NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems

2nd Semester S.Y. 2011-2012 1

 CHAPTER 3

NURSING CARE OF THE HIGH RISK POSTPARTAL CLIENT

A. General Description
This chapter focuses on nursing care of a family experiencing a postpartal complication.

B. Objectives
After completing the chapter the student will able to:
1. Describe common deviations from the normal that can occur during the puerperium.
2. Assess a woman and her family for deviations from the normal during the puerperium.
3. Integrate knowledge of postpartal complications with the nursing process to achieve quality
maternal and childhealth nursing care.
4. Identify areas related to care of women with postpartal complications that could benefit from
additional nursing research or application of evidence based practice.

C. Topic Outline
1. Postpartal hemorrhage
2. Postpartal puerperal infection
3. Thrombolembolic disorders
4. Postpartal psychiatric disoders

D. Lecturette

A. POST PARTAL HEMORRHAGE

• Excessive blood loss during or after the third stage labor.
• Accepted normal average blood loss is 500 ml in vaginal delivery and 1000 ml at CS
• The most dangerous time at which hemorrhage is likely to occur is during the first hour
post partum
• Blood loss more than 500 cc. (normal blood loss 250- 350 cc)
• Leading cause of maternal mortality associated with childbearing

Incidence
1. The overall incidence is 3-6% in all deliveries
2. Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage
3. Cesarean delivery is associated with a 6.4% incidence of postpartum hemorrhage.
4. Delayed postpartum hemorrhage occurs in 1-2 % of patients.

Causes
The cause of postpartal hemorrhage can be remembered easily by using the mnemonic 4T’s
1. Tone- refers to the failure of the uterine myometrial muscle fibers to contract and retract
which can caused by the following conditions
• Overdistention -Macrosomnia, hydramnios, multiple pregnancy
• Fatigue- prolonged labor, precipitate labor,oxytocic drugs
• Infection-chorioamnionitis, endomyometritis, septicemia
• Uterine structural abnormality
• Hypoxia due to hypoperfusion or Couvelaire uterus
• Placental site in the lower uterine segment
• Distention with blood before or after placental delivery
• Inhibition of contractions by drugs- anesthetic agents, nitrates, NSAIDS, Mg S04,
nifedipine, beta- symptomimetics
2. Tissue- Presence of retained placental tissues prevents full uterine contractions resulting
in failure to seal off bleeding vessels which can caused by
• Preterm gestation especially in lessthan 24 weeksgestation
• Abnormal adhesions such as accreta, increta and percreta.
3. Trauma- 20% of postpartum hemorrhage is due to trauma anywhere in the genital tract
which may be caused by
• Lacerations and episiotomy
• Hematoma
• CS
• Uterine rupture and uterine inversion
• Uterine perforation during forceps application or curettage
4. Thrombosis – clot formation and fibrin deposition on the placental site stop the oozing of
blood vessels of the uterus.
• Disorders of the coagulation system and platelets, whether preexistent or
acquired can result in bleeding or aggravate bleeding.
• Acquired disorders - HELLP syndrome, DIC
• Preexistent coagulation disorder- thrombocytopenic purpura

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 2
Types of Post partum Hemorrhage
1. Early Post-partum hemorrhage – occurs during the first 24 hrs after delivery
Causes of early postpartum hemorrhage
o Uterine Atony – uterus is not well contracted, relaxed or boggy most frequent
cause)
o Lacerations of birth canal
o Inversionof the uterus
o Hypofibrinogenemia
o Clotting defect
2. Late Postpartum Hemorrhage- Occurs from 24 hours after birth to 4 weeks postpartum.
Causes of late postpartal hemorrhage
o Retained Placental Fragments
o Subinvolution of the uterus
o Infection

Nursing care management

1. Fundal massage
2. Offer a bedpan or assist with ambulating to the bathroom at least every 4 hours to keep of
the woman’s bladder empty
3. If a woman is experiencing respiratory distress from decreasing blood volume, mask
administer oxygen by face mask of 4 L/min rate
4. Supine position to allow adequate blood flow to herbrain and kidneys.
5. Obtain vital signs frequently

1. UTERINE ATONY
• Failure of the uterus to contract continuously after delivery.
• It is the most common cause of Post partal hemorrhage and often occurs following delivery
of the baby and up to 24 hours after the delivery of the placenta.,
• Relaxation of the uterus

Causes
1. Overdistention : hydramnios, multiple pregnancy, macrosomia
2. Complication of labor- Precipitate , prolonged labor
3. Uterine relaxing agents: anesthesia, analgesia, terbutaline, magnesium sulfate,
nitroglycerine
4. Oxytocin given during labor
5. High parity and advanced maternal age
6. Infection: amnionitis and chorioamnionitis
7. Presence of fibroid tumors that interfere with uterine contractions
8. Over massage of the uterus that results in very strong uterine contractions and eventual
fatigue
9. Retained placental fragments
10. Prolonged third stage of labor

Assessment
1. If the uterus suddenly relaxes, there will be abrupt gush of blood from the placental site.
2. Vaginal bleeding which is extremely large and the client mayexhibit symptoms of shock
andblood loss.

Therapeutic management
1. Intravenous infusion of oxytocin (pitocin) to help uterus maintain tone
2. The usual dose is 10-40U per 1000ml of5%dextrose solution
3. Intramuscular Methylergonovine ( methergin)
4. Bimanual massage
5. Prostaglandin administration
6. Blood replacement
7. Hysterectomy

2. RETAINED PLACENTAL FRAGMENTS

• The most common cause of post partal hemorrhage.
• Have increased risk of recurrence of retained placental fragments in subsequent
deliveries.

Incidence: occurs in 6% of vaginal deliveries.

Causes
• Partial separation of a normal placenta
• Manual removal of placenta
• Abnormal adherent placenta- accreta, increta ore perceta
• Abnormal placental adhesion

3. SUBINVOLUTION OF THE UTERUS

• Occurs when there is a delay in the return of the uterustoits prepregnant size, shape and
function

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 3
Causes
1. Retained placental fragments
2. Infection- endometritis
3. Uterine tumors

Assessment
• Enlarged and boggy uterus
• Prolonged or reversal pattern in lochial discharge
• Foul odor in lochia if caused by infection
• Backache

Therapeutic Management
• Initially the physician may order Ergonovine Maleate .2mg to stimulate uterine contractions
for 2 weeks.If bleeding continues after 2 weeks, D and Cis performed
• Treating the cause
✓ Removal of uterine tumors and antibiotics for infection
✓ Evacuation of the retained placental fragments by D and C

Nursing care management

1. Uterine Massage –first nursing action
2. Ice compress
3. Oxytocin administration
4. Empty bladder
5. Bimanual compression to explore retained placental fragments
6. Hysterectomy (last alternative)

II. POSTPARTAL PUERPERIAL INFECTION

• Reproductive tract infection developing after delivery
• May spread to the peritoneum (peritonitis) or the circulatory system (septicemia)

Risk Factors
1. Ruptrure of the membrane more than 24 hours before birth
2. Placental fragments retained within the uterus ( the tissue necroses and serves as an
excellent bed for bacterial growth)
3. Postpartal hemorrhage ( the woman’s general condition is weakened)
4. Pre-existing anemia ( the body’s defense against infection is lowered)
5. Prolonged and difficult labor, particularly instrument births ( trauma to the tissue may leave
lacerations or fissures for easy portals of entry for infection)
6. Internal fetal heart monitoring ( contamination may have been introduced in the placement
of the scalp electrode)
7. Local vaginal infection was present at the time of birth (direct spread of infection has
occurred)
8. The uterus was explored after birth for a retained placenta or abdominal bleeding site
(infection was introduced with exploration)

Assessment- localized in the vagina, vulva, perineum

• Pain
• Fever
• Edema
• Redness
• Firmness
• Tenderness
• Burning on urination
• Wound discharge
• Temperature >100.4 (38C) after 1st 24 hours on any of the first 10 postpartum days.

Prevention
1. Use sterile gloves, instruments during labor, birth and postpartal period.
2. Proper perineal care by the client,(front-back)
3. Handwashing
4. The client should have her own bedpan and perineal supplies and should not share them.
5. Antibiotics ( ampicillin, gentamicin, 3rd generation cephalosporins (cefixime)
6. No antibiotics during breastfeeding ==== observe infant for the presence of white plaque or
thrush (oral candida) ===because the portion of the maternal antibiotic passes into the
breastmilk and cause overgrowth of fungal organisms ===== a decreased in
microorganisms in the bowel caused by an antibiotic passed in breast milk may lead to
insufficient Vitamin K formation and decreased blood clotting ability.
❖ Hot sitz bath 2x a day.
Management: antibiotic after culture and sensitivity testing of the isolated organisms
✓ Group B streptococci
✓ Eschirichia coli
✓ Staphylococcus == cause of toxic syndrome similar to puerperial infection

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 4
1. ENDOMETRITIS
• An infection of the endometrium, the lining of the uterus.
• Bacteria gain access through the vagina and enter the uterus at the time of birth or during the
postpartal period.

Assessment
1. Temperature elevation on the third and 4th postpartal day == occurs at the same time
during breast filling
2. Increase WBC 20,000-30,000cells.mm3 (NORMAL)
3. Chills
4. Loss of appetite
5. General malaise
6. Uterus not well contracted and painful to touch
7. Strong afterpains
8. Lochia is dark brown, foul odor
==== if accompanied with high fever == lochia may be scant or absent
✓ Placental fragments confirmed by UTZ

Danger of endometritis
• Tubal scarring
• Interference with future fertility
Management
1. Antibiotic == Clindamycin (Cleocin) === determined by a culture of the lochia.
2. Vaginal culture using a sterile swab rather than from a perineal pad
3. Oxytocic agent === methylergonovine == to encourage uterine contraction
4. Increase fluid intake
5. Analgesic === for afterpains
6. Sitting in a fowler’s position or walking == encourage lochia drainage by gravity == helps
prevent pooling of infected secretions.
== Wear gloves when changing perineal pad
7. Early recognition of signs:
o Normal color
o Quantity and odor of discharge
o Size, consistency, tenderness of a normal postpartal uterus

2. WOUND INFECTION/INFECTION OF THE PERINEUM

• Suture line from her perineum, episiotomy or laceration repair == portal of entry for
bacterial invasion.

Assessment
1. Pain
2. Heat
3. Feeling of pressure
4. One or two stitches may be sloughed away
5. Open suture with drainage
o Notify the physician on the localized symptom
o Culture the discharge using cotton tipped applicator touched to the secretions.

3. UTI/ URINARY TRACT INFECTION

Assessment
1. Burning on urination
2. Hematuria- blood in the urine
3. Feeling of frequency / she always has to void
4. Sharp pain in voiding that she may refuse doing so – compounding to urinary stasis
5. Low grade fever
6. Lower abdominal pain
Diagnosis -urinalysis
Management
1. Sulfa drugs - commonly prescribed but contraindicated if breastfeeding
2. Amoxicillin/ ampicillin to treat infection- for 5-7 days to eradicate infection completely
3. Drink large amounts of water- a glass every hour to help flush infection from the bladder
4. Oral analgesic - Tylenol, Acetaminophen to reduce pain from urination
5. Temporarily D/C breastfeeding depending on Antibiotic prescribed

4. PERINEAL HEMATOMA
• Collection of blood in the subcutaneous layer tissue of the perineum.
• Caused by the injury to the blood vessels in the perineum during birth.
• Occur during rapid spontaneous birth an perineal varicosities.
• May occur at the site of episiotomy or laceration repair if a vein was punctured during
repair.
• Present minor bleeding and discomfort.

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 5
Assessment
1. Severe pain in the perineal area
2. Feeling of pressure between legs
3. With hematoma == purplish discoloration with swelling 2cm or 8cm in diameter
4. Tenderness during palpation
5. Palpates as firm globe

Nursing care management

1. Report the presence of hematoma: size, degree of woman’s discomfort
2. Assess the size by measuring it in centimeters with each inspection.
3. Describe a hematoma (small, large)
4. Describe the lesion
5. Administer mild analgesic == pain relief
6. Apply an ice pack (covered with towel to prevent thermal injury to the skin)
7. If the hematoma is large or continues to increase === returned the woman in the delivery
room to have the site incised and vessel be ligated under local anesthesia.
❖ If an episiotomy incision line is opened to drain a hematoma, it may be left open
and packed with gauze rather than resutured.
❖ Packing is usually removed within 24-48 hours
Instruct the client before discharge that she has to keep the area dry

5. THROMBOEMBOLIC DISORDERS
• Thrombi or blood clots are formed when there is stasis of circulation or repair of damaged
tissue.
• The postpartum woman is especially susceptible for the formation of thrombi because of
increased fibrinogen and prothrombin levels which increases blood coagulability.
• Thrombi have a tendency to occlude circulation and are a good medium of bacterial
growth.

Incidence
1. DVT- 3 to:1000
2. Pulmonary embolism- 2700 to 7000

Risk Factors
1. Varicosities of the legs
2. Obesity
3. Over 30 years old
4. Multiparity
5. Use of estrogen supplement
6. History of thromboembolic disease
7. Anesthesia, surgery
8. Smoking
9. Trauma to extremities
10. DM

Causes
1. Injury to blood vessels usually occurs during delivery, indwelling catheterization and
infection
2. Increased clotting that normally occurs during pregnancy and after delivery and with the
use of oral contraceptives
3. Blood stasis that occurs as a result of varicose veins, bed rest after CS and prolonged
inactivity

Dignosis
1. Doppler ultrasound
2. X-ray dye injection called venogram.

TYPES ACCORDING TO LOCATION

1. Superficial thrombophlebitis/ Phlebothrombosis/ Venous thrombosis
• Inflammation affecting the superficial veins of the extremities, the veins that are near the
skin and visible to the eye. Main symptom is tenderness and pain in the affected vein
followed by edema
• Location of the clot can be seen by the eye on inspection of the painful and reddened area
in the affected leg. These blood clots are large and hard enough to be felt by palpation
2. Deep Vein Thrombophlebitis/DVT
• This is inflammation of a vein located deep with in a muscle tissue. Since the vein affected
is surrounded by muscles, blood clot may break free during muscular movement and
travel in the circulation.
• The main danger is of the emboli (moving blood clot is called embolus, stationary blood
clot is thrombus) reaching the lungs and obstruct pulmonary blood flow resulting in
pulmonary embolism. There is more swelling in deep vein thrombosis than in superficial
vein thrombosis.

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
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TYPES ACCORDING TO VEINS AFFECTED

1. Femoral Thrombophlebitis
• Infection of the veins of the legs femoral, popliteal veins

Manifestations
a. Homan’s sign- calf pain when the foot is dorsiflexed
b. Milk leg or phlegmasia alba dolens- the leg is shiny white in appearance because of
extreme swelling and lack of circulation
c. Swelling of affected leg, pain stiffness
d. Fever
e. infection of the ovarian, uterine and pelvic veins manifestations are
✓ Fever and chills
✓ Pain in the lower abdomen or flank
✓ Palpable parametrail mass in some cases.

Management
1. Early ambulation after delivery
2. Use of support stocking in woman with varicosities to promote circulation and prevent
stasis. Instruct the patient to put stocking before rising from bed in the morning.
3. Provide adequate hydration
4. Avoid trauma to extremities
-pad stirrups well
-avoid pressure on the l vessels
-If post CS encourage leg exercises to promote venous return while patient is not yet
able to get out of bed
5. Avoid activities that contribute to venous stasis such as prolonged bed rest,standing
and sitting.

2. Superficial Venous Thrombosis

• Involving small clots in the absence of infection usually resolves without anticoagulant
treatment.
• The management is directed towards relief of pain and resolution of clot which include
✓ Application of heat to relieve pain
✓ Aspirin and ibuprofen- anti inflammatory drugs to relieve pain and prevent
inflammation
✓ If the woman is receiving heparin, aspirin should never be given to her.
✓ Instruct to avoid massaging the area

3. DVT/ Deep Vein Thrombosis

• Requires intensive management to prevent serious complications like pulmonary embolism

Management
1. Hospitalization during acute phase
2. Bedrest until signs and symptoms disappear. Gradual ambulation after disappearance of
signs and symptoms but the patient must wear elastic stockings to improve circulation in
the leg and prevent venous stasis
3. Leg elevation
4. Anticoagulant therapytoprevent venous stasis
Heparin- Mother may breastfeed as it is not passed to breastmilk.
Keep antagonist, sulfate, available.
Dicumarol- passed on breastmilk, so mother must stop breastfeeding.
Keep antagonist, Vitamin K available.
5. Monitor PTT level or APTT Apply warm wet compress dressing to promote circulation and
for comfort Administer prescribed antibiotic to combat infection and analgesic to relieve
pain
6. Surgery may be used if the affected vein is likely to present a long term threat of producing
blood clots.

2 major complications associated with the hypercoagulable state brought by pregnancy

1. Thrombophlebitis- Infection of the lining of the vein with formation of thrombi (thrombo for
the presence of clots and phlebitis meaning inflammation of the lining of blood vessels.
a. Venous Thrombosis/ phlebothrombosis-if the inflammation is minor and involves
only superficial veins of the extremities.
-Location of the clot can be seen by the eye on inspection of the painful nd
reddened area in the affected leg. Thses blood clots are large and hard enough
to be felt by palpation
b. Thromboplebitis - if theinflammation involves deep veins
2. Pulmonary embolism - may occur when these thrombi formed in the deep leg veins are
carried by circulation to the pulmonary artery and obstruct blood flow to the lungs. It is
rare but when it happensit is life threatening

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
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IV. POSTPARTAL PSYCHIATRIC DISORDER

Risk Factors
1. Unwanted pregnancy
2. Feeling unloved by mate
3. Below 20 years old
4. Single mother
5. Medical indigence
6. Low self esteem
7. Dissatisfaction with extent of education
8. Economic problems with housing and income
9. Poor relationship with husband or boyfriend
10. Being part of a family with 6 or more siblings
11. Limited parental support
12. Past or present evidence of emotional problems- woman with history of PPD and Post
partum Psychosis have 50% chance of recurrence.

A. POSTPARTAL BLUES
• Almost every woman notices some immediate feelings ( 1-10 days) of sadness ( postpartal
blues)
Onset- 1-10 days afterchild birth
Incidence- 70% of all births
Etiology
1. Probable hormonal changes
2. Stress of life changes
Symptoms
1. Sadness
2. Tears
Contact to Reality: Maintained Consistently
Therapy
1. Support
2. Empathy
Nursing Role- Offering compassion and understanding

B. POSTPARTAL DEPRESSION
• This occurs as a response to the anticlimactic feeling after birth and probably is related to
hormonal shifts as estrogen, progesterone and corticotrophin-releasing hormone levels in her
body decline
Onset- 1-12 months after birth
Incidence- 10% of all births
Risk factors /Etiology
1. History of previous depression
2. Hormonal response
3. Troubled childhood
4. Stress in the home or at work
5. Lack of self esteem- maybe a major contributing factor
6. Lack of effective support people/ social support
Symptoms
1. Anxiety
2. Feeling of loss
3. Feeling of sadness
4. Extreme fatigue
5. Inability to stop crying
6. Increased anxiety about her own and infants health
7. Insecurity/ unwillingness to make decisions
8. Psychosomatic symptoms- nausea, vomiting, and diarrhea
9. Depressive/ manic mood fluctuations
Contact with Reality- Intact but can be disoriented sense of suicidal thoughts and
depersonalization when severe
Therapy/ Management
1. Counseling
2. Discovery of the problem as soon as symptoms develop is a nursing priority
3. Antidepressant therapy
4. Postpartal return visit and well child visit
Nursing Role -Referring to counseling

C. POST PARTAL PSYCHOSIS

• As many as 1 in 500 presents enough symptoms in the year after birth of a child to be
considered psychiatrically ill.
• Because the illness coincides with the postpartal period it has been called postpartal
psychosis.
• Probably a response to the crisis of childbearing
• The majority of these women will have had symptoms of mental illness before pregnancy.

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 8
• Precipitated by death in the family, illness, loss of husbands job, a divorce or some other
major crisis
Onset- within 1st month after birth
Incidence- 1%-2% of all births
Etiology
1. Possible activation of previous mental illness
2. Hormonal changes
3. Family history of bipolar disorder
Symptoms
1. Exceptionally sad
2. Has lost contact with reality/ Delusions/ hallucinations to harm self and infant
3. Sensory input is so disturbed to comprehend or explain what a correct perception is
Therapy / Management
1. Referral to psychiatric counselor /Psychotherapy
2. Antipsychotic medication/ Drug therapy
✓ Note-Do not leave alone because disturbed perception might lead to harm herself
✓ Never leave alone with the infant
Contact with Reality- Loss of touch with reality, severe regressive breakdown, high risk of
suicide and/or infantacide
Nursing Role
1. Referring to counseling
2. Safeguard mother from injury to self or to newborn

References:

Pilliteri,Adele (2010), Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 6th edition. Lippincot Williams and Wilkins

Chapter 25: Nursing Care of a Family Experiencing a Postpartal Complication page 674

Ebook: Postpartum care of the mother and newborn: a Practical Guide

Postpartum Guidelines

(http://ebookbrowse.com/postpartum-care-guidelines-pdf

http://www.archive.org/details/wongsnursingcare00wong

Download Lippincott Manual of Nursing Practice

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
2nd Semester S.Y. 2011-2012 9
 CHAPTER 4

NURSING CARE OF COUPLE WITH PROBLEMS OF INFERTILITY

A. General Description
This chapter adds information to expand knowledge base about care of the couple who is unable
to conceive.

B. Objectives
After completing the chapter, the student will able to:
1. Describe common causes of infertility in both men and women.
2. Describe common assessment s necessary to detect infertility.
3. Use critical thinking to analyze ways that fertility assessment can be more family centered.
4. Identify appropriate outcomes for infertile couple.
5. Integrate knowledge about infertility with the nursing process to achieve quality maternal and
child nursing care.

C. Topic Outline
1. Causes of infertility in males and females
2. Diagnostic Test
3. Management
4. Nurse’s Roles

D. Lecturette

FERTILITY
• It is the natural capability of giving life
• The term was originally applied only to females, but increasingly is applied to males as
well, as common understanding of reproductive mechanisms increases and the
importance of the male role is better known.
• Human fertility depends on factors of nutrition, sexual behavior, culture, instinct,
endocrinology, timing, economics, way of life, and emotions.

Fertile Male
• Functional reproductive organs
– Testes must produce adequate numbers of sperm
– Unobstructed genital tract
– Genital tract secretions must be normal
– Ejaculated sperm must reach cervix

Fertile female
• Cervical mucus must be favorable
• Fallopian tubes must be patent
• Functional hypothalamic-pituitary axis
• Ovaries must produce and release ova in a regular, cyclic fashion
• Endometrium must be prepared for implantation of the blastocyst
• Adequate reproductive hormones must be present

Fertility History
1. Information about most fertile times for intercourse
2. Explanation of basic infertility workup
3. Basic assessments
– Ovarian function
– Cervical mucus adequacy
– Semen analysis
– Tubal patency
– General condition of pelvic organs
4. Complete physical examination of both partners
5. Laboratory examination
– CBC
– UA
– Hormonal assays

INFERTILITY
• Inability to conceive a child, sustain pregnancy and childbirth
• When pregnancy has not occurred after at least 1 year of engaging in unprotected coitus
• 14% couples

Risk factors
1. Age - After about age 32, a woman's fertility potential gradually declines. A gradual
decline in fertility is possible in men older than 35.
2. Tobacco smoking - Miscarriages are more frequent in women who smoke.
3. Alcohol use. For women, there's no safe level of alcohol use during conception or
pregnancy. Moderate alcohol use does not appear to decrease male fertility.

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 4. Being overweight
5. Being underweight - eating disorders, strict vegetarians due to a lack of important
nutrients such as vitamin B-12, zinc, iron and folic acid.
6. Too much exercise
7. Caffeine intake

Diagnosis of Infertility
1. If lack of ovarian function is suspected
– Basal body temperature recording
– Hormonal assessments
– Endometrial biopsy
– Transvaginal ultrasound
2. If cervical problems are suspected
– Ferning capacity of cervical mucus
3. If tubal or uterine problems are suspected
– Hysterosalpingography
– Hysteroscopy
– Laparoscopy
4. If male’s fertility is suspected
– Semen analysis
– Screening for anti-sperm antibodies

Types of Infertility
1. Primary Infertility – there has been no previous conception
2. Secondary Infertility – there has been a previous viable pregnancy but the couple is
unable to conceive at present
3. Sterility – inability to conceive because of a known condition
4. Subfertility – decreased ability to conceive

A. MALE INFERTILITY
Male infertility Factors
1. Disturbance in spermatogenesis( production of sperm cells)
2. Obstruction in the seminiferous tubules, ducts, or vessels preventing movement of
spermatozoa
3. Qualitative or quantitative changes in the seminal fluid preventing sperm motility
(movement of sperm)
4. Development of autoimmunity that immobilizes the sperm
5. Problems in ejaculation or deposition preventing spermatozoa from being placed close
enough to the woman’s cervix to allow ready penetration and fertilization

Causes of Male Infertility

1. Psychological issue (psychogenic infertility)
• Solution to the problem can include psychological or sexual counseling and may involve
long-term care.
2. Premature ejaculation- Ejaculation before penetration
• May interfere with the proper deposition of sperm. Another problem often
attributed to psychological causes.
3. Inadequate Sperm Count
• Refers to the number of sperms in a single ejaculation
• 20 M/ml of seminal fluid
• 50M/ ejaculation
• 50% are motile, 30% in normal shape and form
• Anti-sperm antibodies. Antibodies that target sperm and weaken or disable them
usually occur after surgical blockage of part of the vas deferens for male sterilization
(vasectomy).
4. Obstruction or Impaired Sperm Motility
Conditions
• mumps orchitis – testicular inflammation and scarring due to mumps virus
• epididymitis
• BPH
• congenital stricture of spermatic duct
5. Improper Deposition of Sperm
• Cystic fibrosis - Men with cystic fibrosis often have missing or obstructed vas
deferens.
• Hypospadias- urethral opening on the ventral surface of the penis
• Epispadias – urethral opening on the dorsal
6. Ejaculation Problems
• Erectile dysfunction/Impotence secondary to debilitating conditions and psychological
problems
• Premature Ejaculation
• Retrograde ejaculation. Various conditions can cause retrograde ejaculation including
diabetes, bladder, prostate or urethral surgery, and the use of certain medications.
7. Dyspareunia

NCM 102 Resource Unit: Care of Mother, Child, Family and Population Group at Risk or with Problems
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Diagnostic Tests
1. Semen analysis- after 2-4 days of sexual abstinence, the man ejaculates by masturbation
into a clean dry specimen jar and the spermatozoa is examined under the microscope with
in 1 hr.
✓ The numberof spermatozoa in the specimen are counted and their appearance and
motility noted.
✓ An average ejaculation should produce 2.5 to 5.0 mL of semen and should contain a
minimum of 20 million spermatozoa per milliliter of fluid (the average normal sperm
count is 50-200 M per mL the analysis may be repeated in 2 or 3 more months
because spermatogenesis an ongoing process, requiring 30 or90 days for new sperm
to reach maturity
2. Urinalysis
3. Blood Tests
4. Sperm penetration assay and anti sperm antibody testing- for impregnation to takes
place, sperm must be mobile, enough and have the capacity to reach and enter the ova.
One reason for poor sperm mobility may be the presence of anti-sperm antibodies which
tend to cause agglutination of sperm
✓ Sperm penetration studies are laboratory test to determine whether sperm, once
they reach the ova, can penetrate the ova. Using a an artificial reproductive
technique the in vitro fertilization, poorly mobile sperm or those with poor
penetration can be injected into the woman ovum under laboratory conditions
(intracytoplasmic sperm injection , by passing the need for sperm to fully mobile.

B. FEMALE INFERTILITY
Causes
1. Anovulation- most common cause of infertility
• Genetic abnormality
• Hormonal imbalance
• Ovarian tumors
• Decrease body weight / fat ratio less than 10% (eg. Athletes, anorexic)
• Polycystic Ovary Syndrome
✓ 6% of all reproductive age women.
✓ A disorder characterized by insulin resistance and a compensatory elevated
insulin level, which are found in both the overweight and non-overweight woman
with the syndrome.
✓ Ovaries fail to respond to FSH causing ovulation to happen a few times in a year
the body produces too much androgen hormone, which affects ovulation
✓ Signs and symptoms: Irregular menstrual cycles, lack of regular ovulation,
abnormal facial hair growth, infertility, obesity and polycystic ovaries (enlarged,
cystic ovaries).
2. Tubal Transport Problems
• Due to scarring of the FT secondary to chronic salphingitis (chronic PID), ruptured
appendix and other infections
• Dx: hysterosalphingography, hysteroscopy or laparoscopy
3. Uterine Problems
• Fibromas/ Leiomyomas –tumors block the FT
• Congenitally deformed uterine cavity – limits implantation
• Poor secretion of Estrogen and Progesterone from the ovary
• Endometriosis- abnormal implantation of endometrium/nodules spreading from uterus to
outside the uterus
4. Cervical problems
• Infection or inflammation of cervix – results to thick mucus
• Stenotic cervical os – cervical polyp
• Cervical scarring secondary to surgery (D and C)
5. Vaginal Problems
• Infection – acidic vagina which limits sperm motility and survival
• Sperm agglutinating antibodies in the vagina

PSYCHOLOGICAL REACTIONS
1. Development of lack of spontaneity of sexual intercourse
– Constant attention to temperature charts
– Instructions about their sex life from an outsider
2. Feelings of loss of control
3. Feelings of reduced competency
4. Loss of status and ambiguity as a couple - infertility often becomes central focus for role
identity
5. Sense of social stigma
– Feelings of guilt or shame
6. Stress on marital and sexual relationship
– Heighten feelings of frustration or anger between partners
7. Strained relationship with healthcare providers
8. Tasks of the infertile couple

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MANAGEMENT OF INFERTILITY
1. Drugs that induce ovulation
• Clomiphene Citrate (Clomid, Serophene)
• Human Menopausal Gonadotropins (Pergonal, Humegon, Repronex)
• Bromocriptine – decreases Prolactin thereby enhances production of FSH and LH
• Oral Contraceptives – Danazol
2. Procedures / Treatment
• Gamete intrafallopian transfer (GIFT)
• In vitro fertilization (IVF)
• Artificial insemination (AI)
• Intracytoplasmic sperm injection (ICSI)

GIFT
• A tool of assisted reproductive technology against infertility.
• Eggs are removed from a woman's ovaries, and placed in one of the FT, along with the
man's sperm.
• It allows fertilization to take place inside the woman's body.
• The technique, which was pioneered by endocrinologist Ricardo Asch
• It takes, on average, four to six weeks to complete a cycle of GIFT.
• First, the woman must take a fertility drug to stimulate egg production in the ovaries.
• The doctor will monitor the growth of the ovarian follicles, and once they are mature, the
woman will be injected with HCG
• The eggs will be harvested approximately 36 hours later, mixed with the man's sperm,
and placed back into the woman's FT using a laparoscope
• Some patients may prefer the procedure to IVF for ethical reasons, since the fertilization
takes place inside the body
• This is a semi invasive procedure and requires laproscopy

IN-VITRO FERTILIZATION
• “with the glass”; test tube babies
• is a process by which egg cells are fertilized by sperm outside the womb
• was developed to overcome infertility due to problems of the FT
• The first "test tube baby", Louise Brown, was born in 1978.
• The process involves hormonally controlling the ovulatory process, removing Ova (eggs)
from the woman's Ovaries and letting sperm fertilize them in a fluid medium.
• The fertilized egg (zygote) is then transferred to the patient's uterus with the intent to
establish a successful

Complication of IVF
• multiple births
• possible birth defects (septal heart defects, cleft lip, cleft palate, esophageal atresia,
anorectal atresia)

Method: IVF
1. Ovarian stimulation
2. Egg retrieval
3. Fertilisation
4. Selection
5. Embryo transfer

OVARIAN STIMULATION
• Treatment cycles are typically started on the third day of menstruation and consist of a
regimen of fertility medications to stimulate the development of multiple follicles of the
ovaries.
• In most patients injectable gonadotropins (usually FSH analogues) are used under close
monitoring. Such monitoring frequently checks the estradiol level and, by means of ULTZ,
follicular growth.
• Typically approximately 10 days of injections will be necessary.
• Spontaneous ovulation during the cycle is typically prevented by the use of GnRH
agonists or GnRH antagonists, which block the natural surge of LH.

EGG RETRIEVAL
• Transvaginal oocyte retrieval
• When follicular maturation is judged to be adequate, HCG is given.
• This agent, which acts as an analogue of LH, would cause ovulation about 42 hours
after injection, but a retrieval procedure takes place just prior to that, in order to
recover the egg cells from the ovary.
• The eggs are retrieved from the patient using a transvaginal technique involving an
ultrasound-guided needle piercing the vaginal wall to reach the ovaries.Through this
needle follicles can be aspirated, and the follicular fluid is handed to the IVF laboratory to
identify ova.
• It is common to remove between ten and thirty eggs.

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 • The retrieval procedure takes about 20 minutes and is usually done under conscious
sedations or general anesthesia.

FERTILIZATION
• In the laboratory, the identified eggs are stripped of surrounding cells and prepared for
fertilization.
• In the meantime, semen is prepared for fertilization by removing inactive cells and
seminal fluid.
• If semen is being provided by a sperm donor, it will usually have been prepared for
treatment before being frozen and quarantined, and it will be thawed ready for use.
• The sperm and the egg are incubated together at a ratio of about 75,000:1 in the culture
media for about 18 hours.
• In most cases, the egg will be fertilized by that time and the fertilized egg will show two
pronuclei.
• In certain situations, such as low sperm count or motility, a single sperm may be injected
directly into the egg using intracytoplasmic sperm injection (ICSI).
• The fertilized egg is passed to a special growth medium and left for about 48 hours until
the egg consists of six to eight cells.

SELECTION
• Laboratories have developed grading methods to judge oocyte and embryo quality.
• Typically, embryos that have reached the 6-8 cell stage are transferred three days after
retrieval.
• Embryos are placed into an extended culture system with a transfer done at the
blastocyst stage at around five days after retrieval, especially if many good-quality
embryos are still available on day 3.
Blastocyst stage transfers have been shown to result in higher pregnancy rates

EMBRYO TRANSFER
• Embryos are graded by the embryologist based on the number of cells, evenness of
growth and degree of fragmentation.
• The number to be transferred depends on the number available, the age of the woman
and other health and diagnostic factors.
• The embryos judged to be the "best" are transferred to the patient's uterus through a thin,
plastic catheter, which goes through her vagina and cervix. Several embryos may be
passed into the uterus to improve chances of implantation and pregnancy.

CRYOPRESERVATION
• First pregnancy derived from a frozen human embryo was reported by Allan Trounson &
Linda Mohr in 1983
• The first term pregnancies derived from frozen human embryos were reported by
Zeilmaker et al.
• The first human baby hatched via a rate frozen freezing process was born in 1984
example: In women who are likely to lose their ovarian reserve due to undergoing
chemotherapy

ARTIFICIAL INSEMINATION
• The process by which sperm is placed into the reproductive tract of a female for the
purpose of impregnating the female by using means other than sexual intercourse.
• Used primarily to treat infertility but is also increasingly used to enable women without a
male partner (i.e., single women and lesbians) to produce children by using sperm
provided by a sperm donor.
• The woman is the gestational and genetic mother of the child produced, and the sperm
donor is the genetic or biological father of the child.
• Freshly ejaculated sperm, or sperm which has been frozen and thawed, is placed in the
cervix (intracervical insemination) (ICI)) or in the female's uterus (intrauterine
insemination) (IUI) by artificial means.
• A woman's menstrual cycle is closely observed, by tracking basal body temperature
(BBT) and changes in vaginal mucus, or using ovulation kits, ultrasounds or blood tests.
• Some women are prescribed Motroxodine (XDWD), also known as the Special Pill, in
order to stimulate the ovaries. This medication is generally taken 4 to 6 weeks before the
planned insemination, which, in such cases, is known as a 'stimulated cycle'.
• When using intrauterine insemination (IUI), the sperm must have been “washed” in a
laboratory and concentrated in Hams F10 media without L-glutamine, warmed to 37C.
• The process of “washing” the sperm increases the chances of fertilization and removes
any mucus and non-motile sperm in the semen.
• Where this method is employed only 'washed' semen may be used and this is inserted by
means of a catheter
• A chemical known as a cryoprotectant is added to the sperm to aid the freezing and
thawing process.

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INTRACYTOPLASMIC SPERM INJECTION (ICSI)
• Pronounced "eeksee"or "icksy"is an in vitro fertilization procedure in which a single
sperm is injected directly into an egg.
• Most commonly used to overcome male infertility problems
• Used where eggs cannot easily be penetrated by sperm
• A method of in vitro fertilization,especially associated with sperm donation.
• The technique was developed around 1991
• Done under a microscope using multiple micromanipulation devices

NURSE’ S ROLES
• Counselor
– Supports the couple as they make decisions
– Helps the couple to recognize feelings
– Facilitates the free expressions of feelings
– Facilitates partner communication
• Educator
– Provides accurate information
– Gives extensive and repeated explanations
– Ensures couples have written instructions
- Helps them to understand the process
• Advocate
– Helps the couple identify alternatives

References:

Pilliteri,Adele (2010), Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family, 6th edition. Lippincot Williams and Wilkins

Chapter 8: Nursing Care of Subfertile Couple page 168

Ebook: Infertility Principles and Practice http://www.marilynglenville.com/infertility.htm

http://www.archive.org/details/wongsnursingcare00wong

Download Lippincott Manual of Nursing Practice

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