BPSU College of Nursing Maternal Child Nurse Responsibilities

BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY

City of Balanga 2100 Bataan
PHILIPPINES
ROLES & RESPONSIBILITIES OF A MATERNAL & CHILD NURSE

IN CHALLENGING SITUATIONS
Maternal and Child Health refer to the philosophy – mother and child relationship to one another and
consideration of the entire family as well as the culture and socio-economic environment as framework of
the patient. It involves the care of the woman and family throughout pregnancy and childbirth and the health
promotion and illness care for the children and families.
GOAL OF MCH
• To ensure that every expectant and nursing mother maintains good health, learns the art of child care,
has normal delivery and bears healthy child.
• That every child, wherever possible lives and grows up in a family unit with love and security, in healthy
surroundings, receives adequate nourishment, health supervision and efficient medical attention, and is
taught the elements of healthy living (Reyala, 2000).
• Promotion and maintenance of optimum health of the women and newborn.
PHILOSOPHY OF MCN:
1. Is community-centered
2. Is research-centered
3. Is based on nursing theory
4. Protects the rights of all family members
5. Uses a high degree of independent functioning
6. Places importance on promotion of health
7. Is based on the belief that pregnancies or childhood illness are stressful because they are crises.
8. Is a challenging role for the nurse and is a major factor in promoting high level wellness in families.
9. Pregnancy, labor and delivery and the puerperium are part of the continuum of the total life cycle.
10. Personal, cultural and religious attitudes and beliefs influence the meaning of pregnancy for
individuals and make each experience unique.
11. Maternal-child nursing is family centered. The father of the child is as important as the mother.
Strategic Thrusts (2005-2010)

1. Launch and implement the Basic Emergency Obstetric Care (BEMONC) strategy in coordination
with the DOH. It entails the establishments of facilities that provide emergency obstetric care for
every 125,000 population and which are located strategically.
2. Improves the quality of prenatal and postnatal care.
3. Reduce women’s exposure to health risks through the institutionalization of responsible parenthood
and provision of appropriate health care package to all women of reproductive age especially those
who are less than 18 years old and over 35 years of age, women with low education and financial
resources, women with unmanaged chronic illness and women who had just given birth in the last
18 months.
4. LGUs and NGOs and other stakeholders must advocate for health through resource generation and
allocation for health services to be provided for the mother and the unborn.
VISION MISSION
A leading univerity in the Philippines recognized for its To develop competitive graduates and empowered community members by providing relevant,
proactive contribution to Sustainable Development through innovative and transformative knowledge, research, extension and production programs and services
equitable inclusive programs and services by 2030. through progressive enhancement of its human resource capabilities and institutional mechanism.
Maternal Neonatal and Child Health and Nutrition Strategy (MNCHN)
− It applies specific policies and actions for local health systems to systematically address health risks
that lead to maternal and especially neonatal deaths which comprise half of the reported infant
mortalities.
BeMONC- Basic Emergency Obstetrics and Newborn Care

1. It refers to lifesaving services for emergency maternal and newborn conditions/complications being
provided by a health facility or professional to include the following services:
a. Administration of parenteral oxytocic drugs.
b. Administration of dose of parenteral anticonvulsants
c. Administration of parenteral antibiotics
d. Administration of maternal steroids for preterm labor
e. Performance of assisted vaginal deliveries
f. Removal of retained placental products
g. Manual removal of retained placenta
2. It also includes neonatal interventions which include at the minimum:
a. Newborn resuscitation
b. Provision of warmth
c. Referral
d. Blood transfusion
3. BeMONC facility shall consist of the core district hospital.
4. For geographically isolated/disadvantaged areas/ densely populated areas, the designated BeMONC
facilities are the following: Rural Health Unit, Barangay Health Station, Lying-in Clinics and
Birthing Homes.
5. Accessibility within 1 hour from residence or referring facility within the ILHZ (Inter-local Health
Zones)
6. Shall operate within 24 hours with 6 signal obstetric function.
7. Shall have access to communication and transportation facilities to mobilize referrals.
8. Staff composition: (1) Medical Doctor, (1) Registered Nurse, (1) Registered Midwife.
CeMONC- Comprehensive Emergency Obstetrics and Newborn Care

Refers to lifesaving services for emergency maternal and newborn conditions/complications as in Basic
Emergency Obstetric and Newborn Care plus the provision of surgical delivery and blood bank services
and other specialized obstetric interventions.
Essential Health Services available in the Health Care Facilities

1. Antenatal Registration/ Prenatal Care
OBJECTIVE: to reach all pregnant women, to give sufficient care to ensure a healthy pregnancy
and the birth of a full-term healthy baby.
a. Normal Patients- following the initial evaluation they will be given healthy instructions and
counseling. This will include advice for prompt prenatal care examination.
b. Patients with mild complications- a thorough evaluation of the needs of patients with mild
complications will determine the frequency of follow-up of these cases by the rural health unit,
city health clinic or puericulture center
c. Patients with potentially serious complications- these patients shall be referred to the most
skilled source of medical and hospital care. As a first choice they will be referred if at all
possible, for continuing care or consultation. Second choice will be followed carefully by the
rural health unit, city health clinic or puericulture center.
d. All RHUs and BHS should have a master list of pregnant women in their respective catchment
center.
e. The Home-Based Mother’s Record (HBMR) shall be used when rendering prenatal care as a
guide in in the identification of risk factors, danger signs and to be able to do appropriate
measures.
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f. There should be at least 3 prenatal visits following the prescribed timing:
− First prenatal visits should be made as early in pregnancy as possible, during the first
trimester.
− Second during the second trimester.
− Third and subsequent visits during the third trimester.
− More frequent visits should be done for those at risk or with complications.
Tetanus Toxoid Immunization

1. Neonatal tetanus is one of the public health concerns, that is why it is important for pregnant women
and child bearing age women to get a tetanus toxoid immunization in order to protect them from
this deadly disease.
2. A series of 2 doses of TT vaccination must be received by woman one month before delivery to
protect baby from neonatal tetanus.
3. And the three booster dose shots to complete the five doses following the recommended schedule
provides full protection. The mother is then called as a “Fully Immunized Mother” (FIM).
Micronutrient Supplementation
It is necessary to prevent anemia, vitamin A deficiency and other nutritional disorders.
Vitamin A
− Dose: 10,000 IU
− Given a week starting on the 4th month of pregnancy.
− Do not give it before the 4th month of pregnancy because it might cause congenital problems in the
baby.
Iron
− Dose: 60mg/400 ug tablet
− Schedule: Daily
Clean and Safe Delivery

1. Check for Emergency signs
− Unconsciousness
− Vaginal bleeding
− Severe abdominal bleeding
− Looks very ill
− Severe headache with visual disturbance
− Severe breathing difficulty
− Fever
− Severe vomiting
2. Make woman comfortable
3. Assess the woman in labor
− LMP
− Number of pregnancies
− Start of labor pains
− Age/height
− Danger signs of pregnancy
4. Determine the stage of labor
5. Decide of the woman can safely deliver
6. Give supportive care throughout labor
7. Monitor and manage labor
8. Monitor closely after delivery
9. Continue care for at least two hours postpartum
10. Inform, counsel and teach woman
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− Birth registration
− Importance of breastfeeding
− Newborn screening
− Schedule of postpartum visits. (1st visit: 1st week postpartum preferably 3-5 days and 2nd visit:
6 weeks postpartum)
Home Delivery
It is for normal pregnancies attended by licensed health personnel. Trained “hilots” may be allowed to
attend home deliveries only in the following circumstances:
1. Areas where there are no health personnel on maternal care.
2. When, at the time of delivery, such personnel is not available.
Actively practicing but untrained birth attendants (hilots) should be identified, trained and supervised by
personnel of the nearest BHS/RHU trained on Maternal Care.
The following are qualified for home delivery:
1. Full term
2. Less than 5 pregnancies
3. Cephalic position
4. Without existing diseases such as diabetes, bronchial asthma, heart disease, hypertension, goiter,
tuberculosis, severe anemia.
5. No history of complications like hemorrhage during previous deliveries.
6. No history of difficult delivery and prolonged labor (more than 24 hours for primi and more than 12
hours for multigravida)
7. No previous cesarean section.
8. Imminent deliveries (those who are about to deliver and can no longer reach the nearest facility in
time for delivery)
9. No premature rupture of membranes
10. Adequate pelvis
11. Abdominal enlargement is appropriate for age of gestation.
Home delivery kit must at least contain two pairs of clamps, a pair of scissors, antiseptic (may use 70%
Povidone/Iodine) soap and hand brush, clean towel/piece of cloth, flashlight, sphygmomanometer,
stethoscope.
Clean hands, clean surface and clean cord must be strictly followed to prevent infection.
Guide for home delivery:
1. For registered patient: time when regular pains started, whether bag of water ruptured or not,
presence of absence of vaginal discharges, bleeding, etc., whether mother moved her bowels and
has urinated, fetal movement felt by the mother or not, unusual symptoms such as bleeding,
headache, spots before eyes.
2. For unregistered patients: get same information as for those registered patients and get medical and
obstetric history.
Delivery in Healthy Facility

− At lying-in clinics, Birthing Homes or within the BHSs/RHUs.
− Normal pregnancies and with labor progressing normally must be encourage to deliver in this facility.
Delivery in Hospitals
Risk pregnancies should be advised to deliver in the hospital are the following:
− Pregnancy more the 4
− Previous CS
− History of postpartum hemorrhage
− History of medical illness such as heart disease, goiter, tuberculosis, diabetes, severe anemia,
hypertension, bronchial asthma
− Antepartum hemorrhage
− Hypertensive disorders of pregnancy and Eclampsia
− Cephalo-pelvic disproportion
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− Placenta previa and abruption placenta
− Multifetal pregnancy
− Post term and preterm pregnancies
− Previous uterine surgery such as myomectomy.
APGAR Scoring
1. It provides a valuable index for evaluation of the infants at birth.
2. It is based on five signs ranked in order of importance as follows: Heart Rate, Respiratory Effort,
Muscle Tone, Reflex Irritability and Color.
3. In general, they made 1 minute of life and 5 minutes.
4. Each sign is evaluated according to the degree to which it is present and is given a score of 0, 1, and
2.
5. The score of each sign is added together to give a total score (10 is the maximum).
Newborn Screening
It is a public health program aimed at the early identification of infants who are affected by certain
genetic/metabolic/infectious conditions. Early identification and intervention can lead to significant
reduction of morbidity, mortality and associated disabilities in affected infant
Significance:
− Most babies with metabolic disorders look “normal” at birth. By doing NBS, metabolic disorders
may be detected even before clinical signs and symptoms are present. And as a result of this,
treatment can be given early to prevent consequences of untreated conditions.
Timing:
− It is ideally done on the 48th-72nd hours of life. However, it may also be done after 24 hours from
birth.
Procedure:
− A few drops are taken from the baby’s heel, blotted on a special absorbent filter card and then sent
to the Newborn Screening Center (NSC). The blood samples for Newborn Screening (NBS) may be
collected by any of the following: physician, nurse, medical technologies or trained midwife. The
procedure costs P550. The DOH advisory Committee on Newborn Screening has approved a
maximum allowable fee of P50 for the collection of the sample. Newborn Screening is now included
in the Philhealth Newborn Care Package. It is widely available in hospitals, Lying- ins, Rural Health
Unit, Health Centers, and some private clinics. If babies are delivered at home, babies may be
brought to the nearest institution offering newborn screening.
− Results can be claimed from the health facility where NBS was availed. Normal NBS results are
available by 7-14 working days from the time samples are received at the NSC. Positive NBS results
are relayed to the parents immediately by the health facility.A NEGATIVE SCREEN MEANS
THAT THE NBS IS NORMAL.
− A positive screen means that the newborn must be brought back to his/her health practitioner for
further testing. Babies with positive results may be referred at once to a specialist for confirmatory
testing and further management.
Disorders detected in Newborn Screening

Phenylketonuria.
− It is the inability to metabolize the amino acid phenylalanine, which is a common component such
a milk. Excessive accumulation of phenylalanine in the blood causes brain damage. The babies may
look like “albino” with musty odor of the skin, hair, sweat and urine. PKU is treated with a special
low-phenylalanine diet which the amount of amino acid is carefully regulated.
Congenital Hypothyroidism.
− Most common causes of mental retardation. Most affected infants may look normal at birth.
However, they may have large fontanels and tongues, big tummies and prolonged yellowish
discoloration of the skin and eyes. Infants are treated with thyroid hormones and it continues
throughout life. If the disorder is not detected and hormone replacement is not initiated within two
weeks, the baby with CH may suffer fro-mental and growth retardation.
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Galactosemia.
− It is the absence of enzymes necessary for conversion of the milk sugar galactose to glucose.
Affected infants present with difficulty in feeding, vomiting and diarrhea, yellowish skin and eyes,
weakness, white eyes (cat’s eyes) and bleeding after blood extraction. Accumulation of excessive
galactose in the body may cause liver damage, brain damage and cataracts. Treatment may include
elimination of milk from the diet and use of milk substitute.
Glucose 6 Phosphate Dehydrogenase Deficiency (G6PD deficiency).
− The body lacks the enzyme called G6PD that may cause hemolytic anemia, when the body exposed
to oxidative substances found in certain drugs, foods and chemicals. Children become pale, with
yellow skin and eye, tea colored urine and fast breathing. It may lead to heart failure.
Congenital Adrenal Hyperplasia.
− Refers to a group of disorders with an enzyme defect that prevents adequate adrenal corticosteroid
and aldosterone production an increases production of androgens. It manifested by poor feeding,
vomiting and diarrhea and weak cry. It also causes short stature, early puberty excessive hair growth
and infertility. Treatment of corticosteroids for the rest of child’s life.
Support to Breastfeeding. Motivate mothers to practice breastfeeding.

The Rooming-in and Breastfeeding Act of 1992.
− To encourage, protect and support the practice of breastfeeding. It shall create an environment where
the basic physical, emotional and psychological needs of mothers and infants are fulfilled.
Milk Code of 1986.
− The aim of this code is to contribute to the provision of safe and adequate nutrition for infants by
the protection and promotion of breastfeeding and by ensuring the proper use of breast milk
substitutes and breastmilk supplements when these are necessary, on the basis of adequate
information and through appropriate marketing and distribution.
Family Planning Counseling

− Proper counseling of couples on the importance of family planning will help them inform on the
right choices of family planning methods, proper spacing of birth and addressing the right number
of children. Birth spacing of three to five years interval will help completely develop the health of
a mother from previous pregnancy and childbirth. The risk of complications increases after the
second birth.
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PHILIPPINES
CARE OF MALE AND FEMALE CLIENTS WITH GENERAL AND

SPECIFIC PROBLEMS IN REPRODUCTION AND SEXUALITY
I. SEXUAL DYSFUNCTION
• Difficulty experienced by individual or couple during any stage of normal sexual activity, including
physical pleasure, desire, preference, arousal, or orgasm.
• Sexual dysfunctions can have profound impact on individual's perceived quality of sexual life.
A. SEXUAL DESIRE DISORDERS

− Or decreased “Libido” are characterized by lack or absence, for some period of time, of sexual
desire or libido for sexual activity.
− The causes vary considerably, but include a possible decrease in the production of normal
estrogen in women or testosterone in both men and women.
− Other causes may be aging, fatigue, pregnancy, medications, or psychiatric conditions, such as
depression and anxiety.
B. SEXUAL AROUSAL DISORDERS

− Previously known as frigidity in women and impotence in men, though these have now been
replaced with less judgmental terms.
− Impotence is now known as erectile dysfunction, and frigidity has been replaced with a number
of terms describing specific problems that can be broken down into four categories: lack of
desire, lack of arousal, pain during intercourse, and lack of orgasm.
1. ERECTILE DYSFUNCTION (ED)

− Or Impotence is a sexual dysfunction characterized by the inability to develop or maintain
an erection of the penis.
Causes
Psychological erectile dysfunction
- Can be helped by anything that patient believes in; there is very strong ‘placebo’ effect.
Physical damage is much more severe.
- Continual or severe damage to the Nervi Erigentes which prevents or delays erection.
- Diabetes as well as cardiovascular diseases simply decreases blood flow to the tissue in
penis. Multiple sclerosis, kidney failure, vascular disease and spinal cord injury are the
other source of erectile dysfunction, many of which are medically reversible.
- The introduction of the first pharmacologically effective remedy for impotence,
Sildenafil (Viagra), in the 1990s caused a wave of public attention, propelled in part by
the news-worthiness of stories and heavy advertising.
2. PREMATURE EJACULATION
− Premature ejaculation is when ejaculation occurs before the partner achieves orgasm (<2
minutes from the time of the insertion of the penis), or a mutually satisfactory length of time
has passed during intercourse.
− Diagnosis – Chronic history of premature ejaculation, poor ejaculatory control, and problem
must cause feelings of dissatisfaction as well as distress the patient, the partner or both.
VISION MISSION
3. ORGASM DISORDERS
− Orgasm disorders, specifically anorgasmia, present as persistent delays or absence of
orgasm following a normal sexual excitement phase in sexual encounters.
− The disorder can have physical, psychological, or pharmacological origins.
- Pharmacological – Antidepressants can delay orgasm or eliminate it entirely.
- Physiological – Orgasm problems during sexual stimulation following menopause.
4. SEXUAL PAIN DISORDERS

Dyspareunia (painful intercourse) may be caused by insufficient lubrication in women.
- Poor lubrication may result from insufficient excitement and stimulation, or from
hormonal changes caused by menopause, pregnancy, or breastfeeding.
- Irritation from contraceptive creams and foams can also cause dryness, as can fear and
anxiety about sex.
Vaginismus (involuntary spasm of the vaginal wall muscles)
- Cause is unclear, but it is thought that past sexual trauma (rape, abuse) may play a role.
Vulvodynia or Vulvar Vestibulitis – The cause is unknown.
- Burning pain during sex related to problems with the skin in the vulvar and vaginal areas.
5. POST-ORGASMIC DISEASES – cause symptoms shortly after orgasm or ejaculation.

Post-Coital Tristesse (PCT)
- Feeling of melancholy and anxiety after sexual intercourse that lasts for up to two hours.
Sexual Headaches
- Occur in skull & neck during sexual activity, including masturbation, arousal or orgasm.
Post-orgasmic Illness Syndrome (POIS)
- In men, it causes severe muscle pain throughout the body and other symptoms
immediately following ejaculation.
- Symptoms – rapid breathing, paraesthesia (tingling or pricking hands “pins and
needles”), palpitations, headaches, aphasia (loss of ability to understand or express
speech), nausea, itchy eyes, fever, muscle pain and weakness and fatigue.
Dhat Syndrome “Culture-Bound Syndrome”
- In men, it causes anxious and dysphoric mood after sex, but is distinct from the low-
mood and concentration problems (acute aphasia).
− From the onset of orgasm, symptoms can persist for up to a week in patients.
− Etiology is unknown, it is believed to be a pathology of either immune system or the ANS.
− There is no known cure or treatment.
6. PELVIC FLOOR DYSFUNCTION

− Underlying cause of sexual dysfunction in both women and men, treatable by physical
therapy.
CAUSES
Emotional
− Interpersonal or psychological problems, which can be the result of depression, sexual fears or
guilt, past sexual trauma, and sexual disorders.
Physical
− Use of drugs, such as alcohol, nicotine, narcotics, stimulants, anti-hypertensives, antihistamines,
and some psychotherapeutic drugs.
− Physiological changes in women that affects the reproductive system; premenstrual syndrome,
pregnancy and the postpartum period, and menopause can have an adverse effect on libido.
− Injuries to the back may also impact sexual activity, as can problems with an enlarged prostate
gland, problems with blood supply, or nerve damage.
− Diseases
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− Hormonal deficiencies
− Some birth defects
− In aging women, it is natural for the vagina to narrow and become atrophied.
TREATMENT
Males
− Psychotherapy – If sexual dysfunction is deemed to have psychological component or cause.
− Lifestyle changes – discontinuing smoking, drug or alcohol abuse.
− Medications – Viagra, Cialis and Levitra have become first line therapy.
− Intracavernous Pharmacotherapy – involves injecting vasodilator drug directly into the penis
in order to stimulate an erection.
− Penile Prosthesis – When conservative therapies fail, insert penile prosthesis or penile implant
Females
− Medications – Flibanserin, pain relievers, desensitizing agents, vaginal lubricants
− Psychotherapy – counselor or sex therapist.
− Alternative treatments – topical estrogen creams and gels can be applied to the vulva or vagina
area to treat vaginal dryness and atrophy
II. INFERTILITY
• According to WHO, infertility is “a disease of the reproductive system defined by the failure to
achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (and
there is no other reason, such as breastfeeding or postpartum amenorrhea).
• Primary Infertility is infertility in a couple who have never had a child.
− The absence of a live birth for women who desire a child and have been in a union for at least
12 months, during which they have not used any contraceptives.
− WHO also adds that 'women whose pregnancy spontaneously miscarries, or whose pregnancy
results in a still born child, without ever having had a live birth would present with primarily
infertility’.
• Secondary Infertility is failure to conceive following a previous pregnancy.
− The absence of a live birth for women who desire a child and have been in a union for at least
12 months since their last live birth, during which they did not use any contraceptives.
• Infertility may be caused by infection in the man or woman, but often there is no obvious underlying
cause.
EFFECTS
Psychological
− Infertility consequences are manifold, can include societal repercussions and personal suffering.
− Partners may become more anxious to conceive, increasing sexual dysfunction.
− Marital discord often develops, especially when under pressure to make medical decisions.
− Women trying to conceive often have depression rates similar to women who have CVD or CA.
− Emotional stress and marital difficulties are greater in couples where infertility lies with the man
Social
− In many cultures, inability to conceive bears a stigma.
− In closed social groups, a degree of rejection (or a sense of being rejected by the couple) may
cause considerable anxiety and disappointment.
CAUSES
Immune Infertility
− Antisperm Antibody (ASA) have been considered as infertility cause in around 10–30% of
infertile couples.
NRCM0109 Lecture 3
− In both men and women, ASA production are directed against surface antigens on sperm, which
can interfere with sperm motility and transport through the female reproductive tract, inhibiting
capacitation and acrosome reaction, impaired fertilization, influence on the implantation
process, and impaired growth and development of the embryo.
− Factors contributing to ASA formation in women are disturbance of normal immune-regulatory
mechanisms, infection, violation of the integrity of the mucous membranes, rape and
unprotected oral or anal sex.
− Risk factors for ASA formation in men include the breakdown of the blood-testis barrier, trauma
and surgery, orchitis, varicocele, infections, prostatitis, testicular cancer, failure of immune-
suppression and unprotected receptive anal or oral sex with men.
Sexually Transmitted Infections
− Chlamidia Trachomatis and Neisseria Gonrrheae can also cause infertility, due to internal
scarring ( fallopian tube obstruction).
− There is a consistent association of Mycoplasm Genitalium infection associated with increased
risk of infertility, and female reproductive tract syndromes.
Genetic
− Mutations to gene encoding have been found in a small subset of men with non-obstructive male
factor infertility where the cause is unknown.
− Affected individuals displayed more severe forms of infertility such as azoospermia and severe
oligozoospermia.
OTHER CAUSES
Factors that can cause male as well as female infertility are:
DNA Damage
− Reduces fertility in female oocytes, as caused by smoking, other xenobiotic DNA damaging
agents (such as radiation or chemotherapy), or accumulation of the oxidative DNA damage 8-
hydroxy-deoxyguanosine.
− Reduces fertility in male sperm, as caused by oxidative DNA damage, smoking, other xenobiotic
DNA damaging agents (such as drugs or chemotherapy) or other DNA damaging agents
including reactive oxygen species, fever or high testicular temperature. The damaged DNA
related to infertility manifests itself by the increased susceptibility to denaturation inducible by
heat or acid.
General Factors
− Diabetes Mellitus, thyroid disorders, undiagnosed and untreated coeliac disease, adrenal disease.
Hypothalamic-Pituitary Factors
− Hyperprolactinemia
− Hypopituitarism
− Presence of anti-thyroid antibodies is associated with increased risk of unexplained subfertility.
Environmental Factors
− Toxins such as glue, volatile organic solvents or silicones, physical agents, chemical dusts, and
pesticides. Tobacco smokers are 60% more likely to be infertile than non-smokers.
Alimentary Habits
− Obesity can have a significant impact on male and female fertility.
- BMI may be a significant factor in fertility, as an increase in BMI in the male by as little as
three units can be associated with infertility.
- Increase in BMI is correlated with a decrease in sperm concentration, a decrease in motility
and an increase DNA damage in sperm.
− Low weight
- Underweight men tend to have lower sperm concentrations than those with normal BMI.
- Underweight women, and having extremely low amounts of body fat are associated with
ovarian dysfunction and infertility and they have higher risk for preterm birth.
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FEMALE INFERTILITY
− Blockage of the Fallopian tube due to malformations, infections such as chlamydia or scar tissue.
- Endometriosis can cause infertility with the growth of endometrial tissue in the Fallopian tubes
or around the ovaries.
- More common in mid-twenties and older, especially when postponed childbirth has taken place.
− Inability to ovulate. Malformation of the eggs themselves may complicate conception.
- Polycystic Ovarian Syndrome (PCOS) is when eggs only partially develop within the ovary and
there is an excess of male hormones.
- Some women are infertile because their ovaries do not mature and release eggs. In this case
synthetic FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate
follicles to mature in the ovaries.
− Other factors
- Advanced maternal age – fertility declines after the age of 30.
- Pelvic inflammatory disease caused by infections like tuberculosis.
- Previous surgery (tubal ligation)
MALE INFERTILITY
− Low sperm count due to endocrine problems, drugs, radiation, or infection.

- There may be testicular malformations, hormone imbalance, or blockage of man's duct system.
− Viable, but Immotile Sperm may be caused by Primary Ciliary Dyskinesia (PCD).
- Sperm must provide zygote with DNA, centrioles, and activation factor for embryo to develop.
- A defect in any of these sperm structures may result in infertility that will not be detected by
semen analysis.
- ASA cause immune infertility.
- Cystic Fibrosis can lead to infertility in men.
UNEXPLAINED INFERTILITY
− In these cases abnormalities are likely to be present but not detected by current methods.
− Possible problems could be that the egg is not released at the optimum time for fertilization that it
may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to
occur, transport of the zygote may be disturbed, or implantation fails.
− It is increasingly recognized that egg quality is of critical importance and women of advanced
maternal age have eggs of reduced capacity for normal and successful fertilization.
DIAGNOSIS
− If both partners are young and healthy, and have not succeed conceiving for one year, a physician
visit could help to highlight early potential medical problems.
− Women over the age of 35 should see the physician after six months as fertility tests can take some
time to complete, and age may affect the treatment options that are open in that case.
- Doctor takes a medical history and gives a physical examination.
- Can also carry out some basic tests on both partners to see if there is identifiable reason for not
having achieved pregnancy.
− If necessary, refer patients to fertility clinic or local hospital for more specialized tests. The results
of these tests help determine the best fertility treatment.
TREATMENT
Grouped as medical or complementary and alternative treatments. Some methods may be used in
concert with other methods.
1. Medical Treatments medical device, surgery, or combination of the following:
a. Fertility Medication. Drugs used for both women and men include:
- Clomiphene Citrate
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- Human Menopausal Gonadotropin (hMG)
- Follicle-Stimulating Hormone (FSH)
- Human Chorionic Gonadotropin (hCG)
- Gonadotropin-Releasing Hormone (GnRH)
- Analogues, Aromatase, and Metformin
b. If sperm are of good quality and mechanics of the woman's reproductive structures are good
(patent fallopian tubes, no adhesions or scarring), a course of ovulation induction maybe used.
c. Conception cap (cervical cap) – placing sperm inside the cap and putting the conception device
on the cervix.
d. Intrauterine Insemination (IUI) – MD introduces sperm into uterus during ovulation, via
catheter.
If conservative medical treatments fail to achieve full term pregnancy, the physician may suggest:
a. Assisted Reproductive Technology (ART) – techniques.
1) Start with stimulating the ovaries to increase egg production.
2) After stimulation, the physician surgically extracts 1 or more eggs from the ovary, and unites
them with sperm in laboratory setting, with the intent of producing 1 or more embryos.
3) Fertilization takes place outside the body, and the fertilized egg is reinserted into the
woman's reproductive tract, in a procedure called embryo transfer.
- In Vitro Fertilization (IVF) – most commonly used ART. Proven useful in overcoming
infertility conditions, such as blocked or damaged tubes, endometriosis, repeated IUI failure,
unexplained infertility, poor ovarian reserve, poor or even nil sperm count.
- Intracytoplasmic Sperm Injection (ICSI) – used in poor semen quality, low sperm count,
failed fertilization attempts during prior IVF cycles. Involves injection of single healthy
sperm directly injected into mature egg. Fertilized embryo is then transferred to womb.
b. Tuboplasty
2. Fertility Tourism / Medical Tourism

− Practice of traveling to another country for fertility treatments.
− Main reasons for fertility tourism are legal regulation of sought procedure in the home country,
or lower price. IVF and donor insemination are major procedures involved.
3. Stem Cell Therapy

Spermatogonial Stem Cells Transplant: it takes places in the seminiferous tubule.
− With this treatment, the patient experience spermatogenesis, and therefore, it has the chance to
have offspring if he wants to.
− It is specially oriented for cancer patients, whose sperm is destroyed due to the gonadotoxic
treatment they are submitted to.
Ovarian Stem Cells: it is thought that women have finite number of follicles from very beginning.
− Nevertheless, scientists have found these stem cells, which may generate new oocytes in
postnatal conditions.
Stem cell therapy is new, and everything is still under investigation. Additionally, it could be the
future for the treatment of multiple diseases, including infertility.
JOCELYN F. VILLANUEVA, EdD, RN
NRCM0109 Lecture 6
PHILIPPINES
#1 HIGH RISK FACTORS OF PREGNANCY

1. 15 years old and below
a. Young adolescents are at risk of having adverse health outcomes since their reproductive system is
not yet fully matured.
b. Have poor antenatal care and increased risk of developing pre-eclampsia, increased risk for CPD.
c. Fetal implications includes: LBW, Increased risk for fetal demise.
2. Above 35 years old

a. Old primis are associated with abnormalities in labor such as C/S pre-eclampsia,
b. Fetal implications include: Increased risk of congenital abnormalities and chromosomal aberrations.
3. Mother is underweight ( less than 45.5 kgs or 100 lbs)

a. Maternal implications include: poor nutrition, CPD, and prolonged labor.
b. Fetal implications includes: IUGR, Hypoxia associated with difficult labor and birth.
4. Mother is overweight (more than 91 kgs or 200lbs)

a. Maternal implications includes: Increased risk of developing hypertension, CPD, and DM
b. Fetal implications include: Increase risk of macrosomia.
5. Mother has anemia (Hgb less than 11g/l)

The iron needs of pregnancy are obtained from maternal iron stores, diet, and supplementation. With
anemia occurring in pregnancy, the most common cause is iron deficiency.
a. Maternal implications include: IDA, low energy levels due to decreased oxygen carrying capacity
of the RBC
b. Fetal implications include: fetal death, prematurity, LBW.
6. Poor nutritional status

a. Maternal implications include: inadequate nutrition, increase risk of anemia, increase risk of pre-
eclampsia,
b. Fetal implications include: fetal malnutrition, prematurity, small for gestational age.
7. Pre-existing medical conditions.

DM
a. Maternal implications include: increase risk of preeclampsia, episodes of hypoglycemia, increase
risk for CS
b. Fetal implications include: LBW, macrosomia, neonatal hypoglycemia, increase risk of congenital
anomalies, increase risk of respiratory distress syndrome.
HPN
a. Maternal implications include: vasospasm, increase risk of CNS irritability which results to
convulsion, increase risk of developing CVA, increase risk of renal damage.
b. Fetal implications include: decreased placental perfusion which leads to LBW, preterm birth
Thyroid disorder
a. Maternal implications include: increased infertility
b. Fetal implications include: increased risk for spontaneous abortion.
Cardiac Disease
a. Maternal implications include: cardiac decompensation
b. Fetal implications include: increased maternal death rate, increase risk of fetal demise.
8. Family history of genetic disease or previous baby with genetic defect.
VISION MISSION
9. Substance abuse
Alcohol
a. Maternal implications include: increased risk of mid-trimester abortions
b. Fetal implications include: mental retardation, behavior and learning disorders, and FAS (Feta-
Alcohol Syndrome)
FAS - mentally deficient with congenital deformities, and usually low birth weight.
▪ Refrain from consuming any alcoholic beverages during pregnancy.
Smoking
a. Maternal implications include: increased risk of spontaneous abortion, premature delivery and still
birth
b. Fetal implications include: increased risk for LBW and birth defects
Nicotine
↓
Vasoconstriction
↓ “Absolutely Avoid Cigarette Smoking”
Decreased blood flow to the placenta
Decreased oxygen to fetus (Hypoxia)
↓
Low birth weight
Caffeine
a. Maternal implications include: frequent urination, mood swings, interferes with iron absorption
b. Fetal implications include: increased risk for DM
1 cup of coffee per day is OK
Cocaine and other illicit drugs.
a. Maternal implications include: increased risk of anemia, blood and heart infection, skin infection,
hepatitis, STD
• Marijuana can cause behavioral problem
• Cocaine can cause prematurity, abruption placenta, and preeclampsia
• Heroine and methadone-can cause withdrawal syndrome and seizure.
b. Fetal implications include:
• Cocaine can cause SIDS, growth defect, and hyperactivity
Perinatal addiction
a. Fetal implications include: drug addicted neonates experience withdrawal syndromes known as:
Neonatal Abstinence Syndrome
Signs and symptoms are: tremors, increased sensitivity to noise, or other stimuli, feeding problems,
poor coordination, excessive crying and irritability.
• Medications
FDA Pregnancy Category of Medications
Category A – safe for fetus in human studies
Category B – safe for fetus in animal studies
Category C – no adequate studies available
Category D – fetal risk but increased benefits than risk
Category E – fetal risk but increased risk than benefits
• OTC drugs and their effects
Drugs Teratogenic effects
Androgen, estrogen, progesterone. Masculinization of female infants
Thalidomide Phocomelia, cardiac and lung defects
Anticonvulsant (Dilantin) Cleft lip and palate, congenital heart defects
Lithium Congenital heart defect
Tetracycline Yellow staining of teeth, inhibit bone growth, not given to
children below 7
Salicylates (Aspirin) Neonatal bleeding, decreased uterine growth
Sodium Bicarbonate Fetal metabolic Alkalosis
Streptomycin Nerve deafness
Vitamin A CNS Defects
NRCM0109 2
Iodides Goiter, Mental Retardation
Steroids, Cortisone Cleft lip and palate
Barbiturate Bleeding disorders.
Vitamin K Hyperbilirubinemia
10. Previous pregnancy loss

a. Maternal implications include: increased emotional, psychological distress
b. Fetal implications include: increased risk for abortion.
11. Multiparity
a. Maternal implications include: increased risk of antepartum or post-partum hemorrhage.
b. Fetal implications include: anemia, fetal death.
12. Low socioeconomic status

a. Maternal implications include: failure to avail prenatal / antepartal services
b. Fetal implications include: increased for developmental problems
DANGER SIGNS OF PREGNANCY

a. Vaginal Bleeding
− Vaginal bleeding no matter how slight be reported immediately for further evaluation
− First trimester bleeding is mostly related to abortion whereas third trimester bleeding is associated
to previa
b. Sudden Escape of Fluid from Vagina
− Means that the membranes have ruptured. Both the mother and the fetus are threatened because
uterine cavity is no longer sealed against infection
− If fetus is small and head does not fit into cervix, umbilical cord may prolapse.
c. Abdominal Pain
− Crampy pain, low abdominal early in pregnancy with or without bleeding is a characteristic of
abortion.
− A sudden sharp, severe, low quadrant unilateral, radiating to the shoulder is a characteristic of
ectopic pregnancy.
− Hard, board-like, painful abdomen is a typical sign of abruptio placenta.
d. Fever and Chills
− May be an evidence of an intrauterine infection w/c is a serious complication for both the woman
and the baby
e. Persistent Vomiting
− Vomiting that continues past the 12 weeks of pregnancy is also extended vomiting. it depletes the
nutritional supply available to fetus
f. Swelling of Hand, Face, Legs and Feet
− This is a sign of generalized edema and is often associated with pre-eclampsia. This swelling is
usually noted as “tightening of the wedding ring”
g. Dysuria
− Mostly associated with UTI
h. Absence of Fetal Movements
− Is a sign of possible fetal death
i. Severe Headache, Dizziness, Blurring of Vision, Spots Before the Eyes

− Is a sign of hypertension and pre –eclampsia
NRCM0109 3
PHILIPPINES
#3 GESTATIONAL CONDITIONS
I. HYPEREMESIS GRAVIDARUM (HG)

• A pregnancy complication that is characterized by severe nausea, vomiting, weight loss, and
possible dehydration.
• Considered more severe than morning sickness.
• Often symptoms get better after the 20th week of pregnancy but may last the entire pregnancy
duration.
Signs and Symptoms

• When vomiting is severe, it may result in the following:
- Loss of 5% or more of pre-pregnancy body weight
- Dehydration, causing ketosis and constipation
- Nutritional disorders, such as vitamin B1 (thiamine) deficiency, vitamin B6 (pyridoxine)
deficiency or vitamin B12 (cobalamin) deficiency
- Metabolic imbalances such as metabolic ketoacidosis or thyrotoxicosis
- Physical and emotional stress
- Difficulty with activities of daily living
• Symptoms can be aggravated by hunger, fatigue, prenatal vitamins (especially those containing
iron), and diet.
• Many women with HG are extremely sensitive to odors in their environment; certain smells may
exacerbate symptoms.
• Excessive salivation, also known as “Sialorrhea Gravidarum”, is another symptom experienced
by some women.
• HG tends to occur in the first trimester of pregnancy and lasts significantly longer than morning
sickness. While most women will experience near-complete relief of morning sickness symptoms
near the beginning of their second trimester, some sufferers of HG will experience severe symptoms
until they give birth to their baby, and sometimes even after giving birth.
Causes
• There are numerous theories regarding the cause of HG, but the cause remains controversial.
• It is thought that HG is due to a combination of factors which may vary between women and include
genetics. Women with family members who had HG are more likely to develop the disease.
• One factor is an adverse reaction to the hormonal changes of pregnancy, in particular, elevated levels
of beta Human Chorionic Gonadotropin (β-hCG). This theory would also explain why hyperemesis
gravidarum is most frequently encountered in the first trimester (often around 8–12 weeks of
gestation), as β-hCG levels are highest at that time and decline afterward.
• Another postulated cause of HG is an increase in maternal levels of estrogens (decreasing intestinal
motility and gastric emptying leading to nausea/vomiting).
Management
• Dry bland food and oral rehydration are first-line treatments.
• If conservative dietary measures fail, more extensive treatment such as the use of antiemetic
medications and intravenous rehydration may be required.
• If oral nutrition is insufficient, intravenous nutritional support may be needed.
VISION MISSION
Complications
Pregnant Woman
• If HG is inadequately treated, anemia, hyponatremia, kidney failure, hypoglycemia, jaundice,
malnutrition, deep vein thrombosis, pulmonary embolism, vasospasms of cerebral arteries are
possible consequences.
• Depression and post-traumatic stress disorder are common secondary complications of HG and
emotional support can be beneficial.
Infant
• The effects of HG on the fetus are mainly due to electrolyte imbalances caused by HG in the mother.
• Infants of women with severe hyperemesis who gain less than 7 Kgs. (15 lb) during pregnancy tend
to be of lower birth weight, small for gestational age, and born before 37 weeks gestation.
• In contrast, infants of women with hyperemesis who have a pregnancy weight gain of more than 7
Kgs. appear similar to infants from uncomplicated pregnancies.
• There is no significant difference in the neonatal death rate in infants born to mothers with HG
compared to infants born to mothers who do not have HG.
• Children born to mothers with undertreated HG have a fourfold increase in neurobehavioral
diagnoses.
II. ECTOPIC PREGNANCY
• In a normal pregnancy, the ovary releases an egg into your fallopian tube. If the egg meets with a
sperm, the fertilized egg moves into your uterus to attach to its lining and continues to grow for the
next 9 months.
• But in up to 1 of every 50 pregnancies, the fertilized egg stays in your fallopian tube. In that case,
it's called an Ectopic Pregnancy or Tubal Pregnancy.
• In rare cases, the fertilized egg attaches to one of the ovaries, another organ in the abdomen, the
cornua (horn) of the uterus or even the cervix. In any case, instead of celebrating the pregnancy,
the pregnant woman’s life is in danger.
• Ectopic pregnancies require emergency treatment.
• Most often, ectopic pregnancy happens within the first few weeks of pregnancy, usually by the 8th
week of pregnancy.
• In extremely rare cases, the fetus might survive (This is not possible in a tubal pregnancy, cornual
or cervical).
Symptoms of Ectopic Pregnancy

• Light vaginal bleeding
• Nausea and vomiting with pain
• Lower abdominal pain
• Sharp abdominal cramps
• Pain on one side of your body
• Dizziness or weakness
• Pain in your shoulder, neck, or rectum
• If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause fainting.
If the patient is experiencing these symptoms, contact the health care provider immediately and go to
the emergency room. Getting to the hospital quickly is important to reduce the risk of hemorrhage
(severe bleeding).
NRCM0109 2
Causes of an Ectopic Pregnancy
One cause of an ectopic pregnancy is a damaged fallopian tube that doesn't let a fertilized egg into the
uterus, so it implants in the fallopian tube or somewhere else.
What caused an ectopic pregnancy might not be known. But the woman is of higher risk if she has:
• Current use of intrauterine device (IUD);
• History of pelvic inflammatory disease (PID);
• Sexually-transmitted diseases such as chlamydia and gonorrhea;
• Congenital abnormality of the fallopian tube;
• History of pelvic surgery (scarring may block the fertilized egg from leaving the fallopian tube);
• History of ectopic pregnancy;
• Unsuccessful tubal ligation (surgical sterilization) or tubal ligation reversal;
• Use of fertility drugs;
• Infertility treatments such as in vitro fertilization (IVF).
Diagnosing an Ectopic Pregnancy

To view the uterus’ condition and fallopian tubes, the following tests may be performed:
• Pregnancy test
• Pelvic examination
• Ultrasound
If an ectopic pregnancy has been confirmed, the health care provider will decide on the best treatment based
on the client’s condition and future plans for pregnancy.
Treating an Ectopic Pregnancy

• If the fallopian tube has ruptured, emergency surgery is necessary to stop the bleeding. In some
cases, the fallopian tube and ovary may be damaged and will have to be removed.
• If the fallopian tube has not ruptured and the pregnancy has not progressed very far,
laparoscopic surgery may be all that is needed to remove the embryo and repair the damage.
LAPAROSCOPE – is a thin, flexible instrument inserted through small incisions in the abdomen.
During this surgery, a tiny incision is made in the fallopian tube and the embryo is removed,
preserving the fallopian tube’s integrity.
• In some cases, medication may be used to stop the growth of pregnancy tissue. This treatment option
may be appropriate if the tube is not ruptured and pregnancy has not progressed very far.
• After medical treatment for an ectopic pregnancy, the patent will usually need to undergo another
blood tests to detect the HCG level to make sure that the entire tubal pregnancy was removed.
Getting Pregnant After an Ectopic Pregnancy

• Most women who had an ectopic pregnancy have normal succeeding pregnancies and births, even
if a fallopian tube was removed.
• As long as there is one normally working fallopian tube, one can get pregnant.
• If caused by a treatable illness, such as a sexually transmitted disease, getting treated for STD can
improve the chances of a successful pregnancy. The infection is not what caused the ectopic – it is
the scarring that occurs due to the infection. Treatment of the infection does not get rid of the damage
already done.
• Talk with your doctor about how long to wait after an ectopic pregnancy before trying to conceive
again. Some doctors suggest waiting 3 to 6 months.
• After an ectopic pregnancy, take the time needed to heal the body and mind.
• Above all, tell the patient not to blame herself. Counseling or pregnancy loss support groups can
help you and your partner cope. Ask your doctor about groups near you.
NRCM0109 3
III. HYDATIDIFORM MOLE
Definition:
• A rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy. It is a
type of Gestational Trophoblastic Disease (GTD).
• A molar pregnancy - is a noncancerous tumor that develops in the uterus.
Causes:
• Results from too much production of the tissue that is supposed to develop into the placenta.
• A molar pregnancy starts when an egg is fertilized, but instead of resulting to a normal, viable
pregnancy, the placenta develops into an abnormal mass of cysts.
Prognosis:
• Most Hydatidiform moles are benign.
• Treatment is usually successful.
• Close follow-up by the health care provider is important to ensure that signs of the molar pregnancy
are gone and pregnancy hormone levels return to normal.
• In some cases, Hydatidiform moles can continue and start changing into cancer. These moles can
grow deep into the uterine wall and cause bleeding or other complications.
• Rarely, a Hydatidiform mole develops into a chorio-carcinoma. This is a fast-growing cancer. It is
usually treated with chemotherapy, and can be life-threatening.
Types:
• Partial Molar Pregnancy. There is an abnormal placenta and some fetal development.
• Complete Molar Pregnancy. There is an abnormal placenta and no fetus.
Both forms are due to problems during fertilization. The exact cause of fertilization problems is unknown.
There are no known ways to prevent these masses from forming.
Risk Factors:
Up to an estimated 1 in every 1,000 pregnancies is molar. Various factors are associated with molar
pregnancy, including:
• Maternal Age. A molar pregnancy is more likely for a woman older than age 35 or younger than
age 20.
• Previous Molar Pregnancy. If you've had one molar pregnancy, you're more likely to have another.
A repeat molar pregnancy happens, on average, in 1 to 2 out of every 100 women.
Symptoms:
• Abnormal growth of the uterus, either bigger or smaller than usual
• Nausea and vomiting that may be severe enough to require a hospital stay
• Vaginal bleeding during the first 3 months of pregnancy
• Symptoms of hyperthyroidism, including heat intolerance, loose stools, rapid heart rate, restlessness
or nervousness, warm and moist skin, trembling hands, or unexplained weight loss
• Symptoms similar to preeclampsia that occur in the first trimester or early second trimester,
including high blood pressure and swelling in the feet, ankles, and legs (this is almost always a sign
of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy)
NRCM0109 4
Exams & Tests:
1. Pelvic Examination
- May show signs similar to a normal pregnancy.
- The size of the womb may be abnormal and there may be no heart sounds from the baby.
- There may be some vaginal bleeding.
2. Pregnancy Ultrasound
- Will show an abnormal placenta, with or without some development of a baby.
Tests may include:
- HCG (quantitative levels) blood test
- Chest x-ray
- CT or MRI of the abdomen (imaging tests)
- Complete blood count (CBC)
- Blood clotting tests
- Kidney and liver function tests
Treatment:
• If the health care provider suspects a molar pregnancy, a Dilation and Curettage (D & C) will most
likely be recommended.
• A Hysterectomy may be an option for older women who do not wish to become pregnant in the
future.
• In case of partial molar pregnancy, a woman may choose to continue pregnancy. However, this
pregnancy has very high-risk which includes:
- Bleeding
- Problems with BP
- Premature delivery
Health care provider needs to thoroughly discuss the risks with the women before deciding to continue the
pregnancy. The condition may become worse.
After the treatment:

• HCG level will be followed.
• Avoid another pregnancy for 6 to 12 months. This time allows for accurate testing to be sure that
the abnormal tissue does not grow back.
• Women who get pregnant too soon after a molar pregnancy are at high risk of having another molar
pregnancy.
Possible Complications:
• Complications of molar pregnancy include:
- Change to invasive molar disease or chorio-carcinoma
- Preeclampsia
- Thyroid problems
- Molar pregnancy that continues or comes back
• Complications from surgery to remove a molar pregnancy include:
- Excessive bleeding, possibly requiring a blood transfusion
- Side effects of anesthesia
IV. INCOMPETENT CERVIX

• Also called Cervical Weakness or Cervical Insufficiency, is a medical condition of pregnancy in
which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term.
NRCM0109 5
• It is the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms
of clinical contractions, or labor, or both in the second trimester.
• Cervical weakness may cause miscarriage or preterm birth during the second and third trimesters.
• Another sign of cervical weakness is funneling at the internal orifice of the uterus, which is a
dilation of the cervical canal at this location.
• In cases of cervical weakness, dilation and effacement of the cervix may occur without pain or
uterine contractions.
• In a normal pregnancy, dilation and effacement occurs in response to uterine contractions.
• Cervical weakness becomes a problem when the cervix is pushed to open by the growing pressure
in the uterus as pregnancy progresses.
• If the responses are not halted, rupture of the membranes and birth of a premature baby can result.
Risk Factors
Risk factors for premature birth or stillbirth due to cervical weakness include:
• Diagnosis of cervical weakness in a previous pregnancy,
• Previous preterm premature rupture of membranes,
• History of conization (cervical biopsy), and
• Uterine anomalies.
Repeated procedures (such as mechanical dilation, especially during late pregnancy) appear to create a risk.
Additionally, any significant trauma to the cervix can weaken the tissues involved.
Diagnosis
• Diagnosis of cervical weakness can be challenging and is based on a history of painless cervical
dilation usually after the first trimester without contractions or labor and in the absence of other
clear pathology.
• Normally, the cervix should be at least 30 mm in length. Cervical weakness is variably defined.
However, a common definition is a cervical length of less than 25 mm at or before 24 weeks of
gestational age. The risk of preterm birth is inversely proportional to cervical length:
- Less than 25 mm; 18% risk of preterm birth
Treatment
Cervical weakness is not generally treated except when it appears to threaten a pregnancy.
• Cervical Cerclage a surgical technique that reinforces the cervical muscle by placing sutures above
the opening of the cervix to narrow the cervical canal.
• Cervical Pessary is being studied as an alternative to cervical cerclage since there are fewer
potential complications. A silicone ring is placed at the opening to the cervix early in the pregnancy,
and removed later in the pregnancy prior to the time of expected delivery. Further study is needed
to determine whether a cervical pessary is equal or superior to current management.
V. SPONTANEOUS ABORTION
• Also known as Miscarriage and Pregnancy Loss, is the natural death of an embryo or fetus before
it reaches the Age of Viability, after which fetal death is known as a stillbirth.
• The most common symptom of spontaneous abortion is vaginal bleeding with or without pain.
Sadness, anxiety and guilt often occur afterwards.
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• Tissue and clot-like material may leave the uterus and pass through and out of the vagina.
• When a woman keeps having miscarriages, infertility is present.
Signs and Symptoms

• Vaginal spotting, abdominal pain, cramping, and fluid, blood clots, and tissue passing from the
vagina.
• Bleeding can be a symptom of spontaneous abortion, but many women also have bleeding in early
pregnancy and don't miscarry.
• Bleeding during pregnancy may be referred to as a threatened abortion. Of those who seek clinical
treatment for bleeding during pregnancy, about half will miscarry.
Spontaneous abortion may be detected during an ultrasound exam, or through serial HCG testing.
Risk Factors
1. Trimesters
First trimester
• Blighted ovum (30 – 40%)
• Chromosomal abnormalities (>half in the 1st 13 weeks)
• Autosomal trisomy (22–32%)
• Monosomy X (5–20%)
• Triploidy (6–8%)
• Tetraploidy (2–4%)
• Other structural chromosomal abnormalities (2%).
Genetic problems are more likely to occur with older parents; this may account for the higher rates
observed in older women.
Second and Third Trimester
• Uterine malformation
• Growths in the uterus (fibroids)
• Cervical problems
• Infection
2. Age
• < 35 – 10%
• >40 – 45%
• Risk begins to increase around the age of 30.
• Paternal age is also associated with increased risk.
3. Obesity, Eating Disorders and Caffeine

• Obesity is not only associated with miscarriage; it can also result in sub-fertility and other
adverse pregnancy outcomes.
• Recurrent miscarriage is also related to obesity.
• Women with Bulimia Nervosa and Anorexia Nervosa
• Hyperemesis Gravidarum
• Caffeine consumption, at least at higher levels of intake.
4. Endocrine Disorders
• Thyroid Disorders
• Iodine deficiency
• Poorly controlled Insulin-Dependent Diabetes Mellitus
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5. Food poisoning
• Food contaminated with listeriosis, toxoplasmosis, and salmonella is associated with an
increased risk of miscarriage.
6. Amniocentesis and Chorionic Villus Sampling (CVS)

Amniocentesis
• A sample of amniotic fluid is obtained by the insertion of a needle through the abdomen and
into the uterus.
Chorionic Villus Sampling
• A similar procedure with a sample of tissue removed rather than fluid.
These procedures are not associated with pregnancy loss during the 2nd trimester but they are
associated with miscarriages and birth defects in the 1st trimester.
Miscarriage caused by invasive prenatal diagnosis (CVS and amniocentesis) is rare (about 1%).
7. Surgery
• The effects of surgery on pregnancy are not well-known including the effects of bariatric
surgery. Abdominal and pelvic surgery are not risk factors in miscarriage.
• Ovarian tumors and cysts that are removed have not been found to increase the risk of
miscarriage.
• The exception to this is the removal of the corpus luteum from the ovary. This can cause
fluctuations in the hormones necessary to maintain the pregnancy.
8. Medications
• Immunizations have not been found to cause miscarriage.
• There is no significant association between antidepressant medication and spontaneous abortion.
9. Chemotherapy and Radiation Treatments for Cancer

• Ionizing radiation levels given to a woman during cancer treatment cause miscarriage. Exposure
can also impact fertility.
• Use of chemotherapeutic drugs used to treat childhood cancer increases the risk of miscarriage.
10. Intercurrent Diseases

• Polycystic Ovary Syndrome (PCOS) – may increase the risk of miscarriage.
• Diabetes – Metformin treatment in pregnancy has not been shown to be safe.
• Hypothyroidism – Severe cases of hypothyroidism increase the risk of miscarriage. The effect
of milder cases of hypothyroidism on miscarriage rates has not been established.
• Luteal Phase Defect (LPD) – is a failure of the uterine lining to be fully prepared for pregnancy.
This can keep a fertilized egg from implanting or result in miscarriage.
• Mycoplasma Genitalium – infection is associated with increased risk of preterm birth and
miscarriage.
• Infections can increase the risk of a miscarriage: Rubella (German Measles), Cytomegalovirus,
Bacterial Vaginosis, HIV, Chlamydia, Gonorrhoea, Syphilis, and Malaria.
11. Anatomical defects and trauma

• The structure of the uterus has an effect on the ability to carry a child to term. Anatomical
differences are common and can be congenital.
• In some women, cervical incompetence or cervical insufficiency occurs with the inability of the
cervix to stay closed during the entire pregnancy. It does not cause 1st trimester miscarriages. In
the 2nd trimester it is associated with an increased risk of miscarriage. It is identified after a
premature birth has occurred at about 16–18 weeks into the pregnancy.
• During the second trimester, major trauma can result in a miscarriage.
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12. Smoking
• Tobacco (cigarette) smokers have an increased risk of miscarriage. There is an increased risk
regardless of which parent smokes, though the risk is higher when the gestational mother
smokes.
13. Morning sickness

• Nausea and Vomiting of Pregnancy (NVP) are associated with a decreased risk. Several
possible causes have been suggested for morning sickness but there is still no agreement. NVP
may represent a defense mechanism which discourages the mother's ingestion of foods that are
harmful to the fetus; according to this model, a lower frequency of miscarriage would be an
expected consequence of the different food choices made by women experiencing NVP.
14. Others
• Alcohol increases the risk of miscarriage.
• Progesterone has not been found to be effective in preventing miscarriage.
• Cocaine use increases the rate of miscarriage.
• Some infections have been associated with miscarriage. These include Ureaplasma urealyticum,
Mycoplasma hominis, group B streptococci, HIV-1, and syphilis. Infections of Chlamydia
trachomatis, Camphylobacter fetus, and Toxoplasma gondii have not been found to be linked to
miscarriage.
Diagnosis
• Blood loss, pain, or both – transvaginal ultrasound
• If viable intrauterine pregnancy is not found with ultrasound – Blood tests (serial βHCG tests) can
be performed to rule out ectopic pregnancy, which is a life-threatening situation.
• When looking for microscopic pathologic symptoms, one looks for the products of conception.
Microscopically, these include villi, trophoblast, fetal parts, and background gestational changes in
the endometrium.
• When chromosomal abnormalities are found in more than one miscarriage, genetic testing of both
parents may be done.
Classification
• Threatened Abortion – describes any bleeding during pregnancy, prior to viability that has yet to
be assessed. At investigation it may be found that the fetus remains viable and the pregnancy
continues without further problems.
• Inevitable Abortion – occurs when the cervix has already dilated, but the fetus has yet to be expelled.
This usually will progress to a complete abortion. The fetus may or may not have cardiac activity.
• Complete Abortion – is when all products of conception have been expelled; these may include the
trophoblast, chorionic villi, gestational sac, yolk sac, and fetal pole (embryo); or later in pregnancy
the fetus, umbilical cord, placenta, amniotic fluid, and amniotic membrane.
• Incomplete Abortion – occurs when some products of conception have been passed, but some
remains inside the uterus.
• Missed Abortion – is when the embryo or fetus has died, but a miscarriage has not yet occurred. It
is also referred to as delayed miscarriage, silent miscarriage, or missed miscarriage.
• Septic Abortion – occurs when the tissue from a missed or incomplete miscarriage becomes
infected, which carries the risk of spreading infection (septicaemia) and can be fatal.
• Recurrent Abortion ("recurrent pregnancy loss" (RPL) or "habitual abortion") is the occurrence of
multiple consecutive miscarriages; the exact number used to diagnose recurrent miscarriage varies.
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• Induced Abortion – may be performed by a physician for women who do not want to continue the
pregnancy.
• Self-Induced Abortion – performed by a woman or a non-medical personnel, is extremely
dangerous and is still a cause of maternal mortality in some countries.
The physical symptoms of abortion vary according to the length of pregnancy, though most miscarriages
cause pain or cramping. The size of blood clots and pregnancy tissue that are passed become larger with
longer gestations.
After 13 weeks' gestation, there is a higher risk of placenta retention.
Prevention
• Prevention of a miscarriage can sometimes be accomplished by decreasing risk factors. This may
include good prenatal care, avoiding drugs and alcohol, preventing infectious diseases, and avoiding
x-rays.
• Identifying the cause of the miscarriage may help prevent future pregnancy loss, especially in cases
of recurrent miscarriage.
Non-Modifiable Risk Factors

Preventing a miscarriage in subsequent pregnancies may be enhanced with assessments of:
• Immune status
• Chemical and occupational exposures
• Anatomical defects
• Intercurrent diseases
• Polycystic ovary syndrome
• Previous exposure to Chemotherapy and Radiation
• Medications
• Surgical history
• Endocrine disorders
• Genetic abnormalities
Modifiable Risk Factors

Maintaining a healthy weight and good pre-natal care can reduce the risk of miscarriage. Some risk factors
can be minimized by avoiding the following:
• Smoking
• Cocaine use
• Alcohol
• Poor nutrition
• Occupational exposure to agents that can cause miscarriage
• Medications associated with miscarriage
• Drug abuse
VI. PLACENTA PREVIA
• When the placenta attaches inside the uterus but near or over the cervical opening.
Signs and Symptoms

• Painless, bright red vaginal bleeding. This commonly occurs around 32 weeks of gestation, but can
be as early as late mid-trimester.
• More than half of women affected by placenta previa have bleeding before delivery.
NRCM0109 10
• This bleeding often starts mildly and may increase as the area of placental separation increases.
Placenta previa should be suspected if there is bleeding after 24 weeks of gestation.
• Bleeding after delivery occurs in about 22% of those affected.
• Women may also present as a case of failure of engagement of fetal head.
Cause
• The exact cause of placenta previa is unknown.
• It is hypothesized to be related to abnormal vascularization of the endometrium caused by scarring
or atrophy from previous trauma, surgery, or infection. These factors may reduce differential growth
of lower segment, resulting in less upward shift in placental position as pregnancy advances.
Risk Factors
The following have been identified as risk factors for placenta previa:
• Previous placenta previa (recurrence rate 4–8%), caesarean delivery, myomectomy or endometrium
damage caused by D & C.
• Women who are younger than 20 are at higher risk and women older than 35 are at increasing risk
as they get older.
• Alcohol use during pregnancy was previous listed as a risk factor, but is discredited by this article.
• Women who have had previous pregnancies (multiparity), especially a large number of closely
spaced pregnancies, are at higher risk due to uterine damage.
• Smoking during pregnancy; cocaine use during pregnancy.
• Women with a large placenta from twins or erythroblastosis are at higher risk.
• Race is a controversial risk factor, with some studies finding that people from Asia and Africa are
at higher risk and others finding no difference.
• Placental pathology (Vellamentous insertion, succinturiate, bipartite i.e. bilobed placenta etc.).
• Baby is in unusual position: breech (buttocks first) or transverse (lying horizontally across womb).
• Placenta previa is itself a risk factor of placenta accreta.
Classification
Minor – Placenta is in the lower uterine segment, but the lower edge does not cover the internal os.
Major – Placenta is in lower uterine segment, and the lower edge covers the internal os.
Other than that placenta previa can be also classified as:
Complete: When the placenta completely covers the cervix
Partial: When the placenta partially covers the cervix
Marginal: When the placenta ends near the edge of cervix, about 2 cm from the internal cervical os
Diagnosis
• History may reveal antepartum hemorrhage.
• Abdominal examination usually finds the uterus non-tender, soft and relaxed.
• Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a
result of the abnormal position of the placenta.
• Malpresentation is found in about 35% cases. Vaginal examination is avoided in known cases of
placenta previa.
NRCM0109 11
Confirmatory
• Previa can be confirmed with an ultrasound. Transvaginal ultrasound has superior accuracy as
compared to transabdominal one, thus allowing measurement of distance between placenta and
cervical os.
False positives may be due to following reasons:
• Overfilled bladder compressing lower uterine segment
• Myometrial contraction simulating placental tissue in abnormally low location
• Early pregnancy low position, which in third trimester may be entirely normal due to differential
growth of the uterus.
In such cases, repeat scanning is done after an interval of 15–30 minutes.
Management
• Initial assessment to determine the status of the mother and fetus is required.
• Although mothers used to be treated in the hospital from the first bleeding episode until birth, it is
now considered safe to treat placenta previa on an outpatient basis if the fetus is at less than 30
weeks of gestation, and neither the mother nor the fetus are in distress.
• Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are
in distress.
• Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain
fibrinogen levels) may be necessary.
Delivery
The method of delivery is determined by clinical state of the mother, fetus and ultrasound findings.
• In minor (traditional grade I & II), vaginal delivery is possible (2 cm away from internal os)
• In cases of fetal distress and major (traditional grade III and IV) a CS is indicated.
• CS is contraindicated in cases of disseminated intravascular coagulation.
Complications
Maternal
• Antepartum hemorrhage
• Malpresentation
• Abnormal placentation
• Postpartum hemorrhage
• Placenta previa increases the risk of puerperal sepsis and postpartum hemorrhage because the lower
segment to which the placenta was attached contracts less well post-delivery.
Fetal
• IUGR (15% incidence)[12]
• Hypoxia
• Premature delivery
• Death
VII. ABRUPTIO PLACENTA

• When the placenta separates early from the uterus, in other words separates before childbirth.
• It occurs most commonly around 25 weeks of pregnancy.
NRCM0109 12
Signs and Symptoms
In the early stages, there may be no symptoms. When symptoms develop, they tend to develop suddenly.
Common symptoms include:
• Sudden-onset abdominal pain, contractions that seem continuous and do not stop,
• Vaginal bleeding,
• Enlarged uterus disproportionate to the gestational age of the fetus,
• Decreased fetal movement, and
• Decreased fetal heart rate.
• Vaginal bleeding, if it occurs, may be bright red or dark.
Risk Factors
• Pre-eclampsia
• Chronic hypertension.
• Short umbilical cord
• Prolonged rupture of membranes (>24 hours).
• Multiparity
• Multiple pregnancy
• Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk
• The risk of placental abruption increases six-fold after severe maternal trauma.
• Anatomical risk factors include uncommon uterine anatomy (e.g. bicornuate uterus) and leiomyoma.
• Substances include cocaine and tobacco when consumed during pregnancy, especially the third
trimester.
• History of placental abruption or previous CS increases the risk by a factor of 2.3.
Diagnosis
• The fundus may be monitored because a rising fundus can indicate bleeding.
• Ultrasound may be used to rule out placenta previa but is not diagnostic for abruption. The diagnosis
is one of exclusion, meaning other possible sources of vaginal bleeding or abdominal pain have to
be ruled out in order to diagnose placental abruption.
• Of note, use of Magnetic Resonance Imaging has been found to be highly sensitive in depicting
placental abruption, and may be considered if no ultrasound evidence of placental abruption is
present, especially if the diagnosis of placental abruption would change management.
Classification
Based on severity:
Class 0: Asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a
depressed area on a delivered placenta.
Class 1: Mild and represents approximately 48% of all cases. Characteristics include the following:
• No vaginal bleeding to mild vaginal bleeding
• Slightly tender uterus
• Normal maternal blood pressure and heart rate
• No coagulopathy
• No fetal distress
NRCM0109 13
Class 2: Moderate and represents approximately 27% of all cases. Characteristics include the following:
• No vaginal bleeding to moderate vaginal bleeding
• Moderate-to-severe uterine tenderness with possible tetanic contractions
• Maternal tachycardia with orthostatic changes in blood pressure and heart rate
• Fetal distress
• Hypofibrinogenemia (i.e., 50–250 mg/dL)
Class 3: Severe and represents approximately 24% of all cases. Characteristics include the following:
• No vaginal bleeding to heavy vaginal bleeding
• Very painful tetanic uterus
• Maternal shock
• Hypofibrinogenemia (i.e., <150 mg/dL)
• Coagulopathy
• Fetal death
Prevention
Although the risk of placental abruption cannot be eliminated, it can be reduced.
• Avoiding tobacco, alcohol and cocaine during pregnancy decreases the risk.
• Staying away from activities which have a high risk of physical trauma is also important.
• Women who have high blood pressure or who have had a previous placental abruption and want to
conceive must be closely supervised by a doctor.
• The risk of placental abruption can be reduced by maintaining a good diet including taking folate,
regular sleep patterns and correction of pregnancy-induced hypertension.
• Use of aspirin before 16 weeks of pregnancy to prevent pre-eclampsia also appears effective at
preventing placental abruption.
Management
Treatment depends on the amount of blood loss and the status of the fetus.
• If the fetus is less than 36 weeks, and neither mother nor fetus are in any distress, then they may be
monitored in hospital until a change in condition or fetal maturity whichever comes first.
• Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in
distress.
• Blood volume replacement to maintain blood pressure and blood plasma replacement to maintain
fibrinogen levels may be needed.
• Vaginal birth is usually preferred over CS unless there is fetal distress. Caesarean section carries an
increased risk in cases of disseminated intravascular coagulation. People should be monitored for 7
days for postpartum hemorrhage. Excessive bleeding from uterus may necessitate hysterectomy.
Other Placental Abnormalities

1. Multiple Placentas
- Placenta Bipartita - not completely divided into lobes
- Placenta Duplex - separated into parts
2. Succenturiate Placenta - with accessory lobe
3. Ring Shaped Placenta - associated with fetal growth retardation, post-partum and antepartum
bleeding
4. Fenestrated Placenta - central portion of the maternal side is missing
NRCM0109 14
5. Extrachorial Placenta - chorionic plate is smaller than the basal plate
- Circumvallate - fetal surfaces presents a central depression surrounded by thickened white
grayish ring
- Circummarginate - white grayish ring is located at the margin of the placenta
6. Membraceous Placenta/Placenta Diffusa - fetal membrane covered by functioning villi
7. Large Placenta - associated with syphilis and erythroblastosis fetalis.
8. Placental Polyp - retained placenta that becomes a polyp may be covered by regenerated
endometrium
9. Abnormally Adherent Placenta - the placenta is implanted in a thin and poorly formed deciduas
- Placenta Accreta - attach to the myometrium
- Placenta Increta - invade deeply in the myometrium
- Placenta Percreta - invade the myometrium, perimetrium, and the bladder.
10. Placental Infection -
11. Placental Insufficiency - reduced placental function.
VIII. PREMATURE RUPTURE OF MEMBRANES

• Is a breakage of the amniotic sac before the onset of labor.
• If it occurs before 37 weeks it is known as preterm PROM otherwise it is known as term PROM.
Signs and Symptoms

• Most women will experience a painless leakage of fluid out of the vagina. They may notice either a
distinct "gush" or a steady flow of small amounts of watery fluid in the absence of steady uterine
contractions.
• Loss of fluid may be associated with the baby becoming easier to feel through the belly (due to the
loss of the surrounding fluid), decreased uterine size, or meconium (fetal stool) seen in the fluid.
Risk Factors
• The cause of PROM is not clearly understood, but the following are risk factors that increase the
chance of it occurring. In many cases, however, no risk factor is identified.
- Infections: urinary tract infection, sexually transmitted diseases, lower genital tract infections
(e.g. bacterial vaginosis), infections within the amniotic sac membranes (chorioamnionitis)
- Tobacco use during pregnancy
- Illicit drug use during pregnancy
- Having had PROM or preterm delivery in previous pregnancies
- Polyhydramnios: too much amniotic fluid
- Multiple gestation: being pregnant with two or more fetuses at one time
- Having had episodes of bleeding anytime during the pregnancy
- Invasive procedures (e.g. amniocentesis)
- Nutritional deficits
- Cervical insufficiency: having a short or prematurely dilated cervix during pregnancy
- Low socioeconomic status
- Being underweight
Diagnosis
To confirm if a woman has experienced PROM, a health care clinician must prove that the fluid leaking
from the vagina is amniotic fluid, and that labor has not yet started. To do this, a careful medical history
NRCM0109 15
is taken, a gynecological exam is conducted using a sterile speculum, and an ultrasound of the uterus is
performed.
• History: a person with PROM typically recalls a sudden "gush" of fluid loss from the vagina, or
steady loss of small amounts of fluid.
• Sterile speculum exam: a clinician will insert a sterile speculum into the vagina in order to see
inside and perform the following evaluations. Digital cervical exams, in which gloved fingers are
inserted into the vagina to measure the cervix, are avoided until the women is in active labor to
reduce the risk of infection.
• Pooling test: Pooling is when a collection of amniotic fluid can be seen in the back of the vagina
(vaginal fornix). Sometimes leakage of fluid from the cervical opening can be seen when the person
coughs or performs a valsalva maneuver.
• Nitrazine test: A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine
(phenaphthazine) paper. Amniotic fluid is mildly basic (pH 7.1–7.3) compared to normal vaginal
secretions which are acidic (pH 4.5–6).Basic fluid, like amniotic fluid, will turn the nitrazine paper
from orange to dark blue.
• Fern test: A sterile cotton swab is used to collect fluid from the vagina and place it on a microscope
slide. After drying, amniotic fluid will form crystallization pattern called arborization which
resembles leaves of a fern plant when viewed under a microscope.
• Fibronectin and alpha-fetoprotein blood tests
Classification
• PROM: when the fetal membranes rupture early, at least one hour before labor has started.
• Prolonged PROM: a case of PROM in which more than 18 hours has passed between the rupture
and the onset of labor.
• Preterm (PPROM): PROM that occurs before 37 weeks gestation.
• Mid-trimester PPROM or pre-viable PPROM: PROM that occurs before 24 weeks' gestation. Before
this age, the fetus cannot survive outside of the mother's womb.
Prevention
• Women who have had PROM are more likely to experience it in future pregnancies.
• There is not enough data to recommend a way to specifically prevent future PROM.
• However, any woman that has had a history of preterm delivery, because of PROM or not, is
recommended to take progesterone supplementation to prevent recurrence.
Management
SUMMARY FETAL AGE MANAGEMENT
• Induction of labor
Term > 37 weeks
• Antibiotics PRN to prevent group B streptococcus (GBS) transmission
Late pre-term 34–36 weeks • Same as for term
• Watchful waiting (expectant management)
• Tocolytics to prevent the beginning of labor
• Magnesium sulfate infusion for 24-48 hours to allow maximum
efficacy of corticosteroids for fetal lungs and also confer benefit to fetal
Preterm 24–33 weeks
brain and gut before delivery.
• One time dose of corticosteroids (2 separate administrations, 12-24
hours apart before 34 weeks
• Antibiotics if needed to prevent GBS transmission
• Discussion of watchful waiting or induction of labor
Pre-viable < 24 weeks
• No antibiotics, corticosteroids, tocolysis, or magnesium sulfate
NRCM0109 16
Complication
• Complications in the baby may include premature birth, cord compression, and infection.
• Complications in the mother may include placental abruption and postpartum endometritis.
Chorioamnionitis
• A bacterial infection of the fetal membranes, which can be life-threatening to both mother and fetus.
• Women with PROM at any age are at high risk of infection because the membranes are open and
allow bacteria to enter.
• Women are checked often (usually every 4 hours) for signs of infection: fever (more than 38 °C or
100.5 °F), uterine pain, maternal tachycardia, fetal tachycardia, or foul-smelling amniotic fluid.
• Elevated white blood cells are not a good way to predict infection because they are normally high
in labor.
• If infection is suspected, artificial induction of labor is started at any gestational age and broad
antibiotics are given. Caesarean section should not be automatically done in cases of infection, and
should only be reserved for the usual fetal emergencies.
IX. PREGNANCY-INDUCED HYPERTENSION (PIH)
• Gestational hypertension is the development of new hypertension (systolic above 145 or diastolic
above 95 mmHg) in a pregnant woman after 20 weeks' gestation without the presence of protein in
the urine or other signs of pre-eclampsia.
• Hypertension is defined as having a blood pressure greater than 140/90 mm Hg.
Signs and Symptoms

High blood pressure is the major sign in diagnosing gestational hypertension. Some women with
gestational hypertension may present asymptomatic, but a number of symptoms are associated with the
condition.
Symptoms
• Edema
• Sudden weight gain
• Blurred vision or sensitivity to light
• Nausea and vomiting
• Persistent headaches
• Increased blood pressure
Risk Factors
Maternal Causes
• Obesity
• Mothers under 20 or over 40 years old
• Past history of DM, hypertension (particularly gestational hypertension) and renal disease
• Pre-existing hypertension
• Thrombophilias (anti-phospholoipid syndrome, protein C/S deficiency, factor V Leiden)
• Having donated a kidney
Pregnancy
• Multiple gestation (twins or triplets, etc.)
• Placental abnormalities:
- Hyperplacentosis: Excessive exposure to chorionic villi
- Placental ischemia
NRCM0109 17
Family History
• Family history of pre-eclampsia
• African American race
Diagnosis – Conditions
There exist several hypertensive states of pregnancy:
• Gestational Hypertension – usually defined as having a BP >140/90 measured on two separate
occasions, >6 hours apart, no presence of protein in the urine and diagnosed after 20 weeks of AOG.
• Pre-eclampsia – is gestational hypertension plus proteinuria (>300 mg of protein in a 24-hour urine
sample). Severe pre-eclampsia involves a blood pressure greater than 160/110, with additional
medical signs and symptoms. HELLP syndrome is a type of pre-eclampsia. It is a combination of
three medical conditions: Hemolytic anemia, Elevated Liver enzymes and Low Platelet count.
• Eclampsia – This is when tonic-clonic seizures appear in a pregnant woman with high blood
pressure and proteinuria.
Pre-eclampsia and eclampsia are sometimes treated as components of a common syndrome.
Treatment
There is no specific treatment, but is monitored closely to rapidly identify pre-eclampsia and its life-
threatening complications (HELLP syndrome and eclampsia).
• Drug treatment options are limited, as many anti-hypertensives may negatively affect the fetus.
Methyldopa, hydralazine, and labetalol are most commonly used for severe pregnancy hypertension.
• The fetus is at increased risk for a variety of life-threatening conditions, including pulmonary
hypoplasia (immature lungs).
• If the dangerous complications appear after the fetus has reached a point of viability, even though
still immature, then an early delivery may be warranted to save the lives of both mother and baby.
• An appropriate plan for labor and delivery includes selection of a hospital with provisions for
advanced life support of newborn babies.
X. BLIGHTED OVUM
• Occurs when a fertilized egg implants in the uterus but does not develop into an embryo.
• Referred to as an Anembryonic (no embryo) pregnancy and is a leading cause of early pregnancy
failure or miscarriage.
• Often, it occurs so early that you don't even know you are pregnant.
• Causes about 1 out of 2 miscarriages in the first trimester of pregnancy.
Woman becomes pregnant

↓
Fertilized egg attaches to uterine wall
↓
About 5-6 weeks of pregnancy
↓ ↓
Gestational sac is about 18mm Pregnancy sac forms & grows
wide
↓ ↓
Embryo is present Embryo does not develop
↓ ↓
NORMAL PREGNANCY ANEMBRYONIC PREGNANCY
NRCM0109 18
Causes
• Miscarriages from a blighted ovum are often due to problems with chromosomes, the structures that
carry genes.
• This may be from a poor-quality sperm or egg.
• It may occur due to abnormal cell division. Regardless, your body stops the pregnancy because it
recognizes this abnormality.
It's important to understand that the mother does not cause the miscarriage, it is unpreventable. For most
women, a blighted ovum occurs only once.
Signs
• With blighted ovum, woman may have had a positive pregnancy test or missed period.
• There may also be signs of miscarriage, such as:
▪ Abdominal cramps
▪ Vaginal spotting or bleeding
▪ A period that is heavier than usual
If any of these signs or symptoms are present, one may be having a miscarriage. But not all bleeding in the
first trimester ends in miscarriage. So be sure to see the doctor right away if any of these signs are present.
Diagnosing
• Many women with blighted ovum think they have normal pregnancy because their HCG levels may
increase. The placenta produces this hormone after implantation.
• With blighted ovum, HCG can continue to rise because the placenta may grow for a brief time, even
when an embryo is not present.
For this reason, an ultrasound is usually needed to diagnose a blighted ovum - to confirm that the pregnancy
sac is empty.
What Happens After a Miscarriage?

• If diagnosed with blighted ovum, discuss with doctor what to do next.
• Some undergo D and C. It may also be helpful if you want a pathologist to examine tissues to
confirm the reason for the miscarriage.
• Using a medication such as Misoprostol on an outpatient basis may be another option. However, it
may take several days to expel all tissue. This medication may have more bleeding and side effects.
With both options, you may have pain or cramping that can be treated.
• Other women choose to let their body pass the tissue by itself. This is a personal decision, but needs
discussion with the doctor.
Prevention
• Unfortunately, in most cases a blighted ovum cannot be prevented.
• Some seek out genetic testing if multiple early pregnancy losses occur. A blighted ovum
is often a onetime occurrence, and rarely will a woman experience more than one.
• Most doctors recommend to wait at least 1-3 regular menstrual cycles before trying to
conceive again after any type of miscarriage.
NRCM0109 19
PHILIPPINES
A. PROBLEMS WITH THE PASSAGEWAY & POWERS
NORMAL LABOR
− Refers to the presence of regular uterine contractions that cause progressive dilatation and
effacement of the cervix and fetal descent.
− 95% of women in labor will have 3-5 contractions per 10 minutes.
− Full cervical dilatation is usually achieved 4 hours after 4 cm dilatation.
− Strength of contractions is at least 25mmHg.
NULLIPAROUS MULTIPAROUS
2ND STAGE-MEDIAN DURATION 50 minutes 20 minutes
CERVICAL DILATATION 1.2 cm/h 1.5 cm/h
ABNORMAL LABOR
Risk Factors of Abnormal Labor
1. Older maternal age 7. Occiput posterior
2. Pregnancy complications 8. Nulliparity
3. Non reassuring FHT 9. Short stature (less than 150 cm)
4. Epidural Anesthesia 10. High station at full dilatation
5. Macrosomia 11. Chorioamnionitis
6. Pelvic contraction 12. Post term pregnancy
I. OBSTRUCTED LABOR
− In spite of strong contractions, the fetus cannot descend through the pelvis because of the presence
of an unsurmountable barrier preventing its descent.
− Can occur anywhere in the pelvis but usually occurs at the pelvic brim.
− Can result in prolonged latent, active or expulsive phase depending on which area of the birth canal
the obstruction is present.
CAUSES OF OBSTRUCTED LABOR

a. CPD – small pelvis or large fetus
b. Abnormal presentations – brow, shoulder, face with chin posterior, after-coming head in breech
presentation.
c. Fetal Abnormalities – hydrocephalus, locked twins.
d. Abnormalities of reproductive tract – pelvic tumor, stenosis of cervix or vagina, tight perineum.
MATERNAL COMPLICATIONS
a. PROM – happens when head is arrested at pelvic inlet
b. Abnormal Dilatation – cervix dilates slowly or not at all because the fetal head cannot descend.
− 1st stage is prolonged if obstruction is at the inlet.
− 2nd stage is prolonged if obstruction is at the outlet.
c. Danger of Uterine Rupture – the narrow lower segment of the uterus stretches and becomes
dangerously thin due to continuous contractions.
− Common in multipara (esp. after CS), rare in nullipara.
Signs of Uterine Rupture – shock, abnormal distension / free fluid, abnormal uterine contour,
tender abdomen, easily palpable fetal parts, no fetal movements, FHT.
NRCM0109 ( - Lecture) | Page 1 of 11

d. Fistula (openings) – portions of the bladder, cervix, vagina and rectum are compressed between the
fetal head and the pelvic bones when the fetal head is trapped in the pelvis for
a long time.
− Excessive pressure on these tissues impair circulation resulting in necrosis and
subsequent formation of Fistula.
Types of Fistula: Vesico-vaginal – between bladder and vagina
Vesico-cervical – between bladder and cervix
Recto-vaginal – between rectum and vagina
− most common in nullipara (esp. young age)
e. Puerperal Sepsis – likely if membranes have been ruptured
− due to repeated vaginal infections
FETAL COMPLICATIONS
a. Caput Succedaneum – swelling of the scalp
b. Fetal death – prolonged pressure on fetus, placenta and umbilical cord by uterine contractions
results in impaired circulation and anoxia.
SIGNS OF OBSTRUCTED LABOR BY:

a. Partograph Recording – alert line to action line
b. Abdominal Examination – palpation of widest diameter of fetal head above the pelvic brim.
− frequent long and strong uterine contractions
− continuous uterine contractions
− Bandl’s ring which is a late sign of obstructed labor
− failure to hear FHT
c. Vaginal Examination – foul smelling meconium draining
− drained amniotic fluid
− edema of vulva (esp. when pushing for a long time)
− cervical edema
− large caput succedaneum can be felt
CAUSE FINDINGS
False labor Cervix not dilated
No palpable contractions/infrequent contractions
Prolonged latent phase Cervix not dilated beyond 4 cm after 8 hours of regular contractions
Prolonged active phase Cervical dilatation to the right of the alert line on the partograph
Cephalopelvic disproportion Secondary arrest of cervical dilatation and descent of presenting part
in presence of good contractions
Obstruction Secondary arrest of cervical dilatation and descent of presenting part
with large caput, edematous cervix, maternal and fetal distress
Inadequate uterine activity Less than 3 contractions in 10 minutes, each lasting less than 40
seconds
Malpresentation/malposition Presentation other than vertex with occiput anterior
Prolonged expulsive phase Cervix fully dilated & woman has urge to push but there is no
descent
MANAGEMENT OF OBSTRUCTED LABOR

a. Rehydrate Patient – IVF (NSS or LR, g18 cannula) and Monitor I&O
b. Administer Antibiotics to prevent or treat infection.
c. Give Supportive Care to Woman – back rub, empty bladder, encourage to ambulate, inform on
POL
d. Deliver Fetus: Dead – CS or craniotomy
CPD – CS
Fully dilated – forceps
NRCM0103 (Fundamentals of Nursing Practice - Lecture) | Page 2 of 11
II. ABNORMAL LABOR PATTERNS
A. PROLONGED LATENT PHASE

− latent phase starts from onset of regular uterine contractions to onset of active phase (0-3 cm)
− prolonged if exceeds more than 8 hours
CAUSE MANAGEMENT
Poor cervical Active intervention if no change in cervical dilatation after 8 hours of labor.
dilatation • Amniotomy to rupture intact membranes
characterized by • Oxytocin stimulation (w/o CPD)
unripe, rigid, • CS if after 8 hrs. induction, cervical dilatation has not progressed more
and firm cervix than 4 cm
Excessive Therapeutic rest
sedation and • Oxytocin stimulation
analgesia • CS
B. PROLONGED ACTIVE PHASE

− prolonged if more than 12 hours
Management
a. Refer to higher level facility
b. If signs without CPD or obstruction and the contractions are strong:
• Amniotomy if the membranes are intact
• Monitor feto-maternal well-being and POL
• Refer to higher level care if normal progress does not resume
• Provide support to client in labor by:
- Rub the back
- Wipe face with washcloth
- Encourage breathing techniques
- Explain procedure and situation
- Encourage and assist to empty bladder
C. PROTRACTION DISORDER
− slower than normal labor progress
− most common abnormality of labor
Types of Protraction Disorders

NULLIPAROUS MULTIPAROUS
Protracted Active Phase < 1.2 cm/h dilatation < 1.5 cm/h
Protracted Descent < 1 cm fetal descent/h < 2 cm in multipara
Cause
a. CPD and fetal malposition
b. Hypotonic Uterine Contraction
Management
a. Reassess pelvic size, presentation, and position to rule out feto-pelvic disproportion
b. Oxytoxin administration if without CPD
c. Provide support to the mother
D. PROLONGED SECOND STAGE OR PROLONGED EXPULSIVE STAGE

− Occurs when:
• Nullipara - 2 hours without analgesia conduction, 3 hours with conduction
• Multipara - 1 hour without analgesia conduction, 2 hours with conduction
− Needs spontaneous maternal pushing in 2nd stage.

− Excessive pushing and prolonged holding of breath should be discouraged because maternal
expulsive efforts exert pressure in the uterus which reduces the delivery of O 2 to the placenta,
and consequently decreases O2 supply to the fetus , which can lead to fetal anoxia and death.
− Most prolonged 2nd stage also have prolonged dilatations – >20 hours.
− Analgesia conduction lengthens 2nd stage by 25 minutes.
Cause
a. Persistent occiput posterior position
b. Epidural Anesthesia
Management
a. Delivery can be achieved via Forceps or vacuum extraction
b. If above measures fails or fetal distress occurs, CS
E. ARREST DISORDERS
− Complete cessation of progress
− Active phase disorders characterized by lack of fetal descent and dilatation
− Uterine contractions with normal frequency and intensity but cervix does not dilate and fetus
does not descend. →same cause and management as protraction disorders.
Types
a. Arrest of Dilatation – absence of progress in cervical dilatation for more than 2 hours in
nullipara and 1 hour in multipara.
b. Arrest of Descent – Absence of progress of fetal descent for more than 2 hours in nullipara
and 1 hour in multipara. Most common cause is CPD.
c. Failure of Descent – Absence of fetal descent in the 2nd stage of labor.
III. DYSTOCIA
− A broad term referring to prolonged labor (any labor that lasts more than 24 hours) caused by an
abnormality or a combination of abnormalities in the essential factors of labor.
− Also known as difficult labor, abnormal labor, difficult childbirth, abnormal childbirth, and
dysfunctional labor.
− The opposite of Dystocia is Eutocia, which means normal labor.
PROLONGED LABOR IS DUE TO ABNORMALITY IN ANY OF THE THREE (3) “PS”:

Powers – poor or uncoordinated uterine action
Passenger – too large fetal head or abnormal position
Passage – abnormal pelvis, tumor
TYPES OF DYSTOCIA
1. Uterine Dysfunction – Abnormalities of Powers of labor.
a. Hypotonic uterine dysfunction
b. Hypertonic uterine dysfunction
c. Inadequate secondary forces
2. Abnormalities of Passageway
a. Pelvic dystocia
• Inlet dystocia
• Midpelvis dystocia
• Outlet dystocia
b. Soft tissue dystocia
• Placenta previa that partially or completely obstructs the birth canal
• Presence of tumor that obstructs the birth canal

3. Fetal Dystocia – Abnormalities of Passenger
a. Malposition – Persistent occiput posterior position
b. Malpresentation – Breech, Face, Brow, Shoulder, Multiple presentation
c. Macrosomia
d. Hydrocephalus
DIAGNOSIS OF ABNORMAL LABOR

1. Laboratory Tests – no specific.
2. Imaging Studies – X-ray pelvimetry and Computerized Tomography (CT) pelvimetry.
− used to assess maternal bony pelvis
− cannot detect dystocia caused by soft tissue obstructions in pelvic outlet (obese)
3. Other Tests
a. POL monitoring
b. FHT assessment – must be reassuring throughout the labor course.
4. Clinical Pelvimetry – useful in assessing if the pelvis is adequate, borderline or contracted
− The bi-ischial diameter is >8 cm
− The distance to the sacral promontory from the symphysis pubis is >12 cm
− The relation of the bony pelvis to the fetal head is acceptable
IV. PELVIC DYSTOCIA

− Occurs when there is narrowing in one or more important diameters of the pelvis: inlet, mid pelvis,
outlet.
− Gynecoid and Anthropoid – good prognosis for vaginal delivery, Android and Platypeloid –
poor prognosis for vaginal delivery.
− Pelvis is contracted when the diagonal conjugate is <11.5 cm and its bi-ischial diameter is less than
8 cm. CS is the management for pelvic contraction.
− CPD
INLET CONTRACTURE
1. Inlet Dystocia is defined as anteroposterior diameter >10 cm, greatest transverse diameter that is >
12 cm, or diagonal conjugate >11.5 cm.
2. Can be due to several conditions including flat pelvis.
3. Lack of engagement between 36th and 38th week of pregnancy in primiparas is an important sign of
pelvic contraction.
4. 1 – 2% in term pregnancies.
MIDPELVIS CONTRACTURE
1. Most common pelvic dystocia. Occurs when the sum of the interspinous and posterior sagittal
diameters of the mid pelvis is <13.5 cm.
2. Fetus is able to engage, but due to the narrowed diameter of the mid pelvis, the fetal head is
prevented from rotating internally from transverse to AP diameter.
OUTLET CONTRACTURE
Outlet Dystocia occurs when the bi-ischial diameter (distance between ischial tuberosities) is < 11 cm.
V. SHOULDER DYSTOCIA
− After delivery of head, the anterior shoulder is trapped and arrested behind the symphysis pubis.
− Usually happens when baby is too large and pelvis is too small.
− Occurs with equal frequency in primi and multigravida.
− Diagnosed only during delivery.

RISK FACTORS
MATERNAL FETAL
a. Gestational Diabetes a. Assisted vaginal delivery (forceps or vacuum)
b. Post-dates pregnancy b. Protracted active phase of first stage of labor
c. Multiparity c. Protracted second stage labor
d. Abnormal pelvic anatomy

e. Previous pelvic dystocia
f. Short stature
COMPLICATIONS
MATERNAL FETAL
a. Postpartum hemorrhage a. Clavicle fracture
b. Recto-vaginal fistula b. Fetal death
rd th
c. 3 or 4 degree episiotomy / tear c. Fetal hypoxia, with or without permanent neurologic
d. Uterine rupture damage
d. Fracture of the humerus
MANAGEMENT
1. Turtle Sign: shoulder dystocia becomes obvious when the fetal head emerges and then retracts
against the perineum.
2. When dystocia is diagnosed, AVOID the following actions which can only cause injury to the
mother and the infant:
• Applying excessive pressure to the fetal head or neck
• Applying fundal pressure
3. The H-E-L-P-E-R-R mnemonic provides a step by step guide for preliminary management for
dystocia before more drastic measures are implemented.
It is designed to achieve one of these three objectives that will help to free the shoulder from its
impaction under the symphysis:
• Increase functional size of the bony pelvis
• Decrease bisacromial diameter (breadth of the shoulders) of the fetus
• Change relationship of the bisacromial diameter within the bony pelvis through internal
rotation maneuvers.
H – Call for HELP – additional personnel and equipment to aid in delivery.
E – EPISIOTOMY – provide additional room for physician’s hand when internal maneuver is
required.
L – LEGS (Mc Roberts maneuver) – done by flexing the legs of the parturient sharply over the
abdomen.
P – Suprapubic PRESSURE – place hand suprapubically over the anterior shoulder.
− Apply pressure in a compression / relaxation cycle (same with CPR). This action can make the
shoulder adduct and slip under symphysis.
E – ENTER Maneuvers (Internal Rotation) – Rotates the anterior shoulder into an oblique plane
under the maternal symphysis to dislodge it from impaction.
R – REMOVE the posterior arm – when the rotation maneuvers are successful, the next step is to
remove the infant’s posterior arm to give more space in the pelvis.
R – ROLL the patient (Gaskin maneuver) – roll patient onto her hand and knees or the “ALL
FOURS” position to increase pelvic diameter (via X ray)
4. If HELPERR maneuvers are unsuccessful:
a. Deliberate clavicle fracture – reduce shoulder-to-shoulder distance.
b. Zavanelli maneuver – cephalic replacement followed by CS

c. General anesthesia – effect general musculoskeletal or uterine relaxation that reduce
tissue resistance in the birth canal, enlarge space, and dislodge
impacted shoulder.
d. Symphysiotomy – symphysis pubis is surgically cut under local anesthesia.
5. Nursing Care
a. Explain the procedure
b. Assess for cord prolapse
c. Monitor for nucchial cord, cut and clamp two ends if present
d. Suction infant’s oropharynx after delivery of the head.
e. Monitor FHT and maternal VS.
VI. UTERINE DYSFUNCTION

May be caused by any or a combination of the following conditions:
• Pelvic contraction
• Fetal malposition
• Over distention
• Excessive rigidity of the cervix
TYPES OF UTERINE DYSFUNCTION

1. Hypotonic Uterine Contraction
− Occurs during active phase
− Characterized by:
• weak and infrequent contractions which are insufficient to dilate the cervix
• uterus is easily indented at the peak of contraction because the strength does not rise beyond
25 mm Hg
• contractions are not painful because of their poor intensity
− Contractions may have already been weak and ineffective at the start of labor (Primary Uterine
Inertia), or labor may have started with good contractions that become weak and infrequent or
stopped altogether when active phase is reached.
Causes
a. Too early administration of analgesia, before 3-4 cm dilatation.
b. Over-distention of the uterus caused by multiple pregnancy, hydramnios, large fetus
c. Bladder and bowel distention that prevents fetal descent.
d. Mal-presentation and malposition.
e. Pelvic bone contraction.
f. Unripe or rigid cervix.
g. Congenital abnormalities of the uterus.
h. Unknown causes.
Complications
a. Maternal and fetal infections – because cervix is dilated for a long time.
b. Postpartum hemorrhage – because of prolonged labor making the uterus too exhausted to
contract effectively in the postpartum period.
c. Fetal distress and death
d. Maternal Exhaustion
Management
a. Reevaluate pelvic size to rule out feto-pelvic disproportion
b. Vaginal delivery:
• Amniotomy if membranes are not yet ruptured
• Augmentation of labor by oxytocin administration
c. If contracted pelvis is present, caesarian section is the method of delivery
d. Provide supportive nursing care
e. Monitor for postpartum hemorrhage
2. Hypertonic Uterine Contraction

− Encountered in the latent phase of labor.
− Characterized by uncoordinated, too frequent contractions that tend to be more painful. The
uterus does not relax completely between contractions.
− Excessive pain is caused by hypoxia of the uterine tissue from inadequate relaxation in between
contractions.
Management
a. Evaluation of pelvic size. If adequate, attempt vaginal delivery.
b. Therapeutic rest:
• Analgesia (Morphine) and sedatives (Phenobarbital) to promote rest.
• Provide environment conducive to rest.
c. Maintenance of fluid and electrolyte balance by IV fluid infusion.
d. Keep bladder empty to provide more space for the passage of fetus.
e. Encourage side lying position to maximize blood flow to the placenta and fetus.
f. Monitor fetal condition.
VII. PRECIPITATE LABOR AND DELIVERY

− Occurs within 3 hours from onset of contraction to delivery of baby.
− Occurs without warning.
CLASSIFICATION
1. Precipitate Dilatation – cervical dilatation is progressing at 5 cm or more per hour in nulliparas,
10 cm or more per hour in multiparas.
2. Precipitate Descent – fetal descent is progressing at 5 cm or more per hour in nulliparas, 10 cm or
more per hour in multiparas.
PREDISPOSING FACTORS
1. Multiparity
2. Large pelvis
3. Lax unresisting maternal tissue
4. Small baby in good position
5. Induction of labor: amniotomy and oxytocin administration
6. Absence of painful sensation causing the woman to be unaware that vigorous labor is occurring.
COMPLICATIONS
MATERNAL FETAL
- Laceration of birth canal & uterine rupture. - Hypoxia
- Premature separation of placenta - Subdural hemorrhage due to sudden change of
- Postpartum hemorrhage intracranial pressure.
- Amniotic fluid embolism - Erb-Duchene palsy
- Injuries (fall)
SIGNS AND SYMPTOMS

1. Similar to women with normal labor pattern but appears suddenly without warning.
2. Patient complains of sudden intense urge to push.
3. Sudden increase in bloody show.
4. Sudden bulging of the perineum.
5. Sudden crowning of the presenting part.
MANAGEMENT
1. Anticipatory guidance for prevention.
a. Adequate prenatal care for early detection of risk conditions.
b. Inform multiparous women that succeeding labors are usually shorter.
c. Warn women with history of precipitate labor and delivery may happen again.

2. If accelerated labor pattern occurs during Oxytocin administration, stop infusion right away and turn
woman on her side.
3. Call for help. Do not leave patient alone.
4. Obtain sterile delivery pack, sterile gloves, bulb syringe, cord clamp, scissors, baby blanket.
5. Instruct / coach the mother.
6. Never hold or push baby’s head back – can result in fetal brain damage.
7. Ask woman to pant and not to push when head is already crowning to prevent rapid expulsion.
VIII. UTERINE RUPTURE

− Tearing of uterine muscles occurs when the uterus can no longer withstand the strain.
− Rare but often a fatal complication of labor.
CAUSES
1. Rupture of scar from previous CS.
2. Prolonged labor, obstructed labor, malposition and malpresentation.
3. Over distention of the uterus from multiple gestation or hydramnios.
4. Injudicious use of oxytocin, forceps and vacuum extraction.
5. Precipitate labor and delivery.
6. Manual removal of the placenta.
7. External trauma – sharp or blunt.
8. Placenta Increta or Acreta
9. Gestational trophoblastic neoplasia.
SIGNS AND SYMPTOMS

1. Impending uterine rupture – pathologic retraction ring.
2. During the peak of contraction, the woman complains of a sudden sharp tearing pain, then felt
relieved as the uterus loses the capacity to contract or contractions are too weak.
TYPES OF UTERINE RUPTURE

1. Complete Rupture
a. Woman experiences a sudden excruciating pain at the peak of a contraction, and then
contractions stop altogether.
b. Two swellings will be visible in the abdomen: the uterus and the extra-uterine fetus.
c. Internal hemorrhage soon follows and vaginal bleeding may or may not occur because blood
from torn uterine vessels pools in the peritoneal cavity. Placental separation results in fetal
hypoxia/death
2. Incomplete Rupture
a. Localized tenderness and persistent pain over the abdomen.
- Contractions may still continue or stop but no progress in cervical dilatation will be
observed.
- Vaginal bleeding may or may not occur because blood pools in the peritoneal cavity.
b. As blood supply to the fetus is cut off, fetal distress occurs and FHT soon becomes absent.
- A sign of maternal shock occurs as manifested by rapid and thread pulse, hypotension, air
hunger, and cold clammy skin.
MANAGEMENT
1. Blood transfusion and IVF administration to correct shock.
2. O2 therapy (mask) at 8L/m.
3. Prepare client for emergency laparotomy.
4. Provide emotional support.
5. For ruptured upper segment – BTL. For extensive damage, hysterectomy is performed.
6. Post op care – no extensive physical activity for 6-8 weeks.

IX. BANDL’S RING
PHYSIOLOGIC RETRACTION PATHOLOGIC RETRACTION RING

RING
During labor, the uterus differentiates • When labor is obstructed, as what happens in
into two parts: contracted pelvis, malposition, or hydrocephalus,
• Upper contracting portion that becomes the fetus cannot descend into the birth canal.
thicker and shorter as labor progresses. • Uterine contractions become stronger and more
• Lower passive portion that distends frequent in an effort to overcome the obstruction
gradually to accommodate the until it reaches a state of tonic contraction when the
descending fetus. uterus no longer relaxes.
BANDL’S (PATHOLOGIC RETRACTION) RING
A horizontal indention running across the abdomen or division of the two uterine segments that
become very prominent which was caused by the continuous retraction of the upper segment and
the over distention of the lower uterine segment.
MANAGEMENT
1. Administration of IV Morphine Sulfate or inhalation of Amyl Nitrate may be given to relax the
uterus and relieve pathologic retraction ring.
2. If above management is ineffective, perform CS to prevent uterine rupture.
3. If Bandl’s ring develops during placental stage – anesthesia and manual extraction of placenta.
X. INADEQUATE VOLUNTARY EXPULSIVE FORCES

− Bearing down efforts of the mother is not adequate to generate sufficient intra-abdominal pressure
to propel the fetus.
CAUSES
1. Paralysis of abdominal musculature.
2. Excessive use of analgesia and general anesthesia.
3. Fear of intense pain.
MANAGEMENT
1. Fear of intense pain – analgesia, forceps delivery when the head is already crowning.
2. Analgesia – wait for analgesia effect to wear off, then coach woman to bear down effectively,
forceps delivery when the head is already crowning.
XI. UTERINE INVERSION

− Uterus is partly or completely turned inside out.
− Serious complication of 3rd or 4th stage of labor.
CAUSES
1. Pulling of the umbilical cord or applying pressure on uncontracted uterus.
2. Uterine relaxation due to the effects of anesthesia or analgesia.
3. Sudden increase in intra-abdominal pressure (coughing, sneezing, straining).
4. Placenta acreta.
SIGNS AND SYMPTOMS

1. Fundus is no longer palpable in the abdomen.
2. Sudden gush of blood from the vagina that can result in shock and death.
3. Uterus appears in the vulva.

MANAGEMENT
1. Prevention
a. Never apply pressure on uncontracted uterus.
b. Never pull cord to hasten placental delivery.
2. If placenta has already separated, the uterus is replaced manually in the uterine cavity then oxytocin
is administered to promote contraction
3. If the placenta is still attached
a. Do not attempt to remove, doing so will only enlarge the bleeding area.
b. Do not administer oxytocin before the uterus is replaced, it will be more tense and difficult to
replace.
c. Woman is placed under anesthesia or given tocolytic to cause muscular relaxation and facilitate
reinsertion of the uterus into the pelvic cavity. Administer oxytocin.
d. The placenta is delivered when uterus is already replaced and contracting.
4. O2 therapy. Be prepared for CPR.
5. Administer IVF to combat shock.
6. Prepare / administer blood transfusion per doctor’s order.
7. Monitor vital signs.

PHILIPPINES
B. PROBLEMS WITH THE PASSENGER
I. ABNORMAL LIE
Where the long axis of the fetus is not lying along the long axis of the mother’s uterus.
• Transverse
• Oblique
• Unstable
Longitudinal (may either be cephalic or breech) is normal
II. MALPOSITION
Where the fetus is lying longitudinally and the vertex is presenting, but not in Occiput Anterior (OA)
position.
A. Occiput Posterior (OP)
– A malposition of vertex presentation
– Arrested labor may occur when head does not rotate and/or descend.
– Delivery maybe complicated by perineal tears or extension of an episiotomy.
B. Occiput Transverse (OT)
– Is the incomplete rotation of Occiput Posterior to Occiput Anterior, which results in a horizontal
or transverse position of the fetal head.
Factors that Favor Malposition

1. Pendulous abdomen – in multiparae
2. Anthropoid pelvic brim – favors direct OP/OA
3. Android pelvic brim
4. Flat sacrum – transverse position
5. Placenta on the anterior uterine wall
Diagnosis
• Course of labor is usually normal, except for prolonged second stage (>2 hours)
Abdominal Examination:
a) Lower part of the abdomen is flattened
b) Difficult to palpate fetal back
c) Fetal small parts are palpable anteriorly
d) Fetal heart tone may be heard in the flanks
Vaginal Examination:
a) Posterior fontanel is towards the sacral-iliac joint (difficult)
b) Anterior fontanel is easily felt, if head is deflexed
c) Fetal head may be markedly molded with extensive caput, making it more difficult to diagnose
the correct station and position.
Management
Spontaneous rotation to occiput anterior occurs in 90% of cases.
• Especially in good uterine contraction, spacious pelvis, average size fetus.
• If arrest of labor occurs in 2nd stage: Emergency cesarean section
III. MALPRESENTATION
Where the fetus is lying longitudinally, but presents in any manner other than vertex.
• Breech

• Brow
• Face
• Shoulder
• Compound
A. Vertex Malpresentation –
1. Brow Presentation
− most uncommon of all presentation
− babies born vaginally from brow presentation experience extreme facial edema
Assessment
a. On abdominal Examination – more than half of fetal head is above the symphisis pubis and
occiput is palpable at a higher level than the sinciput.
b. On vaginal examination – the anterior fontanel and the orbits are felt.
Management – can be delivered by CS only
2. Face Presentation
− Occurs when head is hyper-extended, the face is the presenting part, the chin (mentum) is
the denominator
− The mechanism of labor in face presentation is:
- Descent
- Internal Rotation
- Flexion
- Extension
- External Rotation
- Expulsion
Causes
Maternal Fetal
• Lax uterus due to Multiparity • Large fetus
• Contracted pelvis / CPD • Congenital Malformation (Anencephaly)
• Placenta previa • Multiple cord coil
• Multiple pregnancy • Musculoskeletal abnormality (spasm /
• Occiput posterior due to tendency of fetus shortening of extensor muscle of neck)
of extending head instead of flexing it • Tumors around the neck (congenital goiter)
Signs and Symptoms

a. Absence of engagement occurs
b. On IE, the examining fingers feel the mouth, nose, malar bones. and orbital ridges
c. UTZ confirms the diagnosis
Management
a. If chin is in anterior position (LMA or RMA), uterine contractions are strong, head is small,
shoulders have already entered the pelvis and there is no pelvic contraction, vaginal delivery
is possible but longer than usual. Forceps may be used to hasten 2 nd stage
b. If chin is in posterior position (RMP, LMP), vaginal delivery may be impossible and
dangerous if attempted because it can lead to transverse arrest. CS
3. Sincipal Presentation
− Occurs when the larger diameter of the fetal head is presented.
− Labor progress is slowed with slower descent of the fetal head.
PESENTING PART DIAMETER
Suboccipitobregmatic Flexed vertex presentation 9.5 cm
Suboccipitofrontal Partially deflexed vertex 10.5 cm
Occipitofrontal Deflexed vertex 11.5 cm
Mentovertical Brow 13 cm
Submentobregmatic Face 9.5 cm
B. Breech Presentation – Most common cause of fetal malpresentation.
Types of Breech Presentation

1. Frank Breech – Buttocks comes first
– Hips are flexed, knees are extended
2. Complete Breech – Buttocks comes first
– Hips and knees are flexed
3. Footling (Double or Single) – 1 or both feet come first
– Rare in term, common in premature
4. Kneeling Breech – 1 or both legs extended at the hips & flexed at the knees
– Extremely rare
Assessment
1. Abdominal Examination – Leopold’s Maneuver no. 1 – head is felt on the fundus.
2. Auscultation – Leopold’s Maneuver no. 2 – FHT on upper quadrant of the abdomen.
3. Vaginal Examination – Buttocks and/or feet are felt; thick dark meconium is normal.
Etiology
MATERNAL FETAL PLACENTAL
Polyhydramnios Prematurity Placenta previa
Oligohydramnios Multiple pregnancy
Uterine abnormalities Fetal Anomalies
Pelvic tumor • Hydrocephalus
Uterine surgery • Anencephaly
Contracted pelvis
Previous breech delivery
Complications
1. Prolapse cord – presenting part does not fit well enough into the pelvic brim.
2. Birth trauma that includes:
• Fracture of the skull, clavicle, humerus
• Intracranial hemorrhage
• Rupture of abdominal organs
3. Dysfunctional & prolonged labor – soft buttocks does not aid in cervical dilatation.
4. Meconium aspiration – pressure on abdomen and buttocks can force passage of meconium into
the amniotic fluid before birth.
5. Intrauterine anoxia
6. Fetal death
Management
1. Confirmation by ultrasound – at or after 36 weeks.

2. External Cephalic Version (ECV) – attempt ECV if:
• breech presentation is present at or after 37 weeks
• vaginal delivery is possible
• there are no contraindications (fetal abnormality, placenta previa, uterine bleeding, previous
uterine surgery, hypertension, multiple gestation, Oli or Polyhydramnios)
Risk of ECV
- Placental abruption
- PROM
- Cord accident
- Transplacental Hemorrhage
- Fetal bradycardia
3. Vaginal Breech Delivery – may be attempted if:
• there is no pelvic contraction
• fetal weight is not more than 3,500 grams
• there is experienced/skilled personnel in breech delivery
• spontaneous labor occurs with progressive cervical dilatation
• no evidence of feto-pelvic disproportion
Principle: Masterly Inactivity (Hand-Off).

Important points for safe conduct of vaginal breech delivery are:
- Do not be in a hurry
- Never pull from below, let the mother expel the fetus by her own effort with uterine
contractions
- Always keep the fetus with its back anterior
- Keep a pair of obstetric forceps ready if necessary to assist the coming head
- Anesthetist and pediatrician should attend the delivery
- Inform operating room if cs is needed
General Techniques of Vaginal Breech Delivery

Spontaneous Breech Delivery – born without traction or manipulation from OB
Partial Breech Extraction – born up to the umbilicus; rest of the body is extracted
Total Breech Extraction – entire body is extracted by OB
Different Maneuvers
Pinard’s – done in breech with extended leg
– once the groin is visible, gentle pressure can be applied to abduct the thigh and
reach the knee
– The knee can be flexed with pressure in the popliteal fossa & the leg delivered.
– anterior leg is always delivered first
Loveset Maneuver – automatically corrects any upward displacement of arms
− Baby’s trunk is rotated with downward traction, holding at the iliac crest so that
posterior shoulder comes below the symphysis pubis, arm is delivered by flexing
the shoulder followed by hooking at the elbow and flexing it, followed by bringing
down the forearm like a “hand shake”.
− Same procedure is repeated by reverse rotation of 180° so that anterior shoulder
comes below the symphysis pubis.
Mauriceau-Smellie-Veit Maneuver (Jaw Flexion & Shoulder Traction) – used to extract the
head after delivery of infant’s body
− Baby is rested on obstetrician’s supinated non-dominant hand, with limbs hanging
on either side.
− Non-dominant Index & middle fingers are placed on malar bones, dominant index
& ring fingers are placed on shoulders with middle finger on sub-occipital region.
− To achieve flexion, traction is given in downward and backward direction and
simultaneous suprapubic pressure is maintained by the assistant until nape is
visible.

− Baby is pulled upward and forward direction so that face is born, and by
depressing the trunk the head is born.
Prague Maneuver – used when the back of the fetus fails to rotate to the anterior.
− The operator delivers the shoulders with one hand, while making pressure above
the symphysis pubis with the other hand.
Bracht Maneuver – Delivery by extension of the legs and trunk of the fetus over the symphysis
pubis and abdomen of the mother
− The fetal head is born spontaneously as the legs and trunk are lifted above the
maternal pelvis, and as the body of the infant is extended by the operator.
Abdominal Rescue – fetus is replaced when fully deflexed head is entrapped and cannot be
delivered vaginally. CS follows
Cleidotomy – involves cutting of shoulder to facilitate delivery. Also used in shoulder dystocia
Management
− Continuous assessment of POL; contractions, effacement, dilatation, station, presentation
− Assessment of fetal condition: ultrasound to determine anomalies such as hydrocephaly,
microcephaly and anencephaly
4. Cesarean Section (CS)
C. Shoulder Presentation
− Occurs when fetus assumes a transverse or oblique lie
− The fetus does not engage in this presentation so there is a great danger of cord prolapsed after
membranes have ruptured
Causes
1. Lax uterine and abdominal muscles due to multiparity
2. Contracted pelvis
3. Fibroids and congenital abnormality of the uterus
4. Preterm fetus, hydrocephalus
5. Placenta previa
6. Multiple pregnancy
Signs and Symptoms

1. Shape of uterus is more horizontal than vertical
2. On Leopold’s Maneuver – the fetal head and buttocks occupy the sides of the uterus
Management
1. External version can be performed before labor begins to rotate fetus
2. If version fails, the preferred method is CS
D. Compound Presentation
− A fetal presentation in which an extremity presents alongside the part of the fetus closest to the
birth canal. The majority of compound presentations consist of a fetal hand or arm presenting
with the vertex.
Management
1. Observed closely to ascertain whether the arm retracts out of the way with descent of the
presenting part.
2. If it fails and appears to prevent descent of the head, prolapsed arm should be pushed gently
upward and the head simultaneously downward by fundal pressure.
SUMMARY

PRESENTATION MANAGEMENT
Breech Vaginal delivery +- ECV / CS
Face Vaginal delivery (chin anterior), CS (chin posterior)
Brow Cesarean Section (CS)
Shoulder Cesarean Section (CS)
Compound Replacement of prolapsed arm →vaginal delivery / Cesarean
Section
IV. FETAL DISTRESS
Refers to the presence of signs in a pregnant woman before or during childbirth that suggest that the
fetus may not be well.
Signs and Symptoms
Generally it is preferable to describe specific signs in lieu of declaring fetal distress that include:
1. Decreased movement felt by the mother
2. Meconium stained amniotic fluid
3. Non-reassuring patterns seen on cardiotocography:
- Increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after
a contraction
- Decreased variability in the fetal heart rate
- Late decelerations
Causes
There are many causes of "fetal distress" including:
1. Breathing problems
2. Abnormal position and presentation of the fetus
3. Multiple births
4. Shoulder dystocia
5. Umbilical cord prolapse
6. Nuchal cord
7. Placental abruption
8. Premature closure of the fetal ductus arteriosus
9. Uterine rupture
10. Intrahepatic cholestasis of pregnancy, a liver disorder during pregnancy
Treatment
• Instead of referring to "fetal distress", current recommendations hold to look for more specific signs
and symptoms, assess them, and take the appropriate steps to remedy the situation through the
implementation of intrauterine resuscitation.
• Traditionally the diagnosis of "fetal distress" led the obstetrician to recommend rapid delivery by
instrumental delivery or by caesarean section if vaginal delivery is not advised.
V. PROLAPSE UMBILICAL CORD

− Occurs when the cord passes out the uterus ahead of the presenting part.
− Occurs after membranes have ruptured when the fetus is not yet engaged or does not completely
cover the pelvic inlet.
− Always lead to cord compression as the presenting part descends in the birth canal.

Causes
1. Polyhydramnios
2. Long cord
3. Malposition and malpresentation (shoulder and foot)
4. Prematurity
5. Placenta previa
6. Premature rupture of membranes
Risk Factors
Spontaneous Factors:
• Fetal Malpresentation: Abnormal fetal lie tends to result in space below the fetus in the maternal
pelvis, which can then be occupied by the cord.
• Polyhydramnios, or an abnormally high amount of amniotic fluid
• Prematurity: likely related to increased chance of malpresentation and relative polyhydramnios.
• Low Birth Weight: usually described as <2500g at birth, though some studies will use <1500g.
Cause is likely similar to those for prematurity.
• Multiple Gestation, or being pregnant with more than one fetus at a given time: more likely to
occur in the fetus that is not born first.
• Spontaneous Rupture of Membranes: about half of prolapses occur within 5 minutes of
membrane rupture, two-thirds within 1 hour, 95 % within 24 hours.
Treatment Associated Factors:
• Artificial rupture of membranes
• Placement of internal monitors (for example, internal scalp electrode or intrauterine pressure
catheter)
• Manual rotation of fetal head
Signs and Symptoms

1. Cord protrudes from the vagina.
2. Cord is palpable in vaginal canal /cervix during IE
3. Fetal distress, especially variable deceleration in FHT pattern
Classification
There are three types of umbilical prolapse that can occur:
• Overt Umbilical Cord Prolapse:
- Descent of the umbilical cord past the presenting fetal part.
- Cord is through the cervix and into or beyond the vagina.
- Requires rupture of membranes.
- This is the most common type of cord prolapse.
• Occult Umbilical Prolapse:
- Descent of the umbilical cord alongside the presenting fetal part, but has not advanced past the
presenting fetal part.
- Can occur in intact or ruptured membranes.
• Funic (Cord) Presentation:
- Presence of the umbilical cord between the presenting fetal part and fetal membranes.
- The cord has not passed the opening of the cervix.
- The membranes are not yet ruptured.
Management
1. Prevention - after membranes have ruptured:
a. Always assess FHT.
b. Place client in bed rest.
2. Reduce pressure on the cord by:

a. Place client in Knee-chest or Trendelenburg position, or place folded towel under the hips.
b. Put on sterile gloves and insert 2 fingers into the vagina, then put presenting part upward.
3. If cord is exposed to air, cover with saline moistened sterile compress to prevent it from drying
because drying of the cord may lead to atrophy and constriction of blood vessels.
4. Never replace cord back into the vagina as this can result in cord kinking or knotting.
5. O2 therapy
6. Deliver baby ASAP
a. Vaginal delivery if cervix is fully dilated without fetal distress.
b. CS if cervix is no yet fully dilated and if fetal distress is present.

BPSU College of Nursing Maternal Child Nurse Responsibilities

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BPSU College of Nursing Maternal Child Nurse Responsibilities

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BATAAN PENINSULA STATE UNIVERSITY

COLLEGE OF NURSING AND MIDWIFERY

ROLES & RESPONSIBILITIES OF A MATERNAL & CHILD NURSE

Strategic Thrusts (2005-2010)

BeMONC- Basic Emergency Obstetrics and Newborn Care

CeMONC- Comprehensive Emergency Obstetrics and Newborn Care

Essential Health Services available in the Health Care Facilities

Tetanus Toxoid Immunization

Clean and Safe Delivery

Delivery in Healthy Facility

Disorders detected in Newborn Screening

Support to Breastfeeding. Motivate mothers to practice breastfeeding.

Family Planning Counseling

CARE OF MALE AND FEMALE CLIENTS WITH GENERAL AND

A. SEXUAL DESIRE DISORDERS

B. SEXUAL AROUSAL DISORDERS

1. ERECTILE DYSFUNCTION (ED)

4. SEXUAL PAIN DISORDERS

5. POST-ORGASMIC DISEASES – cause symptoms shortly after orgasm or ejaculation.

6. PELVIC FLOOR DYSFUNCTION

− Low sperm count due to endocrine problems, drugs, radiation, or infection.

2. Fertility Tourism / Medical Tourism

3. Stem Cell Therapy

JOCELYN F. VILLANUEVA, EdD, RN

#1 HIGH RISK FACTORS OF PREGNANCY

2. Above 35 years old

3. Mother is underweight ( less than 45.5 kgs or 100 lbs)

4. Mother is overweight (more than 91 kgs or 200lbs)

5. Mother has anemia (Hgb less than 11g/l)

6. Poor nutritional status

7. Pre-existing medical conditions.

8. Family history of genetic disease or previous baby with genetic defect.

10. Previous pregnancy loss

12. Low socioeconomic status

DANGER SIGNS OF PREGNANCY

i. Severe Headache, Dizziness, Blurring of Vision, Spots Before the Eyes

I. HYPEREMESIS GRAVIDARUM (HG)

Signs and Symptoms

II. ECTOPIC PREGNANCY

Symptoms of Ectopic Pregnancy

Diagnosing an Ectopic Pregnancy

Treating an Ectopic Pregnancy

Getting Pregnant After an Ectopic Pregnancy

After the treatment:

IV. INCOMPETENT CERVIX

Signs and Symptoms

3. Obesity, Eating Disorders and Caffeine

6. Amniocentesis and Chorionic Villus Sampling (CVS)

9. Chemotherapy and Radiation Treatments for Cancer

10. Intercurrent Diseases

11. Anatomical defects and trauma

13. Morning sickness

Non-Modifiable Risk Factors

Modifiable Risk Factors

VI. PLACENTA PREVIA

Signs and Symptoms

VII. ABRUPTIO PLACENTA

Other Placental Abnormalities

VIII. PREMATURE RUPTURE OF MEMBRANES

Signs and Symptoms

IX. PREGNANCY-INDUCED HYPERTENSION (PIH)

Signs and Symptoms

Woman becomes pregnant