MATERNAL ABNORMAL CONCEPTS

1. Which of the following nursing diagnosis would be the priority when caring for the patient
with hyperemesis gravidarum?
a. Altered high maintenance
b. Noncompliance
c. Risk for fluid volume deficit
d. Risk for injury
Rationale:
● Hyperemesis gravidarum is extreme morning sickness that causes long-lasting intense
nausea, vomiting, and weight loss.
● Complications that may arise from excessive vomiting include dehydration, rebel
impairment, malnutrition, and electrolyte imbalance.

2. Which of the ff hormones is responsible for hyperemesis gravidarum?

A. Increase HPL
B. Increase HCG
C. Increase in estrogen
D. Increase in progesterone
Rationale:
● The exact cause is still unknown, many believe hyperemesis is cause by a rapid rise in
hormone HCG levels
● Hyperemesis gravidarum develops between the 4th-6th weeks of pregnancy and may
last longer than week 20
● Symptoms may be so severe that they interrupt the patient's daily activities

HYPEREMESIS GRAVIDARUM
● Excessive nausea and vomiting in pregnancy which persisted beyond 3 months
HYPER: excessive
EMESIS: vomit
GRAVIDARUM: pregnancy

- Defined as unexplained intractable nausea, retching, or vomiting in the first trimester,

incapacitates her in day-to-day activities or sufficient to warrant hospital admission
resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of pre-
pregnancy weight
Cause: unknown
● Hormone changes: increased HCG
- progesterone is increased in 1st trimester only and causes n/v (declines in 2nd and 3rd)
● Changes in GI system:
● Genetics (2 genes that develops hyperemesis gravidarum: GDF15 and IGFBP7)

History
● History of a patient with suspected hyperemesis gravidarum should include their
pregnancy status, estimated gestational age, history of complications during prior
pregnancies, the frequency of nausea and vomiting, any interventions during which the
patient has already tried to treat symptoms and the outcomes of the attempted
interventions
● The average onset of symptoms happens approximately 5 to 6 weeks into gestation
● The onset of nausea and vomiting after nine (9) weeks should speak concern for
alternative diagnoses. Preeclampsia, HELLP (hemolysis, elevated liver enzymes and low
platelets), and acute fatty liver of pregnancy typically present themselves during the late
second or third trimester of pregnancy

ASSESSMENT
1. Nausea most pronounced on arising; may occur at other times during the day
2. Persistent vomiting
3. weight loss
4. Signs of DHN
5. F&E imbalances
6. Physical exam should include
a. FHT (depending gestational age)
b. And examination of fluid status, which should include an examination of bp, hr,
mucous membrane, dryness, capillary refill and skin turgor.

PRINCIPLES OF MANAGEMENT
● To control vomiting
● To correct fluid and electrolytes (IVF: hypertonic; sodium and potassium)
● To correct metabolic disturbance
● To prevent serious complications of severe vomiting
INTERVENTIONS
1. Initiate measures to alleviate nausea, including medication therapy, if unsuccessful, and
weight loss and fluid and electrolytes imbalances occur, intravenously administered fluid
and electrolyte replacement or parenteral nutrition therapy may be necessary
2. Monitor VS, intake and output, weight and calorie count
3. Monitor laboratory data and signs of DHN and electrolyte imbalances
4. Monitor urine for ketones
5. Monitor fetal heart rate, fetal activity and fetal growth
6. Encourage intake small portions of food (Low fat, easily digestible CHO such as cereals,
rice, pasta)
7. Liquids should be taken between meals to avoid distending the stomach and triggering
vomiting

Management
● Initial treatment should begin with non-pharmacologic interventions such as switching
the patient’s prenatal vitamins to folic acid supplementation (250 mg orally 4 times
daily ) as needed
● If the patient continues to experience significant symptoms, the first-line pharmacologic
therapy should include a combination of vitamin B6 (pyridoxine) and doxylamine
(antihistamine, calmative effect on the patient)
● Second-line medications include antihistamines and dopamine antagonist such as
dimenhydrinate 25 to 50 mg every 4 to 6 hours orally, diphenhydramine 25-50 mg every
4-6 hours orally
● If the patient continues to experience significant symptoms without exhibiting signs of
dehydration, metoclopramide, ondansetron, or promethazine may be given orally.
● In the case of dehydration, intravenous fluid boluses or continuous infusions of normal
saline should be given in addition to intravenous metoclopramide, ondansetron, or
promethazine. Electrolytes should be replaced as needed.

NURSING MANAGEMENT
● Initiate measures to alleviate nausea including medication therapy. If unsuccessfully on
weight loss and electrolyte imbalances occur, IV administration of fluid and electrolytes
replacement or total parenteral nutrition may be necessary
● Monitor lab data for sign of dehydration and electrolytes imbalances
● Monitor urine for ketones
● Monitor fetal heart rate, fetal activity and fetal growth
● Encourage intake of small proportion of food
● Liquid should be taken b/w meals to avoid distending stomach and triggering vomit
 ● Encourage patient to sit upright after meal

COMPLICATIONS
1. Dehydration
a. Electrolyte imbalance
b. Renal failure
c. Wernicke's encephalopathy (thiamine deficiency)
2. Vitamin K deficiency: maternal
3. Coagulopathy or fetal intracranial hemorrhage

3. The best time to treat incompetent cervix is between___ and ____ week of pregnancy
before dilitation occurs
a. 12,18
b. 10,12,
c. 2,3
d. 18, 25
Rationale:
 incompetent cervix is characterized by painless dilitation of cervical os without
contractions of the uterus
 Incompetent cervix commonly occurs at about the 20th week of pregnancy
 The treatment for an incompetent/weakened cervix is a procedure is called cerclage
and is usually performed between 14-16 of pregnancy
 These sutures will be removed between 36-38 weeks to prevent any problems when
woman goes into labor

Incompetent cervix or premature cervical dilatation

● Cervical effacement and dilatation in early midtrimester resulting in expulsion of
products of conception

CAUSES
● Increase maternal age
● Congenital maldevelopment of the cervix- short cervix
● Trauma to the cervix (history of repeated D&C's; cervical lacerations with previous
pregnancies)

RISK FACTOR:
1. Short cervical length
 2. Prior miscarriage
3. Prior preterm delivery
4. Prior DC procedure which is a procedure use to clear the uterine lining after miscarriage
or pregnancy termination. It can also be used to diagnose to treat certain uterine
conditions
5. Prior loop electrosurgical excision procedure (LEEP) to remove abnormal/potentially
cancerous cells from cervix.
6. History of other surgical involving the cervix
7. Diagnosis of incompetent cervix in a previous surgery
8. Twins, multiple pregnancy
9. Repeated or late-term abortion
10. Uterine abnormalities
11. Exposure to drug diethylstilbestrol (DES), a synthetic form of hormone estrogen

SIGNS AND SYMPTOMS

1. Painless cervical dilatation
2. Vaginal discharge
3. Rupture of membrane
4. Uterine contractions may or may not be present

DIAGNOSIS
1. History
● An important indicator of an incompetent cervix if the woman has had one or more
miscarriages or extremely premature births (usually before week 28 of pregnancy) an no
or minimal symptoms
● It is also important for physicians to ask about other risk factors for incompetent cervix
2. Physical Exam
● During the second or third trimester, a pelvic exam to check for incompetent cervix can
reveal the partial opening of the cervix (dilation) with shortening and thinning of the
vaginal part of the cervix (effacement), which would indicate a weak cervix
3. Tests
● The physician would order serial transvaginal ultrasound studies (TVS) for women with
risk factors for cervical incompetence. Transvaginal ultrasounds can help monitor the
cervical length and determine if the cervix is shortening/opening

MANAGEMENT
1. CERVIAL CERCLAGE – medical management wherein the physician sutures a certain part of
the cervix
- during a cerclage, a strong suture is sewn in and around the cervix which helps it remain
closed under the weight of the baby

✓ According to the American College of Obstetricians and Gynecologists (ACOG), eligibility for
cerclage can be based off of the following factors:
● A history of incompetent cervix (typically, these women would have a cerclage placed
between approximately 13 and 14 weeks of pregnancy
● Physical examination findings (advanced dilation of the cervix without pain, and no signs
of placental abruption or intraamniotic infection)
● A history of premature birth combined with certain ultrasonographic findings
● ACOG recommends the cerclages only be performed in the second trimester, before
the fetus is viable (able to live outside the womb)
● This means that women generally should receive a cerclage prior to 24 weeks of
gestation. Cerclage is extremely effective in prolonging pregnancy in the face of
cervical insufficiency
● A cerclage should be removed around 36-37 weeks of pregnancy, before the onset of
labor
● If a woman gets into premature labor on her water breaks, it may need to be removed
before earlier
● Cerclage is not recommended in women with preterm premature rupture of
membranes (PPROM), placental abruption, infection, or preterm labor

● McDonald's - Nylon suture are placed

horizontally and vertically across the
cervix and pulled tight to reduce the
cervical canal to a few millimeters in
diameter (placed temporarily; removed at
38-39 weeks of AOG and fetus is delivered
vaginally)
● Shirokdar - sterile tape is threaded in a
purse-string manner under sub mucus
layer of the cervix and sutured in place
achieve a closed cervix (permanent suture and it is placed during the 14-18 th week of
pregnancy; kept in place for subsequent pregnancies; fetus is delivered via CS)
 success for both of the cerclage is 80-90%
After the procedure:
 the mother will be on bed rest
  slight or modified Trendelenburg position for a few days to decrease pressure on the
new sutures
 watch out for bleeding, uterine contractions, PROM
- If there is PROM in McDonald’s, the nylon sutures will be removed and coitus
should be avoided for 2 weeks

2. PROGESTERONE TREATMENT
● Progesterone is a pregnancy hormone that helps to prevent premature contractions/
birth (it also benefits the growing baby in a variety of other ways).
● Women with incompetent cervix should benefit from progesterone treatment. It can
reduce the risk of premature birth by about one third
● ACOG recommends providing progesterone only to women with history of spontaneous
birth before 37 weeks of gestation. It can be given orally or via injection.
● For women with a singleton pregnancy (single fetus on the womb of the mother) and
history of singleton premature birth, UptoDate suggests injections beginning between
16 and 20 weeks of pregnancy
● Progesterone is not always recommended for women pregnant with more than one
baby, however, new research indicates that it may have some value in multiple
pregnancy.

4. A condition wherein the BOW has been ruptured before 37 weeks AOG:
a. PROM
b. Cord prolapse
c. H. mole
d. Ectopic pregnancy
Rationale:
 PROM is a pregnancy complication. In this condition, the amniotic membrane
surrounding the fetus ruptures before weeks 37 of pregnancy.
 Once the amniotic membrane breaks, the pregnant women have an increased risk for
infection.

5. The FHR is checked following rupture of the BOW in order to:

a. Check if the fetus is suffering from head compression
b. Determine if cord compression followed by the rupture
c. Determine if there is utero-placental insufficiency
 d. Check id the fetal presenting part has adequately descended following the rupture
Rationale:
● After a premature rupture of membranes, the umbilical cord is no longer cushioned by
the amniotic fluid, and can become compressed (or flattened). In some cases, the
umbilical cord may also slip out of the birth canal becoming compressed between the
presenting part and the mother’s vaginal canal. This is known as cord prolapse.
● Cord prolapse and other forms of compression are dangerous because of the flow of
oxygen rich blood to the baby is interrupted and the baby may experience dangerous
complications like hypoxic-ischemic encephalopathy (HCE).

6. When BOW ruptures spontaneously, the nurse should inspect the vaginal introitus for
possible cord prolapse. If there is part of the cord that has prolapsed into vaginal opening the
correct nursing interventions:
a. Push back the prolapsed into the vaginal
b. Place the mother in the sunflower position to improve circulation
c. Cover the prolapse cord with sterile gauze soaked with sterile NSS and place the woman
in Trendelenburg position
d. Push back the cord into the vagina and place the women on sim’s position
Rationale:
 The correct action of the nurse is to cover the cord witty sterile gauze wet sterile NSS.
 Observe strict asepsis in the care of the cord to prevent infection
 The cord has to be kept moist to prevent it from dying
 Don’t attempt to put back the cord into vagina but relieve pressure on the cord by
positioning the mother either on Trendelenburg or sim’s position.

7. When prom occurs which of the following provides evidence of the nurse’s understanding
of the clients immediate needs?
a. PROM removes the fetus most effective defense against infection
b. The chorion and amnion rupture 4 hours before the onset of labor
c. Nursing care is based on fetal viability and gestational age.
d. The chorion and amnion rupture 4 hours before the onset of labor.
Rationale:
● PROM can precipitate many potential and actual problems; one of the most serious fetal
loss of an effective defense against infection is the client’s most immediate need this
time.
 ● Typically prom occurs about 1 hour, not 4 hours before labor begins. Fetal viability and
gestational are less immediate considerations that affect the plan of care.
Malpresentation and an incompetent cervix may be cause of PROM

PREMATURE RUPTURE OF MEMBRANE

● Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37
weeks and before the onset of labor.
● The cause is unknown but it is associated with infection of the membranes
(chorioamnionitis)
● it occurs in 5% to 10% of pregnancies

SIGNS AND SYMPTOMS

● Sudden gush of clear fluid from the vagina (with continued minimal leakage)
● Alkaline reaction when tested with nitrazine paper

● Sterile vaginal speculum exam

○ Minimize digital examination of cervix, regardless of gestational age, to avoid
ascending infection/amnionitis
1. Assess cervical dilation and length
2. Obtain cervical cultures (Gonorrhea, Chlamydia)
3. Obtain amniotic fluid samples
 - amniotic fluid cannot be differentiated from urine by appearance, SVSE
is done to observe for vaginal pooling of fluid

● Ferning test

● Ultrasound – shows the level of amniotic fluid

MANAGEMENT
1. Monitor maternal (signs of infection) and fetal status
 Evaluate patient for chorioamnionitis (common etiology of PROM)
 Fever >100.4F (38°C), leukocytosis, maternal/fetal tachycardia, uterine
tenderness, malodorous vaginal discharge
2. Bed rest
3. Observe amount, color, and odor of a fluid
4. Administration of corticosteroid - to hasten fetal lung maturity
5. Administration of antibiotic
 Prophylactic administration of broad spectrum
- delay the onset of labor
- reduce the risk of infection in the newborn sufficiently to allow the
corticosteroid to have its effect
6. Avoid routine IE/Vaginal examination - to decrease risk of chorioamnionitis
7. If labor does not begin within 24 hours, labor is induced.
- It should be induced. CS delivery should be performed for other infections
- labor contractions are usually induced by intravenous administration of oxytocin
so that the infant is born before an infection can occur
COMPLICATIONS
1. Uterine and fetal infection - the seal to the fetus is lost and uterine and fetal infection may
occur
2. Cord prolapse - is most apt to occur when the fetal head is still too small to fit the cervix
firmly
3. Compression Deformities
 Increase pressure on the umbilical cord from the loss of amniotic fluid
 Inhibiting the fetal nutrient supply, or cord prolapse
 Potter like syndrome or Distorted facial features and pulmonary hypoplasia
from pressure – describes the typical physical appearance caused by the
pressure in the utero due to oligohydramnios

8. A condition wherein the umbilical cord descends into the vagina ahead of the fetal
presenting part.
a. Cord prolapse
b. Preterm labor
c. Ectopic pregnancy
d. H. Mole
Rationale:
- Cord prolapse is descent of the umbilical cord into the vagina ahead of the fetal
presenting part with resulting compression of the cord between the presenting part and
the maternal pelvis.
- Cord prolapse is an emergency situation: immediate delivery will be attempted to save
the fetus. This problem occurs most frequently in prematurity, rupture of membranes
with the fetal presenting part unengaged and shoulder or footling breech presentations.
 It may follow rupture of the amniotic membranes because the fluid rush may carry the
cord along toward the birth canal.

9. A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels
that something is coming through the vagina. The nurse performs an assessment and notes
the presence of the umbilical cord protruding from the vagina. The nurse immediately places
the client in what position?
a. Prone
b. Supine
c. Reverse Trendelenburg
d. Knee chest position
Rationale:
- The immediate priority to minimize pressure on the cord. Thus the nurse’s initial action
involves placing the client on bedrest and then placing the client in a knee chest position
or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize
the pressure on the cord.
- Monitoring maternal vital signs and FHR, notifying the physician and preparing the client
for delivery, and wrapping the cord with sterile saline soaked warm gauze are
important. But these actions have no effect on minimizing the pressure on the cord

10. A nurse is providing an emergency measure to a client in labor who has been diagnosed
with cord prolapse cord. The mother becomes anxious and frightened and says to the nurse,
“Why are all of these people here? Is my baby going to be alright? Which of the following
nursing diagnoses would be most appropriate for this client at this time?
a. Fear
b. Fatigue
c. Powerlessness
d. Ineffective coping
Rationale:
 Fear is distressing emotion caused by impending danger or pain whether the threat is
real or imagined. The individual experiencing fear can recognize the person, place, or
thing precipitating this feeling. Some of the most common fears are fear of death, pain
and bodily injury. The mother becomes anxious and frightened and verbalizes “why
are all of these people in here? Is my baby going to be alright?” with the statement the
mother might be thinking that something happened to her baby.
11. A nurse in labor is performing a vaginal assessment on a pregnant client in labor. The
nurse notes that the presence of the umbilical cord protruding from the vagina. Which of the
following in the initial nursing action?
a. Gently push the cord into the vagina
b. Place the client in Trendelenburg position
c. Find the closest telephone and page the physician stat
d. Call the delivery room to notify the staff that the client will be transported immediately.
Rationale:
● When the umbilical cord is protruding, the cord must be protected from drying out and
from becoming compressed. Wrapping the cord with sterile, saline, soaked towel will
help accomplish this.
● The nurse must also help reduce compression of the cord by placing the client in an
extreme Trendelenburg or modified sims position

Nursing Care
 If woman in labor say she feels a loop of the cord is coming out of the vagina (cord
prolapse), the first nursing action is to put her in:
 KNEE CHEST POSITION or TRENDELENDURG POSITION in order to reduce
pressure on the cord
 Apply warm saline saturated gauze on the prolapsed cord to prevent drying of
the cord.
 REMEMBER: Only 5 mins of cord compression can already lead to irreversible
brain damage or even fetal death
12. A nurse in the labor room is preparing to care for a client with hypertonic uterine
contraction. The nurse is told that the client is experiencing uncoordinated contractions that
are erratic in their frequency, duration, and intensity. The priority nursing intervention in
caring for the client is to:
a. Stop the oxytocin infusion
b. Prepare the client for amniotomy
c. Promote ambulation every 30 minutes
d. Continue oxytocin infusion
Rationale:
- Hypertonic uterine contraction occurs in the latent phase of labor, with an increase in
the frequency of contractions and a decrease in their intensity. Usually occurs before
4cm dilation, cause not yet known, may be related to fear tension.
- Contractions are extremely painful because of uterine muscle cell anoxia but are
ineffective dilating and effacing the cervix, which leads to maternal exhaustion.
Contraction may interfere with uteroplacental exchange and lead to fetal distress and
even death. Therefore, the nurse must stop the oxytocin Infusion prevent the
stimulation of uterine contractions.

13. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician's orders and would expect to note which
of the following prescribed treatments for this condition?
a. Increase hydration
b. Oxytocin infusion
c. Medication that will provide sedation
d. Administration of tocolytic medication
Rationale:
 Hypotonic is defined as less than 3 contractions of mild to moderate intensity occurring
in a 10 minutes period during the active phase of labor. Cervical dilation and descent of
the fetus slow greatly or stop.
 Potential fetal effects on the fetus are fetal sepsis (infection) and fetal death. The
attending physician may order oxytocin to stimulate uterine contraction.