Labor and Delivery

1. Different Methods of delivery:

1.)     birthing chair – bed convertible to chair – semifowlers

2.)     birthing bed – dorsal recumbent pos

3.)     squatting – relives low back pain during labor pain

4.)     leboyers – warm, quiet, dark, comfy room. After delivery, baby gets warm bath.

5.)     Birth under H20 – bathtub – labor & delivery – warm water, soft music.

IX. Intrapartal Notes – inside ER

A.            Admitting the laboring Mother:

                                Personal Data: name, age, address, etc

Baseline Data: v/s esppecially BP, weight

Obstetrical Data: gravida # preg, para- viable preg,  – 22 – 24 wks

Physical Exams,Pelvic Exams

B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor

1.) uterine stretch theory ( any hallow organ stretched, will always contract & expel its content) – contraction action

2.) oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin

3.) prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction

4.) progesterone theory – before labor, decrease progesterone will stimulate contractions & labor

5.) theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset labor).

b.2. The 4 P’s of labor

1. Passenger

a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.

Bones – 6 bones  S – sphenoid         F – frontal - sinciput

                                E – ethmoid          O – occuputal - occiput

T – temporal         P – parietal  2 x

Measurement fetal head:

1.       transverse diameter – 9.25cm

-          biparietal – largest transverse

-          bitemporal 8 cm

2.       bimastoid 7cm smallest transverse

Sutures – intermembranous spaces that allow molding.

1.)     sagittal suture – connects 2 parietal bones ( sagitna)

2.)     coronal suture – connect parietal & frontal bone (crown)

3.)     lambdoidal suture – connects occipital & parietal bone

Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis

Fontanels:

1.)     Anterior fontanel – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after birth- close

2.)     Posterior fontanel or lambda – triangular shape, 1 x 1 cm. Closes – 2 – 3 months.

4.) Anteroposterior diameter -

suboccipitobregmatic 9.5 cm, complete flexion, smallest AP

occipitofrontal 12cm partial flexion

occipitomental – 13.5 cm hyper extension submentobragmatic-face presentation

2. Passageway

Mom      1.) < 4’9” tall

2.) < 18 years old

3.) Underwent pelvic dislocation

Pelvis

4 main pelvic types

1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy

2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow

3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow

4. Platypelloid – flat AP diameter – narrow, transverse – wider

b. Pelvis

2 hip bones – 2 innominate bones

                3 Parts of 2 Innominate Bones

                                Ileum – lateral side  of hips

- iliac crest – flaring superior border forming prominence of hips

Ischium – inferior portion

                                                - ischial tuberosity where we sit – landmark to get external measurement of pelvis

Pubes – ant portion – symphisis pubis junction between 2 pubis

1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis

1 coccyx – 5 small bones compresses during vaginal delivery

Important Measurements

1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis.

                Measurement: 11.5 cm  - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Measurement: 11.0 cm

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

Tuberoischi Diameter – transverse diameter of the pelvic outlet. Ischial tuberosity – approximated with use of fist – 8 cm & above.

3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor

a. Involuntary Contractions

b. Voluntary bearing down efforts

c. Characteristics: wave like

d. Timing: frequency, duration, intensity

4. Psyche/Person – psychological stress when the mother is fighting the labor experience

a. Cultural Interpretation

b. Preparation

c. Past Experience

d. Support System

 Pre-eminent Signs of Labor

S&Sx:

- shooting pain radiating to the legs

- urinary freq.

1. Lightening – setting of presenting part into pelvic brim - 2 weeks prior to EDD

* Engagement- setting of presenting part into pelvic inlet

2. Braxton Hicks Contractions – painless irregular contractions

3. Increase Activity of the Mother- nesting instinct. Save energy, will be used for delivery. Increase epinephrine

4. Ripening of the Cervix – butter soft

5. decreased body wt – 1.5 – 3 lbs

6. Bloody Show – pinkish vaginal discharge – blood & leukorrhea

7. Rupture of Membranes – rupture of water. Check FHT

Premature Rupture of Membrane ( PROM)  - do IE to check for cord prolapse

Contraction drop in intensity even though very painful

Contraction drop in frequently

Uterus tense and/or contracting between contractions

Abdominal palpations

Nursing  Care;

Administer Analgesics (Morphine)

Attempt manual rotation for ROP or LOP – most common malposition

Bear down with contractions

Adequate hydration – prepare for CS

Sedation as ordered

Cesarean delivery may be required, especially if fetal distress is noted

Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina.

Danger signs:

PROM

Presenting part has not yet engaged

Fetal distress

Protruding cord form vagina

Nursing care:

1. Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy.
2. Slip cord away from presenting part
3. Count pulsation of cord for FHT
4. Prep mom for CS

Positioning – trendelenberg or knee chest position

              Emotional support

Prepare for Cesarean Section

 Difference Between True Labor and False Labor

False Labor	True Labor
Irregular contractions No increase in intensity Pain – confined to abdomen Pain – relived by walking No cervical changes	Contractions are regular Increased intensity Pain – begins lower back radiates to abdomen Pain – intensified by walking Cervical effacement & dilatation * major sx    of true labor.

Duration of Labor

Primipara – 14 hrs & not more than 20 hrs

Multipara – 8 hrs & not > 14 hrs

Effacement – softening  & thinning of cervix. Use % in unit of measurement

Dilation – widening of cervix. Unit used is cm.

Nursing Interventions in Each Stage of Labor

2 segments of the uterus

1. upper uterine  - fundus

2. lower uterine – isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix.

Latent Phase:

                Assessment:          Dilations:  0 – 3 cm   mom – excited,  apprehensive, can communicate

                                                Frequency:  every 5 – 10 min

                                               Intensity mild

                Nursing Care: 

1. Encourage walking - shorten 1^st stage of labor
2. Encourage to void q 2 – 3 hrs – full bladder inhibit contractions
3. Breathing – chest breathing

Active Phase:

Assessment:          Dilations 4 -8 cm                 Intensity: moderate   Mom- fears losing control of self

                                Frequency    q 3-5 min lasting for 30 – 60 seconds

Nursing Care:

M – edications – have meds ready

A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.

D – dry lips – oral care (ointment)

       dry linens

B – abdominal breathing

Transitional Phase:                                                             intensity: strong     Mom – mood changes with hyperesthesia

Assessment: Dilations 8 – 10 cm

                Frequency   q 2-3 min contractions

                Durations     45 – 90 seconds

Hyperesthesia – increase sensitivity to touch, pain all over

       Health Teaching :    teach: sacral pressure on lower back to inhibit transmission of pain

keep informed of progress

controlled chest breathing

Nursing Care:

T – ires

I – nform of progress

R – estless support her breathing technique

E – ncourage and praise

D – iscomfort

Pelvic Exams

Effacement

Dilation

a. Station – landmark used: ischial spine

- 1 station = presenting part 1cm above ischial spine if (-) floating

- 2 station = presenting part 2 cm above ischial spine if (-) floating

  0 station = level at ischial spine – engagement

+ 1 station = below 1 cm ischial spine

+3 to +5 = crowning – occurs at 2^nd stage of labor

b.  Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother

                                                -spine of mom and spine of fetus

Two types:

b.1. Longitudinal Lie ( Parallel)

cephalic -               Vertex – complete flexion

                                Face

                                Brow      Poor Flexion

                                Chin

Breech -                 Complete Breech – thigh breast on abdomen, breast lie on thigh

                                Incomplete Breech – thigh rest on abdominal

                                Frank – legs extend to head

                                Footling – single, double

                                Kneeling

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

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

Variety:

Occipito – LOA left occipito ant  (most common and favorable position)– side of maternal pelvis

LOP – left occipito posterior

LOP – most common mal position, most painful

ROP – squatting pos on mom

ROT

ROA

Breech- use sacrum                             LSA – left sacro anterior

- put stet above umbilicus                  LST, LSP, RSA, RST, RSP

Shoulder/acromniodorso

LADA, LADT, LADP, RADA

Chin / Mento

LMA, LMT, LMP, RMP, RMA, RMT, RMP

Monitoring the Contractions and Fetal heart Tone

Spread fingers lightly over fundus – to monitor contractions

Parts of contractions:

Increment or crescendo – beginning of contractions until it increases

Acme or apex – height of contraction

Decrement or decrescendo – from height of contractions until it decreases

Duration – beginning of contractions to end of same contraction

Interval – end of 1 contraction to beginning of next contraction

Frequency – beginning of 1 contraction to beginning of next contraction

Intensity - strength of contraction

Contraction – vasoconstriction

Increase BP, decrease FHT

Best time to get BP & FHT just after a contraction or midway of contractions

Placental reserve – 60 sec o2 for fetus during contractions

Duration of contractions shouldn’t >60 sec

Notify MD

Mom has headache – check BP, if same BP, let mom rest. If BP increase , notify MD -preeclampsia

Health teachings

1.) Ok to shower

2.)NPO – GIT stops function during labor if with food- will cause aspiration

3.)Enema administer during labor

a.)To cleanse bowel

b.)Prevent infection

c.)Sims position/side lying

12 – 18 inch – ht enema tubing

Check FHT after adm enema

Normal FHT= 120-160

Signs of fetal distress-

1.) <120 & >160

2.) mecomium stain amnion fluid

3.) fetal thrushing – hyperactive fetus due to lack O2

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

7 – 8 multi – bring to delivery room

10cm primi – bring to delivery room

Lithotomy pos – put legs same time up

Bulging of perineum – sure to come out

Breathing – panting ( teach mom)

Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2^nd stage of labor.

Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum ( urethroanal fistula)

        Mediolateral – more bleeding & pain, hard to repair, slow to heal

-use local or pudendal anesthesia.

Ironing the perineum – to prevent laceration

Modified Ritgens maneuver – place towel at perineum

1.)To prevent laceration

2.) Will facilitate complete flexion  & extension. (Support head & remove secretion, check cord if coiled. Pull shoulder down & up.    Check time, identification of baby.

Mechanisms of labor

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

Three parts of Pelvis – 1. Inlet – AP diameter narrow, transverse diameter wider

                                                    2. Cavity

Two Major Divisions of Pelvis

1. True pelvis – below the pelvic inlet
2. False pelvis – above the pelvic inlet; supports uterus during pregnancy

Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the  false and true pelvis.

Nursing Care:

To prevent puerperal sepsis - < 48 hours only – vaginal pack

Bolus of Ptocin can lead to hypotension.

3.       Third Stage: birth to expulsion of Placenta -placental stage    placenta has 15 – 28 cotyledons

Placenta delivered from 3-10 minutes

Signs of placental separation

1. Fundus rises – becomes firm & globular “ Calkins sign”
2. Lengthening of the cord
3. Sudden gush of blood

Types of placental delivery

Shultz    “shiny” – begins to separate from center to edges presenting the fetal side shiny

Dunkan “dirty” – begin  to separate form edges to center presenting natural side – beefy red or dirty

Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER

Hurrying of placental delivery will lead to inversion of uterus.

Nsg care for placenta:

1. Check completeness of placenta.
2. Check fundus (if relaxed, massage uterus)
3. Check bp
4. Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives
5. Monitor hpn (or give oxytocin IV)
6. Check perineum for lacerations
7. Assist MD for episiorapy
8. Flat on bed
9. Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.

4.       Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. Monitor v/s q 15 for 1 hr. 2^nd hr q 30 minutes.

Check placement of fundus at level of umbilicus.

If fundus above umbilicus, deviation of fundus

1.)     Empty bladder to prevent uterine atony

2.)     Check lochia

a.       Maternal Observations – body system stabilizes

b.       Placement of the Fundus

c.        Lochia

d.       Perineum –

R - edness

E- dema
E - cchymosis
D – ischarges
A – approximation of blood loss. Count pad & saturation

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

e.        Bonding – interaction between mother and newborn – rooming in types

1.)     Straight rooming in baby: 24hrs with mom.

2.)     Partial rooming in: baby in morning , at night nursery

Complications of Labor

Dystocia – difficult labor related to:

Mechanical factor – due to uterine inertia – sluggishness of contraction

1.)     hypertonic or primary uterine inertia

-          intense excessive contractions resulting to ineffective pushing

-          MD administer sedative valium,/diazepam – muscle relaxant

2.)     hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.

Prolonged labor – normal length of labor in primi 14 – 20 hrs

                                                                            Multi 10 -14 hrs

> 14 hrs in multi & > 20 hrs in primi

-          maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma

-          nsg care: monitor contractions and FHR

Precipitate Labor -  labor of < 3 hrs. extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.

Earliest sign: tachycardia & restlessness

Late sign: hypotension

Outstanding Nursing dx: fluid volume deficit

Post of mom – modified trendelenberg

IV – fast drip due fluid volume def

Signs of Hypovolemic Shock:

Hypotension

Tachycardia

Tachypnea

Cold clammy skin

               

Inversion of the uterus – situation uterus is inside out.

MD will push uterus back inside or not hysterectomy.

Factors leading to inversion of uterus

1.)     short cord

2.)     hurrying of placental delivery

3.)     ineffective fundal pressure

Uterine Rupture

Causes: 1.)

1.)Previous classical CS

2.)Large baby

3.) Improper use of oxytocin (IV drip)

Sx:

a.)     sudden pain

b.)     profuse bleeding

c.)      hypovolemic shock

d.)     TAHBSO

Physiologic retraction ring

-          Boundary bet upper/lower uterine segment

BANDL’S pathologic ring – suprapubic depression

a.) sign of impending uterine rupture

Amniotic Fluid Embolism or placental embolism – amniotic fluid or fragments of placenta enters natural circulation resulting to embolism

Sx:

dyspnea, chest pain & frothy sputum

prepare: suctioning

end stage: DIC disseminated intravascular coagopathy- bleeding to all portions of the body – eyes, nose, etc.

Trial Labor – measurement of  head & pelvis falls on borderline. Mom given 6 hrs of labor

Multi: 8 – 14, primi 14 – 20

Preterm Labor – labor  after 20 – 37 weeks) ( abortion <20 weeks)

Sx:

1. premature contractions q 10 min

2. effacement of 60 – 80%

3. dilation 2-3 cm

Home Mgt:

1. complete bed rest

2. avoid sex

3. empty bladder

4. drink 3 -4 glasses of water – full bladder inhibits contractions

5. consult MD if symptoms persist

Hosp:

1. If cervix is closed 2 – 3 cm,  dilation saved by administer Tocolytic agents- halts preterm contractions.YUTOPAR- Yutopar Hcl)

150mg incorporated 500cc Dextrose piggyback.

Monitor: FHT > 180 bpm

Maternal BP - <90/60

Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV

Tocolytic (Phil)

Terbuthaline (Bricanyl or Brethine) – sustained tachycardia

Antidote – propranolol or inderal - beta-blocker

If cervix is open – MD – steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS

Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.

X. Postpartal Period 5^th stage of labor

after 24hrs   :Normal increase WBC up to 30,000 cumm

Puerperium – covers 1^st 6 wks post partum

Involution – return of repro organ to its non  pregnant state.

Hyperfibrinogenia

- prone to thrombus formation

- early ambulation

Principles underlying puerperium

1. To return to Normal and Facilitate healing

A. Physiologic Changes

a.1. Systemic Changes

1. Cardiovascular System

- the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart. This is critical especially to gravidocardiac mothers.

2. Genital tract

a. Cervix – cervical opening

b. Vaginal and Pelvic Floor

c. Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10^th day – no longer palpable due behind symphisis pubis

3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for bacterial growth- (puerperal sepsis)- D&C

after,  birth pain:

1. position  prone

2. cold compress – to prevent bleeding

3. mefenamic acid

d. Lochia-bld, wbc, deciduas, microorganism. Nsd & Cs with lochia.

1. Ruba – red 1^st 3 days present, musty/mousy, moderate amt

2. Serosa – pink to brown 4 – 9^th day, limited amt

                3. Alba – créme white 10 – 21 days very decreased amt

dysuria

- urine collection

- alternate warm & cold compress

- stimulate bladder

3. Urinary tract:                   Bladder – freq in urination after delivery- urinary retention with overflow

4. Colon:               Constipation – due NPO, fear of bearing down

5. Perineal area – painful – episiotomy site – sims pos, cold compress for immediate pain after 24 hrs, hot sitz bath, not compress

                                                sex- when perineum has healed

II. Provide Emotional Support – Reva Rubia

Psychological Responses:

1. Taking in phase – dependent phase (1^st three days) mom – passive, cant make decisions, activity is to tell child birth experiences.

Nursing Care: - proper hygiene

2. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions

HT:

1.)     Care of newborn

2.)     Insert family planting method

common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying, despondence- inability to sleep & lack of appetite. – let mom cry – therapeutic.

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

III. Prevent complications

1. Hemorrhage – bleeding of  > 500cc

CS – 600 – 800 cc normal

NSD 500 cc

I.                    Early postpartum hemorrhage– bleeding within 1^st 24 hrs. Baggy or relaxed uterus & profuse bleeding – uterine atony. Complications: hypovolemic shock.

Mgt:

1.)     massage uterus until contracted

2.)     cold compress

3.)     modified trendelenberg

4.)     IV fast drip/ oxytocin IV drip

1^st degree laceration – affects vaginal skin & mucus membrane.

2^nd degree – 1^st degree + muscles of vagina

3^rd degree – 2^nd degree + external sphincter of rectum

4^th degree – 3^rd degree + mucus membrane of rectum

Breast feeding – post pit gland will release oxytocin so uterus will contract.

Well contracted uterus + bleeding = laceration

-          assess perineum for laceration

-          degree of laceration

-          mgt episiorapy

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen- failure to coagulate.

-          bleeding to any part of body

-          hysterectomy if with abruption placenta

mgt: BT- cryoprecipitate or fresh frozen plasma

II.                   Late Postpartum hemorrhage – bleeding after 24 hrs – retained placental fragments

Mgt: D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta, percreta,

Acreta – attached placenta to myometrium.

Increta – deeper attachment of placenta to myometrium                  hysterectomy

Percreta – invasion of placenta to perimetrium

Hematoma – bluish or purple discoloration of SQ tissue of vagina or perineum.

-          too much manipulation

-          large baby

-          pudendal anesthesia

Mgt:

1.)     cold compress every 30 minutes with rest period of 30 minutes for 24 hrs

2.)     shave

3.)     incision on site, scraping & suturing

Infection- sources of infection

1.)endogenous – from within body

2.) exogenous – from outside

1.)     anaerobic streptococci – most common - from members health team

2.)     unhealthy sexual practices

General signs of inflammation:

1.       Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling)

2.       purulent discharges

3.       fever

Gen mgt:

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

prolonged use of antibiotic lead to fungal infection

inflammation of perineum – see general signs of inflammation

2 to 3 stitches dislocated with purulent discharge

Mgt:

Removal of sutures & drainage, saline, between & resulting.

Endometriosis – inflammation of endometrial lining

Sx:

Abdominal tenderness, pos.

Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic

IV. Motivate the use of Family Planning

1.)     determine one’s own beliefs 1^st

2.)     never advice a permanent method of planning

3.)     method of choice is an individuals choice.

Natural Method – the only method accepted by the Catholic Church

Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)

-          clear, watery, stretchable, elastic – long spinnbarkeit

Basal Body Temperature  13^th day temp goes down before ovulation – no sex

-          get before arising in bed

LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.

breast feeding- menstruation will come out 4 – 6 months

bottle fed 2 – 3 months

disadvantage of lam – might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method – 1.) coitus interuptus/ withdrawal  - least effective method

1. coitus reservatus – sex without ejaculation –
2. coitus interfemora – “ipit”
3. calendar method

OVULATION –count minus 14 days before next mens (14 days before next mens)

Origoknause formula –

-          monitor cycle for 1 year

-          -get short test & longest cycle from  Jan – Dec

-          shortest – 18

-          longest – 11

June 26        Dec 33

       - 18              -11

           8      -        22   unsafe days

21 day pill- start 5^th day of mens

28day pill- start 1^st day of mens

missed 1 pill – take 2 next day

Physiologic Method-

Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3 months. Consult OB-6mos.

Alerts on Oral Contraceptive:

-in case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.

- if a new oral contraceptive is prescribed the mother should continue  taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.

- discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA  and subarachnoid hemorrhage.

Signs of hypertension

Immediate Discontinuation

A – abdominal pain
C – chest pain
H - headache
E – eye problems

S – severe leg cramps

If mom HPN – stop pills STAT!

Adverse effect: breakthrough bleeding

Contraindicated:

1.)     chain smoker

2.)     extreme obesity

3.)     HPN

4.)     DM

5.)     Thrombophlebitis or problems in clotting factors

-          if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.

DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation

                Depomedroxy progesterone acetate – IM q 3 months

- never massage injected site, it will shorten duration

Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.

-          5 yrs – disadvantage if keloid skin

-          as soon as removed – can become pregnant

Mechanism and Chemical Barriers

Intrauterine Device (IUD)

Action: prevents implantation – affects motility of sperm & ovum

-          right time to insert is after delivery or during menstruation

primary indication for use of IUD

-          parity or # of children, if 1 kid only don’t use IUD

HT:

1.)     Check for string daily

2.)     Monthly checkup

3.)     Regular pap smear

Alerts;

-          prevents implantation

-          most common complications: excessive menstrual flow and expulsion of the device (common problem)

-          others:

P eriod late (pregnancy suspected)

Abnormal spotting or bleeding

                                A bdominal pain or pain with intercourse

                                I nfection (abnormal vaginal discharge)

                                N ot feeling well, fever, chills

                                S trings lost, shorter or longer

                                                Uterine inflammation, uterine perforation, ectopic pregnancy

Condom – latex inserted to erected penis or lubricated vagina

Adv; gives highest protection against STD – female condom

Alerts:

Disadvantage:

-          it lessen sexual satisfaction

-          it gives higher protection in the prevention of STDs

Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus. REVERSABLE

Ht:

1.)     proper hygiene

2.)     check for holes before use

3.)     must stay in place 6 – 8 hrs after sex

4.)     must be refitted especially if without wt change 15 lbs

5.)     spermicide – chem. Barrier   ex. Foam (most effective), jellies, creams

S/effect: Toxic shock syndrome

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

Cervical Cap – most durable than diaphragm no need to apply spermicide

C/I: abnormal pap smear

Foams, Jellies, Creams

Surgical Method – BTL , Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects

Vasectomy – cut vas deferense.

HT: >30 ejaculations before safe sex

O – zero sperm count, safe