HORMONES

◦Gonadotrophic - target the gonads (increase the size and produce sex hormones)
‣ FSH - stimulate the follicle and for MATURATION —>
‣ LSH - responsible for OVULATION
◦Sex Hormones
‣ Estrogen (hormone of women) - secondary sex characteristics
• result of estrogen to FSH —> assist FSH in maturation
• If estrogen reach limit it sends negative feedback to FSH and causing decrease or
suppressed FSH
• Thickening of the uterus (there is contraction happen) if estrogen is highly elevated it
is not fully thickened
‣ Progesterone - hormones of mothers or pregnancy
• Maintains pregnancy - by relaxation (thats why constipation is common) Relaxsphincter
• Produce by the corpus luteum
• Increases the basal body temperature (a day after ovulation)
CYLE
• Ovarian Cycle - changes happens in ovary Menstrual ( )
• Endometrial Cycle - changes happens in endometrium
◦Menstrual Phase v
Hypothalamus
‣ decrease estrogen and decrease progesterone
‣ Blood loss is 50cc (more than —> menorrhagia) v
Anterior Pituitary Gland
◦Proliferative Phase
‣ Estrogen was addressed
‣ ovulation happens at the end of proliferative FSH LSH
◦Secretory Phase on a on
‣ Progesterone was addressed Ovary Corpus Luteum
( Progesterone)
v
MENSTRUAL DISORDERS Estrogen
• PMS
◦Signs and Symptoms:
‣ Headache - Increase OFI, NSAIDS (take every 6hrs), paracetamol
‣ Breast tenderness - Bromocryptine Mesylate (Parlodel)
‣ Edema - elevate the legs
‣ Bloating - exercise
‣ Mood swings - listening
‣ irritability - listening

• AMENORRHEA - absence of menstruation

◦Primary Amenorrhea - NEVER experience amenorrhea
‣ Could by pituitary tumor
‣ Hormones
◦Secondary Amenorrhea - cessation of menstruation
‣ Only diagnose if: 3 months of no menstruation (less than 3 months - MISSED PERIODS)
‣ Irregular: 6 months
◦Causes: secondary to
‣ Pregnancy
‣ Fertility problem - ovulatory drug: Clomiphene Citrate “Clomid” SE: H.mole
‣ Underlying disease - CANCER
• DYSMENORRHEA
◦Primary
‣ absence of pathologic cause
‣ Can still do ADLS
◦Secondary
‣ endometriosis - ectopic endometrial implantation (having endometrium not in uterus
• No treatment but can remove through surgery (no guarantee that it will not reoccur
‣ PCOS
‣ Cancer

• MENORRHAGIA & METRORRHAGIA

◦Menorrhagia - heavy bleeding (less than 1hr fully soaked)
◦Metrorrhagia - bleeding between menses
◦Goal:
‣ Identify how much is bleeding and measure the amount of blood —> report to MD
‣ Check VS
◦Causes:
‣ Myoma
‣ Endometrial Carcinoma

FAMILY PLANNING
1. Natural Method
2. Artificial Method
3. Surgical Method

NATURAL METHOD
◦Abstinence
‣ for Teenagers and NOT to adult
◦Coitus Interruptus (Withdrawal method)
‣ Not recommended to sexual worker
◦Lactation Amenorrhea Method
‣ Lactation: EXCLUSIVE breastfeeding, DIRECT latching (maximum 6months)
‣ Amenorrhea - not ovulating
◦Rhythm Method
‣ Calendar Method
‣ Signs of ovulation: teach to client
• Increase BBT
• Mittlescmerz (discomfort at Left or right lower quadrant)
• Cervical Mucus Changes (Spinnbarkeit)
• (+) Ferning Pattern
◦Non pregnant: signs of ovulating.
◦if client is Pregnant: Signs of ruptured membrane

ARTIFICIAL METHOD
◦Barrier
‣ Condoms
• Contraindicated to Allergy of Latex: Check history of foods: banana, papaya
‣ Cervical Cap and Diaphragm - difference is the time it is inserted
• Cervical Cap - 30 mins prior to Sex (half fill the cap of spermicide) Maximum 48hours
• Diaphragm - 2 hours prior (put spermicide gel with lubricant effect) Maximum 6-8 hours
 • If it is not took out beyond the maximum—> TOXIC SHOCK SYNDROME
‣ IUD - can be barrier and hormonal
• Fever, Foul discharges - possible infection
• If string is not there —> notify MD
• CHECK every month
◦Hormonal
‣ Oral
• Combination oral contraceptives (COC)
◦Yellow pills (21)+7 placebo (ferrous)
◦Take the same time of the day
◦1 missed pill —> take the missed pill ASAP
◦2 missed pill —> take 1 missed pill ASAP —> 2 pills the ff day —> 1 week barrier method
◦3 missed pill —> discard
◦Contraindicated: (B.D.C.D.S)
‣ Breastfeeding
‣ Diabetes
‣ Cardiovascular Disorders, Blood vessels and Hx
‣ Dx Migraine
‣ Smoking
• Progesterone only Pills
◦Expected: UGLY
◦28 pills (no placebo)
‣ Injectable
• every 12 weeks or 3 months
• Alters Cycle
• If wanting to pregnant stop injectable or 2 years not using
• Injectable Progestin (Depo Provera)
‣ Implants
• 3-5 years
• Side effects: 1 month using common
◦GERD
◦Headache
◦Patchy hair loss
◦irritability

SURGICAL METHOD: Ethical Considerations Consent

• Vasectomy
◦Done for 20 minutes Max procedure
◦No scalpel Vasectomy - one egg at a time
◦First ejaculation - NORMAL: with blood
◦Instruct Patient to masterbate for 1 week —> 2 negative sperm count before making sure it
will not pregnant
◦Still produce sperm but dili kagawas only semen will come out
◦Pain: medications and Ice packs
• Bilateral Tubal Ligation (BTL)
◦For females
◦After vaginal birth or CS —> through Laparoscopic and instill Carbon Dioxide (elevate the
other parts to visualize Fallopian tube) —> common: felt bloating after
 Confirmations of Pregnancy
Presumptive “think mother”
Probable “think doctor”
Positive “think baby”

PRESUMPTIVE SIGNS
◦least indicative signs of pregnancy
◦Subjective manner
◦Starts: Amenorrhea/Missed periods —> might secondary to stress or Anemia
◦Nausea and Vomiting (morning sickness) - secondary to HCG (peaked in early morning) —> could sec. Ulcer
◦Increase Urinary Frequency —> could sec. to UTI
◦Chloasma (other skin changes: linea nigra, Striae gravidarum)
◦Quickening (movement perceived) —> could sec. to Gas

PROBABLE SIGNS
◦Objective manner
◦(+) pregnancy test - 3-5 drops of urine (High levels of Hormone: HCG)
‣ Could be pregnant
‣ Could be H.mole
‣ Could be Cancer
◦Chadwicks - bluish discoloration
◦Godels - Softening of the cervix
◦Hegars - soft lower uterine segment
◦Braun Von Fernwald
◦Piscacek’s sign
◦Ballotement - gently tap the uterine segment and the content goes up and down

POSITIVE SIGNS
◦FHR —> through ultrasound
‣ Heart rate through doopler —> might be uterine bruit
◦Visualization —> ultrasound
‣ Transvaginal Ultrasound - early part
‣ Trans-abdominal Ultrasound - later part
◦Fetal Movement felt by the examiner
EmONC
• Goal: patient nga kaya maalagaan ug endorse to appropriate facility ang pt nga di kaya maalagaan
—> ALL PATIENT ARE AT RISK
• Skilled attendant - underwent training of EmONC and professionals
• REQUIREMENT: Liscensed and Training
◦Refers to Skilled professional

ANTEPARTUM
• Prenatal Visit
◦Lunar months: 10 months
◦Calendar months: 9 months
◦40 weeks
◦WHO - at least 4 prenatal visits
• Obstetrics History - GTPAL
◦Gravida
‣ # of pregnancies regardless of outcome and # of fetus
◦Term
‣ at least 37 weeks
◦Pre-Term
‣ Age of viability 20 weeks - 36 weeks
◦Abortion
‣ below 20 weeks
◦Living
‣ Count ALL the Baby that is BUHI
• Estimates
◦EDD/EDC
‣ LMP - Naegels Rule
‣ AOG - fundal height (cm)
• Lunar Months: FH (cm) x 2/7
• weeks: FH(cm) x 8/7
‣ Ultrasound - confirmation
◦Fetal Length
‣ Haese’s rule
• Lunar months: 1-5(multiply own number) 6-10 (multiply 5)
• Screening
◦Vital signs
‣ Temp: elevated possible infection—> CemONC
‣ PR, RR - elevated (HF or Anemia) —> Transfer
‣ BP - elevated —> transfer CemONC
◦Height and Weight
‣ below 5ft patient —> transfer
‣ Overweight or underweight —> high risk —> transfer
◦Health History of Patient
‣ Hypertension
‣ Asthma
‣ DM
 ◦Laboratory
‣ Blood Typing with RH Factor
• For possible BT
• Rh factor - high risk if there is RH incompatibility (Rh -) —> Transfer
‣ CBC
• RBC
• Hematocrit
• Hemoglobin - 11-16 g/dL
◦Increase in 40-60% —> pseudoanemia
◦Low hemoglobin —> transfer
◦Ferrous Sulfate or Ferrous gluconate 30-60 mg/day
‣ For better absorption: with citrus juice
◦Folic Acid 400 mcg/day
‣ MOST IMPORTANT
‣ Decrease folic Acid —> neural tube defects
‣ Hx of NTD (multiply dosage to 3= 1200 mcg)
◦Calcium 1200 mg or 2 glasses of milk per day or cheese
• WBC (5-10,000 mm3)
◦elevated —> infection (more than 10,000) —> transfer
◦UTI —> spontaneous abortion = CRANBERYY JUICE or Buko Juice
◦if pregnant (upto 12,000: normal)
• Platelet (150-450,000)
◦decrease —> bleeding —> transfer
‣ Urinalysis
• Protein - (+) indication of PIH (20 wks and above AOG)
• (+) Glucose (GDM)
• (+) pus or (+) bacteria
• Good catch urine: minimal or zero epithelial cells (increase —> retest)
‣ Ultrasound
• Early Pregnancy = Transvaginal
• Preparation:
◦EMPTY THE BLADDER
• Late pregnancy = Trans-abdominal
• Preparation:
◦DRINK WATER
◦Put roll towel

COMMON DISCOMFORTS
◦Fatigue - rest and eliminate stressors
◦Hunger
◦Nausea and Vomiting (morning sickness) - dry crackers
◦Heartburn
‣ Small frequent feedings every 2hrs
◦Urinary Frequency
‣ Kegels Exercise
◦Constipation
‣ increase fluid intake and increase fiber
DANGER SIGNS
◦Bleeding or spotting
◦Severe cramps/pain
‣ 1st trimester
‣ 3rd trimester
◦Dysuria
◦Fever & Chills
◦leaking of fluid from vagina —> possible PROM
◦Increase BP
◦Edema (especially hands and face) —> pos. PIH
◦Severe persistent Headache —> pos Pre-eclampsia

COMPLICATIONS OF ANTEPARTUM

Bleeding Disorders (First trimester)

◦Abortions
‣ Induced
• Therapeutic - with medical reason
• Elective Induced abortion - choice of the mother
‣ Spontaneous
• Unintentional of terminating the baby
• < 20 weeks
• TYPES:
◦Threatened
‣ Cervix is Closed
‣ Can STILL save the Pregnancy
‣ Goal: Prevent complication and Save the Baby
‣ Management:
• Bedrest
• Medications: Progesterone based drugs, Tocolytics (causes palpitations)
• NO SEX for 2 weeks following the last evidence of bleeding
◦Inevitable/Imminent
‣ Cervix is DILATED
‣ Abortive process is on going (there is contraction)
‣ Management:
• IV Oxytocin
◦Incomplete
‣ NOT ALL the productS of conception is expelled
‣ heavy or massive bleeding
‣ Management:
• Completion Curettage or D&C
• Emotional Support
◦Complete
‣ ALL products of conception are expelled
‣ Minimal bleeding
‣ confirmed in Ultrasound —> if there were remnants
‣ Management
• Rest
 • Emotional Support
◦Missed
‣ Less than 20 weeks
‣ Died inside the uterus
‣ Intermittent Bleeding (brownish)
‣ Management:
• Dilatation and Evacuation followed by curettage
◦Habitual
‣ 3 or more consecutive times of spontaneous abortion occurring successively
‣ Because of Uterine Anomaly
‣ Goal: Manage the abortion and identify what is the cause
◦Septic
‣ Presence of infection
◦Ectopic Pregnancy
‣ Common site: Fallopian Tube (due to narrowing of the tube)
• Smoking - paralyses the cilia in the fallopian tube
◦ASSESS
◦# of sticks/20 x # of years
• PID
• Endometriosis
‣ Signs and Symptoms
• Bleeding
• PAIN (radiate to the shoulder)
• decrease BP, Increase HR & RR —> HEMORRHAGIC SHOCK
• Management:
◦Methotrexate
◦Surgery
‣ Salphingostomy - create opening and remove the baby and allow it to close
spontaneously
‣ Salphingoectomy
‣ If in ovary (oophorectomy)

Bleeding Disorders (Second trimester)

◦H. MOLE/Gestational Trophoblastic/ Gestational Neoplasms
‣ Incomplete H.mole - have hands, skin, or hair
‣ DO NOT GET PREGNANT FOR 1 YEAR
‣ Might lead to cancer (malignant and fast to metastasis)
‣ S/S:
• Elevated HCG (1-2million)
• Hyperemesis Gravidarum —> metabolic Alkalosis
• Rapid Growth of Abdomen
• Bleeding (brownish)
• (-) FHR
• ultrasound: Grape-like clusters - complete
‣ Management:
• Methotrexate
• D&C
◦Incompetent Cervix
‣ Congenital
‣ Trauma (frequent D&C)
‣ Signs and Symptoms:
• Bleeding (not all the time; sometimes spotting)
 • Painless Dilatation
‣ Management:
• Bedrest
• Elevation of lower extremity —> trendelenburg Position
• Tocolytics (to prevent contraction)
◦Brethrine
◦Yutopar
• Magnesium Sulfate
• If presenting part is very near to cervix —> DO NOT undergo surgery (Cervical Cerclage)

Bleeding Disorders (Third trimester)

◦Placenta Previa
‣ low lying placenta
‣ NOT emergency if no symptoms
‣ Predisposing:
• Advance age
• Uterine Anomaly
• Previous CS
• Grand-multiparity
‣ TYPES:
• Low lying placenta - lower segment but the lining of the placenta do not touch the cervix
• Marginal palcenta- Touches the margin of the cervix
◦BOTH are possible for Vaginal delivery but DOUBLE set-up (prepared anytime for CR)
• Partial Placenta previa - Portion of the placenta touches the top of cervix
• Placenta Previa Totalis or Total Placenta previa - Placenta totally is on top of the cervix
◦Bedrest and Elective CS
• Expectant Management:
◦If no symptoms START with Elective CS (with downpayment)
◦(+) bleeding EMERGENCY CS (no downpayment)
‣ Signs and Symptoms
• Bleeding (Bright red) FRESH BLOOD
• Soft non-tender uterus
• Painless
‣ Complications:
• HEMORRHAGIC SHOCK

◦Abruptio Placenta
‣ early separation of placenta (hidden bleeding)
‣ ALWAYS EMERGENCY
‣ Decrease BS to placenta
• due to hypertension
• Cocaine
• Trauma & Accident
• Short umbilical cord
‣ Signs and Symptoms:
• painful bleedings (dark red or brownish) OLD BLOOD
• Rigid board like abdomen
‣ Management:
• EMERGENCY CS
‣ Complication:
• SHOCK
• DIC (NEVER DO CS) (S/Sx: Rashes, explode vessels)
 • Covvelaire Uterus (do not contract uterus) —> HYSTERECTOMY

RH INCOMPATIBILITY
◦Mother is Rh (-) developed antibodies with baby of (+)
◦FIRST PREGNANCY: mixture of blood with mother and baby —> give RHOGAM (for PREVENTION of Rh
positive antibody formation) Before 72hrs or within 2 days
‣ Rh (-) mother —> INDIRECT COOMBS (maternal blood) - looking for Rh +AB —> RESULT: NEGATIVE —>
GIVE RHOGAM
‣ Rh (-) mother —> Indirect Coombs (maternal blood) - looking for Rh +AB —> RESULT: POSITIVE —>
DIRECT COOMBS (fetal blood through umbilical ARTERY) —> RESULT: NEGATIVE (Rh(-) = NO PROBLEM
‣ Rh (-) mother —> Indirect Coombs (maternal blood) - looking for Rh +AB —> RESULT: POSITIVE —>
DIRECT COOMBS (fetal blood through umbilical ARTERY) —> RESULT: POSITIVE Rh(+) —> RH
INCOMPATIBILITY —> Amniocentesis (amniotic fluid = baby’s urine) = increase Protein —> Intrauterine
Blood transfusion or else baby die
‣ If not increase protein —> wait until delivery

PRE-EXISTING/CO-EXISTING PROBLEMS
PREGNANCY- INDUCED HYPERTENSION —> transfer
◦Screening - starts @20 weeks
◦Criteria:
‣ @20 weeks
‣ Hypertension
‣ Proteinuria
◦less than 20 weeks: Hypertension
◦NO PROTEINURIA: Gestational hypertension
◦Normal BP with Proteinuria: Gestational Proteinuria

PRE-ECLAMPSIA
◦Mild
‣ +30 SBP , +15 DBP
‣ hands
‣ 1-2 protein
◦Severe
‣ 160/100 (at least) —> seizure precautions (decrease stimulation)
‣ Generalized edema and Puffy Face
‣ Severe persistent headache
‣ 3-5 protein
◦Management:
‣ *apresoline (hydralazine) not used —> LUPUS
‣ Magnesium sulfate initial loading dose: 4-6 grams in the buttocks , + 1-2g/hr
‣ Watch Out: TOXICITY —> put at bedside: Antidote (Calcium Gluconate)
• BP - decrease
• UO - decrease
• RR
• (-) Patellar Reflex
‣ Seizure precautions
• Assess for impending Seizure: AURA —> insert padded tongue depressor
• Decreased stimulation
• Dim light
• Bed is in lowest position with SIDE RAILS UP
• let the pt and monitor what type of seizure
 • Side lying patient —> to prevent aspiration
‣ After Seizures: Diazepam (valium) 10mg
‣ TREATMENT: Termination of Pregnancy (deliver the pregnancy NOW) via emergency CS)
‣ PIH mothers —> Baby is SMALL FOR GESTATIONAL AGE (no RDS/good lungs)

◦ECLAMPSIA

CARDIAC DISEASE
◦Goal: Decrease workload of the heart
◦Classifications:
‣ Class I:
• diagnosed with heart condition but no (-) s/sx
• VAGINAL delivery with DOUBLE set-up
‣ Class II
• (+) s/sx with heavy physical activity
• VAGINAL delivery with DOUBLE set-up
‣ Class III
• (+) s/sx Normal physical Activity
• CAESAREAN SECTION
‣ Class IV
• (+) s/sx @ Rest
• CAESAREAN SECTION
◦Management:
‣ Digitalis/Digoxin —> TOXICITY —> Antidote: DIGIBIND
• Bradycardia - assess baseline
• Anorexia
• N/V
• Diarrhea
• Abd. cramps
• Vision changes (halos - yellow or green)
‣ Penicillin
• to maintain
• Presence of Damage: lifetime
‣ Stress Reduction
‣ Increase Iron in the DIET —> ask pt what she usually eats
‣ ENOUGH sleep 8 hours (night) + 2 hours (day)
‣ Cardiac Mothers —> SGA

GDM
◦Screening - starts @ 24 weeks
◦increase glucose —> To Baby —> MACROSOMIA
◦decrease production of phosphatidyl glyceral (responsible for surfactant) —> RDS
◦Signs and Symptoms:
‣ Polyuria
‣ Polydipsia - thirst mechanism
‣ Polyphagia - cell hunger
◦Management:
‣ Proper screening
• Oral Glucose Tolerance Test(OGTT): @24 weeks
◦(4 times blood extraction every hour for 4hrs)
◦Fasting 8-10hrs
‣ Insulin (GDM, TYPE I, TYPE II)
 • Insulin Requirement:
◦First trimester: Normal or Decrease (if both is presence —> DECREASE)
◦Late: Increase
◦Delivery: Insulin back to normal
◦Breast feeding: Insulin reqs is Zero

INTRAPARTUM
COMPONENTS OF LABOR
Passage
• PELVIS
◦Gynecoid - NORMAL
◦Anthropoid - oval shaped
‣ Possible for vaginal deliver
◦Platypelloid - reversed oval shaped
‣ Possible for NSVD —> difficult
◦Android - heart shaped
‣ CPD —> Caearean section
Passenger
• Head measurements
◦Biparietal = 9.25 cm
‣ one parietal bone to another
‣ Smallest
◦Suoccipitobregmatic = 9.5 cm
‣ Full flexed position
‣ IDEAL
◦Occipitofrontal = 11.75
‣ from occiput to the frontal bone
‣ Neutral neck position
◦Occipitomental = 13.5 cm
‣ From the occiput to the mentum (chin)
‣ Head is extended —> face presentation
• Fetal Lie
◦LONG AXIS (Spine)
‣ Longitudinal
• cephalic
• breech
‣ Transverse
• shoulder presentation
• Fetal attitude
◦DEGREE OF FLEXION
‣ Good flexion
• the chin is touch the chest
‣ Moderate Flexion
• Neck is in neutral
‣ Poor flexion
• extension
• Fetal station
◦ISCHIAL SPINE
‣ Station 0 - ENGAGED
• cm below ischial spine is POSITIVE
• NO AMBULATION
 ‣ Floating is NEGATIVE
• cm above the ischial spine
• Fetal presentation
◦Fetal part presenting to the cervix
‣ Cephalic
• IDEAL —>95%
• Presenting part: Occiput or head
• Moulding: head is adjusting
• VARIATIONS:
◦Vertex
‣ head is fully flexed
‣ ONLY performed the CARDINAL MOVEMENTS
‣ Engaged
‣ Descent
‣ Flexion (9.5cm)
‣ IR (internal rotation)
‣ Extension (9.25cm)
‣ ER (external flexion)
‣ Expulsion
◦Military
‣ Moderate flexion
‣ Occipitofrontal (11.75cm)
◦Face
‣ Occipitomental (13.5cm)
‣ Poor flexion or hyper extended
◦Brow
‣ Head is partially extended and unstable
‣ Presenting part: Brow
‣ CAN MANIPULATE —> can partly flexed
‣ Breech
• Presenting part: Butt or sacrum
• Leopold’s Maneuver —> help know the presenting part and position
◦Empty the bladder
◦Position the supine leg is slightly flexed
◦Put a roller towel
◦WARM HANDS
• BEmONC - eminent BREECH
• External Version
◦Assisted ultrasound
◦Turn breech to Cephalic
◦Bladder empty
◦Make sure the umbilical cord is not short
‣ Frank Breech
• Legs is extended and BUTTOCKS ONLY
• Most ideal in breech
• Common complication: DDH
‣ Complete breech
• BOTH legs is flexed “indian sit”
‣ Incomplete breech
• one leg is flexed and one leg is extended
‣ Footling breech
• “the grudge” position
 • In pushing the foot will be the presenting part
‣ Shoulder
• Presenting part: acromion process or shoulder
• NO NSVD
• CAESAREAN SECTION
• Fetal position Bet
◦3 LETTERS
◦FIRST and LAST LETTER a
◦Fetal presenting part with the Maternal Pelvic Quadrant Ex:
‣ 1. R or L ROP
‣ 2. O M (cephalic) S (breech) AC (shoulde)
‣ 3. Land Mark Points A (anterior) P (posterior) T (transverse)
◦ROP
‣ Most painful
‣ BACK MASSAGE
Power
◦Primary Power: Contraction
PARTOGRAPH
◦Secondary power: Mother’s ability to push
sosecs
minutes nosecs
◦Increment: beginning of contraction
410
◦Acme: Peak
◦Decrement: starts to go down NY macosecs

Resting Periods: GET THE VS (BP)

◦Frequency
‣ Beginning of one contraction to the beginning of the next
‣ In minutes
◦Duration
‣ In seconds
‣ Beginning of one contraction to the end of the SAME contraction
◦Interval or Resting Periods
‣ End of one contraction to the beginning of the next
‣ INTENDED FOR INTERVENTION OR ASSESSMENT

• PSYCHE
◦Relaxed
‣ Good labor
◦Anxiety
‣ Prolong Labor
◦Preparation of Labor and delivery
‣ 1. Bradley
• HUSBAND coached birth
‣ 2. Dick - Read
• BREATHING
• Active labor - (breath and blow)
• Transitioning - (Pant blow)
‣ 3. Le Boyer
• ENVIRONMENT
‣ 4. Lamaze
• Psychoprophylaxis (NO MEDS)
 TRUE LABOR FALSE LABOR
◦(+) cervical dilatation (MARKER) ◦(-) cervical dilatation
◦ Effects of Ambulation: increase ◦Effects of ambulation: Decrease
duration and frequency pain
◦Location of pain: Lower back radiating ◦Location of pain: abdominal pain
to abdomen (braxton or pooping)

LABOR AND DELIVERY

STAGES OF LABOR
1. DILATATION
◦onset of s/sx of TRUE labor to 10cm
◦STAGES:
‣ Latent: every 10 mins
• Duration: 20 sec
• 1-3 cm
• AVOID frequent IE
• Encourage ambulation
• Monitor:
◦V/S
◦Contractions
◦FHR
• Empty Bladder every 2hrs
• NO:
◦IV - inhibit pt in ambulating
◦NPO - not significant
◦SHAVING - some pt are not used to shaving unless requested
◦ENEMA
‣ Active: Every 3-5 mins
• Duration 40 sec.
• 4-7 cm (start using Partograph)
‣ Transition: every 2-3 mins
• Duration; 60 sec.
• 8-10 cm
• on partograph
• uncontrollable urge to push
• Breathing Technique (Pant blow)
2. FETAL DELIVERY
◦10cm until the delivery of the baby
3. PLACENTAL DELIVERY
◦delivery of baby to placenta
4. STAGE OF PHYSICAL RECOVERY
◦until 6 weeks after delivery
BEmONC
10 Principles:
1. Parenteral Antibiotics (initial leading dose)
2. Parenteral Oxytocin (3rd stage of labor)
3. Parenteral Anticonvulsant for pre-eclampsia/eclampsia
4. Placenta (manual removal) - controlled cord traction with counteraction
5. Retained Fragments - Manually removed
6. IMMINENT Breech
7. Corticosteroids -
◦bethamethasone
‣ 12mg IM once a day for 2 days (2 doses)
‣ high compliance
◦dexamethasone
‣ 6mg IM every 12hrs for 2 days (4 doses)
‣ nurse will be the one who will go to the patient for the night dose
8. Unang-yakap

PARTOGRAPH
• Informations include:
◦Progress of Labor
◦Fetal Status
◦Maternal Status
• Starts at 4 cm
• Cervical Dilatation: put x
• T: write
• PR: dot
• BP: Line or arrow
• Urine: put check or 0
• IE: every 4hrs (w/ AB evey 2hrs)
• If it crosess alert: ASSESS and prepare for possible transfer
• If it crosses action line: TRANSFER

FETAL HEART RATE

• Acceleration
◦Good if on moving
◦increase 15bpm (movement)
• Decceleration
◦Types:
‣ Early deceleration
• Fetal head compression
◦No interventions needed
• ONLY decelerations normal
‣ Late deceleration
• Uteroplacental Insufficiency (HPN, Supine position)
◦Repositioning (left side lying) and Oxygen supplementation
• FETAL DISTRESS
‣ Variable Deceleration
• Minimal variability - copy paste of Late deceleration
• Umbilical cord compression
◦Maternal repositioning (left sidelying)
STAGE OF FETAL DELIVERY
10 cm —> baby
• Fourchette (where episiotomy cuts)
◦TYPE:
‣ Medial
• Might go to anal sphincter
‣ Mediolateral
‣ Hockey stick
• use letter “J” scissor
◦First degree
‣ NO
◦Second degree
‣ Yes with training
◦Third - fourth degree
‣ DOCTOR
• Breathing technique
◦2 short breaths, hold and push

UNANG YAKAP
• Preparation:
◦3 pairs of surgical sterile gloves
‣ 2 of which use by the OB (double gloving)
‣ 1 use for pediatrician
◦2 warm blankets
‣ 1 for the drying
‣ 1 for the baby and mother
◦1 bonnet
◦cord care sets
‣ scissors
‣ 1 metal clamp
‣ 1 umbilical cord clamp
◦oxytocin 10 iu IM (inject mother to preven uterine atony)
◦Vitamin K (right)
◦Erythromycin
◦Hep B (left)
• Note the time of birth the doctor will say
• Immediate and thorough drying (minimum of 30 seconds)
◦Rapid assessment:
‣ crying related to BREATHING
‣ Tone (if flaccid stop unang yakap and do the recuscitate)
◦Do not wipe of vernix
◦Do not bath the baby for the first 6 hours
◦newborns are OBLIGATORY NOSE breathers
◦If neccessary: suction
‣ 1. mouth - risk for aspiration pneumonia
‣ 2. nose - (baby- periods of apnea without cyanosis)
• Initiate skin to skin contact (promote bonding)
◦placing prone to the mother’s abdomen or between the breast

• Properly timed cord clamping and cutting

◦help prevents anemia
 ◦Decrease of intraventricular hemorrhage (pre-terms)
◦1-3 mins or when the cord stop pulsating
◦2 cm from the base and apply the cord clamp the 5 cm from the base the metal clamp
◦DO NOT MILK THE CORD
◦After inject 10 IU oxytocin
◦Placental separation
‣ Calkin sign
‣ Sudden gush of blood
‣ Lengthening of the cord
• Non-separation for successful Breastfeeding (6 hours)
◦1. breastfeeding
‣ GOAL: Stimulate the sucking
◦2. Vitamin K
◦3. Hep B
◦4. Erythromycin (to prevent opthlmia neuronotoron)

CEmONC
10 Principles:
1. Parenteral Antibiotics (initial leading dose)
2. Parenteral Oxytocin (3rd stage of labor)
3. Parenteral Anticonvulsant for pre-eclampsia/eclampsia
4. Placenta (manual removal) - controlled cord traction with counteraction
5. Retained Fragments - Manually removed
6. IMMINENT Breech
7. Corticosteroids
8. Unang Yakap
9. BT
10. Caesarean Section

STAGE OF PLACENTAL DELIVERY

S/SX:
◦Calkin’s sign
◦Gushing of Blood - (300 (schultz)-500 - Duncan)
◦Lengthening of the cord
• Shiny (fetal side)
• Dirty (maternal side)

STAGES OF PHYSICAL RECOVERY

• Assess bleeding
◦Inspect Fundus —> firm and well contracted
‣ 1 hour after birth - 24 hrs: in the umbilicus
‣ Start Assess from symphisis pubis
‣ Distended to the side —> distended bladded —> urinate
‣ Soft boggy - massage
‣ 9th day - NO LONGER PALPABLE (1 finger breaths or 1 cm per day)
◦Lochia
‣ Rubra
• red
• 1-3 days
‣ Serosa or Serosanguinous
• brownish
 • 4 - 10 days
‣ Alba
• yellowish or whitish
• 10-14 days (can extend until 20 days)
◦Afterpains
‣ Common: breastfeeding

INTRAPARTUM (ABNORMAL)
TESTS:
Non-stress Test (Stress - contraction)
◦post mature
◦hx still birth
◦DM
• Monitor the fetal movement and fetal heart rate
• Give mother buzzer (instruct to press the bell if the baby move)
• Duration of procedure: 20 mins
• Watch 3-5 movements = increase beat of 15bpm per movement
◦Record: REACTIVE NST (pwedi mag induced ug labor)
• If no change in HR (sometimes decrease) and fetal movement
◦Record: NON-REACTIVE NST
‣ perform another test —> CONTRACTION STRESS TEST (Oxytocin Challenge Test) - trial contraction
‣ Hook 1 IV and diluted Oxytocin
• Look for: Late deceleration
• If deceleration is on PEAK = Early deceleration
◦Documeent: NEGATIVE of deceleration
◦Good for induction
• If late deceleration;
◦Document: POSITIVE
◦Caesarean Section
4 ps —> DYSTOCIA
◦Anthropoid, Platypelloid, android
◦Malposition or Malpresentation
◦Hypertonic Labor Pattern
‣ During LATENT PHASE
‣ not effective in dilatation and PAINFUL (PRIORITIZE) —> Analgesia
◦Hypotonic Labor Pattern
‣ During ACTIVE
‣ Due to full bladder and early analgesia (SHOULD GIVE DURING ACTIVE PHASE instead of latent)
‣ EMPTY the BLADDER (stimulation = sound of flowing water) or (alternative warm and tap water)
‣ Give Oxytocin (monitor BP)
• it can decrease bp
• Methergine = can increase BP
• Complain the Severe Pain due to Titanic Contractio
◦STOP THE INFUSION and Call the Doctor
◦Precipitate Labor
‣ Assess patient
‣ Fast Labor
‣ Risk:
• Grand-multiparity
• Large pelvis
 • Small pelvis
‣ Focus: PREVENTION
• 1. Injury
• 2. Perineal Laceration —> mgt: EPISIOTOMY
◦Vaginal Laceration
◦Not need suture
◦Stop bleeding through balloon catheter and inflate or vaginal packing
• 3. Baby Injury
‣ Management
• EPISIOTOMY
• Pant-blow breathing
◦Pre-Term Labor
‣ S/Sx:
• Cervical Dilatation (4cm)
• Active contractions
‣ Management:
• Corticosteroids (prioritize) - for lung surfactant
◦Test to determine lung maturity
‣ 1 mL of _____
‣ Bubbles: mature
‣ Viscosity: Unmature
‣ L/S N - 2:1
‣ Common Problem:
• 1. RDS
• 2. Necrotizing enterocolitis
• 3. Patent Ductus arteriosus
• 4. Intraventricular Hemorrhage —> Hydrocephalus
• 5. Blindness
• 6. Anemia
◦Due to pre-term or blood sample

CAESAREAN SECTION (30 mins)

• Scheduled or Elective
◦Need direct admission slip and attached dr.’s order
• Emergency
◦not obliged patient to pay downpayment
• Types:
◦Classical CS
‣ Vertical Cut
‣ Need binder
‣ Common but slow healing
◦Low segment CS
‣ “bikini cut”
‣ Fast healing
‣ VBAC
• PRE-OP:
◦Check VS (4hrs)
◦Health Teachings
‣ Breathing exercises (5 times every hour - deep inhalation and hold for 2 secs and exhaled forcefully)
‣ Early ambulation (instruct as early as pre-op) —> for good blood flow
 ‣ Secure informed CONSENT
‣ NPO (8hrs)
‣ Meds:
• Metoclopramide (Reglan)
• Ranitidine (Zantac)
‣ Allergies
‣ PREP
• POST-OP
◦VS
‣ 1st hour: q 15 mins
‣ Next 2 hrs: q 30mins
‣ Next 4 hours: q 1hr
◦Assess PAIN
◦If given morphine
‣ RR
‣ BP
‣ Pulse ox
◦Early ambulation
◦Breathing Exercises
◦Promote Bonding with the newborn
◦Diet:
‣ (+) Flatus = sips water
‣ wait 1 hour before removing IV - if not tolerated —> NPO
‣ If tolerated: Sips
• Ginger ale
• Jell-O
• Tea
• Flavored frozen Ice
‣ Soft diet
‣ Regular diet as prescribed
‣ Instruct that it is normal not to have bowel movements for 3-4 days
POST-PARTUM (NORMAL)
POST-PARTUM (ABNORMAL)
• Fundus
• Bleedings
• Afterpains
UTERINE ATONY
◦Immediate post-partum
◦Retained Fragments: Delayed s/sx
◦S/sx:
‣ Fundus soft and boggy
‣ (+) bleeding
◦Management:
‣ Fundal Massage
‣ Oxytocin
‣ Methylergonovine
‣ Bimanual Compresion
• insert one hand into woman’s vagina while pushing against the fundus through the abdominal wall
with other hand
‣ Go to DR then explore vagina manually (undersonogram)
LACERATION
◦Perineal Laceration
‣ 1st degree
‣ 2nd degree
• Can suture with training
‣ 3rd degree and 4th degree
• Doctor
◦Cervical Laceration
‣ No suture
‣ DOCTOR
‣ fresh blood
◦Vaginal Laceration
‣ Balloon catheter
PERINEAL HEMATOMA
◦Cannot easily identified
◦First: CHANGES IN VS
◦Very restless
◦Management:
‣ Ice compress (not direct)
‣ Ask someone to call the physician

AfterPains
◦NEVER apply heat or warm compress
◦May give NSAIDS

RETAINED PLACENTAL FRAGMENTS:

◦Day 6-10 —> Lochia: mixture of rubra and serosa with contraction
◦Management:
‣ Back to hospital —> Ultz (how much the remnants) —> D&C
EMOTIONAL RECOVERY
◦Taking in
‣ Day 1-3 (maximum)
‣ > 3 = postpartum blues
‣ Passive dependent
‣ Reflection of labor & birth experience
◦Taking Hold
‣ Day 4
‣ usually before discharge
‣ shows interest to baby
‣ Independence
◦Letting go

POST-PARTUM BLUES
◦70% Experienced
◦secondary to: hormonal change
◦Therapeutic communication —> Listening
◦Extended taking in phase (last for 6 months)
◦Assess after 6 months —> postpartum depression
POST-PARTUM DEPRESSION
◦25%
◦First 6 months
◦NO LONGER OUR CARE
◦REFERRAL
POST-PARTUM PSYCHOSIS
◦Hx of mentally unstable
◦within first month
◦Priority: SAFETY
‣ separate the baby from the mother
◦Psychotherapy