ob gyne notes
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TORCH (Terratogenic) Infections – virusesCHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and developmentTORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus.T – toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meatO – others. Hepa A or infectious heap oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids SyphilisR – rubella – German measles congenital heart disease (1st month) normal rubella titer 1:10<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3 months. Vaccine is terratogenicC – cytomegalo virusH – herpes simplex virus
Physiological Adaptation of the Mother to Pregnancy
A. Systemic Changes1. Cardiovascular System
increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood
easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation,
Physiologic Anemia pseudo anemia of pregnant women.
Normal ValuesHct 32 – 42%Hgb 10.5 – 14g/dL
Criteria:1st and 3rd trimester pathologic anemia if lowerHCT should not be 33%, Hgb should not be < 11g/dL2nd trimester Hct should not <32%Hgb Shdn't < 10.5% pathologic anemia if lower
1. A. Pathogenic Anemia
Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.
Assessment reveals:o Pallor, constipationo Slowed capillary refillo Concave fingernails (late sign of progressive
anemia) due to chronic physio hypoxia
Nursing Care: Nutritional instruction kangkong, liver due
to ferridin content, green leafy vegetable-alugbati,saluyot, malunggay, horseradish, ampalaya
Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered, hematoma.
Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation
Monitor for hemorrhage
Alert:o Iron from red meats is better absorbed iron
form other sourceso Iron is better absorbed when taken with foods
high in Vit C such as orange juiceo Higher iron intake is recommended since
circulating blood volume is increased and heme is required from production of RBCs.
1. B. Edema lower extremities due venous return is
constricted due to large belly, elevate legs above hip level.
1 .C. Varicosities pressure of uterus
use support stockings, avoid wearing knee high socks
use elastic bandage – lower to upper
1. D. Vulbar varicosities painful, pressure on gravid uterus, to relieve-
position side lying with pillow under hips or modified knee chest position
1. E. Thrombophlebitis presence of thrombus at inflamed blood vessel
pregnant mom hyperfibrinogenemia increase fibrinogen increase clotting factor thrombus formation candidate
outstanding sign – (+) Homan's sign milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens
Mgt: Bed rest Never massage Assess + Homan sign once only might dislodge
thrombus Give anticoagulant to prevent additional
clotting (thrombolytics will dilute) Monitor APTT antidote for Heparin toxicity,
protamine sulfate Avoid aspirin! Might aggravate bleeding.
2. Respiratory system common problem SOB due to enlarged uterus &
increase O2 demand Position lateral expansion of lungs or side
lying position.
3. Gastrointestinal 1st trimester change
3. A. Morning Sickness Nausea & vomiting due to increase HCG. Eat dry
crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon small freq feeding.
Vomiting in preg emesisgravida. Metabolic alkalosis, F&E imbalance primary
med mgt – replace fluids, Monitor I&O.
3. B. constipation Progesterone resp for constipation. Increase
fluid intake, increase fiber diet (fruits: papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.) Except guava has
pectin that’s constipatin. Veg petchay, malungay.
exercise mineral oil excretion of fat soluble vitamins
3. C. Flatulence avoid gas forming food – cabbage
3. D. Heartburn or pyrosis reflux of stomach content to esophagus small frequent feeding, avoid 3 full meals, avoid
fatty & spicy food, sips of milk, proper body mechanical
3. E. increase salivation ptyalsim mgt mouthwash
3. F. Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for
comfort
4. Urinary System frequency during 1st & 3rd trimester lateral
expansion of lungs or side lying pos – mgt for nocturia
Acetyace test albumin in urineBenedicts test sugar in urine
5. Musculoskeletal5. A. Lordosis
pride of pregnancy
5. B. Waddling Gait wkward walking due to relaxation – causes
softening of joints & bones Prone to accidental falls wear low heeled
shoes
5. C. Leg Cramps causes: prolonged standing, over fatigue, Ca &
phosphorous imbalance (#1 cause while pregnant), chills, oversex,
pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus
Mgt:
Increase Ca diet-milk (Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption Dorsiflexion
B. Local ChangesLocal change: Vagina:V – Chadwick’s sign blue violet discoloration of vaginaC – Goodel's sign change of consistency of cervixI – Hegar's change of consistency of isthmus (lower uterine segment)
LEUKORRHEA (whitish gray, mousy odor discharge)ESTROGEN (hormone, resp for leucorrhea)OPERCULUM (mucus plug to seal out bacteria).PROGESTERONE (hormone responsible for operculum)PREGNANT (acidic to alkaline change to protect bacterial growth (vaginitis)
Problems Related to the Change of Vaginal Environment:a. Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant momFlagellated protozoa wants alkalineS&Sx:
o Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Mgt: FLAGYL – (metronidazole – antiprotozoa).
Carcinogenic drug so don’t give at 1st trimestero treat dad also to prevent reinfectiono no alcohol – has antibuse effect
VAGINAL DOUCHE H2O : 1 tbsp white vinegar
b. Moniliasis or candidiasis due to candida albecans, fungal infection.
Color white cheese like patches adheres to walls of vagina.Signs & Symptoms:
Managemen: antifungal – Nistatin, genshan violet, cotrimaxole,
canesten
Gonorrhea Thick purulent dischargeVaginal warts condifoma acuminata due to papilloma virusMgt: cauterization2. Abdominal Changes
striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue – avoid scratching, use coconut oil, umbilicus is protruding
3. Skin Changes brown pigmentation nose chin, cheeks – chloasma
melasma due to increased melanocytes. Brown pinkish line linea nigra- symphisis pubis to
umbilicus
4. Breast Changes increase hormones, color of areola & nipple
pre colostrums present by 6 weeks, colostrums at 3rd
trimester Breast self exam 7 days after mens supine
with pillow at back. quadrant B upper outer – common site of cancer.
Test to determine breast cancer: mammography 35 to 49 yrs once every 1 to 2 yrs
50 yrs and above – 1 x a yr
6. Ovaries rested during pregnancy
7. Signs & symptoms of PregnancyA. Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . SubjectiveB. Probable signs observed by the members of health team. ObjectiveC. Positive Signs undeniable signs confirmed by the use of instrument.
Ballotment sign of myoma + HCG – sign of H mole trans vaginal ultrasound. Empty
Presumptive Probable Positiveo Breast
changeso Urinary freqo Fatigueo Amenorrheao Morning
sicknesso Enlarged
uteruso Cloasmao Linea negrao Increased skin
pigmentationo Striae
gravidariumo Quickening
o Goodel's- change of consistency of cervix
o Chadwick’s- blue violet discoloration of vagina
o Hegar's- change of consistency of isthmus
o Elevated BBT – due to increased progesterone
o Positive HCG or (+)preg test
o Ultrasound evidence
o (sonogram) full bladder
o Fetal heart tone
o Fetal movement
o Fetal outlineo Fetal parts
palpable
o Ballottement – bouncing of fetus when lower uterine is tapped sharply
o Enlarged abdomen
o Braxton Hicks contractions – painless irregular contractions
Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory)
First Trimester: No tanginal signs & sx, surprise, ambivalence, denial
– sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy
Focus: bodily changes of preg, nutrition
Second Trimester tangible S&Sx. mom identifies fetus as a separate
entity due to presence of quickening, fantasy. Developmental
task accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus.
Third Trimester: mom has personal identification on appearance of
baby Development task: prepare of birth & parenting of
child. HT: responsible parenthood ‘baby’s Layette” – best time to do shopping.
Most common fear let mom listen to FHT to allay fear
Lamaze classes
Pre-Natal Visit:1. Frequency of Visit: 1st 7 months – 1x a month
o 8 – 9 months – 2 x a montho 10 – once a weeko post term 2 x a week
2. Personal data: name, age (high risk < 18 & >35 yrs old) record to determine high risk – HBMR. Home base mom’s record.Sex ( pseudocyesis or false pregnancy on men & women)Couvade syndrome dad experiences what mom goes through – lihi)3. Diagnosis of Pregnancya.) urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine exam.
b.) Elisa test test for preg detects beta sub unit of HCG as early as 7 – 10daysC.) Home preg kit do it yourself
4. Baseline Data: V/S esp. BP, monitor wt. ( increase wt – 1 s t sign preeclampsia)
Weight MonitoringFirst Trimester: Normal Weight gain 1.5 – 3 lbs (.5 – 1lb/month)
Second trimester: Normal weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)
Third trimester: Normal weight gain 10 – 12 lbs (4 lbs/ month) (1lb/wk)
Minimum wt gain – 20 – 25 lbsOptimal wt gain – 25 – 35 lbs
5. Obstetrical Data:nullipara – no pregnancy
a. Gravida- # of pregnancyb. Para - # of viable pregnancy
age of viability: 20 – 24 wksTerm: 37 – 42 wks,Preterm: 20 – 37 weeksAbortion: <20 weeks
c. Important Estimates:1. Nagele’s Rule
use to determine expected date of delivery. Get LMP -3+ 7 +1
2. McDonald’s Rule to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8
3. Bartholomew’s Rule to determine age of gestation by proper
location of fundus at abdominal cavity.
3 months above sym pub5 months level of umbilicus9 months below zyphoid10 months level of 8 months due to lightening
4. Haases rule to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month
2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg 5 x 5 = 25 cm
6 x 5 = 30 cm7 x 5 = 35 cm 2nd ½ of preg8 x 5 = 40 cm9 x 5 = 45 cm
d. tetanus immunizations prevents tetanus neonatum
TT1: any time during pregnancyTT2: 4 wks after TT1 – 3 yrs protectionTT3: 6 months after TT2 – 5 yrs protectionTT4: 1 yr after TT3 – 10 yrs protectionTT5: yr after TT4 – lifetime protection
5. Physical Examination:
Danger Signs of Pregnancy:C - chills/ fever infection Cerebral disturbances ( headache – preeclampsia)A – abdominal pain ( epigastric pain aura of impending convulsionsB – boardlike abdomen abruption placentaIncrease BP – HPNBlurred vision – preeclampsiaBleeding – 1st trimester, abortion, ectopic pre/2nd – H mole, incompetent cervix3rd – placental anomalies
S – sudden gush of fluid PROM (premature rupture of membrane) prone to inf.E – edema to upper ext. (preeclampsia)
6. Leopold’s ManeuverPurpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone
use palm! Warm palm.
Prep mom:1. Empty bladder2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)Procedure:1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate
upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé.Uterine soufflé – maternal H rate3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.To determine degree of engagement.Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable).4th Maneuver: the Examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude – relationship of fetus to 1 another.
Intrapartal
Theories of the Onset of Labor1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin3.) prostaglandin theory stimulation of arachidonic acid – prostaglandin- contraction4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).
The 4 P’s of labor1. Passengera. Fetal head is the largest presenting part – common presenting part – ¼ of its length.Bones – 6 bones S – sphenoid F – frontal - sinciputE – ethmoid O – occuputal - occiputT – temporal P – parietal 2 x
2. PassagewayMom 1.) < 4’9” tall2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis4 main pelvic types1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy2. Android heart shape “male pelvis”- anterior part pointed, posterior part shallow3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow4. Platypelloid flat AP diameter – narrow, transverse – wider
3. Power the force acting to expel the fetus and
placenta – myometrium – powers of labora. Involuntary Contractionsb. Voluntary bearing down effortsc. Characteristics: wave liked. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother is
fighting the labor experiencea. Cultural Interpretationb. Preparationc. Past Experienced. Support System
Pre-eminent Signs of Labor
S&Sx:- shooting pain radiating to the legs- urinary freq.1. Lightening setting of presenting part into pelvic brim - 2 weeks prior to EDD* Engagement- setting of presenting part into pelvic inlet2. Braxton Hicks Contractions – painless irregular contractions3. Increase Activity of the Mother nesting instinct. Save energy, will be used for delivery. Increase epinephrine4. Ripening of the Cervix butter soft5. decreased body wt – 1.5 – 3 lbs6. Bloody Show pinkish vaginal discharge – blood & leucorrhealeukorrhea
7. Rupture of Membranes rupture of water. Check FHT
Premature Rupture of Membrane ( PROM)- do IE to check for cord prolapse Contraction drop in intensity even though
very painful Contraction drop in frequently Uterus tense and/or contracting between
contractions Abdominal palpations
Nursing Care; Administer Analgesics (Morphine) Attempt manual rotation for ROP or LOP –
most common malposition Bear down with contractions Adequate hydration prepare for CS Sedation as ordered Cesarean delivery may be required,
especially if fetal distress is noted
Cord Prolapse a complication when the umbilical cord falls
or is washed through the cervix into the vagina.
Danger signs: PROM Presenting part has not yet engaged Fetal distress Protruding cord form vagina
Nursing care:1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy.2. Slip cord away from presenting part3. Count pulsation of cord for FHT4. Prep mom for CS
Difference Between True Labor and False LaborFALSE LABOR TRUE LABOR
Irregular contractions
No increase in intensity
Pain – confined to abdomen Pain – relived by
Contractions are regular
Increased intensity Pain – begins lower
back radiates to abdomen
Pain – intensified by
walking No cervical changes
walking Cervical effacement
& dilatation * major sx
of true labor.
Duration of LaborPrimipara 14 hrs & not more than 20 hrsMultipara 8 hrs & not > 14 hrs
Effacement softening & thinning of cervix. Use % in unit of measurementDilation widening of cervix. Unit used is cm.
Nursing Interventions in Each Stage of Labor2 segments of the uterus1. upper uterine - fundus2. lower uterine – isthmus
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:Assessment:
Dilations: 0 – 3 cm mom excited, apprehensive, can communicate
Frequency: every 5 – 10 min Intensity mild
Nursing Care:1. Encourage walking shorten 1st stage of labor2. Encourage to void q 2 – 3 hrs full bladder inhibit contractions3. Breathing – chest breathing
Active Phase: Assessment: Dilations 4 -8 cm Intensity: moderate Mom fears losing
control of self Frequency: q 3-5 min lasting for 30 – 60
seconds
Nursing Care:M – edications – have meds readyA – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.D – dry lips – oral care (ointment)dry linensB – abdominal breathing
Transitional Phase: Intensity: strong Mom mood changes
with hyperesthesia Assessment: Dilations 8 – 10 cm Frequency q 2-3 min contractions Durations 45 – 90 seconds
Hyperesthesia increase sensitivity to touch, pain all over
Health Teaching : teach: sacral pressure on lower back to
inhibit transmission of pain keep informed of progress controlled chest breathing
Nursing Care:T – iresI – nform of progressR – estless support her breathing techniqueE – ncourage and praiseD – iscomfort
Monitoring the Contractions and Fetal heart Tone Spread fingers lightly over fundus to
monitor contractions
Increment or crescendo beginning of contractions until it increasesAcme or apex height of contractionDecrement or decrescendo from height of contractions until it decreasesDuration beginning of contractions to end of same contractionInterval end of 1 contraction to beginning of next contractionFrequency beginning of 1 contraction
Contraction vasoconstrictionIncrease BP, decrease FHTBest time to get BP & FHT just after a contraction or midway of contractionsPlacental reserve – 60 sec o2 for fetus during contractionsDuration of contractions shouldn’t >60 secNotify MD
Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD –preeclampsia
2. Second Stage: fetal stage, complete dilation and effacement to birth.
7 – 8 multi bring to delivery room 10cm primi bring to delivery room Lithotomy pos put legs same time up Bulging of perineum sure to come out Breathing panting ( teach mom) Assist doc in doing episiotomy to prevent
laceration, widen vaginal canal, shorten 2nd stage of labor.
Mechanisms of labor1. Engagement -2. Descent3. Flexion4. Internal Rotation5. Extension6. External rotation7. Expulsion
3. Third Stage: birth to expulsion of Placenta placental stage placenta has 15 – 28 cotyledonsPlacenta delivered from 3-10 minutes
Signs of placental separation1. Fundus rises becomes firm & globular “ Calkins sign”2. Lengthening of the cord3. Sudden gush of blood
Types of placental deliveryShultz “shiny” begins to separate from center to edges presenting the fetal side shinyDunkan “dirty” begin to separate form edges to center presenting natural side – beefy red or dirty
Slowly pull cord and wind to clamp –BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.
Nsg care for placenta: Check completeness of placenta. Check fundus (if relaxed, massage uterus)
Check bp Administer methergine IM
(Methylergonovine Maleate) “Ergotrate derivatives
Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. Blanket, give clear
liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.
Fourth Stage: the first 1-2 hours after delivery of placenta – Recovery stage. Monitor v/s q 15 for 1 hr.
2nd hr q 30 minutes. Check placement of fundus at level of
umbilicus. If fundus above umbilicus, deviation of
funduso Empty bladder to prevent uterine atonyo Check lochia
a. Maternal Observations – body system stabilizesb. Placement of the Fundusc. Lochiad. Perineum –
R - ednessE- demaE - cchemosisD – ischargesA – approximation of blood loss. Count pad & saturation
Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc
Preterm Labor labor after 20 – 37 weeks) ( abortion <20
weeks)Sx:1. premature contractions q 10 min2. effacement of 60 – 80%3. dilation 2-3 cm
Home Mgt:1. complete bed rest2. avoid sex3. empty bladder
4. drink 3 -4 glasses of water – full bladder inhibits contractions5. consult MD if symptoms persist
Hosp: If cervix is closed 2 – 3 cm, dilation saved by
administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm Maternal BP - <90/60 Crackles notify MD – pulmo edema –
administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) sustained tachycardia
Antidote – propranolol or inderal - beta-blocker
If cervix is open MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS
Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.
Postpartal Period 5th stage of labor after 24hrs :Normal
increase WBC up to 30,000 cu mm
Puerperium covers 1st 6 wks post partumInvolution return of repro organ to its non pregnant state.
Hyperfibrinogenia- prone to thrombus formation- early ambulation