NCM 219 PRELIM

REVIEW
1. Genetic Assessment and Counselling
Mendelian Inheritance, Chromosomal aberrations
2.Bleeding Disorders
3. Gestational Conditions - Hyperemesis Gravidarum, PIH, Gravido-
Cardiac, GDM, Isoimmunization, Anemia of Pregnancy
4. Problems with the Powers (force of Labor)
5. Problems with the Passenger
6.Problems with the Passageway
7.Problems with Placenta
8.Therapeutic Management: - Induction and Augmentation of Labor,
Forcep Delivery, CS
9. Nursing Care of Clients with Postpartum Complications - Postpartal
Hemorrhage, Puerperal Infection, Postpartum depression / Postpartum
Psychosis
10. Nursing Care of Male and Female Clients with Fertility Problems
 NATURE OF INHERITANCE

Inheritance - is the process by

which genetic information is
passed on from parent to child.
Phenotype - the set of
observable characteristics of an
individual resulting from the
interaction of its genotype with the
environment.
 AUTOSOMAL
DOMINANT
DISORDERS
One One of the parents of a child with the
Parent disorder also will have the disorder

The sex of the affected individual is

Sex unimportant in terms of inheritance.

History There is usually a history of the

disorder in other family members
AUTOSOMAL RECESSIVE INHERITANCE
Both Parent
• Both parents of a child with the disorder are clinically free of
the disorder
Sex
• The sex of the affected individual is unimportant in terms of
inheritance.
History
• The family history for the disorder is negative—that is, no one
can identify anyone else who had it (a horizontal transmission
pattern).
Ancestor
• A known common ancestor between the parents sometimes
exists. This explains how both male and came to possess a like
gene for the disorder
 X-LINKED DOMINANT INHERITANCE
Dominant gene
• All individuals with the gene are affected
Affected
• All female children of affected men are
affected; all male children of affected men
are unaffected
Generation
• It appears in every generation
Homozygous/ Heterozygous
• All children of homozygous affected women
are affected. Fifty percent of the children of
heterozygous affected women are affected
 X-LINKED RECESSIVE INHERITANCE
Males
• Only males in the family will have the disorder
History of death
∙ A history of girls dying at birth for unknown
reasons often exists (females who had the affected
gene on both X chromosomes).
Unaffected
• Sons of an affected man are unaffected
Parents
• The parents of affected children do not have the
disorder
RISK FACTORS FOR HIGH-RISK
PREGNANCY
 Existing health conditions - STD
 Malnourishment
 Low socio economic status
 Multiple births/ gestation
 Maternal age – above 35 years old or below 18
years old – preterm, multiple gestation,
chromosomal abnormalities, bleeding in the first
trimester.
Types of Spontaneous abortion
Types Bleeding Abdominal Cervical Tissue Fever
cramps dilation passage

Threatened Slight May or may not None None No

be present,
usually no pain
Inevitable Moderate Moderate Open None No

Complete Small to Moderate Close or Complete No

negative partially placenta with
open fetus

Incomplete Severe Severe Open with Fetal or, No

(bleeds the tissue in incomplete
most) cervix placental
tissue

Missed None to None None None No

severe No FHT
Habitual: 3 or more May represent signs of any of the above; usually detected in the
consecutive threatened phase; cervical closure may be employed

Septic Mild to Severe Close or Possibly, foul Yes

severe open with or discharge
without
tissue
Management
Types Activity of
Fluid
replacem
Abortion
Medications Procedure/
surgery
Blood
tests
ent
Threatened Monitor POC Tocolytics (Ritodrine,
Avoid sexual Isoxsuprine,
contact, monitor Terbutaline)
bleeding
Inevitable Check the IVF (LR/ Oxytocin (>12) Vacuum Bld.
fundus for PNSS) aspiration (<12) Typing/
firmness Completion Cross-
Currettage matching
Incomplete IVF (LR/ Oxytocin (>12) Vacuum Bld.
PNSS) Antibiotics (Ampicilin/ aspiration (<12) Typing/
metronidazole) Completion Cross-
Analgesics Currettage matching
Missed Oxytocin (>12) If no spontaneous
Prostaglandin expulsion (4
weeks), Dilation &
Evacuation
Habitual Tocolytics Counselling
Oxytocin, Prosta- D&C
glandin, Misoprostol
RhoGam
Septic IVF (LR/ Oxytocin (>12) Urethral Cathete- Bld.
PNSS) Antibiotics rization Typing/
(Cephalosporins, Currettage Cross-
Ampicilin/metronidazol matching
e)
◦ A condition where pregnancy
develops outside the uterine cavity

◦ Types:
◦ Tubal (Fallopian tube - interstitial,
isthmic, ampulla, infundibulum &
fimbrial portion)
◦ Cervical
◦ Abdominal
◦ Ovarian
• Early signs of pregnancy
• Tubal rupture signs
• Sudden, acute low abdominal
pain radiating to the shoulder
(Kehr’s sign) or neck pain
• Nausea and vomiting
• Bluish navel (Cullen’s sign)
• Rectal pressure
• Positive pregnancy test (50%)
• Sharp localized pain when cervix is
touched – unilateral low abdominal
pain
• Signs of shock/ circulatory collapse
• Hemorrhage – major concern
• Immediate surgery to prevent
complications
• Priority nursing diagnosis - Pain
• Infection
(Unruptured) Methotrexate,
Leucovorin

Surgical removal of ruptured

tube (Salphingectomy)

Management of profound shock

if ruptured (Blood replacement)

Antibiotics
CONSERVATIVE
MANAGEMENT:
• Bed rest; avoidance of
heavy lifting; no coitus Cervical Cerclage
procedure
FOR WOMEN WITH
PREVIOUS LOSSES: After cerclage –
elective cervical cerclage position in
(late first trimester or
early second trimester) trendelenberg, may
12-18 weeks of pregnancy
before dilation occurs deliver nsd or cs,
• Shirodkar procedure ultrasound before
• McDonald procedure
the procedure.
Incompetent Cervix

1. History of incompetent cervix

2. Anatomical abnormalities
3. Cervical surgeries
4. Damage cervix
◦ Risk Factors – H mole
◦ Low protein intake
◦ Women older than 35 years old.
◦ Asian women
◦ Women with a blood group of A who marry men with blood
group O
• Passage of vesicles – 1st sign
that aids to diagnosis
• TRIAD signs:
– Big uterus
– Vaginal bleeding
– HCG greater than 1 million
• Ultrasound
• Flat plate of the abdomen
done after 15 weeks

◦ 80% remission after D

& C; may progress to
cancer of the chorion:
Choriocarcinoma
◦ Advise bed rest
◦ Monitor VS, blood loss, molar/ tissue passage, I & O
◦ Maintain fluid and electrolyte balance, plasma,
and blood volume through replacements as
ordered
◦ Prepare for suction D & C, hysterotomy or
hysterectomy as indicated
◦ Provide psychological support
◦ Prepare for discharge
◦ Emphasize need for follow-up HCG titer determination
for 1 year
◦ Reinforce instructions on NO PREGNANCY FOR ONE
YEAR; give instructions related to contraceptions
 ABRUPTIO
PLACENTA
Premature separation of the implanted
placenta before the birth of the fetus
Predisposing factors for
Abruptio placenta
◦ Maternal hypertension: PIH, renal disease
◦ Sudden uterine decompression (multiple
pregnancy, polyhydramnios)
◦ Advance maternal age
◦ Multiparity
◦ Short umbilical cord
◦ Trauma; fibrin defects
 Assessment
findings
◦ Painful, vaginal bleeding
◦ Rigid, board-like, and
painful abdomen
◦ Enlarged uterus due to
concealed bleeding
◦ BP low, HR high
◦ Prepare for emergency
delivery – Nursing priority
Complications of PROM

◦ Maternal infection/
chorioamniotnitis
◦ Cord prolapse
◦ Premature labor
 Management (Mild
Preeclampsia)

◦ Provide detailed
instructions about warning
signs such as:
➢Visual disturbances
➢Severe headache
➢Nausea & Vomiting
➢Epigastric pain
Gravido-Cardiac
◦ Heart disease is divided into 4 categories based on criteria
established by the New York State Heart Association to predict
pregnancy outcome.
◦ Class I (uncompromised) or class II (slightly compromised) heart
disease can expect to experience a normal pregnancy and birth.
◦ Women with class III (markedly compromised) can complete a
pregnancy by maintaining almost complete bed rest.
◦ Women with class IV (severely compromised) heart disease are
poor candidates for pregnancy because they are in cardiac
failure even at rest and when they are not pregnant. They are
usually advised to avoid pregnancy.
Classification of Heart Disease
Class I (uncompromised)

• Ordinary physical activity causes no

discomfort
• No symptoms of cardiac insufficiency and no
anginal pain

Class II (slightly compromised)

• Ordinary physical activity causes excessive

fatigue, palpitation, and dyspnea or anginal
pain
• Minimal limitation of physical activities
*NYHA (New York Heart Association) Functional grading of heart disease
Classification of Heart Disease

Class III (Markedly compromised)

• During less than ordinary activity, woman

experiences excessive fatigue, palpitations,
dyspnea, or anginal pain
• Complete bed rest

Class IV (Severely compromised)

• Severe limitation of physical activity- cardiac

failure even at rest
• Advised to avoid pregnancy
*NYHA (New York Heart Association) Functional grading of heart disease
◦ Common signs and symptoms are those associated with
pulmonary hypertension and pulmonary edema and may
include:
◦ Decreased systemic blood pressure
◦ Productive cough with blood-streaked sputum
◦ Tachypnea
◦ Dyspnea on exertion, progressing to dyspnea at rest
◦ Tachycardia
◦ Orthopnea
◦ Paroxysmal nocturnal dyspnea
◦ Edema, pulmonary edema.
◦ Signs and symptoms of Right-sided heart failure may include:
◦ Hypotension
◦ Jugular vein distention
◦ Liver and spleen enlargement
◦ Ascites
◦ Dyspnea and pain.
 Preterm Labor

◦ Labor that begins after 20 weeks gestation and before 37

weeks gestation
◦ Occurs approximately 9-11% of all pregnancies
◦ Risk factor – history of preterm labor
◦ Any woman having persistent uterine contractions (4 every
20 minutes) Regular uterine dilation with cervical dilation
◦ Management = Administration of tocolytics and
dexamethasone
◦ Magnesium sulfate and terbutaline – given to halt the
progress of preterm labor
◦ Betamethasone – stimulate the production of surfactant
PROM - refers to rupture of the
membranes before term (before 37
weeks of gestation) with or without
uterine contractions.

◦ Nitrazine test
◦ Change in color of Nitrazine paper from yellow
(acidic vaginal pH = 4-6) to blue color because of
neutral to slightly alkaline amniotic fluid (pH = 7-
7.5)
◦ Fern test
◦ Amniotic fluid, high in sodium content, will assume
a ferning pattern when dried on the slide
Management for PROM
◦ 1. Monitor temperature every 4 hours for signs of fever
◦ 2. Hook patient to fetal monitor
◦ 3.. Prepare antibiotics and oxytocin medications
◦ 4. Hook patient to cardiac and fetal monitors
◦ 5. Avoid doing vaginal exam every shift to prevent infection