Human Sexuality
A. Concepts
1. A persons sexuality encompasses the complex behaviors, attitudes emotions and preferences that are related to
sexual self and eroticism.
2. Sex basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
B. Definitions related to sexuality:
Sex biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.
- developed at the moment of conception.
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 bartholenes glands.
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
C. ovaries 2 female sex glands, almond shaped. Ext- vestibule 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. Interstitial site of ectopic pregnancy most dangerous
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
2. Internal
The Process of Spermatogenesis maturation of sperm
Urethra
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Male and Female homologues
Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skenes gands
Cowpers Glands Bartholin's glands
Scrotum Labia Majora
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1. hypothalamus
2. anterior pituitary gland master clock of body
3. ovaries
4. uterus
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.
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
VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of
progesterone)
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
1. Excitement Phase (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) erotic stimuli
cause increase sexual 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 sexual tension with physiologic or
psychologic release, immeasurable peak of sexual experience. May last 2 10 sec- most affected are is pelvic area.
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
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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
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
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Paper turns yellow- urine. Paper turns blue green/gray-(+) rupture of amn fluid.
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.
* 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. Sex 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. Sex is distinguishable
Fourth Month
1. lanugo begins to appear
2. fetal heart tone heard fetoscope, 18 20 weeks
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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
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
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
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 titer 1:10
<1:10 less immunity to rubella, after delivery, mom will be given rubella vaccine. Dont get pregnant for 3 months. Vaccine
is terratogenic
C cytomegalo virus
H herpes simplex virus
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,
Normal Values
Hct 32 42%
Hgb 10.5 14g/dL
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Criteria
1st and 3rd trimester.- pathologic anemia if lower
HCT should not be 33%, Hgb should not be < 11g/dL
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 vegetable-alugbati,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.
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.
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 thats constipating veg petchy, malungay.
- exercise
-mineral oil excretion of fat soluble vitamins
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* Flatulence avoid gas forming food cabbage
*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
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, oversex,
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, seafood-tahong (mussels), lobster, crab.
Vit D for increased Ca absorption
dorsiflexion
B. Local Changes
Local change: Vagina:
V Chadwicks 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)
S&Sx:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Mgt:
FLAGYL (metronidazole antiprotozoa). Carcinogenic drug so dont 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
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.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus
Breast self exam- 7 days after mens supine with pillow at back
quadrant B upper outer common site of cancer
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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
VII. Psychological Adaptation to Pregnancy (Emotional response of mom Reva Rubin theory)
First Trimester: No tanginal 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.
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
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)
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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 612 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 1 1
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:
6 x 5 = 30 cm
7 x 5 = 35 cm 2nd of preg
8 x 5 = 40 cm
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9 x 5 = 45 cm
5. Physical Examination:
A. Examine teeth: sign of infection
Danger signs of Pregnancy
C - chills/ fever - infection
Cerebral disturbances ( headache preeclampsia)
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
7. Leopolds 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).
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4th Maneuver: the Examiner changes the position by facing the patients 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.
B. Nonstress test to determine the response of the fetal heart rate to activity
Indication pregnancies at risk for placental insufficiency
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-fowlers 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.
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
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
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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
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congenital malformation of the fetus. - whole grains, legumes, nuts
Folic Acid, Folacin, Folate 400 mcg/day representing an increase of Increases should reflect
Essential for more then 2 times the daily prepregnant - liver, kidney, lean beef, veal
- formation of red blood cells requirement. 300mcg/day supplement for - dark green leafy vegetables,
and prevention of anemia women with low folate levels or dietary broccoli, legumes.
- DNA synthesis and cell deficiency - Whole grains, peanuts
formation; may play a role in 4 servings of grains/day
the prevention of neutral tube
defects (spina bifida), abortion,
abruption placenta
Additional Requirements Increased requirements of pregnancy can
Minerals easily be met with a balanced diet that meets
- iodine 175 mcg/day the requirement for calories and includes food
- Magnesium 320 mg/day sources high in the other nutrients needed
- Selenium 65 mcg/day during pregnancy.
Vitamins Vit stored in body. Taking it not needed fat
E 10 mg/day soluble vitamins. Hard to excrete.
Thiamine 1.5 mg/day
Riborlavin 1.6 mg/day
Pyridoxine ( B6) 2.2 mg/day
B12 2.2 mg day
Niacin 17 mg/day
2.Sexual 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 sexual desire of mom during preg- air embolism
Changes in sexual 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 sex:
1. vaginal spotting
1st trimester threatened abortion
2nd trimester placenta previa
2. incompetent cervix
3. preterm labor
4. premature rupture of membrane
Squatting strengthen muscles of perineum. Increase circulation to perineum. Squat feet flat on floor
Raise buttocks 1st before head to prevent postural hypotension dizziness when changing position
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:
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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. Psychosexual
1. Kitzinger method preg, labor & birth & care of newborn is an impt turning pt in womans life cycle
- flow with contraction than struggle with contraction
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
Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis
Fontanels:
1.) Anterior fontanel bregma, diamond shape, 3 x 4 cm,( > 5 cm hydrocephalus), 12 18 months after birth- close
2.) Posterior fontanel or lambda triangular shape, 1 x 1 cm. Closes 2 3 months.
4.) Anteroposterior diameter -
suboccipitobregmatic 9.5 cm, complete flexion, smallest AP
occipitofrontal 12cm partial flexion
occipitomental 13.5 cm hyper extension submentobragmatic-face presentation
2. Passageway
Mom 1.) < 49 tall
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2.) < 18 years old
3.) Underwent pelvic dislocation
Pelvis
4 main pelvic types
1. Gynecoid round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android heart shape male pelvis- anterior part pointed, posterior part shallow
3. Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid flat AP diameter narrow, transverse wider
b. Pelvis
2 hip bones 2 innominate bones
3 Parts of 2 Innominate Bones
Ileum lateral side of hips
- iliac crest flaring superior border forming prominence of hips
Ischium inferior portion
- ischial tuberosity where we sit landmark to get external measurement of pelvis
Pubes ant portion symphisis pubis junction between 2 pubis
1 sacrum post portion sacral prominence landmark to get internal measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery
Important Measurements
1. Diagonal Conjugate measure between sacral promontory and inferior margin of the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC 11.5 cm=true conjugate)
2. True conjugate/conjugate vera measure between the anterior surface of the sacral promontory and superior margin of the
symphysis pubis. Measurement: 11.0 cm
Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial tuberosity approximated with use of fist 8 cm &
above.
3. Power the force acting to expel the fetus and placenta myometrium powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Nursing Care;
Administer Analgesics (Morphine)
Attempt manual rotation for ROP or LOP most common malposition
Bear down with contractions
Adequate hydration prepare for CS
Sedation as ordered
Cesarean delivery may be required, especially if fetal distress is noted
Cord Prolapse a complication when the umbilical cord falls or is washed through the cervix into the vagina.
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Danger signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord form vagina
Nursing care:
1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression
causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS
1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Assessment: Dilations: 0 3 cm mom excited, apprehensive, can communicate
Frequency: every 5 10 min
Intensity mild
Nursing Care:
1. Encourage walking - shorten 1st stage of labor
2. Encourage to void q 2 3 hrs full bladder inhibit contractions
3. Breathing chest breathing
Active Phase:
Assessment: Dilations 4 -8 cm Intensity: moderate Mom- fears losing control of self
Frequency q 3-5 min lasting for 30 60 seconds
Nursing Care:
M edications have meds ready
A ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D dry lips oral care (ointment)
dry linens
B abdominal breathing
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I nform of progress
R estless support her breathing technique
E ncourage and praise
D iscomfort
Pelvic Exams
Effacement
Dilation
a. Station landmark used: ischial spine
- 1 station = presenting part 1cm above ischial spine if (-) floating
- 2 station = presenting part 2 cm above ischial spine if (-) floating
0 station = level at ischial spine engagement
+ 1 station = below 1 cm ischial spine
+3 to +5 = crowning occurs at 2nd stage of labor
b. Presentation/lie the relationship of the long axis (spine) of the fetus to the long axis of the mother
-spine of mom and spine of fetus
Two types:
b.1. Longitudinal Lie ( Parallel)
cephalic - Vertex complete flexion
Face
Brow Poor Flexion
Chin
Breech - Complete Breech thigh breast on abdomen, breast lie on thigh
Incomplete Breech thigh rest on abdominal
Frank legs extend to head
Footling single, double
Kneeling
c. Position relationship of the fatal presenting part to specific quadrant of the mothers pelvis.
Variety:
Occipito LOA left occipito ant (most common and favorable position) side of maternal pelvis
LOP left occipito posterior
LOP most common mal position, most painful
ROP squatting pos on mom
ROT
ROA
Chin / Mento
LMA, LMT, LMP, RMP, RMA, RMT, RMP
Parts of contractions:
Increment or crescendo beginning of contractions until it increases
Acme or apex height of contraction
Decrement or decrescendo from height of contractions until it decreases
Duration beginning of contractions to end of same contraction
Interval end of 1 contraction to beginning of next contraction
Frequency beginning of 1 contraction to beginning of next contraction
Intensity - strength of contraction
Contraction vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions
Mom has headache check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia
Health teachings
1.) Ok to shower
2.)NPO GIT stops function during labor if with food- will cause aspiration
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3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 18 inch ht enema tubing
Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
Nursing Care:
To prevent puerperal sepsis - < 48 hours only vaginal pack
3. Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 28 cotyledons
Placenta delivered from 3-10 minutes
Signs of placental separation
1. Fundus rises becomes firm & globular Calkins sign
2. Lengthening of the cord
3. Sudden gush of blood
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7. Administer methergine IM (Methylergonovine Maleate) Ergotrate derivatives
8. Monitor hpn (or give oxytocin IV)
9. Check perineum for lacerations
10. Assist MD for episiorapy
11. Flat on bed
12. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.
4. Fourth Stage: the first 1-2 hours after delivery of placenta recovery stage. Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
d. Perineum
R - edness
E- dema
E - cchemosis
D ischarges
A approximation of blood loss. Count pad & saturation
Complications of Labor
Dystocia difficult labor related to:
Mechanical factor due to uterine inertia sluggishness of contraction
1.) hypertonic or primary uterine inertia
- intense excessive contractions resulting to ineffective pushing
- MD administer sedative valium,/diazepam muscle relaxant
2.) hypotonic secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.
Precipitate Labor - labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
Earliest sign: tachycardia & restlessness
Late sign: hypotension
Outstanding Nursing dx: fluid volume deficit
Post of mom modified trendelenberg
IV fast drip due fluid volume def
Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
Sx:
a.) sudden pain
b.) profuse bleeding
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c.) hypovolemic shock
d.) TAHBSO
Physiologic retraction ring
- Boundary bet upper/lower uterine segment
BANDLS pathologic ring suprapubic depression
a.) sign of impending uterine rupture
Amniotic Fluid Embolism or placental embolism amniotic fluid or fragments of placenta enters natural circulation resulting to
embolism
Sx:
dyspnea, chest pain & frothy sputum
prepare: suctioning
end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body eyes, nose, etc.
Trial Labor measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 14, primi 14 20
Home Mgt:
1. complete bed rest
2. avoid sex
3. empty bladder
4. drink 3 -4 glasses of water full bladder inhibits contractions
5. consult MD if symptoms persist
Hosp:
1. If cervix is closed 2 3 cm, dilation saved by administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar
Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles notify MD pulmo edema administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) sustained tachycardia
Antidote propranolol or inderal - beta-blocker
If cervix is open MD steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS
A. Physiologic Changes
a.1. Systemic Changes
1. Cardiovascular System
- the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal
state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.
2. Genital tract
a. Cervix cervical opening
b. Vaginal and Pelvic Floor
c. Uterus return to normal 6 8 wks. Fundus goes down 1 finger breath/day until 10th day no longer palpable due behind symphisis
pubis
3 days after post partum: sub involuted uterus delayed healing uterus with big clots of blood- a medium for bacterial growth-
(puerperal sepsis)- D&C
after, birth pain:
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1. position prone
2. cold compress to prevent bleeding
3. mefenamic acid
3. Urinary tract: Bladder freq in urination after delivery- urinary retention with overflow
4. Colon: Constipation due NPO, fear of bearing down
5. Perineal area painful episiotomy site sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress
sex- when perineum has healed
c. Letting go interdependent phase 7 days & above. Mom - redefines new roles may extend until child grows.
I. Early postpartum hemorrhage bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding uterine atony.
Complications: hypovolemic shock.
Mgt:
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip
Breast feeding post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
- assess perineum for laceration
- degree of laceration
- mgt episiorapy
II. Late Postpartum hemorrhage bleeding after 24 hrs retained placental fragments
Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta,
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Mgt:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing
Gen mgt:
1.) supportive care CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity for antibiotic
OVULATION count minus 14 days before next mens (14 days before next mens)
Origoknause formula
- monitor cycle for 1 year
- -get short test & longest cycle from Jan Dec
- shortest 18
- longest 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
Physiologic Method-
Pills combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are
essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.
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Alerts on Oral Contraceptive:
-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months
before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.
- if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking
the new one on the first day of the next menses.
- discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase
incidence of CVA and subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A abdominal pain
C chest pain
H - headache
E eye problems
S severe leg cramps
If mom HPN stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
1.) chain smoker
2.) extreme obesity
3.) HPN
4.) DM
5.) Thrombophlebitis or problems in clotting factors
- if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two
consecutive days, or more days, use another method for the rest of the cycle and the start again.
Norplant has 6 match sticks like capsules implanted subdermally containing progesterone.
- 5 yrs disadvantage if keloid skin
- as soon as removed can become pregnant
HT:
1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
Alerts;
- prevents implantation
- most common complications: excessive menstrual flow and expulsion of the device (common problem)
- others:
P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
Condom latex inserted to erected penis or lubricated vagina
Adv; gives highest protection against STD female condom
Alerts:
Disadvantage:
- it lessen sexual satisfaction
- it gives higher protection in the prevention of STDs
Diaphragm rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE
Ht:
1.) proper hygiene
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2.) check for holes before use
3.) must stay in place 6 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
Surgical Method BTL , Bilateral Tubal Ligation can be reversed 20% chance. HT: avoid lifting heavy objects
Vasectomy cut vas deferense.
HT: >30 ejaculations before safe sex
O zero sperm count, safe
1. Hemorrhagic Disorders
General Management
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 40cc) (wt 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges for histopathology to determine if product of conception has been expelled or not
Classifications:
a. Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete all products of conception are expelled. No mgt just emotional support!
2.) Incomplete Placental and membranes retained. Mgt: D&C
Incompetent cervix abortion
McDonalds procedure temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan permanent surgery cervix. CS
c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd trimester
d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty
dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.) Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser evil.
C. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or ampular
Dangerous site - interstitial
Unruptured Tubal rupture
- missed period - sudden , sharp, severe pain. Unilateral radiating to
- abdominal pain within 3 -5 weeks of missed period shoulder.
(maybe generalized or one sided) shoulder pain (indicative of intraperitoneal bleeding that extends
- scant, dark brown, vaginal bleeding to diaphragm and phrenic nerve)
+ Cullens Sign bluish tinged umbilicus signifies intra
Nursing care: peritoneal bleeding
Vital signs syncope (fainting)
Administer IV fluids Mgt:
Monitor for vaginal bleeding Surgery depending on side
Monitor I & O Ovary: oophrectomy
Uterus : hysterectomy
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C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization. Progressive degeneration of
chorionic villi. Recurs.
- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic
villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows &
enlarges the uterus vary rapidly.
Use: methotrexate to prevent choriocarcinoma
Assessment:
Early signs - vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs hypertension before 20th week
Vesicles look like a snowstorm on sonogram
Anemia
Abdominal cramping
Serious complications hyperthyroidism
Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer
could indicative of choriocarcinoma
b. Avoid pregnancy for at least one year
Third Trimester Bleeding Placenta Anomalies
D. Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the
cervical os. Abnormal lower implantation of placenta.
- candidate for CS
Sx: frank
Bright red
Painless bleeding
Dx:
Ultrasound
Avoid: sex, IE, enema may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation ( usually abnormal)
Surgeon in charge of sign consent, RN as witness
- MD explain to patient
complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
E. Abruptio Placenta it is the premature separation of the placenta form the implantation site. It usually occurs after the
twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications: Sudden fetal blood loss
-placenta previa & vasa previa
Nursing Care: Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
Strict I&O
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F. Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental
fragments if vessel is cut.
G. Placenta Circumvalata fetal side of placenta covered by chorion
H. Placenta Marginata fold side of chorion reaches just to the edge of placenta
I. Battledore Placenta cord inserted marginally rather then centrally
J. Placenta Bipartita placenta divides into 2 lobes
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
L. Vasa Previa velamentous insertion of cord has implanted in cervical OS
2. Hypertensive Disorders
I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.
III. Chronic or pre-existing Hypertension HPN before 20 weeks not solved 6 weeks post partum.
Three types of pre-eclampsia
1.) Mild preeclampsia earliest sign of preeclampsia
a.) increase wt due to edema
b.) BP 140/90
c.) protenuria +1 - +2
3.) Eclampsia with seizure! Increase BUN glomerular damage. Provide safety.
Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.
P- prevent convulsions by nursing measures or seizure precaution
1.) dimly lit room . quiet calm environment
2.) minimal handling planning procedure
3.) avoid jarring bed
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Post partum decrease 25% due placenta out.
Fetal effect
1.) hyper & hypoglycemia
2.) macrosomia large gestational age baby delivered > 400g or 4kg
3.) preterm birth to prevent stillbirth
Newborn Effect : DM
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Sx:
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium
Recommendation
Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant heparin doesnt cross placenta
Heart disease
Moms with RHD at childhood
Class I no limit to physical activity
Class II slight limitation of activity. Ordinary activity causes fatigue & discomfort.
Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) early hospitalization by 7 months
Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion
Procedure:
a. classical vertical insertion. Once classical always classical
b. Low segment bikini line type aesthetic use
2 types of infertility
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1.) primary no pregnancy at all
2.) Secondary 1st pregnancy, no more next preg
test male 1st
- more practical & less complicated
- need: sperm only
- sterile bottle container ( not plastic has chem.)
- Sims Huhner test or post coital test. Procedure: sex 2 hours before test
mom remains supine 15 min after ejaculation
Normal: cervical mucus must be stretchable 8 10 cm with 15 20 sperm. If >15 low sperm count
Best criteria- sperm motility for impotency
Factors: low sperm count
1.) occupation- truck driver
2.) chain smoker
administer: clomid ( chomephine citrate) to induce spermatogenesis
Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm count
Implant sperm in ampula
2.) Tubal Occlusion tubal blockage Hx of PID that has scarred tubes
- use of IUD
- appendicitis (burst) & scarring
= dx: hysterosalphingography used to determine tubal patency with use of radiopaque material
Mgt: IVF invitrofertilization (test tube baby)
England 1st test tube baby
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