Obstetric and Gynecology Short notes
OBG notes download complete end of the post
Instruments used in delivery
1. Trocar-Insert into abdomen cavity for laparoscopy
2. Uterine sound - Measuring the length of uterocervical canal
3. Bladder sound - Use for cystocele
4. Ethylone - Non absorbable synthetic suture
5.Catgut suture - Absorbable suture (7days)Made by sheep intestine
6.Spounge holding for shape - to hold the gauss
7. Pinards fetoscope / fetoscope - Auscultation of heart sound
8. ovum holding forceps - To remove the product of Conception
9. Rubin's cannula - Device use for infertility
10. Karmans cannula - Use in abortion
11. Kocher's forcep - To clamp the umbilical cord
12. Hegar's dilator - For D & C
13. Doyen's retractor - Use in contraction of bladder
14. Babcock for shape - To hold the tubular structure
15. Allis forcep - Hold the hard structure of body
16. Ayre's spatula- For taking pap smear
17. Artery forcep - Clamp the bleeding vessels
18. Punch biopsy - Take the biopsy for cervical cancer and skin cancer
19. Myoseizure- To cut the suture
20. Mayotrolly - Trolly use for surgery
21. Kelly's forcep - To control bleeding
External Genital (Vulva)
Anterior Structures :
Mons pubis (Mons veneris) :- At puberty Hair present
Perineum :-(Posterior part) (4x4)
Labia Majora (Homologous to scrotum)
Labia Minora :- Excessive nerve supply
Clitoris (Homologous to penis)
Prepuea (Anterior to clitoris)
Hymen :- Occluded-almost half by mucous membrane
Bartholin Gland :- Pea shape, yellowish white colour gland, during intercose secreate alkaline fluid
Skene's duct :- Act as female ejecullation
Vestibular bulb:-Homologos to corpus spongiosum + penis
Opening in Vestibule :
2 ductal opening of bartholin gland
1 ductal opening of urethral opening
1 Vaginal opening
Internal Organ
1.Vagina
Vagina Fibromuscular Organ
Organ of copulation
Organ for passage of menstrual discharge
Birth Canal
Direction - Upward & backward
Anterior wall 7 cm, posterior wall -9 cm in length
Vaginal Fornix-Space between veginal part of cirvix & veginal holl, Total - 4( Anterior, Posterior & 2 lateral)
PH:- Acidic (4-6, due to presence of doderlein bacilli (Lactobacillus acidophilus) The bacilli convert the glycogen into lactic acid
2... Uterus :- Antiversion & anti flexion
Devolpment- mulirine duct
Hollow muscular organ
Pyriform shape
Measurement 7.5x5x2.5 cm (Length : width: thickness)
35x23x10 cm (during pregnancy) (full term)
length : width : thickness
Weigh-60 gm
900-1000 gm in pregnancy
Pregnant Uterus : Soft & elastic
Parts of uterus
Fundus (upper to Fallopian Tube) - It is a site for Implantation Implantation occurs at anterior or posterior site of fundus.
Body (Corpus) :- 3.5 cm
Isthmus :-(Narrow part)-0.5 cm
Cervix - 3 cm
Layers :
1. Perimetrium : Outermost
2. Myometrium : Three layers of muscles-Outer-longitudinal, middle-Interlacing oblique, Inner-Circular layer of muscles
Significance of Interlacing muscle layer: after delivery it cease the supply of blood to the uterus & prevent the PPH
( Living Ligature:-Due to the 8 shape of interlacing muscle )
3. Endometrium: during pregnancy it has three layers
I.Basai Layer- (regeneration of endometrium)
II. Spongy Layer
It is the site of Placental Separation (Cleavage)
III.Compact Layer (Superficial) After Menstrual cycle Regeneration Start- at the Basal Layer
Decidua :-(Endometrium of pregnant woman](Q)
It shed after delivery.
Decidua may be classified into three layers
Decidua Basalis :- Placenta attach to this site.
Decidua capsularis- Layer that surrounds the fetus (parietalis)
Decidua vera-remaining endometrium, lining uterine cavity
3. Fallopian tubes; Shalphinges (Uterine tube]
10 cm length
Parts
Interstitial/Intramural 1-1.25 cm
Isthmus (narrow part) 2.5 cm
Ampulla (largest) 5 cm- site for Fertilization
Infundibulum:-1.25 cm continuous to the fimbriae
Large ovarian fimbriae that transport ovum is ovarian fimbriae
4. Ovary: -2 in number
Size-3x2x1 cm
Shape - oval shape
Intraperitoneal organ
Function-Ovum or Sex hormone production (Mature follicles releases oestrogen harmone, Corpus leutium releases progesterone & oestrogen
Ovum: Largest cell of body (Pinkish gray colour )
Structure of Ovary
1. Ovarian Cortex (Outer vital part):
It is made of Stroma (connective tissue of the ovary) .
Various sizes of follicles are present
One mature follicle: Graffian follicle
2. Medulla-inner structure, Blood Vessel present
Mesovarium-Structure of ovary through which blood vessels & nerve enters in to ovary
Ligaments supporting to the ovary & uterus
Round Ligament
Broad Ligament
Ovarian Ligament
Present HILLUS CELLS (Homologos to interstitial space of tespis)
It resemble leydig cells
Ovarian Cycle
GnRH (Gorado trophic Releasing hormone) secreted by hypothalamus & it stimulate the anterior pituitary gland to release
FSH: It Mature the follicles
Oestrogen hormone released by growing follicles in ovary
Oestrogen act on a pituitary gland to release Luteinizing hormone
LH is responsible for ovulation.
One mature follicle rupture under the influence of LH & releases the ovum. The ruptured follicle becomes corpus luteum . Corpus luteum secretes progesterone: the hormone prepare the endometrium for Implantation
If pregnancy does not occur the corpus luteum converts into corpus albicans.
If fertilization occurs then up to 10-12 weeks oestrogen & progesterone released by corpus luteum.
Pregnancy maintaining hormone-progesterone
Menstrual Cycle
1. Ovarian Phase: responsible hormones are Oestrogen & Progesterone.
Ovarian phase -
(a) Follicular phase-13 days
(b) Ovulation-on 14 days
(c) Luteal phase-15-28 days
2. Uterine Phase (Menstrual Cycle)-LH, FSH & Pituitary Hormone are responsible.
A. Menstrual Phase (4-6 days)
B. Proliferative Phase (9-10 days)
C. Secretory Phase (14 days)
Q.: The hormone responsible for Proliferative phase of menstrual cycle
ANSWER: FSH & Oestrogen
Ovum viable (Life Span)-12-24 hrs.
Sperm Viability-48-72 hrs.
Amenorrhoea :- Absent of menstrual cycle
Metrorragia:- Irregular menstrual cycle
Menorragea :- Menstrual cycle more than 7 days or blood loss more than 80 ml
Oligomenorrhea:- The interval more than 35 days
Hypomenorrhoea :- Blood loss less than 10 ml
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Female pelvis
Type of pelvis :
1. False Pelvis: - Part above pelvic brim
To support the gravid uterus
2. True pelvis :- Lies below the brim
According to shape type of pelvis :
01. Gynecoid pelvis :- Most favorable pelvis for delivery
Round shape
2. Anthropoid pelvis :- Antero-posterior oval shape
3. Android pelvis :- Heart / triangular / wedge shape Male pelvis
4. Platypoid :- transverse oval shape / flat / kidney
shape Angle of inclination :- In erect position female pelvis make 55 /135° angle
Diameter of pelvis :
Antero-Posterior Diameter of intent :
1. True conguitate - Upper part of SP. to midpoint sacral promontory
2. Obstetrical conjugate - Mid point of SP to midpoint of sacral promontory
3. Diagonal conjugate - Lower part of SP to midpoint of sacral promontory
Weste space of morris :-Distance between symphysis pubis & circumference disk
normal less than 1 cm
Contracted pelvis :- Variation in shape and size of normal pelvis
Type of Contracted pelvis
1 :Rachitic pelvis- increased transverse diameter and decreased A-P diameter
2. Kyphotic Pelvis - Excessive funneling pelvis
3. Negeale’s Pelvis - arrest the development of one side ala of sacrum
4 Robert's Pelvis - Both side aia note develop
Suture of fetal skull :-
1. Frontal suture- Between two frontal bone
2. Sagittal suture- Between two parietal bone
3. Lambdoidal suture- In between parietal and occipital bone
4.Squmus suture - Between parietal and temporal bone
5. Coronal suture-Between frontal and parietal tone
A-P Diameter of fetal skull
1. Sub-occipto bragmatic :- most commonly engaging diameter
Fully flexed /universal diameter
Center of brahma to nape of neck
Length - 9.5 cm
2. Sub-occipto frontal :- 10cm
Extend anterior end of brahma to nape of neck
3. Occipito frontal :- 11.5 cm
Extend glabella to occipital eminence
4. Mentovertical :- 14 cm
Highest diameter
Extend mid point of chin to highest point of sagittal suture
5. Sub-mentovertical :- 11.5 cm
Extend junction of floor to highest point of sagittal suture
6. Sub-mentobragmatic - 9 cm
Extend Junction of floor to center of brahma
Bipiratal diameter (9.5 cm):-Space between two parietal eminence
Most common engagement diameter
Supper sub-piratal diameter :- 8.5 cm
By temporal diameter :-8 cm
By mestoied diameter :- 7.5 cm
Fertilization
Fertilized ovum reach in uterus (fundus) in 6 days (from ampulla to uterus) Implantation (Nidation)-11th day of fertilization Zygote (Interstitial implantation)
Blastomere (2 cell structure)
Morula (16 cell structure)
Blastocyst (64 cell structure)
12th day chorionic villi start to form Primary villi - (12-13 days)
Secondary villi- (16 days)
Tertiary villi - (at 21 days) (Feto placental circulation starts)
Hartman's sign :- bleeding during implantation
Placenta
Placenta is made of Chorionic Frondosum & Decidua basalis
Fetal part of placenta is =5/6 part
Maternal part is = 1/6 part
It is 1/6 (500 gm) of newborn's body weight.
Complete formation of placenta occurs at 12 weeks.
Another name of placenta: - Deciduate-Because it shed at the time of delivery.
Hoemochorian-Because it is in direct contact of maternal blood
Discoid-Because of its shape Functions of placenta:
Function of placenta
Respiratory organ
Excretory organ
Nutritive organ
Structure of placenta:
Maternal Surface
Fetal surface (shiny, jelly)
15-20 Cotyledons (1 cotyledons =4-5 major steam villy)
(Rough, dark, projection)
Nursing responsibility: Significant to watch cotyledons after delivery of placenta & PPH diagnosis.
Blood volume in placenta - 500 ml (350 ml villus space and 150 ml intervillous space)
Phagocytic cells of placenta - hofbaur cell
Pressure of fetal and maternal artery :
Maternal artery - 70-80 mm/hg
Maternal vein - 8 mm/hg
Fetal artery- 60 mm/hg
Fetal vein - 10 mm/hg
Pressure of intervillous space -
During contraction - 30-50 mm/hg
During relaxation - 10-15 mm/hg
Placenta bariour :
Syncytiotrophoblast (outer)
Cytotrophoblast
Basement membrane
Stronal tissue
Endothelium of fetal capillary
Two zone of syncytiotrophoblast
I a-zone (Thin) - Gas exchange
2. B-zone (Thick) - Hormones synthesis
Abnormality of placenta -
1. Placenta succenturiata :- A part of the lobe of the placenta is situated away from the margin of main placenta & communicating blood vessels present between both parts.
Complication - PPH
2. Plasenta spuria :- No connection of blood vessels
3. Placenta extrachorialis :
A. Circumvallate placenta - chorionic plate of placenta is smaller than basal plate
B. Placenta marginata - Chorionic plate of placenta is larger than basal plate
Complication - abortion
4. Placenta membrancia :- Large and thin placenta which covers whole embryo
Complication-Growth retardation
Placenta Accreta :- Normal attachment of placenta
5. Placenta Increata :- chorionic villi invade into myometrium
6. Placenta percreta :- chorionic villi invade throw the myometrium Complication- PPH
7. Placenta reflexa :- Placenta margin's are thick & centre are thin
fundamentals of nursing notes key point quickly revision https://www.nursingofficer.net/2021/04/fundamentals-nursing-notes.htmlUmbilical cords (Funis)
Develop from body stalk
Covered by Wharton's jelly
Length-50 cm.
Diameter:-1.5 cm
First trimester (2 artery + 2vein)
at 4th month (2 A +2 vein)
At birth: 2 A+ 1 vein
IA+1V: Indicate Renal agenesis/Genital agenesis adverds syndrom (Overlapping of finger)
Oxygenated blood from mother to fetus is carried by umbilical vein, while Deoxygenated blood from fetus to mother is carried by umbilical artery.
Abnormality of umbilical cord :
Battledore placenta - U. code attached to margins of placenta
Velamentous placenta -U. code attached to fetal membrane
Short code - less than 20 cm
Long code - more than 200 cm
Acordia - absent of U. code (Placenta directly attached to fetal liver)
Life Cycle
Ovulation occurs at 14 day before next menstruation.
Fertilized ovum: 0 to 2 weeks a Division start after 24 hrs.
On 1st day 2 cells structure, Blastomere: 8 cells, Morula: 16 cells on 3rd day, Blastocyst (5th day) (64 cell)
Time of blastocyst to reach the uterus-[6-7 days) o On 6 days after fertilization implantation start
10-11 day implantation complete
Fetal membrane
1. Chorion:Outer layer of fetal membrane ;develop from trophoblast;outer layer of blastocyst & Fussed to decidua vera & reflexa (cyto & syncytiotrophoblast)
Chorion contains no vessel & no nerve supply
Chorion fetal membrane secrete HCG
2. Ammion:Inner layer No blood, nerve & lymphatic supply
Function-formation of liquor amini
Amniotic fluid Volume of amniotic fluid
12 wks - 50 ml
20 wks - 400 ml
38 wks - 1000 ml
40 wks - 600-800 ml
43 wks - 200 ml
Daily production of amniotic fluid=400 ml
Specific indicator of amniotic fluid
Post term(42 wks): amniotic fluid, saffron colour (Greenish yellow)
Fetal distress (Meconium aspiration Syndrome) Green colour
Golden color: Rh Incompatibility
Tobacco Juice(Dark Brownish color): IUD
Dark color: Concealed Haemorrhage
Amniotic fluid-slightly alkaline
Specific gravity =1.010
Osmolality: 250 mili Osmol/ liter
Examination of amniotic fluid :
To examine fetal maturity
To identify any congenital malformations
Fern test -
To determine leakage of amniotic fluid.
Specimen of vagina Test (Fern Like Pattern) + Present → Amniotic fluid + Present.
Position - Dorsal recumbent position.
Instruct Client to cough
Nitrazine test -
To check presence of amniotic fluid in Vaginal secretion
If Amniotic Fluid present in vaginal discharge: Nitrazine strip changes to blue.
Position - Dorsal recumbent position.
Amniotic fluid embolism -Amniotic fluid enters in maternal circulation & deposits in pulmonary arterioles.
C/M - Chest pain & Respiratory distress.
Fetal bradycardia & distress.
Fetal distress, Prepare client for emergency C.S.
Supine hypotension
Place a pillow or wedge under the client's right hip
Fetal circulation
Ductus venosus :- Connection between umbilical vein and IVC
Functional close - Just after birth (within few minute)
Anatomical close - 7 days after birth
7 days after changed ligamentum venosum
Ductus arteriosus :-Connection between pulmonary artery and aorta
Functional close up just after birth
Anatomical close (1-3 month change ligamentum arteriosum
Foramen oval :- Connection between right atrium and left atrium
Functional close - just after birth
Anatomical close- 1 year after change -Fossa ovalis
Pregnancy & its terminology
Reproductive age begins with the age:13-15
years Safe pregnancy : 20-35 year
High risk pregnancy : < 20 year and > 35 year
Nullipara-No baby delivered
Duration of Pregnancy:
Should be calculated from Ist day of LMP
Fertilization or ovulatory age-(Accurate period)
280-14 = 266 days
Gestational Period- 9 Calendar Month/10 Lunar Month /40 weeks/280 days
Negales formula : EDD = L.M.P. + 9 month + 7 days
Gradiva-No. of pregnancy
Parity / Para-No.of delivery after viability (>20 Weeks) either alive/dead(still birth)
If Twin pregnancy is there then Para-1, Gravida-1
Abortion-Expell the product of conception before 20 weeks.
Primipara mother : One baby delivered
Primigravida: First time conceived
Grand Gravida-more than 4 timos conceivement.
Parity - No. of birth past 20 weeks of gestation (After viability).
G- Gravidity (No. of pregnancies)
T- Term birth (> 37 week)
P- Preterm birth (< 37 week)
A- Abortion
L-Live children.
Division of duration of pregnancy:
First trimester for (0-12 weeks); 12 wks.
II trimester for (13-28 weeks); 16 wks.
III trimester for (29-40 weeks); 12 wks.
First trimester weight gain-1 kg.
II trimester weight gain- 5 kg
III trimester weight gain-5 kg
Antenatal Examinations Four Grip
Stand-right side of the patient
Fundal grip- assess lie, presentation
Lateral grip-(umbilical grip)-fetus in left or right side
First pelvic grip-Leopold's IVth maneuver assess Engagement & presenting part
Ilnd pelvic grip-Leopold's IIIrd grip / Pawlic grip-assess convergence & divergence
Non Stress Test
Reactive NST (Normal, Negative)
FHR acceleration of 15 bpm for 15 sec. in 20min. Observestion.
Non reactive (Abnormal)- No acceleration or <15 bpm
(Positive.) in < 15 sec for 40 min. observation
Contraction Stress test :
To check placental O, & function. (Oxytocin Given to stimulate contraction).
Negative (Normal) - No late deceleration of FHR
Positive (Abnormal) - No late deceleration of FHR with 50% or more of contraction in absence of hyperstimulation of the uterus.
Sign of pregnancy
Positive sign of pregnancy
FHS
Active fetal movement by examiner
Sonography finding
Probable
Ballottement
Braxton Hicks contraction
Enlargement of uterus Presence of HCG in urine quickening
Chedwick's sign (Jacquemier sign) -Bluish discolouration of vagina (8 wks.)
Goodell's sign - Softening of cervix (6 week)
Hegar's sign- Softening of lower uterus (6-10 weeks)
Osiander sign- (Pulsation Feel at lateral fornix) (8 week)
Palmer sign -Regular & rhythmic utérine contraction during bimanual examination of mother(4-8 weeks
Dark pigmentation of skin : Chloasma
Presumptive
Mother feeling
Morning sickness
Quickening
Lighting
Amenorrhoea
Subjective changes
1. Amenorrhoea 2. Nausea & vomiting 3. Fatigue, anorexia 4. Frequency of urine
Breast discomfort & heaviness 6. Heartburn(Pyrosis)
Objective changes
FHS by doppler method can be heard at 10 weeks
Presence of Montgomery tubercles at breast
Upper part of the uterus is enlarged by the growing fetus.
Lower part of the body is empty & soft.
Changes during second trimester of pregnancy
(13-28 weeks, IInd Trimester Weight.gain : 5kg)
Amenorrhoea
Cutaneous changes (hyperpigmentation)
Cloasma gravidarum (face mask) (pigmentation of cheek, forehead)
Linea nigra (dark line from xiphoid process to pubis )
External ballotment -10-12 weeks
FHS (18-20 weeks) by fetoscope
Quickening-18 weeks
Palpation of fetal parts-20 weeks
Braxton Hicks contraction
III Trimester:- 29-40 weeks. Wt. gain-5 kg.
Cutaneous Change more prominent
Amenorrhea continue
Fundal height - increases
Lightening occurs at 36 to 38 weeks
Frequency of urination
In pregnancy Nausea, vomiting-Due to HCG.
In pregnancy constipation, heartburn, flatulenceDue to progesterone.
To prevent heartburn-Sitting upright for 30min after meal.In pregnancy gum bleeding, ptyalism (Excessive salivation)-due to Estrogen. Total weight gain = 1 +5+5 = 11 kg,
IV Trimester-Puerperium; Duration : 42 days
Reproductive part of weight gain:5.5 kg
Fetus- 2.5-3 kg
Placenta- 0.5 kg
Amniotic Fluid-800-1000 ml, ( Uterus- 1 kg
Maternal part of weight gain:5.5 kg
Volume-2-2.5 litre
Blood 1-1.5 L
Intracellular 1-1.5 Lir
Deposition of fat (3-3.5 kg)
Breast-400 gm "
Mammogenesis-Enlargement of mammary gland
Lactogenesis-Production of milk
Galactokinesis-Ejection of milk
Galactopoiesis-Maintenance of Lactation
Uterus Size & shape during pregnancy
Pyriform-Non pregnant
Globular-at 12 wks
Hen's egg-6 weeks.
Cricket ball-8 weeks.
Fetal head-12 weeks. (into pelvic cavity)
Uterus B/w symphysis pubis & Umbilicus-16 weeks
Fundus at umbilicus in 22-24 weeks.
Maximum fundal height-36 weeks. xiphoid process "
Length: 36 cm; symphysis pubis to xiphoid process.
At 38 weeks lightning of fetal Head occurs & uterine length becomes equal to 32 weeks.
If Head flot; the gestational period is 32 weeks "
If head fixed - 40 weeks
Embryonic development
At 3 week-heart begins to beat.
The heartbeat is detected by a doppler transducer --b/w 10 to 12 week.
Heart beat detected by fetoscope at 20 week.
At 24 week-Fetus has the ability to hear.
At 28 week (L/S forms) & lungs are developed sufficiently to provide gas exchange.
At 32 week-L/S ratio 1.2: 1.
At 36 week-L/S ratio > 2:1.
FHR (In I trimester) 160 to 170 bpm.
FHR (In II & III trimester) 120-160 bpm.
(at term) Lie is the relationship b/w fetal & maternal axis
(it is a relationship between fetal spine & maternal spine)
Commonest Lie-Longitudinal
Presentation : Part of fetus that occupy the lower uterine segment.
a Breech: Podalic
Commonest-Cephalic-(Vertex, face)
Presenting part : Part that comes to contact with the pelvic floor.
Attitude :- Relationship of fetal body parts to each other
common attitude -flexion attitude
position
Fundal height of mother is measured Dorsal recumbent position
Sim's-Catheterization, Card prolapse (b)
Lithotomy-Delivery
L. Lateral-enema, before Liver biopsy,
R. Lateral-after liver biopsy
Trendelenberg - pelvic surgery, hypotension : Abruptio placenta
Prone-neural tube defect (Pre & post operat)
Cardiac-Cardiac Pt. asthma
Knee chest-TOF, cord prolapse
Puerperium :
Duration: 42 days(6 weeks)
IV Trimester of pregnancy
6 Weeks after delivery
Minimum Recommended antenatal visits - 4
Ist visit should be advised at 16 weeks
IInd visit - 24 weeks
IIIrd visit - 28 weeks
IVth visit - 36 weeks
Ideal visits :
Up to 28 weeks. Once in each month: total -7
8, 9 months in every 15 day; Total - 4
After 9 month-one in each week Most common time of delivery
2 week before EDD or 1 week after EDD
Investigations in First antenatal visit
History, Physical Examination, Urine, Blood-Hb,Height, B.P.
Advise in antenatal period:
Nutrition :
Pregnancy + 300 cal
Lactation: + 500 to 600 cal
Supplement : IFA
Folic acid-prevent neural tube. Folic acid is given to a woman before pregnancy.
Folic acid should be started at least 2 months before pregnancy & up to 3 months after pregnancy Doses : 0.4 mg/day
Iron : One Tab.- 60 mg elemental iron
Q.: What diet a nurse will advice to a pregnant having hyperemesis gravidarum
Ans. Biscuit & Toast with tea, milk before bed Not fatty food should be given
Vaccination :
TT at Deltoid muscle
Ist dose, 0.5 ml as soon as pregnancy diagnosed;
Ilnd dose : 4 weeks after first dose
Live vaccines should be avoided during the antenatal period because viruses may cross the placenta.
Minor Element of pregnancy
Nausea/Vomiting :-Due to HCG
Constipation :- due to progesterone
Heartburn (Pyrosis)- due to projectrone
Ptyalism - due to oestrogen
Excess vomiting in pregnancy-Hyperemesis gravidarum
Rubella Vaccine :
If client has titer (< 1:8), Susceptible to rubella, give vaccine in postpartum period. Advised for not becoming pregnant up to 1-3 month of Immunization.
Avoid contact with Immunocompromised people.
Not give Rho (D) Ig, bcoz it reduces effectiveness of rubella vaccine.
Rubella-live attenuated virus- So do not give during pregnancy, It crosses placenta & risky for fetus.
To detect syphilis :
VDRL (Venereal Disease Research Laboratory)
RPR (Rapid Plasma Reagine) Test.
USG/Chorionic villus sampling/Amniocentesis (Before 20 week)
In all these, drink water before the test to distend the bladder, to obtain a better Image of the fetus.
Informed Consent should be taken before above said sampling
Position during Amniocentesis: supine.
After Amniocentesis Position: left Side
Complication of Amniocentesis - Amniotic fluid Embolism
After CVS & amniocentesis; If chills, fever, bleeding, leakage at needle site, ved fetal movement, cramping occurs = Notify the physician.
Kleihauer Betke test
It is done to detect presence or fetal blood in maternal circulation & to Identify for need of
additional Rho (D) Ig in Rh negative mothers.
Antenatal examinations :'
Chorionic Villus Sampling : 10-12th weeks
Amniocentesis !4-16 weeks
Cordocentesis 18-20 weeks
Serum AFP (Alpha fetoprotein):To diagnose
Trisomy of 21 Chromosome
NTD
Down syndrome- Advice the antenatal mother for triple test
Triple Test :AFP + HCG+Unconjugated oestriol
Treat the TORCH infections in pregnancy
T - Toxoplasmosis
O - Others-Syphilis VDRL, STD
R- Rubella C-Cytomegalo Virus (congenital cardiac defects)
H - Herpes
Trichomoniasis :
(Trichomonas Vaginalis)
Yellowish to greenish, frothy, mucopurulent,copious, malodorous vaginal discharge.
Bacterial Vaginosis :
(Haemophilus Vaginalis).
Fishy odour of vaginal secretion.
Vaginal candidiasis :
(Candida Albicans)
White, lumpy, cottage cheese-like discharge by vagina. .
Intranatal period
Normal Labour (Eutocia): Product of conception comes out through Vagina.
Precipitated labour -very fast process; labor completes within 3 hours Delivery: product of conception Comes out either vaginally or Cesarean
Dystocia: Abnormal labor
Labour Pain: may be True / Fals
Show :- Vaginal Cervical discharge + Blood
Phases of Labour
Ist Phase of labour
'1. Latent phase :- 1-4 cm cervical dilatation.
2. Active phase :- 4-7 cm cervical dilatation
3. Transient phase :- 7-10 cm cervical dilatation
Duration :- Primi-12 hours.
Multipara:- 6 hours,
First phase begins with Onset of true labour pain and ends to complete cervical dilatation
Partograph should be maintained in first stage of labour,
Changes during first phase
Pain
Braxtan Hick contraction
Cervical dilatation & effacement
IInd Phase :
It begins with Complete Cervical Dilatation to expulsion of fetus
Primi-2 hour, * Multi-30 minutes
IIIrd phase- Expulsion of fetus to placenta removal
Duration: 15 minutes to 30 minutes
IVth Phase Observation after delivery of placenta.
Management during first stage
Maintaining Partograph: It is described by Friedman (1954)
Partograph Detect
1. Cervical Dilatation
2. Descent of Head (Station) Range :- 5 to +5
0 = Fetal head is to the level of ischial spine
-1, -2, -3 above the Ischial Spine.
+-below Ischial Spine.
Cervical dilatation measured with finger & written in centimeter f One finger = 1.25 cm dilatation
Ilnd Phase of Labour : Mechanism of labour
Step-I : Engagement (in Brim)-at 38 weeks. Biparietal suboccipitobregmatic
Step-II : Descent
Step-III : Flexion
Step-IV : Internal rotation-90° (2/8 Angle)
Step-V : Extension : Phase in which Head Delivered
Step-VI : Restitution : head rotate 45° opposite to internal rotation (1/8 Angie)
Step-VII : External Rotation: head rotate 45 opposite to internal rotation
Step-VIII : Expulsion: laterally
Nesting :- Sudden burst of energy in mother before 24-48 hour of labour. :
Management of IInd phase :
Positioning: Lithotomy
Clean with dry Prewarm towel
Take APGAR score: I minute apgar score,
Ind at the 5 minute
Minimum score - 0
Maximum score-10
Score: 7-10 =Normal
4-6 = Birth Asphyxia
0-3 = Severe asphyxia
Clamping of Umbilical cord :
By Koecher's forceps.
At 2 places first clamp 2.5 cm above the umbilicus, second clamp should be 2.5 cm above first.
Keep in mind the 3C: Clean surface, Clean hand, Clean article
Q.: Disease characterised by 3C 3 C - Cyanosis,Coughing Choking
Ans: TEF
Episiotomy
Procedure done in II phase of labour to facilitate the expulsion of the fetus.
Provide perineal care using clean technique.
Give sitz bath
Apply Ice packs on perineum.
Not apply vacuum suction device on head for > 25 min
Amniotomy assists in Increasing Efficiency of contraction.
After an anatomy assessment for the FHR pattern.
During labour on fetal monitoring, if episodic acceleration present- Nurse's action Document finding because acceleration occurs with Contraction & Indicate fetal well being. Oxytocin Given during labour & if hypertonic Contraction occurs than Priority action
(1) Stop oxytocin, (2) Reposition client., (3) Check B.P., (4) Give 0, (8-10 L/min) by mask. (5) Perform vaginal Examination, (6) Give indication
to Uterine activity.
Priority in umbilical cord prolapse:
(1) Elevate the fetal presenting part that is lying on the cord by applying fingers with a gloved hand.
Give trendelenburg, modified sim's or Knee chest position
Give oxygen (8 to 10 L/Min.)
Monitor FHR
. IIIrd Stage (Placental separation)
After Placental Separation; Uterus becomesFirm (hard)
Types of placental separation -
Central separation (Schultz)
Marginal separation (Methwe Dunken method)
Nurse's Responsibility Inspect-cotyledon, if cotyledons are missed it can cause PPH
IVth stage :
Liquid (Hot) should be given because mother may feel hunger
Rooming in :
Mother & newborn should keep in close contact with each other.
Purpose-lactation
Induction of labour :
Initiation of uterine contraction, give oxytocin.
Stop oxytocin (Pitocin) Infusion if uterine contraction frequency < 2min. & duration > 90 sec. or If fetal distress present.
Lochia
Discharge upto 15 days
Amouni : 250-350 ml
Lochia Rubra - 0-4 day (RBC)
Lochia Serosa- 5-9 day (Serous Fluid)
Lochia Alba - 10-15 day (White-WBC)
Duration of Lochia: Normal upto 3 week
If > 3 weeks -Indicate infection
Odour - Fishy smell
Malodorous. Indicate Infection
Ph: Alkaline
Involution
Reproductive organs return to the state of Pre pregnant Stage by retraction mechanism Most Crucial Phase - Phase III because of chance of PPH
Involution of uterus :
Uterus Returns to a non-pregnant state.
More fast in breast feed women bcoz oxytocin release
1 cm per day Involution occurs.
By 10 day postpartum uterus can't palpated abdominally
Flaccid Fundus: - Indicate atonicity (Massage fundus)
Tender Fundus - Indicate Infection,
Postpartum complication
Cystitis :-- Infection of bladder.
Burning & pain on urination.
increased Frequency of urination,
Costovertebral angle tenderness.
Lower abdominal pain, fever
Obtain urine specimens for culture & Sensitivity before initiating antibiotic therapy.
Priority Nsg. Action-Encourage fluid intake (3000 ml/day)
Hematoma :- Life threatening condition.
Vulvar hematoma :Most common Apply Ice to reduce swelling
C/M :- Abnormal severe pain & pressure in perineal area.
Bulging mass present, Inability to void.
decreased Hb value.
Sign of shock -decreased B.P., increase HR ., pallor
Hemorrhage -
Bleeding > 500 ml. after delivery.
In the Postpartum period, the primary cause of maternal mortality & require early intervention.
PPH :- Most common cause-Uterine atonicity. (Massage fundus to The tone of uterus)
Early sign- Restlessness. increased pulse rate.
Late sign -decrease B.P.
Infection :- within 25 days of delivery.
S/S -Fever,increase temp > 100.4°F in 24 hour or after 24 hours
Chills, Anorexia, increased WBC.
Malodorous Vaginal discharge.
Diet :- Nutritious, high calorie & high protein diet.
Pulmonary embolism
Due to thrombus in Uterine or Pelvic vein, DVT.
S/S - Sudden dyspnoea & chest pain.
Tachypnoea & Tachycardia.
Cough & lung crackles, Hemoptysis,
Feeling of impending doom (Feel extremely bad is going to happen).
Initial Nsg. Action - Give Oxygen 8-10 L/min, by facemask.
Position :- Head Elevated.
Thrombophlebitis :
Pelvic [Pulmonary embolism-I sing
Superficial (TPRW)
Femoral
Redness, pain, tenderness, warm
+ve Homan Sing S/S - Severechills or increase body temp.
Shrink white skin over the affected area.
Heparin Sodium may be given to prevent further thrombus formation
Intervention :
Elevate affected leg.
Never massage leg.
Avoid leg crossing: prolonged sitting, constrictive clothing, pressure behind knee.
Subinvolution :
A condition when reproductive organs do not return to their previous anatomical location & functioning or take a longer time to revert back. Uterus larger than expected.
S/S :- Uterine pain on palpation, more vaginal bleeding
Elevate legs to promote venous return.
Give methergine for sustained contraction
Crowning = head visible at vaginal Orifice
Retraction-Permanent shortening of muscle fiber.
Contraction-Shortening of muscles fibers but not permanent
Moulding-overlapping headbone : Spontaneously disappear at 2-3 days
Bleeding in early pregnancy
(< 20 weeks)
Causes may be
1- Hydatidiform mole (vesicular mole):
It is a benign growth of trophoblast type
Tumor benign, may be malignant
Grape like structures comes out through vagina,
Bleeding per vagina -brownish
Type :
Complete Partial
Embryo Absent Present
Uterine size > pregnancy week < pregnancy week
HCG >50,000 mini IU/ml <50,000 mini IU/ml
Thecalutein cyst Present Absent
Clinical manifestation :
Abdomen pain
Red and brown veginal discharge
Pain veginal bleeding
Expulsion of grape like structure
Complication :- Coriocarcinoma
Rx :- Suction and evacuation
NSG :- Advise the mother to conceive within 1 year
2. Ectopic pregnancy:
Implantation does not occur at the anterior or posterior wall of the fundus of the uterus.
Common site : Tubal pregnancy; mostly ampulla.
Before 12 weeks: colicky pain, Vaginal bleeding (Placental ;Ist trimester bleeding )
Syncope loss of conscious if tube rupture
Vaginal Spotting to bleeding Dark red or brown).
Methotrexate (Folic acid antagonist) is given to Inhibit cell division in embryo
3.Abortion
Bleeding per vagina before 20 weeks of gestation.
Spontaneous
Methods of abortion :
1. Chemical method : Mafepristone, PGE
2. Vacuum
3. D & E/C
Type of abortion :
1. Complete abortion : Complete product expells from uterus
C/M :- Subside pain
Absent vaginal bleeding
close the cervical oss
2. Incomplete abortion : Some part of conception retains in to uterus, while most of the part expelled
Vaginal bleeding present
Pain in lower abdomen
3. Missed abortion (Silent abortion) :- Death of fetus in uterus
Brown colour vaginal bleeding.
Absent of S/S of pregnancy
4. Threatened abortion :
Continuous of pregnancy is possible
Painless slightly bleeding
Dull nature abdominal pain
can be prevented by active management
5. Inevitable abortion-abortion occurs after active management
Increase amount of vaginal bleeding
Painful red colour bleeding
Pain in lower abdomen
6. Septic abortion :- Due to infection
After 24 hours increasing body temperature
Offensive vaginal discharge
7. Recurrent/Habitual abortion :- > 3 time spontinous abortion
Late Bleeding in pregnancy
Bleeding after 28 weeks of gestation,
1. - Placenta Previa- Placenta Implant at lower uterus :
I. Low lying, level-1:- Only marginal part attach to lower uterine segment
II. Marginal , level-2 - Placenta comes in touch of margins of internal oss
III. Incomplete, level-3 - Placenta cover internal oss than its close but partly cover vein it diluted
IV. Complete, Level-4 .- Placenta cover internal oss completely even after dilation
Most Severe-Posterior marginal (Level-2, Posterior)
C/M- Sudden recurrent painless bright red colour bleeding
• Stallworthy's sign -down Fetal heart rate during compression of fetal head into pelvis
NSG :-Never attempt vaginal examination
Position - Left lateral /Semifowlers
Complete bed rest
2. Abruptio Placenta - Immature Separation of placenta.
Three types
:I. Revealed - Bleeding externally visible (most common abruptio placenta)
II. Concealed :- Bleeding externally not visible (most dangerous condition)
III. Mixed :- Sub blood loss externally visible and some blood internally accumulation
CM:- Dark red colour painful vaginal bleeding
Tender uterus
Position - Trandleburg position
Fibrine knot's present in hepatic sinusoids
Provide trendelenburg position to avoid fetal compression by placenta
Q. A Mother at 32 weeks of gestation comes to casualty with severe abdominal pain with dark per vaginal bleeding, most accurate position given by a nurse
Ans. Trendelenburg position
Postpartum Haemorrhage : Blood loss > 500 ml after delivery, so cause a condition that leads decrease BP and Hypovolemic shock
C/M:-1st sign - tachycardia
late sign - hypotension
Causes-Multigravida
Atonicity of uterus-most common cause: oxytocin should be given to increase uterine contraction
Primary PPH: Start within 30 minutes after placental expulsion.
Traumatic PPH:
Secondary PPH:-due to infection
Management -
Vaginal packing
Uterine artery ligation
Endometritis:
Infection of uterine lining in Postpartum period.
Caused by bacteria Invade the uterus
Infection may cause peritonitis or pelvic thrombophlebitis
S/S -- Chills, fever,
Tender, large uterus,
Foul odour of lochia or reddish brown lochia,
Position:
Fowler's to facilitate drainage of lochia.
Disorders during pregnancy
PIH
Hydramnios
Precipitated v/s prolonged labour
D.M.
DIC :- Disseminated Intravascular coagulation.
Clotting cascade activate, Intravascular clot formation
platelet & clotting factor.
Bleeding/Vascular occlusion Thrombɔemboli formation in blood.
C/M :- Bleeding,
Renal failure (Complication) of DIC - So check for urine output (should not less than 30 ml/hr)
Pregnancy induced hypertension (PIH)
1. Preeclampsia :
increased BP
Proteinuria - Late appearance
B.P. Oedema Proteinuria
Ankle Oedema-Early morning appearance
Headache - Vision disturbance
Oligurie
Indigestion :- Serum uric acid-> 4.5 mg per day)
2. Eclampsia :-Preeclampsia + seizures, B.P. 140/90 MmHg
Drug of choice : Mgso4 (Dose=4-6 gm/4hour)
The normal therapeutic level of MgSo, in blood -4-7 meq/liter
Action: management of fits
· Antidot : Calcium gluconate (10ml:10mg:10minute)
HELLP Syndrome of PIH
H - Haemolysis
EL - Elevated liver Enzyme
LP-Low platelets
Complication of MgSo4
decres Deep tendon reflex
Respiratory depression
Cardiac arrest
Priority action after seizure episode -
Maintaining airway- (Suction) Suctioning should be done at first mouth than nose
During Seizure mouth gag should not used
Restraint should not used during seizure episode
Hydramnios
Oligohydramnios- <200 ml at term
Polyhydramnios >2000ml
Diabetes Mellitus :Gestational DM :
In II & III trimester placental hormones cause Insulin resistant state, requiring an increased Insulin dose.
Fetus produce Insulin & take glucose from mother, with predispose mother for hypoglycemic
Newborn- Macrosomic.
At Risk- Hypoglycemia, Hyperbilirubinemia, RDS, hypocalcemia, Congenital anomalies.
Oral hypoglycemic agents are never given during pregnancy.
Baby becomes macrosomic (larger than normal) & Hypoglycemic
Q.: Safe period for X-ray in tuberculosis to pregnant mother Ans. After 20 weeks
Safest drug :1. Isoniazid
Side effect :- Peripheral, neuritis, to prevent neuritis VitB6 (pyridoxine) should be given
HIV: - Give zidovudine to pregnant women after 14
week's gestation to prevent maternal to fetal transmission
During labour - Give IV.
In the form of Synup to newborn for 6 weeks after birth.
Test:
ELISA, Western blot & Immunofluorescenceassay (IFA)
Confirmatory test (Reform after ELISA is +ve)
Q.: Highest Risk of HIV transmission is- During Intrapartum period - Through birth canal
All newborn of HIV +ve mother having HIV +ve antibodies from mother but not necessary Infection.
Up to 18 month antibodies persist in the newborn.
HIV +ve mother-Give bottle feeding to newborn Infant
Newborn of HIV +ve mother :
Intervention :
(1) Give zidovudine upto 6 week. (Syrup from).
(2) Bath neonate before Invasive procedure.
(3) At risk for Pneumocystis Jiroveci/Carinii Infection.
(4) Live vaccine not administered & scheduled to follow properly.
During Labour :
Maximum chances of spread of HIV from mother to fetus.
HIV Virus :- Retrovirus
During breastfeeding-HIV may be transmit into newborn
Maximum chance of HIV transmission from mother to child is Breast feed + supplementary food given
Chances are very less if exclusive breast feeding is given, because mother's milk make protective layer against virus in child's GIT
Screening of AIDS-ELISA Test
Confirmation test Western blot test
Anaemia
criteria of anaemia < 10 gm/100 ml/dl
Physiological anaemia- due to haemodilution; fluid increases in pregnancy (2.5-3 litre)
Anemia :-Hb10gm/dl & hematocrit < 30%.
Take Iron + Vit C & citric fruit to increase absorption.
Avoid Iron intake of tea & milk.
Folic acid supplement is given in A trimester bocz organogenesis occurs in this. Iron supplements given in II trimester bocz due to vomiting, Not absorbed in 1st trimester.
Rh incompatibility
If mother Rh Negative Fetus: Rh Positive
Ilnd baby is at more risk
Give Anti-D Immunoglobulin; Doses:befor 12wk 50 mg Rout: IM
Time: within 72 hrs, after delivery or be After 12 weeks of gestation: 300 mg (within three dose) given
Tocolytic drugs :- Uterine relaxants
It is given in case of precipitated & Pre term labour
Eg. salbutamol
Lecithin Sphingomyelin ratio at term: > 2:1 Indicate Lung Maturity
Corticosteroids (Betamethasone)- Given to Mother to make lung mature
Also give to baby after birth (Instill in trachea)
In cord prolapse:
1. Modified Sim's Position 2. Knee-Chest Position 3. Trendelenburg Position
Episiotomy :
Commonest; Mediolateral
Sitz bath should be given (105-1109) F-after 24hours
If hematoma form in episiotomy: Ist 24 hour-Cold application (Ice pack)
After 24 hour-hot application
After delivery up to 24 hours bradycardia & hyperthermia is common findings.
Within 24 hr delivery - Hyperpyrexia (100.4°F)
Delivery BradyCardia (50-80)
Q.: A Peurpera's pulse is 55 bpm, 2 hrs after delivery what a nurse should do
Ans: It is considered as normal, watch constantly
Puerperal Pyrexia
24 hrs-10 day after delivery
Puerperal sepsis-infection is the common cause
Leg cramps in pregnancy-
Due to altered calcium-Phosphorus balance & presser of the uterus on the nerve.
Management : (1) increase Ca+ & vit D intake.
Kick Counts:
Counted inside the lying position.
Place Mother hand on fundus.
10 kicks in 12 hours is normal, If below notify Physician
Drugs Use in pregnancy :
Tocolytic
Function - Decrease uterine contraction
Use in preterm labour
Don't use after 37 week of pregnancy
(A) Prostaglandin inhibitor - Indomethacin 50 mg oral
→ Prevention for preterm labour
(B) MgSO4, Use - Eclampsia and preterm labour
(C)Nifedipine/Amlodipine - Calcium channel blocker
Antihypertensive drug → Dose - 10-20 mg/4 hours
(D) Terbutaline - It is bronchodilator
Decrease contraction
It is a antidote of oxytocin
Dosc- .25mg slc infiction Q4H
2. Anticonvulsant drug :(A) MgSO4; (B) Diazepam - 20-40 mg/IV. (C) Phenytoin - 10 mg/kg/body weight
3. Anticoagulants -
(A) Heparin- Route - SIC Dose - 5000-10000 IU.IV
Antidote - Protamine sulphate
(B) Warfarin :- Dosel- 10 mg oral
Antidote - Vitamin-K
Conradi syndrome-Warfarin toxicity to fetus- Facial and skeletal abnormality
4. Antihypertensive drug :
(A) Methyldopa - 250mg, first choice of drug
Contraindication in puerperium, it cause depression
(B) Labetalol- 100 mg
C) Nifedipine-10-20mg
(D) Sodium nitro fruside - only use hypertensive crisis
(E) ACE- Inhibitor - Captopril (6.25 mg)
It should be avoided in pregnancy after 12 week and before crowning of head because it cause fetal renal failure
5. Oxytocics drug :
Increase uterine contraction
(A) Oxitocina/Pitocin :Does - 10 IU
Uses - MTP,Abortion Expulsion of vesicullar mole, stop bleeding after D&C Induction of labour
(B) Ergot derivatives
Ergometrin - It should not use in induction of labour and abortion, it cause utrine spasm
Methergine - don't use in preeclampsia and eclampsia
Useful to all nursing exam & it's best contact.thank you!!!
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