MCHN / 2nd Sem ORTIZ

CARE FOR MOTHER AND CHILD AT RISK OR mortality 0

WITH PROBLEMS Populatio 0.3 0.8 2.2 1.4 2.3
n growth
Goal

 Improve the survival, health and well being of  70%-home birth

mother and the unborn through a package of  27%-hospitals
services for the:  3%- others
o Pre-pregnancy
o Prenatal Why Do Women Die?
o Natal
 Complications related to pregnancy occurring in
o Postnatal stage
the:
Where are we now? o course of labor delivery
o puerperium (obstructed labor, infection)
 30 mil. Pop-double in 30 years---at current growth  Hypertension complicating pregnancy, childbirth
rate of 2.36% and puerperium (eclampsia etc)
 2002 rice production grew by average of only  Postpartum Hemorrhage---[due to uterine atony,
1.9%. placental retention.]
 Poorest Filipino-not using fam. Planning [57.1%]  Pregnancy with abortive outcome
—b/c poor access and the ineffective outreach.  Hemorrhage related to pregnancy (ectopic
 20.5- married women say they used fam planning pregnancy, placental previa, etc)
but do otherwise.
7 Direct Obstetric Complications
The Global Situation
1. Hemorrhage (antepartum/postpartum)
 529,000 women die b/c of pregnancy related causes. 2. Prolonged/obstructed/labor
Direct Causes: 3. Postpartum sepsis
o 75% direct causes--hemorrhage, 4. Complications of abortion
hypertension, severe infection, obstructed 5. Pre-eclampsia/ Eclampsia
labor. 6. Ectopic pregnancy
o 25% Indirect causes—malaria, severe 7. Ruptured uterus
anemia and other medical
 95% (2000) Africa and asia— CS Cuts
o 4% in Latin America—
o 1% developed regions.
 1 mil are orphan  Low transverse incision
 Children who lost their mothers are [10x more  Low vertical incision
likely to die early].  Classical incision

The Philippine Situation High Risk Pregnancy

 3.1 mil. Pregnancy occur each year.---half  Is one in w/c a

unwanted—1/3 ends in abortion. concurrent disorder,
o 473,000 abortion annually with induced o pregnancy-
abortion as---4th leading cause or related
maternal death. complication
 10 moms die everyday due to childbirth & ,
pregnancy related complications o external
 Mom dies and leave 3 orphans--- effecting 30 factor---
children per year.

Health Indicators

Japa S. Malaysi Thaila Ph

n Kore a nd .
a
Life 81 75 73 70 70
expectanc
y
Infant 3 5 8 24 29
mortality jeopardizes the health of the mother, the
Under5 5 5 8 28 40 fetus, or both.
mortality
Maternal 8 20 41 44 16

1|NININ
MCHN / 2nd Sem ORTIZ

 Some women enter pregnancy w/ a chronic illness  poor placental formation/position

that, when superimposed on the pregnancy; [makes  gestational diabetes
it high risk.]  nutritional deficiency
 Other women enter pregnancy in good health but  poor weight gain
then---develop a complication of pregnancy that  PIH
causes it to become high risk.  Infection
 Amniotic fluid abnormality
Factors that Categorize a pregnancy as High Risk  Post maturity
.
A. Pre-pregnancy

Psychological C. Labor and Delivery

 Hist. of drug dependence Psychological

 Hist. of mental illness
 Hist. of poor/coping mechanism
Social
 Occupation handling of toxic subs.
 Envi. Contaminants at home
 Isolated
 Lower economic level
 Poor transportation access for care
 Poor housing
 Lack of support people
Physical
 Severe frightened by labor
 Inability to participate due to ----anesthesia
 Lack preparation for labor
 Birth of infant who is disappointing in some
way
Social
 Lack support person
 Unplanned cs
 Lack access to continued health care
 Lack access to emergency personnel or
equipment

 Visual/hearing challenges Physical

 Pelvic inadequacy (CPD)
 Hemorrhage
 Secondary major illness—heart disease, DM,
 Infection
kidney disease, hypertension.
 Dystocia
 Poor gynecologic/obstetric history
 Precipitate birth
 History of previous poor pregnancy outcome
 Lacerations of cervix or vagina
----miscarriage, stillbirth, intrauterine fetal
 CPD
depth
 Retained placenta
 Pelvic inflammatory disease
 Obesity
 Small stature
 Younger than 18 y/o or older than 35 y/o A. Bleeding During Pregnancy
 Cigarette smoker
 Substance abuse  Vaginal Bleeding- is a deviation from the normal
that may occur at [any time during pregnancy.]
B. Pregnancy  A woman w/ any degree of bleeding----needs to be
evaluated [for the possibility of blood loss and
Psychological Hypovolemic shock.]
 Signs of hypovolemic shock occurs when 10% of
 Loss of support
blood volume or approximately two units of
 Illness of fam mem.
blood, [have been lost; fetal distress occurs when
 Decrease self-esteem
25% of blood volume is lost.]
 Poor acceptance of preg.

Social
Signs and symptoms of Hypovolemic Shock
 Refusal of or neglected prenatal care
 Exposure to envi. Teratogens 1. Increased pulse rate
 Decrease economic support 2. Decreased blood pressure
 Conception less than 1 year after last 3. Increased respiratory rate
pregnancy or w/in 12 mos of the first 4. Cold, clammy skin
pregnancy. 5. Decreased urine output
6. Dizziness or decreased level of consciousness
Physical
7. Decreased central venous pressure
 intake of teratogen
 multiple gestation

2|NININ
MCHN / 2nd Sem ORTIZ

The Process of SHOCK due to blood loss  MISCARRIAGE-When the interruption

(hypovolemia) occurs spontaneously.
 ABORTION-When pregnancy is medically or
BLOOD LOSS surgically interrupted.
 Stage of viability (a stage when the fetus is
V
capable of surviving outside the uterus, more
Decreased intravascular volume than 20- 24 weeks)
 15% to 30% of all pregnancies and occurs
V from natural causes
 A spontaneous miscarriage is an---early
Decreased venous return, decreased cardiac output, and
miscarriage if it occurs week 16 of pregnancy
lowered blood pressure
and----late miscarriage if it occurs between
V weeks 16 and 24.
 Its presenting symptoms is almost always
Body compensating by increasing heart rate to circulate vaginal spotting
the decreased volume faster;
Causes
V
 The most frequent cause of miscarriage in the
Vasoconstriction of peripheral vessels first trimester of pregnancy is---- abnormal
fetal formation, due to [either to a
V teratogenic factor or to chromosomal
aberration ]
Increased respiratory rate and a feeling of apprehension
 Implantation abnormalities. Approximately
at body changes also occur
50% of zygotes are never implanted
V  Corpus luteum----fails to produce enough
progesterone to maintain the deciduas basalis
Cold, clammy skin, decreased uterine perfusion. In the  Infection---(i.E:
face of continued blood loss, although the body shifts o Rubella
from interstitial spaces into intravascular spaces, blood o Syphilis
pressure will continue to fall o Poliomyelitis
V o cytomegalovirus
o toxoplasmosis infections [readily
Reduced renal, uterine and brain perfusion cross the placenta and possibly
causing fetal death ]
V  Ingestion of teratogenic drug.
Lethargy, coma, decreased renal output

V 1. Threatened Abortion
 Is manifested by vaginal bleeding,---initially
Renal failure
beginning as scant bleeding [usually bright
V red.]
o There may be slight cramping, but
Maternal and fetal death no cervical dilatation is present on
vaginal examination.
 Limiting activity to no strenuous activity for
Conditions Associated With First- Trimester 24-48 hours is the [key intervention to stop
Bleeding vaginal bleeding]
o Complete bed rest is usually not
- two most common causes of bleeding during the first indicated
trimester are:  Coitus---is restricted for 2 weeks after the
bleeding episode to [prevent infection and to
 Abortion
avoid inducing further bleeding ]
 ectopic Pregnancy
2. Imminent (Inevitable) Abortion
A. MISCARRIAGE/ABORTION
 It happens with uterine contraction,
cramping and cervical dilatation
Spontaneous Abortion  The loss of the products of conception---
cannot be halted because of cervical dilatation
 Abortion (defined as any interruption of  Instruct the mother to save tissue fragments
pregnancy before the age of viability) that has passed and bring to the clinic to be
examined

3|NININ
MCHN / 2nd Sem ORTIZ

 The physician may perform D & C (dilatation  Commonly referred to as habitual abortion
and curettage)----to ensure that all products of  3 or more consecutive pregnancies---result in
conception are removed, [preventing further miscarriage usually related to incompetent
complication such as infection ] cervix.
 After D & C---the woman is advised to record  Management (suture of cervix)
the number of pads used [to assess for heavy o McDonald procedure
bleeding]  Temporary Circlage
 Side effect – infection
3. Complete Abortion  May have NSD
 The entire products of conception (fetus, o Shirodkar
membranes and placenta) [are expelled  CS delivery
spontaneously without any assistance.] A. Threatened
 within 2 hours----The bleeding usually slows B. Inevitable
and then ceases within a few days after C. Incomplete
passage of the products of conception. D. Missed

4. Incomplete Abortion McDonald Procedure - Cervical Cerclage

 Part of the conceptus (usually the fetus) is
expelled----but the membranes or
placenta is retained in the uterus
 The physician will usually perform a
D & C or a suction curettage to
[evacuate the remainder of the
pregnancy from the uterus.]

5. Missed Abortion
 Commonly referred to as early
pregnancy failure, the fetus dies in
the utero but is not expelled
 A sonogram---can establish that the
fetus is dead.
o Often the embryo actually
died 4-6 weeks before the
onset of miscarriage
symptoms. After the
sonogram,
o a D & C most commonly
will be done
 If the pregnancy is over 14 weeks---labor may
be induced by a prostaglandin suppository or
misoprostol (cytotec) [to dilate the cervix],
followed by oxytocin administration
Complication Of Abortion
 DIC (disseminated intravascular
coagulation), coagulation defect, may develop 1. Hemorrhage- A woman who develop DIC has a
[if the dead fetus remains too long in utero] major possibility hemorrhage.
 If excessive vaginal bleeding is
6. Recurrent Pregnancy Loss occurring ---immediately position the
woman flat and
massage the
uterine
fundus---to aid
contraction.
 Monitor vital
signs---for change to
detect possible
hypovolemic shock.
 A BT may be necessary
to replace blood loss.
 Instruct the
woman on how
much bleeding is
abnormal (more

4|NININ
MCHN / 2nd Sem ORTIZ

than one sanitary pad per hour is  So after miscarriage, because the blood of
excessive).---what color changes she the fetus is not known, ----all women with
should expect in bleeding (gradually Rh negative blood should receive Rhogan
changes to a dark color and then to (Rh immune globulin) to [prevent the
color of serous fluid) ---and any unusual build up of Rh Antibodies.]
odor or passage of large clots is also 4. Powerlessness- Sadness and grief over the lose or a
abnormal. feeling that she has lost control of her life is to be
2. Infection – The possibility of infection is expected.
minimal---when pregnancy loss occurs a short  Emotional Support
period, bleeding is self-limiting and instrumentation
is limited. Procedures Used in Pregnancy Termination
 Educate the woman about the danger
A. Vacuum Curettage – a.k.a. Vacuum aspiration
signs of infection, such as:
 Cervical dilation followed by controlled
o fever,
suction--- through a plastic cannula to
o abdominal pain [remove all products of conception].
o tenderness  Used for first trimester abortion, also
o foul smelling discharge. used to remove remaining products of
 Organism responsible for infection after conception after spontaneous abortion.
miscarriage is usually Escherichia coli (E  Local anesthesia of the cervix is needed.
coli).
 Caution the woman to wipe the perineal
area from front to back after voiding and
particularly after defecation to----prevent
the spread of bacteria from the rectal area.
 Caution the woman NOT to use
tampons---to control vaginal discharge
because (stasis of any blood increases
the risk of infection.)
3. Isoimmunization- Happens when the mother’s
Blood is Rh negative, while the fetus is Rh Positive.
 After spontaneous abortion or D and C. B.
 Some Rh positive fetal blood may enter
the maternal circulation---[mother will
develops antibodies against Rh positive
fetus blood].
 During the succeeding pregnancies--when
the fetus is rh positive again, [those

antibodies would attempt to destroy the

fetus RBC.] Dilation and Curettage- a.k.a. Dilation and Evacuation.

5|NININ
MCHN / 2nd Sem ORTIZ

 Dilation of cervix followed by gentle  Approximately 2% of pregnancies are ectopic;

scraping of the uterine walls to ectopic pregnancy is the-----second most frequent
[re cause of bleeding early in pregnancy

m
ove
products of conception].
 Used for first-trimester abortion and
to [remove all products of conception
after spontaneous abortion].
 Greater risk of:
o cervical or uterine trauma
o excessive blood loss.
 Local anesthesia or general
anesthesia is needed.

Nursing Care of Clients with Abortion

 Document the amount and character of bleeding

and saves tissues or clots for evaluation.
 Check the bleeding and vital signs to identify
hypovolemic shock resulting from blood loss.
 After vacuum aspiration or curettage, the amount of
vaginal bleeding is observed.
 Provide Home Health Teaching After Curettage
such as:
o Report increase bleeding
o Take temperature every 8 hours for 3 days.
o Take an oral iron supplement if prescribed.
o Resume sexual activity as recommended by
health care provider.
o Return to the health care provider at
recommended time for a check-up.
 Check laboratory test such as hemoglobin level
and hematocrit.
 Promote expression of grief by providing privacy,
allowing support persons to help in pregnancy loss.

B. ECTOPIC PREGNANCY
 Is one in when implantation occurs outside the
uterine
 Fallopian tube--The most common site (in
approximately 95% of such pregnancies).
o Of these sites, approximately
o 80% occur in the ampullar portion.
o 12% occur in the isthmus and;
o 8% in interstitial

6|NININ
MCHN / 2nd Sem ORTIZ

Risk Factors: Transvaginal UTZ

 Increase incidence in women who have PID (pelvic

inflammatory disease) which leads to----tubal
scarring
 Occurs more frequently in women who smoke
 Occurs more frequently in women who douche,--
possibly due to risk of introducing an infection
 Used of IUD (intrauterine device) for contraception

Signs and Symptoms

a. Before Rupture
 No menstrual flow occurs
 Nausea and vomiting
 Positive pregnancy test for hCG
 Abdominal pain within 3- 5wks of missed
period (maybe generalized or one sided)
 Scant, dark brown vaginal bleeding
b. During rupture
 Sharp, stabbing pain in one of the lower
abdominal quadrants at the time of rupture---
followed by scant vaginal bleeding
 Lightheadedness, rapid pulse and signs of
shock (rapid thread pulse, r apid respirations
and falling blood pressure)
 Rigid abdomen---from peritoneal irritation
(boardlike abdomen)
 Cullen’s sign (bluish tinged umbilicus) –
because blood seeping into the peritoneal
cavity
 Dull, excruciating pain on the abdomen ----
that may radiate on the shoulder [caused by
irritation of the phrenic nerve]

Diagnosis

1. Transvaginal UTZ ---will demonstrate ruptured

tube
2. Insertion a needle through the postvaginal fornix
into the cul-de-sac under the sterile conditions--- to
see whether blood that has collected there from
internal bleeding can be aspirated (Culdocentesis)
3. Laparoscopy Culdoscopy can be used to visualize
the fallopian tube .

Culdocentesis

-check for abnormal fluid in the abnormal cavity behind

the uterus.

7|NININ
MCHN / 2nd Sem ORTIZ

Laparoscopy

-pelvic laparoscopy is a less-invasive procedure that open Causes:

 Unknown

surgery and Risk Factors:

recovery is quicker  Occurs most often in women who
have a low protein intake
 In young women (under age 18
years)
 In older women older than 35 years
Management:
Types
1. Once an
ectopic  There are two distinct types of
pregnancy hydatidiform mole – complete/partial
ruptures---it 1. Complete mole
is an  All trophoblastic villi swell and become ----
emergency situation and the woman’s conditions cystic.
must be evaluated quickly (monitor for the  Embryo dies early at only 1 to 2 mm in
symptoms of shock) size----with no fetal blood present in the villi
2. Therapy for a ruptured ectopic pregnancy is  On chromosomal analysis----although the
laparoscopy---- to ligate the bleeding vessels and to karyotype is a normal 46XX or 46XY----this
remove or repair the damaged fallopian tube chromosome component was contributed only
3. Women with Rh negative blood -----should by the father or an “empty ovum” was
receive Rh immune globulin (Rhogam) after an fertilized and the chromosome material was
ectopic pregnancy [for isoimmunization duplicated
protection in future childbearing]  This type usually lead to choriocarcinoma
4. Treated medically by the oral administration of
Methotrexate,
 a folic acid antagonist
chemotherapeutic agent, ----attacks and 2. Partial mole
destroys fast growing cells.  Some of the villi form normally
 Because trophoblast and zygote growth  Although no embryo is present---fetal blood
is rapid, the drug is drawn to the site of may be present in the villi
ectopic pregnancy  Has 69 chromosomes (a triploid formation in
5. Hysterosalphingogram----performed after which there are three chromosomes instead of
chemotherapy to assess the patency of the tube two for every pair,
6. Provide emotional support o one set supplied by an ovum---that
was fertilized by two sperm
o or an ovum fertilized by one sperm
Conditions Associated With Second - Trimester in which meiosis or reduction
Bleeding division did not occur)

Signs and Symptoms

A. Gestational Trophoblastic Disease (Hydatidiform 1. Uterus tends to expand than normally

Mole Or H- Mole) 2. No Fetal heart sounds are heard ----because there
 Is proliferation and degeneration of the is no viable fetus
trophoblastic villi---which becomes filled 3. hCG serum levels are abnormally high
with fluid and appear as grape-sized vesicles 4. Severe nausea and vomiting
 Incidence is approximately 1 in every 2,000 5. Symptoms of hypertension of pregnancy is present
pregnancies before week 20 of pregnancy
6. Sonogram/UTZ will show dense growth (typically
a “snowstorm” pattern)----but no fetal growth in
the uterus
7. Vaginal spotting of dark brown blood
8. Discharge of the clear fluid filled vesicles

Management:

1. Suction curettage to evacuate the mole

8|NININ
MCHN / 2nd Sem ORTIZ

2. After extraction---women should have a baseline
serum test [for the beta subunit of hCG ]
3. Educate on avoiding pregnancy for at least one
year
4. hCG is analyzed every 2-4 weeks for 6-12 months
(gradually declining hCG suggest no complications)
5. Prophylactic course of Methotrexate is the drug of
choice for choriocarcinoma.
 This must be weigh carefully---because it
interferes with WBC formation which can
lead to leucopenia
6. Observe for bleeding and hypovolemic shock
tight---to reduce the cervical canal to a
few millimeters in diameter
2. Shirodkar technique
 Sterile tape is threaded in a purse-string
manner under the sub mucosal layer of the
cervix----and sutured in place to achieve a
closed cervix
 Sutures may be placed trans-
abdominally
Conditions Associated With Third – Trimester
Bleeding

A. PLACENTA PREVIA
B. Premature Cervical Dilatation
 Is low implantation of the placenta
 Previously termed as “incompetent
 It occurs in four degrees:
cervix”
1. Low- lying placenta – implantation in the
 Refers to a cervix that dilates
lower rather than in the upper portion of the
prematurely and therefore cannot hold a
uterus
fetus until term
2. Partial placenta previa – implantation that
 Commonly occurs at approximately week
occludes a portion of the cervical OS
20 of pregnancy
3. Marginal – placenta edge approaches the
Causes cervical OS. Lower border is within 3 cm from
internal cervical OS but does not cover the OS
 Unknown 4. Total placenta previa – implantation that
totally obstructs the cervical OS
Risk factors  Incidence is approximately 5 per 1000 pregnancies
 Associated with increased maternal age,
o congenital structural defects
o trauma to the cervix such as
might occurred with biopsy or
repeated D & C

Signs and Symptoms

1. Often the first symptom is show (a pink-stained

vaginal discharge) or increased pelvic pressure
followed by rupture of membranes and discharge of
amniotic fluid
2. Painless cervical dilatation
3. Uterine contractions followed by birth of fetus

Management

1. Bed rest in trendelenburg position

2. Monitor FHT
3. Observe for the rupture of BOW
4. Avoid coitus and limit activities
5. Avoid vaginal douche
6. Surgical operation termed as “cervical cerlage” is
Risk Factors
performed
 Increased parity
- As soon as sonogram confirms that the fetus of a
 Advanced maternal age
second pregnancy is healthy, at approximately week 12-
 Past cesarean births
14----pursing-string sutures are placed in the cervix by
 Past uterine curettage
vaginal route under regional anesthesia
 Multiple gestation
Types:
Complication:
1. McDonald Procedure
 Postpartum hemorrhage
 Nylon sutures----are placed horizontally
 Hypovolemic shock
and vertically across the cervix and pulled
 Preterm labor

9|NININ
MCHN / 2nd Sem ORTIZ

 Fetal distress  Premature separation of a normally implanted

placenta either partial/marginal or
Signs and symptoms complete/total
 Occurs after 20-24 weeks of pregnancy
 Sudden onset of painless bright red vaginal
bleeding (latter half of pregnancy)
 Bleeding may be profuse or scanty

Causes
Note:
 Unknown
 Site of bleeding: uterine deciduas (maternal blood)
places the mother at risk for hemorrhage Risk factors
 Bleeding may not occur until the onset of cervical
dilatation causing the placenta to---loosen from the  High parity
uterus  Advanced maternal age
 Short umbilical cord
Management  Chronic hypertensive disease
 PIH
1. Bleeding is an emergency. (fetal oxygen may  Direct trauma (from VA)
be compromised and preterm birth may occur)  Cocaine or cigarette use (vasoconctrction)
2. Assess the amount of blood loss (duration,
time of bleeding began, accompanying pain, Complications
and color of the blood)
3. Bed rest ---with oxygenation prescribed 1. Fetal distress (altered HR)
4. Side-lying or trendelenburg position (for 72 2. Couvelaire uterus or Uteroplacental
hours) apoplexy
5. NO internal exams (IE) or rectal exams, may 3. disseminated intravascular coagulation
initiate massive hemorrhage (if necessary, must (DIC)
have double set up; OR/ DR)
Signs and symptoms
6. Keep IV line and have blood available (X-
matched and typed) 1. Vaginal bleeding (may not reflect the true
7. Apt or Kleihauer- Betke test (test strip amount of blood loss)
procedure to determine if blood is fetal or 2. Abdominal and low back pain (dull or
maternal in origin) aching)
3. Sharp stabbing pain high in the fundus
Fetal Assessment:
4. Uterine irritability (frequent low intensity
1. Monitor fetal status;---heart tone and movement contractions)
2. Determine fetal lung maturity; amniocentesis – L/S 5. High uterine resting tone
ratio 6. Uterine tenderness
3. Bethamethasone --- may be prescribed (encourage
Degrees of Separation Grade criteria
maturity of fetal lungs; if fetus is less than 34
weeks gestation)  0 - no symptoms of separation. Slight separation
occurs after birth. When placenta is examined, a
segment shows recent adherent clots
 1 - minimal separation, enough to cause bleeding
and changes in vital signs. However, there is no
B. ABRUPTIO PLACENTA occurrence of fetal distress and hemorrhagic shock
 2 - moderate separation. There is evidence of fetal
distress, and the uterus is tense and painful on
palpation
 3 - extreme separation, and maternal shock or fetal
death will result

Management

1. Keep the client in lateral position, not supine

2. Oxygen therapy (limit fetal anoxia)
3. Monitor FHT and record maternal vital
signs----every5 to 15 minutes
4. Baseline fibrinogen (if bleeding is
extensive. Fibrinogen reserve--- may be

10 | N I N I N
MCHN / 2nd Sem ORTIZ

used up in the body’s attempt to accomplish 2. Indomethacin (prostaglandin

effective clot formation) antagonist)
5. NO IE or rectal exam. No enema  It can decrease fetal urine
6. Keep IV line open (possible BT) output---causing a
decrease in amniotic
fluid, not DOC because it
can stimulate the early
PRETERM LABOR
closure of ductus arteriosus
 aka. Premature labor 3. Magnesium Sulfate
 Labor that occurs---after 20 weeks and before the  Often the first drug used
end to halt contractions
 Approximately 9-10% of all pregnancies  CNS depressant
 Labor contractions that happens every 10-20  Halts uterine contraction
minutes 4. Ritodrine Hydrochloride
 Usually leads to progressive cervical dilatation of (Yutopar) and Terbutaline
>2 cm and effacement of >80% (Brethine)
 Acts on entire beta 2
Causes receptors sites
(uterine and bronchial
 Unknown
smooth muscles)---
Risk Factors causing mild
hypotension and
1. Dehydration (stimulates APG to release tachycardia effects,
ADH/Oxytocin that strengthen uterine contractions) hypokalemia,
2. UTI hyperglycemia,
3. Chorioamnionitis (infection of the fetal pulmonary edema
membranes and fluid)  Side Effects:--
4. Younger than 17 and over 35 years old a. Headache (most
5. Inadequate prenatal care common) --- due
6. Emotional and physical stress to dilatation of
7. Previous pre-term labor cerebral blood
8. Low socio-economic class vessels
b. Nausea and
Signs and Symptoms vomiting
Early Signs and symptoms Nursing Responsibilities before administration of
Tocolytic Therapy
1. Persistent low back pain
2. Vaginal spotting 1. Assess baseline blood data i.e. hct, glucose,
3. Cramping potassium, NaCl, ECG (tachycardia)
4. Increase vaginal discharge 2. Uterine and fetal monitoring (external fetal
5. Uterine contractions monitors)
6. Pelvic pressure or a feeling that the fetus is pushing 3. Mix the drug with lactated Ringers solution ---to
down prevent hyperglycemia (piggyback administration,
7. Pain or discomfort in the vulva or thigh [so that it can be stop immediately if tachycardia
occurs])
Management
4. Assess BP and pulse every 15 minutes and every
FOCUS: Prevention of the delivery of premature fetus 30 minutes until contractions stop
5. Reports
1. The woman should first admitted to the hospital  PR>120
2. Place in Left lateral position  bpm, BP < 90/60
3. BEDREST to relieve the pressure of the fetus on  chest pain,
the cervix  dyspnea,
4. Intravenous fluid therapy to ----promote hydration  rales
5. Medical Management
 Bethamethasone/Glucocortics
o Steroid, given in an attempt to
hasten fetal lung maturity
o Given in 2 dose, 12 mg IM 24 hours
apart
 Tocolytic agents (halt labor)
1. Calcium channel blockers
 Beta adrenergic drugs

11 | N I N I N
MCHN / 2nd Sem ORTIZ

Premature Rupture Of Membranes (PROM)  Occurs 5-10% pregnancies

 Rupture and loss of amniotic fluid ------that occurs Cause

before labor begins
 Occurs in 2-18 % of pregnancies  Unknown

Cause: Risk Factors

 Unknown,----but associated with infection of fetal Related to different associative factors

membranes (Chorioamnionitis)
1. Primipara - < 20 years old and > 40 years old
 Nutritional deficiency----involving ascorbic acid
2. Low socio-economic status (poor nutrition –
Complication decrease CHON intake)
3. Women who have 5 or more pregnancies
1. Fetal infections 4. Multiple pregnancies
 After the rupture of BOW--- the seal to the 5. Hydramnios (pre-exisiting)
fetus is lost 6. Underlying HPN/DM
2. Cord Compression 7. Poor calcium/Magnesium intake
 Pressure on the umbilical cord because of the 8. H-mole
loss of the amniotic fluid----which can cut off
the nutrient supply to the fetus (fetal distress)
3. Cord prolapsed
 The extension of the umbilical cord into the
vagina which can also-----interfere with fetal
blood circulation

Signs and Symptoms

1. Sudden gush of clear fluid from the vagina

 Fluid should be tested for:
a. Nitrazine Paper test
o Amniotic fluid causes alkaline (>6.5
ph) reaction to the paper (turns to
blue) and urine causes acidic reaction
(remains yellow)
b. Ferning test
o Get the sample of fluid then place on Pathophysiology
the slide and viewing it under the  Pregnancy Induced Hypertension
microscope
o (+) Ferning patterns means –BOW

Management

1. Strict Bed Rest

2. Observe, document and report maternal temperature
above 38 ºC, fetal tachycardia
3. Monitor for signs of infections (fever, uterine
tenderness)
4. Avoid sexual intercourse/Orgasm
5. Avoid vaginal exams (risk of infection)
6. Avoid breast stimulation
7. Record fetal movements daily and report fewer than
10 in a 12 hour period
8. Administer broad spectrum antibiotic -----to reduce
the risk of infection e.g. Penicillin/Ampicillin

Pregnancy- Induced Hypertension (Pih)

 Originally called “Toxemia of Pregnancy”

 Condition in which vasospasm occurs during
pregnancy-----accompanied by hypertension,
proteinuria and edema
 Onset: occurs after 20th week of pregnancy
and may appear up to 48 hours (2 weeks)
postpartum

12 | N I N I N
MCHN / 2nd Sem
Kidney Effects
 Vasospasm in the kidney---increases blood
flow resistance
 Leads to increase permeability of the
glomerular membranes, ------allowing the
serum CHONS and globulin to escape in the
urine (protenuria)
 Results in decreased glomerular filtration –
lowers urine output
Interstitials Effects
 Because of more CHON is lost------the
osmotic pressure is decreased and the
excessive fluid shifts/diffuses from vascular
spaces to the interstitials spaces
 Leads to edema (extreme edema can lead to
----pulmonary edema and seizure
(Eclampsia) and it increases tubular
reabsorption of Na in kidneys’
Feto-placental effects
 Poor placental perfusion -----may reduce the fetal
nutrient and oxygen supply
Signs and symptoms
 Triad of Symptoms (classic signs of PIH)
1. HPN
2. Protenuria
3. Edema
Classification of PIH:
1. Gestational HPN – aka, Transcient HPN
 Develops increase BP (>140/90) but has
no protenuria and edema
 Decrease maternal mortality so no drug
therapy is necessary
 BP returns to normal by 10th day of
postpartum
2. Mild Pre-Eclampsia
a. 1st criteria – Increase BP of >140/90
mmHg taken on 2 occasion at least 6
hours apart
2nd criteria – Systolic BP is > 30 mmHg
and Diastolic BP is >15 mm Hg above
baseline BP
b. Protenuria
 +1 or +2 (represents a loss of 1
g/dl of CHON
c. Edema (weight gain)
 due to CHON loss, ----sodium
retention and decrease GFR
 begins to accumulate on the
upper part of the body
(hands/face)
 weight gain of >2 lb/wk in the
second semester or > 1 lb/wk
13 | N I N I N
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in the 3rd trimester
(abnormal)
 Normal Weight Gain; 1st
Trimester – 1 lb/month---
2nd/3rd trimester – 4 lbs/mos
Nursing management
Can be managed at home with frequent follow-ups
1. BED REST (bathroom priviliges)
 - Facilitate na excretion
 - Decreases oxygen demand
 - Position on left lateral position----to
prevent uterine pressure on the vena cava
2. Assess the BP in sitting/left lateral position,
CHON level in the urine, changes in LOC, fetal
movements and FHT
3. Regular diet with NO salt restriction
 Na restriction may activate the RAAS
(renninangiotensin-aldosterone system) which
can result in----increase BP
4. If symptoms progress to Severe Pre-Eclampsia –---
REFER immediately to HOSPITAL.
3. Severe Pre-Eclampsia
 Severe Pre-Eclampsia
a. Increase BP >160/110 mm Hg on at
least 2 occasions 6 hours apart at
bed rest (the position in which BP is
lowest)
b. Marked protenuria – 3+ or 4+ on a
random urine sample
c. Generalized edema noticeable in
woman’s face (facial edema) and
hands (wedding ring can’t be
removed), pulmonary edema:
o Dyspnea
o crackles on auscultation),
cerebral edema:
o visual disturbances
i.e
o blurred vision,
o headache)
d. Urine output – oliguria (less than
500 ml/24 hrs) or 30 ml/hr
Nursing Management
 Usually hospitalized until the baby is delivered
1. BED REST (patient must be observe more
closely)
2. Provide a quiet and calm environment –
any noise can trigger a seizure activity and
leads to eclampsia
3. Administer precautions on the patient’s
room:
a. Patient’s bed must be near nurse’s
station with code cart nearby
b. Placed in private room (undisturbed)
MCHN / 2nd Sem
c. The room should be darkened (because
bright light can trigger seizure)
d. Raise padded side rails to prevent falls
or injury from seizure activity
4. Frequent maternal assessments every 4 hours
(seizure precautions)
a. Sudden rise of BP
b. Blood studies – CBC, platelet count,
liver function, BUN, creatinine, urine
CHONS
c. Urine output – normal 600ml/24hours
or 30 ml/hour
d. Daily weights – same time each day
e. Impeding seizure signs (aura) such as:
o Headache
o visual disturbances
o epigastric pain
5. Monitor Fetal Well-being
o Placed in External fetal
Monitors to asses for FHR and
fetal movements
o Non-Stress test/Biophysical
Profile to assess for Utero-
placental sufficiency
6. Moderate high protein diet to compensate
for CHON lost (proteinuria)
Medical Management
 To prevent eclampsia
1. Hydralazine (Apresoline) – antihypertensive
– to reduce HPN by peripheral dilatation
o Side effects – tachycardia
o Check for PR and BP before
and after administration
2. Magnesium Sulfate
o DOC to prevent eclampsia
o Action:
a. Cathartic – reduces edema
by---causing fluid shifting
from extracellular spaces
into the intestine (removed
by bowel elimination)
b. CNS depressant (anti-
convulsant) – lessens the
possibility of seizure
activity
c. Decrease neuromuscular
irritability (muscle
relaxant effect)
d. Promotes maternal
vasodilatation – promotes
better feto-placental
circulation or tissue
perfusion
Nursing responsibilities during MgSO4 administration
1. Given IV via Piggyback infusing over 15-30
minutes, loading dose 4-6g/hr and
maintenance dose 1-2 g/hr
14 | N I N I N
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2. Assess RR, urine output, DTR and ankle
clonus before after administration
3. Monitor for magnesium sulfate toxicity:
a. Depressed respiration of <12breaths/min
b. Decrease urine output of <30 ml/hr
c. Decrease DTR
d. Decrease LOC
4. Antidote: Calcium Gluconate
o A solution of 10 ml of 10%
Calcium gluconate solution
given for MGSO4 toxicity
o Must be readily available at
bedside
4.Eclampsia
 The most severe classification of PIH
 When cerebral edema occurs----onset of seizure
or coma occurs
 Maternal mortality rate is high 20% due to
hemorrhage (circulatory collapse or renal failure)
Signs and Symptoms
1. Increase HPN precedes SEIZURE
-Impending signs of seizure are headache,
visual disturbances and epigastric pain)
followed by circulatory hypotension and
collapse
Stages
a. Tonic phase - all body contracts, arching of
back, arms and legs are stiff
b. Clonic phase - all of the muscle of body will
contract and relax
c. Post-Ictal phase - semicomatose/ patient
cannot be arouse except for painful stimuli
2. May lead to coma
3. Labor may begin because of premature
separation of placenta secondary to vasospasm
which might lead to preterm delivery
Nursing Management
Priority care for the mother with seizure is to:
1. Maintenance of Patent Airway
 Administer oxygen by face mask
 Turning the mother to the side to allow
the secretions to drain in the mouth
(preventing aspiration)
2. Raised padded side rails 3
3. Avoid placing a tongue depressor (during the
seizure activity) because it can obstruct the
airway
4. minimize environmental stimuli
5. administer medications as ordered i.e MgSO4
and diazepam IV
6. continue to assess FHT and uterine
contractions
7. check for maternal bleeding
MCHN / 2nd Sem ORTIZ

8. Mother can deliver via NSD, CS is very the zygote divides into two identical
hazardous----because hypotension might individuals
result secondary to anesthesia
9. IV therapy as ordered
 Have 1 placenta, 1 chorion, 2 amnion, 2
Hellp Syndrome umbilical cords
 Always of the same sex
 A variation of PIH abbreviated as hemolysis,
elevated liver enzymes and low platelet count
 Occurs in 4-12% of patients with PIH
2. Dizygotic twins
 A life threatening complication of PIH
 aka. Non-
----(because maternal mortality is high at
24% and infant mortality is 25%)

Cause

 Unknown

Associated Factors

 Primipara/Multipara
mothers

Signs and Symptoms

 Nausea identical/fr
 Epigastric pain aternal twins
 General malaise  The result of
 Right upper quadrant tenderness fertilization of two
separate ova by two
Laboratory data
separate spermatozoa
a. Hemolytic RBC  Have 2 placenta, 2 chorions, 2 amnions, 2
b. Thrombocytopenia (low platelet count of umbilical cords
below 100,000/m3)
c. Elevated liver enzyme (because of
hemorrhage and necrosis of liver)
d. Serum ALT (alanine aminotransferase), and
AST (aspartate aminotransferase)

Medical Management: (no known cure)

1. Blood transfusion of fresh frozen plasma or

platelets
2. Infant is deliver ASAP via NSD or CS (lab.
Results will return to normal after delivery
3. Monitor for bleeding

Multiple Pregnancies

 A pregnancy in which there is more than one fetus

in the uterus at the same time.
 Incidence rate is 2% of pregnancies
 Three babies or more is called a 'higher order'
pregnancy, and it's rare – occurring in just 1 in 50
multiple pregnancies.

Types:

1. Monozygotic twins
 aka. Identical twins
 Begins with single ovum and
spermatozoa, during the process of fusion,

15 | N I N I N
MCHN / 2nd Sem ORTIZ

2. Premature rupture of membranes – that

leads to infection and prolapsed cord
3. Preterm labor (because of increasing
pressure, prostaglandin release)

Risk Factors:

1. Maternal diabetes – hyperglycemia in the

 Twins may be of the fetus causes increase urine production leading
same or different sex to increase urine output
 2/3 of twins are dizygotic 2. Anencephaly
Associative Factors: 3. Esophageal atresia – fetus becomes unable to
swallow the amniotic fluid because of
a. More frequent in non-whites than in whites intestinal anomalies or obstruction
b. Increase in parity
c. Advance maternal age Esophageal Atresia
d. Familial inheritance Signs and Symptoms:
Diagnostic procedure 1. Rapid enlargement of the uterus (first sign)
 Sonogram/Ultrasound 2. Difficulty in palpating and auscultating the
fetus due to excessive fluid
Signs and Symptoms 3. Shortness of breath----due to compression of
the diaphragm
1. Increase uterine size faster than usual 4. Ultrasound finding of increase excessive fluid
2. Quickening at the different portion of the
abdomen Management:
3. More than expected fetal activity
4. Multiple sets of FHT 1. Maintain bed rest to reduce pressure on
5. Extreme fatigue and backache cervix and to prevent premature labor
2.
Management

 Mother is more susceptible to complications of

pregnancy i.E. PIH, hydramnios, placenta
previa, preterm labor, anemia than a women
carrying only one fetus
1. BED REST (during the 2 or 3 months of
pregnancy to decrease risk of preterm
labor
2. Closer prenatal supervision

HYDRAMNIOS (Polyhydramnios)
Monitor for rupture or uterine contraction
 Excessive fluid formation of >2000ml or an 3. Avoid constipation--(it will increase uterine
amniotic fluid index of above 24 cm (normal pressure and rupture of membranes)
500-1000ml) 4. Amniocentesis (slow and controlled release
 Complication: of fluid to prevent premature separation of the
1. Fetal placenta) guided by ultrasound
Malpresentation
(because of Post-Term Pregnancy
extra-
 - a pregnancy that exceeds 42 weeks of gestation
uterine
(term pregnancy – 37-42 weeks)
space)
 - incidence rate – 3-12%
of all pregnancies

Risk Factors:

16 | N I N I N
MCHN / 2nd Sem ORTIZ

1. Women who have long menstrual cycles (40- Management:

45 days)
- they do not ovulate on day 14 in a typical 1. Rh Immune globulin (Rhogam) is administered at
menstrual cycle. ----They ovulate 14 days 28 weeks of pregnancy and in the 1st 72 hours after
from the end of the cycle or on day 26 or 31. delivery
Their child will be late by 12 or 17 days. 2. Determine blood typed of infants after birth from
2. Women receiving high dose of Salicylates--- a sample of the cord
(interferes with synthesis of prostaglandins that blood
initiates labor) 3. Blood transfusion
3. associates with myometrial quiescence through Intrauterine
(uterus that do not respond to normal labor) Transfusion
 Done to give
Complication: restore fetal
RBC
1. meconium aspiration  75-150ml of
2. macrosomia – fetus continues to grow
RBC is
3. fetal distress – due to placental aging it causes
administered
decreased blood prefusion and inadequate
 After BT, the
supply of oxygenated blood and nutrients to
mother is
fetus
encouraged to
rest for 30
min. while
Management: FHT and
uterine
1. Induction of labor – prostaglandins or activity are
inoprostol (cytotec) applied to cervix to monitored
stimulate ripening or stripping of membranes. 4. As soon as fetal
Followed by oxytocin infusion to stimulate maturity is reached,
contraction induction of labor is
2. CS delivery followed

------ Gestational Diabetes Mellitus

Rh Incompatibility (Isoimmunization)  A condition in which women exhibit high

 Occurs when the mother is Rh negative (-) who
carries a fetus with an Rh positive (+) blood
 Normally there is no direct contact between
maternal and fetal blood
 Villi ruptures – a drop or two of fetal blood enters
maternal circulation or during amniocentesis
 Small amount of blood (drop) of Rh + fetal blood
leaks across the placenta and goes to the blood
stream of the mother.----Mother will be sensitized
and start to make Rh antibodies (first pregnancy
is not affected)
 An injection of Rh immune globulin (Rhogam) is
given ASAP within 72 hours after the delivery----
(because most of maternal antibodies are formed
during the first 72 hours after birth)
 During the subsequent pregnancy (if fetus is
again Rh +),---the Rh antibodies of the mother
crosses the placenta,---enters the blood stream of the
fetus causing antigenantibody reaction and
Hemolysis of the fetal RBC (Erythroblastosis
Fetalis)
glucose levels during pregnancy
 An abnormal CHO, fat and CHON
metabolism that is first diagnosed during
pregnancy (at the midpoint of pregnancy when
insulin resistance becomes noticeable)
 But the symptoms fade again at the completion
of pregnancy (resolves in delivery)
 Risk of developing type 2 diabetes is high as
56-60% later in life
Cause:
 Unknown (related to excessive insulin
resistance)
Risk Factors:
1. Obesity
2. Age over 25 years old (about 50% of the these
women develop diabetes within 22-28 years old)

Diagnosis:

1. Indirect Coomb’s test – to check if Rh

antibodies are present within RBC surface
2. Antibody titer – determine at first pregnancy
visit and then again at 28 weeks AOG and
after delivery (normal is 0)

17 | N I N I N
MCHN / 2nd Sem ORTIZ

3. History of large babies---macrosomia (16 lbs or  Rate is abnormal----if 2 of the 4 blood

more) samples collected are abnormal
4. Family history of DM/GDM  <70 hypoglycemia,
 >130 hyperglycemia
Pathophysiology of DM  (normal – 80-120mg/dl)

Maternal effects of DM

1. Hypoglycemia during the first

trimester – glucose is being
utilized by the fetus for the
Test type Pregnancies
glucose level
(mg/dl)
Fasting 95
1 hour 180
2 hours 155
3 hours 140
development of the brain
2. Hyperglycemia during the 2nd
/3rd trimester at 6 months – due
to HPL effects (causes insulin
resistance)

-Insulin requirements for insulin

during:-

 1st trimester – decrease in

insulin by 33%
 2nd/3rd trimester – increase
insulin by 50%,
 Postpartum – drops suddenly to
25%---- due to delivery of
placenta
3. Prone to frequent infections e.G.
Moniliasis/candidiasis
4. Polyhydramnios
5. Dystocia – due to abnormality in
fetus/mother

Fetal Effects of DM
Diagnosis: 1. Hypoglycemia during the 1st trimester
2. Hyperglycemia during the 2nd/3rd trimester
 Women who are high risk for DM---- should
3. Macrosomia – abnormally large for gestational
be screened at first prenatal visit and again
age(baby is delivered >4000 g or 4kg)
at 24-28 weeks.
1. Glucose Challenge Test – done at first prenatal Macrosomia
visit and again at 24-28 weeks
 - Usually consists of 8 hour fasting for FBS Newborn Effects:
 - Mother is given 50g of glucose load and a
1.
----blood sample is taken for serum glucose
H
1 hour after
 - Diabetic if FBS is more than 95mg/dl or
y
after 1 hour the serum glucose is >140mg
p
2. Oral Glucose Tolerance Test
 The gold standard for diagnosing
diabetes
 Mother is given 100g of CHO/glucose
then----3 hours fasting

18 | N I N I N
MCHN / 2nd Sem
erinsulinism – because insulin from the mother
does not cross the placenta ------which lead to
increase insulin production from the baby
2. Hypoglycemia – when the umbilical cord is cut –
the supply of glucose from the mother also stops
which results in very hypoglycemia newborn
(normal glucose in NB 45-55mg/dl)
Signs and Symptoms: (newborn)
1. High pitched shrill cry
2. tremors
3. jitteriness
Diagnosis:
 Heel Stick Test to check glucose level
Management:
1. Frequent prenatal visits----for close monitoring]
2. Insulin (regular/Intermediate acting insulin) – given
subcutaneously (slow absorption)
 - do not massage the site of injection
 - rotate the site of injection (to prevent
lipodystrohy- inhibits insulin absorption)
 - gently roll vial in between the palms (do not
shake)
3. Monitor blood glucose – assess once a week
 using finger stick technique----using on
fingertips as the site of lancet puncture,
 the strip is then inserted into a glucose meter to
determine glucose level
 (normal <95mg/dl – FBS, <120mg/dl 2 hours
post prandial (after very meal) level
4. Monitor fetal well being
a. ultrasound/Sonogram – to determine fetal
growth, amniotic fluid volume, placental
location and b-parietal diameter
b. daily fetal movement count (DFMC) –
monitoring for movements of fetus for 1 hour
(normal 10 movement/hour) 
c. amniocentesis – to determine LS ratio by 36
weeks of pregnancy and to assess fetal lung
maturity
5. CS delivery
 - cervix is not yet ripe or not yet responsive to
contractions
 babies of diabetic mother are abnormally
large making vaginal delivery difficult
6. woman with gestational diabetes usually
demonstrates normal glucose levels by 24 hours
after birth (and needs no further insulin therapy)
Heart Disease
 Origin: 90% Rheumatic (incidence expected to
decrease as incidence of rheumatic fever decreases),
10% congenital lesions or syphilis
 Normal hemodynamics of pregnancy that adversely
affect the client with heart disease:
a. Oxygen consumption increased 10% to 20%;
---related to the needs of the growing fetus
19 | N I N I N
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b. Plasma level and blood volume increase;
rbc’s remain the same (physiologic anemia)
Functional or Therapeutic Classification of Heart Disease
during Pregnancy:
A. CLASS I – no limitation of physical activity;
 no symptoms of cardiac insufficiency or
angina
B. CLASS II – slight limitation of physical
activity; may experience;
 excessive fatigue
 palpitation
 angina or dyspnea; slight limitations as
indicated
C. CLASS III – moderate to marked limitation
of physical activity;
 dyspnea,
 angina
 fatigue
-occur with slight activity and bed rest is
indicated during most of pregnancy
D. CLASS IV – marked limitation of physical
activity;
 Angina
 Dyspnea
 discomfort occur at rest; pregnancy
should be avoided; indication for
termination of pregnancy
Nursing Care of Pregnant Client with heart Disease:
1. Assessment
a. Prenatal period
-Vital signs; weight gain; dietary patterns,
knowledge about self care; signs of heart
failure, stress factors such as work, household
duties
b. Intrapartal period
-Vital signs (heart rate will increase);
respiratory changes (dyspnea, coughing,
crackles); FHR patterns
c. Postpartal period
-Signs of heart failure or hemorrhage related to
fluid shifts, intake and output
2. Analysis/ Nursing Diagnosis
a. Activity intolerance related to increased
cardiac workload
b. Anxiety related to unknown course of
pregnancy----possible loss of fetus and
inability to perform role responsibilities
c. Decreased cardiac output ----related to stress
of pregnancy and pathology associated with
heart disease
d. Fear related to possible death
e. Excess fluid volume ----related to fluid shifts
resulting from a decrease in intra-abdominal
pressure ---following birth
f. Risk for impaired parenting related to
increased responsibility of caring for a neonate
MCHN / 2nd Sem
3. Nursing Interventions
A. Prenatal period
a. Teach importance of rest and avoidance
of stress
b. Instruct regarding use of elastic stockings
and periodic evaluation of legs
c. Teach appropriate (dietary intake;
adequate calories to ensure appropriate,
but not excessive, weight gain; limited,
not restricted salt intake
d. Administer medications as ordered;
 heparin
 furosemide (lasix),
 digitalis,
 beta blockers (inderal)
e. Monitor for signs of heart failure such
as;
 respiratory distress and
tachycardia;
 may be precipitated by severe
anemia of pregnancy
B. Intrapartal period
a. Encourage mother to remain in semi
fowler’s position or left lateral position
b. Provide continuous cardiac monitoring
c. Provide electronic fetal monitoring
d. Assist mother to cope with
discomfort;---minimal analgesia and
anesthesia are used
e. Assist with forceps delivery in second
stage of labor to avoid work of pushing
f. Monitor for signs of heart failure, such
as respiratory distress and tachycardia
20 | N I N I N
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C. Postpartal period (most critical time because
of increased circulating blood volume after
birth of placenta)
a. Institute early ambulation schedule;
apply elastic stockings
b. Monitor for signs of heart failure, such
as respiratory distress and tachycardia
c. Monitor heart rate; ----accelerated heart
rate of mother in latter half of
pregnancy puts extra workload on her
heart
d. Provide for adequate rest; the increase
in oxygen consumption with contractions
during labor makes length of labor a
significant factor
e. Provide close supervision; sudden
tachycardia during birth or sudden
bradycardia and normal increase in
cardiac output following birth may cause
cardiac arrest
f. Administer prescribed prophylactic
antibiotics to mother with history of
rheumatic fever
g. Refer to various agencies for family
support, if necessary on discharge
h. Newborn risks include;
 intrauterine growth retardation
 prematurity
 hypoxia fetal demise may occur
INTRAPARTUM COMPLICATIONS
 Occur in as many as 31% of all births
 Broad term for abnormal or difficult labor and
delivery
 Arise from 3 main components
of the labor process:
1. Power (uterine
contractions)
2. Passenger (the fetus)
3. Passageway (the birth
canal)
1. Problems with the Power:
(Force of Labor)
A. Uterine Inertia
 Sluggishness of
contractions or the
force of labor or
defined as difficult,
painful, prolonged
labor----due to
mechanical factors
 Current term –
Dysfunctional labor
Common Causes:
a. Inappropriate use of analgesia (excessive or too
early administration)
MCHN / 2nd Sem ORTIZ

b. Unusually large baby/multiple gestation 5. Examination to detect disproportion,

c. Poor fetal position (posterior rather than anterior malpresentation or malposition and manage
position) according to the case.
 Proper management of the
first stage (see normal
labour).
 Prophylactic antibiotics in
prolonged labour particularly
-----if the membranes are
ruptured.

6. Amniotomy:
 Providing that;
o Vaginal delivery is amenable,
o The cervix is more than 3 cm
dilatation and
o The presenting part occupying
well the lower uterine segment.
 Artificial rupture of
membranes augments the
uterine contractions by:
o Release of prostaglandins.
d. Pelvic bone contraction (leads to narrowing of the o Reflex stimulation of uterine
pelvic diameter so the fetus cant pass) contractions when the
e. Primigravida presenting part is brought closer
f. Hypotonic, hypertonic and prolonged labor to the lower uterine segment.
7. Oxytocin:
2 types:
 Providing that there is no contraindication
1. Primary for it,---5 units of oxytocin (syntocinon)
 Occurring at the onset of labor in 500 c.c glucose
 Weak uterine contractions from the start.  5% is given by IV infusion starting with
2. Secondary 10 drops per minute and increasing
 Occurring later in labor gradually to get a uterine contraction rate
 Inertia developed after a period of good of 3 per 10 minutes.
uterine contractions when it failed to 8. Operative delivery:
overcome an obstruction so the uterus is  Vaginal delivery: by forceps, vacuum or
exhausted. breech extraction according to the
presenting part and its level providing
Signs and symptoms; that,
o Cervix is fully dilated.
 Irregular uterine contractions
o Vaginal delivery is amenable.
 Ineffective uterine contractions
 Caesarean section is indicated in:
(strength/duration)
o Failure of the previous methods.
Management o Contraindications to oxytocin
infusion including
1. Monitor uterine contractions by palpation disproportion.
and with the use of electronic monitor o Foetal distress before full
2. Prevent unnecessary fatigues – check the cervical dilatation.
client level of fatigue
3. Prevent complications of labor B. Ineffective Uterine Force
a. Assess urinary bladder (catheterize as  Uterine contractions are the basic force
needed) moving the fetus through the birth canal.
b. Assess maternal VS  Contractions occur because of ----interplay of
c. Monitor condition of fetus by enzymes, electrolytes, proteins and
monitoring FHR, fetal activity and color hormones.
of amniotic fluid  About 95% of labors are completed with
4. Provide comfort measures contractions that follow a predictable, normal
a. frequent position changes course.
b. walking  When they become abnormal or ineffective,---
c. quiet/calm environment ineffective labor occurs.
d. breathing/relaxation technique
Types;

21 | N I N I N
MCHN / 2nd Sem ORTIZ

1. Hypotonic Contractions  The foetus and mother are usually not

 The uterine contractions are affected apart from maternal anxiety
infrequent, weak and of short duration. due to prolonged labour.
 The number of contractions is usually low  More susceptibility for retained placenta
or infrequent---(not increasing beyond 2 and postpartum haemorrhage---due to
or 3 in a 10 minute period) persistent inertia.
 Occurs during the active phase of labor  Tocography: shows infrequent waves of
 Normal : 3-4/10 min period with contractions with low amplitude.
duration of 30 seconds
 Resting tone: less than 10 mm Hg Management
 Strength of contractions: does not rise
General Measures
above 25 mm Hg.
1. Examination to detect disproportion,
Etiology
malpresentation or malposition and ----
 Unknown but the following factors may manage according to the case.
be incriminated: 2. Proper management of the first stage.
3. Monitor maternal VS and FHR
4. Prophylactic antibiotics in -----
prolonged labour particularly if the
membranes are ruptured.
5. Position changes -----to relieve
General factors:
discomfort and enhance progress
 Primigravida particularly elderly. 6. Ambulation
 Anaemia and asthenia. 7. Nipple stimulation
 Nervous and emotional as anxiety and 8. Enema
fear. 9. Amniotomy (artificial rupture of
 Hormonal due to deficient prostaglandins membranes – to further speed labor,
or oxytocin as in induced labour. provided that:
 Improper use of analgesics.  Vaginal delivery is amenable,
 The cervix is more than 3 cm
Local factors: dilatation and

 Overstretching of the uterus – large
baby, multiple babies, polyhydramnios,
multiparity.
 Developmental anomalies of the
uterus-----e.g. hypoplasia.
 Myomas of the uterus interfering
mechanically with contractions.
 Malpresentations, malpositions and
cephalopelvic disproportion. ----The
presenting part is not fitting in the lower
uterine segment---leading to absence of
reflex uterine contractions.
 Full bladder and rectum.

Types

A. Primary inertia The presenting part occupying well the

-Weak uterine contractions from the start.
B. Secondary inertia
-Inertia developed after a period of good
uterine contractions when it failed to
overcome an obstruction so the uterus is
exhausted.
Clinical Picture/Signs and Symptoms
 Painless contraction
 Uterine contractions are infrequent,
weak and of short duration.
 Slow cervical dilatation.
 Labour is prolonged.
 Membranes are usually intact.
lower uterine segment.
 Artificial rupture of membranes
augments the uterine contractions by:
o Release of prostaglandins.
o Reflex stimulation of
uterine contractions when
the presenting part is
brought closer to the lower
uterine segment.
10. Oxytocin administration – to strengthen
contractions and increase effectiveness,
provided that:

22 | N I N I N
MCHN / 2nd Sem
 There is no contraindication for it, 5
units of oxytocin (syntocinon) in
500 c.c glucose 5%
 is given by IV infusion starting
 with 10 drops per minute and
 increasing gradually to get a uterine
contraction rate of 3 per 10 minutes.
11. Vaginal Delivery - by forceps, vacuum
or breech extraction according to the
presenting part and its level, provided
that:
 Cervix is fully dilated.
 Vaginal delivery is amenable.
12. Caesarean section is indicated in:
 Failure of the previous methods.
 Contraindications to oxytocin
infusion including disproportion.
 Foetal distress before full cervical
dilatation.
2. Hypertonic Contractions
 Intensity of the contractions may not stronger or
very active and frequent contractions but
ineffective
 Occurs more frequently and commonly seen in
latent phase of labor’
 Resting tone: more than 15 mm Hg
 Contractions: Frequent prolonged contractions that
are not productive.
 The muscle fibers of the uterus (myometrium) do
not repolarize
Etiology
 This type of contraction occurs because---
the muscle fibers of the myometrium do
not repolarize or relax after a
contraction, thereby “wiping it clean” to
accept a new pacemaker stimulus.
Types
A. Colicky uterus
-Incoordination of the different parts of
the uterus in contractions.
B. Hyperactive lower uterine segment
-The dominance of the upper segment is
lost.
Clinical Picture/Signs and Symptoms
1. The condition is more common in
primigravidae
23 | N I N I N
ORTIZ
2. Uterine contractions are irregular and
more painful. The pain is felt before and
throughout the contractions with marked
low backache often in occipito-posterior
position.
3. Uterine tenderness
4. Fetal anoxia/distress
5. Dehydration due to excessive perspiration
6. Labour is prolonged.
7. Fatigue and exhaustion
8. High resting intrauterine pressure in
between uterine contractions detected by
tocography (normal value is 5-10 mmHg).
9. Slow cervical dilatation .
10. Premature rupture of membranes.
11. Foetal and maternal distress.
Clinical Picture/Signs and Symptoms
1. Painful nonproductive contractions
2. Uterine tenderness
3. Fetal anoxia/distress
4. Dehydration due to excessive perspiration
5. Fatigue and exhaustion
Complication
1. Fetal anoxia/distress
Management
1. Assess quality of contractions by
uterine/fetal external monitor applied at
least 15 minutes interval
2. Provide comfort measures
3. Bedrest or position changes
4. Hydration
5. Adequate rest
6. Pain relief with morphine sulfate
7. Mild sedation
8. Tocolytics
9. Changing linen/gowns
10. Darkened room lights
11. Decreasing environmental stimuli
12. CS delivery
 Failure of the previous methods.
 Disproportion.
 Fetal distress before full cervical
dilatation.
3. Uncoordinated Contractions
 With uncoordinated contractions, more than----
one pacemaker may be initiating contractions,
or receptor points in the myometrium may be
acting independently of the pacemaker.
 Uncoordinated contractions----may occur so
closely together that they do not allow good
cotyledon (one of the visible segments on the
maternal surface of the placenta) filling.
 Applying a fetal and a uterine external
monitor and assessing the rate, pattern, resting
tone, and fetal response to contractions for at
MCHN / 2nd Sem
least 15 minutes (or longer if necessary in
early labor) reveals the abnormal pattern.
 Oxytocin administration----may be helpful in
uncoordinated labor ----to stimulate a more
effective and consistent pattern of contractions
with a better, lower resting tone.
C.DYSFUNCTIONAL LABOR AND ASSOCIATED
STAGES OF LABOR
Dysfunction at the First Stage of Labor
a. Prolonged Latent Phase
 When contractions become ineffective during
the first stage of labor,----a prolonged latent
phase can develop.
 A prolonged latent phase---is a latent phase
that is longer than
o 20 hours in a nullipara or
o 14 hours in a multipara.
 This may occur if the cervix is not “ripe” at
the beginning of labor and time must be spent
getting truly ready for labor.
o It may occur if there is excessive use
of analgesic early in labor.
 With a prolonged latent phase, ----the uterus
tends to be in a hypertonic state.
o Relaxation between contractions is
inadequate, and the
o contractions are only mild (less than
15 mm Hg) and therefore
ineffective.
 One segment of the uterus -----may be
contracting with more force than another
segment.
 Management of a prolonged latent phase in
labor that has been caused by hypertonic
contractions involves:
o helping the uterus to rest,
o providing adequate fluid for
hydration, and
o pain relief with a drug such as
morphine sulfate.
 Changing the linen and the woman’s gown,
o darkening room lights, and
o decreasing noise and stimulation can
also be helpful.
 These measures usually combine to-----allow
labor to become effective and begin to
progress.
o If it does not----a cesarean birth or
amniotomy (artificial rupture of
membranes) and oxytocin infusion
to assist labor may be necessary..
b. Protracted Active Phase
 A protracted active phase----is usually
associated with cephalopelvic disproportion
(CPD) or fetal malposition,----although it may
reflect ineffective myometrial activity.
24 | N I N I N
ORTIZ
 This phase is prolonged---if cervical
dilatation does not occur ata rate of at
least----
o 1.2 cm/hr in a nullipara or
o 1.5 cm/hr in amultipara, or if the
active phase lasts longer than 12
hours in aprimigravida or 6 hours
in a multigravida.
 If the cause of the delay in dilatation is fetal
malposition or CPD----cesarean birth may be
necessary.
 Dysfunctional labor during the dilatational
division of labor tends to be hypotonic----in
contrast to the hypertonic action at the
beginning of labor.
 After an ultrasound to show that CPD is not
present----oxytocin may be prescribed to
augment labor.
c. Prolonged Deceleration Phase
 A deceleration phase has become prolonged
when it extends beyond;
o 3 hours in a nullipara
o 1 hour in a multipara.
 Prolonged deceleration phase most often
results from----abnormal fetal head position.
 A cesarean birth is frequently required.
d. Secondary Arrest of Dilatation
 A secondary arrest of dilatation has occurred if
there is---- no progress in cervical dilatation for
longer than 2 hours.
 Again, cesarean birth may be necessary.
e. Prolonged Descent
 Prolonged descent of the fetus occurs if---the
rate of descent is less than
o 1.0 cm/hr in a nullipara or
o 2.0cm/hr in a multipara.
 It can be suspected if the second stage lasts
over 3 hours in a multipara.
 With both a prolonged active phase of
dilatation and prolonged descent----
contractions have been of good quality and
proper duration, and effacement and beginning
dilatation have occurred----but then the
contractions become infrequent and of poor
quality and dilatation stops.
 If everything is normal except for the suddenly
faulty contractions and CPD and poor fetal
presentation have been ruled out by
ultrasound----then rest and fluid intake, as
advocated for hypertonic contractions, also
apply.
 If the membranes have not ruptured---
rupturing them at this point may be helpful.
 Intravenous (IV) oxytocin---- may be used to
induce the uterus to contract.
 A semi-Fowler’s position, squatting, kneeling,
or more effective pushing may speed descent.
f. Arrest of Descent
MCHN / 2nd Sem ORTIZ

 Arrest of descent----results when no descent

has occurred for
o 1 hour in a multipara or
o 2 hours in a nullipara.
 Failure of descent has occurred -----when
expected descent of the fetus does not begin or
engagement or movement beyond 0 station has
not occurred.
 The most likely cause for arrest of descent
during the second stage is CPD.----Cesarean
birth usually is necessary.
 If there is no contraindication to vaginal
birth----oxytocin may be used to assist labor.

D. PATHOLOGIC RETRACTION

 A contraction ring ----is a hard band that forms

across the uterus at the junction of the upper and
lower uterine segments and interferes with fetal
descent.
 The most frequent type seen is termed a pathologic
retraction ring (Bandl’s ring).
 The ring usually appears during the second stage of
labor and can be palpated as a ----horizontal
indentation across the abdomen.
 It is a warning sign that severe dysfunctional
labor is occurring as it is formed by excessive
retraction of the upper uterine segment;----the
uterine myometrium is much thicker above than
below the ring.
 When a pathologic retraction ring occurs in early
labor----it is usually caused by uncoordinated
contractions.
 In the pelvic division of labor, it is usually caused
by obstetric manipulation or by the
administration of oxytocin.
 In either event, the fetus is gripped by the retraction
ring and cannot advance beyond that point.----The
undelivered placenta will also be held at that
point.
 Contraction rings often can be identified by
ultrasound. Such a finding is extremely serious and
should be reported promptly.
 Administration of IV morphine sulfate or the
inhalation of amyl nitrite ----may relieve a
retraction ring. A tocolytic can also be administered
to halt contractions.
 If the situation is not relieved, ----uterine
rupture----neurologic damage to the fetus may
occur.
 In the placental stage, massive maternal
hemorrhage----may result, because the placenta is
loosened but then cannot deliver, preventing the
uterus from contracting.
 Most likely, a cesarean birth will be necessary to
ensure safe birth of the fetus.
 Manual removal of the placenta under general
anesthesia may be required if the retraction ring
does not allow the placenta to be delivered.

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MCHN / 2nd Sem ORTIZ

PRECIPITATE LABOR Risk Factors:

 Define as labor that is completed in fewer than 3  Commonly occur from a vertical scar during the
hours previous CS or hysterectomy repair tears
o (normal length of labor; primipara 14-20  Prolong labor
hours, multi – 8-14 hours)  Faulty presentation
 A forceful contractions th  Multiple gestation
  Use of oxytocin
  Traumatic maneuvers
  Usually preceded by pathologic refraction ring (an
 indentation is apparent across the abdomen over the
 at can lead to premature separation of the placenta uterus) and strong uterine contractions without any
(placing the mother and fetus at risk for cervical dilatation, the fetus is gripped by retraction
hemorrhage) ring and cannot descent)

Risk Factors: Signs and symptoms:

1. Likely to occur in multiparity mothers 1. Sudden severe pain during a strong labor
2. Women undergo premature separation of the contractions
placenta 2. Report “a tearing sensation”
3. Previous history of precipitate labor 3. Hemorrhage from a torn uterus into the
abdominal cavity and into the vagina
Complications: 4. Signs of shock (rapid, weak pulse, falling
blood pressure, cold clammy skin)
1. Hemorrhage 5. Absent fetal heart sounds
2. Intracranial hemorrhage in fetus 6. Localized tenderness and aching pain from the
3. Lacerations (because of forceful birth) lower segment
4. Fetal distress 7. Fetal distress
Signs and symptoms: Nursing Management:
1. Tachycardia (earliest sign) 2 1. Administer emergency fluid replacement
2. Restlessness therapy as ordered
3. Hypotension (late sign) 2. Anticipate use of intravenous oxytocin to
4. Signs of hypovolemic shock attempt to contract the uterus and minimize
5. Vulvar pain and bruising bleeding
Nursing Management: 3. Prepare mother from a laparotomy as an
emergency measure to control bleeding and
1. Inform mother at 28 weeks of pregnancy that effect a repair
labor may be shorter than normal 4. Physician may perform “hysterectomy”
2. Tocolytic agent administration to reduce the (removal of a damaged uterus) or BTL at the
force and frequency of contractions time of laparotomy
3. Cold applications to limit bruising, pain and 5. Monitor VS and FHR
edema 6. Administer BT as ordered
4. In time of hemorrhage position the mother in
modified trendelenburg position UTERINE INVERSION
5. IVF replacement – fast drip
 Uterus turns completely or partially inside out,
UTERINE RUPTURE it occurs immediately following delivery of the
placenta or in the immediate postpartum period
 Rupture of the uterus during labor  Incidence rate is 1 in 15, 000 births
 Accounts for 5% of maternal death
 Incidence rate is 1 in 1500 births Causes:

 Occurs after birth of the infant if traction is

applied to umbilical cord to remove placenta
 Pressure is applied to the uterine fundus when
uterus is not contracted

26 | N I N I N
MCHN / 2nd Sem ORTIZ

 Occurs when placenta attached at the fundus

(the passage of the fetus pulls the fundus
down)

AMNIOTIC FLUID EMBOLISM

 Occurs when amniotic fluid is force
to enter the maternal blood
circulation because of some defect
in the membranes or after
membranes rupture (not preventable
because it cannot be predicted)
 Incidence rate is 1 in 8000 births

Risk factors:

1. Oxytocin administration
2. Abruption placenta
3. Hydramnios
 Advanced maternal age. If you're 35 or
older at the time of your child's birth,
you might be at increased risk of amniotic fluid
Signs and symptoms: embolism.
 Placenta problems. Abnormalities in the placenta
1. Sudden gushes of blood from vagina — the structure that develops in your uterus during
2. Fundus is not palpable pregnancy — might increase your risk of amniotic
3. Show signs of blood loss (hypotension, fluid embolism. Abnormalities might include the
dizziness and paleness) placenta partially or totally covering the cervix
4. Bleeding (placenta previa) or the placenta peeling away from
the inner wall of the uterus before delivery
Nursing management; (placental abruption). These conditions can disrupt
the physical barriers between you and your baby.
1. Recognize signs of impending inversion and
 Preeclampsia. Having high blood pressure and
immediately notify the physician
excess protein in your urine after 20 weeks of
2. Never attempt to replace the inversion because
pregnancy (preeclampsia) can increase your risk.
handling may increase the bleeding
 Medically induced labor. Limited research
3. Never attempt to remove the placenta if it still
suggests that certain labor induction methods are
attached
associated with an increased risk of amniotic fluid
4. Take steps to prevent or limit hypovolemic
embolism. Research on this link, however, is
shock
conflicting.
a. Use large gauge IV catheter for fluid
 Operative delivery. Having a C-section, a forceps
replacement
delivery or a vacuum extraction might increase your
b. Measure and record maternal VS every 5
risk of amniotic fluid embolism. These procedures
to 15 minutes to establish baseline
can disrupt the physical barriers between you and
changes
your baby. It's not clear, however, whether operative
5. Administer oxygen by mask
deliveries are true risk factors for amniotic fluid
6. Be prepared to perform CPR if the heart fails
embolism because they're used after the condition
due to sudden blood loss
develops to ensure a rapid delivery.
7. The mother will be given general anesthesia or
 Polyhydramnios. Having too much amniotic fluid
nitroglycerin or a tocolytic drug IV to
around your baby may put you at risk of amniotic
immediately relax the uterus
fluid embolism.
8. Physician/nurse midwife replaces the fundus
manually (push the uterus back inside) Signs and symptoms:

1. Sharp pain on the chest

2. Dyspnea (secondary to pulmonary artery
constriction)
3. Mother becomes pale and cyanotic due to
pulmonary embolism and lack of blood flow
to the lungs

27 | N I N I N
MCHN / 2nd Sem ORTIZ

Nursing management:

1. Immediate management is oxygen

administration by face mask or cannula
2. Prepare the mother for CPR (may be
ineffective because these procedures do not
relieve the pulmonary constriction)
3. Endotracheal intubation to maintain pulmonary
function
4. The mother should be transferred to ICU

Complication:

 DIC – disseminated intravascular coagulation

 Bleeding to all portion of body (eyes, nose,
gums, IV sites)
 Therapy with fibrinogen to counteract DIC

PROBLEMS WITH THE PASSENGER

1. PROLAPSE OF UMBILICAL CORD Associative Factors:
 Descent of the umbilical cord into
the vagina ahead of the fetal 1. Premature rupture of membranes (the fetal
presenting part with resulting fluid may rush and carry the cord along toward
compression of the cord (cord the birth canal)
compression) 2. Breech presentation
 “Emergency situation “, immediate 3. Placenta previa
delivery is attempted to save the 4. Intrauterine tumors preventing the presenting
baby part from engagement
 Incidence rate is 0.2-0.6% of births 5. Small fetus
or 1 of 200 pregnancies 6. CPD preventing engagement
7. Hydramnios
8. Multiple gestation

Signs and Symptoms;

1. The umbilical cord seen or felt during vaginal

exam
2. Reports feeling of cord into the vagina

Management:

 (Relieve compression on the cord and fetal

anoxia)
1. Periodically evaluate FHR especially after
the rupture of membranes (fetal distress)
2. Physician will place a glove hand in the
vagina and manually elevate the fetal head
off the cord
3. Place the mother in knee-chest
position/trendelenburg position (causes
the fetal head to fall back from the cord)
4. Administer oxygen at 10 liters/minute by
facemask to improve oxygenation of the
fetus
5. Do not attempt to push any exposed cord
back into the vagina (adds to
compression)
6. Cover any exposed portion of the cord
with sterile gauge soaked in NSS around
the prolapsed cord
7. If the cervix is fully dilated at the time of
prolapsed (the most emergent delivery
route is NSD and encourage mother to
push)

28 | N I N I N
MCHN / 2nd Sem ORTIZ

8. If not fully dilated, mother is delivered via Risk Factors:

CS (upward pressure on the presenting
part to keep pressure off the cord) 1. Women with android/anthropoid pelvis.

Signs and Symptoms;

PROBLEMS WITH POSITION,

PRESENTATION OR SIZE:
1. OCCIPITO-POSTERIOR POSITION
 - LOA (left occipito-anterior) is the most ideal
and common fetal position
 - LOP (left occipito-posterior) is located on left
and posterior quadrant pelvis
 - ROP (right occipito-posterior) is located at
the right and posterior quadrant pelvis
 ROP – in this position, during the internal
rotation, the fetal head must rotate not through
a 90 degree arc but through an arc of
approximately 135 degrees

29 | N I N I N
MCHN / 2nd Sem ORTIZ

 - Intense lower back pain (lumbosacral pain) – 1. External version is being used to avoid some
due to compression of sacral nerves during CS deliveries for a breech presentations
rotation
 - Shooting leg pains VERSION – is a method of changing the fetal
presentation usually from breech to cephalic.
Nursing Management;
- done after 37 weeks of gestation but before the
1. 1. provide back rub onset of labor
2. change of position (squatting position) – may
help fetus to rotate - begins with non-stress test and BPF to determine
3. encourage voiding every 2 hours to keep of the fetus is in good condition and if there is
bladder empty (because full bladder impedes adequate amount of amniotic fluid
descent of the fetus)
- mother is given tocolytic drug to relax her uterus
4. apply hot/cold compress
during version
5. delivered via CS
- UTZ is used to guide the procedure while
physician pushes the fetal buttocks upward out of
2. BREECH PRESENTATIONS – presenting the pelvis while pushing the fetal head downward
parts are usually buttocks and feet toward the pelvis in either clockwise or
counterclockwise direction
Complications:
3. the head may also be delivered using forceps
1. anoxia (due to prolapsed umbilical cord) delivery to control the flexion and rate of descent
2. intracranial hemorrhage
3. fracture of the pine/extremities 4. CS delivery
4. dysfunctional labor

THE RAPEUTIC MANAGEMENT OF

PROBLEMS OR POTENTIAL PROBLEMS IN
Risk Factors: LABOR AND BIRTH
1. gestational age under 40 weeks 1. Induction of labor – done when labor
2. abnormality in the fetus such as anencephaly, contractions are ineffective -means that labor is
hydrocephalus started artificially
3. hydramnios (allows for free fetal movement)
4. congenital anomaly of the uterus Indications;
5. multiple gestation

Signs and Symptoms;

1. Fetal heart sounds usually heard high in the

abdomen (URQ, ULQ)
2. fetal distress

Diagnosis; Leopold’s maneuver, vaginal exams and

ultrasounds will reveal breech presentations

Nursing Management;

30 | N I N I N
MCHN / 2nd Sem ORTIZ

1. pre-eclampsia Nursing Considerations;

2. eclampsia
3. severe hypertension/DM 1. Place women in flat position to prevent leakage
4. Rh sensitization of medication
5. prolong rupture of membranes 2. the woman remains on bed rest for 1 to 2 hours
6. post maturity and is monitored for uterine contractions
3. monitor FHR continuously for at least 30
Requirements for labor induction; minutes after each application up to 2 hours
4. IV line with saline is initiated in case uterine
1. fetus must be in longitudinal lie  hyperstimulation occurs such as contractions
2. cervix must be ripe longer than 90 seconds or more than 5
3. presenting part must be engaged contraction in 10 minutes
4. No CPD 5. explain the side effects – vomiting, fever,
5. fetus is matured by date, LS ratio or sonogram diarrhea and hypertension
(bi-parietal diameter) 6. oxytocin induction can be started 6-12 hours
after the last prostaglandin dose
Pharmacological Methods:
2. Induction of Labor by Oxytocin – a synthetic
1. Cervical Ripening – softening of the form of pituitary hormone initiates contractions
cervix/consistency in uterus
- is the FIRST STEP the uterus must complete
Nursing Considerations;
in early labor -necessary for dilatation and
uterine contractions 1. Given IV (to hasten effect), IV form of
oxytocin needs to be diluted
2. the drug is traditionally mixed in the
proportion of 10 IU in 1000ml of Ringer’s
Lactated (LR)
Criteria: 3. Administer the medication by piggyback attach
to D5W as the main IV line (if oxytocin needs
 Scoring of cervix for readiness in elective
to be discontinued, the main line will be
conductions (if the scale is 8 or above, the
maintain)
woman is considered ready for birth and
4. when cervical dilatations reaches 4 cm,
induction)
artificial rupture of membranes is performed to
Prostaglandin Gel – commonly used method of further induce labor and oxytocin infusion is
discontinued
5. Monitor FHR/uterine contractions and cervical
dilatation during the procedure
6. side –effects: extreme hypotension due to
peripheral vasodilatation, headache, vomiting
7. monitor VS every 15 minutes
8. complications to watch; fetal distress and
uterine rupture

ANOMALIES OF THE PLACENTA AND

CORD;’
1. Anomalies of the placenta
A. Placenta Succenturiata – has one or more
accessory lobes connected to the main placenta
by blood vessels
- no fetal abnormality associated with it
speeding cervical ripening and is applied to the - can lead to maternal hemorrhage (small lobes
inferior surface of the cervix retain in the uterus after birth)

- applied before labor induction B. Placenta

Circumvallata – fetal
- can also be applied on the external surface by side of the placenta
applying the gel to the diaphragm then placing the is covered with
diaphragm against the cervix chorion (normally,
no chorion covers
- apply every 6 hours for 2-3 doses the fetal side of the
placenta)

31 | N I N I N
MCHN / 2nd Sem ORTIZ

- no abnormalities is associated with this types of Conditions that increase risk for PP hemorrhage:
placental anomaly
1. Over distension of the uterus
C. Battle–dore Placenta – the cord is inserted marginally  Multiple births
rather than centrally - rare/unknown clinical significance  Hydramnios
 Macrosomia
D. Velamentous Insertion of the Cord – situation in
2. Trauma r/t forceps, uterine manipulation
which the cord instead of entering the placenta directly,
3. Prolonged labor
separated into small vessels that reach the placenta by
4. Uterine infection
spreading across a fold of amnion
5. Trauma removing placenta

Causes of Postpartum hemorrhage

1. Uterine Atony:
 Uterus without tone or lack of
normal muscle tone (90% of cases)
 uterine atony allows blood vessels at
the placenta site to bleed freely and
usually massively.
 uterine muscle unable to contract
around blood vessels at placental site

Risk Factors:

1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion
Postpartum Complications
Symptoms:
1. Postpartum hemorrhage
– major cause of maternal death, occurs in 4% 1. uterus is difficult to feel and is boggy (soft)
of deliveries 2. lochia is increased and may have large blood
- defined as blood loss greater than 500 ml clots
after vaginal birth or 1000 ml after CS 3. Blood may “gush” or come out slowly

Classifications:

According to severity: Nursing Management:

a. Mild – 750 – 1250 ml 1. Massage the uterus until firm

2. have mother to urinate or catheterize because
b. Moderate – 1250 – 1750 ml bladder distension pushes the uterus upward or
in the side and interferes with the ability of the
c. Severe – 2500 ml
uterus to contract
3. Encourage mother to breastfeed because
According to time:
sucking stimulation causes the release of
1. Early Postpartum hemorrhage – occurs within
oxytocin from PPG
24 hours of birth
4. Administration of IV oxytocin or
2. Late postpartum hemorrhage – occurs after 24
Methylergonovine (Methergine) to control
hours until 6 weeks after birth
uterine atony
Major Risk: Hypovolemic Shock (low volume) 5. Hysterectomy is performed to remove the
bleeding uterus that does not respond to other
 - occurs when the circulating blood volume is measures
decreased which interrupts blood flow to body
cells
 - manifested as:
2. Lacerations
a. Tachycardia (first sign)
 tearing of the birth canal
b. hypotension
 normally occurs as a result of child
c. cold and clammy skin
bearing
d. mental changes such as anxiety,
confusion, restleness Risk factors:
e. decrease urine output
a. difficult or precipitate births

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b. primigravidas
c. birth of a large infant
d. use of a lithotomy position and instruments Signs and Symptoms:
(forceps)
1. if Large fragments
Sites of lacerations: - Patient bleeds immediately at delivery
- Uterus is boggy
1. Cervical Lacerations 2. if Small fragments
 characterized by gushes of bright red
blood from the vaginal opening if - bleeding occurs at 6th – 10th day PP
uterine artery is torn
- Can cause subinvolution
 difficult to repair because the
bleeding may be so intense that it can Management:
obstruct visualization of the area.
2. Vaginal Lacerations 1. Dilatation and Curettage (D&C) will be
 rare case but easier to assess performed to remove placental fragments and
 oozing of blood after repair, vaginal to stop bleeding
packing is necessary to maintain 2. administration of Methotrexate to destroy the
pressure from the suture line retained placental tissue
 catheterize the mother because 3. instruct the mother to observe the color of
packing causes pressure on urethra lochia discharge
 packing is removed after 24-48 hours 4. check the completeness of the placenta after
(at risk for infection) birth
3. Perineal Lacerations
4.Disseminated Intravascular Coagulation (DIC)
 usually occurs when mother is placed
on lithotomy positions (increases  deficiency in clotting ability caused
pressure on perineum) by vascular injury characterized by
bleeding the IV sites, nose, gums etc.
Classifications:
Associative Factors:
a. First Degree – vaginal mucous membranes and
skin of the perineum to the fourchette a. premature separation of the placenta
b. Second Degree – vagina, perineal skin, fascia b. missed early miscarriage
and perineal body c. fetal death in utero
c. Third Degree – entire perineum and reaches the
external sphincter of the rectum
d. Fourth Degree – entire perineum, rectal
sphincter and some of the mucous membrane 5.Perineal Hematoma
of the rectum
 is a collection of blood in the
Management (Perineal) subcutaneous layer tissue of the
perineum caused by injury to blood
1. sutured and treated using episiotomy repair vessels after birth
2. diet high in carbohydrate and a stool softener is
prescribed for the first week postpartum to Risk Factors:
prevent constipation which could break the
a. rapid spontaneous birth
sutures
b. perineal varicosities
3. do not take rectal temperatures because the
c. episiotomy or laceration repair sites
hard tips of equipment could open sutures

3.Retained Placental Fragments

Signs and Symptoms:
 placenta does not deliver its entire
fragments and left behind leading to 1. severe pain in the perineal area
uterine bleeding 2. feeling of pressure between the legs
3. purplish discoloration/swelling on perineum
Causes:
4. concealed bleeding
a. Placenta Succenturiata –a placenta with
Management:
accessory lobe
b. Placenta Accreta – a placenta that fuses with 1. assess the size by measuring it in centimeters
myometrium because of an abnormal basalis 2. administer a mild analgesic as pain relief
layer 3. apply an ice pack (covered by towel to prevent
thermal injury to the skin)

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4. incision and drainage of the site of hematoma 2. chills, loss of appetite and general body
and is packed with gauze malaise
3. uterine tenderness
Puerperal Infection 4. foul smelling lochia
 Infection of the reproductive tract associated Management:
with giving birth
 Usually occurs within 10 days of birth 1. ATBC administration
 Another leading cause of maternal death 2. oxytocin is given to encourage uterine
contraction
Predisposing factors: 3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after
a. Prolonged rupture of membranes (>24 hours) pains and abdominal discomforts
b. C-section 5. encourage client to ambulate or in Fowler’s
c. Trauma during birth process position to promote lochia drainage and
d. Maternal anemia prevent pooling of infected secretions
e. Retained placental fragments 6. IV therapy
Infection may be localized or systemic : Perineal Infection
a. Local infection can spread to peritoneum
 localized infection of the suture line from an
(peritonitis) or circulatory system (septicemia).
episiotomy site
b. Fatal to woman already stressed with childbirth
Signs and Symptoms:
Assessment findings:
1. feeling of heat, pain and pressure on the suture
1. Temp of 100.4 for more than 2 consecutive
line
days, excluding the first 24 hours.
2. 1 or 2 stitches are sloughed away
2. Abdominal, perineal, or pelvic pain
3. purulent discharges on suture lines
3. Foul-smelling vaginal discharge
4. Burning sensation with urination Management:
5. Chills, malaise
6. Rapid pulse and respirations 1. removal of perineal sutures to open and allow
7. Elevated WBC, positive culture and sensitivity for drainage
(Remember, 20-25,000 is normal after delivery 2. Topical, systemic ATBC as ordered
—MASKING infection) 3. Analgesic to alleviate discomfort
4. Provide Sitz bath or warm compress to hasten
Nursing interventions drainage and cleanse the area
5. Remind the mother to change perineal pads
1. Force fluids; may need more than 3L/day
frequently to prevent contamination/infection
2. Administer antibiotics after culture and
6. Teach proper perineal care wiping from front
sensitivity of the organism (Group B
to back after bowel movement (to prevent
streptococci and E. Coli) and other meds as
bringing the feces to the healing area)
ordered
3. ]Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote
drainage and prevent reflux higher into
reproductive tract
6. Use of sterile equipments on birth canal during
labor, birth and postpartum
7. Educate the mother about proper perineal care
including wiping from front to back

Endometritis

 refers to the infection of the endometrium, the

lining of the uterus at the time of birth or
during Postpartal period

Signs and Symptoms:

1. fever on the third or fourth day

postpartum(increase in oral temperature above
38C for 2 consecutive 24 hour periods,
excluding the first 24 hours period after birth)

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