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NCM 102 - Lecture (Prelims)

NCM 102 - Lecture (Prelims)

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Published by: CJ Angeles on May 02, 2013
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Programs, Trends, and Issues in Maternal Health Introduction – Maternal mortality trends are unacceptable, but not insurmountable

because the major causes are known and avoidable • Nearly 2/3 of maternal deaths are due: – Hemorrhage – Obstructed labor – Pregnancy-induced hypertension – Sepsis/infection – Complications of unsafe abortion Interventions can be made available even in resource-poor settings

1987 – Safe Motherhood Initiative 1990 – World Summit for Children 1994 – International Conference on Populations and Development th 1995 – 4 World Conference on Women 2000 – Millennium Summit/Declaration

irrespective of the duration and site of the pregnancy.000 live births during the same time period. Misreporting because of the complicated definition requiring also its cause and timing OR sometimes done intentionally to avoid legal action. Maternal Mortality Rate – refers to the number of maternal deaths in a given time period per 100. Underreporting – especially if most occur outside of health facilities (in the absence of health personnel to report them). All births are attended by skilled health professionals (ideally facility-based). surviving children esp. those < 5 years old are at risk of dying since no one will attend to their needs • The loss may reverberate throughout an entire community 2. Adult Lifetime Risk of Maternal Death – refers to the probability of dying from a maternal cause during a womans reproductive lifespan.. All complications are managed in adequately-staffed and equipped facilities offering emergency obstetric care. Lessons learned : Most maternal deaths and disabilities would be averted if. 2.. It is a rare event and therefore its number may not be large enough to detect statistically significant changes over time. – Governments must promote dignity and equity for women within the health-care system. Ways in measuring progress in reducing maternal mortality Maternal Mortality Ratio – refers to the number of maternal deaths during a given time period per 100. All pregnancies are wanted and planned. Methodological issues in measuring maternal mortality 1. Social implications • Maternal death or disability can plunge families into poverty and deeper despair.000 women of reproductive age during the same time period. Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy. .Why aim for maternal survival? 1. Moral imperative – The death of a woman during pregnancy or childbirth is a violation of her rights to life and health. 3. from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. All pregnancies are adequately managed throughout its course.

domestic violence. the fetus or both. 2. pregnancy related complications or external factor jeopardize the health of the woman. Skilled attendance at all births. Risk Factors Physiologic - Physiological Socio demographic Psychological Environmental Concurrent illness Malnutrition Physically challenged Frequent pregnancies Socio Demographic Poverty Unemployment Lack of education Age Poor access to transportation for care Lack of support people Psychological Factor Cognitively challenge Single / Separated mothers Victims of Abuse. incest Mental Retardation Environmental factors Exposure to Teratogens due to employment Environmental contaminants at home Poor Housing . Universal access to contraceptive services to reduce unintended pregnancies.One in which a concurrent disorder. rape.Strategies to reduce maternal mortality 1. Nursing Care of the High Risk Pregnant Client High Risk Pregnancy .

 Continued healthy fetal growth. Common Nursing Diagnosis  Anxiety related to guarded pregnancy outcome. vaginal spotting should be discovered and investigated thoroughly.  Ineffective role performance related to increasing level of daily restrictions secondary to chronic illness and pregnancy.CARING FOR A WOMAN WHO DEVELOPS A COMPLICATION OF PREGNANCY Assessment  Provide enough time for a thorough health history. Evaluation  Client’s BP is maintained within acceptable parameters  Couple state they feel able to cope with anxiety associated with the pregnancy complication  Client accurately verbalizes crucial signs and symptoms to report to the health care provider immediately. Sudden        Pregnancy Complications Bleeding during pregnancy Ectopic pregnancy Gestational trophoblastic disease Premature cervical dilatation Placenta previa Abruptio placenta Disseminated intravascular coagulation Bleeding during pregnancy is always a deviation from the normal. Implementation  interventions for woman experiencing a complication of pregnancy include measures to maintain number of different areas.  A woman’s and family ‘s psychological health.  Risk for ineffective tissue perfusion related to pregnancy-induced hypertension. SUDDEN PREGNANCY COMPLICATION In few women.  Continuation of the pregnancy as long as possible.  Risk for infection related to incomplete miscarriage.  Deficient knowledge related to signs and symptoms of possible complications. . blurred vision. unexpected deviations or complications from the normal course of pregnancy happens.  Problems such as headache.

Summary of Primary Causes of Bleeding during Pregnancy Time type cause Assess-ment cautions 1 trimester st Threatened miscarriage Imminenent miscarriage Unknown. perhaps slight cramping.ferti-lization or division defect Cervix begins to dilate and pregnancy is lost at about 20 weeks Retained trophoblast tissue malignant Can have cervical sutures placed to ensure a second pregnancy . Ectopic pregnancy Implan-tation of zygote at site other than the uterus Sudden uni-lateral lower abdominal quadrant pain. highly positive HCG. no apparent loss of Pregnancy Vaginal spotting. cramping . no fetus on ultrasound. possible signs og shock or hemorrhage Overgrowth of uterus.bleeding from vagina Painless bleeeding leading to expulsion of fetus May have repeat ectopic pregnancy in future if tubal scarring is bilateral Hydatidi-form mole Premature cervical dilatation Abnormal proliferation of trophoblast cells. cramping. possibly chromosomal uterine abnormalities Vaginal spotting perhaps slight Cramping Vaginal spotting. cervical dilatation Vaginal spotting.cervical dilatation. minimal vaginal bleeding. but incomplete expulsion of uterine contents Complete expulsion of uterine contents Disseminated intra-vascular coagu-lation associated with missed mis carriage Missed miscarriage Incomplete miscarriage Complete miscarriage 2nd trimester 1.

cervicitis. slight cramping  No cervical dilatation  Mgt:  Fetal heart assessment  Utz  hCG determination  Avoid strenuous activity .Time Type Cause Assess-ment cautions 3 trimester rd Placenta previa Abruptio placenta Low implan-tation of placents possibly because of uterine abnorma-lity Unknown cause.Medical term for any interruption of a pregnancy before a fetus is viable. placenta separates from uterus Trauma.  Should consult attending Obstetrician so that instructions may be given. Threatened Miscarriage  Vaginal bleeding. bright red usually.maternal illness Painless bleeding at beginning of cervical dilatation Sharp abdominal pain followed by uterine tenderness. Spontaneous Miscarriage th  Early miscarriage if it occurs before 16 week  Late between 16-24 weeks  CAUSES:  Terratogenic factor  Chromosomal abberations/abnormal fetal development  Implantation abnormalities  Failure to produce enough Progesterone  Infection Presenting Symptom  Vaginal bleeding/spotting. substance abuse.PIH. increased chance in multiple gestation . vaginal bleeding Show accompanied by uterine contract-ions becoming regular and effective No vaginal examina-tions Disse-minated intra-vascular coagulation Pre-term labor Preterm labor may be halted if the cervix is less than 4 cm dilated and the membranes are intact Abortion .scant.

Incomplete miscarriage  Part of the conceptus is expelled. Increased heart rate. Dilatation and curettage or suction curettage. feeling of apprehension 4.entire products of conception are expelled spontaneously without assistance. Complete Miscarriage .decreased renal output---renal failure----maternal and fetal death Signs and Symptoms of Hypovolemic Shock ASSESSMENT SIGNIFICANCECOLD INCREASED PULSE RATE DECREASED BP INCREASED RR Heart is attempting to compensate to increase BV Less peripheral resistance Increase gas exchange to oxygenate decreased RBC volume . Decreased intravascular volume 3.  Loss of product of conception cannot be halted. Recurrent Pregnancy Loss  Women who had 3 spontaneous miscarriages  Defective spermatozoa or ova  Endocrine factors  Deviations of the uterus  Uterine infections  Autoimmune disorders Complications of miscarriage  Hemorrhage  Infection  Risk for isoimmunization Process of Shock because of Blood Loss 1. Reduced renal.clammy skin. vasoconstriction.decreased uterine perfusion. Lethargy.increased RR.coma. Blood loss 2. but the membrane or placenta is retained.blood pressure falls 5. Cold .  If no FHT and UTZ reveals empty uterus-dilatation and evacuation may be performed.  Mgt. Coitus usually restricted for 2 weeks  Spotting usually stops within 24-48 hours Imminent (inevitable) Miscarriage  Uterine contractions and cervical dilatation occurs.uterine and brain perfusion 6.

bowel perforation.  Danger is infiltration of large blood vessel. vaginal abdominal pain  Movement of cervix cause excruciating pain  Pain in shoulders Management:  Unruptured –methotrexate followed by leucovorin. Decreased venous return DECREASED URINE OUTPUT DIZZINESS DECREASED CVP Ectopic Pregnancy  Implantation occurs outside the uterine cavity.  Fetal outline is easily palpable.  Woman still experiences the signs of pregnancy.  May lead to shock.  Falling hcg level. Ruptured Ectopic Pregnancy  Sharp stabbing pain in lower abdominal quadrant.  Ruptured –emergency situation.  Complete Blood Count  Administration of fluids Abdominal Pregnancy  Woman may report sudden lower quadrant pain.  Utz –provides clear cut picture.  Amount of bleeding not evident. If the woman does not seek help at once…  Cullen’s sign  Dull.  Due to fallopian tube scarring that slow the travel of the zygote.  (+) pregnancy test.  Signs and symptoms of pregnancy is experienced by the woman.  Ovary or cervix.CLAMMY SKIN Vasoconstriction occurs to maintain blood volume in central body core Decrease blood supply in the kidneys Inadequate blood is reaching the cerebru. poor nutrient supply to the fetus.COLD.  Missed period.  Most common is fallopian tube. .  Vaginal spotting. mifepristone (abortifacient).  Laparoscopy-ligate the bleeding vessels and remove/repair fallopian tube.

hCG level  HCG monitoring  Half of woman positive at 3 weeks  ¼ positive result at 40 days  Assess every 2 weeks until normal  Every 4 weeks for the next 6 to 12 months  Should use reliable contraceptive method  Plan pregnancy at 12 months if hcg is normal Prophylaxis  Methotrexate  Dactinomycin Premature Cervical Dilatation  Old name-Incompetent cervix.  Ultrasound-no fetal growth and fetal heart sound. Associated with:  Increased maternal age. .1 to 2 M IU compared to a normal of 400.  Congenital structured defect.  Strong (+) result of hCG.000IU. chest radiograph.  Marked nausea and vomiting.some of the villi form normally.  Painless st  Pink-stained vaginal discharge(1 symptom)  Followed by Rupture of membrane. profuse flesh flow(16 weeks) with clear fluid filled vessicles. th  Symptoms of pregnancy induced hypertension may appear before the 20 week.  Dark brown blood. Therapeutic Management  Suction curettage  Post surgery:  Pelvic examination. Partial mole .  Rate of survival is 60%. Gestational Trophoblastic Disease (Hydatidiform Mole)  Abnormal proliferation and then degeneration of the trophoblastic villi  Cells become filled with fluid and appears as fluid filled grape sized vesicles  1 in every 1500 pregnancies Two types: Complete mole – all trophoblastic villi swell and become cystic.cannot hold a fetus until term. discharge of amniotic fluid.  Cervix that dilate prematurely. Assessment  Uterus tends to expand faster. Infant must be born through laparotomy.  Uterine contractions-birth of the fetus.

 Partial .implantation in the lower rather than in the upper portion of the uterus. painless .Placenta is implanted abnormally in the uterus. Most common cause of painless bleeding in the third trimester of pregnancy.Nylon sutures are placed vertically and horizontally across the cervix and pulled tight to reduce the cervical canal.  Total placenta previa .implantation that totally obstructs the cervical os. Shirodkar .  Marginal – the placenta edge approaches that of the cervical os. Immediate care measures:  Place the woman immediately on bedrest in a side lying position Associated with:  Increased parity  Advanced maternal age  Past CS  Past uterine curettage  Multiple gestation  Male fetus Assess:         Duration of pregnancy Time the bleeding began Estimate amt of blood loss Accompanying pain Color of the blood What has she done Prior episodes of bleeding Prior cervical surgery Therapeutic Management  Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy  Obtain baseline VS  IVF therapy  I and O monitoring  External monitoring equipment  Complete blood count  Blood typing and crossmatching Fetal delivery depends on the percentage of previa and the condition of the pregnancy. . Occurs in 4 degrees:  Low lying.totally obstructs the cervical os.Sterile tape is threaded in a purse string manner under the submucous layer of the cervix. Assessment  Bleeding is abrupt. Management:  Cervical cerclage-purse-string sutures are placed in the cervix by vaginal route. McDonald Procedure . bright red and sudden. Placenta Previa . Trauma to cervix.

 DIC may occur.  Heavy bleeding-evident if separation occurs at the edges. pelvic or vaginal examination  Unless separation is minimal. maternal shock and fetal death may occur 2 3 .diagnosis made after birth Minimal separation. uterus tense and painful Extreme separation.  Couvelaire uterus(uteroplacental apoplexy)-hard board like uterus with no apparent bleeding.Premature Separation of the Placenta/Abruptio Placenta Placenta appears to be implanted correctly Begins to separate and bleeding results Cause is unknown Predisposing Factors:  High parity  Advanced maternal age  Short umbilical cord  Chronic hypertensive disease  Pregnancy induced hypertension  Direct trauma  Vasoconstriction  Autoimmune antibodies  Chorioamnionitis Assessment  Sharp stabbing pain high in the uterine fundus. Degress of Premature Placental Separation Grade Criteria 0 1 No symptoms apparent. each contraction will be accompanied by pain over and above the pain of contraction. but enough to cause vaginal bleeding and changes in maternal VS.there is evidence of fetal distress.  If labor begins. Therapeutic Management  Emergency situation  Large gauge IV catheter  Oxygen by mask  FHT and maternal VS monitoring  Lateral position  No abdominal. pregnancy must be TERMINATED.no fetal distress Moderate separation.

. not enough are left for the rest of the body.  Effects after 24 hours and lasts 7 days. Therapeutic Management  Woman usually admitted  Bed rest  IV fluids  Tocolytic agent-halt labor (terbutaline)  Advised to limit strenuous activities  Fetal assessment-count to 10 test Administration of Terbutaline  Mixed with lactated Ringer’s  Piggy back  Microdrip  Check blood pressure and pulse rate  If contractions are halt.000/uL  Prothrombin –low  Thrombin-elevated  Fibrinogen –less than 150 mg/dL Management  Halt the underlying insult  IV administration of of Heparin  Blood or platelet transfusion Way to Predict which Pregnancy will End Early:  Analyze change in vaginal mucus. Drug Administration  Steroid( betamethasone)-to hasten lung maturity. oral terbutaline may be given.  Presence of fetal fibronectin-preterm contractions are ready to occur. Test Clotting Time  Test tube-clot must form  Platelet assessment-less than or equal to 100. fibrinogen level falls to below effective limits  Conditions asscociated with its development:  Premature separation of placenta  PIH  Amniotic fluid embolism  Placental retention  Septic abortion  Retention of dead fetus Extreme bleeding causes many platelets and fibrin from the general circulation rush to the site.  Absence.Disseminated Intravascular Coagulation  Acquired disorder of blood clotting.labor will not occur at least 14 days.

CS.  Potter –like syndrome-distorted facial features and pulmonary hypoplasia.  Cervix more than 50% effaced and 3-4 cm dilated.  Cord is clamped immediately. Pregnancy Induced Hypertension  Vasospasm occurs during pregnancy in both small and large arteries  Used to be called toxemia Occurs most frequently in women:  Of color  Multiple pregnancy  Primiparas younger than 20 years or older than 40 years  Low socioeconomic backgrounds  Who have had five or more pregnancies  Hydramnios  Underlying disease Classifications:  Gestational hypertension  Mild eclampsia  Severe eclampsia  Eclampsia Assessment  Hypertension  Proteinuria  Edema . Method of Delivery  If very immature .CS. fetus is at point of viability:  Woman is placed on bed rest and receives corticosteroid.  Increased pressure on the umbilical cord(cord prolapse).  If fetus is very immature .  Test with nitrazine paper-turns blue (alkaline).  Membranes resealed by fibrin based commercial sealant. Preterm Rupture of the Membranes  Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks.  Administration of broad –spectrum antibiotics.Labor that cannot be Halted  Membranes have ruptured. Therapeutic Management If labor does not begin. Threats to fetus:  Uterine and fetal infections. Assessment  Sudden gush of clear fluid from vagina.

 Provide emotional support. pulmonary or cardiac involvement. .BP returns to normal after birth BP 140/90 or SBP elevated 30 mm or DPB elevated 15 mm above pre pregnancy nd level. proteinuria 3-4+ on a random sample and and 5g on a 24 hr sample. thrombocytopenia.  Support nutritious diet.  Administer Magnesium sulfate or diazepam (Valium). mild edema in upper extremities or face.  Promote good nutrition.  Administer medications to prevent eclampsia.  Monitor fetal well being.  Monitor maternal well being.heaptic dysfunction. Mild pre eclampsia Severe pre eclampsia Eclampsia BP of 160/110. oliguria.Symptoms of Pregnancy Induced Hypertension Hypertension type Symptoms Gestational HPN BP 140/40 or SBP elevated 30 mm Hg or DBP elevated 15 mm above pre pregnancy level.  Administer oxygen. weight gain over 2 lbs /week in 2 rd trimester and 1lb/wk on the 3 trimester. HELLP SYNDROME  Variation of PIH  H-emolysis  EL-evated liver enzymes  L-ow P-latelet count  Increased BP. no proteinuria or edema.cerebral or visual disturbances.  Management for Severe Pre-eclampsia  Support bed rest. epigastric pain Seizure or coma accompanied by signs and symptoms of pre eclampsia Management for Mild Pre-eclampsia  Promote bed rest.  Assess FHT.RUQ tenderness Management  Improve platelet count by transfusion of fresh frozen plasma or platelets. epigastric pain. extensive peripheral edema. proteinuria+  Nausea. edema.general malaise.  Maintain patent airway.  Turn to side. Management of Eclampsia  Tonic-clonic seizures.  Anti platelet therapy.proteinuria of 1-2 + on a random sample.  Check for vaginal bleeding.

Assessment  Uterus increase in size at a rate faster than usual. 2 umbilical cords.zygote divides into two identical individuals  One placenta.  Reveals by ultrasound.  Quickening-flurries of action at different portions of abdomen.  Mgt: oxytocin to initiate labor or CS is performed.  If there is evidence of placental unsufficiency. DIZYGOTIC(FRATERNAL/NONIDENTICAL  Double ova-2 placentas.  Alpha-fetoprotein levels elevated.2 amnions.2 chorions.  Common in receiving salicylates. Hydramnios  Normal amniotic fluid volume-500-1000mL  Fluid index above 24 cm or more than 2000 mL  Suggests difficulty with the fetus’ ability to swallow  Unusual enlargement of uterus  Difficult to auscultate FHT  Shortness of breath  Increase weight gain  Hemorrhoid  Varicosities Management  Bed rest  Assess VS and edema  NSAID  Amniocentesis. 2 umbilical cord. 2 amnions. MONOZYGOTIC TWINS:  Single ovum and spermatozoon.  Maternal antibodies may cross the placenta causing hemolytic disease of the newborn or erythroblastosis fetalis.almost daily Oligohydramnios  Pregnancy with less than the average amount of amniotic fluid  Caused by bladder or renal disorder  Fetus is cramped for space  Uterus fails to meey expected growth rate  Mgt: Amniotransfusion Post Term Pregnancy  Pregnancy that exceeds 42 weeks.Multiple Pregnancy  A woman’s body must adjust to the effects of more than one fetus. .one chorion. Isoimmunization  Occur when an Rh negative mother carries a fetus with an Rh positive blood (D antigen). Therapeutic Management  Closer prenatal supervisions.

Fetal Death  If labor does not begin. st  Given in the 1 72 hours after birth. it will be induced by a combination of prostagalndin gel such as misoprostol (Cytotec) and oxytocin. Therapeutic Management  Passive Rh (D) antibodies against the Rh factor is administered to women who are Rh-negative at 28 weeks.Assessment st  Anti D antibody titer-done at 1 pregnancy visit. Intrauterine Transfusion  Injection of RBC directly into the vessel of the fetal cord or deposting them in the fetal abdomen. th  If normal (0) or minimal (below 1:8)-test repeated in the 28 week.  If normal-no therapy.  If elevated (1:16) fetal condition monitored every 2 weeks. .  Cord blood is tested-if Rh positive (coomb’s negative)-mother will receive RhIg injection.  If Rh negative-injection not necessary.

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