POSTPARTUM HEMORRHAGE Additional Notes:

✓ Placenta Accreta – rare

OUTLINE
o The villi of the chorion penetrates all over the
I. Postpartum Hemorrhage layers even up to the neighboring organs. In
II. Tone placenta accreta, the villi can grow up to the
III. Lacerations bladder (if it’s going down) or up to the
IV. Hematoma intestines (if going up). The villi is lengthened
V. Uterine Rupture towards the neighboring organs then it would
VI. Uterine Inversion be very hard for the placenta to be delivered,
VII. Retained Placental Fragments leading to retained placenta.
VIII. Subinvolution of Uterus o Chorion – connection of the placenta towards
IX. Disseminated Intravascular Coagulation the endometrium, myometrium, and
perimetrium
o Example: if placental delivery takes up more
POSTPARTUM HEMORRHAGE
than an hour (usual is around 5-40 mins if
• Postpartum haemorrhage refers to any amount of spontaneous), the doctors would decide to do
bleeding from or into the genital tract following birth of the a hysterectomy (if accreta is confirmed),
baby upto the end of puerperium myotomy (opening the uterus to check bakit
o Puerperium – 6 weeks after delivery hindi na deliver)
• Usually occurs 2hrs after birth, but could also occur once o The bladder is also removed if the villi has
the client is home reached it since retained placental fragments,
• NSVD Postpartum Hemorrhage: >500ml blood loss which includes the villi, can cause bleeding
• CS Postpartum Hemorrhage: >1000ml (1L) blood loss

TYPES OF POSTPARTUM HEMORRHAGE CAUSES OF POSTPARTUM HEMORRHAGE

1. EARLY POSTPARTUM HEMORRHAGE 4T’s

a. Uterine atony Tissue (retained placenta)

absence of tone of the uterus
Tone (uterine atony)
b. Lacerations – most common are 2nd, 3rd, & 4th degree
c. Hematomas – accumulation of blood underneath the Traumatic delivery (laceration)
tissue
Thrombin (coagulation disorders)
d. Uterine rupture
e. Uterine inversion – the worst TONE
o Dapat dahan-dahan lang pag handle sa baby
during delivery since pwede masama ang uterus • Atony of the uterus
pagbira sa baby especially if shoulder out na • 75-90% of PPH
• Usually the most common cause of mortality and
2. LATE POSTPARTUM HEMORRHAGE morbidity among women who gave birth
• Uterus did not contract so the blood vessels are open,
a. Retention of Fragements
which means blood is flowing freely
b. Subinvolution – failure of uterus to contract even after
delivery
c. Disseminated Intravascular Coagulation (DIC) – systemic
coagulation of the blood so the client would have internal
bleeding
o Initial symptoms: redness, patches over the
surfaces of the skin, big rashes na akala allergy
o usually happens postpartum especially clients
with preeclampsia or blood disorders

Fig. 1 Postpartum Hemorrhage

Causes:
MAIN CAUSES OF EARLY HEMORRHAGE:
• Overdistention of uterus (large baby, multiple
• Uterine atony – first 2 hours, which is critical
gestation)
• Lacerations
o Large baby and multiple gestation excessively
• Retained placental fragments
stretches the uterine wall making the uterus fail to
• Inversion of the uterus
contract after it empties
• Placenta accreta
• Uterine muscle exhaustion (prolonged labor)
o The uterus failed to contract since it got tired
because contraction and the labor process are
exhausting
• Uterine infection
 o It is important to prevent UTI or any infection in uterus isn’t fully healed during that pregnancy =
general since the bacteria can ascend to the difficulty to contract which would lead to uterine
uterus causing infection. rupture since uterus is stretched again even if it
o Uterine infection = failure to contract isn’t fully healed.
• Uterine relaxants (general anesthetic) • Chorioamnionitis
o Local anesthesia is usually used for episiotomy o Inflammation of the bag of water
o The effect of general anesthesia (GA) is o Can cause uterine infection
vasodilation. If GA is used, usually during CS, the • Full bladder: Distended Uterus = Uterine Atony
blood and muscles are relaxed leading to uterine o After delivery, the uterus should be on top of the
atony bladder at the middle of the umbilicus at the
• Retained placental fragments fundus,
o Since a portion of the placenta is left in the uterus, o If the bladder is full, the uterus is distended to
the chorionic villi is still there which is the pathway either left or right, which will lead to uterine atony
of blood from mother to fetus. If the chorionic villi
is left, it will continue to receive blood and will Additional Notes:
continue to bleed. ✓ Hydramnios, large baby, uterine myoma, over
distended uterus, macrosomia, multiparity – can
FACTORS CAUSING UTERINE ATONY all make uterus distended
o Over distention of the uterine muscle wall will
• Multiple Gestation eventually allow failure of uterine contraction
• Precipitate Labor after delivery
o The stronger contraction and shorter intervals
during precipitate labor would allow the uterus to
get tired, which will cause uterine atony
• Hydramnios
o Polyhydramnios
• Large Baby
• Uterine Myoma
• Over distended uterus
• Macrosomia
• History of PPH
o Most likely to have the same condition on
succeeding pregnancies
• MgSo4 use
o Although it is used to prevent seizures for PIH, it
is also a tocolytic (uterus relaxant). When given
before delivery, it will make the uterus less likely
to contract after delivery since the effect is still in Fig. 2 Uterine Atony
the body SIGNS AND SYMPTOMS
• General anesthesia
• Oxytocic drugs 1. Boggy Uterus
o Oxytocin (Pitocin) and Methergin 2. Large uterus
o Stimulates contraction of the uterus, however, 3. Expulsion of large clots
when more doses are given, it will stimulate the 4. Bright red vaginal bleeding: Dehydration: leads to
uterine muscles to get tired = failure to contract Hypovolemic shock
o Bright red vaginal bleeding came from the arteries
• Multiparity
that has been cut, which is from either episiotomy
• Advanced maternal age
or laceration
• Prolonged tocolytic agents
5. Hypotension, tachycardia, tachypnea
o Ex. duvadilan, isoxsuprine HCL
o highlight from any fluid loss
o Ex. duvadilan is given to a mother to prevent
6. Pallor, poor capillary refill test (CRT), dry skin, dry
preterm labor. However, the bag of water ruptured
mucous membrane, dry lips
so the baby should be delivered to avoid infection.
o Dahil nawalan ng dugo, ang water from cellular
Duvadilan is a muscle relaxant that directly affects
level is pupunta sa blood stream to refill the
the smooth muscles. Since the mother has been
losses. Yung cells, particularly sa skin is
using duvadilan, there would be difficulty of
dehydrated.
contraction after delivery
7. Decrease urine output, concentrated urine
• Dystocia
o Low urine output is the kidney’s compensatory
o Prolonged labor = tired uterus = failure to contract
mechanism to conserve or keep water in the body
• Previous uterine surgery
▪ Brought about by the antidiuretic hormone
o Should allow the exact time of healing of the
which will be released in cases bleeding,
uterine wall and uterine muscles where the
water loss, plasma loss. Antidiuretic
incision took place
hormone will tell the kidney to conserve
o If there is a short interval (ex. less than a year)
water
between the surgery and next pregnancy, the
8. Dizziness, headache, delirium, confusion
o Blood loss - decreased oxygen to the brain since
blood (hemoglobin) carries oxygen
Additional Notes:
✓ Boggy uterus = malambot na uterus
✓ Hypovelemic shock:
o 10% murag standard na percent for
hypovolemic shock
o >10%: irreversible
o <10%: buhay ka pa
✓ E.g the patient is 50kls.
50kls x 60= 30 kls fluids/blood x 10 %=
3kls = 3000g = 1ml
Therefore, 3000ml blood loss. This is irreversible
and may likely result to death, and it denotes hypovolemic
shock.
SIGNS AND SYMPTOMS OF SECONDARY
POSTPARTUM HEMORRHAGE:
General
• Tachycardia and low grade fever
Abdominal Examination
• Subinvolution of uterus
Vaginal Examination
• Lochia heavier in amount; fresh in color and offensive
odor
• If infection occurs, retained placenta may present
Fig. 3 Postpartum Hemorrhage
Additional Notes:
✓ We can only massage the abdomen since the OB is
the only one allowed to do manual fundal massage
GOAL FOR MANAGEMENT OF UTERINE ATONY
• Promote uterine contraction
• Stop bleeding
• Prevent complications: hypovolemic shock (10%), death
Additional Notes:
✓ Oxytocin: promotes/stimulates uterine contraction,
good for the 1st until 4th stage of labor
✓ Contraction: methergin (increases BP, can only be
given on the 4th stage of labor considering the
patient’s BP is normal and the placenta is out), the
effect is more on the blood vessel
▪ If BP is high and methergin is given, the BP
will continue to increase, which could lead to
seizure, will worsen eclampsia, etc.
▪ If given before placental delivery, the uterus
will trap the placenta inside = CS
MEDICAL MANAGEMENT OF UTERINE ATONY
1. Intravenous Fluid: D5LR 1L, PNSS with BT
2. Oxytocic medications:
A. Oxytocin: Pitocin
B. Methylergonovine maleate: Methergin
▪ Methergin: contracts vascular smooth
muscles. Only given IM if the BP of the client
is within Normal level
▪ Contraindicated to elevated BP because the
methergin further increase BP
C. Cytotec: prostaglandin
D. Antibiotics: Amoxicillin
3. Blood transfusion: replace blood loss for vaginal bleeding
4. Catheterization: Full bladder causes uterine distention =
uterine atony
5. Oxygen administration
Additional Notes:
✓ Prostaglandin requires a yellow prescription.
However, it is used as an anti-ulcer and stimulate
uterine contraction.
✓ Amoxicillin is not the standard antibiotic drug but it
is the mostly administered drug/prescribed.
✓ Palpate bladder over symphysis pubis
o Empty bladder – soft; full bladder – firm
MANAGEMENT OF TRUE PPH
• Uterine Massage – if the uterus is soft, massage is
performed by placing one hand in the vagina and pushing
against the body of the uterus while the other hand
compresses the fundus from above through the
abdominal wall. The posterior aspect of the uterus is
massaged with the abdominal hand and the anterior
aspect with the vaginal hand.
MEDICAL MANAGEMENT
• Stopping the blood loss
• Give IV fluids - maintains circulating volume and to
replace fluids
• Give blood transfusions
• Oxygen to increase saturation of remaining blood cells
• Foley to assess urine output (UOP)
SURGICAL MANAGEMENT OF UTERINE ATONY
1. Ligation of uterine arteries 1. Oxytocin promotes rhythmic contractions
o Stops bleeding from arteries and veins 2. Ergometrine
o If the uterus does not contract despite the 3. Hemabate
medications (oxytocin and methergin),
hysterectomy will be done Surgical
2. Hysterectomy
o Removal of the uterus • Balloon tamponade
o Inflate ng air ang balloon para mag shape ang
NURSING INTERVENTIONS uterus
Preventing Infection • Hemostatic brace suturing (B-Lynch)
o Blood vessels around the uterus are sutured
• Instruct the woman to cleanse from the front to the back • Bilateral ligation Uterine artery / Internal Iliac arteries
• Provide instructions on techniques used for perineal care • Selective arterial embolization
• Explain the importance of changing the perineal pad each o Ipa narrow ang arteries para hindi na magdaan
time after urination and defecation and of not touching the ang blood
inner surface of the pad • Hysterectomy – sooner than later
• Explain the importance of proper handwashing before
and after perineal care
• Explain that perineal care should be carried out after
urination and defecation and at least every 4 hours during
the day
• Encourage a diet that is high in protein and vitamin C and
encourage at least 2000 mL of fluid each day
o Protein – tissue repair
o Vit C – boost immune system
o Increased OFI to prevent UTI Fig. 4 Balloon Tamponade

NURSING DIAGNOSIS AND MANAGEMENT OF

UTERINE ATONY

• Fluid Volume Deficit r/t failure of the uterus to contract

NURSING CARE OF UTERINE ATONY
o r/t inability of the myometrium to contract
• Document vaginal bleeding o r/t poor contraction of the uterus aeb blood loss of
• Fundal massage / bimanual compression greater than 500ml
• Assess vital signs (shock) o r/t distended uterus
o r/t retained placental tissue in the uterus
• Give medications – Pitocin, Methergine, Hemabate
▪ pwede with secondary to anesthesia,
• D&C, Hysterotomy/ectomy, replace blood/fluids
secondary to magnesium sulfate use,
o Hysterotomy – open ang uterus then kunin ang
secondary to duvadilan use
fragments
✓ Fundal massage
• Offer a bedpan or assist the woman with ambulating to
✓ Ice pack application on fundus
the bathroom at least every 4 hours to keep her bladder
✓ Encourage voiding
empty (catheterization)
✓ Administer Oxytocin/Methergin as ordered
o Other ways to stimulate urination
✓ Regulate IVF and BT
✓ Listen to running water
✓ Increase OFI
✓ Place hand in water
✓ Monitor CBC, CT/BT, APTT, PT
✓ Increase OFI
▪ APTT: Activated ProtrothromboPlastine Time
✓ Wash perineum w/ warm water
(vasodilation) • Altered Tissue Perfusion r/t
• A full bladder pushes an uncontracted uterus into an even • Decrease Cardiac Output r/t
more uncontracted state ✓ Assess VS, NVS, CRT
• To reduce bladder pressure, insertion of a urinary ✓ Hook to cardiac monitor
catheter may be ordered ✓ Assess skin color and turgor
• Obtain vital signs frequently and make sure to interpret ✓ Trendelenburg position
them accurately, looking for trends. ✓ Oxygen administration as ordered
o For example, a continuously rising PR is an ✓ Hydration: IVF
ominous pattern ✓ Blood transfusion
• If a woman is experiencing respiratory distress from ✓ Increase OFI
decreasing blood volume, administer oxygen by face ✓ Monitor oxygen saturation
mask at a rate of 4L/min. position her supine to allow • Anxiety r/t
adequate blood flow to her brain and kidneys ✓ Emotional support
✓ Give factual information about the condition
MANAGEMENT OF UTERINE ATONY ✓ Explain the procedures
✓ Provide calm environment
Medical
 LACERATIONS

ETIOLOGY AND PATHOPHYSIOLOGY

Lacerations of the birth canal are second only to uterine

atony as a major cause of postdelivery hemorrhage

1. Spontaneous or Precipitous delivery

2. Size, Presentation, and Position of the baby
3. Contracted Pelvis
4. Vulvar, perineal and vaginal varices

Fig. 5 Degree of Lacerations

A. Perineal laceration involving the skin and soft tissue

B. Perineal laceration involving the skin, soft tissue and
Fig. 6 Degree of Lacerations
muscle
C. Perineal laceration involving the skin, soft tissue, RCOG CLASSIFICATION OF PERINEAL TEARS:
muscles, and first two layers of the rectum 2007
D. Perineal laceration wherein the entire layer of the
rectum is cut halfway • First degree: injury to perineal skin only
• Second degree: injury to perineum involving perineal
FACTORS CAUSING LACERATIONS muscles but not involving the anal sphincter
• Precipitate labor • Third degree: injury to perineum involving the anal
sphincter complex:
• Dystocia
o 3a: less than 50% of EAS thickness torn
• Malpresentation
o 3b: more than 50% of EAS thickness torn
• Large babies
o 3c: both EAS and IAS torn
• Instrumentation
• Fourth degree: injury to perineum involving the anal
• Lithotomy position
sphincter complex (EAS and IAS) and anal epithelium
• Rapid cervical dilatation
• Primigravida * EAS – external anal sphincter; IAS – internal anal sphincter

LACERATIONS

Vaginal

• Anterior
• Posterior
• Lateral wall
Perineal

• 1st degree – skin

• 2nd degree – muscles
• 3rd degree – external anal sphincter
• 4th degree – rectal sphincter and rectal mucus membrane
Cervical

• Lateral
Fig. 7 Degree of Lacerations

PERINEAL TEARS
First Degree SURGICAL MANAGEMENT OF LACERATIONS

• Involve the fourchette, • Surgical Repair

perineal skin, and vaginal o Episiorraphaphy
mucous membrane but not • Local Anesthesia
the underlying fascia and o Lidocaine
muscle • Regional Anesthesia
• These includes periurethral o Saddle block (sa
lacerations may hips)

Fig. 8 First Degree

Perineal Tear
Second Degree

• Involve, in addition, the

fascia and muscles of the
perineal body but not the
Fig. 11 Surgical Repair
sphincter. These tears
usually extend upward TECHNIQUE
on one or both sides of
the vagina, forming an • All tears that are bleeding should be identified and ligated
irregular triangular injury. separately.
• The stitching starts from the apex of the vaginal mucosa
using polyglactin stitch with continuous or interrupted
Fig. 9 Second Degree suture
Perineal Tear o Continuous interrupted suture – lock then cut,
lock, cut, lock, cut...
o Continuous suture – continuous pasok lang sa
Third Degree needle then hila
• The muscles are stitched using the same stitch taking full
• Extend further to the anal sphincter thickness of the muscle and achieving hemostasis
Fourth Degree • The skin is stitched with interrupted sutures

• Extends through the rectum’s mucosa to expose its

lumen

Fig. 10 Third and Fourth Degree Perineal Tear

SIGNS AND SYMPTOMS OF LACERATIONS

• Firm and contracted uterus Fig. 12 & 13 Techniques on Surgical Repair

• Bright red bleeding from the arteries
• Tear in the birth canal and perineum

GOAL OF MANAGEMENT FOR LACERATIONS

Fig. 12 Surgical Repair Techniques
• Surgical repair
o 1st needle – round needle (muscles and tissues);
2nd needle: cutting needle (skin)
• Cessation of bleeding - ligation
• Prevent infection
o Pernieal care, change pads, antibiotics
• Alleviate pain
o Analgesics: mefenamic acid
 ✓ Frequent change of gowns and perineal pads
✓ Proper nutrition
✓ Increase OFI
✓ Prophylactic antibiotic as ordered

HEMATOMA

Postpartum Hematoma

• Localized collections of blood in loose connective tissue

beneath the skin covering external genitalia, beneath the
vaginal mucosa, or in the broad ligaments
• Usually occurs without laceration of the overlying tissue

Fig. 13 Surgical Repair VAGINAL HEMATOMA

• Vaginal or paravaginal hematomas

arise from damage to the descending
branch of the uterine artery
• The haematoma is confined to the
paravaginal tissues in the space
bounded inferiorly by the pelvic
diaphragm and superiorly by the
cardinal ligament

Fig. 16 Vaginal
Hematoma
Fig. 14 Surgical Repair
• Rectal pain, vague lower abdominal pain but hematoma
NURSING CARE: MEDICAL MANAGEMENT will not be obvious externally but can be diagnosed by
vaginal examination
• Vaginal Pack: compress the site of lacerations. Must be
• The mass often occludes the vaginal canal and extends
removed after 2 hours and/or before transfer to the
into the ischiorectal fossa
room/ward
o Roll ang OS then ipasok sa vagina
o Napkin gamit sa lying-in
FACTORS CAUSING HEMATOMA
o Remove to prevent infection
• Analgesics: Mefenamic Acid • Rapid spontaneous birth
• Varicosities
• Episiorrhaphy
• Lacerations

SIGNS AND SYMPTOMS OF HEMATOMA

1. Severe perineal swelling

2. Pain not relieved by
analgesia
3. Bluish bulging under the
skin
4. Tenderness
5. Firm to palpate
6. Minor bleeding Fig. 17 Vaginal
Hematoma s/s
Fig. 15 Intra and Post-Operative Conditions of Laceration
MANAGEMENT OF HEMATOMAS
NURSING DIAGNOSIS
Medical Management
• Alteration in Comfort: Pain r/t
✓ Cold compress on the perineum • Analgesics: pain reliever
✓ Perineal douche • Cold compress: vasoconstriction, reduce swelling
✓ High-fiber diet formation
✓ Increase OFI Surgical Management
✓ NSAIDS as ordered
✓ Sitz bath • Incision and drainage: cut and drain the blood on the
• Risks for Infection r/t site of the hematoma
✓ Perineal douche • Removal of sutures, re-suturing
✓ Pat dry the perineum • Vaginal Packing: compress blood to prevent bleeding
• Ligation of Vessels: closing of open arteries/veins
NURSING DIAGNOSIS AND INTERVENTIONS
• Alteration in Comfort; Pain r/t
✓ Proper referral
✓ Ice pack application on the perineum
✓ Analgesics as ordered
✓ Assis for surgical intervention
UTERINE RUPTURE
• AN EMERGENCY COMPLICATION
• Uterine rupture is an emergency pregnancy complication
in which the uterus tears, potentially expelling the unborn
baby into the mother’s abdomen
• It can cause severe blood loss, hypoxic-ischemic
encephalopathy (HIE), and other birth injuries
Complete
• Involves endometrium, myometrium, and perimetrium
• Concealed bleeding
• Change in abdominal contour
FACTORS CAUSING UTERINE RUPTURE
• Difficult vaginal delivery
• Weak uterine operative site
• Vertical uterine scar from previous CS
• Faulty presentation
• Multiple gestation
• Traumatic maneuvers using instruments for delivery
• Injudicious use of oxytoxic agents
• Obstructed labor
GOAL OF MANAGEMENT OF UTERINE RUPTURE
• Repair of tear or laceration
• Prevent hemorrhage
• Prevent hypovolemic shock
• Prevent infection
• Prevent death

Incomplete
MEDICAL MANAGEMENT OF UTERINE RUPTURE
• Intact perimetrium
• Intravenous fluid
• Blood transfusion
• Antibiotics: Amoxcilline
• Oxytoxics: Oxytocin, Methergin

SURGICAL MANAGEMENT OF UTERINE RUPTURE

• Laparotomy
• Tubal ligation
• Hysterectomy

Fig. 19 Uterine Rupture

Fig. 17 Uterine Rupture Posterior and Anterior View NURSING DIAGNOSIS AND INTERVENTIONS

Nursing Diagnosis

• Fluid Volume Deficit r/t

• Decrease Cardiac Output r/t
• Altered Tissue Perfusion r/t
Interventions:

✓ Monitor VS every 15 mins

✓ Evaluate blood loss
✓ IVF and BT
✓ Administer oxygen as ordered

Nursing Diagnosis
Fig. 18 Uterine Rupture
• Dysfunction Grieving
SIGNS AND SYMPTOMS OF UTERINE RUPTURE
• Anxiety
• Localized abdominal pain • Fear
• Abdominal tenderness Interventions
• Tearing feeling
• Hypovolemic shock ✓ Obtain consent for surgery
 ✓ Give factual information • Prevent infection
✓ Explain procedures • Prevent death
✓ Do not give reassurances
MEDICAL MANAGEMENT
✓ Emotional support
Initially
UTERINE INVERSION
• Tocolytic: Duvadilan – relaxes uterus to perform
Johnson’s Manuever
• General anesthesia
• Nitroglycerin patch: potent vasodilator
Later: When Uterus is Back in Place

• Oxytoxic agents: oxytocin

• Double intravenous fluid
• Oxygen administration
• Ready for CPR
• Antibiotics
• Blood transfusion

Fig. 20 Uterine Inversion

SIGNS AND SYMPTOMS

• Visualization of protruded uterus

• Sudden gush of large amount of blood
• Hypovolemic shock after 10 minutes

Fig. 23 Johnson’s Maneuver

SURGICAL MANAGEMENT

• Johnson’s Maneuver
• Surgical Replacement
• Hysterectomy
• Laparotomy
• General Anesthesia

Fig. 21 Degrees of Inversion

Fig. 24 Johnson’s
Maneuver
NURSING DIAGNOSIS AND INTERVENTIONS

Nursing Diagnosis

• Fluid Volume Deficit r/t

Fig. 22 Uterine Inversion
FACTORS CAUSING UTERINE INVERSION
• Pulling the umbilical cord before placental separation
• Extreme pushing of the fundus
• Fundal implantation of the placenta
GOAL OF CARE OF UTERINE INVERSION
• Prevent Hemorrhage
• Johnson’s maneuver
• Prevent shock
• Altered Cardiac Output r/t
• Altered Tissue Perfusion r/t
Interventions:
✓ Determine the degree of inversion
✓ Assess VS, NVS, CRT
✓ Evaluate blood loss
✓ Use large needle/cannula for IVF
✓ Regulate IVF and BT as ordered
✓ Administer oxygen by face mask
• Anxiety r/t
✓ Emotional support
 ✓ Stay with the client
✓ Listen
✓ Give factual information
• Risk for Infection r/t
✓ Aseptic technique
✓ Perineal care
✓ Sitz bath
✓ Administer prophylactic antibiotics

RETAINED PLACENTA

• Definition: Failure of placental delivery within 30 minutes Fig. 25 Postpartum Hemorrhage

after delivery of the foetus
FACTORS CAUSING RETAINED PLACENTAL
• Incidence 1%
FRAGMENTS
• A major cause of PPH
• 3.3% of all deliveries • Failure to inspect after placental
• Placenta separates in fragments delivery
• Can be life-threatening o Parang SOP na after placental
o one cause of mortality and morbidity among delivery ang D&C. Failure to
women which causes PPH inspect means wala gi D&C
• Involves manual removal vs D&C • Placenta accreta
• Neuraxial vs General Anesthesia
• Uterine relaxation may be requested

CAUSES OF RETAINED PLACENTA
• Placenta separated but not expelled: the placenta may
separate completely from the uterine muscle but may still
be retained within the uterus. There are three causes for
this retention:
o Failure of the woman to push out the placenta due
to exhaustion of prolonged labor
o Closure of the cervix preventing the placenta from
being expelled
o A constriction ring in the uterus can hold up the
placenta
Fig. 26 Abnormal
Placental Attachments
Additional Notes:
✓ Placenta accreta – attachment of the chorionic villi
(placenta root) to the endometrial lining
✓ Placenta increta – involving the myometrium
✓ Placenta percreta – involves the entire layer of the
uterus + surrounding organs

RETAINED PLACENTA

Causes

• Partial separation of normal placenta

• Entrapment of the partially or completely separated
placenta by uterine constriction ring
• Mismanagement of the 3rd stage of labor
• Abnormal adherence of the entire placenta or a portion of
placenta to the uterine wall
Types

• Nonadherent retained placenta

• Adherent retained placenta Fig. 27 Abnormal Placental Attachments

CLASSIFICATION OF ABNORMAL PLACENTAL

SIGNS AND SYMPTOMS
ATTACHMENTS
• Incomplete placental delivery
HISTOPATHOLOGICAL
• Uterus remains large DIAGNOSIS
FEATURES
• Bright red vaginal bleeding
Placenta adheres to myometrium
• +hCG in the blood Placenta accreta
with no intervening decidua
o Since placenta releasea hCG
Placenta is within (surrounded by)
• +ultrasound result Placenta increta
the myometrium
Placental tissue is extrauterine or
Placenta percreta
on the uterine serosa
 NORMAL PLACENTA VS. PLACENTA ACCRETA
SPECTRUM (PAS)

Normal Pregnancy

• The placenta attaches to a temporary

layer in the uterus that’s shed at
Fig. 32 Normal Placenta vs. Placenta Accreta Spectrum (PAS)
delivery

Fig. 28 Normal
Placental Attachment
Placenta accreta

• When the placenta attaches too

deeply into the uterine wall

Fig. 33 Placenta Accreta

Fig. 29 Placenta
Placenta increta accreta

• When the placenta attaches into the

uterine muscle, sometimes invading
surrounding organs like the bladder
and intestine

Fig. 30 Placenta
Placenta percreta increta
Fig. 34 Adherent Placenta
• When the placenta goes completely
through the uterine wall, sometimes
invading nearby organs like the
bladder

Fig. 31 Placenta
percreta

Fig. 35 USD of Placenta

 • Minimize blood loss (fundal massage, give meds)
• Stabilize status (IV line, meds, surgery prep)

COMPLICATIONS OF RETAINED PLACENTA

• Shock
• Postpartum hemorrhage
• Puerperal sepsis
• Subinvolution
• Hysterectomy

SURGICAL MANAGEMENT FOR RETAINED

Fig. 36 Normal Placenta
MANAGEMENT OF RETAINED PLACENTA
• Dilatation and Curettage
o Most common
• Oxytocin administration
• Methylergonovine maleate:
intrasmuscular
• Methotrexate
o Dissolve fragments
• IVF: Hydration
• Brandt Andrew’s Maneuver
• Crede’s Maneuver
• Manual Evacuation
o Kamay gamitin as curette
• Placenta Delivery Time: 30 mins
PLACENTA
• Dilation and curettage
• Hysterectomy
NURSING DIAGNOSIS AND MANAGEMENT
• Fluid Volume Deficit r/t • Hydration: IVF & BT
• Oxygen administration
• Decreased Cardiac Output r/t
• Fundal massage
• Altered Tissue Perfusion r/t
• Oxytocin
• Risk for Infection r/t
✓ Antibiotics
✓ Perineal care
Fig. 37 Brandt ✓ Changing of diapers
Andrew’s Maneuver
• Anxiety r/t
✓ Emotional support
SUBINVOLUTION OF UTERUS

MANAGEMENT • Is the failure of the uterus to return to a nonpregnant state.

• The most common causes of subinvolution are retained
If the placenta is undelivered after 30 minutes consider: placental fragments and infection

• Emptying the bladder

• Breastfeeding or nipple stimulation
• Change of position – encourage an upright position
If bleeding, immediately:

• Inform anesthetist
• Insertion of large bore IV (18g) cannula
• Insert urinary catheter
• Commence/continue oxytocin infusion 20 units in 1L / rate
– 60drops per min Fig. 38 Subinvolution of Uterus
• Measure and accurately record blood loss
• Prepare and transfer patient to theatre for manual
removal of placenta (MROP)
MEDICAL MANAGEMENT

• IV Oxytocin infusion; methergine, ergotrate;

prostaglandin
o Stimulate uterine contraction
• Blood work (clotting time, platelet count, fibrinogen level,
Hgb, Hct, CBC)
o Fibrinogen level – since fibrin is responsible sa
pag clot ng dugo
o Include APTT
• Type and cross match for blood replacement Fig. 39 Subinvolution of Uterus USD
• Surgical (repair lacerations; evacuation, ligation of FACTORS CAUSING UTERINE SUBINVOLUTION
hematome; curettage – retained placenta)
• Retained placental fragments
• Uterine myoma
NURSING INTERVENTIONS • Endometritis
 PREDISPOSING FACTORS circulation and ischemic organ damage. Clots use up all
the coagulation factors and platelets, resulting in bleeding
• Grand multiparity tendencies
• Overdistention of uterus as in twins and hydramnios • Fibrinolytic phase: Fibrinolysis (breakdown of fibrin) of
(polyhydramnios) the thrombi occur. The fibrin degradation products
• Maternal ill health suppress thrombin and have an anti-hemostatic effect,
• Caesarean section aggravating bleeding.
• Prolapse of the uterus
• Retroversion after the uterus become pelvic organ
• Uterine fibroid

SIGNS AND SYMPTOMS

Trigger Increased Clotting
• Uterus remains large
• Profused lochial flow
• Altered pattern of lochia Consumption Increased consumption
• Prolonged lochial flow of platelets of clotting factors
• Profuse vaginal bleeding
• Large flabby uterus
Lead to

MANAGEMENT Thrombus formation at the site

of injury + in Microcirculation
Medical Management

• Oxytocin
• Methylergonovine maleate Hemorrhagic syndrome
• IVF: hydration, BT
Called
Surgical Management
DIC
• Hysterectomy
Additional Notes:
NURSING CARE
✓ Thrombus formation at the site of injury +
• Massage the fundus microcirculation – clot formation sa cervix, uterus,
• Put ice pack over the fundus vaginal area, perineum pero mag clot din sa
o Prevent vasoconstriction therefore stimulating systemic circulation that’s why effect ng DIC is
vascular contraction whole body naga clot
• Teach client on nipple stimulation
• Encourage breastfeeding: stimulate release of oxytocin
FACTORS CAUSING DIC
• Monitor for lochial flow
• Measure for vaginal bleeding • PIH
• Regulate IVF with Oxytocin o Promotes microcoagulation causing thrombus
• Monitor I&O formation and thus DIC
• Abruption Placenta
NURSING DIAGNOSIS AND MANAGEMENT • Incomplete Placenta
• Septic Abortion
• Fluid Volume Deficit r/t
• Prolonged retention of dead fetus
• Decrease Cardiac Output r/t
• Amniotic fluid embolism
• Altered Tissue Perfusion r/t
• Hypertonic labor
• Hyperthermia r/t
• Sepsis
• Anxiety r/t
• Fear r/t OTHER CAUSES OF DIC
DISSEMINATED INTRAVASCULAR COAGULATION Hemolysis
(DIC)
• Hemolytic transfusion reaction
• Sometimes a complication of PIH or any bleeding • Massive transfusions
disorders • Malaria
• Systemic effect • Other severe hemolysis
• Pathological activation of clotting in response to
septicemia, cancers, obstetric (e.g. retained dead Malignant Disorders
fetus, amniotic fluid embolism)
• Metastatic malignancy
• Thrombotic phase: Numerous small thrombi and emboli
• Tumors producing cancer procoagulant
form throughout the microvasculature causing block of
• Tumor with tissue necrosis (usually breast cancer)
Vascular Abnormalities Additional Notes:

✓ Once calcium phosphate and blood comes in

• Giant hemangioma
contact, mag form sila ng thrombus formation.
• Hereditary teleangiectasis
Thrombus formation destroy clotting factors and
• Prosthetic devices
platelet. Since thrombus has destroyed the clotting
• Aortic balloon assist devices
factors (13 kabuok) and platelet, wala nay mag hold
• Denver shunts ng bleeding
Other Conditions

• Pancreatitis
• Acute liver necrosis
• Transplant rejection PATHOPHYSIOLOGY OF DIC
• Heat stroke
Precipitating event

Tissue factor/extrinsic pathway activation

Coagulation cascade

Conversion of
Excess thrombin
plasminogen to plasmin
Microvascular
clotting
Microvascular
clotting
Fig. 40 DIC Causes
Thrombocytopenia Consumption of Excess thrombin
clotting factors

Excess Clotting Excess Clotting

Ischemia Shock
Impaired organ perfusion Hypotension
End-organ damage Increased vascular
permeability

Additional Notes:

✓ Once mag form ng microvascular clotting, masira

ang platelet, resulting in thrombocytopenia
(decrease level of platelet)
✓ Excess clotting - RBC are utilized sa clotting,
resulting in decreased oxygenation process

SIGNS AND SYMPTOMS

The symptoms of disseminated intravascular coagulation

(DIC) are often those of the underlying inciting condition

1. Bleeding
o Bleeding on mucous membrane, GI & GU tracts,
and all other orifices (all other exit sites)
Fig. 41 DIC o Petechiae and ecchymosis
o Intravenous (IV) lines and catheters bleed
o Venipuncture sites, surgical sites, drains, and
tracheostomies and within serous cavities
2. Renal Failure
o Blood loss = decreased oxygen to organs, or in
this case the kidneys = renal failure
3. Pulmonary Involvement D. Hemorrhage
o Dyspnea, Hemoptysis, Diaphoresis o Blood escapes through ruptured vessel
4. Jaundice o Insufficient clotting agent available to control
bleeding
Other Signs and Symptoms

• Cold, mottled digits

• Purpura on the chest and abdomen LABORATORY FINDINGS

• Decrease platelet counts

• Decrease fibrinogen
• Increase PT (INR)
o Prothrombin
• Increase PTT
• Increase D-dimer
• Peripheral smear – present schistocytes, helmet cells
Fig. 42 DIC Skin
GOAL OF MANAGEMENT OF DIC
SYMPTOMS
• Treat underlying conditions
Circulatory Signs Include the Following: o OB – D&C, management of PIH
• Stop clotting
1. Signs of spontaneous and life-threatening hemorrhage
• Restore normal clotting functions
2. Signs of subacute bleeding
3. Signs of diffuse or localized thrombosis
4. Bleeding into serous cavities MEDICAL MANAGEMENT OF DIC

Central Nervous System Signs Include the Following: • Heparin: anticoagulant – prevents formation of blood
clots
1. Nonspecific altered consciousness or stupor • Blood transfusion for blood replacement
2. Transient focal or neurologic deficits o Hemoglobin of 8 or 9 = subject to BT
• Fresh frozen plasma transfusion for plasma
Cardiovascular Signs Include the Following:
replacement
1. Hypotension • Platelet transfusion for platelet replacement
2. Tachycardia
3. Circulatory collapse DIC MANAGEMENT
Respiratory Signs Include the Following: • Treatment of underlying cause
• Fluid replacement
1. Pleural friction rub
• Blood products
2. Signs of acute respiratory distress syndrome (ARDS)
o FFP
o Platelets
o PRBCs
• Management of clotting
o Plasmapheresis
o Heparin
• Management of bleeding
o Aminocaproic acid (promote coagulation)
o Antithrombin III (prevent bleeding)

NURSING DIAGNOSIS AND INTERVENTIONS

• Actual/Risk for Fluid Volume Deficit r/t

✓ Frequent monitoring
✓ Evaluate blood loss
✓ Gentle handling of patient
Fig. 43 DIC ✓ Frequent turning to sides
A. Normal Anatomy ✓ Gentle mouth care – use soft bristled toothbrush
o red blood cells and clotting agents flow freely in the
blood stream without active clotting
B. Initial Intravascular Coagulation
o During pregnancy, coagulation can be initiated
spontaneously
C. Advanced Intravascular Coagulation
o The extensive coagulation throughout the blood
depletes supply of free flowing clotting agents
 POSTPARTUM INFECTION • Positive in 75% of histologically confirmed CE
• Common bacteria:
o Escherichia coli, Enterococcus faecalis
OUTLINE
o Streptococcus agalactiae: 77.5%
I. Postpartum Infection o Mycoplasmae/Ureaplasma: 25%
II. Endometritis o Chlamydia: 13%
III. Infection of the Perineum • Often a casual organism cannot be identified
IV. Peritonitis • CE have no correlation with
V. Mastitis o Bacterial colonization of the EM
VI. Thrombophlebitis o Clinical presentation of PID

POSTPARTUM INFECTION

• Infection of the genital tract during postpartum

TYPES OF INFECTION

• Infection of the perineum

• Endometritis
o If infection of the perinuem ascends to the
endometrium Fig. 4 Endometritis
• Peritonitis
o If bacteria from endometritis goes to systemic Additional Notes:
circulation then to the peritoneal cavity
• Mastitis ✓ If you have inflammatory response, it doesn’t
necessarily mean that you have infection but you
Additional Notes: can never have infection without undergoing
through the inflammatory response
✓ 5 inflammatory response: redness, warm, edema,
pain, loss of function
SIGNS AND SYMPTOMS

ENDOMETRITIS • Fever for 2 consecutive 24 hours usually on the 3rd or 4th

day excluding the first 24hrs postpatum
• Inflammation and infection of the endometrium • Chills
• Bacteria may gane access from the vagina into the uterus • Loss of appetite
maybe during delivery process
• General malaise
• Abdominal tenderness
• Uterine atony
• Strong after pains (murag gina kumot)
• Dark brown foul smelling lochia

Fig. 1 Endometritis

Fig. 5 Microscopic Transvaginal Result of Endometritis

MANAGEMENT
Fig. 2 Endometritis
• Antibiotics: Amoxicillin
• Oxytoxic: Oxytocin, Methergin
• Analgesics: Mefenamic Acid
• Antipyretics: Paracetamol

INFECTION OF THE PERINEUM

• Very rare because of improved aseptic technique

Fig. 3 Endometritis vs Normal Endometrium • Occurs at the suture line or repair of lacerations

CULTURE SIGNS AND SYMPTOMS

• Pain on the perineum
Etiology
• Swelling
• Heat • Staphylococcus
• Pressure on the perineum • Streptococcus
• One or two stitches slough off • Escherichia
• Purulent discharges from suture line
• May be afebrile unless systemic

MANAGEMENT

• Systemic (IVTT) or topical antibiotics

• Analgesics: Mefenamic Acid, Ibuprofen, Tramadol
(stronger analgesic)
• Hot sitz bath
• Warm compress
• Perineal sutures may be removed to allow drainage
• Packing with gauge
Fig. 6 Engorged Breasts
PERITONITIS

• An infection of the peritoneal cavity

• Usually an extension of endometritis
• Gravest postpartum complications
• Common cause of mortality death from puerperal
infection

SIGNS AND SYMPTOMS

• Rigid abdomen with guarding behavior

• Abdominal pain
• High fever
• Rapid pulse Fig. 7 Mastitis
• Vomiting
o Increasing pressure in the peritoneal cavity
• Appearance of acutely ill

BREAST ENGORGEMENT

Causes
MANAGEMENT
• Delayed or infrequent feeding
• Right dosage of antibiotics
• Improper latching and positioning
• NGT to relieve vomiting and rest the bowel
• Engorged breast: swollen, hard, warm and painful
• IVF
• Parenteral feeding (ex. Kaviben) Prevention
• Analgesics
• Antipyretics • Early and frequent feeds
• Correct attachment
MASTITIS Treatment

• Infection of the breast tissues • Warm water packs, breast massage, analgesics
• Occurs as early as 7 days postpartum or not until the baby • Milk expressed to soften breast
is weeks or months of age
• Breastfeeding and lactation are the most likely causes of SIGNS AND SYMPTOMS
mastitis
• Localized pain and swelling
• Breastfeeding places stress on the nipple and
• Fever
surrounding breast tissues, which often results in small
cracks. • Body malaise
• Rapid pulse
• Bacteria from the baby’s mouth or the mother’s skin may
enter these abrasion and infect breast tissue • Scanty breast milk
o Nag narrow and duct since inflamed ang breast so
• The nipples on an engorged breast are flat or inverted.
Sometimes it may lead to striae on nipples, mainly hindi makalabas ng maayos ang milk
preceding symptoms of septation mastitis
• Note for: cracked nipples, clogged ducts, bruises on the
breasts
 Additional Notes:
✓ The main symptoms of mastitis are: breast pain,
swelling, redness, fever, enlargement, changed
nipple sensation, discharge, itching, tenderness,
and/or breast lump
o Soup with malunggay
• Alternate breast for breastfeeding
• Administer antibiotics as ordered
• Administer anti-inflammatory meds
• Administer analgesics
NURSING DIAGNOSIS AND INTERVENTIONS

• Actual/potential for infection r/t

✓ Antibiotics, breast care, wet cloth
• Hyperthermia r/t
✓ TSB, increase OFI, comfort measure
• Acute pain r/t
✓ Breast massage, cold compress, analgesics
• Social isolation r/t
✓ Encourage client to verbalize feelings
• Fear r/t
✓ Tell client inflammation will subside with antibiotics
• Ineffective breastfeeding r/t
Fig. 8 Signs and Symptoms of Mastitis THROMBOPHLEBITIS
COMPLICATIONS: BREAST ABSCESS • An inflammatory condition of the veins leading to
formation of blood clot and blocking of one or more veins
Causes
• Inflammation of the lining of the vessel in which a clot
• Engorged breast attaches to the vessel wall
• Cracked nipple • A condition in which a clot forms in a vessel wall as a
• Untreated mastitis result if the inflammation of the vessel wall
• A partial obstruction of the vessel can occur
Clinical Features
• Increased blood clotting factors in the postpartum period
• high grade fever, raised blood count place the client at risk
• May not appear until 10-20 days after delivery
Treatment
• Most common is on the leg (calf) and femoral vein
• analgesics, antibiotics Types
• incision and drainage
• Superficial Thrombophlebitis
MANAGEMENT • Femoral Thrombophlebitis
• Pelvic Thrombophlebitis
Medical Management

• Broad spectrum antibiotics: Dicloxicillin, Cefalexin,

Clindamycin
Fig. 9 Thrombophlebitis
• Analgesics: Mefenamic acid
• Antipyretics: paracetamol;
• Warm compress
Surgical Management

• Incision & Drainage: drains puss, discharges

NURSING CARE

• Assess for color, swelling, discharges from the breast

• DO NOT STOP BREASTFEEDING: EMPTY THE
BREAST
• Wear supportive bra with wire
• Wipe breast with wet cloth
• Cold compress
• Do not touch or scratch the site Fig. 10 Thrombophlebitis
o To prevent further damage
• Continue breastfeeding the baby
• Pump the breast if necessary
• Encourage to eat green leafy vegetables
• Increase oral fluid intake
• Increase intake of soup
 Compression of large vessels
of legs and pelvis

Dilatation of veins

Fig. 11 Thrombophlebitis Pooling of blood

THREE MAJOR CAUSES

• Venous stasis Inflammation of veins

o Hindi naga exercise or less movement ang patient
so there is pooling of blood on the lower
extremities
Thrombus Formation
• Hypercoagulability
o Fast formation of platelet coagulation
• Damage of the intima of the blood vessels

OTHER FACTORS

• Varicosities
o Patient has varicose before delivery
o Pwede mag lodge ang thrombus which can cause
swelling
Decrease fibrinolytic factors
• Obesity Thromboxane (plasminogen & antithrombin)
o Slow venous return
• History of thrombophlebitis
• Oral contraceptives Elevate coagulation
• Age > 35 years old factors
• Multiparity
• Diabetes mellitus
o Slow blood flow Thrombus Formation
• Smoking

Additional Notes:

✓ Once veins are dilated, there would be a bigger

pathway for blood = pooling of blood

CLASSIFICATIONS OF THROMBOPHLEBITIS
ACCORDING TO DEPTH

A. Superficial Venous Thrombosis

o Limited to the calf only
o Swelling of extremity, redness, tenderness, and
warm, pain while walking
o Most common during pregnancy
B. Deep Vein Thrombosis
o Often absent or diffused signs
Fig. 12 Thrombophlebitis o Swelling, erythema, edema, heat, tenderness
o Phlegmasia
Additional Notes:
CLASSIFICATIONS OF THROMBOPHLEBITIS
✓ Embolus – when a portion of a clot formation in vein
ACCORDING TO LOCATION
dislodges; travelling thrombus
✓ Thrombus – localized clot in the vein A. Femoral
o Fever, chills, pain redness
o Swelling of extremities
PATHOPHYSIOLOGY
o White-stretched skin
o + Homan’s sign
B. Pelvic
 o Ovarian, uterine, hypogastric pain
o High fever
o Chills
o Body malaise
SIGNS AND SYMPTOMS
• Warmth, tenderness, fever and pain in the affected area
• Redness and swelling
• Superficial veins may be hard, swollen, and the person
may have fever
o Tender and cordlike vein
• Sluggish flow rate
• Edema in the limbs
• Site warm to touch
• Visible red line above venipuncture site
• Diminished arterial pulses
• Mottling and cyanosis of the extremities
o If thrombus has totally blocked the blood vessels,
the distal portion of the leg has decreased oxygen
Fig. 13 Thrombophlebitis & Homan’s Sign
MANAGEMENT
• Anticoagulant (Heparin, Warfarin)
• Thrombolytic (Streptokinase, Urokinase)
o Will breakdown the clots
• Analgesics (except aspirin)
o Aspirin: Acetylsalicylic acid (chemical component)
– has bleeding tendencies effect
• Laparotomy – locate and incise to remove affected veins
• Monitoring of prothrombin time
• Anti-Embolic Stockings: prevents clot formation
TREATMENT
1. Medications: the doctor will inject the patient with
heparin and then administer Coumadin for several
months to prevent clots. The doctor may also prescribe
medications that will break up the clots at home
2. Support Stockings: support stocking are to help prevent
recurrent swelling and will reduce the chance of
complications associated with thrombophlebitis. These
stockings also come in prescription strength
3. Filters: filters may be placed in the vena cava and will
prevent clots that can break loose in the legs and travel
to the lungs
o Help reduce formation of embolus that can cause
respiratory embolism
4. Varicose Vein Stripping: the doctor may surgically
remove varicose veins that cause pain or recurrent
thrombophlebitis. This procedure is done on an outpatient
basis and involves removing a long vein through several
small incisions. This procedure is routinely done for
cosmetic reasons and recovery is usually a couple of
weeks depending on the health of the individual
5. Clot Removal or Bypass: sometimes surgery is the last
resort. Doctors may bypass the affected vein or they may
do nonsurgical procedure called angioplasty to open up
the vein. In this procedure, the doctor will place a small
wire mesh tube to keep the vein open. This is a similar
procedure as placing a stint in a heart attack patient
NURSING CARE
• Bed rest with leg elevated
• Change position frequently, not flexed knees
• Teach not to rub area
• Daily measurements of calf and thigh
• Support stockings, moist heat application
• Assess for complication: embolism, S&S of pulmonary
embolism (dyspnea, increase RR, hyperventilation, and
bluish lips, palm, digits, fingernails )
HOW TO PREVENT THROMBOPHLEBITIS
• Avoid wearing constricting clothing
• Rest while feet elevated
• Ambulate daily during pregnancy
• Limit woman in lithotomy position
o can impede venous flow
• Aseptic technique in invasive procedures
• If with varicose veins, wear support stockings first 2
weeks postpartum
• Avoid in 1 position for long period of time
• Avoid leg crossing
• Increase oral fluid intake
o Replenish blood flow
• Early ambulation after pregnancy
• If cannot ambulate, PROM exercises
o Passive Range of Motion (PROM) – leg up, leg
down
• Avoid pillows under the knees
• Don’t smoke
NURSING DIAGNOSIS AND INTERVENTIONS
• Alteration in Comfort; pain r/t
✓ Rest
✓ Elevate legs
✓ Anti-embolic stockings
✓ Avoid standing for long period of time
✓ Moist heat application
✓ DO NOT MASSAGE
• Altered Tissue Perfusion r/t
✓ Constantly check the skin
✓ Passive range of motion exercise
✓ Prevent skin ulcerations
✓ Proper nutrition
✓ Avoid gatch (flexion of leg) or pillow under the
knee
• Risk for Injury (bleeding) r/t
✓ Obtain baseline coagulation
 ✓ Avoid IM injection of other drugs
✓ Rotate injection site
✓ Inject heparin subcutaneously, do not massage
✓ Prepare Protamine Sulfate (antidote of heparin)
✓ Prepare vitamin K (antidote of Warfarin)

Additional Notes:

✓ Massage would dislodge thrombus, creating an

embolus. Embolus would travel to the lungs,
causing pulmonary embolism which will cause
respiratory distress = respiratory arrest = death
 EMOTIONAL AND PSYCHOLOGICAL
MANAGEMENT OF POSTPARTUM BLUES
POSTPARTUM COMPLICATIONS
• Allow woman to talk and cry
OUTLINE • Work through their feelings
o Try asking the client how she feels and encourage
I. Emotional Phases of Postpartum verbalization of said feelings
II. Postpartum Blues • Encourage family support
III. Postpartum Depression
IV. Postpartum Psychosis Additional Notes:
V. Nursing Care of Postpartum Emotional
✓ If postpartum blues is not immediately assessed
Disturbances
and addressed, this could progress to postpartum
VI. Nursing Diagnosis and Management of depression
Postpartum Emotional Disturbances ✓ Postpartum blues is the adjustment period of the
mother after pregnancy, labor and delivery which is
EMOTIONAL PHASES OF POSTPARTUM very painful and exhausting

• Taking-in Phase POSTPARTUM DEPRESSION

o Mother only thinks of herself
• Taking-hold Phase • It is a mood disturbance characterized by feelings of
o Mother starts to communicate with others (ex. sadness, despair, apathy, and discouragement
partner, nurses) caused by loss in the person’s life (ex. abortion,
o Tries to interact (ex. touch) the baby miscarriage, FDIU, etc.) or by neurobiological imbalance
• Letting go Phase of neurotransmitters
o Mother is already able to do ADL o Dopamine – example of neurotransmitter
o Takes care of the newborn • It occurs 30 days to 6 months after birth
• Changes in behavior is apparent
POSTPARTUM BLUES
SIGNS AND SYMPTOMS
• It is a maternal adjusment reaction accompanied by
• Excessive crying
irritability, anxiety, and a mild, let-down feeling usually
• Feeling of inadequacy
occuring between the 2nd and 3rd postpartum day through • Low self-esteem
the 1st to 2nd postpartum week • Inability to cope
• Anorexia
SIGNS AND SYMPTOMS • Insomnia
• Psychosomatic symptoms
• Insomnia o Kung unsa gina isip sa patient kay ma manifest sa
• Depressed mood body
o Doesn’t like to talk or interact with others including o Ex. kakaisip na masakit ang ulo then nisakit jod
the partner Kakisip na masakit ang tiyan then nisakit jod
• Headache – since patient is unable to sleep • Depressive or manic mood fluctuation
• Poor concentration o Brought about by fluctuating neurotransmitters
o The ability to focus on a conversation is very o Example – serotonin, norepinephrine
limited. After a minutes muana ra ang patient if • Social withdrawal
pwede matulog na or mag rest FACTORS CAUSING POSTPARTUM DEPRESSION
• Tearfulness
• Confusion • History of depression
• Mood labile • Troubled childhood
o Fluctuating mood • Stress in the home or at work
• Lack of self-esteem
• Lack of support system

MANAGEMENT OF POSTPARTUM DEPRESSION

• Nurse-patient relationship
o Therapeutic relationship
FACTORS CAUSING POSTPARTUM BLUES o Stay with the patient, listen to their concerns, give
them feedback, etc.
• Sudden drop of hormones at about 72 hours postpartum
• Psychopharmacologic
o In relevance to HCG and HPL since the placenta
o Anti-depressive drugs
is already separated from the uterus
o Selective serotonin reuptake inhibitors (SSRI)–
serotonin problems with the neurotransmitters
• Disappointments of body changes
▪ Brand name: Citalopram
• Extreme disappointments of labor and birth
o Escitalopram Oxalate
• Inadequate emotional support from partner
▪ Brand name: Lexapro
• Extreme stress of mothering role o Zoloft – commonly heard
 ▪ Generic Name: Sertraline
• Milieu therapy
o Forceful manipulation of the environment
o Scheduled activity
o Ex. breakfast sa morning, 30 mins walking, then
rest for a while, read at least 2 pages, the lunch,
then sharing with lain mothers with postpartum
depression, then walking naman, so on
Additional Notes:
✓ If postpartum depression is not immediately
assessed and managed, this could progress to
postpartum psychosis
POSTPARTUM PSYCHOSIS
• It is a disrupted mental state in which an individual
struggles to distinguish the external world from his
internally generated perceptions
• The disorder may become apparent 20 to 3 weeks after
birth to as long as 6 to 12 months
• Much more worse than postpartum depression
FACTORS CAUSING POSTPARTUM PSYCHOSIS
• Major life crisis
• Previous mental illness
• Family history of mental illness
• Hormonal changes
SIGNS AND SYMPTOMS
• Psychotherapy and Milieu Therapy (for depression and
psychosis)
o Psychotherapy – emotional and mental support,
counselling
▪ Counselling, Psychologist, Psychiatrist,
Nurses
o Milieu Therapy – change the environment and
activities that is therapeutic in a way
• Observe for suicidal and infanticide thoughts
o Observe self-inflicting harm and wounds with
different rates of healing, particularly on the wrist
o Keep away from sharp objects or anything that
can be used to harm the patient and baby
• Suicidal precautions (Away from sharp objects)
o Raise the side rails, away from sharp objects, etc.
NURSING DIAGNOSIS AND MANAGEMENT OF
POSTPARTUM EMOTIONAL DISTURBANCES
• Risk for/Actual Ineffective Coping r/t
✓ Convey a caring attitude
✓ Acknowledge that the woman feels depressed
✓ Assure that it is not her fault
✓ Encourage support from family members
✓ Adequate rest and nutrition
• Self-Isolation r/t
• Anxiety r/t
• Sleep pattern disturbance r/t
• Altered sensory perceptions (Visual) (Hearing) r/t
• Imbalance nutrition less than body requirements r/t
• Altered parenting r/t

• Suicidal and infanticidal thoughts

• Dissociated
• Delusional
• Confused
• Distortion of reality

MANAGEMENT OF POSTPARTUM PSYCHOSIS

• Professional psychiatric counselling
o To thoroughly assess the patients mental
capacity, status and orientation
o Electroencephalogram (EEG) – checks the activity
of the patient’s brain
▪ If kailangan lang itest ang patient
• Antipsychotic drugs
• Hospitalization
• Woman must be observed during her interaction with the
child

NURSING CARE
• Use therapeutic technique of communication
• Stay with the client
• Listen attentively
• Allow client to verbalize feelings
• Re-orient client to reality
• Counselling
• Encourage support from partner and family
• Provide adequate nutrition
• Encourage rest
• Use non-judgmental response
 INFERTILITY
Tubal

OUTLINE • Scarring
o Mahirapan na maglabas ang egg due to the
I. Infertility scarring
II. Factors Causing Infertility • PID
III. Etiology • Endometriosis Will lead to scarring
IV. Diagnostic Studies Ovarian
V. Management of Infertility
VI. Role of the Nurse in Contraception and • Anovulation
Infertility o when an egg doesn't release from your ovary
VII. Management during your menstrual cycle (hindi naga
VIII. Nursing Care menstruate)
IX. Nursing Diagnosis • Oligo-ovulation
o Infrequent menstruation (ex. mag menstruate
INFERTILITY once every 6 months)
• Secretory
• Normally, 50% of recently married couples conceive o Hormonal
within 6 months and 35% conceive within 12 months
MALE INFERTILITY
• Infertility is the inability to conceive after at least 1 year of
sexual intercourse at leats 4 times a week without Congenital
contraception
• Absence of vas deferens and testes
Primary Infertility
Ejaculatory
• No previous history of conception
• Retrograde ejaculation
Secondary Infertility
o Pabalik ang ejaculation instead na palabas
• Inability to conceive after previous successful pregnancy Sperm Abnormalities
FACTORS CAUSING INFERTILITY • Oligospermia
o Low sperm production
• Not ovulating
• Aspermia
• Male infertility
o No sperm at all
• Age (menopause)
• Inadequate maturation
• Blocked fallopian tubes - egg and sperm aren’t able to
o Hindi naga mature ang sperm na pwede mag
meet due to the obstruction
conceive
• Endometriosis
• Inadequate motility
• Underlying medical problems (ex. diabetes) o Short or slow tail so by the time mag meet sila ng
ETIOLOGY egg, dead na ang egg
• Inability to deposit sperm into the vagina
FEMALE INFERTILITY • Blockage of sperm (ex. vas deferens obstruction)
Vaginal Problems Testicular

• Vaginal infections • Orchitis

• Anatomic abnormalities o Inflammation of the testes
• Sexual dysfunction • Cryptorchidism
o Vaginismus – vaginal lock; gina lock ang penis o Failure of one or both testes to descend from the
during sexual intercourse abdominal cavity to the scrotum
• Highly acidic vaginal environment o Should descend at 7 months AOG
o Since the sperm is alkaline by nature, they will die o Once na deliver na ang baby, ipalpate ng nurse to
when in contact with a highly acidic environment check if the testes has descended
o Surgical repair: ibaba ang testes from the
Cervical abdomen to the scrotum
• Trauma
• Changes during ovulation • Radiation
o Irregular menstruation
• Cervical incompetence Additional Notes:

Uterine ✓ Hypospadias – urethra is nasa bottom ng penis

✓ Epispadias - urethra is nasa taas ng penis
• Functional
o Hindi kumakapit ang baby sa uterine wall Coital
• Structural
o Nakatiklop or baliktad ang uterus • Obesity
 o In relevance to diabetes • Serum Progesterone Test
o Failure to have or achieve erection o Checks for the ability to hold a baby
• Nerve damage o Blood examination during luteal phase
o If there’s damage along the body of the penis, o Normal progesterone: 10mg/ml
there is decreased sensation due to the nerve ▪ If kulang, mahina ang hold ng baby so
damage = no erection malaglag
• Impotence • Endometrial Biopsy
o Can’t keep or get an erection o Histologic information about endometrial tissue
o Identify adequate secretory tissues
Drugs
• Hysterosalpingography
• Methotrexate o Visualization of uterus and fallopian tube
• Sex Hormone o Radiopaque due is inserted into the uterus
• Amebicides
o Radiograph is taken after 24 hours
Other Factors o Done before ovulation or after menses has ceased
o Usually takes place on during 5th to 7th day after
• STD (ex. syphilis) • Inadequate nutrition menstruation or 16th day after fertile period
• Stress • Alcohol and nicotine • Ultrasound Imaging
o decreases sperm activity o Determine patency of fallopian tube
o Determine the depth and consistency of uterine
lining
o Non-invasive and can be done during menses
• Hysteroscopy
o Visual inspection of the uterus
o Determine uterine adhesion and other
abnormalities (ex. myoma or cyst formation)
Other Tests
Fig. 1 Comparison between a Healthy and Abnormal Sperm
• Immunoassay of Semen and Female Serum
INTERACTIVE PROBLEMS o Determine antibody formation against partner’s
sperm
• Insufficient frequency of SI (sexual intercourse)
• Serum penetration assay
• Poor timing of intercourse
o Determine the ability of the sperm to penetrate the
o SI before or after the fertility period (14th day after
zona pellucida (outer layer of the egg)
menstruation)
o Dili mag abot since an egg’s lifespan is 24 hrs lang Additional Notes:
and ang is sperm 3 days
• Development of antibodies against partner’s sperm ✓ Isa lang dapat ang sperm na maka penetrate to
o Autoimmune problem produce conception. However in multiple gestation
o Sirain na agad ng antibodies ang sperm sa vaginal with separate bag of water and placenta, sabay nag
area before pa maka swimming sa cervix penetrate ang sperms at different routes
• Use of spermicidal lubricants
o Spermicidal – pangpatay ng sperm MANAGEMENT OF INFERTILITY
o A type of contraceptive
• Inability of the sperm to penetrate the egg MANAGEMENT OF UNDERLYING PROBLEMS
o Either hindi talaga maka penetrate or the egg • Douche with alkaline solution 30 minutes before
rejected the sperm intercourse to reduce acidity of vaginal area
• Remove environmental hazards
DIAGNOSTIC STUDIES • Surgery
• Semen Analysis • Medication
o Check sperm count and its consistency (ex. 1st o If caused by infection: Antibiotics
test low, 2nd test low = possible infertile) o If hormonal imbalance
o After 48-72 hours of abstinence ▪ Male: Testosterone
o Serial analysis 74 days apart ▪ Female: Estrogen
• Cervical Mucous Assessment • Sexual therapy
o Fern test o Calendar method
o Spinnbarkeit Test
• Postcoital Test ASSISTED REPRODUCTIVE TECHNIQUES
o SI at presumed ovulatory state ARTIFICIAL INSEMINATION
o Check cervical mucus after 48 hours abstinence
• Basal Body Recording • Is the deliberate introduction of sperm into a female’s
o Oral temp when awakening cervix or uterine cavity for the purpose of achieving
o Increase temp 12-14 days before menses - pregnancy
ovulation • Gina consider ang fertile period ng woman and then diyan
pa iinject if fertile na
 Fig. 2 Artificial Insemination
Fig. 3 Artificial Insemination
IN VITRO FERTILIZATION (IVF)
• In vitro fertilization is a process of fertilization where an
egg is combined with sperm outside of the body
• Collect then freeze the healthy sperm and egg then
combined outside the body, usually in a petri dish
Fig. 4 In vitro Fertilization
Fig. 5 Process of In vitro Fertilization
Fig. 6 Stages of In vitro Fertilization
Additional Notes:
✓ Ovarian stimulation hormone therapy – mag
schedule ng ripening of egg then harvesting of egg
(egg pick up)
✓ Sperm preparation – picking the healthiest, strong,
good quality sperm
GAMETE INTRAFALLOPIAN TRANSFER (GIFT)
• Uses multiple eggs collected from the ovaries
• The eggs are placed into a thin flexible tube (catheter)
along with the sperm to be used. The gametes (both eggs
and sperm) are then injected into the fallopian tubes using
a surgical procedure called laparoscopy. The doctor will
use general anesthesia
• Direct placement of eggs and sperm
Fig. 7 Gamete Intrafallopian Transfer
ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT)
• Combines in vitro fertilization (IVF) and GIFT.
• Eggs are stimulated and collected using IVF methods.
Then the eggs are mixed with sperm in the lab. Fertilized
eggs (zygotes) are then laparoscopically returned to the
fallopian tubes where they will be carried into the uterus.
• The goal is for the zygote to implant in the uterus and
develop into a fetus.
 • Allow couple to seek counselling
• Guide in making wise decisions
• Answers all queries and confusion
• Allow them to decide for best option to have a child
• Support the couple’s decision/s
Advantages of Infertility Counseling

• Helps to deal with the emotional stress

• Provide extra support
• Allow the client in exploring all possible options for
family
• Help for couples in overcoming the dilemmas and
deciding the right fertility treatment
Fig. 8 Zygote Intrafallopian Transfer • Explains about the infertility management and specific
treatment
SURROGATE EMBRYO TRANSFER
NURSING DIAGNOSIS
• (Surrogacy) or Fresh Embryo Transfer (FET) involved
• Anxiety r/t • Spiritual distress r/t
the use of thawed embryos that were frozen in a previous • Ineffective family and • Fear r/t
IVF cycle for egg donor, and transfer of the embryo into individual coping r/t • Grief r/t
the uterus of the surrogate. • Decreased self-esteem r/t
• A surrogate is required to undergo Frozen Embryo • Knowledge deficit r/t
Transfer cycle in order to achieve a pregnancy
SURROGATE MOTHERING

• Surrogacy is a method of reproduction whereby a woman

(referred to as surrogate) agrees to carry a pregnancy
and give birth as a substitute for the contracted party/ies.
Surrogacy may be Natural (traditional/straight) or
Gestational (IVF). – Indian Law
• The word “surrogate” has its origin in Latin “surrogatus”,
past participle of ‘surrogare’, meaning a substitute, that is,
a person appointed to act in place of another
• A surrogate mother is a woman who agrees to carry
someone else’s baby
• She becomes pregnancy using some form of assisted
reproductive technology, frequently IVF
• The surrogate mother carries the baby to term and gives
birth, and the baby is released from the hospital to its
intended parents
ROLE OF THE NURSE IN CONTRACEPTION AND
INFERTILITY
• Assess contraceptive knowledge, attitudes and plans for
pregnancy, need for family planning, and preferred
method
• Nurse is an educator, advocate, and counselor who offers
the couple a sense of control and acceptance
MANAGEMENT
General Instructions

• Maintenance of body weight

• Avoid smoking and alcohol
• Maintain ideal coital frequency (3-4 times/week in fertile
period)
• Use of Luteinizing Hormone (LH) surge kit
• Avoid lubricants, spermicidal jellies and creams
• Avoid infertility impairing medications
• Psychological support
NURSING CARE

• Provide support for couple as they undergo diagnosis and

their chosen treatment
• Therapeutic communication skills
 PATHOPHYSIOLOGY OF GDM & PIIH

OUTLINE

I. Pathophysiology of GDM
II. Pathophysiology of PIH

PATHOPHYSIOLOGY OF GDM

• Gestational Diabetes Mellitus is a diabetes that occurs

during pregnancy
• Usually occurs on the 20th week of gestation onwards
• Some studies say that women who has a family history of
diabetes is more likely to develop GDM
• There are also some evidence that women who are
obese are most likely to develop GDM
• Will only occur when the woman is pregnant because
they have placental formation. This placenta releases a
hormone
• When a woman is pregnant, the ovary stops to function.
Ovaries release estrogen and progesterone. Since there
is already a pregnancy and the development of placenta,
the placenta takesover the function of the ovary. The
placenta releases estrogen, progesterone and the
hormones released by the placenta itself – HPL and
HCG.
• Human Placental Lactogen (HPL) and Human Chorionic
Gonadotropin (HCG) influences the development of
GDM.
GDM DIAGRAM 1 Crosses maternal circulation = insulin resistance =
Estrogen/Progesterone/HPL decrease production of insulin/ no insulin at all = Glucose
cannot enter the cell = G will stay in the blood =
HYPERGLYCEMIA

Cell no nutrients Increase G in blood concentration Increase Glucose in Fetal Circulation – Fetal
pancreas will be stimulated to release fetal
insulin – Glucose absorption
Cellular hunger Increase blood viscosity

MACROSOMIA
Water for ICS – Shift to IVS
Cell message the brain (Osmosis) in an attempt to
to tell = hunger; brain dilute the blood viscosity Water & Glucose = Kidneys
response for the body to
eat
More water escape = Cellular dehydration Filtration

Increase eating
Cell message - thirsty GLYCOSURIA Increase in Filtered water
Increase in Urine Output
POLYPHAGIA
Brain response –
POLYDIPSIA POLYURIA
Increase OFI
GDM DIAGRAM 2: EFFECTS ON VITAL ORGANS

HYPERGLYCEMIA

Eyes Skin Heart Lungs MSS

Blood viscosity = Decrease blood Decrease O2 to the Decrease O2 Decrease

decrease blood flow = Decrease O2 heart glucose/O2
flow; decrease O2
to the retina
Compensate –
Decrease sensation Compensate by increase RR Anaerobic metabolism
(Peripheral neuropathy) increasing HR (hyperventilation) – stored glycogen
Blurring of vision (Tachycardia) from muscles are
converted to glucose
Risks for injury on the Respiratory
Blindness skin (pricks/wounds) Increase cardiac acidosis
output Weight loss

Delayed healing Respiratory Produce glucose

Necrosis of affected Increase blood arrest
extremity circulation
Produce Lactic Acid

Amputation Increase in
peripheral resistance Increase Lactic Acid

Increase in blood Metabolic acidosis

pressure
(hypertension)

Cardiac Arrest or CVA

 GDM DIAGRAM 1
• Once Estrogen, Progesteron, and HPL crosses maternal
circulation, this causes insuling resistance. Without
insulin, the glucose cannot enter the cell therefore, the
glucose will stay in the bloodstream = hyperglycemia
POLYPHAGIA
• In the presence of hyperglycemia, the glucose stays in
the blood stream and the cell does not receive any
nutrients therefore, they will be hungry (cellular hunger)
• The cell will then message the brain telling the brain that
the cell is hungry. In response, the brain will tell the
patient to eat (polyphagia).
POLYDIPSIA
• Since the patient has hyperglycemic blood, the blood is
concentrated. When the blood is concentrated, it is
viscous (malapot).
• Increased blood viscosity will allow the fluid from the
intracellular space (ICS) to shift to the intravascular space
(IVS) in the process of osmosis in an attempt to dilute the
high concentration of glucose in the intravascular space.
o Osmosis - transfer of water from low concentration
to higher concentration in a semi-permeable
membrane
• More water escape will lead to cellular dehydration
• The cell will message the brain that the body is thirsty. In
response, the brain will tell the patient to increase OFI
(polydipsia).
POLYURIA
• Since the water shifted from the ICS to the IVS, the water
is already mixed with the glucose and the cell is already
somehow empty that’s why there’s cellular dehydration.
• The majority of the water/fluid from the cell is already in
the bloodstream. The water and glucose will go to the
kidneys and there will be filtration.
• Since there is a mixture of glucose and water going to the
kidney where filtration happens, there will be glycosuria
(presence of glucose in the urine)
• Normally, big molecules like glucose cannot escape in the
urine or in the kidneys. However, since there is a problem,
like GDM, some big particles of this molecules escaped
along with the water
• Filtered glucose and water will result in increase filtered
water and increase urine output (polyuria)
MACROSOMIA
• Since the mother’s blood contains a lot of glucose, this
glucose will circulate to the maternal and fetal circulation
so it will reach the baby = increase glucose circulation
• Increase glucose in the fetal circulation will stimulate the
pancreas to release fetal insulin
• After the baby releases insulin, the glucose from the
mother will be absorbed by the fetus (glucose
absorption). So more glucose will be absorbed =
macrosomia
GDM DIAGRAM 2: EFFECTS ON VITAL ORGANS
EYES
• There is decreased blood flow since the blood is already
viscous.
• Decreased blood flow and oxygen to the retina would
cause inadequate supply of oxygen and glucose to the
blood vessels which helps the eyesight = blurring of
visions
• The client will eventually manifest blindless if not properly
managed. It is a must to regulate the sugar level at all
times to prevent blurring of vision and blindness
SKIN
• Decreased blood flow and oxygen to the skin causes
decreased sensation (peripherial neuropathy) or
numbness
• The client will then be at risk for injury on the skin. Since
healing is delayed for patients with diabetes, this will lead
to necrosis of affected extremity (usually feet), and will
eventually lead to amputation
o More common on type 1 and 2 DM not GDM
• Wound healing requires a lot of nutrients, oxygen, etc.
Since the blood is viscous, the circulation is slow and
most of the time the distal portion of the toes and fingers
receive less amount of oxygen and nutrients. Therefore,
there is a tendency for the cell tissue of the affected site
to die and become necrotic. Once necrosis spreads and
ascends, the affected part will be amputated.
HEART
• Chance of having cardiac arrest or CVA is low
• Most common complication would be a combination of
GDM and hypertension or combination of GDM and PIH
LUNGS
• Hyperventilation – rapid, shallow breathing so there is
more CO2 rather than O2 which will result to respiratory
acidosis
MUSCULOSKELETAL (MSS)
• There is decreased blood flow and O2 to the muscles and
cells, and there is cellular hunger.
• To feed the cell while the client is not yet eating, the
muscle will result to anaerobic metabolism wherein the
stored glycogen from the muscles and fat are converted
into glucose
o Anaerobic metabolism – a metabolism that occurs
without the usage of oxygen because the body
does not receive enough oxygen in compensation
to produce glucose to feed the cell while the client
is not yet eating.
• Aside from producing glucose (good product), anaerobic
metabolism also produces a waste product called lactic
acid
• Increase lactic acid will lead to metabolic acidosis
 Additional Notes:

✓ Signs and symptoms of diabetic is systemic since

there is decreased oxygenation due to decreased
blood flow because the blood is concentrated with
sugar (highly viscous) due to elevated blood sugar
level. Blood sugar is elevated because the
pancreas does not produce enough or does not
release insulin.

GOAL OF MANAGEMENT FOR GDM

• Keep the glucose level within normal limit (80-120 mg/dl)

o Give regular insulin
• Normoglycemia – if hyperglycemia turns into normal
values; reduced possibility of the complications
mentioned above
• Monitor sugar level every 6 hours (5-11-5-11)
• Refer immediately if results are high

Additional Notes:

✓ Regular insulin is the drug of choice. It allows the

glucose from the blood to enter the cell. The
regular insulin also allows the conversion of
excess glucose to become glycogen so it can be
kept in the muscles and fats.

PATHOPHYSIOLOGY OF PIH

• Pregnancy-induced Hypertension is elevation of blood

pressure during pregnancy that usually occurs at 20
weeks gestation onwards.
• One of the leading cause of mortality and morbidity
among women due its various complications
• Gestational hypertension – only elevated blood presure
(130/90 mmHg)
o Will proceed to the developmen of PIH if
associated with two symptoms, which are edema
and proteinuria
• PIH is also known an preeclampsia
• PIH or preeclampsia is characterized by three symptoms:
o Hypertension, edema, proteinuria
• Preeclampsia will become eclampsia if there is presence
of seizures
o Signs and symptoms of eclampsia:
▪ Hypertension, edema, proteinuria,
seizures
PIH DIAGRAM 1

Abnormal cytotrophoblast Hypertension/Vasoconstriction

invasion

Kidneys Loss of Protein = CNS

Hypoalbuminemia
Reduce uterine placental
blood flow Decrease O2 Decrease O2 in
Decrease oncotic the CNS
pressure
Decrease in O2 supply Decrease Nephrotic
renal function damage Alteration in firing of
Allow shifting of electrical impulses
Placental Ischemia fluid from ICS/IVS from synapses
Decrease Big molecules to ISS
GFR like CHON
Placenta will release escape
Seizure
Cytokines Decrease Edema
urine output Proteinuria Bipedal Edema
Ascites
Inflammatory response Pulmonary Edema
Cerebral Edema Increase ICP
ANASARCA
Endothelial Dysfunction

Vasospasm Uteroplacental
Insufficiency

Vasoconstriction
Decrease O2 to
Increase blood pressure the fetus
(hypertension)

Abortion
Preterm labor
Intrauterine Growth Restriction
SGA
FDIU (Fetal death in utero)
Abruptio
PIH DIAGRAM 2: VITAL ORGANS AFFECTED

HYPERTENSION / VASOCONSTRICTION

Eyes CNS MSS Liver

Decrease in O2 Decrease in O2 Decrease in O2 Decrease O2

to the retina to muscles/bone
Liver will Hepatic
Dizziness double time damage
Headache Muscle weakness
Blurring of
Lethargy Fatigue
vision
Confusion Myalgia
Swell Decrease
Arthralgia
(Hepatomegaly) platelet

Seizure
AST/ALT Risk for
release bleeding

Increase
DIC
AST/ALT

CVS Lungs Kidney

Decrease in O2 Decrease in O2 Decrease in O2

Lungs increase RR Nephrotic damage

Compensation:
Increase HR
(Tachycardia)
Hyperventilation Decrease GFR

Increase
Cardiac Output Less O2, More CO2 Decrease urine
output

Increase blood Increase in CO2

flow
Acute Renal
Failure
Respiratory acidosis
Increase peripheral
resistance
Chronic Renal
Failure

Increase BP
 PIH DIAGRAM 1
• There is no exact explanation on the cause of PIH but
there are theories:
o relevant to infection; relevant to immunity; relevant
to genetics
o damage on the endothelial cells – most common
and nearest reason
• Endothelial cells are found in the inner lining of the blood
vessels (arteries and veins). If there are damage on the
endothelial cells, it will cause vasospasm
• They say that during placental development there is an
invasion of abnormal cytotrophoblast on the uterine wall,
which decreases placental blood flow
• Placental ischemia – decrease oxygen in a particular
tissue that comprises of a lot of blood vessels
• Since the endothelial cells are located in the innermost
layer of the arteries and veins and if there is endothelial
dysnfuction then it would create vasospasm
• In the presence of hypertension and vasoconstriction, this
will greatly affect the systemic function at the same time
it will affect the organs
• In the presence of vasoconstriction, it is expected that the
blood flow will decrease and the vital organs will receive
inadequate amount of oxygen = organ ischemia
o Kidney – renal ischemia; Liver – hepatic ischemia
etc.
PROTEINURIA
• Decrease O2 in the kidney has two effects:
o Decrease renal function, which would lead to
decrease GFR, resulting in decrease urine output
o Nephrotic damage will allow big molecules like
CHON to escape, resulting in proteinuria
• GFR – glomerular filtration rate
• Proteinuria – presence of protein in the urine = protein
loss
EDEMA
• Since there is loss of protein in the blood stream, this will
result to hypoalbuminemia
• There is decreased oncotic pressure since protein exerts
oncotic pressure
o Oncotic pressure – pulling force to hold water in
place (inside the cell and blood vessels)
• Since there is decreased oncotic pressure, wala nay mag
hold sa water. This will allow fluid to escape from ICS/IVS
to ISS
o ICS – intracellular space; IVS - intravascular
space; ISS - interstitial space (space outside or in
between the cells)
• Bipedal edema – edema on the lower extremities; usually
starts on the foot and goes up if there is more water
retention
• Ascites – abdominal edema
• Pulmonary edema – if naabot na sa lungs ang water
retention
• If edema the edema is ascending, the water will pass
through the vein, causing cerebral edema
• ANASARCA – generalized edema/edema all over the
body
Additional Notes:
✓ Keep the edema localized as much as possible so
it will not ascend.
SEIZURE
• If the patient has preeclampsia, there are two reasons
why the patient will have seizures = eclampsia
1. Vasoconstriction – blood vessels in the brain are
also constricted
▪ If blood vessels are constricted, there is
decreased O2 in the CNS, causing
alteration in firing of electrical impulses
from synapses thereby, causing seizure
2. Cerebal edema – if the edema ascends in the
brain, the accumulation in the brain causes
decrease intracranial pressure (ICP), promoting
seizure
UTEROPLACENTAL INSUFFICIENCY
• Effect of hypertension on the baby
• Since there is vasoconstriction, there is decreased O2
supply from the mother towards the baby.
PIH DIAGRAM 2: EFFECTS ON VITAL ORGANS
CNS
• Initial symptoms of seizure are dizzines, headache,
lethargy, and confusion
MSS
• Myalgia – muscle pain
• Arthralgia – bone pain
LIVER
• Since there is decrease O2, the liver will work double to
the point that it will swell (hepatomegaly)
• Since the liver is also responsible for the maturity of the
platelet, there will be decrease platelet if the liver is
damaged.
• If the platelet goes down from the normal value (below
150,000) the client will most likely be at risk for bleeding.
If not treated, this will progress to DIC.
KIDNEYS
• The kidney should receive 20% of oxygenated blood.
However, due to vasoconstriction, there is decrease O2 to
the kidney.
• If the kidney receive less oxygenated blood, the nephrons
(kidney’s functional unit) will start to die. If there are
accumulated dead nephrons, the function of the kidney
will reduce.
• If there is nephrotic damage, there would be decrease
GFR then decrease urine output. If this worsens and the
renal ischemia is left untreated/unmanaged, this will
result to acute renal failure. Unmanaged or untreated
acute renal failure will eventuallty progress to chronic
renal failure.
 Additional Notes:

✓ Seizure will lead to coma

✓ DIC will lead to postpartum bleeding
✓ Hypertension will lead to cardiac arrest/CVA
✓ Respiratory acidosis is fatal to the lungs since this
can lead to respiratory arrest
✓ If there is less functional unit of the kidney that is
useful (ex. 10% of the kidney is functioning), this
will progress to ANASARCA
✓ With ANASARCA, the lungs and heart would be
filled with water, which could possibly lead to
cardiopulmonary arrest

GOAL OF MANAGEMENT FOR PIH

• Keep the BP at within normal range

o Give antihypertensive medications
o Methyldopa (drug of choice), Hydralazine
(vasodilator)
• MgSO4 to prevent seizures
o Inhibits acetylcholine release to the muscle which
is responsible for muscle contraction.
o Inhibition of acetylcholine will prevent muscle
contraction therefore no seizure