Bleeding in Pregnancy
ABORTION – any interruption in pregnancy before the age of viability
a. Spontaneous
Blighted ovum/ germ plasma defect= most common cause

Following Trauma, infection (e.g. rubella, influenza) or emotional problems

1. Threatened
Symptom: bright red vaginal bleeding which is moderate in amount

CBR for 24-48 hours Coitus is restricted for 2 weeks after bleeding has stopped Advise the patient to save all pads, clots and expelled tissues

2. Imminent/ Inevitable
Bright red vaginal bleeding which is moderate in amount and accompanied by uterine contractions and cervical dilatation. Loss of the product of conception is Inevitable.

Management- depends on
whether it is

Complete abortion- all products
of conception are expelled; bleeding is minimal and self-limiting. No intervention is therefore needed.

Incomplete Abortion- part of
the conceptus ( usually the fetus) expelled, but membranes or placental fragments are retained. D & C is indicated as management

7 week old baby

8 week old fetus


- fetus dies in utero but is not expelled -Usually discovered at a prenatal visit when the fundic height is measured and no increase is demonstrated or when previously heard fetal heart tones are no longer present. -At 2 weeks time , signs of abortion should occur ; otherwise, labor will have to be induced to prevent hypofibroginemia or sepsis.

Missed abortion

b. Induced abortion
is never allowed in the Phils

performed by a doctor in a controlled hospital or clinic setting for a medical or legal reason. Also known as medical, planned or legal abortion


9 week old fetus

First trimester

First trimester in womb photo

Second Trimester

Second trimester in womb photo

Third Trimester

Third trimester in womb photo

= any gestation located outside the uterine cavity
Signs and symptoms
severe, sharp, knife-like stabbing pain in either the right or left lower quadrant Rigid abdomen (+) Cullen’s sign- bluish umbilicus

Signs of shock: falling BP, PR
more than 100/min, rapid RR, lightheadedness

Risk Factors
1.Pelvic inflammatory disease (PID), gonorrhea, or chlamydia (which may be symptomless) - Rate of ectopic pregnancy in women withprevious known PID is increased 6-10 times higher than in women with no previous history of PID. A published study of 745 women with one or more episodes of PID that attempted to conceive showed that 16% were infertile from tubal occlusion. Of those that conceived, 6.4% had ectopic pregnancies. 2. You've had a previous ectopic pregnancy

3. You have an intrauterine device (IUD) in place when you get pregnant. (IUDs are about 99 percent effective at preventing pregnancy, but if you do get pregnant while using one, the pregnancy is likely to be ectopic. Having used an IUD in the past will not increase your risk for ectopic pregnancy.) 4. Your tubes were damaged by a previous infection or surgery.

- ruptured ectopic pregnancy is an emergency situation

Salpingostomy- if Fallopian Tube can still be replaced and preserved; but the pregnancy has to be terminated Salpingectomy- removal of the Fallopian tube + blood transfusion Nursing Care- Combat Shock
Elevate foot of the bed Maintain body heat by hot water bottles and blankets

Different Procedures used:
•Salpingotomy (or -ostomy): Making an incision on the tube and removing the pregnancy. •Salpingectomy: Cutting the tube out. •Segmental resection: Cutting out the affected portion of the tube. •Fimbrial expression: "Milking" the pregnancy out the end of the tube. In general, the procedure of choice will be salpingectomy if future fertility is of no concern, if the tube is ruptured, if there is significant anatomic distortion, or if there is overt hemorrhage.

Abdominal Surgery- In this case, you'll be given general anesthesia and a surgeon will open your abdomen and remove the embryo as well as the ruptured tube, if necessary. You may need a blood transfusion to replace lost blood if you were bleeding heavily before surgery. Afterward, you'll need about six weeks to recuperate. You may feel bloated, and have sore breasts and abdominal pain or discomfort as you heal.

Medical Management with Methotrexate If the hCG level is below a certain limit and there is no risk of imminent rupture, the doctor may prescribe a drug called methotrexate to treat the ectopic pregnancy. Methotrexate is also used in chemotherapy and works to stop rapidly growing cells from multiplying. The drug is administered as an injection.




- developmental anomaly of the placenta resulting in proliferation and degeneration of the chorionic villi S/Sx- Because of rapid proliferation of the placental tissues and therefore, high levels of HCG -Highly positive urine test for pregnancy -Nausea and vomiting is usually marked -Rapid increase in fundic height. Rapid increase in weight -No fetal heart tones; TOXEMIA -Vaginal bleeding seen as clear, fluidfilled, grape size vesicles

>D & C to evacuate the mole

>Prophylactic course of Methotrexate, the drug of choice for choriocarcinoma >Urine testing for one year to find out if new villi are developing.

= one that dilates prematurely. It is the chief causes of habitual abortion ( 3 or more consecutive abortions)

What is an incompetent cervix? An incompetent cervix is also called cervical insufficiency. The cervix is the bottom part of your uterus (womb). Normally, the cervix remains closed during pregnancy until your baby is ready to be born. A normal pregnancy lasts for about nine months. An incompetent cervix may begin to open at 4 to 6 months of pregnancy. At this time, the cervix may begin to thin and widen without any pain or contractions. The amniotic sac, also called the bag of water, bulges down into the opening of the cervix until it breaks. This may cause a miscarriage or premature (early) delivery of your baby.

What causes an incompetent cervix? The exact

cause of an incompetent cervix is not known. Some women have an incompetent cervix for no obvious reason. The following may cause an incompetent cervix: 1.An abnormal cervix or uterus. 2.Certain medicines, such as diethylstilbestrol (DES). Your mother may have taken DES when you were inside her womb. 3.Changes in hormones during pregnancy. 4.Damage to the cervix, such as during surgery or after a difficult delivery of a baby. 5. Congenital anomalies

What are the signs and symptoms of an incompetent cervix? There are usually no signs and symptoms of an incompetent cervix. The cervix just slowly thins and opens without vaginal bleeding or labor contractions. You may have one or more of the following: 1.Backache. 2.Discomfort or pressure in the lower abdomen (stomach). 3.Gush of warm liquid from your vagina. 4.Mucous-like vaginal discharge. 5.Pain when passing urine. 6. Sensation or feeling of a lump in the vagina.

How is an incompetent cervix diagnosed? You may
need the following tests:

Pelvic exam: This is also called an internal or vaginal exam. During a pelvic exam, Your caregiver gently puts a warmed speculum into your vagina. A speculum is a tool that opens your vagina. This lets your caregiver see your cervix (bottom part of your uterus). With gloved hands, your caregiver will check the size and shape of your uterus and ovaries. Ultrasound: Sound waves are used to show pictures of the inside of your abdomen. A small handle with lotion on it is gently moved about on your abdomen (stomach). The handle may also be placed in your vagina and can measure the thickness of your cervical tissue.

How is an incompetent cervix treated? You
may need to rest in bed during the last 4 to 6 months of your pregnancy. You may also need one or more of the following: Pessary: This is a plastic or rubber device that may be placed in your vagina to elevate and support the cervix. Surgery: You may have surgery called cervical cerclage to tie the cervix closed. This surgery may be done before you get pregnant or during your pregnancy. Tocolytics: These medicines stop or prevent labor contractions.

a. McDonald procedure
(sutures are temporary) – a cerclage procedure wherein purse string sutures are placed around the cervix on the 14th- 18th weeks of gestation. These are removed during vaginal delivery.
b. Shirodkar-

(sutures are permanent) - patient delivers through caesarean section.

Barter procedure


- low implantation of the placenta

so that it is in the way of the presenting part.

Predisposing Factors
-Increasing parity -Advanced maternal age -rapid succession of pregnancies

1. Low

lying 2. Marginal / Partial 3. Complete 4. The placenta edge approaches that of the cervical os- marginal implantation

ULTRASOUND ( also known as Ultrasonic Echo Sounding or Sonar
Preparation for ultrasound

1. Explain the procedure to the patient, informing her that it is painless and there are no known ill effects 2. Empty the bladder but ask the patient to take 6 glasses of water afterwards in order to dilate the bladder. A full bladder displaces a gas filled bowel and, therefore, permits better visualization of the pelvis and its contents.

*Clinical uses of ultrasound
Diagnose pregnancy as early as 5-6 weeks gestational age b. Can establish that the fetus is increasing in size and, therefore can predict EDC c. Can determine gestational age by measuring the biparietal diameter of the fetal skull ( if it is more than 8.5 cm., it is more than 2,500 gms.) d. Can demonstrate size and growth rate of the amniotic sac e. Can confirm presence, size and location of the placenta Can diagnose multiple pregnancy Can visualize ascites, polycystic kidneys, ovarian cysts, etc. Can determine baby’s sex ( during third trimester and if in cephalic presentation)

S/Sx – first and most constant: painless, bright red vaginal bleeding due to tearing of placental attachment as a consequence of dilatation of the internal cervical os

premature separation of the placenta

a. Predisposing factors
1. Maternal Hypertension or toxemia

2. Increasing parity and maternal age 3. Sudden release of amniotic fluid 4. Short umbilical cord 5. Direct trauma 6. Hypofibrinoginemia

1. Severe, sharp, knife-like, stabbing pain high in the fundus 2. Hard, board like uterus; rigid abdomen 3. Signs of Shock 4. Concealed bleeding if extensive, causes uterus to lose its ability to contract. It becomes ecchymotic and copper-colored, called Couvelaire uterus

1. IV catheter 2. O2 by mask 3. FHR every 5 to 15 minutes 4. Baseline Fibrinogen determination 5. Position woman in LATERAL, not supine

a vascular disease of unknown cause which occurs anytime after the 24th week of gestation up to two weeks postpartum TRIAD of SYMPTOMS Hypertension Edema Protienuria (specifically albuminuria)

Predisposing factors primis under 20 and over 30 years Gravida- 5 or more pregnancies Low socioeconomic status (SES) Multiple Pregnancy With underlying medical conditions, e.g. heart dse. hypertension, or diabetes

CLASSIFICATION of TOXEMIA I. Acute Toxemia – symptoms appear after the 24th week of gestation

A. Preeclampsia 1. Mild 2. Severe B. Eclampsia

Diagnosis: roll-over test – assesses the probability of developing toxemia when performed between the 28th and 32nd week of pregnancy Procedure Patient lies in ;lateral recumbent position for 15 minutes until BP has stabilized Then rolls over to supine position BP is taken at 1 minute and 5 minutes after having rolled over Interpretation: if diastolic increases 20 mmhg or more, patient is prone to toxemia.

Details 1. PREECLAMPSIA Underlying Cause: Insufficient production of blood and platelets Generalized vasoconstriction and associated microangiopathy (disease of capillaries) Abnormal retention of sodium and water by body tissues Medical Complications: Cerebrovascular hemorrhage Acute pulmonary edema Acute Renal Failure

Types MILD Preeclampsia – S/Sx 1. sudden, excessive weight gain of 1-5 lbs. per week ( earliest sign of preeclampsia) due to edema which is persistent and found in the upper half of the body (e.g. inability to wear the wedding ring) 2. Systolic BP of 140, or an increase of 30 mmhg or more and a diastolic of 90, or a rise of 15mm hg or more, taken twice 6 hours apart 3. Proteinuria of 0.5 gms/ liter or more

SEVERE PreeclampsiaS/Sx BP of 160/110 mmhg Proteinuria of 5 gm/liter or more in 24 hours Oliguria of 400 ml. or less in 24 hours (normal urine output/ day = 1500ml). Cerebral or visual disturbances Pulmonary edema and cyanosis Epigastric pain ( considered an “aura” to the development of convulsions)

●2. ECLAMPSIA – the main difference between pre eclampsia and eclampsia is the presence of convulsions in eclampsia. ●signs and symptoms as in preeclampsia plus: ●increased BUN ●increased uric acid ●decreased CO2 combining power

3.) Management: CBR- sodium tends to be excreted at a more rapid rate if the patient is at rest. Energy conservation is important in decreasing metabolic rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is the result of vasoconstriction and decreased blood flow that diminishes the amount of nutrients and oxygen in cells. In any condition wherein there is a possibility of convulsions, bed rest should be in a darkened, non-stimulating environment with minimal handling. DIET For Mild Preeclampsia- high Protein, high carbohydrate, moderate salt restriction ( no added table salt, including “bagoong”, “patis”, “tuyo” can goods, bottled drinks, preserved foods and cold cuts) Severe Preeclampsia-high protein, high calorie and saltpoor (3gms of salt per day)

Medications Diuretics- Chlorthiazide/ Diuril. Hourly urine output should be at least 20-30 ml. (normally 50-60 ml per hour) S/E: Fatigue and muscle weakness due to fluid and electrolyte imbalance Nursing Care: closely monitor intake and output Digitalis- if with heart failure -Pharmacologic action: Increase the force of contraction of the heart, thereby decreasing heart rate. - Important: should not be given if heart rate below 60/min -Take the heart rate before giving the drug

Potasium supplements- patients receiving diuretics are prone to hypokalemia; if digitalis is given at the same time, hypokalemia increases the sensitivity of the heart to the effects of digitalis. Potassium supplements (e.g. banana) must be given to prevent cardiac arrhythmias. Barbiturates- sedation by means of CNS depression Analgesics: antihypertensives; antibiotics; anticonvulsants; sedatives

MAGNESIUM SULFATE- the drug of choice Actions CNS Depressant- lessens the possibility of convulsions Vasodilator- decreases the BP Cathartic causes a shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 GMS. initially, either by slow IV push over 5-10 min, or deep IM, 5 gms/ buttock, then an IV drip of 1 gm. per hour (1 gm/100 ml D10W) IF: Deep tendon reflexes are present Respiratory rate is at least 12 per min Urine output is at least 100 ml in 6 hours

Antidote for magnesium sulfate toxicity: CALCIUM GLUCONATE, 10% IV, to maintain cardiac and vascular tone Earliest sign of magnesium sulfate toxicity: disappearance of the Knee jerk/ Patellar reflex Method of Delivery preferably vaginal, but if not possible, CS will have to be done Prognosis the danger of convulsions is present until 48 hours postpartum

2.DIABETES MELLITUS- chronic hereditary disease which is characterized by hyperglycemia due to relative insufficiency or lack of Insulin from the pancreas which in turn leads to abnormalities in the metabolism of carbohydrates, proteins and fats .A.Diabetogenic effects of pregnancy- many women who have had no evidence of diabetes in the past develop abnormalities in glucose tolerance. -Decreased renal threshold for sugar -Increased production of adenocorticoids, anterior pituitary hormones and thyroxin, -Rate of Insulin secretion

B. Attendant risks Toxemia Infection Hemorrhage Polyhydramnios Spontaneous Abortion- because of vascular complications which affect placental circulation Acidosis- because of nausea and vomiting. It is the chief threat to the fetus in utero Dystocia- due to excessively large baby

C. DIAGNOSIS – MADE ON THE BASIS OF THE Glucose tolerance Test (GTT) Procedure NPO after midnight 2 ml of 50% glucose/ 3 kg of prepregnant body weight is given IV ( oral tablet is not advisable because of known decreased gastric motility and delayed absorption of sugar during pregnancy) Interpretation of results If less than 100 mg% - Normal If 100-120 mg % - possible gestational diabetes If more than 120 mg % - overt gestational diabetes

D. CATEGORIES – TO PREDICT THE OUTCOME OF PREGNANCY Class A – GTT is only slightly abnormal; minimal dietary restriction; insulin not needed; fetal survival is high Classes C to E – have 25% perinatal mortality Class F – therapeutic abortion ( in other countries maybe justified, not in the Phils.)

E. MANAGEMENT Diet – highly individualized. Adequate glucose intake (18002200 calories) to prevent intrauterine growth retardation Insulin requirements are likewise highly individualized, requiring close observation throughout pregnancy. Since the effects of the hormones more pronounced during the 2nd and 3rd trimesters there is increased need for insulin Insulin is regulated to keep urine +1 for sugar ( minimal Glycosuria is necessary to prevent acidosis) but negative for acetone. Long- acting insulin (Ultralente) will have to be changed to regular insulin (Lente) during the last few weeks of pregnancy. Often delivered by CS Baby is typically larger or maybe in distress because of placental insufficiency Severe metabolic imbalances in distress because of depletion of glycogen reserve in the liver and skeletal muscles by strenuous muscular exertion during labor Maximum difficulty in controlling diabetes is during the early postpartum period because of the drastic changes in hormonal levels

INFANT OF THE DIABETEC MOTHER (IDM) 1. Typically longer and weighs more because of: a.excessive supply of glucose from the mother b.increased production of growth hormones from the maternal pituitary gland c.increased secretion of insulin from the fetal pancreas d.Increased action of adrenocortical hormones that favor passage of glucose from mother to fetus 2. Congenital anomalies are often seen 3. Cushingoid appearance ( puffy, but limp and lethargic) 4. More often born premature, so respiratory distress syndrome is common 5. Lose a greater proportion of weight than normal newborns because of loss of extra fluid 6. Are prone to the following complications

A. HYPOGLYCEMIA- blood sugar levels less than 30 mg%. It is the most common complication to watch for Cause: While inside the uterus, the fetus tends to be hyperglycemic because of maternal Hyperglycemia. The fetal pancreas thus responded to the high glucose level by producing matching high levels of insulin. Following delivery, the glucose level begins to fall because the baby has been severed from the mother. Since there has been previous production of high level of insulin, hypoglycemia develops.

Clinical signs of Hypoglycemia shrill, high-pitched cry Listlessness/ jitteriness/ tremors lethargy; poor suck Apnea; cyanosis Hypotonia; Hypothermia Convulsions Consequence : hypoglycemia, if not treated, can lead to brain damage and even death Management: feed with glucose water earlier than usual, or administer IV of glucose B. Hypocalcemia- serum calcium level less than 7mg% a.signs same as hypoglycemia b.Sequela: same as hypoglycemia c.Management: Calcium Gluconate to prevent hypocalcemic tetany

3. HEART DISEASE 1. Classification Class I – No limitation physical activity Class II- slight limitation of physical activity; ordinary activity causes fatigue, etc. Class III- moderate to marked limitation of physical activity; less than the ordinary causes fatigue, etc. Class IV- unable to carry on any without experiencing discomfort 2. Prognosis
1. Classes I&II- normal pregnancy and delivery 2. Classes III &IV- poor candidates

3. Signs and Symptoms 1. Because of increased total cardiac volume during pregnancy, heart murmurs are observed 2. Cardiac output may become so decreased that vital organs are not perfused adequately; oxygen and nutritional requirements, therefore, are not met. 3. Since the left side of the heart is not able to empty the pulmonary vessels adequately, the latter become engorged, causing pulmonary edema and hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign. 4. Liver and other organ become congested because blood returning to the heart may not be handled adequately, causing the venous pressure to rise. Fluid then escapes through the walls of engorged capillaries and cause edema or ascites. 5. Congestive heart failure is a high probability also because of the increased cardiac output during pregnancy. Dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion, and cyanosis of nailbeds are obvious.

4. Management – consider the functional capacity of the heart PRENATAL PERIOD 1. Promote frequent rest periods and adequate sleep, decreases stress 2. Teach client to recognize and report signs of infection 3. Compare vital signs to baseline and normal values expected during Pregnancy 4. Instruct in diet to limit weight gain

INTRAPARTAL PERIOD =Labor increases the risk of congestive heart failuremilking effect of contractions and delivery increases blood volume to heart 1. Monitor maternal EKG and FHT continuously 2. Explained to client delivery is preferred over CS 3. Monitor clients response to stress of labor and watch for signs of decompensation 4. Administered O2 and pain medication as order 5. Provide calm atmosphere 6. Side-lying/ low- fowler’s position 7. Encourage “open-glottal” pushing during second stage of labor( forcep and vacuum to minimize pushing)

POSTPARTAL PERIOD Monitor V/S, any bleeding, strict I & O, daily weight, Rest and diet Assist ADL as needed Prevent Infection Facilitate non-stressful mother/baby interactions

4. HYPEREMESIS GRAVIDARUM Excess nausea and vomiting of early pregnancy leads to dehydration and electrolyte disturbances, esp. acidosis causes: possible severe reaction to HCG, not psychological, greater risk in condition where HCG levels increased. HCG levels peak around 6 weeks after conception, then begin to decline after the 12th week . s/sx: nausea and vomiting, progressing to retching between meals : weight loss MGT: 1. Begin NPO and IV fluid and Electrolyte replacement 2. Monitor I & O 3. Gradually re introduce PO intake, monitor taken and retained 4. Provide mouth care 5. Offer emotional support

Self-help for pregnancy nausea 1.Ginger is a good way to cope with mild nausea. 2. Eat a bland, starchy diet in small, frequent amounts to help alleviate symptoms. 3.Avoid foods that are fatty or make you feel nauseous. 4.Try taking vitamin B6 supplements, or increasing this vitamin in your diet (bananas, potatoes, watermelon, chickpeas are all rich in this nutrient). 5.Rest frequently. 6.Get regular, gentle exercise. 7.Try sea-sickness acupressure bracelets or acupuncture. 8.If your vomiting is severe, try electrolyte drinks to keep up the levels of minerals and salts that you need.

Medical treatment for hyperemesis gravidarum 1.fluids via a drip 2. anti-nausea medication via a drip 3. vitamins and other nutrients that you may have lost through your severe nausea 4. rarely, nutrients, via a naso-gastric tube or intravenously, if you are still unable to eat and keep food down.

5. POLYHYDRAMNIOS Definition: excessive amniotic fluid Etiology: a. maternal disease – toxemia, diabetes b. fetal malformation – esophagus not complete c. Erythroblastosis – hemolytic anemia in newborn d. Multiple pregnancies – Treatment : a. Relieve pressure by amniocentesis b. Delivery

6. URINARY TRACT INFECTION affect 10 % of all pregnant women dilated, flaccid, and displaced ureters are a frequent site E. Coli is the usual cause May cause premature labor if severe, untreated s/sx: - frequency and urgency of urination suprapubic pain, flankpain, hematuria, pyuria fever and chills MGT. 1. Encourage high fluid intake 2. Provide warm baths to relieve discomfort and promote perineal hygiene 3. Stress good bladder-emptying schedule 4. Monitor for signs of Premature labor from severe or untreated infection 5. Administer and monitor intake of antibiotics, urinary analgesics)


A. ADOLESCENCE - pregnancy is a condition of both physical and psychologic risk -adolescent is frequently undernourished and not yet matured either physically or Psychosocially -Serious complications: TOXEMIA & LOW BIRTH WEIGHT MGT. 1. Encourage adequate prenatal care 2. provide health teachingpregnancy,labor and delivery 3. provide nutritional counseling 4. teach coping skills for labor and delivery 5. teach child care skills

B. DESSIMINATED INTRAVASCULAR COAGULATION ( DIC) - also known as consumptive coagulopathy - a diffuse, pathologic form of clotting, secondary to underlying disease/ pathology - occurs in critical maternity problems such as abruption placenta, dead fetus syndrome, amniotic fluid embolism, preeclampsia/eclampsia, H-mole and hemorrhagic shock *MECHANISM A. Precoagulant substances released in the blood trigger microthrombosis in peripheral vessles and paradoxical consumption of circulating clotting factors B. Fibrin-split products accumulate, further interfering with the clotting process c. Platelet and fibrinogen levels drop

bleeding may range from massive , unanticipated blood loss to localized bleeding ( purpura and petechiae) Presence of special maternity problems Prolonged prothrombin and partial thromboplastin times

1. Assist with medical management of underlying condition 2. Administer blood component therapy as ordered 3. Observe for signs of insidious bleeding (oozing IV site, petechiae, lowered hematocrit) 4. Institute nursing measures for severe bleeding/ shock if needed 5. Provide emotional support to client and family as needed

C. ANEMIA -low red cell count maybe underlying condition -may or may not be exacerbated by physiologic hemodilutionn of pregnancy -most common medical disorder of pregnancy s/sx client is pale, tired, short of breath, dizzy Hgb is less than 11g/dl; hct less than 37% MGT. Encourage intake of food rich in iron content Monitor iron supplementation Teach sequelae of iron ingestion Assess need for parenteral iron

D. PRENATAL SUBSTANCE ABUSE 1. ALCOHOL =elvates the mood, depresses the CNS =affects every other system in the body of the mother =displaces other nutritional food intake =greatest risk from high blood alcohol levels =NO SAFE Level of maternal alcohol use in pregnancy has been established =FETUS may display : >IUGR >CNS dysfunction and Craniofacial abnormalities( fetal alcohol syndrome)

2. COCAINE -power stimulant, very addictive -causes vasoconstriction, elevated BP, tachycardia -may precipitate seizures -affects ability to transport O2 into the blood -may cause SPONTANEOUS ABORTION, fetal malformation, abruption placenta,neural tube defects -NEWBORN- display irritability, hypertonicity, poor feeding patterns, increased risk of SIDS 3. OPIATES -produce analgesia, euphoria, respiratory depression if IV used, foreign substance may cause pulmonary emboli or infections -if IV used places mother at greater risk of contracting HIV, the passing it on the fetus -NEWBORN - experience withdrawal within 24-72 hours after delivery -high-pitched cry, restlessness, poor feeding



1. PREMATURE/ PRETERM LABOR Labor that occurs before the end of 37thweek of pregnancy assoc. with cervical incompetence preeclampsia/ eclampsia maternal injury infection multiple births placental disorders -Contractions more frequent than every 10 minutes, last 30 seconds or longer,

- assessment 1. uterine contractions( painful/painless) 2. Abdominal cramping (maybe accompanied by diarrhea) 3. low backpain 4. pelvic prassures or heaviness 5. change in the character and amount of usual discharge; maybe thicker or thinner, bloody, brown or colorless, and maybe odorous 6. ruptures of amniotic membranes -PREVENTION 1. stop smoking- major factor 2. stop substance abuse 3. early consistent prenatal care 4. appropriate diet weight gain 5. minimize psychological stressor

- MEDICAL MGT. 1. MAGNESIUM SULFATE -Stops uterine contractions with fewer s/e than beta adrenergic drugs -few serious s/e : initially patient feels hot, flushed, may c/o headache, nausea, diarrhea, dizziness, nystagmus and lethargy - FETAL s/e : HYPOTONIA NSG. AXN- carefully monitor RESPIRATION, reflexes,urinary output 2. BETA- ADRENERGIC DRUGS- TERBUTALINE AND RITODRINE -decreases effect of calcium on muscle activation to slow or stop uterine Contractions -s/e : increased heart rate, nervouseness, tremors, nausea, vomiting, decrease in serum K+ level, cardiac arrythmias, pulmonary edema 3. Nifedipine -calcium channel blocker -s/e: facial flushing, mild hypotension, reflex tachycardia, headache,nausea 4. Indomethacin - prostaglandin synthetase inhibitor -s/e : n/v, dyspepsia 5. BETAMETHASONE( CELESTONE) When labor cannot be arrested to promote fetal lung maturity IM to mother every 12 hrs times 2, then weekly until 34 weeks gestation

2. POSTMATURE/ PROLONGED PREGNANCY PREGNANCY beyond 42 weeks FETUS at risk due to placental degeneration and loss of amniotic fluid(cord accident) Decrease amount of vernix 3. PROLAPSED UMBILICAL CORD displacement of cord in downward direction, near or ahead of the presenting part may occur when membranes rupture assoc. with breech presentation, unengaged presentations, and premature labor OBSTETRICS EMERGENCY-FETAL HYPOXIA may result in CNS DAMAGE or DEATH NSG.AXN. check FHT if fetal bradycardia noted, vaginal exam cord prolapsed= exert upward pressure against presenting part to lift part off cord, reduce pressure of cord KNEE-CHEST or SEVERE TRENDELENBURG’S CORD protrude in vagina- cover with sterile gauze moistened with sterile saline while carrying out above tasks. DO NOT ATTEMP TO REPLACE THE CORD. Notify physician

4. PREMATURE RUPTURE OF MEMBRANES loss of amniotic fluid, prior to term, unconnected with labor danger assoc.= prolapsed cord, infection, and the potential need for premature delivery differentiate ph of vagina (amniotic fluid- ALKALINE; purulent discharge- ACIDIC) NSG. AXN 1. Monitor maternal/fetal VS esp. maternal temperature 2. calculate gestational age 3. observe for signs of infection a. if infection (+)- antibiotics and prepare for immediate delivery b. if infection (-) – induction of labor may be delayed 4. observed color of amniotic fluid

5. FETAL DISTRESS common contributing factors are: 1.cord compression 2.placental abnormalities 3.preexisting maternal disease Assessment finding: 1.check FHR on appropriate basis 2.conduct vaginal exam for presentation and position mother on left side, administer O2, check for cord prolapse, notify doctor mother and family 5.Prepare for emergency birth

6. DYSTOCIA =any labor/delivery that is prolonged or difficult =usually results from a change in 5 Ps( factors in labor/ delivery) PASSENGER,PASSAGE,POWERS,PLACENTA and PSYCHE of mother -Frequently seen causes: 1. Cephalopelvic Disproportion (CPD)= minimal- NSVD =great-CS 2. Problems with presentation a. any presentation unfavorable for delivery- ex. breech, shoulder, face, transverse lie b. posterior presentation that does not rotate or cannot be rotated with at ease. c. C/S 3. Problems with maternal tissue a. full bladder, cervical edema, scar tissue and congenital anomalies b. empty the bladder may allow labor to continue; other cond. = C/S 4. Dysfunctional uterine contractions a. contractions maybe too weak, too short, too far apart,ineffective b. progress of labor is affected; progressive dilation, effacement, and descent do not occur in the expected pattern. c. classification: 1. PRIMARY: inefficient pattern present from beginning of labor; usually a prolonged latent phase 2. SECONDARY: efficient pattern that changes to inefficient or stops; may occur in any stage

- ASSESSMENT > Progress of labor slower than expected rate of dilation, effacement, descent for specific client > Length of labor prolonged > Maternal exhaustion/ distress >Fetal distress -NSG. INT. 1. Individualized as to cause 2. Provide comfort measures for client 3. Provide clear, supportive descriptions of all actions taken 4. Admin. analgesia as ordered 5. Prepare Oxytocin for induction of labor 6. Prepare for C/S

7. PRECIPITOUS LABOR AND DELIVERY labor of less than 3 hours emergency delivery without client’s physician or midwife ASSESSMENT Finding As labor is progressing quickly, assessment may need to be done rapidly client may have history desire to push observe for status of membranes, perineal area for bulging, and for signs of bleeding 8. AMNIOTIC FLUID EMBOLISM - escape of amniotic fluid into the maternal circulation, usually in conjunction with a pattern of hypertonic, intense uterine contractions, either naturally or oxytocin induced - OBSTETRIC EMERGENCY: maybe fatal to the mother and to the baby -ASSESSMENT FINDING 1. sudden onset of respiratory distress, hypotension, chest pain, signs of shock 2. bleeding (DIC) 3. Cyanosis 4. Pulmonary Edema

NSG. INT. 1. Initiate emergency life support activities for mother =Administer O2 =Utilize CPR in case of Cardiac Arrest 2. Establish IV line for blood transfusion and monitoring of CVP 3. Administer Meds. To control bleeding 4. prepare for emergency birth of baby 5. Keep client/ family informed as possible

V METHODS OF DELIVERY ●1. Instrumental deliveries ●Forcep delivery ●Vacuum Extraction ●2. Cesarean Section (C/S) ●3. Induce Labor


A. TOXOPLASMOSIS - is caused by infection with the intracellular protozoan parasite TOXOPLASMA GONDI - produces a rash and symptoms of acute,flulike infections in the mother - is transmitted to the mother through raw meat or handling of cat litter of infected cats - organsm is transmitted to the fetus across the placenta - can cause spontaneous abortion

B. RUBELLA/ GERMAN MEASLES - is teratogenic in the first trimester - Rubella causes congenital defects of the eyes, heart and brains - If not immune (titer of 1:8 or less ), the mother should be vaccinated in the postpartum period; she must wait at least 3 months before becoming pregnant Incidence: Mother- the earlier the mother contacted the disease, the greater the likelihood that the baby will be affected. The rubella virus slows down division of infected cells during organogenesis, thus causing congenital defects. Newborn- can carry and transmit the virus for as long as 12-24 months after birth Signs and Symptoms of Congenital Rubella Syndrome Low birth weight; jaundice; petechiae; anemia; thrombocytopenia; hepatosplenomegaly Classic Sequelae: a. Eyes: Chorioretinitis, cataract, glaucoma b. Heart: Patent ductus Arteriosus, stenosis, Coarctations c. Ear: Nerve Deafness d. Dental and Facial clefts

C. CYTOMEGALOVIRUS -produces mononucleosis-like symptoms in the mother - the mother maybe asymptomatic at birth: cytomegalovirus causes FETAL DEATH, MENTAL RETARDATION, BLINDNESS, DEAFNESS, or SIEZURES - ANTIVIRAL therapy may be prescribed

D. GENITAL HERPES -Affects the external genitalia, vagina and cervix -herpes causes draining, painful vesicles -NO vaginal examinations are done in the presence of active vaginal herpetic lesions - About half of infants exposed to herpes in vaginal delivery become infected -s/sx : PRODROMAL Phase: Headache, generalized aching, malaise, low grade fever and burning in the area where vesicles will appear, inguinal and pelvic lymphadenopthy with pain, pain in urination; vesicles in the labia, vaginal, perianal and endocervical area for 2-6 weeks; recurrent lesions -DX Test : Papsmear, viral isolation from the lesion NSG. AXN. good handwashing cleaning of room using universal precautions C/S delivery ROOMING-IN AND Breastfeeding

1. No sexual activity in the presence of lesions and 10-14 days after lesions subsided 2. Keep vulva clean and dry in presence of lesions 3. Sitz bath and void in water for urinary pain and retention 4. Use of foley catheter if retention persist 5. Povidone-Iodine douche & ACYCLOVIR (not used during pregnancy)

E. SYPHYLLIS Cause: TREPONEMA PALLIDUM A spirochete which enters the body during coitus or through cuts and breaks in the skin or mucous membrane Treatment: 2.4 – 4.8 million units of PENICILLIN – Benzathine Penicillin= DOC ( Antidote: 30-40 grams ERYTHROMYCIN) If untreated, syphilis can cause Midtrimester abortion, CNS lesions in the newborn or even death THE NEWBORN WITH CONGENITAL SYPHILLIS SIGNS AND SYMPTOMS: Jaundice at 2 weeks of life – 1st sign of the disease Anemia and hepatosplenomegaly “SNUFFLES”(persistent rhinorrhea); coppery rashes on palms and soles; mucous patches; condylomas; pseudo paralysis due to bone inflammation If untreated, can progress on to deformed bones, teeth, nose, joints and CNS syphilis Management: Penicillin IM for 10 days or one long- acting Penicillin(Penadur LA)

F. VARICELLA- ZOSTER (CHICKEN POX) - 2% risk of having a child with congenital defects in pregnancy -if infection occurs in the last 4 days of gestation and 2 days postpartum, it results in FATAL NEONATAL INFECTION -s/sx : vesicles on trunk, neck, face and then the extremeties. Varicella pneumonia is quite severe in pregnancy - TX. 1. Strict isolation during dse. 2. Bathe daily to prevent bacterial infection on the vesicles 3. Watch out for varicella pneumonia 4. Varicella-zoster immune globulin within 3 days of exposure to alleviate maternal signs but not alter fetal outcome 5. May breastfed after the dse.

G. GONNORHEA - can cause spontaneous abortion, PROM - if present during delivery it can cause BLINDNESS - profuse and purulent vaginal discharge, itching of the vulva, painful urination and positive in a cervical smear -DOC= CEFTRIAXONE or SPECTINOMYCIN or PROBENECID = 0.5% ERYTHROMYCIN or 1% TETRACYCLINE ointment for babies

H. CHLAMYDIA TRACHOMATIS - RISK of PROM, Prematurity, low birth weight and perinatal mortality - leads to INFERTILITY, ECTOPIC Pregnancy and may cause delayed ENDOMETRITIS - increased yellowish vaginal discharge, painful and frequent urination, bleeding between periods, mucopurulent cervicitis, positive on culture and antigen detection test - TX. ERYTHROMYCIN TETRACYCLINE ( non- pregnant) I. MONILIASIS - vaginal irritation, pruritus with white, cheese-like discharge, yeasty odor dysuria. - Positive finding in KOH or saline wet mount -TX. CLOTRIMAZOLE of antifungal agent used for 7 days

J. TRICHOMONIASIS - frothy-greenish vaginal discharge, perineal itching, erythema, alkalinic vaginal pH, positive motile protozoa in a saline wet mount -TX. METRONIDAZOLE treatment after 20 weeks AOG - Cervical rest for 2 weeks; NO sexual Intercourse K. TUBERCULOSIS - is highly communicable dse. cause be mycobacterium tuberculosis L. ACQUIRED IMMUNE DEFECIENCY SYNDROME (AIDS)


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Early postpartum hemorrhage
1. Uterine Atony – uterus is not
well contracted, relaxed or boggy; most frequent cause

Predisposing Factors
Overdistension of the uteruse.g. multiple pregnancy, multiparity, excessive large baby, polyhydramnios Cesarian section Placental accidents
(previa or abruption)

Prolong and difficult labor

Massage- first nursing action Ice compress Oxytocin administration Empty bladder Bimanual compression to explore retained placental fragments Hysterectomy- last resort

2. Lacerations 3. Hypofibrinoginemia – a clotting defect, Management:

» blood transfusion

Late postpartum hemorrhage
– Retained placental fragments–

management: » dilatation and Curettage (D&C)

– Hematoma due to injury
to blood vessels in the perineum during delivery


Commonly seen in precipitate delivery and those with perineal varicosities

Ice compress during first 24 hours Oral analgesics, as ordered Site is incised and bleeding vessel is ligated

1. Cancer – a neoplasm characterized by the uncontrolled growth of anaplastics cells that tend to invade surrounding tissue and metastasized to distant body sites. Etiology: a. STD Manifestation: a. bleeding between periods or after intercourse, douching b. leucorrhea Treatment: a. hysterectomy b. radiation c. laser surgery d. pap smear

2. Endometrium – malignant neoplastic disease of the endometrium of the uterus. Etiology: > medical history of infertility > administration of exogenous estrogen > familial hereditary Manifestation: a. post menopausal bleeding b. abnormal bleeding c. abnormal low back pain d. large boggy uterus - most often sign of advance disease. Treatment: a. hysterectomy b. radiation therapy c. surgery ( salpingo – oophorectomy with abdominal hysterectomy if metastasized)

3. Pelvic inflammatory Disease (PID) Etiology : a. infections b. venereal disease Manifestations: a. vaginal discharge: foul smelling, purulent b. pain in abdomen and lower back c. Temperature, nausea and vomiting Nursing Management: a. Antibiotic therapy b. client education 4. Menopause – cessation of menstruation for one year Manifestation: > hot flasfes > palpitations > diaphoresis > osteoporosis Nursing interventions / Treatment 1. Assess psychosocial response 2. Discuss merits of estrogen therapy (estrogen decrease bone reabsorption)

5. Infertility – decrease capacity to conceive Etiology : 1. Abnormal genetalia 2. Absence of ovulation 3. Blocked fallopian tubes 4. Altered vaginal ph 5. Sperm deficiency or decrease motility Diagnosis: 1. Assessment of male 2. Assessment of female Management: 1. Medication a. Clomiphene citrate (clomid) or menotropins ( Pergonal) are associated with multiple births b. hormone replacement 2. Artificial insemination 3. In vitro fertilization Nursing Management: 1. Provide emotional support 2. Provide client education

1. Premature Newborn – gestational age of less than 37
weeks regardless of weight. Physical Adaptation: 1. Respiratory a. may lack surfactant b. At risk for respiratory distress Syndrome 1. retractions 2. nasal flaring 3. expiratory grunt 4. tachypnea 5. need mechanical ventilation, O2, continuous positive airway pressure (CPAP) 2. Nutrition ( fluid and Electrolyte) a. May lack gag and sucking reflex if under 34 weeks b. Fed by gavage of hyperalimentation

3. Circulatory
a. Patent ductus arteriosus is common b. Persistent fetal circulation

4. Complications: a. hypothermia b. hypocalcemia c. hypoglycemia d. hyperbilirubinemia e. birth trauma f. sepsis g. intracranial hemorrhage h. apnea 5. Nursing Mgt. a. Monitor v/s b. Maintain temperature c. Assess hydration and nutrition d. Promote attachment and bonding between parents and newborn

2. Small for gestational Age (SGA) Definition: = any newborn who falls below the tenth percentile on thegrowth chart at birth Etiology : a. Placental insufficiency b. PIH c. Twin pregnancy d. Poor nutrition e. Smoking, drugs and alcohol f. Adolescent pregnancy Complication: a. Perinatal asphyxia – severe hypoxia leading to hypoxemia & hypercapnea, loss of conciousness, if not corrected, death may occur .b. Meconium aspiration syndrome c. Hypoglycemia d. Hypothermia e. infections Nursing Mgt. 1. Support respirations 2. Provide neutral thermal environment 3. Provide adequate nutrition 4. Observe for complication 5. Protect from infections 6. Support parents and bonding

3. Large for gestational Age (LGA) Definition: =newborn whose weight is at or above 90th percentile Etiology: 1. Diabetes 2. Genetic predisposition 3. Congenital defects Complication: 1. Birth trauma such as fractured clavicle 2. Hypoglycemia 3. Polycythemia – abnormal increase in number of erythrocytes in the blood 4. Mother diabetic presents same risk and care as premature infant Nursing interventions: 1. Assess for trauma 2. Assess for congenital abnormalities 3. Assess for hypoglycemia especially if infant of diabetic mother (IDM)

4. Jaundice (Hyperbilirubinemia) Causes : 1. Physiological a. Never seen during first 24 hours, usually appears by 3rd day b. Immature Liver 2. ABO incompatibility 3. Rh incompatibility ( Erythroblastosis Fetalis) a. Rh negative mother & Rh + baby b. Kernicterus can lead to brain damage, anemia, hepatosplenomegaly c. Treatment: 1. phototherapy, exchange transfusion, sunlight 2. RhoGAM administered with in 72 hours of delivery Signs & symptoms 1. lethargy, poor feeding & vomiting 2. severe neurologic excitation or depression > tremors > twitching > convulsions, high pitch cry, absence DTR

5. Substance Abuse and the Newborn A. Drug Dependent 1. Manifestations of withdrawal a. irritability is early symptoms b. sneezing and nasal stuffiness c. high pitch cry d. tremors e. perspirations f. feeding problems g. transient tachypnea 2. Nursing interventions a. Prevent overstimulation to prevent possible seizures b. swaddle, hold infant firmly c. Medications as ordered d. small frequent feedings

B. Fetal Alcohol Syndrome 1. Etiology: consumption of alcohol during pregnancy 2. Manifestations a. feeding problem b. distinctive facial features c. CNS dysfunction d. Withdrawal syndrome 3. Nursing interventions a. Protect infant from injury b. administer medication as ordered c. monitor fluid therapy d. decrease stimuli e. Provide support for parents to care for possibly difficult infant f. Provide social service referral

6. Asphyxia Neonatorum

A. occurs when respirations are not well established within 60 seconds after birth as a result of anoxia, cerebral damage or narcosis. B. Therapeutic Interventions: 1. Preventive mgt. = early prenatal care; prenatal education ; early mgt. of deviations from a normal pregnancy 2. Medical mgt. during labor and birth; resuscitative measures at birth = keep under observation first 24 hours C. 2 types : 1. Asphyxia Livida : persistent generalized cyanosis and good muscle tone 2. Asphyxia Pallida: marked pallor, poor muscle tone

7. Opthalmia Neonatorum A. an eye infection caused by Neisseria gonorrhoeae & Chlamydia trachomatis B. Organism is transmitted from the genital tract of infected mother during birth or by infected hands C. Chlamydial infections can also cause pneumonia. D. s/s = perinatal hx of maternal infections = purulent conjunctivitis if prophylactic tx is not used; manifested 3-4 days after birth. = respiratory status with chlamydial infection E. Prevention: ophthalmic antibiotic instilled at birth after providing for initial bonding F. Nursing mgt. 1. Cleanse the eyes with normal saline by wiping from inner to outer canthus 2. Administer prescribe antibiotics 3. Refer for ophthalmic evaluation 4. Monitor v/s & administer O2

8. Cranial Birth Injuries A. CAPUT SUCCEDANEUM: = edema with extravasations of serum into scalp tissues caused by molding during the birth process; crosses the suture lines of the bony plates of the skull; = no tx is necessary; it subsides in a few days. B. CEPHALHEMATOMA: =edema of the scalp with effusion of blood between the bone and periosteum; stops at the suture line; =no tx is necessary; = it disappears within a few weeks to a few months after birth C. INTRACRANIAL HEMORRHAGE = bleeding into cerebellum, pons and medulla oblongata caused by a tearing of the tentorium cerebelli. = occurs in preterm infants and following prolonged labor = difficult forceps birth = precipitate birth or breech extraction

Assessment: 1. abnormal respirations; cyanosis 2. shrill & weak cry 3. Flaccidity or spasticity; seizures 4. restlessness, wakefulness 5. impaired sucking reflex Nursing mgt. 1. Administer O2 2. Maintain in high – fowlers position 3. Administer prescribed vitamins C & K to control & prevent further hemorrhage 4. Institute ordered gavage feedings when sucking reflex is impaired. 5. Support the parents

9. Meconium Aspiration Syndrome (MAS) A. hypoxic insult to fetus that causes increased intestinal peristalsis with passage of meconium into the amniotic fluid; =the meconium – stained fluid is aspirated by the infant during the first few breaths after birth causing an obstruction in the lung that results in chemical pneumonia B. Therapeutic interventions: 1. suctioning after head is delivered 2. oxygenation and ventilation 3. prophylactic antibiotic therapy

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