NURS 10 CARE OF MOTHER AND CHILD AT RISK
The blood that
OR WITH PROBLEMS (ACUTE AND CHRONIC)
MODULE – 1
Anatomy Of Cardiovascular System
Cardiovascular System
 is an organ system that permits blood to
circulate and transport nutrients (such
as amino
acids and electrolytes), oxygen, carbon
dioxide, hormones, enzymes, antibodies,
evacuation of waste products, and blood
cells. Help in fighting diseases, stabilize
temperature, pH, and
maintain homeostasis.
 The system has a capacity to adapt to
changing body needs by adjusting the rate
and force of heart pumping, modifying the
size of the blood vessels, and altering the
volume and composition of blood.
 The heart is enclosed in a protective
sac, the pericardium, which also
contains a small amount of fluid. The
wall of the heart is made up of three
layers: epicardium, myocardium, and
endocardium.
 Blood is a fluid consisting of plasma, red
blood cells, white blood cells,
and platelets that is circulated by
the heart through the vertebrate
vascular system, carrying oxygen and
nutrients to and waste materials away
from all body tissues.
 The heart pumps oxygenated blood to
the body and deoxygenated blood to the
lungs. In the human heart there is
one atrium and one ventricle for each
circulation, and with both a systemic and
a pulmonary circulation there are four
chambers in total: left atrium, left
ventricle, right atrium and right ventricle.
The right atrium is the upper chamber of
the right side of the heart.
is returned to the right atrium is
deoxygenated (poor in oxygen) and
passed into the right ventricle to be
pumped through the pulmonary artery to
the lungs for re-oxygenation and
removal of carbon dioxide. The left
atrium receives newly oxygenated blood
from the lungs as well as the pulmonary
vein which is passed into the strong left
ventricle to be pumped through the aorta
to the different organs of the body.
 The circulatory system of the blood is
seen as having two components, a
systemic circulation and a pulmonary
circulation; (1) The circulation system
provides a blood supply to the heart
muscle itself. It begins near the origin of
the aorta by two coronary arteries: the
right coronary artery and the left
coronary artery. After nourishing the
heart muscle, blood returns through the
coronary veins into the coronary sinus
and from this one into the right atrium.
Back flow of blood through its opening
during atrial systole is prevented by
Thebesian valve. A smallest cardiac
veins drain directly into the heart
chambers. While (2) The pulmonary
circulation on the lungs, oxygen-
depleted blood is pumped away from the
heart, via the pulmonary artery, to the
lungs and returned, oxygenated, to the
heart via the pulmonary vein.
 The systemic circulation begins when
oxygen deprived blood from the
superior and inferior vena cava enters
the right atrium of the heart and flows
through the tricuspid valve (right
atrioventricular valve) into the right
ventricle, from which it is then pumped
through the pulmonary semilunar
valve into the pulmonary artery to the
lungs. Gas exchange occurs in the
lungs, whereby CO2 is released from
the blood, and oxygen is absorbed. The
pulmonary vein returns the now
oxygen-rich blood to the left atrium and
passed to mitral valve. The blood
transport to left ventricle flows through
aortic valve enter to aorta. The
oxygenated blood through the aorta
from the left ventricle where the blood
has been previously deposited from
pulmonary circulation, to the rest of the
body, and returns oxygen-depleted
blood back to the heart.
 A separate system known as the
bronchial circulation supplies blood to
the tissue of the larger airways of the
lung.
 THE CARDIA CYCLE AS
CORRECTED TO THE ECG
 The Cardiac Cycle refers to the
sequence of events in which the heart
contracts and relaxes with every
heartbeat. The period of time during
which the ventricles contract, forcing
blood out into the aorta and main
pulmonary artery, is known as systole,
while the period during which the
 ventricles relax and refill with blood is
known as diastole.
 The systole is a contraction and diastole
is relaxation of the heart.
 stroke volume (SV) by the beats per
 The atria and ventricles work in concert,
so in systole when the ventricles are
contracting, the atria are relaxed and
collecting blood. When the ventricles are
relaxed in diastole, the atria contract to
pump blood to the ventricles. This
coordination ensures blood is pumped
efficiently to the body.
 is 5.25 L/min, with a normal range of
 At the beginning of the cardiac cycle, the
ventricles are relaxing. As they do so,
they are filled by blood passing through
the open mitral and tricuspid valves.
After the ventricles have completed
most of their filling, the atria contract,
forcing further blood into the ventricles
and priming the pump. Next, the
ventricles start to contract. As the
pressure rises within the cavities of the
ventricles, the mitral and tricuspid valves
are forced shut.
 As the pressure within the ventricles
rises further, exceeding the pressure
with the aorta and pulmonary arteries,
the aortic and pulmonary valves open.
Blood is ejected from the heart, causing
the pressure within the ventricles to fall.
Simultaneously, the atria refill as blood
flows into the right atrium through the
superior and inferior vena cavae, and
into the left atrium through
the pulmonary veins.

 Finally, when the pressure within the
ventricles falls below the pressure within
the aorta and pulmonary arteries, the
aortic and pulmonary valves close. The
ventricles start to relax, the mitral and
tricuspid valves open, and the cycle
begins again.

 The x axis reflects time recording of
heart sounds. The y axis represents
pressure.
 Cardiac output (CO)
 is a measurement of the amount of
blood pumped by each ventricle in one
minute (stroke volume).
 It affects the three main factors;
 a) preload – volume of the blood in the
ventricle at the end of diastole or before
contraction.
 b) contractility – ability of the ventricles
to stretch.
 c) afterload – resistance against which
the ventricle pump.
 contractions controls the stroke volume.
 Therapy of the Cardiovascular
Disorder = reducing preload and
afterload and increasing contractility to
promote better cardiac output.

 This is calculated by multiplying the
minute of the heart rate (HR). So that:
CO = SV x HR. The cardiac output is
normalized to body size through body
surface area and is called the cardiac
index.

 The average cardiac output, using an
average stroke volume of about 70mL,
4.0–8.0 L/min.

 The stroke volume is normally measured
using an echocardiogram and can be
influenced by the size of the heart,
physical and mental condition of the
individual, sex, contractility, duration of
contraction, preload and afterload.


 Preload
 refers to the filling pressure of the atria
at the end of diastole, when the
ventricles contract more frequently, then
there is less time to fill and the preload
will be less.
 Preload can also be affected by a
person's blood volume. The force of
each contraction of the heart muscle is
proportional to the preload, described as
the Frank-Starling mechanism. This
states that the force of contraction is
directly proportional to the initial length
of muscle fiber, meaning a ventricle will
contract more forcefully, the more it is
stretched.
 Afterload
 refers to the heart pressure generate to
eject blood at systole.
 It can be influenced by vascular
resistance and narrowing of the heart
valves (stenosis) or contraction or
relaxation of the peripheral blood
vessels.


 The strength of heart muscle
This can be influenced positively or
negatively by agents
termed inotropes. These agents can be
 a result of changes within the body, or fibers which then transmit the electric
be given as drugs as part of treatment charge to the heart muscle.
for a medical disorder, or as a form  Conduction System of the Heart
of life support, particularly in intensive 
care units.

 Inotropes that increase the force of
contraction are "positive" inotropes, and
include sympathetic agents such as;
(1) adrenaline, (2)
noradrenaline and (3) dopamine.

 "Negative" inotropes decrease the force
of contraction and include calcium
channel blockers.

 Conduction System of the Heart

 
 The normal rhythmical heartbeat,
called SINUS RHYTHM, is established
by the Sinoatrial Node, the
heart's pacemaker. Here an electrical
signal is created that travels through the
heart, causing the heart muscle to
contract.
 The Sinoatrial Node is found in the
upper part of the right atrium near to the
junction with the superior vena
cava. The electrical signal generated by
the sinoatrial node travels through the
right atrium and left atrium
via Bachmann's bundle, such that the
muscles of the left and right atria
contract together. The signal then
travels to the Atrioventricular Node.
This is found at the bottom of the right
atrium in the Atrioventricular
Septum—the boundary between the
right atrium and the left ventricle. The
septum is part of the cardiac skeleton,
tissue within the heart that the electrical
signal cannot pass through, which
forces the signal to pass through the
atrioventricular node only. The signal
then travels along the Bundle of His to
left and right Bundle Branches through
to the ventricles of the heart. In the
ventricles the signal is carried by
specialized tissue called the Purkinje


 Cardiac Action Potential refers to the
movement of specific electrolytes into
and out of peacemaker cells that spread
to nearby cells.

 Prepotential is due to slow influx of
sodium ions until the threshold is
reached followed by a rapid
depolarization and repolarization.
 Depolarization refers when the
sinoatrial cells are resting, they have a
negative charge on their membranes.
However a rapid influx of sodium ions
causes the membrane's charge to
become positive.

 Once the cell has a sufficiently high
charge, the sodium channels close
and calcium ions then begin to enter the
cell, shortly after
which potassium begins to leave it. All
the ions travel through ion channels in
the membrane of the sinoatrial cells.
The potassium and calcium start to
move out of and into the cell only once it
has a sufficiently high charge, and so
are called Voltage-Gated.
 Shortly after this, the calcium channels
close and potassium channels open,
allowing potassium to leave the cell.
This causes the cell to have a negative
resting charge and is
called Repolarization. When the
membrane potential reaches
approximately −60 mV, the potassium
channels close and the process may
begin again.
MODULE – 2
Nursing Care of Child with
Cardiovascular Disorder
2020 National Health Goals related to Children with
Cardiovascular Disorder
1. Modify nutrition and exercise to achieve better
cardiovascular health.
2. Guidelines for aerobic physical activity and for
muscle strengthening activity.
3. Reduce consumption of calories from solid fats
due to obesity.
4. Reduce incidence of hypertension in children and
adolescent.
Nursing Responsibilities to Achieve the 2020
National Goals by;
1) Educate the parents and children about the
prevention related to cardiovascular disorder.
2) Assist the parents in planning nutritional meal and
exercise for their children.
3) Advise the parent to avoid giving high caloric
intake or fat diet to their children aged 2 years old
for the purpose of myelination of nerve cells.
4) Providing psychological support to the children
and to their families.
5) Educate the families about the importance of
maintaining a sensible weight, sodium intake, and
reduce saturated fat and cholesterol intake.
Cardiovascular disorder in children occurs as a
result of congenital anomaly;
a) heart develop inadequate in utero or the
embryonic structures
b) heart cannot adapt to extra uterine life.
Open Heart Surgery – often therapy for
cardiovascular disorder to correct the congenital
concerns.
Nursing Process for Care of a Child with a
Cardiovascular Disorder
I. Assessment
 history taking and physical examination.
 diagnostic examination such as
echocardiography, electrocardiography,
cardiac catheterization.
 measuring height and weight.
CHILD CHIEF COMPLAINT:
 fatigue
 cyanosis – (blue tinge to the skin or
mucous) occur if a shunt allowing
deoxygenated blood to enter the arterial
system.
 Acrocyanosis – serious
cardiopulmonary dysfunction
 Cyanosis decreases with crying –
pulmonary dysfunction
 Cyanosis increases with crying –
cardiac dysfunction
 frequent having upper respiratory infection
 feeding difficulty – due to frequently need
to breath or rest.
 poor weight gain
 growth failure
 irregular heart rhythm (tachycardia) and
increase respiration (tachypnea) – displaced
apex, heart murmur.
 Organic murmur = systolic, longer
harsh blowing, loud, heard in all
position.
 Innocent murmur = systolic, short,
soft sound and intensity, usually
supine position.
 edema (periorbital area – swelling around
the eyes and lower extremities) retained
fluid that cannot be voided is a late sign of
heart disorder in children.
 frequent nose bleed and headache – due to
high blood pressure.
 leg pain – (growing pain) due to low blood
pressure in the lower extremities.
 absent femoral pulse and faint peripheral
pulse
 clubbing fingers
 ruddy complexion – overproduction of red
blood cell (polycythemia)
 frequent perspiration – if a child is having a
left to right shunt may perspire excessively
as a result of sympathetic nerve
stimulation.
 Enlargement of the liver (hepatomegaly)
 Lethargy and rapid respiration – ineffective
heart pump
  Prominence of the left side and obvious
heart movement
 Palpable cardiac activity
Abnormal pulse pattern
1. Water hammer pulse – very forceful and
bounding pulse
Corrigan’s pulse – capillary pulsations like
finger nails
2. Pulsus alternans – one strong beat and one
weak beat (myocardial weakness)
3. Dicrotic pulse – a double radial pulse for
every apical beat symptomatic of aortic
stenosis.
4. Thread pulse – weak and usually rapid
(ineffective heart action)
MATERNAL HISTORY
 Toxoplasmosis
 Cytomegalovirus
 Rubella
 Non prescribe medication taken
 Substance abuse, cigarette smoke, and
drink alcoholic beverages
 Poor nutrition intake
 Expose to radiation
 Expose to general anesthesia
 Frequent genito – urinary infection
FAMILY HISTORY
 Polygenic inheritance pattern
 Chromosomal disorder
 Difficulty oxygenating blood tend to
assume knee chest position, whereas
the children often voluntarily squat –
trap blood in the lower extremities
because of the sharp bend at the knee
and hip. Allowing the child to oxygenate
the blood remaining in the upper body
more fully and easily.
 2 weeks after birth cardiovascular
disorder may detected.
II. Diagnosis
 address the effect of poor circulation to
body tissue or the effect of a serious
disorder can create for the children or
parents.
 Need to focus on physical and
psychological care.
1) Decreased cardiac output related to
congenital structure disorder.
2) Tissue perfusion altered related to
decreased cardiac output.
3) Ineffective tissue perfusion related to
inadequate cardiac output.
4) Activity intolerance related to congenital
disorder.
5) Risk for decrease self – esteem altered
related to child illness.
6) Deficient knowledge related to care of the
child pre and post operatively.
7) Fear related to lack of knowledge about
the child’s illness.
8) Interrupted family processes related to
stresses of diagnosis and care
responsibilities.
9) Ineffective coping related to lack of
adequate support people.
10) Impaired parenting related to inability to
bond with critically ill newborn.
III. Planning
 Help parents and child to understand
anatomy of heart to know the process of
illness.
 Help parent’s the importance of
diagnostic testing.
 Prepare parents about the procedures
and recovery at home.
 Teach parents to conscientiously
administer cardiac medication.
 Help the parents about social support or
organization that may support during
treatment.
IV. Intervention
 Educate the possible needed after surgery.
 Allow to express their feelings.
 Assist about treatment plan.
 Monitor vital signs.
 Monitor intake and output.
 Provide safety precaution and prevent
infection.
 Maintain appropriate weight and eating a low
fat diet.
 Providing physical and psychological
support.
 Promotion of wellness after therapy.
 Prevention of possible complication after
surgery.
V. Evaluation
 Long term care – evaluate the family’s ability
to think of their child not in terms of illness,
but in terms of wellness.
 The parents and child demonstrate positive
coping skills related to the disease process
and required care.
 The child’s heart rate remains within
accepted parameters for age.
 Short term care – adequate support during
procedures and treatment.
 The parents demonstrate competence with
procedures required for care of their child.
 The parents verbalize positive aspect about
their child.
MODULE – 3
Diagnostic Test Performed on a Child
with Congenital Heart Disorders
Diagnostic Test Performed on a Child with
Congenital Heart Disorders
1) Electrocardiogram (ECG)
 Is a noninvasive test that used to reflect
underlying heart conditions by
measuring the electrical activity of the
heart.
 A written record of electrical voltages
generated by the contracting heart and
provides information about heart rate
and rhythm.
Electrocardiogram (ECG) can
diagnose;
 Abnormally fast, slow or irregular
heart rhythms.
 Abnormal conduction of cardiac
impulse.
 Evidence of an acute impairment to
blood flow.
 Adverse effect on the heart from
various heart diseases.
 Adverse effect on the heart from
certain lung conditions.
 Certain congenital heart
abnormalities.
 Evidence of abnormal blood
electrolytes.
 Evidence of inflammation of the
heart or its lining.
 Presence or absent of hypertrophy
(thickening of the heart wall).
 Ischemia or necrosis due to
inadequate cardiac circulation.
 Effect of various drugs and
electrolyte imbalance on the heart.
2) Echocardiography or Ultrasound
Cardiography
 High frequency sound waves, directed
toward the heart.
 Used to locate, study the movement,
and dimensions of cadiac structures.
 Used a single beam called M – mode =
reveals chamber contractility.
 Doppler technique = reveals velocity of
blood flow.
 The procedure used decrease the risk of
radiation exposure.
 Transesophageal probe – used in
children, reveals heart anomalies.
3) X – ray Examination
 Is a form of electromagnetic radiation
that can pass through solid objects,
including the body.
 Penetrate different objects more or less
according to their density.
 It is used to view image of the internal
organ such as heart, bone structure and
other organs.
 Furnish an accurate size of the heart
chambers.
 Evidence of fluid collecting in the lungs
or pulmonary artery from poor heart
function.
 Frequently used to confirm the
placement of pacemaker leads.
4) Fluoroscopy
 Is used in many types of examination
and procedure such as barium X-ray,
Cardiac Catheterization, arthrography
(visualization of joints), lumbar puncture,
placement of Intravenous catheters
(hollow tube inserted into veins or
arteries).
 Procedure, an X-ray beam is passed
through the body. The image is
transmitted to a monitor so the
movement of a body part or contrast
agent (dye) through the body can be
seen in detail.
 Provide motion picture record of the size
and configuration of the heart because
prolonged observation is necessary to
record this information.
 The patient undergone with the
procedure is exposes to radiation.
5) Phonocardiography
 Is a diagram of heart sounds translated
into electrical energy by a microphone
placed on the child’s chest and recorded
the diagrammatic representation of the
heart sounds.
 Measure the heart sound
 Direct auscultation.
6) Magnetic Resonance Imaging
 Using a large magnets and radio-
frequency waves to evaluate heart
structures or blood flow to record heart
sounds.
 Not a radioactive or iodine based
 Can be repeated without radiation.
7) Cardiac Catheterization
 A small radiopaque catheter is passed
through a major vein in arm, leg, or neck
into the heart to secure blood samples
or inject dye.
 Used to evaluate and diagnose cardiac
function.
 Used to correct cardiac disorder such as
narrowed valve by the use of balloon
catheter or other device.
 Contrast media is injected for
angiography or Magnetic resonance
scanning.
For Neonates, umbilical artery may be
catheterized
For right side heart catheterization, can
be performed using a right femoral vein
or vein antecubital fossa usually used.
For left side heart catheterization, can
be performed using a vein or an artery.
Under Fluoroscopy = catheter inserted
to the right atrium through foremen
ovale. Once the catheter is in selected
chamber, inject the contrast media to
 outline heart configuration on X – ray or
MRI.
8) Exercise testing
 Used a treadmill walking to demonstrate
proper pulmonary circulation.
 Caution to the children with heart
disorder that obstruct the flow of blood
to the lungs (Pulmonary Stenosis).
Signs and symptoms; exertional
dyspnea – diff. to perform.
2. Shock = due to hypovolemia or cadiac
tamponade
3. Neurologic symptoms = due to hypoxia
4. Post cardiac surgery syndrome – fever
5. Post perfusion syndrome – occurs 3 to 12
weeks after surgery.
 The child develops a fever, an enlarged
spleen, general malaise, maculopapule
rash, increase liver size (hepatomegaly),
increase wbc caused by
cytomegalovirus infection.
6. Infection -

9) Blood Serum Test

MODULE – 4
 Hematocrit or Hemoglobin = assess the
rate of erythrocyte production. Congenital Heart Disorders with
 Erythrocyte Sedimentation Rate (ESR) = Physiological Signs of
assess inflammatory process. Increase Pulmonary Blood Flow.
 Arterial Blood Gas (ABG) = determine
oxygen saturation level in the blood. Congenital Heart Disorder is Classified
 Prothrombin time and Partial based on Physical Signs of Cyanosis.
thromboplastic time = assess blood
clotting. a) Acyanotic – is a circulatory anomaly involve
 Platelet count = assess blood shunt that move blood from arterial to the
coagulation. Reduce platelet count venous system (oxygenated to unoxygenated
(thrombocytopenia). blood or left to right shunts). Make the child
 Serum sodium = assess sodium level prone to CHF.
 Serum potassium = assess potassium
level b) Cyanotic - a shunt that move blood from
venous to the arterial system (deoxygenated
blood to oxygenated blood or right to left
RISK FACTORS LEAD TO HEART DISEASE
shunts).
FOR ADULT
1) Obesity
2) High cholesterol serum level
3) Lack of exercise

CAUSE OF CONGENITAL HEART DISORDER

1) Family pattern of inheritance
2) Maternal history during pregnancy
such as; exposure to Rubella (German
Measles), Varicella (Chickenpox)

RISK FACTORS LEAD TO HEART DISEASE

FOR CHILD
1) rheumatic fever – autoimmune
response that follows a beta hemolytic
streptococcal
infection such as streptococcal Congenital Heart Disorders with
pharyngitis or impetigo. Physiological Signs of
2) hypertension Increase Pulmonary Blood Flow.
3) hyperlipidemia
4) High intake of sodium 1) VENTRICULAR SEPTAL DEFECT
5) Lack of exercise
6) Obesity

Open Heart Surgery or Intracardiac

catheterization Surgery =

Cardiopulmonary bypass or extracorporeal

membrane oxygenation
- Vital signs
- Monitor body temperature
- Monitor fluid volume
- Record height and weight

Complication of Cardiac Surgery

1. Hemorrhage = due to Heparin was given to  is a genetic causes and most common
prevent blood coagulation. type of congenital cardiac disorder.
Protamine Sulfate antidote for heparin
  An opening that is present in the septum
between the two ventricles.
 Blood shunt from left to right across the
septum.
 The blood flow from left ventricle to
aorta shunt back into the pulmonary
circulation, resulting to right ventricular
hypertrophy and increased pressure in
the pulmonary artery resulting to
pulmonary dilatation.
Signs and Symptoms
1) Loud, harsh systolic murmur
 can be heard at birth (left sternal
rd th
border at the 3 or 4 intercostal
space) – due to incomplete opening
of the lung alveoli.
2)Thrill vibration is palpable.
3) High pulmonary artery resistance
 due to the blood that shunt through
the defect.
4) Easy fatigue
Diagnostic test
1) Chest X- ray
2) Electrocardiography
3) Echocardiography with color flow
Doppler
4) MRT
Therapeutic Management
1) Administration of Diuretic drugs and
Digoxin.
2) Septal Occluder device during cardiac
catheterization
 to prevent chronic pulmonary artery
hypertension.
3) Monitor heart rhythm
 observe for arrhythmias due to
edema in the septum may interfere
conduction from the AV node to the
ventricles.
3) ATRIOVENTRICULAR CANAL DEFECT
(AVCD) also known as (Endocardial Cushion
Defect)
 incomplete fusion of endocardial
cushion or the septum of the heart at
the junction of the atria and the
ventricles possibly involving both mitral
and tricuspid valves.
 The blood flow from left to right and
may extent to four chambers.
 Down syndrome (Trisomy 21)
commonly have these type of
congenital heart disorder.
 Cause is unknown.
Fusion means – the process of joining two or
more things together to form a single entity.
Partial Atrioventricular Canal Defect:
 There's a hole in the wall (septum) that
separates the upper chambers (atria) of
the heart.
 Often the valve between the upper and
lower left chambers (mitral valve) also
has a defect that causes it to leak (mitral
valve regurgitation).
Signs and Symptoms of Partial
Atrioventricular Canal Defect
1) Abnormal heartbeat (arrhythmia)
2) Shortness of breath
3) High blood pressure in the lungs
(pulmonary hypertension)
Complete Atrioventricular Canal Defect:
 There's a large hole in the center of the
heart where the walls between the atria
and the lower chambers (ventricles)
meet. Oxygen-rich and oxygen-poor
blood mix through that hole.
 Instead of separate valves on the right
and left, there's one large valve between
the upper and lower chambers.
 The abnormal valve leaks blood into the
ventricles.
 The heart is forced to work harder and
enlarges.
Signs and Symptoms of Complete
Atrioventricular Canal Defect
1) harsh systolic murmur
nd rd
 can be heard over the 2 or 3
intercostal space (pulmonic area) –
due to increase extra amount of
shunted blood crossing the
pulmonic valve) resulting to close 1
or 2 second later than the aortic
valve.
 the second sound hear sound
during auscultation as split lub dub
dub sound.
2)Thrill vibration is palpable.
3) High pulmonary artery resistance – due to
the blood that shunt through the defect.
4) Easy fatigue
5) Difficulty breathing or rapid breathing
6) Wheezing
7) Lack of appetite
8) Poor weight gain
9) Pale skin color
10) Bluish discoloration of the lips and skin
11) Excessive sweating
12) Irregular or rapid heartbeat
13) Swelling in the legs, ankles and feet
(edema)
The same symptoms of Atrial Septal Defect 4. Heart failure. Untreated, atrioventricular
(ASD) canal defect usually results in the heart's
inability to pump enough blood to meet
 Right Ventricular Hypertrophy, increased the body's needs.
pulmonary blood flow, and fixed S2  Common Signs and Symptoms of
splitting. these complications include:
a. Shortness of breath
Diagnostic test b. Fatigue
c. Rapid, fluttering heartbeat
1) Electrocardiography (ECG)
st
 reveal 1 degree heart  Some children who have corrective
block surgery may still be at risk later in life
 impulse conduction is of:
halted before AV node. a. Leaky heart valves
2) Echocardiography with color flow b. Narrowing of the heart valves
Doppler c. Abnormal heart rhythm
 reveal enlarged right d. Breathing difficulties associated with
side of the heart and lung damage
increase pulmonary
circulation 4) PATENT DUCTUS ARTERIOSUS (PDA)
Therapeutic Management  Maternal history – previously exposure
to rubella.
1) Band may be placed on pulmonary artery
to prevent blood from entering and to
 is an accessory fetal structure that
reduce the amount of pressure in connect the pulmonary artery to the
the pulmonary artery. aorta.
2) Surgery  Closure begin with the first breath and
 valve repair and/ or septal usually complete between 7 and 14
repair days of age full closure may not occur
 artificial valve replacement until 3 months of age.
 nursing care after surgery  Blood will shunt from aorta (oxygenated
= observe for jaundice blood) to pulmonary artery
resulting from RBC
destroyed by the newly
(deoxygenated blood) because higher
constructed valve. pressure in the aorta. The shunt blood
returns to the left atrium of the heart,
3) Administer prophylactic, antibiotic therapy passes to the left ventricle, out to the
and anticoagulation. aorta, and shunt back to the pulmonary
Factors that might increase a baby's risk of artery, causing increased pressure in
developing Atrioventricular Canal Defect the pulmonary circulation from the extra
before birth include: shunted blood = resulting to right
 Down syndrome hypertrophy and ineffective heart action.
 German measles (rubella) or another  Often occurs in pre term baby.
viral illness during a mother's early
pregnancy Signs and Symptoms
 Alcohol consumption during pregnancy
 Poorly controlled diabetes during 1) Wide and strong pulse pressure
pregnancy 2) diastolic pressure is low due to blood
 Smoking during pregnancy shunt reduce resistance.
 Certain medications taken during 3) Murmur - in older child = heard at
pregnancy — upper left sternal border or under left
 Having a parent who had a congenital clavicle.
heart defect - in newborn = harsh
systolic sound.
Complications of Atrioventricular Canal 4) Fast breathing
Defect can include: 5) Not feeding well
1. Enlargement of the heart. Increased 6) Poor growth
blood flow through the heart forces it to 7) Shortness of breath
work harder than normal, causing it to 8) Sweating while feeding
enlarge. 9) Easy fatigue

2. Pulmonary hypertension. When there

is a hole (defect) that allows mixing of Diagnostic test
oxygenated (red) and deoxygenated
(blue) blood, the amount of blood that 1) Electrocardiography (ECG)
goes to the lungs is increased. This  reveal ventricle
results in pressure buildup in the lungs, enlargement if the shunt
causing high blood pressure in the is large
lungs. 2) Echocardiography with color flow
Doppler
3. Respiratory tract  patent ductus
infections. Atrioventricular canal defect 3) Cardiac catheterization
can cause recurrent bouts of lung  rule out associate
infections. disorder.
4) CT angiography
  uses a CT scanner to
produce detailed
images of the blood
vessels following a dye
injection.
5) Chest X-ray
 shows pictures of the
heart and lungs,
including extra blood
flow or fluid in the lungs.
Therapeutic Management
1) IV Indomethacin or Ibuprofen,
prostaglandin inhibitors = closure effect.
Assess the side effects of
Indomethacin = glomerular filtration, impaired
platelet
aggregation, diminished
gastrointestinal and cerebral blood flow
2) Ibuprofen = drug of choice for patent
ductus arteriosus and can be used as
prophylaxis.
3) Cardiac Catheterization = Insertion
of Dacron – coated stainless – steel coils
 when the child is 6
months to 1 year of age.
4) Surgery = Ductal Ligation and / or
using three small thoracotomy
incisions on
the chest and not requiring
extra corporeal circulation.
 close a patent ductus
arteriosus to reduce the
risk of developing a
heart infection called
endocarditis, which
affects the tissue lining
the heart and blood
vessels.
MODULE – 5
Congenital Heart Disorders with
Physiological Signs of
Obstruction to Blood Flow from Ventricles
1) PULMONARY STENOSIS
Narrowing of pulmonary valve or pulmonary
artery just distal to the valve
 Inability of the right ventricle to evacuate
blood by way of the pulmonary artery
because of the obstruction leads to right
ventricular hypertrophy.
Signs and Symptoms
1) Asymptomatic or if severe narrowing
may have signs of mild right sided CHF.
2) Cyanosis – a bluish tint to the skin
caused by blood that is low in oxygen.
3) Murmur – heard at the upper left
sternal border, radiating to the substernal
notch.
4) fainting
5) being very tired
6) poor weight gain
7) shortness of breath
8) palpitations (sensation of rapid or
irregular heartbeat)
9) chest pain
10) swollen abdomen
Diagnostic test
1) Electrocardiography (ECG)
 reveal right ventricular
hypertrophy
2) Echocardiography with color flow
Doppler
 reveals right ventricular
hypertrophy
3) Cardiac catheterization
 used for intervention of
large stenosed valve.
 inserts a catheter (a thin
plastic, flexible tube)
into an artery and vein
that lead to the heart.
Therapeutic Management
1) Pulmonary valve will need to be fixed
or replaced = Balloon Valvuloplasty
2) Valve replacement = using an
artificial valve.
3) Balloon angioplasty
 the catheter with uninflated
balloon is inserted and passed
into the stenosed valve. The
balloon is inflated it breaks valve
adhesions and relieves the
stenosis. The child may
experience residual murmur.
2) AORTIC STENOSIS
 the blood passing freely from the left
ventricle of the heart through the structured
 valve, increased pressure resulting to left
ventricle hypertrophy.
 If the pressure increase, the blood goes
to left atrium resulting to back pressure
in the pulmonary vein and possible
pulmonary edema.
Signs and Symptoms
1) asymptomatic
2) typical murmur
 A rough systolic sound
heard loudest in the second
right interspace (aortic
space)
 Decrease cardiac output if
valve stenosis is severe.
3) faint pulse
4) hypotension
5) tachycardia
6) inability to suck in a long period
7) chest pain
 Similar to angina due to
coronary arteries cannot
receive adequate blood with
strenuous exercise.
Diagnostic test
1) Electrocardiography (ECG)
2) Echocardiography
 reveals right ventricular
hypertrophy
3) Cardiac catheterization
 rarely used unless
interventional therapy is
planned to do.
Therapeutic Management
1) Beta – Blocker or Calcium Channel
Blocker
 to reduce ventricular
hypertrophy
2) Surgery – Balloon Valvuloplasty –
to open the stenosed valve
 Valve replacement =
using an artificial valve
or insertion of
homograft valve or
prosthetic valve
3) anticoagulation and antiplatelet
therapy
4) antibiotic prophylaxis – against
endocarditis
3) COARCTATION OF THE AORTA
 The blood shunt difficult to passed due
to narrowing of aortic lumen resulting to
increase blood pressure and may lead
to CHF.
 A child with obstruction proximal to left
subclavian artery may have absent
brachial pulse.
 BP pressure in the arm will be at least
20 mmHg higher than in the legs.
Signs and Symptoms
1) headache
2) vertigo
3) epistaxis
4) elevated blood pressure to upper
extremities
5) decrease blood pressure to lower
extremities
5) leg pain – diminished blood supply to
their lower extremities
6) absent of palpable femoral pulse
Diagnostic test
1) Electrocardiography (ECG)
2) Echocardiography 3) MRI
4) X- ray
 reveal left sided heart enlargement.
 soft to moderately loud systolic murmur
prominent at the base of the heart.
Therapeutic Management
1) Angiography - Balloon Catheter
2) Surgery – narrowed portion of the
aorta is removed and the end of aorta is
anastomosed (a graft of
transplanted subclavian artery or
prosthetic stent
3) Administer Digoxin and Diuretics – to
reduce severity of Hypertension and CHF.
3) Administer antihypertensive drugs.
4) Balloon angioplasty
 the catheter with uninflated
balloon is inserted and passed
into the narrowed aorta. The
balloon is inflated it breaks
narrowed aortic lumen and
relieves the increase BP.
MODULE – 6
Congenital Heart Disorders with
Physiological Signs of
Decrease Pulmonary Blood Flow.
1) TRICUSPID ATRESIA
 Is an extremely serious disorder.
 The tricuspid valve is completely close
 No blood to follow from the right atrium
to the right ventricle or reach the lungs.
o The foremen ovale and ductus
arteriosus remain open the child
can obtain adequate
oxygenation
Signs and Symptoms
 Extreme cyanosis
 Tachycardia
 Dyspnea
Therapeutic Management
 Surgery – construction of a vena
cava to pulmonary artery shunt
 (Fontan procedure) or restructures
the right side of the heart (Glenn
shunt baffle).
 Intravenous infusion.
 Prostaglandin
 is used to keep the
ductus arteriosus patent
 can be life-saving in
neonates with ductal-
dependent cardiac lesio
ns.
 is used to promote
mixing of pulmonary
and systemic blood
flow.
 improve pulmonary or
systemic circulations,
prior to Balloon Atrial
Septostomy or surgery.
2) TETRALOGY OF FALLOT
 is a serious form of heart disease and
the first type of congenital heart disorder
in children.
 Four anomalies are present;
(1) pulmonary stenosis,
(2) ventricular septal defect,
(3) dextroposition (overriding) of the
aorta,
(4) hypertrophy of the right ventricle.
 From the pulmonary stenosis, pressure
increase in the right side of the heart,
causing blood to shunt from the right
ventricle into the left ventricle and the
overriding aorta resulting to hypertrophy
of right ventricle.
Signs and Symptoms
 Hypercyanotic episode (Tet Spells)
– temporary decreased blood and
oxygen supply to the brain due to
prolong crying and exertion.
 Polycythemia – increase red blood
cells = possible complication; blood
increase viscosity and clots lead to
thrombophlebitis, embolism, or
cerebrovascular accident.
 Severe dyspnea
 Growth restriction
 Clubbing of the fingers
 Syncope – fainting
 A loud, harsh, widely transmitted
murmur or a soft scratchy localized
systolic murmur.
Diagnostic test
1) Echocardiography with color flow
Doppler or ECG
 reveal enlarged chamber of the
right side of the heart.
 Reveal decrease in size of the
pulmonary artery and reduced
blood flow through the lungs.
2) Angiography – definitive evaluation of
the extent of disorder.
3) Cardiac catheterization
Therapeutic Management
 Surgery repair correct the heart
disorder and relieves pulmonary
stenosis, VSD, overriding aorta.
 Post op care – observed
arrhythmias cause by
ventricular septal repair,
edema, and conduction
interference.
 Frequent placed the baby or child in
a squatting or knee chest position
when resting due to physiologic
relief to the overstressed heart by
trapping blood in the lower
extremities.
 Administer Propranolol (Inderal)
 Administer Beta – Blocker
 Administer Morphine Sulfate (for
pulmonary artery dilatation).
 Prostaglandin
MODULE – 7
Congenital Heart Disorders with
Physiological Signs of
Mixed Blood Flow
MIXED BLOOD FLOW DISORDER
 involve mixing of blood from the
pulmonary and systemic circulation in
the heart chamber.
 cyanosis disorders.
 the survival depends upon mixing of
blood from pulmonic and systemic
circulation.
1) TRANSPOSITION OF THE GREAT
ARTERIES
 The aorta is arising from the right
ventricle instead of left and the
pulmonary artery arising from the left
ventricle instead of the right.
 Blood enters to the right atrium then flow
to the right ventricle and goes out into
aorta, returns again by the vena cava.
 Pulmonary vein, goes left atrium, left
ventricle and out the pulmonary artery of
the lungs and return to the left atrium.
 The oxygenated blood never reached
the aorta.
Signs and Symptoms
 Cyanotic at birth
 Murmur may not be present
Diagnostic test
1) Echocardiography with color flow
Doppler
 reveals enlarged heart
2) Cardiac catheterization
 reveals low oxygen saturation
resulting to mixing of blood in
the heart chamber.
 Therapeutic Management
1) Administer Prostaglandin
2) balloon atrial septal pull through using
catheterization to enlarge the septal
opening.
3) The deflated balloon catheter is
passed through the foramen ovale into the
left atrium. Then the balloon
inflated and the catheter is
drawn back into the right atrium.
4) Surgical – it is done at 1 week or 3
months of age.
2) TOTAL ANOMALOUS PULMONARY
VENOUS RETURN.
 the pulmonary vein return to the right
atrium or superior vena cava instead of
left atrium.
 often associated with absence of spleen
Signs and Symptoms
 mild cyanotic but if ductus is close or
septal defect is small cyanosis
increases (right sided CHF will
develop).
 easy fatigue
Diagnostic test
1) Electrocardiography
2) Echocardiography
Therapeutic Management
1) Surgery – re-implanting the
pulmonary veins into left atrium.
2) Balloon Atrial Septal pull through - to
enlarge a small foramen ovale and allow
mixing of blood.
3) Continuous Intravenous fluid
3) TRUNCUS ARTERIOSUS
 A rare disorder. A major artery arising
from left and right ventricle in place of
separate aorta and pulmonary artery
vessels.
Signs and Symptoms
 Cyanotic
 Typical VSD murmur
Therapeutic Management
 Repair or restructuring trunk that
separate vessels.
 Graft that separate the aorta
and pulmonary artery.
4) HYPOPLASTIC LEFT HEART SYNDROME
 Is a rare disorder.
 The left ventricle is not functional or lack
adequate strength to pump blood into
the systemic circulation.
 The right ventricle struggles to maintain
the entire heart action.
 This was accompanied by mitral or
aortic valve atresia.
Signs and Symptoms
 Mild to moderate cyanosis at birth
Diagnostic test
 Prenatal ultrasound – early
detection.
 Echocardiography
Therapeutic Management
 Prostaglandin therapy – to maintain
increase blood supply to the aorta.
 Inhaled nitrogen combined with
oxygen – decrease PO2 and
increase pulmonary resistance and
allow right side of heart to shift more
blood into the left heart and aorta.
 Repair or restructuring of the heart
to promote adequate circulation.
 Heart transplantation is the possible
treatment if unsuccessful surgical
outcome.
 Surgery – Three Stage Of
Reconstruction
1) Norwood procedure = right
ventricle pulmonary artery shunt
st
preformed 1
week of life.
2) Glenn procedure completed
between 3 to 8 months.
3) Fontan procedure performed
between 18 months to 3 years
of age for final
repair.
MODULE – 8
Acquired Heart Disease in Children
Acquired Heart Disease in Children
 The congestive heart disorder usually
occurs after birth because of the
following reasons; rheumatic fever,
kawasaki syndrome, infectious
endocarditis, weaken heart muscle,
presence of severe anemia,
hypocalcemia, and myocarditis.
Two Main Compensatory Methods to Increase
Cardiac Output and Move Blood Forward.
1) Increase number of ventricle beats
per minute.
2) lengthen cardia muscle fibers to
manage more blood with each stroke.
1) CONGESTIVE HEART FAILURE
 Occurs when the myocardium of the
heart is overwhelmed and unable to
pump and circulate enough blood to
supply oxygen and nutrients to body
cells.
 Inefficient route of blood goes to the
lungs and eventually the heart finds
difficult to handle. This happens with
certain kinds of holes or connections
also known as shunts. The oxygenated
blood that has already passed to the
 lungs returned from the heart actually Signs and Symptoms of Congestive Heart
ends up back in the lungs then back in Failure in Older Children
the heart again.
 The left side of the heart are so small or  Inability to tolerate exercise.
narrowed that blood has a difficult time  Poor appetite
ejecting from the heart leading to  Weight loss or lack of weight gain
backup into the lungs. This can be seen  Fluid retention
in critical aortic stenosis,  Extra sound when listening to the heart
critical coarctation of the aorta, (called a gallop)
or hypoplastic left heart syndrome.  Enlargement of the liver
 Puffy eyelids
 In older children, the heart structure is  Pedal edema
normal, it is usually due to a weakening  Chest pain
of the heart muscle, or cardiomyopathy,  Palpitations (irregular heartbeat)
infection of the heart muscle  Dizziness
(myocarditis) or Kawasaki disease,  Syncope (fainting)
which all can lead to congestive heart
failure. Signs and Symptoms of Right Sided
 It occurs after birth because of the Congestive Heart Failure
following reasons;
a) structural problem of the heart
 Tachycardia
b) weak heart muscle
 Hepatomegaly (enlarged liver),
c) Left Sided Heart Failure = backup of
distended
blood and fluid into the lungs.
 Ascites
d) Right Sided Heart Failure = backup of
 Increase venous pressure
blood and fluid into the liver and veins.
 Irritable
e) Patent Ductus Arteriosus = a blood
 Restless from abdominal pain
vessel between the aorta and main
 Edema of lower extremities and
pulmonary
periorbital edema
artery is usually closes. If it is
 Weight gain
large and does not close, the
baby will have an excessive
Signs and Symptoms of Left Sided
amount of blood flow to the
Congestive Heart Failure
lungs. This is a very common
problem in premature infants.
 Orthopnea – increase pulmonary
f) Ventricular Septal Defect = a hole
congestion
between the two lower pumping
 Dyspnea
chambers of the
 Rales (crackles)
heart. These will cause
 Tachycardia
congestive heart failure only if
 Tachypnea
the hole is big enough to allow
 Blood sputum on coughing
so much extra blood flow to the
 Cyanotic
lungs that the heart has to work
 Fatigue
a lot harder to pump blood out
to the body.
Diagnostic test
g) Aortapulmonary window or Truncus
arteriosus = a connection between the two
 Electrocardiogram
main arteries leaving the heart,
 Echocardiography and echocardiogram
i.e., aortopulmonary window
 Chest X – ray
or truncus arteriosus. These
 Exercise test
babies are also at risk for having
 Cardiac catheterization
too much blood flow to the
 MRI - provides a useful evaluate heart
lungs.
function.
h) Atrial septal defect = a holes between
the two upper chambers of the heart rarely
cause problems with congestive
Therapeutic Management
heart failure no matter how large.
 heart surgery
Signs and Symptoms of Congestive Heart
 ventricular assist devices (VADs) or the
Failure in Infant
SynCardia Total Artificial Heart.
 stabilize and support patients while they
 Poor growth. wait for a donor heart to become
 Difficulty breathing. available for transplantation (bridge-to-
 Faster breathing and heart rate. transplant therapy), or to support
 Difficulty eating or may not eat. patients who are not eligible for
 Sleep more or have less energy. transplant (destination therapy).
 Small and wasted appearance.  destination therapy may be an
 The liver may also be enlarged and alternative to heart transplant for some
more easily palpated (felt). patients.
 There may be puffiness of the eyes or  There are several types of
pedal edema right heart fails. medications used to treat congestive
 Delays in reaching developmental heart failure.
milestones.
  Diuretic like Furosemide (Lasix),
which helps the kidneys to
eliminate extra fluid in the lungs.
 Angiotensin Converting Enzyme
inhibitor (ACE) (Captopril), lower
the blood pressure
 (Propranolol), lowering the
blood pressure will decrease the
workload of the heart.
 Digoxin, help pump blood more
efficiently.
 Digoxin toxicity =
anorexia, nausea, vomiting,
dizziness, diarrhea,
headache, arrhythmia, and
bradycardia.
 giving babies high calorie formula via
tube directly from the nose to the
stomach or fortified breast milk can help
give the extra nutrition they require.
 Older children with significant heart
failure can also benefit from nasogastric
feeding to give them more calories and
energy to do their usual activities.
2) PERSISTEN PULMONARY
HYPERTENSION
 It is a failure of normal circulation
transition occurring at birth.
 Caused by;
 hypoxemia secondary to right to
left shunting of blood at the
foramen ovale and ductus
arteriosus.
 Vasoconstriction of pulmonary
artery occurs hypoxia and
acidosis.
 This is occurring in full term
infants who experienced
perinatal asphyxia from their
condition.
 Allow the lungs to rest until
adequate pulmonary
vasodilatation and return of
alveoli perfusion can be
achieved.
Signs and Symptoms
 Asphyxia
 Tachypnea
 Low PO2 – due to inability of the
blood to perfuse the lungs resulting
to hypoxia and acidosis.
Diagnostic test
 Echocardiogram – reveals right to
left shunting of blood across patent
ductus or foramen ovale.
Therapeutic Management
 Supportive therapy such as;
a) oxygen
b) ventilation
c) Intravenous glucose to
provide calories
d) Intravenous antibodies /
antibiotics to combat infection
e) medications reduce
pulmonary resistance
f) low dose dopamine
g) surfactant administration =
vasodilation and reduce
resistance
h) inhaled nitric oxide = promote
pulmonary vasodilatation.
3. RHEUMATIC FEVER
 Is an autoimmune disease.
 Occurs as a reaction of a group A beta-
hemolytic streptococcal infection.
 Inflammation from the immune response
leads to fibrin deposits on the
endocardium and valves.
 Most often occurs in children 6 to 15
years old, crowded areas.
Sources of Streptococcal Infection;
 Pharyngitis
 Tonsillitis
 Scarlet fever
 Strep throat or impetigo
Signs and Symptoms
 Fever
 Sore throat
 Headache
 Muscle pain
 Systolic murmur.
 Prolonged P-R and Q-T interval
 Inflammation and slowing of impulse
conduction
 Loss of voluntary muscle control
resulting to dysfunctional speech.
 Poor hand control – due to
inflammation of basal ganglia
 Hand grasp is weak.
 Elevated sedimentation rate, C-
reactive protein level, and
leukocytes
 Erythema marginatum - a macular
rash in the trunk.
 Subcutaneous nodule (painless
lumps) on the tendons sheath by the
joints. Tender swollen large joint
(polyarthritis)
 Arthralgia
Diagnostic test
 Antibody antistreptococcal titer
(ASO)
 Increased ESR and C- reactive
protein level
Therapeutic Management
 Antibiotics
 Maintain bed rest
 Penicillin therapy
 Corticosteroid therapy – to reduce
the inflammation. Hirsutism around
the face (Cushing syndrome)
 Phenobarbital and Diazepam –
reduce purposeless movement of
chorea.
 If CHF is present to reduce
symptoms administer Digoxin and
Diuretics.

4) KAWASAKI SYNDROME
 known as mucocutaneous lymph
node syndrome, is a disease in
which blood vessels throughout the
body become inflamed.
 The most common symptoms include
a fever that lasts for more than five days
not affected by usual medications, large
lymph nodes in the neck, a rash in
the genital area, and red eyes,
[1]
lips, palms or soles of the feet. Other
symptoms include sore
throat and diarrhea. Within three weeks
of the onset of symptoms, the skin from
the hands and feet may peel. Recovery
then typically occurs. In some
children, coronary artery
aneurysms form in the heart.
 The cause is unknown. It may be due to
an infection triggering an autoimmune
response in those who are genetically
predisposed. It does not spread
between people. Diagnosis is usually
based on a person's signs and
symptoms.
 Other conditions that may present
similarly include scarlet
fever and juvenile rheumatoid arthritis.
Diagnostic test
 ultrasound of the heart
 blood tests may support the diagnosis.
Therapeutic Management
 Typically, initial treatment consists of
high doses
of aspirin and immunoglobulin.
 Usually, with treatment, fever resolves
within 24 hours and there is a full
recovery.
 surgery may occasionally be required -
coronary artery aneurysms occur in up
to 25% and about 1% die.
5) ARRHYTHMIAS
 A condition in which the heart beats with
an irregular or abnormal rhythm.
 Caused by septal trauma,
 Use Holter monitor to detect cardiac
arrhythmias.
 Ventricular tachycardia and atrial
fibrillation are syndrome that occur.
Signs and Symptoms
 Atropine sulfate to counter act vagal
stimulation and increase heart rate.
 Digoxin to decrease and
strengthening the heart rate if
needed.
 Pacemaker implanted
 Cryoablation and Radioablation –
non surgical transverse catheter
technique that can disrupt an
abnormal arrhthymia.
TOPIC 2 FRAMEWORK FOR MATERNAL AND
CHILD HEALTH NURSING (HIGH RISK)
In simple terms, risk is the possibility of
something bad happening. Risk involves
uncertainty about the effects/implications of an
activity with respect to something that humans
value (such as health, well-being, wealth,
property or the environment), often focusing on
negative, undesirable consequences.
(Wikipedia) A dictionary definition of the word
“risk” is hazard, danger, exposure to mischance
or peril. It implies the probability, of adverse
consequences is increased by the presence of
some characteristics or factor. Though all
mothers and children are vulnerable to disease
or disability, there are certain mothers and
infants who are at increased or special risk of
complications of pregnancy/ labor or both.
According to WHO, “A risk factor is defined as
any ascertainable characteristics or
circumstance of a person (or group of such
persons) known to be associated with an
abnormal risk of developing, or being adversely
affected by a morbid process”. High risk
pregnancy is defined as one of which is
complicated by factor or factors that adversely
affects the pregnancy outcome- maternal or
perinatal or both.
TOPIC 3
NATIONAL HEALTH SITUATION ON MATERNAL AND
CHILD NURSING
“Sustainable Development Goal: 3” by World Health
Organization

 Syncope There are 9 Health target for SDG 3, but the

 Palpitation, exercise intolerance following are the goals related to
 Bradycardia
 Tachycardia
Maternal and Child Health
Diagnostic test
3.1 By 2030, reduce the global maternal mortality
 Electrocardiogram (ECG) ratio to less than 70 per 100 000

Therapeutic Management live births.

3.2 By 2030, end preventable deaths of newborns
and children under 5 years of
age, with all countries aiming to reduce neonatal
mortality to at least as low as 12
per 1000 live births and under-5 mortality to at least
as low as 25 per 1000 live
births.
3.3 By 2030, end the epidemics of AIDS, tuberculosis,
malaria and neglected
tropical diseases and combat hepatitis, water-borne
diseases and other
communicable diseases.
3.4 By 2030, reduce by one third premature
mortality from non-communicable
diseases through prevention and treatment and
promote mental health and wellbeing.
MATERNAL, NEWBORN, CHILD HEALTH & NUTRITION
(MNCHN) DOH PROGRAM
The MNCHN is one of the programs which were
created based on DOH’s
Administrative Order 2008-0029, or the
“Implementing Health Reforms for Rapid
Reduction of Maternal and Neo-Natal Mortality.”
The objective of the program is to
educate the community on MNCHN programs,
modify community behavior on the
prevention of occurrences of disease and
complication to reduce risk factors, raise
selfresponsibility for health maintenance, and to
conduct an impact assessment of MNCHN
program in the community through research.
The goal of rapidly reducing maternal and neonatal
mortality shall be achieved
through effective population-wide provision and use
of integrated MNCHN services as
appropriate to any locality in the country. The
strategy aims to achieve the following
intermediate results:
1. Every pregnancy is wanted, planned and
supported;
2. Every pregnancy is adequately managed
throughout its course;
3. Every delivery is facility-based and managed by
skilled birth attendants/skilled
health professionals; and
12
4. Every mother and newborn pair secures proper
post-partum and newborn care
with smooth transitions to the women’s health care
package for the mother and
child survival package for the newborn
This was developed to guide local authorities (chief
executives, health officers and
staff) and other concerned stakeholders in
implementing the MNCHN strategy. It aims to
guide local officials, local health managers and other
concerned groups and professionals
to establish, implement and sustain a responsive
MNCHN service delivery network in
identified priority areas and population groups
needing most assistance. Although the
DOH and Phil Health are not the primary target
users, this shall be their guide in extending
technical assistance and other support to LGUs in the
implementation of the MNCHN
Strategy.
The following key strategies employed reflect this
continuum:
MNCHN Core Package of
services and interventions directed not only to
individual women of reproductive
age and newborns at different stages of the life
cycle8, but also to the community.
of a Service Delivery Network at all
levels of care to provide the
package of services and interventions.
development to bring all
localities to create and sustain their service delivery
networks, which are crucial
for the provision of health services to all.
-up of institutional capacities of DOH
and Phil Health, being the lead
national agencies that will provide support to local
planning and development
through appropriate standards, capacity build-up of
implementers, and financing
mechanisms.
There are three levels of care in the MNCHN Service
Delivery Network (SDN):
(1) Community level service providers;
(2) Basic Emergency Obstetrics and Newborn Care
(BEmONC) - capable network
of facilities and providers; and
(3) Comprehensive Emergency Obstetrics and
Newborn Care (CEmONC) -
capable facility or network of facilities.
1. Community level providers give primary health
care services. These may include
outpatient clinics such as Rural Health Units (RHUs),
Barangay Health Stations (BHS),
and private clinics as well as their health staff (i.e.,
doctor, nurse and midwife) and
volunteer health workers (i.e., barangay health
workers, traditional birth attendants).
2. Basic Emergency Obstetric and Newborn Care
(BEmONC)-capable network of
facilities and providers can be based in hospitals,
RHUs, BHS, lying-in clinics or birthing
13
homes. If the BEmONC is hospital based, blood
transfusion services which may or may
not include blood collection and screening will be
provided. These facilities operate on a
24-hour basis with staff complement of skilled health
professionals such as doctors,
nurses, midwives and medical technologists.
3. Comprehensive Emergency Obstetric and
Newborn Care (CEmONC)- capable
facility or network of facilities are end-referral
facilities capable of managing complicated
deliveries and newborn emergencies. It should be
able to perform the six signal obstetric
functions, as well as provide caesarean delivery
services, blood banking and transfusion
services, and other highly specialized obstetric
interventions. It is also capable of
providing newborn emergency interventions, which
include, at the minimum, the following:
(a) newborn resuscitation; (b) treatment of neonatal
sepsis/infection; (c) oxygen support
for neonates; (d) management of low birth weight or
preterm newborn; and (e) other
specialized newborn services.
TOPIC 4 STATISTICS ON MATERNAL AND CHILD
RISK
TOPIC 5
MATERNAL AND CHILD HEALTH COUNSELLING
The World Health Organization (WHO) developed a
clinical guide entitled
“Pregnancy, Childbirth, Postpartum and Newborn
Care: A guide for essential practice”
(PCPNC). The aim of the PCPNC is to provide
evidence-based recommendations to
guide health care professionals in the management
of women during pregnancy,
childbirth, postpartum and post-abortion periods,
and newborns during the first week of
life, including management of endemic diseases like
malaria, HIV/AIDS, TB and anemia.
All recommendations are for Skilled Attendants (SAs)
who work at the primary level of
care, in health facilities or in the community. While
the PCPNC serves as a guide for
clinical decision-making and includes
recommendations on the information to share with
women and their families, little guidance is included
on how to effectively communicate
and counsel.
16
This guidelines aim to:
1. Understand the women and community he/she
provides services for; both the
overall context in which they live as well as their
specific needs.
2. Counsel and communicate more effectively with
women, their partners and
families during pregnancy, childbirth, postnatal and
post-abortion periods.
3. Use different skills, methods and approaches to
counselling in a variety of
situations, with women, their partners and families
in effective and appropriate ways.
4. Support women, their partners and families to
take actions for better health and
facilitate this process.
5. Contribute to women and the communities’
increased confidence and
satisfaction in the services he/she provides.
As of October 17, 2018, the DOH have established
program
“NATIONAL SAFE MOTHERHOOD PROGRAM”
Vision
For Filipino women to have full access to health
services towards making their pregnancy
and delivery safer.
Mission
Guided by the Department of Health FOURmula One
Plus thrust and the Universal Health
Care Frame, the National Safe Motherhood Program
is committed to provide rational and
responsive policy direction to its local government
partners in the delivery of quality
maternal and newborn health services with integrity
and accountability using proven and
innovative approaches.
Objectives
The Program contributes to the national goal of
improving women’s health and well-being
by:
1. Collaborating with Local Government Units in
establishing sustainable,
cost-effective approach of delivering health services
that ensure access of
disadvantaged women to acceptable and high
quality maternal and
newborn health services and enable them to safely
give birth in health
facilities near their homes
2. Establishing core knowledge base and support
systems that facilitate the
delivery of quality maternal and newborn health
services in the country.
Glossary:
Risk- is hazard, danger, exposure to mischance or
peril. It implies the probability, of
adverse consequences is increased by the presence
of some characteristics or factor.
Health promotion - to engage and empower
individuals and communities to
choose healthy behaviors, and make changes that
reduce the risk of developing chronic
diseases and other morbidities.
Health maintenance - involves helping the clients
achieve and continue to enjoy
optimal health. To identify that target state, discover
their strengths and their needs, and
then support their path to full health and wellness
potential
Health restoration- an act of restoring or the
condition of being restored; bringing back
to a former position or condition
Health rehabilitation- care that can help you get
back, keep, or improve abilities that you
need for daily life. These abilities may be physical,
mental, and/or cognitive (thinking and
learning).
MNCHN- Maternal, Newborn, Child Health &
Nutrition, a Department of Health Program
focuses the mother and child health
BEmONC- Basic Emergency Obstetric and Newborn
Care, one of the level in delivery
service network under the MNCHN Program
CEmONC- Comprehensive Emergency Obstetric and
Newborn Care, the higher authority
referral in MNCHN.
PCPNC- Pregnancy, Childbirth, Postpartum and
Newborn Care: A guide for essential
practice” This aim to provide evidence-based
recommendations to guide health care
professionals in the management of women during
pregnancy, childbirth, postpartum and
post-abortion periods, and newborns
Part 1 Pre-gestational Conditions
HEART DISEASE IN PREGNANCY
t (75%): mitral valve affection is
the commonest followed by aortic
valve then both or others.
A. Acyanotic (left to right shunt): more common, According to New York Heart Association (1964)
includes septal defects and
ort (ex. Dyspnea, palpitation or
patent ductus arteriosus. angina pain) on ordinary

B. Cyanotic (right to left shunt): ex. Tetralogy of activity

Fallot and Eisenmenger’s

syndrome which is more dangerous carries a

mental mortality rate exceeding

25%
decompensated

arrhythmias and cardiomyopathy Effects of Pregnancy on Heart Disease

How to diagnose? 8

Ask for history of:

ever
the puerperium.

Heart Failure

time but the maximum incidence

is between 32 and 34 weeks when blood volume

and cardiac output are in their

peaks. After that they have a plateau level up to full

term.

Examination may reveal:

stress on the heart.

the circulation by the blood

from the placental sinuses after retraction of the

uterus.

Effects of Heart Disease on Pregnancy

of left side heart failure ex: gallop

rhythm, crepitations over lung

bases and pleural effusion.

Congested neck veins, enlarged

Management
tender liver, ascites and edema lower limbs.
General Management:
Diagnostic Test

-ray may show cardiac enlargement,

pulmonary congestion or pleural

effusion and
prevent anemia as it increases

cardiac strain

structure and function

Functional Classification
the earliest evidence is
tachycardia exceeding 100 beats/minute and increased risk to the mother or the fetus in closed
crepitations at the lung base. cardiac surgery ex.

Rest in a hospital is desirable in the last 2 weeks of Mitral valvotomy but there is higher incidence of
pregnancy. fetal loss with open

Specific Management surgery.

Management in Labor and Delivery in Clients with

Heart Conditions
A. Digoxin: is indicated in atrial fibrillation to slow
the ventricular response
is preferable to cesarean
and in acute heart failure to increase myocardial
contractility. section but should be an easy and not a prolonged
one.
B. Diuretics are used in an acute and chronic heart
failure with potassium
clients.
supplements in prolonged therapy.
-sitting position
C. Beta-adrenergic blockers: as propranolol may be
indicated for arrhythmia tion if heart failure or
cyanosis develop.
associated with ischemic heart disease

D. Aminophylline: relieves bronchospasm used. Epidural anesthesia is

E. Heparin: is indicated in patients with artificial preferable as it abolishes the bearing down desire
valves or atrial fibrillation so decrease the effort load.

F. Acute pulmonary edema is urgently treated by:

rgometrine is better avoided as it causes sudden

venous return load of the circulation with

blood from the uterus leading to acute heart

failure. Oxytocin can be used

the increase in instead.

the right heart output cannot be handled by the
mitral valve. against subacute bacterial

endocarditis.

blood rapidly may tpartum observation for 48 hours is essential

indicated in severe as the risk of heart failure is

cases. high in this period. Although bed rest is essential,

early ambulation is desirable to

avoid thromboembolism.
9

failure. Estrogen should not be

class III and IV patient is
used to suppress lactation and bromocriptine or
seen early in pregnancy.
lisurdine can be used.

therapeutic abortion. The

if decompensation occurred in
principal indication is recurrent pulmonary edema
this pregnancy.
with mitral stenosis
TOPIC 2
and heart failure not responding to medical
treatment. There is no 10
DIABETES AND PREGNANCY
Diabetes is a condition in which the body does not
make enough insulin or the
body is unable to use the insulin that is made.
Insulin is the hormone that allows glucose
to enter the cells of the body to make fuel. When
glucose cannot enter the cells, it builds
up in the blood and the body’s cells starve to death.
If not managed properly, diabetes
can have serious consequences for you and your
growing baby.
Pre-Gestational Diabetes
If you already have diabetes and become pregnant,
your condition is known as
pre-gestational diabetes. The severity of your
symptoms and complications often
depends on the progression of your diabetes,
especially if you have vascular (blood
vessel) complications and poor blood glucose
control.
Gestational Diabetes
Gestational diabetes is a condition in which the
glucose level is elevated and other
diabetic symptoms appear during pregnancy.
Unlike other types of diabetes, gestational
diabetes is not caused by a lack of insulin but by
other hormones that block the insulin
that is made. This condition is known as insulin
resistance. If you have gestational
diabetes, you may or may not be dependent on
insulin.
In most cases, all diabetic symptoms disappear
following delivery. However, if you
experience gestational diabetes, you will have an
increased risk of developing diabetes
later in life. This is especially true if you were
overweight before pregnancy.
Causes of Gestational Diabetes
Although the specific cause of gestational diabetes
is unknown, there are several
theories about the origin of this condition. For
example, the placenta supplies the growing
fetus with nutrients and water. It also makes a
variety of hormones to maintain the
pregnancy. Some of these hormones (estrogen,
cortisol and human placental lactogen)
can have a blocking effect on the mother’s insulin,
which usually begins about 20 to 24
weeks into pregnancy.
As the placenta grows, it produces more of these
hormones, increasing the level
of insulin resistance in the mother. Normally, the
mother’s pancreas is able to make
additional insulin to overcome insulin resistance.
However, if the mother’s production of
insulin is not enough to overcome the effect of the
placental hormones, gestational
diabetes results.
The following factors increase the risk of
developing gestational diabetes:
A family history of diabetes
or a child with certain birth
defects
Although increased glucose in the urine is often
included in the list of risk factors, it is
not believed to be a reliable indicator for
gestational diabetes.
Diagnosing Gestational Diabetes
A glucose screening test is usually done between 24
and 28 weeks of pregnancy.
To complete this test, client will be asked to drink a
special glucose beverage. Then, they
will measure your blood sugar level one hour later.
If the test shows an increased blood sugar level, a
three-hour glucose tolerance
test may be done. If the results of the second test
are in the abnormal range, client will
be diagnosed with gestational diabetes.
Treatment Options for Gestational Diabetes
The health care provider, doctor, nurse, or midwife
will determine specific
treatment plan for gestational diabetes based on:
 levels and makes more insulin in an attempt to use
this glucose. The extra glucose
-term expectations for the course of the
disease is then converted to fat. Even when you have
gestational diabetes, your fetus is

able to make all the insulin it needs. The

combination of your high blood glucose
therapies
levels and your baby’s high insulin levels may result
Treatment for gestational diabetes focuses on in large deposits of fat that
keeping blood glucose levels in the
cause your baby to grow excessively large.
normal range. Specific treatment plan may include:

difficult to deliver and become

injured in the process.

the baby right after delivery. This

problem happens if mother’s blood sugar levels

Possible Fetal Complications from Gestational
have been consistently high,
Diabetes
causing the fetus to have a high level of insulin in its
Unlike other types of diabetes, gestational diabetes
circulation. After delivery,
generally does not cause birth
baby continues to have a high insulin level, but it no
defects. Birth defects usually originate sometime
longer has the high level of
during the first trimester of pregnancy.
sugar from mother. This results in the newborn’s
They are more likely if client have pre-gestational
blood sugar level becoming very
diabetes, as she may have changes in
low. Following delivery, baby’s blood sugar level
blood glucose during that time. If she have
will be tested. If the level is too
gestational diabetes, she most likely had
low, it may be necessary to administer glucose
normal blood sugar levels during critical first
intravenously until baby’s blood
trimester.
sugar stabilizes.
12

The complications of gestational diabetes are

much insulin or too much
usually manageable and
glucose in a baby’s system may delay lung
preventable. The key to prevention is careful
maturation and cause respiratory
control of blood sugar levels as soon as the
problems. This is more likely if it is born before 37
diagnosis of gestational diabetes is made.
weeks of pregnancy.
Infants of mothers with gestational diabetes are
TOPIC 3
vulnerable to several imbalances,
SUBSTANCE ABUSE IN PREGNANCY
such as low-serum calcium and low-serum
magnesium levels. In addition, gestational If a client is pregnant or thinking about getting
pregnant and want a healthy baby,
diabetes may cause the following:
then it's very important to avoid drug use during
baby
pregnancy. Illegal drugs such
that is considerably larger
as marijuana, cocaine, and methamphetamine
than normal. All of the nutrients your baby receives
aren't the only drugs that are harmful
come directly from your blood.
to fetal development; Commonly used over-the-
If your blood has too much glucose, your baby’s
counter medicines, along with
pancreas senses the high glucose
substances such as caffeine and alcohol, can have
lasting effects on an unborn child.
Why are pregnant women warned not to use
drugs?
It's possible that pregnant mother may not have a
serious or long-lasting problem
after using drugs. But the same is not always true
for a fetus. Drug-using mothers often
give birth to "drug babies." These children have a
host of developmental problems.
Studies show that using drugs -- legal or illegal --
during pregnancy has a direct
impact on the fetus. If client smoke, drink alcohol,
or ingest caffeine, so does the fetus. If
she use marijuana or crystal meth, fetus also feels
the impact of these dangerous drugs.
And if she are addicted to cocaine -- also called
coke, snow, or blow -- you're not only
putting your own life on the line, but mothers are
risking the health of unborn baby.. The
consequences of using cocaine include heart
attacks, respiratory failure, strokes,
and seizures. And these life-threatening health
problems can also be passed to an unborn
baby.
Taking drugs during pregnancy also increases the
chance of birth defects,
premature babies, underweight babies, and
stillborn births. Exposure to drugs such as
marijuana -- also called weed, ganja, dope, or pot --
and alcohol before birth has been
proven to cause behavior problems in early
childhood. These drugs can also affect the
child's memory and attentiveness. In addition,
some findings show that babies born to
women who use cocaine, alcohol, or tobacco when
they are pregnant may
have brain structure changes that persist into early
adolescence.
While cocaine's effects are usually immediate, the
effect it can have on a fetus
may last a lifetime. Babies born to mothers who
smoke crack cocaine during pregnancy
-- so-called ''crack babies'' -- usually have their own
set of physical and mental problems.
According to the National Institute on Drug Abuse,
exposure to cocaine in the womb can
lead to subtle, yet significant, deficits later in
children. These deficits usually show up in
areas such as cognitive performance, information-
processing, and attention to tasks.
These are areas that are vital for success not just in
school, but in life.
Are any drugs safe during pregnancy?
While a few prescription and over-the-counter
medications are considered "safe"
during pregnancy, most drugs are not. If pregnant
mothers are taking medications for
medical purposes, here are some safety tips to
follow when you are pregnant:
14
. Many of the
products will tell you on the label if
they are safe for use while pregnant. If you are
unsure about taking an OTC
product, call your doctor.
-- herbs, amino
acids, minerals, mega-vitamins --
might be considered natural, but that does not
mean they are safe. Talk with
your health care provider before taking any
unproven or "natural" remedy.
should not be taken during the last 3
months of your pregnancy unless you are instructed
by your doctor to take it. And
if you feel like you need either of these medicines
at any time during pregnancy,
make sure you check with your doctor before
taking it. These drugs can cause
problems for your baby or cause problems when
you are in labor.
vitamins that are safe for mom and
baby. OTC vitamins may have doses that are too
high.
Glossary:
Acyanotic- characterized by the absence of cyanosis
acyanotic patients acyanotic heart
disease
people get HIV, they have it for life.
Cyanosic - occurs when oxygen-depleted
(deoxygenated) blood, which is bluish rather t with proper medical care, HIV can be
than red, circulates through the skin.
controlled. People with HIV who

Murmur - is an unusual noise the heart makes other get effective HIV treatment can live long,
than the “lub-DUB” we're familiar healthy lives and protect their partners.

with. The murmur may be a whooshing, swishing or Where did HIV come from?
clicking noise.

Arrhythmia - is a problem with the rate or rhythm chimpanzee in Central Africa.

of the heartbeat. During

an arrhythmia, the heart can beat too fast, too simian immunodeficiency virus, or
slowly, or with an irregular rhythm.
SIV) was probably passed to humans when
Tachycardia - When a heart beats too fast,
humans hunted these chimpanzees
Bradycardia - When a heart beats too slowly,
for meat and came in contact with their
Electrocardiogram (ECG)- is a simple test that can infected blood.
be used to check your heart's rhythm

and electrical activity. Sensors attached to the skin from chimpanzees to humans as far back
are used to detect the electrical signals
as the late 1800s.
produced by your heart each time it beats.

Echocardiogram (echo) - is a graphic outline of the

Africa and later into other parts of the
heart's movement. During an echo

test, ultrasound (high-frequency sound waves) from

world. We know that the virus has existed in
a hand-held wand placed on your the United States since at least the

chest provides pictures of the heart's valves and mid to late 1970s.
chambers and helps the sonographer
Some people have flu-like symptoms within 2
evaluate the pumping action of the hear to 4 weeks after infection (called acute HIV

Part 2 Pre-gestational Conditions infection). These symptoms may last for a few
days or several weeks. Possible symptoms
TOPIC 1
include
HIV (human immunodeficiency virus)/ AIDS
(acquired immunodeficiency

syndrome)

HIV (human immunodeficiency virus) is a virus

that attacks the body’s immune

system. If HIV is not treated, it can lead to AIDS

(acquired immunodeficiency syndrome).

What Is HIV?

virus that attacks the body’s immune lymph nodes, and

system. If HIV is not treated, it can lead to AIDS
(acquired immunodeficiency
But some people may not feel sick during
syndrome).
acute HIV infection. These symptoms don’t
mean you have HIV. Other illnesses can
cause these same symptoms.
8 moves into Stage 3.
What are the stages of HIV?
When people with HIV don’t get treatment,
they typically progress through three stages.
But HIV medicine can slow or prevent
progression of the disease. With the
advancements
in treatment, progression to Stage 3 is less
common today than in the early days of HIV.
Stage 1: Acute HIV Infection
le have a large amount of HIV in their
blood. They are very contagious.
-like symptoms. This is
the body’s natural response to
infection.
or at all.
-like symptoms and think you
may have been exposed to HIV, seek
medical care and ask for a test to diagnose
acute infection.
tests (NATs) can diagnose acute
infection.
Stage 2: Chronic HIV Infection
ptomatic HIV
infection or clinical latency.
levels.
sick during this phase.
may last a decade or longer, but some
may progress faster.
in the blood (called viral load) goes up
and the CD4 cell count goes down. The person
may have symptoms as the virus
levels increase in the body, and the person
may never move into Stage 3.
Stage 3: Acquired Immunodeficiency Syndrome
(AIDS)
immune systems that they get an
increasing number of severe illnesses, called
opportunistic infections.
CD4 cell count drops below 200
cells/mm, or if they develop certain
opportunistic infections.
h viral load
and be very infectious.
typically survive about three years.
A pregnant woman living with HIV can pass on
the virus to her baby
during pregnancy, childbirth and through
breastfeeding. If you are a woman living
with HIV, taking antiretroviral treatment
correctly during pregnancy and breastfeeding
can
virtually eliminate the risk of passing on the
virus to your baby.
9
TOPIC 2
Rh SENSITIZATION
What is Rh sensitization during pregnancy?
If a client is Rh-negative, the red blood cells do
not have a marker called Rh factor
on them. Rh-positive blood does have this
marker. If the blood mixes with Rh-positive
blood, immune system will react to the Rh
factor by making antibodies to destroy it. This
immune system response is called Rh
sensitization.
What causes Rh sensitization during
pregnancy?
Rh sensitization can occur during pregnancy if
client is Rh-negative and pregnant
with a developing baby (fetus) who has Rh-
positive blood. In most cases, blood will not
mix with the baby's blood until delivery. It
takes a while to make antibodies that can
affect
the baby, so during first pregnancy, the baby
probably would not be affected.
But if mother get pregnant again with an Rh-
positive baby, the antibodies already
into the blood could attack the baby's red
blood cells. This can cause the baby to
have anemia, jaundice, or more serious
problems. This is called Rh disease. The
problems will tend to get worse with each Rh-
positive pregnancy.
Rh sensitization is one reason it's important to
see a doctor in the first trimester of
pregnancy. It doesn't cause any warning
symptoms, and a blood test is the only way to
know you have it or are at risk for it
almost always be prevented.
can help protect your baby.
Who gets Rh sensitization during pregnancy?
Rh sensitization during pregnancy can only
happen if a woman has Rh-negative
blood and only if her baby has Rh-positive
blood.
-negative and the father is
Rh-positive, there is a good chance
the baby will have Rh-positive blood. Rh
sensitization can occur.
-negative blood, the
baby will have Rh-negative blood.
Since the mother's blood and the baby's blood
match, sensitization will not occur.
If a mother have Rh-negative blood, the doctor
will probably treat her as though the
baby's blood is Rh-positive no matter what the
father's blood type is, just to be on the safe
side.
How is Rh sensitization diagnosed?
All pregnant women get a blood test at their
first prenatal visit during early
pregnancy. This test will show if a client have
Rh-negative blood and if she is Rhsensitized.
If a mother have Rh-negative blood but are not
sensitized:
and 28 weeks of pregnancy. If the
test still shows that she are not sensitized,
probably will not need another antibody
test until delivery. (She might need to have the
test again if she have an
amniocentesis, if pregnancy goes beyond 40
weeks, or if she have a problem such
as abruptio placenta, which could cause
bleeding in the uterus.)
the newborn has Rh-positive blood, the
mother will have an antibody test to see if she
were sensitized during late
pregnancy or childbirth.
If you are Rh-sensitized, the doctor will watch
the pregnancy carefully. The mother
may have:
vel of
antibodies in the blood.
the baby's brain. This can show anemia
and how severe it is.
baby's blood type and Rh factor and
to look for problems.
How is Rh sensitization prevented?
 -negative blood but are
not Rh-sensitized, the doctor will give
one or more shots of Rh immune globulin
(such as WinRho). This prevents Rh
sensitization in nearly all women who use it.
She may get a shot of Rh immune globulin:
amniocentesis.
-positive.
How is it treated?
If a mother is Rh-sensitized, she will have
regular testing to see how the baby is
doing. She may also need to see a doctor who
specializes in high-risk pregnancies (a
perinatologist).
Treatment of the baby is based on how severe
the loss of red blood cells (anemia) is.
more testing than usual while she is
pregnant. The baby may not need any special
treatment after birth.
deliver the baby early. After delivery,
some babies need a blood transfusion or
treatment for jaundice.
ve a blood
transfusion while still in the uterus.
This can help keep the baby healthy until he or
she is mature enough to be
delivered. You may have an early C-section,
and the baby may need to have
another blood transfusion right after birth
TOPIC 3
ANEMIA IN PREGNANCY
During pregnancy, body produces more blood
to support the growth of the baby.
If a mother is not getting enough iron or
certain other nutrients, body might not be able
to
produce the amount of red blood cells it needs
to make this additional blood.
It's normal to have mild anemia when
pregnant. But mother may have more severe
anemia from low iron or vitamin levels or from
other reasons.
Anemia can leave to feeling tired and weak. If
it is severe but goes untreated, it
can increase the risk of serious complications
like preterm delivery.
Here's what a mother need to know about the
causes, symptoms, and treatment
of anemia during pregnancy.
Types of Anemia during Pregnancy
Several types of anemia can develop during
pregnancy. These include:
on-deficiency anemia
-deficiency anemia
12
Here's why these types of anemia may
develop:
Iron-deficiency anemia. This type of anemia
occurs when the body doesn't have
enough iron to produce adequate amounts of
hemoglobin. That's a protein in red blood
cells. It carries oxygen from the lungs to the
rest of the body.
-deficiency anemia, the blood cannot
carry enough oxygen to tissues
throughout the body.
anemia in pregnancy.
Folate-deficiency anemia. Folate is the vitamin
found naturally in certain foods like
green leafy vegetables a type of B vitamin, the
body needs folate to produce new cells,
including healthy red blood cells.
But sometimes they don't get
enough from their diet. When that happens,
the body can't make enough normal
red blood cells to transport oxygen to tissues
throughout the body. Manmade
supplements of folate are called folic acid.
ctly contribute to
certain types of birth defects, such as
neural tube abnormalities (spina bifida) and
low birth weight.
Vitamin B12 deficiency. The body needs
vitamin B12 to form healthy red blood cells.
When a pregnant woman doesn't get enough
vitamin B12 from their diet, their body can't
produce enough healthy red blood cells.
Women who don't eat meat, poultry, dairy
products, and eggs have a greater risk of
developing vitamin B12 deficiency, which may
contribute to birth defects, such as neural tube
abnormalities, and could lead to preterm
labor.
Blood loss during and after delivery can also
cause anemia.
Risk Factors for Anemia in Pregnancy
All pregnant women are at risk for becoming
anemic. That's because they need
more iron and folic acid than usual. But the risk
is higher if:
child)
Symptoms of Anemia during Pregnancy
The most common symptoms of anemia during
pregnancy are:
Risks of Anemia in Pregnancy
Severe or untreated iron-deficiency anemia
during pregnancy can increase your risk of
having:
-birth-weight baby
amount of blood during delivery)
with developmental delays
Untreated folate deficiency can increase your
risk of having a:
-birth-weight baby
or brain (neural tube defects)
raise your risk of having a baby with
neural tube defects.
Tests for Anemia
hemoglobin -- an iron-rich protein in
red blood cells that carries oxygen from the
lungs to tissues in the body.
the percentage
of red blood cells in a sample of
blood.
Treatment for Anemia
supplement in addition to your prenatal
vitamins
recommend to take a vitamin B12
supplement.
ommend to include more animal
foods in the diet, such as:

Preventing Anemia
To prevent anemia during pregnancy, make
sure to get enough iron. Eat well-balanced
meals and add more foods that are high in iron
to your diet.
Aim for at least three servings a day of iron-
rich foods, such as:
14
broccoli, and kale)
-enriched cereals and grains
ans, lentils, and tofu
Foods that are high in vitamin C can help the
body absorb more iron. These include:
Also, choose foods that are high in folate to
help prevent folate deficiency. These
include:
Glossary:
HIV (human immunodeficiency virus) is a virus
that attacks the body’s immune system
AIDS (acquired immunodeficiency syndrome)
Antiretroviral a drug that HIV person is taking
Rh sensitization a condition in pregnancy that
involves the blood of a mother and a baby
Anemia is a condition in which you lack enough
healthy red blood cells to carry adequate
oxygen to your body's tissues.
Iron-deficiency anemia is a type of anemia
occurs when the body doesn't have enough
iron to produce adequate amounts of
hemoglobin.
Folate-deficiency anemia lack or less folate in
the body that cause anemia
Acyanotic- characterized by the absence of
cyanosis acyanotic patients acyanotic heart
disease
Cyanosic - occurs when oxygen-depleted
(deoxygenated) blood, which is bluish rather
than red, circulates through the skin.
Murmur - is an unusual noise the heart makes
other than the “lub-DUB” we're familiar
with. The murmur may be a whooshing,
swishing or clicking noise.
Arrhythmia - is a problem with the rate or
rhythm of the heartbeat. During an
arrhythmia,
the heart can beat too fast, too slowly, or with
an irregular rhythm.
Tachycardia - When a heart beats too fast,
Bradycardia - When a heart beats too slowly,
Electrocardiogram (ECG)- is a simple test that
can be used to check your heart's rhythm
and electrical activity. Sensors attached to the
skin are used to detect the electrical signals
produced by your heart each time it beats.
Echocardiogram (echo) - is a graphic outline of
the heart's movement. During an echo
test, ultrasound (high-frequency sound waves)
from a hand-held wand placed on your
chest provides pictures of the heart's valves
and chambers and helps the sonographer
evaluate the pumping action of the heart
FIRST TRIMESTER

GESTATIONAL CONDITIONS (Antiemetic)

TOPIC 1

HYPEREMESIS GRAVIDARUM

Other treatment:
nausea, vomiting, weight loss, and

electrolyte disturbance.
changes, rest, and antacids.
the hospital so that the mother can
receive fluid through an Intravenous Fluid
(IVF).
- the pressure to reduce
nausea is located at the middle of the inner
wrist, three finger lengths away from the
crease of the wrist, and between the two
tendons. Locate and press firmly, one wrist
at a time for three minutes.
– ginger or peppermint

problem without consulting.

TOPIC 2
SIGNS and SYMPTOMS
ECTOPIC PREGNANCY

Ectopic pregnancy, also known as tubal

pregnancy, is a complication of pregnancy
-
in which the embryo attaches outside the
pregnancy weight
uterus. Signs and symptoms classically
include

abdominal pain and vaginal bleeding. The

pain may be described as sharp, dull, or

crampy. Pain may also spread to the

shoulder if bleeding into the abdomen has
occurred.

Severe bleeding may result in a fast heart

rate, fainting, or shock. With very rare

exceptions the fetus is unable to survive.

ood pressure
Risk Factors:
-100
beats per minute)
Chlamydia infection

TREATMENTS

Those who have previously had an ectopic

pregnancy are at much higher risk of
having another one. Most ectopic
pregnancies (90%) occur in the Fallopian
tube which
are known as tubal pregnancies.
Implantation can also occur on the cervix,
ovaries, or within the abdomen.
Diagnosis
Transvaginal ultrasonography
An ultrasound showing a gestational sac
with fetal heart in the fallopian tube has
a very high specificity of ectopic
pregnancy. Transvaginal ultrasonography
has a
sensitivity of at least 90% for ectopic
pregnancy.
The combination of a positive pregnancy
test and the presence of what appears to
be a normal intrauterine pregnancy does
not exclude an ectopic pregnancy, since
there may be either a heterotopic
pregnancy or a "pseudosac", which is a
collection of within
the endom Treatment
● Surgery
● Exploratory Laparotomy
● Salphingectomy or Salphingostomy (right
or left)- removal of the ovary
TOPIC 3
GESTATIONAL TROPHABLASTIC DISEASE
(H-mole)
A hydatidiform mole is a growing mass of
tissue inside your womb (uterus) that will
not develop into a baby. It is the result of
abnormal conception. It may cause
bleeding in
early pregnancy and is usually picked up in
an early pregnancy ultrasound scan. It
needs
to be removed and most women can
expect a full recovery. However, close
follow-up is
needed after a hydatidiform mole because
there is a small chance of developing a
type
of cancer.
Understanding conception
The reproductive cells - eggs (ova) in
women and sperm in men - only have 23
chromosomes. This is so that, when a
sperm fertilizes an egg during normal
conception,
the child that is produced has 46
chromosomes in each cell - 23 from their
mother and 23
from their father. The fertilized egg (ovum)
has a complete set of genetic material.
After fertilization, some cells from the
fertilized ovum (called the trophoblast
cells)
develop into the placenta and membranes
that form around the developing baby.
The other cells develop into the embryo
from which the baby grows. As the
placenta
develops, the trophoblast cells grow into
and attach to the lining of the womb
(uterus),
allowing the pregnancy to implant in the
uterus (endometrium).
There are two types of molar pregnancy,
complete molar pregnancy and partial
molar pregnancy. In a complete molar
pregnancy, the placental tissue is abnormal
and
swollen and appears to form fluid-filled
cysts. There's also no formation of fetal
tissue. In
a partial molar pregnancy, there may be
normal placental tissue along with
abnormally

forming placental tissue. There may also

be formation of a fetus, but the fetus is not
able
to survive, and is usually miscarried early
in the pregnancy.
Actual photo of fetus implanted on
Fallopian Tube
Actual photo of an ectopic pregnancy
10
A molar pregnancy can have serious
complications, including a rare form of
cancer
and requires early treatment.
Signs and Symptoms
A molar pregnancy may seem like a normal
pregnancy at first, but most molar
pregnancies cause specific signs and
symptoms, including:
bleeding during
the first trimester
Causes
A molar pregnancy is caused by an
abnormally fertilized egg. Human cells
normally contain 23 pairs of chromosomes.
One chromosome in each pair comes from
the father, the other from the mother.
In a complete molar pregnancy, an empty
egg is fertilized by one or two sperm,
and all of the genetic material is from the
father. In this situation, the chromosomes
from
the mother's egg are lost or inactivated
and the father's chromosomes are
duplicated.
In a partial or incomplete molar pregnancy,
the mother's chromosomes remain but
the father provides two sets of
chromosomes. As a result, the embryo has
69
chromosomes instead of 46. This most
often occurs when two sperm fertilize an
egg,

resulting in an extra copy of the father's

genetic material.
cysts
Risk factors
sure or pain
Approximately 1 in every 1,000
pregnancies is diagnosed as a molar
Other signs: pregnancy.

— the uterus is too Various factors are associated with molar

large for pregnancy, including:

the stage of pregnancy

likely in women older than age 35 or

younger than age 20.

— a condition that causes
high blood pressure and protein in the
one molar pregnancy, you're more
urine after 20 weeks of pregnancy
likely to have another. A repeat molar
pregnancy happens, on average, in 1 out of
every 100 women.
Diagnosis
(first trimester)
Treatment
need to have
it removed. This means having a small
operation. This
is done in hospital by a doctor who is a
gynecology
specialist. You will be given an anesthetic.
In most
cases, a small tube is passed into your
womb (uterus)
through the opening of your uterus (your
cervix) and the
abnormal tissue is removed by suction
(suction
curettage). The tissue is then sent off to
the laboratory
for examination under the microscope.
egularly
TOPIC 4
INCOMPETENT CERVIX
Also called a cervical insufficiency, is a
condition that occurs when weak cervical
tissue causes or contributes to premature
birth or the loss of an otherwise healthy
pregnancy.
Before pregnancy, your cervix — the lower
part of the uterus that connects to the
vagina — is normally closed and rigid. As
pregnancy progresses and you prepare to
give
birth, the cervix gradually softens,
decreases in length (effaces) and opens
(dilates). If
you have an incompetent cervix, your
cervix might begin to open too soon —
causing you
to give birth too early.
An incompetent cervix can be difficult to
diagnose and, as a result, treat. If your
cervix begins to open early, your health
care provider might recommend
preventive
Snow-storm pattern seen in an ultrasound
Actual photo of H-mole
12
medication during pregnancy, frequent
ultrasounds or a procedure that closes the
cervix
with strong sutures (cervical cerclage).
Signs and symptoms
● A sensation of pelvic pressure
● A backache
● Mild abdominal cramps
● A change in vaginal discharge
● Light vaginal bleeding
Risk Factors
abnormalities and genetic disorders
affecting
a fibrous type of protein that makes up
your body's connective tissues
(collagen) might cause an incompetent
cervix. Exposure to diethylstilbestrol
(DES), a synthetic form of the hormone
estrogen, before birth also has been
linked to cervical insufficiency.
cervical tear during a previous labor and
delivery, you could have an incompetent
cervix. Other surgical procedures
involving the cervix, such as those to deal
with an abnormal Pap test, may
cause damage that contributes to cervical
insufficiency
procedure is used to diagnose or treat
various uterine conditions — such as heavy
bleeding — or to clear the uterine
lining after a miscarriage or abortion. On
rare occasions it may cause structural
damage to the cervix.
Complications
your pregnancy — particularly during the
second trimester — including:
Treatment
weakened cervix is a procedure that sews
the cervix closed to reinforce the weak
cervix. This procedure is called a cerclage
and is usually performed between week
14-16 of pregnancy. These sutures will be
removed between 36-38 weeks to
prevent any problems when you go into
labor.
Why is a cervical cerclage done?
stitches in the cervix to hold it closed. In
select cases, this procedure is used to
keep a weak cervix (incompetent cervix)
from opening early. When a cervix opens
early, it may cause preterm labor and
delivery.
Who needs cervical cerclage?
mends cervical stitch
because you've had problems with a
previous pregnancy, it should ideally be
done 12 to 14 weeks into your pregnancy.
Otherwise, you can have the surgery up to
24 weeks. Past that date, cervical stitch
could cause the amniotic sac to rupture
and make your baby come too soon.
TOPIC 5
ABORTION
Abortion is the ending of pregnancy by
removing a fetus or embryo before it can
survive outside the uterus. Abortion that
occurs spontaneously is also known as a
miscarriage.
An abortion may be caused purposely and
is then called an induced abortion, or less
frequently, "induced miscarriage".
INDUCED ABORTION
pregnancies.
due to legality, regional availability, and
doctor or a women's personal preference.
are typically characterized as either
therapeutic or elective. An abortion is
medically referred to as a therapeutic
abortion
when it is performed to save the life of the
pregnant woman; prevent harm to the
woman's physical or mental health;
terminate a pregnancy where indications
are that
the child will have a significantly increased
chance of premature morbidity or
mortality
14
or be otherwise disabled; or to selectively
reduce the number of fetuses to lessen
health risks associated with multiple
pregnancy
SPONTANEOUS ABORTION (MISCARRAGE)
embryo or fetus before the 24th week of
gestation.
of gestation resulting in a live-born infant
is
known as a "premature birth" or a
"preterm birth". When a fetus dies in utero
after
viability, or during delivery, it is usually
termed "stillborn".
abortion during the first trimester is
chromosomal abnormalities of the embryo
or fetus, accounting for at least 50% of
sampled early pregnancy losses
(such as lupus), diabetes, other hormonal
problems, infection, and abnormalities of
the uterus.
history of previous spontaneous abortions
are the two leading factors associated with
a greater risk of spontaneous abortion.
RECURRENT MISCARRIAGE/ABORTION OR
HABITUAL ABORTION
Recurrent pregnancy loss (RPL), also
referred to as recurrent
miscarriage/abortion or
habitual abortion, is historically defined as
3 consecutive pregnancy losses prior to 20
weeks from the last menstrual period.
ETIOLOGY
● Common etiologies of early pregnancy
loss (EPL) include chromosomal
abnormalities, maternal anatomic
abnormalities, and trauma.
Chromosomal abnormalities —
Chromosomal abnormalities are present in
up to 70
percent of pregnancy losses before 20
weeks.
Maternal anatomic anomalies — Anatomic
anomalies, such as uterine leiomyomas
(fibroids), polyps, adhesions, or septa, may
be associated with EPL based on their
size and position in relation to the
developing pregnancy. These may not be
identified
15
prior to experiencing EPL but, once
diagnosed, can often be surgically or
medically
addressed before another pregnancy is
attempted.
Trauma- Significant trauma can cause EPL.
The developing embryo is relatively
protected within the uterus in early
pregnancy, but trauma that results in
direct impact
to the uterus can result in EPL. This can be
due to violent trauma (gunshot wounds,
penetrating injuries) or iatrogenic trauma,
as with chorionic villus sampling and
amniocentesis
A history of intimate partner violence (IPV)
is consistently associated with higher
incidence of EPL, though the data on IPV effects (such as the relief of tension or
directly resulting in EPL are more mixed. pain) — compare shiatsu
GENERAL MATERNAL FACTORS
19
✔ Infections
Hypnosis induction of a state of
✔ Environmental factors consciousness in which a person
apparently loses the
✔ Psychological factors
power of voluntary action and is highly
-Depression responsive to suggestion or direction
-Mental health issues Pelvic inflammatory disease (PID) is an
infection of the female reproductive
-Emotional stress
organs. It
-Systemic disorders
most often occurs when sexually
Diagnosis transmitted bacteria spread from your
vagina to your
Ultrasound (to determine what type of
abortion) uterus, fallopian tubes or ovaries

Treatment/Management Exploratory laparotomy, also known as a

celiotomy or "ex lap," is a type of major
Dilation and curettage (D&C)
surgery that involves opening the
⮚ A procedure to remove tissue from inside
abdomen with a large incision in order to
the uterus. Doctors perform dilation
visualize the
and curettage to diagnose and treat
entire abdominal cavity
certain uterine conditions — such as heavy
Salpingectomy is the surgical removal of a
bleeding — or to clear the uterine lining
fallopian tube
after a miscarriage or abortion.
Salpingostomy is the creation of an
opening into the fallopian tube, but the
od transfusion if with decrease tube itself is
hemoglobin
not removed in this procedure

Pseudosac is a collection of fluid within the

endometrial cavity itself, created by
bleeding
Glossary:
from the decidualized endometrium
Nausea is stomach discomfort and the associated with an extrauterine pregnancy
sensation of wanting to vomit
implantation
Vomiting eject matter from the stomach
through the mouth

Acupressure application of pressure (as

with the thumbs or fingertips) to the same

discrete points on the body stimulated in

acupuncture that is used for its therapeutic
 MODULE
NUSING CARE OF CHILDREN WITH
ALTERATIONS IN
IMMUNOLOGIC RESPONSES
Module 1
2022 NATIONAL HEALTH GOALS
RELATED TO IMMUNE DISORDERS
IN CHILDREN
1. Reduce indoor allergen level such as
cockroach allergens in settled dust.
2. Increased indoor air quality
management program to promote a
healthy and safe environment.
3. Reduce new cases of prenatally
acquired AIDS.
4. reduce new AIDS cases among
adolescents and adult
5. Increase sexually active unmarried
females aged 15 to 44 years’ old who
use condoms or contraceptives.
Nursing Diagnosis associated with
immune dysfunctions
 Risk for infection related to
altered immune response.
 Impaired skin integrity related to
inadequate lymphocytes
protection.
 Activity intolerance related to
chronic illness.
 Risk for delayed growth and
development related to chronicity
of HIV / AIDS.
 Risk for infection related to
altered skin integrity.
Nursing Diagnosis associated with
allergic response
 Situational low self – esteem
related to symptoms of contact
dermatitis.
 Ineffective breathing pattern
related to bronchial spasm of
anaphylaxis.
 Anxiety related to continuing
allergic response.
 Powerlessness related to
difficulty determining cause of
allergy.
UNIT 1 ANATOMY OF
IMMUNE SYSTEM
Lesson 1
The Immune System
 Is a complex network of cells
interacting to protect the body
against invasion by foreign
substances.
 Immunity: the body’s specific
protective response to
invading foreign agent or
organism.
 Immunopathology: the study
of diseases that result from
dysfunction of the immune
system.
 Autoimmune reaction: result
when normal defense become
self-destructive, cause the
body to recognizes its own
antigens as foreign.
Caused by;
1. Genetics
2. Hormonal
3. Environmental
 Immune disorders:
  Automimmunity – attacks
the body, leading to tissue
damage. Immune
response to one’s self.
 Hypersensitivty –
responses to specific
antigens.
 Gammopathies –
immunoglobulins are
overproduced.
 Immune deficiencies:
 Primary –
deficiency results
from improper
development of
immune cells or
tissues, usually with
a genetic basis.
 Secondary –
deficiency results
from some
interference with an
already developed
immune system.
Types of Immunity
1. Active Immunity
Natural – antibodies formed in
body during the course of disease
Artificial – vaccine/ booster
(anamnestic effect)
Killed vaccine – contain
killed microbes (pertussis/ typhoid)
Live vaccine – contain
attenuated microbes (poliomyelitis/
measles) Toxoid –
inactivated bacterial (tetanus/ diphtheria
toxoid)
2. Passive Immunity – antibodies
acquired from the outside source
produce short term immunity
Natural – passage of antibodies
from mother through placental to
fetus or
through colostrum’s, first
few week of life newborn is
immune to certain disease
which mother has active
immunity.
Artificial - injection of antisera
derived from immunized animals.
Types of Immune Response
1. Nonspecific Immune Response
A) Body surface barriers – intact skin,
mucus secretions, mucosa, cilia
(act as physical protective
barriers)
B) Antimicrobial secretions – skin,
tears, gastric juice, vaginal secretion
a) Internal microbial agent
Interferon = response to
viral attack.
Properdin (Factor P) =
protein agent in the body
that destroys certain
gram negative
bacteria and viruses
Lysozyme = destroy gram
positive bacteria
b) Phagocytes (Monocytes,
macrophages – mature white blood
cells) – cell
ingest and destroy
microbes.
 Engulf, ingest,
and neutralize
the pathogens.
c) Inflammatory response –
creates vascular and cellular changes
that help
to rid the body of dead
tissue and the inactivated
antigens.
1st Stage = release
histamine and chemical
mediators
(eg.prostaglandin,
bradykinin) lead to
vascular dilatation
and increased
capillary
permeability,
resulting to signs of
inflammation)
nd
2 Stage = exudates
production
3rd Stage = reparative
phase
2. Specific Immune Response
a) Humoral Mediated Immunity
– B lymphocytes =
 produce/secrete antibodies or B. Cellular Responses (T
immunoglobulins Cells) – Thymus
Functions: • Transplant
a. Antigen – is any foreign rejection
substances (allergen) capable of • Delayed
stimulating hypersensitivity
production of (tuberculin reaction)
antibodies. Most antigens • Graft-versus-host
are protein and disease
polysaccharides. A • Tumor
combination of large surveillance or
molecule is usually destruction
known as protein • Intracellular
process is called infections
Hapten Formation.
b. Antibody – immune Variety of Routes Allergens
substance produced by plasma can Enter to the Body
1. ingested – foods
cell
2. inhaled – pollen, dust,
Immunoglobulin (Ig) mold spores
b) Cellular Mediated Immunity 3. injected – drugs
– T lymphocytes = stimulate 4. absorbed across the
immune system skin and mucous membrane
and invade microbes and
secrete cytokines
Stages of Immune Response
Functions:
a. Protect against
(I) recognition stage, antigens
bacterial infection,
are recognized by circulating
fungal, viral, protozoa
lymphocytes &
b. Reject histo-
macrophages.
incompatible grafts
c. Cause skin
(II) proliferation stage, the
hypersensitivity
dormant lymphocytes proliferate and
reaction
differentiate
d. Assist with diagnosis of
into cytotoxic (killer) T cells
malignancies
or B cells responsible for
formation and release of
antibodies.

(III) response stage, the

Role of Cellular and Humoral
cytotoxic T cells and the B cells perform
Immune Responses
cellular and
A. Humoral Responses
humoral functions.
(B Cells) – Bone marrow
• Bacterial
(IV) effector stage, antigens are
phagocytosis and
destroyed or neutralized through the
lysis
action
• Anaphylaxis
of antibodies, complement,
• Allergic hay fever
macrophages, and cytotoxic T
and asthma
cells.
• Immune complex
disease
The Organs of Immune System
• Bacterial and 1. lymph nodes
some viral 2. bone marrow
infections 3. thymus
 4. spleen
5. tonsils
Types of Immunoglobulins
1. IgG = across the placenta to
supply passive immune
protection.
2. IgA = antibodies present in
tears, salivary gland, respiratory
tract.
3. IgM = first antibodies to be
detected after exposure to
antigen.
4. IgE = hypersensitivity, allergic
response, and parasitic
infections.
5. IgD = antibodies found in
plasma help differentiate B
lymphocytes.
Quantitative immunoglobulin test =
IgG = 600 – 1600 mg/ 100ml
IgA = 20 – 500mg/ 100ml
IgM = 60 – 200mg/ 100ml
IgE = small to measure
IgD = small to measure
Lymphoid Organ Development of Cell
in Immune System
 B lymphocytes mature in
the bone marrow; T
lymphocytes mature in the
thymus where they also
differentiate into cells with
various functions.
The Role of Antibodies
 Agglutination of antigens
 Opsonization
 Promote release of
vasoactive substances;
activation of complement
system and phagocytosis
 Act in concert with other
components of the
immune system
 Types of Immunoglobulins:
IgG, IgA, IgM, IgE, and IgD
Non-T and Non-B Lymphocytes
Involved in Immune Response
 Null cells - destroy antigen
coated with antibody
 Natural killer cells - defend
against microorganisms
and some malignant cells
Variables That Affect Immune
System Function
 Age and gender
 Nutrition
 Presence of conditions
and disorders
 Allergies
 History of infection and
immunization
 Genetic factors
 Lifestyle
 Medications and
transfusions
 Psychoneuroimmunology
factors
Three line of defense; (1) physical
barriers (2) inflammatory response (3)
immune response
Factors that determine the
immunogenic potential of an
antigen:
1. Foreignness – the degree to which a
molecule is different from molecules
normally found in the body. The more
foreign the substance, the more
immunogenic it is.
Example:
Rabbit – injected with own serum
 No immune response
(non-reactive)
Guinea pig – injected with rabbit
serum
 Immune response
(reactive)
2. Chemical Complexity – chemical
composition and molecular complexity.
Proteins are good immunogens because
of its chemical structure
3. High Molecular Weight – it must have
a certain minimal molecular weight.
 Compounds that have
a MW < 1000 Da - are
non-immunogenic
ex. penicillin progesterone
aspirin
 MW between 1000 and
6000 Da – may or may
not be immunogenic
ex. Insulin ACTH
  MW > 6000 Da - are
generally immunogenic
ex. albumin tetanus toxin
Haptens are a small organic
molecule that is not immunogenic by
itself due to:
 low-
molecular
-weight
 chemical
simplicity
Unless conjugated to
high-mw,
physiochemically
complex carriers,
haptens can be
immunogenic.
4. Degradability – substance must be
susceptible to partial enzymatic
degradation that take place during
antigen processing by APCs.
APC - Macrophages,
dendritic cells, B-cells
Tests to Evaluate Immune
Function
1. White Blood Cell Count Differential
Normal range between 5,000 –
10,000mm 3
 Less than called
leucopenia indicates a
compromised inflammatory
response or viral infection.
 Greater than 100,000mm3
indicates an inflammatory
response to a pathogen.
 Neutrophil =responsible for
bacterial infection
 Lymphocytes = responds
to viral infections but may
also be elevated with
some bacterial infections
(tumor and TB).
 Eosinophils = elevated
with allergic reactions and
parasitic infections.
2. Erythrocytes Sedimentation Rate
(ESR)
Normal value = 15 – 20 mm/ hr.
 Increases indicates an
active inflammatory
process or infection
3. Bone Marrow Aspiration
Immunity (1,500 -3,000/cu mm)
 decrease WBC indicate
bone marrow depression
decrease cellular
4. Immunoglobulin Electrophoresis
 Determine presence of
immunoglobulin IgG, IgA,
IgM
 Used to detect
hypersensitivity disorder,
autoimmune disorder,
chronic viral infections,
 immunodeficiency, intra
uterine infection, and
multiple myeloma.
5. Culture and Sensitivity
 Specimens like urine,
sputum, blood, wound
drainage, abscess fluid,
peritoneal fluid. Within 24
to 48 hours, with final
results ready in 72 hours.
 Result revealed that the
cultured organisms not
sensitive to prescribed
antimicrobial agents.
6. Antibody Screening Test
 detect the presence of
antibodies against specific
causative agents.
7. Auto – Antibody Screening Test
 detect presence of
antibodies against
person’s own DNA.
8. Antigen test
 detects the presence of a
specific pathogen. Used to
identify certain infections
or disorder.
9. Gallium Scan
 a nuclear scan that uses a
radioactive substance to
identify the hot spot of
 WBC within the client’s
body. It injects
intravenously.
10. Humoral and cellular immunity tests
11. Phagocytic cell function test
12. Complement component tests
13. Hypersensitivity tests
14. HIV infection tests
Alteration with Immunologic
Response
1. Immunodeficiency Disorder
2. HIV Infection
3. Acquired Immunodeficiency
Syndrome (Aids)
4. Hypersensitivity
UNIT 2 ALTERATION WITH
IMMUNOLOGIC RESPONSE
Module B
I. IMMUNODEFICIENCY
DISORDER
2 types of Immunodeficiency
Disorder
1. Primary (Congenital)
immunodeficiency = genetic disorder/
congenital.
Usually during early in life.
a) T – Cell Deficiency
 Di George’ s Syndrome (thymic
hypoplasia) – chromosomal
disorder
 absence of thymus in the neonate
 hypocalcemia and tetany
secondary to hypoparathyroidism
 congenital heart disease
b) B – cell deficiency = Bruton’s
Agammaglobulinemia/
hypogammaglobulinemia
 complete absence of B cell and
humoral immunity.
 infantile sex – immunoglobulines
are depressed, found in boys
only.
 exposure on chemotherapy,
respiratory, digestive or throat
infection, juvenile arthritis,
systemic lupus erythematosus,
viral, fungal, and parasitic
infections.
Treatment; intravenous or
subcutaneous immune globulin
injections, bone marrow
transplant.
c) Common Variable
Immunodeficiency (CVID)
 deficiency of IgA in surface
secretion and IgM.
 Sinusitis, URTI, inflammatory
bowel disease, atopic disease or
allergy,
 chronic irritation – predispose
exposed tissue to malignancy.
d) Severe Combined
Immunodeficiency Disease
 complete absence of both B – cell
& T- cell
 rare disorder
Treatment; Stem Cell
Transplantation – from the cord blood.
e) Phagocytic defect
 Chronic Granulomatous Disease
 lack of destruction of
phagocytized organism.
Replacement therapy
1. Gamma globulin = B cell
deficiency
2. Plasma therapy = all
immunodeficiency
3. Bone marrow
transplantation
4. Transfer factor – t- cell
deficiency
5. Thymus transplant – Di
George syndrome
2. Secondary Immunodeficiency = loss
of immune system response
a) Protein = caloric malnutrition
b) Induced immunosuppresion = antigen
– antibody administration,
antilymphocytes serum, drug
immunosuppression – prednisone;
released of corticosteroid, cytotoxic
drug, cyclosporine
c) severe systemic infection, cancer,
renal disease, radiation therapy, severe
stress
A. HIV INFECTION
 is a slowly replicating rotovirus,
attacking the lymphoreticular
system particularly the CD4
helper T lymphocytes. Destroying
the lymphocytes. Ability to initiate
an effective B lymphocyte
response.
 Transmission of HIV from mother
to fetus by placental spread
 Transmission; exposure to blood
body secretions
 Sharing contaminated needles
 Sexual contact
 Transfusion of contaminated
blood products.
 Perinatally from mother to fetus
 Breastfeeding
 Sexual maltreatment
 Puncture needles
Incubation period; 10 years in adult
Infant and children – HIV
progress more rapidly
Signs and Symptoms;
 Common cold, fever swollen
lymph nodes, respiratory tract
infection, Oral candidiasis
 CD4 count falls below 500
cells/mm3 or the viral load rises
above 5,000 copies/ ml.
Laboratory test:
 PCR Polymerase Chain Reaction
test – to detect the antigens
 To detect antibody and document
the disease status
 Enzyme Linked
Immunosorbent Assay
(ELISA)
 Western blot confirmation
 CD4 count
Classification of HIV infection in
Children
Category A – MILD SYMTOMATIC
 enlarged lymph nodes, liver,
spleen, recurrent or persistent
uppr respiratory infection,
sinusitis, otitis media are present.
Category B – MODERATELY
SYMTOMATIC
 oropharyngeal candidiasis,
bacterial meningitis, pneumonia,
sepsis, cardiomyopathy,
cytomegalovirus infection,
hepatitis, herpes simplex virus,
bronchitis pneumonitis or
esophagitis, herpes zoster
(shingles), lymphoid interstitial
pnemonia, pulmonary lymphoid
hyperplasia complex,
toxoplasmosis.
Category C – SEVERLY
SYMPTOMATIC
 serious bacterial infection,
septicemia, myobacterial
pneumonia, meningitis, bone and
joint pain, abscess of an internal
organ or body cavity, candidiasis,
encephalopathy, herpes simplex,
histoplasmosis, lymphoma,
tuberculosis, pneumocystic carinii
pneumonia, kaposi sarcoma.
Pregnant with HIV Infection
 it occurs more often in bisexual or
multiple sexual partners.
 Asymptomatic period early
pregnancy such as; fatigue,
anemia, diarrhea, and weight
loss.
 Symptomatic period develops
opportunistic infection such as;
oral and vaginal candidiasis,
gastrointestinal illness, herpes
simplex, candida esophagitis,
Kaposi sarcoma, and HIV
associated dementia. CD4 count
usually below 200 cells/ mm3.
  Thrombocytopenia – lowered  Weight loss
platelet count due to zidovudine  Fatigue
therapy.  Night sweat
 Diagnostic lab; CD4 cell count  Fever
and viral load level
 Treatment; Signs and symptoms of
o Zidovudine – oral antiviral Neurologic Symptoms
o Acyclovir (Zovirax) =  Forgetfulness
Herpes Simplex  Imbalance
o Clotrimazole troches  Weakness
(Mycelex) = Oral  Impaired language
Candidiasis  encepalopathy
o Sulfadiazine (Bactrim) =
Toxoplasmosis Opportunistic Infection for
AIDS
B. ACQUIRED  Cytomegalovirus or
IMMUNODEFICIENCY Cancer
 Kaposi’s Sarcoma
SYNDROME (AIDS)
 Characterized by; gradual
Complication for AIDS
destruction of T- cell immunity
Pneumocystis carinii
and autoimmunity
pneumonia,toxoplasmosis,
 Caused by; HIV Retrovirus
candidiasis, herpes
 Mode of transmission; infected
simplex 1 & 2, retinitis,
blood or blood fluid
tuberculosis, Kaposi’s
Sarcoma
Type of AIDS Effect
1. Immunodeficiency =
Diagnostic Test for Aids
opportunistic bacterial, viral
1. ELISA = Enzyme –
infection, unusual cancer
Linked Immunosorbent
2. Autoimmunity = pneumonitis,
Assay
arthritis
2. Western blot test
3. Neurologic dysfunction = AIDS,
3. CD4 +T cell count les
dementia, HIV encephalopathy,
than 200 cell/ul
peripheral neuropathies
The Infection Process has three
Treatment for AIDS
Phase of Affects can Occur
1. Primary = combination of 3
1. Primary infection = fever,
antiretroviral, 2 nucleosides + 1
fatigue, myalgia, sore throat,
protease
lymphadenopathy, GI problems,
2. Additional treatment =
macula papular rash, headache.
retroviral therapy – cause
2 to 4 weeks after exposure.
anemia, epoetic alfa, anti-
2. Latent phase = lack of
infective, anti- neoplastic
symptoms of disease but
3. Supportive therapy =
gradually falling CD4 + count. 10
nutritional support, F&E
years’ duration.
replacement therapy, pain relief,
3. Overt AIDS =CD4 +counts 200
psychological support.
cells/ul and when the patient
develops an AIDS defining
illness, death occurs in 2 to 3
years if left untreated.
C. HYPERSENSITIVITY
Signs and symptoms of  Exaggerated or
impaired CD4+ cells inappropriate response to
 Lymphadenopathy an antigen, results in
 inflammation and
destruction of healthy
tissue.
Classification Of Hypersensitivity
Reactions
1. TYPE I = IMMEDIATE TYPE/
ANAPHYLAXIS
 food, drugs, spores, seasonal
exposure, house-dust mite,
animal dander, grass and tree
pollen.
 commonly referred to as
Allergy Response.
 IgE receptors sites attached
to the surface of mast cells
found in lining of the blood
vessels, connective tissue,
mucous membranes, and the
skin. It contains histamine,
leukotrienes, and chemotactic
substances,
 Histamine and leukotrienes
cause peripheral vasodilation
and permeability of the blood
vessels resulting to lower
blood pressure and edema –
causes extreme bronchial
constriction.
 Treated immediately with
epinephrine to dilate the
airway and initiate vessel
vasoconstriction, anaphylaxis
that leads to shock and death.
 Effect; Rhinorrhea, Urticaria,
Edema, Asthma, Allergy,
Atopic Dermatitis,
Divided into Early-Phase and
Late-Phase Reactions:
Early Phase Reaction =
Binding of allergens to
allergen-specific IgE receptors
results in the cross-linking of
IgE molecules, which leads to
the degranulation of mast
cells and basophils
Degranulation results in the
release of histamine which
leads to increased vascular
permeability and smooth
muscle contraction, which
may result in the classical
allergic symptoms of
breathlessness and rhinitis
Late Phase Reaction = lipid
mediators (prostaglandins,
leukotrienes) and platelet-
activating factor (PAF), while
enzymes and chemokines can
also be released.
Severe, Potentially Life-
Threatening Form of Type I
Hypersensitivity
Systemic anaphylaxis
occurs when allergen enters
the bloodstream, allowing it to
spread to many different
organ systems. In severe
cases, large quantities of
histamine released leads to
capillary leak, vasodilation
and edema, typical features of
anaphylactic shock.
Airway obstruction can also
occur due to edema of the
larynx (upper airway
obstruction) and smaller
airways (lower airway
obstruction), presenting as
wheezing and dyspnoea
which can be life-threatening.
The skin and GI tract can also
be affected, resulting in
urticaria and nausea and
vomiting.
Severe anaphylaxis may be
treated with adrenaline
(epinephrine), airway
management and fluid
resuscitation.
Localized Anaphylactic
Reactions are generally less
serious and are restricted to
one organ system only. The
organ system affected
depends on the route of entry
of the allergen; ingested
allergens normally manifest as
GI symptoms (diarrhea,
nausea and vomiting), while
inhaled allergens such as
pollen present as allergic
rhinitis or allergic asthma.

2. TYPE II = TISSUES SPECIFIC/
CYTOTOXIC RESPONSE = mismatch
blood transfusion, organ transplant
 IgG or IgM cell involved
 Effect; Hemolytic disease,
neonate ABO or Rh
Incompatibility, Erythroblastosis,
certain drug reaction
Type II Hypersensitivity Reactions/
Cytotoxic Response
a) Autoimmune Hemolytic Anemia
Involves the production of
autoantibodies targeting
erythrocytes
Can be divided into warm
(37oC) and cold (<37oC)
types depending on the
temperature at which the
antibody binds to the
erythrocyte; this also
determines which class of
antibody binds
IgM antibodies are the only
antibody to bind in cold AIHA
while IgG binds in warm AIHA.
Following this, IgM and IgG
activate either intravascular
or extravascular
haemolysis.
In cold AIHA, complement
proteins can bind onto the Fc
region of IgM antibodies,
resulting in the lysis of
erythrocytes in the circulation
(intravascular hemolysis)
In warm AIHA, IgG antibodies
are not as effective at
activating complement and
erythrocytes undergo
extravascular hemolysis
where they are phagocytosed
by macrophages in the spleen
b) Hemolytic Disease of the Newborn
Caused by incompatibility
between fetus and mother
red blood cell antigens,
including rhesus antigens
Sensitization occurs when
cells from Rh+ baby pass
across the placenta into Rh-
mothers’ circulation
Mother forms anti-Rh
antibodies, however the first
pregnancy is not affected
In subsequent pregnancies of
a Rh+ fetus, these
immunoglobulins may pass
across the placenta and
destroy fetal erythrocytes
Anti-D (anti-Rh) is now given
intramuscularly following
delivery, provided that mother
is RhD negative, the fetus is
RhD positive and the mother
has not already been
immunized
c) Drug-Induced Thrombocytopenia
Characterized by formation of
"drug-dependent" antibodies
These bind simultaneously to
surface glycoproteins on
platelets and the drug (ie-
drug needs to present for
antibodies to bind to platelets)
Hundreds of drugs implicated
however most common are
quinine, quinidine, heparin,
penicillin and NSAIDs
Following binding, platelets
are destroyed by complement
proteins which bind to Fc
regions of IgG
Clinically, this condition leads
to clotting disorders,
characterized by bruising,
Abnormal Bleeding and
Purpuric Rashes
3. TYPE III = IMMUNE COMPLEX
MEDIATED = vasculitis and renal
damage
 IgG or IgE cell involved
 Immune complexes are soluble
antigen: antibody complexes.
 They can deposit in particular
tissues and give rise to either a
localized hypersensitivity
reaction (e.g- Arthus reaction) or
a generalized (e.g- rheumatoid
arthritis)
 IgG mediated antigen – antibody
complex reaction that initiate
inflammatory response.
  These immune complexes can
then bind complement or
phagocytes, leading to
significant tissue damage
 Effect; Systemic Lupus
Erythematosus, Rheumatoid
Arthritis
4. TYPE IV = DELAYED CELL
MEDIATED = contact dermatitis, latex
allergy
 T lymphocyte
 Unlike the previous types of
hypersensitivity, type IV reactions
are not mediated by antibodies.
 Instead they are mediated by
antigen-specific T lymphocytes
(CD4+ and CD8+ T cells) which
recognize antigens presented by
antigen-presenting cells (APCs)
 Following activation, these T cells
can secrete cytokines which can
recruit other inflammatory
leukocytes to the affected area.
 Effect; mantoux test, contact
dermatitis, latex allergy,
transplant graft reaction
Diagnostic Test
 (RAST) Radioallergosorbent Test
= to detect IgE serum antibodies.
 Eosinophil count – increase / this
test usually use to detect invasion
of parasitic invasions.
 Systemic or aerosol
administration of an antihistamine
 Skin testing = to detect IgE serum
antibodies.
 Scratch test = done by placing a
drop of allergen solution on the
skin, then scratching through the
drop of liquid with a sterile
needle.
 Patch test
 Corticosteroid therapy
 Intracuteneous injections =
injection of small amount of a
solution of allergen below
epidermis of the skin. Usually
done at the forearms. Painless
Treatment
 Epinephrine (Adrenalin) 1ml
sympathomimetic – relaxes
smooth muscle of the bronchi,
increase BP and heart rate given
IM, dose 0.01ml up to .3mg, skin
testing wheal and erythema
(redness) will occurs.
 Pharmacotherapy;
Cetirizine (Zyrtec) – antihistamine
Loratadine (Claritin) –
antihistamine
Decongestant (Pseudoephedrine)
– decrease nasal edema
Intranasal corticosteroid – reduce
inflammation
 Sublingual Immunotherapy
 Hyposensitization – increase the
plasma concentration by IgG
antibodies which prevent IgE
antibodies stimulate allergens.
D. ANAPHYLACTIC SHOCK
 Is immediate life threatening, type
I hypersensitivity reaction that
occurs after exposure to an
allergen.
 It is fatal and need immediate
treatment.
 Symptoms: nausea and vomiting,
diarrhea, urticarial (itching),
angioedema (swelling),
bronchospasm, dyspnea,
hypoxia, narrow pulse, low blood
pressure, syncope, seizure and
death.
Treatment
 Place the child with the head
level to counteract hypotension.
 Epinephrine (Adrenalin) 1ml
sympathomimetic – relaxes
smooth muscle of the bronchi,
increase BP and heart rate given
IM vastus lateralis muscle of the
thigh or deltoid muscle of the
arms, dose 0.01ml up to .3mg,
skin testing wheal and erythema
(redness) will occurs. To relieves
laryngeal edema and severe
bronchospasm.
 Administer oxygen – for hypoxia.
 Administer IVF.
 Administer anticonvulsant
phenobarbital or diazepam.
E. URTICARIA / HIVES
 characterized by; red lesions with
a red ―flare‖ at the borders,
wheals (welts), itchy and burning
sensation, raised areas of skin
that appear in varying shapes
(round, ring forms, large patches)
and sizes.
 range in size from a few
millimeters to several inches in
diameter.
 occur anywhere on the body,
such as the trunk, arms, and legs.
  caused by type I hypersensitivity
reaction - food, drugs, and insect
stings, exposure to hot and cold
Treatment.
 Intramuscular Epinephrine
(Adrenalin) injection.
 Oral Antihistamine.
F. ANGIOEDEMA
 generally, asymmetrically
distributed edema of the skin and
loosely bound subcutaneous
tissue.
 most frequently occurs on the
eyelids hands, feet, genitalia, and
lips.
 Severe angioedema, laryngeal
edema could be so extreme lead
to airway obstruction and
asphyxiation. It can be fatal.
 Caused by food, drugs, and
insect stings, exposure to hot and
cold
Treatment
 Intramuscular Epinephrine
(Adrenalin) injection.
 Oral Antihistamine.
 Corticosteroid (Cyclosporine)
immunosuppressant.
G. SERUM SICKNESS
 Is an inflammatory reaction that
occurs in the blood vessel walls
and surrounding tissue.
 Begin 7 to 12 days’ after the
serum injection. Then if the child
previously received the same
foreign serum, the symptoms
may occur as earlt as 1 to 5 days.
 Symptoms: itchiness, erythema,
edema on injection site, fever,
erythematous maculopapular
rashes, purpura (hemorrhage into
the skin) malaise,
lymphadenopathy (swollen lymph
nodes), arthralgia (joint pain),
generalized urticarial, and
arthritis. Some children
experienced nausea and
vomiting, abdominal pain, optic
neuritis, laryngeal edema, stupor,
and coma.
 Caused by drugs, infectious
agent, vaccines, or blood
products.
 Example; Foreign Sera like
tetanus antitoxin, diphtheria
antitoxin, rabies antiserum.
Antibiotics such as Cephalosporin
Cefaclor.
Treatment
 Intramuscular Epinephrine
(Adrenalin) injection.
 Oral Antihistamine.
 NSAID Nonsteroidal Anti-
Inflammatory Drug – Ibuprofen or
Corticosteroid
UNIT 3 ALTERATION WITH
ATOPIC
Module C Atopic
Disorder
A. ALLERGIC RHINITIS/
HAY FEVER
 Associated with an IgE mediated
inflammatory response to
allergen exposure.
 primary exposure to an allergen T
cells recognize the foreign
allergens and release chemicals
that instruct B cell to procedure
IgE antibodies. IgE antibodies
attached themselves to the mast
cells then the mast cells with IgE
can remain in the body for years,
ready to react when same
allergen occurs. Secondary time
allergens occur in the body. It
comes to direct contact with the
IgE antibodies attached to the
mast cells. These contacts
stimulate the mast cells to
release chemicals, such as
histamine which initiate a
response that cause =
tightening of the smooth
muscle in the airway
dilatation of small blood
vessels
increase mucus secretion
in the nasal cavity
itchiness or running nose
watery eyes
 Reaction to airborne inhaled
allergen
 occur seasonal and most
common atopic allergen
  Cause; Environmental Allergen
Common Trigger= Reduce
environment exposure to airborne
allergens
1. Perennial allergen
o Dust mite excreta,
fungal spores and
molds
o Feather pillows
o Cigarette smoke
o Animal dander
2. Windborne pollen
o Oak, elm, maple,
birch and
cottonwood during
spring
o Grasses, sheep
sorrel, and English
plantain during
summer
o Ragweed and other
weed during
autumn
Signs / Symptoms of Allergic Rhinitis
Sneezing
Profuse watery rhinorrhea
Nasal obstruction or
congestion
Pruritus of the nose and eyes
caused histamine release
Pale or cyanotic
Edematous of nasal mucous,
eyelid and conjunctiva
Excessive lacrimation
Headache
Exhausted and lethargic
Recurrent otitis media due to
swollen pharyngeal tissue.
Sinus pain result of histamine
response
Possible dark circle under
the patient’s eyes (allergic
shiners) = because of venous
congestion in the maxillary
sinuses.
Across the nose (Dennie line)
constantly rubbing horizontal
or wiping away nasal
secretions.
Complication;
1. Nasal polyps = caused by
edema and increase nasal obstruction
2. Sinus and middle ear infection
= caused by swelling of the turbinate
and mucus
membrane
Diagnostic test;
 Microscopic examination =
Sputum and nasal secretion =
reveal large number of
eosinophils
 IgE level are normal or elevated
 (RAST) Radioallergosorbent Test
= to detect IgE serum antibodies.
Treatment
1. Elimination of environmental
antigen
2. Antihistamine = effect release
anti- cholinergic adverse effect =
sedation, dry mouth, nausea,
dizziness, blurred vision and
nervousness
3. Injectable steroids Triamcinolone
acetonide (Kenalog)
4. intranasal steroids =
beclomethasone (Beconase,
Vancenase), flurisolide
(Nasalide), and fluticasone
(Flonase)
5. Immunotherapy
6. Desensitization
Nursing Consideration
 Keep epinephrine and
emergency resuscitation
available
 Monitor compliance of
patient to treatment
B. INFANTILE ECZEMA/
ATOPIC DERMATITIS
 Disease of an infant, begins as
early as second month of life and
lasting 2 to 3 years of age.
 Food allergy (formula fed infant),
eggs, milk, wheat, chocolate, fish,
tomatoes, and peanuts, sweating,
heat, tight clothing, contact irritant
such as soap,
 Loss of serous fluid out into the
tissue.
 Symptoms: dry, reddened skin
that itches or burning sensation,
 blisters and oozing lesions
resulting to dry and scaly skin,
repeated scratching may lead to
thickened, crusty skin,
 develop popular and vesicular
skin eruption with surrounding
erythema.
 Infected lesions heal become
depigmented and lichenified
(shiny), and dry, flaky scale form,
low grade fever and puss filled
lesions and local swollen lymph
nodes.
 Lesions commonly arise at scalp,
forehead, cheek, behind ears,
and extensor surface of
extremities.
 Generalized discomfort for infant.
 Treatment:
o bathing or apply wet
dressing (tap water)
burow’s solution for 15 to
20 minutes
o Oral Antihistamine.
o Corticosteroid ointment
o Neomycin – antibiotic
C. SEBORRHEIC
DERMATITIS/ CRADLE CAP
 0 – 6 months, rarely 1 year
 Commonly occurs at scalp,
behind ears, near umbilicus,
salmon colored erythema lesion
with greasy scale.
 Low IgE
 soaking the scale in the mineral
oil
PHENYLKETONURIA (PKU) – can lead
to atopic dermatitis
D. MILK
HYPERSENSITIVITY
 allergy to milk occurs in infancy
 failure to gain weight, diarrhea,
vomiting, and abdominal pain,
colic, lactase deficiency (cannot
tolerate ingest the lactose in milk)
 nausea and vomiting –
gastrorenteritis infection
 milk allergy last until 3 to 5 years
of age.
 treatment: oral immunotherapy
E. PEANUT
HYPERSENSITIVITY
 allergy to peanut and tree nut
 fatal caused by food anaphylaxis
F. STING INSECT
HYPERSENSITIVITY
 severe hypersensitivity reaction
to stings from bees, wasps,
hornets, yellow jacket.
 Symptoms; local edema at the
sites, generalized urticaria,
pruritus, wheezing, and dyspnea,
severe shock and death.
 Treatment; immunotherapy
 Epinephrine
 Antihistamine
 Ice apply to the site to minimize
the amount of venom absorbed
G. CONTACT DERMATITIS
Means inflammation of the skin.
This consists of an induction
phase involving the crossing of
allergens across the epidermis
into the lower layers of the skin,
where they can be presented by
dendritic cells (APCs) to naive T
cells, which then develop into
antigen-specific T cells.
Following induction, there is an
elicitation phase whereby
allergen presentation by dendritic
cells results in the activation of
antigen-specific T cells and the
release of inflammatory
cytokines
This leads to a localized
hypersensitivity reaction in the
epidermis, characterized by
erythema, cellular infiltrate and
intraepidermal abscesses.
 In contact dermatitis, the skin
becomes extremely itchy and
inflamed, causing redness,
swelling, cracking, weeping,
crusting, and scaling.
 Dry skin is a very common
complaint and an underlying
cause of some of the typical rash
symptoms.
 Irritation from diaper washing, 
allergy to cosmetics, nickel, latex,  Genetic Engineering: emerging
leather materials. technology designed to enable
replacement of missing or
 Treatment; Epinephrine,
 defective genes.
Antihistamine, Calamine lotion 
and Caladryl lotion,  Helper T Cells: known as
hydrocortisone lotion or cream to CD4. The lymphocytes that attack
decrease itchiness, baking soda foreign invaders (antigens)
or oatmeal soap.  directly.
 Definition of Terms  Humoral Immune Response:
 the immune system’s second line
 Agglutination: clumping of defense; often termed
effect occurring when an antibody  the antibody response.
acts as a cross-link between two 
antigens.  Immunity: the body’s specific
 protective response to an
 Antibody: a protein substance invading foreign agent or
developed by the body in organism. Ability to destroy
response to and interacting with a antigens.
specific antigen. 
  Immunologic Disorders: is a
 Antigen: is any foreign deficiency in the proper
substance that induces the expression of the immune
production of antibodies. response.
 
 Allergen: caused  Immunopathology: study of
tissue injury and allergic diseases resulting in dysfunctions
symptoms. within the immune system.
 
 Apoptosis: programmed cell  Immunoregulation: complex
death that results from the system of checks and balances
digestion of DNA by that regulates or controls
endonucleases.  immune responses
 
 B cells: cells that are  Interferons: proteins formed
important in producing circulating when cells are exposed to viral or
antibodies. foreign agents; capable of
 activating other components of
 Cellular Immune Response: the the immune system.
immune system’s third line of 
defense, involving the attack  Lymphokines: substances
 of pathogens by T cells. released by sensitized
 lymphocytes when they contact
 Complement: series of specific antigens.
enzymatic proteins in the serum 
that, when activated, destroy  Memory Cells: cells that are
 bacteria and other cells. responsible for recognizing
 antigens from previous
 Cytokines: generic term for  exposure and mounting an
non-antibody proteins that act as immune response. Responsible
intercellular mediators, as in the for retaining ability to produce
generation of immune response. specific immunoglobulins.
 
 Cytotoxic T Cells: known as  Natural Killer Cells:
killer cells. With specific ability to lymphocytes that defend against
bind the surface of microorganisms and malignant
 antigens directly destroy the cell cells.
membrane and secrete 
lymphokines. lymphocytes that  Null Lymphocytes: lymphocytes
lyse cells infected with virus; also that destroy antigens already
play a role in graft rejection. coated with the antibody.
  diagnosis, and developing specific treatment
 Opsonization: the coating of
antigen–antibody molecules with
a sticky substance to facilitate
phagocytosis.
 of a disease or condition. They can then be offered
 Phagocytic Cells: cells that
engulf, ingest, and destroy
foreign bodies or toxins.
 any complications arising from the
 Phagocytic Immune Response:
the immune system’s first line of
defense, involving white
 blood cells that have the ability to
ingest foreign particles.
 examination preferably in the first
 Stem Cells: precursors of
all blood cells; reside primarily in
bone marrow.

 Suppressor T Cells:
lymphocytes that decrease B-cell
activity to a level at which the
immune
 system is compatible. Reduce the
production of immunoglobulins
against specific antigen and
prevent overproduction.
 approach is the optimal use of
CARE OF MOTHER, CHILD AT RISK OR
WITH PROBLEMS (ACUTE AND
CHRONIC) NURS-10
TOPIC 1
ASSESSMENT ON HIGH-RISK CLIENT DURING
PRENATAL
High-risk pregnancies are those concurrent
disorders, pregnancy-related
complications, or external factors that endanger
the health of the woman and the fetus.
About 20-30 pregnancies belong to this category.
Nurses must have the awareness
regarding these diseases so they can act swiftly
during these emergencies.
Though all mothers and children are vulnerable to
disease or disability, there are
certain mothers and infants who are at risk of
complications of pregnancy, labor and
delivery. If we desire to improve obstetrics result,
this group must be identified and given
extra care.
ASSESSMENT AND SCREENING
Assessment is a process for defining the nature of
that problem, determining
recommendation.
Screening is a process of identifying apparently
healthy people who may be at risk
information, further test and
appropriate treatment to reduce their risk and or
disease or condition.
Screening of High Risk Cases
The cases are assessed at the initial antenatal
trimester of pregnancy. This examination may be
performed in a big institution (teaching
or non-teaching) or in a peripheral health center.
Some risk factors may later appear and
are detected at subsequent visits. The cases are
also reassessed near term and again in
labor for any new risk factor.
According to WHO, the main objective of the risk
existing resources for the benefit of the majority. It
attempts to ensure a minimum of
care for all while providing guidelines for the
diversion of limited resources to those who
most need them.
High Risk Cases According to WHO:
During Pregnancy:
1. Elderly Primigravida (> 30 years old)
2. Short Saturated Primi (< 140cm)
3. Threatened abortion and Active Postpartum
Hemorrhage
4. Malpresentation and Malposition
5. Pre-eclampsia and Eclampsia
6. Anemia
7. Elderly Grand Multipara
8. Twins and Hyramnious
9. Previous Still birth, IUD, Manual extraction of
Placenta
10.Prolonged Pregnancy
11.History of Previous Cesarean Section and
Instrumental Delivery
12.Pregnancy associated with medical disease

The cases should be reassessed at each antenatal me defect, such as

visit to detect any abnormality that Down syndrome

might have arisen later. Few examples are pre-

eclampsia, anemias, Rh-isoimmunization, spinal cord.

high fever, pyelonephritis, hemorrhage, diabetes Second Trimester ultrasound:

mellitus, large uterus, lack of uterine

growth, post maturity, abnormal presentation,

twins and history of exposure to drugs or
placenta and amniotic fluid
radiation, acute surgical problems.
of the fetus, umbilical
Screening/Assessment cord, and the placenta during a

1. Maternal Age procedure such as amniocentesis

2. Reproductive History
defects, or heart problems
3. Past Hospitalization Record /Medical History
Third Trimester ultrasound:
-eclampsia/Eclampsia

ition of the fetus,

placenta and amniotic fluid

-isoimmunization or ABO B. Cardiotocography

incompatibility
11

C. NON STRESS TEST (NST)

D. CONTRACTION STRESS TEST (CST)

Invasive diagnostic test

A. Chorionic Villus Sampling (CVS) is a

4. Family History
prenatal test that is used to detect birth
-economic status
defects, genetic diseases, and other

problems during pregnancy. During

the test, a small sample of cells

(called chorionic villi) is taken from the

placenta where it attaches to the wall of the

5. Diagnostic Test
uterus.
To establish the presence or absence of a disease as
a basis for treatment B. Amniocentesis is a procedure in which

decisions in symptomatic or screen positive amniotic fluid is removed from the uterus for
individuals (confirmatory test)
testing or treatment. Amniotic fluid is the
Noninvasive diagnostic Tests A. Fetal ultrasound
fluid that surrounds and protects a baby
or ultrasonic Testing
during pregnancy. This fluid contains fetal
First Trimester ultrasound:
cells and various proteins

C. Embryoscopy
Embryoscopy is the examination of the embryo at The services of trained community health workers
9-10 weeks' gestation through the should be utilized to provide the

intact membranes by introducing an endoscope primary care and screening in the rural areas and
into the exocoelomic space urban communities. Cases with

transcervically or transabdominally. significant higher risk should be referred to

specialized referral centers. Cases having a
D. Fetoscopy
previous unsuccessful pregnancy should be seen
Fetoscopy is an endoscopic procedure during and investigated before another

pregnancy to allow surgical access to the fetus, the
amniotic cavity, the umbilical cord, and the fetal
side of
the placenta. A small (3–4 mm) incision is made in
the
abdomen, and an endoscope is inserted through
the
conception occurs. Complete investigations for
hypertension, diabetes, kidney disease,
thyroid disorders should be undertaken and proper
treatment instituted in the non
pregnant state.
Early pregnancy after initial clinical examination,
routine and special laboratory

abdominal wall and uterus into the amniotic cavity. investigations should be undertaken. Clients with
history of previous first trimester
E. Percutaneous umbilical cord blood
abortion should be advised rest and to refrain from
sampling (PUBS) is a diagnostic procedure in which
sexual intercourse. Vaginal
a
examination should be avoided in first trimester in
doctor extracts a sample of fetal blood from the
these case.
vein in
Clients suspected to have cervical incompetence
the umbilical cord. This blood can be analyzed to
should have sonohgraphic
detect chromosomal defects or other
evaluation, early second trimester so that the
abnormalities.
cervical cerclage, if necessary may be
This procedure is similar to amniocentesis except
performed at appropriate time.
the
Clients having premature labor, unexplained still
objective is to retrieve blood from the fetus versus
birth, intrauterine growth
amniotic fluid.
restriction, and may other abnormalities benefited
F. Cordocentesis
by prolonged rest in the hospital with
TOPIC 2
close supervision.
PLANNING AND MANAGEMENT ON CLIENTS AT
Points to remember for effective assessment and
RISK
referral system:
The high risk cases should be identified and give
proper antenatal, intranatal, and
community participation and referral
neonatal care. This is not to say that healthy
system.
uncomplicated cases should not get proper

attention. But in general, they need not to be

the health care facility.
admitted to specialized centers and their

care can be left properly trained health care

with participation of workers
personnel such as doctors, nurses, and
involved in the care of the cases.
midwives. It is necessary that all expectants
mothers are covered by the obstetric services
for management.
of a particular area.
 Conception less than one year after last
health care manpower and financial pregnancy

resources where it is mostly needed.

r necessary Inadequate home for infant care

investigations: availability of good

pediatrics services for neonates.

Physical Factors

health awareness of the community.

TOPIC 3

RISK FACTORS ASSOCIATED WITH A NEGATIVE y major illness

PREGNANCY

More than one factor can contribute to the

classification of a high-risk pregnancy.

Women who already have a disorder before the

pregnancy is termed to have a greater

than normal risk. The factors that categorize the

woman’s pregnancy as high risk were

classified into minimal, moderate, or extensive. old

Psychological, social, and physical factors

also break down the factors that categorize a high-

risk pregnancy.

Psychological Factors

on

ess in newborn TOPIC 4

Social Factors MONITORING OF HIGH RISK CLIENTS

Health care providers that care for women during

pregnancy include:

re medical doctors who

specialize in the care of pregnant

women and in delivering babies. OBs also have

special training in surgery so they

are also able to do a cesarean delivery. Women

who have health problems or are

at risk for pregnancy complications should see an

obstetrician. Women with the
highest risk pregnancies might need special care
from a maternal-fetal medicine
BIRTH PLAN
specialist.

medical doctors who provide

care for the whole family through all stages of life.

This includes care during

pregnancy and delivery, and following birth. Most

red
family practice doctors cannot
in case of emergency
perform cesarean deliveries.
Glossary:
-midwife (CNM) and
Risk- is hazard, danger, exposure to mischance or
certified professional midwife
peril. It implies the probability, of
(CPM) are trained to provide pregnancy and
adverse consequences is increased by the presence
postpartum care. Midwives can be a
of some characteristics or factor.
good option for healthy women at low risk for
Fetal ultrasound- is an imaging technique that uses
problems during pregnancy, labor,
sound waves to produce images of
or delivery. A CNM is educated in both nursing and
a fetus in the uterus
midwifery. Most CNMs practice
Cardiotocography- (CTG) is a technical means of
in hospitals and birth centers. A CPM is required to
recording the fetal heartbeat and the
have experience delivering
uterine contractions during pregnancy.
babies in home settings because most CPMs
practice in homes and birthing Non stress test (NST) is a simple, noninvasive way
of checking on your baby's health
centers. All midwives should have a back-up plan
with an obstetrician in case of a Chorionic Villus Sampling (CVS) is a prenatal test
that is used to detect birth defects,
problem or emergency.
genetic diseases, and other problems during
During pregnancy, regular checkups are very
pregnancy
important. This consistent care can help
Amniocentesis is a procedure in which amniotic
the mother and baby healthy, spot problems if they
fluid is removed from the uterus for
occur, and prevent problems during
testing or treatment
delivery. Typically, routine checkups occur:
Embryoscopy is the examination of the embryo at
9-10 weeks' gestation through the

intact membranes by introducing an endoscope

into the exocoelomic space

Women with high-risk pregnancies need to see transcervically or transabdominally.

their doctors more often.
Fetoscopy is an endoscopic procedure during
Educate them regarding danger signs: pregnancy to allow surgical access to the

fetus, the amniotic cavity, the umbilical cord, and

the fetal side of the placenta

Percutaneous umbilical cord blood sampling (PUBS)

is a diagnostic procedure in

which a doctor extracts a sample of fetal blood

from the vein in the umbilical cord

Cordocentesis, also known as percutaneous

T°>38, weak) umbilical blood sampling, is a diagnostic prenatal
test Cigarette smoking

MNCHN- Maternal, Newborn, Child Health &

Nutrition, a Department of Health Program

focuses the mother and child health

BEmONC- Basic Emergency Obstetric and Newborn

Care, one of the level in delivery
premature rupture of membranes,
service network under the MNCHN Program
delivery of first twin)
CEmONC- Comprehensive Emergency Obstetric and
Newborn Care, the higher authority
(i.e., post amniocentesis)
referral in MNCHN.
diopathic (probable abnormalities of uterine
PCPNC- Pregnancy, Childbirth, Postpartum and blood vessels and decidua)
Newborn Care: A guide for essential

practice” This aim to provide evidence-based

recommendations to guide health care
longer)
professionals in the management of women during
pregnancy, childbirth, postpartum and Normal Placenta vs. Abruptio Placenta

post-abortion periods, and newborns If the bleeding continues, fetal and maternal
distress may develop. Fetal and maternal
CARE OF MOTHER, CHILD AT RISK OR WITH
death may occur if appropriate interventions are
PROBLEMS (ACUTE AND CHRONIC) NURS-10
not undertaken.
Second Trimester
The severity of fetal distress correlates with the
Gestational Conditions degree of placental separation. In
TOPIC 1
near-complete or complete abruption, fetal death is
ABRUPTIO PLACENTA inevitable unless an immediate

Abruptio placentae is defined as the premature caesarian delivery is performed.

separation of the normally implanted
Maternal and fetal complications include issues
placenta from the uterus. related to:

Signs & symptoms:

fetal distress.

-trimester bleeding
associated with fetal and maternal

morbidity and mortality, placental abruption must

significant fetal compromise
be considered whenever
develops
bleeding is encountered in the second half of
pregnancy.
fetal heart rate tracing typically
Risk Factors
shows evidence of fetal decelerations and even
- Most common cause of
persistent fetal bradycardia.
abruptio placenta, occurring in
Complications
approximately 44% of all cases.
Hemorrhage/coagulopathy

[MVC], assaults, falls) - Causes 1.5-

occur as a sequela of placental
9.4% of all cases
abruption. Patients with a placental abruption are What are the symptoms of placenta previa?
at higher risk of developing a
he patient won’t know she have
coagulopathic state than those with placenta placenta previa until the doctor
previa. The coagulopathy must be
finds it during a routine ultrasound.
corrected to ensure adequate hemostasis in the
case of a cesarean delivery
the vagina during the second
Prematurity
half of pregnancy. It can range from light to heavy,
ruption and it’s often painless.
or when significant fetal or

maternal distress occurs, even in the setting of bleeding.

profound prematurity. In some
Low/ Marginal
cases, immediate delivery is the only option, even
before the administration of Previa

corticosteroid therapy in these premature infants. Extends just to the

All other problems and
edge of the cervix
complications associated with a premature infant
Partial Previa
are also possible.
A portion of the cervix
TOPIC 2
is covered by the
PLACENTA PREVIA
placenta
Placenta previa happens when the placenta partly
or completely covers the cervix, Total/ Complete

which is the opening of the uterus. The baby passes Previa

from the uterus into the cervix and
The cervical opening is
through the birth canal during a vaginal delivery.
Normally, the placenta attaches toward completely covered

the top of the uterus, away from the cervix. What is the treatment for Placenta Previa?

Different Types of Placenta Previa

What happens with Placenta Previa?
As the cervix opens during labor, it can cause blood
vessels that connect
the placenta to the uterus to tear. This can lead to
bleeding and put both the mother
and her baby at risk. Nearly all women who have
this condition will have to have a
C-section to keep this from happening.
require bed rest for the mother and
frequent hospital visits. Depending on the
gestational age, steroid shots may be
given to help mature the baby’s lungs. If the mother
experiences bleeding that
cannot be controlled, an immediate cesarean
delivery is usually done regardless
of the length of the pregnancy.

Risk Factors although complete or partial

previas would require a cesarean delivery.

-section before

TOPIC 3

PREGNANCY INDUCED HYPERTENSION

 - Toxemia of pregnancy is a severe
condition that sometimes occurs in
-2 g/L (++)
the latter weeks of pregnancy.

pressure; extreme edema, extreme

swelling of the hands, feet, and face;
elevation of blood pressure, the presence of large
and an excessive amount of protein in the urine. If amounts of protein in the urine,
the condition is allowed to
headache, dizziness, double vision, nausea,
worsen, the mother may experience convulsions vomiting, and severe pain in the right
and coma, and the baby may be
upper portion of the abdomen.
stillborn.

r from the
days when it was thought that

the condition was caused by toxic (poisonous)

substances in the blood. The illness

is more accurately called preeclampsia before the coma.

convulsive stage and eclampsia

afterward.

Causes regular analgesics)

eclampsia are not

clearly understood.

They tend to develop more often in women who

ric or RUQ pain)
are having their first baby,

especially teenage mothers and women from lower

socioeconomic groups. One

theory proposes that certain dietary deficiencies Treatment

may be the cause of cases.

Also, there is the possibility that some forms of completely cured until the pregnancy is
preeclampsia and eclampsia are
over.
the result of deficiency of blood flow in the uterus.

Signs & Symptoms high blood pressure and the

The symptoms of toxemia of pregnancy (which may intravenous administration of drugs to prevent
lead to death if not treated) are convulsions.

divided into three stages, each progressively more

serious: production of urine. In some severe

cases, early delivery of the baby is needed to

(puffiness under the skin due ensure the survival of the mother.

to fluid accumulation in the body tissues, often

noted around the ankles), mild
ure occurred or
elevation of blood pressure, and the presence of convulsions are present, emergency
small amounts of protein in the
C-Section is performed.
urine.
Prevention

-109 mmHg, or

reduce swelling, it does not
prevent the onset of high blood pressure or the
appearance of protein in the urine.
the woman's weight, blood
pressure, and urine.
reduced
TOPIC 4
HYPERTENSIVE VASCULAR DISEASE
ion is the most common medical
problem encountered during
pregnancy, complicating up to 10% of pregnancies.
Hypertensive disorders during pregnancy are
classified into 4 categories:
-eclampsia
d on chronic
hypertension
of pregnancy or
chronic hypertension identified in the latter half of
pregnancy). This
terminology is preferred over the older but widely
used term "pregnancyinduced hypertension" (PIH)
because it is more precise.
-onset, severe hypertension that is
accurately measured using standard
techniques and is persistent for 15 minutes or
longer is considered a hypertensive
emergency.
long been considered first-line
medications for the management of acute-onset,
severe hypertension in pregnant
women and women in the postpartum period.
Available evidence suggests that
oral nifedipine also may be considered as a first-line
therapy.
Magnesium sulfate is not recommended as an
antihypertensive agent, but magnesium
sulfate remains the drug of choice for seizure
prophylaxis in severe preeclampsia and for
controlling seizures in eclampsia.
Glossary:
Hemorrhage an escape of blood from a ruptured
blood vessel, especially when profuse
Coagulopathy is often broadly defined as any
derangement of hemostasis resulting in
either excessive bleeding or clotting, although most
typically it is defined as impaired clot
formation
Prematurity is a baby born before 37 completed
weeks of gestation, counting from the
first day of the last menstrual period (LMP)
Toxemia an abnormal condition associated with the
presence of toxic substances in the
blood
Chronic Hypertension is the term for having high
blood pressure and increases your
risk for heart attack, stroke, heart failure, or kidney
disease
Cesarean delivery (C-section) is a surgical procedure
used to deliver a baby through
incisions in the abdomen and uterus
Magnesium sulfate is a naturally occurring mineral
used to control low blood levels
of magnesium
Seizure is a sudden, uncontrolled electrical
disturbance in the brain. It can cause
changes in your behavior, movements or feelings,
and in levels of consciousness
CARE OF MOTHER, CHILD AT RISK OR WITH
PROBLEMS (ACUTE AND CHRONIC) NURS-10
Nursing Care of the High Risk Labor & Delivery
Client and Her Family
TOPIC 1
NURSING CARE OF THE HIGH RISK LABOR &
DELIVERY CLIENT AND FAMILY
A.HIGH RISK FACTORS:
◦ May develop at any time during labor in a client
who has been otherwise healthy throughout
pregnancy and may be related to:
1. The passenger or fetus
2. The passageway or pelvic bones and other pelvic
structures
3. Powers or uterine contractions
4. The clients psyche or psychological state
B. CLIENTS RESPONSE TO THE ONSET OF HIGH-RISK
FACTORS IN LABOR
1. stress, fear, and anxiety brought about by
unexpected complications during labor may have
profound effects on maternal and feta outcome
2. maternal anxiety can increase tension, produce
higher pain perception, and may make labor
contractions less effective
3. catecholamines released during stress produce
vasoconstriction that may negatively affect
uterine blood flow.
*Catecholamines are hormones made by your
adrenal glands, which are located on top of your
kidneys. Examples include dopamine;
norepinephrine; and epinephrine (this used to be
called
adrenalin or adrenaline). Catecholamines help the
body respond to stress or fright and prepare
the body for "fight-or-flight" reactions
C. FAMILY MEMBERS
◦ Family members may be overwhelmed with
concerns and less capable of providing
needed emotional support for the client
D. NURSING CARE
◦ In addition to basic intrapartal care, nursing care
during complicated labor requires special
knowledge and skills in assessing and caring for
mother and fetus.
COMPONENTS OF LABOR THE 5 “PS”
1. Passenger (fetus)
2. Powers (uterine contractions)
3. Passage (the pelvis & maternal soft parts)
4. Position (maternal)
5. Psyche (maternal psychological status)
PROBLEMS WITH THE PASSENGER
FETAL MALPOSITION
fetal malposition occurs when the occiput of
fetuses who are in vertex presentation is rotated so
that it is not oriented anteriorly in the maternal
pelvis.
* The ideal fetal position is flexed with occiput in
the right or left anterior quadrant of the
maternal pelvis
Types of Malposition
A. Occiput posterior (OP) position - the baby's head
is down, but it is facing the mother's front
instead of her back. It is safe to deliver a baby
facing this way. But it is harder for the baby to get
through the pelvis.
◦ Right or left OP position occurs in about 25% of all
term pregnancies but usually rotates to
occiput anterior as labor progresses
◦ Failure to rotate is termed persistent occiput
posterior
◦ Maternal risk include, potential for operative
delivery, extension of the episiotomy, or 3rd to 4th
degree laceration of the perineum
◦ Maternal symptoms includes:
◦ Intense back pain in labor
◦ Prolonged active phase
◦ Secondary arrest in dilatation
◦ Arrest in descent
B. Occiput Transverse Position (OT)
◦ Incomplete rotation of occiput posterior (OP)
position to Occiput Anterior (OA) position results
in the fetal head being in a horizontal or transverse
position (OT)
◦ Persistent occiput transverse position occurs as a
result of ineffective contractions or a
flattened bony pelvis
◦ In the absence of abnormal pelvis structure,
vaginal delivery can be accomplished by
stimulating contractions with oxytocin (Pitocin) and
application of forceps for delivery
NURSING CARE:
Nursing Diagnosis: Pain, Ineffective coping
Planning and implementation:
◦ Encourage the mother to lie on her side opposite
from the fetal back. Which may help
with rotation
◦ Knee-chest position may facilitate rotation
◦ Pelvic rocking may help with rotation
◦ Apply sacral counterpressure with heel of the
hand to relieve back pain
◦ Continue support and encouragement
◦ Keep client and family informed of the progress
◦ Encourage relaxation with contractions
◦ Praise clients efforts to maintain control
◦ Anticipate forceps rotation and forceps assisted
birt MEDICAL MANAGEMENT:
A. Forceps: metal instruments applied to the fetal
head to facilitate delivery
◦ Provides traction or a means of rotating the fetal
head
◦ Risk are fetal ecchymosis or facial edema,
transient facial paralysis, maternal
lacerations or episiotomy extensions
◦
B. Vacuum extraction – a suction cup applied to the
fetal head to facilitate delivery
◦ Provides traction to shorten the 2nd stage of labor
◦ Risks are newborn cephalhematoma, retinal
hemorrhage, and intracranial hemorrhage
TOPIC 3
FETAL MALPRESENTATION
fetal malpresentation refers to a fetus with a fetal
part other than the head engaging the
maternal pelvis.
TYPES OF MALPRESENTATION
1. Vertex Malpresentation
2. Breech Presentation
3. Shoulder Presentation
4. Compound Presentation
1. VERTEX MALPRESENTATION - Are caused by
failure of the fetus to
assume a flexed attitude.
TYPES OF VERTEX MALPRESENTATION
1. BROW PRESENTATION
◦ Fetal forehead is the presenting part
◦ 50% convert to vertex or face presentation
◦ The presenting diameter is mento-vertical which is
13.5cm
2. FACE PRESENTATION
◦ Increased risk of prolonged labor and operative
delivery
◦ Anticipate vaginal delivery if pelvis is adequate
and the chin mentum) is in the anterior
position
◦ Anticipate cesarean delivery if mentum is
posterior or signs of fetal distress occur
◦ Fetal monitor electrode should not be placed on
presenting part (infants face); requires
external fetal heart rate (FHR) monitoring
◦ Edema and bruising of face, eyes, and lips are
common occurrences; prepare client for this
possibility before seeing the infant for the first time
3. SINCIPAL PRESENTTAION (MILITARY ATTITUDE)
Larger diameter of the fetal head is presented
Labor progress is slowed with slower descent of the
fetal head
2. BREECH PRESENTATION
A breech presentation is when the fetus presents
buttocks or feet first (rather than head first – a
cephalic presentation). It has significant
implications in terms of delivery – especially if it
occurs at
term (>37 weeks).
3 TYPES OF BREECH PRESENTATION
◦ 1. Complete Breech – sacrum is the presenting
part, knees flexed
◦ 2. Frank Breech – sacrum is the presenting part,
legs are extended
◦ 3. Incomplete (Footling) Breech – one or both feet
are presenting , increasing the risk of
umbilical cord prolapse
*during I.E. the nurse may feel the anal sphincter,
the tissue of the fetal buttocks
feels soft
MATERNAL RISK ON BREECH PRESENTATION
◦ Prolonged labor due to decreased pressure
exerted by the breech on the cervix
◦ Premature rupture of membranes may expose
client to infection
4. SHOULDER PRESENTATION
◦ Cesarean or forceps delivery
• Shoulder presentation (transverse Lie) – acromion
FETAL RISK process is the presenting part

◦ Compression or prolapse of the umbilical cord • Vaginal delivery is not considered possible in term
infant
◦ Entrapment of the fetal head in incompletely
dilated cervix • Cesarean birth is preferred method of delivery

◦ Aspiration and asphyxia at birth 5. COMPOUND PRESENTATIONS

◦ Birth trauma from manipulation and forceps to ◦ More than one part of the fetus presents
free the fetal head
◦ Most common type is a hand or arm prolapsing
VAGINAL DELIVERY OF BREECH beside the head

◦ Fetal body may pass through an incompletely ◦ Risk of cord compression and prolapse is
dilated cervix entrapping the larger fetal head increased

that follows ◦ Vaginal versus cesarean delivery depends on size

of the fetus presence of fetal distress and
◦ Delivery of fetal head must be quickly to avoid
hypoxia the progress in labor

◦ Piper (long handle) forceps may be applied to the NURSING CARE OF CLIENT WITH
after-coming fetal head MALPRESENTATION

MANEUVER IN BREECH DELIVERY A. assessment and nursing diagnosis:

◦ 1. Pinard’s Maneuver - is the sweeping/external ◦ Leopold's maneuver may help detect abnormal
rotation of each thigh combined with rotating presentation

the pelvis in the opposite direction resulting in the ◦ Priority nursing diagnosis: Risk for injury, anxiety,
flexion of the knee and the delivery of each fear, deficient knowledge, ineffective

leg. individual coping

2. Loveset’s Maneuver - rotation of the trunk of the B. Planning and implementation

fetus during a breech birth to facilitate
◦ Observe closely for abnormal labor patterns
delivery of the arms and the shoulders .
◦ Monitor FHR and contractions continuously
17
◦ Provide client and family teaching
3. Mauriceau - Smelilie- Viet maneuver - which is
performed by placing the index and middle ◦ Provide client support and encouragement

fingers over the maxillary prominence on either ◦ Anticipate forceps assisted delivery
side of the nose.
◦ Anticipate cesarean birth for incomplete breech or
4. McRoberts maneuver – hyperflex maternal hips shoulder presentation
(knees to chest position) and tell the patient
◦ Be prepared for childbirth emergencies such as CS,
to stop pushing. This widens the pelvic outlet by forceps delivery, and neonatal
flattening the sacral promontory and
Resuscitation
increasing the lumbosacral angle.
Glossary:
CESAREAN SECTION
Amnioninfusion – infusion of warmed, sterile saline
◦ Increased fetal morbidity and mortality has
or ringer’s lactate solution into the uterine
convinced most physicians not to attempt vaginal
cavity to replace amniotic fluid and prevent fetal
delivery
distress
◦ Most breech presentations are delivered by
cesarean section or abdominal delivery
Amniotomy – artificial breaking of the amniotic sac
to hasten labor
Augmentation of labor – stimulating uterine
contractions by pharmacologic means to hasten
labor and delivery
Cesarean section – delivery of the fetus through an
abdominal incision
Malpresentation – abnormal presentation occurring
when any other fetal part besides the
flexed head enters the pelvis
Malposition – abnormal position of the presenting
part of the fetus in relation to the maternal
pelvis occurring when any other position besides
the flexed head enters the pelvis
oxygen supply to meet the demand of
the fetus.
Causes:
◦ Dystocia
◦ Cord coil, cord compression
◦ Improper use of oxytocin,
analgesia or anesthesia
◦ Diabetes mellitus, cardiac
disease, and other co-existing
conditions in the mother
◦ Bleeding complications (placenta
previa, abruptio placenta)
◦ Pregnancy induced hypertension
(PIH)

MODULE 7 (Part II)

Nursing Care of the High Risk Labor

& Delivery Client and Her Family

Sign and Symptoms:

◦ A. Meconium stained amniotic

NURSING CARE OF THE HIGH fluid (excluding breech
presentation)
RISK LABOR & DELIVERY ◦ B. Changes in fetal heart rate
CLIENT AND FAMILY: ◦ Tachycardia (above
160bpm) – early sign of
PROBLEMS WITH THE fetal distress
◦ Bradycardia (below
PASSENGER:
110bpm) – late sign of
fetal distress
FETAL DISTRESS
◦ C. decreased or absence of
variability of heart rate
◦ Fetal sleep, sedation and
hypoxia may affect
variability
◦ D. Fetal hypermobility /
hyperactivity

Nursing Care:

◦ Assess FHR baseline, variability,

and pattern of periodic changes
◦ Assess contraction pattern and
maternal response to labor
◦ Reposition mother to left lateral
recumbent. This relieves
Fetal Distress is a fetal condition pressure on inferior vena cava,
resulting from fetal hypoxia. Insufficient thereby increasing venous return
 resulting in increased perfusion of
placenta and fetus
◦ Stop the oxytocin drip if being
infused
◦ Administer oxygen mask at 6 to 7
liters per minute
◦ Correct hypotension
◦ Elevate legs, increase IV rate (to
increase hydration) provided that
the IV is plain and with no
oxytocin
◦ Monitor FHT continuously
◦ Notify physician for the status of
the mother and baby
◦ Prepare for emergency CS if
indicated
Medical Management:
◦ A. Amnioinfusion – amniotic
fluid may be replaced with
warmed sterile saline or ringer’s
lactate solution through an
intrauterine catheter when signs
of cord compression are present
during labor
◦ FHR monitoring
◦ Intrauterine catheter is
inserted
◦ Warmed sterile saline or
ringer’s lactate is delivered
via catheter using an
infusion pump
◦ Infusion is continued until
signs of cord compression
disappear
◦ Intrauterine resuscitation –
administration of terbutaline, a
tocolytic agent, to stop uterine
contraction and provide an
opportunity for uteroplacental
circulation to improve when fetal
distress if present during the 1st
stage of labor.
◦ Prevention of meconium
aspiration
◦ If meconium is present
during labor (green-tinged
amniotic fluid),
amnioinfusion maybe used
to dilute large amounts of
meconium, and steps to
prevent aspiration at the
time of delivery should be
taken
◦ The nasopharynx of the
infant is suctioned prior to
delivery of the chest and
abdomen
◦ Visualization of the larynx
and vocal cords with deep
suction is preformed
immediately after delivery
and before the first breath
is taken.
T
O
P
I
C
PROLAPSED UMBILICAL CORD
 Nursing Care:

◦ Identify the client at risk for

prolapsed umbilical cord; keep
◦ A cord prolapse is when an
woman with ruptured membranes
unborn baby’s
in a horizontal position (side
umbilical cord slips through the
lying).
cervix and into the vagina after a
mother's water breaks and before
◦ Actions to relieve pressure on the
the baby descends into the birth
cord and restore fetal
canal. During delivery,
oxygenation:
the prolapsed cord can become
◦ Place mother’s hips higher
compressed by baby's body.
than her bed
◦ Knee chest position
Causes:

◦ Fetus is not firmly engaged,

allowing room for the cord to
move beyond (prolapse) or
alongside the presenting part
(occult prolapse)
◦ Rupture of membranes before
engagement of the presenting
part
◦ Small fetus ◦ Trendelenburg
◦ Breech presentation position
◦ Multifetal pregnancy
◦ Transverse lie (shoulder
presentation)

◦ Perform sterile vaginal exam

pushing fetal presenting part
upward with the fingers to relieve
pressure on the cord
 occurring when any other position
besides the flexed head enters the
pelvis

Tocolytic agents – pharmacologic

agents that suppress or stop
uterine contraction

Intrauterine resuscitation – an
emergency procedure instituted
during labor to treat fetal distress by
stopping uterine contractions with a
tocolytic agent and allowing the
restoration of maternal – fetal
circulation so that the fetus can
recover from distress

◦ If cord protrudes through the

vagina, determine the pulsation is
present and apply sterile saline
soaked dressing to prevent Nursing Care of the
drying.
◦ Administer oxygen via facemask High Risk Labor
at 8 to 10 liters per minute
◦ Maintain continuous electronic & Delivery Client and
fetal monitoring
◦ Prepare for rapid delivery Her Family
vaginally or by cesarean section
NURSING CARE OF THE HIGH
RISK LABOR & DELIVERY
Glossary:
CLIENT AND FAMILY:

Amnioninfusion – infusion of PROBLEMS WITH THE POWER:

warmed, sterile saline or ringer’s
lactate solution into the uterine
cavity to replace amniotic fluid and
prevent fetal distress

Amniotomy – artificial breaking of

the amniotic sac to hasten labor

Augmentation of labor –
stimulating uterine contractions by
pharmacologic means to hasten
labor and delivery

Cesarean section – delivery of the

fetus through an abdominal incision

Malpresentation – abnormal
presentation occurring when any
other fetal part besides the flexed  Powers refers to the strength of
head enters the pelvis the uterine contractions – too
weak or uncoordinated and the
baby is not pushed down
Malposition – abnormal position of the birth canal
the presenting part of the fetus in
relation to the maternal pelvis
  Faulty power is the failure of the A
uterus to contract strongly
enough to make labor progress B
to an actual delivery. O
R
PROBLEMS WITH THE POWERS:

A. INDUCTION OF LABOR
B. DYSTOCIA OR DIFFICULT
LABOR
C. PREMATURE LABOR
D. PRECIPITATE LABOR AND
BIRTH
E. UTERINE PROLAPSE
F. UTERINE RUPTURE

T
O  Pharmacological and non
pharmacological measures
P
to initiate contractions and
I cervical change
C
Methods of induction:
A. CERVICAL RIPENING
1 B. AMNIOTOMY
C. MISOPROSTOL
(CYTOTEC)
I ADMINISTRATION
D. OXYTOCIN (PITOCIN)
N
D
U
A. Cervical ripening -
refers to the softening of
C the cervix that typically
T begins prior to the onset of
labor contractions and is
I necessary for cervical
O dilation and the passage of
the fetus.
N
1. Prostaglandins gel
(e.g. Cervidil, Prepidil)
O 2. Laminaria
(Hydrophilic agent) –
F when inserted into the
cervix , it absorbs
water from cervical
L mucus, expands, and
 dilates the cervix

C. MISOPROSTOL
(CYTOTEC)
ADMINISTRATION – a
synthetic prostaglandin
agent administered
intravaginally and/or orally at
doses of 25mg to 50mg to
stimulate the onset of
contractions
 Continuous monitoring
of the FHR, uterine
activity, and maternal
vital signs is essential

B. AMNIOTOMY OR
ARTIFICIAL RUPTURE OF
MEMBRANES (AROM) -
"breaking the water," is the
intentional rupture of the
amniotic sac by an
obstetrical provider.
 Auscultate FHR prior
to and immediately
after AROM to detect
prolapse of the
umbilical cord or fetal
distress
 Take the maternal
temperature every 1 to
2 hours following
AROM to detect signs
of infection

D. OXYTOCIN (PITOCIN)
ADMINISTRATION
 The BISHOP SCORE may
be used to assess
maternal readiness for
 induction by determining and output, and
dilatation, effacement, contraction, frequency and
station, cervical intensity
consistency, and position  Begin primary intravenous
of the cervix infusion
 A Bishop score of  Mix oxytocin to 500ml to
8 or greater is 1000ml of IV balanced –
considered to be saline fluid such as
favorable for lactated ringer’s and
DRUG ROUTE / ACTION SIDE EFFECTS AND POTENTIAL
COMPLICATION

Prostaglandin Intravaginally close to Abdominal cramping, nausea, vomiting,

gel (Cervidil, cervix diarrhea
Prepidil) Causes softening and
effacement or cervical
ripening

Misoprostol Synthetic prostaglandin Sudden onset of hypertonic contractions and

(Cytotec) Administer orally or elevated resting tone of the uterus which
intravaginally to produce may lead to fetal distress
contraction

induction, or the piggyback into the primary

chance of a vaginal iv at a site as close to the
delivery with client as possible
induction is similar  Control and titrate the
to spontaneous oxytocin solution using an
labor. A score of 6 infusion pump
or less is  Begin at 0.5 to 2 ml/min.,
considered to be increasing at the
unfavorable if an increments of 1 to 2ml
induction is every 15 to 60 minutes up
indicated cervical to a maximum of 40ml
ripening agents may according to hospital
be utilized. protocol and until
contraction occur regularly.
 Continue to monitor
contractions and FHR
closely and stop
immediately if with signs of
fetal distress

Drugs used for induction of labor



 Prior to induction, begin

external fetal monitoring
 Assess and record
maternal vital signs, intake
DRUG ROUTE / SIDE EFFECTS AND
ACTION POTENTIAL COMPLICATION
nonprogressive labor, pain
and fatigue
Oxytocin IV / IM Increased risk of water  Fetal risk include hypoxia
(Pitocin) Augment ontoxication: signs includes:
uterine nausea, vomiting,
caused by decreased
contraction hypotension, tachycardia, uteroplacental blood flow
Pitocin and cardiac arrythmia  Medical treatment:
infusion is sedation – aimed at
stopped and
the physician stopping contractions,
notified if: promoting rest, and
*contractions allowing a normal labor
are closer
than 2 min. or pattern to develop
last longer  Nursing Intervention:
than 90sec. Hydration, monitoring
Observe for
signs of fetal intake and output, and
distress promoting relaxation

2. HYPOTONIC UTERINE
DYSFUNCTION – infrequent
contraction with decreased
intensity
DYSTOCIA OR DIFFICULT LABOR  Maternal and Fetal risk:
related to non progressive
labor, which is often
associated with prolonged
rupture of membranes,
and frequent vaginal
examinations leading to
infection
 Medical treatment:
augmentation of labor or
stimulation of contraction
with oxytocin

1. Abnormal progress in
labor – the LABOR GRAPH
or FRIEDMAN’s CRUVE is
used to identify deviations
from normal progress in
labor by plotting cervical
dilatation and descent of
 Dystocia of labor is defined fetal head over time.
as difficult labor or abnormally
slow progress of labor. Other
terms that are often used
interchangeably with dystocia are
dysfunctional labor, failure to
progress (lack of progressive
cervical dilatation or lack of
descent)

Types:

1. HYPERTONIC UTERINE
DYSFUNCTION – frequent
contractions with decreased
intensity and increased uterine
tone  3.1 Prolonged Latent
 Maternal risk are Phase - >20 hours in a
prolonged or nulliparous client or >14
 hours in a multiparous forms during labor
client  Upper segment
 *May indicate CPD contracts and
 *May be caused by becomes thicker
false labor as
 *Medical Treatment:  muscle fibers
sedation and rest shorten
 3.2 Protracted Active  Lower segment
phase – dilatation <1.2 cm distends and
in a nulliparous client or becomes thinner
<1.5cm in a multiparous
client  4.2 Bandl’s ring – a
 *may be caused by pathological retraction
malposition ring that forms when
 CPD labor is obstructed
and Fetal caused by CPD or
presentation and other complications
position is assessed  Upper segment
continuous to
3.3 Protracted descent - thicken
<1cm per hour change in  Lower segment
station in the nulliparous client continuous to
or <2cm per hour in the distend
multiparous client  Risk of uterine
 CPD is ruled out rupture
 Contraction increases if
intensity and contractions
duration are continue
assessed  Cesarean
 Labor maybe delivery is
augment by indicated
oxytocin

 3.4 Secondary arrest of

dilatation – cessation of
dilatation for >2 hours in a
nulliparous client or > 1 hour
in a multiparous client
 CPD is ruled out
 If no CPD, labor

is augmented
with oxytocin
 3.5 Arrest of
descent – no
progress in fetal
station for
>1hour
 CPD is
assessed
 Labor is
augmented if no
CPD

2. RETRACTION RINGS

 4.1 Physiologic
retraction ring -
boundary between
upper uterine segment
and lower uterine
segment that normally

4.3 Constriction ring - retraction
ring forms and impedes fetal
descent
 Relaxation of the
constriction ring with
analgesics, anesthetics or
both allows vaginal
delivery
TOPIC 3
Premature labor
 Premature labor occurs when
regular contractions result in the
opening of the cervix after week
20 and before week 37 of
pregnancy. Preterm labor can
result in premature birth. The
earlier premature birth happens,
the greater the health risks for the
baby.
Signs of premature labor
 Contractions occurring
every 10 minutes or less
with or without pain
 Low abdominal cramping
with or without diarrhea
 Intermittent sensation of
pelvic pressure, urinary
frequency
 Increased vaginal
discharge, may be pink-
tinged
 Leaking amniotic fluid
 Immediate actions to be taken by
clients experiencing suspected
premature labor
 Empty bladder
 Assume a side – lying
position (Left lateral)
 Drink 3 to 4 cups of water
 Palpate abdomen for
uterine contractions; if
10min. Apart or closer,
contact health care
provider
 Rest for 30 minutes and
slowly resume activity if
symptom disappear
 It symptoms do not
subside within 1 hour,
contact health care
provider
Medical management
 Bed rest
 Continued monitoring of uterine
activity and FHR
 Administration of tocolytic agents,
drugs to stop contractions if labor
continue ( Ritodrine, terbutaline,
magnesium sulfate, nifedipine
 Administration of
bethamethasone or
dexamethasone to stimulate fetal
lung maturity
Nursing care
 Identify clients at risk for
 premature labor
 Provide client and family teaching
regarding signs and management
of premature labor
 Promote bedrest encouraging left
lateral position
 Monitor uttering activity and FHR
 Administer tocolytics per doctors
order and monitor for adverse
reaction
 Provide emotional support
encouraging client and family to
express feelings and concerns

Factors influencing the size and

Nursing Care of the High shape of the pelvis:
Risk Labor
• Developmental factor: hereditary
& Delivery Client and Her or congenital.
Family • Racial factor
• Nutritional factor: malnutrition
results in small pelvis.
• Sexual factor: as excessive
androgen may produce android
NURSING CARE OF THE HIGH pelvis.
• Metabolic factor: as rickets and
RISK LABOR & DELIVERY
osteomalacia.
CLIENT AND FAMILY: • Rickets is a condition that
affects bone development
PROBLEMS WITH THE in children. It causes bone
PASAGEWAY: pain, poor growth and soft,
weak bones that can lead
ABNORMAL PELVIC SIZE OR to bone deformities.
• Osteomalacia refers to a
SHAPE marked softening of your
bones, most often caused
by severe vitamin D
deficiency.
• Trauma, diseases or tumours of
the bony pelvis, legs or spines.

TYPES:
It is a pelvis in which one or more
of its diameters is reduced so that it 1. CONTRACTED PELVIC
interferes with the normal mechanism of INLET – Anterior – posterior
labor. diameter less than 10
centimeters; transverse diameter
The female bony pelvis less than 12 centimeters.
◦ EFFECTS:
◦ Makes engagement
difficult, Influences
fetal position and
presentation
 if progressive changes in
dilatation and station do not
occur, a cesarean delivery is
performed.

T
O
P
I
C
2. . CONTRACTED MID-PELVIC
PLANE – interspinous diameter 2
less than 9.5cm
◦ EFFECTS: CEPHALOPELVIC DISPROPORTION
◦ Hampers internal (CPD)
rotation of fetal
head
◦ Secondary arrest of
dilatation or arrest
in descent of the
fetal head occurs

3. CONTRACTED PELVIC
OUTLET – interischial tuberous
diameter less than 8 cm.

Cephalopelvic
disproportion (CPD) occurs when a
baby's head or body is too large to fit
through the mother's pelvis

Management:
Causes:
1. Trial of Labor (TOL) – the
physician may allow labor to Possible causes of cephalopelvic
continue or even stimulate labor disproportion (CPD) include:
with oxytocin when pelvic • Large baby due to:
measurements are borderline to • Hereditary factors
see if the fetal head will descend • Diabetes
making vaginal delivery possible; • Post maturity (still
 pregnant after the due
date has passed)
• Multiparity (not the first
pregnancy)
• Abnormal fetal positions
• Small pelvis
• Abnormally shaped pelvis

Sign and Symptoms:

Fetal head does not descend

even though there are strong
contractions

TOPIC 3

SHOULDER DYSTOCIA

Fetal and Maternal Risk:

MATERNAL:
◦ Prolonged labor
◦ Exhaustion
◦ Hemorrhage
◦ Infection
An obstetric emergency resulting from
difficulty or inability to deliver the
FETAL: shoulder.
◦ Hypoxia
◦ Birth Trauma
Risk Factors:
Diagnosis: 1. gestational diabetes
2. previous history of the condition
Ultrasound is used in 3. operative vaginal delivery
estimating fetal size but not 4. obesity in the mother
totally reliable for determining 5. an overly large baby
fetal weight. A physical 6. epidural anesthesia
examination that measures
pelvic size can often be the
most accurate method
for diagnosing CPD

Maternal and Fetal risk:

MATERNAL:
◦ Laceration and tears of
Management: birth canal
◦ Postpartum hemorrhage
 Cesarean birth is necessary
 FETAL:
◦ Hypoxia
◦ Fractures of clavicle
(collarbone and arm)
◦ Injury to neck and head
(Damage to the brachial
plexus nerves)
• These nerves go
from the spinal cord
in the neck down
the arm. They
provide feeling and
movement in the
shoulder, arm and
3. Assess for maternal and
hand. Damage can newborn injury following
cause weakness or delivery
paralysis in the arm
or shoulder.
Medical Management:
Paralysis is when
you can’t feel or
1. Press mother thighs up
move one or more
against her belly
parts of your body.
(McRoberts maneuver)
• Erb's palsy is
2. Press the lower belly just
a paralysis of
above the pubic bone
the arm
(suprapubic pressure).
caused by
injury to the
upper group
of the arm's
main nerves

3. Help the baby’s arm out of

the birth canal
4. Reach up into the vagina to
try to turn the baby. Or turn
the mother on all fours
position (Gaskin’s
Maneuver)

Nursing Care:

1. Assessment and identification of the

client at risk for shoulder dystocia
2. Assist with positioning during delivery:
McRoberts maneuver

5. The Woods screw maneuv

 er (also called Woods
corkscrew)
is a technique used by
doctors to free a baby from
the birth canal in cases of
shoulder dystocia. The
doctor's hand is placed
behind the non-impacted
shoulder of the baby. The
shoulder is rotated in
a corkscrew maneuver until
the impacted shoulder is
released.
6. Do an episiotomy. This is not
done routinely but only in
cases in which a larger
opening to the vagina is
helpful and the incision won’t
affect the baby.
7. Do a cesarean section, other
surgical procedures or break
your baby’s collarbone to
release the shoulders. These
are done only in severe
cases of shoulder dystocia
that aren’t resolved by other
methods.
Glossary:
Trial of Labor – observation period
to determine if a laboring woman
with a borderline or small pelvis can
progress to a vaginal birth
Episiotomy - is an incision made
in the perineum (the tissue between
the vaginal opening and the anus
during childbirth.
Hypoxia - is a condition in which
the body or a region of the body is
deprived of adequate oxygen
supply at the tissue level.
Amnioninfusion – infusion of
warmed, sterile saline or ringer’s
lactate solution into the uterine
cavity to replace amniotic fluid and
prevent fetal distress
Amniotomy – artificial breaking of
the amniotic sac to hasten labor
Augmentation of labor –
stimulating uterine contractions by
pharmacologic means to hasten
labor and delivery
Cesarean section – delivery of the
fetus through an abdominal incision
Malpresentation – abnormal
presentation occurring when any
other fetal part besides the flexed
head enters the pelvis
Malposition – abnormal position of
the presenting part of the fetus in
relation to the maternal pelvis
occurring when any other position
besides the flexed head enters the
pelvis
Tocolytic agents – pharmacologic
agents that suppress or stop
uterine contraction
Intrauterine resuscitation – an
emergency procedure instituted
during labor to treat fetal distress by
stopping uterine contractions with a
tocolytic agent and allowing the
restoration of maternal – fetal
 circulation so that the fetus can
recover from distress
NURSING CARE OF THE HIGH
RISK LABOR & DELIVERY
CLIENT AND FAMILY:
PROBLEMS WITH THE POWER:
 Powers refers to the strength of
the uterine contractions – too
weak or uncoordinated and the
baby is not pushed down
the birth canal
 Faulty power is the failure of the
uterus to contract strongly
enough to make labor progress
to an actual delivery.
PROBLEMS WITH THE POWERS:
A. INDUCTION OF LABOR
B. DYSTOCIA OR DIFFICULT
LABOR
C. PREMATURE LABOR
D. PRECIPITATE LABOR AND
BIRTH
E. UTERINE PROLAPSE
F. UTERINE RUPTURE
PRECIPITATE LABOR AND BIRTH
 Refers to rapid labor (<3
hours) resulting in
precipitous (unattended or
nurse attended) birth
 refers to childbirth after an
unusually rapid labor
(combined 1st stage and
second stage duration is
under two hours) and
culminates in the rapid,
spontaneous expulsion of
the infant. Delivery often
occurs without the benefit of
asepsis.
Causes of precipitate labor /
birth:
Risk factors for precipitous
labor include:
 chronic high blood
pressure
 younger maternal age
 multiparity
 lower infant birth
weight
 induction of labor with
prostaglandin E2
(PGE2), a medication
that dilates the cervix.
Maternal and fetal risk:
MATERNAL RISK:
 Cervical, vaginal, or
rectal lacerations
 Increased risk for
hemorrhage
FETAL RISK:
 Hypoxia caused by
decreased perfusion to
intervillous spaces
 Intracranial
hemorrhage due to
rapid passage through
the birth canal
 Injury at birth
 Pneumothorax due to
rapid descent
Nursing management:
 Identify the client at risk for
precipitous labor and birth,
who is often a client with a
history of precipitous labor.
 Do not leave the client, send
someone or call for help
 Don sterile gloves if time
allows
 Instruct the client to pant or
 blow to decreased the urge UTERINE PROLAPSE
to push
 Support the perineum with a
sterile towel as crowning
occurs
 Apply gentle pressure on the
fetal head to prevent rapid
delivery
 After delivery of the head,
suction the infant’s mouth
the nose with bulb syringe
 Check around the infant’s
neck for a possible tight
umbilical cord; if present,
cord must be clamped and
cut before delivery
A uterine prolapse is when
 Gentle downward pressure the uterus descends toward or into the
facilitates birth of the anterior vagina. It happens when the pelvic floor
shoulder muscles and ligaments become weak
 Gentle upward traction and are no longer able to support
facilitates birth of the the uterus. In some cases,
the uterus can protrude from the vaginal
posterior shoulder opening.
 Support the infant’s body
with a towel as it expelled
from the birth canal Causes:
 Dry the infant thoroughly and
place the infant on the  Vigorous massage of the fundus
and pulling on the umbilical cord
mother’s abdomen as soon to speed placental separation
as stable may cause prolapse of the cervix
 Clamp and cut the umbilical and lower uterine segment
cord through the introitus
 Observe for signs of
placental separation, gently
UTERINE INVERSION – turning inside
pull the cord while out of the uterus
massaging the fundus to
deliver the placenta
 Continue to massage the
fundus to prevent
hemorrhage
 Inspect the perineum for
lacerations or tears

COMPLETE INVERSION –
inverted uterus is visible outside the
introitus
 Life-threatening because
of severe hemorrhage and
shock
 Uterus must be
 immediately replaced
manually to stop blood
loss

PARTIAL INVERSION – Is not visible
but can be palpated
 Uterine fundus is partially
inverted hampering
contraction and control of
Hemorrhage
 Corrected by a physician
using a bimanual
technique
Uterine rupture is
spontaneous tearing of the
uterus that may result in the fetus
being expelled into the peritoneal
cavity. Uterine rupture is rare. It
can occur during late pregnancy
or active labor. Uterine
rupture occurs most often along
healed scar lines in women who
have had prior cesarean
deliveries

Causes:

 Separation of scar from previous

classical cesarean section
 Uterine trauma (may be caused
by injury from obstetric
instruments, such as uterine
sound or curette used in abortion)
 Intense uterine contraction
 Overstimulation of labor with
oxytocim
 Difficult forceps – assisted birth
 excessive fundal pressure,
forceps delivery, violent bearing-
down, and fetal shoulder dystocia
 previous uterine surgery, grand
multiparity, cephalopelvic
disproportion, malpresentation, or
TOPIC 6 hydrocephalus.
UTERINE RUPTURE

Risk factors:

 Multiparity
 Overdistension of the uterus
(multifetal pregnancy)
 Malpresentation
 Previous uterine surgery

Types:

1. COMPLETE – extends through

uterine wall into the peritoneal
cavity
 2. INCOMPLETE – extends into
peritoneum but not into peritoneal
cavity
Symptoms: (Maybe silent or dramatic)
 Sudden, sharp, lower abdominal
pain
 Tearing sensation
 Signs of shock (decreased BP,
tachycardia)
 Cessation of contractions
 FHR ceases
 Blood loss is often concealed
 Fetal parts may be easily
palpated through abdominal wall
Medical management:
- depends on the type of rupture
 Complete rupture requires
management of shock,
replacement of blood and
hysterectomy
 Incomplete rupture may require
laparotomy, repair and blood
transfusion
Nursing management:
 Prevention is best:
• If the client has signs of possible
uterine rupture, vaginal delivery is
generally not attempted.
• If symptoms are not severe, an
emergency cesarean delivery
may be attempted and the uterine
tear repaired.
• If symptoms are severe,
emergency laparotomy is
performed to attempt immediate
delivery of the fetus and then
establish homeostasis.
• Implement the following
preparations for surgery.
• Monitor maternal blood
pressure, pulse, and
respirations; also monitor
fetal heart tones.
• If the client has a central
venous pressure catheter
in place, monitor pressure
to evaluate blood loss and
effects of fluid and blood
replacement.
• Insert a urinary catheter for
precise determinations of
fluid balance.
• Obtain blood to assess
possible acidosis.
• Administer oxygen, and
maintain a patent airway.
Glossary:
Trial of Labor – observation period
to determine if a laboring woman
with a borderline or small pelvis can
progress to a vaginal birth
Episiotomy - is an incision made
in the perineum (the tissue between
the vaginal opening and the anus
during childbirth.
Hypoxia - is a condition in which
the body or a region of the body is
deprived of adequate oxygen
supply at the tissue level.
Amnioninfusion – infusion of
warmed, sterile saline or ringer’s
lactate solution into the uterine
cavity to replace amniotic fluid and
prevent fetal distress
Amniotomy – artificial breaking of
the amniotic sac to hasten labor
Augmentation of labor –
stimulating uterine contractions by
pharmacologic means to hasten
labor and delivery
Cesarean section – delivery of the
fetus through an abdominal incision
Malpresentation – abnormal
presentation occurring when any
other fetal part besides the flexed
head enters the pelvis
Malposition – abnormal position of
the presenting part of the fetus in
relation to the maternal pelvis
occurring when any other position
besides the flexed head enters the
pelvis
Tocolytic agents – pharmacologic
agents that suppress or stop
uterine contraction
Intrauterine resuscitation – an
 emergency procedure instituted
during labor to treat fetal distress by
stopping uterine contractions with a
tocolytic agent and allowing the
restoration of maternal – fetal
circulation so that the fetus can
recover from distress
THIRD TRIMESTER GESTATIONAL
CONDITIONS
TOPIC 1 PRETERM LABOR According to the
American College of Obstetricians and
Gynecologists, preterm labor occurs when the
mother start having contractions that cause cervical
changes before she is 37 weeks pregnant. Some
women are at greater risk for preterm labor,
including those who:  are pregnant with multiples
(twins or more)  have an infection of the amniotic
sac (amnionitis)  have excess amniotic fluid
(polyhydramnios)  have had a previous preterm
birth Symptoms Signs and symptoms of preterm
labor can be subtle. An expectant mom may pass
them off as part of pregnancy. Symptoms include: 
diarrhea  frequent urination  lower back pain 
tightness in the lower abdomen  vaginal discharge
 vaginal pressure Of course, some women may
experience more severe labor symptoms. These
include regular, painful contractions, leaking of
fluid from the vagina, or vaginal bleeding.
Treatment
Medications
your baby's lung maturity.
Example: Dexamethasone and Betamethasone (IM)
magnesium sulfate if you have a high
risk of delivering between weeks 24 and 32 of
pregnancy. ...
- drugs for treatment in preterm labor.
Other kinds of treatments for preterm labor:
This is a hormone that plays a key
role during
pregnancy. Treatment with progesterone may help
prevent premature birth for
certain women. Talk to your provider to see if
progesterone treatment may be right
for you.
ovider puts in
your cervix. The stitch may help
keep your cervix closed so that your baby isn’t born
too early. Your provider
removes the stich at about 37 weeks of pregnancy.
A cerclage is only used for
certain women. For example, your provider may
recommend a cerclage if you have
a short cervix. Talk to your provider to see if a
cerclage may be right for you.
help you stay pregnant longer, even
if you have signs of preterm labor. Bed rest means
that you take it easy until your
baby’s born and stay calm and still. Your provider
may want you to rest just a few
times each day. Or she may want you to stay in bed
all day
TOPIC 2
PREMATURE RUPTURE OF MEMBRANES (PROM)
Rupture of membranes is a normal part of giving
birth. It’s the medical term for saying
the water broke. This means that the amniotic sac
that surrounds the baby has broken,
allowing the amniotic fluid to flow out.
While it’s normal for the sac to break during labor,
if it happens too early it can cause
serious complications. This is called premature
rupture of membranes (PROM). Although
the cause of PROM isn’t always clear, sometimes an
infection of the amniotic membranes
is the cause.
Treatment
hospitalized and given antibiotics,
steroids (lung maturation of fetus), and drugs to
stop labor (tocolytics) terbutalinebricanyl brand
name, piperidolate hcl- dactyl ob brand.
doctors recommend inducing
labor. At that time, the risks of prematurity are less
than the infection risks. If there
are signs of infection, labor must be induced to
avoid serious complications.
TOPIC 3
INTRAUTERINE GROWTH RESTRICTION (IUGR)
Refers to a condition in which an unborn baby is
smaller than it should be because it
is not growing at a normal rate inside the womb.
IUGR can result in symmetrical or asymmetrical
growth. Babies with asymmetrical
growth often have a normal-sized head with a
smaller-sized body.
Delayed growth puts the baby at risk of certain
health problems during pregnancy,
delivery, and after birth. They include:
blood sugar)
birth to evaluate the newborn's
physical condition and determine need for special
medical care)
while in the uterus), which can
lead to breathing problems
stillbirth. It can also cause long-term
growth problems.
*NOTE: Not all small babies have IUGR —
sometimes their size can be attributed to the
smaller size of their parents.
Causes of Intrauterine Growth Restriction
is a problem with the placenta.
The placenta is the tissue that joins the mother and
fetus, carrying oxygen and
nutrients to the baby and permitting the release of
waste products from the baby.
certain health problems in the mother,
such as:
toxoplasmosis, and syphilis
rugs
defects in the baby or multiple
gestation (twins, triplets, or more).
IUGR Symptoms
The main symptom of IUGR is a small for
gestational age baby. Specifically, the
baby's estimated weight is below the 10th
percentile -- or less than that of 90% of babies of
the same gestational age.
Depending on the cause of IUGR, the baby may be
small all over or look
malnourished. They may be thin and pale and have
loose, dry skin. The umbilical cord is
often thin and dull instead of thick and shiny.
IUGR Diagnosis
Doctors have many ways to estimate the size of
babies during pregnancy. One of the
simplest and most common is measuring the
distance from the mother's fundus (the top of
the uterus) to the pubic bone. After the 20th week
of pregnancy, the measure in centimeters
usually corresponds with the number of weeks of
pregnancy. A lower than expected
measurement may indicate the baby is not growing
as it should.
Other procedures to diagnose IUGR and assess the
baby's health include the following:
growth in the uterus, ultrasound
involves using sound waves to create pictures of
the baby. Ultrasound can be used
to measure the baby's head and abdomen. The
doctor can compare those
measurements to growth charts to estimate the
baby's weight. Ultrasound can also
be used to determine how much amniotic fluid is in
the uterus. A low amount of
amniotic fluid could suggest IUGR.
uses sound waves to measure the
amount and speed of blood flow through the blood
vessels. Doctors may use this test
to check the flow of blood in the umbilical cord and
vessels in the baby's brain.
Weight checks. Doctors routinely check and
record the mother's weight at every
prenatal checkup. If a mother is not gaining weight,
it could indicate a growth problem
in her baby.
sensitive electrodes on the mother's
abdomen. The electrodes are held in place by a
lightweight stretchable band and
attached to a monitor. The sensors measure the
rate and pattern of the baby's
heartbeat and display them on a monitor or print
them.
, a needle is
placed through the skin of the mother's
abdomen and into her uterus to withdraw a small
amount of amniotic fluid for testing.
Tests may detect infection or some chromosomal
abnormalities that could lead to
IUGR.
IUGR Treatments
Preventing Intrauterine Growth Restriction
Although IUGR can occur even when a mother is
perfectly healthy, there are things mothers
can do to reduce the risk of IUGR and increase the
odds of a healthy pregnancy and baby.
g
potential problems may help treat
them early.
doesn't move often or who stops
moving may have a problem. If the mother notice
changes in her baby's movement,
she must call her doctor.
. Sometimes a medication a
mother is taking for another health
problem can lead to problems with her unborn
baby.
help keep her baby well nourished.
and it may even help the baby grow.
Try to get eight hours of sleep (or more) each night.
An hour or two of rest in the
afternoon is also good for her.
drinks alcohol, take drugs, or smoke,
she must stop for the health of her baby.
TOPIC 4
POST TERM PREGNANCY
A pregnancy that lasts more than 42 weeks (294
days since the first day of the last
menstrual period) is considered post-term. Other
terms often used for this are prolonged
pregnancy, post-dates pregnancy and post
maturity.
INCIDENCE: About 7 percent of women deliver at 42
weeks or later.
Causes
gestation
– most of the time, the cause is
unknown
Complications
1. Maternal Complications
extraction and forceps
assisted delivery
-partum hemorrhage and infection
2. Fetal Complications
trauterine growth retardation because of
placenta functions less effectively
after 40weeks gestation
Amniotic fluid is a clear, yellow fluid which is found
within the first 12 days following
conception within the amniotic sac. It surrounds
the growing baby in the uterus other term
“BOW” bag of water

pregnancy and labor Rupture of the membranes is commonly described

as “the water breaks.”

Delayed the act of postponing, hindering, or

- occurs when the glucose level of a causing something to occur more slowly than
newborn causes symptoms
normal
or is below the range considered safe for the baby's
age. It occurs in about 1 Post maturity refers to any baby born after 42
weeks gestation or 294 days past the first
to 3 out of every 1000 births.
day of the mother's last menstrual period
Management
Hypoxia a dangerous condition that happens when
1. Assess fetal wellbeing because one of the your body doesn't get enough oxygen
significant dangers of post-maturity is
Fetal distress is an emergency pregnancy, labor,
placental insufficiency which cause fetal hypoxia and delivery complication in which a
and IUGR. This is achieved by
baby experiences oxygen deprivation
ultrasound, NST, fetal movements count, and
Biophysical profile. Tocolytic agents used for the treatment of preterm
labor
2. The method of delivery will depend on fetal
condition.

3. If fetal status is stable, the choice of delivery is

vaginal with labor induction.

Intervention

BOW for meconium staining which

is common in post-term pregnancies.

4. If fetal assessment shows compromise or if

during labor the fetus show signs of

distress, cesarean section is performed to deliver

the baby right away and prevent

further complication.

5. After delivery of post mature infant (intervention

will be discuss in the latter part of

the topic).

Glossary:

Preterm is defined as babies born alive before 37

weeks of pregnancy are completed

Labor is a physiologic process during which the

fetus, membranes, umbilical cord, and

placenta are expelled from the uterus