1

*H mole [hydatidiform mole]- multiple sperms enter the ovum

- lead to abnormal growth
 Equal maturation of both sperm and ovum
 Ability of sperm to reach the ovum
 Ability of sperm to penetrate the zona pellucida and cell membrane
Ovum form zygote
Placenta accessory
Fetal membranes structures
Amniotic fluid needed for
Umbilical cord IUL support
IMPLANTATION (8-10 days)
First clearage -24 hrs. after fertilization
1st clearage division every 22 hrs.
16-15 cell zygote morula

Blastocyst (attaches to uterine endometrium)

 Trophoblast- cells in the outer ring
-later forms in the placenta and membranes
 Embryoblast cells- inner cell mas
-forms the embryo
APPOSITION- blastocyst brushes against uterine endomemium
ADHESION- attaches to endometrial surface
INVASION- settle downs into the soft folds
 Placenta previa- point of implantation is in the lower level of the uterus
-placenta may occlude cervix
 Vaginal spotting- rupture of capillaries by implantation of trophoblasts
EDC may be 4 weeks late
 Embryo- a zygote that has been implanted
EMBRYONIC AND FETAL STRUCTURES
After fertilization, CL continues function because of the influence of the hCG[human chronic
gonadomopin]
Secreted by trophoblasts
 Endometrium- decidua (shed off after baby is delivered)
Decidua basalis- lies directly under the embryo
Decidua capsularis- stretches/ encapsulates surface of trophoblast
Decidua vera- remaining portion of uterine lining
Embryo continues to growth- pushes decidua capsularis like a blanket- enlargement of
structure leads
to contacts of the
opposite uterine wall
highly susceptible to hemorrhage & infection Inner surface of uterus slipped away
CHORIONIC VILLI (trophoblast)
11th-12th day- chorionic villi reach out form single layers of cells into uterine endometrium
Central core- loose connective tissue
-contains fetal capilliaries
Syncytiotrophoblast (outer) (syncytial layer)
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 2

-production of placental hormones:

 hCG
 somatomammotropin [human placental lactogen (hPL)]
 estogen
 progesterone
cytotrophoblast (Langhan’s layer) – 12th day
-protect growing embryo and fetus from spirochetes & syphilis present only up to
-disappears between 20th-24th weeks. 6 months.
 Syphilis- high potential for fetal damage late in pregnancy
PLACENTA (“pancare”-Latin)
-arises out of trophoblast
-serves as: fetal lungs
Kidneys
Gastrointestinal tract
-separates endocrine organ throughout pregnancy
Circulatory
Endocrine
GCI
Kidneys
Circulation:
12th day- maternal bloods collect in intervillous spaces of uterine endometrium
3rd week- oxygen diffuse from maternal blood
Glucose
Amino acids cell layer of chorionic villi
Fatty acids
Minerals villi capillaries
Vitamins
Water
 No direct change of blood between embryo and mother
 Selective osmosis through chorionic villi
 Cotyledons- 30 segments
 Uteroplacental blood flow rate- 50 mL/min (10 wks.)
500-600 mL/min (term)
Mother’s hR, Total Co, BV
Increase supply to placenta
BRAXTON HICK’S contractions- 12 wk (barely noticeable)
Uterine perfusion most effective when mother
Placental circulation lies on left side

Lifts uterus away from inferior VC which presents blood

from
being trapped in the lower extremities
 When mother lies supine- inferior VC compressed; supine hypertension occurs
@ term= 400-600g (1lb)
Weight of placenta [1/6 weight of baby]
chabetic woman-larger than usual placenta
excess fluid collected
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 3

Endocrine Function:
 Human chorionic gonadotropin (hCG) –hormone analyzed in pregnancy tests
False-negative result- 1st missed mense to 100th day
If checked beyond 100th day
 hCG testing after birth-determine if all placenta has been delivered
-hCG completely negative 1-2 wks. After birth
Ensures corpus luteum to continue producing E & P
 endometrial sloughing- failure of CL to continue
-loss of pregnancy
Suppressing maternal immunologic response [placental tissue not
rejected]
-exerts an effect on fetal testes to begin testosterone production
th
8 wk.-corpus luteum is no longer needed, developing placenta produces P
-after 1st missed menstrual period
-nausea + vomiting
 Estrogen
 Estriol- produced as 2nd product of: synlytial cells &placenta
-mammary gland development
-stimulates uterine growth
-nausea + vomiting, erythema of palms angiomol
 Progesterone- “hormone of mothers”
-maintain endometrial lining of uterus
-present in serum (4th wk.)
-reduce contracitility of uterine muscle [prevents premature labor]
-produce by change in electrolgtes (Ca & K)
 Human Placental Lacrogen (UPL) –growth promoting
-lactogenic (lactallion- promoters)
-produced by placenta at 6th wk.
-assayed in –maternal serum urine
-regulate: maternal glucose, protein, fat levels
UMBILICAL CORD
Formed from fetal membranes [amnion, chorion]
-circulatory pathway
Function: transport O2 to nutrients (P to F)
Return wastes products (F to P)
53 cm long (21 in)
2 cm thick (3/4 in )
 Wharton’s jelly- gelarinous mucopotysaccarids
-gives cord body
-prevents pressure on veins and arteries
 Amniotc fluid-covers cord’s outer surface
1 vein: carries blood from P villi to F (oxygenerated)
2 arteries: carries blood from F to P (deO2)
 Percutanerus umbilical cord sampling ( PUBS)- blood flow rate through the UC:
[350 mL/min at term]
ORTHOSTATIC HYPERTENSION
Flat
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 4

Right-side lying
AMNIOTIC MEMBRANES
Chorion laeve- smooth chorion, medial part of trophoblast
1. chorionic membrane- outermost fetal membrane
-support for vac containing amniotic fluid
2. amniotic membrane- beneath chorion produces amniotic fluid
-no nerve supply
-when ruptured, experiences no pain
-produces phospholipid that initiates formxn of prostaglandis
Uterine contraction

initiating labor.
AMNIOTIC FLUID-continuously formed by amniotic membrane
-never stagnant
-probably absorbed by direct contract with fetal surface of placenta
 Absorption- fetal continually suballows fluid

Fetal intestine

Fetal bloodstream

Umbilical arteries

Exchange across placenta

800-1200 mL of AF at term
Esophagial anesia fetal unable to swallow
Anencephaly fluid
 Hydramnios (>2000 mL) [>8cm on US]
-occur in women with diabetes
Hyperglycemia causes excessive fluid shifts into
amniotic space
Fetal urine-adds into amniotic fluid [fetal kidneys become active]
NOTE: IUL- intrauterine life
Polyhydramnios
Oligo hydramnios- reduction of AF amount [<300 mL total] [pocket <1cm]
-disturbance of kidney function
Amniotic fluid- important protective mechanism
-shield against pressure
-protects fetus from temperature changes [liquid temperature changes slow
than air]
-aids in muscular development
-protects fetal O2 supply [umbilical cord]
-slightly alkaline (pH 7.2) urine (pH 5.0 to5.5)
ORIGIN DEVELOPMENT OF ORGAN SYSTEMS
STEM CELLS
Zygote cells (4 days of life) –totipotent stem cells

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 5

Undifferentiated
 Pluripotent stem cells –become specific body cells ex.[nerve,brain,skin]
 Multipotent stem cells –body organ
Reproductive cloning –nucleus of adult body cell is transferred to oocyte
-grows infant identitical to adult donor
Therapeutic cloning –pheripotent stem cells
ZYGOTE GROWTH
 Cephalocaudal position –head –to- tail
1. head 2. Middle 3. Lower extremities
 Germ layers –develops body organ system
PRIMARY GERM LAYERS
2 separate cavities:
1. amniotic cavity –ectoderm
2. yolk sac –entoderm
-supply nourishment until implantation
-source of RBC until fetus’s hematopoietic system matures (12th wk)
 Mesoderm-between amniotic cavity and yolk sac
 Embryonic shield- electoderm, mesoderm, entoderm
*rubella –capable of infecting all 3 germ layers
Mesoderm
All organ systems complete (8 wks) – in rudimentary form
 Organogenesis- growing structure most vulnerable to invasion of teratogens
CARDIOVASCULAR SYSTEM- one of the 1st systems functional in IUL
16th day- single heart bube formed
24th day- heart tube start beating
6th / 7th wk- septum dividing heart chambers formed
10th / 12th wk- ECG (inaccurate til 20th wk)
 Fetal heart rate- fetal O2 level, body activity, circulating blood volume
28th wk-HR becomes stable [matured symphatetic NS]
-5 bpm
FETAL CIRCULATION
-fetus derives O2 and excrete CO2 in placenta [not in O2 exchange in lung]
-blood enters blood vessels of lungs to supply lung cells [not for O2 exchange]
Most important organs of body supplied:
Brain, liver, hearts, kidneys
Blood- from placental toferus – highly O2nated
[by umbilical veins]

 Veins carries blood to inferior VC through the ductus venosus [O2 blood supplied to fetal liver]

 Foramen ovale- blood enters to Leaf A from right A

-opening at the atrial septum
 Ductus artenosus- descending in corta
-shunts blood away from lungs
Blood- umbilical arteries[deO2nated blood] - carried to placenta villi
 Blood O2 saturation level- 80%
Fetal HR- 120-160 bpm
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 6

FETAL HEMOGLOBIN
--different composition -2 alpha chains
-2 gamma chains
[in adults, 2 alha chains 2 beta chains]
-more concentrated
-greater O2 affinity
 Newborn’s hB level- 17.1g/ 100mL
-53% hematocrite [45% -in adult]
RESPIRATORY SYSTEM
3rd wk IUL- respiratory tract+ digestive tract =1 single tube
4th wk- septum divides esophagus and trachea
-lung bords appear on trachea
th
7 wk- diaphragm divides thoracic cavity and abdomen
 Diaphragmatic hernia- stomach, spleen, liver, intestines may enter thoracic cavity
-diaphragm doesn’t completely close up
-compromising lung and displacing heart
 Respiratory development:
o 24th-28th wk- alveoli and capilliaries form
o 3 months- spontaneous respiratory practice movements
o Specific lung fluid- low surface tension low viscosity
-expansion of alveoli at birth
[24wk] surfactant (phospholipid)
Formed and excreted by alveolar cells
-decreased alveolar ST on expiration [prevent alveolar collapse]
*improve infant’s ability to maintain repirations in outside environment]
Not enough O2 –respiratory acidoses (distress)
SURFACTANT –lecithin (L)
Sphingomyelin (S) –chief component in formation of surfactant
35 wk- surge in L prodxn
 Surfactant mixes with AF (normal ratio = 2:1)
L/S analysis ratio- amniocentesis
 Lack of Surfactant –development of respiratory dishess syndrome
*placenta insufficiency enhances
* hypertension surfactant
Development
(inc. steroid levels)
 Synthetically alveolar levels- hurry alveolar maturation
NERVOUS SYSTEM
3rd wk- 4th wk- NS begins to develop
 3rd wk –neutral pale [thickened portion of ectoderm]

Neutral tube –forms CNS [brain spinal cord]

Neutral crest- PNS
 8th wk- brain waves on EEG
 Brain parts [cerebrum, cerebellum, pons, medula oblongata]- form in utero
 Eye and inner ear- projections of the neutral tube
 24 wk-ear is able to responding to sound
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 7

-eyes exhibit pupillary rxn (slight is present)

*spinal cord disorders –meningocele –lack of folic acid
*NS is vulnerable to damage from ataxia
ENDOCRINE SYSTEM
 Fetal andrenal glands- supply a precursor for estrogen synthesis by the placenta
 Fetal pancreas- produces insulin (for baby only)
 Thyroid gland metabolic fxn
 Parathyroid gland calcium balance
DIGESTIVE SYSTEM
Meconium- baby cellular wastes
-16 wk
-black/ dark green (contains bile pigment)
-sticky
 Not able to synthesize vit. K
Liver- hypoglycemia
Hyperbilirubinemia
MUSCULAR SYSTEM
 Quickening- 20th week
Fetal movement- 11th week
REPRODUCTIVE SYSTEM
Testes descend- 34th wk-38 wk
URINARY SYSTEM
12th week- urine formed
16th week- urine excreted into AF 500mL/ day
INTEGUMENTARY SYSTEM
 Lanugo- down hairs
 Vernix caseosa- lubrication
-keep skin from being macerated
Skin is translucent
1 & 2 trimester- organogenesis
3rd tri –fat deposition
IMMUNE SYSTEM
Immunoglobins
igG maternal antibodies- can cross placenta
 Babies develop antibodies when there is disease
MILESTONE OF FETAL GROWTH & DEVELOPMENT
10 months [40 weeks or 280 days] – pregnancy
Fets- grows in utero- 9.5 months [38 wks 266 days]
 4th G wk
-Length: 0.75 -1 cm -back is bent
-weight: 400 mg -rudimentary heart appears
-spinal cord formed fused at midpoint -arms and legs are budlike structures
-lateral wings that will form body are folded forward -rudimentary eyes, ears, nose are
-head folds forward; becomes prominent duscernible.
 8th G wk
-length: 2.5 cm (1 in) -external genitalia develop
-weight: 2.0g -primitive tail regressing
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 8

-organogenesis complete - abdomen appears large [rapid growth

-heart [ with septum 2 valves] beats shythmically of fetal intestines
-facial features discernible -sonogram shows gestational sac
-arms & legs develop
Babies of diabetic mothers- macrosomia [macrosomic babies]
DIAGNOSIS OF PREGNANCY
 Presumptive findings (subjective)
2- breast changes
Nausea & vomiting
Amenorrhea
3- frequent urination
12- fatigue
Uterine enlargement
18- quickening (fetal movement felt)
Melasma (dark pigment of face)
Striae gravidarum
 Probable findings (documented by examiner)
1- serum lab tests (present of hCG)
6- chadwick’s sign (color change of vagina from pink to violet)
Goodell’s sign (softening of cervix)
Hegar’s sign (softening of lower uterine segment)
Sonographic evidence of gestational sac

16- ballottement (fetus felt to vise against abdominal wall)

20- Braxton Hicks contractions (periodic uterine contractions)
Fetal outline felt by examiner (palpated in abdomen)
 Positive findings
-demonstration of fetal heart separate from mother’s (10-12 wk)
-fetal movement felt by examiner (20 wk)
-visualization of fetus by ultrasound (8 wk)
ACCEPTING OF PREGNANCY
 Ambivalence 1st trimester
 Denial
2nd trimester- narcissism
-introversion
Quickening –fetal movement
3rd trimester- preparing for parenthood
CHAPTER 9
 Psychological tasks of pregnancy
First Trimester: Accepting the Pregnancy
-expected adaptatio as discuss
-fetal growth + development
Shock
Concentrate on what it feels like
Ambivalence
Second Trimester: Accepting the Baby
 Narcissism -feeling of kicking

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 9

Introversion -safe passage

-reling of fetal heart beat
 Role- playing & increased dreaming
Third Trimester: Preparing for Parenthood
 Reworking developmental tasks -safe passage
 Role-playing/ fantasizing -giving of oneself
-childbirth classes
-cribigaments buying
EMOTIONAL RESPONSES
--ambivalence --stress
--grief –loss of tigue --couvade syndrome
-mum
--narcissism –protection of baby --emotional liability
--introversion vs. extroversion --body image & boundary
--changes in sexual desire --changes in the expectant family
DIAGNOSIS OF PREGNANCY
*Presumptive Findings
--breast chagnes (3-4)
--nausea, vomiting (4-14)
--amenorrhea , (4)
--frequent urination (6-12)
--fatigue (12)
--uterine enlargement
--quickening (16-20)
--linea nigra
--melasma
--striae gravidarum
*Probable Findings
--serum laboratory tests --ballottement
--chadwick’s sign (6-8) --Braxton Hick’s contractions (16)
--Goodwell’s sign (5) --fetal outline felt by examiner
--Hegar’s sign (6-12)
--sonographic evidence of gestational sac
*Positive Findings
--sonographic evidence of fetal outline
--fetal heart audible
--fetal movement felt by examiner
Ultrasound –visualize the fetal heart (6-7)
Doppler technique –detect fetal heart sounds (10-12)
ECG –heartbeat (5)
Fetal heart –audible by auscultation (18-20)
PHYSIOLOGIC CHANGES OF PREGNANCY
*Uterine Changes
12 wk- uterus’ fundus just above the pubis symphysis
20-22 wk- fundus is at the umbilical level
36 wk- at the xiphoid process [can make breathing difficult]
38 wk- fetal head settles into the pelvis (lightening)

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 10

 Uterine blood flow increases during pregnancy

15-20 mL/ min (before pregnancy)
500-750 mL/ min (end of pregnancy)
75% of the volume goes into the placenta
Hegar’s sign- 6th wk
Softening of the lower uterine segment
Braxton Hick’s contractions- “practice contractions”
*Amenorrhea (absencce of menstruation)
-suppression of FSA by rising estrogen levels
*Cervical Changes
-becomes more vascular & edematous
Increased fluid cells cervix to soften
Increased vascularity causes cervix to darllen from pale pink to violet
*Vaginal Changes
Vaginal discharge- vaginal epithelium & underlying tissue become hypertonic and enriched with
glycogen
Chadwick’s sign
Vaginal pH- 4-5 (acidic)
Lactobacillus acidophilus – increase lactic acid content glycogen
Makes vagina resistant to bacterial invasion
Candida albicans- yeast-like fungi that can grow in an acidic environment
-oral monilia /thrush
*Ovarian Changes
*Breast Changes
Breast size – hyperplasia of mammary alveoli and fat deposits
 Darkening of areola - MSH
 Vascularity of breast increases
 Montgomery’s tubercules enlargement and protruded
SYSTEMATIC CHANGES
 Integumentary
--striae gravidarum --vascular spiders
--diastasis --palmar erythema
--melasma ( cloasma) estrogen level
*Respiratory
--nasal congestion [resonse of estrogen levels]
--shortness of breathness
Residual of volume by 20%
Tidal volume (40%) [volume of air inspired]
Effectiveness of air exchange
Progesterone level- fetal CO2 level higher than that in the mother [allow CO2 to cross readily
from the fetus
to mother]
 Increased ventulation (mild hyperventilaton)
Keep mother’s pH level from becoming acid *load of CO2 being shifted to the
fetus]
 Total ventilation capacity- 40%
 Kidneys- excerete plasma HCO3 in urine

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 11

-polyuria
TEMPERATURE
Body temp. –secretion of progesterone from the corpus leuteum
16 wks- temp. to normal
CARDIOVASCULAR
30% of BV
300-400 mL –blood loss at a normal vaginal birth
800-1000 mL- cesarean birth
Plasma volume- , concentration of hemoglobin & erythrocytes
 Physiological anemia of Pregnancy
CO
Mother- palpitations
Innocent heart murmurs (heart is wide transversely)
HR by 10 bpm
Peripheral blood flow- in blood flow to lower extremities
-edema
Varicosities [vulvar; rectum; legs]
 Supine hypotension- maternal hypotension- fetal hypoxia
 Blood constitution- clotting factors VII – X present
Platelet count (normal) bleeding
UBC (fight infections)
GASTROINTESTINAL SYSTEM
Uterine size [ push stomach and intestines towards back and sides of abdomen]
 Slow intestinal peristalsis heartburn
Emptying time of stomach constipation -pressure of gravid uterus
Flatulence
 Pressure from the uterus – hemorrhoids
 Relaxin- ovary-secreted hormone
- Gastric mobility
 Progesterone- less active intestine
Estrogen hCG
Progesterone nausea vomiting
Glucose (hypoglycemia)
 Heartburn phyrosis -regurgitation into the lower esophagus [relaxed cardio esophageal
GERD sphineter]
 Gradual slowing of the GI tract - emptying of bile from gallbladder

cholelithiasis Absorption of bilirubin into maternal bloodstream

Generalyzed itching (subclinical jaudice)

 Stone formation- plasma cholesterol level
Cholesterol in bile
 Gingival tissue hypertrophy/hyperplasia estrogen –bleeding of gingival tissue
-epulis of pregnancy
 Hypertyalism- saliva formation
pH of saliva- inc. tooth decay
URINARY SYSTEM
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 12

 estrogen
progesterone
 Compression of bladder
 BV
 Postural influence
total body water to 7.5L
sodium reabsorption (maintain osmolarity)
RAA system response aldosterone production
 Aldosterone- sodium reabsorption
 Progesterone- potassium-sparring
 Retention of H2O –aid in BV
-reddy source of nutrients to the fetus
GFR & renal plasma flow- absortion
-glucose in uria
-glycosuria proteinuria
Blood uria nitrogen (BUN)
Creatinine levels in maternal plasma
-no urge n vvil over distention of bladder
-polyuria
Abnormal- >15mg/100 mL (BUN)
>1mg/100mL (creatinine)
 Creatinine clearance- standard KA for renal function
 90-180 mL/min (normal)
URETHER AND BLADDER FUNCTION
Progesterone level- diameter in ureters
Bladder capacity to 1500 mL
 Uterus rise on the right side of the abdomen (sigmoid colon)
 Pressure on R ureter –urinary stasis pyelonephritis
-poor bladder emptying bladder infection
SKELETAL SYSTEM
Calcium
Phosphorus
 Gradual softening of the woman’s pelvic ligaments and joints [to create phability]

Relaxin (ovanan hormone)

Progesterone (placenta)
 Wide separation of the symphilis pubis [walk difficult with pain] wadding duck gait
 Lordosis- “pride of pregnancy” –middle of gravity
-backache, prutue, low-heeled shoes
ENDCORINE SYSTEM
 Placenta- estrogen- breast & uterine enlargement palmar erythema
-progesterone- inhibit uterine contractility breast development (lactation)
-hPL (human chorionic somatomammotropin)-antagonist to insulin (making insulin less
effective)
-hCG- estrogen and progesterone synthesis
-relaxin- inhibit uterine activity softening of cervix
-prostaglandins- muscle contractility (initiates labor)
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 13

 PITUITARY GLAND-halt the production of FSH & LH

[ estrogen and progesterone]
GH & MSH
Posterior pituitary gland- oxytocin
Prolactin
THYROID AND PARATHYROID GLANDS
20% basal metabolic rate
Protein-bound iodine
Butanol-extractable iodine in bound serum
Thyroxine
 Gouter (thyroid hypertrophy)- iodine insufficiency
 Mistaken diagnosis oh hypertrophy-enotional lability
Tachycardia
Palpitations
Perspiration
Size of parathyroid gland- calcium metabolism
Calcitonin
PTH
 Adrenal glands
Corticosteroids -aids in suppressing an inflammatory reaction
aldosterone -reduce possibility of woman’s body rejecting foreign protein from fetus
-rebalate glucose metabolism
Aldosterone- promoting sodium reabsorption
Maintain osmularity in retain fluid
Safeguards BV
Provide adequate perfussion pressure
 Pancreas
Insulin production [ response to levels of glucorticord]
Insulin less effective- estrogen
Progesterone antagonists
hpL insulin
 Fetal glucose level- 30 mg/100 mL lower than maternal glucose level
IMMUNE SYSTEM
 Immunoglobulin G
WBC
OBSTETRIC HISTORY
 Abortion- pregnancy terminated before age of viability (miscarriage)
 Age of viability- 24 wks
RH immune globulin (RhIG)- Rh sensitization
 Gravida- number of times she is pregnant [including present pregnancy]
 Para- number of children above age of viability she has previously borne
GTPALM iobsteric index
T- number of infants (full-term) (37 wks)
P- number of preterm infants born (before 37 wks)
A- number of spontaneous/induced abortions
L- number of living children
M-multiple pregnancies
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 14

i.e. gravida 4; para 21030

CHAPTER 18: LABOR
THEORIES OF LABOR ONSET
 Uterine muscle stretching [release of prostaglandins]
 Pressure on cervix [release of oxytocin from PPG]
 Oxytocins [with prostaglandins – inhale contractions]
 Change in estrogen- progesterone ratio ( estrogen)
 Placental age
 Fetal cortisol levels ( progesterone; prostaglandin)
 Fetal membrane prodion of prostaglandins
SIGNS OF LABOR
PRELIMINARY SIGNS OF LABOR
 Lightening (10-14 days before labor)
 Relief from diaphragmatic pressure & shortness of breath
 Occurs early in primiparas
 Occurs on the day of labor in multiparas
 Shooting leg pains - pressure on sciatic nerve
 Amount of vaginal discharge
 Urinary frequency- pressure on bladder
 Increased level of activity
 In epinephrine release [initiated by progesterone]
 Braxton Hicks contractions
 Extremely strong Braxton Hicks contractions
 Ripening of cervix
 Goodell’s sign
SIGNS OF TRUE LABOR
 Uterine contractions
 Show- expelled operculum (mucous plug)
 Rupture of membranes
COMPONENTS OF LABOR
(1) passage
(2) passenger
(3) power of labor
(4) psyche
PASSAGE- maternal pelvis
Pelvic measurements- diagonal conjugale anteroposterior
Transverse diameter diameter
 Pelvic inlet- wider transversely
 Pelvic outlet- wider anteposteriorly
cephalopelvic disproportion
PASSENGER- fetus
 Fetal skull bones structures fontanelle
Fontal sagittal anterior (diamond)
2 parietal coronal posterior (triangular)
Occipital lambdoid
 Engagement- setting of fetal heart into pelvis
 Subocipito-begmatic – 9.5 cm
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 15

Occipitofontal (occipitobregmatic) – 12cm

Occipitonental – 13.5cm
 Molding – change in shape of the fetal skull [force of uterine contractions]
 Little molding – brow is presenting part
FETAL PRESENTATION & POSITION
 Attitude – degreee of flexicon a fetus assumes during labor
 Good attitude – complete flexicon
 Helps fetus present the smallest anteroposterior diameter of skull to penis
 Moderate flexicon *“military” attitude+
 Partial flexicon *“brow+
 Complete extension *“face”+ – occipitomental diameter
Less than normal fluid present (oligohydramnios)
Doesn’t allow fetus adequate movement
Neurologic abnormality causing spacity
 Engagement – settling of presenting part of a fetus for enough unto the pelvis [@ level of ischial
spines midpoint of pelvis]
[primapara] – nonengagement of head at beginning of labor
Abnormal presentation/ position
Abnormality of fetal head
Cephalopelvic disproportion
Degreee of engagement – assessed by vaginal & cervical examination
 Station – relationship of presenting part of fetus to the level of ischial spines
0 station – engagement -ischial spine
-1 to -4 cm – above the spines (“floating”)
+1 to +4 cm – dipping
+3 / +4 cm – crowning
 Fetal lie – relationship between long axis of fetal body to long axis of maternal body
Transverse (horizontal) vertex occiput
Longitudnal (vertical)
Oblique
 Fetal Presentation
 Cephalic presentation – aids in cervical dilation
-Prevents prolapsed cord
 caput succedaneum – edema of fetal skull as it contacts the cervix
 Breech presentation – complete
Frank
Footling
 Position
(1) right anterior (3) right posterior
(2) left anterior (4) left posterior
Vertex – occiput
Face – mentum ROA easiest position
Breech – sacrum LOA
Shoulder – scarula Leopold’s manewer
CARDINAL MOVEMENTS OF LABOR
DFIREERE
Descent
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 16

Flexion
Internal rotation
Extension
External rotation
Expulsion
.determining Fetal Presentation & Postion
(1) combined abdonimal inspection & palpation *Leopold’s manewer+
(2) vaginal examination
(3) fetal heart tones
(4) sonography
POWERS OF LABOR
Supplied by fundus of uterus implemented by uterine contractions
Cervical dilations expulsion of fetus
Primary – involuntary uterine contractions
Secondary – abdominal contractions
 Pacemaker - @myometrium neare one of the uterotubal junctions
 Contractons in lower uterine segments – reverse, ineffective contractions
-tightening of cervix
-pain in lower abdomen
-cervical dilation does not occur
 Nursing responsibility: rate
Intensity uterine contractions
pattern
 Increment – start of contractions
Acme - peak
Decrement – end of contractions

Acme Acme

Duration of Duration of
Contraction contractions
Interval

Frequency

 Physiologic retraction ring

 Pathologic retraction ring (Bandl’s ring)
o Abdominal indentation
o Impending rupture of the lower uterine segment
 Effacement – shortening & thinning of cervical canal
Longitudinal fraction from the contracting uterine fundus
 Dilatation – enlargement/ widening of cervical canal
(1) uterine contractions gradually diameter of cervical canal lumen
(2) fluid-filled membranes press against cervix
Amount of vaginal secretions (show)
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 17

STAGES OF LABOR -true uterine contractions to 10 cm dilation of cervix

1st stage – initiations of true labor contractions; ends when cervix is fully dilated
-time consuming
 Latent – 0-3 cm
Duration: 20- 40s
Interval: 6 hrs nullipara 8-6
4.55 hrs multipara 5-3
 Active – 4.7 cm
Duration: 40 -60s
Interval: 2-5 cm (3 min N ; 2min. M)
Moderate 2.6 2.4
 Transition – 8-10 cm
Duration: 60-90s
Interval: 2-3 min
 Squat in latent
Walk phase
 Pain (in active phase) – effleurage
Distraction techniques

2nd stage 10 cm dilation - delivery

 Latent – short period of peace & rest
 Descent - urgency to hear down (ferguson reflex activated
- Intensity of uterine contractions
-grunting sounds / expiratory vocalizations
 Transitional – sense of severe pain & powerlessness
- Ability to listen
-concentrates on birthing the baby
-feeling of “ring of fire”
-eases head out & short expirations
-excitement & relief after head is born
NI: latent – “listen” to her body
Support measures allowing women at rest
Upright position
Descent - respiratory patterns of short breath holds normality & benefits of grunting
sounds
Bearing – down efforts to push
Discourage breath holds
Lateral recumbent position to show descent (if too fast)
Slow gentle breathing
“blowing away” contractions facilitates a slower birth
Mirror to help women see
 DFIREERE
 After delivery, fundus at umbilicus level

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 18

3rd stage birth of baby to delivery of placenta

 Placental separation
 Placental expulsion
 Duncan placenta – dirty ; maternal surface
Schultze placenta – shiny & glistering , fetal surface
5 min. after delivery of baby (after 30 min. at most)

Stage 1 (NI)
 Encouragement
Focusing techniques
Cope with contractions
Fluids
Breathing techniques
Act as buffer
Voluntary relaxation of muscle
Side – lying / upright position

 Transitional: breathing pattern

Panting respirations
Comfort measures
Irritable responses
Relaxation techniqes
 Analgestics (active & transition phase)
Counter pressure on sacrococcygeal area
Encourage to void (empty bladder)

Uterine contractions lengthening of umbilical cord

Abdominal contractions sudden gush of vaginal blood
change in shape of uterus (discoid shape)
Firm contractions of uterus
appearance of placenta

 Prolapse uterus – uterus is inverted when placenta is pulled.

4th stage (1-4 hours after placental delivery) (stage of recovery)

 Complicated stage (susceptible to complications)
CO – blood supply to kidney – excess fluid (polyuria)
BP – 15 mmHg
PR
RR – supply additional 02
Temp. – 10 F – diaphoresis (excessive sweating)
Insensible water loss
Prone to dehydration
NI: IV fluids

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 19

Concentrated urine
Trace amount of protein in urine (+1)
S.G. – more solutes
Bladder tone – urge to void gone
-digestion & emptying is prolonged
-pain in abdomen (labor)
Pain in perineum (crowning)

FETAL RESPONSE TO LABOR

ICP - HR (-5bpm)
 Ecchymosis
 Petechiae
 Caput succedaneum
Stress of labor - steroid levels - maturity of lungs
(NSVD) (surfactant)
DANGER SIGNS OF LABOR
 / HR – hypoxia
 Hyper / hypoactivity – hypoxia
 Meconium staining – green amniotic fluid
-breech presentation
Vertex pres – fetal dishes sphineter control
 Fetal acidosis – acidosis (<7.2 pH)
MATERNAL
/ BP – hypoxemia
Pulse (normal: 70 – 80) - >100bpm
-hemorrhage
Prolonged contractions – CPD too big head
Too small pelves
Pacemaker
LEOPOLD’S MAANEUVER – fetal presentation & position
FETAL HEART RATE (120 – 160 bpm)
HR (5 – 15 bpm)
 Accelerations – temporary normal in FAR
 Early decelerations – periodic decreases
-pressure on the fetal head during contractions

FHR
 Late decelerations
 Acme – peak of contraction
Nadir – lowest intensity of contractions

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 20

FHR

 uteroplacental insufficiency
 hypoxia (fetus)
NI: change position of mother to L side lying position
Causes – uterine hypertrophy
Supine hypotension
Epidural oxytocin infusion
Administer O2 8 -10L/ min.
Fetal scalp/ acoustic stimulation
O2 stat of baby
Assist with birth (forceps)
 variable decelerations
 causes: prolapse umbilical cord
Cord around fetal neck
UC compression
Short cord
Knot in cord
Prolapse cord
 NI: position into knee- chest position (trendelenburg)
Dc oxytocin (causes of variable deceleration)
 Amnioinfusion – addition of sterile fluid as supplement to the AF
-prevents cord compression
-warmed normal saline / lactated Ringer’s Sol’n.
 Amniotomy – artificial ruptures of membranes
-dorsal recumbent position
-amniohook
Hemostat
 Episiotomy – surgical incision of perineum
Prevent tearing of perineum
Release pressure on fetal head with birth
Episiorraphy
 Midline – heal more easily
Mediolateral – away from rectum
 Late clamping of cord – overinfusion of placental blood
Polycythemia
Hyperbilirubinemia
CHAPTER 11
PIH – ecclampsia
Preeclampsia
Blood supply to placenta- / HR [ CO]
RR – hyperventilation – resp. alkalosis
RR – bradypnea - hypoxia
Hypoventilation
Temperature – reflection of infection

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 21

NURSING INTERVENTIONS
 Breast tenderness – wide support bra
 Fatigue – enough rest, sleep, nutrition
 Muscle cramps- calcium
 Nausea & vomiting- carb in morning {small frequent meals}; avoid high fat foods
 Varicosities – elevate legs, don’t stay in one position
 Hemorrhoids – knee –chest position
 Heart palpitations – move slowly
 Frequent urination – not drink too much fluid at night
 Abdominal discomfort – put pressure on uterine fundus
 Leukorrhea – sanitary pads
 Thromboembolic pantyhose – apply before getting out of bed
CHAPTER 12
 EHON – 44-46 – 60g ROA (protein)
 Calories – 2500 kcal
 Vitamin A – 800 ug
D – 5 ug
E – 15 mg
 Folic acid – 600 ug
Vitamin C – 85 mg
 Calcium – 1200 mg
Phosphorus – 700 mg
Iodine – 175 mg
Zinc – 15 mg
Iron – 30 mg (800mg total)
Fluid – 6-8 glasses / day
Fiber – prevent constipation
Hemorrhoids
-vegetables
 40-45 lb weight gai
 Docusate sodium (stool softener)
CHAPTER 13
 Tailor sitting – stretches perineal muscles
 Squatting – sketches perineal muscles
 Pelvic floor contractions (Kegel’s Exercises)
 Abdominal muscle contractions
 Pelvic rocking – to relieve backache
Methods for Pain Management
 Distraction techinique (gating control theory of PM)
 Bradley (Partner-coached) method – walk during labor
 Psychosexual Method – conscious relaxation
 Dick-read Method – fear tension pain
 Lamaze Method – conscious relaxation
Cleansing breath
Consciously controlled breathing
Effleurage

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 22

Focusing / imagery
NURSING CARE OG POSTPARTAL WOMAN & FAMILY
Psychological Changes and Postpartal Period
Phases of Puerperium: 1-6 weeks after delivery
(1) TARING-IN PHASE (2-3 days)
 Time of reflection
-woman is passive ; dependence – physical discomfort

Perineal stitches afterpains hemorrhoids

Uncertainty in caring for newborn
Extreme exhaustion (after childbirth)
(2) TAKING-HOLD PHASE
Woman initiate action
Positive reinforcement
(3) LETTING-GO PHASE
Woman redefines her new role

DEVELOPMENT OF PARENTAL LOVE

Difficult labor may lead to symptoms of traumatic
Separation & transport for newborn stress disorder

*claiming – identification process of mother to child

Bonding
*en face position – looking directly at newborn’s face; direct eye contact
-signs beginning effective interaction
*engrossment – father
*length of time parents take to bond with child
Circumstances of pregnancy and birth wellness and ability to meet parents
Expectations
Reciprocal actions by newborn opportunities of parents
*ROOMING-IN – infant stays in the room with the mother

MATERNAL CONCERNS AND FEELINGS (POSTPARTAL)

*Abandonment
*Disappointment
*Postpartal Blues
“baby blues” – normal changes ( E&P)
-response to dependence & low self-esteem
Postpartal depression
PSYCHOLOGIC CHANGES
 Involution – process where reproductive organs return to their nonpregnant state
(6 wks) - in danger of hemorrhage
 Uterus (50g – after involution
Involution – areawhere placenta was implanted sealed off to prevent bleeding (I)
-organ is reduced to approximate progestational size.
 Sealing of placental size – rapid contraction of uterus

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 23

-Thrombi form within the uterine sinuses and seal the area
(permanently)
-endometrial tissue undermines the size; oblinerales organized
thrombi
Reduced bulk of uterus [walls of uterus thicken & contract]
Mein mechanism: contraction
Autolytic process – cells of uterine wall broken down into profein components

Excreted in urine
FUNDUS
Delivery – halfway beaten umbilicus & symphysis pubis
1 hr – level of umbilicus (24 hrs)
1 day – 1 fingerbreadth below umbilicus
2 day – 2 fingerbreadth below umbilicus
9-10 day – no longer palpate
 Oxytocin – stimulates uterine contractions
Uterine involution delayed by birth of multiple fetuses
Hydramnios
Oxhaustion
Grand multiparty
Physiologic effects of analgesia
 Uterine atomy – boggy uterus
-lose blood rapidly
 Afterpains – intermitting cramping
Most intensely with breastfeeding
-noticed by multipara
Lochia
Separation of placenta & membranes – outer portion of decidua basalis
Inner layer – attached to muscular wall
Outer layer – necrotic; uterine discharge
Blood
Fragments of decidua
WBC
Mucus
Bacteria
 Lochia rubra – red blood
(3 days) fragments of decidua
Mucus
 Lochia serosa – pinkish / brownish blood
(4th day) Mucus
WBC
 Lochia alba (10 ) – colorless / white ( WBC)
th

CERVIX
Soft and malleable
Formation of new muscle cells
 External os – shi-like
Stellate (star shaped)
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 24

VAGINA
Thickening of walls – estrogen stimulation
Vaginal bleeding – thin walled fragile vaginal cells
Kegel’s excessive - strength & tone of vagina
 Perineum
-perineum edema
-generalized tenderness
SYSTEMIC CHANGES
hGG negligible
hPL (wk 1)
estrol – wk 2
FSH – low for 12 days

URINARY
Extensive diuresis
3,000 mL (daily output) [2nd – 5th day]
Transient loss of tone bladder
Ability to sense when she has to void
Percussion – resonant (full)
Dull ( non-fluid-filled)
-uterus uncontracted ; soft palpation ; pushed to side [overfilled bladder]
Hydronephresis- size of uterers
[present after 4 wks]
- urinary stasis (UTI)
Contain more nitrogen- muscle activity
Breakdown of protein
diaphoresis

CIRCULATORY
Diaphoresis reduce added blood
Blood loss volume

300-500 mL – blood loss (vaginal birth)

500-1000 mL – cesarean section

1g in hemoglobin : 250 mL
Excess fluid excreted - hematrocit (hemoconcentration)
Plasma fibrinogen – protective measure against hemorrhage
Risk of thrombus formation
Leukocytes (30,000 cells / mm3) [granulocytes]
Defense against infection & aid to healing

GASTROINTESTINAL SYSTEM
-hemorhoids present
-active bowel sounds
-slow passage of stool (relaxin)
-bowel evacuation difficult pain of episiotomy sutures

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 25

hemorrhoids
INTEGUMENTARY
Striae gravidarum – pale white (3-6 months)
Chlorasma barely detectable
Linea nigra in 6 wks
 Diastasis recti - overstretching & separation of abdominal musculative
-slightly indented
-bluish area
Modified sit-ups
Effect of Retrogressive Changes
 Exhaustion – sleep hunger
 Weight loss – 5lb (diaphoresis) + 12lb (at birth) + 3lb (lochia) = 19 lbs
-6 wks after birth baseline
Postpartal
Weight
VITAL SIGNS CHANGES
 Temperature
temp – 24 hrs. after birth (dehydration)
38oC – febrile
 Pulse
Stroke volume – accommodate BV to heart
Reduce PR [60-70 bpm]
Normal after 1st week
PR – sign of hemorrhage
 BP
-bleeding
(above 140 mmHg systolic) – development of PIH

CHAPTER 23 : POSTPARTAL COMPLICATIONS

 POSTPARTAL HEMORRHAGE
-blood loss >500mL (24hr period)
-may occur early (1st 24 hrs)
Late (1st 24 hrs – 6wks puerperium)
 1st 24 hrs – greatest danger – grossly denuded and unprotected area after detachment of placenta
 Uterine Atony – relaxation of the uterus
ND : deficient fluid volume related to excessive blood loss after birth
OE : BP = 100 / 60 mmHg
PR = 70 -90 bpm
Lochial flow <1 saturated perineal pad / hr
If uterus suddenly relaxes – abrupt gush of blood vaginally from placental site
[1st PP hr.]
Vaginal bleeding extremely copious - may exhibit symptoms of shock & blood loss
Vaginal bleeding occurs gradually – continued seepage of blood
Weigh saturated pads – 1g = 1mL blood volume
Turn woman on side when inspecting blood loss
Palpate woman’s fundus – ascertain that uterus remain in a state of contraction
well contracted uterus – firm and easily recognized
NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING
 26

TM : *uterine massage to encourage contraction

 Uterus may relax after hand is removed from fundus
Uterus may relax
Lethal seepage may begin again
*if uterus cannot remain contracted

Order dilute intrarenous infusion of oxytocin [Pitocin]

IM methylergonovine [methergine]
Oxytocin = 10-40 U / 1,000 mL
[5% dextrose solution]
Immediate action ; short duration
 Bimanual massage – inserts one hand into vagina while pushing against fundus through the
abdominal wall with the other
-sonogram [detect possible retained placental fragments]

Uterine packing inserted [ halt bleeding ]

 Prostaglandin Administration – promote strong, sustained uterine contractions
Prostaglandin F – injected intramuscularly
Adverse effect : nausea
Diarrhea
Tachycardia
Hypertension
 Blood Replacement
-blood transfusion – replace blood loss
-blood typing & cross-matching done when client was admitted
-blood is available
Iron therapy – ensure good hemoglobin formation
-activity level
Exertion restricted
Postpartal exercise
Extensive blood loss – precursor of PP infection
Note changes in lochial discharge
Monitor temp [detect early signs of developing infection]

 Hysterectomy – last resort measure for halting bleeding

 LACERATIONS – large lacerations are complications
Occur in the ff. circumstances:
-with difficult or precipitate births
-in primigravidas
-with the birth of a large infant (>9lbs)
-use of lithotomy position & lacerations
 Cervical lacerations
Artery is torn – blood loss – brighter red than venous blood loss with uterine atony

NSG 123 CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS) NOTES
By GERALDINE S. RIDAD, MAN RN
MSU-IIT, COLLEGE OF NURSING