transmitted Diseases (STDs), Anaerobic microorganisms as
Tetanus and gas gangrene.
 Puerperal infection may occur anywhere in the pelvis or birth canal as
endometritis, vaginitis, vulvitis.
Predisposing Factors:
1. Prolonged labor
2. Postpartum hemorrhage. 3. PROM.
4. Infection elsewhere in the body.
6. Anemia.
5. Intrauterine manipulation.
7. Retention of placental fragments.
8. Malnutrition.
• Endometritis usually occurs at the placental site.
• Localized infection may be followed by salpingitis, peritonitis & pelvic
abscess formation, & septicemia may develop.
• Secondary abscesses may arise in distant sites such as the lungs or liver.
Pulmonary embolism or septic shock with DIC from any serious genital
infection may prove fatal.
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Clinical Findings:
 Symptoms may be mild or fulminating
 Any fever with a temperature of 38 ºC or more on 2 successive days (not
counting the first 24 hours after delivery) must be considered to be caused
by puerperal infection in the absence of another cause.
1. Endometritis
 Endometritis is the most common puriperal infection and it occurs 24-48
hours after delivery.
 Uterus usually larger than expected for postpartum day.
 Lochia may be profuse, bloody and has a foul smelling.
 Chills, fever, anorexia and general malaise.
 Risk factors
 Cesarean birth
 Prolonged rupture of the membranes
 Multiple vaginal examinations
 Internal electronic FHR monitoring
 Low socio-economic status
 Poor nutrition, young age
 Diabetes
 Prior genital infection
 Inadequate aseptic technique
 Anemia
 Smoking
 Nulliparity
 Operative vaginal delivery
 Poor postpartum perineal care
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2. Parametritis Pelvic Cellulitis
 Infection of the pelvic connective tissue.
 Chills, fever, tachycardia, severe unilateral or bilateral pain in the lower
abdornen and tenderness on vaginal examination usually occur about the 4 th
postpartum day.
 May result from infected wound in the cervix, vagina, peritoneum or lower
uterine segment.
 Uterus may be longer than expected.
 Pelvis area warm with an extremely sensitive spot due to an abscess
formation underneath.
 Incision and drainage is performed if an abscess form,
3. Thrombophlebitis
 Inflammation oft venous wall with clot formation.
• Pelvic Thrombophlebitis:
 Infection of veins supplying uterine wall and broad ligament.
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 Symptoms usually begin during in the 2nd week following delivery.
 The women may have severe chills and intermittent high fever (40 ºC), ?
redness, increase skin temperature,
 Blood cultures are taken to isolate the organisms.
• Femoral Thrombophlebitis:
 - Pain, tenderness, redness, hotness, edema of the calf or thigh.
4. Bacteremia
 Presence of bacteria in the blood stream.
 Result of infected thrombi breaking loose.
 Chills, fever, tachypnea, pale skin, cyanosis of the lips and fingers, increase
lochial secretions with foul odor.
5. Peritonitis
 Inflarnmation of the peritoneurn.
 Chills, high fever, tachycardia, vomiting, severe abdominal pain.
Diagnostic Evaluation:
 Clinical history.
 Physical examination.
 Leukocytosis, high neutrophils.
 Culture and sensitivity for discharge and blood for both aerobic and
anaerobic organisms.
 Lung scan, chest X-ray.
Management and Nursing Interventions:
 The most effective and cheapest treatment of puerperal infection is
prevention.
Preventive measures include:
 Good prenatal nutrition.
 Treatment of anemia.
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 Control of intranatal hemorrhage.
 -Good inraternal hygiene.
 Prolonged labor should be avoided.
 Traumatic vaginal delivery should be avoided.
 Best aseptic techniques by medical personnel.
 Determine source of woman’s anxiety regarding complications.
 Explain prescribed treatment regimen.
 Correct misinformation.
 Monitor the woman’s condition:
 Continue monitoring of temperature, pulse and respiration.
 Isolate the woman with infection from other postpartum women.
 Maintain fluids and electrolytes.
 Blood may be necessary to combat severe anemia.
 Antibiotic therapy as prescribed.
 Monitor site of infection for manifestations.
 Provide diet with increased calories, protein and vitamins to promote
healing.
 Institute comfort measures:
 Good skin care.
 Soothing sponge bath.
 Frequent change of perineal pads.
 Analgesics as prescribed
 Assist the woman/family in planning for child care required by prolonged
hospitalization.
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Mastitis
 Mastitis is inflammation of breast tissue
 It may involve formation of subareolar abscess in the underlying milk glands
or connective tissue and fat around the lobes and lobules.
 Is unilateral, and develops well after the flow of milk has been established.
Cause:
 Usually due to Staphylococcus aureus derived from the nursing infant’s nose
and throat into a fissure in the nipple.
Clinical Manifestations:
 Symptoms may occur at the end of the 1st postpartum week but usually occur
in the 3rd to the 4th week postpartum.
 Elevated temperature (usually not above 39.3 ºC).
 Tachycardia
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 Breast pain.
 Breast hardening and redness.
 Inflammatory edema, enlarged axillary lymph nodes.
 Breast engorgement with obstruction of milk flow.
Management and Nursing intervention:
 Acute mastitis can be avoided by:
 Proper nursing technique, to prevent cracked nipple.
 Avoid missed feedings, waiting too long between feedings.
 Maintain cleanliness and personal hygiene of both mother and newborn.
 Implement plan of care:
 Use comfort measures- breast support, tight binder or brassier.
 Analgesics as prescribed.
 Application of heat to affected breast if suppuration is present.
 Suitable antibiotic for Staphylococcus aureus as Cephalosporines as
prescribed.
 If breast milk is contaminated, breast feeding on affected side may be
discontinued, empty breast on affected side with breast pump and discard
milk until infection is controlled.
 If abscess forms, incision and drainage may be necessary.
 Correct misinformation regarding condition and complication.
 Keep the woman/family informed of changes in physiologic status and
treatment plan.
 empty the breasts every 2 to 4 hours by breast feeding, manual expression,
or breast pump.
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Postpartum UTI
Causes:
1. Bladder trauma during delivery.
2. Urinary retention due to anesthesia, venous congestion causing over
distention of the bladder.
3. Frequent catheterization.
Clinical Manifestations:
 Elevated temperature and chills.
 Urinary frequency.
 Pain on urination.
 Flank pain.
Management and Nursing Interventions:
 Explain and implement plan of care:
 Monitor vital signs, degree and site of pain.
 Instruct the woman to increase fluid intake.
 Instruct the woman to empty her bladder completely each time she
urinates.
 Administer suitable antibiotics, analgesics, and antispasmodics as
prescribed.
 Encourage the woman to rest.
 Describe complications and general treatment regimen.
 Correct misinformation regarding condition and complications,
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Subinvolution
 Is the slowing or halting of normal postpartum return of reproductive organs
to their pre-pregnancy state. (is the failure of the uterus to return to the
nonpregnant state).
Causes:
1. Pelvic infection.
2. Retention of placental fragments.
3. Fibroid tumor.
4. Any other factors that interferes with myometrium contractions.
Clinical Manifestations:
1. Uterus larger or softer than expected for postpartum date.
2. Prolonged lochia discharge (after one month or more).
3. Irregular uterine bleeding.
4. Backache or sensation of weight in pelvis.
Management and Nursing Interventions:
1. Explain and implement plan of care.
2. Administration of Ergonovine Maleate as prescribed to increase uterine
contractility.
3. Prepare the woman for uterine curettage if placental fragments have been
retained.
4. Administer suitable antibiotics for infection as prescribed.
5. Instruct the woman to report signs of infection, vaginal bleeding or any
tissue passed vaginally.
6. Describe complications and usual treatment regimen.
7. Correct misinformation regarding condition and complications.
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Postpartum Hemorrhage
• Is defined as a loss of blood excess of 500 ml in the 1st 24 hours following
vaginal delivery and 1000 mL or more after a cesarean birth.
• It occurs more frequently in the 1st hour following delivery.
• Approximately 5% of all women who give birth vaginally experience a
postpartum hemorrhage.
• According to The WHO, 25% of all pregnancy related deaths result from
postpartum hemorrhage.
• Postpartum hemorrhage could be early or late:
o An early hemorrhage occurs within the fi rst 24 hours after birth
(mostly within the first 4 postpartum hours). During this time, the
blood flow to the uterus is between 500 and 800 mL/minute, and the
placental site contains multiple exposed venous areas and low
resistance
o A late hemorrhage occurs more than 24 hours but less than 6 weeks
postpartum.
Causes:
1. Uterine atony “Relaxation of the uterine muscles”.
 Is a failure of the uterine myometrium to contract and retract following birth.
 It occurs secondary to:
 Multiple pregnancies that causes over distention of uterus and larger
placental site.
 High parity.
 Prolonged labor with maternal exhaustion.
 Deep anesthesia: provide uterine relaxation.
 Fibromyomata: prevents uterus from contracting.
 Retained placental fragments.
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 Polyhydramnios.
 Macrosomia.
2. Laceration of the vagina, cervix or perineum secondary to:
 Forceps delivery.
 Large infant.
 Multiple pregnancies.
3. Retained placental fragments:
 These fragments are the major cause of late postpartum hemorrhage.
 Mostly occurs at 2-4 weeks after delivery.
 Results from placenta accreta (placenta with abnormally firm attachments
to the uterine wall) or manual removal of placenta.
4. Retained placenta:
 Hemorrhage may occur after the delivery of baby and before delivery of
the placenta.
Clinical Manifestations:
 Uterine atony:
 Uterus is soft, often difficult to palpate and will not remain contracted.
 Bleeding is steady and slow rather than sudden and massive.
 Blood pressure and pulse may not change until blood loss is significant.
 Lacerations:
 Fundus is firm, bleeding is bright red.
 On examination, lacerations are found.
 Retained placental fragments:
 Hemorrhage usually occurs about the 10th postpartum day.
 Excessive blood loss: pallor, restlessness, dyspnea, thready pulse,
hypotension, chills and air hunger.
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Management and Nursing interventions:
 Monitor changes in physiologic status:
 Monitor vital signs frequently.
 Describe number and saturation of perineal pads used per hour.
 Describe character and amount of vaginal bleeding.
 Evaluate uterine firmness, height and position.
 Restore fluid/blood volume:
 Administer IV Fluids as prescribed to restore fluid volume.
 Administer blood as prescribed.
 When cause has been determined, prepare the woman for further
treatment.
 Uterine atony:
 Vigorous massage is instituted.
 Oxytocics such as Methylergonovin (Methergin) and Oxytocin (Pitocin)
may be given.
 Laceration:
 Prepare the woman to return to the delivery room for inspection and
repair.
 Retained placental fragments :
 Prepare the woman for curettage of the uterus.
 Retained placenta:
 The physician manually removes the placenta by inserting a gloved hand
into the uterus and placing the other hand externally on the fundus.
 O2 at 4-7 L/min is given by facemask.
 Help reduce anxiety:
 Determine 1ujor cause of mother’s anxiety.
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 Explain current status and prescribed treatment regimen.
 Correct misinformation regarding states or potential complications.
 Keep the woman/family informed of changes in physiologic status or
treatment plan with emphasis on improvement condition.
 Results from placenta accreta or manual removal of placenta.
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Breast feeding
 Human breast milk is the ideal infant food choice. It is bacteriologically
safe, fresh, readily available and balanced to meet the infant’s needs.
 “human milk is species-specific, and all substitute feeding preparations
differ markedly from it, making human milk uniquely superior for infant
feeding”
 The World Health Organization and the American Academy of Pediatrics
recommend human milk as the exclusive nutrient source for the first 6
months of life, and indicates that breastfeeding be continued at least through
the first 12 months of life, and thereafter as long as mother and baby
mutually desire.
 Although the composition of infant formula is similar to that of breast milk,
breast milk is still considered to be the best option for optimal health
promotion and disease prevention in the newborn. Research provides good
evidence that breastfeeding decreases the rate of postneonatal infant
mortality (21%), and reduces the incidence of a wide range of infectious
diseases including bacterial meningitis, bacteremia, diarrhea, respiratory
tract infection, necrotizing enterocolitis, otitis media, urinary tract infection,
and late-onset sepsis rates in preterm infants.
Benefits of breastfeeding:
 There are economic benefits as well: breastfeeding reduces the cost of
feeding and preparation time.
 Benefits to infants:
 Enhanced maturation of the gastrointestinal tract
 Enhanced jaw development
 Protective effects against certain childhood cancers
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 Decreased incidence of bacterial and viral infections as a result of
passive immunity, acquired via the transfer of maternal antibodies.
 Breastfed infants are less likely to develop allergies, gastrointestinal
tract diseases, respiratory tract diseases, ear infections, UTI, and
childhood obesity.
 The maternal transfer of antibodies and immune factors enhances
development of the immune system and facilitates the neonate’s
immune system response. The longer the time that an infant is
breastfed, the stronger the protection against infection and the earlier
the maturation of the infant’s immune system.
 In addition, some studies have indicated that breastfed infants
experience lower rates of diabetes, lymphoma, leukemia, Hodgkin’s
disease, and sudden infant death syndrome
 Human breast milk contains more carbohydrates, less protein, and less
casein than cow’s milk or infant formulas; which facilitates its digestion
 At 1 year of age, breastfed infants are leaner than their formula-fed
counterparts and obesity in later life.
 Infants who have been breastfed have a lower incidence of otitis media
than those who have been bottle fed. The number of episodes of otitis
media decreases significantly with increased duration and exclusive
breastfeeding.
 Breast milk contains immunoglobulin A (IgA), which offers protection
against allergies and viruses.
 Breastfeeding is also associated with slight improvements in cognitive
development in both term-born and prematurely born infants, although
the benefits appear to be greatest for the latter group of infants
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 Benefits to mother:
 The total energy cost to a woman who is exclusively breastfeeding an
infant 0 to 6 months is estimated to be 500 kcal/day; could result in 0.5
kg/week of wt loss.
 Facilitates changes in body composition; fat is mobilized from the trunk
and thigh areas.
 Decreased risk of breast cancer
 Lactational amenorrhea (LAM) (although breastfeeding is not
considered an effective form of contraception)
 Enhanced involution (due to uterine contractions triggered by the
release of oxytocin) and decreased risk of postpartum hemorrhage
 Increased bone density
 Enhanced bonding with infant
 Breast feeding is contraindicated in the following conditions:
 Infants with galactosemia (due to an inability to digest the lactose in the
milk)
 Mothers with active tuberculosis or HIV infection
 Mothers with active herpes lesions on the nipples
 Mothers who are receiving certain medications, such as lithium or
methotrexate
 Mothers who are exposed to radioactive isotopes (e.g., during diagnostic
testing)
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 The neonate is most alert during the first 1 to 2 hours after an unmedicated
birth, and this is the ideal time to put the infant to the breast.
 Cesarean deliveries and medicated births, including those with epidural
anesthesia, may require more mother–infant skin to skin contact before a
successful latch-on occurs.
 To feed effectively, the infant must awaken and let his mother know that he
wants to eat.
 An optimal breastfeeding experience begins with the mother’s prompt
response to her infant’s feeding readiness cues.
 The mother should hold the baby so that his nose is aligned with the nipple
and watch for an open mouth gape.
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 Feedings that last less than 10 minutes or continue for longer than 40
minutes are not satisfactory and require consultation.
308
POSITIONS FOR BREASTFEEDING
1. Cradle hold position
2. Football position
309
3. Side-lying position
frequent feeding (at least every 2 to 3 hours) is
 To minimize the stasis of milk, it is advised that the infant is fed at each
breast at least 15 to 20 minutes until at least one breast softens after the
feeding, otherwise, it will cause breast engorgement.
 To help reduce the swelling and enhance milk flow, the nurse should instruct
the mother to use warm compresses and perform hand expression before
nursing.
o This action softens the areola, initiates the let-down reflex, and allows
the infant to more easily grasp the areola.
 Massaging the breasts during feedings, taking a warm shower, and handexpressing some milk before nursing will help to enhance milk flow and
help facilitate infant latch-on.
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 Infant Feeding Patterns
Birth–1 month
Breast every 2–3 hours----Bottle every 3–4
hours
2–3 oz. per feeding
2–4 months
Breast or bottle every 3–4 hours
3–4 oz. per feeding
4-6 months
Breast or bottle 4-6 times per day
4-5 oz. per feeding
6–8 months
Iron-fortified, rich cereal
Breast or bottle 4 times per day
6–8 oz. per feeding
8–10 months
Finger foods
Chopped or mashed foods
Sippy cup with formula, breast milk, juice or
water
Breast or bottle 4 times per day
6–8 oz. per feeding
10–12 months
Self-feeds with fi ngers and spoon
Most table foods are allowed
Breast or bottle 4 times per day
6–8 oz. per feeding
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 Don’t forget, after feeding to burp the infant
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