NCM 102 High Risk Mom

Care of Mother, Child, and Population Group at Risk or

with Problems What is High Risk Pregnancy?
poor maternal or fetal outcome due to :
PRENATAL CARE  medical
THE PURPOSE OF PRENATAL CARE IS TO ENSURE AN  reproductive
UNCOMPLICATED PREGNANCY AND THE DELIVERY OF A  Psychosocial
LIVE AND HEALTHY INFANT.  Obstetrical
 SCREENING
BALANCE OF FORCES IN PREGNANCY Diagnostic and Laboratory Examinations
 FETAL SURVIVAL Complete Blood Count
 MATERNAL SURVIVAL  Hemoglobin
5 Branches of Maternal Health  Hematocrit
• Nutrition  Leukocyte
• Prenatal Care  Thrombocytes
• Safe Delivery  Blood Typing
• Breastfeeding  Rhesus Factor
• Family Planning URINALYSIS
Prenatal Care  Pus cells
• Regular prenatal care increases the chances of a  Bacteria
healthy mother and child after birth.  Protein/albumin
• Early detection of congenital & birth defects  Sugar
• Prenatal immunizations can prevent mother-to-  Squamous epithelial cells
child-transmission and infection. PAP SMEAR
DOH STANDARDS OF PRENATAL CARE ULTRASONOGRAPHY
1. WEIGHT  Transabdominal
2. HEIGHT  TRANSVAGINAL ULTRASOUND
3. BLOOD PRESSURE BLOOD GLUCOSE TEST
4. FHT  FBS
5. FUNDIC HEIGHT  HGT/CBG
• 5th month = 20 cm  OGTT
• 6th month = 21-24 cm  OGCT
• 7th month = 25-28 cm  2 HRS. POST PRANDIAL
• 8th month = 29-30 cm AMNIOCENTESIS
• 9th month = 30-34 cm Maternal Alpha-Feto Protein
6. LEOPOLD’S MANEUVER Fetal neural tube defect:
 anencephaly
 gastroschisis
 spina bifida
DOPPLER VELOCIMETRY
PERCUTANEOUS UMBILICAL BLOOD SAMPLING
BIOPHYSICAL SCORING
30 minutes observation by USD
5 markers:
 non stress test
 fetal breathing
 amniotic fluid
 fetal body movement
 fetal tone
BPS RESULT INTERPRETATION
8 – 10 - Normal fetus
6 - chronic asphyxia
7. TT IMMUNIZATION - repeat the procedure after 24 hours
TETANUS TOXOID WHEN TO GIVE 4 - abnormal result
TT 1 ANYTIME DURING 2 - ill fetus, terminate pregnancy
PREGNANCY Non Stress Test (NST)
TT 2 4 WEEKS AFTER TT 1 2 - 2 or more FHT acceleration
TT 3 6 MONTHS AFTER TT 2 per movement
TT 4 1 YEAR AFTER TT 3 1 - <2 accelerations
TT 5 1 YEAR AFTER TT 4 per movement
0 - no acceleration
8. DIET Fetal Breathing
9. DANGER SIGNS OF PREGNANCY 2 - 1 episode/30 minutes lasting 30 seconds
10. BREASTFEEDING 0 - no episode
11. FAMILY PLANNING - more than 30 minutes
12. POSTPARTUM CARE - not lasting 30 seconds
AMNIOTIC FLUID INDEX  ATRIAL – SEPTAL DEFECT
2 - fluid filled pocket of 1 cm or more  asymptomatic
0 - no amniotic fluid or less than 1 cm in every  increase pulmonary blood flow
pocket  pulmonary hypertension
FETAL BODY MOVEMENT  VENTRICULAR SEPTAL DEFECT
2 - 3 or more discrete movement of limbs and  left ventricular hypertrophy
body in 30 minutes  pulmonary hypertension
1 - less than 3 movements  biventricular hypertrophy
0 - no movements  PATENT DUCTUS ARTERIOSUS
FETAL TONE  rare
2 - 1 or more episodes of active extension with  early surgical repair
return to flexion of limbs and trunk  similar with VSD
1 - slow extension with return to flexion  RHEUMATIC HEART DISEASE
0 - no movements  Group A Beta Hemolytic Streptococcus
HEPATITIS B DETERMINATION  Inflammatory process
1 Hepatitis B Antigen (HBSAg)  Autoimmune disease
2 reactive - positive  Scarring of the valves
3 non-reactive – negative  SIGNS AND SYMTOMS OF CARDIAC DISEASES
4 Hepatitis B Antibiodies (HBSAb)  Shortness of breath
 qualitative  Palpitations
 quantitative  Orthopnea
CONTRACTION STRESS TEST (CST)  Expectoration of blood
 done after 32 weeks AOG  Cyanosis
 Negative - normal; no fetal heart
 Murmur
deceleration
 Heart enlargement
 Positive - abnormal; with deceleration
 FUNCTIONAL CLASSIFICATIONS OF CARDIAC
FETOSCOPY
- Direct visualization of the fetus through a scope DISEASES
- Obtain sample tissues or blood
 CLASS 1 - asymptomatic
- May perform intrauterine fetal surgery
FETAL MOVEMENT COUNTING  CLASS II - symptomatic but with
- Done after 27 weeks AOG normal activities
- Twice daily for 20-30 minutes  CLASS III - symptomatic and with less
- Normal – 5-6movements in 20-30 minutes than normal activities
- Abnormal – less done 3 movements in 1 hour  CLASS IV - symptomatic and at rest
Judgment of safety of pregnancy
• Conception should be prevented if:
1. Severe heart disease
MEDICAL COMPLICATIONS DURING PREGNANCY
2. Functional classification: class III-IV
CARDIOVASCULAR DISORDERS
3. History of heart failure
PREGNANCY
4. Pulmonary hypertension
 Increase blood volume 40 – 50%
5. Right to left shunting
 Increase cardiac output
6. Severe arrhythmia
 Decrease B during first trimester
7. rheumatic fever
 Increase size of ventricular chamber
8. Combined valve disease
 LEFT TO RIGHT SHUNTING
9. Acute myocarditis

MANAGEMENT OF CARDIAC DISEASES

o termination of pregnancy by CS
 Weight reduction
 Rest
 prevent infection
 Digoxin
 Diuretics
NURSING CARE OF CARDIAC DISEASES
 Vital signs
 Provide rest
 Emotional support
 I & O monitoring
 Proper nutrition
 Carry out medical orders
 GESTATIONALDIABETES MELLITUS  Respiratory Depressant
RISK FACTORS CAUSING GDM ALCOHOL EFFECTS ON FETUS
 Obesity  Fetal Alcohol Syndrome (FAS)
 Family history
 Personal history  Intrauterine Growth Restriction
 Sedentary lifestyle  Preterm Delivery
 Improper diet
(PATHOPHYSIOLOGY NOT INCLUDED) CNS Depressants:
 Morphine,
FETAL/NEONA TAL COMPLICATIONS OF GDM  Heroin,
 Fetal hyperglycemia
 Fetal Hyperinsulinemia
 Macrosomia
 Prematurity
 Respiratory Distress
 Neonatal Hypoglycemia
MATERNAL COMPLICATIONS OF GDM
 Preeclampsia
 Polyhydramnious
 Infection
 Dystocia
 Postpartum Bleeding
 Birth canal trauma
 Caesarean delivery

Fasting & 2 hours postprandial venous plasma sugar  Methadone

during pregnancy.  Analgesics
STIMULANTS
FASTING 2HRS POST RESULT  Cocaine
PRANDIAL  Amphetamine
<100 mg/dl < 145mg/ dl. Not diabetic  Ecstacy
 Caffeine
>125 mg/ dl >200 mg/ dl. Diabetic EFFECTS OF STIMULANTS
 Increase Concentration
ORAL GLUCOSE CHALLENGE TEST  Alertness
 fasting post midnight  Paranoia
 blood and urine specimen are obtained  Hypertension
 50 grams glucose intake  Psychosis
 after 1 hour, blood and urine specimen is STIMULANTS’ EFFECTS ON FETUS
 Preterm labor
obtained
 Spontaneous abortion
 A value above 130 – 140 gms/l one hour after
 Placental abruption
is used as threshold for performing a 3-hour  Fetal hypertension
OGTT. PREGNANCY SMOKING
Prerequisites of OGTT:  Higher rates of spontaneous abortion, placenta
 Normal diet for 3 days before the test. previa,
 No diuretics 10 days before.  Preterm labor
 At least 10 hours fast.  Low birth weight infant
 Test is done in the morning at rest.  Fetal hypertension
CRITERIA FOR OGTT MARIJUANA
The maximum blood glucose values during pregnancy:  Relaxant
• fasting 90 mg/dl  Hallucination
• one hour 165 mg/dl  Short term Memory loss
• 2 hours 145 mg/dl  Low birth weight Infant
• 3 hours 125 mg/dl Lifetime Effects of Substance Abuse
MANAGEMENT OF GDM  Physical deformities
 Insulin  Mental Retardation
 Diet  Developmental Problem
 Exercise
(END OF FIRST PRESENTATION)

Substance Abuse During Pregnancy

TERATOGEN
 Any agents that interferes with normal
embryonic development
ALCOHOL
 CNS Depressant
 Reduce Anxiety
 Sedation
 6. AIDS
CD4 counts
 Number of CD4 cells in blood provides a
measure of immune system damage
 CD4 count reflects phase of disease
 CD4 count:
 500 – 1200: Normal
 200 – 500: Beginning of HIV illness
 < 200: AIDS
Window period
 Time between infection & enough antibodies
 Duration: approximately 3 months
 No symptoms or signs of illness
 HIV test is negative
 Virus is multiplying rapidly - viral load is high
ACQUIRED IMMUNODEFFICIENCY SYNDROME  Person is very infectious
 Caused by HIV Seroconversion
 Transmitted through blood, blood products,  Point at which HIV test becomes positive
semen, vaginal fluid, breast milk  Body starts making antibodies to HIV a few
 Diagnosed by enzyme-linked immunosorbent weeks after infection
assay (ELISA)  HIV test becomes positive
 Confirmed by western blot test  Person may have a mild flu-like illness, lasting a
week or two
SYMPTOMS OF AIDS  Afterwards, the person is well again
 Extreme weakness and fatigue Asymptomatic period
 Rapid weight loss  Time period between seroconversion and onset
 Frequent fevers with no explanation of HIV/AIDS-related illness
 Heavy sweating at night  Duration variable: < 1 year to > 15 years
 Swollen lymph glands  Most people remain healthy (asymptomatic) for
 Minor infections that cause skin rashes and about three years
mouth, genital, and anal sores.  Duration may depend on socio-economic
 White spots in the mouth or throat factors
 Chronic diarrhea  The CD4 count is above 500 cells/ml
 A cough that won’t go away HIV/AIDS-Related Illness
 Short-term memory loss  Time period between onset of illness &
 Fact or Fiction? diagnosis of AIDS
You can get AIDS from a mosquito bite  Duration is variable: average about 5 years
 Fact or Fiction?  Illnesses initially mild, with gradual increase in
You can get AIDS by having oral sex with an infected frequency and severity
person  CD4 count is between 500 & 200 cells/ml
 Fact or Fiction? AIDS
HIV survives well in the environment, so you can get it  Final phase of HIV/AIDS
from toilet seats and door knobs  Duration: without antiretroviral drugs, less than
 Fact or Fiction? 2 years with antiretrovirals, potentially many
You can get AIDS by hugging a person with HIV who is years
sweating  CD4 count is below 200 cells/ml
 Fact or Fiction?  Viral loads are high & the person is very
You can get AIDS by kissing someone who is HIV infectious
infected Important Facts
 Fact or Fiction?  Duration of different phases of HIV/AIDS will
Condoms aren't really effective in preventing HIV vary in different people
transmission  Factors affecting the course of HIV/AIDS include
 Fact or Fiction? nutrition, emotional stress, and access to health
There is a connection between other STDS and HIV care
infection  People infected with HIV can infect others at
any phase of the disease
How A Healthy Immune System Works Mother-to-Child Transmission
 Physical Barriers:  25–35% of HIV positive pregnant mothers will
 Innate Immune System: pass HIV to their newborns
 Acquired Immune System:  30% of transmission in utero
How does HIV interrupt the Normal Functioning of the  70% of transmission during the delivery
Immune System?  14% transmission with breastfeeding
 HIV infects T-cell Interventions to Reduce Mother-to-Child Transmission
Phases of HIV/AIDS  HIV testing in pregnancy
1. Infection  Antenatal care
2. Window period  Antiretroviral agents
3. Seroconversion  Obstetric interventions
4. Asymptomatic period o Avoid amniotomy
5. HIV/AIDS - related illness
 o Avoid procedures: Forceps/vacuum
extractor, scalp electrode, scalp blood
sampling
o Restrict episiotomy
o Elective cesarean section
o Remember infection prevention
practices
 Newborn feeding: Breastmilk vs. formula
Antenatal Care
 Watch for signs/symptoms of AIDS and
pregnancy-related complications
 Unless complication develops, no need to
increase number of visits
 Treat STDs and other coinfections
 Counsel against unprotected
intercourse
 Avoid invasive procedures
and external cephalic version
 Give antiretroviral agents
 Counsel about nutrition
Breasfeeding Issues
 Warmth for newborn
 Nutrition for newborn
 Protection against other infections
 Safety – unclean water, diarrheal diseases
 Risk of HIV transmission
 Contraception for mother
 Cost
Breastfeeding Recommendations
 promote exclusive breastfeeding for 6 months
 counsel on the safe and appropriate use of
formula
 HIV-positive and chooses to breastfeed,
promote exclusive breastfeeding for 6 months
Rh Incompatibility
 Rh – mother and Rh+ father
 mostly on the second pregnancy
 during placental accidents
(NOT IN THE HANDOUTS)

Anti-retrovirals TYPES OF ANEMIA

 Zidovudine (ZDV):  Iron Deficiency Anemia
o Long course  Megaloblastic Anemia
o Short course  Pernicious Anemia
 Nevirapine  Folic Acid Deficiency Anemia
 ZDV/lamivudine (ZDV/3TC)  Aplastic Anemia
Obstetric Procedures to be avoided  Hemolytic Anemia
 Amniotomy  Sickle Cell Anemia
 Fetal scalp electrode/sampling  Physiologic Anemia
 Forceps/vacuum extractor  Pathologic Anemia
 Episiotomy SIGNS AND SYMPTOMS OF ANEMIA
 Vaginal tears  Pallor
Intrapartum Management  Fatigue
 Goal is to minimize duration of labor ,  Shortness of breath
 Do not rupture membranes  Hypotension
 Avoid invasive monitoring  Asymptomatic
 Avoid episiotomy or instrumental delivery when DIAGNOSTIC EXAMINATIONS OF ANEMIA
possible  Hemoglobin count......... 12 – 14 grams/dl
Delivery: Cesarean vs. Vaginal Birth  Iron .............................. 50 – 150 grams/dl
 Cesarean section before labor and/or rupture of  Transferin ......................250 – 430 mg/ml
membranes reduces risk of mother-to-child  Ferritin...........................11 – 20 g/ml
transmission by 50–80%  Folate.............................7 – 20 g/ml
 Cesarean section, however, increases morbidity  Vit B12...........................200 – 800 g/ml
and possible mortality to mother MANAGEMENT OF PHYSIOLOGIC ANEMIA
 Give antibiotic prophylaxis for cesarean section  Rest
in HIV-infected women  Fe Supplement
Recommended Infection Prevention Practices  O2 Therapy
 Needles:  Nutrition
o Take care! Minimal use  Blood Transfusion
o Suturing: Use appropriate needle and NURSING DIAGNOSIS OF ANEMIA
holder  Altered Tissue Perfusion
o Care with recapping and disposal  Altered Nutrition Less Than Body Requirements
 Wear gloves, wash hands with soap  Activity Intolerance
immediately after contact with blood and body HYPEREMESIS GRAVIDARUM
fluids  Excessive vomiting that persists beyond 1st
 Cover incisions with watertight dressings for trimester
first 24 hours  contains:
Use: previous food intake
 Plastic aprons for delivery mucus
 Goggles and gloves for delivery and surgery bile
 Long gloves for placenta removal finally blood
 Dispose of blood, placenta and waste safely Predisposing Factors
 PROTECT YOURSELF!  Pancreatitis
Newborn  Biliary tract dse
 Wash newborn after birth, especially face  Decrease Vit B6
 Avoid hypothermia  Psychological
 Give antiretroviral agents, if available  Drug toxicity
Precipitating Factors  Tubal/Uterine Surgery
 Pregnancy  Intrauterine Device
 Multiple pregnancy
 Hydatidiform mole
 Heredity
 Female
MANAGEMENT OF HYPEREMESIS GRAVIDARUM
 May need hospitalization
 IVF infusion
 Parenteral nutrition
 Antiemetics
 Progress diet – clear liquid, full liquid, soft, small
frequent, full diet
 Midnight snacks
 Parenteral vitamins and electrolyte

NURSING DIAGNOSIS OF HYPEREMESIS GRAVIDARUM

 Actual/Potential Fluid Volume Deficit Signs and Symptoms of Ectopic Pregnancy
 Imbalance Nutrition; less than Body  Symptoms of bleeding
Requirements  Bleeding into the uterine cavity
 Fatigue  Sharp one sided abdominal pain
 Ineffective Coping  Syncope
 Anxiety  Referred shoulder pain
Bleeding Complications of Pregnancy  Lower abdominal pain
ABORTION  Vaginal bleeding
- Termination of pregnancy before the age of  Abdominal tenderness
viability  Low HCG hormone
Spontaneous Abortion
 Threatened Abortion
 Imminent Abortion
 Complete abortion
 Incomplete Abortion
 Missed Abortion
 Recurrent/Habitual abortion
 Septic Abortion
Induced Abortion
 Therapeutic Abortion
 Eugenic Abortion
Secondary Abortion

Signs and Symptoms of Abortion

 Bleeding
 Abdominal cramping Diagnostic Examinations of Ectopic Pregnancy
 Passage of watery vaginal discharges  Transvaginal ultrasound
 Passage of product of conception  Physical examination
Management of Threatened Abortion  Pregnancy test
 Bed rest  HCG
 Tocolytic medications  Pelvic examinations
 Treat underlying factors Management of Ectopic Pregnancy
 No sexual activity  Methotrexate
 Fetal monitoring by ultrasound  Salphingostomy via laparoscope
 Avoid stress  Laparoscopic salphingectomy
Management of Other Type Of Abortion Nursing Diagnosis
 Hospitalization  Alteration in Comfort; pain
 Oxytocin administration  Anticipatory grieving
 Completion curettage  Fluid volume deficit
 Prophylactic antibiotic Hydatidiform Mole (H-MOLE/MOLAR PREGNANCY)
 Analgesics Partial Mole
 Fluid/blood replacement  egg cell + 2 sperm cells
 Emotional support  Abnormal first meiotic division
NURSING DIAGNOSIS  With fetus
 Alteration in comfort; Pain Complete Mole
 Anticipatory Grieving  Empty egg + normal sperm
 Risk for Fluid Volume Deficit  Embryo dies at very early age
Ectopic Pregnancy  No embryonic tissues
Signs and Symptoms of H- Mole
Factors Causing Ectopic Pregnancy  Vaginal bleeding
 Pelvic Inflammatory Diseases  Uterine enlargement is bigger than usual
 Previous Ectopic Pregnancy pregnancy
 Increase HCG
  Hyperemesis gravidarum  Fetal death
 No FHT/fetal movement  Maternal factors
Management of H Mole MANAGEMENT OF PRETERM LABOR
 Suction evacuation  Bed rest
 Dilatation and Curettage  Avoid sexual contact
 Hysterectomy  Limit abdominal handling
 Methotrexate  Increase fiber in the diet
Placenta Previa  Treat underlying factors
 Implantation of the placenta at the lower  Tocolytic medications
uterine segment  Steroid
Risk Factors of Placenta Previa SIGNS AND SYMPTOMS
 Advance maternal age  Low back pain
 Multiparity  Suprapubic pressure
 Previous uterine surgery  Vaginal pressure
 Breech and Transverse position  Rhythmic uterine contraction
Signs and Symptoms of Placenta Previa  Cervical changes
 Painless bright red bleeding  Possible rupture of membrane
 Recurrent and heavier as pregnancy progress  Expulsion of cervical mucus plug
 No uterine contraction  Bloody show
ABRUPTIO PLACENTA
Risk Factors Causing Abruptio Placenta Missed Abortion:
 Maternal age  Retention of the conceptus in the uterus for a
 Previous history of abruptio placenta clinically appreciable time after death of the
 Multiparity embryo or fetus.
 Smoking
 Maternal hypertension (END OF SECOND PART)
 Abdominal trauma
Signs and Symptoms of Abruptio Placenta Second and third trimester disorders
 Concealed or visible bleeding
 Painful bleeding Cervical Incompetence
 Dark red bleeding  - the inability of the cervix to support a
 Board like abdomen pregnancy to term due to structural and or
 Fetal distress functional weakness.
 Tetanic contraction  - painless and bloodless cervical dilatation
Management of Abruptio Placenta  - premature cervical dilatation between 16 – 22
 Bed rest weeks
 Tocolytic Factors Causing IC
 Steroids FUNCTIONAL:
 Immediate Delivery  premature triggering of the normal mechanism
 Fluid and blood replacement of cervical dilatation and effacement.
Nursing Diagnosis of Abruptio Placenta  Induction of ovulation
 Altered Tissue Perfusion  3 or more prior fetal losses during the 2nd
 Fluid Volume Deficit trimester
 Risk for Infection CONGENITAL
 Anxiety/Fear  congenital or acquired
 Acute pain Congenital:
Complications of Abruptio Placenta  Weakness of the internal os
 Hypovolemic shock  Short hypoplastic cervix
 Intrauterine growth restriction  Bicornuate uterus
 Placenta accreta  Septate uterus
 Maternal Mortality  overzealous dilatation and curettage
 Fetal Mortality  cone biopsy
 Congenital Anomalies  cervical amputation
 difficult delivery
PRETERM LABOR  instrumentation
- Labor that begins after 20 weeks  infection
gestation and before 37 weeks PATHOPHYSIOLOGY: (NOT INCLUDED)
gestation DIAGNOSIS:
Etiology of Preterm Labor • Dilators or balloons
 Premature rupture of membrane • hysterosalpingograms
 Preeclampsia • Digital examination of the cervix
 Hydramnios • Sonography
 Placenta previa MANAGEMENT:
 Abruptio Placenta • Tocolytics
 Incompetent cervix • Bed rest
 Tauma • Hydration
 Uterine structual anomalies • Progesterone
 Multiple gestation • Trendelenburg position
 Infection • Antibiotics
NURSING DIAGNOSIS:  24hr Urine
• Anxiety  HELLP syndrome
• Risk for maternal injury  Hemolysis
• Risk for fetal injury  Elevated Liver function tests
• Knowledge Deficit  Low Platelet count
• Anticipatory grieving COMPLICATIONS:
 Eclamptic seizures
HYPERTENSIVE DISORDERS OF PREGNANCY  HELLP syndrome
RISK FACTORS:  Hepatic rupture
 FIRST PREGNANCY  DIC
 MULTIPLE GESTATION  pulmonary edema
 POLYHYDRAMNIOS  renal failure
 HYDATIDIFORM MOLE  placental abruption
 MALNUTRITION  cerebral hemorrhage
 FAMILY HISTORY  fetal demise
 VASCULAR DISEASE MANAGEMENT OF PIH:
TYPES OF PREGNANCY INDUCE HYPERTENSION  bed rest with or without BRP
 Gestational Hypertension  BP monitoring
 Preeclampsia  weight and urine checks
 Eclampsia  NST’s early
 Chronic Hypertension  US for IUGR
Superimposed Preeclampsia  IVF
Gestational Hypertension  Check for reflexes
* increased blood pressure  Antihypertensive drugs
- systolic pressure of more than 130mm/Hg  Anticonvulsant drugs
or +30mmHg from baseline  Steroids
- diastolic pressure of more than 90mmHg  Delivery of the baby
or +15mmHg from baseline MGSO4 THERAPHY
* edema  Loading dose IV 4-6 g/20min
PREECLAMPSIA  continued at 2 g/hr
 Hypertension or PIH  check for adverse effects
 Proteinuria  Respiratory rate<12/minute
 Edema (wt gain)  DTR of <1
MILD PREECLAMPSIA  Urine output<30cc/hour
 HYPERTENSION (140/90) POST-TERM PREGNANCY:
 PROTEINURIA>300mg/24 hrs  S&S
 MILD EDEMA,signaled by wt gain  Wt loss
(>2 lb/week or >6 lb/month)   uterine size
 URINE OUTPUT>500ml/24hrs  Meconium in AF
SEVERE PREECLAMPSIA  Risks
 Any of the following symptoms:   fetal mortality
 BP>160/110 (2X, 6hrs apart, bedrest)  cord compression
 Proteinuria.5g/24 hours (3+ or 4+ dipstick)  mec asp
 Massive edema  LGA  shoulder dystocia  CS
 Oliguria <400ml/24 hrs  episiotomy/laceration
 IUGR in fetus  depression
 Systemic symptoms  Treatment
SYSTEMIC SYMPTOMS:  fetal surveillance
 Pulmonary edema  NST, CST, BPP Q wk
 headache  mom monitors mvmt
 visual changes  Induction
 RUQ pain  Pitocin (10-20U/L) @ 1-2
 Liver Enzymes mU/min every 20-60 min
 Thrombocytopenia DISORDERS OF AMNIOTIC FLUID:
ECLAMPSIA:  Polyhydramnios
 Hypertension  S&S
 Proteinuria uterine dist
 Edema dyspnea
 Seizure edema of lower extr
CHRONIC HYPERTENSION SUPERIMPOSED  Treatment
PREECLAMPSIA therapeutic amniocentesis
 hypertensive disorders before pregnancy  Oligohydramnios
that progresses to preeclampsia  Risks
(NOT INCLUDED) cord compression
musculoskeletal deformities
LABORATORY WORK-UPS: pulmonary hypoplasia
 Blood--CBC, electrolytes, BUN, Creatinine  Treatment
 Liver function studies amnioinfusion
 Coagulation studies
PREMATURE RUPTURE OF MEMBRANES:  Treatment
 Premature rupture of membranes (PROM) is a o Tocolytics
rupture (breaking open) of the membranes o IV hydration
(amniotic sac) before labor begins. If PROM o bedrest
occurs before 37 weeks of pregnancy, it is called o steroids, if needed
preterm premature rupture of membranes o abx, if needed
(PPROM). NURSING CARE:
WHAT CAUSES PREMATURE RUPTURE OF  Assessment
MEMBRANES?  Thorough hx
 RUPTURE OF THE MEMBRANES NEAR THE END   bleeding
OF PREGNANCY (TERM) MAY BE CAUSED BY A   ROM
NATURAL WEAKENING OF THE MEMBRANES OR  BPP (for PROM)
FROM THE FORCE OF CONTRACTIONS. BEFORE  Teaching
TERM, PPROM IS OFTEN DUE TO AN INFECTION  Infection Control
IN THE UTERUS.  FMC
 OTHER FACTORS THAT MAY BE LINKED TO Fetal Risk: Pre-maturity, infection
PROM INCLUDE THE FOLLOWING:  *Prevention of infection
o LOW SOCIO ECONOMIC CONDITONS  Monitor temp
o SEXUALLY TRANSMITTED INFECTIONS:  Monitor amniotic fluid, you want white and
CHLAMYDIA AND GONORRHEA sticky – not black, green, smelly
o PREVIOUS PRETERM BIRTH  Antibiotic within 24 hours and have c-sect
o VAGINAL BLEEDING MANAGEMENT:
o CIGARETTE SMOKING DURING  Hospitalized – pre term, NICU, lungs, intubation
PREGNANCY (will be in NICU until Mother’s expected date of
o UNKNOWN CAUSES delivery)
In addition to a complete medical history and physical  Limit sterile vaginal exam
examination, PROM may be diagnosed in several ways,  Antibiotics
including the following:  Bed rest
 an examination of the cervix  Trendelenberg position- to get pressure off
 testing of the pH (acid or alkaline) of the fluid perineum
 looking at the dried fluid under a microscope  Daily CBC
 ultrasound - a diagnostic imaging technique FACTOR MATERNAL FETAL OR NEONATAL
which uses high-frequency sound waves and a IMPLICATIONS IMPLICATIONS
computer to create images of blood vessels,
tissues, and organs. Ultrasounds are used to
view internal organs as they function, and to Social and Poor antenatal Low birth weight
assess blood flow through various vessels. Personal care Intrauterine growth
Possible Nursing Diagnoses: Low income Poor nutrition restriction (IUGR)
 Risk for infection related to preterm rupture of level and/or ↑ risk
membranes without accompanying labor. low preecalmpsia
 Knowledge deficit. educational
 Anxiety related to outcome of labor. level
 Risk for fetal injury related to preterm birth.
Management: Poor diet Inadequate Fetal malnutrition
 bed rest either in the hospital or at home nutrition Prematurity
setting ↑ risk anemia
 monitor for signs of infection such as fever, ↑ risk of
pain, increased fetal heart rate, and/or preeclampsia
laboratory tests.
 giving the mother corticosteroids that may help Living at high ↑ hemoglobin Prematurity
mature the lungs of the fetus. altitude IUGR
 avoid vaginal exams to prevent introduction of ↑ hemoglobin
microorganisms (polycythemia)
 administer antibiotics
 administer tocolytics to stop preterm labor.
 prepare for possible immediate delivery. Factor Maternal Fetal & Neonatal
Premature Rupture of Membrane (PPROM – before 37 Implications Implications
weeks)
 Spontaneous ROM prior to onset of labor at the
end of 37 weeks [high risk]
 Full term = PROM [38 weeks] Multiparity ↑ risk antepartum Anemia
 S&S >3 or postpartum Fetal death
o contractions hemorrhage
o cramps
o backache Weight Poor nutrition IUGR
o diarrhea <45.5 kg Cephalopelvic Hypoxia associated
o vag d/c (100 lb) disproportion with difficult labor &
o ROM Prolonged labor birth
Weight ↑ risk ↓ fetal nutrition Factor Maternal Fetal/Neonatal
>91 kg hypertension ↑ risk macrosomia Implications Implications
(200 lb) ↑ risk
cephalopelvic
disproportion
↑ risk diabetes Anemia: Iron-deficiency Fetal death
hemoglobin <9 anemia Prematurity
g/dL (white) Low energy Low birth
Age <16 Poor nutrition Low birth weight
<29% level weight
Poor antenatal ↑ fetal demise
hematocrit ↓ oxygen-
care
(white) carrying
↑ risk
<8.2 g/dL capacity
preeclampsia hemoglobin
↑ risk
(black)
cephalopelvic
<26%
disproportion
hematocrit
Age >35 ↑ risk ↑ risk congenital (black)
preeclampsia anomalies Hypertension ↑ vasospasm ↓ placental
↑ risk cesarean ↑ chromosomal ↑ risk central perfusion→
birth aberrations nervous system low birth
irritability weight
→ convulsions Preterm birth
↑ risk
Factor Maternal Fetal/Neonatal cerebrovascular
Implications Implications accident
↑ risk renal
damage
Smoking one ↑ risk ↓ placental Thyroid disorder ↑ infertility ↑
pack/day or hypertension perfusion →↓ O2 spontaneous
more ↑ risk cancer and nutrients abortion
available
Low birth weight Hypothyroidism ↓ basal ↑ risk
IUGR metabolic rate, congenital
Preterm birth goiter, goiter
myxedema
Use of ↑ risk poor ↑ risk congenital Hyperthyroidism ↑ risk Mental
addicting nutrition anomalies postpartum retardation →
drugs ↑ risk of ↑ risk low birth hemorrhage cretinism
infection with IV weight ↑ risk ↑ incidence
drugs Neonatal withdrawal preeclampsia congenital
↑ risk HIV, Lower serum Danger of anomalies
hepatitis C bilirubin thyroid storm
↑ incidence
Excessive ↑ risk poor ↑ risk fetal alcohol
preterm birth
alcohol nutrition syndrome
↑ tendency to
consumption Possible hepatic
thyrotoxicosis
effects with
long-term
consumption
Factor Maternal Fetal/Neonatal
Preexisting ↑ risk Low birth weight
Implications Implications
Medical preeclampsia, Macrosomia
Disorders hypertension Neonatal
Diabetes Episodes of hypoglycemia
mellitus hypoglycemia ↑ risk congenital Renal disease ↑ risk renal ↑ risk IUGR
and anomalies (moderate to failure ↑ risk preterm
hyperglycemia ↑ risk respiratory severe) birth
↑ risk cesarean distress syndrome
birth Diethylstilbestrol ↑ infertility, ↑ spontaneous
(DES) exposure spontaneous abortion
Cardiac Cardiac ↑ risk fetal demise
abortion ↑ risk preterm
disease decompensation ↑ prenatal mortality
↑ cervical birth
Further strain
incompetence
on mother’s
body
↑ maternal
death rate
Obstetric ↑ emotional or ↑ risk IUGR Factor Maternal Fetal/Neonatal
Considerations psychological ↑ risk preterm Implications Implications
Previous distress birth
Pregnancy
Syphilis ↑ incidence ↑ fetal demise
Stillborn
abortion Congenital
syphilis
Habitual ↑ emotional or ↑ risk abortion
abortion psychological
distress
Abruptio ↑ risk Fetal or
↑ possibility
placenta and hemorrhage neonatal
diagnostic
placenta previa Bed rest anemia
workup
Extended Intrauterine
hospitalization hemorrhage
Cesarean birth ↑ possibility ↑ risk preterm ↑ fetal demise
repeat cesarean birth
birth ↑ risk Preeclampsia or See ↓ placental
respiratory eclampsia hypertension perfusion
distress → low birth
weight
Factors Maternal Fetal/Neonatal
Multiple ↑ risk ↑ risk preterm
Implications Implications
gestation postpartum birth
hemorrhage ↑ risk fetal
Rh or blood ↑ financial Hydrops fetalis
↑ risk preterm demise
group expenditure for Icterus gravis
sensitization testing Neonatal anemia labor
Kernicterus
Hypoglycemia Elevated Increased Fetal death rate
hematocrit viscosity of 5 times normal
Large baby ↑ risk cesarean Birth injury >41% (white) blood rate
birth Hypoglycemia >38% (black)
↑ risk
gestational Spontaneous ↑ uterine ↑ risk preterm
diabetes premature infection birth
Current Congenital heart rupture of membranes
Pregnancy disease
Rubella (first Cataracts
trimester) Nerve deafness
Bone lesions MONITORING FETAL WELL-BEING
Prolonged virus • Early US for accurate gestational dating
shedding • US if macrosomia is suspected
• amniocentesis for fetal lung maturity
Rubella (second Hepatitis
• antepartum NST weekly p. 34 wks
trimester) Thrombocytopenia
PREGNANCY CATEGORY OF MEDICATIONS:
Cytomegalovirus IUGR • Category A--safe (vitamins)
Encephalopathy • Category B--no animal effects (penicillin)
• Category C--no studies available
Herpes virus Severe Neonatal herpes • Category D--evidence of risk but benefits
type 2 discomfort virus type 2 outweigh the risks
Concern about 2% hepatitis with • Category X--risks outweigh benefits
possibility of jaundice
cesarean birth, Neurologic (END OF 3RD PRESENTATION)
fetal infection abnormalities
NURSING CARE OF THE CLIENT WITH HIGH RISK LABOR
& DELIVERY AND HER FAMILY

ESSENTIAL FACTORS IN LABOR:

1. PASSENGER
a. FETUS-
b. PLACENTA
2. PASSAGEWAY
3. POWERS
a. primary power
b. secondary power
4. POSITION OF THE MOTHER
5. PSYCHE
PROBLEMS WITH THE PASSENGER THE FONTANELLES
PASSENGER:
• FETUS
o fetal skull
o fetal body size
o fetal presentation
o fetal position
o fetal lie

ANTEROPOSTERIOR DIAMTERE:
MOULDINGS:

MEMBRANE SPACES

Synclitism & Asynclitism:

• Asynclitic refers to a fetal head that is not

parallel to the anteroposterior plane of the
pelvis.
• The head is synclitic when the sagittal suture
lies midway between the symphysis pubis and
the sacral promontory.

FETAL MALPOSITION
Persistent Occiput Posterior
 fetus enters the birth canal, descends, and is
delivered in occiput posterior position
 fetus is facing up instead of facing down as it
enters the vagina
Transverse Occiput Arrest
 baby is head-down but the head is turned
completely sideways towards the mother’s
hipbone, causing baby to ‘arrest’ (get stuck)
because it doesn’t fit well.
Factors Causing POP
 lack of rotation due to poor contraction
 abnormal flexion of the head
 incomplete rotation
 inadequate maternal pushing effort
 epidural anesthesia
 large baby
Risk of Fetal Malposition
 prolonged labor
 third to fourth degree perineal lacerations
 extension of midline episiotomy
 forceps/vacuum assisted or caesarean delivery
Management of Fetal Malposition
 monitoring on fetal and maternal status
 cesarean birth if necessary
 Scanzoni’s maneuver
 Forceps assisted
 Vacuum assisted
 Regional anesthesia
FETAL MALPRESENTATION
VERTEX MALPRESENTATION
1. BROW PRESENTATION
2. FACE PRESENTATION
Risk of Brow Presentation
 longer labor
 ineffective contraction
 slow or arrest fetal descent
 cesarean delivery
 neonatal neck and cerebral compression
 damage to the neonatal larynx and trachea
 neonatal facial edema and bruises
Management of Brow Presentation
 monitor for CPD
 left or right mediolateral episiotomy
 cesarean delivery
Risk of Face Presentation
 increase risk of CPD
 prolongation of labor
 increase risk of infection
 Cesarean birth
 neonatal cephalhematoma
 edema of neonatal face and throat
 pronounced molding
Management of Face Presentation
 vaginal birth may be anticipated if not CPD,
reassuring fetal heart pattern, and labor pattern
is effective
 cesarean birth if mentum remains posterior
Risk of Breech Presentation
 higher perinatal morbidity and mortality rate
 cord prolapsed
 neonatal cord injury due to hyperextension
 birth trauma especially the head
Management of Breech Presentation
 external cephalic version at 36 – 38 weeks or
prior to labor
 method of delivery depends on:
 gestational age
 presence of other fetuses
 EFW
 types of breech presentation
 and physician’s preferences
Shoulder Presentation
Fetus is in a transverse lie
ETIOLOGY OF FLUPP
Fetal
 prematurity
 multiple
 anomalies: often those that restrict the ability
of the fetus to assume a vertex presentation
 major malformation:hydrocephaly,
anencephaly, meningomyemocoele
 most common malformation:congenital
dislocation of the hip
Liquor
 oligohydramnios/polyhydramnios
Uterine
 anomalies (bicornuate, fibroid)
Placenta
 Previa
Pelvis
 contracture, pelvic tumors obstructing birth
canal
Management of Shoulder Presentation
 expectant – fetus may change presentation
without intervention if discovered before term
 external cephalic version if evident at 37 weeks
 cesarean delivery if unsuccessful
Compound Presentation  Amnionitis
There are two presenting part  Maternal Hyperthyroidism
COMPOUND:  Fetal Anemia
• baby's hand presents alongside its head Fetal Bradycardia
(sometimes called a 'nuchal hand'), making a  late/profound fetal hypoxia
larger size that has to go through the pelvis;  Maternal Hypotension
many of the same symptoms as other  Umbilical cord compression
malpositions.  Vagal Stimulation
• One other variation of this is when the baby's  Fetal Arrhythmia
arm or elbow is across its face ('nuchal arm'),  Uterine hyperstimulation
which can cause intense pain.
 Abruptio Placenta
• A baby can be born with a nuchal hand
 Uterine Rupture
alongside its head, although the process is
Variability
usually slow.
 a measure of interplay (push-pull effect)
VERSION:
between the sympathetic and parasympathetic
• Turning of the fetus.
nervous system
• is a procedure used to change the fetal
 two abnormal variability:
presentation by abdominal or intrauterine
manipulation.  Decreased variability
External Cephalic Version (ECV)  Increased variability
 most common wherein the fetus is changed Decreased Variability
from a breech to a cephalic presentation  Hypoxia
Podalic Version-  Acidosis
 less common type  CNS depressant agents
 used only with the 2nd fetus during a vaginal  Fetal sleep
twin birth and only if the twin does not descend  < 32 weeks fetus
readily or if the heart rate is non-reassuring.  Fetal anomalies
 medication is used to relax the uterus  Previous neurologic insult
 The OB places a hand inside the uterus, grabs  Tachycardia
the fetus’s feet and draws them down thru the Increased Variability
cervix.  Early mild hypoxia
Contraindications of Versions:  Fetal stimulation or activity
 3rd trimester bleeding  Alteration in placental blood flow
 uterine anomalies Fetal Heart Acceleration
 ROM, oligohydramnios  tansient increase of FHT normally caused by
 need for CS for other reasons (placenta previa, fetal movements
contracted pelvis, hyperextended head)  indicates fetal well being
 indicated vaginal delivery (fetal death)  no accelerations is an ominous sign
Fetal Heart Deceleration
(END OF 4TH PART)  periodic decrease of FHT from its baseline rate
 three types:
FETAL DISTRESS o Early deceleration
 Compromise of the fetus during the antepartum o Late deceleration
period or intrapartum period o Variable deceleration
 Fetal hypoxia (NOT INCLUDED) – 3 types

Criteria in Determining Signs of Fetal Distress Fetal Movements

 Fetal Heart Rate:  at least 10x in 3 hours
 Baseline rate  affected by:
 Variability o fetal sleep
 Accelerations of Fetal Heart rate Decelerations o sound
 Fetal Movements/Activities o time of day
 Meconium Staining o blood glucose level
 Fetal Stimulation o cigarette smoking
 Fetal Scalp Blood Sampling o Drugs
 Fetal Oxygen Saturation o Oxygenation status
Fetal Heart Rate  less than 10 movements in 3 hours or absent
A. Baseline Rate movement are ominous
 average FHR observed during a 10-minute (MECONIUM STAINING – NOT INCLUDED)
period of monitoring
 normal rate ranges from 110 – 160 bpm Fetal Stimulation
 two abnormal baseline:  fetus should response by fetal heart
o Fetal tachycardia accelerations
o Fetal Bradycardia o Fetal scalp stimulation
Fetal Tachycardia  applying pressure to fetal scalp by
 early fetal hypoxia gently stroking or massaging it for 15
 Maternal fever seconds while doing vaginal
 Maternal Dehydration examination
 Beta-sympathomimetic drugs o Vibroaccoustic stimulation
Fetal Blood Scalp Sampling
 acid-base status of fetus
 must be done when:
o RBOW
o 2-3 cms cervical dilatation
o station -2 and below
 must not done when:
o FHR pattern are ominous
o acute emergencies
o vaginal bleeding
 normal during labor is above 7.25 pH
 pH 7.2 – 7.25 is borderline
 below 7.2 is non reassuring and necessitate
birth SIGNS:
Fetal Oxygenation Saturation (FSpO2) Ill-fitting or non-engaged presenting
 40% - 70% are considered reassuring part
 30% - 40% mild acidosis and requires Prolapsed umbilical cord
continuous monitoring umbilical cord visualized in
 below 30% indicates hypoxia and requires vagina or at vulva
immediate birth umbilical cord palpated on
Factors Causing Fetal Distress pelvic exam
 Breathing problems Fetal distress on Fetal Heart Tracing
 Abnormal position and presentation of the May follow rupture of
fetus membranes
 Multiple births PROGNOSIS:
 Shoulder dystocia High perinatal mortality for delayed delivery
 Umbilical cord prolapse >40 min
 Nuchal cord RISK FACTORS:
 Placental abruption Premature rupture of the amniotic sac
 Premature closure of the fetal ductus Polyhydramnios
arteriosus Long umbilical cord
Fetal Distress Management Fetal malpresentation
 continuous fetal monitoring Multiparity
 Oxytocin if indicated Multiple gestation
 discontinue oxytocin if with prolonged late Placenta previa
decelerations Intrauterine tumors
 intrauterine fetal resucitations: A small fetus
 left lateral position CPD
 Oxygen administration DIAGOSTICS:
 Hydration A pelvic examination can also be conducted by a
 fetal stimulation physician and may see the prolapsed cord, or
 prepare for immediate delivery palpate (feel) the cord with the fingers.
NURSING DIAGNOSIS: Cardiotocograph ( Electronic Fetal Monitoring)
 Decreased Cardiac Output (fetal) Ultrasound
 Impaired Gas Exchange (fetal) (PATHOPHYSIOLOGY – NOT INCLUDED)
 Ineffective Tissue Perfusion (fetal) NURSING DIAGNOSIS:
 Risk for fetal injury Impaired Gas Exchange (fetal)
 Anxiety (maternal) Risk for Injury (fetal)
 Deficient Knowledge (maternal) Fear (maternal)
UMBILICAL CORD PROLAPSE Anxiety (maternal)
A rare, obstetrical emergency that occurs when Deficient Knowledge (maternal)
the umbilical cord descends alongside or Umbilical Cord Prolapse Management
beyond the fetal presenting part.  Initial management of cord prolapse in hospital
TYPES OF UMBILICAL CORD PROLAPSE: setting:
Overt Prolapse • immediate delivery
Refers to protrusion of the cord • minimal handling of loops of cord lying outside
in advance of the fetal the vagina.
presenting part, often through To prevent cord compression, the presenting part MUST
the cervical os and into or BE elevated:
beyond the vagina. • knee–chest position or head-down
Occult Prolapse • tilt (preferably in left-lateral position).
Occurs when the cord descends • Tocolysis
alongside, but not past, the Optimal mode of delivery with cord prolapse:
presenting part. • category 1 caesarean section
• Category 2 caesarean section
Vaginal birth, in most cases operative,
can be attempted at full dilatation
A practitioner competent in the
resuscitation of the newborn should
 attend all deliveries with cord
prolapse.
Management in community setting:
• assume the knee–chest face-down position
while waiting for hospital transfer.
• Transport woman to nearest consultant-led
institution
• Left lateral position during transport
• Elevate presenting part
UMBILICAL CORD ABNORMALITIES
• Velamentous insertion of the cord
• Umbilical cord compression
• Umbilical cord prolapse
• Hypercoiling of the cord
• Cord Coil
Velamentous Insertion of the Cord
• Condition where the umbilical cord joins the
placenta at the edge, rather than the typical
insertion in the center.
PROBLEMS WITH THE PASSAGEWAY
CEPHALOPELVIC DISPROPORTION
 Disproportion of fetal head and mother’s pelvis
CAUSES:
 increased fetal weight
 fetal position
 problems with the pelvis
 problems with the genital tract
S/S:
• the delivery of the baby is obstructed
• The labor is prolonged
(PATHOPHYSIOLOGY – NOT INCLUDED)
DIAGNOSTICS:
Estimation of the size of the pelvis:
Clinical Pelvimetry
Radiologic Pelvimetry
Estimation of fetal size
MANAGEMENT:
 CESAREAN SECTION
NURSING DIAGNOSIS:
• Anxiety
• Fatigue
• Risk for fetal injury
• Risk for impaired skin integrity
• Situational low self- esteem
INTERVENTIONS:
• Monitor heart sounds and uterine contractions
continuously, if possible, during trial labor.
• Urge the woman to void every 2 hours s
• Assess FHR carefully
• Establish a therapeutic relationship, conveying
empathy and unconditional positive regard
• Instruct in methods to conserve energy
• Massage bony prominences gently and change
position on bed in a regular schedule
• Convey confidence in client’s ability to cope
with current situation
SHOULDER DYSTOCIA:
 Incidence: about 0.2–1%.
 This is one of the most frightening obstetric
emergencies
 It occurs when the fetal shoulders fail to negotiate
the pelvic inlet
 Prompt (but not forcible) action is required to
prevent fetal
 morbidity or mortality (see Stirrat and Taylor in
‘Further reading’)
Antenatal risk factors
• Mother’s birthweight >90th centile
• Maternal obesity or massive weight gain
• Diabetes mellitus—can be despite seemingly
good blood sugar
control
• Prolonged pregnancy (beyond 42 completed
weeks)
• Previous shoulder dystocia (10% risk of
recurrence) or large baby
• Recognized macrosomia this pregnancy.
PROBLEMS WITH THE POWERS
DYSTOCIA:
General information:
 Any labor or delivery that is prolonged and
difficult.
 Usually results form a change in the
interrelationships among the
5 Ps (factors in labor and delivery):
 >passenger
 >passage
 >powers
 >placenta
 >psyche of mother.
Cesarean birth is needed if disproportion is
great.
Problems with presentation: any
presentation unfavorable for delivery (e.g.
breech, shoulder , face, transverse lie.
Posterior presentation that does not rotate
or cannot be rotated with ease.
1. Problems with maternal soft tissue
 A full bladder may impede the progress of labor,
as can myomata uteri, cervical edema, scar
tissue, and congenital anomalies.
 Emptying the bladder may allow labor to
continue; the other conditions may necessitate
caesarean birth.
2. Dysfunctional uterine contractions
 Contraction may be too weak, too short, too far
apart, ineffectual
 Classification
A.) Primary: inefficient pattern present from
beginning of labor; usually prolonged latent phase.
B.) Secondary: efficient pattern that changes to efficient
or stops; may occur in any stage.
Assessment findings:
 Progress of labor is slower than expected rate
of dilatation, effacement, descent for specific
client.
 Length of labor prolonged; prolonged latent
phase (>20 hrs in nullipara pt. or >4 h in a
multipara pt), protacted active phase dilatation
np. <1-2cm, mp <1.5cm; protacted descengt <1
cm per hr change in station in the nullipara pt.
or <2 cm per hour in the mp pt.
 Maternal exhaustion/ distress
 Fetal distress
 Arrest of descent: no progress in fetal station
greater than 1 hour
Nursing intervention:
 Individual as to cause
 Provide comfort measures for client
 Provide client, supportive descriptions of all
actions taken
 Administer analgesia if ordered
  Monitor mother/ fetus continuously Powerlessness
Pathophysiology: (DIAGRAM NOT INCLUDED)  Provide rest period
 Relaxation technique
PREDISPOSING FACTORS:  Support person
• Genetic Deficient knowledge related to measures that can be
• Overweight used to enhance labor and facilitate birth.
• Multiple gestation  Teach proper breathing techniques used during
• Hydramnios labor
• Maternal fatigue  Educate about the complication of the delivery
• Pelvic malformation  Explain client that caesarean is necessary due to
• Inappropriate timing of analgesic and difficult labor.
anaesthetic administration Ineffective individual coping related to inadequate
• Gestational DM support system.
• STDs  Support mechanism:
• Other diseases  Stay with the patient during labor process
PRECIPITATING FACTORS:  Encourage patient to discuss about her
• Malpresentation and malposition of the fetus condition
• Congenital malformation of the uterus
• Over stimulation with oxytocin DYSFUNCTIONAL LABOR:
• CPD • Possible Causes:
• Fetal anomalies such as neural tube defects, • Catecholamines (response to
large tumor, and gross ascites anxiety/fear), increase
Signs/ symptoms: physical/psychological stress, leads to
 Pain myometrial dysfunction; painful &
 Increase heart rate, pulse, body temp. ineffective labor.
 Increased BP • Premature or excessive analgesia,
 Diaphoresis particularly during latent phase.
 Body weakness • Maternal factors.
 Exhausted appearance • Fetal factors.
 SOB • Placental factors.
 Nasal flaring • Physical restrictions (position in bed).
 Anxiety ASSESSMENT:
 Restlessness • Antepartal history.
 Vaginal hemorrhage • Emotional status.
Medical Management: • Vital signs, FHR.
1. Treatment for contraction abnormalities • Contraction pattern (frequency, duration,
involves stimulation of labor through the use of intensity).
oxytocin. An intrauterine pressure catheter may • Vaginal discharge.
be used. GOAL = to minimize physical/psychological stress during
2. Management for maternal passageway or fetal labor/birth. Emotional support.
passage problems involves delivery in the safest
manner for the mother and fetus. DYSFUNCTIONAL LABOR PATTERN:
 If the problem is related to the inlet or • Hypertonic labor
midpelvis, a CS delivery is indicated. • Hypotonic labor
 If the size of the outlet is the problem, a • Precipitate labor level
forceps or vacuum extraction maybe HYPERTONIC DYSFUNCTION:
perform. • Increased resting tone of uterine myometrium;
Surgical Management: diminished refractory period; prolonged latent
1. Caesarean in necessary for delivery of the fetus phase.
• Nullipara: more than 20 hours.
NURSING DIAGNOSIS: • Multipara: more than 14 hours.
Acute pain related difficulty in labor. • Etiology: unknown. Theory – ectopic initiation
Promoting comfort: of incoordiante uterine ctx.
 Relaxation technique such as breathing • Assessment:
techniques during labor • Onset (early labor)
 Changing position • Contractions:
 Support person • Continuous fundal tension,
 Pain medications incomplete relaxation.
Anxiety related to threat of change in health status of • Painful.
self and fetus. • Ineffectual – no effacement or
Decreasing anxiety: dilation.
 Give brief explanation to the women about the • Signs of fetal distress:
nature of contraction associated with induce • Meconium-stained fluid.
labor • FHR irregularities.
 Provide anticipatory guidance regarding use of • Maternal VS.
meds, procedures and equipment. • Emotional status.
 Prepare for caesarean if necessary • Medical evaluation: to rule out CPD.
• Vaginal examination, x-ray
pelvimetry, ultrasonography.
INTERVENTIONS:
• Short-acting barbiturates (to encourage rest,
relaxation).
• IV fluids (to restore / maintain hydration &
fluid-electrolyte balance).
• If CPD – c/s.
• Provide emotional support.
• Provide comfort measures.
• Prevent infection (strict aseptic technique).
• Prepare patient for c/s if needed.
HYPOTONIC DYSFUNCTION:
• After normal labor at onset, ctx diminish in
frequency, duration, & strength.
• Lowered uterine resting tone; cervical
effacement & dilation slow / cease.
• Etiology:
• Premature or excessive analgesia /
anesthesia (epidural, spinal block).
• CPD.
• Overdistention (hydramnios, fetal
macrosomia, multifetal pregnancy).
• Fetal malposition / malpresentation.
• Maternal fear / anxiety.
• Assessment:
• Onset (latent phase & most common in
active phase).
• Contractions - normal previously, will
demonstrate:
• Decreased frequency.
• Shorter duration.
• Diminished intensity (mild to
moderate).
• Less uncomfortable.
• Cervical changes – slow or cease.
• Signs of fetal distress – rare.
• Usually late in labor d/t
infection secondary to
prolonged ROM.
• Tachycardia.
• Maternal VS (elevated temperature) –
may indicate infection.
• Medical diagnosis – procedures: vaginal
examination, x-ray pelvimetry,
ultrasonography. To rule out CPD (most
common cause).
• Management:
• Amniotomy (artificial ROM).
• Oxytocin augmentation of labor.
• If CPD, prepare for c/s.
• Emotional support, comfort measures,
prevent infection.
PRECIPITATE LABOR:
• Labor that progresses rapidly and ends with the
delivery occurring less than 3 hours after the
onset of uterine activity.
• Rapid labor and delivery.
PRETERM LABOR:
 -Labor that occurs before the end of the thirty-
seventh week of gestation. It occurs
approximately 9%- 11% of pregnancies. Any
woman having persistent uterine contractions
(4 very 20 min) should be considered to be in
labor. A woman is documented as being in
actual labor rather than having false labor
contractions if she is having uterine
contractions that cause cervical effacement
over 80% and dilation over 1cm.
 -Preterm labor is always serious because if it
results in infant’s birth, the infant may be
immature.
ASSESSMENT:
During tocolytic therapy, assess the following:
• Fetal status by electronic fetal monitoring
• Uterine activity pattern
• Respiratory status
• Muscular tremors
• Palpitations
• Dizziness
• Lightheadedness
• Urinary output
• Patient education to S/Sx of PTL
• Patient education to S/Sx of infection
RISK FACTORS:
• Race: African-American women
• Age: Adolescents
• Those with inadequate prenatal care
• Those who continue to work at strenuous jobs
during pregnancy
• Those who have shift works that leads to
extreme fatigue
Signs and Symptoms:
• Persistent, dull, low backache
• Vaginal spotting
• A feeling of pelvic pressure (abdominal
tightening)
• Menstrual-like cramping
• Vaginal discharges
• Uterine contractions
• Intestinal cramping
• Feeling that baby is “pushing down” or that
“something” is in the vagina
Nursing Diagnosis & Interventions:
 Anxiety r/t medication and fear of outcome of
pregnancy
 Know the C/I and potential complications of
tocolytic therapy
 Explain the purpose and common A/E of
tocolytic therapy
 Provide accurate information on the status of
the fetus and labor (contraction pattern).
 Allow the woman and her support person to
verbalize their feelings regarding the episode of
PTL and the treatment.
 If a private room is not used, do not place the
woman in a room with a woman who is in labor
or who has lost an infant.
Situational Low Self-Esteem r/t Inability to carry
pregnancy
 Provide support persons because she is apt to
be more concerned than the average person
about labor.
 Encourage expression of feelings and anxieties
to facilitate coping with actual situation.
 Provide frequent assurance during labor that
she is breathing well with contractions and
continue until postpartum period because she
may not be mentally prepared for the labor
because it has come unexpectedly.
 Comment on strengths of the family unit.
 Convey confidence in client’s ability to cope
with current situation.
Risk for Fetal Injury r/t Preterm Birth
 Monitor fetal status and labor problems.
 Assess WBC count frequently. A count of
18,000-20,000/mm3 suggests infection.
  Reassure misconceptions about difficulty of
labor after preterm rupture of the membranes
(dry labor) since amniotic fluid is always being
formed so there is no such thing as dry labor
 Encourage the woman to assume positions that
will enhance placental perfusion.
 Assist with delivery of infant as needed.
Risk for Injury Secondary to Tocolytic therapy
 Maintain accurate I/O at least every hour. Limit
intake to 2,500mL/day.
 Assess maternal VS.
 Notify Physician if maternal pulse is greater
than 120 bpm.
 Assess for S/Sx of pulmonary edema.
 Educate woman on tocolytic therapy, explaining
the purpose and common A/E.
Compromised Family Coping Secondary to
Hospitalization
 Encourage private time for woman and partner.
 Encourage family members to verbalize feelings
openly and clearly.
 Allow visitation with other children as tolerated
by the woman.
 Comment on strengths of the family unit.
 Promote assistance of family in providing client
care as appropriate.
Medical Management:
• Antibiotics
• Prostaglandin Inhibitors
 Indomethacin (Indocin)
• Calcium Channel Blockers
 Nifepidine (Procardia)
• Corticosteriods
 Betamethazone 12 mg IM q 24 hrs 2
doses
 Dexamethazone 6 mg IM q 12 hrs 4
doses
• Magnesium sulfate
• Beta-sympathomimetic drugs
 Ritodrine hydrochloride (yutopar)
 Terbutaline (brethine)
Surgical Management:
 Cesarean Section
NURSING MANAGEMENT:
• Hydration (Oral or IV)
• Bedrest (Home or Hospital), usually left side
lying
• Medications to stop labor (Magnesium sulfate,
brethine, terbutaline, etc.)
• Medication to help prevent infection (More
likely if your membranes have ruptured or if the
contractions are caused by infection)
• Evaluation of your baby. Biophysical profile,
non-stress or stress tests
• Medications to help your baby's lung develop
more quickly
Preconception Care
 Baseline assessment of health and risks with
advice to decrease the risks attributable to
preterm labor/PTB.
 Pregnancy planning and identification of
barriers to care.
 Adjustment of prescribed and OTC that may
pose a threat to the developing fetus.
 Advise to improve maternal nutrition.
 Screening for and treatment of diseases.
 Genetic counseling for those with a history of
genetic disease/ a previously affected
pregnancy.
Antepartum Treatment
 Educate mother regarding S/Sx of PTL.
 Instruct mother and provide resources for
lifestyle modifications.
o If mother smokes, encourage smoking
cessation classes.
o Ensure mother has a healthy diet and
adequate maternal weight gain during
pregnancy.
 Initial treatment for a patient who is at risk for
PTL is the use of bed rest in a left lateral
position with continuous monitoring of fetal
status and uterine activity.
 Hydration with IV fluids, with careful
assessment of I/O and auscultation of lungs to
assess for the development of pulmonary
edema.
 If this stops the contractions, tocolytic therapy
is not needed.
(PATHOPHYSIOLOGY – NOT INCLUDED)
UTERINE PROLAPSE (Uterine Prolapse/Pelvic
relaxation/Pelvic floor hernia)
• a descent or herniation of the uterus into or
beyond the vagina
• considered under the broader heading of
"pelvic organ prolapse" which also includes
cystocele, urethrocele, enterocele, and
rectocele.
• anatomically, the vaginal vault has 3
compartments:
 an anterior compartment (consisting of the
anterior vaginal wall)
 - a middle compartment (cervix)
 posterior compartment (posterior vaginal
wall).
• UP involves the middle compartment
Four stages of uterine prolapse are defined:
stage I - descent of the uterus to any point in
the vagina above the hymen
stage II - as descent to the hymen
stage III - as descent beyond the hymen
stage IV - as total eversion or procidentia
∆ Uterine prolapse always is accompanied by
some degree of vaginal wall prolapsed.
ASSESSMENT:
• A complete pelvic examination is required,
including a rectovaginal examination to assess
sphincter tone.
• A Sims speculum or a standard bivalve
speculum with the anterior blade removed may
facilitate diagnosis.
• Physical findings may be enhanced by having
the patient strain during the examination or by
having her stand or walk prior to examination.
Standing with an empty bladder may result in a
1-2 stage difference in the degree of prolapse
noted on examination when compared to a
supine position with a full bladder.
• Mild uterine prolapse may be recognized only
when the patient strains during the bimanual
examination.
• Evaluate all patients for estrogen status.
• Signs of decreased estrogens
 • Loss of rugae in the vaginal o + colpopexy - involves the use of
mucosa surgical mesh for supporting the uterus
• Decreased secretions o + hysterectomy – removal of uterus
• Thin perineal skin NURSING MANAGEMENT:
• Easy perineal tearing • preventive measures:
• Physical examination should also be directed  Early visits to HC provider = early
toward ruling out serious conditions that may detection
rarely be associated with uterine prolapse, such  Teach Kegel’s exercises during PP
as infection, urinary outflow obstruction with period
renal failure, and hemorrhage. • preoperative nursing care:
• If urinary obstruction is present, the  Thorough explanation of procedure,
patient may exhibit suprapubic expectation and effect on future sexual
tenderness or a tympanitic bladder. f(x)
• If infection is present, purulent cervical  Laxative and cleansing edema
discharge may be noted. (rectocele) – independently, at home a
LABORATORY STUDIES: day prior procedure
• Laboratory studies are unnecessary in  Perineal shave prescribed also
uncomplicated cases….  Lithotomy position for surgery
• Cervical cultures - cases complicated by • postop nursing care:
ulceration or purulent discharge  Pt. is to void few hours after surgery;
• Papanicolaou test (Pap smear cytology) or catheter if unable (after 6 hrs)
biopsy - in rare cases of suspected carcinoma NURSING DIAGNOSIS:
• BUN and creatinine measurement - if PE PAIN
findings suggest urinary obstruction o Administer analgesic as prescribed.
IMAGING STUDIES: o Provide comfort measures such as backrub.
• Pelvic ultrasound examination o Provide diversional activities such as guided
• Ultrasonography
imagery and socialization.
• MRI - to grade pelvic organ prolapse
SIGNS AND SYMPTOMS: CONSTIPATION
• Pelvic heaviness or pressure o Administer stool softeners/laxatives as
• Protrusion of tissue: A patient who reports of a prescribed.
"bulge" has been found to be a valuable o Encourage increase in fluid and fiber intake.
screening tool for the detection of pelvic organ o Encourage early ambulation.
prolapse (81% PPV, 76% NPV).
• Pelvic pain URINARY INCONTINENCE
• Sexual dysfunction, including dyspareunia, o Determine if client is aware of incontinence.
decreased libido, and difficulty achieving Developmental issues/ medical conditions
orgasm that can impair patient’s awareness and
• Lower back pain sensory perception of voiding.
• Constipation o Determine patient’s particular symptoms
• Difficulty walking (e.g. continuous dribbling).
• Difficulty urinating o Implement bladder training for
• Urinary frequency incontinence management by providing
• Urinary urgency ready acces to bathroom or commode,
• Urinary incontinence encouraging adequate fluid intake, and
• Nausea establishing voiding/bladder emptying.
• Purulent discharge (rare)
• Bleeding (rare) SEXUAL DYSFUNCTION
• Ulceration (rare) o Provide factual information about individual
(PATHOPHYSIOLOGY NOT INCLUDED) condition involved to promote informed
decision making.
COMPLICATIONS: o Provide for ways to obtain privacy to allow
• Urinary retention for sexual expression for individual and/or
• Constipation between partners with out embarrassment
• Hemmorhoids and/or objection of others.
• Cervical ulceration o Establish therapeutic nurse-client
• Infection (possible) relationship to promote treatment and
• Cystitis facilitate sharing of sensitive information.
TREATMENT/MEDICAL MANAGEMENT: RISK FOR INFECTION
• Pessaries o Observe for localized signs of infection.
o + fitted into the vagina to hold the o Note for signs and symptoms for sepsis.
uterus in place o Stress proper hand hygiene.
o + temporary or permanent form
o + fitted individually for each woman UTERINE RUPTURE
o + attaining and maintaining optimal spontaneous or traumatic rupture of the uterus
weight is recommended ie., the actual separation of the uterine
• Surgery myometrium/ previous uterine scar, with
o + uterus sutured back into place & rupture of membranes and extrusion of the
fetus or fetal parts into the peritoneal cavity.
 Dehiscence - partial separation of the old
uterine scar;
- the fetus usually stays inside the uterus and
the bleeding is minimal when dehiscence
occurs.
RISK FACTORS:
• Women who have had previous surgery on the
uterus (upper muscular portion)
• Having more than five full-term pregnancies
• Having an overdistended uterus (as with twins
or other multiples)
• Abnormal positions of the baby such as
transverse lie.
• Use of Pitocin (oxytocin) and other labor-
induced medications (prostaglandin)
• Rupture of the scar from a previous CS
delivery/hysterectomy.
• Uterine/abdominal trauma
• Uterine congenital anomaly
• Obstructed labor; maneuvers within the uterus
• Interdelivery interval (time between deliveries)
(PATHOPHYSIOLOGY NOT INCLUDED)
ASSESSMENT:
evaluate maternal vital signs
note an increase in rate and depth of
respirations, an increase in pulse , or a drop in
BP indicating status change
assess fetal status by continuous monitoring
speak with family, and evaluate their
understanding of the situation
observe for signs and symptoms of impending
rupture
-lack of cervical dilatation
-tetanic uterine contractions
restlessness
anxiety
severe abdominal pain
fetal bradycardia
late or variable decelerations of the
FHR)
SIGNS AND SYMPTOMS:
CLINICAL MANIFESTATIONS:
Developing Rupture
Abdominal pain and tenderness
Uterine contractions will usually continue but
will diminish in intensity and tone.
Bleeding into the abdominal cavity and
sometimes into the vagina.
Vomiting
Syncope; tachycardia; pallor
Significant change in FHR characteristics –
usually bradycardia (most significant sign)
Violent Traumatic Rupture
Sudden sharp abdominal pain during or
between contractions.
Abdominal tenderness
Uterine contractions may be absent, or may
continue but be diminished in intensity and
cord
bleeding vaginally, abdominally, or both
Fetus easily palpated in the abdominal with
shoulder pain
Tenses, acute abdominal with shoulder pain
Signs of shock
Chest pain from diaphragmatic irritation due to
bleeding into the abdomen.
NURSING DIAGNOSIS WITH INTERVENTIONS:
DEFICIENT FLUID VOLUME:
 Start or maintain an IV fluid as prescribed. Use a
large gauge catheter when starting the IV for
blood and large quantities of fluid replacemnt.
 Maintain CVP and arterial lines, as indicated for
hemodynamic monitoring.
 Maintain bed rest to decrease metabolic
demands.
 Insert Foley catheter, and moniter urine output
hourly or as indicated.
 Obtain and administer blood products as
indicated.
FEAR
 Give brief explanation to the woman and her
support person before beginning a procedure.
 Answer questions that the family or woman
may have.
 Maintain a quiet and calm atmosphere to
enhance relaxation.
 Remain with the woman until anesthesia has
been administered; offer support as needed.
 Keep the family members aware of the situation
while the woman is in surgery and allow time
for them to express feelings.
DECREASED CARDIAC OUTPUT
 Administer supplemental oxygen, blood/fluid
replacement, antibiotics, diuretics, inotropic
drugs, antidysrhythmics, steroids,
vassopressors, and/or dilators as ordered.
 Position HOB flat or keep trunk horizontal while
raising legs 20 to 30 degrees in shock situation
 Activities such as isometric exercises, rectal
stimulation, vomiting, spasmodic coughing
which may stimulate Valsalva response should
be avoided; administer stool softener as
indicated.
INEFFECTIVE TISSUE PERFUSION
 Administer O2 using a face mask at 8-12 L/min
or as ordered to provide high oxygen
concentration.
 Apply pulse oximeter, and monitor oxygen
saturation as indicated.
 Monitor ABG levels and serum electrolytes as
indicated to assess respiratory status, observing
for hyperventilation and electrolyte imbalance.
 Continually monitor maternal and fetal vital
signs to assess pattern because progressive
changes may indicate profound shock.
RISK FOR INFECTION
 Observe for localized signs of infection.
 Cleanse incision or insertion sites daily and PRN
with povidone iodine or other appropriate
solutions.
 Change dressings as needed or indicated.
 Encourage early ambulation, deep breathing,
coughing and position changes.
 Maintain adequate hydration and provide.
 Provide perineal care.
MEDICAL MANAGEMENT:
• Immediate stabilization of maternal
hemodynamics and immediate caesarean
delivery
• Oxytocin is given to contract the uterus and the
replacement .
• After surgery, additional blood, and fluid
replacement is continued along with antibiotic
theory.
SURGICAL MANAGEMENT:
• Caesarean Section
• Laparotomy
• Hysterectomy
NURSING MANAGEMENT:
• Continually evaluate maternal vital signs; Oligohydramnios Maternal fear ↑ Incidence of
especially note an increase in rate and depth of of “dry birth” congenital anomalies
respirations, an increase in pulse , or a drop in ↑ Incidence of renal
BP indicating status change. lesions
• Assess fetal status by continuous monitoring. ↑ Risk of IUGR
• Speak with family, and evaluate their ↑ Risk of fetal
understanding of the situation. acidosis
• Anticipate the need for an immediate caesarean ↑ Risk of cord
birth to prevent rupture when symptoms are compression
present. Postmaturity
• Provide information to the support person and Meconium staining ↑ ↑ Risk of fetal
inform him or her about fetal outcome, the of amniotic fluid Psychologic asphyxia
extent of the surgery and the woman’s safety. stress due to ↑ Risk of meconium
• Let the pt express her emotion without feeing fear for baby aspiration
threatened. ↑ Risk of pneumonia
due to aspiration of
meconium
PROBLEMS WITH THE PSYCHE
Factors that may affect the woman’s psyche during Premature rupture ↑ Risk of ↑ Perinatal
labor include the woman’s: of membranes infection morbidity
Current pregnancy experience (chorioamnio Prematurity
Unplanned versus planned pregnancy nitis) ↑ Birth weight
Amount of difficulty conceiving ↑ Risk of ↑ Risk of respiratory
Presence of risk factors preterm labor distress syndrome
Complications of pregnancy ↑ Anxiety Prolonged
Previous birth experiences Fear for the hospitalization
Complications of delivery baby
Mode of delivery (cesarean versus vaginal) Prolonged
Birth outcomes (e.g., fetal demise, birth hospitalizatio
defects) n
Expectations for current birth experience ↑ Incidence
View of labor as a meaningful or a stressful of tocolytic
event therapy
Realistic and attainable goals versus
Induction of labor ↑ Risk of Prematurity if
idealistic views that conflict with reality (a
hypercontrac gestational age not
situation that can lead to disappointment)
tility of assessed correctly
Preparation for birth
uterus Hypoxia if
 Type of childbirth preparation ↑ Risk of hyperstimulation
 Familiarity with institution and its policies uterine occurs
and procedures rupture
 Type of relaxation techniques learned and Length of
practiced labor if cervix
Support system not ready
 Presence and support of a birth companion ↑ Anxiety
 Husband
 Mother Abruptio Hemorrhage ↑ Perinatal
 Lesbian partner placentae/placenta Uterine atony mortality
 Friend previa ↑ Incidence Fetal
 Doula of cesarean hypoxia/acidosis
Culture birth Fetal exsanguination
 A woman’s culture influences and
defines Pain
 The childbirth experience  Meaning and context of pain
 Shameful versus joyful  Acceptable responses to pain
Superstitions and beliefs about pregnancy and birth  The significance of touch
 Prescribed behaviors and taboos during  Soothing versus intruding
the intrapartum period  May be a symbol of intimacy
 Relationships
 Interpersonal interactions
SUMMARY
 Parent–infant interactions
INTRAPARTAL HIGH RISK FACTORS
 Role expectations of family members
 Support person involvement

Factor Maternal Fetal-Neonatal Fetal heart ↑ Fear for baby Tachycardia,
Implications Implications aberrations ↑ Risk of chronic asphyxic
cesarean birth, insult,
forceps, vacuum bradycardia,
Abnormal ↑ Incidence of ↑ Incidence of Continuous acute
presentation cesarean birth placenta pre electronic Asphyxic insult
↑ Incidence of Prematurity monitoring and Chronic hypoxia
prolonged labor ↑ Risk of congenital intervention Congenital heart
abnormality in labor block
Neonatal physical
trauma
↑ Risk of intrauterine Uterine rupture Hemorrhage Fetal anoxia
growth restriction Cesarean birth Fetal
(IUGR) for hysterectomy hemorrhage
via ↑ Risk of death ↑ Neonatal
morbidity and
mortality
Multiple ↑ Uterine Low birth weight
gestation distention →↑risk Prematurity
of postpartum ↑ Risk of
hemorrhage congenital Postdates ↑ Anxiety Postmaturity
↑ Risk of cesarean anomalies (>42 weeks) ↑ Incidence of syndrome
birth Feto-fetal induction of labor ↑ Risk of fetal-
↑ Risk of preterm transfusion ↑ Incidence of neonatal mortality
labor cesarean birth and morbidity
↑ Use of ↑ Risk of
technology to antepartum fetal
monitor fetus death
Hydramnios ↑ Discomfort ↑ Risk of ↑ Risk of ↑ Incidence or
↑ Dyspnea esophageal or shoulder dystocia risk of large baby
↑ Risk of preterm other high-
labor alimentary-tract Diabetes ↑ Risk of ↑ Risk of
atresias hydramnios malpresentation
↑ Risk of CNS ↑ Risk of ↑ Risk of
anomalies hypoglycemia or macrosomia
(myelocele) hyperglycemia ↑ Risk of IUGR
Edema of lower ↑ Risk of ↑ Risk of
extremities preeclampsia- respiratory
eclampsia distress syndrome
↑ Risk of
congenital
anomalies
Preeclampsia- ↑ Risk of seizures ↑ Risk of small-
eclampsia ↑ Risk of stroke for-gestational-age
Failure to Maternal Fetal
↑ Risk of HELLP baby
progress in labor exhaustion hypoxia/acidosis
↑ Risk of preterm
↑ Incidence of Intracranial birth
birth
augmentation of injury
↑ Risk of mortality
labor
↑ Incidence of AIDS/STI ↑ Risk of ↑ Risk of
cesarean birth additional transplacental
infections transmission
Precipitous labor Perineal, vaginal, Tentorial tears
(<3 hours) cervical (END OF 5TH PART)
lacerations
↑ Risk of COMMON POSTPARTUM COMPLICATIONS
postpartum
hemorrhage POST PARTUM ASSESSMENT:
A pperance
Prolapse of ↑ Fear for baby Acute fetal V ital Signs
umbilical cord Cesarean birth hypoxia/acidosis B reasts
U terus
B ladder
B owel
L ochia
E pisiotomy/Episiorrhapy
H oman’s sign
E motions
R hogam
 NORMAL ABNORMAL

Temperature 36.2 – 38 C on the 38 C and above in

first 24 hours any or two
Occasionally consecutive 24-hour
febrile on the 3rd period (excluding
to 4th day the first 24 hours)

ASSESSMENT OF THE BREAST

ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection  Increase in size • Localized

 Colostrum • swelling
 Milk changes • Localized Pain
from thin • Redness
watery to • Purulent
bluish white discharges
 Becomes • Cracked and
heavier irritated
 Veins become nipples
apparent

ASSESSMENT NORMAL ABNORMAL

TECHNIQUE

Palpation Warm and firm Localized mass

Engorged

ASSESSMENT OF THE GENERAL APPEARANCE

Assessment Normal Abnormal
Technique Assessment Assessment
Findings Findings

Inspection/ Exhaustion Extreme

Observation Fatigue exhaustion,
Sleep hunger Weakness, and
depression at the
end of 6th week ASSESSMENT OF THE UTERUS
Pallor
ASSESSMENT NORMAL ABNORMAL
Anxiousness and
TECHNIQUE
restlessness
Dizziness
Inspection • Weight 1000 • No weight
Fainting
gms changes
immediately • Visible cervix or
after birth uterus
ASSESSMENT OF THE VITAL SIGNS
• 500 gms at • Severe
VITAL SIGNS NORMAL ABNORMAL the end of abdominal pain
first week and tenderness
• 50 grms at 6th • Lateral
Blood 90/60 – 130/80 Below 90/60
week displacement
Pressure 40 – 80 bpm 130/90 & above
• After pains of the uterus
Pulse Rate Tachycardia
during
Weak Thready
contractions
Palpitations

Measurement of descent of fundus for the woman with

NORMAL ABNORMAL vaginal birth. The fundus is located two finger-breadths
below the umbilicus. Always support the bottom of the
uterus during any assessment of the fundus.
Respiratory 16 -24 Tachypnea
Rate breaths/cycle Shallow & Irregular
Dyspnea
 ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

• Palpation • Cannot be • Hard and firm

• Percussio palpated • Resonant
n • Dull,
thudding

ASSESSMENT OF THE BOWEL:

ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection • Constipation • Passage of

• Decrease stool out
flatus from the
• Abdominal vaginal orifice
distention
• Decrease
bowel
The uterus becomes displaced and deviated to the right movement
when the bladder is full. •
Hemorrhoids

Auscultation • decrease • Absent

bowel bowel
sound sound

ASSESSMENT OF LOCHIA

ASSESSMENT NORMAL ABNORMAL

TECHNIQUE

Palpation • Contracted • Boggy

uterus
• Cervix is soft
and malleable • Board-like
• Cervical os is abdomen
narrowed

ASSESSMENT OF THE BLADDER

ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection • Temporary • Burning

difficulty of sensation
voiding • Hematuria
• Void within • Inability to void
6 to 8 hours more than 10
postpartum hours
• 3Liters • Oliguria
urinary • Severe
output/day proteinuria
• Zero-trace • Glycosuria
protein
• Zero-trace
sugar
• Urinary
stasis
TYPES OF NORMAL ABNORMAL
LOCHIA  Inspect the perineum for
episiotomy/lacerations with REEDA assessment
Lochia  2 to 3 days  Large  Inspect C/S abdominal incisions for REEDA
Rubra postpartum clots  R = redness (erythema)
 E = edema
 Dark Red in
 E = ecchymosis
color
 D = drainage, discharge
 Contains blood
 A = approximation
and fragments of
Postpartum Hemorrhage
the deciduas and
mucus
POSTPARTUM HEMORRHAGE
1. EARLY POSTPARTUM HEMORRHAGE
TYPES OF NORMAL ABNORMAL  Uterine Atony
LOCHIA  Lacerations
 Hematomas
Lochia • 3 to 10 days • Reappearanc  Uterine Rupture
Serosa postpartum e of bright  Uterine Inversion
• Pink in color red colored 2. LATE POSTPARTUM HEMORRHAGE
• Contains blood, lochia  Retention of Fragments
mucus, and • Foul-smelling  Subinvolution
invading  Dessiminated Intravascular Coagulation
leukocytes
UTERINE ATONY
SIGNS AND SYMPTOMS:
 Boggy uterus
TYPES OF NORMAL ABNORMAL  Large Uterus
LOCHIA  Expulsion of large clots
 Bright red bleeding
LOCHIA ALBA 10 to 14 days Reappearance  Hypovolemic shock
postpartum of bright red FACTORS CAUSING UTERINE ATONY
color  Multiple Gestation
 Hydramnios
Contains Foul-smelling  Large baby
mucus, whitish  Uterine Myoma
 Anestheia
 Oxytoxic drugs
 Multiparity
 Advanced maternal age
 Prolonged tocolytic agents
 Dystocia
 Previous Uterine surgery
 Chorioamnionitis
 Full bladder
MANAGEMENT OF UTERINE ATONY
 Promote Uterine Contraction
 Stop Bleeding
 Prevent Complications:
Hypovolemic Shock - Death
MEDICAL MANAGEMENT OF UTERINE ATONY
 Intravenous Fluid
 Oxytoxic Medications:
ASSESSMENT OF EPISIOTOMY/EPISSIORRHAPY Oxytocin
Maleate
ASSESSMENT NORMAL ABNORMAL
Cytotec
TECHNIQUE
 Antibiotics
 Blood Transfusion
 Catheterization
Inspection • Redness, • Hematomas  Oxygen Administration
edema, and • 1 or 2 stitches SURGICAL MANAGEMENT OF UTERINE ATONY
bruises on sloughed away  Ligation of Uterine Arteries
the • Large  Hysterectomy
perineum lacerations NURSING DIAGNOSIS & MANAGEMENT OF UTERINE
• Slight • Purulent ATONY
separation discharges Actual/Potential Fluid Volume Deficit
of wound  fundal massage
edges  ice pack application on fundus
• 1st degree  encourage voiding
laceration  administer oxytocics as ordered
  regulate IVF and BT  severe perineal and pelvic pain not relieved by
Altered Tissue Perfussion analgesia
 assess VS, NVS, CRT  bluish bulging under the skin
 assess skin color and turgor  tenderness
 trendelenburg position  firm to palpate
 oxygen administration as ordered  minor bleeding
Anxiety FACTORS CAUSING HEMATOMA
 emotional support  Rapid Spontaneous birth
 give factual information about the condition  Varicosities
 explain the procedures  Episiorrhaphy
 provide calm environment  Lacerations
MANAGEMENT OF HEMATOMAS
LACERATIONS MEDICAL MANAGEMENT:
Vaginal :  Analgesics
 anterior  Cold Compress
 posterior SURGICAL MANAGEMENT:
 lateral wall  Incision and drainage
Perineal:  Removal of sutures
 first degree – skin  Packing
 second degree – muscles  Ligation of vessels
 third degree – external anal sphincter NURSING DIAGNOSIS AND INTERVENTIONS
 fourth degree – rectal sphincter and Alteration in comfort; Pain
rectal mucus membrane  proper referral
Cervical:  ice pack application on the perineum
 lateral  analgesics as ordered
SIGNS AND SYMPTOMS OF LACERATIONS  assist for surgical intervention
Firm and Contracted Uterus
Bright red Bleeding UTERINE RUPTURE
Tear in the birth canal, and perineum COMPLETE
FACTORS CAUSING LACERATIONS:  involves endometrium, myometrium
 Precipitate labor and perimetrium
 Dystocia INCOMPLETE
 Malpresentation  intact peritoneum
 Large babies SIGNS AND SYMPTOMS OF UTERINE RUPTURE
 Instrumentation  Localized abdominal pain
 Lithotomy position  Abdominal tenderness
 Rapid cervical dilatation  Tearing feeling
 Primigravida  Hypovolemic shock
MANAGEMENT OF LACERATIONS:  Concealed bleeding
 Surgical Repair  Change in abdominal contour
 Cessation of bleeding FACTORS CAUSING UTERINE RUPTURE
 Prevent Infection  Difficult Vaginal Delivery
 Alleviate pain  Weak uterine operative site
MEDICAL MANAGEMENT  vertical uterine scar from previous CS
o Vaginal pack  Faulty presentation
o Analgesics  Multiple gestation
o Antibiotics  Traumatic manuevers using instruments
o Stool softener for delivery
SURGICAL MANAGEMENT OF LACERATIONS  Injudicious use of oxytoxic agents
 Surgical Repair  Obstructed Labor
 Regional anesthesia GOAL OF MANAGEMENT OF UTERINE RUPTURE
NURSING DIAGNOSIS AND MANAGEMENT OF  Repair of tear or laceration
LACERATIONS  Prevent Hemorrhage
Alteration in Comfort; Pain  Prevent Hypovolemic shock
 cold compress on the perineum  Prevent Infection
 perineal douch  Prevent Death
 high fiber diet MEDICAL MANAGEMENT OF UTERINE RUPTURE
 increase OFI  Intravenous fluid
 NSAIDS as ordered  Blood Transfusion
Potential for infection  Antibiotics
 pat dry the perineum  Oxytoxics
 frequent change of gowns and perineal pads SURGICAL MANAGEMENT OF UTERINE RUPTURE
 proper nutrition  Laparotomy
 increased OFI  Tubal ligation
 prophylactic antibiotic as ordered  Hysterectomy
NURSING DIAGNOSIS AND INTERVENTIONS OF
HEMATOMA UTERINE RUPTURE
SIGNS AND SYMPTOMS OF HEMATOMA Fluid Volume Deficit
Altered Cardiac Output
 Altered Tissue Perfusion  Emotional support
 Monitor VS every 15 minutes  Stay with the client
 Evaluate blood loss  Listen
 IVF and BT  Give factual informations
 Administer oxygen as ordered Risk for infection
Dysfunctional Grieving  Aseptic technique
Anxiety  Administer prophylactic antibiotics
Fear
o Obtain consent for surgery LATE POSTPARTUM HEMORRHAGE
o Give factual informations  Retained Placental Fragments
o Explain procedures  Subinvolution
o Do not give reassurance  Endometritis
o Emotional support RETAINED PLACENTAL FRAGMENTS
Signs and Symptoms:
UTERINE INVERSION  Incomplete placental delivery
DEGREE OF INVERSION  Uterus remains large
 First-degree - the inverted fundus extends to,  Bright red bleeding
but not through, the cervix.  + HCG in the blood
 Second-degree - the inverted fundus extends  + ultrasound result
through the cervix but remains within the FACTORS CAUSING RETAINED PLACENTAL FRAGMENTS
vagina.  Failure to inspect after placental delivery
 Third-degree - the inverted fundus extends  Placenta accreta
outside the vagina. MEDICAL MANAGEMENT OF RETAINED PLACENTA
 Total inversion - the vagina and uterus are  Oxytoxin administration
inverted.  Methotrexate
SIGNS AND SYMPTOMS:  IVF
 Visualization of protruded uterus SURGICAL MANAGEMENT OR RETAINED PLACENTA
 Sudden gush of large amount of blood  Dilatation and Curettage
 Hypovolemic shock after 10 minutes  Hysterectomy
FACTORS CAUSING UTERINE INVERSION NURSING DIAGNOSIS AND MANAGEMENT
 Pulling the umbilical cord before placental  Fluid Volume Deficit
separation  Decreased cardiac Output
 Extreme pushing of the fundus  Altered Tissue Perfusion
 Fundal implantation of the placenta  Risk for infection
GOAL OF CARE OF UTERINE INVERSION  Anxiety
 Prevent Hemorrhage
 Jhonson’s Maneuver SUBINVOLUTION OF THE UTERUS
 Prevent Shock Signs and Symptoms:
 Prevent Infection Uterus remains large
 Prevent Death Lochia is profused
MEDICAL MANAGEMENT Altered pattern of lochia
 Initially: FACTORS CAUSING UTERINE SUBINVOLUTION
 Tocolytic Retained Placental fragments
 General anesthesia Endometritis
 Nitroglycerine Uterine Myoma
 Oxytocic agents MEDICAL MANAGEMENT OF UTERINE SUBINVOLUTION
 Double intravenous fluid Oxytocin
 Oxygen administration Maleate
 Ready for CPR IVF
 Antibiotics SURGICAL MANAGEMENT OF UTERINE
 Blood Transfusion SUBINVOLUTION
SURGICAL MANAGEMENT Hysterectomy
 Jhonson’s Maneuver NURSING DIAGNOSIS AND MANAGEMENT
 Surgical Replacement Fluid Volume Deficit
 Hysterectomy Altered Cardiac Output
 Laparotomy Altered Tissue Perfusion
 General Anesthesia Alteration in thermoregulation; hyperthermia
NURSING DIAGNOSIS AND INTERVENTION Anxiety
Fluid Volume Deficit Fear
Altered Cardiac Output
Altered Tissue Perfusion DISSEMINATED INTRAVASCULAR COAGULATION
 Determine the degree of inversion Signs and Symptoms:
 Assess VS, NVS, and CRT Mild oozing of venipuncture site
 Evaluate blood loss Petechiae
 Use large needles/cannula for FACTORS CAUSING DIC
intravenous fluid PIH
 Regulate IVF and BT as ordered Abruptio Placenta
 Administer oxygen by face mask Incomplete Abortion
Anxiety Septic Abortion
 Prolonged retention of dead fetus PERITONITIS
Amniotic fluid Embolism  an infection of the peritoneal cavity
Hypertonic labor  usually an extension of endometritis
Sepsis  gravest of postpartum complications
GOAL OF MANAGEMENT OF DIC  common cause of mortality death from
Treat underlying conditions puerperal infection
Stop Clotting Signs and Symptoms of Peritonitis
Restore normal clotting functions  rigid abdomen with guarding behavior
MEDICAL MANAGEMENT OF DIC  abdominal pain
Heparin  high fever
Blood Replacement  rapid pulse
Fresh Frozen Plasma  vomiting
Platelet Replacement  appearance of acutely ill
NURSING DIAGNOSIS AND INTERVENTIONS Management of Peritonitis
Actual/Potential Fluid Volume Deficit  large dose of antibiotics
Frequent monitoring  NGT to relieve vomiting and rest the bowel
Evaluate blood loss  IVF
Gentle handling of patient  parenteral feeding
Frequent turning to sides  analgesics
 antipyretics
PUERPERAL INFECTION
 Infection of the genital tract during postpartum MASTITIS
TYPES OF INFECTION  infection of the breast tissues
 Endometritis  occurs as early as 7 days postpartum or not
 Infection of the Perineum until the baby is weeks or months of age
 Peritonitis ETIOLOGY:
 Mastitis  Staphylococcus
Endometritis  Streptococcus
 an infection of the inner lining (endometrium)  Eschericia
of the uterus Signs and Symptoms of Mastitis
 bacteria may gain access from the vagina into  localized pain, swelling, and redness
the uterus maybe during delivery process  fever
Signs and Symptoms of Endometritis  body malaise
 fever for 2 consecutive 24 hours usually on the  rapid pulse
3rd or 4th day excluding the first 24 hours  scanty breast milk
postpartum Management of Mastitis
 chills  broad spectrum antibiotics
 loss of appetite  analgesics
 general malaise  antipyretics
 abdominal tenderness  warm or cold compress
 uterine atony  supportive bra
 strong afterpains  constant emptying
 dark brown foul smelling lochia  incision and drainage
Management of Endometritis Nursing Diagnosis of Puerperal Infection
 antibiotics  Actual/potential for infection
 oxytocic  Alteration in thermoregulation; hyperthermia
 analgesics  Alteration in comfort; pain
 antipyretics  Social Isolation
Infection of the Perineum
 very rare because of improved aseptic THROMBOPHLEBITIS
technique  It is the inflammation of the lining of the
 occurs at the suture line or repair of lacerations vessel in which a clot attaches to the vessel
Signs and Symptoms of Infection of the Perineum wall.
 pain on the perineum  May not appear until 10-20 days after
 swelling delivery
 heat THREE MAJOR CAUSES:
 pressure on the perineum  venous stasis
 one or two stitches slough off  hypercoagulability
 purulent discharges from suture line  damage of the intima of the blood vessels
 may be afebrile unless systemic Other Factors:
Management of the Infection of the Perineum  varicosities
 systemic or topical antibiotics  obesity
 analgesics  history of thrombophlebitis
 hot sitz bath  oral contraceptives
 warm compress  age >35 years old
 perineal sutures may be removed to allow  multiparity
drainage  diabetes millitus
 packing with gauze  smoking
Classifications of Thrombophlebitis according to the
depth
a) Superficial venous thrombosis
 limited to the calf only
 swelling of extremity, redness,
tenderness, and warm, pain while
walking
b) Deep vein thrombosis
 often absent or diffused signs
 swelling, erythema, edema, heat,
tenderness
 phlegmasia
Classifications of Thrombophlebitis according to
location
a) Femoral
 fever, chills, pain, redness,
 swelling of extremeties,
 White - stretched skin,
 + homan’s sign
b) Pelvic
 ovarian, uterine, hypogastric vein
 high fever
 chills
 body malaise
Management of Thrombophlebitis
 Anticoagulant (Warfarin, Heparin)
 Thrombolytic (Streptokinase, Urokinase)
 Analgesics ( except aspirin)
 laparotomy – locate and incise to remove
affected veins
 monitoring of prothrombin time
Nursing Diagnosis and Management of
Thrombophlebitis
Alteration in Comfort; pain
 rest
 elevate legs
 antiembolic stockings
 avoid standing for long period of time
 moist heat application
 DO NOT MASSAGE
Altered Tissue Perfusion
 constantly check the skin
 passive range of motion exercise
 prevent skin ulcerations
 proper nutrition
 avoid gatch or pillow under the knee
Risk for Injury (bleeding) related to therapy
 btain baseline coagulation
 avoid IM injection of other drugs
 rotate injection site
 inject heparin subcutaneously, do not
massage
 prepare Protamin Sulfate ( antidote of
Heparin)
 prepare Vitamin K ( antidote of Warfarin)
How to prevent thrombophlebitis?
 avoid wearing constricting clothings
 rest while feet elevated
 ambulate daily during pregnancy
 limit woman in lithotomy position
 aseptic technique in invasive procedures
 if with varicose veins, wear support
stockings
 first 2 weeks postpartum
 avoid in 1 position for long period of time
 avoid leg crossing
 increase oral fluid intake
 early ambulation after pregnancy
 if cannot ambulate, PROM exercises
 avoid pillows under the knees
 don’t smoke
EMOTIONAL AND PSYCHOLOGICAL POSTPARTAL
COMPLICATIONS
Phases of Puerperium:
1. Taking-in Phase
 This is the time of reflection for a woman.
 The woman is passive letting other people
(husband, nurse, etc.) do things for her and
make decisions for her.
2. Taking-hold Phase
 This is the phase where the woman begins to
initiate action herself.
 shows a woman with great interest on caring
for the baby.
3. Letting-go
 The woman finally defines her new role.
 She gives up the fantasized image of her child
for the real one.
POSTPARTUM BLUES
It is a maternal adjustment reaction
 accompanied by irritability, anxiety, and a mild
let-down feeling
 usually occurring between the 2nd to 3rd
postpartum day through the 1st to 2nd
postpartum week.
Signs and symptoms of Postpartum Blues
 Insomnia
 Depressed mood
 Headache
 Poor concentration
 Tearfulness
 Confusion
 Mood labile
Factors causing Postpartum Blues
 sudden drop of hormone at about 72
hours postpartum
 disappointments of body changes
 extreme disappointments of labor and
birth
 inadequate emotional support from
partner
 extreme stress from mothering role
Management of Postpartum Blues
 allow woman to talk and cry
 work through their feelings
 encourage family support
POSTPARTUM DEPRESSION
 It is a mood disturbance that is characterized by
feelings of sadness, despair, apathy, and
discouragement caused by loss in the person’s
life or by neurobiological imbalance of
neurotransmitters.
 It occurs 30 days to 6 months after birth
SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION
 Excessive crying
 Feeling of inadequacy
 Low self-esteem
 Inability to cope
 Anorexia
 Insomnia
 Psychosomatic symptoms
 Depressive or manic mood fluctuation
 Social withdrawal
Factors causing Postpartum Depression Cervical:
 history of depression  changes during ovulation
 troubled childhood  cervical incompetence
 stress in the home or at work Etiology of Female Infertility
 lack self-esteem
 lack of support system  Uterine
Management of Postpartum Depression  functional
 Nurse-patient relationship  structural
- therapeutic relationship  Tubal
 Psychopharmacologic  scarring
- antidepressive drugs  PID
 Milleu therapy  endometriosis
– forceful manipulation of the environment  Ovarian
 anovulation
POSTPARTUM PSYCHOSIS  oligo-ovulation
 It is a disrupted mental state in which an Etiology of Male Infertility
individual struggles to distinguish the external  Congenital
world from his internally generated  absence of vas deferens and testes
perceptions.  Ejaculatory
 The disorder may become apparent 2 to 3  retrograde ejaculation
weeks after birth to as long as 6 to 12 months.  Sperm abnormalities
Factors causing Postpartum Psychosis  oligospermia
 major life crisis  aspermia
 previous mental illness  inadequate maturation
 family history of mental illness  inadequate motiliy
 hormonal changes  inability to deposit sperm into the vagina
Signs and Symptoms of Postpartum Psychosis  blockage of sperm
 suicidal and infanticidal thoughts  Testicular
 dissociated  orchitis
 delusional  cryptorchidism
 confused  trauma
 distortion of reality  radiation
Management of Postpartum Psychosis  Coital
 professional psychiatric counselling  obesity
 antipsychotic drugs  nerve damage
 hospitalization  impotence
 woman must be observed during her  Drugs
interaction with her child  Methotrexate
Nursing Diagnosis and Management of Postpartum  Amebicides
Emotional Disturbances  Other factors:
Risk for/Actual Ineffective coping  STD
 Convey a caring attitude  stress
 Acknowledge that the woman feels  inadequate nutrition
depressed  alcohol & nicotine
 Assure that it is not her fault Interactive Problems
 encourage support from family  Insufficient frequency of SI
members  Poor timing of intercourse
 Adequate rest and nutrition  Development of antibodies
INFERTILITY against partner’s sperm
 The inability to conceive after at least 1 year of  Use of spermicidal lubricants
sexual intercourse at least 4 times a week  Inability of the sperm to
without contraception. penetrate the egg
Normally……. Diagnostic Studies
 50% of couples conceive within 6  Semen Analysis after 48 – 72 hours of
months abstinence
 35% conceive within 12 months
Primary infertility  Cervical Mucous assessment
 no previous history of conception o fern test
Secondary Infertility o spinnbarkeit test
 inability to conceive after previous successful  Postcoital Test
pregnancy o SI at presumed ovulatory state
Etiology of Female Infertility o after48 hour abstinence
Vaginal problems: o Check cervical mucus
 vaginal infections  Basal Body Recording
 anatomic abnormalities o oral temp when awakening
 sexual dysfunction o increase temp 12-14 days
 highly acidic vaginal environment o before menses- ovulation
MANAGEMENT OF INFERTILITY IVF may be an option if you or your partner have been
1. Management of underlying problems diagnosed with:
 douche with alkaline solution 30 minutes  Endometriosis
before intercourse  Low sperm counts
 surgery  Problems with the uterus or fallopian tubes
 medications  Problems with ovulation
 antibiotic  Antibody problems that harm sperm or eggs
 testosterone  The inability of sperm to penetrate or survive in
 estrogen the cervical mucus
 sexual therapy  An unexplained fertility problem
2. Assisted Reproductive Techniques Surrogate embryo transfer
 artificial insemination  embryos are placed into the uterus of a female
 In vitro fertilization with the intent to establish a pregnancy.
 Surrogate embryo transfer  embryos are typically transferred 3 days
 Surrogate mothering after fertilization.
ARTIFICIAL INSEMINATION PROCESS:
 The process by which a woman is medically  After the follicles are aspirated from the
impregnated using semen from her husband or Intended Mother or Egg Donor they will be
from a third-party donor. examined and mixed with the intended father
 Injecting collected semen into the woman's or a donors sperm.
uterus and is performed under a physician's  They are then incubated for 3 - 5 days to allow
supervision. fertilization to occur.
INDICATION  The gestational surrogate, intended parents and
 men who have very low sperm counts. reproductive physician will have a consult to
 sperm that aren't strong enough to swim determine the number of embryos to transfer.
through the cervix and up into the fallopian  Then, the embryos will be placed in the
tubes. surrogates uterus via invitro fertilization
 option for women who have endometriosis or  the embryo transfer procedure will take place in
abnormalities of any of their reproductive a sterile, surgical room within the fertility clinic
organs. or hospital.
PROCESS:  The process does not cause discomfort and
 washing the sperm requires no medication or anesthesia. .
 liquefying the sperm at room temperature for  The process usually takes approximately ten-
30 minutes fifteen minutes.
 harmless chemical is added to separate out the  surrogates will be required to remain at the
most active sperm. clinic for at least one-two hours after the
 centrifuge is used to collect the best sperm. completion of the transfer procedure to rest .
 sperm are then placed in a thin tube called a  Surrogates will be required to rest with activity
catheter and introduced through the vagina and restrictions for two-three days following the
cervix into the uterus transfer procedure.
 cramping during the procedure and SURROGATE MOTHER
light bleeding afterward  A woman who bears a child for another person,
 Immediately after the procedure, your doctor often for pay.
will probably have you lie down for about 15 to  A substitute mother
45 minutes to give the sperm a chance to get to TWO KINDS OF SURROGATE MOTHER
work. Traditional surrogates
 you can resume your usual activities.  is a woman who is artificially inseminated with
the father's sperm.
Success rates for artificial insemination vary. Factors  She then carries the baby and delivers it for the
that lessen your chance of success include: parents to raise.
 Older age of the woman  is the baby's biological mother. That's because it
 Poor egg quality was her egg that was fertilized by the father's
 Poor sperm quality sperm. Donor sperm can also be used for a
 Severe endometriosis traditional surrogacy.
 Severe damage to fallopian tubes (usually from GESTATIONAL SURROGATES
chronic infection)  has no genetic ties to the child. That's because it
 Blockage of fallopian tubes (IUI will usually not wasn't her egg that was used.
work in this case)  is called the "birth mother.
IN VITRO FERTILIZATION  more common than a traditional surrogate
 is a process by which an egg is fertilized by WHO USES SURROGATES:
sperm outside the body in a laboratory.  Those with medical problems with her uterus.
 The fertilized egg (zygote) is then transferred to  hysterectomy
the patient's uterus.  conditions that make pregnancy impossible or
medically risky, such as severe heart disease.
OTHER REASONS:
 age
 marital status
 sexual orientation
CHOOSING A SURROGATE:
1. Is at least 21 years old
2. Has already given birth to at least one healthy
baby
3. Has passed a psychological screening by a
mental health professional
4. Willingly signs a contract agreeing to her role
and responsibilities in the pregnancy
5. have a complete medical evaluation and
pregnancy history to assess the likelihood of a
healthy, full-term pregnancy.

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