NCM 209  Leukocyte

Care of Mother, Child, and Population Group at Risk or 

with Problems 
 Rhesus Factor
PRENATAL CARE URINALYSIS
THE PURPOSE OF PRENATAL CARE IS TO ENSURE AN  Pus cells
UNCOMPLICATED PREGNANCY AND THE DELIVERY OF A 
LIVE AND HEALTHY INFANT.  Protein/albumin

BALANCE OF FORCES IN PREGNANCY
 FETAL SURVIVAL PAP SMEAR
 MATERNAL SURVIVAL ULTRASONOGRAPHY
5 Branches of Maternal Health  Transabdominal
• Nutrition
• BLOOD GLUCOSE TEST
• Safe Delivery  FBS
• 
• Family Planning 
Prenatal Care  OGCT
• Regular prenatal care increases the chances of a  2 HRS. POST PRANDIAL
healthy mother and child after birth. AMNIOCENTESIS
• Early detection of congenital & birth defects Maternal Alpha-Feto Protein
• Fetal neural tube defect:

DOH STANDARDS OF PRENATAL CARE  gastroschisis
1. WEIGHT 
2. HEIGHT DOPPLER VELOCIMETRY
3. PERCUTANEOUS UMBILICAL BLOOD SAMPLING
4. BIOPHYSICAL SCORING
5. FUNDIC HEIGHT
• 5th month = 20 cm 5 markers:
• 6th month = 21-24 cm  non stress test
• 7th month = cm  fetal breathing
• 8th month = 29-30 cm 
• 9th month = cm 
6. LEOPOLD’S MANEUVER 
BPS RESULT INTERPRETATION
8 – 10 - Normal fetus
6 -
7. TT IMMUNIZATION -
TETANUS TOXOID WHEN TO GIVE 4 - abnormal result
TT 1 ANYTIME DURING 2 - ill fetus
PREGNANCY Non Stress Test (NST)
TT 2 4 WEEKS AFTER TT 1 2 -
TT 3
TT 4 1 YEAR AFTER TT 3 1 - <2 accelerations
TT 5 per movement
0 - no acceleration
8. DIET Fetal Breathing
9. DANGER SIGNS OF PREGNANCY 2 - 1 episode/30 minutes lasting 30 seconds
10. 0 - no episode
11. FAMILY PLANNING
12.

AMNIOTIC FLUID INDEX

High Risk Mom
2 - fluid filled pocket of 1 cm or more
0 -
What is High Risk Pregnancy?
FETAL BODY MOVEMENT
poor maternal or fetal outcome due to :
2 - 3 or more discrete movement of limbs and

body in 30 minutes
 reproductive
1 -

0 - no movements

FETAL TONE
 SCREENING
2 -
Diagnostic and Laboratory Examinations
1 - slow extension with return to flexion
Complete Blood Count
0 - no movements
 Hemoglobin

HEPATITIS B DETERMINATION  FUNCTIONAL CLASSIFICATIONS OF CARDIAC
DISEASES

CONTRACTION STRESS TEST (CST)  CLASS 1 - asymptomatic

 done after 32 weeks AOG  CLASS II - symptomatic but with
FETOSCOPY normal activities
- Direct visualization of the fetus through a scope  CLASS III -
 CLASS IV -
FETAL MOVEMENT COUNTING Judgment of safety of pregnancy
- Done after 27 weeks AOG • Conception should be prevented if:
- Twice daily for 20-30 minutes 1. Severe heart disease
- 2. Functional classification: class III-IV
- 3.
4. Pulmonary hypertension
5.
MEDICAL COMPLICATIONS DURING PREGNANCY 6. Severe arrhythmia
CARDIOVASCULAR DISORDERS 7.
PREGNANCY 8.
 Increase blood volume 40 – 50% 9. Acute myocarditis
 Increase cardiac output
MANAGEMENT OF CARDIAC DISEASES
 LEFT TO RIGHT SHUNTING o termination of pregnancy by CS
 Weight reduction
 Rest


 Diuretics
NURSING CARE OF CARDIAC DISEASES
 Vital signs



 Proper nutrition
 Carry out medical orders

GESTATIONALDIABETES MELLITUS
RISK FACTORS CAUSING GDM
 Obesity
 Family history
 ATRIAL – SEPTAL DEFECT 

 asymptomatic
 Improper diet
 VENTRICULAR SEPTAL DEFECT
(PATHOPHYSIOLOGY NOT INCLUDED)
 left ventricular hypertrophy
FETAL/NEONA TAL COMPLICATIONS OF GDM

 PATENT DUCTUS ARTERIOSUS MATERNAL COMPLICATIONS OF GDM

 rare  Preeclampsia

 Infection
 RHEUMATIC HEART DISEASE 
 Group A Beta Hemolytic Streptococcus  Postpartum Bleeding

 SIGNS AND SYMTOMS OF CARDIAC DISEASES
 Shortness of breath
 Palpitations
Fasting & 2 hours postprandial venous plasma sugar
during pregnancy. ACQUIRED IMMUNODEFFICIENCY SYNDROME
 Caused by HIV
FASTING 2HRS POST RESULT  Transmitted through blood, blood products,
PRANDIAL semen, vaginal fluid, breast milk
<100 mg/dl < 145mg/ dl. Not diabetic

>125 mg/ dl >200 mg/ dl. Diabetic SYMPTOMS OF AIDS

 Extreme weakness and fatigue
ORAL GLUCOSE CHALLENGE TEST  Rapid weight loss
 fasting post midnight 
 blood and urine specimen are obtained 
 50 grams glucose intake 
 Fact or Fiction?
You can get AIDS from a mosquito bite
Prerequisites of OGTT:  Fact or Fiction?
 Normal diet for 3 days before the test. You can get AIDS by having oral sex with an infected
 No diuretics 10 days before. person
 Fact or Fiction?
CRITERIA FOR OGTT HIV survives well in the environment, so you can get it
The maximum blood glucose values during pregnancy: from toilet seats and door knobs
• fasting 90 mg/dl  Fact or Fiction?
• one hour 165 mg/dl You can get AIDS by hugging a person with HIV who is
• 2 hours 145 mg/dl sweating
• 3 hours 125 mg/dl  Fact or Fiction?
MANAGEMENT OF GDM You can get AIDS by kissing someone who is HIV
 Insulin infected
 Diet  Fact or Fiction?
 Exercise Condoms aren't really effective in preventing HIV
transmission
 Fact or Fiction?
Substance Abuse During Pregnancy There is a connection between other STDS and HIV
TERATOGEN infection
 Any agents that interferes with normal
embryonic development How A Healthy Immune System Works
ALCOHOL 
 CNS Depressant 
 Reduce Anxiety 
 Sedation How does HIV interrupt the Normal Functioning of the
 Respiratory Depressant Immune System?
ALCOHOL EFFECTS ON FETUS  HIV infects T-cell
 Fetal Alcohol Syndrome (FAS) Phases of HIV/AIDS
1. Infection
 Intrauterine Growth Restriction 2.
 Preterm Delivery 3.
4. Asymptomatic period
CNS Depressants: 5.
STIMULANTS 6. AIDS
EFFECTS OF STIMULANTS CD4 counts
 Alertness  Number of CD4 cells in blood provides a
STIMULANTS’ EFFECTS ON FETUS measure of immune system damage
 CD4 count:
PREGNANCY SMOKING  500 – 1200:
 Higher rates of spontaneous abortion, placenta  200 – 500:
previa,  < 200: AIDS
 Preterm labor Window period
 Low birth weight infant  Time between infection & enough antibodies
 Fetal hypertension  Duration:
MARIJUANA  No symptoms or signs of illness
 Relaxant  HIV test is ________
 Hallucination  Virus is multiplying rapidly
 Short term Memory loss Seroconversion
 Low birth weight Infant  Point at which HIV test becomes positive
Lifetime Effects of Substance Abuse  Body starts making antibodies to HIV a few
 Physical deformities weeks after infection
 Mental Retardation  HIV test __________
 Developmental Problem  Person may have a mild flu-like illness

(END OF FIRST PRESENTATION)

Asymptomatic period
 Time period between seroconversion and onset
of HIV/AIDS-related illness
 Duration variable
 Most people remain healthy (asymptomatic)
 The CD4 count is above __________
HIV/AIDS-Related Illness
 Time period between onset of illness &
diagnosis of AIDS
 Duration is variable: __________
 CD4 count is between ______________
AIDS
 Final phase of HIV/AIDS
 Duration: __________________________
 CD4 count ________________
Breasfeeding Issues
Breastfeeding Recommendations
 promote exclusive breastfeeding for 6 months
 counsel on the safe and appropriate use of
formula
 HIV-positive and chooses to breastfeed,
promote exclusive breastfeeding for 6 months
Rh Incompatibility
 Rh – mother and Rh+ father
 mostly on the second pregnancy
 during placental accidents

Important Facts
 Factors affecting the course of HIV/AIDS include TYPES OF ANEMIA
nutrition, emotional stress, and access to health
care

Mother-to-Child Transmission

Interventions to Reduce Mother-to-Child Transmission

 HIV testing in pregnancy SIGNS AND SYMPTOMS OF ANEMIA
 Pallor
 Obstetric interventions  Fatigue
 Newborn feeding______________________ 
 Hypotension
Antenatal Care 
 Watch for signs/symptoms of AIDS and DIAGNOSTIC EXAMINATIONS OF ANEMIA
pregnancy-related complications  Hemoglobin count.........
 Give antiretroviral agents  Iron .............................. 50 – 150 grams/dl
 Counsel about nutrition  ......................
 Ferritin...........................
Anti-retrovirals  .............................7 – 20 g/ml
 Zidovudine (ZDV):  Vit B12...........................
o Long course MANAGEMENT OF PHYSIOLOGIC ANEMIA
o Short course  Rest

Obstetric Procedures to be avoided  O2 Therapy


NURSING DIAGNOSIS OF ANEMIA
Intrapartum Management
 Goal ______________________

Delivery: Cesarean vs. Vaginal Birth

 Cesarean section before labor and/or rupture of HYPEREMESIS GRAVIDARUM
membranes reduces risk of mother-to-child  Excessive vomiting that persists beyond 1st
transmission by 50–80% trimester

Recommended Infection Prevention Practices Predisposing Factors

 Needles:  Pancreatitis
o Take care! Minimal use 
o Suturing: Use appropriate needle and 
holder 
o Care with recapping and disposal  Drug toxicity
 Wear gloves, wash hands with soap
immediately after contact with blood and body Precipitating Factors
fluids  Pregnancy
 Cover incisions with watertight dressings for 
first 24 hours 
 Heredity
Newborn
 Wash newborn after birth, especially face
 Avoid hypothermia
MANAGEMENT OF HYPEREMESIS GRAVIDARUM
 May need hospitalization

 Parenteral nutrition


NURSING DIAGNOSIS OF HYPEREMESIS GRAVIDARUM

 Actual/Potential Fluid Volume Deficit
 Imbalance Nutrition; less than Body
Requirements


 Anxiety
Bleeding Complications of Pregnancy
ABORTION
- Termination of pregnancy before the age of Signs and Symptoms of Ectopic Pregnancy
viability  Symptoms of bleeding
Spontaneous Abortion 
 Threatened Abortion  Sharp one sided abdominal pain
 Imminent Abortion 
  Lower abdominal pain
 
 Missed Abortion 
 
 Septic Abortion
Induced Abortion
 Therapeutic Abortion

Secondary Abortion

Signs and Symptoms of Abortion

 Bleeding

 Passage of watery vaginal discharges

Management of Threatened Abortion
 Bed rest

 Treat underlying factors
 Diagnostic Examinations of Ectopic Pregnancy
 Fetal monitoring by ultrasound  Transvaginal ultrasound
 
Management of Other Type Of Abortion 
 Hospitalization  HCG
 
 Completion curettage Management of Ectopic Pregnancy
  Methotrexate
 Analgesics 
 Fluid/blood replacement  Laparoscopic salphingectomy
 Nursing Diagnosis
NURSING DIAGNOSIS  Alteration in Comfort; pain
 Anticipatory grieving
 Fluid volume deficit
Hydatidiform Mole (H-MOLE/MOLAR PREGNANCY)
Partial Mole
Ectopic Pregnancy  egg cell + 2 sperm cells
 Abnormal first meiotic division
Factors Causing Ectopic Pregnancy 
 Pelvic Inflammatory Diseases Complete Mole
 Previous Ectopic Pregnancy  Empty egg + normal sperm
  Embryo dies at very early age
 
Signs and Symptoms of H- Mole
 Vaginal bleeding
 Uterine enlargement is bigger than usual
pregnancy

 Hyperemesis gravidarum
Management of H Mole SIGNS AND SYMPTOMS
 Suction evacuation  Low back pain
  Suprapubic pressure
 
 Methotrexate  Rhythmic uterine contraction
Placenta Previa  Cervical changes
 Implantation of the placenta at the lower 
uterine segment 
Risk Factors of Placenta Previa  Bloody show
 Advance maternal age
 Missed Abortion:
 Previous uterine surgery  Retention of the conceptus in the uterus for a
 clinically appreciable time after death of the
Signs and Symptoms of Placenta Previa embryo or fetus.

 Recurrent and heavier as pregnancy progress (END OF SECOND PART)
 No uterine contraction
ABRUPTIO PLACENTA Second and third trimester disorders
Risk Factors Causing Abruptio Placenta
 Maternal age Cervical Incompetence
  - the inability of the cervix to support a
 Multiparity pregnancy to term due to structural and or
 functional weakness.
 Maternal hypertension  - _____________________ cervical dilatation
  - premature cervical dilatation between 16 – 22
Signs and Symptoms of Abruptio Placenta weeks
 Factors Causing IC
 FUNCTIONAL:
 Dark red bleeding  premature triggering of the normal mechanism
 of cervical dilatation and effacement.
 Fetal distress

Management of Abruptio Placenta CONGENITAL

  congenital or acquired
 Tocolytic Congenital:
 Steroids  Weakness of the internal os
  Short hypoplastic cervix
 Fluid and blood replacement  Bicornuate uterus
Nursing Diagnosis of Abruptio Placenta
 Altered Tissue Perfusion

 Risk for Infection
 PATHOPHYSIOLOGY:
 DIAGNOSIS:
Complications of Abruptio Placenta • Dilators or balloons
 Hypovolemic shock •
 •
 • Sonography
 Maternal Mortality MANAGEMENT:
 Fetal Mortality • Tocolytics
 Congenital Anomalies • Bed rest
•
PRETERM LABOR • Progesterone
- Labor that begins after 20 weeks •
gestation and before _______________ • Antibiotics
NURSING DIAGNOSIS:
Etiology of Preterm Labor
 Premature rupture of membrane
 Preeclampsia
 Hydramnios
 Placenta previa HYPERTENSIVE DISORDERS OF PREGNANCY
MANAGEMENT OF PRETERM LABOR RISK FACTORS:
  FIRST PREGNANCY
 Avoid sexual contact  MULTIPLE GESTATION
 
 Increase fiber in the diet  HYDATIDIFORM MOLE
 Treat underlying factors 
  FAMILY HISTORY
 Steroid 
TYPES OF PREGNANCY INDUCE HYPERTENSION  IVF
 Gestational Hypertension 
 Preeclampsia  Antihypertensive drugs
 
 Chronic Hypertension  Steroids
Superimposed Preeclampsia  Delivery of the baby
Gestational Hypertension MGSO4 THERAPY
* increased blood pressure  Loading dose IV __________________
- systolic pressure of more than _____________  continued at 2 g/hr
- diastolic pressure _______________________  check for adverse effects
* edema  Respiratory rate____________
PREECLAMPSIA  DTR of <1
 Hypertension or PIH  Urine output_______________
 POST-TERM PREGNANCY:
 Edema (wt gain)  S&S
MILD PREECLAMPSIA  Wt loss
 HYPERTENSION (140/90)   uterine size
 PROTEINURIA____________________  Meconium in AF
 MILD EDEMA,signaled by wt gain  Risks
_________________________   fetal mortality
 URINE OUTPUT___________________  cord compression
SEVERE PREECLAMPSIA
 Any of the following symptoms:

 Proteinuria.5g/24 hours (3+ or 4+ dipstick)  Treatment
  fetal surveillance
 Oliguria <400ml/24 hrs  Induction


SYSTEMIC SYMPTOMS: DISORDERS OF AMNIOTIC FLUID:
 Pulmonary edema  Polyhydramnios
  S&S
 visual changes uterine dist
 dyspnea
 edema of lower extr
 Thrombocytopenia  Treatment
ECLAMPSIA: therapeutic amniocentesis
 Hypertension  Oligohydramnios
  Risks
 Edema cord compression
 musculoskeletal deformities
CHRONIC HYPERTENSION SUPERIMPOSED pulmonary hypoplasia
PREECLAMPSIA  Treatment
 hypertensive disorders before pregnancy amnioinfusion
that progresses to preeclampsia
 PREMATURE RUPTURE OF MEMBRANES:

LABORATORY WORK-UPS:
 Blood--CBC, electrolytes, BUN, Creatinine
 Liver function studies WHAT CAUSES PREMATURE RUPTURE OF
 MEMBRANES?
 24hr Urine 

COMPLICATIONS:
 Eclamptic seizures
 HELLP syndrome
 Hepatic rupture  OTHER FACTORS THAT MAY BE LINKED TO
 PROM INCLUDE THE FOLLOWING:
 pulmonary edema o LOW SOCIO ECONOMIC CONDITONS
 o
 placental abruption o PREVIOUS PRETERM BIRTH
 o
 fetal demise o
MANAGEMENT OF PIH: o UNKNOWN CAUSES
 bed rest with or without BRP In addition to a complete medical history and physical
 BP monitoring examination, PROM may be diagnosed in several ways,
 weight and urine checks including the following:
  an examination of the cervix
  testing of the pH (acid or alkaline) of the fluid
Possible Nursing Diagnoses: Poor diet Inadequate Fetal malnutrition
 Risk for infection related to preterm rupture of nutrition Prematurity
membranes without accompanying labor. ↑ risk anemia
 ↑ risk of
 Anxiety related to outcome of labor. preeclampsia

Management: Living at high ↑ hemoglobin Prematurity
 bed rest either in the hospital or at home altitude IUGR
setting ↑ hemoglobin
 (polycythemia)
 avoid vaginal exams to prevent introduction of
microorganisms
 administer antibiotics
 Factor Maternal Fetal & Neonatal
 prepare for possible immediate delivery. Implications Implications
Premature Rupture of Membrane (PPROM – before 37
weeks)
 Spontaneous ROM prior to onset of labor at the Multiparity ↑ risk antepartum Anemia
end of 37 weeks [high risk] >3 or postpartum Fetal death
 Full term = PROM [38 weeks] hemorrhage
 S&S
o contractions Weight Poor nutrition IUGR
o cramps <45.5 kg Cephalopelvic Hypoxia associated
o (100 lb) disproportion with difficult labor &
o diarrhea Prolonged labor birth
o
o ROM
Weight ↑ risk ↓ fetal nutrition
 Treatment >91 kg hypertension ↑ risk macrosomia
o Tocolytics (200 lb) ↑ risk
o cephalopelvic
o bedrest disproportion
o ↑ risk diabetes
o
NURSING CARE: Age <16 Poor nutrition Low birth weight
 Assessment Poor antenatal ↑ fetal demise
 Thorough hx care
  bleeding ↑ risk
  ROM preeclampsia
 BPP (for PROM) ↑ risk
 Teaching cephalopelvic
 Infection Control disproportion
 FMC
Fetal Risk: Pre-maturity, infection Age >35 ↑ risk ↑ risk congenital
 *Prevention of infection preeclampsia anomalies
 ↑ risk cesarean ↑ chromosomal
 Monitor amniotic fluid, you want white and birth aberrations
sticky – not black, green, smelly

MANAGEMENT:
) Factor Maternal Fetal/Neonatal
 Limit sterile vaginal exam Implications Implications
 Antibiotics
 Bed rest

Smoking one ↑ risk ↓ placental
 Daily CBC
pack/day or hypertension perfusion →↓ O2
more ↑ risk cancer and nutrients
FACTOR MATERNAL FETAL OR NEONATAL available
IMPLICATIONS IMPLICATIONS Low birth weight
IUGR
Preterm birth
Social and Poor antenatal Low birth weight
Personal care Intrauterine growth
Low income Poor nutrition restriction (IUGR)
level and/or ↑ risk
low preecalmpsia
educational
level
Use of ↑ risk poor ↑ risk congenital Hyperthyroidism ↑ risk Mental
addicting nutrition anomalies postpartum retardation →
drugs ↑ risk of ↑ risk low birth hemorrhage cretinism
infection with IV weight ↑ risk ↑ incidence
drugs Neonatal withdrawal preeclampsia congenital
↑ risk HIV, Lower serum Danger of anomalies
hepatitis C bilirubin thyroid storm
↑ incidence
Excessive ↑ risk poor ↑ risk fetal alcohol preterm birth
alcohol nutrition syndrome ↑ tendency to
consumption Possible hepatic thyrotoxicosis
effects with
long-term
consumption
Factor Maternal Fetal/Neonatal
Preexisting ↑ risk Low birth weight
Implications Implications
Medical preeclampsia, Macrosomia
Disorders hypertension Neonatal
Diabetes Episodes of hypoglycemia
mellitus hypoglycemia ↑ risk congenital Renal disease ↑ risk renal ↑ risk IUGR
and anomalies (moderate to failure ↑ risk preterm
hyperglycemia ↑ risk respiratory severe) birth
↑ risk cesarean distress syndrome
birth Diethylstilbestrol ↑ infertility, ↑ spontaneous
(DES) exposure spontaneous abortion
Cardiac Cardiac ↑ risk fetal demise
abortion ↑ risk preterm
disease decompensation ↑ prenatal mortality
↑ cervical birth
Further strain
incompetence
on mother’s
body
Obstetric ↑ emotional or ↑ risk IUGR
↑ maternal
Considerations psychological ↑ risk preterm
death rate
Previous distress birth
Pregnancy
Factor Maternal Fetal/Neonatal Stillborn
Implications Implications
Habitual ↑ emotional or ↑ risk abortion
abortion psychological
distress
Anemia: Iron-deficiency Fetal death
↑ possibility
hemoglobin <9 anemia Prematurity
diagnostic
g/dL (white) Low energy Low birth
workup
<29% level weight
hematocrit ↓ oxygen-
(white) carrying Cesarean birth ↑ possibility ↑ risk preterm
<8.2 g/dL capacity repeat cesarean birth
hemoglobin birth ↑ risk
(black) respiratory
<26% distress
hematocrit
(black)
Factors Maternal Fetal/Neonatal
Hypertension ↑ vasospasm ↓ placental Implications Implications
↑ risk central perfusion→
nervous system low birth Rh or blood ↑ financial Hydrops fetalis
irritability weight group expenditure for Icterus gravis
→ convulsions Preterm birth sensitization testing Neonatal anemia
↑ risk Kernicterus
cerebrovascular Hypoglycemia
accident
Large baby ↑ risk cesarean Birth injury
↑ risk renal
birth Hypoglycemia
damage
↑ risk
Thyroid disorder ↑ infertility ↑ gestational
spontaneous diabetes
abortion
Current Congenital heart
Hypothyroidism ↓ basal ↑ risk Pregnancy disease
metabolic rate, congenital Rubella (first Cataracts
goiter, goiter trimester) Nerve deafness
myxedema Bone lesions
 Prolonged virus • Category D--evidence of risk but benefits
shedding outweigh the risks
• Category X--
Rubella (second Hepatitis
trimester) Thrombocytopenia (END OF 3RD PRESENTATION)

Cytomegalovirus IUGR NURSING CARE OF THE CLIENT WITH HIGH RISK LABOR
Encephalopathy & DELIVERY AND HER FAMILY
Herpes virus Severe Neonatal herpes
ESSENTIAL FACTORS IN LABOR:
type 2 discomfort virus type 2
1. PASSENGER
Concern about 2% hepatitis with
a. FETUS-
possibility of jaundice
b. PLACENTA
cesarean birth, Neurologic
2. PASSAGEWAY
fetal infection abnormalities
3. POWERS
a. primary power
b. secondary power
4. POSITION OF THE MOTHER
5. PSYCHE

Factor Maternal Fetal/Neonatal

Implications Implications PROBLEMS WITH THE PASSENGER
PASSENGER:
• FETUS
Syphilis ↑ incidence ↑ fetal demise o fetal skull
abortion Congenital o fetal body size
syphilis o fetal presentation
o fetal position
o fetal lie
Abruptio ↑ risk Fetal or o
placenta and hemorrhage neonatal
placenta previa Bed rest anemia Synclitism & Asynclitism:
Extended Intrauterine
hospitalization hemorrhage • Asynclitic refers to a fetal head that is not
↑ fetal demise parallel to the anteroposterior plane of the
pelvis.
Preeclampsia or See ↓ placental • The head is synclitic when the sagittal suture
eclampsia hypertension perfusion lies midway between the symphysis pubis and
→ low birth the sacral promontory.
weight
FETAL MALPOSITION
Multiple ↑ risk ↑ risk preterm Persistent Occiput Posterior
gestation postpartum birth  fetus enters the birth canal, descends, and is
hemorrhage ↑ risk fetal delivered in occiput posterior position
↑ risk preterm demise Transverse Occiput Arrest
labor  baby is head-down but the head is turned
completely sideways towards the mother’s
Elevated Increased Fetal death rate hipbone, causing baby to ‘arrest’ (get stuck)
hematocrit viscosity of 5 times normal because it doesn’t fit well.
>41% (white) blood rate Factors Causing POP
>38% (black)  lack of rotation due to poor contraction

 incomplete rotation
Spontaneous ↑ uterine ↑ risk preterm

premature infection birth
 epidural anesthesia
rupture of membranes

Risk of Fetal Malposition
 prolonged labor

MONITORING FETAL WELL-BEING  extension of midline episiotomy
• Early US for accurate gestational dating 
Management of Fetal Malposition
• amniocentesis for fetal lung maturity 
•  cesarean birth if necessary
PREGNANCY CATEGORY OF MEDICATIONS: 
• Category A--safe (vitamins)  Forceps assisted
• Category B-- 
• Category C--no studies available
FETAL MALPRESENTATION Podalic Version-
VERTEX MALPRESENTATION  less common type
1. BROW PRESENTATION
2. FACE PRESENTATION
Risk of Brow Presentation Contraindications of Versions:
 longer labor  3rd trimester bleeding
 ineffective contraction
 slow or arrest fetal descent

(END OF 4TH PART)

Management of Brow Presentation
 monitor for CPD FETAL DISTRESS
  Compromise of the fetus during the antepartum
 cesarean delivery period or intrapartum period
Risk of Face Presentation
 Fetal hypoxia
 increase risk of CPD
 prolongation of labor Criteria in Determining Signs of Fetal Distress
 increase risk of infection  Fetal Heart Rate:
 Cesarean birth  Baseline rate
  Variability
 edema of neonatal face and throat 
 
 Meconium Staining
Management of Face Presentation 
  Fetal Scalp Blood Sampling
 cesarean birth if mentum remains posterior 
Risk of Breech Presentation Fetal Heart Rate
 higher perinatal morbidity and mortality rate A. Baseline Rate
 cord prolapsed  average FHR observed during a 10-minute
period of monitoring
 normal rate ranges from ______________
Management of Breech Presentation
 external cephalic version at 36 – 38 weeks or Fetal Tachycardia
prior to labor
 early fetal hypoxia

Shoulder Presentation
Fetal Bradycardia
Fetus is in a transverse lie
 late/profound fetal hypoxia
ETIOLOGY OF FLUPP
Fetal
 prematurity
 multiple Variability
 anomalies: often those that restrict the ability  a measure of interplay (push-pull effect)
of the fetus to assume a vertex presentation between the sympathetic and parasympathetic
Liquor nervous system
 oligohydramnios/polyhydramnios
Uterine
 anomalies (bicornuate, fibroid)
Placenta
 Previa Decreased Variability
Pelvis  Hypoxia
 contracture, pelvic tumors obstructing birth  Acidosis
canal
Management of Shoulder Presentation
 expectant – fetus may change presentation Increased Variability
without intervention if discovered before term  Early mild hypoxia
 Alteration in placental blood flow
Compound Presentation
There are two presenting part Fetal Heart Acceleration
COMPOUND:.
 tansient increase of FHT normally caused by
fetal movements

VERSION:
Fetal Heart Deceleration
• Turning of the fetus.
 periodic decrease of FHT from its baseline rate
External Cephalic Version (ECV)
Fetal Movements SIGNS:
 at least 10x in 3 hours Ill-fitting or non-engaged presenting
 affected by: part
o fetal sleep Prolapsed umbilical cord
o sound Fetal distress on Fetal Heart Tracing
o
o
o PROGNOSIS:
o Drugs High perinatal mortality for delayed delivery
o >40 min
 less than 10 movements in 3 hours or absent RISK FACTORS:
movement are ominous Premature rupture of the amniotic sac
Polyhydramnios

Multiparity

Placenta previa
Fetal Stimulation
 fetus should response by fetal heart A small fetus
accelerations
DIAGOSTICS:
A pelvic examination
Cardiotocograph
Ultrasound
Fetal Blood Scalp Sampling
 acid-base status of fetus PATHOPHYSIOLOGY
 pH 7.2 – 7.25 is borderline
 below 7.2 is non reassuring and necessitate
birth
NURSING DIAGNOSIS:
Impaired Gas Exchange (fetal)
Fetal Oxygenation Saturation (FSpO2)
 40% - 70% are considered reassuring Fear (maternal)
 __________ mild acidosis and requires Anxiety (maternal)
continuous monitoring
 __________ indicates hypoxia and requires Umbilical Cord Prolapse Management
immediate birth  Initial management of cord prolapse in hospital
Factors Causing Fetal Distress setting:
 Breathing problems
 Abnormal position and presentation of the fetus

 Shoulder dystocia To prevent cord compression, the presenting part MUST
 BE elevated:
 Nuchal cord
 Placental abruption

Fetal Distress Management Optimal mode of delivery with cord prolapse:
 continuous fetal monitoring • category 1 caesarean section
 discontinue oxytocin if with prolonged late • Category 2 caesarean section
decelerations
 intrauterine fetal resucitations:
NURSING DIAGNOSIS:
 Decreased Cardiac Output (fetal) Management in community setting:
 Impaired Gas Exchange (fetal) • assume the knee–chest face-down position
 Ineffective Tissue Perfusion (fetal) • Transport woman to nearest consultant-led
 Risk for fetal injury institution
 Anxiety (maternal) •
 Deficient Knowledge (maternal) • Elevate presenting part
UMBILICAL CORD PROLAPSE UMBILICAL CORD ABNORMALITIE
A rare, obstetrical emergency that occurs when 
the umbilical cord descends alongside or • Umbilical cord compression
beyond the fetal presenting part. • Umbilical cord prolapse
TYPES OF UMBILICAL CORD PROLAPSE: •
Overt Prolapse • Cord Coil
Velamentous Insertion of the Cord

Occult Prolapse
PROBLEMS WITH THE PASSAGEWAY 5 Ps (factors in labor and delivery):
 >passenger
CEPHALOPELVIC DISPROPORTION 
 Disproportion of fetal head and mother’s pelvis 
CAUSES:  >placenta
 increased fetal weight  >psyche of mother.

 problems with the pelvis
 1. Problems with maternal soft tissue
S/S:  A full bladder may impede the progress of labor,
• the delivery of the baby is obstructed  Emptying the bladder

2. Dysfunctional uterine contractions

PATHOPHYSIOLOGY  Contraction may be too weak, too short, too far
apart, ineffectual
 Classification
A.) Primary: inefficient pattern present from
DIAGNOSTICS: beginning of labor
Estimation of the size of the pelvis: B.) Secondary: efficient pattern that changes to
efficient or stops; may occur in any stage.
Estimation of fetal size Assessment findings:
MANAGEMENT:  Progress of labor is slower than expected rate.
 CESAREAN SECTION  Length of labor prolonged;
NURSING DIAGNOSIS: 
• Anxiety  Fetal distress
• Fatigue  Arrest of descent
• Nursing intervention:
• Risk for impaired skin integrity  Individual as to cause
•  Provide comfort measures
INTERVENTIONS: 
• Monitor heart sounds and uterine contractions  Monitor mother/ fetus continuously
continuously Pathophysiology: (DIAGRAM NOT INCLUDED)
• Urge the woman to void every 2 hours
• Assess FHR PREDISPOSING FACTORS:
• Establish a therapeutic relationship • Genetic
• • Overweight
• Massage bony prominences •
• Hydramnios
SHOULDER DYSTOCIA: • Maternal fatigue
 Incidence: about 0.2–1%. •
 This is one of the most frightening obstetric • Gestational DM
emergencies •
 It occurs when the fetal shoulders fail to negotiate • Other diseases
the pelvic inlet PRECIPITATING FACTORS:
 Prompt (but not forcible) action is required to • Malpresentation and malposition of the fetus
prevent fetal • Congenital malformation of the uterus
 morbidity or mortality (see Stirrat and Taylor in
‘Further reading’)
Antenatal risk factors Signs/ symptoms:
• Mother’s birthweight >90th centile  Pain
• Maternal obesity or massive weight gain 
• Diabetes mellitus—can be despite seemingly  Increased BP
good blood sugar  Diaphoresis
control 
• Prolonged pregnancy (beyond 42 completed  Exhausted appearance
weeks)  SOB
• Previous shoulder dystocia (10% risk of 
recurrence) or large baby 
• Recognized macrosomia this pregnancy.  Restlessness

Medical Management:
PROBLEMS WITH THE POWERS 1. Treatment for contraction abnormalities.
2. Management for maternal passageway or fetal
DYSTOCIA: passage
General information:  If the problem is related to the inlet or
 Any labor or delivery that is prolonged and midpelvis- CS delivery
difficult.  If the size of the outlet is the problem -
forceps or vacuum extraction
Surgical Management: • Meconium-stained fluid.
-CS • FHR irregularities.
• Maternal VS.
NURSING DIAGNOSIS: • Emotional status.
Acute pain related difficulty in labor. • Medical evaluation: to rule out CPD.
Promoting comfort:
 INTERVENTIONS:
 Changing position • Short-acting barbiturates
 • IV fluids
 Pain medications • If CPD – c/s.
Anxiety related to threat of change in health status of • Provide emotional support.
self and fetus. •
Decreasing anxiety: • Prevent infection
 Give brief explanation to the women about the
nature of contraction associated with induce HYPOTONIC DYSFUNCTION:
labor • Lowered uterine resting tone; cervical
effacement & dilation slow / cease.
• Etiology:
• Premature or excessive analgesia
Powerlessness • CPD.
 Provide rest period •
 Relaxation technique • Fetal malposition / malpresentation.
•
Deficient knowledge related to measures that can be • Assessment:
used to enhance labor and facilitate birth. • Onset (latent phase & most common in
 Teach proper breathing techniques active phase).
 Educate about the complication of the delivery • Contractions - normal previously, will
 Explain client that caesarean is necessary demonstrate:
Ineffective individual coping related to inadequate •
support system. • Shorter duration.
 Stay with the patient during labor process • Diminished intensity
 Encourage patient to discuss about her •
condition • Cervical changes –
• Signs of fetal distress – rare.
DYSFUNCTIONAL LABOR: • Elevated temp
• Possible Causes: • Management:
• Catecholamines • Amniotomy
• Premature or excessive analgesia, •
particularly during latent phase. • If CPD, prepare for ____
• • Emotional support
• PRECIPITATE LABOR:
• Placental factors. • Rapid labor and delivery.
• Physical restrictions PRETERM LABOR:
ASSESSMENT:  -Labor that occurs before the end of the thirty-
• Antepartal history. seventh week of gestation.
•
• Vital signs, FHR.
• Contraction pattern
• Vaginal discharge. ASSESSMENT:
GOAL = to minimize physical/psychological stress during During tocolytic therapy, assess the following:
labor/birth. • EFM monitoring
• Uterine activity pattern
DYSFUNCTIONAL LABOR PATTERN: •
• Hypertonic labor • Muscular tremors
• Hypotonic labor •
• Precipitate labor • Dizziness
HYPERTONIC DYSFUNCTION: • Lightheadedness
• Increased resting tone of uterine myometrium; • Patient education
diminished refractory period; prolonged latent
phase.
• Nullipara: ________________
• Multipara:________________ • RISK FACTORS:
• Etiology: unknown • Race: African-American women
• Assessment: • Age: Adolescents
• Onset (early labor) • inadequate prenatal care
• Contractions:
• Continuous fundal tension
• Painful.
• Signs of fetal distress:
Signs and Symptoms:  Genetic counseling
• Persistent, dull, low backache Antepartum Treatment
• Vaginal spotting  Educate mother regarding S/Sx of PTL.
•  lifestyle modifications.
• Vaginal discharges 
•  Hydration with IV fluids
• Intestinal cramping  If this stops the contractions, tocolytic therapy
• is not needed.
Nursing Diagnosis & Interventions: PATHOPHYSIOLOGY

UTERINE PROLAPSE (Uterine Prolapse/Pelvic

Situational Low Self-Esteem r/t Inability to carry relaxation/Pelvic floor hernia)
pregnancy • a descent or herniation of the uterus into or
 Provide support persons beyond the vagina
 Encourage expression of feelings • anatomically, the vaginal vault has 3
 Provide frequent assurance during labor compartments:
 Comment on strengths of the family unit.  an anterior compartment
 Convey confidence in client’s ability to cope  - a middle compartment (cervix)
with current situation.  posterior compartment (posterior vaginal
Risk for Fetal Injury r/t Preterm Birth wall).
 Monitor fetal status and labor problems.

 Reassure misconceptions about difficulty of Four stages of uterine prolapse are defined:
labor after preterm rupture of the membranes stage I - descent of the uterus to any point in
 the vagina above the hymen
 Assist with delivery of infant as needed. stage II -
Risk for Injury Secondary to Tocolytic therapy stage III - as descent beyond the hymen
 Maintain accurate I/O at least every hour. stage IV -
 Assess VS.
 Notify Physician if maternal pulse ___________ ASSESSMENT:
 Assess for S/Sx of pulmonary edema. • A complete pelvic examination is required
• A Sims speculum or a standard bivalve
speculum with the anterior blade removed may
Compromised Family Coping Secondary to facilitate diagnosis.
Hospitalization •
 Encourage private time for woman and partner. • bimanual examination.
 • Evaluate all patients for estrogen status.
 Allow visitation with other children as tolerated • Physical examination
by the woman. • If urinary obstruction is present, the
 patient may exhibit _______
 Promote assistance of family • tenderness or a tympanitic bladder.
• If infection is present, purulent cervical
discharge may be noted.
Medical Management: LABORATORY STUDIES:
• Antibiotics • Laboratory studies are unnecessary in
• Prostaglandin Inhibitors uncomplicated cases….
• Calcium Channel Blockers • Cervical cultures
• Corticosteriods • Papanicolaou test
• Magnesium sulfate • BUN and creatinine measurement
• Beta-sympathomimetic drugs IMAGING STUDIES:
Surgical Management: • Pelvic ultrasound examination
 Cesarean Section •
• MRI - to grade pelvic organ prolapse
NURSING MANAGEMENT: SIGNS AND SYMPTOMS:
• Hydration • Pelvic heaviness or pressure
• Bedrest • Protrusion of tissue
• • Pelvic pain
• •
• Lower back pain
Preconception Care •
 Baseline assessment of health • Difficulty walking
 Pregnancy planning •
 • Urinary frequency
 improve maternal nutrition. •
 Screening for and treatment of diseases. •
 • Nausea
•
• Bleeding (rare) anxiety
•
PATHOPHYSIOLOGY fetal bradycardia
late or variable decelerations

SIGNS AND SYMPTOMS:

COMPLICATIONS: CLINICAL MANIFESTATIONS:
• Urinary retention Developing Rupture
• Abdominal pain and tenderness
• Hemmorhoids Uterine contractions will usually continue but
• will diminish in intensity and tone.
• Infection Bleeding into the abdominal cavity
• Cystitis Vomiting
TREATMENT/MEDICAL MANAGEMENT: Syncope; tachycardia; pallor
• Pessaries Significant change in FHR characteristics
o + fitted into the vagina to hold the Violent Traumatic Rupture
uterus in place Sudden sharp abdominal pain
o Abdominal tenderness
o + fitted individually for each woman Uterine contractions may be absent
o bleeding
• Surgery Fetus easily palpated in the abdominal with
o + uterus sutured back into place shoulder pain
o + colpopexy - Tenses, acute abdominal with shoulder pain
o + hysterectomy – Signs of shock
NURSING MANAGEMENT:
• preventive measures:
 Early visits to HC provider
 Kegel’s exercises NURSING DIAGNOSIS WITH INTERVENTIONS:
• preoperative nursing care: DEFICIENT FLUID VOLUME:
 Thorough explanation of procedure FEAR
 Laxative and cleansing edema DECREASED CARDIAC OUTPUT
 Perineal shave INEFFECTIVE TISSUE PERFUSION
 Lithotomy position for surgery RISK FOR INFECTION
• postop nursing care: MEDICAL MANAGEMENT:
 void few hours after surgery • Immediate stabilization of maternal
NURSING DIAGNOSIS: hemodynamics and immediate caesarean
PAIN delivery
• Oxytocin
CONSTIPATION •

URINARY INCONTINENCE SURGICAL MANAGEMENT:

• Caesarean Section
SEXUAL DYSFUNCTION •
• Hysterectomy
RISK FOR INFECTION NURSING MANAGEMENT:
• Monitor vital signs
UTERINE RUPTURE • Assess fetal status
spontaneous or traumatic rupture of the uterus. • evaluate understanding of the situation.
Dehiscence
RISK FACTORS:
• previous surgery on the uterus PROBLEMS WITH THE PSYCHE
• Having more than five full-term pregnancies Factors that may affect the woman’s psyche during
• overdistended uterus labor include the woman’s:
• Abnormal positions of the baby Current pregnancy experience
• Previous birth experiences
• Rupture of the scar from a previous CS Preparation for birth
delivery/hysterectomy. Support system
•  Presence and support of a birth companion
• Uterine congenital anomaly Culture
• Superstitions and beliefs about pregnancy and birth
• Interdelivery interval (time between deliveries) Pain
(PATHOPHYSIOLOGY NOT INCLUDED)

ASSESSMENT:
observe for signs and symptoms of impending
rupture
-lack of cervical dilatation
SUMMARY
INTRAPARTAL HIGH RISK FACTORS

Factor Maternal Fetal-Neonatal

Implications Implications
Oligohydramnios Maternal fear ↑ Incidence of
of “dry birth” congenital anomalies
Abnormal ↑ Incidence of ↑ Incidence of ↑ Incidence of renal
presentation cesarean birth placenta pre lesions
↑ Incidence of Prematurity ↑ Risk of IUGR
prolonged labor ↑ Risk of congenital ↑ Risk of fetal
abnormality acidosis
Neonatal physical ↑ Risk of cord
trauma compression
↑ Risk of intrauterine Postmaturity
growth restriction
Meconium staining ↑ ↑ Risk of fetal
(IUGR)
of amniotic fluid Psychologic asphyxia
via
stress due to ↑ Risk of meconium
fear for baby aspiration
↑ Risk of pneumonia
Multiple ↑ Uterine Low birth weight
due to aspiration of
gestation distention →↑risk Prematurity meconium
of postpartum ↑ Risk of
hemorrhage congenital Premature rupture ↑ Risk of ↑ Perinatal
↑ Risk of cesarean anomalies of membranes infection morbidity
birth Feto-fetal (chorioamnio Prematurity
↑ Risk of preterm transfusion nitis) ↑ Birth weight
labor ↑ Risk of ↑ Risk of respiratory
preterm labor distress syndrome
↑ Anxiety Prolonged
Fear for the hospitalization
Hydramnios ↑ Discomfort ↑ Risk of
baby
↑ Dyspnea esophageal or
Prolonged
↑ Risk of preterm other high-
hospitalizatio
labor alimentary-tract
n
atresias
↑ Incidence
↑ Risk of CNS
of tocolytic
anomalies
therapy
(myelocele)
Edema of lower Induction of labor ↑ Risk of Prematurity if
extremities hypercontrac gestational age not
tility of assessed correctly
uterus Hypoxia if
↑ Risk of hyperstimulation
uterine occurs
rupture
Length of
Failure to Maternal Fetal labor if cervix
progress in labor exhaustion hypoxia/acidosis not ready
↑ Incidence of Intracranial birth ↑ Anxiety
augmentation of injury
labor Abruptio Hemorrhage ↑ Perinatal
↑ Incidence of placentae/placenta Uterine atony mortality
cesarean birth previa ↑ Incidence Fetal
of cesarean hypoxia/acidosis
birth Fetal exsanguination
Precipitous labor Perineal, vaginal, Tentorial tears
(<3 hours) cervical Fetal heart ↑ Fear for baby Tachycardia,
lacerations aberrations ↑ Risk of chronic asphyxic
↑ Risk of cesarean birth, insult,
postpartum forceps, vacuum bradycardia,
hemorrhage Continuous acute
electronic Asphyxic insult
Prolapse of ↑ Fear for baby Acute fetal monitoring and Chronic hypoxia
umbilical cord Cesarean birth hypoxia/acidosis intervention Congenital heart
in labor block
Uterine rupture Hemorrhage Fetal anoxia
Cesarean birth Fetal
for hysterectomy hemorrhage
↑ Risk of death ↑ Neonatal
morbidity and
mortality

Postdates ↑ Anxiety Postmaturity

(>42 weeks) ↑ Incidence of syndrome
induction of labor ↑ Risk of fetal-
↑ Incidence of neonatal mortality
cesarean birth and morbidity
↑ Use of ↑ Risk of
technology to antepartum fetal
monitor fetus death
↑ Risk of ↑ Incidence or ASSESSMENT OF THE GENERAL APPEARANCE
shoulder dystocia risk of large baby
Assessment Normal Abnormal
Diabetes ↑ Risk of ↑ Risk of Technique Assessment Assessment
hydramnios malpresentation Findings Findings
↑ Risk of ↑ Risk of
hypoglycemia or macrosomia Inspection/ Exhaustion Extreme
hyperglycemia ↑ Risk of IUGR Observation Fatigue exhaustion,
↑ Risk of ↑ Risk of Sleep hunger Weakness, and
preeclampsia- respiratory depression at the
eclampsia distress syndrome end of 6th week
↑ Risk of Pallor
congenital Anxiousness and
anomalies restlessness
Dizziness
Preeclampsia- ↑ Risk of seizures ↑ Risk of small- Fainting
eclampsia ↑ Risk of stroke for-gestational-age
↑ Risk of HELLP baby
↑ Risk of preterm ASSESSMENT OF THE VITAL SIGNS
birth VITAL SIGNS NORMAL ABNORMAL
↑ Risk of mortality
AIDS/STI ↑ Risk of ↑ Risk of Blood 90/60 – 130/80 Below 90/60
additional transplacental Pressure 40 – 80 bpm 130/90 & above
infections transmission Pulse Rate Tachycardia
Weak Thready
(END OF 5TH PART) Palpitations

COMMON POSTPARTUM COMPLICATIONS

NORMAL ABNORMAL
POST PARTUM ASSESSMENT:
A pperance Respiratory 16 -24 Tachypnea
V ital Signs Rate breaths/cycle Shallow & Irregular
B reasts Dyspnea
U terus
B ladder
B owel
L ochia NORMAL ABNORMAL
E pisiotomy/Episiorrhapy
H oman’s sign
E motions Temperature 36.2 – 38 C on the 38 C and above in
R hogam first 24 hours any or two
Occasionally consecutive 24-hour
febrile on the 3rd period (excluding
to 4th day the first 24 hours)
ASSESSMENT OF THE BREAST
ASSESSMENT NORMAL ABNORMAL ASSESSMENT OF THE BLADDER
TECHNIQUE ASSESSMENT NORMAL ABNORMAL
TECHNIQUE
Inspection  Increase in size • Localized
 Colostrum • swelling
• Inspection • Temporary • Burning
 Milk changes Localized Pain
• Redness difficulty of sensation
from thin
• Purulent voiding • Hematuria
watery to
discharges • Void within • Inability to void
bluish white
• 6 to 8 hours more than 10
 Becomes Cracked and
irritated postpartum hours
heavier
nipples • 3Liters • Oliguria
 Veins become
urinary • Severe
apparent
output/day proteinuria
• Zero-trace • Glycosuria
ASSESSMENT NORMAL ABNORMAL protein
TECHNIQUE • Zero-trace
sugar
Palpation Warm and firm Localized mass • Urinary
Engorged stasis

ASSESSMENT OF THE UTERUS ASSESSMENT NORMAL ABNORMAL

TECHNIQUE
ASSESSMENT NORMAL ABNORMAL
TECHNIQUE • Palpation • Cannot be • Hard and firm
• Percussio palpated • Resonant
Inspection • Weight 1000 • No weight n • Dull,
gms changes thudding
immediately • Visible cervix or
after birth uterus
• 500 gms at • Severe ASSESSMENT OF THE BOWEL:
the end of abdominal pain
first week and tenderness ASSESSMENT NORMAL ABNORMAL
• 50 grms at 6th • Lateral TECHNIQUE
week displacement
• After pains of the uterus Inspection • Constipation • Passage of
during • Decrease stool out
contractions flatus from the
• Abdominal vaginal orifice
distention
• Decrease
bowel
ASSESSMENT NORMAL ABNORMAL movement
TECHNIQUE •
Hemorrhoids
Palpation • Contracted • Boggy
uterus Auscultation • decrease • Absent
• Cervix is soft bowel bowel
and malleable • Board-like sound sound
• Cervical os is abdomen
narrowed
ASSESSMENT OF LOCHIA
 ASSESSMENT OF EPISIOTOMY/EPISSIORRHAPY
ASSESSMENT NORMAL ABNORMAL
TECHNIQUE

Inspection • Redness, • Hematomas

edema, and • 1 or 2 stitches
bruises on sloughed away
the • Large
perineum lacerations
• Slight • Purulent
separation discharges
of wound
edges
• 1st degree
TYPES OF NORMAL ABNORMAL laceration
LOCHIA
 Inspect the perineum for
Lochia  2 to 3 days  Large episiotomy/lacerations with REEDA assessment
Rubra postpartum clots  Inspect C/S abdominal incisions for REEDA
 Dark Red in  R=
color  E=
 Contains blood  E=
and fragments of  D=
the deciduas and  A=
mucus Postpartum Hemorrhage

POSTPARTUM HEMORRHAGE
TYPES OF NORMAL ABNORMAL
1. EARLY POSTPARTUM HEMORRHAGE
LOCHIA
 Uterine Atony
Lochia • 3 to 10 days • Reappearanc 
Serosa postpartum e of bright  Hematomas
• Pink in color red colored 
• Contains blood, lochia  Uterine Inversion
mucus, and • Foul-smelling 2. LATE POSTPARTUM HEMORRHAGE
invading  Retention of Fragments
leukocytes  Subinvolution
 Dessiminated Intravascular Coagulation

UTERINE ATONY
TYPES OF NORMAL ABNORMAL SIGNS AND SYMPTOMS:
LOCHIA  Boggy uterus
 Large Uterus
LOCHIA ALBA 10 to 14 days Reappearance 
postpartum of bright red 
color  Hypovolemic shock
FACTORS CAUSING UTERINE ATONY
 Multiple Gestation
Contains Foul-smelling 
mucus, whitish  Large baby


 Oxytoxic drugs

 Advanced maternal age

 Dystocia


 Full bladder
MANAGEMENT OF UTERINE ATONY
 Promote Uterine Contraction

 Prevent Complications:
Hypovolemic Shock - Death
MEDICAL MANAGEMENT OF UTERINE ATONY
 Intravenous Fluid
 Oxytoxic Medications:
  Antibiotics  Analgesics
 
 Catheterization SURGICAL MANAGEMENT:
 Oxygen Administration  Incision and drainage
SURGICAL MANAGEMENT OF UTERINE ATONY 
 Ligation of Uterine Arteries  Packing
 
NURSING DIAGNOSIS & MANAGEMENT OF UTERINE NURSING DIAGNOSIS AND INTERVENTIONS
ATONY Alteration in comfort; Pain
Actual/Potential Fluid Volume Deficit
Altered Tissue Perfussion UTERINE RUPTURE
Anxiety COMPLETE
LACERATIONS INCOMPLETE
Vaginal : SIGNS AND SYMPTOMS OF UTERINE RUPTURE
 anterior  Localized abdominal pain
 posterior 
 lateral wall  Tearing feeling
Perineal: 
 first degree 
 second degree  Change in abdominal contour
 third degree FACTORS CAUSING UTERINE RUPTURE
 fourth degree  Difficult Vaginal Delivery
Cervical: 
 lateral  vertical uterine scar from previous CS
SIGNS AND SYMPTOMS OF LACERATIONS 
Firm and Contracted Uterus  Multiple gestation

Tear in the birth canal, and perineum 
FACTORS CAUSING LACERATIONS:  Obstructed Labor
 Precipitate labor GOAL OF MANAGEMENT OF UTERINE RUPTURE
  Repair of tear or laceration
 Malpresentation 
  Prevent Hypovolemic shock
 Instrumentation 
  Prevent Death
 MEDICAL MANAGEMENT OF UTERINE RUPTURE
 Primigravida  Intravenous fluid
MANAGEMENT OF LACERATIONS: 
 Surgical Repair  Antibiotics
  Oxytoxics
 Prevent Infection SURGICAL MANAGEMENT OF UTERINE RUPTURE
 Alleviate pain  Laparotomy
MEDICAL MANAGEMENT 
o Vaginal pack  Hysterectomy
o NURSING DIAGNOSIS AND INTERVENTIONS OF
o UTERINE RUPTURE
o Stool softener Dysfunctional Grieving
SURGICAL MANAGEMENT OF LACERATIONS Anxiety
 Fear
 Regional anesthesia
NURSING DIAGNOSIS AND MANAGEMENT OF UTERINE INVERSION
LACERATIONS DEGREE OF INVERSION
Alteration in Comfort; Pain  First-degree
Potential for infection  Second-degree
 Third-degree
HEMATOMA  Total inversion
SIGNS AND SYMPTOMS OF HEMATOMA SIGNS AND SYMPTOMS:
  Visualization of protruded uterus
 bluish bulging under the skin  Sudden gush of blood
  Hypovolemic shock after 10 minutes
 FACTORS CAUSING UTERINE INVERSION
 minor bleeding 
FACTORS CAUSING HEMATOMA  Extreme pushing of the fundus
 Rapid Spontaneous birth 
 GOAL OF CARE OF UTERINE INVERSION
  Prevent Hemorrhage
 Lacerations 
MANAGEMENT OF HEMATOMAS 
MEDICAL MANAGEMENT:  Prevent Infection
MEDICAL MANAGEMENT NURSING DIAGNOSIS AND MANAGEMENT
 Initially: Fluid Volume Deficit
 Tocolytic Altered Cardiac Output
 General anesthesia Altered Tissue Perfusion
 Nitroglycerine Alteration in thermoregulation; hyperthermia
 Oxytocic agents Anxiety
 Fear

 Ready for CPR DISSEMINATED INTRAVASCULAR COAGULATION
 Signs and Symptoms:
 Blood Transfusion Mild oozing of venipuncture site
SURGICAL MANAGEMENT
 FACTORS CAUSING DIC
 Surgical Replacement PIH

 Incomplete Abortion
 General Anesthesia
NURSING DIAGNOSIS AND INTERVENTION Prolonged retention of dead fetus
Fluid Volume Deficit
Altered Cardiac Output Hypertonic labor
Altered Tissue Perfusion
Anxiety GOAL OF MANAGEMENT OF DIC
Risk for infection Treat underlying conditions
Stop Clotting
LATE POSTPARTUM HEMORRHAGE
 Retained Placental Fragments MEDICAL MANAGEMENT OF DIC
 Heparin
 Endometritis
RETAINED PLACENTAL FRAGMENTS Fresh Frozen Plasma
Signs and Symptoms:
 Incomplete placental delivery NURSING DIAGNOSIS AND INTERVENTIONS
 Actual/Potential Fluid Volume Deficit
 Bright red bleeding Frequent monitoring
 Evaluate blood loss
 + ultrasound result
FACTORS CAUSING RETAINED PLACENTAL FRAGMENTS Frequent turning to sides
 Failure to inspect after placental delivery
 PUERPERAL INFECTION
MEDICAL MANAGEMENT OF RETAINED PLACENTA  Infection of the genital tract during postpartum
 Oxytoxin administration TYPES OF INFECTION
  Endometritis
 IVF 
SURGICAL MANAGEMENT OR RETAINED PLACENTA 
 Dilatation and Curettage  Mastitis
 Endometritis
NURSING DIAGNOSIS AND MANAGEMENT  an infection of the inner lining (endometrium)
 Fluid Volume Deficit of the uterus
 Decreased cardiac Output Signs and Symptoms of Endometritis
 Altered Tissue Perfusion  fever for 2 consecutive 24 hours usually on the
 Risk for infection 3rd or 4th day excluding the first 24 hours
 Anxiety postpartum
 chills
SUBINVOLUTION OF THE UTERUS 
Signs and Symptoms:  general malaise
Uterus remains large 
 uterine atony
Altered pattern of lochia 
FACTORS CAUSING UTERINE SUBINVOLUTION  dark brown foul smelling lochia
Retained Placental fragments Management of Endometritis
 antibiotics
Uterine Myoma 
MEDICAL MANAGEMENT OF UTERINE SUBINVOLUTION  analgesics
Oxytocin 
Infection of the Perineum
IVF  very rare because of improved aseptic
SURGICAL MANAGEMENT OF UTERINE technique
SUBINVOLUTION Signs and Symptoms of Infection of the Perineum
Hysterectomy  pain on the perineum
 swelling
  heat Other Factors:
  varicosities
 one or two stitches slough off  obesity
 
 may be afebrile unless systemic  oral contraceptives
Management of the Infection of the Perineum 
 systemic or topical antibiotics  multiparity
 
 hot sitz bath  smoking
 warm compress
 Classifications of Thrombophlebitis according to the
 packing with gauze depth
a) Superficial venous thrombosis
PERITONITIS  limited to the calf only
 an infection of the peritoneal cavity
 common cause of mortality death from
puerperal infection b) Deep vein thrombosis
Signs and Symptoms of Peritonitis

 abdominal pain Classifications of Thrombophlebitis according to
 location
 rapid pulse a) Femoral
  fever, chills, pain, redness,
 appearance of acutely ill  swelling of extremeties,
Management of Peritonitis 
 large dose of antibiotics  + homan’s sign
 b) Pelvic
 IVF  ovarian, uterine, hypogastric vein
  high fever
 
 antipyretics 
Management of Thrombophlebitis
MASTITIS  Anticoagulant
 infection of the breast tissues  Thrombolytic
 Analgesics
ETIOLOGY:  laparotomy
 Staphylococcus  monitoring of prothrombin time
 Nursing Diagnosis and Management of
 Eschericia Thrombophlebitis
Signs and Symptoms of Mastitis Alteration in Comfort; pain

 fever

 rapid pulse Altered Tissue Perfusion

Management of Mastitis
 antibiotics
 analgesics
 Risk for Injury (bleeding) related to therapy
 warm or cold compress How to prevent thrombophlebitis?
  avoid wearing constricting clothings
 constant emptying 
  ambulate daily during pregnancy
Nursing Diagnosis of Puerperal Infection 
 Actual/potential for infection  aseptic technique in invasive procedures
 Alteration in thermoregulation; hyperthermia 
 Alteration in comfort; pain  first 2 weeks postpartum
 Social Isolation 
 avoid leg crossing
THROMBOPHLEBITIS  increase oral fluid intake
 It is the inflammation of the lining of the 
vessel in which a clot attaches to the vessel 
wall.  avoid pillows under the knees

THREE MAJOR CAUSES: EMOTIONAL AND PSYCHOLOGICAL POSTPARTAL
 venous stasis COMPLICATIONS
 Phases of Puerperium:
 damage of the intima of the blood vessels 1. Taking-in Phase
 This is the time of reflection for a woman.
2. Taking-hold Phase POSTPARTUM PSYCHOSIS
 This is the phase where the woman begins to  It is a disrupted mental state in which an
initiate action herself. individual struggles to distinguish the external
world from his internally generated
perceptions.
3. Letting-go
 The woman finally defines her new role. Factors causing Postpartum Psychosis
 major life crisis

POSTPARTUM BLUES 
 hormonal changes
It is a maternal adjustment reaction
Signs and Symptoms of Postpartum Psychosis
 usually occurring between the 2nd to 3rd 
postpartum day through the 1st to 2nd  dissociated
postpartum week. 
Signs and symptoms of Postpartum Blues  confused
 Insomnia 
 Depressed mood Management of Postpartum Psychosis
  professional psychiatric counselling
 
 Tearfulness  hospitalization

 Mood labile Nursing Diagnosis and Management of Postpartum
Factors causing Postpartum Blues Emotional Disturbances
 sudden drop of hormone at about 72 Risk for/Actual Ineffective coping
hours postpartum
 disappointments of body changes


 extreme stress from mothering role INFERTILITY
Management of Postpartum Blues  The inability to conceive after at least 1 year of
 allow woman to talk and cry sexual intercourse at least 4 times a week
 without contraception.
 encourage family support Normally…….
 50% of couples conceive within 6
POSTPARTUM DEPRESSION months
 It is a mood disturbance that is characterized by  35% conceive within 12 months
feelings of sadness, despair, apathy, and Primary infertility
discouragement caused by loss in the person’s  no previous history of conception
life or by neurobiological imbalance of Secondary Infertility
neurotransmitters.  inability to conceive after previous successful
pregnancy
SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION Etiology of Female Infertility
 Excessive crying Vaginal problems:
  vaginal infections
 Low self-esteem 
  sexual dysfunction
 Anorexia 

 Psychosomatic symptoms
 Cervical:
 Social withdrawal  changes during ovulation
 cervical incompetence
Etiology of Female Infertility

 Uterine
Factors causing Postpartum Depression
 functional
 history of depression


 Tubal
 stress
 scarring
 lack of support system

Management of Postpartum Depression
 endometriosis
 Nurse-patient relationship
 Ovarian
- therapeutic relationship
 anovulation
 Psychopharmacologic

- antidepressive drugs
Etiology of Male Infertility
 Milleu therapy
 Congenital
– forceful manipulation of the environment
 absence of vas deferens and testes
 Ejaculatory
  retrograde ejaculation  Injecting collected semen into the woman's
 Sperm abnormalities uterus and is performed under a physician's
 oligospermia supervision.
 INDICATION
 inadequate maturation  men who have very low sperm counts.
  sperm that aren't strong enough to swim
 inability to deposit sperm into the vagina through the cervix and up into the fallopian
 tubes.
 Testicular
 orchitis
 PROCESS:
  washing the sperm
 radiation  liquefying the sperm at room temperature for
 Coital 30 minutes
 obesity 
 nerve damage  centrifuge is used to collect the best sperm.
 impotence 
 Drugs
 Methotrexate
 
 Other factors:
 STD  you can resume your usual activities.
 stress
 Success rates for artificial insemination vary. Factors
 alcohol & nicotine that lessen your chance of success include:
Interactive Problems  Older age of the woman
 
 Poor timing of intercourse 
  Severe endometriosis
 Use of spermicidal lubricants 
 Blockage of fallopian tubes
IN VITRO FERTILIZATION
 is a process by which an egg is fertilized by
Diagnostic Studies sperm outside the body in a laboratory.
 Semen Analysis after 48 – 72 hours of
abstinence

 Cervical Mucous assessment

o fern test
o IVF may be an option if you or your partner have been
 Postcoital Test diagnosed with:
o SI at presumed ovulatory state  Endometriosis
o  Low sperm counts
o Check cervical mucus 
 Basal Body Recording  Problems with ovulation
o oral temp when awakening 
o 
o before menses- ovulation  An unexplained fertility problem
Surrogate embryo transfer
 embryos are placed into the uterus of a female
MANAGEMENT OF INFERTILITY with the intent to establish a pregnancy.
1. Management of underlying problems
 douche with alkaline solution 30 minutes PROCESS:
before intercourse  After the follicles are aspirated from the
 Intended Mother or Egg Donor they will be
 medications examined and mixed with the intended father
 antibiotic or a donors sperm.
 testosterone  They are then incubated for 3 - 5 days to allow
 estrogen fertilization to occur.
 sexual therapy 
2. Assisted Reproductive Techniques
 artificial insemination
  Then, the embryos will be placed in the
 surrogates uterus via invitro fertilization
 Surrogate mothering 
ARTIFICIAL INSEMINATION
 The process by which a woman is medically  The process does not cause discomfort and
impregnated using semen from her husband or requires no medication or anesthesia. .
from a third-party donor.
  The process usually takes approximately ten-
fifteen minutes.


 Surrogates will be required to rest with activity

restrictions for two-three days following the
transfer procedure.
SURROGATE MOTHER
 A woman who bears a child for another person,
often for pay.

TWO KINDS OF SURROGATE MOTHER
Traditional surrogates
 is a woman who is artificially inseminated with
the father's sperm.
 She then carries the baby and delivers it for the
parents to raise.

GESTATIONAL SURROGATES
 has no genetic ties to the child. That's because it
wasn't her egg that was used.

 more common than a traditional surrogate
WHO USES SURROGATES:
 Those with medical problems with her uterus.
 hysterectomy


OTHER REASONS:
 age

 sexual orientation

CHOOSING A SURROGATE:
1. Is at least 21 years old
2.
3. Has passed a psychological screening by a
mental health professional
4.

5. have a complete medical evaluation and

pregnancy history to assess the likelihood of a
healthy, full-term pregnancy.