BACHELOR OF SCIENCE IN NURSING:

CARE OF MOTHER AND CHILD AT RISK OR

WITH PROBLEMS (ACUTE AND CHRONIC):
OBSTETRIC NURSING
COURSE MODULE COURSE UNIT WEEK
1 1a 1

High-Risk Pregnant Client

(Bleeding Disorder)

Read course and unit objectives

Read study guide prior to class attendance
Read required learning resources; refer to unit
terminologies for jargons
Proactively participate in online discussions
Participate in weekly discussion board (Canvas)
Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Define high-risk pregnancy, including pre-existing factors that contribute to its development.
2. Identify the different types of bleeding disorder per trimester
 3. Determine the therapeutic management and nursing intervention of the different types of bleeding
disorder
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect of other students’ opinions and ideas.
3. Accept comments and reactions of classmates openly.
Psychomotor:
1. Participate actively during class discussions.
2. Follow Class rule and apply Netiquettes.
3. Integrate knowledge of high-risk pregnancy and nursing process to achieve quality maternal and child
health nursing care

Adele Pilliteri, JoAnne Silbert-Flagg. (2018). Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family. (8 th Ed.).

Ricci, Susan Scott Essentials of Maternity, Newborn, and Women's Health Nursing (4th Ed.)

RA 9262: the Anti-Violence Against Women and their Children Act of 2004 | Philippine Commission on Women
(pcw.gov.ph)

Republic Act 9262: Anti-Violence Against Women and their Children

This law refers to any act or a series of acts committed by an intimate partner (husband, ex-husband, live-in partner,
boyfriend/girlfriend, fiance, who the woman had sexual/dating relationship):
 against a woman who is his wife, former wife.
 against a woman with whom the person has or had a sexual or dating relationship,
 against a woman with whom he has a common child.
 against her child whether legitimate or illegitimate within or without the family abode,

Of which results in or is likely to result in physical, sexual, psychological arm or suffering or economic abuse
including threats of such acts, battery, assault, coercion, harassment or arbitrary deprivation of liberty.
 Physical Violence – acts that include bodily or physical harm to a woman or her child (battery)
o Causing/ threatening/ attempting to cause physical harm to the woman or her child.
o Placing the woman or her child in fear of imminent physical harm
 Sexual Violence – the acts which are sexual in nature committed against a woman or her child. It includes,
but is not limited to:
o Rape, sexual harassment, acts of lasciviousness, treating a woman or her child as a sex object,
making demeaning and sexually suggestive remarks, physically attacking the sexual parts of the
victim’s body, forcing him or her to watch obscene publications and indecent shows or forcing the
woman or her child to do indecent acts and/ or make films thereof, forcing the wife and mistress/
lover to live in the conjugal home or sleep together in the same room with the abuser.
o Causing or attempting to make the woman or her child to perform sexual acts (that do not constitute
 Rape) by use of force, threats, intimidation directed against the woman, her child, or her immediate
family.
o Prostituting the woman or her child.
 Psychological Violence – Acts or omissions causing or likely to cause mental or emotional suffering of the
victim which includes, but is not limited to the following:
o Controlling or restricting the woman’s or her child’s movement or conduct
 Threatening to or actually depriving the woman or her child of custody or access to her/
his family;
 Depriving or threatening to deprive the woman or her child of a legal right;
o Causing mental or emotional anguish, public ridicule or humiliation to the woman or her child, e.g.
repeated verbal and emotional abuse, and denial of financial support or custody or minor children
or denial of access to the woman’s child/ children.
o Threatening or actually inflicting physical harm on oneself for the purpose of controlling the
woman’s actions or decisions;
o It includes causing or allowing the victim to witness the physical, sexual, or psychological abuse
of a member of the family to which the victim belongs, or to witness pornography in any form or to
witness abusive injury to pets or to unlawful or unwanted deprivation of the right to custody and/
or visitation of common children.
o Causing substantial emotional or psychological distress to the woman or her child:
 Stalking or following the woman or her child in public places;
 Peering in the window or lingering outside the residence or the woman or her child;
 Entering or remaining in the dwelling or on the property of the woman or her child against
her/ his will;
 Destroying the property and personal belongings or inflicting harm to animals or pets of
the woman or her child;
 Engaging in any form of harassment or violence
 Economic Abuse – Acts that make or attempt to make woman financially dependent upon her abuser,
which includes, but is not limited to the following:
o Preventing the woman from engaging in any legitimate profession, occupation, business or activity
except in cases wherein the other spouse/ partner objects on valid, serious and moral grounds as
defined in Article 73 of the Family Code;
o Controlling the woman’s own money or property; or solely controlling the conjugal or common
money/ properties;
o Destroying household property.
Protection Order
A protection order is an order issued under this act for the purpose of preventing further acts of violence against
women or her child. And granting other relief as may be needed. The relief granted under a protection order serve
the purpose of safeguarding the victim from further harm, minimizing any disruption in the victim’s daily life, and
facilitating the opportunity and ability of the victim to independently regain control of her life. The provisions of the
protection order shall be enforced by law enforcement agencies.
Kinds of Protection Order:
1. Barangay Protection Orders (BPO) refer to the protection order issued by the Punong Barangay
ordering the perpetrator to desist from committing acts under Section 5 (a) and (b) of R.A. 9262. BPO
shall be effective for 15 days.
2. Temporary Protection Orders (TPO) refers to the protection order issued by the court on the date of the
filing of the application after ex parte determination that such order should be issued. The court may grant
in a TPO any, some or all of the reliefs mentioned in R.A. 9262 and shall be effective for thirty (30) days.
The court shall order the immediate personal service of the TPO on the respondent by the court sheriff who
may obtain the assistance of law enforcement agents for the service.
 3. Permanent Protection Order (PPO) refers to the protection order issued by the court after notice and
hearing. The court shall not deny the issuance of protection order based on the lapse of time between the
act of violence and the filing of the application. PPO shall be effective until revoked by the court upon
application of the person in whose favor it was issued.

High Risk Pregnancies

When a woman enters pregnancy with a chronic condition such
as vascular disease of kidney disease, both she and the fetus can be at
risk for complications because either the pregnancy can complicate the
disease or the disease can complicate the pregnancy, affecting the
baby or leaving a woman less equipped to function in the future or
undergo a future pregnancy.
High-risk pregnancy

is one in which a concurrent disorder, pregnancy-related

complication, or external factor jeopardizes the health of the
mother, the fetus, or both.
Remembering the term “high-risk” rarely refers to just one causative
factor helps in the planning of holistic and ultimately effective nursing
care growth was slowed and whose birth weight falls below the 10th
percentile on intrauterine growth curves.

Risk Factors

Any findings that suggest the pregnancy may have a negative

outcome, for either the woman or her unborn child.

Assessments and Care for Continuing Prenatal Visits

Health Interview  Interim history or new personal or family

developments since last visit
 Review danger signs of pregnancy
 Review symptoms of beginning labor
Physical examination  Blood pressure (every visit)
 Clean-catch urine for glucose, protein, and
leukocytes (every visit)
 Blood serum level for alpha-fetoprotein (MSAFP)
(16 weeks)
 VDRL test for syphilis if possibility of new exposure
 Glucose screen (28 weeks)
 Glucose challenge (24–28 weeks) if warranted
 Anti-Rh titer (28 weeks)
 Group B streptococci (GBS) (35–37 weeks)
Fetal Health  Fetal heart rate
  Fundal height
 Quickening or fetal movement
 Ultrasound dating of pregnancy

Assessments That Might Categorize a Pregnancy as “at Risk”

1. Obstetric History
 History of subfertility
 Previous premature cervical dilatation
 Existing uterine or cervical anomaly
 Previous preterm labor or preterm birth or cesarean birth
 Previous macrosomic infant
 Two or more spontaneous miscarriages or therapeutic abortions
 Previous hydatidiform mole
 Previous ectopic pregnancy or stillborn/neonatal death
 Previous multiple gestation
 Previous prolonged labor
 Previous low-birth-weight infant
 Previous midforceps birth
 Last pregnancy less than 1 year
 Previous infant with neurologic deficit, birth injury, or congenital anomaly

2. Medical History
 Cardiac or pulmonary disease, chronic hypertension
 Metabolic disease such as diabetes mellitus
 Renal disease, recent urinary tract infection, or bacteriuria
 Gastrointestinal disorders
 Seizure disorders
 Family history of severe inherited disorders
 Surgery during pregnancy
 Emotional disorder or cognitive challenge
 Previous surgeries, particularly
 involving reproductive organs
 Endocrine disorders such as hypothyroidism
 Hemoglobinopathies
 Sexually transmitted infections
 Reproductive tract anomalies, history of abnormal Pap smear, malignancy

3. Psychosocial Factors
 Inadequate finances
 Lack of support person
 Adolescent
 Poor nutrition
  More than two children at home; no help
 Lack of acceptance of pregnancy
 Attempt or ideation of suicide
 Inadequate or poor housing
 Father of baby uninvolved
 Minority status
 Dangerous occupation
 Dysfunctional grieving
 Psychiatric history

4. Demographic Factors Lifestyle

 Maternal age under 16 or over 35
 Education less than 11 years
 Cigarette smoking greater than 10 cigarettes a day or living with a person who smokes this much
 Substance abuse
 Long amounts of time spent commuting
 Nonuse of seatbelts
 Alcohol intake
 Heavy lifting or long periods of standing
 Unusual stress
 No in-home smoke detectors Prenatal High-Risk Factor

Prenatal High-Risk Factors

Factor Maternal Implications
Social and Personal Poor antenatal care
Low income level and/or Poor nutrition
low educational level  risk preeclampsia
Poor diet Inadequate nutrition
 risk anemia
 risk of preeclampsia
Living at high altitude  hemoglobin
Multiparity > 3  risk antepartum or
postpartum hemorrhage
Weight < 45.5 kg (100 lbs) Poor nutrition
Cephalopelvic disproportion
Prolonged labor
Weight >91 kg (200 lb)  risk hypertension
 risk cephalopelvic
disproportion
 risk diabetes
Fetal or Neonatal
Implications
Low birth weight
Intrauterine growth restriction
Fetal malnutrition
Prematurity
Prematurity
IUGR
 hemoglobin (polycythemia)
Anemia
Fetal death
IUGR
Hypoxia associated with
difficult labor and birth
↓ fetal nutrition
 risk macrosomia
 Age < 16 Poor nutrition
Poor antenatal care
 risk preeclampsia
 risk cephalopelvic
disproportion
Age > 35  risk preeclampsia
 risk cesarean birth
Smoking one pack/day or  risk hypertension
more  risk cancer
Use of addicting drugs  risk poor nutrition
 risk of infection with IV drugs
 risk HIV, hepatitis C
Excessive alcohol  poor nutrition
consumption Possible hepatic effects with
long term consumption
Low birth weight
 fetal demise
 congenital anomalies
 chromosomal aberrations
↓ placental perfusion → ↓O2and
nutrients available low birth
weight
IUGR
Preterm birth
 risk congenital anomalies
 risk low birth weight
neonatal withdrawal
lower serum bilirubin
risk fetal alcohol syndrome

Bleeding Disorders
Vaginal bleeding during pregnancy is always a deviation from the normal, may occur at any point during
pregnancy, and is always frightening. It must always be carefully investigated because if it occurs in sufficient
amount or for sufficient cause, it can impair both the outcome of the pregnancy and a woman’s life or health. A
woman with any degree of bleeding, therefore, needs to be evaluated for the possibility that she is experiencing a
significant blood loss or is developing hypovolemic shock. Because the uterus is a nonessential body organ, danger
to the fetal blood supply occurs when a woman’s body begins to decrease blood flow to peripheral organs (although
the increased blood volume of pregnancy allows more than normal blood loss before hypovolemic shock processes
begin).

A. Spontaneous Abortion
Abortion is the medical term for any interruption of a pregnancy before a fetus is viable (able to survive outside
the uterus if born at that time). A viable fetus is usually defined as a fetus of more than 20 to 24 weeks of
gestation or one that weighs at least 500 g. A fetus born before this point is considered a miscarriage or
premature or immature birth. A spontaneous miscarriage is an early miscarriage if it occurs before week 16 of
pregnancy and a late miscarriage if it occurs between weeks 16 and 24. For the first 6 weeks of pregnancy,
the developing placenta is tentatively attached to the decidua of the uterus; during weeks 6 to 12, a moderate
 degree of attachment to the myometrium is present. After week 12, the attachment is penetrating and deep.
Because of the degrees of attachment achieved at different weeks of pregnancy, it is important to attempt to
establish the week of the pregnancy at which bleeding has become apparent. Bleeding before week 6 is rarely
severe; bleeding after week 12 can be profuse because the placenta is implanted so deeply. Fortunately, at
this time, with such deep placental implantation, the fetus tends to be expelled as in natural childbirth before
the placenta separates. Uterine contractions then help to control placental bleeding as it does postpartally. For
some women, then, the stage of attachment between weeks 6 and 12 can lead to the most severe, even life-
threatening, bleeding.
Causes of Spontaneous Abortion:
 Abnormal fetal formation (teratogenic factor/ chromosomal aberration)
 Immunologic factors
 Implantation abnormalities
 Failure of the corpus luteum to produce progesterone
 Systemic infection
 Ingestion of teratogenic drug
 Ingestion of alcohol at time of conception
Assessment
 Vaginal spotting/ bleeding
 Description of the bleeding
 History of bleeding episode
 Actions taken by the pregnant woman before and during the episode of bleeding
Types of Abortion
1. Threatened abortion
 Symptoms begin as vaginal bleeding, initially only scant and usually bright red. A woman may notice
slight cramping, but no cervical dilatation is present on vaginal examination.
 A woman with an apparent threatened miscarriage may be asked to come to the clinic or office to have
fetal heart sounds assessed or an ultrasound performed to evaluate the viability of the fetus.
 Blood for human chorionic gonadotropin hormone (hCG) may be drawn at the start of bleeding and
again in 48 hours.
 If it does not double, poor placental function is suspected. Avoidance of strenuous activity for 24 to 48
hours is the key intervention, assuming the threatened miscarriage involves a live fetus and presumed
placental bleeding.
 Women are apt to be extremely worried at the sight of bleeding. They need to talk with a sympathetic,
supportive person about how distressed they feel. Be certain to convey concerned assurance that
miscarriages happen spontaneously, not because of anything a woman did.
 If the spotting with threatened miscarriage is going to stop, it usually does so within 24 to 48 hours after
a woman reduces her activity. Once bleeding stops, she can gradually resume normal activities.
 Coitus is usually restricted for 2 weeks after the bleeding episode to prevent infection and to avoid
inducing further bleeding.
 As many as 50% of women with a threatened miscarriage continue the pregnancy; for the other 50%,
unfortunately, the threatened miscarriage changes to imminent or inevitable miscarriage.
2. Inevitable (Imminent) Abortion
 A threatened miscarriage becomes an imminent (inevitable) miscarriage if uterine contractions and
cervical dilation occur. With cervical dilation, the loss of the products of conception cannot be halted.
 A woman who reports cramping or uterine contractions is usually asked to come to the hospital.
 She should save any tissue fragments she has passed and bring them with her so they can be
examined.
 If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, a
 physician may perform a vacuum extraction D&E to ensure that all the products of conception are
removed.
 Be certain the woman has been told that the pregnancy was already lost and that all procedures are to
clean the uterus and prevent further complications such as infection, not to end the pregnancy.
 Save any tissue fragments passed in the labor room, along with any brought from home, so they can
be examined for an abnormality such as gestational trophoblastic disease or for assurance that all the
products of conception have been removed from the uterus.
 A woman should assess vaginal bleeding by recording the number of pads she uses. Saturating more
than one pad per hour is abnormally heavy bleeding.
3. Complete Abortion
 In a complete miscarriage, the entire products of conception (fetus, membranes, and placenta) are
expelled spontaneously without any assistance.
 The bleeding usually slows within 2 hours and then ceases within a few days after passage of the
products of conception.
4. Incomplete Abortion
 Part of the conceptus (usually the fetus) is expelled, but the membrane or placenta is retained in the
uterus. The term “incomplete” can be confusing for women. They may interpret it to mean that because
the miscarriage is incomplete, the pregnancy will continue.
 Be careful not to encourage false hopes by also misinterpreting this term.
 There is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus
because the uterus cannot contract effectively under this condition.
 The physician will usually perform a dilation and curettage (D&C) or suction curettage to evacuate the
remainder of the pregnancy from the uterus.
5. Missed Abortion
 Also commonly referred to as early pregnancy failure, the fetus dies in utero but is not expelled.
 A missed miscarriage is usually discovered at a prenatal examination when the fundal height is
measured and no increase in size can be demonstrated or when previously heard fetal heart sounds
cannot be heard.
 An ultrasound can establish the fetus has died. Often the embryo died 4 to 6 weeks before the onset
of miscarriage symptoms or failure of growth was noted.
 After the ultrasound, most commonly a D&E will be done. If the pregnancy is over 14 weeks, labor may
be induced by a prostaglandin suppository or misoprostol (Cytotec) to dilate the cervix, followed by
oxytocin stimulation or administration of mifepristone techniques used for elective termination of
pregnancy
 If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously within 2 weeks.
 There is a danger of allowing this normal course to happen, however, because disseminated
intravascular coagulation (DIC), a coagulation defect, may develop if the dead (and possibly toxic) fetus
remains too long in utero.
6. Recurrent Pregnancy Loss (Habitual Abortion)
 In the past, women who had three spontaneous miscarriages that occurred at the same gestational age
were called “habitual aborters.”
 They were advised they were apparently too “nervous” or that something was so wrong with their
hormones that childbearing was not for them.
 Today, the term recurrent pregnancy loss is used to describe this miscarriage pattern, and a thorough
investigation is done to discover the cause of the loss and help ensure the outcome of a future
pregnancy.
 Recurrent pregnancy loss occurs in about 1% of women who want to be pregnant.
 Although many losses occur for unknown reasons, possible causes include:
  Defective spermatozoa or ova
 Endocrine factors such as lowered levels of protein-bound iodine (PBI), butanol-extractable iodine
(BEI), and globulin-bound iodine (GBI); poor thyroid function; or luteal phase defect
 Deviations of the uterus, such as septate or bicornuate uterus
 Chorioamnionitis or uterine infection usually Escherichia coli (spread from the rectum forward into
 Autoimmune disorders such as those involving lupus anticoagulant and antiphospholipid antibodies.

Complications of Miscarriage:
1. Hemorrhage
2. Infection
3. Septic abortion
4. Isoimmunization
5. Powerlessness or Anxiety
B. Ectopic pregnancy
An ectopic pregnancy is one in which implantation
occurs outside the uterine cavity. The implantation may
occur on the surface of the ovary or in the cervix. The most
common site (in approximately 95% of such pregnancies)
is in a fallopian tube. Of these fallopian tube sites,
approximately 80% occur in the ampullar portion, 12%occur
in the isthmus, and 8% are interstitial or fimbrial. Withectopic
pregnancy, fertilization occurs as usual in the distalthird of
the fallopian tube. Immediately after the union of ovum and
spermatozoon, the zygote begins to divide and grow.
Unfortunately, because an obstruction is present, such as
an adhesion of the fallopian tube from a previous infection
(chronic salpingitis or pelvic inflammatory disease),
congenital malformations, scars from tubal surgery, or a
uterine tumor pressing on the proximal end ofthe tube, the
zygote cannot travel the length of the tube. It lodges at a
stricture site along the tube and implants there instead of in
the uterus.
 Approximately 2% of pregnancies are ectopic; it is the second most frequent cause of bleeding early
in pregnancy. The incidence is increasing because of the increasing rate of pelvic inflammatory disease, which
leads to tubal scarring. It occurs more frequently in women who smoke compared with those who do not. There
is some evidence that intrauterine devices (IUDs) used for contraception may slow the transport of the zygote
and lead to an increased incidence of tubal or ovarian implantation. The incidence also increases following in
vitro fertilization. Women who have one ectopic pregnancy have a 10% to 20% chance that a subsequent
pregnancy will also be ectopic. This is because salpingitis that leaves scarring is usually bilateral. Congenital
anomalies such as webbing (fibrous bands) that block a fallopian tube may also be bilateral. For unknown
reasons, oral contraceptives used before pregnancy reduce the incidence of ectopic pregnancy.
There are no unusual symptoms at the time of implantation. The corpus luteum of the ovary continues
to function as if the implantation were in the uterus. No menstrual flow occurs. A woman may experience the
nausea and vomiting of early pregnancy, and a pregnancy test for hCG will be positive. Many ectopic
pregnancies are diagnosed by an early pregnancy ultrasound. Magnetic resonance imaging (MRI) is also
effective to use for this. If not revealed by an ultrasound, at weeks 6 to 12 of pregnancy (2 to 8 weeks after a
missed menstrual period), the zygote grows large enough to rupture the slender fallopian tube or the
trophoblast cells break through the narrow base. Tearing and destruction of the blood vessels in the tube result.
The extent of the bleeding that occurs depends on the number and size of the ruptured vessels. If implantation
is in the interstitial portion of the tube (where the tube joins the uterus), rupture can cause severe intraperitoneal
bleeding. Fortunately, the incidence of tubal pregnancies is highest in the ampullar area (the distal third), where
the blood vessels are smaller and profuse hemorrhage is less likely. However, continued bleeding from this
area may, in time, result in a large amount of blood loss. Therefore, a ruptured ectopic pregnancy is serious
regardless of the site of implantation. A woman usually experiences a sharp, stabbing pain in one of her lower
abdominal quadrants at the time of rupture, followed by scant vaginal spotting. The amount of bleeding evident
with a ruptured ectopic pregnancy often does not reveal the actual amount present, however, because the
products of conception from the ruptured tube and the accompanying blood may be expelled into the pelvic
cavity rather than into the uterus. With this type of rupture, blood does not reach the vagina to become evident.
With placental dislodgment, progesterone secretion stops, and the uterine decidua begins to slough, causing
additional bleeding. If internal bleeding progresses to acute hemorrhage, a woman may experience
lightheadedness and rapid pulse, signs of shock. Any woman with sharp abdominal pain and vaginal spotting
needs to be evaluated by her health care provider to rule out the possibility of ectopic pregnancy. When helping
determine the possibility of an ectopic pregnancy, ask a woman whether she has pain or vaginal bleeding.
Occasionally, a woman will move suddenly and pull one of her round ligaments, the anterior uterine supports.
This can cause a sharp, but momentary and innocent, lower quadrant pain. However, it would be rare for this
phenomenon to be reported in connection with vaginal spotting. By the time a woman with a ruptured ectopic
pregnancy arrives at the hospital or physician’s office, she may already be in severe shock, as evidenced by a
rapid, thready pulse, rapid respirations, and falling blood pressure. Leukocytosis may be present, not from
infection but from the trauma. Temperature is usually normal. A transvaginal ultrasound will demonstrate the
ruptured tube and blood collecting in the peritoneum. Either a falling hCG or serum progesterone level suggests that
the pregnancy has ended. If the diagnosis of ectopic pregnancy is in doubt, a physician may insert a needle
through the posterior vaginal fornix into the cul-de-sac under sterile conditions to see whether blood can be
aspirated. A laparoscopy or culdoscopy can be used to visualize the fallopian tube if the symptoms alone do
not reveal a clear picture of what has happened. However, ultrasonography alone usually reveals a clear-cut
diagnostic picture. If a woman waits for a time before seeking help, gradually her abdomen becomes rigid from
peritoneal irritation. Her umbilicus may develop a bluish tinge (Cullen’s sign). A woman may have continued
extensive or dull vaginal and abdominal pain; movement of the cervix on pelvic examination may cause
excruciating pain. There may be pain in her shoulders from blood in the peritoneal cavity causing irritation to
the phrenic nerve. A tender mass is usually palpable in Douglas’ cul-de-sac on vaginal examination.
An unruptured ectopic pregnancy can be treated medically by the oral administration of methotrexate
followed by leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent, attacks and destroys
 fast-growing cells. Because trophoblast and zygote growth are so rapid, the drug is drawn to the site of the
ectopic pregnancy. Women are treated until a negative hCG titer is achieved. A hysterosalpingogram or
ultrasound is usually performed after the chemotherapy to assess whether the tube is fully patent. Mifepristone,
an abortifacient, is also effective at causing sloughing of the tubal implantation site. The advantage of these
therapies is that the tube is left intact, with no surgical scarring that could cause a second ectopic implantation.
If an ectopic pregnancy ruptures, it is an emergency. Keep in mind the amount of blood evident is a poor
estimate of the actual blood loss. A blood sample needs to be drawn immediately for hemoglobin level, typing
and cross-matching, and possibly hCG level for immediate pregnancy testing, if pregnancy has not yet been
confirmed. Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun. Blood then
can be administered through this same line when matched. The therapy for a ruptured ectopic pregnancy is
laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. A rough suture
line on a fallopian tube may lead to another tubal pregnancy, so either the tube will be removed or suturing on
the tube is done with microsurgical technique.
C. Gestational Trophoblastic Disease (Hydatidiform Mole)
Gestational trophoblastic disease is
abnormal proliferation and then degeneration of the
trophoblastic villi. As the cells degenerate, they
become filled with fluid and appear as clear fluid-
filled, grape-sized vesicles. The embryo fails to
develop beyond a primitive start. Abnormal
trophoblast cells must be identified because they are
associated with choriocarcinoma, a rapidly
metastasizing malignancy. The incidence of
gestational trophoblastic disease is approximately 1
in every 1500 pregnancies. The condition tends to
occur most often in women who have a low protein
intake, in women older than age 35 years, in women
of Asian heritage, and in blood group A women who
marry blood group O men.
Types of Molar Growth:
1. Complete Mole
 All trophoblastic villi swell and become cystic.
 If an embryo forms, it dies early at only 1 to 2 mm in size, with no fetal blood present in the
villi.
 On chromosomal analysis, although the karyotype is a normal 46XX or 46XY, this
chromosome component was contributed only by the father, or an “empty ovum” was fertilized
and the chromosome material was duplicated.
2. Partial Mole
 Some of the villi form normally.
 The syncytio-trophoblastic layer of villi, however, is swollen and misshapen. A macerated
embryo of approximately 9 weeks’ gestation may be present and fetal blood may be present
in the villi.
 Has 69 chromosomes (a triploid formation in which there are three chromosomes instead of
two for every pair, one set supplied by an ovum that apparently was fertilized by two sperm or
an ovum fertilized by one sperm in which meiosis or reduction division did not occur). This
could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum that
did not undergo reduction division supplied 46.
 Rarely lead to choriocarcinoma.
 hCG titers are lower in partial than in complete moles; titers also return to normal faster after
 mole evacuation.
Because proliferation of the trophoblast cells occurs so rapidly with this condition, the uterus tends to
expand faster than normally. This causes the uterus to reach its landmarks (just over the symphysis brim at 12
weeks, at the umbilicus at 20 to 24 weeks) before the usual time. Because hCG is produced by the trophoblast
cells that are overgrowing, a serum or urine test of hCG for pregnancy will be strongly positive (1 to 2 million
IU compared with a normal pregnancy level of 400,000 IU). The nausea and vomiting of early pregnancy is
usually marked, probably because of the high hCG level present. Symptoms of pregnancy-induced
hypertension such as hypertension, edema, and proteinuria are ordinarily not present before week 20 of
pregnancy. With gestational trophoblastic disease, they may appear before this time. An ultrasound will show
dense growth (typically a snowflake pattern) but no fetal growth in the uterus. No fetal heart sounds are heard
because there is no viable fetus. At approximately week 16 of pregnancy, if the structure was not identified
earlier by ultrasound, it will identify itself with vaginal bleeding. This may begin as spotting of dark brown blood
or as a profuse fresh flow. As the bleeding progresses, it is accompanied by discharge of the clear fluid-filled
vesicles. Therefore, it is important for any woman who begins to miscarry at home to bring any clots or tissue
passed to the hospital with her. The presence of clear fluid-filled cysts changes the diagnosis from miscarriage
to gestational trophoblastic disease.
Therapy for gestational trophoblastic disease is suction curettage to evacuate the mole. Following mole
extraction, women should have a baseline pelvic examination, a chest radiograph, and a serum test for the
beta subunit of hCG. After surgery, hCG levels remain high. Half of women still have a positive reading at 3
weeks; one-fourth still have a positive test result at 40 days. The hCG is then analyzed every 2 weeks until
levels are again normal. After that, serum hCG levels are assessed every 4 weeks for the next 6 to 12 months.
Gradually declining hCG titers suggest no complication is developing. Levels that plateau for three times or
increase suggest that a malignant transformation is occurring. A woman should use a reliable contraceptive
method such as an oral contraceptive agent for 12 months so that a positive pregnancy test (the presence of
hCG) resulting from a new pregnancy will not be confused with increasing levels and a developing malignancy.
After 6 months, if hCG levels are still negative, a woman is theoretically free of the risk of a malignancy
developing. By 12 months, she could plan a second pregnancy.
D. Incompetent Cervix (Premature Cervical Dilatation)
Premature Cervical Dilatation was previously termed an
incompetent cervix, refers to a cervix that dilates prematurely and
therefore cannot hold a fetus until term. It occurs in about 1% of
women. The dilatation is usually painless. Often the first symptom
is show (a pink-stained vaginal discharge) or increased pelvic
pressure, which may be followed by rupture of the membranes
and discharge of the amniotic fluid. Uterine contractions begin,
and after a short labor the fetus is born. Unfortunately, this
commonly occurs at approximately week 20 of pregnancy, when
the fetus is still too immature to survive.
Although it may be diagnosed by an early ultrasound
before symptoms occur, it is usually diagnosed only after the
pregnancy is lost. After the loss of one child because of
premature cervical dilatation, a surgical operation termed
cervical cerclage can be performed to prevent this from
happening in a second pregnancy.
As soon as an ultrasound confirms that the fetus of a
second pregnancy is healthy, at approximately weeks 12 to 14,
purse-string sutures are placed in the cervix by the vaginal route
under regional anesthesia. This procedure is called a McDonald
or a Shirodkar procedure after the surgeons who perfected the
 technique. The sutures serve to strengthen the cervix and
prevent it from dilating. In a McDonald procedure, nylon
sutures are placed horizontally and vertically across the
cervix and pulled tight to reduce the cervical canal to a few
millimeters in diameter. With a Shirodkar technique, sterile
tape is threaded in a purse string manner under the
submucous layer of the cervix and sutured in place to
achieve a closed cervix. Although routinely accomplished by
a vaginal route, sutures may be placed by a transabdominal
route. With these procedures, the sutures are then removed
at weeks 37 to 38 of pregnancy so the fetus can be born
vaginally. When a transabdominal approach is used, the
sutures may be left in place and a cesarean birth performed.
Be certain to ask women who are reporting painless bleeding (the symptoms of spontaneous
miscarriage also) whether they have had past cervical operations, to remind them they may have sutures in
place. After cerclage surgery, women remain on bed rest (perhaps in a slight or modified Trendelenburg
position) for a few days to decrease pressure on the new sutures. Usual activity and sexual relations can be
resumed in most instances after this rest period.
E. Abruptio Placenta
The placenta appears to have been implanted correctly. Suddenly, however, it begins to separate and
bleeding results. Premature separation of the placenta occurs in about 10% of pregnancies and is the most
frequent cause of perinatal death. The separation generally occurs late in pregnancy; it may occur as late as
during the first or second stage of labor.
Because premature separation of the placenta may occur during an otherwise normal labor, it is
important always to be alert to the amount and kind of vaginal bleeding a woman is having in labor. Listen to
her description of the kind of pain she is experiencing to help detect this grave complication. The primary cause
of premature separation is unknown, but certain predisposing factors have been identified, including:
 High parity
 Advanced maternal age
 A short umbilical cord
 Chronic hypertensive disease, pregnancy-induced hypertension
 Direct trauma (as from an automobile accident or intimate partner abuse)
 Vasoconstriction from cocaine or cigarette use
 Thrombophilitic conditions that lead to thrombosis such as autoimmune antibodies, protein C,
and factor V Leiden (a common inherited thrombophilia that occurs in 5% of whites and 1% of
blacks).

Premature separation of the placenta may also follow a rapid decrease in uterine volume, such as
occurs with sudden release of amniotic fluid.
A woman experiences a sharp, stabbing pain high in the uterine fundus as the initial separation occurs.
If labor begins with the separation, each contraction will be accompanied by pain over and above the pain of
the contraction. In some women, additional pain is not evident with contractions, but tenderness can be felt on
uterine palpation. Heavy bleeding usually accompanies premature separation of the placenta, like placenta
previa, although it may not be readily apparent. There will be external bleeding only if the placenta separates
first at the edges and blood escapes freely from the cervix. If the center of the placenta separates first, blood
can pool under the placenta, and although bleeding is intense, it is hidden from view. The uterus becomes
tense and feels rigid to the touch. If blood infiltrates the uterine musculature, Couvelaire uterus or uteroplacental
apoplexy, forming a hard, board like uterus with no apparent, or minimally apparent, bleeding present occurs.
As bleeding progresses, a woman’s reserve of blood fibrinogen may be used up in her body’s attempt to
 accomplish effective clot formation and disseminated intravascular coagulation (DIC syndrome) can occur.

Separation of the placenta is an emergency. A woman needs a large gauge intravenous catheter
inserted for fluid replacement and oxygen by mask to limit fetal anoxia. Monitor fetal heart sounds externally
and record maternal vital signs every 5 to 15 minutes to establish baselines and observe progress. The baseline
fibrinogen determination is followed by additional determinations up to the time of birth. Keep a womanin a lateral,
not supine, position to prevent pressure on the vena cava and additional interference with fetal circulation. For
better prediction of fetal and maternal outcome, the degrees of placental separation can be graded. Unless the
separation is minimal (grades 0 and 1), the pregnancy must be terminated because the fetus cannot obtain.
adequate oxygen and nutrients. If vaginal birth does not seem imminent, cesarean birth isthe birth method of
choice. If DIC has developed, cesarean surgery may pose a grave risk because of the possibility of hemorrhage
during the surgery and later from the surgical incision. Intravenous administration of fibrinogen or
cryoprecipitate (which contains fibrinogen) may be used to elevate a woman’s fibrinogen level prior to and
concurrently with surgery. Fetal prognosis depends on the extent of the placental separation and the degree
of fetal hypoxia. Maternal prognosis depends on how promptly treatment can be instituted. Death can occur
from massive hemorrhage leading to shock and circulatory collapse or renal failure from the circulatory
collapse.
F. Premature Labor
Premature Labor occurs before the end of week 37 of gestation. It occurs in approximately 9% to 11%
of all pregnancies. It is responsible for almost two-thirds of all infant deaths in the neonatal period. Any woman
having persistent uterine contractions (four every 20 minutes) should be in labor. A woman is documented as
being in actual labor rather than having false labor contractions if she is having uterine contractions that cause
cervical effacement over 80% or dilation over 1 cm. Preterm labor is always serious because if it results in the
infant’s birth, the infant will be immature. It can happen for unknown reasons, but it is associated with
dehydration, urinary tract infection, periodontal disease, and chorioamnionitis. Women who continue to work
at strenuous jobs during pregnancy or perform shift work that leads to extreme fatigue may have a higher
incidence than others. It tends to occur in pregnancies of women who were born small, but the father of their
child is overweight, as if the fetus growing faster than its mother can accommodate might trigger preterm birth.
Intimate partner abuse may be yet another cause. Participating in mild leisure sports activities such as walking
may help prevent preterm birth. Common symptoms of early preterm labor include a persistent, dull, low
backache; vaginal spotting; a feeling of pelvic pressure or abdominal tightening; menstrual-like cramping;
increased vaginal discharge; uterine contractions; and intestinal cramping.
Medical attempts can be made to stop labor if the fetal membranes are intact, fetal distress is absent,
there is no evidence that bleeding is occurring, the cervix is not dilated more than 4 to 5 cm, and effacement is
not more than 50%. Intravenous fluid therapy to keep her well hydrated is begun because hydration may help
stop contractions. If a woman is dehydrated, the pituitary gland is activated to secrete antidiuretic hormone,
and this may cause it to release oxytocin as well. Oxytocin strengthens uterine contractions. By keeping a
woman well hydrated, therefore, the release of oxytocin may be minimized. Vaginal and cervical cultures and
a clean-catch urine sample are obtained to rule out infection. If a urinary tract infection is present
 the woman will be started on an antibiotic. She may also receive an antibiotic for group B streptococcus
prophylaxis as an infection with this could be fatal in a newborn. A tocolytic agent, an agent to halt labor, such
as terbutaline may be prescribed. Following this initial therapy, women in preterm labor can be safely cared for
at home if they can dependably drink enough fluid to remain well hydrated and continue to take an oral tocolytic
agent.
For reasons not clearly understood, the administration of a corticosteroid to the fetus appears to
accelerate the formation of lung surfactant. During the time labor is being chemically halted, therefore, if the
pregnancy is under 34 weeks, a woman may be given a steroid (betamethasone) to attempt to hasten fetal
lung maturity (two doses of 12 mg betamethasone given intramuscularly 24 hours apart, or four doses of 6 mg
dexamethasone given intramuscularly 12 hours apart). Betamethasone is preferred as it leads to lower rates
of respiratory distress syndrome or bronchopulmonary dysplasia in newborns (Feldman et al., 2007). It takes
about 24 hours for betamethasone to have an effect, so it is important labor be halted for at least this long.
Beta-sympathomimetic drugs are yet another tocolytic option. Beta-1 receptor sites are found in adipose tissue,
heart, liver, pancreatic islet cells, and gastrointestinal smooth muscle. Beta-2 receptor sites are found in uterine
smooth muscle, bronchial smooth muscle, and blood vessels. All of these drug act to halt contractions by
coupling with adrenergic receptors on the outer surface of the membrane of myometrial cells. Ritodrine
hydrochloride (Yutopar) and terbutaline (Brethine) are examples of drugs that act almost entirely on beta-2
receptor sites and so have only mild hypotensive and tachycardiac effects. Before a tocolytic drug is
administered, obtain baseline blood data (hematocrit, serum glucose, potassium, sodium chloride, and PCO2).
An electrocardiogram may be scheduled. An external uterine and fetal monitor should be in place. When
administering terbutaline, mix the drug with Ringer’s lactate rather than a dextrose solution to prevent any
unnecessary hyperglycemia. Administer it as a piggyback connected to a main intravenous solution so that it
can be stopped immediately if effects such as tachycardia or arrhythmias occur. After contractions halt, a
tocolytic infusion usually is continued for 12 to 24 hours, and then oral administration of terbutaline is begun.
The first oral dose is given 30 minutes before the intravenous infusion is discontinued to prevent any drop in
the serum concentration.
In addition to supervising tocolytic therapy, be certain to assess overall fetal welfare daily in a woman
trying to delay preterm labor. A woman may be instructed to use a daily fetal movement count or “count to 10”
test. Teach her how to do this before hospital discharge so she can continue it when she is at home. The typical
fetus moves 10 times in an hour. To evaluate fetal movement, a woman lies down on her left side and times
the number of minutes it takes for her to feel 10 fetal movements (about an hour) or counts the number of fetal
movements she feels in 1 hour (the average is 10 to 12).
G. Premature Rupture of Membranes (PROM)
Premature Rupture of the Membrane is rupture of fetal membranes with loss of
amniotic fluid during pregnancy before 37 weeks. The cause of preterm rupture
is unknown, but it is associated with infection of the membranes
(chorioamnionitis). It occurs in 5% to 10% of pregnancies. If rupture occurs early
in pregnancy, it poses a major threat to the fetus as, after rupture, the seal to
the fetus is lost and uterine and fetal infection may occur. A second complication
that can result from preterm membrane rupture is increased pressure on the
umbilical cord from the loss of amniotic fluid, inhibiting the fetal nutrient supply,
or cord prolapse (extension of the cord out of the uterine cavity into the vagina),
a condition that could also interfere with fetal circulation. Cord prolapse is most
apt to occur when the fetal head is still too small to fit the cervix firmly. Yet
another risk to the fetus of remaining in a non-fluid-filled environment is the
development of a Potter-like syndrome or distorted facial features and
pulmonary hypoplasia from pressure.
Rupture of the membranes is suggested by the history. A woman
usually describes a sudden gush of clear fluid from her vagina, with continued
 minimal leakage. Occasionally, a woman mistakes urinary incontinence caused by exertion for rupture of
membranes. Amniotic fluid cannot be differentiated from urine by appearance, so a sterile vaginal speculum
examination is done to observe for vaginal pooling of fluid. If the fluid is tested with Nitrazine paper, amniotic
fluid causes an alkaline reaction on the paper (appears blue) and urine causes an acidic reaction (remains
yellow). The fluid can also be tested for ferning, or the typical appearance of a high-estrogen fluid on
microscopic examination (amniotic fluid shows this; urine does not). Because preterm rupture of membranes
is associated with vaginal infection, cultures for Neisseria gonorrhoeae, Streptococcus B, and Chlamydia are
usually taken. Blood is drawn for white blood count and C-reactive protein, which increase with membrane
rupture. Avoid doing routine vaginal examinations because the risk of infection rises significantly when digital
examinations are performed after preterm rupture of membranes. If a fetus is estimated to be mature enough
to survive in an extrauterine environment at the time of rupture and labor does not begin within 24 hours, labor
contractions are usually induced by intravenous administration of oxytocin so the infant is born before infection
can occur.
If labor does not begin and the fetus is not at a point of viability, a woman is placed on bed rest either
in the hospital or at home and administered a corticosteroid to hasten fetal lung maturity. Prophylactic
administration of broad-spectrum antibiotics during this period may both delay the onset of labor and reduce
the risk of infection in the newborn sufficiently to allow the corticosteroid to have its effect. Women positive for
Streptococcus B need intravenous administration of penicillin or ampicillin to reduce the possibility of this
infection in the newborn. A woman with no signs of infection may be administered a tocolytic agent if labor
occurs.

EBSCO HOST http://search.ebscohost.com Usersname: OLFU PW: #fatima2020

http://dbctle.erau.edu/initiatives/seven/ Iowa State Center for Excellence in Learning and Teaching.

Bernstein, H. B., & Weinstein, M. (2007). Normal pregnancy and prenatal care. In A. H. DeCherney & L. Nathan
(Eds.). Current diagnosis and treatment in obstetrics and gynecology (10th ed.). Columbus, OH:
McGraw-Hil

Levine P, Burnham L, Katzin EM, Vogel P. The role of isoimmunization in the pathogenesis of erythroblastosis
fetalis. Amer J Obstet Gynec. 1941; 42:925-937

Watch the Case scenario from Lecturio (Case Study: 19-year-old G2P1 Woman and 34-year old G3P2 Woman (Nursing).
Answer the following:
1. What are the risk factors presented by the women in the Case study?
2. Identify the symptoms presented by each client.
3. List and describe the diagnostic criteria for the pre-eclamptic clients.
4. What is the classification of each woman’s PIH?
5. What are the clinical features of a magnesium sulfate toxicity?
Adele Pilliteri, JoAnne Silbert-Flagg. (2018). Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family. (8 th Ed.).

Wolters Kluwer. Audrey Berman, Shirlee J. Snyder, Geralyn Frandsen. (n.d.).

Fundamentals of Nursing by Kozier and Erbs (10th ed.).

Pearson. Maternal and Child Health. (n.d.). https://apha.org/topics-and-

issues/maternal-and-child-health Maternal, newborn and adolescent health.
(n.d.). https://www.who.int/maternal_child_adolescent/en/
RA 9262: the Anti-Violence Against Women and their Children Act of 2004 | Philippine Commission on Women
(pcw.gov.ph)

R.A. 9262 (lawphil.net)

Rosalinda Parado Salustiano. (2009). Dr. RPS Maternal & Newborn Care: A Comprehensive Review Guide and
Source Book for Teaching and Learning. C & E Publishing, Inc.

The American Journal of Maternal and Child Nursing. (n.d.).

https://journals.lww.com/mcnjournal/pages/default.aspx

Levine P, Burnham L, Katzin EM, Vogel P. The role of isoimmunization in the pathogenesis of erythroblastosis
fetalis. Amer J Obstet Gynec. 1941;42:925-937