Every year there are an estimated 200 million
pregnancies in the world.
Each of these pregnancies is at risk for an
adverse outcome for the woman and her
infant. While risk can not be totally eliminated,
they can be reduced through effective,
affordable, and acceptable maternity care.
To be most effective, health care should begin
early in pregnancy and continue at regular
intervals.
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9)
The antenatal period.
Signs and symptoms of pregnancy.
Physical and psychological changes during
pregnancy.
Prenatal care.
First trimester of pregnancy.
Second trimester of pregnancy.
Third trimester of pregnancy.
Antenatal complications.
Care of pregnant client.
The period from conception to the end of the
fourth stage of labor.
The antenatal care
The periodic ‫ تقييم دوري‬evaluation of specific,
critical elements to determine fetal and
maternal wellbeing and to take appropriate
action for health maintenance.
 Presumptive
signs of pregnancy:
These signs are least indicative of pregnancy;
they could easily indicate other conditions.
Signs lead a woman to believe that she is
pregnant
 Amenorrhea.
 Vaginal changes
 Nausea & vomiting.



Frequent urination.
Fatigue
quickening :sensations of fetal movement in
the abdomen. Firstly felt by the patient.
More reliable than the presumptive signs.
Still are not positive or true diagnostic findings.
1.
abdominal changes:- increase girth
2.
Uterine changes :more globule enlarged,
soft and spongy.
3.
Fetal outlines at 24 weeks
4.
Ballottement. dropping and rebounding of
the fetus in its surrounding amniotic fluid in
response to a sudden tap on the uterus
5.
Goodell’s sign (softening of the cervix ) 4-6
weeks
6. Chadwick's sign:
 Bluish or purplish discoloration of the
mucous membrane of cervix, vagina and
vulva due to increased vascularity due to
estrogen.
7. Braxton hicks contractions.
more frequently felt after 28 weeks.
they usually disappear with walking or
exercise.
 .
8. Positive pregnancy test
1.
2.
3.
Fetal heart sound can be
detected as early as 10
to 12 weeks from the
last menstrual period
(LMP) by Doppler.
Fetal movement felt by
the examiner after about
20 weeks' gestation
Visualization of the fetus
by the ultrasound at 4
weeks
Serum HCG and urine HCG within 8-9 days
after fertilization.

aHCG similar to pituitary hormone.

BHCG unique structure specific to pregnancy.
The body of uterus
developed to provide protective and nutritive
environment.
Myometrium
muscle fibers grow up to(15-20) of nonpregnant uterus.
Becomes hypertrophy, hyperplasia due to
estrogen and progesterone effect.
The cervix
glandular tissue mucus
Cervical discharge
Increased blood flow softening, discoloration.
Vagina
Estrogen causes hypertrophy, increased
vascularization, and hyperplasia.
loosing of connective tissue increased
secretions, and alkaline media prevent bacterial
infection but favor monilia.
The breasts





Glandular hypertrophy and hyperplasia
large and more glandular breasts.
Prominent superficial veins.
More erected nipples and enlarged darker
areola
Montgomery's follicle enlarge.
Colostrums may appear by the 12 week.
GASROINTESTINAL SYSTEM



Nutritional requirements increased.
Appetite |(Inc or Dec)due to N and V.
oral cavity :
increase saliva due to swallowing difficulty
tooth decay inc due to dec (pH)
Gums may hypertrophic and friable.
GI MOTILITY:
reduced due to inc progesterone which dec
motilin (constipation)

STOMACH AND ESOPHAGUS:
gastric acid production inc, gastric hormone
inc leads to inc stomach volume and dec ph
then gastric production of mucous inc and dec
esophageal peristalsis with dec gastric reflux
due to relaxation of cardiac sphincter (heart
burn).

GALLBLADER:
altered function so slower emptying time with
thickening and stasis of bile (gallstone
formation).

LIVER:
liver enzyme inc due to high alkaline
phosphates isoenzyme.

Kidneys and urinary tract
Each kidney increase in length by (1-1.5)cm,
renal pelvis is dilated, ureters are dilated,
elongated, widen and become more curved
urinary stasis may lead to infection.
The glomerular filtration rate increase.
Bladder: As the uterus enlarges, the bladder
is displaced upward‘ and flattened pressure
uterus leads to increased in urinary frequency
Hematologic System
BLOOD VOLUME:
Blood volume increased(45-50)% for extra
blood flow to the uterus, extra metabolic needs
of fetus and increased perfusion of other
organs e.g. kidneys.
IRON:
increased RBC the need of iron for production
of hemoglobin increased. if supplemental iron
not sufficient iron deficiency anemia will result.
CLOTTING FACTORS:
Level of fibrinogeli and factor 8.
Also factorsVII,IX,X and XII increased.
Pregnancy is a hypercoagulability state with
increased risk of DVT.
Cardiovascular system
HEART:
Cardiac size increase about 12%.
Cardiac output increase 25%—50%.
Heart Rate increase by 10 beats/ minute.
Blood pressure: reduced during the2nd trimester.
Interstitial fluid volume:
increases 40% in the 3rd trimester causing
edema in legs.
Femoral venous "saphenous, iliac, femoral"
pressure increases due to pressure of
enlarging fetus on pelvic veins cause varicose
veins and edema.
Respiratory System
Shortness of breathing due to crowding of chest
cavity because uterus growth displace the
diaphragm by as much as 4cm.
Thoracic breathing replaces abdominal breathing.
upper resp vascularity increase. Epistacsis.
Resp resistance decrease.
Res Rate may increase.
Functional residual capacity decrease. Dyspnea.
Hyper ventilation occur PCO2 falls to 27-30
P02 increase to 104
Skin and Hair
increased estrogen and progesterone and
increased melanocyte stimulating hormone
pigmentation increases in the areola, nipple,
vulva, perineal area and linea nigra, chlaosma
the mask pregnancy.
Sweat and Sebaceous glands are hyperactive
striae gravidarum (reddish, slightly depressed
streaks "stretch marks" on abdomen, thighs)
Vascular spider nevi may appear.
Hair and nail growth may increase.
Musculoskeletal system
Progesterone and Relaxin hormone cause
loosening of the pelvic joints and ligament
causing discomfort, and wide separation of the
symphysis pubis by 32 weeks of pregnancy
makes women walk with difficulty.
The lumbodorsal curve of the spine increase.
Lordosis may occur to compensate.
"Diastases recti" separation of the rectus
abdominal muscle. Caused by the abdominal wall
has difficulty stretching enough to accommodate
the growing fetus.
Neurologic system
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
Compression of nerves may occur due to
edema "Carpal tunnel syndrome".
Compression by the gravid uterus leads to
sciatic pain.
Faintness and syncope may occur.
Muscle cramping.
Endocrine system
ANTERIOR PITUITARY GLAND:
 Suppresses FSH, LH un ovulation.
 Prolongs corpus luteum phase in pregnancy.
 Prolactin initiates lactation.
POSTERIOR PITUITARY GLAND:
 Oxytocin which causes uterine contractions,
milk ejection.
THYROID GLAND:
Slight enlargement inc basal metabolic rate.
Increased thyroid hormone production.
PARATHYROID GLAND:
Slight enlargement.
increased parathyroid hormone production.
better utilization of calcium and vitamin D.
PANCREAS:
Early in pregnancy, decreased insulin production
because of heavy fetal demand for glucose.
After first trimester, increased insulin production
because of insulin antagonist properties of
estrogen progesterone and human placental
lactogen additional glucose is available for fetal
growth
RELAXIN:
Appears early in pregnancy inhibit uterine
activity, remodels collagen to the cervix and
loosen joints.
PROSTAGLANDIN:
Involved in initiating labor.
Immune system
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
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Immunologic competency during pregnancy
apparent decreases, probably to prevent the
woman's body from rejecting the fetus as if it
were a transplanted organ.
Increased capacity to fight bacterial infection
as WBCs increase.
Decreased ability to fight viral infection.
Metabolism
Weight gain
1.
2.
3.
4.
uterus and its contents
increase breast tissue.
blood and water volume in the form of extra
vascular and extra cellular fluid.
deposition of fat and protein.
The average weight gain during pregnancy is
12.5 kg.
Psychological changes during
pregnancy

1.
2.
3.
4.
A woman's attitude toward a pregnancy
depends on:
Environment in which she was raised
Messages about pregnancy and child bearing
her family communicated to her.
Society and culture in which she lives
And whether the pregnancy has come at a
good aspect in her life.
Common psychosocial changes during
pregnancy
First trimester
Accepting the pregnancy, woman spend time
recovering from shock of learning she is
pregnant, and concentrate on what it feels like
to be pregnant.

A common reaction is ambivalence, or feeling
both pleased and not pleased at the pregnancy.
Second trimester
Accepting the baby, woman move through
emotions such as narcissism‫ اناني‬and
introversion ‫احتواء‬as she concentrate on what it
will feel like to be apparent, role-playing and
increased dreaming are common.

Third trimester
preparing for the baby and end of pregnancy.


Woman grow impatient with pregnancy as she
prepares her self for birth
Discomforts of pregnancy

Constipation: as the weight of the growing
uterus presses against the bowel and peristalsis
so constipation may occur.
Management and Nursing intervention:
1) Discuss preventive measures early in pregnancy
to avoid this problem.
2) Encourage mother to evacuate bowels regularly.
3) Eat raw fruits and vegetables.
4) Drink at least 8 glasses of water daily.
5) Enemas should be avoided, because their action
may initiate labor.

Nausea and vomiting:
Present between 4 and 16 weeks gestation.
 Management:
1) Explain the probable reasons understanding
the cause provides comfort.
2) Small frequent meals (not meals).
3) Carbohydrate snacks like crackers at bed time
and before rising from bed.
4) Avoiding fluid with meals.
If vomiting severe, mother may lose weight and
dehydrated this case called "Hyper emesis
gravidarum” and need special care.

Heartburn: pyrosis
Burning sensation in the midiastinal region
occur at about 30-40 weeks of gestation.
 Management:
1) Avoiding bending over, not lying down
immediately after eating.
2) Small frequent meals.
3) Sleeping with more pillows, or right side.

fatigue:
early pregnancy due to inc metabolic needs
 relieved by increasing rest and sleep.

Muscle cramps:
Decreased serum calcium and increased serum
phosphorus levels commonly cause muscle
cramps at lower extremities during pregnancy.

management:
It relieved by the woman lying on her back and
extending the involved leg while keeping her
knee straight and dorsiflexing the foot until the
pain is gone.

Hypotension:
"Supine hypotensive syndrome"
when she lies on her back ,the uterus presses
on the vena cava, impairing blood return to the
heart.

1)
2)
3)
management:
Relieved by turning the woman to her side.
If she rises suddenly lying or sitting position
or stands for along time in a warm or crowd
area she may faint.
Rising slowly and avoiding extended
standing prevent this problem.
Heart palpitations:
On sudden movement its due to the circular
adjustments necessary to accommodate her
increase blood supply during pregnancy.
Gradual, slow movement will help prevent
It is reassuring for her to know (palpitations
are normal and to be expected occasions).
Varicosities: Tortuous leg veins caused by:
1) Pressure of the distended uterus on lower
extremities.
2) Pressure causes pooling of blood in the vessel
veins become engorged, inflamed and painful
this can extend to the vulva.
 Management:
1) Resting in sims’ position.
2) Avoid sitting (legs crossed ,knees bended).
3) Wear elastic support stockings before arising
from bed in the morning.
4) Avoid standing or sitting/for long periods.
Frequency of urination:
Occurs in early pregnancy due to the pressure
of the growing uterus on the bladder.

Management:
1) No solutions for dec frequency of urination.
2) Reduce the amount of caffeine.


Leucorrhea:
A whitish viscous vaginal secretions due to
estrogen and increased blood supply to the
vaginal epithelium and cervix.
Management:
1) Daily bath or shower.
2) Wearing cotton underwear.
3) Avoid tight underwear.
Backache:
Due to lumbar lordosis, postural changes to
maintain balance.
Management:
1) Wearing shoes with low to moderate heels.
2) Encourage to walk with her pelvis tilted
forward.
3) Applying local heat. Avoid back strain.
Dyspnea:
Pressure of the uterus on the diaphragm, cause
shortness of breath.
occurs usually at night when sleeping in flat
position, or on exertion.

Management:
1) Sitting upright to relieve pressure on
diaphragm.
2) Sleep on extra pillows to relieve dyspnea.
3) Limit activities to prevent dyspnea.

Ankle edema:
Swelling of ankles and feet during late pregnancy
noticed at the end of the day.
Management:
1) Relieved by resting in side-lying position.
2) Sitting twice a day at evening with legs
elevated.
3) Avoid wearing constricting clothing "kneehigh stockings".
4)
Reassure the woman that it is normal during
pregnancy "ankle edema".
Carpal tunnel syndrome:
She complain of numbness as "pins and
needles" in her fingers and hands.
Happen in morning or at any time of the day,
due to fluid retention which create edema and
pressure on the median nerve.

Management:
Wearing a splint at night with the hand resting
high on two or three pillows.
Danger signs of pregnancy
1)
2)
3)
4)
5)
6)
7)
8)
Vaginal bleeding.
Persistent vomiting.
Chills and fever.
Sudden escape of clear fluid from vagina.
Abdominal or chest pain.
Pregnancy induced hypertension (PIH).
Rapid Weight gain, Flashes on light or dots
before the eyes. Blurring of vision. Severe
continuous headache,Dec urine output.
Increase or decrease fetal movement.
Aims Of Antenatal Care
1)
2)
3)
4)
5)
To promote and maintain good physical and
mental health during pregnancy.
To ensure a mature, live, healthy infant, to
monitor the growth and wellbeing of fetus.
To prepare the woman for labor, lactation
and subsequent care of her child.
To recognize deviation from normal and
provide management or treatment as
required "high risk pregnancies".
To offer the family advice on parenthood.
"health education".
Frequency of Antenatal Visits:
1)
Every month till 28 week.
2)
Every two weeks till 36week.
3)
Weekly till delivery.

First Visit: "History taking"
1) Demographic data: name, age.
2) Past medical and surgical history.
3) Family history: D.M, HTN, Twins.
4) Past obstetric history. Gravida, parity.
5) Previous pregnancies complications.
6) Previous deliveries complications
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7)
8)
9)
10)
11)
12)
Previous puerperium.
Number of children their condition.
Contraceptive.
Nutritional history, daily meals.
Current obstetric history.
Pre pregnancy weight.
First visit: complete assessment, height,
weight, blood group, Rh, Hb%, VDRL.
Every visit: Wt,vital signs, routine exam fundal
height, fetal heart rate, gestational age, lower
limbs exam, breast exam, teeth exam.
Urine analysis and Hb test usually done at first
visit, 28 weeks, and 36 weeks of pregnancy
Revisit "interval history“
1) How she has been since her last visit, in
term of sleep, rest, nutrition, signs of minor
disorder.
Abdominal Examination
1)
2)
3)
4)
5)
6)
7)
The uterus cant be palpable until 16th week.
Aims of abdominal examination:
To observe signs of pregnancy.
To assess fetal size growth.
To assess fetal health.
To diagnose the location of fetal parts.
To detect any deviation from normal.
Methods:
1) Inspection:
size, shape of uterus, fetal movement, skin
changes.
Palpation:
estimate the period of gestation by fundal height:
 At 12 week at the level of symphysis pubis
 At 24 Week at the level of umbulica.
 At 36 week at the level of xiphisternum.
2)
Areas of palpation
1) Fundal palpation.
2) Lateral palpation.
3) Pelvic palpation.
Auscultation:
hearing FHR 120-160 bpm.
3)
Lie:
the relation of the long axis of the fetus to the
long axis of mother.
Longitudinal lie, transverse lie, oblique lie.
Presentation:
the part of the fetus which lies at the pelvic brim
or in the lower pole of uterus.
 Head: vertex 97%, face 0.2%, brow 0.1%
 Breach 2.5%.
Position:
the relation of the back of the fetus to the right
or left sides of the mother Weather is directed
anterior or posterior.
Denominator:
The name of part of presentation, which is used
when referring to fetal position.
 In vertex: occiput.
 In Breech: sacrum.
 In face: mentum.
Attitude:
The relation of fetal pans to each other, Flexion,
Extension.
Engagement:
When the Widest presenting transverse diameter
pass through the pelvic brim.
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
In primigravida engagement between 36-38
weeks.
In multipara engagement during labor.
Calculate the estimated date of delivery, EDD,
using Neglal's formula.
1)
Add 7 days on the first day of L.M.P,
2)
Subtract 3 months then add one year.
3)
Or add 7 days and 9 months.
Indicators Of Fetal Well Being
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Increasing maternal weight in association With
increasing uterus size compatible with
gestational age.
Fetal movement.
Fetal Heart rate should be between(120-160)
beat/minute.
High Risk Pregnancy
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Grand multipara (5 or more).
Primigravida.
Multiple Pregnancy.
Woman with serious medical disorder
(Heart disease, DM, HTN, anemia).
Malpresentation "Breech, Transverse”.
Previous cesarean section or uterine operation.
Ant partum hemorrhage and/0r previous post
partum hemorrhage.
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Rh negative mother.
Previous history of complicated labor, preterm
of instrumental delivery. .
Recurrent abortion or preterm labor.
Age factor less than 18 or more than 35 years.
These cases need additional antenatal care.
More frequent visits, referral to medical care
hospital, delivery, and post natal follow up,
advice for family planning.
Fetal Growth And Development
Three periods of prenatal development:
 Pre embryonic or ovum.
Period from conception until day 14.
Zygote develops into the blastocyst and
implants it self into the endometrium.
Embryonic:
Period from day 15 until 8 weeks.
Referred to as an embryo.
Critical stage for organ and external feature
development highly vulnerable to teratogens.

Fetal:
Period from 9 weeks gestation until pregnancy
ends.
Characterized by refinement of structure and
function developed during the previous two
stages.
Referred to as a fetus.
Less vulnerable to teratogens except for those
that can interfere with the development of the
brain and central nervous system (CNS).

Three Germ Layers:
 Ectoderm:
The epithelium of the skin, hair, nails,
sebaceous glands, sweat glands, and nasal
and oral passages; the salivary glands and
mucous membranes of the mouth and nose;
the enamel of the teeth; the mammary
glands; the central nervous system (brain and
spinal cord) and the peripheral nervous
system.

Mesoderm:
Muscles, bones, cartilage, the dentin of the
teeth, ligaments, tendons, areolar tissue,
striated and smooth muscles, kidneys,
spleen, ureters, ovaries, testes, heart, blood,
lymph and blood vessels and the lining of the
pericardial, pleural and peritoneal cavities
Endoderm:
Epithelium of the digestive tract and
respiratory tract (except the nose), thymus,
liver, pancreas, bladder, urethra, thyroid, and
tympanic tantrum and auditory tube.

Progress of fetal development:
 These illustrations can be an effective
prenatal teaching tool when working with
pregnant women and their families.
Early morphologic formations
The embryo is 4 to 5 mm in length.
 Trophoblast embed in deciduas.
 Chorionic villa form.
 Foundation for nervous system,
genitourinary system.
 Skin, bones, and lungs are formed.
 Buds of arms and legs begin to form.
 Rudiments of eyes, ears and nose appear.
Five to Eight Weeks
 The embryo is 27 to 31 mm in length and
weighs 2 to 4g.
 Embryo is markedly bent.
 Head is disproportionately large as a result
of brain development.
 Sex differentiation begins.
 Centers of bone begin to ossify.
Nine to Twelve Weeks
 The fetus average length is 50 to 87 mm
and weight is 45g.
 Fingers and toes are distinct.
 Placenta is complete.
 Rudimentary kidneys secrete urine.
 Fetal circulation is complete.
 External genitalia show definite
characteristics.
Thirteen To Sixteen Weeks
 The fetus is 94 to 140 mm in length and
Weighs 97 to 200g.
 Head is erect.
 Lower limbs are well developed.
 Coordinated limb movements are present.
 Heart beat is present.
 Lanugo develops.
 Nasal septum and palate close.
 Fingerprints are set.
Seventeen to Twenty Weeks
 The fetus is 150 to 190m in length and
weighs approximately 260 to 460g.
 Lanugo covers entire body.
 Fetal movements are felt by woman.
 Eyebrows and scalp hair are present.
 Heart sounds are perceptible by
auscultation.
 Vernix caseosa covers skin.
Twenty-one To Twenty-five Weeks
 The fetus is about 200 to 240m in length
and weighs 495 to 910g.
 Skin appears and pink to red.
 REM begins.
 Eyebrows and fingernails develop.
 Sustained weight gain occurs.
Twenty-six to Twenty-Nine weeks
 The fetus is 250 to 275 mm in length and
Weighs about 910 to 1.500g.
 Skin is red.
 Rhythmic breathing movements occur.
 Pupillary membrane disappears from eyes.
 The fetus often survives if born
prematurely.
Thirty to Thirty-Four weeks
 The fetus is 280 to 320m in length and
Weighs - 1.700 to 2.500g.
 Toenails become visible.
 Eyelids open.
 Steady weight gain occurs.
 Vigorous fetal movement occurs.
Thirty Five to Thirty Seven Weeks
 The fetus average length is 330 to 360mm;
weight is about 2.700 to 3.400g.
 Face and body have a loose wrinkled
appearance because of subcutaneous fat
deposit.
 Body is usually plump.
 Lanugo disappears.
 Nails reach fingertip edge.
 Amniotic fluid decreases
Thirty Eight weeks (full term)
 The average fetus is 360m in length and
weighs 3.400 to 3.600g. Skin is smooth.
 Chest is prominent.
 Eyes are uniformly slate colored.
 Bones of skull are ossified and nearly
together at sutures.
 Testes are in scrotum.
Amnion And Amniotic Fluid
The amnion expands as the embryo grows.
Amniotic fluid increase between (500-1000)
ml non foul characterized odor.



ORIGIN:
Source of amniotic fluid is both fetal and
maternal.
Secreted by amnion, some fluid is exuded
maternal blood vessels in decidua and some
from fetal vessels in the placenta.
During the first half of pregnancy the fluid is
similar in composition to maternal plasma,
later the fetus contributes to the amniotic
fluid.
Function of the amniotic fluid:
1) Cushion
2) allows for fetal movement.
3) Prevents the embryo/ fetus adhering to
surrounding tissues. protect the embryo
from infection.
4) Maintain even temperature for the
embryo/ fetus.
 Chorion develops from the chorionic villi
Umbilical Cord



Extends from the fetus to the placenta
contains 2 arteries and 1 vein.
Third month connecting stalk elongate and
become umbilical cord.
The vessels in the cord are surrounded by a
connective tissue known as Wharton's jelly
(a protective layer for blood vessels).





Average length is a bout 50cm,
Less than 40cm called short cord which may
lead to separation of placenta and bleeding.
More than 50 cm called long cord which may
lead to wrapped around the fetal neck or
become knoted which may result on
occlusion of blood vessels especially during
labor.
True knot vessels compression.
False knot not significant.
Placental Development

Into the area of deciduas basalis the blood
supply is richest.
By12weeks placenta developed into:
- Fetal portion (Amnion).
- Maternal portion(Chornion) contact with
deciduas basalis.

Cotyledons:
- Irregularly shaped lobes (16-20).
- (red and rough).




Fetal surface of placenta (amnion) contact
with the fetus, very smooth, regular surface.
Placenta covered with 2 membranes. chorion
and amnion.
Material surface: rough, irregular, made up of
chorionic villi.
Placenta at term-weight 500 gm or 1/6 the
Weight of the fetus.
FUNCTIONS OF PLACENTA:
Respiratory organ:
-exchange of 02 and C02
-fetus obtain O2 from the mother's hemoglobin
by simple diffusion and give CO2 in the maternal
blood.
Nutritive:
-passing nutrition for fetus in simple form,
amino acid, glucose, fatty acid, Water and
vitamins.
Excretory:
-take waste products from fetal blood to
maternal blood as C02,Billirubin,urea &uric acid
Protective:
-barrier for organism except syphilis and TB,
and viruses as rubella, IgG immunoglubulin.
Storage:
-glucose store in the form of glycogen and
convert it to glucose when required and store
iron and fat soluble vitamins.
Endocrine:
1) HCG-large amount excreted during(7-10)
weeks. until 12 weeks then low until term.
2) Progesterone: from 12 wks. it increases
through pregnancy then fall after placenta
expelled.
3) Estrogen: from 6-12 wks. then decreased after
expulsion of placenta and allow prolactin to
initiate lactation.
4) Human placental lactogen (HPL):



Secrete about 6th weeks.
Stimulate metabolism of glucose in fetus.
Increase in multiple pregnancy which is this case.
Anatomical Variations Of Placenta And Cord
Succenturiate lobe of placenta.
This is the most significant of the variations in
conformation of the placenta. A small extra
lobe is present, separate from the main
placenta, and joined to it by blood vessels
which run through the membranes to reach it.
The danger is that this small lobe may be
retained in utero after delivery, and if it is not
removed, it may lead to infection and
hemorrhage.

Circumvallate placenta.
In this situation an opaque ring is seen on the
fetal surface. It is formed by a doubling back of
the chorion and amnion and may result in the
membranes leaving the placenta nearer the
centre instead of at the edge as usual.

Battledore insertion of the cord.
The cord in this case is attached at the very
edge of the placenta in the manner of a table
tennis bat. It is unimportant unless the
attachment is fragile.

Velamentous insertion of the cord.
The cord is inserted into the membranes some
distance from the edge of the placenta.
The umbilical vessels run through the
membranes from the cord to the placenta.
 Bipartite placenta:
Two complete, separate lobes are present, each
with cord leaving it. It is different from the two
placenta in a twin pregnancy (two umbilical
cords, but don't join at any point).
Tripartite placentae:
Is similar but with three distinct lobes.

Influencing Factors Of Fetal Growth And
Development.
Exposure to teratogens can adversely affects
fetal newborn health.
Nature of harmful effect: is influenced by:
1) Toxicity of the teratogens.
2) Amount and length of exposure.
3) Timing of the exposure.
-Pre embryonic period(spontaneous abortion).
-Embryonic period(structural and anatomic abnormalities).
-Fetal period(behavioral abnormality,(I.U.G.R)).
Teratogens Type:
1) Drugs and chemicals as alcohol, nicotine,
cocaine or certain antibiotics
2) Environmental pollutants.
3) Infectious agents that cause rubella,
syphilis.
4) Radiation.
5) Maternal health problems as diabetes.
Maternal health habits and life style
1) Poor nutrition.
2) Stressful life style.
3) Poor hygiene.
4) Environmental pollutants at home or at
Work.
Paternal health habits
1) Fertility, as sperms (number, viability,
motility).
2) genetic problems, should receive
preconception care counseling to adapt a
healthy life styles.
Hyperemesis gravidarum



Severe nausea and vomiting lead to
dehydration, electrolytes imbalance, loss of
weight.
The etiology is uncertain, endocrine and
psychological factors being proposed,
increased level of estrogen and HCG.
More in multiple pregnancy and hydatiform
mole.
Diagnoses:
History of persistent vomiting & nausea(severe).
1) The mother suffering from unable to retain
food or fluid.
2) Loss of weight, distressed by her symptoms.
3) Admission to hospital for assessment and
management.
In sever dehydration:
-Rapid pulse.
-Low blood pressure.
-Dry furred tongue.
-Mothers breath (smell of acetone).
-Sign of ketosis.



Nothing by mouth.
when vomiting controlled ,gradual
introduction of fluid and then soft diet.
Management:
1)
2)
3)
4)
5)
Treatment of dehydration and electrolytes
imbalance.
Antihistamines are recommended.
No anti emetic being approved for treatment.
Mother encouraged to rest ,cared for in
single room.
Some women may be prescribed mild
sedative.
6)
7)
8)
Supportive psychotherapy or counseling to
treat some cases.
I.V fluid for correction of hypovolemia,
electrolytes.
There may be other causes for vomiting
(UTI or gastroenteritis)
Hemorrhagic disorders, complications
Causes of bleeding during first half of pregnancy:
1) Abortion.
2) Ectopic pregnancy.
3) Hydatidiform mole.
Causes of bleeding in second half of pregnancy:
1) Placenta previa.
2) Abruption placenta.
"Abortion" Miscarriage


Termination of pregnancy before fetus is
sufficiently developed to survive, before 20th
weeks or delivery of a fetus weight<500gm.
Incidence: (10-15) % of all pregnancies.
Types of abortion
Spontaneous:
Threatened, Inevitable, Incomplete, Complete,
Missed, Recurrent, Illegal, Septic.
Induced: Therapeutic
Bleeding due to separation of the fertilized
ovum its uterine attachment. Followed by
cramps, then soften dilate cervix, then abortion
complete.
Causes of abortion
Fetal causes:
1) Chromosomal most common.
2) Inherent defect. First trimester abortion 80%
associated with some defect of embryo or
trophoblastic or both.
Maternal causes:
1) Severe acute infection e.g. rubella.
2) Endocrine disorder affecting progesterone
estrogen levels, alter the endometrial lining
of the uterus causing abortion (DM, Renal,
thyroid disorders).
3) Malformation of genital tract, short cervix,
uterine malformation, retro position of
uterus, bicornuate uterus or fibroid.
4) Trauma
Environmental factors:
 Alcohol.
 Smoking.
Classification of abortion
Spontaneous abortions:
1) Threatened Abortion:
 Any vaginal blood loss in early pregnancy.
 Scanty blood loss.
 With or Without back pain and cramps.
 Cervix closed, uterus soft, no tenderness.
Management:
1) Mothers advised to rest, stay in bed.
2) Well balanced diet.
3) Instruct client to save pads.
4) Avoid coitus.
5) Hospitalization.
6) IV fluid or therapy.
7) Blood transfusion.
2) Inevitable abortion:
 Heavy vaginal bleeding With clots or products
of conception.
 The uterus if palpable is smaller than expected.
 Membranes rupture.
 Cervix dilate.
Management:
1) To control vaginal bleeding:
syntocinon 20 IU I.M or ergometrine 0.5mg I.V
or I.M. can be given.
2) Analgesics administered.
3)Incomplete abortion:
 Reminants of placenta remain within the
uterus.
 Heavy and profuse vaginal bleeding.
Management:
1) Ergometrine 0.5mg I.V or IM. to control
bleeding.
2) Evacuation to remove any retained tissue.
3) (D&C) dilatation and curettage if cervix closed.
4) (E&C) Evacuation and curettage if cervix
opened.
4) Complete abortion:
1) The conceptus, placenta, and membranes are
expelled completely from the uterus.
2) Pain stops, signs of pregnancy will regress.
3) Uterus on palpation is firmly contracted.
4) No medical intervention is required.
5) Missed abortion:
 When the embryo dies, despite the presence of
viable placenta, and the sac retained.
 Brown blood loss degeneration of placental
tissue.
 Woman report a reduction, then cessation" of
the symptoms of pregnancy.
 Uterine growth stops.
Management:
 Evacuation of uterus by D & C under G.A
Complication:
 Hypofibrinogenaemia may occur if the fetus
has been retained for some weeks.
6) Septic abortion:
 It’s a complication of induced abortion or
incomplete abortion.
 It is due to ascending infection.
 Signs and symptoms:
in addition to the signs of miscarriage the other
complains of feeling un well, headache nausea
and pyrexia.
 Localized uterine tubes and cavity.
 Generalized septicemia with peritonitis.
Management of septic abortion 
Blood culture and vaginal swabs to identify the 
cause of the infection.
IV Antibiotics should be given. 
G. Recurrent abortion: 
The loss of three or more consecutive pregnancies.
Causes: 
1- Genetic causes. 
2- Immunological factors lack of immunoglobulin G 
blocking agent.
In normal pregnancy IgG coats the fetal antigen 
and prevent rejection of the fetus.
3- Hyper secretion of luteinizing hormone may act 
on the endometrium resulting in errors in
implantation.
4- Infections. 
5- Structural anomalies: 
Cervical incompetence. Uterine abnormalities. 
Incompetent cervix:
Is a mechanical defect in the cervix, causes the
cervical OS to dilate prematurely during the mid
trimester lead to habitual abortion or pre term
labor.
Causes: Congenital abnormalities. Prior trauma.
Signs and Symptoms: painless dilatation, 
presence of bloody show. Bulging membranes.
Management: Surgical treatment: (cerclage): 
Suturing cervix shirodkar technique. 
McDonald technique: at 12-14 Week success 
rate 80% to 90%.

After cerclage care: 
1. Monitor F .H.R.
2. Observe signs of rupture membrane and uterine
contractions.
Cerclage usually removed the 37th Week. 
Sometime C/ S delivery may be elected to 
preserve the suture for other pregnancies.
2 Induced abortion: when allowed:
1- If continuation of pregnancy Would involve 
risk greater than if pregnancy were
terminated.
2- Termination is necessary to prevent grave 
or permanent injury to the physical or mental
health of the Woman.
3- The continuance of the pregnancy would 
involve risk to the life of the pregnant
Woman, greater than if pregnancy was
terminated.
4- There is substantial risk that if the child 
was born it would suffer such physical or
mental abnormalities as to be seriously
handicapped
Methods of induced abortion:
Abortion can be carried out in the first
trimester.
l-Using vacuum aspiration, dilatation and
evacuation.
2-Mifepristone anti progesterone compound
taken orally.
I In the second trimester: 
Methods used are extra uterine
prostaglandin and oxytocin.
Ectopic pregnancy
Any gestation that is implanted out side 
the uterine cavity.
Sites of ectopic pregnancy: 
Ampullar portion of the fallopian tube, the
most frequently. Interstitial portion of the
tube, (5%).
Cornual in a rudimentary horn of uterus. 
Cervical, abdominal and ovarian 
gestations.

Causes of ectopic pregnancy
Pelvic inflammatory disease. "salpingitis". 
Previous inflammatory processes of the 
external peritoneal surface of the tube.
Endometriosis of the tube wall and lumen. 
Developmental abnormalities segmental 
narrowing or excessive length of kinking.
Previous abdominal or tube surgery scarring or
adhesions.
Previous tubal sterilization. 
Use of low dose progesterone oral 
contraceptive.
Suggested factors: smoking, using IUCD, prior
induced abortion


Clinical Picture: "Depending on the Site"
Un ruptured ectopic pregnancy: 
Vague and variable discomfort may develop. At
first the woman exhibits the usual signs and
symptoms of pregnancy.
Vaginal bleeding occurs when the embryo dies 
the decidua slough Characteristics scant and
dark brown bleeding.
Abdominal pain vary with the length of 
gestation, site, blood loss: abdominal pain is the
pre dominant symptom of tubal rupture. May be
local on one side or felt entire the abdomen.
Cramping or knifelike pain 
Referred shoulder pain intra peritoneal
bleeding extending to the

diaphragm and irritating the
phrenic nerve The Woman may or
may not manifest syncope,
hypotension, tachycardia and other
symptoms of shock, depend on the
amount of blood loss.
Medical Management:
Early diagnosis based on a detailed health 
history, physical exam, and diagnostic tests.
HCG, culdocentesis, curettage, laparoscopy, and
ultrasonography.
HCG is usually lower than in uterine pregnancy 
at same gestational period.
Positive pregnancy test and fluid in the Sac or 
abnormal pelvic mass diagnostic ectopic.
Surgery is necessary (salpingectomy). 
Salpingetomy, or segmental resection and 
anastomosis is preferred to conserve tubes.
Nursing Assessment: 
Nurse should focus on missed period, 
abdominal pain, vaginal spotting and
characteristics of pain.
Ask about history of IUCD, or history of tubal 
damage, vital signs assessed deviate. If tube
rupture.
monitor for signs and symptoms of 
hypovolemie shock, rapid thready pulse,
tacehypnea, hypotension.
The umbilicus may display a blue tinge cullen's
sign which indicate peritoneal bleeding.
Incidence of recurrence is 7-15%. 

Nursing Diagnosis:
1- Fluid volume deficit related to bleeding from
rupture at implantation site or excessive blood loss
from surgery.
2- Anticipatory grieving related to loss of
pregnancy.
3- Pain related to tubal rupture,intra peritoneal
bleeding.
4- Knowledge deficit related to lack of information
about treatment and possible complication.
Nursing Intervention:
Explain the various diagnostic tests. IV infusion 
is maintained to replace blood loss.
Post operative: 
Vital signs, fluid replacement, Intake and output 
record.
NPO, early ambulation, assess vaginal bleeding. 
Monitor signs and symptoms of hemorrhage, 
dressing site of operation.
Antibiotics administered. 
Steroids administered to decrease post operative 
inflammation and to prevent adhesions.
Hydatidiform mole
Is a gross malformation of the trophoblast in which
the chorionic villi proliferate and become a vesicular.
Incidence:0.5-2.5 in 1000 pregnancies 
Types 1- Complete hydatidiform mole: 
This contains no evidence embryo, cord or 
membranes.
Hyperplasia affects the syncytiotrophoblast, the 
cytotrophoblast layers.
Usually have 46 chromosomes of paternal only a 
haploid sperm fertilizes empty ovum.
Choriocarcinoma can develop this type. 
2- Partial mole:

Evidence of an embryo, fetus or amniotic sac be found, as death
occurs around the eighth or ninth week.
Hyperplasia affects only the syncytiotrophoblast layer of the 
trophoblast.
Its less spread than in the complete moles. 
Usually(69) chromosomes, one male and two paternal sets. 
Causes of moles
1- Cause of the abnormal ovum and spermatic fertilization and 
replication in molar pregnancies is unknown.
2- Incidence is higher among: Low socioeconomic status. 
Women from southeast Asia. (one in every 2000) 
Prior gestational trophoblastic neoplasia.- 
Women under 20 and over 40 years of age. 

Clinical picture:
Pregnancy appears to be normal at first.
The uterus is larger than expected for
gestational age.
Bleeding vary from brownish-red spotting to
heavy, bright red bleeding.
Severe vomiting.
Fetal heart tones are absent, in the presence of
other signs of pregnancy.
Pre eclampsia, may appear before 20th week.
Women with partial moles typically have a clinical
diagnosis of spontaneous or missed abortion.
Vesicles may be evident in the vaginal discharge or
abortus.
A blood or urine BhCG level is Strongly positive
higher than normal pregnancy.
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Medical diagnosis:
Ultra sound :multiple dense regions within the
uterus: hydropic villi and focal intra uterine
hemorrhage without any fetus detected.
Prognosis:
Complete moles have a higher incidence of
choriocarcinoma.
The calutein cyst, remobilization of the lung.
DIC (Disseminated intravascular coagulation).
Blood loose leads to "anemia".
Medical Management:
1- Emptying the uterus usually by D&C.
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2- Hysterectomy for patients who have
complete child bearing.
3- The tissues evaluated by pathologist.
4- BHCG to detect any changes that suggest
trophoblastic malignancy.
Weekly for 3 weeks then monthly for 6 months
then every two months for next 6 months.
Negative BHCG levels should be evident within
6 weeks after evacuation.
5- Physical and pelvic examination every 2
Weeks, chest x-ray to detect metastases.
6- Avoidance of pregnancy is recommended
during the period of follow up.
7- Chemotherapy, administered if carcinoma
developed.
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Nursing Interventions 
1- Assist with client preparation for evacuation. 
2- Pre and post operative nursing care. 
3- Client teaching :emphasize on the need for 
follow up surveillance of HCG levels. Family
planning, counseling.
4- Psychological support. 
Choriocarcinoma: 
Highly malignant trophoblastic neoplasm that
develop during or shortly after some forms of
pregnancy.
One third to one half of chorioearcinoma are 
preceded by hydatidiform mole.
Treatment: Chemotherapy and radiation. 
Hemorrhagic complications of late pregnancy

Ante partum Hemorrhage
Bleeding from genital tract in late pregnancy, 
after 24th Wk of gestation and before the onset
of labor.
Effects on the fetus 
1- Fetal mortality and morbidity are increased.
2- Stillbirth or neonatal death.
3- Mentally and physically impaired child, related
to hypoxia resulting from premature separation
of placenta.
Effects on the mother 
1- Shock"Hypovo1emic".
2- Disseminated intravascular coagulation (DIC).
3- Mother may die or with permanent illness.
Types of antepartum hemorrhage: 
1- Placenta previa. 
2- Placental abruption. 
3- Extra uterine causes "incidental". 
Cervical lesions: polyp, erosion, cancer.
Trauma to the vagina.
Causes(Incidental causes) 
Cervicitis. 
Trauma. 
Genital infection. 
Hematuria, polyps. 
Factors aid in differential diagnosis. 
Pain 
Onset of bleeding. 
Amount of visible blood loss. 
Color of blood. 
Degree of shock.
Tenderness of the abdomen.
Audibility of the fetal heart.
U/S.




Placenta previa
The placenta is partially or Wholly implemented in
the lower uterine segment, anterior or posterior
location.
In later weeks of pregnancy the placenta
separated, sever bleeding occur because of the
stretching of uterine Wall.
Placenta previa put mother and fetus in high risk
condition.
Degrees of placenta previa:
1- Type 1 placenta‘ previa: "low implantation",





2- Type 2 placenta previa: "marginal placenta
previa", placenta is partially located in the lower
segment near the internal os.
3- Type 3 placenta previa: "partial placenta
previa". placenta partially cover the internal os,
bleeding is likely to be severe, vaginal delivery is
inappropriate.
Type 4 "Total placenta previa", (placenta previa
centralis) placenta completely cover the internal
os, severe hemorrhage. Caesarean section is
essential. Incidence: 1: 167 deliveries
Clinical picture:
Painléss, bright red vaginal bleeding.
Bleeding may begin as spotting or profuse
Hemorrhage. - Occur during the second or third
trimester.
The uterus remain soft

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Indicators of placenta previa.
Painless vaginal bleeding.
Uterus not tender or tense.
Fetal head not engaged in primigravida.
Malpresentation (breech).
Lie-oblique or transverse: unstable in
multigravida.
Ultrasound confirm localization of placenta
Assessing mother's condition
Assess the amount of bleeding, ask mother
about onset of bleeding. (sudden onset).
Hemorrhage-mild, moderate, sever: occur at
rest.
The color of blood is bright red.
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Assess . pulse, temperature, blood pressure,
respiration.
Mother looks pale and cold moist skin.
Assess fetal condition.
Observe signs of shock (pallor, breathlessness).
Causes of placenta previa: . Unknown cause.
Risk factors associated with placenta previa:Multiparty, advanced maternal age > 35,
Multiple gestation, previous C/S birth , and
uterine incisions.
Medical diagnosis:
Ultrasonographic techniques 95% accuracy.
Physical examination of the cervix, performed
in the operating room under special
preparations.
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Prognosis: 
l-Obstruction of the birth canal leads to C/S
delivery
2-Post partum hemorrhage.
3- Anemia
4-Infection.
5-Premature fetus.
6-Intra uterine growth retardation "IUGR".
Management of placenta previa Depends on: 
1- The amount of bleeding. 
2- The condition of mother and baby. 
3- Location of placenta. 
4- The stage of pregnancy. The goal of medical 
management: Ensure the birth of a mature
neonate without complications to the mother and
Conservative management:
Appropriate when the fetus is not mature and the
bleeding is not excessive:
Bed rest.
Observation of maternal and fetal wellbeing.
Tocolysis used to prolong gestation to term.
Delivery planned when fetal maturity.
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If the fetus is at term, if labor has begun or if bleeding
is sufficient to threaten the Wellbeing of the woman
or fetus —>Delivery is initiated.
Under emergency situations Delivery must be
performed regardless of gestational age.
Caesarean birth is the delivery of choice in all
instances of total previa or greater than 30% partial
previa.
Nursing Assessment:
1- Baseline vital signs.
2- Bleeding, onset, characteristics.
3- Uterine activity "contraction, relaxation".
4- Pain or tenderness in the abdomen.
5- Fetal heart tones and activity.
6- Level of consciousness.
7- X-matching client blood "prepare blood" .
8- Perineal pads should be saved and
examined by the nurse to estimate blood loss.
9- Instruct client to report vaginal discharge.
10- Assess client for signs of shock.
11- Hemoglobin measured daily to assess
blood loss.
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Nursing Intervention:
Depending on whether conservative or active 
medical management is prescribed.
1- Continuous close monitoring of maternal 
and fetal condition for signs of infection.
2- Replacement of blood loss. 
Abruptio placenta



Is the premature separation of a normally
implanted placenta from the uterine Wall,
occurring after 24 weeks of pregnancy.
Causes: The precise cause is unknown.
Associated risk factors:
◦ Hypertension
◦ grand multigravida (more than 5)
◦ accident and trauma,
◦ multiple gestation,
◦ polyhydramnios,
◦ sudden reduction of uterine size,
◦ short cord.

Incidence: 0.5% - 1.5% of all pregnancies.
Clinical picture:
Depending on the type of premature separation:
 l- Covert abruptio placenta: "Concealed"
Characterized by central separation entraps lost
blood between the uterine Wall and the placenta.
◦ Blood may infiltrate the myometrium causing couvelaire
uterus "blue discoloration of uterus.

2- Overt or revealed abruption placenta:

3- Mixed: concealed and revealed.
Peripheral detachment, blood escapes from the
placental site and drain through the vagina.
Manifestations of abruptio:
 Dark vaginal bleeding.
 Abdominal pain, sudden, knife like.
 Firm and tender uterus.
 Distention 0f the uterus.
 Signs of shock: low blood pressure, increased
pulse rate, decreased respiratory rate.
 Fetal distress or IUFD.
 Difficult to palpate fetal parts.
Clinical Grading of abruptio placenta
 Grade one: "mild"
◦ - Placental bleeding <500cc
◦ - Placental separation <1/4.
◦ Abdominal pain, discomfort, uterus incomplete
relaxation. No fetal distress.
◦ Altered coagulation.

Grade two: "Moderate“
Blood loss 500-1000cc.
Placental separation fourth to half
Continuous tenderness, uterus firm contraction.
Signs of shock: pale, low blood pressure and high
pulse. Fetal distress.
◦ Possible early consumption coagulopathy.
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Grade three: "Severe"
◦
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Blood loss > 500cc or Concealed. > 2000 cc.
- placental separation > 1/ 2
Knifelike pain, tearing, uterus bourd like, unrelaxed.
Patient shocked low blood pressure and high pulse.
Fetal severe distress or demise.
Consumption coagulopathy.
Management:
Grade one
Premature baby
Bed rest , sedation, FHR, U/S induct of labor at 37
week.
 Mature and active baby
Artificial Rupture Membrane (ARM), syntocinon,

C/ S if fetal distress.
Grade two
◦ Blood transfusion, sedation.
◦ If no fetal distress or death -ARM, syntocinon or by C/S.
Grade three
◦ Blood transfusion. Clotting factors. C/S.
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Complications of abruptio placenta
Maternal
Mortality higher than other types of antepartum
hemorrhages.
Renal failure hypovolemia.
Pituitary necrosis Sheehan's syndrome.
Postpartum hemorrhage due to hypo
fibrinogenemia and failure of blood clotting.
Disseminated intravascular coagulopathy.
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Fetal:
IUGR "intra uterine growth retardation".
Preterm delivery.
IUFD "Intra uterine fetal death".
Conservative management:
Hospital admission for rest.
Monitor placental function.
Kick chart. Cardiotocograph (C.T.G).
U/S.
Psychological support for mother. Prepare for
preterm baby.
Active management:
In sever bleeding
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◦
◦
X-Match and full blood count, clotting studies.
I.V. infusion.
Blood transfusion may be needed.
Prepare for C/S.
Prepare for preterm baby (resuscitation).
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Maternal shock.
Anesthetic and surgical complications.
Placenta accrete.
Air embolism.
Postpartum hemorrhage.
Maternal death.
Fetal hypoxia.
Fetal death.
Complications in severe bleeding:


Blood which retained behind the placenta may be
forced into myometrium and between muscles
fibers of the uterus causing damage of the uterus.
causing enlargement of the uterus an extreme
pain.
Assessing mother's condition
History of PIH as headache, epigastric pain, amniotomy.
Assess blood loss, color, onset, pain (localized pain).
Assess general condition, signs of shock.
Assess vital signs.
Assess pale, moist skin.
Obvious edema P.E.T.
Low B.P. raised pulse rate. (Shock).
and hard and tense, difficult palpation in concealed
hemorrhage.
◦ FHR difficult to be heard, U/S, CTG should be used.
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Management:
woman need urgent medical attention. Emergency
obst care.
Doctor to be called.
Comfort woman, physical and emotional support
Shock alleviation
Pain relief(Pethidine100mg IM)
IV infusion (hypovolemia)
X-Match (blood transfusion)
C.B.Cs, clotting study to detect DIC.
Intake and output chart.
Observation of V/S, blood loss (vaginal bleeding).
Observe fetal condition by C.T.G.
Fundul height.
Observe any deterioration of maternal and fetal
condition and report immediately.
Management: according to degree of placental
abruption (in general), assess:
◦
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◦

Fetal condition.
Amount of bleeding.
Gestational age.
Mother condition.
Care of the baby:
◦ Preparation for asphyxiated baby.
◦ Pediatrician to resuscitate the infant.
◦ The baby may need Special Care Baby Unit (S.C.B.U.)
(preterm baby).

Complications:
◦ DIC, postpartum Hge, Renal failure. Hypovolemia.
◦ Pituitary necrosis.
◦ Prolonged and sever hypotension.

Metabolic disorders
Anemia
Anemia is a reduction in the oxygen carrying
capacity of blood may be due to:
◦ Reduce number of red blood cells.
◦ Low concentration of haemoglobin.
◦ Combination of both.
Physiological anemia of pregnancy
During pregnancy maternal plasma volume
increase 50%) most take place before 32-34
weeks of pregnancy.
R.B.Cs increase 25%
This relative haemodilution produce a fall in
Hb% concentration present as iron deficiency
anemia.
Iron requirements in pregnancy.
During pregnancy. about 1500mg iron is needed for:

◦
◦
◦
◦
Increase in maternal haemoglobin (400-500mg).
The fetus and placenta (300-400 mg).
Replacement of daily loss through stools, urine, skin .
Replacement of blood lost at delivery .
Lactation (1 mg/day).
Routine screening of anemia
Level of Hb less than 10.5g/dl….
Serum ferritin 30Micgm/L
1- Iron deficiency anemia resulting from
 Excessive menses.
 Post Partum hemorrhage.
 Iron deprivation from previous pregnancies.
about 95% of pregnancy. Women with anemia have
iron deficiency anemia.




Causes of anemia
Reduce intake or absorption of iron.
Excess demand as frequent pregnancies.
Chronic infection (UTI).
Blood loss
-



Menorrhagia before pregnancy.
Bleeding hemorrhoids.
APH and PPH.
Hook worm.
Signs and symptoms.
Pallor of mucous membranes. Fatigue.
Fainting.
Tachycardia and palpitation dyspnea.
The risk of anemia on
Mother
 Reduce enjoyment of pregnancy and
motherhood due to fatigue
 Reduce resistance of infection.
 Danger of post partum haemorrhage.
 Potential threat to life.
Baby / fetus.
 Increased risk of hypoxia and growth
retardation.
 preterm birth ( <37/Wks).
 Low birth weight< 2500g.
 increase risk of perinatal morbidity and
mortality.






Prevention:
Taught women about sources of iron and
absorption.
Iron intake linked with calorie intake (2000K
cal/day).
Daily recommended of iron l3mg/day
Iron easily absorbed in red meat, whole
meal, bread, Egg yolk.
Absorption of iron inhibited by tea or
coffee.
Absorption of iron enhanced by ascorbic
acid in orange juice and fresh fruit.
Management
 Increase iron intake. (dietary advice).
 Oral iron.
Ferrous sulphate I 200mg tab 60mg iron.
Ferrous gluconate = 300mg tab 35mg iron.
Side effect of oral iron intake
 Nausea
 Epigastric pain
 Diarrhea
 constipation black stool.
2- Folic acid deficiency anemia


Folic acid needed for the increased cell
growth of both mother and fetus but there is
a physiological decrease in serum folate levels
in pregnancy.
Anemia is more likely to found towards the
end of pregnancy When the fetus grows
rapidly.
Causes:
◦ Reduce dietary intake.
◦ Reduce absorption.
◦ Interference with utilization drugs as
anticonvulsants, sulphonamides and
alcohol are folate antagonists.
◦ Excessive demand and loss.
◦ Multiple pregnancies.


Prevention
Correct selection and preparation of food rich in folic acid.
Green leafy vegetables, spinach, banana, citrus fruit.
Broccoli, peanuts, peas, mushrooms. Avocado, bread
Folic acid destroyed by prolonged boiling or steaming.
All Women in child bearing should eat folate rich foods.
Take a folic acid supplement of (0.4) mg/day.
Folic acid is prescribed for the following conditions in
pregnancy, the dose is 5mg/day.
 Folate deficiency.
 Malabsorption syndrome.
 Haemoglobinopathy.
 Epilepsy anticonvulsant treatment.
 Multiparity.
 Multiple pregnancies.
 Adolescence.
Endocrine disorders
1- Diabetes Mellitus
 Carbohydrate metabolism in pregnancy:
The fetus obtains glucose its mother via the
placenta.
From 10th weeks of pregnancy there is
progressive fall in maternal - fasting glucose.
 During third trimester the mother utilize fat stores.
Which laid down during lst and 2nd trimester this
results in arise free fatty acid and glycerol in blood
stream the Woman become ketosis.
 The feto placenta unit alters the mother's
metabolism.
 The placenta manufactures HPL. Which produce a
resistance to insulin.


Estrogen and progesterone contribute to these
changes and by the end of pregnancy, Cortisol
levels rise which leads to rise blood glucose.
The extra demands on pancreatic beta cells
precipitate glucose intolerance or overt diabetes in
Women.
Glycosuria in pregnancy
 Glucose is more liable to appear in the urine of a
pregnant woman because:
◦ I Glomerular filtration rate rise. (non diabetic pregnant).
◦ Lowering renal threshold for glucose, due to rise blood
glucose. Renal tubular damage interferes with glucose
reabsorption.
Glycosuria in pregnancy not diagnostic as diabetes.
 G.T.T. should be done (glucose tolerance test)

Gestational diabetes
When history reveals one or more of the following:
◦
◦
◦
◦
◦
◦
◦
◦
Diabetes in 1st degree relative.
Recurrent abortion.
Unexplained stillbirth.
Congenital abnormality.
A baby weight greater than 97% for gestational age.
Previous gestational diabetes.
Persistent glycosuria.
Detection of diabetes in pregnancy by GTTand FBS
The effect of pregnancy on diabetes.
 Complicated nausea and vomiting.
 Mother needs more CHO—> ketosis induced more
easily.
 Mothers
who have diabetes since
childhood, have nephropathy and
retinopathy must monitored for
signs of deterioration of their
condition.
The effect of diabetes on pregnant
Woman
If diabetes well controlled, its effect on
pregnancy may be minimal. If control
inadequate there may be
complications.
◦ Fertility reduced increase risk of
spontaneous abortion, Stillbirth, fetal
abnormality.
◦ More susceptible for UTI and candida
Albicans.
◦ Increase incidence of pre-eclampsia
and polyhydramnios.
Effect of diabetes on the fetus
◦ Sever maternal ketosis cause: (IUFD)
, Maternal death.
◦ Congenital abnormality leads to
 fetal hyperglycemias.
 Neurological defect.
 Defect in kidney or heart.
◦ Intra uterine growth retardation leads to:
Over weight baby.
Neonatal jaundice.
Care during pregnancy
 Complications reduced if diabetes controlled.
 Woman should consult her physician
preconception.
 Pregnancy lead to deterioration of diabetes so
pregnant woman must be examined for renal,
cardiovascular, retinal changes before becoming
pregnant.
 Weight control and stop smoking.
 Good antenatal care, give insulin requirements.
 Use family planning method- progesterone only
pill, barrier method.
Antenatal care




Combined antenatal and diabetic clinic.
Increase visit of antenatal 28 Week until term
Weekly.
Treatment for possible signs and symptoms of
urinary and vaginal infections.
Assess progress of pregnancy and detect any
complication.
◦ - Fetal growth: retardation, fetal abnormalities.
◦ - Maternal weight detect polyhydramnios.
◦ - Signs of diabetic complications.

Maintains hygiene.
Control of diabetes in pregnancy
The aims of diabetic control in pregnancy:
◦ Avoid hypoglycemia.
◦ Maintain blood glucose between 4-5.5m.mol/L, not
exceed 7.2 mmol/L.
◦ Advice about nutritional requirements, importance of
maintaining adequate caloric intake.
◦ 24 hours urine sample for sugar in urine.
◦ Subcutaneous insulin (Short and intermediate acting)
twice daily.
◦ Diabetic woman may be admitted to hospital to
control diabetes or in case of complications.

Management of labor
Deterioration of maternal or fetal condition need induction of
labor.

Steroids (Dexamethasone) aid lung maturity (need increase
insulin requirement).

Blood glucose should maintain 4-5.5 m.mol/L.

Maternal hyperglycemia lead to increase fetal insulin
production(cause neonatal hypoglycemia).

Continue monitoring fetal heart. (Fetal condition): call pediatrician
during delivery for resuscitation.

Polyhydramnios increase risk of malpresentation, cord prolaps,
abruptio placenta

Birth asphyxia more common.

Large baby risk of injuries Shoulder dystocia.
Post-natal care
Mother





Carbohydrate metabolism returns to normal
quickly after delivery, So insulin requirement fall.
Increased nutritional demand for breast feeding
increase CHO intake need to adjust insulin
according to blood glucose.
Poor diabetic control interfere with lactation.
Diabetic Woman more prone to infection and
delayed healing so advice to frequent changing
pads.
Keep wound clean and dry.
Baby




Asphyxia is common in macrocosmic and
growth retarded baby( birth injuries).
Examine the baby carefully for congenital
abnormalities.
Hypoglycemia may occur so early, feeding and
monitor Blood glucose.
Polycythemia: due to destruction of R.B.Cs and
relative immaturity of the liver (jaundice).

Cardio vascular disorders
Cardiac disease
◦
Rheumatic Heart disease
◦ Congenital heart defect
◦ Coronary artery disease.
Changes in cardiovascular system during
pregnancy.



Increase cardiac output 40%.
Increase blood volume by 35%.
Decrease In total peripheral resistance maximum
at 30th Week.
These changes are associated with several
clinical signs.




Increase cardiac out put produce a physiological
systolic flow in third of pregnant woman.
The heart dilates and a third heart sound is
common.
As uterus enlarges heart displaced upwards.
During third stage of labor 300-400ml of blood
is added to circulation by the contracting uterus.
Classification
 based on exercise tolerance.
◦
◦
◦
◦
I- No symptoms during ordinary physical activity.
11- Symptoms during ordinary physical activity.
111- Symptoms during mild physical activity.
IV - Symptoms at rest
Risk to mother and fetus
 Bacterial endocarditis and thromboembolism.
 increased maternal mortalitiy.
 I.U.G.R.
 Perinatal mortality.
 High incidence of congenital H.D.
Preconception care and advice
◦ The Woman should help to control obesity.
◦ Stop smoking.
◦ Choose diet which prevent anemia.
◦ Family size to be limited(contraceptive
methods)
Antenatal care
Diagnosis: history taking
Breathlessness.
Fatigue.
Swollen ankles.
Palpitation.
Must be referred to cardiologist for (ECG,
echo).
Assessment
◦ Problem and its prognosis can be made by cardiac and
obstetric clinic.
◦ Evidence of cardiac lesion (cover with antibiotics).
◦ Follow up.
Management:


Keeping steady homodynamic state.
Preventing complication.
Major complication (maternal)
◦ Bacterial endocarditis.
◦ Thromboemboli.
◦ Cyanosis.
◦ Heart failure complications include. ( Infection, risk
factor for H.F or UTI , Hypertension, Anemia, Multiple
pregnancy,Obesity,Smoking).
Physical care:








Frequent antenatal visit.
Dental care.
Antibiotic cover(induce risk of endocarditis).
At late pregnancy(hospital admission for rest and
close monitoring).
Monitor the fetus for fetal growth and amniotic
fluid volume by US
Monitor F.H.R.
Measurement of fetal and maternal placental
blood flow by U/ S.
Psychological support
Intrapartum care
1st stage of labor







The nurse inform anesthetist and cardiologist.
X- match.
02 and resuscitation equipment.
Observation of pulse and respiration every 15
min.
Monitor heart by ECG.
Blood pressure and fetal heart rate.
Antibiotic as prophylaxis in labor and 48 hours
after delivery.



Semi setting position.
Maintain fluid balance because increase fluid
lead to pulmonary edema.
Nitrous oxide or pethidine for pain relief as
doctor order.
2nd stage of labor




Must be shorter.
lateral position.
3rd stage.
Use oxytocin- Not to use ergometrine.
Lasix I.V. to prevent pulmonary edema.
Pregnancy Induced Hypertension
Pre-eclampsia:


Incidence: 5-8%
80% of pre-eclampsia is more in:
a. Young primigravida.
b. Mothers over 35 year old.
c. Hydatidiform mole.
d. Multiple pregnancies
e. maternal diabetes.
 Etiology:
Unknown, but there is one or more factors
which damage the endothelial cells producing
vasoconstrictor substance the effects become
manifest throughout the body producing
multi system disorder.
Classification:
 Pregnancy-induced
hypertension,
develops during pregnancy and
regresses postpartum.
1. Transient (Gestational) hypertension:
a- diastolic arise 25mmHg,or B.P above
140/90 for two occasions after 20th
week of pregnancy
b- edema on feet and ankles.
2. Pre-eclampsia:
Mild/ moderate pre-eclampsia.
a. Marked rise in systolic and diastolic pressure.
b. Proteinuria (+2).
c. Generalized edema.
Two out of the 3 indicating pre-eclampsia.
3. Sever pre-eclampsia.
A. Blood pressure exceed 170/110.
B. Increase proteinuria (+3).
C. Marked edema.
D. Frontal headaches.
E. Visual disturbances.
F. Upper abdominal pain with or without
vomiting (epigastric pain).
diagnosis of P.E.T



Rising Blood pressure.
Proteinuria.
Edema excessive Weight gain
Effects on the mother:




The condition may worsen (eclampsia|).
Placenta abruptio.
Hematological disorder--- damage of liver,
kidney, lung or brain.
Blindness—because of the capillaries damage
of the fundus of the eye.
Effect on the fetus:




Reduce placental function= low birth weight.
Hypoxia= minor placenta abruptio.
Intra uterine death =placenta abruptio major.
Preterm baby =when the case worsens and
need induction.
Predisposing factors





Poverty, adverse social circumstances prevent
woman attending antenatal care clinic. (early
detection).
Familial tendency to hypertension.
Mother's age and parity.
History of renal disease.
Past history of pre-eclampsia.
Management
The aims of care:
Provide rest.
Tranquil environment.
Monitor the condition.
Appropriate treatment preventing getting worse.
Rest may be at home======
if B.P. rise and proteinuria increase, hospital
admission to monitor the maternal fetal
condition.
1.
2.
3.
4.
Diet rich protein diet, fibers and vitamins,
low salt diet.
Weight gain, may be useful in monitoring
P.E.T.
Blood pressure monitored regularly.
Anxiety, smoking, effort, Position.
5. Urine: test for protein daily. - 24 hours urine
collection
6. Abdominal examination
◦ Any discomfort or tenderness reported immediately
as placenta abruptio.
◦ Upper abdominal pain or epigastic pain.
HELLP syndrome.
Diagnosis of HELLP syndrome

Haemolysis

Elevated liver enzymes

Low platelets
◦ Abnormal blood picture
◦ Increased bilirubin > 20 pmol/L
◦ Increased lactic dehydrogenase (LDH) > 600 lU/L
◦ Increased serum glutamic-oxaloacetic
transaminase (SGOT)/ aspartame
aminotransferase (AST) > 72 IU/L
◦ Increased LDH > 600 lU/L
◦ Platelet count 100 *109/L

Fetal assessment
◦ Kick charts.
◦ Cardiotochograph monitoring.
◦ U/S to chick fetal growth, liquor volume, sign of
placental separation.

Antihypertensive therapy:
◦
◦
◦
◦
Methyldopa for mild and moderate cases.
Betablocker (atenolol and labetalol).
Hydralazine.
Antithrombic agent like aspin'n for women at high
risk of P.E.T.
Management of labor





In first stage.
Monitor blood pressure., proteinuria, edema,
urinary output, fluid balance carefully.
Marked deviations should be noted, medical
assistance needed.
Mother should be in comfortable quite
environment.
Pain relief, Epidural analgesia may be best pain
relief, reduce blood pressure, rapid cesarean
section.
Monitor fetal condition. (F.H.S continuously) and
report any deviation.
In 2nd stage



Notify obstetrician and pediatrician.
Continue monitoring mother and fetus
condition.
May need ventouse or forceps so prepare
for instrumental delivery.
In 3rd stage.

Ergometrine and syntometrine it causes
increase hypertension, syntocinon is
preferred to used.
Care following delivery
 Mother condition should continue to
monitor at least every 4 hours for 24
hours.
Impending eclampsia

Alert signs and symptoms to the onset of
eclampsia:
◦ A sharp rise in blood pressure
◦ Diminished urinary output which is due to acute
vasospasm
◦ Increase in proteinuria
◦ Headache which is usually severe, persistent and
frontal in location
◦ Drowsiness or confusion due to cerebral edema.
◦ Visual disturbances such as blurring of vision or
flashing lights due to retinal edema
◦ Epigastric pain which denotes liver edema and
impairment of liver function.
◦ nausea and vomiting.

The aims of care at this time are:
1. To control hypertension, convulsions and coma.
2. To Prevent death of the mother and fetus.

Treatment is intensified to this end and delivery
will be expedited by caesarean section.
Eclampsia
the occurrence of one or more convulsions with the
syndrome of PET.

The aims of immediate care are to:
◦ - Summon medical aid. Maintain clear air way.
Administer oxygen and prevent hypoxia.
◦ protect mother from being injured.



* Anticonvulsant therapy:
Control of convulsion is main aim in eclampsia.
The anticonvulsant drugs used:◦ Diazepam Control seizures and sedative effect.
◦ Phenytoin Control convulsion and sedative effect.
◦ Magnesium sulphate vasodilatation and reduce cerebral ischemia,

Calcium gluconate antidote for magnesium sulphate.

Treatment of hypertension
◦ Hydralazine to control Blood pressure
The role of the nurse (midwife)
◦ The mother need intensive care she is comatose and heavily
sedated.
◦
◦ Observe the periodic restlessness may be uterine contraction.
◦ C.S may be needed, anaesthesia by expert person because
intubation is difficult.
◦ Baby need neonatal intensive care unit.
◦ After delivery the mother need 4 days to monitor. B.P. urine
out put, oedema.
◦ Laboratory tests checked routinely.
Complications of Eclampsia








Cardiovascular vasospasm.
Pulmonary edema.
Renal ischemia, oliguria, renal failure.
Hematological ==hypovolemia,
haemoconcentration,
thrombocytopenia.
DIC (disseminated intra vascular coagulation),
Hemorrhage.
Neurological.
- Cerebral edema.
- Cerebral Hemorrhage.
Hepatic== hepatocellular damage, Hepatic
rupture.
Fetal== placenta abruption, IUGR, Fetal
distress then IUFD.
Disseminated intravascular
coagulation. (DIC)
Inappropriate coagulation within blood vessels
which leads to consumption of clotting factors. As a
result clotting fails to occur at bleeding site.

Etiology:
◦ Its occur as a response to another disease process
◦ Formation of macro thrombi throughout the
circulation. Clotting factors used up.
◦ Fibrinolysis and production of FDPs. (fibrin
Degradation products). reduce the efficiency of
normal clotting.

When DIC occur during delivery== the reduce level of clotting and
presence of FDPs
◦ Prevent normal homeostasis of placental site.
◦ Inhibit myometrial action and prevent uterine muscle
form constricting blood vessels.
◦ Torrential hemorrhage may occur.
◦ Clotting may occur but unstable clot.
◦ Macro thrombi may cause circulatory obstruction in
small vessels
◦ the effect vary from cyanosis of fingers to C.V.A. or
failure of organ like kidneys or liver.

Causes of DIC or events which trigger DIC
◦
◦
◦
◦
◦

Placenta abruption.
IUFD or missed abortion.
Septic abortion.
Amniotic fluid embolism.
P.E.T and eclampsia.
Management
◦ In conditions may Cause DIC should be alert for signs
of abnormal clotting.
◦ Oozing or bleeding from mucus membrane of
mother's mouth and nose to be noted.
◦ Full blood count and Rh + group (X-Matching) clotting
studies for platelets, fibrinogen and FDPs should be
done.
Treatment

replacement of blood cells and clotting
factors by giving:
1. Fresh frozen plasma, platelet.
2. Backed cells transfusion.

Care by the nurse: Its frightening situation
which require speed recognition and action.
◦ Frequent and accurate observation for blood
pressure, pulse and temperature.
◦ General condition of the mother.
◦ Fluid balance== intake and output.
◦ Reassurance for family and house bands.
◦ The death of mother is a real possibility.
Pyelonephritis
1-2%f all pregnancies the ‘causative organism
Escherichia coli.
 Bacterurea in early pregnancy is a predispose
factor.
Signs and symptoms
◦
◦
◦
◦
◦
◦
◦
Mother feel extremely un Well.
Marked pyrexia may reach 40c°.
Rigors.
Maternal and fetal tachycardia.
Nausea, vomiting which may lead to dehydration.
Pain and tenderness over the loins.
Burning micturition.

Diagnosis:
◦ by urine analysis urine culture

Effects on pregnancy:
◦ l. Intra uterine growth retardation.
◦ 2. Congenital abnormality.
◦ 3. Pre term labor pain.

Management
◦ If mother exhibits any of above symptoms the
midwife must refer to a doctor immediately
◦ Admission to hospital is usual.
◦ Intravenous fluid to correct dehydration.
◦ Intake-output chart.
◦ Bed rest.
◦ Management of pyrexia.
◦ Vital signs recording.
◦ Antiemetic if needed.
◦ Buscopan 20mg as doctor order to relieve pain.
◦ Appropriate antibiotic as doctor order.
◦ Fetal monitoring by U/S, sonic aid, CTG.
◦ Follow-up excretion urography is often carried
out 3 months postnatal as persistent or recurrent
infection, with or Without symptoms may be
associated with an abnormality of the renal tract.
Pre-term labor


Definition: is labor that occurs before the end of
week 37 of gestation.
Causes:
Early adolescents.
Dehydration.
Urinary tract infection.
polyhdramnios,
Twins (increase intra uterine pressure).
Chorioamnionitis (infection of fetal membranes and
fluid).
◦ Increase activity.
◦
◦
◦
◦
◦
◦

Signs and symptoms:
◦ 1. Persistent lower backache.
◦ 2. Increase vaginal discharge.
◦ 3. Uterine contraction and intestinal cramping.
Therapeutic management
1-Assess signs of true labor

medical attempts to stop labor pain if:
◦ Fetal membranes are intact.
◦ Fetal distress is absent.
◦ Cervix not dilated more than 4cm, cervical effacement
not more than 50%.
2. hospitalization, bed rest.
3. IV fluid to maintain hydration.
4. Vaginal and cervical swab culture to rule out
infection.
5. Drugs like
◦ a- Tocolytic drugs to stop contraction
◦ b- Cortisone (betamethasone) to stimulate production of
surfactant

Observation
◦
◦
◦
◦
ECG before medication begin
Vital signs - Blood pressure. Pulse rate.
Uterine contractions.
F.H.S.
Preterm Rupture of Membranes (PROM) Definition:
is rupture of fetal membranes with loss of amniotic
fluid during pregnancy.

Causes: un known May associated with:
◦ 1. Pre term labor.
◦ 2. Polyhydramnios.
◦ 3. Multiple pregnancy.

Management:
◦
◦
◦
◦
◦
◦
◦
1. Hospitalization and bed rest .
2. Prophylactic administration of broad spectrum antibiotics.
3. U/S frequently to check adequacy of fluid
4. observation oftemperature to exclude infection - Pulse
5.Observe F.H.R.
6. W.B.C, CRP continuously
Polyhydramnios


Amniotic fluid which exceeds 1500ml. It may not be
clinically apparent until it reaches 3000m1. It occurs in l
in 250 pregnancies.
Causes
◦ Esophageal atresia.
◦ Open neural tube defect.
◦ Multiple pregnancy, especially in the case of
monozygotic twins.
◦ Maternal diabetes mellitus.
◦ Rarely, Rhesus iso-immunisation is associated With
polyhydramnios.
◦ Chorioangioma, a rare tumor of the placenta.

Types
◦ Chronic Polyhydramnios:
 is gradual in onset, usually from about the
30th Week of pregnancy. It is the most
common type.
◦ Acute polyhydramnios:
 very rare. occurs at about 20 Weeks and very
suddenly.

Recognition:
◦ complain of breathlessness and discomfort.
◦ polyhydramnios is acute in onset, she may have severe abdominal
pain.
◦ indigestion, heartburn and constipation. Edema and varicosities of
the vulva and lower limbs may be present.
◦ Abdominal examination: On inspection, the uterus is larger than
expected for the period of gestation and is globular in shape.
◦ On palpation the uterus feels tense and it is difficult to feel the fetal
parts, but the fetus may be balloted between the two hands.
◦ Auscultation of the fetal heart is difficult, because the quantity of
fluid allows the fetus to move away from the stethoscope.

Ultrasonic scan:
◦ may be used to confirm the diagnosis of
polyhydramnios and may reveal a multiple pregnancy or
fetal abnormality.
◦ X-ray examination is not often performed and the
images are usually hazy if there is a large quantity of
amniotic fluid.

Complications
◦ Increased fetal mobility leading to unstable lie and
malpresentation.
◦ Cord presentation and cord prolapse
◦ Premature rupture of the membranes
◦ Placental abruption when the membranes rupture
◦ Premature labour
◦ Postpartum haemorrhage.
Management


The cause of the condition should be determined
if possible. The mother will usually be admitted
to a consultant obstetric unit.
Subsequent care will depend on:
◦ 1. Mother's condition.
◦ 2. Cause of the polyhydramnios.
◦ 3. Stage of pregnancy.
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Diabetes mellitus will be managed as an entity;
the polyhydramnios is managed much as in other
cases.
The presence of fetal abnormality will be taken
into consideration in choosing the mode and
timing of delivery
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The mother should rest in bed. An upright
position will help to relieve any dyspnea,
and she may be given antacids to relieve
heartburn and nausea.
If the discomfort from the swollen abdomen is
severe, abdominal amniocentesis may be
considered.
This is not without risk, as infection may be
introduced or the onset of labor provoked.
No more than 500 ml should be withdrawn at a
time.
It is at best a temporary relief as the fluid Will
rapidly accumulate again and the procedure may
need to be repeated.
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Acute polyhydramnios is managed by
amniocentesis but the outlook is very poor.
◦ The usual course of events is that the fluid
continues to increase at an alarming rate, the
membranes rupture spontaneously and the fetus or
fetuses are washed out in a river of amniotic fluid.
◦ As this generally occurs prior to 24 weeks the
babies are unlikely to survive.
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The mother may need to have labour induced in late
pregnancy if the symptoms become Worse.
The lie must be corrected if it is not longitudinal and
the membranes will be ruptured cautiously, allowing
the amniotic fluid to drain out slowly in order to avoid
altering the lie and to prevent cord prolapse.
Placental abruption is also a hazard if the uterus
suddenly diminishes in size.
Labor is usually normal but the midwife should be
prepared for the possibility of postpartum
haemorrhage.
The baby should be carefully examined for
abnormalities and a tube must be passed in order to
confirm the patency of the oesophagus. '
Oligohydramnios
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small amount of amniotic fluid.
At term it may be 300-500 ml but amounts
vary and it may be much less.
It is associated with renal agenesis (absence of
kidneys) or Potter's syndrome in which the baby
also has pulmonary hypoplasia.
The lack of amniotic fluid reduces the intrauterine space and causes compression
deformities.
The baby has a squashed-looking face,
flattening of the nose, micrognathia and talipes.
The skin is dry and leathery in appearance.
Recognition
On inspection,
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the uterus appears smaller than expected for the
period of gestation.
◦ The mother who has had a previous normal
pregnancy may have noticed a reduction in fetal
movements.
◦ When the abdomen is palpated the uterus is small
and compact and fetal parts are easily felt.
◦ Breech presentation is possible.
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Auscultation is normal.
 Ultrasonic scan will enable differentiation
from intra-uterine growth retardation. Renal
abnormality may be visible on the scan.
Management
 The Woman should be admitted for investigations which
will include placental fimction tests. If there is no fetal
abnormality the pregnancy will be allowed to continue.
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Labor may begin early or may be induced because of the
possibility of placental insufficiency.
Epidural analgesia may be indicated because uterine
contractions may be very painful.
Impairment of placental circulation may result in fetal
hypoxia.
Constriction rings are a possibility due to the small
amount of amniotic fluid.
In rare cases the membranes may adhere to the fetus.
The paediatrician should be present to resuscitate the
baby who will be examined carefully for abnormality.