MODULE 1: ANTEPARTAL

Ectopic Implantatio Sudden May have

OUTLINE
(Tubal) n of zygote unilateral lower repeat
I. High Risk Pregnancy: First Trimester Pregnancy at site abdominal ectopic
II. High Risk Pregnancy: Second & Third rather than quadrant pain pregnancy
Trimester in uterus minimal in future is
III. Pre-existing or Newly Acquire Disease associated vaginal tubal
IV. Pre-existing or Newly Acquired Disease with tubal bleeding scarring is
(Pregnant mother with Asthma & Diabetes contracture possible signs bilateral
Mellitus) s of hypovolemic
V. Pre-existing Disease (Pregnant mother with
Anemia and Cardiovascular Disease)
shock or
VI. Pregnant mother with Special Needs hemorrhage

HIGH-RISK PREGNANCY: FIRST TRIMESTER FIRST TRIMESTER BLEEDING

INTRODUCTION
• Spontaneous Miscarriage
• Early bleeding in pregnancy refers to the vaginal bleeding o Threatened Miscarriage
Links to an external site. before 24 weeks of gestational o Imminent (Inevitable) Miscarriage
age (during the first and second trimester). If the bleeding o Missed Miscarriage
is observed as significant, hemorrhagic shock may occur. o Incomplete Miscarriage
Concern for shock is increased to those patients who o Complete Miscarriage
have loss of consciousness, chest pain and shortness of • Ectopic Pregnancy
breath.
SPONTANEOUS MISCARRIAGE
Table 1. Summary of Primary Causes of Bleeding during • Any interruption of a pregnancy before the fetus is
Pregnancy viable (more than 20 to 24 weeks gestation or
Type Cause Assessment Caution weighs at least 500 g).
Threatened Unknown, Vaginal Caution • Early – occurs before wk 16 of pregnancy
spontaneous possibly Spotting, women not • Late – between 16-24 wks
miscarriage chromosom perhaps slight to used • Abortion – Medical term of any interruption of a
(early under al or uterine cramping tampons to pregnancy before a fetus is viable
16 weeks; abnormaliti halt • Elective Abortion – Planned medical termination of
late 16-24 es bleeding as pregnancy
weeks this can • Miscarriage – interruption occurs spontaneously
lead to • CAUSES:
infection
Imminent Unknown Vaginal o Abnormal fetal formation
(inevitable) reason but spotting, o Teratogenic factors
miscarriage possible cramping, o Chromosomal aberration
poor cervical dilation o Rejection of the embryo through immune
placental response
attachment o Implantation abnormalities
Missed Unknown Vaginal Disseminat o Inadequate endometrial formation or
Miscarriage Spotting, ed inappropriate site of implantation
perhaps slight intravascula o Inadequate implantation
cramping; no r o Inadequate placental circulation and fetal nutrition
apparent loss coagulation o Corpus luteum fails to produce enough
of pregnancy is progesterone
associated o Infection: Rubella, syphilis, poliomyelitis, CMV
with missed and Toxoplasmosis, UTI crosses the placenta
miscarriage fetus fails to grow placental production of
Incomplete Unknown, Vaginal High risk for estrogen and progesterone fails endometrial
Spontaneou possibly Spotting, uterine sloughing prostaglandins are released uterine
s chromosom cramping infection contraction and cervical dilation
miscarriage al or uterine cervical and o Teratogenic Agents
abnormaliti dilatation but hemorrhage
es incomplete ECTOPIC PREGNANCY
expulsion of
• Implantation occurs outside the uterine cavity
uterine content
• Ovary
Complete Unknown, Vaginal
• Cervix
Spontaneou possibly Spotting,
s chromosom cramping • Fallopian tube 95%
miscarriage al or uterine cervical o Ampullar portion 80% (distal third)
abnormaliti dilatation but o Isthmus 12%
es complete o Interstitial 8%
expulsion of • Predisposing Factors:
uterine content o Obstruction - tubal scarring from PID
o Smokes

ANDREA DENISE SAMBRANO | BSNS2C

 o IUD – slows the transport of the zygote Passage of Tissue: No, loss of products
o History of ectopic pregnancy of conception cannot be halted
• Signs and Symptoms: Cervical Dilation: Yes
o Nausea and vomiting Management:
o Positive pregnancy test • Sonogram – if no fetal heart tone,
o 6 to 12 weeks AOG empty uterus, non-viable fetus→ D &
§ Rupture of fallopian tube E
§ Trophoblast cells break • D & E – remove products of
§ Tearing and destruction of the blood conception, prevent infection
vessels • Assess vaginal bleeding post D & E
• Sharp, stabbing pain in the lower abdominal Incomplete Amount of Bleeding: Heavy, profuse
quadrant Uterine Cramping: Severe
• Scant vaginal spotting Passage of Tissue: Yes, membrane or
• The amount of bleeding evident with a ruptured placenta is retained in the uterus
ectopic pregnancy does not reveal the actual Cervical Dilation: Yes, with tissue in
amount present cervix
• Signs of shock: Management:
o Lightheadedness • D & C or suction curettage to prevent
o Rapid pulse hemorrhage and infection
• Complications: Complete Amount of Bleeding: Slight
o Peritoneal irritation Uterine Cramping: Mild
§ Cullen’s sign – bluish discoloration Passage of Tissue: Yes, fetus,
of the umbilicus membranes, placenta
§ Excruciating pain upon movement Cervical Dilation: Yes
of cervix on pelvic exam Management:
§ Blood from the peritoneal cavity à • No further intervention is needed if
irritates the phrenic nerve à uterine contractions are adequate to
Shoulder pain prevent hemorrhage and there is no
§ Tender mass palpated in cul-de-sac infection.
• Diagnosis: • Suction or curettage to ensure no
o Ultrasound retained fetal or maternal tissue.
• Treatment: • Bleeding slows down within 2 hours
o Before the rupture: and ceases within a few days after
§ Methotrexate passage of products of conception
• A folic acid antagonist Missed • Fetus dies in the utero but is not
chemotherapeutic agent (early expelled
• Attacks and destroys fast pregnancy • No increase in fundic height
growing cells failure) • No FHT
§ Mifepristone Amount of Bleeding: With
• An abortifacient Uterine Cramping: Perhaps slight
• Slough of the tubal cramping
implantation Passage of Tissue: No apparent loss of
o Ectopic Pregnancy ruptures: pregnancy
§ Emergency case Cervical Dilation: No
§ Ligate the bleeding vessels Management:
§ Remove or repair the damaged • Sonogram – failure of growth
fallopian tube • D&E
• If over 14 weeks – induction of labor
(misoprostol and oxytocin)
Table 2. Assessing Miscarriage and the Usual Management • Spontaneous miscarriage within 2
Threatened Amount of Bleeding: Slight, spotting weeks (danger of DIC)
Uterine Cramping: Mild Recurrent Amount of Bleeding: Varies
Passage of Tissue: No (generally Uterine Cramping: Varies
Cervical Dilation: No defined as 3 Passage of Tissue: Yes
Management: or more Cervical Dilation: Yes, usually
• Bed rest sedation consecutive Management:
• Avoid: abortions) • Varies, depends on type.
o Stress • Prophylactic cerclage may be done if
o Sexual stimulation premature cervical dilation is the
o Orgasm usually recommended cause.
• Further treatment depends on the • Tests:
woman’s response to treatment. o Parental Cytogenetic Analysis
o Sonogram-check for fetal heart o Lupus Anticoagulant And
sounds o Anticardiolipin Antibodies Assay
o hCG determination Septic • Abortion complicated by infection
o Avoid strenous activity for 24 to • More common among those who self-
48 hrs abort
o Emotional support
• Fever, crampy abdominal pain, uterine
o No coitus for 2 weeks after the tenderness
bleeding episode Amount of Bleeding: Varies
Inevitable Amount of Bleeding: Moderate Uterine Cramping: Varies
(imminent) Uterine Cramping: Mild to severe Passage of Tissue: Yes
 Cervical Dilation: Yes, usually
Management:
• Immediate termination of pregnancy
• Cervical culture and sensitivity studies
• broad-spectrum antibiotic therapy
(e.g. ampicillin) is started.
• Treatment for septic shock is initiated,
if necessary.
• Tetanus toxoid/ tetanus Ig
COMPLICATIONS OF PREGNANCY
Hemorrhage • Assess amount of bleeding
• Rule of thumb: More than one
sanitary pad per hour is
excessive
• Monitor vital signs to detect
hypovolemic shock
• Massage the uterine fundus to
aid contraction
• Dilatation and curettage
• Suction curettage
• Transfusion
Infection • Fever (>38˚C),
• Abdominal pain / tenderness
• Foul vaginal discharge
• Management:
o Perineal care (front to back
wiping)
o Not to use tampons à stasis
of body fluid à increasing
risk of infection
Isoimmunization • Production of antibodies against
Rh-positive blood
• Next pregnancy, these antibodies
would attempt to destroy the red
blood cells of the next infant
• Treatment: Rh (D antigen)
immune globulin (RhoGAM) –
prevent the buildup of antibodies
Powerlessness Assess feelings and grief over the loss
or anxiety
SURGICALLY INDUCED ABORTION
IRON DEFICIENCY ANEMIA
• Simplest type
• Ambulatory Setting
• A narrow polyethylene catheter is introduced vaginally
into the cervix
• Lining of the uterus is then suctioned and removed by
vacuum pressure
• Nursing Interventions:
o Remain on supine position for 15 minutes after
the procedure
o Oral oxytocin
o Watch signs and symptoms of complications
o Vaginal bleeding for a week after the procedure
o Avoid douche, use of tampons, resume coitus
after 1 week to avoid introducing infection
DILATATION AND CURETTAGE
• Used for less than 13 weeks AOG
• Ambulatory setting
• Paracervical anesthetic block
• Uterus is cleaned with a curette removing the zygote and
trophoblast cells with the uterine lining
• Remains in the hospital for 1 to 4 hours
• Oxytocin
• Complications:
o Perforation
o Uterine Infection
DILATATION AND VACUUM EXTRACTION
• Used for 12 and 16 weeks
• Cervical dilatation is begun the day before the procedure:
o Oral misoprostol
o Laminera tent (seaweed that has been dried and
sterilized)
• Vacuum Extraction
• Complications:
o Incompetent cervix
o Infection
PROSTOGLANDIN INDUCTION
• Between 16 to 24 weeks
• Prostaglandin F2-alpha
• Prostaglandin E2 suppository
o Cervical dilatation and uterine cramping
SIGNS AND SYMPTOMS OF HYPOVOLEMIC
SHOCK
• Decreased central venous pressure
• Increased pulse rate
• Heart is attempting to circulate decreased blood volume
• Decreased blood is returning to heart due to reduced
blood volume
• Less peripheral resistance because of decreased blood
volume
• Increased respiratory rate
• Increases gas exchange to better oxygenate decreased
red blood cell volume
• Cold, clammy skin
• Vasoconstriction occurs to maintain blood volume in
central body core
• Inadequate blood is entering kidney due to decreased
blood volume
• Dizziness or decreased level of consciousness
• Inadequate blood is reaching the cerebrum
HIGH-RISK PREGNANCY: SECOND & THIRD
TRIMESTER
GESTATIONAL HYPERTENSION
• A condition in which vasospasm occurs in both small and
large arteries during pregnancy causing increased blood
pressure.
• Defined as having a blood pressure higher than 140/90
measured on two separate occasions, more than 6 hours
apart, without the presence of protein in the urine and
diagnosed after 20 weeks of gestation.
• Pre-eclampsia affects all organs
• Vascular spasm – increase cardiac output required by
pregnancy which injures endothelial cells and arteries
that reduce action of prostacyclin, a prostaglandin
vasodilator and excess production of thromboxane – a
prostaglandin vasodilator
• Usually during pregnancy blood vessels are resistant to pressure returns to normal
the effects of pressor substances such as angiotensin after birth.
and norepinephrine, so even there is increase blood Preeclampsia w/o severe Blood pressure is 140/90
supply, blood pressure remains normal features mmHg or systolic pressure
• But in gestational hypertension-----reduce elevated 30 mmHg or
responsiveness to blood pressure changes appears to be diastolic pressure elevated
lost because of the prostaglandin is released. 15 mmHg above pre
• Vasoconstriction occurs and BP increases dramatically. pregnancy level; proteinuria
• Heart – is forced to pump against rising of peripheral of 1+ to 2+ on a random
resistance-----Reduce blood supply to organs (kidney, sample; weight gain over 2
pancreas, liver, brain and placenta. lb/week in second trimester
• Poor Placenta perfusion- reduce fetal nutrient and blood and 1 lb/week in third
supply. trimester; mild edema in
• Ischemia in pancreas---result in epigastric upper extremities or face.
• Pain and elevated amylase creatinine ratio. Preeclampsia w/ severe Blood pressure is 160/110
• Spasm in retina – retinal hemorrhage and even blindness features mmHg; proteinuria 3+ to 4+
• Vasospasm in kidney – increase blood flow resistance--- on a random sample and 5
degenerative changes in the glomeruli because of back g on a 24-hour sample;
pressure----increase permeability of glomeruli oliguria (500 mL or less in
membrane---allowing serum protein albumin to escape in 24 hours or altered renal
urine (proteinuria) function tests; elevated
serum creatinine more than
• Degenerative change – decreased glomeruli filtration ---
1.2 mg/dl); cerebral or
lowered urine output and clearance of creatinine
visual disturbances
• Increase kidney tubular reabsorption – retention of
(headache, blurred vision);
sodium begins- as sodium retains in the fluid – Edema
pulmonary or cardiac
occurs
involvement; extensive
• Extreme edema – lead to maternal cerebral and
peripheral edema; hepatic
pulmonary edema and seizure (Eclampsia)
dysfunction;
• Arterial spasm – causes bulk of the blood volume in the thrombocytopenia;
maternal circulation to be pooled in venous circulation --- epigastric pain.
--low arterial intravascular volume
Eclampsia Either seizure or coma
• Thrombocytopenia or a lowered platelet counts occur---- accompanied by signs and
could damage endothelial cells symptoms of preeclampsia
• Monitor hct –the higher the hct, the higher is lost. are present.
• Normal proteinuria level. Normal 24-hour excretion of
urine albumin is less than 30 mg. Usually, PREECLAMPSIA
microalbuminuria is defined as greater than 20 μg/min (or
30 mg/24 h) and less than 200 μg/min (or 300 mg/24 h).
• Is a pregnancy related disease process evidenced by
increased blood pressure and proteinuria,
CAUSES OF GESTATIONAL HYPERTENSION
• Toxemia of pregnancy – older term
• Pre-existing hypertension (high blood pressure)
• Pre-eclampsia is a condition that affects some pregnant
• Kidney disease.
women usually during the second half of pregnancy (from
• Diabetes. around 20 weeks) or immediately after delivery of their
• Hypertension with a previous pregnancy. baby. Women with pre-eclampsia have high blood
• Mother's age younger than 20 or older than 40. pressure, fluid retention (edema) and protein in the urine
• Multiple fetuses (twins, triplets) (multiple pregnancy) (proteinuria).
• African-American race.
• Low socio economic group (poor nutrition)
NURSING INTERVENTIONS
• Polyhydramnios (overproduction of amniotic fluid)
Preeclampsia 1. Monitor antiplatelet therapy –
w/o severe due to increase tendency of
SIGNS AND SYMPTOMS OF GESTATIONAL features platelets to cluster along arterial
HYPERTENSION walls, such as low dose aspirin,
• Headache that doesn't go away. it will prevent or delay
• Edema (swelling) preeclampsia
• Sudden weight gain. 2. Promote bed rest
• Vision changes, such as blurred or double vision. 3. Promote good nutrition
• Nausea or vomiting. 4. Promote emotional support
• Pain in the upper right side of your belly, or pain around
your stomach. Preeclampsia w/ 1. Support bed rest
• Making small amounts of urine. severe features 2. Monitor maternal well-being (BP
q 4, lab, daily weighing)
Table 3. Symptoms of Gestational Hypertension 3. Monitor fetal well being
HYPERTENSION TYPE SYMPTOMS 4. Support a nutritious intake
Gestational Hypertension Blood pressure is 140/90 5. Administer medication to
mmHg or systolic pressure prevent eclampsia
elevated 30 mmHg or
diastolic pressure elevated • (Hypotensive drugs: apresoline
15 mmHg above pre- or hydralazine, betalol, nifidifine
pregnancy level; no and
proteinuria or edema; blood • Magseium So4-drug of choice
for eclampsia
 • Ca gluconate – Antidote for
magnesium toxicity
ECLAMPSIA
• It is the most severe classification of pregnancy-related
hypertensive disorders. A woman has passed into this
stage when cerebral edema is so acute a grand mal
(tonic-clonic) seizure or coma has occurred. With
eclampsia, the maternal mortality can be as high as 20%
from causes such as cerebral hemorrhage, circulatory
collapse, or renal failure.
• The fetal prognosis with eclampsia is also poor because
of hypoxia, possibly caused by the seizure, with
consequent fetal acidosis.
• If premature separation of the placenta from extreme
vasospasm occurs, the fetal prognosis becomes even
graver. If a fetus must be born before term, all the risks of
immaturity will be faced.
Table 4. Drugs used in Preeclampsia
Magnesium Indication: Muscle relaxant; prevents
Sulfate seizures
Dosage: Loading dose 4-6 g
Maintenance dose 1-2 g/hr IV
Comments:
• Infuse loading dose slowly over 15-
30 minutes.
• Always administer as a piggyback
infusion.
• Assess respiratory rate, urine output,
deep tendon reflexes, and clonus evry
hour.
• Urine output should be over 30 ml/hr
and respiratory rate over 12
breaths/min. Serum magnesium level
should remain below 7.5 mEq/l
Hydralazine Indication: Antihypertensive (peripheral
(Apresoline) vasolidator); used to decrease
hypertension
Dosage: 5-10 mg IV
Comments:
• Observe for central nervous system
(CNS) depression and hypotonia in
infant at birth and calcium deficit in the
mother.
• Administer slowly to avoid sudden fall
in blood pressure.
• Maintain diastolic pressure over 90
mmHg to ensure adequate placental
filling.
Diazepam Indication: Halt seizures
(Valium) Dosage: 5-10 mg IV
Comments:
• Administer slowly. Dose may be
separated q 5-10 minutes (up to 30
mg/hr).
Calcium Indication: Antidote for magnesium
Gluconate intoxication
Dosage: 1 g IV (10 ml of a 10% solution)
Comments:
• Have prepared at bedside as the
antidote when administering
magnesium sulfate.
• Administer at 5 ml/min.
HELLP SYNDROME
• HELLP syndrome – is a variation of the gestational
hypertensive process named for the common symptoms
that occur:
o Hemolysis leads to anemia
o Elevated liver enzymes lead to epigastric pain
o Low platelets lead to abnormal bleeding/clotting
(Pourrat, Coudroy, & Pierre, 2015)
• The syndrome occurs 4% to 12% of patients who have
elevated blood pressure during pregnancy. It is a serious
syndrome because it results in a maternal morality rate
as high as 24% and an infant mortality rate as high as
35%.
• HELLP syndrome is a complication of pregnancy
characterized by hemolysis, elevated liver enzymes, and
a low platelet count. It usually begins during the last three
months of pregnancy or shortly after
• The cause of HELLP syndrome is unknown, but there
are certain factors that may increase your risk of
developing it. Preeclampsia is the greatest risk factor.
This condition is marked by high blood pressure, and it
typically occurs during the last trimester of pregnancy.
• Pregnant women developing HELLP syndrome have
reported experiencing one or more of these symptoms:
o Headache.
o Nausea/vomiting/indigestion with pain after eating.
o Abdominal or chest tenderness and upper right
upper side pain (from liver distention)
o Shoulder pain or pain when breathing deeply.
o Bleeding.
o Changes in vision.
• Causes:
o Unknown but there are certain factors that may
increase your risk of developing it.
o Preeclampsia is the greatest risk factor. This
condition is marked by high blood pressure, and it
typically occurs during the last trimester of
pregnancy.
• Though the cause of HELLP is not yet fully understood,
it can lead to lung and heart failure, permanent liver and
kidney damage, internal bleeding, stroke, and other
serious complications in the mother.
• Other serious complications for the fetus include
intrauterine growth restriction and respiratory
distress syndrome.
MULTIPLE PREGNANCY
• Is considered a complication of pregnancy because a
woman’s body must adjust the effects of more than one
fetus. The incidence of multiple births has increased
dramatically because of the use of in vitro fertilization, but
still only occurs in 2% to 3% of all births (Bush & Pernoll,
2012).
• Usually referred to as multiple gestation, is one in which
more than one fetus develops simultaneously in the
mother's womb.
• The frequency of multiple births in the United States has
been steadily increasing with advances in reproductive
technologies. It is estimated that pregnancies resulting
from assisted technologies have a 25–30 percent
incidence of twins and a 5 percent incidence of triplets.
The frequency of naturally occurring twins is
approximately one in 80 births; however the frequency of
multiple births in the United States for 2002 was as
follows:
o twins, one in 32
o triplets, one in 583
o quadruplets, one in 9,267
o quintuplets and up, one in 58,286
FRATERNAL TWINS
• Fraternal twins develop from two separate ova released
at the same time and fertilized by two separate sperm.
• Fraternal twins are referred to as dizygotic twins, meaning
that two unions of two gametes or male/female sex cells
occurred to produce two separate embryos.
• Characteristics:
o Each has its own placenta and amniotic sac.
o May be the same or different sex,
o Occur twice as frequently as identical twins,
o And have a mortality rate of 11.5 percent
IDENTICAL TWINS
• Will have the same DNA, genetic material (genotype), but
it may be expressed differently (phenotype).
• Three ways identical twins can exist in the uterus:
o Dichorionic-diamniotic twins;
§ Division of the fertilized egg occurs within 72
hours past fertilization, before the inner cell
mass has developed.
§ About 30 percent of identical twins have this
classification, and each twin has its own
chorion, amnion, and placenta.
§ Mortality is 9%
o Monochorionic-diamniotic twins;
§ Division occurs in the range of four to eight days
after fertilization, and the inner cell mass divides
in two.
§ Placenta has one chorion and two amnions,
so each twin has its own amniotic sac.
§ Approximately 68 percent of identical twins are
in this classification, and they have a mortality
rate of 25 percent.
o Monochorionic-monoamniotic twins;
§ Contained in the same amniotic sac.
§ The division of the fertilized egg .
§ In this case occurs nine to 13 days past
fertilization or near the time of implantation in the
uterus.
§ Since they share an amniotic sac, they have an
increased risk of their umbilical cords becoming
entangled or knotted.
§ Only 2 percent of identical twins are in this
classification, and they have a mortality rate of
greater than 50 percent.
• If a complete separation does not take place during the
division process, the result is Siamese (or conjoined)
twins.
o Conjoined twins also known as Siamese twins are
identical twins joined in utero. An extremely rare
phenomenon, the occurrence is estimated to range
from 1 in 49,000 births to 1 in 189,000 births, with a
somewhat higher incidence in Southwest Asia and
Africa.
• Only 2 percent of identical twins are in this classification,
and they have a mortality rate of greater than 50 percent.
• If a complete separation does not take place during the
division process, the result is Siamese (or conjoined)
twins.
POLYHYDRAMNIOS
• Polyhydramnios is a medical condition describing an
excess of amniotic fluid in the amniotic sac. It is seen in
about 1% of pregnancies. It is typically diagnosed when
the amniotic fluid index (AFI) is greater than 24 cm.
• Usually, the aminiotic fluid volume at term is 500 to 1,000
ml.
• Polyhydramnios occurs when there is excess fluid of
more than 2,000 ml or an aminiotic fluid index above
24cm (Weigand, Beamon, Chescheir, et al., 2016).
• Women with polyhydramnios may experience:
o Premature contractions,
o Longer labor,
o Difficulties breathing, and
o Other problems during delivery.
o The condition can also cause complications for the
fetus, including anatomical problems, malposition,
and, in severe cases, death.
CAUSES OF POLYHYDRAMNIOS
• Gestational diabetes,
• Fetal anomalies with disturbed fetal swallowing of
amniotic fluid,
• Fetal infections and other, rarer causes.
• The diagnosis is obtained by ultrasound.
TREATMENT OF POLYHYDRAMNIOS
• Drainage of excess amniotic fluid from uterus
• Amniocentesis - the sampling of amniotic fluid using a
hollow needle inserted into the uterus, to screen for
developmental abnormalities in a fetus.
• Indomethacin (Indocin) Medication----may prescribe
orally to help reduce fetal urine production and amniotic
fluid volume.
o Indomethacin is an appropriate first-line tocolytic for
the pregnant patient in early preterm labor (< 30 wk)
or preterm labor associated with polyhydramnios.
• The fetal renal effects of indomethacin may be beneficial
to reduce polyhydramnios.
OLIGOHYDRAMNIOS
• Oligohydramnios refers to a pregnancy with less than the
average amount of amniotic fluid (Kumar, 2012).
• Because 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.
• Low amniotic fluid (oligohydramnios) is a condition in
which the amniotic fluid measures lower than expected
for a baby's gestational age.
• No treatment has been proved effective long term. But
short-term improvement of amniotic fluid is possible and
might be done in certain circumstances.
• Oligohydramnios refers to amniotic fluid volume that is with with RH positive blood and may result to
less than expected for gestational age. It is typically heymolytic disease of a Newborn (HDN)
diagnosed by ultrasound examination and may be
described qualitatively (eg, normal, reduced) or HOW IS PLACENTA AFFECTED BY Rh INCOMPATIBILITY
quantitatively (eg, amniotic fluid index [AFI] ≤5) • During pregnancy, red blood cells from the unborn baby
o AFI between 8-18 is considered normal. can cross into the mother's blood through the placenta.
• During pregnancy, amniotic fluid provides a cushion that • If the mother is Rh-negative, her immune system
protects the baby from injury and allows room for growth, treats Rh-positive fetal cells as if they were a foreign
movement and development. substance.
• Amniotic fluid also keeps the umbilical cord from being • The mother's body makes antibodies against the fetal
compressed between the baby and the uterine wall. blood cells.
• In addition, the amount of amniotic fluid reflects the
baby's urine output — a measure of a baby's well-being.
TREATMENT FOR Rh INCOMPATIBILITY
• Rh incompatibility is treated with a medicine
CAUSES OF OLIGOHYDRAMNIOS called Rh immune globulin. Treatment for a baby who
• Bag of water is breaking has hemolytic anemia will vary based on the severity of
• The placenta peeling away from the inner wall of the the condition.
uterus — either partially or completely — before delivery
(placental abruption)
• Certain health conditions in the mother, such as chronic 2ND TRIMESTER: HYDATIDIFORM MOLE
high blood pressure
• Use of certain medications, such as angiotensin- Table 5. Summary of Primary Cause of Bleeding during
converting enzyme (ACE) inhibitors Pregnancy (Second Trimester)
• Certain health conditions in the baby, such as restricted TYPE CAUSE ASSESSMENT CAUTION
growth or a genetic disorder Gestationa Abnormal Overgrowth of Retained
l proliferati uterus highly trophoblast
TREATMENT OF OLIGOHYDRAMNIOS trophoblas on of positive human tissue may
tic disease trophobla chorionic become
• 36 to 37 weeks pregnant – the safest treatment might be
(hydatidifo st cells, gonadotrophin malignant
delivery.
rm mole) fertilizatio (hCG) test; no (choriocarci
• Less than 36 weeks pregnant – monitoring your
n or fetus present on noma)
pregnancy with fetal ultrasounds.
division ultrasound; follow for 6
• Might recommend drinking more fluids — especially if defect bleeding from months to 1
you're dehydrated.
vagina of old year with
• If you have low amniotic fluid during labor – and fresh blood hCG testing
amnioinfusion, a procedure in which fluid is placed in the accompanied
amniotic sac , done during labor if there are fetal heart by cyst
rate abnormalities. formation
o Amnioinfusion is done by introducing saline into the Premature Cervix Painless Can have
amniotic sac through a catheter placed in the cervix
Cervical begins to bleeding cervical
during labor.
Dilatation dilate and leading to sutures
pregnanc expulsion of placed to
ISOIMMUNIZATION (Rh INCOMPATIBILITY) y is lost at fetus ensure a
about 20 second
weeks; pregnancy
• Isoimmunization is a condition where a mother
with Rh-negative blood is pregnant with a baby that unknown
has Rh-positive blood. This can cause a problem if the cause but
cervical
baby's blood enters the mother's blood flow. The Rh-
trauma
positive blood from the baby will make the mother's body
create antibodies. from
dilatation
• Rh incompatibility, also known as Rh disease, is a
and
condition that occurs when a woman with Rh-negative
curettage
blood type is exposed to Rh-positive blood cells, leading
(D&C)
to the development of Rh antibodies.
maybe
• Rh incompatibility can also occur when an Rh-negative
associate
female receives an Rh-positive blood transfusion.
d
• Rh Incompatibility in Pregnancy. Rh incompatibility
occurs when a pregnant woman whose blood type
is Rh-negative is exposed to Rh-positive blood from her
fetus, leading to the mother's development of
Rh antibodies. This causes the fetus to become anemic,
which can lead to hemolytic disease of the newborn.
• Coombs' Test. - used to detect antibodies that act against
the surface of your red blood cells. The presence of
these antibodies indicates a condition known as
hemolytic anemia, in which your blood does not contain
enough red blood cells because they are destroyed
prematurely.
o Coombs test – A positive result means the blood has • Also called Gestational trophoblastic disease
antibodies that fight against RBC. This can caused • The abnormal proliferation and degeneration of the
by a blood transfusion of incompatible blood or baby trophoblastic villi (ACOG, 2004)
• As the cells degenerate, they become filled with fluid and
appear as clear fluid-filled, grape-sized vesicles.
• The embryo fails to develop beyond a primitive start
• Associated with choriocarcinoma, a rapidly metastasizing
malignancy
• Incidence: 1 in every 1, 500 pregnancies
• Risk Factors:
o Women with low protein intake
o Women older than 35 years
o Asian heritage
• Pathophysiology:
o Trophoblastic villi cells located in the outer ring of the
blastocyst rapidly increase in size, begin to
deteriorate, and fill with fluid
o The cells become edematous, appearing as
grapelike clusters of vesicles.
o As a result, the embryo fails to develop past the early
stages
TYPES OF HYDATIDIFORM MOLE
• Complete Mole –
o All trophoblastic villi swell and become cystic
o Embryo dies early at 1-2 mm in size
o No fetal blood present
o Karyotype normal, 46xx, 46xy
o An “empty ovum” was fertilized
• Partial Mole –
o Some of the villi will form normally
o Syncytiotrophoblast layer of villi is swollen and
misshapen
o A macerated embryo of approximately 9 weeks
gestation may be present
o Fetal blood may be present
o Has 69 chromosomes (a triploid formation in which
there are three chromosomes instead of two for
every pair.
§ One set supplied by an ovum that apparently
was fertilized by two sperm
§ An ovum fertilized by one sperm in which
meiosis or reduction division did not occur
§ Rarely lead to choriocarcinoma
ASSESSMENT OF HYDATIDIFORM MOLE
• Uterus tends to expand faster than normally
• Absent fetal heart sound
• Positive pregnancy test (hCG produced by the
throphoblast cells)
• Symptoms of PIH before 20 weeks gestation
• Sonogram shows dense growth (typically snowflake
pattern) but no fetal growth in the uterus
• Vaginal spotting of dark-brown blood or as a profuse fresh
flow
THERAPEUTIC MANAGEMENT
• Suction curettage to evacuate the mole
• Baseline pelvic examination, chest X-ray, serum test for
beta subunit of HCG after mole extraction
• HCG Monitoring
o Every 2 weeks until normal
o Every 4 weeks for 6-12 months, thereafter
• Gradually declining HCG titers suggest no complication
• Oral contraceptive for 12 months
• If HCG levels are negative after 6 months – free of
malignancy
• By 12 months, second pregnancy can be planned
2ND TRIMESTER: PREMATURE CERVICAL
DILATATION
• Incompetent Cervix –
o Cervix dilates prematurely approximately 20 weeks
AOG
o Cannot hold a fetus until term
• Signs and Symptoms –
o Painless dilatation
o Pink-stained vaginal discharge
o Increased pelvic pressure
o Discharge of amniotic fluid
o Uterine contractions
• Causes –
o Increased maternal age
o Congenital structural defects
o Trauma to the cervix
o Repeated D & C
ASSESSMENT
• Pink-stained vaginal discharge
• Increased pelvic pressure followed by rupture of
membranes and discharge of amniotic fluid
• Uterine contractions and birth of fetus
• Occurs at 20 wks of pregnancy
THERAPEUTIC MANAGEMENT
• Cervical cerclage –
o Surgical procedure used to treat cervical
insufficiency involving the use of a heavy suture
placed at the internal cervical os
o May be done:
§ As an outpatient procedure
§ During a short 1- to 2-day hospitalization
§ As an emergency procedure requiring
hospitalization for approximately 5 days
o Usually performed during:
§ Late first trimester
§ Early second trimester
o May be removed:
§ At approximately 3 7 weeks' gestation
§ Kept in place with plans for cesarean delivery
o Purpose:
§ Treatment of cervical insufficiency
§ To help keep the cervix closed until term or until
the patient goes into labor
§ For patients who have experienced previous
pregnancy losses
o Procedure:
§ The patient receives regional anesthesia.
§ The health care provider uses a suture or band
to close the cervix using a vaginal approach.
o In a McDonald cerclage - sutures placed horizontally
and vertically high up on the cervix to pull it tightly
together.
o In Shirodkar’s procedure - a submucosal band
applied at the level of the internal cervical os.
o Postprocedure Care:
o Maintain the patient on bed rest as ordered.
o Assess for evidence of uterine contractions and
rupture of membranes.
o Monitor vital signs, especially temperature.
o Assess for signs and symptoms of infection.
• Done at 12-14 weeks
• McDonald or Shirodkar procedure
• Sutures can then be removed at 37 to 38 weeks AOG or
left in place if CS
 3RD TRIMESTER: PLACENTA PREVIA • Vaginal exams are prohibited because of the risk of
hemorrhage
Table 6. Summary of Primary Cause of Bleeding during • Risk Factors –
Pregnancy (Third Trimester) o Uterine scarring (previous uterine surgery)
TYPE CAUSE ASSESSME CAUTION o Multiple gestation
NT o History of placenta previa
o Closely-spaced pregnancies
Placenta Low Painless at Don’t allow
o Uterine tumors
Previa implantation beginning of vaginal
o Increased maternal age
of placenta cervical examination
o Endometritis
possible dilatation to minimize
o Advanced maternal age (older than age 35)
because of placental
o Smoking
uterine trauma
abnormality • Signs and Symptoms –
o Painless vaginal bleeding
Prematur Unknown Sharp Disseminate
o Intermittent or in gushes
e caused abdominal d
o Most commonly occurring in the third trimester (30
separatio associated pain followed intravascular
n of the with by uterine coagulation weeks AOG)
placenta hypertensio tenderness is associated § Lower uterine segment begins to differentiate
(Abruptio n; placenta vaginal with the from upper segment
§ Cervix begins to dilate
Placenta) separates bleeding; condition
o Progressively more severe bleeding as delivery
from uterus signs of
nears
before the maternal
o Decreasing urinary output
birth of the hypovolemic
o Anxiety and fear
fetus shock, fetal
o Malpresentation or high presenting part
distress
Preterm Many Show (pink- Preterm • Diagnostic Tests and Labs –
Labor possible stained labor may o Abdominal ultrasound
etiologic vaginal not be halted o If hospitalized, perform a non-stress test
factors such discharge) if the cervix o Pelvic examination is contraindicated
as trauma, accompanied is less than 4 • Therapeutic Nursing Management –
substance but uterine cm dilated o Assess amount and character of bleeding
abuse, contractions and the o Monitor vital signs
hypertensio becoming membranes o Monitor urinary output
n of regular and are intact. o Monitor fetal heart rate and fetal activity continuously
pregnancy effective Corticosteroi o Avoid digital exams –
or cervicitis; ds are § Instruct client to avoid enemas, douching, or
increased administered sexual intercourse
chance in to aid fetal § Provide bed rest if previa occurs prior to 36
multiple lung maturity. weeks gestation
gestation, § Monitor for continued bleeding and onset of
maternal labor
illness § Administer IVF replacement
• Pharmacology –
o Betamethasone:
§ For preterm labor prior to 34 weeks gestation
§ To promote fetal lung maturity if delivery seems
unavoidable
o Blood transfusion may be needed for severe anemia,
chronic abruptio placenta, or placenta previa
• Complications –
o Hemorrhage
o Fetal distress/demise related to hypoxia in utero
• Occurs when placenta implants near or over the cervical o Intrauterine growth retardation (IUGR)
os rather than in the uterine fundus o Cesarean delivery
• Total - internal os is completely covered by the placenta o Preterm birth
when the cervix is fully dilated
• Low Lying - implantation in the lower rather than in the
upper portion of the uterus
3RD TRIMESTER: ABRUPTIO PLACENTA
• Marginal - placenta extends to the internal os; it may
extend into the os during cervical dilation in labor
• Partial - when the placenta partially covers the internal
os

• Abruptio placenta is the premature separation of only part

or of the entire placenta from the uterine wall
• Usually occurs in the third trimester
• Occurs in 1:200 pregnancies after age 35.
• Occurs in 10% of all deliveries
• More common in multigravidas than in primigravidas
• Mild to severe abdominal pain and uterine rigidity o Folic acid deficiency
differentiate it from placenta previa o Smoking
• Abruption is a medical emergency: o Cocaine use
o Risk of maternal hemorrhage o Premature rupture of membranes
o Fetal death o Maternal hypertension: most consistently identified
o 10-30% of clients develop clotting defects (e.g. risk factor
disseminated intravascular coagulation (DIC) o Multifetal pregnancies
• Should be suspected when there is sudden onset of o Short umbilical cord
intense, localized uterine pain, with or without vaginal • Diagnostic Tests and Labs –
bleeding o Hemoglobin
• Hospitalization is nearly always necessary because the o Hematocrit
placenta can separate further at any time o Ultrasound of abdomen
• Vaginal birth is usually feasible o Blood type and crossmatch
o Coagulation profile
o Sonogram (to rule out placenta previa)
• Signs and Symptoms –
o Dark red vaginal bleeding
o Uterine rigidity
o Sudden onset of severe abdominal pain
o Uterine contractions
o Fetal distress
• Therapeutic Nursing Management –
o Assess:
§ Amount and character of bleeding
§ Degree of abdominal rigidity
§ Degree of abdominal pain
§ Fetal activity and heart tones
§ Measure fundal height if concealed bleeding is
• Pathophysiology – suspected
o The spontaneous rupture of blood vessels at the o Monitor for shock (vital signs, urine output, physical
placental bed may be caused by a lack of resiliency assessment)
or by abnormal changes in uterine vasculature. o Keep the woman on the lateral position
• Normally 5-7 minutes after birth of the baby, placenta o No vaginal nor pelvic exam nor enema
separates from the myometrium. o Prepare woman for possible emergency cesarean
• If 20 minutes had passed with no signs of separation the delivery
uterus is atonic. o Administer blood transfusion as ordered
• Treatment depends on severity of blood loss and on fetal o If Grade 2 or 3 – termination of pregnancy
maturity and status o Cesarean birth-method of choice
o Vaginal bleeding is present in 70-80% o If with DIC- IV fibrinogen or cryoprecipitate
o Concealed (retroplacental hemorrhage) o Monitor for infection and shock
§ Couvelaire uterus – blood infiltrate the uterine • Complications –
musculature o Severe compromised fetal well being
o Hard, boardlike uterus with no o Fetal demise (frequent if separation is 50% or
apparent bleeding greater)
• Clinical symptoms may vary with degree of separation o Maternal disseminated intravascular coagulopathy
– (DIC)
Grade I (mild) • Mild vaginal bleeding o Concealed central placental bleed
• Mild uterine tenderness o Shock
• Mild uterine tetany
• 10-20% of placental surface is 3RD TRIMESTER: PRETERM LABOR
detached
• Neither mother or fetus is in
• Labor that occurs after the twentieth week but before the
distress
37th week of gestation.
Grade II • Uterine tenderness and tetany,
• Contractions occur more frequent than every 10 minutes,
(moderate) with or without external bleeding
last 30 seconds or longer, and persistent (4 every 20
• Mother not in shock minutes)
• Fetal distress present • Preterm labor may be associated with infection
• About 20-50% of placental • Cause is frequently unknown, but the following conditions
surface is detached are associated with premature labor:
Grade III • Severe uterine tetany o Cervical incompetence
(severe) • woman in shock (although o Preeclampsia/eclampsia
bleeding may not be obvious) o Maternal injury
• fetus is dead o Infection – UTI and chorioamnionitis (infection of
• Woman often has coagulopathy the fetal membranes and fluid)
• More that 50% of placental o Multiple births
surface is detached o Placental disorders
• Assessment:
• Risk Factors – o Uterine contractions (painful or painless)
o External uterine trauma o Abdominal cramping (may be accompanied by
o Drug abuse during pregnancy, especially cocaine diarrhea)
o Pregnancy-induced hypertension o Low back pain
o Previous abruption o Pelvic pressure or heaviness
 o Change in the character and amount of usual
discharge; may be thicker or thinner, bloody, brown
or colorless and may be odorous.
o Rupture of amniotic membranes
• Interventions: Goal: halt labor
o Focus on stopping the labor: identify and treat
infection, restrict activity and ensure hydration.
o Maintain bed rest and a lateral position
o Monitor fetal status
o Administer fluids
o Administer medications as prescribed Tocolytics
(nifedipine, indomethacin, magnesium sulfate,
terbutaline sulfate)
• Labor that cannot be halted
o Membranes ruptured
o Cervix > 50% effaced, 3-4 cm dilated
o If very immature fetus: CS
o NSD: Caution against analgesic agents
o Epidural is preferred
• Prevention:
o Minimize or stop smoking: a major factor in preterm
labor and birth.
o Minimize or stop substance abuse/chemical
dependency.
o Early and consistent prenatal care
o Appropriate diet/weight gain
o Minimize psychological stressors.
o Minimize/prevent exposure to infections
o Lear to recognize signs and symptoms of preterm
labor
• Therapeutic Management
o Medical intervention is to attempt to arrest the
premature labor (tocolysis)
o Unless labor is irreversible:
§ A condition exists in which the mother or fetus
would be jeopardized
§ The membranes have ruptured
o Medications used in the treatment of premature labor
§ Magnesium Sulfate
§ Beta adrenergic drugs – Terbutaline and
Ritodrine
§ Nifedipine (Procardia)
§ Indomethacin
o Betamethasone (Celestone)
§ Fetal lung maturity.
§ It is administered IM
§ Every 12 hrs times 2
§ Then weekly until 34 weeks gestation
• Nursing Interventions:
o Keep client at rest, side lying position
o Hydrate the patient and maintain with IV or PO fluids.
o Maintain continuous maternal/fetal monitoring
o Maternal/fetal vital signs every 10 minutes; be alert
for abrupt changes.
§ Monitor maternal I and O
§ Monitor urine for glucose and ketones.
§ Watch cardiac and respiratory status carefully
§ Evaluate lab test results carefully
o Keep client informed of all progress/changes.
o Identify side effects/complications as early as
possible.
o Carry out activities designed to keep client
comfortable.
3RD TRIMESTER: PRETERM RUPTURE OF
MEMBRANES
• Rupture of fetal membranes with loss of amniotic fluid
during pregnancy before 37 weeks
• 5-10% of pregnancies
• Cause unknown
• Associated with chorioamnionitis
• Spontaneous break or tear in the amniotic sac before
onset of regular contractions, resulting in progressive
cervical dilation.
• PROM: rupture 1 or more hours before the onset of labor
• Preterm PROM: rupture of the membranes before the
onset of labor in a preterm gestation
• The mother is at risk for chorioamnionitis if the latent
period (time between rupture of membranes and onset of
labor) is longer than 24 hours.
• Signs of Chorioamnionitis:
o Fetal tachycardia
o Maternal fever
o Foul smelling amniotic fluid
o Uterine tenderness
• Complications of chorioamnionitis:
o Sepsis
o Death
• Risks:
o Fetal infection
o Sepsis
o Perinatal mortality
• Increase risks:
o With every hour of ruptured membranes
o Every hour of labor
o Every vaginal examination
• Pathophysiology: The exact mechanism of premature
rupture of membranes is unclear.
• Causes:
o Unknown
o Accompanied by malpresentation and a contracted
pelvis
• Signs and symptoms:
o Sudden gush of clear fluid from the vagina
o Differentiate from urinary incontinence
§ Maternal fever
§ Fetal tachycardia
§ Foul smelling vaginal discharge (indicate
infection)
§ Transvaginal ultrasonography reveals a rupture
or tear of the amniotic sac
• Treatment:
o In term pregnancy:
§ Spontaneous labor and vaginal delivery
§ Induction of labor
§ Cesarean delivery
o Preterm pregnancy less than 34 weeks:
§ Hospitalization and observation for signs of
infection while waiting for fetal maturation.
• If clinical status suggests infection: baseline cultures and
sensitivity test.
• If tests confirm infection:
o Induce labor
o IV administration of antibiotic
o Temperature monitoring every 2 hours.
• Culture of gastric aspirate or a swabbing from the
neonate’s ear to determine the need for antibiotic therapy.
PRE-EXISTING OR NEWLY ACQUIRED DISEASE
INTRODUCTION
• When a woman enters pregnancy with a chronic condition
or a newly acquired 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.
PRE-EXISTING OR NEWLY ACQUIRED DISEASE
(PREGNANT MOTHER WITH ASTHMA AN
DIABETES MELLITUS)
INTRODUCTION
• Respiratory diseases range from mild (common cold) to
severe (pneumonia) to chronic (tuberculosis). Any
respiratory condition can worsen in pregnancy because
 the rising uterus compresses the diaphragm, reducing the
size of the thoracic cavity and available lung space.
• Any respiratory disorder can pose serious hazards to the
fetus if allowed to progress to the point where the
mother’s oxygen-carbon dioxide exchange is altered or
the mother or fetus cannot receive enough oxygen.
• Diseases of the endocrine system are relatively
common. An endocrine system disease usually involves
the secretion of too much or not enough of a hormone.
When too much hormone is secreted, the condition is
called hypersecretion. When not enough hormone is
secreted, the condition is called hyposecretion. The
most common endocrine disease is diabetes. There are
many others. They are usually treated by controlling how
much hormone your body makes. Hormone supplements
can help if the problem is too little of a hormone.
ASTHMA
• It is a disorder marked by airflow obstruction, airway
hyperactivity and airway inflammation. It complicates
about 1% of pregnancies and associated with increased
risk of perinatal complications.
• Symptoms are often triggered by an irritant (e.g. an
inhaled allergen such as pollen or smoke)
• With inhalation of the allergen, there is an immediate
release of bioactive mediators such as histamine and
leukotrienes from an IgE/immunoglobulin interactions
which results in constriction of the bronchial smooth
muscle, marked mucosal inflammation and swelling and
the production of thick bronchial secretion.
• These processes caused a marked reduction in the size
of the lumen of air passages. This causes difficulty pulling
in air, on exhalation that has so much difficulty releasing
air that makes a high-pitched whistling sound (bronchial
wheezing) from air being pushed past the bronchial
narrowing.
• The inhaled corticosteroids Beclomethazone (Beclovent),
Vancenase) and Budesonide (Pulmicort, Rhinocort) are
commonly used by women with persistent asthma and
are the best choice for pregnant women and those who
might become pregnant.
• Women who have been taking a corticosteroids during
pregnancy may need parenteral administration of
Hydrocortizone during labor because of the added stress
during this time.
• Beta-adrenergic agonists such as Terbutaline and
Albuterol maybe taken safely during pregnancy, but due
the potential to reduce labor contractions, the dosage is
tapered close to term if possible.
• Women may use Cromolyn Sodium (Intal), a mast cell
stabilizer, to help prevent symptoms.
• Many adolescents with asthma are prescribed
Leukotreine Receptor antagonists such as montelukast
sodium (Singulair) or zafirlukast (Accolate). These are
oral medications and so maybe continued during
pregnancy.
• Nursing Diagnosis and Related Interventions –
o Risk for ineffective breathing pattern related to
respiratory changes during pregnancy
o Outcome Evaluation - Respiratory rate is 16 to 20 per
minute, PO2 is above 80 mm Hg, PCO2 is below 40
mm Hg and fetal heart rate is 120 to 160 bpm with
good variability
• Family Teaching –
o Be sure to get extra rest and sleep and eat a light diet
high in vitamin C (orange juice and fruit) to help boost
the immune system
o If you experience any aches and pains, take
acetaminophen every 4 hours
o Apply a medicated vapor rub to your chest if you
prefer to help relieve nasal congestion
o Use a room humidifier, especially at night, to moisten
nasal secretions and help mucus
o Use only over-the-counter cough drops or syrups
that contain natural ingredients such as honey and
lemon to help reduce coughing.
o Use cold or warm compresses to relieve sinus
headaches. Check with your healthcare provider
regarding the use of over-the-counter cough drops,
syrups or decongestants
ENDOCRINE DISORDER
• Diseases of the endocrine system are relatively
common. An endocrine system disease usually
involves the secretion of too much or not enough of a
hormone. When too much hormone is secreted,
the condition is called hypersecretion. When not enough
hormone is secreted, the condition is called
hyposecretion. The most common endocrine disease
is diabetes. There are many others. They are usually
treated by controlling how much hormone your body
makes. Hormone supplements can help if the problem is
too little of a hormone.
DIABETES MELLITUS
• Even a woman who has successful regulation of glucose
and insulin metabolism before pregnancy is apt to
develop less-than-optimal control during pregnancy,
because all women experience a number of changes in
the glucose-insulin regulatory system as pregnancy
progresses.
• Glomerular filtration of glucose is increased (the
glomerular excretion threshold is lowered), causing slight
glycosuria.
• The rate of insulin secretion is increased, and the fasting
blood sugar is lowered. All women appear to develop
insulin resistance as pregnancy progresses
• Placental insulinase may cause increased breakdown of
degradation of insulin. This resistance to or destruction of
insulin is helpful in a normal pregnancy because it
prevents the blood glucose from falling to dangerous
limits, despite the increased insulin secretion that occurs.
It causes difficulty for a diabetic pregnant woman in that
she must increase her insulin dosage beginning at about
week 24 of pregnancy to prevent hyperglycemia.
• A woman with Gestational Diabetes –
o Approximately 2% to 3% all women do not begin a
pregnancy with diabetes become diabetic during
pregnancy, usually at the midpoint of pregnancy
usually when insulin resistance becomes most
noticeable. This is termed gestational diabetes
mellitus. The symptoms fade again at the completion
of pregnancy, but the risk of developing type 2
diabetes may be as high as 50% to 60% later in life.
• It is unknown whether gestational diabetes results from
inadequate insulin response to carbohydrate or from
excessive resistance to insulin: a combination of both
may occur. Risk factors for gestational diabetes
include:
 o Obesity
o Age over 25 years
o History of large babies
o History of unexplained fetal or perinatal loss
o History of congenital anomalies in previous
pregnancies
o Family history of diabetes ( one close relative or two
distant one)
o Member of a population with high risk for diabetes
• Classification of Diabetes Mellitus –
TYPE 1 • Formerly known as insulin dependent
diabetes mellitus
• A state characterized by destruction
of the beta cells in the pancreas that
usually ends to absolute insulin
deficiency.
TYPE 2 • Formerly known as non-insulin-
dependent diabetes Mellitus
• A state that usually arises because of
insulin resistance combined with a
relative deficiency in the production of
insulin
Gestational • A condition of abnormal glucose
Diabetes metabolism that arises during
pregnancy. Possible signal of an
increased risk for type 2 diabetes
later in life
Impaired • A state between “normal” and
Glucose “diabetes” in which the body is no
Homeostasis longer using and/or secreting insulin
properly.
o Impaired fasting glucose. A state
when fasting plasma glucoseis
at least 110 but under 126 ml/dl
o Impaired glucose tolerance. A
state when results of the oral
glucose tolerance test are at
least 140 but under 200 mg/dl in
the 2 hour sample
• Assessment of Gestational Diabetes –
o After the oral 50-g glucose load is ingested, a venous
blood sample is taken for glucose determination 60
minutes later. If the serum glucose at 1 hour is more
than 140mhg/dL, the woman is scheduled for a 100-
g 3-hour fasting glucose tolerance test. If two of the
four blood samples collected for this test are
abnormal or the fasting value is above 95mg/dL, a
diagnosis of diabetes is made.
Table 7. Oral Glucose Challenge Test Values for Pregnancy
TEST TYPE PREGNANT GLUCOSE LEVEL (mg/dL)
Fasting 95
1 hour 180
2 hours 155
3 hours 140
• Monitoring a woman with diabetes –
o A woman who is diabetic (type1 or type 2) should go
to her obstetrician for care before she becomes
pregnant so that her condition will be regulated so
that hyperglycemia does not develop during the early
weeks of pregnancy, when the tendency for
congenital anomalies in the fetus is highest.
o The measurement of glycosylated hemoglobin is
used to detect the degree of hyperglycemia present.
This is a measure of the amount of glucose attached
to hemoglobin.
o Opthalmic examination should be done once during
pregnancy for a woman with gestational diabetes
and at each trimester for women with known
diabetes.
o A urine culture may be done each trimester to detect
asymptomatic UTI.
• Nursing Diagnosis and Related Interventions –
o Risk for ineffective tissue perfusion related to
reduced vascular flow
o Imbalanced nutrition less than body requirements,
related to inability to use glucose
o Risk for ineffective coping related to required change
in lifestyle
o Risk for infection related to impaired healing
accompanying condition
o Deficient fluid volume deficit related tp polyuria
accompanying disorder
o Deficient knowledge related to difficult and complex
health problem
o Health-seeking behaviors related to voiced need to
learn home glucose monitoring
• Education regarding Nutrition during pregnancy –
o An 1,800-2,200- calorie diet or one calculated at 35
Kcal per Kg of ideal weight) divided into three meals
and three snacks, is a usual regimen for a woman
with diabetes during pregnancy. Keeping calories
evenly distributed helps keep the serum glucose
level constant.
o In addition, her diet should include a reduced amount
of saturated fats and cholesterol and an increased
amount of dietary fiber which can decrease
postprandial hyperglycemia and lowers insulin
requirements.
o Of dietary calories, 12% to 20% should be from
protein, 40% to 45% from carbohydrate and up to
40% from fat
PRE-EXISTING OR NEWLY ACQUIRED DISEASE
(PREGNANT MOTHER WITH ANEMIA &
CARDIOVASCULAR DISEASE
ANEMIA IN PREGNANCY
• During pregnancy, a woman may develop a slight
expansion in the blood volume than the normal RBC
count as the body prepares for catering to the growing
fetus inside the mother’s womb. It is called pseudoanemia
of early pregnancy- which is part of the normal changes
in the woman’s body. True anemia, however, occurs as a
complication of pregnancy.
• According to Anderson & Anderson (1990), it can be
classified as pathologic or physiologic. It can be
considered as pathologic if it is because of a disorder in
the production of erythrocytes or is there is excessive loss
of erythrocytes due to bleeding or destructions.
Meanwhile, it can be a physiologic type of anemia in
pregnancy if the decline in production is due to
hemodilution or when the plasma volume expands more
than the RBC volume.
TYPES OF ANEMIA
IRON DEFICIENCY ANEMIA
• Most common one, which can be simply described as a
condition which is presented with a decrease in
hemoglobin and oxygen transport. Its etiology may vary
but maybe sometimes due to an anemic state, heavy
menstrual periods, and poor nutritional intake prior to
pregnancy. It can be suspected when the hemoglobin
level is below 11 mg/dl. Furthermore, it is characterized
by a small-sized RBC and a reduced hemoglobin level
than the average cell count. The mean corpuscular
volume and the mean corpuscular hemoglobin are both
observed to be low in this type of anemia. Thus, it is
associated with low birth weight and premature delivery.
FOLIC ACID DEFICIENCY
• Megaloblastic anemia or folic acid deficiency is defined
as a disorder in the RBC production in which the red cells
fail to divide and become enlarged. Folic acid is very
important in the synthesis of nucleic acid which is also
required for the production of red blood cells. During
pregnancy, a woman needed more folic acid than ever
before. He MCV is, however, elevated compared to Iron
deficiency anemia. Its complications may correspond to
adverse defects in fetal development and also for early
abortion and abruption placenta.
SICKLE CELL ANEMIA
• It is caused primarily of the Hemoglobin S causing other
red blood cells to sickle or follows a crescent shape.
Thus, it is considered as an autosomal recessive
disorder. It does not influence the pregnancy itself but a
woman with a sickle disease, pregnancy is considered
the complication. The threat is directed to the growth and
well-being of the fetus since this disease usually results
in clumping (due to increased tension to the cells) which
in return causes some veno- occlusive crisis. The
blockage in blood vessels especially to the placental
circulation could lead to fetal compromise and worse to
death.
• Nursing considerations in general for pregnant
clients with anemia include:
o Assessment of nutritional intake and status
o Assess for fatigue, pallor, sore tongue, anorexia,
nausea and vomiting, stomatitis, some signs of
infection, and severe pain (due to veno-occlusive
crisis
o Observe and monitor hematologic laboratory results
o Encourage the client to eat foods high in iron and
folic acids like green leafy vegetables, fish, meat,
poultry, eggs, and legumes.
o Teach how to prepare food in order to minimize the
loss of iron and folic acid (steaming with small
amount of water)
o Encourage to take foods high in Vitamin C for iron
absorption
o Emphasize diet high in fiber and fluids to avoid
constipation (a side effect of iron intake)
o Emphasize also good hygiene to avoid urinary tract
infection
o Also instruct the client to avoid people with infection,
as they may be prone to acquire the infection, too.
o Teach the client to watch out for signs of preterm
labor
o Observe and monitor the fetal well being
o Allow the client to rest as much as possible and
provide emotional support
CARDIOVASCULAR DISEASE IN PREGNANCY
• Women with heart disease – the leading cause of death
during pregnancy – should be closely cared for by a
specialized team during pregnancy, according to a new
report from the American Heart Association.
• Women with preexisting cardiovascular conditions, such
as chronic high blood pressure, heart disease and high
cholesterol, would benefit from careful monitoring and
counseling, from preconception until post-childbirth, the
scientific statement says. Doctors may choose to
prescribe regular exercise, medications or other
strategies.
• "Cardiovascular diseases are the leading cause of
pregnancy-related death and are increasing, possibly
because women are having babies at older ages and are
more likely to have preexisting heart disease or heart
disease risk factors," Dr. Laxmi Mehta, chair of the group
that wrote the statement, said in a news release. Mehta
is a professor of medicine and director of preventive
cardiology and women's cardiovascular health at The
Ohio State University Wexner Medical Center in
Columbus, Ohio.
• "For each of these cardiac conditions, pregnancy can
impact treatment as there are limitations in medication
management and invasive procedures given the potential
fetal risks."
• Between 1987 and 2015, pregnancy-related deaths rose
from 7.2 to 17.2 deaths per 100,000 live births in the
United States, according to the statement published
Monday in the American Heart Association's journal
Circulation. It highlights several potential dangers for
women with heart issues that could be helped with the
correct treatment.
• For example, pregnant women with the high blood
pressure disorder called preeclampsia have a 71%
greater risk of dying from heart disease or stroke over
their lifetime. The statement reports that several studies
have linked regular exercise during pregnancy to
preeclampsia prevention.
• Other conditions may require pharmaceutical
intervention. Pregnant women with valvular heart
disease, which increases the risk of a clot-caused
ischemic stroke, could benefit from medications after the
first trimester to reduce clotting, the statement says.
• Heart rhythm disorders could be treated with medication
or surgery if they are severe enough. Data show these
disorders are on the rise, potentially because women are
having babies later in life.
• Older mothers should take extra precautions, the
statement says. Advanced maternal age – defined as 35
or older – is associated with a higher risk of premature
birth, chronic hypertension, preeclampsia and gestational
diabetes.
• The statement recommends women with the preexisting
cardiovascular disease be cared for by a cardio-
obstetrics team that includes an obstetrician, cardiologist,
anesthesiologist, maternal-fetal medicine specialist, and
nurses.
• While medications may help some patients, all expectant
mothers should recognize the importance of healthy
habits, Mehta said.
• "The role of a healthy lifestyle during pregnancy –
whether or not a woman has a cardiovascular condition –
cannot be emphasized enough," she said. "Healthy diet,
moderate exercise including walking, smoking cessation
and other healthy behaviors are important tools for a
healthy pregnancy for both mother and child."

• Responsible for 5% maternal death in pregnancy
• Commonly caused by valve damage from rheumatic
fever or Kawasaki disease, congenital anomalies and
uncorrected coarctation of the aorta
• Cardiac affects left or right of the heart
• Caring of Pregnant Mother with Cardiovascular
Disease
o Team of internist, OB, and nurse
o Visit OB before pregnancy
o Baseline of echocardiogram
o Visit prenatal as soon as suspected of pregnancy
• Normal pregnancy –
o Pregnancy taxes the circulatory system even without
cardiovascular diseases because both CO and blood
volume increase by 30%. Half of this occurs by 8
weeks.
o Due to increase blood flow past valves, functional or
transient murmurs can be heard.
o Heart palpitation or sudden exertion is normal.
o These are normal physiologic changes adjustment to
pregnancy.
• Dangers for Pregnancy for woman with
Cardiovascular Disease –
o Increase in circulatory volume. Heart can be
overwhelmed by increase blood volume toward the
end of pregnancy that cardiac output falls to the vital
organs including are no longer perfused adequately.
No enough oxygenation nutrients to the fetus.
• Woman with left sided heat failure –
o Left sided heart failure – occurs in conditions such as
Mitral stenosis, mitral insufficiency and Aortic
Caorctation
o Left ventricle – cannot move the volume of the blood
by left atrium from the pulmonary circulation
o Heart becomes overwhelmed, it fails to function.
Failure is at the level of the mitral valve.
o Normal physiologic tachycardia of pregnancy
shortens the diastole (atrial contraction) and
decrease the time available for blood to flow across
the valve.
o Inability of the mitral valve to push blood forward
cause back pressure on the pulmonary circulation,
causing distention, systemic blood pressure
decrease – decrease cardiac output and pulmonary
hypertension occurs.
o Pressure in pulmonary vein reaches to 25mmHg,
fluid becomes to pass from pulmonary capillary
membranes into interstitial spaces surrounding the
alveoli – pulmonary edema
o Pulmonary edema – produce dyspnea that interfere
with the O2 CO2 exchange
o Pulmonary capillaries rupture – under pressure,
small amounts of blood leak into the alveoli and a
productive cough of speckled sputum develops
o Due to limited oxygen exchange – women with
pulmonary hypertension are extremely high risk of
spontaneous miscarriage, preterm labor, and
maternal death.
o Increase RR – due to oxygen saturation of blood
decrease from dysfunction of alveoli
o Increase fatigue, weakness and dizziness due to
lack of O2 in the brain
o Heart rate increase and peripheral vasoconstriction
in an attempt to increase systemic blood pressure
o Fall of BP is registered in the renal angiotensin
system, retention of both sodium and water occurs
o Placenta – do not receive enough O2 due to
decrease peripheral circulation
o Orthopnea – best position in sleeping where chest
and head is elevated due to pulmonary edema where
it allows fluid to settle to the bottom of the lungs and
space for lung exchange.
o Paroxysmal nocturnal dyspnea – suddenly waking
up in the night for shortness of breath
o If mitral stenosis is present – difficult of blood to leave
the left atrium and secondary problem of the
thrombus occur
o Anti-Coagulant – may be prescribe to prevent
thrombus
o Heparin is the drug of choice for pregnant mother
because it doesn’t have teratogenic effect
o Warfarin (coumadin) – can be used after 12 weeks
but should return to heparin therapy during the last
month
o If coarctation of the aorta is causing difficulty of
breathing then dissection of the blood pressure from
trying to push the blood of the aorta –
antihypertensive drug can be given to control blood
pressure – diuretics to reduce blood volume
o Impaired blood flow to the uterus, poor placental
perfusion, intrauterine growth restriction, maternal
death
• Right sided heart failure –
o Congenital heart defect such as pulmonary valve
stenosis and atrial and ventricular septal defect –
result to RSHF
o Occurs when the output RV is less than the blood
volume received by the right atrium from vena cava
o Back pressure result to congestion of the systemic
venous circulation and decreased cardiac output to
the lungs
o Blood pressure decrease in the aorta because less
blood is reaching, pressure is high in the vena cava
due to back pressure, both jugular distention and
increase portal circulation.
o Liver and spleen – distented liver enlarge due to
dyspnea and pain due to enlarged liver as it pressed
upward by enlarged uterus
o Distention of abdominal vessels – lead to exudate of
fluid from the vessels to peritonela cavity – Ascites
o Fluid moves to systemic circulation into lower
extremities – peripheral edema
o Eisenmenger syndrome – congenita anomaly, a right
to left atrial or ventricular septal defect with an
accompanying pulmonary stenosis
o Uncorrected – not advised to get pregnant. If
pregnancy, need monitoring and administration of
O2
• Digoxin – is used to treat heart failure, usually along with
other medication. It is also used to treat certain types of
irregular heartbeart (such as chronic atrial fibrillation).
Treating heart failure may help to maintain your ability to
 walk and exercise and may improve the strength of your
heart.
PREGNANT MOTHER WITH SPECIAL NEEDS
PREGNANT ADOLESCENT
• Reasons for high number of teenage pregnancies –
o Earlier age of menarche in girls
o Rates of sexual activity among teenagers
o Lack of knowledge about (or failure to use)
contraceptives or abstinence
o Desire by young girls to have a baby
o Developmental Tasks –
o To establish a sense of self-worth or a value system
o To emancipate from parents
o To adjust a new body image
o To choose a vocation
PRENATAL ASSESSMENT
• High Risk Patients because of the ff –
o Iron deficiency anemia
o Premature labor
o Low birth weights infants
o Cephalopelvic disproportion
o Hemorrhoids
o Conflicting development crises
o Intimate partner violence
• Early and consistent prenatal care is essential to their
health and health of their baby
• A primary nursing or case management approach is
effective
• Factors contributing to the lack of prenatal care include –
o Denial she is pregnant
o Lack of knowledge of the importance of prenatal care
o Dependence on others for transportation
o Feeling awkward in a prenatal setting
o Fear of first pelvic examination
o Difficulty relating to authority figures
HEALTH HISTORY
• Be certain for press for the responses needed to allow
you to assess them safely
• Ask for the reason for delayed first prenatal visit
• Ask the parent separately if there are any concerns he or
she wishes to discuss
• If the baby’s father attends prenatal care
o Help him to feel welcome
o Allow him to offer support in the current pregnancy
o Be sure he receives compassionate education on
preventing further pregnancies until he is more
mature
• Teach adolescent common pregnancy symptoms and
reassure her they are part of a normal pregnancy
• Listen for signs of “nest-building” behavior
• Role- playing or simulation may be an effective technique
to help them tell their parents about the pregnancy
FAMILY PROFILE
• Ask the girl where she is living, the source of her income,
and whom she would call if she suddenly became ill
• Ask about home life may reveal dysfunctional family or an
incest relationship as the cause of the pregnancy
• Know local and state laws on this topic and make
necessary report
• Help in making arrangements for the next few months of
her pregnancy and for a child care afterward
• Ask the girl if planning to continue with school
• Get a detailed day history to learn more about her as a
whole person ( nutritional practices, sleep, daily activities,
use of drugs or alcohol or friends who can support her
throughout this experience
PHYSICAL EXAMINATION
• Make the health examination both a learning experience
and relieves anxiety who tend to be very concerned about
body appearance
• Obtain a baseline pressure at the first prenatal visit
• Use doppler technique to obtain FHT and assess fundal
height
• Check the urine sample for specific gravity ( water has
1.000 and urine has 1.003 to 1.030)
• Teach adolescent that a healthy weight gain is important
for fetal growth and this weight can be lost afterward.
PREGNANCY EDUCATION
• They need a great deal of health teaching during
pregnancy
• Adolescents may respond to health teaching that is
directed to their own health more than to that of a fetus
• They need instructions about possible discomforts and
changes associated with pregnancy and measures
• Focus on hemorrhoids, striae gravidarum and chloasma
• Suggest cover makeup and offering reassurance the
pigmentation will fade after pregnancy
NUTRITION
• Lack of nutritional stores is serous because it can result
to preterm births and low-birth-weight newborns
• The girl should have an intake that both allows for growth
of the fetus and her own growing body
• Protein, iron, folic and vitamins A, C and D are necessary
• They may need to gain more weight than a mature
woman to supply adequate pregnancy nutrients
• Overweight and obese adolescents should not actively
restrict nutrients during pregnancy , their body maybe
deficient in proteins and vitamins
• Talk to the person who does the cooking in the family
• Need to advice to abandon a food fad like drinking soda
switch to noncaffeinated soft drinks
• Teach how to “ brown bag or buy nutritious cafeteria
lunch
• Need to construct a quick healthy breakfast and
midmorning snacks such as fruits that also supply
vitamins
• Remind to take their vitamin and iron supplement
ACTIVITY AND REST
• Assess participation in sports and determine which ones
such as diving, gymnastics, or touch football, may need
to discontinued during pregnancy
• Suggest an alternative activities such as joining a drama
or language clubs
• Planning for enough rest times during pregnancy without
compromising social relationships
PHYSIOLOGIC CHANGES
• They need substantial education on the physiological
changes that will occur during pregnancy
• They need to know a great deal more about her body and
her ability to monitor her health
• They need substantial education on the physiological
changes that will occur during pregnancy
• They need to know a great deal more about her body and
her ability to monitor her health
CHILDBIRTH PREPARATION
• Peer companionship is a strong need
• Suggest to join a class of other adolescents in preparation
for childbirth
BIRTH DECISIONS
• Pelvic measurements should be taken early and carefully
because CPD is real because of the girls’ incomplete
pelvic growth
• Information on cesarean birth must be scheduled is
shared with the girl and her parents
PLANS FOR THE BABY
• Be certain they know all the options available to them
when the baby is born (keeping the baby, placing the
baby in a temporary foster home, adoption)
• Encourage to breastfeed
COMPLICATIONS OF PREGNANCY
• Iron Deficiency Anemia –
o Because their low intake cannot balance the amount
of iron lost with menstrual flows
o Chronic fatigue, pale mucous membranes, and a hgb
level less than 11 g/dl , associated with pica
o Must take iron and folic acid supplement
o Review iron rich foods she needs to eat daily
o Reticulocyte account may be scheduled after 2
weeks of taking supplemental iron
o Taking a stool swab and assessing for black tinge of
an iron supplement or reassessing her serum iron
level
• Preterm Labor –
o Their uterus is not fully grown
o Review the signs of labor by the third month of
pregnancy
o Stress labor contractions usually begin as only a
sweeping contractions no more intense than
menstrual cramps
o Any vaginal bleeding must be reported
COMPLICATIONS OF LABOR, BIRTH, AND THE
POSTPARTUM PERIOD
• Cephalo Pelvic Disproportion –
o Suggested by lack of engagement at the beginning
of labor, prolonged first stage of labor and poor fetal
decent
o Be certain an adolescent has a support person with
her in labor
• Postpartum Hemorrhage –
o Because a girl’s uterus is not fully developed, it
becomes overdistended by pregnancy , not likely to
contract as readily, bleeding will occur
o May have more frequent and deeper perineal and
cervical lacerations because of the size of the baby
• Inability to Adapt Postpartally –
o Immediate postpartum period almost an unreal time
o Urge her to talk about labor and birth
o Prevent postpartum depression
• Lack of Knowledge about Infant Care –
o Spend time with the girl, observing how she handles
her infant
o Demonstrate bathing and changing the baby
o Model good parenting behaviors
o Education about the importance of breastfeeding
o Select a feeding method that is satisfying to them
and safe for the baby
PREGNANT WOMAN OVER AGE 40 YEARS
DEVELOPMENTAL TASK AND PREGNANCY
• Advance maternal age is the label for pregnant women
35 years and older at delivery the developmental
challenge is to expand their awareness or develop
GENERATIVITY
• This is the moving away forms themselves and becoming
involved with the world or community
• They will feel ambivalent during the pregnancy
• Help her balance her life and manage two life phases
• They may also be dealing with the issues of older adults
• It may also create extra strain on her finances and time
and it creates “sandwich generation “
• Important worries include having enough energy,
arranging for child care , and financial and space strains
PRENATAL ASSESSMENT: HEALTH HISTORY
• Ask woman to document their symptoms of pregnancy,
how they feel about the pregnancy , and how it fits into
their lifestyle
• Ask if she has been taking any medication or herbal
remedies
PRENATAL ASSESSMENT: FAMILY PROFILE
• Plans to become pregnant immediately
• She finds herself making many adjustments at once (new
life partner, house or apartment and community and also
to a pregnancy )
• Identify woman’s source of income
• Extra emotional support is needed
PRENATAL ASSESSMENT: DAY HISTORY
• Ask about the type of work or home responsibilities
• Estimate the amount of walking or back strain those entail
• Ask about recent diet or exercise programs
• saunas and hot tubs for longer than 10 minutes at a time
is contraindicated because of possible hyperthermia and
teratogenic effects of extreme heat
• Identify personal habits such as cigarette smoking and
alcohol consumption
PRENATAL ASSESSMENT: PHYSICAL EXAMINATION
• She needs a thorough physical examination to establish
her general health specifically circulatory disturbances
• Check for varicosities
• Obtain urine specimen and test it for specific gravity.
Glucose, and protein
• Assess breast for any abnormalities
• Assess carefully for fundal height and fetal movement at
prenatal visits
PRENATAL ASSESSMENT: CHROMOSOMAL
ASSESSMENT
• Genetic screening to detect if an open spinal cord or
chromosomal defect could be present in the fetus
• Ultrasound to examine for nuchal translucency and
analysis of maternal serum levels of alpha-fetoprotein
(MSAFP), pregnancy associated plasma protein A
(PAPP-A) and free beta human chorionic gonadotrophin
(done at 11-13 weeks)
• Blood test, circulating free DNA testing as early as 10
weeks
• Chorionic villi sampling and amniocentesis , they asses
actual karyotype of the fetus to give a definite answer
• At 15 and 20 weeks MSAFP is repeated to identify of the
fetus is at risk for open neural tube defects
PREGNANCY EDUCATION: NUTRITION
• Give tips on how to obtain the same nutrition whether she
prepares her meals at home or eats them at an office or
community function
• Substitute a caffeine-free soft drink in place of an
alcoholic beverages
• Substitutes milk or juice or decaffeinated coffee for
regular coffee
• Increase calcium like puddings or yogurt or calcium
supplements
PREGNANCY EDUCATION: PRENATAL CLASSES
• She is interested in joining a childbirth preparation or
prenatal exercise
• Offer interventions on how to avoid complications such as
varicosities
• Breathing exercises in preparation for labor
• How to integrate pregnancy with a full-time work position
and supplying discussion time on how she is reacting to
this dramatic life changes
COMPLICATIONS OF PREGNANCY
• Gestational Hypertension
o Take adequate supply of protein and obtain
adequate rest each day
§ Preterm or post term birth
§ Cesarean birth
o Because the circulatory system may not be as
competent as when she was younger
o Her body tissues may not be as elastic as they were
once
o Failure to progress in labor
§ Labor may be prolonged because cervical
dilatation does not seem to occur spontaneously
§ Graphing labor is a good method
§ May need cs
§ Encourage women to verbalize how she is
feeling and allow for reassurance and prompt
intervention
• Difficulty accepting the event
o Review plans for child care and postpartum rest
o Help women learn how to balance their lives
o Help making child care arrangement
• Postpartum Hemorrhage
o The uterus may not contract as readily
o More prone to perineal-anal tears because her
perineum is less supple, check for amount of lochial
flow or potential perineal bleeding
o Respect for need for independence
PREGNANT WOMAN WHO IS PHYSICALLY OR
COGNITIVELY CHALLENGED
DEVELOPMENTAL TASK AND PREGNANCY
• Women with conditions such as vision, hearing, cognitive,
neurologic , or orthopedic challenges
• Begin with preconception care so medicines they are
taking can be evaluated, careful planning for safe
pregnancy can be started
• General areas of care that are important
o Transportation
o Pregnancy counselling
o Support person
o Health
o Work
o Recreations
o Self-esteem
RIGHTS
• Hospital cannot deny care to a person with disability
• She has full rights to her child, so the baby cannot be
taken from her at birth without her full consent
• She cannot be forced to terminate a pregnancy or
undergo sterilization unless that is her informed decision
MODIFICATIONS FOR PREGNANCY
• Safety measures to explore
• Emergency contacts
• Transportation
• Mobility
• Elimination
• Autonomic responses
PRENATAL CARE MODIFICATIONS TO MEET SPECIFIC
NEEDS
• PE may be modified depending on individual
circumstances for women with disabilities
• Clear instruction is needed for pelvic examination
• Secure a ramp so the wheelchair can be elevated to the
level of the obstetric examining table
• Dorsal recumbent position may be required for pelvic
examination for woman with a spinal cord injury or
cerebral palsy
• If sexually abused, talk and work through this experience
before pelvic examination
• Resist petting guide dogs of visually challenged women
• For visually challenged women , use demonstration aids
that allow woman to feel or touch instead
• Always alert a visually challenged women when you are
going to tough her
• For women with hearing impairment, stand by the head
of the table where they can see your lips and repeat
instructions or questions as necessary
PREGNANCY EDUCATION
• Modify health teaching to meet each woman’s specific
needs
• For a woman who is cognitively challenged , instructions
about pregnancy may need to be given her care provider
• For visually challenged woman, offer the pamphlets to the
support person to read these to the pregnant woman
• Those using assistive technology (visually challenged
woman) provide material in an audio file
• Nutritional counseling needs to center on foods that can
be prepared without cooking or only microwave warmed
• Activity and rest : Walking around her home or apartment
is suggested
• Childbirth preparation is still valuable
• Practice breathing exercises to control pain in labor
• Emphasized on not smoking or drinking alcohol during
pregnancy
• If they depend on lip reading , be certain she is
deciphering new words such as amniotic, gestation, or
edema.
• Show printed words when presenting new pregnancy
terms
• Be certain to talk to the woman with hearing challenged,
NOT to the interpreter
MODIFICATIONS FOR LABOR & BIRTH: FEW
ADAPTATIONS
• For woman with spinal cord injury: palpate her abdomen
periodically for tightening or the presence of contractions
so she is aware of beginning labor
• Women with spasticity or spinal cord injury: may need
Cesarean birth or forceps birth
• Birth from a Sims or dorsal recumbent position is usually
best
• Visually challenged may need to time the length of
contractions by counting their length rather than timing
them by watch
• Hearing challenged: directly face the client when giving
information; keep her hands unencumbered by
equipment; hand the infant to her a soon as possible after
birth
• Be certain to identify the usual sounds of birthing rooms
for the visually challenged woman
MODIFICATIONS FOR POST PARTUM CARE
• Whether a woman needs additional support to be
successful at breastfeeding
• Return appointment for follow-up care
• Whether she desires contraceptive information and what
would be best for her individual circumstances
MODIFICATIONS FOR PLANNING CHILD CARE
• Allow ample time during the first days after birth for
mother-child interaction
• For visually challenged : may need extra time to
understand the transition from being pregnant to having
a baby; want to reassure herself that her baby can see
• For spinal cord disability may be interested in inspecting
her baby’s back
• For hearing challenged: point out other features such as
pretty eyes or long to help with bonding if their baby can
hear (couple who are hearing challenged may not be
pleased)
• Breastfeeding has special advantages for women who
are physically or cognitively challenged
• Will need referral for home care follow-up and the use of
home health aide to ensure safe child care
• Encourage what baby equipment will be best for them
• If a woman has difficulty with mobility , ask how she
anticipates carrying her infant
• Urge a visually challenged woman to remember to make
eye contact with newborns ; encourage her to turn the
light after dinner to help develop the vision of her infant
• For hearing impaired : help her plan to bring the infant’s
crib or bassinet close to her so she can feel the vibration
of the baby’s stirring and waking
• If the baby can hear, urge her to talk to her infant as she
gives care so the baby is introduced to sounds and words
, will develop speech pattern
• For cognitively challenged : investigate whether a
newborn will receive safe care before hospital discharge
; know if the woman has a responsible friend or partner to
help her with child care
A WOMAN WHO IS SUBSTANCE DEPENDENT
DEFINITION
• 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 substances
• Substance dependent:
o When he or she has withdrawal symptoms following
discontinuation of the substance ,
o With -abandonment of important activities ,
o Spending increased time in activities related to the
substance use
o Substance for a longer time than planned
o Continued use despite worsening problems because
of substance use
• Illicit substances tend to be of small molecular weight ,
they cross the placenta , can lead to fetal effects, fetal
abnormalities, or preterm birth
• The risk for hepatitis B or HIV infection increases
• The risk for STI poses threat to the fetus
COCAINE
• Extremely harmful during pregnancy because of extreme
vasoconstriction , severely compromised placental
circulation leading to premature separation of the
placenta, preterm labor and fetal death
• Infants can suffer immediate effects of intracranial
hemorrhage and an abstinence syndrome of
tremulousness, irritability, an muscle rigidity.
• Learning and social interactions defects as long term
effects
AMPHETAMINES
• Women develop blackened and infected teeth
• Newborn show jitteriness and poor feeding at birth and
growth may be restricted
MARIJUANA AND HASHISH
• They produce tachycardia and a sense of well-being
• Associated with loss of short-term memory and increased
incidence of respiratory infections in adults
• Woman maybe advised not to breastfeed because of
reduced milk production and the risk to the newborn from
excretion of the substance in breast milk
PHENCYCLIDINE
• It creates a sense of euphoria and causes irritation and
possibly long-term hallucination
• Tends to leave the maternal circulation and concentrate
in fetal cells it may particularly injurious to a fetus
NARCOTIC AGONISTS
• Pregnancy complications related to use include
gestational hypertension , phlebitis , subacute bacterial
endocarditis and hepatitis B and HIV infection
• Heroin dependency in the pregnant women can result to
fetal opiate dependence and severe abstinence
symptoms , tend to be SGA, increased incidence of fetal
distress and meconium aspiration
• Baby will demonstrate the same abstinence symptoms
after birth
• Fetal liver may mature faster than usual , better able to
cope with bilirubin at birth
• Fetal lung tissue also appears to mature more rapidly

INHALANTS

• Refers to sniffing or huffing of aerosol substances

• They contain freon as a propellant which can lead to
severe respiratory and cardiac irregularities
• Have similar effect to alcohol dependency
• Respiratory depression can cause limitation of fetal
oxygen supply to a serious level

ALCOHOL

• It is detrimental to fetal growth as illicit substances

• Fetal alcohol spectrum disorder, a syndrome with
recognizable facial features, possible cognitive
challenges and memory deficits occur
• Women are advised not to drink alcohol during pregnancy
• Discuss alcohol ingestion with late adolescents, mention
about binge drinking ( 5 or more alcohol drinks on one
occasion ) is not safe during pregnancy
 MODULE 2: INTRAPARTAL

OUTLINE
I. Complications with the Power
II. Problems with the Passenger
III. Problems with the Passage
IV. Anomalies of the Placenta and Cord

COMPLICATIONS WITH THE POWER (THE FORCE

OF LABOR)
INTRODUCTION

• Inertia is a time-honored term to denote sluggishness of

contractions, or that the force of labor, is less than usual.
A more current term is dysfunctional labor (Neal, Lowe, HYPOTONIC CONTRACTIONS
Schorn, et al., 2015). Dysfunction can occur at any point • The number of contractions is unusually infrequent.
in labor, but it is generally classified as primary (i.e., • Not more than two or three occurring in a 10-minute
occurring at the onset of labor) or secondary (i.e., period
occurring later in labor). The risk of maternal postpartal • Resting tone of the uterus remains less than 10 mmHg,
infection, hemorrhage, and infant. and the strength of contractions does not rise above 25
• Mortality is higher in women who have a prolonged labor mmHg.
than in those who do not. Therefore, it is vital to recognize • Occurs during –
and prevent dysfunctional labor to the extent possible. o Active phase of labor after administration of
(Hunt & Menticoglou, 2015) analgesia
o Bowel or bladder is distended preventing descent
• Inertia –
o If uterus is overstretched by multiple gestation
o Term to denote sluggishness of contractions, or that
o A larger fetus
force of labor, less than usually.
o Polyhydramnios
o Another term used is dysfunctional labor. o If uterus is lax from grand multiparity
§ Primary – occurring at the onset of labor. • Management –
§ Secondary – occurring later in labor. o Oxytocin (Pitocin)
§ Given piggyback (can be d/c without interrupting
COMMON CAUSES OF DYSFUNCTIONAL LABOR the main line)
§ Monitor uterine contractions and FHR q 15 min
• Primigravida status. § Keep magnesium sulfate available (to relax
• Pelvic bone contraction that has narrowed the pelvic uterus)
diameter so a fetus cannot pass (cephalopelvic § If contractions are:
disproportion [CPD]) such as could occur in a woman o 2 mins apart
with rickets. o Lasts 90 secs or longer
• Posterior rather than anterior fetal position or extension o Exceed 50 mmHg
rather than flexion of the fetal head. o Hypertension
o Discontinue
• Failure of the uterine muscle to contract properly or
o Turn woman to side
overdistention of the uterus, as with a multiple
o Notify MD
pregnancy, polyhydramnios, or an excessively oversized
• Adverse Effects –
fetus. o Hypotension
• A nonripe cervix. o Dizziness
• Presence of a full rectum or urinary bladder that impedes o N/V
fetal descent. o Tachycardia
• A woman becoming exhausted from labor. o Fetal tachycardia and bradycardia
• Inappropriate use of analgesia (excessive or too early o Hypertonic contractions
administration). o Decreased urine output

I. INEFFECTIVE UTERINE FORCE HYPERTONIC CONTRACTIONS

• Marked by an increase in resting tone to more than 15
• Uterine contractions are the basic force that moves the mmHg
fetus through the birth canal • Commonly seen in the latent phase of labor
• Occurs –
o More than one uterine pacemaker is stimulating
contractions
o Muscle fibers of the myometrium do not repolarize or
relax after a contraction, thereby, “wiping it clean” to
accept a new pacemaker stimulus
• Management –
o Analgesic: morphine sulfate
o Narcotic analgesic
o Respiratory depressant

ANDREA DENISE SAMBRANO | BSNS2C

UNCOORDINATED CONTRACTIONS hours. Again, cesarean birth may be necessary
• More than one pacemaker may be initiating contractions, (Hamilton, Warrick, Collins, et al., 2015).
or receptor points in the myometrium may be acting
independently of the pacemaker
• Can occur so closely together that they can interfere with
the blood supply to the placenta
• May be difficult for a woman to rest between contractions
or to breath effectively with contractions
• Fetal and uterine monitoring every 15 mins reveals the
abnormal pattern
• Oxytocin administration helps stimulate a more effective
and consistent contractions

II. DYSFUNCTIONAL LABOR AND ASSOCIATED

STAGES OF LABOR

• Dysfunction that occurs with the first stage of labor

involves:
• Prolonged latent phase
o A prolonged latent phase, as defined by Friedman
(1978), is a latent phase that lasts longer than 20
hours in a nullipara or 14 hours in a multipara. This
may occur if the cervix is not “ripe” at the beginning
of labor. It may occur if there is excessive use of an
analgesic early in labor. With a prolonged latent
phase, the uterus tends to be in a hypertonic state.
Relaxation between contractions is inadequate, and
the contractions are only mild (less than 15 mmHg
on a monitor printout) and, therefore, ineffective. One
segment of the uterus may be contracting with more
force than another segment
o Management –
§ Management of a prolonged latent phase in
labor that has been caused by hypertonic
contractions involves helping the uterus to rest,
providing adequate fluid for hydration, and pain
relief with a drug such as morphine sulfate.
Changing the linen and the woman’s gown,
darkening room lights, and decreasing noise
and stimulation can also be helpful. These
measures usually combine to allow labor to
become effective and begin to progress. If it
does not, a cesarean birth or amniotomy (i.e.,
artificial rupture of membranes) and oxytocin
infusion to assist labor may be necessary
• Protracted active phase
o A protracted active phase is usually associated with
fetal malposition or cephalopelvic disproportion
(CPD) (the diameter of the fetal head is larger than
the woman’s pelvic diameters), although it may
reflect ineffective myometrial activity. This phase is
prolonged if cervical dilatation does not occur at a
rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in
a multipara, or if the active phase lasts longer than
12 hours in a primigravida or 6 hours in a
multigravida (see Table 23.2).
o If the cause of the delay in dilatation is fetal
malposition or CPD, cesarean birth may be
necessary. Dysfunctional labor during the dilatational
division of labor tends to be hypotonic in contrast to
the hypertonic action at the beginning of labor. After
an ultrasound to show CPD is not present, oxytocin
may be prescribed to augment labor.
• Prolonged deceleration phase; and
o A deceleration phase has become prolonged when it
extends beyond 3 hours in a nullipara or 1 hour in a
multipara. A prolonged deceleration phase most
often results from abnormal fetal head position. A
cesarean birth is frequently required
• Secondary arrest of dilatation
o A secondary arrest of dilatation has occurred if there
is no progress in cervical dilatation for longer than 2
• Dysfunction that occurs with the second stage of labor
involves:
• Prolonged descent; and
o Prolonged descent of the fetus occurs if the rate of
descent is less than 1.0 cm/hr in a nullipara or 2.0
cm/hr in a multipara. It can be suspected if the
second stage lasts over 2 hours in a multipara
(Zheng, 2012). With both a prolonged active phase
of dilatation and prolonged descent, contractions
have been of good quality and duration, effacement
and beginning dilatation have occurred, but then the
contractions become infrequent and of poor quality,
and dilatation stops.
o If everything else is within normal limits except for the
suddenly faulty contractions and CPD and poor fetal
presentation have been ruled out by ultrasound, then
rest and fluid intake, as advocated for hypertonic
contractions, also applies. If the membranes have
not ruptured, rupturing them at this point may be
helpful. Intravenous (IV) oxytocin may be used to
induce the uterus to contract effectively (see later
discussion on induction of labor by oxytocin). A semi-
Fowler’s position, squatting, kneeling, or more
effective pushing may speed descent
• Arrest of descent
o Arrest of descent results when no descent has
occurred for 2 hours in a nullipara or 1 hour in a
multipara. Failure of descent occurs when expected
descent of the fetus does not begin or engagement
or movement beyond 0 station does not occur. The
most likely cause for arrest of descent during the
second stage is CPD. Cesarean birth usually is
necessary. If there is no contraindication to vaginal
birth, oxytocin may be used to assist labor (Choubey
& Werner, 2015).
III. PRECIPITATE LABOR
• Occur when uterine contractions are so strong that a
woman gives birth with only a few, rapidly occurring
contractions.
• It is often defined as a labor that is completed in fewer
than 3 hours
• Precipitate dilation is cervical dilation that occurs at a rate
of 5 cm or more per hour in a primipara or 110 cm or more
per hour in a multipara
o Contractions can be so forceful that they lead to
premature separation of the placenta, placing the
woman at risk of hemorrhage.
o Rapid labor also poses a risk to the fetus, because
subdural hemorrhage may result from the rapid
release of pressure on the head.
o A woman may sustain lacerations of the birth canal
from the forceful birth. She also can feel
overwhelmed by the speed of labor.
• A precipitate labor can be predicted from a labor graph if,
during the active phase of dilation, the rate if greater than
5cm/hr (1cm every 12 minutes) in a nullipara or 10cm/hr
(1cm every 6 minutes) in multipara.
o In such instances, a tocolytic may be administered to
reduce the force and frequency of contractions.
• Caution a multiparous woman by week 28 of pregnancy
that, because past labor was so brief her labor this time
may also be brief.
o This allows her to plan for appropriately timed
transportation to the hospital or alternative birthing
center.
• Both grand multiparas and women with histories of
precipitate labor should have the birthing room converted
to birth readiness before full dilation is obtained. Then,
even a sudden birth can be accomplished in a controlled
surrounding.
IV. UTERINE RUPTURE
• Rupture of the uterus during labor, although rare, is
always a possibility. It is always serious, because it
accounts for as many as 5% of all maternal deaths.
• It occurs when uterus undergoes more strain than it is
capable of sustaining.
• Rupture occurs most commonly when a vertical scar from
a previous cesarean birth of hysterotomy repair tears (it
occurs in less than 1% of women who have a low
transverse cesarean scar from a previous pregnancy;
about 4% to 8% of women who have a classic cesarean
incision).
• Contributing factors may include prolonged labor,
abnormal presentation, multiple gestation, unwise use of
oxytocin, obstructed labor, and traumatic maneuvers of
forceps or traction.
• When uterine rupture occurs, fetal death will follow unless
immediate cesarean birth can be accomplished. In these
instances, fetal outcome can be optimal
• Impending rupture may be preceded by a pathologic
retraction ring (a contraction ring that form across the
uterus at the junction of the upper and lower uterine
segment and interferes with fetal descent) and by strong
uterine contractions without any cervical dilation.
• To prevent rupture when these symptoms are present,
anticipate the need for an immediate cesarean birth.
• If a uterus should rupture the woman experiences a
sudden, severe pain during a strong labor contraction,
which she may report as a “tearing” sensation
• 2 conditions that can occur –
o Rupture can be complete, going through the
endometrium, myometrium and peritoneum layers.
o Incomplete, leaving the peritoneum intact.
• With a complete rupture, uterine contractions will
immediately stop.
o Two distinct swellings will be visible on the woman’s
abdomen: the retracted uterus and the extrauterine
fetus.
o Hemorrhage from the torn uterine arteries flood into
the abdominal cavity and possibly into the vagina.
o Signs of shock begin, including rapid, weak pulse;
falling BP; cold clammy skin; and dilation of the
nostrils from air hunger.
o Fetal heart sounds fade and then are absent.
o If the rupture is incomplete, the signs of rupture are
less evident.
o With an incomplete rupture, a woman may
experience only a localized tenderness and
persistent aching pain over the area of the lower
uterine segment. However, fetal heart sounds, a lack
of contractions, and the changes in the woman’s vital
signs will gradually reveal fetal and maternal
distress.
o Uterine rupture can be confirmed by ultrasound
o Because the uterus at the end of pregnancy is such
a vascular organ, uterine rupture is an immediate
emergency situation, comparable to splenic or
hepatic rupture.
o Administer emergency fluid replacement therapy as
ordered.
o Anticipate use of IV oxytocin to attempt to contract
the uterus and minimize bleeding.
o Prepare the woman for a possible laparotomy as a n
emergency measure to control bleeding and achieve
repair.
o The viability of the fetus depends on the extent of the
rupture and the time elapsed between rupture and
abdominal extraction.
o A woman’s prognosis depends on the extent of the
rupture and blood loss.
• Most women are advised not to conceive again after the
rupture of the uterus, unless the rupture occurred in the
inactive lower segment.
o The physician with consent, may perform cesarean
hysterectomy (removal of the damaged uterus) or
tubal ligation.
V. INVERSION OF THE UTERUS
• Refers to the uterus turning inside out with either the birth
of the fetus or the delivery of the placenta.
• The uterine fundus may lie within the uterine cavity or the
vagina, or it may protrude from the vagina.
• The fundus is not palpable in the abdomen.
• If the loss of blood continues unchecked for longer than a
few minutes, the woman will show signs of blood loss;
hypotension, dizziness, paleness, or diaphoresis.
Because the uterus is not contracted in this position,
bleeding continue as short as a period of 10 minutes
• Never attempt replacing inversion, because handling of PROBLEMS WITH THE PASSENGER
the uterus may increase the bleeding. INTRODUCTION
• Never attempt to remove the placenta if it is still attached,
because this will only create a larger surface area for
bleeding.
• In addition, administration of oxytocic drug only
compounds the inversion or makes the uterus more tense
and difficult to replace an IV fluid line needs to be started
if one is not already present
• Administer oxygen by mask, and assess vital signs
• Be prepared to perform cardiopulmonary resuscitation
• If the woman’s heart should fail from the sudden loss of
blood, the woman will immediately be given general
anesthesia or possible nitroglycerin to relax the uterus.

• Although the fetus is basically passive during birth,

complications may arise if an infant is immature or
preterm or if the maternal pelvis is so undersized that its
diameters are smaller than the fetal skull, such as occurs
in early adolescence or in women with altered bone
• The physician or a nurse then replace the fundus growth from a disease such as rickets. It also can occur
manually if the umbilical cord prolapses, if more than one fetus is
• Administration of oxytocin after manual replacement present, or if a fetus is malpositioned or too large for the
helps the uterus to contract and remain its natural place birth canal.
• Because the uterine endometrium was exposed, a
woman will need antibiotic therapy to prevent infection. I. PROLAPSED OF THE UMBILICAL CORD
• Occurs when amniotic fluid is forced to an open maternal
uterine blood sinus through some defect in the membrane
or after membrane rupture or partial premature
separation of the placenta
• Previously, it was thought that particles such as
meconium or shed fetal skin cell in the amniotic fluid
entered the maternal circulation and reach the lungs as
small emboli. Now, it is recognized a humoral or
anaphylactoid response is more likely cause. This
condition may occur during labor or in the postpartal
period. • Extremely critical obstetrical situation
• It is not preventable because it cannot be predicted. • Cord protudes from cervix into vagina
Possible risk factors include oxytocin administration,
• Seen in breech and when presenting part is unengaged
abruption placentae and hydramnios.
• Position Mom
• A woman, in strong labor sits up suddenly and grasps her
o Knee-chest, Trendelenburg, elevate hips
chest because of sharp pain and inability to breathe. As
o Sterile gloved hand—hold presenting part off cord
she experiences pulmonary artery constriction.
• EMERGENCY C/SECTION,
• She becomes pale and turn the typical bluish gray o O2, ↑IV flow rate
associated with pulmonary embolism and lack of blood
flow in the lungs.
II. MULTIPLE GESTATION
VI. AMNIOTIC FLUID EMBOLISM
• Increase risk of PTL, Malpresentation, PIH, Maternal
Hemorrhage
• The immediate management is oxygen administration
within a minute, she will need CPR. • ↑ incidence d/t fertility treatments
• CPR may be ineffective however this because this • Most common is twins
procedure (inflating the lungs and massaging the heart) • 1/85 births is a twin
do not relieve the pulmonary constriction. Therefore, the
blood still cannot circulate to the lungs, and death may
occur within minutes.
• A woman prognosis depends on the size of the embolism,
the speed in with which emergency condition was
detected and the skill and speed of emergency
interventions. -Even if the woman survives, the initial
insult, the risk for disseminated intravascular coagulation
is high, further compounding her condition.
• In these events, she will need continued management
endotracheal intubation to maintain pulmonary function
and therapy with fibrinogen to counteract DIC • Monozygotic—33% of all twins -1 egg + 1 sperm=
• Most likely, she will be transferred to an ICU “Identical”
• The prognosis to the fetus is guarded because reduced o Variations
placental perfusion result from the severe drop in the § 2 amnions/2 chorions 30%
maternal blood pressure. Labor often begins of the fetus (Dichorionic/diamniotic)
is born immediately by cesarean birth. § 2 amnions & 1 chorion—68%
(monochorionic/diamniotic)
 § 1 amnion & 1 chorion –2%
(monochorionic/monoamniotic)
§ MOST COMPLICATIONS
o Twin-to-twin transfusion
• Dizygotic— 67% of all twins -2 eggs = 2 sperm =
“Fraternal”
• 2 ova + 2 placentas = 2 babies
• Risk for Multiple Gestation –
o Family HX
o Increased maternal age
o Increased parity § Because the fetal head rotates against the
o Conceiving within 1 month of stopping OC sacrum, pain and pressure at the lover back due
o Increased frequency of Coitus to sacral nerve compression
§ Back rub relieves pain
MATERNAL FETAL § Instruct to void every 2 hours to keep fetus from
1. PTL 1. Congenital anomalies not descending
2. Cardia stress 2. Monozygotic – § IV glucose solution during active labor
3. Anemia • Twin-to-twin § Forceps delivery to help the fetus rotate
4. PIH transfusion § Watch out for hemorrhage from cervical
5. Polyhydramnios • Polycythemic laceration or infection in the postpartum period
6. Placenta previa • Anemic o BREECH PRESENTATION
7. Dysfunctional labor § Types – Complete, Frank, Footling
8. Abnormal presention § Risk to the Fetus:
o Developing dysplasia of the hips
• Management – o Anoxia from a prolapsed cord
ANTEPARTUM INTRAPARTAL POSTPARTAL o Traumatic injury to the aftercoming head
1. U/S early to 1. Monitor twins 1. Assess (possibility of intracranial hemorrhage or
confirm twins • -1 CLOSELY for anoxia)
2. > # of office tocotransducter Uterine Atony o Fracture of the arm or spine
visits • -2 U/S 2. Emotional o Dysfunctional labor
3. ↑ caloric transducers or Support o Early rupture of the membrane because of
needs—see • 1 U/S 3. Support with the poor fit of the presenting part
dietician transducer and Breastfeeding o Meconium staining
4. ↑ rest • 1 scalp 4. Referrals to o FACE PRESENTATION
5. Assess for electrode social
infection 2. Maternal VS, IV’s worker/PHN
6. Monitor fetal 3. Vaginal delivery
status -U/S, with C/Sec back up
NST’s, BPP 4. 2
OB’s/Peds/RN’s
5. May have 1 baby
• vaginally and 1
baby by
C/Section
6. If Triplets or
Quads or +++ § A fetal head presenting at a different angle than
7. C/Section is expected is termed ASYNCLITISM.
delivery method of § Face and brow presentation are examples of
choice asynclitism.
§ Face (chin, or mentum) is rare but when it does
III. PROBLEMS WITH FETAL POSITION, occur, the head diameter the fetus presents to
PRESENTATION OR SIZE the pelvis is often too large for birth to proceed.
o BROW PRESENTATION
• MALPRESENTATION
o OCCIPITOPOSTERIOR POSITION

§ The rarest of the presentations.

§ Occurs in a multipara or a woman with relaxed
§ The occiput is directed diagonally and abdominal muscles.
posteriorly, either to the right or the left § Also leave an infant with extreme ecchymotic
§ Tend to occur in women with android, bruising on the face
anthropoid, or contracted pelvises o TRANSVERSE LIE
§ Occurs in women with;
o pendulous abdomens,
 o with uterine fibroid tumors that obstruct the o Asphyxia
lower uterine segment, o Neurologic damage
o with contraction of the pelvic brim, § Maternal Complications
o with congenital abnormalities of the uterus, o Heavy bleeding after delivery
o or with polyhydramnios. o Tearing of the uterus, vagina, cervix or
§ Occurs in infant with; rectum
o Hydrocephalus or o Bruising of the bladder
o Another abnormality that prevents the head • FETAL ANOMALIE
from engaging
o Prematurity if the infant has free movement
o Multiple gestations
o Short umbilical cord
o OVERSIZED FETUS (MACROSOMIA)

§ Fetus weighing more than 4,000 to 4,500 grams

(9-10 lbs)
§ May cause uterine dysfunction during labor
because of overstretching of the fibers of the
myometrium.
§ Associated with gestational diabetes or • Fetal anomalies of the head such as hydrocephalus (fluid
multiparity because each infant born to a woman filled ventricles) - or anencephaly (absence of the
tends to be slightly heavier and large than the cranium)
one born just before.
• SHOULDER DYSTOCIA PROBLEMS WITH THE PASSAGE
INTRODUCTION

• Passage where the newborn will pass through plays an

important role, however problems may occur if there is
narrowing of the passageway or the birth canal. This can
happen at the inlet, at the midpelvis, or at the outlet. This
narrowing causes CPD (Cephalopelvic Disproportion)
which describe as a disproportion between the size of the
fetal head and the pelvic diameter. This results in failure
o An intrapartum event that occurs when the infant’s of labor to progress.
head has been delivered, but the shoulders remain
wedged behind the mother’s pubic bone
INLET CONTRACTION
o Risk factors –
§ Macrosomic babies are most at risk
§ GDM, Obesity, hx of previous LGA baby or
§ Previous shoulder dystocia
o Shoulder dystocia may occur when the woman has
no risk factors
o Management –
§ Position in McRobert’s position

• This is the narrowing of the anteroposterior diameter to

less than 11 cm or of the transverse diameter to 12 cm or
less. It is usually cause by rickets in early life or more
commonly if the pregnant women has small pelvis. If
engagement does not occur in a primigravida, then either
o Legs and thighs flexed up to her abdomen a fetal abnormality (larger than usual head) or a pelvic
with the head of the bed lowered abnormality (smaller than usual pelvis) should always be
o Apply suprapubic pressure suspected. Every primigravida, should have pelvic
o Apply pressure directly over they measurements taken and recorded before week 24 of
symphysis pubis to aid in dislodging the pregnancy. Based on these measurements and the
fetal shoulder assumption the fetus will be of average size, a birth
o Complications – decision can be made. If the fetus remains to be “floating”,
§ Permanent injury to baby malposition may occur that may lead to fetal
o Brachial plexus injury (caused by excessive complications and possible cord prolapse.
traction on fetal head)
o Fractured clavicles
FORCEPS BIRTH o If membranes rupture, the possibility of cord
prolapse greatly increases.
• Causes –
o Size of the patient’s pelvis (major contributing factor)
o Inlet contractions
§ Anteroposterior diameter is less than 11 cm
§ Transverse diameter is 12 cm or less
o Outlet contraction (narrowing of the transverse
diameter located at the distance between the ischial
tuberosities) at the outlet to less than 11 cm
• Assessment Findings –
• This is the narrowing of the anteroposterior diameter to
less than 11 cm or of the transverse diameter to 12 cm
or less. It is usually cause by rickets in early life or more
commonly if the pregnant women has small pelvis. If
engagement does not occur in a primigravida, then either
a fetal abnormality (larger than usual head) or a pelvic
abnormality (smaller than usual pelvis) should always be
suspected. Every primigravida, should have pelvic
measurements taken and recorded before week 24 of
pregnancy. Based on these measurements and the
assumption the fetus will be of average size, a birth
decision can be made. If the fetus remains to be
“floating”, malposition may occur that may lead to fetal
complications and possible cord prolapse.

o Lack of fetal engagement in primigravida due to fetal

INLET CONTRACTION abnormality:
§ Larger-than-usual head
• Narrowing of the anteroposterior diameter to less than 11 § Pelvic abnormality such as smaller-than-usual
cm pelvis
• Transverse diameter to 12 cm or less • Test Results –
• Caused by rickets in early life or by inherited small pelvis o Anteroposterior diameter 11 cm and the maximum
• Assessment: Pelvic measurements taken and recorded transverse diameter < 12 cm or less (inlet
before week 24 of pregnancy contraction)
o Transverse diameter at outlet < 11 cm
OUTLET CONTRACTION o Ultrasonography reveals a larger than usual fetal
head
• Narrowing of the transverse diameter at the outlet to less • Treatment –
than 11 cm o Possible trial labor - determine whether labor can
• The distance between the ischial tuberosities. progress normally if the pelvic measurement are
borderline or just adequate, and the fetal lie and
CEPHALOPELVIC DISPROPORTION position are good
o Cesarean delivery

SHOULDER DYSTOCIA

• Occurs at the second stage of labor

• The fetal head is born but the shoulders are too broad to
enter and be born through the pelvic outlet.
• Risk Factors –
o Women with diabetes
o Multipara
o Post-date pregnancies
• Management –

• Narrowing of the birth canal

• Disproportion between the size of the normal fetal head
and the pelvic diameters
• Results in failure to progress in labor
• Pathophysiology –
o In primigravidas, the fetal head normally engages
between 36 to 38 weeks of gestations o McRobert’s maneuver to widen the pelvic outlet
§ Assumed that the pelvic inlet is adequate. o Suprapubic pressure
o With CPD, the fetus’ head does not engage.
o The head remains a floating
 ANOMALIES OF THE PLACENTA AND CORD
ANOMALIES OF THE PLACENTA
PLACENTA SUCCENTURIATA
• This anomaly of the placenta is described as with one or
more accessory lobe connected the main placenta by
Blood vessels. The fetus is not affected, however
thisanomalies should be inspected because these small
lobes maybe retained in the uterus after birth leading to
severe maternal hemorrhage. Upon inspection, the
placenta appears torn at the edge, or torn blood vessels
extend beyond the edge of the placenta. The remaining
lobes are removed from the uterus manually to prevent
maternal hemorrhage from poor uterine contraction.
PLACENTA CIRCUMVALLATA
• In placenta circumvallata, the fetal side of the placenta is
covered to some extent with chorion. The umbilical cord
enters the placenta at the usual midpoint, and large
vessels spread out from there. They end abruptly at the
point where the chorion folds back into surface.
BATTLEDORE PLACENTA
• In Battledore placenta the cord is inserted marginally
rather than centrally. This anomaly is rare and has no
known clinical significance.
VELAMENTOUS INSERTION OF THE CORD
• In this anomaly of the cord, instead of the cord entering
the placenta directly, it separates into small vessels that
reach the placenta by spreading across a fold of amnion
VASA PREVIA
• In vasa previa, the umbilical vessels of a velamentous
cord insertion cross, the cervical os and therefore deliver
before the fetus. In this anomaly, the vessels may tear
with cervical dilatation, just as a placenta previa may tear.
If there is a sudden painless bleeding occurs with the
beginning of cervical dilatation, either placenta previa or
vasa previa is suspected. This can be confirmed by
ultrasound. If vasa previa is identified, the infant needs to
be born by ceasarean birth.
PLACENTA ACCRETA
• Is an unusually deep attachment of the placenta to the
uterine myometrium so deeply the placenta will not
loosen and deliver. Attempts to remove it manually may
lead to extreme hemorrhage because of the deep
attachment. Hysterectomy or methotrexate treatment to
destroy the still attached tissue maybe necessary.
ANOMALIES OF THE CORD
TWO VESSEL CORD
• Normally, a cord contains two arteries and one vein. The
absence of one of the umbilical arteries is associated with
congenital heart and kidney anomalies. Inspection of the
cord as to how many vessels are present must be done
immediately after birth, before the cord begins to dry.
Document the number of vessels present, an infant with
only two vessels needs to be observed for other
anomalies during the newborn period.
UNUSUAL CORD LENGTH FETAL DISTRESS

• Assessment –

• An unusually short umbilical cord can result in premature

separation of the placenta or an abnormal fetal lie. An
unusually long cord maybe easily compromised because
of its tendency to knot or twist, it may also cause to wrap
around the fetal neck causing intrauterine fetal demise.

PROLAPSE OF THE UMBILICAL CORD

• A loop of the umbilical cord slips down in front of the

o Fetal heart rate less than 120 or greater than 160
presenting fetal part:
beats per minute
o Compression of the cord
o Meconium-stained amniotic fluid
o Compromising fetal circulation.
o Fetal hyperactivity
• Risk Factors –
o Progressive decrease in baseline variablity
o Premature rupture of membranes
o Severe variable decelerations
o Fetal presentation other than cephalic
o Late decelerations
o Placenta previa
• Causes –
o Intrauterine tumors preventing the presenting part
from engaging
o A small fetus
o CPD
o Hydramnios
o Multiple gestation
• Assessment –
o Mother has a feeling that something is coming
through the vagina.
o Umbilical cord is visible or palpable
o The fetal heart rate is irregular and slow
• Interventions –
o Check fetal heart tones immediately when
membranes rupture, and again after next
contractions, or within 5 minutes; report
decelerations
o Relieve cord pressure immediately:
§ Reposition mother:
o Turn her side to side
o Elevate her hips to shift the fetal presenting
part toward her diaphragm.
o Knee-chest or Trendelenburg position
§ Elevate fetal presenting part that is lying on the
cord by applying finger pressure with a sterile
glove hand.
§ Do not attempt to push the cord into the uterus.
§ Assess fetus for hypoxia
§ Administer oxygen by face mask to the mother
as prescribed.
§ Prepare for emergency cesarean birth.
§ Tocolytic agent
§ If cord protrudes outside vagina, cover with
sterile gauze moistened with sterile saline
§ Do not attempt to replace cord.
o Cord Compression
§ Notify physician
o Placental abnormalities
o Preexisting maternal disease
• Interventions –
o Place the mother in a lateral position; elevate her
legs
o Administer oxygen at 8 to 10 L/min via face mask.
o Discontinue oxytocin (Pitocin) if infusing
o Monitor maternal and fetal status
 o Prepare for emergency cesarean section • Placenta will not loosed and
• Assessment – deliver
o Tachypnea • Hemorrhage
o Flaring nares Management –
o Expiratory grunting • Hysterectomy
o Retractions • Methotrexate to destroy the
o Decreased breath sounds attached tissue
o Apnea Two vessel Definition - Absence of one of the
o Pallor and cyanosis cord umbilical arteries
o Hypothermia Effects –
o Poor muscle tone • Associated with congenital heart
and kidney anomalies
Table 1. Anomalies of the Placenta and Cord Management –
Placenta Definition - One or more accessory • Inspection of the cord
Succenturiata lobes connected to the main placenta immediately at birth
by blood vessels Unusual Cord Definition - Short umbilical cord
Effects – length Long umbilical cord
• No fetal abnormality Effects –
• Small lobes retain in the uterus • Premature separation of the
after birth leading to severe placenta or abnormal fetal lie.
maternal hemorrhage • Tendency to twist or knot.
Management – Management –
• Inspection – placenta appears • Unusual Cord length
torn at the edge or torn blood
vessels extend beyond the edge
of the placenta.
• Remaining lobes must be
removed from the uterus
manually
Placenta Definition - Fetal side of the
circumvallata placenta is covered to some extent
with chorion
Effects –
• No fetal abnormality
Battledore Definition - The cord is inserted
placenta marginally rather than centrally
Effects –
• Rare
Management –
• No clinical significance
Velamentaous Definition - The cord separates into
Insertion of the small vessels that reach the placenta
cord by spreading across a fold of amnion
Effects –
• Associated with fetal anomalies
Management –
• Newborn must be examined
Vasa Previa Definition - The umbilical cord
vessels of velamentous cord insertion
across the cervical os, therefore
deliver before the fetus
Effects –
• The vessel tear with cervical
dilatation as a placenta previa
• Sudden, painless bleeding with
the beginning of cervical
dilatation
• Sudden fetal blood loss
Management –
• Structures should be identified
before inserting any instrument to
prevent accidental tearing
through ultrasound.
• Cesarean birth
Placenta Definition - Unusual deep
Accreta attachment of the placenta to the
uterine myometrium
Effects –
 MODULE 3: POSTPARTAL
OUTLINE
I. Nursing Care of a woman and family
experiencing a postpartal complications
II. Thrombophlebitis
NURSING CARE OF A WOMAN AND FAMILY
EXPERIENCING A POSTPARTAL COMPLICATIONS
1.1 POSTPARTAL/POSTPARTUM HEMORRHAGES
• One of the primary causes of mortality associated with
childbearing, a major threat during the entire pregnancy
and continuing into the postpartum bleeding.
• Blood loss of 500 ml or more following a vaginal birth,
while for caesarean section blood loss of 1000 ml and
decreased in hematocrit level.
§ if woman uterus does not remain contracted -
call the physician
o Administer Pitocin (Oxytocin) intraveneously (as
ordered) - its action is immediate
§ If Oxytocin is not effective at maintaining tone
- give Methylergonovine (Methergine) as
second possibilities
• Nursing Considerations: while giving oxytocin or
methergine (increase Blood Pressure)
§ Elevate woman's lower extremities to improve
circulation to essential organs
§ Offer bedpan or assist woman to the bathroom
at least every 4 hours
§ Administering oxygen by facemask at a rate of
about 10 to 12L/min. (if woman is experiencing
respiratory distress from decreasing blood
volume)
§ Position on supine to allow adequate blood flow
to her brain and kidneys.
o Blood Replacement - Iron therapy may be prescribed
to ensure hemoglobin formation
o Hysterectomy or Suturing - removal of uterus upon
woman experiencing extreme bleeding.

LACERATIONS

• May occur in the cervix, vagina or perineum.

• DISSEMINATED INTRAVASCULAR COAGULATION -
deficiency in clotting ability caused by vascular injury
• SUBINVOLUTION – incomplete return of the uterus to its
prepregnant size and shape.
• PERINEAL HEMATOMAS – collection of blood in the
subcutaneous layer of tissue of the perineum.
• PUERPERAL INFECTIONS –
o CERVICAL LACERATIONS -usually found on the
sides of the cervix near the branches of the uterine
artery; if it is torn the blood loss maybe so great that
blood gushes from the vaginal opening - arterial
bleeding - brighter red than the venous blood loss
with uterine atony.
o VAGINAL LACERATIONS - are easier to locate and
assess than cervical lacerations
o PERINEAL LACERATIONS - are more apt to occur
when a woman is placed in a lithotomy position.

o ENDOMETRITIS – Infection of the endometrium, the

lining of the uterus.
o PERITONITIS – infection of the peritoneal cavity.
o THROMBOPHLEBITIS - inflammation with the
formation of blood clots.
o PELVIC THROMBOPHLEBITIS – involves the
ovarian, uterine or hypogastric veins.
o PULMONARY EMBOLUS – obstruction of the
pulmonary artery by a blood clot. S/s: sudden sharp
chest pain, tachypnea, tachycardia, orthopnea and
cyanosis.

FOUR MAIN REASONS OF HEMORRHAGE

UTERINE ATONY

• Relaxation of the uterus. Predisposing factors such as:

multiple gestation, a large baby, polyhydramnios
(excessive amount of amniotic fluid), placenta previa,
placenta accreta, premature separation of placenta.
• Therapeutic Management:
o Attempt Fundal Massage - to encourage
contraction
§ to remain with the woman after massaging her
fundus - to assess to be certain her uterus is not
relaxing. Continue to assess for the next 4
hours.

ANDREA DENISE SAMBRANO | BSNS2C


RETAINED PLACENTAL FRAGMENTS
• A placenta does not detach in its entirety; fragments of it
separate and are left still attached to the uterus.
• Portion retained keeps the uterus from contracting fully
thus uterine bleeding occurs.
• Assessment: large, bleeding will be apparent immediate
after postpartal period.
• Management: dilatation and curettage (d&c); maybe
prescribed by methotrexate - to destroy retained
fragments.
UTERINE INVERSION
• Prolapse of the fundus of the uterus through the cervix so
that the uterus turns inside out.
DISSEMINATED INTRAVASCULAR COAGULATION
• Deficiency in clotting ability caused by vascular injury; it
is usually associated with premature separation of the
placenta, missed early carriage or fetal death in utero.
• Assessment: Chest pain and shortness of breath, pain,
redness, warmth and swelling in the lower leg, headache,
double vision and seizure.
• Subinvolution:
o incomplete return of the uterus to its prepregnant
size and shape.
o @ 4 – 6 weeks postpartal visit, the uterus is still
enlarged and soft.
• MANAGEMENT:
o Methylergonovine 0.2mg 4x daily
1.2 INFECTION
ENDOMETRITIS
• It is an infection of the endometrium, the lining of the
uterus; infection is usually associated with
chorioamnionitis and caesarean birth.
• Assessment: fever on the 3rd and 4th day pp; chills, loss
of appetite, and general body malaise.
• Uterus is not well contracted and is painful to touch.
• Lochia – dark brown and has foul odor (increased in
amount because of poor uterine contraction).
• Therapeutic Management:
o Administration of antibiotic such as Clindamycin
(Cleocin)
o Oxytocin agent such as Methylergonovine - to
encourage uterine contraction
o Instruct to increase oral fluid intake - to combat fever
o May give analgesics (strong afterpains and
abdominal discomfort)
INFECTION OF THE PERINEUM
• Infection of the perineum is usually remains localized.
• Assessment:
o pain, heat and feeling of pressure
o pt may or may not have elevated temperature
depending on the systemic effect and spread of
infection.
• Therapeutic Management:
o sutures may remove - to open the area and allow
drainage.
o Sitz baths, moist warm compress or hubbard tank
treatments (to hasten drainage and cleanse the
area)
o Remind the woman to change perineal pads
frequently.
o Analgesic may be prescribed (to alleviate
discomfort)
THROMBOPHLEBITIS
INTRODUCTION
• Inflammation with the formation of blood clots.
• Classification: svd (superficial vein disease) and dvt
(deep vein thrombosis)
• Reasons of occurence on postpartum period:
o Woman's fibrinogen level is still elevated from
pregnancy leading to increased blood clotting
o Dilatation of lower extremity veins is still present as
a result of pressure of fetal head during pregnancy
and birth so blood circulation is sluggish
o Develop postpartal infection
o Preexistent obesity and a pregnancy weight gain
o Smoke cigarettes because nicotine cause
vasoconstriction and reduces blood flow.
FEMORAL THROMBOPHLEBITIS
• Femoral, saphenous, or popliteal veins are involved.
• Inflammation site is vein, arterial spasm often occurs -
diminishing circulation to the leg - edema - gives leg a
 white or drained appearance - condition is formerly known Table 1. Comparing postpartal blues, depression, and
as MILK LEG OR PHLEGMASIA ALBA DOLENS (white psychosis
inflammation)
• Assessment: Postpartal Postpartal Postpartal
o unilateral localized symptoms such as redness, Blues Depressio Psychosis
swelling, warmth and hard inflamed vessel in the n
affected leg. Onset 1-10 days 1-12 Within first
o symptoms present about 10 days after birth after birth months year after birth
o HOMANS sign - pain in the dorsifexion of the foot is after birth
positive. Symptom Sadness, Anxiety, Delusions or
• Therapeutic management: s tears feeling of hallucinations
o administration of anticoagulants loss, of harming
o application of moist heat (to decrease inflammation) sadness infant or self
o bed rest with the affected leg elevated. Incidence 70% of all 10& of all 1%-2% of all
• NEVER MASSAGE THE SKIN OVER CLOTTED AREA - births births births
could loosen the clot, causing a pulmonary or cerebral Etiology Probable History of Possible
embolism hormonal previous activation of
changes, depression mental illness,
PELVIC THROMBOPHLEBITIS stress of life , hormonal hormonal
changes response, changes,
• Involves the ovarian, uterine or hypogastric veins. lack of family history
• Follows mild endometritis and occurs later than femoral social of bipolar
thrombophlebitis around 14th to 15th day of the support disorder
puerperium. Therapy Support, Counseling Psychotherap
• Assessment: empathy , possibly y, drug
o Woman suddenly becomes extremely ill, with a high drug therapy
fever, chills, abdominal pain, weakness, and general therapy
malaise Nursing Offer Screen for Refer to
• Therapeutic management: role compassion depression psychiatric
o Total bedrest and and refer to care,
o Administration of analgesics, antibiotics and understandin counseling safeguarding
anticoagulants g mother from
injury to self
and newborn
PULMONARY EMBOLUS

• Obstruction of the pulmonary artery by a blood clot;

occurs as a complication of thrombophlebitis when blood
clot moves from a leg vein to the pulmonary artery.
• Assessment:
o Signs are sudden, sharp chest pain
o Tachypnea, tachycardia
o Orthopnea (inability to breathe except in an upright
position)
o Cyanosis (blood clot is blocking both blood flow to
the lungs and return of the heart)
• Therapeutic management:
o Oxygen administration (high risk for
cardiopulmonary arrest)
o May be transferred to an ICU unit for continuing care

PROBLEM OF THE PSYCHE/EMOTIONAL &

PSYCHOLOGICAL COMPLICATIONS

• POSTPARTAL DEPRESSION
o manifested by overwhelming sadness, can occur in
new mothers and fathers.
• RISK FACTORS:
o History of depression
o Troubled childhood
o Low self esteem
o Stress in the home or at work
o Lack of effective support
o Different expectations between partners
o Disappointment in child
• POSTPARTAL PSYCHOSIS
o when the illness coincides with the postpartal period
or occurs during the following year
o woman appears exceptionally sad.
 MODULE 4: HIGH-RISK NEWBORN
Placental Grading Refers to a
OUTLINE
(Grannum ultrasound grading system of
I. Altered Gestational Age or Birthweight classification) the placenta based on its
II. Problems related to Maturity maturity Ultrasonically
III. Illness in the Newborn diagnosed maturity changes in
the placenta, Grades 0 to III,
ALTERED GESTATIONAL AGE OR BIRTHWEIGHT have been previously shown to
ALTERED BIRTH WEGITH correlate with fetal lung maturity

• Infants need to assessed after birth to determine weight, • Grade 0: Placental body is
height, head circumference, and gestational age to homogeneous. The
determine the immediate needs and to manage it amniochorionic plate is
promptly. even throughout. Late
• Normally, birth weight increases for each additional week 1st trimester-early
of age. Infants who fall between the 10th and 90th 2nd trimester
percentile of weight for their gestational age, are • Grade I : Placental body
considered appropriate for gestational age (AGA). Infants shows a few echogenic
who fall below the 10th percentile of weight for their age densities ranging from 2-4
are considered small for gestational age (SGA). Those mm in diameter. Chorionic
who fall above the 90th percentile in weight are plate shows small
considered large for gestational age (LGA). indentations. Mid
2nd trimester to early
SMALL-FOR-GESTATIONAL-AGE INFANT (SGA) 3rd trimester (~18-29 wks).
• Grade II : Chorionic plate
shows marked indentations,
• SGA infants are small for their age because they have creating comma-like
experienced intrauterine growth restriction (IUGR) or densities which extend into
failed to grow at the expected rate in utero. the placental substance but
• Common etiologies are lack of adequate nutrition, do not reach the basal plate.
pregnant adolescents, placental anomaly. Women with The echogenic densities
systemic diseases that decrease blood flow to the within the placental also
placenta, such as severe diabetes mellitus or pregnancy increase in size and
induced hypertension (both are diseases in which blood number. The basal layer
vessel lumens are narrowed) and who smoke heavily or comes punctuated with
use narcotics also tend to have SGA infants. linear echoes which are
• Birth weight below 10th percentile on intrauterine growth enlarged with their long axis
curve parallel to the basal layer.
• Maybe preterm, term, post term Late 3rd trimester (~30 wks
• Associated with IUG (intrauterine growth restriction)- to delivery)
small for their age • Grade III : Complete
• Etiology/Causes: indentations of chorionic
o Placental anomaly: most common plate through to the basilar
o Pregnant adolescents: lack of adequate nutrition plate creating cotyledons
o Placental damage: abruptio placenta (portions of placenta
o Woman with DM, PIH, smoker separated by the
o Infant has intrauterine infection (rubella or indentations). 39 wks post
toxoplasmosis or chromosomal abnormality) dates
• Assessment:
o Prenatal – APPEARANCE OF SGA
§ FH less than expected
§ Sonogram: ↓ size • Generally, an infant is below average in weight, length,
§ NST, Biophysical Profile, placental and head circumference. Regardless of when deprivation
grading, AF: poor placental function → occurs, an infant tends to have an overall wasted
CS appearance, a small liver, which can cause difficulty
regulating glucose, protein, and bilirubin levels after birth.
Biophysical Profile A prenatal ultrasound evaluation The infant also may have poor skin turgor and generally
(BPP) of fetal well-being involving a appear to have a large head because the rest of the body
scoring system, with the score is so small. Skull sutures may be widely separated from
being termed Manning's score. It lack of normal bone growth. Hair is dull and luster stained
is often done when a non-stress yellow.
test (NST) is non-reactive, or for • Sunken abdomen
other obstetrical indications. • Cord dry and yellow-stained

The "modified biophysical

Laboratory • ↑ Hct
profile" consists of the NST • Polycythemia
and amniotic fluid index only. • Prolonged acrocyanosis

ANDREA DENISE SAMBRANO | BSNS2C

 • Hypoglycemia (<45 mg/dL)
COMMON PROBLEMS OF SGA
• Because SGA infants have decreased glycogen stores,
one of the most common problems is hypoglycemia
(decreased blood glucose, or a level below 45 mg/dL).
Birth asphyxia is a common problem for SGA infants, both
because they have underdeveloped chest muscles
and because they are at risk for developing meconium
aspiration syndrome as a result of anoxia during labor.
• Although SGA infants may gain weight and appear to
thrive in the first few days of life, their cognitive
development may have been impaired because of lack of
oxygen and nourishment in utero.
• Hypothermia
LARGE-FOR-GESTATIONAL-AGE INFANT (LGA)
• An infant is LGA (also termed macrosomia) if the birth
weight is above the 90th percentile on an intrauterine
growth chart for that gestational age. Such a baby
appears deceptively healthy at birth because of the
weight, but a gestational age examination will reveal
immature development.
• Infants who are LGA have been subjected to an
overproduction of growth hormone in utero. This happens
most often to infants of women with diabetes mellitus or
women who are obese.
• Multiparous women are also prone to have large babies
because with each succeeding pregnancy, babies tend to
grow larger. Other conditions associated with LGA infants
include transposition of the great vessels, Beckwith
syndrome (a rare condition characterized by overgrowth),
and congenital anomalies such as omphalocele.
• Assessment:
o FH greater than expected
o Sonogram
o Non-stress test (NST)
o Amniocentesis: lung maturity
APPEARANCE OF LGA
• At birth, LGA infants may show immature reflexes and low
scores on gestational age examinations in relation to their
size. They may have extensive bruising or a birth injury
such as a broken clavicle or Erb-Duchenne. Because the
head is large, it may have been exposed to more than the
usual amount of pressure during birth, causing a
prominent caput succedaneum, cephalhematoma, or
molding.
COMMON PROBLEMS OF LGA
• Observe LGA infants closely for signs of
hyperbilirubinemia (increased serum bilirubin level),
which may result from absorption of blood from bruising
and polycythemia. If cyanosis is present, it may be a sign
of transposition of the great vessels, a serious heart
anomaly associated with macrosomia.
• LGA infants also need to be carefully assessed for
hypoglycemia in the early hours of life because infants
require large amounts of nutritional stores to sustain their
weight.
• Some LGA infants have difficulty establishing respirations
at birth because of birth trauma. Increased intracranial
pressure from birth of the larger-than-usual head could
have led to pressure on the respiratory center.
• CPD→ Cesarean Birth
• Birth trauma
• Imbalanced nutrition
PROBLEMS RELATED TO MATURITY
PRETERM INFANT
• A preterm infant is traditionally defined as a live-born
infant born before the end of week 37 of gestation;
another criterion used is a weight of less than 2500 g (5
lbs 8 oz) at birth.
• The exact cause of premature labor and early birth is
rarely known. The major influencing factor in these
instances appears to be inadequate nutrition before and
during pregnancy.
• 7% of all pregnancies
• Needs intensive care
• Responsible for 80-90% of infant mortality
• Common Factors Associated with Preterm birth:
o Low socioeconomic level
o Poor nutritional status
o Lack of prenatal care
o Multiple pregnancy
o Previous early birth
o Race (nonwhites have a higher incidence of
prematurity than whites)
o Cigarette smoking
o Age of the mother (highest incidence is in mothers
younger than age 20)
o Order of birth (early termination is highest in first
pregnancies and in those beyond the fourth
pregnancy)
o Closely spaced pregnancies
o Abnormalities of the mother’s reproductive system,
such as intrauterine septum
o Infections (especially urinary tract infection)
o Obstetric complications, such as premature rupture
of membranes or premature separation of
the placenta
o Early induction of labor
o Elective cesarean birth
o Respiratory distress syndrome
o Hypoglycemia
o Intracranial hemorrhage
• Assessment:
o On gross inspection, a preterm infant appears small
and underdeveloped. The head is disproportionately
large (3 cm greater than chest size). The skin is
generally unusually ruddy because there is little
subcutaneous fat beneath it; veins are easily
noticeable, and a high degree of acrocyanosis may
be present. Both anterior and posterior fontanelles
 are small. There are few or no creases on the soles
of the feet.
o Covered with vernix (25-36 wks)
o < 25 weeks: vernix absent
o ↑ lanugo
o The eyes of most preterm infants appear small.
Although difficult to elicit, pupillary reaction is
present. The ears appear large in relation to the
head. Neurologic system is still so immature.
o Varying degrees of myopia
o Pinna falls forward, ear is large
o Reflexes absent (< 33 weeks)
o Less active
o Weak-, high-pitch cry
o Potential Complications:
§ Anemia of prematurity
o Normochromic, normocytic anemia
o ↓ reticulocyte count
o Pale, lethargic, anorectic
o Mgt: Erythropoeitin, BT, Vit E, iron
§ Kernicterus
• Destruction of brain cells by invasion of
indirect bilirubin due to extensive breakdown
of RBC
• Brain cells are more susceptible to
destruction than term infants due to:
o Poor respiratory exchange→ acidosis
o ↓ serum albumin levels
o Occur at 12 mg per 100 mL level of
Indirect bilirubin
o Mgt: phototherapy, exchange
transfusion
§ Persistent Patent Ductus Arteriosus
o Premature→ lack of surfactant→ non-
compliant lungs → pulmonary artery
HPN → Non-closure of ductus
arteriosus
o Mgt: caution in Intravenous therapy,
Indomethacin, Ibuprofen to close the
PDA (urine output must be monitored)
§ Periventricular/Intraventricular Hemorrhage
o Bleeding into the tissue surrounding
the ventricles (periventricular) or into
the ventricles (intraventricular)
o Occur 50% in very LBW infants
o Cause: fragile capillaries and immature
cerebral vascular development
o Rapid change in cerebral blood
pressure e.g. hypoxia, IVF, ventilation
or pneumothorax
o Complications: hydrocephalus, brain
anoxia distal to rupture
o Labs: cranial UTZ (to detect
hemorrhage)
§ Other Potential Complications. Preterm infants
are particularly susceptible to several illnesses
in the early postnatal period, including
respiratory distress syndrome, apnea,
retinopathy of prematurity.
Problems: • Impaired gas exchange r/t immature
pulmonary functioning
• Risk for deficient fluid volume r/t
insensible water loss at birth and small
stomach capacity
• Risk for imbalanced nutrition, less than
body requirements r/t addt’l nutrients
needed for maintenance of rapid growth,
possible sucking difficulty and small
stomach
• Ineffective thermoregulation r/t
immaturity
• Risk for infection r/t immature immune
defenses
• Risk for impaired parenting r/t
interference with parent-infant
attachment
• Deficient diversional activity (lack of
stimulation) r/t preterm infant’s rest
needs
• Risk for disorganized infant behavior r/t
prematurity and environmental
overstimulation
• Parent health-seeking behaviors r/t
preterm infant’s needs for health
maintenance
POSTTERM INFANT
• A postterm infant is one born after the 42nd week of a
pregnancy. An infant who stays in utero past week 42 of
pregnancy is at special risk because a placenta appears
to function effectively for only 40 weeks. After that time, it
seems to lose its ability to carry nutrients effectively to the
fetus. A fetus who remains in utero with a failing placenta
may die or develop postterm syndrome.
• Infants with this syndrome have many of the
characteristics of the SGA infant: dry, cracked, almost
leather-like skin from lack of fluid, and absence of vernix.
They may be lightweight from a recent weight loss that
occurred because of the poor placental function.
• Amniotic Fluid < than normal, may be meconium-stained
• Alertness like 2-week old infant
• At birth, the postterm baby is likely to have difficulty
establishing respirations, especially if meconium
aspiration occurred. In the first hours of life, hypoglycemia
may develop because the fetus had to use stores of
glycogen for nourishment in the last weeks of intrauterine
life.
• Subcutaneous fat levels may also be low, having been
used in utero. This can make temperature regulation
difficult, making it important to prevent a postterm infant
from becoming chilled at birth or during transport.
Polycythemia may have developed from decreased
oxygenation in the final weeks.
• The hematocrit may be elevated because the
polycythemia and dehydration have lowered the
circulating plasma level.
Laboratory • Sonogram to measure biparietal
diameter of the fetus
• Nonstress test, Biophysical Profile
to check if placenta is still functioning
 • ↑ Hct – polycythemia and dehydration

Management CS: compromised placental functions

Problems • Difficulty establishing respirations
• Meconium aspiration
• Hypoglycemia- had used the stores
glycogen
• Difficult thermoregulation-low
subcutaneous fat levels
• Polycythemia- decreased
oxygenation

ILLNESS IN THE NEWBORN

RESPIRATORY DISTRESS SYNDROME
• Respiratory distress syndrome (RDS) of the newborn,
formerly termed hyaline membrane disease, most often
occurs in preterm infants, infants of diabetic mothers,
infants born by cesarean birth, or those who for any
reason have decreased blood perfusion of the lungs,
such as occurs with meconium aspiration.
• The pathologic feature of RDS is a hyaline-like (fibrous)
membrane formed from an exudate of an infant’s blood
that begins to line the terminal bronchioles, alveolar
ducts, and alveoli. This membrane prevents exchange of
oxygen and carbon dioxide at the alveolar–capillary
membrane. The cause of RDS is a low level or absence
of surfactant, the phospholipid that normally lines the
alveoli and reduces surface tension to keep the alveoli
from collapsing on expiration.

MECONIUM ASPIRATION SYNDROME

• Meconium is present in the fetal bowel as early as 10

weeks’ gestation. If hypoxia occurs, a vagal reflex is
stimulated, resulting in relaxation of the rectal sphincter.
This releases meconium into the amniotic fluid. Babies
born breech may expel meconium into the amniotic fluid
from pressure on the buttocks.
• In both instances, the appearance of the fluid at birth is
green to greenish black from the staining. Meconium
aspiration does not tend to occur in extremely low-birth-
weight infants because the substance has not passed far
enough in the bowel for it to be at the rectum in these
infants.

SUDDEN INFANT DEATH SYNDROME (SIDS)

• SIDS is sudden unexplained death in infancy. It tends to

occur at a higher-than-usual rate in infants of adolescent
mothers, infants of closely spaced pregnancies, and
underweight and preterm infants. Also prone to SIDS are
infants with bronchopulmonary dysplasia, twins,
economically disadvantaged black infants, and infants of
narcotic-dependent mothers. The peak age of incidence
is 2 to 4 months of age.

HEMOLYTIC DISEASE OF THE NEWBORN

• The term “hemolytic” is derived from the Latin word for
“destruction” (lysis) of red blood cells. Lysis of red blood
cells in the newborn leads to hyperbilirubinemia (an
elevated level of bilirubin in the blood). This can result
from destruction of red blood cells by a normal
physiologic process When abnormal destruction of red
blood cells occurs, it is termed hemolytic disease. In the
past, hemolytic disease of the newborn was most often
caused by an Rh blood type incompatibility.
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ILLNESS RESPIRATORY DISTRESS SYNDROME

IN THE §Formerly hyaline membrane

NEWBORN disease
§Often occurs in preterm infants,
infants of diabetic mothers, born
via CS, meconium aspiration
§Cause: low or absent surfactant

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RESPIRATORY DISTRESS SYNDROME

RESPIRATORY DISTRESS SYNDROME

§Pathology: hyaline-like Lack of surfactant

membrane (exudate of hypoinflation ↑ pulmonary resistance
infant’s blood) lining the
terminal bronchioles, poor oxygen exchange
alveolar ducts and tissue hypoxia

alveoli→ prevents gas Acidosis ↓ surfactant production

exchange
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RESPIRATORY DISTRESS SYNDROME RESPIRATORY DISTRESS SYNDROME

§Assessment: §Expiratory grunt

§Fine rales, ↓ breath sounds
§Difficulty initiating respiration §↑ distress
§↓ body temperature §Seesaw respirations
§Nasal flaring §Heart failure
§Retractions §Pale, gray skin
§Apnea
§↑ RR §↓ PR
§Cyanotic mucous membranes §Pneumothorax
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RESPIRATORY DISTRESS SYNDROME RESPIRATORY DISTRESS SYNDROME

Diagnosis: Therapeutic Management

§Clinical signs §Surfactant administration via
§Chest X-ray (ground-glass ET
pattern of opacity) §Surfactant replacement
§ABG §O2 administration
§Blood, CSF, Skin cultures §Ventilation
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Set-up for a child with RDS RESPIRATORY DISTRESS SYNDROME

§Additional therapy
§ECMO
§Liquid ventilation
§Nitric oxide
§Supportive care
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Extracorporeal Membrane Oxygenation

RESPIRATORY DISTRESS SYNDROME

Prevention:
§Dating pregnancy
§L:S ratio determination
§Preterm labor: tocolytics
§Corticosteroids:
Betamethasone (24-34 wks)
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MECONIUM ASPIRATION
IMECONIUM ASPIRATION SYNDROME SYNDROME
Fetal Hypoxia Breech
§Aspiration of meconium in utero or
with first breath after birth Vagal reflex
§Associated with fetal hypoxia in Relaxation of rectal sphincter
utero
Aspiration of meconium
§Breech presentation
§Green to Greenish Black fluid Bronchioles
Mechanical plugging
Dec. in surfactant
inflammation production
§10-12 % of pregnancies
§Severe respiratory distress Hypoxemia CO2 Intra/ extra pulmonary
shunting
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MECONIUM ASPIRATION SYNDROME MECONIUM ASPIRATION SYNDROME

Assessment §ABG: ↓ PO2, ↑PCO2

§Apgar score↓
§↑ RR §Chest X-ray:
§Retractions honeycomb effect
§Cyanosis
§Coarse bronchial sounds
§Barrel chest (Air trapping)
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MECONIUM ASPIRATION SYNDROME MECONIUM ASPIRATION SYNDROME

Therapeutic Management §Antibiotic therapy

§Amniotransfusion §Problems:
§Suctioning at perineum, before §PDA – observe for ↑ hypoxia,
birth of shoulders heart failure
§Tracheal suctioning after birth §Maintain temperature-neutral
§O2 administration environment
§Assisted ventilation §Chest physiotherapy
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MECONIUM ASPIRATION SYNDROME SUDDEN INFANT DEATH SYNDROME

§ECMO (Extracorporeal §Unexplained death in infancy

membrane oxygenation) §Higher rate in infants of
§Liquid ventilation or adolescent mothers, closely
administration of spaced pregnancy,
perfluorocarbons – exchange of underweight, preterm infants,
oxygen occurs
§inhalation of nitric oxide - infants with
pulmonary vasodilation bronchopulmonary dysplasia
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SUDDEN INFANT DEATH SYNDROME SUDDEN INFANT DEATH SYNDROME

Contributing factors: §Distorted familial

§Viral respi or botulism breathing patterns
infection
§Pulmonary edema §↓ arousal responses
§Brainstem abnormality §Lack of surfactant
§Neurotransmitter deficiency §Prone position in
§Heart rate abnormalities sleeping
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SUDDEN INFANT DEATH SYNDROME SUDDEN INFANT DEATH SYNDROME

§Death due to Management:

laryngospasm §Reassurance to parents
§Autopsy: petechiae in and siblings that death is
lungs, mild inflammation not their fault
and congestion in respi §Put newborns to sleep on
tract their back
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HYPERBILIRUBINEMIA HYPERBILIRUBINEMIA

§Elevated level of bilirubin in §Hemolytic Disease of the

the blood Newborn
§Causes: §Destruction (lysis) of RBC
§Destruction of RBC by §Caused by Rh or ABO
normal physiologic process incompatibility
§Abnormal destruction of
RBC §Results to severe anemia
and hyperbilirubinemia
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HYPERBILIRUBINEMIA HYPERBILIRUBINEMIA

§Rh incompatibilty §Rh incompatibilty

§Occur in Rh negative mother §Assessment
and Rh positive fetus §↑ anti-Rh titer
§Mother forms antibodies §↑ antibody level in mother
against the D antigen within 72 (indirect Coomb’s test)
hrs after birth which will destroy §(+) direct Coomb’s test
(presence of antibodies in fetal
fetal RBC’s
blood
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HYPERBILIRUBINEMIA HYPERBILIRUBINEMIA

§Rh incompatibilty §Rh incompatibilty

§Assessment §Assessment
§Hepatomegaly/splenomegaly §Progressive jaundice within 1st
§Extreme edema 24 hrs of life
§Indirect bilirubin > 20 mg/dL
§Severe anemia→ heart failure (term), 12 mg/dL (preterm)
§Hydrops fetalis (hydrops: §Kernicterus can occur
edema; fetalis: lethal state §Anemia→hypoglycemia
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HYPERBILIRUBINEMIA
HYPERBILIRUBINEMIA

§Rh incompatibilty §ABO incompatibility

Management: §Maternal blood type O and fetal
§Intrauterine transfusions blood type A
§Induced preterm labor §If fetus has type B or AB blood
§Most serious: Type B
§Phenobarbital §Antibodies formed does not cross
§Rh immunoglobulin placenta
§Preterms not affected
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HYPERBILIRUBINEMIA HYPERBILIRUBINEMIA

§Hemolysis of RBC §Therapeutic Management

§Initiation of early feeding
begins with birth – 2 §Phototherapy
weeks of life §Quartz halogen, cool white
§Labs: (+) Coomb’s test daylight, blue fluorescent
§12-30 in above
§ ↑ reticulocyte count §Home Phototherapy
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HYPERBILIRUBINEMIA Phototherapy

§Exchange transfusion
§Used when this level
exceeds 5 mg/dL at birth,
10 mg/dL at age 8 hrs, 12
mg/dL at age 16 hrs, 15
mg/dL at age 24 hrs

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Exchange transfusion

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