NCM 109
Reviewer 2
3-Genitourinary Infection
Urinary Tract Infection
 The short urethra (4.8-5.1 cm in length) provides a ready
pathway for invasion of organisms. The closure of the
urethra at the end of micturition may return
contaminated urine (bacteria) to the bladder. If left
untreated, it can cause PTL (Preterm Labor); Sexual
Activity > UTI
 The single most important HOST factor is URINARY
STASIS (stopping urine)
 Urinary retention = multiplication of bacteria = UTI
 Caused by:
o E. Coli (Pathogenic; found in lower intestines;
caused by poor hygiene)
o Klebsiella (Gram negative bacteria; found
everywhere; spread thru person-to-person contact)
o Proteus (Found in the human digestive system;
spread thru contact with infected person or any
contaminated object/surface; can move easily to
the affected area)
 Dx Test:
o U/A (+Bacteria in urine cx)
 Mid-stream urine collection means you don't
collect the first or last part of urine that comes
out; to reduce the risk of the sample being
contaminated with bacteria
 Normal urinalysis (U/A) result: No bacteria
present in the urine, WBC is ≤2-5 WBCs/hpf,
Color – Yellow (light/pale to dark/deep amber)
 Abnormal U/A result: Concentrated urine, tea-
colored
 Presence of WBC indicates infection; infection
= inflamed /contaminated bladder
 Urine Culture (cx): Detects the specific bacteria
that caused the UTI
 NOTE: Filipinos are at risk for antibiotic
resistance therefore, it is imperative to comply
to this test to determine the specific bacteria
and administer the RIGHT ANTIBIOTICS
 S/Sx:
o Dysuria, suprapubic discomfort, scanty urine output
(<400 mL/day--lack of urine production because of
the inflammation), urinary frequency, hematuria (if
WBC count is elevated, it will irritate bladder
resulting to blood in urine), fever
 What to do:
o Avoid straining; do not delay urination
 Classifications:
o Bacteriuria – presence of bacteria in urine
o Asymptomatic Bacteriuria – significant bacteriuria
(more than 100,000 colony-forming units) with no
evidence of clinical infection
Stepanie Bryn Agustero
BSN 2A
02/24/23
o Symptomatic Bacteriuria – bacteriuria accompanied
by physical signs of UTI (s/sx manifestations)
o Recurrent UTI – repeated episode of bacteriuria or
symptomatic UTI
o Persistent UTI – persistence of bacteriuria despite
antibiotic treatment
o Febrile UTI – bacteriuria accompanied by fever and
other physical signs of UTI; with seizures, high grade
fever
o Cystitis – inflammation of the bladder (dysuria,
urgency, frequency, low grade fever); also known as
honeymoonitis/honeymoon cystitis (term often
used when you get cystitis after sex); upper portion
of bladder is affected; severe infection
o Urethritis – inflammation of the urethra
o Pyelonephritis – inflammation of the upper urinary
tract and kidneys (chills, fever, flank pain, dysuria,
low UO, elev. BP, N/V)
o Urosepsis – febrile UTI coexisting with systemic
signs of bacterial illness; blood culture reveals
presence of urinary pathogen; affects nearby organs
 Preventive Measures:
o Perineal hygiene
 Females: q4h change of sanitary pads, Vaginal
wash q8h, daily bath
 More moisture = more bacterial load
o Avoid tight clothing or diapers (wear cotton panties,
rather than nylon)
o Avoid 'holding' urine; encourage to void frequently
o Empty bladder completely with each void
o Avoid straining during defecation and avoid
constipation (simple exercise to defecate faster)
o Encourage generous fluid intake (8-12 glasses/day)
o SAFE MEDS DURING PREGNANCY: Bactrim
(flouroquinolone); small risk for birth defects;
helpful to the mother has UTI in 1st Trimester
o UTI can increase risk of PTL
Sexually Transmitted Diseases
 Monilial Vaginal Infection (Candidiasis, Monilia, or
Vaginal Yeast Infection)
o Caused by an overgrowth of a fungus that naturally
lives in the vagina called Candida albicans
o S/Sx:
 Thick white curdy discharge, severe itching,
dysuria, vaginal itching, pain with sex, redness
around the vagina
o Dx Test:
 Wet Mount (Vaginal smear or wet prep)
 Test to detect an infection of the vagina
 To determine what fungus caused the
infection
 NCM 109
Reviewer 2
 Wear PPE to avoid contamination of the
sample or cross-contamination bet.
sample and the examiner
 Test result: Hyphae (fungal growth) Budding
yeast
o Risk Factors:
 HIV, DM, Pregnancy, Stress; and
 Antibiotic Treatment – can cause an imbalance
in the natural vaginal flora (lactic acid --->
inhibits the growth of fungus)
o Treatment:
 Antifungal suppository (Miconazole) @HS for
1 week
 Oral antifungal Fluconazole (Diflucan)
o Health Teaching:
 Yogurt in diet (Has lactobacillus content;
antimicrobial property)
 No douching (Douching is washing or cleaning
out the inside of the vagina with water or
other mixtures of fluids)
 Cotton underwear (for free flow of air; no
moisture)
 Teach the couple, not only the infected
partner
o NOTE: Fetus may contact thrush during
delivery/treatment of baby with oral Nystatin 1cc
q6h
 Bacterial Vaginosis (BV, Gardnerella Vaginalis, Vaginitis)
o Overgrowth of bacteria naturally found in the
vagina (normal vaginal flora); Transmitted thru
sexual contact; loss of protective lactobacilli
bacteria
o Risk Factors:
 Douching, new or multiple sex partners,
antibiotics, using an intrauterine device (e.g.
IUD, tampons)
o S/Sx:
 Thin-watery vaginal discharge with fishy odor
(vaginal pH>5)
 Normal vaginal pH: 4.5
o Dx Test:
 Whiff Test
 Performed by adding a small amount of
potassium hydroxide to a microscopic
slide containing the vaginal discharge
o Treatment:
 Flagyl (Metronidazole 500 mg BID x 7days)
(oral or IV)
 Causative agent will resist if you will not
complete or continue the medication regimen
(antibiotic resistance)
o Risk for PTL and PROM
 Trichomoniasis/Trich (Trichomonas Vaginalis)
o A very common STD/STI caused by protozoan
parasite Trichomonas Vaginalis
o S/Sx:
 70% of the infected population don’t have sx
when infected
 When Sx occur, they typically begin after 5-28
days after exposure
 Thin-greenish-yellow foamy or frothy foul-
smelling vaginal discharge in women and no
symptoms in men, itching in the genital area,
burning with urination, pain with sex
o Dx Test:
 Microbiological culture or microbial culture
 Method of multiplying the
microorganisms by letting the collected
sample reproduce in a predetermined
culture or medium; to detect the specific
causative agent
o Treatment:
 Metronidazole (Safe in pregnancy)
o Risk for PTL and PROM
 Chlamydia
o The most common STD
o Caused by Bacterium Chlamydia Trachomatis
o Can be transmitted during vaginal, anal, or oral sex;
can be transmitted to infected mother to newborn
during childbirth; the greater the number of sex
partners, the greater the risk of infection
o Can cause PID and infertility by blocking the tubes
o Hydrosalpinx – blocked fallopian tubes that may
make it difficult for you to become pregnant
o If there's an infection;
 Greater risk for infertility
 they can also develop scar formations
surrounding the fallopian tube that makes it
difficult to pick up eggs during ovulation
 Risk for Ectopic pregnancy (occurs when a
fertilized egg implants and grows outside the
main cavity of the uterus) or tubal pregnancy
(most common ectopic pregnancy that occurs
in the fallopian tube)
o S/Sx:
 Often asymptomatic; often appears within 1-3
weeks after exposure
 thin-purulent discharge; burning and
frequency with urination; lower Abd'l. pain
o Dx Test:
 Nucleic Acid Amplification Test (NAAT)
 technique used to detect a particular
nucleic acid sequence

Stepanie Bryn Agustero

BSN 2A
02/24/23
 NCM 109
Reviewer 2
 detects and identifies a particular species
or sub-species of an organism
 oftentimes, virus or bacteria are the
pathogens present in the blood, tissues,
and urine
 Enzyme-linked Immunosorbent Assay (ELISA)
 A serologic test (identifies the specific
antibody present in the serum)
 Enzyme is linked to a specific antibody to
detect the presence of protein; if protein
is present in the sample, it is definitive
that chlamydia is positive
o Treatment:
 Azithromycin 1g single dose (Safe in
pregnancy)
 Potent medication
 Function is to clear the infection by
preventing bacteria from producing the
protein that is essential for the bacteria
to survive; prevents the causative agent
to multiply
 Both the couple should be treated; they
should be instructed to abstain from
sexual intercourse until they have
completed the treatment (re-infection if
they will not abstain or not complete the
regimen)
 Having multiple infection increases the
risk for infertility
 More infection or re-infection -> more
scarring -> more chance to block the FT ->
female cant ovulate well = infertility
 Doxycycline 2 caps a day for 1 week
o Complications:
 NB Conjunctivitis (Erythromycin ointment)
 Also known as Pink Eye
 Inflammation of outer eye of the
newborn
 Blocked tear duct; eyelids becomes puffy
with lots of rheum (muta); drainage from
canthus (either corner of the eye where
the upper and lower eyelids meet) excess
tears can develop pus ( thick yellowish or
greenish opaque liquid that oozes out of
the infected tissue)
 Can develop 1 day-2 weeks after birth
 Neonatal Pneumonia
 Cause: NB ingests bacteria during birth; if
left untreated, whole respiratory can be
affected leading to distress of NB
 PTL/Fetal death
o NOTE: Perinatal transmission occurs in 50% infants
where mom is infected @ time of delivery
Stepanie Bryn Agustero
BSN 2A
02/24/23
 Gonorrhea
o A bacterial STI caused Neisseria Gonorrhea
o Can lead to PID > infertility
o Often asymptomatic in females with green-frothy
discharge; males have burning sensation with
urination and penile discharges (sira)
o Dx Test:
 Vaginal or urine cx (DOH notifies partners)
o Treatment:
 Rocephin IM (Ceftriaxone)
 Buttocks for faster absorption and effect
 Zithromax (Azithromycin) 1g SD
o S/Sx:
 Patient manifests cramping, fever, chills,
purulent discharge (heavy discharge and pus
formation), N/V, uterine swelling, adnexal and
cervical tenderness (when performing IPPA)
 Severe manifestations compared to other STDs
o NOTE: Multiple sex partners with no condoms
should also be treated
 Drugs of Choice (DOC): Doxycycline P.O. (for
non-pregnant)
 DOC: Rocephin IM, Clindamycin, Gentamycin
(for pregnant)
 May need hospitalization
 Herpes (Herpes Simplex Virus)
o Viral infection
o HSV 1 – oral outer lesion (Cold Sore)
o HSV 2 – genital (painful, open lesions)
o S/Sx:
 Blisters that break open and form small ulcers
 Small pocket of body fluids or pus/blood
formation
 Appearance small bubbles bet. the layer
of the skin that contains water /blood
 Caused by infection
 Fever, swollen lymph nodes (vesicles rupture
& appear right after exposure or within 20
days), burning sensation with urination (1st
sign)
 Tingling sensation occurs before new outbreak
(outbreak several times/year)
o Dx Test:
 Viral culture test
 NAAT of a sample skin, crust, or fluid from a le
sion
o Treatment:
 Anti-viral Meds: Acyclovir or Valtrex 500 mg
OD; during pregnancy, reduces viral load
enough to deliver vaginally
 Hygiene is important
 Syphilis (Treponema Pallidum - Spirochete)
 NCM 109
Reviewer 2
o Bacterial STI: causative agent is Treponema
Pallidum
o Also known as great imitator because it imitates
similar symptoms of other diseases; can't be easily
detected without aid of Dx test
o Stages:
 Primary Stage:
 Small painless sores (chancre/skin ulcer)
1-2cm in diameter, approx. 2-3 weeks
initial exposure
 fever
 malaise
 Secondary Stage:
 6 weeks-6 months
 A diffuse rash occurs, which frequently
involves the palm of the hands and soles
of the feet, there may also be sores in the
mouth or vagina
 Latent Stage:
 Can last for years
 Few or no symptoms
 Tertiary Stage:
 Gumma – a soft, tumor-like growth of the
tissues (granuloma) that occurs in people
with syphilis
 Infection ascends from genital area to the
point of affecting the CNS
 Neurological problems --> Neurosyphilis
 Heart symptoms
o Congenital Syphilis
 Transmitted during pregnancy or during birth
 Enlargement of the liver and spleen
(hepatosplenomegaly: life threatening), rash,
fever, neurosyphilis, and lung inflammation
 Enlargement of liver – hepatomegaly
 Enlargement of spleen – splenomegaly
o Dx Test:
 Venereal Disease Research Laboratory (VDRL)
 Rapid Plasma Reagin (RPR) Tests
o Treatment:
 Syphilis is curable with the right
antibiotic/right medication regimen
 Can be cured but the damage in the genital
will not be totally repaired
 <1yr. 2.4 million units Benzathine Penicillin x 1
dose
 IM, right & left buttocks (2 doses)
 1 vial = 600 000 units (4 vials in total is
needed)
 2 vials for each side of buttocks
 >1yr. Same medication 1x/week for 3 weeks
 Treat both the couple
o NOTE: Sexual partners screened and treated
Stepanie Bryn Agustero
BSN 2A
02/24/23
 DOC: Ceftriaxone (1st Trimester)
 40% chance of stillbirth or death; infant may
be born with congenital syphilis or
Ophthalmia neonatorum that causes
blindness (appears as Conjunctivitis in NB)
 Give baby Penicillin (PCN) everyday x 10 days
 Genital Warts
o Condyloma, Condylomata Acuminata, Venereal
Warts, Anal warts, Anogenital Warts
o STI caused by certain types of Human
Papillomavirus (HPV)
o Spread thru direct skin-to-skin contact, usually
during oral, genital, or anal sex with infected
partner
o Contact occurs during vaginal birth (infant may have
laryngeal warts)
o Sx:
 Skin lesion that is generally pink and project
outward
 Usual onset: 1-8 months ff. exposure
o Dx Method:
 Based on symptoms, can be confirmed by
biopsy (obtain sample, the warts itself)
remove small amount of tissue and will be
examined under the microscope
 Gynecologic examination using speculum to
magnify the internal organ
 Colposcopy – a procedure to closely examine
your cervix, vagina and vulva for signs of
disease; use of lighted speculum to view the
gynecologic organ
o Prevention:
 HPV Vaccine
 40 types of HPV that can affect the
genital area
 Usually, 3 doses
 1st dose: on or before 15th birthday
 2nd dose: 1-2 months from 1st dose
 3rd dose: 6 months from 1st dose
 Done via routine vaccination if 13-26 y/o
(sexually active young adults bracket)
 Most effective not yet sexually active at 9
y/o
 Condoms
o Treatment:
 Cryotherapy – medical therapy using extreme
cold to freeze and remove abnormal tissue;
cryoablation (A procedure in which an
extremely cold liquid or an instrument called a
cryoprobe is used to freeze and destroy
abnormal tissue)
 Trichloroacetic Acid – act by inflicting burn to
the warts
 NCM 109
Reviewer 2
 Gardasil Vaccine (3 doses) – The HPV vaccine; incompetent cervix, exposure to radiation, &
Initial dose at age ≥ 15 years: A 3-dose series is infection)
given at 0, 1 to 2 months, and 6 months  If exposed to radiation, wear protective suits;
loose-fitting apparel (e.g. satin or silk) can be
Preventing Sexually Transmitted Diseases effective to protect the person since it reflects
(STDs) the radiation
 Consider that not having sex is the only sure way to  Types of Abortion:
prevent STD (abstain from all intimate contact) o Missed Abortion
 Only have sex within a mutually monogamous  Retention of all products of conception after
relationship the death of the fetus in the uterus
 Make all sex safer sex by use of condom  No FHT
 Consider vaccination  Signs of pregnancy disappear
o Inevitable Abortion
Bleeding Disorders of Pregnancy  The loss of the products of conception cannot
 Bleeding d/o according to: be prevented
o 1st Trimester Bleeding  Moderate to profuse bleeding, moderate to
 Abortion severe uterine cramping
 Ectopic Pregnancy  Open cervix – can't hold the developing fetus
o 2nd Trimester Bleeding  Rupture of Membrane
 Hydatidiform Mole o Septic Abortion
 Incompetent Cervix  Abortion complicated by infection
o 3rd Trimester Bleeding  Foul smelling vaginal discharge
 Placenta Previa  Uterine cramping
 Abruptio Placenta  Fever in relation to the infection
 Common Terms: o Habitual Abortion
o Abortion – most common bleeding d/o of early  Abortion occurring in 3 or more successive
pregnancy; termination of pregnancy before pregnancies
viability (before 20 weeks)  Most common cause is a significant genetic
o Abortus – a fetus that is aborted before it is 500g in abnormality of the conceptus (fertilized egg)
weight (23 week of pregnancy); Fetus normally o Threatened Abortion
reaches 3500-3800g (41-42 weeks)  Possible loss of product of conception
o Blighted Ovum – a small macerated fetus,  If there is threatened abortion, the OB-GYN
sometimes there is no fetus surrounded by a fluid will prescribe tocolytic agents (designed to
inside the sac inhibit contractions to avoid miscarriage; e.g.
o Maceration – a dead fetus undergoing necrosis Magnesium Sulfate, Terbutaline, Nifedipine
(decay); change in the skin of the fetus due to the which are calcium ion antagonists)
loss of vernix caseosa, skin will peel off  Light vaginal bleeding
o Early Abortion – termination of pregnancy before 16  None to mild uterine cramping
weeks (avocado-sized: 4.6 inches)  Vaginal exam at this stage usually reveals a
o Late abortion – abortion that occurs between 16-20 closed cervix (25%-50% results in loss of
weeks pregnancies)
 Fetal Causes of Abortion:  Complete bed rest, provide commode
o Most common cause of early spontaneous abortion o Incomplete Abortion
is abnormal development of zygote, embryo, and  Expulsion of some parts & retention of other
fetus parts of conceptus in uterus
o These abnormalities are incompatible with life and  Needs a dilation and curettage procedure, also
would have resulted to severe congenital called a D&C to expel retained body parts
anomalies if pregnancy has not been aborted  Medications: Misoprostol & Mifepristone via
 Maternal Causes of Abortion: vagina
o Congenital or acquired conditions of the mother &  Heavy vaginal bleeding
environmental factor that had adversely affected  Severe uterine cramping
the pregnancy outcome & led to abortion (e.g. DM,  Open cervix
 Passage of tissue

Stepanie Bryn Agustero

BSN 2A
02/24/23
 NCM 109
Reviewer 2
o Complete Abortion
 Spontaneous expulsion of the products of
conception after the fetus has died in the
utero
 Light bleeding, mild uterine cramping, passage
of tissue, closed cervix
 Close watch: risk for excess bleeding
 Development of Abortion
 Nursing Responsibilities
o Save all tissue passed (histopathology
exam)
o Strict Bed Rest (SBR), provide bedside
commode, & monitor bleeding q4h to check
if there's an active bleeding or not
o Increased oral fluid or IV solution as
ordered
 Excessive bleeding: Plain LR
(isotonic solution, same
concentration of our bodily fluids)
o Prepare client for surgical intervention (D&C
or suction evacuation) if needed
o Maternal Sepsis if procedure is not
performed
4-Multiple Pregnancy
Definition of Terms
 Multiple pregnancy – occurs when more than one fetus
simultaneously develop in the uterus
 Twin pregnancy – simultaneous development of two
fetuses
 Although rare, development of three fetus (triplets), four
(quadruplets), five (quintuplets), six (sextuplets) may
also occur
Twin Pregnancy
 Most common variety of multiple pregnancy
 Two types:
o Dizygotic Twins (80%) – results from fertilization of
two ova leading to fraternal twin
o Monozygotic Twins (20%) – results from fertilization
of one ova leading to identical twin
 Risk Factors:
o Increasing maternal age (30-35 y/o)
 30 is the ideal maternal age since it is the time
when egg production is good quality
o Increasing parity (5 gravida onwards)
o Nutritional factors
 Increased CHON, Folic Acid, Iron, Low-Fat Low-
Salt
o Pituitary gonadotropin
o Infertility therapy
 30-35 eggs/day for adults
 AMA – 100 to 150/year
o Assisted reproductive therapy
o Genetic, hereditary
o Race, b>w
 Caucasians have higher chance of multiple
pregnancy
 Dizygotic Twins
o Heteropaternal superfecundation – Phenomenon of
having two different fathers for twins
o Results from fertilization of two ova, most likely
rupture from two distinct graafian follicles usually
the same or one from each ovary, by two sperms
during single ovarian cycle
o There are two placentae either completely
separated or more commonly fused at the margin
o Each fetus is surrounded by a separate amnion and
chorion
o Sex of the fetus may differ
o Genetic features, blood group, finger prints also
differs
o The earlier splitting of the single zygote occurs, the
more independently the twins will develop
o Most common; represents 2/3 of cases
o Fertilization of more than one egg by more than one
sperm
o Nonidentical, may be of different sex
o Two chorion, two amnion
o Fetus Papyraceous – is when intrauterine fetal
demise of a twin occurs early in pregnancy
 Monozygotic Twins
o The twinning may occur at different periods after
fertilization
o Constant incidence of 1:250 births
o Not affected by heredity
o Not related to induction of ovulation
o Constitutes 1/3 of twins
o 70% are Diamniotic monochorionic
o 30% are Diamniotic dichorionic
o Division of fertilized egg:
 0-72 hrs –> Diamniotic dichorionic
 4-8 days –> Diamniotic monochorionic

Stepanie Bryn Agustero

BSN 2A
02/24/23
 NCM 109
Reviewer 2
 9-12 days –> Monoamniotic monochorionic  Increased minor disorders of pregnancy
 >12 days –> Conjoined Twins (e.g. back ache, leg pain, inability to walk
o Conjoint Twins properly, hemorrhoids, palpitations,
 Anterior (Thoracopagus) dyspnea, and varicosities)
 Posterior (Pygopagus)  Anemia and placenta previa
 Cephalic (Craniopagus)  Preterm Labor and delivery (PTL)
 Caudal (Ischiopagus)  Risk of hypertensive disease
 Diagnosis of Twins Pregnancy  Antepartum Hemorrhage (APH)
o History:  During Labor:
 History of ovulation inducing drugs  PROM
 ART and FD  Cord prolapse – when the umbilical cord
 Family history of twinning (maternal side) comes out of the uterus with or before
o Sx: the presenting part of the baby
 Minor ailments of normal pregnancy are  Prolonged Labor
often exaggerated. Some of the symptoms are  Increased OP Interference
related to the undue enlargement of uterus  Bleeding (intrapartum) – IPH
 Increased N/V in early months  PPH
 HCG – hormone  During Puerperium:
that triggers N/V  Subinvolution – a medical condition in
and cravings which after childbirth, the uterus does
 Cardiorespiratory embarrassment not return to its normal size
(palpitations and shortness of breath)  Increased risks of infections
 Tendency of swelling legs, varicose veins,  Lactation failure
and hemorrhoids is greater o Fetus
 Unusual rate of abdominal enlargement  Stillbirth/neonatal death
and excessive fetal movement may be  Abortion
noticed  Single fetal death in twin pregnancy
o General Examination:  Intrauterine Growth Restriction (IUGR)
 Increased prevalence of anemia  Small for Gestational Age (SGA)
 Check capillary refill  Higher risks of congenital anomalies
 Pale conjunctiva and lips  Death of one Fetus
 Unusual weight gain not explained by  Prognosis of the surviving twin depends
preeclampsia or obesity on the gestational age at the time of the
 Evidence of preeclampsia is a common demise, the chorionicity, and the length
association of time between the demise and delivery
o Abdominal Examination: of surviving twin
 Elongated shape of normal pregnant uterus is  Early demise such as vanishing twin does
changed to a more barrel shape and the not appear to increase the risk of death in
abdomen is unduly enlarged the surviving fetus after the first
 Height of the uterus is more than the gestation trimester
age  Management
 Fetal bulk seems disproportionally larger in o Antenatal Management
relation to the size of fetal head  Diet about 350 kcal/day
 Palpation of too many fetal parts  Increased rest at home and early cessation of
 Finding two fetal heads work
 Two distinct fetal heart sounds at separate  Increased number of antenatal visit
spots with a silent area in between  Supplementally therapy Fe increase 100-
 Complications of Twin Pregnancy 200mg/day, vitamins, calcium, and folic acids
o Maternal o During Labor
 During Pregnancy:  Vaginal delivery – both or at least one baby in
 Exaggerated early symptoms vertex presentation
 Increased miscarriage risk  Bed rest – prevent early rupture of membrane
 Malpresentation  Electronic Fetal monitoring

Stepanie Bryn Agustero

BSN 2A
02/24/23
 NCM 109
Reviewer 2
 Internal examination should be done soon
after the rupture of membrane to exclude cord
prolapse
 Ringer’s Lactate and 1 unit for BT ready
 Delivery of Twin Fetuses
o Vertex-vertex (50%) – vaginal delivery, interval
between twins not to exceed 20 minutes
o Vertex-Breech (20%) – vaginal delivery by senior
obstetrician
o Breech-Vertex (20%) – safer to deliver by CS to
avoid the rare interlocking twins (1:1000 twins)
o Breech-Breech (10%) – usually by CS
 Vaginal Delivery
o When the first twin is cephalic, delivery can usually
be accomplished spontaneously or with forceps
o As in singletons, when the first fetus presents as
breech, major problems are most likely to develop
if:
 Fetus is unusually large and the aftercoming
head is larger than the capacity of the birth
canal
 Fetus is sufficiently small so that the
extremities and trunk are delivered through a
cervix inadequately effaced and dilated to
allow the head to escape easily
 Umbilical cord prolapses
 VD of Second Twin
o If the fetal head of the breech is fixed in the birth:
 Moderate fundal pressure is applied and
membranes are ruptured.
 Digital examination of the cervix is repeated
to exclude prolapse of the cord.
 Labor is allowed to resume, and the fetal heart
rate is monitored.
 With reestablishment of labor there is no need
to hasten delivery unless a non-reassuring
fetal heart rate or bleeding develops.
 If contractions do not resume within
approximately 10 minutes, dilute oxytocin be
used to stimulate contractions
o If the occiput or the breech presents immediately
over the pelvic inlet but is not fixed in the birth
canal
 Presenting part can often be guided into the
pelvis by one hand in the vagina while a
second hand on the uterine fundus exerts
moderate pressure caudally
 Alternatively, an assistant can maneuver the
presenting part into the pelvis using
ultrasonography for guidance and to monitor
heart rate.
 It is essential to have an obstetrician skilled in
intrauterine fetal manipulation and an
Stepanie Bryn Agustero
BSN 2A
02/24/23
anesthesiologist skilled in providing anesthesia
to effectively relax the uterus for vaginal
delivery of an noncephalic second twin to
obtain a favorable outcome.
o Interval Between First and Second Twins
 The American college of obstetricians and
gynecologist (1998) has determine that the
interval between delivery of twins is not
critical in determining the outcome of the twin
delivered second.
 Cesarean Delivery
o The American College of Obstetricians and
Gynecologists (1998) has concluded that in general,
CS delivery is the method of choice when the first
twin is noncephalic.
o It is important to place the patients in a left lateral
tilt so as to deflect the uterine weight off the aorta
to avoid hypotension
o The uterine incision should be large enough to allow
a traumatic delivery of both fetuses
o It is important that the uterus remain well
contracted during completion of the cesarean
delivery and thereafter
o Remarkable blood loss may be concealed within the
uterus and vagina and beneath the drapes during
the time taken to close the incisions
o Delivery of the First Baby
 Babies are small – pose less difficulties
 Forceps delivery – if necessary, should be
under Pudendal block anesthesia, avoid
general anesthesia as the 2nd baby may be
subjected effect of prolong anesthesia
 Don’t give Ergometrine
 Leave 8-10 cm of the cord for admin of any
drugs or transfusion
o Delivery of Second Baby
 After delivery of the first; the lie, presentation,
and size of the 2nd baby is ascertained
through abdominal examination
 Perform vaginal exam to exclude cord prolapse
and ascertain membrane status
 Delivery of the second baby as required
Additional Info
 After the onset of the menstrual cycle, women release
about 1,000 immature eggs per month, about 30-35 per
day.
 NCM 109
Reviewer 2
5-Bleeding during Pregnancy o Management:
First Trimester Bleeding  If not yet ruptured, Therapeutic Abortion is
performed
 Ectopic Pregnancy
o Sites:  If ruptured, removal or repair of ruptured
tube (many physician choose to remove the
ruptured tube because the presence of scar
if the tube is repaired and left, can lead to
another tubal pregnancy)
 Prevent and treat hemorrhage which is the
main danger of EP
 Prevent infection – loss of too much blood is
susceptible to infection
 Prep client for surgery
 Institute measures to control and treat shock
if hemorrhage is severe and continue to
monitor post-op
 Allow client to express feelings about loss of
 Most frequent site is in the fallopian tube, so
pregnancy and concern about future
rupture of the site usually occurs before 12
pregnancy
weeks
o The Classic Symptom Triad:
Second Trimester Bleeding
 Amenorrhea  Hydatidiform Mole (H. Mole)
 Vaginal Bleeding o Also known as Molar Pregnancy, Gestational
 Abdominal Pain Trophoblastic Disease
o Assessment Findings o It is the growth of an abnormal fertilized egg or an
 History of missed periods & Symptoms of overgrowth of tissue from the placenta (women
Early Pregnancy appears to be pregnant) and uterus enlarges much
 Abdominal pain, may be localized on one more rapidly much more than a normal pregnancy
side o It is an alteration of early embryonic growth
 Rigid. Tender abdomen; sometimes causing placental disruption, rapid proliferation of
abnormal pelvic mass abnormal cells, and destruction of the embryo .
 Bleeding: If severe may lead to shock o Types:
 Low Hgb & Hct, rising WBC count  Complete Mole – the chromosomes are
o Signs of Hemorrhage: either 46XX or 46XY but are contributed by
 Cullen's sign – bluish discoloration of the only one parent and the chromosome
umbilicus due to the presence of blood in the material duplicated. This type usually leads
peritoneal cavity to choriocarcinoma.
 Hard rigid board like abdomen due to  Partial Mole – has 69 chromosomes. There
presence of blood in the peritoneal cavity are three chromosomes for every pair
 Signs of shock: cyanosis, pallor, cold clammy instead of two. This type of mole rarely leads
skin, rapid pulse, decreased BP to choriocarcinoma.
o Etiology:
 Unknown
o Pathophysiology
 A hydatidiform mole is a placental tumor
that develops after pregnancy has occurred;
it may be benign or malignant. The risk of
malignancy is greater with a complete mole.
 The embryo dies and the trophoblastic cells
continue to grow, forming an invasive
tumor.
 It is characterized by proliferation of
placental tissues that become edematous

Stepanie Bryn Agustero

BSN 2A
02/24/23
 NCM 109
Reviewer 2
and form grapelike clusters. The fluid-filled
vesicles grow rapidly, causing the uterus to
be larger than expected for the duration of
pregnancy.
 Blood Vessels are absent (no fetal skeleton)
o S/Sx:
 Vaginal bleeding (may contain some of the
edematous villi or tissues)
 Uterus larger than expected for the duration
of the pregnancy
 Abdominal cramping from uterine distention
 Signs and symptoms of preeclampsia before
20 weeks gestation
 Severe nausea and vomiting
o Dx:
 UTZ – reveals: no fetal skeleton,
characteristics appearance of molar growth
 hCG serum levels are abnormally high
o Management:
 D&C to remove the mole
 If the woman is >40, hysterectomy since she
has a higher chance of developing
choriocarcinoma
 Anticancer drug prescribed to the woman
for one year to prevent development of
malignant or cancer cells in the uterus
o Nursing Responsibilities/Management:
 Ensure physical well-being of the client
through accurate assessment and
interventions
 Review pertinent history and history of
this pregnancy
 Provide pre-operative care for
evacuation of uterus (usually suction
curettage)
 Induction of labor with oxytocic agents
or prostaglandins is not recommended
because of the increased risk of
hemorrhage
 Administer IV fluid as prescribed
 Provide client and family teaching
 Ensure appropriate follow-up and self-
care by explaining that frequent
possibility of recurrence of the problem
or progression to choriocarcinoma;
explain that hCG levels should be
monitored for 1 year
 Discuss the need to prevent pregnancy
for at least 1 year after diagnosis and
treatment
 Inform the client that oral (and
injectable) birth control agents are not
Stepanie Bryn Agustero
BSN 2A
02/24/23
recommended because they suppress
pituitary luteinizing hormone, which
may interfere with serum hCG
measurement
 Describe and emphasize s/sx that must
be reported (e.g., irregular vaginal
bleeding, persistent secretion from the
breast, hemoptysis, and severe
persistent headaches). These may
indicate spread of the disease to other
organs
 Address emotional and psychosocial needs
 Hyperemesis Gravidarum
o Is intractable vomiting
o Is severe N/V during pregnancy, which leads to
electrolyte, metabolic, and nutritional imbalances
in the absence of medical problems
o It occurs in 1 of every 1000 pregnancies
o Causative Factors:
 High levels of hCG in early pregnancy
 Metabolic or nutritional deficiencies
 More common on first pregnancies
 Ambivalence toward the pregnancy or family-
related stress
 Thyroid dysfunction (hyperthyroidism –
overactive thyroid)
o Pathophysiology
 Continued vomiting results in dehydration and
ultimately decreases the amount of blood and
nutrients circulated to the developing fetus
 Hospitalization may be required for severe
symptoms when the client needs IV hydration
and correction of metabolic imbalance
o Assessment Findings:
 S/Sx occur during the first 16 weeks of
pregnancy and are intractable
o Clinical Manifestations:
 Unremitting N/V (>3 episodes of vomiting/day)
 Vomitus initially containing undigested food,
bile, and mucus; later containing blood and
material that resembles coffee grounds
 Loss of weight (LOW) 5% or 3kg has occurred
 ketones are present in the uterine
o S/Sx:
 Pale, dry skin
 Rapid pulse
 Fetid, fruity breath odor from acidosis
 CNS effects such as confusion, delirium,
headache, lethargy, stupor, or coma
 N/V –> dehydration –> nutritional deficiency –>
fluid-electrolyte imbalance
 NCM 109
Reviewer 2
 Symptoms often get better after the 20th week
of pregnancy; there are also instances that it
may last the entire pregnancy
o Risk Factors:
 First preg., Multiple preg., obesity, hx of an
eating d/o
o Nursing Management:
 Promote resolution of the complication.
 Make sure that the client is NPO until
cessation of vomiting.
 Administer intravenous fluids as
prescribed;
 Measure and record fluid intake and
output.
 Encourage small frequent meals and snacks
once vomiting has subsided.
 Medical: replacement of fluids,
electrolytes, and vitamins, along with
tranquilizer or antiemetic. Administer
antiemetics for pregnancy as prescribed.
 Prochlorperazine (Compazine)
 Trimethobenzamide (Tigan)
 NPO for 48 hours; after condition improves, 6
small feedings are alternated with liquid
nourishment in small amount every 1-2 hors
 If vomiting recurs, NPO status is resumed and
administration of IV is restarted
 Address emotional and psychosocial needs.
Maintain a non-judgmental atmosphere in which
the client and family can express concerns and
resolve some of their fears.
Third Trimester Bleeding
 Placenta Previa (PP)
o It is the most common bleeding disorder of the 3rd
trimester
o The placenta implants in the lower uterine segment,
near the cervical os.
o The degree to which it covers the os leads to three
different classifications:
 Total PP – occurs when the placenta completely
covers the internal os
 Partial PP – occurs when the placenta partially
covers the internal os
 Low-lying or low implantation PP – occurs when
the placenta partially covers the placental
border
Stepanie Bryn Agustero
BSN 2A
02/24/23
o Etiology (Predisposing Factors)
 Multiparity (80% of affected clients are
multiparous)
 Multiple pregnancy
 Advance Maternal Age (over 35 y/o in 33% of
cases)
 Smoking
 Previous cesarean section and abortion
 Uterine incision
 Prior PP (incidence is 12 times greater in women
with previous PP)
o Pathophysiology
 Pathologic process seems to be related to the
conditions that alter the normal function of the
uterine decidua and its vascularization
 Bleeding, which results from tearing of the
placenta villi from the uterine wall as the lower
uterine segment contracts and dilates, can be
slight of profuse
o Assessment Findings:
 Associated Findings:
 In cases of suspected PP, a vaginal
examination is delayed until UTZ results are
available and the client is moved to the
operating room (OR) for what is termed a
double set-up procedure. The OR is needed
because the examination can cause further
tearing of the villi and hemorrhage, which
can be fatal to the client and fetus
 Common Clinical Manifestations (S/Sx):
 Bright red, painless vaginal bleeding
 Soft, nontender abdomen, relaxes between
contractions, if present
 FHR stable and within normal limits
 Laboratory and Diagnostic Study Findings
 Transabdominal utz confirms suspicion of
PP
o Placenta Previa Care
 Painless bright red bleeding
 Replace blood loss
 Evident in lower segment
 NCM 109
Reviewer 2
 Vitals indicated shock  Watchful waiting – delay delivery until fetus is
 Inspect FHR mature enough
 Avoid Vaginal Exam  No IE is performed in diagnosed PP
o Nursing Management:  Abruptio Placenta (AP)
 Ensure the physiologic well-being of the client o Is premature separation of a normally implanted
and fetus placenta after the 20th week of pregnancy, typically
 Take and record v/s, assess bleeding, and with severe hemorrhage.
maintain a perineal pad count; weigh o Usually occurs after 20 weeks of gestation and before
perineal pads before and after use to delivery of the fetus
estimate blood loss
 Observe for shock, which is characterized
by a rapid pulse, pallor, cold moist skin,
and a drop in BP
 Monitor the FHR
 Enforce strict bed rest to minimize risk to
the fetus
 Observe for additional bleeding episodes
 Maintain sterile conditions for any invasive
procedure
 Make provisions for emergency cesarean
birth
 Continue to monitor maternal/fetal vital o Etiology: unknown
signs o Risk Factors:
 Provide client and family teaching  Uterine anomalies
 Explain the condition and management  Multiparity
options. To ensure an adequate blood  Preeclampsia
supply to the mother and fetus, place the  Previous cesarean delivery
woman at bed rest in a side-lying position  Renal or vascular disease
 Anticipate the order for a sonogram to  Trauma to the abdomen
localize the placenta. If the condition of the  Previous 3rd trimester bleeding
mother or fetus deteriorates, a cesarean  Abnormally large placenta
birth will be required  Short umbilical cord
 Prepare the client for ambulation and  Maternal hypertension
discharge (may be within 48 hours of last  Advance Maternal Age
bleeding episode)  Trauma to the uterus
 Discuss the need to have transportation to  Cigarette smoking and cocaine abuse
the hospital available at times o Pathophysiology:
 Instruct the client to return to the hospital  The placenta detaches in a whole or in part from
if bleeding recurs and to avoid intercourse the implantation site. This occurs in the area of
until after birth the deciduas basalis
 Instruct client proper handwashing and o Assessment Findings:
toileting to prevent infection  Associated Findings:
 Address Emotional and Psychosocial Needs  Severe abruption placentae may produce
 Offer emotional support to facilitate the complications such as:
grieving process if need  Renal failure
 After birth of the newborn, provide  Disseminated intravascular coagulation
frequent visits with the new born that  Maternal and Fetal death
mother can be certain of the infants  Common Clinical Manifestations:
condition  Intense, localized uterine pain, with or
o Management: without vaginal bleeding
 Cesarian is the delivery of choice for all kinds of  Concealed or external dark red bleeding
placenta previa  Uterus firm to board-like, with severe
 Manage bleeding episodes continuous pain
Stepanie Bryn Agustero
BSN 2A
02/24/23
 NCM 109
Reviewer 2
 Uterine contractions  Vaginal delivery if there is no sign of fetal
 Uterine outline possibly enlarged or distress, CS if bleeding is severe and fetus can't
changing shape be delivered with vaginal method
 FHR present or absent
 Fetal presenting part may be engaged
 Board-like abdomen caused by
accumulation of blood behind the
placenta with fetal parts hard to
palpate
 Sharp pain over the fundus as the
placenta separates
 Signs of shock and fetal distress if
bleeding is severe
 Laboratory and Diagnostic Study Findings:
 UTZ may be able to identify the extent
of abruption. However, the absence of
an utz finding doesn't rule out the Additional Info
presence of abruption  Medical Terms:
o o Lavage – washing out of a body cavity, such as the
Nursing Intervention:
 Continuously evaluate maternal and fetal colon or stomach with water or a medicated solution
o Gavage – the administration of food or drugs by
physiologic status, particularly:
 Vital signs force, especially to an animal, typically through a tube
 Bleeding leading down the throat to the stomach
 Electronic fetal and maternal monitoring  An hCG level of less than 5 mIU/mL is considered
tracings negative for pregnancy, and anything above 25 mIU/mL
 Signs of shock-rapid pulse, pallor, cold and is considered positive for pregnancy. An hCG level
most skin, decrease in blood pressure between 6 and 24 mIU/mL is considered a grey area,
 Decreasing urine output and you'll likely need to be retested to see if your levels
 Never perform a vaginal or rectal examination rise to confirm a pregnancy.
or take any action that would stimulate uterine  Consume PRBC w/in 4 hours
activity.  Tramadol Ketorolac infused in D5W (?)
 Ensure bed rest  BP Reading:
o 130/80 is borderline for hypertension
 Assess the need for immediate delivery. If the
o If 1st reading 130/80, rest for 30 mins. then take 2nd
client is in active labor and bleeding cannot be
stopped with bed rest, emergency cesarean reading
o If after 2nd reading is still high, pt is considered
delivery may be indicated.
 Provide appropriate management. hypertensive
 On admission, place the woman on bed  Chemoreceptor Trigger Zone (CTZ) – A zone in the
rest in a lateral position to prevent medulla that is sensitive to certain chemical stimuli.
pressure on the vena cava. Stimulation of this zone may produce n/v.
 Insert a large gauge IV cath. into a large  Lactated Ringer's and Normal Saline Solution – used for
vein for fluid replacement. Obtain a blood fluid resuscitation in hemorrhagic shock
sample for fibrinogen level.  Lactated Ringer IV Fluid if active labor
 Monitor the FHR externally and measure  Methergine (methylergometrine) is a vasoconstrictor
maternal vital signs every 5 to 15 minutes. and often used in obstetrics to control bleeding after a
Administer oxygen to the mother by mask. delivery or spontaneous or induced abortion.
 Prepare for cesarean section, which is the  Pudendal Block – is anesthesia given in the second stage
method of choice for the birth. of labor and is used to relieve pain in the perineum area.
 Provide client and family teaching.
 Address emotional and psychosocial needs.
Outcome for the mother and fetus depends on
the extent of the separation, amount of fetal
hypoxia, and amount of bleeding.

Stepanie Bryn Agustero

BSN 2A
02/24/23