NATIONAL HEALTH SITUATION STATISTICS

OF MATERNAL AND CHILD  Maternal mortality – increase by 26%

HEALTH NURSING  Unintended pregnancies – increase by 42%

 No use of contraception- increase of 67%

UNINTENDED PREGNANCY AND ABORTION

1. Increase maternal death and unintended
pregnancies related to the following:
a. Declining utilization of facilities for antenatal
check-up and delivery
a.1 service DisruptIon
RATES
-In the Philippines, the unintended pregnancy rate
declined 33% between 1990-1994 and 2015-2019.
During the same period, the abortion rate increased
51%. The share of unintended pregnancies ending in
abortion rose from 22% to 51%.

a.2 difficulty in commuting

a.3 fear of having COVID

b. poor access to modern contraception

2. Increase teenage pregnancy

 Teenage pregnancy affects about 6% of

Filipino girls.

 An estimated 538 babies are born to Filipino

teenage mothers EVERY SINGLE DAY,
according to the Philippine Statistical
Authority from 2017.

 96,370 babies born each year to teenage

mothers in the Philippines! 
PREGNANCY OUTCOMES
 Nearly 200,000 teenagers get pregnant every
year!  -In the Philippines in 2015-2019, there were a total of
3,770,000 pregnancies annually. Of these, 1,930,000
 there are roughly 40 births each year by girls
pregnancies were unintended and 937,000 ended in
who have not yet reached the age of 13
abortion. Abortion is prohibited in the Philippines.

3. Increase intImate partner violence

4. Disrupted access to life-saving sexual amd

reproductive health services

2022
 MANILA – Deaths due to complications
from childbirth in the Philippines are up 10
percent in 2022, according to data from the
Philippine Statistics Authority.
 The PSA said 468 maternal deaths have been
recorded in the first 6 months of 2022, up
from the 425 recorded in the same period last
year.
 Lolito Tacardon, Executive Director of the
Commission for Population and Development
(POPCOM), said they are still investigating
the uptick in maternal deaths in the country.
 More Filipino mothers are dying at childbirth,
new data says
 Pregnant women urged to give birth in health
facilities after 'sharp increase' in maternal
mortality
Reason/s:
 delay in the referral, and of course other
service-related, pertaining in general on the
quality of the services being provided in the
health facility,”
Strategy:
 together with the Department of Health, we’re
in the process of intensifying and developing
multi-sectoral comprehensive action plan for
the more intensified implementation of
reproductive health (measures) ANC, 21
October 2022
INTERNATIONAL
 The high number of maternal deaths in some
areas of the world reflects
 inequities in access to health services, and
highlights the gap between rich and poor.
 Maternal mortality is higher in women living
in rural areas and among poorer communities.
 Young adolescents face a higher risk of
complications and death as a result of
pregnancy than older women.
GENETIC ASSESSMENT AND
COUNSELLING
 Genetics- a branch of biology concerned with
the study of genes, genetic variations and
heredity in living organism
 Genetic counselling- is a process of
communicating between two or more persons
 who meet to solve a problem, resource a curse
or take decisions on various matters. It is not a
oe way process where in the counseling tells
the client what to do nor it is a forum for
presentation of the counselor’s value
oe ears, number of fingers and toes,
presence of webbing
 DERMATOGLYPHICS – study of
surface markings of the skin

-Is the process of advising individuals and

fmilies affected by or at risk of genetic
disorders to help them understand and adapt
to the medical, psychological and familial
implications of genetic contributions to
disease

 Phenotype – refers to outward appearance of

the expression of genes

 Genotype – refers to actual gene composition

 Genome – complete set of genes present

- Normal genome ; 46XX/46XY

COMMON CHROMOSOMAL DISORDERS
 Genetic disorders – disorder passed from one
generation to the next Down syndrome/Trisomy 21
e: 47XXY21/47D XY21
-Occur in same ethnic group Code: 47XXY21/47 XY21
Characteristics
-Occur at the moment an ovum and sperm
fuse or even earlier in the meiotic division
phase of the ovum or sperm when the  Late closure of  Extra pad of fat at the
chromosome count is halved from 46 to 23. fontanelle base of the head causes
 Slant eyes the skin to loose
 Epicanthal  Poor muscle tone ( rag-
METHODS OF ASSESSMENT fold( extrafold doll appearance)
of tissue at the  Fingers are short and
A. History Taking inner cannula ) thick
 Brushfield  Little finger is often
 Include any one related to the family
spots ( iris with curved inward
 Maternal age (> 35 y/o)
white specks)  Wide space between
 Paternal age (>55y/o)
 Large tongue the 1st and 2nd finger
 Document parents if and toes
 Low set ears
consanguineous/related to each other
 Small mouth  Palm- with one single
 Document ethnic background horizontal simian
cavity
 Extensive prenatal history crease
 Back of the
B. Physical assessment head is flat  Small head
 Neck is short  Brain is not well
 Pay particular attention to the space developed
between the eyes, height, contour, shape  IQ= 50-70
  Prone for infection - do not survive beyond  SGA at birth
 Clinodactyly early infancy  Marked low set ears
 Abnormal  Small jaw
dermatoglyphics  Congenital heart
defects
 Misshapen fingers
and toes (index
fingers deviates or
cross over other
finger)
 Multiple hair whorls

Fragile X syndrome Turner syndrome

Code: 46XY23q) Code: 45X0

Characteristics characteristics

Most common cause  Bossing (prominent Has only 1 functional  Low set hair line
f cognitive challenge forehead) X chromosome  Webbed neck
in males  Prominent lower jaw  Gonadal dyagenesis
 Large hands  Short in structure
-An X linked
 Marked deficit in Can be identified  Has only streak (small
disorder in which 1
speech and with an UTz during and nonfunctional)
long arm of an X
mathematics/problem pregnancy because of ovaries
chromosome is
solving the increase neck  Sterile
defective
 Large head folds  Exception of pubic
- before puberty:  Long face hair; secondary sex
displays maladaptive  Large protruding ears characteristics do not
behavior such as  After puberty: enlarged develop at puberty
hyperactivity and testicles  Newborns= edema on
autism the hands and feet
 With coarctation
(stricture) of aorta and
kidney disorder
 Severely cognitively
Trisomy 18 syndrome / Edward’s syndrome challenge
Code: 47XY18/47XX18

Characteristics

have copies of  Microcephaly

chromosome 18  Severely cognitively
challenges
Klinefelter syndrome
Karyotyping sample of peripheral venous
Code: 47XXY
blood or a scraping of cells
from the buccal membrane is
characteristics
taken

Males  Absence of secondary sex Cells are allowed to grow

characteristics until they reach metaphase-
With an extra X most easily observed phase
 Small testes- produces
chromosome
ineffective sperm Cells are stained, placed
 Gynecomastia ( enlarged under a microscope and
breast size) photographed
 Increased risk of male
breast cancer Chromosomes are identified
according to size, shape and
stain
Trisomy 13/patau syndrome
Code: 47 XX13/47 XY13

Characteristics

 Has an extra  Microcephaly

chromosome  Clip lip and palate Maternal serum Done at 15th week of pregnancy
13 and  Low set ears screening
cognitively  Multiple hair whorls Alphafetoprotein (AFP)- a
challenged  Wide set nipples glucoprotein produced by the
 Most do not fetal liver
 Rocker bottom feet
survive beyond  Heart defects Peak is between 13th and 32nd
early childhood ( ventricular septal week of pregnancy
defect)
 Abnormal genitalia RESULT: if elevated – it
 Small eyes means spinal cord disease/
(microphthalmus) neural tube defects

If below – it means
chromosomal disorder/Down
syndrome

MSAFP (Maternal Serum

Alphafetoprotein)
C. Diagnostic Testing
CVS (Chorionic – a diagnostic techniques that
Villi Sampling involves the retival and
analysis

of chorionic villi from the

 growing placenta for Fetal Imaging MRI and UTZ = used to
chromosome assess a fetus for general
size and structure
disorder of the internal
or DNA analysis organs, spine and limbs
Commonly done at 8-10 weeks
r 10-12 weeks of pregnancy

May be done as early as 5

weeks GENETIC COUNSELLING

 Provide concrete, accurate information about

Amniocentesis withdrawal of amniotic fluid
through the abdominal wall
for analysis
Done between 14th-16th week
of pregnany
A pocket of amniotic fluid is
located by ultrasound (UTZ)
A needle is inserted
transabdominally
Aspirate 20 ml of amniotic
fluid
Client receieves Rh immune
globulin administration after
the procedure (Rhogam)
the process of inheritance and inherited
disorder
 Reassure people who are concerned that their
child may inherit a particular disorder that the
disorder will not occur
 Allow people who are affected by inherited
disorder to make informed choices about
future reproduction
 Offer support on people who are affected by
genetic disorder
 oBserve data privacy
 ideal time for counseling is before 1st
pregnancy

ROLE OF A NURSE IN GENETIC

COUNSELLING

 Guiding women or couple through prenatal

diagnosis

 Helping parents to make decisions in regards

PUBS ( Percutaneous Other name:
to abnormal prenatal diagnosis results
Umbilical Blood Cordocentesis
Sampling)  Assisting parents whi have hada child with a
Removal of blood from
the fetal umbilical cord birth defect to locate needed service and
at about 17 weeks using support
an amniocentesis  Providing support to help the family deal with
technique
the emotional impact of a birth defect
  Coordinate services of other professionals
such as social workers, physical and
occupational therapists, psychologist,
dietatcian
IMPORTANCE OF GENETIC COUNSELLING
1. Aid in determining the risk of disease
2. Help in identifying a hereditary condition
3. Assist in whether genetic testing is
appropriate
4. Offer duagnosis and disease prevention and
management
5. Offer emotional and psychological support,
ethical guidance to help clients make well
informed autonomous health care decisions
and resproductive choices
ASSESSMENT OF HIGH-RISK
PREGNANCY
 When a woman enters pregnancy with a
chronic condition such as cardiovascular, or
kidney disease, both she and the fetus can be
at risk for complications because either the
pregnancy can complicate the disease or the
disease can complicate the pregnancy
affecting the baby or leaving a woman less
equipped to function in the future or undergo
a future pregnancy
 In addition to pre-existing illnesses, the
pregnant woman like any person may develop
new illness during pregnancy which can
adversely affect not only the woman but her
unborn child.
 When accidents and illness occur despite
precautionary measures, nursing care focuses
on
o Preventing such disorders from
affecting the health of the fetus
o Helping a woman regain her health as
quickly as possible so she can continue
a healthy pregnancy and prepare
herself psychologically and physically
for labor and birth and the arrival of
her newborn
o Helping a woman learn more about her
chronic illness so she can continue to
safeguard her health during her
childrearing years
High Risk
● Is one in which a concurrent disorder,
pregnancy related complication, or external
factor jeopardizes the health of the woman,
the fetus or both.
● One in which some condition puts the mother,
the developing fetus, or both at higher-than-
normal risk for complications during or after
the pregnancy and birth.
Causes
● Related to the pregnancy itself when they
exist in pregnancy
● Occurs because the woman has a medical
condition
● Results from environmental hazards
● Arise from maternal behavior or lifestyle
circumstances that causes women to be high risk
● Poverty
● Lack of support people
● Poor coping mechanisms
● Genetic inheritance
● Past history of pregnancy complications
****Should be seen more frequently for prenatal care
 1. Weight <100 lbs: associated
with LBW
>200 lbs: PIH, LGA
infants, difficult labor,
CS due cpd

2. Height ( <5 feet) Increased risk for CS

due to CPD
Assesment of Risk Factors

DEMOGRAPHIC 3. Smoking LBW, preterm birth

FACTORS 4. Alcohol/illegal drug Congenital anomalies,
use fetal withdrawal
EFFECTS
Lifestyle & Occupation syndrome, fetal alcohol
Maternal Age (<18 or Less than 18: increased What she consumes & syndrome
>35 years) risk for LBW and what she is exposed to
preterm labor, PIH, can seriously affect her
anemia, Cesarean pregnancy
Section for CPD. Ex. a. OTC drugs
More than 35 years: 5. Substance abuse
increased risk of
chromosomal
abnormalities, PIH,
placenta previa , H-
Mole, CHVD Babies
with chromosomial
abnormalities Obstetric factors& Gynecologic HX

Associate with LBW,

EFFECTS
preterm infants

Poverty Hemorrhage, CS and Birth of previous infant Increased risk for CS,
fetal loss/ abortion with weight >8.5 lbs/ 2 or birth injury, maternal
more premature gestational diabetes
deliveries/ abortions and neonatal
Maternal Parity/ hypoglycemia
mulitiparity ( >4
pregnancies) Increased risk of
maternal
Previous stillbirth psychological distress
PERSONAL-SOCIAL
FACTORS  Increased risk for
fetal anemia,
eryhroblastosis and
Rh sensitization kernicterus
 Associated with  Concurrent Severe fetal effects if maternal
delivery of previable infection disease occurs in the first
fetus trimester
Cervical insufficiency
/cervical incompetency Associated with Increased risk for spontaneous
nutritional anemia, abortion and congenital
Multiple gestations/ preeclampsia, anomalies
pregnancies preterm labor,
 malposition malpresentation, CS, Seizure disorders Increased risk of fetal
malpresentation postpartum malformation, increased
previous dystocia hemorrhage incidence of cerebral palsy,
placental abnormalities seizure disorder and mental
etc retardation in offspring

Existing medical conditions /Maternal Medical Liver disease Preterm and stillbirths
History
Environmental
agents
EFFECTS
Impair fertility,
DM Increased risk of PIH. CS, LGA, interfere with
SGA , neonatal hypoglycemia, normal placental
fetal or neonatal death, congenital function and may
anomalies be toxic to the
fetus leading to
fetal death
Hypothyroidism Increased risk of spontaneous
abortion, congenital anomalies,
congenital hypothyroidism

Cardiac disease Increased risk of fetal or neonatal

death

Watch out for signs of worsening

heart disease such as edema, FACTORS THAT CATEGORIZES CLIENT TO
crackles, activity intolerance, and BE HIGH-RISK
irregular heart rate
PSYCHOLOG SOCIAL PHYSICAL
Renal disease Associated with maternal renal ICAL
failure, preterm delivery,
intrauterine growth retardation History of drug Occupation Visual or
dependence involving hearing
handling of
(including toxic, challenges >30)
alcohol) substances
(including Pelvic Underweight (
History of radiation and inadequacy or BMI <18.5)
intimate partner anesthesia misshape
abuse Pelvic
gases) Uterine inflammatory
History of Environment incompetency, disease
mental illness al position or
structure History of
History of poor contaminants inherited
coping at home Secondary disorder
mechanisms Isolated major illness
(heart disease, Small stature
Cognitively Lower diabetes
challenged Potential of
economic mellitus, blood
Survivor of level kidney incompatibilit
childhood disease, y
Poor access hypertension.
sexual abuse to Chronic Younger than
transportatio infection such age 18 years
n for care as or older than
High altitude tuberculosis, 35 years
hemopoietic
Highly Cigarette
or blood
mobile smoker
disorder,
lifestyle malignancy) Substance
Poor housing abuser
Poor
gynecologic
Lack of
or obstetric
support
history Pregnancy
people
History of Psychological SOCIAL PHYSICAL
previous poor
pregnancy
outcome Loss of support Refusal of or Fluid or
(miscarriage, person neglected electrolyte
stillbirth, prenatal care imbalance
Illness of a
intrauterine family member Exposure to Intake of
fetal death) environmental teratogen such
Decrease in self teratogens as a drug
History of esteem
child with Disruptive Multiple
congenital Drug abuse family incident gestation
anomalies ( including
alcohol and Conception less A bleeding
Obesity ( BMI cigarette than 1 year after
 smoking) last pregnancy disruption disappointing in some health care
way (such as sex,
Poor acceptance Poor placental appearance, or Lack of
of pregnancy formation or congenital anomalies) access to
position emergency
Illness in newborn personnel or
Gestational equipment
diabetes

Nutritional
deficiency of
iron, folic acid,
or protein

Poor weight
gain

Pregnancy-
VULNERABLE GROUPS OF PREGNANT
induced
WOMEN
hypertension
● Adolescent
Infection
● Mentally ill
Amniotic fluid ● 18 y/o and below
abnormality ● Women over 40 y/o
● Physically and cognitively challenge
Postmaturity ● Woman who is a substance dependent

DIAGNOSTIC TESTS AND LABORATORY

Labor and delivery EXAMS AND SCREENING PROCEDURES

PSYCHOLOGICA SOCIAL PHYSICA 1. UTZ: abdominal, transvaginal, Doppler UTZ – 18-

L L 20 weeks detect gross anomalies

2. Bioprofile = 36-38 weeks

Severely frightened Lack of Hemorrhage
by labor and birth support ● Biophysical profile- uses ultrasonography and
experience person Infection
NST to assess 5 biophysical variables in
Fluid and determining fetal well being.
Inability to Inadequate
electrolyte ● Performed during a 30 minute time frame
participate because of home for
imbalance ● NST – assessing for FHR acceleration in
anesthesia infant care
relation to fetal movements
Separation of infant Unplanned ● Amniotic fluid index – assessing for one or
at birth cesarean more pockets of amniotic fluid measuring 3⁄4
birth inch (2 cm) or more in 2 perpendicular planes.
Lack of separation -normal amount- 800-1000 ml
for labor Lack of ● Gross fetal body movements- one or more
access to episodes lasting at least 30 seconds.
Birth of infant who is continued
 ● Fetal muscle tone – one or more active ● VDRL for sedone at 32 weeks
extension with return to flexion of spine, hand ● Urine testing/ Urinalysis
or limbs. ● Pap’s smear for STD
● Stool culture for ova and parasites
● To test for high risk patient
3. Amniocentesis = for L/S ratio - done between 14-
16TH weeks
DANGER SIGNS OF PREGNANCY
● Invasive procedure for amniotic fluid analysis
to assess fetal lung maturity done after 14 ● Pain
weeks gestation ● Persistent vomiting
● Sudden gush of fluid from the vagina
● Headache
4. NST (Non street test)
● Vaginal bleeding
● Reactive test – 3 accelerations of FHR 15 ● Blurred vision
beats/min above baseline FHR lasting for 15 ● Dizziness
sec. Or more, over 20 minutes ● Chills and fever over 38C ( 100.4F)
● Non reactive test – no accelerations or ● Painful urination
acceleration less than 15 beats/ minute above
baseline FHR. May indicate fetal jeopardy.

5. AFI (amniotic fluid index) – the sum of the

amniotic fluid in the quadrants of the uterus

6. Kick count assessment tool: Sandovsky or

Cardiff method - usually done after meal 10
movements per hour

7. AFP (amniotic fetoprotein) – to detect neural

tube defects, done at 15-20 weeks

8. Diabetic screening - done at 24-28 weeks

9. Percutaneous blood sampling/ cordocentesis

10. MSAFP- maternal serum alpha fetoprotein –

done to detect neural tube defects or open abdominal
wall defects Done between 16-18 weeks

11. Sickle cell test – done to detect presence of sickle

hemoglobin in at risk women.

12. Group B beta Streptococcus (cervical and

pharyngeal swabs) – done to detect carriers or active
group B beta streptococcus.

13. BASIC LAB TEST

● Blood screening for Rh factor

 SUBSTANCE ABUSE

 Inability to meet major role obligations, an

increase in legal problems or risk taking
behavior or exposure to hazardous situations
because of an addicting substance.
 10%-20% of pregnant women use illegal
drugs
 Use of cocaine, amphetamines, and multiple
drugs
 Adolescents have an increased rate of inhalant
abuse and binge drinking
 also known as drug abuse
 refers to a maladaptive pattern of use of a
substance
 occurs when an individual abuses
alcohol/drugs as away of reducing their stress
levels

substance abuse as:

A maladaptive pattern of substance use leading to

clinically significant impairment or distress, as
manifested by one (or more) of the following,
occurring within a 12-month period:

Recurrent substance use resulting in a failure to fulfill

major role obligations at work, school, or home (e.g.,
repeated absences or poor work performance related
to substance use; substance-related absences,
suspensions or expulsions from school; neglect of
children or household)

Recurrent substance use in situations in which it is

physically hazardous (e.g., driving an automobile or
operating a machine when impaired by substance use)

Recurrent substance-related legal problems (e.g.,

arrests for substance-related disorderly conduct)

Continued substance use despite having persistent or

recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (e.g.,
PREGESTATIONAL CONDITIONS arguments with spouse about consequences of
intoxication, physical fights)

Substance dependent
 When he or she has withdrawal symptoms
following discontinuation of the substance
combined with abandonment of important
activities,
 Spending increased time in activities related
to substance use
 Using substances for longer time than planned
 Continued use despite worsening problems
because of substance use
Substance-dependent women
 Usually younger age group
 MARK:
 Late in prenatal care because she s afraid her
drug use will be discovered and be reported to
authorities.
 Cannot wait long at health care facility to be
seen for an appointment
 Difficulty following instructions for proper
nutrition
 Prefer to buy drugs than food
Behavioral indications of substance abuse
 Can’t wait long at a health care facility
 May have difficulty following prenatal
instructions for proper nutrition- lack money
to buy both drugs and nutritious food and
choosing drugs over food makes her nutrition
inadequate
 May not have money for supplemental
vitamins or iron preparations
Effects of Drugs
 Cross the placenta
 Fetal abnormalities /Preterm birth
 Hepatitis – if using injected drugs B or HIV
 Increased Risk of STD
Outcomes
 Have few effective support people
 Require a multidisciplinary team approach not
only from pregnancy HCP but substance
abuse treatment providers
 Still using drug when labor begins--------
infant will have drug withdrawal symptoms
after birth
 Nervousness
 Irritability/lethargy
 Possibly seizures
 Breastfeeding is not encouraged because
drugs are being carried and excreted into
breast milk.
 Women receiving METHADONE as part of
their drug treatment can breastfeed as only a
small amount of this drug is excreted in breast
milk
COMMON SUBSTANCES ABUSED DURING
PREGNANCY
COCAINE
 Derived from Erythroxylum coca
 A powerfully addictive stimulant drug-
increases levels of dopamine, a brain chemical
(or neurotransmitter) associated with pleasure
and movement,
 Crack is the street name given to the form of
cocaine that has been processed to make a
rock crystal, which, when heated, produces
vapors that are smoked. The term “crack”
refers to the crackling sound produced by the
rock as it is heated.
 When sniffed-=absorbed in the mucous
membrane affecting the central nervous
system= vasoconstriction occurs
 RR , BP and HR increases rapidly in response
to vasoconstriction
  Immediate death may result from cardiac
failure
 If there is vasoconstriction, placental
insufficiency premature of the placenta
preterm labor or fetal death
 INFANT will suffer intracranial hemorrhage
and a withdrawal syndrome of tremulousness,
irritability and muscle rigidity.
 Long tern effects: learning defects
 Morphine sulfate, meperidine HCL and
codeine (Cough suppressant)
 Potent analgesic and euphoric effect
 Heroin- raw opiate – used recreationally to the
point of dependence
 Sedative effect
 PIH, phlebitis, subacute bacterial endocarditis,
hepatitis B and HIV infection

AMPHETAMINES HEROIN

 Methamphetamine (speed)  A raw opiate, short acting narcotic

 Effects are similar to cocaine  Inactive until it crosses the blood brain barrier
 Smoked  Administered ID, IV and inhalation
 Newborns show jitterness, poor feeding at  Produces a short lived feeling of euphoria
birth, growth restricted. followed by sedation.

Pregnant woman
MARIJUANA AND HASHISH
 Results in fetal opiate dependence and severe
 Obtained from the hemp plant CANNABIS
withdrawal symptoms in the infant after birth
 May be used in pregnancy to counteract
 Infants tend to be small for gestational age
nausea but is not advised
and with increased incidence of fetal distress
 When smoked produce tachycardia and sense and meconium aspiration
of well being
 Liver tends to mature faster- rare
 Associated with short term memory and hyperbilirubinemia
increased respiratory infection in adults
 Fetal lung tissue appears to mature more
 Frequent user may NOT ne able to breastfeed rapidly – rare RDS
because of reduced milk production and the
risk of the newborn from excretion of the drug
in the milk. Complications

PHENCYCLIDINE  PIH
 HIV
 An animal tranquilizer that is frequently used
 Phlebitis
street drug in polydrug abuse.
 Subacute bacterial endocarditis,
 Causes increased cardiac output and sense of
 Hepatitis B
euphoria, long term hallucination
 (Flashback episodes)
 Injurious to the fetus Withdrawal symptoms may begin as soon as 6
 Tend to leave the maternal circulation and hours after the last drug
concentrate in fetal cells-----injurious to a
 Nausea
fetus.
 Diarrhea
NARCOTIC AGONISTS  Hypertension
 Shivering
 Pain reliever
  Body aches
 Vomiting
Fetal Alcohol Syndrome Facial Characteristics
 Abdominal pain
 Restlessness  Small head
 Insomnia  Low nasal bridge
 Muscle jerks  Short eyelid opening
 Flat midface
Effects of Opiates to Infants
 Epicanthal folds
 SGA  Short nose
 Meconium aspiration  Flat midface
 Fetal distress  Short nose
 Withdrawal symptoms after birth  Smooth philtrum
 Underdeveloped jaw
NOTE: Because the fetus is exposed to drugs that
must be processed by the liver during pregnancy, the
fetal liver is forced to mature faster than normally.
Fetal lung tissue also appears to mature from the
stress of intrauterine drug exposure, thus being born
in preterm

Treatment

 Methadone maintenance program

 Buprenorphine if not treated with methadone
 Suboxone (combination of nalone and
buprenorphine)- an analgesic similar to
morphine

INHALANTS

 Sniffing/huffing of aerosol drugs

 Can lead to respiratory and cardiac
irregularities
 Ex: airplane glue, cooking sprays, and
computer keyboard cleaner
 Contain freon as a propellant and can lead to
severe respiratory and cardiac irregularities

ALCOHOL

 Detrimental to fetal growth

 Fetal alcohol syndrome – significant facial
features, cognitive challenge and memory
deficit
HIV
HIV/ HUMAN IMMUNODEFICIENCY  CD4 count : below 200 cells/mm3
VIRUS/AIDS- ACQUIRED  Toxoplasmosis
IMMUNODEFICIENCY SYNDROME  Oral and vaginal candidiasis
 GI illness
 USA- ¼ of nearly one million people in the
US are infected- female  Herpes simplex
 Leading cause of death in women 25-44 yrs of  P carinii pneumonia
age  Kaposi sarcoma
 1% -2% of every women giving birth  Higher risk of developing toxoplasmosis and
cytomegalovirus infections
 HIV positive woman may invade the
Risk factors cerebrospinal fluid and cause extreme
neurologic involvement.
 Multiple sexual partners of the individual or
sexual partner  Tuberculosis
 Bisexual partners
 Intravenous drug used by the individuals or
sexual partner Diagnostic Test

1. ELISA ( enzyme linked immunoassay)

Assessment  To detect antibodies in the blood

EARLY 2. Western blot analysis

 Fatique - to separate and identify proteins ( a mixture of

 Anemia proteins is separated based on molecular
weight
 Diarrhea
 Weight loss
 Flu-like symptoms
Mode of transmission

- Exposure to blood and body secretions

Stages of HIV through sexual contact
- Sharing of contaminated needles for injection
1. Initial invasion of the virus with mild, flulike
- transfusion of contaminated blood
symptoms
- Breastfeeding
2. Seroconversion- a woman converts from HIV - Multiple sexual partners
serum negative to HIV serum positive

3. Asymptomatic period – disease-free except for

Effects of HIV to pregnancy
symptoms-weight loss, fatique
- Low birth weight
 The virus is replicating
- Preterm birth
 3-11 yrs
- 20-50% of infants will develop AIDS in the
4. Symptomatic period first yr of life

 Presence of opportunistic infection and

malignancies Issues to be addressed when HIV+
 - Safer sex practices
- testing of sexual contacts
- Continuations or termination of pregnancy
Therapeutic Management
1, HIV positive women are advised to avoid
pregnancy
2. Monitoring of the CD4 cell counts and viral load
level
Goal of therapy
To maintain the CD4 cell count at greater than 500
cell/mm3 by administering oral ZVD + one or more
protease inhibitors: ritonavir (Norvir) or
indinavir(Crixivan) in conjunction with
NRTI(nucleoside reverse transcriptase inhibitor drug
3. Medications:
a. Zidovudine (ZVD) - administerd to the woman
beginning with the 14th week of pregnancy and
newborns receives antiviral therapy beginning with
birth and a follow- up of 6 weeks
Advised not to be pregnant
b. Trimethoprin with sulfamethoxazole (bactrim)-
with pneumonia
Teratogenic in early pregnancy
c. Sulfamethoxazole (Gantanol)- may lead to
increase bilirubin levels in newborn if administered
late in pregnancy
4. Chemotherapy for those with Kaposi’s sarcoma-
contraindicated during early pregnancy because of
potential for fetal injury but can be used later in
pregnancy to halt the malignant growth.
5. CS delivery- – to reduce the risk of mother-to-
newborn transmission
P carinii pneumonia – trimethroprim with
sulfamethoxazole (Bactrim) or Pentamidine (Pentam)
Kaposi’s sarcoma – skin cancer in AIDS; treated
with chemotherapy late in pregnancy
Thrombocytopenia – platelet transfusion close to
birth to restore coagulation ability( poor candidate for
epidural injection for anesthesia or episiotomy)
Follow-up testing of newborns being treated with
zidovudine for the first 6 weeks
2 (-) HIV culture at 4 mos of age: HIV infection is
excluded
6. No amniocentesis
7. No episiotomy
8. Use standard infection precaution
Nursing Diagnoses
Risk for infection related to dysfunction of the
immune system secondary to invasion of HIV
- Administer acyclovir (Zovirax) for Herpes
simplex, clotrimazole troches (Mycelex) for
oral thrush, pyrimethamine (Daraprim) and
sulfadiazine for toxoplasmosis and
trimethoprim w/ sulfamethoxazole (Bactrim)
for PCP
- Immunization against pneumonia, influenza
and hepatitis B
- During labor – internal fetal monitor, scalp
blood sampling, forceps and vacuum
extraction are avoided to prevent bleeding
- At birth – episiotomy and breastfeeding are
avoided
- Educate that patient about the mode of HIV
transmission and safer sex practices
Use standard infection precautions to protect
against the spread of
CARDIAC DISEASE/HEART DISEASE

Heart disease/cardiac disease

Assessment:

Thorough health history

 ask her level of exercise performance

 ask if she has a cough or edema
 instruct the woman to report coughing during
pregnancy
- make comparison assessment of nail bed

- jugular venous congestion

-assess liver size

 Echocardigraphy
 Chest radiograph
 ECG

Signs of heart failure:

  Edema Cough
 Irregular pulse
Pulmonary edema
 Rapid or difficult respirations
 Chest pain on exertion

4 categories of heart failure:

Class 1 – can experience normal pregnancy and birth

Class 2 – slightly compromise

Class 3 – markedly compromise ( can complete

pregnancy , in CBR)

Class 4 – severely compromise ( poor candidate)

DROWNING

 D-dyspnea
 R- rales ( crackles)
 0-orthopnea
Heparin – drug of choice for early pregnancy
 W- weakness
- no teratogenic effect  N-nocturnal paroxysmal dyspnea
 I-increase HR
- does not cross the placenta and the fetus
 N-nagging cough
Sodium warfarin ( Coumadin)- can be used after  G-gaining weight
week 12

Returns to heparin during the last month of pregnancy Nsg Interventions

 Assess client’s symptoms

 Assess client’s responsiveness to medications
Left sided heart failure ( digoxin, diuretics, ACE and betablockers)
Causes:  Monitor BP
 Monitor volume status
 mitral stenosis  Assess weight daily
 mitral innsufficiency  Monitor potassium level
 aortic coarctation  Monitor diet( low sodium /day ; not 2-3 grams
per day)
 Assess edema of legs (shd be elevated)
1. The left ventricle cannot move the volume of  High-fowlers position/ semi-upright
blood forward  Safety- risk for falling when shifting positions
2. Heart becomes overwhelmed and fails to  Compliance for medication
function  No smoking and limiting alcohol consumption
3. Decrease CO
4. Increase pressure in pulmonary veins
Management:
Orthopneic position
 1. Anticoagulant
2. Antihypertensive drugs
3. Diuretics-
4. Beta blockers- slowing hR
5. Digoxin – increase heart ability to contract
stronger (above .2= toxicity)
6. Balloon valve angioplasty
b) Adenosine beta blockers and angiotensin
convertine enzyme ( ACE) inhibitors- reduce
HPN
c) Nitroglycerin –
4. Educate regarding the avoidance of infection
Right-sided heart failure

 Occurs when the output of the RV i sless than

Women with pulmonary HPN are extremely high-risk
for: spontaneous miscarriage
 preterm labor
 maternal death
the placenta may not receive adequate blood because
of the decreased peripheral circulation
the blood volume received by the Raof the
vena cava
 Back pressue—congestion of the systemic
venous circulation
 Decrease CO to the lungs
 Less blood – BP decreases in the aorta
- pressure is high in the vena cava

If complications result in impaired blood flow to the assessment

uterus this leads to:
 Jugular distention
a) Poor placental perfusion  Liver and spleen becomes distented
b) Intrauterine growth restriction  Liver enlargement
c) Fetal abnormality  Distended abdominal vessels
Needs UTZ and nonstress stest after 30-32 weeks of  Peripheral edema
pregnancy  Ascites

Fetal assessment: SWELLING

 LBW  S-swelling of hands and liver

 Preterm labor  W-weight gain
 Immaturity  E-edema ( pitting)
 Infant may not respond to labor ( late  L-large neck vein
deceleration)  L-lethargic
 I-irregular HR
 N-nocturnal (frequent urinatiion)
Other interventions:  G-girth ( abdomen), anorexia

1. Promote healthy nutrition

2. Take iron supplements

3. Educate regarding medication

a) Digoxin – to slow FHR

 ANEMIA

RHEUMATIC HEART DISEASE

A beta hemolytoc streptococcal infection resulting in

Decreased oxygen carrying capacity of the blood
valve laekage ( insufficiency) and or obstruction
( narrowing/stenosis) 1st Tri

 Hemoglobin is less tab 11g/dl

 Hematocrit less than 33%

2nd tri

 Hgb less than 10.5 g/dl

 Hct less than 32%

types

 Iron deficinecy anemia

Management  Folic acid deficiency anemia
 Sickle cell anemia
1. Throat culture
2. Penicillin- drug of choice Normally, blood volume expands during
3. Rest pregnancy( pseudo anemia)= faster increase of
4. NSAIDS plasma volume than RBC production BUT in 2nd
trimester, RBC increases

Iron deficiency anemia

 A microcytic (small red blood cells)

 Hypochromic ( less hemoglobin than the
average
 Inadequate supply of iron or iron is
unavailable
 Most commo anemia in pregnancy

Causes of IDA

 Diet low in iron

 Heavy menstrual flow
  Unwise weight reduction programs  Associated in preventing neural tube defects
 Pregnant less than 2years in the fetus
 Low socio economic levels Symptoms of vitamin B12 or folate deficiency

 extreme tiredness.
 a lack of energy.
Clinical presentation  pins and needles (paraesthesia)
 a sore and red tongue.
 Pallor  mouth ulcers.
 Fatigue  muscle weakness.
 Dizziness  disturbed vision.
 SOB  psychological problems, which may include
 Palpitation depression and confusion.
 Weakness
high-risk
 Headache
 Fast HB  Multiple pregnancies
 Unusual craving  With Secondary hemolytic illness
 Use of hydantoin
effects  Using oral contraceptives
 Had gastric bypass
 LBW
 Heart dss
 Preterm birth Megaloblastic anemia – enlarged RBC
 Pica (food craving)
Apparent during 2nd tri
 Delayed growth
Contributory factor:
Management  early miscarriage or premature separation of
 Women should take prenatal vitamins the placenta
 Iron supplement of 60 mg  Occur in the 1st few weeks of fetal
development
 +++take with vitamin C
 +++take with food to prevent gastric iritation *take 400mcgram folic acid daily
 +++increase roughage diet to prevent
*eat folacin food ( green
constipation
 Diet high in iron and vitamins leafy vegetables, oranges and dried beans)
If iron deficiency is severe and with difficulty with
oral therapy, IM or IV dextran can be prescribed
Management

During pregnancy
Folic acid deficiency anemia
 ***folic acid requirements: 600microgram
 Folic acid/folacin necessary for the normal daily
formation of RBC in the mother
Sickle cell anemia

An inherited hemolytic anemia caused by the Therapeutic management

abnormal amino acid in the beta chain of hemoglobin
1. Periodic exchange transfusion throughout
Majority of RBC are irregular /sickle shaped pregnancy
2. Oxygen adminsitration
***sickle shape = cannot carry as much hbg 3. Increase fluid vol
4. Hospitalizaton
5. Electrophoresis of RBC
What happens?
Symptoms of sickle cell anemia do not become
 Decrease oxygen apparent until an infant’s fetal hemoglobin converts
 blood becomes viscid to a largelt adult pattern ( in 3-6 months)
 Cells clump
Fetal hgb= 2 alpha 2 gamma chains
 Vessel blockage
 Decrease blood flow to organs Adult hgh= 2 alpha 2 beta chains
 Hemolysis
 Decrease # of RBC
 Severe anemia

Sickle cell anemia is a threat to life

In pregnancy= blockage to the placental circulation

can directly compromise the fetus, causing LBW and
possibly death

Assessment

1. Monitor hemoglobin level

2. Clean catch urine sample

3. Monitor diet throughout pregnancy

4. Fluid intake carefully monitored

***should consume 8 glasses /daily

***if nauseated – decrease fluid intake

5. Assess for presence of varicosities

6. Encourage woman to elevate legs while sitting

7. sim’s position to encourage venous return from the

lower extremities

8. Monitor fetal health by: UTZ, NST and blood flow

velocity
 Rh (+) blood are not formed during pregnancy but
in the first 72 hours after birth making them a
threat to a 2nd pregnancy

Rh(-) mother + Rh (-) father= Rh (-) baby

Rh (-) mother =Rh (+) father = Rh (+) baby

 Previous miscarriage, abortion

 Had ectopic pregnancy
 Didn’t receive Rh immune globulin to prevent
sensitization
 Had amniocentesis or CVS
 ****the test could let your blood and baby’s
blood mix
Blood will mix during delivery

1st baby will not be affected

2nd baby will be affected

*****the antibodies that is already in the mother’s

blood could attack the baby’s RBC leading to:

a. Anemia
b. jaundice
c. More serious problems

Therapeutic Management:

R h (D) immune globulin- to prevent the formation of

matenal antibodies

** 28th weeks

**40 weeks
RH SENSITIZATION
** within 72 hours after delivery

2. Intrauterine Transfusion( injecting RBC via

amniocentesis directly to the fetal cord

Occurs when Rh (-) mother carries a fetus with an - Blood type O (-)
Rh (+) blood type

------Maternal antibodies formed against the

If the mother is Rh sensitized, she will have:
A, regular blood test- check the level of antibodies
B. Doppler UTZ – to check blood flow to the baby’s
brain( showing anemia and its severety)
C. Amniocentesis after 15 weeks- to check baby’s
type and Rh factor and to look for problems
DIABETES MELLITUS
 An endocrine disorder in which the beta cells
in the pancreas cannot produce adequate
insulin to regulate body glucose levels.
 Pregnancy places demands on carbohydrate
metabolism and causes insulin requirements
to change:
○ First trimester – decreased insulin
requirement
○ 2nd trimester and 3rd trimester – increased
insulin requirement
After placental delivery- decrease insulin
requirement
● Women who has DM: not a good candidate for oral
contraceptive
○ Oral contraceptives contain hormones.
○ Ex. COC
■ Hormones present in the contraceptives tries to
prevent the action of the insulin
■ Estrogen increases levels of lipids and cholesterol
● Not a candidate for using IUD
○ Risk for pelvic inflammatory disease
○ CONTRACEPTIVES: IM injections, subcutaneous
implants
CLASSIFICATION:
TYPE 1
● Formerly known as insulin-dependent diabetes
mellitus
● A state characterized by the destruction of the beta
cells in the pancreas that usually leads to absolute
insulin dependency
TYPE 2
● Formerly known as non-insulin dependent DM
● A state that usually rises because of insulin
resistance combined with relatively deficiency in the
production of insulin
GESTATIONAL DIABETES
● A condition of abnormal glucose metabolism that
arises during pregnancy ( 24th-28th weeks)
Risk factors:
 Obesity
 Age over 25 years
 Hx of large babies (10 lb or more)
 Hx of unexplained fetal or perinatal loss
 Hx of congenital anomalies in previous
pregnancies
  Hx of polycystic ovary syndrome lower extremities)
 Family history of diabetes Polyhydramnios STILLBIRTH
 Member of a population with a high-risk for (excessive amount of
diabetes amniotic fluid)
Spontaneous abortion Spontaneous miscarriage
IMPAIRED GLUCOSE HOMEOSTASIS

 A state between normal and diabetes in which DIAGNOSTIC TESTS

the body is no longer using and secreting
insulin properly. NORMAL FASTING SUGAR = 95

Impaired fasting glucose 1. Oral Glucose Tolerance test (OGCT)

 a state when fasting plasma glucose is at ● 50 g glucose challenge test

least 110 but under 126mg/dl
● Done during the 1st prenatal visit and repeat at 24-
Impaired glucose tolerance 28th weeks AOG

 A state when the results of the oral glucose ● After the 50 g glucose load = a venous sample is
tolerance test are at least 140 but under taken for glucose determination after 60 minutes
200mg/dl in the 2 hour sample.
● To confirm: fasting plasma glucose of 126 mg/dl or
CLINICAL PRESENTATION above or a non fasting plasma glucose of 200 mg/dl
or above (with diabetes)
● 4 P’s
○ Below 126 mg/dl, no more OGTT
○ Polyuria - excessive urination
○ >126, do the second test (OGTT)
○ Polydipsia - excessive thirst
● 3 days high caloric diet tapos fasting on the day of
○ Polyphagia - excessive hunger the blood extraction.
○ Pruritus - itchiness 2. 100g Glucose tolerance test
● Weight loss ● Done at 32-34 weeks
● Frequent UTI ● If the serum glucose level at 1 hour is more than
140mg/dl, the woman is scheduled for a 100g, 3 hour
● Large fetus
fasting glucose tolerance test
● Presence of sugar in the urine (proteinuria)
● If 2 of the 4 blood samples collected for this test are
COMPLICATIONS abnormal or if the fasting value is above 95mg/dl
diabetes is present
MATERNAL FETAL
PIH (pregnancy-induced Macrosomia (large baby ○ 3x blood extraction with 1 hr interval + 1 for
hypertension) bc they consume challenge test Oral glucose challenge test values
glucose) (fasting plasma glucose values) for pregnancy
Infection (bacteria’s like Congenital anomalies
TEST TYPE Pregnant glucose level
yeast) (caudal regression
(mg/dl) by carpenter and
syndrome; affects
coustan
development of the
FASTING 95
1HR 180
2HR 155
3HR 140
3. Serum alpha-fetoprotein level
● Determines if baby has neural tube defects
● Diabetic mother = fetal risk for congenital
anomaly (neural tube defects)
4. UTZ
● View the amniotic fluid
5. Creatinine clearance test each trimester
○ Diabetes affects the kidneys too
6. NST ○ Non stress test
7. Recording of fetal movements
8. Lecithin/ sphingomyelin ratio at week 36 ○ Used
to determine surfactant
○ Babies w/ diabetic mothers are at risk for
respiratory distress syndrome
9. Biophysical profile
○ Assesses fetal activity, fetal movement, amniotic
index
10. Glycosylated hemoglobin
○ Used to detect degree of hyperglycemia
○ Reflects the average blood glucose levels over the
past 4-6 weeks (the time the RBC were picking up
glucose)
THERAPEUTIC MANAGEMENT
1. Insulin
● Short acting insulin (regular) combined with an
intermediate type
● 2/3 is given in the morning
● 1/3 is given in the evening
● Self administered 30 min in a ratio of 2:1
(intermediate to regular) and again just before dinner
in a ratio of 1:1
● Oral hypoglycemic NOT RECOMMENDED for
pregnant women because they cross the placenta and
are potentially teratogenic to the fetus.
● Route: Subcutaneously
● Regular insulin ( clear)
● If mixing insulin: draw clear (regular) then cloudy
(intermediate)
❖ Oral hypoglycemic drugs are not recommended
because they can cross the placenta and harm the
fetus.
2. Blood glucose monitoring
● Fingerstick technique – use of glucose meter
● FBS = below 95-100 mg/dl
● 2 hr postprandial (after lunch or dinner) level below
120 mg/dl 3. Insulin pump therapy
● An automatic pump about the size of mp3 player

11. Ophthalmic examination ● Used to control the rate, volume of medication

○ Diabetes causes eye problems like cataract or ● A syringe of regular insulin is placed in the pump
blindness chamber and a small gauge needle is attached to a
length of thin polyethylene tubing and implanted into
the subcutaneous tissue of a woman’s thigh or
abdomen
12. Urine culture for UTI

○ Clients with diabetes are at risk for having UTI

NURSING CARE MANAGEMENT
1. Complete patient database and document test Hypoglycemia ● Hyperglycemia ●
results during pregnancy common in the 2nd common in the 6th
and 3rd month (1st month (2nd trimester)
2. Educate both patient and her family regarding:
trimester)
A. Nutrition sweating fatigue
Pallor, cold clammy skin Flushed, hot skin
○ 1800-2400 calorie diet divided into 3 meals and 3 Disorientation, Dry mouth, excessive
snacks irritability thirst
○ Reduced amount of saturated fats and cholesterol, Headache Frequent urination
increased dietary fiber 20% CHON, 40-50% CHO, Hunger Rapid, deep breathing,
30% fat ○ IV supplementation for those who cannot fruity breath odor
eat due to N/V (nausea & vomiting) Blurred Vision Depressed reflexes
Nervousness Drowsiness, headache
■ Usually IV Glucose Shallow breathing but
normal PR
○ Final snack of the day one of CHON and complex
Urine (-) for glucose and
carbohydrate to allow slow digestion during the night
ketones
○ Weight gain at 25-30 lb Blood glucose level

a. Exercise

○ Lowers serum glucose and the need for insulin

○ May cause hypoglycemia- insulin is released

quickly

○ Extreme exercise will cause hypoglycemia and

ketoacidosis
GESTATIONAL CONDITIONS
3. Explain the importance of continued evaluation
even during postpartum and even when blood glucose
levels are normal
ECTOPIC PREGNANCY
○ Continuous check up
 It is when a fertilized egg implants itself
4. Encourage regular exercise (3-4xx/week; duration: outside of the womb, usually in one of the
15-30 minutes; HR maintains between 130-180 bpm fallopian tubes. Ectopic pregnancies can also
happen on the ovary, or somewhere else in the
5. Ensure patient’s preparation for intensive and belly.
regular intrapartum assessment

6. Advise contraception in diabetic woman

Signs and symptoms
7. Monitor BP and lipid levels 8. Woman who is type
1 or 2 should meet with her OB before she becomes ● Sharp abdominal pain
pregnant
○ Pain at lower quadrant
Signs and symptoms of hypoglycemia and
● Triad symptoms of ectopic pregnancy ○ Vaginal
hyperglycemia
spotting
○ Vaginal bleeding MANAGEMENT

■ Assess for signs of shock ● Administration of methotrexate- can be

administered until negative Hcg
● Increased RR, heart rate and BP
● Administration of mifepristone- drug that causes
○ amenorrhea abortion; slows tubal implantation site

● Intravenous therapy - can be performed when

Risk factors ectopic pregnancy has ruptured; done to restore
intravascular volume
● Previous ectopic pregnancy

● Inflammation or infection
NURSING INTERVENTIONS
● Congenital malformation
● Assess vital signs
● Tubal surgery
● Maintain accurate intake and output
● Choice of birth control
● Ensure that appropriate physical needs are
● Smoking addressed ● Address emotional and psychosocial
needs

● Provide client and family teaching

ADDITIONAL NOTES
Pathology
Observed at 1st trimester
● Fertilization occurs at the usual distal third of the
fallopian tube. ● Ampulla = site of fertilization 80% of ectopic
pregnancy; Isthmus 7% of ectopic pregnancy
● After the union, zygote begins to divide and grow.
● Ectopic pregnancy is common during the first
● Due to an obstruction, the zygote cannot travel
trimester
through the length of the tube.
● Sharp abdominal pain is caused by:
● It lodges on that constricted part and implantation
takes place at that area instead of the uterus. ○ The growth of the fetus in the fallopian tube

○ Growth of the fetus = stretched fallopian tube =

pain
DIAGNOSTIC TEST
● Triad symptoms of ectopic pregnancy
● Urine test
○ Vaginal spotting
● Blood test = Serum beta Hcg level
○ Vaginal bleeding
● Ultrasound = used to see where the fertilized egg is
implanted ■ Assess for signs of shock

● Increased RR
● Increased PR ■ Drug of choice

● Decrease BP ■ Used to shrink and absorb the products of

● Elevated vital signs except bp
● Cold clammy skin
● Decreased level of consciousness
○ Amenorrhea
○ Elevated level of WBC (leukocytosis)
■ Due to trauma sa affected parts
conception and will eventually be absorbed by the
body
■ Used for unruptured ectopic pregnancy
■ Will be administered until Hcg is negative
■ Chemo drug
■ Side effects: difficulty of breathing = CO2 tends to
accumulate

○ Cullen’s sign ○ Mifepristone

■ Bluish discoloration of umbilical cord if there will ■ Sloughing of the tubal implantation???/./f./.?>
be delayed referral ○ Hysterosalpingogram
○ Rigid abdomen ■ Viewing of the uterus and the fallopian tube
○ Cervical motion tenderness ■ Done after the administration of methotrexate to
■ Movement of pelvis…… causes pain check the patency of the fallopian tube

■ Presence of pain during internal exam

○ Presence of shoulder pain RUPTURED ECTOPIC PREGNANCY

■ Related to irritation of phrenic nerve because of ● Need to confirm if the blood is maternal blood or
accumulation of blood in peritoneal area ectopic blood

● Risks: ● Culdocentesis

○ Presence of infection ○ Consent is obtained

■ There will be adhesions in the fallopian tubes
therefore preventing the zygote to move out from the
FT to the uterus
○ Congenital Malformation
■ Problem in the structure of FT
○ Tubal surgery/ Tumors
■ Presence of scars prevents zygotes to move out
○ Aspirate blood from cul de sac to confirm whether
it is ectopic or maternal blood
■ Non-clotting: ectopic blood
■ Clotting: maternal blood
○ Procedure
■ Client is in a lithotomy position
■ Uses speculum

■ The inserts the spinal needle directed to the

Management of UNRUPTURED PREGNANCY posterior part of the cervix

○ Methotrexate (Oral) ● Need to determine blood type, Hgb, Hgc

○ To determine what blood to infuse in case blood
infusion is needed
● Laparoscopy
○ Ligates bleeding vessels to repair or remove the
ruptured fallopian tube
○ They will give RhD Immunoglobulin
■ To prepare for Rh sensitization
■ For isoimmunization
ABORTION
 Abortion is a medical term for any
interruption of a pregnancy before a fetus is
viable or mature enough to live outside the
uterus, but it is better to speak of these early
pregnancy losses as spontaneous miscarriages
to avoid confusion with intentional
terminations of pregnancies.
 A fetus born before 20 to 24 weeks or weighs
less than 500g is considered a miscarriage or
is termed a premature or immature birth

ACRONYM
CAUSES
E Extrauterine pregnancy
The most frequent causes of spontaneous miscarriage
C Cullen’s Sign in the first trimester of pregnancy are:

T Tender, Rigid, Abdominal pain LQ, Amenorrhea ● Teratogenic Factor / Chromosomal Aberration

O Observe for shock ○ In other miscarriages, immunologic factors may be

present or rejection of the embryo through an immune
P Prepare for surgery (laparoscopy) response may occur and cause abnormal fetal
I Inject Rhogam (RhD Immunoglobulin; IM development.
deltoid/thigh) ● Implantation abnormalities
C Care for the client ○ Placental circulation does not mature sufficiently to
maintain the pregnancy due to insufficient
implantation which unables zygotes to implant firmly
resulting in poor fetal nourishment.

● Corpus luteum insufficient production of

progesterone

○ As progesterone maintains the decidua basalis.

Progesterone therapy may be attempted to prevent
this if this cause is documented

● Lifestyle Factors (smoking, drinking alcohol, using

of illegal drugs)

○ Ingestion of alcohol at the time of conception or

during early pregnancy. It can contribute to
pregnancy loss because of abnormal fetal growth.

● Ingestion of a teratogenic drug

○ It can cause complications like preterm labor,
spontaneous abortions, miscarriage and birth defects.
● Systemic Infections
○ Such as rubella, syphilis, poliomyelitis,
cytomegalovirus, and toxoplasmosis readily cross the
placenta and affects the the growing fetus, estrogen
and progesterone production by the placenta falls it
leads to endometrial sloughing and the prostaglandins
were released, leading to uterine contraction and
cervical dilatation along with expulsion of the
products of the pregnancy.
● Urinary tract infections
ASSESSMENT
Presenting symptom: vaginal spotting
● Take history of episode
○ What actions did the woman do to cause/stop the
bleeding? Did she try to abort the fetus?
● Confirmation of pregnancy
○ Does the woman know for certain that she is
pregnant?
● Pregnancy length
○ What is the length of the pregnancy in weeks?
● Duration
○ How long did the bleeding episode last? Is it
continuing?
● Intensity
○ How much bleeding occurred?
● Description
○ Was blood mixed with amniotic fluid or mucus?
Was it bright red (fresh blood) or dark (old blood)?
Was it accompanied by tissue fragments? Was it
odorous?
● Frequency
○ Is the bleeding a steady spotting? Did it only occur
in a single episode?
● Associated symptoms
○ Does the woman feel any cramping, sharp pain, or
dull pain? Has she ever had cervical surgery?
● Actions
○ What was happening when the bleeding started?
What has she done (if anything) to control bleeding?
● Blood type
○ Does the woman know that Rh-negative women
will need Rh immune globulin to prevent Rh
isoimmunization?
MANAGEMENT
 Depending on the symptoms and the
description of the bleeding a woman gives, the
physician or nurse-midwife will decide
whether she needs to be seen by a health care
provider and, if so, whether she should be
seen in an ambulatory setting or the hospital.
COMPLICATIONS
Hemorrhage - Blood loss is referred to as bleeding,
sometimes known as hemorrhage. Internal bleeding
refers to blood loss that occurs within the body,
whereas external bleeding refers to blood loss that
occurs outside of the body.
https://www.healthline.com/health/bleeding
● Infection - When a microbe penetrates a person's
body and causes harm, it is called an infection. The
microorganism survives, reproduces, and colonizes in
that person's body. Pathogens are contagious tiny
organisms that have the ability to reproduce swiftly.
Examples of Pathogens include Bacteria, Virus, and
Fungi.
● Septic Abortion - when a pre-viable pregnancy's
placenta and fetus, or products of conception, become
infected. The placenta is the primary site of infection; O - ovary fails to produce (progesterone)… corpus
nevertheless, persistent or potent toxin-producing luteum —- shet
bacteria can spread to the surrounding uterine, pelvis,
and distant organs. R - Recurrent infection (UTI)

● Isoimmunization - A condition that happens when T - teratogenic drug use and intake of alcohol What to
a pregnant woman's blood protein is incompatible assess
with the baby's, causing her immune system to react ● Vaginal spotting
and destroy the baby's blood cells.
● Low abdominal cramps

● fever/ body malaise

● Signs of shock (hypovolemic shock)

○ Elevated VS except BP
ADDITIONAL NOTES
○ Cold clammy skin
When to observe the occurrence?
○ Decreased level of consciousness
● Occurs during 1st trimester (16- 24 weeks)

● Before the fetus is viable (20-24 weeks; when the

fetus can survive on its own) TYPES

We need to determine if it is an early/late miscarriage THREATENED MISCARRIAGE

● Early: happens before 16th week ● Signs and symptoms

● Late: happens between 16th-24th week ○ Scant, bright red vaginal bleeding

Moderately/Deeply attached ○ Slight abdominal cramping

● 1st 6 weeks: placenta tentatively attached to the ○ Cervix is closed

decidua of the uterus
● Management:
○ Could lead to miscarriage
○ Tell client to come to hospital for FHT monitoring
○ “Madaling matanggal si baby” and UTZ to evaluate viability of fetus

○ Considered severe ○ Hemoglobin test check

● 6-12 weeks: placenta is moderately attached ■ If result is doubled, the placenta is still intact

○ Moderate flow of bleeding + ??
● 12 weeks: placenta is deeply attached
○ Profuse bleeding
CAUSES OF SPONTANEOUS MISCARRIAGE
A - Abnormal fetal development
○ Encourage the client to avoid strenuous activity for
24-48 hours to not aggravate/worsen her condition
■ After the bleeding stops the client may resume her
activity
■ If bleeding persists, coitus should also be restricted
for 2 weeks (could cause infection)

B - bleeding due to abnormal implantation

 ○ If bleeding cannot be prevented, dilatation and ● Prostaglandin suppository or the Misoprostol or
evacuation is done Cytotec (vagina)

○ Given if pregnancy is at 14 weeks

IMMINENT/INEVITABLE MISCARRIAGE ○ Used to dilate the vagina para matanggal ‘yung ded
fetus
● Opposite of threatened miscarriage
RECURRENT PREGNANCY LOSS
● Cervix is open
● Causes ○ defective sperm or egg cell ○ Endocrine:
● Moderate vaginal bleeding low protein
● Severe abdominal cramping ○ Deviation of the uterus
Management: ■ Bicornuate uterus - malformed uterus
● Ask client to bring sanitary pad or underwear ○ Blood loss
where the doctor can check the tissue fragments
○ Infection of the chorion
● Vacuum extraction if there is no FHT
○ Uterine infection
● When discharged: Ask client to count or record
sanitary pads used ○ Autosomal disorders

COMPLETE MISCARRIAGE ● Complications

● INCOMPLETE MISCARRIAGE ○ Hemorrhage

● Part of the fetus/ only the fetus is expelled ○ Infection

● Membranes are intact ■ Untreated infection

● Dilation and Curettage or Suction Curettage ○ Septic abortion

○ Curette is inserted into the vaginal and membranes ■ The mother herself will remove the baby
will be scraped
■ Can lead to toxic shock syndrome and septicemia
MISSED PREGNANCY
○ Isoimmunization
● Fetus died inside uterus

● Mother is at risk for infection

ACRONYM
● There is decreased size of abdomen Risk factor:
A Age before viability
● Disseminated intravascular coagulation
B Bleeding is scant, low abdominal cramps, there is
Management: fever

● UTZ (to check if fetus is ded or not) O Observe for infection, hemorrhage

● Oxytocin administration to initiate contraction R Record vital signs, bleeding, pain, and intravenous
fluids (part of intervention)
T Toxic shock syndrome, septicemia, kidney failure,
& death (if miscarriage is left untreated)

I Inject Rhogam; give Iron Supplement

O Ovary fails to produce progesterone (used to

maintain pregnancy)

N No sexual intercourse/ notify the physician

HYPEREMESIS GRAVIDARUM

- Pernicious or presistent vomiting

- N/V that is prolonged , beyond 12 weeks

- Severe dehydration, weight loss

 - Associated with helicobacter pylori ( causes  Record I and O
peptic ulcer)
 Advise SFF once vomiting has subsided

 Administer antiemetics as prescribed

Assessment
 Attends to client’s emotional and
 Severe N/V psychological needs

 Elevated hct

 Low Na, K and chloride ACRONYM

 Hypokalemic  E – exaggerated N/V beyond 1st trimester

 Polyneuritis  M – metabolic alkalosis, hypoproteinuria

 Weight loss  E – electrolyre, fluid, vitamins and minerals

 Urine test (+) for ketones
 Poor skin turgor
 If left untreated === associated withh
intrauterine growth restriction, preterm birth
replacement and nutrition
 S – skin turgor and mucus membrane
assessment for dehydration
 I – ingest bland solid foods
 S – strict hygiene and bedrest

Therapeutic Mgt

 Hospitalization

 Withheld oral food and fluid

 IVF ( 3000 LR with added Vit B)

 Antiemetic- metoclopramide
 Measure I and O and amt of vomitus
 If no vomiting within 24 hrs= may start small
amount of clear liquids
 Dry crackers, dry toast or cereal and be added
every 2 hours the soft diet
HYDATIDIFORM MOLE (H MOLE) AKA
GESTATIONAL TROPHOBLASTIC DISEASE
● Rare mass or growth that develops inside the uterus
(womb) at the start of a pregnancy. It’s a form of
trophoblastic illness that affects pregnant women
(GTD).

 If vomiting returns = TPN is used ● 2nd trimester (16th week)

Nursing care Mgt

 Ensure that the client has no oral intake until CAUSES

vomiting stops - Caused by aberrant oocyte fertilization (egg).
 Administer IVF It leads to a fetus that is abnormal. The
placenta grows regularly, with little or no fetal
 tissue growth. In the uterus, placental tissue
creates a bulk. Because it contains many tiny
cysts, this mass appears grape-like on
ultrasound.
- Low protein intake
● Vacuum aspiration to remove grape-sized vesicles
● Monitoring hCG (bc it’s elevated)
○ Monitored for 1 year (‘di dapat maging pregnant sa
time na ‘to kasi ‘di mo alam kung ‘yung elevation ng
hCG is dahil sa pregnancy or ‘yung H mole na ‘to)

RISK FACTORS ○ Should be negative ○ If positive: there are still

remnants of H mole
● Mother’s age
● Previous abortion
● History of previous mole MANAGEMENT
● Ethnicity
● History of OCP  Suction curettage
● IUD use  Pelvic exam
● Blood group  Chest x-ray
● Radiation Because the vesicles may metastasize and
● Socioeconomic status may go to the lungs
● Infertility  Serum test for HCG (every 2 weeks until
● Artificial insemination normal then begin monthly testing for 6
● Gene mutation months, then every 2 months for a total of 1
yr.)
 Use of oral contraceptive (progestin)
ASSESSMENT
 Methotrexate
- Uterus tends to expand faster than normally + urine Drug of choice for choriocarcinoma
test of HCG (1-2 M); NV= 400,000 IU ● Dactinomycin
○ Added regimen if metastasis occur
- Marked N/V

-UTZ show dense growth (snowflake pattern (-) FHR

2 CLASSIFICATIONS
- Vaginal bleeding (approx. 16 weeks);DARK
BROWN Partial

- Early s/s of preeclampsia (proteinuria, edema, HPN) ● Both normal and abnormally developing placental
before 20 weeks tissue present.

● Development of a fetus is also possible, but the

fetus is also possible, but the fetus is unable to
TREATMENTS
survive and is usually miscarried early in the
May involve one or more of the following: pregnancy

● Dilation and curettage (D&C) . ● Some of the villi form normally

● Chemotherapy drugs ● Syncytiotrophoblastic layer of villi is swollen and

misshapen
● Hysterectomy

● RhoGAM
● A macerated embryo of approx. 9 weeks gestation ○ Dark brown
may be present and fetal blood may be present in the
villi ACRONYM

● Has 69 chromosomes H HCG is elevated, uterus is large for gestational age,

persistent bleeding, N/V
● Rarely lead to choriocarcinoma
M Mole is detected buy UTZ, and removed by
Complete vacuum aspiration and curettage

● There is an abnormal placenta and no fetus O Observe for s/s of shock, prepare for BT and IV

● It happens when chromosomes from the mother’s L Lower the risk by avoiding pregnancy for least 1
egg are lost or not working, and chromosomes from year
the father are copied, so all 46 chromosomes come
from the father. E Educate on the need to monitor HCG for 1 year

● All trophoblastic villi swell and become cystic

● If embry forms, it dies at 1 to 2 mm in size w/ no

fetal blood present in the villi

● EMPTY OVUM

○ The sperm enters empty egg and its chromosome

replicates

● Snowstorm

additional

● AKA Gestational trophoblastic disease

● Happens because of the degeneration of

trophoblastic villi

● Abnormal development of the trophoblast

○ Abnormal growth of placenta

○ Vesicles are formed inside the uterus

● Signs and symptoms are present but there is no

baby ○ Grape sized vesicles are present

○ SIGNS: the patient looks pregnant but 90abdomen

is too large for gestational age

● Check for bleeding

○ Color of blood coming out is brown-ish

INCOMPETENT CERVIC (PREMATURE
CERVICAL DILATION)

● Cervical insufficiency, occurs when weak cervical

issue causes or contributes to premature birth or the
loss of an otherwise healthy pregnancy

● 2nd trimester

RISK FACTORS

● Uterine abnormality

● Cervical trauma

● Been exposed to DES

● Had cervical surgery

● Experienced premature birth or miscarriage

● Maternal age

● Congenital defects (anatomical structure of the

cervix and presence of trauma)

SIGNS AND SYMPTOMS

● Mild discomfort or spotting

● New backache

● Mild abdominal cramps

● Change in vahginal discharge

● Light vaginal bleeding

● Sensation of pelvic pressure

COMPLICATIONS

● Premature birth

● Pregnancy loss
DIAGNOSIS ● Get regular prenatal care

● Transvagial ultrasound ● Abstain from, the harmful substances

● Lab tests NURSING INTERVENTIONS

● Pelvic exam ● Determine any factors that further contribute to the

anxiety of the woman do it could be avoided

● Monitor vital signs to determine any physical

TREATMENT responses of the patient that could affect her
● Progesterone treatment condition ● Convey empathy and establish a
therapeutic relationship to encourage client to express
● Cerclage her feelings ● Provide accurate information about the
situation to help the client back into reality.
○ Done between 14th- 16th week

○ Sew the cervix to prevent the delivery of the baby

Additional Main problem:
○ Types:
● Cervix opens too early (week 20 or 5th month)
■ Mcdonald
○ Cervix normally opens during labor
● Temporary sewing of the cervix
● AKA premature cervical dilatation
● NSD
● Inability of the cervix to support growing fetus and
■ Shirodkar
is painless
● Permanent suture
● No uterine contraction
● CS
● If the color of the blood is color pink, it is
● Bed rest incompetent cervix

○ Modified Trendelenburg position ● Increased pelvic pressure

○ Pillow will be placed under the hips of client ACRONYM

● Restrict coitus temporarily I Inability of the cervix to support the newborn baby

● Tocolytic Drug will be given to prevent the uterus N No douching - The chemical might enter the cervix
to contract since the cervix is open

○ If there is uterine contraction C Cervical cerclage

○ Ritodrine ○ Terbutaline ○ Progesterone O Occur at week 20, bloody show- pink

M Maternal age, congenital structure defects, trauma

of cervix
TIPS TO PREVENT
P Premature cervical dilation w/o uterine contraction
● Eat a healthy diet
E Elevated pelvic pressure
● Gain the right amount of weight
T Trendelenburg (modified) ● Pre-viable PROM

E Encourage bed rest ○ Before 24 weeks AOG

N No coitus temporarily ● Prolong PROM

T Tocolytic drug ○ 24 hrs has passed between membrane rupture and

onset of labor

CAUSES

● Natural weakening of the membranes

● The force of contractions

● Low socioeconomic conditions

● Sexually transmitted infections

○ Chlamydia ○ Gonorrhea

● Previous preterm birth

● Cigarette smoking during pregnancy

● Unknown causes

SYMPTOMS

● An obvious loss of clear or slightly colored liquid

● If intra-amniotic infection is present

○ Maternal fever

○ Heavy or foul smelling discharge

PROM (PRETERM RUPTURE OF
MEMBRANES) ○ Abdominal pain

- Preterm rupture of membranes is rupture of

fetal membranes with loss of amniotic fluid
during pregnancy before 37 weeks. TESTS
- Preterm labor may follow rupture of the Nitrazine Test
membranes and end pregnancy
- 3rd Trimester ● This test involves putting a drop of fluid obtained
from the vagina onto the paper strips (Nitrazine
paper) ○ Blue: Alkaline=amniotic fluid (7.1=7.3)
TYPES ○ Yellow: Urine ● Ferning
● Preterm PROM ○ Viewing amniotic fluid under microscope
○ Before 37 week AOG ● UTZ
 ● Mother has infection (HSV, GBS, UTI, Chorio)

TREATMENT ● Mother is currently using combustible tobacco

products/cocaine
I. Rupture of the membranes can stimulate the uterus.
Most women who have a rupture will begin labor in Additional
24-48 hours
● BOW normally ruptures before labor
1. If labor does no start, one must perform
risk/benefit analysis on expectant management versus ○ In PROM, it ruptures before 37th week
induction of labor ○ After rupture, baby follows
2. 36 weeks gestation: if labor does not start, consider COMPLICATIONS
induction 24-48 hours after rupture. At this point risk
of infection is greater than any benefit of fetus ● Could lead to cord prolapse
remaining in utero
○ Bak magka-compression
a. Monitor for s/s of chorio
● Preterm labor
b. Clindamycin/Penicillin during labor if GBS+
● Infection There is sudden gush of clear liquid from
4. 34-36 weeks: with advances in neonate care, the vagina
delivery at 34 weeks deemed acceptable, so long as
MANAGEMENT
course of steroids has been completed
● Monitor FHR
a. Monitor s/s for chorio
● Bedrest
b. Clindamycin if between 34 and 34+6 weeks
gestation c. Delivery if there is fetal compromise, ○ Change position/ reposition mother in a —--
infection, or gestational age less than or equal to 34 position ● Tocolytic drug
weeks
○ Prevent delivery of baby
d. IV magnesium sulfate should be considered in
pregnancies
ACRONYM

RISK FACTORS P pH of more than 6.5 indicates alkaline amniotic

● Cervical incompetence or insufficiency
● Invasive procedures/cervical (?)
● Vaginal bleeding during pregnancy →
● Mother has poor nutrition (lacking copper and
ascorbic acid)
● Malpresentation of fetus (face or breech)
● Multipara or polyhydramnios →
● Prior PROM or PPROM
fluid (nitrazine paper turns blue)
R Refer for tocolytic therapy until fetal lungs are
mature
R Refrain from coitus and douching
O Observe closely for s/s of infection
M Maintain strict bedrest
C Cover any exposed portion with sterile saline
compress to prevent drying of cord
O O2 therapy to improve oxygenation to the fetus
 R Relieve pressure on the cord by elevating fetal
head OFF the cord or by placing the woman in a
knee-chest/ trendelenburg position
D Do not push cord back to the uterus, this may add
to compression
PLACENTA PREVIA
● Placenta previa is a condition in which the placenta
lies very low in the uterus and covers all or part of the
opening to the cervical opening that sits at the top of
the vagina.
● Placenta previa happens in about 1 in 200
pregnancies.
● If you develop the condition early in your
pregnancy, it usually isn’t a problem since the
placenta grows upward with the uterus during
pregnancy.
● If you develop the condition later in pregnancy (20
weeks) and the birth canal is blocked it can cause
serious bleeding and may prevent vaginal delivery.
TYPES
There are 3 types of placenta previa:
● Complete placenta previa.
○ The placenta completely covers the cervix.
○ Mode of delivery: CS
● Partial placenta previa.
○ The placenta is partly over the cervix.
○ Mode of delivery: NSD
● Marginal placenta previa.
○ The placenta is near the edge of the cervix.
○ Placenta approaches the cervical opening
○ Mode of delivery: NSD
PATHOPHYSIOLOGY
Placenta previa is initiated by implantation of the
embryo (embryonic plate) in the lower (caudad)
uterus. With placental attachment and growth, the
cervical os may become covered by the developing
placenta. A defective decidual vascularization exists,
possibly secondary to inflammatory or atrophic
changes.
When an absence of the decidua basalis exists and
incomplete development of the fibrinoid layer occurs,
the placenta can be attached directly to the
myometrium (accreta), invade the myometrium
(increta), or penetrate the myometrium (percreta). In
general, placenta accreta occurs in approximately 1 of
2500 deliveries. The incidence increases to 10% in
women with placenta previa. The risk for placenta
accreta with placenta previa increases from 4% for
those with no surgeries to 65% for those with a
history of multiple cesarean deliveries. Two out of 3
patients with placenta accreta require cesarean
hysterectomy.
A low-lying placenta is more susceptible to
hemorrhage, possibly due to a defective attachment to
the uterine wall. Bleeding can be spontaneous, or
provoked by mild trauma (e.g vaginal examination).
Additionally, the placenta may be damaged as the
presenting part of the fetus moves into the lower
uterine segment in preparation for labor.
Effects on the Mother and the Baby
Baby
● Premature birth ● Low birth weight ● Growth
problems ● Brain injury from lack of oxygen ●
Stillbirth
MOTHER
-Blood clotting issues ● Blood transfusion ●
Hemorrhage ● Kidney failure ● Blood loss
Signs and Symptoms
● Bleeding is the primary symptom of placenta previa
and occurs in the majority (70%-80%) of women with
this condition. The mother can notice bright red
bleeding from the vagina during the second half of
her pregnancy, after intercourse, or it starts, stops,
and begins again days or weeks later. It can range
from light to heavy, and it's often painless. The
bleeding is accompanied by contractions wherein the
mother might feel the cramping or tightening that
comes with contractions, or feel pressure in her back.
○ Bright red bleeding
● Other signs and symptoms if the bleeding is too
much include anemia, pale skin, rapid and weak
pulse, shortness of breath, or low blood pressure.
Risk factors:
● A pregnant woman is more likely to get the
condition if she smokes cigarettes or uses cocaine
● 35 years old or older
● Has been diagnosed of placenta previa before
● Has been pregnant and has had a C-section before
● Has had other types of surgery on her uterus
● Currently pregnant with more than one baby
● A person who is African American or of another
nonwhite ethnic background
● Unusual position of the baby (breech or transverse)
● Prior miscarriage
● Large placenta
● Abnormally shaped uterus
Management and Treatment
There is no cure for placenta previa. However, the
doctors will decide how to treat your placenta previa
based on: the amount of bleeding, the month of your
pregnancy, the baby’s health, or the position of the
placenta and the baby.
Minimal to no bleeding
● For cases of placenta previa with minimal or no
bleeding, your doctor will likely suggest pelvic rest.
This means refraining from putting anything into
your vagina during pregnancy in order to prevent
medical complications. You’ll also be asked to avoid
sex and likely exercise as well. If bleeding occurs
during this time, you should seek medical care as
soon as possible.
Heavy bleeding
● In the case of heavy bleeding, your doctor will
advise scheduling a cesarean delivery as soon as it’s
safe to deliver — preferably after 36 weeks. If the C-
section needs to be scheduled sooner, your baby may
be given corticosteroid injections to speed up their
lung growth.
Uncontrollable bleeding
● In the case of uncontrolled bleeding, an emergency
cesarean delivery will have to be performed.
ADDITIONAL INFO:
Site of implantation of placenta is wrong
○ Implantation takes place on the lower part of uterus
(Normal: upper portion)
○ Causes bleeding
■ Bright red bleeding
○ Uterus is soft and non tender
○ FHR- when auscultated, it is normal
Doctors can perform double set up

● Client is in OR and can deliver via NSD but if the

client can’t delivery through NSD = CS

COMPLICATIONS

● Endometritis

○ Placenta is close to the cervix, the portal of entry

for pathogens

● Hemorrhage

○ Placenta does not contract effectively

● Congenital fetal anomaly

○ If it does not allow the optimal fetal nutrients and

oxygenation

ABRUPTIO PLACENTA
PRESENTING PART: PLACENTA ● The premature separation of the placenta from the
ACRONYM uterus

P Position is sidelying/trendelenburg, painless bright ● Abruptio placentae aka placental abruption

red bleeding PATHOPHYSIOLOGY
R Refrain from IE/rectal exam, relaxed uterus, soft ● Rupture of the maternal vessels within the basal
and non tender layer of the endometrium
E Encourage strict bedrest and oxygen as indicated, ● Blood accumulates and splits the placental
episodes of bleeding attachment from the basal layer
V v/s monitoring, FHT and movement, and fetal lung ● Detached portion of the placenta is unable to
maturity, visible bleeding function, leading to rapid fetal compromise
I IV line available and prepare for blood transfusion,
intercourse post bleeding
TYPES
A Assessment of blood loss and preventive measures,
abnormal fetal position ● Revealed

○ Bleeding tracks down from the site of placental

separation and drains through the cervix ○ This
results in vaginal bleeding

● Concealed

○ The bleeding remains within the uterus and

typically forms a clot retroplacentally. This bleeding
is not visible, but can be severe enough to cause
systemic shock
SIGNS AND SYMPTOMS
● Vaginal bleeding
● Abdominal pain ● Back pain ● Uterine tenderness
or rigidity ● Uterine contractions
TREATMENT
● Mild placental abruption at 24 to 34 weeks.
○ Patient may be given medications by the doctor to
try and speed up the baby’s lung development and
allow them to keep developing.
○ If bleeding seems to have stopped or slowed,
patient may be sent home.
● Mild placental abruption at 34 weeks or greater.
○ If near full-term, the doctor may induce labor or
perform a cesarean delivery. If your baby has had
time to develop, an earlier delivery can reduce the
risks for further complications.
● Moderate to severe placental abruption.
○ Usually requires immediate delivery, often by
cesarean
ADDITIONAL
● Placenta separates too early
○ 1st or second stage of labor
○ Causes bleeding
○ Placenta separates while baby is still in utero
● Baby can hardly breathe
○ FHR is none/ low because baby is in distress
● Bleeding is dark red and is painful at the upper
quadrant of uterus (stabbing pain)
● Abnormal separation of a normal placenta that
happens during 1st/ 2nd stage of labor
● Uterus is rigid/ hard because of the presence of
blood in the uterus giving way to a board- like uterus
● Uterus is tender (Placenta previa- visible bleeding;
Abruptio- accumulated in the uterus)
● Bleeding leads to increased blood loss, tachycardia,
pallor, hypotension and shock Premature separation
of placenta (grade of placental separation)
● Grade of placental separation is used to determine
if the baby is to be terminated or not
GRADE CRITERIA
0 No symptoms of separation
1 Minimal separation, not enough to
cause vaginal bleeding and
changes in maternal vital signs, no
fetal distress or hemorrhagic shock
occurs
2 Moderate separation; there is
evidence of fetal distress, the
uterus is tense and painful on
palpation
3 Extreme separation; without
immediate interventions, maternal
shock and fetal death will result
MANAGEMENT
● IVF
● Oxygen by mask
● Monitor FHT
● Record maternal v/s every 5-15mins
● Lateral position
● No abdominal, vaginal and pelvic exam
● If placental grade is 2-3, terminate the pregnancy E Extended fundal height

● CS- birth of choice T Tender uterus

● IV administration of fibrinogen A Abdominal pain/contraction

● hysterectomy C Concealed bleeding

H Hard uterus

PREDISPOSING FACTORS E Experience DIC

● High parity D Distressed baby

● Advanced maternal age

● Short umbilical cord Abruptio VS Previa

● Chronic hypertensive disease CHARACTERIC ABRUPTIO PREVIA

TIC
● PIH
ONSET 3RD 3RD
● Direct trauma BLEEDING Concealed, Mostly
external dark
external,
● Vasoconstriction from cocaine or thrombosis hemorrhage, small to
bloody amniotic
profuse in
fluid amount,
ACRONYM bright red
Pain and uterine Usually present, Usually
A Abruptio placenta is premature separation of the tenderness irritable uterus, absent,
placenta from the uterine wall characterized by progresses to uterus is
painful dark red, non-clotting vaginal bleeding, boardlike soft
abdominal pain and tenderness consistency
B Baseline fibrinogen (if bleeding is extensive, FHT May be irregular Usually
fibrinogen reserve may be used up in body’s attempt or absent normal
to accomplish effective clot formation
Presenting part May be Usually not
R Refrain from IE/rectal exam and enema engaged/baby engaged/
placenta
U Utilize oxygen therapy to limit fetal anoxia
Shock Moderate to Usually not
P Position: Lateral position severe depending present
on the extent of unless
T Total FHT and V/S monitoring concealed, bleeding is
I IV line should be open for possible Blood external excessive
transfusion hemorrhage
Delivery Immediate May be
O Observe for s/s of hypovolemic shock due to delivery, CS delayed
unseen bleeding depending
on the the
D Dark red bleeding
size of the
 fetus and ○ Obesity (with a BMI of more than 35 kg/m*2)
amount of
■ If an obese woman's vasculature is already
bleeding
inflamed, the placenta's additional oxidative burden
and an increase in the number of neutrophils during
pregnancy may cause vascular inflammation severe
enough to cause preeclampsia's clinical symptoms.

○ Maternal age of less than 20 years old or more than

40 years old

■ The risk of preeclampsia is higher for very young

pregnant women as well as pregnant women older
than 40.

○ Multiple pregnancy

■ These increased risk of preeclampsia who are

carrying twins, triplets or other multiple pregnancies
may be due to increased placental mass that leads to
increased circulating levels of soluble fms-like
tyrosine kinase-1 (sFlt1).

○ Molar pregnancy/ hydatidiform mole

■ is a rare complication of pregnancy characterized

PREGNANCY-INDUCED HYPERTENSION
(TOXEMIA)
● PIH or pregnancy-induced hypertension is
characterized by an increase in blood pressure (more
than 140/90 mmHg) due to pregnancy and this
happens after 20 weeks of gestation (2nd trimester),
which differentiates it from chronic hypertension,
which is already present even before pregnancy.
● Pregnancy induced hypertension is a major
contributor to maternal and perinatal morbidity and
mortality.
by the abnormal growth of trophoblasts, the cells that
normally develop into the placenta.
○ Underlying disease
■ This disease might contribute to the occurence of
pregnancy induced hypertension such as pre-existing
hypertension, kidney disease, diabetes.
● Hydramnios
○ Lower socioeconomic status
■ poorer health if households have limited access to
health resources and exhibit suboptimal health
behaviors

PREDISPOSING FACTORS/RISK FACTORS

TYPES
● Predisposing factors or the risk factors of PIH
includes the following: ● There are three types of Pregnancy- Induced
Hypertension
○ Previous history of PIH
○ Gestational hypertension
○ Being a primigravida
*Only occurs during pregnancy - Usually diagnosed by the onset of late decelerations
and decreased fetal heart rate and is associated with
■ Manifestations of G.H fetal hypoxemia that (may result in permanent fetal
● High blood pressure (140/90) brain damage and death), acidemia and has a high
perinatal mortality. In this case, delivery is often done
● No proteinuria in cesarean section.

● No signs of end organ damage ■ Low birthweight

○ Pre-eclampsia ■ And growth retardation Effects on the mother

includes:
■ Manifestations of Preeclampsia
■ First, ineffective platelet function which can lead to
● High blood pressure
thrombocytopenia
○ Mild: 140/90
- This occurs during the 3rd trimester and is most
○ Severe: 160/110 common in pregnant women with low platelet count.

● With proteinuria ■ And decreased blood volume which causes end

organ damage
○ Mild: (+1, +2)
. ● The following are signs of end organ damage
○ Severe: (+3, +4)
○ Uterine
● With signs of organ damage
■ Placental abruption
● Weight gain of 2 lbs per week during the 2nd
trimester - A complete separation of the inner wall of the
uterus and blocks the baby’s supply of oxygen that
● Thrombocytopenia can cause-
● Epigastric pain (related to decreased amt of blood ■ Heavy bleeding - Severe abruption can cause heavy
going to the pancreas) bleeding which can be life threatening for both of the
mother and the baby.
● Edema
○ Kidneys
○ Eclampsia
■ Increased creatinine which causes proteinuria and
■ High blood pressure
oliguria
■ With proteinuria
○ Brain
■ With signs of end organ damage
■ Eclampsia causes seizures
■ With seizures & coma
■ Visual symptoms: temporary blindness

■ Cerebral symptoms like confusion

EFFECTS
○ Lungs
Effects on the fetus includes the following:
■ Pulmonary edema
■ Fetal decompensation
■ Respiration problems
○ Liver ○ Doppler with 4 hr interval

■ Increased liver enzymes (2x the normal) ○ FHT ○ NST daily

○ Oxygen administration to mother

MANAGEMENT ● Support nutrition diet

MILD HPN ○ High CHON and moderate sodium

● Monitor antiplatelet therapy ○ IVF

● Promote bed rest- lateral recumbent position ● Administer medications to prevent eclampsia

○ Prevents supine hypotension syndrome ○ Hydralazine (apresoline)

● Promote good nutrition - give little sodium ○ Labetalol (normodyne)

● Provide emotional support ○ Nifedipine

SEVERE HPN ○ Magnesium SO1- drug of choice to prevent

eclampsia
● Support bed rest
■ Given first 1V for 15 min in blous dose
● Hospitalization
■ Anticonvulsant
○ No visitors
*Before administering MGSO4, check ff:
○ Private room
a. Urine output should be 25-30 ml/hr
○ Raise side rails to prevent injury
b. Specific gravity 1.010 or lower
○ Darken the room
c. RR should be above 12 bpm
○ No shining of flashlight into the woman’s eyes
d. Ankle clonus should be minimal
● Monitor maternal well-being
e. DTR (+) f. Calcium Gluconate - antidote for
○ BP MGSO4
○ Obtain blood studies ECLAMPSIA
○ Daily Hct monitoring ● Happens late in pregnancy up to 48 hours after
○ Frequent plasma estriol levels birth ● Tonic clonic seizure

○ Daily weights at the same time each day wearing
the same amount of clothing
○ Insert IFC /indwelling foley catheter/ (should be
600/24hours)
○ 24hr urine sample
○ Preliminary signals/ aura
■ All muscles contract
■ Back arches, her arms and leg stiffen, jaw closes,
RR stops, (because he thoracic muscles are held in
contraction)

● Monitor fetal well-being ■ Last 20 seconds

■ Cyanotic
○ During the 2nd clonic stage
■ Bladder and bowel contracts and relax
■ Incontinence of urine and feces
■ Begins to breathe but not entirely effective
■ Remain cyanotic
■ Last up to 1 min
NURSING CARE MANAGEMENT
ECLAMPSIA
● To maintain a patent airway
● Administer oxygen by face mask
○ To protect the fetus
● Turn woman to her side
○ To prevent aspiration and allow drainage
● Magnesium sulfate/diazepam (valium) via IV as an
emergency measure
● Assess oxygen saturation
● Apply external heart monitor
● Assess FHT and uterine contractions
● Check vaginal bleeding
● CS is more hazardous for the fetus
● Woman with eclampsia is NOT a good candidate or
surgery
● Vaginal - Preferred birth
● If labor does not begin spontaneously. ROM or
induce labor with oxytocin via IV
● If ineffective, CS is indicated because the fetus is
in danger
COMPLICATION
HELLP Syndrome
● Hemolysis
● elevated Liver enzymes
● Low Platelets Signs and Symptoms
● Proteinuria
● Edema ● Nausea ● Epigastric pain ● General
malaise RUQ
FOR
ACRONYM
P Primary concern is to reduce the cardiac workload
and strengthen the cardiac fxn
R Rest - bedrest (8-12 hours) which aids in the
excretion of Na
E Eat high in CHON and low Na diet
E Employ the use of MgSO4, drug of choice and
prevention of seizure
C Calcium gluconate as antidote for MgSO4 at
bedside
L Left lateral recumbent position to avoid uterine
pressure in the vena cava
A Administer O2 as needed M Monitor maternal V/S
BP, CHON level in the urine, LOC and FHT
P Protect from injury
S Seizure precaution - raise the side rails I IV open
A Assess the need to early induction of Labor and
delivery
NOTES

NATIONAL HEALTH SITUATION OF MCN

 Increase teen pregnancy -10 years old-

youngest mother
 Increase intimate partner violence- physical,
emotional, sexual abuse of wife and also
husband, sexual harrasment- daughter and
father and relatives
 Disrupted access to life-saving sexual and
reproductive health services

STATISTICS

 Unintended Pregnancy And Abortion Rates

  Pregnancy Outcomes -have gynecomastia that leads to breast cancer

GOALS Trisomy 13

 Partially met
 Focus is to address neonatal mortality
Diagnostic testing

Maternal serum screening

GENETICS ASSESSMENT AND COUNSELING
Amniocentesis- make sure the abdomen is clean with
 The doctor betadine, make sure not to puncture the fetus
 Genetic disorders- inherited

ASSESSMENT OF HIGH-RISK PREGNANCY

Fragile x syndrome Causes
-everything is long or large- long x chromosome  Risk of radiation
-common among males  Exposure to other chemodrugs
 Agriculturist (pesticide)
-Cognitive challenge  Smoking, drinking alcohol

Trisomy 18 syndrome/edward’s syndrome ASSESSMENT OF RISK FACTORS

-has less chance of survival in early infancy
-die within infancy
-small gestational age at birth but conguent
-congenital heart defects (atrial heart defect- club
fingers, cyanotic, difficulty breathing)
Demographic factors
 Maternal age (<18 0r >35 years)- the placenta
is implanted on lower portion of uterus
 Poverty
 Maternal oarity/multiparity (>4 pregnancies)-
their uterus is overly stretched, there is
already a failure of the uterus to contract

Personal-social factors
Turner syndrome

-common among females  Weight- >200 lbs: macrosomal babies

 Height
-increase neck folds means turner syndrome
Obstetric factors and gynecologic hx
-no production of egg cell that leads to sterility
 Babies are hyperglycemic inside the utero,
they tend to consume glucose which is gives
the growth hormone
Klinefelter syndrome
 Babies are hypoglycemic when delivered
-small nonfunctional sperm
  Stillbirth is beyond 20 weeks that happen  If woman is expose to haazardous
inside utero that causes maternal environment, it could lead to fetal death
psychological sitress
 Rh is blood compatibility- if Baby is Rh+,
their will be blood compatibility except the
first baby, the mother will release antibodies
that will kill the newborn PREGESTATIONAL CONDITIONS
-the mixture of the blood will only affect the
ANEMIA
second baby and also destroy the rbc
 More erhyoblastosis destroyed, more bilirubin IRON DEFICIENCY ANEMIA
 Cervical insuffiency means there is a
premature opening of cervix and this is  Iron deficiency anemia- small rbc, common
painless among adolescents because they eat junk
foods
 Multiple gestations- may present compound
presentation CAUSES OF IDA
Existing medical conditions/maternal medical history  Woman feels dizzy because of heavy
menstrual flow
 Dm- macrosomic babies, congenital
anomalies- codal regression syndrome means CLINICAL PRESENTATION
there is a problem on the development of
lower extremities  PICA
 Hypothyroidism
EFFECTS
 Cardiac disease- if mother has heart disease,
there will be vasous spasms and there will be  Low birth weight
decrease blood volume that could lead to fetal  Heart disease
death
-doctor needs to categorize it, type is still MANAGEMENT
okay for mother, type is okay but has
 Give iron supplements with vitamin c
limitations, type 3 is okay but mother should
be in complete bedrest, if type 4 the mother is
a poor candidate to be pregnant
 Renal disease FOLIC ACID DEFICIENCY ANEMIA

Signs and symptoms

Other  Problems in vitamin b12

 Concurrent infection- most commonis uti,

treat first uti to avoid abortion and congenital
 Megaloblastic anemia- big rbc
anomalies
 Seizure disorders- problems to movement and
coordination MANAGEMENT
 Liver disease
 Before pregnancy- 400 mcg of folic acid
Environmental agents  During pregnancy- 600 mcg of folic acid
SICKLE CELL ANEMIA  Youl will not be infected if you borrow the
glass of infected
 Crescent shape
 If the mothre has hiv, there is high risk to
 Carries little amount of rbc, oxygen, baby
hemoglobin
 As the virus invade wbc, they start to multiply
 Blood becomes Viscid means sickles tend to that takes for how many years with still no
clamp together and they block the blood symptoms but the virus is working, cd4 level
vessels is from 15000 to 500 or 100. Client is at risk
 It can be inherited for opportunistic infection (fungal, bactreria,
Symptoms virus)

 Fatigue
 Sob DIAGNOSTIC TEST

 ELISA test
-detect antibodies
MANAGEMENT
-antibodies are made by protein to detect
 Does not need iron supplements because their  WESTERN BLOT ANALYSIS
will be iron build up
 Blood transfusion is needed as management
MODE OF TRANSMISSION

 Exposure, sharing, transfusion, breastfeeding

Symptoms- seen in 3-6 months

 Beta chain is the one affected

EFFECTS OF HIV TO PREGNANCY

 If mother is hiv positive, there is high risk of

baby developing it
HIV

ASSESSMENT
ISSUES TO BE ADDRESSED WHEN HIV+
Early
 Safer sex practices
 Common illness that cant tell if you have hiv  Testing of sexual contacts
 Continuations or termination of pregnancy
STAGES OF HIV

 Virus likes to invade wbc, when uit invades

cd4, virus tends to increase with 5000 copies, THERAPEUTIC MANAGEMENT
Normal cd4 500-15000 cubic mm, there is
decrease level of platelet that lead to bleeding  When hiv +, avoid pregnancy because it
 Is mother is hiv- but father is hiv+, it depends harms fetus
if the father is taking medications, there will  Medications
no risk that the wife will be having hiv, but if
not taking, there is a high risk for the women
GESTATIONAL CONDITIONS  Congenital fetal anomaly-placenta cannot
support baby because of decrease blood
PLACENTA PREVIA
supply and nutrients

 Uterus should be at the upper segment Management

 Problem in attachment
 Complete placenta previa- totally covered, CS  Bed rest for 3 days in side-lying to allow good
delivery perfusion in uterus
 Partial- half is covered, depends the size of  Ask the following
baby, big baby- cs, normal size-nsd -duration of preg.
 Marginal- near the cervical os, nsd -time of bleeding
 Low-lying- approaching the cervical os, nsd -estimated amount of blood
 Less 30%- nsd, more than 30%- cs -pain- identify what kind of previa, painful-
abruptio
-Color of the blood- pink, peach, dark red,
brown, bright red
Predisposing factors
-what she had done for the bleeding
 Increased parity/number of deliveries  Inspect perineum
 Advanced maternal age- >35 -kleihauer betke test
 Past cs- presence of scar  No pelvic/rectal exam/enema because it leads
 Uterine massage to bleeding
 Multiple gestation-displacement of placenta  Obtain vs and fht
 Male fetus  Ivf- replace fluid loss, needle is gauge 18
because the mother will have blood
transfusion
 Monitor urine output every hour to know
Assessment
volume and adequcy
 Painless bright red bleeding related to tearing  Assess hgb,hct,prothrombin time, fibrinogen,
 Relax uterus platelet
 Placenta is presenting part  Determine the placental location tru utz-
 No engagement under 30%- be born, over 30%- cs
 Abnormal presentation- breech, transverse  Double set-up- try first nsd but if unsuccessful
 Fhr is normal they will do cs
 In lower segment of uterus- there is less blood  Betamethasone- lung maturation, given to
supply that cannot support the placenta and mother less than 34 weeks, 12-12.5 mg IM, 24
placenta cannot support baby hours before birth
 Avoid coitus
 have adequate rest
 Call hcp
Complications

 Endometritis
 Hemorrhage- bleeding is mild to moderate P- position, side lying/trendelenburg- good perfusion
in uterus, painless bright red bleeding
r- no pelvic exam, no ie, relaxed uterus
E- strict bedrest and oxygen which is given via
facemask with 10 for mother
v- vs monitoring, fht and movement, and fetal lung
maturity, visible bleeding
i-iv line available and prepare or blood transfusion
a-Asessment of blood loss
 heavy bleeding- concealed hemorrhage,
accumulates inside the uterus
 dark red bleeding- making uterus tender , hard
 rigid and tense uterus- hard
 abnormal rigidity- couvelaire, board like
uterus or abdomen, painful
 hard, boardlike uterus
 hypotension, tachycardia, pallor
 dic- problem in clotting factor
 low fibrinogen, low platelet

p-painless, brigh red bleeding

management
r-relaxed, soft , non tender uterus
e-episodes of bleeding to avoid hypovolemia
v-visible bleeding
i-intercourse post bleeding
a-abnormal presentation
ABRUPTIO PLACENTA
-problem in detachment
-uterus is at fundus
Predisposing factors
 High parity
 Short umbilical cord- when the baby moves, it
tends to pull the placenta, the placenta then
detach, normal cord length- 50 cm
 Advanced maternal age- >35
 Chonic hypertensive disease- vasoconstriction
of blood vessels that decreases blood to the
placenta to the baby, placenta contracts and
separates, also smoking illegal drugs
 Pih
 ivf- large needle
 oxygen by mask- 10 liters
 monitor fht- when placenta detach, blood
covers baby causing distress, irreg or absent
fht
 record maternal vs every 5- 15 mins- esp. bp
 lateral position
 no abdominal plapation, pelvic and vaginal
exam, and enema
 if placental grade is 2-3, terminate the
pregnancy- because placental becomes
ineffective to baby
 cs- birth of choice
 iv administration of fibrinogen to prevent
bleeding, this is for clot formation
 hysterectomy- removing of uterus
A- painful dark red
B- baseline fibrinogen through iv
r- no ie
u- utilize oxygen to limit anoxia

p-position:lateral/side lying
Assessment t- total fht

 Bloody amniotic fluid i-iv line

 Sharp stabbing pain is at the upper quadrant of
uterus o-observe for signs of hypovolemic shock
 uterine tenderness
 -elevated bp- 140/90 mmhg
-+1+2 proteinuria
d- dark red bleeding -Weight gain 2 lb in 2nd tri and 1 lb/wk in 3 rd
e-extended/big fundal height due to accumulation tri (normal weight gain- 3, 12, 12- 1 pound
of blood per month in 1st tri, increase of 1 pnd per week
in 2nd and 3rd tri)
t-tender uterus because of accumulation -mild edema in upper extremities or face,
hands, puffy eyelids
a-abdominal pain
b. sever preeclampsia
c-concealed bleeding -bp of 160/110
-+3+4 proteinuria
h-hard uterus -oliguria (Normal volume of urine- 600 ml)
-elevated serum creatinine (normal serum
e-experience dic
creatinine level is 0.6-1.1 mg/dl)
d-dic -cerebal or visual disturbance
-pulmonary movement
-sob
-edema, Ankle clonus- to know, dorsiflex the
foot
PREGNANCY-INDUCED HYPERTENSION -hepatic dysfunction- problem in liver
(PIH) -decrease level of platelet or
thrombocytopenia
Predisposing factors
-right upper quadrant pain/ epigastric pain
 hydramnios- excessive amniotic fluid related -liver, lungs, kidneys, heart, hands, face
to diabetes

ASSESSMENT
 eclampsia-nsd because of effect of anaesthesia
 hypertension -seizure or coma accompanied by sighs and
 proteinuria- protein in urine symptoms of preeclampsia
 edema
 vision changes- blurred
 weight gain -preeclampsia is rooted from placental problems

-thropoblast – it tries to attack itself in lining to

attach in uterus
CLASSIFICATIONS
-inside uterus, there are spiral arteries in uterus
 gestational hpn which increase in diameter to allow increase in
-observed in pregnancy blood volume
-elevated bp – 140/90 mmhg
-disappears after delivery -in preeclampsia, the spiral arteries in uterus
-no presence of protein in urine and no edema narrows which decreases the blood volume going
-develop after 20 weeks to placenta which cause ischemia which then
damage the placenta
 preeclampsia -if placenta is damaged, it will release a
a. mild preeclampsia substance(toxins) that will be added to the
maternal circulation and that will try to affect the -bed rest
endothelial cells of the different organs of the -hospitalization
body. -30 ml of urine per hour
-give 8-10 liters of oxygen
-if the endothelia cells has been damaged, there
will be decrease tone or elesticity or ability to
expand of these that would cause vasospasm that
could lead to hypertension.

-aside from the tone, it also tries to affect the H- hemolysis- destruction of platelets
permeability of organs like kidneys, there will be e-elevated liver enzymes
increase permeability that could make escape of
protein which then adds to urine then later l-low platelets
becomes proteinuria, proteinuria (means problem
in kidneys)

-if the fluid escape in interstitial fluid or shift In

fluid, this could lead to edema of upper
extremities, pitting edema in lower extremities,
fluid may penetrate the brain which lead to edema
of brain that affect neurofunction(headache,
confusion, ankle clonus), may also affect eyes
(blurred vision)

-if endo cells has been the damaged, it could

affects the liver, which make the client experience
epigastric pain, this could also elevate enzyme, and
hepatic dysfunction

-the platelets needs to do something to help endo

cells wherein they cluster that lowers the level of
platelet, they also undergo hemolysis, patients also
experience bleeding because of low platelet level

-patient is also risk for abruptio placenta

-if this is not managed, it will lead to hellp

syndrome

MANAGEMENT

 mild hpn
-antiplatelet therapy- low dose of aspirin 50 QUIZ 1
mg
-bed rest- side lying
-good nutrition- high protein, low sodium
-emotional support
 severe hpn
1. Hyperemesis gravidarum is a nausea and
vomiting during pregnancy. Which of the
following is NOT true about hyperemesis
gravidarum
● Prolonged nausea and vomiting past week 12
of pregnancy
2. In assessing a client suffering from hyperemesis
gravidarum, the following laboratory examination
results are included EXCEPT
● increase glucose.
3. The nurse knowing the nursing management of
hyperemesis gravidarum should include in her
plan
● administer IVF
● record intake and output
● antiemetics as prescribed
4. Hyperemesis gravidarum is a complication of
pregnancy because it most often leads to which of
the following?
● Dehydration
5. Which can be given to hyperemesis gravidarum
to relive the signs and symptoms?
● Have the patient eat crackers before rising
from the bed in the morning
6. Which of the following nursing diagnoses would
be given priority in the care plan of a pregnant
woman who is experiencing hyperemesis
gravidarum?
● Fluid volume deficit
7. Nurse Kim is assigned at the prenatal clinic.
Which of the following findings at 10 weeks
suggest an H-Mole?
● Fundic height of 18 cm
8. Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated
with this condition?
● Excessive fetal activity.
9. At 16 weeks gestation, no fetal heart rate was
detected during assessment of a pregnant patient.
An ultrasound confirmed a hydatidiform molar
pregnancy. Which of the action should the nurse
tell, the patient to expect during her one year
follow-up?
● Multiple serum chorionic gonadotrophin
levels will be drawn
10. Which of the following findings might be noted
in a client with a hydatidiform mole?
● Marked nausea and vomiting noted in early
pregnancy
11. Trixie, 37 years old and 26 weeks pregnant is
admitted for evacuation of hydatidiform mole.
Which the following signs and symptoms will you
NOT consider in H-mole?
● FHT at 110 bpm
12. The diagnostic technique of choice for
determining the presence of H-mole is
● ultrasonography.
13. When asked about the cause of H-mole, the
nurse's answer should reflect an understanding
that the exact cause is
● low protein diet.
14. The assessment findings for a client with an
incompetent cervix should contain which of the
following?
● History of repeated, spontaneous second
trimester termination of pregnancy
15. The obstetrician gave another order to have a
Mc Donald procedure done. When asked about
the
purpose of the procedure, the nurse answers
correctly by explaining that this procedure is to
dilate the cervix to
● reinforce the incompetent cervix temporarily.
16. Suppose Chiona develop H-Mole and
undergoes extraction, which of the following
should the nurse include in her health teachings?
● the importance of follow-up care (chest x-ray
and pelvic exam) to detect metastasis due to
high risk for choriocarcinoma
17. The doctor diagnosed Mayumi as having
unruptured ectopic pregnancy. Which medical
intervention below is used to induce abortion in
unruptured ectopic pregnancy?
● methotrexate administration
18. if there is bleeding and the cervix is close, this
is known as
● threatened abortion
19. Hyperemesis gravidarum is a nausea and
vomiting during pregnancy. Which of the
following is NOT true about hyperemesis
gravidarum?
● Prolonged nausea and vomiting past week 12
of pregnancy
20. Which of the following signs will distinguish
threatened abortion from imminent abortion?
● dilation of the cervix
21. The patient asks the nurse when she can get
pregnant again after suction and evacuation of her
complete hydatidiform mole, The nurse should
advise the patient not to get pregnant for at least
● 12 months
22. Which of the following signs and symptoms will
most likely make the nurse suspect that the patient is
having hydatidiform mole? Select all that apply
● Slight bleeding
● Absence of fetal heart beat
● Enlargement of the uterus
23. Guerly, amenorrheic for two months is
diagnosed to have ruptured ectopic pregnancy.
Which of the following are signs and symptoms of
ectopic pregnancy? Select all that apply
● shoulder pain
● cullen's sign
● amenorrhea
24. A physician ordered culdocentesis for Lanie
with suspected ruptured tubal pregnancy. Which
of
this preparations are appropriate? SElect all that
apply
● Check if there is an informed consent
● Prepare sterile gloves, vaginal speculum,
lubricant and floor lamp
25. The assessment findings for a client with an
incompetent cervix should contain which of the
following?
● History of repeated, spontaneous second
trimester termination of pregnancy
26. When a woman confirmed to be 12 weeks
gestation has sudden vaginal bleeding and uterine
cramps, she would be suspected to be experiencing
● abortion
27. These are drugs that are used to halt uterine
contractions. Answer should be in small letters
● tocolytic drugs
28. Which of the following statements are true
regarding incompetent cervix? select all that apply
● painless cervical dilatation
● with acoompanied uterine contraction
● increase pelvic pressure
29. Meaning of SFF ( answer in small letters)
● small frequent feeding
30. The following are causes of abortion EXCEPT
● ovary fails to produce estrogen
QUIZ 2
1. Arheumatic heart disease is a beta hemolytic
streptcoccal infection which particularly involves
the
● valves
2. When assessing a pregnant woman's risk fr
complications, which of the following would lead
the nurse to suspect that the woman is considered
high risk? Select all that apply
● history of intimate partner abuse
● previous pregnancy with twins
● two previous miscarriages
3. Angelique Abaga is 22 years old who developed
deep vein thrombosis during her stay in the
hospital. On bed rest and is prescribed low
molecular weight heparin subcutaneous. What
education will she need in relation to this?
● heparin does not cross the placenta and she
does not affect the fetus
4. During an assessment of Angela Parong, a
perinatal client with a history of left-sided heart
failure. Nurse Acosta notes that Angela Parong is
experiencing unusual episodes of non-productive
cough on minimal exertion. Nurse Acosta
interprets that this finding may be the first initial
indicator of which important cardiac problem?
● pulmonary edema
5. As oxygen saturation of Lailanie decreases,
chemoreceptors stimulate the respiratory center to
● increase respiratory rate
6. When planning care for a pregnant woman with
heart disease, the nurse should do which of the
following?
● Assess complaints of fatigue and note as
desired to promote maximum fetal and
maternal nutrition
7. Almost all women are screened for gestational
diabetes by a 50 gram glucose challenge test. For
this test, you would instruct a woman that
● if serum glucse is above 140 mg/dl, more
testing will be required.
8. Anurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes. Which statement if made by
the client indicates for further education?
● I need to avoid exercise because negative
effects on insulin production.
9. Which statement is INCORRECT regarding the
oral glucose challenge test on mothers being
screened for gestational diabetes
● If two or more blood samples collected for
fasting glucose are above 120mg/dl, a
diagnosis of diabetes is made
10. Marie is suffering from cardiovascular disease
and therefore needs a team approach during
pregnancy. She should visit her obstetrician before
conception so her health care team can be familiar
with her health state and evaluate her heart
function. A pregnant client with cardiac
classification II is
● a woman who has moderate to marked
limitation of physical activity. her less than
ordinary activities are enough for her to
experience excessive fatigue, palpitation and
dyspnea.
11. Patricia's cousin develops diabetes during
pregnancy. What are the possible complications?
SElect all that apply
● hydramnios
● LGA
● hyperbilirubinemia
● difficult labor
● congenital anomalies
12. absence of lower extremities for the baby as a
result of having diabetic mother. This refers to
● caudal regression syndrome
13. THis is a test that is being done on the 4th-6th
week of pregnancy detecting hyperglycemia
● glycosylated hemoglobin
14. What are the signs and symptoms of left sided
heart disease EXCEPT. Select all that apply
● peripheral edema
● jugular distention
15. if polyuria is for excessive urination what
about for excessive thirst?
- polydipsia
16. The normal fasting blood glucose per mg/dl is
just indicate the whole number
- 95
17. After an Rh(-) mother has delivered her Rh (+)
baby, the mother is given Rhogam. This is done in
order to
● Prevent the mother from producing antibodies
against the Rh (+) antigen that she may have
gotten when she delivered to her Rh(+) baby.
18. Because of a rapidly rising bilirubin level,
exchange transfusion was performed on the
newborn.
The nurse understands that the blood to be
transfused to the newborn should be
● type O, Rh negative
19. Anurse provides instructions to a
malnourished client regarding iron
supplementation during pregnancy. Which
statement when made by the client would indicate
an understanding of the instructions?
● The iron is best taken on full stomach
20. Marina with sickle cell anemia has an
increased risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle cell
crisis includes which of the following measures?
Select all that apply
● hospitalization
● Intravenous fluids
● Blood transfusion
21. Clients with megaloblastic anemia should be
encouraged to do which of the following?
● Take the prescribed folic acid supplements
22. Rh (D) immune globulin is being given when?
select all that apply
● 28th weeks gestation
● 40 weeks gestation
● within 72 hours after delivery
23. When are most pregnant patients tested for
gestational diabetes?
● 24-28 weeks gestation
24. A client is said to be Rh sensitized if select all
that apply
⁃ history of miscarriage
⁃ had a history of Rh (-)
⁃ baby had ectopic pregnancy
⁃ had amniocentesis
25. The student nurse was asked to enumerate the s / s
of left sided heart failure. She's correct if
⁃ pulmonary edema
⁃ weight gain
⁃ cough
26. Teresa is in her fourth month of pregnancy and
confides to the nurse that she is addicted to heroin
and uses prostitution to afford her habit. Which
response would be most appropriate
⁃ Plan to include tests for sexually transmitted
diseases in Teresa's future prenatal visit.
27. When planning care for a pregnant woman with
heart disease, the nurse should do which of the
following?
⁃ Assess complaints of tatique and note as desired to
promote maximum tetal and maternal nutrition
28. The nurse is teaching a community women's
group about the effects of drug use on pregnancy.
Which of the following would the nurse include as
possible effects of heroin use?Select all that apply.
⁃ fetal opiate dependence
⁃ Pregnancy induced hypertension
⁃ hepatitis B
29. A patient with HIV is 6 weeks pregnant. What
would you educate the patient about?
⁃ How breast feeding will help the newborn after
birth.
30. Rh isoimmunization in a pregnant client develops
during which of the following conditions?
⁃ Rh-positive fetal blood crosses into mat blood
stimulating maternal antibodies
QUIZ 3
1. In conducting history taking of couple for genetic
counselling the following data are needed, select all
that apply
⁃ Relationship of the couple by blood
⁃ environmental exposures
⁃ prenatal history
2. A diagnostic test that is used to determine presence
of neural tube defects
⁃ maternal serum alphafetoprotein test
3. This refers to the actual gene composition
( answers must be in small letters)
⁃ genotype
4. What do you need to observe to a child diagnosed
with Trisomy 18 syndrome. Select all that apply
⁃ small head
⁃ low set of ears
5. A condition that usually affects boys/males in
which they do not have secondary sex characteristics,
small testes and risk for breast cancer is called
⁃ Klinefelter syndrome
6. In conducting genetic assessment, we need to be
guided by the following EXCEPT. Select all that
apply
⁃ the people who are affected by inherited disorder
allows the nurse to decide about their future
reproduction and medical management
⁃ offer financial support to those who are affected by
genetic disorder
7. Turner syndrome has a code of
⁃ 45X0
8. If genome refers to the complete set of genes
present, genotype refers to the outward appearance of
the expression of genes
⁃ False
9. What are common among trisomy syndromes,
select all that apply
⁃ Low set ears
⁃ cognitively challenge
10. The importance of genetic counselling are as
follows, select all that apply
⁃ aid in dtermining the risk of disease
⁃ help in identifying a hereditary condition
⁃ assist in whether genetic testing is appropriate
⁃ offer diagnosis and disease prevention and
management
11. This is a disorder in which the child exhibit a rag
doll appearance, with brushfield spots, large tongue
and with small mouth cavity. This
⁃ trisomy 21
12. A diagnostic procedure wherein a sample of
peripheral venous blood or a scraping of cells from
the bucca membrane is taken Answer should be in
small letters
⁃ karyotyping
13. Trisomy 13 is also known as patau syndrome.
What are the characteristics of this disorder. Select all
that apply
⁃ cleft lip and palate
⁃ small eyes
⁃ most do not survive beyond early childhood
14. The following characteristics are TRUE about
Turner's syndrome, select all that apply
⁃ it has a code of 45X0
⁃ low set hairline
⁃ webbed neck

15. Assessment is very important to determine if the

couple are at risk to have a child with genetic
disorder. What are the things to be noted or recorded
by the nurse during assessment? Select all that apply
⁃ age of the father ( >55 years old)
⁃ relationship of the couple by blood
⁃ ethnic background
⁃ prenatal history

QUIZ 4

1. The following are signs and symptoms of placenta

previa. Select all that apply
⁃ Bright red vaginal bleeding
⁃ Soft, relaxed nontender uterus
2. A woman, who is 22 weeks pregnant, has a routine
ultrasound performed. The ultrasound shows that the
placenta is located at the edge of the cervical opening.
As the nurse you know that which statement is
FALSE about this finding:
⁃ The patient will need to have a c-section and cannot
deliver vaginally

3. Your patient who is 34 weeks pregnant is
diagnosed with total placenta previa. The patient is A
positive. What nursing interventions below will you
include in the patient's care? Select all that apply
⁃ Monitoring vital signs
⁃ Placing patient on side-lying position
8. For the nurse to distinguish that the bleeding of the
patient is placenta previa or abruption placenta what
should she ask the woman.
9. The client has been diagnosed of abruption
placenta.

4. A 28 year old female, who is 33 weeks pregnant

with her second child, has uncontrolled hypertension.
What risk factor below found in the patient's health
history places her at risk for
abruptio placentae?
⁃ preeclampisa

5. A 36 years old woman, who is 38 weeks pregnant,

reports having dark red bleeding.
10. A type of uterus resulted from the accumulation
of blood in the uterus making it rigid or hard…

Answer: COUVELAIRE UTERUS

11. Situation: Cara a 24 years old primigravida in her

third trimester is admitted for vaginal bleeding and
several pain.

6. Tyra experienced painless vaginal bleeding has just 12. While observing Cara’s signs and symptoms. the
been diagnosed as having a placenta previa. nurse understand that abruption placenta is.

7. In taking care of patient with placenta previa, the

health personnel should do the following EXCEPT.
13. The etiology of abruption placenta is usually
unknown.

14. Other pertinent signs and symptoms of abruption

placenta are the following Except.

19.You’re performing a head-to-toe assessment on a

patient admitted with abruptio placenta.

20. Which statement is TRUE regarding abruptio

15. Abruptio placenta may result on shock placenta?
16. All of the following are signs of placenta previa
except.

17. Nurse Lenie is assessing a pregnant client in the

second trimester of pregnancy who was admitted to
the maternity unit with suspected diagnosis of
abruption placenta.
21. The nurse knowns that preeclampsia tends to
18. Select the patient below who are at risk for occur during what time in pregnancy?
developing placenta previa.
22. You’re providing an in-service to a group of new
labor and delivery nurse graduates about the
pathophysiology of preeclampsia.
 28. Mrs. Flores was admitted because of PROM.

23. Select all the rish factor below that increase a

woman’s risk for developing preeclampsia

29. Mrs.Del Rosario has premature rupture of

membranes at 2cm dilation.

30.Mrs. Celeste, a multigravida client at 24 weeks

gestation is admitted to the hospital due to early
rupture of membrane.
24.Your patient with preeclampsia is started on
Magnesium sulfate.

25. A 39 week pregnant patient is in labor.

26. In patient with preeclampsia, what signs and

symtomps indicate that the patient has a high risk of
experiencing a seizure due to centrak nervous
system…

27. A 37 weeks pregnant patient is admitted with a

severe preeclampsia.