MATERNAL/OB NOTES Human uality A. Concepts 1.

A person's uality encompasses the complex behaviors, attitudes emotions and preferences that are related to ual self and eroticism. 2. basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human uality. B. Definitions related to uality: Gender identity sense of femininity or masculinity 2-4 yrs/3 yrs gender identity develops. Role identity attitudes, behaviors and attributes that differentiate roles biologic male or female status. Sometimes referred to a specific ual behavior such as ual intercourse. uality behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change. - developed at the moment of conception. II. ual Anatomy and Physiology A. Female Reproductive System 1. External value or pretender a. Mons pubis/veneris a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty covered by pubic hair that serves as cushion or protection to the symphysis pubis. Stages of Pubic Hair Development Tannerscale tool used to determine ual maturity rating. Stage 1 Pre-adolescence. No pubic hair. Fine body hair only Stage 2 Occurs between ages 11 and 12 sparse, long, slightly pigmented & curly hair at pubis symphysis Stage 3 occurs between ages 12 and 13 darker & curlier at labia Stage 4 occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 ual maturity- normal adult- appear inner aspect of upper thigh . b. Labia Majora large lips longitudinal fold, extends symphisis pubis to perineum c. Labia Minora 2 sensitive structures clitoris- anterior, pea shaped erectile tissue with lots sensitive nerve endings sight of ual arousal (Greek-key)

fourchette- Posterior, tapers posteriorly of the labia minora- sensitive to manipulation, torn during delivery. Site episiotomy. d. Vestibule an almond shaped area that contains the hymen, vaginal orifice and bartholene's glands. 1. Urinary Meatus small opening of urethra, serves for urination 2. Skenes glands/or paraurethral gland mucus secreting subs for lubrication 3. hymen covers vaginal orifice, membranous tissue 4. vaginal orifice external opening of vagina 5. bartholene's glands- paravaginal gland or vulvo vaginal gland -2 small mucus secreting subs secrets alkaline subs. Alkaline neutralizes acidity of vagina Ph of vagina acidic Doderleins bacillus responsible for acidity of vagina Carumculae mystiformes-healing of torn hymen e. Perineum muscular structure loc lower vagina & anus Internal: A. vagina female organ of copulation, passageway of mens & fetus, 3 4inches or 8 10 cm long, dilated canal Rugae permits stretching without tearing B. uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights. Size- 1x2x3 Shape: nonpregnant pear shaped / pregnant ovoid Weight nonpregnant 50 -60 kg- pregnant 1,000g Pregnant/ Involution of uterus: 4th stage of labor 1000g 2 weeks after delivery - 500g 3 weeks after delivery - 300 g 5-6 weeks after delivery - returns to original, state 50 60 Three parts of the uterus 1. fundus - upper cylindrical layer 2. corpus/body - upper triangular layer 3. cervix - lower cylindrical layer * Isthmus lower uterine segment during pregnancy Cornua-junction between fundus & intersal Muscular compositions: there are three main muscle layers which make expansion possible in every direction.

2. Internal 1. Endometrium- inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during menstruation. Decidua- thick layer. Endometriosis-proliferation of endometrial lining outside uterus. Common site: ovary. S/sx: dysmennorhea, low back pain. Dx: biopsy, laparoscopy Meds: 1. Danazole (Danocrene) a. to stop mens b. inhibit ovulation 2. Lupreulide (Lupron) -inhibit FSH/LH production 2. Myometrium largest part of the uterus, muscle layer for delivery process Its smooth muscles are considered to be the living ligature of the body. - Power of labor, resp- contraction of the uterus 3. Perimetrium protects entire uterus C. ovaries 2 female glands, almond shaped. Extvestibule int ovaries Function: 1. ovulation 2. Production of hormones d. Fallopian tubes 2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus. 4 significant segments 1. Infundibulum distal part of FT, trumpet or funnel shaped, swollen at ovulation 2. Ampulla outer 3rd or 2nd half, site of fertilization 3. Isthmus site of sterilization bilateral tubal ligation 4. Intersal site of ectopic pregnancy most dangerous B. Male Reproductive System 1. External penis the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female the glands penis. 3 Cylindrical Layers 2 corpora cavernosa 1 corpus spongiosum Scrotum a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes. - cooling mechanism of testes - < 2 degrees C than body temp. - Leydig cell release testosterone The Process of Spermatogenesis maturation of sperm Male and Female homologues Male Female Penile glans Clitoral glans Penile shaft Clitorial shaft Testes ovaries Prostate Skene's gands Cowper's Glands Bartholin's glands Scrotum Labia Majora III. Basic Knowledge on Genetics and Obstetrics 1. DNA carries genetic code 2. Chromosomes threadlike strands composed of hereditary material DNA 3. Normal amount of ejaculated sperm 3 5 cc., 1 tsp 4. Ovum is capable of being fertilized with in 24 36 hrs after ovulation 5. Sperm is viable within 48 72 hrs, 2-3 days 6. Reproductive cells divides by the process of meiosis (haploid) Spermatogenesis maturation of sperm Oogenesis process maturation of ovum Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or diploid 7. Age of Reproductivity 15 44yo 8. MenstruationMenstrual Cycle beginning of mens to beginning of next mens Average Menstrual Cycle 28 days Average Menstrual Period 3 5 days Normal Blood loss 50cc or cup Related terminologies: Menarche 1st mens Dysmenorrhea painful mens Metrorrhagia bleeding between mens Menorhagia excessive during mens Amenorrhea absence of mens Menopause cessation of mens/ average : 51 years old 9. Functions of Estrogen and Progestin * Estrogen "Hormone of the Woman" Primary function: development secondary ual characteristic female. Others: 1. inhibit production of FSH ( maturation of ovum) 2. hypertrophy of myometrium 3. Spinnbarkeit & Ferning ( billings method/ cervical) 4. development ductile structure of breast 5. increase osteoblast activities of long bones 6. increase in height in female

7. causes early closure of epiphysis of long bones 8. causes sodium retention 9. increase ual desire *Progestin " Hormone of the Mother" Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted) Secondary Function: uterine contractility (favors pregnancy) Others: 1.inhibit prod of LH (hormone for ovulation) 2.inhibit motility of GIT 3. mammary gland development 4. increase permeability of kidney to lactose & dextrose causing (+) sugar 5. causes mood swings in moms 6. increase BBT 10. Menstrual Cycle 4 phases of Menstrual Cycle 1. Proliferative 2. Secretory 3. Ischemic 4. Menses Parts of body responsible for mens: 1. hypothalamus 2. anterior pituitary gland master clock of body 3. ovaries 4. uterus 5. Initial phase 3rd day decreased estrogen 13th day peak estrogen, decrease progesterone 14th day Increase estrogen, increase progesterone 15th day Decrease estrogen, increase progesterone I. On the initial 3rd phase of menstruation, the estrogen level is decreased, this level stimulates the hypothalamus to release GnRH or FSHRF II. GnRH/FSHRF stimulates the anterior pituitary gland to release FSH Functions of FSH: 1. Stimulate ovaries to release estrogen 2. Facilitate growth primary follicle to become graffian follicle (secrets large amt estrogen & contains mature ovum.) III. Proliferative Phase proliferation of tissue or follicular phase, post mens phase. Pre-ovularoty. -phase of increase estrogen. Follicular Phase causing irregularities of mens Postmenstrual Phase Preovulatory Phase phase increase estrogen

IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the hypothalamus to release GnRF on LHRF 1.) Mittelschmerz slight abdominal pain on L or RQ of abdomen, marks ovulation day. 2.) Change in BBT, mood swing V. GnRF/LHRF stimulates the ant pit gland to release LH. Functions of LH: 1. (13th day-decreased progesterone) LH stimulates ovaries to release progesterone 2. hormone for ovulation VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation. VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone) VIII. Secretory phaseLutheal Phase Postovulatory PhaseIncreased progesterone Premenstrual Phase IX. 24th day if no fertilization, corpus luteum degenerate ( whitish corpus albicans) X. 28th day if no sperm in ovum endometrium begins to slough off to begin mens Cornix- where sperm is deposited Sperm- small head, long tail, pearly white Phonones-vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation- ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida. 11. Stages of ual Responses (EPOR) Initial responses: Vasocongestion congestion of blood vessels Myotonia increase muscle tension 1. Excitement Phase (sign present in both es, moderate increase in HR, RR,BP, flush, nipple erection) erotic stimuli cause increase ual tension, lasts minutes to hours. 2. Plateau Phase (accelerated V/S) increasing & sustained tension nearing orgasm. Lasts 30 seconds 3 minutes. 3. Orgasm (involuntary spasm throughout body, peak v/s) involuntary release of ual tension with

physiologic or psychologic release, immeasurable peak of ual experience. May last 2 10 sec- most affected are is pelvic area. 4. Resolution (v/s return to normal, genitals return to pre-excitement phase) Refractory Period the only period present in males, wherein he cannot be restimulated for about 10-15 minutes A. Fertilization B. Stages of Fetal Growth and Development 3-4 days travel of zygote mitotic cell division begins *Pre-embryonic Stage a. Zygote- fertilized ovum. Lifespan of zygote from fertilization to 2 months b. Morula mulberry-like ball with 16 50 cells, 4 days free floating & multiplication c. Blastocyst enlarging cells that forms a cavity that later becomes the embryo. Blastocyst covering of blastocys that later becomes placenta & trophoblast d. Implantation/ Nidation- occurs after fertilization 7 10 days. Fetus- 2 months to birth. placenta previa implantation at low side of uterus Signs of implantation: 1. slight pain 2. slight vaginal spotting - if with fertilization corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. 3 processes of Implantation 1. Apposition 2. Adhesion 3. Invasion C. Decidua thickened endometrium ( Latin falling off) * Basalis (base) part of endometrium located under fetus where placenta is delivered * Capsularies encapsulate the fetus * Vera remaining portion of endometrium. C. Chorionic Villi- 10 11th day, finger life projections 3 vessels= A unoxygenated blood V O2 blood A unoxygenated blood Wharton's jelly protects cord

Chorionic villi sampling (CVS) removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes. E. Cytotrophoblast inner layer or langhans layer protects fetus against syphilis 24 wks/6 months life span of langhans layer increase. Before 24 weeks critical, might get infected syphilis F. Synsitiotrophoblast synsitial layer responsible production of hormone 1. Amnion inner most layer a. Umbilical Cord- FUNIS, whitish grey, 15 55cm, 20 21". Short cord: abruptio placenta or inverted uterus. Long cord:cord coil or cord prolapse b. Amniotic Fluid bag of H2O, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo-skeletal development 3. maintains temp 4. prevent cord compression 5. help in delivery process normal amt of amniotic fluid 500 to 1000cc polyhydramnios, hydramnios- GIT malformation TEF/TEA, increased amt of fluid oligohydramnios- decrease amt of fluid kidney disease Diagnostic Tests for Amniotic Fluid A. Amniocentesis empty bladder before performing the procedure. Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac; fluid is tested for: 1. Genetic screening- maternal serum alpha fetoprotein test (MSAFP) 1st trimester 2. Determination of fetal maturity primarily by evaluating factors indicative of lung maturity 3rd trimester Testing time 36 weeks decreased MSAFP= down syndrome increase MSAFP = spina bifida or open neural tube defect Common complication of amniocenthesis infection Dangerous complications spontaneous abortion 3rd trimester- pre term labor Important factor to consider for amniocentesisneedle insertion site

Aspiration of yellowish amniotic fluid jaundice baby Greenish meconium A. Amnioscopy direct visualization or exam to an intact fetal membrane. B. Fern Test- determine if amniotic fluid has ruptured or not (blue paper turns green/grey + ruptured amniotic fluid) C. Nitrazine Paper Test diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amniotic fluid. 1. Chorion where placenta is developed Lecithin Sphingomyelin L/S Ratio- 2:1 signifies fetal lung maturity not capable for RDS Shake test amniotic + saline & shake Foam test Phosphatiglyceroli PG+ definitive test to determine fetal lung maturity a. Placenta (Secundines) Greek pancake, combination of chorionic villi + deciduas basalis. Size: 500g or kg -1 inch thick & 8" diameter Functions of Placenta: 1. Respiratory System beginning of lung function after birth of baby. Simple diffusion 2. GIT transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If mom hypoglycemic, fetus hypoglycemic 3. Excretory System- artery carries waste products. Liver of mom detoxifies fetus. 4. Circulating system achieved by selective osmosis 5. Endocrine System produces hormones Human Chorionic Gonadrophin maintains corpus luteum alive. Human placental Lactogen or sommamommamotropin Hormone for mammary gland development. Has a diabetogenic effect serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen progestin

6. It serves as a protective barrier against some microorganisms HIV,HBV Fetal Stage " Fetal Growth and Development" Entire pregnancy days 266 280 days 37 42 weeks Differentiation of Primary Germ layers * Endoderm 1st week endoderm primary germ layer Thyroid for basal metabolism Parathyroid for calcium Thymus development of immunity Liver lining of upper RT & GIT * Mesoderm development of heart, musculoskeletal system, kidneys and repro organ * Ectoderm development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth First trimester: 1st month Brain & heart development GIT& resp Tract remains as single tube 1. Fetal heart tone begins heart is the oldest part of the body 2. CNS develops dizziness of mom due to hypoglycemic effect Food of brain glucose complex CHO pregnant womans food (potato) Second Month 1. All vital organs formed, placenta developed 2. Corpus luteum source of estrogen & progesterone of infant life span end of 2nd month 3. organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Buds of milk teeth appear 3. Fetal heart tone heard Doppler 10 12 weeks 4. is distinguishable Second Trimester: FOCUS length of fetus Fourth Month 1. lanugo begins to appear 2. fetal heart tone heard fetoscope, 18 20 weeks 3. buds of permanent teeth appear Fifth Month 1. lanugo covers body 2. actively swallows amniotic fluid 3. 19 25 cm fetus, 4. Quickening- 1st fetal movement. 18- 20 weeks

primi, 16- 18 wks multi 5. fetal heart tone heard with or without instrument Sixth Month 1. eyelids open 2. wrinkled skin 3. vernix caseosa present Third trimester: Period of most rapid growth. FOCUS: weight of fetus Seventh Month development of surfactant lecithin Eighth Month 1. lanugo begin to disappear 2. sub Q fats deposit 3. Nails extend to fingers Ninth Month 1. lanugo & vernix caseosa completely disappear 2. Amniotic fluid decreases Tenth Month bone ossification of fetal skull Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus A. Drugs: Streptomycin anti TB & or Quinine (anti malaria) damage to 8th cranial nerve poor hearing & deafness Tetracycline staining tooth enamel, inhibit growth of long bone Vitamin K hemolysis (destr of RBC), hyperbilirubenia or jaundice Iodides enlargement of thyroid or goiter Thalidomides Amelia or pocomelia, absence of extremities Steroids cleft lip or palate Lithium congenital malformation B. Alcohol lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by microcephaly C. Smoking low birth rate D. Caffeine low birth rate E. Cocaine low birth rate, abruption placenta TORCH (Terratogenic) Infections viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects

on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O others. Hepa A or infectious heap oral/ fecal (hand washing) Hepa B, HIV blood & body fluids Syphilis R rubella German measles congenital heart disease (1st month) normal rubella r 1:10 <1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Don't get pregnant for 3 months. Vaccine is terratogenic C cytomegalo virus H herpes simplex virus VI. Physiological Adaptation of the Mother to Pregnancy A. Systemic Changes 1. Cardiovascular System increase blood volume of mom (plasma blood) 30 50% = 1500 cc of blood - easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis due to hyperemia of nasal membrane palpitation, Physiologic Anemia pseudo anemia of pregnant women Normal Values Hct 32 42% Hgb 10.5 14g/dL Criteria 1st and 3rd trimester.- pathologic anemia if lower HCT should not be 33%, Hgb should not be < 11g/dL 2nd trimester Hct should not <32% Hgb Shdn't < 10.5% pathologic anemia if lower Pathogenic Anemia - iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women. - Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia Nursing Care: Nutritional instruction kangkong, liver due to ferridin content, green leafy vegetablealugbati,saluyot, malunggay, horseradish,

ampalaya Parenteral Iron ( Imferon) severe anemia, give IM, Z tract- if improperly administered, hematoma. Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hrs after, black stool, constipation Monitor for hemorrhage Alert: Iron from red meats is better absorbed iron form other sources Iron is better absorbed when taken with foods high in Vit C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs Edema lower extremities due venous return is constricted due to large belly, elevate legs above hip level. Varicosities pressure of uterus - use support stockings, avoid wearing knee high socks - use elastic bandage lower to upper Vulbar varicosities- painful, pressure on gravid uterus, to relieve- position side lying with pillow under hips or modified knee chest position Thrombophlebitis presence of thrombus at inflamed blood vessel - pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor - thrombus formation candidate outstanding sign (+) Homan's sign pain on cuff during dorsiflexion milk leg skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Mgt: 1.) Bed rest 2.) Never massage 3.) Assess + Homan sign once only might dislodge thrombus 4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute) 5.) Monitor APTT antidote for Heparin toxicity, protamine sulfate 6.) Avoid aspirin! Might aggravate bleeding. 2. Respiratory system common problem SOB due to enlarged uterus & increase O2 demand Position- lateral expansion of lungs or side lying position.

3. Gastrointestinal 1st trimester change Morning Sickness nausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon small freq feeding. Vomiting in preg emesisgravida. Metabolic alkalosis, F&E imbalance primary med mgt replace fluids. Monitor I&O constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet - fruits papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha. Except guava has pectin that's constipating veg petchy, malungay. - exercise -mineral oil excretion of fat soluble vitamins * Flatulence avoid gas forming food cabbage * Heartburn or pyrosis reflux of stomach content to esophagus - small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical increase salivation ptyalsim mgt mouthwash *Hemorrhoids pressure of gravid uterus. Mgt; hot sitz bath for comfort 4. Urinary System frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos mgt for nocturia Acetyace test albumin in urine Benedicts test sugar in urine 5. Musculoskeletal Lordosis pride of pregnancy Waddling Gait awkward walking due to relaxation causes softening of joints & bones Prone to accidental falls wear low heeled shoes Leg Cramps causes: prolonged standing, over fatigue, Ca & phosphorous imbalance(#1 cause while pregnant), chills, over, pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Mgt: Increase Ca diet-milk(Inc Ca & Inc phosphorus)-1pint/day or 3-4 servings/day. Cheese, yogurt, head of fish, Dilis, sardines with bones, brocolli, seafoodtahong (mussels), lobster, crab. Vit D for increased Ca absorption dorsiflexion

B. Local Changes Local change: Vagina: V Chadwick's sign blue violet discoloration of vagina C Goodel's sign change of consistency of cervix I Hegar's change of consistency of isthmus (lower uterine segment) LEUKORRHEA whitish gray, mousy odor discharge ESTROGEN hormone, resp for leucorrhea OPERCULUM mucus plug to seal out bacteria. PROGESTERONE hormone responsible for operculum PREGNANT acidic to alkaline change to protect bacterial growth (vaginitis)

Brown pinkish line- linea nigra- symphisis pubis to umbilicus 4. Breast Changes increase hormones, color of areola & nipple pre colostrums present by 6 weeks, colostrums at 3rd trimester Breast self exam- 7 days after mens supine with pillow at back quadrant B upper outer common site of cancer Test to determine breast cancer: 1. mammography 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above 1 x a yr 6. Ovaries rested during pregnancy

Problems Related to the Change of Vaginal Environment: a. Vaginitits trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa wants alkaline S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so don't give at 1st trimester 1. treat dad also to prevent reinfection 2. no alcohol has antibuse effect VAGINAL DOUCHE IQ H2O : 1 tbsp white vinegar b. Moniliasis or candidiasis due to candida albecans, fungal infection. Color white cheese like patches adheres to walls of vagina. Signs & Symptoms: Management antifungal Nistatin, genshan violet, cotrimaxole, canesten Gonorrhea -Thick purulent discharge Vaginal warts- condifoma acuminata due to papilloma virus Mgt: cauterization 2. Abdominal Changes striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue avoid scratching, use coconut oil, umbilicus is protruding 3. Skin Changes brown pigmentation nose chin, cheeks chloasma melasma due to increased melanocytes.

7. Signs & symptoms of Pregnancy A. Presumptive s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective B. Probable signs observed by the members of health team. Objective C. Positive Signs undeniable signs confirmed by the use of instrument. Ballotment sign of myoma * + HCG sign of H mole - trans vaginal ultrasound. Empty bladder - ultrasound full bladder placental grading rating/grade o immature 1 slightly mature 2 moderately mature 3 placental maturity What is deposited in placenta which signify maturity there is calcium Presumptive Probable Positive Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Cloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening Goodel's- change of consistency of cervix Chadwick's- blue violet discoloration of vagina Hegar's- change of consistency of isthmus Elevated BBT due to increased progesterone Positive HCG or (+)preg test

Ballottement bouncing of fetus when lower uterine is tapped sharply Enlarged abdomen Braxton Hicks contractions painless irregular contractions Ultrasound evidence (sonogram) full bladder Fetal heart tone Fetal movement Fetal outline Fetal parts palpable VII. Psychological Adaptation to Pregnancy (Emotional response of mom -Reva Rubin theory) First Trimester: No l signs & sx, surprise, ambivalence, denial sign of maladaptation to pregnancy. Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg, nutrition Second Trimester tangible S&Sx. mom identifies fetus as a separate entity due to presence of quickening, fantasy. Developmental task accept growing fetus as baby to be nurtured. Health teaching: growth & development of fetus. Third Trimester: mom has personal identification on appearance of baby Development task: prepare of birth & parenting of child. HT: responsible parenthood baby's Layette" best time to do shopping. Most common fear let mom listen to FHT to allay fear Lamaze classes

3.) Home preg kit do it yourself 4. Baseline Data: V/S esp. BP, monitor wt. (increase wt 1st sign preeclampsia) Weight Monitoring First Trimester: Normal Weight gain 1.5 3 lbs (.5 1lb/month) Second trimester: normal weight gain 10 12 lbs (4 lbs/month) (1 lb/wk) Third trimester: normal weight gain 10 12 lbs (4 lbs/ month) ( 1lb/wk) Minimum wt gain 20 25 lbs Optimal wt gain 25 35 lbs 5. Obstetrical Data: nullipara no pregnancy a. Gravida- # of pregnancy b. Para # of viable pregnancy Viability the ability of the fetus to live outside the uterus at the earliest possible gestational age. age of viability 20 24 wks Term 37 42 wks, Preterm -20 37 weeks abortion <20 weeks Sample Cases: 1 abortion GTPAL 1 2nd mo 2 0 01 0 G2 P0 1 40th AOG GT P A L 1 36th AOG 6 1 2 2 4 2 misc 1 twins 35 AOG 1 4th month G6 P3 1 39th week 1 miscarriage GP GTPAL 1 stillbirth 33 AOG (considered as para) 4 2 4 11 11 1 preg 3rd wk 1 33 P 1 41st L 1 abort A 1 still 39 GP GTPAL 1 triplet 32 6 4 6 2 2 15 1 4th mon c. Important Estimates: 1. Nagele's Rule use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP Jan Feb Mar M D Y +9 +7 no year LMP Jan 25, 04 +9 +7 10 / 32 / 04

VII. Pre-Natal Visit: 1. Frequency of Visit: 1st 7 months 1x a month 8 9 months 2 x a month 10 once a week post term 2 x a week 2. Personal data name, age (high risk < 18 & >35 yrs old) record to determine high risk HBMR. Home base mom's record. ( pseudocyesis or false pregnancy on men & women) Couvade syndrome dad experiences what mom goes through lihi) Address, civil status, religion, culture & beliefs with respect, non judgmental Occupation financial condition or occupational hazards, education background level knowledge 3. Diagnosis of Pregnancy 1.) urine exam to detect HCG at 40 100th day. 60 70 day peak HCG. 6 weeks after LMP- best to get urine exam. 2.) Elisa test test for preg detects beta subunit of HCG as early as 7 10days

1 add 1 month to month 11/31/04 EDD 2. McDonald's Rule to determine age of gestation IN WEEKS FUNDIC HT X 7/8=AOG in WK Fundic Ht X 7 = AOG in weeks 8 Fr sypmhisis pubis to fundus 24 X 7 =21 wks 8 3. Bartholomew's Rule to determine age of gestation by proper location of fundus at abdominal cavity. 3 months above sym pub 5 months level of umbilicus 9 months below zyphoid 10 months level of 8 months due to lightening 4. Haases rule to determine length of the fetus in cm. Formula: 1st of preg , square @ month 2nd of preg, x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st of preg 5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 2nd of preg 8 x 5 = 40 cm 9 x 5 = 45 cm d. tetanus immunizations prevents tetanus neonatum -mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 any time during pregnancy TT2 4 wks after TT1 3 yrs protection TT3 6 months after TT2 5 yrs protection TT4 1 yr after TT3 10 yrs protection TT5 yr after TT4 lifetime protection 5. Physical Examination: A. Examine teeth: sign of infection Danger signs of Pregnancy C chills/ fever infection Cerebral disturbances ( headache preeclampsia) A abdominal pain ( epigastric pain aura of impending convulsions B boardlike abdomen abruption placenta Increase BP HPN Blurred vision preeclampsia Bleeding 1st trimester, abortion, ectopic pre/2nd

H mole, incompetent cervix 3rd placental anomalies S sudden gush of fluid PROM (premature rupture of membrane) prone to inf. E edema to upper ext. (preeclampsia) 6. Pelvic Examination internal exam 1. empty bladder 2. universal precaution EXT OS of cervix site for getting specimen Site for cervical cancer Pap Smear cervical cancer - composed of squamous columnar tissue Result: Class I normal Class IIA acytology but no evidence of malignancy B suggestive of infl. Class III cytology suggestive of malignancy Class IV cytology strongly suggestive of malignancy Class V cytology conclusive of malignancy Stages of Cervical Cancer Stage 0 carcinoma insitu 1 cancer confined to cervix 2 cancer extends to vagina 3 pelvis metastasis 4 affection to bladder & rectum 7. Leopold's Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone - use palm! Warm palm. Prep mom: 1. Empty bladder 2. Position of mom-supine with knee flex (dorsal recumbent to relax abdominal muscles) Procedure: 1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to determine presentation 2nd Maneuver: with both hands moving down, identify the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. Get V/S(before 2nd maneuver)

PR to diff fundic souffl (FHR) & uterine souffl. Uterine souffl maternal H rate 3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers. To determine degree of engagement. Assess whether the presenting part is engaged in the pelvis )Alert : if the head is engaged it will not be movable). 4th Maneuver: the Examiner changes the position by facing the patient's feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude relationship of fetus to 1 another. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting. Attitude relationship of fetus to a part or degree of flexion Full flexion when the chin touches the chest

Postmaturity a.) pregnancy induced hypertension (PIH), diabetes b.) warning signs noted during DFMC c.) maternal history of smoking, inadequate nutrition Procedure: Done within 30 minutes wherein the mother is in semi-fowler's position (w/ fetal monitor); external monitor is applied to document fetal activity; mother activates the "mark button" on the electronic monitor when she feels fetal movement. Attach external noninvasive fetal monitors 1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs) 2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected 3. monitor until at least 2 FMs are detected in 20 minutes if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST Result: Noncreative Nonstress Not Good Reactive Responsive is Real Good Interpretation of results i. reactive result 1. Baseline FHR between 120 and 160 beats per minute 2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at least 15 seconds in a 10 to 20 minute period as a result of FM 3. Good variability normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip. 4. result indicates a healthy fetus with an intact nervous system ii. Nonreactive result 1. Stated criteria for a reactive result are not met 2. Could be indicative of a compromised fetus. Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)

8.Assessment of Fetal Well-BeingA. Daily Fetal Movement Counting (DFMC) -begin 27 weeks Mom- begin after meal breakfast a. Cardiff count to 10 method one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs) (2) Expected findings 10 movements in 1 hour or less 3) Warning signs a.) more then 1 hour to reach 10 movements b.) less then 10 movements in 12 hours(nonreactive- fetal distress) c.) longer time to reach 10 FMs than on previous days d.) movement are becoming weaker, less vigorous Movement alarm signals < 3 FMs in 12 hours 4.) warning signs should be reported to healthcare provider immediately; often require further testing. Examples: nonstress test (NST), biographical profile (BPP) B. Nonstress test to determine the response of the fetal heart rate to activity Indication pregnancies at risk for placental insufficiency

9. Health teachings a. Nutrition do nutritional assessment daily food intake High risk moms: 1. Pregnant teenagers low compliance to heath regimen. 2. Extremes in wt underweight, over wt candidate for HPN, DM 3. Low socio economic status 4. Vegetarian mom decrease CHON needs Vit B12 cyanocobalamin formation of folic acid needed for cell DNA & RBC formation. (Decrease folic acid spina bifida/open neural tube defect) How many Kcal CHO x4,CHON x4, fats x 9

Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement Protein increase should reflect - Lean meat, poultry, fish - Eggs, cheese, milk - Dried beans, lentils, nuts - Whole grains * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quanes of all amino acids

Recommended Nutrient Requirement that increases During Pregnancy Nutrients Requirements Food Source Calories Essential to supply energy for - increased metabolic rate - utilization of nutrients - protein sparing so it can be used for - Growth of fetus - Development of structures required for pregnancy including placenta, amniotic fluid, and tissue growth. 300 calories/day above the prepregnancy daily requirement to maintain ideal body weight and meet energy requirement to activity level - Begin increase in second trimester - Use weight gain pattern as an indication of adequacy of calorie intake. - Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage. Caloric increase should reflect - Foods of high nutrient value such as protein, complex carbohydrates (whole grains, vegetables, fruits) - Variety of foods representing foods sources for the nutrients requiring during pregnancy - No more than 30% fat Protein Essential for: - Fetal tissue growth - Maternal tissue growth including uterus and breasts - Development of essential pregnancy structures - Formation of red blood cells and plasma proteins * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH) 60 mg/day or an increase of 10% above daily requirements for age group

Calcium-Phosphorous Essential for - Growth and development of fetal skeleton and tooth buds - Maintenance of mineralization of maternal bones and teeth - Current research is : Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension Calcium increases of - 1200 mg/day representing an increase of 50% above prepregnancy daily requirement. - 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous Calcium increases should reflect: - dairy products : milk, yogurt, ice cream, cheese, egg yolk - whole grains, tofu - green leafy vegetables - canned salmon & sardines w/ bones - Ca fortified foods such as orange juice - Vitamin D sources: fortified milk, margarine, egg yolk, butter, liver, seafood Iron Essential for - Expansion of blood volume and red blood cells formation - Establishment of fetal iron stores for first few months of life 30 mg/day representing a doubling of the pregnant daily requirement - Begin supplementation at 30- mg/day in second trimester, since diet alone is unable to meet pregnancy requirement - 60 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia. - 70 mg/day of vitamin C which enhances iron absorption - inadequate iron intake results in maternal effects anemia depletion of iron stores, decreased

energy and appe, cardiac stress especially labor and birth - fetal effects decreased availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder of pregnancy. Iron increases should reflect - liver, red meat, fish, poultry, eggs - enriched, whole grain cereals and breads - dark green leafy vegetables, legumes - nuts, dried fruits - vitamin C sources: citrus fruits & juices, strawberries, cantaloupe, broccoli or cabbage, potatoes - iron from food sources is more readily absorbed when served with foods high in vit C Zinc Essential for * the formation of enzymes * maybe important in the prevention of congenital malformation of the fetus. 15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements. Zinc increases should reflect - liver, meats - shell fish - eggs, milk, cheese - whole grains, legumes, nuts Folic Acid, Folacin, Folate Essential for - formation of red blood cells and prevention of anemia - DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects (spina bifida), abortion, abruption placenta 400 mcg/day representing an increase of more then 2 times the daily prepregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency 4 servings of grains/day Increases should reflect - liver, kidney, lean beef, veal - dark green leafy vegetables, broccoli, legumes. - Whole grains, peanuts Additional Requirements Minerals - iodine - Magnesium - Selenium 175 mcg/day 320 mg/day 65 mcg/day Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.

Vitamins E Thiamine Riborlavin Pyridoxine ( B6) B12 Niacin 10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day Vit stored in body. Taking it not needed fat soluble vitamins. Hard to excrete. 2.ual Activity a.) should be done in moderation b.) should be done in private place c.) mom placed in comfy pos, sidelying or mom on top d.) avoided 6 weeks prior to EDD e.) avoid blowing or air during cunnilingus f.) changes in ual desire of mom during preg- air embolism Changes in ual desire: a.) 1st tri decrease desire due to bodily changes b.) 2nd trimester increased desire due to increase estrogen that enhances lubrication c.) 3rd trimester decreased desire Contraindication in : 1. vaginal spotting 1st trimester threatened abortion 2nd trimester- placenta previa 2. incompetent cervix 3. preterm labor 4. premature rupture of membrane 3. Exercise to strengthen muscles used during delivery process - principles of exercise 1.) Done in moderation. 2.) Must be individualized Walking best exercise Squatting strengthen muscles of perineum. Increase circulation to perineum. Squat feet flat on floor Tailor Sitting 1 leg in front of other leg ( Indian seat) Raise buttocks 1st before head to prevent postural hypotension dizziness when changing position - shoulder circling exercise- strengthen chest muscles - pelvic rocking/pelvic tilt- exercise relieves low

back pain & maintain good posture - * arch back standing or kneeling. Four extremities on floor Kegel Exercise strengthen pulococcygeal muscles - as if hold urine, release 10x or muscle contraction Abdominal Exercise strengthens muscles of abdominal done as if blowing candle 4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience. a. Psychophysical 1. Bradley Method Dr. Robert Bradley advocated active participation of husband at delivery process. Based on imitation of nature. Features: 1.) darkened rm 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep 2. Grantly Dick Read Method fear leads to tension while tension leads to pain b. Psychoual 1. Kitzinger method preg, labor & birth & care of newborn is an impt turning pt in woman's life cycle - flow with contraction than struggle with contraction c. Psychoprophylaxis prevention of pain 1. Lamaze: Dr. Ferdinand Lamaze req. disciple, conditioning & concentration. Husband is coach Features: 1. Conscious relaxation 2. Cleansing breathe inhale nose, exhale mouth 3. Effleurage gentle circular massage over abdominal to relieve pain 4. imaging sensate focus

4.) leboyers warm, quiet, dark, comfy room. After delivery, baby gets warm bath. 5.) Birth under H20 bathtub labor & delivery warm water, soft music. IX. Intrapartal Notes inside ER A. Admitting the laboring Mother: Personal Data: name, age, address, etc Baseline Data: v/s esppecially BP, weight Obstetrical Data: gravida # preg, para- viable preg, 22 24 wks Physical Exams,Pelvic Exams B. Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) contraction action 2.) oxytocin theory post pit gland releases oxytocin. Hypothalamus produces oxytocin 3.) prostaglandin theory stimulation of arachidonic acid prostaglandin- contraction 4.) progesterone theory before labor, decrease progesterone will stimulate contractions & labor 5.) theory of aging placenta life span of placenta 42 wks. At 36 wks degenerates (leading to contraction onset labor). b.2. The 4 P's of labor 1. Passenger a. Fetal head is the largest presenting part common presenting part of its length. Bones 6 bones S sphenoid F frontal sinciput E ethmoid O occuputal occiput T temporal P parietal 2 x Measurement fetal head: 1. transverse diameter 9.25cm - biparietal largest transverse - bitemporal 8 cm 2. bimastoid 7cm smallest transverse Sutures intermembranous spaces that allow molding. 1.) sagittal suture connects 2 parietal bones ( sagitna) 2.) coronal suture connect parietal & frontal bone (crown) 3.) lambdoidal suture connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

5. Different Methods of delivery: 1.) birthing chair bed convertible to chair semifowlers 2.) birthing bed dorsal recumbent pos 3.) squatting relives low back pain during labor pain