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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
Underreporting – especially if most occur outside of health facilities (in the absence of health personnel to report them). Methodological issues in measuring maternal mortality 1. from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. All complications are managed in adequately-staffed and equipped facilities offering emergency obstetric care. . 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. All pregnancies are adequately managed throughout its course. It is a rare event and therefore its number may not be large enough to detect statistically significant changes over time. Moral imperative – The death of a woman during pregnancy or childbirth is a violation of her rights to life and health. Adult Lifetime Risk of Maternal Death – refers to the probability of dying from a maternal cause during a womans reproductive lifespan.000 live births during the same time period.Why aim for maternal survival? 1. 2. 3. – Governments must promote dignity and equity for women within the health-care system. Social implications • Maternal death or disability can plunge families into poverty and deeper despair... Lessons learned : Most maternal deaths and disabilities would be averted if. Misreporting because of the complicated definition requiring also its cause and timing OR sometimes done intentionally to avoid legal action. All births are attended by skilled health professionals (ideally facility-based). surviving children esp. Maternal Mortality Rate – refers to the number of maternal deaths in a given time period per 100. All pregnancies are wanted and planned. Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy.000 women of reproductive age during the same time period. 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. irrespective of the duration and site of the pregnancy.
Universal access to contraceptive services to reduce unintended pregnancies. incest Mental Retardation Environmental factors Exposure to Teratogens due to employment Environmental contaminants at home Poor Housing . Skilled attendance at all births.One in which a concurrent disorder. pregnancy related complications or external factor jeopardize the health of the woman. Nursing Care of the High Risk Pregnant Client High Risk Pregnancy . rape.Strategies to reduce maternal mortality 1. 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. domestic violence. the fetus or both. 2.
vaginal spotting should be discovered and investigated thoroughly. Continuation of the pregnancy as long as possible. 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. Problems such as headache. unexpected deviations or complications from the normal course of pregnancy happens. SUDDEN PREGNANCY COMPLICATION In few women. 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. Risk for infection related to incomplete miscarriage. Continued healthy fetal growth. blurred vision. Risk for ineffective tissue perfusion related to pregnancy-induced hypertension. Common Nursing Diagnosis Anxiety related to guarded pregnancy outcome. . A woman’s and family ‘s psychological health. Implementation interventions for woman experiencing a complication of pregnancy include measures to maintain number of different areas. 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. Deficient knowledge related to signs and symptoms of possible complications.
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. cramping. no apparent loss of Pregnancy Vaginal spotting. cervical dilatation Vaginal spotting. perhaps slight cramping.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. Ectopic pregnancy Implan-tation of zygote at site other than the uterus Sudden uni-lateral lower abdominal quadrant pain.Summary of Primary Causes of Bleeding during Pregnancy Time type cause Assess-ment cautions 1 trimester st Threatened miscarriage Imminenent miscarriage Unknown. no fetus on ultrasound. cramping .cervical dilatation.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 . highly positive HCG. possibly chromosomal uterine abnormalities Vaginal spotting perhaps slight Cramping Vaginal spotting. possible signs og shock or hemorrhage Overgrowth of uterus.
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. bright red usually.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 . placenta separates from uterus Trauma. 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.scant. Threatened Miscarriage Vaginal bleeding. Should consult attending Obstetrician so that instructions may be given.Medical term for any interruption of a pregnancy before a fetus is viable. cervicitis. substance abuse.
Coitus usually restricted for 2 weeks Spotting usually stops within 24-48 hours Imminent (inevitable) Miscarriage Uterine contractions and cervical dilatation occurs. Cold . If no FHT and UTZ reveals empty uterus-dilatation and evacuation may be performed. vasoconstriction.entire products of conception are expelled spontaneously without assistance. Complete Miscarriage . Decreased intravascular volume 3. Dilatation and curettage or suction curettage.blood pressure falls 5. Loss of product of conception cannot be halted.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 .coma.clammy skin. Incomplete miscarriage Part of the conceptus is expelled. Lethargy.decreased uterine perfusion. feeling of apprehension 4.uterine and brain perfusion 6. but the membrane or placenta is retained.increased RR. Increased heart rate. Reduced renal. Blood loss 2. 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. Mgt.
Woman still experiences the signs of pregnancy. poor nutrient supply to the fetus. mifepristone (abortifacient). Danger is infiltration of large blood vessel. Missed period. vaginal abdominal pain Movement of cervix cause excruciating pain Pain in shoulders Management: Unruptured –methotrexate followed by leucovorin. Ruptured Ectopic Pregnancy Sharp stabbing pain in lower abdominal quadrant. If the woman does not seek help at once… Cullen’s sign Dull. (+) pregnancy test. Amount of bleeding not evident. Signs and symptoms of pregnancy is experienced by the woman. Vaginal spotting. May lead to shock.bowel perforation. Most common is fallopian tube. Laparoscopy-ligate the bleeding vessels and remove/repair fallopian tube. Falling hcg level. Fetal outline is easily palpable. Decreased venous return DECREASED URINE OUTPUT DIZZINESS DECREASED CVP Ectopic Pregnancy Implantation occurs outside the uterine cavity. Ruptured –emergency situation. Due to fallopian tube scarring that slow the travel of the zygote.COLD. Ovary or cervix. . Complete Blood Count Administration of fluids Abdominal Pregnancy Woman may report sudden lower quadrant pain.CLAMMY SKIN Vasoconstriction occurs to maintain blood volume in central body core Decrease blood supply in the kidneys Inadequate blood is reaching the cerebru. Utz –provides clear cut picture.
Dark brown blood. discharge of amniotic fluid. th Symptoms of pregnancy induced hypertension may appear before the 20 week. Uterine contractions-birth of the fetus. Therapeutic Management Suction curettage Post surgery: Pelvic examination.1 to 2 M IU compared to a normal of 400. . Infant must be born through laparotomy. chest radiograph. profuse flesh flow(16 weeks) with clear fluid filled vessicles. Strong (+) result of hCG.cannot hold a fetus until term. Ultrasound-no fetal growth and fetal heart sound. Partial mole . Assessment Uterus tends to expand faster. Painless st Pink-stained vaginal discharge(1 symptom) Followed by Rupture of membrane. Marked nausea and vomiting. Cervix that dilate prematurely.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. Rate of survival is 60%. Associated with: Increased maternal age.000IU. 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. Congenital structured defect.some of the villi form normally.
Marginal – the placenta edge approaches that of the cervical os. Placenta Previa . Assessment Bleeding is abrupt. painless . Total placenta previa . Most common cause of painless bleeding in the third trimester of pregnancy. Occurs in 4 degrees: Low lying.Sterile tape is threaded in a purse string manner under the submucous layer of the cervix.Placenta is implanted abnormally in the uterus.Nylon sutures are placed vertically and horizontally across the cervix and pulled tight to reduce the cervical canal. McDonald Procedure .implantation in the lower rather than in the upper portion of the uterus. .totally obstructs 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. Shirodkar . Trauma to cervix. Partial . bright red and sudden.implantation that totally obstructs the cervical os. Management: Cervical cerclage-purse-string sutures are placed in the cervix by vaginal route.
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.diagnosis made after birth Minimal separation. Therapeutic Management Emergency situation Large gauge IV catheter Oxygen by mask FHT and maternal VS monitoring Lateral position No abdominal.there is evidence of fetal distress. Couvelaire uterus(uteroplacental apoplexy)-hard board like uterus with no apparent bleeding. pregnancy must be TERMINATED. but enough to cause vaginal bleeding and changes in maternal VS. Degress of Premature Placental Separation Grade Criteria 0 1 No symptoms apparent. maternal shock and fetal death may occur 2 3 .no fetal distress Moderate separation. uterus tense and painful Extreme separation. pelvic or vaginal examination Unless separation is minimal. Heavy bleeding-evident if separation occurs at the edges. DIC may occur. If labor begins. each contraction will be accompanied by pain over and above the pain of contraction.
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. oral terbutaline may be given.labor will not occur at least 14 days. Test Clotting Time Test tube-clot must form Platelet assessment-less than or equal to 100. Drug Administration Steroid( betamethasone)-to hasten lung maturity. Effects after 24 hours and lasts 7 days.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. Presence of fetal fibronectin-preterm contractions are ready to occur. 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. not enough are left for the rest of the body.Disseminated Intravascular Coagulation Acquired disorder of blood clotting. .
Method of Delivery If very immature . Cord is clamped immediately. Assessment Sudden gush of clear fluid from vagina. 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 . Potter –like syndrome-distorted facial features and pulmonary hypoplasia.CS.Labor that cannot be Halted Membranes have ruptured. Increased pressure on the umbilical cord(cord prolapse). Cervix more than 50% effaced and 3-4 cm dilated. Administration of broad –spectrum antibiotics. fetus is at point of viability: Woman is placed on bed rest and receives corticosteroid. Therapeutic Management If labor does not begin. Preterm Rupture of the Membranes Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks. Test with nitrazine paper-turns blue (alkaline). If fetus is very immature . Membranes resealed by fibrin based commercial sealant.CS. Threats to fetus: Uterine and fetal infections.
Turn to side. proteinuria 3-4+ on a random sample and and 5g on a 24 hr sample. weight gain over 2 lbs /week in 2 rd trimester and 1lb/wk on the 3 trimester.heaptic dysfunction. Provide emotional support.RUQ tenderness Management Improve platelet count by transfusion of fresh frozen plasma or platelets.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. Monitor fetal well being. Support nutritious diet. extensive peripheral edema. Administer oxygen. no proteinuria or edema. Administer Magnesium sulfate or diazepam (Valium). edema. . Promote good nutrition. HELLP SYNDROME Variation of PIH H-emolysis EL-evated liver enzymes L-ow P-latelet count Increased BP. Administer medications to prevent eclampsia. Management for Severe Pre-eclampsia Support bed rest. pulmonary or cardiac involvement. Management of Eclampsia Tonic-clonic seizures. epigastric pain Seizure or coma accompanied by signs and symptoms of pre eclampsia Management for Mild Pre-eclampsia Promote bed rest.cerebral or visual disturbances. epigastric pain.BP returns to normal after birth BP 140/90 or SBP elevated 30 mm or DPB elevated 15 mm above pre pregnancy nd level. Maintain patent airway. Assess FHT. Anti platelet therapy. mild edema in upper extremities or face. thrombocytopenia. Monitor maternal well being.general malaise. Mild pre eclampsia Severe pre eclampsia Eclampsia BP of 160/110. Check for vaginal bleeding. oliguria.proteinuria of 1-2 + on a random sample. proteinuria+ Nausea.
Mgt: oxytocin to initiate labor or CS is performed.2 chorions. MONOZYGOTIC TWINS: Single ovum and spermatozoon. DIZYGOTIC(FRATERNAL/NONIDENTICAL Double ova-2 placentas. 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. Maternal antibodies may cross the placenta causing hemolytic disease of the newborn or erythroblastosis fetalis. If there is evidence of placental unsufficiency.Multiple Pregnancy A woman’s body must adjust to the effects of more than one fetus.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. Quickening-flurries of action at different portions of abdomen. 2 umbilical cord. .zygote divides into two identical individuals One placenta.one chorion. 2 amnions. Isoimmunization Occur when an Rh negative mother carries a fetus with an Rh positive blood (D antigen).2 amnions. Therapeutic Management Closer prenatal supervisions. Common in receiving salicylates. 2 umbilical cords. Assessment Uterus increase in size at a rate faster than usual. Reveals by ultrasound. Alpha-fetoprotein levels elevated.
If elevated (1:16) fetal condition monitored every 2 weeks. th If normal (0) or minimal (below 1:8)-test repeated in the 28 week. . If Rh negative-injection not necessary. Therapeutic Management Passive Rh (D) antibodies against the Rh factor is administered to women who are Rh-negative at 28 weeks. If normal-no therapy. it will be induced by a combination of prostagalndin gel such as misoprostol (Cytotec) and oxytocin. Cord blood is tested-if Rh positive (coomb’s negative)-mother will receive RhIg injection. Intrauterine Transfusion Injection of RBC directly into the vessel of the fetal cord or deposting them in the fetal abdomen.Assessment st Anti D antibody titer-done at 1 pregnancy visit. Fetal Death If labor does not begin. st Given in the 1 72 hours after birth.
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