ESMAS, LEXI MCN 2 LE 1

Part 1: Care of the At Risk, High Risk and  ■ 4&5a ​ re the most important for 
IMPROVED ACCESS OF WOMEN TO​: 
Sick Mother and Child  MCHN 
UNIT 1: NURSING CARE OF THE HIGH RISK  ■ Created in 2000, but revisited in   
PREGNANT CLIENT  2015  1. BEMONC 
    ■ Birthing centers w/ ​BEMONC 
  capability 
NATIONAL SAFE MOTHERHOOD 
■ Designated referral to 
FRAMEWORK OF MCHN  PROGRAM 
hospitals to women needing 
  1. Collaborate with Local Gov(Who +  CEMONC  
Current National Health Situation on  DOH)  2. Safe Blood 
Maternal and Child Health:    2. Establish care knowledge base  3. Efficient emergency transport 
▶ Maternal Health​: T​he health of  and support systems   service 
women during pregnancy, childbirth    4. At least ​4 antenatal care visits 
and postpartum.  5. At least ​2 postnatal care checkups 
THE PARADIGM SHIFT 
■ It encompasses the   
healthcare dimensions of:    
PHILIPPINE VITAL STATISTICS  
✓ Family Planning  ■ From r​ isk approach​(aims to identify 
✓ Preconception  high risk pregnancy) to   
✓ Prenatal care  EmONC​(considers a pregnancy to be  ► Neonatal Mortality Rate​: Neonates 
✓ Postnatal care  at risk of complications)  dying before reaching 28 days of live 
▶ 2020 population: 109,581, 078  ■ All pregnancies are at risk  per 1,000 live births in a given year 
▶ Ischemic Heart Disease​ is at the top    ► Infant Mortality Rate​:​ # of infants 
10 global causes of death  dying before reaching 1 year of age 
MATERNAL & NEWBORN MORTALITY 
▶ Goal to be met 2030  per 1,000 live births in a given year 
REDUCTION​: ​WHAT WORKS?  
▶ CORE​: Safety of mother and child   ► Maternal Mortality Rate​: # of 
    women who die during pregnancy + 
  childbirth per 100,000 live births 
THE 8 MDGs 
➢ Women deciding to give birth:   ► Child Mortality Rate​: the 
In facilities with capabilities  probability of dying before reaching 
to provide BeMONC  5 years old per 1,000 live births  
Assisted by skilled health 
4 ELEMENTS ESSENTIAL TO PREVENT 
professionals 
MATERNAL AND CHILD DEATHS 
 
  1. 4 Prenatal healthcare checkups 
  2. Postpartum Care 
  3. Skilled birth attendant 
 
4. Emergency obstetric care 
ESMAS, LEXI MCN 2 LE 1

✓ Parity  ■ Anatomical(incompte
COMPLICATIONS OF PREGNANCY 
○ Primigravida(18 and younger  tant cervix) 
  or older than 35  ■ Environmental 
A. ​10 DANGER SIGNS:   ○ Multigravida(5 or more)  ■ Alcohol Indigestion 
  ✓ Exposure to teratogens   
✓ Vaginal bleeding  ✓ Family or environmental violence  Embryonic Factor:  
✓ Sudden escape of fluid from    ■ Fetal 
vagina    maldevelopment 
○ use of nitrazine paper  ■ Immunologic factors 
HIGH RISK PREGNANCY 
○ Blue → basic  ■ Assessment:  
○ Yellow → acidic    ■ Confirmation of pregnancy 
✓ Chills, Fever  A. BLEEDING CONDITIONS:   ■ Length of pregnancy 
✓ Persistent and prolonged  1. Miscarriage  ■ Duration 
vomiting  2. Incompetent Cervix  ■ Intensity 
✓ Increase/Decrease in fetal  3. Ectopic Pregnancy  ■ Description 
movements  4. Gestational Trophoblastic Disease  ■ Frequency 
✓ Abdominal/Chest pains  5. Placenta Previa  ■ Symptoms 
○ Again, round ligament pain  6. Abruptio Placenta   ■ Blood Type 
may be sign of ectopic  7. Hypertension Disorder on Pregnancy   
pregnancy    SUB - CLASSES OF S​ PONTANEOUS 
✓ Edema  1. MISCARRIAGE(ABORTION)  MISCARRIAGE:  
✓ Sudden increase in BP and rapid  ■ Interruption of a pregnancy before a  ► Threatened:  
weight gain  fetus is viable  ○ Cervical Status  
○ Again, may be a sign of  ➢ A fetus is viable 20 -24 weeks  ○ FHT 
preeclampsia  AOG, and 500g  ○ HCG 
  ➢ Abortion​ → less than 20  ○ Bed Rest 
B. ​INDICATORS OF HIGH RISK  weeks and leess than 500g  ○ Coitus(Abstinence) 
  ■ 2 Major Classes:  ○ Hormonal ttt 
✓ Maternal age: 20-35  ➢ Induced  ○ Physical Activity(Like 
○ Younger 18 and older than  ➢ Spontaneous  ambulation) 
40 is dangerous  ■ Common Causes:  ○ Instability of the uterus 
✓ Low socio-econmoc status  Maternal Factor:  ○ Rubbing of abdomen 
✓ Poor nutritional status  ■ Hormonal  releases oxytocin to progress 
✓ History of OB complications  ■ Infection  labor -- so tell mother to limit 
✓ Maternal Lifestyle  ■ Uterine  it 
  Malformation   
   
ESMAS, LEXI MCN 2 LE 1

► Imminent:  ► Missed Misscariage (Early Preg  2. INCOMPETENT CERVIX 

○ Cervical status  Failure)  ■ Cervical Insufficiency / Premature 
○ Uterine Cramping  ○ Misoprostol(Cytotec)  ■ Cervical Dilation 
○ Save tissues passed out  ○ Oxytocin stimulation  ■ S/S:  
○ Include pad count  ○ DIC complication  ✓ Painless dilation of cervical 
■ Scanty → 2’’  ○ Primrose ripens the cervix  OS 
■ Light → 4’’    ✓ Vaginal spotting 
■ Moderate → 6’’  ■ Complications of Miscarriage​:   ✓ Prolapse and ballooning of 
■ Heavy → 1 pad  ➢ Hemorrhage  membrane into the vagina 
saturated within 1  ➢ Infection  ■ Management​:  
hour is already a sign  ➢ Isoimmunization  ○ Cerclage surgery technique 
of postpartum    is the surgery of choice 
hemorrhage  ■ Management​:   ○ Tocolysis 
➢ Blood clots are hard  ➢ Prevent Hypovolemic Shock  ○ Bred rest and positioning 
to pull apart, while  ○ Monitor VS  ○ Hydration 
tissues are meaty  ○ Monitor bleeding   
white membranes  ○ Position client in  3. ECTOPIC PREGNANCY 
likely soaked in blood  trendelenburg  ■ Occurs when implantation occurs 
■ Vaginal fluid  ○ Oxytocin   outside the uterine cavity 
■ Include status of  ○ Surgery  ■ Causes​:  
uterus  ○ Broad Spectrum  ○ Infection 
  Antibiotics  ○ Presence of tubal growth 
► Incomplete:   ➢ SIGNS of HS:   ○ Congenital strictures 
○ Surgery done to fix this:  ✓ Pale  ○ tubal scarring 
Dilation  ✓ Increased PR  ○ history of IUD use 
○ Placental fragments still  ✓ Decreased BP  ■ S/S​:  
there, and uterus will not be  ✓ Decreased Cardiac  ○ Abdominal pain ( RUQ ) 
able to go back to its normal  Output  ○ Amenorrhea 
state, leading to continual  ✓ Decreased perfusion  ○ Bleeding 
bleeding  to kidney leading to  ○ Abdominal and pelvic 
  less kidney function  tenderness 
► Complete:   ✓ Decreased urine  ○ Temperature elevation but 
○ Check products of  output  not fever 
conception  ✓ Decreased HR sa bby  ○ Pelvic mass 
○ Observe and wait  ➢ Provide family support  ○ Shoulder tip pain w/ 
    peritoneal bleeding  
► Recurrent Pregnancy Loss / Habitual     
ESMAS, LEXI MCN 2 LE 1

■ Assessment:   ➢ Partial Mole​: 69  ■ Predisposing Factors:  

○ Pain characteristics  chromosomes and  ○ Multiparity 
○ Bleeding characteristics  some fetal tissue  ○ Advancing Age 
○ Decreasing pregnancy  present  ○ Hx of present uterine 
hormone(progesterone)    surgery 
○ Signs of shock  ■ Predisposing Factors​:   ○ Multiple gestation 
○ (+) Culdocentesis via UTZ  ○ Age  ○ Maternal smoking 
○ (+) Cullen sign (bluish  ○ Multiparity  ○ High altitude 
discoloration of umbilical  ○ Low protein intake  ■ Assessment​:  
cord)  ○ Asian Heritage  ○ Characteristic of 
○ IE assessment  ■ Assessment​:   bleeding 
○ Referred shoulder pain  ○ S/S of pregnancy  ■ Clinical Manifestations of 
  ○ Inappropriate fundal  bleeding:  
■ Management:   height  ○ Bright red in color 
○ Hydrate patient  ○ Characteristic of  ○ Painless vaginal 
○ Blood tests  vaginal bleeding  bleeding 
○ Anticipate for an emergency  ■ ​Management​:   ○ Bleeding after 20 
surgery if unruptured  ○ Mole Evacuation  weeks AOG 
○ Administration of  ○ HCG Titer Monitoring  ○ Intermittent / 
methotrexate or  ○ Chemotherapy  Continuous 
hysterosalpingogram  Methotrexate ○ Can increase during 
  (DACTINOMY labor 
  CIN)  ■ Associated Factor: 
4. GESTATIONAL TROPHOBLASTIC  ○ Counseling on  PLACENTA ACCRETA:  
DISEASE (Hydatidiform Mole)  contraception, ff-up  ○ Part of the placenta 
■ Abnormal proliferation and  care  abnormally attached 
degeneration of the    to the myometrium 
trophoblastic villi  5. PLACENTA PREVIA:   ○ TYPES​:  
■ If not addressed, can  ■ The abnormal placental  ➢ ​ACCRETA​ → 
progress to  implantation at or near the  At the 
Choriocarcinoma   cervical OS  Myometrium 
■ TYPES​:   ■ TYPES​:   ➢ INCRETA ​→ 
➢ Complete Mole​: 46  ➢ Low - lying(1st △)  invades into 
chromosomes and  ➢ Marginal  myometrium  
no fetal tissue  ➢ Complete  ➢ PERCRETA​ → 
present  ■ Incidence​: 5 per 1,000  Penetrate 
pregnancies  into uterine 
ESMAS, LEXI MCN 2 LE 1

serosa and  6. ABRUPTIO PLACENTA   ■ Management​:  

surrounding  ■ Premature separation of  ○ Monitor for s/s of 
organs   placenta  shock 
  ■ Predisposing factors:   ○ Transfusion 
■ Management:   ○ Hx of hypertension  ○ Anticipate for 
○ Bedrest  ○ Smoking  emergency 
○ Monitor blood loss  ○ Direct Trauma  termination of 
○ No attempts of IE  ○ Multiparity  pregnancy 
speculum exam  ○ Short Umbilical cord  ○ No abdominal, pelvic 
○ Blood chemistries  ○ Chorioamnionitis  or vaginal exam 
○ Monitor input /  ○ Rapid reduction of  ■ D E T A C H E D :  
output   amniotic fluid  ○ D - Dark, red 
○ Tocolysis  ■ TYPES​:   bleeding 
○ Amniocentesis  ➢ Partial​ (detached  ○ E - Extended fundal 
○ Administration of  from center) →  height 
corticosteroids given  Concealed bleeding  ○ T - Tender uterus 
to infants for lung  ➢ Marginal​ (center to  ○ A - Abdominal pain, 
maturation →  side) → External  contractions 
betamethasone  bleeding  ○ C - Concealed 
○ Oxygen  ➢ Complete​ →  bleeding 
administration   External bleeding  ○ H - Hard, abdomen 
○ Anticipate for  and / or concealed  ○ E - Experience DIC 
emergency delivery  bleeding  ○ D - Distressed baby 
of baby   ■ Assessment​:    
  ○ Labor  7. HYPERTENSION DISEASE ON 
■ P R E V I A  ○ Bleeding  PREGNANCY  
○ P - Painless, bright  characteristics  ■ Most common cause of 
red bleeding  ■ Complications​:    death  
○ R - Relaxed, soft    ■ 4 TYPES:  
non-tender uterus  Couvelaire Uterus​: a life-threatening  ➢ Pre-Eclampsia 
○ E - Episodes of  condition in which loosening of the placenta  ➢ Eclampsia 
bleeding  (abruptio placentae) causes bleeding that  ➢ Gestational 
○ V - Visible bleeding  penetrates into the uterine myometrium  Hypertension 
○ I - Intercourse post  forcing its way into the peritoneal cavity →  ➢ Chronic 
bleeding  hard board like uterus  Hypertension  
○ A - Abnormal fetal    ■ Hallmark: ​20 weeks AOG 
position     
ESMAS, LEXI MCN 2 LE 1

    ➢ 2+ → moderate 
▶ PRE - ECLAMPSIA:     indentation 
■ Pregnancy - specific  ■ Pathophysiology:   ➢ 3+ → deep 
syndrome of reduced end-  ○ Generalized vasospasm  indentation 
organ perfusion 2ndary to  ○ Platelet aggregation w/  ➢ 4+ → indentation 
vasospasm + endothelial  intravascular coagulation  remains 
activation  ○ Endothelial dysfunction   
■ Hypertension, Proteinuria,  ○ #1: due to an abnormal  ■ Management​:  
and Edema   placenta  ○ Removal of placenta or 
    pregnancy termination 
▶ ECLAMPSIA:   ■ S/S:    
■ The onset of convulsion in  ○ Blurred vision  ■ Home Care​:  
women with pre eclampsia  ○ Hyperreflexia  ○ Activity restrictions 
■ Seizures now occur  ○ Decreased platelets  ○ Fetal activity 
  ○ Impaired liver enzymes  ○ BP monitoring 
▶ GESTATIONAL HYPERTENSION:   ○ Decreased urinary output  ○ Weight monitoring 
■ Develops after 20 weeks  ○ Headache + dizziness  ○ Urinalysis 
AOG  ○ Mental confusion  ○ Diet 
    ○ Fetal surveillance 
▶ CHRONIC HYPERTENSION:   ■ MILD:   
■ BP = 140/90 before  ✓ 1+ or 300 mg in 24 hour  ■ Hospital Care​:  
pregnancy or before 20  collection urine output  ○ Best rest 
weeks AOG  ✓ 0.3 or above on protein -  ○ Anticonvulsant Medications 
■ Has nothing to do with the  creatinine ratio  MGSO4 
pregnancy at all  ✓ 140/90 2x 6 hrs apart   
  ✓ Decreased liver enzyme  ■ MGSO4 is the anticonvulsant of 
PREECLAMPSIA  ■ SEVERE:   choice 
  ✓ 3+ or 4+ on random urine  ■ IV Diazepam is NOT the drug of 
■ Risk Factors:   sample, or more than 5g in a  choice 
○ Age + parity  24 hour sample  ■ Avoid polypharmacy 
○ Colored women(due to the  ✓ 160/110  ■ Protocol:  
large quantity of melanin)  ✓ Edema  ○ IV​:  
○ (+) Family hx  ➢ Non pitting → does  Loading dose of 4gm 
○ Overweight  not indent  over 10-15 mins 
○ Chronic hypertension / renal  ➢ 1+ → slight  Maintain with 
disease  indentation  1gm/hr 
   
ESMAS, LEXI MCN 2 LE 1

  IV Calcium Gluconate  ■ Twitching starts in fade then 

  10% Ca Glu 10ml/iv  involve one side of 
○ IM​: (if iv not available)  over 3- 5 mins  extremities and ultimately 
5mg(10ml) in each    whole body in involved 
buttock @ IV 4g over  ■ ​Intervention to prevent seizures:   ■ Tongue biting 
10 -15 mins)  ○ Therapeutic environment  Use palate tongue 
Maintain with 5mg  ○ Schedule activities  depressor 
every 4 hours  ○ Prepare emergency drugs  ■ Stertorous + blood stained 
Risk for gluteal  ○ Sedatives  frothy secretions from 
abscess  ○ Prepare suction apparatus  mouth 
1% xylocain to  ○ Appropriate position  ■ Cyanosis gradually 
reduce pain  ○ Prepare o2 setup  disappears 
  ○ Limit visitation  ■ lasts for 1-4 mins 
■ Hourly monitoring for MGS04     
toxicity:   ECLAMPSIA  4. POSTICTAL:  
○ Patellar reflexes(earliest sign    ■ Flaccid muscles 
of MGS04 toxicity)  ■ 4 STAGES:   ■ Unconscious 
○ RR > 12 - 16 cpm    ■ Lasts until patient regains 
○ Urine Output > 30ml/hour @  1. PREMONITORY STAGE​:   consciousness 
100ml/4hours  ■ Unconscious   
○ O2 Saturation 98 - 100  ■ Muscle twitching  ■ Nsg responsibilities:  
  ■ Eyeballs rolled, set or fixed  ○ Signs of labor 
■ Management for toxicity:   ■ Lasts for 30 secs  ○ Signs of abruptio placenta 
○ Urine output < 100 ml/4    ○ Position client properly 
hours @ < 30ml/hr  2. TONIC STAGE​:  ○ NPO → risk for aspiration 
May challenge with  ■ Trunk opisthotonus  ○ Monitor FHT 
haemen solution  ■ Flex limbs and clenched fists  ○ Signs of HELLP syndrome 
○ Absent patellar reflex  ■ RR ceases  ■ H​emolysis leads to 
Stop infusion  ■ Tongue protrudes  anemia 
○ Respiratory depression  ■ Cyanosis  ■ E​levated ​Li​ ver 
give o2 and stop  ■ Eyeball rolling  enzymes 
infusion  ■ lasts for 30 secs  ■ L​ow ​Pl​ atelets 
○ Cardiorespiratory arrest:      
resuscitate via CPR,  3. CLONIC STAGE:    
intube and  ■ All the voluntary muscles   
ventilation  undergo alternate 
stop infusion  contractions and relaxation 
ESMAS, LEXI MCN 2 LE 1

DIC: Disseminated Intravascular   

Coagulation  
    
Acquired disorder of blood clotting in which    
fibrinogen levels fall to below effective limits   
→ blood clots form throughout the body,   
blocking small blood vessels. 
 
POLYHYDRAMNIOS / 
OLIGOHYDRAMNIOS:  
 
2,000+ ml or 24 cm / less than average 
 
ISOIMMUNIZATION:  
 
The production of antibodies against RH - 
positive blood; against mothers 2nd baby if 
it is RH positive.  
 
ERYTHROBLASTOSIS FETALIS:  
 
Maternal antibodies cross the placenta and 
cause destruction of fetal red blood cells. 
The fetus becomes so deficient in red blood 
cells from this that a sufficient oxygen 
transport to the body cannot be maintained.  
 
PRETERM LABOR / POST TERM LABOR:  
 
Before 37 weeks AOG / After 42 weeks AOG