Cervical Incompetence- the cervix open prematurely without any reason

Definition
• the inability of the cervix to support a pregnancy to term due to structural and or functional
weakness.
• painless and bloodless cervical dilatation
• premature cervical dilatation between 16 – 22 weeks

Normal cervix
• under normal circumstances. The cervix is closed and rigid until delivery. Then, it effaces and
dilates in response to contractions

Incompetent cervix
• an incompetent cervix shortens or opens too soon during early pregnancy. It can cause preterm
labor and serious injury

Usually happens in 2nd and 3rd trimester

Factors Causing IC
Functional= premature triggering of the normal mechanism of cervical dilatation and effacement. – the
cervix dilates itself and manifest effacement on its own

• Induction of ovulation
• 3 or more prior fetal losses during the 2nd trimester – like habitual abortion

Structural= congenital or acquired – congenital anomaly of the cervix

• Congenital:
• Weakness of the internal os
• Short hypoplastic cervix
• Bicornuate uterus – reverse uterus
• Septate uterus

Congenital:
> overzealous dilatation and curettage

> cone biopsy

> cervical amputation – cutting and closing of the cervix

> difficult delivery

> instrumentation

> infection

Etiology
• Idiopathic (most)
• Congenital disorders (congenital mullerian duct abnormalities.
• DES exposure in utero. – diethylstilbestrol – chemicals that harm the uterus
• Connective tissue disorder (Ehlers-Danlos syndrome.- it allows the cervix to stretch and open
allowing the baby to go out
• Surgical trauma (conization, (repeated cervical dilatation associated with termination of
pregnancies).

Cautery –
sinusunug
ang cells
SYMPTOMS
• No symptoms in the first affected pregnancy.
• The cervix dilates without any contraaions
• Bulging of fetal membranes leading to PROM
• Spotting or bleeding might be there, but usually by the time the condition is detected it is too
late to stop the preterm birth.
• With a previous history, some women may present with pelvic pressure, cramping, back pain, or
increased vaginal discharge.
• Uterine contractions are typically rare or absent

Diagnosis
•Dilators or balloons

•hysterosalpingograms – specific sa uterus kasali si fallopian tube

•Digital examination of the cervix

•Sonography

Cervical Sonography: test done to Assess for Cervical incompetent

Okay lang sa full term mag ka incompetent cervix kay ang chances ni baby mag survive pero kung below
28 weeks delikado na kay risk si baby sa bleeding and ARDS
Surgical Management
cervical cerclage
• a stitch inserted around the cervix
• usually done 14 to 16 weeks
• on bed rest for a short period of time
• can be removed at the time of delivery, or it can be left in place if a cesarean section is done
 Shirodkar cerclage 1955
• usually requires anesthesia for removal there for carries an additional anesthetic (risk)
• it is a permanent suture around the cervix to prevent preterm birth. When full term
needs CS to delivery the baby

Shirodkar procedure
• original idea was to leave stitch in situ and opt for cesarean section
• modified Shirodkar: the delivery does not necessarily have to be by cesarean, nor the suture left
intact.
• Success rate 80%

Methods/ techniques of cervical cerclage:

McDonald’s Cerclage
- In this method medically designed thread and needle are used, the internal os is stitched together like
the mouth of a closed purse or pouch.

- Internal os is the junction od uterus and cervix

Shirodkar
•Transverse incision anterior cervix, bladder
pushed up above internal cervical os
•Vertical incision in posterior vaginal wall
•5mm Mersilene tape or monofilament non-
absorble suture to surround the cervix at level of
internal os. Knot anteriorly
McDonald
•5mm Mersilene tape or monofilament non-
absorbable suture
•Cervix encircled as high as possible, purse string
suture in 5 to 6 bites with knot positioned
anteriorly

Shirodkar versus McDonald:

No difference in rate of preterm birth or neonatal survival in retrospective studies.

Medical Management
• Tocolytics: Isoxuprine HCL: Duvadilan

• Bed rest

• Hydration

• Progesterone

• Trendelenburg position

• Antibiotics – prophylactic

• Cervical Cerclage

Nursing Diagnosis
•Anxiety r/t _____

•Risk for maternal injury r/t ____

•Risk for fetal injury r/t _____

•Knowledge Deficit r/t______

•Anticipatory grieving r/t_____

 Post Term Pregnancy
Definition
- pregnancy which has extended beyond 42 weeks of gestation period ( > 294 days)

- Incidence of post-term pregnancy is 4-14% ( generally 10% )

Etiology
- inaccurate dating (ex: patient doesn't remember the last day of menstruation )- the LMP is
wrong

-biological variability ( hormonal factors and genetic predisposition ) -family of post term
pregnancy

- maternal factors : previous prolonged pregnancy, elderly multiparae, primiparity, irregular

menstrual cycle, obesity – first mother beyond 30 up

- fetal factors : congenital anomalies (anencephaly)

-extra uterine pregnancy

-placental factors : sulphate deficiency

Physiological changes associated with post-term pregnancy

•Placental changes : ageing of the placenta, calcification - magtigas, infractions- magliit

•Amniotic fluid changes: oligohydramnios, cloudy, presence of meconium – normal is 5-25 amniotic
index

•Fetal changes : macrosomia, intrauterine malnutrition

Fetal & maternal risks

•Fetal risks :
-fetoplacental insufficiency

-Meconium aspiration – cause pneumonia

-oligohydramnios- decrease amniotic fluid

•Maternal risks:
-large for gestational age

-increased incidence of vacuum assisted, forceps assisted or cesarean delivery

-psychological stress

-probable labour induction

Path physiology
Abnormal fetal hypothalamic-pituitary-adrenal and adrenal hypoplasia as in anencephaly deficiency of
dehydro-epiandrosterone reduced fetal cortisol response.- the substance of the pitiary gland ni baby is
kulang

Placental Salphatase deficiency- this enzyme play a critical role in synthesis of placental estrogens which
are necessary for the expression of oxytocin & PG receptors in myometrial cells

Post-term Pregnancy S&S

-Wt loss

- decrease uterine size

-Meconium in AF

•Risks
-increase fetal mortality

-cord compression – inadequest oxygen in the baby that causes fetal hypoxia

-mec asp- mag lodge sa lungs that causes meconium induced pnemonia

- LGA shoulder dystocia

>CS

- episiotomy/lacertaion

- depression

Treatment
- fetal surveillene

- NST, CST, BPP Q wk

- mom monitors fetal movement atlest 5-10 in 20 mins

- induction- we initiate the labor

- pitocin (10-20U/L) @ 1-2 mU/min every 20-60 min – syntethic oxytoxin aftre that give prostaglandin
intavaginal for dilation of cervix

Post term infant charactreics

• Dry peeling skin
• Creases cover soles
• Newborn emaciated
• Meconium stained
• Limited vernix and lanugo H
 • Hair and nails long

Vernix caseosa – it is a white, cream cheese-like subtance that serves as a lubricant, is secreted by the
fetal sebaceous glands and which disappear within a few days

Lanugo- is the fine, downy hair, that covers a newborn shoulder, back and upper arms. It may be found
also on the forehead and ears. Pre-term newborns has more lanugo then post-term
EXPECTANT 0BSERVATIONAL MANAGEMENT
•Women with prolonged pregnancy, who refuse (or IOL are kept under strict monitoring.

•Many different tests are performed for assessment of post-term fetus. These includes:

- CTG

- Ultrasound examination that include

• Amniotic fluid index (AF[)

• Biophysical profile
• umbilical artery doppler waveform analysis

•These tests should be performed twice in a week.

MANAGEMENT OF PROLONGED PREGNANCY

immediate induction of labour or delivery post-date should take place if:

I. there is reduced amniotic fluid on scan .

II. fetal growth is reduced.
III. reduced fetal movements.
IV. CTG is abnormal.
V. the mother suffer medical illness such as hypertension, diabetes mellites
Management of post term pregnancy
Antepartum management ;
Decision of delivery : if the patient is <42 weeks with engaged head and favorable cervix then labour
should be induced

Patient with <42 weeks and unfavorable cervix

- Twice weekly NST and BPP.

- AFI amniotic fluid index (sum of 4 pocket of liquor in 4 quadrant)

Management of post term pregnancy

■Women with post-term pregnancies who have unfavorable cervices also should undergo labour
induction.

■ Prostaglandin can be used to promote cervical ripening and induce labour.

■Delivery should be effected if there is evidence of fetal compromise or oligohydramnios.

■If induction leads to fetal distress at any stage, cesarean section should be done

Nursing plan for postpartum pregnancy

• teach fetal kick counts antenatally
• ongoing FHR assessment for signs of cord compression in labor
• take corrective action for cord compression due to oligohydramnios: position change, O2
amnioinfusion – position in left lateral
• carefully monitor labor progress
• provide emotional support

Nursing Care While on Induction Of Labor

• monitor uterine contraction
• monitor FHT
• Monitor for progress of labor (IE)
• Start IV induction of labor (oxytocin drip)
• Induction of labor: stimulate strong uterine contraction, shorten intervals, and longer durations
and helps dilate the cervix
• Administers prostaglandin: cervical ripening intravaginally
• Prepare for delivery
• Assess for post term signs of the newborn
Check si baby

1. Dry skin
2. Staining
3. Long nails
4. Weak
5. Creases
6. Meconium strain

Amniotic Fluid

Amniotic fluid abnormalities

Oligohydramnios:
- It is defined as reduced amniotic fluid i.e. amniotic fluid index of 5 cm or less or the deepest
vertical pool < 2 cm.

Polyhydramnios:
- It is defined as excessive amount of amniotic fluid of 2000 ml or more AFI of> 25 cm or the
deepest vertical pool of> 8 cm
Etiology
Polyhydramnios – more on obese and diabetic maam

• Maternal OM
• Multiple Gestation
• Isoimmunization – like RH incompatibility
• Pulmonary Abnormalities
• Fetal anomalies

- Duodenal atresia/TE fistula

- Anencephaly

• Twin-Twin transfusion

Oligohydramnios
•Fetal UT problems

- Renal agenesis (Potter's)

- GU obstruction

•Uteroplacental insufficiency

•ROM
 Low amniotic fluid
- Also called oligohydramnios, low amniotic fluid is a potentially life-threatening pregnancy
complication.

- In most cases, it occurs towards the end of the third trimester.

- Most commonly, low amniotic fluid is treated with a preterm delivery.

DEFINITION (oligohydramnios)
- AMNIOTIC FLUID VOLUME< 5 tn percentile ff gestational age

- AMNIOTIC FLUID INDEX < 5

- SINGLE VERTICAL POCKET < 2 ems

- Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation

Low amniotic fluid levels

• Oligohydramnios occurs when the volume of flu d In the amnitoc sac is lower than
average, usually because the placenta is not functioning properly,
• When the placenta isn't working as expected. the baby gets less oxygen and nutrients.
This cause HIE. ( cause hypoxia in the endometrium lining) premature birth. lUGR. and
other serious complications and injuries –
SUMMARY:
Therapeutic Management of Oligohydramnios
Antepartal
- Serial Ultrasounds

- Non-stress Testing

- Biophysical Profiles

lntrapartal
- Continuous fetal monitoring

- Amnioinfusion (crystalloid fluid Normal Saline)

- Intrauterine resuscitation

TREATMENT
ADEQUATE REST - decreases dehydration

·HYODRATION - Oral/IV Hypotonic fluids(2 Lit/d)

·SERIAL USG – Monitor growth, A FI, BPP

·INDUCTION OF LABOUR/ LSCS – observation for 24 hours

Nursing Management
® DFMC

® Left lateral position

® FHR monitoring

® Administration of fluids

® Anti D after amnioinfusion SOS

® Close monitoring during labour