MCN Lec Prelim

NCM 109: Maternal & Child Health Nursing
FRAMEWORK FOR MCN FOCUSING ON AT ○ >200 indicators

● In 1992 leaders set out the principles
RISK AND SICK CLIENT of sustainable development at the
United Nations Conference on
WHAT DO WE MEAN BY GOALS? Environment and Development in
● Remote state that we want Rio de Janeiro, Brazil
● Direction; “papuntahan”
● “Mithiin; Hangarin; Wish ko lang” What is Sustainable Development?
● Ambition ● Many definitions, including this
landmark definition in 1987:
Goals ● “Development that meets the needs
● Can be Personal, of the present without compromising
Team/Organizational, Local, the ability of future generations to
National or Global, etc. their needs” - from the World
Commission on Environment and
Mistakes in Setting Goals Development
● Too big ● Sustainable development calls for a
● Not specific convergence between the three
● Too many pillars of economic development,
● Not written social equity, and environmental
protection
Goals should be… ● Sustainable development is a
● Specific visionary development paradigm;
● Measurable and over the past 20 years
● Attainable governments, businesses, and civil
● Realistic/relevant society have accepted sustainable
● Time-bound development as a guiding
principle, made progress on
sustainable development metrics,
SUSTAINABLE DEVELOPMENT GOALS and improved business and NGO
participation in the sustainable
development process.
● MDGs: 1990-2015
○ 8 goals
○ 21 targets
○ 60 indicators
● SDGs: 2016-2030
○ 17 goals
○ 169 targets
Austria, Echague, Fernandez, Forcadilla, Guzman 1

SDG # 3: Good Health and Well-being ● 94% of all maternal deaths occur in
By 2030… low and lower middle income
● Reduce the Global MMR to less than countries.
70/100,000 live births ● Young adolescents (ages 10-14)
● End preventable deaths of newborn face a higher risk of complications
and children under 5 years of age and death as a result of teenage
○ Reduce NMR to 12 per pregnancy than other women.
1,000 live births ● Skilled care before, during and after
○ Reduce under 5 MR to 25 childbirth can save the lives of
per 1,000 live births women and newborns.
○ Neonate - 0-28 months old
● End the epidemics of AIDS, Why Do Women Die?
Tuberculosis, malaria and ● Severe bleeding (after childbirth)
neglected tropical diseases and ● Infections (after childbirth)
combat hepatitis, water borne ● High blood pressure during
diseases and other communicable pregnancy
diseases. ○ Preeclampsia - High Blood
● Reduce by ⅓ premature mortality Pressure during pregnancy
from non-communicable diseases ● Complications from delivery
through prevention and treatment ● Unsafe abortion
and promote mental health and well-
being Factors That Prevent Women From
● Ensure universal access to sexual Seeking Care During Pregnancy/
and reproductive healthcare Childbirth
services, including for family ● Poverty
planning, information and education ● Distance to facilities
and the integration of reproductive ● Lack of information
health into national strategies and ● Inadequate and poor quality services
programs
Newborns - Key Facts
(WHO - September 2019)
GLOBAL SITUATIONER ● Globally 2.5 million children died
Maternal Mortality - Key Facts in the first month of life in 2018 —
(WHO - September 2019) approximately 7 000 newborn
● Every day in 2017, approximately deaths every day with about one
810 women died from preventable third dying on the day of birth and
causes related to pregnancy and close to three quarters dying within
childbirth. the first week of life.
● Between 2000 and 2017, the ● Neonatal mortality declined more
maternal mortality ratio (MMR, slowly than mortality among children
number of maternal deaths per aged 1–59 months. As a result, the
100,000 live births) dropped by share of neonatal deaths among all
about 38% worldwide. under-five deaths increased from 40

(39, 41) per cent in 1990 to 47 (45, of dietary diversity and feeding
49) percent. frequency that are appropriate for
● Children who die within the first 28 their age.
days of birth suffer from conditions ● Over 820 000 children's lives
and diseases associated with lack could be saved every year among
of quality care at birth or skilled children under 5 years, if all
care and treatment immediately children 0–23 months were
after birth and in the first days of optimally breastfed. Breastfeeding
life. improves IQ, school attendance, and
● Preterm birth, intrapartum-related is associated with higher income in
complications (birth asphyxia or lack adult life.
of breathing at birth), infections and ● Improving child development and
birth defects cause most neonatal reducing health costs through
deaths. breastfeeding results in economic
● Women who receive midwife-led gains for individual families as well
continuity of care (MLCC) provided as at the national level.
by professional midwives, educated
and regulated to international
standards, are 16% less likely to NATIONAL SITUATION OF MATERNAL
lose their baby and 24% less likely AND CHILD HEALTH
to experience preterm birth.
WHO region Western pacific
Infant And Young Child Feeding Key World Bank income Lower-middle-
Facts group income
(WHO - April 2020)
Child Health
● Every infant and child has the right
to good nutrition according to the Infants exclusively 34
"Convention on the Rights of the breastfed for the
Child". first six months of
● Undernutrition is associated with life (%) (2008)
45% of child deaths.
Diphtheria tetanus 60
● In 2019, 144 million children under 5 toxoid and pertussis
were estimated to be stunted (too (DTP3)
short for age), 47 million were immunization
estimated to be wasted (too thin for coverage among 1-
height), and 38.3 million were year-olds (%)
overweight or obese. (2015)
● About 40% of infants 0–6 months old Mortality and Global Health Estimate
are exclusively breastfed.
● Few children receive nutritionally Neonatal Mortality 12.6 (9.0-17.1)
adequate and safe rate (per 1000 live
complementary foods; in many births) (2015)
countries less than a fourth of infants Under-five mortality 28.0 (21.2-36.7)
6–23 months of age meet the criteria rate (probability of

dying by age 5 per

1000 live births)
(2015)
Maternal mortality 114 (87-175)

ratio (per 100,000
live births) (2015)
Births attended by 72.8

skilled health
personnel (%)
(2013)
Ambisyon Natin 2040

● Investing in People
● Protection against instability
● Universal Health Coverage
● Strengthen Implementation of RPRH
Law
● War Against Drug
● Additional funds from PAGCOR
All for Health Towards Health for All

Ph Agenda 2016-2022 Healthy
Philippines 2022
(Mother) Baby-Friendly Hospital Initiative

(M)BFHI
● The Initiative was launched in 1991
and by the end of 2007 more than
20,000 health facilities worldwide
had been officially designated baby-
friendly.
● The BFHI is a global initiative of the
World Health Organization and
UNICEF that aims to give every
baby the best start in life by creating
a health care environment that
supports breastfeeding as the norm.

Practice Guidelines on Intrapartum &

Immediate Postpartum Care
● Updated, evidence based national
guideline on intrapartum and
immediate postpartum care
● Intended for use by health
professionals (OB Specialists, OB
Practitioners, Nurses, Midwives) in
all GOVERNMENT & PRIVATE
health facilities
Four Core Steps in Immediate Newborn

Care
1. Immediate and thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non separation of newborn from
mother for early breastfeeding
Care for Small Babies

1. Essential Intrapartum and Newborn
care
● Prevention and management of
premature birth
● 4 core steps
● Postnatal care of mother and
newborn
● Basic newborn resuscitation
2. Kangaroo Mother Care
● Continuous skin-to-skin contact w
● Exclusive breastfeeding
● Early discharge from the hospital
● Close follow-up in the clinic
3. Community Support

GENETICS
GENES
● Basic units of heredity that
determine both the physical and
cognitive characteristics of people
● Composed of segments of DNA
(deoxyribonucleic acid), they are
woven into strands into the nucleus
of all the body cells from the
chromosomes
Mitosis & Meiosis

● Mitosis
○ The type of cell division that Cytogenetics
occurs in non-reproductive ● The study of chromosomes by light
cells microscopy and the way by which
○ Produces exact copies of cellular aberrations are identified
the parent cell
● Meiosis Genome
○ Cell division that occurs in ● The complete set of genes present
reproductive cells or gametes (about 50,000 to 100,000)
○ Produces egg and spen cells ● A normal genome is abbreviated as
with half the genetic material 46XX or 46XY (total number of
of the parent cells auotsomes plus a graphic
○ Haploid = 23 chromosomes description of the sex chromosome
(to produce offspring) present)
○ Diploid = 46 chromosomes
Genotype
Haploid and Diploid ● Actual gene composition
● Haploid
○ 23 chromosomes (n) Phenotype
○ Chromosomes from the ● A person’s phenotype refers to his or
gametes (Egg and sperm her outward appearance of the
cells) expression of genes
● Diploid
○ 46 chromosomes (2n) GENOTYPE PHENOTYPE
○ 22 homologous autosomal
pairs + 1 pair sex Genetic make-up of an Physical traits and
chromosomes individual characteristics of an
individual and are
influenced by their
genotype and the
environment

INHERITANCE OF THE DISEASE Autosomal Dominant Inheritance

Gregor Mendel
Mendelian Inheritance: Dominant and
Recessive Patterns (autosomes)
● Genetics is the field of Biology that
studies how characteristics (traits)
are passed from parent to child
● Gregor Mendel, the Father of
Genetics, was an Austrian Monk..
gardened and grew peas in the Mid
1800’s
● Looked at 7 different traits in pea
plants
○ Height
○ Pod appearance
○ Seed texture
○ Position of flowers
○ Flower color
○ Pod color
○ Seed color
● Principles of genetic inheritance of
disease are the same as those that
govern genetic inheritance of other
physical characteristics
○ Homozygous - with 2 health
genes from the mother and
father
○ Heterozygous - 1 gene is
healthy, 1 gene is unhealthy
Autosomal Recessive Inheritance
X-Linked Recessive Inheritance (Sex

chromosomes)

X-Linked Dominant Inheritance (Sex

chromosomes) CHROMOSOMAL ABNORMALITIES
(CYTOGENETIC DISORDERS)
Nondisjunction Abnormalities
● Uneven cellular division during
meiosis
● Failure of homologous
chromosomes to separate properly
Deletion Abnormalities
● Structural Abnormalities
○ Deletions - A portion of the
Multifactorial Inheritance chromosomes is missing or
deleted
○ Translocations - a portion of
one chromosome is
transferred to another
chromosome
GENETICS & GENETIC COUNSELLING

Genetics
Genomic Imprinting ● Study of the way such orders occur
● For a few special genes, alleles ● Branches of Genetics:
inherited from the father are ○ Molecular
expressed differently than alleles ○ Microbial
inherited from the mother. ○ Population
○ Lant and Animal

○ Mendellian outcomes and reduce family’s

○ Cytogenetics anxiety
● The strategies to achieve these
Modern Genetics outcomes vary within and across
● Mendelian genetics countries
○ Gregor Mendel
○ Investigates family patterns Genetic Counselors
of inheritance ● Healthcare professionals who are
● Cytogenetics trained in medical genetics and
○ Uses technology of cytology psychosocial counseling with
and microscopy to study specialized training in psychosocial
chromosomes and their counseling of patients and
relationships to hereditary members of their families with risks
traits for genetic disorders.
● Molecular Genetics ○ They provide genetic
○ Uses biochemistry to study counseling which involves
structure and function of DNa data gathering of family
● Genomic Medicine history information and
○ Treatment of genetic assessment
diseases through an ● Genetic Counselors
understanding of the human ○ Work closely with the
genome clinical/medical geneticists
● Medical Geneticists
Genetic Counseling ○ Provides the clinical
● Provide an opportunity for patients to diagnosis and management
understand and incorporate of a patient and other
genetic information to make medical specialists (e.d.,
informed decisions perinatologists, medical
● Increase the family’s oncologists, neurologists,
understanding about: etc.) in providing genetic
○ A hereditary disease(s) counselling for patients and
○ The risks assessments and their families who are known
occurence or suspected to have a
○ Risk And benefits of hereditary condition.
confirmatory or genetic ● Works also with a team of other
testing healthcare providers (e.g social
○ Disease management workers, nurses, nutritionists, and
○ And other available options other specialized medical
● Further explains results of testing professionals) to provide genetic
related to hereditary disease(s) counseling and support in:
● Identify with the individual and ○ Pediatric
family the psychosocial tools ○ Metabolic
required to adjust to potential ○ Cancer
○ Prenatal

○ Neurology ● Risk assessment and counseling

○ Cardiovascular ● Genetic counseling services are
○ Various high-risk specialty primarily available in government
clinics tertiary level facilities but there are
● Given the increasing number of plans to improve access to genetic
individuals seeking genetic testing counselling services in the periphery
and the expanding utilization of through the continuity clinics
genomic technologies in assessing a attached to National Newborn
patient’s disease risk, diagnosis and Screening
prognosis., there is an urgent need
to increase availability of qualified MS Genetic Counseling
genetic counselors across the globe. ● A two-year degree program that
● Genetic counselor to population ratio prepares students to become
in the Philippines is 1:16,390,000 competent genetic counselors
● Clinical geneticists to population ● Offered by the University of the
ratio is 1:10, 930,000 Philippines College of Medicine
● There is an increasing demand for Department of Pediatrics
genetic counseling services in the Other Roles
country due to: Graduates of the program are also expected
○ Expansion of the Philippine to:
Newborn Screening Program ● Manage patient registries
and ● Manage genetic services programs
○ Various public health ● Organize and mobilize patients to
genetics programs, including form support groups
the Birth Defects ● Serve as educators to other health
Surveillance Project, professionals
Telegenetics Referral ● Participate in the formulation of
System and the clinical genetic counseling practice
establishment of the guidelines.
Philippine Genome Center
Employment Opportunities
Role of Genetic Counselor ● Newborn Screening Centers
● Education about inheritance, ● Continuity clinics located
testing, management, prevention, strategically nationwide
resources, and research ● Specialty clinics in either
● Counseling to promote informed government or private healthcare
choices and adaptation to the risk or institutions
condition
● Provision of psychosocial support to
patients and their family members ROLE OF NURSES
● Patient and family medical history ● Works also with a team of other
taking health care providers (e.g. social
● Interpretation of family and medical workers, nurses, nutritionists,, and
histories other specialized medical

professionals) to provide genetic ● Health-seeking behaviours related to

counseling and support potential for genetic transmission of
disease
● Altered sexuality pattern related to
fear of conceiving child with genetic
disorder
Intervention
● Management of signs and symptoms
specific to the disease (independent
and dependent nursing functions)
● Health education
● Counselling and support
How to Provide Psychosocial Support?

● Assessing for supportive needs of
parents
● Listening to them without compelling
them to talk
● Comforting them and acknowledging
their concerns
● Helping them to obtain further
information by giving them
Nursing Process educational resourced or directing
Assessment them to reputable online sources
● Detailed family hx (preferably 3 and
generations ● Referring them to appropriate
● Physical examination: both parents specialty as needed
and any affected children
● Referral to the multidisciplinary
healthcare team SUPPORT GROUPS IN THE PHILIPPINES
Support Groups
Diagnosis ● A group of people with common
● Decisional conflict related to testing experiences and concerns who
for an untreatable genetic disorder provide emotional and moral support
● Fear related to outcome of genetic for one another
screening tests ● A support group may also work to
● Situation low self-esteem related to inform or educate the public or
inheritance pattern of the family’s engage in advocacy.
inherited disorder ● Members with the same issues can
● Knowledge deficit related to come together to:
inheritance pattern of the family’s ○ Share coping strategies
inherited disorder ○ Feel more empowered and
have a sense of community

○ Provide sympathetic parents, between families,

understanding and health care providers
establishing social networks ○ Provide training for parents
to increase skills
Types of Support Groups ○ Help in dealing with
● Self-help Group educational, medical, and
○ Fully organized and other service agencies.
managed by its members, ● Social Support
who are commonly made-up ○ Promote social interaction
of volunteers and have ○ Reduce or eliminate
personal experience in the stigmatization
subject of the group’s focus. ○ Opportunity to learn from
○ MSUD Support Group other families and other
○ Osteogenesis Imperfecta support groups
Care Philippines ○ Opportunity to network with
● Professionally Operated Support other support groups,
Groups advocacy groups,
○ Facilitated by professionals foundations, for financial
who most often do not share assistance and
the problem of the members, ○ Empowerment
such as social workers, ● Research Support
psychologists, or members of ○ Encourage Research (As a
the clergy. participant or by raising
● Advocacy Groups money for research)
○ Group of people who does
not necessarily share the Take Home Message
same issues but wanted to ● Support
advocate or promote the ○ Patient differ in the type and
issues by concerned groups amount of support that they
need
Functions of Support Group ■ Providing additional
● Emotional Support resources (both
○ Provide on-going support educational, and
○ Help in time of crisis supportive)
○ Reinforce positive coping ○ Extend genuine help where
mechanisms they need it
○ Help focus anger and use its ○ Encourage and respond to
energy in positive ways the patient’s emotional needs
○ Give an opportunity to relieve ○ Patient autonomy must be
loneliness and form new respected
friendships ○ Recognize that patients are
● Educational Support resilient
○ Share information, ideas and ○ Use of patient-centered
resources with fellow language

● Empowerment
○ Occurs when individuals
maximize their ability to
function and develop their
inner strength
○ This goal is achieved in part
by:
■ Discussion what
patients wish to
discuss
■ Respecting patients’
points of view, and
■ Enabling informed
actions and decisions
NURSING CARE OF WOMEN WITH

COMPLICATIONS DURING PREGNANCY

○ Maternal age
HIGH RISK PREGNANCY ■ Below 18 years old,
● A high risk pregnancy is defined as above 30 years old
one in which the health of the ○ Parity
mother or fetus is in jeopardy. ■ High risk if more than
● Early and consistent assessment for 4 pregnancies due to
risk factors during prenatal visits is overused elasticity of
essential for a positive outcome for the uterus
the mother and the fetus. ○ Marital status
○ Residence
○ Ethnicity
IDENTIFYING CLIENTS AT RISK ■ Cultural practices
Ways for Identification Clients at Risks ○ Income
Assessment of risk factors: ○ Racial and ethnic origin
● Physiological ○ Occupational hazards
○ Diabetic, hypertensive, heart
problem
● Psychological WHAT IS THE ROLE OF THE NURSE?
○ Raped, can’t accept ● Identify risk factors and estimate the
pregnancy, depressed potential effect of the pregnancy
● Social outcome
○ Addiction ○ Number 1 role of a nurse is
to assess. (ADPIE)
Categories for High Risk Pregnancy ○ Give health teaching and
● Biophysical provide emotional support
○ Refers to the genes of the
mother and father
○ Medical conditions CAUSES OF MATERNAL MORTALITY
● Behavioral ● Normal delivery and other
○ Lazy for check-up complications related to pregnancy
○ Cigarette smoking, occuring in the course of labor,
substance abuse delivery and puerperium.
○ Unhealthy diet of the mother ● Hypertension complicating
○ Hygiene pregnancy, childbirth and
○ Abuse and violence brought puerperium
by the husband ○ Lack of oxygen supply, high
● Psychological status blood pressure
○ Below 18 years old high risk ○ Cannot feel fetal movements
○ Depression, anxiety (for 3 days sa example ni
○ Stress maam g)
○ Results to abortion or ○ 180/90 BP
negligence that could cause ● Postpartum hemorrhage
hemorrhage ○ Hypertension, anemia,
● Socio-demographic laceration

○ Multiple parity, increased preterm labor, especially in women

blood pressure, the px died who have a history of preterm birth
● Pregnancy with abortive outcome (Berghella et al, 2003)
○ Abortion medications ● Hindi raw ganon kasakit, but may
(cytotec) pain pa rin daw
● Hemorrhage related to pregnancy
ULTRASOUND
● Uses high frequency sound waves to
visualize structures within the body
● Abdominal ultrasound during early
pregnancy requires a full bladder for
proper visualization (1-2 quarts of
water)
● Non-invasive procedure that uses
intermittent ultrasonic waves (high
frequency soundwaves) which are Transabdominal Ultrasound
transmitted by an alternating current ● The transducer is moved across the
to a transducer applied to the woman’s abdomen
woman’s abdomen ● Is often scanned with a full bladder
● The ultrasonic waves deflect off
tissues within the woman’s
abdomen, showing structures of
varying densities
● Quickening: fetal movements (10
counts in one hour)
● Fetal heart tone: use doppler in 16
weeks
Transvaginal Ultrasound
● Uses a probe inserted into the
vagina
● Internal visualization can also be Nursing Responsibility
used as a predictor for preterm birth ● Inform the patient about the
in high-risk cases (Berghella, procedure
Talucci, Desai, 2003) ● Provide comfort and privacy
● Use to detect shortened cervical ○ Empty bladder (transvaginal
length or funnelling is helpful in UTZ)
predicting preterm labor, especially ○ Full bladder
in women who have a history of (transabdominal UTZ)
preterm birth (Berghella et al, 2003) ○ Proper position → supine
● Use to detect shorted cervical length ○ Proper draping
or funnelling is helpful in predicting

● Procedure: Attached the fetal heart

FETAL DIAGNOSTIC TESTS rate monitor abdominally, record the
Fetal Well-Being heart rate for 20 minutes.
● Fetal movements are directly related
to the infant’s sleep-wake cycle Possible Result
and vary from the maternal sleep- ● Absent
wake cycle ○ No peak-to-trough range is
● A healthy fetus moves with a degree detectable
of consistency at about 10 times per ● Minimal
hour ○ An amplitude range is
● The typical active fetal period lasts detectable but the rate is 5
40 minutes and peaks between beats per minute
9:00pm and 1:00am in response to ● Moderate or normal
maternal hypoglycemia (Moses, ○ An amplitude range is
2003) detectable, rate is greater
● Baby still moves even if he/she is a than 25 beats/min.
asleep ● Marked
○ An amplitude range is
Alpha-Fetoprotein Testing (AFP) detectable, rate is greater
● Determines the level of fetal protein than 25 beats/min. (check
in the pregnancy woman’s serum or daw ni maam)
in a sample of amniotic fluid
● Correct interpretation requires an Chorionic Villi Sampling
accurate gestational age ● Chorion - outer membrane of the
● Identify low levels, which are decidua
associated with chromosome ● Amnion - inner membrane of
abnormalities or gestational decidua
trophoblastic disease (hydatidiform ● Obtaining a small part of the
mole, in 12 weeks time) developing placenta to analyze fetal
○ May lead to carcinoma cells at 10-12 weeks of gestation
(malignant) ● Results of chromosome studies are
● Identify high levels, which are available 24-48 hours later
associated with chromosome ● Cannot be used to determine spinal
abnormalities, such as spina bifida or anencephaly
bidfida (open spine); or anencephaly ○ AFP
(incomplete development of the skull ● Identify chromosome abnormalities
and the brain); gastroschisis (open or other defects that can be
abdominal cavity) determined by analysis of cells
● Reports of limb reduction defects in
Rhythm Strip Testing newborn
● Assessment of fetal well-being and ● Rh(D) immune globulin (RhoGam) is
assesses the fetal heart rate for a given to Rh-negative woman
normal baseline rate
● Position: Semi-fowlers

○ A- (mother) & A+ (father) = ○ Identify chromosome

2nd baby might be having a abnormalities, biochemical
problem (hyperbilirubinemia) disorders (such as Tay-
○ Check the chorionic villi of Sachs’ disease) and level of
the 1st baby to detect AFP
○ The mother will be given ○ A fetus can’t be tested for
RhoGam when detected every possible disorder
within 72 hours after delivery ○ Spontaneous abortion
● Higher rate of spontaneous abortion following the procedure is the
after procedure than after primary risk
amniocentesis ● Late Pregnancy
○ Identify severity of maternal
fetal blood incompatibility
and assess fetal lung
maturity (dexamethasone,
betamethasone given 2
dose every 12 hours)
○ Rh(D) immune globulin is
given to the Rh-negative
woman
Amniocentesis Nursing Responsibility

● Insertion of thin needle through the ● Obtain informed consent
abdominal and uterine walls to ○ What? Why? How? Possible
obtain a sample of amniotic fluid, complications?
which contains cast-off fetal cells ● Provide comfort and privacy
and various other fetal products ○ Full bladder, position,
● Standard genetic amniocentesis is draping
done at 15-17 weeks of gestation ● Aseptic technique
● Early genetic amniocentesis is done ○ Handwashing, sterile gloving
at 11-14 weeks of gestation for ● Skin preparation
some disorders
Non-Stress Test (NST)
● Measures the response of the fetal
Usage heart rate to the fetal movement
of ● Evaluation with an electronic fetal
monitor of the fetal heart rate (FHR)
for accelerations of at least 15
beats/min lasting 15 seconds in a
10 to 20-minute period
● Is based on the knowledge that
when the fetus has adequate
Amniocentesis oxygenation and an intact CNS,
● Early pregnancy

there are accelerations of the fetal ● Means of evaluating the respiratory

heart with fetal movement function of the placenta
● A nonreactive NST is fairly
consistent in identifying a high Usage of Contraction Test
risk/at-risk fetuses ● Identifies the fetus at risk for
● Women with a high risk factor will intrauterine asphyxia by observing
probably begin having NSTs at 30- the response of the FHR to the
32 weeks of gestation and at stress of uterine contractions
frequent intervals for the remainder (spontaneous or induced)
of the pregnancy
Interpretation of CST Results
Usage of NST ● Negative (normal/good result)
● Identify fetal compromise in ○ Shows 3 contractions of
conditions associated with poor good quality lasting 40 or
placenta function, such as more seconds in 10 minutes
hypertension, diabetes mellitus, or without evidence of late
post term gestation decelerations
● Adequate accelerations of the FHR ○ This is the desired result
are reassuring that the placenta is ○ Implication:
functioning properly and the fetus is ■ Fetus can handle the
well oxygenated hypoxic stress of
uterine contractions
Interpretation of NST Results ● Positive (not normal)
● Reactive (normal) ○ Shows repetitive persistent
○ At least 2 accelerations of late decelerations with more
FHR with fetal movements of than 50% of the contractions
15 beats per minute lasting ○ This is not the desired results
15 seconds or more for over ○ Implication:
20 minutes ■ The hypoxic stress of
○ 2 - 15 beats - 15 seconds - the uterine
20 minutes contraction causes
● Non Reactive (not normal) slowing of the FHR
○ Reactive criteria not met
● Unsatisfactory test:
○ If the data cannot be ● Equivocal or Suspicious
interpreted ir there was an ○ Shows non persistent late
inadequate fetal activity decelerations or
○ Nonreactive = nonstress test decelerations associated with
= not good hyperstimulation (contraction
○ Reactive = responsive = real frequency of every 2 mins or
good duration of longer than 90
seconds)
Contraction Test Percutaneous Umbilical Blood Sampling

● Obtaining a fetal blood sample from performing an elective caesarean

a placental vessel or from the birth or inducing labor if the
umbilical cord gestation age is questionable
● May be used to give a blood ● Also used to evaluate whether the
transfusion to an anemic fetus fetus should be promptly delivered
or allowed to mature further when
the membranes rupture and the
gestation is at less than 37 weeks or
of the gestation is questionable
Biophysical Profile
● A group of five fetal assessments:
○ FHR and Reactivity (NST)
○ Fetal Breathing Movements
■ Contraction test
○ Fetal Body Movements
○ Fetal Tone (closure of the
hand)
■ NST
○ Volume of amniotic fluid
(AFI)
■ Normal value of
amniotic fluid: 1000-
2000mL
● Identify reduced fetal oxygenation in
conditions associated with poor
placental function
● As fetal hypoxia gradually increases,
FHR changes occur first, followed by
body movements, gross body
Usage of PUBS
movements, and finally loss of fetal
● Identify fetal conditions that can be
tone
diagnosed only with a blood sample
● Amniotic fluid volume is reduced
● Blood transfusion for fetal anemia
when placental function is poor
caused by maternal-fetal blood
(shows pockets of low absent
incompatibility, placenta previa, or
amniotic fluid)
abruptio placenta
Lecithin-to-Sphingomyelin (L/S) Ratio

● 2:1
● Evaluate whether the fetus is likely
to have respiratory complications in
adapting to extrauterine life
● May be done to determine whether SCORING THE BIOPHYSICAL PROFILE
the fetal lungs are mature before

Observation Normal (2 pts) Abnormal (0

pts)
Non-Stress Reactive Non-reactive

Test
Fetal 3 discrete and Less than 3

Breathing definite discrete
Movement movements of movements of
(during 30 the arms, legs arms/legs or
Minute or body body
Observation
Period)
Fetal Muscle Arms and legs Arms and

Tone are usually legs are
(during 30 flexed with usually flexed
Minute head on chest. with head on
Observation One definite chest
Period) extension and
return to flexion No flexion
Amniotic Largest Pocket Largest

Fluid Volume of fluid is pocket is less
greater than 1 than 1 cm in
cm in vertical vertical
diameter diameter
without without loops
containing of cord
loops of cord
PREGESTATIONAL PROBLEMS
SEXUALLY TRANSMITTED DISEASE

● Each year estimated 8 million new
cases of STDs occur among young
people aged 15-24.
● Sexually active youth have the
highest STD rates of any age group
in the country.
● The largest number of new
infections occurred in the region of
South & Southeast Asia followed by

suh-Saharan African and Latin ■ Profuse greenish-

America & the Caribbean yellow discharge with
● Pregnant women with STDs are at foul odor
greater risk of miscarriage and Management
premature delivery. In some cases ● Discuss the importance of partner
they can also transmit the infection treatment (have to complete the
to their babies. treatment 7-10 days)
● Risk Factors ● Discuss the sexual transmission of
○ Lower socio-economic status this disease
○ Lower educational level
○ Sexual activity with multiple Effect to Fetus/Pregnancy
partner ● Preterm labor
○ Unsafe sexual intercourse ● Premature Rupture of Membranes
(PROM)
Candidiasis ● Post-cesarean infection
● Yeast infection, thrush
● Affects the skin, skin of the vagina, Medical Management
the penis and the mouth ● Metronidazole (anti-fungal)
● Can also infect the bloodstream or ○ Oral or IV
internal organs such as liver and ○ Usually 7 days
skin.
● Etiologic Agent Bacterial Vaginosis
○ Candida Albicans (Fungus) ● It is a syndrome in which the H2O2-
■ Thick yellow vaginal producing lactobacilli and are
discharge replaced with high concentration of
■ Pruritus anaerobic bacteria
● Vaginal amines is increase
Medical Management ● Etiologic Agent
● Application of an OTC antifungal ○ Gardnerella vaginalis
cream (Monistat) for 7 days
● Oral fluconazole (antifungal)
● S/Sx:
Management ○ Gray and has a “fishy” or
● Sitz bath “musty” odor vaginal
● Not wearing underpants discharge
○ Pruritus
Trichomoniasis
● Common cause is vaginal infection Effects to the Fetus
and discharge ● D. Nelson & G. macones (2002)
● Inflammation of the vulva and vagina relates BV with gynecologic
● Etiologic Agent conditions and complications of
○ Trichomonas Vaginalis pregnancy like:
■ Irritation and itching in ○ Pelvic Inflammatory Disease
vaginal area (PID)

■ Post hysterectomy ● Etiologic Agent

vaginal cull cellulitis ○ Chlamydia vaginalis
■ Endometritis ● S/Sx:
■ Amniotic fluid ○ Heavy, gray-white discharge
infection ○ Common clinical
■ Preterm delivery, manifestation include:
preterm labor ■ Cervicitis
■ Premature rupture of ■ Urethritis
the membranes ■ Vaginitis
(PROM) ■ PID
■ Spontaneous abortion ● Studies have shown that infants
born through an infected birth canal
Medical Management have a 60-70% risk of acquiring the
● Topical infection. In approximately 25% of
○ Metronidazole (Flagyl) infected infants, conjunctivitis will
■ 0.75% vaginal gel develop; in 10-20% of the infants,
○ Clindamycin pneumonia will develop
■ 2 % vaginal cream ● In pregnant women, Chlamydia
● Oral infections can lead to ectopic
○ Metronidazole pregnancy, preterm premature
■ 500 mg orally twice rupture of membrane (PROM), and
daily premature delivery
○ Clindamycin
■ 300 mg orally twice Medical Management
daily ● Tetracycline & Doxycycline (non-
● At twice-daily, 5-day therapy of pregnant state)
vaginal metronidazole had a ● Amoxicillin (pregnant)
reported cure rate of 75-81 percent, ● Azithromycin (pregnant)
while treatment with clindamycin ○ 1g orally
cream was reported to resolve 82-
96% of cases of BV
● There is no evidence that ● Etiologic Agents
metronidazole is teratogenic or ○ Treponema pallidum
mutagenic, and it is considered safe ● S/Sx
for use in pregnancy ○ Primary stage
■ Small, hard-based
chancre or sore
SEXUALLY TRANSMITTED BACTERIAL ○ Secondary stage
INFECTION ■ Skin rashes
Chlamydia ■ Loss of patches of
● In Asia rates among pregnant hair
women tend to be much higher: up ■ Malaise
to 17% in India and 26% in rural ■ Fever
Papua New guinea ○ Latent stage

■ Asymptomatic ● Etiologic Agent

○ Tertiary stage ○ Neisseria Gonorrhoeae
■ Gumma formation ● S/Sx
(rubbery mass of ○ Yellow-green vaginal
tissue) discharge
Effects to Fetus Effects to Fetus/Pregnancy

● Spontatneus abortion ● Severe eye infection (fetus)
● Still born infant ● Blindness
● Premature labor ● Endocervicitis
● Congenital syphilis (enlarged liver ● Premature rupture of membrane
and spleen, skin lesion, rashes, (PROM)
pneumonia, hepatitis)
Medical Management
Diagnostic Procedure ● Oral cefixime (Suprax)
● VDRL (Venereal Disease Research ○ 400 mg PO once
Laboratory) Test ● Ceftriaxone (Rocephin)
● Patients suffering from syphilis ○ 125-250 IM once
produce antibodies that react with ● Common Side Effects:
cardiolipin antigen (present in beef ○ Nausea and vomiting
meat) in a slide flocculation test
which are read using a microscope. HIV/AIDS
● For women in their reproductive
Medical Management years (15-44), HIV/AIDS is the
● Benzathine penicillin G leading cause of death; unsafe sex
(pregnancy) is the main risk factor
● Erythromycin
○ 500 mg four times a day Stages of HIV Infection
should be given for 14 days 1. Initial invasion
(Allergy to PenG) ● Flu-like symptoms
● Azithromycin 2. Seroconversion
○ 500 mg should be given daily ● Converts from having no HIV
for 10 days (allergy to PenG) antibodies in her blood
serum to having HIV
Jarisch-Herxcheimer Reaction antibodies
● Caused due to sudden destruction of ● Usually happens 6 weeks - 1
spirochetes; may last about 24 hours year after exposure
● S/Sx: 3. Asymptomatic Period
○ Hypotension, fever, ● Weight loss and fatigue (3-11
tachycardia, and muscle years)
aches 4. Symptomatic Period
● Opportunistic infections
Gonorrhea occur like oral and vaginal

candidiasis, Kaposi sarcoma, ○ Provide care with a non-

herpes complex, judgmental attitude
pneumocystis carinii
SUBSTANCE ABUSE
Diagnostic Procedure Classification
● ELISA (Enzyme-linked ● Alcohol
immunosorbent assay) ● Cocaine and crack
○ Detects presence of ● Marijuana
antibodies in the blood ● MDMA (Ecstasy)
● Western blot analysis ● Heroin
○ Confirmatory test of ELISA ● Methadone
○ Separation of proteins
Alcohol
Diagnosis ● Women may experience withdrawal
● Risk for infection related to seizures in the intrapartal period as
dysfunction immune system early as 12-48 hours after she stops
drinking
Nursing Management ○ Watch out for occurrence of
● Aseptic technique seizure
○ Handwashing and gloves; ● Delirium tremens may occur in the
reverse isolation postpartal period
● Administration of medications as ○ Newborn may suffer a
prescribed withdrawal syndrome
○ Acyclovir, Antiretroviral
therapy
Effects of Alcohol
● Provide health teaching on:
○ Breast feeding Mother Fetus
○ Protected sexual activity
● Malnutrition - folic ● Fetal Alcohol
acid & thiamine Syndrome (FAS)
deficiency ● Physical & mental
● Bone marrow abnormalities
Nursing Management for STD suppression ● Intoxicate the
● Assessment ● Increased maternal letdown
○ History taking (multiple incidence of relextal
partners, unprotected sexual infections ● Fetal Mental
intercourse) ● Liver diseases retardation
● Diagnosis ● Fetal growth
restrictions
○ Knowledge deficit r/t STDs
● Interventions
○ Discuss the causes of STD: Nursing Interventions
multiple partners ● Sedation to decrease irritability and
○ Teach about proper hygiene: tremors
perineal washing ○ Caution - fetal depression
● Seizure precautions

● Intravenous fluid therapy for

hemorrhage ● Cerebral infarction
hydration ● Respiratory failure ● Altered brain
● Preparation for an addicted newborn ● Heart problems development
● Breastfeeding is not contraindicated ● Spontaneous ● Shorter body
** Alcohol is excreted in breast milk abortion length
● Abruptio ● Malformations of
Drug-dependent Baby placentae the genitourinary
● Preterm birth tract
● Small head
● Still birth ● Apgar score
● Undeveloped pinna (outer ear) (low/poor)
● Short nose
● Missing groove above lip
Effects of Cocaine on Newborn
● Pointed, small chin
● Exposed in utero may have
● Small eye openings
neurobehavioral disturbances
● Flat face
● Irritability
● Thin lips
● Exaggerated startle reflex
● Labile emotions
Cocaine
● Sudden Infant Death Syndrome
● Placental vasoconstriction decrease
blood flow to the uterus
Caution
● Feeling of euphoria and excitement
● Cocaine crosses into breast milk
● Usually followed by irritability,
● Extreme irritability, vomiting,
depression, pessimism, fatigue, and
diarrhea, dilated pupils, apnea
addiction
● Cocaine metabolites may be present
Heroin
in the urine of the pregnant woman
● Is an illicit CNS depressant narcotic
for 4-7 days after use
● Alters perception and produces
● S/Sx
euphoria
○ Mood swings
● Addictive drug that is administered
○ Appetite changes
IV
○ Withdrawal symptoms
● Pregnant women: increased
● Withdrawal syndrome
incidence of poor nutrition, iron
○ Depression
deficiency anemia and pre-
○ Irritability
eclampsia
○ Nausea
● Fetus
○ Lack of motivation
○ Increase Risk for IUGR,
○ Psychomotor changes
meconium aspiration,
hypoxia
Effects of Cocaine ● Newborn
○ Restlessness, shrill, high-
Mother Fetus
pitched cry, irritability, fist
● Seizures, ● IUGR (Intrauterine sucking, vomiting, seizures
hallucinations growth restriction) ● Withdrawal Signs
● Pulmonary edema ● Small head ○ Appear within 72 hours
● Cerebral circumference

Methadone EVALUATION OF SUBSTANCE ABUSE

● Most commonly used therapy for Expected outcomes of nursing care
women dependent on opiods including the following
● Blocks withdw ● The woman is able to describe the
● Reduces or eliminates the craving impact of her substance abuse on
for narcotics herself and her unborn child
● It crosses the placenta ● The woman gives birth to a healthy
● Prenatal exposure: infant
○ Reduced head ● The woman accepts a referral to
circumference, lower birth social services for follow-up care
weight after discharge
● Newborn may experience withdrawal
symptoms that are often severe and
longer lasting
Nursing Diagnosis
● Imbalanced Nutrition: Less Than
Body Requirements related to
inadequate food intake secondary to
substance abuse
● Risk for infection related to use of
inadequately clean syringes and
needles secondary to IV drug use
● Risk for ineffective Health
maintenance related to a lack of
information about the impact of
substance abuse on the fetus
PLANNING AND IMPLEMENTATION FOR MENSTRUAL DISORDER

SUBSTANCE ABUSE
● Prevention of substance abuse
PHYSIOLOGY OF MENSTRUATION
during pregnancy
● Provide information about the
relationship between substance
abuse and existing health problems
● Preparation for labor and birth
should be part of prenatal planning
● Preferred methods of pain relief
○ Psychoprophylaxis and
regional blocks (epidurals)
○ Local anesthetics (pudendal
block, local infiltration)

● Sharp cramps
● Several hours of discomfort
● Felt on the one side of the abdomen
(felt on the left lower quadrant most
of the time)
● Scant vaginal bleeding
● Release of accompanying
prostaglandins
● Pain is caused by a drop or two of
follicular fluids or blood that spills in
the abdominal cavity
● It can be relieved by a mild
analgesic such as acetaminophen
(biogesic/paracetamol is the safest)
if there’s pain
Dysmenorrhea
● Painful menstruation
● Pain is caused by release of
prostaglandin in response to tissue
destruction (prostaglandin makes
the smooth muscle contract)
MENSTRUAL FREQUENCY ○ PID - Pelvic Inflammatory
● Stabilized at 28 days within 1-2 Disease
years of puberty with a range of 24- ○ Uterine myoma
34 days ○ Endometritis
● Irregular menstruation at the ○ Endometrium - abnormal
extreme of the reproductive years (2 growth of tissues outside the
years after menarche, 5 years uterus
before menopause) ● Classification
○ Before menopause - the ○ Primary - occurs in the
eggs are having difficulty to absence of organic disease
mature and the hormones ○ Secondary - occurs as a
are slowly stopping in result of organic disease,
reproduction underlying disease
○ After menarche - the body is ● Symptoms
still adjusting ○ Bloated (light cramping, 24
● 15 months for completion of the first hours before menstrual flow)
10 cycles, average of 20 cycles ○ Pain
before ovulation occurs regularly ○ Colicky (sharp pain, dull pain
DISORDERS across the lower abdomen)
Mittelschmerz ○ Aching, pulling sensation of
● Abdominal pain during ovulation the vulva and inner thigh
○ Ovulation - 14th day ● Management

○ It can be controlled by
analgesics Metrorrhagia
■ Aspirin (mild ● Bleeding between menstrual periods
prostaglandin ● Low level of progesterone
inhibitor - suppresses ● First day with 80mL blood =
the release of abnormal
prostaglandins) ● Menses stopped at 2nd day = might
■ Ibuprofen have anemia
■ Naproxen sodium ● 3-5 days = normal
○ Low dose or oral
contraceptive Endometriosis
● Abnormal growth of extrauterine
Menorrhagia endometrial cells
● Abnormally heavy menstrual flow ○ Abnormal tissue → Excessive
greater than 80 ml per menses endometrial production →
● Normal flow of blood: reflux of menstrual flow →
○ 10-35 ml/hr; standard is 25 deficient immunologic response
ml/hr → excessive estrogen
○ 35 mL = 2 ¼ tablespoon production → failure of luteal
● Happens subsequently with phase → irregular/absence of
progesterone and estrogen ovulation
secretion; causes proliferation of ○ Usually happens to
endometrium nulliparous women
● Heavy flow indicates endometriosis ● Cul-de-sac of the peritoneal cavity or
(cul-de-sac); sign of PID/early on the uterine ligaments of ovaries
pregnancy loss causes dyspareunia (painful
● Excessive iron less might coitus/intercourse)
experience anemia ● Endometriosis causes
● Assessment dysmenorrhea because of the
○ Ask client normal flow rate abnormal tissue response to
for the saturation of the estrogen and progesterone
napkin or tampon stimulation
○ 25 ml/hr is the normal flow; ○ Swelling/sloughing of uterine
3-4 pads lining → shedding off →
● Management inflammation on surrounding
○ Administration of iron tissue in the abdominal cavity
supplements (to achieve → release of prostaglandin →
sufficient hemoglobin pain
formation) ● Assessment
○ Give progesterone during the ○ Uterus is displaced by tender
luteal phase to touch
○ Low dose oral contraceptive ○ Fixed palpable nodules
or GnRH inhibitor to ○ Nodules in the ovary or in
decrease the flow cul-de-sac

● Management ○ Decrease the intensity of

○ Surgical/medical intervention training
■ Remove the nodules ○ Estrogen therapy
○ Estrogen/progesterone oral ■ Can protect bone
based contraceptive loss
■ Will stimulate implant ○ Progesterone
regression supplementation
○ Synthetic androgen ■ Has a positive effect
(Danazol) in the bone density
■ Will shrink the ○ Develop plans altering the
abdominal tissue lifestyle and decreasing
○ GnRH agonist stress
■ Suppresses the
pituitary gland to
stimulate GnRH
Amenorrhea
● Absence or cessation of menstrual
flow
● Common to athletes
○ Intensive training → Low ratio
of body fat to body muscles →
excessive secretion of prolactin
→ decrease of GnRH → low
FSH → decrease of follicular
development and estrogen
secretion
Hypogonadotropic Amenorrhea
● Problem in the central hypothalamic
- pituitary axis
● Results from hypothalamic
suppression that results to stress
and body fat-to-lean ratio
● May have pituitary lesion or genetic
disability to produce FSH and LH
● Management ANTEPARTUM COMPLICATIONS (PREGNANCY

○ Counseling and education
○ Plan how to discontinue or AT RISK: GESTATIONAL PROBLEMS)
decreases medication known
to affect the menstruation ● Antepartum - Before/during
○ Resolve the source of stress pregnancy
● Intrapartum - During labor/childbirth

● Postpartum - After childbirth (presence of air in the respiratory

system)
DANGER SIGNS OF PREGNANCY Absence of Fetal Heart Sounds

Vaginal Bleeding ● After they have been initially
● Should be reported immediately auscultated - on the 4th or 5th month
● Abnormal (IUFD)
● Bright red bleeding might be sign of ● IUFD - Intrauterine Fetal Death
miscarriage
Swelling of Face and Fingers = Edema
Persistent Vomiting ● Sign of pregnancy induced hypertension
● Nausea and vomiting that continues (because of vasoconstriction → less O2
after 12 weeks of pregnancy is supply to the fetus → may lead to
extended vomiting fetal/maternal death)
● It depletes the nutritional value to the ● Lower extremities (normal)
fetus (as well as the mother) ○ 7 months - normal
● Can cause dehydration, may lead to ○ 20 weeks (small uterus) -
fetal/maternal death abnormal
● 1st and 2nd trimester edema
Chills and Fevers ○ Not normal, big problem. Px
● May be due to intrauterine infection might have hypertension
● Serious complication to both mother
and fetus Flashes of Lights or Dots (Scotoma)
Sudden Escape of Fluid from Vagina Blurring of Vision

● Membranes are ruptured ● Diabetes
● Mother and fetus are threatened
because uterine cavity is no longer Severe Headache and Dizziness
sealed against infection ● May mean signs of pregnancy-
● Normal value of amniotic fluid: induced hypertension
800-1200 CC
**Refer the client to the physician
Abdominal or Chest Pain **Check from head to toe
● May mean tubal pregnancy that
have ruptured
● Suppression of phrenic nerve
● Separation of placenta (destruction COMPLICATIONS OF PREGNANCY:
of tissues—release of
prostaglandins so may pain) FIRST TRIMESTER
● Preterm labor - unstoppable
contraction Hyperemesis Gravidarum
● Chest pains - pulmonary embolus ● Excessive nausea and vomiting that
that follows thrombophlebitis persist beyond 12 weeks gestation

● Leads to complications like ● It can happen any time from

dehydration, weight loss, starvation conception (when the egg is
and fluid & electrolyte imbalance fertilized) to the end of pregnancy
● Abortion
Etiology
● Unknown Spotting
● Few drops of blood on your
Signs and Symptoms underwear
● Excessive nausea and vomiting not ● It is not even enough to cover your
relieved by ordinary remedies panty liner
persisting beyond 12 weeks
● Signs of dehydration: thirst, dry skin, Bleeding
increased pulse rate, weight loss, ● Heavier flow of blood
concentrated and scanty urine ● With bleeding, a liner or pad is
needed to keep the blood from
Nursing Diagnosis soaking clothes
● Imbalanced nutrition, less than body ● Amount of blood is less than 500 cc
requirements, related to ● 3-4 pads/day
● Risk for deficient volume related to
vomiting Abortion (Miscarriage)
● Interruption of pregnancy before a
Management fetus is viable (fetus is 20-24 weeks;
● Small amounts of clear fluid intake the fetus is able to survive outside
○ If large amount, may cause the uterus)
vomiting reflux ● Expulsion or extraction of an embryo
● Measure intake and output to or fetus weighing 500 g or less from
monitor hydration its mother (WHO)
● Small quantities of toast, crackers, ● Abortus - less than 500 g
cereals
○ To not irritate the gastric Risk Factor
mucosa ● In women younger than 20 years,
● Soft diet miscarriage occurs in an estimated
○ Monitor IV fluids 12% of pregnancies, in women older
● D10 NSS 3000 ml in 24 hours = is than 20 years, miscarriace occurs in
the priority of the treatment an estimated 26% of pregnancies
○ D10 NSS is hypotonic (low Causes
salt concentration, dilates ● Abnormal fetal formation
RBC) (teratogenic factor)
● Rest ○ Teratogenic - can easily pass
● Antiemetic or cross the placenta that
○ Ex. Aprepitant can harm the baby; might
cause abortion because of
Vaginal Bleeding During Pregnancy vasconstriction in the blood
● Discharge of blood from the vagina vessels (ex. Smoking,

alcohol, cocaine); can cause ■ Need for sympathetic

withdrawal from substance and supportive
abuse person
● Implantation abnormalities ■ Restrict coitus for 2
● Lack of progesterone produced weeks after bleeding
● Infections (STIs) episode
● Teratogenic drugs ● If there is
○ Ex. Methadone sexual
● Stress intercourse
○ Due to the release of cortisol there will be
which can cause constriction
vasoconstriction
Early abortion - before 16 weeks

Late abortion - between 16-29 weeks
Types of Abortion
1. Threatened
○ Possible loss of product of
conception; patient can
continue the pregnancy
○ A threatened abortion is
vaginal bleeding that occurs
in the first 20 weeks of
pregnancy. The bleeding is 2. Imminent (Inevitable)
sometimes accompanied by ○ Inevitable abortion
abdominal cramps. ■ The loss of the
○ The fetus can survive products of
○ Signs and Symptoms conception cannot be
■ Vaginal bleeding → prevented
scant and usually bright ○ Cervix is open
red ○ Clinical Manifestation
■ Slight cramping ■ Moderate to profuse
■ No cervical dilation bleeding
during IE ■ Moderate to severe
○ Management uterine cramping
■ Assess FHR ■ Open (dilated) cervix
■ Check what activity ■ Rupture of membrane
causes the event ■ Miscarriage when
■ Avoid strenuous uterine contractions
activity for 24-48 and cervical dilations
hours occur
○ Management

■ Save any tissue ○ Products of conception is

fragments and bring expelled, but membrane or
to the hospital for placenta is retained in the
examination uterus
■ Assess FHR and fetal ○ Signs and Symptoms
being (but negative) ■ Vaginal bleeding
■ If no FHR, D&E ■ Abdominal cramping
(dilation and ○ Management
evacuation) is ■ Dilation and curettage
advised (D&C)
■ Oxytocin after D&C - ■ Inform patient that
contraction of uterus pregnancy is lost
to prevent bleeding 5. Missed
■ Inform that the ○ Also known as “early
pregnancy is lost pregnancy failure”
○ Dilation and Evacuation ○ Fetus dies in utero but it is
■ To clean the uterus not expelled
and prevent infection ○ Laminaria
■ After the procedure, ○ Signs and Symptoms
assess patient for ■ Fundal height
vaginal bleeding → remains to be the
count number of pads same (prenatal exam)
used ■ Previously heard FHR
3. Complete is no longer heard
○ Entire products of conception ■ Painless vaginal
are expelled spontaneously bleeding
without any assistance ■ UTZ confirmation that
○ Signs and Symptoms the fetus is lost
■ Lower abdominal ○ Management
cramping ■ Dilation and
■ Vaginal bleeding evacuation (D&E) is
■ Passage of products commonly done
of conception ■ If over 14 weeks,
labor induced by
prostaglandin
suppository or
misoprostol (Cytotec);
oxytocin stimulation
● If more than
14 weeks,
induce for
labor; hindi na
4. Incomplete pwede ma-
suction

■ Provide emotional ○ Insert indwelling

support and catheter as
accepting attitude prescribed
■ Refer patient to ○ Initiate IV insertion
counseling and monitoring as
6. Recurrent Pregnancy Loss prescribed
(Habitual Miscarriage) ○ Administer
○ A micarriage pattern when antibacterial
women who has three medications as
spontaneous miscarriage ordered
that occured at the same ○ Assist in D&E or D&C
gestational age procedure
○ Incompetent cervix ○ Inform the patient of
○ 1-3 mos/1-12 weeks - pwede possible risks if this is
maabort si baby present
○ Causes ○ Refer patient to
■ Defective counseling
spermatozoa or ova
■ Endocrine factors
■ Deviation of the
uterus (ex.
Anteflexed,
retroflexed,
hyperflexed)
■ Infection
■ Autoimmune
disorders
7. Septic Abortion
● Abortion that is complicated Complications of Miscarriage
by labor Hemorrhage
● Signs and Symptoms ● Assess the cause of miscarriage
○ Foul smelling ● Check the extent of bleeding, color
○ Uterine Cramping and odor of blood
○ Fever ○ Hemoglobin count (baka may
● Management anemia)
○ Check for s/sx of ● Monitor vital signs
infection ● Pace patient in supine position
○ Assist patient during ● Provide fundal massage (to keep the
intensive treatment uterus contracted)
(CBC, electrolyte ● Management:
evaluation, urine ○ Demonstrated supportive
culture, etc) attitude
○ Prepare for D&C if possible
○ Administer blood
components (as prescribed)

○ Administer oral medication ● Previous ectopic pregnancy

(Methergine) as prescribed ● Tubal surgery
● Previous genital infections
Infection (gonorrhea, chlamydia, pelvic
● Check for fever (38 C), abdominal inflammatory disease)
pain or tenderness and foul vaginal ● Smoking
discharge ● Previous pelvic or abdominal
● Instruct the patient to practice proper surgery
perineal cleaning ● Sexual intercourse before 18 years
● Avoid use of tampons. Tampons can old
aggravate the situation of having
infection. Signs and Symptoms
● Demonstrated aseptic technique in ● Bleeding/vaginal spotting → scant to
handling the patient profuse
● Lower abdominal pain
Isoimmunization ● Sharp, stabbing pain in lower
● Administer Rh Ig as prescribed (72 abdominal quadrants (ruptured)
hours after the delivery) ● Adnexal tenderness
● RhoGam, Rh sensitization. Rh ● UTZ → gestational sac outside uterus
positive mother, Rh negative father ● Quantitative B-HCG is usually less
= no problem in 1st baby, but on the ○ In a normal pregnancy, B-
2nd baby, yes HCG level reaches 10,000-
● The baby might have 20,000 mIU/mL
hyperbilirubinemia ● Cul de sac mass
● Powerlessness and anxiety ● Absence of amniotic sac
○ Deal with the patient with an ● Amenorrhea or abnormal
understanding and menstruation followed by slight
supportive attitude uterine bleeding
○ Encourage verbalization of
feelings
○ Refer to counseling (if
necessary)
The Process of Shock due to Blood
Loss
Blood loss
Ectopic Pregnancy
↓
● Implantation occurs outside the
Decreased intravascular volume
uterine cavity
↓
● Usually occurs in the fallopian tube,
Decreased venous return, cardiac output
cervix and ovaries
and BP
● Second leading cause of bleeding in
↓
early pregnancy
Vasoconstriction of peripheral blood
vessels & inc. respiratory rate
Etiology

↓
Cold, clammy skin, decreased uterine
perfusion
↓
Reduced renal, uterine, and brain
perfusion
↓
Lethargy, coma, decreased renal output
↓
Renal failure
↓
Maternal and fetal death
Signs of Tubal Rupture

● Severe sharp knife like pain in the
lower quadrant of the abdomen
● Abdominal rigidity (matigas)
● Nausea and vomiting
● Low hgb and Hct
● Sharp localized pain in the cervix on
internal examination (wiggling sign)
Complication of Ectopic Pregnancy
Signs of Shock ● Sonogram reveals ruptured fallopian
● Falling BP, rapid pulse tube and blood accumulation in the
● Lightheadedness peritoneum
● Pallor ● Abdominal rigidity → peritoneal
● Cyanotic nail beds irritation
● Cold clammy skin ● Cullen’s sign → bluish discoloration in
umbilicus
Signs of Hemorrhage ● Extensive or dull vaginal or
● Cullen’s Sign abdominal pain
○ Bluish discoloration of the ● Shoulder pain → phrenic nerve irritation
umbilicus du to the presence ● Lightheadedness (late)
of blood in peritoneal cavity ● Tachycardia, tachypnea,
● Hard or rigid boardlike abdomen hypotension
Pathophysiology of Ectopic Pregnancy Diagnostic Test

● Culdocentesis - aspiration of bloody
fluid from cul de sac of douglas
● Ultrasound reveals presence of the
gestational sac outside of the uterine
cavity

■ Removal of the
ovaries
○ Salpingectomy
■ Removal of the
fallopian tube
○ Salphingo-oopherectomy
■ Removal of fallopian
tubes and ovaries
● Administration of RhIG
● If not yet ruptured
○ Salpingostomy - removal of a
conceptus less than 2 cm
located at the distal portion of
the fallopian tube by
performing a linear incision
over the ectopic pregnancy.
The conceptus will extrude
Medical Management from the incision and be
● Conservatory therapy removed manually.
○ Goal: remove ectopic ○ Salpingotomy - longitudinal
pregnancy and preserve rep. incision is made over the
Function ectopic pregnancy and the
○ Single dose of Methotrexate conceptus is removed using
● Single-dose parenteral methotrexate forceps or gentle suction.
has been shown to be safe, ○ Fimbrial evacuation -
effective, and associated with removal of the conceptus by
minimals costs when used in milking and suctioning of the
carefully selected patients. fallopian tube.
● If ruptured:
Criteria for Methotrexate Therapy ○ Removal of the ruptured tube
● Hemodynamically stable because the presence of a
● Reliable, compliant patient who will scar if tube is repaired and
return for follow up care left can lead to another tubal
● Ectopic pregnancy smaller than 4 pregnancy
cm in diameter or smaller than 3.5
cm with cardiac activity
● Absence of fetal cardiac activity on Nursing Management
ultrasonographic findings ● Prevent and treat hemorrhage which
● No evidence of tubal rupture is the main danger of ectopic
● hCG less than 5000mlIU/mL pregnancy
○ Blood transfusion
Surgical Intervention ○ Place patient flat n bed with
● Goal: Planning of future pregnancy legs elevated
○ Salpingostomy

○ Monitor vital signs, I&O, and Types of H Mole

amount of blood loss ● Complete
● Provide comfort ○ Trophoblastic villi swell and
○ Administer analgesics becomes cystic
○ Relaxation techniques ○ Embryo is dead (1-2 mm)
● Provide support during grief ○ No fetal blood present
○ Provide emotional support ○ 46XX or 46XY
○ Refer patient to counseling ● Partial
○ Listen to concerns ○ Some villi are formed
● Provide patient education ○ Villi are swollen and
○ S/Sx of ectopic pregnancy misshapen
○ Report to primary care ○ 69 chromosomes
○ Bring support person ○ 69 XXX or 69 XXY
○ Chances of another ectopic
pregnancy
○ Contraception
■ Ovulation begins as
early as 19 days or 3
weeks after resection
of ectopic pregnancy
Hydatidiform Mole
● Also known as Gestational
Trophoblastic Disease or Molar
Pregnancy
Signs and Symptoms
● Abnormal proliferation and
● Amenorrhea
degeneration of trophoblastic villi
● Positive pregnancy test
● Is a mass of abnormal rapidly
● hCG → 1-2 M IU
growing trophoblastic tissue in which
● Uterine size increases
avascular vesicles hang in grapelike
● Nausea and vomiting
clusters that produce large amounts
● Hypertension
of HCG
● Edema Proteinuria
● UTZ reveal
Predisposing Factors
● 17 years old below and 35 years old
above
● Low socioeconomic status
Management
● Low protein intake
● D and C or D and E to remove the
● Previous mole
mole. (If the woman is more than 40
● Higher incidence in Asian women
years old, hysterectomy is done
since she has a higher chance of
Etiology
developing choriocarcinoma)
● Unknown

● Monitor HCG for 1 year (HCG ● Hysterectomy

should be negative 2-6 weeks after
removal of H. mole) Nursing Management
● Chest X ray every 3 months for 6 1. Maintain fluids and electrolytes
months. The lungs are the most 2. Emphasize that pregnancy should
common site of metastasis of be avoided for 1 year
choriocarcinoma. 3. Administer blood replacement as
● Chemotherapy (Methotrexate) if: ordered
○ hCG titers are increased for 4. Emotional support
3 consecutive weeks or
double at anytime
○ hCG titers remain elevated 3-
4 months after delivery
● The woman is advised not to get
pregnant not to get pregnant for 1
year, contraceptive method should
NOT be pills.
○ Pills contain estrogen which
promote regrowth of the
chorionic villi
● Hysterectomy is the method of tx for
woman above 40 years old because
of the higher incidence of
malignancies and to clients who
have completed childbearing and
require sterilization
Prognosis
● Favorable if hCG titers do not recur
after
● Unfavorable if malignancy develops
and is untreated
Complications of H. Mole
● Gestational Trophoblastic Tumors
○ Persistent trophoblastic
proliferation after H. Mole
● Choriocarcinoma most severe COMPLICATIONS OF PREGNANCY: SECOND
malignant complication that involve
the transformation of chorion into TRIMESTER BLEEDING
cancer cells that invade & erode
blood vessels & uterine muscles. Premature Cervical Dilation
● Also known as Incompetent Cervix
Management

● The cervix Dilates prematurely and

cannot hold the fetus until term
● Painless cervical effacement &
dilatation in early mid-trimester
resulting in expulsion of products of
conception
● Most common cause of habitual
abortion ● Shirodkar
○ Permanent
Risk Factors ○ Sterile tape is the threaded in
● Increased maternal age a purse-string manner under
● Congenital structural defects the submucosal layer of the
● Trauma to cervix cervix and sutures in place to
● Repeated DC achieve a closed cervix
Signs and Symptoms

● Show → pink-stained vaginal discharge
● Increased pelvic pressure
● Premature rupture of membrane
● Contractions in mid-trimester
● Presence of painless cervical
dilatation ● After suturing the cervix..
○ Place woman on bed rest for
Management 24 hours
● Surgical ○ Observe for bleeding, uterine
○ Cervical cerclage contractions, and rupture of
(Shirodkar/McDonald BOW
technique) ○ If BOW ruptures - sutures are
○ 14-16weeks of gestation removed
○ Purse string sutures are ○ If uterine contractions occur -
placed in the cervix by the the woman is given ritodrine
vaginal route under regional to stop the contractions
anaesthesia ○ Post-op Care
○ To strengthen cervix and ■ Restrict activities for
prevent it from dilating the next 2 weeks
including coitus
○ Place in a slight or modified
● McDonald’s trendelenburg position
○ Temporary nylon sutures are
placed horizontally and
vertically across the cervix
and pulled tight to reduce the
cervical canal to a few
millimeters

COMPLICATIONS OF PREGNANCY:
THIRD TRIMESTER BLEEDING

Placenta Previa ● Marginal - near the edge of the

● Abnormal implantation of placenta in cervix; double set up
the lower uterine segment, partially
or completely covering the internal
cervical os
● Habitual abortion, smoking, multiple
pregnancy
● Previa - placenta nauuna sa baby
● Cesarean delivery, hindi pwede
mauna si placenta, no oxygen for
baby
Types of Placenta Previa Marginal Placenta Previa can give birth

● Complete - the placenta completely normally but close monitoring, monitor the
covers the cervix; not for vagnal bleeding of the mother.
delivery, bleeding may occur
Normal Placenta
● 500 grams
● 15-20 cm in diameter
● 1.5-3.0 cm thick
● Weight approximately 1/6th of the
fetus
● Partial - the placenta is partially over

the cervix; not for vaginal delivery

Pathophysiology of Placenta Previa ● Palpate for presence of uterine

contractions
● Evaluate laboratory data on Hct and
Hgb
● Assess fetal status with continuous
fetal monitoring
● Never perform a vaginal examination
when patient is bleeding
○ Pag nagbbleed and wala
pang previous record, ask
when was the last time she
had an ultrasound
○ No vaginal examination if
patient is bleeding on the
third trimester. Suspect for
placenta previa
P - Painless
R - Red vaginal bleeding or Relaxed
uterine
E - Episodes of bleeding
V - Visible bleeding
I - Intercourse post-bleeding
A - Abnormal fetal position
**Not all are manifested for a patient who has the

condition
Nursing Interventions and Diagnoses

1. Altered Tissue Perfusion related
to excessive bleeding causing
fetal compromise
● Position on side to promote
placental perfusion
○ Priority nursing
intervention
○ To expand the
diaphragm and lungs
● Frequently monitor mother
Assessment
and fetus
● Determine the amount and type of
● Administer oxygen as
bleeding
facemask as indicated (8-10
● Inquire as to presence or absence of
per minute)
pain in association with the bleeding
● Record and fetal VS

● Administer IV fluids as ●
Provide information on a CS
prescribed delivery
2. Fluid volume deficit related to ● Discuss the effects of long
excessive bleeding term hospitalization or
● Position in a sitting position prolonged bed rest
to allow weight of fetus to 5. Fear related to outcome of
compress the placenta and pregnancy after episodes of
decrease bleeding bleeding
○ Priority nursing ● Explain all treatments and
intervention procedure
● Maintain strict bed rest ● Encourage verbalization of
during any bleeding episode feelings by patient and family
● Establish and maintain a ● Provide information on a CS
large-bore IV line, as delivery
prescribed and draw blood
for type and screen for blood
Anxiety Diagnosis vs. Fear Diagnosis
replacement
● Anxiety - Outcome is unknown
● Administer blood or blood
● Fear - Outcome is known
products protocol per
institutional policy
● Prepare woman for a Assessment
cesarean delivery ● Determine the amount and type of
3. Risk for infection related to bleeding
excessive blood loss ● Inquire as to presence or absence of
● Assess odor of all vaginal pain in association with the bleeding
bleeding or lochia ● Record maternal and fetal VS
○ Priority nursing ● Palpate for the presence of uterine
intervention contractions
● Evaluate temperature q4h ● Evaluate laboratory data on Hct and
unless elevated; then Hgb
evaluate q2h ● Assess fetal status with continuous
● Evaluate WBC and fetal monitoring
differential count ● Never perform a vaginal examination
● Use aseptic technique when when patient is bleeding
providing care
● Teach perineal care and CHARACTERI PLACENTA ABRUPTIO
hand washing techniques STIC PREVIA PLACENTA
4. Anxiety related to excessive
bleeding Onset 3rd trimester 3rd trimester
commonly at
● Explain all treatments and
32-36 weeks
procedure
● Encourage verbalization of Bleeding Mostly May be
feelings by patient and family external, small concealed,
to profuse in external dark

○ Increta - invades the

amount, bright hemorrhage
red or bloody myometrium and
amniotic fluid endometrium
○ Accreta - removal of uterus
Pain & Uterine Usually Usually ○ Damaged endometrium
Tenderness absent; uterus present; ● Immediate hemorrhage, with
soft irritable
possible shock and maternal death
uterus,
progresses to ● Increased risk for anemia secondary
board-like to increased blood loss and infection
consistency secondary to invasion procedures to
resolve bleeding
Fetal Heart Usually normal Maybe ● Intrauterine growth restriction
Tone irregular or
(IUGR)
absent
● Congenital anomalies
Presenting Usually not May be ● Fetal mortality resulting to hypoxia in
Part engaged engaged utero and prematurity
Shock Usually not Moderate to

Medical Management
present unless severe
bleeding is depending on ● IV access
excessive extent of ● Laboratory examinations
concealed ● Blood typing and cross matching
and external ○ Should be done before
hemorrhage infusion to determine the
compatibility of the blood
Delivery Delivery may Immediate
be delayed delivery, ● Administer Betamethasone
depending in usually by CS (Celestone)
size of fetus section ○ q12 hours
and amount of ○ For lung maturity
bleeding ○ Can preserve the mother
when bleeding occurs
Complications ○ Mother who undergoes
● Placenta accreta premature delivery or
○ The placenta adheres into preterm labor
the entire uterus that will
cause too much Surgical Management
bleeding/hemorrhage ● Amniocentesis
○ Dumikit na yung placenta ○ Lung maturity
kaya mahirap alisin ● CS section
○ Hysterectomy ○ L/S ratio: 2:1
○ Pecreta - only penetrates the
endometrium; can do manual
extraction

Abruptio Placenta ● If the placenta begins to detach

during pregnancy, there is bleeding
from these vessels. The larger the
area that detaches, the greater the
amount of bleeding.
Pathophysiology of Abruptio Placenta
● Is premature separation of the

implanted placenta before the birth
of the fetus
● Hemorrhage can either be occult or
apparent
● Occult
○ With an occult hemorrhage,
the placenta usually
separates centrally, and a
large amount of blood is
accumulated under the
placenta.
● Apparent
○ When the apparent
hemorrhage is present, the
separation is along the
placental margin, and blood
flows under the membranes
and through the cervix.
Assessment
● Determine the amount and type of
bleeding and the presence or
absence of pain

● Monitor maternal and fetal vital ○ Reassuring pattern

signs, especially maternal BP, pulse, 2. Acute Pain related to increase
FJR, and FHR variability uterine activity
● Palpate the abdomen ● Instruct and encourage the
○ Note the presence of use of relaxation technique to
contractions and relaxations augment analgesics
between contractions (if ○ Use one verb for the
contractions are present) ncp
○ If contractions are not ● Instruct patient on the cause
present, assess the of pain to decrease anxiety
abdomen for firmness ○ What causes pain
■ Board-like abdomen, ● Administer pain medications
super firm as needed and as prescribed
● Measure and record fundal height to 3. Fluid volume deficit related to
evaluate the presence of concealed excessive bleeding
bleeding ● Establish and maintain a
● Prepare for possible delivery large-bore IV line, as
prescribed and draw blood
Nursing Interventions and Diagnoses for type and screen for blood
1. Ineffective tissue perfusion replacement
(placental) related to excessive ○ Priority nursing
bleeding, hypotension, and intervention
decreased cardiac output, ● Evaluate coagulation studies
causing fetal compromise (pick ● Monitor maternal VS and
one) contractions
● Position in the left lateral ● Monitor vaginal bleeding and
position, with the head evaluate fundal height to
elevated to enhance detect an increase in
placental perfusion bleeding
○ Priority nursing 4. Risk for infection related to
intervention excessive blood loss
● Evaluate fetal status with ● Use aseptic technique when
continuous external fetal providing care
monitoring ● Evaluate temperature q4
● Evaluate the amount of hours unless elevated; then
bleeding by weighing all evaluate q2 hours
pads. Monitor CBC results ● Evaluate WBC and
and VS differential count
● Administer oxygen through a ● Teach perineal care and
snug face mask at 8-12L per hand washing techniques
minute or as prescribed ● Assess odor of all vaginal
● Prepare for possible CS bleeding or lochia (Priority
delivery if maternal or fetal Intervention)
compromise is evident

5. Fear r/t excessive bleeding

● Central:
procedures and unknown Detachment of the
outcome center surface;
● Inform the woman and her edges stay
family about the status of attached
herself and the fetus (Priority
Vaginal Bleeding Vaginal bleeding
intervention ?)
● Usually bright, ● Visible dark, or
● Explain all procedures in may be profuse concealed
advance when possible as bleeding within the
they are performed uterus
● Answer questions in a calm
manner, using simple terms Enlarged uterus
● Encourage the presence of a suggests that blood is
accumulating within the
support person
cavity
Complications Pain Pain

● Maternal shock ● Only present ● Gradual or abrupt
● Anaphylactoid syndrome of during labor onset of pain and
pregnancy uterine
tenderness,
● Postpartum hemorrhage possibly low back
● Acute respiratory distress syndrome pain
● Sheenhan’s syndrome
● Renal tubular necrosis Uterine is soft no Uterus is firm and
● Rapid labor and delivery abnormal contractions broadlike; may be
● Maternal and fetal death or irritability irritable, with frequent,
brief contractions
● Prematurity
Fetus may be in Fetal presentation is
Medical Management breech position usually normal
● IV administration of fibrinogen or
cryoprecipitate Normal blood clotting Often accompanied by
impaired blood clotting
● Laboratory examinations
Postpartum Postpartum
Surgical Management Complications: Complications:
● CS section ● Infections - ● Infections –
Placental site is Bleeding into
near the non uterine muscle
Placenta Previa Abruptio Placentae sterile vaginal fibers predisposes
● Hemorrhage – to bacterial invasion
Abnormal implantation Premature separation Lower uterine ● Hemorrhage –
of the placenta in the of the normally segment does not Bleeding into
lower uterus implanted placenta contract as uterine muscle
● Marginal ● Partial effectively to fibers damages
● Partial ● Total compress them, inhibiting
● Total ● Marginal: bleeding vessel uterine contraction
Detachment at the ● Signs of fetal after birth
edge compromise if ● Signs of fetal

maternal shock or compromise delivered to the of the uterus

extensive depending on fetus ● Fetus sometimes
placental amount and ● Vaginal dies before
detachment occur location of the examination is not delivery –
● Fetal/neonatal placental surface done because it emotional support
anemia may occur that is disrupted may precipitate
because of blood ● Fetal/neonatal bleeding
loss anemia may occur
because of blood
loss Premature Rupture of Membranes
(PROM)
Treatment: Treatment: ● Spontaneous rupture of the
● The goal is to ● Immediate CS membranes
maintain the the because of risk of ● Wait for at least 6-7 hours for the
pregnancy until maternal shock,
progress of labor, and if the labor is
the fetal lungs are clotting disorders,
mature enough and fetal death progressing then we can deliver the
that respiratory ● Blood and clotting fetus normally; if not, CS.
distress is less factor replacement
likely (at about 34 may be needed Etiology
weeks of because of DIC ● Infections
gestation) ● Incompetent cervix
● Should lie on her
● Fetal abnormalities
side or have a
pillow under one ● Sexual intercourse
hip to avoid
supine Risks
hypotension ● Major Risk
● With low-lying ○ Ascending intrauterine
placenta or infection
marginal placenta
● Other Risk
previa may be
able to deliver ● Precipitous labor (mabilis na
vaginally unless labor, 3 hours)
the blood loss is
excessive Treatment and Nursing Care
● Wait and watch, bed rest, no
Nursing Care: Nursing Care:
intercourse
● Observation of ● Preparation for CS
vaginal blood loss delivery ○ Discharge: foul odor +
and of signs and ● Monitor vital signs meconium → sign that the
symptoms of ● Monitor FHR mother has infection
shock ● Signs of shock ● Assess tie membranes ruptures and
● Vital signs are and bleeding from if labor started
taken every 15 the nose, the ○ Ruptured - labor will start;
minutes if the gums and other
need ilabas ni baby
woman is actively unexpected sites
bleeding should be ○ Leak - parang urine lang;
● O2 is given to promptly reported promote bedrest
increase amount ● Assess for the size ● Check temperature frequently

○ Maybe there’s an infection ○ Ruptured membranes

● Describe character of amniotic fluid ● Tocolysis - procedure to stop the
● Check WBC labor
○ Increase WBC indicates ● Tocolytics - referring to medication
infection
○ Normal: 10 Tocolytic Medications
● Provide psychological support B-adrenergic Agonist
● Yutopar (ritodrine)
Accelerating Fetal Lung Maturity ● Brethine (terbutaline sulfate)
● Betamethasone (Celastone) or ● Bricanyl
Dexamethasone (Decadron) to ● Side Effects or Warning Signs
stimulate the lungs and accelerate ○ Palpitations
fetal lung maturity thereby ○ Tachycardia - pulse: 120
decreasing chance of respiratory ○ Tremors, nervousness,
distress syndrome restlessness
● Lasts for about 7 days and need to ○ Headache, severe dizziness
repeat as prescribed ○ Hyperglycemia
○ STOP IV INFUSION PAG
Preterm Labor MERON
● Labor that occurs after 20 weeks but ● Toxic Effects (Pulmonary Edema)
before 37 weeks ○ Rales, crackles, dyspnea
noted on routine nursing
Etiology chest assessment every shift
● Urinary tract infections
● Premature rupture of membranes Nursing Care for Tocolytic Drugs
● Stop the medication
Goal ● Notify physician
● Stop the labor ● Start oxygen
● Suppress uterine activity ● Give antidote: Inderal
○ 0-2 cm latent stage
Magnesium Sulfate
Therapeutic Interventions Drug Therapy ● Tocolytic Medication
Tocolytics ● Decreases frequency and intensity
● Uses of uterine contractions
○ Stop or arrest labor ● Lowers calcium level that relaxes the
● Criteria for Use, Don’t Give If: uterus
○ Patient is in Active labor (3- ● Given via IV infusion pump
7cm), cervix has dilated to 4 ○ Loading dose 4-6 g in 100 ml
cm or more given over 20 minutes
○ Presence of Severe Pre- ○ Maintenance dose 1-4 g per
eclampsia hour
○ Fetal complications/Fetal ● Side Effects
demise ○ Lethargy and weakness
○ Hemorrhage is present ○ Sweating, flushing

○ N/V, headache, slurred ○ Used for pregnancies <32

speech weeks gestation and not
● BURP given for more than 72 hours
○ BP ○ Not widely used medication
○ Urine output ● Self Care Measures
■ 10-30cc/hr ○ Rest
○ Respiration ○ Drink plenty of fluids - 2-3
■ Not below 12bpm quarts/day
○ Patellar reflexes ○ Empty bladder every 2-3
■ Positive patellar hours when awake
reflexes ○ Avoid lifting heavy objects
○ If there’s no BURP, do not ○ Avoid overexertion
administer magnesium ○ Modify sexual activity (no
sulfate sexual activity if preterm
● Toxic Effects labor)
○ Absences of reflexes
○ Respiratory depression Preterm Labor Nursing Care
● Antidote: Calcium Gluconate ● Teach how to take medication on
time
Calcium Channel Blocker ● Teach patient to check pulse, call
Nifedipine physician if > 120 - 140 (dehydration
● Decreases smooth muscle increases contractions)
contraction by blocking the slow ● Teach to assess fetal movement
calcium channels at cell surface daily, kick counts
● Administration ● Drink 8-10 glasses of water per day
○ Orally or sublingually ● Monitor uterine activity - home
● Side Effects monitoring - call physician if has
○ Hypotension, tachycardia contractions
○ Facial flushing ● Decrease activity
○ Headache ● Lie on left side
■ Because of sudden ● Keep bladder activity
decrease of blood
pressure Accelerating Fetal Lung Maturity
● Betamethasone/Celestone
Prostaglandin Synthesis Inhibitor ○ Provides stressor to the
Indomethacin (Indocin) lungs of the fetus to stimulate
● Action production of surfactant
○ Inhibits prostaglandin ● Effective if have 24 hours prior to
synthesis thus reducing delivery
uterine contractions
(Prostaglandin stimulate Polyhydramnios and Oligohydramnios
uterine contractions) Polyhydramnios
● Excessive amniotic fluid usually >
2000 ml

● Associated with fetal GI ○ Pregnancy, preeclampsia,

abnormalities and maternal diabetes and eclampsia
● Treatment ● Incidence
○ Watch and do nothing unless ○ Occur in 5-7% of all
becomes short of breath and pregnancies
in pain - then do an ○ Primigravidas, teenagers of
amniocentesis low socioeconomic class
● May be related to decreased
Oligohydramnios production of some vasodilating
● Scanty amniotic fluid usually <500 prostaglandins, vasospasm occurs
ml ● Onset after 20th week of pregnancy,
● Etiology: unknown may appear in labor or up to 48
● Risks hours postpartum
○ Fetal adhesions and fetal ● Cause essentially unknown
malformations
● Treatment
○ Amnioinfusion
Grieving Process
● Baptism and naming - best
remembrance of parents
● Positive relationship will lead to
increase support to the grieving
family
● Somatic symptoms of grieving
process
○ E.g. Nausea, loss of appetite,
sleepiness
Plan Of Care for Pregnant Client with

Unexpected Intrauterine Fetal Demise
● Ask an open ended questions
○ Offer yourself if the patient
will not open/talk
● Education
● Encourage acceptance
Pathophysiology of PIH
Pregnancy Induced Hypertension Danger Signs of Pregnancy (Induced
(Toxemia) Hypertension (PIH))
● Gestational hypertension replaced ● Swelling of the face or fingers
the term PIH and is used for ● Flashes of light or dots
hypertensive disorders that are ● Blurring of vision
specifically associate with ● Severe continuous headache
Mild Preeclampsia

● BP of 140/90 or +30/+15 mmhg on ○ Will keep the muscles

two consecutive occasions at least 6 relaxed
hours ● 150/100 BP ni mother pag may
● Sudden weight gain convulsion
● Proteinuria of 300 mg/l in 24 hour ● Antidote: Calcium Gluconate
urine collection
● AOG = 20 weeks above Nursing Responsibilities
● Check weight: 2 lbs 1st trimester ● Magnesium Sulfatesevere pre
added weight monthly ○ Monitor respirations, BP,
○ Normal: 25-35 lbs reflexes, urinary output
○ Higher than that, mild ○ Administer medicine: IV or IM
preeclampsia ● Hydralazine
Nursing Intervention Nursing Interventions

● Promote bed rest as long as signs of ● Bed rest, left side lying
edema or proteinuria are minimal, ● Carefully monitor maternal/fetal vital
preferably side lying. signs
● Provide well-balanced diet with ● Monitor input and output, results of
adequate protein laboratory test
● Explain need for close follow-up, ● Take daily weights
weekly or twice weekly visits to ● Institute seizure precautions
physician ● Continue to monitor 24-48 hours
post delivery
Severe Preeclampsia
● Headaches, epigastric pain, nausea Eclampsia
and vomiting, visual disturbances, ● Increased HPN precede convulsion
irritability followed by hypotension and
● BP of 150-160/100-110 mmhg collapse
● Increased edema and weight gain ● Coma may ensue
● Proteinuria (5g/24 hours) 4+ ● Labor may begin, putting fetus in
● Positive III protein great jeopardy
● Convulsion may occur
Management
● Magnesium sulfate Medical Management
○ Acts upon the myoneural ● Same with severe preeclampsia
junction, diminishing ● Magnesium sulfate
neuromuscular transmission ○ Acts upon the myoneural
○ It promotes maternal junction, diminishing
vasodilation, better tissue neuromuscular transmission
perfusion and has ○ It promotes maternal
anticonvulsant vasodilation, better tissue
○ Stop convulsion during perfusion and has
delivery anticonvulsant

○ Stop convulsion during ○ May have hypermagnesemia

delivery because of maternal
○ Will keep the muscles treatment with MgSO4
relaxed
● 150/100 BP ni mother pag may
Danger Signs of Pregnancy
convulsion
● Hydralazine Signs Possible Cause
● Antidote: Calcium Gluconate
Swelling of face, HPN of pregnancy
Nursing Intervention fingers
● Minimize all stimuli Headache, continuous HPN of pregnancy
● Have airway, oxygen and suction and severe
equipment available
○ May lead to fetal demise Abdominal/chest pain Ectopic pregnancy,
■ Placental perfusion uterine rupture,
pulmonary embolism
● Administer medication as ordered
● Prepare for C-Section with seizures Vaginal bleeding Placental problems,
stabilized abortion
● Continue observations 24-48 hours
postpartum Vomiting, persistent Infection, hyperemesis
gravidarum
Complications Visual changes HPN of pregnancy
● Maternal Complications
○ Increase intraocular pressure Escape of vaginal fluids PROM
leading to retinal detachment
○ HELLP (hemolysis, Elevated Diabetes
Liver function test, Low ● The pancreas can not produce
platelet count) syndrome has adequate insulin to regulate body
been associated with severe glucose levels
preeclampsia ○ Key to your glucose to use
■ Low platelet may lead as energy
to perfused bleeding, ○ Insulin → glucose → energy
to hemorrhage, to ○ Insulin very important to
death regulate glucose level
● Fetal Complications
○ Usually small for gestational
Classification of Diabetes Mellitus
age
○ May be born prematurely Class Description
○ Newborn may be born over
sedated because of Type 1 Destruction of beta cells in the
medications given to mother pancreas that leads to insulin
■ Give valium pag head deficiency (IDDM)
ng bata ay lumabas Type 2 Insulin resistance combined with
na a relative deficiency in the

● Increase risk of congenital

production of insulin (Type 2
DM) abnormalities, sacral agenesis,
congenital heart disease, neural
Gestational Abnormal glucose metabolism tube defects
Diabetes that arises during pregnancy (20 ● Hba1c level
weeks, progesterone) ○ Normal: 6-6.5 (if increased,
Impaired State between normal and at risk for developing
glucose diabetes in which the body is no diabetes)
homeostasis longer using or secreting insulin ○ Normal: 6 in PH, 6.5 in US
properly ● Risk
○ Not increased 5%, 25%
Pathophysiology of Diabetes
Maternal hyperglycemia
↓
Fetal Hyperglycemia
↓
Fetal pancreatic beta-cell hyperplasia
↓
Fetal hyperinsulinemia
↓
Macrosomia, Organomegaly,
Polycythaemia, Hypoglycemia, RDS
Pre Existing DM in Pregnancy Management

Effects of Pregnancy on Pre Existing DM ● Goal
● Increase requirement for insulin ○ Achieve maternal near
doses normoglycemic level to
● Nephropathy, autonomic neuropathy prevent adverse perinatal
may deteriorate outcomes (like macrosomia,
● Progress in diabetic retinopathy (2X) organomegaly,
● Hypoglycemia polycythaemia)
● Diabetic ketoacidosis ● Diet
● Stop oral hypoglycemic agents ○ Low carbohydrate diet, high
fibre with caloric restriction
On Maternal ○ Frequent small snacks may
● Increase risk of miscarriage be needed between meals
● Increase risk of preeclampsia (q2h)
● Increased risk of infection eg vaginal ○ Fruit (once per day)
candidiasis, UTI, endometrial or ○ Avoid starvation
wound infection ● Insulin
● Increase LSCS rate (lower segment ○ 3 pre-meal short acting
Cesarean section) insulin (actrapid) +.-
On Fetal intermediate-acting insulin

(protaphane) as it allows ● 4%-20% patients failed to achieve

maximum flexibility glucose control with maximum dose
○ Target blood glucose: of drug
■ Fasting < 5 mmol/L ● Increase risk of preeclampsia and need
( x 18 = 90 or 70-100 for phototherapy → jaundice
mg/dL target before
meals) Insulin Analogues
■ 2 hr < 7 mmol/L ( x 18 1. Rapid-Acting Insulin Analogs
= 126 or until 140 (Lispro) Category B
target after meals) ● Concerns about teratogens
is, antibodies formation,
Oral Hypoglycemic Agents growth-promoting properties
● Replace it with insulin ● Majority of evidence showed
● Implicated as teratogenic in animal that it does not cross
studies esp first generation placenta, and has no
sulfonylureas adverse maternal or fetal
● In humans, scattered case reports of effects
congenital abnormality 2. Long Acting Analogs
● Risk of congenital abnormality (Glargine) Category C
related to maternal glycemic control ● Not well studied
rather than mode of the anti-DM systematically
agents Monitoring
● For Type 2 DM patients: ● Regular home glucose monitoring
○ To stop oral hypoglycemic ● Insulin may be need to be adjusted
agents and change to insulin as gestation advanced
○ Reassure that the risk of ● Hba1c monitoring
congenital abnormality due to ● Fetal monitoring with USG
drug is small ● Refer to ophthalmologist
Biguanides (Metformin) Delivery

● Commonly used in Polycystic ● Timing and mode of delivery
Ovarian Disease (PCOD) to treat individualized
insulin resistant and normalize ● Intrapartum insulin infusion with
reproductive function glucose monitoring
● Not teratogenic ● No contraindication for breastfeeding
● Reduce first trimester miscarriage
● 10x reduce gestational diabetes Preconception Counseling
● Allowed for optimisation of diabetic
Sulfonylureas control prior to conception, and
● 1st generation drug increase risk of assessment of the presence of
neonatal hypoglycemia complications like hypertension,
● 2nd generation drug (Glyburide) no neuropathy
such effect on other morbidities ● Should counsel that good control
and lower hba1c lower the risk of

congenital abnormalities and ○ BMI > 25

improve outcome ○ Previous GDM
● If necessary, proliferative retinopathy
may be treated with
One Step Diagnosis Two Step Diagnosis
photocoagulation prior to Strategy Strategy
conception.
● Contraindications to pregnancy only Perform 75 g OGTT Step 1:
ischemic heart disease, untreated with plasma glucose Perform a 50 g
proliferative retinopathy, severe measurement when nonfasting GLT with
patient is fasting and at plasma measurement 1
renal impairment (creatinine >250)
1 and 2 hr at 24-48 hr at 24-48 weeks in
weeks in women not women not previously
Gestational Diabetes previously diagnosed diagnosed with overt
● Carbohydrate intolerance of variable with overt diabetes diabetes. If PG
severity first recognized during the measured 1 hr after the
present pregnancy load is >140 mg/dL
● Incidence rate is 2.9% more (7.8 mmol/L). Proceed
to 100 g OGTT
common in Asian and Indian women
● In developed countries, increasing Perform OGTT in the Step 2:
trend because of epidemic of obesity morning after an Perform 100 g OGTT
overnight fast of >8 hrs while patient is fasting
Clinical Significance of GDM Diagnosis when >2 PG
Diagnosis when PH levels meet or exceed
1. High incidence of macrosomia, and
levels meet or exceed ● Fasting 95 mg/dL
adverse pregnancy outcomes ● Fasting 92 mg/dL or 105 mg/dL
(5.1 mmol/L) ● 1 hr: 180 or 190
Risk Factors ● 1 hr: 180 mg/dL ● 2 hr: 155 or 165
1. Obesity (10.0 mmol/L) ● 3 hr: 140 or 145
2. Age over 25 years old ● 2 hr: 153 ml/dL
3. History of large babies
4. Unexplained fetal loss Screening
5. History of congenital anomalies ● Fasting/random glucose/glucose
6. Family history challenge test (50 gm)
7. Member of population with a high
risk for diabetes Fetal Complications
● Macrosomia (>4 kg)
Screening and Diagnosis ○ Risk is 16-29% as compared
● The test is performed between 24-28 to 10% in control
weeks, because at this point in ● Increase in cesarean delivery,
gestation, the diabetogenic effect of instrumental deliveries
pregnancy is manifesting and there (forceps/vacuum), birth trauma, such
is sufficient time remaining in as brachial plexus injuries, clavicular
pregnancy for therapy to exert its fractures
effect ● Increase in neonatal hypoglycemia
● Risk ● Children mahirap magpapayat
○ Age >25

Maternal Complications
● Increase risk of hypertensive
disorders
● Increase risk of cesarean and
instrumental deliveries
● Increased risk (40-60%) of
developing type 2 DM within 10-15
years
Management
● Management similar as pre existing
DM
● Need for glucose

MCN Lec Prelim

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NCM 109: Maternal & Child Health Nursing

FRAMEWORK FOR MCN FOCUSING ON AT ○ >200 indicators

Austria, Echague, Fernandez, Forcadilla, Guzman 1

Austria, Echague, Fernandez, Forcadilla, Guzman 2

Austria, Echague, Fernandez, Forcadilla, Guzman 3

dying by age 5 per

Maternal mortality 114 (87-175)

Births attended by 72.8

Ambisyon Natin 2040

All for Health Towards Health for All

(Mother) Baby-Friendly Hospital Initiative

Austria, Echague, Fernandez, Forcadilla, Guzman 4

Practice Guidelines on Intrapartum &

Four Core Steps in Immediate Newborn

Care for Small Babies

Austria, Echague, Fernandez, Forcadilla, Guzman 5

Mitosis & Meiosis

Austria, Echague, Fernandez, Forcadilla, Guzman 6

INHERITANCE OF THE DISEASE Autosomal Dominant Inheritance

Autosomal Recessive Inheritance

X-Linked Recessive Inheritance (Sex

Austria, Echague, Fernandez, Forcadilla, Guzman 7

X-Linked Dominant Inheritance (Sex

GENETICS & GENETIC COUNSELLING

Austria, Echague, Fernandez, Forcadilla, Guzman 8

○ Mendellian outcomes and reduce family’s

Austria, Echague, Fernandez, Forcadilla, Guzman 9

○ Neurology ● Risk assessment and counseling

Austria, Echague, Fernandez, Forcadilla, Guzman 10

professionals) to provide genetic ● Health-seeking behaviours related to

How to Provide Psychosocial Support?

Austria, Echague, Fernandez, Forcadilla, Guzman 11

○ Provide sympathetic parents, between families,

Austria, Echague, Fernandez, Forcadilla, Guzman 12

NURSING CARE OF WOMEN WITH

Austria, Echague, Fernandez, Forcadilla, Guzman 13

Austria, Echague, Fernandez, Forcadilla, Guzman 14

○ Multiple parity, increased preterm labor, especially in women

Austria, Echague, Fernandez, Forcadilla, Guzman 15

● Procedure: Attached the fetal heart

Austria, Echague, Fernandez, Forcadilla, Guzman 16

○ A- (mother) & A+ (father) = ○ Identify chromosome

Amniocentesis Nursing Responsibility

Austria, Echague, Fernandez, Forcadilla, Guzman 17

there are accelerations of the fetal ● Means of evaluating the respiratory

Contraction Test Percutaneous Umbilical Blood Sampling

Austria, Echague, Fernandez, Forcadilla, Guzman 18

● Obtaining a fetal blood sample from performing an elective caesarean

Lecithin-to-Sphingomyelin (L/S) Ratio

Austria, Echague, Fernandez, Forcadilla, Guzman 19

Observation Normal (2 pts) Abnormal (0

Non-Stress Reactive Non-reactive

Fetal 3 discrete and Less than 3

Fetal Muscle Arms and legs Arms and

Amniotic Largest Pocket Largest

SEXUALLY TRANSMITTED DISEASE

Austria, Echague, Fernandez, Forcadilla, Guzman 20

suh-Saharan African and Latin ■ Profuse greenish-

Austria, Echague, Fernandez, Forcadilla, Guzman 21

■ Post hysterectomy ● Etiologic Agent

Austria, Echague, Fernandez, Forcadilla, Guzman 22

■ Asymptomatic ● Etiologic Agent