NCM 109 Lecture: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (Acute and Chronic)
PRELIM S.Y 2021-2022
Lecturer: Jocelyn T. Sanchez
Pre-pregnancy
Factors that categorize a pregnancy as high risk:
4P’s:
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Passenger
Passageway
Psyche
Powers
Normal Duration of Pregnancy:
 9 months
 37 to 42 weeks
 266-280 days
 10 lunar months has a period of 4
weeks
Before 37 weeks – preterm
After 42 weeks – post term or post mature
Between 37-42 weeks – full term
120-160 BPM – normal fetal heart rate
30- 40% ‒ increase in blood volume
Signs of fetal distress:
 Bradycardia – heart rate below 120
(above 160 tachycardia)
 Meconium-stained amniotic fluid –
clear normal (green – meconium
stained)
 Hyperactivity of the fetus – 10 times or
movements per hour
Identification of Risk Clients
 A high-risk pregnancy is one in which a
concurrent disorder, pregnancy related
complication, or external factor
jeopardizes the health of the mother;
the fetus or both.
 There should be no vaginal
bleeding/spotting during the entire
pregnancy.
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A. Psychological
 History of drug dependence
 History of intimate partner abuse
 History of mental illness
 History of poor coping mechanism
 Survivor of childhood sexual abuse
 Cognitively challenged
B. Social
 Occupation involving handling of toxic
substances (including radiation and
anesthesia)
 Environmental contaminants at home
 Isolated
 Lower economic level
 Poor access to transportation of care
 High altitude
 Highly mobile lifestyle
 Poor housing
 Lack of support people
C. Physical
 Visual or hearing challenges
 Pelvic inadequacy of misshape
 Uterine incompetency, position or
structures
 Secondary major illnesses
 Poor gynecologic or obstetric history
 History of previous poor pregnancy
outcome (miscarriage, stillbirth)
 History of child with congenital
anomalies
 Obesity
 Pelvic inflammatory disease
 History of inherited disorder
 Small stature
 Potential of blood incompatibility
 Younger than 18 years or older than 35
years
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Cigarette smoker
Substance abuse
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Cardiovascular Disorders and Pregnancy
 The number of women of childbearing
age who have heart disease is
diminishing as more congenital heart
anomalies are corrected in early infancy
 Cardiovascular disease is still a concern
in pregnancy because it can lead to such
serious complications
 It is responsible for 5% maternal deaths
during pregnancy.
 The danger of pregnancy in woman
with cardiac disease occurs primarily
because of this increase in circulatory
volume
 The most dangerous for her is in 28-32
weeks just after the blood volume
peaks.
 As a rule, a woman with an artificial but
well-functioning heart valve, a woman
with pacemaker implant, and even with
heart transplant can expect to have
successful pregnancies as long as they
have effective prenatal postnatal care.
Classification of Heart Disease:
Class 1
 Uncompromised
 Ordinary physical activity causes no
discomfort
 No symptoms of cardiac insufficiency
and no anginal pain
Class 2
 Slightly compromised
 Ordinary physical activity causes
excessive fatigue, palpitation and
dyspnea or anginal pain.
Class 3
 Markedly compromised
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During less ordinary activity, woman
experiences excessive fatigue,
palpitations, dyspnea or anginal pain.
Class 4
 Severely compromised
 Woman is unable to carry out any
physical activity without experiencing
discomfort.
 Even at rest, symptoms of cardiac
insufficiency or anginal pain are
present.
A woman with Class 1 or 2 heart disease can
expect to experience normal pregnancy by
maintaining special interventions such as bed
rest.
Woman with Class 3 can complete pregnancy by
maintaining special interventions such as bed
rest.
Woman with Class 4 heart disease is usually
advised to avoid failure even at rest and when
they are not pregnant.
A woman with Cardiac Disease:
 Cardiac disease can affect pregnancy in
different way depending on whether it
involves the left or the right side of the
heart.
Normal Blood Circulation:
Unoxygenated blood from the different parts of
the body empty to the superior and inferior
Vena Cava – > Right Atrium –> Tricuspid Valve –
>Right Ventricle –> Pulmonary Artery –> Lungs
for oxygenation
Oxygenated blood from the lungs will empty
into the Pulmonary Veins –> Left Atrium –>
Mitral Valve – Left Ventricle – >Aorta –> to be
delivered to the different parts of the body.
A woman with left sided heart-failure
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Left-sided heart failure occurs in conditions
such as Mitral stenosis, mitral insufficiency
and aortic coarctation.
In these instances, the left ventricle cannot
move the large volume of blood forward
that it has received by the left atrium from
the pulmonary circulation.
This causes back-pressure-the left side of
the heart becomes distended, systemic
blood pressure decreases in the face of
lowered cardiac output and pulmonary
hypertension occurs.
Pulmonary edema produces profound
shortness of breath as it interferes with
oxygen-carbon dioxide exchange.
If pulmonary capillaries rupture under the
pressure, small amounts of blood leak into
the alveoli and the woman develops
productive cough with blood-speckled
sputum.
Because of the limited oxygen exchange,
woman with left-sided heart failure is at an
extremely high risk for spontaneous
miscarriage, preterm labor or even
maternal death.
A woman experiences increase fatigue,
weakness and dizziness.
The placenta may not receive adequate
blood because of the decrease peripheral
circulation.
As pulmonary edema becomes severe a
woman cannot sleep in any position except
with her chest and head elevated
(orthopnea) as elevating her chest this way
allows fluids to settle to the bottom of her
lungs and free space for gas exchange.
She may also notice Paroxysmal Nocturnal
Dyspnea – suddenly waking at night with
shortness of breath.
This occurs because heart action is more
effective when she is at rest.
With more effective heart action,
interstitial fluid returns to the circulation
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This overburdens the circulation, causing
increased left side failure and increases
pulmonary edema.
A woman with right sided heart failure
 Right sided heart failure occurs when the
right ventricles is overwhelmed by the
amount of blood received by the right
atrium from the vena cava.
 It can be used but an unrepaired congenital
heart defect such as pulmonary valve
stenosis, but the anomaly most apt to
cause right sided heart failure.
 With this congestion of the systemic
venous circulation and decrease cardiac
output to the lungs occur.
 Blood pressure decreases in the aorta
because less blood is able to reach it
 In contrast, pressure is high in the vena
cava form the back pressure of blood.
 Both jugular venous distention and
increase portal circulation are evident.
 The liver and spleen both become
distended
 Extreme liver enlargement can cause this
dyspnea and pain a pregnant woman
because the enlarged liver, as it is pressed
upwardly by the enlarge uterus, puts
extreme pressure of the diaphragm.
 Distention of abdominal and lower
extremity vessels can lead to exudate of
fluid from, the vessels into the peritoneal
cavity or peripheral edema.
 With this systemic congestion of the
systemic venous circulation and decrease
cardiac out put to the lungs occurs
 Blood pressure decreases in the aorta
because less blood is able to reach it.
 In contrast, pressure is high in the vena
cava from the back pressure of blood
 Both jugular venous distention and
increase portal circulation are evident.
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Assessment of a woman with cardiac disease
 Nurses play a major role in the care of
pregnant woman with cardiovascular
disease because continuous assessment
of women’s health promotion activities
are so essential
 Assessment begins with a through
health history document pre-pregnancy
cardiac status
 Document a woman’s level of exercise
performance.
 Ask if she normally has a cough or
edema
 Documenting edema is also important
because the usual innocent edema of
pregnancy must be distinguished from
the beginning of edema from heart
failure
 An important difference is the usual
edema of pregnancy involves only on
the feet and ankles but become
systemic with heart failure.
 It can be as early as first trimester, and
other symptoms such as irregular pulse,
rapid or difficult respiration and
perhaps chest pain on exertion will
probably be present.
 Be certain to record a baseline blood
pressure, pulse rate and respiratory rate
in either a sitting or lying position for
the most accurate comparison
 Making comparison assessments for
nail bed filling and jugular venous
distention can also be helpful
throughout pregnancy.
A woman with chronic hypertensive vascular
disease.
 Women with chronic hypertensive
disease enter pregnancy with an
elevated blood pressure (140/90mmHg
or above)
 Hypertension of this kind is usually
associated with arteriosclerosis or renal
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disease, making it a problem for the
older pregnant woman.
Chronic hypertension can be serious
because it places both woman and the
fetus at high risk because of poor heart,
kidney and or placental perfusion
during pregnancy.
Management includes a prescription of
beta-blocker and ACE inhibitors to
reduce blood pressure
Methyldopa (aldomet) is a typical drug
that may be prescribed.
A woman with thromboembolic disease
 The incidence of venous
thromboembolic disease increases
during early pregnancy because of a
combination of stasis of blood in the
lower extremities from uterine
hypercoagulability.
 When the pressure of the fetal head at
birth puts additional pressure on lower
extremity veins, damage can occur to
the walls of the veins.
 With this triad of effects in place (stasis,
vessel damage, and hypercoagulation),
the stage is set for thrombus formation
in the lower extremities.
 The likelihood of deep vein thrombosis
(DVT) leading to pulmonary emboli is
highest in women 30 years of age or
older because increased age is yet
another risk factor for thrombosis
formation.
The risk of thrombus formation can be reduced
by:
o Avoiding the use of constrictive
knee-high stockings
o Not sitting with legs crossed at
the knee
o Avoiding standing in one
position for a long period.
Clinical manifestation:
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Woman will notice pain and redness
usually in the calf of a leg. It is
diagnosed by woman’s history and
Doppler ultrasonography.
To keep the thrombus from moving and
becoming a pulmonary embolus:
 A woman will be treated with bed rest
and intravenous heparin for 24 to 48
hours.
 After this, she may be prescribed
subcutaneous heparin she can selfinject every 12 or 24 hours for the
duration of the pregnancy.
 It is generally recommended-the-lower
abdomen be used for rotating sites for
subcutaneous heparin administration.
With pregnancy, however this site is
usually avoided and the injection sites
are limited to the arms and thighs.
Signs of pulmonary embolism:
 Chest pain
 A sudden onset of dyspnea
 Cough with hemoptysis
 Tachycardia or missed beats
 Dizziness and fainting
Needs to be recognized because it is an
immediate emergency and measures should
be immediately begun.
 Caution women taking heparin during
pregnancy not to take any additional
injections once labor begins to help
reduce the possibility of hemorrhage at
birth.
 Women taking heparin are not
candidates for routine episiotomy or
epidural anesthesia for this same reason
unless at least 4 hours has passed since
the last heparin dose was given.
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Venous thromboembolism “the classic patient”
 A young person
 Recent leg fracture
 Unilateral lower extremity swelling
 Sudden onset of pain breathing
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Shortness of breath
Lungs are clear on exam
Leg is swollen
HEMOLYTIC DISORDERS AND PREGNANCY
Anemia and Pregnancy
 Because the blood volume expands
during pregnancy slightly ahead of the
red count cell, most women have a
pseudo anemia in early pregnancy.
 True anemia is typically considered to
present when a woman’s hemoglobin
concentration is less than 11g/dl
(hematocrit <33%) in the first or third
trimester of pregnancy or when the
hemoglobin concentration is less than
10.5 g/dl(hematocrit<32%) in the
second trimester.
A woman with deficiency anemia
 Iron-deficiency anemia is the most
common anemia of pregnancy,
complicating as many as 15% to 25% of
all pregnancies.
Deficiency of iron stores resulting from a
combination of:
 Diet low on iron
 Heavy menstrual period
 Unwise weigh reducing programs
 Iron stores are also apt to be low in
women who were pregnant less than 2
years before the current pregnancy
 Those from low socioeconomic levels
who have not had iron-rich diets.
 Iron is made available to the body by
absorption from the duodenum into the
bloodstream after it has been ingested.
 In the blood stream, it is bound to
transferrin for transport to the liver,
spleen, and bone marrow. At these
sites, it is incorporated into hemoglobin
or stored as ferritin.
 The type pf anemia is characteristically
a microcytic (i.e., small red blood cell)
and hypochromic (i.e., less hemoglobin
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than the average red cells) anemia,
which occurs when such as inadequate
supply of iron is ingested that iron is not
available for incorporation into red
blood cells.
 A woman experiences extreme fatigue
and poor exercise tolerance because
she cannot transport oxygen efficiently.
 The condition is mildly associated with
lower birth weight and preterm birth.
 Because the body recognizes that it
needs increased nutrients, some
women with this condition develop pica
or the craving and eating substances
such as icer or starch.
 To prevent common anemia, women
should take prevent is common anemia,
women should take prenatal vitamins
containing 27mg of iron as prophylactic
therapy during pregnancy.
 They need to eat in a diet high in iron
and vitamins (e.g., green leafy
vegetables, meat and legumes) so that
supplement is truly a supplement.
 Some women report constipation or
gastric irritation when taking oral iron
supplements.
 Increasing roughage in the diet and
always taking pills with food can help
reduce these symptoms.
 Ferrous sulfate turns stool black, so
caution women about this to prevent
them from worrying that they are
bleeding internally. If has difficulty with
oral iron therapy, intravenous iron can
be prescribed.
A woman with folic acid deficiency anemia
 Folic acid or folacin, one of the B
vitamins is necessary for the normal
formation of red blood cells in the
woman as well as being associated with
preventing neural tube and abdominal
wall defects in the fetus.
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Folic-acid deficiency anemia occurs
most often in multiple pregnancies
because of the increase fetal demand.
The anemia that develops is a
megaloblastic anemia (enlarged red
blood cells)
Slow progress, the deficiency make take
several weeks to develop or may not be
apparent until the second trimester of
pregnancy.
Full blown, it may be a contributory
factor in early miscarriage or premature
separation of the placenta.
Megaloblastic Anaemia
 All women expecting to become
pregnant are advised to begin a
supplement of 400 µg folic acid daily in
addition to eating folacin-rich foods
(e.g., green leafy vegetables, oranges,
dried beans)
A woman with sickle-cell anemia
 Sickle-cell anemia is a recessively
inherited hemolytic anemia caused by
an abnormal amino acid in the beata
chain of hemoglobin.
 With the disease, the majority of red
blood cells are irregular or sickleshaped, so they cannot carry as much
hemoglobin as normally shaped red
blood cells can.
 When oxygen tension becomes
reduced, as occurs at high altitudes, or
blood becomes more viscid than usual,
such as occurs with dehydration, the
cells clump together because of their
irregular blockage with reduced blood
flow to organs.
 The cells will hemolyse (i.e., be
destroyed), thus reducing the number
of available and causing a severe
anemia.
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Approximately 1 in every 10 African
Americans has the sickle-cell trait.
 In pregnancy, blockage to the placental
circulation can directly compromise the
fetus, causing low birth weight and
possibly fetal death.
 A woman with sickle-cell disease may
normally have hemoglobin level of 6 to
8 mg/100 ml.
 Throughout pregnancy, monitor a
woman’s nutritional intake to be certain
she is consuming sufficient amounts of
folic acid and possibly an additional folic
acid supplement, which is necessary for
replacing red blood cells that have been
destroyed.
 Women should not take a routine iron
supplement as sickled cells cannot
incorporate iron in the same manner as
non-sickled cells.
 Ensure the woman is drinking at least
eight glasses of fluid daily to be certain
she is guarding against dehydration.
 Early in pregnancy, when she may be
nauseated, it is easy for her fluid intake
to decrease, causing dehydration and
subsequent sickle-cell crisis.
 Asses a woman’s lower extremities at
prenatal visits for varicosities or pooling
of blood in leg veins, which can lead to
red cell destruction.
Therapeutic Management
 Interventions to prevent a sickle-cell
crisis include periodic exchange or
blood transfusions throughout
pregnancy to replace sickle-cells n=with
non-sickled cells.
 If a crisis occurs, controlling pain,
administering oxygen as needed, an
increasing the fluid volume of the
circulatory system to lower viscosity are
important interventions.
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A woman with diabetes mellitus
 Diabetes mellitus is an endocrine
disorder which the pancreas cannot
produce adequate insulin to regulate
body glucose levels.
Pathophysiology and clinical manifestations
 The primary concern for any woman
with this disorder is controlling the
balance between insulin and blood
glucose levels to prevent hyperglycemia
or hypoglycemia.
 In of women with unregulated diabetes
are given times more apt to be born
large of gestational age or with
abnormalities.
 If a woman’s insulin production is
insufficient glucose cannot be used by
body cells.
 The cells register the need for glucose,
and the liver quickly converts stored
glycogen to glucose to increase the
serum glucose level.
 Because insulin is still not available,
however, the body cells cannot use the
glucose, so the serum glucose level rise.
(i.e., hyperglycemia)
Diabetes
1. Stomach converts food to glucose
2. Glucose enters bloodstream
3. Pancreas produces sufficient insulin but
it is resistant to effective use.
4. Glucose is unable to enter the body
effectively
5. Glucose level increases
Diabetes during pregnancy
 In type 1 diabetes, which although
unproven, is probably an autoimmune
disorder because marker antibodies are
present, the pancreas fails to produce
adequate insulin for the body
requirement.
 In type 2 diabetes, there is a gradual
loss of insulin production, but some
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ability to produce insulin will be
present.
When the level of blood glucose
reaches 150 mg/100ml (normal level is
80-120mg/dl), the kidneys begin to
excrete quantities of glucose in the
urine (i.e., glucosuria) in an attempt to
lower the level. This causes quantities
of fluids to be excreted with urine (i.e.,
polyuria).
Infants of women with poorly controlled
diabetes tends to be large (>10lb)
because the increased insulin the fetus
produce counteract the overload of
glucose, he or she receives acts as a
growth stimulant.
Hydramnios may develop because a
high glucose concentration causes extra
fluid to shift and enlarge the amount of
amniotic fluid.
A macrocosmic infant may create birth
problems at the end of the pregnancy
because of cephalopelvic disproportion.
This combined with an increased risk for
women with diabetes to be born by
cesarean birth.
There is also a high incidence of
congenital anomaly, especially caudal
regressions syndrome (failure of the
lower extremities develop),
spontaneous miscarriage, and stillbirth
in women with uncontrolled diabetes.
At birth, neonate is more prone to
hypocalcemia, respiratory distress
syndrome, hypoglycemia and
hyperbilirubinemia.
The first trimester of pregnancy is the
most important time for fetal
development; if a woman can be kept
from becoming hyperglycemic during
this time, the chances of a congenita
anomaly greatly lessened.
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Risk factors that developing gestational diabetes
include:
 Obesity
 Age over 25 years
 History of large babies (10lb or more)
 History of unexplained fetal or perinatal
loss
 History of congenital anomalies in
previous pregnancies
 History of polycystic ovary syndrome
 Family history of diabetes (one close
relative or two distant ones)
 Member of a population with a high risk
for diabetes
Assessment
 A fasting plasma glucose greater than or
equal to 126mg/dl or non-fasting
plasma glucose greater than or equal to
200 mg/dl meets the threshold for the
diagnosis of diabetes and needs to be
confirmed on a subsequent test as soon
as possible. This usually done using a
75-g oral glucose challenge test.
 For this, after a fasting glucose sample is
obtained, the woman drinks an oral 75g glucose solution; a venous blood
sample is then taken for glucose
determination at 1,2 and 3 hours later.
 If two of the four blood samples
collected for this test are abnormal or
the fasting value is above 95mg/dl, a
diagnosis of diabetes is made.
 The values that confirm diabetes are
reviewed in the table.
Oral glucose challenge test values (fasting
plasma glucose values) for pregnancy following
a 75-g glucose solution
Test type
Pregnant glucose
level (mg/dl)
Fasting
95
1hr
180
2hrs
155
3hrs
140
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The best insulin control program for her
during pregnancy can be then
determined
The measurement of glycosylated
hemoglobin, a measure of the amount
of glucose attached to hemoglobin is
used to detect the degree of
hyperglycemia present.
Measuring glycosylated hemoglobin is
advantageous not just because it
reflects the average blood glucose
attached to hemoglobin is used to
detect the degree of hyperglycemia
present.
Measuring glycosylated hemoglobin is
advantageous not just because it offers
a present value of glucose, but because
it reflects the average blood glucose
level over the past 4 to 6 weeks (i.e., the
time the hemoglobin in red blood cells
were picking up the glucose)
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SPONTANEOUS MISCARRIAGE
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Abortion
Is a medical term for any interruption of a
pregnancy before a fetus is viable. (Able to
survive outside the uterus if born at that time).
A viable fetus is usually defined as a fetus of
more than 20 to 24 weeks of gestation or one
that weighs at least 500g. A fetus born before
this point is considered a Miscarriage or is
termed premature or immature birth.
Early miscarriage occurs before week 16 of
pregnancy.
Late miscarriage occurs between week 16 and
20.
Common causes:
 The most frequent cause of miscarriage is
– abnormal fetal development due to
either a teratogenic factor or to a
chromosomal aberration.
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Immunologic factors may be present or
rejection of the embryo through an
immune response may occur.
Implantation abnormalities as up to 50%
of zygotes probably never implant
securely because of inadequate
endometrial formation of from an
inappropriate site of implantation.
Miscarriage may also occur if corpus
luteum in the ovary fails to produce
enough progesterone to maintain the
decidua basalis.
Ingestion of alcohol at the time of
conception or during early pregnancy can
contribute to pregnancy loss because of
abnormal fetal growth.
Urinary tract infection may be a cause but
are more strongly associated with
preterm birth.
Systemic infection such as Rubella,
Syphilis, Poliomyelitis, Cytomegalovirus
and Toxoplasmosis readily cross the
placenta and so may also be responsible.
Assessment:
The presenting symptom of spontaneous
miscarriage is almost always vaginal
spotting.
Diagnosis:
1. Threatened Miscarriage
 Symptoms begin as vaginal bleeding
initially only scant and usually bright red.
 Slight cramping, but no cervical dilation is
present on vaginal examination.
 Blood may be drawn to test for HCG
hormone at the start of bleeding and
again in 48 hours (if the placenta is still
intact the level in the blood steam should
be double at this time). If it does not
double up poor placental function is
suspected and pregnancy probably will be
lost.
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Avoidance of strenuous activity for 24 to
48 hours is the key intervention
 Complete bedrest may not be necessary
 If spotting is going to stop it usually does
so between 24 to 48 hours after a woman
reduces her activity.
 Coitus may be restricted for 2 weeks.
2. Imminent (inevitable) Miscarriage
 A threatened miscarriage becomes an
Imminent Miscarriage if uterine
contractions and cervical dilatation occur,
with cervical dilation the loss of the
products of conception cannot be halted.
 Save any tissue fragments she has pass to
check for abnormality.
 If no fetal heart rate sounds are detected
and an ultrasound reveals an empty
gestational sac or nonviable fetus, her
primary health care provider may offer
medication to help the pregnancy pass or
perform Dilatation and Curettage (D&C)
or Dilatation and Evacuation (D&E) to
ensure all products of conception are
removed.
 After a woman is discharged, she should
assess the amount of vaginal bleeding
she is having by recording the number
of pads she uses.
 Saturating more than 1 pad per hour is
abnormally heavy bleeding.
3. Complete Miscarriage
 The entire products of conception (fetus,
membranes and placenta) are expelled
spontaneously without any assistance.
 The bleeding usually slows within 2 hours
and then ceases within a few days after
passage of the products of conception.
 Because the process is complete, no
therapy other than advising the woman to
report heavy bleeding is needed.
4. Incomplete Miscarriage
 Part of the conceptus (usually the fetus) is
expelled, but the membranes or placenta
are retained in the uterus.
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With an incomplete, there is danger of
maternal hemorrhage as long as part of the
conceptus is retained in the uterus because
the uterus cannot contract effectively
under this condition.
 The woman will usually have D&C or
suction Curettage to evacuate the
remainder of the pregnancy.
5. Missed Miscarriage
 Also commonly referred to as an early
pregnancy failure.
 The fetus dies in utero but is not expelled.
 A missed miscarriage is usually discovered at
a prenatal examination when the fundal
height is measured and no increase in size
can be demonstrated or when previously
heard fetal heart sounds can no longer be
heard.
 A woman may have painless vaginal bleeding
or she may have no prior clinical symptoms.
 A missed miscarriage is usually discovered at
a prenatal examination when the fundal
height is measured and no increase in size
can be demonstrated.
 Or when previously heard fetal heart sounds
can no longer be heard.
 A woman may have painless vaginal bleeding
or she may have had no prior clinical
symptoms.
 D&C or D&E may be done to evacuate the
pregnancy.
 If pregnancy is over 14 weeks in length and
therefore procedures are no longer possible
labor can be induced by a prostaglandin
suppository or Misoprostol (Cytotec)
introduced into the posterior fornix of the
vaginal to cause dilation
 Followed by oxytocin stimulation or
administration of Mifepristone techniques
used for elective termination or pregnancy
which cause contraction and birth.
6. Recurrent Pregnancy Loss
 In the past woman had three spontaneous
miscarriages were called “habitual aborters”
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Complications of Miscarriage
1. Hemorrhage
 With a complete spontaneous miscarriage,
serious or fatal hemorrhage is rare.
 With an incomplete miscarriage or in a
woman who develops accompanying
coagulation defect (usually DIC) major
hemorrhage becomes a possibility.
 Monitor vital signs for any changes to detect
possible hypovolemic shock.
 If excessive vaginal bleeding occurs,
immediately position flat and massage the
uterine fundus to try to aid contraction.
 D&C if bleeding does not halt
 Suction Curettage to empty the uterus of the
material that is preventing it from
contracting and achieving hemostasis.
 A transfusion may be necessary to replace
blood loss.
 Any unusual odor or passing of large clot is
also abnormal.
 Oral medications such as Methylergonovine
maleate (Methergine) to aid uterine
contraction.
2. Infection
 The possibility of infection is minimal when
pregnancy loss occurs over a short time,
bleeding is self-limiting and instrumentation
is limited.
 Infection is often a reason for excessive
blood loss.
 Be certain the women is familiar with a
common danger sign of infection such as
fever higher than 38C, abdominal pain or
tenderness and a foul smelling vaginal
discharge.
 Caution women to always wipe the perineal
area from the front to back after voiding and
defecation to avoid the spread of bacteria.
 Infection usually involves the inner lining of
the uterus (endometritis)
ECTOPIC PREGNANCY
Implantation occurred outside the uterine
cavity.
The most common site (approximately 95%) is
in the Fallopian tube
Of these Fallopian tube sites approximately:
Ampullar portion 19%
Isthmus
12%
Interstitial and fimbrial 8%
With most ectopic pregnancy fertilization occurs
as usual in the fallopian tube.
Cause:
 Unfortunately, because an obstruction in
present, such as an adhesion of the
fallopian tube from a previous infection
(chronic Salpingitis or pelvic inflammatory
disease)
 Congenital malformities
 Scars from tubal surgery
 Uterine tumor pressing on the perineal end
of the tube.
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Assessment:
No menstrual flow occurs
Nausea and vomiting of early pregnancy
Positive pregnancy test for HCG
The zygote grows large enough that is rupture
the slender fallopian tube tearing and
destruction of blood vessels and bleeding
result.
Sharp, stabbing pain in one of the lower
abdominal quadrants at the time of rupture
followed by scant vaginal spotting (blood may
be expelled in the pelvic cavity rather than the
uterus)
Signs of hypotension from the blood loss light,
headedness, rapid pulse, signs of hypovolemic
shock.
Signs of severe shock, rapid, thready pulse,
rapid respirations, falling blood pressure.
Leukocytosis may be present from trauma and
not from infection
Temperature is usually normal
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 Rigid abdomen from peritoneal irritation
 Cullen’s sign (bluish tinged umbilicus)
 Movement of cervix on pelvic examination can
cause excruciating pain
 Pain in the shoulder from blood in in the
peritoneal cavity causing irritation on the
phrenic nerve.
 A tender mass palpable in douglas cul-de sac on
vaginal examination.
Therapeutic Management:
 Some ectopic pregnancies spontaneously end
before they rupture and are reabsorbed over
the next few repairing no treatment.
 Medically treated by intramuscular or less often
real administration of Methotrexate treated
until a negative HCG titer is achieved
 The therapy for ruptured ectopic pregnancy is
laparoscopy to ligate the bleeding vessel and
to remove or repair the damaged fallopian
tube
GESTATIONAL TROPHOBLASTIC DISEASE
(hydatidiform mole) (H-Mole)
 Abnormal proliferation and degeneration of
trophoblast villi
 As the cell degenerate, they become filled with
fluid and appear as clear fluid-filled, grapesized vesicles
 The embryo fails to develop beyond a primitive
start
 Abdominal trophoblase cells are must be
identified because they are associated with
choriocarcinoma, a rapidly metastatic
malignancy.
Assessment:
 Uterus expands faster than usual. This rapid
development is also diagnosis of multiple
pregnancy or miscalculated due date,
 Strongly positive pregnancy test (1 to 2 million
international Units compared with a normal
pregnancy level of 400, 000) international
units.
 Marked nausea and vomiting
 Symptoms of gestational hypertension;
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Increased blood pressure
Edema
Proteinuria
An ultrasound will show dense growth (typically
a snowflake pattern) but no fetal growth in the
uterus.
 No fetal heart sounds can be heard because
there is no viable fetus.
 Vaginal spotting of dark brown blood
resembling prune juice or as a profuse fresh
flow.
 As bleeding progresses, it is accompanied by
discharge of clear fluid filled vesicles.
Therapeutic management:
 Suction curettage to evacuate the abnormal
trophoblast cells.
 Have a baseline pelvic examination and a serum
test for HCG.
 The HCG is analyzed every 2 weeks until normal.
 The serum HCG is then assessed every 4 weeks
for the next 6-12 months to bee if it is
declining. If the level of the plateaus of
increases, it suggests a malignant
transformation (choriocarcinoma) is occurring
 During the waiting time for the HCG to deadline
a woman should use a reliable contraceptive
tracheal such as oral estrogen/progesterone
do that positive pregnancy test will be
mistaken will malignancy.
 If malignancy should occur, it can be treated
with methotrexate dactinomycin a second
agent can be added with the regimen of
metastasis occurs.
Cervical insufficiently
(Premature cervical dilatation)
 Previously termed as incompetent cervix
 Refers to a cervix that dilates prematurely and
therefore cannot retain a fetus until term.
 Painless dilation the cervix is
 First symptom is show (a pink stained vaginal
discharge)
 Increased pelvic pressure, followed by rupture
of the membrane and discharge of amniotic
fluid
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 Uterine contractions begin and after a short
labor the fetus is born.
o It is associated with:
o Increased maternal age
o Congenital structural defects
o Trauma to the cervix that might have
occurred with a cone biopsy or repeated
D&C’s.
Management:
 Cervical cerclage a surgical operation can be
performed to prevent this from happening in a
second pregnancy.
 McDonald procedure a nylon sutures are placed
horizontally and vertically across the cervix
and pulled tight to reduce the cervical canal to
a few millimeters in diameter
 Shirodkar technique sterile tape is threaded in a
purse sewing manner under the submucous
layer of the cervix and sutured in place to
achieve a closed cervix.
 After cerclage surgery, women remain on
bedrest (slight or modified Trendelenburg
position) for a few days to decrease pressure
on the new sutures.
 Usual activity and sexual relations can be
resumed in most instances after this rest
period
 The sutures are removed at weeks 37 to 35 of
pregnancy so the fetus can be born vaginally.
PLACENTA PREVIA
 A condition a pregnancy in which the placenta is
implanted abnormally in the lower part of the
uterus.
 It is the most common cause of painless
bleeding in the third trimester of pregnancy.
 It is associated with:
o Increased parity
o Advanced maternal age
o Past cesarean births
o Past uterine curettage
o Multiple gestation
o A male fetus
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Assessment:
The bleeding with placenta previa usually begins
until the lower uterine segment starts to
differentiate from the upper segment late in
pregnancy and the cervix begins to dilate.
Because the placenta is unable to stretch to
accommodate the differing shape of the lower
uterine segment of the cervix, a small portion
loosens and damaged blood vessels begin to
bleed.
The bleeding is usually abrupt, painless, bright
red and sudden.
Therapeutic management:
Place woman immediately on bedrest in a side
lying position to ensure an adequate supply to a
woman and fetus.
Inspect the perineum for bleeding and estimate
the presence rate of blood loss.
Obtain baseline vital signs to determine
whether the symptoms of hypovolemic shock
are present.
Continue to assess blood pressure every 5 to 15
mins.
Never attempt to give a pelvic or rectal exam
with painless bleeding late in pregnancy
because any agitation in the cervix might tear
the placenta further and initiate massive
hemorrhage.
Attach external monitoring equipment to record
fetal heart sounds and uterine contractions.
Ready for blood replacement if necessary.
Monitor urine output as often as every hour as
an indicator her blood volume is remaining
adequate to perfuse her kidneys.
Administer intravenous fluids as prescribed,
preferably with a large gauge catheter to allow
for blood replacement through the same line.
A vaginal birth is always the safest for the infant.
But if the previa is under 30% it may be possible
for the fetus to born normal. If over 30% and
the fetus is mature the safest birth method is
cesarean delivery.
If only a minimum previa is suspected and may
attempt a speculum examination, this should be
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done in an operating room or a fully equipped
as immediate cesarean birth is carried out.
Have oxygen equipment available is case of fetal
distress.
Continuing care measures:
If labor has begun, bleeding is occurring or the
fetus is compromised birth must be
accomplished regardless of gestational age.
If bleeding has stopped the fetal heart sounds
are of good quality, maternal vital signs are
good and the fetus is not yet 36 weeks of age, a
woman is usually managed by expectant
watching. Typically, a woman remains in the
hospital on bed rest for clinic observation for 24
to 48 weeks
If bleeding stops, she can be sent home for
bedrest.
Assessment of fetal heart sounds and laboratory
tests such as hemoglobin and hematocrit are
obtained frequently.
Betamethasone, a steroid that lessen fetal lung
maturing may be prescribed for the mother to
encourage the maturity if fetal lungs if the fetus
is less than 34 weeks gestation.
PREMATURE SEPARATION OF THE PLACENTA
(ABRUPTIO PLACENTA)
 The placenta appears to have been
implanted correctly
 Refers to the premature separation of the
placenta.
 The separation generally occurs late in
pregnancy: even as late as during the 1st and
2nd stage of labor.
 The primary cause of premature separation
is unknown
Predisposing factors:
 High parity
 Advanced maternal age
 Short umbilical cord
 Chronic hypertensive disease
 Hypertension of pregnancy
 Direct trauma
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Vasoconstriction from cigarette or cocaine
use
 Thrombophilic condition that lead to
thrombosis formation
 Chorioamnionitis or infection of the fetal
membrane or fluids
 Rapid decrease in uterine volume such as in
sudden release of amniotic fluid in
polyhydramnios
Assessment:
 Sharp stabbing pain high in the uterine
fundus as the initial separation occurs
 Tenderness on uterine palpation
 Heavy bleeding will only be evident if the
placenta separates first at the edges so blood
escapes freely into the uterus and then the
cervix.
 It the center of the placenta separates first;
blood can pool under the placental and it
will be hidden from view.
 Uterus becomes tense and feels rigids to
touch
 If blood infiltrates the uterine musculature,
Couvelaire uterus or uteroplacental
apoplexy, forming a hard board like uterus.
 Therapeutic management:
 Monitor fetal heart sounds externally and
record maternal vital sign every 5 to 15 mins
to establish baseline and observe progress.
 A large gauge intravenous catheter inserted
for fluid replacement
 Oxygen by mask no limit fetal anoxia
 Keep woman in lateral, or supine position to
prevent pressure on the vena cava and
additional interference with fetal circulation.
 Do not perform any abdominal, vaginal or
pelvic examination with a diagnosed or
suspected placental separation.
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Premature separation of the placenta:
Degrees of separation:
 0 – no symptom of separation is
apparent from maternal or fetal signs.
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1 – minimal separation, that enough to
cause vaginal bleeding and changes in
the maternal vital signs, no fetal distress
or hemorrhagic shock occurs
 2 – moderate separation there is
evidence of fetal distress the uterus is
tense and painful on palpation
 3 – extreme separation without
immediate interventions, maternal
hypovolemic shock and fetal death will
result.
PRECIPITATE DILATION
Precipitate dilation is a cervical dilation that
occurs at a rate of 5 com or more per hour in a
primipara or 10 cm or more per hour in
multipara.
Precipitate birth occurs when uterine
contractions are strong a woman gives birth
with only a few rapidly occurring contractions
Often defined as a labor as a labor is completed
in fewer than 3 hours
Such rapid labor is likely to occur with:
Grandmultiparity
After induction of labor by oxytocin
Contractions can be so forceful they lead to
premature separation of the placenta or
laceration of the perineum.
A precipitate labor can be predicted from a
graph if during the active phase of dilatation,
the rate is greater than 5cm/hr in a nullipara
or 10 cm/hr in multipara.
Caution multiparous women by week 28 of
pregnancy that because a past labor was so
brief, her labor this time may be brief.
Plan for adequate transportation to the hospital
Should have the birthing room converted
readiness before full dilatation id obtained.
When labor contractions are ineffective, several
interventions are made:
Induction of labor means labor is started
artificially
Augmentation of labor refers to assisting labor
that has started spontaneously but is not
effective.
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The following should be present before
induction of labor:
 The fetus is in longitudinal lie
 The cervix is ripe or ready for birth
 A presenting part is engaged
 There is no CPD
 The fetus is estimated to be mature by
date (over 39 weeks)
Prolapse of the umbilical cord
 A loop of the umbilical cord slips down in front
of the presenting fetal part.
 Prolapse may occur at any time after the
membranes rupture if the [resenting fetal part
is not fitted firmly into the cervix
 It tends to occur most often with:
 Premature rupture of the membranes
 Fetal presentation other than cephalic
 Placenta previa
 Intrauterine tumors
 A small fetus
 CPD preventing from engagement
 Hydramnios
 Multiple gestation
Assessment:
 The cord may be felt as the presenting part
on initial vaginal examination can be
visualized.
 On inspection, the cord may be visible at
the vulva.
 To rule out cord prolapse, always assess
fetal heart sounds immediately after
rupture of membranes
Therapeutic management:
 A prolapsed cord is always an emergency
situation cord compression and decreased
oxygenation to the fetus.
 Relieve pressure on the cord by placing a
gloved hand in the vagina and manually
elevating the fetal head of the cord of by
placing the woman in knee chest or
Trendelenburg position
 Administering oxygen at 10L/min by face
mask to improve oxygenation
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 Amnioinfusion is another way to relieve
pressure on the cord.
 Amnioinfusion is the additional sterile fluids
into the uterus to supplement the amniotic
fluid and reduce compression on the cord
 A sterile double lumen catheter is
introduced through the cervix into the
uterus
CESAREAN BIRTH
 Birth accomplished through an abdominal
incision into the uterus
 Scheduled Cesarean Birth are planned which
means there is time for thorough preparation
for the experience throughout the antepartal
period.
 Emergent Cesarean Birth are done for reasons
that arise suddenly in labor, such as placenta
previa, premature separation of placenta, fetal
distress or failure to progress
 With this second type of cesarean birth,
preparation must be done rapidly but with the
same concern for fully informing a woman and
her support person about what circumstances
created the need for cesarean birth and how
the birth will proceed.
Indications:
Maternal factors:
 Active genital herpes
 Aids and hiv positive status
 Cephalopelvic disproportion
 Cervical cerclage
 Disabling conditions such as gestational
hypertension that would prevent pushing
 Failed induction or failure to progress labor.
 An obstructive benign or malignant tumor
 Previous cesarean birth by classic incision
fear of birth or wish to help prevent uterine
prolapse or urinary incontinence in later
years
Placental factors:
 Placenta previa
 Premature separation of placenta
 Umbilical cord prolapse
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Fetal factors:
 Compound conditions such as macrosomic
fetus in breech lie
 Extreme low birth weight
 Fetal distress
 A major fetal anomaly such as hydrocephalus
 Multigestation or conjoined twins
 Transverse fetal lie and perhaps breech
presentation
Types of cesarean incision
 In a CLASSIC CESAREAN INCISION, the
incision is made vertically through both the
abdominal skin and uterus
 The incision is made high on the uterus so
that it avoids cutting a possible placenta
previa
 A disadvantage of this type of incision is that
is leaves a wide skin scare and also runs
through the active contractile portion of the
uterus.
 Because this type of scar could rupture
during labor, if this type of incision is used, it
is likely that a woman may not be able to
have a subsequent vaginal birth.
 A LOW SEGMENT INCISION (low transverse
or Pfannenstiel incision) is one made
horizontally across the abdomen just over
the symphysis pubis and also horizontally
across the uterus just over the cervix.
 This is the most common type of cesarean
incision used today.
 This is also referred to as Misgav-ladach or
bikini incision because even a low-cut
bathing suit will cover the scar
 Because this type of incision is through non
active portion of the uterus (the part that
contracts minimally with labor) it is less likely
to rupture in subsequent labors making it
possible for woman to have a vaginal birth
after cesarean (VBAC) with a future
pregnancy
 It also results in less blood loss, is easier to
suture decreases postpartal uterine
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infections and is less likely to cause
postpartum gastrointestinal complications.
Topic: Preterm Labor
3.
PRETERM LABOR
Is labor that occurs before the end of week
37 of gestation.
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Any woman having persistent uterine
contractions (4 contractions every 20 mins)
should be considered to be in labor.
A woman is documented as being in actual
labor rather than having false labor contractions
if she is having uterine contractions that cause
cervical effacement over 80% and dilatation
over 1cm.
It results in infant’s birth; the infant may be
immature.
Cause is unknown but is associated with
dehydration, UTI and chorioamnionitis
(infections of the fetal membrane and fluid).
Common symptoms are:
 Persistent dull
 Lower backache
 Vaginal spotting
 A feeling of pelvic pressure or abdominal
tightening
 Menstrual like cramping
 Increased vaginal discharge
 Uterine contractions and intestinal
cramping
Therapeutic Management:
1. Analyzing changes in vaginal mucus.
If there is the presence of fetal
fibronectin, a protein produced by
trophoblast cells, preterm contraction
are ready to occur.
Absence of the protein predicts that
labor will not occurs for at least 4days.
2. Medical attempts can be made to stop labor
is the fetal membranes are intact, fetal
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4.
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distress is absent, there is no evidence that
bleeding is occurring, the cervix is not
dilated more than 4 to 5 cm, and
effacement is more than 50%.
Placed on bedrest to relive the pressure of
the fetus on the cervix.
Intravenous fluid therapy to keep a woman
well hydrated to stop the contractions.
Vaginal and cervical cultures and a cleancatch urine sample are obtained to rule out
infection
Take an oral Tocolytic agents (drugs to halt
labor) Terbutaline
It is important that women also maintain
adequate nutrition and do not smoke
cigarettes.
Drug Administration:
 An antibiotic for group B streptococcus
prophylaxis.
 Administration of a corticosteroid to the
fetus appears to accelerate the formation
of lung surfactant.
 If the pregnancy is under 34 weeks, a
woman may be given a steroid
(betamethasone) to attempt to hasten
fetal lung maturity (two doses of 12 mg
betamethasone given intramuscularly 24
hours apart or four doses of 6 mg
dexamethasone given intramuscularly 12
hours apart)
 Magnesium sulfate is the drug of choice
used to halt contractions, has a central
nervous system depressant action that
slows and halts uterine contractions.
 Ritodrine hydrochloride (Yutopar) and
terbutaline (Brethine), as a beta 2
receptor, it causes blood vessels and
bronchi to relax along with the uterine
muscles.
 After the halt of contractions, a tocolytic
infusion usually is continued for 12 to 24
hours, and then oral administration of
terbutaline is begun.
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 The first oral dose is given 30 minutes
before the intravenous infusion is
discontinued to prevent any drop in the
serum concentration, a woman will
continue to take an oral tocolytic until 37
weeks.
Labor that cannot be halted.
 If membranes have ruptured or the
cervix is more than 50% effaced and
more than 3 to 4 cm dilated, it is
unlikely labor can be halted.
 If the fetus is very immature at the time
labor.
Premature Rupture of Membranes
 Preterm rupture of membrane is
rupture of fetal membrane with loss of
amniotic fluid during pregnancy before
37 weeks.
 The cause of preterm rupture is
unknown, but is associated with
infection of the membranes
(chorioamnionitis)
 After rupture, the seal to the fetus is
lost therefore uterine and fetal infection
may occur.
 Second complication that can result
from preterm membrane rupture is
increased pressure on the umbilical
cord from the loss of amniotic fluid,
inhibiting the fetal nutrition supply.
 A condition that could also interfere
with fetal circulation.
 Cord prolapse is most apt to occur when
the fetal head is still small to fit the
cervix firmly.
ASSESSMENT
 A sudden gush of clear fluid from the
vagina, with continued minimal leakage.
 If the fluid is tested with Nitrazine
paper, amniotic fluid causes an alkaline
reaction on the paper (appears blue)
and urine an acidic reaction (remains
yellow).
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The fluid can also be tested for ferning,
or the typical appearance of a highestrogen fluid on microscopic
examination (amniotic fluid shows this:
urine does not)
 A sonogram may be ordered to assess
the amniotic fluid index.
 If the fetus is estimated to be mature
enough in an extrauterine environment
and labor does not begin within 24
hours, labor contraction is usually
induced by an intravenous
administration of oxytocin.
Therapeutic Management:
 If labor does not begin and the
fetus is near a point of viability, a
woman is placed on bed.
 Corticosteroid to hasten fetal lung
maturity.
 Broad spectrum antibiotics.
 Take her temperature twice a day
and to report a fever, uterine
tenderness, or odorous vaginal
discharge.
 Refrain from tub bathing, douching
and coitus because of the danger of
introducing infection.
 White cell count will need to
assessed frequently.
 A count of more than 18, 000 to
20,00/mm3 suggest infection.
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Gestational Hypertension
 It is a condition in which vasospasm
occurs in both small and large arteries
during pregnancy, causing signs of:
o Increased blood pressure
o Proteinuria
o Edema
 The cause of the disorder is unknown
the condition tends to occur most
frequently in
o Women of color
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o
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o
o
o
o
With a multiple pregnancy
Primiparas younger than 20
years of age or older than 40
years
Women from low
socioeconomic backgrounds
(perhaps because of poor
nutrition)
Those who have had five or
more pregnancies
Those who have hydramnios
Those who have underlying
disease such as a heart disease,
diabetes with vessel or renal
involvement
Essential hypertension
o
Assessment:
Classical signs:
 Vision changes
 Typically, hypertension
 Proteinuria
 Edema
Gestational hypertension
 Blood pressure is 140/90 mmHg or
systolic pressure elevated 30mmHg or
diastolic pressure elevated 15mmHg
prepregnancy level
 No proteinuria
 No edema
 Blood pressure return to normal after
birth
Mild Preeclampsia
 Has proteinuria and BP of 140/90
mmHg taken on two occasions at least 6
hours apart.
 Blood pressure is 140/90mmHg or
systolic pressure elevated 30mmHg or
diastolic pressure elevated 15mmHg
above prepregnancy values
 Proteinuria of 1+ or 2+ on a reagent test
strip on random sample
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Edema can be separated from the
typical ankle edema of pregnancy
because it begins to accumulate in the
upper part of the body.
A weight gain of more than two
lbs/weeks on the second trimester or
1lb/week on the third trimester.
Severe Preeclampsia
 Blood pressure is 160 systolic and 110
mmHg diastolic
 Marked proteinuria 3+ or 4+ on a
random sample or more than 5g in a 24hour sample.
 Extensive edema is present
Edema can be described as:
Non-pitting – swelling cannot be indented with
finger pressure
1+ pitting edema – tissue can be indented
slightly.
2+ pitting edema – moderate indentation
3+ pitting edema – deep indentation
 Accumulating edema will reduce a
woman’s urine output to approximately
400 to 600 ml/24hrs
 Some woman reports severe epigastric
pain and nausea or vomiting possible
because abdominal edema or ischemia
to the pancreas and liver has occurred.
 If pulmonary edema has developed a
woman may report feeling short of
breath.
 If cerebral edema has occurred, reports
of visual disturbances such as blurred
vision or seeing spots before the eyes
may be reported
Eclampsia
 Most severe classification of gestational
hypertension
 A woman has passed into this stage
when cerebral edema is so acute and
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excreted at a faster rate than the
during activity.
 Bedrest therefore is the best
method of aiding increased
evacuation of sodium and
encouraging diuresis of edema fluid.
 Be certain women know to rest in
lateral recumbent position to avoid
uterine pressure on the vena cava
and prevent supine hypotension
syndrome.
Promote Good Nutrition
 A woman needs to continue her
usual pregnancy nutrition while on
bedrest
grand mal seizure (tonic-clonic) or coma
has occurred
The maternal mortality rate can be as
high as 20% from causes such as
cerebral hemorrhage, circulatory
collapsed or renal failure
Patellar Reflex
 With the woman in a supine position,
ask her to bend her knee slightly
 Place your hand under her knee to
support the leg.
 Locate the patellar tendon in the
midline of the anterior leg just below
the kneecap
 Strike it firmly and quickly with a reflex
hammer or the side of your hand
 If the leg and foot move, a patellar
reflex is present
Patellar reflex is scored as:
 0 – no response, hypoactive, abnormal
 1+ somewhat diminished response but
not abnormal
 2+ average response
 3+ brisker than average but not
abnormal
 4+ hyperactive very brisk abnormal
Nursing Interventions:
Monitor antiplatelet therapy
 Mild antiplatelet agent, such as low
dose Aspirin, may prevent or delay the
development pf preeclampsia
 Antiplatelet: work by making your blood
less sticky. This prevents arteries from
being plugged by clots.
 Aspirin 50 to 80mg (sold as baby
aspirin) because excessive salicylic
levels can cause maternal bleeding at
birth.
Promote bedrest
 When the body is in recumbent
position, sodium tends to be
3
Nursing intervention of woman with severe
gestational hypertension
Support bedrest
 Most woman are hospitalized so
that bedrest can be enforced and a
woman can be observed more
closely that she can be on home
care.
 Visitors are usually restricted to
support people because a loud
noise can be sufficient to trigger
seizure that initiates eclampsia.
 Admit to a private room so she can
rest and undisturbed as possible.
 Raise side rails to prevent injury is a
seizure should occur.
 Darken the room if possible
because a bright light can also
trigger seizure.
 Shining a flashlight beam into a
woman’s eyes is the kind of sudden
stimulation to be avoided.
 Stress is another stimulus that could
increase BP and evoking seizures in
a woman with severe preeclampsia.
 Be certain a woman receives clear
explanations of what is happening
0
 Uterine contractions begin and after a short
labor the fetus is born.
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o It is associated with:
o Increased maternal age
o Congenital structural defects
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o Trauma to the cervix that might have
occurred with a cone biopsy or repeated
D&C’s.
Management:
 Cervical cerclage a surgical operation can be
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performed to prevent this from happening in a
second pregnancy.
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 McDonald procedure a nylon sutures are placed
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horizontally and vertically across the cervix
and pulled tight to reduce the cervical canal to
a few millimeters in diameter
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 Shirodkar technique sterile tape is threaded in a
purse sewing manner under the submucous
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layer of the cervix and sutured in place to
achieve a closed cervix.
 After cerclage surgery, women remain on 3
0
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bedrest (slight or modified Trendelenburg
position) for a few days to decrease pressure
Assessment:
The bleeding with placenta previa usually begins
until the lower uterine segment starts to
differentiate from the upper segment late in
pregnancy and the cervix begins to dilate.
Because the placenta is unable to stretch to
accommodate the differing shape of the lower
uterine segment of the cervix, a small portion
loosens and damaged blood vessels begin to
bleed.
The bleeding is usually abrupt, painless, bright
red and sudden.
Therapeutic management:
Place woman immediately on bedrest in a side
lying position to ensure an adequate supply to a
woman and fetus.
Inspect the perineum for bleeding and estimate
the presence rate of blood loss.
Obtain baseline vital signs to determine
whether the symptoms of hypovolemic shock
are present.
Continue to assess blood pressure every 5 to 15
mins.
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on the new sutures.
 Usual activity and sexual relations can be
resumed in most instances after this rest
period
 The sutures are removed at weeks 37 to 35 of
pregnancy so the fetus can be born vaginally.
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PLACENTA PREVIA
 A condition a pregnancy in which the placenta is
implanted abnormally in the lower part of the
uterus.
 It is the most common cause of painless
bleeding in the third trimester of pregnancy.
 It is associated with:
o Increased parity
o Advanced maternal age
o Past cesarean births
o Past uterine curettage
o Multiple gestation
o A male fetus
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Never attempt to give a pelvic or rectal exam
with painless bleeding late in pregnancy
because any agitation in the cervix might tear
the placenta further and initiate massive
hemorrhage.
Attach external monitoring equipment to record
fetal heart sounds and uterine contractions.
Ready for blood replacement if necessary.
Monitor urine output as often as every hour as
an indicator her blood volume is remaining
adequate to perfuse her kidneys.
Administer intravenous fluids as prescribed,
preferably with a large gauge catheter to allow
for blood replacement through the same line.
A vaginal birth is always the safest for the infant.
But if the previa is under 30% it may be possible
for the fetus to born normal. If over 30% and
the fetus is mature the safest birth method is
cesarean delivery.
If only a minimum previa is suspected and may
attempt a speculum examination, this should be
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done in an operating room or a fully equipped
as immediate cesarean birth is carried out.
Have oxygen equipment available is case of fetal
distress.
Continuing care measures:
If labor has begun, bleeding is occurring or the
fetus is compromised birth must be
accomplished regardless of gestational age.
If bleeding has stopped the fetal heart sounds
are of good quality, maternal vital signs are
good and the fetus is not yet 36 weeks of age, a
woman is usually managed by expectant
watching. Typically, a woman remains in the
hospital on bed rest for clinic observation for 24
to 48 weeks
If bleeding stops, she can be sent home for
bedrest.
Assessment of fetal heart sounds and laboratory
tests such as hemoglobin and hematocrit are
obtained frequently.
Betamethasone, a steroid that lessen fetal lung
maturing may be prescribed for the mother to
encourage the maturity if fetal lungs if the fetus
is less than 34 weeks gestation.
PREMATURE SEPARATION OF THE PLACENTA
(ABRUPTIO PLACENTA)
 The placenta appears to have been
implanted correctly
 Refers to the premature separation of the
placenta.
 The separation generally occurs late in
pregnancy: even as late as during the 1st and
2nd stage of labor.
 The primary cause of premature separation
is unknown
3
0
Predisposing factors:
 High parity
Vasoconstriction from cigarette or cocaine
use
 Thrombophilic condition that lead to
thrombosis formation
 Chorioamnionitis or infection of the fetal
membrane or fluids
 Rapid decrease in uterine volume such as in
sudden release of amniotic fluid in
polyhydramnios
Assessment:
 Sharp stabbing pain high in the uterine
fundus as the initial separation occurs
 Tenderness on uterine palpation
 Heavy bleeding will only be evident if the
placenta separates first at the edges so blood
escapes freely into the uterus and then the
cervix.
 It the center of the placenta separates first;
blood can pool under the placental and it
will be hidden from view.
 Uterus becomes tense and feels rigids to
touch
 If blood infiltrates the uterine musculature,
Couvelaire uterus or uteroplacental
apoplexy, forming a hard board like uterus.
 Therapeutic management:
 Monitor fetal heart sounds externally and
record maternal vital sign every 5 to 15 mins
to establish baseline and observe progress.
 A large gauge intravenous catheter inserted
for fluid replacement
 Oxygen by mask no limit fetal anoxia
 Keep woman in lateral, or supine position to
prevent pressure on the vena cava and
additional interference with fetal circulation.
 Do not perform any abdominal, vaginal or
pelvic examination with a diagnosed or
suspected placental separation.
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Advanced maternal age
Short umbilical cord
Chronic hypertensive disease
Hypertension of pregnancy
Direct trauma
Premature separation of the placenta:
Degrees of separation:
 0 – no symptom of separation is
apparent from maternal or fetal signs.
3
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1 – minimal separation, that enough to
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The following should be present before
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induction of labor:
 The fetus is in longitudinal lie
 The cervix is ripe or ready for birth
 A presenting part is engaged
 There is no CPD
 The fetus is estimated to be mature by
date (over 39 weeks)
cause vaginal bleeding and changes in
the maternal vital signs, no fetal distress
or hemorrhagic shock occurs
 2 – moderate separation there is
evidence of fetal distress the uterus is
tense and painful on palpation
 3 – extreme separation without
immediate interventions, maternal
hypovolemic shock and fetal death will
result.
PRECIPITATE DILATION
Precipitate dilation is a cervical dilation that
occurs at a rate of 5 com or more per hour in a
primipara or 10 cm or more per hour in
multipara.
Precipitate birth occurs when uterine
contractions are strong a woman gives birth
with only a few rapidly occurring contractions
Often defined as a labor as a labor is completed
in fewer than 3 hours
Such rapid labor is likely to occur with:
Grandmultiparity
After induction of labor by oxytocin
Contractions can be so forceful they lead to
premature separation of the placenta or
laceration of the perineum.
A precipitate labor can be predicted from a
graph if during the active phase of dilatation,
the rate is greater than 5cm/hr in a nullipara
or 10 cm/hr in multipara.
Caution multiparous women by week 28 of
pregnancy that because a past labor was so
brief, her labor this time may be brief.
Plan for adequate transportation to the hospital
Should have the birthing room converted
readiness before full dilatation id obtained.
When labor contractions are ineffective, several
interventions are made:
Induction of labor means labor is started
artificially
Augmentation of labor refers to assisting labor
that has started spontaneously but is not
effective.
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Prolapse of the umbilical cord
A loop of the umbilical cord slips down in front
of the presenting fetal part.
Prolapse may occur at any time after the
membranes rupture if the [resenting fetal part
is not fitted firmly into the cervix
It tends to occur most often with:
Premature rupture of the membranes
Fetal presentation other than cephalic
Placenta previa
Intrauterine tumors
A small fetus
CPD preventing from engagement
Hydramnios
Multiple gestation
Assessment:
 The cord may be felt as the presenting part
on initial vaginal examination can be
visualized.
 On inspection, the cord may be visible at
the vulva.
 To rule out cord prolapse, always assess
fetal heart sounds immediately after
rupture of membranes
Therapeutic management:
 A prolapsed cord is always an emergency
situation cord compression and decreased
oxygenation to the fetus.
 Relieve pressure on the cord by placing a
gloved hand in the vagina and manually
elevating the fetal head of the cord of by
placing the woman in knee chest or
Trendelenburg position
 Administering oxygen at 10L/min by face
mask to improve oxygenation
Fetal factors:
 Compound conditions such as macrosomic
fetus in breech lie
 Extreme low birth weight
 Fetal distress
 A major fetal anomaly such as hydrocephalus
 Multigestation or conjoined twins
 Transverse fetal lie and perhaps breech
presentation
 Amnioinfusion is another way to relieve
pressure on the cord.
 Amnioinfusion is the additional sterile fluids
into the uterus to supplement the amniotic
fluid and reduce compression on the cord
 A sterile double lumen catheter is
introduced through the cervix into the
uterus
CESAREAN BIRTH
 Birth accomplished through an abdominal
incision into the uterus
 Scheduled Cesarean Birth are planned which
means there is time for thorough preparation
for the experience throughout the antepartal
3
period.
 Emergent Cesarean Birth are done for reasons
0
Types of cesarean incision
 In a CLASSIC CESAREAN INCISION, the
incision is made vertically through both the
abdominal skin and uterus
 The incision is made high on the uterus so
that it avoids cutting a possible placenta
previa
that arise suddenly in labor, such as placenta
previa, premature separation of placenta, fetal
distress or failure to progress
 With this second type of cesarean birth,
preparation must be done rapidly but with the
same concern for fully informing a woman and
her support person about what circumstances
created the need for cesarean birth and how
the birth will proceed.
Indications:
Maternal factors:
 Active genital herpes
 Aids and hiv positive status
 Cephalopelvic disproportion
 Cervical cerclage
 Disabling conditions such as gestational
hypertension that would prevent pushing
 Failed induction or failure to progress labor.
 An obstructive benign or malignant tumor
 Previous cesarean birth by classic incision
fear of birth or wish to help prevent uterine
prolapse or urinary incontinence in later
years
Placental factors:
 Placenta previa
 Premature separation of placenta
 Umbilical cord prolapse
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A disadvantage of this type of incision is that
is leaves a wide skin scare and also runs
through the active contractile portion of the
uterus.
Because this type of scar could rupture
during labor, if this type of incision is used, it
is likely that a woman may not be able to
have a subsequent vaginal birth.
A LOW SEGMENT INCISION (low transverse
or Pfannenstiel incision) is one made
horizontally across the abdomen just over
the symphysis pubis and also horizontally
across the uterus just over the cervix.
This is the most common type of cesarean
incision used today.
This is also referred to as Misgav-ladach or
bikini incision because even a low-cut
bathing suit will cover the scar
Because this type of incision is through non
active portion of the uterus (the part that
contracts minimally with labor) it is less likely
to rupture in subsequent labors making it
possible for woman to have a vaginal birth
after cesarean (VBAC) with a future
pregnancy
It also results in less blood loss, is easier to
suture decreases postpartal uterine
infections and is less likely to cause
postpartum gastrointestinal complications.
Topic: Preterm Labor
3.
PRETERM LABOR
Is labor that occurs before the end of week
37 of gestation.
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4.
5.
Any woman having persistent uterine
contractions (4 contractions every 20 mins)
should be considered to be in labor.
A woman is documented as being in actual
labor rather than having false labor contractions
if she is having uterine contractions that cause
cervical effacement over 80% and dilatation
over 1cm.
It results in infant’s birth; the infant may be
immature.
Cause is unknown but is associated with
dehydration, UTI and chorioamnionitis
(infections of the fetal membrane and fluid).
Common symptoms are:
 Persistent dull
 Lower backache
 Vaginal spotting
 A feeling of pelvic pressure or abdominal
tightening
 Menstrual like cramping
3
 Increased vaginal discharge
 Uterine contractions and intestinal
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7.
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distress is absent, there is no evidence that
bleeding is occurring, the cervix is not
dilated more than 4 to 5 cm, and
effacement is more than 50%.
Placed on bedrest to relive the pressure of
the fetus on the cervix.
Intravenous fluid therapy to keep a woman
well hydrated to stop the contractions.
Vaginal and cervical cultures and a cleancatch urine sample are obtained to rule out
infection
Take an oral Tocolytic agents (drugs to halt
labor) Terbutaline
It is important that women also maintain
adequate nutrition and do not smoke
cigarettes.
Drug Administration:
 An antibiotic for group B streptococcus
prophylaxis.
 Administration of a corticosteroid to the
fetus appears to accelerate the formation
of lung surfactant.
 If the pregnancy is under 34 weeks, a
woman may be given a steroid
(betamethasone) to attempt to hasten
fetal lung maturity (two doses of 12 mg
betamethasone given intramuscularly 24
hours apart or four doses of 6 mg
dexamethasone given intramuscularly 12
hours apart)
 Magnesium sulfate is the drug of choice
used to halt contractions, has a central
cramping
nervous system depressant action that
slows and halts uterine contractions.
 Ritodrine hydrochloride (Yutopar) and
terbutaline (Brethine), as a beta 2
receptor, it causes blood vessels and
bronchi to relax along with the uterine
muscles.
 After the halt of contractions, a tocolytic
infusion usually is continued for 12 to 24
hours, and then oral administration of
terbutaline is begun.
Therapeutic Management:
1. Analyzing changes in vaginal mucus.
If there is the presence of fetal
fibronectin, a protein produced by
trophoblast cells, preterm contraction
are ready to occur.
Absence of the protein predicts that
labor will not occurs for at least 4days.
2. Medical attempts can be made to stop labor
is the fetal membranes are intact, fetal
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0
The fluid can also be tested for ferning,
or the typical appearance of a highestrogen fluid on microscopic
examination (amniotic fluid shows this:
urine does not)
 A sonogram may be ordered to assess
the amniotic fluid index.
 If the fetus is estimated to be mature
enough in an extrauterine environment
and labor does not begin within 24
hours, labor contraction is usually
induced by an intravenous
administration of oxytocin.
Therapeutic Management:
 If labor does not begin and the
fetus is near a point of viability, a
woman is placed on bed.
 Corticosteroid to hasten fetal lung
maturity.
 Broad spectrum antibiotics.
 Take her temperature twice a day
and to report a fever, uterine
tenderness, or odorous vaginal
discharge.
 Refrain from tub bathing, douching
and coitus because of the danger of
introducing infection.
 White cell count will need to
assessed frequently.
 A count of more than 18, 000 to
20,00/mm3 suggest infection.
 The first oral dose is given 30 minutes
before the intravenous infusion is
discontinued to prevent any drop in the
serum concentration, a woman will
continue to take an oral tocolytic until 37
weeks.
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Labor that cannot be halted.
 If membranes have ruptured or the
cervix is more than 50% effaced and
more than 3 to 4 cm dilated, it is
unlikely labor can be halted.
 If the fetus is very immature at the time
labor.
Premature Rupture of Membranes
 Preterm rupture of membrane is
rupture of fetal membrane with loss of
amniotic fluid during pregnancy before
37 weeks.
 The cause of preterm rupture is
unknown, but is associated with
infection of the membranes
(chorioamnionitis)
 After rupture, the seal to the fetus is
lost therefore uterine and fetal infection
may occur.
 Second complication that can result
from preterm membrane rupture is
increased pressure on the umbilical
cord from the loss of amniotic fluid,
inhibiting the fetal nutrition supply.
 A condition that could also interfere
with fetal circulation.
 Cord prolapse is most apt to occur when
the fetal head is still small to fit the
cervix firmly.
ASSESSMENT
 A sudden gush of clear fluid from the
vagina, with continued minimal leakage.
 If the fluid is tested with Nitrazine
paper, amniotic fluid causes an alkaline
reaction on the paper (appears blue)
and urine an acidic reaction (remains
yellow).
3
Gestational Hypertension
 It is a condition in which vasospasm
occurs in both small and large arteries
during pregnancy, causing signs of:
o Increased blood pressure
o Proteinuria
o Edema
 The cause of the disorder is unknown
the condition tends to occur most
frequently in
o Women of color
0
o
o
o
o
With a multiple pregnancy
Primiparas younger than 20
years of age or older than 40
years
Women from low
socioeconomic backgrounds
(perhaps because of poor
nutrition)
3
Those who have had five or
more pregnancies
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Edema can be separated from the
typical ankle edema of pregnancy
because it begins to accumulate in the
upper part of the body.
A weight gain of more than two
lbs/weeks on the second trimester or
1lb/week on the third trimester.
Severe Preeclampsia
 Blood pressure is 160 systolic and 110
o
o
Those who have hydramnios
Those who have underlying
disease such as a heart disease,
diabetes with vessel or renal
involvement
Essential hypertension
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o
Assessment:
Classical signs:
 Vision changes
 Typically, hypertension
 Proteinuria
 Edema
Edema can be described as:
Non-pitting – swelling cannot be indented with
finger pressure
1+ pitting edema – tissue can be indented
slightly.
2+ pitting edema – moderate indentation
3+ pitting edema – deep indentation
 Accumulating edema will reduce a
woman’s urine output to approximately
400 to 600 ml/24hrs
 Some woman reports severe epigastric
pain and nausea or vomiting possible
because abdominal edema or ischemia
to the pancreas and liver has occurred.
 If pulmonary edema has developed a
woman may report feeling short of
breath.
 If cerebral edema has occurred, reports
of visual disturbances such as blurred
vision or seeing spots before the eyes
may be reported
Gestational hypertension
 Blood pressure is 140/90 mmHg or
systolic pressure elevated 30mmHg or
diastolic pressure elevated 15mmHg
prepregnancy level
 No proteinuria
 No edema
 Blood pressure return to normal after
birth
Mild Preeclampsia
 Has proteinuria and BP of 140/90
mmHg taken on two occasions at least 6
hours apart.
 Blood pressure is 140/90mmHg or
systolic pressure elevated 30mmHg or
diastolic pressure elevated 15mmHg
above prepregnancy values
 Proteinuria of 1+ or 2+ on a reagent test
strip on random sample
3
mmHg diastolic
Marked proteinuria 3+ or 4+ on a
random sample or more than 5g in a 24hour sample.
Extensive edema is present
Eclampsia
 Most severe classification of gestational
hypertension
 A woman has passed into this stage
when cerebral edema is so acute and
0
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grand mal seizure (tonic-clonic) or coma
has occurred
The maternal mortality rate can be as
high as 20% from causes such as
cerebral hemorrhage, circulatory
collapsed or renal failure
Patellar Reflex
 With the woman in a supine position,
ask her to bend her knee slightly
 Place your hand under her knee to
support the leg.
 Locate the patellar tendon in the
midline of the anterior leg just below
the kneecap
 Strike it firmly and quickly with a reflex
hammer or the side of your hand
 If the leg and foot move, a patellar
reflex is present
Patellar reflex is scored as:
 0 – no response, hypoactive, abnormal
 1+ somewhat diminished response but
not abnormal
 2+ average response
3
 3+ brisker than average but not
abnormal
excreted at a faster rate than the
during activity.
 Bedrest therefore is the best
method of aiding increased
evacuation of sodium and
encouraging diuresis of edema fluid.
 Be certain women know to rest in
lateral recumbent position to avoid
uterine pressure on the vena cava
and prevent supine hypotension
syndrome.
Promote Good Nutrition
 A woman needs to continue her
usual pregnancy nutrition while on
bedrest
0
Nursing intervention of woman with severe
gestational hypertension
Support bedrest
 Most woman are hospitalized so
that bedrest can be enforced and a
woman can be observed more
closely that she can be on home
care.
 Visitors are usually restricted to
support people because a loud
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4+ hyperactive very brisk abnormal
Nursing Interventions:
Monitor antiplatelet therapy
 Mild antiplatelet agent, such as low
dose Aspirin, may prevent or delay the
development pf preeclampsia
 Antiplatelet: work by making your blood
less sticky. This prevents arteries from
being plugged by clots.
 Aspirin 50 to 80mg (sold as baby
aspirin) because excessive salicylic
levels can cause maternal bleeding at
birth.
Promote bedrest
 When the body is in recumbent
position, sodium tends to be
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noise can be sufficient to trigger
seizure that initiates eclampsia.
Admit to a private room so she can
rest and undisturbed as possible.
Raise side rails to prevent injury is a
seizure should occur.
Darken the room if possible
because a bright light can also
trigger seizure.
Shining a flashlight beam into a
woman’s eyes is the kind of sudden
stimulation to be avoided.
Stress is another stimulus that could
increase BP and evoking seizures in
a woman with severe preeclampsia.
Be certain a woman receives clear
explanations of what is happening
and what is planned esp. about the
visitor’s restriction.
 Allow her opportunities to express
her feelings about what is
happening.
Monitor fetal well being
 Take BP frequently (at least every 4hrs)
or with a continuous monitoring device
to detect any increase which is a
warning that a woman’s condition is
worsening.
 Obtain blood studies such as CBC,
platelet count, blood urea nitrogen and
fibrin degeneration products as
prescribed to assess renal and liver
function.
 Daily hematocrit levels are used to
monitor blood concentration (this level
will rise if increased fluid is leaving the
bloodstream for interstitial tissue
edema)
 A woman’s fundus should be assessed
daily for signs of arterial spasm, edema
or hemorrhage.
 An indwelling urinary catheter may be
inserted to allow accurate recording of
output and comparison with intake.
 Urinary output should be more than
30ml/hr
 A 24hr urine sample may be collected
for protein and creatinine clearance
determination to evaluate kidney
function.
Monitor fetal well being
 Single doppler auscultations at
approximately 4hrs
 A woman may have non stress test or
biophysical profile done daily to assess
uteroplacental insufficiency.
 If fetal bradycardia occurs, oxygen 3
0
administration may be necessary to
maintain adequate fetal oxygenation.
HELLP Syndrome
 Is a variation of gestational
hypertension that is named for the
common symptoms that occurs.
 H – hemolysis that leads to anemia
 EL – elevated liver enzymes that lead to
epigastric pain
 L – low platelets that leads to abnormal
bleeding/clotting and petechia.
 The syndrome occurs in 4% to 12%of
patients who have elevated blood
pressure during pregnancy.
 Because of low platelet count women
need extremely close observation for
bleeding, in addition to observations
necessary for preeclampsia.
 Therapy for this condition is transfusion
of fresh frozen plasma or platelets in
order to improve the platelet count.
Multiple pregnancy
 Is considered a complication of
pregnancy because a woman must
adjust to the effects of more than one
fetus
1. Identical (monozygotic) twin b
 Begin with a single ovum and a
spermatozoon in the process of fusion,
or in one of the first bell divisions, the
zygote divides into two identical
individuals
 Usually have 1 placenta, 1 chorion, 2
amnions and 2 umbilical cords
 The twins are always of the same sex.
 They account for 1/3 of twin births
 Fraternal (Dizygotic, Nonidentical) twins
 They account 2/3 of twin births
 The result of the fertilization of two
separate ova by two separate
spermatozoa.
 Have 2 placentas, 2 chorions, 2 amnions
and 2 umbilical cords
ASSESSMENT:
 Uterus begins to increase in size at 3a
rate faster than usual
 AFP levels will also be elevated
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The twin may be of the same or
different sex.
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Amniotic fluid is formed by a
combination of the cells of the amniotic
membrane and from fetal urine
It is evacuated by being swallowed by
0
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the fetus, absorbed across the
interstitial membrane into the fetal
bloodstream, and transferred across the
placenta.
 Accumulation of amniotic fluid suggests
difficulty with the fetus ability to
swallow or absorb or excessive urine
production.
 Inability to swallow occurs in infants
who are anencephalic who have
tracheoesophageal fistula with stenosis
or who have interstitial obstruction
 Excessive urine output occurs in the
fetus of diabetic women (hyperglycemia
in the fetus causes increased urine
production)
 The first sign of hydramnios may be
unusually rapid enlargement of the
uterus.
 The first sign of hydramnios may be
usually rapid enlargement of the uterus
 The small parts of the uterus become
difficult to palpate because the uterus is
unusually tense.
 Auscultating the fetal heart rate can be
difficult because the depth of the
increased amount of fluid surrounding
the fetus.
 A woman may notice extreme shortness
of breath as the overly distended uterus
pushes up against the diaphragm
 Lower extremity varicosities and
hemorrhoids
 Increased weight gain
 An ultrasound is done to document the
presence of hydramnios.
Therapeutic management:
 Maintain bedrest helps to increase
uteroplacental circulation and reduces
At the time of quickening, a woman
may report flurries of action at different
portions of her abdomen rather at one
consistent spot.
 On auscultation of the abdomen,
multiple sets of fetal heart sounds can
be heard.
 An ultrasound can reveal multiple
gestation sacs early in pregnancy.
THERAPEUTIC MANAGEMENT:
 Women with multiple gestation are
more susceptible to complications of
pregnancy such as gestational
hypertension, hydramnios, placenta
previa, preterm labor and anemia that
are women carrying one fetus.
 Following birth, they are more prone to
postpartum bleeding because of the
additional uterine stretching that
occurred
 Need closer prenatal supervision
 A woman carrying more than two
fetuses is at greater risks.

Hydramnios
 Usually, the amniotic fluid volume at
term is 500 to 1000ml
 Hydramnios occurs when there is excess
fluid of more than 200ml or an amniotic
fluid index above 24cm
 Hydramnios can cause fetal
malpresentation because the additional
uterine space can allow the fetus to
turn to a transverse lie.
 It also lead to premature rupture of the
membranes from the increased
pressure, which leads to additional risk
to infection, prolapsed cord and
preterm birth.
Assessment:
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pressure on the cervix which may help
prevent preterm labor.
Straining to defecate could increase
uterine pressure and cause a rupture of
membranes-high fiber
Assess vital signs as well as lower
extremity edema frequently
Amniocentesis can be performed to
remove some of the extra fluid.
If contraction begin, tocolysis may be
necessary to prevent or halt preterm
labor.
Oligohydramnios
 Refers to a pregnancy with less than the
average amount of amniotic fluid
 Because part of the volume of the
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amniotic fluid is formed by the addition
of fetal urine, this reduced amount of
fluid is usually caused by a bladder or
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Remaining in utero for longer than 2
weeks beyond term creates danger to a
fetus for several reasons:
Meconium aspiration is more apt to
occur as fetal interstitial contents are
more likely to reach the rectum
Macrosomia could create a birth
problem
Lack of growth because the placenta
seems to have adequate functioning
ability for only 40 to 42 weeks.
Prostaglandin gel or misoprostol
(Cytotec) applied to the cervix to initiate
ripening flowed by an Oxytocin infusion
are common methods used to begin
labor
Pseudocyesis
 False pregnancy
 Nausea and vomiting, amenorrhea and
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enlargement of the abdomen occur in
either a nonpregnant women or man
renal disorder in the fetus that is
interfering with voiding
It can also occur from severe growth
restriction
Oligohydramnios is suspected during
pregnancy when the uterus fails to
meet its expected growth rate.
Post term pregnancy
 A term is 38 to 42 weeks long
 A pregnancy that exceeds these limits is
prolonged (post term pregnancy, post
mature, postdate)
 Included in this group are some
pregnancies that appear to extend
beyond the due date set for them
because of a faulty due date.
 Women who have long term menstrual
cycle
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MIDTERM NOTES:
Small for Gestational-Age Infant
 An infant is SGA (also called microsomia) if
the birth weight is below the 10th
percentile on an intrauterine growth curve
for that age.
 SGA infants are small for their age because
they have experienced intrauterine growth
restriction (IUGR) or failed growth at the
expected rate in utero.
Etiology:
 A woman’s nutrition during pregnancy plays
a major role in fetal growth, so a lack of
nutrition may be a major contributor to
IUGR.
 Adolescents are prone to having a high
incidence of SGA infants because, if they
eat only enough to meet their own
nutritional and growth needs of the fetus
can be compromised.
 The most common cause of IUGR is
placental anomaly; either the placenta did
not obtain sufficient nutrients from the
uterine arteries or it was inefficient at
transporting nutrients to the fetus.
Assessment:
 The SGA infant may be detected in utero
when fundal height during pregnancy
becomes progressively less than expected.
 The infant may have poor skin turgor and
generally appears to have large head
because the rest of the body is so small.
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 Skull sutures may be widely separated. 3
 Hair may be dull and lusterless.
 The child may have a small liver, which can
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amount of plasma in proportion to RBC
are present because of lack of fluid) and
an increase in the total number of Red
Blood Cells RBC (Polycythemia).
Acrocyanosis (blueness of the hands
and feet) may be prolonged and
persistently more marked than usual.
SGA infants have decreased glycogen
stores Hypoglycemia develop.
Large for Gestational-Age Infant
 An infant is LGA (also known as
macrosomia) if the birth weight is above
the 90th percentile on an intrauterine
growth chart for the gestational age.
 Such babies appear deceptively healthy
at birth because of the weight but a
gestational age examination often
reveals immature development.
Etiology:
 Infants who are LGA have been
subjected to an over production of
nutrients and growth hormone in the
utero – obese and diabetic.
 Multiparous women may also have
large babies because with each
succeeding pregnancy babies tends to
grow larger.
Assessment:
 A fetus is suspected to descend CS may
be necessary because shoulder dystocia
(the wide fatal shoulders cannot pass
through the outlet of the pelvis) would
halt vaginal birth.
Appearance:
 At birth LGA infants may show
immature reflexes and low scores on
gestational age examinations in relation
to their size.
 They may have extensive bruising on
birth injury such as broken clavicle.
cause difficulty regulating glucose, protein,
and bilirubin levels after birth.
 The abdomen may be sunken.
 The umbilical cord often appears dry and
may be stained yellow.
Laboratory Findings:
 Blood studies at birth usually shows a
high hematocrit level (less than normal
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Because the head is large, it may have
been exposed to more than the usual
pressure during birth causing a
prominent Caput Succedaneum,
Cephalhematoma or molding.
Pres
norm
Capput Succedaneum
 Bruising and edema of presenting part
extending beyond the margin of the
skull bone.
 Prolonged delivery, ventouse delivery.
 Pressure from uterus and vaginal wall
during vaginal delivery.
 Detected on ultrasound/vaginal
examination.
 Resolves in few days.
 Usually no complications.
May
well
Soft, pits on pressure.
Skin ecchymotic.
Size largest at birth,
gradually subsides
within a day.
Underlying skull bone
fracture.
No treatment required.
Become largest after
birth and then
disappears within 6-8
weeks to few months.
May underlying skull
bone fracture.
No treatment required.
The Post term Infant
 Is one born after the 41st week of
pregnancy.
 Infants who stay in utero past week 41
are at special risk because a placenta
appears to function effectively for only
40 weeks.
 After that week it seems to lose its
ability to carry nutrients effectively to
the fetus and the fetus begins to lose
weight) post term syndrome.
Features include:
 Wrinkled, patchy, peeling skin.
 Long thin body suggesting wasting
 Advanced maturity i.e., open-eyed,
usually alert and appears old and
worried.
 The nails are typically long.
 10% of pregnancies born 41 and 43
weeks, 33% at 44 weeks.
Cephalhematoma
 Bleeding between the baby’s skull
bones and the lining over the bones
(the perineum).
 Swelling appears 8-48 hours after birth,
which has clear edges that end at the
suture lines.
 May be associated with fracture of the
underlying skull bone.
 Can cause anaemia and/or jaundice in
newborn.
 Gets spontaneously absorbed in some
weeks.
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hard edge.
Soft elastic but does
not pit on pressure.
No skin change.
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Associated with oligohydramnios
increases the likelihood of post
maturity.
Post mature infant delivered at 43
weeks gestation. Thick, viscous
meconium coated the desquamating
skin.
Demonstrate many of the
characteristics of the SGA infant.
Dry, cracked, almost leatherlike skin
from lack of fluid and absence of vernix.
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They may be SGA, and the amount of
amniotic fluid surrounding them may be
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less at birth than usual and it may be
meconium stained.
Fingernails will have grown well beyond
the end of the fingertips.
Because they are older than term
infants, they may demonstrate an
alertness much more like a 2-week-old
baby than a newborn.

Respiratory Distress Syndrome
 Formerly termed Hyaline Membrane
Disease.
Most often occurs in:
o Preterm infants.
o Infants with diabetic mothers.
o
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Infants born by C-section.
Or those who have decreased
blood perfusion of the lungs.
The pathologic feature is a hyaline
(fibrous) membrane formed from
exudate of an infant’s blood that begins
to line the terminal bronchioles,
alveolar ducts and alveoli.
This membrane (hyaline) precents the
exchange of oxygen and carbon dioxide
at the alveolar-capillary membrane that
interferes with effective oxygenation.
The cause is low or absence of
Surfactant, the phospholipid that
normally lines the alveoli and reduces
surface tension to keep the alveoli from
collapsing on expiration.
Surfactant does not form until the 34th
week of gestation.
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During this time subtle signs may
appear such as:
o Low body temperature.
o Nasal tachypnea.
o Sternal and subcostal
retractions.
o Tachypnea (more than 60
breaths per min.)
o Cyanotic mucous membrane.
Within several hours, expiratory
grunting occurs caused by closure of
glottis.
As distress increases, an infant may
exhibit:
o Seesaw respirations (on
inspiration the anterior chest
wall retracts and the abdomen
protrudes; on expiration the
sternum rises).
o Heart failure evidenced by
decreased urine output and
edema of the extremities.
o Pale gray skin.
o Periods of apnea.
o Bradycardia.
o Pneumothorax.
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Therapeutic Management:
 Surfactant replacement (Survanta) to
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Prevention:
 Magnesium sulfate – can help prevent
preterm birth.
 Betamethasone – steroids appear to
quicken the formation of lecithin (24 –
34 weeks).
Most infants have difficulty initiating
respirations at birth.
After resuscitation they appear to have
free symptoms for hours and day
because of initial release of surfactant.
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restore naturally occurring lung
surfactant to improve lung compliance.
Oxygen administration.
Kept warm-reduces the infant’s
metabolic oxygen demand.
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