ncm 101 maternal health nursing

Maternal and Child Health NursingNCM 101 CMO 14

Mary Lourdes Nacel G. Celeste, RN, MD

Genetic Disorders

MLNGCeleste, RN, MD

Facts

• 1 in 20 newborns has an inherited genetic disorder

• Over 30% of pediatric admissions are for genetic-influenced disorders

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MLNGCeleste, RN, MD

Genetic Disorders

• Inherited or genetic disorders -disorders that can be passed from one generation to the next

• Genetics-Study of why disorders occur

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MLNGCeleste, RN, MD

Nature of Inheritance

• In humans, each cell, with the exception of the sperm and ovum, contains 46 chromosomes (44 autosomes and 2 sex chromosomes) in the nucleus

• Each chromosome contains thousands of genes

• Sex chromosomes 46XX: female 46XY: male

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MLNGCeleste, RN, MD

Normal Female Karyotype

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MLNGCeleste, RN, MD

Normal Male Karyotype

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MLNGCeleste, RN, MD

Nature of Inheritance

• Genes– Basic units of heredity; structures

responsible for hereditary characteristics– May or may not be expressed or passed to the

next generation– According to Mendel’s Law, one gene for each

hereditary property is received from each parent; one is dominant (expressed); one is recessive

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MLNGCeleste, RN, MD

Karyotype• Chromosomal pattern of a cell including genotype,

number of chromosomes and normality or abnormality of the chromosomes

Genotype• Actual gene composition; Sequence and

combination of genes on a chromosome

Phenotype• Outward appearance or observable expression

of genes (hair color, eye color, body build, allergies)9

MLNGCeleste, RN, MD

Alleles• Pairs of genes located on the same site on

paired chromosomes• Homozygous alleles (DD or dd)• Heterozygous alleles are two different

alleles for the same trait (Dd)

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MLNGCeleste, RN, MD

CONGENITAL and GENETIC are not synonymous

• Congenital - present at birth because of abnormal development in utero (teratology)

• Genetic – pertains to genes or chromosomes; some genetic disorders may be noticeable at birth and others may not appear for decades

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MLNGCeleste, RN, MD

Dominant and Recessive Patterns

• Homozygous - a person who has 2 like genes for a trait (eg, blue eyes: 1 from the mother and 1 from the father)

• Heterozygous – if the genes differ (eg, 1 gene for blue eyes from the mother, 1 gene for brown eyes from the father)

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MLNGCeleste, RN, MD

Dominant and Recessive Patterns

• Dominant genes – genes which are expressed in preference to others

• Recessive genes – genes that are not dominant

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MLNGCeleste, RN, MD

• Homozygous dominant - an individual with 2 homozygous genes for a dominant trait

• Homozygous recessive – an individual with 2 homozygous genes for a recessive trait

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MLNGCeleste, RN, MD

Their children have a 100% chance of being heterozygous for the trait.Phenotype – brown eyed (phenotype) ; but they will carry a recessive gene for blue eyes in their genotype.

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MLNGCeleste, RN, MD

The child will have an equal chance of being brown eyed (50%) or blue eyed (50%).

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MLNGCeleste, RN, MD

All the children will be brown- eyed. Chances are equal that their children will be homozygous dominant (50%) like the father or heterozygous (50%) like the mother.

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MLNGCeleste, RN, MD

Both parents are heterozygous. 25% chance of their children being homozygous recessive (blue-eyed), 50% chance of being heterozygous (brown eyed) and a 25% chance of being homozygous dominant (brown eyed).

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MLNGCeleste, RN, MD

Inheritance of DiseaseMendelian or Single gene disorders

A. Autosomal disorders1. Autosomal dominant disorders2. Autosomal recessive disorders

B. Sex – linked disorders1. X-linked dominant inheritance2. X-linked recessive inheritance

Multifactorial inheritanceChromosomal aberrations or abnormalities

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MLNGCeleste, RN, MD

Autosomal disorders

• Occur in any chromosome pair other than the sex chromosomes

• Result from a single altered gene or a pair of altered genes on one of the first 22 pairs of autosomes

• Autosomal dominant or Autosomal recessive

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MLNGCeleste, RN, MD

Autosomal dominant traits• Those in which the abnormal gene dominates

the normal gene; thus, the condition is always demonstrated when the abnormal gene is present.

• The affected parent has a 50% CHANCE OF PASSING ON THE ABNORMAL GENE IN EACH PREGNANCY.

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Autosomal dominant traits

MLNGCeleste, RN, MD

• Osteogenesis imperfecta (bones are exceedingly brittle)

• Marfan syndrome (disorder of connective tissue; child is thinner and taller than normal; heart defects)

• Huntington’s disease• Neurofibromatosis• Achondroplasia (dwarfism)

Autosomal dominant

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MLNGCeleste, RN, MD

Family pedigrees findings(Autosomal dominant )

• 1 of the parents of the child with the disorder also has the disorder

• The sex of the affected individual in unimportant in terms of inheritance

• History of the disorder in other family members

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MLNGCeleste, RN, MD

Autosomal recessive traits• Require transmission of the abnormal gene from

both parents for demonstration of the defect in the child

• Each child has a 50% CHANCE OF BEING A CARRIER OF THE DISORDER

• Almost all carriers are free from symptoms

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MLNGCeleste, RN, MD

• Albinism• Sickle cell anemia (chronic intensely painful

episodes caused by obstruction of blood vessels by odd-shaped RBC’s; precipitated by dehydration, infection, exposure to cold, trauma, fatigue, lack of oxygen, strenuous physical activity)

- The primary nursing action in caring for an adolescent in sickle cell crisis is directed at maintaining adequate hydration

- the spleen usually becomes enlarged due to congestion and engorgement with sickled cells

Autosomal recessive

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MLNGCeleste, RN, MD

Autosomal recessive• Cystic fibrosis (multiple organ disease; the

primary pathophysiologic mechanism in cystic fibrosis mucus buildup in the lungs and pancreas; steatorrhea; azotorrhea)

• Inborn errors of metabolism (disorders caused by the absence of or defect in enzymes that metabolize proteins, fats or carbohydrates)

• Phenylketonuria or PKU (phenylalanine hydroxylase) – brain damage and mental retardation

• Tay Sach’s disease (hexosaminidase)- child is attentive, passive and regresses in motor and social development

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MLNGCeleste, RN, MD

GROUP Disorder

Blacks/ African Americans

Sickle cell Anemia

Northern European descendants of Ashkenazic Jews

Tay-Sachs disease

Caucasian/ Non-Hispanic

Cystic fibrosis

Mediterranean Thalassemia

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MLNGCeleste, RN, MD

Family pedigrees findings(Autosomal recessive)

• Both parents of a child with the disorder are clinically free of the disorder

• The sex of the affected individual in unimportant in terms of inheritance

• History of the disorder in the family is negative• A known common ancestor between the parents

sometimes exists. This is how both male and female have come to possess a like gene for the disorder.

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MLNGCeleste, RN, MD

X-linked disorders• Result from an altered gene on the X chromosome• May be dominant or recessive; recessive is more

common

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MLNGCeleste, RN, MD

• All individuals with the gene are affected• Female children of affected men are all affected;

male children of affected men are unaffected• It appears in every generation• All children of homozygous affected women are

affected.• EXAMPLE: Hypophosphatemia

Family pedigrees findings(X-linked dominant)

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MLNGCeleste, RN, MD

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MLNGCeleste, RN, MD

X- linked recessive

• More common• Mother is the carrier of the disorder• In female children, expression of the disease is

blocked• In male children, disease will be manifested

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MLNGCeleste, RN, MD

• Only males will have the disorder• A history of girls dying at birth for unknown reasons

often exists• Sons of an affected man are unaffected• The parents of affected children do not have the

disorder

Family pedigrees findings(X-linked recessive)

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MLNGCeleste, RN, MD

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MLNGCeleste, RN, MD

X-linked recessive

• Hemophilia• Color blindness• Duchenne-type muscular dystrophy• Christmas disease• Fragile X syndrome

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MLNGCeleste, RN, MD

Multifactorial inheritance

• Abnormalities caused by multifactorial reasons which do not follow the mendelian laws of inheritance because more than a single gene is involved

• Environmental influences may be instrumental in determining whether the disorder is expressed

• Difficult to counsel parents regarding these disorders because their occurrence is unpredictable

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MLNGCeleste, RN, MD

• Cleft lip or palate• Neural tube disorders• Mental illness• Pyloric stenosis• Hypertension• Heart disease• diabetes

Multifactorial inheritance

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MLNGCeleste, RN, MD

Genetic Counseling

• Purposes– Provide accurate information– Provide reassurance– Make informed choices– Educate people about disorders– Offer support

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MLNGCeleste, RN, MD

Nursing Responsibilities• Alert couple to what procedures they can expect to

undergo• Explain how genetic screening tests are done and

when they are offered• Assess for signs and symptoms of genetic disorders• Offer support• Assist in value clarification• Educate on procedures and tests

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MLNGCeleste, RN, MD

Assessing for Genetic Disorders• History• Physical assessment

Diagnostic testing• Karyotyping – visual presentation of

chromosomes (sample: peripheral venous blood; scraping of cells from buccal membrane)

• Barr body determination – if a child is born with ambiguous genitalia; scraping of cells from buccal membrane; stained and magnified; presence of nondominant X chromosome in the nucleus- Barr body (chromosomally female)

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MLNGCeleste, RN, MD

Assessing for Genetic DisordersAFP analysis• alpha fetoprotein (AFP) is a glycoprotein produced by

the fetal liver• AFP level in the amniotic fluid or maternal serum will

differentiate from normal if a chromosomal or a spinal cord disorder is present (eg, in mothers who have gestational diabetes; infants 10x risk of having a neural tube defect)

• Serum test is done at 15th week of pregnancy; if result is abnormal, amniotic fluid will be assessed

• elevated 3-5x in amniotic fluid secondary to leakage from open neural tube

• low AFP, < 5% Down syndrome• maternal serum AFP has a false positive rate 30%; use

of triple study (AFP, estriol and hCG) reduces false positive rate

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MLNGCeleste, RN, MD

Chorionic villi sampling• Retrieval and analysis of chorionic villi for

chromosome analysis• Transcervical or transabdominal; may be done as

early as 5 weeks, but more commonly done at 8-10 weeks of pregnancy

• Risks: bleeding/ loss of pregnancy; limb reduction syndrome; infection

• Diagnosis of Sickle cell disease, thalassemia

Assessing for Genetic Disorders

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MLNGCeleste, RN, MD

Chronic villi sampling

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MLNGCeleste, RN, MD


Amniocentesis• Withdrawal of amniotic fluid from the

abdominal wall for analysis at 14th to 16th week of pregnancy

• May include karyotyping, analysis of AFP and acetylcholinesterase

• Used to diagnose potential genetic problems in the fetus (Down Syndrome), to estimate fetal lung maturity or to diagnose fetal hemolytic disease

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MLNGCeleste, RN, MD

Amniocentesis

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MLNGCeleste, RN, MD


Percutaneous umbilical blood sampling• removal of blood from the umbilical cord using an

amniocentesis technique• more rapid karyotyping

Sonography/ Fetal imaging• assess fetus for general size and structural disorders

of the internal organs, spine and limbs• may be used concurrently with amniocentesis

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MLNGCeleste, RN, MD

Percutaneous umbilical blood sampling

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MLNGCeleste, RN, MD

Fetoscopy • insertion of a fiberoptic fetoscope through a

small incision in the mother’s abdomen into the uterus and membranes to inspect the fetus for gross abnormalities

• can be used to confirm sonography finding, remove skin cells for DNA analysis or perform surgery for a congenital defect

Preimplantation diagnosis• may be possible in the future• to remove the fertilized ovum from the uterus

before implantation for biopsy or cell analysis

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MLNGCeleste, RN, MD

Legal and Ethical Aspects

• Participation must be elective• Informed consent• Results must be interpreted correctly • Confidentiality must be maintained• Participation must be a free and individual

decision

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MLNGCeleste, RN, MD

Common Chromosomal Disorders

• Detected at birth on physical examination• Most common are nondisjunction syndromes• Many of these disorders leave children

cognitively challenged

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MLNGCeleste, RN, MD

1. Trisomy 13 syndrome (Patau syndrome)

• Children have extra chromosome 13• Severely cogitively challenged• Incidence is low, .45 per 1,000 live births• Midline body disorders present, microcephaly,

with abnormalities of the forebrain and forehead• Eyes are smaller than normal (microphthalmos) or

absent• Cleft lip and palate• Low set ears• Heart defects, VSD• Abnormal genitalia• Most do not survive beyond early childhood 54

MLNGCeleste, RN, MD

2. Trisomy 18 syndrome

• 3 Number 18 chromosomes• Severely cognitively challenged• Incidence .23 per 1,000 live births• Small for gestational age (SGA)• Low set ears, small jaw, congenital heart defects,

misshapen fingers and toes (Index deviates or crosses over other fingers)

• Soles of the feet are rounded not flat (rocker-bottom feet)

• Do not survive beyond early infancy

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MLNGCeleste, RN, MD

3. Cri-du-chat syndrome

• Result of a missing portion of chromosome 5• Abnormal cry – like a sound of a cat• Small head, wide-set eyes, downward slant to the

palpebral fissure of the eye• Severely cognitively challenged

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MLNGCeleste, RN, MD

4. Turner syndrome- female with only 1 X chromosome

• Gonadal dysgenesis, 45XO• Has only 1 functional X chromosome• Short in stature• Hairline at the nape is low set• Neck may appear webbed and short• May have edema of the hands and feet• Congenital anomalies, eg, coarctation (stricture) of the aorta;

kidney disorders• Streak (small and nonfunctional) gonads; may have pubic

hair in puberty, no other secondary characteristics• Incidence is 1 per 10,000 live births• On karyotyping, 1 X chromosome only (no Barr body

present)• Lack of fertility; learning disabilities; socioemotional

problems• Growth hormone may help achieve additional height;

Estrogen may induce withdrawal bleeding57

MLNGCeleste, RN, MD

5. Klinefelter syndrome- male with an extra X chromosome

• Males with XXY chromosome pattern (47XXY) –may be revealed by karyotyping

• At puberty – poorly developed secondary characteristics; small testes that produce ineffective sperm- often infertile

• Usually of normal intelligence or have mental retardation

• Gynecomastia• Incidence is about 1 per 1,000 livebirths

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MLNGCeleste, RN, MD

6. Fragile X syndrome

• X linked, 1 long arm of the X chromosome is defective• 1 in 1,000 livebirths• Most common cause of cognitive challenge in boys• Before puberty – maladaptive behaviors: hyperactivity

and autism• Reduced intellectual functioning (speech and

arithmetic)• Large head, long face with a high forehead, prominent

lower jaw, large protruding ears• Hyperextensive joints, cardiac disorders• After puberty – enlarged testicles; fertile• Folic acid and phenothiazine may improve symptoms

of poor concentration and impulsivity; intellectual function cannot be improved

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MLNGCeleste, RN, MD

7. Down syndrome (trisomy 21)

• Most frequent; 1 in 800 live births• In pregnancy of women >35 years (1 in 100 live

births); paternal age > 55• Diagnosis may be possible by sonography in

utero• Nose is broad and flat; epicanthal fold;

palpebral fissure tends to slant upward; iris of the eyes may have white speck in it (Brushfield spots); tongue may be protruding; back of the head is flat; short neck; extra apd of fat at the base of the head; low-set ears; poor muscle tone;simian crease on palm

• Cognitively challenged; educable (IQ 50 – 70) to profound MR (IQ< 20)

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MLNGCeleste, RN, MD

• Prone to upper respiratory infections• Congenital heart disease (atrioventricular defects)• Stenosis/ atresia of the duodenum• Strabismus; cataract disorders• Acute lymphocytic leukemia• Lifespan: 40 – 50 years• Should be exposed to educational and play

opportunities

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Reproductive and Sexual Health


Reproductive Anatomy and Physiology

• Male reproductive system–External structures

• Scrotum• Testes• Penis



Male internal structures• Epididymis• Vas deferens• Seminal vesicles• Prostate gland• Bulbourethral glands• Urethra


MALE REPRODUCTIVE SYSTEM

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MALE REPRODUCTIVE SYSTEM: ANDROLOGY

A. External Structures1. Penis: the male organ of copulation; a cylindrical shaft consisting

of:a. corpora cavernosa -two lateral columns of erectile tissue b. corpus spongiosum - encases the urethra

-The glans penis, a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males.

-Erection is stimulated by parasympathetic nerve

2. Scrotum: a pouch hanging below the penis that contains the testes.

3. Testes: two solid ovoid organs 4-5 cm long and 2-3 cm wide, divided into lobes containing Seminiferous tubules -produce spermatozoaLeydig cells - testosterone production

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Parts of the Penis:

1.The glans penis, a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males

2. Shaft or body

3. Prepuce or Foreskin – retractable skin covering the glans & removed during circumcision. Unretractable or tight foreskin is called PHIMOSIS.

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MALE REPRODUCTIVE SYSTEM:

A. External Structures continued

SPERMATOZOA are produced by: Hypothalamus Control by

GnRH (+/-) feedback Anterior Pituitary gland

FSH / LH Testes

FSH - release of Androgen Binding Protein (ABP) which promotes SPERMATOGENESIS

LH - release of Testosterone.

“Spermatozoa do not survive at body temperature. They usually survive at temperature 1°F lower than body temperature”. Hence, testes are suspended outside the body.

MLNGCeleste, RN, MDMLNGCeleste, RN, MD70

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B. Internal Structures

1. Epididymis: serves as reservoir for sperm storage and maturation. Approximately 20 ft. it takes 12-20 days for the sperm to travel the length of Epididymis.

A total of 64 days before the sperm reach maturity. Aspermia - absence of spermOligospermia- if < 20 million sperm/ ml

2. Vas deferens: a duct extending from epididymis to the ejaculatory duct and seminal vesicle, providing a passageway for sperm. Sperm mature as they pass through. Varicocele- varicosity of internal spermatic cord (may

contribute to infertility)Vasectomy- severing vas deferens (male birth control)


• Beginning in early adolescence, boys need to learn testicular self-examination.

• Testes should feel firm, smooth, egg-shaped.

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B. Internal Structures continued3. Seminal vesicles: are two convoluted pouches that lie

along the lower portion of the bladder and empty into the urethra by the way of the ejaculatory ducts

4. Ejaculatory ducts: the canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland.

5. Prostate Gland: located just below the urinary bladder. Secretes alkaline fluid and most of the seminal fluid.

6. Bulbourethral glands or Cowper’s Gland: adds alkaline fluid to the semen.

7. Urethra: the passageway for both urine and semen, extending from the bladder to the urethral meatus. (8 inches long)

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B. Internal Structures continued

SEMEN: • Is a thick whitish fluid ejaculated by the male during orgasm,

contains spermatozoa and fructose-rich nutrients. • During ejaculation, semen receives contributions of fluid from

Prostate gland (60%)Seminal vesicle (30%)Epididymis ( 5%)Bulbourethral gland (5%)

• Average pH = 7.5• The average amount of semen released during ejaculation is

2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours.

• 50-200 million/ml of ejaculation• ave. of 400 million/ejaculation • 90 seconds- cervix• 5 minutes- end of fallopian tube

MLNGCeleste, RN, MD

Spermatogenesis

Testes

Contain Leydig cells produces testosterone

Testosterone

Stimulates APG secrete FSH & LH

stimulates seminiferous tubules to produce spermatozoa

ALERT: it takes 64 days for sperm to reach maturity

MLNGCeleste, RN, MD

Sperm Pathway

Testes ---produces sperms

Epididymis conducts sperm to Vas deferens

Seminal vesicles ( secretion of fructose & protein)

Ejaculatory duct

Urethra ( 8 inches) ( cowper’s gland secretes alkaline fluid)

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• Female reproductive system–External structures–Internal structures


EXTERNAL REPRODUCTIVE SYSTEM

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FEMALE REPRODUCTIVE SYSTEM: GYNECOLOGY

A.External Structures

1. Mons pubis/ Mons veneris – pad of adipose tissues, which lies over the symphysis pubis, which protects the surrounding delicate tissue from trauma.

2. Labia majora – longitudal folds of pigmented skin extending from the mons pubis to the perineum. Contains the Bartholin’s gland that secretes yellowish mucus that acts as a lubricant during sexual activity.

3. Labia minora – soft longitudal skin folds between the Labia majora.

4. Glans clitoris – erectile tissue located at the upper end of Labia minora; primary site of sexual arousal.

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FEMALE REPRODUCTIVE SYSTEM:

A.External Structures continue

5. Vestibule – a narrow space seen when labia minora are separated that also contains the vaginal introitus, Bartholin’s gland and urethral meatus.

6. Urethral Meatus – small opening between the clitoris and vaginal orifice for the purpose of urination.

7. Vaginal orifice/introitus/opening – external opening of the vagina that contains the hymen.

8. Hymen – a membranous tissue ringing the vaginal introitus

9. Perineum – tissue between the anus and vagina. Site of episiotomy

The external genitalia’s blood supply: Arteries: a. pudendal artery b. inferior rectus artery. Vein: Pudendal vein

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• FEMALE INTERNAL STRUCTURES

1. Ovaries2. Fallopian tubes3. Uterus4. Vaginal canal

http://rds.yahoo.com/S=96062883/K=female+reproductive+system/v=2/SID=w/l=IVI/*-http:/www.hunterdonhealthcare.org/webmd/topics/Ovarian_Cancer/FemaleAnatomy.jpg


Female reproductive systemInternal structures

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B. Internal Structures

1. Ovaries – female sex glands located on each side of the uterus with two ovaries (4 x 2 x 1.5 cm thick).

Ovaries are formed with 3 principal divisions:a. A protective layer of surface epitheliumb. The cortex filled with the ovarian and graafian follicle c. The central medulla containing nerves, blood vessels, lymphatic tissue and some smooth muscle tissue

Functions: -Ovulation (release of ovum) and Secretion of hormones like estrogen and progesterone.

Estrogen- helps to prevent osteoporosis, and atherosclerosis and potential risk for breast cancer/ endometrial cancer

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Ovary-

Ovary - firm almond shaped organ covered by the peritoneum

3 principal divisions:a. protective layer of surface

epithelium

b. The cortex filled with follicles

c. The central medulla containing nerves, blood vessels, lymphatic tissue and some smooth muscle tissue

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B. Internal Structures continued

2. Fallopian Tubes – 4 inches (10 cm) long from each side of the fundus

Divided into four separate parts:

1. Intramural portion- most proximal (1 cm in length)

2. Isthmus portion- extremely narrow (2cm) Important: tubal ligation

3. Ampulla- longest portion (5cm) and widest part Function: site of fertilization

4. Infundibular portion- funnel- shaped with Fimbrae (2cm):finger like projections.

Function: responsible for the transport of mature ovum from ovary to uterus

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Fallopian Tube 4 parts1. Infundibulum- funnel shape, with fimbriae

2. Ampulla- wide middle segment; usual site of FERTILIZATION

3. Isthmus- narrowest part

4. Interstitial or Intramural- embedded in the uterine wall

•Bilateral ducts extend laterally from the uterus•receive oocyte and provide site for fertilization

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B. Internal Structures continue

3. Uterus – hollow pear-shaped muscular organ.Size: 3 inches long (5-7cm), 2 inches wide(5cm) and 1 inch thick (3x2x1)Wt: 60 gms. in non pregnant Location: lower pelvisParts: Corpus, Isthmus, and Cervix Position: anteverted and anteflexedLayers: perimetrium, myometrium and endometrium

Functions: 1. receives the ova to fallopian tube; place for implantation and nourishment during fetal growth; furnishes protection to a growing fetus2. aids in labor and delivery

Cervix (2-5cm long)Internal cervical os - an impt. relationship in estimating the External cervical os level of dilatation of the fetus

in the birth canal before birth.


3 main parts of the Uterus1. Fundus- rounded portion superiorly2. Corpus or Body- major portion3. Cervix- outlet which protrudes into vagina

• Isthmus- junction between the body and the cervix• POSITION: Anteverted and Anteflexed


Layers of Uterine wall1. endometrium (or mucosa) – inner layer

2. myometrium – thick, middle circular layer (stratum vasculare)

3. epimetrium- superficial part surrounded by the perimetrium


Layers of the Endometrium

1. Stratum Functionale– Stratum compactum– Stratum spongiosum

2. Stratum basale or germinativum

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Uterus continue

Nerve Supply:Efferent (motor) nerve- spinal ganglia (T5 to T10) Afferent (sensory) nerve - hypogastric plexus (T-11 & T-12)

Impt: Controlling pain in labor ( Epidural anesthesia)

Uterine Ligaments:1. Broad Ligaments – from the sides of uterus to pelvic walls

2. Round Ligaments – from sides of uterus to mons pubis.

3. Cardinal and uterosacral ligaments- provide middle support

4. Pelvic muscular floor ligaments- provide lower support

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3. Vaginal Canal – 3-4 inch long dilatable canal between the bladder and the rectum; contains rugae that permits stretching without tearing.

Anterior Vaginal wall- 6-7 cm (anterior fornices)Posterior Vaginal wall- 8-9 cm (posterior fornices)

Functions: 1. passageway for menstrual discharges 2. receives penis during intercourse and 3. serves as birth canal.

- lined with stratified squamous epithelium

- Bulbocavernosus: a circular muscle acts as voluntary sphincter (Kegel exercises)

Blood supply to the vagina:Arteries: vaginal artery branch of internal iliac arteryVein: pudendal vein

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Vagina continued…

The external genitalia’s blood supply: mainly from the a. pudendal artery and b. a portion of inferior rectus artery.

Nerve supply: has both parasympathetic & sympathetic (S-1 to S-3 levels)

Nerve supply of the anterior portion: (L1)a. Ilio-inguinal nerves b. Genito-femoral nerves Nerve supply of the posterior portion: (S3)

Pudendal nerves

“This is the reason why one type of anesthesia used for childbirth is called Pudendal block.”


Vaginal canal• Connects the cervix to the vestibule• Fibromuscular walled tube lined with mucus and

covered with hymen• hymen – vascular and tends to bleed when ruptured • The remnant of hymen is called CARUNCULAE

MYRTIFORMIS• Bulbocavernosus: a circular muscle acts as voluntary

sphincter (Kegel exercises)

Function: organ of copulation and passageway of menstrual flow and baby


Variations of Uterine Formation

NORMAL Bicornuate Septum- DoubleUTERUS Uterus dividing uterus uterus


Uterine DeviationsBicornuate – oddly shaped horns at the junction of

the fallopian tubesRetroversion – fundus is tipped backRetroflexion – body of the uterus is bent sharply

back just above the cervix

Normal : Anterted and AnteflexedAnteversion – fundus is tipped forwardAnteflexion – body of the uterus is bent sharply

forward at the junction of the cervix


Anteversion Anteflexion

Retroversion Retroflexion



• Female internal structures– Vagina– Breasts– Pelvis


Analogous Structures

Female MaleGlans Clitoris Glans penisLabia majora ScrotumVagina PenisOvaries TestesFallopian tubes Vas deferensSkene’s glands Prostate glandsBartholin’s glands Cowper’s glandsOvum Spermatozoa


Mammary glands

- MODIFIED SWEAT GLAND- glands consist of 20 individual compound alveolar

glands w/ separate openings (lactiferous ducts) at nipple

- internally 15-25 lobes- under effects of estrogen and progesterone for

development; prolactin for milk secretion; oxytocin - milk ejection reflex

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• HORMONES THAT INFLUENCE THE MAMMARY GLANDS:– ESTROGEN – STIMULATES THE DEVELOPMENT OF

THE DUCTILE STRUCTURES OF THE BREST– PROGESTERONE – STIMULATES THE DEVELOPMENT

OF THE ACINAR CELLS– HUMAN PLACENTAL LACTOGEN – PROMOTES

BREAST DEVELOPMENT DURING PREGNANCY– OXYTOCIN – LET DOWN REFLEX– PROLACTIN – STIMULATES MILK PRODUCTION


Reproductive Development• Intrauterine development

-sex of an individual is determined at the moment of conception

• Gonad- body organ that produces sex cells (ovary, testis)

Week 5: primitive gonadal tissue is formed- Mesonephric (wolffian) and paramesonephric

(mullerian) ducts are presentWeek 7 or 8 - in choromosomal males: primitive testes;

formation of testosteroneWeek 10 - ovaries in females; oocytes formedWeek 12 – external genitalia


REPRODUCTIVE AND SEXUAL HEALTH

PUBERTAL DEVELOPMENT:

Puberty is the stage of life at which the secondary sex changes begin.

Girls- age 9 to 12 years

Theory: must reach a critical weight of approx. 95 lbs (43kgs) or develop a critical mass of fat before the hypothalamus is triggered to stimulate the anterior pituitary gland to begin gonadotropic hormone formation.



Boys- age 12 to 14 yearsThe role of Androgen- hormones responsible for :1. Muscular development2. Physical growth 3. Increase sebaceous gland secretion

(acne)Androgen- produced by the adrenal cortex

and testes in the males; by the adrenal cortex and the ovaries in the females



“Testosterone -1° androgenic hormone”

In girls, testosterone influences the development of labia majora, clitoris, and axillary & pubic hair latter termed as (adrenarche)

In males, it influences the development of testes, scrotum, penis, prostate and seminal vesicle; the appearance of pubic, axillary hair; facial hair; laryngeal enlargement; voice change; maturation of spermatozoa and closure of growth in long bones.


• Estrogen – excreted by the ovarian follicles (3 compounds: estrone, estradiol and estriol)- Influences the development of the uterus, fallopian tubes and vagina at puberty; typical female fat distribution and hair patterns; breast development and end of growth of long bones




Secondary sex characteristics of boys occur in the following order:

1. increase in weight 2. growth of testes3. growth of face, axillary and

pubic hair4. voice changes5. penile growth6. increase in height 7. spermatogenesis



Secondary sex characteristics of girls occur in the following order:

1. growth spurt2. increase in the transverse diameter of the pelvis3. breast development (thelarche)4. growth of pubic hair (adrenarche)5. onset of menstruation (menarche

12.5 y/o ave.)-Ovulation occurs 1 – 2 years after menarche6. growth of axillary hair (adrenarche)7. vaginal secretion


Menstruation

• Episodic uterine bleeding in response to cyclic hormonal changes

• Brings an ovum to maturity and renews uterine tissue bed

• PERIODIC, SLOUGHING OFF OF THE ENDOMETRIUM WHICH OCCURS EVERY 28 DAYS BUT COULD BE ANYWHERE FROM 25 TO 35 DAYS & LASTS FOR 3-5 DAYS.

MLNGCeleste, RN, MD

Characteristics of Menstrual Blood:

1.Does not appear to clot

2.Dark red as that of venous blood

3.Offensiveness ( Fleshy stale odor)

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MENSTRUAL CYCLE / FEMALE REPRODUCTIVE CYCLE

= EPISODIC UTERINE BLEEDING IN RESPONSE TO HORMONAL CHANGES

= PERIODIC SERIES OF CHANGES THAT RECUR IN THE UTERUS AND ASSOCIATED ORGANS BEGINNING AT PUBERTY AND ENDING AT MENOPAUSE

= TAKEN FROM THE FIRST DAY OF MENSTRUATION TO THE FIRST DAY OF THE NEXT MENSTRUATION

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Basis for menstrual cycle is 6-12 month graphing.

Menarche – first menstrual period that occurs typically at age 12 but may occur as early as 9 or as late as 17

Thelarche – development of the breast buds that occur at puberty

Adrenarche – development of pubic & axillary hair due to androgen stimulation

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BODY STUCTURES INVOLVED IN MENSTRUATION

1. HYPOTHALAMUS – ultimate initiator of menstrual cycle. Secretes GnRH. Releases FSHRF during the first half of the cycle & LHRF during the second half of the cycle.

2. ANTERIOR PITUITARY GLAND – releases the gonadotropin hormones (GH) FSH & LH

3. OVARIES- site of ovulation & releases estrogen & progesterone.

4. UTERUS – the organ from which menstrual discharge is formed. The changes in the uterine endometrium are due to ovarian hormones

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PITUITARY HORMONES ( GONADOTROPIC HORMONES) WHICH REGULATE MENSTRUAL CYCLIC ACTIVITIES:

1. FOLLICLE STIMULATING HORMONE ( FSH)

2. LUTEINIZING HORMONE ( LH )

OVARIAN HORMONES WHICH REGULATE MENSTRUAL CYCLE ACTIVITIES:

2. ESTROGEN – hormone of women; produced by the graafian follicle

2. PROGESTERONE – hormone of mothers; produced by the corpus luteum


HORMONES

Estrogen - female secondary sexual characteristics, such as breast development, increased adipose tissue deposition, and increased vascularization of the skin, widening and lightening of pelvis


HORMONES

Progesterone - triggers uterine changes during the menstrual cycle


Characteristics of Normal Menstrual Cycles

• Beginning (menarche) – average of onset 12 -13 yrs; average range 9 -17 years

• Interval between cycles – Average 28 days; cycles of 23 – 35 days not unusual

• Duration of menstrual flow – Average flow 2-7 days; ranges 1-9 days not abnormal

• Amount of menstrual flow –difficult to estimate; average 30-80 ml

• Color of menstrual flow – dark red; combination of blood, mucus and endometrial cells

• Odor- similar to that of marigolds


FEMALE REPRODUCTIVE FUNCTIONS AND CYCLES

OOCYTES

• in utero - 5 to 7 million• at birth - 2 million• 7 yrs of age only - 500,000/ovary • Reproductive age only - 400–500 oocytes• Menopause - none


Uterine cycle

3 phases1. Menstrual phase2. Proliferative phase3. Secretory phase


Menstrual Phase

• Day 1- day 5• First day of bleeding is the first day of cycle• Stratum functionale (compactum and

spongiosum) are shed• Around 60 ml average


Proliferative Phase

• Days 5- day 14• Eptihelial cells of functionale multiply

and form glands• Due to the influence of estrogen


Secretory Phase

• Day 15- day 28• Endometrium becomes thicker and glands

secrete nutrients• Uterus is prepared for implantation• Due to progesterone• If no fertilization constriction vessels

menstruation


Ovarian cycle

3 phases1. Pre-ovulatory : follicular phase2. Ovulatory phase3. Post-ovulatory : Luteal phase


Ovarian Cycle; preovulatory/follicular

• Variable in length: day 6- day 13• Dominant follicle matures and

becomes graafian follicle with primary oocyte

• FSH increases initially then decreases because of estrogen increase


Ovarian cycle: Ovulatory phase

• Day 14• Rupture of the graafian follicle

releasing the secondary oocyte• Due to the LH surge• MITTELSCHMERZ- pain during rupture

of follicle


OVARIAN cycle: Post-ovulatory: luteal phase

• Day 15- day 28• MOST CONSTANT 14 days after ovulation• Corpus luteum secretes Progesterone• If no fertilization, corpus luteum will become corpus

albicans then degenerate• Decreased estrogen and progesterone production


Hormonal cycle

1. Menstrual phase– Decreased Estrogen, decreased progesterone,

decreased FSH and decreased LH

2. Proliferative/Pre-ovulatory phase– Increased FSH and Estrogen in small amounts


3. Ovulatory phase– Increased LH (surge); Increased Estrogen

4. Post ovulatory/luteal Phase– Increased Estrogen, increased progesterone until

corpus luteum degenerates


‘


SUMMARY OF MENSTRUAL CYCLE

- monthly changes in the uterine lining that lead to menstrual flow as the endometrium is shed

STEPS:1. Corpus luteum of previous cycle fades,

progesterone decreases, FSH rises (proliferative phase)


SUMMARY OF MENSTRUAL CYCLE

2. FSH stimulates follicular growth and differentiation and stimulate Estrogen secretion

3. Estrogen stimulates endometrial growth and differentiation along w/ follicular growth


4. Rising Estrogen levels exert a negative feedback on the pituitary gland and hypothalamus to decrease secretion of FSH

5. Dominant follicle is destined grow for ovulation


6. Sustained high Estrogen level cause the LH surge w/c triggers ovulation 24-36 hours later, progesterone production and shift to luteal/secretory phase

7. Estrogen level decreases until the midluteal phase when it rises d/t corpus luteum secretion


8. Progesterone also rises because of corpus luteum secretion; protein rich secretory products in glandular lumen (secretory phase)

9. If pregnancy does not occur, the corpus luteum degenerates, hormone levels decline, and the uterine lining disintegrates and shed (menstrual phase)

*time from ovulation to the onset of the next menstrual period is usually constant (2 weeks)


10. If fertilization and implantation occur, ovary continues producing progesterone and the endometrium remains intact to support embryo development and pregnancy.


Education


Menopause

• Cessation of menstruation for at least one year occurring at the age of 45-52 due to cessation of ovarian function

• Decreased estrogen and progesterone• Genetically determined• May occur earlier in smokers, nulliparous and

patients who underwent hysterectomy


A. MENSTRUAL CYCLE CHANGES:- changes in menstrual cycle regularity- remaining follicles in both ovaries become less

sensitive to GnRH stimulation which results to:1.increased level of fsh2.reduction in estrogen concentration


- the limited follicle maturation leads to either a decrease in cycle interval or lapses of cycles, with oligomenorrhea

B. CESSATION OF MENSES:- menses usually cease between Ages of 45 and 52 years,

(reduced level of estrogen from the remaining follicles is no longer sufficient to induce endometrial proliferation / changes capable of producing visible menstruation)


C. PREMATURE MENOPAUSE:- manifested by permanent amenorrhea before 35 years of age due to:

1.genetic predilection2.ovarian failure due to auto-

immune reaction


Concerns

1. Loss of childbearing capacity2. Loss of youth3. Skin changes-related to estrogen deficiency that has a role in

collagen storage and restoration4. Depression-related to changes in relationship w/ children,

spouse and other life events5. Anxiety and irritability –”climacteric syndrome”; psychocial6. Loss of libido-related to vaginal atrophy secondary to

decreased estrogen


7. Abnormal bleeding – irregular, heavy or prolonged related to to anovulatory cycles

* rule out pregnancy, malignancies and polyps8. Hot flashes/flushes – recurrent, transient flushing,

sweating, palpitations, anxiety, chills9. Urinary symptoms – dysuria, urgency and recurrent

UTI10. Difficulty in concentration and short term memory

loss11. Cardiovascular disease12. osteoporosis


TARGET ORGAN RESPONSE TO DECREASED ESTROGEN:

• VAGINA- becomes smaller and the size of the upper vagina diminishes- epithelium becomes pale, thin, and dry- labia minora has a pale , dry appearance; reduction in fat content of labia majora

• Uterus - endometrial tissue become sparse, with numerous small petecchial hemorrhages, has atrophic appearance- myometrium atrophies, uterus decreases in size


• Breast - general loss of turgor, form, fullness of the breast

• Bones - gradual loss of calcium, lading to osteoporosis, characterized by reduction in bone density and fracture

• Hair - with the loss of estrogen, there is relative decrease in circulating androgens; increase quantity of hair with male pattern distribution


Sequelae of reduced estrogen:

Vasomotor symptoms:- Hot flash/ flush, is the hallmark of the menopausal

woman- last for a few seconds or several minutes- more frequent and severe at night or during time

of stress- coincides with a surge of luteinizing hormones


• Altered menstrual function:– Oligomenorrhea followed by amenorrhea– Amenorrhea for 6 to 12 months– If vaginal bleeding occurs after 12 months of

amenorrhea, endometrial biopsy must be ruled out

• osteoporosis:– Main health hazard associated with menopause


Menopausal syndrome:-Such as fatigue, headache, nervousness, loss of libido, insomnia, depression, irritability, palpitation, muscle pain

•Atrophic changes:- atrophy of the vaginal mucosa leads to atrophic vaginitis, pruritus of vulvovaginal area, dyspareunia and stenosis- urethral changes- increased frequency of cystitis- vaginal, urethral and bladder symptoms


Treatment:Estrogen replacement therapy

• Advantages:– Eliminate hot flashes– Reversal of atrophic vaginitis, dyspareunia, affective

symptoms– Prevention and treatment of osteoporosis– Prevention of cardiovascular disease– Retention of youthful skin


•Disadvantages -can cause acute liver

disease-Acute vascular thrombosis-Seizure disorder-Hypertension-Migraine headache-Breast cancer-Endometrial cancer


Menstrual Disorders

Dysmenorrhea

Primary – due to prostaglandin excess or increased sensitivity to prostaglandin w/ no pathologic pelvic disorder

Secondary – with underlying diseaseie, PID (Pelvic inflammatory disease)Endometriosis, Adenomyosis, Uterine prolapse, Uterine myomas, Polyps


DysmenorrheaPathophysiology

Prostaglandin myometrial contractions muscle spasm constricts blood vessels ischemia and pain


Clinical Manifestations • Primary – within 1-2 yrs after menarche in conjunction

with ovulatory cycles- pain few hours before menses up to 72 hours thereafter- Nausea and vomiting, diarrhea, syncope, headache, back

pain

• Secondary – years after menarche- 1-2 wks prior to menses and persist few days after

menstrual cessation

DiagnosisHistory and PE


Medical Management

1. combination OCP – inhibit ovulation, decrease prostaglandin and uterine activity

2.promote exercise 3.administer prostaglandin synthesis inhibitors – ibuprofen,

mefenamic acid

Nursing Management1. Education and reassurance2. adequate nutrition and rest3. stress management


Menstrual cycle irregularities

Oligomenorrhea – infrequent, irregular bleeding at intervals > 35 days

Polymenorrhea – frequent, regular bleeding at intervals < 21 daysAmenorrhea – cessation of menses x 6 monthsMenorrhagia – regular bleeding that is excessive in amount and

duration > 5 daysMetrorrhagia – irregular bleedingMenometrorrhagia – excessive prolonged bleeding at irregular

intervals


PREMENSTRUAL SYNDROME

- emotional and physical manifestations that occur cyclically before menstruation and regress thereafter

- peak 30-40 yo- mood and behavioral changes- No specific hormone, treatment or markers- inherent to menstrual cycle


Etiology and Risk Factors- Caffeine- Smoking- Lack of exercise- Improper diet- Inadequate sleep- Stress

Management:supportive

MLNGCeleste, RN, MD

Sexuality

• Includes feelings, attitudes and actions• Has both biologic and cultural components• Encompasses and gives direction to a person’s physical

emotional social, and intellectual responses throughout life

• Each person is born a sexual being.• Gender identity and gender role behavior evolve from

and usually conform to societal expectations within a person’s culture.

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Sexuality and Sexual IdentityTerms

• Biologic gender – denotes chromosomal development: XX, XY

• Gender identity or sexual identity: inner sense a person has of being male or female

• Gender role - behavior a person conveys about being male or female (may or may not be the same as biologic gender or gender identity)


Human Sexual Response

Sexual response cycle (Masters and Johnson)• Excitement• Plateau• Orgasm• Resolution

MLNGCeleste, RN, MD

Mechanisms involved in response to sexual stimulation:

1. Vasocongestion – the engorgement of blood vessels and increased influx of blood into the tissues. Congested tissues, because of its excess blood content, become swollen, red and warm

2. Myotonia – increased muscles tension affecting both smooth and skeletal muscles and occurs both voluntarily and involuntarily

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Excitement• occurs with physical and psychological (sight,

sound, emotion, thought) stimulation that causes parasympathetic nerve stimulation

• Arterial dilation and venous congestion in the genital area

• Vasocongestion:-clitoris in women increases in size, mucoid fluid appears in vaginal walls as lubrication, vagina widens/ increase in length, nipples become erect

• In men, erection occurs; scrotal thickening, elevation of testes

• Increase in PR, RR and BP


Plateau• just before orgasm• Women: clitoris is drawn forward and retracts under

the clitoral prepuce; lower part of the vagina becomes extremely congested (formation of the orgasmic platform), increased nipple engorgement

• Men: vasocongestion leads to full distention of the penis

• HR increases to 100 to 175 beats per minute and RR to approximately 40 respirations per minute


Orgasm• Occurs when stimulation proceeds through

the plateau stage to a point at which the body suddenly discharges accumulated sexual tension

• Vigorous contractions of muscles in the pelvic area expels or dissipates blood and fluid from the area of congestion


• Shortest stage in the sexual response cycle• Usually experienced as intense pleasure

affecting the whole body not just the pelvic area

• Highly personal experience; vary greatly from person to person


Resolution• Period during which the external and internal genital

organs return to unaroused state• Males: refractory period – during which further

orgasm is impossible• Females: no refractory period; may have additional

orgasms immediately after the first• Generally takes about 30 minutes

The Growing Fetus


Stages of Fetal Development

During pregnancy, the fetus undergoes 3 major stages of development:

1. PRE-EMBRYONIC PERIOD – fertilization to week 2

2. EMBRYONIC PERIOD –week 3 – week 8

3. FETAL PERIOD – week 8 to birth


Stages of Fetal DevelopmentFertilization

• Beginning of pregnancy• Union of the ovum and spermatozoon • Usually occurs at the outer third of

fallopian tube


Stages of Fetal DevelopmentImplantation

• Contact between growing structure and uterine endometrium

• Occurs 8-10 days after fertilization


Embryonic and Fetal Structures

• Decidua• Chorionic villi• Placenta



Umbilical Cord• From fetal membranes• Provides circulatory pathway• Contains one vein and two arteries



Amniotic Membranes• Chorionic membrane• Amniotic membrane


I. PREGNANCY• refers to condition of carrying an offspring

within the body.• a form of reproduction that unites the cell

of 2 individuals to form a unique new individual who embodies characteristics of both parents

II. FERTILIZATION • union of ovum and spermatozoa• union generally occurs in the distal third of

the fallopian tube


• Cells of the human body develop from chromosomes

• Normal human cell tissue contains 46 chromosomes-22 pairs of homologous autosomes (any chromosome other than sex chromosome) and one pair of sex chromosomes; one chromosome of each pair of chromosomes is received from the mother and the other one from the father

• Sex determination occurs at the moment of conception as a result of the sex chromosome contributed by the male; an X-carrying sperm fertilizing the ovum produces a female (XX), a Y-carrying sperm produces a male (XY)

• Aberration in the number of chromosomes result in abnormal offspring or spontaneous abortion


Process of fertilization (conception)

– only one sperm penetrates ovum• Usually occurs in the outer third of the fallopian

tube• Implantation usually occurs in the upper part of

the uterus about 7-10 d after fertilization when the developing zygote burrows into the endometrium, which has undergone changes to provide for its nourishment and is now called the deciduas


There are three groups of cells in the developing embryo:

• Outer layer (ectoderm) – develops into the following structures; hair, nails, sebaceous glands, sweat glands, epithelium of nasal and oral passages

• Middle layer (mesoderm)– develops into the following structures: muscles, bones, sexual structures, heart, kidneys, teeth dentin

• Inner layer (endoderm) – develops into the following: epithelium of digestive tract, respiratory tract, bladder


• Zygote- fertilized ovum

• Cell division:- occurs as the zygote travels the fallopian tube to the uterus.it takes 3 to 4 days of cell division or mitosis for the zygote to become morula( resemble mulberry), this morula entering the uterus is now

called a blastocyst

Blastocyst- differentiates into 1. inner mass of embryonic cell which becomes the EMBRYO2. outer layer called the TROPHOBLAST, which is involved in

implantation, hormone secretion, and membrane and placental formation


III. IMPLANTATION - 7 days or 5 days after fertilization, the trophoblast burrows into the endometrium (upper part of uterus), embedding the fertilized egg into the uterine lining

decidua - what the endometrium is called after implantation

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Formation of twins:

• Fraternal or dizygotic - 2 ova are being fertilized by 2 sperm, they are nonidentical, there are 2 amnion, 2 chorion, 2 placenta

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Formation of twins:

• Identical or monozygotic twins:

- one ovum is fertilized by one sperm and the inner cell mass of the blastocyst splits into 2 to form two embryos

- maybe 2 males or 2 females, there are 2 amnion , one chorion and one placenta


• Chorion - outer fetal membrane, formed from the trophoblast ( maternal side of placenta)

• Amnion - originates in the blastocyst during early stages of development, expands as the fetus grows until it slightly adheres to the chorion ( fetal side of placenta)

• Amniotic sac - formed by 2 fetal membranes (chorion, amnion)


IV. AMNIOTIC FLUID - formed by the secretion of: 1. amniotic cells2. lungs and skin of fetus3. fetal urine

- 98% water, but also contains glucose, protein, sodium, urea, creatinine, lanugo, vernix caseosa

- slightly alkaline, replaced approximately every 3 hours

- amniotic cells and the fetus urinating and swallowing regulate the secretion and reabsorption of the fluid


Functions of amniotic fluid: Never stagnant

Serves to protect fetus• - Shields against pressure; equalizes the

pressure around the fetus; cushions the fetus from external compression

- Protects from temperature changes; . provides constant temperature and fluid for

the fetus to swallow - Protects umbilical cord

- allows freedom of movement for the fetus - lubricates the membrane and the fetus


yolk sac - cavity in the blastocyst - forms primitive red blood cell until the

liver is able to take over the process in about 6 weeks


V. PLACENTA AND UMBILICAL CORD: placenta- formed by the : 1. chorionic villi at the base of the implanted

fertilized ovum and the decidua basalis2. endometrium at the side of implantation


Placenta - membranous vascular organ connecting the fetus to the mother, supplies the fetus with oxygen and food and transports waste product out of fetal system

- development is stimulated by progesterone secreted by corpus luteum ( 3rd wk after fertilization)

- fully functional by the 12th week


2 sides of placenta: 1.maternal side which is irregular and is

divided into subdivisions called cotyledons 2. fetal side covered by amnion, so it is

smooth and shiny


Placental Circulation


umbilical cord - a structure that connects the fetus to the placenta.

- has 2 arteries and 1 vein (AVA)- 2 arteries carry deoxygenated blood from the fetus to the placenta

- 1 vein carries oxygenated blood to the fetus, along with nutrients, hormones etc


Circulatory system of the mother and fetus are separate

- maternal blood enters the intervillous spaces of the placenta

- fetal blood is in the vessels of chorionic villi


Functions of placenta:1.Transport: ( substances) a. by diffusion from an area of higher

concentration to area of lower concentration (oxygen, carbon dioxide, electrolytes, fat soluble vitamins, gases and drugs)

b. facilitated diffusion uses carrier system to move molecules ( some glucose and oxygen)


c. active transport – allows molecules to move from lower concentration to area of higher concentration (amino acids, iron, calcium,iodine and water soluble vitamins)

d.Pinocytosis - transfers larger molecules(albumins, globulins, antibodies, viruses) e. osmotic pressure and hydrostatic pressure

Insulin, heparin IgM, and blood cell do not move across the placenta unless there is tear


2. Endocrine: secretes 5 hormones

1. hCG- basis of pregnancy test2. human placental lactogen3.estrogen.4.progesterone5.relaxin


HCG- secreted by trophoblast, during early pregnancy

- prevents involution of corpus luteum, stimulates it to continue producing progesterone and estrogen for 11-12 weeks

- 8 to 10 days after fertilization, hCG is present in maternal blood

- few days from missed menses, (+) in urine


Human placental lactogen - makes sufficient amount of protein,

glucose, and minerals - an insulin antagonist (maternal

metabolism of glucose)- ensures that the mother’s body is

prepared for lactation


Estrogen - stimulates development of uterine and breast tissues in the mother

- increases vascularity and vasodilation in the villous capillaries


Progesterone - after 11 weeks of pregnancy, placenta takes over the production of progesterone from the corpus luteum

- it is a smooth muscle relaxant, prevents uterine contraction by decreasing its contractility

- also maintains the endometrium

relaxin - causes changes in collagen


3. Metabolic:- produces fatty acid, glycogen and cholesterol for fetal use and

hormone production


DEVELOPMENT OCCURS IN SYSTEMATIC MANNER FROM HEAD TO TOE

- from proximal to distal and from general to specific

- or described in general term of trimester(1st trimester -12 wks, 2nd trimester-13 to 27 weeks, 3rd trimester-28 to 40 weeks)


week 4 - (wt 0.4g, length is 4- 6mm), half the size of a pea, brain differentiates, G.I. tract begins to form, limbs buds appear

MLNGCeleste, RN, MD

week 5 - cranial nerves present, muscles have innervation ( L 6-8mm)

week 6 - fetal circulation established. liver produces red blood cells, CNS forms, primitive kidney forms, lung buds present, cartilage forms, primitive skeleton forms, muscles differentiate

week 7 - eyelids form, palate and tongue form stomach formed, diaphragm formed, arms and legs move (L 22-28mm)

MLNGCeleste, RN, MD219


week 8 - resembles human being, eyes move to face front, heart development complete, hands and feet well formed; bone cells begin to replace cartilage, all body organs have begun forming (wt-2g, L 3cm,)

MLNGCeleste, RN, MD

Fetal Stage

week 9 - fingers and toenails form; eyelids fuse shut

week 10 - head growth slows, islets of langerhans

differentiated, bone marrow forms, rbc produced; bladder sac forms, kidneys make urine

( wt-14g,L 5-6cm C – H )

week 11 - tooth buds appear, liver secretes bile; urinary system functions, insulin forms in pancreas MLNGCeleste, RN, MD

221


week 12 - lungs takes shape, palate fuses, heart beat heard with Doppler, ossification established, swallowing reflex present; external genitalia, male or female distinguished

MLNGCeleste, RN, MD

week 16 - meconium forms in bowels, scalp hair appears, frequent fetal movement, skin thin and pink ,sensitive to light, 200 ml of amniotic fluid



week 20 - myelination of spinal cord begins, peristalsis begins, lanugo covers body; vernix caseosa

covers body, brown fat deposit begins, swallows and sucks amniotic fluid, heart beat heard by fetoscope, hands can grasp, regular schedule of sucking ,

kicking and sleeping ( wt 435 g L 19cm)

MLNGCeleste, RN, MD

week 24 - alveoli present in lungs/ begin producing surfactant , eyes completelyformed, eyelashes and eyebrows appear, many reflexes appear, (+) chance of survival if born



week 28 -subcutaneous fat deposits begin; lanugo begins to disappears, nails appear, eyelids open and close ; testes begin to descend

week 32 - more reflexes present, CNS direct rhythmic breathing movement/ partially

controls body temperature, begins storing iron, calcium phosphorus; ratio of lungs surfactant lecithin and sphingomyelin is 1.2:2

week 36 - a few creases on soles of feet, skin less wrinkled, fingernails reach fingertips, sleep-wake cycle fairly definite, transfer of maternal

antibodies

MLNGCeleste, RN, MD

week 38 - L/S ratio 2:1 week 40 - lanugo only on shoulders and upper

back; creases cover sole, vernix mainly in folds of skin, ear cartilage firm, less active, limited space, ready to be born


228

System development:-all systems in the fetus begin forming by the 8th

week• cardiovascular system -primitive heart begins to

beat on the 21st day following conception ,the 1st to function in the embryo; congenital malformation may develop during the 6th to 8th weeks


Fetal Circulation


Fetal circulation:

oxygenated blood(placenta)

umbilical vein

liver ductus venosus

inferior vena cava

right atrium

foramen ovale( flap opening in the atrial septum that allow only R-L movement of blood)


• Continuation: left atrium left ventricle right ventricles( small amount)

aorta pulmonary arteries ductus arteriosus supply the body aorta

supply blood to the body


Continuation:

superior vena cava right atrium

right ventricle

pulmonary arteries ( ductus arteriosus) aorta

supply blood to the body


Special Structures:Foramen OvaleConnects the left and right atriaBypassing fetal lungsObliterated after birth to become fossa ovalisUmbilical VeinBrings oxygenated blood coming from the placenta to the heart and liverBecomes ligamentum teresUmbilical arteriesCarry unoxygenated blood from the fetus to placentaBecome umbilical ligaments after birthDuctus venosusCarry oxygenated blood from umbilical vein to IVCBypassing fetal liverBecomes ligamentum venosum after birthDuctus arteriosusCarry oxygenated blood from pulmonary artery to aortaBypassing fetal lungsBecomes ligamentum arteriosum; closes after birth


• Hematologic development: - day 14 , primitive blood cells are formed in

the yolk sac. - fifth week of gestation before the fetal liver begins hematopoiesis - fetal hemoglobin ( Hgb F ) found only

during gestation and early neonatal period, has great attraction for oxygen

- blood type is genetically determined at conception


• Gastrointestinal system: - 4th week of gestation ,G.I.T. begins to

form - 20th week fetus begins to swallow

amniotic fluid, but there is no coordination of the swallow and suck reflexes until about the 34th week

meconium - fecal material stored in the fetal intestine, begins to form about

week 16 - if the fetus encounters hypoxic stress

anal sphincter may relax and meconium may be passed


• Musculoskeletal system: - limb buds appear late in the 4rth week and

development is complete by the 8th week - growth of skeleton is determined by

genetics and maternal supply of calcium and phosphorous

- cartilage is noted about the 5th week - ossification begins about the 12th week but not

completed until after puberty - end of 12th week skeletal muscles begin involuntary

movement ( depend s on volume amniotic fluid)


• Genitourinary system: - kidneys begin forming about 3 weeks - 12th week -begins to produce hypotonic urine ( all nephrons are in the kidneys at birth)

• Reproductive system: - testes seen on abdomen by 7 weeks, and

begin to descend to the scrotum about 30 weeks;

ovaries develop in the abdomen and stay in the pelvic cavity


• Integumentary sytem: - creases form on the palms, fingers, soles, during

week 11, permanent design formed by week 17 - lanugo appears during week 20 and slowly

dissappears - mammary glands develop during the 6th week

• Respiratory system: - lung buds form during the 6th week - bronchi form by week 16


-surfactant production begins between weeks 20-24 - primitive lungs formed by week 23 - surfactant production matures between weeks 35 and 37

• Immunologic system: - between 12-15th weeks immune capability

begins to develop - fetus produces small amount of immunoglobulin

IgA, IgG, and IgE


Fetal development: - preembryonic or germinal stage: weeks 1 and 2 - rapid cell division and differentiation - germinal layers form

-embryonic stage: week 3 - primitive nervous system, eyes, ears,

rbc present, heart begins to beat day 21


Teratogens

Any factor that adversely affects fertilized ovum, embryo or fetus


Teratogenic Fetal Exposure • Maternal infections• Toxoplasmosis• Rubella• Cytomegalovirus• Herpes simplex virus• Syphilis


Teratogenic Fetal Exposure• Lyme disease• Infections• Vaccines• Drugs• Alcohol• Cigarettes


Drugs Teratogenic Effects

• Androgen, Estrogen Musculinization of female infants• Progesterone • Thalidomide Phocomelia, cardiac & lung

defect• Anticonvulsant left lip & palate; CHD• Lithium CHD• Tetracycline yellow staining of teeth,

inhibits bone growth• Vitamin K Hyperbilirubinemia• Salicylates ( aspirin) neonatal bleeding,

decreased IUG• Streptomycin Nerve defects• Vitamin A CNS defects• Barbiturates Bleeding disorders


Teratogenic Fetal Exposure• Environmental• Metal and chemical• Radiation• Hyperthermia and hypothermia• Maternal stress

Assessing Fetal and Maternal Health: Prenatal Care

247

PRENATAL CARE (ANTEPARTUM CARE)

3 PHASES:

1. PRE-CONSULTATION = HISTORY TAKING, FAMILY, MEDICAL, OB HISTORY

2. CONSULTATION = PHYSICAL ASSESSMENT

3. POST CONSULTATION = HEALTH TEACHINGS

248

COMPONENTS OF PRE NATAL VISIT

1.PRE- CONSULTATION PHASE:

PERSONAL DATA: AGE, SEX, CIVIL STATUS, WEIGHT, HEIGHT

1 AGE : UNDER 17 OR ABOVE 35 (GREATER RISK IF OVER 40)

** PREGNANT ADOLESCENTS HAVE A HIGHER INCIDENCE OF PREMATURITY, PIH, CEPHALOPELVIC DISPROPORTION, POOR NUTRITION & INADEQUATE ANTEPARTAL CARE.

** WOMEN OVER 35 YEARS OLD ARE AT RISK FOR CHROMOSOMAL DISORDERS IN INFANTS, PIH & CESARIAN DELIVERY.

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** THE DURATION OF A NORMAL PREGNANCY IS 266 – 280 DAYS OR 38-42 WEEKS ( AVERAGE IS 40 WEEKS) ; OR 9 CALENDAR MONTHS OR 10 LUNAR MONTHS.

** BOTH OVULATION & GESTATIONAL AGE ARE ALSO SOMETIMES MEASURED IN LUNAR MONTHS ( 4 WEEK PERIODS) OR IN TRIMESTERS ( 3 MONTH PERIOD) RATHER THAN IN WEEKS.

IN LUNAR MONTHS, A PREGNANCY IS 10 MONTHS ( 40 WEEKS OR 280 DAYS) LONG; A FETUS GROWS IN UTERO 9.5 LUNAR MONTHS OR THREE FULL TRIMESTERS ( 38 WEEKS OR 266 DAYS)

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Health Assessment• Initial interview

– Health history• Demographic data• Chief concern• Family profile• History of past illnesses

• History of family illness• Gynecologic history• Obstetric history• Review of systems

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Health Assessment• Initial interview

– Support person’s role– Physical exam

• Baseline height/weight, vital signs• Assessment of systems

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• Assessment of systems– General appearance and mental status– Head and scalp– Eyes– Nose– Ears– Sinuses– Mouth, teeth and throat

– Neck– Lymph nodes– Heart – Lungs– Back– Rectum– Extremities and

skin

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OBSTETRICAL DATA:

MENSTRUAL HISTORY: INCLUDES MENARCHE, LENGTH & REGULARITY OF MENSES, INTERVAL BETWEEN PERIODS, AMOUNT OF FLOW, DYSMENORRHEA

HISTORY OF PAST PREGNANCIES:

GRAVIDA = ALL PREGNANCIES REGARDLESS OF DURATION OR OUTCOME

PARA = PAST PREGNANCIES RESULTING IN VIABLE FETUS ( 20 WEEKS) WHETHER BORN DEAD OR ALIVE. ( TWINS, TRIPLETS ETC. CONSIDERED AS ONE).

MLNGCeleste, RN, MD

History

1. Initial visita. Obstetrical history (TPAL)

Gravida – the total number of pregnancies regardless of duration (includes present pregnancy)

Nulligravida – a woman who has never been pregnant Primigravida – a woman who is pregnant for the first timeMultigravida – a woman who has two or more pregnancy

MLNGCeleste, RN, MD

• Para – number of past pregnancies that have gone beyond the period of viability (capability of the fetus to survive the outside of the uterus; currently considered any time after 20-wk gestation), regardless of the number of fetuses or whether the infant was born alive or dead

• Nullipara – a woman who has never delivered a fetus that reached the age of viability

• Primipara – a woman who has completed one pregnancy to viability

• Multipara – a woman who has completed two or more pregnancy to the age of viability


• Term infant – an infant born between 38 and 42 weeks of gestation

• Preterm – an infant born before 38 weeks• Post term – an infant born after 42 weeks• Abortion – pregnancy that terminates before the

period of viability (20 wks)• Live birth – a live birth is recorded when an

infant born shows sign of life

MLNGCeleste, RN, MD

• Other terms to know:Stillbirth – infant born without signs of life

Parturient – a woman in laborPuerpera – a woman who just delivered (within six weeks after delivery)


• Low birth weight < 2500 grams• Normal Birth weight 2500 – 4000

grams• Large birth weight > 4000 grams


PRENATAL ASSESSMENTA. VERIFYING PREGNANCY• Signs and Symptoms

PresumptiveProbablePositive

• Pregnancy Test

B. LMPEstimated Date of Delivery/ ConfinementEDD/ EDC/EDBAge of gestationMeasure Fundic Height


Last Menstrual Period (LMP)

• First day of the last menstrual period


EDC/ EDD/ EDB


AOGCOMPUTATION OF AGE OF GESTATIONExample: LMP: January 1, 2010 Date of consult: August 31, 2010

AOG: Total # of days from LMP up to date of consult 7

January 30 daysFebruary 28 Total = 242 daysMarch 31 AOG = 242April 30 7May 31 34 to 35 weeks June 30July 31August 31


Obstetrical History/ NumberG__ P__ (T, P, A, L)• Gravida – the total number of pregnancies regardless of

duration (includes present pregnancy)• Para – number of past pregnancies that have gone

beyond the period of viability (capability of the fetus to survive the outside of the uterus; currently considered any time after 20-wk gestation), regardless of the number of fetuses or whether the infant was born alive or dead

• Term infant – an infant born between 38 and 42 weeks of gestation

• Preterm – an infant born before 38 weeks• Post term – an infant born after 42 weeks• Abortion – pregnancy that terminates before the period

of viability (20 wks)• Live birth – a live birth is recorded when an infant born

shows sign of life

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OTHER COMPUTATIONS (Nice to know):

MC DONALD’S RULE = ( ESTIMATION OF AOG IN MONTHS & WEEKS BY FUNDIC HEIGHT MEASUREMENT)=

FORMULA :

FUNDIC HEIGHT IN CMS X 2/7

EXAMP[LE:

FUNDIC HEIGHT IS 21 CMS

21 CMS X 2 =42

42/ 7 = 6 ( AOG IN MONTHS)

6 MONTHS X 4 = 24 ( AOG IN WEEKS)

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HAASE’S RULE = ESTIMATION OF FETAL LENGTH

RULE:

**DURING THE FIRST HALF OF PREGNANCY, SQUARE THE NUMBER OF THE MONTH ( EX. FIRST LUNAR MONTH: 1X1 = 1CM.

**DURING THE SECOND HALF OF PREGNANCY, MULTIPLY THE MONTH BY 5

( EX. 6TH LUNAR MONTH: 6X5 = 30 CM.)

FORMULA: 1 TO 5 MONTHS = MONTHS SQUARED

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EXAMPLES:

5 MONTHS X 5 = 25 CMS LENGTH

8 MONTHS X 5 = 40 CMS LENGTH

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JOHNSON’S RULE = ESTIMATION OF WEIGHT IN GRAMSFORMULA: FUNDIC HEIGHT IN CM – N X K

“K” IS CONSTANT, IT IS ALWAYS 155“N” IS MINUS 11 IF PART IS NOT YET ENGAGED

MINUS 12 IF PART IS ALREADY ENGAGED

EXAMPLE: 21 CM, NOT ENGAGED21 – 11 = 10 X 155 = 1,550 GMS

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BARTHOLOMEW’S RULE = ESTIMATION OF AOG BY THE RELATIVE POSITION OF THE UTERUS IN THE ABDOMINAL CAVITY.

** BY THE 3RD LUNAR MONTH, THE FUNDUS IS PALPABLE SLIGHTLY ABOVE THE SYMPHYSIS PUBIS

** ON THE 5TH LUNAR MONTH, THE FUNDUS IS AT THE LEVEL OF THE UMBILICUS

** ON THE 9TH LUNAR MONTH , THE FUNDUS IS BELOW THE LEVEL OF THE XIPHOID PROCESS

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2. CONSULTATION PHASE = PHYSICAL ASSESSMENT

A.PHYSICAL EXAMINATION = A REVIEW OF SYSTEMS IS INDICATED, INCLUDING INSPECTION OF THE TEETH BECAUSE THEY ARE A COMMON CAUSE OF INFECTION.

B. PELVIC EXAMINATION

(CARDINAL RULE: EMPTY THE BLADDER FIRST)

** INTERNAL EXAMINATION (IE) = TO DETERMINE CHADWICK’S, GOODEL’S, HEGAR’S


Physical assessment Initial visit – complete physical exam

• Breast exam – nipple formation using “pinch test” in which the areola is pinched gently and pushed in with the examiner’s thumb and forefinger; an everted or normal nipple protrude, an inverted nipple will look flat or turned inward, indicating potential difficulty with breastfeeding

• Pelvic exam – Pap smear; culture for gonorrhea and herpes if appropriate; smear for chlamydia; bimanual (palpation of reproductive organs between abdominal and vaginal hands) to establish uterine size, consistency, and contour; pelvic measurements

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C. VITAL SIGNS = TEMPERATURE, PULSE AND RESPIRATORY RATES ARE IMPORTANT ESPECIALLY DURING THE INITIAL PHASE OF THE PRENATAL VISIT . BUT CERTAINLY MORE IMPORTANT ARE THE WEIGHT & BLOOD PRESSURE AS BASELINE DATA TO DETERMINE ANY SIGNIFICANT INCREASE.

D. BLOOD STUDIES

** BLOOD TYPING

** CBC, INCLUDING HgB, & HcT TO DETERMINE ANEMIA

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E. URINE EXAMINATIONS:

** HEAT & ACETIC ACID TEST TO DETERMINE ALBUMINURIA. ANY SIGN OF ALBUMIN ( PROTEIN) IN THE URINE SHOULD BE REPORTED IMMEDIATELY BECAUSE IT IS A SERIOUS SIGN OF TOXEMIA ( PIH).

** BENEDICT’S TEST FOR GLYCOSURIA, A SIGN OF POSSIBLE GESTATIONAL DIABETES.SPECIMEN SHOULD BE TAKEN BEFORE BREAKFAST TO AVOID FALSE POSITIVE RESULT


Laboratory screening• Initially and at routine visits, urine dipstick for glucose,

protein (pregnancy induced hypertension and UTI), CBC, rubella IgG antibody

• Repeat GC culture late third trimester (more often if indicated)

• Maternal serum alpha-fetoprotein (AFP) at 16-18 wk to identify risk of neural tube defect in fetus

• Glucose screening between 24-28 wk to detect gestational diabetes

• Repeat CBC at 24 –28 wk• Rh antibody titers for Rh woman at 24, 28, 32, and 40 wk• ultrasound


• Fundal height• Fetal heart sounds• Pelvic exam

– External genitalia– Internal genitalia

• Pap smear• Vaginal inspection• Exam of pelvic organs• Rectovaginal exam


THE APPEARANCE OF THE CERVIX

1. NULLIGRAVID 2. AFTER CHILDBIRTH 3. AFTER MILD CERVICAL TEARING (Stellate)


Assessment of Fetal GrowthEstimating fetal growthFUNDIC HEIGHT ( in cm)

McDonald’s Rule – determining during midpregnancy, that the fetus is growing in utero by measuring the fundal (uterine) height

- typically, the distance from the fundus to the symphysis in centimeters is equal to the week of gestation between the 20th and 31st weeks of pregnancy

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• Measure from the notch of the symphysis pubis to over the top of the uterine fundus using a tapemeasure in centimeters as the woman lies supine

• inaccurate during the 3rd trimester

• Typical measurements- Over the symphysis pubis: 12

weeks- At the umbilicus: 20 wks- At the xiphoid process:

36 wks Rises about 1cm per week;

after which it varies


Location of the fundus:

• 12 weeks at the level of the symphysis pubis• 16 weeks halfway between symphysis pubis and

umbilicus• 20weeks at the level of the umbilicus• 24 weeks two fingers above umbilicus• 30 weeks midway between umbilicus and xiphoid

process• 36 weeks at the level of xiphoid process• 40 weeks two fingers below umbilicus,

drops at 34 weeks level because of lightening

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Assessment of Fetal GrowthAssessing fetal well-being

• Fetal heart rate• Fetal movement• Ultrasound• Nonstress Test• Electrocardiography• MRI• Amnioscopy• Fetoscopy

• Maternal serum alpha-fetoprotein

• Triple screening (AFP, estriol and hCG)

• Chorionic villi sampling• Amniocentesis• Percutaneous umbilical

blood sampling• Biophysical profile

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Fetal heart rate• FHR should be 120-160

beats per minute

• Can be heard with a Doppler : 10 – 11th week of pregnancy

• Fetoscope: 18-20 weeks


Fetal heart rate• Assist the patient to a supine position.• Drape her with a blanket to minimize exposure.• Apply water soluble lubricant to her abdomen or the

monitoring device.• To assess FHR in a fetus 20 weeks or younger, position

Doppler/Stethoscope/ fetoscope on the abdominal midline above the symphysis pubis. After 20 weeks AOG, when you can palpate fetal position, use Leopold’s maneuvers and position the listening instrument over the fetal back.

• Place the earpieces in your ears and press gently on the patient’s abdomen. If there are no earpieces, turn the device on and adjust the volume. As needed. Start listening at the midline, midway between the umbilicus and the symphysis pubis.

• Move the instrument from side to side to locate the loudest heart tones then palpate the maternal pulse.


Fetal heart rate• If the maternal radial pulse and FHR are the same, try to

locate the fetal thorax/ back by Leopold’s maneuver, then reassess FHR for 60 seconds. Record FHR.

• During labor, monitor FHR during the relaxation period between the contractions to determine baseline.

• In a low-risk labor, assess FHR every 60 minutes during the latent phase, every 30 minutes during the active phase and then every 15 minutes during the 2nd stage of labor. In high risk labor, assess FHR every 30 minutes during the latent phase, every 15 minutes during the active phase, and every 5 minutes during the 2nd stage of labor.

• Auscultate FHR during a contraction and for 30 seconds afterward to identify the response to the contraction.

• Auscultate FHR before administration of medications, ambulation, and artificial rupture of membranes, changes in the characteristics of contractions, vaginal examinations and medications.


LOCATING FETAL HEART SOUNDS BY FETAL POSITIONFHT – heard best at the FETAL BACK

Fetal Heart Rate Patterns Indicative of… Intervention

Tachycardia (>160 bpm) Maternal or fetal infectionFetal hypoxia (ominous sign)

Depends on the cause

Bradycardia (<120 bpm) Fetal hypoxia or stressMaternal hypotension after

epidural initiation

Place client on her left sideIncrease fluids to counteract

hypotensionStop oxytocin (Pitocin) if in

use

Early deceleration (deceleration begins and ends with uterine contraction)

Head compression :not ominous

Vagal stimulation

None required

Late deceleration(HR decreases after peak of contraction and recovers after contraction ends)

Fetal stress and hypoxiaDeficient placental perfusionSupine positionMaternal hypotensionUterine hyperstimulation

Change maternal positionCorrect hypotensionIncrease IV fluid rate as

orderedDiscontinue oxytocinAdminister oxygen as

ordered

Variable deceleration(transient decrease in HR anytime during contraction

Cord compressionHypoxia or hypercarbia

Change maternal positionAdminister Oxygen

Decreased variability Fetal sleep cycleDepressant drugsHypoxiaCNS anomalies



Fetal movement

• Fetal movement that can be felt by the mother : QUICKENING begins at approximately 18 – 20 weeks of pregnancy;peaks at 28-38 weeks

• Primigravid- quickening:20 weeks• Multigravid- 16 weeks• Ask the mother to observe fetal movement.• A healthy fetus moves at least 10x a day.


• Sandovsky method- mother is in a left lateral recumbent position; fetus normally moves a minimum of twice every 10 minutes or an average of 10 -12x an hour

• Cardiff method – Count to ten- records the time it takes for her to feel 10 fetal movements; usually within 60 minutes


LEOPOLD’S MANEUVER

• systematic method of observation and palpation to determine fetal position

• woman empties her bladder; lies supine with her knees flexed slightly

• examiner warms hands to avoid contraction of abdominal muscles

• gentle but firm touch


LEOPOLDS MANEUVER• First Maneuver Palpation of the Uterine

Fundus • Will usually indicate the fetal part situated in

the fundus; usually a fetal head; infrequently a fetal breech.Place hands on either side of the fundal area so that the fingers of both hands almost touch each other (face the woman's head).

• A somewhat hard and roundish shape, which when moved back and forth between the finger pads, also moves the entire fetus usually indicates a fetal breech.

• Press gently and firmly with finger pads.A very hard round well-defined shape that can be moved backand forth (balloted) usually indicates a fetal head.


First Maneuver Palpation of the Uterine Fundus


Second Maneuver Determines small parts and back of fetus

along the sides of maternal abdomen

• Lateral Palpation of the Uterus • Examiner faces woman's head • Palpate with one hand on each side of

abdomen• Palpate fetus between two hands • Assess on which side is the fetal back or

spine and which side has small parts or extremities


• Generally provides information regarding the location of the fetal back and the fetal small parts consisting of arms and legs.Hands should alternately apply pressure against the opposite hand.Directing alternating pressure against each hand is the technique.

• Alternating hands using firm resistance while the other hand gently and firmly applies pressure and rotates in a circular fashion.This technique can be used up and down the entire length of the uterus.


Second Maneuver Determines small parts and back of fetus

along the sides of maternal abdomen


Third Maneuver (Lower uterine segment or uterine pole)

• Face the woman's head and spread your hands widely apart.

• Grasp the uterine contents just above the symphysis pubis (firmly but gently).

• Hold presenting part between index finger and thumb.

• Assess for cephalic versus Breech Presentation Move the fetal presenting part gently back and forth in your hand Fetal head will shift more easily back and forth Fetal breech will move the whole body.


• The 3rd Leopold's Maneuver (Pawlick's grip) will provide either initial information or confirm prior data gained from the previous steps of Leopold's maneuvers.

• Anchoring the uterine fundus with the non-dominant hand assistin identifying the location of the fetal back and small parts.


Third Maneuver (Lower uterine segment or uterine pole)


Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part)

• Provides information about the presenting part: breech or head, attitude (flexion or extension), and station (level of descent of the presenting part).

• Examiner faces woman's feet .• Place hands on either side of the lower abdomen

with finger pads at the lower uterine pole (bikini line) and thumbs directed toward the umbilicus.

• Carefully move fingers of each hand towards each other in a downward and inward manner using gentle pressure.


• The nurse's thumbs should point towards the woman's umbilicus.

• If there is a head palpated in the pelvis, the fetal presentation is referred to as a cephalic or vertex presentation.

• Assess if a prominence on one side of the abdomen can be palpated higher than a prominence on the other side. The first prominence felt indicates the sinciput (forehead) of the infant and is on the same side as the fetal small parts. Therefore, the sinciput is on the side opposite the fetal back. The prominence felt further down the pelvis is the fetal occiput back of the head) and is on the same side as the fetal back.


Fourth Maneuver (pelvic palpation of the uterus - assess the presenting part)


LEOPOLD’S MANEUVER1st MANEUVER

What is at the uterine fundus? Head is more firm, hard and round that moves independently of the body. Breech is less well defined that moves only in conjunction with the body.

2nd MANEUVER

Where is the fetal back? Fetal back is smooth, hard, resistant surface. Knees and elbows of fetus feel with a number of angular nodulation.

3rd MANEVER

What is at the inlet of the pelvis? By grasping the lower portion of the abdomen (just above the symphisis pubis. Not engaged (not firmly settled in the pelvis) if the presenting part moves upward so an examiner’s hands can be pressed together.

4th MANEUVER

What is the fetal attitude? (degree of flexion) Fingers on both sides of the uterus (2 inches above inguinal ligaments) pressing down and inwards. The fingers of the hand that do not meet obstruction above the ligament palpates the fetal brow. Good attitude if brow corresponds to the side (2nd maneuver) that contained the elbows and knees. Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). Also palpates infant’s anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman’s back).


• Estimating pelvic size• Type• Measurements

• Diagonal conjugate• True conjugate or conjugate vera• Ischial tuberosity diameter


Passage (maternal) – size and type of pelvis, ability of the cervix to efface and dilate, and distensibility of vagina and introitus

• Pelvis – the bony ring through which the fetus passes during labor and delivery; consists of four united bones (two hip or innominate bones, the sacrum, and the coccyx) between the trunk and thighs

• Measurements – may be obtained by internal and external pelvic examination (using pelvimeter), x-ray pelvimetry (used rarely in pregnancy and only late in third trimester or in labor), and ultrasound


Pelvic types:a. Gynecoid – classic female pelvis inlet, well rounded (oval);

ideal for delivery- most ideal for childbirth (50% of women)b. Android – resembling a male pelvis, narrow and heart-shaped;

usually requires cesarean section or difficult forceps delivery (20% of women)

c. Platypelloid – flat, broad pelvis; usually not adequate for vaginal delivery (5% of women)

d. Anthropoid – similar to pelvis of anthropoid ape; long, deep, and narrow; usually adequate for vaginal delivery (25% of women)


TYPES OF PELVIS


PELVIS:• provides protection to the organs found within the

pelvic cavity• provides attachment to muscles, fascia and ligaments• supports the uterus during pregnancy• serves as birth canal


Division of the pelvis: a. False • “ SUPERIOR HALF” upper flaring portion of the ilia provides support to the uterus during

pregnancy to direct the fetus to the true pelvis during

labor

b. True • “INFERIOR HALF”• FORMED BY THE PUBIS IN FRONT, THE ILIA &

THE ISCHIA ON THE SIDES & THE SACRUM & COCCYX BEHIND

forms the passageway of the fetus during labor

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** THE FALSE PELVIS IS DIVIDED FROM THE TRUE PELVIS ONLY BY AN IMAGINARY LINE: THE LINEA TERMINALIS DRAWN FROM THE SACRAL PROMINENCE AT THE BACK TO THE SUPERIOR ASPECT OF THE SYMPHYSIS PUBIS AT THE FRONT OF THE PELVIS. **

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a.PELVIC INLET / pelvic brim= ENTRANCE TO THE TRUE PELVIS, OR THE UPPER RING OF BONE THROUGH WHICH THE FETUS MUST FIRST PASS TO BE BORN VAGINALLY. ITS TRANSVERSE DIAMETER IS WIDER THAN ITS AP DIAMETER. THUS:

** TRANSVERSE DIAMETER = 13.5 CM

** AP DIAMETER = 11 CM


• Consists of the following parts:1. Inlet/ pelvic brim – entrance to true pelvis• AP diameters:

– Diagonal Conjugate = 12.5 cm– Obstetric Conjugate = 11 cm

(Substract 1-1.5cm from diagonal conjugate)– True Conjugate/ Conjugate Vera = 11.5 cm

(or 10.5 – 11cm)(Substract 1-1.5 cm (or 1.2-2cm) from diagonal conjugate)

• Transverse diameter = 13.5 cm• Right and left oblique diameter = 12.75 cm


DIAGONAL CONJUGATE

• The distance between (the anterior surface of) the sacral promontory of the sacrum and (the anterior surface of the inferior margin of) the symphysis pubis

• Measured clinically• Most useful measurement for estimating the pelvic

size (AP diameter of pelvic inlet)• AVERAGE = 12.5 TO 13 CMS• >12.5 cm adequate for birth


Measurement of Diagonal Conjugate


Obstetric conjugate

• Shortest anteroposterior diameter between the sacral promontory and the symphysis pubis

• Can only be measured radiographically

• AVERAGE = 11 CM• Normal > 10 cm


TRUE CONJUGATE/ CONJUGATA VERA

THE DISTANCE BETWEEN THE MIDPOINT OF THE SACRAL PROMONTORY TO THE UPPER MARGIN OF THE SYMPHYSIS PUBIS.

• VERY IMPORTANT MEASUREMENT BECAUSE IT IS THE DIAMETER OF THE PELVIC INLET.

• AVERAGE = 11.5 CM

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2. Pelvic canal - situated between inlet and outletMIDPELVIS/ PELVIC CAVITY = THE SPACE BETWEEN

THE INLET & THE OUTLET. THIS IS NOT A STRAIGHT BUT A CURVED PASSAGE-Interspinous (smallest diameter of pelvic)= 10 cm-AP diameter at level of ischial spines = 11.5 cm-Posterior sagittal diameter = 4.5 cm


3. Pelvic Outlet –most important diameter of the outlet is its transverse diameter or Bi-ischial diameter =11.5 cm

AP diameter = 9.5 to 11.5 cmPosterior sagittal diameter = 7.5 cm

MLNGCeleste, RN, MD

3.POST – CONSULTATION PHASE = HEALTH TEACHINGS

• Schedule of clinic visits• Exercises• Dental hygiene• Clothing • Traveling• Bathing• Employment• Sexual relation• Immunization

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Routine visits • every 4 weeks until 32 weeks• then every 2 weeks until 36 weeks• weekly until delivery - to monitor vital signs, weight, fetal heart

tones, fundal height and outline

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HEALTH TEACHINGS

NUTRITION = MOST IMPORTANT ASPECT

FOOD SOURCES:** PROTEIN RICH FOODS = MEAT, FISH, EGGS, MILK, POULTRY,

CHEESE, BEANS, MONGO** VIT. A = EGGS, CARROTS, SQUASH, CHEESE, BEANS, VEGETABLES** VIT. D = FISH, LIVER, EGGS, MILK ( EXCESS VIT.D DURING

PREGNANCY CAN LEAD TO FETAL CARDIAC PROBLEMS)**VITAMIN E = GREEN LEAFY VEGETABLES, FISH

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**VITAMIN C= TOMATOES, GUAVA, PAPAYA**VITAMIN B= PROTEIN RICH FOODS**CALCIUM/PHOSPHORUS=MILK, CHEESE**IRON= ESPECIALLY IMPORTANT DURING THE LAST TRIMESTER WHEN THE PREGNANT WOMAN IS GOING TO TRANSFER HER IRON STORES FROM HERSELF TO HER FETUS SO THAT THE BABY HAS ENOUGH IRON STORES DURING THE 1ST 3 MONTHS OF LIFE WHEN ALL HE TAKES IS MILK(WHICH IS DEFICIENT IRON). IRON HAS A VERY LOW ABSORPTION RATE: ONLY 10% OF THE IRON INTAKE CAN BE ABSORBED BY THE BODY. THUS, FOR OPTIMUM ABSORPTION, GIVE VITAMIN C.

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IRON SHOULD BE GIVEN AFTER MEALS BECAUSE IT IS IRRITATING TO THE GASTRIC MUCOSA.

SOURCES: LIVER AND OTHER INTERNAL ORGANS, CAMOTE TOPS, KANGKONG, EGG YOLK, AMPALAYA, MALUNGGAY, SALUYOT.

**MALNUTRITION DURING PREGNANCY CAN RESULT IN PREMATURITY, PREECLAMPSIA, ABORTION, LOW BIRTH WEIGHT BABIES, CONGENITAL DEFECTS OR EVEN STILL BIRTHS.

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** FOLIC ACID – TO PREVENT NEURAL TUBE DEFECTS ( SPINA BIFIDA, MENINGOCOELE )

SOURCES:

** GREEN LEAFY VEGETABLES

** FRUITS

** RDA FOR SALT IN A PREGNANT WOMAN IS 3g/DAY BECAUSE OF INC IN BLOOD VOLUME TO MAINTAIN F & E BALANCE.

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TT IMMUNIZATION:

• TT1 GIVEN ANYTIME DURING PREGNANCY

• TT2 ONE MONTH AFTER TT1 ( 3 YEARS PROTECTION)

• TT3 SIX MONTHS AFTER TT2 ( 5 YEARS PROTECTION)

• TT4 ONE YEAR AFTER TT3 ( 10 YRS)

• TT5 ONE YEAR AFTER TT4 OR NEXT PREGNANCY

( LIFETIME PROTECTION)

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** THE PROVISION OF PRENATAL CARE IS THE PRIMARY FACTOR IN THE IMPROVEMENT OF MATERNAL MORBIDITY & MORTALITY STATISTICS. “”


ANTENATAL FETAL TESTING

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Ultrasound• Response of sound waves against objects

• Allows visualization of the uterine content

• Transabdominal UTZ- full bladder- client lies on her back

• Transvaginal UTZ- probe is inserted in the vagina- lithotomy position- empty bladder


• Diagnose pregnancy as early as 6 weeks• Confirm the presence, size and location of the

placenta and amniotic fluid• Establish that the fetus is growing and has no gross

defects (eg, hydrocephalus, anencephaly, spinal cord, heart, kidney and bladder defects)

• Establish the presentation and position of the fetus (sex can be diagnosed)

• Predict maturity by measurement of the biparietal diameter (BPD)

• discover complications of pregnancy / fetal anomalies


Estimation of Fetal Age• Gestational sac – 5 – 6 weeks• Crown rump length – 7 – 14 weeks• Femoral length – 12 – 22 weeks • Biparietal Diameter 17 -26 weeks


Biophysical profile (BPS)

• Assesses 4 to 6 parameters (fetal breathing movement, fetal movement, fetal tone, amniotic fluid volume, placental grading, and fetal heart reactivity/ reactive NST)

• Each item has a potential for scoring a 2; 12 highest possible score

• BPS 8 – 10: fetus is doing well• BPS 4 – 6: fetus is in jeopardy

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Nonstress Test

• Measures the response of fetal heart rate to fetal movement

• Determines fetal well-being

• Performed to assess placental function and oxygenation


• An external ultrasound transducer and the tocodynamometer are applied to the mother and a tracing of at least 20 minutes’ duration is obtained so that the FHR and the uterine activity can be observed.

• Obtain baseline blood pressure and monitor blood pressure frequently.

• Position mother in semi-fowler’s or side- lying position or left lateral position to avoid vena cava compression.

• The mother may be asked to press a button every time she feels fetal movement; the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response.


RESULTS OF NST:• REACTIVE NONSTRESS TEST:Normal/Negative

- indicates a healthy fetus- requires 2 or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period.

• NONREACTIVE NONSTRESS TEST: Abnormal-No accelerations or accelerations of less than 15 bpm or lasting than 15 seconds in duration occur in a 40 minute observation.

• UNSATISFACTORY – The result cannot be interpreted because of the poor quality of the FHR tracing.


Contraction Stress Test

• Assesses placental oxygenation and function

• Determines fetal ability to tolerate labor and determines fetal well-being

• Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions.


• External fetal monitor is applied to the mother, and a 20 to 30 minute baseline strip is recorded.

• The uterus is stimulated to contract by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in a 10 minute period have been achieved.

• Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of oxytocin are given.


RESULTS OF CST:• NEGATIVE CST/ NORMAL

- no late or variable decelerations of FHR

• POSITIVE CST/ ABNORMAL- late or variable decelerations of FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus.

• EQUIVOCAL – with decelerations but with less than 50% of the contractions, or the uterine activity shows a hyperstimulated uterus.

• UNSATISFACTORY – adequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation.


Amniocentesis- Withdrawal of amniotic fluid from the

abdominal wall for analysis


Amniocentesis- amniotic fluid is aspirated by a needle inserted through

the abdominal and uterine walls; indicated early in pregnancy (14-17 wk) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural tube defect); determine sex of fetus and sex-linked disorders after 28 wk

- Used to diagnose potential genetic problems in the fetus (Down Syndrome), to estimate fetal lung maturity or to diagnose fetal hemolytic disease

• Indicated for pregnant women 35 years and older; couples who already have had a child with a genetic disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders


• Prior to the procedure, the patient’s bladder should be emptied; ultrasonography (x-ray only if necessary) is used to avoid trauma from the needle

• Post procedure, monitor for signs and symptoms of hemorrhage, labor, premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for Rh- mothers


Chorionic villi sampling-transcervical (or transabdominal) aspiration of chorionic villi


• Retrieval and analysis of chorionic villi for chromosome analysis

• Transcervical or transabdominal; may be done as early as 5 weeks, but more commonly done at 8-12 weeks of pregnancy

• Risks: bleeding/ loss of pregnancy; limb reduction syndrome; infection

• Diagnosis of Sickle cell disease, thalassemia• diagnosing of genetic disorders comparable to

amniocentesis (except for NTD); preprocedure: there should be full bladder; ultrasound is used as in amniocentesis; post procedure: precautions as for amniocentesis

Chorionic villus sampling (CVS)


Percutaneous umbilical blood sampling (PUBS)

– second- and third-trimester method to aspirate umbilical cord blood (location identified by ultrasound) to test for genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders


Percutaneous umbilical blood sampling


Estriol levels

– serial 24-h maternal urine samples or serum specimens to determine fetoplacental status; falling levels usually indicate deterioration


Lecithin/ Sphingomyelin ratio (2:1)

– important components of surfactant, a phosphoprotein that lowers surface tension of the lungs that facilitates extrauterine expiration


Perinatal Exercises


PRE-EXERCISE POINTERS1. Always let breath flow freely. Let abdomen

and ribcage expand and compress naturally as you inhale and exhale.

2. Warm up with gentle stretching before exercise program - increase blood flow to muscles and loosen them up.

3. When you finish, take time to relax fully; lie in comfortable position on floor for 10 minutes with eyes closed; let breathing slow down.

4. As strength improves, add one repetition of each exercise until you’re up to 10; also, try holding positions from 3 to 5 counts.


PRE-EXERCISE POINTERS5. Do each exercise slowly and thoroughly. Allow

rest between each exercise.6. Avoid extreme motions like deep lunges or

twisting movements.7. Avoid lying flat on your back for prolonged

periods; it may become uncomfortable and the position allows less blood flow to the uterus. Lying on your side increases blood flow.

8. Think of opportunities for exercises during day; Kegel’s while standing in line at grocery store, squatting while peeling potatoes, talking on the phone, watching television, etc.

9. If there is a prenatal exercise class in your area, join it. It is fun to get into shape with other pregnant women.

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A. Tailor Sitting

1. It strengthens the thigh and stretches the perineal muscles

2. Done at least 15 min/day• Sit on floor with thighs

apart, knees bent, legs parallel to each other, one ankle should NOT be on top of the other, push knees gently towards the floor until you feel the perineum stretch. Use this when watching TV, reading or entertaining friends. Do this for 15 minutes daily.

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B. Squatting 1. Helps to stretch

muscle of the pelvic floor.

2. Done at least 15min/day

• When lifting something from the floor, bend knees rather than the back; do not squat on tiptoes but keep feet flat on the floor; incorporate this into daily activities; practice for 15 minutes daily


C. Pelvic Floor Contractions (Kegel’s Exercise)

• It is designed to strengthen pubococcygeus muscle. • It may lead to increased sexual enjoyment.• Each is a separate exercise and should be done

3x a day.1. Squeeze the muscle surrounding the vagina as

if stopping the flow of urine, hold for 3 seconds then relax. (10x)

2. Contract and relax the muscles surrounding the vagina as rapidly as possible 10 – 25x

3. Imagine that you are sitting in the bath tub of water and squeeze muscles as if sucking water into the vagina. Hold for 3 seconds then relax. 10x


D. Abdominal Muscle Contractions

1. strengthen the abdominal muscles2. help prevent constipation 3. may be done as often as she wishes • Tighten abdominal muscles, then relax and repeat as

often as you can; can be done on lying or standing position along with pelvic floor contractions.


E. Pelvic Rocking

1. Helps to relieve backache during pregnancy and early labor

2. Makes the lumbar spine more flexible3. Can be done on a variety of positions

The woman arches her back, trying to lengthen or stretch her spine. She holds the position for 1 minute, and then hollows her back.

- do this at the end of the day (5x)


F. Pelvic Tilt

1. PELVIC TILT – SUPINEDo daily and after delivery.Position: Backlying, knees bent.Exercise: Press small of back against floor by tightening

abdominal muscles and buttocks muscles.

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F. Pelvic Tilt

2. PELVIC TILT – STANDING

Position: Stand with back to wall, feet about three inches from base of wall.

Exercise: Tighten stomach and buttocks and press low back against the wall so that your back is touching the wall. Your knees must be relaxed or slightly bent to do this.

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F. Pelvic Tilt3. PELVIC TILT - ALL

FOURS

Position: On hands and knees.

Exercise:Tighten stomach muscles and arch backtoward the ceiling. Hold. Tighten buttocks, pelvic floor and back muscles and archback to produce hollow. Hold.

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G. Sit ups 1. SIT-UPS - ModifiedPurpose: Strengthen abdominal muscles. Good muscle tone is important for maintaining good posture, for effective pushing, and for early return of figure postpartum.

Position: Backlying, knees bent, low back flat (pelvic tilt).

Exercise: Lift head and shoulders off floor, reaching hands toward knees (lift trunk to about 45° angle). Slowly return to starting position; do not drop back.

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G. Sit ups 2. OBLIQUE

(DIAGONAL) SIT-UPS - Modified

Purpose: Strengthen oblique abdominal muscles.

Position: Backlying, knees bent, low back flat.

Exercise: As above, but reach up and across to the outside of the opposite knee.


H. GLUTEAL / PELVIC FLOOR SETTING

Position: Backlying, legs straight, ankles crossed, arms at sides.

Exercise: Pinch buttocks, squeeze pelvic floor muscles, squeeze thighs together, raise head off floor.


I. ADDUCTOR LENGTHENING

Position: Sit on floor with legs straight and slightly apart.

Roll knees outward.

Exercise: Slowly lean body forward towards the floor with arms stretched out in front of you. Your knees may bend slightly. Do not jerk or bounce. Hold forward for 3 to 5 seconds.


SPECIFIC ACTIVITIESTo the pregnant Client1. Jogging:Wear good shoes; supportive bra. Keep pelvic floor

muscles strong with Kegel exercises. Jog at a slower pace, shorter distances, less frequently.

Remember: Increased weight and laxity of ligaments means more strain on lower body (lower spine, hip joints, knees, ankles and feet). Do not overexert yourself.

2. Bicycling and Swimming:Excellent activities with reasonable limitations.

Don’t push yourself!

MLNGCeleste, RN, MD

3. Tennis, Basketball, other “sudden stop and start” Activities.

More awkward as bulk increases; listen to your body and slow down when necessary.

4. Skating, Horseback Riding:Danger of falling! Advise against. Consult your

obstetrician as needed.

5. Walking:Most highly recommended for the pregnant

woman; ideal alternative to more strenuous exercise. Walk uphill, downhill, and at different speeds.



Patient Teaching: Consult your obstetrician early in your pregnancy. In general, you can continue your pre-pregnant routine of exercising. Stop when something hurts, or when you become fatigued. Know your limits, and avoid exercising to the point of exhaustion. It is generally advised that you do not begin any new sport or activity during pregnancy. You may want to taper off your sports participation during the last few months, but you may still continue to exercise gently. Avoid exercising in very hot or humid weather, or at high altitudes if you’re not used to it.

Psychological and Physiologic Changes of

Pregnancy


Diagnosis of Pregnancy

• Presumptive signs of pregnancy

• (subjective) – experienced by the woman; (+) suspicion of pregnancy, not proof, could easily indicate other conditions

• Amenorrhea• Nausea/ vomiting• Breast sensitivity and increased size/fullness• Fatigue• Quickening (maternal perception of fetal movement

occurring between 16-20 weeks• Abdominal (uterine) enlargement• Skin pigmentation changes (melasma, chloasma, linea

nigra, striae gravidarum)• Frequent urination


Probable signs of pregnancy – objective, can be documented by examiner; increased suspicion of pregnancy but

still not the true diagnostic proof

• Serum Laboratory tests (hCG)• Home pregnancy tests• Chadwick’s sign (color change of the vagina from pink to

violet)* - presumptive in some references• Goodell’s sign - softening of the cervix• Hegar’s sign - Softening of the lower uterine segment• Ballotement -when LUS is tapped on a bimanual exam, fetus

can be felt to rise against abdominal wall or rebound caused by the fetus floating away and returning back to its previous position

• Fetal outline or contour palpated by examiner• Braxton hicks sign -periodic uterine tightening/ contractions

occurs; painless palpable contractions occurring irregular interval and felt by the mother as sensation of tightness over her abdomen

• Sonographic evidence of gestational sac• Uterine soufflé – a muffed swishing sound over the abdomen in

union with the mother’s heart beat


• Pregnancy test - HCG (human chorionic gonadotropin)- Immunologic test that can detect HCG in woman’s urine by 2 weeks after missed period; cannot measure the amount of HCG; false readings may occur inappropriate timing, handling error, or some medications


Positive signs of pregnancy- definite signs of pregnancy; not subjective data

• Fetal heart separate from the mother’s (Doppler, auscultation)

• Fetal movements felt by examiner• Visualization of fetus: fetal outline can be seen

and measured by sonogram


Psychological Tasks

Emotional responses • Ambivalence• Grief• Narcissism• Introversion vs extroversion• Body image and boundary• Stress• Couvade syndrome – men experience

physical symptoms• Emotional lability• Changes in sexual desire• Changes in the expectant family


MATERNAL ADAPTATIONS IN PREGNANCY

A.AnatomicalUterus •changes in size, structure, and position to become a thin-walled, muscular abdominal organ capable of containing the fetus, placenta, and amniotic fluid•In the early months of pregnancy, growth is partly due to formation of new muscle fibers and enlargement of preexisting muscle fibers•After the first trimester, the increase in size is partly mechanical due to the pressure of the developing fetus•The full-term pregnant uterus and its contents weigh about 12 lb


Location of the fundus:12 weeks at the level of the symphysis pubis16 weekshalfway between symphysis pubis and

umbilicus20weeks at the level of the umbilicus24 weeks two fingers above umbilicus30 weeks midway between umbilicus and

xiphoid process36 weeks at the level of xiphoid process40 weeks two fingers below umbilicus,

drops at 34 weeks level because of lightening


FUNDIC HEIGHT AT VARIOUS AGES OF GESTATION


Contractility:• Being muscular, the uterus is a highly contractile

organ.• Beginning on the first trimester, the uterus

undergoes irregular contractions.• Late in pregnancy, these contractions, known as

Braxton-Hicks, become more intense and frequent causing some discomfort on the pregnant woman.

• It is the cause of false labor.


Vagina and external genital organs enlarge, soften, thicken, and develop blue-violet hue as a result of increased vasculatureVaginal secretions become alkaline, causing an increased risk of vaginitisConnective tissue loosens in preparation for labor and deliveryA blue-violet color (Chadwick’s sign) about 6-8 wk


• Cervix • undergoes increased blood supply, edema, and

hyperplasia of the cervical glands contributing to:– Softening (Goodell’s sign) about 6 wk– Increased friability (bleeds easily after Pap smear and

intercourse)– Distention of cervical mucosa glands with mucus, creating

a tenacious “mucous plug” that seals the endocervical canal and inhibiting the ascent of bacteria and other substances into the uterus


• Isthmus• During pregnancy, the isthmus softens and

elongates up to 25 mm. It will later form the lower uterine segment, together with the cervix

• Hegar’s sign softening of the lower uterine segment begins as early as 5 weeks gestation

• Ovaries• No Graafian follicles develop and no ovulation

occurs during pregnancy• Corpus luteum of pregnancy the corpus

luteum is the chief source of hormone progesterone during the first 12 weeks of gestation. The corpus luteum also produces estrogen, relaxin, inhibin and sometimes oxytocin


• Breasts • enlarge early in pregnancy, causing progressive

feelings of heaviness, fullness, and tenderness; the nipple and areola become larger, darker in color; blood vessels enlarge and become prominent beneath the skin


Body mass changes with weight gain; total desirable weight gain in pregnancy (for average woman) is about 23-28 lb (11-13 kg); 3-4 lb (1.36-1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy 1st trimester: 3-4 lbs2nd trimester: 12-14 lbs3rd trimester: 8-12 lbs


• Skin • Pink or reddish streaks (striae gravidarum) may

occur on breasts, abdomen, buttocks, and/or thighs as a result of fat deposits, which cause stretching of the skin

• Increased pigmentation can occur on the face as blotchy brown areas on the forehead an cheeks (chloasma or “mask of pregnancy”) and on the abdomen as dark line from the symphysis pubis (linea nigra)

• Minute vascular spiders may occur• The umbilicus is pushed outward, and by about

the seventh month its depression disappears and becomes a darkened area on the abdominal wall

• Sweat and sebaceous glands are more active


• Musculoskeletal • Change in the center of gravity, decreased muscle

tone, and increased weight-bearing cause in accelerated lumbosacral curve, which may lead to lower back pain and difficulty with locomotion

• Progesterone – produced relaxation and increased mobility of the pelvic joints may cause discomfort and difficulty in walking

• The vertical abdominal muscles may separate (diastasis recti)


B.Physiological

• Hormonal• Placental• Estrogen – enlargement of uterus, breasts, genitals;

growth of glandular tissue, ducts, alveoli, and nipples of breasts; fat deposition; increased elasticity of connective tissue; altered thyroid function; altered nutrient metabolism; sodium and water retention by kidneys; hypercoagulability of blood; vascular changes


• Progesterone – development of decidua; decreased contractility of the uterus; decreased gastric motility (sphincters relaxed); increased sensitivity to CO2 in respiratory center; decreased tone of smooth muscle; development of secretory portions of lobular-alveolar system in breasts; sodium excretion


• Human chorionic somatomammotropin and human placental lactogen; anabolic effect; insulin antagonist


Pituitary gland

Anterior lobe secretes prolactin hormone after delivery of the placenta

Posterior lobe secretes oxytocin during labor and lactation


• Blood• total blood volume in body increases during

pregnancy by about 30%; normal blood pressure is maintained by peripheral vasodilatation

• RBC production increases; WBC count increases; clotting factors increase while fibrolytic activity decreases

• Hemoglobin and hematocrit levels decrease slightly in response to hemodilution (increased plasma content); hemoglobin <10 g/dL or hematocrit <35% may indicate anemia


• The increased blood volume creates the need for the heart to pump more blood through the aorta (about 50% more blood per minute) resulting increased heart rate; occasional palpitations (possibly due to sympathetic nervous imbalance in the early months of pregnancy or to intra-abdominal pressure of the enlarged uterus toward the end of the pregnancy)


• Respiration• in the later months of pregnancy, the enlarged uterus

causes the diaphragm to be displaced upward, putting pressure on the lungs and causing shortness of breath


• Digestion• Nausea and vomiting may occur in the first

trimester; vomiting that is excessive or persists beyond this time (hyperemesis gravidarum) may require medical management; appetite usually improves as pregnancy advances

• Progesterone – induces relaxation of smooth muscle tone, reduction in total acidity of gastric juices, and pressure from the growing uterus may cause heartburn, flatulence, and constipation


• Aversion or cravings for certain foods or unusual substances (e.g., pica) may occur

• Carbohydrate metabolism is profoundly affected to meet growth and development needs of fetus and the metabolic needs of mother to support tissue expansion


• The first half of pregnancy• -Maternal glucose is moved across the placenta by

active transport; causing maternal glucose levels to fall slightly; her pancreas responds by decreasing production of insulin

• -Maternal insulin does not cross the placenta• -By 8 wk the fetus’s own insulin production is

consistent with the amount of glucose received from the mother


• The second half of pregnancy – the placental hormones impede the mother’s ability to utilize insulin; the resulting demand for added insulin can be met by a normally functioning pancreas


• Urinary system• Urinary output is increased and has a low specific

gravity; possible tendency to excrete glucose; reabsorption of sodium and decreased water output (latter half of pregnancy) is a compensatory mechanism to maintain increased blood volume

• Ureters become dilated (especially the right ureter) due to the pressure of the enlarged uterus; the dilated ureters are unable to propel urine as efficiently, resulting in stasis of urine and possible urinary tract infection

• Bladder – urinary frequency may occur early in pregnancy and later again when “lightening” occurs as a result of increased pressure on the bladder from the enlarged uterus


C. Psychological• First trimester –ACCEPTING THE

PREGNANCY• maternal ambivalence, even in planned

pregnancy, is usual; there may be some anticipation and concern related to fears and fantasies about the pregnancy


• Second trimester • ACCEPTING THE BABY• usually increased maternal feelings of physical and

emotional well-being; mother is often described as self-absorbed and introverted


• Third trimester –PREPARING FOR PARENTHOOD

• possible new fears related to labor and delivery and fantasies about the appearance of the baby; feelings of awkwardness, clumsiness, and decreased femininity related to changes in body image


• Paternal reactions – may parallel those of mother; some may experience physical symptoms of pregnancy (couvade syndrome)

• Adaptation of siblings – age and experience related

Promoting Fetal and Maternal Health


Nursing Process

• Nursing Diagnosis• AnxietyHealth-seeking behaviors• Risk for deficit fluid• Constipation• Disturbed body image• Risk for altered sexuality patterns• Disturbed sleep pattern• Fatigue• Risk for fetal injury


Health Promotion During Pregnancy

• Self-care needs• Bathing• Breast care• Dental care• Perineal hygiene• Sexual activity• Exercise• Sleep• Employment• Travel

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Health Promotion During PregnancyFirst-Trimester Discomforts

• Breast tenderness• Palmar erythema• Constipation• Nausea, vomiting and pyrosis• Fatigue• Muscle cramps

• Hypotension• Varicosities• Hemorrhoids• Heart palpitations• Frequent urination• Abdominal discomfort• Leukorrhea


Health Promotion During Pregnancy

• Middle to Late Pregnancy Discomforts• Backache• Headache• Dyspnea• Ankle edema• Braxton Hicks contractions


Discomforts associated with pregnancy 1. First trimester

• Nausea and vomiting (“morning sickness”) related to altered hormone levels and metabolic changes; advise small snacks of dry crackers before arising, small feedings of bland food, milk

• Urinary frequency and urgency without dysuria; fluid intake should not be restricted

• Increased vaginal discharge; manage with good hygiene (but no douching) and loose-fitting cotton underwear; report signs or symptoms of vaginitis


• Breast soreness due to hormonal changes; suggest wearing a well-fitting, supportive brassiere

• Headache due to tension from emotional and physical stresses at any time during pregnancy; provide reassurance, suggest relaxation techniques; inform patient to report persistent and/or severe episodes


Second and third trimester• Heartburn may be related to tension and

vomiting in early pregnancy, progesterone-induced decreased motility and relaxation of the cardiac sphincter; displacement of the stomach by the growing uterus; encourage small, frequent meals and discourage overeating, ingesting fried/fatty foods, lying down soon after eating, avoid use of sodium bicarbonate (would interfere with sodium balance)


• Constipation related to progesterone-induced hypoperistalsis, compression/displacement of the bowel by the enlarging uterus, poor food choices, lack of fluids, and/or iron supplementation; advise bulk foods, fruits and vegetables, exercise, and generous fluid intake; avoid laxatives

• Hemorrhoids due to pelvic congestion related to pressure from enlarged uterus; suggest regulation of bowel habits, gentle reinsertion into rectum with use of lubricant, relief measures, e.g., ice packs, topical ointments, sitz baths, lying down with legs elevated


• Uterine contractions (Braxton-Hicks) due to tension on the round ligaments as a result of displacement of the uterus; instruct patient to rest, change position or activity

• Backache due to increased spinal curvature; educate the patient on the importance of good posture

• Faintness related to vasomotor lability or postural hypotension; instruct the patient to use slow, deliberate movements when rising, avoid prolonged standing and warm, stuffy environments; elastic hose may be needed


• Leg cramps related to pressure on the nerves supplying the lower extremities aggravated by poor peripheral circulation or fatigue; instruct the patient to increase calcium and decrease phosphorus intake; encourage dorsiflexion of feet

• Ankle edema related to decreased venous return from lower extremities, instruct the patient to avoid wearing anything that constricts blood flow, elevate legs when sitting or resting, and dorsiflex feet when sitting or standing for any length of time; medical management if edema persists in AM, is pitting, involves the face, or associated with elevated BP, proteinuria, persistent headaches


• Varicosities of extremities or vulva related to uterine compression of venous return, increased vein wall distensibility from progesterone-initiated relaxation, or inherited tendency; suggest elevating legs frequently, avoid sitting with legs crossed, standing/sitting for long periods of time, or wearing constrictive clothing; support/elastic stockings may be helpful.

MLNGCeleste, RN, MD

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DISCOMFORTS OF PREGNANCY Assessment Nursing Considerations

Nausea and vomiting (morning sickness)

May occur any time of day Eat dry crackers on arising Eat small, frequent meals

Constipation, hemorrhoids Bulk foods, fiber Generous fluid intake

Leg cramps Increase calcium intake Flex feet, local heat

Breast soreness Well-fitting bra Bra may be worn at night

Backache Emphasize posture Careful lifting Good shoes

Heartburn

Small, frequent meals Antacids – avoid those containing phosphorous Decrease amount of fatty and salty foods

Dizziness Slow, deliberate movements Support stockings

Vertigo, light-headedness Vena cava or supine hypotensive syndrome Turn on left side

Urinary frequency Kegel exercises Decrease fluids before bed Report signs of infection


DANGER SIGNS OF PREGNANCY

SIGN POSSIBLE CAUSE

Swelling of face. fingers; legs Hypertension of pregnancy, thrombophlebitis (for leg swelling)

Headache, continuous and severe Hypertension of pregnancy

Blurring of vision Hypertension of pregnancy

Abdominal/ chest pain Ectopic pregnancy, uterine rupture, pulmonary embolism

Vaginal bleeding Placental problems (previa, abruption, premature separation)

Vomiting, persistent Infection (also with fever and chills), hyperemesis Gravidarum

Visual changes Hypertension of pregnancy

Escape of vaginal fluids Premature rupture of membrane

Others: change or decrease in fetal

movements; dysuria


Preparing for Labor

• Lightening• Show• Rupture of membranes• Excess energy• Uterine contractions

Promoting Nutritional Health During Pregnancy


THE FOOD PYRAMID


Maternal Diet and Infant Health• Recommended weight gain• Components of healthy nutrition

• Calorie needs• Protein needs• Fat needs• Vitamin needs


Total desirable weight gain in pregnancy (for average woman) •about 23-28 lb (11-13 kg)•3-4 lb (1.36-1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy 1st trimester: 3-4 lbs2nd trimester: 12-14 lbs3rd trimester: 8-12 lbs


Maternal Diet and Infant Health• Components of healthy nutrition

• Mineral needs• Calcium and phosphorus• Iodine• Iron• Fluoride• Sodium• Zinc


Maternal Diet and Infant Health

• Components of healthy nutrition• Fluid needs• Fiber needs• Foods to avoid

• Alcohol• Caffeine• Artificial sweeteners• Weight loss diets


• Nutritional status1. Weight gain should be within expected parameters2. increased nutrient requirements

a. Calories – 300 kcal/d; may need adjustment for prepregnant under/overweight

b. There should be no attempt at weight reduction during pregnancy

c. Carbohydrates – needed to prevent unsuitable use of fats/proteins for added energy needs; important to avoid “empty” calorie sources

d. Proteins to 60 g/d; additional increase for adolescent/multiple pregnancies; efficient use of requires complete protein (contains all essential amino acids; animal sources) or complemented with other protein sources, e.g., legumes, grains, nuts


e. Iron – to a total of 30 mg/d of elemental iron; usually requires supplement

f. Calcium to 1,200/d; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium supplement may be necessary

g.Sodium – should not be restricted without serious indication; excess should be discouraged

3. 24-h recall/diet diaries may be used to evaluate high-risk woman

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RDAs for Pregnant Women(Recommended Dietary Allowances)

• Calories 2,500 kcal• Protein60 g

• MineralsCalcium 1,200 mgPhosphorous 1,200 mgIodine 175 μgIron 30 mgZinc 15 mg

• Water-soluble VitaminsAscorbic Acid (Vit C) 75 mgFolic Acid 400 μg Niacin 17 mgRiboflavin 1.6 mgThiamine 1.5 mgVitamin B6 2.2 μg Vitamin B12 2.2 μg

• Fat-soluble vitaminsVitamin A 800 μgVitamin D 10 μgVitamin E 10 μg


Assessment: Nutritional Health

Preparation for Childbirth and Parenting


CHILDBIRTH PREPARATION CLASSES

• Bradley • Dick-Read • Lamaze Method• Leboyer Method


CHILDBIRTH PREPARATION CLASSES1. Bradley (Partner-Coached) Method

• stresses the important role of the husband during pregnancy, labor and early newborn period

• woman uses muscle toning exercises• limits or omits food that contain preservatives,

animal fat and high salt content• abdominal breathing exercise• woman is encouraged to walk during labor• use of dissociation technique


2. Dick-Read Method

• tension (psychic and muscular) is aroused by fear and anticipation of pain

• sympathetic stimulation brought about by fears causes contraction of the circular muscle of the cervix

• prenatal courses and training reduce fear, educate and boost self-confidence

• Covers: fetal development and childbirth; pain relief methods; muscle strengthening exercises; breathing techniques; physical and emotional health for children; mother gets emphatic understanding from partner, nurse, physician

• fear >>> tension >>> pain• abdominal breathing contraction


3. Lamaze Method (Psychoprophylactic method)

• based on stimulus – response conditioning (Pavlov Theory of Classical Conditioning) where unfavorable responses are replaced by favorable conditioned responses

• high level of activity can excite higher brain centers to inhibit other stimuli as pain

• woman is taught to replace responses of anxiety, fear and loss of control with more useful activity


• Conscious relaxation• Cleansing breath• Conscious controlled breathing• Effleurage• Focusing• Second-stage breathing


• Covers: practice of breathing techniques during labor; controlled perception; relaxation of involved muscles; mouthing silently words or songs with rhythmical tapping of fingers; supportive person nearby in a calm environment

• Use 3 Gate Control Method of pain relief»education and relaxation »use of imagery and focusing

(breathing patterns) »conditioned reflex


4. Leboyer Method

• The contrast of intrauterine environment and the external world causes infant to suffer psychological shock at the time of delivery

• Gentle controlled delivery• Covers: Relaxing the craniosacral axis by supporting

the head, neck and sacrum• Restoring body heat loss by warm bath• Allowing infant to breathe spontaneously• Delaving cutting of cord to permit placental blood

flow• Bonding mother and infant by skin to skin contact


• Conscious Relaxation – learning to relax muscles deliberately

• Cleansing Breath – woman breathes in deeply and exhales deeply

• Consciously Controlled Breathing (Set breathing Patterns)

Level 1 – full respiration, 6 – 12cpm, early contraction

Level 2 – lighter, 40cpm, 4-6cm dilatedLevel 3 – more shallow, 50 - 70cpm,

transition contractionLevel 4 – pant blow pattern, 3-4 quick

breaths then forceful expiration

Level 5 – continuous chest panting (60cpm), strong contraction and 2nd stage of labor


• Leboyer method• Birthing room is darkened• Soft music• Infant placed immediately into a warm-water bath

• Hydrotherapy and water birth

Caring for a Woman During Vaginal Birth


LABOR AND DELIVERY• Labor is a process whereby with time regular uterine

contractions bring about progressive effacement and dilatation of the cervix, resulting in the delivery of the fetus and expulsion of the placenta.

Critical factors affecting the process of labor:• Passage• Passenger• Power


THEORIES OF LABOR ONSET

1. Uterine Stretch Theory – Any hollow muscular organ when stretched to the capacity will contract and empty

2. Oxytocin Theory – Increased production of oxytocin by the anterior pituitary increases as pregnancy nears term while production of oxytinase by the placenta decreases


3. Progesterone Deprivation Theory – as pregnancy nears term, progesterone level drops, hence uterine contraction occurs

4. Prostaglandin Theory – when pregnancy reaches term, the fetal membranes produces high levels of arachidonic acid

5. Theory of the aging Placenta – as the placenta ages it becomes less efficient


Components of Labor

• Passage• Passenger• Power

• Psyche


I. Passage (maternal)– size and type of pelvis, ability of the cervix to

efface and dilate, and distensibility of vagina and introitus

• Pelvis – the bony ring through which the fetus

passes during labor and delivery; consists of four united bones (two hip or innominate bones, the sacrum, and the coccyx) between the trunk and thighs

• Measurements – may be obtained by internal and external pelvic examination (using pelvimeter), x-ray pelvimetry (used rarely in pregnancy and only late in third trimester or in labor), and ultrasound


Pelvic types:a. Gynecoid – classic female pelvis inlet, well

rounded (oval); ideal for delivery- most ideal for childbirth (50% of women)b. Android – resembling a male pelvis, narrow and

heart-shaped; usually requires cesarean section or difficult forceps delivery (20% of women)

c. Platypelloid – flat, broad pelvis; usually not adequate for vaginal delivery (5% of women)

d. Anthropoid – similar to pelvis of anthropoid ape; long, deep, and narrow; usually adequate for vaginal delivery (25% of women)


II. Passenger (fetal)

• Size – primarily related to fetal skull• Fetopelvic relationships• Lie – relationship of spine of fetus to spine of

mother; longitudinal (parallel)transverse (right angles)oblique (slight angle off a true transverse lie)


Presentation

• part of fetus that presents to (enters) maternal pelvic inlet

– Cephalic/vertex – head presentation (>95% of labors)


Breech presentation

• Complete – flexion of hips and knees• Frank (most common) – flexion of hips and extension

of knees• Footling/incomplete – extension of hips and knees


Attitude/ habitus

• relationship of fetal parts to each other; usually flexion of head and extremities on chest and abdomen to accommodate to shape of uterine cavity

• Vertex – head is maximally flexed• Military – head is partially flexed• Brow – head is partially extended• Face – head is maximally extended


Position - relationship of fetal reference point to mother’s

pelvis

Fetal reference point• Vertex presentation – dependent upon

degree of flexion of fetal head on chest; full flexion–occiput (O); full extension–chin (M); moderate extension–brow (B)

• Breech presentation – sacrum (S)• Shoulder presentation – scapula (SC)


Position

• Relation of the presenting part to a specific quadrant of a woman’s pelvis• Right anterior• Left anterior• Right posterior• Left posterior


• Maternal pelvis is designated per her right/left and anterior/posterior– Expressed as standard three letter abbreviation;

e.g., LOA = left occiput anterior, indicating vertex presentation with fetal occiput on mother’s left side toward the front of her pelvis

– Fetal position reflects the orientation of the fetal head or butt within the birth canal.


• Anterior FontanelThe bones of the fetal scalp are soft and meet at "suture lines." Over the forehead, where the bones meet, is a gap, called the "anterior fontanel," or "soft spot." This will close as the baby grows during the 1st year of life, but at birth, it is open.

• The anterior fontanel is an obstetrical landmark because of its' distinctive diamond shape. Feeling this fontanel on pelvic exam tells you that the forehead is just beneath your fingers.

• Early in labor, it is usually difficult (if not impossible) to feel the anterior fontanel. After the patient is nearly completely dilated, it becomes easier to feel the fontanel.

• When attaching a fetal scalp electrode, it is better to not attach it to the area of the fontanel.


• Posterior FontanelThe occiput of the baby has a similar obstetric landmark, the "posterior fontanel."

• This junction of suture lines in a Y shape that is very different from the anterior fontanel.

• In cases of fetal scalp swelling or significant molding, these landmarks may become obscured, but in most cases, they can identify the fetal head position as it is engaged in the birth canal.


Left occiput anterior (LOA)


Right occiput anterior(ROA)


Left occiput transverse(LOT)


Right occiput transverse(ROT)


Occiput posterior(OP)


Occiput Anterior(OA)


Left occiput posterior (LOP)


Right occiput posterior (ROP)


FETAL POSITION


Station

- level of presenting part of fetus in relation to imaginary line between ischial spines (zero station) in midpelvis of mother

• –5 to –1 indicates a presenting part above zero station (floating); +1 to +5, a presenting part below zero station

• Engagement – when the presenting part is at station zero


STATION or DEGREE OF ENGAGEMENT


III. Power – force expelling the fetus and placenta

1. Primary – involuntary uterine contractions• Three phases• Increment – steep crescent slope from

beginning of a contraction until its peak• Acme/peak – strongest intensity• Decrement – diminishing intensity


Characteristics of contractions• 1. Frequency – time frame in minutes from the

beginning of one contraction to the beginning of the next one; frequency of less than every 2 min should be reported

• 2. Duration – time frame in seconds from the beginning of a contraction to its completion; more than 90 s should be reported because of potential risk of uterine rupture or fetal distress

• 3.Intensity – the strength of a contraction at acme; may be assessed by subjective description from the woman, palpation (mild contraction would feel like the tip of the nose, moderate like the chin, strong like the forehead), or electronic intrauterine pressure catheter (IUPC)


2. Secondary – voluntary bearing-down efforts

• Psychological state of the woman – fear and anxiety may lead to increased perception of pain and impede progress of labor; preparation and support for childbirth may enhance coping efforts

• Preparation for childbirth education about the birthing process and methods to decrease discomfort and tension

• Relaxation of voluntary muscles• Distraction, focal point, imagery• Breathing techniques with each contraction


• a.Always begin and end with “cleansing” or “relaxing” breath (inhale deeply through nose and exhale passively through relaxed, pursed lips)

• b.Hyperventilation – may cause maternal respiratory alkalosis and compromise fetal oxygenation; characterized by light-headedness, dizziness, tingling of fingers and/or circum-oral numbness; managed by having woman breathe into her cupped hands or a paper bag

• Support person/”coach” should be involved in the formal preparation


• Position (maternal)• Side-lying enhances blood flow to the utero-

feto-placental unit and maternal kidneys• Upright (standing, walking, squatting) enlists

gravity to aid in fetal descent through the birth canal

• Frequent changes relieve fatigue and improve circulation


• Cardinal mechanisms/ movements of labor in vertex presentation

• usually flow smoothly and often overlap; failure to accomplish one or more usually requires obstetrical intervention

(ED FIrE ErE)


Cardinal mechanisms/ movements of labor in vertex presentation

• Engagement*• Descent• Flexion• Internal rotation• Extension• Restitution and external rotation• Expulsion


• Engagement - movement of the presenting part below the plane of the pelvic inlet

• Descent – progress through the maternal pelvis; continuous throughout labor

• Flexion – as a result of resistance from maternal pelvis and musculature, the head flexes so that a smaller diameter enters pelvis

• Internal rotation – head rotates from occiput transverse or oblique position (usual position as it enters the pelvis) to anterior/posterior at pelvic outlet; head is under symphysis pubis and neck is twisted


• Extension – the head is moved backward as it proceeds under the symphysis pubis and baby is born by extension over the perineum

• Restitution and external rotation – movement of head to align itself with face and shoulders (restitution) and then rotation bringing shoulders into anteroposterior diameter appears as one movement

• Expulsion – first the anterior shoulder under the symphysis pubis, then the posterior shoulder over the perineum, followed rapidly by the rest of the body; time of birth is recorded at this time


Signs of Labor• Preliminary signs of labor

• Lightening• Increase in level of activity• Braxton Hicks contractions• Ripening of the cervix


Signs of Labor• Signs of true labor

• Uterine contractions• Show• Rupture of membranes


Signs and symptoms of labor:

1. Impending – may begin several weeks prior to labor• Lightening “the baby dropped” • settling of uterus and fetal presenting part into pelvis• sensation of decreased abdominal distention• Increase Braxton-Hicks contractions • mild, intermittent, irregular, abdominal

contractions decrease/disappear with activity


• May be heightened anxiety, and anticipation, fatigue

• Weight loss of about 2-3 lb 3-4 d before onset of labor; related to changes in estrogen and progesterone levels

• Increased vaginal mucus discharge• Fetal movements may appear less active• May be episodes of false labor


2. Onset• Expulsion of mucous plug; pink/brown-tinged discharge

(bloody show)• Regular contraction increasing in frequency, duration,

and intensity• Spontaneous rupture of membranes (SROM) may occur

before or during• Check FHR by auscultation for 1 min and with next

contraction• May be a gush or trickle; report strong/foul odor

(infection), meconium-stained (in vertex presentation, may indicate fetal anoxia) or wine-colored (indicative of premature separation of placenta)


• Questionable leakage of amniotic fluids should be tested for alkalinity to differentiate from urine:

– Nitrazine tape turns blue/gray/green (alkaline); urine (acidic) does not change the yellow color

– A mixture of cervical mucus and amniotic fluid dried on a slide looks like crystallized ferns by microscopic examination


Cervical changes

• Effacement – thinning and shortening of the cervix during late pregnancy and/or labor; measured in percentages (100% is fully effaced)

• Dilation – opening and enlargement of the cervical canal; measured in centimeters 0-10 cm (10 cm is fully dilated)


EFFACEMENT AND DILATION OF CERVIX


TRUE VERSUS FALSE LABOR

True False Contractions –

regular with increasing frequency (shortened intervals), duration, and intensity

Contractions – irregular with usually no change in frequency, duration, or intensity

Discomfort radiates from back around the abdomen

Discomfort is usually abdominal

Contractions do not decrease with rest

Contractions may lessen with activity or rest

Cervix progressively effaced and

Cervical changes do not occur


DIVISIONS OF LABOR/ FRIEDMAN’S CURVE


Stages of Labor• First stage

• Latent phase• Active phase• Transition phase


Stages of Labor• Second stage

• Period from full dilatation and cervical effacement to birth of the infant

• Third stage• Placental separation• Placental expulsion


Friedman’s Division of LaborStages of Labor:First stage (dilating/ Cervical stage) – from onset of

regular contraction to full cervical dilationAVE: 13-18 h for nulliparas 8-9 h for multiparas

A. Latent phase (0-4 cm) – the cervix begins effacing and dilating and contractions become increasingly stronger and more frequent

DURATION: nulliparas 7-10 h multiparas 5-6 h


B. Active phase (5-7 cm) – more rapid dilation of cervix and descent of presenting part

DURATION: approximately 3-4 h for both

C. Transition (8-10 cm) – contractions may be every 1.5 to 2 min and last 60-90sec

DURATION: should not > 3 h for nulliparas 1 h for multiparas


• May be accompanied by irritability and restlessness, hyperventilation, and dark heavy show, as well as leg cramps, nausea/vomiting, hiccups, belching

• Possible rectal pressure creating a desire to push; should discourage before full dilation because it may cause maternal exhaustion and cervical and fetal trauma


• * Monitor vital signs and FHR• *Provide comfort measures (ambulate if

tolerated and if BOW is not ruptured yet; side lying is usually most comfortable, sacral pressures, back rubs)

• *Breathing technique during transition phase: Take a deep breath and exhale slowly and completely. At beginning of contraction, take a fairly deep breath. Then engage in shallow breathing. If there is an urge to push, puff out every 3rd, 4th, or 5th breath. Take deep breath at the end of contraction.


2. Second stage (stage of expulsion) – from complete dilation of cervix to delivery of the baby

AVE: 2 h for nulliparas 20 min for multiparas

Contractions are now severe, lasting 60-90sec at 1.5 to 3 min intervals


• Bearing down/pushing increases intra-abdominal pressure from voluntary contraction of maternal abdominal muscles and pushes the presenting part against the pelvic floor, causing a stretching, burning sensation and bulging of the perineum; “crowning” occurs when the presenting part appears at the vaginal orifice, distending the vulva

• Timing of transfer to delivery room• Nulliparas – during second stage when the

presenting part begins to distend the perineum • Multiparas – at the end of first stage when the

cervix is dilated 8-9 cm


• Third stage (placental stage) – from delivery of the baby to delivery of the placenta; if more than 30 min, placenta is considered retained

• AVE: < 30mins• Separation of placenta from the uterine wall

evidenced by a change in the fundus from discoid to globular shape as it becomes firm and rises in the abdomen, a sudden gush/trickle of blood and lengthening of the umbilical cord

• Expulsion of the placenta through the vagina by uterine contractions and pushing by mother or by gentle traction on the umbilical cord


Placental delivery make take 5-10 minutes (maximum 30 minutes) Either by

• Duncan – margin of the placenta separates first and the dull, red, rough maternal surface emerges from from the vagina first (dirty presentation)“dirty by Duncan”

• Schultze – center portion of the placenta separates first and the shiny and glistening fetal surface emerges from the vagina“shiny by Schultz”


• *Crede’s maneuver – gentle pressure on the contracted uterine fundus (never on a noncontracted uterus; uterus may evert and lead to hemorrhage)

• Contraction of the uterus following delivery controls uterine hemorrhage and produces placental separation: if necessary, Pitocin (oxytocin) or Methergine (methylergonovine maleate) may be administered to help contract the uterus


• Fourth stage – immediate recovery period from delivery of placenta to stabilization of maternal systemic responses and contraction of the uterus

• DURATION: from 1 to 4 h– Mother begins to readjust to non-pregnant state– Areas of concern include discomfort due to

contraction of uterus 9after pain) and/or episiotomy, fatigue or exhaustion, hunger, thirst, excessive bleeding, bladder distention, parent-infant interaction


STAGES OF LABOR STAGE PHASE Dilatation Duration/Interval Intensity

First Stage

Phase1-Latent

0-4 cm 10-30 sec/ 5-30 min

Mild to moderate

Phase 2-Active

5-7 cm 30-40 sec/ 3-5 min

Moderate to strong

Phase 3-Transition

8-10 cm 45-90sec/ 2-3 min strong

Second Stage

From full cervical dilatation (10 cm) up to the expulsion of the fetus -in the later phase of this stage, station becomes (+); +4 to birth -contraction becomes 1-2 minutes apart; fetal head visible; increased urgency to bear down

3rd Stage

Placental Delivery- sudden gush of blood, lengthening of the cord, rising of the fundus, globular uterus

4th Stage

First 4 hours after delivery of the placenta (monitor VS, fundus and lochia until stable)


Maternal and Fetal Responses to Labor

• Danger signs of labor - fetal• Heart rate• Meconium staining• Hyperactivity• Fetal acidosis


Maternal and Fetal Responses

• Danger signs of labor - maternal• Blood pressure• Abnormal pulse• Inadequate or prolonged contractions• Pathologic retraction ring• Abnormal lower abdominal contour• Apprehension


Maternal and Fetal Assessment • Assessment of stage one

• History• Physical exam• Leopold’s maneuvers• Rupture of membranes• Vaginal exam• Pelvic adequacy


Assessment• Laboratory analysis

• Blood• Urine

• Uterine contractions• Length• Intensity• Frequency


LOCATING FETAL HEART SOUNDS BY FETAL POSITION


Electronic Monitoring• External and Internal Monitoring

• Telemetry• FHR and uterine contractions• FHR patterns• Baseline FHR• Periodic changes


Fetal Heart Monitoring

• Labor is stressful for the fetus; therefore, continual assessment of fetal well- being through fetal heart rate monitoring is essential.

• Fetal well-being is determined by the response of the fetal heart rate to uterine contractions.

• Fetal anoxia resulting from stressful labor must be avoided to prevent intrauterine death or neurological damage.


NORMAL FHR: 120 – 160 bpmFetal monitoring during labor and deliveryMethods1. Periodic auscultation of the fetal heart by fetoscope

(stethoscope adapted to amplify sound or Doptone (ultrasound stethoscope) during contractions and for 30sec beyond; best heard over fetal back

Electronic fetal monitoring (EFM) – continuous monitoring providing audio and visual recordings as well as tracing strips

External – indirect, noninvasive method using a lubricated (water-soluble gel) ultrasound transducer attached to the abdomen

Internal – small electrode attached to the fetal scalp; indicated for high-risk maternity patient, problematic labor, or with oxytocin use; requires ROM, cervical dilation of at least 2 cm, and presenting part can be reached


Alterations in fetal heart rate

a. Normal – 120-160 BPMb. Tachycardia (>160 BPM) – associated with

prematurity, maternal fever, fetal activity, or fetal hypoxia/infection, drugs; if continued for an hour or more, or accompanied by late deceleration, indicates fetal distress

c. Bradycardia (<120 BPM) – associated with fetal hypoxia, maternal drugs/hypotension, prolonged cord compression, congenital heart lesions; persistent bradycardia or persistent drop of 20 beats per min below baseline may indicate cord compression or separation of the placenta


Variability – beat-to-beat fluctuations; measured by internal EFM only

a. Normal (6-25 BPM) – significant indicator of fetal well-being

b. Absent (0-2 BPM) or decreased (3-5 BPM) may be associated with fetal sleep state, fetal prematurity, reaction to drugs, congenital anomalies, hypoxia, acidosis; if persists for more than 30 min is indicator of fetal distress

c. Increased (>25 BPM) – significance is not knownd. Loss of the baseline (beat-to-beat variation) or

“smoothing out” of the baseline is often prelude to infant death


Periodic changes1.Accelerations – rise above baseline followed by a return;

usually in response to fetal movement or contractions2.Decelerations – fall below baseline followed by a returnEarly – occurs before peak contraction; most often uniform

mirror image of contraction on tracing; associated with head compression, commonly in second stage with pushing

Late – onset after the peak with slow return to baseline; indicative of fetal hypoxia because of deficient placental perfusion

Variable deceleration – transient U/V/M-shaped reduction occurring at any time before, during, or after contraction; indicative of cord compression, which may be relieved by change in mother’s position; ominous if repetitive, prolonged, severe, or has slow return to baseline


• Nursing interventions– None for early decelerations– For late decelerations (at the first sign of

abnormal tracing) – position mother left side-lying (if no change, move to other side, Trendelenburg or knee/chest position); administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate; if the pattern persists, fetal scalp blood sampling for acidosis (pH >7.25 is normal, 7.20-7.24 is considered preacidotic – repeat in 10-15 min; 7.2 or less indicates serious acidosis; prepare for cesarean section)


Fetal Heart Rate Patterns Indicative of… Intervention

Tachycardia (>160 bpm) Maternal or fetal infectionFetal hypoxia (ominous sign)


Bradycardia (<120 bpm) Fetal hypoxia or stressMaternal hypotension after epidural initiation

Place client on her left sideIncrease fluids to counteract hypotensionStop oxytocin (Pitocin) if in use

Early deceleration (deceleration begins and ends with uterine contraction)

Head compression :not ominousVagal stimulation

None required

Late deceleration(HR decreases after peak of contraction and recovers after contraction ends)

Fetal stress and hypoxiaDeficient placental perfusionSupine positionMaternal hypotensionUterine hyperstimulation

Change maternal positionCorrect hypotensionIncrease IV fluid rate as orderedDiscontinue oxytocinAdminister oxygen as ordered

Variable deceleration(transient decrease in HR anytime during contraction

Cord compressionHypoxia or hypercarbia

Change maternal positionAdminister Oxygen

Decreased variability Fetal sleep cycleDepressant drugsHypoxiaCNS anomalies



Nursing Care: First Stage• Respect contraction time• Change positions• Voiding and bladder care• Support• Pain management


Nursing Care: Second Stage• Preparing for birth• Positioning for birth• Pushing• Perineal cleaning• Episiotomy• Birth• Cutting and clamping the cord


Perineal cleaning


EPISIOTOMY


RITGEN’S MANEUVER


A child is considered born when the whole body is delivered.

541

UMBILICAL CORD CLAMP APPLIED TO CORD

Providing Comfort During

Labor and Birth


Intapartal nursing management• Stage 1• Maternal

• Monitor vital signs, fluid and electrolyte balance, frequency, duration, and intensity of uterine contractions and degree of discomfort (hourly, at minimum); urine protein and glucose with every voiding; laboratory results; preparedness; ROM

• Provide comfort measures – e.g., positioning, back massage/effleurage (light abdominal stroking in rhythm with breathing during a contraction to ease mild/moderate discomfort), warm/cold compresses, ice chips


1. Support coping measures – reassure, explain procedures, reinforce/teach breathing techniques, relaxation, focal point

2. Assist support person• Fetal – monitor status


• Stage 2• Maternal

– Monitor physical status; assess progress of labor, perineal and rectal bulging, increased vaginal show

– Assist in techniques to foster expulsion – encourage bearing down focus on vaginal orifice (discourage breath holding for more than 5sec), position squatting, side-lying, Fowler’s as appropriate

– Provide comfort measures; support coping measures; assist support person


• Fetus/neonate• Monitor fetal heart rate and regularity• Provide immediate neonatal care

– Assist M.D./nurse/midwife in newborn care– Please refer to ESSENTIALS OF NEWBORN

CARE


• Stage 3• Maternal – observe for signs and symptoms of placental

separation; assess amount of blood loss; monitor blood pressure, pulse, and fundus frequently

• Neonate• Apgar scores at 1 and 5 min to evaluate condition at

birth – Based on five signs: heartbeat, respiratory effort,

muscle tone, reflex irritability, color– Each sign rated 0-2 2 is top score); all the scores are

added for total score– 7-10 (good condition) should do well in normal

neonatal nursery; 4-6 (fair condition) may require close observation; 0-3 (extremely poor condition) resuscitation and intensive care are acquired


Assessment for Well-Being

• Apgar scoring• Heart rate• Respiratory effort• Muscle tone• Reflex irritability• Color


APGAR SCORE

0 1 2 Cardiac tone Respiration Muscle tone Reflexes Color

Absent Absent Flaccid No response Blue, pale

Slow (<100 BPM) Slow, irregular Some flexion Cry Body pink,

extremities blue

Normal (>100 BPM) Good cry Active Vigorous cry Completely pink


• Maintain temperature – minimize exposure to environmental heat loss (evaporation, radiation, conduction, convection); skin-to-skin with mother or at 36.4°C skin temperature

• Weigh and measure infant• Place identification band on infant• Record time of first void and stool (meconium)

after delivery; monitor physical status


• Initiate parent-child interaction• Instill prophylactic eye drops/ointment – legally

required to prevent conjunctival gonococcal infection that could lead to blindness in the neonate; 1% silver nitrate or 0.5% erythromycin

• Administer intramuscular vitamin K – for first 34 d of life the neonate is unable to synthesize vitamin K, which is necessary for blood clotting and coagulation


• Stage 4• Monitor maternal blood pressure and pulse; uterine

contractility tone and location; amount and color of lochia, presence of clots; condition of episiotomy every 15 min x 4

• Monitor bladder function• Provide comfort• Evaluate parenteral interaction


FOURTH STAGE OF LABOR First 1-2 h Nursing Considerations

Vital signs (BP, pulse) q 15 min Follow protocol until stable

Fundus

q 15 min Position – even to 1 cm/finger breadth above the umbilicus for the first 12 h, then descends by one finger breadth each succeeding day, pelvic usually by day 10

Lochia (color, volume)

q 15 min Lochia (endometrial sloughing) – day 1-3 rubra (bloody with fleshy odor; may be clots); day 4-9 serosa (pink/brown with fleshy odor); day 10+ alba (yellow-white); at no time should there be a foul odor (indicates infection)

Urinary Measure first void May have urethral edema, urine retention Bonding Encouraged interaction Emphasize touch, eye contact


Delivery1. Normal spontaneous vaginal delivery

• The mother is encouraged not to push as the head is delivered; the infant cries (or is encouraged to do so to expand the lungs); if the cord is encircling the neck (nuchal cord), it is gently slipped over the head

• Episiotomy (a surgical incision of the perineum) may be done at the end of the second stage of labor to facilitate delivery and to avoid laceration of the perineum


Types of Episiotomy• Median – rare faulty healing, easier to make

and repair• Mediolateral – tearing in the anus and rectum

is rare


Classification of Perineal Laceration

• First Degree – involves the perineal mucosa • Second Degree – involves the muscle of the

perineal body but does not involve the rectal sphincter

• Third Degree – involves the rectal sphincter but not the rectal mucosa

• Fourth Degree – involves the rectal mucosa


Operatives deliveries

2.Forceps delivery forceps - two doubled-curved, spoonlike

articulated blades used to extract the fetal head; indicated if mother cannot push fetus out or compromised maternal/fecal status in late second stage; contraindicated in cephalopelvic disproportion (CPD)

•


• Classification:–Outlet – fetal head is on the pelvic floor–Low – fetal head is below station +2 but

not reached the pelvic floor–Mid – fetal head is below station 0 but

not reached station +2–High – fetal head is above station 0


Indications:• Prolonged second stage (most common)• Non reassuring EFM strip• Avoiding maternal pushing• Breech presentation

Complications• Maternal – lacerations• fetal – neonatal – soft tissue

compression or cranial injury


2. Vacuum extractor – delivery with use of suction device that is applied to the fetal scalp for traction; used in prolonged second stage; contraindicated in CPD and face/breech presentation

Indications:• Prolonged second stage (most common)• Non reassuring EFM strip• Avoiding maternal pushing• Breech presentation


Complications• Maternal – lacerations• fetal – neonatal – cephalhematoma and scalp

laceration, subgluteal hematoma and intracranial hemorrhage (>10min)


4. Cesarean delivery (next chapter)


Comfort and Pain Relief• Support from doula or coach• Alternative therapies

• Relaxation• Focusing and imagery• Breathing• Herbal preparations


Comfort and Pain Relief

• Pharmacological Measures• Goals• Preparation• Narcotic analgesics

• Intrathecal• Regional anesthesia


Nursing Care: Promoting Comfort

• Reducing anxiety• Coping strategies• Comfort measures• Positioning• Childbirth method• Pharmacologic pain relief


Pharmacological control of discomfort

• Principles of use – minimize pain without increasing risk to mother or fetus; type of pain relief is influenced by length of gestation, mother’s emotional status, response to pain, previous history with analgesics or anesthesia, and general character of labor process


Analgesia – alleviation of the sensation of pain or the elevation of one’s thresshold for perception of

pain

• Narcotic analgesics – effective for relief of severe, persistent pain- with no amnesic effect- adverse effects: nausea and vomiting, maternal respiratory depression, neonatal CNS depression (blocking nerve impulses to the brain) requiring stimulation or resuscitation at delivery- cross the placental barrier and affect the neonateEX: Meperidine HCl (Demerol); Morphine sulfate


Anesthesia- includes analgesia, amnesia, and relaxation; abolishes pain perception by CNS

depression• epidural block –most common; local anesthetic such

as lidocaine or bupivocaine is injected into the epidural space surrounding the spinal cord; a catheter is placed for continuous epidural anesthesia- - if hypotension occurs, woman should be placed on her left side; IV rate should be accelerated as ordered; oxygen support should be administered if ordered and doctor should be notified


Regional Anesthesia• Injection of local anesthesia to block specific

nerve pathways• Epidural anesthesia

• Nursing care• Administration

• Spinal anesthesia


Medication for Pain Relief: Birth• Local anesthesia

• Local infiltration• Pudendal nerve block

• General anesthesia• Preparation• Aspiration of vomitus


• Timing of administration• 1. Before 5 cm (latent phase) – may retard or

stop labor• From 5 to 7 cm (early active phase) – may aid

relaxation• After 8 cm (transition phase) – may result in

respiratory depression requiring resuscitative measures in sedated neonate

• - Because most medications cross the placental barrier, FHR is taken frequently before and after administration of medication


• Obstetrical analgesia – functions through alleviation of sensation of pain or enhancement of threshold for pain

• Sedatives/hypnotics – used less frequently than previously because of incidence of side effects

• Narcotics– Morphine sulfate – used rarely because of adverse

reactions– Meperidine hydrochloride (Demerol) – most

commonly used; mother and infant interaction may be limited in immediate postpartum period because infant may still be sluggish and less alert

– Alphaprodine (Nisentil) – may be given IV/SC but never IM because of unpredictability by this route


– Mixed narcotic agonist-antagonist compounds (Stadol [IM/IV/SC], Talwin [IV/IM] but not SC, which can cause severe tissue damage) – analgesia while decreasing side effects but can still produce respiratory depression, nauseas and vomiting, light-headedness

– Narcotic antagonist (Narcan) – counteracts respiratory depressant effects; may be administered to mother IM/IV 5-15 min prior to delivery or to neonate IV via umbilical vein immediately after birth

• Note: Narcotic antagonist given to a woman who is addicted to narcotics may cause immediate withdrawal symptoms.


• Analgesic potentiator/ataractic (Phenergan, Largon, Vistaril, Sparine) – tranquilizing effect, decreasing apprehension and anxiety as well as the nausea and vomiting associated with many analgesics; fetal and neonatal problems are rare


• Anesthetics • Inhalation

– Nitrous oxide and oxygen – used intermittently with each contraction; patient is able to cooperate in bearing down; increased danger of neonatal depression with continued use after 15-20 min

– Trilline/Penthine – self-administered by mother with inhaler (under supervision); may cause maternal and fetal narcotic depression


• Regional blocks – allow mother to be awake and participate in process; can increase incidence of maternal hypotension and fetal bradycardia; need for forceps delivery, prolonged labor or uterine atony, necessity for catheterization, and sometimes post spinal headache1. Lumbar epidural block –affects the entire pelvis by

blocking impulses at level of T12 through S5; may be administered continuously through tubing left in place; incidence of maternal hypotension may be minimized if 500-1000 ml of IV fluids is infused at a rapid rate prior to administration and mother is maintained in side-lying position

• There must be vigilant monitoring of maternal BP and FHR every 1-2 min x 15 min and every 10-15 min thereafter


• Treatment of maternal hypotension includes– Mild/Moderate – place mother in left lateral

position, increase the rate of IV fluid; administer oxygen by mask

– Severe/prolonged – place mother in Trendelenburg position for 2-3 min

2. Caudal – administered during second stage just before delivery; not commonly used

3. Subarachnoid block/ “saddle block” (nerves from S1 to S4) – anesthetizes perineum, lower pelvis, and upper thighs; diminishes pushing efforts; high incidence of maternal hypotension and potential for fetal hypoxia


3. Spinal block – now used primarily just prior to cesarean delivery

4. Paracervical block analgesics – injection of an anesthetic solution into region around cervical area to relieve pain caused by cervical dilation; thought to have a depressing effect on infant’s respiratory center

5. Intravenous anesthesia (Pentothal) – rarely used, can cause fetal depression, maternal laryngospasm, vomiting and aspiration, postpartal uterine atony


COMMON ANALGESICS AND ANESTHETICS OF LABOR AND DELIVERY Medication Side Effects Nursing Considerations Meperidine hydrochloride

(Demerol) Hypotension Respiratory depression Gastric irritability Constipation Bradycardia Constricted pupils

Increases pain tolerance Do not administer within 2 h of

expected delivery

Secobarbitol sodium (Seconal) Drowsiness Lethargy Respiratory depression Angioedema

Sedates Anxiety relief

Naloxone hydrochloride (Narcan)

Tachycardia Hypertension Tremors

IV into umbilicus vein for neonates (0.01 mg/kg)

Reverses narcotic depression Thiopental sodium (Sodium

pentothal) Respiratory depression Induction anesthesia for cesarean

secretion T Tetraccaine hydrochloride

(Pontocaine; lidocaine) Confusion Tremors Restlessness Hypotension Dysrhythmias Tinnitus Blurred vision

If subarachnoid space used, keep patient flat for 6-8 h

Regional nerve block Relieves uterine or perineal pain

Cesarean Birth


Nursing Care: Anticipating a Cesarean

• Immediate preoperative care• Informed consent• Hygiene• GI tract preparation• Baseline intake and output• Hydration• Preoperative medication• Checklist• Transport• Role of support person


Nursing Care: Cesarean Birth

• Intraoperative care• Anesthesia• Skin preparation• Surgical incision

• Types of incisions• Birth


Nursing Care: Cesarean Birth

• Postpartal care• Pain control• Fluid volume• Output • Circulation• Parenting • Infection


Cesarean BirthBirth accomplished through an abdominal incision into

the uterus


Cesarean section

– fetus is delivered through an incision in anterior abdominal and uterine wall

Indications:• Cephalopelvic disproportion• Fetal malpresentation• non reassuring EFM strip


Complications:• hemorrhage• Infection• Visceral injury• Thrombosis


Uterine Incisions1. Low segment Transverse - incision is made in the non contractile portion

of the uterus - low chance of uterine rupture, may have trial

of labor - fetus must be in longitudinal lie

2. Classical- incision is made in the contractile portion of

the uterus- risk uterine rupture - lower segment varicosities and myomas can be

bypassed


Anesthesia in C/S

Most popular:• Regional block• Epidural• Spinal anesthesia• Because the mother is awake and aware of the birth

of her infant• When time is of the essence or when an epidural or

spinal cannot be used, general anesthetic is used.


Scheduled or Unscheduled C/S• Scheduled Cesarean Birth- If it is to be a repeat cesarean birth

(eg, cephalopelvic disproportion)- If labor is contraindicated (eg, complete placenta

previa, hydrocephaly)- If labor cannot be induced and birth is necessaryClients have some time to prepare for the cesarean

birth


• Unscheduled/ Emergency Cesarean Birth- Usually a result of some difficulty in the labor

process/ failure to progress in labor- Placenta previa- Abruptio placenta- Fetal distress


• Vaginal Birth after Cesarean (VBAC)- When the reason for the initial cesarean is a

nonrecurring situation such as placenta previa, prolapsed cord, or breech presentation, the client may be able to have a vaginal birth with the next pregnancy

- Low transverse uterine incision: trial of labor is recommended

- Classic uterine incision: trial of labor is CI

Nursing Care of a Postpartal

Woman and Family


• FROM STAGE 4 UNTIL 6 WEEKS AFTER DELIVERY

Postpartum


POSTPARTUM ASSESSMENT

B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy S - sex

H - Homan’s sign E - emotion


BREAST ASSESSMENT• Breasts – Soft, engorged, filling, swelling, redness,

tenderness.• Nipples – Inverted, everted, cracked, bleeding,

bruised, presence of colostrum or breastmilk.


Breasts – progress from soft filling with potential for engorgement (vascular congestion related to increased blood and lymph supply; breasts are larger, firmer, and painful)

• Non-nursing woman – suppress lactation• Mechanical methods – tight-fitting brassiere, ice

packs, minimize breast stimulation• Nursing woman – successful lactation is

dependent on infant sucking and maternal production and delivery of milk (letdown/milk ejection reflex); monitor and teach preventive measures for potential problems


Nipple – irritation/cracking• Nipple care – clean with water, no soap, and dry

thoroughly; absorbent breast pads if leaking occurs; expose to air

• Position nipple so that infant’s mouth covers a large portion of the areola and release infant’s mouth from nipple by inserting finger to break suction

• Rotate breastfeeding positions


Engorgement • nurse frequently (every ½-3 h) and long enough to

empty breasts completely (evidenced by sucking without swallowing)

• warm shower or compresses to stimulate letdown • alternate starting breast at each feeding • mild analgesic 20 min before feeding and ice packs

between feedings for pronounced discomfort

• Plugged ducts – area of tenderness and lumpiness often associated with engorgement; may be relieved by heat and massage prior to feeding


Expression of breast milk • to collect milk for supplemental feedings • to relieve breast fullness or to build milk supply • may be manually expressed or pumped by a

device and refrigerated for no more than 48 h or frozen in plastic bottles (to maintain stability of all elements) in refrigerator freezer for 2 wk and deep freezer for 2 mo (do not thaw in microwave or on stove)

• Medications – most drugs cross into breast milk; check with physician before taking any medication


LACTATION PRINCIPLES

Breast Care – Antepartum and Postpartum

Initiating Breast Feeding

Soap on nipples should be avoided during bathing to prevent dryness

Nipples can be “prepared” antepartum by exposure to sun, air, and by wearing loose clothing

Redness or swelling can indicate infection and should always be investigated

Relaxed position of mother is essential – support dependent arm with pillow

Both breasts should be offered at each feeding

Five minutes on each breast is sufficient at first – teach proper way to break suction

Most of the areola should be infant’s mouth to ensure proper sucking


Uterus

FUNDAL ASSESSMENT• Location in relation to umbilicus• Degree of firmness• Midline or deviated to one side

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ASSESSING THE UTERINE FUNDUS• The uterus is best

evaluated with the patient in a supine position and with an empty bladder.

• The nurse should support the lower uterine segment just above the symphysis pubis with the non-dominant hand and palpate the uterine fundus for degree of involution.

• Fundal descent is measured in relationship to the umbilicus in fingerbreadths or centimeters.


• Involution – (uterus reduced to prepregnant size)

• Fundus – midline, firm• Position – even to 1 cm/finger breadth above

the umbilicus for the first 12 h, then descends by one finger breadth each succeeding day, pelvic organ usually by day 10

• If with deviations, check bladder and have patient void; if deviations continue, massage fundus


Bowels

• GI – bowel sluggishness, decreased abdominal muscle tone, perineal discomfort may lead to constipation; managed by early ambulation, increased dietary fiber and hydration, stool softeners


• After pains – cramps due to uterine contractions lasting 2-3 d; more common in multipara and with nursing; may be relieved by lying on abdomen with small pillow, heat, ambulation, mild analgesic (if breast feeding, 1 h before nursing)

• Rubella vaccine – for susceptible woman; RhoGam as appropriate

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BLADDER ASSESSMENT

• Voiding pattern, complete emptying, pain burning on urination

• Record first three voids with the amount and times voided

• A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY = > risk of postpartum hemorrhage.


• Elimination• Urinary – increased output (postpartum

diuresis), urethral trauma, decreased bladder sensation, and inability to void in the recumbent position may cause bladder distention, incomplete emptying and/or urinary stasis increasing the risk of uterine relaxation and hemorrhage and/or UTI; monitor I and O encourage voiding every 24 h (early ambulation and pouring warm water over perineum); catheterization may be necessary if no voiding after 8 h


Lochia

• Lochia – (endometrial sloughing) – day 1-3 rubra (bloody with fleshy odor; may be

clots)– day 4-9 serosa (pink/brown with fleshy odor)– day 10+ alba (yellow-white); at no time should

there be a foul odor (indicates infection)

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EPISIOTOMY/PERINEAL ASSESSMENT

• Assessment of the episiotomy/perineum should occur with the woman in lateral Sims (side lying) position.Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy) to guide assessment.

• Even if there is no episiotomy, the perineum should still be assessed.

• Unusual perineal discomfort may be a symptom of impending infection or hematoma.Hemorrhoids ?


• Perineum – possible discomfort, swelling, and/or ecchymosis

• Managed with analgesics and/or topical anesthetics, ice packs for first 12-24 h and then 20 min sitz baths 3-4 times/d, tightening buttocks before sitting

• Monitor episiotomy/laceration – teach techniques to prevent infection, e.g., change pads on regular basis, peri care (cleaning from front to back using peri-bottle or surgigator after each voiding and bowel movement), and sitz baths


SEX

• Sexual activities – abstain from intercourse until episiotomy is healed and lochia has ceased (usually 3-4 wk); may be affected by fatigue, fear of discomfort, leakage of breast milk, concern about another pregnancy; assess and discuss couple’s desire for and understanding about contraceptive methods; breastfeeding does not give adequate protection, and oral contraceptives should not be used during breastfeeding.


• Psychosocial adjustment• Attachment/bonding – influenced by maternal

psychosocial-cultural factors, infant health status, temperament, and behaviors, circumstances of the prenatal, intrapartal, postpartal, and neonatal course; evidenced initially by touching and cuddling, naming, “en face” positioning for direct eye contact, later by reciprocity and rhythmicity in maternal-infant interaction


Psychological Changes• Phases

• Talking-in • Taking-hold• Letting-go


Phases of adjustment• “Taking in”/dependency (day 1-2 after

delivery) – preoccupied with self and own needs (food and sleep); talkative and passive; follows directions and is hesitant about making decisions; retells perceptions of birth experience


• “Taking hold”/dependency-independency (by day 3) – performing self-care; expresses concern for self and baby; open to instructions


• “Letting go”/independence (evident by weeks 5-6) – assuming new role responsibilities; may be grief for relinquished roles; adjustment to accommodate for infant in family


• “Postpartum blues” (day 3-7) – normal occurrence of “roller coaster” emotions, weeping, “let-down feeling”; usually relieved with emotional support and rest/sleep; report if prolonged or later onset


Pregnant Adolescent• Complications

• Pregnancy-induced hypertension• Iron-deficiency anemia• Preterm labor


Pregnant Adolescent

• Complications and concerns of labor, birth and postpartum• Cephalopelvic disproportion• Postpartal hemorrhage• Inability to adapt • Lack of knowledge


Over Age 40• Complications

• Pregnancy-induced hypertension• Complications and concerns of labor, birth and

postpartum• Failure to progress• Difficulty accepting event• Postpartal hemorrhage

Reproductive Life Planning


Reproductive Life Planning

• Includes all decisions an individual or couple make about having children:

- If and when to have children- How many children to have- How children are spaced- Conception, fertility and counseling


• A responsible person is a man or woman who is able and willing to give the proper response to the demands of a given situation.

• With specific reference to marriage and family life, the responsible spouse is one who gives the proper responses to the needs of his/ her spouse, as well as his own, and of their life together. Similarly, responsible parents give proper responses to the needs of their children.

Responsible Parenthood


• Although some people object to the idea, we tend to equate family planning with responsible parenthood.

• Family planning refers more specifically to the voluntary and positive action of a couple to plan and decide the number of children they want to have and when to have them.



The concept of family planning includes these elements:

• Responsibility of parents to themselves and to each other

• Responsibility to their present and future children

• Responsibility to their community and country



Purposes of Family Planning• improvement of health• promotion of human right to determine reproductive

performance• relation of demographic change to economic

development



The ultimate goal of family planning is directed towards:

• Birth spacing, to allow the mothers time to rest and regain their health before the next pregnancy

• Birth limitation, when the desired number of children is reached

• Helping those who do not have children to have children



Contraceptive

• Any device used to prevent fertilization of an egg


Considerations:

• Personal values• Ability to use method correctly• How method will affect sexual enjoyment• Financial factors• Status of couple’s relationship• Prior experiences• Future plans• Contraindications


CONTRAINDICATIONS OF CONTRACEPTIVE USE


Contraceptives

1. Abstinence• 0% failure rate• Most effective method to prevent STDs• Difficult to comply with


Contraceptives

2. Natural Family Planning

• No chemical or foreign material into the body• Failure rate of approximately 25%


ContraceptivesFertility Awareness Methods• Calendar (rhythm) method• Basal body temperature• Cervical mucus (Billings) method• Symptothermal method• Ovulation awareness• Lactation amenorrhea method• Coitus interruptus


Calendar/ Rhythm (Natural Family Planning)

• Action – periodic abstinence from intercourse during fertile period; based on the regularity of ovulation; variable effectiveness


• Teaching – fertile period may be determined by a drop in the basal body temperature before and a slight rise after ovulation and/ or by a change in cervical mucus from thick, cloudy and sticky during nonfertile period to more abundant, clear, thin, stretchy and slippery as ovulation occurs

Calendar/ Rhythm (Natural Family Planning)


• Entails keeping a day-by-day record of your cycle for 6 consecutive months

• noting the onset of bleeding as day 1 and the last day before your next menstrual bleeding as the final day of your cycle

• This 6 month record will show you your longest and shortest cycles- from which you can calculate your FERTILE days

1. Calendar (rhythm) method


• The first day of menstrual bleeding (day 1 of your period) counts as the first day of the cycle.

• Approximately 14 days (or 12 to 16 days) before the start of the next period, an egg will be released by one of the ovaries.



• While the egg from the woman lives for only around 24 hours, sperm from the man can survive for up to 3 days, possibly longer.



• First unsafe day: subtract 18 from the number of days in your shortest cycle

• Last unsafe day: subtract 11 from the number of days in your longest cycle

• Ex: shortest: 26 – 18 = day 8 longest: 31 – 11 = day 20

UNSAFE PERIOD!! Days 8 -20-avoid coitus or use a contraceptive



LONGEST CYCLE

12 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

11 DAYS

SHORTEST CYCLE

12 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

18 DAYS

UNSAFE TIME

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

UNSAFE TIME


2. Basal Body Temperature

• Involves taking the temperature every morning BEFORE the woman gets out of bed and recording it

• The temperature drops slightly 24 hours before ovulation, then rises to about half a degree higher than normal and remains thus for up to three days: UNSAFE period!

• Not a very efficient method unless combined with calendar and mucus methods


3. Cervical Mucus (Billings) Method

• Involves becoming aware of the normal changes in the cervical secretions that occur throughout your cycle by inserting the forefinger into the vagina first thing in the morning


• A few days after menstrual bleeding: little secretion, vagina is dry

• Gradually, secretion increases and becomes thicker, cloudy white and sticky

• As ovulation approaches, this secretion or mucus becomes copious, clear, thin, less viscous, more liquid, slippery or stringy; as soon as this change begins and for 3 full days later: UNSAFE PERIOD!!

3. Cervical Mucus (Billings) Method

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3. Cervical Changes

• Spinnbarkeit test• Cervical mucus is

thin, watery and can be stretched into long strands

• high level of estrogen: ovulation is about to occur

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3. Cervical Changes

• Ferning or arborization of cervical mucus

• At the height of estrogen stimulation just before ovulation

• Ferning- due to crystallization of sodium chloride on mucus fibers


Symptothermal method

• Combines BBT and cervical mucus methods


Ovulation awareness

• Use of over-the-counter OTC ovulation test kit which detects the midcycle LH (luteinizing hormone) surge in the urine 12 to 24 hours before ovulation

• 98 to 100% accurate

http://www.amazon.com/gp/product/images/B000GHUVFQ/ref=dp_image_0?ie=UTF8&n=3760901&s=hpc


Lactation amenorrhea method

• As long as a woman is breastfeeding an infant, there is some natural suppression of ovulation

• Not dependable- woman may be fertile even if she has not had a period since childbirth

• After 6 months, she should another method of contraception


Coitus interruptus

• Oldest method• Couple proceeds with coitus until the moment of

ejaculation, then the man withdraws and spermatozoa are emitted outside the vagina

• Offers little protection because ejaculation may occur before withdrawal is complete and despite the care used, spermatozoa may be deposited in the vagina


Contraceptives

3. Oral Contraceptives• Composed of varying amounts of estrogen

combined with small amount of progesterone

99.5% effective

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3. Oral Contraceptives

• Estrogen suppresses FSH and LH, thereby suppressing ovulation

• Progesterone decreases the permeability of cervical mucus


• Monophasic - Fixed doses of estrogen and progesterone ; 21-28 day cycle

• Biphasic - Constant amount of estrogen with increased progesterone

• Triphasic - Varying levels of estrogen and progesterone



3. Oral ContraceptivesBenefits of OC’s: DECREASED incidences of:• Dysmenorrhea• Premenstrual dysphoric syndrome• Iron deficiency anemia• Acute PID with tubal scarring• Endometrial and ovarian cancer and ovarian cysts• Fibrocystic breast disease


Side Effects• Nausea• Weight gain• Headache• Breast tenderness• Breakthrough bleeding• Monilial vaginal infections• Mild hypertension• Depression



Absolute Contraindications to OC’s• Breastfeeding• Family history of CVA or CAD• History of thromboembolic disease• History of liver disease• Undiagnosed vaginal bleeding



Possible Contraindications to OC’s• Age 40+• Breast or reproductive tract malignancy• Diabetes Mellitus• Elevated cholesterol or triglycerides• High blood pressure• Mental depression



• Migraine or other vascular type headaches• Obesity• Pregnancy• Seizure disorders• Sickle cell or other hemoglobinopathies• Smoking• Use of drug with interaction effect


Other Contraceptives

• Continuous or extended regimen pills• Mini-pills• Estrogen-progesterone patch• Vaginal rings


Estrogen-progesterone patch


• Highly effective, weekly hormonal birth control patch that’s worn on the skin

• Combination of estrogen and progestin• Absorbed on the skin and then transferred into the

bloodstream• Can be worn on the upper outer arm, buttocks,

upper torso or abdomen• Worn for 1 week, replaced on the same day of the

week for 3 consecutive weeks. No patch-4th week


Emergency Postcoital Contraceptives

• “Morning-after pills”• High level of estrogen• Must be initiated within 72 hours of

unprotected intercourse


4. Other Contraceptives

Subcutaneous implants (eg, Norplant)• 6 nonbiodegradable Silastic implants with

synthetic progesterone embedded under the skin on the inside of the upper arm

• Slowly release the hormone over the next 5 years• Suppress ovulation, stimulating thick cervical

mucus and changing the endometrium so implantation is difficult


4. Other Contraceptives

• Intramuscular injections-administered every 12 weeksMedroxyprogesterone (depo-provera)-100% effective


Contraceptives5. INTRAUTERINE DEVICES• T-shaped plastic device with copper• With progesterone• Mechanism of action not fully understood• Must be fitted by physician, nurse practitioner or midwife• Insertion performed in ambulatory setting after pelvic

examination and pap smear• Device is contained within uterus – string protrudes into

vagina• Effective for 5-7 years (mirena type) or 8 years (Copper

T380)

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INTRAUTERINE DEVICE


5. INTRAUTERINE DEVICES

Side Effects:• Spotting or uterine cramping• Increased risk for PID• Heavier menstrual flow• Dysmenorrhea

• Ectopic pregnancy


6. Barrier Methods

• Vaginally inserted spermicidal products• Diaphragms• Cervical caps• Condoms

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6. BARRIER METHODS

• SPERMICIDAL AGENT

goal: to kill the sperm before the sperm enters the cervix

-Nonoxynol-9-gel, creams,

films,foams, suppositories

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6. BARRIER METHODS• DIAPHRAGM -mechanically blocks sperm

from entering the cervix -soft latex dome supported by

a metal rim-can be inserted 2 hours before intercourse; removed at least 6 hours after coitus or within 24 hours-size must fit the individual-washable, may be used for 2-3 years

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6. BARRIER METHODS

• CERVICAL CAP-similar to diaphragm but smaller-thimble-shaped rubber cap held onto the cervix by suction

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6. BARRIER METHODS

MALE CONDOM FEMALE CONDOM


• MALE CONDOMAction – prevents the ejaculate and sperm from entering the vagina; help prevent venereal disease; effective if properly used; OTC

• Teaching – apply to erect penis with room at the tip every time before vaginal penetration; use water-based lubricant, e.g., K-Y jelly, never petroleum-based lubricant; hold rim when withdrawing the penis from the vagina; if condom breaks, partner should usecontraceptive foam or cream immediately

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7. Surgical Methods• Tubal Ligation

-28% of all women in US-fallopian tubes are cut,tied/ cauterized to block passage of ova and spermABDOMINAL INCISION

MINILAPAROTOMYLAPAROSCOPY FOR TUBAL

STERILIZATION

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7. Surgical Methods

• Vasectomy - 11% of all men in US-incisions are made in the sides of scrotum; vas deferens is cut and tied, then plugged or cauterized-blocks passage of sperm-viable sperm for 6 months post op-reversible 95%


8. Elective Termination of Pregnancy

Procedure to deliberately end a pregnancy before fetal viability

• Induced(mifepristone-progesterone antagonist; misoprostol-prostaglandin analog

• Medically inducedD&C, D&E, saline induction, hysterotomy

MLNGCeleste, RN, MD

• an easy way to plan or prevent pregnancy naturally• color-coded string of beads which enables a woman

to track her cycle and know if she is on a day when pregnancy is likely or not

Advantages • Effective - more than 95%* • Side-Effect Free • Easy to use • Inexpensive • Educational & Empowering


Cycle Beads

MLNGCeleste, RN, MD

• To use CycleBeads a woman simply moves a ring over the series of color-coded beads that represent the days of her cycle.

• The color of the beads lets her know whether she is on a day when she is likely to be fertile or not. The one medical criterion for using CycleBeads to prevent pregnancy is that a woman should have cycles between 26 and 32 days long.


MLNGCeleste, RN, MD

CycleBeads are a color-coded string of beads that represent a woman's menstrual cycle. Each bead represents a day of the cycle and the color helps a woman to determine if she is likely to be fertile that day.



The day a woman starts her period she puts the rubber ring on the red bead.

MLNGCeleste, RN, MD

• When the ring is on the red bead or a dark bead, there is very low likelihood of pregnancy, so she can have intercourse on these days without getting pregnant.

• When the ring is on a white bead - Days 8 through 19 - there is a high likelihood of getting pregnant if a woman has unprotected intercourse.


MLNGCeleste, RN, MD

Health Teaching 1. Remembering to move the ring2. Checking to make sure that the ring is on the

right day.3. Making sure that no one else moves the ring.4. Talking to the partner about Cycle Beads and

how it works


MLNGCeleste, RN, MD

CycleBeads • based on a natural method of family planning

called the Standard Days Method• developed by the Institute for Reproductive

Health at Georgetown University• The Standard Days Method works best for

women who have regular menstrual cycles between 26 and 32 days long.

• Days 8 through 19 of their cycles are the days these women are likely to get pregnant if they have unprotected intercourse. On other days of their cycles, pregnancy is very unlikely.


The Newborn

MLNGCeleste, RN, MD

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