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OB Lecture HandoutsTRANSCRIPT
Maternal and Child Nursing
1 Maria Nazarethe A. Sulit| ©2009
THE FEMALE REPRODUCTIVE SYSTEM
I. External Genitalia
a. Mons pubis
b. Labia majora
Nulliparous:
multiparous:
c. Labia minora
d. Clitoris
Sensitive to touch & temperature
2 erectile tissue: corpus cavernosa
Sexual intercourse:
Clitoral congestion & erection
Produce cheese-like secretion:
e. Vestibule
a.
b.
c.
d.
e.
II. Internal Genitalia
a. Vagina
8-12 cm long
Before puberty
After puberty
b. Uterus
Organ of:
Layers:
Parts:
2.5-3 inches long
2 inches wide
50-70 gms
Supporting ligaments:
1. Broad
2. Round
3. Posterior
c. Fallopian Tube
Parts:
Interstitial
Isthmus
Ampulla
Infundibulum
d. Ovaries
6-19 gms, 1.5-3cm wide, 2-5 cm long
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III. Accessory Structures
a. Mammary glands
S- W- D-
Parts:
o Acini cells
o Lactiferous duct
o Lactiferous sinus
Dilated portion behind the nipple
Reservoir of milk
o Nipples
o Areola
Montgomery tubercles
Hormones
o Estrogen
Stimulates dev’t of the ductile structures of the breast
o Progesterone
Stimulates the dev’t of acinar structures of the breast
o Human Placental Lactogen
Promotes breast dev’t during pregnancy
o Prolactin
Stimulates milk production
inhibited by estrogen
o Oxytocin
Let down reflex
inhibited by progesterone
THE MALE REPRODUCTIVE SYSTEM
I. External Genitalia
a. Penis
b. Scrotum
II. Internal Genitalia
a. Testes
Descends in the scrotum at 28 week gestation
4-5 cm long
Parts
o Seminiferous tubules
where spermatogenesis takes place
o Leydig’s/ interstitial cells
Found around the semineferous tubules
o Sertoli cells
b. Epididymis
Appx 20 feet long
Passageway for the traveling sperm for 12-20 days
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c. Vas deferens
Passageway of the sperm from the epdidymis in the testes to the urethra
d. Ejaculatory duct
The Process of Spermatogenesis
Testes
epididymis
Vas Deferens
Seminal Vesicle (secreted: fructose form of glucose, nutritative value)
Ejaculatory Duct
Prostate Gland
Cowpers Gland
Urethra
III. Accessory structures
a. Seminal vesicles
b. Prostate gland
c. Bulbourethral gland
The Analogous
Male Female
Spermatozoa
Glans clitoris
Scrotum
Vagina
Testes
Fallopian tube
Prostate gland
Bartholin’s gland
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THE EVOLUTION OF LIFE
I. Prefertilization
a. Ovum moves to the ampulla by means of peristaltic movement
b. Sperm moves into the ampulla by means of their tail
c. Before sperm can penetrate the ovum, the cap must be removed
Capacitation- physiologic removal of the acrosome
d. Acrosome reaction-
Hyaluronidase- proteolytic enzyme released
Zona pellucid-protective covering of the ovum
Corona radiate-cells that encircle the zona pellucida
II. Conception/Fertilization
Zona reaction- ovum becomes impenetrable to other sperms
Zygote
Blastomere
Morula
Blastocyst
Embryo
Fetus
III. Implantation
Trophoblast
o Placenta
o Fetal membrane
o Umbilical cord
o Amniotic fluid
Embryoblast
o Germ Layers
Ectoderm
mucus membrane, acessories, nervous system
Entoderm
bladder, GIT, tonsils, thyroid gland, respiratory system
Mesoderm
kidneys, musculoskeletal, reproductive, cardiovascular
Embryonic Membrane
a. Chorion - Outer membrane
b. Amnion - Inner membrane
c. Amniotic fluid
Slightly yellow
d. Placenta
Contains 30 separate (cotyledons)
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2 Functions:
a. Metabolic exchange
produces nutrients needed by the embryo
systhesis of glycogen, cholesterol & fatty acids
b. Endocrine Function
HCG
HPL
o Human chorionic somatomammotropin
o Promotes normal nutrition & growth of the fetus
Estrogen
Progesterone
e. Umbilical cord
IV. Fetal Development
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
ANTEPARTUM
I. Schedule of Visits
II. Classification of Pregnancy
Gravida
Para
TPALM
III. Determination of Pregnancy
Presumptive Sign
o Amenorrhea
o Breast changes
o Skin changes
o Quickening
o Chadwick’s Sign
Probable Sign
o Goodell
o Hegar
o Piskacek
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Positive Sign
o
o
o
IV. Physiologic Changes of Pregnancy
a. Breast
Increase in size & nodularity
Enlarged Montgomery’s tubercles
Veins become prominent
Colostrum
b. Uterus
Increase in vascularity
Presence of Hegar’s sign
c. Cervix
Formation of mucus plug or operculum
Presence of Goodell’s sign
d. Vagina
e. Gastrointestinal system
Constipation
Heartburn
Hemorrhoids
Morning sickiness
f. Urinary system
g. Musculoskeletal system
h. Intergumentary system
Chloasma
Linea nigra
Striae gravidarum
i. Endocrine system
Increase activity & hormone production
V. Antepartum Assessment
a. Nagele’s Rule
b. Fundal Height
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c. Leopold’s Maneuver
VI. Evaluation of Fetal Well Being
Fundic Souffle
o Caused by blood rushing through the umbilical arteries. Synchronous with the
FHR.
Uterine Souffle
o Caused by the sound of blood passing through the uterine vessels. Synchronous
with the maternal pulse.
Amniocentesis
o TEST RESULTS: within 2-4 weeks
o Complication: Premature labor, Infection, Rh isoimmunization
Electronic Fetal Heart Rate Monitoring
a. NST
o Tocodynamometer records fetal movements and Doppler ultrasound measures
fetal heart rate to assess fetal well-being after 28 weeks.
o 2 or more FHR accelerations of 15 seconds over a 20 minute interval, and return
of FHR to normal baseline.
b. Contraction Stress Test
o Late decelerations with at least 50% of contractions
o No late decelerations with a minimum of 3 contractions lasting 40-60 seconds in
10 minute period.
Fetal Activity
o Daily recording of fetal movements
o 3 or more movements felt in 1 hour
VII. Psychosocial Adaptation to Pregnancy
a. 1st Trimester
o acceptance of the biological fact of pregnancy
b. 2nd Trimester
o acceptance of the fetus as a distinct individual and a person to care for
c. 3rd Trimester
o prepare realistically for the birth and parenting of the child
INTRAPARTUM
I. Theories of Labor
a. Uterine Stretch Theory
b. Oxytocin Theory
c. Progesterone Deprivation Theory
d. Prostaglandin Theory
e. Theory of the Aging Placenta
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II. Factors Affecting Labor
A. Passageway
o Diagonal Conjugate- from lower border of symphysis pubis to sacral promontory
o Obstetric conjugate- distance between inner surface of symphysis pubis & sacral
promontory
o True conjugate or conjugate vera
o Tuber-ischial diameter/ Intertuberous diameter- measures the outlet between
the inner borders of ischial tuberosities
Pelvic Divisions
o False
o True- Consists of the pelvic inlet, pelvic cavity, and pelvic outlet
o Linea Terminalis
Types of Pelvis
Android
Anthropoid
Gynecoid
Platypelloid
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B. Passenger
a. Fetal Attitude
b. Fetal Presentation
c. Fetal Lie
d. Fetal Positions
C. Power- refers to the frequency, duration, and strength of uterine contractions to cause
complete cervical effacement and dilation
D. Placental factors
E. Psyche
III. Premonitory Signs of Labor
a. Lightening
b. Cervical changes
Effacement
Dilation
c. Regular Braxton Hick’s Contraction
d. Rupture of amniotic membrane
e. Nestling behaviors
f. Weight loss
IV. True vs False Labor
True Labor False Labor
Regular contractions
Decrease in frequency & intensity
Shorter intervals bet. contractions
Activity such as walking either has
no effect or decreases contraction
Activity such as walking, increases
contractions
Disappear while sleeping
No appreciable change in the cervix
V. Labor Contractions
VI. Fetal Monitoring
Variability
o Irregular fluctuations in the baseline of FHR of 2 cycles per minute or greater
Accelerations
o 15 bpm rise above baseline followed by a return to baseline
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Decelerations-
o Fall below baseline lasting 15 seconds or more followed by a return to baseline
a. Type 1
b. Type 2
c. Type 3
VII. Labor
a. Stage 1
Latent Active Transition
Time
Cervix
Contraction
Intensity
Manifestations
b. Stage 2
Cardinal Movement of Labor (Even Donna Failed In Easy English Exam)
c. Stage 3
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d. Stage 4
VIII. APGAR
A
P
G
A
R
POSTPARTUM
I. Uterine involution
II. Lochia
a. Rubra
b. Serosa
c. Alba
III. Post Partum Psychosocial Adaptation
a. Taking In
b. Taking Hold
c. Letting Go
TERATOGENS
– any drug or irradiation, the exposure to which may cause damage to the fetus
a. Streptomycin/Anti – TB –
b. Tetracycline
c. Vitamin K –
d. Iodides –
e. Thalidomides –
f. Steroids –
g. Lithium –
Substances Effects to Fetus
a. Alcohol LBW
b. Cigarette LBW
c. Caffeine LBW
d. Cocaine LBW
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TORCH – group of infections that can cross the placenta or ascend through the birth
canal and adversely affect fetal growth
T-
O-
R-
C-
H-
ANTEPARTUM COMPLICATIONS
I. Ectopic Pregnancy
Causes:
a.
b.
c.
Assessment Findings:
Complications:
Hemorrhage/shock
Peritonitis
Diagnostics:
Culdocentesis
Ultrasound
Management:
II. Abortion
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Causes:
a.
b.
c.
Assessment Findings:
Management:
III. Hydatidiform Mole
Types:
a. Complete
b. Partial
Assessment Findings:
Management:
IV. Incompetent Cervix
Assessment Findings:
Management:
V. Hyperemesis Gravidarum
VI. Anemia
VII. Placenta Previa
Perdisposong Factors:
Assessment Findings:
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VIII. Abruptio Placenta
Risk Factors:
Uterine anomalies
Multiparity
Trauma to the abdomen
Previous 3rd trimester bleeding
Abnormally large placenta
Types:
Assessment Findings:
CHARACTERISTCS ABRUPTIO PLACENTA PLACENTA PREVIA
Onset 3rd Trimester 3rd Trimester
Bleeding
Pain & Uterine Tenderness
FHR
Presenting Part
Shock Moderate to severe Usually not present
Delivery Immediate delivery, usually
by CS
Delivery maybe delayed,
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IX. Pregnancy Induced Hypertension
Incidence:
Severe nutritional deficiencies
< 15 years or > 35 years of age
Common Types:
Gestational HTN
Preeclampsia
Eclampsia
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Assessment Findings:
a) Mild Pre-Eclampsia
Increase systole > 30 mmhg (3 measurements)
Increase diastolic 15 mmhg
b) Severe Pre-Eclampsia
>160/110 mmhg or higher (2 occasions)
Proteinuria 3-4+
c) Eclampsia
Presence of convulsions
Coma
Management:
Hydralazie (Apresoline)
Magnesium sulfate
Magnesium sulfate
Diazepam
Phenobarbital
Phenytoin
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X. Gestational Diabetes Mellitus
Assessment Findings:
Diagnostics:
FBS
HbA 1cv
Oral Glucose Tolerance Test
Management:
XI. RH Incompatibility
Management:
Blood test early pregnancy
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XII. Multiple Gestation
Types:
Monozygotic Twins
Dizygotic Twins
Assessment Findings:
Uterine size is greater than expected
Palpation of three or more large parts
Different FHT
Complications:
Fetal malpresentation
Uterine dysfunction due to over stretching
Twin to twin transfusion
Management:
Prenatal care
Balanced diet
Rest periods
Anticipatory guidance & support
INTRAPARTUM COMPLICATIONS
I. Premature Rupture of Membranes
Amniotic fluid gushing from the vagina in the absence of contraction
Contributing Factors:
Amniotic sac with weak structure
Recent sexual intercourse
Diagnostics:
Nitrazine test tape
Management:
Monitored : infection / spontaneous labor
Bed rest
Tocolytic therapy
Betamethasone (Celestone)
II. Cord Prolapse
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Etiology:
Rupture of membranes with the fetal presenting part unengaged
Hydramios
Assessment Findings:
Cord protruding from the vagina
Cord palpated in the vagina or cervix
Fetal distress
Management:
O2 therapy
Push presenting part forward
Deliver ASAP
III. Preterm Labor
Etiology:
Incompetent cervix
Placenta previa/Abruptio placenta
Previous preterm labor
Management:
Tocolytic therapy not needed if contractions stops
Fetal and uterine contraction monitoring
Ritodrine HCl (Yutopar)
Terbutaline sulfate (Brethine)
Magnesium Sulfate
NSAIDS
Indomethacin (Indocin)
Betamethasone
IV. Post Term Labor
Assessment Findings:
Weight loss and decreased uterine size
Management:
Provide emotional and physical support
V. Induction of Labor
a. Amniotomy
- Initiated when the cervix is soft, partially effaced, slightly dilated,
presenting part is engaged
b. Prostaglandin
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- 8-12 hours after Prostaglandin E2 administration, pump infusion of
Oxytocin (Pitocin)
c. Oxytocin
Dinoprostone (Prepidil)
Prostin E2 suppository or gel
OXYTOCIN (Pitocin, Syntocinon)
VI. Precipitate Labor
Complications:
a. mother
b. infant
Management:
- Support and guide fetal head through birth canal when birth occurs
VII. Uterine Rupture
Causes:
Rupture of the scar from a previous CS
Forceps delivery
Use of oxytocin
Fundal push
Management:
IVF
maintain patent airway
VIII. Episiotomy
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Assessment Findings:
R-
E-
E-
D-
A-
Management:
Apply ice packs to perineal area for the first 12-24 hours after delivery.
Sitz bath with either warm or cool water
IX. Lacerations
1st Degree
2nd Degree
3rd Degree
4th Degree
X. Forceps Delivery
Purpose:
Prevents excessive pounding of the fetal head against the perineum
Prevents exhaustion from a woman’s pushing effect
Assessment Findings:
Cervix fully dilated before use of forceps
Fetus in vertex presentation
Bowel and bladder empty
XI. Cesarean Section
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Types:
a. Classical
Advantage
Simple and rapid to perform
Disadvantage
Potential for rupture of the scar with subsequent pregnancy
b. Pfannenstiel’s incision
Advantages
Less chance of rupture of uterine scar during future deliveries
Fewer postpartum complications
Disadvantages
Longer to perform than classic incision
XII. Uterine Inversion
Types:
a. Forced Inversion
Cause : excessive pulling of the cord , vigorous manual expression of the placenta or
clots from an atonic uterus
b. Spontaneous Inversion
Cause: due to increased abdominal pressure from bearing down, coughing, or sudden
abdominal muscle contraction
Predisposing Factors:
Straining after delivery of the placenta
Vigorous kneading of the fundus to expel the placenta
Manual separation and extraction of the placenta
Assessment Findings:
Extrusion of the inner uterine lining into the vagina
Management:
Restore the uterus to its normal position
use of general anesthesia and tocolytic therapy
POSTPARTUM COMPLICATIONS
I. Post Partum Hemorrhage
Management:
Monitor BP and PR Q5-15 minutes
Prepared for a possible D&C
IV infusion, oxytocin, and BT
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Oxytoxic methylergonovine maleate (Methergine)
II. Subinvolution
Delayed return of the enlarged uterus to normal size and function
Assessment Findings:
Larger than normal uterus
Prolonged lochial discharge
Management:
Massage uterus, facilitate voiding
Administer prescribed medications
III. Puerperal Infection
IV. Mastitis
Inflammation of the breast tissue caused by infection or stasis of milk in the ducts
Management:
Administer antibiotics
Breast feed frequently
V. Post Partum Mood Disorders
Postpartum Blues
Postpartum Depression
Postpartum Psychosis
FAMILY PLANNING
Natural Method
Abstinence Coitus interruptus (withdrawal)
80% effective with typical use
Rhythm (Calendar method) Ovulation occurs 14 days (plus or minus 2 days) prior to next menses sperm viable for 5 days ovum is capable of being fertilized for 24 hours fertile period = shortest cycle minus 18 days and longest cycle minus 11 days 91% effective with perfect use; 75% effective with typical use
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Basal body temperature (BBT) Temperature drops just prior to ovulation, rises and fluctuates at higher
level until 2-4 days prior to next menses basal thermometer – shows tenths of a degree get temperature each AM prior to getting out of bed avoid intercourse on the day temperature drops and for 3 days thereafter 97% effective with perfect use; 75% effective with typical use
Cervical Mucus method (Billing’s, Ovulation)
Luteal Phase - infertile period - dominant hormone: progesterone - vaginal characteristics:dry - cervical mucus characteristics:
scant
cloudy, white to yellow
beading – on microscope
Follicular phase – ovulation - fertile period - dominant hormone: estrogen - vaginal characteristics: wet - cervical mucus characteristics:
profuse, clear
thin, watery, slippery
stretchable (spinnbarkheit)
ferning – on microscope assess cervical mucus daily avoid intercourse when cervical mucus is first noted to become more
clear, stretchable and slippery and for about 4 days effectiveness the same as basal body temperature
Symptothermal Method
o Ovulation o Menstrual calendar o Effectiveness: 98% (perfect use), 75% (typical use)
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Mechanical Methods
Male condom Latex, plastic or natural membranes effectiveness: 97% (perfect use); 86% (typical use)
Female condom
Thin polyurethane sheath with flexible rings at each end Cover the cervix, lines the vagina and partially shields the perineum May be inserted up to 8 hours before intercourse Effectiveness: 95% (perfect use); 79% (typical use)
Spermicides
Kill spermatozoa before it reaches cervix Make vaginal pH strongly acidic Helps prevent STDs Active ingredient: nonoxynol Forms:
a. contraceptive foam b. creams and jellies c. spermicidal vaginal tablet d. spermicidal condom e. film
allergic reaction is possible must be applied with each act of intercourse onset of action varies
Diaphragm
Circular rubber disc fitted over cervix to prevent entrance of sperm cells into uterus
Of different sizes Fitted by an obstetrician during:
a. first time of use b. after every delivery/abortion c. weight loss of at least 10lbs
largest size that fits is chosen inspect for tears and holes by holding against the light can be inserted 2 hours before intercourse but left for 6 hours after
intercourse do not leave more than 24 hours complication: toxic shock syndrome
a. elevation of temperature b. diarrhea and vomiting c. weakness and faintness d. muscle aches e. sore throat f. sunburn type rash
effectiveness: 94% (perfect use), 80% (typical use)
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Cervical Cap Resembles a diaphragm but smaller with taller dome Insert at least 20 minutes but no longer than 4 hours prior to intercourse May be left in place for 48 hours
Hormonal Methods
Contraceptive Pills Consist of estrogen and progesterone inhibit ovulation by suppressing FSH and LH cause thickening of cervical mucus alter motility of fallopian tubes 2 types of packets:
a. 21 day pill – rest day of 7 days b. 28 day pill – last 7 pills either iron supplement or lactose
Forms of OCP a. Combination Oral Contraceptives
- contain both an estrogen and a progestin - formulations:
1. monophasic contains fixed amount estrogen and progestin e.g.: cyproterone/ethinylestradiol,
Desogestrel/ethinylestradiol 2. biphasic
fixed or variable amount of estrogen progestin increases in the 2nd half of the cycle e.g.: desogestrel/Ethinyldestradiol 7 tabs 25 mcg progestin/40mcg estrogen 15 tabs 125mcg progestin/30mcg estrogen
3. Triphasic amount of estrogen may be fixed or variable while amount
of progestin increases in 3 equal phases e.g., Levonorgestrel/Ethinyldestradiol 6 tabs 30 mcg progestin/50mcg estrogen 5 tabs 40 mcg progestin/75mcg estrogen 10 tabs 30mcg progestin/75mcg estrogen
- effectiveness: 99.1% (perfect use), 95% (typical use) b. progestin-only pills (POPs)
- “mini-pills” - contain low doses of progestins - considered in women seeking a highly effective, reversible and
coitally independent method of contraception - action:
a. prevents ovulation b. thickens cervical mucus and suppresses the endometrium
- effectiveness with perfect use: 95.5% - with typical use: 95%
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- warning signs and symptoms
(ACHES)
A – abdominal pain
C – chest pain,cough
H – headache, dizziness
Norplant (Subdermal Implant) - six silastic capsules containing progestin - implanted subdermally - upper inner arm - first 7 days of menstrual cycle - action:
a. prevent ovulation b. stimulate production of thick cervical mucus
Long Acting Progestin Injections
- medroxyprogesterone acetate (Depo-Provera) 150mg IM every 3 months starting with 1st 5-7 days of the menstrual cycle
- blocks LH surge - action:
a. suppress ovulation b. thickens cervical mucus
- effectiveness: 97.7%
Combination transdermal contraceptive patch - Norelgestromin/ethinylestradiol - 150mcg/20mcg per 24 hr patch - apply 1 patch weekly x 3 weeks followed by 1 week patch free period. - Women >90kg may find patch less effective - Patch applied to clean, dry, hair-free skin on: buttock, abdomen, upper outer
arm or upper torso - Avoid irritated or broken skin, breasts or skin in contact with tight
clothing/cosmetic
INTRAUTERINE DEVICE - Contraception achieved by immobilizing sperm and impeding travel from cervix
to fallopian tube - Types:
a. Progesterone T (progestasert) for women allergic to copper
b. Copper T380A (ParaGard)
for women with at least 1 child can be left in place x 10 years
c. Levonorgestrel Suited for women with heavy menstruation Inserted in uterus during 1st 7 days of menstrual cycle Effective x 5 years
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- warning signs & symptoms (PAINS)
P – period late, abnormal spotting
A – abdominal pain, pain with
intercourse
I – Infection exposure abnormal
Discharges
N – not feeling well, fever
S – string missing
Surgical Methods
a. vasectomy b. tubal ligation