-WEEK 1
Chapters: 1, 3, 4
Female anatomy: internal vs external, introitus (vaginal opening)
Concerns of women’s health: Cardiovascular health
PAP screening tests start at 21, every 3 years in your 20s
Gardasil 9: ages 9 – 12/ HPV Vaccine
Mammograms start at 40 yrs old
What are all STIs treated with
Breast health, structures, normal findings
Menstrual cycle/ problems
PCOS
Endometriosis- laparoscopy is used to diagnose it
1 Week after the menstrual period, do a breast exam
Pg. 37
Menses: blood and other matter discharged from the uterus at menstruation
Motrin is used for menstrual cramps
Sex (Semen) can cause preterm labor
Menopause is when a woman has not had a period in 1 calendar year
Menarche: The first menstrual cycle
Sexual response in 4 phases:
 Excitement
 Plateau
 Orgasmic
 Resolution
25 and under are the most likely to have STIs
Cycle of violence:
 Phase 1- Tension building
 Phase 2- Abusive incident
 Phase 3- The honeymoon period
Fecal occult test is done, electrocardiogram after 50 yrs old
Everyone should get an annual HIV test
Under 25 should be offered an STD screening
Amenorrhea: absence of a menstrual period
 Primary: Due to anatomic issues
 Secondary: Often caused by pregnancy, a sign of disorders
Hypogonadotropic amenorrhea: Can be caused by hormone suppression
 Management is stress management, exercise, weight loss, Increase in Calcium & vitamin D
Dysmenorrhea: Pain during/before menstruation, NSAIDS #1 way to treat
 Primary: Release of prostaglandins, Treated with NSAIDs, heat, exercise
 Secondary: Acquired menstrual pain, Treated with the removal of underlying pathology,
Diagnosis by pelvic exam, ultrasound, dilation and curettage, endometrial biopsy, laparoscopy
Premenstrual syndrome (PMS): Occurs in the luteal phase of the menstrual cycle
 S/S: Cluster of physical, psychologic, and behavioral symptoms
 30% - 80% experience symptoms
 Treatment: Diet, exercise, herbal therapies, yoga, massage
Premenstrual Dysphoric Disorder (PMDD): Symptoms in the last 7 – 10 days of the menstrual cycle
 Severe variant of PMS, Emphasis on mood change
 Affects 3% - 8% of women
 Treatment similar to PMS: Plus, counseling, medications, hypnosis, acupuncture
-
-
-
Endometriosis: Growth of endometrial tissue outside of the uterus
 S/S: Dysmenorrhea, Painful intercourse (Dyspareunia)
 Treatment: Total Hysterectomy, Lupron depot (Med), Birth control
 Diagnosed through a laparoscopy,
Oligomenorrhea or hypomenorrhea: Bleeding only 1 day, bleeding very little
Menorrhagia (Hypermenorrhea): Excessive bleeding,
Metrorrhagia: Bleeding in between menstrual cycles
Abnormal uterine bleeding: Dysfunctional uterine bleeding
Dysfunctional uterine bleeding:
 Treatments are birth controls
STI prevention:
 Primary: Condoms, STI screening
 Secondary: Treatment
HPV causes cervical cancer
Bacterial infections:
-
-
-
-
-
Chlamydia:
 Most common STI
 Drugs are Azithromycin 1g/1 time, Doxycycline 100mg/2x day for 10 days
Gonorrhea:
 PAP test
 Urine sample
 Drugs are Ceftriaxone 125 – 250 IM
 S/S green mucus discharge
Syphilis:
 Transmitted through tissue abrasions
 Stages are- Primary: 5-90 days, Secondary: 6 weeks – 6 months
 Meds: Penicillin/Pen G.
Pelvic Inflammatory Disease (PID):
 Spread of INFECTION from the vagina to endocervix to upper genital tract
 Cultures are done
 At risk for an ectopic pregnancy
 Symptoms:
 Salpingitis (uterine tube inflammation)
 Endometriosis (Growth of endometrial tissue outside of the uterus)
 At risk for:
 Ectopic pregnancy
 Infertility
 Chronic pelvic pain
 Management:
 Prevention
 Oral/parenteral therapy
 Bed rest
 Education
Pg. 76/77
Viral Infections:
-
HPV (Genital warts):
 More common in pregnant women

-
-
-
-
-
S/S-
 Irritating vaginal discharge with itching,
 Dyspareunia
 Postcoital bleeding
 PAP screening
 Skin-to-skin transmission
 Medications given for discomfort- Tricyclic acid, screening starts at 21 and every 3 years if
negative
HSV:
 (HSV-1 is nonsexual) (HSV-2 is sexual)
 Condoms don’t help prevent
 S/S:
 Burning
 Itching
 Pain
 Inguinal tenderness
 Fever
 Chills
 Malaise
 Severe dysuria
 Treated with:
 Antiviral
 Acyclovir
 Lidocaine jelly for pain
 Increased risk for miscarriage/cervical cancer,
Hepatitis A virus (HAV):
 Acquired through:
 Fecal-oral route
 Eating contaminated food
 Person-to-person contact
 Vaccination is the #1 way of preventing HAV transmission
Hepatitis B virus:
 Most threatening to the fetus and neonate
 Vaccine is given 0/2/6 months old
 Transmitted:
 Parenterally
 Perinatally
 Orally (Rarely)
 Intimate contact
Hepatitis C virus:
 Most common bloodborne infection in the United States
 IV drug users at higher risk, NO vaccine available
HIV:
 Primarily from the exchange of body fluids
 S/S Sever depression of cellular immune system, Symptoms- Fever, headache, night sweats,
malaise, lymphadenopathy, myalgias, nausea, diarrhea, weight loss, sore throat, rash
 Screening-
-
 Antibody testing, Transmission MAY occur to infants
Zika virus:
 Spread through:
 Mosquito bites
 Semen
 Infection increases the risk for microcephaly in infants
 Prevention Avoid travel to areas with known cases
 Men should use condoms
Vaginal Infections:
-
-
-
-
-
-
Vaginitis:
 General inflammation of the vagina
 Associated with preterm labor and birth
 Can be caused by tight clothes/anything that doesn’t allow normal airflow
 S/S Abnormal fishy vaginal discharge
 Itching
 Burning
 Lower pelvic cramping
 Treatment Antibiotics (metronidazole) advise the patient to void alcohol
Candidiasis (yeast infection):
 #2 most common type of vaginal infection
 Predisposition Antibiotic therapy, diabetes, pregnancy, obesity, a diet high in refined sugars, use of
corticosteroids, the patient is immunosuppressed
 Interventions Culture is done, weight loss, diet modification, proper airflow
 S/S Curdy white discharge, redness
 Treatment OTC antifungals, prescription fluconazole, ice pack, loose clothing
Trichomoniasis:
 Also, an STI
 Common cause of vaginal infection
 Screening/Diagnosis Specular exam or PAP smear
 Treatment metronidazole 2g/ 1 dose, avoid alcohol
Group B streptococci:
 Poor pregnancy outcomes
 Screening at 35 – 37 weeks gestation
Fibrocystic changes:
 Caffeine can cause it
 Can be tender, dense
Fibroadenoma:
 Solid mass
 Ultrasound, a mammogram is used
-
Nipple discharge:
 Test for cytology (cellular changes) to check for any cancer or infection
Mammary duct ectasia:
 Benign, occur in mammary duct
Intraductal papilloma:
 CAN become Malignant
Cancer of the breast:
 1/8 women
 Risk increases with age
 Screening Annual mammogram screening starting at 40
 Needle aspiration
 Treatment:
 Chemotherapy before surgery
 Radiation
 Adjuvant hormonal therapy
 Surgical interventions
o Lumpectomy: Taking a portion of cancer out
o Total simple mastectomy: the removal of the entire breast, including the nipple,
areola, fascia (covering) of the pectoralis major muscle (main chest muscle), and
skin
o Modified radical mastectomy: removal of some underarm lymph nodes
o Radical mastectomy: removal of all the underarm lymph nodes plus the entire
chest muscle, Breast reconstruction
 Most women will have a Total radical mastectomy
 Care management: risk for lymph edema, take BP on the opposite side of surgery
-Week 2-
- Menstrual cycle (3) Phases:



Hypothalamic- Pituitary Cycle
Ovarian cycle- Involves estrogen, progesterone, testosterone
Endometrial cycleMental shirtz- pain
Pg. 37 illustration
Normal cycle length 21 – 35 days
3 things needed for conception: sperms, eggs, pathway
- Sperm- lasts 48 – 72 hours
- Egg- lasts 24 hours
- Barrier method is 85% efficient
- Patient with excessive mood changes, breast tenderness, nausea, crying, need to take the progestin-only pill without
estrogen
- Estrogen can increase blood pressure causing blood clots
- Blood clots, stroke, breast cancer, and smoking are a contraindication by hormonal methods
- Sperm gets fertilized in the 3rd portion of the tubes
- Contraception:







Hormonal- Progesterone-only pill
Nonhormonal- Barrier method
Progesterone thins lining
IUDs are 99.7% effective
Assessment of female infertility:
Ovarian factors
 Is the woman ovulating?
Tubal and peritoneal factors
 Is there anything wrong with her tubes?
Uterine factors
 Deformities
 Septum
 Fibroids
Vaginal-cervical factors
 Increase of Ph, preventing sperm living
 Septum
 Infections
Other factors
Test or Examination:
 Evaluation of the anatomy
 Detection of ovulation
 Hormone analysis
 Ultrasonography
 Endometrial biopsy
 Hysterosalpingography
 Laparoscopy
Assessment of male infertility
Hormonal factors
 Is there enough sperm
 Is the sperm motile
Testicular factors
Factors associated with sperm transport
Idiopathic male infertility
Semen analysis
 Check hormone levels
Hormone analysis
Scrotal ultrasound
Medications to give women to hyper stimulate FSH hormone and inhibit ovulation
Clomiphene
Surgical therapies
Hysterosalpingography
 Contrast is injected into the uterus
 X-ray test shows the internal shape of the uterus, and shows if Fallopian tubes are blocked
Laparoscopy
 Poke a hole in the umbilicus and fill the abdomen with C02 to look for structural damage
 Look for endometriosis
Coitus interrupts (pulling out)




Fertility Awareness Methods (FAMs)
Calendar rhythm method to keep track of cycles
Basal body temperature method
 Must be taken before getting out of bed
Predictor test kits for ovulation (OTC)
Abstinence
Barrier methods
Spermicides
 A chemical that kills sperm
Condoms, Male (STI protection)
Vaginal sheath (STI protection)
Diaphragm
 Must be fitted
 Can only leave them in 24 hours
Cervical cap, lasts 1 YEAR
Contraceptive sponge
Hormonal methods- 99.7% efficacy
Combined estrogen-progestin contraception
 Progestin IS the contraception
 Progestin-only pill for women who have:
 High BP
 Smoker over 35
 History of blood clot or stroke
 Estrogen CONTRAINDICATIONS:
 High BP
 Smoker over 35
 History of blood clot or stroke
 Transdermal contraception
 Put around underwear lining
 Change the patch once a week for 3 weeks, 1 week off
Progestin-only contraceptives
 Oral progestins (Mini pill)
 Injectable progestins
 Implantable progestins (Nexplanon)
Emergency Contraception
 Plan B
 Can be taken 72 hours after intercourse
IUD
 ‘T’ shaped device wrapped in copper
 Inserted in the uterine cavity
 Good for 10 years
 Mirena good for 3/5/7 years
 Does not stop menstruation
 The copper used for getting rid of sperm
Sterilization
 Female
 Tubal occlusion
 Tubal reconstruction
 Male

-
-
-
-
Vasectomy
o Tubal tying
Tubal reconstruction (Anastomosis)

Abortion
 Termination of pregnancy before 20 weeks gestation
 Can be:
 Elective
 Therapeutic
st
 1 -trimester abortion
 Surgical aspiration abortion
 Medical abortion
o Methotrexate & Misoprostol
o Mifepristone & Misoprostol
nd
 2 -trimester abortion
 Dilation and evacuation
 Cervix prepared with prostaglandins
 Induced abortion in the 1st trimester is the safest and least complex
 Common complications:
 Infection
 Retained products of conception
 Excessive vaginal bleeding
The preconception period is an ideal time to review family history and provide personalized
recommendations based on:
 Family history
A monosomy is the product of the union between a normal gamete and a gamete that is missing a
chromosome
The product of the union of a normal gamete with a gamete containing an extra chromosome is a
trisomy
Oogenesis, the process of egg (ovum) formation
The amniotic cavity initially derives its fluid by diffusion from the maternal blood
Amniotic fluid serves many functions:
 It helps maintain a constant body temperature.
 It serves as a source of oral fluid and as a repository for waste
 Assists in the maintenance of fluid and electrolyte homeostasis.
 Cushions the fetus from trauma by blunting and dispersing outside forces.
 Allows freedom of movement for musculoskeletal development.
 A barrier to infection and allows fetal lung development
 Keeps the embryo from tangling with the membranes
 Facilitates symmetric growth
 If the embryo does become tangled with the membranes, amputations of extremities or
other deformities can occur from constricting amniotic bands
The yolk sac is formed during the formation of the amniotic cavity
 The yolk sac aids in transferring maternal nutrients and oxygen
 Which diffuse through the chorion, to the embryo
 Hematopoiesis (The formation of blood)
o Occurs in the yolk sac beginning in the third week.
 During the 4th week the shape of the embryo changes from straight to a ‘C’ shape
 A part of the yolk sac is incorporated into the body from head to tail as the primitive gut
(digestive system)
-
-
-
Umbilical cord is compressed during the 5th week by the amnion & forms a narrower umbilical cord
 2 arteries carry blood from the embryo to the chorionic villi & 1 vein returns blood to the
embryo
Placenta begins to form at implantation
 Carbohydrates, proteins, calcium, and iron are stored in the placenta to meet fetal needs.
 Water, inorganic salts, carbohydrates, proteins, fats, and vitamins pass from the maternal blood
supply across the placental membrane into the fetal blood, supplying nutrition
The two most reported maternal medical risk factors are HTN associated with pregnancy & diabetes
 Both of which are associated with obesity
-Week 3-




















Five Ps:
o Position: Both baby and mom
o Power: Uterine contractions
o Passenger: Baby
o Pathway: Female Pelvis
o Psyche.: Mom
Pg. 166 & 167 Know the signs stated on pages
Urinary frequency can indicate pregnancy
Increased estrogen can cause increased discharge
Ballotable:
o The cervix floats up and down
Quickening:
o The first time the baby moves
o 16 – 20 weeks gestation
Lightening:
o When the baby drops into the pelvis (Baby Drop)
Round ligament pain:
o Around 20 weeks
Braxton hicks’ contractions:
o Are felt during pregnancy and can be mistaken for true labor contractions. Unlike true labor
o Braxton Hicks are irregular in frequency and less intense
What makes a pregnant woman constipated:
o Not enough water intake, should drink 1 gallon a day
Figure 7.3 on page 153
Ovaries stop producing during pregnancy
Women who have not had a pregnancy are at higher risk for ovarian cancer
Women who have had babies are at lower risk for ovarian cancer
Prolactin suppresses FSH
Ravda
Naegele’s Rule:
o It assumes that the woman has a 28-day cycle and that fertilization occurred on the 14th day.
o According to Naegele’s rule, after determining the first day of the LMP,
 Subtract 3 calendar months and add 7 days & 1 years
Prenatal care:
o Prenatal vitamins- Folic Acid
LMP: Last menstrual period
What not to take in pregnancy:
























o Blood thinners
o Come off of any nonessential medications
What to know for pregnancy:
o First day of last menstrual period
o Any medical problems
o Blood type
o STI screening
o Any previous pregnancies
o History
o Genetic defects
They should come in every 4 weeks until 24 weeks then every week after 36 weeks
Heartbeat is at 7 weeks
Blood work is done 15 – 20 weeks
Syphilis is taken in the third trimester
Collect weight every week
Urine samples are looking for:
o Glucose
o Leukocytes
o Protein
o Ketones
Ketones in urine can indicate not eating
Hyperemesis:
o S/S:
 Severe nausea
 Vomiting
 Weight loss
 Electrolyte disturbance
30 mins of activity a day
No heavy weights after 20 weeks
UTIs are more possible during pregnancy
UTIs can cause preterm labor due to uterine irritation
Go to the dentist during pregnancy during the 2nd trimester to make sure health is good
You can travel after 36 weeks because traveling can induce labor
No sex during preterm labor
Educate patients on bleeding, cramping, headaches, epigastric pain,
Prenatal period care: Teaching, 30 mins of exercise a day,
Pregnancy trimesters:
First: 1-13 weeks
Second: 14-26 weeks
Third: 27-40 weeks
Nagele Rule: First day of last menstrual period, SUBTRACT 3 months, ADD 7 days PLUS 1 year
Most Women give birth 7 days before and 7 days after the EDB
Three phases of parental adaptation:
Denial/worry about the pregnancy
Adjusting to the pregnancy
Figuring out roles
Folic Acid before pregnancy
Good nutrition is pushed during pregnancy






















Organogenesis: The first 12 weeks of pregnancy
Lab Tests:
Full STD screening
Vaginal cervical cultures
PAP screening
Blood type
CBC
Urine
Pg. 178
Fundal height:
Measured from super pubic bone to the fundus
 Measured in cm
 Measured in supine position
HR- 110-160
18-20 weeks an anatomy scan is ordered
Group B streptococcus test between 35-37 weeks
Kegel exercises to strengthen pelvic floor and helps in delivering
Dental needs taken care of in the second trimester
Rubella is taken AFTER pregnancy because it is a live virus
At 28 weeks given ROGAM
Uterus causes pelvic pressure
Preterm labor symptoms:
Cramping
Low back pain
Midwife vs Certified nurse Midwife
Midwifes do not have certification
Certified nurse midwife is certified and works with a physician
Gravida:
Woman who is pregnant
Gravidity:
Pregnancy
Nulligravida:
Woman who has never been pregnant
Primigravida:
Woman pregnant for first time
Multigravida:
Woman who has had two or more pregnancies past 20 weeks
Parity:
Number of pregnancies that have gone to 20 weeks
Term:
Preterm: 20 – 37 weeks
Late preterm: 34 – 36 weeks 6 days
Early term: 37 – 38 weeks 6 days
Full Term: 39 – 40 weeks 6 days
Post Term: 41 – 42 weeks
Viability: Capacity to live outside the uterus 22 – 25 weeks gestation
 These premature infants are vulnerable to brain injury, neurological defects
Obstetric History:
-
-

















Two Digits: (GP)
 Gravida: number of pregnancies
 Para: Number of pregnancies that went to at least 20 weeks
Five Digits: (GTPAL)
 Gravida: Number of pregnancies
 Term: Number of pregnancies full term
 Preterm Deliveries: 20 – 37 weeks
 Abortions: Spontaneous or planned
 Living children
Table 7.1
hCG is an early biomarker for pregnancy
Pregnancy tests are based on hCG or b subunit of hCG
Detected in serum of urine as early as 7 – 8 days after ovulation
Signs of pregnancy:
Presumptive: Changes felt by the woman (Subjective)
Probable: Changes observed by the examiner (Objective)
Positive: Signs only attributed to the presence of the fetus
-3 Positive signs of pregnancy: (Confirmed by a Provider)
See a baby (Ultrasound)
Hear a baby (Doppler/Ultrasound)
Feel a baby (Feel it with hands on abdomen)
Ballottement:
Inserting a finger in vagina and pushing up on the lower uterine segment to feel it float up and down
Quickening:
Mothers feeling of the babies first movement, felt 14 – 16 weeks
Goodells Sign:
Blue coloration
Hegar’s Sign:
Softening of the lower uterine segment
Leukorrhea:
Caused by increased blood flow, discharge is white or slightly gray with musty odor
Between 36 – 40 weeks the uterus changes shape, into a more ‘O’ shape from a ‘0’ shape
Enlarged heart in pregnancy is caused by increased blood supply
Supine hypotension:
Caused by compression of the vena cava
Increased fluid volume:
About 1500 more:
 1000 is plasma
 500 is RBC
Coagulation factors is increased in pregnancy:
-Sitting for a long time
-Smoking can increase coagulation
Respiratory System:
-Snore more
-Diaphragm is compressed
Renal System:
Dilation of the ureters
Fluid balance shift
Sodium retention















Kidney damage evidenced by urinating protein, sugar
Integumentary System:
Striae
Linea nigra, caused by hormonal change
Angiomas, BENIGN tumors
Musculoskeletal System:
Loosened joints
Hips will curve because of pregnancy
 NO bicycling, crunches
Nerve compression
LORDOSIS
 BACK BRACE is used
McBurney’s Point:
Movement of the appendix during pregnancy
GI System:
Appetite decreases early on
Appetite increases in the 2nd trimester
Increased heartburn resulting from decreased muscle tone
PICA: Craving of things that are not food like:
Ash
Starch
Stucco
Baking soda
2nd Trimester is the best time for dental cleaning
Before conception:
Folate (From dietary sources): Chicken, turkey, goose, lamb, beef, veal, peas, beans, spinach, bread,
egg, corn
Folic Acid (0.4 mg or 400 mcg prior to pregnancy) (4 mg every day for the first 3 months)
 Foods high in Folate include:
 Leafy vegetables
 Dried peas
 Seeds
 Orange juice
 Neural Tube Defects result from poor folic acid intake
 Blood volume peaks around 28 – 34 weeks
Recommended weight gain is supported through eating carbs, fats, and protein during pregnancy
Underweight women are more likely to have preterm labor and have LBW infants
1st trimester weight gain is only:
2 – 4 Lbs
1st trimester Kcal intake is:
1800/day
2nd trimester Kcal intake is:
2200/day
3rd trimester Kcal intake is:
2400/day
Ketonuria is associated with preterm labor
Omega-3 fatty acids (DHA) are essential to fetal growth
Eat seafood


















 8 – 12 ounces/ week
Fluids are important to avoid preterm labor:
8 – 10 glasses (2.3 L) / DAY
Iron:
Is needed for the expansion of RBC for pregnancy
Increased RBC depends on the iron available
Women are anemic if the hemoglobin is less than 11g/dL
Calcium is not increased during pregnancy because a normal healthy mom makes enough of it
Calcium is given for leg cramps
Magnesium is managed when its low by:
Eating nuts
Whole grains
Leafy greens
Dairy
Sodium can be gotten from:
Grain
Milk
Meat
Sodium restriction for
Renal or liver failure
Hypertension
Sodium intake should be:
1.5 g/day
Potassium intake reduces the risk for
Hypertension
8 – 10 servings for fruits and vegetables help with providing adequate potassium
Zinc deficiency causes:
Malformations of the CNS in infants
Iron and Folic acid lower:
Zinc levels
Zinc and copper are given for women with:
Anemia
Fluoride is NOT used in intake
Vitamins A, D, E, K:
Vitamin E is the most likely vitamin lacking
Vitamin E is used for oxidative stress
Vitamin D helps absorb vitamin C
Pyridoxine (Vitamin B6) is involved in
Synthesizing RBCs
Antibodies
Neurotransmitters
Vitamin B12 is involved in producing:
Nucleic acids
Protein
RBC formation
Vitamin C plays a role in:





Tissue formation
Enhanced absorption of IRON
CONTRAINDICATIONS IN PREGNANCY:
-Alcohol
 Causes birth defects
-Caffeine
 Coffee
 Tea
 Soft drinks
 Chocolate
Artificial sweeteners
PICA
 Eating nonfood substances
Exercise is recommended:
(20 – 30 minutes)
Lactation needs increase in
Vit. C
Zinc
Protein
Oral contraceptives interfere with
Folic acid metabolism
Test for hematocrit/hemoglobin levels to check for anemia
-Week 4-













5 factors that affect labor: Five P’s:
Position of mom: Both baby and mom
Power: Uterine contractions and mom pushing
Passenger: Baby
Pathway: Female Pelvis
Psychological response: Mom
Pg. 322- fetal presentation
Babies want to be preferably ROA or LOA positions
Fontanels should be soft and nondistended
Frank breach:
Baby comes out butt first, legs up
Complete breach:
Babies’ legs are crossed
Single footing breach:
Babies leg comes out first
Shoulder presentation:
C-section birth
Vertex presentation is the IDEAL baby position for delivery
Primary powers:
Contractions
Secondary powers:
Mom pushing
Moms must be repositioned every 2 HOURS
Pg.325 Female pelvis anatomy


















Pelvic inlet is the narrowest part of the pelvis
Cervix thins and dilates during pregnancy
Signs before labor:
Lightening/Dropping
Bloody show (burst capillaries)
Stages of labor:
1st Stage- onset of contractions
 Latent phase: 0-4 cm
 Active phase: 4-7 cm
 Transitional phase: 7-10 cm
Check heart tones every 30 mins
Visceral pain
2nd Stage- Full dilation
Mom is going to be pushing, and positioning
Check heart tones every 5 mins
Somatic pain
3rd- Birth of the fetus until delivery of the placenta
Placenta takes 20 mins to detach
Visceral pain
4th- 2 hours postdelivery of the placenta
Vitals taken every 15 mins
SEVEN cardinal movements:
Engagement
Decent
Flexion
Internal rotation
Extension
Restitution and external rotation
Expulsion (BIRTH)
Hormones during labor:
Decreased progesterone
Increased estrogen, prostaglandins, oxytocin
Monitor glucose levels
Visceral pain: From cervical changes, distention of lower uterine segment, and uterine ischemia, usually during
labor
Somatic pain: intense, sharp, burning, usually during delivery
Pg, 336, visual of pain areas
Non-Pharmacologic pain management: Breathing exercises, childbirth classes, shower, rocking back and forth,
Pharmacologic pain management: Sedatives (Ambien), Analgesia, Anesthesia
Drugs used: Ambien, Newfane, tarbagan, Morphine, Demerol,
Opioids are not used when close to giving birth to avoid the drug being in the baby’s system at birth
Systemic analgesia
Opioid agonist analgesics
Opioid agonist-antagonist analgesics
Opioid antagonists
Spinal block anesthesia goes into the actual spine for a C-section
Epidural block anesthesia goes lower than a spinal block for a vaginal birth













EVERYONE IS PREHYDRATED prior to getting an epidural injection with an isotonic solution 500-1000 mL
(Lactated Ringers)
Checking pulse oximeter
General anesthesia is only used in emergencies
Pg. 338- Non-Pharmacologic pain management TABLE
Electronic fetal monitoring is used to see fetal heart rate
Primarily used for intrapartum assessment in the US
Frequent monitoring for HIGH-risk pt. Q5-15 mins
Frequent monitoring for LOW-risk pt. Q30 mins
Fetal O2 supply can be decreased by:
Decreased maternal O2 in blood
Hypertension
Hypotension
Blood loss
Cord compression
Reduction of blood flow through the placenta
External monitoring:
Tocotransducer
 Monitors CONTRACTIONS
Ultrasound transducer
 Monitors FETAL HEART RATE
Internal monitoring: (Invasive)
Internal fetal heart rate monitor
 Attaches to the SCALP of fetus
Montevideo units
 Measures contraction patterns, 80-120
Baseline fetal heart rate: The average between a 10-minute segment
Normal Fetal Heart Rate is:
 110-160 bpm
Variability:
Absent and minimal
 A sign of hypoxemia
Moderate
 Normal
Marked
 Unclear
Sinusoidal pattern
 When it looks like an ‘S’ shape, is a sign of fetal infection
Baseline Fetal Heart Rate: 110-160 bpm
Tachycardia
 More than 160 bpm for 10 mins or longer
Bradycardia
 Less than 110 bpm for 10 mins or longer
Deceleration: Dips below the Base line
Types:
 Early: Head compression, MIRRORS CONTRACTIONS
 Variable: Cord compression
 Late: O2 insufficiency
 Prolonged: O2 issues
V.E.A.L.
C.H.O.P.
V- Variable Deceleration
C- Cord Compression
E- Early Deceleration
H- Head Compression
A- Acceleration
O- OKAY!!!
L- Late Deceleration
P- Placental Insufficiency
Prolonged Deceleration  Prolapsed umbilical cord
 Acceleration: 15 beats high by 15 seconds long
Dips above the Base line
Shows that a baby is oxygenated and healthy
 Late Deceleration:
A sign of a bad placenta or bad placenta supply
DISCONTINUE oxytocin if in late deceleration
Interventions:
 Reposition patient on their side: (LEFT SIDE) to increase blood supply to the placenta
 Increase IV Fluids: To increase the fluid volume
 Put a non-rebreather mask on mom (10L): To increase O2 concentration
 Variable Deceleration:
A sign of cord compression
‘U’ ‘V’ or ‘W’ sign on strip
Interventions:
 Repositioning
 Increase fluid volume
 Tocolytic therapy:
Used to decrease contractions
Used for preterm labor
 Fetal tachycardia is a sign of
Maternal fever
 Pg. 360 THE 3 CATEGORIES
 Category 1: normal baseline
No intervention: it’s normal
 Category 2: bradycardia; deceleration, minimal variability, variable deceleration
Intervention: Lessen Pitocin, use the bathroom
 Category 3: absent variability, sinusodal
Intervention: Lower Pitocin, lower contractions
 Placenta goes bad after “post 8”: (after the expected birth date)
 Pitocin:
Causes contractions
 Methylergonovine
Promotes uterine contractions
 Montevideo numbers: DEFINITE NUMBERS:
  3 – 5 minutes lasting 45 – 60 seconds
 Latent phase can last 2 weeks
 Newbane, ambien, is given as a:
Short acting narcotic in latent phase
 1 cm per hour in ACTIVE PHASE
 No epidural BEFORE
4 cm










NO narcotics after
4 cm
Peudenal block:
Is injected in the cervix, numbs the peudenal nerve
Epidurals take about 20 mins to kick in
Facial edema indicates:
Kidney issue
True labor is:
Cervical change
Lochia:
Scant: Less than 2.5 cm
Light: 2.5 – 10 cm
Moderate: More than 10 cm
Heavy: 1 pad saturated within 2 hours
Saturated: Saturation in 15 mins or less
Pre-eclampsia
Treated with magnesium
 Antidote for magnesium is calcium gluconate
Cullen’s sign:
Blood in the peritoneum
Oral contraception
Contraindications
 Cholecystitis
 HTN
 Migraine headaches
 Visual changes
BMI:
BMI 18.5 or less--Underweight
BMI 18.5 to 24.9-Normal weight
BMI 25.0 to 29.9-Overweight
BMI 30.0 to 34.5-Obese
BMI 35.0 to 40--Very obese
ASK ABOUT WEIGHT GAIN DURING PREGNANCY
-
How much weight gained in each trimester, DEPENDING ON BMI
Normal weight gain: 11.5-15.9kg (25-35 lbs.)
Underweight weight gain: 12.7-18.1kg (28-40 lbs.)
Overweight weight gain: 6.8-11.3kg (15-25 lbs.)
Normal/Abnormal contraction rates