NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)

ABORTION ➢ Mild fever

- Abortion is a method of terminating a Advantages
pregnancy. The embryo or fetus, as well as the
placenta, are removed from the uterus using ➢ It does not involve surgery
medicine or surgery. The procedure is performed ➢ Available for the first trimester
by a licensed healthcare professional. ➢ Does not require anesthetic

Etiology/Cause Disadvantages:
About 50% cases of early pregnancy loss is believed to be ➢ Not available in the 2nd trimester
due to fetal chromosomal abnormalities. ➢ Only part of the treatment takes
Most common risks factors also include: place in a clinic
➢ May cause painful cramping
- Maternal age 2. Vacuum Aspiration
- Alcohol consumption • A type of surgical abortion in which a
- Smoking pregnancy is terminated by using gentle
- Substance abuse suction.
- Chronic diseases (diabetes, autoimmune • The procedure begins by inserting a a
conditions) speculum into the woman’s vagina. The
- Structural uterine abnormalities healthcare professionals will then open
- Infections the cervix with thin rods called dilators
Types before inserting a tube into the uterus.
The following are the types of abortion according to a The uterus is then emptied using either
certain trimester: a manual or mechanical suction device.

In the first trimester, options for abortion include: Recovery:

1. Medical Abortion ➢ Rest for an hour after treatment

• This type requires the woman to take ➢ Taking antibiotics to prevent
two types of medication: mifepristone infection
and misoprostol. ➢ Avoid sex for 1 week
• Mifepristone inhibits the development Risks:
of a pregnancy. Misoprostol causes the
uterus to empty, which occurs 1–4 hours ➢ Bleeding and cramping
after the pill is taken. Advantages:
• Cramping and bleeding will then take
place as the woman’s uterus empties. ➢ Available in the first 12 weeks of
pregnancy
Risks: ➢ Quick procedure (5-10 minutes)
Some women experience side effects of the ➢ Pain-free
medication. These include: ➢ Does not require a general
anesthesia
➢ Nausea
➢ Heavy vaginal bleeding Disadvantages:
➢ Dizziness ➢ Not available in the 2nd trimester
➢ Diarrhea
➢ Fatigue For the second trimester,

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
1. Dilation and evacuation
• A type of surgical abortion that is
commonly used by doctors. Usually
recommended between 14 and 24
weeks.
• A general anesthesia may be given as
this type of anesthetic ensures that a
person does not feel anything during the
procedure.
• The doctor begins by inserting a
speculum into the woman’s vagina.
Then, they use dilators to open the
cervix. Next, they remove the pregnancy
tissue with small forceps. Lastly, they use
suction to remove any remaining tissue.
This procedure takes about 10-20
minutes.
Recovery:
3. Incomplete release of pregnancy tissue
➢ A few hours of rest is advised
Risks:
➢ Infection
➢ Heavy bleeding
➢ Injury to the uterus
Advantages:
➢ It is safe and effective
Disadvantages:
➢ Requires a general anesthesia
2. Labor induction abortion
• A late-term method of ending a
pregnancy in the second or third
trimester. A procedure reserved for
when there is a medical complication/s
detected to the fetus or the mother that
may pose a threat to their life.
• Labor induction involves using
medications to start labor, which causes
the uterus to empty over a period of
around 12–24 hours. A woman can take
these medications by mouth or the
doctor may place them into the vagina
or inject them into the uterus.
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Recovery:
➢ Remain in the clinic or hospital for
anywhere from a few hours to 1–2
days
Risks:
The medication that induce labor may cause
side effects, such as:
➢ Nausea and vomiting
➢ Fever
➢ Diarrhea
Complications are rare but includes:
➢ Hemorrhage
➢ Cervical injury
➢ Infection
➢ Rupture of the uterus
• This type of abortion is commonly
performed for pregnancies with birth
defects or pregnancy complications.
• The process often begins with an
injection to stop the fetal heartbeat. The
skin on the abdomen is numbed with a
painkiller, and then a needle is used to
inject a medication (digoxin or
potassium chloride) through the
abdomen into the fluid around the fetus
or the fetus to stop the heartbeat.
• Medication is then given to start
contractions and to cause the cervix to
dilate. One medication (Misoprostol)
can be taken by mouth or put in the
vagina. Another medication (Pitocin)
which is administered through IV.
Recovery:
➢ The length of stay in the hospital
after the induction is complete will
depend on the client’s health and
other factors. Some women stay for
a few hours and other women stay
for 1-2 days.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Risks:
➢ Infection
➢ heavy bleeding
➢ Hole or tear in the wall of the uterus
➢ Injury to the cervix
➢ Failed induction
Signs and Symptoms
❖ Vaginal spotting
❖ Scant and bright red vaginal bleeding
❖ Slight cramping
❖ Cervical dilatation
❖ Fever
❖ Depression
Management
Nursing Management:
Nurses must also have their own independent functions
to ensure the safety and well-being of the patient. The
following are measures that would allow the nurse to act
independently.
• The presenting symptom of an abortion is always
vaginal spotting, and once this is noticed by the
pregnant woman, she should immediately notify
her healthcare provider
• As nurses, we are always the first to receive the
initial information so we should be aware of the
guidelines in assessing bleeding during
pregnancy.
• Ask of the pregnant woman’s actions before the
spotting or bleeding occurred and identify the
measures she did when she first noticed the
bleeding.
• Inquire of the duration and intensity of the
bleeding or pain felt.
• Lastly, identify the client’s blood type for cases of
Rh incompatibility.
Medical Management:
• Medical interventions should also be
incorporated in the patient’s care plan to
reinforce his treatment. These are physician’s
orders wherein nurses and other caregivers
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would assist or take into action, thus ensuring
the recovery of the patient.
• Aside from our own nursing management,
physicians would also have to order a series of
therapeutic management for the pregnant
woman.
• Administration of intravenous fluids. Such as
Lactated Ringer’s, IV therapy should be
anticipated by the nurse as well as
administration of oxygen regulated at 6-
10L/minute by a face mask to replace
intravascular fluid loss and provide adequate
fetal oxygenation.
• Avoid vaginal examinations. The physician would
also avoid further vaginal examinations to avoid
disturbing the products of conception or
triggering cervical dilatation.
• The physician might also order an ultrasound
examination to glean more information about
the fetal and also maternal well-being.
Our role as nurses in these medical interventions would
be to assist in every aspect possible, and ensure the
wellbeing of both the mother and the fetus. Through our
nursing interventions, we could initiate care without
needing to run after the physicians and ask for their
orders. We should be able to function independently as
caregivers and promote their wellness in our own way as
nurses. The most vital pieces of information are always
handed to us first, so it would be up to us to initiate the
first intervention to make or break the condition of the
client before a doctor arrives. Nurses are the first line of
defense of every hospital, and we should live up to that
expectation.
Pharmacologic Management:
• Oral mifepristone (Mifeprex) and oral
misoprostol (Cytotec). This is the most common
type of medical abortion. These medications are
usually taken within seven weeks of the first day
of your last period. Mifepristone (mif-uh-PRIS-
tone) blocks the hormone progesterone, causing
the lining of the uterus to thin and preventing
the embryo from staying implanted and growing.
Misoprostol (my-so-PROS-tol), a different kind of
medication, causes the uterus to contract and
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
expel the embryo through the vagina. If you
choose this type of medical abortion, you'll likely
take the mifepristone in your doctor's office or
clinic. Then you will probably take the
misoprostol at home, hours or days later. You'll
need to visit your doctor again about a week
later to make sure the abortion is complete. This
regimen is approved by the Food and Drug
Administration (FDA).
• Oral mifepristone and vaginal, buccal or
sublingual misoprostol. This type of medical
abortion uses the same medications as the
previous method, but with a slowly dissolving
misoprostol tablet placed in your vagina (vaginal
route), in your mouth between your teeth and
cheek (buccal route), or under your tongue
(sublingual route). The vaginal, buccal or
sublingual approach lessens side effects and may
be more effective. These medications must be
taken within nine weeks of the first day of your
last period.
• Methotrexate and vaginal misoprostol.
Methotrexate (Otrexup, Rasuvo, others) is rarely
used for elective, unwanted pregnancies,
although it's still used for pregnancies outside of
the uterus (ectopic pregnancies). This type of
medical abortion must be done within seven
weeks of the first day of your last period, and it
can take up to a month for methotrexate to
complete the abortion. Methotrexate is given as
a shot or vaginally and the misoprostol is later
used at home.
• Vaginal misoprostol alone. Vaginal misoprostol
alone can be effective when used before nine
weeks of gestation of the embryo. But vaginal
misoprostol alone is less effective than other
types of medical abortion.
Surgical Management:
Aside from the medical interventions ordered by
physicians, incidences might occur which would lead to a
surgical operation.
• Dilatation and evacuation. This is to make sure
that all products of conception would be
removed from the uterus. However, before
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undergoing this intervention, the physician must
be sure that no fetal heart sounds could be heard
anymore and the ultrasound must show an
empty uterus.
• Dilation and curettage. This is most commonly
performed for incomplete abortions to remove
the remainder of the products of conception
from the uterus. Since the uterus would not be
able to contract effectively, the contents might
be trapped inside and could cause serious
bleeding and infection.
INCOMPETENT CERVIX
- Incompetent cervix, also called cervical
insufficiency, occurs when weak cervical tissue
causes or contributes to premature birth or the
loss of an otherwise healthy pregnancy. Before
pregnancy, the lower part of the uterus or the
cervix that opens to the vagina is normally closed
and firm. The cervix softens, shrinks and length
and opens as the pregnancy advances and the
mother is prepared to give birth. The cervix may
open too quickly if the mother has an
incompetent cervix which may force them to
deliver their child early.
Etiology/Cause
Incompetent cervix usually occurs during the middle or
early third trimester, depending on the severity of the
insufficiency. Cervical incompetence may be congenital
or acquired. The most common congenital cause is a
defect in the embryological development of Mullerian
ducts, while the most common acquired cause of cervical
trauma such as cervical lacerations during childbirth,
cervical conization, or forced cervical dilatation during
the uterine evacuation in the first or second trimester of
pregnancy.
Below are also conditions that cause incompetent cervix.
These include:
- Abnormally formed uterus or cervix.
- Previous cervix surgery.
- Short cervix.
- Damaged uterus from previous miscarriage or
childbirth.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
- Exposure to diethylstilbestrol (DES), a synthetic Medical Management:
(human-made) hormone given to some women
• With the help of the physician, he/she will not
in the past to help them have successful
include medications that could prevent the
pregnancies.
dilation of a woman’s cervix. Therefore, surgical
Signs and Symptoms procedures are immediately conducted to avoid
No signs or symptoms during early pregnancy, although a compromised pregnancy
some women may experience spotting and feel
Pharmacologic Management:
discomfort starting between the 14th-20th week of
pregnancy. • There is possible treatments in managing an
A few signs and symptoms are starting between the incompetent cervix that might include
14th-20th week of pregnancy Progesterone supplementation. Having a history
of premature birth, the physician could suggest
A few signs and symptoms are the following: the the patient to take weekly shots of the hormone
following: progesterone in a form called
hydroxyprogesterone caproate (Makena) during
❖ A sensation of pelvic pressure A new backache
the second and third trimester. Moreover,
❖ Mild abdominal cramps
further research is still in demand to determine
❖ A change in vaginal discharge
the best use of progesterone in cervical
❖ Light vaginal bleeding
insufficiency.
Management
Surgical Management:
Nursing Management:
• There is two options of surgical management in
Upon assessment, the nurse must conduct an interview
addressing incompetent cervix. First is
to ask the patient, who is experiencing painless bleeding,
McDonald’s Cervical Cerclage. The nylon sutures
if she is having an intense pressure on her pelvis.
are placed horizontally and vertically across the
Determine next if the woman is experiencing true
cervix. They are pulled back together until the
contractions to prepare for the birth of the fetus. Lastly,
cervical canal is only a few millimeters in
inspect and save pads used by the woman during
diameter. Another one is Shirodkar Cervical
bleeding to determine any clots or tissues that already
Cerclage in where a sterile tape is used for this
passed out.
technique, where it is threaded in a purse-string
In conducting the nursing interventions, the nurse must manner under the submucous layer of the cervix.
perform the following: Then, it is sutured in place so it would close the
cervix.
1. Determine certain factors that can further
• The sutures in both procedures mentioned are
contribute to the anxiety of the patient so that it
then removed on the 37th or 38th week of
can be avoided.
pregnancy for the fetus to be born vaginally.
2. Monitor vital signs in order to determine any
Cervical cerclage is not appropriate for everyone
physical responses of the patient that could
at risk of premature birth and the procedure is
affect her current condition.
not recommended for women carrying twins or
3. Show empathy and establish a therapeutic
more.
nurse-client relationship so that the patient will
be able to express her feelings freely.
4. Provide simple and accurate information about
the situation to aid the patient in addressing her
concerns.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
ECTOPIC PREGNANCY
- An ectopic pregnancy occurs when a fertilized
egg implants and grows outside the main cavity
of the uterus. In most cases, an ectopic
pregnancy occurs in a fallopian tube. This is a life-
threatening condition as the pregnancy cannot
be carried to term and can be dangerous for the
mother if not immediately treated.
Etiology/Cause
Usually an ectopic pregnancy happens when a fertilized
egg gets stuck on its way to the uterus because of an
obstruction due to:
- Adhesion of the fallopian tube from a previous
infection (chronic salpingitis or pelvic
inflammatory disease)
- Congenital malformations
- Scars from tubal surgery
- Uterine tumor pressing on proximal end of tube
- Hormonal imbalances
- Endometriosis
- Abnormal development of the fertilized egg,
Types
1. Tubal Ectopic Pregnancy
• This type is the most common and
makes up 95% of ectopic pregnancies It
occurs in the Fallopian tube.
2. Interstitial Pregnancy
• 3% of ectopic pregnancies are
interstitial. This type occurs in the part of
the Fallopian tube that crosses into the
uterus.
3. Cesarean Scar Pregnancy
• Cesarean scar ectopic pregnancies are a
rare case and occur when the fertilized
egg implants into the gap in the muscle
of the uterus caused by a previous
Cesarean section. The pregnancy may
then grow out of the uterus or onto the
cervix and cause torrential internal or
vaginal bleeding.
4. Cervical Pregnancy
• Cervical pregnancies occur on the cervix
and are one of the rarest forms of
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ectopic pregnancy. This type is thought
to be of special concern because of the
risk of life-threatening vaginal
hemorrhage.
5. Cornual Pregnancy
• This is another rare type of ectopic that
only occurs in a uterus that has not
formed as expected. It is also known as
Rudimentary Horn pregnancy because it
happens on the side of the irregularly
shaped uterus that is not connected to
the cervix or vagina, called the
rudimentary horn.
6. Ovarian Pregnancy
• This rare type of ectopic pregnancy
occurs on the ovary. These are difficult
to diagnose as they look very similar to a
tubal ectopic pregnancy that is stuck to
the ovary or a ‘corpus luteum’ which is
the place that the egg was released
from. This can mean that ovarian
pregnancies are often not diagnosed
until surgery.
7. Intramural Pregnancy
• Intramural type is a pregnancy that
implants outside the cavity of the uterus,
but within its muscular wall. These
pregnancies are thought to occur when
the uterus has been scarred by previous
surgery or a condition called
adenomyosis.
8. Abdominal Pregnancy
• Abdominal pregnancies, in most
instances, are thought to have begun in
the Fallopian tube and then separated
from the wall of the fallopian tube,
floating into the abdominal cavity to
then reattach to one of the structures in
the abdomen.
9. Heterotopic Pregnancy
• Heterotopic pregnancy is when there is
the coexistence of an intrauterine
pregnancy with an ectopic pregnancy.
Although it is rare, it is possible to have
a twin pregnancy with one embryo to
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implant in the uterus and another
elsewhere.
Signs and Symptoms
❖ A missed or late period
❖ Positive hCG pregnancy test
❖ Vaginal bleeding
❖ Pain in lower abdomen, pelvis, lower back -
Dizziness or weakness.
❖ Shoulder tip pain
❖ Diarrhea
❖ Pain while urinating or defecating
❖ shooting/sharp vaginal pain
Management
Nursing Management:
Upon arrival of the patient
• A woman with a ruptured ectopic pregnancy
may show signs of shock when she arrives at the
hospital, such as a rapid, thread pulse, rapid
respirations, and low blood pressure.
• Once a rupture has occurred, the woman will
likely experience sharp, stabbing pain in the
lower region, followed by scant vaginal bleeding.
Nursing Interventions
• Upon arrival of the patient, place the woman in
a supine position on a bed
• Assess the vital signs to establish baseline data
and determine if the patient is under shock.
• Maintain accurate intake and output to establish
the patient’s renal function.
Medical Management:
• Blood sampling or withdrawal of blood is
ordered wherein a large amount of blood would
be lost when there is a rupture of ectopic
pregnancy, thus, blood typing and crossmatching
must be done in anticipation of a blood
transfusion. The pregnant woman's hemoglobin
levels would also be determined using the blood
sample.
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Pharmacologic Management:
• A woman who is diagnosed early of ectopic
pregnancy without unstable bleeding is often
treated with a medication of methotrexate. This
stops rapidly growing cells such as trophoblasts
and the zygote.
Surgical Management:
Following the rupture of the ectopic pregnancy, surgical
treatments would be conducted to ensure that the
reproductive system remained functional and that no
complications arose.
• Laparoscopy
→ The bleeding blood vessels will be
ligated, and the injured fallopian tube
will be repaired or removed.
• Salpingectomy
→ If the fallopian tube is fully destroyed,
this procedure would be performed. The
damaged tube would be removed, and
the remaining portion would be sutured
appropriately.
HYPEREMESIS GRAVIDARUM
- Hyperemesis gravidarum is extreme, persistent
nausea and vomiting during pregnancy. It can
lead to dehydration, weight loss, and electrolyte
imbalances. Morning sickness is mild nausea and
vomiting that occurs in early pregnancy.
Etiology/Cause
- Most women have some nausea or vomiting
(morning sickness), particularly during the first 3
months of pregnancy. The exact cause of nausea
and vomiting during pregnancy is not known.
However, it is believed to be caused by a rapidly
rising blood level of a hormone called human
chorionic gonadotropin (HCG). HCG is released
by the placenta. Mild morning sickness is
common. Hyperemesis gravidarum is less
common and more severe.
- Women with hyperemesis gravidarum have
extreme nausea and vomiting during pregnancy.
It can cause a weight loss of more than 5% of
body weight. The condition can happen in any
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
pregnancy, but is a little more likely if you are
pregnant with twins (or more babies), or if you
have a hydatidiform mole. Women are at higher
risk for hyperemesis if they have had the
problem in previous pregnancies or are prone to
motion sickness.
Types
1. Mild
A woman can function somewhat but is still
feeling miserable with mild *HG:
• Usually ends by mid-pregnancy
• Weight loss is about 5%
• Requires medications and sometimes IV
fluids
• Mother can continue some daily
activities
• Recovery may take a few months or
more
Nursing Management:
2. Moderate
A woman struggles to function and is very
miserable with moderate HG:
• May continue beyond mid-pregnancy
but severity lessens
• Weight loss is 5-10% (less with early
treatment)
• Requires medications, and sometimes
fluids and/or nutrition therapy
Medical Management:
• Mother is extremely fatigued and only
able to do a few tasks
• Recovery may take several months
• Signs of trauma and changes in family
planning may occur
3. Severe
A woman is unable to function and constantly
Pharmacologic Management:
sick with severe HG:
• Symptoms are often difficult to control
with medications
• Weight loss is 10% or more (less with
early treatment)
• Requires fluids, medications, and
sometimes nutrition support for months
• Mother is exhausted, malnourished, and
unable to care for herself
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• Recovery can take 1-2 months for every
month sick
• Signs of trauma and changes in family
planning are common
• Delivery may be complicated and
difficult due to debility
• Without treatment, the life of mother
and baby are at risk
Signs and Symptoms
❖ Feeling nearly constant nausea
❖ Loss of appetite
❖ Vomiting more than three or four times per day
❖ Becoming dehydrated
❖ Feeling light-headed or dizzy
❖ Losing more than 10 pounds or 5 percent of your
body weight due to nausea or vomiting
Management
• Reestablishing normal fluid and electrolyte levels
often relieves nausea and vomiting. Encourage
the patient to eat, and tell her to avoid going for
a long period without eating. Advise her to eat
when she feels hungry, starting with small,
frequent low fat meals. She should avoid
drinking fluids with meals.
• Treatment methods include a range of options,
including maternal diet and lifestyle alterations,
administration of intravenous fluids, antiemetics
or steroids, and alternative therapies such as
acupuncture and hypnosis.
• Treatment methods include:
o Intravenous fluids (IV) – to restore
hydration, electrolytes, vitamins, and
nutrients
Tube feeding:
o Nasogastric – restores nutrients through
a tube passing through the nose and into
the stomach
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Medications – metoclopramide, antihistamines,
and antireflux medications*
Surgical Management:
• Percutaneous endoscopic gastrostomy – a
surgical procedure that restores nutrients
through a tube passing through the abdomen
and into the stomach
HYDATIDIFORM MOLE
- A hydatidiform mole (also known as a molar
pregnancy) is a gestational trophoblastic disease
(GTD), which originates from the placenta and
can metastasize. It is unique in that the tumor
originates from gestational tissue rather than
from maternal tissue. Hydatidiform moles (HM)
are categorized as complete and partial and are
usually considered the noninvasive form of
gestational trophoblastic disease. While
hydatidiform moles are typically deemed benign,
they are premalignant and do have the potential
to become malignant and invasive.
Etiology/Cause
- HM, or molar pregnancy, results from abnormal
fertilization of the oocyte (egg). It results in an
abnormal fetus. The placenta grows normally
with little or no growth of the fetal tissue, and
the placental tissue forms a mass in the uterus.
Types
• Hydatidiform moles are divided into 1) Complete
moles, and 2) Partial moles. Complete mole is
the most common type and does not contain
fetal parts, whereas in a partial mole there might
be identifiable fetal residues. Complete moles
are typically diploid, whereas partial moles are
triploid. Complete moles tend to cause higher
levels of the human chorionic gonadotropin
(hCG), which is one of the main clinical features
of this process. In complete moles, the karyotype
is 46,XX 90% of the time and 46,XY 10% of the
time. It arises when an enucleated egg is
fertilized either by two sperms or by a haploid
sperm that then duplicates and therefore, only
paternal DNA is expressed. On the other hand, in
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partial moles, the karyotype is 90% of the time
triploid and either 69,XXX or 69,XXY. This
karyotype arises when a normal sperm
subsequently fertilizes haploid ovum duplicates
and or when two sperms fertilize a haploid
ovum. In partial moles, both maternal and
paternal DNA is expressed.
• Under normal circumstances, the fertilised
empty ovum would die and not implant in the
uterus. But rarely, the ovum doesn't die and
implantation takes place. The trophoblast cells
grow and develop as a disorganised mass of
tissue but the embryo does not develop. This is a
complete hydatidiform mole. There is no tissue
resembling an unborn baby (a fetus) at all.
• A partial hydatidiform mole is also possible if
conception doesn't take place normally. It is
usually due to two sperm fertilising one normal
ovum (which should not usually happen). This
means that there is too much genetic material
present. There is also too much trophoblastic
tissue. The growth of the trophoblastic tissue
overtakes the growth of any fetal tissue and the
fetus does not develop normally.
• Partial and complete hydatidiform moles will not
produce a live baby. (They are 'non-viable'
pregnancies.)
To summarize, Molar pregnancy can be of two types:
● Partial molar pregnancy: There is an abnormal
placenta and some fetal development.
● Complete molar pregnancy: There is an abnormal
placenta and no fetus.
Signs and Symptoms
Women with a hydatidiform mole usually have higher-
than-average levels of the pregnancy hormone human
chorionic gonadotrophin (hCG) compared with women
with a normal pregnancy. This hormone is produced by
the trophoblastic tissue. It is the hormone that is
detected in a standard pregnancy test. The high levels of
hCG occur because there is an excessive amount of
trophoblastic tissue with a hydatidiform mole. The high
hCG levels are responsible for some of the symptoms.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
❖ Pregnancy symptoms. The woman may have
signs of pregnancy, including periods stopping,
feeling sick (nausea), being sick (vomiting),
breast tenderness, etc. They may feel bigger
than expected for the number of weeks they are
pregnant. This is because a molar pregnancy
grows more quickly than a normal pregnancy
would, due to the abnormally developing
trophoblastic tissue.
❖ Bleeding. Vaginal bleeding may occur early in the
pregnancy. This is the most common symptom.
Many women suspect that they are having a
miscarriage.
❖ No symptoms. Some women with a hydatidiform
mole have no symptoms. The molar pregnancy is
diagnosed after a routine pregnancy ultrasound
scan
❖ Rare symptoms. Very rarely, problems with high
blood pressure may occur, as well as very bad
nausea and vomiting (hyperemesis gravidarum)
or symptoms of an overactive thyroid gland may
develop.
Management
Nursing Management:
• Remember to assess the BP, check if the patient
is bleeding profusely, and make sure to notify the
doctor immediately.
• Teach deep breathing techniques to alleviate the
pain. Use diversional activities if possible.
• Check for abdominal pain, assess the abdominal
area for signs of internal bleeding (e.g. Cullen’s)
• If nausea and vomiting are present, make sure
the patient would not aspirate it.
• After dilate and curettage patient is at risk for
infection. Make sure the patient has good
perineal hygiene.
• Administer all medications as ordered. Observe
the 10 Rs
• Remember that this might very hard for the
patient to accept, make sure to provide
emotional support. Explain to the patient that it
is not her fault this happened.
MODULE 1M: ANTENATAL COMPLICATIONS
• Discussed the family planning methods available
for her. Remember to reiterate the importance
of
• monitoring the hCG level and follow-ups.
Medical Management:
• After D&C the specimen will be sent for a
histopath. Management will then be based on
the findings. If it is an H. Mole which is benign,
the patient will then be monitored by getting the
hCG serum level that should fall to 0. Usually, the
serum hCG test will be for 6 to 12 months.
Pharmacologic Management:
• A contraceptive method such as implants or pills
is necessary during the hCG monitoring period to
avoid pregnancy for accurate monitoring. H.
mole patients are not eligible for IUDs to lessen
the risk of bleeding and infection.
• Chemotherapy will be done if the hCG levels are
not decreasing even though there is no
conceptus left in the uterus. The most commonly
used drug is Methotrexate, but the drug
Dactinomycin is also used.
Surgical Management:
• Suction curettage is the standard treatment for
both complete and partial molar pregnancies.
Sometimes the doctor will use medical
evacuation if the mass is with fetal parts that are
hard to remove.
• A hysterectomy is performed if the patient no
longer wants kids and opts for this surgery
instead of a dilate and curettage.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
PLACENTA PREVIA
- When a pregnant woman’s placenta blocks the
opening to the cervix, this is referred to as
placenta previa. It is important that the cervix’
opening should be unblocked as this is where the
baby passes through as it is born. According to
Porter and Kaplan (2011), this commonly occurs
during the 3rd trimester of the pregnancy. In
cases such as these, instances of severe bleeding
have been noted. Bleeding can happen
spontaneously or trigger due to digital
examination or onset of labor. It has also been
documented those mothers experiencing
placenta previa may be at risk of delivering
prematurely. Due to the risk of bleeding, women
with placenta previa will undergo a cesarean
section operation to avoid such from happening.
Etiology/Cause
- What exactly causes placenta previa is unknown.
However, it is speculated that pregnant women
end up experiencing this due to past uterine
surgeries or past pregnancies with placenta
previa. Factors such as age, smoking, and
presence of fibroids in the uterus are also
considered. Once again, the earlier mentioned
conditions are not the exact cause of placenta
previa happening during a pregnancy but are
speculated to contribute to its manifestation.
Types
Cases of placenta previa are classified in regards to how
they cover the placenta. Thus, they are identified
accordingly:
• A total placenta previa means that the placenta
is completely covering the internal os
• A partial placenta previa means that the placenta
is only covering part of the os
• A marginal placenta previa means that the
placenta is at the edge of the os and not covering
it. This is also referred to as a low-lying placenta
and may resolve itself before labor.
MODULE 1M: ANTENATAL COMPLICATIONS
Signs and Symptoms
❖ The mother will start noticing symptoms as they
are halfway through their pregnancy. During this
time, vaginal bleeding occurs but without
contractions. Blood is usually of a bright red
color. However, bleeding may be heavy and this
may lead the client into experiencing
hemorrhagic shock. This can also lead the client
into manifesting symptoms of blood loss such as
anemia and low blood pressure. Despite some
clients experiencing no pain, there are cases
wherein uterine contractions happen with the
bleeding. Patients have reported the
contractions to have a tightening pain which
radiates to the back.
Management
Nursing Management:
• Assess fetal heart sounds so the mother would
be aware of the health of her baby.
• Monitor uterine contractions to establish the
progress of labor of the mother.
• Weigh perineal pads used during bleeding to
calculate the amount of blood lost.
• Assist the woman in a side lying position when
bleeding occurs.
Medical Management:
• Determine the following
• The amount of bleeding
• Whether the bleeding has stopped
• How far along your pregnancy is
• Your health
• Your baby's health
• The position of the placenta and the baby
For little bleeding- Rest is recommended which means
avoiding activities that can trigger bleeding, such as sex
and exercise.
For heavy bleeding- Immediate medical attention at
your nearest emergency health facility. Severe bleeding
might require a blood transfusion.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
For bleeding that won’t stop- If your bleeding can't be 4. Concealed placental abruptions - Vaginal
controlled or your baby is in distress, you'll likely need an bleeding is little or non-existent. Between the
emergency C-section even if the baby is premature. placenta and the uterine wall, blood is trapped.

Pharmacological Management: Signs and Symptoms

❖ Vaginal bleeding, although there might not be
• No medication is of specific benefit to a patient
any
with placenta previa. There is no improvement in
❖ Abdominal pain
perinatal outcome with prolonged tocolytics,
❖ Back pain
and tocolysis beyond 48 hours is not clinically
❖ Uterine tenderness or rigidity
indicated. Maintain intake of iron and folate as a
❖ Uterine contractions, often coming one right
safety margin in the event of bleeding.
after another
Surgical Management:
Management
• There is no medical or surgical treatment to cure Nursing Management:
placenta previa, but there are several options to
• Continuously evaluate maternal and fetal
manage the bleeding caused by placenta previa.
physiologic status, particularly
Management of the bleeding depends on
Vital signs
various factors.
Bleeding
• These include: The amount of bleeding and
Electronic fetal and maternal monitoring
whether the bleeding has stopped.
tracings
Signs of shock-rapid pulse, pallor, cold
ABRUPTIO PLACENTA
and most skin, decrease in -blood
- Abruptio Placenta is a complication of pregnancy
pressure
that develops when the placenta separates from
Decreasing urine output
your uterus before the baby is born. The
Never perform a vaginal or rectal
placenta may detach fully or partly during
examination or take any action that
placental abruption. This can lower the quantity
would stimulate uterine activity.
of oxygen and nutrients to the baby and cause
• Assess the need for immediate delivery
excessive bleeding in the mother.
If the client is in active labor and the
Etiology/Cause bleeding cannot be controlled with bed
- In most cases, the cause is unknown, but risk rest, an emergency cesarean delivery
factors include maternal hypertension, may be recommended.
abdominal trauma (e.g., from fall or accidents), • Provide appropriate management.
and substance abuse. Place the woman on bed rest in a lateral
position upon admission to avoid putting
Types
pressure on the vena cava.
1. Partial Placental Abruption - when the placenta
Insert a large gauge intravenous
does not fully separate from the uterine wall
catheter into a large vein for fluid
2. Complete or Total Placental Abruption - when
replacement. Obtain a blood sample for
the placenta separates from the uterine wall
fibrinogen level.
entirely. This form of abruption is frequently
Monitor the FHR externally and measure
accompanied by increased vaginal bleeding.
maternal vital signs every 5 to 15
3. Revealed placental abruption - have moderate
minutes. Administer oxygen to the
to severe vaginal bleeding that you can see.
mother by mask.
• Provide client and family teaching.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Address emotional and psychosocial needs.
Outcome for the mother and fetus
depends on the extent of the separation,
amount of fetal hypoxia, and amount of
bleeding.
Medical Management:
To help identify possible sources of vaginal bleeding,
your provider will likely recommend blood and urine
tests and ultrasound.
• Blood Test - a standard part of routine and
preventive healthcare.
• Urine Test - is a test that examines the visual,
chemical and microscopic aspects of your urine.
• Ultrasound - is an imaging method that uses
high-frequency sound waves to produce images
of structures within your body.
Pharmacologic Management:
• Large gauge IV catheter for fluid replacement
• Oxygen administration
Surgical Management:
Once the condition has reached a stage that mightily
endangers the life of both patients, then surgical
management is put into action.
• Cesarean delivery. If the baby's born quickly, it is
best to have a caesarean section.
• Hysterectomy. The worst-case situation is that
the woman develops DIC, in which event a
hysterectomy is required to prevent
exsanguinations.
MODULE 1M: ANTENATAL COMPLICATIONS
HYPERSENSITIVITY DISORDER OF
PREGNANCY
- Hypersensitivity disorder of pregnancy refers to
undesirable reactions produced by the normal
immune system, including when there is altered
reactivity where the body reacts with an
exaggerated immune response to what is viewed
as a foreign substance that is normally harmless
called allergens.
Etiology/Cause
- Hypersensitivity syndrome is caused by a
complex set of interactions between a
medication, your own immune system, and
viruses in your body, especially herpes viruses.
- Caused by excessive antigen-antibody response
when the invading organism is an allergen rather
than an immunogen
- Environmental allergy: Dust, Pollen
- Reaction from taking of meds: Antibiotics
Types
The four types of hypersensitivity are:
• Types I, II, III = mediated by antibodies (humoral
response)
• Type IV = cell-mediated (T lymphocytes)
Type I: Immediate → IgE and Anaphylaxis
• Exposure to allergen
• Allergies, asthma, dermatitis
• Extreme vasodilation ➡circulatory shock
• Extreme bronchoconstriction
Type II: cytotoxic reaction mediated by:
• IgG or IgM
• Hemolytic anemia
• Transfusion reaction
• Erythroblastosis fetalis
Type III: reaction mediated by immune complexes.
• IgG or IgE
• Rheumatoid arthritis
• Systemic lupus erythematosus
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Type IV: delayed reaction mediated by cellular Medical Management:
response.
• Medication: Insert epinephrine related to
• T lymphocytes constriction of airway.
• Calls lymphokines → calls macrophages • Immunotherapy/ hyposensitization
• Contact dermatitis Continuous exposure to reduce
• Transplant graft reaction sensitization to allergen.

Signs and Symptoms Pharmacologic Management:

Here’s a list of the more common symptoms:
• Rx Commercial preparation of passive Rh (D)
❖ a pink or red rash with or without pus-filled antibodies against the Rh factor
bumps or blisters • RhIG (RhoGAM) given again via injection in the
❖ scaly, flaky skin first 72 hours after birth of a Rhpositive child to
❖ fever prevent formation of natural antibodies.
❖ facial swelling • Pharmacologic therapy
❖ swollen or tender lymph nodes Intranasal steroids
❖ swollen saliva glands 2nd & 3rd generation antihistamines
❖ dry mouth (Cetirizine/ Zyrtec, Loratadine/ Claritin)
❖ abnormalities in your white blood cell counts Decongestants (pseudoephedrine)
❖ difficulty moving normally
Surgical Management:
❖ headache
❖ seizures • No surgical interventions are needed as the
❖ coma interventions listed above should suffice.
Management ISOIMMUNIZATION
Nursing Management:
- Isoimmunization is an immune response of the
• Reduce exposure to allergen (food, etc.) mother to foreign antigen of the same species.
• Environmental Control One occurrence of this is Rh incompatibility
Replacing carpets with hardwood which occurs when the pregnant woman’s blood
Goal is to decrease allergic triggers in the protein is incompatible with the baby’s blood
environment. protein. Rh factor is a red blood cell surface
• Promote good nutrition, since the woman has antigen which could be negative or positive.
still to continue her usual pregnancy nutrition. When a pregnant woman with Rh-negative
Pay particular attention in lowering sodium blood type is exposed to the fetal Rh-positive
intakes. blood cells, this can lead to sensitization–the
• Assess the patient for the presence of edema on development of antibodies to D antigen (anti-D).
the face, fingers, and upper extremities. Anti-D would cross the placenta and attack the
• Provide information about signs/symptoms fetal Rh-positive blood cells resulting in mild to
indicating worsening of condition, and instruct severe effects such as hemolytic anemia,
patients to notify health care providers. kernicterus, hydrops fetalis and many other fetal
problems.

Etiology/Cause
- Rh incompatibility occurs when the fetal Rh-
positive blood cells escape and expose the
circulatory system of the mother who has Rh-
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
negative blood cells. This sensitizes the mother
to produce antibodies called antigen D. Antigen
D or anti-D is well known for causing severe
immunogenic response as well as its ability to
cross the placenta. Anti-D would be formed
during the first pregnancy and in the next
pregnancy, these antibodies would cross the
placenta to attack the baby's Rh-positive red
blood cells leading to anemia and hemolysis.
Types
An Rh incompatibility occurs when a mother is Rh-
negative and her unborn child is Rhpositive.
Potential birth injuries that result from an untreated Rh
incompatibility can range from mild to fatal:
• Mild injuries: Might include jaundice, low
muscle tone and lethargy.
• Severe injuries: Might include stillbirth, heart
failure, a brain syndrome called kernicterus as a
result of high bilirubin levels, fluid buildup in the
body, seizures and other movement or cognitive
impairments.
Signs and Symptoms
Symptoms will only be in the baby. They can be mild to
severe, such as:
❖ Anemia—red blood cells are destroyed faster
than they are made
❖ Jaundice—a buildup of a substance in the blood
that causes the skin to look yellow
❖ Swelling of the body, which can lead to heart
failure or breathing problems.
❖ Lethargy
❖ low muscle tone
Management
Nursing Management:
1. All pregnant women should be screened for
blood ABO & Rh groups at the first antenatal
visit.
2. If negative, she is advised to obtain her
husband’s ABO & Rh group.
3. At 35wks, repeat maternal blood for Rh
antibodies. If negative, observe her until
MODULE 1M: ANTENATAL COMPLICATIONS
delivery. If positive, treat her like any Rh
sensitized patient.
4. Collect previous history.
5. The prevention of maternal sensitization due to
Rh positive fetal rbcs that leak into the maternal
circulation, when the placenta separation at
delivery, is achieved by the administration of
HUMAN Rh ANTI-D within 72 hrs. Of the event.
6. Send grouping & Rh typing of baby after delivery
as well as serum bilirubin to detect neonatal
jaundice.
7. Observe for anemia, jaundice, sucking reflex,
irritability, etc.
8. Observe the child for change in color of urine &
stool.
9. Counsel the patient party before phototherapy &
exchange blood transfusion.
10. Phototherapy care should be provided.
11. Prevent from complications of phototherapy
Medical Management of Isoimmunization Antenatal
Management:
• Detection of maternal sensitization. Detection of
maternal sensitization is confirmed by the
detection of Rh antibodies in maternal
circulation, it is done by titre technique. Titre
below 4IU/ml are unlikely to produce severe
fetal disease. All Rh-negative pregnant women
should have their blood tested for Rh antibodies
at the 1st antenatal visit and again at 28th & 34th
weeks of gestation. .[acc. To DC Dutta, textbook
of obstetrics, 16th edition]
• Management of affected fetus by intrauterine
intravascular transfusion. Blood may be given to
the baby by a needle introduced through
mother’s abdomen. Blood is given either
intravascularly [into the umbilical vein] or
intraperitoneally. The first method is preferable,
as blood enters the fetal circulation directly and
severely anemic fetuses may be saved.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
IRON DEFICIENCY ANEMIA
- Iron deficiency anemia is a common type of
anemia that occurs when the body has a low
level of iron and hemoglobin. To produce
hemoglobin that functions to carry oxygenated
blood throughout the body, a sufficient amount
of iron is needed. And if the body has a low
amount of iron, this will fail in producing enough
hemoglobin. Pregnant mothers must intake
double the amount of iron compared to non-
pregnant mothers to also supply oxygen to the
baby.
Etiology/Cause
- In order to nourish and accommodate the
developing child, the pregnant woman goes
through significant anatomical and physiological
changes throughout pregnancy. Because of the
changes occurring to the body, there will be an
increase in blood volume and also an increased
requirement for iron for the fetus and
hemoglobin production. If the increased
requirement of iron will not be met, this will
result in iron deficiency anemia.
Signs and Symptoms
Signs and symptoms of iron deficiency anemia may
include:
❖ Extreme fatigue
❖ Weakness
❖ Pale skin
❖ Chest pain, tachycardia or shortness of breath
❖ Headache, dizziness or lightheadedness
❖ Cold hands and feet
❖ Inflammation or soreness of your tongue
❖ Brittle nails
❖ Unusual cravings for non-nutritive substances,
such as ice, dirt or starch
❖ Poor appetite
MODULE 1M: ANTENATAL COMPLICATIONS
Management
Nursing Management:
• Administer medications as prescribed
When oral iron is poorly absorbed,
administer IM or IV iron. Intravenous
iron is extremely effective in treating
iron deficiency anemia and should be
utilized when oral iron is ineffective.
Perform sensitivity testing of IM iron
injection to minimize the risk of
anaphylaxis.
Advise the patient to take iron
supplements an hour before meals for
optimal absorption; if gastric distress
arises, suggest taking the supplement
with meals; if symptoms subside,
continue to the between meal schedule.
Advise the patient to take liquid forms of
iron with a straw and to rinse his or her
mouth with water.
• Reduce fatigue
Assist the client or caregivers in
establishing a daily activity and rest
regimen, and emphasize the significance
of having frequent rest periods.
Monitor hemoglobin, hematocrit, RBC
count, and reticulocyte counts of the
patient
Teach patients on energy-conservation
techniques
• Educate the client and caregivers on iron
deficiency anemia
Explain the significance of diagnostic
procedures, bone marrow aspiration,
and iron replacement/supplementation.
Educate the client and his or her family
on iron-rich diets
• Prevent infection
Examine for signs of infection, either
local or systemic, such as fever, chills,
edema, discomfort, and malaise.
WBC count should be monitored, and
antibiotic, antiviral, and antifungal
therapy should be considered.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Instruct the client to avoid contact with
others with existing infections, and
emphasize the necessity of daily
hygiene, mouth care, and perineal care.
• Prevent bleeding
Platelet count should be monitored, and
the client or caregivers should be
informed about bleeding precautions.
When the platelet count falls to a
severely low level, expect a platelet
transfusion.
Examine the patient's skin for bruising
and petechiae.
Medical Management:
The first approach in this type of management is to
determine the cause and diagnosis of the iron deficiency.
• Iron Therapy
o Oral ferrous iron salts are by far the most
inexpensive and effective treatment for
iron deficiency anemia. Ferrous sulfate is
the most widely used of the numerous
iron salts available.
• Diet
o Nonheme iron supplementation has
been undertaken in several parts of the
world for the treatment of patients with
iron deficiency anemia.
Pharmacological Management:
The following are the medications administered to
patients with iron deficiency anemia:
• Iron Products
o These medicines are used to provide
sufficient iron for hemoglobin
production as well as to restore iron
stores in the body.
• Parenteral Iron
o Parenteral iron should be reserved for
patients who are unable to absorb oral
iron or who have progressive anemia
despite adequate doses of oral iron; it is
more expensive and has a higher
morbidity than oral iron preparations.
MODULE 1M: ANTENATAL COMPLICATIONS
Surgical Management:
Management of Hemorrhage
• Surgical treatment includes preventing the
bleeding and treating the underlying defect so
that it does not reoccur; which may include
surgery for the treatment of either neoplastic or
non-neoplastic disease of the gastrointestinal
tract, genitourinary tract, uterus, and the lungs.
PIH (PREGNANCY-INDUCED
HYPERTENSION)
- Pregnancy-induced hypertension (PIH) also
called toxemia or preeclampsia, is a form of high
blood pressure in pregnancy. It occurs most
often in young women with a first pregnancy. It
is more common in twin pregnancies, and in
women who had PIH in a previous pregnancy.
Etiology/Cause
- Some conditions may increase the risk of
developing PIH such as pre-existing hypertension
(high blood pressure), kidney disease, diabetes,
PIH with a previous pregnancy, mother's age
younger than 20 or older than 40, multiple
fetuses (twins, triplets).
Types
There are three main types of high blood pressure during
pregnancy:
1. Chronic Hypertension
◼ This is high blood pressure you had before
you became pregnant. It can also refer to
high blood pressure you get before the 20th
week of pregnancy. Sometimes you may
have high blood pressure for a long time
before becoming pregnant but don’t know it
until your first prenatal visit with your
doctor. Chronic hypertension can lead to
serious problems, including preeclampsia.
This type of high blood pressure continues
after you have your baby.
2. Gestational Hypertension
◼ This is high blood pressure you get after your
20th week of pregnancy. Most of the time,
this hypertension doesn’t hurt you or your
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
baby. You may not even have other
symptoms. However, sometimes this type of
hypertension is severe. It can cause your
baby to be born smaller than normal (born in
a low birth weight). Your baby may even be
born early because of it. It can lead to
preeclampsia. And while it usually goes away
within three months of giving birth, it can
raise your risk of getting high blood pressure
in the future.
3. Preeclampsia
◼ This is a sudden rise in your blood pressure
after your 20th week of pregnancy, typically
in your third trimester. It also may cause
damage to your liver, kidneys, or brain. You
may have seizures. You may have significant
swelling in your legs and sometimes your
arms and face. This condition is serious. It
can hurt both you and your baby, and even
be life threatening. Some women get
preeclampsia after they deliver their baby.
This calis led postpartum preeclampsia.
Signs and Symptoms
❖ Increased blood pressure
❖ Protein in the urine
❖ Blurred or double vision
❖ Nausea and vomiting
❖ Right sided abdominal pain
❖ Edema
❖ Sudden weight gain
❖ Changes in liver or kidney function
❖ Urinating small amounts
Management
Nursing Management:
• Promote bed rest
• Medication
• Good nutrition
• (For mild and severe preeclampsia); No sodium,
emotional support, monitor maternal and fetal
well being.
• (For Eclampsia); Maintain patient airway,
Magnesium sulfate, check for vaginal bleeding
and contractions
MODULE 1M: ANTENATAL COMPLICATIONS
• Monitor deep tendon reflexes
• Patellar reflex
Pharmacologic Management:
• Magnesium sulfate
• Hydralazine
• Diazepam
• Calcium Gluconate
PREECLAMPSIA
- Preeclampsia is a serious blood pressure
condition that occurs during pregnancy and is
characterized by high blood pressure and
symptoms of injury to another organ system,
most commonly the liver and kidneys.
Preeclampsia commonly starts after 20 weeks of
pregnancy in women whose blood pressure has
been normal.
Etiology/Cause
- Preeclampsia is thought to be caused by a
problem with the health of the placenta, the
organ that nourishes the fetus throughout
pregnancy. New blood vessels form and evolve
early in pregnancy to efficiently transport blood
to the placenta.
- In women with preeclampsia, these blood
vessels don't seem to develop or function
properly. They are narrower than normal blood
vessels and respond differently to hormonal
signaling, limiting the amount of blood that can
pass through them.
- Causes of this abnormal development may
include:
A problem with the immune system
Damage to the blood vessels
Insufficient blood flow to the uterus
Certain genes
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Types
Preeclampsia is one of four types of high blood pressure
that can arise during pregnancy. The other three are as
follows:
1. Gestational hypertension
◼ This occurs when your blood pressure rises
in the second half of your pregnancy, or
earlier if you're pregnant with twins. Women
with gestational hypertension have high
blood pressure but no excess protein in their
urine or other signs of organ damage.
2. Chronic hypertension
◼ Chronic hypertension is defined as high
blood pressure that existed before
pregnancy or that occurs before 20 weeks of
pregnancy. However, because high blood
pressure normally has no symptoms, it may
be difficult to pinpoint when it started.
3. Chronic hypertension with superimposed
preeclampsia
◼ This condition occurs in women who had
chronic high blood pressure prior to
pregnancy but later developed worsening
high blood pressure, protein in the urine, or
other health issues during pregnancy.
Signs and Symptoms
❖ Excess protein in urine( proteinuria) or additional
signs of kidney problems
❖ Severe headaches
❖ Changes in vision , including temporary loss of
vision , blurred vision or light sensitivity
❖ Upper abdominal pain, usually under the ribs on
the right side
❖ Nausea or vomiting
❖ Decreased levels of platelets in the blood (
thrombocytopenia)
❖ Impaired liver function
❖ Shortness of breath , caused by fluid in the lungs
MODULE 1M: ANTENATAL COMPLICATIONS
Management
Nursing Management:
Without severe features
• Monitor Antiplatelet Therapy
• Promote bed rest
• Promote good nutrition
• Provide Emotional support
With severe features
• Support bed rest
• Monitor maternal well-being
• Monitor fetal well-being
• Support a nutritious intake
• Administer medication to prevent eclampsia
Medical Management:
• Most sufficient treatment for preeclampsia is
delivery as long as the pregnancy is in term.
• Patient with severe preeclampsia feature is
required for hospitalization for careful
monitoring.
• Treatment goals are fluid management, seizure
prevention , lowering BP to prevent maternal
end-organ damage.
• Urine output should be maintained above 30 ml
per hour and Foley catheter should be used to
monitor urine output.
• Administering of medications to prevent
eclampsia.
Blood Pressure Management:
• Patient with severe preeclampsia is unknown.
Excessive lowering of BP may lead to
uteroplacental insufficiency. It is recommended
that systolic BP be maintained at less than 160
mmHg and diastolic at less than 110 mmHg.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Pharmacological Management:
Drugs used in preeclampsia
Drug : Magnesium sulfate ( pregnancy risk category B)
Indication: Muscles relaxant ; prevents seizures
Dose : loading dose 4-6g
Maintenance dose 1-2g/hr IV
• Infuse loading dose slowly over 15-30 minutes.
• Always administer as a piggyback infusion.
• Assess respiratory rate. Urine output, deep
tendon reflexes, and clonus every hour.
Drug : Hydralazine ( Apresoline ) pregnancy risk category
C
Indication: Antihypertensive ( peripheral vasodilator)
used to decrease hypertension
Dosage: 5-10mg IV
• Administer slowly to avoid sudden fall in blood
pressure. Maintain diastolic pressure over 90
mmHg to ensure adequate placental filling.
Drug : Diazepam ( Valium) pregnancy risk category D
Indication : Halt seizures Dosage: 5-10 mg IV
• Administered slowly. Dose may be repeated q5-
10 minutes (up to 30 mg/hr)
• Observe for respiratory depression or
hypotension in mother and respiratory
depression and hypotonia in infant at birth.
Drug: Calcium gluconate ( pregnancy risk category C)
Indication: Antidote for magnesium intoxication Dosage
: 1g IV ( 10 ml of 10% solution)
• Have prepared at bedside as the antidote when
administering magnesium sulfate.
• Administer at 5ml/min.
Surgical Management:
• Attempted vaginal delivery is recommended in
women who have preeclampsia with severe
features if it is not otherwise contraindicated
MODULE 1M: ANTENATAL COMPLICATIONS
• Indications for cesarean delivery include
recurrent seizures refractory to medical
management, severely elevated BP that is
resistant to antihypertensive medications, and
maternal or fetal deterioration remote from
delivery.
• Some experts recommend cesarean delivery in
preeclamptic patients with severe features and
an unfavorable cervix who require delivery
before 30 weeks' gestation
ECLAMPSIA
- Eclampsia is the onset of fits/seizures in a
woman whose pregnancy is usually complicated
by pre-eclampsia. The fits may occur in
pregnancy after 20 weeks gestation, in labor, or
during the first 48 hours of the postpartum
period.
Etiology/Cause
- The definitive cause of eclampsia is still
unknown. However, eclampsia is known to
follow preeclampasia as a severe complication
which is characterized by high blood pressure
occurring in pregnancy affecting the brain that
leads to seizures.
Signs and Symptoms
❖ convulsions
❖ diastolic blood pressure 90mmHg or more after
20 weeks gestation
❖ proteinuria 2+ or more
❖ coma
❖ hyper-reflexia
❖ severe headache (increasing frequency,
unrelieved by regular analgesics)
❖ Vision problems, such as temporary blindness
❖ oliguria (passing less than 400ml urine in 24
hours)
❖ upper abdominal pain (epigastric pain or pain in
right upper quadrant)
❖ Generalized edema
❖ Nausea and vomiting
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Management
Nursing Management:
• Monitor blood pressure.
• Assess fetal heart rate
• Send blood and urine for testing.
• Administer prescribed medications.
• Monitor reflexes on patients on magnesium
sulfate.
• Neurologic checks regularly.
• Seizure precautions if ordered
Medical Management:
• Controlling fits/seizures
o ABCDE assessment and intervention as
appropriate.
o Patients should lie in the left lateral
position to reduce the risk of aspiration
of secretions, vomit and blood
o Give oxygen if available and continue for
five minutes after each fit, or longer if
cyanosis persists
o After a convulsion, aspirate the mouth
and throat as necessary to clear the
airway ○ Stay with the woman and
ensure that her airway is clear
o Fits are controlled by giving the woman
anticonvulsant drugs. The drug of choice
for both the prevention and treatment
of eclampsia is magnesium sulfate. If
magnesium sulfate is not available,
diazepam may be given, but there is a
greater risk of neonatal depression
because diazepam crosses the placenta
freely.
Pharmacologic Management:
• Cessation of Seizures
o Eclamptic seizures are treated with
magnesium sulfate. The patient should
be assessed for signs of
hypermagnesemia (hyper-reflexia,
respiratory depression), and the fetus
monitored via continuous CTG.
MODULE 1M: ANTENATAL COMPLICATIONS
• Magnesium sulfate loading dose:
o Give 4g of 20% magnesium sulfate IV
slowly over 5 minutes. Magnesium
sulfate should not be given as a bolus.
Follow immediately with 10g of 50%
magnesium sulfate solution, 5g in each
buttock as deep IM injection, with 1ml of
2% lignocaine in the same syringe.
o If convulsions recur after 15 minutes,
give 2g magnesium sulfate (50%
solution) IV over 5 minutes.
• Maintenance dose:
o Give 5g magnesium sulfate (50%
solution) together with 1ml lignocaine
2% in the same syringe every 4 hours
into alternate buttocks. Continue the
treatment with magnesium sulfate for
24 hours after delivery or the last
convulsion, whichever occurs last.
Observations which must be made before giving repeat
doses of magnesium sulfate:
• respiratory rate
• patellar reflexes (knee jerk)
• urinary output
Repeat doses of magnesium sulfate must be withheld or
delayed if:
• the respiratory rate is less than 16 per minute
• patellar reflexes are absent
• urinary output is less than 30ml per hour over
the preceding 4 hours.
Antidote:
In cases of respiratory arrest:
• give calcium gluconate 1g (10ml of 10% solution)
IV slowly until respirations satisfactory
• assist ventilation using mask and bag, anesthetic
apparatus or intubation.
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• Blood Pressure Control
o Antihypertensive drugs should be given
if the diastolic blood pressure is
110mmHg or more. The aim is to keep
the diastolic blood pressure between
90–100mmHg to prevent cerebral
hemorrhage. The two most commonly
used intravenous antihypertensives are
labetalol and hydralazine. A rapid
decrease in maternal blood pressure can
cause fetal heart rate abnormalities.
Therefore, continuous CTG monitoring is
used during and for 30 minutes after
giving IV antihypertensives.
Surgical Management:
• The only definitive treatment of eclampsia is
delivery of the fetus. However, the mother must
be stable before delivery – with any seizures
controlled, severe hypertension treated and
hypoxia corrected. This is the case regardless of
any fetal compromise.
• Cesarean section is the ideal mode of delivery.
However, intrapartum seizures in established
labor may be managed by vaginal delivery. After
delivery, the patient will require high
dependence unit care until she is stable – well
controlled blood pressure, adequate urine
output, and discontinuation of magnesium
sulfate. This usually takes a minimum of 24
hours.
GESTATIONAL DIABETES
- Gestational diabetes is a temporary form of
diabetes that occurs during pregnancy when the
body stops producing or responding to insulin
adequately. It is a condition in which a hormone
made by the placenta prevents the body from
using insulin effectively. Glucose builds up in the
blood instead of being absorbed by the cells.
Etiology/Cause
- Diabetes occurs during pregnancy because
hormones produced in a pregnancy make the
body resistant to insulin's effects. These
hormones include growth hormone and human
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placental lactogen. Both of these hormones are
essential to a healthy pregnancy and fetus, but
they partially block the action of insulin. In most
women, the pancreas reacts to this situation by
producing enough additional insulin to
overcome the insulin resistance. In women with
gestational diabetes, not enough extra insulin is
produced, so sugar accumulates in the
bloodstream.
Types
Gestational diabetes is divided into two classes:
• Class A1 is used to describe gestational diabetes
that can be managed through diet alone.
• Class A2 is used to describe gestational diabetes
where insulin or oral medications are needed to
manage the condition.
Signs and Symptoms
❖ Increased, frequent urination
❖ Increased thirst
❖ Fatigue
❖ Nausea and vomiting
❖ Blurred vision
❖ Yeast infections
Management
Nursing Management:
• Assess urine for glucose during prenatal visits
glucose starts to leak into the urine and assess
for burning during urination which could indicate
infection.
• Recommend dietary changes and increased
physical exercise.
Medical Management:
• Screening for GDM should occur after 24 weeks
of gestation in all women without known
diabetes mellitus.
• Glucose monitoring, pregnant mother will
monitor her blood glucose on a daily basis.
Pharmacologic Management:
• Pharmacologic therapy with metformin
(Glucophage), glyburide, or insulin is appropriate
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for women with GDM whose glucose values are
above goal despite lifestyle modifications.
Surgical Management:
• A C-section is an operation to deliver the baby
through the mother’s belly. Complications
caused by gestational diabetes may lead to a c-
section being advised. A woman who has
diabetes that is not well controlled has a higher
chance of needing a C-section to deliver the
baby.
HELLP SYNDROME
- HELLP is a life-threatening pregnancy
complication syndrome characterized by
Hemolysis, Elevated Liver enzymes and Low
Platelets. This is usually considered to be a
variant of preeclampsia, however the risk factors
for HELLP syndrome differ from those associated
with preeclampsia that occur during the later
stages of pregnancy or sometimes develop in the
week after a baby is born.
Etiology/Cause
- The cause of HELLP syndrome is still unknown as
it can be difficult to diagnose because all the
typical signs of preeclampsia may not be
apparent and is frequently misdiagnosed at
initial presentation. Early detection is important
because the morbidity and mortality rates
associated with the syndrome have been
reported to be as high as 25 percent.
Types
HELLP syndrome is classified according to the severity of
certain blood test values which reflect the condition of
the mother’s blood vessels, liver and other organ
systems.
• Class I (severe thrombocytopenia): AST ≥ 70
IU/L, LDH ≥ 600 IU/L, platelets ≤ 50,000/uL
• Class II (moderate thrombocytopenia): AST ≥ 70
IU/L, LDH ≥ 600 IU/L, platelets > 50,000 ≤
100,000/uL
• Class III (mild thrombocytopenia): AST ≥ 40 IU/L,
LDH > 600 IU/L, platelets > 100,000 ≤ 150,000/uL
MODULE 1M: ANTENATAL COMPLICATIONS
Signs and Symptoms
❖ Blurry vision
❖ Chest pain or pain in the upper right or middle
part of the belly
❖ Headache, fatigue (feeling really tired)
❖ Nausea (feeling sick to your stomach) or
throwing up that gets worse
❖ Quick weight gain
❖ Nosebleed or other bleeding that doesn’t stop
❖ Swelling (Hands or face)
❖ Breathing problems
Management
Nursing Management:
• Assist the client to a setting with intensive care
facilities available.
• To Administer magnesium sulfate per doctor’s
order to control seizures.
• Control the blood pressure, give Hydralazine as
ordered.
• Manage prescribed fluid replacement accurately
to avoid worsening the woman’s reduced
intravascular tone.
Medical Management:
• blood transfusions to treat anemia and low
platelet levels.
• magnesium sulfate to prevent seizures
• antihypertensive medication to control blood
pressure
• corticosteroid medication to help your baby’s
lungs mature in case an early delivery is needed
Pharmacologic Management:
• Patients with HELLP syndrome should be treated
prophylactically with magnesium sulfate to
prevent seizures, whether hypertension is
present or not. A bolus of 4 to 6 g of magnesium
sulfate as a 20 percent solution is given initially.
This dose is followed by a maintenance infusion
of 2 g per hour. The infusion should be titrated
to urine output and magnesium level. Patients
should be observed for signs and symptoms of
magnesium toxicity. If toxicity occurs, 10 to 20
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mL of 10 percent calcium gluconate should be
given intravenously.
Surgical Management:
• Delivery of patients with HELLP syndrome was
routinely accomplished by cesarean section.
Patients with severe HELLP syndrome, a
gestation of less than 32 weeks should be
delivered by cesarean section. A trial of labor is
appropriate in patients with mild to moderate
HELLP syndrome who are stable, have a
favorable cervix and are at 32 weeks of gestation
or greater.
CARDIAC DISEASE
- Also known as Cardiovascular Disease (CVD), is
the general term used to call diseases or
complications that affect the structures and
functions of the heart and blood vessels.
According to the World Health Organization
(2019), it represents 32% of all global deaths
making it the leading cause of death in the world.
Cardiac disease may occur rarely in pregnancy
but, according to the NHS, it is the leading cause
of death in pregnancy.
Etiology/ Cause
- Cardiac disease may directly arise from different
etiologies such as emboli in a patient with atrial
fibrillation resulting in ischemic stroke,
rheumatic fever causing valvular heart disease,
among others. During pregnancy, increased
cardiac output may lead to heart failure and may
also lead to ischemic events during the third
trimester. Risk factors attributed to cardiac
disease of pregnancy include drug use, alcohol
abuse, hypertension, diabetes mellitus, pre-
existing heart disease, myocarditis, and familial
heart disease of pregnancy.
Types
The common cardiovascular diseases of pregnancy are
the following:
• Coronary artery disease - This happens when the
heart’s blood supply is blocked or interrupted
due to the build-up of fatty-substances within
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the coronary arteries thus making it unable to
deliver enough oxygen-rich blood to the heart.
• Pregnancy-associated myocardial infarction -
Commonly called as a heart attack, this happens
when blood flow is blocked and the heart doesn’t
get enough oxygen.
• Valvular disease - This happens when one or
more valves of the heart doesn’t work properly
caused by changes in its structure due to aging,
Myxomatous degeneration, or a birth defect,
among others.
• Left-sided heart failure - This happens when the
left side of the heart is failing and can’t handle
the blood and it wouldn’t pump efficiently.
• Right-sided heart failure - This happens when
the right chamber of the heart becomes too
weak or loses its ability to pump enough blood to
the lungs.
• Peripartum Cardiomyopathy - The weakening of
the heart muscle that may begin sometime
during the final month of pregnancy through
about five months after delivery, without any
other known cause. The heart may even be at
higher susceptibility to the aforementioned risk
factors. It is a rare condition that can carry mild
or severe symptoms.
Signs and Symptoms
❖ Decreased Exercise capacity and Fatigue -
Pumping ability of the heart reduces that causes
lesser chance of blood to reach the muscles and
tissues. Heart action is effective in resting state.
❖ Palpitations - Palpitations can be a symptom of a
greater heart condition
❖ Dyspnea - Pulmonary edema hinders gas
exchange resulting to shortness of breath
❖ Peripheral edema - Blood enters backward,
forcing fluids out resulting in an edema of the
legs, ankles and feet.
❖ Physiologic systolic murmur
❖ 3rd Heart sound
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Management Pharmacologic and Medication Measures:
Pregnant women should be closely monitored by nurses
Medication therapy include:
and a continuous assessment is needed. Nurses should
assess the women’s health status, health education and • Prenatal vitamins and iron
health-promotion activities. In addition, documentation • Stool softeners
and assessment are necessary to attain a baseline data • Prophylactic Antibiotics with any invasive
for the pregnant woman. procedures and before delivery
Nursing Management: • Cardiac glycosides (digitals)
• Anti-dysrhythmia agents
Assessment and Documentation • Furosemide (Lasix) - only with CHF (Congestive
• Health history to prepregnancy cardiac status Heart Failure)
• Vital signs • Heparin as needed with anticoagulant therapy
• Level of exercise performance • No warfarin (Coumadin)
• Assess for cough and edema Surgical Management:
• Nail bed filling
• Additional Cardiac status assessment: • Cardiac surgery is a rare occurrence. Cardiac
Electrocardiogram (ECG) for periodic points of surgical therapy must be considered when the
pregnancy underlying cardiac disease immensely influences
the cardiovascular changes of pregnancy.
Fetal Assessment • During pregnancy, Stanford type A dissection is a
surgical emergency that would necessitate
• Monitor Fetal well being with FMC
cardiothoracic surgical intervention to rapidly
Health Teaching deliver the fetus and repair the dissection.

Teach client to adhere to a healthy lifestyle: DRUG ABUSE

• Nutrition for pregnancy - Drug abuse is the excessive, maladaptive, or
• Head of bed elevated as necessary addictive use of drugs for nonmedical purposes
• Prompt to take prenatal vitamins and iron as despite social, psychological, and physical
prescribed problems that may arise from such use.
• Avoid getting extra weight gain Etiology/Cause
• Manage Stress Biological Factors:
• Exercise (e.g walking)
- The genes that people are born with account for
• Avoid overexertion and longer resting time
about half of a person's risk for addiction.
periods.
- Gender, ethnicity, and the presence of other
• Remind to attend appointments with the
mental disorders may also influence risk for drug
physicians
use and addiction.
Medical Management:
Environmental Factors:
• Electrocardiogram (ECG or EKG).
- A person’s environment includes many different
• Holter monitoring
influences, from family and friends to economic
• Echocardiogram
status and general quality of life.
• Stress test
- Factors such as peer pressure, physical and
• Cardiac Catheterization sexual abuse, early exposure to drugs, stress,
• Cardiac magnetic resonance imaging (MRI)

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
and parental guidance can greatly affect a
person’s likelihood of drug use and addiction.
Developmental Factors
- Genetic and environmental factors interact with
critical developmental stages in a person’s life to
affect addiction risk.
Types
1. Alcohol Abuse
◼ Alcohol abuse, also called alcohol misuse is a
serious problem. It is a pattern of drinking
too much alcohol too often.
2. Marijuana Abuse
◼ Marijuana refers to the leaves, flowers, and
extracts of the plant Cannabis sativa and
several closely related species commonly
known as hemp. Marijuana is the most
commonly used illicit drug in the United
States and is known by a large variety of
names including cannabis, pot, weed, grass,
hash, and many others.
3. Prescription Drug Abuse
◼ Prescription drug abuse is the use of a
prescription medication in a way not
intended by the prescribing doctor.
Prescription drug abuse or problematic use
includes everything from taking a friend's
prescription painkiller for your backache to
snorting or injecting ground-up pills to get
high.
4. Methamphetamine Abuse
◼ Methamphetamine (meth) is a commonly
abused, potent stimulant drug that is part of
a larger family of that is an amphetamine
derivative with similar stimulant properties.
It is sometimes referred to a poor man's
cocaine.
5. Cocaine Abuse
◼ Cocaine is a white powdery substance that
reacts with the body’s central nervous
system, producing energy and euphoria. It is
most commonly snorted, but can also be
smoked (also known as “freebasing”) or
dissolved in water and injected. Cocaine is
also referred to as coke, blow, or powder.
MODULE 1M: ANTENATAL COMPLICATIONS
6. Hallucinogen Abuse
◼ Hallucinogens are Psychoactive drugs that
are widely abused around the world,
sometimes with alarming and dangerous
side effects.
7. Inhalant Abuse
◼ Inhalant abuse, also known as volatile
substance abuse, solvent abuse, sniffing,
huffing and bagging, is the deliberate
inhalation of a volatile substance to achieve
an altered mental state. Inhalant abuse is a
worldwide problem that is especially
common in individuals from minority and
marginalized populations, and is strongly
correlated with the social determinants of
health.
Signs and Symptoms
❖ Bloodshot eyes
❖ Sudden weight loss
❖ Interrupted sleep patterns
❖ Change in complexion
❖ Depression and anxiety
❖ Irritability and mood swings
❖ Secretive behavior
Management
Nursing Management:
• produce a list of screening methods used to
identify drug use in pregnant women
• Identify complication s caused to the mother and
fetus by drug use
• Provide treatments for pregnant women with
drug use
• Plan nursing care for the woman with drug abuse
during pregnancy
Medical Management:
• For mothers who are taking opioid pain relievers
(narcotics), the mother can pass the drug from
her bloodstream through the placenta to the
fetus.
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Pharmacologic Management:
• Methadone and buprenorphine ne are
prescription drugs, sometimes called
pharmacotherapy. They are used to help treat
heroin and opioid dependency. The risks to the
fetus and pregnancy associated with heroin use
are greatly reduced with both of these
treatments
Surgical Management:
• Infants with organ damage, birth defects or
development al issues may need medical or
surgical therapy and long-term therapies.
UTI
- Urinary tract infection (UTI) is a clinical condition
that may involve the urethra and bladder (lower
urinary tract) and the ureters, renal pelvis,
calyces, and renal parenchyma (upper urinary
tract).
Etiology/Cause
- A variety of organisms can be responsible for
UTI. Escherichia coli (85% of cases) and other
gram-negative enteric organisms are most
commonly implicated; all are common to the
anal, perineal, and perianal region. Other gram-
negative organisms associated with UTI include
Proteus, Enterobacter, Citrobacter,
Pseudomonas, and Klebsiella. Gram-positive
bacterial pathogens include Staphylococcus
saprophyticus, Enterococcus, and, rarely,
Staphylococcus aureus. Viruses and fungi are
uncommon causes of UTI in children. Most
uropathogens originate in the gastrointestinal
tract, migrate to the periurethral area, and
ascend to the bladder. A number of factors
contribute to the development of UTI, including
anatomic, physical, and chemical conditions or
properties of the host’s urinary tract.
MODULE 1M: ANTENATAL COMPLICATIONS
Types
1. Upper urinary tract infection
◼ Upper tract UTIs affect the kidneys. These
can be potentially life-threatening if bacteria
move from the infected kidney into the
blood. This condition, called urosepsis, can
cause dangerously low blood pressure,
shock, and death. These are often rarer but
more severe.
2. Lower urinary tract infection
◼ A lower urinary tract infection refers to the
inflammation and infection of the bladder
and the urethra, which is the tube that leads
from the bladder, enabling urine to exit the
body. Women are more prone to lower UTIs
than men. Cystitis refers to inflammation of
the bladder and urethritis refers to
inflammation of the urethra.
Signs and Symptoms
Signs and symptoms of a kidney infection can include:
❖ Fever
❖ Chills
❖ Lower back pain or pain in the side of your back
❖ Nausea or vomiting
Signs and symptoms of a bladder infection can include:
❖ Pain or burning while urinating
❖ Frequent urination
❖ Feeling the need to urinate despite having an
empty bladder
❖ Bloody urine
❖ Pressure or cramping in the groin or lower
abdomen
Management
Nursing Management:
• Identification of children with UTI and education
of parents and children regarding prevention
and treatment of infection
• Encouragement of good toilet habits and dietary
intake of fluid and fiber
• Instruct parents to observe for signs of UTI
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Take every precaution to obtain acceptable,
clean voided specimens in order to avoid using
other collecting procedures
Medical Management:
Urinalysis
- It's used to detect and manage a wide range of
disorders, such as urinary tract infections
Urine culture and sensitivity
- Collection of sterile specimen which helps
determine presence of pathogens
Cystoscopy
There are three major causes of STDs:
- Is a procedure that lets the healthcare provider
view the urinary tract, particularly the bladder,
the urethra, and the openings to the ureters.
Pharmacologic Management:
Antibiotics such as the following are used in the
treatment of UTI:
• Trimethoprim- sulfamethoxazole
• Amoxicillin
• Nitrofurantoin
• Cephalexin
• Ceftazidime
• Gentamicin
Surgical Management:
While surgeries are not normally recommended for
treating UTI, a surgery may be required when there is an
anatomical defect or a physical blockage in the urinary
tract. The surgical interventions may include the
following:
• Bladder neck incision (B.N.I.) and a
urethrotomy
these are operations for men who have
a decreased urinary stream and
problems passing urine because of a
bladder neck stenosis or a urethral
stricture.
MODULE 1M: ANTENATAL COMPLICATIONS
• Transurethral resection of prostate (TURP)
this is a surgery used to treat urinary
problems that are caused b y an
enlarged prostate, which may be the
cause of UTI for men usually o ver the
age of 50.
STD
- Sexually transmitted diseases are infections that
are passed from one person to another through
sexual contact. The contact is usually vaginal and
oral sex. But sometimes they can spread through
other intimate physical contact.
Etiology/Cause
- Bacteria - chlamydia, gonorrhea, and syphilis are
STDs that are caused by bacteria.
- Viruses -including HIV/AIDS, herpes simplex
virus, human papillomavirus, hepatitis B virus,
cytomegalovirus (CMV), and Zika
- Parasites - STDs caused by parasites include
trichomonas vaginalis, or insects such as crab lice
or scabies mites.
Types
1. Chlamydia
◼ It is caused by bacteria called Chlamydia
trachomatis. It can infect both men and
women. Women can get chlamydia in the
cervix, rectum, or throat. Men can get
chlamydia in the urethra (inside the penis),
rectum, or throat.
2. Gonorrhea
◼ It is caused by the bacterium Neisseria
gonorrhoeae. This common STI tends to
target warm, moist areas of the body,
including the urethra, eyes, throat, vagina.
Gonorrhea can affect people of any age or
gender, but it’s particularly among teens and
young adults between the ages of 15 and 24.
3. Genital Herpes
This STD causes herpetic sores, which are painful
blisters (fluid-filled bumps) that can break open
and ooze fluid.
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4. Syphilis
◼ Syphilis is a bacterial infection usually spread
by sexual contact. The disease starts as a
painless sore — typically on the genitals,
rectum or mouth. Syphilis spreads from
person to person via skin or mucous
membrane contact with these sores.
5. HIV (human immunodeficiency virus)
◼ Is a virus that attacks the body's immune
system. It can be spread by contact with
infected blood or from mother to child
during pregnancy, childbirth or breast-
feeding.
6. Trichomoniasis.
◼ Is a sexually transmitted disease caused by a
parasite. It spreads from person to person
during sex.
7. Human papillomavirus (HPV)
◼ Is a viral infection that’s passed between
people through skin-to-skin contact.
Signs and Symptoms
❖ Sores or bumps on the genitals or in the oral or
rectal area
❖ Painful or burning urination
❖ Discharge from the penis
❖ Unusual or odorous vaginal discharge
❖ Unusual vaginal bleeding
❖ Pain during sex
❖ Sore, swollen lymph nodes, particularly in the
groin but sometimes more widespread
❖ Lower abdominal pain
❖ Fever
❖ Rash over the trunk, hands or feet
Management
Nursing Management:
• Adopt a nonjudgmental attitude. When taking
history, be honest and straightforward.
• Assure clients that all information will be treated
in the strictest confidence. Compile a complete
sexual history.
Sexual orientation
Sexual practices
Type of protection (barrier used)
Contraceptive practices
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Previous history of STDs
• Develop teaching Plan include:
sign and symptom of STDs.
STD transmission mode
A reminder that sexual contact with
anybody should be avoided when
infected.
Brief written instructions about therapy;
seek a verbalization of these instructions
in order to confirm the client has heard
and understood them.
• Encourage the client to disclose all sexual
relations.
• Notify relevant health authorities and
departments about STD incidents.
Medical Management:
• Abstinence
Avoiding sexual contact with other
persons is one of the most effective
strategies to prevent STD transmission.
• Barrier contraceptive
such as condoms, operate as a barrier to
the transmission of STDs from an
infected person. Condoms, on the other
hand, must be used appropriately in
order to avoid transmission. To avoid the
transmission of infection, used condoms
must be removed and properly disposed
of.
• Sexual health screenings
Getting a sexual health screening before
having sexual contact with a partner may
help avoid new infections. If a partner
has had contact with someone else, it is
also necessary to check before resuming
sexual interactions. This procedure isn't
always flawless, since many illnesses
may go unnoticed for long periods of
time.
Pharmacologic Management:
• Vaccination
Important vaccinations that protect
against hepatitis B and certain strains of
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the human papillomavirus are now
available (HPV).
• Nonoxynol-9
is a spermicidal and microbicidal
chemical that is used to lubricate
condoms and may kill certain vaginal
microorganisms. The combination,
however, does not provide
comprehensive protection against all
STDs.
TORCH
- TORCH Syndrome refers to infection of a
developing fetus or newborn by any of a group
of infectious agents. TORCH is an acronym
meaning (T)oxoplasmosis, (O)ther Agents,
(R)ubella (also known as German Measles),
(C)ytomegalovirus, and (H)erpes Simplex.
Infection with any of these agents may cause a
constellation of similar symptoms in affected
newborns.
Etiology/Cause
- The TORCH infections include causative
organisms Toxoplasma gondii, rubella virus,
cytomegalovirus, HSV 1 and 2, hepatitis B virus,
HIV, and others like syphilis, parvovirus, and
varicella. Transmission of the pathogens may
occur prenatally by the transplacental route,
perinatally by blood or vaginal secretions.
Postnatal infections tend to be less impactful.
Others, such as HIV, hepatitis B, and syphilis, can
be transmitted via sexual contact to a
susceptible mother. Rubella and varicella can be
prevented by properly immunizing mothers.
Types
1. Toxoplasmosis
◼ The primary manifestations of congenital
toxoplasmosis include intrauterine growth
restriction and low birth weight,
hepatosplenomegaly, jaundice,
chorioretinitis, intraparenchymal
calcifications, and anemia. Less commonly,
petechiae, hydrocephalus, and microcephaly
can be found.
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2. Congenital Rubella Syndrome
It includes low birth weight,
hepatosplenomegaly, cataracts, congenital heart
disease (patent ductus arteriosus, and
ventricular septal defect), and a petechial rash.
Congenital sensorineural hearing loss is very
common.
3. Herpes Simplex Virus
◼ It rarely presents with in utero infection but
instead presents due to perinatal exposure.
Therefore, clinical manifestations normally
will present ten to twenty-one days after
infection. There are three major
manifestations: Skin-eye-mucous
membranes (SEM), central nervous system
(CNS), and disseminated disease.
4. Cytomegalovirus
◼ CMV is the most common congenital
infection. It will present with intrauterine
growth restriction and low birth weight,
hepatosplenomegaly, jaundice,
paraventricular calcifications, cataracts, and
sensorineural hearing loss and bone marrow
suppression that will present with
thrombocytopenia and anemia. Patients
often have a petechial rash at birth.
5. HIV
◼ Patients with congenital HIV rarely have any
evidence of outward manifestations at birth.
They may have a low birth weight and
hepatosplenomegaly at birth.
6. Syphilis
◼ In utero, there may be fetal loss or hydrops
fetalis. In the neonatal period, children with
primary syphilis may present with cutaneous
lesions on the palms and soles,
hepatosplenomegaly, jaundice,
inflammation of the umbilical cord (funisitis)
and discharge from the nose (sniffles).
Periostitis may be found on x-rays of the
bones. Late findings include frontal bossing,
high palatal arch, sensorineural hearing loss,
a saddle nose, perioral fissures, and
Hutchinson teeth.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Signs and Symptoms
❖ listlessness (lethargy)
❖ fever
❖ difficulties feeding
❖ enlargement of the liver and spleen
(hepatomegaly)
❖ and decreased levels of the oxygen-carrying
pigment (hemoglobin) in the blood (anemia)
In addition, affected infants may develop areas of
bleeding, resulting in reddish or purplish spots or areas
of discoloration visible through the skin (petechiae or
purpura); yellowish discoloration of the skin, whites of
the eyes, and mucous membranes (jaundice);
inflammation of the middle and innermost layers of the
eyes (chorioretinitis); and/or other symptoms and
findings. Each infectious agent may also cause additional
abnormalities that may vary in degree and severity,
depending upon the stage of fetal development at time
of infection and/or other factors.
Management
Nursing Management:
• Advice the patient not to eat uncooked meat or
raw eggs
• Encourage the patient to always wash their
hands with soap and water often
• Avoid being around sick people
• Advice the patient to get vaccinated
• Advice the client to visit their doctor to talk
about their concern
Medical Management:
TORCH SCREEN
• A doctor usually performs some component s of
the TORCH screen routinely when a woman has
her first prenatal visit. They may perform other
components if a woman shows symptoms of
certain diseases during the pregnancy. These
diseases can cross the placenta and cause birth
defects in the newborn.
MODULE 1M: ANTENATAL COMPLICATIONS
Pharmacologic Management:
• treatment may include administration of the
medication pyrimethamine with sulfadiazine.
Herpes simplex may be treated with the antiviral
agent acyclovir. The treatment of newborns and
infants with rubella or cytomegalovirus primarily
includes symptomatic and supportive measures.
MULTIPLE PREGNANCY
- A pregnancy with more than one fetus is called
multiple pregnancy, where a mother is carrying
more than one baby. If you’re carrying two
babies, they are called twins. Three babies that
are carried during one pregnancy are called
triplets. You can also carry more than three
babies at one time called high-order multiples.
There are typically more risks linked to a multiple
pregnancy than a singleton (carrying only one
baby) pregnancy.
Etiology/Cause
There are many factors related to having a multiple
pregnancy. Naturally occurring factors include the
following:
• heredity - A family history of multiple pregnancy
increases the chances of having multiple
pregnancy.
• older age - Women over 30 years old have a
greater chance of multiple conception. Many
women today are delaying childbearing until
later in life, and may have twins as a result.
• high parity - Having one or more previous
pregnancies, especially a multiple pregnancy,
increases the chances of having multiples.
• race - African-American women are more likely
to have twins than any other race. Asian and
Native Americans have the lowest twinning
rates. Caucasian women, especially those over
age 35, have the highest rate of higher-order
multiple births (triplets or more).
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Other factors that have greatly increased the multiple
birth rate in recent years include reproductive
technologies, including the following:
• Ovulation stimulating medications such as
clomiphene citrate and follicle stimulating
hormone (FSH) help produce many eggs, which,
if fertilized, can result in multiple babies.
• Assisted reproductive technologies such as in-
vitro fertilization (IVF) and other techniques help
couples conceive. These technologies often use
ovulation stimulating medications to produce
multiple eggs which are then fertilized and
returned to the uterus to develop.
Types
1. Fraternal twins
◼ Two separate eggs are fertilized and
implanted in the uterus. The babies are
siblings who share the same uterus — they
may look similar or different, and may either
be the same gender (2 girls or 2 boys) or of
different genders. A pregnancy with
fraternal twins is statistically the lowest risk
of all multiple pregnancies since each baby
has its own placenta and amniotic sac. Some
fraternal twins are referred to as 'dizygotic'
twins, referring to 2 zygotes (fertilized eggs).
2. Identical twins
◼ Identical twins are formed when a single
fertilized egg is split in half. Each half
(embryo) is genetically identical, so the
babies share the same DNA. That means the
babies will share many characteristics.
However, because their appearance is
influenced by the environment as well as by
genes, sometimes identical twins can look
quite different. Identical twins may share the
same placenta and amniotic sac, or they may
have their own placenta and amniotic sac.
Some identical twins are referred to as
'monozygotic', referring to one zygote
(fertilized egg).
3. Triplets and 'higher order multiples' (HOMs)
◼ Triplets, quadruplets, quintuplets, sextuplets
or more can be a combination of both
MODULE 1M: ANTENATAL COMPLICATIONS
identical and fraternal multiples. For
example, triplets can either be fraternal
(trizygotic), forming from 3 individual eggs
that are fertilized and implanted in the
uterus; or they can be identical, when one
egg divides into 3 embryos; or they can be a
combination of both.
Signs and Symptoms
❖ Excessive weight gain at the start of the
pregnancy
❖ Severe morning sickness
❖ More than one heartbeat is picked up during a
prenatal examination
❖ Uterus is larger than expected
❖ Fetal movements can be felt in different parts of
the abdomen at the same time
❖ Increased breast tenderness
A multiple pregnancy is confirmed by an ultrasound scan,
usually in the first trimester (the first 12 weeks). The
ultrasound will confirm the type of multiple pregnancy,
whether there is one placenta or 2, and how many
amniotic sacs there are. These are all important factors
for later in the pregnancy and it's important to identify
them as early as possible.
Management
Nursing Management:
• Advocate healthy eating and physical activity to
the mother in her daily routine to improve
health.
• Refer to a dietitian for complete nutrition
assessment and methods for nutritional support.
• Advise the mother to avoid caffeine, alcohol, and
tobacco.
• Advise women to have proper amount of sleep.
• Refer to a perinatologist, a maternal-fetal
medicine specialist for special testing or
ultrasound evaluations, and to coordinate care
of complications.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Medical Management:
• Ultrasound
Takes measurements of parts of the
baby's body, such as the head, abdomen
and femur to formulate an estimation of
the baby's weight.
• Blood studies
Determines the amount of glucose,
calcium, hematocrit and bilirubin.
Pharmacologic Management:
• Tocolytic medicines
Tocolytic drugs help slow or stop
contractions. These may be given orally,
by injection or intravenously . Tocolytic
medicines often include nifedipine.
Surgical Management:
• Cesarean birth
A cesarean section is usually considered
safest when there are 3 or more babies.
For twins, C-section is indicated
depending on the twins’ presentation.
Giving birth to triplets or more vaginally
is very rare and not recommended
because of the higher risk of labor
complication s and infant mortality.
HYDRAMNIOS
- Hydramnios is a condition that occurs when too
much amniotic fluid builds up during pregnancy.
It is an amount of amniotic fluid more than 2000
ml and the amniotic fluid index (AFI) is greater
than 20 to 25.
Etiology/Cause
This condition may happen for several reasons. Either
too much fluid is made or there’s a problem with the fluid
being taken away. Or both of these things may be
happening. Hydramnios may be caused by diabetes in
the mother.
Pregnant women normally have about one-half to 1
quart (500 to 1,000 ml) of amniotic fluid. Too much or
too little amniotic fluid can cause problems. These issues
MODULE 1M: ANTENATAL COMPLICATIONS
can affect how your baby develops. They can also cause
pregnancy complications. Or the amount of amniotic
fluid may be a sign of another issue
1. Fetal Cause:
➢ Congenital anomalies
➢ Single-ovum twins
➢ Increased placental mass: Edema of the
placenta due to Rh-incompatibility,
severe anemia, haemoglobinopathies
and cytomegalovirus infection
➢ True knot of the cord causes obstruction
of venous return with placental
congestion
➢ Fetal liver cirrhosis as in syphilis: Chorio-
angioma and large placenta 2
2. Maternal causes:
➢ Diabetes mellitus
➢ Pregnancy induced hypertension due to
edema of the placenta
➢ Severe generalised edema cardiac,
hepatic or renal
Types
1. Acute hydramnios
◼ This is very rare - Usually occurs at about 20
weeks and develops very suddenly - The
uterine size reaches the xiphisternum in
about 3 or 4 days - Is frequently associated
with monozygotic twins or severe fetal
malformation.
2. Chronic hydramnios
◼ This is gradual in onset, usually starting from
about the 30th week of pregnancy - The
most common type
Signs and Symptoms
Hydramnios symptoms are a result from pressure that is
being exerted within the uterus and nearby organs.
Symptoms can occur a bit differently in each pregnancy.
They can include:
❖ Fast growth of your uterus
❖ Stomach discomfort
❖ Uterus that is larger than normal for how far
along you are in pregnancy
❖ Labor pains (contractions)
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Severe polyhydramnios may cause: Due to the risk of fetal heart problems. Other
side effects may include nausea, vomiting, acid
❖ Shortness of breath or the inability to breathe
reflux and inflammation of the lining of the
❖ Swelling in the lower extremities and abdominal
stomach (gastritis).
wall
❖ Uterine discomfort or contractions
❖ Fetal malposition, such as breech presentation
❖ Indigestion
❖ Difficulty with bowel movements (constipation)
❖ Enlargement of vulva
❖ Sensation of tightness in stomach

Management
Nursing Management:

• Prepare the patient for biophysical profile and

non-stress test.
• Place the mother on close monitoring.
• Expectant treatment if the fetus is healthy: rest ,
sedative, salt restriction.
• Obtain consent from the patient to perform
amniocentesis after explaining the procedure’s
purpose, benefits, and risks.
• Treat the underlying conditions related to
polyhydramnios, such as gestational/ maternal
diabetes and rhesus disease.

Medical Management:

• Utilization of Ultrasound would determine the

presence of hydramnios and also the reason for
the excessive amount of fluid.
• Non-stress test. This is done to check the
reaction of the baby’s heart rate when he/she
moves.
• Drainage of excess amniotic fluid. Utilization of
amniocentesis to drain excess amniotic fluid
from your uterus. This procedure carries a small
risk of complication s, including preterm labor,
placental abruption and premature rupture of
the membranes.

Pharmacologic Management:

• Prescription of oral medication indomethacin

(Indocin) to help reduce fetal urine production
and amniotic fluid volume. Indomethacin isn't
recommended beyond 31 weeks of pregnancy.

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
INEFFECTIVE UTERINE FORCE
- abnormal labor pattern, notable especially
during the active phase of labor, characterized
by poor and inadequate uterine contractions
that are ineffective to cause cervical dilation,
effacement, and fetal descent, leading to a
prolonged or protracted delivery. Hypotonic
labor is primarily a dysfunction of power. There
is inadequate propulsive power to cause fetal
descent, cervical dilatation, and eventual
expulsion of the fetus and placenta.
- Uterine contractions are the basic force that
moves the fetus through the birth canal. They
occur because of the interplay of the contractile
enzyme adenosine triphosphate and the
influence of major electrolytes such as calcium,
sodium, and potassium, specific contractile
proteins (actin and myosin), epinephrine and
norepinephrine, oxytocin (a posterior pituitary
hormone), estrogen, progesterone, and
prostaglandins. In about 95% of labors,
contractions follow a predictable, efficient
course. When they have less strength than usual
or are rapid but ineffective, dysfunctional labor
occurs
Etiology/Cause
- Overdistension of the uterus.
- Developmental anomalies of the uterus e.g.
hypoplasia.
- Myomas of the uterus interfere mechanically
with contractions.
- Malpresentations, malpositions and
cephalopelvic disproportion. The presenting part
is not fitting in the lower uterine segment leading
to absence of reflex uterine contractions.
- Full bladder and rectum.
Types
1. Hypotonic Contractions
◼ Primary inertia: weak uterine contractions
from the start.
◼ Secondary inertia: inertia developed after a
period of good uterine contractions when it
failed to overcome an obstruction so the the
uterus is exhausted.
MODULE 2M: INTRAPARTAL COMPLICATIONS
2. Hypertonic Contractions
◼ Colicky uterus: incoordination of the
different parts of the uterus in contractions.
◼ Hyperactive lower uterine segment: so the
dominance of the upper segment is lost.
Signs and Symptoms
Hypotonic Contractions
❖ There are only two or three contractions
occurring within a 10- minute period.
❖ The strength of contractions does not rise above
10 mmHg, and they occur mostly during the
active phase of labor.
❖ The number of uterine contractions in hypotonic
contractions is unusually slow or infrequent.
Hypertonic Contractions
❖ marked by an increase in resting tone to more
than 15 mmHg.
❖ They are more painful than usual, and they make
the woman frustrated with her breathing
techniques because they are ineffective.
Management
Nursing Management:
• Place the client in a lateral recumbent position
• Assess Uterine contraction pattern
• Encourage bed rest or sitting
position/Ambulation
• Monitor vital signs
• Explain to the woman and her partner that
although the contractions are very strong, they
are ineffective and are not achieving cervical
dilatation.
Medical Management:
• Uterine and fetal external monitor
should be applied at least 15 minutes to
check the resting phase of the
contractions and that the fetal pattern is
not showing a late deceleration
• Intravenous infusion
is frequently administered to maintain
hydration and electrolyte balance.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Pharmacologic Management:
• Administer short-acting tocolytics (eg,
terbutaline 0.25 mg IV once)
• Discontinuation of oxytocin if it is being used
• Administer analgesics to reduce pain
Surgical Management:
• Caesarean section
(is necessary if) there is late
deceleration, an abnormally long first
stage of labor or lack of progress with
pushing.
HYPOTONIC UTERINE CONTRACTION
- Occurs mostly during the ACTIVE PHASE of labor
- When uterine contractions are unusually slow or
infrequent
- Increased chance of postpartal hemorrhage
- Resting tone remains less than 10 mmHg
- . With hypotonic uterine contractions, the
number of contractions is unusually infrequent
(not more than two or three occurring in a 10-
minute period). The resting tone of the uterus
remains less than 10 mmHg, and the strength of
contractions does not rise above 25 mmHg (Fig.
23.1B). Hypotonic contractions occur during the
active phase of labor and tend to occur after the
administration of analgesia, especially if the
cervix is not dilated to 3 to 4 cm or if bowel or
bladder distention is preventing descent or firm
engagement. They also may occur in a uterus
that is overstretched by a multiple gestation, a
larger than usual single fetus, polyhydramnios,
or in a uterus that is lax from grand multiparity.
Such contractions are not exceedingly painful
because of their lack of intensity. Keep in mind,
however, that pain is a subjective symptom.
Some women, therefore, may interpret these
contractions as very painful.
- Hypotonic contractions will increase the length
of labor because more of them are necessary to
achieve cervical dilatation. If the uterus becomes
exhausted, this can cause it to not contract as
effectively during the postpartal period, thus
increasing a woman’s chance for postpartal
MODULE 2M: INTRAPARTAL COMPLICATIONS
hemorrhage. In the first hour after birth
following a labor of hypotonic contractions, it is
very important to palpate the uterine fundus,
obtain the woman’s blood pressure, and assess
the amount of lochia every 15 minutes for the
first hour to ensure postpartal contractions are
not also hypotonic and therefore not adequate
to halt postpartal hemorrhage.
Etiology/Cause
Hypotonic contractions occur after administration of
analgesia, bowel or bladder distention, if the uterus is
overstretched due to multiple gestation, a large fetus,
hydramnios, or a uterus that is lax from grand
multiparity.
- Hydramnios
- Overstretched uterus by a multiple gestation
- Bowel or Bladder distention
- Administration of analgesia if cervix is not dilated
to 3 to 4 cm
Types
1. Poor and inadequate uterine contractions that
are inadequate in causing cervical dilatation,
effacement, and fetal descent, resulting in a
prolonged or protracted delivery, especially
during the active phase of labor.
2. There are only two or three contractions
occurring within a 10- minute period.
3. The contractions in the uterus are feeble,
infrequent and have short durations. (no more
than two or three in a 10-minute span).
4. The contractions have a strength of less than 10
mmHg and are most common during labor's
active phase.
Signs and Symptoms
❖ The number of uterine contractions in hypotonic
contractions is unusually slow or infrequent.
❖ Number of Contractions: There are only two or
three contractions occurring within a 10-minute
period.
❖ The strength of contraction: does not rise above
10 mmHg, and they occur mostly during the
active phase of labor.
❖ Resting tone remains less than 10 mmHg
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Management
Nursing Management:
Always remember that it is significant to assess the
mother and fetus to exclude other causes of abnormal
labor progression, such as cephalopelvic disproportion
(CPD) a n d fetal malpositioning.
• Optimize uterine activity. In monitoring uterine
Pharmacologic Management:
contractions for dysfunctional patterns, the
nurse can use palpation and an electronic
monitor.
• Checking the client’s level of fatigue and ability
to cope with pain is important to prevent
unnecessary fatigue.
• Prevent complications of labor for the client and
infant such as:
Assessing the urinary bladder
Assessing maternal vital signs, including
temperature, pulse, respiratory rates,
and blood pressure.
Checking maternal urine for acetone (an
Surgical Management:
indication of dehydration and
exhaustion).
Assessing the condition of the fetus by
monitoring FHR, fetal activity, and color
of amniotic fluid.
• Promote relaxation by, giving back rubs,
promoting comfortable position (sidelying),
coaching the client in breathing and relaxation
techniques, and keeping the environment quiet.
• In the first hour after birth following labor of
hypotonic contractions, palpate the uterus and
assess the lochia every 15 minutes to ensure that
there are no postpartal hypotonic contractions
and inadequate to halt bleeding.
Medical Management:
• Amniotomy aids in the stimulation of
contractions by releasing prostaglandins and
reflex stimulation of the uterus when the
presenting part becomes closely applied to the
lower uterine segment. This should be
attempted when vaginal delivery is probable and
if cervical dilatation is less than 4 cm, there is
adequate fetal descent (station -2 or lower), and
MODULE 2M: INTRAPARTAL COMPLICATIONS
the presenting part is well applied to the lower
uterine segment.
• The combination of amniotomy and oxytocin
augmentation is more effective in the
management of hypotonic labor than
amniotomy alone when instituted early in the
active phase of labor.
• The use of intravenous oxytocin to stimulate
contractions can be followed provided there are
no contraindications. Oxytocin is the medication
of choice for augmenting contractions. The
dosage regimen should be titrated to effect for
achieving adequate uterine contractions. The
usual protocol is 5 units of oxytocin in 500mls of
5% Dextrose intravenous infusion, starting with
10 drops/min and gradually titrating the rate to
achieve a contraction rate of at least 3 per
minute.
• Assisted vaginal delivery using forceps, vacuum,
or breach extraction may be indicated if
ineffective efforts for bearing down are
observed and if the cervix is already fully dilated,
and vaginal delivery is indicated and probable.
• Cesarean section delivery is performed if all
other measures have failed to stimulate the
uterine contractions such as when oxytocin is
contraindicated, and if there is maternal
exhaustion, fetal distress, or even before full
cervical dilation.
HYPERTONIC UTERINE CONTRACTION
- Hypertonic labor is characterized by more
frequent, ineffective, and painful contractions,
which does not allow the uterus to relax
between contractions . It is most noticeable
during the latent phase of labor.
- Hypertonic uterine contractions are marked by
an increase in resting tone to more than 15
mmHg (Fig. 23.1C). However, the intensity of the
contraction may be no stronger than that
associated with hypotonic contractions. In
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
contrast to hypotonic contractions, these occur
frequently and are most commonly seen in the
latent phase of labor. Hypertonic contractions
may occur because more than one uterine
pacemaker is stimulating contractions or
because the muscle fibers of the myometrium do
not repolarize or relax after a contraction,
thereby “wiping it clean” to accept a new
pacemaker stimulus. They tend to be more
painful than usual because the myometrium
becomes tender from constant lack of relaxation
and the anoxia of uterine cells that results.
- A danger of hypertonic contractions is that the
lack of relaxation between contractions may not
allow optimal uterine artery filling; this can lead
to fetal anoxia early in the latent phase of labor.
Applying a uterine and a fetal external monitor
to any woman whose pain seems out of
proportion to the quality of her contractions will
help identify that the resting phase between
contractions is adequate and that the FHR is not
showing late deceleration
- If decelerations in the FHR, an abnormally long
first stage of labor, or lack of progress with
pushing (i.e., “second-stage arrest”) occurs,
cesarean birth may be necessary. Although this
is disappointing, be certain the woman and her
support person understand that, although
contractions are strong, they are ineffective and
are not achieving cervical dilatation
Etiology/Cause
- Uterine hyperstimulation is a complication that
can occur with excessive use of Pitocin during
labor. Pitocin is a medication administered to
pregnant women to induce or speed up labor. It
is a synthetic form of oxytocin – the hormone a
mother's body produces naturally during labor.
Signs and Symptoms
❖ Hypertonic contractions are marked by an
increase in resting tone to more than 15 mmHg.
❖ Hypertonic contractions tend to occur more
frequently and during the latent phase of labor.
MODULE 2M: INTRAPARTAL COMPLICATIONS
❖ They are more painful than usual, and they make
the woman frustrated with her breathing
techniques because they are ineffective.
Management
Nursing Management:
• Assess uterine contraction pattern; provide rest
(analgesia); provide comfort measures; monitor
maternal vital signs; frequently monitor fetal
status. Lateral position; administer oxygen by
mask.
Medical Management:
• Prostoglandin E2 is administered before labor to
minimize risk of uterine hyperstimulation and to
minimize the effects on Fetal Heart Rate.
• Administration of tocolytic treatment with β2-
adrenergic drugs has shown to stabilize uterine
contractions while also effectively lowering Fetal
Heart Rate.
• The usage of a balloon catheter to induce labor
rather than Prostoglandin E2 lowers the risk of
uterine hyperstimulation and its effect on fetal
heart rate.
Pharmacologic Management:
• Hypertonic uterine dysfunction is difficult to
treat, but repositioning, short-acting tocolytics
(eg, terbutaline 0.25 mg IV once),
discontinuation of oxytocin if it is being used, and
analgesics may help.
Surgical Management:
• Assisted vaginal delivery
may be performed using forceps,
vacuum, or breech extraction provided
the cervix is fully dilated, and vaginal
delivery is indicated and probable.
• Operative delivery by cesarean section
should be considered early when the
assessment indicates a CPD or fetal
malpositioning/malpresentation.
However, in the absence of an early
indication, cesarean section is
performed if all other measures have
YUSON, DREA
NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
failed to stimulate the uterine Types
contractions; when oxytocin is The first stage starts with uterine contractions leading to
contraindicated (including cephalopelvic complete cervical dilation and is divided into latent and
disproportion), if there is maternal active phases.
exhaustion, fetal distress (category III
1. Latent phase:
fetal heart tracing), or before full cervical
◼ Irregular uterine contractions occur along
dilation. Cesarean birth would be
with cervical effacement and dilatation that
necessary if there is late deceleration, an
is slow and progressive.
abnormally long first stage of labor or
2. Active phase
lack of progress with pushing.
An higher rate of cervical dilatation and fetal
COMPARISON OF HYPOTONIC AND descent indicates the active phase. The
HYPERTONIC CONTRACTIONS acceleration, maximum slope, and deceleration
Criteria Hypertonic Hypotonic phases are all part of the active phase, which
Most common Latent Active normally begins around 3-4 cm cervical dilation.
phase of
occurrence Management
Symptoms Painful Limited pain Nursing Management:
Medications • Nursing care for patients with dysfunctional
used
labor revolves around identifying and treating
Oxytocin Unfavorable Favorable
abnormal uterine patterns, preventing
reaction reaction
Sedation Helpful Little value unnecessary fatigue, monitoring maternal/fetal
physical response to contractile pattern,
providing emotional support for the client/
DYSFUNCTIONAL LABOR – 1ST STAGE couple, and preventing complications for the
- Dysfunctional or prolonged labor refers to a client and infant.
labor that lasts longer than expected, usually in
Medical Management:
the first stage. The intensity, duration, and
frequency of uterine contractions, cervical • For those in the latent phase, the treatment of
dilatation, and the descent of the fetus through choice is rest for several hours. During this
the pelvis are all used to diagnose labor delay. interval, uterine activity, fetal status, and
cervical effacement must be evaluated to
Etiology/Cause determine if progress to the active phase has
- Dysfunctional labor can be due to abnormalities
occurred. Approximately 85% of patients so
in uterine contraction and/or lack of ability of the
treated progress to the active phase.
mother to forcibly expel the fetus, a large fetus
Approximately 10% will cease to have
and/or an unusual orientation of the fetus in the
contractions, and the diagnosis of false labor
uterus, or abnormalities in the pelvis such that
may be made. For the approximately 5% of
the passage is blocked or too small.
patients in whom therapeutic rest fails and in
patients for whom expeditious delivery is
indicated, oxytocin infusion may be used.

Pharmacologic Management:

MODULE 2M: INTRAPARTAL COMPLICATIONS YUSON, DREA

NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Options for managing the latent phase of labor
include observation, sedation with
antihistamines or mild narcotics, and labor
augmentation.
Surgical Management:
• Cesarean delivery for dystocia should not be
performed in women who remain in latent labor
for being induced with sedatives.
DYSFUNCTIONAL LABOR – 2ND STAGE
- Failure to progress in labor is a situation in which
labor stalls out or stops. This can relate to the
cervix not dilating enough, the baby’s head not
engaging with the mother’s pelvis, differences
between the size of the baby’s head and
mother’s pelvis, or with contractions not being
sufficiently strong or frequent to push the baby
out, among other factors.
- The active phase usually starts at 3-4 cm cervical
dilation and is subdivided into the acceleration,
maximum slope, and deceleration phases. The
second stage of labor is defined as complete
dilation of the cervix to the delivery of the infant.
Etiology/Cause
- Dysfunctional labor can be due to abnormalities
in uterine contraction and/or lack of ability of the
mother to forcibly expel the fetus, a large fetus
and/or an unusual orientation of the fetus in the
uterus, or abnormalities in the pelvis such that
the passage is blocked or too small.
Types
1. Prolonged latent phase
◼ Friedman defined prolonged latent phase as
> 20 hours in a nulliparous woman, and > 14
hours in a multiparous woman.
2. Protracted active phase dilation
Protracted labor is abnormally slow cervical
dilation or fetal descent during active labor.
3. Secondary arrest of dilation
◼ This is diagnosed when there has been no
change in cervical dilation for at least 2
hours. This time criterion is the same for
nulliparas and multiparas and is based in
MODULE 2M: INTRAPARTAL COMPLICATIONS
part on the certainty with which cervical
dilation can be determined on digital
examination.
4. Prolonged deceleration phase
◼ progress in dilation slows after 8 cm and
uterine contractions become dysfunctional,
even after oxytocin administration. In this
situation, the cervix starts to swell and take
on fluid. In this situation, a C-section may be
needed.
5. Protracted descent
◼ abnormally slow cervical dilation or fetal
descent during active labor.
6. Arrest of descent
◼ the head of the fetus is in the same place in
the birth canal during the first and second
examinations, which your doctor performs
one hour apart. This signifies that the baby
hasn't moved farther down the birth canal
within the last hour.
Signs and Symptoms
❖ The abnormally slow descent of the fetus during
the second stage of labor
❖ Abnormally slow dilation of the cervix during
active labor
❖ Lodging of the shoulders of the fetus once the
head has been delivered (shoulder dystocia)
Management
Nursing Management:
• Monitor uterine contractions for dysfunctional
patterns
• Check the patient’s level of fatigue and ability to
cope with pain
• Assess urinary bladder, catheterize as needed.
• Assess maternal vital signs Assess condition of
fetus by monitoring fetal heart rate, fetal
activity, and color of amniotic fluid
• Coach the client in breathing and relaxation
techniques
• Provide back rubs
• Nipple stimulation to produce endogenous
oxytocin
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• Assess for malpositioning of fetus using
Leopold’s Maneuvers
Medical Management:
• Prepare for forceps delivery as necessary:
Excessive maternal fatigue, resulting in
ineffective bearing-down efforts in stage II labor,
indicates the use of forceps.
• Apply vacuum extractor as indicated: Vacuum
extractor may be used to rotate and expedite
delivery of fetus.
Pharmacologic Management:
• Administer narcotic or sedative such as
morphine, pentobarbital, or secobarbital
• Infusion of exogenous oxytocin (Pitocin) or
prostaglandins.
Surgical Management:
• Amniotomy: Rupture of membranes relieves
uterine overdistension and allows presenting
part to engage and labor to progress in the
absence of cephalopelvic disproportion.
• Cesarean Delivery: Immediate cesarean birth is
indicated for Bandl’s ring or fetal distress due to
CPD.
CONTRACTION RING
- A contraction ring is a spasmodic contraction of
the lower portion of the uterus which usually
occurs during the first phase of labour, but
persists into the second stage. The ring then
contracts round the child's neck and prevents
the child descending, thus delaying and
preventing delivery. It is a cause of obstructed
labor or dysfunctional labor.
Etiology/Cause
- Tonic uterine contraction
- Inco-ordinated uterine contractions
Types
1. Bandl’s Ring
◼ An end result of tonic uterine contraction
and retraction following obstructed labor. It
always occurs at the junction of upper and
MODULE 2M: INTRAPARTAL COMPLICATIONS
lower segments and progressively moves
upwards.
2. Constriction Ring
◼ A manifestation of localized inco-ordinated
uterine contractions caused by undue
irritability of the uterus . The constriction
ring usually occurs at the junction of upper
and lower segment, and the position does
not alter.
Signs and Symptoms
❖ Maternal exhaustion
❖ Fetal anoxia
Management
Nursing Management:
The nursing care for patients with dysfunctional labor
revolves around identifying and treating abnormal
uterine patterns, monitoring maternal/fetal physical
response to contractile pattern and length of labor,
providing emotional support for the client/couple and
preventing complications.
In conducting the nursing interventions, the nurse must
perform the following:
1. Optimize uterine activity. Monitor uterine
contractions for dysfunctional patterns; use
palpation and an electronic monitor.
2. Prevent unnecessary fatigue. Check the client’s
level of fatigue and ability to cope with pain.
3. Prevent complications of labor for the client and
infant.
Assess urinary bladder; catheterize as
needed.
Assess maternal vital signs, including
temperature, pulse, respiratory rates,
and blood pressure.
Check maternal urine for acetone (an
indication of dehydration and
exhaustion).
Assess the condition of the fetus by
monitoring FHR, fetal activity
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Medical Management:
• In cases when amniotic banding is constricting
the umbilical cord or cutting off the blood supply
to a baby's limb, a doctor can attempt to
surgically remove the bands before your baby is
born.
Pharmacologic Management:
• The classical treatment is morphia, anesthesia,
adrenaline, and inhalation of amyl nitrite which,
sometimes, relaxes the contraction ring
dramatically, and spinal anesthesia. If those
means prove unsuccessful, weight traction
attached to a scalp forceps is advised.
Surgical Management:
• In cases when amniotic banding is constricting
the umbilical cord or cutting off the blood supply
to a baby's limb, a doctor can attempt to
surgically remove the bands before your baby is
born.
PRECIPITATE LABOR
- Characterized as rapid labor and delivery that
can be completed in less than 3 hours. This can
be predicted from a labor graph. During the
active phase of dilatation, the rate is greater than
5 cm/hr (1cm every 12 minutes) in a nullipara or
10 cm/hr (1cm every 10 minutes) in a multipara.
However, this can result in maternal injury (i.e
cervical or perineal lacerations) and place the
fetus at risk for traumatic or asphyxia insults.
Etiology/Cause
- Grand multiparity
- Abnormally strong uterine and abdominal
contractions
- Abnormally low resistance of the soft pass of the
birth canal
- Absence of painful sensations
- Induction of labor by oxytocin
Signs and Symptoms
❖ Painful
❖ Sudden onset of strong contractions
❖ An intense feeling to bear down and push
MODULE 2M: INTRAPARTAL COMPLICATIONS
Management
Nursing Management:
• Monitor Vital signs
• Encourage oral intake
• Provide supplemental fluids as indicated
• Provide a quiet environment and privacy within
parameters of the situation.
• Note client’s level of consciousness and
mentation
Medical Management:
• Check for history of precipitate labor
• Induce labor with a low rupture of membranes
and a controlled delivery with care.
• Woman should be cautioned during the 28th
week.
• Cardiotocography
o The heart rate of your baby is measured
using cardiotocography (CTG).
o It also focuses solely on the womb's
contractions at the same time (uterus).
o It is used to monitor the baby for any
signs of distress both before birth
(antenatally) and throughout labor.
Pharmacologic Management:
• A tocolytic, such as a bolus of subcutaneous
terbutaline or intravenous ritodrine, should be
given to the mother if a syntocinon infusion is
being administered.
Surgical Management:
• Performing a cesarean delivery immediately
after the diagnosis of placental abruption may
have contributed to a reduction in the rate of
vaginal births.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
UTERINE RUPTURE
- During a uterine rupture, the endometrium,
myometrium, and peritoneum of the uterus
divide completely (Togioka & Tonismae, 2021). It
can also be described as a condition wherein the
woman’s uterus will tear through the uterine
wall and serosa. The hole resulting from the tear
could possibly lead to the entry of the fetus,
amniotic fluid, or umbilical cord into the
peritoneal cavity or broad ligament. This mainly
occurs in pregnant women but can also manifest
in women who are not pregnant.
Etiology/Cause
- In pregnant women, those who had previously
undergone cesarean deliveries were most likely
to experience a uterine rupture. Another reason
is having an overdistended uterus or the uterus
being larger than normal. Different procedures
may also cause this condition inadvertently
(Porter & Kaplan, 2011). Specifically, these are an
external or internal fetal version, an iatrogenic
perforation, and excessive use of drugs which
stimulate uterine contractions. In non-pregnant
women, the uterus may have a uterine rupture if
it is exposed to trauma, an infection, or cancer
(Herrera, Hassanein & Bansal, 2011)
Types
When it comes to uterine ruptures, a complete tear
through the epithelial layer until the serosal outer layer
is usually expected. However, sometimes the
perimetrium is left intact. In a complication such as
uterine rupture, there are two types which are both
equally concerning and require immediate attention
(Gibbins et al., 2015):
1. A complete uterine rupture
◼ refers to the tear going through the
endometrium, myometrium, and
peritoneum. Due to the damage done to the
myometrium (which is the smooth muscle
layer), uterine contractions stop. Two
swellings will also be made visible on the
woman’s abdomen.
MODULE 2M: INTRAPARTAL COMPLICATIONS
2. An incomplete uterine rupture
◼ is when the outer layer of the uterus is left
untorn. This makes it difficult to immediately
identify a uterine rupture as signs of rupture
won’t be easily seen.
Signs and Symptoms
❖ When uterine rupture occurs, immediate care
should be provided to the mother. This is mainly
because the signs and symptoms of uterine
rupture can lead to morbidity or mortality. These
include fetal bradycardia, noticeable signs of
hypovolemia, loss of fetal station, and severe or
constant abdominal pain (Guiliano et al., 2014).
Cases wherein the fetus entered the peritoneal
cavity due to uterine rupture have led to an
increase towards possible fetal and maternal
death. This is treated right away through a
laparotomy which helps control bleeding and the
birth of the fetus.
Management
Nursing Management:
• Monitor maternal blood pressure, pulse, and
respirations of the mother and the fetal heart
tones.
• Help with the patients physical and their
emotional support when needed
• Check cervical dilation
• Monitor uterine contractions
Medical Management:
• Look for circulatory accommodations
• Blood product might be used such as fibrinogen
or platelets
• Initiate cardiopulmonary resuscitation if the
patient arrest. If no response perform a
perimortem cesarean delivery
Pharmacologic Management:
• Rx emergency replacement therapy
• IV Oxytocin- contracts the uterus and minimize
bleeding
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Surgical Management:
• Laparotomy- to control bleeding and birth of the
fetus
• Cesarean hysterectomy- removal of the uterus at
the time of cesarean delivery
INVERSION OF THE UTERUS
- When the uterine fundus collapses into the
endometrial cavity, the uterus is turned partially
or entirely inside out, resulting in uterine
inversion. It's an uncommon consequence of
vaginal or cesarean birth, but it's a life-
threatening obstetric emergency when it does
happen. If not detected and treated
immediately, uterine inversion can result in
severe bleeding and shock, which can lead to
maternal death.
Etiology/Cause
The main cause of uterine inversion remains unclear.
However, it is linked to the following risk factors:
- labor lasting longer than 24 hours
- a short umbilical cord
- prior deliveries
- use of muscle relaxants during labor
- abnormal or weak uterus
- previous uterine inversion
- placenta accreta, in which the placenta is too
deeply embedded in the uterine wall
- fundal implantation of the placenta, in which the
placenta implants at the very top of the uterus
Types
1. 1st degree (also called incomplete) – The fundus
is within the endometrial cavity
2. 2nd degree (also called complete) – The fundus
protrudes through the cervical os
3. 3rd degree (also called prolapsed) – The fundus
protrudes to or beyond the introitus
4. 4th degree (also called total) – Both the uterus
and vagina are inverted
Signs and Symptoms
❖ Dizziness
❖ Abdominal pain
❖ A mass in the vagina
MODULE 2M: INTRAPARTAL COMPLICATIONS
❖ Low blood pressure.
Management
Nursing Management:
• Insertion of IV line using a large gauge needle.
• Assess vital signs.
• Prepare to perform CPR if a woman's heart fails
from blood loss.
• Rx Oxygen mask.
Medical Management:
• Immediate uterine repositioning is essential for
acute puerperal inversion.
• Measures to reposition the uterus may include:
• Preparing theatres for a possible laparotomy.
• Attempting prompt repositioning of the uterus.
This is best done manually and quickly,
as delay can render repositioning
progressively more difficult. Reposition
the uterus (with the placenta if still
attached) by slowly and steadily pushing
upwards towards the umbilicus,
commonly referred to as Johnson's
method.
Pharmacologic Management:
• Administer uterotonic drugs- Atony is common
after restoration of the normal uterine position.
• Antibiotic prophylaxis -administration of a single
dose of a first-generation cephalosporin.
Surgical Management:
Huntington procedure
• Locate the cup formed by the inversion
• Place a clamp, such as an Allis or Babcock clamp,
on each round ligament entering the cup,
approximately 2 cm deep in the cup.
• Gently pull on the clamps to exert upward
traction on the inverted fundus.
• Repeatedly clamp in 2 cm increments along the
ligament and exert traction until the inversion is
corrected.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Haultain procedure
• Make an incision (approximately 1.5 inches in
length) in the posterior surface of the uterus to
transect the constriction ring and thus increase
the size of the previously constricted area.
• Manual reduction can be performed through the
vagina or by placing a finger abdominally
through the myometrial incision to below the
fundus and then exerting pressure on the fundus
to reduce the inversion.
• The incision is repaired when the uterus has
been returned to a normal position.
AMNIOTIC FLUID EMBOLISM
- Amniotic fluid embolism (AFE) is one of the
catastrophic complications of pregnancy that
occurs when amniotic fluid is forced into an open
maternal uterine blood sinus after a membrane
rupture or partial premature separation of the
placenta (Balinger, Chu Lam, Hon, et al., 2015).
Etiology/Cause
- Etiology largely remains unknown, but may
occur in healthy women during labour, during
cesarean section, after abnormal vaginal
delivery, or during the second trimester of
pregnancy. It may also occur up to 48 hours post-
delivery. It can also occur during abortion, after
abdominal trauma, and during amnio-infusion.
Previously, it was thought particles such as
meconium or shed fetal skin cells in the amniotic
fluid entered the maternal circulation and
reached the lungs as small emboli. A more likely
cause of symptoms is a humoral or
anaphylactoid response to amniotic fluid in the
maternal circulation. Although it is associated
with induction of labor, multiple pregnancy, and
perhaps polyhydramnios (i.e., excess amniotic
fluid), it is not preventable because it cannot be
predicted.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
1. Typical AFE:
◼ Phase 1-respiratory and circulatory disorders
◼ Phase 2-coagulation disturbances of
maternal hemostasis
◼ Phase 3-acute renal failure and acute
respiratory distress syndrome (ARDS), and
leading to cardiopulmonary collapse.
2. Atypical AFE:
◼ Uterine Hemorrhage
◼ Adult respiratory syndrome (ARDS)- as form
of atypical AFE
◼ Paradoxical AFE
◼ Cesarean section- related atypical AFE
Signs and Symptoms
❖ Acute or sudden shortness of breath (dyspnea)
❖ Excess fluid in the lungs (pulmonary edema)
❖ Sudden low blood pressure
❖ Sudden failure of the heart to effectively pump
blood (cardiovascular collapse)
❖ Life-threatening problems with blood clotting
(disseminated intravascular coagulopathy)
❖ Bleeding from the uterus, cesarean incision or
intravenous (IV) sites
❖ Altered mental status, such as anxiety or a sense
of doom
❖ Chills, shivering, sweating
❖ Rapid heart rate or disturbances in the rhythm of
the heart rate
❖ Fetal distress, such as a slow heart rate, or other
fetal heart rate abnormalities
❖ Seizures
❖ Loss of consciousness
Management
Nursing Management:
• Admit the patient with amniotic fluid embolism
(AFE) into the intensive care unit (ICU).
Medical Management:
• Initiate cardiopulmonary resuscitation (CPR) if
the patient arrests. If she does not respond to
resuscitation, perform a perimortem cesarean
delivery.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Treat hypotension with crystalloid and blood
products. Use pressors as necessary.
• Avoid excessive fluid administration. During the
initial phase, right ventricular function is
suboptimal. Excess fluid may over distend the
Right ventricle which could increase the risk of a
right sided myocardial infarction.
Pharmacological Management
• Drugs are used in amniotic fluid embolism (AFE)
to stabilize the patient. Pressors are used to
maintain blood pressure, and inotropes are used
to improve contractility. Use of steroids has been
suggested because the process may be immune
mediated. Uterotonics may be used to limit
postpartum bleeding.
Surgical Management
• Perform emergent cesarean delivery in arrested
mothers who are unresponsive to resuscitation.
PRETERM LABOR
- Preterm labor happens when your cervix opens
after week 20 and before week 37 of pregnancy
due to consistent contractions. Premature birth
can be the outcome of preterm labor. The higher
the risk of your baby's health if he or she is born
prematurely. In the neonatal intensive care unit,
many premature babies (preemies) require
special attention. Preemies can suffer from long-
term mental and physical problems as well.
Etiology/Cause
- There are a number of reasons for preterm birth.
For no apparent reason, a woman may go into
labor early. There may be a medical reason for
early labor and delivery at other times. Like
premature rupture of membranes, bleeding
during pregnancy, and weak cervix.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
Preterm occurs when babies are born alive before 37
weeks of pregnancy. There are sub-categories of preterm
birth based on gestational age:
• Extremely preterm which is less than 28 weeks
• Very preterm is 28 to 32 weeks,
• Moderate to late preterm occurs between 32 to
37 weeks.
Signs and Symptoms
❖ Regular or frequent contractions
❖ Constant low, dull backache
❖ Pelvic or abdominal pressure
❖ Mild abdominal cramps
❖ Vaginal spotting
❖ Preterm rupture of membranes
❖ Watery, mucus-like or bloody vaginal discharge
Management
Nursing Management
• When tests reveal immature fetal lung
development, cervical dilatation is less than 4
cm, and there are no contraindications to
continuing the pregnancy, premature labor is
suppressed. For patients with preterm labor, the
nurse should keep a watchful eye out for
indicators of fetal or maternal discomfort and
give complete supportive care.
Medical Management
• Pelvic exam. Your health care provider might
evaluate the firmness and tenderness of your
uterus and the baby's size and position.
• Ultrasound. A transvaginal ultrasound might be
used to measure the length of your cervix. An
ultrasound might also be done to check for
problems with the baby or placenta, confirm the
baby's position, assess the volume of amniotic
fluid, and estimate the baby's weight.
• Uterine monitoring. Your health care provider
might use a uterine monitor to measure the
duration and spacing of your contractions.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Pharmacological Management
• Exogenous progesterone, corticosteroids, and
tocolytics (-adrenergic agonists, magnesium
sulfate, calcium channel blockers, prostaglandin
inhibitors, nitrates, and oxytocin receptor
blockers) this is to prolong pregnancy as safely as
possible to permit fetal development and
maturation
Surgical Management
• Cervical cerclage might be recommended if
you're less than 24 weeks pregnant, you have a
Nursing Management:
history of early premature birth, and an
ultrasound shows your cervix is opening or your
cervical length is less than 25 millimeters.
PREMATURE RUPTURE OF MEMBRANES
- Premature rupture of membranes (PROM) is the
rupture or breaking open of gestational
membranes that surrounds the baby, amniotic
sac, prior to the onset of labor. When the sac
ruptures, the pregnant woman has an increased
risk for infection and has a higher chance of
having the baby born prematurely.
Etiology/Cause
- There is a variety of mechanisms that cause
prelabor rupture of membranes. Rupture of the
membranes before the end of pregnancy (term)
can be caused by a physiologic weakening of the
membranes or from the force of contractions.
Some causes or risk factors may be infections of
the uterus, cervix, or vagina; too much stretching
of the amniotic sac which can happen if there is
too much fluid, or if there is more than one baby
putting pressure on the membranes; smoking; if
the mother has had cervix surgery or biopsies;
and if the mother was pregnant before and had
a PROM or PPROM.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
1. Preterm premature rupture of membranes
◼ Amniotic sac ruptures before 37 weeks of
pregnancy
2. Spontaneous rupture of membrane
◼ Rupture of membranes after or with the
onset of labor occurring prior to 37 weeks.
Management
❖ Leaking or a gush of watery fluid from the vagina
❖ Constant wetness in underwear
Management
• Prevent infection and other tissues from
occurring.
Using sterile speculum examination and
ferning determination, make an early
and accurate assessment of membrane
health. To avoid infection, restrict
vaginal inspections to be a bare
minimum after that.
Take smear samples from the vaginal
and rectum as directed to check for beta
hemolytic streptococci, a bacteria that
puts the fetus at risk.
Determine the status of the mother and
fetus, including the approximate
gestational age. Examine for indications
of infection on a regular basis.
If the fetal head is not engaged, keep the
client in bed. If there is another rupture
and fluid loss, this approach may avoid
cord prolapse. Ambulation can be
promoted once the fetal head is
engaged.
• Provide client and family education.
If the fetus is at term, tell the client that
the possibilities of spontaneous labor
starting are high; encourage the client
and partner to prepare for labor and
birth.
Explain the therapies that will likely be
required if labor does not start or if the
fetus is determined to be premature or
at risk of infection.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Fever, discomfort, an elevated fetal heart rate,
and/or laboratory testing are all indicators of
infection and should be monitored.
Medical Management
• Determine if the cervix is suitable for labor
induction.
If the patient’s cervix is in good shape,
there’s no need to wait. As a result,
intravenous oxytocin should be used to
induce labor as soon as feasible.
Pharmacological Management
• Give corticosteroids to the mother.
This might help the fetus’ lungs grow
since lung immaturity is a major problem
of premature babies. This medication,
on the hand, may hide a uterine
infection.
• Antibiotics
This is to avoid or treat infections.
• Tocolytics
These are medications that are used to
prevent premature labor.
Surgical Management
• If PPROM is stable, women with the condition
generally deliver at 34 weeks. Early delivery is
required if there is evidence of abruption,
chorioamnionitis, or fetal compromise.
MODULE 2M: INTRAPARTAL COMPLICATIONS
PROLAPSE OF THE UMBILICAL CORD
- The umbilical cord connects to the placenta. It
delivers nutrients and serves as the baby’s
lifeline to the mother. Prolapse of the umbilical
cord happens when the cord between the baby’s
body and pelvic bones are compacted, reducing
the baby’s blood supply. This occurrence will
hinder oxygen supply to the baby. This condition
occurs when the umbilical cord falls out between
the fetal presenting part and the cervix into the
vagina
Etiology/Cause
- Premature rupture of the membranes
◼ The most common cause of prolapse. When
the membranes rupture earlier than
expected or undergo an amniotomy
procedure, the baby’s head may be high up
in the uterus, allowing the umbilical cord to
fall out through the cervix.
- Fetal Presentation other than cephalic
- Placenta previa
- Intrauterine tumors preventing the presenting
part from engaging
- CPD preventing firm engagement
- Prematurity / A small fetus
◼ Premature infants are vulnerable to
malpresentation and they tend to be
smaller. (a higher volume of amniotic fluid in
relation to the baby’s size)
- Multiple gestation pregnancies (twins,triplets,
etc.)
◼ Upon exiting the mother’s womb, the baby
may possibly push the other baby’s cord out.
- Polyhydramnios
◼ Excessive amniotic fluid may push the cord
forcefully due to the pressure of the fluid
exiting the mother.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Types
Cord prolapse may be subdivided into three types the
following are:
1. Overt cord prolapse
◼ After the membranes are ruptured, the
umbilical cord descends through the cervix
into the vaginal canal.
2. Funic Presentation
◼ The loop of the umbilical cord lies between
the fetal presenting part and the still-intact
fetal membranes covering the cervical os.
3. Occult prolapse
◼ Occult cord prolapse results when the cord’s
location is alongside the presenting part, but
it cannot be detected by the examiner.
Signs and Symptoms
An umbilical cord prolapse may occur with no outward
physical signs on the mother and no fetal heart trace but
upon examination, an ill-fitting or unengaged presenting
part should alert one to the possibility of cord prolapse.
Another sign/symptom can be:
❖ Seeing/feeling the umbilical cord before the
baby is delivered. This is the most obvious sign of
a cord prolapse.
❖ Fetal distress from lack of oxygen.
❖ Prolonged fetal heart rate deceleration on the
fetal monitor.
Management
Nursing Management
• Inform the neonatal team for possible neonatal
resuscitation.
Medical Management
• Funic Decompression - Until delivery is possible,
relieving the pressure on the cord by elevation of
the fetal presenting part, is the cornerstone of
management in cord prolapse. It is done
manually by the medical provider through the
placement of their finger or hand in the vaginal
vault and gentle elevation of the presenting part
off the umbilical cord.
Pharmacologic Management
• Consider Tocolysis (e.g. terbutaline) - If delivery
is imminently unavailable, this treatment can
relax the uterus and stop contractions which can
relieve the pressure off the cord. It may also
allow sufficient time for transfer to a location
where delivery is feasible. This can be
particularly useful when there are fetal heart
rate abnormalities while preparing for a C-
section.
Surgical Management
• Lower Segment Cesarean Section (LSCS) -
Cesarean delivery, also known as “C-section”, is
a surgical procedure wherein a baby is delivered
by making an incision in the mother’s abdomen
and another in the mother’s uterus.

• Identify prolapsed cord and apply immediate

intervention.
• Assess fetal viability.
• Call for assistance.
• Change the patient’s position to trendelenburg
or modified sims position.
• Relieve pressure from cord.
• Prepare for emergency delivery or cesarean
birth.
• Administer oxygen by mask by 10-12 L/min.
• Fill maternal bladder with 500-700 cc NS
• Continuous fetal monitoring.

MODULE 2M: INTRAPARTAL COMPLICATIONS YUSON, DREA

NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
MULTIPLE GESTATION
- considered a complication of pregnancy because
a woman’s body must adjust to the effects of
more than one fetus. It begins with single ovum
and spermatozoon. In the process of fusion, or in
one of the first cell divisions , the zygote divides
into one of the first cell divisions , the zygote
divides into two identical individuals. Single -
ovum twins usually have one placenta , one
chorion, two amnions , and two umbilical cords.
Etiology/Cause
- The use of fertility drugs to induce ovulation
often causes more than egg to be released from
the ovaries and can result in twins, triplets , or
more.
- In vitro- fertilization (IVF) can lead to multiple
pregnancy if more than one embryo is
transferred to the uterus. Identical multiple also
may result if the fertilized egg splits after
transfer.
- Women older than age 35 are more likely to
release two or more eggs during a single
menstrual cycle than younger women. So older
women are more likely than younger women to
become pregnant with multiple.
Types
1. Fraternal twins
◼ ‘dizygotic’ twins referring two zygotes
(fertilized eggs)
◼ two separate eggs
◼ may look the same or different
◼ Same or different
◼ baby has its own placenta and amniotic sac.
2. Identical twins
◼ ‘monozygotic ‘ referring to one zygote (
fertilized egg)
◼ single fertilized egg is split in half
◼ each half (embryo) genetically identical
◼ Babies share same DNA means they may
share same characteristics
◼ share same placenta amniotic sac or they
may have their own placenta and amniotic
sac
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3. Triplets and ‘higher order multiples’ (HOMs)
◼ Triplets, quadruplets ,sextuplets or more can
be a combination both of identical and
fraternal multiples.
◼ example: triplets can be either fraternal (
trizygotic) forming from 3 individuals egg
that fertilized and implanted the uterus ; or
they can be identical , when one egg divides
into 3 embryos ; or they can be a
combination of both.
Signs and Symptoms
The following are the most common symptoms of
multiple pregnancy. However, each woman may
experience symptoms differently. Symptoms of multiple
pregnancy may include:
❖ Uterus is larger than expected for the dates in
pregnancy
❖ Increased morning sickness
❖ Increased appetite
❖ Breast tenderness than women who are
pregnant with a single fetus.
❖ Excessive weight gain, especially in early
pregnancy
❖ Fetal movement felt in different parts of
abdomen at same time
Management
Nursing Management:
• Advice the mother for frequent prenatal visits
this is to detect problems as early as
possible. The mothers’s nutritional
status and weight should also be
monitored
• Increase nutrition
Carrying two or more fetuses need more
calories,protein and other nutrients,
including iron. Higher weight gain is also
recommended for multiple pregnancy.
• Increase rest
Higher -order multiple pregnancies
often require bedrest starting in the
middle of the second trimester.
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Preventive bed rest has not been shown
to prevent preterm birth in multiple
pregnancy.
• Referrals
Referrals to a maternal -fetal medicine
specialist called a perinatologist , for
special testing or ultrasound
evaluations, and to coordinate care of
complications , may be necessary
Medical Management:
• Pregnancy blood testing
levels of human chorionic gonadotropin
(hCG) may be quite high with multiple
pregnancy
• Alpha-fetoprotein
levels of a protein released by the fetal
liver and found in the mother’s blood
may be high when more than one fetus
is making the protein
• Ultrasound
a diagnostic imaging technique that uses
high-frequent sound waves to create
images of blood vessels, tissues , and
organs. Ultrasound can be done with a
vaginal transducer, especially in early
pregnancy .
Pharmacologic Management:
• Tocolytic medications
May be given if preterm labor occurs, to
help slow or stop contractions of the
uterus . These may be given orally, in an
injection , or intravenously. Tocolytic
medications often used include
magnesium sulfate.
• Corticosteroid medications
a medication may be given to help
mature the lungs of the fetuses. Lung
immaturity is a major problem of
premature babies.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Surgical Management:
• Cervical cerclage
Cerclage ( a procedure used to suture
shut the cervical opening) is used for
women with an incompetent cervix. This
is a condition in which the cervix is
physically weak and unable to stay
closed during pregnancy . Some women
with higher - order multiple may require
cerclage in early pregnancy.
HYDRAMNIOS
- There is too much amniotic fluid around the baby
during pregnancy in this complication. It’s also
called polyhydramnios.
- It occurs when the excess fluid is more than
2,000 ml or an amniotic fluid index above 24 cm.
- It can cause fetal malpresentation because the
additional uterine space can allow the fetus to
turn to a transverse lie. It can also lead to
premature rupture of the membranes from the
increased pressure, leading to the additional
risks of infection, prolapsed cord, and preterm
birth.
Etiology/Cause
- Amniotic fluid is formed by a combination of the
amniotic membrane cells and from fetal urine. It
is swallowed, absorbed into the fetal
bloodstream through the intestinal membrane,
and then transmitted to the placenta. Although
polyhydramnios can occur separate from fetal
involvement, accumulation of amniotic fluid
suggests difficulty with the fetus's ability to
swallow or absorb or excessive urine production.
Inability to swallow occurs in anencephalic
infants with a tracheoesophageal fistula with
stenosis or intestinal obstruction (Bishop &
Ebach, 2015). Excessive urine output appears in
the fetuses of diabetic women (hyperglycemia in
the fetus causes increased urine production)
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Signs and Symptoms
❖ Rapid enlargement of the uterus.
❖ The overly distended uterus pushes up against
the diaphragm with extreme shortness of
breath.
❖ Lower extremity varicosities and hemorrhoids
because good venous return from the lower
extremities is blocked by extensive uterine
pressure.
❖ The increased amount of fluid will cause
increased weight gain.
Management
Nursing Management:
• Encourage bed rest
• Encourage high fibre diet
• Suggest a stool softener if diet alone is
ineffective
• Assess vital signs as well as edema in lower
extremities
Medical Management:
• Monitor fluid levels
• Remove excess amniotic fluid.
Pharmacologic Management:
• Administer Indomethacin- decreased
urinary output.
Surgical Management:
• Tocolysis -To slow or halt labor, suppression of
uterine contractions
• “Needling” of membranes - To allow slow
controlled release of fluids
• Amniocentesis -to reduce the volume of the
amniotic fluid
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OCCIPITO-POSTERIOR POSITION
- This term refers to the fact that the back of your
baby's skull (the occipital bone) is in the back (or
posterior) of your pelvis. You may also hear this
position referred to as "face-up" or "sunny-side
up."
- Occipitoposterior position is a delivery
presentation wheir, the baby's head is down, but
it is facing the mother's front instead of her back.
Etiology/Cause
- The occipitoposterior position in the main is
caused by the adaptation of the head to a pelvis
having a narrow fore pelvis and an ample
anteroposterior diameter and therefore may be
considered “physiologic.”
Types
1. Right Occipitoposterior
◼ In the right occiput posterior position (ROP),
the baby is facing forward and slightly to the
right (looking toward the mother's left
thigh). This presentation may slow labor and
cause more pain.
2. Left Occipitoposterior
The baby is facing forward and slightly to the left
(looking toward the mother's right thigh). This
fetal presentation can lead to more back pain
(sometimes referred to as "back labor") and slow
progression of labor.
3. Direct Occipitoposterior
◼ In direct occipito-posterior, the head can be
delivered by flexion supposing that the
uterine contractions are strong and there is
no contracted pelvis.
Signs and Symptoms
Symptoms:
❖ Back labor
❖ Prolonged labor
Signs:
❖ Abdominal examination
◼ The mother may complain of backache and
she may feel that her baby’s bottom is very
high up against her ribs.
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◼ Upon inspection: There is a saucer-shaped
depression at or just below the umbilicus.
This depression is created by the ‘dip’
between the head and the lower limbs of the
fetus.
◼ Upon palpation: While the breech is easily
palpated at the fundus, the back is difficult
to palpate as it is well out to the maternal
side, sometimes almost adjacent to the
maternal spine. Limbs can be felt on both
sides of the midline.
◼ Upon auscultation: The fetal back is not well
flexed so the chest is thrust forward,
therefore the fetal heart can be heard in the
midline. However, the heart may be heard
more easily at the flank on the same side as
the back.
❖ Vaginal examination
◼ The findings will depend upon the degree of
flexion of the head; locating the anterior
fontanelle in the anterior part of the pelvis is
diagnostic. The direction of the sagittal
suture and location of the posterior
fontanelle will help to confirm the diagnosis.
Management
Nursing Management:
• Apply counterpressure by a back rub to relieve
mother’s back pain.
• During a long labor, be certain that the mother
voids approximately every 2 hours to keep her
bladder empty.
• REBOZO method of jiggling and massaging the
uterus.
• Provide frequent assurance and support when
the mother is getting worried during prolonged
labor.
Medical Management:
• Manual rotation during vaginal exam.
o Flex fetal head
➢ Place hand in posterior pelvis
behind occiput
➢ Wedge head into flexion
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o Rotate head
➢ Perform during contraction with
mother pushing
➢ OP: Examiner pronates
dominant hand on exam
➢ ROP: Examiner pronates left
hand clockwise
➢ LOP: Examiner pronates right
hand counter clockwise
Pharmacologic Management
• Administer narcotic or sedative
• Administer antibiotic
Surgical Management
• Cesarean section
• Vacuum delivery
• Forceps delivery
FACE, BREECH, BROW PRESENTATION
Face Presentation
- In a face presentation, the fetal head and neck
are hyperextended, causing the occiput to come
in contact with the upper back of the fetus while
lying in a longitudinal axis. The presenting
portion of the fetus is the fetal face between the
orbital ridges and the chin.
Breech Presentation
- In a breech presentation, the baby’s feet or
buttocks are positioned to come out of the
vagina first. The baby’s head is up closest to the
chest of the mother and its bottom is closest to
the vagina.
Brow presentation
- One of many abnormal positions that can lead to
labor and delivery complications and subsequent
birth injuries. A fetus in brow presentation has
the chin untucked, and the neck is extended
slightly backward. It is similar to face
presentation, except the neck is less extended.
As the term “brow presentation” suggests, the
brow (forehead) is the part that is situated to go
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through the pelvis first. Vaginal delivery can be Signs and Symptoms
difficult or impossible with brow presentation, Breech Presentation
because the diameter of the presenting part of
❖ Fetal heartbeat primarily above the umbilicus
the head may be too big to safely fit through the
❖ Head ballotable in the fundal area
pelvis.
❖ Softer irregular mass in the pelvis
Etiology/Cause ❖ Subcostal tenderness
There are many different reasons why a baby may
Face Presentation
present brow-first, face-first or breech-first. It could be
due to: ❖ deflexed/ hyperextended neck
❖ Soft tissue with an orifice
- if a woman has had several pregnancies
❖ Facial features of the chin, mouth nose, and
- if a woman has had a premature birth in the past
cheekbones can be felt
- if the uterus has too much or too little amniotic
fluid, meaning the baby has extra room to move Brow Presentation
around in or not enough fluid to move around in
- if the woman has an abnormally shaped uterus ❖ Chin is untucked
or has other complications, such as fibroids in ❖ Neck extended slightly backward
the uterus Management
- if a woman has placenta previa Nursing Management:
- Fetal Macrosomia (large baby)
- Cephalopelvic disproportion, or CPD(a mismatch • FHR Monitoring
in size between the mother’s pelvis and the • Examine patient and document of a partograph
baby’s head) • Examine the patient to exclude cord prolapse in
- Multiple nuchal cords (umbilical cord wrapped the event of membrane rupture.
around baby’s neck more than once)
Medical Management:
- Multiparity (the mother has previously given
birth) • ECV may be offered to the patient if there are no
- Maternal obesity contraindications.
• Inform the patient ECV may risk complications of
Types
future pregnancies.
Types of breech presentation
• Inform the patient of less complications with a
1. Frank breech: successful vaginal birth.
◼ The baby’s buttocks are aimed at the vaginal
Pharmacologic Management:
canal with its legs sticking straight up in front
of their body and the feet near their head. • Terbutaline may be used to prevent uterine
2. Complete breech contractions and relax the uterus if need be.
◼ The baby’s buttocks are pointing downward
and both the hips and the knees are flexed Surgical Management:
(folded under themselves). • Emergency C-sections are performed when the
3. Footling breech: baby or mother are at risk.
◼ One or both of the baby’s feet point
downward and will deliver before the rest of
their body.

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TRANSVERSE LIE
- A transverse lie position in pregnancy means that
the baby is horizontal in your belly. The position
of the baby becomes an issue as your due date
approaches. The optimal position for vaginal
delivery is the head down or vertex position.
Etiology/Cause
Some of the more common reasons why a baby may be
in the transverse lie position include the following:
- Abnormality of the uterus
- Having a cyst or fibroid blocking your cervix
- Pelvic structure
- Polyhydramnios (too much amniotic fluid) or low
fluid levels
- Position of the placenta
- Second (or more) pregnancy
- Twin or multiple pregnancy
Signs and Symptoms
❖ Abdominal examination— In transverse position,
the presenting part of the fetus is typically the
shoulder. During abdominal examination, the
head or the buttocks cannot be felt at the
bottom of the uterus and the head is usually felt
in the side.
❖ Vaginal examination— A shoulder may be felt
during a vaginal examination. An arm of the fetus
may even slip forward and the hand or elbow
may be felt during pelvic examination.
❖ Confirmation - An ultrasound scan of the uterus
confirms the transverse lie position.
Management
Nursing Management:
• Adequate prenatal care to diagnose the case
antenatally.
• Develop a delivery plan.
Medical Management:
• Manually rotate the fetus into a head-first
presentation.
• Pushing on the mother’s abdomen to roll the
fetus.
MODULE 2M: INTRAPARTAL COMPLICATIONS
• Reaching into the mother’s uterus to move the
fetus.
Pharmacologic Management:
• If it is needed to do internal and external
versions, medications are also involved.
Surgical Management:
• The medical team may also perform an
amniotomy in order to induce labor after turning
the baby.
• If the version is unsuccessful, a C-section may be
necessary
MACROSOMIA
- Macrosomia is used to describe a newborn who's
much larger than average or has an excessive
birth weight. A baby who is diagnosed as having
fetal macrosomia weighs more than 8 pounds,
13 ounces (4,000 grams), regardless of his or her
gestational age.
- An accurate diagnosis of fetal macrosomia can
be made only by measuring birth weight after
delivery; therefore, the condition is confirmed
only retrospectively, ie, after delivery of the
neonate.
Etiology/Cause
- Having a family history of fetal macrosomia.
- Excessive weight gain during pregnancy.
- Obesity during pregnancy.
- Multiple pregnancies.
- A pregnancy lasting more than 40 weeks.
- A mother with an above-average height and
weight.
- Maternal diabetes
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Signs and Symptoms
During pregnancy, fetal macrosomia can be difficult to
detect and diagnose. Among the signs and symptoms
are:
❖ Large Fundal Height
◼ A larger-than-expected fundal height may
indicate fetal macrosomia.
❖ Excessive amniotic fluid (polyhydramnios)
◼ The amount of amniotic fluid in a baby
reflects his or her urine output, and a larger
baby produces more urine.
Management
Nursing Management:
• Antenatally, intervention is aimed at identifying
and preventing macrosomia and sudden fetal
death.
• Intrapartally, screening and monitoring are used
to identify cephalopelvic disproportion and
shoulder dystocia in order to avoid birth trauma
and fetal asphyxia.
• A thorough assessment should be performed
during the neonatal period to identify
respiratory distress, birth trauma, problems with
metabolic transition, and congenital anomalies.
Medical Management
• The doctor may advise to have the baby
delivered via C-section.
Pharmacologic Management
• Prescriptions for diabetes medications are
provided.
• Blood sugar levels should be checked three times
per day, or as directed.
Surgical Management
• Elective cesarean section for women whose
pregnancies are complicated by macrosomia if
the estimated fetal weight is greater than 5000 g
without underlying glucose intolerance or 4500
g with underlying glucose intolerance.
• In women with macrosomic pregnancies,
assisted vaginal delivery, such as forceps or
MODULE 2M: INTRAPARTAL COMPLICATIONS
vacuum-assisted deliveries, should be
performed with extreme caution.
SHOULDER DYSTOCIA
- Shoulder dystocia is a birth injury (also called
birth trauma) is an obstetric complication of
cephalic vaginal deliveries during which the fetal
shoulders do not deliver after the head has
emerged from the mother’s introitus. It occurs
when one or both shoulders become impacted
against the bones of the maternal pelvis.
Etiology/Cause
- Fetal macrosomia: (Your baby weighs more than
8 pounds, 13 ounces.)
- Your baby is in the wrong position.
- Your pelvic opening is too small.
- You are in a position that limits the room in your
pelvis.
- Being overweight
- Deliveries past due date
Signs and Symptoms
❖ Signs include retraction of the baby's head back
into the vagina, known as "turtle sign" which
involves the appearance and retraction of the
baby's head, and a red puffy face . Shoulder
dystocia is not identified until the head has
already been born and the wide anterior
shoulder locks beneath the symphysis pubis.
Management
Nursing Management
• Assess maternal vital signs, including
temperature, pulse, respiratory rates, and blood
pressure.
• Assess the condition of the fetus by monitoring
FHR, fetal activity, and color of amniotic fluid.
• Assess the condition of the fetus by monitoring
FHR, fetal activity, and color of amniotic fluid,
and coach the client in breathing and relaxation
techniques.
Medical Management
• Assist the and ask the client to flex her thighs
sharply on her abdomen to perform McRoberts
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Maneuver to widen the pelvic outlet and allow Management
the anterior shoulder to be born. Nursing Management:
• Apply Suprapubic pressure to help the shoulder
• Identify and treat abnormal uterine pattern
escape from beneath the symphysis pubis and be
• Monitor maternal/fet al physical response to
born.
contractile pattern
• Perform further maneuvers such as the internal
• observe the length of labor
maneuvers.
• Provide emotional support for the client and
Pharmacologic Management prevent complication s.
• Note signs of fetal distress, cessation of
• The client may be given medicines to reduce
contractions, presence of vaginal bleeding.
your pain or to prevent or treat a bacterial
• Assist with preparation for cesarean delivery, as
infection. She may also need treatment to stop
indicated.
severe bleeding.
Medical Management:
Surgical Management
• Treatment is often multimodal, and includes
• When the labor is very long, and medical
dietary changes, pelvic floor physical therapy or
management is not progressing as it should, or
biofeedback, and ultrasound-guided botulinum
causing complications for the mother or the
injection.
baby, an emergency C-section is performed in
order to deliver the baby safely. A Pharmacologic Management:
symphysiotomy is performed as an alternative to
an emergency C-section. Symphysiotomy is the • Administration of narcotic or sedative, such as
artificial division and separation of the pubic morphine, pentobarbital (Nembutal), or
symphysis in order to facilitate vaginal delivery. secobarbital (Seconal), for sleep as indicated.

Surgical Management:
INLET CONTRACTION
- Inlet contraction is the narrowing of the • Surgery is generally reserved for refractory
anteroposterior diameter of the pelvis to less cases.
than 11 cm, or of the transverse diameter to 12
cm or less.

Etiology/Cause
- Inlet Contraction is usually caused by rickets in
early life or by an inherited small pelvis. Rickets
is caused by a lack of calcium and is therefore
rare in developed countries but can occur among
immigrants who were raised where milk supplies
were not plentiful.

Signs and Symptoms

❖ Anteroposterior diameter is less than 11 cm
❖ Transverse diameter is to 12 cm or less
❖ Diagonal Conjugate is less than 11.5 cm
❖ If there is no engagement in primigravidas, then
either a fetal abnormality or a pelvic abnormality
should be suspected

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OUTLET CONTRACTION
- The pelvic outlet is composed of two triangular
areas that share the same base but are not in the
same plane. The anterior triangle is formed by
the pubic arch. The apex of the posterior triangle
is the tip of the sacrum, and the sides are the
sacral sciatic ligaments and ischial tuberosities.
The anteroposterior diameter, from the inferior
edge of the pubic symphysis to the tip of the
sacrum, usually measures approximately 11.5
cm. The transverse diameter, the distance
between the inner edges of the ischial
tuberosities, measures approximately 10 cm.
Etiology/Cause
Causes in the pelvis
• Developmental (congenital):
◼ Small gynaecoid pelvis (generally contracted
pelvis).
◼ Small android pelvis.
◼ Small anthropoid pelvis.
◼ Small platypelloid pelvis (simple flat pelvis).
◼ Naegele’s pelvis: absence of one sacral ala.
◼ Robert’s pelvis: absence of both sacral alae.
◼ High assimilation pelvis: The sacrum is
composed of 6 vertebrae.
◼ Low assimilation pelvis: The sacrum is
composed of 4 vertebrae.
◼ Split pelvis: splitted symphysis pubis
• Metabolic:
◼ Rickets.
◼ Osteomalacia (triradiate pelvic brim).
◼ Traumatic: as fractures.
◼ Neoplastic: as osteoma.
Causes in the spine
- Lumbar kyphosis.
- Lumbar scoliosis.
- Spondylolisthesis: The 5th lumbar vertebra with
the above vertebral column is pushed forward
while the promontory is pushed backwards and
the tip of the sacrum is pushed forwards leading
to outlet contraction.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Causes in the lower limbs
- Dislocation of one or both femurs.
- Atrophy of one or both lower limbs.
Signs and Symptoms
❖ inter ischial tuberous diameter is 8 cm or less
❖ Arresting of the head in the pelvic inlet
❖ Uterine contractions abnormality.
❖ Signs of urinary bladder compression.
❖ Edema of the cervix, and vaginal walls,
productions of fistulas.
❖ Pushing occurs in the location of the fetal head
in the inlet
Management
Nursing Management:
• Review the history of labor, onset, and duration.
• Obtain baseline lab investigations.
• Assess uterine contractile pattern manually
(palpation) or electronically, depending on the
availability.
• Evaluate the current level of maternal
fatigue/emotional stress.
• Observe any signs of infection.
• Monitor vitals.
• Evaluate the degree of hydration. Note down the
quantity and type of intake.
• Place the client in a lateral recumbent position
and encourage bed rest or sitting
position/ambulation, as tolerated.
• Note signs of fetal distress, cessation of uterine
contractions, and presence of vaginal bleeding.
• Alert the obstetrician of any warning signs.
Medical Management:
• Therapeutic rest and analgesia may be provided
during a prolonged first stage of labor.
Pharmacologic Management:
• Administration of oxytocin.
• Administer narcotic or sedative, as indicated
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Surgical Management:
• In the case of maternal/fetal compromise,
immediate intraoperative delivery is indicated.
SUCCENTURIATE PLACENTA
- A succenturiate placenta is a condition
characterized by the development of one or
more accessory lobes in the membranes that are
separate from the main placental body and are
usually connected by vessels of fetal origin. It is
a smaller variant of a bilobed placenta. Only the
communicating membranes support the vessels.
- A placenta succenturiata (Fig. 23.13A) is a
placenta that has one or more accessory lobes
connected to the main placenta by blood vessels.
No fetal abnormality is associated with this type.
However, it is important it be recognized
because the small lobes may be retained in the
uterus after birth, leading to severe maternal
hemorrhage. On inspection, the placenta
appears torn at the edge, or torn blood vessels
extend beyond the edge of the placenta. If the
remaining lobes are recognized and removed
from the uterus manually, the uterus will
contract as usual with no adverse maternal
effects.
Etiology/Cause
Factors that leads to succenturiate placentas are the
following:
- Advanced maternal age
- In vitro fertilization (IVF)
- Implantation over leiomyomas, in areas of
previous surgery, in the cornu, or over the
cervical os.
Signs and Symptoms
Signs
❖ Hemorrhage from vessels from vessels attaching
main placental mass to succenturiate lobe
❖ Velamentous attachment
❖ Retained products
Symptoms
❖ Vaginal Bleeding
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Management
Nursing Management:
• Assist the patient in a side lying position when
she starts to bleed.
• Monitor baseline vital signs especially the blood
pressure, and the uterine contractions to
manage the labor of the patient.
Medical Management:
• Intravenous treatment
The use of intravenous treatment to
inject blood into the mother's
bloodstream is encouraged in order to
assist her recover from her bleeding.
Performing vaginal examinations is not
recommended since they might result in
bleeding, which is dangerous to both the
mother and the baby.
Pharmacologic Management:
• The patient must be administered a
corticosteroid for the development of the fetus’
lungs.
Surgical Management:
• Cesarean Section
Because of its risk factors, such as pelvic
infection and preeclampsia , a centuriate
placenta raises the likelihood of a
cesarean delivery for a patient.
CIRCUMVALLATE PLACENTA
- A circumvallate placenta is a rare condition that
occurs when the amnion and chorion fetal
membranes of the placenta fold backward
around the edges of the placenta. It is an
abnormality in the shape of the placenta where
the chorionic plate, which is the part of the
placenta that’s on the fetal side, is smaller than
the basal plate, resulting in hematoma retention
in the placental margin.
- Ordinarily, the chorion membrane begins at the
edge of the placenta and spreads to envelop the
fetus; no chorion covers the fetal side of the
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placenta. In placenta circumvallata, the fetal side
of the placenta is covered to some extent with
chorion (Fig. 23.13B). The umbilical cord enters
the placenta at the usual midpoint, and large
vessels spread out from there. However, they
end abruptly at the point where the chorion
folds back onto the surface. (In placenta
marginata, the fold of chorion reaches just to the
edge of the placenta.) Although no abnormalities
are associated with this type of placenta, its
presence should be noted.
Etiology/Cause
The exact cause of Circumvallate placenta is still
unknown, however it is associated with the following:
- Poor pregnancy outcomes due to increased risk
of vaginal bleeding beginning in the first
trimester
- Premature rupture of the membranes (PROM)
- Preterm delivery
- Placental insufficiency
- Placental abruption
Signs and Symptoms
A circumvallate placenta does not always cause
symptoms during pregnancy. However, a doctor may be
able to notice some signs that a woman has a
circumvallate placenta. These signs may include:
❖ Vaginal bleeding
◼ A circumvallate placenta leads to a higher
chance of persistent vaginal bleeding during
the first trimester.
◼ It is found that the incidence of vaginal
bleeding was higher in these women than in
those in the control group during all three
trimesters
Management
Nursing Management:
• Assessing the fetal heart sounds to monitor the
wellbeing of the fetus and advise the mother to
improve her lifestyle such as eating a balanced
diet, taking in nutrient supplements, and getting
plenty of rest to give both herself and the fetus
sufficient.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Medical Management:
Ultrasound
• One of the main concerns of a circumvallate
placenta is the decreased birth weight of the
baby. Therefore, to help monitor this, the doctor
may recommend checking the growth of the
baby using ultrasound.
• If the fetus is not growing fast enough, the
doctor may recommend early delivery. A vaginal
delivery will usually be possible, but a cesarean
section might be the best option if the baby is
not tolerating labor.
• In order to treat oligohydramnios from a
circumvallate placenta, the doctor may conduct
a procedure known as Amnioinfusion, in which
the amniotic sac is replaced with other fluid. This
reduces the risk of umbilical cord shrinking and
underdevelopment of the fetus’ body organs.
Pharmacologic Management:
• There is no treatment for a circumvallate
placenta, and doctors often do not diagnose it
until after the birth.
Surgical Management:
Emergency Cesarean Section
• If there is severe blood loss and placental
abruption as a result of circumvallate placenta,
an emergency C-section might be conducted in
order to save the life of both mother and the
baby.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
PLACENTA ACCRETA
- Placenta accreta, a dangerous pregnancy illness,
occurs when the placenta grows too far into the
uterine wall. The placenta usually separates from
the uterine wall after childbirth. In placenta
accreta, part or all of the placenta stays
attached. This can result in a lot of blood loss
after birth. Placenta accreta is considered a high-
risk pregnancy complication. If the condition is
diagnosed during pregnancy, you'll likely need an
early C-section delivery followed by the surgical
removal of your uterus (hysterectomy).
- Placenta accreta is an unusually deep
attachment of the placenta to the uterine
myometrium, so deep that the placenta will not
loosen and deliver (Silver, 2015). Attempts to
remove it manually may lead to extreme
hemorrhage because of the deep attachment.
Hysterectomy to remove the uterus or
treatment with methotrexate to destroy the still-
attached tissue may be necessary.
Etiology/Cause
Placenta accreta is thought to be caused by scarring or
other abnormalities with the lining of the uterus. Several
risk factors have been linked to placenta accreta,
including:
- Multiple cesarean sections (c sections)
◼ Women who have had multiple cesarean
sections have a higher risk of developing
placenta accreta. This results from scarring
of the uterus from the procedures. The more
cesarean sections a woman has over time,
the higher her risk of placenta accreta.
- Placenta previa
◼ This condition occurs when the placenta is
located at the bottom of the uterus, blocking
the opening of the cervix. The lower part of
the uterus is less suited for the placenta to
implant. In patients with placenta previa and
a history of prior cesarean section(s), the risk
for placenta accreta increases with the
number of cesarean sections the patient has
had.
MODULE 2M: INTRAPARTAL COMPLICATIONS
- History of fibroid removal
◼ If the woman has had a fibroid (a non-
cancerous growth or tumor of the uterine
muscle) removed, the scarring could lead to
placenta accreta.
Types
There are three types of this condition. The type is
determined by how deeply the placenta is attached to
the uterus.
1. Placenta accreta
◼ The placenta firmly attaches to the wall of
the uterus. It does not pass through the wall
of the uterus or impact the muscles of the
uterus. This is the most common type of the
condition.
2. Placenta increta
◼ This type of the condition sees the placenta
more deeply imbedded in the wall of the
uterus. It still does not pass through the wall,
but is firmly attached to the muscle of the
uterus.
3. Placenta percreta
◼ The most severe of the types, placenta
percreta happens when the placenta passes
through the wall of the uterus. The placenta
might grow through the uterus and impact
other organs, such as the bladder or
intestines.
Signs and Symptoms
❖ There are often no signs or symptoms of
placenta accreta during pregnancy. In some
cases, though, bright red vaginal bleeding
without pain during the third trimester or a little
earlier could be a sign.
❖ This type of bleeding may also be a sign of
placenta previa, which is when the placenta lies
low in the uterus and covers all or part of the
cervix. Occasionally, placenta accreta is detected
during a routine ultrasound. Speak to your
healthcare provider right away if you notice any
vaginal bleeding during your pregnancy.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Management
Nursing Management:
• Assess baseline vital signs especially the blood
pressure. The physician would order monitoring
of the blood pressure every 5-15 minutes.
• Assess fetal heart sounds to monitor the
wellbeing of the fetus.
• Monitor uterine contractions to establish the
progress of labor of the mother.
• Weigh perineal pads used during bleeding to
calculate the amount of blood lost.
• Assist the woman in a side lying position when
bleeding occurs.
Medical Management:
• Intravenous therapy. This would be prescribed
by the physician to replace the blood that was
lost during bleeding.
• Avoid vaginal examinations. This may initiate
hemorrhage that is fatal for both the mother and
the baby.
• Attach external monitoring equipment. To
monitor the uterine contractions and record
fetal heart sounds, an external equipment is
preferred than the internal monitoring
equipment.
• Ultrasound. Early detection of placenta previa is
always possible through ultrasonography. It is
the most common and initial diagnostic test that
could confirm the diagnosis.
Surgical Management:
• Cesarean delivery. Although the best way to
deliver a baby is through normal delivery, if the
placenta has obstructed more than 30% of the
cervical os it would be hard for the fetus to get
past the placenta through normal delivery.
Cesarean birth is then recommended by the
physician.
MODULE 2M: INTRAPARTAL COMPLICATIONS
BATTLEDORE PLACENTA
- Battledore placenta (Marginal cord insertion) is a
condition in which the umbilical cord is inserted
at or near the placental margin rather than in the
center. The cord can be inserted as close to 2 cm
from the edge of the placenta (velamentous cord
insertion).
- In a battledore placenta, the cord is inserted
marginally rather than centrally This anomaly is
rare and has no known clinical significance
either.
Etiology/Cause
- The incidence is 7% to 9% of singleton
pregnancies and 24% to 33% in twin
pregnancies. Complications associated with
battledore placenta are preterm labor, fetal
distress, and intrauterine growth restriction.
Signs and Symptoms
This condition rarely causes complications in singleton
gestations prior to the 3rd stage of labor, during which,
the marginal cord insertion can be avulsed during
placental delivery . In monochorionic twin gestations, a
marginal cord insertion may lead to unequal sharing of
the placental mass and therefore lead to discordant fetal
weight.
Associated with:
❖ Fetal Distress
❖ IUGR
❖ Preterm Labor
❖ Reduction Birth Weight
Management
Nursing Management:
• Assess and monitor vital signs of the patient.
• Brief the patient with ultrasound procedure and
preparation is done.
• Ensuring the pregnant is well-hydrated and has
adequate oxygen for fetal distress.
Medical Management:
• Ultrasonography and should include placental
cord insertion site and transvaginal ultrasound
may be considered in with marginal insertion of
YUSON, DREA
NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
the cord or otherwise known as battledore
placenta.
• Tocolysis is done to delay preterm labor by
temporarily stopping contractions.
Surgical Management:
• Perform Cesarean hysterectomy. Performing
hysterectomy minimizes the risk of hemorrhage
which is also the safest option for the mother ,
however, this involves the complete removal of
the uterus. Hence, it is crucial to discuss this
procedure with the patient.
VASA PREVIA
- In Vasa previa, the umbilical vessels of a
velamentous cord insertion cross the cervical os
and therefore deliver before the fetus. These
vessels are at risk of rupture during cervical
dilation and may cause serious complications to
the fetus. However, prenatal diagnosis of this
condition can allow the safe birth of the newborn
and avoid fetal blood loss.
- In vasa previa, the umbilical vessels of a
velamentous cord insertion cross the cervical os
and therefore deliver before the fetus (Suzuki &
Kato, 2015). The vessels may tear with cervical
dilatation, just as a placenta previa may tear.
Before inserting any instrument such as an
internal fetal monitor, be certain to identify
structures to prevent accidental tearing of a vasa
previa because tearing would result in sudden
fetal blood loss. If sudden, painless bleeding
occurs with the beginning of cervical dilatation,
either placenta previa or vasa previa is
suspected. It can be confirmed by ultrasound. If
vasa previa is identified, the infant needs to be
born by cesarean birth.
Etiology/Cause
There are two main causes of vasa previa:
- Velamentous cord insertion - where the cord
inserts directly into the membranes, leaving
unprotected vessels running to the placenta
- Bilobate placentas - vessels crossing between
lobes of the placenta such as in succenturiate
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
There are three types of Vasa Previa, namely:
1. Type 1 Vasa Previa
◼ this is a type of Vasa Previa where there is a
single placental lobe with velamentous cord
insertion.
2. Type 2 Vasa Previa
this is a type of Vasa Previa where in which the
vessels traversing the cervix are connected
between the lobes of a multilobed placenta
3. Type 3 Vasa Previa
◼ this is a type of Vasa Previa where fetal
vessels follow a boomerang orbit, without
velamentous cord insertion or
bilobed/accessory placenta.
Signs and Symptoms
The classic signs and symptoms of Vasa Previa are the
following:
❖ Painless vaginal bleeding
❖ Rupture of membranes
❖ Fetal bradycardia
Management
Nursing Management:
• Assess fetal heart sounds so the mother would
be aware of the health of her baby.
• Allow the mother to vent out her feelings to
lessen her emotional stress.
• Assess any bleeding or spotting that might occur
to give adequate measures.
• Answer the mother’s questions honestly to
establish a trusting environment.
• Include the mother in the planning of the care
plan for both the mother and the baby.
Medical Management:
• Intravenous therapy. This would be prescribed
by the physician to replace the blood that was
lost during bleeding.
• Avoid vaginal examinations. This may initiate
hemorrhage that is fatal for both the mother and
the baby.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Attach external monitoring equipment. To
monitor the uterine contractions and record
fetal heart sounds, an external equipment is
preferred than the internal monitoring
equipment.
Pharmacologic Management:
• Corticosteroids- for the maturity of the baby’s
lungs
Surgical Management:
• Cesarean delivery. Although the best way to
deliver a baby is through normal delivery, if the
placenta has obstructed more than 30% of the
cervical os it would be hard for the fetus to get
past the placenta through normal delivery.
Cesarean birth is then recommended by the
physician.
TWO VESSEL CORD
- A normal cord contains one vein and two
arteries. The absence of one is also known as
Single Umbilical artery and is associated with
congenital heart and kidney anomalies.
Physicians usually identify a two-vessel cord
during a prenatal ultrasound.
- A normal cord contains one vein and two
arteries. The absence of one of the umbilical
arteries is associated with congenital heart and
kidney anomalies because the insult that caused
the loss of the vessel may have also affected
other mesoderm germ layer structures.
Inspection of the cord as to how many vessels
are present must be made immediately after
birth, before the cord begins to dry, because
drying distorts the appearance of the vessels.
Document the number of vessels conscientiously
because an infant with only two vessels needs to
be observed carefully for other anomalies during
the newborn period.
Etiology/Cause
The patient is thought to be more at risk if she is:
- Caucasian
- Over the age of 40
- Carrying more than one baby (Multiple
Pregnancy)
- Diabetic
- High blood pressure
Management
Nursing Management:
• Immediate inspection of the cord as to how
many vessels are present must be performed
after birth before the cord starts to dry.
• Obtain personal medical history
• Obtain family medical history
• Monitor vital signs
• Assist patient during tests
• Observe carefully for other anomalies during the
newborn period
Medical Management:
• Doctors can identify a two-vessel cord during a
prenatal ultrasound.
• The doctor may instruct the mother to go
amniocentesis.
• Fetal echocardiogram (viewing the chambers
and workings of the fetal heart)
• Screening for genetic abnormalities in
pregnancy, like an aneuploidy screening
• Karyotyping
Pharmacologic Management:
• Avoid medications such as Phenytoin because it
can affect fetal growth which can be harmful to
the growing fetus inside the womb.
Surgical Management:
• Normal Spontaneous Vaginal Delivery
• Cesarean delivery

MODULE 2M: INTRAPARTAL COMPLICATIONS YUSON, DREA

NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
UNUSUAL CORD LENGTH
- The cord may be too long or too short. Length
rarely varies. Short cord can result in premature
separation from the placenta or an abnormal
fetal lie. A long cord may be easily compromised
because of its tendency to twist or knot.
- Although the length of the umbilical cord rarely
varies, some abnormal lengths may occur. An
unusually short umbilical cord can result in
premature separation of the placenta or an
abnormal fetal lie. An unusually long cord may be
easily compromised because of its tendency to
twist or knot. Occasionally, a cord actually forms
a knot, but the natural pulsations of the blood
through the vessels and the muscular vessel
walls usually keep the blood flow adequate. It is
not unusual for a cord to wrap once around the
fetal neck (nuchal cord) but, again, with no
interference to fetal circulation
Etiology/Cause
- Short umbilical cord is caused by the premature
separation of placenta and abnormal fetal lie.
While the exact cause of the long umbilical cord
is unknown. Studies have indicated that a long
cord is more common with single pregnancies
than multiple pregnancies (such as twins and
triplets)
Types
1. Short umbilical cord
◼ A short umbilical cord is usually defined as an
umbilical cord that measures less than 35 cm
in length. Excessively short cords have been
associated with a delay in the second stage
of labor, irregular fetal heart rate, placental
abruption, rupture of the umbilical cord,
inversion of the uterus, and cord herniation.
2. Long umbilical cord
◼ Long cords have alternatively been defined
as umbilical cords longer than 70 cm and 100
cm. Excessively long umbilical cords are
associated with cord prolapse, torsion, true
knot entanglement around the fetus, and
delivery complications.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Signs and Symptoms
Short Umbilical Cord
❖ Decreased blood flow to the fetus
❖ Nonreassuring fetal heart rate
Long Umbilical Cord
❖ Obstruction of blood flow
❖ Compression of the umbilical cord
❖ Fetal distress
❖ Decreased fetal heart rate
Management
Nursing Management:
• Establish rapport with patient
• Obtain patient health history and lifestyle
patterns (such as alcohol consumption or
smoking)
• Monitor baseline vital signs
• Monitor fetal heart rate
• Provide health teaching that left side lying
position is the most ideal when lying down
Medical Management:
• Physicians would request a routine ultrasound in
order to determine umbilical cord abnormalities.
• Prenatal tests such as biophysical or non-stress
test
• Continuous monitoring of the mother
Pharmacologic Management:
• Oxygen therapy in cases of umbilical cord
prolapse which is associated to long umbilical
cord
Surgical Management:
• Cesarean Delivery may be indicated
• Normal Spontaneous Vaginal Delivery
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
SUBINVOLUTION OF THE UTERUS • Assist the client and family to deal with physical
- Subinvolution is the delayed return of the and emotional stresses of postpartum
enlarged uterus to normal size and function. complications

Etiology/Cause Medical Management:

Subinvolution results from retained placental fragments • Methods for treating patients with subinvolution
and membranes, endometritis, or uterine fibroid tumor; of the placental site include conservative
treatment depends on the cause. The most common medical therapy (a type of medical treatment
causes of subinvolution of the uterus are the following: defined by the avoidance of invasive measures
- grand multiparity such as surgery or other invasive procedures,
- overdistension of uterus as in twins and usually with the intent to preserve function or
hydramnios body parts) and fertility-sparing percutaneous
- ill maternal health embolotherapy (the use of any type of embolic
- caesarean section material (autologous thrombus, muscle
- uterine prolapse fragment, or foreign body for therapeutic
- uterine fibroid occlusion of a blood vessel).
- Persistent lochia/fresh bleeding Pharmacologic Therapy:
- Long labor
- Precipitate labor Administer Medications to contract the uterus a
- anesthesia
• Oxytocin
- full bladder
• Methylergonovine
- difficult delivery
• Carboprost Tromethamine
- retained placenta
- maternal infection/uterine sepsis Surgical Management:

Signs and Symptoms • Hysterectomy (the removal of the uterus) is one

The following features are indicative of Subinvolution of of the surgical treatments for subinvolution.
uterus: Dilation and Curettage (D & C) is also
recommended to manually remove retained
❖ irregular cramps
placental tissues that may have caused the
❖ abnormal lochial discharge
complication.
❖ excessive uterine bleeding It is possible that
Subinvolution of uterus shows no physical UTERINE ATONY
symptoms and still is present in a patient.
- Atony of the uterus, also called uterine atony, is
Management a serious condition that can occur after
Nursing Management: childbirth. It occurs when the uterus fails to
contract after the delivery of the baby, and it can
• Prevent excessive blood loss, infection, and lead to a potentially life-threatening condition
other complications. known as postpartum hemorrhage. After
Massage uterus, facilitating voiding, and delivery, the uterine muscles of the myometrium
reporting blood loss. usually continue to contract in order to halt
Monitor the blood pressure and pulse bleeding from the spiral arteries, which supply
rate the endometrium with blood. These uterine
Administer prescribed medications. contractions mechanically reduce the blood flow
Be prepared for possible D&C. and consequently increase the likelihood of

MODULE 3M: POSTNATAL COMPLICATIONS YUSON,DREA

NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
coagulation, or blood clotting, which can help
prevent postpartum hemorrhage (i.e., heavy
bleeding after giving birth). With uterine atony,
however, the uterine muscles do not contract as
needed, putting the individual at risk of
postpartum hemorrhage. Uterine atony is
considered an obstetric emergency. According to
the American College of Obstetricians and
Gynecologists, it is the most common cause of
postpartum hemorrhage, and globally, it is
considered to be one of the main causes of
maternal mortality.
Etiology/Cause
- Uterine atony is caused by the inability of the
myometrium to contract sufficiently in response
to oxytocin, a hormone the body releases before
and during childbirth to stimulate uterine
contractions.
Signs and Symptoms
❖ The main sign of uterine atony is postpartum
hemorrhage, or excessive blood loss after
delivery. This can cause a drop in the arterial
blood pressure and consequently increase the
heart rate. Individuals may also experience pain,
especially in the lower back.
Management
Nursing Management:
• Nurses also need to intervene early or during the
course of a hemorrhage to help the patient
regain her strength and vitality. The data that the
nurse would give would be essential in the care
of the patient with hemorrhage.
Medical Management:
• Uterine massage, is done by the doctor by doctor
placing one hand in the vagina and pushing
against the uterus while their other hand
compresses the uterus through the abdominal
wall.
MODULE 3M: POSTNATAL COMPLICATIONS
Pharmacologic Management:
• In most cases, uterine atony can be managed
with uterine massage in conjunction with
oxytocin, prostaglandins, and ergot alkaloids.
Surgical Management:
• Surgical options include B-Lynch and Hayman
uterine compression sutures and/or bilateral
closure of the ascending branches of the uterine
arteries if uterine atony occurs during cesarean
section and medication therapy fails.
HEMORRHAGE
- Postpartum hemorrhage is excessive bleeding
following the birth of a baby. About 1 to 5
percent of women have postpartum hemorrhage
and it is more likely with a cesarean birth.
Hemorrhage most commonly occurs after the
placenta is delivered. The average amount of
blood loss after the birth of a single baby in
vaginal delivery is about 500 ml (or about a half
of a quart). The average amount of blood loss for
a cesarean birth is approximately 1,000 ml (or
one quart). Most postpartum hemorrhage
occurs right after delivery, but it can occur later
as well.
Etiology/Cause
- Major causes of postpartum hemorrhage are
uterine atony (responsible for at least 80% of all
early postpartum hemorrhages); laceration of
cervix, vagina, or perineum; and retained
placental fragments.
- Predisposing factors include hypotonic
contractions, overdistended uterus, multiparity,
large newborn, forceps delivery, and cesarean
delivery.
Types
- There are two types of PPH.
- Primary postpartum hemorrhage occurs within
the first 24 hours after delivery.
- Secondary or late postpartum hemorrhage
occurs 24 hours to 12 weeks postpartum.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Signs and Symptoms
❖ Uncontrolled bleeding
❖ Decreased blood pressure
❖ Increased heart rate
❖ Decrease in the red blood cell count
❖ Swelling and pain in the vagina and nearby area
if bleeding is from a hematoma
Management
Nursing Management:
• Save all perineal pads used during bleeding and
weigh them to determine the amount of blood
loss.
• Place the woman in a side lying position to make
sure that no blood is pooling underneath her.
• Assess lochia frequently to determine if the
amount discharged is still within the normal
limits.
• Assess vital signs, especially the blood pressure
• Assess for signs of shock
A retained placenta may be caused by:
Medical Management:
• Blood transfusion; Cross matching and blood
typing is necessary to replace the blood loss
• Administration of Oxygen; If the woman is
experiencing respiratory distress, administration
of oxygen at 4L/min via face mask could be
prescribed by the physician.
Pharmacologic Management:
• Administration of Pitocin to maintain the tone of
the uterus if it is unable to contract
• Administration of Carboprost tromethamine,
which is a prostaglandin derivative that could
help promote sustained uterine contractions
Surgical Management:
• Hysterectomy; In a worst case scenario, the
uterus needs to be surgically removed to save
the life of the mother.
• Suturing is necessary for extreme uterine atony
to stop the bleeding.
MODULE 3M: POSTNATAL COMPLICATIONS
RETAINED PLACENTAL FRAGMENTS
- Retained placenta is a rare complication
affecting only about 2 to 3 percent of all
deliveries that occurs when all or a portion of the
placenta is left inside the uterus after baby's
birth. Sometimes the placenta or part of the
placenta or membranes can remain in the womb,
which is known as retained placenta.
Furthermore, retained placental fragments (RPF)
are most often clinically manifested as delayed
postpartum hemorrhage, or prolonged
postpartum spotting. This is a rare complication
of labor, yet can potentially cause severe
morbidity and discomfort. Evaluation of RPF is
based upon clinical manifestations combined
with ultrasonography and other imaging
techniques. The diagnosis is confirmed by
positive histology.
Etiology/Cause
- The uterus not contracting properly after the
baby is born
- The umbilical cord snapping (this isn’t very
common and will not hurt your baby if managed
quickly – your midwife will simply clamp the cord
to prevent any bleeding)
- The placenta attaching abnormally deeply into
the wall of the uterus – this is rare.
Types
1. Placenta Adherens
◼ Placenta adherens is the most common type
of retained placenta. It occurs when the
uterus, or womb, fails to contract enough to
expel the placenta. Instead, the placenta
remains loosely attached to the uterine wall.
2. Trapped Placenta
◼ A trapped placenta occurs when the
placenta detaches from the uterus but
doesn’t leave the body. This often occurs
because the cervix starts to close before the
placenta is removed, causing the placenta to
become trapped behind it.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
3. Placenta Accreta
◼ Placenta accreta causes the placenta to
attach to the muscular layer of the uterine
wall rather than the uterine lining. This often
makes delivery more difficult and causes
severe bleeding. If the bleeding can’t be
stopped, blood transfusions or a
hysterectomy may be required.
Signs and Symptoms
❖ The most obvious sign of a retained placenta is a
failure of all or part of the placenta to leave the
body within an hour after delivery.
❖ When the placenta remains in the body, women
often experience symptoms the day after
delivery. Symptoms of a retained placenta the
day after delivery can include:
➢ a fever
➢ a foul-smelling discharge from the
vagina that contains large pieces of
tissue
➢ heavy bleeding that persists
➢ severe pain that persists
Management
Nursing Management:
• Uterine exploration and removal under
anesthesia is the final therapy of retained
placenta. Uterine exploration can be done
manually or under ultrasound guidance with
currettage. These patients are often young and
healthy, with few comorbid medical conditions
Medical Management:
• The conventional therapy for a retained
placenta, regardless of its kind, is physical
removal. Medical treatment has not been
demonstrated to be useful in reducing the risk of
anesthetic and surgical complications.
Complications can include significant bleeding,
endometritis, or retained parts of placental
tissue, the latter of which can cause delayed
hemorrhage or infection.
MODULE 3M: POSTNATAL COMPLICATIONS
Pharmacologic Management:
• Women with retained placenta after vaginal
birth. Antibiotic prophylaxis (gentamicin,
ampicillin, clindamycin). Oxytocin (Pitocin) is one
type of medication that may be used. They can
apply controlled cord traction (CCT) after the
placenta has separated. During CCT, your doctor
clamps the baby's umbilical cord and then pulls
on the cord while applying pressure.
Surgical Management:
• Conventionally, surgical management of
retained placental tissue is largely performed
using blind dilatation and curettage.
Hysteroscopic removal using diathermy loop has
been shown to be successful while increasing
complete removal rates and reducing risk of
uterine perforation. Sometimes retained
placenta can be treated simply if you empty your
bladder, change position and have the doctor or
midwife gently pull on the umbilical cord. If that
doesn't work, you will need a procedure to
remove the placenta.
DISSEMINATED INTRAVASCULAR
COAGULATION
- Also called Consumption Coaulapathy,
Disseminated Intravascular Coagulation is a
serious and rare condition that leads to
abnormal blood clotting throughout the body’s
blood vessels, therefore, compromising proper
blood flow. It is characterized by systemic
activation of blood coagulation that results in the
generation and deposition of fibrin which results
in microvascular thrombi in various organs and
highly contributes to multiple organ failure. DIC
can quickly develop over hours or days or rather
more slowly. If this action begins to consume the
clotting factors and platelets in a positive
feedback loop then hemorrhage will take place
which is considered to be the presenting
symptom for patients diagnosed with DIC.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Etiology/Cause
- There are multiple medical cases that can lead to
the development of Disseminated Intravascular
Coagulation and it is either due to a release of
procoagulants into the bloodstream or because
of a systemic inflammatory response. Moreover,
this condition typically occurs as an acute
complication to patients with underlying life-
threatening illnesses such as placental
abruption, severe trauma, severe sepsis, and
hematologic malignancies. According to Costello
and Nehring, the pathological process of DIC has
been estimated to occur in up to 30% to 50% of
cases of severe sepsis, which is the most
common cause of DIC. Obstetrical complications
such as placental abruption, hemolysis, elevated
liver enzymes, low platelet count (HELLP
syndrome), and amniotic fluid embolism lead to
DIC. Furthermore, about 15.5% of cases of DIC
have also been linked to complications occurring
after surgery and other causes include liver
disease, transplant rejection, and transfusion
reactions.
Types
1. Acute Disseminated Intravascular Coagulation
◼ More severe and develops quickly over
hours or days.
◼ The first sign may be bleeding.
2. Chronic Disseminated Intravascular
Coagulation
◼ Happens more slowly and sometimes has no
signs or symptoms especially when it
originates from cancer.
Signs and Symptoms
❖ Bruising - often in various areas as small dots or
larger patches (Petechia and purpura)
❖ Bleeding
◼ At the site of wounds from surgical cuts or
from placement of a needle
◼ from the nose, gums, or mouth, including
when you brush your teeth
❖ Pain, redness, warmth, and swelling in the lower
leg
MODULE 3M: POSTNATAL COMPLICATIONS
❖ Blood in the stools from bleeding in the
intestines or stomach.
❖ Stools may appear dark red or like tar.
❖ Blood in the urine
❖ Unusually heavy periods
❖ Low blood pressure
❖ Chest pain
❖ Trouble breathing and shortness of breath
❖ Headaches
❖ Confusion, speech changes or trouble speaking,
dizziness, or seizures
Management
Nursing Management:
• Assess the client’s breath sounds. Assess cough
for signs of bloody sputum. Assess for
tachycardia, shortness of breath, and use of
accessory muscles.
Medical Management:
• Treatment of underlying conditions is
recommended in three types of DIC, with the
exception of massive bleeding. Blood
transfusions are recommended in patients with
the bleeding and massive bleeding types of DIC.
Pharmacologic Management:
• Treatment with heparin is recommended in
those with the non-symptomatic type of DIC. The
administration of synthetic protease inhibitors
and antifibrinolytic therapy is recommended in
patients with the bleeding and massive bleeding
types of DIC. Furthermore, the administration of
natural protease inhibitors is recommended in
patients with the organ failure type of DIC, while
antifibrinolytic treatment is not. The diagnosis
and treatment of DIC should be carried out in
accordance with the type of DIC.
Surgical Management:
• During the treatment of DIC surgical drainage in
patients with infectious diseases and anticancer
drugs or surgery in patients with malignant
diseases are performed.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
LACERATION AND TYPES
- For the most part, lacerations in the birth canal
quite commonly occur as the delivery process
goes on. These are simply considered to be a
normal consequence of childbearing. That is, of
course, if these are small lacerations. It is
possible for lacerations to potentially harm the
patient if these lacerations are larger than
expected. These can cause harm because these
put the client at risk for infection or hemorrhage
(Silbert-Flagg & Pillitteri, 2018).
Etiology/Cause
- Small lacerations come about as the baby’s head
is making its way to the vaginal opening. The
tears mainly happen because it’s either the
baby’s head is bigger than the vagina can stretch
or the head may be normal sized yet the vagina
cannot stretch itself wide enough to allow the
baby to exit (Nall, 2016). Again, lacerations
occurring this way is normal. Large lacerations
are mainly the result of:
➢ Clients with difficult or precipitate births
➢ In primigravidas
➢ Clients that gave birth to a large infant
that usually weighs more than 9 lbs.
➢ Clients who are placed in the lithotomy
position and the usage of instruments
such as forceps and vacuum extraction
Types
Lacerations are classified based on where they appear.
Mainly, these are the cervix, the vagina, or the perineum.
The types of lacerations are:
1. Cervical lacerations
◼ these can be found on the sides of the cervix
close to the branches of the uterine artery.
As this is the case, there is a risk of tearing
this artery which will result in major blood
loss. The blood may gush out of the vagina
since bleeding can be intense and appear to
be a brighter red since it comes from an
artery. This commonly occurs after the
placenta is detached.
MODULE 3M: POSTNATAL COMPLICATIONS
2. Vaginal lacerations
◼ in comparison to cervical lacerations, these
are less difficult to find and begin
assessment with as they are easier to view.
3. Perineal lacerations
◼ this occurs due to a difference in positioning
of the pregnant client; if the woman is placed
in a lithotomy position, this increases the
tension on the perineum. Perineal
lacerations are also further classified based
on how deep the tear goes:
o First degree – goes through the
vaginal mucous membrane and skin
of the perineum to the fourchette
(at bottom of the inner folds of the
vulva)
o Second degree – vagina, perineal
skin, fascia, levator ani muscle, and
perineal body
o Third degree – Entire perineum,
extending to reach the external
sphincter of the rectum
o Fourth degree – Entire perineum,
rectal sphincter, and some of the
mucous membrane of the rectum
Signs and Symptoms
❖ When a laceration happens, the client will mainly
feel pain and bleeding will occur.
Management
Nursing Management:
• Support the patient and inform her about the
babies condition.
• Maintain that the setting of the room stays calm
and if possible stand beside the woman.
Medical Management:
• Use of warm or cold pads to help with pain.
• A indwelling urinary catheter can be put to help
with the pressure of the urethra.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Pharmacologic Management: Types
1. Vulvar hematoma is a collection of blood in the
• If there are any cervical laceration appears to be
vulva.
extensive or difficult, the use of anesthetic is
2. Perineal hematoma is a collection of blood in the
used to relax the uterine muscle.
tissue around the peri.
Surgical Management:
Signs and Symptoms
• For cervical lacerations it requires to have Vulvar Hematoma:
sutures to be more difficult because the bleeding
❖ Pain and swelling
can be intense.
❖ Painful or difficult urination
❖ Bulging tissue
HEMATOMA AND TYPES
- Vulvar Perineal hematoma:
- Perineal
- Hematoma is one of the postpartum problems ❖ bubbling or bulging skin near the anus
that can occur as a result of damage to one of the ❖ mild to severe pain, depending on the size
larger blood vessels in the body specifically in the ❖ bloody stools
vulva or perineum. A hematoma is similar to a Management
hemorrhage, but a hemorrhage refers to Nursing Management:
ongoing bleeding while the blood in a hematoma
has typically already clotted. This happens • Report presence of hematoma:
because of an injury that can cause blood vessel o Size
walls to break, allowing blood to make its way o Degree of discomfort.
into the surrounding tissue. Vulvar hematoma is • Report a definite size (5 cm) rather than “large or
a collection of blood in the vulva. The vulva is soft small”
tissue mainly composed of smooth muscle and • Apply ice pack (covered with towel)
loose connective tissue and is supplied by
Pharmacologic Management:
branches of the pudendal artery. A perineal
hematoma is a pool of blood that collects in the • Prescribe mild analgesic for pain relief
tissue surrounding the perineum. It’s usually
Surgical Management:
caused by a ruptured or bleeding vein.
• Incision of the site
Etiology/Cause
- Direct injury of the soft tissue (episiotomy, • Vessel ligation under anesthesia
vaginal lacerations, etc.) • If episiotomy incision; may be left open and
- Indirect injury of the soft tissue (extensive packed with gauze rather than resutured.
stretching of birth canal) • Remove gauze packing in 24 to 48 hours
- Surgery of vulva
- Spontaneous vessel rupture
- Prolonged second stage of labor
- Macrosomia
- Vulvovaginal varicosity
- Primiparity

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
EDEMA
- Postpartum edema, or postpartum swelling, is
caused by an excess amount of fluid remaining in
the body tissue after childbirth. Swollen
extremities (hands, feet, and ankles) and weight
gain are the main symptoms of edema. Swelling
can lead to the skin looking stretched and
inflamed, and sometimes will cause the outer
layer of the skin to look puffy or shiny.
Etiology/Cause
- It's perfectly normal for a woman to have some
swelling after her baby's birth. During
pregnancy, hormones cause her body to retain
fluid. In fact, that extra liquid can make her blood
volume increase by almost 50 percent. Those
same hormones – at least some of them – take a
while to go back to pre-pregnancy levels.
- When fluid builds up in areas like her face, hands,
or feet, the swelling may become obvious. The
force of gravity can push the fluid downward into
her ankles and feet and make these areas swell
more, especially if she stands a lot.
- After she gives birth, her body gradually
eliminates the built-up fluid through urine and
sweat. But it takes up to two weeks for her body
to fully remove all that fluid.
Types
1. Breast engorgement
◼ This happens when your breasts swell
because they are full of milk. It most
commonly happens a few days after
delivery. Your breasts may also feel tender
and sore. The discomfort will go away once
you start breastfeeding regularly.
2. Hemorrhoids
◼ You may develop painful swelling of a vein in
the rectum during your pregnancy. If not,
you may get them from the strain and
pushing during delivery. Hemorrhoids are
painful and may bleed after a bowel
movement. Sometimes they itch too.
Applying cold witch hazel may help relieve
hemorrhoid pain. They should shrink over
time, but if they don’t, contact your doctor.
MODULE 3M: POSTNATAL COMPLICATIONS
3. Water retention
◼ Also known as postpartum edema (swelling).
After giving birth, your body will continue to
hold on to water because of an increase in
progesterone. You may notice the swelling in
your hands, arms, feet, ankles, and legs.
Edema shouldn’t last much longer than a
week after delivery. If it does or if it gets
worse over time, consult your doctor
Signs and Symptoms
❖ Swelling or puffiness under the skin in your feet
and ankles
❖ Skin that looks stretched
❖ Indentations when you press down on your skin
for a few seconds
❖ Quick weight gain over a period of a few days
Management
Nursing Management:
• During the first 24 hours after your surgery you
can place an icepack over the surgical site. This
can help reduce swelling and pain.
• A warm pack can also be helpful during the
recovery period. Hemorrhoid surgery is
predictably painful.
Medical Management:
• Apply an over-the-counter hemorrhoid cream or
use pads containing witch hazel or a numbing
agent.
• Soak regularly in a warm bath or sitz bath. Soak
your anal area in plain warm water for 10 to 15
minutes two to three times a day
Pharmacologic Management:
• over-the-counter creams, ointments,
suppositories or pads. These products contain
ingredients such as witch hazel, or
hydrocortisone and lidocaine, which can
temporarily relieve pain and itching.
Surgical Management:
• Closed hemorrhoidectomy is the surgical
procedure most commonly used to treat internal
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
hemorrhoids. It consists of the excision of
hemorrhoidal bundles using a sharp instrument,
such as a scalpel, scissors, or even laser followed
by complete wound closure with absorbable
suture.
MASTITIS
- Mastitis is a condition in which the breast tissue
becomes inflamed and infected. Breast
discomfort, swelling, warmth, and redness are all
symptoms of inflammation. You may also get a
fever and chills. Breast-feeding mothers are the
ones who are most likely to have mastitis
(lactation mastitis).
Etiology/Cause
- Mastitis is commonly caused by bacteria found
on your infant's skin or in the mouth. These
bacteria can enter your breast through a nipple
gap or a hole in the milk duct. Infection is more
likely when milk is trapped in the breast.
Types
1. Lactation
◼ breastfeeding mothers are susceptible to
this infection. It's also known as puerperal
mastitis and is the most frequent.
2. Periductal
◼ Periductal mastitis is more common in
menopausal and postmenopausal women,
as well as smokers. This disorder, also known
as mammary duct ectasia, arises when milk
ducts thicken. The damaged breast's nipple
may bend inward (inverted nipple), resulting
in a milky discharge.
Signs and Symptoms
❖ Breast Tenderness
❖ Skin redness
❖ Breast swelling
❖ Fever
❖ Thickening of breast tissue
❖ Pain or a burning sensation continuously or while
breast-feeding
MODULE 3M: POSTNATAL COMPLICATIONS
Management
Nursing Management:
• Apply warm, moist compresses to the affected
breast every few hours or take a warm shower.
• Breastfeed every two hours or more often to
keep milk flowing through the milk ducts.
• Drink plenty of fluids and rest when possible.
• Massage the area using a gentle circular motion
starting at the outside of the affected area and
working in toward the nipple.
Medical Management:
• Before breast-feeding, avoid overfilling your
breasts with milk for an extended period of time.
• Varying your breast-feeding positions.
• Expressing a small amount of milk by hand
before breast-feeding might help.
Pharmacologic Management:
• Antibiotics- It's important to take all of the
medication to minimize your chance of
recurrence.a 10-day course of antibiotics is
usually needed.
• Pain relievers- The physician may recommend
an over-the-counter pain reliever, such as
acetaminophen (Tylenol, others) or ibuprofen
(Advil, Motrin IB, others).
Surgical Management:
• It requires surgical drainage in the operating
room.
• excisional biopsy
• partial mastectomy
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
PUERPERAL INFECTION
- After a woman gives birth, bacteria infects the
uterus and surrounding areas, causing a
puerperal infection. Postpartum Infection is
another name for it.
- Postpartum infections are a broad category of
illnesses that can develop after vaginal or
cesarean delivery, as well as during
breastfeeding. Physiologic changes during
pregnancy, in addition to trauma received during
the birth process or cesarean surgery, contribute
to the development of postpartum infections.
The common discomfort experienced by many
women in the immediate postpartum period
makes it difficult to distinguish between
postpartum infection and postpartum pain.
Etiology/Cause
- After delivery, postpartum infections frequently
begin in the uterus. If the amniotic sac becomes
infectious, the uterus can become infected as
well. The majority of postpartum infections are
caused by physiologic and iatrogenic damage to
the abdominal wall, reproductive, genital, and
urinary systems, which allows germ to enter
these normally sterile environment during
childbirth or abortion.
- Since the introduction of antiseptics and
penicillin, postpartum infections have become
less common. However, skin flora such as
streptococcus or staphylococcus, as well as other
bacteria, continue to cause infections. These
bacterias are at their best in damp, warm
settings.
Types
1. Endometritis
◼ It is an infection of the uterine lining.
2. Myometritis
◼ This is a type of postpartum infection of the
uterine muscle caused by placental
fragments remaining in the uterus. Excessive
bleeding can occur as a result of severe
myometritis.
MODULE 3M: POSTNATAL COMPLICATIONS
3. Parametritis
◼ This is also known as pelvic cellulitis, which is
an infection that affects the surrounding
area of the uterus
Signs and Symptoms
Symptoms of puerperal infections may appear several
days after birth. Sometimes, after leaving the hospital.
The following are the most common signs and symptoms
of Puerperal infection:
❖ Fever- This happens when the body tries to kill
bacteria or viruses that are a result of an
infection.
❖ Pain in the lower abdomen or pelvis caused by a
swollen uterus
❖ Foul-smelling vaginal discharge- This is caused by
an infection known as bacteria vaginosis (BV),
which occurs when a specific bacteria
accumulates in the vagina
❖ Pale skin, which can be a sign of large volume
blood loss
❖ Chills
❖ Feelings of discomfort or illness
❖ Headache
❖ Loss of appetite
❖ Increased heart rate
It may take several days for symptoms to show.
Infections can sometimes go unnoticed until you leave
the hospital. Even after you've been discharged, it's
critical to keep an eye out for signs of infection.
Management
Nursing Management:
• Inspect the perineum twice daily for redness,
edema, ecchymosis, and discharge.
• Evaluate for abdominal pain, fever, malaise,
tachycardia, and foul-smelling lochia.
• Obtain specimens for laboratory analysis; report
the findings.
• Offer a balanced diet, frequent fluids, and early
ambulation.
• Administer prescribed antibiotics or
medications; document the client’s response.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Medical Management:
• Blood tests. Check for a high white blood count
to check for bacterial infection.
• Imaging tests. use an X-ray to check for holes or
other perforations in the gastrointestinal tract.
Ultrasound also may be used.
Pharmacologic Management:
• Administer analgesics to relieve pain
• Antibiotic therapy for early treatment of
peritonitis
• Administer antiemetics to relieve and prevent
nausea and vomiting
Surgical Management:
• Clot removal or by-pass. Surgery is necessary to
remove an acute clot blocking a pelvic vein or an
abdominal vein. Procedures such as
bypass/stent/filter may be necessary.
• Infected episiotomies can be opened and
allowed to drain. Abscesses and blood clots may
require surgery.
CYSTITIS
- An inflammation of the bladder wall is referred
to as cystitis and it is a type of urinary tract
infection that is fairly common (UTI). Cystitis is
usually caused by bacteria that normally live
harmlessly on the skin or in the bowel and enter
the urethra and bladder. The bacteria then
adheres to the bladder lining, causing it to
become irritated and inflamed.
Etiology/Cause
The type of cystitis depends on its cause. Possible causes
of cystitis include:
- Urinary tract infection (UTI)
- Taking certain drugs
- Exposure to radiation
- Ongoing use of a catheter
- Irritating hygiene products
MODULE 3M: POSTNATAL COMPLICATIONS
Acute cystitis is usually caused by the bacteria
Escherichia coli. Other bacterial causes are as follows:
- Proteus mirabilis
- Klebsiella pneumoniae
- Staphylococcus saprophyticus
- Group B streptococci
- Lactobacillus
- S. saprophyticus
- Enterococci
Cystitis in men can also occur as a result of problems that
restrict normal urine flow.
Types
1. Acute cystitis:
◼ A case of cystitis that occurs suddenly.
2. Interstitial cystitis (IC):
◼ A chronic or long-term case of cystitis that
affects multiple layers of bladder tissue.
3. Bacterial cystitis:
◼ This occurs when bacteria enters the urethra
or bladder and causes an infection.
4. Drug-induced cystitis:
◼ Certain medications can cause bladder to
become inflamed.
5. Acute cystitis with hematuria:
◼ Cystitis with the presence Trusted Source of
blood in the urine.
6. Hemorrhagic cystitis:
◼ This is where the blood vessels in the lining
of the bladder are also damaged.
7. Radiation cystitis:
◼ Radiation treatment in the pelvic area can
cause bladder to become inflamed.
8. Foreign body cystitis:
◼ The continued use of a catheter, a tube used
to aid in the release of urine from the
bladder, can increase the risk of bacterial
infection and damage urinary tract tissues.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Signs and Symptoms
Signs and symptoms of Cystitis may include:
❖ A strong, persistent urge to urinate.
❖ Feeling pain or burning sensation when
urinating.
❖ Passing frequently but only small amounts of
urine.
❖ Cloudy or foul-smelling urine.
❖ Pelvic discomfort.
If Cystitis worsens, the patient may also experience:
❖ Fever and chills.
❖ Nausea and vomiting.
❖ Sensation of pain in the lower back or side.
❖ Hematuria (blood in the urine that may appear
red, pink, or brown).
Management
Nursing Management
• The manifestation of Cystitis has to be assessed
– This includes taking note of the presence of
pain, frequency, urgency, hesitancy, and changes
in the urine. All of this has to be assessed,
documented, reported.
• Taking note of the voiding pattern – Changes in
the patient’s pattern of voiding would be
assessed to detect the factors that may
predispose the patient to UTI.
• Document the characteristics of the urine – The
volume, color, concentration, cloudiness, and
odor are assessed as they can be altered by the
presence of bacteria in the urinary tract.
Medical Management
• Ensure adequate fluid volume to prevent sepsis
and shock.
• Order a urine test to detect the infection. ○ If
evidence of dehydration exists, fluids must be
administered.
• Administration of appropriate antibiotics for UTI
that are considered safe by the American
Academy of Pediatrics (AAP) for nursing infants,
with no reported effects seen in infants who are
breastfeeding.
MODULE 3M: POSTNATAL COMPLICATIONS
• Advise the patient to take the medications after
breastfeeding to minimize drug exposure.
• Cardiac monitoring and administration of oxygen
may be advised.
• The doctor will order another urine test 6 to 8
weeks after your baby is born to make sure the
infection is cured.
Pharmacologic Management:
• The following are the appropriate antibiotics
administered to postpartum mothers with
cystitis:
Nitrofurantoin
Fosfomycin
Trimethoprim-sulfamethoxazole
Nitrofurantoin
Ciprofloxacin
Levofloxacin
Ofloxacin
Fluoroquinolones
• It is important to note that fluoroquinolones
should not be first-line therapy and temporary
discontinuation of breastfeeding should be
considered. Secondly, Trimethoprim-
sulfamethoxazole and nitrofurantoin are to be
avoided in mothers with breastfeeding infants
with G-6-PD deficiency.
• If symptoms do not ease after taking antibiotics,
the patient should return to her doctor.
SVT
- Superficial vein thrombosis (SVT) is thrombosis
and inflammation of the superficial vein,
characterized by painful, warm, erythematous,
tender, and palpable cord-like structure along
the course of a superficial vein, usually in the
lower extremities, but potentially affecting any
superficial vein in the body.
Etiology/Cause
- An injury to a vein
- An inherited blood-clotting disorder
- Being immobile for long periods, such as during
an injury or a hospital stay
- Injection into a vein
- Infection
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
- Varicose veins
Signs and Symptoms
Symptoms of superficial thrombophlebitis include:
❖ redness and inflammation of the skin along a
vein
❖ warmth of the skin and tissue around the vein
❖ tenderness and pain that worsens with added
pressure
❖ pain in the limb
❖ darkening of the skin over the vein
❖ hardening of the vein
Call your doctor if the above symptoms appear or get
worse, or you develop new symptoms such as fever and
chills. This could be a sign of a more serious illness or
condition
Management
Medical Management
• Most times, treatment for patients with
superficial thrombophlebitis includes only ways
to manage pain and inflammation.But, if you are
at risk of developing a DVT or have problems that
affect the way your blood clots, you will likely
need to take anticoagulation medication.
Pharmacologic Management
• patients received a daily therapeutic
subcutaneous dose (190 anti-Xa iu/kg) for 10
days the addition of the NSAID, acemetacin, 60
mg orally twice daily.
Surgical Management
• Endovenous ablation- A special catheter (long,
thin tube) is placed in the saphenous vein (the
longest vein in your body; it runs along the inside
of your leg). The catheter is inserted by making a
small puncture in your calf. Sclerotherapy-A
solution is injected directly into the affected
vein. The solution irritates the lining of the
vessel, causing it to swell and stick together.
Over time, the vessel turns into scar tissue that
fades from view. This treatment is performed in
the office by a vascular specialist or surgeon
MODULE 3M: POSTNATAL COMPLICATIONS
DVT
- Deep vein thrombosis (DVT) is a medical
condition that occurs when a blood clot forms in
a deep vein. These clots usually develop in the
lower leg, thigh, or pelvis, but they can also occur
in the arm.
Etiology/Cause
DVT is caused by a blood clot. The clot blocks a vein,
preventing blood from properly circulating in the body.
Clotting may occur for several reasons. These include:
- Injury. Damage to a blood vessel’s wall can
narrow or block blood flow. A blood clot may
form as a result.
- Surgery. Blood vessels can be damaged during
surgery, which can lead to the development of a
blood clot. Bed rest with little to no movement
after surgery may also increase risk of
developing a blood clot.
- Reduced mobility or inactivity. When you sit
frequently, blood can collect in your legs,
especially the lower parts. If you’re unable to
move for extended periods of time, the blood
flow in your legs can slow down. This can cause
a clot to develop.
- Certain medications. Some medications
increase the chances your blood will form a clot.
Types
1. Acute DVT
◼ refers to a clot for which has been present
for 14 days or less. The symptoms of acute
DVT are limb swelling and pain. During this
period the clot is soft or doesn't get very
hard and not become tightly attached to the
walls of the vein and it is easily treated with
clot dissolving drugs.
2. Subacute DVT
◼ Refers to a clot that has been present
between 14 to 28 days. The thrombus is
likely to have become slightly harder than it
was during the acute stage but not as hard
as it will get in the chronic stage.
Connections between the thrombus and
walls of the vein may start to form as well.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
The symptoms will be the same as those of
acute DVT, and the blood clot can still be
dissolved using clot-dissolving medications.
3. Chronic DVT
◼ refers to a clot present for more than 28
days. The clot becomes harder and scars the
vein. As a result of this process, the vein
becomes much smaller and does not allow
blood to flow through effectively. Chronic
DVT can either totally permanently block the
vein or it can adhere to the wall of the vein.
Chronic DVT that doesn’t block the vein can
still cause long-term problems as the valves
in the vein are often damaged or destroyed.
Signs and Symptoms
Common DVT signs and symptoms include:
❖ swelling in your foot, ankle, or leg, usually on one
side
❖ cramping pain in your affected leg that usually
begins in your calf
❖ severe, unexplained pain in your foot and ankle
❖ an area of skin that feels warmer than the skin
on the surrounding areas
❖ skin over the affected area turning pale or a
reddish or bluish color, depending on skin tone
People with an upper extremity DVT, or a blood clot in
the arm, may not experience symptoms. If they do,
common symptoms include:
❖ Neck pain
❖ Shoulder pain
❖ swelling in the arm or hand
❖ blue- or darker-tinted skin color
❖ pain that moves from the arm to the forearm
❖ Weakness in the hand
Management
Nursing Management
• Bed rest to prevent clot dislodgement
• Elevate affected or both legs
• Turn patient every 2 hours without crossing legs
• Range-of-motion exercises to the unaffected leg
• Warm compresses to help reduce swelling
• Monitor vital signs every 4-6 hours
MODULE 3M: POSTNATAL COMPLICATIONS
• Assess patient for complications of PE, such as
shortness of breath, chest pain, apprehension,
cough, hemoptysis, crackles, tachycardia,
diaphoresis, and fever
Medical Management
• Anticoagulants
The first line of treatment for DVT
involves the use of blood thinners. They
decrease the ability of the blood to clot,
preventing the clot to become bigger
and reducing the risk of developing more
clots. However, they are not able to
break up the existing clot. These can
either be oral tablets or subcutaneous
injections.
• Thrombolytics
These are clot buster medications that
are able to break up the clot easily for
cases of severe DVT or DVT with
pulmonary embolism. However, they are
used with caution due to the risk of
serious bleeding.
• Filter insertion
If the patient is not eligible for
anticoagulant therapy, the physician
may insert a filter in the abdominal vena
cava to prevent clot from the leg to
break loose and travel to the lungs, thus
lowering the risk for pulmonary
embolism.
• Compression stockings
These are helpful to reduce swelling of
the legs, as well as to lower the risk of
blood pooling and eventual clotting. The
compression stockings should be worn
for at least 2 years.
Pharmacologic Management
The doctor might prescribe medications to thin the blood
such as:
• Heparin
• Warfarin(Coumadin)
• Enoxaparin (Lovenox)
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• fondaparinux (Arixtra)
Heparin is typically given by IV. The most commonly
used injectable blood thinners for DVT are enoxaparin
(Lovenox) and fondaparinux (Arixtra). After taking an
injectable blood thinner for a few days, the doctor may
switch to a pill such as warfarin.
If blood thinners don’t work, or if the DVT is severe,
the doctor might use thrombolytics drugs. Thrombolytic
drugs work by breaking up clots which patients receive
intravenously (through a vein).
Surgical Management
• The doctor might suggest surgical
thrombectomy, or surgery to remove a blood
clot. This is typically only recommended in the
case of very large blood clots or clots that are
causing serious issues, like tissue damage.
PULMONARY EMBOLUS
- A pulmonary embolus is obstruction of the
pulmonary artery by a blood clot; it usually
occurs as a complication of thrombophlebitis
when a blood clot moves from a leg vein to the
pulmonary artery.
Etiology/Cause
Pulmonary embolism is linked to a lot of causes and these
are the most common:
- Trauma
◼ Trauma anywhere in the body could cause
PE especially if a clot is released from the
venous system.
- Surgery
◼ Certain surgical procedures such as
orthopedic, major abdominal, pelvic, and
gynecologic surgeries could cause PE.
- Hypercoagulable states
◼ A patient with hypercoagulability disorders
would most likely develop a clot that could
result in PE.
- Prolonged immobility
◼ Being unable to move for a prolonged time
predisposes a person to PE.
MODULE 3M: POSTNATAL COMPLICATIONS
Signs and Symptoms
The signs of pulmonary embolus are
❖ Sudden sharp chest pain
❖ Tachypnea
❖ Tachycardia
❖ Orthopnea (inability to breathe except upright
position)
❖ Cyanosis (the blood clot is blocking both blood
flow to the lungs and return to the heart)
Management
Nursing Management
• Ambulation and active and passive leg exercises
to prevent venous stasis
• Monitor thrombolytic and anticoagulant therapy
through INR or PTT
• Turn and reposition to improve ventilation-
perfusion ratio
• Assess for signs of hypoxemia and monitor pulse
oximetry values
Medical Management
• Anticoagulation therapy
Anticoagulant therapy is the treatment
of choice for established venous
thrombosis with or without embolism.
Heparin must be given parenterally and
is destroyed by gastric juices.
• Thrombolytic therapy
Thrombolytic therapy is usually reserved
for patients with clinically serious or
massive pulmonary embolism (PE).
Evidence suggests that thrombolytic
agents may dissolve blood clots more
rapidly than heparin and may reduce the
death rate associated with PE.
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Pharmacologic Management Other causes of peritonitis include:

1. Anticoagulant Medication - A hole in your stomach, intestine, gallbladder,

uterus, or bladder
• Rivaroxaban
- An infection during treatment for end-stage
• Heparin kidney (renal) disease (peritoneal dialysis)
• warfarin - An infection of fluid in the belly from end-stage
2. Thrombolytic Medication liver disease (cirrhosis)
- Pelvic inflammatory disease in women
• Alteplase - Surgery (if bacteria enter your belly during
• Reteplase surgery)
Surgical Management Types
• The two main types of peritonitis are primary
• Surgical embolectomy
spontaneous peritonitis, an infection that
This is the removal of the actual clot
develops in the peritoneum; and secondary
and must be performed by a
peritonitis, which usually develops when an
cardiovascular surgical team with the
injury or infection in the abdominal cavity
patient on cardiopulmonary bypass.
allows infectious organisms into the
• Transvenous catheter embolectomy.
peritoneum. Both types of peritonitis are life-
This is a technique in which a vacuum-
threatening.
cupped catheter is introduced
transvenously into the affected Signs and Symptoms
pulmonary artery. ❖ Swollen abdomen when your belly area is
• Interrupting the vena cava bigger than usual
This approach prevents dislodged ❖ Abdominal pain
thrombi from being swept into the ❖ Diarrhea
lungs while allowing adequate blood ❖ Loss of appetite
flow. ❖ Fever
❖ Fatigue
PERITONITIS ❖ Confusion
- Peritonitis is a redness and swelling ❖ Low urine output
(inflammation) of the tissue that lines the belly ❖ Nausea
or abdomen. This tissue is called the ❖ Thirst
peritoneum. It can be a serious, deadly disease ❖ Inability to pass stool or gas
❖ Vomiting
Etiology/Cause
- Peritonitis is usually caused by infection from Management
bacteria or fungi. Bacteria can enter the lining Nursing Management
of the stomach from a hole in the GI
(gastrointestinal) tract. This can happen if there • Monitor vital signs, noting presence of
is a hole in the colon or a burst appendix.Left hypotension, tachycardia, tachypnea, and fever.
untreated, peritonitis can rapidly spread into • Monitor the blood pressure of the patient.
the blood (sepsis) and to other organs, resulting • Observe skin or mucous membrane dryness,
in multiple organ failure and death. turgor.
• Move the patient slowly and deliberately,
splinting the painful area.

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Provide frequent oral care and remove noxious
environmental stimuli.
Medical Management
In cases of peritonitis in which the infection may be a
result of other medical conditions (secondary
peritonitis) or in which the infection arises from fluid
buildup in the abdominal cavity (spontaneous bacterial
peritonitis), may recommend the following tests to
confirm a diagnosis:
1. Blood tests. A sample of blood may be drawn
and sent to a lab to check for a high white blood
cell count. A blood culture also may be
performed to determine if there are bacteria in
the blood.
2. Imaging tests. Use an X-ray to check for holes or
other perforations in the gastrointestinal tract.
Ultrasound also may be used. In some cases, it
may use a computerized tomography (CT) scan
instead of an X-ray.
3. Peritoneal fluid analysis. Using a thin needle,
take a sample of the fluid in the peritoneum
(paracentesis), especially if the patient receives
peritoneal dialysis or has fluid in the abdomen
from liver disease. If confirmed to have
peritonitis, examination of this fluid may show
an increased white blood cell count, which
typically indicates an infection or inflammation.
A culture of the fluid may also reveal the
presence of bacteria.
Pharmacologic Management
• Analgesics - to relieve pain for the acute pain
experienced by the client
• Antibiotic therapy - this is initiated early in the
treatment of peritonitis
• Antiemetics - to relieve and prevent nausea and
vomiting
• Intubation and suction - intestinal intubation
and suction assist in relieving abdominal
distention and in promoting intestinal function
MODULE 3M: POSTNATAL COMPLICATIONS
Surgical Management
• Surgery is often needed to remove infected
tissue, treat the underlying cause of the
infection, and prevent the infection from
spreading, especially if peritonitis is due to a
ruptured appendix, stomach or colon.
PARAMETRITIS
- Parametrium is a connective tissue adjacent to
the uterus and a band of fibrous tissue that
separates the supravaginal portion of the cervix
from the bladder. When the ligaments around
the uterus are inflamed, it will lead to
parametritis.
- The infection spreads through lymphatics to the
uterine wall and to the connective tissue with
either the broad ligament or entire pelvis
inflamed. Parametritis is also called “Pelvic
Cellulitis”. Parametritis is a type of a
postpartum infection, occurs when bacteria
infect the uterus and surrounding areas after a
woman gives birth.
Etiology/Cause
After giving birth, a bacteria that causes infections
becomes present in the uterus, which is the main cause
of this infection. After a woman has given birth or had
an abortion, infection frequently emerges.
The cause of parametritis that infection can gain access
are the following:
- Skin flora such as Streptococcus or
Staphylococcus and other bacteria can cause
infections.
- Lacerations of the cervix
- Delivery and abortion through placental site,
vaginal vault or lower uterine segment.
- Cesarean section,or hysterectomy - abdominal
or vaginal
- Secondary to pelvic peritonitis
- Carcinoma cervix or radium introduction
- Exudative & Abscess
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Types
There are two forms of parametritis:
1. Acute parametritis
◼ diagnosed by the symptoms of elevated
temperature and pulse as well as slightly
uncomfortability.
2. Chronic parametritis
◼ the symptoms of the disease are severe and
can cause other underlying problems like
gonorrhea.
Signs and Symptoms
Parametritis has various different signs and symptoms.
These symptoms can occur several days after the
discharge from hospital after birth, hence it's critical to
check for signs of infection even after the discharge.
Some of these could include:
❖ Fever
❖ Headaches
❖ Chills
❖ An increased heart rate
❖ Lack of appetite
❖ Experience pain in the lower abdomen
❖ Vaginal discharge that is smelly
❖ Feeling discomfort of illness
Management
Nursing Management
• Promote resolution of the infectious process
• Provide client and family teaching
Medical Management
• Isolation, if possible, the removal of the patient
from the maternity ward.
• Meticulous hand washing.
• Patient placed in Fowler’s position to facilitate
drainage.
• Reeducation of the patient on handwashing and
peri-care.
• Emotional support since the patient may be
prevented from rooming in with her infant
while her temperature is elevated.
MODULE 3M: POSTNATAL COMPLICATIONS
Pharmacologic Management
• Antibiotics to which the causative organisms are
sensitive, analgesics, and sedatives.
• Initial antibiotics are given by IV until the fever
resolves.
• May possibly switch from IV and give oral
medication if fever remains normal for 48 to 72
hours.
• May use a course of triple antibiotics until all
cultures are obtained.
Surgical Management
• Surgical Modalities
ENDOMETRITIS
- Endometritis is an inflammatory condition of
the lining of the uterus and is usually due to an
infection.
- Endometritis is an inflammation or irritation of
the lining of the uterus (the endometrium). It is
not the same as endometriosis.
Etiology/Cause
- Endometritis is caused by an infection in the
uterus. It can be due to chlamydia, gonorrhea,
tuberculosis, or a mix of normal vaginal
bacteria.
- It is more likely to occur after miscarriage or
childbirth. It is also more common after a long
labor or C-section.
Types
1. Acute Endometritis
◼ Is characterized by the presence of
microabscesses or neutrophils within the
endometrial glands.
2. Chronic Endometritis
◼ Is distinguished by variable numbers of
plasma cells within the endometrial stroma.
Signs and Symptoms
❖ Swelling of the abdomen
❖ Abnormal vaginal bleeding or discharge
❖ Discomfort with bowel movement (including
constipation)
❖ Fever
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❖ General discomfort, uneasiness, or ill feeling
❖ Pain in lower abdomen or pelvic region (uterine
pain)
Management
Nursing Management
• Monitor the patient's condition and administer
treatment as needed.
• Impart knowledge to the client on how to
provide self care at home.
• Encourage the client to take a rest until they
feel better and to religiously take their
medication.
Medical Management
• The physician will give the patient a physical
exam and assess the symptoms to have a
diagnosis. A vaginal swab, blood test, or urine
test will be done in order to confirm the
infection.
Pharmacologic Management
• Postpartum endometritis is treated with
antibiotics, which are mostly administered
through an IV. Three of the most effective
antibiotics to fight off this type of infection are
clindamycin, gentamicin, and ampicillin which
will be prescribed by the physician.
Surgical Management
• Surgical management is not usually necessary in
acute endometritis in the obstetric population,
but it may be applicable if the infection has
produced a drainable fluid collection.
Laparoscopic or vaginal hysterectomy may be
done in order to manage endometriosis.
MODULE 3M: POSTNATAL COMPLICATIONS
THROMBOPHLEBITIS
- Thrombophlebitis is an inflammatory process
causing blood clots begin to form and block one
or more veins.
Etiology/Cause
- An injury to a vein
- Inherited blood clotting disorder
- Being immobile for long periods, such as during
an injury or a hospital stay.
- History of thrombosis
- Smoking
- Varicose veins
- Obesity
Types
1. Thrombophlebitis of lower extremity
superficial veins
◼ Blood clots in veins just below the surface
of your skin
2. Migratory Thrombophlebitis
◼ Also called Trousseau’s syndrome pr
thrombophlebitis migrants, it is when blood
clots appear and reappear in different parts
of your body. Can be linked to cancer
typically in the lungs or pancreas.
Signs and Symptoms
❖ Swelling in the part of the body affected
❖ Pain in the part of the body affected
❖ Skin redness ( not always present)
❖ Warmth and tenderness over the vein
Management
Nursing Management
• Instruct client to avoid massaging or rubbing the
affected extremity.
• Maintain bed rest with elevation of feet and
lower legs .
• Instruct client to avoid crossing the legs or wear
constrictive clothing.
• Apply warm, moist compresses or heating pad
to affected extremity as ordered.
• Emphasize the importance of deep - breathing
exercises.
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Medical Management
To determine whether superficial thrombophlebitis or
deep vein thrombosis. The client might choose one of
these tests.
• Ultrasound
A wandlike device ( transducer ) moved
over the affected area of the leg sends
Surgical Management
sounds waves into leg. As the sound
waves travel through the leg tissue and
reflect back, a computer transforms the
waves into a moving image on a video
screen.
This test can confirm the diagnosis and
distinguish between superficial and
deep vein thrombosis.
• Blood test
Almost everyone with a blood clot has
an elevated blood level of a naturally
occuring, clot dissolving substance
called D dimer. But D dimer levels can
be elevated in other conditions. So a
test for D dimer isn’t conclusive, but can
indicate the need for further testing.
Its also useful for ruling out DVT and for
identifying people at risk of developing
thrombophlebitis repeatedly.
Pharmacologic Management
• Blood - thinning medications.
If the patient have a deep thrombosis,
injections of a blood - thinning (
anticoagulant) medication , such as low
molecular weight heparin, fondaparinux
(Arixtra )or apixaban (Eliquis), can help
prevent clots from growing bigger. After
the first treatment, you'll likely be told
to take warfarin (Jantoven) or
rivaroxaban (Xarelto) for several
months to keep preventing clot growth.
Blood thinners can cause excessive
bleeding. Always follow your doctor's
instructions carefully.
MODULE 3M: POSTNATAL COMPLICATIONS
• Clot-dissolving medications.
Treatment with a clot-dissolving drug is
called thrombolysis. The medication
alteplase (Activase) is used to dissolve
blood clots in people with extensive
DVT, including those who have a blood
clot in the lungs (pulmonary embolism).
• Varicose vein stripping
A surgeon can remove varicose veins
that cause pain or recurrent
thrombophlebitis. The procedure
involves removing a long vein through
small incisions. Removing the vein
won't affect blood flow in your leg
because veins deeper in the leg take
care of the increased volumes of blood.
CHIARRI-FROMMEL SYNDROME
- Chiari-Frommel Syndrome is a rare endocrine
disorder that affects women who have recently
given birth (postpartum) and is characterized by
the overproduction of breast milk
(galactorrhea), lack of ovulation (anovulation),
and the absence of regular menstrual periods
(amenorrhea). In Chiari-Frommel Syndrome,
these symptoms persist long (for more than six
months) after childbirth. The absence of normal
hormonal cycles may result in reduced size of
the uterus (atrophy). Some cases of Chiari-
Frommel Syndrome resolve completely without
treatment (spontaneously); hormone levels and
reproductive function return to normal.
Etiology/Cause
- The exact cause of Chiari-Frommel Syndrome is
not fully understood but may be related to an
abnormality of the hypothalamus and/or
pituitary glands. Some research suggests that
microscopic tumors of the pituitary gland
(microadenomas), stimulated by the hormones
associated with pregnancy (e.g., prolactin, a
stimulator of lactation) are responsible. When
such microtumors grow, they may be detected
by imaging techniques (CT scan or MRI).
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Approximately 50 percent of affected women
eventually resume normal menstruation over a
period of months or years.
- The cause of the abnormal hormonal
relationship between the pituitary and
hypothalamus gland associated with Chiari-
Frommel Syndrome is not known. Some studies
suggest that microscopic lesions of the
hypothalamus may also cause Chiari-Frommel
Syndrome. An association with the use of oral
contraceptives has also been suggested.
Signs and Symptoms
❖ Chiari-Frommel Syndrome is a rare disorder
characterized by the abnormal production of
breast milk (galactorrhea), and the absence of
regular menstrual periods (amenorrhea) and
ovulation (anovulatory) for more than 6 months
after childbirth. These symptoms occur even
though the mother is not nursing the baby.
Management
Nursing Management
• Advise the mother not to wear any clothing that
can rub or scratch her breasts.
• Teach the mother to apply cold compress every
15 minutes at a time for every hour that is
needed.
• Teach the mother some stress management
techniques.
Medical Management
• If the symptoms persist for a long period of
time, affected individuals should be monitored
(CT scan or MRI) for the presence of a pituitary
tumor.
Pharmacologic Management
• The drug bromocriptine may be prescribed to
help reduce prolactin levels.
Surgical Management
• If a tumor is discovered, it may be difficult to
treat if it is very small. Larger tumors may be
surgically removed.
MODULE 3M: POSTNATAL COMPLICATIONS
SHEEHANS SYNDROME
- Sheehan syndrome (SS) is a form of pituitary
apoplexy. It is a condition that happens when
the pituitary gland is damaged during childbirth.
Sheehan syndrome is also known as postpartum
hypopituitarism and/or postpartum pituitary
necrosis which refers to the necrosis of the
pituitary gland following significant post-partum
bleeding, hypovolemia, and shock. Its frequency
is decreasing worldwide, however, it is still
frequent in underdeveloped and developing
countries.
Etiology/Cause
- Sheehan syndrome is caused by necrosis of the
pituitary gland or the result of severe
hypotension or shock. It’s caused by excess
blood loss or hemorrhage or extremely low
blood pressure during or after labor. A lack of
blood deprives the pituitary of the oxygen it
needs to work properly. It basically happens
when the pituitary gland is damaged during
childbirth.
Signs and Symptoms
The signs and symptoms of Sheehan's syndrome vary
from person to person and depend on the extent to
which the pituitary gland is failing to produce its
hormones. These are the following common symptoms:
❖ Fatigue
❖ Inability to lactate
❖ Low blood pressure
❖ Irregular or absent menstruation
❖ Thinning of vaginal lining
❖ Loss of pubic hair
❖ Weight gain
If these symptoms occur, they usually appear within
weeks or months after the baby is born. Since
Sheehan’s syndrome is a disorder affecting adults, the
effects of growth hormone deficiency are limited to
some loss of muscle strength, increased body fat and
increased insulin sensitivity.
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Management
Nursing Management
• Control bleeding especially after birth.
• Prevention of pregnancy related complications
• Post-puerperal follow up
• Improved obstetrical care and perinatal
monitoring
Medical Management
• Blood tests. Necessary in checking the hormone
level o the pregnant mother especially those
that are produced by the pituitary gland.
• MRI / CT scans. Allows visualization of the
status of the pituitary gland to check for tumors
and other problems that can cause similar
symptoms.
• Dietary change. Necessary especially when
considering the side effects of hormone
imbalance. Women with Sheehan's Syndrome
are at increased risk of osteoporosis and
hypogonadism. Diet changes are needed to
mitigate or prevent these effects.
• Hormonal Replacement Therapy. A therapy
that involves intaking medications with pure
hormones which is necessary to compensate for
the destruction of the pituitary gland.
Pharmacologic Management
• Hydrocortisone (Cortef) or prednisone (Rayos),
replace the adrenal hormones that aren't being
produced because of an adrenocorticotropic
hormone (ACTH) deficiency.
Surgical Management
• Treatment includes hormone replacement
therapy, and steroids to help manage early
symptoms.
MODULE 3M: POSTNATAL COMPLICATIONS
POSTPARTUM BLUES
- Postpartum "blues" is defined as low mood and
mild depressive symptoms that are transient
and self-limited and are extremely common in
the perinatal period. Baby blues are feelings of
sadness that you may have in the first few days
after having a baby. Up to 4 in 5 new parents
(80 percent) have the baby blues. It can affect
new parents of any race, age, income, culture,
or education level.
Etiology/Cause
- Several risk factors can lead to the development
of postpartum blues. These include a history of
menstrual cycle-related mood changes or mood
changes associated with pregnancy, a history of
major depression or dysthymia, a larger number
of lifetime pregnancies, or a family history of
postpartum depression. Other studies have also
proposed that elevated monoamine oxidase
levels or decreased serotonergic activity in the
immediate postpartum period are also
significant risk factors or etiological
characteristics that could predispose a woman
to the development of postpartum blues
Signs and Symptoms
Signs and symptoms of baby blues which last only a few
days to a week or two after your baby is born may
include:
❖ Mood swings
❖ Anxiety
❖ Sadness
❖ Irritability
❖ Feeling overwhelmed
❖ Crying
❖ Reduced concentration
❖ Appetite problems
❖ Trouble sleeping
Management
• The nurse should provide validation, education,
reassurance, and psychosocial support.
• Nurse must provide precise data of the patient’s
well-being to give way to a more accurate care
plan for a woman with postpartum depression.
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• Nurse must advice patient to have time for
herself, eat well, open up to others on what she
feels, get help if needed ,and have proper sleep.
Medical Management
• If insomnia persists, cognitive therapy and/or
pharmacotherapy can be recommended.
• Counseling -Carefully screened for suicidal
ideation, paranoia, or homicidal ideation
towards the infant.
POSTPARTUM DEPRESSON
- “Postpartum” means the time after childbirth.
Most women get the “baby blues,” or feel sad
or empty, within a few days of giving birth. For
many women, the baby blues go away in 3 to 5
days. If your baby blues don’t go away or you
feel sad, hopeless, or empty for longer than 2
weeks, you may have postpartum depression.
Feeling hopeless or empty after childbirth is not
a regular or expected part of being a mother.
- Postpartum depression is a serious mental
illness that involves the brain and affects your
behavior and physical health. If you have
depression, then sad, flat, or empty feelings
don’t go away and can interfere with your day-
to-day life. You might feel unconnected to your
baby, as if you are not the baby’s mother, or
you might not love or care for the baby. These
feelings can be mild to severe.
Etiology/Cause
There's no single cause of postpartum depression, but
physical and emotional issues may play a role.
• Physical changes. After childbirth, a dramatic
drop in hormones (estrogen and progesterone)
in your body may contribute to postpartum
depression. Other hormones produced by your
thyroid gland also may drop sharply — which
can leave you feeling tired, sluggish and
depressed.
• Emotional issues. When you're sleep deprived
and overwhelmed, you may have trouble
handling even minor problems. You may be
anxious about your ability to care for a
MODULE 3M: POSTNATAL COMPLICATIONS
newborn. You may feel less attractive, struggle
with your sense of identity or feel that you've
lost control over your life. Any of these issues
can contribute to postpartum depression.
Signs and Symptoms
❖ Depressed mood or severe mood swings
❖ Excessive crying
❖ Difficulty bonding with your baby
❖ Withdrawing from family and friends
❖ Loss of appetite or eating much more than
usual
❖ Inability to sleep (insomnia) or sleeping too
much
❖ Overwhelming fatigue or loss of energy
❖ Reduced interest and pleasure in activities you
used to enjoy
❖ Intense irritability and anger
❖ Fear that you're not a good mother
❖ Hopelessness
❖ Feelings of worthlessness, shame, guilt or
inadequacy
❖ Diminished ability to think clearly, concentrate
or make decisions
❖ Restlessness
❖ Severe anxiety and panic attacks
❖ Thoughts of harming yourself or your baby
❖ Recurrent thoughts of death or suicide
Management
Nursing Management
• Nurses must be alert in sensing the current
psychological state of the patient too. They
must provide a precise data of the patient’s
well-being to give way to a more accurate care
plan for a woman with postpartum depression
Medical Management
• Psychotherapy
It may help to talk through your
concerns with a psychiatrist,
psychologist or other mental health
professional. Through therapy, you can
find better ways to cope with your
feelings, solve problems, set realistic
goals and respond to situations in a
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positive way. Sometimes family or Management
relationship therapy also helps. Nursing Management

Pharmacologic Management • Assess the mother’s psychological health even

before delivery
• Antidepressants
• Assess her history of illnesses
Your doctor may recommend an
• Assist the mother in planning for her daily
antidepressant. Most antidepressants
activities
can be used during breast-feeding.
• Recommend support groups
• Sertraline, paroxetine, nortriptyline and
• Advise mother to take some break from her
imipramine
regular baby care
are the most evidence-based
• Encourage the mother to keep in touch with her
medications for use during
breastfeeding. social circle
• Never leave the woman alone while waiting for
POSTPARTUM PSYCHOSIS a professional
- Postpartum psychosis is a serious mental illness • Provide family education
that starts soon after childbirth. It is the most Medical Management
severe form of postpartum psychiatric illness. It
is a rare event that occurs in approximately 1 to • Refer to psychiatric care or Psychotherapy
2 per 1000 women after childbirth. Its • For severe cases, ECT ( Electroconvulsive
presentation is often dramatic, with onset of Therapy) will be implemented
symptoms as early as the 48 to 72 hours after
Pharmacologic Management
delivery. The majority of women with puerperal
psychosis develop symptoms within the first • Treatment may require a combination of
two postpartum weeks. medications such as antipsychotic medications,
mood stabilizers and benzodiazepines
Etiology/Cause
- Possible activation of previous mental illness,
hormonal changes, and family history of bipolar
disorder.

Signs and Symptoms

❖ Delusions or strange beliefs
❖ Hallucinations (seeing or hearing things that
aren’t there)
❖ Feeling very irritated
❖ Hyperactivity
❖ Decreased need for or inability to sleep
❖ Paranoia and suspiciousness
❖ Rapid mood swings
❖ Difficulty communicating at times
❖ Changes in appetite or eating
❖ Irritability
❖ Confusion

MODULE 3M: POSTNATAL COMPLICATIONS YUSON,DREA