NCM 109 Notes

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NCM 109 Lecture: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (Acute and Chronic)
Pre-pregnancy
4P’s: Factors that categorize a pregnancy as high risk:
• Passenger
A. Psychological
• Passageway
• History of drug dependence
• Psyche
• History of intimate partner abuse
• Powers
• History of mental illness
Normal Duration of Pregnancy: • History of poor coping mechanism
• 9 months • Survivor of childhood sexual abuse
• 37 to 42 weeks • Cognitively challenged
• 266-280 days B. Social
• 10 lunar months has a period of • Occupation involving handling of
4 weeks toxic substances (including radiation
Before 37 weeks – preterm and anesthesia)
After 42 weeks – post term or post • Environmental contaminants at home
mature Between 37-42 weeks – full term • Isolated
• Lower economic level
120-160 BPM – normal fetal heart • Poor access to transportation of care
rate 30- 40% ‒ increase in blood • High altitude
volume • Highly mobile lifestyle
• Poor housing
Signs of fetal distress: • Lack of support people
• Bradycardia – heart rate below C. Physical
120 (above 160 tachycardia) • Visual or hearing challenges
• Meconium-stained amniotic fluid • Pelvic inadequacy of misshape
– clear normal (green – meconium • Uterine incompetency, position
stained) or structures
• Hyperactivity of the fetus – 10 times • Secondary major illnesses
or movements per hour • Poor gynecologic or obstetric history
• History of previous poor
Identification of Risk Clients pregnancy outcome (miscarriage,
• A high-risk pregnancy is one in which a stillbirth)
concurrent disorder, pregnancy • History of child with
related complication, or external congenital anomalies
factor jeopardizes the health of the • Obesity
mother; the fetus or both. • Pelvic inflammatory disease
• There should be no vaginal • History of inherited disorder
bleeding/spotting during the entire • Small stature
pregnancy. • Potential of blood incompatibility
• Younger than 18 years or older than
35 years
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• Cigarette smoker • During less ordinary activity, woman
• Substance abuse experiences excessive fatigue,
palpitations, dyspnea or anginal
pain.
Class 4
Cardiovascular Disorders and Pregnancy • Severely compromised
• The number of women of childbearing • Woman is unable to carry out any
age who have heart disease is physical activity without
diminishing as more congenital heart experiencing
anomalies are corrected in early discomfort.
infancy • Even at rest, symptoms of
• Cardiovascular disease is still a concern cardiac insufficiency or anginal
in pregnancy because it can lead to pain are present.
such serious complications
• It is responsible for 5% maternal deaths A woman with Class 1 or 2 heart disease can
during pregnancy. expect to experience normal pregnancy by
• The danger of pregnancy in woman maintaining special interventions such as
with cardiac disease occurs primarily bed rest.
because of this increase in
circulatory volume Woman with Class 3 can complete pregnancy
• The most dangerous for her is in 28-32 by maintaining special interventions such as
weeks just after the blood bed rest.
volume peaks.
• As a rule, a woman with an artificial but Woman with Class 4 heart disease is usually
well-functioning heart valve, a woman advised to avoid failure even at rest and
with pacemaker implant, and even when they are not pregnant.
with heart transplant can expect to
have successful pregnancies as long as A woman with Cardiac Disease:
they have effective prenatal postnatal • Cardiac disease can affect pregnancy
care. in different way depending on
whether it involves the left or the right
Classification of Heart Disease: side of the heart.
Class 1 Normal Blood Circulation:

• Uncompromised
• Ordinary physical activity causes Unoxygenated blood from the different parts
no discomfort of the body empty to the superior and inferior
• No symptoms of cardiac Vena Cava – > Right Atrium –> Tricuspid Valve
insufficiency and no anginal pain –
Class 2 >Right Ventricle –> Pulmonary Artery –>
• Slightly compromised Lungs for oxygenation
• Ordinary physical activity causes
excessive fatigue, palpitation Oxygenated blood from the lungs will empty
and into the Pulmonary Veins –> Left Atrium –>
dyspnea or anginal pain. Mitral Valve – Left Ventricle – >Aorta –> to
Class 3 be delivered to the different parts of the
• Markedly compromised body.
A woman with left sided heart-failure

• Left-sided heart failure occurs in • This overburdens the circulation,
conditions such as Mitral stenosis, mitral causing increased left side failure and
insufficiency and aortic coarctation. increases pulmonary edema.
• In these instances, the left ventricle
cannot move the large volume of blood A woman with right sided heart failure
forward • Right sided heart failure occurs when
that it has received by the left atrium the right ventricles is overwhelmed by
from the pulmonary circulation. the amount of blood received by the
• This causes back-pressure-the left side of right atrium from the vena cava.
the heart becomes distended, • It can be used but an unrepaired
systemic blood pressure decreases in congenital heart defect such as pulmonary
the face of lowered cardiac output and valve stenosis, but the anomaly most apt
pulmonary hypertension occurs. to cause right sided heart failure.
• Pulmonary edema produces profound • With this congestion of the systemic
shortness of breath as it interferes venous circulation and decrease
with oxygen-carbon dioxide exchange. cardiac output to the lungs occur.
• If pulmonary capillaries rupture under the • Blood pressure decreases in the
pressure, small amounts of blood leak aorta because less blood is able to
into the alveoli and the woman develops reach it
productive cough with blood-speckled • In contrast, pressure is high in the
sputum. vena cava form the back pressure of
• Because of the limited oxygen exchange, blood.
woman with left-sided heart failure is at • Both jugular venous distention and
an extremely high risk for spontaneous increase portal circulation are
miscarriage, preterm labor or even evident.
maternal death. • The liver and spleen both
• A woman experiences increase fatigue, become distended
weakness and dizziness. • Extreme liver enlargement can cause this
• The placenta may not receive adequate dyspnea and pain a pregnant woman
blood because of the decrease because the enlarged liver, as it is
peripheral circulation. pressed upwardly by the enlarge uterus,
• As pulmonary edema becomes severe a puts extreme pressure of the diaphragm.
woman cannot sleep in any position except • Distention of abdominal and lower
with her chest and head elevated extremity vessels can lead to exudate of
(orthopnea) as elevating her chest this way fluid from, the vessels into the
allows fluids to settle to the bottom of her peritoneal cavity or peripheral edema.
lungs and free space for gas exchange. • With this systemic congestion of the
• She may also notice Paroxysmal Nocturnal systemic venous circulation and
Dyspnea – suddenly waking at night decrease cardiac out put to the lungs
with shortness of breath. occurs
• This occurs because heart action is more • Blood pressure decreases in the
effective when she is at rest. aorta because less blood is able to
• With more effective heart action, reach it.
interstitial fluid returns to the • In contrast, pressure is high in the
circulation vena cava from the back pressure of
blood
• Both jugular venous distention and
increase portal circulation are
evident.

Assessment of a woman with cardiac disease disease, making it a problem for
• Nurses play a major role in the care of the older pregnant woman.
pregnant woman with cardiovascular • Chronic hypertension can be serious
disease because continuous because it places both woman and the
assessment of women’s health fetus at high risk because of poor
promotion activities are so essential heart, kidney and or placental
• Assessment begins with a through perfusion during pregnancy.
health history document pre-
• Management includes a prescription of
pregnancy cardiac status beta-blocker and ACE inhibitors
• Document a woman’s level of exercise to reduce blood pressure
performance.
• Methyldopa (aldomet) is a typical drug
• Ask if she normally has a cough that may be prescribed.
or edema
• Documenting edema is also important A woman with thromboembolic disease
because the usual innocent edema of • The incidence of venous
pregnancy must be distinguished thromboembolic disease increases
from the beginning of edema from during early pregnancy because of a
heart failure combination of stasis of blood in
• An important difference is the usual the lower extremities from uterine
edema of pregnancy involves only hypercoagulability.
on the feet and ankles but become • When the pressure of the fetal head at
systemic with heart failure.
birth puts additional pressure on
• It can be as early as first trimester, and lower extremity veins, damage can
other symptoms such as irregular occur to the walls of the veins.
pulse, rapid or difficult respiration and • With this triad of effects in place (stasis,
perhaps chest pain on exertion will vessel damage, and hypercoagulation),
probably be present. the stage is set for thrombus
• Be certain to record a baseline blood formation in the lower extremities.
pressure, pulse rate and respiratory • The likelihood of deep vein thrombosis
rate in either a sitting or lying position (DVT) leading to pulmonary emboli
for the most accurate comparison is highest in women 30 years of age
• Making comparison assessments for or older because increased age is yet
nail bed filling and jugular venous another risk factor for thrombosis
distention can also be helpful formation.
throughout pregnancy. The risk of thrombus formation can be
reduced by:
A woman with chronic hypertensive vascular
o Avoiding the use of
disease.
constrictive knee-high
• Women with chronic hypertensive stockings
disease enter pregnancy with an
o Not sitting with legs crossed
elevated blood pressure
at the knee
(140/90mmHg or above)
o Avoiding standing in one
• Hypertension of this kind is usually
position for a long
associated with arteriosclerosis or renal
period.
Clinical manifestation:

• Woman will notice pain and • Shortness of breath
redness usually in the calf of a leg. • Lungs are clear on exam
It is diagnosed by woman’s history • Leg is swollen
and Doppler ultrasonography.
To keep the thrombus from moving HEMOLYTIC DISORDERS AND PREGNANCY
and becoming a pulmonary embolus: Anemia and Pregnancy
• A woman will be treated with bed rest • Because the blood volume expands
and intravenous heparin for 24 to during pregnancy slightly ahead of
48 hours. the red count cell, most women have
• After this, she may be prescribed a pseudo anemia in early pregnancy.
subcutaneous heparin she can • True anemia is typically considered to
self- inject every 12 or 24 hours for present when a woman’s hemoglobin
the duration of the pregnancy. concentration is less than 11g/dl
• It is generally recommended-the-lower (hematocrit <33%) in the first or third
abdomen be used for rotating sites trimester of pregnancy or when the
for subcutaneous heparin hemoglobin concentration is less
administration. With pregnancy, than
however this site is usually avoided 10.5 g/dl(hematocrit<32%) in the
and the injection sites are limited to second trimester.
the arms and thighs. A woman with ficiency anemia
Signs of pulmonary embolism: • Iron-deficiency anemia is the most
• Chest pain common anemia of pregnancy,
• A sudden onset of dyspnea complicating as many as 15% to 25%
• Cough with hemoptysis of all pregnancies.
• Tachycardia or missed beats Deficiency of iron stores resulting from
• Dizziness and fainting a combination of:
Needs to be recognized because it is an • Diet low on iron
immediate emergency and measures • Heavy menstrual period
should be immediately begun. • Unwise weigh reducing programs
• Caution women taking heparin during • Iron stores are also apt to be low in
pregnancy not to take any additional women who were pregnant less than
injections once labor begins to help 2
reduce the possibility of hemorrhage years before the current pregnancy
at birth. • Those from low socioeconomic
• Women taking heparin are not levels who have not had iron-rich
candidates for routine episiotomy or diets.
epidural anesthesia for this same • Iron is made available to the body by
reason unless at least 4 hours has absorption from the duodenum into
passed since the last heparin dose was the bloodstream after it has been
given. ingested.
• In the blood stream, it is bound to
Venous thromboembolism “the classic patient” transferrin for transport to the
• A young person liver,
• Recent leg fracture spleen, and bone marrow. At these
• Unilateral lower extremity swelling sites, it is incorporated into
hemoglobin or stored as ferritin.
• Sudden onset of pain breathing
• The type pf anemia is characteristically
a microcytic (i.e., small red blood cell)

and hypochromic (i.e., less
hemoglobin

than the average red cells) anemia, • Folic-acid deficiency anemia occurs
which occurs when such as inadequate
most often in multiple pregnancies
supply of iron is ingested that iron is because of the increase fetal
not available for incorporation into red demand.
blood cells. • The anemia that develops is a
• A woman experiences extreme fatigue megaloblastic anemia (enlarged
and poor exercise tolerance because red
she cannot transport oxygen blood cells)
efficiently. • Slow progress, the deficiency make
• The condition is mildly associated with take several weeks to develop or may
lower birth weight and preterm birth. not be apparent until the second
• Because the body recognizes that it trimester of pregnancy.
needs increased nutrients, some • Full blown, it may be a contributory
women with this condition develop factor in early miscarriage or
pica or the craving and eating premature separation of the placenta.
substances such as icer or starch.
• To prevent common anemia, women Megaloblastic Anaemia
should take prevent is common • All women expecting to become
anemia, women should take prenatal pregnant are advised to begin a
vitamins containing 27mg of iron as supplement of 400 µg folic acid daily
prophylactic therapy during pregnancy. in addition to eating folacin-rich foods
• They need to eat in a diet high in iron (e.g., green leafy vegetables, oranges,
and vitamins (e.g., green leafy dried beans)
vegetables, meat and legumes) so
that supplement is truly a A woman with sickle-cell anemia
supplement. • Sickle-cell anemia is a recessively
• Some women report constipation or inherited hemolytic anemia caused
gastric irritation when taking oral by an abnormal amino acid in the
iron supplements. beata chain of hemoglobin.
• Increasing roughage in the diet and • With the disease, the majority of red
always taking pills with food can blood cells are irregular or sickle-
help reduce these symptoms. shaped, so they cannot carry as
• Ferrous sulfate turns stool black, so much hemoglobin as normally
caution women about this to prevent shaped red blood cells can.
them from worrying that they are • When oxygen tension becomes
bleeding internally. If has difficulty reduced, as occurs at high altitudes, or
with oral iron therapy, intravenous blood becomes more viscid than
iron can be prescribed. usual, such as occurs with
A woman with folic acid deficiency anemia dehydration, the cells clump together
• Folic acid or folacin, one of the B because of their irregular blockage
vitamins is necessary for the normal with reduced blood flow to organs.
formation of red blood cells in the • The cells will hemolyse (i.e., be
woman as well as being associated destroyed), thus reducing the
with preventing neural tube and number of available and causing a
abdominal wall defects in the fetus. severe anemia.

• Approximately 1 in every 10 • Diabetes mellitus is an endocrine
African Americans has the sickle- disorder which the pancreas cannot
cell trait.
produce adequate insulin to
• In pregnancy, blockage to the placental regulate body glucose levels.
circulation can directly compromise Pathophysiology and clinical manifestations
the fetus, causing low birth weight and • The primary concern for any woman
possibly fetal death.
with this disorder is controlling the
• A woman with sickle-cell disease may balance between insulin and blood
normally have hemoglobin level of 6 glucose levels to prevent
to 8 mg/100 ml. hyperglycemia or hypoglycemia.
• Throughout pregnancy, monitor a • In of women with unregulated diabetes
woman’s nutritional intake to be are given times more apt to be
certain she is consuming sufficient born large of gestational age or
amounts of folic acid and possibly an with abnormalities.
additional folic acid supplement, which
• If a woman’s insulin production is
is necessary for replacing red blood insufficient glucose cannot be used
cells that have been destroyed. by body cells.
• Women should not take a routine iron • The cells register the need for glucose,
supplement as sickled cells cannot and the liver quickly converts
incorporate iron in the same manner stored glycogen to glucose to
as non-sickled cells. increase the serum glucose level.
• Ensure the woman is drinking at least • Because insulin is still not available,
eight glasses of fluid daily to be however, the body cells cannot use the
certain she is guarding against glucose, so the serum glucose level
dehydration. rise. (i.e., hyperglycemia)
• Early in pregnancy, when she may be Diabetes
nauseated, it is easy for her fluid 1. Stomach converts food to glucose
intake to decrease, causing 2. Glucose enters bloodstream
dehydration and subsequent sickle-cell 3. Pancreas produces sufficient insulin
crisis. but it is resistant to effective use.
• Asses a woman’s lower extremities at 4. Glucose is unable to enter the
prenatal visits for varicosities or pooling body effectively
of blood in leg veins, which can lead to 5. Glucose level increases
red cell destruction.
Therapeutic Management Diabetes during pregnancy
• Interventions to prevent a sickle-cell • In type 1 diabetes, which although
crisis include periodic exchange or unproven, is probably an autoimmune
blood transfusions throughout disorder because marker antibodies
pregnancy to replace sickle-cells are present, the pancreas fails to
n=with non-sickled cells. produce adequate insulin for the body
• If a crisis occurs, controlling pain, requirement.
administering oxygen as needed, an • In type 2 diabetes, there is a
increasing the fluid volume of the gradual loss of insulin production,
circulatory system to lower viscosity but some
are important interventions.
A woman with diabetes mellitus

ability to produce insulin will • Obesity
be present. • Age over 25 years
• When the level of blood glucose • History of large babies (10lb or more)
reaches 150 mg/100ml (normal level
• History of unexplained fetal or
is 80-120mg/dl), the kidneys begin to perinatal loss
excrete quantities of glucose in the
• History of congenital anomalies
urine (i.e., glucosuria) in an attempt to in previous pregnancies
lower the level. This causes quantities • History of polycystic ovary syndrome
of fluids to be excreted with urine
• Family history of diabetes (one
(i.e., polyuria). close relative or two distant ones)
• Infants of women with poorly controlled • Member of a population with a high
diabetes tends to be large (>10lb) risk for diabetes
because the increased insulin the Assessment
fetus produce counteract the overload • A fasting plasma glucose greater than
of glucose, he or she receives acts as a or equal to 126mg/dl or non-fasting
growth stimulant. plasma glucose greater than or equal to
• Hydramnios may develop because a 200 mg/dl meets the threshold for the
high glucose concentration causes diagnosis of diabetes and needs to be
extra fluid to shift and enlarge the confirmed on a subsequent test as soon
amount of amniotic fluid. as possible. This usually done using a
• A macrocosmic infant may create birth 75-g oral glucose challenge test.
problems at the end of the pregnancy • For this, after a fasting glucose sample
because of cephalopelvic disproportion. is obtained, the woman drinks an oral
This combined with an increased risk 75- g glucose solution; a venous blood
for women with diabetes to be born by sample is then taken for glucose
cesarean birth. determination at 1,2 and 3 hours later.
• There is also a high incidence of • If two of the four blood samples
congenital anomaly, especially caudal collected for this test are abnormal
regressions syndrome (failure of the or the fasting value is above 95mg/dl,
lower extremities develop), a diagnosis of diabetes is made.
spontaneous miscarriage, and • The values that confirm diabetes are
stillbirth in women with uncontrolled reviewed in the table.
diabetes. Oral glucose challenge test values (fasting
• At birth, neonate is more prone to plasma glucose values) for pregnancy
hypocalcemia, respiratory distress following a 75-g glucose solution
syndrome, hypoglycemia and Test type Pregnant glucose
hyperbilirubinemia. level (mg/dl)
• The first trimester of pregnancy is the Fasting 95
most important time for fetal 1hr 180
development; if a woman can be 2hrs 155
kept from becoming hyperglycemic 3hrs 140
during this time, the chances of a • The best insulin control program for
congenita anomaly greatly lessened. her during pregnancy can be then
Risk factors that developing gestational determined
diabetes include:

• The measurement of glycosylated
hemoglobin, a measure of the
amount of glucose attached to
hemoglobin is used to detect the
degree of hyperglycemia present.
• Measuring glycosylated hemoglobin is
advantageous not just because it
reflects the average blood glucose
attached to hemoglobin is used to
detect the degree of
hyperglycemia present.
• Measuring glycosylated hemoglobin is
advantageous not just because it offers
a present value of glucose, but because
it reflects the average blood glucose
level over the past 4 to 6 weeks (i.e.,
the time the hemoglobin in red blood
cells were picking up the glucose)

SPONTANEOUS MISCARRIAGE and Toxoplasmosis readily cross the
placenta and so may also be
Abortion responsible.
▪ Is a medical term for any interruption of a
pregnancy before a fetus is viable. (Able to Assessment:
survive outside the uterus if born at that The presenting symptom of
time).
spontaneous miscarriage is almost
▪ A viable fetus is usually defined as a fetus of always vaginal spotting.
more than 20 to 24 weeks of gestation or
one
Diagnosis:
that weighs at least 500g. A fetus born
1. Threatened Miscarriage
before this point is considered a Miscarriage
or is termed premature or immature birth. • Symptoms begin as vaginal bleeding
initially only scant and usually bright
red.
Early miscarriage occurs before week 16
• Slight cramping, but no cervical dilation
of pregnancy.
is present on vaginal examination.
Late miscarriage occurs between week 16
• Blood may be drawn to test for HCG
and 20.
hormone at the start of bleeding and
again in 48 hours (if the placenta is still
Common causes:
intact the level in the blood steam should
• The most frequent cause of miscarriage is be double at this time). If it does not
– abnormal fetal development due
double up poor placental function is
to either a teratogenic factor or to a
suspected and pregnancy probably will
chromosomal aberration.
be lost.
• Immunologic factors may be present or
• Avoidance of strenuous activity for 24
rejection of the embryo through to 48 hours is the key intervention
an immune response may occur.
• Complete bedrest may not be necessary
• Implantation abnormalities as up to 50%
• If spotting is going to stop it usually does
of zygotes probably never implant
so between 24 to 48 hours after a
securely because of inadequate woman
endometrial formation of from an reduces her activity.
inappropriate site of • Coitus may be restricted for 2 weeks.
implantation. 2. Imminent (inevitable) Miscarriage
• Miscarriage may also occur if corpus • A threatened miscarriage becomes an
luteum in the ovary fails to produce Imminent Miscarriage if uterine
enough progesterone to maintain contractions and cervical dilatation
the decidua basalis. occur, with cervical dilation the loss of
• Ingestion of alcohol at the time of the products of conception cannot be
conception or during early pregnancy halted.
can contribute to pregnancy loss • Save any tissue fragments she has pass to
because of abnormal fetal growth. check for abnormality.
• Urinary tract infection may be a cause but • If no fetal heart rate sounds are detected
are more strongly associated and an ultrasound reveals an empty
with preterm birth. gestational sac or nonviable fetus, her
• Systemic infection such as Rubella, primary health care provider may offer
Syphilis, Poliomyelitis, Cytomegalovirus medication to help the pregnancy pass
or perform Dilatation and Curettage
(D&C) or Dilatation and Evacuation

(D&E) to

ensure all products of conception height is measured and no increase in
are removed. size can be demonstrated.
• After a woman is discharged, she should • Or when previously heard fetal heart sounds
assess the amount of vaginal bleeding can no longer be heard.
she is having by recording the • A woman may have painless vaginal
number of pads she uses. bleeding or she may have had no prior
• Saturating more than 1 pad per hour is clinical symptoms.
abnormally heavy bleeding.
• D&C or D&E may be done to evacuate
3. Complete Miscarriage the pregnancy.
• The entire products of conception • If pregnancy is over 14 weeks in length and
(fetus, membranes and placenta) are therefore procedures are no longer
expelled spontaneously without any possible labor can be induced by a
assistance. prostaglandin suppository or Misoprostol
• The bleeding usually slows within 2 (Cytotec) introduced into the posterior
hours and then ceases within a few days
fornix of the vaginal to cause dilation
after
• Followed by oxytocin stimulation or
passage of the products of conception.
• Because the process is complete, no administration of Mifepristone techniques
used for elective termination or
therapy other than advising the woman
pregnancy which cause contraction and
to report heavy bleeding is needed.
birth.
4. Incomplete Miscarriage
6. Recurrent Pregnancy Loss
• Part of the conceptus (usually the fetus)
• In the past woman had three spontaneous
is expelled, but the membranes or
miscarriages were called “habitual
placenta are retained in the uterus. aborters”
• With an incomplete, there is danger of
maternal hemorrhage as long as part of Complications of Miscarriage
the
1. Hemorrhage
conceptus is retained in the uterus
• With a complete spontaneous
because the uterus cannot contract
miscarriage, serious or fatal hemorrhage
effectively under this condition. is rare.
• The woman will usually have D&C or • With an incomplete miscarriage or in
suction Curettage to evacuate
a woman who develops
the remainder of the pregnancy.
accompanying coagulation defect
5. Missed Miscarriage
(usually DIC) major hemorrhage
• Also commonly referred to as an becomes a possibility.
early pregnancy failure.
• Monitor vital signs for any changes to detect
• The fetus dies in utero but is not expelled. possible hypovolemic shock.
• A missed miscarriage is usually discovered • If excessive vaginal bleeding occurs,
at a prenatal examination when the fundal immediately position flat and massage
height is measured and no increase in the uterine fundus to try to aid
size can be demonstrated or when contraction.
previously heard fetal heart sounds can • D&C if bleeding does not halt
no longer be heard. • Suction Curettage to empty the uterus of
• A woman may have painless vaginal bleeding the material that is preventing it from
or she may have no prior clinical symptoms. contracting and achieving hemostasis.
• A missed miscarriage is usually discovered • A transfusion may be necessary to
at a prenatal examination when the fundal replace blood loss.
• Any unusual odor or passing of large clot

is also abnormal.

• Oral medications such as Assessment:
Methylergonovine maleate (Methergine) No menstrual flow occurs
to aid uterine contraction. • Nausea and vomiting of early pregnancy
2. Infection • Positive pregnancy test for HCG
• The possibility of infection is minimal when • The zygote grows large enough that is
pregnancy loss occurs over a short time, rupture the slender fallopian tube tearing
bleeding is self-limiting and and
instrumentation is limited. destruction of blood vessels and
• Infection is often a reason for excessive bleeding result.
blood loss. • Sharp, stabbing pain in one of the lower
• Be certain the women is familiar with a abdominal quadrants at the time of rupture
common danger sign of infection such as followed by scant vaginal spotting (blood may
fever higher than 38C, abdominal pain be expelled in the pelvic cavity rather than
or tenderness and a foul smelling vaginal the uterus)
discharge. • Signs of hypotension from the blood loss light,
• Caution women to always wipe the perineal headedness, rapid pulse, signs of
area from the front to back after voiding hypovolemic shock.
and defecation to avoid the spread of • Signs of severe shock, rapid, thready pulse,
bacteria. rapid respirations, falling blood pressure.
• Infection usually involves the inner lining of • Leukocytosis may be present from trauma
the uterus (endometritis) and not from infection
• Temperature is usually normal
ECTOPIC PREGNANCY • Rigid abdomen from peritoneal irritation
Implantation occurred outside the • Cullen’s sign (bluish tinged umbilicus)
uterine cavity. • Movement of cervix on pelvic examination
The most common site (approximately 95%) can cause excruciating pain
is in the Fallopian tube • Pain in the shoulder from blood in in the
Of these Fallopian tube sites peritoneal cavity causing irritation on
approximately: Ampullar portion the phrenic nerve.
19% • A tender mass palpable in douglas cul-de sac
Isthmus 12% on vaginal examination.
Interstitial and fimbrial 8% Therapeutic Management:
• Some ectopic pregnancies spontaneously end
With most ectopic pregnancy fertilization before they rupture and are reabsorbed
occurs as usual in the fallopian tube. over the next few repairing no treatment.
Cause: • Medically treated by intramuscular or less
• Unfortunately, because an obstruction in often real administration of Methotrexate
present, such as an adhesion of the treated
fallopian tube from a previous infection until a negative HCG titer is achieved
(chronic Salpingitis or pelvic • The therapy for ruptured ectopic pregnancy is
inflammatory disease) laparoscopy to ligate the bleeding vessel
• Congenital malformities and to remove or repair the damaged
• Scars from tubal surgery fallopian tube
• Uterine tumor pressing on the perineal
end of the tube.

GESTATIONAL TROPHOBLASTIC DISEASE declining. If the level of the plateaus of
(hydatidiform mole) (H-Mole) increases, it suggests a malignant
• Abnormal proliferation and degeneration transformation (choriocarcinoma) is
of trophoblast villi occurring
• As the cell degenerate, they become filled
• During the waiting time for the HCG to deadline
with fluid and appear as clear fluid-filled, a woman should use a reliable
grape- sized vesicles contraceptive tracheal such as oral
• The embryo fails to develop beyond a estrogen/progesterone do that positive
primitive start pregnancy test will be mistaken will
• Abdominal trophoblase cells are must be malignancy.
identified because they are associated • If malignancy should occur, it can be treated
with choriocarcinoma, a rapidly metastatic with methotrexate dactinomycin a
malignancy. second agent can be added with the
• Assessment: regimen of metastasis occurs.
• Uterus expands faster than usual. This Cervical insufficiently
rapid development is also diagnosis of (Premature cervical dilatation)
multiple
• Previously termed as incompetent cervix
pregnancy or miscalculated due date,
• Strongly positive pregnancy test (1 to 2 • Refers to a cervix that dilates prematurely
and therefore cannot retain a fetus until
million international Units compared with a term.
normal pregnancy level of 400, 000)
• Painless dilation the cervix is
international units.
• First symptom is show (a pink stained
• Marked nausea and vomiting
vaginal discharge)
• Symptoms of gestational hypertension;
• Increased pelvic pressure, followed by
• Increased blood pressure
rupture of the membrane and discharge of
• Edema
amniotic fluid
• Proteinuria
• Uterine contractions begin and after a
• An ultrasound will show dense growth (typically
short labor the fetus is born.
a snowflake pattern) but no fetal growth in
o It is associated with:
the
o Increased maternal age
uterus.
o Congenital structural defects
• No fetal heart sounds can be heard
because there is no viable fetus. o Trauma to the cervix that might have
• Vaginal spotting of dark brown blood occurred with a cone biopsy or
resembling prune juice or as a profuse repeated D&C’s.
fresh flow. Management:
• Cervical cerclage a surgical operation can be
• As bleeding progresses, it is accompanied
by discharge of clear fluid filled vesicles. performed to prevent this from happening in
Therapeutic management: a second pregnancy.
• Suction curettage to evacuate the • McDonald procedure a nylon sutures are
abnormal trophoblast cells. placed horizontally and vertically across the
cervix
• Have a baseline pelvic examination and a
and pulled tight to reduce the cervical canal
serum test for HCG.
to a few millimeters in diameter
• The HCG is analyzed every 2 weeks until normal.
• Shirodkar technique sterile tape is threaded in a
• The serum HCG is then assessed every 4
purse sewing manner under the
weeks for the next 6-12 months to bee if it is
submucous layer of the cervix and sutured
in place to achieve a closed cervix.

• After cerclage surgery, women remain on • Obtain baseline vital signs to determine
bedrest (slight or modified Trendelenburg whether the symptoms of hypovolemic
position) for a few days to decrease shock are present.
pressure on the new sutures. • Continue to assess blood pressure every 5 to
• Usual activity and sexual relations can be 15 mins.
resumed in most instances after this • Never attempt to give a pelvic or rectal exam
rest period with painless bleeding late in pregnancy
• The sutures are removed at weeks 37 to 35 because any agitation in the cervix might
of tear the placenta further and initiate massive
pregnancy so the fetus can be born vaginally. hemorrhage.
• Attach external monitoring equipment to record
fetal heart sounds and uterine contractions.
PLACENTA PREVIA • Ready for blood replacement if necessary.
• A condition a pregnancy in which the placenta • Monitor urine output as often as every hour
is implanted abnormally in the lower part of as an indicator her blood volume is remaining
the uterus. adequate to perfuse her kidneys.
• It is the most common cause of painless • Administer intravenous fluids as prescribed,
bleeding in the third trimester of preferably with a large gauge catheter to
pregnancy. allow for blood replacement through the
• It is associated with: same line.
o Increased parity • A vaginal birth is always the safest for the
o Advanced maternal age infant. But if the previa is under 30% it may be
o Past cesarean births possible
o Past uterine curettage for the fetus to born normal. If over 30% and
o Multiple gestation the fetus is mature the safest birth method
o A male is cesarean delivery.
fetus Assessment: • If only a minimum previa is suspected and may
• The bleeding with placenta previa usually begins attempt a speculum examination, this should
until the lower uterine segment starts to be done in an operating room or a fully
differentiate from the upper segment late equipped as immediate cesarean birth is
in pregnancy and the cervix begins to carried out.
dilate. • Have oxygen equipment available is case of fetal
• Because the placenta is unable to stretch to distress.
accommodate the differing shape of the Continuing care measures:
lower uterine segment of the cervix, a small • If labor has begun, bleeding is occurring or
portion loosens and damaged blood vessels the fetus is compromised birth must be
begin to bleed. accomplished regardless of gestational age.
• The bleeding is usually abrupt, painless, bright • If bleeding has stopped the fetal heart
red and sudden. sounds are of good quality, maternal vital
signs are
• Therapeutic management:
good and the fetus is not yet 36 weeks of age, a
• Place woman immediately on bedrest in a side
woman is usually managed by expectant
lying position to ensure an adequate supply to
a watching. Typically, a woman remains in the
woman and fetus. hospital on bed rest for clinic observation for
• Inspect the perineum for bleeding and 24 to 48 weeks
estimate the presence rate of blood loss. • If bleeding stops, she can be sent home for
bedrest.

• Assessment of fetal heart sounds and • It the center of the placenta separates
laboratory tests such as hemoglobin and first; blood can pool under the placental
hematocrit are obtained frequently. and it will be hidden from view.
• Betamethasone, a steroid that lessen fetal • Uterus becomes tense and feels rigids
lung maturing may be prescribed for the to touch
mother to • If blood infiltrates the uterine
encourage the maturity if fetal lungs if the
musculature, Couvelaire uterus or
fetus is less than 34 weeks gestation.
uteroplacental apoplexy, forming a hard
board like uterus.
• Therapeutic management:
PREMATURE SEPARATION OF THE
• Monitor fetal heart sounds externally and
PLACENTA (ABRUPTIO PLACENTA) record maternal vital sign every 5 to 15
• The placenta appears to have been mins
implanted correctly to establish baseline and observe progress.
• Refers to the premature separation of • A large gauge intravenous catheter
the placenta. inserted for fluid replacement
• The separation generally occurs late in • Oxygen by mask no limit fetal anoxia
pregnancy: even as late as during the 1st • Keep woman in lateral, or supine position
and 2nd stage of labor. to prevent pressure on the vena cava and
• The primary cause of premature additional interference with fetal circulation.
separation is unknown • Do not perform any abdominal, vaginal
Predisposing factors: or pelvic examination with a diagnosed
• High parity or suspected placental separation.
• Advanced maternal age Premature separation of the
• Short umbilical cord placenta: Degrees of separation:
• Chronic hypertensive disease • 0 – no symptom of separation is
• Hypertension of pregnancy apparent from maternal or fetal signs.
• Direct trauma • 1 – minimal separation, that enough to
• Vasoconstriction from cigarette or cause vaginal bleeding and changes in
cocaine use the maternal vital signs, no fetal
• Thrombophilic condition that lead distress or hemorrhagic shock occurs
to thrombosis formation • 2 – moderate separation there is
• Chorioamnionitis or infection of the evidence of fetal distress the uterus
fetal membrane or fluids is tense and painful on palpation
• Rapid decrease in uterine volume such as • 3 – extreme separation without
in sudden release of amniotic fluid in immediate interventions, maternal
polyhydramnios hypovolemic shock and fetal death
Assessment: will result.
• Sharp stabbing pain high in the PRECIPITATE DILATION
uterine fundus as the initial separation • Precipitate dilation is a cervical dilation that
occurs
occurs at a rate of 5 com or more per hour in
• Tenderness on uterine palpation a primipara or 10 cm or more per hour in
• Heavy bleeding will only be evident if the multipara.
placenta separates first at the edges so • Precipitate birth occurs when uterine
blood contractions are strong a woman gives birth
escapes freely into the uterus and then
with only a few rapidly occurring
the cervix.
contractions

• Often defined as a labor as a labor is • Intrauterine tumors
completed in fewer than 3 hours • A small fetus
• Such rapid labor is likely to occur with: • CPD preventing from engagement
• Grandmultiparity • Hydramnios
• After induction of labor by oxytocin • Multiple gestation
• Contractions can be so forceful they lead Assessment:
to premature separation of the placenta • The cord may be felt as the presenting
or
part on initial vaginal examination can be
laceration of the perineum.
visualized.
• A precipitate labor can be predicted from a
• On inspection, the cord may be visible
graph if during the active phase of at the vulva.
dilatation, the rate is greater than 5cm/hr in
• To rule out cord prolapse, always
a nullipara or 10 cm/hr in multipara.
assess fetal heart sounds immediately
• Caution multiparous women by week 28 of
after rupture of membranes
pregnancy that because a past labor was
Therapeutic management:
so brief, her labor this time may be brief.
• A prolapsed cord is always an emergency
• Plan for adequate transportation to the hospital
situation cord compression and
• Should have the birthing room converted decreased oxygenation to the fetus.
readiness before full dilatation id
• Relieve pressure on the cord by placing
obtained.
a gloved hand in the vagina and
• When labor contractions are ineffective, manually
several interventions are made: elevating the fetal head of the cord of
• Induction of labor means labor is by placing the woman in knee chest or
started artificially Trendelenburg position
• Augmentation of labor refers to assisting
• Administering oxygen at 10L/min by face
labor that has started spontaneously but is mask to improve oxygenation
not effective. • Amnioinfusion is another way to
The following should be present relieve pressure on the cord.
before induction of labor: • Amnioinfusion is the additional sterile
• The fetus is in longitudinal lie
fluids into the uterus to supplement the
• The cervix is ripe or ready for birth amniotic fluid and reduce compression on
• A presenting part is engaged the cord
• There is no CPD • A sterile double lumen catheter is
• The fetus is estimated to be mature introduced through the cervix into
by date (over 39 weeks) the uterus
Prolapse of the umbilical cord CESAREAN BIRTH

• A loop of the umbilical cord slips down in • Birth accomplished through an
front of the presenting fetal part. abdominal incision into the uterus
• Prolapse may occur at any time after the • Scheduled Cesarean Birth are planned which
membranes rupture if the [resenting fetal means there is time for thorough
part is not fitted firmly into the cervix preparation for the experience throughout
• It tends to occur most often with: the antepartal period.
• Premature rupture of the membranes • Emergent Cesarean Birth are done for reasons
• Fetal presentation other than cephalic that arise suddenly in labor, such as placenta
• Placenta previa

previa, premature separation of placenta, • A disadvantage of this type of incision is
fetal distress or failure to progress
that is leaves a wide skin scare and also runs
• With this second type of cesarean birth, through the active contractile portion of the
preparation must be done rapidly but with uterus.
the same concern for fully informing a woman • Because this type of scar could rupture
and her support person about what during labor, if this type of incision is used,
circumstances created the need for cesarean it is likely that a woman may not be able to
birth and how the birth will proceed. have a subsequent vaginal birth.
Indications: • A LOW SEGMENT INCISION (low transverse
Maternal factors: or Pfannenstiel incision) is one made
• Active genital herpes horizontally across the abdomen just
• Aids and hiv positive status over the symphysis pubis and also
• Cephalopelvic disproportion horizontally across the uterus just over
• Cervical cerclage the cervix.
• Disabling conditions such as gestational • This is the most common type of cesarean
hypertension that would prevent incision used today.
pushing
• This is also referred to as Misgav-ladach
• Failed induction or failure to progress labor.
or bikini incision because even a low-cut
• An obstructive benign or malignant tumor
bathing suit will cover the scar
• Previous cesarean birth by classic incision
• Because this type of incision is through
fear of birth or wish to help prevent
non active portion of the uterus (the part
uterine
that
prolapse or urinary incontinence in
contracts minimally with labor) it is less likely
later years
to rupture in subsequent labors making it
Placental factors:
possible for woman to have a vaginal birth
• Placenta previa after cesarean (VBAC) with a future
• Premature separation of placenta pregnancy
• Umbilical cord • It also results in less blood loss, is easier to
prolapse Fetal factors: suture decreases postpartal uterine
• Compound conditions such as infections and is less likely to cause
macrosomic fetus in breech lie
postpartum gastrointestinal
• Extreme low birth weight complications.
• Fetal distress
• A major fetal anomaly such as hydrocephalus
• Multigestation or conjoined twins
• Transverse fetal lie and perhaps
breech presentation
Types of cesarean incision

• In a CLASSIC CESAREAN INCISION, the
incision is made vertically through both
the abdominal skin and uterus
• The incision is made high on the uterus
so that it avoids cutting a possible
placenta
previa

Topic: Preterm Labor dilated more than 4 to 5 cm,
and effacement is more than
PRETERM LABOR 50%.
Is labor that occurs before the end of 3. Placed on bedrest to relive the pressure
week 37 of gestation. of the fetus on the cervix.
4. Intravenous fluid therapy to keep a
• Any woman having persistent uterine woman well hydrated to stop the
contractions (4 contractions every 20 contractions.
mins) should be considered to be in labor. 5. Vaginal and cervical cultures and a clean-
• A woman is documented as being in actual catch urine sample are obtained to rule
labor rather than having false labor out infection
contractions
6. Take an oral Tocolytic agents (drugs to
if she is having uterine contractions that cause
halt labor) Terbutaline
cervical effacement over 80% and dilatation
7. It is important that women also
over 1cm.
maintain adequate nutrition and do not
• It results in infant’s birth; the infant may be
smoke cigarettes.
immature.
• Cause is unknown but is associated with
Drug Administration:
dehydration, UTI and chorioamnionitis
•An antibiotic for group B
(infections of the fetal membrane and
streptococcus prophylaxis.
fluid).
•Administration of a corticosteroid to the
Common symptoms are: fetus appears to accelerate the
formation of lung surfactant.
• Persistent dull
• Lower backache •If the pregnancy is under 34 weeks,
a woman may be given a steroid
• Vaginal spotting
(betamethasone) to attempt to hasten
• A feeling of pelvic pressure or
fetal lung maturity (two doses of 12 mg
abdominal tightening
betamethasone given intramuscularly 24
• Menstrual like cramping
hours apart or four doses of 6 mg
• Increased vaginal discharge
dexamethasone given intramuscularly
• Uterine contractions and
12 hours apart)
intestinal cramping
•Magnesium sulfate is the drug of choice
used to halt contractions, has a
Therapeutic Management:
central nervous system depressant
1. Analyzing changes in vaginal mucus.
action that slows and halts uterine
If there is the presence of fetal
contractions.
fibronectin, a protein produced by
trophoblast cells, preterm •Ritodrine hydrochloride (Yutopar) and
terbutaline (Brethine), as a beta 2
contraction are ready to occur.
receptor, it causes blood vessels and
Absence of the protein predicts that
bronchi to relax along with the
labor will not occurs for at least 4days.
uterine muscles.
2. Medical attempts can be made to stop
labor is the fetal membranes are intact, •After the halt of contractions, a tocolytic
infusion usually is continued for 12 to
fetal distress is absent, there is no
24 hours, and then oral administration
evidence that bleeding is occurring, the
of terbutaline is begun.
cervix is not
•The first oral dose is given 30 minutes
before the intravenous infusion is

discontinued to prevent any drop in the estrogen fluid on microscopic
serum concentration, a woman will examination (amniotic fluid shows
continue to take an oral tocolytic until this: urine does not)
37 weeks.
• A sonogram may be ordered to assess
the amniotic fluid index.
Labor that cannot be halted. • If the fetus is estimated to be mature
• If membranes have ruptured or the enough in an extrauterine
cervix is more than 50% effaced environment and labor does not begin
and more than 3 to 4 cm dilated, it within 24 hours, labor contraction is
is unlikely labor can be halted. usually induced by an intravenous
• If the fetus is very immature at the time administration of oxytocin.
labor. Therapeutic Management:
Premature Rupture of Membranes
• If labor does not begin and the
• Preterm rupture of membrane is
fetus is near a point of viability,
rupture of fetal membrane with loss a woman is placed on bed.
of amniotic fluid during pregnancy
• Corticosteroid to hasten fetal
before 37 weeks. lung maturity.
• The cause of preterm rupture is • Broad spectrum antibiotics.
unknown, but is associated
• Take her temperature twice a
with infection of the
day and to report a fever,
membranes (chorioamnionitis) uterine
• After rupture, the seal to the fetus is tenderness, or odorous
lost therefore uterine and fetal vaginal discharge.
infection may occur. • Refrain from tub bathing, douching
• Second complication that can result and coitus because of the danger
from preterm membrane rupture is of introducing infection.
increased pressure on the umbilical • White cell count will need to
cord from the loss of amniotic assessed frequently.
fluid, inhibiting the fetal nutrition • A count of more than 18, 000
supply. to 20,00/mm3 suggest
• A condition that could also interfere infection.
with fetal circulation.
• Cord prolapse is most apt to occur Gestational Hypertension
when the fetal head is still small to fit • It is a condition in which vasospasm
the cervix firmly. occurs in both small and large
ASSESSMENT arteries during pregnancy, causing
• A sudden gush of clear fluid from the signs of:
vagina, with continued minimal o Increased blood pressure
leakage. o Proteinuria
• If the fluid is tested with Nitrazine o Edema
paper, amniotic fluid causes an • The cause of the disorder is
alkaline reaction on the paper unknown the condition tends to
(appears blue) and urine an acidic occur most frequently in
reaction (remains yellow). o Women of color
• The fluid can also be tested for ferning, o With a multiple pregnancy
or the typical appearance of a high-

o Primiparas younger than 20 because it begins to accumulate in
years of age or older than the upper part of the body.
40 years • A weight gain of more than two
o Women from low lbs/weeks on the second trimester
socioeconomic backgrounds or 1lb/week on the third trimester.
(perhaps because of poor
nutrition) Severe Preeclampsia
o Those who have had five • Blood pressure is 160 systolic and
or more pregnancies 110 mmHg diastolic
o Those who have hydramnios • Marked proteinuria 3+ or 4+ on a
o Those who have underlying random sample or more than 5g in a
disease such as a heart 24- hour sample.
disease, diabetes with vessel or • Extensive edema is present
renal involvement
o Essential hypertension Edema can be described as:
Assessment: Non-pitting – swelling cannot be indented
Classical signs: with finger pressure
• Vision changes 1+ pitting edema – tissue can be
• Typically, hypertension indented slightly.
• Proteinuria 2+ pitting edema – moderate
• Edema indentation 3+ pitting edema – deep
indentation
Gestational hypertension • Accumulating edema will reduce a
• Blood pressure is 140/90 mmHg or woman’s urine output to
systolic pressure elevated 30mmHg approximately 400 to 600 ml/24hrs
or diastolic pressure elevated • Some woman reports severe epigastric
15mmHg prepregnancy level pain and nausea or vomiting possible
• No proteinuria because abdominal edema or
• No edema ischemia to the pancreas and liver has
• Blood pressure return to normal occurred.
after birth • If pulmonary edema has developed a
woman may report feeling short
Mild Preeclampsia of breath.
• Has proteinuria and BP of 140/90 • If cerebral edema has occurred, reports
mmHg taken on two occasions at least of visual disturbances such as
6 hours apart. blurred vision or seeing spots before
• Blood pressure is 140/90mmHg or the eyes may be reported
systolic pressure elevated 30mmHg
or Eclampsia
diastolic pressure elevated • Most severe classification of
15mmHg above prepregnancy gestational hypertension
values • A woman has passed into this stage
• Proteinuria of 1+ or 2+ on a reagent test when cerebral edema is so acute and
strip on random sample grand mal seizure (tonic-clonic) or
• Edema can be separated from coma has occurred
the typical ankle edema of
pregnancy

• The maternal mortality rate can be • Bedrest therefore is the best
as high as 20% from causes such as method of aiding increased
cerebral hemorrhage, circulatory evacuation of sodium and
collapsed or renal failure encouraging diuresis of edema
fluid.
Patellar Reflex • Be certain women know to rest in
• With the woman in a supine lateral recumbent position to
position, ask her to bend her knee avoid uterine pressure on the vena
slightly cava and prevent supine
• Place your hand under her knee hypotension syndrome.
to support the leg. Promote Good Nutrition
• Locate the patellar tendon in the • A woman needs to continue her
midline of the anterior leg just usual pregnancy nutrition while
below the kneecap on bedrest
• Strike it firmly and quickly with a
reflex hammer or the side of your Nursing intervention of woman with
hand severe gestational hypertension
• If the leg and foot move, a Support bedrest
patellar reflex is present • Most woman are hospitalized so
Patellar reflex is scored as:
that bedrest can be enforced and
• 0 – no response, hypoactive, abnormal
a woman can be observed more
• 1+ somewhat diminished response closely that she can be on home
but not abnormal
care.
• 2+ average response
• Visitors are usually restricted to
• 3+ brisker than average but support people because a loud
not abnormal noise can be sufficient to
• 4+ hyperactive very brisk abnormal trigger seizure that initiates
eclampsia.
Nursing Interventions:
• Admit to a private room so she can
Monitor antiplatelet therapy
rest and undisturbed as possible.
• Mild antiplatelet agent, such as low
• Raise side rails to prevent injury is
dose Aspirin, may prevent or delay a seizure should occur.
the development pf preeclampsia
• Darken the room if possible
• Antiplatelet: work by making your
because a bright light can
blood less sticky. This prevents arteries
also trigger seizure.
from
being plugged by clots. • Shining a flashlight beam into a
woman’s eyes is the kind of
• Aspirin 50 to 80mg (sold as baby
sudden
aspirin) because excessive salicylic stimulation to be avoided.
levels can cause maternal bleeding • Stress is another stimulus that
at birth.
could increase BP and evoking
Promote bedrest
seizures in a woman with severe
• When the body is in recumbent preeclampsia.
position, sodium tends to be • Be certain a woman receives clear
excreted at a faster rate than explanations of what is
the during activity. happening
and what is planned esp. about
the visitor’s restriction.

• Allow her opportunities to • Is a variation of gestational
express her feelings about what is hypertension that is named for
happening. the common symptoms that
Monitor fetal well being occurs.
• Take BP frequently (at least every • H – hemolysis that leads to anemia
4hrs) or with a continuous monitoring • EL – elevated liver enzymes that lead
device to detect any increase which is to epigastric pain
a warning that a woman’s condition is • L – low platelets that leads to
worsening. abnormal bleeding/clotting and
• Obtain blood studies such as CBC, petechia.
platelet count, blood urea nitrogen • The syndrome occurs in 4% to
and fibrin degeneration products as 12%of patients who have elevated
prescribed to assess renal and liver blood pressure during pregnancy.
function. • Because of low platelet count
• Daily hematocrit levels are used to women need extremely close
monitor blood concentration (this observation for
level will rise if increased fluid is bleeding, in addition to observations
leaving the bloodstream for interstitial necessary for preeclampsia.
tissue edema) • Therapy for this condition is transfusion
• A woman’s fundus should be assessed of fresh frozen plasma or platelets
daily for signs of arterial spasm, in order to improve the platelet
edema or hemorrhage. count.
• An indwelling urinary catheter may be
inserted to allow accurate recording Multiple pregnancy
of output and comparison with intake. • Is considered a complication of
• Urinary output should be more than pregnancy because a woman must
30ml/hr adjust to the effects of more than
• A 24hr urine sample may be one fetus
collected for protein and creatinine 1. Identical (monozygotic) twin b
clearance determination to evaluate • Begin with a single ovum and a
kidney function. spermatozoon in the process of
Monitor fetal well being fusion, or in one of the first bell
• Single doppler auscultations divisions, the zygote divides into two
at approximately 4hrs identical individuals
• A woman may have non stress test or • Usually have 1 placenta, 1 chorion, 2
biophysical profile done daily to amnions and 2 umbilical cords
assess uteroplacental insufficiency. • The twins are always of the same sex.
• If fetal bradycardia occurs, oxygen • They account for 1/3 of twin births
administration may be necessary • Fraternal (Dizygotic, Nonidentical) twins
to • They account 2/3 of twin births
maintain adequate fetal oxygenation. • The result of the fertilization of
two separate ova by two separate
spermatozoa.
HELLP Syndrome • Have 2 placentas, 2 chorions, 2
amnions and 2 umbilical cords
• The twin may be of the same
or different sex.
ASSESSMENT:

• Uterus begins to increase in size at • Amniotic fluid is formed by a
a rate faster than usual combination of the cells of the
• AFP levels will also be elevated amniotic membrane and from fetal
• At the time of quickening, a woman urine
may report flurries of action at • It is evacuated by being swallowed
different by the fetus, absorbed across the
portions of her abdomen rather at interstitial membrane into the fetal
one consistent spot. bloodstream, and transferred across
• On auscultation of the abdomen, the placenta.
multiple sets of fetal heart sounds • Accumulation of amniotic fluid suggests
can be heard. difficulty with the fetus ability to
• An ultrasound can reveal multiple swallow or absorb or excessive
gestation sacs early in pregnancy. urine production.
THERAPEUTIC MANAGEMENT:
• Inability to swallow occurs in infants
• Women with multiple gestation are who are anencephalic who have
more susceptible to complications of tracheoesophageal fistula with
pregnancy such as gestational stenosis or who have interstitial
hypertension, hydramnios, placenta obstruction
previa, preterm labor and anemia
• Excessive urine output occurs in the
that are women carrying one fetus. fetus of diabetic women
• Following birth, they are more prone (hyperglycemia in the fetus causes
to postpartum bleeding because of the increased urine production)
additional uterine stretching that • The first sign of hydramnios may be
occurred unusually rapid enlargement of
• Need closer prenatal supervision the uterus.
• A woman carrying more than • The first sign of hydramnios may be
two fetuses is at greater risks. usually rapid enlargement of the uterus
• The small parts of the uterus become
Hydramnios
difficult to palpate because the uterus
• Usually, the amniotic fluid volume is unusually tense.
at term is 500 to 1000ml
• Auscultating the fetal heart rate can
• Hydramnios occurs when there is
be difficult because the depth of the
excess fluid of more than 200ml or an increased amount of fluid
amniotic fluid index above 24cm surrounding the fetus.
• Hydramnios can cause fetal • A woman may notice extreme shortness
malpresentation because the of breath as the overly distended
additional
uterus pushes up against the
uterine space can allow the fetus
diaphragm
to turn to a transverse lie.
• Lower extremity varicosities and
• It also lead to premature rupture of the
hemorrhoids
membranes from the increased
• Increased weight gain
pressure, which leads to additional
risk to infection, prolapsed cord and • An ultrasound is done to document
the presence of hydramnios.
preterm birth.
Therapeutic management:
Assessment:
• Maintain bedrest helps to increase
uteroplacental circulation and
reduces

pressure on the cervix which may • Meconium aspiration is more apt to
help prevent preterm labor.
occur as fetal interstitial contents
• Straining to defecate could increase are more likely to reach the rectum
uterine pressure and cause a rupture • Macrosomia could create a
of membranes-high fiber birth problem
• Assess vital signs as well as lower • Lack of growth because the
extremity edema frequently
placenta seems to have adequate
• Amniocentesis can be performed functioning ability for only 40 to 42
to remove some of the extra fluid. weeks.
• If contraction begin, tocolysis may • Prostaglandin gel or misoprostol
be necessary to prevent or halt (Cytotec) applied to the cervix to
preterm labor. initiate
ripening flowed by an Oxytocin
Oligohydramnios infusion are common methods used to
• Refers to a pregnancy with less than begin labor
the average amount of amniotic fluid
• Because part of the volume of the Pseudocyesis
amniotic fluid is formed by the • False pregnancy
addition of fetal urine, this reduced • Nausea and vomiting, amenorrhea
amount of fluid is usually caused by a and enlargement of the abdomen
bladder or renal disorder in the fetus occur in
that is interfering with voiding either a nonpregnant women or man
• It can also occur from severe
growth restriction
• Oligohydramnios is suspected
during pregnancy when the uterus
fails to meet its expected growth
rate.
Post term pregnancy

• A term is 38 to 42 weeks long
• A pregnancy that exceeds these limits is
prolonged (post term pregnancy,
post mature, postdate)
• Included in this group are some
pregnancies that appear to
extend beyond the due date set
for them because of a faulty due
date.
• Women who have long term menstrual
cycle
• Remaining in utero for longer than 2
weeks beyond term creates danger to
a fetus for several reasons:

Notes for NCM 109: Final Term
Hydrocephalus Communicating Hydrocephalus or

• Cause is unknown Extra ventricular Hydrocephalus
• Overproduction of fluid • this type of hydrocephalus
• Obstruction of the passage of occurs when there is no
fluid. obstruction to the flow of CSF
• Interference with the absorption within the ventricular system.
of CSF from the subarachnoid • The condition arises either due
space if the portion is removed to inadequate absorption.
Function of Cerebrospinal Fluid: Obstructive Hydrocephalus or
• It acts as “shock absorber” Intraventricular Hydrocephalus
(absorbing the energy of • it occurs when the flow of CSF is
sudden impulse) for the brain blocked in the passages
and spinal cord. connecting the ventricles
• It acts as a vehicle for delivering causing enlargement of the
nutrients to the brain and pathways leading to an increase
removing waste from it. in pressure within the skull.
• It flows between the cranium • Can be demonstrated
and spine to regulate changes by sonogram, computed
in pressure. tomography, magnetic
Congenital Hydrocephalus – present resonance imaging
at birth that occur during fetal • Transillumination (holding a
development or as a result of genetic bright light against the skull
abnormalities. with the child in the darkened
room) revealed the skull is
Acquired Hydrocephalus – develops filled with fluid.
at birth or in adulthood and is
typically caused by injury or disease. Hydrocephalus
Assessment: • Is the build up of fluid or excess

of fluid in the cavities or
• Excessive fluid accumulates and ventricles of the brain
dilates the system above the • The excess fluid increased the
point of obstruction. size of the ventricles and puts
• The infant’s fontanelles widen pressure on the brain.
and appear tense, the suture • Cerebrospinal Fluid normally
lines on the skull separate and flows through the ventricles and
the head diameter enlarges. bathes the brain and spinal
• The scalp becomes shiny and column.
scalp veins become prominent. • Too much CSF associated with
• Brow bulges in a typical hydrocephalus can damage
appearance (bossing) and brain tissues and cause brain
the eyes become sunset function problems.

• Cerebrospinal Fluid (CSF) is by the peritoneal membrane
formed in the first and second and into the body circulation.
ventricles of the brain and
passes through the aqueduct of Imperforate Anus
Sylvius and the fourth ventricle
• Is stricture of the anus
to empty into the subarachnoid
• There may be
space of the spinal cord where
accompanying fistula to the
the it absorbed. bladder in boys
• Total volume 150ml and to the vagina in girls
• Color: colorless, clear • It may occur as an additional
• All children under 2 complication of the spinal cord
years should have their disorders because both the
head external canal and the spinal
circumference recorded.
cord arise from the same germ
• Measure head circumference of layer.
all infants within an hour of
birth and before discharge Assessment:
• The infant’s motor function
• No anus is present
becomes impaired as the head
enlarges. • The condition may be revealed
because a membrane filled with
Signs: black meconium can be seen
protruding from the anus. A
• Signs of increased intracranial
wink reflex (touching the skin
pressure such as decreased
near the rectum should make it
pulse and respiration, increased
contract) will not be present if
temperature and blood
present. If sensory nerve
pressure, hyperactive reflexes,
endings in the rectum are not
strabismus and optic atrophy.
intact.
• Irritable or lethargic, fail to
thrive. • Inability to insert a rubber
catheter into the rectum.
• High pitched cry.
• No stool will be passed and
Therapeutic Management: abdominal distention become
evident.
• Overproduction of fluid =
Acetazolamide (Diamox) to Therapeutic Management
promote excretion of fluid
• Obstruction = removal • Surgery – anastomosis of
the separated bowel
• Laser surgery to reopen of flow segments.
or bypassing the point of
obstruction by shunting the fluid
to another point of absorption
Alteration in Fluid and Electrolytes and
• Shunting procedure to divert
Acid-Base Balance
the excess CSF away from the
brain to another cavity such as Nursing Management of Child
peritoneal cavity. with Burns
• Fluid drains by this route into
the peritoneum and is absorbed Burns

• Burns are tissue damage that Burns in children are considered a
results from heat, overexposure preventable accident. Education is
to the sun, or other radiation, directed toward removing risks.
chemical or electrical contact.
Types of Burns:
Top Causes of Injury
1. Thermal Burns
Children (to age 15)
Burns due to external heat
1. Scalding (hot liquids sources which raise the
2. Contact with embers temperature of the skin and
3. Flams (fires/lighters) tissues and cause tissue cell
4. Friction (mostly involving death. Hot metals, scalding
treadmill mishaps) liquids, steam and flames when
coming in contact with the skin,
can cause thermal burns.
Adults
These are most common type
1. Flames pf burn
2. Scalding
3. Contact with embers Children are particularly at risk
4. Chemicals to accident thermal burns
Risk Factors: Result from any heated source

(flame, scald, contact from a
• Water heaters with temperature hot object)
set too high
• Access to very hot liquids Frequently because of fires, car
(coffee, soup etc.) accidents, matches/lighter,
improperly stored gasoline and
• Room heaters with pans of
water for humidity kitchen accidents
• Children with access to Range from superficial
stovetops for electrical damage to all layers of the
appliances skin and underlying tissue.
• Unguarded bathroom faucets
• Young children left 2. Radiation Burns
unattended in bathtubs or Burns caused by prolonged
shoers exposure to ultraviolet rays of
• Cooking without supervision the sun or other sources of
• Playing with fire or matches radiation such as x-ray.
• Child abuse 3. Chemical Burns
Burns caused by strong acids,
alkalies, detergents or solvents
2seconds of exposure to 148F coming into contact with the
liquid causes burns serious enough skin and/or eyes.
to require surgery 4. Electrical Burns
Burns from electrical current,
Coffee is often served at 175F, making either alternating current
it high-risk for causing severe burns. (AC) or direct current (DC).

hyperkalemia. Because of the
high risk for hypovolemia and
Nursing Diagnosis
electrolyte imbalance, once
• Impaired tissue integrity the client has an airway,
• Fluid volume deficit establsing and maintaining
• Altered nutrition less than body intravenous access is a priority.
requirements • Other priorities should be given
• Risk for injury to prevention of infection,
• Pain management maintenance of the airways and
• Body image disturbance proactive administration of pain
• Altered growth and medications to decrease the
development suffering of the child (pain is
• Altered family process more difficult to control once it
• Caregiver role strain peaks)
• Activity intolerance • Early and continuous
administration iof pain
Clinical overview: medications – (following orders-
• Extensive or severe burn is essential)
injuries account for some of the
BURN TYPE DESCRIPTION
most difficult nursing care in the
Superficial 1st Involves
pediatric age group.
degree epidermis,
• Children who have suffered tender, slightly
serious burn trauma must swollen, red,
undergo prolonged, painful and like
often restrictive a sunburn.
hospitalizations. Thermal, Partial Thickness involves
electrical and chemical agents 2nd degree epidermis and
cause burns. dermis. Blister
• Burns occur in children of all formation or
ages after infancy and are the reddened
second leading cause of injury discoloration
with moist
to children 1-4 years old.
weeping surface.
• Typically, toddlers sustain hot
Full Thickness 3rd Involves entire
water scalds, while older
degree dermis and
children are most likely to portions of
suffer flame-related burns. subcutaneous
• Approximately, 10% of burn tissue. leathery
injuries can be attributed to brown with little
child abuse, most frequently by surface moisture.
submersion in hot water. Full Thickness 4th Involves
• Children with severe burns have degree subcutaneous,
rapid fluid and electrolyte shifts fascia, muscle
in the first 24hours resulting in and bone.
hypovolemia and Minor Burns Superficial and
hypoproteinemia, partial thickness
first- and second-
hyponatremia, and
degree,

body surface • Burns caused by chemicals
area (BSA) or electricity
and not • Difficulty breathing or burns to
involving face, the airway
hands, feet, or
genitalia.
Moderate Burns Partial thickness Therapeutic Nursing Management of
second degree the Child with Burns:
covering15% but
30 Emergency Care
BSA or full
thickness a. Stop the burning process
involving <10% b. Assess the victim's condition
BSA c. Cover the burn with clean
Major (severe) Partial thickness dressing
Burns second-degree d. Transport the victim to
involving 30% medical facility
BSA or full e. Provide analgesia if possible
thickness f. Reassure and comfort the child
involving>10%
BSA or face, Minor Burns
hands, fact, or
genitalia a. Immerse area in cold water to
reduce pain and
b. Cleanse with mild soap and
1ST DEGREE  EPIDERMIS water (iodophor)
2ND DEGREE  DERMIS c. Cover with fine mesh gauze
lightly lubricated with water-
3RD DEGREE  SUBCUTANEOUS soluble antimicrobial ointment
TISSUE d. Update tetanus if indicated
e. Provide analgesia as
needed Wound Care
When to see a doctor
1. Shave hair adjacent to wound.
• Seek emergency
2. Cleanse wound with soap and
medical assistance for:
iodophor soap or saline.
• Burns that cover the hands,
3. Apply silver nitrate 0.5%
feet, face, groin, buttocks,
(AgN04) or silver sulfadiazine
a major joint or
1% (Silvadene topical
• a large area of the body
preparation.
• Deep burns, which means burns
4. Apply topical antibiotic
affecting all layers of the skin or
even deeper tissues ointment for bactericidal and
bacteriostatic properties.
• Burns that cause the skin to
5. Apply dressing using sterile
look leathery
technique.
• Burns that appear charred or
have patches of black, brown or
white

Rehabilitation • Cover unused electrical outlets
1. Splinting. traction, and with safety caps. Keep
frequent position changes electrical cords and wires out of
the way so that children can't
2. Plastic surgery. chew on them
Educate the family on the importance • If you smoke, never smoke in
bed.
of having working smoke detectors in
• Be sure you have working
the home. New batteries should be put
smoke detectors on each floor
in annually and the batteries should
of your home. Check them and
be checked each month.
change their batteries at least
once a year.
• Keep a fire extinguisher on
Prevention:
every floor of your house.
To Reduce the Risk of Common • When using chemicals, always
Household Burns: wear protective eyewear and
clothing.
• Never leave items cooking on • Keep chemicals, lighters and
the stove unattended. matches out of the reach of
• Turn pot handles toward children. Use safety latches.
the rear of the stove. And don't use lighters that look
• Don't carry or hold a child like toys.
while cooking at the stove. • Set your water heater's
• Keep hot liquids out of the reach thermostat to below 120 F (48.9
of children and pets. C) to prevent scalding. Test
• Keep electrical appliances away bath water before placing a
from water. child in it.
• Check the temperature of food
before serving it to a child.
Don't heat a baby's bottle in the
RULE OF NINES
microwave.
• Never cook while wearing loose- The Rule of Nines is a quick way to
fitting clothes that could catch estimate the extent of burns in adults
fire over the stove. through dividing the body into
• If a small child is present, block multiples of nine and the sum total of
his or her access to heat these parts is equal to the total body
sources such as stoves, outdoor surface area injured.
grills, fireplaces and space
heaters.
• Before placing a child in a car
seat, check for hot straps or
buckles.
• Unplug irons and similar devices
when not in use. Store them out
of reach of small children.

• Stress ulcer
• Contracture deformities
Down Syndrome
PARKLAND FORMULA:
• The most common
4ml x BSA (%) x Body Weight chromosomal abnormality
(kg) • Seen as frequently as 1 in
800 live births
• Most frequently in the
The Child with Burns: Pharmacology pregnancies of women who
are over 35 years of age. The
• Analgesics incidence is high 1 in 100 live
• Antibiotics (1V) births
• Antibiotics (topical) • Paternal age (over 55) may also
1. Mafenide cream 10% contribute to the increased
Sulfamylon incidence
2. Silver sulfadiazine 1% 5ilvadene • Even in the newborn, the
• Cimetidine (Tagamet) tongue may protrude from the
• Antacids mouth because the oral cavity
is smaller than normal
Child with Burns: Complications
• The back of the head is flat
• Mucosal erosion resulting in • The neck is short and an extra
gastrointestinal bleeding pad of fat at the base of the
• Anemia due to cell destruction head causes the skin to be
and hemolysis loose and can be lifted up (like a
• Metabolic acidosis puppy’s neck)
• Scarring • The ears may be low set
• Body image changes • Muscle tone is poor, giving
• Shock the baby a rag-doll
• Third spacing appearance
• Fluid and electrolyte imbalance • Fingers are short and thick and
• Respiratory injury secondary to the little finger is often curved
smoke inhalation or carbon inward
monoxide • There may be a wide space
• Pulmonary edema between the first and second
• Infection/pneumonia toes and the first and second
fingers

• The palm of the hand shows a Failure to Thrive
peculiar crease (a simian line)
or a horizontal palm crease • Is a unique syndrome in which
rather than the normal 3 an infant fall below that 5th
creases in the palm. percentile for weight and height
• Have some degree of cognitive on a standard growth chart or is
challenge the degree can range falling in percentiles on a
from that of less involvement growth chart.
(IQ 50 to 70) to one requiring
Two Categories:
total care (IQ less than 20)
• Appear to have altered immune 1. Severe loss of weight –
function, making them prone to organic causes e.g., Cardiac
respiratory infections. Disease
2. Disturbance in the parent – child
Common in Down Syndrome:
relationship resulting in
• Lymphocytic leukemia maternal role insufficiency (a
• Congenital heart disorders non-organic cause)
esp. atrioventricular • Syndrome can lead to cognitive
disorders impairment in the child and
• Stenosis or atresia of even death if allowed to
the duodenum continue.
• Strabismus and Assessment:
cataract disorders
• Their lifespan generally is • Take a detailed pregnancy
only 50 to 60 years. history of children at
routine health assessments
Therapeutic Management: • Always weigh children at routine
• Need to be exposed to early assessments and plot and
educational and play compare their weight with
opportunities standard growth curves
• Sensible precautions such Typical Characteristics:
as handwashing technique
because they are prone to • Lethargy with poor muscle tone
infection • Lack of resistance to the
• In infancy the enlarged tongue examiner’s manipulation
may interfere with swallowing • rocking in all fours excessively,
and cause choking unless the as if seeking stimulation
child is fed slowly • possibly greater reluctance to
• Need physical examination at reach for toys or initiate human
birth so that genetic disorder contact
can be detected and counseling • diminished or non-existent
and support for parents and crying
siblings can begin • staring hungrily at people who
approach them as if they are
starved for human contact
REACTIVE ATTACHMENT DISORDER: • little cuddling or conforming
to being held

• delays in sitting, pulling to • aggressive actions such as
standard position, crawling and shitting, head banging and
walking because the child biting, inability to feel pain
spends so much time alone may also be present
• delayed or absent speech • labile mood (crying occurs
because of the lack of suddenly and is followed
interaction immediately by giggling or
Therapeutic Management: laughing)
• react with over responsiveness
• need to be removed from to sensory stimuli such as light
parents’ care for evaluation and or sound, but unaware of the
therapy major event in the room e.g.,
• studies other than routine blood sound of fire alarm
work and urinalysis and are • long term memory and “savant”
usually delayed skills (e.g., Virtuoso piano
• placed on diet appropriate for playing)
ideal weight • excellent memory and able to
recall dates and spoken words
Therapeutic Management:
PERVASIVE DEVELOPMENT DISORDER:
Autism Spectrum Disorder • need intensive therapeutic to
learn improved communication
• attachment to odd objects such techniques
as always carrying a string or a • parental support to learn self-
shoe care and proceed with therapy
• repetitive hand movements
(clapping or flapping) and
constant body rocking are often Assessment:
observed
• difficult to gain the child’s • impairment in communication
attention as the child becomes both verbal and nonverbal skills
intensely preoccupied by music and communication may be
or objects that revolve, such as totally absent
fan, the swirling water in the • echolalia repetition of words
toilet bowl or a spinning top or phrases spoken by others)
• characterized by impairment in • bizarre responses to the
social and communication skills environment may include
and the display of stereotypical intense reactions to minor
behaviors changes in the environment
• marked by deficits in language,
perceptual, motor development
and the inability to function Essential Intrapartum and Newborn
well in social settings Care Practice
• most often diagnosed when
• Millennium Development Goal
the child is 2 to 3 years old
(MIDG) our Commitment by
2015

• MIDG 4 = reduce child • Fundal pressure to
mortality facilitate second stage of
• MDG 5 = improve maternal labor
health
Unnecessary Intervention in Newborn
Care:
Antennal Care • Routine suctioning

• Early bathing
1. Have at least 4 antennal visits
• Routine separation from the
with the skilled health mother
provider. • Foot printing
• To detect diseases which • Application of various
may complicate substances to the cord
pregnancy
• Giving prelacteals or
• To educate women in artificial infant milk formula
danger and or other breastmilk
emergency signs and substitutes
symptoms
• To prepare the Prior to Woman’s Transfer to
woman and her family the Delivery Room
for childbirth.
• Ensure that mother is in her
Recommended Practices during labor: position of choice while in
labor
• Admit when the parturient is • Asks mother if she wishes to
already in active labor eat/drink or void
• Continuous maternal support • Communicate with the mother-
by a companion of her choice, informed her of the progress of
during labor and delivery labor, give reassurance and
• Mobility during labor encouragement.
• Position of choice during labor
and delivery Woman already in the Delivery Room
• Episiotomy will not be done, (preparing for delivery)
unless necessary
• Check temperature in the
• Active Management of the Third DR area to be 25 – 28
Stage of Labor (AMSL) Celsius; eliminate airdraft
• Monitoring the progress of labor
• Asks woman if she is
with use of Partograph
comfortable in the semi-upright
position
• Ensure the woman’s privacy
1. Immediate and thorough drying • Removed all jewelries then
of the newborn wash hands thoroughly
Unnecessary Interventions Eliminated: observing the WHO 1-2-3-4-
5 procedure
• Enemas and perineal shavings • Prepare a clear, clean newborn
• Fluid and food intake resuscitation area. Checked the
restrictions equipment if clean,
• Routine insertion of Intravenous functional and within easy
fluids reach.
• Arrange materials/supplies in a
linear sequence: gloves, dry

linen, bonnet, oxytocin
• Exclude a 2nd baby by palpating
injection, plastic clamp, scissors the abdomen in preparation for
2 kidney basins giving Oxytocin
In a separate sequence, for after • Used wet cloth to wipe
the 1st breastfeed: the soiled gloves.
• Give IM oxytocin within one
• Eye ointment, stethoscope, minute of baby’s birth. Dispose
vit K, hepatitis B and BGC wet cloth properly
vaccines (cotton balls) • Remove first set of gloves and
• Clean the perineum with decontaminate for at least 10
antiseptic solution minutes
• Wash hands and put on 2 • Palpate the umbilical cord
pairs of sterile gloves to check for positions
aseptically (if same worker • After pulsations stopped, clamp
handles perineum and cord) cord using the plastic clamp or
cord tie 2cm from the base
At the time of Delivery:
• Place the instrument clamp 5cm
• Encourage woman to push from the base
as desired • Cut near plastic cord clamp (not
• Drape the clean, dry linen over midway)
the mother’s abdomen or arms • Perform the remaining steps of
in preparation for drying the the delivery of placenta
baby • Wait for strong uterine
• Apply perineal support and do contractions then apply
not control the delivery of the controlled cord traction and
head counter traction on the uterus,
• Call out time of birth and sex continuing until the placenta is
of baby delivered
• Inform the mother of the • Massage the uterus until firm
outcome • Inspect the lower vagina and
perineum for lacerations/tears
First 30 secs: and repair lacerations/tears as
• Thoroughly dry the baby for at necessary
least 30 seconds, starting from • Examine the placenta for
the face and head, going down completeness and abnormalities
to the trunk and extremities • Clean the mother, flush
while performing a quick check perineum and apply perineal
for breathing pad/napkin/cloth
• Check the baby’s color and
1-3 minutes breathing, check if the mother
is comfortable, check if uterus
• Remove the wet cloth
contracts
• Place baby in skin to skin
contact on the mother’s • Dispose the placenta in a leak-
abdomen or chest proof container or plastic bag
• Cover baby with dry cloth and • Decontaminate (soaked in 0.5%
the baby’s head with a bonnet chlorine solution) instruments
before cleaning:

Decontaminate 2nd pair of the baby’s heel. Ideally, newborn
gloves before disposal for 10 screening should be done two days
minutes after birth or before discharge from
• Advise mother to maintain skin- the hospital. The blood sample is
to-skin contact. Baby should be placed on a special filter paper
positioned in prone on mother’s card.
chest/in between the breast
with head turned to one side
What are the most common
newborn screening disorders?
• The most common screening
NEWBORN SCREENING tests in the US include those for
Newborn screening (NBS) is an hypothyroidism (underactivity
essential public health strategy that of the thyroid gland) PKU
enables the early detection and (phenylketonuria), galactosemia
management of several congenital and sickle cell disease.
disorders, which if left untreated, • Early diagnosis and initiation of
may lead to mental retardation treatment along with
and/or death. appropriate long-term care help
ensure normal growth and
development of the affected
individual. It has been an
How do you do a newborn screening?
integral part of routine newborn
• Touch the first cycle on the care in most developed
newborn screening card gently countries for five decades
against the large blood drop • It ensures that all babies are
and in one step allow the blood screened for certain serious
to soak through the filter paper conditions at birth, and for
and fill the circle. Do not press those babies with the condition,
the paper directly against the it allows doctors to start
baby’s heel. Each of the five treatment before some of the
circles need to be filled and harmful effects happen.
saturated through.
There are three parts to newborn
• Newborn screening (NBS) is an
screening
essential public health strategy
that enables the early detection • The heel stick to collect a small
and management of several blood sample, pulsetoximetry to
congenital disorders, which if look at the amount of oxygen in
left untreated, may lead to baby’s blood, and a hearing
mental retardation and/or screen.
death. • The blood test is generally
performed when a baby is 24 to
48 hours old. This timing is
The Newborn Screening Test is done important because certain
by collecting a few drops of blood from conditions may go undetected if
the blood sample is drawn
before 24 hours of age.

PKU
• Neurological problems that may
• Phenylketonuria also called PKU, include seizures
is a rare inherited disorder that • Skin rashes (eczema)
causes an amino acid called • Fair skin and blue eyes, because
phenylalanine to build up in the phenylalanine can’t transform
body. PKU is caused by a defect into melanin – the pigment
in the gene that helps create responsible for hair and
the enzyme needed to break skin tone
down phenylalanine • Abnormally small head
• For the rest of their lives, (microcephaly)
people with PKU babies, • Hyperactivity
children and adults – need to • Intellectual disability
follow a diet that limits • Delayed development
phenylalanine, which is found • Behavioral, emotional and social
mostly in foods that contains problems
protein. • Psychiatric disorders
How does PKU affects the body?

• Phenylketonuria (PKU) is a Galactosemia
treatable disorder that • Is a disorder that affects how
affects the way the body the body processes a simple
processes protein sugar called galactose.
• Children with PKU cannot use • A small amount of galactose is
a part of the protein called present in many foods. It is
phenylalanine. If left primarily parts if a larger
untreated, phenylalanine sugar called lactose, which is
builds up in the bloodstream found in all dairy products and
and causes brain damage. many baby formulas.
• Without the enzyme
necessary to process What causes galactosemia?
phenylalanine, a dangerous
• If your body has this condition,
buildup can develop when a
it means the genes that
person with PKU eats foods
produce the enzymes to break
that contain protein or eats
down galactose into glucose (a
aspartame, an artificial
sugar) are missing key parts.
sweetener.
Without these parts, the genes
• This can eventually lead to can’t tell the enzymes to do
serious health problems.
their job. This causes galactose
to build in the blood, creating
problems, especially for
PKU signs and symptoms can be newborns.
mild or severe and may include:
Is there a cure for galactosemia?
• A musty order in the breath,
skin or urine, caused by too • There is no cure for
much phenylalanine in the body. galactosemia or approved

medication to replace the
enzymes, although a low-
galactose diet can prevent or What are the symptoms
reduce the risk of some of galactosemia in adults?
complications, it may not stop
• Initial signs/symptoms may
all of them. In some cases,
include poor feeding, vomiting,
children still develop problems
diarrhea, jaundice, bleeding
such as speech delays learning
tendencies, lethargy, abdominal
disabilities and reproductive
distension with liver swelling
issues.
and increased risks of sepsis (a
reaction from a blood
What happens if you infection). Later symptoms can
have galactosemia? include liver failure cataracts
and brain damage.
• Galactosemia happens when • Sickle cell anemia is one of a
there’s a change (mutation) in group of inherited disorders
the genes that make an enzyme known as sickle cell disease. It
that breaks down galactose. affects the shape of cred blood
• To have galactosemia, a child cells, which carry oxygen to all
must inherit two galactosemia parts of the body. Red blood
genes, one from each parent. In cells are usually round and
galactosemia, galactose and its flexible, so they move easily
by-products build up in the through blood vessel.
blood. This can damage cells
and parts of the body.
Hypospadias
What foods should be avoided • Hypospadias is a birth defects

with galactosemia? in the boys where the opening
of the urethra (the tube that
• Food ingredients which are carries urine from the bladder to
unacceptable in the diet the outside of the body) is not
for galactosemia: located at the tip of the penis.
- Butter • The urethra is the tube through
- Buttermilk which urine drains from your
- Buttermilk solids bladder and exits your body.
- Cheese (exceptions: Jarlsberg,
Gruyere, Emmentaler, Swiss, Causes:
Tilster, grater 100% • Hypospadias is present at birth
parmesan aged >10 months (congenital). As the penis
and sharp Cheddar cheeses develops in a male fetus,
aged >12 months) certain hormones stimulate the
- Cream formation of the urethra and
- Dry milk foreskin.
- Dry milk protein • Hypospadias results when a
- Dry milk solids malfunction occurs in the action

of these hormones, causing the If hypospadias is not treated, it can
urethra to develop abnormally. result in:
• Abnormal appearance of the

Risk Factors: penis
• Problems learning to use a toilet
• Family history – this condition is • Abnormal curvature of the penis
more common in infants with a with laceration
family history of hypospadias. • Problems with impaired
• Genetics – certain gene ejaculation
variations may play a role in
disruption of the hormones that
stimulate formation of male Hypospadias repair is surgery to
genitals. correct a defect in the opening of the
• Maternal age over 35 – some penis that is present at birth. The
research suggests that urethra (the tube that carries urine
there may be an increased from the bladder to outside the body)
risk of hypospadias in infant dose not end at the tip of the penis)
males born to women older
than 35 years.
• Exposure to certain substances
When should hypospadias be
during pregnancy – there is
corrected?
some speculation about an
association between • In some cases, the repair is
hypospadias and a mother’s done in stages. These are often
exposure to certain hormones proximal cases with severe
or certain compounds such as chordee the pediatric urologists
pesticides or industrial often want to straighten the
chemicals, but further studies penis before making the urinary
are needed to confirm this. channel. Surgeons prefer to do
hypospadias surgery in full term
and otherwise healthy boys
Signs and Symptoms may include: between the ages of 6 and 12
months.
• Opening of the urethra at a
location other than the tip Can baby with hypospadias
of the penis. be circumcised?
• Downward curve of the penis
(chordee) • Babies with hypospadias should
not be circumcised.
• Hooded appearance of the penis
• The surgeon may use extra skin
because only the top half of the
penis is covered by foreskin from the uncircumcised foreskin
to do the repair.
• Abnormal spraying during
• Epispadias is a rare birth defect
urination.
located at the opening of the
Complication: urethra. In this condition, the
urethra does not develop into a

full tube, and the urine exits the high heat. Dry-clean items you
body from an abnormal location. can’t wash at home.
• The causes of epispadias are • Starve the mites – consider
unknown. It may be related to placing items you can’t wash
improper development of the in
pubic bone. a sealed plastic bag and leaving
it in an out-of-the-way place,
such as in your garage, for a
Scabies couple of weeks. Mites die after
a few days without food.
• Is an itchy skin condition caused
by a tiny burrowing mite called
Sarcoptes scabiei.
• Intense itching occurs in the Pediculosis
area where the mote burrows. • Head lice (pediculosis capitis) is
The urge to scratch may be a common, highly contagious
especially strong at night. infection the often occurs in
• Scabies is a contagious and can nurseries, day care centers and
spread quickly through close schools.
physical contact in a family, • It is caused by infestation with
child care group, school class, the human head louse.
nursing home or prison. Pediculus humanus capitis and
Because scabies is so it is usually very itchy.
contagious, doctors often • Lice are very small insects that
recommend treatment for entire feed on human blood. The
families or contact groups. female louse attaches her eggs
(nits) to the base of the hair
near the scalp and the nits
Signs and symptoms: hatch 7-10 days later. While the
adult louse cannot survive for
• Itching often severe and usually more than 2 days off the
worse at night.
human head. A nit can stay
• Thin, irregular burrow alive for up to 10 days off the
tracks made up of tiny body (for example) on clothes,
blisters or bumps on your
hairbrushes or carpets). Lice are
skin.
spread from child to child by
close contact and by sharing
belongings that are infested
Prevention:
with lice.
To prevent re-infestation and to
prevent the mites from spreading to
other people take these steps: Signs and symptoms:
• Clean all clothes and linens – • Moving lice or nonmoving nits
use hot, soapy water to wash all may be seen on the scalp and
clothing, towels and bedding hair. Each louse is
used within three days before approximately 1-3 mm long and
beginning treatment. Dry with is whitish gray in color. Lice

crawls they do not jump or fly. lice will die within 2 days and
Nits are smaller, about 0.5-1 the nits will hatch and die
mm white and are firmly within 2 weeks)
attached to the hair very close • Vacuum floors and furniture.
to the scalp.
• Examine the hair and scalp
• Small red bumps or sores may of household members and
be seen on the scalp, neck and treat
shoulders. Occasionally, the them if they are infested.
lymph nodes behind the ears or • Notify the school nurse, teacher
in the neck may be swollen and or day care provider if your child
tender is diagnosed with head lice. Your
• Lice may sometimes be seen child can return to school after
on the eyelashes causing the proper treatment.
eyes • Do not share combs,
to become red and irritated. hairbrushes, hats, towels,
Management: bedding, clothing, headphones,
stuffed toys or other items with
• Over-the-counter medications someone who has head lice.
for head lice are effective and
should be the first treatment
you use. These includes
pyrethrin and permethrin lotion
1%.
• Both medicines kill only live
lice, not the eggs, so they
should be reapplied in 7-10 days
to kills newly hatched lice.
• These treatments are only
minimally absorbed through the
skin.
• These treatments are only
minimally absorbed through the
skin.
• Before applying the over-the-
counter lotions, do not use
conditioner on the hair, as this
will coat the hair and protect
the lice from the medicine.
Also do not wash the hair for 1-
2 days after treatment.
• Wash any object that your child
has come into contact with
during the past 48 hours in hot
water for at least 5 minutes.
• Seal potentially contaminated
but non washable objects in
plastic bags for 2 weeks. (the

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Risk Factors: Result from any heated source

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• Abnormal appearance of the

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