NCM 109 REVIEWER
woman is pregnant; detectable in the blood or urine 1 to 2
A. Bleeding Disorder During the First
Trimester of Pregnancy
1.Abortion
Is a medical term for any interruption of a pregnancy before a
fetus is viable (able to survive outside the uterus if born at
that time)
termination of pregnancy before the age of viability (20
weeks or 5 mos)
a procedure, either surgical or medical, to end a pregnancy
by removing the fetus and placenta from the uterus
A viable fetus is usually defined as a fetus of more than 20
to 24 weeks of gestation or one that weighs at least 500
grams
A fetus born before this point is considered a miscarriage or
is termed as premature or immature birth
Types:
a. Spontaneous Abortion – termination of pregnancy after
the age of viability
> A miscarriage is an early miscarriage if it occurs before
week 16 of pregnancy and a late miscarriage if it occurs
before weeks 16 and 20
> For the first 6 weeks (between 1st to 2nd month) of
pregnancy, the developing placenta is tentatively attached to
the decidua of
the uterus.
During weeks 6 to 12 (2nd to 3rd month) of
pregnancy, the placenta is moderately attached
After week 12, the attachment is penetrating and deep
Bleeding before week 6 is rarely severe
Bleeding after week 12 can be profuse because the placenta
is implanted so deeply.
Signs and symptoms:
> Low back pain or abdominal pain that is dull, sharp, or
cramping
> Vaginal bleeding, with or without abdominal cramps
> Tissue or clot – like material that passes from the vagina
COMMON CAUSES
1. Abnormal fetal development due either to teratogenic
factor (Any agent that can disturb the development of an
embryo or fetus.) or chromosomal aberration (changes
in chromosome number:gains or losses)
2.mmunologic factors
3.Implantation abnormalities
4.Failure of the corpus luteum on the ovary to produce
enough progesterone to maintain the decidua basalis
5. Ingestion of alcoholic beverages during pregnancy
6. Urinary tract infection
7. Systemic infections such as rubella, syphylis, poliomyelitis,
cytomegalovirus and toxoplasmosis
Signs and Test
1. Pelvic Exam – thinning of cervix (effacement)
* Increased cervical dilatation
* Evidence of rupture membranes
2. HCG – (qualitative and quantitative urine and blood) –
urine HCG test is a common method of determining if a
days after implantation of the fertilized egg ( that is 10 days
after ovulation)
Normal Values: Qualitative Urine and Blood
> the test is negative if client is not pregnant
> the test is positive if client is pregnant
Treatment and Management
> Tissue passed from the vagina should be examined to
determine the source (fetal V/S H-Mole)
> If remaining tissues are present – surgery or D & C
Classification Of Spontaneous Abortion:
a.1. Threatened Abortion – pregnancy is jeopardized by
bleeding and cramping but the cervix is closed
Signs and Symptoms
> Vaginal bleeding during the first 20 weeks of pregnancy
> Abdominal cramps may or may not accompany vaginal
bleeding
Treatment/Management
> Complete Bed Rest (CBR) or pelvic rest for 24 to 48 hours-
key intervention
> Abstaining from intercourse
> Avoid douching
> Avoid using tampons
2. Imminent/ Inevitable Abortion
– moderate bleeding, cramping, tissue protrudes from the
cervix (cervical dilatation)
Signs and Symptoms
> low back pain or abdominal pain that is dull,
sharp, or cramping
> vaginal bleeding, with or without abdominal
cramps
> tissue or clot – like material that passes from the
vagina
TYPES
A.2.1.Complete Abortion – all products of conception are
expelled
A.2.2. Incomplete Abortion – placenta and membranes are
retained
Complication:
> Infection-may also occur after a complete abortion
* Escherrichia coli- organism responsible after miscarriage
>spread from the rectum forward into the vagina
*Group A streptococcus
Management:
> For complete abortion – emotional support
for incomplete abortion – D & C – dilating the cervix and
scraping the lining of the uterus with an instrument called a
curette
b. Habitual Abortion – three or more consecutive pregnancies
result in abortion usually related to incompetent cervix
Other Possible Causes:
> Defective spermatozoa
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Test to detect the cause: >Low blood pressure
1.X-ray or ultrasound of the uterus >Low body temperature
2. Transvaginal ultrasound >Little or no urine output
3.Blood test: >Troubled breathing
>Thrombophilia and thyroid function test Causes of Septic Abortion:
>Karyogram > The membranes surrounding the fetus have ruptured
>CBC to determine the degree of blood loss sometimes without detected
>WBC and differential to rule out infection >STD
Management: >IUD left in place during pregnancy
> Surgery for Habitual Abortion, if the cause is incompetent >Tissue from the fetus or placenta is left inside the uterus
cervix after a miscarriage or abortion
Temporary >Attempts were made to end the pregnancy, often illegally,
> McDonald Procedure by inserting tools, chemicals, or soaps into the uterus
> Temporary Circlage Long Term effects : Infertility Treatment: D & C
> Delivery: Normal Delivery Risks: Death of the fetus
Permanent
> Shirodkar procedure 1. Septicemia – is the presence of bacteria in the blood
> Delivery: C/S (bacteremia) and is often associated with severe disease.
Causes: Septicemia is a serious, life-threatening infection that
Nursing Management: get worse very quickly. It can arise from infections
throughout the body, including infections in the lungs,
>Check for signs of infection abdomen, and urinary tract
>Check for signs of labor Septicemia can rapidly lead to septic shock and death.
>Check for normal bleeding Septicemia associated with some organisms (germs) such as
meningogococci can lead to shock, adrenal collapse, and
c. Missed abortion disseminated intravascular coagulopathy, a condition called
– fetus dies; product of conception remain in uterus 4 weeks Waterhouse-Friderichsen syndrome
or longer; signs of pregnancy cease Signs and Symptoms:
Signs and Symptoms >Fever (sudden onset, often spiking)
>Scanty dark bleeding >Chills
>Negative pregnancy test >Toxic looking (looks acutely ill)
Management >Changes in mental state
>Induced labor – oxytocin/vaginal suppositories with >Irritable
prostaglandin hormone >Lethargic
>Vacuum extraction >Anxious
>Agitated
Infected/Septic Abortion >Unresponsive
– abortion associated with an infection inside a pregnant >comatose
woman’s uterus. Test that can confirm infection:
>Abortion may be spontaneous, which is referred to as >Blood culture
miscarriage. >Urine culture
>May also be an elective surgical or medical abortion, >CSF culture
meaning, the woman chose to terminate her pregnancy. >CBC
>Platelet count
Pathophysiology: A septic abortion can occur when bacteria >Clotting studies – Pt, PTT, fibrinogen levels
enter the uterus through the mucus plug. These bacteria can Complications:
be introduced by unclean tools used during an elective >Irreversible shock
abortion. The bacteria may also be those that normally live >Waterhouse-Friderichesen syndrome
in a woman’s vagina. If the woman has a sexually transmitted >Adult respiratory distress syndrome (ARDS)
disease (STD) such as chlamydia, the bacteria causing the STD Ectopic Pregnancy
can infect the uterus. If the infection reaches the > occurs when gestation is located outside the uterine
bloodstream, it is called sepsis cavity/tubal pregnancies
Signs and Symptoms: Causes:
>High fever, usually above 101 F >Fallopian tube damage often from infection-can block the
>Chills fertilized egg’s path to the uterus causing it to implant and
>Severe abdominal pain or cramping grow in the tube
>Prolonged or heavy vaginal bleeding >Surgery
>Foul-smelling vaginal discharge >Endometriosis
>backache >Smoking
If condition becomes serious, signs of shock may appear: >Previous ectopic pregnancy
These include: >Pelvic infection – chlamydia or gonorrhea
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>Fertility drugs that increase egg production
>Pelvic or abdominal surgery
Risks:
B. BLEEDING DISORDER DURING THE
>Can damage the fallopian tube SECOND TRIMESTER OF BLEEDING
Signs and Symptoms:
1. Hydatidiform Mole ( H-Mole)-
Normal signs of pregnancy - an abnormal proliferation and degeneration of the
Pain- first red flag sign trophoblastic villi
>Molar pregnancy
Other Signs and Symptoms: >Gestational Trophoblastic Disease
Vaginal spotting or bleeding >Bunch of Grapes
Dizziness or fainting (caused by blood loss) >Hydatid – means drop of water; mole – means spot
Low blood pressure (caused by blood loss) Types:
Lower back pain a.Partial Molar – pregnancy that includes an abnormal
embryo (a fertilized egg that has begun to grow) but does not
Unruptured Tubal Ruptured survive
>missed period >sudden sharp severe pain b.Complete Molar –pregnancy in which there is small cluster
> abdominal pain within >shoulder pain (indicative of clear blisters or pouches that don’t contain an embryo
3-5 weeks of intraperitoneal bleeding that Drug of choice: Methotrexate
> scant, dark brown extends to diaphragm and vaginal
> vague discomfort > + Cullen’s sign – bluish tinged Etiology: Unknown
Diagnostic Test:
>Urine pregnancy test Other Causes:
> If (+) pregnancy test – quantitative HCG test >Problems with the chromosome
>Pelvic exam >Problem with the nutrition – low protein intake
>Ultrasound >Problem with the ovaries and uterus
>Culdocentesis >Mole sometimes can develop from a placental tissue that is
Treatment: left behind in the uterus after a miscarriage or childbirth
>Vary depending on its size and location
>Injection of methotrexate Signs and Symptoms
>Surgery >(+) pregnancy test
>Laparoscopy >Symptoms for the first 3-4 months
>Uterus grow abnormally fast
Future Pregnancies: >End of 3rd month-woman will experience vaginal bleeding
ranging from scant spotting to excessive bleeding
>30% who have had ectopic pregnancy will have difficulty >Presence of hyperthyroidism (overproduction of thyroid
becoming pregnant again hormone) leads to:
>If the fallopian tube has been spared, the chances of a >Weight loss
future successful pregnancy are 60%. Even if one fallopian >Increase appetite
tube has been removed, the chances of having a successful >Intolerance to heat
pregnancy with the other tube can be greater than 40%.
Early Signs:
High Risk Women: >Vesicles passed thru the vagina
>Age – 35 and 44 y/o >Hyperemesis gravidarum
>With PID – Pelvic Inflammatory Disease >Fundal height – rapidly increases
>Previous Ectopic Pregnancy >Vaginal bleeding (scant or profuse)
>Surgery on fallopian tube > Pre-eclampsia at about 12 weeks
>Infertility problems or medication to stimulate ovulation
Nursing Care: Serious Late Complications
>Vital Signs >Hyperthyroidism
>Administer IVF >Pulmonary embolus
>Monitor vaginal bleeding
>Monitor I&O Diagnosis:
> Prepare for Culdocentesis- > suspect until 3rd month or later if fetal heartbeat is
Result: to determine if clotting or non clotting present with bleeding and severe nausea and vomiting
>If clotting – negative for ectopic pregnancy >Physician will examine the woman’s abdomen feeling for
>If non – clotting – positive for ectopic pregnancy any strange humps or abnormalities in the uterus
> Culdocentesis- is a procedure in which peritoneal fluid is >Tubal pregnancy will be ruled out
obtained from the cul de sac of a female patient. It involves >Abnormally increased HCG level with vaginal bleeding; (-)
the introduction of a spinal needle through the vaginal wall FHB and unusually large uterus will indicate a molar
into the peritoneal space of the pouch of Douglas pregnancy
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Ultrasound – confirm no living fetus >Complete or partial previous would require a C/S
2. Avoid intercourse
Treatment 3. Limit or no travelling
4. Avoid pelvic exams/internal exams – can cause profuse
>often, the tissue is naturally expelled by the fourth month of bleeding
pregnancy. In some instances, the physician will give the Predisposing Factors
woman a drug called oxytocin to trigger the release of the >Old Age
mole that is not spontaneously aborted >Smoking
>If this does not happen, a vacuum aspiration can be >intake of alcoholic beverages
performed to remove the mole >history of placenta previa in the past pregnancy
1.D&C Surgical Management:C/S with blood transfusion based on
* woman is given anesthetic blood loss
* Cervix is dilated and the contents of the uterus is
gently sunctioned out. 2. Abruptio Placenta
* After the mole has been mostly removed, gentle
scraping of the uterus lining is usually performed. > Premature separation of the placenta from the
* If the woman is older and does not want any implantation site. It usually occurs after the 20th week of
more children, the uterus can be surgically removed pregnancy
(hysterectomy) instead of a vacuum aspiration because of the > Bleeding into the deciduas basalis (the layer between the
higher risk of cancerous moles in this age group placenta and myometrium) compresses and compromises
* Monitoring the patient for at least 2 months after the function of adjacent placenta
nthe end of a molar pregnancy for HCG level
Other Names:
C. BLEEDING DISORDERS DURING THE
>Premature Separation of Placenta
THIRD TRIMESTER OF PREGNANCY >Accidental Hemorrhage
>Ablatio Placenta
1. Placenta Previa >Placental Abruption
– occurs when the placenta is improperly implanted in the
lower uterine segment, sometimes covering the cervical os Signs and Symptoms:

Signs and Symptoms >Painful vaginal bleeding

>Severe abdominal pain
> Frank, bright red, painless vaginal bleeding >Concealed bleeding (retroplacental)
>Engagement (usually has not occurred) >Rigid abdomen
>Fetal distress >Couvelaire uterus (caused by bleeding into the
>Presentation (usually abnormal) – baby is breech or in myometrium)
transverse position >Dropping Coagulation factor ( a potential for DIC)
>Uterus measures larger than it should according to
gestational age Other Signs and Symptoms:

Types: >Uterine hypertonous

>Back pain
a.Partial Placenta Previa – a portion of the cervix is covered >Preterm labor
by the placenta >Hypovolemic shock
b.Complete Placental Previa/Total – cervical opening is >Non reassuring fetal heart trackings and fetal demise
completely covered
c.Marginal Placenta Previa – extends just to the edge of the Severe Cases
cervix >Maternal hypotension
>Uterine hypertonicity
Management >Fetal distress
1.Bed Rest >Death
>If the patient presents with mild bleeding before the fetal >Clotting abnormalities
lungs are mature Cause: unknown
2.Depending on the gestational age; steroid shots may be
given to help mature the baby’s lungs
3.If the bleeding cannot be controlled, an immediate cesarian
delivery is usually done regardless of the length of pregnancy
4.Near term, fetal lung maturity may be assessed by Predisposing Factors:
amniocentesis and the preferred method is C/S
>Some marginal previas can be delivered vaginally
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>Mechanical factors such as: abdominal trauma – car >Increased blood pressure, reading greater than 140/90
accident of fall mmHg or a significant increased in one or both pressures
>Sudden loss in uterine volume as occurs with rapid loss of >Protein in the urine – proteinuria
amniotic fluid or the delivery of a first twin >Edema – swelling of face and fingers
>Abnormally short umbilical cord Cause : unknown
>Hypertension
>Pre-eclampsia Predisposing Factors:
>Multiparity >Pre – existing HPN (increased BP) >PIH with previous
>Rupture of membranes more than 24H pregnancy
>Kidney disease >Mother’s age
Signs and Tests: younger than 20 or >Diabetes
older than 40
>During a physical examination, uterine tenderness and or >Multiple gestation (twins/triplets)
increased uterine tone may be noticed
>CBC – decreased hematocrit and hemoglobin and platelets Note:
>Prothrombin time test * PIH should be treated immediately since with sincreased
>Partial thromboplastin time test BP, there is also an increased in the resisitance of blood
>Fibrinogen level test vessels. This may hinder blood flow in many different organ
>Ultrasound systems in an expectant
Other Problems:
Treatment and Management: >Occurrence of placental abruptio
>IVF > Fetal problems such as intrauterine growth restriction (poor
>Blood Transfusion fetal growth) and stillbirth
>Check for presence of shock and fetal distress
>Emergency C/S – for fetal distress or maternal bleeding Signs and Symptoms: may experience symptoms differently
Immature fetus with small placental separation – >Increased BP
hospitalization – for observation – release after several days >Proteinuria
if no evidence of progressing abruption occurs >Edema on face and fingers
If mature fetus – vaginal delivery if maternal and fetal >Sudden weight gain
distress is minimal >Blurring or double vision
C/S – to protect the mother and child >Nausea and vomiting
>Right sided upper abdominal pain or pain around the
General Nursing Care stomach
>Infuse IVF, prepare to administer blood >Decreased urine output
>Type and cross match blood components (PRBC) >Changes in liver or kidney function test
>Monitor FHR
>Insert foley catheter Diagnosis:
>Measure blood loss – count pads >BP assessment
>Report signs and symptoms of DIC >Urine testing
>Monitor V/S >Assessment of edema
>Strict I & O >Frequent weight measurement
>Eye examination to check for retinal changes
Pregnancy Induced Hypertension >Liver and kidney function test
> A form of increased blood pressure in pregnancy >Blood clotting tests
> Also called toxemia or pre – eclampsia
> Eclampsia is a severe form of PIH accompanied with Treatment:
seizures Goal: to prevent the condition from becoming worse and to
> HELLP Syndrome – Hemolysis with Elevated Liver Enzymes prevent other complications
and Decreased Platelet Counts- is a complication of severe 1. Bed rest – either at home or in the hospital
pre-eclampsia or eclampsia 2.Magnesium Sulfate (MgSO4) – drug of choice
Action: CNS Depressant/ Anti Convulsive Drug
Signs and Symptoms of HELLP Syndrome: Route: IM/IV
> Breakdown of RBC Site: 1st dose – IV; 2nd dose – buttocks
> Changes in the liver
> Decreased platelets (cells found in the blood that are Nursing Considerations:
needed to help the blood to clot in order to control bleeding) >Consider the rights in giving medications
>Check the expiration date of the medication
>Check for proper color of the medication
> Check the patient’s BP before and after giving of
THREE PRIMARY CHARACTERISTICS: medication
> Insert foley catheter as per doctor’s order
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GENERAL NURSING CARE:
P – PROMOTE BED REST
> Prevent convulsion by nursing measures: seizure
precautions
*Quiet and calm environment
E - NSURE HIGH PROTEIN INTAKE ( 1 G/KG/DAY)
A – NTIHYPERTENSIVE DRUG : HYDRALIZE
C - NS DEPRESSANT (MGSO4) ANTICONVULSANT DRUG
E – VALUATE PHYSICAL PARAMETERS FOR MAGNESIUM
SULFATE TOXICITY
B – BP decreased
U – urine output decreased
R – RR less than 12/min
P – patellar reflex absent
Olygohydramnios
Refers to a pregnancy with less than the average amount of
amniotic fluid.
Part of the volume of amniotic fluid is formed by the addition
of fetal urine, this reduced amount of fluid is usually caused
by a bladder or renal disorder in the fetus that is interfering
with voiding
Another cause: due to growth restriction of the fetus, he/she
is not voiding as much as usual
Diagnosis:
1.Physical Assessment: Inspection: suspected during
pregnancy if the uterus fails to meet its expected growth rate
2.Ultrasound – pockets of amniotic fluid are less than average
Effects on the fetus after birth:
Muscles are weak due to cramped space during pregnancy
Lungs fail to develop that can lead to hypoplastic lungs-
difficulty of breathing
Potter syndrome- distorted features of the face
Nursing Consideration:
> Careful inspection among infants at birth to rule out kidney
disease and compromised lung development
Polyhydramnios
Occurs when there is excess fluid of more than 2,000ml or an
amniotic fluid index above 24 cm.
Normal volume at term: 500 to 1000 ml
Effects on Pregnancy:
Can cause fetal malpresentation due to the additional uterine
space and can allow the fetus to turn on a transverse lie
Can lead to premature rupture of the membranes from the
increased pressure that can lead to risks for infection,
proplapsed cordand preterm birth
Normal Process during Pregnancy:
> Amniotic fluid is formed by a combination of the cells of the
amniotic membrane and from fetal urine
Polyhydramnios
Occurs when there is excess fluid of more than 2,000ml or an
amniotic fluid index above 24 cm.
Normal volume at term: 500 to 1000 ml
Effects on Pregnancy:
Can cause fetal malpresentation due to the additional uterine
space and can allow the fetus to turn on a transverse lie
Can lead to premature rupture of the membranes from the
increased pressure that can lead to risks for infection,
proplapsed cordand preterm birth
Normal Process during Pregnancy:
> Amniotic fluid is formed by a combination of the cells of the
amniotic membrane and from fetal urine
t is evacuated by being swallowed by the fetus, absorbed
across the intestinal membrane into the fetal bloodstream
and transferred across the placenta
With polyhydramnios, accumulation of amniotic fluid
suggests difficulty with the fetus’s ability to swallow or
absorb fluid
Causes of inability to swallow fluids:
Anencephalic
Fetus with tracheoesophageal fistula with stenosis
Fetus with intestinal obstruction
Occurs among infant with diabetic mother
Assessment/Diagnosis:
Physical Assessment: Inspection- rapid enlargement of the
uterus
Difficulty to palpate fetal parts because the uterus is
unusually tense
Difficulty in auscultating the FHR due to the depth of the
increased amount of fluid surrounding the fetus
Woman may have extreme shortness of breath due to
pushing up of the uterus against her diaphragm
Therapeutic Management:
Hospitalization or home care
Goal:
a.For adequate rest
b.For further evaluation
C. Amniocentesis – to remove excess some of the extra fluid
D. .Tocolytics- to prevent or halt preterm labor
If preterm rupture of the membranes occurs:
E. Membranes can be “Needled” (insertion of a thin needle
vaginally to pierce them) to slow, control the release of fluid
and to prevent proplapsed cord during labor
Postterm Pregnancy
> A term pregnancy is 38 to 42 weeks
Any pregnancy that extends this period is postterm
Causes:
1. Women who have long menstrual cycle
40 to 45 days: they do not ovulate on day 14 which is the
normal period
They ovulate 14 days from the end of their cycle, or on day
26 or 31, children will be considered “late” by 12 to 17 days
2. Women who are receiving high dose of salicylates for their
severe sinus headaches or rheumatoid arthritis- this
interferes with the synthesis of prostaglandin
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3.Myometrial quiescence-uterus that does not respond to
normal labor stimulation
Danger to the fetus:
1.Meconium aspiration
2.Macrosomia
3.Lack of growth-placenta is functioning for only 40-42
weeks-exposes the fetus to decreased blood perfusion,
oxygen, fluid and nutrients
Management:
Biophysical profile- to evaluate the placental perfusion and
amount of amniotic fluid present;
if normal, it is assumed miscalculation occurs
If abnormal result or physical examination or biparietal
diameter on ultrasound result the fetus is in term size, labor
will be induced
How to induce labor:
1.Prostaglandin gel or misoprostol (Cytotec) –applied to the
vagina to initiate uterine contraction followed by an oxytocin
infusion
2.If oxytocin is ineffective, C/S is performed
Nursing Consideration during the labor process:
1.Monitor FHR, V/S
After Birth:
1.Assess newborn for meconium aspiration
>Establish and maintain patent airway
2.Assess for polycythemia – due to decreased oxygenation in
the final weeks
>hematocrit may be elevated due to polycythemia and
dehydration that leads to lowered circulating plasma level.
3.Asess for hypoglycemia-because fetus had to use stores of
glycogen for nourishment in the final weeks of intrauterine
life
Care of the Woman:
Allow woman to stay a longer period of time with her
newborn and let her or assist her in providing appropriate
interventions to her newborn
Preterm Labor
Labor that occurs before the end of week 37 of gestation (9
months)
Danger:
Infant is immature
Assessment:
> Any pregnant woman having persistent uterine
contractions, mild and widely spaced should be considered to
be in labor, if contractions have caused cervical effacement
or dilatation over 1 cm
Measures on How to Prevent Preterm Labor:
1.Remain on bed rest except to use on bathroom.
2.Drink 8 to 10 glasses of fluids daily
3.Keep mentally active by reading or working on a project to
prevent boredom
4.Avoid activities that could stimulate labor
5. Consult your primary care giver whether sexual relations
should be restricted
6.Immediately report signs of ruptured membranes9sudden
gush of fluid from the vagina) or vaginal bleeding
7.Report signs of urinary tract infections or vaginal infection
(burning or frequency of urination, vaginal itching or pain)
8.Keep appointments for prenatal care.
9.Empty bladder to prevent pressure on the uterus
10.Lie down on your left or right side to encourage blood
return to the fetus
Signs and Symptoms:
persistent, dull, and low backache
vaginal spotting
Feeling of pelvic pressure
Abdominal tightenin
Menstrual-like cramping
Increased vaginal discharge
Uterine contractions
Intestinal cramping
Diagnosis:
Analyzing changes in the length of the cervix by ultrasound
Analysis of vaginal mucus for the presence of fetal
fibronectin, a protein produced by trophoblast cells
* If this is present in vaginal mucus, preterm labor occurs,
labor will not occur if the protein is absent for at least 14
days
Therapeutic Management:
1.Medical attempts can be made to stop preterm labor if:
a.The fetal membranes have not ruptures
b.No fetal distress
c.No evidence of bleeding
d.Cervix is not dilated more than 4 to 5 cm
e.Effacement is not more than 50%
2.If in preterm labor:
a.Admission in the hospital
b.Bed rest – to relieve the pressure of the fetus in the cervix
c.Monitoring the uterine contractions
d.IVF therapy-to keep the woman well hydrated
e.Vaginal and cervical cultures and a clean catch urine
sample- to rule out infection
Drug Administration:
1.Tocolytic drugs- an agent to halt labor
>Terbutaline-drug of choice
*carries a “black box” warning- should not be used for over
48 to 72 hours
*Reason: could cause serious maternal heart problems and
death
*should not be used in out patient or home setting-requires
constant professional assessment
2.Magnesium Sulfate-used traditionally to treat pre
eclampsia and prevent eclamptic seizures, can also be used
*recent research does not support this as tocolytic agent
3.Corticosteroid
> bethamethasone- to promote the formation of lung
surfactant to prevent respiratory distress syndrome among
newborn
Fetal Assessment: if woman is sent home:
1.Advice woman to keep herself well hydrated
2.Maintain adequate nutrition
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3.Mainatin bed rest and avoid strenuous activities
4.Advice the woman to have a record of daily” kick” count or
“count to 10” test of her baby’s movements inside her
womb.
LABOR THAT CANNOT BE HALTED
Membranes have ruptured-point of no return
Effacement is more than 50%
Cervical dilatation is more than 3 to 4 cm

Management:
> If fetus is very immature, C/S – to reduce pressure on the
fetal head and reduce the possibility of subdural or
intrventricular hemorrhage from a vaginal birth

What to expect:
Missed abortion – when the fetus dies before 20 weeks of
gestation and is not aborted spontaneously
Fetal death – occurs after 20 weeks of gestation and may be
used when labor does not begin within 48H of death

Signs and Symptoms:

Painless spotting
Uterine contractions with cervical effacement and dilatation
Fetus is born lifeless and emaciated
Dx:
> (-) fetal movement
> (-) FHB
> Uterine growth ceases
> Uterine size decrease
> Fetal heart movement cannot be visualized by UTZ
> X-ray detected by the appearance of intravascular or intra
abdominal fetal gas (Robert’s sign)

Management:
1.Induced labor- combination of misoprostol(Cytotec) applied
to the vagina to effect cervical ripening and oxytocin
administration to begin uterine contraction
2.Bllod studies: test for DIC
J. Rh Incompatibility
> Occurs when an Rh-negative mother (one negative for a D
antigen or one with a dd genotype0 carries a fetus with an Rh
positive blood type (DD or Dd genotype)
For this to happen:
> The father of the child must either be homozygous (DD) or
heterozygous (Dd) Rh positive
If the father of the child is homozygous (DD) for the factor,
100% of the couple’s children will be Rh positive (Dd)
If the father is heterozygous for the trait, 50% of their
children can be Rh positive (Dd)
People who have Rh-positive blood have a protein factor
(the D antigen) that Rh – negative people do not, when an Rh
–positive fetus begins to grow inside an Rh-negative mother
who is sensitized, her body reacts by forming antibodies
against the invading substance-the fetus.