Wednesday, February 23, 2011

Professional adjustment and jurisprudence


First Hospitals:

I – Iloilo

L – St Lukes
M – Mary Johnson
S –St Paul

Nsg is a profession.

  • Profession – defined by PNA adapted from Americans NA
  • a calling which its members profess to have acquired a unique body of knowledge & skills for purpose of guiding & caring others.
  • Calling – service oriented
  • Members – RN
  • Unique – special body of knowledge
  • Others – pt – recipient of care

Characteristics of nsg prof:

  • A ccountability – liable for his/her actions
  • C ompetency – having scientific knowledge
  • E thics –
  • S ervice oriented

Prof nsg resp: RA 9173 Oct 21,’02
1. Promotive, Preventive, Curative, Rehabilitative in all health care settings.
2. Preventive – immunization. Provide health education
3. Utilization of nsg process
4. Link of pts & families to diff community resources - community health nurses – libreng bakuna
5. Collaboration of pts care to other health care team - for continuity of care.
6. Resp for training/ supervision of nsg students
7. Accurate reporting/ recording.
8. Observation of S&Sx – provide proper intervention
Dependent fx 9. Execution of valid Dr’s order

General rule: RN can’t give meds without Drs order otherwise RN will be liable for malpractice.
Exception, under code of ethics, RN can give drugs during emergency, calamity, national epidemics, no MD around.
Life of patient is in danger. Protected under Good Samaritan Act.
Good Samaritan Act – universal law that protects any person who will give an aid to another person whose life is in danger.

RA 8344 – “ No deposit policy” during emergency cases.
emergency care 1st before asking for deposit.

Mom calls re: 2 yo girl ingested baby aspirin at home. What’s best action for RN to advice mom on phone.
1. Advice mom to bring kid to hosp
2. Advice to call doc
3. Advice to take emetic meds
4. Advice to call h nrse

Health teaching – child proofing the home! Aspirin should not be reached by kid.

  • Principal – direct author of crime. Dispensable
  • Accomplice – dispensable, crime will still happen without accomplice.
  • Accessory – entered scene after the crime

1. CONTRACTS/ CONSENTS – absence of coercion
char: V – voluntary – Free act. Independent act. Rational
O – opportunity to ask questions, suggestions & make recommendations
T – treatment, surgery, procedure – specifically explained to the patient by MD
U – understood by patient
M – matured physically – age 18 yo & above
Mentally – with sound mind, same & not an imbecile.

Substitute or proxy consent – if pt is mentally or physically incapable of giving consent
1. Parent
2. Guardian
3. Adliter – (not a relative!) DSWD, MD

2. ILLEGAL DETENTION – limit freedom of patient to move or travel from one place to another.
Hosp – promissory note or guarantee
HIV – don’t detain patient
High risk HIV transmission – felatio
Quarantine regulation – SARS, Meningococcemia, anthrax
- public safety is priority.

3. LAST WILL & TESTAMENT - a person in permitted by the law to control/ dispose of his estate.
Effect is only upon his death.

Decedent – person who died and left no will. The law will handle estate.
Testator / Testatoux – died and left a will
Testate succession – heirs will inherit under a last will and testament.
Illegitimate – entitled to ½ of what legit children will inherit
Kabit – will get nothing
Intestate Succession – without last will

2 types of last will & testament

1.) Properties 2.) Life/ Body
a) Ordinary will - Advance directives
- RN should check LOC of pt - pt is still alive giving instructions
-determine location of signature a) Living will – DNR,
- end of last word – last page organ donation, order for cremation
- sign all pages
- RN is part of 3 witnesses

b) Holographic will
handwritten by testator
dated and signed by testator
no need for witness

1. MD, DVM, DMD – can prescribe meds
2. Should have :
a.) Name MD, PTR, PRC#, location of clinic/ hospital
b.) Name of patient, age, sex
c.) Information about drug – frequency duration
d.) Generic & brand name in prescription

RA 6675 – Generics Act
Should have BOTH generic & brand name on prescription

Impossible Prescription – generic & brand name does not correspond with each other.

3. Know 10 rights in giving meds
What is the right way to ask identity of patient
a. call patent by his name
b. check chart
c. verify name at nurses station
d. check name at identification wrist band
4. Telephone orders -
General rule - no telephone order
“Whatever is not written is not an order”
Exception – Emergency!
After MD says order – repeat instruction on phone
Have resident MD sign! Administer meds.
When MD arrives – have him counter sign his order

5. Documentation – recording/ charting

  • C – communication
  • A –assurance of quality
  • R – research purposes
  • L – legal document
  • S – statistics source

SUBPOENA - an order from court
Duces Tecum (papers) – documents obj, materials, papers, chart
Ad Testificadum (person) – witness

Do’s & Don’ts of charting

Do’s Don’ts

  • F – full, factual & accurate L – language – unacceptable
  • L – legible I – improper corrections
  • I – immediately after procedure S- spaces, skips
  • P – personal notes, not delegated A – avoid using too much abbreviations

“addendum” – late entry

Negligence – failure to do something which a reasonable & prudent person should have done.

2 types:
1. Commission
2. Omission – total neglect of care – didn’t do anything

Elements to prove negligence
1. Duty
2. Failure to do his duty
3. Injury, harm, death= result

Malpractice – doing acts or conducts that you are not authorized/ licensed/ competent/ skilled to perform, resulting to injuries/ non injurious consequences
RN exceeding the scope of nursing practice & does an MD’s job.

Episioraphy – after proper training, RN can perform this procedure.

In absence of fetal & maternal aberration, RN can perform internal examination

RES IPSA LOQUITOR – the thing speaks for itself
obvious fault

FORCE MAJEURE - God nature – storm, earthquake, flood, - not liable

Fortuitous event – created by man – traffic not liable due beyond his control.

1.) Manner of its commission – dolo (deceit) – with criminal content
- culpa – (fault) – without criminal intention, negligence
2.)Stages of execution –
Consumated – all elements to commit crime were all present.
Frustrated – offender performs everything to consummate but it did not happen for reasons beyond his control
Attempted – overt acts – mere intensions to commit crime.

3.) Degree of participation
Principal – indispensable. Without the principal = no crime- author of crime
Accomplice – with or without accomplice = crime will happen
- dispensable, look out.
- enters scene before or during crime
Accessory – enters scene after crime is committed
conceals/ destroys evidence.

RA 7877 – anti sexual Harassment act
1. Any person who exercises authority (Prof & student, Dr & RN)
2. Asking sexual favors in exchange of another favor
a.) Ordinary rape – forcible penetration of sex organ to a sex organ
b.) Sexual assault – anything forcibly inserted to any orifice.

Illegal abortion – termination of product of conception before the age of viability.

Infanticide – crime committed of person killed is age < 72h or <3days old
Parricide – killing of a person with relationship, ex. Bro in-law, sis, - relative
Homicide – killed a person to whom you have no relationship- product of negligence.
Murder – killing of a person with intension.

Simulation of birth – any person who shall substitute 1 child or identity of a child for the purpose of losing his civil status.

PD651 – Birth registration act
- requires any person (RN,OB, midwife, pilot) who shall assist in giving birth to report within 30 days without penalty any live birth at Local Civil Registrars Office.

RA 2808 – (y1919) – BON 1 chairman, 2 members = all RNs
1920 – 1st board exam

RA 9173 (Oct21,02)
BON qualifications

  • M – masters in NSG
  • A- accredited nsg org (PNA)
  • S – seven (1 chairman, 6 members)
  • I – immediately resign upon appointment
  • N – not convicted of any crime

  • P – pecuniary interest, absence of
  • T – ten yrs experience (last 5 years hr in RP)
  • C – citizen & resident of RP

DEAN qualification- RN + MAN + 5 yrs experience in nsg

Nurse Licensure Exam
1. Cert of Good Moral Char (Optional)
2. Proof – holder of Fil citizenship – Birth cert.
3. Proof – BSN degree – Transcript with scanned picture – done by reg.


  • S – supervisor head nurse/ ward/ shift/ day
  • M – manager

  • C – chief nurse manage whole hosp
  • D – director

Supervisor B – BSN holder – RN
Manager A – accredited nsg org PNA
N – Nine units nsg mgt
T – two years practice

Chief nurse RN+ MAN
Director 5 years supervisory experience

PD 223 - PRC – regulatory body to all profession in Phil

RA 1080 – Civil Svc Act
Automatic civil service eligible once you pass PRC nsg exam

RA 6425 (9165) – Dangerous Drugs Act

Prohibited – totally absolutely, can’t be used by human being.
Ex. Methaphetamine Hcl (Shabu) cocaine, cannabis

Regulated – can use this drug
with appropriate prescription
MD with appropriated license (BFAD, PDEA licence)
Valium, dormicum

Penalty for licensed health care provider
1. Fines
2. Imprisonment
3. Automatic revocation of license

RA 7600 – Mother Baby Friendly Hosp Act
early bonding of mom to child through breast feeding & rooming in technique
Sen. Flavier

December 1 – World AIDS day

RA 8981 – PRC modernization / Computerization Act
after 5 days – result of board exam will come out
June 11 – result
results of board exam – Nurse
or txt 233 globe/ 136 smart
txt PRC (space) Rating (space) TABUENA,ABIGAILC

Registration. Sign in both of registry of BON
Special – can get license by reciprocity
RN in a foreign country & that country where you are registering has employment for Fil RN in their country

Imprisonment / jail 1-6 yrs / P50 – 100k fines

  • L – license , without
  • O – own (using as your own license of another)
  • I – invalidated license + revoked , suspended
  • S – sign name & attach title BSN, RN (not true)

  • F – falsification of documents (diploma, experiences)
  • A – assist another person in illegal practice of nsg
  • U – underwaging
  • R – review/ training centers for RN not accredited by government
  • A- any person violating this act


a neoplastic disorder that can invade all body organs.
- cells lose their normal growth controlling mechanism and growth is uncontrolled.

Immunologic factors

Cellular origin
a. Carcinoma
b. Adenocarcinoma
c. Sarcoma
d. Embryonal
e. Lymphomas
f. Leukemias

TNM system:

American Warning Signs of Cancer:
C hange in bowel & bladder pattern
A sore that does not heal
U nusual bleeding & discharge
T hickening or lump
I ndigestion
O bvious change in wart or mole
N agging cough or hoarseness of voice

A. Cancer Screening Guide

Breast Self-Exam (BSE)
Timing:7-10 days after menses
:menopause: done one particular date monthly
Position: standing or lying down
use inspection & palpation: must be reported

Position: horizontal/ oblique
explain procedure
Don’t put deodorant before procedure
CI: pregnant & breast implant

explain procedure
No douching done 24hrs before procedure

Testicular Self-exam
monthly/ after a warm bath
what do you need to look /feel for:
a. painless “pea” sized lump
b. feeling of heaviness
c. painless swelling
d. sudden collection of fluid in the scrotum
e. dull ache in the lower abdomen or in the groin
f. pain in the testicle or in the scrotum

Digital Rectal Exam
Men: bending over the examination table
Women: lithotomy

what to assess in men:
a. prostate gland for alterations in size, consistency & evidence of tumors
b. for acute & chronic infection

what to assess in women:
a. hemorrhoids
b. uterine position

Oncofetal Antigens

Proteins which are typically present only during fetal development but are usually found in adults who has certain kind of cancer.
Example: Alpha-fetoprotein & Carcinoembryonic antigen

Liver Function Test
albumin- 3.9-5 g/dl
alanine transaminase (alt)
aspartate transaminase (ast)
alkaline phosphatase (alp)- 44-147 iu/l

Bone marrow exam
Site: Adults – Iliac Spine
Children – Tibia
Explain Procedure
Informed Consent
After procedure: apply pressure at site for 5mins or more
Monitor for signs of bleeding and infection

Explain Procedure
Informed Consent
After procedure: apply pressure at site and rest
Monitor for signs of bleeding and infection

Cancer Therapies
Types of Chemotherapeutic Drugs:
1. Alkylating agent
a. Cyclophosphamide (Cytoxan)
SE: alopecia/ gonadal suppression/ tinnitus/ cystitis

2. Antimetabolites
a. Methotrexate (Rheumatrex)
SE: alopecia/ stomatitis/hyperuricemia/ hepatotoxicity
b. Procardazine

3. Plant alkaloids
a. Vincristin(Oncovin)
SE: neuropathy/ neurotoxic/ numbness/ paresthesia/ constipation / phlebitis at IV site
4. Hormones
a. Tamoxifen (Nolvadex)
SE: edema / hypercalcemia
SE:edema/hypercalcemia/impotence/gynecomastia in males
c. Prednisone (Deltasone)
SE: edema, impotence

5. Antitumor Antibiotic
a. Doxorubicin (Adriamycin):
SE: Diarrhea
Damage the tissue

Damage the heart
Hair follicles- temporary alopecia
Mucous Membrane- stomatis/ pain/anorexia
Stomach Lining- Nausea/vomiting/alkalosis/hypokalemia/weakness/fatigue
Sperm-aspermia & sterility
Isolation – offer suggestion of a referral to the cancer society

Common side effects
Bone marrow depression
a. Leukopenia
b. Anemia
c. Thrombocytopenia
2) Alopecia
3) GI tract problem
4) Elevated uric acid

Bone Marrow Transplant

Reverse Isolation Technique (during Bone Marrow Suppression)
1. Private room, laminar air flow, sterile linen, sterile hygiene equipment.
2. Put on shoe covers, put on mask and cap, put on sterile gown, gloves.
3. Remove gown after leaving room.

SE: erythema at site with possible dry to wet desquamation
fatigue/ malaise/ nausea/ vomiting/ diarrhea/ esophagitis/ xerostamia
except: alopecia
Nanda: Impaired skin integrity

S hielding – lead lined apron
T ime- short: 30 mins per 8hr
D istance- 3-6 ft away (36 inches or more)

Nursing care-
Room precaution
Head of Bead: elevated 30degrees
Nanda: patient: Social Isolation
Nurse: Altered protection related to brachytherapy
in cases of dislodgement/ care of intracavitary cessium:
L ead-lined apron
L ong handled forcep
L ead- lined container

Common sites of metastasis
Breast cancer : bone, lung
Lung cancer: brain
Colorectal cancer: liver
Prostate cancer: bone, spine and legs
Brain tumors: central nervous system.

Acute Lymphocytic Leukemia (ALL)
mostly lymphoblasts present in bone marrow.
Age of onset is less than 15 years.
Acute Myelogenous Leukemia (AML)
mostly myeloblasts present in bone marrow.
Age of onset is between 15 and 39 years.
Chronic Myelogenous Leukemia (CML)
mostly granulocytes present in bone marrow
Age of onset is after 50 years
Chronic Lymphocytic Leukemia (CLL)
mostly lymphocytes present in bone marrow
Age of onset is after 50 years.

-anorexia, fatigue, weakness, weight loss
-anemia, bleeding, petechiae.
-elevated temperature, lymphadenopathy, splenomegaly
- palpitations, tachycardia, orthostatic hypotension
-pallor, headache, dyspnea
-decreased hemoglobin, hematocrit, platelet count.
-positive bone marrow biopsy: leukemic blast cells

1. Medications
a. Corticosteriods
b. Antineoplastic agents
c. Xanthine-oxidase inhibitor: Allopurinol (Zyloprim)
2. Bone Marrow Transplant
3. Radiation
4. Blood transfusions
Nx: Assess for transfusion reactions (hemolytic, allergic, febrile rxn)
Remission is characterized by absence of leukemia cells and disorders, and disappearance of all disease symptoms.

Infection is a major cause of death in the immunocompromised client. Use strict aseptic technique, use masks, frequent handwashing, protective isolation procedures.
** Bleeding is another main complication. Use bleeding precautions. – soft foods, avoid injections, bp readings, suppositories, enemas or any unnecessary trauma.

1. unknown
2. slight increase in males
3. increase incidence in early 20s and after 50

Stage 1- lesions limited to one lymph node
Stage 2- 2 or more nodes on same side of diaphragm
Stage 3- lymph nodes on both sides of the diaphragm are involved, invt of spleen
Stage 4- diffused involvement of extralymphatic organs

fever, malaise, fatigue and weakness, night sweats
loss of appetite and significant weight loss
anemia, thrombocytopenia, enlarged lymph nodes, spleen and liver

Lymph node biopsy- presence of REED-sternberg cells

radiation therapy
more extensive cases : multiagent chemotherapy
M ustargen- nitrogen mustard- alkylating agents
SE: gonadal suppression/ hyperuricemia
O ncovin(Vincristine)-mitotic inhibitor
infection and bleeding precautions.

low socioeconomic groups
early first marriage
early and frequent intercourse
multiple sex partners
high parity
poor hygiene
- painless vaginal bleeding post menstrual and post coital
- foul smelling serosanguinous discharge
- pelvic, lower back, leg or groin pain
- anorexia and weight loss
- dysuria, hematuria
1. Pap smear
2. Schiller test- cervical biopsy

1. Surgery: Hysterectomy
- Conization
2. Radiation: Intracavitary Cessium
Nx: Complete Bed Rest
Low Residue Diet
Nurse Safety: Radiation Bandages
3. Prevention: Annual Papsmear

low socioeconomic groups
early first marriage
early and frequent intercourse
multiple sex partners
high parity
poor hygiene
- painless vaginal bleeding post menstrual and post coital
- foul smelling serosanguinous discharge
- pelvic, lower back, leg or groin pain
- anorexia and weight loss
- dysuria, hematuria
1. Pap smear
2. Schiller test- cervical biopsy

1. Surgery: Laparotomy, Bilateral salphingo-oophorectomy, TAH-BSO
2. Chemotherapy: Taxol (Placitaxel)
Nx: teratogenic
3. Radiation
4. Immunotherapy
5. Hormonal agents: Tamoxifen (Nolvadex)
Nx: edema, hypercalcemia

Risk Factors:
History of uterine polyps
Polycystic ovary disease
Estrogen stimulation
Late menopause
Family history

Post menopausal bleeding
Watery serosanguinous discharge
Low back, pelvic or abdominal pain
Enlarged uterus in advanced stages

1. Endometrial Biopsy
2. Fractional Curettage

1. Surgery: Total hysterectomy & Bilateral salphingo-oophorectomy

2. Radiation- external/internal

3. Hormonal Agents- Progestational therapy: Depo-provera( medroxyprogesterone) SE: anorexia, nausea, vomiting, edema

4. Chemotherapy- advance stages

Family history
Early menarch or late menopause
Previous cancer of the breast, uterus, or ovaries
High-dose radiation exposure to chest.

Asymmetry of breast
Skin dimpling, flattening or nipple deviation
Skin coloring and thickening, large pores, sometimes called peau d’orange
Changes in the nipple
Painless, singular breast mass

1. Noninvasive techniques
a. Mammography
b. Xerography
2. Breast biopsy
1. Surgery : Lumpectomy
: Modified Radical Mastectomy
: Radical Mastectomy
Nursing Care:
1. Pressure dressing in place immediately postoperative.
2. Position arm on affected side such that each joint is elevated and positioned higher than the more proximal joint.
3. Do not take blood pressure or perform any injections or venipuncture on the arm of the affected side.
4. Arm exercises are usually started 24 hours after surgery.
2. Radiation
3. Chemotherapy

Diet high in complex carbohydrates/ grains/ salt
Low in fresh green leafy vegetables
Use of nitrates
History of ulcers

Fatigue, Anorexia, Weight loss
Nauseas, Vomiting, Indigestion
Dysphagia, Anemia, Ascites, Palpable mass

1. Gastric analysis- achlorhydria
2. Gastroscopy & biopsy

1. Surgery:
a. Billroth I- gastroduodenostomy
b. Billroth II- gastrojejunostomy
Cx: Dumping Syndrome
c. Total gastrectomy- esophagojejunostomy
Cx: Pernicious Anemia
2. Chemotherapy
3. Radiation

Laryngeal Cancer
Environmental pollution
Exposure to radiation
Voice strain

Persistent hoarseness and sore throat
Painless neck mass
Feeling of a lump/burning sensation in the throat
Dysphagia, foul breath odor

1. Laryngioscopic Exam
2. Biopsy

1. Endoscopic Removal of early malignancy
2. Surgery: Partial Laryngectomy
: Total Laryngectomy
Nx: pre-op- alternative non verbal com.
post-op- humidifier
3. Radiation
4. Nutrition
5. Speech Pathologist

males over age 55
High androgens

Asymptomatic in early stage
Hard, Pea-sized nodule palpated on rectal examination
PSA test is not indicative, is used to monitor response to therapy

Nanda: Altered Bladder Pattern
Digital rectal exam: done bet age 40-60 yearly
Tumor Markers:
a. Elevated acid phosphatase
b. Elevated alkaline phosphatase

1. Hormone therapy
2. Radiation
3. Chemotherapy
4. Surgery

Continuous Bladder Irrigation (CBI)
Maintain traction on catheter
Use NS solution or prescribed solution to prevent water intoxication
Run solution at prescribed rate but run rapidly if drainage is bright red until pink.
Discontinue CBI and catheter usually after 24 to 48hrs as prescribed.
Avoid heavy lifting, straining

Alcohol/Cigarette Smoking
High fat diet

Abdominal pain at night

inc serum lipase
inc bilirubin
inc serum amylase

1. Surgery: Pancreatoduodenectomy ( Whipples procedure)
Cx: Hypovolemic Shock
2. Radiation
3. Chemotherapy
4. Drugs necessary after surgery:
- pancreatic enzymes
- oral hypoglycemic agents or insulin
- bile salts

Malignancy elsewhere in the body
High incidence in Men

Weakness, Anorexia, Nausea, Vomiting
Right upper quadrant pain
Peripheral edema
Blood-tinged Ascites

1. biopsy
2. CBC: blood sugar decreased/ alpha fetoprotein increased

1. Surgery- resection
2. Chemotherapy and Radiation
3. Liver transplant- Sandimmune
Nx: adm 10% glucose for first 48hrs to avoid rapid blood sugar drop
Assess for bleeding (cx: hemorrhage)
Assess for signs of hepatic encephalopathy

Occurs in men
Peak age 50-70 years old
Exposure to chemicals
Cigarette smoking
Chronic bladder infections

Intermittent painless hematuria
Frequent urination

Dx: biopsy

1. Surgery
a. Cystectomy
b. Ileal conduit (urinary diversions)
Report signs of impaired healing
Prevent skin breakdown
Prevention of UTIs
Control of odor
Report signs of UTI
2. Radiation
3. Chemotherapy-

Men 50-70 years old
Drugs : nephrotoxic

Palpable abdominal mass
Weight loss

1. IVP
2. CT scan
1. Surgery: Nephrectomy
2. Radiation
3. Chemotherapy
4. Immunotherapy-Intravenous Interleukin

Mass palpated in the scrotum
With or without pain
Heaviness in the scrotum
Pain in the abdomen
Weight loss
1. TSE
2. Increase alpha-fetoprotein
1. Surgery- Unilateral Orchiectomy
2. Radiation to lymphatic
3. Chemotherapy- Cysplatin

Can resume activities within a week
No lifting >20lbs/ stair climbing
Monthly TSE
Sutures removed 7-10days after surgery

Oral lesion

Nanda: Altered Nutrition less than body requirements

1. Surgery: Glossectomy:
- Radical neck dissection
Cx: hypocalcemia
2. Radiation
3. Chemotherapy
1. Monitor for hemorrhage
2. Promote drainage
3. Promote oral hygiene/comfort
4. Promote Nutrition
5. Monitor signs of hypocalcemia

Loss of hearing
Vertigo/ Vomiting

Nanda: Sensory perceptual deficit
High Risk for Injury

1. Surgery- removal of benign tumor
2. Radiation- Gamma knife

Cats eye reflex
White pupilary reflex
Unilateral blindness

1. Surgery- Enucleation- artificial eye- plastic : worn continuously & will only remove during cleansing
2. Radiation- 3-4wks- interstitial seed
3. Chemotherapy
4. Genetic counseling - hereditary

Tuesday, February 22, 2011


RESEARCH – (Kerlinger) systematic, empirical, controlled & critical investigation of a hypothetical proposition related to natural phenomenon.

PHENOMENON – anything that affects human life
disease, signs & symptoms, procedures, MD, RNs

HYPOTHESIS – educated guess, scientific guess, tentative statement of a supposed answer.
not known yet if true of false, right or wrong

RESEARCH - must be conducted to affirm or deny a hypothesis.

4 major Characteristics of a Scientific Research
1. Systematic – follow step by step process. Fr identification of problem to conclusion.
2. Empirical – proper objective. To collect data, facts & evidence to support hypothesis.
3. Controlled – proper planning/ direction. Research design.
4. Critical investigation – fact finding investigation. (synonym)

D – descriptive purpose. Gain richer familiarity regarding a phenomena. Observation. 100% known to RN.
E – exploratory purpose. 50% still unknown to RN.
E – experimental purpose. Perform manipulation. Perform intervention. What to find out cause & effect.
D – developmental purposes. Fro improvement of system of care.

F Nightingale – birthplace. Italy
Training ground: Germany
Greatest contribution: environmental theory & training of RNs in Crimean War
School: St. Thomas School of Nursing

Patient –nursing focus on research


1. Identification or formulation of research problem
2. Review of related literature
3. conceptualization of conceptual/ theoretical framework
4. Formulation/ Adapting hypothesis
5. Choosing the appropriate design
6. Choosing sample from pop
7. Conducting final study or pilot study
8. Collection of data base
9. Analysis & interpretation of data base
10. Disseminating the conclusion & recommendation.

Problem: in res – requires a solution

Sources (CLIENT) of good problem
C – concepts
L – literatures
I – issues
E – essays
N – nursing problems
T – theories

Char of good problem (GRIFINS)
G – general applicability – result should be helpful or applicable to all.
a.) basic/ Pre – for personal knowledge
b.) Applied – focus is solving problems of others
Re – researchable – collectable & abundant data
F – feasible or measurable
a.) time
b.) money/ cost
c.) participants
d.) instruments
e.) experience
f.) proper ethics of good researcher

I – important
N – novelty – original to avoid plagiarism.
S – significant


S – scientific objective always (good faith)
C – consent
I – integrity
E – equitable (appropriate acknowledgments) liable for
N – noble – Respect 3 basic rights of research sample
T – truthfulness
I – importance of topic to nursing profession
C – courage to look for data.

Legal owner of chart: Hospital
Legal owner of data in the chart: Patient
Plagiarism – illegal replication: no consent & acknowledge

3 rights of sample/ pt
1.) Right not to be harmed
2.) Right to self determination – get consent & right to withdraw consent
3.) Right to privacy
a.) anonymity – privacy of identity of informant
b.) confidentiality – name given but privacy of info/ data

Harm that can happen to sample/pt
1.) right from physical , mental & moral harm
2.) Right to self determination

1.) Commission – unacceptable in standard of practice
2.) Owrission – didn’t do anything. No intervention done.

Mental Harm:
1.) Assault – threatened. Mental fear
2.) Assault & Battery – with mental fear & physical harm
3.) Battery – with physical harm.
Moral harm –
Slander –
Oral defamation –

Restraint – dependent with doctors order
physical – vest or jacket
chemical – valium

A study in the difference in the financial income of Filipinos working in NYC & QC (comparative & basic)

Variables – anything that is subject t change on manipulation.
1.) Independent variable – target population IV – stimulus intervention
2.) Dependent variable – response DV – response measured

Independent variable

Place of work
Target Population

Filipino RNs
Dependent Variable

Financial income early review Jan

Pavolovian Theory
(SOR) Stimulus Organism Response

Intervening variables comes between independent & dependent
ex. Organismic variable internal factors age, sex, gender, color.

Extraneous variable – ext influences can be changed

Allure, citizenship, educational status

Dichotomus variable – 2 choices/ results
Ex. Male or Female

Polychotmus – multiple choices/ multi variables

Preferred food – Japanese, Chinese, Filipino, American

1.) Identity Problem
2.) Purpose – objective (SMART)
3.) Define terms
4.) Revision of terms

S – smart
M – measurable
A – attainable
R – realistic
T – time bound (limit)

Conceptual definition – dictionary meaning
Operational definition – based on use of research char of problem

Toxic – conceptual – waste products
Operational – very busy day for RNs

Review of related literature
Purpose: for proper formulation of conceptual & theoretical framework.

Theory – relationship bet concepts
Conceptual framework. Illustration showing relationship between variables

Paradigm- diagrammatic presentation / illustration of conceptual framework.

Source of review literature
1. Conceptual Sources – authors & conceptualists ( DOH book, Lippincott, Mosbys)
for general use, can be sold.
2. Research sources – researchers cant be sold.

Types of Hypothesis:
1. NULL hypothesis (-) no relationship, no difference bet 1 variable to another
ex. There’s no diff regarding prof Opportunities in US & RP

2. Alterative, simple or operational hypothesis – (+) show a relationship bet 1 variable to another
ex. Filipino RNs has more prof opportunities un US

3. complex hypothesis – shows a relationship bet 2 or more variables to another.
Ex. Filipino RNs who worked for 5 yrs & passing all CG tests have opportunities to acquire starting salaries, insurance.

4. Directional Hypothesis – specifies the direction of relationship bet variables
Ex. Filipino RNs working in USA have more prof opportunities than those in Phil

5. Non directional Hypothesis – no specific direction
There is a big difference between all Filipino RNs working in the USA

5 Choosing appropriate design:
- skeletal framework of research

Research Design:
According to application or motive
According to approach
According to data

Method used applicable to quantitative research: survey

Case study – focus 1 patient only or 1 family

Research Design

Non experimental
1.) Observe sample subject, Research has
2.) Massive participation
3.) Describe & record
4.) Natural setting – where pop exists

1.) Active manipulation – treatment or intervention done
2.) Active participation to sample pop
3.) Controlled setting – lab research units

Types of non experimental res design.
1. Historical research design – happened in the past
collect written, published, circulated or archived
pt’s chart
ex. Health practices during Crimean War
2. Expost Facto (after facts) (Retrospective)
Antecedent facts happened
Study a group of people who have naturally experienced a particular phenomena related to a problem & has something to do with present study
Interview only, no manipulation! Subject is related to present problem.
3. Prospective – focus; future time to look for a data existing subject with future happening
Focus: weekend review in pentagon Result: of board exam this coming June
Present future

4. Descriptive – no intervention but merely observe & collect data.
Ex. Study on absentism in St Lukes
Study on environmental pollution in Quezon

a.) comparative study – similarity & difference of variables
ex. Environmental pollution between variables

b.) Correlatonal – relationship between variables
ex. Environmental pollution & increased TB cases

c.) Evaluative – effects/ results
ex. Effects of environmental pollution

d.) Survey type – data collection based on majority result

Types or survey research
1.) groups – small group
2.) Face to face method
- can get response/ feed back right away
b.) Mailed survey method
Problem; data collection
3.) Time orientation
Cross sectional & longitudinal – extend period of time.
2 or more # of groups – 1 core group/ long term study
unidentical groups - purpose: dev’t/ study
- purpose: comparison - initial & fallow up survey
- short term study # of time

Steps in experimental type of research design
1. controlled stage – discipline/ direction
a controlled group – will not be subjective
experimental – group will be manipulated
2. Randominization – choose your sample by chance
3. Manipulation - intervention
4. Measurements of effect – determine the result

Quasi experimental- when you lack in steps in experimental

Pop – group where you get your sample

Types of sampling
1.) Probability – choose sample by chance
Types of probability Incidental sampling – these present in coffee shop
a.) Simple random sampling – equal chance/ opportunity to be chosen
- done if identical or equal footing
b.) Stratified random sampling – create subdivided population (divide into 4 levels in school) or substrata before doing randominization
c.) Cluster random sampling – create sub areas MNL hospitals – UST – 3rd floor
d.) Systematic random sampling – sampling frame
3,000 HIV patients in Phil – write list of names appearing in pop uses multiple number in choosing.

2. Non probability sampling – not by chance
- with pre-selected group, with braised group, favoritism
a.) Accidental or convenience sampling.
Criteria – immediate availability/ accessibility of sample.
b.) Purposive/ judgmental sampling.
- based on personal knowledge/ info
ex. Research on prostitution
I know location of prostitution – Ermita
Prostitution also in Pasay & Makati
I will not choose Pasay & Makati only
Ermita because I have personal info
c.) Snowball sampling – based on last referral
d.) Quota sampling – setting a certain criteria, with favoritism will choose only who he likes.

Collection of Data Base:
- time & budget consuming – 70 –80% time

Methods of collection of data
1.) Questionnaire – source of collection f data
- pen & paper type of data

3 Major type of Q
a.) Dichotomasis – (2) – answerable by T/F, Y/N, right or wrong
b.) Checklist style – rating scale 1,2,3,4,5 poor, fair, average. . .
c.) Multiple choice – a) man b) dog c) cat d) all of the above

2.) Records – easiest – get pre existing data – journals, essays, documents, newspapers
3.) Interviewer – use oral communication
1.) Structured – with checklist formal
2.) Non structured – anything goes answer open ended questions.
The sample will expand on topic researcher will illicit answers their ACTIVE LISTENING.
4.) observation – ocular approach
a.) Participant – journey
b.) Non-participant – passive observer but uses tools to determine results of data.

2 main problems in colleting data
1. Hawthorne’s effect – problem in experimental design inaccurate due to consciously being observed (PAASCU accreditation – management keeps school clean before PAASCUA comes to school.
2. Halo Effect – special relationship inaccurate due bias
- solution of researcher to avoid halo effect do double blind res method
Double blind research – no bias or prejudice on treatment blind folded
- gives accuracy due not conscious & biased

Analysis & Later pultation of data phase
- research is forming a body of knowledge for the purpose providing an answer

2 Methods in presenting your analysis
1.) Qxuantitative – using numerical or graphical presentation of answer
ex. 50% of q 500 Filipinos becomes 75% richer
or use pie chart, bar graph, line graph

2.) Quantitive – narrative approach using words (text) & facts
ex. Majority of all graduating students prefer to nursing course than PT

Dissemination of Finding/ Core/ Recommendations
Importance of core – conc is final result of study
How can conc affect others – recommendation

Methods of dissemination of Findings/ Result
a.) Book
b.) Symposia – oral
c.) Publication

Principles for effective leadership
1. Unity of command – all will receive orders, command from nurse manager/ supervisor
2. Unity of direction – whole group leader &newborns will have goal – towards patient.
3. Subordination of personnel to the general interest
- save patient 1st before self (ex fire in pt room)

R – remove/ rescue patients
A – alert fire alarm
C – confine fire in / area
E – extinguish fire
R – run

4. Esprit de corps – team spirit
fault of one is fault of all
credit of 1 is credit of all
5. Chain of command - hierarchy

Patient reacted to meds given, allergy. Inform MD he will give anti-histamine.

Incident report – for purpose of risk management
- Report of sudden occurrence
- Go to Head nurse

Pt has appendicitis. Pain in RLQ who is primarily responsible for patient – Head nurse.
HN can delegate to staff nurse pt died. Head Nurse is liable
Command responsibility – Respondia Superior

Theories of effective leader.
1. Great man theory – to be a good leader, leader must be born. Leaders cant be developed. Some are born a follower.
2. Trait theory – behavior/ characteristic
P – personality
I – intelligence
A – ability
Personality –
+ attitude/ trait/ knows to adjust to pt – adaptability
a.) acceptability – can cope, adjust to needs of pt
b.) independent
c.) creative/ assertive
d.) advocate

Char of nurse if you are defender of patient against harm/ negligence – advocate

Intelligence – proper judgment
Proper decision
Fluency of speech
Ability – influence others – most effective way to influence pt – HI optimum level of is attain OLF
Command of others
Respect others

3. Charismatic theory – charm, charisma, inspirational quality
4. situational theory – a person can be a good leader in 1 situation & a follower in another situation.

Case to case
Adv – can get best person to the job
Disadvantage – there’s no continuity of leadership

Styles of leadership:
1. Autocratic – authoritarian, dictatorial, bureaucratic traditional or “Hard leader”
- Unilateral style of nursing
- Leader is only 1 performing without input from other staff.
- Not getting opinion, recommendations
Char – unilateral from style of staff leadership – leader does decision making without.
A – apathy – not sensitive
B – boisterous speech
C – consistent
Demanding –
E – egoistic
F – ferocious

Putting self in shoes of pet recognize & sensitive to pt. – empathy

Not good style in leadership but good in emergency cases. Or during acute crisis.

2. Laizzes Faire/ Frierein/ Loose
- excess freedom / or liberates to members
- authority neglect patients will suffer
control malpractice

3. Democratic / Participative
- gets input from members (decision making)
- Mutual participation
- Members makes mistake – member will get notice/ hearing before discipline = due process

Quality/ Skills/ Abilities of good nursing leader:
A – authority
B – behavior
C – Communication skills
D – decision making
E – ethics
F – face conflict

A – ability – basis of a leader to unsure / demand task, obligation & resp to his subordinates.

2 types
1. Centralized – top to bottom for proper management of whole hospital
- to problems of whole institution
2. Declaralized – bottom (delegation)
- to manage directly pts or concerns

B. Behavior of good nurse leader:
S – specific body of knowledge & skills to do safe care to patient. RN should be competent with scientific rationale
P – patient cettered/ client focus
A – accountability – liable for result of actions
C – confidentiality
E – ethics

General rule: RN: can be charged with :
Invasion of privacy, breach of confidentiality

Exemption to gen rule (RN cant be charged with breach of confidentiality )
P – patients consent
I – inform/ report to other members of HC team for precautionary measure
C – common dse (report) – DOH/ WHO
C – crimes – within 48h – report child abuse

RA 3573 – Law on notifiable disease
Within 24h report disease like – polio & measles
1 week – HIV/ tetanus/ severs acute diarrhea
Priority for child – rape – sexual abuse, domestic abuse, all kinds of abuse
a.) report to barangay official
b.) report to police
c.) provide safe environment – focus on pt 1st – reporting can be done within 48h
d.) call med legal

Rule!! (in order)
1. S – safety
2. R – report
3. R – referral – DSWD, NGO
C – communication skills
- transfer of ideas / info with understanding

Without understanding barrier/ backlog
Sender – message – (idea/ info which sender would like to transmit

Encoding – verbal or non verbal method

Receiver – recipient of communication

Decoding – manner of interpretation after receiving messages

Feedback – response of receiving after interpreting messages
D –decision making
E – ethics
1. Autonomy – independent judgment & decision making who should decide for care of patient.
a.) doc
b.) attending pt
c.) pt
d.) relatives
Pt refuses to remove lucky bracelet before surgery Bt due- Jehovah’s witness
a.) respect decision of pt – respect cultural diversity
b.) refer to doc – let doc explain risks involve
c.) let pt sign a waver

Doctrine of assumption or risk
pt given risks & signed waver
pt will assume all the risks/ danger


IUD - string should be checked during & after mens
Diaphragm – removed after 6h Toxic shock syndrome
Vasectomy – after 2 negative sperm count, 1st is probable 2nd is confirmatory
BTL – can do coitus anytime. When pain & bleeding ceases.

Principles in leadership

Veracity – truth don’t give false reassurance
- all med prognosis, dx, sex of baby – given by MD!

Beneficence – doing good to pt
Non malefience – do no harm

3 type of harm
1. Physical – negligence by commission – performed wrong action
negligence by omission – neglect of care
2. Mental – assault – mental threat/ fear
battery – physical harm
3. Moral – slander – verbal
libel – written, published pictures
Tolality – let pt feel like a whole being even if a part is removed.
offer wigs, bandana – CA pt prosthesis, casts, w/c – amputation
Double effect – if made to choose between 2 evils, choose the one that will have les bad effect. More good effect
Justice of care – priority coz @ pt has unique needs.

Basic char or nursing process
A – acceptance universable
B – based on pts needs
C – client focus
D – dynamic – update nursing process depending on clients needs
E – equitable care
F – familiarity
G – goal oriented toward solving problem

Inviolability of life – respect of life (promote H & prevent disease)
- no abortion!

Conflict – clash of ideas resulting to crisis
Methods to solve conflict.
A – avoidance – putting in one corner – dedma – not good method
S – smoothing – appealing to conscience/ kindness
U – unilateral – force fear, threats correction
N – negotiation – best method – both parties will mutually decide & participate to solve problem.

Nsg management
Mgt – MAN+ TASK = GOAL (pts)

1. Human relations theory – must focus on proper relationship
If needs provided to member (rest day, leave)
Achievement of organization
2. Frederick Taylors scientific mgt theory

4 t’s
Tao – get rt person/ tao
3. Douglas McGregor mgt theory -
Theory Y Theory X
Positive worker Negative worker
- efficient - inefficient
diligent negligent
trustworthy non trustworthy
reliable don’t love job
love their job for the money only
= minimal supervision only = increase cases of negligence affecting pts.
= use cozf I d power to discipline workers

4. Max Weber’s burocaratic (autocratic) theory
whoever is on top would perform mgt functions
not good style of management
5. Elton Mayo’s behavioral theory
overtime pay, rest day, day off
provide physical needs of worker like rest & recreation
HAWTHORNE’S EFFECT – if worker knows that they are being observed, workers will have better output.
6. Henry Fayol’s principles of mgt
a.) Unity of command – one person given instructions to workers
b.) Unity of direction – whole team should have one goal, objective, direction towards pt.
c.) Subordination – personal general interest – pt 1st before self
d.) Esprit de corp – team spirit – all (-) & (+) output credited to the group
e.) Chain of command – heiarchy of command
Get appropriate orders from MD
f.) Channels of communication –
MD orders

g.) Respondent supervisor – command responsibility
- let master answer for negligence conduct of subordinate
liable: both
HN liable for damages – due resp supervisor

SN – negligence - jail

h.) Security of tenure –
i.) Re-numeration of workers – compensation
probationary – 6 months
regular employee
Private – RA 4901 – 40% work 8h a day 5 days a week
Gov’t – RA 7375 – magna carta for public HWorker 15k
Overtime = + 25%
Night shift differential = +10%
Special non working holiday + 30%
Legal Holiday= X2 +100%
Occupational Hazard – work related disease
Private – SSS – employees compensation
Gov’t – GSIS
National health Insurance Act – PhilHealth
Provide for unemployed/ employed
Aesthetic, cosmetic, dental not included
Maternity leave – 60 days NSD
78 days C/S
1st 4 pregnancies to legit spouse
4. Abortions 5th pregnant - & delivered – not entitled to maternity leave
Paternity leave 7 days

Stage/ Steps in nursing management process
P – planning
O – organizing
S – staffing

D – directing/ delegating

Co – coordinating
Co – controlling/ eval

Planning stage – conceptualizing/ product of mind/ looking at future/ looking prospectively
Vision – what org likes to achieve in future
Ex. Health for all by 2000

Heath in the hands of the people by 2020

Mission – focus in present
- reason why org was established
ex. DOH – to five quality health

Philosophy – values. Besides org (members)
Goal – gen statement of mission
Objective – specific statement of mission

Goal- nursing form St. Lukes should provide quality care to pt
Objective – nursing from St Lukes should have IV training (specific)

Policies – set of rules/ regulation of org

3 types of plan
1.) Short term – for every day ordinary activity
ex. NCP
2.) Contingency plan – for emergency or acute crisis, stand by plan
3.) Long term plan – duration of care is linger for chronic pts. Ex. CVA pts

Budgeting – performed in planning stage
proper allocation of resources
Money, manpower, machine
1.) Operati0nal budget – cheapest – everyday ordinary activities (gloves, gown, goggles – OR, LR, DR,ER)
2.) Personal/ labor budget – used to compensate & re-numerate labor – most important
3.) Capital budget – long term use equipment
- MRI equipment, beds
Budget – asks “How”
Organizing stage – answers the question ‘WHO”

Nurse Mgr


Nsg personnel – nurse aid

RN will do: (for stable & unstable pt)

A – assessment
T – health teaching – when best time start discharge
E – explain proc to pt health teaching – start during admission of pt
P – preparation – computation of dosage
A – adm – give meds or treatment
T – treatment – oral, IV, ID
E – evaluation – nursing care plan
J – judgment – PRN meds – nursing will decide when to five

Subordinates can perform: (comfort measures only not VS)
R – routine tasks – standard procedure, monitor I & O ambulating, bathing bed making
stable pts – predictable outcomes
S – stable pts
S – supervision of RN

Styles/ method delivery care
1. Primary nursing – private duty nurse – from admission to d/c!
D – direct plan of care to pt
A – active participation/ consent of pt.
M – mgt of care – from basic to complex PD will do
24h – from admission t o discharge
tip = answer is primary nurse
2. Functional – most useful type
D – duty task – 1 RN all patients
O – one task
H – highly recommended
RNS budget

3. Case Method – ICU critical case
resp for: T – total care (from basic care to most complex)
O – one RN: 1 patient

In extreme cases 1:2 pts

Staffing stage – “how many”
- nurse manager will determine correct # of patients/ RN
Staffing pattern – Phil – 40h/ wk/ 5d
Traditional – 8h/40h/5d
10h shift – 10h/ 4d Monday – Thursday
On call – emergency schedule
Baylor plan – M – F (traditional)
Sat-Sun (skeletal force)

Directing/ Delegation stage – job/ task is done by another pt for you.
Gen rule: RN can delegate any task to another RN
Except: disciplinary task (this is done by higher person)
: confidential task (charting)
: technical task (expertice should be done by same expert)
: official medical task

Coordinating/ collaboration stage
1. canned food – highest purine content (uric)
2. Anchovies – next highest purine content

1. Interpersonal/ intra departmental – collaboration bet 1 nurse to another nurse -
under 1 ward
ex. Endorsement
2. Interdepartmental – collaboration between two or more hosp for benefit of pt.

Why RN needs to collaborate to others in HC team?
- pt is entitled to continuous care.

Evaluation stage – determine whether, plan goal, objective where met or achieved

1. Nurse rounds – 2 x rounds/ day
short term plan
Psyche ward – contraindicated nurse rounds in psych ward
2. Checklist – Nurse mgr – evaluates/ rates member
3. Gam H chart – used to evaluate nurses , multiple plan at same time
4. Peer evaluation – co workers – poorest type of eval – cause might be effected by halo effect due to special relationship.
Performance Appraisal – pt or client evaluates most reliable coz --------- or care evaluates.



Human Sexuality
A. Concepts
1. A person’s 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:

Gender identity – sense of femininity or masculinity
2-4 yrs/3 yrs gender identity develops.
Role identity – attitudes, behaviors and attributes that differentiate roles

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.

II. Sexual 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 sexual 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 sexual 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 sexual 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
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 & interstitial
Muscular compositions: there are three main muscle layers which make expansion possible in every direction.
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 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

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

2. Internal

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. Menstruation-
Menstrual 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 ¼ 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 sexual characteristic female.
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 sexual 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. 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
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 phase-
Lutheal 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 Sexual Responses (EPOR)
Initial responses:
Vasocongestion – congestion of blood vessels
Myotonia – increase muscle tension

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.

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. Dicidua – 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 feto-protein 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 amniocentesis- needle 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 amn 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 ½ 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

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. 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

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
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. 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

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 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

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

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, 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

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)

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

Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
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.
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

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
Breast changes
Urinary freq
Morning sickness
Enlarged uterus

Linea negra
Increased skin pigmentation
Striae gravidarium
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 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.

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

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. Sex ( 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
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
G – 2
P – 0

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 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:

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
- 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 = AOG in weeks
Fr sypmhisis pubis to fundus 24 X 7 =21 wks
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 ½ of preg , square @ month
2nd ½ of preg, x @ month by 5
3mos x 3 = 9cm
4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg
5 x 5 = 25 cm

6 x 5 = 30 cm
7 x 5 = 35 cm 2nd ½ 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

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)
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 soufflé (FHR) & uterine soufflé.
Uterine soufflé – 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

8.Assessment of Fetal Well-Being-
A. 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(non-reactive- 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
a.) pregnancy induced hypertension (PIH), diabetes
b.) warning signs noted during DFMC
c.) maternal history of smoking, inadequate nutrition

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

Not Good
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)

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

Recommended Nutrient Requirement that increases During Pregnancy
Food Source
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

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

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 quantities of all amino acids
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
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 appetite, 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

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

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.
Pyridoxine ( B6)

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.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

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.

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 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
1. Conscious relaxation
2. Cleansing breathe – inhale nose, exhale mouth
3. Effleurage – gentle circular massage over abdominal to relieve pain
4. imaging – sensate focus

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
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 – ¼ 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

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.) < 4’9” tall
2.) < 18 years old
3.) Underwent pelvic dislocation
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

3. Obstetrical conjugate – smallest AP diameter. Pelvis at 10 cm or more.

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

Pre-eminent Signs of Labor
- shooting pain radiating to the legs
- urinary freq.
1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD
* Engagement- setting of presenting part into pelvic inlet
2. Braxton Hicks Contractions – painless irregular contractions
3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine
4. Ripening of the Cervix – butter soft
5. decreased body wt – 1.5 – 3 lbs
6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea
7. Rupture of Membranes – rupture of water. Check FHT

Premature Rupture of Membrane ( PROM) - do IE to check for cord prolapse
Contraction drop in intensity even though very painful
Contraction drop in frequently
Uterus tense and/or contracting between contractions
Abdominal palpations

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.

Danger signs:
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

Positioning – trendelenberg or knee chest position
Emotional support
Prepare for Cesarean Section

Difference Between True Labor and False Labor
False Labor
True Labor
Irregular contractions
No increase in intensity
Pain – confined to abdomen
Pain – relived by walking
No cervical changes
Contractions are regular
Increased intensity
Pain – begins lower back radiates to abdomen
Pain – intensified by walking
Cervical effacement & dilatation * major sx
of true labor.
Duration of Labor
Primipara – 14 hrs & not more than 20 hrs
Multipara – 8 hrs & not > 14 hrs

Effacement – softening & thinning of cervix. Use % in unit of measurement
Dilation – widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

2 segments of the uterus
1. upper uterine - fundus
2. lower uterine – isthmus

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

Transitional Phase: intensity: strong Mom – mood changes with hyperesthesia
Assessment: Dilations 8 – 10 cm
Frequency q 2-3 min contractions
Durations 45 – 90 seconds

Hyperesthesia – increase sensitivity to touch, pain all over
Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain
keep informed of progress
controlled chest breathing
Nursing Care:
T – ires
I – nform of progress
R – estless support her breathing technique
E – ncourage and praise
D – iscomfort

Pelvic Exams
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
Brow Poor Flexion
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

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.

c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.

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

Breech- use sacrum LSA – left sacro anterior
- put stet above umbilicus LST, LSP, RSA, RST, RSP

Chin / Mento

Monitoring the Contractions and Fetal heart Tone
Spread fingers lightly over fundus – to monitor contractions

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

Placental reserve – 60 sec o2 for fetus during contractions
Duration of contractions shouldn’t >60 sec
Notify MD

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
3.)Enema administer during labor
a.)To cleanse bowel
b.)Prevent infection
c.)Sims position/side lying
12 – 18 inch – ht enema tubing

Check FHT after adm enema
Normal FHT= 120-160

Signs of fetal distress-
1.) <120 & >160
2.) mecomium stain amnion fluid
3.) fetal thrushing – hyperactive fetus due to lack O2

2. Second Stage: fetal stage, complete dilation and effacement to birth.

7 – 8 multi – bring to delivery room
10cm primi – bring to delivery room
Lithotomy pos – put legs same time up
Bulging of perineum – sure to come out
Breathing – panting ( teach mom)
Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2nd stage of labor.
Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula)
Mediolateral – more bleeding & pain, hard to repair, slow to heal
-use local or pudendal anesthesia.

Ironing the perineum – to prevent laceration
Modified Ritgens maneuver – place towel at perineum
1.)To prevent laceration
2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby.

Mechanisms of labor
1. Engagement -
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion

Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider
2. Cavity
Two Major Divisions of Pelvis
1. True pelvis – below the pelvic inlet
2. False pelvis – above the pelvic inlet; supports uterus during pregnancy

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

Bolus of Ptocin can lead to hypotension.

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

Types of placental delivery
Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny
Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty

Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER
Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta:
4. Check completeness of placenta.
5. Check fundus (if relaxed, massage uterus)
6. Check bp
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.

If fundus above umbilicus, deviation of fundus
1.) Empty bladder to prevent uterine atony
2.) Check lochia
a. Maternal Observations – body system stabilizes
b. Placement of the Fundus
c. Lochia

d. Perineum –
R - edness
E- dema
E - cchemosis
D – ischarges
A – approximation of blood loss. Count pad & saturation

Fully soaked pad : 30 – 40 cc weigh pad. 1 gram=1cc

e. Bonding – interaction between mother and newborn – rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery

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.

Prolonged labor – normal length of labor in primi 14 – 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma
nsg care: monitor contractions and FHR

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

Signs of Hypovolemic Shock:
Cold clammy skin

Inversion of the uterus – situation uterus is inside out.
MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus
1.) short cord
2.) hurrying of placental delivery
3.) ineffective fundal pressure

Uterine Rupture
Causes: 1.)
1.)Previous classical CS
2.)Large baby
3.) Improper use of oxytocin (IV drip)
a.) sudden pain
b.) profuse bleeding
c.) hypovolemic shock
Physiologic retraction ring
Boundary bet upper/lower uterine segment
BANDL’S 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
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

Preterm Labor – labor after 20 – 37 weeks) ( abortion <20 weeks)
1. premature contractions q 10 min
2. effacement of 60 – 80%
3. dilation 2-3 cm

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

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

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.

X. Postpartal Period 5th stage of labor
after 24hrs :Normal increase WBC up to 30,000 cumm

Puerperium – covers 1st 6 wks post partum
Involution – return of repro organ to its non pregnant state.
- prone to thrombus formation
- early ambulation

Principles underlying puerperium
1. To return to Normal and Facilitate healing

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:
1. position prone
2. cold compress – to prevent bleeding
3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.
1. Ruba – red 1st 3 days present, musty/mousy, moderate amt
2. Serosa – pink to brown 4 – 9th day, limited amt
3. Alba – créme white 10 – 21 days very decreased amt
- urine collection
- alternate warm & cold compress
- stimulate bladder

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

II. Provide Emotional Support – Reva Rubia
Psychological Responses:
a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to tell child birth experiences.
Nursing Care: - proper hygiene
b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions
1.) Care of newborn
2.) Insert family planting method
common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic.

c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child grows.

III. Prevent complications

1. Hemorrhage – bleeding of > 500cc
CS – 600 – 800 cc normal
NSD 500 cc

I. Early postpartum hemorrhage– bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock.
1.) massage uterus until contracted
2.) cold compress
3.) modified trendelenberg
4.) IV fast drip/ oxytocin IV drip

1st degree laceration – affects vaginal skin & mucus membrane.
2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum

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

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.
bleeding to any part of body
hysterectomy if with abruption placenta
mgt: BT- cryoprecipitate or fresh frozen plasma

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,

Acreta – attached placenta to myometrium.
Increta – deeper attachment of placenta to myometrium hysterectomy
Percreta – invasion of placenta to perimetrium

Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.
too much manipulation
large baby
pudendal anesthesia
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing

Infection- sources of infection
1.)endogenous – from within body
2.) exogenous – from outside
1.) anaerobic streptococci – most common - from members health team
2.) unhealthy sexual practices
General signs of inflammation:
1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)
2. purulent discharges
3. fever

Gen mgt:
1.) supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for antibiotic

prolonged use of antibiotic lead to fungal infection
inflammation of perineum – see general signs of inflammation
2 to 3 stitches dislocated with purulent discharge
Removal of sutures & drainage, saline, between & resulting.
Endometriosis – inflammation of endometrial lining
Abdominal tenderness, pos.
Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning
1.) determine one’s own beliefs 1st
2.) never advice a permanent method of planning
3.) method of choice is an individuals choice.

Natural Method – the only method accepted by the Catholic Church
Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)
clear, watery, stretchable, elastic – long spinnbarkeit
Basal Body Temperature 13th day temp goes down before ovulation – no sex
get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.
breast feeding- menstruation will come out 4 – 6 months
bottle fed 2 – 3 months
disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method – 1.) coitus interuptus/ withdrawal - least effective method
2. coitus reservatus – sex without ejaculation –
3. coitus interfemora – “ipit”
4. calendar method

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

21 day pill- start 5th day of mens
28day pill- start 1st day of mens
missed 1 pill – take 2 next day

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.

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
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.

DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation
Depomedroxy progesterone acetate – IM q 3 months
- never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
5 yrs – disadvantage if keloid skin
as soon as removed – can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)
Action: prevents implantation – affects motility of sperm & ovum
right time to insert is after delivery or during menstruation

primary indication for use of IUD
parity or # of children, if 1 kid only don’t use IUD

1.) Check for string daily
2.) Monthly checkup
3.) Regular pap smear
prevents implantation
most common complications: excessive menstrual flow and expulsion of the device (common problem)
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

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

1.) proper hygiene
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

Alerts: Should be kept in place for about 6 – 8 hours

Cervical Cap – most durable than diaphragm no need to apply spermicide
C/I: abnormal pap smear

Foams, Jellies, Creams

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

XI. High Risk Pregnancy

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

First Trimester Bleeding – abortion or eptopic
A. Abortions – termination of pregnancy before age of viability (before 20 weeks)
Spontaneous Abortion- miscarriage
Cause: 1.) chromosomal alterations
2.) blighted ovum
3.) plasma germ defect


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)
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
Tubal rupture
missed period
abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)
scant, dark brown, vaginal bleeding

Nursing care:
Vital signs
Administer IV fluids
Monitor for vaginal bleeding
Monitor I & O
sudden , sharp, severe pain. Unilateral radiating to shoulder.
shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve)
+ Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding
syncope (fainting)
Surgery depending on side
Ovary: oophrectomy
Uterus : hysterectomy

Second trimester bleeding

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
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
Abdominal cramping
Serious complications hyperthyroidism
Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
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
Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR

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
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.

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)
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
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.

1.) Gestational hypertension - HPN without edema & protenuria H without EP
2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A
3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension – HPN between 20 – 24 weeks

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

2.) Severe preeclampsia
Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110 , protenuria +3 - +4

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

P- prepare the following at bedside
- tongue depressor
- turning to side done AFTER seizure! Observe only! for safely.
E – ensure high protein intake ( 1g/kg/day)
- Na – in moderation

A – anti-hypertensive drug Hydralazine ( Apresoline)
C – convulsion, prevent – Mg So4 – CNS depressant
E – valuate physical parameters for Magnesium sulfate
Magnesium SO4 Toxicity:
1. BP decrease
2. Urine output decrease
3. Resp < 12
4. Patella reflex absent – 1st sigh Mg SO4 toxicity. antidote – Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas)
Function: of insulin – facilitates transport of glucose to cell
Dx: 1 hr 50gr glucose tolerance test GTT
Normal glucose – 80 – 120 mg/dl < 80 – hypoclycemic
( euglycemia) > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL
maternal effect DM
1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic
2.) Frequent infection- moniliasis
3.) Polyhydramnios
4.) Dystocia-difficult birth due to abnormalities in fetus or mom.
5.) Insulin requirement, decrease in insulin by 33% in 1st tri; 50% increase insulin at 2nd – 3rd trimester.
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
Hypoglycemia high pitch shrill cry tremors, administer dextrose
3.) hypocalcemia - < 7mg%
Calcemia tetany
Trousseau sign
Give calcium gluconate if decrease calcium

Therapeutic abortion
If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta

Class I & II- good progress for vaginal delivery
Class III & IV- poor prognosis, for vaginal delivery, not CS!
NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver
Regional anesthesia!
Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

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.

Recommendation of class I & II
1.) sleep 10 hrs a day
2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion

XII. Intrapartal complications
1. Cesarean Delivery Indications:
a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i. Breech presentation
j. Transverse lie

a. classical – vertical insertion. Once classical always classical
b. Low segment – bikini line type – aesthetic use

VBAC – vaginal birth after CS
INFERTILITY - inability to achieve pregnancy. Within a year of attempting it
STERILITY - irreversible
Impotency – inability to have an erection

2 types of infertility
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

1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia
Administer; parlodel ( Bromocryptice Mesylate)
Action; antihyper prolactineuria
Give mom clomid: action: to induce oogenesis or ovulation
S/E: multiple pregnancy

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

To shorten 2nd stage of labor!
1.) fundal pressure
2.) episiotomy
3.) forcep delivery