NCM 109 : MATERNAL AND CHILD

Trisomy 18 syndrome – 47xy18/47xx18

GENETIC AND GENETIC COUNSELINGS:
• A process of communicating between or more people Characteristic:
to solve a problem related to hereditary problem. • Do not survive infancy
• Congenital heart defects
Genetic counseling – related to poor assessment with a child • SGA
with genetic disorder • Low set of ears
• These are common in or usually occur in the same ethnic • Microcephaly
group. • Multiple hair whorls

• Phenotype – outward appearance of expression Misshapen fingers and toes.

• Genotype – actual gene composition
• Genome – complete set of gene composition
• Normal – 46XY / 46XY Turner Syndrome -- -X

GENETIC DISORDER – disorder that are passed from one Characteristic:

generation to another generation. • can only affect females
• short in structure
Method of assessment: • webbed neck
1. History taking • gonadal dyagenesis
• Anyone in the family (with the disorder) • secondary sex dev. do not developed in puberty
• Maternal age + 35 mother • has edema on hands and feet// is identified with
• Maternal age +55 father UTZ
• Document if parents is related each other by blood
• Prenatal history.
Kinefelter syndrome – 47xxy
2. Physical assessment
• Pay attention to the; space between eyes, height and Characteristic:
contour, shape of ears, numbers of fingers, or toes • males are born with extra x chromosome
webbing • absence of sex development
Webbing – 2 or more toes. • small testes
• gynecomastia – enlarge breast
Down Syndrome/ Trisomy – 47xxy21/47xy21 • males are risk of breast cancer
Characteristic:
• Late closure of fontanelle
• Slant eyes
• Brush field spot Patau syndrome / trisomy 18
• Large tongue
Characteristic:
• Low set of ears
• most do not survive childhood
• Back of head is flat
• has extra 13 chromosome
• Prone to infection
• microcephaly
• Finger and toes is wide space
• cleft lip palate
• Small head – cause head is not well developed
• low ears
• Clinodactyly – finger that curved
• hair whorls
• wide nipples
• heart defects – ventri
Fragile x syndrome – 46x423q • small eyes
Characteristic: • rocker bottom feet
• Common in males
• Display mal adaptive behavior – is hyperactive and
autism.
Karyotyping -- sample of x in
taken.
Maternal serum screening
• •
 CVS (chorionic villi
sampling)
 Amniocentesis
PUBS (percutaneous umbilical
blood sampling)
 Fetal imaging
MRI AND UTZ – assess the
fetus for general size and
structure disorder of internal
organs, spine and limbs
• HIGH RISK – PREGNANCY
• Check your chromosome
• sample of x in taken
( peripheral venous blood
or cell from buccal
membrane)
• cell with grow until reach
metaphase – most easily
observed.
Done at 15th week of pregnancy
Alphafetoprotein (AFP) – a
glucoprotein produced by liver.
• Elevated AFP – spinal cord
disease/ neural tube defects/
spinabifida
• Low AFP – chromosomal
disorder/ down syndrome
done 8-11th weeks of pregnancy
• a diagnostic technique that
involved the retrival and
analysis of embryonic villi
from growing placenta for
the chromosome
• done between 14th-16th weeks
• withdrawal of amniotic fluid
thru abdominal wall for
analysis
• UTZ first to determine
amniotic – aspirate 2oml of
amniotic fluid
• A needle will be inserted
transabdominal (needle
should not be touching the
baby)
• FHR is monitored
• Mother will received
RH immune globulin
or RHOGAM after the
procedure
Also named as Cordocentesis
• Removal of blood from
fetal umbilical cord at about
17th weeks using
amniocentesis is technique
• Can be used for diagnosis of
anemia and chromosome
ASSESSMENT:
• When accidents and illness occur despite precautionary
measures
What nursing care focus?
• Preventing disorder that might affect fetus
• Regain health
Teach about illness
HIGH RISK – is one in which concurrent disorder pregnancy,
related complication or external factor that jeopardize the
health of woman or the fetus.
What causes a pregnant woman to be at high risk?
• Existing medical conditions
• Environmental hazards
• Maternal behavior or lifestyle
• Poverty
• Lack of support
• Poor coping
• Genetic condition
• Past history of pregnant complication
== demographic factors:
 Maternal age ( - 18 & +35 )
• Lower than 18 – risk for preterm , SGA, PIH, CPD,
and CS.
• Higher than 35 – risk for genetic disorder, placenta
previa, H-mole, and CHVD,
 Poverty – risk for LBW
 Personal social factor
 Weight
• Less 100lb/45kg – mother who eat less
• More 200lb/ -- PIH, LGA, CPD, Shoulder dystocia,
Macrosomic, and CS.
• Height
• 5 higher – CPD
 Smoking – cause preterm and LBW ==   tissue damage in
the unborn baby, particularly in the lung and brain.
Smoking -- associated with reduced fetal measurements in
the second and third trimesters but not in the first trimester.
Mothers who do not quit smoking during the first trimester
deliver smaller infants who go on to have adverse respiratory
outcomes in childhood.
 Alcohol, drug abuse, lifestyle and occupation
 • Fetal alcohol substance, fetal withdrawal and
congenital anomalies.  Concurrent infection
• Fetal defects that occur in first trimester, spontaneous
OBSTETRIC FACTORS AND GYNECOLOGIC abortions and congenital anomalies
FACTORS:
 Seizure disorder
(1) Birth of previous infant w/ weight of 8.5lb, multiparity, • Increase risk for fetal malformations and cerebral
premature, and abortion palsy, and mental retardation of offspring.

 Increase risk for cs, birth injury cause by birth  Liver disease
trauma, maternal gestational diabetes, neonatal • Stillbirth and preterm.
hypoglycemia
FACTORS THAT CATEGORIZE CLIENTS IN HIGH RISK:
MGD- normally goes away after birth. • Psychological
• Social
• If baby is LGA – expect mother to have diabetes. • Physical

(2) Previous still birth – psychological problems – high bp Danger sign: abdominal pain, vaginal spotting, fever
and HR
DX:
(3) RH Sensitization – when a mother is RH negative and a. Ultrasound – abdominal, transvaginal, Doppler
baby is RH positive • 18th-20th weeks
• It detect anomalies
• It’s possible that first born will survive
• But second born will not since the mother will release b. Bioprofile – ultrasonography and NCT
antibodies that will try to attack baby. • 36-38th weeks
• Assess 5 biophysical variable in determining fetal
TAKING RHOGAM WILL PREVENT RHS.
well-being.
• Performed in 30 mins
• Taken every pregnancy
 NST – assess fhr acceleration
o Previable delivery - not considered sufficiently  Amniotic fluid index
developed to survive outside the uterus  Gross fetal movement
 Fetal muscle tone
• Can cause fetal anemia related to  erythroblastosis
(HDFN) - hemolysis c. Amniocentesis – L/S ratio
Kernicterus – brain damage • Procedure for amniotic fluid analysis
• Assess fetal lung maturity.
(4) Cervical insufficiency/ Cervical incompetence, and Multiple
pregnancy d. NST
• Can affect nutrition and anemia, pre eclampsia, • Reactive test – 3 acceleration of FHR w/ 15 beats per
preterm, pph, CS hr. FHR lasting for 15mins.
• Non- Reactive test – no acceleration = indicate fetal
(5) Existing medical conditions jeopardy.

 DM – test for OGTT e. AFI

• Test for amniotic fluid in the quadrant of the uterus
• Risk for PIH, CS, LGA, neonatal hypoglycemia, death,
and congenital defects.
f. Kick count assessment tool – sandovsky or Cardiff
method
 Hyperthyroidism
• Usually done after meals
• Risk for spontaneous abortion, congenital anomalies.
• 10 movements per hour
 Cardiac disease
g. Diabetic screening – required
• Risk for fetal death – watch out for edema, crackles,
• Done 24th-25th weeks
HR and activity.

 Renal disease
• Risk for maternal renal failure, preterm delivery, IGR
 PREGESTATIONAL PREGNANCY  Paresthesia
– Existing condition before pregnancy disturbed vision
 Sore and red tongue
psychological problem
ANEMIA
High risk for folic acid deficiency anemia;
---- Number of red blood cells or the hemoglobin concentration
 Multiple pregnancy
within them is lower than normal.
 Secondary hemolysis illness
 Hemoglobin is responsible in transporting oxygen to
 Taking hydantoin (anticonvulsant) and oral contraception –
issue
prevent effectiveness of folic acid.
 Gastric bypass – problem in absorption of folic
 Anemia in first trimester is called: Pseudoanemia
 RBC second trimester increases
c) SICKLE CELL ANEMIA
– threat to life and cannot carry much hgb
Types:
a) IRON DEFICIENCY ANEMIA (IDA)
 Is an inherited hemolytic anemia – can be pass to
• Very common
the baby (observed in 3-6 months)
• RBC is microcytic (small/pale) and hypochromic (less
HGB)  Cause by abnormal amino acid chain in beta
chain.
What cause IDA? • Symptoms in baby do not become apparent until fetal hgb
o Diet low in iron convert into adult hgb.
o Heavy menstrual flow cause blood loss
• Majority of RBC in sickle cell are irregular or C-shaped/
o Unwise weight reduction
Crescent shape.
o Pregnancy less than 2 years
o Low socio economic status What happen?
• Decrease oxygen – due to low level of hgb
Clinical presentation • Blood become viscid or glutinous – means cell clamped
o Pale and fatigue together and blocked vessels == that can now effect other
o DOB organs.
o Palpitation • Decrease blood flow – hemolysis that cause further
o Weakness and headache reduced RBC
o Tachycardia
o Unusual craving Assessment:
 Hgb level
IDA cause – LBW, heart disease, preterm birth and delayed  Clean catch urine
growth  Diet
 Fluid intake – 8 glasses
Management: • Because cell clamping causes DEHYDRATION (but if pt.
 Iron supplement 60mg is nauseated, reduce fluid)
• Take it with vit. C  Assess varicosities – as there might be a problem in
• Take it with food to prevent gastric blood circulation.
• Increase roughage diet
 Increase fluid intake.  There might be: rupture blood vessels poor
peripheral perfusion -- Elevate the leg and monitor
How to determine if patient is taking iron supplement? UTZ, NST and Blood flow.
Signs and symptoms
• Ask what color is the stool?- color should be BLACK!
• Eye damage
• Heart
b) FOLIC ACID DEFICIENCY ANEMIA
• Leg ulcer
• Folacin or folic acid is necessary for normal formation or
production of RBC to prevent neural tube defect.
Management:
• B-12 is also related
 Blood transfusion
• B-9 can cause folic acid deficiency but not anemia.
 Oxygen administration
 Increase fluid intake
Sign and symptoms
 Electrophoresis of RBC
 Extreme tiredness mouth
ulcer  Hospitalization
 Lack of energy muscle
d) MEGALOBLASTIC ANEMIA
weakness
• Enlarged RBC
 Apparent during second trimester – contributory factor
– early miscarriage and p separation of placenta.
ALSO occur in first week of fetal development
3 CAUSES
Management:
 400 mcg of folic acid daily before getting pregnant and
600 mcg during – to prevent neural tube defect.
 Eat green vegetable.
• problem in left ventricle and pumping of blood – left
ventricle cannot move the blood forward but backflow
– lead to --- heart becomes overwhelm and fails to
function = result to DECREASED CARDIAC OUTPUT
and INCREASED PULMUNARY PRESSURE in
Pulmonary veins.
 Mitral Stenosis – narrowed valve
 Mitral Insufficiency – has problem in opening or
closing
 Aortic Coarctation – narrowing aorta (birth defect)

If patient has LSHF, Observed:

HEART DISEASE • Orthopnea
• Coughing of blood
-- A type of disease that affects the heart or blood vessels. The
• Edema in peripheral area.
risk of certain heart diseases may be increased by smoking,
• Dyspnea
high blood pressure, high cholesterol, unhealthy diet, lack of
• Rales
exercise, and obesity.
• Weakness
• Nocturnal paroxysmal dyspnea –
Assessment:
• Nagging cough
== do a thorough health history
• Gain weight
• Ask level of exercise? – is she gasping after 10 mins
Management:
of exercise or?
• Assess symptoms
• Report coughing during pregnancy – this maybe bc
• Responsive to medication?
of heart problem
• Monitor bp
• Assess nail beds and shape (spoon is sign)
• Urine volume
• Check jugular vein – distended or swollen.
• Assess weight daily
• Check liver size -- liver enlargement due to heart not
• Monitor potassium
able to pump properly.
• Monitor diet esp. NA
• Assess edema
• May order ECG, Chest radiograph, and
• Do high-fowler
Echocardiography.
• No smoke/alcohol allowed
• Compliance to medication.
What are the sign and symptoms?
Drugs:
• Edema
• Anti-coagulant – heparin = given 3 months
• Irregular pulse
• Anti- hypertensive – ace inhibitor drugs/beta blockers
• Rapid / difficulty respiration
• Give diuretics
• Chest pain
• Digoxin ( assess pulse first/ + .2mg can cause
toxicity)
4 CATEGORIES OF HEART FAILURE?
• Balloon valve angioplasty – operation

Class 1: can still experience normal pregnancy and birth.

Class 2: slightly compromise – can still have normal
PREGNANT WOMAN WITH LSHF
delivery but has restriction
Class 3: Markedly compromised – can still complete
Complication results in impaired blood flow:
pregnancy but in complete bed rest.
• Poor placental perfusion
Class 4: Is severely compromised – advised not to get
• Intrauterine growth restriction
pregnant because it could lead to death.
• Fetal abnormality

Drugs that can be given?

Fetal assessment;
• HEPARIN – does not cross placenta and has no
1. LBW
teratogenic effect
2. Preterm
 Given in first trimester and last month of pregnancy
3. Immature
• SODIUM WARFARIN
4. Late deceleration – due to poor placental
Given after 3 months or 12 weeks.
insufficiency.

TYPES OF HEART PROBLEM?

• Right-sided Heart Failure – related to tricuspid valve
• Left-sided Heart Failure – related to biscuspid or mitral
Affect lower extremities ( peripheral )
valve
 • Occur when the output of the right ventricle is less than Contraindications:
the blood volume that are received by the vena cava and
backflow = result to decrease CO to the lungs. • Not advised to use combine oral contraceptive as it
prevent the production of insulin
Patient has; • IUD
• Jugular distention
• Liver and spleen is distended TYPES:
• Liver enlarge
• Distended abdominal vessel’
TYPE 1 – insulin dependent / has a problem in production
• Edema
• Ascites TYPE 2 – Non – insulin dependent or is Insulin resistant

Sign and symptoms– swelling Gestational Diabetes --- acquired and usually disappear after
S -- Swelling birth - arises during 24-28th weeks
W – Weight Gain
E – Edema • But mother can still acquire Type 2.
L – Lethargic •
L – Large Neck Vein
I - Irregular Hr Impaired glucose homeostasis – means state between
N – Nocturnal normal and diabetes on which body no longer using or secrete
G – Girth/ anorexia insulin.

SAME MANAGEMENT AS LSHF! a. impaired fasting glucose – is when blood glucose in body
are raised but not high enough that the person has diabetes
• Rheumatic Heart Disease == sometimes called Pre- diabetes.
• Will only progress to RHD if you have Rheumatic Fever
-- 110 but under 126 mg/dL
(untreated)
b. impaired tolerance glucose – same as IFG / high level but
Connective tissue and valve(mitral and bicuspid) is affected
not high enough to warrant a diabetes diagnosis

RHD – Is a beta hemolytic streptococcal infection resulting -- 140 – 200 mg/Dl

in valve leakage or obstruction
• This streptococci – invade the tissue as it release an Sign and symptoms:
enzyme called “ M-protein”
• and when tissue is affected or destroyed this lead to – • Polydipsia
Necrosis ( death of body tissue) • Polyuria
• Polyphagia
S/Sx – chest pain and joint pain, • Pruritus
Management • UTI
• throat culture – a procedure done by using throat swab
to detect presence of group a strep.
• Penicillin (drug of choice)
• Rest
• NSAIDS – for pain What are the complications?
• Visit Dr. Maternal:
• PIH
• Infection
DIABETES MELLITUS • Polyhydramnios

Endocrine disorder or metabolic disorder in which pancreas Fetal

cannot produce insulin to regulate body’s glucose. • Macrosomia
• Congenital anomalies
There might be a problem in beta cells. • Still birth
• Spontaneous birth – because diabetes damage
A pregnant woman demand carbohydrates per trimester: development of fetal

1. First – there’s a decrease in insulin DX:

2. Second – increase insulin – due to high level need of
o Oral Glucose Challenge Test (OGCT)
the placenta
3. After placental delivery – decrease Insulin
 it measure your body’s response to glucose
  done during first prenatal visit - If mixing if insulin : draw clear (regular) and cloudy
Also called as one-hour glucose tolerance test. ( intermediate)

• 50 g glucose challenge test Site: 2 inches from belly button.

• done first – 24-28th weeks
- after a 50 g glucose load-- a venous sample is II. Blood glucose monitoring
taken after 60 mins - Fingerstick technique – glucometer
• fasting plasma glucose – 126 mg/dl or above
• non-fasting plasma glucose – 200 mg/dl above FBS --Below 95-100 mg/dl
 Diabetes is present. 2 hr postprandial level below 120 mg/dl

o Oral Glucose Tolerance test (OGTT) III. Insulin Pump Therapy

• 100 g glucose tolerance test - An automatic pump therapy about the size of mp3
• Done at 32-34th weeks player
- If the glucose level at 1 hour is more than 140 mg/dl
== woman is scheduled for 100 g, 3 hr OGTT Management:
• if 2 out of 4 blood sample is abnormal or if the fasting • Complete data base
value is above 90 mg/dl – diabetes is present • Educate family
• 1800-2400 kcal should be divided into 3 meals and
o Serum Alpha-Fetoprotein level should be high in FIBER
• Reduce saturated, cholesterol
– done between 15-20th weeks • IV for those who cannot eat
- test to measure AFP on pregnant woman and detect • Final snack – chon, complex carb for slow digestion
baby’s risk. • Exercise – BEST MANAGEMENT
- Usually high during pregnancy – but too much means - Should be 15-30 mins in 3-4x a week
baby has defect. - Lower serum glucose and need for glucose
• Hr – 130-180 Bpm
o Ultrasound • Ensure pt. preparation for intensive/ regular
intrapartum assessment.
o Creatinine Clearance Test – very trimester • Advice contraception in diabetic
- Provide information of the kidney • Monitor bp and lipid levels
NV – 0.8-1.4 mg/dl

o NST and Recording of fetal movements

HYPOGLYCEMIA -- 2nd -3rd HYPERGLYCEMIA –
o Lecithin/ Sphyngomyelin ration at week 36th
trimester common in 6th month
o Biophysical profie

Sweating, pallor, irritability, Fatigue, Hot skin, thirsty,

Glycosylated Hemoglobin – HbA1c
headache, hunger, blur vision, polyuria, Tachypnea, fruity
• Detect degree of hyperglycemia
nervousness, shallow odor, Depressed reflex, and
• Done during 4-6th weeks – more glucose
breathing, + ketones Drowsiness and Headache.
Ophthalmic examination -- incase pt feel blur visions

Urine Culture – due to polyuria RH SENSITIZATION

Occurs when a RH (-) mother carries a RH(+) baby
Therapeutic Management
RH – Rhesus is a type of protein on the outside of RBC
I. Insulin
- Short-acting insulin (regular) combined with Mother RH- + father RH- = Rh negative baby
intermediate type Mother RH - + father RH+ = RH positive baby
• 2/3 is given in morning
• 1/3 is given in evening RH sensitization can only be observed in second pregnancy
- Self-administered 30 mins in ratio of 2:1 and again - In the first birth, if the blood mix together = that is
b4 dinner in ratio of 1:1 the time that the body will produce antibody to
 oral hypoglycemic is not recommended attack second baby .
Second baby risk
Route: Subcutaneous -- Regular insulin (clear) - Anemia
- Jaundice
- Kidney problems
 - Fetal death - TB
Management Diagnostic
• Rhogam or RH immune globulin – prevent  ELISA – test that detect antibodies or protein in the
formation of anti-bodies blood that used to detect antigen
- Given every pregnancy except first pregnancy.  Western Blot Analysis – used to separate and identify
protein.
o Given 28th or 7th month Mode of transmission:
o 72 hours after delivery. o Sexual
o 40 weeks o Exposure to BT
o Sharing contaminated needles
• Intrauterine Transfusion – or injecting RBC via o Breast feeding
amniocentesis directly to fetal cord
- Blood type should be = O negative Therapeutic management:
If patient already have HIV;
If mother is already RH- Sensitized  Advised not to get pregnant
Have the mother to;  Monitor CD4 and Viral loads( Viral loads is the virus
 do regular blood test to check antibodies cells)
 Doppler
 Amniocentesis after 15 weeks Medications
 Zidovudine
HIV - Administered in 14th weeks of pregnancy and
Virus that attack cells that help the body fight infection newborn received antiviral therapy beginning at
- (CD4 cells) that can progress to (AIDS) if birth and 6th week
untreated.  Trimethoprim w/ Sulfamethoxazole
Note: Virus can enter the breast milk! - For pneumonia
 Sulfamethoxazole (Gantanol)
Woman who are at risk: - Increase bilirubin levels in newborn if
- Multiple sexual partner administered late.
- Engage d in bisexual partner - -- an increase in BLB levels cause Jaundice and
- Use a used IV for drugs kernicterus (hearing loss and cerebral palsy)
 Chemotherapy – Kaposi sarcoma
Signs/symptoms are same with any respiratory disease - Contraindicated during early pregnancy
 CS delivery
 Fatigue - Reduce transmission.
 Anemia
 Diarrhea P carinii pneumonia.
 Flu symptoms - trimethoprim with sulfamethoxazole or
 Weight loss pentamidine.
Kaposi sarcoma
Stages - chemotherapy
1. Initial invasion of virus with mild symptoms Thrombocytopenia
2. Seroconversion – women converts from serum – to - platelet transfusion close to birth to restore
3. Asymptomatic period – disease free except there is coagulation ability.
still weight loss and fatigue. HIV newborn
- Virus replication - zidovudine in the first 6th weeks
- 3-11 years
4. Symptomatic period (2) – HIV culture at 4 months of age
- Presence of opportunistic infection and malignant No amniocentesis
– due to low wbc. No episiotomy
- CD4 count – below 200 cells/mm3
 NV: 500-15,000 cells/mm3
- Risk for;
- Toxoplasmosis and cytomegalovirus
- Oral and vaginal candidiasis
- GI illness
- Herpes simplex – mouth ulcer
- P. carini pneumonia
- Kaposi sarcoma – type of skin cancer
- Neurologic problem
 COMPLICATION IN FIRST  Mifepristone
TRIMESTER: - Has abortification and destroy the product of
conception.

II. Ruptured Ectopic Pregnancy – fallopian tube is

ECTOPIC PREGNANCY damaged.
- Patient feels shoulder pain, rigid abdomen and
 Implantation of products of conception outside uterus has Cullen sign.
or when the fertilized egg attached to the lining of the -
uterus. Management:
 Prepare Blood sample – for Hgb, Blood type, Hcg
NOTE: problem in IMPLANTION! level for preparation for BT.
 IVF is administered due to decrease fluid.
 Laparoscopy – removed FT.
Common location of ectopic pregnancy:
- After surgery, Rhogam is given.
 Ampulla (common) – 80%
 Culdocentesis
 Isthmus – 12%
- Consent is taken
 Fimbria – 8%
- Patient in Lithotomy position
- Speculum is introduced.
Normally; fertilization happens in fallopian tube but
- Spinal needle.
implantation happens in uterus.

Assessment: ABORTION
 Amenorrhea
 Pain in lower abdomen quadrant – sharp stab  Termination of pregnancy before the age of viability
 Scant vaginal bleeding – can lead to shock less 20 weeks.
 Increase level of WBC *leukocytosis
Early abortion – 14-16 or 4 months = do curettage.
 No gestational sacs
Late abortion – 16- 24 or 6 months =
 Rigid abdomen
 Umbilicus develop blush tinge – Cullen sign
Lab Findings
- Cause by accumulation of blood in abdomen.
 HCG is low
 Extensive pelvic pain – cervical motion tenderness.
 Ultrasound – absence of viable fetus.
 Shoulder pain
- Cause by the accumulation in peritoneal/
diaphragm which cause pressure in prenic nerve
1st -16th weeks  F. is tentatively attached.
- And due to delayed referral.
- If vaginal spotting is seen.
6-12th weeks  moderately attached.
Risk factors:
- If vaginal spotting is checked, patient experience
- Obstruction or adhesion from previous infection
more bleeding and severe if in 12th weeks.
- Congenital malformation
After 12 weeks  more risk of profuse bleeding because of
th
- Scars from tubal surgery
deep attachment of placenta.
- Uterine tumor.

Assessment:
I. Unruptured Ectopic Pregnancy – fallopian tube is still
intact but patient feels pain in LQA.  Vaginal spotting – ask her AOG
Management;  Lower abdominal cramp
 Oral methotrexate ( has escharotic effect)  Fever and Body malaise
Also used in chemotherapy  Signs of infection.
- It shrink and absorbs the product of conception..
- Given 2 divided doses with 2 hours apart for 60 Threatened abortion Management
mg.  Scant vaginal bleeding  Do ultrasound and check
 Hysterosalpingograms or UTZ  +/- contraction for viability
- Check the potency of uterus and FT.  BOW is intact  Check HCG/ Pregnancy
- Use dye to color or cover fallopian tube and if it  + FHT test
flows slowly – means no obstruction.  Avoid strenuous activity
- Done midway or 6-12 b4 menstruation.  Coitus restricted
 D&C
Adverse effect – ALLERGIC REACTION Imminent/ Inevitable Management
 Moderate vb
 Cervix is open
 Uterine dilation
 Painful cramp
 BOW is ruptured
 + FHT
Complete
 Part of fetus or the fetus
itself is expelled w/o
resistance
Incomplete
 Part of fetus is expelled
but some parts like
placenta is retained
Missed/Early pregnancy
 Baby died inside utero
 No FHT
 Abdomen stop to enlarge
 Fetus die 4-6th week or
before onset of
miscarriage
 Spotting- dark color
 Profuse bleeding
Recurrent / Habitual
 Already defective in
spermatozoa or in the
ova – result to
abnormal fetal dev.
 Bicornate uterus
Uterus is divided in 2
 Chorioamnioitis or uterine
contraction
 Behavior of GRO
COMPLICATIONS:
 Hemorrhage
 Infection
 Septic abortion – self abortion
- If these are left untreated it could lead to = toxic
shock syndrome. Septicemia, and maternal
death.
Nursing Management
 Perform appropriate management/ prevent
complication
 Monitor VS, bleeding and pain
 Administer Rhogam
 Advise iron supplement
 Refrain from coitus until bleeding stops.
HYPEREMESIS GRAVIDARUM
Persistent vomiting and nausea
- Morning sickness should only last for 12 weeks!
 Ask pt to come in hospital Cause?
and bring her garment to  Elevated HCG that cause morning sickness.
check for quantity.  Weight loss – due to dehydration and vomiting
 Vacuum extraction –  Electrolyte imbalance
expulsion of fetus  Nutrition imbalance
 Record the pads  Helicobacter pylori – cause peptic ulcer.
- 6-8 pads is
normal Assessment
 Monitor bleeding • N/V
Management • Elevated HCT – because of dehydration
 D and C • Hypokalemic – low level of potassium
• Polyneuritis – deficiency of Vit. B – numbness and
affect nerves,
Management • Weight loss
 D and C • Urine test -- +ketones (patient is unable to eat thus
body use fat for energy and fat break down ketones.
 Suction Curettage
Management
Management
 Hospitalization – to received water replacement and
 Ultrasound
electrolytes.
 D&C evacuation
- Lactated ringer solution (3L or 3000 ml) + vit.B
Give prostaglandin or
 Prescribed Anti-emetic
misoprostol (14th week) –
- Metoclopramide or reglan
dilate cervix
 Measure I and O and amount of Vomitus.
 give oxytocin to
 If no vomiting within 24 hrs – start small amount of CLL.
contraction
 If vomiting returns -- TPN is administered
 DIC
 Ensure no oral intake until vomiting subsides.
Management
 ?
H-MOLE
 Hytatidiform or Gestational Trophoblastic disease
 An abnormal proliferation and degeneration of
trophoblastic
Patient is pregnant but don’t have baby inside the
uterus or no FHT
Normally:
• Trophoblast become the placenta
• Embryoblast become the fetus
Risk:
- Low protein intake
- Woman older than 35 y/o – defective egg cell
- Blood A who marry to group O men – blood
incompatibility.
TYPES OF H-MOLE
1. Complete mole
- Trophoblast villi swells and become cystic
- If embryo forms it will die if it reaches 1-2 mm in size
with no fetal blood.
2. Partial mole
- Only some are affected
- Psyncytiotrophoblastic layers of villi are swollen/
misshapen.
• Produce maternal hormones
• Outer layer of embryo
 - Embryo is present (not survived) – die at 9 weeks
Fetal blood is present.
- 69 chromosome Assessment;
Rarely lead to Carcinoma • Bloody shows (pink)
• Increase pelvic pressure/ low abdominal pressure
Assessment: followed by ruptured bag of water
o Increase level of HCG – 1-2 million • Uterine contraction and dilatation begin and short labor.
o Result in enlargement of uterus (larger than its • Occurs approx.. 20th weeks or 5 months.
AOG size) • Progressive dilatation of cervix
o NV: 400,000 • Urinary frequency – when baby goes down it also affects
o Nausea and Vomiting the bladder.
o Ultrasound show dense growth ( snowflake
pattern) Risk factors:
o Suction curettage - Maternal age
- Congenital structure defects
o (-) FHR
- Trauma to the cervix
o Vaginal bleeding – dark brown.
Ex. Repeated abortion can lead to D&C and frequent
instrument could affect or traumatize the cervix.
Management
• Grape size vesicles will be remove by suction curettage.
Treatment:
• Pelvic exam and chest x-ray – to check if lungs is
affected.
Cervical cerclage – treatment that involves temporarily sewing
• Ultrasound – most important test.
the cervix closed with stitches.
• Methotrexate – drug of choice for chariocarcinoma.
- Performed 14-16th weeks – in these weeks there is
• Dactinomycin – if cancer metatized already.
no shortening or effacement, and dilatation yet.

Since patient is high risk of chariocarcinoma, this cancer

(1) Mcdonald’s - temporary
might spread and affect other organs.
- Remove suture on 37th-- 38th weeks
- NSD
• Serum test for HCG given
(2) Shirodkar – permanent
- Every 2 weeks until normal
- Suture will not be removed.
- Every month until 6 months
- CS
- Every 2 month until 1 year.
Nursing management.
What is expected in a year?
• Modified Trendelenburg position
- Negative HCG (a + result means that hcg still
- to decrease the pressure in the pelvic area.
present)
- Position in labor.
• Bedrest
 Advise patient not to get pregnant for one year
• Coitus is temporarily restricted as it could to infection
 Use oral contraceptive and contain only progestin
• Tocolytic drug
without estrogen
- to stop uterine uterine contraction if present.
 COC - (Ritodrin ad terbutaline
 Estrogen – help the growth of cancer cell.
PREGNANCY INDUCED HYPERTENSION

COMPLICATION IN SECOND  Condition in which vasospasm occurs during

pregnancy in both small and large arteries.
TRIMESTER: - Also called toxemia.

INCOMPETENT CERVIX Predisposing factors

- Multiple pregnancy
 Also called as premature cervical dilatation - Primipara
 Painless dilatation of the cervix in the absence of - Age younger than 20 and older than 40
uterine contraction – 20th weeks - Multipara
- Hydramnios
• Inability of the cervix to support and growing weight of
pregnancy associate with repeated spontaneous in 2nd Assessment
trimester. • Hypertension ( underlying condition)
• Proteinuria
The cervixes normally, dilate during delivery. • Edema
 • Vision changes
• Weight gain.
Classifications:
1. Gestational HPN
- Develops an elevated BP 140/90 mmHg
- Systolic elevate up to 30 mmHg
- Diastolic elevate up to 15 mmHg
- BP returns to normal after birth
- No proteinuria and edema
- Develop after 20 weeks

2. Mild pre-eclampsia
- BP 140/90
- Proteinuria +1 +2
Presence of protein in urine means kidney is
damaged.
- Weight gain over 2lb per week in 2nd trimester and
1lb in 3rd trimester (should only be 1lb per week)
- Mild edema in upper extremities or face.
4. Eclampsia
- Seizure or coma accompanied by s/sx of pre-
3. Severe pre-eclampsia
eclampsia
- BP 160/110
- Hypertension, edema and proteinuria.
- Proteinuria +3, +4 on a random sample
- Oliguria – 500ml or less in 24hr. Pathophysiology
Normal output – 600ml in 24hr.
- Elevated serum creatinine more than 1.2 mg/dl Root cause – related to defective placenta.
- Presence of headache, blurred vision
- Pulmonary or cardiac involvement Trophoblast attaches itself to the uterus for placental growth
- Extensive pulmonary edema – SOB Spiral arteries expand in diameter to increase blood volume
- Cerebral edema – headache, confusion, and ankle
clonus
Narrowed arteries that leads to ischemia lead  placenta
damaged  lead to release substance that affects endothelial
Note for ankle clonus
cells  tone will be affected causing vasoconstriction
 Dorsiflex the foot and observe the movement
 Tone
Mild – 2 movements
- Vasospasm / vasoconstriction = HPN
Moderate – 3-5 movement
- Decrease permeability especially in the kidneys
Severe – over 6 movements
(glomeruli) = lead to leakage of protein in the urine
 shifting the fluids in the interstitial space (edema)
• Pulmonary or cardiac involvement - bc of decrease
amount of fluid.
• Decrease blood volume = decrease urine output
• Hepatic dysfunction
• Increase uric acid
• Thrombocytopenia
• Epigastric pain
Edema on face, finger and brain (cerebral edema),
• Pitting edema
blurred vision, ankle clonus, lungs (pulmonary edema)
manifested by SOB, and pitting edema and weight gain
.
If liver is damaged = elevated liver enzymes, SGPT, and
SGOT

Because the endothelial cells has been damaged – hemolysis

- Destruction of platelets as well as RBC and DIC.

HELLP SYNDROME
- H – hemolysis
- EL – elevated liver enzyme
- LP – low platelets

Client also risk for abruptio placenta!

It’s all about DAMAGED OF ENDOTHELIAL CELLS  Liver
 Increase blood volume due to narrowed spinal arteries.

Nursing Management.

MILD HPN
• Monitor anti platelet therapy 5. ECLAMPSIA
• Promote bed rest – recumbent position Happens late in pregnancy up to 48 hours after birth
• Promote good nutrition – give only little sodium. a. Tonic clonic seizure
• Provide emotional support
 Preliminary signal/aura
SEVERE HPN  All muscles contracts
• Support bed rest  Back arches, her arms and leg stiffen, jaw closes, RR
• Hospitalization stops (because her thoracic muscles are held in
o No visitors contraction)
o Private room  Last 20 seconds
o Raise side rails  Cyanotic
o Darken room
o No shining of flashlight into women eyes. b. During the 2nd clonic stage:
• Monitor maternal well being
o BP  Bladder and bowel contracts and relax
o Blood test  Incontinence of urine and feces
o Daily hct monitoring  Begins to breathe but not entirely effective
o Frequent plasma estriol levels  Remain cyanotic
o Check daily weight at the same time each wearing  Last up to 1 minute
same clothes.
o Insert IFC (600/24hrs) c. During the 3rd stage of seizure (postictal state)
o 24 hour urine sample
o Monitor fetal well being  Semi-comatose
 FHT  Cannot be roused except by painful stimuli for 1-4 hours
 NST daily  Close observation is important ----- can cause premature
 Oxygen administration to mother separation of the placenta --- labor BUT the woman will
 Support nutrition diet be unable to report sensation of contractions.
 High protein and moderate sodium
 IVF NURSING CARE DURING THE 3RD STAGE OF SEIZURE
• Administer medication
o Hydralazine (apresoline)  Keep the woman on her side
o Nifedipine  Give her nothing by mouth
o Labetalol (normodyne)  Limit conversation
Magnesium So4 – DRUG OF CHOICE  Continuously monitor FHT
- Given in IV for 15 mins in bolus dose  Check vaginal bleeding every 15 minutes
- Anti-convulsant  If pregnancy is >24 weeks – decision will be made as
soon as her condition stabilizes usually 12-24 hrs
Before giving magnesium sulfate check first:  Terminate the fetus coz it does not continue to grow
 Urine output should be 25-30 ml/hr  CS is more hazardous for the fetus
 Specific gravity 1.010 or lower  Woman with eclampsia is NOT a good candidate for
 RR should be above 12 bpm  surgery
 Ankle clonus should be minimal
 Vaginal – preferred birth
 DTR +
 If labor does not begin spontaneously, ROM or induct
o Calcium Gluconate (antidote)
labor with oxytocin via IV
 If ineffective ---CS is indicated because the fetus is in
Sign and symptoms of overdose:
danger
 Decrease urine output
 Decrease rr
NURSING CARE MANAGEMENT FOR ECLAMPSIA
 Reduced consciousness
 Decrease DTR
 Administer oxygen by face mask ---- to protect the fetus
 Hyperreflexia (4+DTR)
 Turn woman to her side ----- to prevent aspiration, and
 Feeling hot/ warm..
allow drainage
 Magnesium sulfate/diazepam (valium) via IV as an Occur to;
emergency measure - Prom, multiple gestational, previa, SGA,
 Assess oxygen saturation - Hydramnios. – too much fluid
 Apply external heart monitor
 Assess FHT and uterine contractions Assessment
 Check vaginal bleeding
 UTZ , VAGINAL EXAMINATION
HELLP SYNDROME  FHR is unusual slow or there is a variable
deceleration
H- Hemolysis - If (+) ROM = assess the FHS immediately whether caused
by spontaneously or amniotomy ( intentional ROM)
E – Elevated Liver enzymes ( SGOT/ AST= serum glutamic  Cord could be monitor by fetal monitoring
oxaloacetic transaminase/ Aspartate aminotransferase;
SGPT/ALT – serum glutamic pyruvic transaminase/ alanine Therapeutic – management aimed is to relieved cord
Transaminase) compression = to relieved compression and prevent risk of
fetal anoxia.
LP – Low platelets
 Placed hand in vagina and elevate fetal head to relieve
SIGN AND SYMPTOMS compression
 Placed pt in KNEE-CHEST position or TREDELENBURG
 Proteinuria  Tocolytic drug can also be administered.
 Edema  Administer 10 1/min oxygen by facemask – improved
 Hypertension oxygenation of the fetus.
 Nausea  If cord is already exposed --- instead cover the cord with a
 Epigastric pain RUQ gauze sterile saline.
 General malaise DO NOT PUSH THE CORD BACK INSIDE as this
could worsen and cause more compression.
Needs close supervision
 The birth method choice is – CS
Complications:
 Amnioinfusion – replaced the lost amniotic fluid.
1. Liver hematoma  Infused warmed sterile water or LR 500 ml
2. Hyponatremia  Position pt in LATERAL RECUMBENT position to
3. Renal failure prevent hypotension syndrome.
4. Hypoglycemia  Monitor FHR, contraction, and temperature – fever is a
sign of infection.
 Be certain that solution is warmed – placed the bag in
NCM 109 MIDTERM radiant warm heater.
 Changed bed frequently and assess drainage
PROBLEMS IN PASSENGER  If drainage stops, means that fetal head is firmly
engaged and all infused fluid are in the uterus which
– problem in fetal lie, position, presenting or attitude. cause POLYHYDRAMNIOS and UTERINE RUPTURE

- Normally, fetus is passive in childbirth. But problem occurs

arises if the infant is immature or preterm or if maternal
pelvis is undersized or larger than its diameter is small
than the fetal skull.
Problems can occur;
- Early pregnancy, rickets, umbilical cord prolapse, multiple
gestational, fetus malposition and macrosomia.
 Fetal Scalp Ph testing – test that determine if fetus is
getting enough oxygen
Lower than 7.25 is consider acidosis and signifies
fetal distress
Greater than 7.25 is normal for fetus in labor
7.21 – 7.25 should be monitored every 30 mins.

1. PROLAPSE UMBILICAL CORD

- a loop of umbilical cord tend to slip away down to the
2. MULTIPLE GESTATIONAL – a pregnancy with 2 or more
presenting part- cervix.
fetus
- Only discovered in there is a ROM / cord can be visible in
vulva
 Twins may be born by cesarean birth to decrease the
- Is an EMERGENCY as PUC can cause cord compression
risk the second fetus will experience anoxia; often;
that DECREASE oxygen going to the fetus and cause
FETAL DISTRESS.
  this is also the situation in multiple gestations of three
or more because of the increased incidence of cord
entanglement and premature separation of the
placenta
 abnormal fetal presentation may occur and cord
prolapse since fetus in multiple gestational is small.
Therapeutic;
 Assess (hematocrit level and blood pressure) during labor
or while waiting for cesarean – to detect gestational
hypertension and anemia.
 Instruct client about breathing exercise. –support the
woman’s breathing exercises to minimize the need for
analgesia or anesthesia; this helps to minimize any
respiratory difficulties the infants may have at birth
because of their immaturity
 Oxytoxin will not be given to avoid compromising the
circulation of the infants not yet born
 After the birth of the first child, -- second fetus lie is
determined BY EXTERNAL ABDOMINAL PALPATION OR
ULTRASOUND.
 Sublingual nitroglycerin may be prescribed to relax the
uterus and make EXTERNAL VERSION possible -- if
not possible, be ready for CS or breech birth.
 ECV – a external cephalic version is a procedure that
turn breech into a cephalic position so that mother can still
have vaginal delivery.
 Assess the woman carefully in the immediate postpartal
period since uterus can be distended and have difficulty
contracting – which leads to hemorrhage and uterine atony
and infection.

Assessment
- when taking FHRs by Doppler or a fetal monitor, you are
definitely hearing two separate beats
- Pt who have multiple gestational is usually instructed to
come to the hospital early in labor
- Labor is long
 Uterine dysfunction from a long labor,
 an overstretched uterus,
 unusual presentation, and
 premature separation of the placenta after
the birth of the first child may also be more
common
- Multiple gestational usually end before its full term
PROBLEMS WITH FETAL POSITION,
PRESENTATION, OR SIZE
3. OCCIPITOPOSTERIOR POSITION – R or L Occiput
Posterior;
- Problem in fetal position – baby laying against mother
back
Landmark; Supine looking at mothers belly
- 1/10th of labor result in posterior instead of anterior.
- Posterior positions tend to occur; in women with
android, anthropoid, or contracted pelves.
1. prolonged active phase- prolonged cervix dilation
2. Arrested descent – related to shape and size of
pelvis.
3. Position of fetus
4. fetal heart sounds heard best at the lateral
sides of the abdomen
Baby needs to rotate 135 degree and this cause
COMPRESSION IN SACRAL NERVES == cause mother in
pain.
 OCA – 90 Degree
 OCP – 135 Degree
Assessment and therapeutic;
- a posterior position can be aided by having the woman
assume -- a hands-and-knees position, squatting, or
lying on her side
 left side if the fetus is right occiput posterior
 right side if the fetus is left occiput posterior
- a woman may experience pressure and pain in her lower
back because of sacral nerve compression.
 Applying counter pressure on the sacrum by a
back rub – relieve pressure on sacrum.
 Applying heat or cold, whichever feels best,
 maintaining a hands-and-knees position or
leaning forward over a birthing ball ----help
the fetus rotate
- woman voids every 2 hours to keep her bladder empty –
full bladder impede descent of fetus.
- Provide an oral sports drink or IV glucose solution to
replace glucose store
- Although rare, if forceps are used to help the fetus rotate,
- observe a woman closely for hemorrhage from cervical
lacerations or infection in the postpartum period.
4. BREECH PRESENTATION
- most fetuses in early pregnancy are In breech presentation
however, by week 38 they rotate into cephalic. -- maybe
because even tho the head has the widest diameter, the
buttocks plus the legs takes up more space and fundus is the
most largest part of the uterus.
So the first thing to do is to ask the mother her AOG.
What causes breech presentation?
- Less than 40 weeks
 Hydramnios - allows for free fetal movement, so the
fetus fits within the uterus in any position.
 Abnormality in a fetus, such as anencephaly,
hydrocephalus, or meningocele.
- fetus with hydrocephalus, the widest fetal diameter is the
head, so it retains the most “comfortable” position
 Pendulous abdomen
 Presence of mass
 Multiple gestational
Assessment
  FHR are heard high in abdomen, UQA, and level of
umbilicus.
 Leopold maneuvers and a vaginal examination
usually reveal the presentation.
 During vaginal exam, the cleft of the buttocks can be
mistaken as the sagittal suture
- So if the presenting part is unclear, do an UTZ to confirm.
 Always monitor FHR and uterine contractions – to
detect early fetal distress.
 If the infant will be born vaginally, a woman is
allowed to push after full dilatation is achieve
 Birth of the head is the most hazardous part of a
breech birth – because the umbilical cord passes
alongside with the head = causes compression to the
cord.
 difficulties with birth of the head is the reason why
planned cesarean birth is the usual method of birth
RISK?
 Risk for PROM, CORD PROLAPSE AND ANOXIA –
 Traumatic injury to the coming head – possibility of
intracranial hemorrhage/ anoxia
 Fracture in the spine and arm
 Cause Dysfunctional labor
 Early rupture of membrane because pf the poor fit of
presenting part
 Presence of meconium
- meconium stain in breech presentation is normal - bc
when uterus contract it cause pressure on the buttocks
and compress this lead to hypoxia which result the anal
spinchter to relax and release stool .
- however, if meconium aspiration occur there is possibility
that the baby might swallow meconium.
Meconium stain in cephalic – not normal since it’s a sign of
fetal distress.
So if meconium stain is (+) don’t initiate baby to cry – suction
the meconium stain first.
Meconium stain obstruct airway.,
5. FACE PRESENTATION
- fetal head presenting at a different angle than expected is
termed ASYNCLITISM.
- the head diameter the fetus presents to the pelvis is often
large for birth to proceed –
- A head that feels more prominent than normal suggest a
face presentation
The back is difficult to outline because it is concave ==
FHT may be transmitted to the forward-thrust chest
and FHS heard on the side of the fetus where feet
and arms can be palpated.
- If the chin is anterior and the pelvic diameters are within
normal limits, it may be possible for the infant to be born
without difficulty -- but accompanied with prolonged labor
because the face is still not mold and its soft.. – if face is
still soft there is no 100% of engagement.
- If the chin is posterior, cesarean birth is usually the
method of choice ---- but it necessary to wait for a long
posterior-to-anterior rotation to occur == but such rotation
could result in uterine dysfunction or a transverse
arrest.
Assessment
 Can be determined by vaginal ultrasound.
 Facial edema and ecchymosis bruising is common in
face presentation – due to the pressure of uterine
contraction in the presenting part which is the face.
 Lip edema
 May cause backache to the mother.
Normally after the delivery, baby is hypoglycemic so the first
thing to do is to feed the baby.
Nursing management
- Observe for clear patent airway
- some infants, lip edema is so severe that they are unable
to suck for a day or two = gavage feeding to obtain fluid
- infant may be sent to NICU for 24 hours to observe.
- Reassure parents that edema do not last long and
eventually disappear for few days.
6. BROW PRESENTATION
- A brow presentation is the rarest of the presentations.
- Results in obstructed labor, because the head becomes
jammed in the brim of the pelvis.
 CS maybe necessary for normal fetus delivery.
- leave an infant with extreme ecchymotic bruising on the
face--- reassure parents that baby is well.
7. TRANSVERSE LIE
Occurs in women with;
 pendulous abdomen
 congenital abnormalities of the uterus
 hydramnios
 uterine fibroid tumors
 multipara
Assessment
- Transverse lie usually is obvious on inspection --- bc
uterus is found to be more horizontal than vertical.
- Both Leopold’s maneuver and UTZ is done to confirm
- CS is necessary because mature fetus cannot be born by
this presentation/
. MACROSOMIA
- a problem in a fetus who weighs more than 4,000 to
4,500 == 9-10 lb - possible if patient has gestational
diabetes or diabetes or also common in multipara.
- The fetal use glucose for growth development.
 oversized infant may cause uterine dysfunction
during labor or at birth because of overstretching of
the fibers of the myometrium – this cause to
hypotonic contraction or weak contraction
  wide shoulders -- can cause fetal pelvic POSTERIOR IS ABNORMAL
disproportion ( the pelvis is too small to Anterior in facing the anterior of the mother while the
accommodate the delivery of the fetus) or even anterior is the opposite.
uterine rupture from obstruction
mode of delivery? CS

9. SHOULDER DYSTOCIA – difficult delivery of shoulder.

DYSTOCIA also mean – painful, prolonged delivery.
- Occurs at the second stage of labor == when the
fetal head is born but the shoulders are too broad to
enter and be born through the pelvic outlet. == this
cause CERVICAL TEARS and endanger mother PROBLEMS IN POWER
- most apt to occur in women with diabetes, in
multiparas, and in postdate pregnancies. – Problems to the force of labor ( uterine contraction )

MOTHER BABY Inertia is a term to denote sluggishness of contractions

- trauma and 3rd - Brachial plexus injury - more current term is dysfunctional labor
degree laceration - Brain injury – due to
and postpartum decrease oxy  Generally classified as primary ( occurring at the
hemorrhage - Chest compression - onset of labor) or secondary (occurring later in labor).
once the head is out
it cause the chest not
to expand
Ineffective Uterine Force
Suspected earlier is;
- Uterine contractions are the basic force that moves
1. prolonged second stage of labor
the fetus through the birth canal
2. Arrest of descent
Uterine contraction occurs due to;
when the head appears on the perineum (crowning), it retracts
o Contractile enzyme – adenosine
instead of protruding with each contraction (a turtle sign)
triphosphate
o Major electrolytes – sodium, calcium etc.
Management
o Contractile protein – actin and myosin
 call for help
o Pph – epi and nor epi, estrogen,
 Asking a woman to flex her thighs sharply on her
progesterone, and prostaglandin.
abdomen (McRoberts maneuver) -- widen the
pelvic outlet and allow the anterior shoulder to be born
3 classification;
---- Flex the leg – hyperflex = to widen and flatten the
sacrum.
1. HYPOTONIC CONTRACTION – weak and infrequent
 Applying suprapubic pressure (Mazzanti
contraction.
maneuver) may also help the shoulder escape from
beneath the symphysis pubis and be born
 Possibility of absence of contraction (not more than
- Heel of the hand compress the anterior shoulder
two or three occurring in a 10-minute period.)
above the symphysis pubis
 Resting tone – 10 mmhg NORMAL: 10-15mmhg
 Deliver posterior arm ( Rubin’s maneuver)
– start at 15
 Woods corkscrew
 Strenght: not rise above 25mmhg
 Gaskin maneuver – pull baby downward and mother
 Normal; 10-15 mmhg; normally, as labor
is in hands-knees position
progresses, the INTENSITY AND STRENGHT
 Episiotomy
start in 25mmgh and pataas ng pataas.
 Lazavanelli maneuveur – last option
- Rotate the head and flex it downward then push it
When does hypotonic occur?
back to uterus after that MOD is CS
- Occur during active phase
- Early (latent phase) administration of analgesia esp if
10. FETAL ANOMALY
the cervix is not dilated to 3 to 4 cm – prevent cervix
to dilate.
- HYDROCEPHALUS OR ANENCEPHALY can
- if bowel or bladder distention is preventing descent or
complicate birth because the fetal presenting part
firm engagement
does not engage the cervix well.
- overstretched uterus
NOTES
LOA AND ROA – Normal presentation
Assessment; - deceleration in the FHR,
- lack of progress with pushing
Contractions are not exceedingly painful --- lack of intensity
- however, that pain is a subjective symptom Cesarean birth may be necessary

Hypotonic contractions will increase the length of

labor because more of them are necessary to achieve
cervical dilatation 3. UNCOORDINATED CONTRACTION

It also increasing a woman’s chance for postpartal hemorrhage

– if uterus exhaust, it can cause it to not contract. DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF
LABOR
MANAGEMENT:
FIRST STAGE OF LABOR
 After delivery,
 assess if the uterus is hypotonic – PALPATE 1. Prolonged latent phase - caused by hypertonic
UTERUS - When contractions become ineffective during the first
stage of labor.
Hard = + contraction
Soft = - no contraction Defined as;
Nullipara – 20 hrs
 location Multipara – 14 hrs

if uterus is displaced – means full bladder Management;

 lochia – check for presence of contraction; every
15 mins. -
If hypotonic is present --- there’s a risk for hemorrhage ==
cause uterus is not contracting very well.
- Rest and increase fluid intake – to replaced loss fluid.
Remember – dehydration cause blood to be vicous, risk for
thrombophlebitis, slow labor
- Administer morphine sulfate – for pain relief.
- Changing the linen and the woman’s gown
- darkening room lights, and decreasing noise and
stimulation can also be helpful – slow contraction.

2. Protracted active phase -- usually associated with fetal

2. HYPERTONIC CONTRACTION – strong and frequent
malposition or cephalopelvic disproportion (CPD) ;
contraction
Hypotonic
1) CD is:
 resting tone --- to more than 15 mmHg
 Nulli – 1.2 cm per hour
 occur frequently and are most commonly seen in the
 Multi – 1.5 cm per hour
latent phase of labor
2) Hours of labor
 Nulli – 12 hr
 Multi – 6 hr
Contractions may occur because the myometrium do not relax
or repolarize Management;

 Although contractions are strong, they are ineffective
and are not achieving cervical dilatation.
Assessment;
3.
- tend to be more painful than usual – tender
myometrium due to lack of relaxation 
=== lack of relaxation between contractions may not allow Prolonged when it extends beyond;
optimal uterine artery filling == lead to FETAL ANOXIA
EARLY IN THE LATENT PHASE OF LABOR
 MODE OF DELIVERY -- Cesarean birth
 Administration of oxytocin if CPD is not present --
augment labor
Prolonged deceleration phase – problem in the
descent of fetus. // problem in fetal head position
 nullipara --- 3 hours
 multipara --- 1 hour

mode of delivery ; CS

Mgn – fetal monitor – to identify that the resting phase between 4. Secondary arrest dilation – no progress in cervical
contractions is adequate and that the FHR is not showing late dilatation longer than 2 hrs.
deceleration
Mode of delivery; CS

MNG
 Morphine sulfate – pain reliever due to painful
SECOND STAGE OF LABOR contraction due to frip
 Amyl nitrate – relaxes contraction
1. Prolonged descent  Tocolytic agents ( ritrodin ) – stop contraction
 CS
Rate of descent  For the delivery of placenta -- Manual removal of
 Nulli – 1cm per hr placenta under anesthesia
 Multi – 2 cm per hr Only if the contraction ring does not allow placenta do
be delivered.
 Can be suspected if 2nd stage last over 3hours in a
multipara. Complication
 Contraction lead to infrequent and poor quality ==  Uterine rupture = since there is presence of indention
lead to hypotonic or a line between two segment in the abdomen there
 Cervix dilatation stop will be accumulation of pressure in those segment
and it tends of burst.
Management:  Neurologic damage – rlt to hypoxia
 Rest and increase fluid intake  Massive hemorrhage – if uterus rupture
 Amniotomy – if no ROM
 Administer oxytoxin – to induce contraction = always refer to dr.
 Semi-fowlers, squatting and kneeling – help in the
descent. UTERINE RUPTURE
 Uterus burst or when uterus undergoes more strain
2. Arrest of descent than it is capable of sustaining.

 CPD is most likely the cause.
 No engagement
 No descent has occur
 Nulli – 1 hr
 Multi – 2 hr
 CS is necessary but if there is no contraindication to
vaginal birth, OXYTOXIN IS ADMINISTERED to
assist in labor – NSD.
What is physiologic contraction ring?
CONTRACTION RING – a hard abd that forms across the
uterus at the junction of the upper and lower uterine segment
and interferes with fetal descent.
What is PATHOLOGIC RETRACTION RING/ BANDL’S
RING? A common type of contraction ring but abnormal.
 It obstruct labor ( not allow for fetal descent )
 It grip the baby and placenta not allowing the fetal to
descend.
 Common during 2nd stage of labor (active) – presence
of distended abdomen.
 Observe also in latent phase –related to presence of
uncoordinated contraction
It happens;
 if there is obstetric manipulation – use of forceps or
traction
 if there is an excessive administration of oxytocin –
Reason? --- It reach its maximum level of expansion.
Occur MOST COMMONLY in CS or hysterectomy.
 Confirmed by an ultrasound.
Predisposing factor
 Prolonged labor – since the uterus will still
keep contracting there will be an increase
pressure and this will lead to uterine rupture
–
 Also related to presentation, MG,
 Unwise use of oxytocin.
 Normal: 10-40 ml/units == if more than 40 ml/unit --
can cause hyper stimulation of uterus – eventually
leads to UR.
Assessment
 Tearing sensation
 Sudden severe pain during strong contraction.
Side effects of oxytocin. ( Excessive )
--- DIZZINESS, HEADACHE, VOMITING, CONFUSION
---- Continuous contraction of uterus.
 If these side effects are observed – Stop the
regulation and inform the doctor.
 Obstructed labor
 Use of forceps and Traction
TYPE:
1. COMPLETE
  3 Layers of uterus has been affected
( myometrium, endometrium, and pericardium) CD rate:
 since myometrium is affected – no (+) Dilatation : Nullipara – 5cm/hr Multipara – 10 cm/hr
contraction Descend : Nulipara – 5 cm/hr Multipara – 10 cm/hr
 There will be 2 distinct swelling that are visible
on the woman abdomen. Predisposing Factors:
a. Retracted uterus
b. Extra uterine fetus - Multipara
 Shock – since uterus ruptured - Large pelvis
s/sx – weak rapid pulse,  RR,  Temp,  - Lax maternal tissue
BP and cold clammy skin, widening of - SGA
nostril – DOB and no FHR = baby dead. - Use of excessive oxytocin
- Painless uterine contraction
2. INCOMPLETE
 Only myometrium and endometrium affected – Assessment:
pericardium is intact  Sudden labor w/o warning
 Pain in lower segment. (persistent but localized)  Pt feel the urge to push
 Not uterine contraction.  Sudden increase bloody show – ROM happened.
o Fetal and maternal distress  Bulging of perineum
 Crowning
Management
Complication:
 Administer IV fluid and prepare for Blood transfusion –
replace fluid loss and blood loss.
 Use gauge 18
 Use oxytocin – attempt to contract uterus and minimizes Maternal:
bleeding - Laceration in birth canal due to force labor
 Laparotomy – emergency measure to control bleeding and - Amniotic fluid embolism – (moving blood clot) – its
repair uterus. when a pregnant woman gets/mixed amniotic fluid
 If uterus is severely damaged – uterus need to be into their blood stream
removed ( Cesarean hysterectomy ) = result in loss of s/sx – chest pain, DOB, cough
childbearing - Hypoxia – Due to PROM
- Intracranial hemorrhage
 Advised woman not to conceive again – unless rupture
- Erb Duchenne palsy – if hindi na monitor ng maigi
occur in lower inactive segment.
baka malaglag si baby.
- Premature labor
PRECIPITATE LABOR -- contraction is strong and rapid
Management
delivery of the baby.
- Adequate prenatal care –
 Labor last less than 3 hours
- Warn woman with history of precipitate labor
- Monitor oxytocin administration.
Common in;
 Grand multipara, received amniotomy, and excessive
UTERINE INVERSION -- The uterus turning inside out with
used of oxytocin.
either birth of the fetus or delivery of the placenta

This can cause

 Laceration, uterine rupture and hemorrhage.
 Rapid strong contraction cause PREMATURE
SEPARATION OF PLACENTA – that also cause
HEMORRHAGE
 LACERATION due to pressure and rapid contraction
Baby risk for;
 Subdural hemorrhage or hematoma – pressure due
to rapid release of the head.
- Occur in 3rd stage
Use of traction – applied in the umbilical cord to remove the
placenta == one hand on the forceps while the other hand pull
the umbilical cord downward
- Palpate the uterus
= if its hard =uterus contracting
= if its soft = uterus not contracting ( so don’t pull the
placenta = because if you push, uterine inversion
happens)

Caution! Advice mother to not go out alone if she’s 28th weeks Occur – if placenta is pulled and placenta Is still not
pregnant – since mother will not feel pain when in labor and detach.
CD is painless.
Measured in Degree
 1. Incomplete – uterus is inverted - Assess the maternal status – VS, S/Sx of labor,
2. Incomplete – uterus extend in cervical ring cervical dilation and effacement, Descend of fetus.
3. Out in the vagina - Check for past, present, family history – to know if
4. Inverted uterus is out. mother has already experience this before.
- Obtain blood and urine specimens for lab test.
How will you know if placenta is detached? - Observe the BOW – what color is the fluid?
- Sudden gush of blood - Assess the frequency, intensity and duration of
- Lengthening of umbilical cord contraction
- Contraction of uterus - Prepare client for administering steroids --
- Appearance of placenta in vaginal opening BETHAMETAXONE – hasten lungs
- Also inform client about the side effects of tocolytic drugs
Assessment: – like your TERBUTALINE
 Large amount of blood – if this continue there will be;
hypotension, diaphoresis, dizziness and paleness. Side effects are; tachycardia, chest pain, difficulty of
 Fundus is not palpable breathing
 Uterus not contracting
 Because the uterus is not able to contract in this If pulse rate is 120bpm/ min – stop the infusion
position, bleeding cannot be halted or will continue. - Emotional support

Nursing management: PROLONGED LABOR/ POSTERM LABOR

- Do not push back or attempt to removed placenta -
because this would create a larger surface area for - Baby deliver up to 42 weeks.
bleeding
- Oxytocin, if being used, should be discontinued Causes by;
because it makes the uterus tenser and difficult to  Macrosomia baby – can overdistend uterus
replace.  Hypotonic, hypertonic, uncoordinated contraction
- Administer oxygen by mask, and assess vital signs.
- perform cardiopulmonary resuscitation (CPR) if the  Mother is risk for – infection and hemorrhage
woman’s heart should fail from the sudden blood loss  Baby is in fetal distress- can cause decrease FHR
- Anesthesia -- nitroglycerin or a tocolytic drug by IV to and fetal death.
relax the uterus
- Replaces the fundus manually – opening or doing Assessment;
abdominal surgery. == only if the physician is skilled,  Weight loss and decrease size of abdomen – placenta
they can replaced fundus. will no longer support baby and baby will experience
- oxytocin after manual replacement helps the uterus to intrauterine growth --- less body mass
contract  Meconium – sign of fetal distress == decrease FHR
- Administer antibiotics - to prevent infection
MNG
If the woman is pregnant in second time ; MOD is CS. - Evaluate fetal heart rate and relate to fetal movement
- Prevent birth complication –
- Since there is meconium stain – prevent the baby to cry
PRETERM LABOR – baby deliver B4 37th weeks – 20-36. - Give emotional and physical support
- Educate the patient and her family
Related to
- PROM PROBLEMS IN PASSAGEWAY
- Placenta previa – Problem in the pelvis (size and shape)  lead to CPD
- Hydramnios
- Preeclampsia - A narrowed shaped pelvis – do not allow fetus out from
- Incompetent cervix the woman womb.
- Trauma
- Abruption placenta. Types;
a) Gynoecia - good prognosis
Assessment b) Anthropoid – good prognosis/ shape is oval
 Suprapubic pressure c) Android – poor prognosis/ male pelvis
 Vaginal pressure d) Platypelloid --- poor prognosis / shape is oval and
 Low back pain flat.
 Regular contraction
 Cephalopelvic disproportion – pelvic is the problem
Management  Fetopelvic disproportion – baby is small /
hydrocephalus
 - The problem here is the fetus 1. Postpartum blues – observed in 1-10 days and last up to
2 weeks (normal)
1. INLET CONTRACTION - Mild depression after giving birth.
- Narrow APD
mother feels;
APD – Less than 11 cm - Overwhelm sadness
Transverse – Less than 13 cm - Cries easily
- Irritable
Caused by;
- Rickets Cause by;
- Small pelvis  Hormonal changes
 Absence of support system
2. OULET CONTRACTION  Tiredness from giving labor
- Narrow transverse  prolonged labor
Management:
APD – less than 13 cm  Provide adequate rest, food and comfort measures
Transverse – 11 cm  Encourage her to express her feelings or vent.
 Let her know that crying spell is normal
IF THERE IS A PROBLEM IN THE PELVIS – THE
MOD IS ALWAYS CS 2. Postpartum Depression – observed 1-2 months.
- Undiagnosed or unreported
3. SHOULDER DYSTOCIA – head is out, shoulder in/ - It also affect the husband or partner.
impacted in ischial spine.
Mother feels;
Mazzanti and Mcroberts – common maneuver used. - Overwhelm sadness
- Lack of interest
Hazardous to mother – - Unable to feel love
 laceration and hemorrhage. - Felt guilt/ unworthiness, shame, difficulty in
Hazardous to baby – concentrating, panic attack and fatigue.
 cord compression – cause by chest compression that - Unable to care for the child – feels that the child is
lead to uncoordinated breathing demanding.
 brachial plexus injury - Low self-esteem.
 Brain injury Management
 Promote emotional and psychological support –
understand the patient situation
PROBLEM IN PSYCHE  Maintain helpful situation – help her do her role
- She should not be blamed for her condition.
– related to the way how client behaves, perceived things.  Inform the patient that PPD is an illness and need
treatment
 Fear/ Anxiety – client unable to focus and participate  Inform attending physician – that everything u
– making px more in pain. observed that is not normal
 Stress – cause decrease oxygen (patient might feel – - Observed mother when she is provoking care to infant.
dizzy, not responding, and no participation)
 Presence of support system – it affect self-esteem. 3. Postpartum psychosis – worst type of PPD and
 Coping ability – inability to cope due to observed 3 weeks – 1 year.
- Unpreparedness or lack of emotional support.  - Mother is detached from reality.
irritable, sensitive and no response.
Mother might have Bipolar ( manic and depression )
Management:
Management:
 Check for support group that are available  Medical treatment
 Patient teaching  Lithium – antidepressant and anti-psychosis.
- Like proper technique in breathing during labor.  Observed if she’s suicidal
 Provide non-pharmacological measure  Do not leave patient alone with the infant.
- Back rub, Music therapy, or Focus imagery  Give emotional support to pt and family.
 Keep the patient and family informed about the  Encourage patient to involved in self-care
progress of labor - Reinforce healthy behavior – treat mother normally.
 Provide quiet calm environment. - Promote expression of feeling and concerns – use broad
or open ended questions.
 Lochia that is more than 1 cm –
The common factor is lacking support system – Acquired disorder – HELLP , DIC
family.
Coagulation – thrombocytopenia purpura – decrease level of
platelets.
POSTPARTUM COMPLICATIONS
2 types of PPH
POSTPARTUM HEMORRHAGE 1. EARLY --- occurs first 24hrs after delivery
– excessive blood loss during or after 3rd stage of labor. - Cause by; uterine atony, laceration, fibrinogenimia,
- No.1 cause of maternal death. uterine rupture
Normal blood loss: 2. LATE – happens after 24 hrs
 NSD – 500 ml (higher than 500 ml - hemorrhage) - Retained placental fragment
 CS – 1000 ml ( higher than 1000 ml – hemorrhage) - Subinvolution
- Infection
Incidence
- 3-6% cause of all deliveries Management:
- 3.9 % NSD  Uterine massage – first thing to do = this allow uterine
- 6.4 % CS contraction
 Offer bed pan – for voiding at least 4 hours
CAUSE ? 4PS  Administer 4L / min of Oxygen via face mask – due to
respiratory distress.
a) Tone – failure of the uterus to contract and relax.  Position pt in Supine or elevate the legs – for
adequate blood flow.
Cause by;  Obtain vital signs
- Uterus distention
- Fatigue – due to prolonged labor s/sx of shocks – Headache, Dizziness, and Clammy skin.
- Infection – just like chorion, endometritis, and septicemia
- Abnormal fetus presentation
- Hypoxia – due to hypo perfusion or hard uterus UTERINE ATONY -- lead to early pph
- Abnormal placental site - Experience during first 24 hours.
- Inhibition of contraction – using NSAIDs, Nitrates,
Anesthetic agents etc. Atony – relaxed uterus and no contraction

b) Tissue – there is a retained placental tissue inside uterus

First management is = UTERINE MASSAGE
= prevent full contraction.
RETAINED PLACENTAL FRAGMENT – experience after 24
 If uterus is occupied with something – it prevent
hrs.
contraction
- One cause of late pph

This might be cause by – abnormal adhesion/attachment of

Related to;
the placenta – such as accrete, incretta, pacreta
- Partial separation of placenta
- The deeper the adhesion – more possibility of retained
- Manual removal of placenta
tissue.
- Abnormal placenta adhesion

c) Trauma – injury in genital tract

If placenta is deeply implanted or penetrated to the
uterine wall – there is possible RPF.
Cause by;
- Laceration and episiotomy
- Hematoma – lead to postpartum hemorrhage
What is expected?
- CS
- Uterus not contracting and is soft – lead to profuse
- Uterine rupture and inversion
bleeding
- Uterine perfusion
What to do?
- D and C
- Removed it manually
- Use of forceps
- D&C
- Prescribed Methotrexate – to destroy placental fragment.

How to know if there is still retained fragments?

d) Thrombosis – presence of blood clot – prevent
- HCG test.
contraction
 + hcg – there is still placental fragments inside  Presence of Retained placental fragments –
uterus could be a breeding ground for microorganism.
 hcg – no placental fragment inside uterus.  Experience PPH
 Pre-existing anemia due to low body defenses
SUBINVOLUTION UTERUS  Prolonged and difficult labor – due to use of
- Delay in the uterus to return into pre-pregnant state. instrument
- Fundus is not descending  Local vaginal infection
 Exploration of uterus
Involution? – return of pre pregnancy state (observed in 6  Contaminated fetal heart monitor.
days)
Assessment:
Midway between symphysis pubis – location of uterus  Pain, edema, elevated temp, and fever
 = 104 °C or 38 °C – after 24 hrs is
24 hrs – fundus taas ng umbilicus not normal = infection
After 24 hrs – fundus need to descent – one finger breath  = 104 °C or 38 °C – in first day is
(another 24 hr – another finger breath) normal = due to leukocytosis
= until 9-10 day – until fundus is can no longer palpate  Firmness, tenderness and redness
 Burning sensation
Assessment:  Lost of appetite
 Uterus is enlarged and boggy, and Soft means not  Lochia – is dark brown and foul odor
contracting  Chills.
 Affect lochia – has foul odor and color is dark brown.
Normal Prevention
o Rubra – 1-3 days = red
 Use sterile gloves/instrument when doing vaginal
o Serosa – 4-10 days = pink –brown exam
o Alba – 10 days = white  Perineal care ( front-back)
 Hand washing
 Backache  Client should have own bedpan
 Antibiotic – Gentamicin, ampicillin (no breastfeeding)
Management:
 antibiotic caused fungal infection to the
 Ergonovine maleate .2 mg – help uterine contraction
baby (oral candida)
and prevent bleeding (2weeks)  decrease the production of Vit. K – and
- If there is still bleeding after 2 weeks – dr. perform D&C decrease vitamin k lead to ==
 Treating the cause decrease blood clot.
- Treating infection ( antibiotics)  Culture and sensitivity testing
- Removing retained placental fragment (D&C)
 Hot sizt bath 2x day – use of lukewater with
medication or guava. – help in treating the wound.
NSG management:
 Uterine massage – initial action
ENDOMETRITIS
 Ice compress- decrease and minimize bleeding – infection in the endometrium – lining in the uterus.
 Administer oxytocin - Could affect another organ.
 Empty the bladder
 Bimanual massage Assessment
 Elevated body temperature – 3rd-4th day
Last alternative is = HYSTEROCTOMY  Full breast milk
 Increase WBC – 20,000-30,000
 Chills
 Lost of appetite
POSTPARTAL PUERPERAL INFECTION
 Fatigue
- Affect the reproductive tract
 Uterus is not contracting
 Pain to touch
Episiotomy site / laceration – point of entry of microorganism.
 Strong afterpain
It affects peritoneum –peritonitis  Lochia is dark brown and has foul odor
Circulatory system – septicemia
X. if with high fever = lochia is absent.
How come?
 ROM after 24 hrs – check temperature - RFP is confirmed by utz.
(elevated)
Danger:
 - Tubal scarring – further lead to infertility and ectopic - Remove suture and ligate the affected blood v. – keep
pregnancy. area open and cover it with pack gauze.
- Infected lochia - Packing – removed every 24-48 hrs to prevent infection.

Management The area should be dry to prevent further infection.

 Antibiotic is given ( depending on the type of bacteria)
o == CLINDAMYCIN is common antibiotic
 Vaginal culture – getting sample directly from the THRONIBO-EMOBLIC – inflammation on the lining of blood
vagina vessels = it forms blood clot.
 Methylergonovine (IM) – sustain uterine contraction Risk factor
but decrease breast milk. - Varicosities in the legs
 Increase fluid intake – to flush out the lochia - Obesity – damage those veins.
- Multiparity – increase fibrinogen (levated fibrinogen
 Analgesic for pain
levels, which are part of the inflammatory response, lead
 Fowler position or standing and walking – lochia will
to increases in clot stiffness, and increased blood
be drained due to gravity.
viscosity)
 Wear gloves when changing the perineal gloves.
- Use of estrogen supplement – use of oral contraceptives
lead to varicosities.
When assessing the lochia check for,
- History of thromboembolic disease;
 Quantity
- Diabetes mellitus – tries to elevate the coagulation
 Color factors.
 Odor
 Related to the position of delivery (semi-upright)
When assessing the uterus check; - Legs are being raised and placed at stirrups at the same
 Size time to avoid injury.
 Consistency
 Tenderness  When raising the legs? – should not be too long –
 Location too long leads to low peripheral flow of blood =
thrombophlebitis.
 Crossing the legs, prolonged standing, and sitting =
could impede blood circulation

PERINEAL HEMATOMA – blood in the subcutaneous layer

tissue of the perineum. Causes:
- Use of oral contraceptives can damage blood vessels
- Blood maybe came from blood vessels or during repair - Prolonged bed rest or inactivity.
in episiotomy (episioraphy)
DIAGNOSIS
Related to; precipitate labor that could injure blood vessels or  Doppler Ultrasound
laceration.  X-ray dye injection called == Venogram – to see if
veins are blocked.
Assessment
- Client will feel pressure between legs (difficulty in  Encourage to raise legs in CS
walking)  Ambulatory for NSD
- Will feel uncomfortable
- Hematoma – purple and size is 2cm- 8cm in diameter Types according to location
- Presence of tenderness in palpation 1. Superficial thrombophlebitis - an inflammation of a
- Firm in globe vein just below the surface of the skin, which results
from a blood clot.
Management: 2. Phlebothrombosis -- blood clot formation within
- Report observation – size, color and the degree of venous.
discomfort. 3. Thrombosis – blood clot.
- Describe the size and lesion - Inflammation of vein located DEEP in a muscle tissue
- Prescribed analgesic  blood clot may break free during muscular
- Ice pack (covered with linen to prevent thermal injury into activity and travel in circulation.
skin s/sx – swelling on muscle tissue.

If hematoma is large and tend to increase – they incised and Types according to veins affected
drain the blood and repair the blood vessels that is affected. 1. Femoral thrombophlebitis
Manifestation Good positioning
 Homan’s sign – Tummy To Tummy.
 Milk leg or Phlegmasia alba dolens (PAD) - Body of baby should be facing the mother.
describes the patient with swollen and white
leg. Poor positioning – cracking of nipple

Interval of breastfeeding – 2-3 hours.

- A deep suckled has no sound however, u can still hear
 the baby swallowing.

Management: Assessment
 Malaise
- Early ambulation – initial action and best management.
 Elevated HR
- If has thrombophlebitis already
= wear supportive stockings before waking in  Redness and fissured ( crack)
the bed every morning.  Swelling in the auxillary lymph nodes.
- Hydration is a must!
- Don’t massage the legs as there might be blood clot = Management
this also to avoid dislodge.  Observe s/sx of infection (fever or chills)
 Administer antibiotics
2. Superficial Venous Thrombosis - PAIN is the  Provide comfort measure ( ice packs or warm
ONLY problem compress)
 Educate the px and family on how to clean the
Management: breast, abt proper position, and attachment.
- Warm compress  Frequent BF
- Ibuprofen and aspirin
- Heparin (Anti-coagulant) = is safe bc It does not cross How to clean the breast?
breast. - To clean the breast – use breast milk.

If receiving heparin, aspirin is not needed!

3. Deep vein Thrombosis

- A serious type.

Management.
- Pt need to be in complete bed rest until it disappear.
- Leg elevation
Anticoagulant therapy
- Heparin toxicity --  protamine sulfate
- Dicoumarol – vit. K
2 MAJOR COMPLICATION:

o Thrombophlebitis – venous thrombosis.

o Pulmonary Embolism – obstruct blood flow in the
lungs

If NSD after 24 hrs – encourage pt to go to restroom

and slowly rise up.

MASTITIS
- Breast tissue inflammation due to milk stasis or infection
of the lactiferous ducts.
- Observed 3rd-4th week of PP.

Due to:
 Breast injury (overdistention or cracking of nipple).
 Missed feeding – it tend to clog
 Tight feeding bra.
 Impaired infant sucking related to attachment.
 == Portal entry is oropharynx

Sign and symptoms

• Fever (intermittent)– give acetaminophen
• Mild pain in salivary gland
• Trouble chewing
• Muscle ache
• Headache
• Body malaise
• Parotid gland is swollen and painful.
- Submaxillary and sublingual gland may be affected ==
anorexia and dysphagia
- In large swelling, the ear lobe may be pushed upward.

Management
o Isolation – nursing priority
o Comfort the patient – either hot or cold application
maybe used on the swollen jaws to alleviate the
discomfort.
o Remain in bed for atleast 4 days after the swelling
o Diet: Soft bland.
o Increase fluid intake
o Gargle with warm water
o Aspirin for pain
ALTERATION WITH INFECTIOUS AND
o Avoid acidic foods
INFLAMMATORY RESPONSE o Analgesic for headache
o Corticosteroid for orchitis (pain reliever)
Mumps o Alternate warm and cold compress.
- An acute viral infection of the salivary glands
particularly the parotids with constitutional Diagnosis:
manifestation of varying degrees.  Blood examination – to check leukocyte count which
- Mouth and saliva shows leukopenia with relative lymphocytosis
- Caused by myxovirus  Viral culture – isolation of virus from saliva, mouth or
urine
Onset?  Viral serology
- 7 days before onset or until 9 days after the parotid
gland swell – 14-21 days incubation. Complications:
 Meningoencephalitis --- infection in the neuron with the
Recovery? parotitis occurring at the same time
- 2 weeks  Epididymo-orchitis (common in male in puberty)
 May occur even without evident swelling on the
FACTORS: parotids.
- Unvaccinated individuals  Last about 5 days
- Affect children aged 5-15 y/o s/sx
- International travel - Scrotum swelling
- Living with a person with rubella virus - Hyperpyrexia
- Weak immune system - Chills

Other name of MUMPS:  Oophoritis (common in female)– pelvic pain and

 Epidemic parotitis tenderness without impairment in fertility
 Viral parotitis  Pancreatitis
 Infectious parotitis  Nephritis
 Thyroiditis – diffuse, swelling of the thyroid about a week
Mod after the onset of parotitis.
- Direct contact  Mycocarditis – depression on the ST segment with
- Droplet precordial pain?
- Airborne  Mastitis
 Deafness - Augmentin – penicillin
- Rest
Some management: - Turn or reposition child frequently – to avoid secretion
Before puberty – no prophylaxis indicated on one area.
After puberty -- live attenuated mumps virus - IV therapy
- Administer oxygen (humidify) – prevent hypoxia
Contraindication – allergy with eggs, administration of - Antipyretic – acetaminophen
immunosuppressive drugs or the presence of weak immune - Assess o2 sat
system.
- Chest physiotherapy – encourage movement of
- Not recommended below 1 year of age.
mucus
- For older patient – encourage coughing.
Control measure
- Active immunization – live attenuated mumps virus
2. Chlamydial pneumonia
vaccine (Mmr) – given by a private doctor
- 12-15 months of age – 1st dose
 Most often seen in newborn up to 12 weeks of age.
- 4-6 years – 2nd dose
 Contracted in mothers vagina during birth.
- Can be given late until 12y/o
Assessment:
PNEUMONIA:
• Nasal congestion
• Sharp cough
Types – Hospital and community acquired disease.
• Infants fail to gain normal weight
• Tachypnea
Is no. 1 cause of death among infants younger than 48 hours
• Wheezing
of life? ---- occurs at the rate of 2-4 children in 100.
• Rales
Affect:
• Elevated level of immunoglobulin (IgG and IgM)
- Premature babies
- Meconium baby Management
- - Erythromycin – drug of choice.
Causes? 3. Viral pneumonia
- Can be bacterial origin ( pneumococcal, streptococcal  Caused by RSV (myxovirus or adenovirus)
-- hospital
- staphylococcal and chlamydia ---- acquired) Assessment:
- Viral (RSV) --- community acquired • Low grade fever
- Aspiration of lipids or hydrocarbon. • Non-productive cough
• Tachypnea
1. Pneumococcal pneumonia – caused by streptococcus • Diminished breath sound
pneumonia • Fine rales
• Apnea
 Infants remain bronchopneumonia? With poor • Chest x-ray – shows diffuse infiltrated areas.
consolidation of exudate into alveoli.
 Older children only localized in single lobe. Management:
- Rest
Assessment: - Antipyretic for fever
• High fever - IVF
• Nasal flaring - Explain difference of bacterial and viral infection to
• Rectraction – sign of respiratory disease parents
• Chest pain
• Dyspnea As for bacterial infection – antibiotic
• Tachypnea As for viral infection – rest and no antibiotic
• Pain in abdominal
• Breath sounds are bronchial
CELLULAR ABERATIONS
• Crackles due to fluid inside alveoli
• Dullness in percussion due to total consolidation
• Chest x-ray – full of white patches WILMS TUMOR
• Lab result – elevated leukocytes. – also called as nephroblastoma

 Is a a malignant tumor that rises from the

Management:
metanephric mesoderm cells of the upper pole of the
- Antibiotics – ampicillin or 3rd generation
kidney.
----- cephalosporin or amoxicillin.
  A rare kidney cancer that mostly affect children  Kidney function or BUN – assess function of kidney
(females) b4 surgery.
 Without treatment – it could metastasized into
different organ (lungs, liver and brain) When tumor metastasized rapidly it result – large blood
going to the kidney and adrenal glands.
 Associated with congenital anomalies: RULE – do not palpate abdomen ( place it in the crib)
----- anirida (lack of color in the iris)
STAGE 1 Tumor confine in the kidney , can still
----- hypospadias
remove surgically
----- cystic kidney STAGE 2 Tumor extending beyond, complete
----- hemangioma removed surgically
----- talipes disorder STAGE 3 Regional spread of the disease with
residual abdominal disease
----- deletion of chromosome 11
STAGE 4 Metastasized to lungs, liver etc.
STAGE 5 Both kidneys are already affected. ---
Predisposing factors: assess one kidney at a time since one
• Age – 3-4 years of age (less common in older can affect organs rapidly.
children)
• Race – African-american Management:
• Family history – have the same genetic // has missing • Nephrectomy – remove affected kidney ( excision)
chromo. • Radiation therapy – omitted in stage
• Certain genetic disorder --- warg • Chemotherapy – undergo chemo phases.
• Gender – girls ( has x chromosome – and most x ---- Dactinomycin, doxorubicin or vincristine.
contain chromosome 11)
Chemotherapy
Some syndromes associated to nephroblastoma?  May be given in varying interval for 15 months
• WARG (wilms, aniridia, genital tract abnormalities,  2nd surgical procedure may be scheduled after 2-3
mental retardation)
months – remove remaining.
• Denys – Drash syndrome
 If tumor is bilateral – both needs to be removed or
• Frasier Syndrome
only the kidney with larger tumor removed.
• Beckwith-wiedmann syndrome
 Tumor sites are treated with both chemo and
radiation.
Predisposing factors:
• Age – 3-4 years of age (less common in older
High powered or side effects:
children)
- Nausea
• Race – African-American
- Vomiting
• Family history – have the same genetic
- Loss of hair ( alopecia)
• Certain genetic disorder
- Higher risk of infection

Complications
Assessment:
• Small bowel obstruction
- Discovered early in life; 6-5 months – 3-4 years
• Hepatic damage from radiation
- Firm, non-tender abdominal mass
• Nephritis
- Hematuria – increase amount of blood going to the
• Damage to ovaries
kidney and urine
• Pneumonia
- Low grade fever
• Scoliosis – radiation
- Anemic – low rbc
- Hypertension – excessive renin production.
ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
------------------------sx-----------------------------------------
- Constipation
 Most frequent type of cancer in children and affect the
- Loss of appetite
blood and bone marrow
- Weight loss
- Hematuria  “acute” mean that leukemia can progress quickly is
- Frequent urination not treated.
- Baby is big for its age  Lymphocytic (immature wbc increase, platelets and
- Vomiting RBC fall.

DX: Bone marrow – overproduce leukocyte rapidly.

 CT-scan or Ultrasound - neoplasms composed of immature T cells are referred
as lymphocytes
 papilledema, nuchal rigidity, meninges and 6-7th
Most common cancer in children: -- between 2 and 6 years cranial nerves)
of age
Lumbar puncture result – presence of blast cell in CSF ==
Prognosis: younger than 1 year old or older than 10 year old at treated with methotrexate via – intrathecal injection (1x)
the first time of occurrence is not as good those between 2 and
10 years of age.  RENAL involvement (kidney impairment, increase
uric acid, kidney failure) – limit the use of
Factors: chemotherapy agents because they cannot be
- radiation excreted effectively.
- taking benzene
- inherited genetic disorder – down syndrome or  TESTICULAR involvement (Leukemic cells tend to
Fanconi syndrome invade the testes and cannot be destroyed with
chemotherapy, sterilization)
Assessment: Boy is past puberty- sperm banking to preserve sperm
• pallor
• low-grade fever I. When at home: parents must report signs of infection
• lethargic such as low grade fever or behavior that does not
• Petechiae seem typical for the child.
• Bleeding from oral mucous membrane - Prophylactic antibiotics
• Bruise easily ( due to low thrombocyte ct) - Limit visitors
• Abdominal pain - Leukocyte transfusion – increase functioning
• Vomiting leukocytes – fever and chills are not true sign of
• spleen and liver transfusion.
• anorexia II. Risk for deficient fluid volume related to increased
• Bone and joint pain- due to abnormal lymphocytes in chance of hemorrhage from poor platelet production
the bone periosteum
• Headache invaded CNS - Prone to massive hemorrhage
• Unsteady gait - Epistaxis (nose bleeding) – lower head and ice
• painless, generalized swelling of lymph nodes o Digital pressure is effective to stop epistaxis
especially in submaxillary or cervical nodes o BT – platelet transfusion
DX: o Heparin lock/multilumen central nervous
 Bone marrow aspiration – first (bone marrow is catheters- minimizing the need for repeated
aspirated at the iliac crest, why? --- accessible, less venipunctures
trauma, and is safer)
o ---- if there are more than 25% blast cell = III. Pain related to invasion of leukocytes Due to vast
+leukemia number of RBC that invades the periosteum of the
 Radiograph – reveal lesion on long bones bone
 Lumbar puncture
o Handle arms and legs gently
Management: o Use of an alternating mattress or sheepskin
1. Chemotherapy helps to reduce skin irritation caused by always
– Administered by central venous catheter – to resting in the same position
prevent irritation on vessel wall. (the access device can o Give analgesia as needed
be clamped so that child can still ambulate.
IV. Ineffective health maintenance related to long term
Drugs used during chemo? therapy for leukemia
• Vincristine – given at 1 month
• Prednisone - Report signs of infection
• Asparaginase o Ask the child’s school to notify them if any other
• Doxorubicin child in the school develops
• Methotrexate chickenpox==immune protection can be given
• Allopurinol – reduce the formation of uric acid. o Evaluation/follow-up
----- Formation of uric acid is related to the death of
release cancer cell from chemotherapy Treatment
----- being hydrated maintain safe uric acid excretion. CHEMOTHERAPY AND RADIOTHERAPY

Complications: a. Induction (remission induction) -to kill the most of the

 CNS involvement ( blindness, hydrocephalus, tumor cells rapidy
recurrent seizure, headache, irritability, vomiting,
 - Drugs commonly used: vincristine, asparginase,
dexamethasone  Anastomosis –a pull through operation.

b. Consolidation- high doses of multidrug chemotherapy are Two staged surgery

used to eliminate the disease or reduce tumor burden to 1. Temporary colostomy – repair at 12-18
very low level months of age. == remove colostomy with
presence of nerve endings.
- Drugs commonly used: Vincristine, 2. Permanent colostomy – if nerve ending is
cyclophosphamide, cytosine arabinoside, not present in the anus
doxoorubicin, etoposide or mercaptopurine  Post op
 NGT -- if peristalsis is present, remove NGT.
c. Maintenace therapy -- Aims to eliminate completely any  IV and IFC
remaining leukemic cells  Observe abdominal distention
 Assess bowel sounds
o Given with daily oral mercaptopurine and once  Observe the passage ( anal patency – use
weekly oral methotrexate. ( continued for 2-3 years) thermometer)
o Leukovorin is given to neutralize side effects of
chemo.  When feeding:
o Blood values are monitored at least monthly  Full fluids --- soft diet ---- minimal residue
diet ---- normal diet for age.
Bone marrow transplantation or immunotherapy can
be used for children who do not respond well to standard INTUSSUSCEPTION
therapy.
 Telescoping/ invagination of one portion of the
bowel into another portion which results in an
HIRSCHPRUNG DISEASE obstruction to the passage of intestinal
contents
 Known as aganglionic megacolon or intestinal  Common cause of intestinal obstruction in 3months
aganglionosis – 6 years.
 Absence of ganglionic innervation to the muscle
section of the bowel (sigmoid colon) Sign and symptoms:
 Mostly occur in male newborn - Nausea and vomiting
- Abdominal pain
First sign? Fail to defecate 24 hours. - Currant jelly stool (bloody red)
- Lethargic
Sign and symptoms: - Sausage shaped mass (dance’s mass)
- Constipation - Cry and draw legs towards chest (15-20)
- Abdominal distention - Fever
- Vomiting - Hypo/Hyperactive bowel sound
- Malnourished w/ bloated stomach
- Rectum is empty Management:
- Diarrhea – report immediately  Monitor fever, increase HR, LOC, BP and respiratory
- Associated with genetic mutation distress.
- Ribbon like stool  Antibiotics
 IVF
DX:  NGT
 Abdominal x-ray  Monitor for brown stool
 Contrast enema  Hydrostatic reduction
 Rectal biopsy  Barium enema – first procedure
 Anorectal manometry – check pressure and function  Ultrasound
of anus and rectum  Rectal exam – anesthesia is given after affected area
is removed (general anesthesia)
Management:
 Pre op Difference between general and local anesthesia?
 Minimal residue diet – low fiber --- Local anesthesia is used when a small part of the body is
 Omit foods – highly seasoned foods numbed and u remain conscious, in General anesthesia is
 Stool softener where you’re totally unconscious and unaware of the
 Daily enema procedure
 IVF normal saline
DIABETES MELLITUS  Regular blood testing
 Urinalysis.
 Involved the absence of insulin secretion (type 1) or
peripheral insulin resistance (type 2), causing Complications:
hyperglycemia. - Ketoacidosis --- blood sugar very high and body start
using fats result to ketones.
Risk factors:  Risk for diabetic coma -- loses
- Weight consciousness because of brain swelling
- Inactivity due to high blood sugar
- Diet - Hypoglycemia --- Insulin reaction (low blood sugar)
- Family history - Eye problem – blindness
- Race or birth ethnicity - Ear problem – nerve damage result to hearing loss
- Gestational diabetes - Nerve damage –
- LBW or preterm birth. - Tooth and Gum problems --- tooth decay, cavities.
- - Skin and Foot problem --- discoloration in armpit
DX: and nape
 Glycosylated hemoglobin (A1C) test. - Heart and Blood vessels problem --- stroke and
---- This test indicates your child's average blood high cholesterol.
sugar level for the past 3 months.
- 6.7% - Have diabetes ( more helpful) Type 2 diabetes mellitus
- Is chronic disease that without treatment it could lead
to serious consequence (most do not have symptoms)
Type 1 diabetes mellitus - A condition in where the body no longer uses
- Long term condition that develops quickly in pattern. insulin.
- A condition where insulin is no longer produce. - Occur more in adolescent
- Usually begins a 4-6 years of age or 10-14 y/o - Called: adult-onset diabetes.

Sign and symptoms: Children with type 2 diabetes do not progress easily, and
 High level of glucose in blood and urine do not likely to develop ketoacidosis or severe
 Unusual thirst dehydration.
 Dehydration
 Frequent urination
 Extreme hunger but weight loss
 Loss of appetite Sign and symptoms:
 Blurred vision  Increase thirst
 Nausea and vomiting – due to ketones in blood  Frequent urination
 Belly (abdominal) pain  Increased hunger
 Weakness and fatigue  Fatigue
 Irritability and mood changes  Blurry vision
 Serious diaper rash  Darkened areas; armpit or around the neck
 Fruity breath  Weight loss ( less common in type 2)
 Fast breathing  Frequent infection
 Yeast infection in girls
 Diabetes screening is recommended for children
DX: who hit puberty or at least 10 years old, overwight.
 Fasting plasma glucose. The blood is tested after at Causes:
- Family history
least 8 hours of not eating.
- Genetics
• 126 or higher – diagnose diabetes
- Most sugar in the body came from the food.
 Random plasma glucose. The blood is tested when
Risk factors:
there are symptoms of increased thirst, urination, and
- Weight
hunger.
- Inactivity
• 200 ml or higher – probably have diabetes and test for
- Diet – red meat and processed meat.
fasting glucose to confirm
- Family history
- Race or ethnicity – black, Hispanic and American
Management:
Indian as well as Asian.
 Daily injection of insulin
- Age and sex –
 Eating right foods - Low birth weight and pretem
 Exercise
 - Metabolic syndrome Incomplete unilateral cleft
- PCOS lip
• Opening on the side of
Complications one lip that does not
- High cholesterol extend to nose
- Heart and blood vessel disease Complete unilateral cleft lip
- Stroke • Opening on one side that
- Eye and Kidney and nerve disease extend to the nose
Incomplete bilateral cleft lip
Management: • Opening on both side of
• eat healthy food the lip but does not
• Exercise extend to nose
• Metformin – orally, it can be taken with foods to Complete bilateral cleft lip
prevent N/V. dosage increase overtime. • Opening on both side of
• Liraglutide – IV , given 10 years of age who have type the lip and extend to
2. nose.

Complication of diabetes in children and adolescents: Management:

• the most serious immediate complication is
ketoacidosis.
• Long term complication maybe due to issues with
social, psychological or blood vessel problems.
PRE OP
• Feed in upright position using a soft large holed
nipple or a rubber tipped syringe.
• Burp frequently due to swallowed air
• Teach parent to give water after feeding to cleanse
mouth
• Prevent infection from irritation on the lip
• Restraint arms if needed
• Provide pacifier to increase sucking pleasure.

CLEFT LIP AND PALATE
 Congenital malformation resulting from failure of
fusion of maxillary process during intrauterine
development.
Cleft lip – a physical split or separation of the two sides of the
upper lip and may extends beyond the base of the nose.
 Deviation maybe unilateral or bilateral
 Nose is flattened
 More prevalent in boys
 Are associated with birth defects.
POST OP
• Maintain airway
• Clean suture line to prevent crust formation
• PREVENT CRYING – because of the pressure on the
suture line
• Place infant in SUPINE position with arm and elbow
restraint. (change position to side or sitting up to
prevent hypostatic pneumonia and remove restraint
atleast 3x)
• Support patient by accepting and treating infant as
normal.
• Suture line is held by LOGAN BAR
Management:
Cleft lip – fetal surgery while still in utero or repaired surgically
shortly after
--- nasal mold apparatus is applied before surgery to shape
better nostril
Nasal Rhinoplasty --- Another surgery will be done when child
reaches 4-6 yr

Cause: Cleft palate --- split or opening in the roof of the mouth (can be
• Teratogenic factors that occur 5-8 weeks hard or soft palate)
• Viral infection
• Deficiency of folic acid Types:
Types:
Incomplete cleft palate
Forme fruste or microform • Opening in the back of
cleft lip the mouth (soft palate)
•Small indention on one or Complete cleft palate
both side of the lip • Opening in the front and
 back of the mouth • Explain the condition
Sub mucous cleft palate • Feeding – condition reduce the ability of the infant to
• Muscles within the soft suck
palate are separated but ---- breast feeding is possible with the use of Palatal
the skin are closed. obturator, or using syringe.
• Parents should be demonstrated different techniques
about feeding
What is the incidence? • Small bolus should be given
- Monozygotic twins are more prone to get than zygotic • Immunization
twin
- Cleft lip and palate are more common in Asian PRE OP
• NPO for 6 hours
Predisposing factors: • Administer medication
• Maternal infection
• Being expose to radiation POST OP
• Smoking • Keep airway clear – avoid using suction that
• Hypo proteinuria traumatize operative site.
• Maternal malnourished • Mild sedation is given to stop baby from crying
• Corticosteroid • Careful position (never in the abdomen)
• Place in Prone/ Trendelenburg -- prevent aspiration
Complication: • Parents should remain with the kid
- Difficulty in Feeding – most immediate concern as • Infant is fed in dropper
they make sucking difficult • Mouth should be rinse after feeding
- ear fluid and hearing loss • Do not brush teeth 1-2 weeks after surgery
- Dental problems • Suture line must be clean
- Speech problems – because palate is the one • Speech therapy should be given
forming sound. • Encourage child to socialize
- Challenges in coping medical condition. • NO MILK!

Clinical manifestation: A cleft palate need a 2 stage palate repair:

• Notched vermillion border - Soft – 3-6 months of age
• Dental anomalies - Hard – 15-18 months of age
• DOB
• Exposed nasal cavities
• Recurrent ear and throat infection
• Speech defects and physiological factors ------------------------------------------------------------------------------------
• Inability to coordinate breathing and feeding ALTERATION IN PERCEPTION AND
• Mouth breathing COORDINATION
DX:
 History collection CEREBRAL PALSY
 Prenatal ultrasonography – enable to identify while in
utero  A disorder of movement, muscle tone and posture or
 Physical examination an Impairment in perception and coordination
 X-ray – show deformity of palate bone  Could happen after or most often before birth
 MRI – to evaluate the extent of abnormality
 Dental imprecision for expansion prosthesis Sign and symptoms:
 Genetic evaluation – to determine recurrence risk • Variations in muscle tone, such as being either too
stiff or too floppy
TEAM BUILDING • Stiff muscles and exaggerated reflexes (spasticity)
- Pedia • Stiff muscles with normal reflexes (rigidity)
- Plastic surgeon • Lack of muscle coordination (ataxia)
- Orthodontist • Slow, writhing movements (athetosis)
- ENT specialist • Delays in reaching motor skills milestones, such as
- Speech therapist pushing up on arms, sitting up alone or crawling
- Psychologist • Difficulty walking, such as walking on toes, a
- CHN crouched gait, a scissors-like gait with knees crossing,
• a wide gait or an asymmetrical gait
Nursing management: • Excessive drooling or problems with swallowing
• Avoid complication • Difficulty with sucking or eating
 • Delays in speech development or difficulty speaking • LBW
• Dificulty with precise motions, such as picking up a • Multiple babies
crayon or spoon • Premature birth
• Seizures • RH Incompatibility

The disability associated with cerebral palsy may be TYPE OF CEREBRAL PALSY
limited primarily one side of the body, or it may affect
the whole body. However, muscle shortening and muscle 1. Spastic cerebral palsy ---- weak and stiff muscle with
rigidity may worsen if not treated aggressively. exaggerated reflexes, making a scissor –like
Some other symptoms are; movement with their legs
- Difficulty in vision and hearing
- Intellectual disabilities 2. Dyskinetic cerebral palsy --- have trouble controlling
- Seizures their body movements, it causes unusual movement, it
- Abnormal touch make the child difficult to swallow, sit and walk or even
- Oral disease talk.
- Mental health
- Urinary incontinence. 3. Ataxic cerebral palsy ---- voluntary muscle movement
that appear disorganized, clumsy or jerky, have
SOME SPECIFIC AGE difficulty in walking and performing motor function,
Infants younger than 6 • Cannot hold their head
months of age • Stiff or floppy 4. Hypotonic cerebral palsy --- diminished muscle tone
• Legs get stiffed or cross and overly relaxed muscle. Arms and legs move easily.
• Overextend their back and And they struggle to stand up straight
neck and constantly
pushing away from you.
Infants older than 6 months • Cannot roll over Management:
of age • Cannot bring their hands • Muscle relaxant ( baclofen, dantrolene (Dantrium),
to their mouth diazepam (valium), tizanidine (Zana flex)
• Cannot bring their hands • Assistive aids (Eyeglasses, hearing aids. Walking
together aids)
• Reach with one hand • Surgery (Orthopedic maybe used to relieve pain and
while other is fist improve mobility and release tight muscle or correct
bone structure)
Infants older than 10 • Crawl lopsided
• Other treatment (speech therapy, counseling etc)
months of age • Scoot on their buttocks or
hop on their knees.
What are the causes?
Complications:
- Mutations that lead
• Muscle weakness, muscle spasticity and coordination
- Maternal infection
problems
- Fetal stroke – a disruption of blood supply to developing • Contracture – muscle tissue shortening due to severe
brain muscle tightening (spacity)
- Infant infection • Malnutrition – feeding and swallowing can be difficult
- Traumatic head injury due to impaired growth and weaker bone
- Lack of oxygen – asphyxia • Mental health condition – depression can occur
• Lung disease – breathing disorder
Maternal risk factor • Neurological condition
• Rubella – a viral infection • Osteoarthritis – pressure on joints and abnormal
• Cytomegalovirus alignment of joints from muscle spasticity.
• Herpes • Eye muscle imbalance --- affect visual fixation and
• Toxoplasmosis tracking.
• Syphilis
• Exposure to toxins Prevention:
• Zika virus infection - Make sure child is fully vaccinated
- Seek early and continuous prenatal care
Infant risk factor - Practice child safety.
• Bacterial meningitis
• Viral encephalitis HYDROCEPHALUS
• Jaundice
• Breech births  A condition in which excess CSF build up within
• Complicated labor and delivery the fluid containing cavities or ventricles of the brain.
 All children under 2 years old should have head
 CSF is formed in the 1st and 2nd ventricles then circumference recorded ( an hour after birth and before
passes to aqueduct of sylvus and to 4th ventricle discharge)
to empty in subarachnoid space of spinal cord ----- Note for symmetry.
where it is absorbed.
 CSF is produced by ependymal cells A skull that is enlarging anteriorly suggests an obstruction
 Excessive CSF due to; in 3rd ventricle.’
a. overproduction of choroid plexus in 1st and
2nd ventricle Sign and symptoms:
b. Obstruction of the passage of fluid; narrow • Motor function impair as head enlarge
the aqueduct of sylvius. --- Both atrophy and neurologic impairment caused the
c. Interference to the obstruction of CSF from …inability of head to move.
subarachnoid space if portion of it is • However, intelligence remain normal.
removed
DX:
 Since infant cranial nerve still not firmly knitted – the  Ultrasound
excess fluid cause the enlargement of the skull = this  Computed tomography?
enlargement increase ICP  MRI?
 Skull x- ray – reveal separating of suture
2 TYPES OF HYDROCEPHALUS:  Chun gun – reveal whether skull is full of fluid or solid
brain.
1. Non- Communicating or obstructive – cause
blockage on the passage of CSF
- Can be caused by tumor, cyst, and congenital,
hemorrhage , Arnold Chiari disorder, meningitis or
encephalitis - this leave adhesion to block fluid flow

2. Communication or Non-obstructive -- due to

decrease CSF reabsorption or if the fluid reaches
spinal cord.

Other classification:
1. Congenital – taken from maternal infection or
meningitis.
2. Acquired – from an incident later in life (accidents)

If obstruction is present
- Excessive fluid accumulates and dilates the system above
the point of obstruction. Management:

 If the atresia is I the aqueduct sylvius

- if caused by overproduction:
- The 1st and 2nd and 3rd ventricles will dilate.
 If it is in the exit from 4th ventricle • Acetazolamide (diuretic) -- if caused by overproduction
of CSF
- All ventricles will dilate.
• Ventricular endoscopy -- if there is a destruction in the
 If hydrocephalus is present prenatally. choroid plexus
- Fontanel widens and tense • Remove tumor --- if tumor is the cause.
- Suture lines separate
- Head diameter enlarge - if caused by obstruction:
- Bossing (brow bulges forward)
- Sunset eyes • Laser surgery – reopen route
- ICP – s/sx; decrease PR and RR, increase tempt and • Shunting procedure – threading a thin polyethylene
BP. catheter under the skin from ventricles to peritoneum.
- Hyperactive reflexes --- Bed should be flat (30 degrees) – do not raise
- Strabismus excessively.
- Optic atrophy
Shunting procedure
- Failure to thrive
 One ways valve that is inserted in the shunt that
- High pitched cry
opens when CSF has accumulated to the extent that it
cause pressure.
  It closes when enough fluid has drained to reduce
pressure
 Infant should lie on UNAFFECTED SIDE to prevent
pressure.
Management:
POST OP
• Assess signs of ICP and symptoms for infection and
meningitis(stiff neck and irritability)
• Assess if child receives adequate pain management
to prevent crying as this cause pressure.
• NPO until bowel sound return
• Introduce small fluid after NGT is removed
• Support head when moving (hold their head with
whole palm)
• Use rocking chair to support the feeding
• Note how the child suck
• Observe for constipation --- could also cause ICP.
• Increase fluid and high roughage diet
HIGH RISK OF NEWBORN
Initiation and Maintenance of Respiration:
If breathing is ineffective – ductus arteriousus will fail to close
due to —-- increase pressure on left heart and blood circulate
through a patent ductus left to right going to aorta
Ineffective breathing cause newborn to use – GLUCOSE = that
result them being hypoglycemic. 
Resuscitation is done when a newborn fails to take first breath.  •
Establish and maintain airway
 Bulb syringe – standard piece used in delivery room
but can be associated with bradycardia. 
 Rub the back – baby should be dry when rubbing
 If a newborn still hasn’t withdraw first breath
 Put him under radiant heat warmer in sniffing
position,  rub back and hair.  
If newborn attempt to raise it temperature == this need
increase oxygen..
If with meconium
 Do not stimulate the baby to cry or rub his back. 
 Administer oxygen without pressure
 Wait laryngoscope to be passed for deep suction 
 Place the infant in back with folded towel in
his shoulder
 Slide catheter (french 8-12)
 Dont suction for more than 10 seconds
 Use gentle touch. 
If still no effort
— laryngoscope — endotracheal tube insertion — and
oxygen administration by PPV with 100% at 40-60 bpm.
Primary apnea —- a pause in respiration longer than 20
seconds with bradycardia of 1 - 2 mins.
Secondary apnea —- respiratory efforts are weakened and
resuscitation efforts become difficult. 
Size?
Laryngoscope – 0-1cm
Endotracheal – 2.5 mm (100 g baby),, 4 mm (300 g)
Lung expansion
 Newborn lung need to expand.
 Oxygen should be administered at rate of 40-60 vent
every mins. Warmed (89.6 – 93.2 F (32-34 C) and
humidified (60-80%).

Crying – proof of lung expansion
40cm H20 – pressure to open lung alveoli for the first time.
15 – 20 cm H20 --- pressure to continue inflating alveoli.
REMEMBER!
The pressure and level should not fluctuate ( as excessive
force can rupture lung alveoli and cause bleeding in cranial
vessels.
To be certain that oxygen is reaching the lungs – use oximeter
to check and auscultate lungs,
But if air can only be heard in one side:
- Endo is probably at bifurcation of the trachea and blocking
one stem. ---- drawing the tube half back centimeter will
likely free it and allow oxygen to flow.
If oxygen is given under pressure it fills the stomach
quickly with oxygen causing == vomiting and
aspiration.
If resuscitation last for over 2 mins
Insert orogastric tube (mouth to stomach)
• Leave distal end open to help deflate stomach.
DRUG THERAPY
- Narcotic drugs such meperidine during labor cause
respiratory depression
Antidote – NARCAN = given intramuscular (0.01 to 0.1 mg/kg)
Atropine
 Calcium chloride
 Dopamine
  Sodium bicarbonate
 Epinephrine
 Lidocaine
VENTILATION MAINTENANCE
- Use of pulse oximetry is essential
An increase respiratory rate in newborn is first sign of
respiratory compromise (deterioration of respiratory function)
If RR is increased --- check for retraction in abdomen.
Intervention:
• Place newborn under warmer and remove clothing
• Position in SUPINE and elevate it 15 degrees – allow
content fall away from diaphragm.
• Suction secretion
• Monitor oxygen level.
Establishment of extra uterine circulation
 If infant has no audible heartbeat or PR is below 60.
Close chest massage should be started
• Hold infant with fingers supporting the back and
depress the sternum with 2 fingers.
• Depress approximately 1/3 its depth at rate of
100time/min
• Lung ventilation for 30x/min
• Ration 1:3
If newborn HR is still between 60-100/min = ensuring
adequate ventilation is major priority.
If heart sound not resumed above 60bpm/min after 30 seconds
of combined PPV and cardiac compression , epinephrine is
administered to stimulate heart action (spray into
endotracheal tube)
Maintaining Fluid and Electrolyte Balance
 Lactated ringers solution or 5% dextrose are
commonly used to maintain fluid and electrolytes.
Sodium, potassium and glucose are needed.
 Rate of fluid must be carefully monitored:
 A high fluid intake can lead to fluid overload =
result to patent ductus arteriosus or heart failure.
 Use of radiant warmer may increase
 Monitor urine output and specific gravity to determine
dehydration -- less than 2ml or 1.015 suggest inadequate
fluid intake.
If an infant has hypotension w/ hypovolemia, a vasopressor
such as dopamine maybe given to increase BP
w/ hypovolemia; S/SX
- Tachypnea
- Pallor
- Tachycardia
- Metabolic acidosis.
Hematocrit maybe normal
ISOTONIC SOLUTION is administered to increase blood
volume.
Regulating Temperature
 All high risk may have difficulty maintaining temperature.
- Maintain neutral temperature
Remember! If environment
- Is too hot = metabolism decreases
- Is to cold = metabolism increases
 An increase metabolism requires oxygen = newborn
become hypoxic as it cannot supply oxygen,
To spare oxygen = vasoconstriction of peripheral blood vessel
occurs so blood can pushed into central torso.
Infant Po2 level will fall and Pco2 will increase
Effect: a lower Po2 causes fetal shunts, surfactant stops
producing.
To supply glucose to maintain metabolism, Infant resort to
anaerobic glycolysis this pours acid into bloodstream.
- As infant becoming more acidic, the risk for kernictus
increases, In short becoming chilled and all become
compromised.
Intervention:
 Wipe infant
 Cover head with cap
 Skin-skin contact
 Ensure temperature stays 97.8 F (36.5C)
 Use axillary, plastic shield and warmed mattresses to
prevent heat loss.
Establishing Adequate Nutritional Intake
 Infants who experience asphyxia (body is deprived of
oxygen) at birth.
--- received IV fluids so they do not get exhausted
from sucking or until necrotizing enterocolitis (NEC),
 If infant RR remain and cannot suck, NGT is
introduced.
 Preterm babies should be fed breast milk at all cost.
Expressed breastmilk should be stored in non-shiny plastic
bags or bottle to avoid infant being exposed to polycarbonate
Establishing Waste Elimination
 Most infants void within 24 hours of birthz
----- reason: BP may not be adequate to optimally
supply their kidneys.
 Immature infants pass stools late than term.
---- reason: Meconium has not yet reached the end of
intestine.
Document voiding that occur during resuscitation as a proof
that hypotension is improving and kidney is perfuse.
Preventing Infection - Premature separation of placenta
 Common viruses the affect during intrauterine life are
cytomegalovirus and toxoplasmosis virus. Characteristic
- Immature respiratory system
Early onset sepsis: - Temperature regulation
- Grp B. Strep - Low resistance to infection
- E. Coli - Immature liver
- Kelbsiela - NEC
- Listeria - Unable to concentrate urine
- Monocytogenes - Neuromuscular
Late onset sepsis: - Physiologically immature.
- Staphylococcus aureus
- Enterbacter Complication
- Candida  Anemia
 Kernicterus
Establishing Parent-Infant Bonding  Persistent patent ductus arteriosus
 a tour on NICU during pregnancy  RDS
 Parents should be kept informed of what is happening  Retinopathy of prematurity
during resuscitation.  NEC
 If infant died, parents need to see the infant
without covered by myriad equipment. Nursing Intervention:
• Keep baby warm
Anticipating Developmental Needs • Give 100% oxygen
 High risk newborn need special care to ensure that • IVF via infusion pump
the amount of pain they experience during procedures • Check site frequently
is limited • Monitor weight
• Monitor urine output
Follow up of high risk. • Test urine for glucose
• Check blood in the stools
• NGT
• Chest radiograph
• Feed every 2-3 hours
• Administer vitamin K
• Kept under radiant warmer
• Monitor closely
• Linen or equipment must not be shared with other infants.
• Offer pacifier.

PROBLEMS RELATED TO MATURITY

Post term infant
Preterm infant  Infant born after 42nd week of pregnancy
 Infant born before the end of 37th week gestation.  Fetus remain in utero with a failing placenta
 Weight less than 2,500 or 5lb
 Account for 80-90% of infant mortality Characteristic:
 They lack surfactant makes them vulnerable to RDS. - Dry cracked skin from lack of fluid
---- hypoglycemia and intracranial hemorrhage. - Absence of vernix caseosa
- Lightweight
LBW – 1500-2500g - Possible meconium stain
Very LBW --- 1,000-1500g - Fingernails have grown
Extremely LBW --- 500-1000g - May demonstrate alertness such a 2 week old baby
- Abundant hair
Risk factor - Reduced subcutaneous tissue or loose skin – buttocks or
- Low socio economic level thigh
- Cigarette smoker - Hypoglycemia
- Age of mother - Difficult stablishing respiration
- Closely spaced pregnancies - Polycythemia (elevated RBC)
- Abnormalities on the reproductive system of mother. - Elevated hct due to dehydration.
- PROM
Nursing intervention:
• Determine AOG, Glucose level • Right ventricle will receive extra blood from both vena
• Assess for asphyxia neonatorom cava and all this will go to lungs causing the right
• Meconium ventricle to ENLARGE and overwork the heart.
• Tachypnea and tachycardia • This will also cause narrow the arteries = Pulmonary
• Retraction of chest Hypertension === can also lead to HF.
• Expiratory grunting
• Increase anterioposterior diameter
• Palpable liver
• Crackles and rhonchi
• X-ray
• Antibiotics
• NGT
• Monitor output and intake
• Respiratory support.

Sign and Symptoms:

• Swelling
• Crackles
• Easy fatigue
• Swelling in extremities
• Low growth rate
• Loud, harsh pan systolic murmur (3-4th intercostal)
• Thrill
• Cyanosis.

Diagnosis:
• Echocardiography with color flow
• Doppler
• MRI
• ECG

Management:
• Cardiac cauterizations
• Open heart surgery
• Digoxin
• Diuretic – remove extra fluid.

ALTERATION IN OXYGEN b. ATRIAL SEPTAL DEFECT (AVD)

- There is an opening or hole in between two atrial
Classification of the heart disease: - A left to right shunt cause increase lung blood flow.

1. Acyanotic Heart Disease/ Increase Pulmonary Blood
Flow.
 Move blood from arterial to venous system.
 Left-Right shunt of blood flow (Higher-lower pressure)
 Causes the heart to function as an ineffective pump
and make child prone to HF.
a. VENTRAL SEPTAL DEFECT (VSD)
- Most common type of congenital HD.
- There is an opening or a hole in between two
ventricles
Since pressure in the left side is stronger, more blood is going
to the right side – lead to impairment effort of the heart and
ineffective pump to make child prone HF.
This hole causes the oxygenated blood to enter the right
atrium, and might cause;
 Heart Failure
 Pulmonary Hypertension
 Stroke
There should be no connection between both atria after birth
but, in utero, there is a connection between but this is through
foramen ovale. (close after birth)
• In ASD, there will be a pressure on lungs and lungs
will not be able to handle EXTRA blood = result to
narrowing and damaged of arteries (pulmonary
hypertension)
Sign and Symptoms:
• Harsh systolic murmur
• Low growth rate Sign and Symptoms:
• Stroke risk • Wide pulse pressure
• Crackles • Low diastolic pressure
• Often experience lung infection • ECG is normal
• Edema • Machinery Murmur – heard at upper left sterna
border.
Diagnosis • C – continuous murmur, endocarditis, low 02,
• Echocardiography Crackles
• Cardiac Cauterizations • A -- activity intolerance.
• Doppler • L --- lung risk of infection
• L --- Loss of weight
Management: • Endocarditis – due to fluid congestion in the lungs.
• Surgery – close defect
• Large detects may require open heart surgery and Diagnosis:
cardiopulmonary bypass (1-3 y/o) • Echocardiography

c. PATENT DUCTUS ARTERIOSUS Management:

- Patent – fails to close
- Most common in girls
Ductus arteriosus
• It’s a vessel that connects aorta to pulmonary artery in
fetus, should be present in all newborn.
• Helps carry blood to the right side of the heart and the
rest of the body.
- Remain open due to PGE1 cause by placenta.
- close shortly after birth (7-14 days) and last for 3
months
Infant in womb doesn’t use their lungs yet.
A large PDA cause a lot more serious complication than a
small PDA
• A large PDAs will cause oxygenated blood to go back
to pulmonary artery back to the lungs – increase extra
blood to the lungs create pressure = damage arteries
causing them to narrow leading to = pulmonary
hypertension (decrease O2, HF, and Risk for lung
infection).
• Indomethacin or Ibuprofen (drug of choice)
• Prophylaxis – for preterm babies
• Insertion of Dacron – done in 1-6 y/o
---- done if medical management fails.
• Ductal ligation – involve major surgery
---- opening the chest and manipulating vessels.
• Prostaglandin inhibitors.
2. Cyanotic Heart Disease/ Decrease Blood Flow
 Venous to arterial system or R-L shunts.
 It indicates that unoxygenated blood to bypass
the lungs and enter general circulation directly
 Increase pressure on the Right side of the heart.
a. TRICUSPID ATRESIA
 Atresia – close or absent
 Tricuspid valve is completely closed allowing no
blood flow going to right ventricle.
This cause to make the blood flow go through foramen ovale
bypassing lungs. This shunt cause = cyanosis, dyspnea, poor
feeding
 • Place baby in KNEE-CHEST position – this trap the
blood in lower extremities and keep heart being
overwhelm.
• Morphine sulfate
• Blalock Tausig procedure – create shunt between
the aorta and pulmonary artery (creating ductus
arteriosus
• Postoperatively
--- observe arrhythmias.

c. MIXED BLOOD FLOW

Management:
 IV infusion of Prostaglandin (PGE1) for ductus to
remain open until surgery is possible
 Surgery – Fontan procedure/ Glenn shunt.
 Cardiac anomalies that involve missing of blood from
pulmonary and systemic circulation in heart
chambers.
 Cyanosis is always visible due to relative
deoxygenated of systemic flow

b. TETRALOGY OF FALLOT d. TRANSPOSITION OF GREAT ARTERIES

 4 PROBLEMS  The aorta arises from right ventricle instead of left and
1) VSD pulmonary artery arises from left ventricle.
2) Dextroposition of the aorta  Main arteries carrying blood switched in position.
3) Hypertrophy of right ventricle
 Most common in boy and large newborns (9-10lb)
4) Pulmonary stenosis
 Occur in the womb
 Stenosis – narrowing
 Hypertrophy --- enlarge

In TOF, there is a mixing of unoxygenated blood and

oxygenated blood.

Sign and Symptoms:

• Cyanotic
• Enlarged Heart
• Heart changes
Sign and Symptoms: • Low oxygen saturation
• Skin is cyanotic
• Polycythemia – this cause blood to clot Diagnosis:
• Clubbing of the fingers • Echocardiography – reveal heart
• Syncope (fainting) – due to low oxygen • ECG – reveal heart changes
• Hyper cyanotic effect • Cardiac catherization – reveal low oxygen sat.
• Loud harsh, widely transmitted murmur in
systolic. Management:
• No palpable pulse in Right arm • PGE1/prostaglandin – if no septal defect
• No taking of BP and venipuncture in affected arm. • Balloon atrial septal pull through operation
--- deflated balloon catheter is passed in right atrium
Diagnosis: through foramen ovale into left atrium (1-3months)
• ECG • Survival rate is 95%
• Cardiac cauterizations
• LAB FINDINGS e. TOTAL ANOMALOUS PULMONARY VENOUS RETURN
 Pulmonary VEIN return oxygenated blood to
Right atrium instead left atrium.
Management:  For blood to reach systemic circulation, blood
• Surgery – connect the heart defects (1-2 y/o) must shunt across patent foramen ovale or PDA.
• Administer oxygen
Sign and Symptoms: • THRILL from upper left sterna border
• Absent spleen • Widely split of the 2nd hear sound --- late closure of
• Mildly cyanotic pulmonary valve
• Easily gets tired.
Diagnosis:
Management: • ECG/ Echocardiography – reveal hypertrophy
• Surgery – replanting the pulmonary veins into left • Cardiac catherization – used for interventional
ventricle enlargement of stenosed valve.
• Balloon atrial septal pull through – enlarge foramen
ovale Management:
• Maintain continuous IV infusion of PGE1 • Balloon angioplasty – procedure of choice.
- A catheter with uninflated balloon with tip is
f. HYPOPLASTIC LEFT HEART SYNDROME inserted and passed through the heart into
 Left ventricle is non-functional – lack adequate stenosed valve
strength to pump out blood into systemic - As balloon is inflated, it breaks the valve
circulation. adhesion and relives stenosis.
 Might be accompanied: mitral or aortic valve - Children may have hear t murmur
atresia. - Can expect a normal life span.

g. OBSTRUCTION OF BLOOD FLOW i. AORTIC STENOSIS

 The vessel or valve is narrower than normal
 Pressure from blood flow increases prior to
narrowing and decreases after narrowed.
This prohibit enough blood from reaching enough oxygen to
lungs and body and overwhelm it because of heart pressure.
 The aortic valve is narrowed preventing the blood
from passing freely from left ventricle into aorta
Since the heart cannot force blood through the stricture valve
this increase the pressure and hypertrophy occur in left
ventricle == cause edema and back pressure

h. PULMONARY STENOSIS
 Stenosis – narrowing
 Narrowing of the pulmonary valve or pulmonary
artery which controls the flow of blood
 10% congenital anomalies
 Inability of the right ventricle to evacuate blood by
way of pulmonary artery that leads to right
ventricle hypertrophy.

During stenosis, the pulmonary valve flaps are thickened, or

fused together and this narrowed opening of the valve slows or Sign and Symptoms:
block the flow of blood into and through pulmonary artery. • Asymptomatic
• Murmur – transmitted to right shoulder – clavicle and
• can also lead to HF since right ventricle needs to work up the vessel of the heart, neck and apex.
more harder to pump out blood going to lungs causing • Rough systolic sound – 2nd interspace.
the heart to strained. • Thrill
• Decrease cardiac output.
• Faint pulse
• Hypotension
• Tachycardia
• Inability to suck
• Chest pain

Diagnosis:
• ECG/Echocardiography

Sign and Symptoms: Management:

• Cyanosis – this is due to the inability of the blood to
reach lungs for oxygenation.
• Systolic ejection murmur (grade IV or V crescendo-
decrescendo in quality) loudest at the upper sternal
border radiating to suprasternal border.
• Beta-blocker or CCB
• Balloon valvuloplasty – a treatment of choice.
• Dividing stenotic valve
• Prosthetic valve maybe needed in some children.
 - If used, continue to receive anticoagulation
or antiplatelet and antibiotic to prevent
endocarditis.
• Children need to exercise testing before participating
in competitive sports if artificial is in valve.
Planning is important!
j. AORTIC COARCTION
 Narrowing of the lumen of the aorta due to
constricting band.
 Occurs most frequently in boys
 Leading cause of congestive heart failure in first few
months.
Management:
• Interventional Angiography/ surgery
• Digoxin is given before surgery – aim to reduce
severity of CHF.
 It would be best if children could achieved the greater
part of their adult height b4 surgical = to prevent strain
on incision site.
 Correction is best done b4 children begin to think of
themselves as chronically ill.
 Girls must have defect repair before childbearing age

 Preductal – constriction occurs between subclavian Surgical repair is done by 2 y/o

artery and ductus arteriosus.
 Postductal -- constriction is distal to ductus
arteriosus.
Narrowed aortic cause difficulty of blood to pass through the
narrowed lumen, causing BP increase = headache, vertigo,
epistaxis (nose bleed) and CVA.
• Before narrowing – increase BP (proximal)
• After narrowing – decrease BP.(distal)
 After the operation = abdominal vessel receives more
blood result to abdominal pain
 This also needs continual treatment with
hypertensive drugs.
 May have elevated upper body hypertension after
repair.
 May require repeat balloon angioplasty at
adolescence

k. MECONIUM ASPIRATION SYNDROME

 Respiratory disorder caused by inhalation of
amniotic fluid contained with meconium into
tracheobronchial tree.
 Meconium – first stool.

Contents of meconium:
o Water
o Amniotic fluid
o Mucopolyssachiaride
o Bile salts
o Desquamated epithelium
Sign and Symptoms: o Desquamated epidermis
• Absence of palpable femoral pulse
o Vernix
- Always include evaluation of femoral pulsed
in all initial assessment.
What make meconium pass? FETAL DISTRESS
• Absent brachial pulses
• Lower BP in lower extremities
Problem is in airway and lungs and can be infectious and
• Leg pain
metabolic, hematological, neuro, cardio, respiratory,
• Cold feet
abdominal and pharma logical.
• Muscle spasm
• Pulse is weak, delayed and absent
Sign and Symptoms:
• Collateral arteries enlargement
• Airways (choanal atresia, pierre, and vocal cord
• Soft, moderately loud systolic murmur
paralysis)
• BP is higher in upper extremities
• Lungs (Transient tachypnea of the newborn,
• Headache
• MAS, and persistent pulmonary HTN of newborn)
• Epistaxis
• Pulse in upper extremities is rapid.
Management:
When infant is not vigorous,
Diagnosis:
• Clear airways
• BP in the arms is at least 20mmgHg higher.
• Free flow of oxy
• Echocardiography
• Radiant warmer
• ECG
• Direct laryngoscope with suction of the mouth
• MRI
followed by intubation
• X-RAY
 • Process is repeated until little meconium is aspirated
or until baby’s HR indicated that resuscitation must
proceed without delay
Management:
• Ventilation strategies
- Avoid air leak, check CXR with acute
deterioration
- Prevent pulmonary hypertension == 02
- HFOV if unable to maintain on conventional.
• Steroids (o human data, controversial)
• ROS, Antibiotics == ampicillin, and gentamicin
• Surfactant
• Inhaled nitric oxide
• ECMO
ALTERATION IN FLUID AND ELECTROLYTES, ACID BASE
BALANCE
GI system
• Play a major role in maintaining fluid, electrolyte and
acid-base balance
FLUID
Constitute a greater fraction of the infant’s total weight.
• Adult—60% total weight
• Infant – 75-80% total weight
• Children – 65-70% total weight.
Fluid is distributed in 3 body composition:
1. Intracellular (within cells) – 35-45%
2. Interstitial (surrounding of cells) – 20%
3. Intravascular (blood plasma) – 5%
Fluid is normally obtained by oral ingestion and by water
formed in metabolic breakdown.
• Fluid is lost from: Feces, urine, insensible loss due to
evaporation.
• Infants do not concentrate urine because kidney are
immature.
• Result: they have proportionally greater loss of fluid.
• Fluid intake is altered = if infant experience nauseated
and unable to ingest fluid or vomiting.
• Diarrhea – a child become diaphoretic because of the
fever, and fluid output increase.
FLUID IMBALANCE
 Dehydration is when body loses more fluid than it
takes in = illness.
• Water account for about 60% of a man’s body weight,
and a 50% in woman.
• Young and middle aged drink do not generally have to
do anything more to maintain fluid in the body.
• Children need more water = since they expand
more energy
• A hot dry climate, prolonged exposure to sun, not
drinking enough and overuse of diuretics medication.
3 main type of Dehydration:
1. Hypertonic ( cell shrink) – loss of water
2. Isotonic --- equal loss of water and electrolytes
3. Hypotonic (cell swell) – loss of electrolytes.
1. HYPERTONIC DEHYDRATION
 Also called Hypernatremia
 Imbalance between water and sodium in body
Generally, when water is excreted, electrolyte concentration in
the body increases. Losing more solution than solute.
Occur in child with;
• Nausea
• Fevwe
 • Overexposure to heat
• Profuse diarrhea
• Renal disease
• Diabetes insipidus – kidney cannot regulate body fluid
and leafs to frequent urination (polyuria)
• Use of diuretics

Sign and Symptoms:

• Fatigue
• Dark urine
• Less frequent urination
• Dry lips and skin.
Severe
• Hypotension
• Lightheadedness 3. HYPOTONIC DEHYDRATION
• Muscle cramps  Decrease in electrolyte concentration in
• Headaches Extracellular fluid.
• Dizziness  Cell grows in water in the extracellular as it
moves towards the higher concentration
Management:
• Treatment largely focused in fluid replacement to Losing more solute than solution and increase urine
return individual into euvolemia. output cause;
• Mild Dehydration – oral rehydration. • Excessive loss of electrolytes by vomiting
• IV (Lr or normal saline) • Low intake of salt associated with extreme diuresis
Anyone who have been dehydrated for fewer than 24 hours • In disease – adrenocortical insufficiency or diabetic
can experience rapid correction on electrolyte level. acidosis
• Renal failure
2. ISOTONIC DEHYDRATION
 Both water and sodium are lost proportionally and Management:
serum sodium concentration maintain NORMAL • Treatment of cause should always be considered
serum osmolality • Urine output should be monitored if patient is
hospitalized.
Occur in child with; Severe
• Restoration of blood volume is main goal and is
Vomiting and diarrhea can be life-threatening to children. achieved by -- Fluid saline or LR
Management: • Adults can use oral fluid
• Wash hands with soap and water frequently • IV fluid is
• Drink lots of clear fluid • Breastfeed and normal diet should be continued as
• BRAT diet – banana, rice, apple sauce, and toast. long as treatment with fluid replacement prevents
• Avoid foods that are greasy, spicy or high in fat. weight loss or developmental delay in infants.
• Avoid caffeine
• Antiemetic drugs (Dramamine and Gravol) 4. OVERHYDRATION
 People drink more water than their body needs.
BURNS fluid is loss thru skin, dehydration can lead to life-  Particularly athletes to avoid dehydration or with
threatening shocks people who have Psychogenic Polydipsia. or
much more common in people whose kidney do
First degree burn: not excrete urine normally.
• Run cool water. DO NOT APPLY ICE.
• Apply aloe vera for sunburn Sign and Symptoms:
• Apply antibiotic cream and cover – thermal burn. Mild dehydration;
Second degree burn: • Distractibility
• Similar treatment in first degree burn. • Lethargy
• Prescribed STRONGER antibiotic cream that contain If vomiting and trouble develop;
silver(sulfadiazine) • Confusion
• Elevating the burn area can reduce swelling and pain. • Seizure
Third degree burn: • Coma
• Can be life-threatening
• Skin-grafts replaced damage tissue with healthy skin Management:
from another of the uninjured part of the body (graft • Fluid intake is restricted (0.9L quarts of liquid is ok)
here is taken usually heals itself so.)
 • Restrict intake of sodium – because sodium cause • Increased BP and Pulse.
body to retain water.
• Diuretics HYPOKALEMIA (potassium) – 3.5-5 mEq/L
-------------------------------------------------------------------------------- Potassium: help maintain normal levels of fluid inside our cells,
FLUID DEFICIT VOLUME help muscle to contract and support normal blood pressure.

HYPOVOLEMIA (water) Sign and Symptoms:

 occurs when loss of ECF volume exceed the intake • Fatigue
• Anorexia
Sign and Symptoms: • Muscle weakness
• weight loss and skin tugor • Polyuria
• oliguria • Decrease bowel movement
• concentrated urine • Abdominal distension
• orthostatic • Hypoactive reflexes
• hypotension • Increase BP
• weak rapid heart HYPERKALEMIA (potassium) – 3.5-5 mEq/L
• flat neck veins Potassium: help maintain normal levels of fluid inside our cells,
• increase temp and thirst help muscle to contract and support normal blood pressure.
• cool clammy skin
• weakness Sign and Symptoms:
• cramps • Muscle weakness
• Tachycardia
FLUID VOLUME EXCESS • Paresthesia
• Dysrhythmias
HYPERVOLEMIA (water) • Intestinal colic
 occurs when intake of ECF volume exceed. • Cramps
• Abdominal distention
Sign and Symptoms: • Anxiety
• Edema
• Distended neck veins HYPOCALCEMIA (calcium) – 9-10.5 mEq/L
• Crackles Calcium: found in body cells, bones and teeth. Needed for
proper functioning of cardiovascular, blood clotting, teeth
HYPONATREMIA (sodium) – 135-145 formation, and normal rhythms and nerve function.
Sodium: help regulate water inside and outside of the cells,
conduct nerve impulses, contract and relax muscle Sign and Symptoms:
• Numbness
Sign and Symptoms: • Tingling of finger, toes and circumoral
• Anorexia • Positive trousseau’s sign and Chvostek sign.
• Nausea and vomiting • Seizures
• Lethargy • Hyperactive
• Dizziness • Irritability
• Confusion • Bronchospasm
• Muscle cramps
• Twitching HYPERCALCEMIA (calcium) – 9-10.5 mEq/L
• Seizure Calcium: found in body cells, bones and teeth. Needed for
• Dry skin proper functioning of cardiovascular, blood clotting, teeth
• Edema formation and normal rhythms and nerve function.

HYPERNATREMIA (sodium) Sign and Symptoms:

Sodium: help regulate water inside and outside of the cells. • Muscle weakness
conduct nerve impulses, contract and relax muscle • Constipation
• Anorexia
Sign and Symptoms: • Nausea and vomiting
• Thirst • Dehydration
• Elevated body temperature • Hypoactive
• Hallucination • Calcium stone
• Lethargy • Flank pain
• Restlessness • Deep bone pain
• Pulmonary edema • Pathological fracture.
• Twitching
HYPOMAGNESEMIA (magnesium) – 1.3-2.1 mEq/L ARTERIAL BLOOD GAS (ABG) ANALYSIS
Magnesium: helps maintain normal nerve and muscle function  Measurement of the acidity or alkalinity of the arterial
are mostly are found in bones, regulating blood sugar, blood circulation. It also measure gases such as oxygen
pressure and making protein, bone and DNA and carbon dioxide.
 This test is used to check how well the lungs are able
Sign and Symptoms: to move oxygen into the blood and remove carbon
• Neuromuscular dioxide.
• Irritability
• Positive trousseau’s and chvostek’s sign Purpose
• Insomnia • Acid base statis
• Vomiting • Degree of oxygenation of blood and adequacy of
• Increased deep reflexes. alveolar ventilation
• Continuous arterial blood pressure

Components:
HYPERMAGNESIA (magnesium) – 1.3-2.1 mEq/L A pH (power of hydrogen) is a measurement of how acidic or
Magnesium: helps maintain normal nerve and muscle function alkalotic your blood is:
are mostly are found in bones, regulating blood sugar, blood NV: 7.35—7.45
pressure and making protein, bone and DNA
A PaCO2 is a measurement of carbon dioxide (lungs)
Sign and Symptoms: NV: 35-45
• Flushing
• Hypotension A HCO3 is a measurement of bicarbonate (kidney)
• Muscle weakness NV: 22-26
• Drowsiness
• Hypoactive A Pa02 or oxygen (lungs)
• Reflexes NV: 80-100
• Depressed respiration
• Diaphoresis (excessive sweating)

HYPOPHOSPHATEMIA (phosphorus) – 2.8-4.5 mEq/L

Phosphorus: growth and maintenance and repair for all tissue
and for genetic building blocks, DNA and RNA.

Sign and Symptoms:

• Paresthesia
• Muscle weakness
• Boone pain and tenderness
• Chest pain
• Seizures
• Tissue hypoxia
• Nystagmus

HYPERPHOSPHATEMIA (phosphorus) – 2.8-4.5 mEq/L

Phosphorus: growth and maintenance and repair for all tissue
and for genetic building blocks, DNA and RNA

Sign and Symptoms:

• Tetany
• Tachycardia
• Anorexia
• Nausea and vomiting
• Muscle weakness
• Hyperactive reflexes