reviewer Flashcards by Lala Lolo

Puberty: initiated when the hypothalamus releases __________

Gonadotropin-releasing hormone(GnRH)

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The release of Gonadotropin-releasing hormone(GnRH) triggers anterior pituitary to release _____and ____ which initiate the production of androgen and estrogen

FSH

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Male around ______ & Female around ______

12-14yrs old

9-12 yrs old

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Are a group of hormones that play a role in male traits and reproductive activity. Both present in male and female. It is responsible for muscular development, physical growth, and increase in sebaceous gland secretions

Androgens

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Androgens are produced by the ______, and the _______

adrenal cortex

testes or ovaries

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In male, specific function of androgen is further development of _____, _______ , ______, _____, and _______. Also for the appearance of _____, _____, and ______, _______ enlargement , maturation of ________, and closure of growth in ______

testes
scrotum
penis
prostate
seminal vesicles
pubic
axillary
facial hair
laryngeal enlargement
spermatozoa
long bones

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In female, ________ influences enlargement of labia majora and clitoris, formation of axillary and pubic hair termed as _______

testosterone

adrenarche

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Estrogen is triggered at puberty of ____

FSH

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Estrogen contains 3 compounds _____,

(Estrone or E1, Estradiol or E2, Estriol or E3)

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Influences development of uterus, fallopian tubes and vagina; female fat distribution, hair patterns, breast development, and closure of long bones

Estrogen

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Beginning of breast development

Thelarche

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First menstrual period

Menarche

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Arrange the typical pubertal changes of female in order.
Onset of Menstruation 
Growth of pubic hair 
Growth of axillary hair
Vaginal Secretions
Growth of Spurt
Breast Development
Increase in the transverse diameter of the pelvis

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Arrange the typical pubertal changes of male in order
Penile growth
Growth of face, axillary, and pubic hair
Voice changes
Increase in weight
Growth of testes
Spermatogenesis (production of sperm)
Increase in height

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Study of female reproductive organs

Gynecology

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Study of male reproductive organs

Andrology

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Rugated, skin-covered, muscular pouch suspended from the perineum. Support the testes and to help regulate the temperature of sperm

Scrotum

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Two ovoid glands, 2 to 3 cm wide, that lie in the scrotum

Testes

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Each testis is encased by a protective white fibrous capsule and is composed of several lobules, with each lobule containing _________ and a ________

interstitial cells (Leydig’s cells) 
seminiferous tubule

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Are responsible for production of testosterone

Leydig’s cells

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Responsible for release of androgen-binding protein which promotes sperm formation

FSH

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LH responsible for release of _________

testosterone

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Usually, the ______ is slightly larger and suspended slightly lower than the other

left testis

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Penis
-composed of three cylindrical masses of _________ in the penis shaft: two termed the ________ , and a third termed the _________

erectile tissue
corpus cavernosa
corpus spongiosum

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Is released by endothelium during sexual excitement which results in dilation of blood vessels and increase blood flow.

Nitric Oxide

Outlet for both the urinary and the reproductive tract

Penis

When the Nitric oxide is released, the _________ at the base of the penis then contracts, trapping both venous and arterial blood

ischiocavernosus muscle

Penile erection is stimulated by __________

parasympathetic nerve innervations

Bulging,sensitive ridge of tissue at the distal end of penis which is protected by Prepuce(retractable casing of skin)

Glans

Tightly coiled tube. Responsible for conducting sperm from the tubule to the vas deferens

Epididymis

Epididymis is ___ long

-Over 20ft long

Some sperm are stored in the epididymis, and a portion of the______ that will surround sperm at maturity

alkaline fluid

Semen, or seminal fluid that contains a ______ and _____, a form of protein

basic sugar | mucin

Is produced by the cells lining the epididymis

Semen or seminal fluid

It takes at least ______for them to travel the length of the epididymis and a total of _____ for them to reach maturity

12 to 20 days | 64 days

Absence of sperm

aspermia

<20 million sperm/mL

oligospermia

Hollow tube surrounded by arteries and veins and protected by a thick fibrous coating

Vas deferense (Ductus deferens)

Vas deferens carries sperm from the epididymis through the _______ into the abdominal cavity, where it ends at the seminal vesicles and the ejaculatory ducts

inguinal canal

Sperm mature as they pass through the _______

vas deferens

The blood vessels and vas deferens together are referred to as the __________

spermatic cord

Sperm are still not mobile at this point (as they pass through the vas deferens, however, probably because of the _____________ produced at this level

fairly acidic medium of the semen

Varicosity of the internal spermatic vein

varicocele

Severing of the vas deferens to prevent passage of sperm

Vasectomy

Two convoluted pouches that lie along the lower portion of the posterior surface of the bladder and empty into the urethra by way of the ejaculatory ducts

Seminal Vesicles

Seminal Vesicles secrete a viscous alkaline liquid that has a ______, _____, and _______

high sugar protein prostaglandin content

Sperm become increasingly motile with this added fluid, because it surrounds them with nutrients and a more favorable pH

Secreted viscous alkaline liquid of seminal vesicle

The two _______ pass through the prostate gland and join the seminal vesicles to the urethra

Ejaculatory ducts

- chestnut-sized gland that lies just below the bladder - The urethra passes through the center of it, like the hole in a doughnut - secretes a thin, alkaline fluid - alkaline fluid further protects sperm from being immobilized by the naturally low pH level of the urethra

Prostate Gland

- Cowper’s glands - lie beside the prostate gland and empty via short ducts into the urethra - secrete an alkaline fluid that helps counteract the acid secretion of the urethra and ensure the safe passage of spermatozoa

Bulbourethral glands

Semen, therefore, is derived from the ______ (60%), the ______ (30%), the ______ (5%), and the _______ (5%).

prostate gland seminal vesicles epididymis bulbourethral glands

Hollow tube leading from the base of the bladder, which, after passing through the prostate gland, continues to the outside through the shaft and glans of the penis

Urethra

Urethra is approximately _______ long

8 in (18 to 20 cm)

Urethra is lined with ____________

mucous membrane

Female External Structures- Female external genitalia. _____ which means covering

Vulva

- pad of adipose tissure over the symphysis pubis - covered by a triangle of coarse, curly hairs - protects the junction of pubic bone from trauma

Mons Veneris

- posterior to the mons veneris - two hairless folds of connective tissue - firm and full in childbearing age and atrophies on menopause - normally pink in color - internal surface is covered with mucous membrane and the external surface with skin - abundant with sebaceous glands

Labia Minora

- two folds of adipose tissue covered by loose connective tissue and epithelium - lateral to the labia minora - covered with pubic hair - serve as protection for the external genitalia and distal urethra and vagina - fused ______ but separated ______

Labia Majora anteriorly posteriorly

- flattened, smooth surface inside the labia | - urethra and vagina both arises on this organ

Vestibule

- small (approximately 1 to 2 cm), rounded organ of erectile tissue at the forward junction of the labia minora - covered by prepuce - sensitive to touch and temperature and is the center for sexual arousal and orgasm - rich in arterial blood supply

Clitoris

- lateral to the urinary meatus, one on each side - their ducts open into the urethra - help to lubricate the external genitalia during coitus - the alkaline pH of their secretions helps to improve sperm survival in the vagina

Skene’s glands (paraurethral glands)

- lateral to the vaginal opening on both sides - their ducts open into the distal vagina - help to lubricate the external genitalia during coitus - the alkaline pH of their secretions helps to improve sperm survival in the vagina

Bartholin’s glands (vulvovaginal glands)

- ridge of tissue formed by the posterior joining of the two labia minora and the labia majora - sometimes cut (episiotomy) during childbirth to enlarge the vaginal opening

Fourchette

- posterior to fourchette - easily stretched during childbirth to allow for enlargement of the vagina and passage of the fetal head - Kegel’s exercise makes this organ flexible

Perineal muscle or the Perineal body

- tough but elastic semicircle of tissue that covers the opening to the vagina in childhood - often torn during the first time of sexual intercourse

Hymen

Complete hymen that does not allow for passage of menstrual blood from the vagina or for sexual relations until it is surgically incised

Imperforate hymen

The blood supply of the external genitalia is mainly from the pudendal artery and a portion of the inferior rectus artery.

Vulvar Blood Supply

Venous return is through the ___________

pudendal vein

The anterior portion of the vulva derives its nerve supply from the ______ and ________ The posterior portions of the vulva and vagina are supplied by the _________.

``` ilioinguinal genitofemoral nerves (L1 level). pudendal nerve (S3 level) ```

- approximately 4 cm long by 2 cm in diameter and approximately 1.5 cm thick, or the size and shape of almond - grayish white and appear pitted, or with minute indentations on the surface - located close to and on both sides of the uterus in the lower abdomen

Ovaries

Ovaries produce, mature, and discharge _______

ova (the egg cells)

- produce estrogen and progesterone and initiate and regulate menstrual cycles - necessary for maturation and maintenance of secondary sex characteristics in females - held suspended and in close contact with the ends of the fallopian tubes by three strong supporting ligaments attached to the uterus or the pelvic wall - not covered by the peritoneum

ovaries

Principal divisions of ovaries: 1. Protective layer of surface _______ 2. _________ , where the immature (primordial) oocytes mature into ova and large amounts of estrogen and progesterone are produced 3. _________, which contains the nerves, blood vessels, lymphatic tissue, and some smooth muscle tissue

epithelium Cortex Central medulla

Division of Gametes (Reproductive cells) - At birth, each ovary contains approximately _______________, which formed during 5 mos of intrauterine life - __________ differ in other body cells in the number of chromosomes which contains only half the usual number of chromosomes - oocytes divide in _________ by mitosis which halt until puberty when meiosis occurs - in male, meiosis(reduction division) occurs just before the ________, while in female, in occurs just _________

``` 2 million immature ova reproductive cells intrauterine life spermatozoa mature before ovulation ```

Maturation of Oocytes - Each oocyte lies in the ovary surrounded by a protective sac, or thin layer of cells, called a _________ - 5 and 7 million ova form in ____. The majority never develop beyond the primitive state and actually atrophy, so that by birth only 2 million are present. - By age ____, only approximately 500,000 are present in each ovary - by ____, there are approximately 300,000; and - by ____, none are left (all have either matured or atrophied). “The point at which no functioning oocytes remain in the ovaries” is one definition of menopause

``` primordial follicle utero 7 years 22 years menopause ```

- arise from each upper corner of the uterine body and extend outward and backward until each opens at its distal end, next to an ovary - approximately 10 cm long in a mature woman - Their function is to convey the ovum from the ovaries to the uterus and to provide a place for fertilization of the ovum by sperm - smooth, hollow tunnel - composed of mucous membrane with cilia, connective tissue and muscular layer(circular)

Fallopian Tubes

The mucus in fallopian tube contains _____, ______, and _____ which help in nourishment of the ovum

water protein salt

Four parts of a fallopian tube: | proximal to uterine wall, 1 cm in length and its lumen is about 1mm in diameter

Interstitial portion

Four parts of a fallopian tube: | extremely narrow, 2 cm in length, cut or sealed in tubal ligation

Isthmus

Four parts of a fallopian tube: | longest portion approx 5cm and this is where fertilization occurs

Ampulla

Four parts of a fallopian tube: most distal, approx 2cm and is funnel shaped, the rim is covered by fimbria(small hairs) which help to guide ovum to fallopian tube

Infundibular

- hollow, muscular, pear-shaped organ - located in the lower pelvis, posterios to the urinary bladder, and anterior to the rectum - size of an olive in childhood - receives ovum from the fallopian tube, and site of implantation and nourishment, protection, and maturity of a growing fetus, and expel it from the woman’s body

Uterus

Uterus begins to increase at ________ up to _______

8yrs of age | 17 yrs of age

Uterus us approx ____ long, ____ wide in upper part and ____ deep. ___ in nonpregnant state In a woman who has a borne child, it is approx ___ long, ____ wide, ____ thick, and ____ in weight

5-7cm 5cm 2.5cm 60g 9cm 6cm 3cm 80g

Uterus is consist of _____, ____ and _____

body, isthmus, and cervix

Uppermost and forms bulk of the organ. | Enlarges during pregnancy

Body

Portion between the points of attachment of fallopian tubes. Can be palpated to determine uterine growth, measure contraction

Fundus

Short segment between the body and cervix, 1-2mm in length, enlarges during pregnancy, and most commonly cut during cesarean birth

Isthmus

Lowest portion, approx 1/3 of uterus size, approx 2-5cm long | -approx half of it lies above the vagine, and half of it extends into the vagina

Cervix

Central cavity

- cervical canal

Opening of the canal at junction of cervix & isthmus

Internal cervical os

Opening of the canal at junction of distal opening to vagina, the level of ischial spines

External cervical os

Uterine and Cervical Coats - Important for menstrual function - shed when pregnancy does not occur as menstrual flow

Endometrium

Endometrium is formed by two layers of cells, ______ (not influenced by hormone) and inner _______(influenced by estrogen and progesterone)

basal layer | glandular layer

Mucous lining of the cervix, affected by hormones - secretes mucus to lubricate surface for sperm passing through cervix - when estrogen is at its peak, about ____ mucus is produced per day

Endocervix | 700mL

The mucus secreted by the endocervix is ______

alkaline

Endocervix becomes plugged during ________ to keep ascending infections

pregnancy

Are not lined with mucous membrane but with stratified squamous epithelium and location for obtaining Papanicolaou smear

Lower surface of cervix

- muscle layer - composed of fibers arranged in longitudinal, transverse, and oblique directions - provides extreme strength to the organ

Myometrium

Adds strength and support to the organ

Perineum-

Uterine blood supply | -large descending abdominal aorta divides to two _____, main divisions of these are the _______

iliac arteries | hypogastric arteries

Uterine nerve supply | The uterus is supplied by both ______ and _______

efferent (motor) | afferent (sensory) nerves

The efferent nerves that supply the uterus arise from the ___ through ____

T5 | T10 spinal ganglia

The afferent nerves join the ______and enter the spinal column at ___and ____

hypogastric plexus | T11 T12

``` Uterine deviations (shape and position) Oddly shaped “horns” in junction of the fallopian tubes ```

Bicornuate uterus

``` Uterine deviations (shape and position) Fundus is tipped forward ```

Anteversion

``` Uterine deviations (shape and position) Fundus is tipped back ```

Retroversion

``` Uterine deviations (shape and position) Body of uterus is bent sharply forward at junction with cervix ```

Anteflexion

``` Uterine deviations (shape and position) Body of uterus is bent sharply back just above the cervix ```

Retroflexion

Suspended in the pelvic cavity by several ligaments that also help support the bladder and is further supported by a combination of fascia and muscle

Uterine support

herniated bladder in anterior wall of vagina

Cystocele

herniated rectum in posterior wall of vagina

Rectocele

The anterior wall of the vagina is about _____ and posterior wall is around _____

7-6cm | 8-9cm

The vagina has both sympathetic and parasympathetic nerve innervations originating at the _____ to _______

S1 | S3 levels

The mucus produced by the vaginal lining has a rich _____ which is broken down by the lactose-fermenting bacteria that frequent the vagina (Döderlein’s bacillus), and lactic acid is formed

glycogen content

Recesses at the side of the cervix. Anterior, posterior(place for pooling of semen), and lateral sides

Fornix

Breasts or mammary glands are located __________ and extends well into the axilla

anterior to the pectoral muscle

Milk glands of the breasts are divided by connective tissue partitions into approximately ______.

20 lobes

All of the glands in each lobe produce milk by ________ and deliver it to the nipple via a ________

acinar cells | lactiferous duct

A _____ is composed of smooth muscle that is capable of erection on manual or sucking stimulation

nipple

Acts to constrict milk gland cells and push milk forward into the ducts that lead to the nipple

Oxytocin

Areola: darkly pigmentation around nipples which contains many sebaceous glands, called ________

Montgomery’s tubercles

Although not a part of the female reproductive system but of the skeletal system, it is a very important body part of pregnant women.

Pelvis

A. Structure of Pelvis | Two os coxae/innominate bones made up of:

Ilium Ischium Pubes

Upper extended part; curved upper border is the _______.

Ilium | iliac crest

Under part; when sitting, the body rests on the ischial tuberosities; ______are important landmarks.

Ischium | ischial spines

Front part; join to form an articulation of the pelvis called the ________

Pubes | symphysis pubis.

Wedge-shaped, forms the back part of the pelvis. Consists of 5 fused vertebrae, the first having a prominent upper margin called the __________

Sacrum | sacral promontory.

Lowest part of the spine;

Coccyx

Degree of movement between sacrum and coccyx made possible by the third articulation of the pelvis called _________ which allows room for delivery of the fetal head.

sacroccygeal joint

B. Divisions – set apart by the _______, an imaginary line from the sacral promontory to the ilia on both sides to the superior portion of the symphysis pubis.

linea terminalis

Superior half formed by the ilia. Offers landmarks for pelvic measurements; supports the growing uterus during pregnancy; and directs the fetus into the true pelvis near the end of gestation.

False pelvis

Inferior half formed by the pubes in front, the iliac and the Ischia on the sides and the sacrum and coccyx behind.

True pelvis

The true pelvis is made up of three parts:

Inlet Cavity Outlet

Entranceway to the true pelvis. Its transverse diameter is wider than its anterosposteior diameter.

Inlet

The measurements of inlet Transverse diameter = . Anteroposterior diameter (AP) = . Right and left oblique diameter = .

13.5 cm 11 cm 12.75 cm

Space between the inlet and the outlet. Contains the bladder and the rectum, with the uterus between them in an anteflexed position towards the bladder.

Cavity

Inferior portion of the pelvis, bounded on the back by the coccyx, on the sides by the ischial tuberosities and in front by the inferior aspect of the symphysis pubis and the pubic arch. Its _____ diameter is wider than its _______.

Outlet AP transverse diameter

“normal” female pelvis. Inlet is well rounded forward and back. Most ideal for childbirth.

Gynecoid

transverse diameter is narrow, AP diameter is lager than normal.

Anthropoid

inlet is oval, AP diameter is shallow

Platypelloid

“male” pelvis. Intel has a narrow, shallow posterior portion and pointed anterior portion.

Android

Distance between the middle points of the iliac crests. Average = ____.

Intercristal diameter | 28 cm

Distance between the anterosuperior iliac spines. Average = _____.

Interspinous diameter | 25 cm

Distance between the trochanters of the | femur. Average = _____

Intertrochanteric diameter | 31 cm

Distance between the anterior aspect of the symphysis pubis and depression below L5. Average = ______

External conjugate/Baudelocque’s diameter | 18-20cm

Suggestive only of pelvic size:

External

Give the actual diameters of the inlet and outlet

Internal

Distance between the sacral promontory and inferior margin of the symphysis pubis. Average = _____ Important measurement because it is the diameter of the pelvic inlet. Average = ________.

Diagonal conjugate 12. 5 cm. 10. 5 – 11 cm

Transverse diameter of the pelvic outlet. Is measured at the level of the anus. Average = ____.

Bi-ischial diameter/tuberischii | 11 cm

Episodic uterine bleeding in response to cyclic hormonal changes

Menstruation

Temporary cessation of menstrual flow.

Amenorrhea

Markedly diminished menstrual flow, nearing amenorrhea

Oligomenorrhea

Excessive bleeding during regular menstruation.

Menorrhagia

Bleeding at completely irregular intervals.

Metrorhagia

Frequent menstruation occurring at intervals of less than 3 weeks.

Polymenorrhea

Markedly diminished menstrual flow.

Oligomenorrhea

Physiology of Menstruation Four body structures are involved in the physiology of the menstrual cycle: the _______, the ______, the _____, and the ______.

hypothalamus pituitary gland ovaries uterus

Hormones which regulate cyclic activites - ____ and ____

FSH and LH

Effects of _____ in the body | -Inhibits production of FSH

estrogen

Effects of ______ in the body | -Inhibits production of LH

progesterone

-Stimulates growth of the ductile structures of the breasts.

estrogen

-Causes hypertrophy of the myometrium

estrogen

Effects of ______ in the body -Increases body temperature after ovulation. Just before ovulation basal body temperature decreases slightly (because of low ______ level in the blood) and then increases slightly a day after ovulation (because of the presence of ________)

progesterone

Effects of ______ in the body - Increases endomentrial tortuosity - Increases endometrial secretions - Inhibits uterine motility

progesterone

Effects of ______ in the body -Increases quantity and pH of cervical mucus, causing it to become thin and watery and can be stretched to a distance of ____cm. (Spinnbarkheit test of ovulation).

estrogen | 10-13

Effects of ______ in the body | -Decreases muscle tone of gastrointestinal and urinary tracts

progesterone

Effects of ______ in the body | -Increases musculoskeletal motility

progesterone

Effects of ______ in the body | -Facilitates transport of the fertilized ovum through the Fallopian tubes

progesterone

Effects of ______ in the body - Decreases renal threshold of lactose and dextrose - Increases fibrinogen levels; decreases hemoglobin and hematocrit

progesterone

Sequential steps of the menstrual cycle 1. On the third day of the menstrual cycle, serum _____ is at its lowest. This low level serves as the stimulus for the hypothalamus to produce the ______.

estrogen level | Follicle-Stimulating Hormone Releasing Factor (FSHRF)

Sequential steps of the menstrual cycle 2. FSHRF is the one responsible for stimulating the _______ to produce the first of two hormones which regulate cyclic activities, the Follicle-Stimulating Hormone (FSH).

Anterior Pituitary Gland (APG)

Sequential steps of the menstrual cycle 3. FSH, in turn, will stimulate the growth of an ________ inside a primordial follicle by stimulating production of _____ by the ovary.

immature oocytes | estrogen

Sequential steps of the menstrual cycle 3. Once estrogen is produced, the primordial follicle is now termed as ______, therefore, is the structure which contains high amounts of estrogen).

Graafian follicle (The Graafian follicle)

4.________ will cause the cells in the uterine endothelium to proliferate (grow very rapidly), thereby increasing its thickness to about eightfold. This particular phase in the uterine cycle, therefore, is called _______.

Estrogen in the Graafian follicle | proliferative phase

In view of the change from primordial to Graafian follicle, it is also called _____. Because of the predominance of estrogen, it is also called the _______. And since it comes right after the menstrual period, it is also called ________. And it is also called the ________.

follicular phase estrogenic phase postmenstrual phase pre-ovulatory phase

5. On the ____ of the menstrual cycle, there is now a very low level of _______ in the blood. This low serum level is the stimulus for the Hypothalamus to produce the _________

13th day progesterone Luteinzing Hormone Releasing Factor (LHRF).

6. LHRF is responsible for stimulating the APG to produce the second hormone which regulates cyclic activity, the ________.

Luteininzing Hormone (LH)

7. The LH, in turn, is responsible for stimulating the ovary to produce the second hormone produced by the ovaries, _______.

progesterone

8. The increased amounts of both estrogen and progesterone push the _________ to the surface of the ovary until, on the following day (the 14 th day of the menstrual cycle)

new mature ovum

On the following day (the 14 th day of the menstrual cycle), the Graafian follicle ruptures and releases the mature ovum, a process called _______.

ovulation

9. Once ovulation has taken place, the Graafian follicle, because it now contains increasing amounts of ______, giving it its yellowish appearance, is termed ______.

progesterone | Corpus Luteum

The structure which contains high amounts of progesterone is the

Corpus Luteum

10. Progesterone causes the glands of the uterine endothelium to become corkscrew or twisted in appearance because of the increasing amount of ___________.

capillaries

________, therefore, is said to be the hormone designed to promote pregnancy because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place, that is why this phase in the uterine cycle is what we call __________.

Progesterone | progestational phase

Progestational phase in the uterine cycle is also called _________ because it secretes the most important hormone in pregnancy.

secretory phase

In view of the change from Graafian follicle to corpus Luteum, it is called ______ . Because it occurs just after ovulation, it is also called the_______. And, it is also called the _____

luteal phase post-ovulatory phase pre-menstrual phase.

11. Up until the _____ of the menstrual cycle, if the mature ovum is not fertilized by a sperm, the amounts of hormones in the corpus Luteum will start to decrease.

24 th day

The corpus Luteum turning white is now called the _______ and in 3-4 days, the thickened lining of the uterus produced by _____ starts to degenerate and slough off and capillaries rupture. And thus begins another _____.

corpus albicans estrogen menstrual period

When the ovary releases the mature ovum on the day of ovulation, sometimes a certain degree of pain in either the _______ is felt by the woman. This sensation is normal and termed ______.

right or left lower quadrants | mittelschmerz

The first 14 days of the menstrual cycle is a very ______ period. The last 14 days of the menstrual cycle is a ____ period

variable | fixed

Exactly _____ after ovulation, menstruation will occur (unless a pregnancy has taken place) because the ______ has only this length of life span .

2 weeks | corpus Luteum

In a 28-day cycle, ovulation takes place on the 14th day. In a 32-day cycle, ovulation takes place on the 18 thday. In a 26-day cycle, ovulation takes place on the 12 th day (Subtract ____ from the cycle).

14 days

Menstruation does not occur during pregnancy because _____ does not decrease in amount. Corpus ______continues to produce progesterone until the placenta takes over production of hormones by the_______of pregnancy.

progesterone Luteum 8 th week

Menstruation can occur even _____ (as in women taking oral contraceptives). Ovulation can likewise occur even ______

``` without ovulation without menstruation (as in lactating mothers). ```

Sexual Response Cycle | Occurs with physical and psychological stimulation

Excitement

Excitement - Vaginal _____ and ______ of genitalia - Penile erection due to ______

lubrication vasocongestion vasocongestion

Before orgasm - In woman, ______ is draw on forward and retracts under ______, ______ becomes congested and increased ____ elevation - Formation of orgasmic platform due to prominent _____ - Generalized ______, ______, ______, ______ in the late plateau phase. - __________ with live spermatozoa

``` Plateau clirotis clitoral prepuce lower part of the vagina nipple vasocongestion ``` muscle tension hyperventilation increased BP tachycardia Pre-ejaculatory phase

When body suddenly discharges accumulated sexual tension shortest stage in sexual cycle intense pleasure affecting the body -vigorous contraction of muscles in the _____ and ____ from the area of congestion - ______ in woman -In men, contractions project semen into the ______ followed by ________ contractions

``` Orgasm pelvic area expels blood fluid 8-15 contractions (one every 0.8sec) proximal urethra three to seven propulsive ejaculatory ```

External and internal genitalia return to an unaroused state

Resolution

Only in males; the period during which no amount of stimulation can cause another erection. Not manifested in females because females are multi- orgasmic. This phase lengthens with age.

Refractory phase

Abstinence from sexual activity

Celibacy

Self-stimulation for erotic pleasure

Masturbation

Use of visual materials such as magazines or photographs for sexual arousals

Erotic stimulation

Sexual arousal resulting from the use of certain objects or situations

Fetishism

An individual who dresses to take on the role of the opposite sex

Transvestism

Obtaining sexual arousal by looking at other’s person’s body

Voyeurism

Involves inflicting pain (sadism) or receiveing pain (masochism)

Sadomasochism

Revealing one’s genitals in public

Exhibitionism

Individuals who are interested in sexual encounters with children

Pedophiles

PREGNANCY AND PRENATAL CARE | Definition: the union of the sperm and the mature ovum in the outer third or outer half of the Fallopian tube.

I. FERTILIZATION

Fertilization General considerations 1. Normal amount of semen per ejaculation = ______

3-5 cc. = 1 teaspoon.

Fertilization | 2. Number of sperms in an ejaculate = _____

120-150 million/cc

Fertilization 3. Mature ovum is capable of being fertilized for_______ after ovulation. Sperms are capable of fertilizing even for _____ after ejaculation.

12-24 hours | 3-4 days

Fertilization | 4. Normal life span of sperms = ______

7 days

Fertilization | 5. Sperms, once deposited in the vagina, will generally reach the cervix within _____ after deposition.

90 seconds

Fertilization 6. Reproductive cells, during ______, divide by meiosis (haploid umber of daughter cells); therefore, they contain only 23 chromosomes (the rest of the body cells contain 46 chromosomes).

gametogenosis

Sperms have 22 autosomes and 1 X sex chromosome or 1 Y sex chromosome. The union of an X-carrying sperm and mature ovum results in a ______; the union of a Y-carrying sperm and a mature ovum results in a _____. Important: Only _____, therefore, determine the sex of their children.

``` baby girl (XX) baby boy (XY) fathers ```

II. IMPLANTATION - Implementation after fertilization, the fertilization ovum or zygote stays in the ______ for 3 days, during which time rapid cell division (mitosis) is taking place.

Fallopian tube

II. IMPLANTATION | The developing cells are now called ______ and when there are already about 16 blastomeres, it is now termed a ____.

blastomere | morula

In this morula for, it will start to ravel (by ciliary action and peristaltic contractions of the Fallopian tube) to the _____ where it will stay for another 3-4 days.

uterus

When there is already a cavity formed in the morula, it is now called a _____.

blastocyst

Fingerlike projections, called ______ (Table 4), form around the blastocyst

trophoblasts

Are the ones which will implant high on the anterior or posterior surface of the uterus. Thus, implantation, also called ______, takes place about a week after fertilization.

trophoblasts | nidation

II. IMPLANTATION General Considerations: 1. Once implantation has taken place, the uterine endothelium is now termed _____.

decidua

2. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the _________ = implantation bleeding. Implication: this should not be mistaken for the Last Menstrual Period (LMP)

implanting trophoblasts

III. STAGES OF HUMAN PRENATAL DEVELOPMENT A. First 12-14 days = _____ B. From 15th day up to the 8th week = ____ C. From 8th week up to the time of birth = _____ D. Developing embryo or fetus and placental structures throughout pregnancy- _____

zygote embryo fetus Conceptus

III. STAGES OF HUMAN PRENATAL DEVELOPMENT | The inner layer.

Cytotrophoblast

III. STAGES OF HUMAN PRENATAL DEVELOPMENT | The outer layer containing fingerlike projections called chorionic villi

Syncytiotrophoblast

Chorionic villi which differentiate into:

Langhan’s layer | Syncytial layer

believed to protect the fetus against Treponema Pallidum (etiologic agent of syphilis). Present only during the _________ of pregnancy.

Langhan’s layer | second trimester

gives rise to the fetal membranes:

Syncytial layer

Syncytial layer gives rise to the fetal membranes:

Amnion | Chorion

Inner membrane which gives rise to Umbilical cord/funis Amniotic fluid

Amnion

Contains two arteries and one vein, which are supported by the Wharton’s jelly.

Umbilical cord/funis

- Clear, albuminous fluid in which the baby floats. - Begins to form at _______. - Approximates water in specific gravity ______and is neutral to slightly alkaline _____ Note: the higher the pH, the more alkaline; the lower the pH, the more acidic

Amniotic fluid 11-15 weeks gestation (1.007-1.025) (pH = 7.0-7.25).

-Near term is clear, colorless, containing little white specks of vernix caseosa and other solid particles.

Amniotic fluid

Amniotic fluid is produced at a rate of ____ in 24 hours and fetus swallows it at an equally rapid rate.

500 ml

By the 4th lunar month, _____ is added to the amount of amniotic fluid.

urine

Amniotic fluid, therefore, is derived chiefly from _________ and ________.

maternal serum | fetal urine

Is the excessive accumulation of amniotic fluid — the fluid that surrounds the baby in the uterus during pregnancy.

Polyhydramnios

Implication: a case of polyhydramnios (=more than ________ of amniotic fluid) stems from the inability of the fetus to swallow amniotic rapidly, as in tracheoesophageal fistula;

1500 ml

- Amniotic fluid less than 500 ml | - is due to the inability of the kidneys to add urine to the amniotic fluid, as in congenital renal anomaly.

Oligohydramnios

Amniotic fluid also known as __________,

bag of water (BOW)

Amniotic fluid serves the following purposes:

Protestion | Diagnosis

Shields the fetus against blows or pressures on the mother’s abdomen; against sudden changes in temperature because liquid changes temperature more slowly than air; and from infections

Protestion

As in amniocentesis; meconium-stained amniotic fluid means fetal distress

Diagnosis

Aids in descent of the fetus during active labor

Amniotic fluid

Is a procedure in which amniotic fluid is removed from the uterus for testing or treatment

amniocentesis

meconium-stained amniotic fluid means ________

fetal distress

Together with the deciduas basalis, gives rise to the placenta, which starts to form at 8th week gestation.

Chorion

Chorion develops into ____________ call cotyledons.

15-20 subdivisions

Respiratory system – exchange of gases takes place in the _______, not in the fetal lungs

Placenta

Renal system – waste products are being excreted through the ________

placenta

In pregnancy: it is the ______ which detoxifies the fetal waste products

mother's liver

Gastrointestinal system nutrients pass to the fetus via the placenta by ________ through the placental tissues

diffusion

Placenta serves the following purposes: Circulatory system – __________ is established by selective osmosis

feto-placental circulation

Placenta serves the following purposes: Endocrine system – it produces the following important hormones (before 8 weeks gestation, the _________ is the one producing these hormones):

corpus luteum

Placenta serves the following purposes: “orders” the corpus luteum to keep on producing estrogen and progesterone, that is why menstruation does not take place during pregnancy.

Human chorionic gonadotropin (HCG)

– promotes growth of mammary glands necessary for lactation. Also has growth-stimulating properties

Human placental lactogen (HPL) or human chorionic somatomammotropin

– promotes growth of mammary glands necessary for lactation. Also has growth-stimulating properties

Human placental lactogen (HPL) or human chorionic somatomammotropin

Serves the following purposes: Estrogen and Progesterone Protective barrier – inhibits the passage of same bacteria and large molecules

Placenta

FETAL DEVELOPMENT First Lunar Month 1. Germ layers differentiat by the _______: (in cases of multiple congenital anomalies, the structures that will be affected are those that arise out of the same germ layer).

2nd week

FETAL DEVELOPMENT – develops into the lining of the GIT, the respiratory tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of immunity), bladder and urethra

Endoderm

FETAL DEVELOPMENT – forms into the supporting structures of the body (connective tissues, cartilagem muscles and tendons); heart, circulatory system, blood cells, reproductive system, kidneys and ureters

Mesoderm

FETAL DEVELOPMENT - responsible for the formation of the nervous system, the skin, hair and nails, and the mucous membrane of the anus and mouth.

Ectoderm

Fetal Development | 2. _____________ appear by the second week.

Fetal membranes (amnion and chorion)

Fetal Development 3. ___________ very rapidly develops by the 3rd week. (Dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, _______ stores of the mother are depleted, thus causing hypoglycemia in the latter).

Nervous system | glucose

Fetal development | 4. Fetal heart begins to form as early as the __________

16th day of life

“When does the fetal heart begin to beat?”, the answer is ________.

first lunar month

But to the question, “When can fetal heart tones to first heard?” the answer is __________

fifth month

Fetal Development | 5. The ________ and __________ exist as a single tube until the 3rd week of life when they start to separate.

digestive | respiratory tracts

Fetal Development Second Lunar Month 1. All vital organs are formed by the _______; placenta develops fully

8th week

Fetal development | 2. Are formed by the 8th week. (To the question, “When is sex determined?” the answer is “At the time of conception”).

Sex organs (ovaries and testes)

Fetal Development | 3. __________ are formed in the instestines by the 5th – 8th week.

Meconium (first stools)

Fetal development Third Lunar Month 1. Kidneys are able to function – urine is formed by the ______.

12th week

What month in Fetal development does this happen Buds of milk teeth form

Third lunar Month

What month in Fetal development does the beginning bone ossification

Third Lunar Month

What month in Fetal development does the | fetus swallows amniotic fluid

Third Lunar Month

What month in Fetal development does the | Feto-placental circulation is established by selective osmosis; no direct exchange between fetal and maternal blood.

Third Lunar Month

What month in Fetal development does the Lanugo appears | .

Fourth Lunar Month

What month in Fetal development does the Buds of permanent teeth form.

Fourth Lunar Month

What month in Fetal development does the Heart beats maybe audible with fetoscope

Fourth Lunar Month

What month in Fetal development does the Vernix caseosa appears

Fifth Lunar Month

What month in Fetal development does the Lanugo covers entire body

Fifth Lunar Month

What month in Fetal development does the | Quickening (fetal movements) felt

Fifth Lunar Month

What month in Fetal development does the | Fetal heart beats very audible

Fifth Lunar Month

What month in Fetal development does the Skin markedly wrinkled

Sixth Lunar Month

What month in Fetal development does the Attains proportions of fullterm baby

Sixth Lunar Month

What month in Fetal development does the alveoli begin to form (28th weeks of gestation is said to be the lower limit of prematurity because if baby is delivered at this time, will cry and breathe but usually dies)

Seventh Lunar Month

What month in Fetal development does the Fetus is viable

Eighth Lunar Month

What month in Fetal development does the Lanugo begins to disappear

Eight Lunar Month

What month in Fetal development does the Nails extend to ends of fingers

Eight Lunar Month

What month in Fetal development does the | Subcutaneous fat deposition begins

Eight Lunar Month

What month in Fetal development does the Lanugo and vernix disappear

Ninth Lunar Month

What month in Fetal development does the Amniotic fluid volume somewhat decreases

Ninth Lunar Month

What month in Fetal development does the – all characteristics of the normal newborn

Tenth Lunar Month

FOCUS OF FETAL DEVELOPMENT | Period of organogenesis

First trimester –

Period of continued fetal growth and development; rapid increase in fetal length

Second trimester

Period of most rapid growth and development because of rapid deposition of subcutaneous fat

Third trimester

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 1. Circulatory/Cardiovascular - Beginning the end of the first trimester there is a Gradual increase of about ________ reaching its peak during the 6th month.

30% - 50% in the total cardiac volume,

The increase in the total cardiac volume causes a drop in _________ and _________ since the increase is only in the plasma volume = physiologic anemia of pregnancy.

hemoglobin | hematocrit values

Consequences of increased total cardiac volume are: Easily fatigability and shortness of breath because of _____

increased workload of the heart

Consequences of increased total cardiac volume are: | Slight hypertrophy of the heart, causing it to be displaced to the ____, ______________

left | resulting in torsion on the great vessels (the aorta and pulmonary artery).

Consequences of increased total cardiac volume are: | Systolic murmurs are common due to _____________

lowered blood viscosity

Consequences of increased total cardiac volume are: | Nosebleeds may occur because of ___________ as pregnancy progresses.

marked congestion of the nasopharynx

Circulatory/Cardiovascular Palpitations are due to: ____________ stimulation during the first half of pregnancy

Sympathetic nervous system

Circulatory/Cardiovascular Palpitations are due to: Increased pressure of uterus against the diaphragm during __________

Second half of pregnancy

Circulatory/Cardiovascular - Because of poor circulation resulting from pressure of the gravid uterus on the ____________: • __________ occurs. Management legs above hip level. Important: Edema of the lower extremities is normal during pregnancy; it is not a sign of toxemia • _________ can also occur. Management: o Use/wear support hose or elastic stockings to promote venous flow, thus preventing stasis in lower extremities o Apply elastic bandage – start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap toes so as to be able to determine adequacy of circulation (Principle behind bandaging: blod flow through tissues is decreased by applying excessive pressure on blood vessels) o Avoid use of constricting garters, e.g., knee-high socks

blood vessels of the lower extremities Edema of the lower extremities Varicosities of the lower extremities

Important: ______________ is normal during pregnancy; it is not a sign of toxemia

Edema of the lower extremities

Management of varicosities of the lower extremities: o Use/wear _____________ to promote venous flow, thus preventing stasis in lower extremities o Apply ______ – start at the distal end of the extremity and work toward the trunk to avoid congestion and impaired circulation in the distal part; do not wrap ____ so as to be able to determine adequacy of circulation o Avoid use of _______, e.g., knee-high sock

support hose or elastic stockings elastic bandage toes constricting garters

Principle behind bandaging: blood flow through tissues is decreased by _______________)

applying excessive pressure on blood vessels

Circulatory/Cardiovascular - Because of poor circulation in the blood vessels of the genitalia due to the pressure of the gravid uterus, ________ and ______ can occur.

varicosities of the vulva | rectum

Circulatory/Cardiovascular | Management: _______ with hips elevated on pillow and _________.

side-lying position | modified knee-chest position

Circulatory/Cardiovascular - There is increased level of circulating _______, that is why pregnant women are normally safeguarded against undue bleeding. However, this also predisposes them to formation of ___________.

``` fibrogen blood clots (thrombi) ```

The implication is that pregnant women should not be massaged since __________ and cause ________.

blood clots can be released | thromboembolism

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 2. Gastrointestinal changes - Morning sickness – nausea and vomiting during the first trimester is due to increased ___________. It may also be due to increased ______ or even to ______.

human chorionic gonadotropin (HCG) acidity emotional factors

Management morning sickness: Eat ____or ____ 30 minutes before arising in the morning (or ___, ________, _____ and _____ in the diet).

``` dry toast crackers dry high carbohydrate low fat low spices ```

Excessive nausea and vomiting which persists beyond 3 months; results in dehydration, starvation and acidosis.

Hyperemesis gravidarum

Management of Hyperemesis gravidarum : _______ in 24 hours is the priority treatment; complete bed rest is also important.

D 10NSS 300 ml

Constipation and flatulence are due to ____________, thus slowing peristalsis and gastric emptying time. May also be due to increased _____ during pregnancy.

displacement of the stomach and intestines | progesterone

Constipation and flatulence management: | • Increase _____ and ______ in the diet

fluids | roughage

Constipation and flatulence management: • Establish regular ________ • Increase ______ • Avoid _______ • Avoid harsh laxatives like ______; stool softeners, e.g. _____, are better • _______ should not be taken because it interferes with absorption of fat-soluble vitamins.

``` elimination time exercise enemas Dulcolax Colace Mineral oil ```

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 2. Gastrointestinal changes - _______ are due to pressure of enlarged uterus.

Hemorrhoids

Management of hemorrhoids: _____ with witch hazel or Epsom salts.

cold compress

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 2. Gastrointestinal changes - ________, especially during the last trimester, is due to _______ which decreases gastric motility, thereby causing ___________ which lead to ________ contents through the cardiac sphincter into the esophagus, causing irritation.

Heartburn increased progesterone reverse peristaltic waves regurgitation of stomach

``` Management of heartburn: • _______ before meals • Avoid ___, ____foods • Sips of _____ at frequent intervals • Small, frequent meals taken ______ • Bend at the _____, not at the waist • Take ____ (e.g. milk of Magnesia) but never sodium bicarbonate (e.g. Alka Seltzer or baking soda) because it promotes ______. ```

``` Pats or butter fried, fatty milk slowly knees antacids fluid retention ```

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 3. Respiratory changes – ___________ -Causes • Increased oxygen consumption and production of carbon dioxide during the first trimester. • Increased uterine size causes diaphragm to be pushed or displaced, thus crowding the chest cavity. - Management: Lateral expansion of the chest to compensate for shortness of breath increases oxygen supply and vital lung capacity.

shortness of breath

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 3. Respiratory changes causes • Increased oxygen consumption and production of carbon dioxide during the _________.

first trimester

Respiratory changes causes increased _______ causes diaphragm to be pushed or displaced, thus crowding the chest cavity.

uterine size

Management of Respiratory changes: _______ of the chest to compensate for shortness of breath increases oxygen supply and vital lung capacity.

Lateral expansion

The only sign in pregnancy seen during the first trimester disappears during the second and reappears during the third trimester.

Urinary frequency

The urinary frequency in early in pregnancy is due to increased__________ and to the ____________;

blood supply to the kidneys | uterus rising out of the pelvic cavity

The urinary frequency in the last trimester is due to __________ on the bladder, especially with lightning (descent of the fetus into the pelvic brim).

pressure of enlarged uterus

- Decreased renal threshold for sugar due to increased production of ___________ which cause lactose and dextrose to spill into the urine; also an effect of the increased _______.

glucocorticoids | progesterone

It would be difficult to diagnose diabetes in pregnancy based on the urine sample alone because a pregnant women have __________.)

sugar in their urine

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 5. Muscoloskeletal changes - Because of the pregnant woman’s attempt to change her center of gravity, she makes ambulation easier by standing more straight and taller, resulting in a ____________

lordotic position (“pride of pregnancy”)

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 5. Muscoloskeletal changes - Due to increased production of the _________ , pelvic bones become more supple and movable, increasing the incidence of accidental falls due to the _______.

hormone relaxin | wobbly gait

Because of the increased incidence of accidental falls due to wobbly gait. Advise use of low-heeled shoes after the _______

first trimester

5. Muscoloskeletal changes - Leg cramps Causes: • Increased pressure of ______on lower extremities • F______ • C_____ • M____ __________ • Low _____, high _____ intake

``` gravid uterus fatigue chills Muscle tenseness calcium phosphorus ```

Management of Frequent Leg cramps rest periods with ______ • Wear _____, more comfortable clothing • Increase ______ (calcium tablets and diet) • Do not massage – blood clots can cause ______. • Most effective treatment: _____ of the affected leg and ______ the foot.

``` feet elevated warm calcium intake embolism Press knee dorsiflex ```

NORMAL ADAPTATIONS IN PREGNANCY A. Systemic Changes 6. Temperature – slight ______________ due to increased progesterone, but the body adapts after the ____ month

increase in basal temperature | 4th

NORMAL ADAPTATIONS IN PREGNANCY 7. Endocrine changes - Addition of the placenta as an endocrine organ, producing large amounts of ____, ____, ______ and ________.

HCG HPL estrogen progesterone

NORMAL ADAPTATIONS IN PREGNANCY 7. Endocrine changes - Moderate enlargement of the _______ due to hyperplasia of the glandular tissues and increased vascularity. Could also be due to increased _________ to as much as +25% because of the metabolic activity of the products of conception.

thyroid gland | basal metabolic rate

NORMAL ADAPTATIONS IN PREGNANCY 7. Endocrine changes - Increased size of the parathyroid, probably to satisfy the increased need of the ________.

fetus for calcium

NORMAL ADAPTATIONS IN PREGNANCY 7. Endocrine changes - Increased size and activity of the adrenal cortex, thus increasing the amount of circulating ______, ______ and _____, all of which affect carbohydrate and fat metabolism, causing ________.

cortiso aldosterone ADH hyperglycemia

NORMAL ADAPTATIONS IN PREGNANCY 7. Endocrine changes - Gradual increase in ________ but the body’s sensitivity to insulin is ______during pregnancy.

insulin production | decreased

NORMAL ADAPTATIONS IN PREGNANCY 8. Weight - During the first trimester, weight gain of ______ is normal

1.5-3 lbs

NORMAL ADAPTATIONS IN PREGNANCY 8. Weight - On 2nd and 3rd trimesters, weight gain of _______ per trimester is recommended.

10-11 lbs.

NORMAL ADAPTATIONS IN PREGNANCY 8. Weight - Total allowable weight gain during entire period of pregnancy, therefore, is _________.

20-25 pounds (10-12 kgs)

NORMAL ADAPTATIONS IN PREGNANCY 8. Weight - ______of weight gain is more important than the _______ of weight gained.

Pattern | amount

``` Fetus ____ Placenta ____. Amniotic fluid ____. Increased weight of uterus ____. Increased weight of the breasts ________. Weight of additional fluid ____. Fat and fluid accumulation _____. Characteristics of pregnancy TotaL ______. ```

``` 7lbs. 1 lb 1 ½ lbs 2 lbs 1/1 – 3 lbs 2 lbs 4-6 lbs 20-25 lbs ```

NORMAL ADAPTATIONS IN PREGNANCY 9. Emotional responses ____________. The fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, disbelief, even depression. (Implication: when giving health teachings, emphasize the _________).

First trimester | bodily changes in pregnancy

NORMAL ADAPTATIONS IN PREGNANCY 9. Emotional responses ________: fetus is perceived as a separate entity. Fantasizes appearance of the baby.

Second trimester

NORMAL ADAPTATIONS IN PREGNANCY 9. Emotional responses ________: has personal identification with a real baby about to be born and realistic plans for future childcare responsibilities. Best time to talk about layette and infant feeding method. Fear of death, though is prominent (To allay fears, let pregnant woman listen to the__________.)

Third trimester | fetal heart sounds

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 1. Uterus - Weight increases to about 1000 grams at full term; due to increase in the amount of _____ and ________. - Change in shape from pear-like to _____ ; enormous change in consistency of __________

fibrous elastic tissues ovoid lower uterine segment

Enormous change in consistency of lower uterine segment causes extreme softening, known as ________ , seen at about the _____

Hegar’s sign | 6th week

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 1. Uterus - Mucous plugs in the cervix, called _______, are produced to seal out bacteria. - Cervix becomes more vascular and edematous, resembling the consistency of an earlobe, known as _________.

operculum | Goodell’s sign

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 2. Vagina - Increased vascularity causes change in color from light pink to _____ or ______ as ________.

deep purple violet known Chadwick’s sign

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 2. Vagina -To prevent confusion as to pregnancy signs, arrange the body parts from “out to in” and the different signs alphabetically. Thus: Vagina – ________ Cervix – ________ Uterus – ________ - Due to increased estrogen, activity of the epithelial cell increases, thus increasing amount of vaginal discharges called leucorrhea. As long as the discharges are not excessive, green/yellow in color, foul-smelling or irritatingly itchy, it is normal. Management: maintain or increase cleanliness by taking twice daily shower baths using cool water. - The pH of the vagina changes from normally acidic (because of the presence of Dederlein bacillie) to alkaline (because of increased estrogen). Alkaline vaginal environment is supposed to protect against bacterial infection; however, there are two microorganisms which thrive in an alkaline environment.

Chadwick’s sign Goodell’s sign Hegar’s sign

Softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week. An indication of pregnancy detectable between the 6th and 12th weeks: used before modern urine tests for pregnancy were available. If the fingers of one hand are inserted into the vagina and those of the other are placed over the pelvic cavity, the lower part of the uterus feels very soft compared with the body of the uterus above and the cervix below.

Hegar's sign

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes Vagina - Due to increased ______, activity of the epithelial cell increases, thus increasing amount of vaginal discharges called ______.

estrogen | leucorrhea

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes The discharges are not excessive, green/yellow in color, foul-smelling or irritatingly itchy, it is ______. Management: maintain or increase cleanliness by taking ______ shower baths using cool water.

normal | twice daily

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes - The pH of the vagina changes from normally acidic (because of the presence of ________) to alkaline (because of increased ______).

Dederlein bacillie | estrogen

________ vaginal environment is supposed to protect against bacterial infection;

Alkaline

There are two microorganisms which thrive in an alkaline environment.

Trichomonas, a protozoa or flagellate | Candida albicans, a fungus or yeast

Trichomonas, a protozoa or flagellate. The condition is called ____________.

trichomonas vaginalis or trichomonas vaginitis or trichomoniasis

Signs and symptoms of Trichomoniasis o _____, _____-colored, irritatingly itchy, foul-smelling discharges o _______ and ______ due to irritation from the discharges

Frothy cream Vulvar edema hyperemia

Management of Trichomoniasis | ______ for 10 days p.o. or _______ of trichomonicidal compounds. (e.g., Tricofuron, Vagisec or Devegan).

Flagyl | vaginal suppositories

Management of Trichomoniasis o Is ________ during the first trimester o Treat male partner also with ____. o Avoid ______ when taking Flagyl – can cause ________ – like reactions: vomiting, flushed face and abdominal cramps. o ______ a minor side effect – no need to discontinue the drug. o Acidic vaginal douche (____. white vinegar in ______ of water or _____ white vinegar in ______ of water) to counteract alkaline – preferred environment of the protozoa. o Avoid ______ to prevent reinfection

``` carcinogenic Flagyl alcoholic drinks, Antabuse Dark brown urine 1 tbsp, 1 quart 15 ml., 1000 ml. intercourse ```

Candida albicans, a fungus or yeast. The condition is called ________.

Moniliasis or Candidiasis

Fungus also thrives in an environment rich in _______ (that is why it is common among _________) and in those on ____ or _______ when acidic environment is altered.

carbohydrates poorly-controlled diabetics steroid or antibiotic therapy

Is seen as oral thrush in the newborn when transmitted during delivery through the birth canal of the infected mother.

Moniliasis

Symptoms of Moniliasis o White, patchy, cheese-like particles that adhere to ________ o Irritatingly itchy and foul-smelling __________

vaginal walls | vaginal discharges

Management of Moniliasis o _________. or ____________ twice a day for 15 days o _________ to vagina (use panty shields to prevent staining of clothes or underwear) o Correct _____ o Avoid ________ o _____ vaginal douche

``` Mycostatin/Nystatin p.o vaginal suppositories/peccaries (100,000 U) Gentian violet swab diabetes intercourse Acidic ```

``` NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 3. Abdominal Wall _______ increase uterine size results in rupture and atrophy of connective tissue layers, seen as pink or reddish streaks (gently rubbing oil on the skin helps prevent ______) - ______ pushed out ```

Striae gravidarum diastasis Umbilicus

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 4. Skin _______ brown line running from umbilicus to symphais pubis

Linea nigra

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 4. Skin _________ – extra pigmentation on cheeks and across the nose due to increased production of melanocytes by the _________

Melasma or chloasma | pituitary gland

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 4. Skin - ________unduly activated

Sweat glands

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 5. Breasts – all changes due to increased ______

estrogen

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 5. Breasts - Increase in size due to hyperplasia of ______ and ________.

mammary alveoli | fat deposits

``` NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 5. Breasts - Feeling of _____ and ______ sensation in the breasts - _____ more erect. ```

fullness tingling Nipples

For mothers who intend to breastfeed, advise: Nipple _______ Drying nipples with ______ to help toughen the nipples. Not to use _______ as this can cause drying which could lead to sore nipples. - _______ become bigger and more protruberant - ______ becomes darker and diameter increases - Skin surrounding ______ turns dark -By the fourth month, a thin, watery, high protein fluid, called ______, is formed. It is the precursor of breast milk.

``` rolling rough towel soap or alcohol Montgomery glands Areola areolae colostrums ```

NORMAL ADAPTATIONS IN PREGNANCY B. Local Changes 6. Ovaries – ______whatsoever since ovulation does not take place during pregnancy. Progesterone and estrogen are being produced by the ______.

no activity | placenta

Signs of Pregnancy | First Trimester Presumptive (5)

``` Amenorrhea Morning sickness Breast changes Urinary frequency Enlarging uterus ```

Signs of Pregnancy | First Trimester Probable (5)

``` Chadwick’s sign Goodell’s sign Hegar’s sign Positive HCG Elevation of BBT ```

Signs of Pregnancy | First Trimester Positive

Ultrasound evidence

Signs of Pregnancy | Second Trimester Presumptive

Quickening Skin pigmentation (chloasma and linea nigra) Striae gravidarum

Signs of Pregnancy | Second Trimester Probable

Enlarged abdomen Braxton Hicks Ballottement

Signs of Pregnancy | Second Trimester Positive

Fetal heart tones Fetal movements felt by examiner Fetal outline on x-ray

THE PRENATAL VISIT A. The provision of ______ is the primary factor in the improvement of maternal and infant morbidity and mortality statistics. To ensure the success of the prenatal care programs, it should be remembered that the patient’s understanding of the modalities of care is basic to cooperative action

prenatal care

THE PRENATAL VISIT | B. The duration of a normal pregnancy is _______ , or _____.

266-280 days | 38-42 weeks (average is 40 weeks), or 9 calendar months or 10 lunar months

Any baby, therefore, who is born before the 38th week of gestation is called ____ and a baby born after the 42nd week of gestation is said to be ______.

pre-term | post-term

THE PRENATAL VISIT C. Diagnosis of Pregnancy. Urine examination – ______________ in the urine is the basis for pregnancy tests. It is present from the ____ day through the ____ day, reaching a peak level on the ____ day.

human chorionic gonadotropin (HCG) 40th 100th 60th

THE PRENATAL VISIT C. Diagnosis of Pregnancy. HCG, therefore, is most correct _____ after the last menstrual period (LMP). If more than 1 hour would lapse before being tested, _____ specimen because HCG is unstable under room temperature.

6 weeks | refrigerate

THE PRENATAL VISIT C. Diagnosis of Pregnancy. _______ are no longer done. ______________ are widely used at present because results are obtained faster and do not involve the sacrifice of an animal. E.g., Gravindex, Pregnex, Prognosticon.

``` Biological tests (e.g., frog tests) Immunodiagnostic tests (antigen-antibody reaction) ```

THE PRENATAL VISIT | D. Components of a Prenatal Visit

1. History-taking 2. Assessment 3. Important Estimates 4. Health Teachings

THE PRENATAL VISIT D. Components of a Prenatal Visit 1. History-taking

Personal data | Obstetrical data

THE PRENATAL VISIT D. Components of a Prenatal Visit 1. History-taking - _______ – patient’s name, age, address, civil status, (an unwed pregnancy is a risk pregnancy) and family history (With whom does she live? Are there familial diseases that could possibly affect the pregnancy?)

Personal data

``` THE PRENATAL VISIT D. Components of a Prenatal Visit 1. History-taking - ________ • Gravida . • Para • TPAL score • Past pregnancies • Present pregnancy • Medical data ```

Obstetrical data

number of pregnancies a woman has had.

• Gravida

number of viable pregnancies, regardless of number and outcome

• Para

number of full term babies (T, premature (P) babies, abortion (A), living children (L)

• TPAL score

Past pregnancies (4) Questions

o Method of delivery – normal spontaneous vaginal? Caesarion section (CS)? Indication for past CS? o Where – At home? In the hospital? o Risks involved – Prematurity? Toxemia?

Present Pregnancy Question

o Chief concern – is there nausea and vomiting?

Present Pregnancy Danger signals

``` o Vaginal bleeding, no matter how slight o Swelling of face and fingers o Severe, continuous headache o Dimness or blurring vision o Flashes of light or dots before eyes o Pain in the abdomen o Persistent vomiting o Chills and fever o Sudden escape of fluids from the vagina o Absence of fetal heart sounds after they have been initially auscultated n the 4th or 5th month ```

THE PRENATAL VISIT D. Components of a Prenatal Visit 2. Assessment

``` Physical examination Leopold’s maneuvers Vital signs Blood studies Urine examinations ```

Review of systems is indicated, including inspection of the _____ because they are common foci of infection.

Physical examination | teeth

Pelvic examination (Cardinal rule: _________ first)

Empty the bladder

Pelvic examination • Internal exam (IE) to determine ______, ______, and ______ • _______ – fetus will bounce when lower uterine segment is tapped sharply (on 5th month of pregnancy) • ___________ – cytological examination to diagnose cervical carcinoma.

Hegar’s, Chadwick’s and Goodell’s Ballotement Papanicolau (Pap smear)

``` Pelvic examination Classification of findings o Class 1 – _________- o Class 2 – ___________ o Class 3 – ___________ o Class 4 – ___________ o Class 5 – ___________ ```

absence of a typical or abnormal cells (normal) atypical/abnormal cytology but no evidence of malignancy cytology suggestive of malignancy cytology strongly suggestive of malignancy conclusive for malignancy

Pelvic examination Clinical stages that reflect localization or spread of malignant cervical changes. o Stage 1 – _________ o Stage 2 – _________ o Stage 3 – _________ o Stage 4 – _________. But since X-rays are teratogenic, the procedure can be done only _____ before Estimated Date of Confinement

- CA confined to the cervix - CA extends beyond the cervix into the vagina but not into the pelvic wall or lower 1/3 of the vagina - Metastasis to the pelvic wall - Metastasis beyond pelvic wall into the bladder and rectum disproportion (CPD or Cephalopelvic Disproportion). 2 weeks

are a common and systematic way to determine the position of a fetus inside the woman's uterus

- Leopold’s maneuvers

Leopold’s maneuvers | Purposes (3)

* To determine presentation, position, and gratitude * Estimate fetal size * Locate fetal parts

Leopold’s maneuvers Preparatory steps • Palpate with warm hands; cold hands cause _____________ • Use palms, not _____ • Position patient on _____ with knees flexed slightly (_____ position) so as to relax __________. • Apply gentle but _________

``` abdominal muscles to contract fingertips supine dorsal recumbent abdominal muscles firm motions ```

Leopold’s maneuvers Procedure • First maneuver: Facing head part of pregnant woman, palpate for fetal part found in the _____ to determine _____ (a hard, smooth, ballotable mass at the fundus means the fetus is in ________

fundus presentation breech presentation

Is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head

Breech presentation

Leopold’s maneuvers Procedure • Second maneuver: Palpate sides of the uterus to determine the _________ (best place to hear fetal heart tones) and _______

location of fetal back | small fetal parts

Leopold’s maneuvers Procedure • Third maneuver: Grasp lower portion off abdomen just above the symphysis pubis to find out ____________.

degree of engagement

Leopold’s maneuvers Procedure • Fourth maneuver: Facing the feet part of the patient, press fingers downward on both sides of the uterus above the inguinal ligaments to determine ___________

attitude (degree of flexion of fetal head)

Temperature, pulse and respiratory rates are important especially during the initial prenatal visit. More important, however, are the weight and blood pressure as baseline data to determine any significant increases.

Vital signs

- Blood studies (3)

* Blood Typing * Complete blood count, including Hgb and Hct, to determine anemia * Serological tests (VDRL and Kahn Wasserman) to diagnose for syphilis

- Urine examinations | Any sign of albumin in the urine should be reported immediately because it is a sign of ________

toxemia

- Urine examinations | • _________ to determine albuminuria.

Heat and acetic acid test

- Urine examinations | • _________ for glycosuria,

Benedict’s test

- Urine examinations | a sign of possible gestational diabetes.

glycosuria,

Urine should be collected ________- to avoid false positive results. Should not be more than +1 sugar.

before breakfast

• Determination of pyura. ________ has been found to be a common cause of premature delivery.

Urinary tract infection

3. Important Estimates -Age of Gestation (AOG) • – calculation of expected date of confinement (EDC). Count back three months from the first day of the last menstrual period (LMP) then add 7 days. Substitute number for month for easy computation. E.g., LMP is September 6 September is the 9th month of the year – 3 = 6 (June) Add 7 days to 6 = 13 EDC – June 13

Nagele’s Rule

3. Important Estimates -Age of Gestation (AOG) • – determine age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months. E.G., fundic height of 16 cm. divided by 4 = 4 months AOG = 16 weeks AOG

McDonald’s Method

3. Important Estimates -Age of Gestation (AOG) • – estimate AOG by the relative position of the uterus in the abdominal cavity

Bartholomew’s Rule

Bartholomew’s Rule o By the _________, the fundus is palpable slightly above the symphysis pubis o On the _________, the fundus is at the level of the umbilicus o On the ________, the fundus is below the xiphoid process

3rd lunar month 5th lunar month 9th lunar month

3. Important Estimates -Age of Gestation (AOG) – determines the length of the fetus in centimeters.

Haase’s Rule

Haase’s Rule o During the ____________, square the number of the month (E.g., first lunar month: 1 x 1 = 1 cm.) o During the _________, multiply the month by 5 (E.g., 6th lunar month: 6 x 5 = 30 cm)

first half of pregnancy | second half of pregnancy

3. Important Estimates -Age of Gestation (AOG) – estimates the weight of the fetus in grams. Formula: fundic height in ___. – n x k “k” is a constant, it is always ___ “n” is = ___ (if fetus is engaged) = ___(if fetus is not yet engaged)

``` Johnson’ss Rule cm 155 12 11 ```

4. Health Teachings | most important aspect

Nutrition

Women who need special attention (5)

* Pregnant teenagers * Extremes in weighing scale – low prepregnant weight and the obese * Low income women * Successive pregnancies * Vegetarians – although with high vitamin intake, are low in proteins and minerals because there are many essential amino acids that can be found only in animal sources

Nutritional assessment is based on taking a _________

diet history first

Diet history (3)

* Food preferences/eating habits * Cultural/religious influences * Educational/occupational level

- Computation of caloric equivalents • Carbohydrates ___ • Proteins ___ • Fats ___

x 4 x 4 x 9

Food sources • ______ – meat, fish, eggs, milk, poultry, cheese, beans, mongo • ______ – eggs, carrots, squash, all green and leafy vegetables • ______ – fish, liver, eggs, milk, (Caution: excess Vit. D during pregnancy can lead to ______) • _______ – green leafy vegetables, fish • _______ – tomatoes, guava, papaya • _______ – especially needed to prevent megaloblastic anemia, abruption placenta and prematurity because, together with iron, is needed for __________. E.g., asparagus • _____ – food rich in protein • _____ – milk, cheese • _____ o Especially important during the last trimester when the pregnant woman is going to transfer her stores from herself to her fetus so that the baby has enough stores during the first three months of life when all he takes is milk (which is deficient in of this).

``` Protein-rich foods Vitamin A Vitamin D, fetal cardiac problems Vitamin E Vitamin C Folic acid, hemoglobin formation Vitamin B Calcium/phosphorus Iron ```

Iron has very ___________; only ___ of iron intake can be absorbed by the body. Thus, for optimum absorpotion, give _______.

low absorpotion rate 10% Vitamin C

Iron should be given after meals because it is irritating to the ___________.

gastric mucosa

Foods rich in ___: liver and other internal organs, camote tops, kangkong, egg yolk, amplaya, amlunggay.

iron

- __________during pregnancy can result in prematurity; preeclampsia, absorption, low birth weight babies, congenital defects or even stillbirths.

Malnutrition

- _________ – causes vasoconstriction, leading to low birth weight babies and, therefore, is contraindicated during pregnancy

Smoking

Drinking – in moderation is not contraindicated but when excessive can cause ______ in the newborn and ______; besides, alcohol supplies only empty _____.

transient respiratory depression fetal withdrawal syndrome calories

Drugs – dangerous to fetus especially during the first trimester when the ______ is still incomplete and the different body organs are developing. Are teratogenic (can cause congenital defects) and, therefore contraindicated unless prescribed by the doctor.

placental barrier

• – causes Amelia or phocomelia (short or no extremeties)

Thalidomide

• – can cause cleft palate and even abortion

Steroids

• – contained in many over-the-counter cough suppressants, cause enlargement of the fetal thyroid gland, leading to tracheal compression and dyspnea at birth

Iodine

• – causes hemolysis and hyperbilirubinemia

Vitamin K

• – cause bleeding disorder

Aspirin and Phenobarbital

• – cause damage to the 8th cranial nerve (nerve deafness)

Streptomycin and quinine

• – causes staining of tooth enamel and inhibits growth of long bones (not given also to children below 8 years for the same reasons)

Tetracycline

Sexual activity | • _____ continue throughout pregnancy, but levels change

Sexual desires

Sexual activity o During the first trimester, there is a ______ in sexual desire because the woman is more preoccupied with the changes in her body o During the second trimester, there is another ______ because the woman is afraid of hurting the fetus

decreased | decrease in sexual desire

Sexual activity • Sex in moderation is permitted during pregnancy but not during the last _____ since there is increased incidence of postpartum infection in women

6 weeks

Sex is contraindicated in the following situations (4)

o Spotting or bleeding o Ruptured BOW o Incompetent cervical os o Deeply-engaged presenting part

Employment – as long as the job does not entail handling toxic substances, or lifting heavy objects, or excessive physical or emotional strain, there is no contraindication to working. Advise pregnant women to walk about ______ of her work day ______ or _____ to promote circulation.

every few hours long periods of standing sitting

Traveling – no travel restrictions but postpone a trip during the ________. On long rides, _____ rest periods every ______ about or empty the bladder is advisable.

last trimester 15-20 minute 2-3 hours to walk

Exercises • Chief aim: To strengthen the ____ used in labor and delivery • Should be done in _____ • Should be individualized: according to _____,______ ,______, _______

muscles moderation age, physical condition, customary amount of exercises (swimming or tennis not contraindicated unless done for the first time) and the stage of pregnancy)

Recommended exercises • – to stretch and strengthen perineal muscles; increase circulation in the perineum; make pelvic joints more pliable. When standing from squatting position, raise buttocks first before raising the head to prevent postural hypotension.

Squatting and Tailor Sitting

• – maintains good posture; relieved pressure abdominal pressure and low backache; strengthens abdominal muscles following delivery

Pelvic rock

• - relieves pelvic pressure and cramps in the thighs or buttocks; relieves discomfort from hemorrhoids

Modified knee-chest position

• – strengthens muscles of the chest

Shoulder-circling

• – said to be the best exercises

Walking

• – relieves congestion and discomfort in pelvic region; tones up pelvic floor muscles

Kegel

preparing the pregnant couple for childbearing

Prepared Childbirth/Childbirth Education

Prepared Childbirth/Childbirth Education • Operates basically on the _____________: pain is controlled in the spinal cord. To ease pain in one body part, the “gate” to this pain should be “closed”.

“Gate Control Theory” of pain

Prepared Childbirth/Childbirth Education • Premises o Discomfort during labor can be minimized if the woman comes into labor informed about what is happening and prepared with_______ to use during labor o Discomfort during labor can be minimized if the ______ is relaxed and the _____ is allowed to rise freely against the abdominal wall during contractions.

breathing exercises woman’s abdomen uterus

• Major approaches to prepared childbirth –pregnant couples are taught about _______, ______, _____ and _______, __________, __________, ______, __________

anatomy, pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet comfort measures

Fear leads to tension and tension leads to pain. Is a psychophysiological preparation for childbirth. This technique alleviates pain during childbirth by blocking feelings of fear and tension

Grantly – Dick Read Method

Based on stimulus-response conditioning. To be effective, full concentration on breathing exercises during labor should be observed (Implication: Nurse should not interrupt the couple doing breathing exercises.)

Lamaze or Psychoprohylactic method

Given 0.5 ml IM (deltoid region of the upper arm) to all pregnant women anytime during pregnancy.

Tetanus immunization

Tetanus immunization It shall be given in two doses at least _________, with the second dose at least _______ before delivery. _______ shall be given during succeeding pregnancies regardless of the interval. __________ will confer lifelong immunity. Clinic appointments • First _____ month – every month • On ___ and _____month – every other week or twice a month • On _____ month – every week until labor pains set in

``` 4 weeks apart 3 weeks Booster doses Three booster doses 7 lunar 8th 9th lunar 10th lunar ```

``` LABOR AND DELIVERY THE FETAL SKULL A. Importance: From an obstetrical point of view the _____ is the most important part of the fetus because it is the: • largest part of the body • most frequent presenting part • least compressible of all parts ```

fetal skull

``` LABOR AND DELIVERY THE FETAL SKULL B. Cranial bones - the first 3 are not important part of the fetus because it is the: • ______ • ______ • ______ • ______ • ______ • ______ ```

``` Sphenoid Ethmoid Temporal Frontal Occipital Parietal ```

LABOR AND DELIVERY THE FETAL SKULL C. Membrane space – _____ are important because they allow the bones to move and overlap, changing the shape of the fetal head in order to fit through the birth canal, a process called ______.

suture lines | molding

LABOR AND DELIVERY THE FETAL SKULL C. Membrane space • ______ – the membranous interspace which joins the parietal bones

Sagittal suture line

LABOR AND DELIVERY THE FETAL SKULL C. Membrane space • ______– the membranous interspace which joins the frontal bone and the parietal bones

Coronal suture line

LABOR AND DELIVERY THE FETAL SKULL C. Membrane space • ______ – the membranous interspace which joins the occipital and the parietals.

Lambdoid suture line

LABOR AND DELIVERY THE FETAL SKULL D. _______ – membrance – covered spaces at the junction of the main suture lines

Fontanels

D. Fontanel | • ______– the larger, diamond-shaped fontanel which closes beween 12-18 months in an infant

Anterior fontanel

D. Fontanel | • ________ – the smaller, triangular shaped fontanel which closes between 2-3 months in the infant

Posterior fontanel

LABOR AND DELIVERY THE FETAL SKULL D. Measurements – the shape of the fetal skull causes it to be wider in its _______than in its ________

anteroposterior (AP) diameter | transverse diameter

• Transverse diameters of the fetal skull o Biparietal = ______ o Bitemporal = ____. o Bimastoid = _____.

9.25 cm. 8 cm 7 cm

From below the occiput to the anterior fontanel

Suboccipitobregmatic (A)

``` • Anteroposterior diameters o Suboccipitobregmatic (A) – from below the occiput to the anterior fontanel = ________ ```

9.5 cm. (the narrowest AP diameter)

From the occiput to the mid-frontal bone .

Occipitofrontal (B)

``` • Anteroposterior diameters o Occipitofrontal (B) – from the occiput to the mid-frontal bone = _____. ```

12 cm

From the occiput to the chin

Occipitomental © -

• Anteroposterior diameters | o Occipitomental © - from the occiput to the chin = _________

13.5 cm (the widest AP diameter)

Which one of these diameters is presented at the birth canal depends on the __________.

degree of flexion (known as attitude) the fetal head assumes prior to delivery

In full flexion (______________), the smallest _____________ is the one presented at the birth canal.

``` very good attitude when the chin is flexed on the chest suboccipitobregmatic diameter (A) ```

If in poor flexion, the widest ________ will be the one presented and will give mother and the baby more problems.

occipitomental diameter (D)

THEORIES OF LABOR ONSET | ___________ any hallow body organ when stretched to capacity will necessarily contract and empty.

A. Uterine Stretch Theory

THEORIES OF LABOR ONSET __________ – labor, being considered a stressful event, stimulates the ________to produce oxytocin from the posterior pituitary gland.

B. Oxytocin theory | hypophysis

Causes contraction of the smooth muscles of the body, e.g., uterine muscles.

Oxytocin

THEORIES OF LABOR ONSET C. _________ – ______, being the hormone designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if its amount decreases, labor pains occur.

Progesterone Deprivation theory | progesterone

THEORIES OF LABOR ONSET D. _________ – initiation of labor is said to result from the release of arachidonic acid produced by steroid action on lipid precursors.

Prostaglandin theory

_______ is said to increase prostaglandin synthesis which, in turn, causes uterine contractions.

Arachidonic acid

THEORIES OF LABOR ONSET | E. ________ – because of the decrease in blood supply, the uterus contracts.

Theory of Aging Placenta

PRELIMINARY/PRODROMAL SIGNS OF LABOR | ______ the settling of the fetal head into the pelvic brim.

Lightening

In lightening In primis, it occurs _____ before EDC; in multis, _____ labor onset.

2 weeks | on or before

Lightening should not be confused with ______ which occurs when the presenting part had descended into the pelvic inlet.

engagement

``` Lightening results in: • increase in ________ • relief of ________ and ________ • shooting pains down the legs because of pressure on the _______ • increase in the amount of ________ ```

urinary frequency abdominal tightness and diaphragmatic pressure sciatic nerve vaginal discharges

PRELIMINARY/PRODROMAL SIGNS OF LABOR B. Increased activity level – due to increased _______ secreted to prepare the body for the coming “work” ahead. Advise the preganant woman no to use this increased energy for doing household chores.

epinephrine

PRELIMINARY/PRODROMAL SIGNS OF LABOR C. Loss of weight – about ______. 1 to 2 days before labor onset; probably due to decrease in ______ leading to decrease in fluid retention.

2-3 lbs | progesterone production

PRELIMINARY/PRODROMAL SIGNS OF LABOR | D. __________ – painless, irregular practice contractions.

Braxton Hicks contractions

PRELIMINARY/PRODROMAL SIGNS OF LABOR | E. ________ – from Goodell’s sign, the cervix becomes “butter-soft”

Ripening of the cervix

PRELIMINARY/PRODROMAL SIGNS OF LABOR F. _________– it is important to remember that one membranes (BOW) have ruptures: • Labor is inevitable. It will occur within _______. • The integrity of the uterus has been destroyed. _______, therefore, can easily set in. • Umbilical cord compression and/or cord ______ can occur (especially in breech presentation).

Rupture of the membranes 24 hours Infection prolapsed

That is why once membranes have rupture: o __________ should be observed in all procedures o Doctors do less _______ (e.g. IE) o ______ is no longer ordered o Temperature should be taken regularly so that _____ a sign of infection, can be detected.

Aseptic techniques obstetric manipulations Enema fever,

PRELIMINARY/PRODROMAL SIGNS OF LABOR | G. _______ – shortening and thinning of the cervical canal as distinct from the uterus. It is expressed in percentage.

Effacement

Nursing action depends on the specific situation: Umbilical cord compression and/or cord prolapsed can occur (especially in breech presentation). o A woman in labor seeking admission to the hospital and saying that her BOW has rupture should be _______immediately, and the ______ taken consequently o If a woman in Labor Room says that her membranes have rupture, the initial nursing action is to take the _________. o she feels a_______ coming out of the vagina (cord prolapse)

put to bed fetal heart tones fetal heart tones

PRELIMINARY/PRODROMAL SIGNS OF LABOR H. _______ – enlargement of the external cervical os up to 10 cm primarily as a result of ______ and secondarily as a result of________and the_____.

Dilatation uterine contractions pressure of the presenting part , BOW

PRELIMINARY/PRODROMAL SIGNS OF LABOR I. Uterine Changes • The uterus is gradually differentiated into two distinct portions o ________ – becomes thick and active to expel out fetus o _________ – become thin-walled, supple and passive so that fetus can be pushed out easily

Upper uterine segment | Lower uterine segment

PRELIMINARY/PRODROMAL SIGNS OF LABOR I. Uterine Changes • _________ is formed at the boundary of the upper and lower uterine segments.

Physiological retraction ring

In difficult labor when the fetus is larger than the birth canal, the________ become tense during dilatation and expulsion, causing an abdominal indentation called _________, a danger sign of labor signifying impending rupture of the uterus if the obstruction is not relieved.

round ligaments of the uterus | Bandl’s pathological retraction ring

Remain irregular

FALSE LABOR PAINS

Accompanied by cervical effacement and dilatation (the most important difference)

TRUE LABOR PAINS

May be slightly irregular at first but become regular and predictable in a matter of hours.

TRUE LABOR PAINS

No increase in duration, frequency and intensity

FALSE LABOR PAINS

Absent cervical changes

FALSE LABOR PAINS

First felt in the lower back and sweep around to the abdomen in a girdle-like fashion.

TRUE LABOR PAINS

Increase in duration, frequency and intensity.

TRUE LABOR PAINS

Continue no matter what the woman;s level of activity is

TRUE LABOR PAINS

Often disappears if the women ambulates

FALSE LABOR PAINS

Generally confined to the abdomen

FALSE LABOR PAINS

Nursing Care - Hospital admission – provide _____ and _______ from the very start • ________ – name, age, address, civil status • ________ – determine EDC; obstetrical score (gravida, para, TPAL); amount and character of show; and whether or not membranes have ruptured

privacy, reassurance Personal data Obstetrical data

Nursing Care - General physical examination, internal exam and Leopold’s maneuvers are done to determine: • ______ and ______ • ______ – relationship of the fetal presenting part to the level of the ischial spine • ___________ – relationship of the long axis of the mother to the long axis of the fetus; also known as _____. Presenting part if the fetal part which enters the pelvis first and covers the _______

``` Effacement and dilatation Station Presentation lie internal cervical os ```

o ______ – at the level of the ischial spines; synonymous to engagement o ______ – presenting part above the level of the ischial spines o ______ – presenting part below the level of the ischial spines o ______ – synonymous to crowning (encircling of the largest diameter of the fetal head by the vulvar ring)

Station 0 Station -1 Station +1 Station +3 or +4

``` VERTICAL A. ______ – head is the presenting part • _____ – head sharply flexed, making the parietal bones the presenting parts • If in poor flexion o ____ o ____ o ____ ```

``` Cephalic Vertex Face Brow Chin ```

VERTICAL B. ______ – buttocks are the presenting parts • _____ – thighs flexed on the abdomen and legs are on the thighs • _____ – thighs are flexed and legs are extended, resting on the anterior surface of the body

Breech Complete Frank

VERTICAL C. Footling • ____ – one leg unflexed and extended; one foot presenting • ____ – legs unflexed and extended; feet are presenting

Single | Double

HORIZONTAL = Transverse lie = Shoulder presentation | - In vertex presentation, Fetal hearts sound are usually located in either the ___________________;

left or right lower quadrant (LLQ or RLQ)

HORIZONTAL = Transverse lie = Shoulder presentation | in breech presentation, ___________, either _____________

at or above the level of the umbilicus | left or right upper quadrant (LUQ or RUQ)

``` HORIZONTAL = Transverse lie = Shoulder presentation - Hazards of breech delivery • _________ • _________ • _________ ```

Cord compression Abruption placenta Erb – Duchenne paralysis

is a paralysis of the arm caused by injury to the upper trunk C5–C6 nerves

Erb's palsy or Erb–Duchenne palsy

is when, after vaginal delivery of the head, the baby's anterior shoulder gets caught above the mother's pubic bone.

Shoulder dystocia

- Horizontal lie is very rare (1%) and maybe due to a ______ because of multiparity, pelvic contraction or placenta previa

relaxed abdominal wall

Placenta previa (pluh-SEN-tuh PREH-vee-uh) occurs when a baby's placenta partially or totally covers the mother's cervix — the outlet for the uterus.

placenta previa

________ – relationship of the fetal presenting part to a specific quadrant in the mother’s pelvis

Position

``` The pelvis is divided into four quadrants • ______ • ______ • ______ • ______ ```

Right anterior Left anterior Right posterior Left posterior

o _______ result in more backaches because of pressure of the fetal presenting part on the maternal sacrum

Posterior positions

``` Points of direction in the fetus • ______ – in vertex presentations • ______ – in face presentations • ______ – in breech presentations • __________ – in horizontal presentations ```

Occiput Chin (mentum) Sacrum Scapula (acromio)

Possible fetal positions • Vertex o ____ – ______________ (most common and favorable position at birth)

LOA - left occipitoanterior

``` Possible fetal positions • Vertex o LOP – _________ o LOT – _________ o ROA – _________ o ROP – _________ o ROT – _________ ```

``` left occipitoposterior left occipitotransverse right occipitoanterior right occipitoposterior right occipitotransverse ```

``` • Breech o LSA – _______ o LSP – _______ o LST – _______ o RSA – _______ o RSP – _______ o RST – _______ ```

``` left sacroanterior left sacroposterior left sacrotransverse right sacroanterior right sacroposterior right sacrotransverse ```

``` • Face o LMA – ______ o LMP – ______ o LMT – ______ o RMA – ______ o RMP – ______ o RMT – ______ ```

``` left mentoanterior left mentoposterior left mentotransverse right mentoanterior right mentoposterior right mentotransverse ```

``` • Shoulder o LADA – ___________ o LADP – ___________ o RADA – ___________ o RADP – ___________ ```

left acromiodorsoanterior left acromiodorsoposterior right acromiodorsoanterior right acromiodorsoposterior

Monitoring and evaluating important aspects | - Uterine contractions –___________ over the fundus.

fingers should be spread lightly

Monitoring and evaluating important aspects • ______ – from the beginning of one contraction to the end of the same contraction (A to B) • ______ – from the end of one contraction to the beginning of the next contraction (B to C) Interval early in labor _______ Interval late in labor _______ • ______ – from the beginning of one contraction to the beginning of the next contraction (A to C). Observe _______ to have a good picture of the frequency of contractions • ______ – the strength of contraction; maybe mild, moderate or strong.

``` Duration Interval – 40 – 45 minute – 2 – 3 minutes Frequency 3 – 4 contractions Intensity ```

Intensity is measured by the __________ at the acme of the contraction. When estimating intensity, check fundus at the _________ to determine whether it relaxes.

consistency of the fundus | end of contraction

Blood Pressure – should not be taken during a _______ as it tends to increase. Because no blood supply goes to the ______ during a contraction, all of the blood is in the periphery that is why there is increased BP during uterine contractions. • BP readings should be taken at least ________ during active labor • When a woman in labor complains of a _______, the first nursing action is to take BP. If it is normal, it is only stress headache; if the BP is increased, refer immediately to the doctor (it could be a sign of _____)

``` contraction placenta every half hour headache toxemia ```

_______ – should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate) • Normally _______ per minute • Should not be taken during a uterine contraction because it tends to _______. Compression of the fetal head when the uterus contracts stimulates the _______ which, in turn, causes bradycardia • Should be taken _______ during the latent phase of labor, _______ during the active phase and _______ during the transition period • For any abnormality in FHR, the initial nursing action is to ______________

``` Fetal heart rate (FHR) 120 to 160 decrease vagal reflex every hour every half hour every 15 minutes change the mother’s position ```

• Signs of fetal distress Bradycardia __________or tachycardia ___________ _______ – stained amniotic fluid in non – breech presentation _______ – hyperactivity of the fetus as it struggles for more oxygen

(FHR less than 100/minute) (FHR more than 180/minute) Meconium Fetal thrashing

Emotional support is provided for the woman in labor by keeping her constantly ___________

informed of the progress labor

Solid or liquid foods are to be avoided because _________ during labor,

digestion is delayed

A ________ interferes with proper bearing down, May ____ and cause _______

full stomach vomit aspiration

_______ – not a routine procedure • Purposes o A full bowel hinders the progress of labor o Expulsion of feces during second stage of labor predisposes mother and baby to ______ o Full bowel predisposes to ______

Enema infection postpartum discomfort

Effectiveness of enema in labor can be determined by evaluating change in _______ and the _______

uterine tone | amount of show

Procedure of enema administration o Enema solution may either be ______ or _______ (contraindicated in patients with toxemia because of its _______) o Optimum temperature of the solution ___________ o Patient on _______ o When there is resistance while inserting rectal catheter, withdraw the tube slightly while letting a small amount of solution enter o Clamp rectal tube during a _______ o Important nursing action: Check _____ after enema administration to determine fetal distress

``` soap suds Fleet enema sodium content 105°F to 115°F (40.5 °C – 46.1°C) side – lying position FHR ```

``` • Contraindications to enema in labor o Vaginal _____ o ______ labor o Abnormal ______ or _____ o Ruptured o ______ ```

``` Bleeding Premature fetal presentation or position membranes Crowning ```

Encourage the mother to void every_______ by offering the bedpan because • A _______ retards fetal descent • ________ can lead to urinary tract infection • A _______ can be traumatized during delivery

2 – 3 hours full bladder Urinary stasis full bladder

Perineal prep – done aseptically. Use ______, always from front to back

“No. 7” method

____________– not a routine procedure; maybe done to provide a clean area for delivery. Muscles at the symphysis pubis should be kept ____ and razor moved along the ______ of hair growth

Perineal shave taut direction

``` Perineal prep Encourage _____ because it: • Favors ______ of the fetal head • Promotes _____ between contractions • Prevents continual pressure of the gravid uterus on the ________ (the blood vessel which brings unoxygenated blood back to the heart); ```

Sim’s position anterior rotation relaxation inferior vena cava

Pressure of the gravid uterus on the inferior vena cava results in ______, also called _________ .

Supine Hypotensive Syndrome | Vena Cava Syndrome

Is due to the reduced venous return resulting in decreased _______ and therefore, a fall in arterial BP.

Hypotension | cardiac output

Woman in labor should not be allowed to push or bear down unnecessarily during contractions of the_____ because • It leads to unnecessary exhaustion • Repeated strong pounding of the fetus against the pelvic floor will lead to _________, thus interfering with dilatation and prolonging length of labor.

first stage | cervical edema

__________ – advised for contractions during the first stage in order to reduce tension and prevent hyperventilation

Abdominal breathing

Administer analgesics as ordered. The dosage is based on the _______, ________ and _________.

patient’s weight status of labor age of gestation

Administer analgesics as ordered | ________ are the most commonly used, specifically Demerol.

Narcotics

Narcotics specifically Demerol. o Pharmacologic effect: depresses the sensory portion of the ______. It is not only a potent analgesic, it is also a sedative and an antispasmodic. o It is not given early in labor because it can ______, _______ , but cannot also be given if delivery is only one hour away because it causes ________ in the newborn (that is why it can be given only if cervical dilatation is _____.) o Given _____., depending on body weight o Takes effect in _____ – patient experiences a sense of well – being and euphoria

``` cerebral cortex retard, progress (is an antispasmodic) respiratory depression 6 – 8 cm 25 – 100 mg 20 minutes ```

o Narcotic antagonist (e.g. ____, ___) are given to counteract any toxic effects of Demerol

Narcan | Nalline

Assist in administration of ______ – preferred over any other form of anesthesia because it does not enter maternal circulation and so does not affect the fetus. Patient is completely awake and aware of what is happening. Does not depress _____, thus ______ is achieved.

regional anesthesia uterine tone optimal uterine contraction

______ is the anesthetic of choice

Xylocaine

• Patient on NPO with IV to prevent dehydration, exhaustion and aspiration and because ___ aids in proper functioning of the fetus

glucose

• Types of Anesthesia o (purplish discoloration of the skin due to blood in _______) area or _____ in the perineum may be an aftermath. No special treatment is needed: ice bag applied to the area on the first day may reduce the swelling

subcutaneous tissues | hematoma

______ are generally needed in delivery of patient under anesthesia because of loss of coordination in _______ pushing.

Forceps | second – stage

• Postspinal headaches maybe due to leakage of _______ or injection of ___ at time of needle insertion. Management: Flat on bed for _______ and increase ________

anesthetic into the CSF air 12 hours fluid intake

Assist in administration of regional anesthesia • Common side effects o Hypotension – because _______ is vasodilator. Management – turn to side; prompt elevation of ____; administration of vasopressor and oxygen, as ordered. o _____ o Decreased ________

Xylocaine legs Fetal bradycardia maternal respirations

A sure sign that the baby is about to be born is the bulging of the ______.

perineum

a woman who is pregnant for the first time.

primigravidas

Primigravidas are transported from the Labor Room to the Delivery Room when the ______ or when there is _______.

cervix is fully dilated | bulging of the perineum

Mutiparas, on the other hand, are transported when cervical dilataton is ______

7 – 8 cm.

a woman who has had two or more pregnancies resulting in viable offspring; called also pluripara

Mutiparas

when the mood of the woman suddenly changes and the nature of contractions intensify

Transition Period

Transition Period Characteristics • If membranes are still intact, this period is marked by a sudden gush of _____ as fetus is pushed into the birth canal. If spontaneous rupture does not occur, _____ (snipping of BOW with a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid to drain) is done to prevent fetus from ________ as it makes its different fetal position changes.

amniotic fluid amniotomy aspirating the amniotic fluid

Amniotomy, however, can not be done if station is still _____, as this can lead to cord compression

“minus”

a blood-stained or sometimes bloody discharge from the uterus, often mixed with plenty of mucus. It originates in the loosening and expulsion of the thick mucus plug that blocks the cervical canal throughout normal pregnancy.

show

Transition Period Characteristics • ______ becomes more prominent. • There is an _______ , a sign of impending second stage of labor. _______ and ____________ are seen. • Nausea and vomiting is a reflex reaction due to _________ and ________. • In primis, baby is delivered with _________; in multis, after _______.

``` Show uncontrollable urge to push with contractions Profuse perspiration distention of neck veins decreased gastric motility absorption ``` ``` 20 contractions (40 minutes) 10 contractions (20 minutes) ```

``` Nursing actions are primarily ________ • Sacral pressure (applying pressure with the _____ on the sacrum) relieves discomfort from contractions • __________: push with contractions • ________ during contractions • ______ support ```

``` comfort measures heel of the hand Proper bearing down techniques Controlled chest (costal) breathing Emotional ```

– begins with complete dilatation of the cervix and ends with the delivery of the baby.

Second Stage (Stage of expulsion)

``` Second Stage (Stage of expulsion) Powers/forces:________ and _______________ ```

involuntary uterine contractions | contractions of the diaphragmatic and abdominal muscles

Mechanisms of labor/Fetal Position Changes (D FIRE ERE) • ______ – may be preceded by engagement. • ______- as descent occurs, pressure from the pelvic floor causes the chin to bend forward onto the chest. • ______ – from AP to transverse, the AP to AP • ______ – as head comes out, the back of the neck stops beneath the pubic arch. The head extends and the forehead, nose, mouth and chin upper. • ______ (also called ______)– anterior shoulder rotates externally to the AP position. • _______ – delivery of the rest of the body.

``` Descent Flexion Internal Rotation Extension External Rotation , (restitution) Expulsion ```

Nursing Care • When positioning legs on lithotomy, put them up at the same time to prevent injury to the ________ • As soon as the fetal head crowns, instruct mother ____, but to ____ (rapid and shallow breathing to prevent rapid expulsion of the baby).

not to push pant uterine ligaments

Nursing Care If panting is deep and rapid, called ____________, the patient will experience lightheadedness and tingling sensation of the fingers leading to __________ because of respiratory alkalosis. Management: let the patient breathe into a brown paper bag to recover ___________; a cupped hand over the mouth and nose will serve the same purpose.

hyperventilation carpopedal spasms lost carbon dioxide

Nursing Care • Assist in ______ (incision made in the perineum primarily to prevent lacerations, Prevent prolonged severe stretching of muscles supporting the ___________, Reduce duration of _______ when there is hypertension or fetal distress, Enlarge outlet, as in ________ or __________

episiotomy bladder or rectum second stage breech presentation or forceps delivery

• Types of episiotomy o ______ – from middle portion of the lower vaginal border directed towards the anus o _______ – begun in the midline but directed laterally away from the anus. Often done because it prevents ________ should it occur despite episiotomy.

Median | Mediolateral, 4th degree laceration

Nursing Care • ______ is used in episiotomy, i.e., no anesthetic is injected because pressure of fetal presenting part against the perineum is so intense that ________ are momentarily deadened

Natural Anesthesia | nerve endings for pain

Nursing Care • Apply the _____________ o Cover the anus with sterile towel and exert upward and forward pressure on the _____, while exerting gentle pressure with _____ on the head to control emerging head. This will not only support the perineum, thus preventing lacerations, but will also favor flexion so that the _____________ of the fetal head is presented. o Ease the head out and immediately wipe the ____ and ____ of secretions to establish a patent airway (remember: the first and most important principle in the care of the newborn is _________). The head should be delivered in _________. o Insert 2 fingers into the vagina so as to feel for the presence of a ______ around the neck (_____). If so, but loose, slip it down the shoulders or up over the head; but if tight, ______, an inch apart, and then cut it in between. o As the head rotates, deliver the ________ by exerting a gentle

``` Modified Ritgen’s Maneuver fetal chin two fingers smallest suboccipitobregmatic diameter nose mouth establish and maintain a patent airway between contractions cord looped, nuchal cord clamp the cord twice anterior shoulder ```

Nursing Care • Immediately after delivery, the newborn should be held below the level of the mother’s vulva for a few minutes to _____________________ • The infant is held with is head in a dependent position (head lower thatn the rest of the body) to allow for ________. Remember: never _______ unless you have drained him out of his secretions. • Wrap the baby in a sterile towel to keep him warm. Remember: Chilling increase the ________

encourage flow of blood from the placenta to the baby drainage of secretions stimulate a baby to cry body’s need for oxygen

Nursing Care • Put the baby on the mother’s abdomen. The weight of the baby will help _________ • Cutting the cord is postponed until the _________ because it is believe that _________ is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp it twice, an inch apart and then cut in between. • Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the circulating nurse.

contract the uterus. pulsations have stopped 50 – 100 ml. of blood

– begins with the delivery of the baby and ends with delivery of placenta.

Third Stage (Placental Stage)

Signs of placental separation • Uterus becoming _____ and _____ again, rising high to the ________ (Calkin’s sign) – the earliest sign of placental separation • Sudden gush of ______ from the vagina • ________ of the cord

round, firm level of the umbilicus blood Lengthening

The earliest sign of placental separation

(Calkin’s sign)

Types of placental delivery • _______– if placenta separates first at its center and last at its edges, it tends to fold on itself like an umbrella and presents the _______ which is shiny (“Shiny” for Schultz); ____ of placentas separate in this manner. • ______– if placenta separates first at its edges, it slides along the uterine surface and presents with the_______ which is raw, red, beefy, and irregular and “dirty” (“Dirty” for Duncan). Only about _____ of placentas separate this way.

Schultz , fetal surface, 80% | Duncan , maternal surface, 20%

Nursing Care • Do not hurry the expulsion of the placenta by _______ or doing _______ as this can cause ______. Just watch for the signs of placental separation.

forcefully pulling out the cord vigorous fundal push uterine inversion

Nursing Care • Tract the ____ slowly, winding it around the clamp until the placenta spontaneously comes out, slowly rotating it so that no membranes are left inside the uterus, a method called _______. • Take note of the time of placental delivery. It should be delivered within _______ after the delivery of the baby. Otherwise, refer immediately to the doctor as this can cause _______ in the mother. • Inspect for _______; any placental fragment retained can also cause severe bleeding and possible death. • Palpate the uterus to determine _________. If relaxed boggy or non - contracted, first nursing action is to _______and _______. An ice cap over the abdomen will also help contract the uterus since cold causes _______. • Inject ________ to maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not given before ________ • Inspect the ________ for lacerations. Any time the uterus is ____ following placental delivery, yet bright red vaginal bleeding is gushing forth from the vaginal opening, suspect lacerations (tend to heal more slowly because of ragged edges)

``` cord Brandt – Andrews maneuver 20 minutes severe bleeding completeness of cotyledons degree of contraction massage gently and properly vasoconstriction oxytocin (Methergin = 0.2 mg./ml. or Syntocinon = 10U/ml) IM placental delivery perineum firm ```

Categories of lacerations o ______ – involves the vaginal mucous membranes and perineal skin o ______ – involves not only the muscles, vaginal mucous membranes and skin, but also the muscles. o ______ – involves not only the vaginal mucous membranes and skin, but also the external sphincter of the rectum o _______ – involves not only the external sphincter of the rectum, the muscles, vaginal mucous membranes and skin, but also the m mucous membranes of the rectum.

First degree Second degree Third degree Fourth degree

Assist the doctor in doing _______ (repair of episiotomy or lacerations).

episiorrhaphy

In vaginal episiorrhaphy, packing is done to maintain______ , thus prevent further bleeding. Note: Vaginal packs have to be removed after _______ • Make mother comfortable by perineal care and applying clean sanitary napkin snugly to prevent its moving forward from the anus to the vaginal opening. Soiled napkins should be removed from ______ • Position the newly – delivered mother flat on bed without pillows to prevent dizziness due to _______. • The newly – delivered mother may suddenly complain of chills due to ____________, _____ or ________ in the delivery room. Management: provide additional blankets to keep her warm. • May give _______; e.g., milk, coffee or tea • Allow patient to ____ in order to regain lost of energy.

``` pressure on the suture line 24 – 48 hours front to back. decrease in intraabdominal pressure decreased blood pressure, fatique or cold temperature initial nourishment sleep ```

– first 1 – 2 hours after delivery which is said to be the most critical stage for the mother because of unstable vital signs

Fourth Stage

Fourth Stage Assessment • Fundus – should be checked every _____ for 1 hour then every ______ for the next 4 hours. Fundus should be _____, in ____, and during the first 12 hours postpartum, is a _______. First nursing action for a non- contracted uterus: _____. • Lochia – should be moderate in amount. Immediately after delivery, a perineal pad can be completely saturated after _____. If saturated in 15 minutes or earlier, may mean ____ • Bladder – a ______ is evidenced by a fundus which is to the right of the midline and dark – red bleeding with some clots. Will prevent adequate uterine contraction. • Perineum – is normally _____, ______and ______. It should be clean, with intact sutures. • Blood pressure and pulse rate may be slightly increased from excitement and effort of delivery, but normalize within ______

``` 15 minutes 30 minutes firm in the midline little above the umbilicus massage 30 minutes hemorrhage full bladder tender, discolored and edematous one hour ```

Is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue.

lochia

given within the first hours postpartum to prevent breast milk production in mothers who will not (or cannot) breastfeed. E.g., _______, ________, _______, ______.

Lactation – suppressing agents – estrogen – androgen preparations diethylstilbestrol, TACE, Parlodel and deladumone

diethylstilbestrol, TACE, Parlodel and deladumone. These drugs tend to increase ______ and _______

uterine bleeding, retard menstrual return

– mother and baby are together while in the hospital. The concept of a family, therefore, is felt from the very beginning because parents have the baby with them, thus providing opportunities for developing a positive relationship between parents and newborn (maternal – infant bonding). Eye – to –eye contact is immediately established, releasing the _______

Rooming – in concept | maternal caretaking responses.

DEFINITION OF TERMS | A. – refers to the six – week period after delivery of the baby

Puerperium/Postpartum

B. - return of the reproductive organs to their prepregnant state

Involution

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes The 30% - 50% increase in _________ during pregnancy will be reabsorbed into the general circulation with _______ after placental delivery.

total cardiac volume | 5 – 10 minutes

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes Implication: the ________ is crucial to gravidocardiacs because the weak heart may not be able to handle such workload. While blood cell (WBC) count increases to _______________. implication: the WBC count, therefore, ___________ sign of postpartum infection

first 5 – 10 minutes after placental delivery 20,000 – 30,000/mm3 cannot be used as a indicationor

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes There is extensive activation of the clothing factors, which encourages ____________. This is the reason why: Ambulation is done ______€ after normal vaginal delivery. When ambulating the newly – delivered patient for the first time, the nurse _______

thromboembolization early – 4 – 8 hours should hold on to the patient’s arm.

``` PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes AMBULATE Recommended exercises ``` ____________ on postpartum day one (PPD1). ____________ on PPD2 to tighten and firm up abdominal muscles ____________ when perineum has healed, to strengthen abdominal and gluteal muscles. Massage is ________ All blood values are back to prenatal levels by the ___________ postpartum

``` Kegel and abdominal breathing Chin – to – chest – Knee – to – abdomen contraindicated 3rd or 4th week ```

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 2. Genital Changes Uterivolution iine assessed by measuring the ____________

fundus by fingerbreadth (=1 cm.).

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes Uterine involution is assessed by measuring the fundus by _________ .

fingerbreadth (=1 cm.)

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes On PPD1, fundus is ____________; on PPD2, ____ fingerbreaths below and so forth until on PPD10, it can no longer be palpated because it is already behind the _________.

1 finger breadth below the umbilicus 2 symphysis pubis

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes ________ is a uterus larger than normal and vaginal bleeding with clots since blood cltos are good media for bacteria, it is , therefore, a sign of ___________.

Subinvoluted uterus | puerperal sepsis

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes To encourage the return of the uterus to its usual anteflexed position, ________ are advised. __________ – strong uterine contractions felt more particularly by multis, those who delivered large babies or twins and those who breastfeed. It is normal and rarely lasts ___________.

prone and knee chest positions Afterpains/afterbirth pains for more than 3 days

``` PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes Management Afterpains/afterbirth pains -Never apply ____ on the abdomen -Give analgesics as ordered ```

heat

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes – uterine discharge consisting of blood,deciduas, WBC, mucus and some bacteria.

Lochia

Pattern Lochia __________ – first 3 days postpartum; red and moderate in amount _______ – net 4 – 9 days; pink or brownish and decreased in amount ______ – from 10th day up to 3 – 6 weeks postpartum; colorless and minimal in amount

Rubra Serosa Alba

Characteristics Lochia Pattern __________ It should approximate menstrual flow. However, it increases with _________ and decreases with _________. It should ________. It has the same ________ as menstrual blood. If fol smelling, may mean either ________ It should not contain ______ It should _______, regardless of method of delivery. Lochia has the ____________ whether CS or normal vaginal delivery

``` should not reverse activity breastfeeding not have any offensive odor fleshy odor poor hygiene or infection large clots never be absent same pattern and amount, ```

Pain in perineal region may be relieved by: _________ – minimizes strain on the suture line Perineal ___________________ twice a day – vasodilatation increases blood supply and, therefore, promotes healing Application of _______________ or ________ of mild oral analgesics as ordered

Sim’s Position heat lamp or warm Sitz baths topical analgesics or administration of mild oral analgesics

Sexual activity – maybe resumed by the ________________ if bleeding has stopped and episiorrhappy has healed. Decreased physiologic reactions to sexual stimulation are expected for the first 3 months postpartum because of __________ and ___________.

3rd or 4th week postpartum | hormonal changes, emotio factors

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes • Menstruation – if not breastfeeding, return of menstrual flow is expected within ______ after delivery. If breastfeeding, menstrual return is expected in _______; in some women, no menstruation occurs during the ________.

8 weeks 3-4 months entire lactation period

(important: _______ during lactation is no guarantee that the woman will not become pregnant. She may be ovulating the absence of menstruation may her body’s way of _______ for lactation. Implication: she should be protected against a _________ by observing a method of contraception, except the pill).

amenorrhea conserving fluids subsequent pregnancy

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes • Postpartum check – up – should be done after the _______ postpartum to assess involution.

6th week

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes 3. Urinary Changes - There is marked diuresis within _______ postpartum to eliminate excess ________ during pregnancy. - Some newly delivered mothers may complain of ________ ; explain that this is due to urinary retention with overflow. Other, on the other hand, may have difficulty voiding because of ___________ or ___________.

``` 12 hours tissue fluid accumulation frequent urinating in small amounts decreased abdominal pressure trauma to the trigone of the bladder ```

Is a condition in which the kidneys filter too much bodily fluid

Diuresis

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes 3. Urinary Changes Voiding may be initiated by: • Pouring warm and cold water alternately over the _____ • Encouraging the client to go the ______ • Let her listen to the __________ • If these measures fail, ________, done gently and aseptically, is the last resort on doctor’s order. (if there is resistance to the catheter when it reaches the _________, ask patient to breathe through the _____ while rotating the catheter before moving it inward again).

``` vulva comfort room sound of running water catheterization internal sphincter mouth ```

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes 3. Urinary Changes 4. Gastrointestinal changes – delayed bowel evacuation postpartally may be due to: • Decreased ______ • Lack of _________during labor • _________ • Fear of pain from _______ due to episiotomy, lacerations or hemorroids

muscle tone food + enema Dehydration perineal tenderness

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. 1. Vascular changes 2. Genital Changes 3. Urinary Changes 5. Vital Signs -Temperature may increase because of the ________ of labor. Implication: any increase in body temperature during the first _______ postpartum is not necessarily a sign of postpartum infection. Bradycardia (heart rate of 50 – 70 per minute) is common for ________

dehydrating effects 24 hours 6 – 8 days

PRINCIPLES OF POSTPARTUM CARE B. Provide emotional support – the psychological phases during the postpartum period are: • ______– first 1 – 2 days postpartum when mother is passive and relies on others to care for her and her newborn. She keeps on verbalizing her feelings regarding the recent delivery for her to be able to integrate the experience into herself.

Taking – in phase

(an overwhelming feeling of sadness that cannot be accounted for) may be observed. Could be due to hormonal changes, fatigue or feeling of inadequacy in taking care of a new baby.

Postpartum blues

PRINCIPLES OF POSTPARTUM CARE B. Provide emotional support – the psychological phases during the postpartum period are: • _______ – begins to initiate action and make decisions. Postpartum blues (an overwhelming feeling of sadness that cannot be accounted for) may be observed. Could be due to hormonal changes, fatigue or feeling of inadequacy in taking care of a new baby. Management: explain that it is normal; ________ is therapeutic, in fact.

Taking hold phase | crying

PRINCIPLES OF POSTPARTUM CARE C. Prevent postpartum complications - ___________ - ___________

Hemorrhage | Infection

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. B. Provide emotional support – the psychological phases during the postpartum period C. Prevent postpartum complications D. Establish successful lactation -________ and _________ after placental delivery fall rapidly. Stimulates anterior pituitary gland to produce _______ acts on Acinar cells to produce foremilk stored in collecting tubules.

Estrogen progesterone levels proclatin

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. B. Provide emotional support – the psychological phases during the postpartum period C. Prevent postpartum complications D. Establish successful lactation When infant sucks ________ is stimulated to Produce ______ causes contraction of smooth muscles of Collecting tubules milk ejected forward let – down or milk ejection _________ is produced

posterior pituitary gland oxytocin Reflex hindmilk

As your baby continues to nurse, they begin to pull milk from deeper within the breast where the fatty milk cells are stored. This milk, which is more fat-filled than the earlier milk, is called the ______. Often appears thick and creamy and is richer and more calorie dense than the foremilk.

hindmilk

Implications of physiology of Breastmilk production | • Regardless of the mother’s _________, ________, or ________, milk will be produced.

physical condition method of delivery breast size/condition

Implications of physiology of Breastmilk production • Lactation does not occur during pregnancy because ______ and _______ are present and therefore inhibit prolactin production. • Lactation – suppressing agents are to be given immediately after _________ to be effective. • Oral contraceptives are contraindicated in lactating mother because they contain ______ and _________, thereby decreasing milk supply. • Afterpains are felt more by breastfeeding women because of __________; they also have less _____and experience more ________.

``` estrogen progesterone placental delivery estrogen , progesterone oxytocin production lochia rapid involution ```

Is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue.

lochia

Implications of physiology of Breastmilk production • In an emergency delivery; • Determine the ____, whether the woman in labor is a _______, and the stage of labor. • If no sterile equipment is available to cut the cord, wrap the ________ ; never cut the cord unless sterile equipment is are available. • If the uterus fails to contract after delivery, put the infant to the _____; the sucking of the infant produces _______ which causes uterine contraction

``` EDC primi or a multi baby and placenta together breast oxytocin ```

Implications of physiology of Breastmilk production Advantages of Breastfeeding For mother • _____ in terms of time, money and effort • More rapid _____ • Less incidence of __________, according to some studies For the baby • Closer _______ relationship • Contains _______ that protect against common illnesses • Less incidence of ________ • Always available at the ____________

``` Economical involution cancer of the breast mother – infant antibodies gastrointestinal diseases right temperature ```

Implications of physiology of Breastmilk production Health Teachings Hygiene • Wash breasts ____ at bath or shower time. • ______ should never be used on the breasts as they tend to dry and crack the nipples and cause sore nipples. • Wash hands ______ every feeding. • Insert clean ______ or _______ in the brassiere to absorb moisture when there is considerable breast discharge.

daily Soap or alcohol before and after OS squares or piece of cloth

Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League • ________ with a pillow under the mother’s head while holding the bulk of breast tissues away from the infant’s nose. • Stimulate the baby to open his mouth to grasp the _______ by means of the rooting reflex. • Infant should grasp not only the nipple but also the _____ for effective sucking motion. Effectiveness is ensured when the: o baby’s mouth parts “hike well up” into ______ o mother feels _____ as the baby sucks _______ flows with milk while baby is feeding on other breast • To prevent nipples from becoming sore and cracked, infant should be introduced to the breast _____ The baby should be fed for only ______ at each breast during each feeding on the first day, increasing the time at each breast by ______ per day until the infant is nursing for ______ at each breast, making a total feeding time of _________.

``` Side-lying position nipples areola areola after pains other nipple gradually 5 minutes 1 minute 10 minutes twenty minutes per feeding ```

Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League • For continuous milk production, at each feeding, the infant should be placed first on the breast he fed ________ . This ensures that each breast will be ______ at every other feeding. If breasts are completely emptied, they completely refill; if only half-emptied will also half-refill and after some time, will become insufficient. • To break away from the ______ at the breast after feeding, insert a clean little ________ to release the suction, then pull the chin down. This also helps prevent sore nipples. • Feed as often as the baby is hungry, especially during the first few days, because he is receiving _____ which is not very filling; however, it contains _______, the only group of substances that can never be replicated by any artificial formula. • Advise the mother to learn how to relax during feedings because tension prevents ______

``` last in the previous feeding completely emptied closed suction finger in the corner of the infant’s mouth colostrums gamma globulin (antibodies) good let-down ```

Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League Associated problems _________ – feeling of tension in the breasts during the third postpartum day sometimes accompanied by an increase in temperature (milk fever). The breasts become full, feel tense and hot, with throbbing pain.

Engorgement

Engorgement lasts for about _____ and is due to increased _______ and __________.

24 hours lymphatic venous circulation

Management of Engorgement: • Advise use of _______ brassiere for good support. It will not only decrease the discomfort from breast engorgement but will also prevent ________. • _______ is is applied if the mother does not intend to breastfeed; ________ is applied if she will breastfeed. • ______ should not be used and _________ should not done if the mother is not going to breastfeed, since either will stimulate milk production.

``` firm-fitting contamination of the nipples and areolae Cold compress warm compress Breast pump breast massage ```

Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League Associated problems _________– not contraindications to breastfeeding. Management: • Do not use _______that are found in some nursing bras because they prevent air from circulating around the breasts. - Use ________.

Sore nipples plastic liners nipple shield

``` Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League Associated problems ________ – inflammation of the breasts Symptoms • ______ pain, ______ and _______ in breast tissues • _____ in the breasts • Milk becomes ______ Management • ______ as ordered • ____ compress • Proper breast _______ • _________ in affected breast ```

``` Mastitis Localized swelling redness Lumps scantly Antibiotics Ice support Discontinue breastfeeding ```

Implications of physiology of Breastmilk production Health Teachings Method – as suggested by the La Leche League Nutrition – lactating mothers should take _______ calories daily and should have larger amounts of _________, ______, _____, ________, ________ and

``` 3000 proteins (96 Gms per day) calcium iron Vitamins A Vitamins B ```

PRINCIPLS OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. B. Provide emotional support – the psychological phases during the postpartum period are: C. ________ women can have the same requirements as in pregnancy.

Non-breastfeeding

PRINCIPLES OF POSTPARTUM CARE C. Non-breastfeeding women can have the same requirements as in pregnancy. Contraindications • Drugs – ______, ______, ________, _________, _______, ________. (Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are generally not contraindicated. Therefore, diabetics and those with asthma can breastfeed.)

``` oral contraceptives atropine anticoagulants antimetabolites cathartics tetracyclines ```

PRINCIPLES OF POSTPARTUM CARE C. Non-breastfeeding women can have the same requirements as in pregnancy. Contraindications • Certain disease conditions, specifically ________, because of the close contact between mother and baby during feeding. (However, mothers may use masks to prevent droplet spread) TB germs, however, are not transmitted thru breast milk.

tuberculosis

PRINCIPLES OF POSTPARTUM CARE A. Promoting and return to normal (involution) of different parts of the body. B. Provide emotional support – the psychological phases during the postpartum period are: C. Non-breastfeeding women can have the same requirements as in pregnancy. E. Motivate use of ______– the success of the family planning program depends to a large extent on the motivation of both husband and wife.

family planning methods

RISK CONDITIONS INFECTIONS A. _______ Cause: Treponema pallidum – a spirochete which enters the body during coitus or through cuts and breaks in the skin or mucous membrane

Syphilis

Treatment for Syphilis: ______________ will usually prevent congenital syphilis in the newborn because penicillin readily crosses the placenta.

2.4-4.8 million units of Penicillin (if allergic, 30-40 gms. erythrocin)

If untreated, syphilis can cause ________, _______ in the newborn or even _______.

midtrimester abortion CNS lesions death

The newborn with congenital syphilis Signs and symptoms - _________– first sign of the disease - ______ and ____________ - ___________; coppery rashes on _____ and ______; ________; ________; _________due to bone inflammation - If untreated, can progress on to _______, _______, _______, _______

``` Jaundice at 2 weeks of life Anemia, hepatosplenomegaly “Snuffles” (persistent rhinorrhea) palms, soles mucous patches condylomas pseudoparalysis ``` ``` deformed bones teeth nose joints CNS syphilis ```

Is the free discharge of a thin nasal mucus fluid.

Rhinorrhea or rhinorrhoea

Is the medical term for genital warts.

Condyloma

Management congenital syphilis: _______ for ___ days or ______________

Penicillin IM 10 one long-acting Penicillin (Penadur LA)

``` RISK CONDITIONS INFECTIONS B. ___________ Incidence- - Mother – the _____ the mother contracted the disease, the greater the likelihood that the baby will be affected. ```

Rubella/German Measles | earlier

The rubella virus slows down division of infected cells during _______, thus causing congenital defects

organogenesis

- Newborn – can carry and transmit the rubella virus for as long as _______ after birth

12-24 months

Signs and symptoms of Congenital Rubella Syndrome | - ____ birth weight; _____; _______; _______; _________; _______

Low, jaundice, petechiae, anemia, thrombocytopenia | hepatosplenomegaly

``` - Classic sequelae Congenital Rubella Syndrome • Eyes: _______, ______, ______ • Heart: _______, ______, ________ • Ear: ________ • Dental and facial _____ ```

``` chorioretinitis cataract glaucoma Patent Ductus Arteriousus stenosis coarctations Nerve deafness clefts ```

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Sources - Endogenous (primary) sources – bacteria in the normal flora become virulent when _________ ```

tissues are traumatized and general resistance is lowered.

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Sources - Exogenous sources – pathogens introduced from external sources. (Most common is ________). ```

anaerobic streptococci

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Common exogenous sources: • __________ • Excessive __________ • __________ – faulty handwashing, unsterile equipments and supplies • ______ in late pregnancy • Premature ________ ```

``` Hospital personnel obstetric manipulations Breaks in aseptic techniques Coitus rupture of the membranes ```

RISK CONDITIONS INFECTIONS C. Postpartum Infection General symptoms: ______, _____, ______ and ______

malaise anorexia, fever, chills and headache

``` General management Postpartum Infection Sources - _________ - _________ - _________ - _________ - _______ and _______, as ordered ```

``` Complete bed rest (CBR) Proper nutrition Increased fluid intake Analgesics Antipyretics , antibiotics ```

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Types of infection Specific symptoms - Pain, heat and feeling of pressure in the perineum - Inflammation of the suture line, with 1 or 2 stitches sloughed off - With or without elevated temperature ```

1. Infection of the perineum

1. Infection of the perineum Specific management

- Doctor removes sutures to drain area and resutures | - Hot sitz bath or warm compress

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Specific symptoms - Abdominal tenderness - Uterus not contracted and painful to touch - Dark brown, foul-smelling lochia ```

2. Endometritis

2. Endometritis Specific management

- Oxytocin administration | - Fowler’s position to drain out lochia and prevent pooling of infected discharge

RISK CONDITIONS INFECTIONS C. Postpartum Infection – infection of the lining of a blood vessel with formation of clots; usually an extension of endometritis

3. Thrombophlebitis

RISK CONDITIONS INFECTIONS 3. Thrombophlebitis Specific symptoms - ____, ______ and _____ - Leg begins to swell below the lesion because _______ has been blocked - Skin is stretched to a point of shiny whiteness, called ________

Pain, stiffness and redness in the affected part of the leg venous circulation milk leg or phlegmasia alba dolens

``` RISK CONDITIONS INFECTIONS 3. Thrombophlebitis Specific symptoms - _______ – pain in the calf when the foot is dorsiflexed ```

Positive Homan’s sign

Specific management 3. Thrombophlebitis - Bed rest with affected leg ______ - Anticoagulants, e.g., ______ or _______, to prevent further clot formation or extension of a thrombus - Analgesics are given but never Aspirin because it inhibits _______ therefore causes hemorrhage

elevated Dicumarol or Heparin prothrombin formation

RISK CONDITIONS INFECTIONS C. Postpartum Infection 4. _____– inflammation of breast tissues

Mastitis

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Mastitis Pathophysiology – local inflammatory response to _______ ; ______may occur; organism can be recovered from ______. Etiology – most common: _________ ```

bacterial invasion suppuration breast milk Staphylococcus aureus

``` RISK CONDITIONS INFECTIONS C. Postpartum Infection Mastitis Assessment - Signs of infection (may occur several weeks postpartum). - ____ - ____ - ____ - ____ - ____ Breast - ______ areas - Localized/generalized ______ - _____, _____, _______. ```

``` Fever Chills Tachycardia Malaise Abdominal pain ``` Reddened swelling Heat, tenderness, palpable mass.

RISK CONDITIONS INFECTIONS C. Postpartum Infection Mastitis Nursing care – goal: _________. Health teaching in early postpartum - _______ - ______ • Wash with_____ only (no soap) • Let breast milk dry _____ to prevent drying of tissue. • Clean bra ______ to support breasts, reduce friction, minimize exposure to microorganisms. • Good _________

``` prevent infection Handwashing Breast care warm water on nipples (with no plastic pads or liners) breastfeeding techniques ```

``` RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding A. _____ 1. Spontaneous 1.1 Threatened 1.2 Imminent 1.2.1 Complete 1.2.2 Incomplete 2. Induced 3. Missed B. ______ 1. Tubal – most common 2. Cervical 3. Ovarian Second Trimester Bleeding A. __________ B. __________ Third Trimester Bleeding A. ________ B. ________ ```

Abortion Ectopic pregnancy Hydatidiform Mole Incompetent Cervical Os Placenta Previa Abruptio Placenta

``` RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding 1. _______ any interruption in pregnancy before the age of viability ```

Abortion

Occurs when an embryo implants somewhere other than the uterus, such as in one of the fallopian tubes.

Ectopic pregnancy

``` RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding Abortion Spontaneous Natural causes - ________= most common cause. It is nature’s way of eliminating the birth of a congenitally defective baby _________abnormality Following _______, ______ (e.g., rubella, influenza) or _______ ```

Blighted ovum/germ plasma defect Implantation or hormonal trauma, infection or emotional problems

RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding Abortion Types of Spontaneous - Threatened Symptom: _______ bleeding which is moderate in amount Management • Complete bed rest for ______; if bleeding will stop it usually stops within this time • Coitus is restricted for _____ after bleeding has stopped in order to prevent further bleeding or infection • _______ therapy • Advise patient to _____ all pads, clots and expelled tissues

``` bright red vaginal 24-48 hours 2 weeks Endocrine/hormonal save ```

``` RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding Abortion Types of Spontaneous - Imminent/inevitable Symptom: Bright red vaginal bleeding which is moderate in amount and accompanied by _______ and _______. Loss of the ______ is inevitable. ```

uterine contractions cervical dilatation products of conception

Abortion Types of Spontaneous - Imminent/inevitable Management – depends on whether it is: • ________ – all products of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed. • _______ – part of the conceptus (usually the fetus) is expelled, but membranes or placental fragments are retained. D & C is indicated as management.

Complete abortion | Incomplete abortion

Abortion 2. - ________ – is never allowed in the Philippines

Induced abortion

• Therapeutic – performed by a doctor in a controlled hospital or clinic setting for a medical or a legal reason. Also known as ____, ______ and _____

medical, planned or legal abortion.

Abortion - 3. _______ – fetus dies in utero but is not expelled. Usually discovered at a prenatal visit when ________ is measured and no increase is demonstrated or when previously heard fetal heart tones are no longer present. In _______, signs of abortion should occur; otherwise, labor will have to be induced to prevent _________ or _____.

``` Missed abortion fundal height two weeks’ time hypofibrinoginemia sepsis ```

``` RISK CONDITIONS BLEEDING/HEMORRHAGE A. Bleeding in pregnancy First Trimester Bleeding 1. Abortion 2. ________ – any gestation located outside the uterine cavity. ```

Ecotopic Pregnancy

Ecotopic Pregnancy Signs and symptoms – since the wall of the Fallopian tube is not sufficiently elastic, it ruptures within the _______ of gestation as it can no longer give way for growing fetus - _____________ either the right or left lower quadrant (in bleeding wherein there is no exit or egress of blood from the body, pain is the outstanding symptom; this pain differentiates Ectopic pregnancy from abortion) - Rigid ______ - _______ – bluish umbilicus - Excruciating pain when cervix is moved on IE - Signs of shock: ____, ________, _____, __________

``` first 12 weeks Severe, sharp, knife-like stabbing pain abdomen (+) Cullen’s sign falling BP, PR more than 100/minute, rapid RR, lightheadedness ```

Management – ruptured Ectopic pregnancy is an emergency situation. - ________ – if Fallopian tube can still be replaced and preserved

Salpingosomy

A _________ is a surgical incision into a fallopian tube

salpingostomy

Second Trimester Bleeding A. _________ – developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi Incidence: Is the most common lesion anteceding _______.

Hydatidiform Mole | choriocarcinoma

``` Second Trimester Bleeding A. Hydatidiform Mole It occurs most often in women: - From low socioeconomic backgrounds with _________ - Over ____ and under _____ of age. ```

low protein intake | 35 years, 18 years

Second Trimester Bleeding A. Hydatidiform Mole Signs and symptoms – Because of rapid proliferation of the placental tissues and, therefore, high levels ____

of HCG

Second Trimester Bleeding A. Hydatidiform Mole Signs and symptoms – - Highly _____ for pregnancy (that is why a positive pregnancy test cannot be considered a positive sign of pregnancy) - _____ and _____ is usually marked - Rapid increase in _____. Rapid increase in _____ - Toxemia signs and symptoms appear before the _______ - No ________ - Vaginal bleeding seen as ___, ______, _________

``` positive urine test Nausea and vomiting fundic height, weight 24th week of gestation fetal heart tones clear, fluid-filled, grape-sized vesicles ```

Management of Hydatidiform Mole - D & C to evacuate the mol - Prophylactic course of _______, the drug of choice for choriocarcinoma - _____ for one year to find out if new villi are developing. ______ (but not the pills) have to be used so as not to confuse the results

Methotrexate Urine testing Contraceptives

Second Trimester Bleeding A. Hydatidiform Mole B. ______________ – one that dilates prematurely. It is the chief cause of habitual abortion (3 or more consecutive abortions).

Incompetent Cervical Os

``` Second Trimester Bleeding A. Hydatidiform Mole B. Incompetent Cervical Os Causes - _________factors - _________ factors - Trauma to the ___ ```

Congenital developmental Endocrine cervix

``` Incompetent Cervical Os Signs and symptoms - Presence of ___ and _______ - _____ of membranes - ______ cervical dilatation ```

show and uterine contractions Rupture Painless

Second Trimester Bleeding A. Hydatidiform Mole B. Incompetent Cervical Os Management: ___________– a cerclage procedure wherein purse string sutures are placed around the cervix on the ______________. These are removed during vaginal delivery (if _______, since sutures are temporary) or the patient delivers by cesarean section (if _________, since sutures are permanent).

``` McDonald method /Shirodkar-Barter procedure 14th - 18th week of gestation McDonald’s method Shirodkar method ```

``` Third Trimester Bleeding A. __________ – low implantation of the placenta so that it is in the way of the presenting part. Predisposing factors - Increasing _____ - Advanced ________ - Rapid succession of _______ ```

Placenta Previa parity maternal age pregnancies

Types of Placenta Previa - Low lying - Partial - Complete Diagnosis – made by means of ______and ______ Uses intermittent waves of very ________ in order to “picture the fetus”. ________ are projected towards the mother’s abdomen, are reflected back and converted into electrical impulses and recorded on a permanent graph paper).

symptoms and ultrasound (also known as Ultrasonic Echo Sounding or Sonar. high frequency/above audible range Sound waves

Placenta Previa Diagnosis - Preparation for ultra sound • Explain the procedure to the patient, informing her that it is ______ and there are ________ • Empty the bladder but ask the patient to take _____ of water afterwards in order to _______ the bladder. A full bladder displaces a _______ and, therefore, permits better visualization of the pelvis and its contents.

``` painless no known ill effects 6 glasses dilate gas filled bowel ```

- Clinical uses of ultra sound • Diagnose pregnancy as early as ___________ • Can establish that the fetus is _______ and, therefore, can predict ____ • Can determine gestational age by measuring the _________ (if it is more than _____., it is more than _____ gms); therefore, can diagnose ________, ________, ________ and _________ • Can demonstrate size and growth rate of the _______; therefore; can identify poly- or oligo-hydramios • Can confirm presence, size and location of the ______; therefore, is valuable before amniocentesis • Can diagnose ______ • Can visualize ____, ______, ______, etc. • Can determine ___________ ( _________and if in _________)

5-6 weeks gestational age increasing in size, EDC biparietal diameter of the fetal skull, 8.5 cm, 2500 intrauterine growth retardation, hydrocephaly, microcephaly, anencephaly amniotic sac placenta multiple pregnancy ascites, polycystic kidneys, ovarian cysts baby’s sex (during third trimester and cephalic presentation)

Third Trimester Bleeding Placenta Previa Signs and Symptoms – first and most constant: _____, ________ due to tearing of placental attachment as a consequence of ___________

painless, bright red vaginal bleeding | dilatation of the internal cervical os

``` Third Trimester Bleeding Placenta Previa Management - _____ bed rest - Monitor _______ and the ______ - Prepare _____ and ______ - ____________ is not done. If ever it is to be done, it has to be a double set-up (done in the operating room wherein the patient has already signed the consent form, _______ have been given, ______ has been done, etc., so that if ever placenta is accidentally detached ____, can be done immediately. ```

``` Complete vital signs of the mother and fetal heart rate oxygen and blood Internal examination (IE) preop medication abdominal prep CS ```

``` Third Trimester Bleeding Placenta Previa Complications - _______ - _______ - _______ ```

Hemorrhage Infection Prematurity

Third Trimester Bleeding A. Placenta Previa B. _______ – premature separation of the placenta

Abruptio Placenta

Predisposing factors of Abruptio Placenta - Maternal ______ or ______ - Increasing ____ and _______ - Sudden release of _______ - Short ____________ - Direct ______ - _________

``` hypertension or toxemia parity and maternal age amniotic fluid umbilical cord trauma Hypofibrinoginemia ```

Abruptio Placenta Signs and symptoms - Severe, sharp, knife-like, stabbing pain high in the ______ - Hard, boardlike ______; rigid _____

fundus uterus abdomen

Abruptio Placenta Signs of shock - Concealed bleeding, if extensive, causes uterus to lose its ability to ______. It becomes ecchymotic and copper-colored, called ________, causing severe bleeding. Since the uterus no longer has the ability to contract, ________ will have to be done.

contract Couvelaire uterus hysterectomy

BLEEDING/HEMORRHAGE B. Postpartum Hemorrhage 1. ______ – uterus is not contracted, relaxed or boggy; most frequent cause

Uterine Atony

Predisposing factors Uterine Atony - _______multiple pregnancy, multiparity, excessively large baby, polyhydramnios - ________ - ________ (previa or abruptio) - ______ and _____ labor

Overdistention of the uterus Caesarian section Placental accidents Prolonged and difficult

Management Uterine Atony - _____ – first nursing action - ____ compress - ________ administration - ______ the bladder - ________ to explore retained placental fragments - ______ – last resort

``` Massage Ice Oxytocin Empty Bimanual compression Hysterectomy ```

``` BLEEDING/HEMORRHAGE B. Postpartum Hemorrhage 1. Uterine Atony 2. Lacerations 3. ________ – a clothing defect, Management: _______ Late postpartum _________________ ```

Hypofibrinoginemia blood transfusion hemorrhage

``` BLEEDING/HEMORRHAGE B. Postpartum Hemorrhage 1. Uterine Atony 2. Lacerations 3. Hypofibrinoginemia 4. _______ – management: dilatation and curettage (D & C) ```

Retained placental fragments

Is a procedure to remove tissue from inside your uterus.

Dilation and curettage (D&C)

``` BLEEDING/HEMORRHAGE B. Postpartum Hemorrhage 1. Uterine Atony 2. Lacerations 3. Hypofibrinoginemia 4. Retained placental fragments 5. _________ – due to injury to blood vessels in the perineum during delivery Incidence: Commonly seen in _______ and those with _______ Treatment - ______ during first 24 hours - ______, as ordered - Site is ______ and bleeding vessel is _____ ```

Hematoma precipitate delivery perineal varicosities Ice compress Oral analgesics incised ligated

Is extremely rapid labor and delivery.

Precipitous labor

- a vascular disease of unknown cause which occurs anytime after the 24th week of gestation up to two weeks postpartum.

TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH)

``` TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) Triad of symptoms - _________ - _________ - _________ (specifically albumiuria). ```

Hypertension Edema Proteinuria

TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) Predisposing factors - Age – primis under ___ and over ____ years - Gravida – _____ pregnancies - Low socioeconomic status (SES) - _____ pregnancy - With underlying ________, e.g., heart disease, hypertension or diabetes

20, 30 5 or more Multiple medical conditions

describes the total number of confirmed pregnancies that a woman has had, regardless of the outcome. .

Gravida or gravidity

is defined as the number of births that a woman has had after 20 weeks gestation

Para or parity

``` Classification TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) 1. Acute toxemia – symptoms appear after the _______ of gestation A. _______ Mild Severe B. _______ II. Chronic hypertension with pregnancy III. Unclassified ```

24th week Preeclampsia Eclampsia

A._______ - Generalized vasoconstriction and associated microangiopathy disease of capillaries - Abnormal retention of _____ and _____ by body tissues Medical complications - _______ hemorrhage - Acute _______ - Acute ______

``` Preeclampsia sodium and water Cerebrovascular pulmonary edema renal failure ```

Types of Preeclampsia Mild preeclampsia – signs and symptoms - _____________ per week (earliest sign of preeclampsia) due to edema which is persistent and found in the _______ of the body (e.g. inability to wear the wedding ring) - Systolic BP of ___, or an increase of __ and a diastolic of ___, or a rise of _______, taken twice 6 hours apart. - Proteinuria of _______

``` Sudden, excessive weight gain of 1-5 lbs. upper half 140, 30mm. Hg. or more 90, 15 mm. Hg. or more 0.5 gms/liter or more ```

``` Types of Preeclampsia Severe preeclampsia – signs and symptoms - BP of _________. - Proteinuria of _______ in 24 hours - ______ of 400 ml. or less in 24 hours (normal urine output/day = ______). - ________ disturbances - Pulmonary ____ and _____ - ________ (considered an “aura” to the development of convulsions) ```

``` 160/110 mm Hg 5 gm/liter or more Oliguria 1500 ml Cerebral or visual edema and cyanosis Epigastric pain ```

B. Eclampsia – the main difference between preeclampsia and Eclampsia is the presence of ______ in eclampsia.

convulsion

Signs and symptoms of Eclampsia as in preeclampsia plus: - increased _______ - increased ______ decreased ____ combining power

BUN/Blood urea nitrogen uric acid CO2

Diagnosis of Eclampsia: ________– assesses the probability of developing toxemia when performed between the ___ and _____ of pregnancy. Procedure - Patient lies in _________ for 15 minutes until BP has stabilized - Then rolls over to _______ - BP is taken at 1 minute and ______ after having rolled over. Interpretation: if diastolic increases ______, patient is prone to toxemia.

``` roll-over test 28th 32nd week lateral recumbent position supine position 5 minutes 20 mm Hg or more ```

Management of Eclampsia - Complete bed rest – _______ tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in _________ to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of ________ and decreased blood flow that diminishes the amount of _____ and _____ in cells. In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling.

sodium decreasing metabolic rate vasoconstriction nutrients and oxygen

Diet - For mild preeclampsia – high _____, high _______, moderate ______ (no added table salt, including “bagoong”, “patis”, “tuyo”, canned goods, bottled drinks, preserved foods and cold cuts) - For severe preeclampsia – high _____, high _____ and _______

protein, carbohydrate, salt restriction | protein, calorie, salt-poor (3 gms of salt per day)

Medications - _______ – e.g., chlorthiazide/Diuril. Hourly urine output should be at least ______. (normally 50-60 ml. per hour) Pharmacologic effect: decreased reabsorption of _____ and ______ at the proximal tubules, thereby increasing renal excretion of sodium, chloride and water, including ______. Side effects: _____ and _____ due to fluid and electrolyte imbalance Nursing care: closely monitor intake and output

``` Diuretics 20-30 ml sodium and chloride potassium fatigue and muscle weakness ```

Medications - ______ – if with heart failure. Pharmacologic action: Increase the force of ________, thereby decreasing heart rate. Important: Should not be given, therefore, if heart rate is _____. Implication: take the heart rate before giving the drug.

Digitalis contraction of heart below 60/minute

Medications - ______– patients receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the heart to the effects of ______. Potassium supplements (e.g., banana) must be given tot prevent ______

Potassium supplements digitalis cardiac arrhythmias.

Medications - _______ – sedation by means of CNS depression - Analgesics; antihypertensives; antibiotics; anticonvulsants; sedatives

Barbiturates

Medications - ________ – the drug of choice Actions: ________– lessen the possibility of convulsions ________– decreases the BP Cathartic causes a shift of fluid from the extracellular spaces into the ______ from where the fluid can be excreted. Dosage: ____ initially, either by _________, or _______, then _________ IF: ________ are present Respiratory rate is at least ____per minute Urine output is at least _____ in 6 hours Antidote for magnesium sulfate toxicity: ________, _____, to maintain cardiac and vascular tone. Earliest sign of magnetism sulfate toxicity: disappearance of the __________.

``` Magnesium sulfate CNS depressant Vasodilator intestines 10 gms. slow IV push over 5-10 minutes deep IM, 5 gms/buttock IV drip of 1 gm. per hour (1 gm/100 ml. D10W) Deep tendon reflexes 12 100 ml. Calcium gluconate 10% IV knee jerk/patellar reflex ```

Method of delivery – preferably ______, but if not possible, ____ will have to be done. Prognosis: the danger of convulsions is present until ____ postpartum.

vaginal CS 48 hours

_______ – chronic hereditary disease which is characterized by hyperglycemia due to relative ______ from the pancreas which, in turn, leads to abnormalities in the metabolism of ______, ______ and ___.

DIABETES MELLITUS insufficient or lack of insulin carbohydrates, proteins and fats.

Diabetogenic effects of pregnancy – many women who have had no evidence of diabetes in the past develop abnormalities in _______ - Decrease ______because of increased _____; that is why it is common to find dextrose and lactose in the urine of pregnant women - increased production of adrenocorticoids, anterior pituitary hormones and thyroxin, which affect ______ in blood (hyperglycemia) - rate of insulin secretion is ______ but sensitivity of the pregnant body to insulin is _____, i.e., _____ does not seem to be normally effective during pregnancy

``` glucose tolerance renal threshold for sugar , estrogen carbohydrate concentration increased decreased insulin ```

``` DIABETES MELLITUS Attendant risks - _____ - _____ - _____ - _____ - _________ – because of vascular complications which affect placental circulation - ______– because of nausea and vomiting. It is the chief threat to the fetus in utero - _____ – due to excessively large baby ```

``` Toxemia Infection Hemorrhage Polyhydramnios Spontaneous abortion Acidosis Dystocia ```

``` DIABETES MELLITUS Diagnosis – made on the basis of the ________ Procedure - _____ after midnight - If more than 120 mg% - ________ ```

glucose Tolerance Test (GTT) NPO overt gestational diabetes

DIABETES MELLITUS Categories – to predict the outcome of pregnancy - ______– GTT is only slightly abnormal; minimal dietary restriction; insulin not need; fetal survival is high - ______– have 25% perinatal mortality - _____– therapeutic abortion (in other countries may be justified, not in the Philippines)

Class A Classes C to E Class F

DIABETES MELLITUS Management - Diet – highly individualized. Adequate glucose intake (1800-2200 calories) to prevent _________. - Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones are more pronounced during the ________ there is increased need for insulin. • Insulin is regulated to keep urine________ (minimal _______is necessary to prevent acidosis) but negative for _______. • __________will have to be changed to regular insulin (Lente) during the ______ of pregnancy. - Often delivered by ____ • Baby is typically larger or maybe in distress because of ________ • Severe metabolic imbalances in vaginal delivery can occur because of _______ reserve in the liver and skeletal muscles by strenuous muscular exertion during labor. - Maximum difficulty in controlling diabetes is during the _______because of the drastic changes in hormonal levels.

``` intraurine growth retardation 2nd and 3rd trimesters +1 for sugar glycosuria acetone Long-acting insulin (Ultralente) last few weeks CS placental insufficiency depletion of glycogen early postpartum period ```

Infant of the Diabetic Mother (IDM) Is typically ___ and _____ because of: - excessive supply of ____ from the mother - increased production of _______ from the maternal pituitary gland - increased secretion of _____ from the fetal pancreas - increased action of _______ that favor passage of glucose from mother to fetus

``` longer weighs more glucose growth hormones insulin adrenocortical hormones ```

Infant of the Diabetic Mother (IDM) ________ are often seen _________ (puffy, but limp and lethargic) More often born premature, so _______ syndrome is common Lose a greater proportion of _____ than normal newborns because of loss of extra fluid

Congenital anomalies Cushingoid appearance respiratory distress weight

Infant of the Diabetic Mother (IDM) Are prone to the following complications - _______ – blood sugar level less than 30 mg%. It is the most common complication to watch for Cause: while inside the uterus, the fetus tends to be _______ because of maternal hyperglycemia. The fetal pancreas thus responded to the high glucose level by producing matching high levels of insulin. Following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high levels of insulin, hypoglycemia develops. Clinical signs of hypoglycemia • ______ • ________ • _______ • _______ • _______ Consequences: hypoglycemia, if not treated, can lead to ______ and even death Management: feed with ______earlier than usual, or administer ______

``` Hypoglycemia hyperglycemic Shrill, high-pitched cry Listlessness/jitteriness/tremors Lethargy; poor suck Apnea; cyanosis Convulsions brain damage glucose water IV of glucose. ```

Infant of the Diabetic Mother (IDM) Are prone to the following complications - _____ – serum calcium level of less than 7 mg%. Signs: same as hypoglycemia Sequela: Same as that of hypoglycemia Management: _______ to prevent hypocalcemic tetany

Hypocalcemia | Calcium gluconate

HEART DISEASE Classification - ____ – no limitation physical activity - ____ – slight limitation of physical activity; ordinary activity causes fatigue; palpitation, dyspnea or angina - ____ – moderate to marked limitation of physical activity; less than ordinary activity causes fatigue, etc. - ____ – unable to carry on any activity without experiencing discomfort

Class I Class II Class III Class IV

HEART DISEASE Prognosis - _______ – normal pregnancy and delivery - ______ – poor candidates

Classes I and II | Classes III and IV

HEART DISEASE Signs and symptoms - Because of increased ______ during pregnancy, heart murmurs are observed - Cardiac output may become so _____ that vital organs are not perfused adequately; oxygen and nutritional requirements, therefore, are not met. - Since the left side of the heart is not able to empty the ______ adequately, the latter become engorged, causing ______ and ______. _____ in gravidocardiacs, therefore, is a danger sign. - Liver and other organs become congested because blood returning to the heart may not be handled adequately, causing the ______ to rise. Fluid then escapes through the walls of engorged capillaries and cause ____ or _____ - ________ is a high probability also because of the increased cardiac pain on exertion, and cyanosis of nailbeds are obvious.

``` total cardiac volume decreased pulmonary vessels pulmonary edema and hypertension Moist cough venous pressure edema or ascites. Congestive heart failure ```

HEART DISEASE Management – consider the functional capacity of the heart - Bed rest – especially after the_______ to ensure that pregnancy is carried to term or at least _______ - Diet – should ___enough, but not too much as it would add to the workload of the heart - Medications • _____ • _______ e.g., Fer-in-sol or Feosol – anemia should be prevented because the body compensates by increasing cardiac output, thus further increasing cardiac workload. - Classes III and IV are not placed in ________ during delivery to avoid increasing venous return. The ______is preferred to facilitate easy respirations. - Anesthetic of choice is _______ for effortless, pushless and painless delivery. Remember: Gravidocardiacs are not allowed to push with contractions (to prevent ________ which increases venous return to an already weak, damaged heart). _______, therefore, is the best method of delivery. - ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral contraceptives are contraindicated because they cause ______ and promote ________ - Most critical period – the ________ because the 30% - 500

``` 30th week of gestation 36 weeks gestation gain Digitalis Iron preparations, lithotomy position semi-sitting position caudal anesthesia Valsalva maneuver Low forceps fluid retention thromboembolization. period immediately following delivery ```

``` MULTIPLE PREGNANCY (Twin Pregnancy) Classification - _______ – twins begin with a single ovum and sperm, but in the process of fusion or in one of the first cell divisions, the zygote divides into two identical but separate individuals. Characteristics - Always of the ____ - With _____, _____, _____and _______fused as one. Incidence – a ________ - More frequent among - ____ - More frequent among _____ and _____ ```

``` Monozygotic/Identical same sex 2 amnions 1 chorion 2 umbilical cords 2 placentas chance occurrence non-whites young primis , old multis ```

``` MULTIPLE PREGNANCY (Twin Pregnancy) Classification Dizygotic/Fraternal – two separate ova are fertilized by 2 separate sperms. They are actually sibling growing at the same time in utero. Characteristics - May or may not be of the _____ - With______, ______, ______ and _______ Incidence – ______ ```

same sex 2 amnions, 2 chorions, 2 placentas and 2 umbilical cords familial maternal pattern of inheritence

Suspect multiple pregnancy if: - faster rate of increase in ______ - on quickening, there are ___________________ - on auscultation, ____________ are heard - there is marked ______ not due to toxemia or obesity

uterine size several flurries of action in different abdominal positions 2 sets of fetal heart tones weight gain,

``` MULTIPLE PREGNANCY (Twin Pregnancy) complications - ______ - ______ - ______ - ______ - ______ - ______ ```

``` Toxemia Polyhydramnios Anemia Abruptio placenta Prematurity Postpartum hemorrhage ```

BLOOD INCOMPABILITY – an antigen-antibody reaction which causes excessive destruction of ______ - Mother is _____ and the fetus is _______ (because the father is either a homozygous or a heterozygous Rh positive) - Mother is ___ and the fetus is either ______ (because the father is either Type A or Type B)

``` fetal red blood cells Rh negative Rh positive Type O Type A or Type B ```

_______– broad term for abnormal or difficult labor and delivery

DYSTOCIA

``` ______ – sluggishness of contractions Causes - Inappropriate use of _____ - Pelvic bone _____ - Poor ______ - ________ – due to multiparity, multiple pregnancy, polyhydramnios or excessively large baby ```

``` Uterine Inertia analgesics contraction fetal position Overdistention ```

Uterine Inertia Types - ________ – relaxation are inadequate and mild, thus are ineffective. Since uterine muscles are in a state of greater than normal tension, _______ stage of labor is prolonged. Treatment: _______.

Primary (hypertonic) Uterine Dysfunction latent phase of the first sedate patient

Uterine Inertia Types - ________ – contractions have been good but gradually become infrequent and of poor quality and ______________ . Treatment: stimulation of labor either by ________or _______.

Secondary (hypertonic) Uterine Dysfunction cervical dilatation stops Oxytocin administration amniotomy

– labor and delivery that is completed in less than 3 hours after the onset of true labor pains. Probably due to multiparity or following Oxytocin administration or amniotomy. Can lead to: - _______ - ________ - ______ due to sudden release of pressure, leading to shock.

Precipitate Delivery extensive lacerations abruptio placenta hemorrhage

– in primis, labor lasting more than 18 hours and in multis, more than 12 hours. Can lead to: - ______ - ______ - ________

Prolonged Labor maternal exhaustion uterine atony caput succedaneum

``` – occurs when the uterus undergoes more straining than it is capable of sustaining. Causes - _______ - Unwise use of ______ - ______ - ______ - ______ ```

``` Uterine Rupture Scar from a previous classic Cesarean section (CS) oxytocins Overdistention Faulty presentation Prolonged labor ```

Uterine Rupture Signs and symptoms - _______ - ______ and clinical signs of shock (_______, _____, ______ ,_______, _______) - Change in ______, with two swellings on the abdomen: the ______and the ______ management: ______

Sudden, severe pain Hemorrhage restlessness, pallor, decreasing BP, increasing respiratory and pulse rates abdominal contour retracted uterus and the extrauterine fetus hysterectomy

– fundus is forced through the cervix so that the uterus is turned inside out. Causes - Insertion of _____ at the fundus, so that as fetus is rapidly delivered, especially if unsupported, the fundus is pulled down - Strong fundal push when mother fails to bear down properly during _____ - Attempts to ______before signs of placental separation appear Management: ______

``` Uterine Inversion placenta 2nd stage of labor deliver the placenta hysterectomy ```

– occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter maternal circulation and reach the ______

Amniotic Fluid Embolism | lungs as emboli.

Amniotic Fluid Embolism Signs and symptoms – are dramatic - Woman in labor suddenly sits up and grasps her chest because of ___________________ - Turns pale and then the typical bluish-gray color associated with _______ - _____ may occur in a few minutes

inability to breathe and sharp chest pain pulmonary embolism Death

``` Amniotic Fluid Embolism Management - Emergency measures to maintain life: ___, ___, ____ - Provide _____ in the ICU - Keep ______ - Provide _____ ```

IV, oxygen, CPR intensive care family informed emotional support

– if a woman has borderline (just adequate) pelvic measurements but fetal position and presentation are good. Maybe continued for as long as there is progressive ______ and the _______.

Trial Labor | fetal descent of the presenting part

Trial Labor Management: - Monitor ___ and ______ - Keep ______to allow all available space to be used by the fetus - Emotional support - _______ – blocks the release of Oxytocin. Side effects: nausea and vomiting, mental confusion, etc. (same side effects when alcohol is taken orally in excessive amounts) - _____– a vasodilator. Side effects: hypotension and tachycardia - ______ – a muscle relaxant given orally - _____ – a known bronchodilator If premature uterine contractions are accompanied by progressive fetal descent and cervical dilatation, _______is inevitable. - May not necessarily be _____ full term labor - ______ are kept to a minimum because analgesics are known to cause ________. As it is, premature babies already have enough difficulty breathing on their own; giving analgesics, therefore, would add up to the problem. Implication: give ______to the mother such that she focuses her attention not on her own needs but those of her baby. - ________ are given to the mother to help in the maturation of the fetal lungs by hastening production of surfactants - ________ is preferred because it does not compromise fetal respiration. - Episiotomy is not necessary smaller than in full term deliveries; may even be ____ so that the preemie can be delivered at the shortest possible time, since excessive pressure on the fragile preemie’s head can cause________ that could be fatal - _____ may be applied gently - ____ is cut immediately, rather than waiting for pulsations to stop, because preemies have difficult time ________ that will be formed from the extra amount of blood.

``` FHRs and uterine contractions bladder empty Ethyl alcohol (Ethanol) IV Vasodilan IV Ritodrine Bricanyl premature delivery shorter than Pain medications respiratory depression emotional support Steroids (glucocorticoids) Caudal, spinal or infiltration anesthesia larger subarachnoid hemorrhage Forceps Cord excreting large amounts of bilirubin ```

– to bring about labor either by amniotomy or drugs (Oxytocin, prostaglandins) before the time when it would have occurred spontaneously or because it does not occur spontaneously.

INDUCED LABOR

``` INDUCED LABOR Indications Maternal - ______ - ________ - ________ ```

Toxemia Placental accidents Premature rupture of the BOW

INDUCED LABOR Fetal - Diabetes – terminated about_______ if indicated - Blood incompatibility with rising titer - Excessive size - Postmaturity Prerequisites - No _____ - Fetus is viable – survival is decreased if ______ - Single fetus in _______ and ______ - Ripe cervix – _______; dilated______

``` 37 weeks AOG CPD below 32 weeks AOG longitudinal lie is engaged fully or partially effaced at least 1-2 cm. ```

INDUCED LABOR Procedure - _____ administration • _____ in 1000 ml of D5W at a slow rate of _____ given initially. If no fetal distress is observed in 30 minutes, infusion rate is increased _____ • Amniotomy will be done when cervical dilatation reaches _____. Check ___and ______ after amniotomy

``` Oxytocin 10 IU of Pitocin 8 gtts/minute 16-20 drops/minute 4 cm FHR quality of fluid ```

INDUCED LABOR Nurisng Care - Primary concern: monitor ______. If uterine contractions are unduly sustained, _____ can occur. - Monitor ____ regularly - _____ if with abnormalities in FHR or uterine contractions.

intensity of uterine contractions uterine rupture flow rate Turn off IV drip