1

Benguet State University

College of Nursing

La Trinidad, Benguet

CARE OF MOTHER AND CHILD AT RISK

(NCM 109)

Nurse Learners’ Guide

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 Introduction

The study of childbearing is the study of a process that has

taken place throughout human history. Childbearing is a normal and natural
occurrence. Maternity nursing focuses on the care of the childbearing women
and their families through all stages of pregnancy. Obstetric problems are
life-threatening medical problems that develop during pregnancy, labor, or
delivery. There are several pregnancy-related illnesses and disorders that can
endanger both the mother's and the child's health. Obstetrical emergencies
may also occur during active labor and after delivery. Reducing maternal
mortality, according to the original Millennium Development Goals (2000–
2015) and now to the 2015–2030 Sustainable Development Goals, requires
not only changes in the structure of services, availability of financial
resources, and provision of adequate equipment, but also a model of care
during pregnancy, childbirth, and the puerperium based on interpersonal
human factors regarding respect and compassion. Since 2003, international
guidelines have published evidence-based practices for pregnancy, childbirth,
and postpartum care. Some of these practices promote ambulation during
labor, changes in position, a companion during childbirth, and use of non-
pharmacological techniques for pain management, among others. These
elements are integrated into the framework of respectful maternity care,
which ensures the fulfilment of women’s rights during childbirth and a
renewed focus on the respect and dignity of women and their families. The
White Ribbon Alliance has advanced a human rights framework to affirm
respect and dignity for women and their newborns, including: freedom from
harm and ill treatment; the right to information, informed consent, and
respect for choices and preferences; the right to privacy and confidentiality;
the right to treatment with dignity and respect from the moment of birth; and
the right to equality, freedom from discrimination, and equitable care, among
others.

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 Acknowledgement

We are profoundly grateful to Ma'am Ervina Luisa Campus,

whose unwavering dedication and expertise as our facilitator have been the
cornerstone of our academic journey. Ma'am Campus's tireless guidance,
insightful feedback, and genuine care for our development have shaped not
only this booklet but also our growth as individuals. Her commitment to
fostering a supportive and enriching learning environment has left an
indelible mark on each of us, and for that, we extend our sincerest
appreciation.

We also extend our heartfelt thanks to Sir Vicente G. Panagan

Jr., our esteemed Dean, whose visionary leadership and unwavering support
have been instrumental in shaping the educational landscape of our
institution. Sir Panagan's commitment to excellence, innovation, and student
success has inspired us to strive for greatness in all our endeavors.

Furthermore, we would like to express our gratitude to Benguet

State University for providing us with a nurturing academic community and
the resources necessary to pursue our educational aspirations. The
university's commitment to academic excellence and holistic development
has empowered us to reach new heights and make meaningful contributions
to society.

In closing, we acknowledge with deep appreciation the

collective efforts of Ma'am Ervina Luisa Campus, Sir Vicente G. Panagan Jr.,

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and Benguet State University in supporting our academic journey and
helping us realize our full potential.

GROUP 2E3

DELA RAGA, Sharmaine C.

DOLINTA, Shaiyen P.

ESTABILLO, Missy Ashley P.

FAUSTINO, Willard Jade S.

GALAUS, Fely Rose D.

GARCILIAN, Stefie Franz B.

GOLOCAN, Elma Kit A.

KUENGAN, Danica Mae B.

LAMPACAN, Juleen Grecel L.

LITAWEN, Rhey Caleen P.

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 Course Study Guide

NCM 109 – CARE OF MOTHER AND CHILD AT RISK

This lecture note offers nurses comprehensive knowledge

necessary for the modern health care of women with up-to date clinically
relevant information in women’s health care. It addresses and contains
selected chapters and topics which are incorporated in the obstetrics and
gynecology course for nurses. However, a major focus is provided on the role
of the nurse in providing quality maternal and newborn care.

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 Table of Contents
INTRODUCTION i
Acknowledgement ii
Group Members iii
Course Study Guides iv
Table of Contents V

CHAPTER I. PRE-GESTATIONAL PROBLEMS 1

Topic1 Diabetes Mellitus 2
Topic2 Substance Abuse 9

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Topic3 Anemia 14
Topic4 Acquired Immunodeficiency Syndrome (AIDS) 16
Topic5 Cardiovascular Problems 19

CHAPTER II. GESTATIONAL PROBLEMS 26

Topic1 Ectopic Pregnancy 27
Topic2 Spontaneous Abortion 29
Topic3 Incompetent Cervix 31
Topic4 Gestational Trophoblastic Disease / H-Mole 32
(Hydatidiform Mole)
Topic5 Gestational Diabetes 34
Topic6 Hypertension 36
Topic7 Placenta Previa 37
Topic8 Abruptio Placenta 38
Topic9 Preterm Labor 39
Topic10 Premature Rupture Of Membranes 40
Topic11 Disseminated Intravascular Coagulation (DIC) 41
Topic12 Hyperemesis Gravidarum 43
Topic13 Polyhdramnios / Hydramnios 44
Topic14 Oligohydramnios 45

CHAPTER III. POSTPARTAL PROBLEMS 46

Topic1 Puerperal Infection 47
Topic2 Endometritis 48
Topic3 Postpartum Haemorrhage 49
Topic4 Thrombophlebitis 51
Topic5 Superficial Thrombophlebitis 53
Topic6 Deep Vein Thrombosis 54
Topic7 Pulmonary Embolism 55
Topic8 Mastitis 56
Topic9 Urinary System Disorders: Urinary Retention, 57
Urinary Tract Infection
Topic10 Psychiatric Disorders 61
REFERENCES 64

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 CHAPTER 1

PRE-GESTATIONAL PROBLEMS

Objective:

The objectives in learning about pre-gestational problems

encompass understanding the diverse risk factors associated with conditions
such as diabetes, Substance abuse, anemia, and Cardiac problems, along
with recognizing potential complications during pregnancy. Mastery
involves grasping management strategies to optimize maternal health and
minimize risks to both mother and fetus, necessitating a multidisciplinary
approach involving obstetrician and other healthcare professionals. Effective
patient education is paramount, emphasizing preconception care,
maintaining optimal health pre-pregnancy, and adherence to recommended
treatments and lifestyle changes. Awareness of long-term health implications
for both mother and offspring, coupled with staying abreast of research and
innovation in prevention and management, completes the comprehensive
understanding needed for navigating pre-gestational challenges in
pregnancy.

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 WOMAN WITH DIABETES MELLITUS

An endocrine disorder in which the pancreas cannot produce

adequate insulin to regulate body glucose levels. The disorder affects 3% to
5% of all pregnancies and is the most frequently seen medical condition in
pregnancy (Strehlow et al., 2007). Before insulin was produced synthetically
in 1921, women with type 1 diabetes, or diabetes acquired in childhood, died
before reaching childbearing age, were infertile, or had spontaneous
miscarriages early in pregnancy. Now that diabetes can be well managed and
type 2 diabetes is occurring more frequently in young adults.

Signs and Symptoms

1. Polyuria (Frequent Urination): Increased urination occurs as the

body tries to eliminate excess glucose through the urine.
2. Polydipsia (Excessive Thirst): Increased thirst is often a result
of the body's efforts to replenish fluids lost through frequent
urination.
3. Polyphagia (Increased Hunger): Despite eating regularly,
individuals with diabetes may experience persistent hunger due
to the body's inability to properly utilize glucose for energy.
4. Unexplained Weight Loss: Despite increased hunger and food
intake, some individuals with diabetes may experience

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 unexplained weight loss due to the body's inability to use
glucose effectively, leading to breakdown of fat and muscle
tissues for energy.
5. Fatigue and Weakness: Feeling tired and weak can be
symptoms of diabetes, especially when the body's cells are
deprived of glucose for energy.
6. Blurred Vision: High blood sugar levels can cause changes in
the shape of the lens in the eye, leading to blurry vision.
7. Slow Wound Healing: Diabetes can impair the body's ability to
heal wounds and injuries due to poor circulation and
compromised immune function.
8. Recurrent Infections: Individuals with diabetes may be more
susceptible to infections, such as urinary tract infections, skin
infections, and yeast infections, due to elevated blood sugar
levels and impaired immune function.
9. Numbness or Tingling in Extremities: Diabetes-related nerve
damage (neuropathy) can cause numbness, tingling, or burning
sensations, typically in the hands and feet.
10. Dry Skin and Itching: Diabetes can lead to dry skin and itching,
particularly in the extremities, as a result of poor circulation and
nerve damage.

Classification of Diabetes Mellitus

Class

Type 1 Formerly known as insulin-

dependent diabetes
mellitus.

A state characterized by the

destruction of the beta cells in the
pancreas that usually leads to absolute
insulin deficiency.

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 a. Immune-mediated diabetes mellitus
results from autoimmune destruction
of the beta cells.

b. Idiopathic type 1 refers to forms

that have no known cause.

Type 2 Formerly known as non-insulin-

dependent diabetes
mellitus.

A state that usually arises because of

insulin resistance combined with a
relative deficiency in the production
of insulin.

Gestational A condition of abnormal glucose

diabetes metabolism that arises during
pregnancy.

Possible signal of an increased risk

for type 2 diabetes later
in life.

Impaired glucose A state between “normal”

Homeostasis and “diabetes” in which the body is
no longer using and/or
secreting insulin properly.

a. Impaired fasting glucose:

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 A stated when fasting plasma

glucose is at least

110 but under 126 mg/dL.

b. Impaired glucose tolerance:

A state when results of the

oral glucose tolerance test is at least

140 but under 200 mg/dL in the 2hour

sample.

Source: American Diabetes Association. (2005). New classifications and

recommendations for diabetes mellitus. New York: Author.

Classes of pregestational diabetes:

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 The onset of class A diabetes may occur at any age. You can

control this class of diabetes by dieting alone.

 Class B diabetes occurs if you developed diabetes after age 20,

have had diabetes for less than 10 years, and you have no

vascular complications.

 Class C diabetes occurs if you develop it between the ages of

10 and 19. Diabetes is also class C if you’ve had the disease for

10 to 19 years and you have no vascular complications.

 Class D diabetes occurs if you develop diabetes before age 10,

have had diabetes for more than 20 years, and you have

vascular complications.

 Class F diabetes occurs with nephropathy, a kidney disease.

 Class R diabetes occurs with retinopathy, an eye disease.

 Class RF occurs in people who have both nephropathy and

retinopathy.

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  Class T diabetes occurs in a woman who’s had a kidney

transplant.

 Class H diabetes occurs with coronary artery disease (CAD) or

another heart disease.

Diagnostics

1. Fasting Plasma Glucose (FPG) Test: This test examines blood

glucose levels following an overnight fast lasting at least 8
hours. Diabetes is diagnosed when fasting plasma glucose
levels exceed 126 milligrams per deciliter (mg/dL) on two
distinct occasions.
2. Oral Glucose Tolerance Test (OGTT): .In this test, you will
consume a glucose solution and then take measurements of
your blood glucose at regular intervals over the course of two
hours. A blood glucose level of 200 mg/dL or greater two hours
after drinking the glucose solution suggests diabetes.
3. Hemoglobin A1c (HbA1c) Test: This test evaluates the average
blood glucose levels during the previous 2-3 months. An
HbA1c reading of 6.5% or above suggests diabetes.
4. 4.Random Plasma Glucose Test: .This test measures blood
glucose levels at any time during the day, independent of the
previous meal. A random plasma glucose level of 200 mg/dL or
greater, together with diabetic symptoms such as increased
thirst or urine, suggests diabetes.
5. Glycated Serum Protein (GSP) Test: Similar to HbA1c, this test
monitors average blood glucose levels over time, however it is
less often utilized.

Nursing Interventions

Independent:

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 1. Promote frequent physical exercise as part of diabetes care.
Provide safe and suitable exercise recommendations, taking into
account the woman's fitness level and any pregnancy-related
constraints. Highlight the benefits of exercise for insulin
sensitivity and general health
2. Promote stress-reduction practices such as deep breathing,
relaxation, mindfulness, and guided visualization.
3. Ensure that the woman knows her prescribed drugs, such as
insulin or oral hypoglycemic. Provide instruction on correct
administration procedures, dose regimens, potential adverse
effects, and drug adherence strategies.
4. Provide instructions for daily foot checks, correct footwear
selection, injury avoidance, and rapid treatment of any foot
disorders or wounds.
5. Offer individualized dietary advice to women with diabetes
who are planning a pregnancy.
6. Encourage the woman to implement stress management
techniques into her daily routine to improve her emotional well-
being and glycemic control.
7. Encourage the lady to take an active part in controlling her
diabetes by teaching self-care skills such as insulin
administration, carbohydrate counting, and detecting hypo- and
hyperglycemia symptoms. Encourage problem-solving ability
and decision-making autonomy in diabetes management.
8. Educate the woman on the importance of foot care in diabetes
treatment. Emphasize the importance of frequent podiatric
exams.
9. Provide resources and assistance to assist her in navigating
healthcare systems and gaining access to critical services and
networks.
10. 1Educate patients thoroughly on pre-gestational diabetes
mellitus, its effects on pregnancy, and the necessity of glycemic
management. Include information on blood glucose testing,
medication management, dietary considerations, and lifestyle
changes.
11. Encourage the lady to speak clearly with her healthcare team,
ask questions, and advocate for her needs.

Dependent:

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 1. Administer prescription drugs as directed by the physician, such
as insulin or oral hypoglycemic agents, to reach and maintain
target blood glucose levels.
2. Work with obstetricians and perinatologists to monitor fetal
health using non-stress testing, biophysical profiles, ultrasound
examinations, and Doppler studies. Inform the healthcare staff
of any anomalies or indicators of fetal distress so that they can
be managed appropriately.
3. Conduct regular blood glucose testing as directed by your
doctor, including fasting and postprandial glucose assessments,
to check glycemic control. Adjust insulin dosages or other
drugs in response to blood glucose levels and physician's
orders.

WOMAN UNDER SUBSTANCE ABUSE

It is defined as the inability to meet major role obligations, an

increase in legal problems or risk-taking behavior, or exposure to hazardous
situations because of an addictive substance. A person is substance
dependent when he or she has withdrawal symptoms following
discontinuation of the substance, combined with abandonment of important
activities, spending increased time in activities related to substance use,
using substances for a longer time than planned, or continued use despite
worsening problems because of substance use.

Substance dependence is a growing health problem in women

of childbearing age, so its incidence during pregnancy is increasing. As
many as 10% to 20% of pregnant women use illegal drugs during pregnancy
(NCHS, 2009). The use of cocaine, amphetamines, and multiple drugs has

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increased dramatically in recent years. Adolescents have an increased rate of
inhalant abuse and binge drinking.

Recreational drugs commonly used in pregnancy are those

commonly used by women in their childbearing years: cocaine,
amphetamines, marijuana, phencyclidine, inhalants, opiates, and alcohol.

Signs and Symptoms

1. Changes in Behavior:

 Mood swings
 Irritability
 Agitation
 Anxiety or depression
 Social withdrawal or isolation
 Secretive behavior
2. Physical Signs:

 Changes in appetite (increase or decrease)

 Changes in sleep patterns (insomnia or excessive
sleeping)
 Weight loss or weight gain
 Poor hygiene and grooming habits
 Slurred speech
 Bloodshot eyes or dilated pupils
 Tremors or shaky hands
3. Psychological Symptoms:

 Poor concentration and memory

 Confusion or disorientation
 Impaired judgment

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  Hallucinations or delusions (in severe cases)
 Paranoia or suspiciousness
4. Neglect of Responsibilities:

 Neglecting work, school, or household

responsibilities
 Financial problems or frequent requests for money
 Legal issues related to substance abuse (e.g.,
arrests, DUIs)
5. Physical Health Issues:

 Chronic fatigue or lethargy

 Frequent headaches or migraines
 Gastrointestinal problems (e.g., nausea, vomiting,
diarrhea)
 Respiratory issues (e.g., coughing, shortness of
breath)
 Increased susceptibility to infections

6. Social and Interpersonal Problems:

 Relationship conflicts or breakdowns

 Loss of interest in previously enjoyed activities
 Engaging in risky behaviors (e.g., unsafe sex,
driving under the influence)
 Loss of friendships or social support networks
7. Withdrawal Symptoms:

 Experiencing withdrawal symptoms when not

using the substance (e.g., nausea, sweating,
shaking, cravings)
 Using the substance to relieve or avoid withdrawal
symptoms

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Diagnostics

1. Clinical Assessment: Healthcare practitioners conducts a

complete clinical evaluation, which may involve collecting a
full medical history, completing a physical examination, and
completing a comprehensive interview to determine substance
use patterns, frequency, quantity, and duration.
2. Screening Tools: Alcohol Use Disorders Identification Test
(AUDIT), Drug Abuse Screening Test (DAST), and the CAGE
questionnaire (for alcohol abuse) can be used to assess
substance misuse and dependence.
3. Toxicology Screening: Toxicology screening involves testing
biological samples (such as urine, blood, and hair) for the
presence of certain chemicals or their metabolites. Urine drug
testing is widely utilized due to its noninvasive nature and
affordable cost.
4. Laboratory Tests: Laboratory tests may be performed to
check liver function, renal function, complete blood count
(CBC), electrolyte levels, and other metabolic parameters in
order to determine the impact of substance usage on health.
5. Psychological Assessment: Mental medical professionals may
perform psychological evaluations to identify associated mental
health issues, such as depression, anxiety, or post-traumatic
stress disorder (PTSD), which frequently occur with drug
misuse.
6. Diagnostic Imaging: In some circumstances, diagnostic
imaging examinations (e.g., MRI, CT scan) may be used to
look for structural abnormalities or complications of substance
addiction, such as brain injury or organ damage.

Nursing Interventions
Independent:

1. Provide information on the dangers of drug misuse during

pregnancy and the advantages of obtaining treatment.
2. Educate the woman on the consequences of substance usage on
her health, pregnancy, and potential future child.

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 3. Engage in therapeutic contact with the lady to elicit her
feelings, worries, and motives around substance misuse.
4. Provide emotional support, encouragement, and nonjudgmental
listening.
5. Conduct an in-depth assessment of the woman's drug use
history, including the types of substances used, frequency and
quantity of use, triggers for use, and prior efforts to quit.
6. Collaborate with the woman to develop healthy coping methods
for stress, cravings, and substance-use triggers.
7. relaxation techniques, mindfulness exercises, and problem-
solving strategies.
8. Encourage self-care activities that benefit both physical and
emotional well-being, such as regular exercise, healthy eating
habits, enough sleep, and engaging in fun hobbies.

Dependent:

1. Work with healthcare practitioners to provide referrals to

specialist drug addiction treatment programs, such as outpatient
counseling, intensive outpatient programs (IOPs), or residential
rehabilitation facilities.
2. Collaborate with doctors to deliver prescription drugs to treat
withdrawal symptoms, cravings, or co-occurring mental health
conditions like anxiety or depression.
3. Work with the healthcare team to monitor the woman's physical
and mental health, including withdrawal symptoms, and any
medication-related side effects. Work with obstetricians and
perinatal experts to monitor the woman's pregnancy and
identify any possible issues caused by substance addiction, such
as fetal growth restriction or placental anomalies.

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 WOMAN WITH ANEMIA

Anemia is a condition in which the number of red blood cells or

their oxygen carrying capacity is insufficient to meet the physiological needs
of the individual, which consequently will vary by age, sex, attitude,
smoking and pregnancy status (WHO, 2013).

A condition in which the number of red blood cells circulating

in the bloodstream is abnormally low or dysfunctional. This can be an acute
or chronic condition with symptoms ranging from mild to severe, requiring
hospitalization.
There are several different types of anemia which all have other
causes, Poor diet/ malnourishment, age, menstruation, pregnancy, chronic
conditions, and family history.

Signs and Symptoms

(What is the Clinical presentation of anemia?)

1. General: fatigue, general weakness

2. CNS: dizziness, lightheadedness, headaches
3. Respiratory: dyspnea, tachypnea

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 4. Cardiovascular: fast or irregular heartbeat, palpitations, chest
discomfort, chest pain
5. Integumentary: pale skin, cool skin, reports of feeling cold,
numbness in the hands and feet, brittle nails
6. Pallor
7. Pale nails
8. Pale, dry or easily bruised skin.
9. Koilonychias
10. Sore tongue

Diagnostics

1. CBC
 Hemoglobin <10 g/ dL
 Hematocrit <36%
 RBCs <4 x 1012
2. Positive bone marrow aspiration for anemia
3. Colonoscopy to determine if there is any bleeding
4. Fecal occult blood sample

Nursing Interventions
Independent Interventions:

1. 1. Diet modification: Eating foods high in iron content (beef

and other meats, beans, lentils, iron-fortified cereals, dark green
leafy vegetables, and fruits.) can help ensure that you maintain
the supply of iron your body needs to function properly.
2. 2. Supplemental treatment
3. 3. Lifestyle adjustments

Dependent:
1. Administer IV fluids as ordered.
2. IV fluids can increase the intravascular volume in instances of
trauma or acute blood loss.
3. Transfuse blood as ordered.
4. Packed red blood cells (RBCs) should only be transfused to
actively bleeding patients and those with severe and
symptomatic anemia with a hemoglobin level of 7 g/dL or less.
5. Apply oxygen as needed. RBCs are the oxygen-carrying
components of blood, if the patient is anemic, they may

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 experience hypoxia or dyspnea. Apply supplemental oxygen as
needed.
6. Administer supplements as recommended.
7. Supplements and their prescribed route will depend on the
patient’s deficiencies and include: Oral/IV iron
8. Oral/IM vitamin B12
9. Oral/IV/IM folate.
10. 5.Refer to dietitians can assist and educate the patient regarding
recommended foods for nutritional deficiencies (iron, vitamin
B12, and folate)
11. Severe anemia would necessitate a blood transfusion to
supplement cardiac output and aid in circulating oxygenated
blood throughout the body.

Woman with Acquired Immunodeficiency

Syndrome (AIDS)

An infection that attacks cells in your immune system, known

as CD4 cells, immunodeficiency syndrome (AIDS), which increases the risk
of severe infections
Women with AIDS may notice early menopause, menstrual
cycle changes, and more frequent vaginal infections than average. AIDS
develops an opportunistic infection or cancer that’s rare in people who don’t

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have HIV. Human immunodeficiency virus (HIV) is an infection that attacks
the body’s immune system.
HIV targets the body’s white blood cells, weakening the
immune system. This makes it easier to get sick with diseases like
tuberculosis, infections and some cancers. HIV can be treated and prevented
with antiretroviral therapy (ART). Untreated HIV can progress to AIDS,
often after many years.
WHO now defines Advanced HIV Disease (AHD) as CD4 cell
count less than 200cells/mm3 or WHO stage 3 or 4 in adults and
adolescents. All children with HIV younger than 5 years of age are
considered to have advanced HIV disease.

Signs and Symptoms

1. Primary infection occurs 4 to 10 weeks after unprotected sexual
practice with an AIDS-infected person. The primary AIDS
infection is characterized by the following symptoms:
 Fever
 Joint pain
 Skin rash
 Sore throat
 Swollen lymph nodes
2. The infection progressively weakens the immune system. This
can cause other signs and symptoms:
 swollen lymph nodes
 weight loss
 fever
 diarrhea
 Without treatment, people with AIDS infection can also develop
severe illnesses:
 tuberculosis (TB)
 cryptococcal meningitis
 severe bacterial infections
 cancers such as lymphomas and Kaposi's sarcoma.

Diagnostics
1. An HIV antibody test, either from a blood sample or an oral
sample (Orasure), can tell whether you have been infected. A
negative test result means no HIV antibodies were found. This
usually means you are not infected. However, if you engaged in

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 behavior that could spread the virus within three months of
having the test, A positive test result means antibodies to HIV
were found. This means you are infected with the virus and can
pass HIV to others even if you have no symptoms.

2. HIV can be diagnosed through blood or saliva testing. Tests

include:

3. Antigen-antibody tests. These tests most often use blood from a

vein.

4. Antibody tests. These tests look for antibodies to HIV in blood

or saliva. Most rapid HIV tests are antibody tests. This includes
self-tests done at home. You may not show a positive result on
an antibody test until 3 to 12 weeks after you've been exposed
to HIV.

5. Nucleic acid tests (NATs). These tests look for the virus in your
blood, called viral load. They use blood from a vein.

Nursing Interventions
Independent Interventions:
1. People living with HIV will need lifelong treatment. The best
treatments right now are combinations of prescription drugs.
2. dipivefrine vaginal rings, injectable long acting cabotegravir.
3. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) turn
off a protein needed by HIV to make copies of itself., include
efavirenz, rilpivirine (Edurant) and doravirine (Pifeltro).
4. Antidiarrheal therapy: Therapy with octreotide acetate, a
synthetic analog of somatostatin, for the management of severe
chronic diarrhea.
5. Antidepressant therapy: Monitor patients' sleep/wake cycle, any
changes in appetite or concentrations and get help from
psychiatrists if needed.
6. Nutrition therapy: For all patients with unexplained weight loss,
calorie counts should be obtained, and oral supplements and
appetite stimulants should be discussed with the primary
physician.
7. Pain therapy: Administer NSAIDS or opioids as needed by the
patient, in recommended dosages.
8. Taking antiretroviral therapy (ART) and who have no evidence
of virus in the blood will not pass HIV to their sexual partners.

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 Access to testing and ART is an important part of preventing
HIV

Dependent :
1. Eat healthy foods. Fresh fruits and vegetables, whole grains,
and lean protein help keep you strong, give you more energy
and support your immune system. Eat enough calories to keep
your weight stable.
2. Avoid raw meat, eggs and more. Foodborne illnesses can be
severe in people who are infected with HIV. Cook meat until it's
well done. Don't use dairy products that aren't treated for
bacteria, called pasteurized. Don't eat raw eggs and raw seafood
such as oysters, sushi or sashimi. Don't drink water you don't
know is safe.
3. Cat stool can cause toxoplasmosis, reptiles can carry
salmonella, and birds can carry cryptococcus or histoplasmosis.
Wash hands thoroughly after handling pets or emptying litter
boxes.
4. Practices such as yoga, meditation and massage have been
shown to reduce stress as well as provide relaxation and
improve quality of life. While they need more study, these
practices may be helpful if you're living with HIV/AIDS.

WOMAN WITH CARDIOVASCULAR

PROBLEMS

Many cardiac diseases during pregnancy are under

investigation, and many others which are still not understood require further

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inquiry. Some of these diseases may be exacerbations of pre-existing
conditions that the pregnant woman may already have, or they may develop
a new disease process that presents because of the complex hormonal
changes and physiology of pregnancy.

Types of Maternal Cardiac Problems

1. Rheumatic Heart Disease: RHD in pregnancy (RHD-P) is

associated with an increased burden of maternal and perinatal
morbidity and mortality. A sequellae of rheumatic fever
resulting in heart valve damage if untreated, RHD is twice as
common in women. Rheumatic heart disease is described as a
complication of rheumatic fever in which the heart valves have
been permanently damaged. Rheumatic fever is an
inflammatory disease caused by an autoimmune response to a
bacterial (Group A beta-hemolytic Streptococcus pyogenes)
infection during childhood. During pregnancy, there is an
increase in blood volume which results in increased pressure on
the heart valves. For pregnant women with rheumatic heart
disease, an increased pressure on the damaged heart valve leads
to increased maternal and fetal risks. These complications
might include death of mother and baby, increased risk of
preterm delivery which may affect baby and mother’s health, in
some cases, serious complication is associated with a greater
risk of heart failure shortly before, during or after delivery, and
increased risks of other complications during pregnancy.

2. Congenital Heart Defects: Most women with congenital heart

disease (CHD) can have a successful pregnancy, but it requires
careful planning and discussion with your adult CHD
healthcare team. Pregnancy has its risks – even in healthy
women – but there may be greater risk for women with CHD
and their baby. For some women, the risk is high enough that
pregnancy is not recommended. Pregnancy makes your heart
work much harder. It has to pump almost twice as much blood
per minute. Blood pressure changes and irregular heartbeat
(arrhythmia) are common. All of these changes are normal and
occur in all pregnant women. But for a heart affected by CHD,
these changes can be a serious burden. Women with
mechanical valves are at high risk because they have to take a
blood thinner, which poses a risk to fetal development. Also,
pregnancy makes managing a blood thinner more difficult and
less stable for the mother. Women with tissue valves tend to do

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 well during pregnancy as long as the valve is working well and
there are no other complications.
A. Atrial Septal Defect: An atrial septal defect is a birth defect of
the heart in which there is a hole in the wall (septum) that
divides the upper chambers (atria) of the heart. A hole can vary
in size and may close on its own or may require surgery.
B. Atrioventricular Septal Defect: An atrioventricular septal defect
(AVSD) is a heart defect in which there are holes between the
chambers of the right and left sides of the heart, and the valves
that control the flow of blood between these chambers may not
be formed correctly. This condition is also called
atrioventricular canal (AV canal) defect or endocardial cushion
defect. Partial or Complete AVSD.
C. Coarctation of the Aorta: Coarctation of the aorta is a birth
defect in which a part of the aorta is narrower than usual. The
narrowing of the aorta usually happens in the part of the blood
vessel just after the arteries branch off to take blood to the head
and arms, near the patent ductus arteriosus, although sometimes
the narrowing occurs before or after the ductus arteriosus.
D. Hypoplastic Left Heart Syndrome: Hypoplastic left heart
syndrome (HLHS) is a birth defect that affects normal blood
flow through the heart. As the it develops during pregnancy, the
left side of the heart does not form correctly. Hypoplastic left
heart syndrome is one type of congenital heart defect.
E. Pulmonary Atresia: Pulmonary atresia is a birth defect of the
pulmonary valve, which is the valve that controls blood flow
from the right ventricle (lower right chamber of the heart) to the
main pulmonary artery (the blood vessel that carries blood from
the heart to the lungs). Pulmonary atresia is when this valve
didn’t form at all, and no blood can go from the right ventricle
of the heart out to the lungs.
F. Tetralogy of Fallot: Sometimes, if you have holes in your heart,
or septal defects, you might also have other congenital heart
problems. One is called the tetralogy of Fallot, which is a
combination of four defects, including: A large ventricular
septal defect (VSD); Thickened wall around your right
ventricle, or lower chamber; Your aorta is located above the
hole in your ventricular wall; Stiff pulmonary valve that
prevents blood from flowing easily from the heart to the lungs.
G. Total Anomalous Pulmonary Venous Return: Total anomalous
pulmonary venous return (TAPVR) is a birth defect of the heart.
In a baby with TAPVR, oxygen-rich blood does not return from

21
 the lungs to the left atrium. Instead, the oxygen-rich blood
returns to the right side of the heart. Here, oxygen-rich blood
mixes with oxygen-poor blood. This causes the baby to get less
oxygen than is needed to the body.
H. Tricuspid Atresia: Tricuspid atresia is a birth defect of the
tricuspid valve, which is the valve that controls blood flow from
the right atrium (upper right chamber of the heart) to the right
ventricle (lower right chamber of the heart). Tricuspid atresia
occurs when this valve doesn’t form at all, and no blood can go
from the right atrium through the right ventricle to the lungs for
oxygen.
I. d-Transposition of the Great Arteries: Dextro-Transposition of
the Great Arteries or d-TGA is a birth defect of the heart in
which the two main arteries carrying blood out of the heart –
the main pulmonary artery and the aorta – are switched in
position, or “transposed.”
J. Truncus Arteriosus: Occurs when the blood vessel coming out
of the heart in the developing baby fails to separate completely
during development, leaving a connection between the aorta
and pulmonary artery. There are several different types of
truncus, depending on how the arteries remain connected. There
is also usually a hole between the bottom two chambers of the
heart (ventricles) called a ventricular septal defect.
K. Ventricular Septal Defect: A ventricular septal defect happens
during pregnancy if the wall that forms between the two
ventricles does not fully develop, leaving a hole. A ventricular
septal defect is one type of congenital heart defect. Congenital
means present at birth.

New York Heart Association Functional Classification:

Class I: Symptom onset with more than ordinary level of activity

Class II: Symptom onset with an ordinary level of activity
Class III: Symptom onset with minimal activity
Class IV: Symptoms at rest

Signs and Symptoms

1. For some people, signs or symptoms of congenital heart disease aren't
noticed until adulthood. Symptoms may return years after a congenital
heart defect is treated. Common congenital heart disease symptoms in
adults include:

22
  Irregular heart rhythms (arrhythmias)
 Blue skin, lips and fingernails (cyanosis)
 Shortness of breath
 Feeling tired very quickly with activity
 Swelling of body tissue or organs (edema)
If you're having worrisome symptoms, such as chest pain or shortness
of breath, seek emergency medical attention.

2. Although some women have no symptoms, others may have:

 Angina—usually felt as a dull or heavy chest discomfort or
ache.
 Pain in the neck, jaw, or throat
 Pain in the upper abdomen or back
3. These symptoms may happen when you’re resting or active. Women
also may have other symptoms, including:
 Nausea
 Vomiting
 Tiredness that won’t go away or feels excessive

Diagnostics
1. Many different tests are used to diagnose heart disease. Besides
blood tests and a chest X-ray, tests to diagnose heart disease can
include:

2. Electrocardiogram (ECG or EKG): An ECG is a quick and

painless test that records the electrical signals in the heart. It can
tell if the heart is beating too fast or too slowly.

3. Holter monitoring: A Holter monitor is a portable ECG device

that's worn for a day or more to record the heart's activity
during daily activities. This test can detect irregular heartbeats
that aren't found during a regular ECG exam.
4. Echocardiogram: This noninvasive exam uses sound waves to
create detailed images of the heart in motion. It shows how
blood moves through the heart and heart valves. An
echocardiogram can help determine if a valve is narrowed or
leaking.
5. Exercise tests or stress tests: These tests often involve walking
on a treadmill or riding a stationary bike while the heart is
monitored. Exercise tests help reveal how the heart responds to
physical activity and whether heart disease symptoms occur
during exercise. If you can't exercise, you might be given
medications.

23
 6. Cardiac catheterization: This test can show blockages in the
heart arteries. A long, thin flexible tube (catheter) is inserted in
a blood vessel, usually in the groin or wrist, and guided to the
heart. Dye flows through the catheter to arteries in the heart.
The dye helps the arteries show up more clearly on X-ray
images taken during the test.
7. Heart (cardiac) CT scan: In a cardiac CT scan, you lie on a
table inside a doughnut-shaped machine. An X-ray tube inside
the machine rotates around your body and collects images of
your heart and chest.
8. Heart (cardiac) magnetic resonance imaging (MRI) scan: A
cardiac MRI uses a magnetic field and computer-generated
radio waves to create detailed images of the heart.
Nursing Interventions
Independent Interventions:

1. Auscultate apical pulse, assess heart rate.

2. Obtain a comprehensive health history focusing on HF
symptoms and self-management strategies.
3. Note heart sounds.
4. Assess rhythm and document dysrhythmias if telemetry is
available.
5. Assess for palpitations or irregular heartbeat.
6. Palpate peripheral pulses.
7. Monitor blood pressure (BP).
8. Inspect the skin for mottling.
9. Inspects the skin for pallor or cyanosis.
10. Monitor urine output, noting decreasing output and
concentrated urine.
11. Note changes in sensorium: lethargy, confusion, disorientation,
anxiety, and depression.
12. Evaluate the patient’s level of consciousness for changes that
may indicate decreased cerebral perfusion.
13. Examine lower extremities for edema and rate its severity.
14. Assess the abdomen for tenderness, hepatomegaly, and signs of
ascites.
15. Assess jugular vein distention (JVD).
16. Monitor results of laboratory and diagnostic tests.
17. Monitor oxygen saturation and ABGs.

Dependent:
1) Diuretics:
Thiazide diuretics [hydrochlorothiazide (Microside)]
Loop diuretics [furosemide (Lasix), ethacrynic acid (Edecrin)]

24
 Potassium-sparing diuretics [spironolactone (Aldactone)]
2) Vasodilators, arterial dilators, and combination drugs.
Isosorbide dinitrate (ISDN) [Nitro Dur, Isordil]
Hydralazine [Apresoline]
Nitroglycerin
3) Sodium nitroprusside [Nitropress]
Nesiritide
4) Angiotensin-converting Enzyme Inhibitors (ACE Inhibitors)
[benazepril (Lotensin), captopril (Capoten), lisinopril (Prinivil),
enalapril (Vasotec), quinapril (Accupril), ramipril (Altace),
moexipril (Univasc)]
5) Angiotensin II receptor blockers (ARBs) [eprosartan (Teveten),
irbesartan (Avapro), valsartan (Diovan)] are for patients who
are unable to tolerate ACE inhibitors (usually owing to
intractable cough).
6) Cardiac glycosides [Digitalis (Lanoxin)]
7) Beta-Blockers: Beta-adrenergic receptor antagonists [carvedilol
(Coreg), bisoprolol (Zebeta), metoprolol (Lopressor)].
8) Inotropic agents [amrinone (Inocor), milrinone (Primacor),
vesnarinone (Arkin-Z), dobutamine [Dobutrex]].

25
 CHAPTER 2

GESTATIONAL PROBLEMS

Objective:
The objectives in learning about gestational problems revolve
around comprehensively understanding the various challenges that can arise
during pregnancy. This includes familiarizing oneself with common
gestational issues such as gestational diabetes, preeclampsia, gestational

26
hypertension, and placental abnormalities. Mastery involves recognizing the
signs and symptoms of these conditions, understanding their underlying
mechanisms, and appreciating the potential risks they pose to maternal and
fetal health. Additionally, learning effective management strategies,
including medical interventions and lifestyle modifications, is crucial to
mitigate complications and ensure favorable outcomes for both mother and
baby. Educating patients about the importance of prenatal care, monitoring,
and adherence to treatment plans is essential for empowering expectant
mothers to navigate gestational problems successfully. Finally, staying
informed about advancements in research and best practices in managing
gestational issues ensures that healthcare professionals can provide the
highest quality of care to pregnant individuals.

1st Trimester

ECTOPIC
PREGNANCY
: A pregnancy
that grows outside
of the uterus,
usually in the
fallopian tube.

Signs and Symptoms

1. Severe, Sharp, Knife-like pain
2. Sign: CULLEN (bluish)
3. Stiff board-like abdomen
4. Signs of shock

Diagnostics
1. Transvaginal Ultrasound
This allows visualization of the uterus and fallopian tubes to
detect the presence of the embryo outside the uterus.

27
 2. Laparoscopy
In cases where diagnosis is uncertain or if there's a high
suspicion of ectopic pregnancy, laparoscopy may be performed.
It allows direct visualization of the fallopian tubes and
confirmation of the diagnosis.

3. Blood Tests
Includes measurement of serum beta-human chorionic
gonadotropin (β-hCG) levels. In ectopic pregnancy, β-hCG
levels may not rise normally or may plateau.

4. Pelvic examination

Nursing Management
Independent Interventions:

1. Elevate foot of the bed

2. Maintain thermoregulation and hydration
3. Monitor vital signs
4. Assist with Activities of Daily Living (ADL’s)
5. Provide emotional support

Dependent:
Pharmacological for unruptured EP
1. Methotrexate
2. Mifepristone

28
SPONTANEOUS ABORTION: Pregnancy loss before 20 weeks'
gestation.

Classifications of Abortions

1. Missed Abortion
When a pregnancy stops developing, where the
embryo/fetus/embryonic or empty gestational sac remains in the
uterus and cervical os is closed.

Signs and Symptoms

- No increase in fundic height

- (-) FHT
- Absence of fetal movement or growth
- Nausea and breast tenderness
2. Inevitable Abortion
The cervix has dilated, but the products of conception have
not been expelled.

Signs and Symptoms

- (+) uterine contraction

- (+) cervical dilatation
3. Threatened Abortion

29
 Vaginal bleeding before 20 weeks gestational age in the
setting of a positive urine and/or blood pregnancy test with a
closed cervical os, without passage of products of conception
and without evidence of a fetal or embryonic demise.

Signs and Symptoms

- (+) bleeding
- (-) cervical dilatation
4. Habitual Abortion
The miscarriage of 3 or more consecutive pregnancies.

5. Complete Abortion
All of the products (tissue) of conception leave the body.

6. Incomplete Abortion
Only some of the products of conception leave the body.

Nursing Management:

1. McDonald Procedure
- Removed by 37-38 weeks AOG
- Temporary cerclage, NSD required
- Nylon sutures reduce diameter of cervical canal
- SE: infection
2. Shirodkar Procedure
- Removed by 37- 38 weeks AOG
- Sterile tape is sutured in place to close the cervix
- PERMANENT
- CS required

Independent Interventions:
1. Complete bed rest
2. Side lying position
3. Comfort measures
4. Monitor vital signs

30
Dependent:
1. Hormonal therapy

2nd trimester

INCOMPETENT CERVIX :Cervix dilates prematurely and therefore

cannot hold a fetus until term.

31
Signs and Symptoms
1. Pelvic pressure
2. Backache
3. Mild stomach cramps
4. Change in vaginal discharge
5. Light vaginal bleeding
6. Mild contractions
Diagnostics
1. Ultrasound
an imaging test that uses sound waves to make pictures of
organs, tissues, and other structures inside your body. It allows
your health care provider to see into your body without surgery.
Ultrasound is also called ultrasonography or sonography.
Ultrasound images may be called sonograms.

2. Pelvic Exam
During a pelvic exam, the doctor checks the cervix to see if
the amniotic sac can be felt through the opening.

Nursing Management:
1. Cerclage: Involves temporarily sewing the cervix closed with
stitches. This may help the cervix hold a pregnancy in the
uterus.
2. Maintain hydration and a healthy diet
3. Side lying position (left)
4. Monitor vital signs
5. Activity restrictions
6. Monitor FHT

32
GESTATIONAL TROPHOBLASTIC DISEASE / H-
MOLE (HYDATIDIFORM MOLE): A rare grape-like mass or
growth that forms inside the uterus at the beginning of a pregnancy.

Signs and Symptoms

● Early signs
- Vesicles (fluid-filled) passed through the vagina
- Hyperemesis gravidarum
- Rapidly increasing fundic height
- Scant or profuse vaginal bleeding
● Early in Pregnancy
- High levels of HCG
- Pre- eclampsia at about 12 weeks

● Late Signs
- HTN before 20th week
- Vesicles look like a snowstorm or sonogram
- Anemia
- Abdominal cramping
● Serious Late Complications
- Hyperthyroidism
- Pulmonary embolism
1. (+) Urine Test
2. Weight Gain
3. Nausea and vomiting

33
 4. Increase in Fundic Height (Rapid)
5. (-) FHT
6. Bleeding (Profuse Brown)

Diagnostics
1. Pelvic examination
2. Pelvic ultrasound

Nursing Management
Independent Interventions
1. Maintain hydration
2. Monitor contraction, vaginal bleeding or pelvic pressure

Dependent Interventions
1. Methotrexate

GESTATIONAL DIABETES: Gestational diabetes mellitus

(GDM) is high blood sugar (glucose) that develops during pregnancy and
usually disappears after giving birth.

Signs and Symptoms:

34
 ● Increased thirst (polydipsia): Some women may experience
increased thirst due to elevated blood sugar levels.
● Frequent urination (polyuria): High blood sugar levels can lead
to increased urine production, causing frequent trips to the
bathroom.
● Fatigue: Elevated blood sugar levels can lead to feelings of
fatigue and low energy.
● Increased hunger (polyphagia): Some women may experience
increased hunger due to insulin resistance and inefficient
glucose uptake by cells.
● A dry mouth
● Blurred eyesight
● Genital itching or thrush

Diagnostics
1. Glucose Challenge Test (GCT)
This screening test is usually performed between 24 to 28
weeks of gestation. A glucose solution is consumed, and blood
sugar levels are measured one hour later. If the result is
elevated, a further diagnostic test is conducted.

2. Glucose Tolerance Test (GTT)

If the GCT result is higher than normal, a GTT is performed.
Fasting blood sugar levels are measured, followed by drinking a
glucose solution, and blood sugar levels are measured at
specific intervals (usually at one, two, and three hours) to
diagnose gestational diabetes.

Nursing Management:
1. Monitor blood glucose levels.
2. Provide dietary guidance and develop a personalized meal plan
to maintain stable blood sugar levels.
3. Educate patients on self-monitoring of blood glucose and
proper techniques for glucose testing.
4. Collaborate with healthcare professionals to adjust medication,
such as insulin, if necessary.

35
 5. Monitor fetal growth and development through regular
ultrasounds and other tests.
6. Promote physical activity and exercise, as recommended by
healthcare providers.
7. Educate patients on the potential risks of GDM to both the
mother and baby.
8. Schedule regular prenatal visits to monitor maternal and fetal
health.

HYPERTENSION: Gestational Hypertension also referred to as

Pregnancy-Induced Hypertension (PIH) is a condition characterized by high
blood pressure during pregnancy.

Classification of Hypertension:

1. Chronic Hypertension
Women who have high blood pressure (over 140/90) before pregnancy,
early in pregnancy (before 20 weeks), or continue to have it after delivery .

2. Gestational Hypertension

36
 High blood pressure that develops after week 20 in pregnancy and goes
away after delivery.

3. Preeclampsia
Both chronic hypertension and gestational hypertension can lead to this
severe condition after week 20 of pregnancy. Symptoms include high
blood pressure and protein in the urine. This can lead to serious
complications for both mom and baby if not treated quickly.

Signs and Symptoms

● Headache that doesn’t go away
● Edema (swelling)
● Sudden weight gain
● Vision changes, such as blurred or double vision
● Nausea or vomiting
● Pain in the upper right side of your belly, or pain around your
stomach
Making small amounts of urine

Diagnostics

1. Roll-over test
2. Hand grip test
3. Angiotensin II sensitivity
4. Liver and kidney function tests to rule out preeclampsia
5. Blood clotting tests to rule out preeclampsia

Nursing Management
1. Assess blood pressure and pulse every hour (1) or as indicated.
2. Assess the client for visual disturbances.
3. Assess the client for indications for an earlier delivery.
4. Monitor and measure the client’s urine output as per protocol.
Maintain strict intake and output.
5. Provide frequent rest periods with bed rest. Restrict activity
rather than instituting complete bed rest.
6. Instruct the client to elevate legs when sitting or lying down.
7. Instruct monitoring of BP at home.
8.
37
3rd Trimester

PLACENTA PREVIA: Placenta previa is a problem of

pregnancy in which the placenta grows in the lowest part of the womb
(uterus) and covers all or part of the opening to the cervix.

The placenta grows during pregnancy and feeds the developing

baby. The cervix is the opening to the birth canal.

Classifications of Placenta Previa:

1. Marginal placenta previa

The placenta is positioned at the edge of the cervix. It’s
touching the cervix, but not covering it. This type of placenta
previa is more likely to resolve on its own before the baby’s due
date.

2. Partial placenta previa

The placenta partially covers the cervix.

3. Complete or total placenta previa

The placenta is completely covering the cervix, blocking the
vagina. This type of placenta previa is less likely to correct
itself.

Signs and Symptoms

1. Painless
2. Sudden bright red bleeding
3. Mild cramping or contractions in the abdomen, belly or back

Nursing Management

38
 4. C-section
Independent Interventions
● Left side-lying position
● Assess amount of blood, duration, color
● Modify ADLs
Dependent Interventions
● Betamethasone

ABRUPTIO PLACENTA: Premature separation of the placenta

Signs and Symptoms

1. Sharp abdominal pain followed by uterine tenderness
2. Painful Bleeding
3. Couvelaire’s Uterus
Nursing Management
1. Fluid Replacement
2. Oxygen Support
3. FHT and VS monitoring every 5-15 mins
4. Lateral Position
5. No abdominal, vaginal or pelvic examination
6. Prepare for emergency C-Section

39
PRETERM LABOR: It occurs before the end of 37th week of Age
of Gestation (AOG). Results to premature infants.

Signs and Symptoms

● Effacement and dilatation
● Progressive, persistent, dull, low back pain
● Vaginal Spotting
Pelvic pressure/abdominal tightening or cramping
Diagnostics
1. Ultrasound
2. Vaginal mucus analysis
Nursing Management
● Complete bed rest
● Contraction monitoring
● FHT monitoring
● IVF therapy

40
 PREMATURE RUPTURE OF MEMBRANES:
Rupture of fetal membranes with loss of amniotic fluid during pregnancy
before 37 weeks.

Signs and Symptoms

● Sudden gush of clear liquid with continued minimal leakage
● Cramping
● Contractions
● Back Pain

Diagnostics
1. Nitrazine paper test
2. Blood testing
3. Ferning test
4. AFP testing

Nursing Management
Independent Interventions
1. Assess maternal and fetal distress
2. Assess signs of infection
3. No vaginal and pelvic exam
4. Complete bed rest
Dependent Interventions
1. Corticosteroids
4. Antibiotics

41
DISSEMINATED INTRAVASCULAR
COAGULATION (DIC): Acquired disorder of blood clotting in
which the fibrinogen level falls to below effective limit

Signs and Symptoms

1. Severe Bleeding
2. Hemoptysis (coughing up blood)
3. Acute Renal Failure
4. Signs of Shock

Diagnostics
1. Clinical Features + Laboratory (Coagulopathy)
2. Increase PT
3. Increase APTT
4. Decrease Platelets
5. Decrease Fibrinogen

Nursing Management
1. Fetal assessment
2. Monitor VS and I&O
3. Stabilization - IV Access, Fluid, and Oxygenation

42
 4. Airway Management
5. Lab studies every 30 mins: PT, PTT, Fibrinogen
6. Blood transfusion or platelet transfusion
7. Heparin IV to stop clotting cascade

HYPEREMESIS GRAVIDARUM: Extreme, persistent

nausea and vomiting that occur during pregnancy. It can lead to weight loss
and dehydration.

Signs and Symptoms

Severe, persistent nausea and vomiting during pregnancy.
Salivating a lot more than normal.
Weight loss.
Signs of dehydration, such as dark urine, dry skin, weakness,
lightheadedness, or fainting.
Constipation.

43
 Inability to take in adequate amounts of fluid or nutrition.

Diagnostics
1. Urinalysis
2. Electrolytes
3. I and O
4. ECG

Nursing Management
● Initially NPO, after 24 hrs, smaller amounts of food and fluid
● Supportive counseling or crisis intervention on stress and
relaxation
● Intravenous fluids

POLYHDRAMNIOS / HYDRAMNIOS: Excessive

amniotic fluid.

Signs and Symptoms

● Difficulty breathing
● Painful preterm contractions
● Uterus is larger than expected for dates

44
Diagnostics
1. Ultrasonographic measurement of AFI (the sum of the
vertical depth of fluid measured in each quadrant of the
uterus)
- Maternal testing for causes suspected based on
history

Nursing Managements
1. Amnioreduction
2. Prenatal monitoring

OLIGOHYDRAMNIOS: Deficient volume of amniotic fluid,

associated with maternal and fetal complications.

Signs and Symptoms

1. A sense of decreased fetal movement
2. Uterine size may be less than expected based on dates

45
Diagnostics
1. Ultrasonographic measurement of amniotic fluid volume
2. Comprehensive ultrasonographic examination at least once
every 4 weeks, including evaluation for fetal malformations

CHAPTER 3

POSTPARTAL COMPLICATIONS

46
Objectives:
The objectives in learning about postpartum problems
encompass a thorough understanding of the range of physical,
emotional, and psychological challenges that can arise after childbirth.
This includes recognizing common complications such as postpartum
hemorrhage, perineal trauma, mastitis, and postpartum depression.
Mastery involves learning effective management strategies, including
medical interventions, supportive care, and counseling techniques to
address these issues promptly and effectively. Additionally,
understanding the importance of postpartum care and monitoring for
both the mother and newborn is crucial to ensure optimal recovery and
early detection of any complications. Education on self-care practices,
mental health awareness, and resources available for support is essential
for empowering new mothers to navigate the postpartum period with
confidence and resilience.

PUERPERAL INFECTION

Infection of the reproductive tract is another leading cause of maternal

mortality. Theoretically, the uterus is sterile during pregnancy and until the
membranes rupture. After rupture, pathogens can invade. The risk of
infection is even greater if tissue edema and trauma is present.

Risk Factors:
1. Chorioamnionitis
2. Prolonged operative time
3. Bacterial vaginosis
4. Internal monitoring
5. Multiple vaginal exams

Signs and Symptoms

47
 1. Constant urination
2. Lower back aches
3. Rapid heart rate
4. High fever
5. Swollen or tender uterus
6. Foul smelling discharge

Diagnostics
1. Blood tests
2. Cultures of vaginal discharge or urine
3. Ultrasound or CT scans
4. Physical examination

Nursing Management

1. Promoting Infection Control and Management

2. Monitor temperature, pulse, and respiration. Note the presence
of chills or reports of anorexia or malaise.
3. Observe perineum/incision for other signs of infection (e.g.,
redness, edema, ecchymosis, discharge, and approximation.
4. Note subinvolution of the uterus, extreme uterine tenderness,
and lochia.
5. Monitor oral/parenteral intake, stressing the need for at least
2000 ml fluid per day
6. Investigate reports of leg or chest pain. Note pallor, swelling, or
stiffness of the lower extremity.

ENDOMETRITIS: An infection of the endometrium, the lining of

the uterus. Bacteria gain access to the uterus through the vagina and enter
the uterus either at the time of birth or during the postpartum period.

DIAGNOSTICS
Cultures from the cervix for chlamydia, gonorrhoea, and other organisms
● Endometrial biopsy
● ESR (erythrocyte sedimentation rate)
● Laparoscopy

48
 ● WBC (white blood count)
● Wet prep (microscopic exam of any discharge)

NURSING INTERVENTIONS

INDEPENDENT
1. Monitor temperature, pulse, and respiration. Note the presence of chills or
reports of anorexia or malaise.
2. Observe perineum/incision for other signs of infection (e.g., redness,
edema, ecchymosis, discharge, and approximation [REEDA scale]).
3. Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid
per day—note urine output, degree of hydration, and presence of nausea,
vomiting, or diarrhea.
4. Demonstrate and maintain a strict hand-washing policy for staff, clients,
and visitors.
5.Demonstrate correct perineal cleaning after voiding and defecation and
frequent changing of peripads.
6. Demonstrate proper fundal massage. Review the importance and timing of
the procedure.

DEPENDENT
1. Administer oral medications as ordered
2. Administer and regulate IV medications as prescribed
3.DRUG OF CHOICE: Clindamycin

49
POSTPARTUM HAEMORRHAGE: Severe bleeding
following childbirth is known as postpartum haemorrhage (PPH). It's a
dangerous and terrible condition. PPH often manifests 24 hours after
delivery, however it can sometimes arise up to 12 weeks after delivery.
Early detection and prompt treatment of bleeding can result in better
outcomes.

Causes:
● Uterine atony
● Lacerations
● Retained placental fragments,
● Uterine inversion
● Disseminated intravascular coagulation

Diagnostics
● Continual monitoring of your pulse rate and blood pressure to
detect problems.
● Blood tests to measure red blood cells (hematocrit) and clotting
factors.
● Ultrasound to get a detailed image of your uterus and other
organs.

Nursing Management
INDEPENDENT:
1. Assess and record the characteristics, amount, and site of the bleeding,
including the stage of labor.
2.Assess for the presence of a vulvar and vaginal hematoma.
3.Measure a 24-hour intake and output. Observe for signs of voiding
difficulty.
4.Apply counterpressure on labial or perineal lacerations.
5.Maintain bed rest with an elevation of the legs by 20-30° and the trunk
horizontal.
6.Educate the client and significant others on identifying the signs and

50
symptoms that need to be reported urgently.

DEPENTDENT:
1.Administer IV fluids using an 18-gauge catheter or via a central venous
line.
2.Administer fresh whole blood or other blood products as indicated.
3.Administer medications such as uterotonic drugs (e.g., oxytocin [pitocin],
methylergonovine maleate [Methergine], and prostaglandin F2a [Prostin
15M].
4.Insert an indwelling Foley catheter (IFC) as ordered.
5.DRUG OF CHOICE: Oxytocin

51
THROMBOPHLEBITIS: Phlebitis is inflammation of the
lining of a blood vessel.
-Thrombophlebitis is inflammation with the formation of
blood clots. When thrombophlebitis occurs in the postpartum period, it is
usually an extension of an endometrial infection.

Causes:
• A woman’s fibrinogen level is still elevated from preg-
nancy, leading to increased blood clotting.
• Dilatation of lower extremity veins is still present as a
result of pressure of the fetal head during pregnancy
and birth.
• The relative inactivity of the period or a prolonged time
spent in delivery or birthing room stirrups leads to pool-
ing, stasis, and clotting of blood in the lower extremities.
• Obesity from increased weight before pregnancy and preg-
nancy weight gain can lead to relative inactivity and lack
of exercise.
• The woman smokes cigarettes

Nursing Management
INDEPENDENT

1. Assess and monitor the affected limb for signs and symptoms of
thrombophlebitis, such as redness, warmth, swelling, and tenderness.
2. Elevate the affected limb to promote venous return and reduce swelling.
3. Apply warm compresses to the affected area to promote vasodilation and
relieve pain.
4. Encourage regular movement and ambulation to prevent blood stasis and
improve circulation.
5. Promote adequate hydration to prevent dehydration and promote blood
flow.
6. Provide patient education about the condition, including medication
compliance, signs of complications, and when to seek medical attention.
7. Assist with pain management through the administration of prescribed
medications and non-pharmacological pain relief measures.

52
8. Instruct the patient on the proper use of compression stockings, if
prescribed, to promote venous return and reduce the risk of blood clot
formation.
9. Ensure a safe environment free from hazards that could increase the risk
of injury or clot formation.

DEPENDENT
1.Administer prescribed medications, such as anticoagulants, as ordered to
prevent further clot formation.
2. Collaborate with the healthcare team to develop and implement a
comprehensive treatment plan.
3. Monitor laboratory values, such as prothrombin time (PT) or international
normalized ratio (INR), to assess the effectiveness of anticoagulant therapy.
4. Collaborate with the healthcare team to determine the need for additional
interventions, such as thrombolytic therapy or surgical intervention.
5.DRUG OF CHOICE: low molecular weight heparin, fondaparinux
(Arixtra) or apixaban (Eliquis)

SUPERFICIAL THROMBOPHLEBITIS

-More prevalent postpartum than during pregnancy seen more in women

experiencing varices. It involves the saphenous vein of the lower leg.

Signs And Symptoms

● Tenderness

53
 ● Pain
● Hard
● Redness and swelling
● Warm
● Phlegmasia alba dolens-Skin stretched to a point of shiny
whiteness, called milk leg

DEEP VEIN THROMBOSIS

-Medical condition that occurs when a blood clot forms in a deep vein.
Usually develop in the lower leg, thigh, or pelvis, but they can also occur in
the arm.

Signs And Symptoms

● Pain

54
 ● calf tenderness
● leg edema
● colour changes
● pain when walking positive
● Homan's sign

PULMONARY EMBOLISM

-Pulmonary artery is obstructed by a blood clot that breaks off and lodges in
the lungs

Signs And Symptoms

● Chest pain
● Cough
● Dyspnea
● Decreased level of consciousness
● Signs of heart failure.

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Diagnostic
1. Blood test
2. X-ray
3. CT pulmonary angiography
4. MRI

Nursing Management
INDEPENDENT
1. Deep breathing exercise
2. Pain management
3. Monitoring for clot progression
4. Infection control
5. Ambulation and mobility
6. Follow-up and monitoring

DEPENDENT
1. Administer prescribed medications (such as anticoagulants or
thrombolytics) as ordered by the physician
2. DRUG OF CHOICE: heparin or warfarin

MASTITIS
56
Mastitis (infection of the breast) may occur as early as the seventh
postpartum day or not until the baby is weeks or months old. The organism
causing the infection usually enters through
cracked and fissured nipples.

Signs and Symptoms

1. Breast tenderness or warmth to the touch
2. Breast swelling
3. Thickening of breast tissue, or a breast lump
4. Pain or a burning sensation continuously or while breast-
feeding
5. Skin redness, often in a wedge-shaped pattern
6. Generally feeling ill

Diagnostics
1. Physical examination
2. Milk examination

Nursing Management

INDEPENDENT
1. Making certain the baby is positioned correctly and graspsthe
nipple properly, including both nipple and areola
2. Releasing a baby’s grasp on the nipple before removingthe
baby from the breast
3. Washing hands between handling perineal pads and touching
the breasts
4. Exposing nipples to air for at least part of every day
5. Using a vitamin E ointment to soften nipples daily. If a woman
has one cracked and one well nipple, encourage her to begin
breastfeeding (when the infant sucks most forcefully) on the
unaffected nipple.

DEPENDENT
1.DRUG OF CHOICE: Dicloxacillin

57
 - Bactericidal antibiotic that inhibits cell wall synthesis. Used to
treat infections caused by penicillinase-producing staphylococci

URINARY SYSTEM DISORDERS

-Because a woman’s bladder is compressed by the infant’s birth, several
urinary tract disorders can occur.

A) Urinary Retention

- occurs as a result of inadequate bladder emptying. After childbirth, bladder

sensation for voiding is decreased because of bladder edema caused by the
pressure of birth. Unable to empty, the bladder fills to overdistention.

Signs & symptoms

1. Difficulty starting urination
2. Weak or interrupted urine stream
3. Decreased urine flow
4. Incomplete emptying of the bladder
5. Urgency to urinate
6. Frequent urination in small amounts
7. Sensation of bladder fullness or pressure
8. Abdominal discomfort or pain
9. Lower back pain
10. Involuntary leakage of urine (overflow incontinence)
11. Urinary tract infection (UTI) symptoms, such as burning or
pain during urination, cloudy urine, or blood in the urine

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Diagnostics
1. Urodynamic testing
2. Post-void residual urine test

Nursing Management
INDEPENDENT
1. Assess and monitor the patient's urinary symptoms, including
difficulty starting urination, weak urine stream, and incomplete
bladder emptying.
2. Encourage the patient to maintain a regular voiding schedule to
promote bladder emptying.
3. Assist the patient with positioning and comfort measures, such
as providing a commode or bedpan, to facilitate urination.
4. Promote relaxation techniques, such as deep breathing exercises
or guided imagery, to help the patient relax the pelvic muscles
and facilitate urination.
5. Encourage the patient to drink an adequate amount of fluids to
promote urinary flow and prevent urinary tract infections.
6. Provide education to the patient about the importance of
maintaining good hygiene to prevent urinary tract infections.
7. Assist the patient with toileting needs, including providing
privacy and assistance as needed.
8. Encourage regular physical activity and mobility to promote
bladder function and prevent urinary retention.
9. Collaborate with the healthcare team to ensure appropriate pain
management for any sampling conditions that may contribute to
urinary retention.

DEPENDENT
1. Collaborate with the healthcare team to determine the
underlying cause of urinary retention and develop a
comprehensive treatment plan.
2. Administer prescribed medications, such as alpha-blockers or
anticholinergic drugs, to relax the bladder muscles and improve
urine flow.
3. Assist with bladder catheterization, if necessary, to relieve
urinary retention and ensure bladder emptying.

59
 4. Collaborate with the healthcare team to monitor and manage
any complications related to urinary retention, such as urinary
tract infections or bladder distention.
5. Coordinate referrals to other healthcare professionals, such as
urologists or physical therapists, for further evaluation and
management of urinary retention.
6. DRUG OF CHOICE: Trimethoprim and sulfamethoxazole
(Bactrim, Bactrim DS) Fosfomycin (Monurol) Nitrofurantoin
(Macrodantin, Macrobid, Furadantin)

B) Urinary Tract Infection

- A woman who is catheterized at the time of childbirth or

during the postpartum period is prone to development of a urinary tract
infection, because bacteria may be introduced
into the bladder at the time of catheterization.

Signs & Symptoms

● Pain or burning sensation during urination
● Frequent urge to urinate, even when the bladder is empty

60
 ● Cloudy or bloody urine
● Strong and unpleasant urine odor
● Lower abdominal pain or discomfort
● Feeling tired or shaky
● Fever or chills (in more severe cases)

Diagnostics
● Urinalysis
● Cystoscopy
● CT scan
● Ultrasound

Nursing Management:
INDEPENDENT
1. Assess the symptoms of UTI
2.Encourage patient to drink fluids
3.Administer antibiotic as ordered
4.Encourage patient to void frequently
5.Educate patient on drinking acidic juices which help deter
growth of bacteria

DEPENDENT
1.Analyzing a urine sample
2.Creating images of the urinary tract.
3. DRUG OF CHOICE: Trimethoprim and Sulfamethoxazole

PSYCHIATRIC DISORDERS
61
 Psychiatric disorders, also known as mental illnesses, are
diagnosed by mental health professionals and are characterised by
disturbances in thinking, moods, and/or behaviour.
These disorders significantly increase the risk of disability,
pain, death, or loss of freedom.

Signs and Symptoms

● Feeling sad or down
● Confused thinking or reduced ability to concentrate
● Excessive fears or worries, or extreme feelings of guilt
● Extreme mood changes of highs and lows
● Withdrawal from friends and activities
● Significant tiredness, low energy or problems sleeping
● Detachment from reality (delusions), paranoia or hallucinations
● Inability to cope with daily problems or stress
● Trouble understanding and relating to situations and to people
● Problems with alcohol or drug use
● Major changes in eating habits
● Sex drive changes
● Excessive anger, hostility or violence
● Suicidal thinking

Diagnostics
● Physical Exam
● Lab Tests
● Psychological Evaluation

Nursing Interventions
INDEPENDENT
1. Provide a safe and therapeutic environment by ensuring a calm
and structured setting, free from potential triggers or hazards.
2. Encourage and facilitate engagement in therapeutic activities
such as art therapy, music therapy, or group therapy to promote
self-expression and emotional healing.

62
 3. 3.Teach and promote stress management techniques such as
deep breathing exercises, mindfulness, and relaxation
techniques to help patients cope with anxiety and stress.
4. 4.Collaborate with the interdisciplinary team to develop and
implement a comprehensive care plan that addresses the
physical, emotional, and social needs of the patient.
5. 5.Monitor and document the patient's response to medication
and report any adverse effects or changes in behaviour to the
disorders:

DEPENDENT
1. Administer prescribed medications as ordered by
the healthcare provider.
2. Assist with activities of daily living (ADLs) such
as bathing, grooming, and dressing to ensure
personal hygiene and self-care.
3. Implement behavioural management techniques as
directed by the healthcare provider to address
challenging behaviours and promote positive
coping skills.
4. Coordinate referrals to other healthcare
professionals such as psychologists, social
workers, or occupational therapists for specialised
interventions.
5. Collaborate with the healthcare provider to provide
psychoeducation to the patient and their family
regarding the nature of the psychiatric disorder,
treatment options, and community resources
available for ongoing support.
6. DRUG OF CHOICE: Selective serotonin reuptake
inhibitors (SSRIs) Serotonin-norepinephrine
reuptake inhibitors (SNRIs) Norepinephrine-
dopamine reuptake inhibitors (NDRIs)

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