Maternal and Child Health Nursing

Antepartal Complication

MCHN Abejo


MATERNAL and CHILD HEALTH NURSING

PREGNANCY COMPLICATION

Lecturer: Mark Fredderick R. Abejo RN, MAN
_____________________________________________________________________________

PREGNANCY COMPLICATIONS
( ANTEPARTAL )

A. Abortion
- termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g)


TYPES DEFINITION S/S NURSING INTERVENTION
1. Threatened The continuation of
the pregnancy is in
doubt
Bleeding or
spotting closed
cervix
Bedrest, Restrictive activity, Sedation, Avoid coitus
for 2 weeks following last evidence of bleeding

Rhogam indicated when a young patient has a
threatened abortion in the first trimester and a
laboratory studies reveal an Rh negative and the
husband is Rh positive
2. Inevitable Threatened loss
that can be
prevented; abortive
process is going on
Bleeding and
cervical dilation
Save tissue fragments
3. Complete Products of
conception are
totally expelled
Minimal
bleeding
Continuous monitoring
4. Incomplete Some fragments
are retained inside
the uterine cavity
Profuse
bleeding
Dilatation & Curettage;
Use of oxytocin:
Oxytocin nasal spray should be administered while
the client is sitting with her head in a vertical
position. A nasal preparation must not be
administered with the client lying down or the head
tilted back because this could cause aspiration.
Evacuation
5. Missed Retention of the
products of
conception after
fetal death
Intermittent
bleeding;
absence of
uterine growth
Evacuation, D & C
6.Habitual /
Recurrent
3 spontaneous
abortions occurring
successively
Provide IV, Monitor bleeding, Count perineal pads,
psychological support

NOTE:Because spontaneous abortion is
threatening, all perineal pads must be inspected for
the products of conception. Fluid replacement is
necessary because of blood loss



B. Ectopic Pregnancy

A pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes

A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in
the pelvic and abdominal cavities.
Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular
volume until the bleeding is surgically controlled.
Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo




Causes Signs and Symptoms Diagnostic Tests Management
Narrowing of
tube
Pelvic
infection
Endometriosis
Smoking
History of
IUD usage
.
Vaginal Bleeding
Knife-like abdominal pain
Referred pain on the right
shoulder
Pelvic pressure of pelvic
fullness
Cullens sign
Pain unilaterally, with
cramping and tenderness
Mass in the adnexal or cul-
de-sac
Slight, dark vaginal bleeding
Profound shock if rupture
occurs
Symptoms of Shock:
decreased BP
increased RR,
fast but thready pulse.
This is the number 1
complication.

Culdocentesis
Culdoscopy
Radioimmunoassay of
elevated serum
qualitative -Beta-HCG
Abdominal
Ultrasound
Blood samples of Hgb
and Hct; blood type
and group


Monitor amount of
bleeding
Assess vital signs
Assess abdominal
pain
Blood transfusion
Surgery:
Salpingostomy
Administer Rhogam
for Rh (-) client






C. Hydatidiform mole / Trophoblastic Disease / Molar Disease

Gestational trophoblastic neoplasm that arise from the chorion; characterized by the proliferation and
degeneration of the chorionic or trophoblastic villi.

Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
A patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant.
The #1 Complication is Choriocarcinoma
The Three H of H-mole
1.Hyper - emesis gravidarum
2. increase Hcg
3. increase incidence for piH


PREDISPOSING
FACTORS
TYPES MANIFESTATIONS DIAGNOSTIC
TESTS
MANAGEMENT
Low
socioeconomic
status
Women below
18 or above 35
Intake of
Clomid
(Clomiphene
Citrate)
Women of
asian heritage
Complete/
classical parts
of the villi are
affected

Incomplete/
partial- some
parts are
normal

The #1
Complication of
H-mole is
choriocarcinoma
Vaginal bleeding
Excessive N/V
Rapid
enlargement of the
uterus
(+) Pregnancy test
Possible PIH
Abdominal
cramps
Absent FHR
Elevated HCG
titer: 1-2 million
IU; Normal level:
400,000 IU
HCG titer
determination
Ultrasound
X-ray of the
abdomen
Molar evacuation
/ D&C
Chemotherapy
Monitor HCG
levels
Delay
childbearing plans
for a year
Perineal pad
counts
Instruct the
couple to have
VAGINAL REST
( no sex) for 1
year.


D. Incompetent Cervix

- Painless premature dilatation of the cervix (usually in the 16
th
to 20
th
week)

INCOMPETENT CERVIX

Synonyms Dysfunctional cervix
Predisposing/Contributing
Factors:
Repeated dilatation of the cervix,
maternal DES ( Diethylstilbestrol) Exposure,
Traumatic injuries to the cervix.
Congenital anomaly
Trauma to the cervix (surgery / birth)
1. Uterine anomaly
2. Habitual abortion
3. Pre-term labor
Initial Signs Show (a pink-stained vaginal discharge)
#1 Sign: Rupture of membranes and discharge of amniotic fluid
Late signs:

Pressure or heaviness on the lower abdomen.
Cardinal/Pathognomonic/maj
or sign:

The cervix dilates painlessly in the second trimester of pregnancy.
Bloody show
PROM
Painless dilatation
Birth of dead/non-viable fetus
Screening or initial diagnostic
test:
Ultrasound
Conformity test: Ultrasonography
Best major surgery: Cervical Cerclage, McDonald Cerclage
Possible surgical
complication:
Sterility, rupture of the cervix premature delivery, pelvic bleeding
and infection.
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
Disease complication #1 Hemorrhage, Ectopic pregnancy, birth defects, viruses and
pregnancy diseases, diabetes in pregnancy, HPN

Best position before and after
surgery
Side lying position
Prone position
Best side equipment Suction
Nursing Intervention Pre-op: Encourage patient to maintain bed rest
Post-op: Check for excessive vaginal discharge and severe pain.
Bed rest in trendelenburg position
Administer tocolytic medications as ordered Eg; Ritodrine
Hydrochloride (Yutopar): Terbutaline sulfate (Brethine):
Magnesium Sulfate, Hydroxyzine hydrochloride (Vistaril) is a
common drug ordered to counteract the effect of terbutaline
(Brethine)
Surgery: Cervical Cerclage
Shirodkar-Barter Technique ( internal os) permanent
suture: subsequent delivery by C/S.
Mc Donald Procedure ( external os)-suture removed at
term with vaginal delivery

Usually 4-6 weeks after vaginal delivery is the safe period for a
patient to resume sexual activity, when the episiotomy has healed
and the lochia had stopped
- Monitor V/S and report HPN Monitor FHR
Limit activities
Observe for Ruptured BOW
Avoid vaginal douche
Avoid coitus



E. DIABETES MELLITUS
Gestational diabetes mellitus (pregnancy induced)

A pregnant, insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism
are affected b pregnancy, making sudden hypoglycemic episodes more common for diabetics.

Changes in the glucose-insulin mechanism:
o Early in pregnancy:
A. Increase production of insulin
B. Maternal glucose is consumed by fetus
o Late in pregnancy:
A. Mother develops insulin resistance
B. The presence of placental insulinase breaks down insulin rapidly

B. Description of Diabetes in Pregnancy

1. Maternal glucose crosses the placenta but insulin does not
2. During the first trimester, maternal insulin needs decrease
3. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to
hypoglycemic reactions
4. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state,
requiring an increase in the client's insulin dose
5. Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third trimester.
Premature delivery is more frequent. The newborn infant of a diabetic mother may be large in size but will
have functions related to gestational age rather than size. The newborn infant of a diabetic mother is subject
to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Stillborn and
neonatal mortality rates are higher in pregnancies of a diabetic woman

NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third
months, the incidence of the diabetic coma during pregnancy occurs around the sixth months.





Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
GESTATIONAL DIABETES
Definition A type of Diabetes where only pregnant women gets where her
blood sugar rate elevates but never had a high blood sugar rate
before pregnancy.
Synonyms Diabetes during Pregnancy
Predisposing/Contributing
Factors
Hyperglycemia develops during pregnancy because of the secretion
of placenta hormones such as Prolactin, Progesterone&
Corticosteroids
Maternal age more than 35
Previous macrosomic infant
Previous unexplained stillbirth
Previous pregnancy with GDM
Family history of DM
Obesity
Hypertension
FBS more than 140 mg/dl
Initial Signs 3-Ps: Polyuria, Polydipsia and Polyphagia
MATERNAL SIGNS & SYMPTOMS:
1.Excessive thirst
2. Hunger
3. Weightless
4. Blurred vision
5. Frequent urination
6. Recurrent urinary tract infections and vaginal yeast infections
7. Glycosuria and ketonuria
8. Signs of pregnancy-induced hypertension
9. Polyhydramnios
10. Fetus large for gestational age
Late signs

Fatigue, weakness, sudden vision changes, tingling or numbness in
hands
Cardinal/Pathognomenic/majo
r sign

Weight loss, fatigue, nausea, and vomiting excessive thirst, decrease
urination
Screening or initial diagnostic
test
50 gms oral glucose challenge test
Confirmative test 3- hour glucose tolerance test will be performed to confirm
diabetes mellitus
Glycosolated Hemoglobin less than 8%
Best diet Strict Diabetic Diet
Calories in diet should consist of 50% to 60% carbohydrates, 12% to
20% protein, and 20% to 30% fat

NOTE: Because insulin does not pass into the breast milk,
breastfeeding is not contraindicated for the mother with diabetes.
Breastfeeding is encouraged; it decreases the insulin requirements for
insulin-independent clients. Breastfeeding does not increase the risk of
maternal infection; it leads to an increased caloric demand. Infants of
diabetic mothers often display jitteriness in response to hypoglycemia
after birth
Best diet for the disease: Well-balanced Caloric Diet
Disease complication Maternal Complications: PIH, Placental disorders, stillbirth,
macrosomia, neural tube defects.

Fetal Diabetic Complications:
Macrosomia
Pre-eclampsia
Hydramnios
Congenital anomalies

NOTE:
The incidence of congenital anomalies among infants of
diabetic pregnancies is three to four times higher than that in general
population and is related to the high maternal glucose levels during the
third to sixth gestational weeks.
Best side equipment Glucometer
Insulin Equipment
#1 Eternal Electronic Fetal Heart Rate monitoring
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
Best drug Insulin therapy ( dont use Oral hypoglycemics, they are
Teratogenic)
Nature of the drug Insulin
Nursing Diagnosis #1 High Risk for fluid volume deficit related to polyuria and
dehydration
Imbalanced nutrition related to imbalanced of insulin, food and
physical activity
Potential heath care deficit related to physical improvements or
social factors..
Nursing Intervention MANAGEMENT
Screen clients between the 24th and 28th weeks of pregnancy
Prenatal visits bimonthly for 6 months and weekly thereafter.
Calories in diet should consist of 50% to 60% carbohydrates, 12%
to 20% protein, and 20% to 30% fat
Observe client closely for an insulin since a precipitous drop in
insulin required is usual
Monitor for signs of infection or post hemorrhage
If a pregnant diabetic is in labor, her blood glucose should be
monitored hourly.
The preferred method of administration if insulin is required
during labor is intravenous

OTHER IMPORTANT MANAGEMENT:
Urine testing
Blood glucose determination
Insulin administration
Dietary management
Exercise
Fetal surveillance:
(* Non-stress test * contraction stress test * amniocentesis)



F. CARDIAC DISEASE


CLASSIFICATION EFFECTS MANAGEMENT
Class I Asymptomatic
Class II Asymptomatic at rest;
symptomatic with heavy physical
activity
Class III Asymptomatic at rest;
symptomatic with ordinary activity
Class IV Symptomatic with all
activity; symptomatic at rest

a. Class I: no limitation of activities. No
symptoms of cardiac insufficiency.

b. Class II: slight limitation of activity,
Asymptomatic at rest. Ordinary
activities causes fatigue, palpitations
and dyspnea

c. Class II: marked limitation of
activities, comfortable at rest, less
than ordinary activities causes
discomforts

d. Class IV: unable to perform any physical
activity without discomfort. May have the
symptoms during rest.
Retarded growth
Fetal distress
To relieve fetal distress let
the patient lie on her side

Premature labor
You dont have to notify
the physician if the patient
complains of a
fluttering sensation in
her chest because of
taking terbutaline
(Brethine) SQ for
premature contractions
because it is a common
side effect unless vital
signs indicate stress
Goal is to reduce
workload of heart
Promote rest
Promote a healthy diet
Educate regarding
medication
Educate regarding
avoidance of infection
Promote reduction of
physiologic stress




Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
PREGNANCY I NDUCED HYPERTENSI ON (TOXEMI A OF PREGNANCY)

NAME OF THE
DISEASE
PRE-ECLAMPSIA ECLAMPSIA
MILD SEVERE
Synonym (PREGNANCY-INDUCED HYPERTENSION)
Predisposing /
Contributing factors
Primiparas younger than age 20 years or older than 40 years
women from low socioeconomic background because of poor nutrition
women of color; women with heart disease
diabetes with vessel or renal involvement
essential hypertension
poor calcium and magnesium intake
hydatidiform mole
multiple gestation
polyhydramnios
pre-existing vascular disease

Initial Sign B140/90 mmGh
on at least two
occasion 6 hours
apart

proteinuria of 1-2+
on a random
sample; weight gain
over 2 lbs per week
in second trimester
and 1 lb per wk,
third trimester

mild edema in
upper extremities or
face
BP160/110 mmHg or
diastolic pressure110
mmHg on two
occasions at least 6
hours apart with the
patient on bedrest

proteinuria 5 b/24 h
or 3+ to 4+ on
qualitative assessment
(urine dipstick)

extreme edema in
hands and
face/puffiness

temperature rises
sharply to 39.4C or
40C (103F to
104F) from
increased cerebral
edema; reflexes
become hyperactive

premonition that
something is
happening;
epigastric pain and
nausea; urinary
output less than 30
ml/h


Late Sign Signs of Worsening PIH
or Impending Seizures:

BP 160/110 mm Hg
or above
Epigastric pain
Decreased urinary
output
Visual changes
Headache

Oligauria 400 to 500
ml/24h
cerebral or visual
disturbances (altered
level of consciousness
headache, scotomata,
or blurred vision)
epigastric pain or
RUQ pain, pulmonary
edema or cyanosis
impaired liver
function of unclear
etiology
thrombocytopenia
(platelet count
<150,000);
development of
eclampsia elevated
serum creatinine > 1.2
mg/dl

During pregnancy,
blurred vision may be a
danger sign of
preeclampsia or
eclampsia,
complications that
require immediate
attention because they
can cause severe
maternal and fetal
consequences.
Cardinal /
Pathognomonic/ Major
Sign


Hypertension and proteinuria are the most significant. Edema is significant only
if hypertension and proteinuria or signs of multi-organ system involvement are
present.
Nursing Diagnosis and
Nursing Interventions






Fluid volume excess
related to
pathophysiologic
changes of PI H and
increased risk of fluid
overload.


Maintaining Fluid Balance
1. Control IV intake using a continuous infusion
pump.
2. Monitor input and output strictly; notify health care
provider if urine output is <30 ml/h.
3. Monitor hematocrit levels to evaluate intravascular
fluid status.
4. Monitor vital signs every hour.
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo


















































Altered tissue
perfusion, Fetal
cardiac and cereral,
related to altered
placental blood flow
caused by vasospasm
and thombosis.

Risk for injury related
to convulsions.

Decreased cardiac
output related to
decreased preload or
antihypertensive
therapy.
5. Auscultate breath sounds every 2 hours, and report
signs of pulmonary edema (wheezing, crackles,
shortness of breath, increased pulse rate, increased
respiratory rate).

Promoting Adequate Tissue Perfusion
1. Position on side, preferably the left side to
promote placental perfusion.
2. Monitor fetal activity.
3. Evaluate NST to determine fetal status.
4. Increase protein intake to replace protein lost
through kidneys.

Preventing Injury
1. Instruct on the importance of reporting
headaches, visual changes, dizziness, and
epigastric pain.
2. Instruct to lie down on left side if symptoms are
present.
3. Keep the environment quiet and as calm as
possible.
4. If patient is hospitalized, side rails should be
padded and remain up to prevent injury if seizure
occurs.

NOTE: The patient with a diagnosis of PI H should
be close to the nurses station because she requires
close observation. The patient also should be placed
in a room with decreased stimuli.

Maintaining Cardiac Output
1. Monitor IV intake using a continuous infusion
pump.
2. Monitor input and output strictly; notify primary
care provider if urine output is < 30 ml/h.
3. Monitor maternal vital signs; especially mean
blood pressure and respirations.
4. Assess edema status, and report pitting edema of
+ 2 to primary care provider.
5. Monitor oxygenation saturation levels with pulse
oximetry. Report oxygenation saturation rate of
<90% to primary care provider.

Screening/Initial
diagnostic test
Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic over
pre-pregnancy level.

Confirmatory Test 24-hour urine for protein of 300 mg or greater; elevated serum BUN and
creatinine; increased deep tendon reflexes and clonus; blood pressure changes
meeting criteria for diagnosis

Best Diet The woman needs a moderate to high-protein, moderate-sodium diet to
compensate for the protein she is losing.

Disease Complications Abruptio placentae (Hypertension in PIH leads to vasopasm. This in turn
causes the placenta to tear away from the uterine wall (abrupto placentae)

disseminated intravascular coagulation; HELLP syndrome; prematurity;
intrauterine growth restriction (IUGR) from decreased placental perfusion;
maternal/fetal death; hypertensive crisis; acute renal failure; hemorrhage;
cerebrovascular accident; blindness; hypoglycemia; hepatic rupture

Best Position SEVERE PRECLAMPSIA: Lateral recumbent position ECLAMPSIA: to prevent
aspiration, turn the woman on her side to allow secretions to drain from her
mouth.

Beside Equipment Infusion pump; pulse oximeter
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
Best Drug Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by
a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in
each buttock) as a loading dose followed by 5 g every 4 hours

Administer antihypertensives such as hydralazine (Apresoline) as prescribed, to
prevent a cerebrovascular accident

Nature of the Drug


Best tocolytic agent; antihypertensive; anticonvulsant/eclampsia
#1 Complication of MgSO4 is : Respiratory Depression

PRIORITY DRUG
ASSESSMENT:
SIDE EFFECT
Reflexes, respiration and urinary output are priority assessments during
administration of magnesium sulfate therapy in patients with PIH.
If the patients magnesium levels increase above the therapeutic range (4 to 8
mg/dl), the absence of reflexes is often the first indication of toxicity.
Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl.
Respiratory depression occurs at levels of 10 to 15 mg/dl, and cardiac
conduction problems occur at levels of 15 mg/dl and higher.
Urinary output of less than 30ml/hour may result in the accumulation of toxic
levels of magnesium.

Proper Assessment of
Abnormal Reflexes
Assessment Patellar Reflexes

Position the client with legs dangling over the edge of the examining table or
lying on back with legs slightly.
Strike the patellar tendon just below the kneecap with the percussion hammer.
Normal Response: Flexion of the arm at the elbow.

Clonus
Position the client with legs dangling over the edge of the examining table.
Support the leg with one hand and sharply dorsiflex the clients foot with the
other hand.
Maintain the dorsiflexed position for a few seconds; then release the foot.

Normal Response: (Negative Clonus Response)
Foot will remain steady in the dorsiflexed position.
No rhythmic oscillation of jerking of the foot will be felt.
When released, the foot will drop to a plantar flexed position with no
oscillations.

Abnormal Response: (Positive Clonus Response)
Rhythmic oscillations when the foot is dorsiflexed.
Similar oscillations will be noted when the foot drops to the plantar flexed
position.




G. BLEEDING DISORDERS AFFECTING THE PLACENTA

Placenta: contains 20 cotyledons, weighs 400-600 grams. Develops on the 3
rd
month. Form from Chorionic
villi & deciduas basalis. Deciduas (meaning endometrial changes & growth)
Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus.

Placental Problem
Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further
protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With
cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum
hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the
placenta has been delivered.






Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
PLACENTA PREVIA




PLACENTA PREVIA
Definition Improperly implanted placenta in the lower uterine segment near or over
the internal cervical os
Total: the internal os is entirely covered by the placenta when cervix is
fully dilated
Marginal: only an edge of the placenta extends to the internal os
Low-lying placenta: implanted in the lower uterine segment but does
not reach the os

Predisposing Factor Maternal age
Parity (no. Of pregnancy)
Previous uterine surgery
Assessment . Painless
. Heavy bleeding
. Soft, non tender, relaxed uterus w/ normal tone
. Shock in proportion to observed blood loss
. Signs of fetal distress usually not present

Complication Anemia
#1hemorrhage
#2shock,
renal failure
#3 disseminated intravascular coagulation
cerebral ischemia, maternal and fetal death
Therapeutic Interventions > Ultrasonography to confirm the pressure of placenta previa.
> Depends on location of placenta, amount of bleeding and status of the
fetus.
> Home monitoring with repeated ultrasounds may be possible with type I-
low lying
> Control bleeding
> Replace blood loss if excessive
> Cesarean birth if necessary
> Betamethasone is indicated to increase fetal lung maturity.
Nursing Diagnosis with
Nursing Intervention
#1 NURSI NG DI AGNOSI S: Potential fluid volume deficit

Maintain bed rest
> #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity
> Assess bleeding (amount and quality)
> Monitor and treat signs of shock
> Avoid vaginal examination if bleeding is occurring
> Prepare for premature birth or cesarean section
> Administer IV fluids as ordered
> Administer iron supplements or blood transfusion as ordered (maintain
hematocrit level)
> Prepare to administer Rh immune globulin

Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
BESTPOSITION The patient with placenta previa should be maintained on bed rest, preferably
in a side-lying position.
Additional pressure from an upright position may cause further tearing of the
placenta from the uterine lining.
Ambulating would therefore be indicated for this patient. Performing a
vaginal examination and applying internal scalp electrode could also cause
the placenta to be further torn from the uterine lining.
Confirmatory Test > Ultrasound for placenta localization
NOTE:
Manual pelvic examinations are contraindicated when vaginal
bleeding is apparent in the third trimester unit a diagnosis is
made and placenta previa is ruled out.
Digital examination of the cervix can lead to maternal and fetal
hemorrhage.
A diagnosis of placenta previa is made by ultrasound.
The hemoglobin and hematocrit levels are monitored and external
electronic fetal heart rate monitoring is initiated. Electronic fetal
monitoring (external) is crucial in evaluating the status of the fetus
who is at risk for severe hypoxia.
Best Position > Left lateral position


ABRUPTIO PLACENTAE





ABRUPTIO PLACENTAE
Definition Premature separation of the placenta from the uterine wall after the 20
th

week of gestation and before the fetus is delivered (Saunders page 299-
300)
Synonyms > Placental abruption
> Premature separation of placenta
Predisposing Factor > Maternal age
> Parity
> Previous abruptio placentae, multifetal gestation
> Hypertension
NOTE:
Abruptio placentae is associated with conditions characterized by poor
uteroplacental circulation, such as hypertension, smoking and alcohol or
cocaine abuse. It is also associated with physical and mechanical factors
such as over distension of the uterus that occurs with multiple gestation
or polyhydranions. In addition, a short umbilical cord, physical trauma,
and increased maternal age and parity are risk factors.
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
Pathophysiology > Spontaneous rupture of blood vessels at the placental bed may due to
lack of resiliency or to abnormal changes in uterine vasculature.
> May be complicated by hypertension or by an enlarged uterus that
cant contract sufficiently to seal off the torn vessels
> Consequently, bleeding continues unchecked, possibly shearing off the
placenta partially or completely.

Manifestation > Painful vaginal bleeding
> Hypertonic to tetanic, enlarged uterus
> Board-like rigidity of abdomen (Cullen Sign)
> Abnormal/absent fetal heart tones
> Pallor
> Cool, moist skin
> Bloody amniotic fluid
> Rising fundal height from blood trapped behind the placenta
> Signs of shock
> Manifestation of coagulopathy

NOTE:
Uterine tenderness accompanies placental abruption, especially with a
central abruption and trapped blood behind the placenta. The abdomen
will feel hard and boardlike upon palpation as the blood penetrates the
myometrium and causes uterine irritability. Observation of the fetal
monitoring often reveals increased uterine resting tone, caused by failure
of the uterus to relax in an attempt to constrict blood vessels and control
bleeding.

Complication > Hemorrhage, shock, renal failure, disseminated intravascular
coagulation, maternal death, fetal death(Nursing Alert p.4)

Therapeutic I nterventions > Replacement of blood loss.
> With moderate or severe separation or maternal or fetal distress:
emergency childbirth.

NOTE:
The goal of management in abruption placentae is to control the
hemorrhage and deliver the fetus as soon as possible. Delivery is
the treatment of choic if the fetus is at term gestation or if the
bleeding is moderate to severe and mother or fetus is in jeopardy.

> With mild separation without fetal distress and in the presence of some
cervical effacement and dilatation: induction of labor may be
attempted
>Oxygen if necessary
> Maintenance of fluid and electrolytes balance.

Nursing Diagnosis with
Intervention
#1 NURSI NG DI AGNOSI S: Risk for fluid volume deficit
>#1 Assessment: Monitor and FHR
> Assess for vaginal bleeding, abdominal pain, and increase in fundal
height
> Maintain bed rest
> Administer oxygen as prescribed
> Monitor and report any uterine activity
> Administer IV fluid as prescribed
> Monitor I & O
> Administer blood products as prescribed
> Monitor blood studies
> Prepare for the delivery of the fetus as quickly as possible
> Monitor for signs of disseminated intravascular coagulation in the post-
partum period

Confirmatory Test > Ultrasound detects retro-placental bleeding






Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo
VENA CAVA SYNDROME

Definition The venous return to the heart is impaired by the weight of uterus.
Synonym Supine Hypotensive Syndrome
Predisposing factors Thrombophlebitis
NOTE:
Contribute to clot formation motion include inactivity,reduced cordiac
output, compression of the viens in pelvis or legs

The most likely cause of supine hypotension is feeling dizzy, short of
breath and clammy when lying back for long periods of time in patients 6
th

month of pregnancy.
The cause of supine hypotension during pregnancy is the weight of the
uterus compresses the inferior vena cava, decreasing the return of blood
to the heart, thus decreasing cardiac output, which lowers the blood
pressure
Initial sign Fatique
proxymal nocturnal
dyspnea
orthopnea
hypoxia
cyanosis
Late Sign Reduce renal perfection, Decrease glomerular filtration
Cardinal sign Shock such as tachycardia
NOTE:
Caused by reduced cardiac output, respiratory distress, fatal distress
Initial / Screening test FHT monitor
NOTE:
Above 160 or below 120 beats per minutes, Fetal PH below 7.5
Confirmatory test Amniotomy:
NOTE:
Above keeping the significant other improved of the progress of care,
the fatal status would he the priority
Nursing Diagnosis Altered tissue perfection related to decrease blood circulation
Risk for altered Health maintenance related to insufficient knowledge
of treatments, drug therapies, home care management and prevention
of future infection
Altered comfort related to maladaptive coping
Nursing Intervention Closely monitor for shock and decreasing blood. Pressure,
tachycardia, coal, clammy Skin
Maintain patient on bed rest to reduce Oxygen demands and risk for
bleeding. Monitor prescribed medication given to preserve right
Ventricular felling pressure and increase blood pressure
Instruct patient in self care activities Provide information about anti
smoking strategies and allow patient time to return demonstration of
treatment to the done at home
Assess physical complaints matters of facts without emphasizing
concern. Use deep breathing, muscle relaxation, and imagery to
relieve discomfort. Express a caring attitude
Best major Surgery Caesarian Section note if cervix is incomplete deleted.
Best dirt for pre-operative Food and fluid are withheld before invasive procedure is not resumed until
the client is stable and free of nausea & vomiting.
Best diet for Disease Hypoallergenic Ionic diet Calcium increased
Possible Surgical
Complication
Interruption of vena cava, which reduce channel size.
Complication of Disease > Bleeding as a result of treatment
NOTE:
Observation of the fetal monitoring often reveal increase uterine
rustling tone, caused by failure of the uterus to relax in an attempt to
constrict blood vesicle and control bleeding
> Respiratory failure.
Best position pre-operative Sims Position
NOTE:
Turning to the left side to shift right of the fetus off the inferior vena
cava.
Bed Side Equipment Oxygen obtain equipment for external electronic fetal heart rate
monitoring Oxygen with Cannula
History of Disease Angina, myocardial infarction
Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo

OTHER DISEASES AND CONDITION

Name of the Disease Disseminated I ntravascular Coagulation
Predisposing /
Contributing Factors
Overwhelming infections particularly bacterial sepsis; #1 abruption placenta;
eclampsia; amniotic fluid embolism; IUFD(Intra-uterine fetal death) or retention of
dead fetus; burn; trauma; fractures; major surgery; fat embolism; sock; hemolytic
transfusion reaction; malignancies particularly of lung, colon, stomach, and
pancreas

NOTE:
Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which
clotting factors are consumed. This leads to widespread bleeding. Platelet are
decreased because they are consumed by the process, coagulation studies show no
clot formation (and are thus normal to prolonged); and fibrin plugs may clog the
microvasculature diffusely, oozing from injection sites, and presence of hematuria
are signs associated with the presence of DIC. Swelling and pain in the calf of one
leg are more likely to be associated with thrompophlebitis. (Saunders

Initial Sign Coolness and mottling of extremities; pain; dyspnea; abnormal bleeding
Late Sign Altered mental status; acute renal failure
Nursing Diagnosis &
Intervention
Risk for injury related
to bleeding due to
thrombocytopenia


















Altered tissue perfusion
(all tissues) related to
ischemia due to
microthrombi
formation


Minimizing Bleeding
1. Institute Bleeding precautions
2. Monitor pad count/amount of saturation during
menses; administer or teach self-administration of
hormones to suppress menstruation as prescribed.
3. Administer blood products as ordered. Monitor for
signs and symptoms of allergic reactions,
anaphylaxis, and volume overload.
4. Avoid dislodging costs. Apply pressure to sites of
bleeding for at least 20 mins, use topical hemostatic
agents. Use tape cautiously.
5. Maintain bed rest during bleeding episode.
6. If internal bleeding is suspected, assess bowel sounds
and abdominal girth.
7. Evaluate fluid status and bleeding by frequent
measurement fo vital signs, central venous pressure,
intake and output.

Promoting Tissue Perfusion
1. Keep patient warm
2. Avoid vasoconstrictive agents (systemic or topical).
3. Change patients position frequently and perform
ROM exercises.
4. Monitor electrocardiogram and laboratory test for
dysfunction of vital organs casued by ischemia
arrhythmias, abnormal arterial blood gases, increased
blood urea nitrogen and creatinine.
5. Monitor for signs of vascular occlusion and report
immediately.
a. Brain decreased level of consciousness, sensory
and motor deficits, seizures, coma.
b. Eyes Visual deficits.
c. Bone Pain
d. Pulmonary vasculature chest pain, shortness of
breath, tachycardia.
e. Extremities cold, mottling, numbness.
f. Coronary arteries chest pain, arrhythmias.
g. Bowel pain, tenderness, decreased bowel sounds.

Screening or Initial
Diagnostic Test
PT; PTT; Platelet count
Confirmative Test Decreased Fibrinogen level; increased fibrin split products; decreased anti-thrombin
III level
Beside Equipment ECG; CVP
Best Drug Heparin inhibits clotting components of DIC
Nature of the Drug Anticoagulant

Maternal and Child Health Nursing
Antepartal Complication

MCHN Abejo

Name of the Disease Hyperemesis gravidarum

Definition Hyperemesis gravidarum is persistent, uncontrolled vomiting that begins in the first
weeks of pregnancy and may continue throughout pregnancy. Unlike morning
sickness, hyperemesis can have serious complications, including severe weight loss,
dehydration, and electrolyte imbalance.

NOTE: The defining factor for hyperemesis gravidarum should be the time of
occurrence and that is the 2nd trimester, usually the 14 16
th
week. I f this is
on the 1
st
trimester, usually this is morning sickness.

Causes Gonadotropine production
Psychological factors
Trophoblastic activity

Assessment Findings Continuous, severe nausea and vomiting
Dehydration
Dry skin and mucous membranes
Electrolyte imbalance
Metabolic acidosis
Non-elastic skin turgor
Oliguria

Diagnostic Result Arterial blood gas and analysis reveals alkalosis.
Hb level and HCT are elevated.
Serum potassium level reveals hypokalemia
Urine ketone levels are elevated.
Urine specific gravity is increased.

Nursing Diagnosis Fluid volume deficit
Altered nutrition; less than body requirements
Pain

Treatment Total parenteral nutrition (TPN)
Restoration of fluid and electrolyte balance
Anti-emetics, as necessary for vomiting, for example Plasil , Hydroxyzine and
Prochlorperazine

Nursing Intervention Monitor vital signs and fluid intake and output to assess for fluid volume
deficit.
Obtain blood samples and urine specimens for laboratory tests, including Hb
level, HCT, urinalysis, and electrolyte levels.
Provide small frequent meals to maintain adequate nutrition.
Maintain I.V. fluid replacement and TPN to reduce fluid deficit and pH
imbalance.
Provide em0otional support to help the patient cope with her condition.

Teaching Topics
Using salt on foods to replace sodium lost by vomiting.