OVERVIEW OF THE NURSING PROCESS

NURSING PROCESS

systematic, rational method of planning and providing nursing care.

Cyclical, its components follow a logical sequence.
Terminated if goal is achieved.
The cycle may continue with reassessment, or the plan of care maybe
modified.

GOAL

to identify a client’s health care status, and actual or potential health

problems.
To establish plans to meet the identified needs.
To deliver specific nursing interventions to address those needs.
STEPS OF NURSING PROCESS

1. ASSESSMENT (includes subjective and objective data)

Collect data
Organize data
Validate data
Document data

2. DIAGNOSING (Ineffective airway clearance related to accumulated

mucus obstructing airways)

Analyze data
Identify health problems, risks and strengths
Formulate diagnostic assessment
3. PLANNING (restore effective breathing and lung ventilation, develop
care plan)

Prioritize problems/diagnosis
Formulate goals/desired outcome
Select nursing interventions
Write nursing orders

4. IMPLEMENTING (implementation of care plan/nursing intervention)

Reassess the client

Determine the nurse’s need for assistance
Implement the nursing interventions
Supervise delegated case
Document nursing activities
5. EVALUATING (evaluation of nursing interventions)

Collect data related to outcomes

Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
Continue , modify, terminate the client’s care plan
COMPONENTS OF A NURSING HEALTH HISTORY

1. CHIEF COMPLAINT/REASON FOR VISIT

2. HISTORY OF PRESENT ILLNESS

3. BIOGRAPHIC DATA

When the symptoms started

Whether the onset of symptoms was sudden or gradual
How often the problems occurs
Character of the complaint
Activity in which the client was involved when the problem occurred
1. Phenomena or symptoms associated with the chief complaint
2. Factors that aggravate or alleviate the problem
4. PAST HISTORY

Childhood illness
Childhood immunizations
Allergies
Accidents and injuries
Hospitalization for serious illnesses
Medications

5. FAMILY HISTORY OF ILLNESS

6. LIFESTYLE

Personal habits
Diet
Sleep/rest patterns
ADL
Instrumental activities of daily living
Recreation /hobbies
7. SOCIAL DATA

Family relationships/friendships (clients support system)

Ethnic affiliation (health customs, beliefs and practices)
Educational history (highest level of education)
Occupational history (employment status, absences from work,
occupational hazards)
Economic status (financial concerns)
Home and neighborhood conditions (safety measures at home)

8. PSYCHOLOGIC DATA
Major stressor
Usual coping pattern
Communication style (verbal expression)

9. PATTERNS OF HEALTH CARE

All health care resources the client is currently using and has used in the
past
 • PHYSICAL ASSESSMENT
1. Inspection
2. Auscultation
3. Palpation

• DIAGNOSTIC ASSESSMENT
Using of laboratory procedures to help diagnose (medical) the disease.
• Change lecture with positive sign/probable signs of pregnancy/HIGH
RISK PREGNANCY

• Related nursing diagnosis for high risk pregnancy:

Anxiety
Fluid volume deficit
Risk for infection
Ineffective tissue perfusion
Knowledge deficit
 NCM 109-CARE OF MOTHER
AND CHILD AT RISK OR WITH
PROBLEMS (ACUTE AND
CHRONIC)

Abnormal Obstetrics
 CONTENTS

▣ RISK FACTORS ASSOCIATED WITH PREGNANCY

▣ BLEEDING COMPLICATIONS IN PREGNANCY
First Trimester Abortion
Ectopic Pregnancy
Second Trimester Hydatidiform Mole
Incompetent Cervix
Third Trimester Abruptio/Ablatio Placenta
Placenta Previa
▣ HYPERTENSIVE DISORDERS IN PREGNANCY
Gestational Hypertension
Chronic Hypertension
Pregnancy Induced Hypertension
Pre-eclampsia
Eclampsia
▣ METABOLIC DISORDER IN PREGNANCY
Gestational Diabetes Mellitus
▣ MEDICAL CONDITIONS COMPLICATING
PREGNANCY
Heart Disease
Anemias
Infertility
 Risk Factors associated with Pregnancy
▣ Maternal age factor
◼ Teenage pregnancy of 16 yrs. and below is considered a high risk pregnancy
from both physical and psychosocial standpoint
Physical
▣ Because of the physical task of adolescence
Rapid growth during adolescence
Rapid growth of the fetus
▪ Psychosocial
Lack of motivation
Denial
Ignorance
Rebellion against authority
Failure to complete education
Dependence on others for support
Failure to establish a stable family life
High rate of marital failure
High incidence of repeated out of wedlock pregnancy
 Risk Factors associated with Pregnancy
◼ Advanced age of 35 yrs and above is a high risk of pregnancy
because of increased incidence of :
Placenta previa
Chromosomal abnormalities
Abruptio / Ablatio placenta
Hypertension
Toxemia
Low birth weight babies
▣ Parity
▣ First pregnancy – is the period of highest risk
▣ Second / Third and Fourth pregnancy – the risk of death
for the mother is at its lowest
▣ Fifth pregnancy – marked increase especially when the
pregnant mother is over 40 years of age.
 DANGER SIGNS OF PREGNANCY
1. VAGINAL BLEEDING = VAGINAL BLEEDING
SHOULD BE REPORTED IMMEDIATELY FOR
FURTHER EVALUATION
2. PERSISTENT VOMITING ( HYPEREMESIS
GRAVIDARUM) = NAUSEA & VOMITING THAT
CONTINUES PAST THE 12 WEEK OF
PREGNANCY IS EXTENDED VOMITING. IT
DEPLETES THE NUTRITIONAL SUPPLY
AVAILABLE TO THE FETUS.
3. CHILLS & FEVER = MAY BE EVIDENCE OF
INTRAUTERINE INFECTION WHICH IS A
SERIOUS COMPLICATION FOR BOTH THE
WOMAN & THE BABY.
4. SUDDEN ESCAPE OF FLUID FROM THE
VAGINA = MEANS THAT THE MEMBRANES
HAVE RUPTURED. BOTH THE MOTHER & THE
FETUS ARE THREATENED BECAUSE UTERINE
CAVITY IS NO LONGER SEALED AGAINST
INFECTION.
** IF FETUS IS SMALL & HIS HEAD DOES NOT
FIT INTO THE CERVIX, THE UMBILICAL CORD
MAY PROLAPSE WITH THE RUPTURED
MEMBRANE , THE HEAD MAY BE
COMPRESSED AGAINST THE CORD. ANOTHER
DANGEROUS COMPLICATION IS ASCENDING
INFECTION.
5. ABDOMINAL OR CHEST PAINS = ABDOMINAL
PAINS MAY MEAN TUBAL PREGNANCY THAT
HAVE RUPTURED, SEPARATION OF THE
PLACENTA, PRETERM LABOR WHILE CHEST
PAINS MAY INDICATE PULMONARY EMBOLUS
THAT FOLLOWS THROMBOPHLEBITIS.
6. ABSENCE OF FETAL HEART SOUNDS AFTER
THEY HAVE INITIALLY BEEN AUSCULTATED
ON THE 4TH & 5TH MONTH ( MAY INDICATE
INTRAUTERINE FETAL DEATH - IUFD)
7. SWELLING OF THE FACE & FINGERS =
EDEMA
8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA)
9. BLURRING OF VISION
10. SEVERE HEADACHE & DIZZINESS
** MAY MEAN SIGNS OF PREGNANCY
INDUCED HYPERTENSION
 COMPLICATIONS OF PREGNANCY
A. FIRST TRIMESTER BLEEDING:
1. ABORTION
- THE EXPULSION OF THE
PRODUCTS OF CONCEPTION BEFORE
THE AGE OF VIABILITY ( FETUS CAN
SURVIVE EXTRAUTERINE LIFE)
- FETUS IS LESS THAN 20 WEEKS OR
LESS THAN 500 GRAMS
CAUSES OF ABORTION:
1. ABNORMAL DEVELOPMENT OF THE ZYGOTE –
WHICH WOULD HAVE RESULTED IN SEVERE
CONGENITAL ANOMALIES
2. ABNORMALITY IN THE IMPLANTATION
PROCESS - IUD
3. TRAUMA – PSYCHOLOGICAL,
PHYSICAL
4. HORMONAL IMBALANCE ( LOW
PROGESTERONE)
5. INTAKE OF DRUGS – CYTOTEC
6. INFECTIOUS DISEASES – GERMAN
MEASLES, PTB, HERPES
7. PRESENCE OF VENEREAL DISEASES
8. ABNORMALITY IN THE REPRODUCTIVE
SYSTEM – INCOMPETENT CERVIX
8. SEVERE MALNUTRITION
EARLY ABORTION – HAPPENS BEFORE 16 WEEKS
LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS
 COMPLICATIONS OF PREGNANCY
A. FIRST TRIMESTER BLEEDING:
1. ABORTION
- THE EXPULSION OF THE
PRODUCTS OF CONCEPTION BEFORE
THE AGE OF VIABILITY ( FETUS CAN
SURVIVE EXTRAUTERINE LIFE)
- FETUS IS LESS THAN 20 WEEKS OR
LESS THAN 500 GRAMS
CAUSES OF ABORTION:
1. ABNORMAL DEVELOPMENT OF THE ZYGOTE –
WHICH WOULD HAVE RESULTED IN SEVERE
CONGENITAL ANOMALIES
2. ABNORMALITY IN THE IMPLANTATION
PROCESS - IUD
3. TRAUMA – PSYCHOLOGICAL,
PHYSICAL
4. HORMONAL IMBALANCE ( LOW
PROGESTERONE)
5. INTAKE OF DRUGS – CYTOTEC
6. INFECTIOUS DISEASES – GERMAN
MEASLES, PTB, HERPES
7. PRESENCE OF VENEREAL DISEASES
8. ABNORMALITY IN THE REPRODUCTIVE
SYSTEM – INCOMPETENT CERVIX
8. SEVERE MALNUTRITION
EARLY ABORTION – HAPPENS BEFORE 16 WEEKS
LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS
Types of Abortion:
• SPONTANEOUS = UNINTENDED
TERMINATION OF PREGNANCY AT ANY
TIME BEFORE THE FETUS HAS
ATTAINED VIABILITY.
THREATENED – POSSIBLE LOSS OF THE
PRODUCTS OF CONCEPTION
S/SX: SLIGHT BLEEDING; MILD UTERINE
CRAMPING BUT NO CERVICAL
DILATATION ON VAGINAL
EXAMINATION;NO PASSAGE OF TISSUE
▣ Management:
◼ Bed rest
◼ Save all pads
◼ No coitus up to 2 weeks after bleeding has stopped
 INEVITABLE OR IMMINENT ABORTION - is
a loss of pregnancy that cannot be prevented.
Clinical Manifestations:
▣ Moderate to profuse Bleeding
▣ Moderate to severe uterine cramping
▣ Cervix dilated
▣ Membranes rupture
▣ Management:
◼ Hospitalization
◼ D&C
◼ Oxytocin after D & C
◼ Emotional support
TYPES OF INEVITABLE ABORTION:

1) Complete – all products of conception are

expelled.
Sxs of complete abortion:
▣ Moderate bleeding
▣ Mild uterine cramping
▣ Passage of tissue
Management:
▣ Sympathetic understanding & emotional
support

2) Incomplete – not all products of conception

are expelled from the uterus.
Signs and Sxs:
▣ Profuse vaginal bleeding
▣ Severe uterine cramping
▣ Open cervix
▣ Passage of tissue
▣ Other products are retained
Treatment and MX:
▣ D and C

▣ Oxytocin after D & C

▣ Emotional support
▣ Missed Abortion
◼ Retention of all products of conception after the
death of the fetus in the uterus
S/Sx:
- No FHT
- Signs of pregnancy disappear
Management:
D&C
▣ Septic Abortion
◼ Abortion complicated by infection

S/Sx:
- Foul smelling vaginal dischrage
- Uterine cramping
- Fever
Management:
- Treat abortion
- Antibiotics
 HABITUAL OR RECURRENT PREGNANCY
LOSS –SPONTANEOUS ABORTION IN
THREE OR MORE SUCCESSIVE
PREGNANCIES USUALLY DUE TO
INCOMPETENT CERVIX.
B. Induced Abortion – is an intentional loss of
pregnancy through direct stimulation either by
chemical or mechanical means.
Types of induced abortion:
1) Therapeutic abortion – to preserve the life of the
mother
2) Elective abortion
Reasons for Induced Abortion:
▣ Therapeutic – to end a pregnancy that is life
threatening to the mother
▣ To end a pregnancy of a fetus found to have severe
congenital abnormalities that may be incompatible
with life
▣ To end an unwanted pregnancy that is a result of rape
or incest
▣ To end a pregnancy because of woman’s choice not to
have a child yet
Prevention of abortion:
▣ Prepregnancy correction of maternal disorders

▣ Immunization against infectious diseases

▣ Proper early antenatal care

▣ Treatment of pregnancy complications

▣ Correction of cervical incompetency

Complications:
▣ Hemorrhage

▣ Sepsis

▣ Rh sensitization
2. ECTOPIC PREGNANCY
- ANY PREGNANCY THAT OCCURS
OUTSIDE THE UTERINE CAVITY.
---SECOND LEADING CAUSE OF
BLEEDING IN EARLY PREGNANCY.
TYPES:
1. AMPULAR 4. CERVICAL
2. INTESTINAL 5. ABDOMINAL
3. OVARIAN
Predisposing causes:
▣ Salpingitis

▣ Peritubal adhesions

▣ Previous ectopic pregnancy

▣ Previous tubal surgery

▣ Multiple previous abortion

▣ Tumors that distort the tubes

▣ External migration of the ovum

▣ Intrauterine device (IUD)

Signs and Sxs:

▣ Vaginal spotting or bleeding

▣ Cul de sac mass
▣ Absence of amniotic sac
▣ Amenorrhea or abnormal menstruation
followed by slight uterine bleeding
Signs of tubal rupture:

Severe sharp knife like pain in the lower quadrant

of the abdomen
▣ Abdominal rigidity
▣ Nausea and vomiting
▣ Low hgb. And hct.
▣ Sharp localized pain in the cervix on internal
examination ( wiggling sign)
▣ Signs of hemorrhage:
▣ - Cullen’s sign – bluish discoloration of the
umbilicus due to the presence of blood in the
peritoneal cavity
-Hard or rigid boardlike abdomen
. Signs of shock:
- Falling BP, rapid pulse
- Light headedness
- Pallor
- Cyanotic nail beds
- Cold clammy skin
 Diagnostic Aids
▣ Culdocentesis – aspiration of bloody fluid from Cul
de sac of Douglas
▣ Ultrasound reveals presence of the gestational sac
outside of the uterine cavity
Treatment and management:
▣ If not yet ruptured:
◼ Salpingostomy – removal of a conceptus less than 2
cm located at the distal portion of the fallopian tube
by performing a linear incision over the ectopic
pregnancy. The conceptus will extrude from the
incision & removed manually.
◼ Salpingotomy – longitudinal incision is made over
the ectopic pregnancy & the conceptus is removed
using forceps or gentle suction
◼ Fimbrial evacuation – removal of the conceptus by
milking & suctioning of the fallopian tube
▣ If ruptured:
- removal of the ruptured tube because
the presence of a scar if tube is repaired &
left can lead to another tubal pregnancy.
Surgical treatment:
-Salpingotomy
-Salpingectomy – removal of the oviducts
▣ Prevent and treat hemorrhage which is the main
danger of ectopic pregnancy.
◼ Blood transfusion
◼ Place patient flat in bed with legs elevated
◼ Monitor Vital signs, I & O, & amount of blood loss
▣ Prevent infection as the woman who lost so much
blood is susceptible to infection

▣ Contraception must be started upon discharge from

hospital. Ovulation begins as early as 19 days or 3
weeks after resection of ectopic pregnancy.
B. SECOND TRIMESTER BLEEDING
1. GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE OR
H-MOLE))
- is a mass of abnormal rapidly growing
trophoblastic tissue in which avascular
vesicles hang in grapelike clusters THAT
PRODUCE LARGE AMOUNTS OF HCG.
Predisposing factors:
cause is unknown
▣ 17 years old below and 35 yrs. Above

▣ Low socioeconomic status

▣ Low protein intake

▣ Previous mole

▣ Higher incidence in Asian women

TYPES:
1. COMPLETE MOLE – LACKS AN EMBRYO
OR FETUS
2. PARTIAL MOLE – INVOLVES A
CHROMOSOMALLY ABNORMAL
EMBRYO OR FETUS.
- 69 XXX or 69 XXY
CAUSES:
1. SPERM + OVUM + DUPLICATION =46 (COMPLETE
( 23) ( 0) MOLE)
2. SPERM + OVUM =69 (PARTIAL
(46) (23) MOLE)
3. SPERM
( 23) OVUM
+ + ( 23) =69 (PARTIAL
SPERM MOLE)
( 23)
Gestational trophoblastic disease
(hydatidiform mole)
Signs and Sxs:
▣ Rapid increase in uterine size greater than
gestational age of the fetus
▣ Marked increase HCG titer; NV:400,000 iu
▣ Excessive nausea and vomiting due to elevated
HCG
▣ Brownish vaginal discharge around 4th month
containing grapelike vesicles
▣ No FHT is detected after 10 to 12 weeks, no fetal
movement after 18-20 weeks
▣ No fetal parts
▣ Bleeding which may vary from spotting to
profuse hemorrhage and is usually brownish but
may be bright red
▣ No fetal skeleton

▣ Hypertension & other sx of preeclampsia

▣ Symptoms of PIH before 24th week
gestation

**difference bet.H-mole & pre-eclampsia

- before 20 weeks =H mole
- after 20 weeks up to 2 weeks post partum
= preeclampsia
 DX:
▣ Ultrasound will identify the characteristic vesicles.
Treatment and management:
▣ D and C or D & E to remove the mole. ( If the
woman is more than 40 yrs old, hysterectomy is done
since she has a higher chance of developing
CHORIOCARCINOMA
▣ Monitor HCG for 1 year ( HCG shld be negative 2-6
weeks after removal of H-mole.)
▣ Chest X ray every 3 mos for 6 mos. The lungs are the
most common site of metastasis of choriocarcinoma
▣ Chemotherapy ( Methotrexate) if:
-HCG titers are increased for 3 consecutive weeks
or double at anytime
-HCG titers remain elevated 3-4 mos. after delivery
▣ The woman is advised not to get pregnant for 1 year,
contraceptive method should NOT be the pills. Pills
contain estrogen which promote regrowth of the
chorionic villi.
▣ Hysterectomy is the method of tx for women above 40
yrs old because of the higher incidence of
malignancies & to clients who have completed
childbearing & require sterilization.
Prognosis:
▣ Favorable if HCG titers do not recur after
evacuation of the mole
▣ Unfavorable if malignancy develops and is
untreated
 Complications of H-Mole:
▣ Gestational Trophoblastic Tumors – persistent
trophoblastic proliferation after H-mole.
** Choriocarcinoma – most severe malignant complication
that involve the transformation of chorion into cancer cells
that invade & erode blood vessels & uterine muscles.
*** Management of all trophoblastic tumors is
HYSTERECTOMY ****
NURSING MANAGEMENT:
1. MAINTAIN F & E BALANCE.
2. EMPHASIZE THAT PREGNANCY
SHOULD BE AVOIDED FOR 1 YEAR (
GREATER CHANCE OF IT RECURRING
& MAY EVEN LEAD TO
CHORIOCARCINOMA)
3. ADMINISTER BLOOD REPLACEMENT
AS ORDERED.
4. PROVIDE EMOTIONAL SUPPORT
5. USE MECHANICAL EQUIPMENTS
AGAINST PREGNANCY ( Ex. Condom)
2. INCOMPETENT CERVIX OR
PREMATURE CERVICAL DILATATION:
- PAINLESS CERVICAL EFFACEMENT &
DILATATION IN EARLY MIDTRIMESTER
RESULTING IN EXPULSION OF
PRODUCTS OF CONCEPTION.
- MOST COMMON CAUSE OF HABITUAL
ABORTION
CAUSES:
1. INCREASED MATERNAL AGE
2. CONGENITAL MALDEVELOPMENT OF
THE CERVIX – short cervix
3. TRAUMA TO THE CERVIX ( HISTORY OF
REPEATED D & C’S; CERVICAL
LACERATIONS WITH PREVIOUS
PREGNANCIES)
Signs and Sxs:
▣ Slight vaginal bleeding

▣ Presence of uterine contractions in

midtrimester
▣ Rupture of the bag of waters

▣ Expulsion of the conceptus

▣ Presence of painless cervical dilatation

▣ Relaxed cervical os on pelvic examination

MX:
1. CERVICAL CERCLAGE – MEDICAL
MANAGEMENT WHEREIN THE PHYSICIAN
SUTURES A CERTAIN PART OF THE
CERVIX BETWEEN 14 AND 16 WEEKS
GESTATION TO PREVENT CERVICAL
DILATATION.
a. MCDONALD’S – ( temporary) NYLON
SUTURES ARE PLACED
HORIZONTALLY & VERTICALLY
ACROSS THE CERVIX & PULLED TIGHT
TO REDUCE THE CERVICAL CANAL TO
A FEW MILLIMETERS IN DIAMETER.
b. SHIRODKAR – ( permanent) STERILE
TAPE IS THREADED IN A
PURSE-STRING MANNER UNDER THE
SUBMUCUS LAYER OF THE CERVIX &
SUTURED IN PLACE TO ACHIEVE A
CLOSED CERVIX.
▣ After suturing the cervix:
◼ Place woman on bed rest for 24 hours
◼ Observe for bleeding, uterine contractions, and rupture
of BOW
◼ If BOW ruptures – the sutures are removed
◼ If uterine contractions occur, the woman is given
ritodrine to stop the contractions
◼ Post-op care: Restrict activities for the next 2 weeks
including coitus
 Prerequisites of Cervical Cerclage

▣ Cervix not dilated

▣ Intact membranes
▣ No vaginal bleeding & uterine cramping
C. THIRD TRIMESTER BLEEDING
1. PLACENTA PREVIA
- LOW IMPLANTATION OF THE
PLACENTA
TYPES:
1. LOW-LYING – IMPLANTATION OF THE
PLACENTA IN THE LOWER RATHER
THAN IN THE UPPER PORTION OF THE
UTERUS
2. MARGINAL – PLACENTA EDGE
APPROACHES THAT OF THE CERVICAL
OS
3.PARTIAL – IMPLANTATION THAT
OCCLUDES A PORTION OF THE
CERVICAL OS
4. COMPLETE ( TOTALIS) – PLACENTA
THAT TOTALLY OBSTRUCTS THE
CERVICAL OS
Predisposing factors:
▣ Multiparity

▣ Advanced maternal age – over 35 yo

▣ Multiple pregnancy

▣ Uterine tumor

▣ Cigarette smoking

▣ Scarring from previous previous CS

▣ Decreased vascularity of upper uterine

segment
Past uterine D&C
Signs and Sxs:
▣ Painless, bright red vaginal bleeding during
the 3rd trimester
▣ Abdomen soft, non tender

▣ Ultrasound reveals placenta previa

NURSING MANAGEMENT:
1. MONITOR VITAL SIGNS & BLEEDING (
WEIGH UNUSED PERINEAL PAD, THEN
WEIGH PERINEAL PAD SOAKED IN
BLOOD, THEN SUBTRACT. THE
DIFFERENCE IS THE WEIGHT OF THE
BLOOD LOSS.)
2.PROVIDE STRICT BED REST TO MINIMIZE THE
RISK TO FETUS.( CBR without BRP’s )
3.OBSERVE FOR FURTHER BLEEDING
EPISODES.( PREPARE FOR BT) ( Hgb & Hct)
4. AVOID VAGINAL EXAMINATIONS ( NO IE). IF IE
IS INDICATED, IT SHOULD BE DONE IN A
DOUBLE SET-UP ENVIRONMENT. ( MEANING:
the DR is prepared for vaginal exam and for
cesarean birth in case the examination precipitates
profuse bleeding) WHEREIN THE PATIENT HAS
ALREADY SIGNED A CONSENT FORM, PRE-OP
MEDS HAVE BEEN GIVEN, ABDOMINAL
PREP HAS BEEN DONE SO THAT IF THE
PLACENTA IS ACCIDENTALLY DETACHED
BECAUSE OF MANIPULATIONS, CS CAN
BE DONE IMMEDIATELY.
6. PROVIDE EMOTIONAL SUPPORT
DURING THE GRIEVING PROCESS.
** CLASSICAL CESARIAN SECTION
UTERUS IS INCISED IN THE VERTICAL
SEGMENT) IS DONE IN CASE OF SEVERE
BLEEDING.**
▣ Assess fetal lung maturity
▣ Observe for PP hemorrhage
▣ Observe strict aseptic technique

Complications of placenta previa:

▣ Hemorrhage

▣ Infection

▣ Prematurity
 ** BLEEDING WITH PLACENTA PREVIA
OCCURS WHEN THE LOWER UTERINE
SEGMENT BEGINS TO DIFFERENTIATE
FROM THE UPPER SEGMENT LATE IN
PREGNANCY ( APPROXIMATELY WEEK 30
because of uterine contractions ) & THE
CERVIX BEGINS TO DILATE. THE
BLEEDING PLACES THE MOTHER AT RISK
FOR HEMORRHAGE. BECAUSE THE
PLACENTA IS LOOSENED, THE FETAL
OXYGEN MAY BE COMPROMISED”
IMMEDIATE CARE MEASURES:
** TO ENSURE AN ADEQUATE BLOOD
SUPPLY TO THE MOTHER & FETUS,
PLACE THE WOMAN ON BED REST IN A
LEFT SIDE LYING POSITION.**
2. ABRUPTIO PLACENTA
- ABRUPT SEPARATION OF AN
OTHERWISE NORMALLY IMPLANTED
PLACENTA AFTER 20 WEEKS AOG.
TYPES:
1. MARGINAL ( OVERT)
SEPARATION BEGINS AT THE EDGES
OF THE PLACENTA ALLOWING BLOOD
TO ESCAPE FROM THE UTERUS.
BLEEDING IS EXTERNAL.
2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE CENTER
RESULTING IN BLOOD BEING TRAPPED
BEHIND THE PLACENTA. BLEEDING
THEN IS INTERNAL AND NOT OBVIOUS.
CAUSES:
1.MATERNAL HYPERTENSION ( CHRONIC
OR PREGNACY INDUCED)
2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – MORE THAN 5
PREGNANCIES
4. TRAUMA TO THE UTERUS
5. SUDDEN RELEASE OF AMNIOTIC FLUID
THAT CAUSE SUDDEN DECOMPRESSION
OF TE UTERUS.
6. SHORT UMBILICAL CORD
7. CIGARETTE SMOKING & COCAINE
ABUSE
8. PROM
S/SX:
1. SHARP PAIN IN THE FUNDAL AREA AS
THE PLACENTA SEPARATES
2.PAINFUL DARK RED VAGINAL
BLEEDING IN COVERT TYPE
3.PAINFUL BRIGHT RED VAGINAL
BLEEDING IN OVERT TYPE
4.HARD, RIGID, FIRM,BOARD-LIKE
ABDOMEN CAUSED BY ACCUMULATION
OF BLOOD BEHIND THE PLACENTA WITH
FETAL PARTS HARD TO PALPATE.
5. ABNORMAL TENDERNESS DUE TO
DISTENTION OF THE UTERUS WITH
BLOOD.
6. SIGNS OF SHOCK & FETAL DISTRESS
AS THE PLACENTA SEPARATES.
PREMATURE SEPARATION OF THE PLACENTA
 CLASSIFICATION ACCORDING TO
PLACENTAL SEPARATION:
1. GRADE 0 = NO SYMPTOMS OF
PLACENTAL SEPARATION, DIAGNOSED
AFTER DELIVERY WHEN PLACENTA IS
EXAMINED & FOUNDTO HAVE DARK,
ADHERENT CLOT ON THE SURFACE.
2. GRADE 1 = SOME EXTERNAL
BLEEDING, NO FETAL DISTRESS, NO
SHOCK, SLIGHT PLACENTAL
SEPARATION
3. GRADE 2 = EXTERNAL BLEEDING,
MODERATE PLACENTAL SEPARATION,
UTERINE TENDERNESS, FETAL DISTRESS
4. GRADE 3 = INTERNAL & EXTERNAL
BLEEDING, MATERNAL SHOCK, FETAL
DEATH, DIC
MX:
1. WHEN PLACENTA ABRUPTIO IS
SUSPECTED OR DIAGNOSED,
HOSPITALIZATION IS A MUST.
2. BEDREST OR SIDE LYING POSITION
FOR OPTIMUM PLACENTAL PERFUSION.
3. MONITOR VITAL SIGNS, FHT, AMOUNT
OF BLOOD LOSS – GIVE MASK O2 IF
FETAL DISTRESS IS PRESENT.
4. DELIVERY:
** VAGINAL DELIVERY – IF THERE IS
NO SIGN OF FETAL DISTRESS, BLEEDING
IS MINIMAL & VITAL SIGNS ARE STABLE.
** CESARIAN DELIVERY – IF BLEEDING
IS SEVERE, FETAL DISTRESS IS PRESENT
& FETUS CANNOT BE DELIVERED
IMMEDIATELY WITH VAGINAL METHOD.
COMPLICATIONS:
1. COUVELAIRE UTERUS OR UTERINE
APOPLEXY – INFILTRATION OF BLOOD
INTO THE UTERINE MUSCULATURE
RESULTING IN THE UTERUS
BECOMING HARD & COPPER
COLORED.
2. HEMORRHAGE & SHOCK – TREATED
BY BLOOD TRANSFUSION
3. DIC – MANAGED BY FIBRINOGEN &
CRYOPRECIPITATE
 3. Disseminated Intravascular Coagulation (DIC)
▣ Disorder of blood clotting
Fibrinogen levels fall below effective limits (
Hypofibrinogenemia)
▣ Symptoms
Bruising or bleeding
massive hemorrhage initiates coagulation process causing
massive numbers of clots in peripheral vessels (may result in
tissue damage from multiple thrombi), which in turn
stimulate fibrinolytic activity, resulting in decreased platelet
and fibrinogen levels
signs and symptoms of local generalized bleeding (increased
vaginal blood flow, oozing IV site, ecchymosis, hematuria,
etc)
❑ monitor PT, PTT, and Hct, protect from injury; no IM
injections
 3. Disseminated Intravascular Coagulation (DIC)

▣ Result from an imbalance between clot formation systems and

clot breakdown systems that results in hemorrhage. This
problem begins with the excessive triggering of coagulation
mechanisms, most commonly encountered in abruptio placenta,
PIH, amniotic fluid embolism. This overstimulation of the
coagulation system leads to rapid formation of massive numbers
of clots. In turn, the fibrinolytic system is overactivated & clots
are broken down. As a result, clotting factors are used up &
generalized hemorrhage occurs leading to shock & death.
▣ Tx:
◼ Replacement of clotting factors _ Cryoprecipitate or fresh frozen plasma
or platelet transfusion
 HYDRAMNIOS / POLYHYDRAMNIOS
- CHARACTERIZED BY EXCESSIVE
AMOUNT OF AMNIOTIC FLUID, MORE
THAN 2000 ML.
- NORMAL AMOUNT OF AMNIOTIC FLUID
AT TERM IS 500 TO 1200 ML
CAUSES:
1. MULTIPLE PREGNANCY = ONE FETUS
USURPS THE GREATER PART OF THE
CIRCULATION RESULTING IN
CARDIOMEGALY, WHICH IN TURN
RESULTS IN INCREASED URINE OUTPUT.
2. FETAL ABNORMALITIES:
a. ESOPHAGEAL ATRESIA – FETAL
SWALLOWING OF AMNIOTIC FLUID IS ONE
OF THE MECHANISMS THAT REGULATE
THE AMOUNT OF AMNIOTIC FLUID. IN
ATRESIA, THE FETUS CANNOT SWALLOW
 b. SPINA BIFIDA – INCREASED
TRANSUDATION OF AMNIOTIC FLUID
FROM THE EXPOSED MENINGES.
S/SX:
1. EXCESSIVE UTERINE SIZE, OUT OF
PROPORTION TO AOG WITH DIFFICULTY
PALPATING FETAL PARTS & FINDING
FHT – PRIMARY CLINICAL FINDINGS
2. SHORTNESS OF BREATH CAUSED BY
PRESSURE OF THE OVERLY
DISTENDED UTERUS AGAINST THE
DIAPHRAGM.
3. BACK PAIN, VARICOSITIES,
CONSTIPATION, FREQUENCY OF
URINATION & HEMORRHOIDS
DIAGNOSTIC AIDS:
1. ULTRASOUND
2. RADIOGRAPHY
COMPLICATIONS:
1. PREMATURE LABOR & DELIVERY
2. ABRUPTIO PLACENTA
3. POSTPARTUM HEMORRHAGE DUE TO
OVERDISTENTION
4. CORD PROLAPSE
MX:
1. MILD TO MODERATE DEGREES
USUALLY DOES NOT REQUIRE
TREATMENT.
2. HOSPITALIZATION IF SX INCLUDES
DYSPNEA, ABDOMINAL PAIN, DIFFICULT
AMBULATION.
3. AMNIOCENTESIS – REMOVAL OF
AMNIOTIC FLUID TO RELIEVE
MATERNAL DISTRESS
4. INDOMETHACIN THERAPY – A DRUG
THAT DECREASES FETAL URINE
FORMATION.
SE: POTENTIAL PREMATURE CLOSURE
OF THE DUCTUS ARTERIOSUS.
5. HEALTH INSTRUCTIONS FOR RELIEF
OF SYMPTOMS:
1. PLACE IN SEMI-FOWLERS POSITION TO
ASSIST IN BREATHING
2. EMPTY BLADDER FREQUENTLY
3. INCREASE FLUID INTAKE & HIGH
FIBER DIET TO PREVENT CONSTIPATION
4. REST FREQUENTLY ON LEFT LATERAL
POSITION TO PREVENT FATIGUE & BACK
PAIN.
5. WATCH CLOSELY FOR HEMORRHAGE
AFTER DELIVERY.
 OLIGOHYDRAMNIOS
- AMNIOTIC FLUID LESS THAN 500 ML
CAUSES:
1. FETAL RENAL ANOMALIES THAT
RESULTS IN ANURIA
2. PREMATURE RUPTURE OF MEMBRANES
MX:
1. OBSERVE NEWBORN FOR
COMPLICATIONS THROUGHOUT THE
REMAINDER OF PREGNANCY.
a. CLUBFOOT
b. AMPUTATION
c. ABORTION
d. STILLBIRTH
e. FETAL GROWTH RETARDATION
 f. ABRUPTIO PLACENTA
2. DURING LABOR & DELIVERY
a. CORD COMPRESSION
b. FETAL HYPOXIA AS A RESULT OF
CORD COMPRESSION
c. PROLONGED LABOR
 PSEUDOCYESIS
▣ Or spurious pregnancy occurs in women nearing
menopause & in women who have intense desire to
become pregnant. These women develop the belief
that they are pregnant when in fact they are not. The
women often experiences all the subjective
symptoms of pregnancy: fatigue, amenorrhea,
tingling sensations & fullness of the breast, nausea
& vomiting. Some of these women repost feeling
fetal movements which are actually movement of air
in the intestines or muscular contractions of the
abdominal wall.
▣ Management:
◼ Explain pregnancy test result, clarify misconceptions &
false beliefs
◼ Provide referrals when necessary, psychologic counselling
◼ Provide emotional support & understanding
 Hyperemesis Gravidarum
▣ Excessive nausea & vomiting that persists beyond
12 weeks gestation & which leads to complications
like dehydration, weight loss, starvation & fluid &
electrolyte imbalance.
▣ Etiology: Unknown

SSx:
1.Excessive nausea & vomiting not relieved by
ordinary remedies persisting beyond 12 weeks
2. Signs of dehydration: thirst, dry skin, increased
pulse rate, weight loss, concentrated & scanty urine.
Management:
MX: D10NSS 3000 ML IN 24 HOURS IS THE
PRIORITY OF TREATMENT
> REST
> ANTI-EMETIC – ( EX. PLASIL)
HYPERTENSIVE DISORDERS IN
PREGNANCY:
GESTATIONAL HYPERTENSION:
- HYPERTENSION THAT DEVELOPS
DURING PREGNANCY OR DURING THE
FIRST 24 HOURS AFTER DELIVERY
WHICH IS NOT ACCOMPANIED BY
EDEMA, PROTEINURIA & CONVULSIONS
& DISAPPEARS WITHIN 10 DAYS AFTER
DELIVERY.
CHRONIC HYPERTENSION:
- THE PRESENCE OF HYPERTENSION BEFORE
PREGNANCY OR HYPERTENSION THAT DEVELOP
BEFORE 20 WEEKS GESTATION IN THE ABSENCE
OF H-MOLE & PERSIST BEYOND THE POSTPARTUM
PERIOD.
PREGNANCY INDUCED HYPERTENSION
(TOXEMIA):
- HYPERTENSION THAT DEVELOPS AFTER THE
20TH WEEK OF GESTATION TO A PREVIOUSLY
NORMOTENSIVE WOMAN.
RISK FACTORS:
1. SAID TO BE A DISEASE OF PRIMIPARAS – HIGHER
INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35
YEARS.
2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE
)
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER,
H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE
4. HEREDITARY – hx of preeclampsia in mothers or sisters
5. H-mole
6. Previous hx of preeclampsia
CAUSES:
1. UNKNOWN
2. PROTEIN DEFICIENCY THEORY
3. UTERINE ISCHEMIA
4. ARTERIAL VASOSPASM
TRIAD SX:
I HYPERTENSION
2. EDEMA ( INCRESE IN WEIGHT)
3. PROTEINURIA
= 2nd leading cause of maternal death
= chief causes of maternal death due to PIH:
- cerebral hemorrhage
- cardiac failure with pulmonary edema
- rena, hepatic or resp. failure
- obstetric hemorrhage assoc. with abruptio placenta
 VASOSPASM – due to damge to the endothelium
VASCULAR EFFECTS KIDNEY EFFECTS INTERSTITIAL EFFECTS

VASOCONSTRICTION DECREASED DIFFUSION OF FLUID

GLOMERULI FILTRATION FROM BLOOD STREAM
RATE & INCREASED INTO INTERSTITIAL
PERMEABILITY OF TISSUE
GLOMERULI MEMBRANES

POOR ORGAN Inc BLOOD EDEMA

PERFUSION UREA NITROGEN, URIC
ACID, CREATININE
INCREASED BP DECREASED URINE OUTPUT
& PROTEINURIA
Warning Signs:
◼ Rapid weight gain, 4-5 lbs in a single week
◼ Sudden swelling
◼ Swelling of face & hands
◼ Swelling of ankles or feet that does not go away after 12
hours rest
◼ A rise in BP
◼ Protein in the urine
◼ Severe headaches
◼ Blurry vision
◼ Seeing spots in the eyes
◼ Severe pain over the stomach, under the ribs
◼ Decrease in the amount of urine
SIGNS & SYMPTOMS:
S & SX MILD PREECLAMPSIA SEVERE
PREECLAMPSIA
BLOOD PRESSURE 140/90; Systolic elevation 160/110
of 30 mm/Hg
Diastolic elevation of 15
mm/Hg
Proteinuria +1 to +2 +3 to +4 in clean catch
300 mg/ L24 hour urine urine or 5 g/24 hour urine
collection collection
Edema Digital edema ( +1 +2) Pitting edema (+3 +4)
Dependent edema Generalized edema
Weight Gain 3 lb/week More rapid weight gain
Urinary Output Not less than 500 ml/24 Less than 500 ml/24
hours hours; oliguria
Headache Occasional headache Severe headache
Reflexes Normal to +1 +2 Hyperreflexia,+3 +4
Visual Disturbances Absent Photophobia, blurring
spots before the eyes
Epigastric Pain (liver Absent Right upper quadrant
involvement) pain (aura to
convulsion)
EDEMA:
(+1) – PHYSIOLOGIC TYPE IN PREGNANCY, THERE
IS SLIGHT EDEMA IN THE LOWER EXTREMITIES (
DUE TO PRESSURE & POSTURE)
(+2) – MARKED EDEMA OF LOWER EXREMITIES
(PATHOLOGIC)
(+3) – EDEMA FOUND ON THE FACE & FINGERS.
(+4) – GENERALIZED EDEMA ( ANASARCA)
SEIZURE PRECAUTIONS:
1. SIDE RAILS UP
2.PAD THE SIDE RAILS
3. PUT BED AT LOWEST POSITION.
4. ROOM SHOULD BE DIM, QUIET,& AWAY FROM
AREAS OF ACTIVITY. ( AVOID BRIGHT LIGHTS
SUCH AS FLASHLIGHTS)
5. RESTRICT VISITORS TO ALLOW PATIENT TO
REST.
6. HAVE EMERGENCY EQUIPMENT AVAILBLE:
- SUCTION APPARATUS, MAGNESIUM SULFATE,
CALCIUM GLUCONATE, O2
MEDICATIONS:
1. HYDRALAZINE – ( APRESOLINE )
- ANTIHYPERTENSIVE ( PERIPHERAL
VASODILATOR) USED TO DECREASE Hpn
Dosage – 5-10 mg/IV - administer slowly to
avoid sudden fall in BP
- Maintain diastolic pressure at 90 mm/Hg to
ensure adequate placental filling
2. MAGNESIUM SULFATE ( MgSO4)
- DRUG OF CHOICE TO TREAT & PREVENT
CONVULSIONS, also a muscle relaxant
- Loading dose is 4-6g. Maintenance dose is
1-2g/h IV
- Infuse loading dose slowly over 15-30 min.
- Always administer as a piggyback infusion
- Serum Mg level should remain below 7.5 mEq/L
ACTIONS OF MgSO4:
a. PREVENT CONVULSION
b. REDUCE BLOOD PRESSURE
CHECK THE FOLLOWING FIRST BEFORE
ADMINISTERING MgSO4:
1. DEEP TENDON REFLEX PRESENT - +2 ( NORMAL)
2. RR SHOULD BE AT LEAST 12 BPM
3. URINE OUTPUT SHOULD BE AT LEAST 30 ML/HR
▣ Diazepam ( Valium)
◼ Halt seizures
◼ 5-10 mg/IV
◼ Administer slowly
◼ Dose may be repeated every 5-10 mins ( up to 30 mg/hr)
◼ Observe for respiratory depression or hypotension in
mother & respiratory depression & hypotonia in infant at
birth.
** IF MgSO4 TOXICITY DEVELOPS AS SHOWN BY
RR DEPRESSION TO LESS THAN 12 BPM &
DISAPPEARANCE OF THE DTR, GIVE THE ANTIDOTE
CALCIUM GLUCONATE & NOTIFY PHYSICIAN.
- 1g/IV ( 10 ml of a 10% sol)
- have prepared at bedside when administering
MgSO4
** IF MgSO4 IS GIVEN POSTPARTUM, MONITOR
FOR UTERINE ATONY AS IT CAN CAUSE UTERINE
RELAXATION.
SIGNS & SYMPTOMS OF ECLAMPSIA
1. ALL THE SIGNS & SYMPTOMS OF PREECLAMPSIA
2. CONVULSION FOLLOWED BY COMA IS THE MAIN
DIFFERENCE OF ECLAMPSIA & PREECLAMPSIA
3. OLIGURIA
MANAGEMENT:
A. AMBULATORY MX
1. HOME MANAGEMENT IS ALLOWED ONLY IF:
a. BP IS 140/90 O BELOW
b. THERE IS NO PROTEINURIA
c. THERE IS NO FETAL GROWTH
RETARDATION
d. THE PATIENT IS NOT A YOUNG
PRIMIPARA.
2. BED REST – THE WOMAN SHOULD BE IN BED
REST FOR MOST PART OF THE DAY & FREE
FROM PHYSICAL & EMOTIONAL STRESS.
3. THE WOMAN SHOULD CONSULT THE CLINIC AS
OFTEN AS NECESSARY.
4. DIET SHOULD BE HIGH IN PROTEIN &
CARBOHYDRATES WITH MODERATE SODIUM
RESTRICTION.
5. HOSPITALIZATION IS NECESSARY IF CONDITION
WORSENS.
6. PROVIDE DETAILED INSTRUCTIONS ABOUT
WARNING SIGNS:
a. EPIGASTRIC PAIN –AURA TO CONVULSION
b. VISUAL DISTURBANCES
c. SEVERE CONTINUOUS HEADACHE
 d. NAUSEA & VOMITING
B. HOSPITAL MANAGEMENT:
1. BP GOES ABOVE 140/90 mm Hg
2. BED REST IS ONE OF THE MOST IMPORTANT
PRINCIPLES OF CARE.
a. REST IN LEFT LATERAL POSITION TO
PROMOTE BLOOD SUPPLY TO THE PLACENTA &
THE FETUS.
 STAGES OF CONVULSION:
1. STAGE OF INVASION – FACIAL TWITCHING,
ROLLING OF THE EYES TO ONE SIDE, STARING
FIXEDLY IN SPACE.
2. TONIC PHASE – BODY BECOMES RIGID, AS ALL
MUSCLES GO INTO VIOLENT SPASMS OR
CONTRACTIONS, EYES PROTRUDE, HANDS ARE
CLENCHED, WOMAN STOPS BREATHING FOR
15-20 SECONDS.
3. CLONIC PHASE – JAWS & EYELIDS CLOSE & OPEN
VIOLENTLY, FOAMING OF THE MOUTH, FACE
BECOMES CONGESTED & PURPLE,MUSCLES OF
THE BODY CONTRACT & RELAX ALTERNATELY.
THE CONTRACTIONS ARE SO VIOLENT THAT THE
WOMAN MAY THROW HERSELF OUT OF BED.
LASTS FOR ABOUT A FEW MINUTES.
4. POST ICTAL PHASE –WOMAN IS
SEMICOMATOSE, NO MORE VIOLENT MUSCULAR
CONTRACTIONS. THE PATIENT WILL NOT
REMEMBER THE CONVULSION & THE EVENTS
IMMEDIATELY BEFORE & AFTER.
 RESPONSIBILITIES DURING A CONVULSION
1. ALWAYS MONITOR PATIENT FOR IMPENDING
SIGNS OF CONVULSION: EPIGASTRIC PAIN, SEVERE
HEADACHE, NAUSEA & VOMITING.
2 THE MAIN RESPONSIBILITIES OF A NURSE
DURING A CONVULSION ARE: MAINTENANCE PF
PATENT AIRWAY & PROTECTION OF PATIENT FROM
INJURY.
3. TURN PATIENT TO HER SIDE TO ALLOW
DRAINAGE OF SALIVA & PREVENT ASPIRATION.
4. NEVER LEAVE AN ECLAMPTIC PATIENT ALONE
5. DO NOT RESTRICT MOVEMENT DURING A
CONVULSION AS THIS COULD RESULT IN
FRACTURES.
6. WATCH FOR SIGNS OF ABRUPTIO PLACENTA:
VAGINAL BLEEDING, ABDOMINAL PAIN,
DECREASED FETAL ACTIVITY.
7. TAKE VITAL SIGNS & FHT AFTER A CONVULSION.
8. DO NOT GIVE ANYTHING BY MOUTH UNLESS
THE WOMAN IS FULLY AWAKE AFTER A
CONVULSION
** THE ONLY KNOWN CURE OF PIH IS DELIVERY
OF THE BABY.
** AS SOON AS THE BABY IS STABLE, THE BABY
IS DELIVERED.
** THE PREFERRED METHOD OF DELIVERY IS
VAGINAL .
** IF LABOR INDUCTION IS UNSUCCESSFUL &
FETAL DISTRESS IS SO SEVERE THAT THE FETUS
NEED TO BE DELIVERED, CESARIAN SECTION IS
PERFORMED.
POSTPARTUM CARE:
1. THE DANGER OF CONVULSION EXISTS UNTIL 24
HOURS AFTER DELIVERY. MgSO4 THERAPY IS
CONTINUED UNTIL THE IMMEDIATE 24 HOUR
POSTPARTUM.
2. ERGOT PRODUCTS ARE CONTRAINDICATED
BECAUSE THEY ARE HYPERTENSIVES.
3. TWO YEARS SHOULD ELAPSE BEFORE ANOTHER
PREGNANCY IS ATTEMPTED TO DECREASE THE
LIKELIHOOD THAT PIH WILL RECUR ON THE
SUBSEQUENT PREGNANCY.
 HELLP Syndrome
▣ Serious complication of pregnancy induced
hypertension & the client develops multiple organ
damage.
▣ Usually develops before delivery but may occur
postpartum as well.
▣ HELLP syndrome consists of the following
problems:
◼ Hemolysis – red blood cells break down
◼ Elevated liver enzymes – damage to liver cells cause
changes in liver function lab tests
◼ Low platelets – cells found in the blood that are needed to
help clot the blood to control bleeding
▣ HELLP syndrome can cause other problems
◼ Anemia – breakdown of RBC’s may cause anemia
◼ DIC – may lead to severe bleeding
◼ Placenta abruptio – may also occur
SSx of HELLP syndrome:
▣ Right sided upper abdominal pain around the
stomach ( epigastric area)
▣ Nausea & vomiting

▣ Headache

▣ Increased BP

▣ Protein in the urine

▣ edema
How is HELLP diagnosed?
▣ BP measurement

▣ RBC count ( hemolysis)

▣ Bilirubin level – substance produced by the

breakdown of RBC
▣ Liver function tests ( ALT & AST)

▣ Platelet count ( thrombocytopenia )

▣ Urine tests for protein

Treatment:
▣ Bedrest
▣ Blood transfusion
▣ MgSO4 ( as anti convulsant)
▣ Antihypertensive medications
▣ Lab testing of liver, urine & blood ( for changes
that may signal worsening of HELLP syndrome
▣ Corticosteroids – to help in the maturity of fetal
lungs
▣ Delivery ( if HELLP syndrome worsens &
endangers the well being of the mother or fetus)
 Multiple Pregnancy

⦿ When 2 ( twin), 3 (triplet), 4 (quadruplet) or even

5 ( quintuplet) fetuses develop in the uterus at the
same time
⦿ Associated with more risks than a singleton
pregnancy
⦿ TYPES:
⦿ MONOZYGOTIC or IDENTICAL TWIN
› Develop from one ovum & one sperm cell that
undergo rapid cell division after fertilization that
resulted in two or more individuals. Since they come
from only one sperm and one ovum, these individuals
possess the same genetic traits and are always of the
same sex.
⦿ If twinning occurred within 72 hours after
fertilization, there will be:
› 2 amnions ( diamnionic)
› 2 chorions ( dichorionic)
› 2 embryos
⦿ If twinning occurred between the 4th & 8th day
after fertilization, there will be :
› 2 amnions
› 1 chorion ( monochorionic)
› 2 embryos
⦿ If twinning occurred after 8 days, there will be :
› 1 amnion ( monoamnionic)
› 1 chorion
› 2 embryos
⦿ If twinning occurred after the embryonic disc is
formed, CONJOINED TWINS will develop.
Conjoined twins are classified according to the
part of the body where they are attached.
› Anterior – Thoracopagus
› Posterior – pyopagus
› Cephalic – craniopagus
› Caudal – Ischiopagus
⦿ DIZYGOTIC TWINS or FRATERNAL TWINS
› Develop from 2 or more ova and sperm cells that were
fertilized at the same time. They have the same genetic
traits, may or may not be of the same sex and always
have 2 chorions & 2 amnions.
** More females than males because female zygote has a
higher tendency to divide into twins
** Female zygotes have higher rate of survival than male
zygotes
⦿ Predisposing factors of Dizygotic Twinning
› Race – highest in black women
› Heredity – more common in women with familial history of
twinning
› Age & parity – increased incidence in high parity &
advanced maternal age
› Higher incidence in women taking fertility drugs that
promote ovulation & release of several ova at the same time
› Higher incidence within the first months after stopping oral
contraceptives because of the sudden & greater amount of
pituitary gonadotropin released at this time
› In vitro fertilization – stimulation of formation of numerous
follicles, harvesting them in the ovary & fertilizing them in
vitro. All zygotes that were fertilized are returned to the
uterus to grow & develop
⦿ Complications of Multiple Fetuses:
› Abortion
› Death of one fetus
› Perinatal mortality
› Preterm labor – as the number of fetuses increases, the
duration of pregnancy decreases
› Low birth weight
› Congenital malformations
› Hydramnios
› Maternal hypertension
› Placenta previa & Abruptio placenta
› Intrauterine growth retardation
› Cord entanglement, prolapse & compression
› Maternal anemia
⦿ S/Sx
› 1. Uterus large for gestational age
› 2. Auscultation of two or more fetal heart tone
› 3. Hx of twins in the family
› Palpation of three or more large fetal parts
› Ultrasound reveals two or more gestational sac
 Management:

⦿ Clinic Visit:
⦿ First Trimester – every month
⦿ Second Trimester – every 2 weeks
⦿ Third Trimester – every week
⦿ Nutrition – additional 300 kcal to the normal
pregnancy requirement
⦿ 6 small meals rather than 3 large meals to
decrease discomfort of a large uterus
compressing a full stomach
Labor and Delivery:
⦿ The cord is cut right after delivery of the first infant
⦿ Presentation of second infant is ascertained after
birth of first twin either by ultrasound or Leopold’s
or both
⦿ The normal interval of delivery of the first twin and
second twin is (30 minutes)
⦿ If the second twin cannot be delivered vaginally
because of abnormal position, CS is done.
⦿ Cesarean delivery – delivery of choice if the
twins or one of them cannot be delivered
normally or if complications arise that necessitate
immediate delivery.
⦿ Post partum period – watch out for Hemorrhage
due to overdistention of the uterus.
 Premature Labor:
▣ Is labor that occurs between 20 weeks to 37 weeks
gestation characterized by regular uterine
contraction that lasts more than 30 seconds & result
in cervical dilatation & effacement. It is the greatest
cause of neonatal mortality & morbidity.
Causes:
▣ PROM – most often associated with infection
▣ Infection of amniotic fluid –
▣ Retained IUD
▣ Fetal death
▣ History of premature labor & abortion
▣ Overdistention of the uterus – caused by multiple
pregnancy, hydramnios
▣ Abnormal placentation
▣ Uterine abnormalities
▣ Incompetent cervix
▣ Serious maternal conditions
SSx:
▣ Dx is made when there is regular uterine contractions
occuring 5-8 minutes apart accompanied by:
◼ Progressive cervical changes
◼ Cervical dilatation of more than 2 cm
◼ Cervical effacement of 80% or more
◼ Duration of at least 30 secs
◼ 10 mins apart
▣ Menstrual like cramping
▣ Watery or bloody vaginal discharge
▣ Low back pain
MX:
1. Prevention – regular prenatal check up
2. If fetus is less than 32-34 weeks, and still premature to be
delivered, labor must be arrested:
1. Bedrest on LLP to promote blood flow to the placenta
2. Hydration – IV fluids
3. Tocolytics – medications to stop uterine contractions (
relaxes smooth muscles)
1. Ritodrine Hcl
2. Terbutaline –( check pulse rate because it can
cause tachycardia)
3. Prostaglandin inhibitors ( Indomethacin)
Drugs to hasten fetal lung maturity:
- GLUCOCORTICOID therapy if labor can be
delayed for 48 hours – administration of
BETAMETHASONE accelerate fetal lung maturity &
prevents respiratory distress & hyaline membrane
disease ( most common problem of the premature
neonate).
-
MEDICAL CONDITIONS COMPLICATING
PREGNANCY
 HEART DISEASE
CLASSIFICATION:
1. CLASS I = NO LIMITATION,UNCOMPROMISED
= ASYMPTOMATIC, NO DISCOMFORT
WITH ORDINARY PHYSICAL
ACTIVITY.
2. CLASS II =SLIGHT LIMITATION, SLIGHTLY
COMPROMISED, ORDINARY
ACTIVITY CAUSES DYSPNEA,
FATIGUE, CHEST PAIN &
PALPITATIONS.
3. CLASS III = MARKED LIMITATION LESS THAN
ORDINARY ACTIVITY CAUSE
EXCESSIVE FATIGUE;
PALPITATIONS, CHEST PAIN & DYSPNEA.
4. CLASS IV =SEVERE LIMITATION; PATIENT
EXPERIENCES SYMPTOMS EVEN
AT REST; UNABLE TO PERFORM ANY
PHYSICAL ACTIVITY WITHOUT
DISCOMFORT.
SIGNS & SYMPTOMS:
1.DIFFICULTY OF BREATHING – DYSPNEA,
ORTHOPNEA, NOCTURNAL DYSPNEA
2. HEMOPTYSIS
3. SYNCOPE WITH EXERTION
4. CHESTPAIN
5. CYANOSIS
7. CLUBBING OF FINGERS
8. NECK VEIN DISTENTION
9. SYSTOLIC & DIASTOLIC MURMURS
NURSE ALERT:
** REMEMBER A PREGNANT WOMAN WITH
HEART DISEASE SHOULD AVOID INFECTION,
EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA
BECAUSE THESE CONDITIONS INCREASE THE
WORKLOAD OF THE HEART.
MX:
A. PRENATAL CARE:
1. PROMOTION OF REST ( CLASS I & CLASS II)
* 8 HOURS OF SLEEP DURING THE NIGHT &
HAVE FREQUENT REST PERIODS DURING THE
DAY.
* LIGHT WORK IS ALLOWED BUT NO HEAVY
WORK, NO STAIR CLIMBING, NO EXHAUSTION.
2. DIET
* HIGH IN IRON, PROTEIN,MINERALS &
VITAMINS
3. AVOID HIGH ALTITUDES, SMOKING AREAS,
UNPRESSURIZED PLANES & OVERCROWDED AREAS.
CIGARETTE SMOKING & ALCOHOLIC BEVERAGES
ARE STRICTLY PROHIBITED.
4.PREVENTION OF INFECTION
* AVOID PERSONS WITH ACTIVE INFECTIONS
(COLDS, COUGH).
* EARLY TREATMENT OF INFECTIONS
5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF
HEART FAILURE:
* COUGH WITH CRACKLES IS USUALLY THE
FIRST SIGN OF AN IMPENDING HEART FAILURE.
 * INCREASING DYSPNEA, TACHYCARDIA, RALES,
EDEMA

MEDICATIONS:
>IRON SUPPLEMENTATION TO PREVENT ANEMIA
>DIGITALIS TO STRENGTHEN MYOCARDIAL
CONTRACTION AND SLOW DOWN HEART RATE
>NITROGLYCERINE TO RELIEVE CHEST PAIN
>ANTIBIOTICS TO PREVENT AND TREAT
INFECTION
>DIURETICS MAY BE PRESCRIBED IN CASE OF
HEART FAILURE
INTRAPARTAL CARE
1.EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED
BEFORE LABOR BEGINS TO PROMOTE REST, FOR
CLOSER SUPERVISION AND PREVENT INFECTION
2.WOMAN IN LABOR IS IN SEMI-FOWLER’S POSITION
OR LEFT LATERAL RECUMBENT POSITION. NO
LITHOMY POSITION.
3.VITAL SIGNS- VITAL SIGNS ARE MONITORED
CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY
RATE MORE THAN 24 ARE SIGNS OF IMPENDING
CARDIAC DECOMPENSATION. DURING THE FIRST
STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES
AND MORE FREQUENTLY DURING THE SECOND STAGE
4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR
PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS
USED TO SHORTEN THE SECOND STAGE. PUSHING IS
CONTRAINDICATED
5. WOMEN WITH HEART DISEASE ARE POOR
CANDIDATE FOR CS DUE TO INCREASED RISK FOR
HEMORRHAGE, *INFECTION AND
THROMBOEMBOLISM
POSTPARTUM CARE
1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE
POSTPARTUM BECAUSE OF THE SUDDEN INCREASE
IN CIRCULATORY BLOOD VOLUME.
2. MONITOR VITAL SIGNS.
3. PROMOTE REST- RESTRICT VISITORS TO ALLOW
PATIENT TO REST, THE WOMAN STAYS IN THE
HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS
STABILIZED.
4. EARLY BUT GRADUAL AMBULATION TO PREVENT
THROMBOPHLEBITIS.
5. MEDICATIONS
*ANTIBIOTICS
*STOOL SOFTENERS TO PREVENT STRAINING AT
STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE
ORDERED TO PROMOTE REST.
6. BREASTFEEDING IS ALLOWED IF THERE ARE NO
SIGNS OF CARDIAC DECOMPENSATION DURING
PREGNANCY, LABOR AND PUEPERIUM.
 The Anemias of Pregnancy
▣ Hemoglobin level of less than 11g/dl in the first and
third trimester and less than 10.5g/dl in the second
trimester.
 Iron Deficiency Anemia
▣ Most common type of anemia during pregnancy.
Most women enter pregnancy without enough iron
reserve so that deficiency develops particularly on
the 2nd and 3rd trimester when iron requirements
increases.
Predisposing Factors:
▣ Poor diet and poor nutrition

▣ Heavy menses

▣ Pregnancies at close intervals, successive

pregnancies
▣ Unwise reducing programs
▣ **Nurse Alert**
“ The newborn of the severely anemic mother IS
NOT AFFECTED by iron deficiency anemia.
This is because the amount of iron transported to
the fetus of an anemic mother is almost the same
as the amount transported to the fetus of a
mother without anemia”
Signs and Symptoms
▣ Easy fatigability

▣ Sensitivity to cold

▣ Proneness to infection

▣ Dizziness

▣ Laboratory findings will reveal low hgb

 Effects of Anemia to Pregnancy

▣ Decreased resistance to infection

▣ Associated with prematurity & low birth weight
infants
▣ Predispose to heavy bleeding during labor &
puerperium
▣ May increase digestive discomfort of pregnancy
 Management:
1. Oral iron supplementation – 200 mg of elemental
iron daily in the form of:
◼ Ferrous Sulfate – the most absorbable form of iron
◼ Ferrous Fumarate
◼ Ferrous Gluconate
Inform the mother about the possible side effects. Tarry stool,
constipation, GI discomfort
Never take with milk but with citrus juice
If given in liquid form, use straw to prevent staining
the teeth. Tell patient to rinse mouth.
If iron is to be given parenterally, give IM by Z
tract technique to prevent tissue staining. Do not
massage after injection.
▣ Oral iron should be continued until 3 months after
anemia has been corrected.
▣ Increase intake of iron rich foods: lean meat, liver,
dark green leafy vegetables. Good food sources of
iron include the following:
◼ Meats – beef, pork, lamb, liver,& other organ meats
◼ Poultry – chicken, duck, turkey, liver ( especially dark
meat)
◼ Fish – shellfish, including clams, mussels, oysters,
sardines and anchovies
◼ Leafy greens of the cabbage family such as broccoli
◼ Legumes such as lima beans & green peas; dry beans
& peas
◼ Yeast-leavened whole wheat bread & rolls
◼ Iron enriched, white bread, pasta, rice & cereals
 Folic Acid Deficiency Anemia
▣ Folic acid is necessary for the normal formation and
nutrition of red blood cells. Deficiency in folic acid
leads to the formation of large and immature blood
cells that have shorter life span than normal red
blood cells. Women who have folic acid deficiency
during pregnancy are more at risk of giving birth to
babies with neural tube defects.
Effects on Pregnancy:
◼ ABORTION, Abruptio placenta, Neural defect in fetus
Predisposing Factors:
◼ 1. Long term use of oral contraceptives
◼ 2. Poor nutrition
◼ 3. Multiple pregnancies
◼ 4. Successive pregnancies
Signs and Symptoms
◼ 1. Nausea
◼ 2. Vomiting
◼ 3. Anorexia – lack of appetite
 Management:
▣ Folic acid supplementation of 1 mg/day accompanied oral
iron. RDA for all women – 0.4mg/day
▣ Vit supplements containing 400 micrograms of folic acid are
now recommended for all women of chilbearing age and
during pregnancy. These supplements are needed because
natural food sources of folate are poorly absorbed and much
of the vitamin is destroyed in cooking. Food sources of folate
include the ff:
▣ Leafy dark green vegetables, dried beans & peas, nuts, citrus
fruits & juices & most berries, fortified breakfast cereals,
enriched grain products
Hemolytic Disease:
ISOIMMUNIZATION / RH INCOMPATIBILITY
- OCCURS WHEN AN RH-NEGATIVE MOTHER IS
CARRYING AN RH-POSITIVE FETUS.
- FOR SUCH A SITUATION TO OCCUR, THE
FATHER OF THE CHILD MUST EITHER BE A
HOMOZYGOUS ( DD) OR HETEROZYGOUS ( Dd) RH
POSITIVE.
- IF THE FATHER OF THE CHILD IS
HOMOZYGOUS (DD), 100% OF THE COUPLE’S
CHILDREN WILL BE RH (+).
 -PEOPLE WHO HAVE RH (+) BLOOD HAVE A
PROTEIN FACTOR ( D ANTIGEN) THAT RH (-)
PEOPLE DO NOT.
- WHEN AN RH(+) FETUS BEGINS TO GROW
INSIDE AN RH (-) MOTHER, IT IS THOUGH HER
BODY IS BEING INVADED BY FOREIGN AGENT, OR
ANTIGEN.
- THEORETICALLY, THERE IS NO CONNECTION
BETWEEN FETAL BLOOD & MATERNAL BLOOD
DURING PREGNANCY BUT
BUT SOMETIMES ACCIDENTAL BREAKS IN THE
PLACENTAL VILLI RESULTS IN FETAL BLOOD
ENTERING THE MATERNAL BLOODSTREAM. (also
AMNIOCENTESIS , PUBS).
- ONLY A FEW ANTIBODIES ARE FORMED THIS
WAY SO THAT IT DOES NOT AFFECT THE FIRST
INFANT.
- DURING PLACENTAL SEPARATION AND
DELIVERY, A GREAT AMOUNT OF MATERNAL &
FETAL BLOOD ARE MIXED, CAUSING THE MOTHER
TO PRODUCE LARGE AMOUNTS OF ANTIBODIES
DURING THE FIRST 72 HOURS AFTER PLACENTAL
DELIVERY.
 - IF THE FETUS IN SUBSEQUENT PREGNANCIES
IS RH (+), THE ANTIBODIES ALREADY PRESENT IN
THE BLOODSTREAM WILL CROSS THE PLACENTA
ATTACK & DESTROY THE FETAL RED BLOOD CELLS
( HEMOLYSIS). THE FETUS BECOMES SO
DEFICIENT IN RBC’S THAT SUFFICIENT O2
TRANSPORT TO BODY CELLS CANNOT BE
MAINTAINED. THIS CONDITION IS TERMED “
HEMOLYTIC DISEASE OF THE NEWBORN” OR
ERYTHROBLASTOSIS FETALIS.
DX:
1. INDIRECT COOMB’S TEST – TEST TO CHECK
FOR THE PRESENCE OF ANTIBODIES IN MATERNAL
SERUM.
2. DIRECT COOMB’S TEST –TEST TO CHECK THE
PRESENCE OF ANTIBODIES IN FETAL CORD
BLOOD.
 Prevention:
▣ Administration of Rh ( anti D) globulin (Rhogam) at
28 weeks gestation and within the first 72 hours
after delivery to a woman who:
◼ Have delivered Rh positive fetus
◼ Have had untypeable pregnancies such as ectopic
pregnancies, stillbirth & abortion
◼ Have received ABO compatible Rh positive blood
◼ Have had invasive diagnostic procedure such as
amniocentesis, PUBS ( cordocentesis)
▣ ABO INCOMPATIBILITY
◼ Occurs when maternal blood type is O and fetus is:
Type A – most common
Type B – most serious
Type AB – rare
MX of HEMOLYTIC DISEASE:
1. SUSPENSION OF BREASTFEEDING DURING THE
FIRST 24 HOURS TO PREVENT PREGNANEDIOL
(BREAKDOWN PRODUCT OF PROGESTERONE
EXCRETED IN BREASTMILK) FROM INTERFERING
WITH THE CONJUGATION OF INDIRECT
BILIRUBIN TO DIRECT BILIRUBIN.
2. PHOTOTHERAPY – DESTRUCTION OF RBC’S
RESULTS IN THE FORMATION OF INDIRECT
BILIRUBIN. INDIRECT BILIRUBIN MUST FIRST BE
CONVERTED TO DIRECT BILIRUBIN BY THE LIVER
CELLS BEFORE IT CAN BE EXCRETED IN THE
BODY. THE LIVER IS IMMATURE AT BIRTH SO IT
CANNOT CONVERT LARGE AMOUNTS OF
BILIRUBIN FORMED DURING HEMOLYSIS OF RBC.
a. USES BILI OR FLUORESCENT LIGHTS
POSITIONED 12 – 30 INCHES ABOVE THE
INFANT.
NURSING CARE DURING PHOTOTHERAPY:
1. COVER EYES WITH DRESSING
2. COVER GENITALS TO PREVENT PRIAPISM.
3. EXPECT THE STOOL TO BE LOOSE & BRIGHT
GREEN FROM EXCESSIVE BILIRUBIN EXCRETION
& THE SKIN TO BE DARK BROWN ( BRONZE
BABY SYNDROME).
4. PROVIDE GOOD SKIN CARE BECAUSE STOOL
CAN BE IRRITATING TO THE SKIN.
5. EXPECT THE URINE TO BE DARK COLORED
BECAUSE OF UROBILINOGEN FORMATION.
6. ASSESS FOR DEHYDRATION ( I & O ; SKIN
TURGOR). FLUID LOSS THROUGH INSENSIBLE
WATER LOSS MAY OCCUR BECAUSE OF THE HEAT
FROM THE FLUORESCENT LIGHT ABOVE THE
INFANT.
7. OFFER GLUCOSE WATER EVERY 3 HOURS TO
PREVENT DEHYDRATION.
8. MAINTAIN BODY TEMP BETWEEN 36C & 37C.
EXCHANGE TRANSFUSION:
1. INTRAUTERINE TRANSFUSION:
- DONE BY INJECTING RBC’S DIRECTLY INTO A
VESSEL IN THE FETAL CORD OR DEPOSITING
THEM IN THE FETAL ABDOMEN USING
AMNIOCENTESIS TECHNIQUE.
- BLOOD USED FOR TRANSFUSION IS EITHER
THE FETUS’ OWN TYPE OR GROUP O NEGATVE
IF THE FETAL BLOOD TYPE IS UNKNOWN.
-FROM 75 TO 150 ML OF WASHED RBC’S WILL
BE USED, DEPENDING ON THE AGE OF THE
FETUS.
 - INTRAUTERINE TRANSFUSION IS NOT
WITHOUT RISK. A CORD VESSEL MAY BE
LACERATED BY THE NEEDLE. BUT FOR A FETUS
WHO IS SEVERELY AFFECTED BY
ISOIMMUNIZATION, HOWEVER, SUCH A RISK IS
NO GREATER THAN LEAVING THE FETUS
UNTREATED.
- MOTHER RECEIVES AN RhIG INJECTION(
RhoGAM) AFTER THE TRANSFUSION TO HELP
REDUCE ISOIMMUNIZATION FROM THE
AMNIOCENTESIS.
- AS SOON AS FETAL MATURITY IS REACHED (
L:S RATIO 2:1), DELIVERY WILL BE INDUCED.
NOTE:
ADMINISTER RhoGAM TO ALL Rh (-) MOTHERS
DURING PREGNANCY ( AT 28 WEEKS GESTATION)
AND WITHIN 72 HOURS OF DELIVERY OR
ABORTION OF AN Rh (+) FETUS **
 - AFTER BIRTH, THE INFANT MAY REQUIRE AN
EXCHANGE TRANSFUSION TO REMOVE
HEMOLYZED BLOOD CELLS & REPLACE THEM
WITH HEALTHY ONES.
Notify your healthcare provider if your baby has
any of the following s/s after returning home:
> Fever
> Jaundice
> Poor appetite or poor weight gain
> Excessive crying that does not stop when the
baby is held.
Signs in the newborn:
▣ Paleness
▣ Jaundice that begins within 24 hours after
delivery ( pathologic jaundice)
▣ Unexplained bruising or blood spots under the
skin
▣ Tissue swelling ( edema)
▣ Seizures
▣ Lack of normal movement
▣ Poor reflex response