NCMA 219 WEEK 1-5 CARE OF THE MOTHER & CHILD AT RISK

Progressive
WEEK 1 & 2
✓ Hypotension
✓ Tachycardia
✓ Tachypnea

HIGH-RISK PREGNANCY Irreversible

FACTORS IN THE DEVELOPMENT OF HIGH-RISK PREGNANCY ✓ Everything goes down – DEATH

• Age- <15/>35
E M ERGENCY INTERVENTIONS FOR BLEEDING
• Parity- Primigravida/G5 or more
• Birth Interval- <3mos /> 5years ✓ Alert health care team
• Height- <4’10’’ ✓ Place woman flat or SIDE LYING
• Family history ✓ Begin IVF with LARGE BORE needle
• Pre-existing health conditions ✓ Administer O2 as necessary Monitor Uterine
• Low socioeconomic status contractions and fetal movements
• Exposure to teratogens ✓ OMIT vaginal examination
• Fetal Development anomalies ✓ Withhold oral fluid
✓ BT preparation
BLEEDING DISORDERS IN PREGNANCY
✓ I and O monitoring
HYPOVOLEMIC SHOCK ✓ VS q15
✓ Measure blood loss
Hypovolemic shock is an emergency condition in which severe
blood or other fluid loss makes the heart unable to pump
BLEEDING DISORDERS (1st TRIMESTER)
enough blood to the body. This type of shock can cause many
organs to stop working. ABORTION

What causes hypovolemic shock?

The most common cause of hypovolemic shock is blood loss

when a major blood vessel bursts or when you're seriously
injured. This is called hemorrhagic shock. You can also get it
from heavy bleeding related to pregnancy, from burns, or even
from severe vomiting and diarrhea.

What is the first treatment for hypovolemic shock?

Treating hypovolemic shock means treating the underlying

medical cause. Physicians first will try to stop fluid loss and
stabilize blood volume levels before more complications
develop. Doctors usually replace lost blood volume with
Any interruption of pregnancy BEFORE the age of viability
intravenous (IV) fluids called crystalloids.
(24 weeks).
MANIFESTATIONS:
Abortion is the termination of a pregnancy by removal or
Initially – elevated vital signs expulsion of an embryo or fetus. An abortion that occurs
without intervention is known as a miscarriage or
✓ Cold clammy skin
"spontaneous abortion" and occurs in approximately 30%
✓ Decreased urine output
to 40% of pregnancies.
✓ Dizziness

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Is abortion legal in Philippines?
Abortion r emains illegal in the Philippines under all
cir cumstances and is highly stigmatized. While a liberal
interpretation of the law could exempt abortion provision
from criminal liability when done to save the woman's life,
there are no such explicit provisions.
SPONTANEOUS ABORTION
Spontaneous abortion is the loss of pregnancy naturally before
twenty weeks of gestation. Colloquially, spontaneous abortion
is referred to as a 'miscarriage' to avoid association with
induced abortion. Early pregnancy loss refers only to
spontaneous abortion in the first trimester. Medical staff
working in the field of obstetrics use this term to describe
miscarriage before 24 weeks gestation and is also referred to
as spontaneous abortion.
How does a spontaneous abortion happen?
Isolated spontaneous abortions may result from certain
viruses—most notably cytomegalovirus, herpesvirus,
parvovirus, and rubella virus—or from disorders that can cause
sporadic abortions or recurrent pregnancy loss.
Which is the most common cause of spontaneous abortions?
Genetic abnormalities within the embryo (ie, chromosomal
abnormalities) are the most common cause of spontaneous
abortion and account for 50-65% of all miscarriages.
What is the difference between missed abortion and
spontaneous abortion?
A missed abortion is not an elective abortion. Medical
practitioners use the term “spontaneous abortion” to refer to
miscarriage. A missed abortion gets its name because this type
of miscarriage doesn't cause symptoms of bleeding and cramps
that occur in other types of miscarriages.
CARE OF THE MOTHER & CHILD AT RISK
THREATENED ABORTION
When the symptoms indicate a miscarriage is possible, the
condition is called a "threatened abortion." (This refers to a
natural event that is not due to a medical or surgical abortion.)
Miscarriage is common. Small falls, injuries or stress during the
first trimester of pregnancy can cause threatened miscarriage.
✓ Mild-moderate bright red vaginal bleeding
✓ (+) Uterine cramping
✓ (-) cervical dilatation
A threatened abortion is defined as 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.
What are the signs and symptoms of threatened abortion?
Symptoms of a miscarriage or threatened miscarriage include
vaginal bleeding and pain. The bleeding may be mild or severe.
Pain and cramping in the lower abdomen, lower back,
buttocks, and genitals may be present. Other symptoms
associated with a true miscarriage include passage of blood
clots and tissue fragments.
Why does threatened miscarriage happen?
Small falls, injuries, or stress during the first trimester of
pregnancy can cause threatened miscarriage. It occurs in
almost one half of all pregnancies. The chance of miscarriag e
is higher in older women. About one half of women who have
bleeding in the first trimester will have a miscarriage.
IMMINENT/INEVITABLE ABORTION
Inevitable abortion is an early pregnancy with vaginal bleeding
and dilatation of the cervix. Typically, the vaginal bleeding is
worse than with a threatened abortion, and more cramping is
present. No tissue has passed yet.
✓ Mild-moderate-severe bright red vaginal bleeding
✓ (+) Uterine cramping
✓ (+) cervical dilatation
COMPLETE: all products of conception expelled
INCOMPLETE: parts of the product of conception not expelled
Is Inevitable abortion a miscarriage?
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An inevitable abortion describes a live intrauterine pregnancy
with an open cervical os, which uniformly results in
miscarriage when this occurs in the first trimester. Again,
ultrasound can document fetal heart rate.
How is inevitable abortion treated?
Inevitable and incomplete abortions are typically treated
surgically with suction D&C. A septic abortion requires broad
spectrum antibiotic therapy prior to a suction D&C, if possible
without delaying the D&C.
MISSED ABORTION
A missed abortion is a nonviable intrauterine pregnancy that
has been retained within the uterus without spontaneous
abortion. Typically, no symptoms exist besides amenorrhea,
and the patient finds out that the pregnancy stopped
developing earlier when a fetal heartbeat is not observed or
heard at the appropriate time.
✓ (-) fetal movement
✓ Foul-smelling vaginal bleeding
When do missed abortions happen?
How is a missed abortion diagnosed? A missed miscarriage is
most often diagnosed by ultrasound before 20 weeks'
gestation. Usually, the doctor diagnoses it when they cannot
detect a heartbeat at a prenatal checkup. Sometimes, it's
simply too early in the pregnancy to see a heartbeat.
What caused missed abortion?
Causes: Causes of missed abortion generally are the same as
those causing spontaneous abortion or early pregnancy failure.
Causes include anembryonic gestation (blighted ovum), fetal
chromosomal abnormalities, maternal disease, embryonic
anomalies, placental abnormalities, and uterine anomalies.
How is missed abortion treated?
Misoprostol is a non-invasive, effective medical method for
completion of abortion in missed abortion. Sublingual
misoprostol of 600 ug or vaginal misoprostol of 800 ug may be
a good choice for the first dose. The ideal dose and medication
interval of misoprostol however needs to be further
researched.
INDUCED ABORTION
CARE OF THE MOTHER & CHILD AT RISK
An abortion that is brought about intentionally. Also called an
artificial or therapeutic abortion. As opposed to a spontaneous
abortion (a miscarriage).
✓ a.k.a. Eugenic/ medical/therapeutic/elective
✓ Defective pregnancies
Induced abortion is the termination of a pregnancy by artificial
means. Governments can be permissive or restrictive in their
legislation regulating abortion. Induced abortion is legal in the
United States today, where more than one in five pregnancies
end in induced abortion. Although women of all types use
abortion services, women seeking abortions in the United
States tend to be young, poor, unmarried mothers.
RECURRENT PREGNANCY LOSS
Recurrent pregnancy loss is defined as having two or more
miscarriages. After three repeated miscarriages, a thorough
physical exam and testing are recommended.
✓ Habitual abortion of more than 3x
✓ Common cause: incompetent cervix
What is the most common cause of recurrent pregnancy loss?
The most commonly identified causes include uterine
problems, immunologic factors, hormonal disorders and
genetic abnormalities. At Yale Medicine, our Recurren t
Pregnancy Loss Program is the only such dedicated program in
the state.
How can I get pregnant after a recurrent miscarriage?
Doing a fertility cleanse to remove toxins and rebalance your
body. Eating a nutrient-dense fertility diet for at least 90 days.
Building a healthy foundation with vitamins and supplements.
Using Traditional Chinese Medicine to support your body so you
can have a successful pregnancy after recurrent pregnancy
loss.
THERAPEUTIC MANAGEMENT
THREATENED ABORTION
✓ Evaluation of the viability of the fetus and HCG level
✓ Avoid strenuous activity for 28-48 hrs (CBR s BRPs)
✓ No coitus for 2 weeks
(x) viability (LS ratio – 2 or above) and normal HGC level
✓ Tocolytic (Isoxilan or duvadilan)
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✓ Betasympathomimetic (terbutaline) Causes of an Ectopic Pregnancy:

(x) viability (LS ratio - <1.5) and low HCG level ✓ Infection
✓ Tumors
✓ Betametasone or Dexametasone ✓ Previous tubal surgery
✓ Congenital tubal malformation
IMMINENT ABORTION
What causes an ectopic pregnancy?
✓ Advise to save any tissue fragments
✓ Suction curettage or D/C (incomplete) • inflammation and scarring of the fallopian tubes from
✓ Monitor for excessive bleeding a previous medical condition, infection, or surgery.
• hormonal factors.
INCOMPLETE: Pregnancy test (+)
• genetic abnormalities.
✓ D/C • birth defects.
✓ Misoprostol (Cytotec) – aids in cervical dilatation • medical conditions that affect the shape and
condition of the fallopian tubes and reproductive
COMPLETE: organs.

✓ OXYTOCIN Predisposing Factor:

✓ PROPHYLACTIC ANTIBIOTIC
✓ Smoking, IUDs, In Vitro Fertilization
MISSED ABORTION
MANIFESTATIONS OF ECTOPIC:
✓ Allow the normal course of spontaneous delivery of
the dead fetus ✓ Kehr’s sign – sudden, sharp, knife-like (stabbing) pain
✓ Vacuum extraction in the LOWER ABDOMEN that sometimes radiates to
✓ D/E the shoulder
✓ Scant vaginal bleeding
SEPTIC ABORTION
RUPTURED:
✓ Broad spectrum antibiotic
✓ Resuscitation and correction of shock ✓ Rigid abdomen
✓ Hysterectomy ✓ (+) CULLEN’S SIGN
✓ Signs of shock
ECTOPIC PREGNANCY
How do you detect an ectopic pregnancy?
In an ectopic pregnancy, the egg implants somewhere other
than the uterus — often, in the fallopian tubes. This is why How is an ectopic pregnancy diagnosed?
ectopic pregnancies are commonly called "tubal pregnancies."
The egg also can implant in the ovary, abdomen, or the cervix. • A pelvic exam to check the size of your uterus and feel
for growths or tenderness in your belly.
✓ (Symptoms: Vaginal Bleeding) • A blood test that checks the level of the pregnancy
✓ Implantation outside the uterine cavity hormone (hCG). This test is repeated 2 days later. ...
• An ultrasound. This test can show pictures of what is
An ectopic pregnancy occurs when a fertilized egg implants and
inside your belly.
grows outside the main cavity of the uterus. An ectopic
pregnancy most often occurs in a fallopian tube, which carries
eggs from the ovaries to the uterus. This type of ectopic
pregnancy is called a tubal pregnancy.

Treatments: Methotrexate

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THERAPEUTIC MANAGEMENT IN ETOPIC
METHOTREXATE FOLLOWED BY LEUCOVORIN
These complications and side effects of methotrexate can be
either prevented or decreased by using Leucovorin, which
provides a source of folic acid for the body's cells. Leucovorin
is normally started 24 hours after methotrexate is given. This
delay gives the methotrexate a chance to exert its anti-cancer
effects.
✓ Abortifacient/antineoplastic
✓ Kills rapidly growing cells
MIFEPRISTONE:
✓ Sloughs off endometrial lining
✓ Abortifacient
RUPTURED:
✓ Laparoscopy Laparotomy
ECTOPIC PREGNANCY/ ABDOMINAL PREGNANCY
✓ Very Rare Product of conception implants into the
abdominal cavity (e.g. liver/intestine)
✓ Fetal outline – easily palpated
✓ Painful fetal movements
✓ Danger: placenta infiltrates major blood vessel
✓ Placenta: left in place and will be reabsorbed (2-3
mos)
✓ 60% survival rate
✓ Delivery through laparotomy
BLEEDING DISORDERS (2 nd TRIMESTER)
CARE OF THE MOTHER & CHILD AT RISK
HYDATIDIFORM MOLE
A molar pregnancy — also known as hydatidiform mole — is a
rare complication of pregnancy characterized by the abnormal
growth of trophoblasts, the cells that normally develop into
the placenta. There are two types of molar pregnancy,
complete molar pregnancy and partial molar pregnancy.
✓ a.k.a Gestational Trophoblastic Disease
✓ Abnormal proliferation and then degeneration of the
trophoblastic villi
What causes a hydatidiform mole?
A molar pregnancy is caused by an abnormally fertilized egg.
Human cells normally contain 23 pairs of chromosomes. One
chromosome in each pair comes from the father, the other
from the mother.
PREDISPOSING FACTORS:
✓ >35 years old
✓ Asian heritage
✓ Low protein intake
✓ Blood type A women to type O men
What is the serious complication of hydatidiform mole?
Hydatidiform moles can cause serious complications, including
the following: Infection of the uterus. A temperature of 100.4°
F (38° C) or higher during the first 12 hours after delivery could
indicate an infection but may... read more. A widespread
infection of the blood (sepsis.
TYPES OF HYDATIDIFORM MOLE
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✓ COMPLETE MOLE - A complete hydatidiform mole

(CHM) is a type of molar pregnancy and falls at the
benign end of the spectrum of gestational
trophoblastic disease
✓ All trophoblastic villi swell and become cystic
✓ PARTIAL MOLE - A partial molar pregnancy is a
variation of a molar pregnancy, an abnormal
pregnancy in which an embryo (the fertilized egg)
either develops incompletely or doesn't develop at
all. Instead, a cluster of grape-like cysts (known as a
hydatidiform mole) grows in the uterus.
✓ Some of the villi form normally
HYDATIDIFORM MOLE MANIFESTATIONS:
✓ RAPID uterine growth
✓ EXCESSIVE nausea and vomiting
✓ NO FHT
✓ (+) pregnancy test
✓ Passage of grape-like vesicles
THERAPEUTIC MANAGEMENT IN HYDATIDIFORM MOLE
✓ Suction and Curettage
✓ HCG monitoring
✓ Methotrexate
✓ Use of RELIABLE contraceptive method for 12
✓ months
✓ Complication: CHORIOCARCINOMA
Cervix that dilates which cannot hold fetus until term.
An incompetent cervix, also called a cervical insufficiency,
occurs when weak cervical tissue causes or contributes to
premature birth or the loss of an otherwise healthy pregnancy.
Before pregnancy, your cervix — the lower part of the uterus
that opens to the vagina — is normally closed and firm.
Symptoms of an Incompetent Cervix
Mild discomfort or spotting when you are 14 to 20 weeks
pregnant. Feeling pressure in your pelvis. Backache that you
haven't had before. Abdominal cramps.
Associated factors:
✓ Increased maternal age
✓ Congenital structural defects
✓ Trauma to the cervix
Mngt: Cervical Cerclage
✓ McDonald’s (diamond/temporary)
✓ Removed at 37 weeks (NSD)
Shirodkar (circle/permanent)

✓ Method of delivery: CS
✓ Bed rest and no coitus for few days
Choriocarcinoma is a fast-growing cancer that occurs in a
woman's uterus (womb). The abnormal cells start in the tissue BLEEDING DISORDERS (3 rd TRIMESTER)
that would normally become the placenta. This is the organ
that develops during pregnancy to feed the fetus. PLACENTA PREVIA
Choriocarcinoma is a type of gestational trophoblastic disease.

INCOMPETENT CERVIX

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✓ Low (placenta implanted near the cervical OS)

✓ Marginal (the edge of the placenta is near the cervical
OS)
✓ Partial (partial obstruction of the cervical OS)
✓ Complete/Total (total obstruction of the cervical)

MANIFESTATIONS OF PLACENTA PREVIA:

✓ Abrupt, PAINLESS bright red vaginal bleeding

THERAPEUTIC MANAGEMENT:

✓ NO IE unless in a double set-up

✓ Betamethasone ✓ CS birth (80%)
✓ Prevent hypovolemic shock and fetal distress

ABRUPTIO PLACENTA
Placenta previa (pluh-SEN-tuh PREH-vee-uh) occurs when a
baby's placenta partially or totally covers the mother's cervix
— the outlet for the uterus. Placenta previa can cause severe
bleeding during pregnancy and delivery. If you have placenta
previa, you might bleed throughout your pregnancy and during
your delivery.

✓ Low implantation of the placenta

The placenta is an organ that develops in the uterus during

pregnancy. Placental abruption occurs when the placenta
separates from the inner wall of the uterus before birth.
Placental abruption can deprive the baby of oxygen and
nutrients and cause heavy bleeding in the mother.

Is Abruptio placenta an emergency?

PREDISPOSING FACTORS:
Placental abruption is often a medical emergency, leaving you
✓ Increased parity
no time to prepare. However, it's possible that your health care
✓ Advanced maternal age
provider might notice signs of a coming abruption. Depending
✓ Post cesarean births
on the suspected severity of your placental abruption, you
✓ Post uterine curettage
might be admitted to the hospital and monitored.
✓ Multiple gestation
✓ Male fetus ✓ Premature separation of the placenta

TYPES: Predisposing factors:

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✓ Toxemia (PIH) • Uterine tenderness or rigidity.

✓ Increasing parity/maternal age • Uterine contractions, often coming one right after
✓ Sudden release of amniotic fluid another.
✓ Short umbilical cord
✓ Direct trauma (most common) What are the characteristics of Abruptio placenta?

TYPES ACCORDING TO SEPARATION Class 2 characteristics include the following: No vaginal

bleeding to moderate vaginal bleeding. Moderate to severe
✓ Partial (part of the placenta separated) uterine tenderness with possible tetanic contractions.
✓ Complete (entire placenta separated) Maternal tachycardia with orthostatic changes in BP and heart
rate.
TYPES ACCORDING TO BLEEDING
PRETERM LABOR
✓ Apparent (bleeding seen on vagina)
✓ Concealed (bleeding confined inside Preterm labor is labor that starts before 37 weeks of
pregnancy. Going into preterm labor does not automatically
DEGREE OF SEPARATION mean that a woman will have a preterm birth. But preterm
labor needs medical attention right away. What is preterm
✓ 0 (no manifestations/ placenta incomplete: DUNCAN)
✓ 1 (Maternal manifestations: changes in VS and birth? Preterm birth is the birth of a baby before 37 weeks.
bleeding)
What are the signs of preterm labor?
✓ 2 (Maternal and fetal manifestations: hard, board-like
uterus, fetal distress) Signs and symptoms of preterm labor include:
✓ 3 (hypovolemic shock – mother / fetal death)
• Regular or frequent sensations of abdominal
What is the difference between placenta previa and abruptio tightening (contractions)
placentae?
• Constant low, dull backache.
Q: What's the difference between placenta abruptio and
placenta previa? A: With placenta abruptio, the placenta • A sensation of pelvic or lower abdominal pressure.
partially or completely detaches itself from the uterine wall
• Mild abdominal cramps.
before delivery. With placenta previa, the placenta is located
over or near the cervix, in the lower part of the uterus.
• Vaginal spotting or light bleeding.
MANIFESTATIONS OF ABRUPTIO PLACENTA
What triggers preterm labor?
✓ Severe, SHARP, knife-like stabbing pain HIGH in the
When a woman has a spontaneous preterm birth at a very
FUNDUS
early gestational age (between 20- and 32-weeks’ gestation)
✓ Board-like uterus (Couvelaire uterus)
the most common reason is infection or inflammation. In some
✓ Bleeding
cases, bacteria or viruses can cause an infection in your uterus,
✓ Signs of Shock
vagina, bladder, or some other part of your body. This can
THERAPEUTIC MANAGEMENT: cause preterm birth.

✓ Continuous monitoring Labor that occurs before the end of week 37 of gestation.
✓ Prepare for emergency delivery Prevalence: 9-11% of pregnancies

Signs and symptoms of placental abruption include: Predisposing factors:

• Vaginal bleeding, although there might not be any. ✓ DEHYDRATION is the most common cause
• Abdominal pain. ✓ UTI
✓ Chorioamnionitis
• Back pain.
✓ African American descent
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✓ Adolescents ✓ Potter-like syndrome (distorted facial features)

✓ Inadequate prenatal care ✓ Pulmonary hypoplasia

MANIFESTATIONS OF PRETERM LABOR:

MANIFESTATION:
✓ Vaginal spotting
✓ Persistent, dull, low backache ✓ Sudden gush of fluid from vagina
✓ Menstrual-like cramping
Nitrazine paper test:
THERAPEUTIC MANAGEMENT:
✓ Amniotic fluid (alkaline) – paper turns BLUE
✓ CBR/Daily fetal movement count (n=10-20 mvts/hr) ✓ Urine (acidic) – paper remains YELLOW (+) Ferning –
✓ IVF Amniotic fluid (d/t high estrogen fluid on microscope.
✓ Antibiotic
THERAPEUTIC MANAGEMENT
Corticosteroid (Dexa/Betamethasone) – 24 hrs to take effect:
2 doses – 12 g betamethasone IM 12 hrs apart: (X) viable

6 doses – 6 mg dexamethasone IM 12 hrs apart. Bed rest and corticosteroid and antibiotic

✓ B-sympathomimetic Amnioinfusion – reduces pressure on the cord and fetus (not

✓ Tocolytics (Ritorine HCl (Yutopar) and Terbutaline well document).
(Brethine)
Fibrin-based commercial sealant (endoscopic uterine
PREMATURE RUPTURE OF MEMBRANES procedure).

Premature rupture of membranes (PROM) is a rupture

(breaking open) of the membranes (amniotic sac) before labor
begins. If PROM occurs before 37 weeks of pregnancy, it is
called preterm premature rupture of membranes (PPROM).
PROM occurs in about 8 to 10 percent of all pregnancies.
NATIONAL HEALTH SITUATION ON MCN
What causes premature rupture of membranes?
The maternal and child population is constantly changing
In most cases, the cause of PROM is unknown. Some causes or
because of changes in social structure, variations in family
risk factors may be: Infections of the uterus, cervix, or vagina.
lifestyle, and changing patterns of illness. Client advocacy,
Too much stretching of the amniotic sac (this may happen if
participating in cost containment measures, focusing on health
there is too much fluid, or more than one baby putting pressure
education, and creating new nursing roles are ways in which
on the membranes)
nurses have adapted to these changes. Client advocacy is
PREMATURE RUPTURE OF MEMBRANES safeguarding and advancing the interests of clients and their
families. The role includes knowing the health care services
Rupture of fetal membranes with loss of amniotic fluid during available in a community, establishing a relationship with
pregnancy before 37 weeks. families, and helping them make informed choices about what
course of action or service would be best for them.
PREDISPOSING FACTORS:
FOCUS ON NATIONAL HEALTH GOALS (LEADING HEALTH
✓ Chorioamnionitis
INDICATORS)
Complication:
• Physical Activity
✓ Fetal infection • Mental Health
✓ Cord compression • Overweight and Obesity

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• Injury and Violence

• Tobacco use
• Environmental Quality
• Substance abuse
• Immunization
• Responsible sexual behavior
• Access to Health Care

GENETIC DISORDERS

ONE PARENT

✓ One of the parents of a child with the disorder also

will have the disorder.

NATURE OF INHERITANCE
Genes are the basic units of hereditary that determine both
the physical and cognitive characteristics of people. Composed
of segments of DNA, they are woven into strands in the nucleus
of all body cells to form chromosomes. A person’s phenotype
refers to his or her outward appearance or the expression of
the genes. A person’s genotype refers to his or her actual gene
composition. A person’s genome is the complete set of genes
present which is about 50,000- 100,000.
AUTOSOMAL DOMINANT DISORDERS
With an autosomal dominant condition, either a person has
two unhealthy genes or is heterozygous, with the gene causing
the disease stronger than the corresponding healthy recessive
gene for the same trait. (Autosomal dominant inheritance is a
way a genetic trait or condition can be passed down from
parent to child. One copy of a mutated (changed) gene from
one parent can cause the genetic condition.)
SEX
✓ The sex of the affected individual is unimportant in
terms of inheritance.
HISTORY
✓ There is usually a history of the disorder in other
family member.
AUTOSOMAL RECESSIVE INHERITANCE
More than 1,500 autosomal recessive disorders have been
identified. In contrast, to structural disorders, these tend to be
biochemical or enzymatic. (One of the ways a genetic trait or a
genetic condition can be passed down (inherited) from parent
to child.)
✓ Examples include cystic fibrosis, adrenogenital
syndrome, albinism, TaySachs disease, galactosemia,
phenylketonuria, limb-girdle muscular dystrophy and
Rh-factor incompatibility.

When family genograms are assessed for the incidence of

inherited disease, situations commonly discovered when a
recessively inherited disease is present in the family include
the following:

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1. Both parents of a child with the disorder are clinically
free of the disorder
2. The sex of the affected individual is unimportant in
terms of inheritance
3. The family history for the disorder is negative – that is
no one can identify anyone else who had it (a
horizontal transmission pattern)
4. A known common ancestor between the parents
sometimes exists. This explains how both male and
female came to possess a like gene for the disorder.
BOTH PARENT
✓ Both parents of a child with the disorder are clinically
free of the disorder.
SEX
✓ The sex of the affected individual is unimportant in
terms of inheritance.
HISTORY
✓ The family history for the disorder is negative—that
is, no one can identify anyone else who had it (a
horizontal transmission pattern).
ANCESTOR
✓ A known common ancestor between the parents
sometimes exists. This explains how both male and
came to possess a like gene for the disorder.
X-LINKED DOMINANT INHERITANCE
There are about 300 known X-linked disorders. If the gene is
dominant, only one X chromosome with the trait need be
present for symptoms of the disorder to be manifested. (One
of the ways a genetic trait or condition caused by a mutated
(changed) gene on the X chromosome can be passed down
(inherited) from parent to child.)
CARE OF THE MOTHER & CHILD AT RISK
Family characteristics seen with this type of inheritance
include the following:
1. All individuals with the gene are affected.
2. All female children of affected men are affected; all
male children of affected men are unaffected.
3. It appears in every generation.
4. All children of homozygous affected women are
affected. 50% of the children of heterozygous
affected are woman.
DOMINANT GENE
✓ All individuals with the gene are affected.
AFFECTED
✓ All female children of affected men are affected; all
male children of affected men are unaffected.
GENERATION
✓ It appears in every generation.
HOMOXYGOUS/HETEROZYGOUS
✓ All children of homozygous affected women are
affected. Fifty percent of the children of heterozygous
affected women are affected.
X-LINKED RECESSIVE INHERITANCE
The majority of X-linked inherited disorders are recessive, and
inheritance of the gene from both parents is incompatible with
life.
✓ Examples are Hemophilia A, color blindness,
Duchenne muscular dystrophy and fragile X
syndrome
When family genograms are assessed for inherited disorders,
the following findings usually are apparent if an X-linked
recessive inheritance disorder is present in the family:
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1. Only males in the family will have the disorder ✓ Do not follow the mendelian laws
2. A history of girls dying at birth for unknown reasons ✓ No set patterns in family history
often exists (females who had the affected gene on
both X chromosomes IMPRINTING
3. Sons of an affected man are unaffected
✓ Refers to the differential expression Of genetic
4. The parents of affected children do not have the
material
disorder
✓ Allows researchers to identify Whether chromosomal
material Comes from the male or female parent

CHROMOSOMAL ABNORMALITIES (CYTOGENIC DISORDERS)

NONDISJUNCTION ABNORMALITIES

✓ Abnormalities occur if the division is uneven

✓ If spermatozoon or ovum with 24 or 22 Chromosomes
fuses with a normal Spermatozoon or ovum. The
zygote will Have either 47 or 45 chromosomes, not
the Normal 46 5 chromosomes is not compatible with
life and could lead to abortion.

DELETION ABNORMALITIES

✓ Part of the chromosomes breaks during cell division

causing the Affected person to have an extra portion
of a chromosome.

TRANSLOCATION ABNORMALITIES

MALES ✓ A child gains additional chromosome through another

route.
✓ Only males in the family will have the disorder

HISTORY OF DEATH
ISOCHROMOSOMES
✓ A history of girls dying at birth for unknown reasons
often exists (females who had the affected gene on ✓ Results from chromosome accidentally dividing not
both X chromosomes). by vertical separation but by horizontal one so a new
chromosome with mismatched long and short arms.
UNAFFECTED
MOSAICISM
✓ Sons of an affected man are unaffected
✓ Abnormal condition that is present when the
PARENTS
nondisjunction disorder occurs after fertilization of
✓ The parents of affected children do not have the the ovum as the structure begins mitotic division.
disorder ✓ Different cells in the body will have different
chromosome counts.
MULTIFACTORIAL (POLYGENIC) INHERITANCE
GENETIC COUNSELLING
✓ Many childhood disorders tend to have Higher-than
usual incidence ✓ Provide concrete, accurate information about the
✓ Occur from multiple gene combinations Possibly process of inheritance and inherited disorders .
combined with environmental Factors
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✓ Reassure people who are concerned that their child
may inherit a particular disorder or that the disorder
will not occur.
✓ Allow people who are affected by inherited disorders
to make informed choice about future reproduction.
✓ Offer support to people who are affected by genetic
disorders.
WHO SHOULD GO FOR GENETIC COUNSELLING?
✓ Couple who has a child with congenital disorder or an
inborn error of metabolism.
✓ Couple whose close relatives have a child with a
genetic disorder.
✓ Any individual who is known balanced translocation
carrier.
✓ Any individual who has an inborn error of metabolism
or chromosomal disorder.
✓ A consanguineous (closely related) couple.
✓ Any woman older than 35 years and any man older
than 55 years.
✓ Couples of ethnic backgrounds in which specific
illnesses are known to occur.
NURSING RESPONSIBILITIES
✓ Explain what procedures to undergo.
✓ Explain how different genetic screening tests are
done and when offered.
✓ Support the couple during the wait for test results.
✓ Assist couples in values clarification, planning, and
decision making based on test results.
GENETIC DISORDERS ASSESSMENT
✓ HISTORY
✓ PHYSICAL ASSESSMENT
✓ DIAGNOSTIC TESTING
Karyotyping
✓ karyotype is a visual presentation of the chromosome
pattern of an individual.
(a test to identify and evaluate the size, shape, and number of
chromosomes in a sample of body cells. Extra or missing
chromosomes, or abnormal positions of chromosome pieces,
can cause problems with a person's growth, development, and
body functions.)
Maternal serum screening
CARE OF THE MOTHER & CHILD AT RISK
✓ Alpha-fetoprotein is a glycoprotein produced by the
fetal liver that reaches a peak in maternal serum
between the 13th and 32nd week of pregnancy. The
AFP level deviates from normal if a chromosomal or a
spinal cord disorder is present.
(a blood test used to identify pregnancies with an increased
chance of having a chromosome condition, such as Down
syndrome. Serum screening can be done during the first
trimester, called combined first trimester screening (CFTS), or
during the second trimester.)
Chorionic villi sampling
Amniocentesis
✓ The withdrawal of amniotic fluid through the
abdominal wall for analysis at the 14th to 16th week
of pregnancy
(Procedure used to take out a small sample of the amniotic
fluid for testing. This is the fluid that surrounds the fetus in a
pregnant woman. Amniotic fluid is a clear, pale-yellow fluid
that: Protects the fetus from injury. Protects against infection.)
Percutaneous umbilical blood sampling (PUBS)
✓ or Cordocentesis is the removal of blood from the
fetal umbilical cord at about 17th week of pregnancy
using an amniocentesis technique.
(a diagnostic prenatal test. During cordocentesis, an
ultrasound transducer is used to show the position of the fetus
and umbilical cord on a monitor. Then a fetal blood sample is
withdrawn from the umbilical cord for testing.)
Fetal imaging
✓ Computed tomography (CT), Magnetic Resonance
Imaging (MRI) and ultrasonography are all diagnostic
tools used to assess a fetus for general size a
structural disorders of the internal organs, spine, and
limbs.
(An imaging technique that uses sound waves to produce
images of a fetus in the uterus. Fetal ultrasound images can
help your health care provider evaluate your baby's growth and
development and monitor your pregnancy)
Fetoscopy
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✓ Insertion of a fiberoptic fetoscope through a small
incision in the mother’s abdomen into the uterus and
membranes to visually inspect the fetus for gross
abnormalities.
(Procedure where a small instrument (laparoscope) is inserted
into the uterus in order to see the fetus and placenta.
Fetoscopic laser surgery offers the best chance of curing twin-
to-twin transfusion syndrome (TTTS) or twin anemia
polycythemia sequence (TAPS) in a single treatmen t
procedure.) Preimplantation diagnosis.
R.A 9262
RA 9262 acknowledges that women who have retaliated
against their partner or who commit violence as a form of self-
defense may have suffered from Battered Woman Syndrome
(BWS). Any victim who suffers from BWS should be diagnosed
by a Psychiatric expert or a clinical psychologist.
✓ Refers to any act or a series of acts committed by an
intimate partner.
✓ Against a woman who is his wife, former wife.
✓ Against a woman with whom the person has or had
sexual or dating relationship.
✓ Against a woman with whom he has a common child.
CARE OF THE MOTHER & CHILD AT RISK
✓ Against her child whether legitimate or illegitimate
within or without the family abode.
TYPES OF ABUSE
PHYSICAL VIOLENCE
Physical violence is when a person hurts or tries to hurt a
partner by hitting, kicking, or using another type of physical
force.
SEXUAL VIOLENCE
Sexual violence refers to any sexual act or attempt to obtain a
sexual act, or unwanted sexual comments or acts to traffic,
that are directed against a person's sexuality using coercion by
anyone, regardless of their relationship to the victim, in any
setting, including at home and at work.
PSYCHOLOGICAL VIOLENCE
In the private sphere, psychological violence includes
threatening conduct which lacks physical violence or verbal
elements, for example, actions that refer to former acts of
violence, or purposeful ignorance and neglect of another
person.
ECONOMIC ABUSE
a situation in which someone harms another person in a close
relationship using money or property, for example by
controlling how they are able to get or spend money or
preventing them being able to buy things that they need: With
economic abuse, money becomes a way to control the victim.
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PROTECTION ORDER
BARANGAY PROTECTION ORDERS (BPO)
✓ Barangay protection order" (BPO) refers to the
protection order issued by the Punong Barangay, or in
his absence the Barangay Kagawad, ordering the
perpetrator to desist from committing acts of
violence against the family or household members
particularly women and their children under Sections
5a and 5b of R.A.
TEMPORARY PROTECTION ORDERS (TPO)
✓ Temporary Protection Orders (TPOs) refers to the
protection order issued by the court on the date of
filing of the application after ex parte determination
that such order should be issued. A court may grant
in a TPO any, some or all of the reliefs mentioned in
this Act and shall be effective for thirty (30) days.
PERMANENT PROTECTION ORDER (PPO)
✓ It is issued when a TPO is violated, or when there is a
threat of imminent danger. The Permanent
Protection Order is requested by the prosecutor or
lawyer from the judge. In this case, the danger is not
only physical.
INTIMATE PARTER ABUSE
Abuse by a family member against another adult living in the
household.
Common injuries suffered by abused women:
✓ Burns
✓ Lacerations
CARE OF THE MOTHER & CHILD AT RISK
✓ Bruises
✓ Head injuries
BEHAVIORS OF ABUSED WOMEN
✓ May come for care late in pregnancy or not at all.
✓ Purchase no maternity clothing.
✓ Decline laboratory tests if they involve additional
transportation or money.
✓ Difficulty following recommended pregnancy
nutrition.
✓ Anxious if her appointment is running late.
✓ Call and cancel appointments frequently.
✓ Dress inappropriately for warm weather, wearing
long-sleeved, tight-necked blouses to cover up
bruises.
ASSESSMENT
✓ Presence of bruises or lacerations on breasts,
abdomen, or back she cannot explain during physical
examination.
✓ Ask woman with bruises to account for them and
determine whether explanation correlates with the
extent and placement of bruise or laceration.
✓ Ultrasound may reveal minimal placental infarcts
from blunt abdominal trauma.
✓ Record fetal heart tones and fundal height.
NURSING INTERVENTIONS
✓ Support any ability the woman had to make
constructive decisions.
✓ Discuss how she can call the police any time and take
her to shelter.
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✓ Help to file charges or obtain restraining order to keep
the abusive person from coming near the woman if
necessary.
✓ Be careful not to blame the victim.
✓ Help find a shelter where the woman will feel safe.
✓ Do not leave an abused woman without support
system after the birth of her child.
NCMA219 RLE
PAIN MANAGEMENT
Pain management nurses are responsible for the care of
patients with chronic or acute pain. Once they have assessed
a patient's pain, they work closely with doctors and other
nurses to create a treatment plan. Pain management nurses
administer medications and provide pain relief through other
therapeutic methods.
OBJECTIVES
+ Discuss common misconceptions about pain
+ Describe the physiology of pain
+ Identify components of the pain experience, explain
how the physiology of pain relates to selecting
interventions for pain relief
+ Assess a patient experiencing pain
+ Explain how cultural factors influence the pain
experience
+ Explain various pharmacological approaches to
treating pain
+ Describe application for use of nonpharmacologic
pain interventions
+ Discuss nursing implications for administering
analgesics
+ Identify barriers to effective pain management
+ Evaluate a patients' response to pain management
Potter, P., Stockert, P., Perry, A., Hall, A. (2018).
Fundamentals in Nursing. Singapore: Elsevier. Chapter 44
CARE OF THE MOTHER & CHILD AT RISK
DEFINITIONS OF PAIN
By: (IASP) International Association for Study of Pain
✓ Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage.
By: Stenback
✓ a personal private sensation of hurt.
✓ a harmful stimulus that signals current or impending
tissue damage.
✓ a pattern of responses to protect the organism from
burn.
By: Mc Caffery (1979)
✓ whatever the experiencing person says it is existing
whenever the person say it is
Misconceptions and Myths of Pain
+ Pain is a part of aging
+ If a person is asleep, they are not in pain
+ If pain is relieved by non-pharmaceutical pain relief
techniques, the pain was not real
+ Real pain has an identifiable cause
+ It is better to wait until a client has pain before giving
medications
+ Very young or very old people do not have as much
pain
+ Some clients lie about the existence or severity of
their pain
+ Addiction occurs with prolonged use of morphine or
morphine derivatives
+ The same physical stimulus produces the same pain
intensity, duration and distress in different people
+ Clients experience severe pain only when they have
had major surgery.
+ The nurse or other health care professionals are the
authorities about a client’s pain
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+ Visible or physiologic or behavioral signs accompany

pain and can be used to verify its existence.
TERMINOLOGIES

Pain Related Terms

Radiating pain

▪ Perceived at the source of the pain and extends

to the nearby tissues.
Radiating pain is caused by medical conditions that
affect the nerves in your body. This results in traveling
pain that spreads from the original pain point to a
larger area of the body. Conditions that may trigger
radiating pain are those that punch or pull on a nerve,
such as a herniated or bulging disc.
What is radiating pain feel like?
Radiating pain can range from dull to sharp or
electric shock-like, and it may come and go or be
continuous. It is usually only felt on one side of the
body, such as going into the chest on one side.
Tingling, numbness, or weakness.
Referred pain
▪ Felt in a part of the body that is considerably
removed or far from the tissues causing the pain.
Referred pain is pain perceived at a location other than the
site of the painful stimulus/ origin. It is the result of a network
of interconnecting sensory nerves, that supplies many different
tissues.
What is an example of referred pain?
Hyperalgesia
+ Excessive sensitivity to pain
Hyperalgesia is an enhanced pain response. It can result from
either injury to part of the body or from use of opioid
painkillers. When a person becomes more sensitive to pain as
a result of taking opioid medication, it's called opioid-induced
hyperalgesia (OIH).
Pain Threshold/ sensation
+ the amount of pain stimulation a person requires
before feeling pain
+ least level of pain that the patient can detect
Pain threshold refers to the lowest intensity at which a given
stimulus is perceived as painful; it is relatively constant across
subjects for a given stimulus. For example, most subjects will
define a thermal stimulus as painful when it reaches about 50°
C.
Pain Reaction

Referred pain is when the pain you feel in one part of your body
is actually caused by pain or injury in another part of your body.
For example, an injured pancreas could be causing pain in
your back, or a heart attack could be triggering pain in your
jaw.

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Includes the ANS and behavioral

responses to pain
Pain Receptor Pain Stimuli Pain Fibers

Types:
Pain receptors, also called nociceptors, are a group of sensory
neurons with specialized nerve endings widely distributed in
autonomic reaction of the body
the skin, deep tissues (including the muscles and joints), and
that often protect the individual most of visceral organs.
ANS response from further harm. (automatic
withdrawal of hand from hot
object.) Pain stimulus is a technique used by medical personnel for
assessing the consciousness level of a person who is not
is a learned responding to normal interaction, voice commands or gentle
response used as a
Behavioral response physical stimuli (such as shaking of the shoulders).
method of coping
with pain.
Aδ fibers carry cold, pressure, and acute pain signals; because
they are thin (2–5 μm in diameter) and myelinated, they send
Reaction of pain is observed by dilation of the pupil or any
impulses faster than unmyelinated C fibers, but more slowly
other involuntary act occurring in response to a stimulus
than other, more thickly myelinated group A nerve fibers.
causing sharp pain anywhere. This is a long pathway, in which
neurons make connections in both the brain and the spinal Pain Stimuli
cord.

Pain Tolerance

+ maximum amount and duration of pain that an

individual is willing to endure
+ greatest level of pain that the patient can tolerate
Your pain tolerance refers to the maximum amount of pain
you can handle. This is different from your pain threshold. Your
pain threshold is the minimum point at which something, such
as pressure or heat, causes you pain. + Thermal
+ Mechanical
Pain Perception
+ Chemical
+ the point which the person becomes aware of the • Tissue anoxia
pain
+ Nociceptors
the perception of physiological pain, usually evoked by stimuli
• Skin
that cause or threaten to cause tissue damage. In some cases,
• Periosteum
such as phantom limb pain and causalgia, the persistence of
• Plerual
pain cannot be explained by stimulation of neural pathways.
• Peritoneum
TRIAD OF PAIN PERCEPTION • Joint surfaces
AND PATHOPHYSIOLOGY • Cornea
• T of CV
TRIAD OF PAIN PERCEPTION • Arterial wall
Pain Fibers

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Transduction

Transmission

Perception

Modulation

Perception

There are two separate pathways

that transmit pain impulses to the
brain:

are associated with

Type A-delta ▪ cerebral cortex
fast, sharp, acute
fibers ▪ somato sensory cortex
pain and
▪ association cortex
▪ limbic system
The brain does not passively receive pain information from the
are associated with body, but instead actively regulates sensory transmission by
2) Type C fibers slow, chronic, aching exerting influences on the spinal dorsal horn via descending
pain projections from the medulla.

Where does perception happen for pain?

Physiology of Pain
Perception of pain occurs when stimulation of nociceptors is
intense enough to activate. Activation of nociceptors reaches
to the dorsal horn of the spine along the axons of peripheral.
After that, nerve messages are relayed up to thalamus by the
spinothalamic tract.

4. Modulation

+ endogenous opioids (endorphins & enkephalins

o chemical substances
▪ spinal and medullary dorsal horn
▪ periaqueductal gray matter
▪ hypothalamus
▪ amygdala in the CNS)
+ serotonin 5HT
+ norepinephrine
+ gamma amino butyric acid (GABA)
Modulation is the process of converting data into radio waves
by adding information to an electronic or optical carrier signal.

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A carrier signal is one with a steady waveform -- constant

height, or amplitude, and frequency.

Pain Syndrome

Psychogenic
Referred Pain Radiating Pain
Pain

+ no pathologic cause
Neurologic Phantom Limb Intractable
Pain Pain Pain + Caused:
• Mental
• Emotional
▪ Referred pain is pain perceived at a location other • Behavioral factors
than the site of the painful stimulus/ origin. It is the + induced by
result of a network of interconnecting sensory nerves, • social rejection, broken heart, grief, love
that supplies many different tissues. sickness, or other such emotional events.
▪ Radiating pain is caused by medical conditions that Psychogenic Pain
affect the nerves in your body. This results in traveling
pain that spreads from the original pain point to a
larger area of the body. Conditions that may trigger
radiating pain are those that punch or pull on a nerve,
S/S: HEADACHE BACK PAIN STOMACH
such as a herniated or bulging disc.
, PAIN
▪ Psychogenic pain is not an official diagnostic term. It
is used to describe a pain disorder attributed to Neurologic Pain
psychological factors. Such things as beliefs, fears,
and strong emotions can cause, increase, or prolong
pain.
▪ Neuropathic pain can happen if your nervous system
is damaged or not working correctly. You can feel
pain from any of the various levels of the nervous
system—the peripheral nerves, the spinal cord and
the brain. Together, the spinal cord and the brain are
known as the central nervous system.
▪ Phantom limb pain is pain that is felt in the area
where an arm or leg has been amputated. Although
the limb is gone, the nerve endings at the site of the
+ MAIN PROBLEM:
amputation continue to send pain signals to the brain
• neurologic system
that make the brain think the limb is still there.
▪ Intractable pain refers to a type of pain that can't be + Damage PNS & CNS Nerve fibers
controlled with standard medical care. Intractable
essentially means difficult to treat or manage. This
type of pain isn't curable, so the focus of treatment is
to reduce your discomfort. The condition is also known
as intractable pain disease, or IP.
Psychogenic Pain

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What causes neuropathic pain? + This type of pain is a chronic pain that is resistant to
cure or relief.
Types of pain

+ Categories of pain according to its

+ Alcoholism
▪ Origin
+ Amputation
+ Back, leg, and hip problems ▪ Onset
+ Chemotherapy
+ Diabetes ▪ Cause or etiology
+ Facial nerve problems
+ HIV infection or AIDS According To Location/origin
+ Multiple sclerosis
1. Superficial Cutaneous Pain
+ Spine surgery
Phantom Limb Pain ▪ occurs over body surface or skin segments.

is described as burning, sharp, or prickling. Deep somatic pain

is labeled as dull, aching, cramping, prickling, and throbbing.
Somatic pain may also be described as constant. Localization:
Superficial somatic pain can be well localized.

2. Deep Somatic Pain

▪ occurs in the skin, muscles and joints

(musculoskeletal – muscle, bone,
periosteum, cartilage, tendons, deep fascia,
ligaments, joints, blood vessels and nervous)
+ Painful perception perceived in a missing body part or
occurs when stimuli activate pain receptors deeper in the body
in a body part paralyzed from a spinal cord injury
including tendons, joints, bones, and muscles. Deep somatic
6. Intractable pain
pain usually feels more like “aching” than superficial somatic
pain.

3. Visceral Pain

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▪ pain from body organs 1965 by Ronald Melzack and Patrick Wall,

defined as pain that originates from internal organs of the

body. 16. Stress-induced visceral pain: toward animal models
of irritable-bowel syndrome and associated comorbidities.

Types of PAIN (Onset)

+ Acute pain
▪ following acute injury, disease or some type
of surgery

+ Chronic malignant pain Gate control theory

▪ associated with cancer or other progressive
disorder

+ Chronic nonmalignant pain

▪ in the persons whose tissue injury is non
progressive or healed

TYPES OF PAIN ACCORDING TO DURATION AND INTENSITY

Factors influencing reaction to pain

Psychological Physiological Cultural

Types of PAIN (Cause/Basis) Age (Physiological)

Mechanical Infant:

▪ trauma + perceive pain and respond to its increasing sensitivity

▪ blockage of body duct
▪ tumor Toddler:
▪ muscle spasm
Thermal + respond by crying and anger because they perceive it
as a threat to security or sense that pain is a
▪ extreme temp punishment
Chemical
School age:
Tissue ischemia
+ try to be brave and not to cry or express much pain so
➢ Blocked artery parents and nurse will not be angry with them
➢ Stimulation of pain receptors
➢ Accumulation of lactic acid Adolescent:
Gate control theory
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+ may not want to report pain in front of peers because Advantages of PCA
they perceive complaints of pain as weakness
+ Easy access for clients for medication
Adult: + Allows self-administration with no risks
+ Pain relief without depending on nurses
+ may not report pain for fear that it indicates poor + Small doses of medications at short intervals for
diagnosis. Nurse may mean weakness and failure sustained pain relief
+ Stabilized serum drug levels
Pain Management
+ Decreased anxiety
Pharmacologic Treatment Disadvantages of PCA
o Patient becomes dependent on PCA
Pharmacologic Pain Relief Interventions o If mobility is contraindicated, client may move due
to decreased or no pain by PCA
+ Analgesics:
o Respiratory depression
Non opioids/ non- narcotic analgesics o Side effect may be constipation
o Mechanical failure of pump
NSAIDs o Relatives may press button for client
o Wrong programming parameters
Narcotic analgesics / opioids o Incorrect placing of syringe can cause infusion of
excessive drug doses
Adjuvants / co- analgesics
o Costly & if client may not understand the system
Local anesthesia SURGICAL TREATMENT

Patient controlled analgesia Dorsal Rhizotomy:

Epidural analgesia

Patient Controlled Analgesia (PCA)

▪ A drug delivery system which is a safe method for post

operative, trauma & obstetrics, burns, terminal care
pediatrics and cancer pain management
▪ Involves self IV drug administration
▪ Goal: to maintain a constant plasma level of analgesic
so that the problems of client with needed dosing
(PRN) are avoided
▪ Client preparation & teaching is important
+ Dorsal nerve roots (posterior) are resected as they
▪ Check IV line & PCA device regularly
enter spinal cord
ALTERNATIVE DELIVERY SYSTEMS FOR OPIODS:
+ Effective for local pain relief
+ Loss of pain sensation but has full motor function and
thermal sensation
Cordotomy or spinothalamic tractotomy

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+ Extensive & involves resection of the spinothalamic
tract (unrelieved pain)
+ Risk of permanent paralysis is more due to edema /
accidental resection of motor nerves
+ Permanent loss of pain & temporary sensation in the
affected areas
Cordotomy is essentially a lateral spinothalamic tractotomy;
the spinothalamic tract carries nociceptive signals,
temperature, and nondiscriminative touch from the
contralateral side of the body.
NON-PHARMACOLOGIC
Non pharmacologic interventions
A. Cognitive Behavioral Approaches:
▪ Diverting attention
▪ Reducing awareness of pain
▪ Increase pain tolerance
Cognitive behavioral approaches contd…
2. Reducing Pain Perception
▪ Removing / preventing painful stimuli
▪ Consider aspects that can cause discomfort & pain
and avoid them
▪ Control painful stimuli in your client's environment
Cognitive behavioral approaches
3. Bio-feed back
▪ measures the degree of muscular tension
▪ Effective for muscle tension & migraine headache
▪ It is used in treating pain and stress-related
Biofeedback is a mind-body technique that involves using
visual or auditory feedback to teach people to recognize the
CARE OF THE MOTHER & CHILD AT RISK
physical signs and symptoms of stress and anxiety, such as
increased heart rate, body temperature, and muscle tension.
4. Guided Imagery
Guided imagery is a type of focused relaxation or meditation.
Focused relaxation involves concentrating on a specific object,
sound, or experience in order to calm your mind. In guided
imagery, you intentionally think of a peaceful place or scenario
5. Hypnosis
+ Called as therapeutic suggestion
+ Induces trance like state
+ Intense concentration reduces apprehension or stress
+ Should be done by trained person
+ Only effective when the individual cooperates
Hypnosis, also referred to as hypnotherapy or hypnotic
suggestion, is a trance-like state in which you have heightened
focus and concentration. Hypnosis is usually done with the help
of a therapist using verbal repetition and mental images.
B. Physical Approaches
Goals:
▪ to provide comfort
▪ to correct physical dysfunctions
▪ to alter physiological responses
▪ to reduce fears associated with pain related
immobility
Examples:
1. Acupressure / acupuncture
2. Cutaneous stimulation (massage, heat application,
TENS)
3. Binders, Chiropractic
1. Acupressure / Acupuncture
▪ Acupressure - application of pressure to various
points of body
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▪ Acupuncture – insertion of extremely fine needles ✓ reduces swelling, calming muscle spasms, reducing
into various points of the body. The needles unblock pain in joints & muscles
the meridians allowing free flow of energy and relief Cutaneous Stimulation
of symptoms
▪ Used for backache, migraines, and post operative D. TENS (Transcutaneous Electric Nerve Stimulation)
pain
The needles are inserted gently and painlessly
into acupuncture points along meridians (or energy pathways)
that run along your body. Instead of needles, acupressure
practitioners use fingers to apply pressure to the points.

1. Acupressure / Acupuncture

+ Placing electrodes on the painful area of patient’s skin

+ Low current running through the electrodes acts to
block the pain sensation.
+ Must have a doctor’s order
+ Should be done by a trained person
+ Used for post operative pain and post traumatic
patients
Cutaneous Stimulation
2. Cutaneous Stimulation

+ E. Percutaneous Electrical Stimulation (PENS)

A. Massage + For relief of back pain, headaches
+ Electric current sent through thin needle probes
✓ stimulates circulation, relaxes muscles, increases positioned in soft tissues & muscles of the back
patients’ sense of well being Cutaneous stimulation involves stimulation of nerves via
Cutaneous Stimulation skin contact in an effort to reduce pain impulses to the
brain, based on the "gate control" theory of pain. A device
B. Application of heat
used to provide electro cutaneous nerve stimulation was
✓ used to soothe relieve pain from muscular strain / studied for its effect on symptoms of peripheral
overwork neuropathy.

Cutaneous Stimulation 3. Binders

C. Application of cold
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PAIN ASSESSMENT

+ Clothes wrapped around a limb / body part

+ Used for strains, sprains & surgical incisions
Nursing Assessment Questions
+ Supports the surface & internal tissues during
movement, coughing and other activities PQRST
4. Rest and Sleep
+ Palliative or Provocative Factors
+ Quality
+ Relief measures
+ Region (location)
+ Severity
+ Timing
The mnemonic device PQRST offers one way to recall
assessment: P. stands for palliative or precipitating
factors, Q for quality of pain, R for region or radiation of
▪ May be interrupted due to pain, fear or side effects of pain, S for subjective descriptions of pain, and T for
medication temporal nature of pain (the time the pain occurs).
▪ Assist patient in obtaining enough sleep and rest to
promote healing & maintain health
5. Chiropractic

▪ Involves manipulation or adjustment of the joints and

adjacent tissues of the body, particularly spinal
column
▪ Non-invasive
▪ Drug free treatment
▪ Should be done by a doctor chiro-practitioner. PREGNANCY-INDUCED HYPERTENSION
Chiropractic is a form of alternative medicine concerned with
Pregnancy-induced hypertension (PIH) is a form of high blood
the diagnosis, treatment, and prevention of mechanical
pressure in pregnancy. It occurs in about 7 to 10 percent of all
disorders of the musculoskeletal system, especially of the
pregnancies. Another type of high blood pressure is chronic
spine. ... A 2011 critical evaluation of 45 systematic reviews
hypertension - high blood pressure that is present before
found that spinal manipulation was ineffective at treating any
pregnancy begins.
condition.
Symptoms
6. Use of Placebos
+ Excess protein in your urine (proteinuria) or additional
+ Any medication / procedure that produces an effect
signs of kidney problems.
resulting from its implicit / explicit intent even with or
+ Severe headaches.
without its specific physical / chemical properties
+ Changes in vision, including temporary loss of vision,
+ e.g.: normal saline, empty capsules, or same
blurred vision, or light sensitivity.
procedure as electrodes with no
therapeutic value
26 | P a g e
NCMA 219 WEEK 1-5
+ Upper abdominal pain, usually under your ribs on the
right side.
+ Nausea or vomiting.
+ Decreased urine output.
TRIAD OF PIH
• Proteinuria
• Idema/Edema
• Hypertension
INTERSTITIAL FLUID
✓ is the body fluid between blood vessels and cells ,
containing nutrients from capillaries by diffusion and
holding waste products discharged out by cells due to
metabolism.
EXTRACELLULAR FLUID
✓ in turn, is composed of blood plasma, interstitial
fluid, lymph, and transcellular fluid (e.g.,
cerebrospinal fluid, synovial fluid, aqueous humor,
serous fluid, gut fluid, etc.). The interstitial fluid and
the blood plasma are the major components of the
extracellular fluid.
+ The intravascular to interstitial fluid can cause edema
because of the shifting of fluid and another organ that
can be affected by the vasoconstriction is the liver part
of your body.
WEEK 3
PROBLEMS WITH THE POWERS (Force of Labor)
INERTIA
+ is a time-honored term to denote that sluggishness of
contractions, or the force of labor, has occurred. A
more current term used is dysfunctional labor.
Dysfunction can occur at any point in labor, but it is
generally classified as primary (occurring at the onset
of labor) or secondary (occurring later in labor). The
risk of maternal postpartum infection, hemorrhage,
CARE OF THE MOTHER & CHILD AT RISK
and infant mortality is higher in women who have a
prolonged labor than in those who do not. Therefore,
it is vital to recognize and prevent dysfunctional labor
to the extent possible.
+ Prolonged labor appears to result from several
factors. It is most likely to occur if a fetus is large.
Hypotonic, hypertonic, and uncoordinated
contractions all play additional roles.
INEFFECTIVE UTERINE FORCE
UTERINE CONTRACTIONS
+ contractions are the basic force moving the fetus
through the birth canal. They occur because of the
interplay of the contractile enzyme adenosine
triphosphate and the influence of major electrolytes
such as calcium, sodium, and potassium, specific
contractile proteins (actin and myosin), epinephrine
and norepinephrine, oxytocin (a posterior pituitary
hormone), estrogen, progesterone, and
prostaglandins. About 95% of labors are completed
with contractions that follow a predictable, normal
course. When they become abnormal or ineffective,
ineffective labor occurs.
HYPOTONIC CONTRACTIONS
+ With hypotonic uterine contractions, the number of
contractions is unusually low or infrequent (not more
two or three occurring in a 10-minute period). The
resting tone of the uterus remains less than 10 mm
Hg, and the strength of contractions does not rise
above 25 mm Hg.
+ Hypotonic contractions are most apt to occur during
the active phase of labor. They may occur after the
administration of analgesia, especially if the cervix is
not dilatated to 3 to 4 cm or if bowel or bladder
distention prevents descent or firm engagement.
They may occur in a uterus that is: overstretched by a
multiple gestation, a larger-than-usual single fetus,
hydramnios, or in a uterus that is lax from grand
multiparity.
+ Such contractions are not exceedingly painful,
because of their lack of intensity. Keep in mind,
however, that the strength of a contraction is a
subjective symptom. Some women may interpret
these contractions as very painful.
+ Hypotonic contractions increase the length of labor
because more of them are necessary to achieve
27 | P a g e
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cervical dilatation. This can cause the uterus to not
contract as effectively during the postpartum period
because of exhaustion, increasing a woman’s chance
for postpartal hemorrhage.
HYPERTONIC CONTRACTIONS
+ Hypertonic uterine contractions are marked by an
increase in resting tone to more than 15 mm Hg.
However, the intensity of the contraction may be no
stronger than that associated with hypotonic
contractions. In contrast to hypotonic contractions,
hypertonic ones tend to occur frequently and are
most commonly seen in the latent phase of labor.
+ This type of contraction occurs because the muscle
fibers of the myometrium do not repolarize or relax
after a contraction, thereby “wiping it clean” to
accept a new pacemaker stimulus. They may occur
because more than one pacemaker is stimulating
contractions.
+ They tend to be more painful than usual, because the
myometrium becomes tender from constant lack of
relaxation and the anoxia of uterine cells that results.
A woman may become frustrated or disappointed
with her breathing exercises for childbirth, because
such techniques are ineffective with this type of
contraction.
+ A danger of hypertonic contractions is that the lack of
relaxation between contractions may not allow
optimal uterine artery filling; this could lead to fetal
anoxia early in the latent phase of labor.
UNCOORDINATED CONTRACTIONS
+ Normally, all contractions are initiated at one
pacemaker point high in the uterus. A contraction
sweeps down over the organ, encircling it;
repolarization occurs; relaxation or a low resting tone
is achieved; and another pacemaker activated
contraction begins. With uncoordinated contractions,
more than one pacemaker may be initiating
contractions, or receptor points in the myometrium
may be acting independently of the pacemaker.
+ Uncoordinated contractions may occur so closely
together that they do not allow good cotyledon (one
of the visible segments on the maternal surface of the
placenta) filling. Because they occur so erratically
such as one on top of another and then a long period
without any, it may be difficult for a woman to rest
CARE OF THE MOTHER & CHILD AT RISK
between contractions or to use breathing exercises
with contractions.
+ Applying a fetal and a uterine external monitor and
assessing the rate, pattern, resting tone, and fetal
response to contractions for at least 15 minutes (or
longer, if necessary, in early labor) reveals the
abnormal pattern. Oxytocin administration may be
helpful in uncoordinated labor to stimulate a more
effective and consistent pattern of contractions with
a better, lower resting tone.
+ If deceleration in the fetal heart rate (FHR) or an
abnormally long first stage of labor or lack of progress
with pushing (“second-stage arrest”) occurs, cesarean
birth may be necessary. Both the woman and her
support person need to understand that, although the
contractions are strong, they are ineffective and are
not achieving cervical dilatation.
PRECIPITATE LABOR
+ Precipitate labor and birth occur when uterine
contractions are so strong that a woman gives birth
with only a few, rapidly occurring contractions. It is
often defined as a labor that is completed in fewer
than 3 hours. Precipitate dilatation is cervical
dilatation that occurs at a rate of 5 cm or more per
hour in a primipara or 10 cm or more per hour in a
multipara.
+ Such rapid labor is likely to occur with grand
multiparity, or it may occur after induction of labor by
oxytocin or amniotomy. Contractions can be so
forceful that they lead to premature separation of the
placenta, placing the woman at risk for hemorrhage.
Rapid labor also poses a risk to the fetus because
subdural hemorrhage may result from the rapid
release of pressure on the head. A woman may
sustain lacerations of the birth canal from the forceful
birth. She also can feel overwhelmed by the speed of
labor. Both grand multiparas and women with
histories of precipitate labor should have the birthing
room converted to birth readiness before full
dilatation is obtained. Then, even a sudden birth can
be accomplished in a controlled surrounding.
PROLONGED LABOR
PROLONGED LABOR APPEARS TO RESULT FROM SEVERAL
FACTORS:
PROLONGED LATENT PHASE
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+ When contractions become ineffective during the
first stage of labor, a prolonged latent phase can
develop A prolonged latent phase is a latent phase
that is longer than 20 hours in a nullipara or 14 hours
in a multipara. This may occur if the cervix is not
“ripe” at the beginning of labor and time must be
spent getting truly ready for labor. It may occur if
there is excessive use of an analgesic early in labor.
With a prolonged latent phase, the uterus tends to be
in a hypertonic state. Relaxation between
contractions is inadequate, and the contractions are
only mild (less than 15 mm Hg on a monitor printout)
and therefore ineffective. One segment of the uterus
may be contracting with more force than another
segment.
+ Management of a prolonged latent phase in labor
that has been caused by hypertonic contraction s
involves helping the uterus to rest, providing
adequate fluid for hydration, and pain relief with a
drug such as morphine sulfate. Changing the linen and
the woman’s gown, darkening room lights, and
decreasing noise and stimulation can also be helpful.
PROTRACTED ACTIVE PHASE
+ A protracted active phase is usually associated with
cephalopelvic disproportion (CPD) or fetal
malposition, although it may reflect ineffective
myometrial activity. This phase is prolonged if cervical
dilatation does not occur at a rate of at least 1.2
cm/hour in a nullipara or 1.5 cm/hour in a multipara,
or if the active phase lasts longer than 12 hours in a
primigravida or 6 hours in a multigravida. If the cause
of the delay in dilatation is fetal malposition or CPD,
cesarean birth may be necessary.
PROLONGED DECELERATION PHASE
+ A deceleration phase has become prolonged when it
extends beyond 3 hours in a nullipara or 1 hour in a
multipara. Prolonged deceleration phase most often
results from abnormal fetal head position. A cesarean
birth is frequently required.
SECONDARY ARREST OF DILATATION
+ A secondary arrest of dilatation has occurred if there
is no progress in cervical dilatation for longer than 2
hours. Again, cesarean birth may be necessary.
CARE OF THE MOTHER & CHILD AT RISK
PROLONGED DESCENT
+ Prolonged descent of the fetus occurs if the rate of
descent is less than 1.0 cm/hr in a nullipara or 2.0
cm/hour in a multipara. It can be suspected if the
second stage lasts over 3 hours in a multipara.
+ If everything is normal except for the suddenly faulty
contractions and CPD and poor fetal presentation
have been ruled out by ultrasound, then rest and fluid
intake, as advocated for hypertonic contractions, also
apply. If the membranes have not ruptured, rupturing
them at this point may be helpful. Intravenous (IV)
oxytocin may be used to induce the uterus to contract
effectively.
ARREST OF DESCENT
+ Arrest of descent results when no descent has
occurred for 1 hour in a multipara or 2 hours in a
nullipara. Failure of descent has occurred when
expected descent of the fetus does not begin or
engagement or movement beyond 0 station has not
occurred. The most likely cause for arrest of descent
during the second stage is CPD. Cesarean birth usually
is necessary. If there is no contraindication to vaginal
birth, oxytocin may be used to assist labor.
CONTRACTION RINGS
+ A contraction ring is a hard band that forms across the
uterus at the junction of the upper and lower uterine
segments and interferes with fetal descent. The most
frequent type seen is termed a pathologic retraction
ring (Bandl’s ring). The ring usually appears during the
second stage of labor and can be palpated as a
horizontal indentation across the abdomen. It is a
warning sign that severe dysfunctional labor is
occurring as it is formed by excessive retraction of the
upper uterine segment; the uterine myometrium is
much thicker above than below the ring. When a
pathologic retraction ring occurs in early labor, it is
usually caused by uncoordinated contractions. In the
pelvic division of labor, it is usually caused by
obstetric manipulation or by the administration of
oxytocin.
+ Contraction rings often can be identified by
ultrasound. Such a finding is extremely serious and
should be reported promptly. Administration of IV
morphine sulfate or the inhalation of amyl nitrite may
relieve a retraction ring. A tocolytic can also be
29 | P a g e
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administered to halt contractions. If the situation is
not relieved, uterine rupture and neurologic damage
to the fetus may occur.
UTERINE RUPTURE
+ Rupture of the uterus during labor, although rare, is
always a possibility. It is always serious because it
accounts for as many as 5% of all maternal deaths.
Uterine rupture occurs when a uterus undergoes
more strain than it is capable of sustaining.
+ Rupture occurs most commonly when a vertical scar
from a previous cesarean birth or hysterotomy repair
tears (it occurs in less than 1% of women who have a
low transverse cesarean scar from a previous
pregnancy; about 4% to 8% of women who have a
classic cesarean incision).
+ Rupture can be complete, going through the
endometrium,
+ myometrium, and peritoneum layers, or incomplete,
leaving the peritoneum intact. With a complete
rupture, uterine contractions will immediately stop.
Two distinct swellings will be visible on the woman’s
abdomen: the retracted uterus and the extrauterin e
fetus. Hemorrhage from the torn uterine arteries
floods into the abdominal cavity and possibly into the
vagina. Signs of shock begin, including rapid, weak
pulse; falling blood pressure; cold and clammy skin;
and dilatation of the nostrils from air hunger. Fetal
heart sounds fade and then are absent.
+ If the rupture is incomplete, the signs of rupture are
less evident. With an incomplete rupture, a woman
may experience only a localized tenderness and a
CARE OF THE MOTHER & CHILD AT RISK
persistent aching pain over the area of the lower
uterine segment.
+ Administer emergency fluid replacement therapy as
ordered. Anticipate use of IV oxytocin to attempt to
contract the uterus and minimize bleeding. Prepare
the woman for a possible laparotomy as an
emergency measure to control bleeding and achieve a
repair. The viability of the fetus depends on the extent
of the rupture and the time elapsed between rupture
and abdominal extraction. A woman’s prognosis
depends on the extent of the rupture and the blood
loss. Most women are advised not to conceive again
after a rupture of the uterus, unless the rupture
occurred in the inactive lower segment.
UTERINE INVERSION
+ Uterine inversion refers to the uterus turning inside
out with either birth of the fetus or delivery of the
placenta. It is a rare phenomenon, occurring in about
1 in 20,000 births. It may occur if traction is applied to
the umbilical cord to remove the placenta or if
pressure is applied to the uterine fundus when the
uterus is not contracted. It may also occur if the
placenta is attached at the fundus so that, during
birth, the passage of the fetus pulls the fundus down.
+ Inversion occurs in various degrees. The inverted
fundus may lie within the uterine cavity or the vagina,
or, in total inversion, it may protrude from the vagina.
When an inversion occurs, a large amount of blood
suddenly gushes from the vagina. The fundus is not
palpable in the abdomen. If the loss of blood
continues unchecked for longer than a few minutes,
the woman will show signs of blood loss: hypotension,
dizziness, paleness, or diaphoresis. Because the
uterus is not contracted in this position, bleeding
continues, and exsanguination could occur within a
period as short as 10 minutes.
✓ Never attempt to replace an inversion because
handling of the uterus may increase the bleeding.
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Never attempt to remove the placenta if it is still
attached, because this only creates a larger surface
area for bleeding. In addition, administration of an
oxytocic drug only compounds the inversion or makes
the uterus more tense and difficult to replace.
✓ An IV fluid line needs to be started, if one is not
already present (use a large-gauge needle, because
blood will need to be replaced). If a line is already in
place, open it to achieve optimal flow of fluid to
restore fluid volume. Administer oxygen by mask and
assess vital signs. Be prepared to perform
cardiopulmonary resuscitation (CPR) if the woman’s
heart should fail from the sudden blood loss.
PROBLEMS WITH THE PASSENGER
+ Birth complications may arise if an infant is immature
or preterm. Complications may also occur if the
maternal pelvis is so undersized, such as occurs in
early adolescence or in women with altered bone
growth from a disease such as rickets that its
diameters are smaller than the fetal skull diameters.
It also can occur if the umbilical cord prolapses, if
more than one fetus is present, or if a fetus is
malposition or too large for the birth canal.
UMBILICAL CORD PROLAPSE
+ In umbilical cord prolapse, a loop of the umbilical cord
slips down in front of the presenting fetal part.
Prolapse may occur at any time after the membranes
rupture if the presenting fetal part is not fitted firmly
into the cervix. It tends to occur most often with:
✓ Premature rupture of membranes
✓ Fetal presentation other than cephalic
✓ Placenta previa
CARE OF THE MOTHER & CHILD AT RISK
✓ intrauterine tumors preventing the
presenting part from engaging
✓ A small fetus
✓ Cephalopelvic disproportion preventing firm
engagement
✓ Hydramnios
✓ Multiple gestation
+ The incidence is about 0.5% of cephalic births; this
rises as high as 15% to 20% with breech or transverse
lies. In rare instances, the cord may be felt as the
presenting part on an initial vaginal examination
during labor. It may also be identified in this position
on an ultrasound.
FETAL MALPOSITION
A. OCCIPITOPOSTERIOR POSITION
+ In approximately one tenth of all labors, the fetal
position is posterior rather than anterior. That is, the
occiput (assuming the presentation is vertex) is
directed diagonally and posteriorly, either to the right
(ROP) or to the left (LOP). In these positions, during
internal rotation, the fetal head must rotate, not
through a 90-degree arc, but through an arc of
approximately 135 degrees. Rotation from a posterior
position can be aided by having the woman assume a
hands and knees position, squatting, or lying on her
side (on her left side if the fetus is right occiput
posterior; on her right side if the fetus is left occiput
posterior).
FETAL MALPRESENTATION
A. BREECH PRESENTATION
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+ Most fetuses are in a breech presentation early in
pregnancy. However, by week 38, a fetus normally
turns to a cephalic presentation. Although the fetal
head is the widest single diameter, the fetus’s
buttocks (breech), plus the legs, actually take up more
space. The fact that the fundus is the largest part of
the uterus is probably the reason why, in
approximately 97% of all pregnancies, the fetus turns
so that the buttocks and lower extremities are in the
fundus. Breech presentation is more hazardous to a
fetus than a cephalic presentation, because there is a
higher risk of:
✓ Anoxia from a prolapsed cord
✓ Traumatic injury to the aftercoming head
(possibility of intracranial hemorrhage or anoxia)
✓ Fracture of the spine or arm
✓ Dysfunctional labor
✓ Early rupture of the membranes because of the
poor fit of the presenting part
B. TRANSVERSE LIE
+ Transverse lie occurs in women with pendulous
abdomens, with uterine fibroid tumors that obstruct the
lower uterine segment, with contraction of the pelvic
brim, with congenital abnormalities of the uterus, or with
hydramnios. It may occur in infants with hydrocephalus or
another abnormality that prevents the head from
engaging. It may also occur in prematurity if the infant has
room for free movement, in multiple gestation
(particularly in a second twin), or if there is a short
umbilical cord.
+ A transverse lie usually is obvious on inspection because
the ovoid of the uterus is found to be more horizontal than
vertical. The abnormal presentation can be confirmed by
Leopold’s maneuvers. An ultrasound may be taken to
further confirm the abnormal lie and to provide
information on pelvic size.
+ A mature fetus cannot be delivered vaginally from this
presentation. Often, the membranes rupture at the
beginning of labor. Because there is no firm presenting
part, the cord or an arm may prolapse, or the shoulder may
obstruct the cervix. Cesarean birth is necessary.
C. FACE PRESENTATION
+ A fetal head presenting at a different angle than
expected is termed asynclitism. Face (chin, or
mentum) presentation is rare, but when it does occur,
CARE OF THE MOTHER & CHILD AT RISK
the head diameter the fetus presents to the pelvis is
often too large for birth to proceed. A head that feels
more prominent than normal, with no engagement
apparent on Leopold’s maneuvers, suggests a face
presentation. It is also suggested when the head and
back are both felt on the same side of the uterus with
Leopold’s maneuvers. The back is difficult to outline
in this presentation because it is concave. If the back
is extremely concave, fetal heart tones may be
transmitted to the forward-thrust chest and heard on
the side of the fetus where feet and arms can be
palpated. A face presentation is confirmed by vaginal
examination when the nose, mouth, or chin can be
felt as the presenting part.
D. BROW PRESENTATION
+ A brow presentation is the rarest of the
presentations. It occurs in a multipara or a woman
with relaxed abdominal muscles. It almost invariably
results in obstructed labor because the head becomes
jammed in the brim of the pelvis as the
occipitomental diameter presents. Unless the
presentation spontaneously corrects, cesarean birth
will be necessary to birth the infant safely. Brow
presentations also leave an infant with extreme
ecchymotic bruising on the face. On seeing this
bruising over the same area as the anterior
fontanelle, or “soft spot,” parents may need
additional reassurance that the child is well after
birth.
4. FETAL SIZE
MACROSOMIA
+ Size may become a problem in a fetus who weighs
more than 4000 to 4500 g (approximately 9 to 10 lb).
Babies of this size complicate up to 10% of all births
and are most frequently born to women who enter
pregnancy with diabetes or develop gestational
diabetes. Large babies are also associated with
multiparity, because each infant born to a woman
tends to be slightly heavier and larger than the one
born just before.
+ An oversized infant may cause uterine dysfunction
during labor or at birth because of overstretching of
the fibers of the myometrium. The wide shoulders
may pose a problem at birth because they can cause
fetal pelvic disproportion or even uterine rupture
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from obstruction. If the infant is so oversized that he
or she cannot be born vaginally, cesarean birth
becomes the birth method of choice. The large size of
a fetus may be missed in an obese woman, because
the fetal contours are difficult to palpate, and obesity
does not necessarily indicate a larger-than-usual
pelvis. Pelvimetry or ultrasound can be used to
compare the size of the fetus with the woman’s pelvic
capacity.
b. Shoulder Dystocia
+ Shoulder dystocia is a birth problem that is increasing
in incidence along with the increasing average weight
of newborns. The problem occurs at the second stage
of labor, when the fetal head is born but the
shoulders are too broad to enter and be born through
the pelvic outlet.
+ This is hazardous to the woman because it can result
in vaginal or cervical tears. It is hazardous to the fetus
if the cord is compressed between the fetal body and
the bony pelvis. The force of birth can result in a
fractured clavicle or a brachial plexus injury for the
fetus. Shoulder dystocia is most apt to occur in
women with diabetes, in multiparas, and in post-date
pregnancies. The problem often is not identified until
the head has already been born and the wide anterior
shoulder locks beneath the symphysis pubis. The
condition may be suspected earlier if the second
stage of labor is prolonged, if there is arrest of
descent, or if, when the head appears on the
perineum (crowning), it retracts instead of protruding
with each contraction (a turtle sign).
PERSONAL NOTES
CAUSES/PATHOPHYSIOLOGY
Vasoconstriction/CNS/Hypoxia
Vasoconstriction
+ is the narrowing (constriction) of blood vessels by
small muscles in their walls. When blood vessels
constrict, blood flow is slowed or blocked.
Vasoconstriction may be slight or severe. It may result
from disease, drugs, or psychological conditions.
Central nervous system
CARE OF THE MOTHER & CHILD AT RISK
+ The CNS is the processing centre of the body and
consists of the brain and the spinal cord. Both of these
are protected by three layers of membranes known as
meninges.
Hypoxia
+ is a state in which oxygen is not available in sufficient
amounts at the tissue level to maintain adequate
homeostasis; this can result from inadequate oxygen
delivery to the tissues either due to low blood supply
or low oxygen content in the blood (hypoxemia).
SIGNS & SYMPTOMS
+ Affect the consciousness of the patient/ Altered and
Increase neuromuscular activity and there will be a
headache, visual disturbances, hyperreflexia. Patient
is agitated, cannot focus and limited attention are
also signs and symptoms for impending seizure,
pounding headache (it lasts and effect of
vasoconstriction), and epigastric pain.
WHAT WILL HAPPEN TO THE BABY? (MATERNAL EFFECT)
+ Limited nutrition because of the transport the fetus
development is delayed, low birthweight, SGA small
gestational age (IUGR) Intrauterine growth
constriction of the effect on the baby and another
effect is the placenta who are not receiving
(decreasing) proper oxygen resulting in placental
perfusion to placental necrosis. Fetal distress &
infection there will be construction. (Abruptio
Placenta). Remember when it comes to the IUGR on
early trimester or 2nd half of trimester the baby’s
body upon delivery the size of the baby is
proportionate or when PIH is on last trimester during
the development CNS is the first development it will
become bigger because of the nutrition.
ONSET:
+ If the mother has hypertension, there will be an
increased blood pressure (PIH)? Yes, or No? = Hydatid
Mole Increased HCG there will be increased placental
growth. PIH will start in the 2nd trimester. Manifest
on 20th week of AOG. When is the peak of PIH it will
be in the 5th month. Why? because of the HCG.
FOUR 4 TYPES:
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+ Gestational Preeclampsia: BP it depends on the
person 140/90, there will be no edema, no
proteinuria,
+ Mild Preeclampsia: BP: Systolic + 30, Diastolic + 15,
present edema on hands and legs, present proteinuria
the edema is 1+, and 2 positive, other accompany
signs and symptoms abnormal weight gain
+ Severe Preeclampsia: 160/110, present edema on
generalized face (like puffy eyes), present proteinuria
3+ and +4, edema when you press or apply pressure
on dorsum of the foot it there will be a dimple and you
will measure it just multiply it by 2. Other
accompanying signs and symptoms are visual
disturbances, hyperreflexia. Patient is agitated,
cannot focus and limited attention are also signs and
symptoms for impending seizure, pounding headache
(it lasts and effect of vasoconstriction), and epigastric
pain.
+ Eclampsia: It will progress (PIH) Seizure.
TREATMENT/MANAGEMEN T:
PIH
+ Bed rest, left side lying
+ Kidney increases permeability (Diet) We need to
increase the protein of the patient like accompanying
diagnostic test on PIH. The salt can be retained or
added because there are no signs of water retention
to maintain the pressure of the patient's body.
Decrease fat.
+ No tongue depressor if active (Yes if with aura)
+ Oxygenation and suction machine (beside)
+ Supine position during seizure
DOC (Drug of choice)
▪ Magnesium Sulphate MGSO4 Anticonvulsant Route:
IM and IV Site: Gluteal IM
▪ Done by the doctor (Administer) Responsibility of the
nurse is to document and other.
▪ Therapeutic level 5-8mg/100ml
▪ Toxicity - 8-10mg/100ml
▪ Calcium gluconate (Antidote)
WOF: MGSO4 Toxicity (Pre-assessment)
+ D - decrease DTR (Deep Tendon Reflex) (Elevate the
leg part hanging freely that's the time you assess)
Upper outer. Of the gluteus Maximus to avoid hitting
the sciatic nerve.
+ R - espiration Rate of the patient, to have baseline
data of the patient (Side-lying with high-fowler
position)
+ O - liguria (Urine Output)
+ P - pressure (BP) Decreasing
+ C- Cardiac Arrhythmia because of the decrease in
calcium
CLASSIFICATION OF HEART DISEASE

PREECLAMPSIA

+ The doctor needs to increase the blood pressure when

there is a vasoconstriction. We need a vasodilator.
(Drug of choice) like meta blockers or hydralazine,
metaldopha.

ECLAMPSIA

+ Observe seizure precautions, prepare oxygen, prepare

on the bedside padded of the patient tongue GRAVIDOCARDIAC
depressor only if the seizure is only an aura but if it’s
occurring it doesn’t need to be used. Head protection What causes it?
floor/bed.
+ The most common cause involves congenital
+ AHNO
anomalies: Atrial Septal Defect/Coarctation of aorta
+ Airway- turn head to side to prevent aspiration and + Valvular disease: Rheumatic fever, Kawasaki disease
facilitated the secretion of oral activity.
+ Head protection (floor)
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+ Women becoming pregnant at an older age, the What to look for?

incidences of ischemic cardiac disease and myocardial
infarction are increasing. Ageing theory needs to
produce more blood during 28 and 32 weeks are most
dangerous when the baby is growing. Drop cardiac
output there will have decreased oxygen supply to
the baby and it’s nutrients.

RIGHT

What test tells you?

ECG

+ An electrocardiogram (ECG) is one of the simplest

and fastest tests used to evaluate the heart.
Electrodes (small, plastic patches that stick to the
skin) are placed at certain spots on the chest, arms,
and legs. The electrodes are connected to an ECG
machine by lead wires.
LEFT
Echocardiogram
Signs and Symptoms:
+ An echocardiogram, or "echo", is a scan used to look
+ C - ough at the heart and nearby blood vessels. It's a type of
+ H - emoptysis (Blood) Shifting of blood vessels ultrasound scan, which means a small probe is used
+ O - rthopnea position, paroxysmal nocturnal dyspnea to send out high-frequency sound waves that create
(awaken at night difficult breathing) echoes when they bounce off different parts of the
+ P - pulmonary congestion body.

UTZ

+ A fetal ultrasound (sonogram) is an imaging

technique that uses sound waves to produce images
of a fetus in the uterus. Fetal ultrasound images can
help your health care provider evaluate your baby's
growth and development and monitor your
pregnancy.

Intervention:

✓ Bed rest
Signs and Symptoms: ✓ 30 weeks AOG of the patient complete bed rest
(Requires more blood) Supply and demand of the
+ H - epatomegaly (Pain, Dyspnea) oxygen
+ E - dema ✓ Ensure good nutrition
+ A - Ascites (palpate bimanually the liver but if ✓ Avoid infection like UTI to avoid vasoconstriction on
pregnant no need) the blood vessels
+ D - istended neck vein
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Pharmacologic Treatment: + Subacute bacterial endocarditis

+ To promote venous return of the patients,
+ Digoxin (Lanoxin) encourage to wear anti embolic stockings or
+ Antihypertensive and arrhythmia agents such as pneumatic compression (IPC) boots
adenosine, beta blockers, and calcium channel + Stool softener for patient undergo caesarean to
blockers. prevent Valsalva maneuver.
+ Nitroglycerin
+ Heparin (to prevent clotting to your patient, and given
to patient with mitral stenosis)
+ Penicillin (to patient with rheumatic fever and NURSING CARE OF THE PREGNANT CLIENT: GESTATIONAL
excessive fluid to your patient causing edema) CONDITIONS
+ Furosemide (Lasix) Diuretics (given to increase blood
GESTANIONAL TROPHOBLASTIC DISEASE
volume)
Hydatidiform mole, molar pregnancy
NURSING CARE: ANTEPARTUM
+ Abnormal proliferation of trophoblasts cells;
+ Assess maternal vital signs and cardiopulmonary
fertilization or division defect then degeneration of
status closely for changes
the trophoblastic villi.
+ Monitor weight gain throughout pregnancy. Assess
for edema and note any pitting + Factor of choriocarcinoma (malignant cancer of the
+ Reinforce use of prescribed medications to control patient if not found out earlier it can metastasize the
cardiac disease near organ in the abdominal cavity of the patient
+ Encourage frequent rest periods throughout the day (kidney and intestine etc.)
+ Advice the woman to immediately report signs and
symptoms of infection CAUSES:
+ Assess FHR and ultrasound results to monitor fetal
+ Women who have low protein intake, older than 35
growth.
years old, women of Asian heritage, blood group A
NURSING CARE: INTRAPARTUM women who marry blood group O men.

+ Advise the women to rest in the left lateral recumbent TYPES OF MOLAR GROWTH:
position
+ All trophoblastic villi swell and become cystic.
+ Frequently assess a woman’s blood pressure, pulse,
+ Early termination of embryonic development
and respirations and monitor fetal heart rate and
+ Chromosomal Analysis: Karyotype is a normal 46XX or
uterine contractions.
46XY
+ Prepare the woman for labor, anticipating the use of
epidural anesthesia. Sperm 23 + Ovum + Duplication = 46
+ Swan Ganz catheter to monitor the heart function of
the patient. + A blighted ovum, also called an anembryonic
+ Left lateral position to provide oxygen to the fetus pregnancy, occurs when an early embryo never
develops or stops developing, is resorbed and leaves
NURSING CARE: POSTPARTUM an empty gestational sac. The reason this occurs is
often unknown, but it may be due to chromosomal
+ Anticipate anticoagulant and cardiac glycoside
abnormalities in the fertilized egg.
therapy immediately after delivery for the woman
+ Slow decomposition
with severe heart failure.
+ Encourage ambulation, as ordered, as soon as ASSESSMENT FINDINGS:
possible after delivery.
+ Anticipate administration of prophylactic antibiotics, + Overgrowth of uterus
if not already ordered, after delivery.

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+ Highly positive human chronic gonadotropin (HCG) ASSESMENT FINDINGS:

test
+ No fetus present on ultrasound + Painlessly dilatation
+ Bleeding from vagina of old fresh blood accompanied + Pink-stained vaginal discharge
by cyst formation + Increased pelvic pressure, which then is followed by
+ Gestational hypertension rupture of the membranes and discharge of the
+ Spotting with the dark brown or prune color amniotic fluid.
+ If the bleeding is perfused, the cyst will be passed out + Uterine contractions begin and, after a short labor,
+ Encourage to bring any clots while at home the fetus is born.
+ Suspect that the patients have HCG
MCDONALD PROCEDURE

+ Every 2 weeks the HCG will be checked to see if it’s

normal. Third week there’s a chance that the HCG is
high.
+ Serum HCG check every 4 weeks naman to 6 weeks -
12 months’
NURSING INTERVENTION:
+ Observes for bleeding and shock
+ Assess or monitor blood pressure
+ Encourage verbalization of feelings
+ Provide an open and trusting environment
+ H mole always if always increased the HCG and
possible sa bleeding ng patient.
+ A McDonald cerclage, described in 1957, is the most
common, and is essentially a purse string stitch used
to cinch the cervix shut; the cervix stitching involves a
band of suture at the upper part of the cervix while the
lower part has already started to efface.
+ Nylon sutures are placed horizontally and vertically
across the cervix and pulled tight to reduce the
cervical canal to a few millimeters in diameter.
SHIRODKAR TECHNIQUE

INCOMPETENT CERVIX

CERVICAL INSUFFIENCY, PREMATURE CERVICAL

DILATATION)

+ Refers to a cervix that dilates prematurely and

therefore cannot retaina fetus until term.

Risk factors:

+ Increased maternal age

+ Congenital structural defects
+ Trauma to the cervix, such as might have occurred
with a cone biopsy or repeated D&C’s.

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+ A modified Shirodkar procedure was performed in all
women. The modification in the Shirodkar cerclag e
used in this study was that the knot of the suture and
the suture itself were fully embedded under the
vaginal mucosa in order to avoid infection.
+ Sterile tape is threaded in a purse-string manner
under submucous layer of the cervix and sutured in
place to achieve a close cervix. Although routinely
accomplished by a vaginal route, sutures may be
placed by a transabdominal route.
NURSING INTERVENTION:
After cerclage surgery, women remain on bed rest (perhaps in
a slight or modified Trendelenburg position) for a few days to
decrease pressure on the sutures.
CERVICAL CERLAGE
+ The sutures are then removed at weeks 37 to 38 of
pregnancy so the fetus can be born vaginally.
+ When transabdominal approach is used, the sutures
may be left in place and a cesarean birth performed.
+ Cervical cerclage is the placement of stitches in the
cervix to hold it closed. In select cases, this procedure
is used to keep a weak cervix (incompetent cervix)
from opening early. When a cervix opens early, it may
cause preterm labor and delivery.
PREMATURE RUPTURE OF MEMBRANES (PROM)
+ Premature rupture of membranes (PROM) is a rupture
(breaking open) of the membranes (amniotic sac)
before labor begins. If PROM occurs before 37 weeks
of pregnancy, it is called preterm premature rupture
of membranes (PPROM). PROM occurs in about 8 to
10 percent of all pregnancies.
+ Is the spontaneous rupture of the membranes at term
(38 or more weeks of gestation) more than 1 hour
before labor contractions begin.
Risk factors:
+ Vaginal or cervical infection
Diagnosis:
Nitrazine Test
+ Will turn to blue that means there’s an amniotic fluid
CARE OF THE MOTHER & CHILD AT RISK
+ The nitrazine test is a pH indicator. Vaginal pH is
normally between 4.5 and 5.5 but the presence of
amniotic fluid in the vagina increases the pH value.
The test was interpreted as positive if the test paper
turned blue.
Fern Test
+ There will be a ferning pattern seen under microscope
also has an amniotic fluid
+ The fern test is used to aid the physician in the
diagnosis of ruptured membranes by detecting the
presence of amniotic fluid. This fluid, when placed on
a glass slide, is allowed to dry.
Management:
+ If PROM occurs at 36 weeks of gestation or later, labor
is induced within 24 hours.
+ Amniotomy will be performed
✓ Remember when the bag of water ruptures part of the
cord is protruded. Do not attempt to push out the
cord. Just position the patient left lying or
Trendelenburg position.
NURSING MANAGEMENT:
+ Report a temperature that is above 38°C (100.4°F).
+ Avoid sexual intercourse or insertion of anything in
the vagina
+ Limit physical activity
+ Note any uterine contractions, reduced fetal activity,
or other signs of infection.
+ Record fetal kick counts daily, and report fewer than
10 kicks in a 12-hour period.
+ No breast stimulation can cause contractions and
release of the oxytocin, IE, vaginal examination, no
sexual intercourse, if the patient had sex naman
orgasm should avoided when there is no cervical
dilation and when the bag of water ruptures.
+ Prepare for induced labor or caesarean delivery.
WEEK 4
POSTPARTAL HEMORRHAGE
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+ Any blood loss from the uterus greater than 500ml

within a 24-hour period

FIVE MAIN CAUSES:

✓ Uterine atony
✓ Lacerations
✓ Retained placental fragments
✓ Uterine Inversion
✓ Disseminated Intravascular Coagulation (DIC)

UTERINE ATONY LACERATIONS

+ Relaxation of the uterus

+ Most frequent cause of postpartal hemorrhage

THERAPEUTIC MANAGEMENT:

+ Weigh pads
+ Palpate the uterus frequently (best measure of
prevention)
+ FIRST step in controlling: UTERINE MASSAGE
+ Remains uncontracted: OXYTOCIN IV and methergine
(contraindicated for hypertension)
+ Empty the bladder A vaginal tear (perineal laceration) is an injury to the tissue
+ Nipple roll/Ice pack on the abdomen around your vagina and rectum that can happen during
+ Relaxation of the uterus childbirth. There are four grades of tear that can happen, with
+ Most frequent cause of postpartal hemorrhage a fourth-degree tear being the most severe. An episiotomy is a
+ Bimanual massage procedure that may be used to widen the vaginal opening in a
+ Prostaglandin (promote strong, sustained uterine controlled way.
contractions)
Occurs most often due to:
+ Blood replacement
+ Hysterectomy or Suturing + Difficult or precipitate labor
+ Primipara
+ Macrosomia
+ Use of lithotomy position and instruments

CERVICAL LACERATIONS

+ Usually on the sides

+ Severe bleeding (artery)
+ Mngt: SUTURE

VAGINAL LACERATIONS

+ Suture and vaginal packing

+ Packing removed: 24-48 hrs. (prevent toxic shock
syndrome)
+ Mngt: SUTURE

PERINEAL LACERATIONS

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What causes a perineal laceration?

Vaginal tears during childbirth, also called perineal lacerations

or tears, occur when the baby's head is coming through the
vaginal opening and is either too large for the vagina to stretch
around or the head is a normal size but the vagina doesn't
stretch easily. These kinds of tears are relatively common.

Lithotomy: increases tension on the perineum

1st degree:

+ vaginal mucus membrane and skin of the perineum

to the fourchette

2nd degree:
RETAINED PLACENTAL FRAGMENTS
+ vagina, perineal skin, fascia, levator ani, perineal body

3rd degree:

+ entire perineum to external anal sphincter

4th degree:

+ entire perineum, rectal sphincter, and some mucus

membrane of the rectum

+ Mostly happens with succenturiate placenta and

placenta accreta
+ Uterus not fully contracted
+ Mngt: D/C

SUBINVOLUTION

+ Subinvolution is a medical condition in which after

childbirth, the uterus does not return to its normal
size.

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Mngt:
+ 4-Incomplete return of uterus to pre-pregnancy size
and shape
+ 6 weeks postpartum (uterus still enlarged and soft
with lochial discharge)
CAUSES:
What causes puerperal infection?
+ Retained placental fragment
+ Endometritis
+ Uterine mass (myoma)
+ The cause of subinvolution is not known, but this
process may be a manifestation of an abnormal
interaction between fetal-derived trophoblasts and
maternal tissue. Subinvolution is an important process
to recognize, as it implies an idiopathic, and not an
iatrogenic, cause of delayed postpartum bleeding.
Mngt:
+ Methylergonovine maleate (Methergine)
+ (+) tenderness = endometritis (Antibiotics)
PERINEAL HEMATOMAS
+ A perianal hematoma is a pool of blood that collects
in the tissue surrounding the anus. It's usually caused
by a ruptured or bleeding vein. Not all perianal
hematomas require treatment. However, some need
CARE OF THE MOTHER & CHILD AT RISK
to be drained during a simple in-office procedure. If a
blood clot has formed, a doctor will need to remove it.
+ Collection of blood in the subcutaneous layer of the
perineum
+ (+) pain in the perineum and pressure between legs
+ Ice pack (covered with cloth)
+ and I/D
PUERPERIAL INFECTION
+ A puerperal infection occurs when bacteria infect the
uterus and surrounding areas after a woman gives
birth. It's also known as a postpartum infection. It's
estimated that 10 percent of pregnancy-related
deaths in the United States are caused by infections.
+ Infection that occurs just after childbirth is also known
as puerperal sepsis. Bacteria called group A
Streptococcus (GAS) are an important cause of
maternal sepsis. GAS usually cause mild throat
infections and skin infections or may have no
symptoms at all.
ENDOMETRITIS
+ Infection of the lining of the uterus
+ Can lead to tubal scarring
+ Endometriosis (en-doe-me-tree-O-sis) is an often-
painful disorder in which tissue similar to the tissue
that normally lines the inside of your uterus — the
endometrium — grows outside your uterus.
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Endometriosis most commonly involves your ovaries,
fallopian tubes and the tissue lining your pelvis
MANIFESTATIONS:
+ Fever on the 3rd or 4th day postpartum
+ Elevated WBC count
+ Uterus is not well contracted
+ Brownish lochia with foul odor
Mngt:
+ Antibiotic (Clindamycin)
+ Methergine
+ Fluids
PERINEAL INFECTION
+ Infection that may start from suture line
(episiorrhaphy) after an episiotomy.
+ A perineal abscess is an infection that causes a painful
lump in the perineum. The perineum is the area
between the scrotum and the anus in a man. In a
woman, it's the area between the vulva and the anus.
The area may look red and feel painful and be swollen.
MANIFESTATIONS:
+ Signs of inflammation
+ Fever
Mngt:
+ Removal of suture
+ Packing (iodoform gauze)
+ Systemic/Topical antibiotic
+ Analgesics
+ Sitz bath/moist warm compress/Hubbard tank
THROMBOPHLEBITIS
+ Thrombophlebitis (throm-boe-fluh-BY-tis) is an
inflammatory process that causes a blood clot to form
and block one or more veins, usually in the legs. The
affected vein might be near the surface of the skin
(superficial thrombophlebitis) or deep within a muscle
(deep vein thrombosis, or DVT).
+ Inflammation with the formation of
+ blood clots
+ Superficial Vein Disease (SVT)
+ Deep Vein Thrombosis (DVT)
CARE OF THE MOTHER & CHILD AT RISK
CAUSES:
+ Elevated fibrinogen from pregnancy
+ Lower extremity vein dilatation
+ Period of relative inactivity/Smoking
MANIFESTATIONS:
+ Elevated temperature
+ Chills, pain, leg redness
+ (+) Homan’s sign
+ Increased diameter of the leg
+ Doppler UTZ/Contrast venography – confirmation
MANAGEMENT:
+ BED rest with affected leg ELEVATED
+ Thrombolytics
Streptokinase/Urokinase
+ Anticoagulants
Heparin (can continue breastfeeding)
Warfarin (stop breast feeding)
+ Moist heat application
+ NEVER massage the skin over the clot
DISSEMINATED INTRAVASCULARINATED COAGULATION
+ Disseminated intravascular coagulation (DIC) is a rare
and serious condition that disrupts your blood flow. It
is a blood clotting disorder that can turn into
uncontrollable bleeding. DIC can affect people who
have cancer or sepsis.
+ Acquired disorder of blood clotting in which the
+ fibrinogen level falls to below effective limits
CAUSE:
UNKNOWN
+ Clients are usually critically ill with an obstetric,
surgical, hemolytic, or neoplastic disease
+ May be linked with entry of thromboplastic
substances into the blood
+ Mortality rate is high, usually because underlying
disease cannot be corrected
+ Abruptio placenta, placental retention, septic
abortion, PIH, amniotic fluid embolism
MANIFESTATIONS:
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+ Clients are usually critically ill with an obstetric, + Analgesic (Acetaminophen)

surgical, hemolytic, or neoplastic disease
+ May be linked with entry of thromboplastic
substances into the blood
+ Mortality rate is high, usually because underlying
disease cannot be corrected

MANAGEMENT:

HEPARIN administration

+ Somewhat CONTROVERSIAL!!!
+ Inhibits thrombin thus preventing further clot
formation, allowing coagulation factors to EMOTIONAL & PSYCHOLOGICAL COMPLICATIONS OF
accumulate PUERPERIUM
✓ Antithrombin III factor
POSTPARTAL DEPRESSION
✓ Fibrinogen
✓ FFP/Platelet concentrate
✓ Bleeding precaution
URINARY TRACT INFECTION

+ Postpartal depression (PPD) is a complex mix of

physical, emotional, and behavioral changes that
+ A urinary tract infection (UTI) is an infection in any happen in some women after giving birth. According
part of your urinary system — your kidneys, ureters, to the DSM-5, a manual used to diagnose mental
bladder, and urethra. Most infections involve the disorders, PPD is a form of major depression that
lower urinary tract — the bladder and the urethra. begins within 4 weeks after delivery. The diagnosis of
Women are at greater risk of developing a UTI than postpartum depression is based not only on the length
are men. of time between delivery and onset but on the severity
of the depression.
MANIFESTATIONS: + Postpartal depression is linked to chemical, social, and
+ Burning on urination psychological changes that happen when having a
+ Hematuria (blood in urine) baby. The term describes a range of physical and
+ Urinary frequency emotional changes that many new mothers
+ Low-grade fever experience. PPD can be treated with medication and
MANAGEMENT: counseling.
+ Sulfa drugs (Co-trimoxazole) – contraindicated to BF,
can cause neonatal jaundice Postpartal “blues”
+ Amoxicillin/Ampicillin
+ Increased oral fluid intake + Immediate (1-10 days postpartum) feelings of sadness

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Postpartal “depression” + (There has been a previous viable pregnancy, but the
couple is unable to conceive at present)
+ A more serious problem than postpartal blues
+ RISK FACTORS: STERILITY
+ History of depression
+ Troubled childhood + Inability to conceive because of a known condition
+ Low self-esteem
SUBFERTILITY
+ Stress
+ Lack of support system MALE SUBFERTILITY FACTORS

Postpartal “Psychosis” + Disturbance in spermatogenesis

+ Obstruction in the transport of sperm
+ Psychiatric illness that coincides with postpartal
+ Qualitative/Quantitative change in seminal fluid
period
affecting sperm motility
+ Response to crisis of childbearing
+ Autoimmunity that immobilizes sperm
+ Ejaculation problems

INADEQUATE SPERM COUNT

+ Sperm count – number of sperm in a single

ejaculation or in a milliliter of semen
+ Normal count: 20 million/mL or 50 million/ejaculation
(at least 50% is motile and 30% should be normal in
shape and form)

FACTORS: (conditions that increases body temperature)

+ Chronic infection
+ Actions that increase scrotal heat (desk job, driving)
+ Cryptorchidism
WEEK 5
+ Varicocele
+ In general, infertility is defined as not being able to get + Trauma to the testes
pregnant (conceive) after one year (or longer) of + Exposure to radiation
unprotected sex. Because fertility in women is known
SPERM MORPHOLOGY
to decline steadily with age, some providers evaluate
and treat women aged 35 years or older after 6
months of unprotected sex.
+ Term used to describe the inability to conceive a child
or sustain a pregnancy to birth

SUBFERTILITY

+ Exists when pregnancy has not occurred at least 1

year of engaging in unprotected coitus

PRIMARY SUBFERTILITY

+ (There have been no previous conceptions) + refers to the size, shape and appearance of a man's
sperm, which when abnormal can decrease fertility
SECONDARY SUBFERTILITY
and make it more difficult to fertilize the woman's
egg. Sperm can be misshaped based on the size of the
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head, having an extra head, and having no head or
tail.
FACTORS:
SPERMATOGENESIS
+ is the process of sperm cell development. Rounded
immature sperm cells undergo successive mitotic and
meiotic divisions (spermatocytogenesis) and a
metamorphic change (spermiogenesis) to produce
spermatozoa. Mitosis and meiosis.
FACTORS:
SUBFERTILITY
MALE SUBFERTILITY FACTORS
CARE OF THE MOTHER & CHILD AT RISK
OBSTRUCTION OR IMPAIRED SPERM MOTILITY
✓ Mumps orchitis/epididymitis
✓ Tubal infections (gonorrhea/ascending UTI)
✓ Congenital stricture of spermatic duct
✓ Benign Prostatic Hypertrophy
✓ Autoimmunity post vasectomy (production of
✓ antibodies that immobilize sperm)
✓ Penile anomalies (hypospadias/epispadias)
✓ Extreme obesity
EJACULATION PROBLEMS
✓ Erectile dysfunction (impotence)
✓ Psychological
✓ Stress
✓ Diabetes
✓ Neurological diseases (Parkinson’s
✓ Disease/Stroke)
✓ Mngt: Sildenafil citrate (Viagra)
✓ Premature ejaculation
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+ SECRETORY phase (Progestational/Luteal)

+ CORPUS LUTEUM produces PROGESTERONE
✓ uterine wall thickens and blood flow increases
✓ Inhibits smooth muscle contraction
✓ Increases basal body temperature
✓ If NO FERTILIZATION occurs, uterus sloughs off

FEMALE SUBFERTILITY FACTORS

✓ Anovulation
✓ Problems in ova transport
✓ Cervical/vaginal factors that immobilize the sperm
✓ Nutritional problems
✓ Body weight/exercise

MENSTRUAL CYCLE

OVARIAN CYCLE

+ MENSES; sloughing off the uterine lining d/t

decreased estrogen and progesterone
+ FOLLICULAR phase (Estrogenic/Proliferative)
✓ Uterus thickens
✓ FSH increases (ovum maturation)
✓ OVULATION (occurs on the 14th day before the
start of the next cycle) - constant
+ LUTEAL phase (Progestational/Secretory)
✓ LH increases (oocyte release)
✓ Remaining CORPUS LUTEUM produces
PROGESTERONE, and the uterine wall thickens
✓ If NO FERTILIZATION occurs, uterus sloughs off

UTERINE CYCLE

+ MENSES
+ PROLIFERATIVE phase (Estrogenic/Follicular); FEMALE SUBFERTILITY FACTORS
✓ increase in estrogen stimulates uterine
thickening ANOVULATION
✓ Cervix produces more mucus
+ Most common cause of subfertility in women
✓ OVULATION (occurs on the 14th day before the
start of the next cycle) - constant

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+ Anovulation happens when an egg (ovum) doesn't

release from your ovary during your menstrual cycle.
An egg is needed to have a pregnancy. Since multiple
hormones are involved in ovulation, there are many
causes of anovulation. Chronic anovulation is a
common cause of infertility.

FACTORS:

✓ Turner’s syndrome: Hypogonadism – no ovaries to

produce ova
✓ Ovarian tumors
✓ Exposure to radiation
✓ Poor nutrition/obesity/DM – elevated insulin/glucose
disrupts the production of FSH and LH
✓ STRESS – reduces hypothalamic secretion of GnRH –
lowers the production of FSH and LH
✓ Polycystic Ovarian Syndrome (PCOS) – ovaries
produce excessive testosterone, lowering FSH and LH

TURNER SYNDROME

FEMALE SUBFERTILITY FACTORS

TUBAL TRANSPORT PROBLEM

+ Usually caused by tubal scarring

+ Tubal factor infertility occurs when a blockage in the
fallopian tubes will not allow the egg and sperm to
meet. Tubal factor infertility accounts for about 25-
30% of all cases of infertility.

FACTORS:

+ Chronic salphingitis – post abdominal

surgery/ruptured appendix
+ Pelvic Inflammatory Disease

+ A condition that affects only females, results when
one of the X chromosomes (sex chromosomes) is
missing or partially missing. Turner syndrome can
cause a variety of medical and developmental
problems, including short height, failure of the
ovaries to develop and heart defects.
UTERINE PROBLEMS
FACTORS:
+ Endometriosis– implantation of uterine endometrium
that have spread from the inferior of the uterus to
locations outside the uterus

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+ Tumors (fibromas blocking the entrance of fallopian

tubes)
+ Congenitally deformed uterus

FERTILITY ASSESSMENT

+ <35 years old – 1 year of subfertility

+ >35 years old – 6 months of subfertility

FERTILITY TESTING

+ Semen analysis
+ Ovulation monitoring
+ Tubal patency assessment

SEMEN ANALYSIS

+ 2-4 days of sexual abstinence

+ Average ejaculation: 2.5 to 5.0 mL
+ Normal count: 20 million/mL or 50 million/ejaculation
(at least 50% is motile and
+ 30% should be normal in shape and form)
+ May be repeated after 2-3 months (spermatogenesis
takes 30-90 days)

SPERM PENETRATION ASSAY AND ANTISPERM ANTIBODY

CERVICAL PROBLEMS TESTING

FACTORS: + Determines if a sperm can successfully penetrate the

ovum
+ Improperly timed coitus that does not coincide when
cervical mucus is thin and watery (ovulation – 12-72 OVULATION MONITORING
hrs.)
+ Cheapest way – Basal Body Temperature
+ Infection/inflammation of cervix –
+ Monitored for at least 4 months
+ thickens the mucus
+ Cervical os stenosis/polyp OVULATION DETERMINATION BY TEST STRIP

UTERINE PROBLEMS + Checks the upsurge of LH that occurs just before

ovulation
FACTORS:
TUBAL PATENCY
+ Vaginal infections – increased
+ secretion’s acidity SONOHYSTEROGRAPHY
+ Sperm agglutinating antibodies
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+ uterus is filled with sterile saline and a transvaginal

+ ultrasound is performed to check for uterine
abnormality

HYSTEROSALPHINGOGRAPHY

+ radiologic examination of the fallopian tube using a

radiopaque medium (performed immediately after
menstrual flow to avoid reflux of menstrual debris
into the tubes)

CONTRAINDICCATIONS: INFECTION

+ is an X-ray procedure that is used to view the inside

of the uterus and fallopian tubes. It often is used to
see if the fallopian tubes are partly or fully blocked. It
also can show if the inside of the uterus is a normal
size and shape.

SUBFERTILITY MANAGEMENT

CORRECTION OF THE UNDERLYING PROBLEM

INCREASING SPERM COUNT AND MOTILITY

+ Abstain from coitus for 7-10 days

+ Syringe extraction of sperm
+ Corticosteroid for women

REDUCING THE PRESENCE OF INFECTION

HORMONE THERAPY

CLOMIPHENE CITRATE

+ estrogen agonist that stimulates the ovaries to

ovulate
HYSTEROSALPINGOGRAPHY (HSG)
HUMAN MENOPAUSAL GONADOTROPINS

+ combination of FSH and LH derived from post-

menopausal urine plus HCG to stimulate ovulation

CONJUGATED ESTROGEN

+ increases mucus production on the 5th to 10th day of

cycle

PROGESTERONE VAGINAL SUPPOSITORIES

+ if (+) for luteal phase problem

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 NCMA 219 WEEK 1-5 CARE OF THE MOTHER & CHILD AT RISK

SURGERY

THERAPEUTIC INSEMINATION

+ Installation of sperm into the female reproductive

tract to aid conception

IN VITRO FERTILIZATION

+ One or more mature oocytes are harvested and are

fertilized by exposure to sperm under laboratory
conditions outside a woman’s body.

GAMETE INTRAFALLOPIAN TRANSFER

+ Same procedure for harvesting oocyte but the

harvested egg is immediately instilled together with
sperm within a matter of hours

ZYGOTE INTRAFALLOPIAN TRANSFER

+ Oocyte retrieval thru transvaginal, ultrasound-guided

aspiration, followed by insemination in the lab and
within 24 hours, the fertilized eggs are transferred by
laparoscopic technique into the end of the waiting
fallopian tube

SURROGATE EMBRYO TRANSFER

+ Frozen Embryo Transfer (Surrogacy) Frozen Embryo

Transfer (FET) involves the use of thawed embryos
that were frozen in a previous IVF Cycle for Egg Donor
and transfer of the embryo into the uterus of the
surrogate. A surrogate is required to undergo a Frozen
Embryo Transfer cycle in order to achieve a
pregnancy.

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