OB 1

OB Pacabis Pregnancy Days: 260-290 days (Average 280 days!) Weeks: 38-42 weeks (Average 40 weeks) Months: 9 months Lunar: 10 lunar months L and D Puerperium: as early as 6 but not later than 8 weeks

MCN Womens Health Perinatal Nursing fetal and neonatal care

What is the approximate length of a termed fetus? Haeses Rule: Determine the length fetus using lunar months 1-5 lunar months: AOG2 6-10 lunar months: X 5

Stages of Labor Stage 1: Cervical Dilatiion Stage 2: Fetal Expulsion Stage 3: Placental stage 20 hours cut off time for dystocia

Assessment OB Clients: Fetus and Mother! IPPA + Interview Fetal Health Indicators 1. FHR (120-160bpm) 2. Fetal Movement (Starting 20 weeks, grandmultigravida 16-18 weeks); daily fetal movement (10! 1 Every 2 hours!); 20 minutes after meals; danger sign if 3 times in 8 hours! Factors in Labor 1. Power 2. Passage Soft Cervical canal Vagina Hard Pelvis (4 Bones) 2 innominate bone (Ileum biggest, ischium lowermost of the pelvis, pubis anterior), 1 sacrum, 1 coccyx Gynecoid (round) and Anthropoid (Oval) can deliver normally Android (heart shaped) and Platypelloid (flat) abnormal!

OB 2

Inlet shape of the pelvis Diagonal Conjugate can be clinically measured through I/E (11.5cm) OB conjugate most important (narrowest diameter of inlet); cannot be measure, can be estimated by subtracting from the diagonal conjugate (Diagonal conjugate -1.5 to 2cm) = OB conjugate (10cm) complete flexion is important in order for the fetus to pass! Anatomical conjugate 11cm (1cm bigger than OB) Inlet Contraction Mid Pelvis ischial spine Bispinous diameter distance between ischial spines (10cm) ~ most common in CPD Outlet tuberosities 11cm AP Diameter symphysis pubis to the sacrum Transverse Diameter (12.75-13cm)- where fetal head engages

3. Passenger Fetus Attitude Complete Flexion Partial Flexion Partially extended Fully extended 4. Psyche

Presenting Part Vertex Military Brow Face

Presentation Occiput Bregma Brow Chin/Mentum

Position SOB OF MO SMB

Diameter 9.5cm 11cm 13.5cm 9.5cm

Reproductive Process All women must ovulate If no sperm, the woman must also be able to menstruate If there is sperm, the woman must be able to get pregnant o Fertilization phase o Implantation phase

Child Bearing Age 15 years (standard) to 44 (49 years old: Family Planning International ) 45 beginning of menopause: if she has 12 missed cycles, ends at 55 years old

Ideal Reproductive Age 18-35 years old Have its lowest complications if within this range

Ovary Estrogen hormone of being a woman Progesterone hormone of pregnancy Relaxin

OB 3

Fallopian tube Uterus Fundus Corpus Cervix Layers o Endometrium o Myometrium o Perimetrium For gestation and menstruation Isthmus Ampulla (site of fertilization) Infundibulum widest part

Oral Contraceptive Pills DPV Implant (Norplant) Patch Method

Suppresses ovulation by increasing estrogen and progesterone dec FSH and LH; systemic effect, C/I to cardio, liver disorders. Complaints: headache, chest pain, weight gain

Tubal Ligation Permanent (but can recanulate) Prevents fertilization

IUD (CuT380A) Good for 10 years Copper because it kills the sperm Prevents implantation May cause cramps and menorrhagia

Diaphragm Covers cervix Inserted by the woman Does not allow sperm to enter prevents fertilization

Cervical Mucus Method (Billings Method) LAM No ovulation Higher prolactin, lower the progesterone Testing for spinbarkeit characteristics of mucus

*Inc HPL, low Insulin

Ovulation

OB 4

1. 2. 3. 4.

Each ovary will ovulate alternately Starts during menarche (12 years) Release of an egg from menarche to menopause Ovulation occurs 14 days before the next menstruation E.g. April 29-14 = April 15 ~ date of ovulation

Menstruation Brain Hypothalamus GRH FSH and LH APG will release FSH (matures follicles)in the ovary ovary releases estrogen Estrogen develops ducts of breast (breast tenderness); uterus (proliferates endometrium); cervix (Spinbarkeit 8-10cm); Uterus contracts the uterus; proliferative phase! Progesterone relaxes smooth muscles; acts on the breasts Acini cells for BF; thick mucus secretions in the cervix (mucus plug); secretory phase! Implantation phase usually occurs in this phase (Decidua if pregnant) Hormone of ovulation LH Birth 2M Puberty 400K Adults 30K Menopause 0 Ovary Uterus

Menstruation 28 days Duration: 1-9 days (average is 3-5 days) Women One Mature 23 chromosomes X Men Millions Mature/Immature (average 60 days to mature) 23 chromosomes X or Y

Sperm 100M/cc; normal ejaculation is 3-5cc = 300M-500M; should not go <20M/mL=60-100M; if less 20M, low sperm count

Fallopian tube to uterus in 3-4 days; implants in 3-4 days Fertilization to Implantation zygote Implantation to 7 weeks embryo 8 weeks to birth fetus

OB 5

Morulla travelling zygote of the fallopian tube; blastocyst implanting zygote Germ Layer where organs are formed Inner cell mass Amnion and fetus OCM trophoblast (secretes HCG) sustains the pregnancy before the placenta by maintaining the corpus luteum (Effects: N and V, + pregnancy test) Placenta from the decidua basalis; functions at the end of the 12 th weeks! Develops as early as 2 months

4 Weeks heart begins to beath 6-7 Weeks UTZ can show + sign of pregnancy (confirms pregnancy, ages the pregnancy, tells the location of pregnancy) 8 weeks, all major organs are formed 10-12 weeks Doppler can be used for FHR; placental functioning fetal circulation; amniotic fluid develops; fetus voids 12 weeks suck and swallow 12-16 weeks sex can be seen 20 weeks age of viability: FHB, Fetal Movement; Vernix, Lanugo 24 weeks fetal lungs begin to secrete surfactant 32 weeks testes begin to descend 36 weeks presentation is definite (cephalic, breech, shoulder) 38 weeks baby is term

20 weeks 500g Term baby 2500g (5.5lbs) 4000g (4kg) LGA (8.8lbs) Average 3000g (6.6lbs)

Parts of the Placenta 1. 2. Cotyledons Found in the maternal parts Attached to decidua basalis N: 27-30 cotyledons Membrane Fetal side Amnion (clear transparent) and Chorion (thicker, manually removed) components of BOW

Functions of the Placenta Respiratory function fetal circulation (veins carry oxygen)

OB 6

FO DA PDA(Indomethacin) DV No liver and lung circulation Nutritive function Endocrine Excretory Barrier (except viruses)

Amniotic Fluid: 1000mL inc as the baby becomes more mature; decreases once in term; clear with specks of vernix and lanugo pH: alkaline Nitrasine test to differentiate urine from amniotic fluid (blue) Alkaline vagina pruritus

Prenatal Visit 1-7 months monthly 8 q2weeks 9 q week

Integrated Management of Pregnancy and Childbirth Skilled birth attendant at primary level 10-11g of Hb ok (1 tab of Fe) If 7-9g moderately anemic (2tab) <7g severely anemic (2tab) 30-60mg/tablet Folic acid 400mg

Labor Duration increases Freq and Interval decreases FHB Early deceleration normal (HR reduces when contracting) Late deceleration pathologic, uteroplacental insufficiency Variable deceleration cord compression Position Oxygenation 5lpm Refer

OB 7

Leopolds Maneuver LM1 presentation of the fetus presenting part LM2 position of the fetus LM3 confirm LM1 and engagement LM4 Pawlicks grip fetal attitude ROA/LMA 1. 2. 3. 4. 5. 6. 7. 8. Presentation Presenting part Lie Attitude Presenting diameter Measurement of FD FHB Turn Ext Rotation

Reva Rubin Psychologist of Pregnancy

Assessment Data PX Height (<5ft High risk for CPD) Weight high risk for preeclampsia (rapid increase will inc possible preeclampsia) Cephalocaudal Eye conjunctiva (anemia) Teeth infection (streptococcal infection) Neck thyroid Breast nipples (overted, inverted and protruding) Fundic height Primigravida 2 weeks before EDC lightening Vulva any discharge Clear (Mucoidal) Any discoloration pathologic, curd like (fungi), frothy, creamy, greenish (trichomonas), foul, gray (GABS), milky (bacteria) PID ectopic pregnancy and sterility Varicosities Edema Warts Extremities varicosities and edema Lab

OB 8

Health Education Hygiene of Pregnancy Danger Signs Teratogens Infections Chemicals Drugs Smoking (SGA), Alcohol (Mental Retardation, IUGR, facial defects), Caffeine (mother is hyperstimulated) Radiation Exercises Kegels Pelvic Rocking Tailor Sitting Walking Minor Discomforts Varicosities avoid prolonged standing, Leg cramps adequate Ca intake (milk); dorsiflex the foot and massage Constipation high fiber

Nutrition RDA 2200kcal/day; add 300 for pregnant; 500 if lactating Fe: 1 tab CHON: 60-75 grams Ca: 1200mg/day Folic acid: 400-600mcg

Fe: 1g total pregnancy (500mgmother, 300mgfetus and placenta, 200mg blood loss)

Fetal Well Being Fetal Heart Rate UTZ (6-7 weeks) 120-160bpm APGAR 100 and above 2

Daily Fetal Movement

OB 9

28 weeks above Quickening (16 weeks, 20 weeks to majority of women) Kick chart

Non Stress Test Evaluating the FHR vs. Fetal Movement HR inc as the fetus moves HR inc at least 15 beats that will last for 15 seconds If does not accelerate abnormal N: Reactive

Contraction Stress Test FHR vs. UC Decelerations are expected N: Negative

Biophysical Profile FHR F movement F Tone N is fisted hand Respiratory Breathing movements Amniotic Fluid Volume N is 800-1000cc 10 perfect, N is 8-10, <6 Abnormal Done by UTZ

Amniocentesis 1st trimester chromosomal effects 2nd trimester lung maturity o LS Ratio 2:1 higher the lecithin more mature (performed more often in DM mother) DM Mothers Macrosomnia (8lbs above) 37-38 weeks, induct labor, to extract baby at the lowest possible weight (considering the lung maturity) CPD and Fetal Distress most common indication for CS Chorionic Villa Sampling Cordocentesis To evaluate chromosomal aberrations

Congenital Anomaly Scan 20 weeks and above

Labor series of process by which the products of conception are expelled from the uterus

True vs. False Labor Inc duration Regular pains Pain that come from the back and to the front Cervical changes (MAJOR SIGN)

Inc BHC False labor true labor

OB 10

Theory of Labor Estrogen placenta Progesterone placenta; relaxes smooth muscles (withdraws when labor starts) Oxytocin PPG Prostaglandin Decidua (specialized endometrium of pregnancy) Corticosteroid from fetal adrenals; initiates secretion of oxytocin from brain Relaxin placenta

Factors Powers forces that expel products of conceptions Passage hard and soft Passengers each may cause dystocia Fetus size, presentation, gross congenital anomaly (e.g. hydrocephalus) Placenta previa, abruptio, accreta (pregnancies every year! grandmultigravida!) Succenturiata, Circumvallata, Velamentous insertion of cord Amniotic Fluid Poly overdistention (may cause uterine atony) If yellowish chorioamnionitis if there is PROM! BOW transitional to second stage of labor! Membranes (Amnion and Chorion usually left) Cord length is as long as the fetus (50-55cm) Whartons jelly whitish, bluish; if brownish/greenish distress Inspect AVA (if one is absent, congenital anomalies) Cord Loops we can untangle Prolapse of the cord position Position best LOA, a mobile mother!

Stages of Labor First Stage (Cervical Dilatation) Latent 0-3 Mother is very congenial, establish IPR, reinforce teachings given at prenatal (Breathing exercises), mother is receptive at this point

OB 11

Nutrition community setting (food), Hospital (normal nourishment, light CHO diet soups, hot milk) Upright position, mother should be mobile (enhances descent of fetus) Let the mother walk around or comfortable position BOW (+) Active 4-7 Mother feels true pain! 4cm is critical; pain management

Transitional 8-10 Assist mother to take control of situation

Elimination bladder distention may prevent descent Monitor progress of labor check the uterine contraction, cervical dilation (R.A. 9173, mother is in labor, no antenatal bleeding; Suturing suture perineal laceration) Vaginal Exam q4h Primi 1.2cm/h Multi 1.5cm/h (minimum) 2-3cm/h *1cm/1hrD Precipitate Labor labor that lasts 3 hours or less precipitate delivery (grandmultiparities! Oxytocin drips, analgesia) Mother (laceration), Fetus (Brain damage/intracranial hemorrhage); Amniotic fluid embolism (cyanosis, DOB, chest pain, cough give O2 call MD) FHR
st

1 2nd

LR Q30 Q15

HR Q15 Q5

Pain Management Non Pharmacologic - Breathing exercises (breath deeply during contraction; pant and breath transitional ) - Massage effleurage - Hydrotherapy (warm baths, whirlpool) Pharmacologic - Meperidine HCl (Respi Dep) - Nalbuphine (Respi Dep) - Butorphanol (Stradul) - Epidural Anesthesia (Hydrate the patient! S/E is hypotension)

2nd Stage Engagement Primi 2 weeks before EDC; lightening occurs that lightening occurs 2 weeks EDC Multi any time during labor! Descent occurs throughout labor Flexion assumes smallest diameter (SOB smallest diameter)

OB 12

Internal Rotation Crowning Ritgens extends fetal head Extension External Rotation Expulsion

Crowning biggest diameter is in introitus

Active Management of the Third Stage Shortened third stage Preventing bleeding As soon as baby is out, inject Oxytocin contract uterus Calkins sign, thus placental separation

BEMONC Functions: RM, RN, MD primary birth setting (Lying-in, Birthing centers, clinics) Number 1 resource: Blood more than 100mL during placental stage 1 bag of Blood (CEMONC facility)

Patient Median Attendant Mediolateral

Blood transfusion and CS CEMONC (2ndary District Hospital)

Signs of Placental Separation 1. Calkins Sign 2. Gushing of blood 3. Lengthening of cord

Placental Stage Placental Separation 1. Schultz inverted umbrella 2. Duncan Placental Expulsion Brandt Andrews Calkins /Modified Credes Maneuvre

Oxytocics

OB 13

Hormonal oxytocin, pitocin, Syntocinon (dec BP) rhythmic IM, IV Push, IVF IU; 10u/amp; do not exceed 3 liters with 3 amps of hormonal (may not contract!) Herbal methergin, ergotrate, ergonovine maleate (inc BP) sustained action Oral, IM, IV push, never IVF! .2mg never give more than 1 mg (may cause rupture)

4th Stage of Labor: 1-4 hours Vigilance of the mother right after labor Uterus immediately after birth, below the navel, next few hours will rise at the level of navel If above the navel boggy uterus massage/ice dislodge clots Ten days, return to normal uterine size, if subinvolution may be caused by infection Vaginal bleeding Bleeding vaginal pad soaked in 1 hour, heavy bleeding Laceration ice pack in 24 hours, heat after 24 hours First Degree forche, mucosa Second Degree 1st degree + muscles Third Degree 1st, 2nd and anus Fourth Degree 1st, 2nd, 3rd rectum

Vital signs q15min x 4 hours; q30min x 2hours; if stable discharge, take q4h x 24 hour; q8h then discharge Laceration/Episiotomy

Breast RA 7600; EO 51 Gavage/NGT/Dropper/Cup/Human Milk Bank (give within 24 hours, frozen 3-6 months) 3rd to 4th day, post partum, engorgement of breast increase of temperature Uterus Involution; after pains oxytocin (let down reflex hormone) myoepithelial cell of breast (more frequent after pains) Bladder Difficulty of voiding edematous perineum and urethral sphincter Assess distention Bowel 2nd to 3rd days Lochia Emotionality Post partum blues (withdrawal of hormones blues)

OB 14

Important: support of significant others Post partum depression Post partum psychosis Manic Skin Chloasma, linea nigra, striae (silvery) Homans Sign Thromboembolic disease Post partum infection any elevation of temperature above 38 degrees that occurs twice within 10 days after birth UTI most common post partum infection

3 Classic Causes of Maternal Death Bleeding HPN Infection Obstructed Labor Unsafe Abortion Drugs Massage Inserting catheter into vulva and probing

Phil MMR 160-162/100000 7-11 daily

Pregnancy

Bleeding Abortion Ectopic H Mole Previa/Abruptio Atony, wounds, placental problems

HPN CHVD PEM Preeclampsia mild PES Preeclampsia severe

Infections TORCH UTI Moriliasis

Others DM, heart disease, multiple gestation, polyhydramnios Preterm labor Dystocia (power, passage, passenger)

Labor and Delivery

Eclampsia Post partum Atony (number 1 killer in 24 hours) Retained Secundings

PROM Frequent Vaginal Exam Wounds Endometritis Wound infections (DM Mothers) Thrombophlebitis Mastitis

Post partum blues psychosis

Pre eclampsia 200 weeks

OB 15

Define Cause Characteristic Signs Management

Abortion termination of pregnancy before the age of viability 1. Spontaneous (Miscarriage) Cervix BOW a. Threatened Closed + Spotting Rest (Physical, Emotional, Sexual) Duvadilan/Duphaston relaxing drugs (non teratogenic) Avoid sex b. Inevitable Open Imminent Abortion c. Incomplete Open d. Habitual Open + 3 or more successive abortions Incompetent cervix cerclage e. Missed Close The fetus has been dead for at least 2 weeks and the mother is not aware; uterus is smaller than AOG; secretion of brownish secretions; Pregnancy Test: (-), no more HCG Mgt: i. Cytotec (misoprostol)/Laminaria/Prostaglandin gel ii. Induce labor (D5LR + 1amp oxytocin) expel the dead fetus; D and C after Causes: o Stress o Infection o Chronic diseases of mother (DM) o Chromosomal effects (non modifiable) 2. Induced a. Therapeutic b. Illegal/Criminal

Ectopic Pregnancy Sharp knifelike abdominal pain radiating to the shoulder Ruptured dull pain in the left or right Surgical Salphingostomy Salphingectomy

Medical Methotrexate pregnancy must not be more than 2 months; fetus should not be longer than 4cm; no heart rate;

H Mole Abnormal zygote

OB 16

Complete More bleeding An empty ovum penetrated by 1 sperm (23 chromosomes) Rapidly enlarging uterus with soft and no FHR

Partial Normal ovum with 23 chromosomes fertilized by 2 sperms (69 chromosomes)

Rapidly enlarging uterus with faint FHR 15-16-18 weeks

May lead to choriocarcinoma No pregnancy for 1 years Monitor for HCG Small doses of Methotrexate 2x (-) HCG, pregnancy is allowed