ESSENTIAL INTRAPARTUM & NEWBORN - Transform all health institutions w/

CARE (EINC) maternity & newborn services into

facilities that protect, promote &
EINC - package of evidence-based practices support rooming-in, breastfeeding &
recommended by DOH, PhilHealth & WHO as mother-baby friendly practices
the standard of care in all births
- Basic component of the Dept. of B. Implementing Health Reforms for the
Health’s Maternal, Newborn & Child Rapid Reduction of Maternal & Neonatal
Health Nutrition to achieve Millenium Mortality - AO No. 2008-0029
Dev’t Goals (MDG) 4 & 5 by 2015 - Issued on Sept. 9, 2008
- Goal is rapidly reduce maternal &
MILLENIUM DEVELOPMENT 4 & 5 neonatal death
MDG 4 - reduce child mortality by ⅔ b/w 1990 - 3 Major Pillars in Reducing MNM:
& 2015 under 5 mortality rate ● Emergency obstetric care
Maternity 2 MDG 5:
● Target 5A - reduce by three quarters,
● Skilled birth attendants
● Family planning
b/w 1990 & 2015, the maternal
Prof. Annalie Dona mortality ratio C. Adopting New Policies & Protocol on
2nd Semester ● Target 5B - by 2015, universal access Essential Newborn Care - AO No. 2009-0025
to reproductive health - Issued on Dec. 7, 2009
s/y 2019-2020 - 3.4 million pregnancy every year - Policies to follow for all health care
- 11 mothers die of pregnancy-related providers involved in newborn health
Causes of maternal deaths: care
● PPH 4 Steps to Save Newborn Lives:
● HPN 1. Immediate & thorough drying of the
● Abortion related complications newborn
● Obstructed labor 2. Early skin-to-skin contact b/w mother
- 40,000 newborns die each year & newborn
Causes: 3. Properly timed cord clamping &
● Prematurity (41%) cutting
● Birth asphyxia (15%) 4. Non-separation of newborn & mother
● Severe infection (16%) for early breastfeeding

DOH POLICIES D. The Aquino Health Agenda: Achieving

A. Revitalization of the Mother-Baby Friendly Universal Health Care for All Filipinos - AO
Hospital Initiative in Health Facilities w/ No. 2010-0036
Maternity & Newborn Care Services - AO No.
2007-0026 WOH GUIDELINES

1
A. Baby Friendly Hospital Initiative: Revised, 4 - Reduce Child Mortality - Comfortable position + companion:
Updated & Expanded for Integrated Care: ● Under-five mortality rate - ↓ need for pain relief &
Section 4: Hospital Self-Appraisal & Monitoring, ● Infant mortality rate sedation
Jan. 2006 5 - Improve Maternal Health - Shortened length of labor
- Launched by WHO & UNICEF in 1991 ● Maternal mortality ratio - ↓ chances of cesarean section
- Protect, promote & support ● Skilled birth attendant - ↑ chances of normal delivery
breastfeeding ● Contraceptive prevalence rate - ↑ mother’s satisfaction w/ birth
Freedom of Movement - distract mothers
B. Pregnancy, Childbirth, Postpartum & MDGs SDGs
from discomfort of labor, release muscle
Newborn Care: A Guide for Essential tension, & gives mother control over labor
Practice: Integrated Management of Pregnancy Developing countries Universal Positions for Laboring Out of Bed:
& Childbirth, 2006 ● Walking, Standing & Leaning - use
8 soiled goals for dev’t 17 goals, 169 targets,
- Provide evidence-based integrating 3 dimensions gravity
recommendations to guide health care of SD ● Kneeling - relieve back pain,
professionals in giving high-quality hemorrhoids
UN Secretariat Member States w/
care during pregnancy, delivery & stronger country ● Sitting - use gravity, allows rest b/w
postpartum period, making pregnancy ownership contractions
& childbirth safer ● Squatting - use gravity, opens pelvis
Means of Implementation MoI inter- governmentally
(MoI), monitoring & negotiated, global Upright Position During Labor:
C. WHO Recommendations for the follow-up not defined in architecture & monitoring - 1st stage of labor shorter by 1 hour
advance system being shaped
Prevention of Postpartum Hemorrhage, 2006 - Need for epidural analgesia ↓ 17%
1. Active management of the 3rd stage of - No diff in rates of SVD, CS & APGAR
labor by skilled attendants RECOMMENDED PRACTICES BASED ON EINC score of <7 at 5mins.
2. Use oxytocin for prevention of PPH 1. Admission to labor room when the Restricting Practices:
3. Cord should not be clamped earlier parturient is already in the active phase ● IV lines
than is necessary - Active phase of labor: ● Fetal monitoring
4. Delivery of placenta by controlled ● 2-3 contractions in 10 mins ● Labor stimulating meds that require
traction ● Cervix is 4cm dilated monitoring of uterine activity
- ↓ need for cesarean section by 82% ● Small labor rooms
D. Newborn Care until the First Week of Life - No diff in need for labor augmentation ● Epidural placement
Clinical Practice Pocket Guide, 2009 - No diff in neonates w/ APGAR scores ● Absence of support persons
<7 at 5mins
MDG 2. Continuous maternal support 4. Routine use of WHO partograph to monitor
1 - Eradicate extreme poverty & hunger - Less need for pain relief progress of labor
● Underweight - Duration of labor shorter - No significant diff b/w use & nonuse of
● Stunting 3. Upright position or position of choice partograph in terms of:
● wasting during first stage of labor - CS rate

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 - Maternal infection - Prophylactic insertion should be NOT RECOMMENDED RECOMMENDED
- Instrumental vaginal delivery unnecessary intervention
+ Routine perineal shaving + Admission to labor when
Advantage Disadvantage + Routine enema active phase
5. Limit total number of IE to 5 or less + Routine NPO + Companion of choice to
- Less incident of endometritis Ready access for Interferes w/ natural + Routine IVF provide maternal support
emergency meds birthing process + Routine vaginal + Mobility & upright
- Less incident of UTI by 34%
douching position
- Less chorioamnionitis by 72% Maintain maternal Restricts freedom to + Routine amniotomy + Allow food & drink
- Less neonatal sepsis by 61% hydration move + Routine oxytocin + Use of WHO partograph
augmentation + Limit IE to 5 or less
Not as effective as
INTERVENTION NOT RECOMMENDED allowing food & fluids in
DURING LABOR: labor to treat/ prevent DIAGNOSIS of 2nd STAGE OF LABOR
dehydration, ketosis or
❖ Routine enema during 1st stage of electrolyte imbalance TRADITIONAL NON-TRADITIONAL
labor
❖ No diff in maternal puerperal infection, Defined by a “fully dilated Redefined as “complete
episiotomy dehiscence, neonatal ROUTINE NPO DURING LABOR cervix” cervical” + spontaneous
expulsive efforts” (Simkin,
infection & neonatal pneumonia - Risk of aspirating gastric contents 1991)
❖ Comparable level of patient w/ administration of anesthesia ➢Pelvic phase of passive
descent
satisfaction - Risk of maternal aspiration ➢Perineal phase of active
❖ Fecal soiling during delivery reduced mortality, 7 in 10 million births pushing
❖ Admission CTG for low risk term - No evidence of improved Coaches to push through
patients in labor
outcomes out-of-phase w/ her own
- No benefit for use of CTG sensation
- Use of epidural anesthesia in
- ↑ in CS by 20%
- No diff in instrumental vaginal normal labor should not preclude Directed Pushing Involuntary Bearing
1. Valsava pushing Down
birth, perinatal mortality, Apgar oral intake 2. Venus return + Exhalation pushing
score <7 & NICU admission - For normal, low risk, no need for 3. Perfusion to uterus, + Let air out
placenta & fetus + Parturient- directed
❖ Routine amniotomy to shorten restriction except where 4. FHR changes + Physiologic: force of
spontaneous labor intervention is anticipated 5. Fetal hypoxia & acidosis bearing down efforts
increases as fetal descent
- Less risk of dysfunctional labor - Diet of easy to digest food & fluids occurs
- No diff in duration of labor, CS during labor is recommended + Avoid hypoxia & acidosis
rate, cord prolapse, maternal
- Isotonic calorific drinks during labor
infection & apgar <7 at 5 mins
reduce the incidence of maternal UPRIGHT POSITION DURING DELIVERY
ROUTINE IVF ketosis w/o increasing gastric - More efficient uterine contractions
- No study found that having IV in place volumes - Improved fetal alignment
improves outcome - Larger anterior-posterior &
CARE DURING LABOR transverse diameters of pelvic

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 outlet - enhance fetal movement ➢ Palpate abdomen to rule out APPROACHES IN THE MGT of the 3rd STAGE
through maternal pelvis in descent second baby prior to IM OF LABOR
for birth oxytocin PHYSIOLOGIC ACTIVE
(EXPECTED) (AMTSL)
- Faster delivery
PROPHYLACTIC OXYTOCIN FOR THE 3rd
- Leads to less interventions - less Uterotonic Not given Given w/ in 1
STAGE OF LABOR before the min of baby’s
episiotomy - Postpartum loss >500ml reduced by placenta is birth
39% delivered
INTERVENTION THAT ARE - Need for additional uterotonic reduced Signs of WAIT DON’T WAIT
RECOMMENDED DURING DELIVERY by 47% Placental
- No diff in need for maternal blood separation
1. Perineal massage in the 2nd stage of
labor transfusion, need for manual removal Delivery of the By gravity w/ CCT w/ counter
- Complications (perineal edema, of placenta & duration of 3rd stage Placenta maternal efforts traction on the
uterus
wound infection & wound
DELAY CORD CLAMPING Uterine After the After the
dehiscence) not evaluated
- 30 to 45 seconds massage placenta is placenta is
2. Selective (non-routine) episiotomy - 2 to 3 mins delivered delivered
Non Routine Episiotomy - Once the cord has stopped pulsating
- ↑ anterior perineal trauma by 84% or after placental birth CARE DURING DELIVERY
- Less posterior perineal trauma by 12%
NOT RECOMMENDED RECOMMENDED
- Less need for suturing by 29% ★ Controlled Cord Traction w/
- Less healing complications counter-traction to deliver placenta + Coaching mother to + Upright position during
- No diff in severe vaginal & perineal push delivery
+ Perineal massage in the + Selective episiotomy
trauma, infection rate UTERINE MASSAGE AFTER PLACENTAL 2nd stage of labor + Use of prophylactic
DELIVERY + Fundal pressure during oxytocin for mgt of 3rd
PERINEAL SUPPORT & CONTROLLED the 2nd stage of labor stage of labor
- Lower mean blood loss + Delay cord clamping
DELIVERY OF THE HEAD - Less need for uterotonics + Controlled cord traction
❖ Keep one hand on the head as it w/ counter-traction to
deliver the placenta
advances during contraction while ACTIVE MANAGEMENT of the 3rd STAGE +uterine massage
supporting the perineum (AMTSL)
❖ During delivery of the head, encourage - Administration of uterotonics w/in 1
POSTPARTUM CARE
women to stop pushing & breathe min. of delivery of baby NOT RECOMMENDED RECOMMENDED
rapidly w/ mouth open - Controlled cord traction w/ counter
+ Manual exploration of + Routine inspect the birth
❖ Use of prophylactic oxytocin for traction on the uterus uterus canal for lacerations
management for 3rd stage of labor - Uterine massage + Routine use of ice packs + Inspect the placenta &
over hypogastrium membranes for
+ Routine oral completeness
methylergometrine + Early resumption of

SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.4

 feeding (<6hrs after
delivery)
+ Massage uterus
+ Prophylactic antibiotics
for 3rd or 4th degree
perineal tear
+ Early postpartum
discharge

BREASTFEEDING CUES
❖ Eye movement under closed lids
❖ ↑ alertness, movements of arms & legs
❖ Tossing, turning or wiggling
❖ Mouthing, licking, tonguing
movements
❖ Rooting
❖ Changes in facial expression
❖ Squeaking noises or light fussing
Newborn Needs:
● To breathe normally
● To be warm
● To be protected
● To be fed

SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.5

NURSING CARE OF THE HIGH-RISK 2. Maternal anemia b. Congenital defects
PREGNANT CLIENT 3. Rh sensitization c. Arteriosclerosis - hardening of blood
4. Antepartal bleeding: placenta previa & vessels; cause high-caloric foods
High Risk Pregnancy - pregnancy in mother or abruptio placenta d. MI: pregnancy is contraindicated in clients
fetus has significant increased chance of harm, 5. Pregnancy induced hypertension who have MI before pregnancy
damage, injury or disability, & loss of life or death 6. Multiple gestation e. Pulmo diseases
- One in which concurrent disorder, 7. Premature or postmature labor f. Heart surgery
pregnancy related complication or external 8. Polyhydramnios
factor jeopardized the health of the mother 9. PROM Classification of Heart Disease Based on
and/or fetus 10. Fetus inappropriately large or small; Functional Capacity of the Heart:
Risk Factors: abnormality in test for fetal well being, Class I: no limitation of physical activities; no
a. Demographic Factors abnormality in presentation symptoms
1. Age - under 16 or over 35yrs old d. Maternal Medical History/ Status Class II: slight limitation; asymptomatic at rest but
2. Weight - overweight or underweight 1. Cardiac or pulmonary disease regular activities; produce palpitation, fatigue,
before pregnancy 2. Metabolic disease: diabetes, thyroid dyspnea & anginal pains
3. Height - less than 5 ft. disease Class III: marked limitation; less than regular
b. Socioeconomic Status: 3. Endocrine disorder: pituitary, adrenal activities causes symptoms (under med supervision)
1. Inadequate finances 4. Chronic renal disease: repeated UTI, Class IV: marked limitation of activities;
2. Overcrowding, poor standards of housing, bacteriuria symptomatic at rest (no sex)
poor hygiene 5. Chronic hypertension
3. Nutritional problems 6. Venereal & other infectious diseases Complication of HD in Pregnancy:
4. Sever social problems 7. Major congenital anomalies of the 1. Congestive heart failure
5. Unplanned & unprepared pregnancy reproductive tract 2. Maternal dysrhythmias
c. Obstetric History 8. Hemoglobinopathies 3. Spontaneous abortion
1. History of infertility or multiple gestation 9. Seizure disorders 4. Premature labor
2. Grand Multiparity (6 & above) 10. Malignancy 5. Intrauterine growth retardation
3. Previous abortion or ectopic pregnancy 11. Major emotional disorders, mental Common Signs that Mimic HD:
4. Previous loses: fetal death, stillbirth, retardation ● Palpitation, Edema, Tachypnea, Fatigue,
neonatal or perinatal deaths e. Habits Syncope, Dyspnea, Transent, soft systolic
5. Previous operative OB: CS, mid forceps 1. Smoking during pregnancy murmurs, Elevated ESR near term
delivery 2. Regular alcohol intake (erythrocyte sedimentation rate) 20mm/hr
6. Previous uterine or cervical abnormality 3. Drug use/abuse Criteria for a Diagnosis of Cardiac Disease:
7. Previous abnormal labor: premature labor, ● Persistent diastolic or pre-systolic murmurs
postmature labor & prolonged labor MEDICAL CONDITION AFFECTING PREGNANCY ● Permanent/ unequivocal cardiomegaly
8. Previous high risk infant: low birth weight OUTCOME ● Severy dysrhythmias
(SGA), macrosomia (LGA) w/ neurologic 1. CARDIAC DISEASE - variety of heart conditions ● Severe dyspnea prior to stage of pressure
deficit, birth injury or malformation both congenital & acquired on the diaphragm
d. Current OB Status Risk Factors: ● Loud persistent systolic murmur
1. Late or no prenatal care a. Rheumatic fever - acquired 90%; Signs of Cardiac Decompensation:
streptococcus ● Moist cough
SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.6
 ● Pedal edema; signs of pulmonary edema - ➢ Avoid activities that decrease b. Increased blood volume by 30% to 50%
crackles oxygenation (hemodilution)
● Dyspnea, increasing in minimal activity ➢ Avoid constipation c. Increased ability of the intestinal tract to
● Tachycardia ➢ Observe proper nutrition absorb iron for both maternal & fetal needs
● Tachypnea ➢ Early hospitalization d. Increased transport or iron placenta for
● Chest pains on exertion During Labor liver storage (7th-8th months)
● Cyanosis ● Thorough physical assessment e. Inadequate dietary intake & maternal
● Persistent heart murmurs ● Position stores
● Administer O2 (prn) Risk Factors:
Treatment/ Management ● Provide meticulous skin care (aseptic a. Decrease nutritional intake/malnutrition
❖ Frequent prenatal visits - every month until technique) b. Heredity, cultural practices, fad diets
36 months, every 2 weeks; near term every ● Strict monitoring of I&O to avoid volume c. Increased demands
week overload d. Poor absorption as in stomach & intestinal
❖ Rest, physical & mental rest ● Observe NPO disease
❖ Digitalis (lanoxin .25mg) check CR if less ● Psychological, emotional & spiritual Complication:
than 60 & higher than 100 - HOLD; regulate support ● Associated w/ fetal problem - IUGR,
cardiac rate ● Continuous cardiac monitoring increased perinatal mortality
❖ Diuretics (furosemide - lasix 200mg) ● Anticipate episiotomy & forceps delivery ● Increased incidence of abortion, infection,
observe bradycardia, nausea, vomiting, ● Prepare regional anesthesia (epidural) premature labor, post partal hemorrhage,
diarrhea, colored vision - pulmonary Post Partum Care - cardiac failure & PIH, heart failure in existing disease of the
edema decompensation occurs in early postpartum heart
❖ Antibiotics because: Assessment findings:
❖ Iron supplement to prevent anemia 1. Loss of placental circulation (30-50% Objective - pale skin & mucous lining, pearl white
❖ Oxygen increase in blood volume reabsorbed sclera, brittle, flattened nails, alter VS - rise in
Intra-partum Period Goals - minimize causing sudden fluid overload) systolic pressure w/ widened pulse pressure,
hemodynamic changes & optimize perfusion. 2. Rapid decrease in intra-abdominal tachycardia & tachypnea
Minimize changes in pulse & BP pressure Subjective - fatigue or SOB on exercise, headache,
- Lateral position a. Monitor blood loss, I&O & fluid rate anorexia, menorrhagia, heartburn, flatulence
- Adequate pain relief; anesthesia/ analgesia b. Assess signs of bleeding, sepsis &
- Avoidance of hemorrhage CHF Diagnosis:
- Avoidance of infection c. Non-stressful mother-infant ● Physical exam
- Oxygenation interaction ● Laboratory findings:
- forceps/ vacuum delivery d. Routine post partum care ○ Low hemoglobin (10g/100ml_
- Elective CS ○ Low hematocrit (37% in 1st tri, 35%
Nursing Care 2. IRON-DEFICIENCY ANEMIA - decrease in oxygen in 2nd tri 33& in 3rd tri)
❖ Encourage early, regular & frequent carrying capacity of the blood due to decrease ○ Serum iron less than 65 ug/ 100ml
prenatal care hemoglobin in the blood blood
❖ Encourage compliance of meds & Pregnancy Related Risk Factors: Nursing Responsibilities:
therapeutic regimen a. Red blood cell volume increase by 30% but ❖ Promote a balance activity & rest w/
➢ Decrease workload of the heart drops avoidance of fatigue
SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.7
 ❖ Dietary instructions on iron-rich foods ○ 140 (diet) ❖ Diet: Record dietary intake & blood glucose
❖ Regular intake of hematinics ○ >140 (meds) level
❖ Administer ordered IM (iron dextran/ ● Insulin shock & ketoacidosis are common ❖ Serial ultrasound
imferon) ● Discomfort nausea & vomiting predispose ❖ Hospitalization
❖ Keep warm & free from infection because to ketoacidosis ❖ Provide teaching
of increased susceptibility to infection ● Insulin requirement change in pregnancy ❖ Promote control of DM (diet, exercise,
3. DIABETES MELLITUS meds & insulin administration)
- Chronic, metabolic characterized by a Assessment Findings ❖ Prevention of infection, stress
deficiency in insulin production by the islets - Family history of DM, gestational DM in 4. HIV/ AIDS
of Langerhans resulting in improper previous pregnancy - Caused by retrovirus
metabolic interaction of carbohydrates, - Previous large infant weighing 4000g HUMAN IMMUNODEFICIENCY VIRUS (HIV)
fats, protein & insulin - Previous infant w/ congenital defects; - Affects specific T cells that decrease the
- Incidence: may be a concurrent disease in polyhydramnios body’s immune response
pregnancy or may have first onset in - Fetal wastage; spontaneos abortion, fetal - Leading the individual more susceptible to
pregnancy death, still birth opportunistic infections
- Onset 20 weeks & above - Obesity w/ rapid weight gain ACQUIRED IMMUNODEFICIENCY SYNDROME
Risk Factors: - Increased incidence of vaginal moniliasis & - Positive in HIV w/ an existing opportunistic
a. Family history UTI infection
b. Rapid hormonal change in pregnancy - Marked abdominal enlargement & Risk Factors:
c. Tumor/ infection of the pancreas macrosomia a. IV drug abuse
d. Obesity b. Promiscuous
e. Stress 3 P’s of Hyperglycemia c. Prostitutes
Effects of DM on Mother & Baby: 1. Polyphagia - hunger d. Bisexual partners
Mother: 2. Polydipsia - thirst Maternal Risk - AIDS defining disease that are most
❖ Infertility, Spontaneous, abortion, PIH, 3. Polyuria - frequent urination common in women than men
Infections: Monilias, UTI, Premature Labor, ● Weight loss May include the ff:
Dystocia, Hypoglycemia/ Hyperglycemia, ● Increased blood & urine sugar ● Wasting syndrome
Cesarean Section, Uterine Atony - ● Esophageal candidiasis
postpartal hemorrhage Diagnosis ● Herpes simplex virus disease
Baby: ● Screening Test/ FBS (26-28 AOG) Non-AIDS defining gynecologic disorders include:
❖ Congenital Anomalis, Polyhydramnios, 140mg/dl ● Candidiasis or Cervical pathology
Macrosomia, Fetal Hypoxia - IUFD, still ● Glucose Tolerance Test (GTT) Medical Management:
birth, increased perinatal mortality, ● 2hrs postprandial blood sugar ❖ Administration of Antiretroviral Drug using 3
Neonatal Hypoglycemia, Prematurity, RDS ● Glycosylated hemoglobin part ZDV ( Zidovudine)
(6hrs after birth), Hypocalcemia ● Urine glucose monitoring ❖ Oral ZDV
Effects of Pregnancy on DM ❖ IV ZDV
● DM is more difficult to control: difficult to Nursing Responsibility ❖ Oral ZDZ for infant starting 8-12hrs after
maintain blood sugar ❖ Early detection birth continuing up to 6 weeks of life
○ 80-100 (glucose fbs) ❖ Early prenatal management & supervision
○ 100-120 (normal) ❖ Frequent regular prenatal visits 1st Prenatal Visit Include Assessment:
SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.8
 ❖ Platelet count, CBC w/ differential count & ● Premature rupture of membranes - Hard Drugs cause growth retardation &
repeated each trimester to monitor anemia, Causes of Adverse Effects of Smoking: drug withdrawal = increased neonatal
thrombocytopenia, leucopenia that are ● Nicotine, a vasoconstrictor = ↓placental mortality
associated w/ HIV infection & antiviral perfusion - Most common effect of heroin is
therapy ● Increase of carbon monoxide causes withdrawal or neonatal abstinence
❖ Monitoring for early signs of complications functional inactivation of maternal & fetal syndrome w/ signs:
such as weight loss inactivation of maternal & fetal hemoglobin ● Sneezing
2nd & 3rd Trimester ● Smokers have decreased plasma volume ● Irritability
❖ Presence of fever ● ↓ appetite = ↓ caloric intake ● Vomiting & diarrhea
❖ Inspection of mouth infections: oral thrush ● Seizures
or leukoplakia Alcohol - ingestion by pregnant women is likely to
❖ Frequent assessment of the lungs for cause fetal abnormalities 5. HYPEREMESIS GRAVIDARUM
presence of pneumonia - Leading known teratogens - Severe nausea & vomiting & weight loss &
❖ Assessment of serology regularly to dehydration
monitor HIV/ AIDS progress Effects of Chronic Alcoholism: Fetal Alcohol - Seen in patient w/ Hydatidiform mole
❖ Close monitoring of fetal status BPS, Syndrome (H-mole), advanced diabetes. Anorexia
Non-stress test, UTZ ● Retardation/ delays nervosa or bulimia, or gastrointestinal
Nursing Care ● Mental retardation; microcephaly, down disease like peptic ulcer
❖ Universal precaution/ reverse isolation syndrome & seizure disorders Other Reasons:
precaution ● Craniofacial defects; flat midface, wide ● High level of HCG
❖ Help patient understand that is a fatal nasal bridge., thin upper lip ● High level of Estrogen
disease & help her accept that other ● Cardiovascular defects ● Increased glucose drain on maternal
people will raise her child ● Lim defects metabolism
❖ Provide emotional support ● Impaired fine & gross motor function ● Family history (genetics)
❖ Discuss how to prevent acquiring ● Caffeine - reduce intake of coffee, tea, ● Psychogenic factors
opportunistic infections colas & cocoa to 300mg per day. No > 2 to Therapy
❖ Encourage strict adherence to therapeutic 3 per day ❖ Prevention: multivitamin at time of
regimen & management Drugs - should only be taken by pregnant women conception
when prescribe by physicians ❖ Increased dietary sources of potassium &
SAD HABITS OF PREGNANCY - Should have benefits or advantages magnesium
Smoking - pregnancy should not smoke outweighing the risks ❖ Ginger 1grm
Use of 5 cigarettes delivers a low birth infant - Best recommendation: no meds is taken ❖ Acupressure at pressure points
- Prenatal tobacco exposure causes learning during pregnancy unless necessary & ❖ Antiemetic: metopramide (plasil, reglan),
& attention problems in children prescribed ondansetron(zofran)
Effects of Tobacco Use: - Intake of illicit drugs in the 1st trimester ❖ Antihistamine: diphenhydramine (benadryl),
● Increased risk of SGA cause adverse fetal malformation because: meclizine (antivertigo), diphenhydramine
● Prematurity 1. Placental barrier is not fully (dramamine)
● Infant mortality developed; placenta mature by ❖ IV formula of nutrients & supplementation
● Spontaneous abortion 10-12 weeks of gestation ❖ Enteral feeding
● Placenta previa/ Abruption placenta 2. Rapid organogenesis
SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.9
6. ECTOPIC PREGNANCY - pregnancy develop Nursing Implementation:
outside of uterine cavity ● Assessment for shock
Predisposing Factors: ● Shock treatment
a. Fallopian tube narrowing or constricted ● Position on modified Trelenberg
b. PID (common cause) ● Infuse D5LR for plasma administration,
c. Puerperal & postpartum sepsis blood transfusion or drug admin
d. Surgery of the fallopian tubes ● Monitor VS. Bleeding, I&O
e. Congenital abnormalities of fallopian tubes ● Physical & psychological support - pre-op
f. Adhesions, spasms, tumors & post op
g. IUD dosage ○ Anticipate grief, guilt response,
Types: fear
1. Tubal - most common; found in 90-90%;
tubal rupture occurs before 12 weeks
2. Cervical
3. Abdominal
4. Ovarian
Assessment Findings:
- Amenorrhea or abnormal menstrual period
- spotting (most common)
- Early sign of pregnancy
- Nausea & vomiting
- Bluish navel (Cullen’s signs) because of
the blood in the peritoneal cavity
- Rectal pressure because of blood in t
cul-de-sac
- (+) PT
- Sharp localized pain when cervix is
touched
- Signs of shock/ circulatory collapse
- Kehr’s Sign - sudden acute low abdominal
pain radiating to the shoulder

Culdocentesis - checks for abnormal fluid in the

abdominal cavity behind the uterus
Treatment:
❖ Salpingectomy/ Salpingostomy
(non-rupture) - surgical removal of rupture
tube
❖ Blood replacement - for shock if rupture:
❖ Antibiotics
SIASOCO, PAULINE ERIKA | MATERNITY 2nd SEM 2019-2020 P.10
7, HYDATIDIFORM MOLE ● Excessive nausea & vomiting because of - Uterine bleeding
- 20% w/ primary hydatidiform mole develop excessive HCG (1-2million IU/L/24 hours) - Clinical diagnosis of a misses or
persistent GTD (invasive mole, ● + PT spontaneous abortion
choriocarcinoma, placental site ● No fetal signs - heart tones, parts & - Serum hCG level is normal or low
trophoblastic tumor) movements for gestational age
- Benign neoplasm of chorion. Chorion fails ● Abdominal pain Chromosomal Abnormalities: karyotype shows
to develop to a full placenta & generates & Diagnosis triploidy (69 chromosomes), w/ 2 paternal sets & a
become fluid-filled vesicles ❖ Passage of vesicles - first sign maternal chromosome complement
❖ Triad signs: - Chromosomal complement is XXY in 70%
➢ Big uterus - Abnormal conceptus from fertilization of an
Gestational age 8 - 16 wk 10 - 22 wk
➢ Vaginal bleeding: brownish & egg w/ a haploid set of chromosomes by
Uterine size intermittent two sperms, each w/ a set of haploid
➢ HCG >1 million chromosomes or by a single sperm w/ a
Large for 33% 10% ❖ Ultrasound: no fetal sac, no fetal parts diploid 46XY complement
gestational age
❖ Flat plate of the abdomen done after 15wks
Small for 33% 65% - no fetal skeleton Treatment:
gestational age Types of HMole ❖ Evacuation by D&C or hysterectomy if no
1. Complete Mole - b/w 11 & 25wks, w/ an spontaneous evacuation
Diagnosis by Common Rare
ultrasonography ave. AOG of 16wks ❖ Hysterectomy if above 45 y/o & no future
- Vaginal bleeding most common pregnancy is desired or w/ ↑ chorionic
Theca lutein 25 to 25% Rare then excessive uterine gonadotropin level after D&C
cysts enlargement ❖ HC titer monitoring for 1 year - no
Human >50,000 <50,000
- Severe vomiting, HTN & pregnancy for one year
chorionic Hyperthyroidism ❖ Medical replacement: blood, fluid plasma
gonadotropin - Ovarian enlargement caused by ❖ Chemotherapy for malignancy:
(mIU/mL)
theca lutein cyst occurs in 25% to methotrexate
Malignant 15% - 25% <5% 35% ❖ Chest x-ray to detect early lung metastasis
potential - HCG >50k Complication:
Chromosomal Abnormalities: most complete ● Choriocarcinoma - most dreaded
Metastatic <5% <1% moles are diploid w/ 46, XX karyotype; rare eg. of ● Hemorrhage - most serious during early
disease
triploid or tetraploid treatment
Gross Findings: ● Uterine perforation
Assessment Findings: - Enlarged edematous villi give classic ● Infection
● Brownish/ reddish, intermittent or profuse grape-like appearance to the placenta & Nursing Implementation:
vaginal bleeding by 12 weeks lack embryonic tissue ❖ Bed rest
● Expulsions, spontaneous of molar cyst b/w - ❖ Monitor VS, blood loss, molar/tissue
16th & 18th wks 2. Incomplete Mole or Partial Mole - b/w 9 & passage I&O
● Rapid uterine enlargement inconsistent w/ 34wks of gestation ❖ Maintain fluid & electrolyte balance,
AOG - Uterine size is small for gestational plasma & blood volume
● Symptoms of PIH before 20wks date ❖ Prepare for D&C or hysterectomy
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 ❖ Psychological support 9. ABORTION ● Passage of tissues or product of
➢ Fear related to cancer - Termination of pregnancy before the age of conception
➢ Self-esteem for abnormal viability usually before 2 to 24 wks ● Signs of related to blood loss/ shock:
pregnancy Types of Abortion: pallor, tachycardia, tachypnea, cold
❖ Prepare for discharge 1. Spontaneous w/ medical or mechanical clammy skin restlessness, oliguria, air
➢ Need for follow-up HCG titer intervention hunger & hypotension
determination for one year Causes: Treatment
➢ Instruction on no pregnancy for ● Defective ovum/ Congenital defects ❖ Surgery: D&C or dilatation/ suction
one year ● Unknown causes curettage
● Maternal factors: ❖ Antibiotics; septic abortion
8. INCOMPETENT CERVIX ○ Viral infection ❖ Blood, plasma, fluid replacement
- Mechanical defect in the cervix causing ○ Malnutrition ❖ Hbaitual abortion: determine etiology;
cervical effacement & dilation & expulsion ○ Trauma (physical & mental) treatment of underlying causes: cerclage
of the products of conception in ○ Congenital defects of the operation/ cervical closure
midtrimester of pregnancy reproductive tract ❖ Blood tests: BT, Rh factor, Coombs; test,
Risk Factors: ○ Incompetent cervix serum fibrinogen, clotting time, platelet
a. Congenital defect of the cervix ○ Hormonal - ↓ progesterone
b. Trauma of the cervix by forceful D&C & ○ Systemic diseases in mother (DM. 10. PLACENTA PREVIA
difficult delivery thyroid dysfunction, severe - Abnormally low implanted placenta
c. Cervical laceration anemia) - Incidence: most common cause of
Assessment Finding ○ Environmental hazards bleeding in the third trimester, occurs in
- Painless contractions resulting in delivery ○ Rh incompatibility 1:150 to 200 pregnancies
of dead or non-viable fetus Types of Spontaneous Abortion: Risk Factors:
- History of abortion a. Threatened Abortion ● Multiparity - most important
- Finding of a relax cervical os on pelvic b. Inevitable Abortion ● ↓ vascularity in the upper uterine segment
exam c. Incomplete Abortion as in scarring & tumor
Treatment d. Complete Abortion ● Above 35yrs old
● Cerclage - during 14 - 15wks AOG or to e. Missed Abortion ● Multiple pregnancies
next pregnancy; suture or ribbon beneath f. Recurrent Abortion Types or Degree of Placenta Previa:
cervical mucus to close cervix 2. Induced w/ medical or mechanical intervention 1. Low-lying - at the lower third of the uterus;
● Shirodkar - permanent suturing Types: does not cover the internal os
● McDonalds - temporary, purse string a. Medical 2. Marginal - lies over the margins of internal
suturing of cervix; suture removed at term i. Oxytocin os
Nursing Implementation ii. Misoprostol (Cytotec) 3. Partial - partially covers the internal os
❖ Psychological support Complication of Abortion: 4. Complete or Total - totally covers the
❖ Post cerclage procedure care ● Septicemia internal os
❖ Advice limitation of physical activities w/ in Signs of Abortion Assessment Findings:
2 weeks after treatment ● Vaginal bleeding or spotting - Painless vaginal bleeding (fresh, bright red,
❖ Maternal & fetal growth monitoring; routine ● uterine/ abdominal cramps external in the 3rd trimester)
prenatal care
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 - Uterus soft/ flaccid - intermittent ❖ Diagnostic UTZ
hardening if in labor ❖ Shock measures as necessary. Initially,
- Intermittent pain if it happens in labor bleeding in previa is rarely life-threatening
secondary to uterine contractions but may become profuse w/ IE
- Bleeding may be slight or prefuse after an ❖ Psychological support
activity, coitus or internal exam ❖ Conservative management, double setup
Diagnosis ❖ Observe bleeding after delivery. Lower
● Ultrasonography - detects sites of uterine segment, site of placental
placenta detachment is not as contractile as the
Treatment: upper fundal portion
❖ Watchful waiting: Expectant Management
(conservative)
- Mother is not in labor
- Fetus is premature. Stable & not in
distress
- Bleeding not severe
❖ Amniotomy - artificial rupture of the BOW
causes fetal head to descend causing
mechanical pressure at placental site
controlling bleeding
❖ Double set up (one set of vaginal delivery &
another for CS)
- Term gestation
- Mother in labor & progressing well
- Mother & fetus are stable
- If the women is not in labor or in
shock or the fetus is distress,
emergency CS is performed
❖ Delivery done in hospital perform CS
Complication:
● Placenta Accreta
● Hemorrhage
● Prematurity
● Obstruction of birth canal
Nursing Implementation:
❖ Bed rest - left lateral recumbent w/ a head
pillow
❖ Do not perform IE or vaginal exam
❖ Careful assessment: VS, bleeding,
onset/progress of labor, FHT
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11. ABRUPTIO PLACENTA the degree of external bleeding (classic ● Generalized edema: face, hand & ankles
- Complication of late pregnancy by type) ● Weight gain of 1.5kg (3.3lbs) per month
premature partial or complete separation - If in labor: tetanic uterine contraction w/ ● Proteinuria
of a placenta absence of altering contraction & relaxation
- Also called accidental hemorrhage & of uterus 13. HELLP SYNDROME
ablatio placenta Complications - Variation of PIH
- Incidence: 2nd leading cause of bleeding in ● Hemorrhagic Shock - Named for common symptoms: hemolysis.
the 3rd trimester. Occurs in 1:300 ● Couvelaire Uterus - bleeding behind Elevated liver enzymes, low platelets
pregnancies placenta may cause blood to enter the - Cause is unknown
Factors: uterine musculature causing the uterine - Occurs in both primigravidas &
● Maternal HPN: PIH, renal disease muscles not to contract once placenta is multigravidas
● Sudden uterine decompression as in delivered Hemolysis - RBCs are damaged by their travel
multiple pregnancy & polyhydramnios ● DIC through smaill, impaired blood vessels
● Advanced maternal age ● CVA Elevated Liver Enzymes - obstruction in liver flow
● Multiparity ● Hypofribronogenemia by fibrin deposits
● Short umbilical cord ● Renal Failure Low Platelets - vascular damage due to
● Trauma; fibrin defect ● Infection vasospasms
Types: ● Prematurity, fetal distress/ demise
1. Type I: concealed, covert or central type; Nursing Implementation: Signs & Symptoms:
Classic type ❖ Bed rest ● RLQ, epigastric area & lower chest pain
- Placenta separates at the center ❖ Monitor maternal VS, FHT, labor, I&O, ● Nausea
causing blood to accumulate uterine pain & bleeding ● Vomiting
behind the placenta ❖ Administer IV, plasma or blood as ordered ● General malaise
- External bleeding not evident ❖ Observe for other problems after delivery ● Severe edema
- Signs of shock not proportional to ➢ Poorly contracting uterus ● RUQ may tender on palpation (distended
amount of external bleeding ➢ DIC - hemorrhage - CVA liver)
2. Type II: Marginal, overt or external ➢ Hypofibrinogenemia - postpartum Management
bleeding type hemorrhage ❖ MgSO4
- Placenta separates from the ➢ Prematurity - neonatal distress - ❖ Transfusion of fresh frozen plasma
margins neonatal morbidity & mortality ❖ Delivery of the fetus
- Bleeding is external; proportional ❖ Bed rest
to the amount of internal bleeding 12.. PREGNANCY INDUCED HYPERTENSION ❖ Bleeding precaution
- May be complete or incomplete a. Preeclampsia - multisystem, vasospastic ❖ Monitor maternal & fetal well being
depending on the detachment disease process
Assessment Findings: - hemoconcentration, HPN, 14. PREMATURE RUPTURE OF MEMBRANES
- Painful vaginal bleeding in 3rd trimester proteinuria & edema (PROM)
- Rigid, board-like & painful abdomen b. Eclampsia - extension of preeclampsia - Rupture of membranes before term/ labor
- Enlarged uterus due to concealed - seizure Assessment FIndings:
bleeding; signs of shock not proportional to Signs & Symptoms: - Maternal report of passage of fluid per
● BP > 140/90 vagina
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 - Determination of alkaline amniotic fluid & - Occurs b/w 20-37 weeks of gestation ➢ Cardiac & respiratory status &
non acid uterine vaginal discharge - Fetal prognosis depends on birth weight & distress
Diagnosis length of gestation ➢ Early sign of edema; pulmonary
● Nitrazine Test - change color from yellow Complications: edema
(acidic pH 4-6) to blue (alkaline 7-7.5) ● Prematurity ❖ Promotion of physical & emotional comfort
● Ferning Test - amniotic fluid, high in ● Fetal death - Keep client informed
sodium content, will assume ferning ● SGA/ IUGR ❖ Administration of Tocolytics to arrest labor
pattern when dried on the slide ● Increase perinatal morbidity & mortality by causing relaxation of the uterus
● Sterile Speculum Examination - most Risk Factors: ● Magnesium Sulfate
reliable diagnosis of PROM (Maternal Factors) ● Terbutaline (Bricanyl)
Complications: ● Infection, illness or disease, DM ● Isoxuprine (Duvadilan)
● Materna infection/ Chorioamnionitis ● Premature rupture of membrane ● Ritodrine
● Cord prolapse ● Bleeding Contradictions:
● Premature labor ● Uterine abnormalities/ overdistention, ● Advance pregnancy
Nursing Implementation: incompetent cervix ● Ruptured BOW
❖ Bed rest; Do not ambulate (cord prolapse) ● Previous preterm labor, preeclampsia ● Maternal diseases: bleeding complication,
❖ Calculate gestational age ● Trauma, poor nutrition PIH, cardio disease
❖ Observe character amount. Color & odor of ● Extreme ages, decreased weight, less ● Fetal distress
the amniotic fluid height ● Presence of fetal problem (Rh
❖ Observe signs of infection (fever, chills, ● Lack of rest/ excessive isoimmunization)
malaise, & signs of labor onset ● Smoking ● Administration of Corticosteroids
❖ Monitor for signs of prolapsed cord ● Extreme emotional stress ○ Betamethasone 12mg IM q 24hrs x
❖ Provide appropriate treatments as ordered; (Fetal Factors) 2 doses
➢ If there are signs of infection: ● Multiple pregnancy ○ Dexamethasone 6mg IM q 12hrs x
antibiotics & immediate delivery ● Infection 4 doses
➢ If w/o infection, induction of labor ● Polyhydramnios
delayed, provided fetus is healthy ● Congenital adrenal hyperplasia 15. MULTIPLE PREGNANCY
➢ Provide psychological support: ● Fetal malformation - Gestation of 2 or + fetus
■ Explain procedure & (Placental Factors) - Carrying if more than 1 fetus during the
findings ● Placental separation same pregnancy
■ Support client & family ● Placental disorders Risk Factors:
■ Inform of progress Treatment: ● Rise in infertility management (ovulation
■ Prepare client & family for ❖ Bed rest on left lateral recumbent induction)
early interruption of ❖ Adequate hydration ● Advanced maternal age
pregnancy as indicated ❖ Monitoring ● Use of clomiphene citrate (Clomid)
➢ Uterine contractions & irritability ● Parity
14. PREMATURE LABOR ➢ VS & fetal wellbeing Types:
- Onset of rhythmic uterine contractions that ➢ I&O 1. Monozygotic Twins - results from single
produce cervical changes after the fetal ➢ Signs of infection ovum then divides
viability - Identical twins
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 - Shares one set of traits, placenta, ● Intrauterine asphyxia (In Women)
chorion, usually one amnion ● Cerebral palsy & other neurologic - Age of menarche, length, regularity &
except umbilical cord impairments frequency, amount of flow
- Same genotype & of the same sex - Menstrual disorders
- 1/250 births, survival was 10% 15. INFERTILITY - History of contraceptive use
lower - Exist when a pregnancy has not occured - History of previous pregnancies & abortion
- More risk for congenital defects after 1 year of engaging in unprotected - Thorough assessment of breast, thyroid
2. Dizygotic Twins - results from 2 separate coitus gland, secondary sex characteristics
ovum Primary Infertility - no previous conception Assisted Reproductive Technique
- Fraternal twins Secondary Infertility - has been previous viable ● Artificial Insemination
- May have same or diff sex pregnancy & couple cannot conceive at present ● In Vitro & Embryo Transfer
3. Super Twins - rare triplets & other multiple ● Gamete Intra-fallopian Transfer
birth; such as quadruplets or quintuplets Male Infertility Factors: ● Zygote Intrafallopian Transfer
Assessment Findings: ● Disturbance in spermatogenesis ● Surrogate Embryo Transfer
- (+) history of twinning ● Obstruction in tubules, ducts, vessels; ● Intra-vaginal Culture
- Big uterus preventing movement of spermatozoa ● Blastomere Analysis
- Two FHT ● Changes in seminal fluid prevents sperm Alternative to Childbirth
- Palpation of 3 + legs motility - Surrogate mothers, Adoption, Child-free
- 2 fetal outline on ultrasound ● Development of autoimmunity that Living
- ↑ maternal weight & discomforts, edema, immobilizes sperm
varicosities, SOB, ↑ susceptibility to supine ● Problems in ejaculation
hypotension syndrome Female Infertility Factors:
Diagnosis ● Anovulation
● UTZ ● Tubal transport problems
● High serial estrol ● Uterine problems
● Palpation ● Cervical problems
Complication: ● Vaginal problems
(Maternal) Assessment:
● Iron deficiency anemia - General health
● Threatened abortion - Nutrition
● Preterm labor/ PROM - Alcohol, drug, or tobacco use
● PIH - Congenital problems
● Hyperemesis gravidarum - Illness such as mumps, UTI
● Anxiety & depression - Operations such as surgical repair of hernia
(Fetal) - Current illness
● Prematurity - Past occupations
● RDS - Sexual practices
● Hypoglycemia, hyperbilirubinemia & - Secondary sex characteristics
anemia - Genital abnormalities
● Conjoining abnormalities
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 PROBLEMS ON MALE REPRODUCTIVE - Mild ED: 17&; Moderate ED: 25%; Evaluation:
SYSTEM Complete ED: 10% 1. Sexual History -Sexual relationships,
- ED prevalence increases with age Current emotional status, Onset & duration
1. UNDESCENDED TESTICLE - 50% @50; 60% @60; 70% of erectile problem, Previous treatments,
- Or cryptorchidism @70 Erotic & morning erections in terms of
- One or both testicles are not seen or felt in Risk Factors: (same rf for cardiovascular disease) rigidity & duration, Use of International
the scrotum consistently ● Lack of exercise Index for Erectile Function (IIEF)
- Occurs in 30% of premature boys, 3.4% of ● Obesity 2. Physical Examination
full term boys, 0.8% of 1 yr olds ● Smoking ● Exam of genitourinary, endocrine,
- Must be differentiated from retractile testis ● Hypercholesterolemia vascular & neurological systems
- Orchiopexy performed after 1 years old ● The metabolic syndrome ● Rectal exam in 50 y/o & up
Complications: Etiology ● BP & heart
● Failure of testicle to produce viable sperm 1. Psychogenic 3. Laboratory Testing (basic lab tests)
● Malignant degeneration of testicle 2. Vasculogenic - cardiovascular disease, ● Fasting blood glucose
● Predisposition to torsion & traumatic HPN, DBM, Major surgery or radiotherapy ● Lipid profile
injuries (pelvis or retroperitoneum) ● Morning sample of total
● Associated inguinal hernia 3. Neurogenic testosterone
a. Central Causes - Multiple Principles of Treatment:
sclerosis, Parkinson’s disease, ❏ Primary goal is to determine aetiology of
Tumors, Stroke, Spinal cord disease & treat it; not to treat it alone
disorders (Disc disease) ❏ Modifiable or reversible factors: lifestyle or
b. Peripheral Causes - DBM, drug-related should be modified first
Alcoholism, Polyneuropathy, ❏ ED can be treated but not cure except
Surgery psychogenic ED, post-traumatic
4. Anatomic/ Structural - Peyronie’s disease, arteriogenic ED in young & hormonal
Penile fracture, Congenital curvature of the causes
penis Treatment
5. Hormonal - Hypogonadism, 1. Lifestyle Modification
Hyperprolactinemia, Hyper & 2. Treatment of curable ED
Hypothyroidism, Cushing’s disease 3. Therapy for assisted erection
6. Drug-Induced a. First-line therapy
- Antihypertensives (beta-blocker, ● Oral drugs (PDE5 &
2. ERECTILE DYSFUNCTION thiazide & clonidine) less w/ ACE Apomorphine)
- Persistent inability to attain and/or maintain inhibitors ● Topical pharmacotherapy
an erection for sexual performance - Antidepressants (tricyclic ● Intraurethral alprostadil
- Or called impotence antidepressants & MAO inhibitor) (MUSE)
Prevalence: - Antipsychotics, Antiandrogens, b. Second-line therapy
(Men 40-70 years old) Antihistamine, Recreational drugs ● Vacuum constriction
- 52% have ED (Heroin & Cocaine) devices
● Intracavernous injections
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 c. Third-line therapy 3. PRIAPISM ○ Neisseria gonorrhea & Chlamydia
● Penile prosthesis - Uncontrolled & long-maintained erection trachomatis - 14-35 yrs old
w/o sexual desire ○ E.coli & Mycobacterium
- Cause penis to become large & painful tuberculosis - 35 & older
- Erection that lasts for more than 4 hours ● Common Routes of spread of infection::
Types: ○ Via the vas deferens
1. Low-flow or Ischemic Priapism - blood ○ Via lymphatic
gets trapped in the erection chambers ○ Hematogenous routes
2. High-flow or Nonischemic Priapism - rare Signs & Symptoms:
& less painful.. Happens when an injury to ● Gradual onset of scrotal pain & swelling
the penis or perineum ruptures and artery ● Located on 1 side
prevents blood in the penis from moving ● Fever & chills (25% of adults & 71% of
normally children w/ acute epididymitis)
Occur From: ● Urethral discharge preceding the onset of
Vacuum Devices ● Thrombosis of veins of corpora cavernosa acute epididymitis
- Cylinder fits over penis & sits firmly against ● Leukemia
body ● Sickle cell disease
- Created to draw blood into th penis to ● DBM
maintain an erection ● Malignancies
- Rubber ring (tension band) is placed ● Abnormal reflex
around the base of the penis to maintain ● Some drug effects
erection; cylinder is moves ● Recreational drugs Gross Morphology:
● Prolonged sexual activity ➔ Acute stage: testicle is firm, tense, enlarged
Treatment: - goal is to improve venous drainage of & congested
the corpora cavernosa ➔ May be multiple abscesses esp. in
❖ Urologic emergency gonorrheal infection
❖ Meperidine Treatment:
❖ Warm enemas ❖ Bed rest
❖ Urinary or suprapubic catheterization ❖ Elevate scrotum
❖ Large-bore needle or Surgery ❖ Ice pack
❖ Antibiotics
Intraurethral Applications: ❖ Analgesics
INFLAMMATORY DISORDERS
- Prostaglandin E is a self-administered ❖ Anti-inflammatory
4. ORCHITIS or EPIDIDYMITIS
suppository placed in the urethra w/ an
- Inflammation of the testicle secondary to
applicator
infection
- Erection occurs in 10mins & lasts 30-60
- May be acute or chronic
mins.
Etiopathogenesis:
- Burning of urethra occurs after
● Most common pathogens:
○ E.coli & Mumps - 14 yrs & below

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 ➔ Cut section shows multiple abscesses & (Acquired hydrocele) - usually late-onset noted in
pockets of focal necrosis men above 40 years
- Due to local injury, infections &
7. TORSION OF THE SPERMATIC CORD radiotherapy
- Twisting of the spermatic cord leading to
cutting off the venous & arterial blood 8. HEMATOCELE
supply to the testicle - Accumulation of blood in the tunica
- Common in boys & young men vaginalis
Signs & Symptoms: - Caused by trauma or malignant tumor of
● Enlargement of the testicle; edema the testis
involving the entire scrotum
● Scrotal erythema 9. VARICOCELE
5. BALANITIS ● Fever - Abnormal dilation of the veins of the
- Inflammation of the glans penis ● Nausea or vomiting pampiniform plexus & internal spermatic
- Associated w/ poor hygiene, allergies & ● Pain duration of less than 24 hours vein of the spermatic cord
STIs Gross Morphology - Most common cause of oligospermia
- Rare in circumcised individuals ➔ There may be coagulative necrosis of the - Unilateral (on the left) in 80% patients
testis & epididymis - Bilateral in 18%
6. PROSTATITIS ➔ There may be hemorrhagic infarction
- Inflammation of the prostate gland
- Acute or chronic OTHER CONDITIONS:
Causes: 8. HYDROCELE
● Ascension of bacteria from urethra - Abnormal collection of serous fluid in the
● Descent of bacteria from the upper urinary tunica vaginalis
tract or bladder - May be congenital or acquired; acute or
● Lymphatic system or haematogenous chronic
spread of bacteria from a distant focus of Pathophysiology;
infection (Congenital)
Causative Microorganism - Embryologically, the processus vaginalis is
- Common are that cause UTIs; E.coli a diverticulum of the peritoneal cavity
- Other: klebsiella, proteus, pseudomonas - It descends w/ testes into the scrotum via
enterobacter, gonococci, chlamydia the inguinal canal around the 28th week
trachomatis, staphylococci & streptococci w/ gradual closure through infancy &
Clinical Findings: childhood
- Fever, low back pain, perineal pain, dysuria - In congenital hydrocele (communicating
- Pain of digital rectal examination hydrocele), processus vaginalis does not
Gross Morphology: close completely permitting flow of
➔ Prostate is enlarged, swollen & tense peritoneal fluid into the scrotum leading to
accumulation of fluid in the tunica vaginalis
- Noted in children b/w 1-2 years
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 MODULE 3 a. BILATERAL GYNECOMASTIA - due to
BREAST DISORDERS systemic causes
Clinical Features:
Congenital & Developmental Abnormalities - Full history and exam and testes should be
- Normal location of breast is the anterior examined
thorax and occur along the milk line Useful Investigations:
- Milk line - an ectodermal thickening ● Chest x-ray
appearing at 6 weeks of gestation axilla to ● Full blood count
the midportion of inguinal ligament ● Liver function test
● Ultrasound - suspicion of
testicular tumor
● Hormonal assay - for
2. MASTALGIA endocrinopathies
- Breast pain Treatment
- Rare symptom of breast cancer - Stop drugs that causes gynecomastia
a. CYCLICAL MASTALGIA - associated w/ - Subcutaneous mastectomy in troublesome
menstrual periods cases
- Begin at 34y/o relieved by - Liposuction - assisted mastectomy
menopause, physical activity
b. NONCYCLIC MASTALGIA - affects older 4. DUCT ECTASIA
women (43y/o) - Plasma Cell mastitis, comedo mastitis &
- From chest wall; breast itself or chronic abscess of stimulating carcinoma
● Amastia - total lack of breast tissue outside of the breast - Benign lesion impossible to differentiate
● Athlelia - no nipple Treatment from CARCINOMA
● Polythelia - supernumerary nipples ● Danazol - 200-300mg daily, slowly - Widening of the ducts of the breast
● Polymastia - supernumerary breast reduced to 100mg daily or alternative day - Occur frequently in 40s & 50s women
- Given on days 14-28 of menstrual Signs & Symptoms:
1. AMASTIA cycle - Thick & sticky discharge, gray to green in
- No growth of breast or nipple - Responses in 3 months color, is the most common symptom
- Distinguished from AMAZIA - absence of - Weight gain, acne, hirsutism - Tenderness & redness of the nipple &
breast tissue but nipple is present surrounding breast tissue
- Result of radiation or surgery 3. GYNECOMASTIA - Sometimes scar tissue forms around the
a. UNILATERAL AMASTIA -absence of breast - Growth of glandular tissue in male breasts abnormal duct, leading to a lump
on just one side - Greek term gyne + mastos meaning Treatment
- Absence of pectoral muscles “female-like breasts” - Discharge is treated by major duct excision
b. BILATERAL AMASTIA - absence of both - Benign condition; 65% of male breast
breasts abnormalities 5. GALACTOCELE
- 40% with multiple congenital - Distinguished from - Cystically dilated terminal ductules that are
anomalies PSEUDOGYNECOMASTIA - excess fat in filled w/ milk & lined by double layer of
male breasts breast epithelial and myoepithelial
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 - Appears as a painless lump. Weeks to - Corpus Luteum Deficiency/ Anovulation in
months after cessation of breastfeeding 70%
- Formed by obstruction to a duct in the - Patients w/ premenstrual tension
puerperium. Milk retained proximal to the syndrome likely to develop FDB
obstruction becomes cheese-like
- Complication of swelling is infection ● Prolactin - levels increased in ⅓ of women
Treatment - Due to oestrogen dominance on
- Surgical excision pituitary
● Thyroid - suboptimal levels sensitize
6. FIBROADENOMA mammary epithelium to prolactin
- Benign tumors composed of stromal & a. CYSTIC HYPERPLASIA - variant of normal stimulation
epithelial elements cyclic changes in the breast that occur w/ ● Methylxanthines - increased intake of
- Common in young women menstruation coffee, tea, cold drinks, chocolate associate
- Well-circumscribed lesion of the breast & - Bilaterally in the upper outer w/ dev’t of FDB
develop prior to menopause quadrant of the breast Treatment
a. PERICANALICULAR TUMORS - found - Painful in the premenstrual period 1. Medical
below the age of 30 Synonyms Goal: to stop progression, relieve pain, reverse
b. INTRACANALICULAR TUMOR - after 30 ● Mammary dysplasia, Cystic disease, Cyclic changes, soften Breast tissue
- Either breast may be affected & multiple & Mastopathy, Cystic Hyperplasia Indicated when: FDB not increasing in size, no
successive tumors may develop Pathophysiology nipple discharge, no psychological effect
- Cause is unknown ● OC Pills
- Hormonal basis ● Progestogens - given in the luteal phase
- Oestrogen & Progesterone for 9-12 months
- Prolactin - 80% get relief but 40% require
- Thyroid restart of therapy
- Methylxanthines ● Danazol - most effective therapy
- Trauma - not a cause - 200 to 600mg/day
Ineffective modalities:
Oestrogen & Progesterone ❖ Diet therapy - caffeine restriction
● Oestrogen predominance over ❖ Diuretics
progesterone is considered causative ❖ Iodine containing agents
- Serum levels of oestrogen high ❖ Thyroid hormone
- Luteal phase is shortened ❖ Evening primrose oil
● Progesterone level decreased to ⅓ normal ❖ Vitamin E & B6
- Women w/ progesterone ❖ Dihydroergotamine
7. FIBROCYSTIC DISEASE deficiency carry a five fold risk of ❖ Anti Prolactin drugs
- Most common lesion of the female breast of premenopausal breast cancer Hormones
- Cystic lobular hyperplasia & fibrocystic ● Low oestrogen combined OC pills
disease of the breast are the two common ● Progestogens in the luteal phase
acceptable description ● Anti Oestrogens - tamoxifen
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 ● Androgens - Danazol ● Missed feedings or longer intervals b/w
2. Surgical feedings
Indicated when: FDB is increasing in size, serous/ ● Inflammation
serosanguinous/ bloody discharge occurs, ● Abscess
psychologically disturbed Treatment
- Antibiotics
8. MASTITIS - Warm water on infected area to help
- Infection that affects women who are stimulate let-down (milk-ejection reflex)
breastfeeding (esp. First 2 months after - Breastfeed or pump frequently
childbirth) - Breastfeed only until breast is soft
- Benign treated w/ antibiotics - Apply icy compresses to breasts after
breastfeeding to relieve pain or swelling
- Drink fluids & get rest
- Analgesia to control pain

Inflammation caused by many types of injury:

● Infectious agents & their toxins
● Physical trauma
● Chemical irritants
Signs & Symptoms
● Part or all of the breast is intensely painful,
hot, tender, red & swollen
● Breastfeeding mother who thinks she has
the flu might have mastitis
● Chills or temp higher than 38C may have
infection
● Cracked or bleeding nipples
● Stress or getting run down

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 MODULE 4 V. Composite - Postabortal infection
FEMALE REPRODUCTIVE DISORDERS Signs & Symptoms: - Acquiring other STD, esp. HIV
● 100% Pain: Premenstrual, intermenstrual & Treatment According to the Cause:
postmenstrual 1. Vulvitis - acc. to the cause
1. ENDOMETRIOSIS ● 80% Chronic pelvic pain 2. Simple atrophic Vaginitis - by HT
- Presence of endometrial tissue outside the ● 60% Dysmenorrhea 3. Desquamative Vaginitis - by clindamycin
lining of the uterine cavity ● 45% Dyspareunia creams
- Proliferation of endometrium in any site ● 40% Infertility 4. Urethral Caruncle - by Estrogen creams &
other than the uterine mucosa Consideration: biopsy if there’s no improvement
- Excess estrogen stimulates adhesion and ❖ Age, symptoms, stage, infertility Home Remedies for Vaginitis:
pain through invasion, angiogenesis, cell Treatment: - Yogurt, Garlic, Apple cider vinegar, Cold
proliferation Treatment: compress, Chamomile, Hydrogen Peroxide
❖ Laparoscopy - accurate diagnosis
❖ Hormonal treatments does not work for 3. PELVIC INFLAMMATORY DISEASE
deep infiltrative disease, adenomyosis & - Major co-morbidity in young sexually active
scar endometriosis women
- Results from sexually transmitted
2. VAGINITIS pathogens ascending from the lower to
- Inflammation of the vagina upper genital tract
- Often complain of an abnormal discharge - Can have long term sequelae
w/ offensive odor and itching Pathology: ACUTE PID
Common cause in premenopausal women:
Factors: a. Bacterial Vaginosis
● Hyperestrinism - Caused by imbalance of naturally
○ Fibroid & metropathia occurring bacterial flora of vagina w/
hemorrhagica overgrowth of anaerobic bacteria
○ Delayed marriage, infertility - Most common cause of vaginitis
○ Oestrogen secreting tumors of the - Triggered by ↑ PH of the vagina
ovary (intercourse, douches)
● Cervical Stenosis - Recurrence are common
● Insufflation - 50% are asymptomatic
● Curettage - Itching & inflammation are uncommon
Pathogenesis: - Not a STD
I. Implantation Theory - retrograde Complications:
menstruation Increased risk for
II. Embolisation Theory - vascular & - Preterm labor Causative Organisms:
lymphatic. Mechanical - Endometritis and postpartum
- Polymicrobial infection
III. Metaplasia Theory - In situ deve’t fever ● Neisseria Gonorrhoeae
IV. Immunological - Post-hysterectomy vaginal-cuff ● Chlamydia Trachomatis
cellulitis
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 ● Others: Gardnerella vaginalis, ● Cervical motion tenderness on bimanual Treat Partner
Anaerobes (Prevotella, exam - PID partner should be contacted
Atopobium, Leptotrichia) & ● Abnormal vaginal or cervical discharge - - Offer health advice
Mycoplasma genitalium often purulent - Screening of gonorrhea & chlamydia
● General Measures: - IM Ceftriaxone 500mg STAT
Who Gets PID? ❖ Rest for severe cases - Avoid SI until completed treatment *
- young age <25 ❖ Urine Pregnancy Test (UPT) should be
- Multiple sex partners performed 3. UTERINE PROLAPSE
- Past history of STI ❖ Appropriate analgesia - Also called descensus or procidentia
- Termination of pregnancy ❖ Avoid unprotected intercourse until - Means the uterus has descended from its
- Procedure: Hysterosalpingography (HSG), completed treatment normal position in the pelvis farther down
IVF ❖ Contact tracing to the vagina
- Smoker Treatment; - Due to loss of support by cardinal,
Examinations: ❖ Low threshold for empirical treatment of uterosacral ligaments, levator ani
1. Abdominal Examination - show distention PID
w/ tenderness & rigidity in lower abdomen ❖ Broad spectrum antibiotics to cover:
2. Speculum Examination - show purulent ➢ Neisseria Gonorrhoeae
discharge emanating from the cervical ➢ Chlamydia Trachomatis
canal ➢ Aerobic & Anaerobic Bacteria
3. Bimanual Examination - in an acute stage, ❖ Outpatient
cervical movement tenderness & Regimes:
tenderness in the fornices 1. IV Cetriaxone 2g OD & IV Doxycycline
Long Term Sequelae of PID: followed by T. Doxycycline 100mg OD & T.
● Chronic pelvic pain Metronidazole 400mg BD for 2 weeks Prolapse - organs, such as the uterus, fall
● Infertility OR down or slip out of place
● Ectopic pregnancy 2. IV Clindamycin 900mg TDS & IV Signs & Symptoms:
Symptoms: Gentamicin (2mg/kg loading dose) then ● Pelvic Pressure - feeling of heaviness or
● Can be symptomatic or asymptomatic 1.5mg/kg tds followed by T. Clindamycin pressure in the pelvis
● Lower abdominal pain which is typically 450mg QID or T. Doxycycline 100mg BD & ● Pelvic Pain - discomfort in the pelvis,
bilateral T. Metronidazole 400mg ND for 2 weeks abdomen or lower back
● Fever (>38 deg) Procedures: ● Pain during intercourse
● Deep dyspareunia 1. Laparoscopy - dividing adhesions & ● Protrusion of tissue - from the opening of
● Chronic pelvic pain draining pelvic abscess the vagina
● Abnormal vaginal bleeding - post-coital 2. Laparotomy - digital division of all ● Recurrent bladder infections
bleed, intermenstrual bleed, menorrhagia adhesions & any loculated area of abscess ● Unusual or excessive discharge from
● Abnormal vaginal or cervical discharge - formation vagina
often purulent 3. Ultrasound Guided Aspiration - less ● Constipation
Signs: invasive ● Difficulty w/ urination, including involuntary
● Fever - Can be done if small abscess loss of urine or urinary frequency or
● Lower abdominal tenderness urgency
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 4 Main Kinds of Fistula: ● Pus in the vagina
1. Vesicovaginal Fistula - passage or hole ● Soreness around the genital area
Degree of Uterine Prolapse that forms b/w the vagina & urinary tract ● Foul smelling; vaginal discharge
1. First Degree (Mild) - descent of the uterus 2. Rectovaginal Fistula - forms b/w vagina & ● Pain during secual intercourse
to any point in the vagina above the hymen rectum ● Irritation & discomfort in vagina
2. Second Degree (Moderate) - descent to 3. Colovaginal Fistula - forms b/w vagina &
the hymen the colon 7. FIBROIDS
3. Third Degree (Severe) - descent beyond 4. Enterovaginal Fistula - forms b/w vagina - Benign (non cancerous) growth of the
the hymen & the bowel uterus
- Arise from single muscle cells within the
womb
Cause:
- No known cause
Fibroid Locations:
1. Subserous - most fibroid is located
superficially
2. Submucous - most fibroid is located in the
cavity of the womb
4. RECTOCELE
3. Intramural - most fibroid is located w/ in
- herniation (bulge) of the front wall of the
the muscle of the womb
rectum into the back wall of the vagina
4. Pedunculated - fibroid is attached to the
- tissue between the rectum and the vagina
womb by a stalk containing blood vessels
is known as the rectovaginal septum and
this structure can become thin and weak Causes of Vaginal Fistula:
over time, resulting in a rectocele - Common cause is breakdown of tissue in a
specific area in the organ, Damaged tissue
5. ENTEROCELE forces the fistula to open up
- is the descending of the small intestine into ● Crohn’s disease
the lower pelvic cavity ● Diverticulitis
- When this occurs, the small intestine ● Inflammation in the bowel
pushes on the top part of the vagina, ● Perineum tear after childbirth
creating a bulge. It is a form of pelvic organ ● Ulcerative colitis
prolapse. ● Surgery of the vagina, rectum, or anus
● Infection in the abdomen
6. VAGINAL FISTULA ● Injuries during childbirth Symptoms:
Fistula - abnormal connection that has developed Symptoms: ● Heavy periods - Anemia
b/w two organs in the body o b/w skin and any - Depends upon the size & location of the ● Pressure symptoms:
organ fistula ○ Constipation
Vaginal Fistula - abnormal connection formed in ● Gas released from vagina ○ Frequent urination
the wall of the vagina ● Urine incontinence ○ Difficulty in passing urine

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 ● Infertility A. Serous Cystadenomas Natural Treatment:
● Pain - Common cystic ovarian tumors ❖ Reduce Estrogen
○ Back pain - Multilocular - Stop eating soy foods
○ Pain during sex - Eat only organic meats & dairy
○ Pain during periods B. Polycystic Ovarian Syndrome - Do not microwave foods in plastic
Effects: - Stop drinking water from plastic
8. CERVICAL POLYPS ➔ Type-2 diabetes bottles
- are small, elongated tumors that grow on ➔ High BP - Avoid mineral oil & parabens in
the cervix ➔ Heart diseases skin care products
➔ High body fat - Use natural detergents
➔ Bones & joints problem ❖ Increase Progesterone & Balance
➔ Depression, frustration Hormones
➔ Infertility
➔ Hirsutism
➔ Hair loss, acne, tender breasts
➔ Irregular, painful periods, heavy/ scanty
bleeding

C. Theca-lutein (lutein) Cysts

9. OVARIAN CYST - May develop w/ high hCG levels in patients
- Are fluid-filled sacs or pockets within or on w/ a molar pregnancy
the surface of an ovary - May develop in patients receiving Assisted
Types of Ovarian Cysts: Reproductive Technology (ART) treatment
1. Functional Cysts - normal cyst that shrink for infertility
& disappear w/in 2 or 3 menstrual cycles - Luteoma of Pregnancy
2. Dermoid Cysts - filled w/ various types of - Associated w/ choriocarcinoma
tissues, including hair & skin
3. Endometrioma Cysts - “chocolate cysts” of Signs of Ovarian Cyst:
endometriosis ● Menstrual Irregularities
- Form when tissue similar to the ● Pelvic pain shortly before period begins or
lining of the uterus attaches to the just before it ends
ovaries ● Pelvic pain during intercourse
4. Cystadenoma Cysts - develop from cells ● Pain during bowel movement or pressure
on the outer surface of the ovaries on the bowel
5. Polycystic Ovarian Disease ● Nausea, vomiting or breast tenderness
- Form from a build up of follicles similar to pregnancy
- Cause the ovaries to enlarge & ● Fullness or heaviness in abdomen
create a thick outer covering, ● Pressure on rectum or bladder that causes
which may prevent ovulation from a need to urinate more frequently or
occurring & cause of fertility probs difficulty emptying bladder completely
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