obstetric nursing

MATERNAL & CHILD HEALTH NURSING │ BRAINHUB REVIEW CENTER │ TOP THE BOARD EXAM

Menstrual Cycle
− To produce a mature ovum/egg (only 1)
− To prepare the endometrium for implantation
FIA) our maturation
−
-

4 ORGANS INVOLVED IN MENSTRUAL CYCLE

1. Hypothalamus – ultimate initiator, releases GnRH LH ovulation -

▪ FGHRH Estrogen-thickness
▪ LHGRH
2. Anterior Pituitary Gland – releases gonadotropin Progestro vascularity -

▪ FSH
▪ LH
3. Ovaries – releases female hormones
▪ Estrogen – Increase thickness
▪ Progesterone – Increases vascularity
▪ Alternate production of egg cell
▪ When both ovaries produces eggs → multiple pregnancies: twins (fraternal)
4. Uterus – release the menses (Glandular Layer – layer that fell off)

− FUNCTIONS:
1. FSH – always remember ovum maturation, development of ovum, development of Graafian Follicle
2. LH – responsible for ovulation, rupture of Graafian Follicle
3. Estrogen – Increases thickness of endometrium
4. Progesterone – increases vascularity of endometrium

No fertilization

− When the woman has low estrogen and progesterone it will be sensed by the hypothalamus to release gonadotropin releasing hormone (GnRH), it will now
act on the anterior pituitary gland and produce follicle stimulating hormone (FSH) and luteinizing hormone (LH), this FSH will act on the ovaries affecting 7-8
follicles that will produce estrogen, with the action of estrogen, it will act on the endometrium to thicken. The LH now will act on the ovary to discharge the egg
on the uterus and ovulation now happens. The ovulation follicle acts on the corpus luteum and causes a release of progesterone/some estrogen which
increases the blood supply.
− Estrogen is at its peak on the 13th day. 14th day is the surge of the LH
− If no fertilization occurs, the corpus luteum will regenerate and regress (2 weeks after the cycle), it will cause a decrease in progesterone and estrogen that
causes ischemia and the endometrium now sloughs off causing menstruation to occur.
− DIVIDED INTO 2 PHASES
1. Ovarian cycle

o
a. Follicular phase – FSH (maturation of the follicle – produces estrogen)
b. Ovulatory phase – LH (ovulation)
c. Luteal phase – follicle that release the egg form corpus luteum until regression produces progesterone and estrogen

2. Endometrial cycle
1. Menstrual phase (Last Phase) – menstruation

I •
•
Happens in Day 1-5 of the cycle (5 days duration)
Uterus at thinnest due to endometrial slough off (Glandular layer) due to progesterone withdrawal → decrease
progesterone -estrogen is lowesto n the 3rd day

• Day 1 of Menstrual Cycle

o Not Pregnant: Decrease estrogen + decreases progesterone = menses
o Increase prostaglandins causing uterine contraction & vasoconstriction = dysmenorrhea

Pregnantestunprogesternene
o Management of Dysmenorrhea
▪ Proper Position
• 1st choice: position of comfort
• 2nd choice: knee-chest
▪ Warm compress
• Uterine relaxation and vasodilation
▪ Exercise
• Body releasing endorphins (pain killers)
• Sex = serotonin (sleep) and endorphins (painkillers)
▪ Analgesics
• Ibuprofen (prostaglandin inhibitor)
• If pregnant:
o Expect: increases estrogen + increase progesterone
o Effect: No menses

1. DELA CRUZ, CHARMAINE GALE RN

 2. Proliferative phase (1st Phase) – endometrium thicken (due to estrogen)
• Aka Follicular Phase, Estrogen Phase, Post-Menstrual, Pre-ovulatory
13

• Day 6-14 ovulation

• Keyword: Proliferate: increase in number of endometrial cells → increase thickness in endometrium
• Vary in Length/Duration
o Day 6 → decrease estrogen → (+) feedback → hypothalamus → GnRH: FSHRH → APG → FSH → Ovaries
(cortex) → ovum maturation → (primurdial) → (graafian) → increase estrogen (13th day) → increase thickness
of endometrium → suppress FSH → hypothalamus → GnRH: LHRH → APG → LH → ovulation (14th day) →
ends proliferation
• Ovulation occurs here
• Signs of Ovulation
o Spinbarkett - increase mucous elasticity
o Increase basal temperature
o Abdominal pain upon ovulation – Mittelschmerz

3. Secretory phase (2nd Phase) – increase in blood supply and secretions (progesterone)
• Aka Luteal, Progesteronic, Post-ovulatory, Premenstrual
• Day 15-21
• Fixed in length/duration
• Keyword: Secrete nourishing substances
• Best time for implantation
• Day 15: RUPTURE OF GRAAAFIAN FOLLICLE → CORPUS LUTEUM (YELLOWBODY): high in progesterone →
Increase vascularity of endometrium → Suppress LH → RELAX UTERUS

4. Ischemic phase – decrease on blood supply on the endometrium

25th.Forth day • Keyword: decrease blood supply of endometrium (ischemia) → slough off
• *NOT PREGNANT: CL Degenerate after 8-10 days → Corpus Albican (White Body) → Decrease Estrogen + Decrease
Progesterone → Signal Ischemia → Decrease Blood supply → Decrease Oxygen + Decrease Nutrients → Endometrial
Slough Off → MENSES
• *PREGNANT: CL stays for 2 months: While waiting for the placenta to develop

− Normal Characteristics of Menstrual Cycle:

o Beginning (Menarche): 9 years old – 17 years old (average: 12 years old)
o Interval: 23 – 35 days (average: 28 days) – (1st day – 1st day of menses)
o Duration: 3 – 8 days (average: 5 days)
o Amount: 30 cc - 80 cc
o Color: Dark red
o Odor: Marigold
o Iron loss: 11 mg

− Menstrual Terms
o Menarche: 1st menses
o Dysmenorrhea: painful
o Amenorrhea: absent
o Menopause: stop for 12 months
o Hypomenorrhea: lower than 3 days
o Polymenorrhea: higher than 8 days
o Oligomenorrhea: lower than 30 cc
o Menorrhagia: higher than 80 cc

− Ovulation – discharge of ovum going to the fallopian tube

− Ovulation occurs 14 days before the next cycle (length – 14 = O)
− Ejaculation: 150-400 million sperms
o When 2 sperm enters the egg → twin (identical)
− 3 LAYERS OF THE UTERUS
1. Endometrium – innermost, affected by hormones, implantation of zygote
2. Myometrium – middle muscular layer (provides strength), if implants up to myometrium → Placenta Accreta
3. Perimetrium – outer layer that adds more strength to the uterus

The main function of the ovaries is to:

a. Secrete hormones that affects the build up and shedding of the c. Produce mature ova
endometrium during the menstrual cycle d. Channel blood discharged from the uterus during menstruation
b. Accommodate the growing fetus during pregnancy

The maternity nurse is describing the ovarian cycle to a group of nursing students. She asks a nursing student to identify phases of the cycle. Which of the following if
identifies as a phase of the cycle by the nursing student, indicates a need to further research this area?
a. Follicular phase c. Luteal phase
b. Ovulatory phase d. Proliferative phase

Which of the following hormones stimulates the ovary to produce estrogen during the menstrual cycle?
a. Follicle stimulating hormone (FSH) c. Luteinizing hormone (LH)
b. Gonadotropin releasing hormone (GNRH) d. Human chorionic gonadotropin (HCG)

The endometrium thickens during which phase of the menstrual cycle?

a. Secretory phase c. Menstrual phase
b. Proliferative phase d. Ischemic phase

The nursing instructor asks the nursing student about physiology related to the cessation of ovulation that occurs during pregnancy. Which of the following responses, if
made by the student, indicates an understanding of this physiological process?
a. “Ovulation ceases during pregnancy because the circulating levels d. “The high levels of estrogen and progesterone promote the release
of estrogen and progesterone are high.” of FSH and LH.”
b. “Ovulation ceases during pregnancy because the circulating
estrogen and progesterone are low.”
c. “The low levels of estrogen and progesterone increases the
release of FSH and LH.”

STAGES OF FETUS
a. Ovum: Ovulation to fertilization
b. Zygote: fertilization to implantation
a. 3 germ layers (where system originates)
a. Endoderm – reproductive & renal & GIT

1. DELA CRUZ, CHARMAINE GALE RN

 b. Mesoderm – musculoskeletal & cardio-vascular I heart)
c. Ectoderm – CNS (brain)
c. Embryo: 3-8 weeks (2 months)
d. Fetus: 9 weeks - birth

HUMAN CELLS – 46 chromosomes

• Gametes – specialized sex cells, when matured divide into haploid and undergo miosis
• Chromosomes – contains 22 autosomes and 1 sex
• Sperm – when mature contains 23 chromosomes
• Sperm Cells survive 48-72 hours
• Egg cells – eggs will survive for 12-24 hours

SEMEN ANALYSIS
− Done usually in infertile couple (1 year still no offspring)
− Normal – 3-5 ml semen and reveal 50-200 million/ml
o 50% of the sperm should be motile

CELL CYCLE

Stages of Fetal Development

1. Pre-embryonic: fertilization/fecundation, conception, impregnation to implantation (2 weeks)
− Fertilization
− Union of the egg and sperm on the fallopian tube (uterine tube) specifically on the ampulla (distal 1/3 of the fallopian tube)
− Upon conception, the gender is already established, after fertilization, cell returns to mitosis division and become diploid (Zygote)
− Occurs in the fallopian tube
• 4 parts of the fallopian tube
o Interstitial – most dangerous site of Ectopic Pregnancy
▪ Due to its narrow structure, it may cause rupture of FT → hemorrhage
o Isthmus – site of Bitubal Ligation
o Ampulla – site of fertilization and common site of Ectopic Pregnancy
o Fimbriae
▪ By-product: Zygote
• Implants in the upper posterior wall/segment of the uterus
• Same implantation with the placenta
o If implants in the lower segment: Placenta Previa
− Blastocyst
• Structure that implants at endometrium
• 2 TYPES
1. Embryoblast (inner) – embryo
2. Trophoblast (outer) – contains chorionic villi that produce HCG
▪ Embryonic structure
▪ Placenta
▪ Cord
▪ Amniotic Fluid + sac
− HCG – maintain the corpus luteum
− 2 TYPES OF CELLS
1. Ovum
o Female sex cell
o Chromosome: X
o Life span: 24-48 (12-24) hours
o 2 LAYERS
▪ Corona radiata – outer layer
▪ Zona pellucida – inner layer
2. Sperm
o Male sex cell
o Chromosome: X or Y
o Life span: 48-72 hours

1. DELA CRUZ, CHARMAINE GALE RN

 o 3 PARTS OF SPERM
▪ Head – where chromosomes are found
▪ Neck: ATP (energy)
▪ Tail: flagella (use for motility)
o 2 TYPES OF SPERM
1. Androsperm – Male Sperm (Y)
• Small head
• Long tail
• Fast
• Alkaline
• Shorter life span
• More in number
2. Gymnosperm – Female Sperm (X)
• Big head
• Short tail
• Low
• Acidic
• Longer life span
• Less in number
o NOTE: Sperm determines gender
− Implantation/Nidation
• 3 PROCESSES
1. Apposition: Blastocyst Floating
2. Adhesion: Attachment
3. Invasion: Spotting
• Sequence
o Ovum → zygote → blastomere → morula → blastocyst → embryo → fetus
2. Embryonic: 3-8 weeks (2 months)
− Structures:
1. Amniotic Membranes
• 2 LAYERS: chorion & amnion (nerveless – when it ruptures, it’s painless)
o Chorion
⑧ –0 outer covering, part of the placenta
▪ amniotic sac → no nerve supply, no pain upon ROM
o 10
Amnion – Inner layer
▪ Gives rise to the umbilical cord
▪ Also secretes the amniotic fluid (initially)
2. Trophoblast
• 2 LAYERS OF BLASTOCYST
o Cytotrophoblast/Langhan's Layer 2)
▪ Protect fetus from STD (Syphilis)
o Syncytiotrophoblast/syncytial layer SM
▪ Produce maternal hormones
1. Human Chorionic Gonadotropin (HCG)
o First hormone to detect pregnancy (PT)
o Good for 100 days (1st 3 months)
o Decrease after 1st trimester
o Reason for nausea & vomiting (Emesis Gravidarum, Morning Sickness
normal in 1st trimester
▪ Abnormal: beyond 1st trimester - Hyperemesis Gravidarum
o Function:
▪ HCG take care of corpus luteum for 2 months - stays 3 months
(1st trimester), enough staying
▪ CL takes care of the decidua
▪ High in progesterone: increase vascularity
▪ Less in estrogen: increase in thickness
▪ Suppress the maternal immune system
▪ To prevent rejection of fetus → foreign body
▪ HCG mimics testosterone
▪ Helps develop fetal male reproductive organs
2. Estrogen
mildherehere
o Function:
▪ Increase thickness of endometrium
▪ Causes uterine growth → estrogen helps/causes softening of
the entire uterus
▪ Causes mammary gland development
3. Progesterone
uterine o Function:
relaxation ▪ Maintaining endometrium by increasing the vascularity
▪ Maintains uterine lining, inhibit uterine contraction
▪ Decreases intestinal motility = constipation
▪ Rationale: GIT near in the uterus, uterus borrows blood supply
in GIT. GIT decrease blood supply = decrease motility =
constipation. Progesterone goal is to increase blood supply to
fetus.
▪ Management:
▪ Increase fiber & OFI, Walking exercise)
▪ Relaxes uterus to prevent preterm labor
4. Human Placental Lactogen (hPL)
o Aka Human Chorionic Somatomammotropin (hCS)
o Function:
▪ It is lactogenic (Helps in mammary gland development)
▪ Known as Anti-insulin (Diabetogenic)
▪ Hormone that causes Gestational DM
▪ Prepare the breast for lactation
5. Relaxin
o Function:
▪ Soften the joints - lead to lordosis (Pride of Pregnancy)
▪ Relax/soften the pelvic joints of the pregnant for the preparation
of delivery but causes waddling gait

1. DELA CRUZ, CHARMAINE GALE RN

3. Placenta/Secundines
• Comes from the chorionic villi + decidua basalis (endometrium when the woman is pregnant)
• Lifespan: 42 weeks (for nutrition, if dies – ↓ glucose)
• Weight: 400-600g
• Average: 500g/1 lb
• Shape: Round-flat/Pie/Pancake/Disk-like organ
• Special Elements
o Cotyledons
▪ Compartments that have O2 reserve
▪ Normal: 20-30 cotyledons
• <20 – Retained Placental Fragment → Hemorrhage
o Management: D&C
• >25 – normal
• >45 – H. Mole
• Maternal and fetal blood never mixed
o Strictly no alcohol: if mother is alcoholic, baby is Small
o Amniotic fluid is bitter
▪ Fetus do not swallow amniotic fluid
▪ Small for Gestational Age
>

o If more on sweet: amniotic fluid is sweet

▪ Fetus swallow amniotic fluid a lot
▪ Large for gestational age
>

o No smoking: no 1st, 2nd, 3rd hand smoking

▪ Nicotine causes vasoconstriction in the cord → compromise nutrients → SGA (microsomia)
• Function:
o Lungs 0 – O2 and CO2 exchange via 0 Simple Diffusion
o l – glucose transport via Facilitated
GIT & &
Diffusion
o Kidneys – excretion of waste
o Endocrine – produces hormones
▪ HCG – morning sickness
▪ Human Placental Lactogen (HPL) – antagonist of insulin, responsible for GDM (increases blood
sugar)
▪ Melanocyte Stimulating Hormone (MSH) – increases melanin level, responsible for chlosasma &
linea nigra
▪ Estrogen
▪ Progesterone
o Circulatory
O – fetoplacental circulation via Selective & Osmosis
o Immune system – IgG (last few weeks of pregnancy) – transient – passive immunity
o Protective barrier – allow things to pass through
▪ Maternal surface – decidua
▪ Fetal surface – chorionic villi
• X Bacteria
• ✓ Virus
• X Insulin
• ✓ OHA
o Virus
O 8
– can get inside placenta via Pinocytosis
o ⑧
Amino acids (precursor of protein) - via 8 Active Transport
• Has 2 surface
o Fetal surface (Schultz) – white shiny
o Maternal surface (Duncan) – red meaty part
▪ Barrier in between allows gas, virus to pass through but does not allow bacteria and insulin to pass
through
• Aged placenta – low progesterone causes uterine contraction

4. Amniotic Fluid/Fetal Urine

− Rich in prostaglandin (promotes cervical dilatation)
− Color: wait for the Rupture of BOW
o Early pregnancy: clear, transparent
o Later pregnancy: clear-straw colored or slight/pale yellow → fetus is starting to urinate
o To differentiate from mother’s urine: base on acidity/alkalinity:
▪ Nitrazine Paper Test
• Yellow – acidic – urine
• Blue – alkaline – amniotic fluid
o Abnormal colors
▪ Greenish: Meconium Staining = Fetal Distress
• Common in post term (>42 weeks)
o Normal: 37-42 weeks
• Problem: Meconium Aspiration
o After delivery: suction (not done in well baby → causes hypoxia)
▪ After suction: Prophylactic Antibiotic (Tetracycline) – to prevent
infection because not all meconium was suctioned 100%)
▪ Red/Pink: Bleeding
• 1 trimester:
st

o Abortion
o Ectopic pregnancy
• 2 trimester
nd

o H. mole
• 3rd trimester
o Placenta previa (bright red bleeding)
o Abruptio placenta (dark red bleeding)
▪ Dark Yellow/Golden Yellow: Hyperbilirubinemia/hemolysis of fetal RBC
• Apparent during delivery
• Can't be seen through ultrasound
• Chanak is yellow
▪ Dark Brown/Tea/Cola Colored/Black: Fetal Death/Demise or IUFD
• Due to tissue necrosis
• R/F: sepsis/septic shock (mother)
▪ Gray/Cloudy: Infection
− Volume
o To determine: UTZ
o Normal: 800-1200 ml (Average: 1000 ml)
o Abnormal volume: (BOW) → amniotic sac/membrane
▪ Oligohydramnios – <300/800 ml

1. DELA CRUZ, CHARMAINE GALE RN

 • Problem:
o Renal Agenesia – Fetus can swallow but cannot excrete
• Management: Amnioinfusion (Add because it's lacking)

▪ Polyhydramnios – >1200/2000 ml
• Problem:
o Fetus
▪ Tracheoesophageal Fistula and Atresia (TEFA) – cannot
swallow because there is no opening in the trachea
▪ Anencephaly – brain is not well developed and swallowing
needs nervous control
▪ Macrosomia (increase urine)
▪ GI problem: cleft lip/palate
o Mother
▪ GDM
• Management: Amniocentesis
− Normal pH: alkaline (7.0-7.5/7.2)
− Normal composition: 99% H2O + 1% solid particles
− Function
o Protect the cord and the fetus against pressure and trauma/cushion the fetus
o Thermoregulation/controls temperature/conserve heat
▪ Hypothalamus is immature → R/F: Hypothermia
o Promotes musculoskeletal development
▪ Provides space to allow fetal movements (growth & development)

o For nutrition
▪ First stool: meconium (intestine is sterile therefore meconium is sterile)
↓
No good bacteria → no synthesis of Vitamin K
↓
Give Vitamin K shot in newborn
− Sources
o Amnion
20 weeks AOG – baby starts to urinate
16 weeks AOG – baby starts to swallow
o Fetal urine (rules out AOG) - 12 weeks AOG
o Respiratory secretions
− Diagnostics
o Fern Test/Arborization Test
▪ Swab - dry test using glass slide & microscope
▪ Result:
• (+) AF = (+) Ferning
• (-) AF = (-) Ferning, (+) urine
o Nitrazine Test
▪ Litmus paper
BA – blue - alkaline ▪ Result
YU – yellow – urine
• (+) AF = blue (alkaline)
• (-) AF = Red/Yellow (acidic)
o Amniocentesis
▪ Aspiration of amniotic fluid
▪ Done at 14-16 weeks (2nd trimester)
▪ Not in the 1st trimester because of little amniotic fluid
▪ Invasive: Informed consent
▪ Purpose:
• Check for abnormalities via Alpha Fetoprotein (AFP) Level
o Normal: AFP = 2.5 mom (multiple of means)
o Result:
▪ High AFP: Neural Tube Defect (NTD) - Decrease Folic Acid
(Vitamin B9)
▪ Low AFP: Down syndrome
• Check for Lung Maturity via Shake Test
o Shake Amniotic Fluid - Presence of bubble = lung is mature
o Result:
▪ (+) bubbles: lung mature
▪ L/S ratio: 2:1 (Lecithin - lipid/Sphingomyelin-fat therefore oil)
▪ (-) bubbles: lung immature
▪ L/S ratio: 1:1
o Management
▪ IM steroids to mother
▪ Betamethasone
▪ Dexamethasone
▪ Indication:
• 2nd trimester: check down syndrome

o Advance maternal age = possibility of down syndrome

• 3rd trimester: Fetal lung maturity
o GDM = check for fetal lung maturity
− Complication: "I"
o Infection
▪ Early: Spontaneous abortion
▪ Late: Preterm labor

5. Umbilical Cord/Funis – passageway of oxygen & nutrients

• Normal:
2 reasons that prevents cord kinking o Thickness: 2 cm
1. Wharton’s jelly o Length: through UTZ: 50-560
A cm (20-22 inches) – average: 55 cm
2. High blood volume ▪ Abnormal:
• Short: <50 cm
o abruptio placenta
o uterine inversion
• Long: >60 cm
o cord coil/cord loop/nuchal cord
o cord prolapse
o Blood vessels: 3 blood vessels
▪ To determine if artery or vein: Check the diameter
• Small – artery
• Large – vein (carrier of oxygenated)

1. DELA CRUZ, CHARMAINE GALE RN

 ▪ AVA (2 arteries, 1 vein)
• Arteries – carries low O2 and waste
• Vein – carries high O2 and nutrients
▪ 1 artery, 1 vein – sign of congenital heart defect (check for cardiac/kidney abnormalities)
• Special Element
o Wharton's Jelly: jelly white substance that serves as cushion and prevents kinking of the cord
• Cord Infection
o Check drying: 7-10 days (>10 days: wet: infection → Omphalitis)
3. Fetal: 9 weeks - birth
o Full term: 37-42 weeks

A nursing student is preparing a prenatal class on the process of fetal circulation. The nursing instructor asks the student to specifically describe the process through the
umbilical cord. The best response from the student is which of the following?
a. “The one artery carries freshly oxygenated blood and nutrient-rich c. “The two arteries in the umbilical cord carry blood that is high in
blood back from the placenta to the fetus.” carbon dioxide and other waste products away from the fetus to
b. “The two arteries carry freshly oxygenated blood and nutrient-rich the placenta.”
blood back from the placenta to the fetus.” d. “The two veins in the umbilical cord carry blood that is high in
carbon dioxide and other waste products away from the fetus to
the placenta.”

The nurse plans to instruct a group of mothers about the development of the placenta. Which of the following should be included in the teaching plan?
a. The placenta is formed by the fusion of chorionic villi and decidua d. Viruses are not able to pass cross the placental barrier
basalis
b. In the male fetus, hpl promotes the synthesis of testosterone
c. The weight of the placenta at term is 1,000 to 1500g

In response to an expectant couples’ questions, the nurse is explaining various hormones and their functions during pregnancy. Which of the following should the nurse
include in the discussion?
a. Human chorionic gonadotropin ensures continued production of c. Progesterone contributes to mammary gland development and
progesterone and estrogen during early pregnancy uterine growth
b. Estrogen prevents uterine contraction d. Human placental lactogen maintains the development of the
uterine lining

The nurse informs the doctor that the bag of water had ruptured if the Nitrazine paper turns
a. Pink c. Blue
b. Yellow d. White

The outermost membrane that helps form the placenta

a. Amnion c. Chorion
b. Yolk sac d. Decidua

Physiological Changes and Discomforts of Pregnancy

CARDIOVASCULAR SYSTEM
− Increase blood volume – 1500 ml (75% is plasma and 25% is RBC) – causes hemodilution that leads to low hemoglobin = 11-14 dl, hematocrit = 30-32% -
physiologic anemia/gestational anemia
o High in iron supplement/diet – liver, green leafy vegetables, red meat
▪ Dark stool, constipation, acidic stomach (vit.C)
▪ Empty stomach – best taken
− Increase pulse rate (10-15 bpm)
− Palpitations are common
− Blood pressure should be normal – estrogen decreases peripheral resistance of the blood vessels
− Increase WBC
− Increase fibrinogen level – fibrin (clot) – blood is hypercoagulable
o Improve circulation during pregnancy
o Long travels
▪ Stop and walk every 2 hours
− DISCOMFORTS
o Supine hypotension syndrome – when supine portion of inferior vena cava is compressed that causes a decreased in venous return, the
cardiac output will also decrease then decrease blood pressure (hypotension) will happen and low oxygen going to the brain causes dizziness,
perspiration, palpitation and may turn pale
▪ Turn the client into left lateral/left side position (improve circulation)
o Varicosities – gravid uterus will compress the veins in the lower extremities causes decrease venous return leading to ankle edema and
varicosities
▪ Elevate legs frequently, avoid crossing legs when sitting, avoid constrictive clothing, walking
o Hemorrhoids – uterus will compress the anal veins and the veins will dilate
▪ Avoid constipation and prolong sitting

RESPIRATORY SYSTEM
− Increase oxygen requirement → increase respiratory rate (breathing o2 for 2 person)
− Gravid uterus compresses the diaphragm → shortness of breath (extra pillow to elevate head part)
− Estrogen causes high blood supply (nose) leading to nasal congestion & prone to epistaxis, in the gums (epulis-swelling) – dental visit
− Prone to hyperventilation causes increase RR and loses c02 causing respiratory alkalosis

URINARY SYSTEM
− Uterus compresses the urinary bladder causing urge to urinate (urinary frequency) – 1st trimester because of the growing uterus
− Nocturia because of the position assumed at night. Lying position increases venous return which in turn increases cardiac output and increases blood in the
kidney causing increase urine formation
− Decrease bladder tone

DIGESTIVE SYSTEM
− Nausea & vomiting due to HCG
− Increase progesterone decreases the peristalsis and the gravid uterus compresses the intestines causing constipation
o Increase fiber, fluid intake (8-10 glasses of fluid and 4-6 should be water), walking, exercise
− Relaxin decreases the tone of the LES (less competent) and the gravid uterus compresses the stomach causing heart burn/pyrosis
o Small frequent feedings, increase fluid between meals, tell the patient to stay upright atleast 1 hr after meals
o Avoid fatty, gas forming and spicy foods

1. DELA CRUZ, CHARMAINE GALE RN

INTEGUMENTARY SYSTEM
− Chloasma/melasma (mask of pregnancy) due to increase melanocyte stimulating hormone (MSH) that produces melanin that leads to hyperpigmentation
during pregnancy (cheeks, nose, forehead)
o Avoid direct sunlight
− Linea nigra – also due to MSH
− Striae gravidarum - red streaks on the abdomen due to mechanical stretching (capillaries that rupture)
o Post-partum becomes pearly white (blood has been absorbed)

SKELETAL SYSTEM
− Waddling gate due to relaxin
− Change in the center of gravity
o Not pregnant – pelvic
o Pregnant – lordosis (increase in the lumbosacral curvature) – complaint of backpain
▪ Use firm mattress
▪ Low heeled shoes/flat
▪ Pelvic rock/pelvic tilt exercise
• Assume knee-hand position then rock and relax the back
− Muscle cramps due to hypocalcemia (especially around 32 weeks of fetus – bone & tooth bud development)
o Milk requirement: 1200 mg/day in diet such as milk and milk products (yogurt, cheese, malunggay, broccoli, dried fish, green leafy vegetables)
o Avoid plantar flexion (triggers leg cramps)
▪ To relieve do dorsiflexion

ENDOCRINE SYSTEM
− Increase thyroid hormone production (regulates basal metabolic rate) thus BMR increases leading to increase basal body temperature causing them to feel
tired/fatigue after rest
− Vital signs: ↑ RR, PR and temperature, BP is normal
− Increase aldosterone production (na & h2o retention) causing edema

REPRODUCTIVE SYSTEM
− Enlarge uterus (estrogen)
o Fundic height (measured by Bartholomew’s rule – rule of 4)
▪ Symphysis pubis – 12 weeks
▪ Umbilicus – 20 weeks
▪ Xiphoid process – 36 weeks
▪ 38-40 weeks AOG – 2 cm below the xiphoid process (primigravida)
o Lightening – descend of uterus to the pelvic area
▪ Primigravida – 2 weeks before labor
▪ Multigravida – onset of labor
− Operculum – white mucus plug on the cervix that helps prevent infection
o During labor operculum + blood = show (indicates cervical dilatation)
− Chadwick’s sign – bluish discoloration of the vagina/cervix
− Goodlle’s sign – softening of the cervix (palpation)
− Hegar’s sign – softening of the lower uterus
− Leukorrhea – increase vaginal discharge
o Use pantyliners

A prenatal clinic nurse asks a co-assigned nursing student to identify physiological adaptations of the cardiovascular system that occurs during pregnancy, the nurse
determines that the student understands these physiological changes if the student states which of the following?
a. “A decrease in cardiac output occurs.” c. “The systolic and diastolic blood pressure increases by 20 mmHg.”
b. “An increase in pulse occurs.” d. “A decrease in blood volume occurs.”

While the patient is lying supine on the examination table, she tells the nurse that she is feeling dizzy. After observing that the client is pale and perspiring freely, the
nurse
a. Obtain the clients pule c. Assess the client for vaginal bleeding
b. Turn the client onto her left side d. Lower the client’s head between her knees

A nurse is developing a plan of care for a pregnant who is complaining of intermittent constipation. To help alleviate the problem, the nurse instructs the client to
a. Consume low-roughage diet c. Use fleet enema when the episodes occur
b. Drink 6 glasses of water per day d. Take a mild stool softener daily in the evening

The client tells the nurse that she has been having discomfort from her hemorrhoids. After giving instruction about strategies to decrease the discomfort, the nurse
determines that the client needs further instruction when she says she should
a. Avoid straining to have a bowel movement c. Discontinue iron supplements if they have been prescribed
b. Change position frequently during the day d. Use warm sitz baths frequently during the day

Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravida client at 30 weeks AOG who is experiencing
occasional heartburn?
a. “Decrease fluid intake to 3-4 glasses daily c. “Drink several cups of regular tea throughout the day.”
b. “Take a pinch of baking soda with water before meals” d. “Eat smaller and more frequent meals during the day.”

When the client complaints of leg cramps, the nurse suggests which exercise to relieve the cramps?
a. Elevate the legs periodically during the day c. Push upward in the toes and downward in the knees
b. Alternately flex and extend the toes d. Lie prone in bed with legs extended

Signs of Pregnancy
1. PRESUMPTIVE SIGNS – subjective cues, may come from the patient or the mother
o M – Morning Sickness
▪ Cause: State of pregnancy causes elevation of hormones
• HCG (produced by the placenta)
• Progesterone (secondary)
▪ Normal: 1st trimester (1,2,3 months)
▪ Abnormal: 2nd trimester (4,5,6 months)
• H. Mole – enlargement of the abdomen with no fetus but d/t enlargement of the placenta → excessive production of HCG
→ excessive vomiting → Hyperemesis Gravidarum)
▪ Management
• Provide dry crackers/skyflakes in the morning before arising/getting up from bed
o Do not dip in any liquid (should be dry)
o Prevent
de water after to prevent choking

1. DELA CRUZ, CHARMAINE GALE RN

 • Rationale:
All crackers is rich in sodium bicarbonate (alkaline)
↓
HCG increases stomach acid (acidic)
↓
To neutralize acidity, give alkaline

o A – Amenorrhea – temporary loss of menstrual cycle

▪ May return after depending if:
• Breastfeeding – 6 months after delivery
o Natural contraceptive method: LAM (6 months only)
• Non-breastfeeding – 3 months after delivery
▪ Cause:
• increase estrogen
o uterine contraction: mild (Braxton Hick’s Contraction)
• increase progesterone
o uterine relaxation (1-9 months)
o hormone of pregnancy (more elevated than estrogen)

o B – Breast Changes/Montgomery's Sign

▪ Cause: estrogen

o F – Fatigue/Lassitude
▪ Cause:
• increase metabolic rate
• decrease RBC (anemia): Iron Deficiency Anemia
▪ Management:
• Provide Iron Supplements
o Taken for 7 months (210 days) – once a day 200 mg
▪ Rationale
Fetus during pregnancy will deposit iron on their liver
↓
Mother’s iron will be consumed
↓
Iron deficiency anemia to the mother
▪ Another Rationale:
o When newborns are born, they need breastfeeding (contains little to no iron)
o Iron that was deposited in the liver will only last for 6 months therefore start solid food introduction beginning with rice
cereals

o L – Linea Nigra -

dIt:MSA

o U – Urinary Frequency
▪ Rationale:
• Enlarging uterus causes compression of the bladder
↓
Decrease bladder capacity
↓
Increase bladder emptying

▪ 1st trimester: present

• due to uterine enlargement
▪ 2nd trimester: absent
• the bladder has adjusted (the fetus moves upward)
• if present – H. Mole (enlargement of the placenta → continuous compression of the placenta)
▪ 3rd trimester: present
• due to fetal presentation (fetus moves downward in preparation for delivery)

o Q – Quickening (1st fetal movement felt by the mother)

▪ Starts: 2nd trimester (20 weeks) – the child moves his upper body (cephalon-caudal)
⑰
• Depending if:
th
o Primi – 18-20 weeks/5 month (average: best answer)
o Multi – 16-18 weeks/4th month
• If the baby is breech at 5th month: Normal (the baby will still move)
▪ 3rd trimester: the child moves his lower body (legs)

o S – Striae gravidarum (stretchmarks)

▪ Management
• Use calamine lotion
• Eat oatmeal

o I – Increase in Pigmentation (chloasma)/Mask of pregnancy

▪ Cause: increase melanocytes

o E – Enlarge abdomen

2. PROBABLE SIGNS – objective cues, needs an observer

o P – Positive Pregnancy Test
▪ Could be a sign of H. mole
▪ Detects HCG in the urine

o O – Outline of The Fetus as Palpated in the Abdomen

a.k.a
Jacquimier's sign
o C – Chadwick’s Sign (bluish discoloration of the cervix)
▪ Cause: estrogen (↑ blood supply in the cervix)
▪ Observed through: Insertion of vaginal speculum (to open the vagina)
▪ Mode of assessment: inspection
▪ Result:
• Non-pregnant: Pink
• Pregnant: Bluish

1. DELA CRUZ, CHARMAINE GALE RN

 o G – Goodell's Sign (softening of the cervix)
▪ Method of assessment: Palpation
▪ Observed through: internal examination
• During labor: effacement & dilatation
• Contraindication:
o Placenta Previa
o Abruptio Placenta Causes further bleeding

o H – Hegar’s Sign (softening of the lower uterus)

↓
Organ for implantation
↓
Outside the uterus: Ectopic Pregnancy

o E – Enlarged Uterus

o B – Ballottement
▪ Rebounding/bouncing movement of the Fetus → floating
↓
R/F: cord prolapse

o B – Braxton Hick’s Contraction/False Labor Contraction

▪ Painless Irregular Contraction (16 Weeks AOG)
▪ Cause: Estrogen
▪ Mild contraction
▪ Pain: lower abdomen & relieved by walking

o L – Leukorrhea
▪ Increase in Vaginal Discharge

o L – Ladin (softening ofthe uterus after 6 weeks)

o P – Piskacek lasymmetry in the shape of the uterus detectable in the area where the orum has implanted)
o E – Elevated Basal Body Temperature
o V – Von Braun Fernwald Sirregular softening and enlargement the
of uterine
fundus
-
5-8 weeks)
o O – Osiander It pulsations feltthrough the lateral Fornices 8th week)-

o O – Operculum
▪ Mucus Plug, Sealant,
▪ Prevents Ascending Infection
▪ During Labor It Will Fell Off (Bloody Show)

o M – Mcdonald's Can ease in flexing the body the uterus

of against the cervix)

3. POSITIVE SIGNS – diagnostic signs/confirmatory

o H – Heart Tone (120-160 Bpm)
▪ D – Doppler: 3 Months (12 Weeks)
▪ F – Fetoscope: 4 months (16 Weeks)
▪ S – Stethoscope: 5 Months (20 Weeks)
▪ Result:
• >160 bpm – fetal distress (tachycardia – early sign/compensatory stage)
• <120 bpm – fetal distress (late sign) – PRIORITY!

o O – Outline (seen under the Ultrasound)

o M – Movements (felt by the examiner)
▪ Counted every hour
▪ Normal: 10-12/hr
▪ Result:
• >12/hr – fetal distress (early)
• <10/hr – fetal distress (late) – PRIORITY!
o S – Skeleton

Psychological Tasks of Pregnancy

− 1ST TRIMESTER
o Accept: the pregnancy
o Feeling:
▪ Denial is common
▪ Shock
▪ Surprise
▪ Ambivalence – 2 opposing feelings
o Health Teaching: nutrition and body changes during pregnancy

− 2ND TRIMESTER
o Accept: the baby via quickening
o Feeling:
▪ Fantasize
▪ Dream
▪ Narcissism (focus is self, mood changing D/T: hormones - reason)
o Health Teaching: fetal growth and development

− 3RD TRIMESTER
o Accept: motherhood/parenthood
o Feeling:
▪ Impatient
▪ Ugly
▪ Awkward
o Health Teaching: responsible parenthood

Couvade Syndrome – father exhibits/experiences pregnancy signs

Pseudocyesis – false pregnancy, happens to a woman who experiences a lot of miscarriages

1. DELA CRUZ, CHARMAINE GALE RN

A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
a. Uterine enlargement c. Fetal heart tones
b. Breast sensitivity d. Presence of menses

Which of the following would the nurse expect to assess as presumptive signs of pregnancy?
a. Amenorrhea and quickening c. Positive test and a fetal outline
b. Uterine enlargement and chadwick’s sign d. Braxton hick’s contraction and hegar’s sign

When measuring the fundic height of primigravida client at 20 weeks AOG, the nurse would anticipate locating the fundus at which of the following points?
a. Halfway between the client’s symphysis pubis and umbilicus c. Between the client umbilicus and xiphoid process
b. At about the level of the client’s umbilicus d. Near the client xiphoid process and compressing the diaphragm

Prenatal care
FREQUENCY OF VISIT
• Pilitteri
o 1st – 7 months (until 28 weeks AOG) = every 4 weeks/once a month
o 8th month (29-36 weeks AOG) – every 2 weeks/twice a month
o 9th month (37 weeks to labor) = every week
▪ 4 weeks = 1 lunar month (28 days)
▪ 40 weeks AOG = 10 lunar month = 9.5 calendar month
• DOH Program
o Minimum: 4 visits
▪ 1st trimester: 1 visit
▪ 2nd trimester: 1 visit
▪ 3rd trimester: 2 visits (9th month: q2 weeks)

ASSESSMENT
• Age – below 18 and above 35 (high risk for complication)
• Weight gain – 25 to 35 kg
o 1st trimester – 1 lb/month
o 2nd & 3rd – 1 lb/week
o Single fetus
▪ Minimum: 20-25 lb
▪ Maximum: 30-35 lb
o Multiple fetus: 40-45 lb
• BP – increase is PIH
• Fundic height – symphysis pubis → fundus (cm)
• Calorie intake
o Non-pregnant: 2200 kcal/day
o Pregnant: +300 = 300 2500 kcal/day
o Lactating: +500 = 500 2700 kcal/day
• Avoid mineral oil because oil inhibits absorption of fat soluble vitamins (ADEK)

OB SCORE A pregnant woman who has had previous pregnancies, has

• G – gravida (all pregnancies) delivered two term children.
o If twins, count as 1 G3P2 2-0-0-2
• P – para (all deliveries after the age of viability 20 weeks AOG)
o If twins, count as 1 A woman has had two abortions at 12 weeks and is pregnant
• T – term (all infants born after end of 37 weeks) again.
G3P0 0-0-2-0
o If twins, count as 1
• P – preterm (all infants born 21-37 weeks before end of 37 weeks
A pregnant client has two spontaneous abortions. The first
o If twins, count as 1
pregnancy was a single fetus and was terminated at 10
• A – abortion (all pregnancies terminated before 20 weeks)
weeks AOG. The second was a twin and was terminated at
o If twins, count as 1
12 weeks AOG. Two years ago, she had delivery at 34 weeks
• L – living (all living children) AOG but the baby died after 24 hours.
o If twins, count as 2 G4P1 0-1-2-0
RULES OF PREGNANCY
1. Naegele’s Rule
o Determine expected date of birth (EDB), expected date of confinement (EDC) and expected date of delivery (EDD) via LMP (1st day)
▪ LMP – - 3 month +7 days + 1 year (if April – December)
▪ LMP – + 9 months + 7 days (if January – march)
o NOTE: leap year February 29 every 4 years

2. Bartholomew's Rule
o Determine AOG via fundic location
▪ Fundus (superior part)
• 3 landmarks:
o Symphysis pubis – 12 weeks (3 months)
o Umbilicus – 20 weeks (5 months)
o Xiphoid process/ensiform cartilage – 32 weeks (8 months)
o Level
▪ 9 months = 1-2 cm below xiphoid process due to lightening
▪ 8 months = xiphoid process
▪ 7 months = between xiphoid process & umbilicus
▪ 6 months = 2 cm above the umbilicus
▪ 5 months = umbilicus
▪ 4 months = between the symphysis pubis & umbilicus
▪ 3 months = symphysis pubis
3. McDonald's Rule
o Determine the AOG via fundic height (cm)
o Tool: tape measure
o Pattern: symphysis pubis to xiphoid process
o Formula: fh (cm) x 8/7 = AOG (weeks)
o Formula: fh (cm) x 2/7 = AOG (months)
o Example: 20 cm
▪ 20 x 2 / 7 = AOG
▪ 40 / 7 = 5.7 = 5 months and 7 days
4. FH (cm) = AOG weeks

1. DELA CRUZ, CHARMAINE GALE RN

 o Example: 20 cm = 20 weeks

5. Haase's Rule
o Estimate the fetal height
o Formula: (1-5 months)2 = cm
o Formula: (6-9 months) x 5 = cm
▪ 1 month = 1 cm
▪ 2 months = 4 cm
▪ 3 months = 9 cm
▪ 4 months = 16 cm
▪ 5 months = 25 cm
▪ 6 months = 30 cm
▪ 7 months = 35 cm
▪ 8 months = 40 cm
▪ 9 months = 45 cm
6. Johnson's Rule
o Estimate fetal weight
o Normal: 2500-3500g
▪ <2500g = SGA
▪ >3500g = LGA
o Constant:
▪ K = 155
▪ N = station
• Unengaged = 11 (station -1, -2, -3)
• Engage = 12 (station +1, +2, +3) &

o Formula: fh (cm) - n x k = grams

▪ Example: 32 cm, station 0
• 32 - 12 x 155 = -1,828 3100 g

LEOPOLD’S MANEUVER
• Preparation
o Empty the bladder (for comfort and accuracy of the assessment)
o Dorsal recumbent position (relax the abdominal muscle)
o Use warm hands to avoid cramping of the abdominal muscle
• 4 stages &

o 1st – fetal presentation

Funtal grip ▪ Palpate over the fundus
▪ Result
• Breech – hard & round (fetal head) paatootingcoming the

• Cephalic – soft & irregular/curvy (fetal buttocks) Face

-

Facial
o 2nd – fetal lie – fetal heart tone
umbilical grip ▪ Palpate sides of uterus
▪ Landmark:
• Fetal back – long, smooth and curve
o Cephalic – below the maternal abdomen
o Breech – above the maternal abdomen
• Knees and elbows – small parts
▪ Result
• Longitudinal – fetal back is vertical (normal)
• Transverse – fetal back is horizontal
Pawlik's grip • Oblique – fetal back is diagonal/side
o 3rd – fetal engagement

AutemaneSaga
inthe ▪ Use 3 fingers
▪ Grasp just above the symphysis pubis (below the abdomen)
▪ Determine if there is ballottement (not yet engaged)
o 4th – fetal attitude
Pelvicgrip
▪ Examiner faces foot part of the patient
▪ Palpate lower part of uterus
▪ Result
• Flexion – nape (hands doesn’t meet an obstruction) – Normal
-bregma
• Extension - brow/head/face presentation (hands meet obstruction)
-mentum

PAIN MANAGEMENT DURING LABOR

1. Bradley Method
o Made by Dr. Robert Bradley
o Coach: partner
2. Dick-Read Method
o Made by Dr. Grantly Dic-Read
o Reduce fear to manage pain

3. Psychosexual Method
o Made by Dr. Shiela Kitzinger
o Go with the flow
4. Lamaze Method
o Made by Dr. Ferdinand Lamaze
o 4 activities that should be done
1. Cleansing breath
2. Conscious relaxation
3. Effleurage (light stroking of the abdomen)
4. Guided imagery

LABORATORY TESTS
1. PREGNANCY TEST papsmear-determine cervical CA

o Basis: presence or absence of HCG one"sexually -

classes:

!-MrF-mamtmatandrgNnntenrig
active
o Specimen: urine -

35-40-y year
o Result:
▪ 1 line – negative e
▪ 2 lines – positive
Cancer
2. URINALYSIS

E cheminmoreresup ort
↳ -

o To detect presence of UTI (increases R/F preterm labor) -

Upera
o To check proteinuria (sign of PIH)0
o Trace glucosuria (normal)

1. DELA CRUZ, CHARMAINE GALE RN

 3. BLOOD STUDIES
o Hemoglobin – low
o Hematocrit – low
o WBC – high
o Fibrinogen – high
o MSAFP (maternal serum alpha-fetoprotein (AFP) -from the fetal liver → maternal blood)
▪ Checked on 2nd trimester (15-18 weeks)
▪ Result:
• Increase – Neutral tube defect (e.g spina bifida, anencephaly) – associated with folic acid deficiency (should be at least
400 mcg/day)
o Diet: green leafy vegetable, fresh fruits
o Supplements
• Decrease – Down Syndrome or any other chromosomal disease
o Rubella Titer Screening
▪ Determine antibodies against rubella
▪ Result
• 1:8 or less – negative (susceptible to rubella)
o After delivery should receive Rubella vaccine (live attenuated)
o No pregnancy for the next 3 months
• 1:9 or more – positive (immune to rubella)

4. ACETIC ACID TEST

o Can be found inside the OB bag
o Purpose: determine protein in the urine (Proteinuria)
↓
Abnormal during pregnancy
↓
Signifies Pregnancy Induced Hypertension

5. BENEDICT’S SOLUTION
o Present in the OB bag (blue solution)
o Purpose: to determine sugar in the urine (Glycosuria)
↓
Abnormal in the pregnancy
↓
Signifies Gestational Diabetes Mellitus

6. ALPHA-FETO PROTEIN
o Specimen: Maternal Blood (to distinguish fetal disorder)
o Disorders:
▪ Down Syndrome (Trisomy 21)
▪ Neural Tube Defect
• Spinal cord disorders (check the back of the baby – sack or dimpling)
o Spina biffida occulta – Dimpling formation (depression)
o Spina biffida cystica – Sack formation (bukol)
▪ Cause: deficient folic acid
▪ Intervention: Folic Acid supplementation
o Result:
▪ Normal: 38-42 mg/dl
▪ <38 mg/dl: Down Syndrome (Trisomy 21)
▪ >42 mg/dl: Neural Tube defect
o US: ↓ AFP
▪ Abortion or not
o Philippines: no abortion
o Done: 2nd trimester

When answering OB questions always take note the AOG.

After instructing a primigravida client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states
which of the following?
a. “A total weight gain of 20 lbs (9 kgs) is recommended.” c. “A weight gain of 12 lbs (5.5 kg) every trimester is recommended.”
b. “A weight gain of 6.6 lbs (3 kg) in the 2nd trimesters is considered d. “Although it varies, a gain of 25-35 lbs is about the average.”
normal.”
↓ 3
The nurse is interbiweing a pregnant woman in the clinic. The woman has had 3 previous pregnancies. She now has 2 sons and a daughter; all of them were born full
term. She is now 8 weeks pregnant. What is the TPAL score?
a. G4P4 (4004) c. G3P4 (3004)
b. G4P3 (3003) d. G3P4 (4003)

Compute for EDC. Client says her last menstrual period is from August 10-14, Membrane that secretes amniotic fluid? – amnion
2021 – May 18, 2022
Membrane that is part of the placenta – chorion
Determine the OB Score. A postpartum mother is being assessed at the OB
unit. She has 2 children: one born via NSVD at 38 weeks and the other via CS Length of the umbilical cord – 20-22 inches
at 36 weeks. – G2P2 1102
Gelatinous substance that prevents kinking of the cord – wharton’s jelly
The client has a regular 29 days cycle. At what of the cycle does she ovulate?
– day 15 pH of the amniotic fluid – 7-7.2

What hormone initiates the menstrual cycle? – GnRH the client has missed abortion 2 weeks ago. What color of amniotic fluid do
you expect? – coffee/tea colored
What hormone is the basis for positive pregnancy test? – HCG
What hormone causes the waddling agit? – relaxin the client has Rh incompatibility. What color of amniotic fluid do you expect? –
What hormone causes nausea & vomiting? – HCG golden yellow
What hormone causes uterine enlargement? – Estrogen The client has chorioamnionitis. What color of amniotic fluid do you expect? –
gray
What hormone causes heartburn? – relaxin
The client’s baby has fetal distress. What color of amniotic fluid do you
What hormone causes ovulation? – LH expect? – green
What hormone causes thickening of endometrium during menstrual cycle? – Antibody passed by mother via placenta? – IgG (igA – colostrum)
estrogen

1. DELA CRUZ, CHARMAINE GALE RN

¤ Estrogen is elevated from ovulation to conception to pregnancy. ¤ biggest head diameter 9.5
¤ Hypercoagulability may cause blood clotting

Diagnostic Procedures
1. ULTRASOUND
• Transvaginal
o Used in early pregnancy (1st trimester)
o Lithotomy/dorsal recumbent to expose the perineal area
o Empty bladder – to increase visualization of organ
• Abdominal
o Used in later pregnancy
o Full bladder – this pushes the uterus up to make visualization better
o Transmission gel – improve transmission of sound
• Indication
↓ 1. 1st trimester
determine
Fetal maturity a. Confirm pregnancy – outline of the baby
b. Determine AOG/EDC
c. Determine multiple fetus
d. Determine implantation site
2. 2nd trimester
a. Determine sex (absence or presence of penis)
b. Determine if the baby has gross anomalies – big or obvious abnormalities eg hydrocephaly, microcephaly, anencephaly (no skull), cleft lip,
spinal bifida
c. Determine location of the placenta
3. 3rd trimester
a. Determine fetal size & presentation
b. If the baby is still viable/alive

2. AMNIOCENTESIS
− the aspiration of amniotic fluid
− 1st-3rd trimester
• Purposes
o To determine chromosomal abnormalities (testing of fetal cells)
o To determine fetal lung maturity (contains respiratory secretions that contains lung surfactant combines in the amniotic fluid)
▪ Lecithin
▪ Sphingomyelin
• If the L:S ratio is 2:1 then the fetal lung is mature (normally achieved at 36 weeks AOG)
• If 1:2 – immature
o DOC: steroids
▪ Betamethasone a
injection
▪ Dexamethasone 4 dos
• How it is done
o Use of needle
o 15-20 ml is aspirated
o Empty the bladder – prevent puncture
o Left lateral position
o Consent is needed
o Ultrasound is needed (guide the needle position)
• Post-procedure
o Rest: 30 mins
o Light activities for 24 hours
o Increase fluid intake (to replace fluid that was aspirated)
o Out-patient department
• Watch out for Complications (BLIP)
o B – bleeding (prevented by correct technique and procedure)
o L – leakage of amniotic fluid
o I – infection
o P – preterm labor (myometrium is being irritated) – difficult to control

3. CHORIONIC VILLI SAMPLING (CVS)

− Done 8 to 12 weeks AOG
− With the use of catheter, they will obtain chorionic villi
− Done abdominal or transvaginal/cervical
• Purpose
o Determine chromosomal abnormalities
• Consent is needed
• Ultrasound is needed
• Complications
o Bleeding
o Leakage of amniotic fluid
o Infection
• Post-procedure
o Rest
o Light activities 24-48 hours

Test For Fetal Well-Being

1. KLEIHAUER – BETKE'S TEST
− Differentiate maternal from fetal blood
− Used in Rh antibodies

2. DAILY FETAL MOVEMENT COUNTING (DFMC) VIA QUICKENING (fetal movement felt by the mother)
− Done after meals
− Normal: 10-12 movements per hour and 1-2 movements in 10 minutes
− 2 WAYS TO CHECK:
1. Sandovsky Method
▪ Count the fetal movement (kicks)
2. Cardiff's Method
▪ Count to ten
▪ Count duration (how long does the baby takes to reach 10 movements)

1. DELA CRUZ, CHARMAINE GALE RN

3. NON-STRESS TEST
− Check for fetal heart rate response to fetal movement
− Done for high-risk mother’s
− Normally there should be acceleration (increase in FHR by 15 bpm from the baseline for 15 seconds in every movement)
− Look for acceleration
− Happens in 20 minutes
− Instruct the mother to do this after meals
− Rule: get at least 2 accelerations
− Position: left lateral position or semi-fowler’s
− Procedure:
o A transducer applied in the abdomen that will measure the fetal heart rate
o When the baby moves push the button (asterisk or arrow)
− Results
o Reactive: real good
▪ When the baby moves, there was an increase in fetal heart beats for 15 bpm lasting for 15 minutes
▪ Normal, there is fetal well-being
o Non-reactive: not good
▪ The heart rate increases but less than 15 bpm or no increase at all
▪ Suggest placental insufficiencies/fetal distress
▪ Proceed to contraction stress test to confirm
DECELERATION PATTERNS
4. CONTRACTION STRESS TEST • Early deceleration
o Decrease FHR that occurs with the
− Before: inject synthetic oxytocin unfortunately others have preterm labor
contraction
− Now: nipple stimulation o Reflects mirror image/u-shaped
− Assessment of FHR response to uterine contraction pattern
− Procedure: Left lateral or semi-fowler’s position o Cause: head compression
• Variable deceleration
− 2 transducers attached to the abdomen
o Decrease FHR not associated with the
o 1 for fetal heart rate contraction
o 1 for uterine contraction o Could occur anywhere in the contraction
− Stimulate uterine contraction (oxytocin or nipple stimulation) o V-shaped pattern
− Look for deceleration o Cause: cord compression
• Late deceleration
− Results
o Decrease FHR towards the end of the
o Negative: (-) deceleration contraction
▪ No late deceleration patterns o U-shaped pattern
▪ Normal, fetal well-being o Cause: placental insufficiency
o Positive: (+) deceleration
▪ Presence of late deceleration pattern
▪ Placental insufficiency/fetal distress
▪ Management
• Stop nipple stimulation
• Turn mother to left side
• Oxygen via face mask @ 8-10 lpm (high flow oxygen)
− 3 TYPES OF DECELERATIONS
1. Early deceleration – head compression due to stimulation of the vagus nerve causing bradycardia
2. Variable deceleration – cord compression
3. Late deceleration – uteroplacental insufficiency

V – variable C – cord compression

E – early H – head compression

A – acceleration O – okay
L – late P – placental insufficiency

5. BIOPHYSICAL PROFILE/BIOPHYSICAL SCORING (BPP/BPS)

− Combination of NST + UTZ (30 mins) real time
− Doctor will score the baby using parameters
• NST
o Fetal heart rate
• UTZ
o Fetal movement
o Fetal breathing movement (Rise and fall of the chest)
o Fetal muscle tone
o Amniotic fluid volume
− Done near term/delivery
− Fetal APGAR
o Highest score is 2, a total of 10
o 5 areas
1. Fetal reactivity/heart rate
2. Fetal breathing
3. Fetal tone
4. Fetal movement
5. Amniotic fluid index
o Score Interpretations
▪ 0-3 - fetal distress (assess for delivery)
▪ 4-6 - suspicious
▪ 7-10 - fetal well-being

A physician has prescribed transvaginal ultrasound for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. The nurse tells the
client that:
a. The procedure takes about 2 hours c. Gel is spread over the abdomen and a round disk transducer will
b. It will be necessary to drink 1 to 2 quarts of water before the be moved over the abdomen to obtain the picture.
examination d. The probe that will be inserted into the vagina will be covered with
disposable cover and coated with a gel

The physician schedules the client for chorionic villi sampling test. After instructing the client about the procedure, the nurse considers the teaching effective if the client
says
a. “The procedure requires use of needle that is inserted into the b. “I can’t have anything to eat or drink after midnight on the day of
uterus” the procedure”

1. DELA CRUZ, CHARMAINE GALE RN

 c. “The procedure involves the insertion of a catheter into my uterus” d. “The test will detect fetal lung maturity”

A client is told she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews strip and finds 15-beat accelerations
that lasted 15 seconds. What should the nurse do next?
a. Continue to monitor the baby for fetal distress c. Inform the physician and prepare for discharge; the client has
b. Notify the physician and transfer the mother to labor and delivery assuring strip
for imminent delivery. d. Ask the mother to eat something and return for a repeat test; the
results are inconclusive

A nurse observes a late deceleration. It’s characterized by and indicates which of the following?
a. U-shaped deceleration occurring after the first half of the c. V-shaped deceleration occurring after the contraction variable
contraction d. Deep U-shaped deceleration occurring before the contraction
b. U-shaped deceleration occurring with the contraction early
-

Labor And Delivery

Components Of Delivery
1. PASSENGER
• Placenta
• Fetus
o Head (1/4 of the baby) – biggest diameter is 9.5 cm
▪ Frontal (sinciput)
▪ Occipital (occiput)
▪ Parietal
o Sutures – juncture between bones (allow molding)
▪ Allow rapid growth of brain
o Molding – overlapping of bones
o Fontanelle – intersection of sutures (covered with membrane)
▪ Anterior – diamond-shaped, close at 12-18 months of life
▪ Posterior – triangle shaped, closes at 2-3 months
o Characteristics of baby during childbirth
▪ L – Lie
− Relationship of the long axis (spine) of the mother and of the fetus
o Longitudinal – same direction, parallel
o Transverse – not same direction, perpendicular
▪ A – Attitude
− Relationship between fetal parts
o Complete Flexion – chin is touching the chest
o Moderate flexion/military position – chin not touching chest
o Partial extension – head is partially extended, back not arched
o Complete extension – head is hyperextended
▪ P – Presentation
− Determined by the lie and attitude
− Determined by fetal part that touches the cervix first
o Cephalic – longitudinal and head first
▪ Vertex – longitudinal & complete flexion
▪ Military/sinciput – longitudinal & moderate flexion
▪ Brow – longitudinal & partial extension
▪ Face – longitudinal & complete extension
o Breech – longitudinal and buttocks first
▪ Complete breech – completely flexed, hips & knees flexed
▪ Frank breech – hips flexed; knees extended
▪ Footling – foot is the presenting part (2 or 1)
o Transverse – transverse and shoulder presentation
▪ Shoulder – transverse lie
▪ P – Position
• 1st letter
o R – right
o L – left
• 2nd letter – fetal landmarks
o O – occiput (flexion)
o S – sacrum (breech)
o A – acromion (transverse)
o M – mentum/chin (complete extension)
• 3rd letter – maternal pelvis
o P – posterior (maternal sacrum) – most painful
o A – anterior (symphysis pubis) – most common
o T – transverse (side)
▪ ROA & LOA – the only normal position
▪ ROP & LOP – most painful position and give client back labor (compresses sacral nerve)
▪ S – Station
− Relationship between the fetal head and ischial spine
o Negative station – above the ischial spine
o Station 0 – at the level of ischial spine
o Positive station – below the ischial spine (+4 is crowning)
2. PASSAGE
• Hard - Maternal pelvis
o Types
▪ Gynecoid
− Female pelvis
− Well-rounded, ischial spine is not prominent
− Ideal for childbirth
▪ Android
− Male pelvis
− Heart shaped
− AP diameter is longer than the transverse diameter
▪ Anthropoid
− Ape-like pelvis
− AP diameter is longer than transverse diameter
▪ Platypelloid
− Flat pelvis
− Transverse is longer than AP diameter

1. DELA CRUZ, CHARMAINE GALE RN

 • Soft – stretches & dilate
o Lower uterus
o Cervix – 10 cm (max)
o Vagina
3. POWER
− Primary power: Uterine Contraction
− Secondary: Mother’s bearing down
− Characteristics of Contraction
o Duration – measured from the beginning of one contraction to the end of same contraction.
▪ IMPORTANCE: NEED TO MEASURE THE DURATION BECAUSE THE BLOOD SUPPLY FROM THE PLACENTA ALMOST STOPS
o Interval – From the end of one contraction to the beginning of the next contraction. (Uterus relaxes)
▪ IMPORTANCE: THE PLACENTA STARTS TO REFILL THE BLOOD SUPPLY
o Frequency – From the beginning of one contraction and the beginning of the next contraction.
o Intensity: Mild, Moderate, Severe
▪ DYSTOCIA – Difficult labor
▪ HYPOTONIC – Contraction is low and weak; therefore, it is ineffective. In terms of pain, it is less pain.
o Treatment: Oxytocin (Side drip), amniotomy – artificial ROM
▪ HYPERTONIC – Experience very strong contraction and irregular, therefore it is ineffective. In terms of pain, it is more painful.
Treatment: Morphine – analgesic and sedative,

5. PSYCHOLOGY

Signs Of Labor
− W – Weight Loss
o Decrease production of progesterone therefore there will also a decrease in fluid retention.
− O – Observe Sensations
o Increase energy due to elevated epinephrine due to stress
o Increase Braxton Hick’s contraction (Painless irregular contraction)
▪ Walking to subside the contraction
− R – Rupture of Membrane/Ripening of the Cervix (butter soft)
o R/F: Prolapse Cord & infection
▪ Intervention:
1. Position: Trendelenburg
2. Do not pull/push (pushing causes infection)
3. Cover with moist dressing (to prevent drying of the cord)
− L – Lightening
o Descend of Uterus to the Pelvic Area
o (-) Shortness of Breath
o (-) Heartburn
o Urinary bladder will be compressed by the descended uterus causing Urinary Frequency
o Leg cramps
− D – Dilatation and Effacement (shortening of the cervix)– progressive cervical dilation
− S – Show (Pink Show)
o Mucus plugs and +Labor

TRUE LABOR FALSE LABOR

Location of pain Lumbo-sacral (lower back) to abdomen Lower abdomen
Hormone Oxytocin Estrogen
Pain Painful Painless
Walking X ✓
Pain after walking Increases Relieved/decreases
Frequency of contraction ↑ (more) ↓
Duration of contraction ↑ (stronger) ↓ (weak)
Interval of contraction ↓ (short) ↑
Effacement
Dilation
Passage of bloody show

Stages Of Labor
1ST STAGE: Cervical Dilatation
− Focus: cervix (passage)
− Onset: once the mother felt a true labor contraction
− Ending: full cervical dilatation
− 2 processes that happens in the cervix
o Effacement – thinning of the cervix
▪ Measured in percentage (0-100%)
o Dilatation – opening of the cervix
▪ Measured in cm (0-10 cm)
− Primi – effacement first before dilatation
− Multi – dilatation first before effacement
− Hours of labor
o Primi – 20 hours
o Multi – 14 hours
− Cervix length
o 1/4 – 75% efface
o 1/2 – 50 % efface
o 3/4 – 25% efface
o NOTE: cervical length and effacement is inversely proportional
− Terms
o Frequency
▪ Rate of contraction
▪ From the beginning of the first contraction to the beginning of the next contraction
o Intensity
▪ Strength of contraction
o Duration
▪ Length of contraction
▪ From the beginning to the end of the same contraction

1. DELA CRUZ, CHARMAINE GALE RN

 o Interval
▪ From the end of the contraction to the beginning of the next contraction
− Bring to DR if:
o Multi – 7-8 cm
o Primi – 10 cm

− 3 phases of Stage 1.
o L – latent
o A – active
o T – transition

PHASES DILATATION FREQUENCY DURATION INTERVAL INTENSITY EMOTIONS ACTIVITY FHT BREATHING
MONITORING EXERCISES
Latent 1-3 cm 8-15 minutes 20-40 Q5-15 Mild Happy, Ambulation Every hour Chest
(10) seconds minutes excited Void q2 breathing
(30) hours
Active 4-7 cm 3-5 minutes 40-60 Q3-5 Moderate Serious Comfort Q30 minutes Abdominal
(5) seconds minutes analgesics breathing
Transitional 8-10 cm 2-3 minutes 60-90 Q2-3 Severe Irritable, 2 legs up Q15 minutes Panting
seconds minutes tremble, (prevents
nausea & pushing)
vomiting generally,
mother
should push
only when
there is a full
dilatation (10
cm)

− Interventions:
o Early: Ambulation
o Rupture of Membrane: Left Lateral Position
o Effleurage = Light stroking
o Due to NPO, for dry Lips, wet lips with moisten cotton ball
o Provide Support
o PROMOTE FETAL DESCENT
▪ Empty bladder every 2 hours, if not emptied, it will impede the baby’s delivery
▪ Early/ (-) ROM: walking, sitting, standing
▪ Provide support / comfort

2ND STAGE: Expulsion

− Focus: Fetus (passenger)
− Onset: full cervical dilatation (10 cm)
− Ending: delivery of the fetus (expulsion)
o Gradual process USUAL QUESTION: Arrangement of the mechanism of labor.
o Undergoes mechanism of labor

o Mechanism of Labor/Cardinal Movements: ED FIRE ERE

▪ E – engagement
• Landmark: ischial spine
o Above the level of the IS – (-) station – floating
o At the level of the IS – station 0 engaged
o Below the level of the IS – (+) station
▪ Crowning – (+) station
• Instruct the mother to pant blow (muscle of the perineum relaxes → lesser laceration)
• If pushing – higher chances of greater laceration
• After engagement:
o Allow ambulation/walking
o Increase pressure on lower back (↑ pain)
▪ D – Descent (↑ pain)
▪ F – Flexion
▪ IR – Internal Rotation
▪ E – Extension
• Expulsion of the fetal head
• Ritgen's maneuver (support the perineum during crowning to prevent laceration)
▪ ER – External Rotation
▪ E – Expulsion

− Interventions:
o Transfer to DR
o DR table, position in Lithotomy/Semi upright position
o Assessment
▪ Urge to Push during contraction
▪ Urge to defecate due to the fetal head compressing the bowel
▪ Vagina-First, Slit like then Oval up to Circular (Crowning)
▪ Bulging of the perineum followed by crowning
o Episiotomy:
▪ Midline
• Heals faster
• Less painful
• Risk for laceration up to anal area
▪ Mediolateral (most popular)
• Away from the anus
• No laceration from the anus
• Causes more pain
• Heals more slowly
− Essential Newborn Care
o Immediate during
e of the baby
▪ Purpose: for thermoregulation
▪ Where: abdomen of the mother (movement of the baby massage the abdomen that promotes uterine contraction → ↓ bleeding)
▪ Duration: 30 seconds (maximum)
▪ Pattern: cephalon-caudal
A
• Largest part: head (largest heat loss)
• Eyes → nose → mouth → face

Clear airway: healthy baby: no suctioning → causes hypoxia

1. DELA CRUZ, CHARMAINE GALE RN
 o Skin-to-skin contact/Unang Yakap/First Embrace/Kangaroo Care
▪ Purpose: promote thermoregulation
▪ Source of heat: Mother
• Post-partum temperature: ↑ (38.1°C) within 24 hours
• 4 types of Heat Loss
o Conduction – with contact
o Radiation – without contact
o Convection – via air currents (fan/aircon)
o Evaporation – through water vapor
▪ Where: Chest of the mother
▪ Position: Prone (facing the breast → promotes early latching & breastfeeding)
▪ Cover the baby
• Head (bonnet)
Prevent hypothermia
• Body (dry blanket)

o Proper time to cut the cord

▪ Criteria
• When the pulsation stops
• Duration: 1-3 minutes after delivery
• Proper clamping: near the first clamp (the shorter the cord, the lesser the infection)
o 1st clamp (disposable – retains in the baby): 2 cm from the base of the cord
o 2nd clamp (forcep – hold to deliver the placenta): 5 cm from the base of the cord/3 cm from the first clamp
o Do not cover the cord → causes moisture → infection
o Promote air drying (fold the diaper downward)
• Clean everyday with water only (good bacteria is alive that fasten drying)
o Alcohol kills the good bacteria that eats necrotic cells → delays drying
• Dries @ 7-10 days

o Non-separation of the Mother and Child

▪ Purpose: promotes bonding
• Breastfeeding (mother)
o Promotes consistency (promotes trust)
▪ Duration: 90 minutes (1 hour and 30 minutes)

3RD STAGE: Placental

− Onset: delivery of the fetus
− Ending: Delivery of placenta
o Gradual process
o Before delivery, should undergo Placental separation

o 2 Phases
▪ Placental Separation
• Signs of separation
o C – Calkin’s Sign – Uterus is firm and globular (1st sign)
o L – Lengthening of the cord
▪ Brandt-Andrews Maneuver (up-down-side-side)
o S – Sudden gush of blood
• 2 Types
o Schultz
▪ Placenta separated in the center
▪ Shiny/ fetal surface will be presented first
o Duncan
▪ Placenta separated in the Edge
▪ Dirty (Bloody) Maternal surface is presented first.

▪ Placental Expulsion (Normally within 20 minutes, if not mother may bleed)

• Fetal Surface – Shiny
• Maternal Surface

4TH STAGE: RECOVERY/POST-PARTUM

− 1st 1-4 hrs after delivery of placenta
− Check for Lochia (NSD, CS, Abortion, Ectopic Pregnancy, H. Mole)
o 3 Types of Lochia
▪ Rubra (1-3 days) – Red
• Maraming Blood
• Clot (less than 1 cm)

▪ Serosa (4-10 days) – Pink/Brown

• Konting blood
• Madaming mucus and WBC

▪ Alba (>11 days) – White

• mucus and WBC
− Blood Loss
o NSD – 500 ml
If more than → Hemorrhage
o CS – 1000 ml

− Breastfeeding
o Immunoglobulin: IgA
o Key Principle: EO 51 (Milk Code of the PH)
▪ Exclusive breastfeeding (6 months)
▪ Solid food: rice cereal
▪ Extended breast feeding: 2 years and beyond (up to 4 years old)
▪ Storage:
• Freezer – 6 months
• Body of the ref – 3 months
▪ Container: plastic with date & time of collection
o Contraindication:
▪ HIV/AIDS
▪ Phenylketonuria (Lofenalac)
▪ Galactosemia (Nutramigen)
o As frequent as possible (soft stool)/as per demand

1. DELA CRUZ, CHARMAINE GALE RN

 o Bottle feeding (every 2 hours)

− Laceration – tear
o 1st Degree
▪ Vaginal Mucosa
▪ Perineal Skin
o 2nd Degree
▪ 1st+Perineal Muscle
o 3rd Degree
▪ 2nd+Anal Sphincter
o 4th Degree
▪ 3rd+Rectal Mucosa due to fetal head and rapid expulsion of the baby
− Episiorrhaphy – Repair
− Interventions:
o P – Perineal Care/ Perineal Cleansing
o L – Lower Legs-at same time
o A – Apply Perineal pads (Front to back)
o C – Check VS every 15 min. (especially BP and PR)/ check clients fundus: midline and firm
o E – Empty Bladder (Full bladder may cause breathing)
o B – Blanket (Chilling is common after delivery)
o O – Oxytocin/Methergine (to promote contraction)

Oxytocin Methergine
Contraction Intermittent Sustained
Complication HPN
Monitor FHT Blood pressure

− How To Determine if The 4th

Stage of Labor Is Done
o Normal VS
o Fundus – Firm & midline
▪ Abnormal: right or left d/t: Full bladder
o No sign of complications

− POST PARTUM PERIOD

o After the 4th stage of labor after 6 weeks

Psychological & Physiological Changes

PSYCHOLOGICAL ADAPTATION
− Taking In – the focus of the mother is herself
o Rest
o Verbalize her experience
o Dependent
− Taking Hold
o Holding the baby
o Open to instructions
o Learning newborn care
o Doing things herself
− Letting – go actual
-

care

o Let go of her old roles

o Let go of the fantasies of the baby

PHYSIOLOGICAL CHANGES
− Vital Signs
o Slight increase of the body temperature (1st 24)- slight Dehydration <38 degrees
o Decrease Pulse Rate- Bradycardia is normal after delivery (50-70 bpm)
o RR/BP- Normal
− White Blood Cells
o Expected to be elevated even after delivery
o Increase Fibrinogen x 7 days
o Watch out for: Thrombophlebitis/DVT
▪ Assess Homan’s Sign
• Assess by dorsi flexing and Assess for the presence of pain. (+) sign of the thrombophlebitis
▪ Pathophysiology
• Clot formation in the legs
↓
↓ venous return
↓
Accumulation of fluid
↓
Leg edema
▪ Management
• Prevention:
o AMBULATE
▪ if dizziness is still present FREQUENT TURNING IS GOOD AND DO LEG EXCERCISES
o Do not massage the legs (R/F: Pulmonary Embolism)
o While in bed rest you could elevate the legs to promote venous return
o Apply anti-embolic stockings (prevent clot dislodgement)
o Apply warm compress (dilation of vein promotes venous return)
• DOC: Anti-coagulant (WOF: bleeding)
o Heparin – safe for pregnancy
o Warfarin – teratogenic

OTHER CHANGES (BE BLUE)

− B – BLADDER – Empty
− E – ELIMINATION – bowel elimination: Normal elimination pattern will return after 3 days. Common problem is CONSTIPATION.
− B – BREAST – delivery of the placenta – decrease on the level of estrogen → this will trigger to produce prolactin from the pituitary → stimulates the acini
cells → Milk production.
o Sucking → triggers the release of oxytocin → which cause the contraction of the milk duct → lead to the milk let down reflex
o 3-4days = BREAST ENGORGEMENT (normal: 1-3 days – baby is a bad sucker)– Increase blood supply in the breast: Warmth and Redness
(Bilateral), There is accumulation of milk in the milk duct *when you palpate there is tenderness.
▪ Intervention In Breast Engorgement:

1. DELA CRUZ, CHARMAINE GALE RN

 • Continue breastfeeding
• Express breastfeeding (pump)
• Breast feeding: warmth application, use support bra, Increase the frequency of breast feeding
• Non-Breast feeding: Cold application, constrictive bra, Avoid stimulation of the breast.
o Complications: MASTITIS
▪ NOTE: can happen anytime
▪ Common among mother who breast feed for the first time.
• Infection of lactating breast
• Commonly UNILATERAL
o Cause: improper breastfeeding technique
o Signs and Symptoms:
▪ Redness
▪ Warmth
▪ Pain
▪ Fever > 38 degrees
o Management:
▪ Continue breastfeeding in the unaffected side
▪ Antibiotics
▪ Antypyretics
− L – LOCHIA – (-) absence of lochia is a sign of DHN/ INFECTION
o Amount of lochia- 500ml in 24 hours
▪ More than 500 ml is a sign of hemorrhage
▪ Complication: HEMORRHAGE
• EARLY – if occurs during the first 24 hours
• LATE – After 24 hours to 6 weeks
o Causes:
▪ D – DIC management: BT with heparin
▪ R – Retained Placental Fragment – Treatment: D and C
▪ U – Uterine Atony Management: oxytocin/ methergine contraindicated to the patient with HPN
▪ L – Laceration Management: Suturing
− Odor of the lochia – Normal Fleshy
▪ Odorless – infection
− Color
o 1-3 days = Rubra = Red- Maraming Blood, clot (less than 1 cm)
o 4-9 day = Serosa = Pink/Brown- Konting blood , Madaming mucus and WBC
o 10 – onwards = Alba = White = mucus and WBC

− U – Uterus – Check for involution – the return of the uterus to the non-pregnant state
o 1st 24 hours- umbilicus
o 1 Postpartum – 1 finger breath below/day
o Ideally 10th day post partum the fundus is no longer palpable
o Afterpains
▪ Cramping
▪ Due to uterine contraction
▪ NOTE: no to warm compress instead give cold compress
▪ Assume prone position
▪ Analgesics
− E – Endometritis
o Infection of the endometrium
o E. Coli
o Risk Factor:
▪ Poor perineal hygiene (front to back)
▪ PROM
▪ Receive frequent IE
▪ Prolonged Labor
▪ Hemorrhage – has decrease resistance to infection
o Manifestations:
▪ Subinvolution – inflamed uterus
▪ Fever more than 38 degrees
▪ Lochia- foul smelling/ odorless
▪ Abdominal tenderness – pain upon palpation
o Management:
▪ IV antibiotics
▪ Antipyretic
▪ Client should be in bed rest to promote healing and recovery
▪ Assume fowlers/ semi fowlers position that is done to promote the drainage of the lochia

Obstetric Problems
Placenta Related Problems
1. Placenta previa
2. Abruptio placenta
3. Placenta Bipartita
o Divided into 2 lobes
4. Placenta tripartita
o Divided into 3 lobes
5. Placenta percreta
o Placenta attached at perimetrium
6. Placenta accreta
o Placenta deeply attached at the uterus
o Placenta attached at myometrium
7. Placenta increta
o Placenta attached at the endometrium
8. Placenta succenturiata
o May mga anak at connected by blood vessel
o Has accessory lobes
9. Placenta circumvallata
o Chorion covers the placenta
o Normally amnion covers the placenta
10. Battledore placenta
o Normally cord should be at the center
o There is marginal attachment of the cord

1. DELA CRUZ, CHARMAINE GALE RN

Cardiac Disorder
• Septal defects, congenital heart disease, etc
• Mode of delivery is NSVD under epidural anesthesia (no pain but with contractions), no valsalva maneuver therefore assisted delivery (forceps, vacuum)
o Excessive epidural anesthesia → vasodilation of blood vessels → impairment of circulation → vasogenic shock (EMERGENCY!)
▪ Intervention: independent – positioning (modified Trendelenburg)
• If CS, get ready for cardiac overwhelming
• Blood loss
o NSVD – 350-500 ml
o CS – 1000 ml

New York Classifications

• Class I. Uncompromised
o Mother has no signs and symptoms (palpitations, dyspnea, chest pain (angina))
o No limitations
o Prognosis: can continue pregnancy (good prognosis)

• Class II. Slightly Compromised

o Mild signs and symptoms
o Signs and symptoms on ordinary activities (ex. Reached 2nd floor using stairs)
o Prognosis: can continue pregnancy but should sleep 8-10 hours per day and rest 30 mins after meals (good)

• Class III. Markedly Compromised

o Moderate signs and symptoms
o Signs and symptoms present on less ordinary activities (cannot finished the stairs going to 2nd floor)
o Prognosis: can continue pregnancy but on complete bed rest (bad)

• Class IV. Severely Compromised

o Severe signs and symptoms
o Signs and symptoms happens at rest
o Severe limitations
o Prognosis: Bad
o They cannot be candidate for pregnancy but if they got pregnant, the couple can sort to therapeutic abortion

Hemolysis Disorders
a. Rh Incompatibility
o Rh (-) – mother
o Rh (+) – fetus (foreign body)
o Mother will produce maternal antibodies against the fetus causing fetal blood hemolysis that will lead to hyperbilirubinemia (erythroblastosis
fetalis)
o Management:
▪ Inject RhoGam to the mother (to prevent Rh sensitivity)
• Route: IM
• Site: Deltoid
• When: 28 weeks AOG or within 72 hours after delivery
• Who is being protected: the next babies to come, if not given, the babies will experience erythroblastosis fetalis and this
can be fatal

Mother Father Fetus

(+) (+) (+)
(+) (-) (+)
Rh (-) (+) (+)
(-) (-) (-)

*Direct Coombs test – fetus blood (to know what blood type)
*Indirect Coombs – maternal blood

b. ABO Incompatibility
o Happens to mother's with Type O blood
Patient/Mother Blood to be transfused/Fetus
A A, O
B B, O
AB (universal recipient) A, B, AB, O
O (universal donor) O
Mother Fetus
O A: (+) reaction; less severe
O B: (+) reaction; more severe
O AB: very rare
O O: no reaction

*if there will be reaction, there will be production of antibodies causing fetal blood hemolysis known as Hydrops Fetalis

Mother Father
O
Fetus should be O,A
1st baby: O (no reaction) A
2nd baby: A (+) reaction: less severe
Management: transfusion of mother's blood
Mother Father
B
Fetus: B, O
1st baby: B: no reaction O
2nd baby: O: (+) reaction:
Most rare: B- ; prone to fetal hemolysis
Mother Father
B
Fetus: A, B, O
1st baby: B (no reaction) A
2nd baby: O (no reaction)
3rd baby: A (+) reaction

1. DELA CRUZ, CHARMAINE GALE RN

Pregnancy Induced Hypertension (PIH)
− Vasospasm of small arteries and veins
− Occurs after 24 weeks (during 3rd trimester)
− Problem: increase blood pressure/hypertension
− Cause: Placenta (produces HCG → causes vasoconstriction → ↑ BP)
− Onset:
o 1st trimester: if mother is already hypertensive (not PIH)
▪ Problem: H. Mole (large placenta → ↑ HCG)
o 2nd trimester: if mother is hypertensive
▪ PIH usually starts @ 5th month (20 weeks)
− General rule: BP 140/90 mmHg for 2 consecutive takings, 6 hours apart (use if no baseline given)
− Specific rule:
1. Roll – over test
▪
I Left side lying for 15 mins
▪ Then Left supine
▪ 2.4. And take BP immediately
32x I6 hrs apart)
▪ Result:
• (+) PIH: if increase SBP by ≥30 mmHg from baseline, if increase DBP by ≥15 mmHg from the baseline
− Triad of PIH Pre-eclampsia
1. H – hypertension
• Occurs in the 2nd trimester (5th month)
• If BP is 120/80, it is not necessarily normal, check first the BP during non-pregnant state (baseline BP)
• Criteria to Diagnose
• Systolic – increase by 30 mmHg
Both should increase
• Diastolic – increase by 15 mmHg

2. P – proteinuria/albuminuria
• Determine through Acetic Acid test
• Kidney: has glomeruli that filters and has tiny blood vessels
• Pathophysiology:
• Prolong HPN may damage the tiny blood vessels of the glomeruli causing an opening
↓
Protein will pass through
↓
Proteinuria
3. E – edema
• Albumin: control oncotic pressure (pulling force)
• Pathophysiology
• Albumin decreases because protein is excreted in the urine
↓
No control of oncotic pressure
↓
Fluid shifting from IV to ITS
↓
Edema
• Location:
o Lower body/leg – normal
▪ Intervention: Promote elevation of legs (promote venous return)
o Upper body/facial – generalized edema (anasarca) – abnormal

• First 2 that comes first

▪ Hypertension
▪ Proteinuria

− Classifications/Levels

TYPES BP PROTEINURIA EDEMA SEIZURE MANAGEMENT

Mild pre-eclampsia 120/80 – 140/90 mmHg +1, +2 Upper arm X Non-pharmacologic (diet &
(-) facial edema exercise)
Severe pre- >140/90 mmHg +3, +4 (+) facial edema X Main problem: HPN
eclampsia (vasoconstriction)
DOC: Antihypertensive
(vasodilator) – Hydralazine (Apresoline)
Eclampsia ✓ ✓ ✓ ✓ Main Problem: Seizure
DOC: Anti-convulsant (MgSO4)

− Types of PIH
1. Gestational Hypertension
▪ BP: 140/90 mmHg
▪ No proteinuria
▪ No edema
▪ Management:
• Rest to left side lying position
• Diet:
o adequate protein
o moderate sodium (do not limit sodium coz water retention is needed for the amniotic fluid)
• Methyldopa
2. Mild Preeclampsia
▪ BP: 140/90 mmHg
▪ (+) proteinuria +1,+2
▪ (+) edema: non-pitting
▪ Management:
• Rest to left side lying position
• Diet:
o adequate protein
o moderate sodium (do not limit sodium coz water retention is needed for the amniotic fluid)
• Methyldopa
3. Severe Preeclampsia
▪ BP: 160/110 mmHg
▪ (+) proteinuria +3,+4
▪ (+) edema: pitting

1. DELA CRUZ, CHARMAINE GALE RN

 ▪ Management:
• Hospitalization to prevent seizure to happen (tonic clonic/grand mal)
• Conservative/Seizure precaution
o Bedside
▪ Oxygen
▪ Suction
o Darken the room
o Limit the noise
o Raise the side rails
o Pad side rails

• Drug of choice: Magnesium Sulfate (anti-convulsant, muscle relaxant – it blocks acetylcholine (muscle contraction))
o Nursing Care:
▪ IV piggyback continuous dose
▪ Infusion pump
▪ Deep IM (z-track) one-time dose
▪ Normal sensation: burning sensation

▪ Assess every hour,

• B – bp
• U – urine output
• R – RR
• P – patellar reflex
o knee jerk
o Scoring:
▪ 0 - absent (abnormal)
▪ 1+ - diminished (normal)
▪ 2+ - average (normal)
▪ 3+ - brisker than normal (normal)
▪ 4+ - hyperreflexia (abnormal)
• A – ankle clonus
o Dorsiflex the foot 3x
o Result:
▪ (-) movement: (-) AC (normal)
▪ (+) movement: (+) AC (abnormal)
• L – LOC

▪ Assessment
Normal Abnormal
BP ↓ ↑
Urine Output >30 cc/hr <30 cc/hr
RR >12 cpm <12 cpm
Patellar Reflex +1, +2, +3 0, +4
Ankle clonus (-) (+)
Level of consciousness Can answer questions Cannot answer questions

▪ Levels:
• Therapeutic: 5-8 mg/dl
• (-) patellar reflex: 8-10 mg/dl
• Respiratory depression: 10-15 mg/dl
• Cardiac arrest: >20 mg/dl

▪ Toxicity
• First sign: absent deep tenson reflex
• Most fatal:
o Respiratory depression
o Cardiac depression
• Before giving:
o Monitor RR (N: 12-20 cpm)
▪ If 12 – withhold & refer
o Monitor HR (bradycardia) Di ·

o Monitor urine output (N: 30-60 ml/hr) – oliguria

• Magnesium effect:
o ↑ Mg = ↓ Ca

▪ Antidote: Calcium Gluconate IV

Mursingcampenioneer
·

4. Eclampsia
▪ (+) tonic clonic seizure
▪ Aura/premonition: epigastric pain
-awightenheadachesmostdangeret
·

▪ Ultimate treatment: delivery of the baby

5. Gestational Diabetes Mellitus (type 4)
▪ Types of DM
• Insulin dependent
• Non-insulin dependent
• Diabetes insipidus
• GDM

▪ Classis signs of DM
• Polydipsia
• polyphagia
• Polyuria
• Glucosuria

▪ Cause:
• unknown/idiopathic
• Known factor: due to placenta that produces hPL/hCS: antagonizes insulin (resist function of insulin)

▪ Effects of GDM to the Mother

• 1st trimester: hypoglycemia (due to fetal organogenesis) – glucose is needed for organ formation
• 2nd – 3rd trimester: hyperglycemia (due to hormone hPL)
• UTI (due to glucosuria)

1. DELA CRUZ, CHARMAINE GALE RN

 • Fungal infection (candida albicans)
• Metabolic acidosis (due to ketone production) – ketone can damage fetal CNS
• Polyhydramnios (during GDM mother experience maternal hyperglycemia, there is glucose transport to the fetus via facilitated
diffusion, the fetus will now experience fetal hyperglycemia, the fetus will also experience polyuria, polyphagia, polydipsia, polyuria
is the reason why the fetus experience polyhydramnios, polyphagia and polydipsia will cause the fetus to become macrosomia)
• Preterm labor (due to excessive stretching of the uterus secondary to polyhydramnios and macrosomia)
• Dystocia (difficulty in labor due to macrosomia)

▪ Effects of GDM to the fetus

• Inside the utero: hyperglycemia
• Outside the utero: hypoglycemia (due to fetal hyperinsulinism) – hyperinsulinism started inside and persisted outside
• Macrosomia
o Pathophysiology
▪ Excessive sugar
↓
Pass through placenta
↓
Fetus
↓
Macrosomia (large for gestational age)

o Intervention
▪ Monitor blood sugar level (hypoglycemia)
• Pathophysiology
o Environment during pregnancy is high sugar content
↓
After delivery, there is no source of sugar
↓
Hypoglycemia
↓
Hypothermia (fatal)

• Best site to collect blood sugar: corner of the heel (painless)

o Center of the heel is rich in nerve endings (painful)
• Normal blood sugar of babies: 40-60 mg/dl

▪ Diagnostic Tests:
• Oral Glucose Challenge Test (OGCT)
o No fasting is needed
o 1 hour glucose test
o Instruct:
▪ Allow oral glucose 50 g for 5 mins
▪ NPO for 1 hour
▪ Take blood glucose
• Normal: <140 mg/dl
• Abnormal: >140 mg/dl - proceed to OGTT to confirm
• Oral Glucose Tolerance Test (OGTT)
o 3 hour glucose test
o Fasting needed
o Instruct:
▪ Fasting for 8-10 hours
▪ Take FBS
▪ Take breakfast
▪ Oral glucose 100g
▪ NPO for 3 hours
▪ Take blood glucose for 1st hour, 2nd hour and 3rd hour
▪ Result:
• fasting: <95 mg/dl
• 1st hour: <180 mg/dl
• 2nd hour: <155 mg/dl
• 3rd hour: 1<140 mg/dl
• (+) GDM: at least 2 elevated results
▪ Management:
• Conservative:
o Exercise
o Diet:
▪ H – High fiber
▪ A – Adequate protein
▪ M – Moderate sodium
o Weight gain: 25 – 35 lbs
o Calorie needed: 1800 – 2400 kcal/day

• Drug of Choice: Insulin (↑ AOG = ↑ insulin)

o 1st trimester: non-pharmacologic (diet & exercise) – do not give: teratogenic
o 2nd trimester: start of insulin (lowest dosage)
o 3rd trimester: highest dosage
o Post-partum: ↓ HPL = ↓ insulin
o Type of insulin
▪ Mixture of regular (clear) + NPH (cloudy)
• Aspirate clear first then cloudy
o Requirements:
▪ 1st trimester: low insulin (due to organogenesis)
▪ 2nd trimester: high insulin (due to hPL)
▪ Postpartum: low insulin
o Route: SQ
o Site: abdomen
▪ Alternate: upper outer arm
• No oral hypoglycemics (OHA) – teratogenic

▪ Mode of delivery: Cesarean Section

• Once the mother undergo CS, all succeeding deliveries is not necessarily CS
• 2 types of CS
o Classic – vertical cut
▪ Once Classic CS, all succeeding deliveries are all CS

1. DELA CRUZ, CHARMAINE GALE RN

 ▪ Rupture of uterus may happen (>3 CS)
o Bikini – transverse/horizontal cut
▪ More pricey
▪ May undergo normal delivery (vaginal birth after CS – VBAC)
▪ Myometrium has horizontal muscles
• Maximum: 3 CS
• Gap/Interval: 3 years
• Incision site: same site

Sudden Pregnancy Complications

1ST Trimester Abortion

Ectopic Pregnancy
2nd Trimester H-mole
Incompetent Cervix
3rd Trimester Placenta previa
Abruptio placenta

1st Trimester
1. ABORTION
Management: hrs− Definition: Termination of pregnancy before the age of viability (> 20 weeks or > 400g)
CBR For 12-24 − Better term: Miscarriage
-

-coitus restricted for a weeks

-

save all pads, dots− a tissues 2 MAJOR CLASSIFICATIONS:

Ito measure bleeding) 1. Spontaneous/Miscarriage – due to natural causes
by weighing pads ▪ Natural Causes:
D&C (toclean uterus to
preventbleeding)
-

• Abnormal fetal development

• Beauty products (contains Isotretinoin- teratogenic)
• Corpus luteum failure
• Drug teratogens (alcohol, nicotine, cocaine)
• E/Immune response (bahala na wrong spelling hehe)
▪ TYPES OF SPONTANEOUS ABORTION:
a. M – Missed
↓ o
<20 weeks
Also known as early pregnancy failure learly Fetal death withoutexpulsion
o Fetus died within 1 month
weeks
IUFD/ stillbirth
>20
o Retention after death
o Signs and Symptoms:
▪ (-) FHR
▪ Closed cervix
▪ (-) Increase in fundal height
▪ (-) PT
▪ Dark brown, scanty bleeding
o Management:
▪ < 16 weeks
• D & C- scraping of uterus
• Monitor post-op: Hemorrhage and Infection
▪ > 16 weeks
• Induce labor using uterotonics
• First attempt: Insertion of Dinoprostone (prostaglandin E), Misoprostol (Cytotec)
• Second attempt: IV oxytocin and Mifepristone (RU 486)
o Complication of Missed Abortion:
▪ DIC (Disseminated Intravascular Coagulation)
• S/Sx: Oozing of blood at IV Site
• Management: Infusion of FFP (Fresh Frozen Plasma)
b. I – Inevitable/Imminent
o cannot be prevented
o Signs and Symptoms:
▪ (+) FHR
▪ Open cervix
▪ Moderate to profuse bleeding
▪ Moderate to severe contractions
▪ ROM
o 2 types of Inevitable Abortion:
1. Complete Abortion
• Fetus and placenta out call products of conceptus isexpelled
• Management: emotional support
2. Incomplete Abortion more dangerous
-

RIF* • intravascular
bleedingdessiminated
•
Fetus out, placenta in leach partonly
coagulation
Management: D & C
DF) (death Fetus syndrome)
c. T – Threatened
o Can be prevente d
o Signs and Symptoms:
▪ (+) FHR
▪ Closed cervix
▪ Bright red, scanty bleeding
o Management:
D82:tocolytics (half ▪labor) CBR for 2 weeks
MyJ04 ▪ No strenuous activities for 2 weeks
↳

↳ Terbutaline
↳

↳
Indomethin
Nifedipine
▪ No coitus for 2 weeks
d. S – Septic
o Due to infection
o Causative agents:
▪ H – Hemolytic streptococcus
▪ E – E. coli
▪ P – Proteus vulgaris
▪ E – Enterobacter aerogenes
▪ S – Staphylococcus

1. DELA CRUZ, CHARMAINE GALE RN

 o Signs and Symptoms:
▪ F – Fever, chills; foul- smelling discharges
▪ L – Leukocytosis (16,000- 22,000)
▪ A – Abdominal pain
▪ T – Tender uterus
o Management:
▪ D&C
▪ Antibiotics: High-dose, IV
• Penicillin – gram (-) aerobic
• Gentamycin – gram (+) aerobic
• Clindamycin – gram (+) anaerobic
e. H – Habitual Recurrent
o > 3 consecutive abortion
o Cause: Incompetent cervix (cervix opens prematurely)
o Management: Suture cervix (Cerclage)
▪ Placed at 12-14 weeks AOG
▪ 2 types of Cerclage:
1. Shirodkar-barter
o Permanent
o Mode of delivery: CS
2. McDonald
autopia pregnancy o Temporary
o Mode of delivery: NSVD
medical/planned legal never
allowed in
the PH

2. Therapeutic/Induced/Intentional/Medical/Elective/Criminal- deliberate termination of pregnancy

▪ 2 Types:
1. Illegal Abortion
o Hilot
o Misoprostol (Cytotec)
o Mifepristone (RU 486)
2. Legal Abortion
o Therapeutic abortion

2. ECTOPIC PREGNANCY
− Definition: implantation outside the uterus (no chance living) Management:
severingit
of

combats hock
−
↳
Causes: footofbed
↳elevate (modified trendelenburg)
amimry, inallmarkin o S – Smoking
"A
-spotting
It) cullen's
sign-discolorcanart o
o I – IUD propmYte-kil srapids, dividing all(normal feltit

P – PID (Pelvic Inflammatory Disease)

rupture ofectopic pregnancy
-shocks
-
− Most common causative agent of PID: gonorrhea
hypo
− Most common site of ectopic pregnancy: ampulla
-

achy
-farky − Most dangerous site of ectopic pregnancy: interstitial/ intramural
− Most reliable diagnostic test: Transvaginal UTZ + Beta HCG

2 TYPES OF ECTOPIC PREGNANCY

UNRUPTURED RUPTURED
Less than 12 weeks AOG More than 12 weeks AOG
− Signs and Symptoms: − Signs and Symptoms:
o Brief amenorrhea o Pain (sudden, sharp, severe, stabbing, knife-like pain
o Unilateral abdominal pain radiating to shoulder or neck- Kehr’s sign)
o Nausea and vomiting o Less vaginal bleeding
o (+) PT o Why? Bleeding is inside
o (+) Cullen’s sign- bluish discoloration of umbilicus due
to hemoperitoneum
o Rigid, board-like abdomen
− Management: − Management:
o Methotrexate + Leucovorin o Blood transfusion
o Mifepristone (RU 486) – potent abortifacient o IVF – PNSS (Gauge 18 needle)
o Laparoscopy
− Note: ✓ Ligate bleeding blood vessels
o Methotrexate – anti-cancer agent that destroys fast growing cells but ✓ Remove/repair damaged fallopian tube
known to be ANTI-FOLIC ACID AGENT o Salpingotomy – Incision of Fallopian tube
o Leucovorin – active folic acid used to rescue normal cells from o Salpingostomy – artificial opening of Fallopian Tube
damaging effect of Methotrexate o Salpingectomy – removal of fallopian tube

2nd Trimester
1. H- MOLE
− Other names: Hydatidiform mole, Molar pregnancy, Gestational Trophoblastic Disease, Chromosome 69
− Definition: Abnormal proliferation and degeneration of trophoblasts resulting to grape-like vesicles
− Cause: unknown
− Risk Factors
o History of H-mole in previous pregnancy
o Geography: Asians (Filipinos and Taiwanese)
o Type A women married to Type O men
o Low socioeconomic status (low protein intake)
o Women <18 years old and > 40 years old
− Diagnostic test: Abdominal ultrasound
o Snow-flake pattern
o Absent FHT
o Absent fetal skeleton
− Signs and symptoms
o LGA- classic sign
o High HCG- 1-2 million IU resulting to hyperemesis gravidarum
▪ Normal HCG level: 400, 000 IU
o Grape-like vesicles
o Dark brown or prune juice-like bleeding
o Signs of PIH (Pregnancy Induced Hypertension)
− Management
o D&C

1. DELA CRUZ, CHARMAINE GALE RN

 o No oxytocin – can lead to pulmonary embolism
o Methotrexate and Dactinomycin- prevent choriocarcinoma
o HCG monitoring for 1 year
▪ Once a month in 1st 6 months
▪ Every 2 months in the next 6 months
o No pregnancy for 1 year
o Hysterectomy
▪ If completed childbearing
▪ If sterilization desired
− Complication: Choriocarcinoma (a type of cancer)

2. INCOMPETENT CERVIX
− Definition: Cervix opens prematurely
− Causes:
o T – Trauma from forceps delivery
o F – Forced D & C
o C – Congenitally short cervix
− Diagnostic test
o IE (Internal Examination)
o UTZ (ultrasound)
▪ Cervical os > 2.5 cm
▪ Cervical length < 20 mm
− Signs and Symptoms:
o Open cervix- 1st sign
o Bloody show
o ROM
− Management:
o Application of Cerclage (Suture cervix)
o When to apply? 12-14 weeks AOG (the earlier the better)
o Criteria for application: NICE
▪ N – No contractions, No vaginal bleeding
▪ I – Intact membrane
▪ CE – Cervix not dilated beyond 3 cm
o Types of Cerclage:
▪ Shirodkar- Barter
▪ Permanent
▪ Mode of delivery: CS
o McDonald
▪ Temporary
▪ Mode of delivery: NSVD
o Post-op Management:
▪ CBR for 24 hours
▪ Position: slight and modified Trendelenburg position
▪ Monitor for contractions
▪ If present, notify physician so patient will be given Ritodrine (tocolytic) to help relax uterus and not affect the cerclage

3rd Trimester
CONDITION PLACENTA PREVIA ABRUPTIO PLACENTA
Classic Definition Low-lying placenta Premature separation of placenta
Alternative Definition Premature separation of ABNORMALLY IMPLANTED PLACENTA Premature separation of NORMALLY IMPLANTED
PLACENTA
Types 1. Complete 1. Covert
o Placenta totally covers the cervix o Central detachment
2. Incomplete o Bleeding is occult
o Placenta partially covers the cervix 2. Overt
3. Marginal o Marginal detachment
o Placenta at the edge of internal cervical opening o Bleeding is profuse and obvious

Cause Multigravida C – Cocaine

A – Advanced maternal age
M – Methamphetamine
P – PIH
S – Short umbilical cord
Diagnostic test Abdominal ultrasound- locate placenta Abdominal ultrasound- to locate retroplacental clot

Hallmark sign BRIGHT RED, PAINLESS BLEEDING DARK RED, PAINFUL BLEEDING
COUVELAIRE UTERUS- uterine hypoplexy
Management Double set-up for delivery Emergency CS
1 set-up for NSVD
1 set-up for CS

NO IE unless delivery is imminent or patient is in the OR

1. DELA CRUZ, CHARMAINE GALE RN