◦ Rh incompatibility/ Isoimmunization
◦ Gravidocardia
◦ Decelerations (late/ variable)
◦ Umbilical cord compression/ prolapse
◦ Gestational diabetes
◦ Insulin administration
◦ Induction and augmentation of labor/ Bishops scoring
◦ Precipitate labor
◦ Uterine rupture
◦ Bandl’s retraction ring
◦ Placenta succenturiata
◦ Shoulder dystocia
◦ CS delivery/ forcep delivery
◦ Pneumonia
◦ NBS/ G6PD/ CAH/ PKU/ Galactosemia
◦ Congenital hypothyroidism
◦ Tetralogy of fallot (TOF)
◦ Rheumatic fever
◦ ASD/ VSD/ PDA
◦ Kawasaki disease
◦ Infective endocarditis
◦ Coarctation of Aorta (COA)
OPERATIVE OBSTETRICS
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INDUCTION OF LABOR- deliberate initiation of labor or
uterine contractions before spontaneous labor
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INDICATION
→ Post maturity: placental insufficiency
→ Diabetic; LGA baby, mother can develop
ketoacidosis and baby will develop acidosis.
A mother who has poorly controlled labor is
encouraged to undergo induced labor
→ PIH& PROM- prom may cause infection.
DIFFERENCE OF AUGMENTATION AND INDUCTION OF
LABOR
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AUGMENT- already in labor, but uterine
contraction is weak. Stimulate to produce higher
contraction. Administer oxytocic drug.
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INDUCTION- not yet in labor
Head is already engage
No contraindications for the use of oxytocin like CS
scar, hypertonic uterine contractions, no CPD, fetal
distress and placenta previa
METHOD OF INDUCTION
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ADMINISTRATION OF PITOCIN- via IV on a separate IV
bottle, piggy back. D5 water w/ 10u Pitocin. FOR
AUGMENTATION
ARTIFICIAL RUPTURING OF BOW- amniotomy
STRIPPING THE MEMBRANE- hihiwalay yung
membrane, di irarupture, ilalabas lang konti.
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Watch out for fetal distress
Watchout BP ni mommy.
Fetal hr of 160 above is a sign of fetal distress
Evaluate successful induction- 3 uterine contractions in
10 min duration
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Cervix is fully effaced and fully dilated
Forcep is not done if BOW is not ruptured
Epidural anesthesia
Cervical consistency- GOODELL’s SIGN
Minimum score of 8 to perform induction of augment
labor
If score is less than 8, it is because of the CERVICAL
CONSISTENCY, not yet ripe. Causes the baby to not go
down affecting all the parameters.
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PROSTAGLANDIN GEL
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CYTOTEC- di na malalaglag yan kasi lalabas na
nga eh. 100 mg of scored tab, ¼ is only given 25
mcg.
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LAMINARIA TENT- doctor only, promote cervical
dilatation. Cone-shaped dried sterile seaweed.
PRE-REQUISITE FOR SUCCESSFUL INDUCTION
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Mature fetus; mother at or near term
No CPD- cs na to dapat
Soft and pliable cervix with moderate amount of CD
and CE
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0 station for midforceps
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Cystocele- protrusion of bladder to vaginal wall
Rectocele- rectum protrude to vag wall
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BLADDER AND BOWEL EMPTYING
Cord compression, causes fetal tachycardia
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Latent- 0-3 cervical dilatation
Due to cervix is not yet ripe
PROTRACTED ACTIVE PAHSE- when active phase is 12
hrs above for primi and 6hrs above for multi
Malpresentation usually CS or forcep
SECONDARY ARREST OF DILATATION- no progress in
CD, increase UC using Pitocin or CS
Prolonged descent may be due to hypotonic UC
CPD ALWAYS CS!!!
GESTATIONAL DIABETES
3RD TRIMESTER BLEEDING AND GDM
PLACENTA PREVIA
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Remove nail polish
NPO at night
Emptying of bowel and bladder
Shaving
CONSENT
Administration of preop meds
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Premature separation of abnormal implanted placenta=
UPPER UTE. SEGMENT
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LOW LYING- does not touch internal os
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MARGINAL- touching the margin of internal os
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PARTIAL- half covered internal os
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TOTAL- full covered internal os
→ Need for cs because pathway of baby is
blocked. OBSTRUCTED
MULTIPARITY- leading factor
Decrease vascularity in UUS
No pain and abd is soft and no uterine contraction
Bleeding is always overt
Bright red blood
Fetal presenting part is not engaged
Dx: UTZ
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Abdomen utz will locate the placenta, will not
determine the obstruction
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TRANSVAGINAL UTZ, determines degree of
obstruction
MGT:
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Watchful waiting, Complete bedrest
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Complete bedrest
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Amniotomy
Classical CS, location of incision, vertical incision above
umbilicus
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Not qualified for VBAC anymore because it cuts
against the muscle fibers resulting to longer
healing time
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Low transverse incision, allowed for VBAC
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NURSING CARE:
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Maintain bed rest
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No IE, will increase bleeding
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Monitor VS, bleeding, FHR, FMOVEMENT,
amniotic color, I&O
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Prepare utz
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Shock management: VS, I&O, increase O2 sat by
o2 therapy via mask, BT
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Observe post-partum complication
→ Bleeding and infection
Administer dexamethasone for fetal lung maturity for 4
doses- 6mg IM q 12hrs
Betamethasone, 12 mg IM q12hrs for 2 dose
ABRUPTIO PLACENTA
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Premature and abrupt sep of normal implanted
placenta
More dangerous than P. previa
Center to periphery, SCHULTZ
Periphery to center, DUNCAN
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OVERT- obvious bleeding
→ DUNCAN, blood will not pool in the middle
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COVERT- concealed bleeding
→ SCHULTZ, bleeding occurs at the back of the
placenta because periphery is not yet
separated.
→ Pooling blood at the back of placenta
HPN, Renal disease, multiple pregnancy, short cord
(cord coil) 52-55 cm, trauma- LEADING FACTOR
Rigid, board like abdomen, continuous UC, pain is
present
Bleeding may be overt or covert
dark red blood
either engaged or not engaged
DX: UTZ and clotting studies
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To determine DIC (disseminated intravascular
coagulation)
→ Abnormality in clotting mechanism of
mother
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Placental site due to CS is damaged
and will result to bleeding
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Bleeding to other parts of the body will
more likely to occur
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Anticoagulant drugs should be
administered in the form of heparin not
coumadin because it can cause CCC
and it crosses the placenta and cause
cranio facial malformation
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HYPOFIBRINOGEMIA
Hemorrhage, shock, CVA, infection, prematurity
Couvelaire uterus- infiltration of blood in myometrial
tissues resulting to post-partum atony
MGT: CS, BT, Rhogam
Administer betametasone or dexamethasone to
improve fetal lung maturity.
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Administered during 6 mos of pregnancy
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DEXA- 4 doses 6 mg IM q12
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BETA- 12 mg 2 doses IM q24
Left lat recumbent, monitor, IVF & BT, dx test,
psychological support, monitor post partrum
complication
DIABETES
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Problem in production of insulin
Increase resistance of insulin
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Maybe concurrent (may dm na talaga bago pa
mabuntis) or GDM
Fam hx, rapid hormonal change during pregnancy,
tumor of pancreas
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HPL- produced by placenta, increases during 24
to 28th wk of pregnancy, block action of insulin
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Estrogen, progesterone, HPL- main diabetogenic
agent made by placenta
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Screening for dm is best made during 24-28wks
of pregnancy
3 SIGNS OF GDM
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Polyuria, excessive wiwi
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Polydipsia, excessive thirst
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Polyphagia- excessive eating
HYPERGLYCEMIA- glucose in blood is high which
attracts more water. Blood will carry excess water to
kidney resulting to polyuria.
Since the fluid is leaving the cell which cause the cell
to shrink resulting to cellular dehydration aka
polydipsia.
The glucose does not enter body cell causing no energy
resulting to eating aka polyphagia
Glucose will still not enter the cell and will remain in
blood.
Body will look for another energy and will use protein
as energy. Causing the muscle mass to decrease.
Fat will be converted to fatty acid a s source of energy.
Ketone is produced when fat is converted into fatty acid
and leads to acidosis, ketones go to brain and affects
consciousness and may result in coma
Keto-acidosis affect the baby in a way that it crosses
placenta and causes the baby to develop trisomy 21
When ketones reach the brain of baby, it will cause
neurologic impairment which is irreversible. (low iq)
If glucose cross placenta, the insulin production of fetus
is increased leveling the mothers glucose. It will result
to LGA baby. FETAL HYPERINSULENEMIA
NEONATAL HYPOGLYCEMIA, neonates glucose level
will drop
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NORMAL: 40-60 mg/dl of blood
→ Administer oral glucose solution or IV
glucose solution
If poorly controlled DM in early part of pregnancy,
DOWN SYNDORME
If poorly controlled on the later part of pregnancy,
NEUROLOGICAL IMPAIRMENT.
LS RATIO- test for lung surfactant, normal: 2:1
DIAGNOSIS: 24th wk of preg
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GCT- GLUCOSE CHALLENGE TEST
→ Screening only
→ 50 g glucose solution
→ No special preparation
→ No NPO post-midnight
→ Less than 145 mg/dl of blood (NORMAL)
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OGTT- ORAL GLUCOSE TOLERANCE TEST
→ Confirmatory test
→ 100g glucose solution
→ Increase intake of carbs 2-3 days prior to
test
→ NPO post-midnight
→ If there is 4 above normal, DM is confirmed
NURSING CARE:
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PNC
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1800-2000kcal per day
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Exercise= WALKING
→ Eat small amount of food b4 walking, one
piece bread
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UTZ- to determine fetal size
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NST- to determine FHR
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CVS- chromosomal defect
→ If positive, baby will undergo MSAFP
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Daily kickcount= 10-15
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Regular is given during emergency while intermediate
is given as maintenance
We can combine reg and int insulin but we should
aspirate regular insulin first. To prevent contamination.
REGULAR- fast acting but not long acting
INTERMEDIATE- slow acting but long acting
ABORTION, ECTOPIC PREGNANCY AND RH
INCOMPATIBILITY
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Antigen triggers the body to produce antibodies
against the antigen.
RH FACTOR
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Rhesus factor- factor located outside the blood. +
and –
→ That is why blood typing and cross matching
is important
→ Blood typing- A,B,AB, O
→ Cross matching, compatibility test for other
details of blood and RH
HOW RH INCOMPATIBILITY HAPPENS
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PLACENTAL
BARRIERsemi-permeable
membrane, which means the not everything can
pass through.
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Maternal blood will not pass the placental barrier
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No mixing of blood of mommy and baby because
of placental barrier
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The baby usually follows the RH of the mommy
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If incompatibility happens during the 1st
pregnancy, no problem will occur because mother
hasn’t produce antibodies.
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RH compatibility happens when mothers blood
and fetal blood with different RH meet. Might
happen if abruptio placenta. Mother will produce
antibodies and it will be permanent.
→ Blood cannot pass the PB however, the
antibodies can. This will result to the
antibodies of the mother attacking the blood
of the baby causing HEMOLYSIS. Hemolysis
will produce bilirubin and cause jaundice.
HOW WILL WE PREVENT THE ANTIBODY
PRODUCTION?
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COOMB’S TEST- to know if the mother produced
antibodies or not. We want a NEGATIVE result. It
should be done 48hrs after deliver.
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If the result for coombs is negative, and
immunoglobulin is given to the mother called
rhogam IM. It prevents antibody production by
neutralizing the fetal blood. It should be given
w/in 72 hours of delivery. It is temporary.
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IUEBT- intrauterine Exchange Blood Transfusion.
→ DIRECT COOMBS- fetal blood is used
→ INDIRECT COOMBS- maternal blood is used
BLEEDING DISORDERS OF PREGAGNANCY
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Bleeding anytime during pregnancy is risky except for
show.
GRAVIDOCARDIA AND RH INCOMPATIBILITY
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Gravidocardia- a pregnant women with heart disease
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RISK FACTORS
→ Rheumatic heart disease
→ CHD
→ Arteriosclerosis
→ Myocardial infarction
→ Pulmo disease
→ Renal disease
→ Heart surgery
PATHOPHYSIO
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GABHS- group A beta-hemolytic strepto. That
causes RHD
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If the lungs is also affected with infection, if the
blood pumps and circulate the blood going to
lungs, as unoxygenated blood travels to lungs
for reoxygenation, the blood will also carry the
infection. Tas ripple effect na
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As blood passes the mitral valve, the organisms
will be trapped in the valve. It will release toxin
and causes the mitral valve irritated resulting to
inflammation. MVP- mitral valve prolapse
→ PENICILLIN
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MVS-mitral valve stenosis- mitral walve will not
fully close. PERMAMNENT CARDIAC DAMAGE
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The blood is continuously flowing in LV which
causes the LV to distends resulting to
cardiomegaly. Increasing the pump as
compensatory mechanism.
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If not corrected, the pumping will weaken over
time and it will congest more. CONGESTIVE
HEART FAILURE.
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The blood will go back to LA then to pulmonary
vein then to lungs resulting to pulmonary
edema.
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It will decrease the oxygen consumption.
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Results to ACTIVITY INTOLERANCE.
CLASSIFICATION
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Digitalis- Digoxin and lanoxin: increases the force of
heart contraction but decreases the rate of heart
contraction. Lumalakas ang contraction pero
bumabagal ang contraction.
Make sure that HR is not less than 60bpm.
Increases urine output because the blood in kidneys go
high with minimum 30 ml/ hour and above.
Diuretics, potassium increase the contractility of the
heart.
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Potassium sparring■
Nonpotassium sparring- Lasix of furosemide,
Aldactone
RHOGAM is an immunoglobulin D given to the
mother to prevent antibody production. GIVEN IF
NEGATIVE ANG RESULT. w/in 72 hours.
IUEBT- intrauterine exchange blood transfusion.
INTRA PARTAL COMPLICATIONS: PROBLEMS IN POWER
AND PLACENTA
POWER OF LABOR
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DYSTOCIA- more painful and difficult labor.
UTERINE CONTRACTIONS
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Hypertonic uterine dysfunction- can make the delivery
shorter and faster. PRECIPITATE LABOR less than 3
hours.
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Can lead to perineal laceration.
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Happens during latent phase of labor
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Predisposing factors; primigravid, young age,
unwise use of oxytocin, trauma
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TOCOLYTIC, duvadilan, mag sul, yutopar, dactyl
ob, bricanyl terbutaline- smooth muscle relaxant.
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may lead to fetal distress causing maternal
vasoconstriction.
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Tell the mother to not push, just pant to relax
abdominal muscle.
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Ilabas and head during between contractions to
avoid lacerations. RITGENS
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Hypotonic uterine dysfunction- can result to
prolonged labor. More than 24 hrs.
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Occur during active phase of labor.
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Predisposing factors; overdistended uterus
(masyadong nabatak na matres), high parity,
fetal malpresentation.
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OXYTOCIC, syntocinon, Pitocin, metergine
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leads to fetal distress by uteroplacental
insufficiency.
Fetal tachycardia is an early sign of fetal distress.
Check for fetal hr
Check for fetal movement. 5-15 movement per hour.
Hyperactive as sign of fetal distress.
Color of amniotic fluid. Should be clear, meconiumstained amniotic fluid indicates distress. Non breech
presentation. Meconium staining is common in breech.
Not allowed to push during CS kasi sa effort,
mapapagod si heart.
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NURSING MANAGEMENT
RH INCOMPATIBILITY
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Mother is – baby is +
Mother is – father is +
When mother produces an antibody, it is called
isoimmunization. It is permanent affecting the next
pregnancy. 1st pregnancy is not affected because no
antibody is formed.
The amniotic fluid will be golden.
Erythroblastosis fetalis- blood of baby is hemolyzed by
the antibody of the mother. Bilirubin and water. More
water will come out causing the body of the baby to be
edematous.
GOAL OF CARE; PREVENT ISOIMMUNIZATION AND
PREVENT ANTIBODY PRODUCTION BY UNDERGOING
COOMB’S TEST.
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To know if mother produce antibody or not.
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We want a NEGATIVE result.
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Left lateral position of mother.
O2 therapy via mask atleast 5-8L/ min
If incorporated with oxytocic drug, you may
slowdown or completely stop the flow rate.
Watchout for bleeding ang uterine atony.
INDUCTION AND AUGMENTATION OF LABOR
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Induction- induce; to force
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Oxytocic
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Not yet in labor
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Post term pregnancy
Augmentation- to assist in labor
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Oxytocic
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Client is already in labor.
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hypotonic uterine contraction.
COMPLICATIONS OF LABOR
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400 mcg of folic acid to be taken every day.
Folic acid deficiency- causes spinabifida
if the bag ruptured, the baby should go out w/in the
next 4 hours
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steroids are used to promote fetal lung maturity
dexa- 6mg im q12 4 doses
beta (celestone) - 12mg im q24 hours 2 doses
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if there is previous CS, to get pregnant again wait at
least 3 years.
Hypertonic uterine contraction may lead to possible
uterine rupture. The intense and prolonged
contractions can lead to excessive pressure on the
uterine wall, potentially causing it to tear or rupture.
Bandl retraction ring-
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After the baby is taken out, hysterectomy will be done.
Shock position, moderately elevate the lower
extremities
by
30
degrees.
MODIFIED
TRENDELENBURG
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Most common reason is abuptio placenta.
If amniotic fluid went to the circulation of the mother,
it will disrupt the circulation of the blood of the mother
and she might lose oxygen in her brain and is very fatal.
Prevalent in women who experience abruptio placenta
due to PIH
Digitalis- to increase pumping action of the blood but
decrease the rate of pumping action.
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Bandl's ring, also known as a pathological uterine ring,
is a constriction between the thickened upper uterine
segment and the thinned lower uterine segment, a late
sign of obstructed labor that can lead to complications
like uterine rupture.
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Shoulder dystocia- too wide shoulders
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Turtle sign- no 1 sign of shoulder dystocia, head
retraction.
Preterm labor- depends on the preterm birth because
the head of the fetus is not yet developed.
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Battle dore- edge
Velamentous- superficially attached
Succenturiate- may anak ang placenta
Circumvallate- makapal membrane at maliit placenta
Cicummarginate- normal placenta size, thick membrane
DnC is the management.
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Hysterectomy is the only management.
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