NCM 109 LEC FRAMEWORK CARE OF MOTHER, CHILD AT RISK OR W/ PROBLEMS:

Framework for MCN Care

• Can be visualized in which nurses use nursing
process, nursing theory and Quality & Safety
Education for Nurses (QSEN) competencies to
care for families during child bearing and
child rearing years through the
Framework for MCN Care:
1. Health Promotion
2. Health Maintenance
3. Health Restoration
4. Health Rehabilitation

National health situation focusing on maternal health

 A lack of autonomy to make decisions about
one’s own health care Are factors which may preclude women from
 low levels of education circumscribing receiving the quality of care essential for
 the ability to make informed health
ensuring healthy pregnancies and deliveries.
care decisions
 limited control over financial resources
 restricted mobility to access health care
services
 power differentials between health care
 providers and recipients

Levels of Maternal Mortality Causes of Maternal Death

1. Indirect - 28%
 The number of women that died each year from 2. Direct – 10%
complications of pregnancy and childbirth declined 3. Sepsis – 11%
from 451,000 in 2000 to 295,000 in 2017. Still, 4. Hypertension – 14%
over 800 women are dying each day from complications 5. Hemorrhage – 27%
in pregnancy and childbirth. Every woman who dies, 6. Embolism – 3%
approximately 20 others suffers’ serious injuries, 7. Abortion – 8%
infections or disabilities.

RISK FACTORS OR CONDITIONS AFFECTING HIGH RISK PREGNANCY

HIGHRISK PREGNANT CLIENT
 is one in which a concurrent disorder,
pregnancy-related complication, or
external
factor jeopardizes the health of the
HOW TO PREVENT THE RISK IN PREGNANCY?
surviving childbirth:
1. Physiologic problems such as concurrent illness and malnutrition.
2. Mothers who are too young, too old, pregnant too frequently
3. Presence of physical deformity.
4. Physiological/ mental illness/mental retardation
5. Marginalized because of
 Poverty
 Unemployment
 Lack of education
 Exposure to teratogens due to occupation
 Victims of abuse or domestic violence, rape, incest
ASSESSMENT
 Single or separated mothers OF CLIENTS AT RISK BEGINS
WITH THE 1ST PRENATAL VISIT AND
CONTINUES THROUGH THE PUERPERIUM!!!
  Adequate health care during pregnancy
 The delivery of her baby happens with the
assistance of a skilled birth attendant (SBA),
which generally includes a medical doctor,
nurse or midwife who can provide uninterrupted and quality care.

This NHS is intended to:

1. help citizens more easily understand the importance of health promotion and disease prevention
2. encourage wide participation in improving health in the next decade
3. Maternal and child health nurses because nurses play such a vital role in helping the nation achieve these objectives
through both practice and research.
4. Serves as the basis for grant funding and financing of evidence- based practice.

RISK CONDITION RELATED TO PREGNANCY

MDG-4, “Reduce child mortality”
WHY MATERNAL HEALTH IS IMPORTANT? MDG-5, “Improve maternal health
 Indicator of a well-being our future generation.

WHAT IS MATERNAL MORTALITY

 the number of MATERNAL DEATHS
o Pregnancy Associated but not related deaths
o Pregnancy Related Deaths

Risk conditions related to pregnancy Medical conditions affecting pregnancy Medical conditions affecting pregnancy
(pre-gestational conditions) (pre-gestational conditions) (pre-gestational conditions)

• Abortion •Hepatitis B • Eclampsia

• Anemia •Hematoma • Incompetent Cervix
• Cardiovascular Disorders •Human Immunodeficiency Virus (HIV) • Infections TORCH Complex Acronym)
• Diabetes Mellitus and Acquired Immunodeficiency • Multiple Gestation
• Disseminated Intravascular Coagulation Syndrome (AIDS) • Sexually Transmitted Infections
(DIC) •Hydatidiform Mole • Tuberculosis
• Ectopic Pregnancy •Hyperemesis Gravidarum • Urinary Tract Infections
• Endometritis •Gestational Hypertension • Obesity in Pregnancy
• Fetal Death in Utero

ABORTION
 A pregnancy that ends before 20 weeks’
gestation, spontaneously or electively.
Assessment:
1. Spontaneous vaginal bleeding
2. Low uterine cramping or contractions
3. Blood clots or tissue through the vagina
4. Hemorrhage and shock can result if bleeding
is excessive.

Types of abortion Types of abortion

1.Spontaneous 1.Incomplete
- Pregnancy ends because of - Loss of some of the products
natural causes. of conception occurs, with part
of the products retained.
2.Threatened
- Spotting and cramping occur 2.Habitual
without cervical change. -Spontaneous abortions occur
in 3 or more successive
3. Induced pregnancies.
- therapeutic or elective
reasons exist for terminating 3.Missed
pregnancy. - Products of conception are
retained in utero after fetal
4.Inevitable death.
-spotting and cramping occur
and cervix begins to dilate and 4.Complete
efface. -Loss of all
INTERVENTIONS
• Maintain bed rest as prescribed.
• Monitor vital signs.
• Monitor for cramping and bleeding.
• Count perineal pads to evaluate blood loss, and save
expelled tissue clots.
• Maintain intravenous (IV) fluids as prescribed; monitor
for signs of hemorrhage or bleeding.
• Prepare the client for dilation and curettage as
prescribed for incomplete abortion.
• Administer Rh immune globulin, as prescribed, for an
Rh-negative woman.
• Provide Psychological support.

Assessment: Interventions
ANEMIA  Monitor hemoglobin and hematocrit level every 2
1. Fatigue
 Iron deficiency anemia is a condition 2. Headache
weeks.
 Administer and instruct the client about iron and
that develops as a result of an 3. Pallor folic acid supplements.
inadequate amount of serum ion. 4. Tachycardia  Instruct the client to take iron with a source of
5. Hemoglobin Vitamin C.
 It predisposes the client to  Instruct the client to eat foods high in iron, folic acid,
value is usually and protein.
postpartum less than 10 g/dl,  Teach the client to monitor for signs and symptoms
infection. (100mmol/L; of infection.
6. Hematocrit value  Prepare to administer parenteral iron or blood
transfusions.
is usually less  Prepare for the administration of oxytocic
than 30% medications in the postpartum period if excessive
bleeding is a concern.

Cardiovascular Disorders/ Cardiac Disease

Assessment:
 commonly cause difficulty during pregnancy
1. Signs and symptoms of cardiac decompensation
 Commonly, valve damage concerns caused by
a. cough and respiratory congestion
rheumatic fever or Kawasaki disease and b. dyspnea and fatigue
congenital anomalies c. palpitations and tachycardia
 A pregnant client with cardiac disease may be unable d. Peripheral edema
physiologically to cope with the added plasma volume e. Chest pain
and increased cardiac output that occur during 2. Signs of respiratory infection
3. Signs of heart failure and pulmonary edema.
pregnancy; Blood volume peaks at weeks 32 to 34
and then declines slightly to week 40.

Maternal Cardiac Disease Risk Groups

Group 1 (Mortality Rate, 1%) Group 2 (Mortality Rate, 5% to 15%) Group 3 (Mortality Rate, 25% to 50%)

•Corrected Tetralogy of Fallot •Mitral Stenosis •Aortic coarctation (complicated)

• Pulmonic or tricuspid disease
•Mitral stenosis (Class 1 and 2)
•Patent Ductus Arteriosus
•Ventricular Septal Defect
•Atrial Septal Defect
•Porcine valve
•Artificial heart valves •Myocardial infarction
•Mitral stenosis (Class III and IV) •Marfan syndrome
•Uncorrected tetralogy • True cardiomyopathy
•Aortic coarctation (uncomplicated) • Pulmonary hypertension
•Aortic Stenosis

Can A woman with CV disease successfully

complete her pregnancy?
YES, As a rule,
• A woman with artificial but well-functioning heart valve
• A woman with pacemaker implant
• A woman who has had a heart transplant
As a rule, they can have successful pregnancies as long as they have
effective prenatal and postnatal care (Abdalla & Mancini, 2014)
 Classification of heart disease

I. Uncompromised
Ordinary physical activity causes
no discomfort. No symptoms of
cardiac insufficiency and no
angina pain.
II. Slightly compromised.
Ordinary physical activity causes
excessive fatigue Palpitation, and
dyspnea or angina pain.
III. Markedly compromised.
During less than ordinary activity,
woman experiences excessive
fatigue, palpitations, dyspnea, or
angina pain.
IV. Severely compromised.
Women is unable to carry out any
physical activity without
experiencing discomfort. Even at
rest, symptoms of cardiac
insufficiency
or angina pain are present.

Left-sided heart failure

 Occurs in conditions such as mitral stenosis, LSHF Medical interventions: LSHF Medical interventions:
mitral insufficiency, and aortic coarctation.
1. Anticoagulant 1. Serial ultrasound
 This causes BACK PRESSURE
 to prevent thrombus
 Left heart becomes distended
formation 2. Nonstress Tests after
 Systemic Blood Pressure decreases
week 30 to 32 of
 Pulmonary hypertension occurs
2. Antihypertensive pregnancy
 control BP (Dennis, 2016)
 Pulmonary Edema ----- Spontaneous miscarriage  Nonstress Test monitor
Preterm labor 3. Heparin fetal health and to rule
Maternal death  drug of choice for early out poor placental
pregnancy perfusion.

•Orthopnea 4. Diuretics
 Chest and head elevated.  reduce the blood
 Allows the fluid to settle to the bottom of volume.
her lungs and free space for gas exchange.
5. Beta blockers
•Paroxysmal Nocturnal Dyspnea  to improve ventricular
 suddenly waking at night with shortness of filling
breath.

RIGHT-SIDED HEART FAILURE RSHF assessment Interventions:

 Occurs when the right ventricle
is overwhelmed by the amount
of blood received by the right
atrium from the vena cava.
 It can be caused by:
 unrepaired congenital heart
defect such as pulmonary valve
stenosis
Caused by:
 Eisenmenger syndrome, a
right-to-left atrial or
ventricular septal defect
with an accompanying
pulmonary valve stenosis
1. Congestion of the systemic
venous circulation and
decreased cardiac
output to the lungs occur.
2. Blood pressure decreases in
the aorta because less blood is
able to reach it.
3. In contrast, pressure is high in
the vena cava from back
pressure of blood.
Resulted to:
 jugular venous distention
 Increased portal circulation
 Distended liver and spleen
 Distention of abdominal and
lower extremity vessels can
lead to exudate offluid from
the vessels into the peritoneal
cavity or peripheral edema
1.Monitor vital signs, fetal heart rate,
and condition of the fetus.
2.Limit physical activities, and stress
the need for sufficient rest.
3. Monitor for signs of cardiac stress
and decompensation.
4. Monitor for signs of heart failure
and pulmonary edema.
5.Encourage adequate nutrition to
prevent anemia, which would worsen
the cardiac status.
6. Low sodium-diet
7. Avoid excessive weight gain.

Interventions: During labor, prepare to do the following:

a. Monitor vital signs frequently.
b. Place the client on a cardiac monitor and on external fetal monitor.
Rest should be in the Left Lateral
c. Maintain bed rest, with the client lying on her side with her head and
recumbent shoulders elevated.
position to prevent supine d. Administer oxygen as prescribed.
hypotension syndrome and e. Manage pain in early labor.
increased heart effort. f. Use controlled pushing efforts to decrease cardia stress.
CHORIOAMNIONITIS
1. Bacterial infection of the amniotic cavity.
2. Can result from premature or prolonged
rupture of the membranes, vaginitis,
amniocentesis, or intrauterine
procedures.
3. May result in the development of
postpartum
4. endometritis and neonatal sepsis.
Assessment:
-Uterine tenderness and
contractions
-Elevated temperature
-Maternal or fetal tachycardia
-Foul odor to amniotic fluid
-leukocytosis
Interventions
1. Monitor maternal vital signs and
fetal heart rate.
2. Monitor for uterine tenderness,
contractions and fetal activity.
3. Monitor results of blood cultures.
4. Prepare for amniocentesis to obtain
amniotic fluid for Gram stain and
leukocyte count.
5. Administer antibiotics as prescribed
after cultures are obtained.
6. Administer oxytocic medications as
prescribed to increase uterine tone.
7. Prepare to obtain neonatal cultures
after birth.

Diabetes Mellitus
5. Pregnancy places demands on carbohydrate RESULTED TO:
metabolism and causes insulin requirements  The newborn of a diabetic mother may be large in size, but
has functions
to change.
related to gestational age rather than size.
6. Maternal glucose crosses the placenta, but
 The newborn of a diabetic mother is at risk for
insulin does not. hypoglycemia,
7. The fetus produces its own insulin and hyperbilirubinemia, respiratory distress syndrome,
pulls glucose from the mother, hypocalcemia, and
8. which predisposes the mother to congenital anomalies.
hypoglycemic reactions.

GESTATIONAL DIABETES MELLITUS

9. occurs in pregnancy (during the second or third trimester)

in clients not previously diagnosed as diabetic and occurs
when the pancreas cannot respond to the demand for
more insulin.

When do pregnant women be screened for gestational diabetes?

10. Pregnant women should be screened for gestational diabetes
between 24 and 28 weeks of gestation.
Confirmatory test: 3-hour oral glucose tolerance test (OGTT)

Oral Glucose Tolerance Test

11. NO FOOD FOR OR DRINK: 8-12 HOURS
12. BLOOD IS TESTED FOR 2 HOURS LATER
High Glucose Level = POTENTIAL FOR DIABETES

Three-hour OGTT results are interpreted

differently. For this, a
preliminary diagnosis is made based on one or
more high glucose values
during one or more of the four blood draws.
Abnormal values need to
be confirmed with a repeat OGTT.
• The normal Ranges for a 3 HOUR OGTT
• Normal in a fasted state: Less than 95 mg/dL
• Normal after one hour: Less than 180 mg/dL
• Normal after two hours: Less than 155 mg/dL
• Normal after three hours: Less than 140 mg/dL
If any one of these values is high, the test is repeated in four weeks.
If, after the second test, two or more values are elevated,
gestational diabetes is definitively diagnosed.
How can GESTATIONAL DIABETES MELLITUS be treated?

13. Can be treated by diet alone;

however, some clients may need insulin.

Will there be a chance that they will return back to normal state?
14. Most women with gestational diabetes return to
euglycemic state after birth; however, these
individuals have an increased risk of developing diabetes
mellitus in their lifetime.
ASSESSMENT FOR GESTATIONAL DIABETES MELLITUS
Predisposing Conditions To Gestational Diabetes 1. Excessive thirst
 Older than 35 years 2. Hunger
3. Weight loss
 Obesity 4. Frequent urination
 Multiple gestation 5. Blurred vision
6. Recurrent urinary tract infections and vaginal yeast
 Family history of diabetes mellitus infections
 Large for gestational age fetus 7. Glycosuria and ketonuria
8. Signs of gestational hypertension
9. Polyhydramnios
10. LARGE FOR GESTATIONAL AGE FETUS

INTERVENTIONS INTERVENTIONS

1. Employ diet, medications (if diet cannot
control blood glucose levels),
exercise, and blood glucose
determinations to maintain blood glucose
levels between 65 mg/dL (3.7 mmol/L) and
130 mg/dL (7.4 mmol/L) as
prescribed.
2. Observe for signs of hyperglycemia,
glycosuria and ketonuria, and
hypoglycemia.
3. Monitor weight.
4. Increase calorie intake as prescribed,
with adequate insulin therapy so that
glucose moves into the cells.
5. Assess for signs of maternal
complications such as preeclampsia
(hypertension and proteinuria).
6. Monitor for signs of infection.
7. Instruct the client to report burning and
pain on urination,
vaginal discharge or itching, or any other
signs of infection.
8. Assess fetal status and monitor for signs
of fetal
compromise.

ECTOPIC PREGNANCY ETIOLOGY

• Implantation occurs outside the uterine cavity  Pelvic infection often is caused by
• Mostly tubal in nature (95 %). Chlamydia or Neisseria gonorrhoeae.
• Can be abdominal or ovarian in nature that account for 5%.  A failed tubal ligation, even if
• Most common predisposing factor is Pelvic Inflammatory Disease (PID) performed many years ago
 A history of previous ectopic pregnancy
• Other factors include:
 delayed or premature ovulation, with
Previous Surgery the tendency of the fertilized ovum to
Presence of Intrauterine Device implant before arrival in the uterus,
History of previous ectopic pregnancy  altered tubal motility in response to
changes in estrogen and progesterone
15. Although implantation can occur in the abdomen or cervix, more than levels that occur with conception.
98% of  Multiple induced abortions
ectopic pregnancies occur in the fallopian tube (Seeber & Barnhart, 2008).  salpingitis (infection of the fallopian
• Ectopic pregnancy has been called “a disaster of reproduction” tube) that occurred after induced
abortion
• Ectopic pregnancy remains a significant cause of maternal death from hemorrhage.
• Tubal damage caused by an ectopic pregnancy reduces the woman’s chances
of subsequent pregnancies.

Triad Symptoms: Clinical Manifestations:  sudden, severe pain in one

 Amenorrhea
  Vaginal bleeding or spotting
 Unilateral lower abdominal pain
or tenderness
 Severe sharp knife-like abdominal pain, unilateral
of the lower quadrants of
pain
 Abdominal rigidity
the abdomen as the tube
 Bleeding inside tears open and the embryo
 Hemoperitoneum (profuse abdominal hemorrhage) is expelled into the pelvic
 Peritonitis cavity,
 Positive (+) Cullen’s Sign  Radiating pain under the
 Ecchymosis around the umbilicus due to scapula may indicate
hemoperitoneum bleeding into the abdomen
 Decreased blood pressure (80/50) caused by phrenic nerve
 Excruciating pain when the cervix is moved (wiggling
irritation.
 tenderness)

Clinical Manifestations:
More subtle signs and symptoms depend on the site of 1. If implantation has occurred in the proximal
implantation. end of the fallopian tube, rupture of the
 If implantation occurs in the distal end of the fallopian tube, tube may occur within 2 to 3 weeks of the
which can contain the growing embryo longer, the woman missed period because the tube is narrow in
may at first exhibit the usual early signs of pregnancy and this area.
consider herself to be normally pregnant. 2. Hypovolemic shock (acute peripheral
circulatory failure from loss of circulating
 Several weeks into the pregnancy, intermittent abdominal
blood) is a major concern because
ain and small amounts of vaginal bleeding occur, and initially systemic signs of shock may be rapid and
this could be mistaken for threatened abortion. extensive without external bleeding.

RISK FACTORS

1. Previous infection such as salpingitis or

pelvic inflammatory disease.
2. Scars from a tubal surgery.
3. Congenital malformations.
4. Uterine tumors.
5. Use of intrauterine device. IUDs
OTHER RISK FACTORS
 Smoking.
 A recent in vitro
fertilization
 Previous ectopic
pregnancy.

DIAGNOSTIC TESTS

1. transvaginal ultrasound examination

2. determination of beta-Hcg
1. The use of sensitive pregnancy tests
2. Maternal serum progesterone levels
3. High-resolution transvaginal ultrasound
4. A characteristic bluish swelling within the tube
3. Culdocentesis.
5. Refers to the extraction of fluid from therecto-
uterine pouch posterior to the vagina through
a needle.
4. Pelvic Ultrasound. Surgical Management
6. An early pregnancy ultrasound is the most 1. Laparoscopy.
common determinant of an ectopic 3. Examination of the peritoneal cavity by means of a
laparoscope, occasionally maybe necessary to diagnose rupture of an
pregnancy.
ectopic pregnancy. This will be performed to ligate the bleeding blood
5. Magnetic Resonance Imaging. vessels and repair or remove the damaged fallopian tube.
7. This is also another way to detect the 2. Salpingectomy.
presence of ectopic pregnancy and it is 4. This intervention would be performed if the fallopian
tube is completely damaged. The affected tube would be removed and
safer
what would be left would be sutured appropriately.
than undergoing a CT scan for
pregnant women.
Nursing Assessment
NURSING DIAGNOSIS
1. No unusual symptoms are usually present at the time of
•Risk for Deficient Fluid Volume related to bleeding from a
implantation of an ectopic pregnancy. ruptured ectopic pregnancy.
2. The usual signs of pregnancy would occur, such as a positive •Powerlessness related to early loss of pregnancy secondary to
pregnancy test, nausea and vomiting, and amenorrhea. ectopic pregnancy.
3. At 6-12 weeks of pregnancy, the trophoblast would be large NURSING INTERVENTIONS
enough to rupture the fallopian tube. •Upon arrival at the emergency room, place the woman flat in
4. Bleeding would follow, and it would depend on the number bed.
•Assess the vital signs to establish baseline data and determine if
and
the patient is under shock.
size of the affected blood vessels the amount of bleeding that •Maintain accurate intake and output to establish the patient’s
would occur. renal function.
5. Sharp, stabbing pain in the lower quadrant is likely to be felt MEDICAL MANAGEMENT
by the Methotrexate
woman once a rupture has occurred, followed by scant •A sclerosing agent
vaginal •A folic acid antagonist chemotherapeutic agent attacks and
destroys fast growing cells. It is used to inhibit cell division in
bleeding.
the developing embryo.
6. Upon arrival at the hospital, a woman who has a ruptured •Because trophoblast and zygote growth is so rapid, the drug is
ectopic pregnancy might present signs of shock such as rapid, drawn to the site of the ectopic pregnancy
thread pulse, rapid respirations, and decreased blood •Given to shrink and absorb products of conception and eventual
pressure. absorption to the circulation
7. There would be a decreased HCG levels or progesterone •Given I.M. to the mother if ectopic pregnancy is less than 3 cm.
levels
that would indicate that the pregnancy has ended.

EVALUATION

16. The goal of the evaluation is to ensure that maternal blood loss is replaced and the
bleeding would stop.
17. The patient must maintain adequate fluid volume at a functional level as evidenced by
normal urine output at 30-60mL/hr and a normal specific gravity between the ranges of
1.010 to 1.021.
18. Vital signs, especially the blood pressure and pulse rate, should be stable and within the
normal range.
19. Patient must exhibit moist mucous membranes, good skin turgor, and adequate capillary
refill.
• Medical management may be possible if the tube is unruptured. The
goal of medical management is to preserve the tube and improve the
chance of future fertility.
• Surgical management of a tubal pregnancy that is unruptured may
involve a linear salpingostomy to salvage the tube
• When ectopic pregnancy results in rupture of the fallopian tube, the
goal of therapeutic management is to control the bleeding and
prevent hypovolemic shock.

Disseminated Intravascular Coagulation (DIC)

• begins with excessive clotting.
• The excessive clotting is usually stimulated
by a substance that enters the blood as part
of a disease (such as an infection or certain cancers)
or as a complication of childbirth, retention of a
dead fetus, or surgery.

Diseases that cause DIC fall into three major groups:

1. Infusion of tissue thromboplastin into the circulation, which consumes, or “uses up,” other clotting factors such as fibrinogen and platelets.
Abruptio placentae (premature separation) and prolonged retention of a dead fetus cause this because the placenta is a rich source of
thromboplastin.
2. Conditions characterized by endothelial damage: Severe preeclampsia and HELLP (hemolysis, elevated levels of liver enzymes, and low
platelet levels) syndrome are characterized by endothelial damage.
3. Nonspecific effects of some diseases: Diseases such as maternal sepsis or amniotic fluid embolism are in this category.
DIC allows excess bleeding to occur from any vulnerable area such as IV sites, incisions, gums, or the nose and from expected sites such as the
site of placental attachment during the postpartum period.
SIGNS AND SYMPTOMS
 Bleeding, from many sites in the body
 Blood clots
 Bruising
 Drop in blood pressure
 Shortness of breath
 Confusion, memory loss or change of behaviour
 Fever

Laboratory Studies TREATMENT

 Levels of fibrinogen and platelets usually are decreased
 Prothrombin time (PT) and activated partial
thromboplastin
time (aPTT) may be prolonged
 levels of fibrin degradation products, the most sensitive
measurement, are increased
 d-dimer serum assay, which normally has negative results,
confirms fibrin split products (FSP) and is presumptive for
DIC when results are positive.
• The priority in treatment of DIC is to correct the cause.
• In the case of a missed abortion, delivery of the fetus and
the placenta ends the production of thromboplastin, which
is fueling the process.
• Blood replacement products such as whole blood, packed
red blood cells (RBCs), and cryoprecipitate, are
administered, as needed, to maintain the circulating volume
and to transport oxygen to body cells.

NURSING CONSIDERATION
•The nurse should:
20. observe for bleeding from unexpected sites.
21. If her coagulation studies are severely abnormal:
• Epidural block may be contraindicated because of possible
bleeding into the spinal canal, so other types of labor pain
management should be anticipated

Gestational Trophoblastic Disease (Hydatidiform Mole) ETIOLOGY

 is one form of gestational trophoblastic disease,
which occurs when trophoblasts (peripheral
cells
that attach the fertilized ovum to the uterine
wall)
develop abnormally.
 As a result of the abnormal growth, abnormality
of placenta develops, and, if present, a fetus has
a fatal chromosome defect.
 characterized by proliferation and edema of the
chorionic villi.
 The fluid-filled villi form grapelike clusters of
tissue that can rapidly grow large enough to fill
the uterus to the size of an advanced
pregnancy.
 The mole may be complete, with no fetus
present, or partial, in which fetal tissue or
membranes are present.
 Age
 Persistent gestational
trophoblastic disease may undergo malignant change
(choriocarcinoma) and may metastasize to sites such as the
lung, vagina, liver, and brain.
1. Complete mole is thought to occur when the ovum is
fertilized by a sperm that duplicates its own
chromosomes while the maternal chromosomes in
the ovum are inactivated.
2. In a partial mole, the maternal contribution is usually
present, but the paternal contribution is doubled, and
therefore the karyotype is triploid (69,XXY or 69,XYY).
If a fetus is identified with the partial mole, it is
grossly abnormal because of the abnormal
chromosomal composition.

Clinical Manifestations: Diagnosis

Possible signs and symptoms of molar pregnancy include the following:
• Higher levels of beta-hCG than expected for gestation
• Characteristic “snowstorm” ultrasound pattern that shows the vesicles
and the absence of a fetal sac or fetal heart activity in a complete
molar
pregnancy
• A uterus that is larger than expected for gestational age
• Vaginal bleeding, which varies from dark-brown spotting to profuse
hemorrhage
• Excessive nausea and vomiting (HEG), which may be related to high
levels of beta-hCG from the proliferating trophoblasts
• Early development of preeclampsia, which is rarely diagnosed
before 24 weeks in an otherwise normal pregnancy
• Measurement of the beta-hCG levels detects the abnormally
high levels of the hormone before treatment.
• Following treatment, beta-hCG levels are measured to
determine if they fall and then disappear.
In addition to the characteristic pattern showing the vesicles,
ultrasound examination allows a differential diagnosis to be
made between two types of molar pregnancies:
 a partial mole that includes some fetal tissue and
membranes and
 a complete mole that is composed only of enlarged
villi but containsno fetal tissue or membranes.

Therapeutic Management
 1. evacuation of the trophoblastic tissue
of the mole and
2. continuous follow-up of the woman to
detect malignant changes of
any remaining trophoblastic tissue.
•Before evacuation, chest radiography,
computed tomography (CT), or
magnetic resonance imaging (MRI) may be
performed to detect
metastatic disease.
•A complete blood count, laboratory assessment
of coagulation
status, and blood type screening or
crossmatching are also necessary
in case a transfusion is needed.
•Blood chemistries are done to evaluate renal,
hepatic, and thyroid
functions.
1. The mole usually is removed by 5. Beta-hCG is repeated at 6 weeks
vacuum aspiration followed by postpartum.
curettage. 6. Follow-up protocol involves evaluation
2. After tissue removal, IV oxytocin is of serum beta-hCG levels monthly for
given to contract the uterus. 6 months, then every 2 to 3 months for
Avoiding uterine stimulation with 6 months until normal for three
oxytocin before evacuation is values.
important.
3. Uterine contractions can cause
trophoblastic tissue to be pulled into
the large venous sinusoids in the
uterus, resulting in embolization of the
tissue and respiratory distress.
4. The tissue obtained is sent for
laboratory evaluation.
22. Although a hydatidiform mole is
usually a benign process,
choriocarcinoma may occur.

Placenta Previa
23. implantation of the placenta in the lower uterus.
As a result, the placenta is closer to the internal cervical
os than to the presenting part (usually the head) of the fetus.

Three classifications of placenta previa

Marginal placenta previa is common in
early ultrasound examinations

INCIDENCE AND ETIOLOGY

• In the United States, the average incidence of placenta previa is 1 in
300 births, and evidence indicates that the rate of placenta previa is
increasing.
• It is more common in older women, multiparas, women who have
had cesarean births, and women who have had suction currettage for
induced or spontaneous abortion.
• It is also more likely to recur if a woman has had a placenta previa.
• African or Asian ethnicity also increases the risk.
• Cigarette smoking and cocaine use are personal habits that add to

Clinical Manifestations
• The classic sign of placenta previa is the sudden onset of painless uterine
bleeding in the last half of pregnancy.

24. Bleeding results from tearing of the placental  Digital examination of the cervical os or stimulation of
villi from the uterine wall as the lower uterine contractions when a placenta previa is present can cause
segment thins and the internal os begins additional placental separation or tear the placenta itself, causing
dilation near term. severe hemorrhage and extreme risk to the fetus. Until the
location and position of the placenta are verified by
25. Bleeding is painless because it does not occur ultrasonography, no manual Vaginal examinations should be
in a closed cavity and does not cause pressure performed, and administration of
on adjacent tissue. It may be scanty or oxytocin should be postponed to prevent strong contractions that could
profuse, result in sudden placental separation and rapid hemorrhage.
NURSING CONSIDERATIONS
and it may cease spontaneously, only to recur Teaching also includes emphasizing the importance of:
later. (1) assessing color and amount of vaginal discharge or
bleeding, especially after each urination or bowel
Therapeutic Management movement,
(2) assessing fetal activity (kick counts) daily
• Medical interventions are based on the condition of the expectant (3) assessing uterine activity at prescribed intervals, and
mother and the fetus. (4) refraining from sexual intercourse to prevent disruption
• The woman is evaluated to determine the amount of hemorrhage, of the placenta.
and electronic fetal monitoring is initiated to evaluate the fetus.
• Administration of corticosteroids to the mother speeds Home care nurses may be responsible for making daily
maturation of phone contact to assess the woman’s perception of uterine
the fetal lungs, if needed. activity (cramping, regular or sporadic contractions),
• Antepartum units are often designed to consider the woman’s bleeding, fetal activity and adherence to the
needs prescribed treatment plan.
•Nurses should provide specific, accurate information about
for physical and occupational therapy and for diversion as well as
the condition of the fetus. and they may: make home visits
care
for comprehensive maternal-fetal assessments with
for her pregnancy complication
portable equipment, such as nonstress tests.
•The woman and her family instructed to report a decrease
Home Care
in fetal movement or an increase in uterine contractions or
vaginal bleeding.
 26. Making a medical decision on home care versus inpatient care
27. is difficult. General criteria for home care include the following
• No evidence of active bleeding is present.
• The woman is able to maintain bed rest at home.
• Home is located within a short distance from the hospital.
• Emergency systems are available for immediate transport to
the hospital 24 hours a day.
• The woman can verbalize her understanding of the risks
associated with placenta previa and how to manage her care.

INPATIENT CARE A significant change in fetal heart activity, an episode of

• When the expectant mother is confined to the
hospital, nursing assessments focus on determining
whether she experiences bleeding episodes or signs
of preterm labor.
• Periodic electronic fetal monitoring is necessary to
Determine whether there are fetal heart activity
changes in association with fetal
compromise.
vaginal bleeding, or signs of preterm labor should be
reported immediately to the physician.
•delivery may be scheduled if the fetus is older than
36 weeks of gestation and the lungs are mature.
• Immediate delivery may be necessary regardless
of fetal immaturity if bleeding is excessive, the
woman demonstrates signs of hypovolemia, or signs of
fetal compromise are present.
• If cesarean birth is necessary, nurses must prepare the
Expectant mother for surgery.The major dangers for the woman are
1. Hemorrhage
2. consequent hypovolemic shock
3. clotting abnormalities.

The major dangers for the fetus are:

 asphyxia,
 excessive blood loss,
 prematurity.

Abruptio Placentae
28. Separation of a normally implanted placenta before the fetus is born.
29. Also called abruptio placentae, placental abruption, or premature
separation of the placenta, occurs in cases of bleeding and formation
of a hematoma (clot) on the maternal side of the placenta.
As the clot expands, further separation occurs.
 Hemorrhage may be apparent (vaginal
bleeding) or concealed. The severity of the
complication depends on the amount of
bleeding and the size of the hematoma.
If bleeding continues, the hematoma expands
and obliterates intervillous spaces.
Fetal vessels are disrupted as placental
separation occurs, resulting in fetal and
maternal bleeding.

ETIOLOGY: CAUSE UNKNOWN

RISK FACTORS:

• Maternal use of cocaine, which causes vasoconstriction

(narrowing of blood vessel lumen) in the endometrial
arteries, is a leading cause of abruptio placentae.
• maternal hypertension
• maternal cigarette smoking
• multigravida status
• short umbilical cord
• abdominal trauma
• Premature rupture of the membranes
• history of previous premature separation of the
placenta
• Maternal age is also associated with abruption
placentae, probably associated with a larger
number of births for each mother
• Recently identified factors that are
associated with abruptio placentae can be
Clinical Manifestations
Five classic signs and symptoms of abruptio placentae include the
following:
1. Bleeding, which may be evident vaginally or may be
concealed behind the placenta
2. Uterine tenderness that may be localized at the site of the
abruption
3. Uterine irritability with frequent low-intensity contractions
and poor relaxation between contractions
4. Abdominal or low back pain that may be described as
aching or dull
5. High uterine resting tone identified with use of an
intrauterine pressure catheter
Additional signs include:
 back pain
 nonreassuring fetal heart rate patterns
 signs of hypovolemic shock, or fetal death.
 grouped under the classification
“autoimmune antibodies that result in
various coagulopathies.”

Two (2) Main Types of Abruptio Placentae

1. hemorrhage is concealed
the bleeding occurs behind the placenta but the margins remain intact, causing formation of a
hematoma.
2. hemorrhage is apparent
 when bleeding separates or dissects the membranes from the endometrium and blood flows out
through the vagina.
 Amniotic fluid often has a classic “port wine” color.
 Apparent bleeding does not always correspond to the actual amount of blood lost
 signs of shock (tachycardia, hypotension, pale color, and cold, clammy skin) may be present when
little or no external bleeding occurs.
 The woman may have an undiagnosed hypertensive disorder that masks hypovolemia until late
hypotension occurs.
In either type, the placental abruption may be complete or partial. In cases of concealed hemorrhage, The hemorrhage is apparent.

NOTE:
Note:
Abdominal pain is also related to the type of separation:
• Sudden and severe when bleeding occurs into the myometrium (uterine muscle) or be intermittent and difficult to distinguish
from labor contractions.
• The uterus may become exceedingly firm (boardlike) and tender, making palpation of the fetus difficult.

Ultrasound examination is helpful to rule out placenta previa as the

cause of bleeding, but it cannot be used to diagnose abruptio
placentae reliably because the separation and bleeding may not be
obvious on ultrasonography.

THERAPEUTIC MANAGEMENT
If the condition is mild and the fetus is under 34 weeks and shows no
signs of distress, conservative management may be initiated.
• bed rest
• administration of tocolytic medications to reduce uterine activity
• steroids to accelerate fetal lung maturity.
• Immediate delivery of the fetus is necessary if signs of fetal
compromise exist or if the mother exhibits signs of excessive bleeding,
• Intensive monitoring of both the woman and the fetus is essential
• Blood products for replacement should be available, and two large-
bore IV lines should be started for replacement of fluid and blood.

 Serial Kleihauer-Betke (K-B) tests

determine if fetal bleeding is worsening. It
is utilized to determine if there is
fetal blood in maternal circulation.

 For the Rh-negative woman, RhoGAM

is usually ordered to prevent possible
maternal Rh sensitization. (This happens
if the pregnant woman has an Rh+ baby)
RhoGAM is a medicine that stops your blood from making
antibodies that attack Rh-positive blood cells
HYPERTENSIVE DISORDERS OF PREGNANCY

Gestational hypertension Preeclampsia Eclampsia Chronic hypertension

Blood pressure elevation after 20
weeks of pregnancy that is not
accompanied by proteinuria.
Gestational
hypertension must be considered
a working diagnosis because it
may progress to preeclampsia. If
gestational hypertension persists
after birth, chronic hypertension
is diagnosed.
A systolic blood pressure of 140 Progression of preeclampsia The elevated blood pressure
mm Hg or greater or a diastolic to generalized seizures that was known to exist before
blood pressure of 90 mm Hg or cannot be attributed to other pregnancy or before 20 weeks
greater occurring after 20 weeks causes. Seizures may occur of gestation. Unrecognized
of pregnancy that is accompanied chronic hypertension may not
postpartum.
by significant proteinuria (≥0.3 g be diagnosed until well after
in a 24- hour urine collection,
the end of pregnancy when
which usually correlates with a
random urine dipstick evaluation the blood pressure remains
of ≥1+). Edema, although high.
common in preeclampsia, is now
considered to be nonspecific
because it occurs in many
pregnancies not complicated by
hypertension.

Preeclampsia
 is a condition in which hypertension
develops during the last half of pregnancy
in a woman who previously had normal
blood pressure.
• In addition to hypertension, renal
involvement may cause proteinuria.
• Many women also experience
generalized edema.
• The only known cure is birth of the fetus. Classic Signs
Note: 1. Hypertension
 Maternal and fetal morbidity can 2. Proteinuria
be minimized if preeclampsia is detected 3. Generalized edema
Additional Signs:
early and managed carefully. •When the retina is examined, vascular constriction and
narrowing of the small arteries are obvious in most women with
Incidence preeclampsia.
•DTRs may be very brisk (hyperreflexia), suggesting cerebral
irritability secondary to decreased brain circulation and edema
• Preeclampsia is relatively common, affecting 5% to 10%
of all pregnancies.
• It is a major cause of perinatal death, and it is often
associated with intrauterine fetal growth restriction
• Preeclampsia is most likely to occur in a first pregnancy,
in women older than 35 years, in African-Americans, in
those with a positive family history, and in those with
chronic hypertension or renal disease.
Risk Factors
• obesity and prepregnancy diabetes may be interrelated.
• Being overweight increases a woman’s risk for
preeclampsia,
as it does for chronic hypertension.
•Women with diabetes or multifetal gestations are also
more likely to have preeclampsia.
•The presence of immunologic or genetic disorders such
as
lupus or clotting disorders
Symptoms
• Continuous headache
• Drowsiness
• Mental confusion indicate poor cerebral perfusion and may be
precursors of seizures
• Visual disturbances such as blurred or double vision or spots before
The eyes indicate arterial spasms and edema in the retina.
• Numbness or tingling of the hands or feet occurs when nerves are
compressed by retained fluid
• Epigastric pain or “upset stomach” are particularly ominous because
They indicate distention of the hepatic capsule and often mean that a
seizure is imminent.
• Decreased urinary output indicates poor perfusion of the kidneys and
may precede acute renal failure

•The woman who had prior pregnancies with hypertension

is more likely to have
Preventive Measures
• Low-dose aspirin
• Prenatal Care • calcium and magnesium supplements
-Early and regular prenatal care with attention to pattern of • fish oil supplements
weight gain and monitoring of blood pressure and urinary • Low-dose aspirin of 81 mg/day appears to have minimum
protein level may minimize maternal and fetal morbidity and benefit in high-risk women.
mortality by allowing early detection of the problem.
Mild Pre-eclampsia

• Has proteinuria and blood pressure rises to 140/90 mm Hg, taken on two
occasions at least 6 hours apart.
• A systolic blood pressure greater than 30 mm Hg and a diastolic pressure
greater than 15 mm Hg above prepregnancy values.
• Proteinuria (1+ or 2+ on a reagent test strip on a random sample)
• Edema develops because of the protein loss, sodium retention, and
lowered glomerular filtration rate.
• The edema is not just the typical ankle edema of pregnancy but begins to
accumulate in the upper part of the body.
• A weight gain of more than 2 lb/wk in the second trimester or 1 lb/wk in
the third trimester usually indicates abnormal tissue fluid retention.

Therapeutic Management of Mild Preeclampsia

• The only cure for preeclampsia is delivery of the baby.

• If the fetus is less than 34 weeks of gestation, steroids to
Accelerate fetal lung maturity will be given and an attempt
made to delay birth for 48 hours.
• However, if the maternal or fetal condition deteriorates, the
Infant must be delivered, regardless of fetal age or
administration of steroids.
• Vaginal birth is preferred because of the multisystem
impairments.

Therapeutic Management of Mild Preeclampsia

1. Activity Restrictions. The mother should rest

frequently, although full bed rest is not required for
mild preeclampsia.
2. A lateral position for at least 1 1/2 hours a day
decreases pressure on the vena cava, thereby
increasing cardiac return and circulatory volume and
improving perfusion of the woman’s vital organs and
the placenta.
3. Blood pressure should be checked in the same arm
and in the same position two to four times each day
4. Weight. The woman should weigh herself each
morning, preferably on the same scale and in
clothing
of similar weight.
5. Urinalysis. A urine dipstick test for protein, using the
first voided midstream specimen, should be
performed daily.
6. Fetal Assessment. Because vasoconstriction can
reduce placental flow, observe for evidence of fetal
compromise.
 Fetal compromise can be evidenced by reduced
fetal movement noted by the mother (“kick
counts”).

7. Ultrasonography for fetal growth and quantity of

amniotic fluid or as part of a biophysical profile
(BPP).

 A diminishing amount of amniotic fluid suggests

placental impairment. If the pregnancy is less
than 34 completed weeks and delivery is being
considered but is not yet urgent, amniocentesis
is often done to evaluate fetal lung maturity.
Severe Pre-eclampsia Other Clinical Manifestations:
• Blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic 1. severe epigastric pain
or above on at least two occasions 6 hours apart at bed rest (the 2. nausea and vomiting, possibly
position in which blood pressure is lowest) or her diastolic pressure is because of abdominal edema or
30 mm Hg above her prepregnancy level. ischemia to the pancreas and liver
• Marked proteinuria, 3+ or 4+ on a random urine sample or more 3. feeling of shortness of breath if
than 5 g in a 24-hour Urine collection, and extensive edema are also pulmonary edema develops
present. 4. visual disturbances such as blurred
• Extreme edema is most readily palpated over bony surfaces, such as vision or seeing spots before the eyes
over the tibia on the anterior leg, the ulnar surface of the forearm,
if cerebral edema occurs.
and the cheekbones, where the sponginess of fluid-filled tissue can
5. Cerebral edema also produces
be palpated against bone.
• If there is swelling or puffiness at these points to a palpating finger but symptoms of severe headache and
the marked hyperreflexia and perhaps
swelling cannot be indented with finger pressure, the edema is ankle clonus (a continued motion of
nonpitting. the foot).
• If the tissue can be indented slightly, this is 1+ pitting edema;
• moderate indentation is 2+;
• deep indentation is 3+;
• and indentation so deep it remains after removal of the finger is
4+ pitting edema
 This accumulating edema will reduce their urine
output to approximately 400 to 600 mL per 24 hours.

INPATIENT MANAGEMENT OF SEVERE PRE-ECLAMPSIA Anticonvulsant Medications

Antepartum Management.
1. Goals of management are to improve placental
blood
flow and fetal oxygenation and to prevent
seizures and other maternal complications such
as stroke as the woman’s condition is stabilized
before birth.
 Bed Rest. The woman is prescribed bed
rest in
the lateral position, and her environment
is
kept quiet. External stimuli (e.g., lights,
noise)
that might precipitate a seizure should be
reduced.
 Electronic fetal monitoring (EFM) is
usually
 continuous.
Antihypertensive Medications
 Hydralazine (Apresoline) is a
vasodilator that increases cardiac
output and blood flow to the placenta.
 Nifedipine (a calcium channel blocker)
or labetalol (a beta-adrenergic blocker)
1. Caution! is essential when
antihypertensive medications are given to the
woman receiving magnesium sulfate because
hypotension may result, reducing placental
perfusion.
•Magnesium sulfate is the drug most often used to prevent
seizures.
Adverse reactions to magnesium sulfate:
1.CNS depression, including depression of the respiratory center.
2.Absence of deep tendon reflexes
3.Reduced urine output as the Magnesium is excreted solely by the
kidneys, in preeclampsia, allows magnesium to accumulate to toxic
levels in the woman.
Magnesium acts as a central nervous system (CNS) depressant by
blocking neuromuscular transmission and decreasing the amount of
acetylcholine liberated. Magnesium is not an antihypertensive
medication, but it relaxes smooth muscle, including the uterus, and
thus reduces vasoconstriction, possibly resulting in modest blood
pressure reduction. Decreased vasoconstriction promotes circulation
to the vital organs of the expectant mother and increases placental
circulation.
The therapeutic serum level for magnesium is 4 to 8 mg/Dl
Magnesium is administered via a secondary line so that the
medication can be discontinued at any time while the primary
line remains functional.
The major advantage of magnesium is its long record of safety
for mother and baby while preventing maternal
seizures
The loading dose is 4 g IV over 20 to 30 min, followed by a
maintenance dose of 1 g/h by continuous infusion for 24 h or
until 24 h after delivery.
SIGNS OF MAGNESIUM TOXICITY
•Magnesium excess depresses the entire CNS, including
the brainstem, which controls respirations and cardiac
function, and the cerebrum, which controls memory,
mental processes, and speech.
•Carbon dioxide accumulates if the respiratory rate is
reduced, leading to respiratory acidosis and further CNS
depression, which could culminate in respiratory arrest.
1. Respiratory rate of less than 12 breaths per minute
(hospitals may specify a rate of less than 14 breaths per
minute)
2. Maternal pulse oximeter reading lower than 95%
3. Absence of DTRs
4. Sweating, flushing
5. Altered sensorium (confused, lethargic, slurred speech,
drowsy, disoriented)
6. Hypotension
7. Serum magnesium value above therapeutic range of 4
to 8 mg/dL
INTRAPARTUM MANAGEMENT
1. The woman should be kept in a lateral
position to promote circulation through the
placenta
1. Efforts should focus on controlling pain that may
cause agitation and precipitate seizures
2. Oxytocin to stimulate uterine contractions and magnesium
sulfate to prevent seizures are often administered
simultaneously during labor when a woman has
preeclampsia.
The woman will have two secondary infusions in addition
to her primary infusion line, one for oxytocin
and one for magnesium.
3. Opiate analgesics or epidural analgesia may be
administered
to provide comfort and to reduce painful stimuli that could
precipitate a seizure.
4. A pediatrician, neonatologist, or neonatal nurse
practitioner must be available to care for the newborn at
birth.
5. A neonatal resuscitation team is often called to the birth.
Protect the Woman and the Fetus during a Seizure
• Remain with the woman and press emergency bell for assistance.
•If she is not on her side already, attempt to turn the woman onto her
side when the tonic phase begins. A side-lying position permits
greater circulation through the placenta and may prevent aspiration.
•Note the time and sequence of the seizure. Eclampsia is
marked by a tonic-clonic seizure that may be preceded by facial
twitching that lasts for a few seconds. A tonic contraction
of the entire body is followed by the clonic phase, which may last
about 1 minute. Insert an airway after the seizure, and suction the
woman’s mouth and nose to prevent aspiration.
•Administer oxygen by mask at 8 to 10 L/min to increase
oxygenation of the placenta and all maternal body organs.
•Notify the physician that a seizure has occurred. This is an
obstetric emergency that is associated with cerebral hemorrhage,
abruptio placentae, severe fetal hypoxia, and death. Administer
medications and prepare for additional medical interventions as
directed by the physician.
RESPOND TO SIGNS OF MAGNESIUM TOXICITY
1. Discontinue magnesium if the respiratory rate
is below 12 breaths per minute, a low pulse
oximeter level(<95%) persists, or DTRs are absent.
2. If the urinary output falls below 30 mL/hr, the
physician is notified so that the drug’s
administration can be adjusted to maintain a
therapeutic range.
3. Calcium opposes the effects of magnesium at
the neuromuscular junction, and it should be
readily available whenever magnesium is
administered. Magnesium toxicity can be
reversed by IV administration of 1 g (10 mL of
10% solution) of calcium gluconate at 1
mL/min
Therapeutic Management of Eclampsia
• Early identification of preeclampsia in a pregnant woman
allows intervention before the condition reaches the seizure
stage in most cases.
Generalized seizures usually start with facial twitching,
followed by rigidity of the body.
Tonic-clonic movements then begin and last for about 1
minute.
 Breathing stops during a generalized seizure but
resumes with a long, noisy inhalation.
 The woman is temporarily in a coma and is
unlikely to remember the seizure when she
resumes consciousness.
 Transient fetal heart rate patterns such as
bradycardia, loss of variability, or late
decelerations may be nonreassuring.
 Fetal tachycardia may occur as the fetus
compensates for the period of maternal apnea
during the seizures.
 Eclampsia may occur during pregnancy or in the
intrapartum or postpartum period.
Magnesium sulfate is the drug of choice to control eclamptic
seizures.
 Furosemide (Lasix) may be administered pulmonary
edema develops.
Administration of oxygen via a face mask at 8 to 10 L/min
improves maternal and fetal oxygenation. Digitalis may be
needed to strengthen contraction of the heart if circulatory
failure results.
Postpartum Management
• After birth, careful assessment of the mother’s blood loss and signs
of shock is essential because the hypovolemia caused by
preeclampsia may be aggravated by blood loss during the delivery.
• Assessments for signs and symptoms of preeclampsia must be
continued for at least 48 hours, and administration of magnesium
along with its associated care usually is continued to prevent
seizures for 24 hours.
Signs that the woman is recovering from preeclampsia
 Urinary output of 4 to 6 L/day
 rapid reduction in edema
 rapid weight loss
 Decreased protein in the urine
 Return of blood pressure to normal, usually within 2 weeks
HEMORRHAGIC CONDITIONS OF
LATE PREGNANCY
Venous Thromboembolic Disease
• A combination of stasis of blood in the
lower extremities from uterine pressure
and hypercoagulability (the effect of elevated
estrogen)
• When the pressure of the fetal head at
birth puts additional pressure on lower extremity
veins, damage can occur to the walls of the veins.
Treatment:
1. Bed rest
2. Intravenous heparin for 24 to 48 hours.
3. She may be prescribed subcutaneous heparin
every 12 or 24 hours for the duration of the pregnancy.
Chief danger of thrombophlebitis:
1. pulmonary embolism or a clot lodging in
the pulmonary artery and blocking circulation
to the lungs and heart
Urinary Tract Infection
• In a pregnant woman, the ureters dilate
from the effect of progesterone, stasis of urine occurs.
• The minimal glucosuria that occurs with pregnancy
allows more than the usual number of organisms to grow.
• This causes asymptomatic urinary tract infections (UTIs) in
as many as 10% to 15% of pregnant women (
Why potentially dangerous?
1. they can progress to pyelonephritis
(infection of the pelvis of the kidney)
2. preterm labor
3. premature rupture of membranes
Causative agent: Escherichia coli from an ascending
infection.
• A UTI can also occur as a descending infection, or begin in the
kidneys from the filtration of organisms present from other
body infections.
• If determined by Streptococcus B, vaginal cultures should be
obtained because streptococcal B infection of the genital tract
is associated with pneumonia in newborns
UTI typically is manifested by:
• frequency and pain on urination
With Pyelonephritis:
• pain in the lumbar region (usually on the right side)
that radiates downward
• The area feels tender to palpation
• nausea and vomiting
• malaise
• pain
• frequency of urination
• temperature may be elevated only slightly or may be as high
as 103° to 104° F (39° to 40° C)
• A urine culture will reveal over 100,000 organisms
per milliliter of urine, a level diagnostic of infection
Note: The infection usually occurs on the right side because there is greater compression and urinary stasis on the right ureter from the
uterus being pushed that way by the large bulk of the intestine on the left side.
Triad effects:
1. Stasis
2. vessel damage
3. hypercoagulation
s/s: pain and redness usually in the calf of a leg
Common-sense measures:
• avoiding the use of constrictive knee-high stockings
• not sitting with legs crossed at the knee
• avoiding standing in one position for a long period
Diagnostic Test: Doppler ultrasonography
• Generally, lower abdomen be used for rotating sites for
subcutaneous heparin administration. With pregnancy,
however, this site is usually avoided and the injection sites are
limited to the arms and thighs.
• Heparin dosage is regulated by frequent partial
thromboplastin time (PTT) determinations.
Symptoms:
• Chest pain
• Sudden onset of dyspnea
• Cough with hemoptysis
• Tachycardia or missed beats
• Severe dizziness or fainting from lowered blood pressure
Therapeutic Management
• Obtain a clean-catch urine for Culture and Sensitivity Test will
determine which antibiotic will best combat the infection.
 Amoxicillin, ampicillin, and cephalosporins are effective
against most organisms causing UTIs and are safe
antibiotics during pregnancy
 The sulfonamides can be used early in pregnancy but not
near term because they can interfere with protein binding
of bilirubin, which then leads to hyperbilirubinemia in the
newborn.
 Tetracyclines are contraindicated in pregnancy as they
cause retardation of bone growth and staining of the fetal
teeth
Common measures to prevent UTIs, such as:
• Voiding frequently (at least every 2 hours)
• Wiping front to back after voiding and bowel movements
• Wearing cotton, not synthetic fiber, underwear
• Voiding immediately after sexual intercourse
• take the additional measure of drinking an increased amount of
fluid to flush out the infection from the urinary tract
• Give a specific amount to drink every day (up to 3 to 4 L per 24
hours) to make certain she does increase her fluid intake
sufficiently.
• Assume a knee–chest position for 15 minutes morning and evening
 the weight of the uterus is shifted forward, releasing the
pressure on the ureters and allowing urine to drain more
freely
Pyelonephritis
Incidence:
 Pyelonephritis is the most common
urinary tract complication in pregnant
women, occurring in approximately
0.5-2% of all pregnancies
 Up to 90% of cases have been reported
to occur in the second and third
trimesters.
Causes:
 Increased progesterone and increased
pressure on the ureters can result in an
increased risk of pyelonephritis.
• occurs as an extension of a urinary tract infection
or infection that originated in or spread to the
kidney
Effects to pregnancy:
• Premature baby or low birthweight baby
• complications in the kidneys
Note: The risks are higher if there are no any
symptoms
TRIAD Symptoms: fever, flank pain, and nausea or
vomiting
Other Symptoms:
• vomiting.
• cloudy, dark, bloody, or foul-smelling urine.
• frequent, painful urination.
NURSING MANAGEMENT
1. Advise patients to drink plenty of fluids
2. urinate as soon as they have the urge
3. empty the bladder completely before bed
4. promptly report signs and symptoms of UTI or pyelonephritis
5. complete the course of antibiotic therapy as prescribed
Management
• If this develops, a woman may be hospitalized for 24 to 48 hours while she is
treated with intravenous antibiotics.
• After this acute episode, she will be maintained on a drug such as Oral
nitrofurantoin (Macrodantin) for the remainder of the pregnancy.
• A 3rd generation cephalosporin (4 dd 1000 mg cefotaxime or 1 dd 2000 mg
ceftriaxone) is the drug of first choice for the treatment of pyelonephritis
during pregnancy.
• The treatment duration of cystitis and pyelonephritis during pregnancy should
be at least 5 days, and 10-14 days, respectively.
• Acidifying urine by the use of ascorbic acid (vitamin C), which is often
recommended in nonpregnant women, is NOT usually recommended during
pregnancy because a newborn can develop scurvy in the immediate neonatal
period from withdrawal.
DIAGNOSTIC TEST
 urine test can determine whether symptoms are the result of a kidney
infection.
 The presence of white blood cells and bacteria in urine, which can be
viewed under a microscope, are both signs of infection
Possible complications if not treated:
• renal abscess formation
• sepsis
• renal vein thrombosis
• papillary necrosis
• acute renal failure
• emphysematous pyelonephritis

Hemolysis is believed to occur as a result of the fragmentation

and distortion of erythrocytes during passage through small
damaged blood vessels.
Elevated Liver Enzyme when hepatic blood flow is obstructed
by fibrin deposits. Hyperbilirubinemia and jaundice may occur as
a result of liver impairment.
Low platelet levels are caused by vascular damage resulting
from vasospasm; platelets aggregate at sites of damage, resulting
in thrombocytopenia, which increases the risk for bleeding,
usually in the

Diagnostic Test:
Blood Tests to Evaluate:
• platelet levels
• liver enzymes
• red blood cell count
• rine test to check for abnormal proteins
• MRI to determine whether there's bleeding in the liver
CLINICAL MANIFESTATIONS
The prominent symptom of HELLP syndrome is:
• pain in the right upper quadrant, the lower right chest,
or the mid- epigastric area
• tenderness because of liver distention

Additional signs and symptoms include:

• nausea
• Vomiting
• severe edema
• A sudden increase in intraabdominal pressure, including
that caused by a seizure, could lead to rupture of a
subcapsular hematoma, resulting in internal bleeding and
hypovolemic shock.
• Hepatic rupture can lead to fetal and maternal mortality

Infants born to mothers with HELLP syndrome may

have a variety of birth injuries: Bleeding inside or around the ventricles.
• Intrauterine growth restriction (IUGR) Bleeding can occur because blood vessels in a
• Severe respiratory distress premature baby's brain are very fragile and
• Intraventricular hemorrhage (IVH) immature and easily rupture.
Anomalies of the Placenta
-The normal placenta weighs approximately 500 g and is
15 to 20 cm in diameter and 1.5 to 3.0 cm thick.
Its weight is approximately one sixth that of the fetus.

Placenta Succenturiata
 is a placenta that has one or more accessory lobes
connected to the main placenta by blood vessels.

Placenta Circumvallata
 the fetal side of the placenta is covered to
some extent with chorion

Placenta Marginata
 the fold of chorion reaches just to the edge of
the placenta.

Battledore Placenta
 The cord is inserted marginally rather than centrally Vasa Previa
 This anomaly is rare and has no known clinical  the umbilical vessels of a velamentous cord insertion
significance cross the cervical os and therefore deliver before the fetus
either.
Placenta Accreta
Velamentous insertion of the cord is a situation in which  is an unusually deep attachment of the placenta to the
uterine myometrium so deeply the placenta will not loosen
the
and deliver
cord, instead of entering the placenta directly, separates  Hysterectomy or treatment with methotrexate to destroy
into the still-attached tissue may be necessary.
small vessels that reach the placenta by spreading across a
fold of amnion

Fetal death in utero

Causes of FDIU
 Refers to the death of a fetus after
the twentieth week of gestation and 1. chromosomal abnormalities
before birth. 2. congenital malformations
 The client can develop DIC if the 3. infections such as hepatitis B,
dead fetus is retained in the uterus 4. immunologic causes
5. complications of maternal disease
for 3-4 weeks or longer.

Assessment:
1. Absence of fetal movement
2. Absence of fetal heart tones
3. Maternal weight loss
4. Lack of fetal growth or decrease in
fundal height
5. No evidence of fetal cardiac activity
6. Other characteristics suggestive of
fetal death noted on ultrasound.
INTERVENTIONS
• Prepare for the birth of the fetus.
• Support the client’s decision about labor, birth and the postpartum period.
• Accept behaviors such as anger and hostility from the parents.
• Refer the parent to an appropriate support group.
Note: Cultural, spiritual, and religious practices and beliefs are important to
consider when caring for the parents of a fetus who has died.

Hepatitis B
 The risk of prematurity, low birth weight, and
neonatal death increase if the mother has hepatitis
B infection.

Interventions:
1. Minimize the risk for intrapartum ascending infections (limit the number of vaginal examinations).
2. Remove maternal blood from the neonate immediately after birth.
3. Suction the fluids from the neonate immediately after birth.
4. Bathe the neonate before any invasive procedures.
5. Clean and dry the face and eyes of the neonate before instilling eye prophylaxis.
6. Infection of the neonate can be prevented by the administration of Hepatitis B immune globulin and hepatitis B vaccine soon after birth.
7. Discourage the mother from kissing the neonate until the neonate has received the vaccine.
8. Inform the mother that the hepatitis B vaccine will be administered to the neonate and that a second dose should be administered at 1
month after birth and a third dose at 6 months after birth.
Hematoma
 It occurs following the escape of blood into the maternal tissue after birth.
 Predisposing conditions include operative delivery with forceps or injury to a blood vessel.

Assessment Findings: Interventions:

1. Abnormal, severe pain 1. Monitor vital signs.
2. Pressure in perineal area (client states that she 2. Monitor client for abnormal pain, especially when forceps delivery has been
feels like she has to have a bowel movement. performed.
3. Palpable, sensitive swelling in the perineal 3. Apply ice to the hematoma site.
area, with discolored skin. 4. Administer analgesics as prescribed.
4. Inability to void 5. Monitor intake and output.
5. Decreased hemoglobin and hematocrit levels 6. Encourage fluids and voiding, prepare for urinary catheterization if unable to void.
6. Signs of shock if significant blood loss has 7. Administer blood replacements as prescribed.
occurred: 8. Monitor for signs of infection, such as increased TPR and WBC count.
7. pallor, 9. Administer antibiotics as prescribed because infection is common after
8. tachycardia, and hematoma formation.
9. hypotension 10. Prepare for incision and evacuation of the hematoma if necessary.

INCOMPATIBILITY BETWEEN MATERNAL AND FETAL BLOOD
Rhesus (Rh) factor incompatibility during pregnancy is possible only
when two specific circumstances coexist:
(1) the mother is Rh-negative (D-negative)
(2) the fetus is Rh-positive.
For such a circumstance to occur, the father of the fetus must be Rh-
positive.
 Rh incompatibility is a problem that affects the fetus; it causes no
harm to the mother.
 Rh-negative blood is an autosomal recessive trait, and a person
must inherit the same gene from both parents to be Rh-negative.
rhesus positive (RhD positive)
 it means that a protein (D antigen) is found on the
surface of the red blood cells.
 Most people are RhD positive. If one has rhesus
negative (RhD negative), she do not have the D
antigen on her blood cells
Pathophysiology
• When blood from a person who is Rh-positive enters the
bloodstream of a person who is Rh-negative, the body
reacts as it would to any foreign substance:
• It develops antibodies to destroy the invading antigen. To
destroy the Rh antigen, which exists as part of the RBC, the
entire RBC must be destroyed.
• Destruction of Rh-positive cells occurs in the Rh-negative
person after they have become sensitized to the Rh-positive
antigens.
• Most exposure of maternal blood to fetal blood occurs
during the third stage of labor, when active exchange of
fetal and maternal blood may occur from damaged
placental vessels.
• In this case the woman’s first child is not usually affected
because antibodies are formed after the birth of the infant.

Management
RhoGAM is administered to the unsensitized Rh-negative
woman at 28 weeks of gestation to prevent sensitization ,
which may occur from small leaks of fetal blood across the
placenta. Administration of RhoGAM is repeated after birth if
the woman delivers an Rh-positive infant.

RhoGAM is a commercial preparation of passive antibodies

against Rh factor. It effectively prevents the formation of
active antibodies against Rh-positive erythrocytes if a small
amount of fetal Rh- positive blood enters the circulation of
the Rh-negative mother during the remainder of the
pregnancy.
ABO Incompatibility
 occurs when the mother is blood type O and the fetus is blood type A, B, or AB.
 Types A, B, and AB blood contain a protein component (antigen) that is not present in type O blood.
 Some women with blood type O have developed high serum anti-A and anti-B antibody titers before pregnancy.
 The antibodies may be either immunoglobulin G (IgG) or IgM.
 When the woman becomes pregnant, the IgG antibodies cross the placental barrier and cause hemolysis of fetal RBCs.
 ABO incompatibility is less severe than Rh incompatibility because the primary antibodies of the ABO system are IgM,
which do not readily cross the placenta.
Assessment and management
1. No specific prenatal care is needed.
2. During the delivery, cord blood is taken to determine the blood type of the newborn and the antibody titer (direct
Coombs’ test).
3. Newborn is carefully screened for jaundice, which indicates hyperbilirubinemia.

MULTIPLE PREGNANCY Identical (monozygotic) Twins

 begin with a single ovum and spermatozoon.
 In the process of fusion, or in one of the first cell divisions, the zygote divides into two identical individuals.
 Single-ovum twins usually have one placenta, one chorion, two amnions, and two umbilical cords.
 The twins are always of the same sex and have same genotype.
Two thirds of twins are fraternal (dizygotic, nonidentical), the result of the fertilization of two separate ova by two separate
spermatozoa (possibly not from the same sexual partner).

Double-ova twins have two placentas, two chorions, two amnions, and two umbilical cords.
 The twins may be of the same or different sex.
 It is sometimes difficult to determine by ultrasound or at birth whether twins are identical or fraternal because the two
fraternal placentas may fuse and appear as one large placenta

With monozygotic twins, the fetuses

can share vascular communication,
possibly leading to overgrowth of
one fetus and undergrowth of the
second (a twin-to-twin transfusion),
resulting in discordant infants

Factors Influencing Embryonic and Fetal

Development
1. Environment:
a. poverty
b. malnutrition
c. maternal alcohol, nicotine, or illicit Genetic Principles Influencing Fetal Growth And Development
drug use
Chromosomal Structure
d. maternal prescription drug use (e.g.
• Chromosomes
anticoagulants, anticonvulsants, antibiotics)
 in the nucleus of the cell, carry the hereditary material that determines
the individual’s physical characteristics.
2. Anatomic Problems:
 A threadlike strands of DNA.
a. Maternal Problems: ectopic
pregnancy, uterine abnormality,
•Genes
retroversion of the uterus,
 Are small segments of DNA contained in the chromosomes.
incompetent cervical os)
 Some are dominant, some are recessive, and some may be sex-linked
b. Fetal problems include chromosomal
defects and poor implantation
• Alelles
 pairs of genes. There CHROMOSOMAL
are two (2) genesINHERITANCE DISORDER
for every human trait.
3. Maternal Complications
 Some gene comes from ovum and one comes from the sperm.
4. Fetal Complications 1. Autosomal dominant disorder
5. Physiologic problems - The clinical expression of a gene when one allele at a given chromosome
• Phenotype
 is anlocus is mutant
individual’s (heterozygous).
physical appearance determined by the alleles.
2. Autosomal recessive disorder
• Genotype- the clinical expression of a gene when both alleles at a given chromosome
 refers locus are individual’s
to the mutant (homozygous).
actual gene composition.
3. X-linked dominant disorder
Inheritance Patterns Note: The -sex
thisofrefers only is
the fetus todetermined
women. at the time of fertilization by
• A person who has two genes for a trait is
- Men, having only one X chromosome
the combination of the sex chromosomes andsperm
of the (X or Y) and , will
one Y chromosome
always
the ovum (X or X). be affected if they inherit an X- linked mutant gene
homogenous for that trait. 4. X- linked recessive disorder
• A person who has two genes that differ a. Women will be asymptomatic for a trait if heterozygous for an X- linked
(one is dominant, one is recessive) is recessive trait.
heterozygous for that trait. b. Women will be affected if homozygous for an X-linked recessive disorder.
• The dominant gene will be expressed for any trait. 5. Multifactoral Inheritance
- involves traits and disorders resulting from the interaction of many genetic
factors or the interaction of genetic and environmental factors.
• Recessive genes will be expressed only if both
genes in the allele carry them.
MENDELIAN LAWS: • allow to predict inheritance of
characteristics such as eye and
hair color.
• Can also predict whether the child
will be born with genetic disorder.

CHROMOSOMAL ABNORMALITY DISORDER

CAUSES: Specific Diagnostic Tests
1. Hereditary • Karyotyping – is a visual display of the individual’s actual chromosome
2. Exposure to teratogens pattern.
3. Advance maternal age or conception • Heterozygous screening – is directed at detecting clinically normal
carriers of a disease-causing mutant gene, particularly in people of
Types:
ethnic groups with high frequency of the mutant gene under investigation
A. Numeric Abnormalities • Maternal serum alpha-fetoprotein (MSAFP) – screen is selectively
- usually too many; too few chromosomes usually done when an open neural tube defect is suspected.
results in miscarriage) in sex chromosomes and • Triple screening – analysis of 3 indicators (MASFP), estriol, and HCG.
autosomes (Turner syndrome, trisomy 18, 21) • Chorionic Villi Sampling
• Amniocentesis
• Percutaneous umbilical blood sampling
B. Structural disorders
• Sonography
- such as deletions ( cri du chat syndrome) and
translocations.

INFECTIONS (TORCH COMPLEX ACRONYM)

TOXOPLASMOSIS (“T”)
• caused by infection with the intracellular protozoan parasite Toxoplasma gondii
• Produces a rash and symptoms of acute, flulike infection in the mother
• Transmitted to the mother through raw meat or handling of cat litter of infected cats
• Organism is transmitted to the fetus across the placenta
• Can cause spontaneous abortion in the first trimester
OTHER INFECTIONS (“O”, includes HIV, syphilis, STI, HBV, etc.)
RUBELLA (GERMAN MEASLES) (“R”)
• Teratogenic in the first trimester
• Organism is transmitted to the fetus across the placenta
• Causes congenital defects of the eyes, heart, ears, and brain
• If not immune (titer less than 1:8), the client should be vaccinated in the postpartum period; the client must wait 1 to 3 months before
becoming pregnant.
CYTOMEGALOVIRUS (“C”)
• Organism is transmitted through close personal contact; it is transmitted across the placenta to the fetus, or the fetus may be infected
through the birth canal.
• The mother may be asymptomatic; most infants are asymptomatic at birth.
• Cytomegalovirus causes low birth weight, intrauterine growth restriction, enlarged liver and spleen, jaundice, blindness, hearing loss, and
seizures.
• Antiviral medications may be prescribed for severe infections in the mother, but theses medications are toxic and may only temporarily
suppress shedding of the virus.
HERPES SIMPLEX (“H”)
• It affects the external genitalia, vagina, and cervix and causes draining, painful vesicles.
• Acyclovir can be used to treat recurrent outbreaks during pregnancy or used as a suppressive therapy late in pregnancy to prevent an
outbreak during labor and birth.
• Virus usually is transmitted to the fetus during birth through the infected vagina or via an ascending infection after rupture of the
membranes.
• No vaginal examinations are done in the presence of active vaginal herpetic lesions.
• Herpes can cause death or severe neurological impairment in the newborn.
• Delivery of the fetus is usually by cesarean section if active lesions are present in the vagina.
• Delivery may be performed vaginally if the lesions are in the anal, perineal, or inner thigh area.
• Maintain contact precautions.

GROUP B Streptococcus (GBS) • Early onset newborn GBS occurs within the first week after birth,
•is the leading cause of life-threatening perinatal infections. usually within 48 hours, and can include infections such as sepsis,
• The gram-positive bacterium colonizes the rectum, vagina, cervix, pneumonia, or meningitis; permanent neurological disability can
And urethra of pregnant and non pregnant women. result.
•Transmission occurs during vaginal delivery. • Antibiotics such as penicillin may be prescribed for the mother during
• Diagnosis of the mother is done via vaginal and renal cultures at 35 to labor and birth.
37 weeks of gestation. • IV antibiotics may be prescribed for infected infants.
SEXUALLY TRANSMITTED DISEASE
CHLAMYDIA
 Sexually transmitted pathogen associated with an increased risk for premature birth, stillbirth, neonatal conjunctivitis, and newborn
chlamydial pneumonia.
 Can cause salpingitis, pelvic abscesses, ectopic pregnancy, chronic pelvic pain and infertility.
Diagnostic test: culture for Chlamydia trachomatis
ASSESSMENT:
• Usually asymptomatic
• Bleeding between periods or after coitus
• Mucoid or purulent cervical discharge
• Dysuria and pelvic pain
INTERVENTIONS:
• Screen the client to determine whether she is high risk
• Vaginal Culture is indicated for all pregnant clients if the client is in high-risk group or if infants from previous pregnancies have developed
neonatal conjunctivitis or pneumonia.
• Instruct the client in the importance of rescreening because reinfection can occur as the client nears team.
• Ensure that the sexual partner is treated.

SYPHILIS
• A chronic infectious disease caused by the organism Treponema pallidum
• Transmission is by physical contact with syphilitic lesions, which usually are found on the skin, mucous membranes of the mouth, or genitals.
• The infection may cause abortion or premature labor and is passed to the fetus after the fourth month of pregnancy as congenital syphilis.

STAGES OF SYPHILIS
1. PRIMARY STAGE
 Most infectious stage
 Appearance of ulcerative, painless lesions produced by spirochetes at point of entry into the body
2. SECONDARY STAGE
 Highly infectious stage
 Appearance of lesions about 6 weeks to 6 months after primary stage; located anywhere on the skin and mucous membranes
3. TERTIARY STAGE
 Entrance of spirochetes into internal organs, causing permanent damage
 Symptoms occur 10 to 30 years after untreated primary lesion
 Invasion of CNS, causing meningitis, ataxia, general paresis, and progressive mental deterioration
 Deleterious effects on aortic valve and aorta

INTERVENTIONS:
1. Obtain a serum test (Veneral Disease Research Laboratory or rapid plasma reagin) for syphilis on the first prenatal visit.
2. Prepare to repeat the test at 36 weeks of gestation because the disease may be acquired after the initial visit.
3. If the test result is positive, treatment with an antibiotic such as penicillin may be necessary.
4. Instruct the client that treatment of her partner is necessary if infection is present.

GONORRHEA
 An infection caused by Neisseria gonorrhoeae, which causes inflammation of the mucous
membranes of the genitals.
 Transmission of the organism is by sexual intercourse.
 Infection may be transmitted to the newborn’s eyes during delivery, causing blindness (ophthalmia neonatorum).
ASSESSMENT
• Usually asymptomatic INTERVENTIONS
 Obtain a vaginal culture during the
• vaginal discharge
 initial prenatal examination; may be
• Urinary frequency
 repeated in the third trimester
• Lower abdominal pain  Ensure that the sexual partner is treated

CONDYLOMATA ACUMINATUM (HUMAN PAPILLOMAVIRUS)

 Caused by human papillomavirus
 infection affects the cervix, urethra, anus, penis, and scrotum
 A culture is indicated for clients with positive history or with active lesions, and weekly cultures may be done starting at week 35 or 36
of pregnancy until delivery- to determine the route of delivery.
 Transmitted through sexual contact
ASSESSMENT
• Infection produces small to large wart-like growths to the genitals.
• Cervical ell changes
INTERVENTIONS
 Lesions are removed by the use of cytotoxic agents, cryotherapy,
electrocautery, and laser
 Encourage annual Papanicolaou test
 Sexual contact should be avoided until lesions are healed.

TRICHOMONIASIS
ASSESSMENT INTERVENTIONS
 Caused by Trichomonas vaginalis
•Yellowish to greenish, frothy, mucopurulent, •Metronidazole may be prescribed
 A normal saline wet smear of vaginal copious, malodorous vaginal discharge •Sexual partner needed to be
Secretions indicates the presence of •Inflammation of vulva or vagina treated.
protozoa
 Transmitted through sexual contact
 Infection is associated with PROM and
 postpartum endometritis

VAGINAL CANDIDIASIS
 Caused by Candida abicans
 Predisposing factors include use of
antibiotics, diabetes mellitus, and obesity.
ASSESSMENT
INTERVENTIONS
• Vulvar and vaginal pruritus
•Antifungal preparations (Miconazole)
• White, lumpy, cottage cheese-like •Sitz bath
discharge from vagina • Sexual partner needed to be treated

HUMAN IMMUNODEFIEFICIENCY VIRUS (HIV) and ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)

• Causative agent: HIV
• Incubation period: 10 years or longer
• Women infected with HIV may first show signs and symptoms at the time of pregnancy or possibly develop life-threatening infections
because normal pregnancy involves some suppression of the maternal immune system.
• Repeated exposure to the virus during pregnancy through unsafe sex practices or IV drug use increase the risk of transmission to the fetus.
• Zidovudine is recommended for the prevention of maternal-to-fetal HIV transmission and is administered orally beginning after 14 weeks of
gestation, intravenously during labor, and in the form of syrup to the newborn for 6 weeks after birth

TRANSMISSION
1. Sexual exposure to genital secretions of an infected person
2. Parenteral exposure to infected blood and tissue
3. Perinatal exposure of an infant to infected maternal secretions through birth or breastfeeding.

Assessment
• Malaise, fever, anorexia, weight loss, influenza-like symptoms
• Lymphadenopathy for at least 3 months
• Leukopenia
• Diarrhea
• Fatigue
• Night sweats

Presence of opportunistic infections

• Protozoan infections (Pneumocystis jiroveci pneumonia,
a major source of mortality)
• Neoplasms (Kaposi’s sarcoma, purplish-red lesions of internal
organs and skin, B-cell non-Hodgkin’s Lymphoma, cervical cancer)
• Fungal infection (candidiasis)
• Viral infections (cytomegalovirus, herpes simplex)
• Bacterial infections

DIAGNOSIS
•Enzyme-linked immunosorbent assay (ELISA), Western Blot, and Immunofluorescence assay (IFA) – test used to determine the presence of
antibodies to HIV.
•A single reactive ELISA test by itself cannot be used to diagnose HIV, and the test should be repeated with the same blood sample; if the result
is again reactive, follow-up tests using WESTERN BLOT OR IFA should be done.
• A positive Western blot or IFA is considered confirmatory for HIV.
• A positive ELISA that fails to be confirmed by Western Blot or IFA should not be considered negative, and repeat testing should be done in 3
to 6 months.
INTERVENTIONS
Prenatal Period
• Prevent opportunistic infections
• Avoid procedure that increase the risk of perinatal transmission, such as amniocentesis and fetal scalp sampling.
Intrapartal Period
• If the fetus has not been exposed to HIV in utero, the higher risk exists during delivery through the birth canal.
• Avoid the use of internal scalp electrodes for monitoring of the fetus.
• Avoid episiotomy to decrease the amount of maternal blood in and around the birth canal.
• Avoid the administration of oxytocin because contraction induced by oxytocin can be strong, causing vaginal tears or necessitating an
episiotomy.
Intrapartal Period
• Place heavy absorbent pads under the mother’s hips to absorb amniotic fluid and maternal blood.
• Minimize the neonate’s exposure to maternal blood and body fluids; promptly remove the neonate from the mother’s blood after delivery.
• Suction fluids from the neonate promptly.
• Prepare to administer Zidovudine as prescribed to the mother during labor and delivery.
Postpartum Period
• Monitor signs of infection
• Place the mother in protective isolation if she is immunosuppressed.
• Restrict breast-feeding.
• Instruct the mother to monitor for signs of infection and report any signs if they occur.

THE NEWBORN AND HUMAN IMMUNODEFIEFICIENCY VIRUS (HIV)

 Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after
birth
 All neonates acquire maternal antibody to HIV infection, but not all acquire infection.
 The use of antiviral medication, reduced the exposure of the neonate to maternal blood and body fluids, and early identification of HIV
in pregnancy reduce the risk of transmission to the neonate.

Interventions:
1. Bathe the neonate carefully before any invasive procedure, such as administration of Vitamin K, heel sticks, or venipunctures
2. Clean the umbilical cord stump meticulously every day until healed.
3. The newborn can room with the mother.
4. Administer Zidovudine to the newborn as prescribed for the first 6 weeks of life.
5. All HIV exposed newborns should be treated with medication to prevent infection by neumocystis jiroveci.
6. HIV culture is recommended at 1 and 4 months after birth; infants at risk for HIV infection should be seen by the HCP at birth and at 1
week, 2 weeks, 1 month, 2 months, and 4 months of age.
7. The child may be asymptomatic for the first several years of life and should be monitored for early signs of immunodeficiency.
Infants at risk for HIV infection need to receive all recommended immunizations on the regular schedule; however, no live vaccines
should be administered.

Tuberculosis
 lung tissue is invaded by Mycobacterium tuberculosis, Transmission:
an acid- fast bacillus. • Transplacental transmission is rare
 Transmitted by airborne route • Occur during birth through aspiration of infected amniotic fluid.
 Multidrug-resistance can result from improper compliance, Diagnostic Test:
• Chest radiograph after 20 weeks of gestation
noncompliance with treatment programs, or development
of mutation in tubercle bacillus.

ASSESSMENT: INTERVENTIONs: ASSESSMENT: INTERVENTIONS:

Mother Pregnant Client NEONATE Newborn
 Possibly asymptomatic 1. Administration of isoniazid,  Fever Administration of isoniazid,
 Fever and chills pyrazinamide, and Rifampin daily for  Lethargy pyrazinamide, and Rifampin
 Night sweats 9 months, ethambutol is added if  Poor feeding daily for 9 months, ethambutol
 weight loss medication resistance is likely.  Failure to thrive is added if
 Fatigue 2. Pyridoxine should be administered  Respiratory distress medication resistance is likely.
 Cough and hemoptysis or with Isoniazid to prevent neurotoxicity  Hepatosplenomegaly • Skin Testing is performed in
Green or yellow sputum caused by Isoniazid  Meningitis newborn
 Dyspnea 3. Promote breastfeeding if and repeated in 3 to 4 months.
 Pleural pain noninfectious •If positive, Isoniazid for 6
months

COMPLICATIONS DURING LABOR & DELIVERY

A.DYSFUNCTIONAL LABOR
B.INVERSION OF THE UTERUS
C.UMBILICAL CORD PROLAPSE

A. DYSFUNCTIONAL LABOR
 Sluggishness of contractions, difficult, painful, prolonged
labor due to mechanical factors

1. Hypotonic
• low or infrequent contractions
• Prolongs labor causing exhaustion of uterus & risk for
 postpartal hemorrhage
• Cervix dilated for a long period risk for infection to mother and
fetus
Causes:
a. Inappropriate use of analgesia (excessive or too early)
b. Posterior and extension fetal position
c. Overdistention of the uterus multiple gestation, LGA,
hydramnios
d. cervical rigidity (unripe)
e. Full rectum or urinary bladder impedes fetal descent
Management: OXYTOCIN, AMNIOTOMY

2. Hypertonic
• Myometrium do not relax after a contraction
• Do not allow optimal uterine artery filling causing fetal
anoxia
Management: Rest, morphine sulfate, darken room lights,
decrease noise & stimulation
CS if: deceleration in FHR long 1st stage, lack of progress with pushing

B. INVERSION OF THE UTERUS

• Uterus turning inside out
• It occurs immediately following delivery of the placenta
or in the immediate postpartum period.
Causes:
• Traction applied to cord to remove placenta
• Pressure is applied to fundus when not contracted
1. Forced inversion 2. Spontaneous inversion – due to 3. Predisposing factors:
caused by excessive pulling of the increased abdominal • straining after delivery of the placenta,
cord or vigorous manual expression pressure from bearing down, • vigorous kneading of the fundus to expel the placenta
of the placenta or clots from an coughing, or sudden abdominal • Manual separation and extraction of the placenta
atonic uterus. muscle contraction. •Rapid delivery with multiple gestation

Signs & Symptoms: Large amount of blood gushes from vagina >>> hypotension, dizziness, paleness, diaphoresis
Fundus not palpable in abdomen
Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina
* never attempt to replace an inversion
Management:
• Do not attempt to remove an attached placenta • Increase IVF to restore fluid volume,
• Do not administer oxytocin • O2,
• assess VS every 5 to 15 minutes

C. UMBILICAL CORD PROLAPSE

 Loop of cord slips down in front of the presenting fetal part that results in the compromise or cessation of fetoplacental perfusion.

Risk Factors: Signs & Symptoms: deceleration in FHR,

• PROM Management: cord felt as presenting part or seen at the vulva
• Fetal Presentation other than cephalic 1. Place gloved hand in vagina & manually elevate the fetal head off the cord
• Placenta previa 2. Place in knee chest or Trendelenburg
• Intrauterine tumors 3. Administer O2 10 L/min
• Small fetuS 4. Do not push any exposed cord to vagina- cover exposed part with sterile saline
compress
• CPD
• Hydramnios
• Multiple gestation