Wesleyan University –Philippines

Cabanatuan City
College of Nursing

NCM 109- Care of Mother and Child at Risk or with

Problems
(Acute and Chronic)-LECTURE
PRELIM PERIOD
WEEK 3
II. Care given to a mother experiencing a sudden pregnancy complication utilizing the nursing care plan.
1.Assessment
 Always ask women during prenatal visit about any symptoms that may indicate a complication such as pain or
vaginal symptoms (leaking of fluid, or bleeding)
 Other symptoms: head ache, blurring of vision, back pains
 Review the danger signs of pregnancy
2.Nursing Diagnosis: should reflect both the physical problem and the woman’s or family’s concern
Examples:
 Anxiety related to guarded pregnancy outcome
 Fear of preterm labor ending the pregnancy
 Anticipatory grieving related to uncertain pregnancy outcome
 Deficient knowledge related to signs and symptoms of possible complications
 Risk for infection related to incomplete miscarriage
 Deficient fluid volume related to third-trimester bleeding
 Risk for ineffective tissue perfusion related to gestational hypertension
3.Outcome Identification and Planning:
 Outcomes addresses both fetal and maternal (mother) welfare as well as family welfare
 Treatment and management should be regularly updated and maintained
 Referrals can be included for counseling
4.Implementation:
 Interventions require an interpersonal approach that speaks to several different areas:
 Continued both healthy maternal and fetal physical growth
 A woman’s and family’s psychological health
 Continuation of the pregnancy for as long as possible
5. Outcome Evaluation
 Patient’s blood pressure is maintained within acceptable parameters for remainder
of pregnancy
 Couple states they feel able to cope with anxiety associated with the pregnancy
complication
 Patient’s signs and symptoms of hypertension of pregnancy do not progress to
eclampsia
 Patient accurately verbalizes crucial signs and symptoms she should immediately
report to her primary health care provider
 Couple expresses feelings of sadness over pregnancy loss.
 Patient is able to adhere to the medical treatment regimen and experiences no
adverse effects from the treatment
 Bleeding during pregnancy
 Vaginal bleeding during pregnancy is always a deviation from the normal, is always
potentially serious, may occur at any point during pregnancy, and always frightening.
 Any degree of bleeding during pregnancy is a potential emergency because it may mean
the placenta has loosened and cut off nourishment to the fetus.
 Bleeding during pregnancy are summarized in table 21.1 page 535.
 IMMEDIATE ASSESSMENT OF VAGINAL BLEEDING DURING PREGNANCY
 1.confirmation of pregnancy
 2.pregnancy length
 3.duration
 4.intensity
 5.description
 6.frequency
 7.associated symptoms
 8. action
 9.blood type
A.Bleeding Disorder During the First Trimester of Pregnancy
1.Abortion
 Is a medical term for any interruption of a pregnancy before a fetus is viable (able to
survive outside the uterus if born at that time)
 termination of pregnancy before the age of viability (20 weeks or 5 mos)
 a procedure, either surgical or medical, to end a pregnancy by removing the fetus
and placenta from the uterus
 A viable fetus is usually defined as a fetus of more than 20 to 24 weeks of
gestation or one that weighs at least 500 grams
 A fetus born before this point is considered a miscarriage or is termed as
premature or immature birth
Types:
1. a. Spontaneous Abortion – termination of pregnancy after the age of viability
> A miscarriage is an early miscarriage if it occurs before week 16 of pregnancy and a
late miscarriage if it occurs before weeks 16 and 20
> For the first 6 weeks (between 1st to 2nd month) of pregnancy, the developing placenta is tentatively
attached to the decidua of
the uterus.
 During weeks 6 to 12 (2nd to 3rd month) of
pregnancy, the placenta is moderately attached
 After week 12, the attachment is penetrating and deep
 Bleeding before week 6 is rarely severe
 Bleeding after week 12 can be profuse because the placenta is implanted so deeply.
Signs and symptoms:
 > Low back pain or abdominal pain that is dull, sharp, or cramping
 > Vaginal bleeding, with or without abdominal cramps
 > Tissue or clot – like material that passes from the vagina
Common causes:
1. Abnormal fetal development due either to teratogenic factor (Any agent that can
disturb the development of an embryo or fetus.) or chromosomal aberration
(changes in chromosome number: gains or losses)
2.mmunologic factors
3.Implantation abnormalities
4.Failure of the corpus luteum on the ovary to produce enough progesterone to
maintain the decidua basalis
5. Ingestion of alcoholic beverages during pregnancy
6. Urinary tract infection
7. Systemic infections such as rubella, syphylis, poliomyelitis, cytomegalovirus and
toxoplasmosis
Signs and Test
 1. Pelvic Exam – thinning of cervix (effacement)
* Increased cervical dilatation
* Evidence of rupture membranes
 2. HCG – (qualitative and quantitative urine and blood) – urine HCG test is a
common method of determining if a woman is pregnant; detectable in the blood or
urine 1 to 2 days after implantation of the fertilized egg ( that is 10 days after
ovulation)

Normal Values: Qualitative Urine and Blood

> the test is negative if client is not pregnant
> the test is positive if client is pregnant
Treatment and Management
 > Tissue passed from the vagina should be examined to determine the source (fetal
V/S H-Mole)
 > If remaining tissues are present – surgery or D & C
Classification Of Spontaneous Abortion:
a. a.1. Threatened Abortion – pregnancy is jeopardized by bleeding and cramping
but the cervix is closed
Signs and Symptoms
 > Vaginal bleeding during the first 20 weeks of pregnancy
 > Abdominal cramps may or may not accompany vaginal bleeding
Treatment/Management
 > Complete Bed Rest (CBR) or pelvic rest for 24 to 48 hours-key intervention
 > Abstaining from intercourse
 > Avoid douching
 > Avoid using tampons
a.2. Imminent/ Inevitable Abortion – moderate bleeding, cramping, tissue protrudes
from the cervix (cervical dilatation)
Signs and Symptoms
> low back pain or abdominal pain that is dull, sharp, or cramping
> vaginal bleeding, with or without abdominal cramps
> tissue or clot – like material that passes from the vagina
TYPES
1. A.2.1.Complete Abortion – all products of conception are expelled
2. A.2.2. Incomplete Abortion – placenta and membranes are retained
Complication:
 > Infection-may also occur after a complete abortion
 * Escherrichia coli- organism responsible after miscarriage
 >spread from the rectum forward into the vagina
 *Group A streptococcus
Management:
> For complete abortion – emotional support
 for incomplete abortion – D & C – dilating the cervix and scraping the lining of the
uterus with an instrument called a curette
 b. Habitual Abortion – three or more consecutive pregnancies result in abortion
usually related to incompetent cervix
 Other Possible Causes:
 > Defective spermatozoa
 > endocrine factors such as lowered levels of protein bound iodine (PBI), butanol-
extractable iodine (BEI), and globulin-bound iodine (GBI), poor thyroid functions or
a luteal phase defect
 >deviations of the uterus such as separate or bicornuate uterus
 >resistance to uterine artery blood flow
 >chorioamnionitis or uterine infection
 >autoimmune disorders such as those involving lupus anticoagulant and
antiphospholipid antibodies
Test to detect the cause:
1.X-ray or ultrasound of the uterus
2. Transvaginal ultrasound
3.Blood test:
 >Thrombophilia and thyroid function test
 >Karyogram
 >CBC to determine the degree of blood loss
 >WBC and differential to rule out infection
Management:
 > Surgery for Habitual Abortion, if the cause is incompetent cervix
Temporary
> McDonald Procedure
> Temporary Circlage
> Delivery: Normal Delivery
Permanent
> Shirodkar procedure
> Delivery: C/S

Nursing Management:

 >Check for signs of infection

 >Check for signs of labor
 >Check for normal bleeding
c.Missed abortion – fetus dies; product of conception remain in uterus 4 weeks or
longer; signs of pregnancy cease
Signs and Symptoms
 >Scanty dark bleeding
 >Negative pregnancy test
Management
 >Induced labor – oxytocin/vaginal suppositories with prostaglandin hormone
 >Vacuum extraction

b. Infected/Septic Abortion – abortion associated with an infection inside a pregnant

woman’s uterus.
 >Abortion may be spontaneous, which is referred to as miscarriage.
 >May also be an elective surgical or medical abortion, meaning, the woman chose
to terminate her pregnancy.
Pathophysiology: A septic abortion can occur when bacteria enter the uterus through
the mucus plug. These bacteria can be introduced by unclean tools used during an
elective abortion. The bacteria may also be those that normally live in a woman’s
vagina. If the woman has a sexually transmitted disease (STD) such as chlamydia,
the bacteria causing the STD can infect the uterus. If the infection reaches the
bloodstream, it is called sepsis
Signs and Symptoms:
 >High fever, usually above 101 F
 >Chills
 >Severe abdominal pain or cramping
 >Prolonged or heavy vaginal bleeding
 >Foul-smelling vaginal discharge
 >backache
If condition becomes serious, signs of shock may appear: These include:
 >Low blood pressure
 >Low body temperature
 >Little or no urine output
 >Troubled breathing
Causes of Septic Abortion:
> The membranes surrounding the fetus have ruptured sometimes without detected
 >STD
 >IUD left in place during pregnancy
 >Tissue from the fetus or placenta is left inside the uterus after a miscarriage or
abortion
 >Attempts were made to end the pregnancy, often illegally, by inserting tools,
chemicals, or soaps into the uterus
Long Term effects : Infertility Treatment: D & C
Risks: Death of the fetus
b.1. Septicemia – is the presence of bacteria in the blood (bacteremia) and is often associated with
severe disease.
Causes: Septicemia is a serious, life-threatening infection that get worse very quickly. It can arise
from infections throughout the body, including infections in the lungs, abdomen, and urinary tract
 Septicemia can rapidly lead to septic shock and death. Septicemia associated with some
organisms (germs) such as meningogococci can lead to shock, adrenal collapse, and
disseminated intravascular coagulopathy, a condition called Waterhouse-Friderichsen syndrome
Signs and Symptoms:
 >Fever (sudden onset, often spiking)
 >Chills
 >Toxic looking (looks acutely ill)
 >Changes in mental state
• >Irritable
• >Lethargic
• >Anxious
• >Agitated
• >Unresponsive
• >comatose
 >Shock
• >cold, clammy skin
• >Pale
• >Cyanotic
• >Skin signs associated with clotting abnormalities
 >Petechiae
 >Ecchymosis (often large, flat, purplish lesions that do not blanch when pressed)
 >Gangrene (early changes in the extremities suggesting decresed or absent blood flow)
 >Decreased or no urine output
Test that can confirm infection:
 >Blood culture
 >Urine culture
 >CSF culture
 >CBC
 >Platelet count
 >Clotting studies – Pt, PTT, fibrinogen levels
Complications:
 >Irreversible shock
 >Waterhouse-Friderichesen syndrome
 >Adult respiratory distress syndrome (ARDS)

2. Ectopic Pregnancy
> occurs when gestation is located outside the uterine cavity/tubal pregnancies
Causes:
 >Fallopian tube damage often from infection-can block the fertilized egg’s path to the uterus
causing it to implant and grow in the tube
 >Surgery
 >Endometriosis
 >Smoking
 >Previous ectopic pregnancy
 >Pelvic infection – chlamydia or gonorrhea
 >Fertility drugs that increase egg production
 >Pelvic or abdominal surgery
Risks:

Signs and Symptoms:

 Normal signs of pregnancy

 Pain- first red flag sign

Other Signs and Symptoms:

 Vaginal spotting or bleeding
 Dizziness or fainting (caused by blood loss)
 Low blood pressure (caused by blood loss)
 Lower back pain

Unruptured Tubal Ruptured

>missed period
> abdominal pain within
3-5 weeks
> scant, dark brown
vaginal bleeding
> vague discomfort
umbilicus
>sudden sharp severe pain
>shoulder pain (indicative
of intraperitoneal bleeding that
extends to diaphragm and
Phrenic nerve)
> + Cullen’s sign – bluish tinged
Diagnostic Test:
 >Urine pregnancy test
 > If (+) pregnancy test – quantitative HCG test
 >Pelvic exam
 >Ultrasound
 >Culdocentesis
Treatment:
 >Vary depending on its size and location
 >Injection of methotrexate
 >Surgery
 >Laparoscopy

Future Pregnancies:

 >30% who have had ectopic pregnancy will have difficulty becoming pregnant again
 >If the fallopian tube has been spared, the chances of a future successful pregnancy are 60%.
Even if one fallopian tube has been removed, the chances of having a successful pregnancy
with the other tube can be greater than 40%.
High Risk Women:
 >Age – 35 and 44 y/o
 >With PID – Pelvic Inflammatory Disease
 >Previous Ectopic Pregnancy
 >Surgery on fallopian tube
 >Infertility problems or medication to stimulate ovulation
Nursing Care:
 >Vital Signs
 >Administer IVF
 >Monitor vaginal bleeding
 >Monitor I&O
 > Prepare for Culdocentesis-
Result: to determine if clotting or non clotting
 >If clotting – negative for ectopic pregnancy
 >If non – clotting – positive for ectopic pregnancy
> Culdocentesis- is a procedure in which peritoneal fluid is obtained from the cul de
sac of a female patient. It involves the introduction of a spinal needle through the
vaginal wall into the peritoneal space of the pouch of Douglas
B. BLEEDING DISORDER DURING THE SECOND TRIMESTER OF BLEEDING

1.Hydatidiform Mole ( H-Mole)-an abnormal proliferation and degeneration of the

trophoblastic villi
 >Molar pregnancy
 >Gestational Trophoblastic Disease
 >Bunch of Grapes
 >Hydatid – means drop of water; mole – means spot
Types:
 a.Partial Molar – pregnancy that includes an abnormal embryo (a fertilized egg that
has begun to grow) but does not survive
 b.Complete Molar –pregnancy in which there is small cluster of clear blisters or
pouches that don’t contain an embryo
Hydatidiform Mole ( H-Mole)

Drug of Choice: Methotrexate

Etiology: Unknown

Other Causes:
 >Problems with the chromosome
 >Problem with the nutrition – low protein intake
 >Problem with the ovaries and uterus
 >Mole sometimes can develop from a placental tissue that is left behind in the uterus after a
miscarriage or childbirth

Signs and Symptoms

 >(+) pregnancy test
 >Symptoms for the first 3-4 months
 >Uterus grow abnormally fast
 >End of 3rd month-woman will experience vaginal bleeding ranging from scant spotting to excessive
bleeding
 >Presence of hyperthyroidism (overproduction of thyroid hormone) leads to:
• >Weight loss
• >Increase appetite
• >Intolerance to heat
 >Grapelike cluster of cells itself will be shed with the blood during this time
 >Nausea and vomiting due to increase HCG and progesterone
 >(-) fetal movement
 >(-)fetal heart rate

Early Signs:
 >Vesicles passed thru the vagina
 >Hyperemesis gravidarum
 >Fundal height – rapidly increases
 >Vaginal bleeding (scant or profuse)
 > Pre-eclampsia at about 12 weeks
Late Signs
 >HPN before 20th week
 >Vesicles look like a ‘snowstorm” on sonogram
 >Anemia
 >Abdominal cramping
Serious Late Complications
 >Hyperthyroidism
 >Pulmonary embolus

Diagnosis:
> suspect until 3rd month or later if fetal heartbeat is present with bleeding and severe
nausea and vomiting
 >Physician will examine the woman’s abdomen feeling for any strange humps or
abnormalities in the uterus
 >Tubal pregnancy will be ruled out
 >Abnormally increased HCG level with vaginal bleeding; (-) FHB and
unusually large uterus will indicate a molar pregnancy
 >Ultrasound – confirm no living fetus

Treatment

 >often, the tissue is naturally expelled by the fourth month of pregnancy. In some instances, the
physician will give the woman a drug called oxytocin to trigger the release of the mole that is not
spontaneously aborted
 >If this does not happen, a vacuum aspiration can be performed to remove the mole
 1.D&C
* woman is given anesthetic
* Cervix is dilated and the contents of the uterus is gently sanctioned out.
* After the mole has been mostly removed, gentle scraping of the uterus lining is usually
performed.
* If the woman is older and does not want any more children, the uterus can be surgically
removed (hysterectomy) instead of a vacuum aspiration because of the higher risk of cancerous
moles in this age group
* Monitoring the patient for at least 2 months after the end of a molar pregnancy for HCG
level
 >Hcg level will be checked every 2 weeks – if don’t return to normal by that time,
the mole may have become cancerous
 >If HCG level is normal, the woman’s HCG will be tested each month for 6 months
and every 2 months for a year
 >If mole become cancerous, treatment includes removal of the cancerous tissue
and chemotherapy
 >If cancer spread to other parts of the body, radiation will be added
 >Woman should not be pregnant within a year after HCG levels have returned to
normal
 >If woman got pregnant within that time, it is difficult to tell whether the resulting
high levels of HCG were caused by the pregnancy or as a cancer from the mole
Cervical insuffiency
(premature cervical dilatations)
 Termed as incompetent cervix
 Cervix that dilates prematurely and therefore cannot retain a fetus until term
 Signs and Symptom
 1. painless
 2. blood show
 3. pelvic pressure
 4. discharge amniotic fluid
 5. uterine contraction.
 CERVICAL CERCLAGE
 -a treatment that involves temporarily sewing the cervix closed with
stitches prior to child loss or cervix hold a pregnancy in the uterus at
2nd trimester to prevent preterm labor.
 After surgery patient needs to remain on bed rest for a days to
decrease pressure on the new sutures.
C. BLEEDING DISORDERS DURING THE THIRD TRIMESTER OF PREGNANCY

1. 1.Placenta Previa – occurs when the placenta is improperly implanted in the lower uterine
segment, sometimes covering the cervical os

Signs and Symptoms

> Frank, bright red, painless vaginal bleeding

>Engagement (usually has not occurred)
>Fetal distress
>Presentation (usually abnormal) – baby is breech or in transverse position
>Uterus measures larger than it should according to gestational age

Types:

a. a.Partial Placenta Previa – a portion of the cervix is covered by the placenta

b. b.Complete Placental Previa/Total – cervical opening is completely covered
c. c.Marginal Placenta Previa – extends just to the edge of the cervix
Management
1.Bed Rest
 >If the patient presents with mild bleeding before the fetal lungs are mature
2.Depending on the gestational age; steroid shots may be given to help mature the
baby’s lungs
3.If the bleeding cannot be controlled, an immediate caesarean delivery is usually
done regardless of the length of pregnancy
4.Near term, fetal lung maturity may be assessed by amniocentesis and the
preferred method is C/S
 >Some marginal previas can be delivered vaginally
 >Complete or partial previous would require a C/S
2. Avoid intercourse
3. Limit or no travelling
4. Avoid pelvic exams/internal exams – can cause profuse bleeding
Predisposing Factors
>Old Age
>Smoking
>intake of alcoholic beverages
>history of placenta previa in the past pregnancy
Surgical Management: C/S with blood transfusion based on blood loss

2. Abruptio Placenta

 > Premature separation of the placenta from the implantation site. It usually occurs after the 20 th week
of pregnancy
 > Bleeding into the decidua basalis (the layer between the placenta and myometrium) compresses and
compromises the function of adjacent placenta

Other Names:

 >Premature Separation of Placenta

 >Accidental Hemorrhage
 >Ablatio Placenta
 >Placental Abruption
Signs and Symptoms:
 >Painful vaginal bleeding
 >Severe abdominal pain
 >Concealed bleeding (retroplacental)
 >Rigid abdomen
 >Couvelaire uterus (caused by bleeding into the myometrium)
 >Dropping Coagulation factor ( a potential for DIC)

Other Signs and Symptoms:

 >Uterine hypertonous
 >Back pain
 >Preterm labor
 >Hypovolemic shock
 >Non reassuring fetal heart tracking's and fetal demise
Severe Cases
 >Maternal hypotension
 >Uterine hypertonicity
 >Fetal distress
 >Death
 >Clotting abnormalities
Cause: unknown

Predisposing Factors:

 >Mechanical factors such as: abdominal trauma – car accident of fall

 >Sudden loss in uterine volume as occurs with rapid loss of amniotic fluid or the delivery of a
first twin
 >Abnormally short umbilical cord
 >Hypertension
 >Pre-eclampsia
 >Multiparity
 >Rupture of membranes more than 24H
Signs and Tests:

 >During a physical examination, uterine tenderness and or increased uterine tone may be
noticed
 >CBC – decreased hematocrit and hemoglobin and platelets
 >Prothrombin time test
 >Partial thromboplastin time test
 >Fibrinogen level test
 >Ultrasound
Treatment and Management:
 >IVF
 >Blood Transfusion
 >Check for presence of shock and fetal distress
 >Emergency C/S – for fetal distress or maternal bleeding
 Immature fetus with small placental separation – hospitalization – for observation – release
after several days if no evidence of progressing abruption occurs
 If mature fetus – vaginal delivery if maternal and fetal distress is minimal
 C/S – to protect the mother and child
General Nursing Care
 >Infuse IVF, prepare to administer blood
 >Type and cross match blood components (PRBC)
 >Monitor FHR
 >Insert foley catheter
 >Measure blood loss – count pads
 >Report signs and symptoms of DIC
 >Monitor V/S
 >Strict I & O
DISSEMINATED INTRAVASCULAR COAGULATION
 -acquired disorder of blood clotting in which the fibrinogen level falls to
below effective limits.
 symptoms are easy bruising, bleeding in IV site
 It occurs when there is such extreme bleeding and so many platelets and
fibrin from the general circulation rush to the site that there is not enough
left in the rest of the body.
 DIC is an emergency because it can result to excessive blood loss
 A blood platelet transfusion is needed.
 Anti coagulant is also given which precaution
 Fetal and newborn assessment is equally important to evaluate the efficiency
of the placental circulation in light of the increase clotting.
D. Pregnancy Induced Hypertension
 > A form of increased blood pressure in pregnancy
 > Also called toxemia or pre – eclampsia
 > Eclampsia is a severe form of PIH accompanied with
seizures
 > HELLP Syndrome – Hemolysis with Elevated Liver Enzymes
and Decreased Platelet Counts- is a complication of severe
pre-eclampsia or eclampsia
Signs and Symptoms of HELLP Syndrome:
 > Breakdown of RBC
 > Changes in the liver
 > Decreased platelets (cells found in the blood that are needed to help the blood to
clot in order to control bleeding)
THREE PRIMARY CHARACTERISTICS:
 >Increased blood pressure, reading greater than 140/90 mmHg or a significant
increased in one or both pressures
 >Protein in the urine – proteinuria
 >Edema – swelling of face and fingers
Cause : unknown
Predisposing Factors:
 >Pre – existing HPN (increased BP) >PIH with previous pregnancy
 >Kidney disease >Mother’s age younger than 20 or
>Diabetes older than 40
 >Multiple gestation (twins/triplets)
Note:
* PIH should be treated immediately since with increased BP, there is also an
increased in the resistance of blood vessels. This may hinder blood flow in many
different organ systems in an expectant
Other Problems:
 >Occurrence of placental abruptio
 > Fetal problems such as intrauterine growth restriction (poor fetal growth) and
stillbirth

Signs and Symptoms: may experience symptoms differently

 >Increased BP
 >Proteinuria
 >Edema on face and fingers
 >Sudden weight gain
 >Blurring or double vision
 >Nausea and vomiting
 >Right sided upper abdominal pain or pain around the stomach
 >Decreased urine output
 >Changes in liver or kidney function test

Diagnosis:
 >BP assessment
 >Urine testing
 >Assessment of edema
 >Frequent weight measurement
 >Eye examination to check for retinal changes
 >Liver and kidney function test
 >Blood clotting tests
Treatment:
Goal: to prevent the condition from becoming worse and to prevent other
complications
1. Bed rest – either at home or in the hospital
2.Magnesium Sulfate (MgSO4) – drug of choice
Action: CNS Depressant/ Anti Convulsive Drug
Route: IM/IV
Site: 1st dose – IV; 2nd dose – buttocks

Nursing Considerations:
 >Consider the rights in giving medications
 >Check the expiration date of the medication
 >Check for proper color of the medication
> Check the patient’s BP before and after giving of medication
 > Insert foley catheter as per doctor’s order
Before giving the 2nd dose: check for the following:

 >BP – increased or decreased

 >Urine output – 30 cc/H; if less than 30 cc/H, hold the 2 nd dose, notify the physician at once
and document the findings
 >Check for knee jerk – (+) or (-), if (-), hold the 2 nd dose, notify the physician at once
 *(-) knee jerk is a sign of MgSo4 toxicity
 >Give antidote: Calcium Gluconate
3. Fetal Monitoring – to check for the health of the fetus when the mother has PIH
Include the following
 >Fetal movement counting – increased or decreased – fetal distress
 >Non stress testing test – tests that measure the fetal HR in response to fetus’ movements
 >Biophysical profile – test that combine nonstress test with ultrasound to observe the fetus
 >Doppler waves – to measure the flow of blood through a blood vessel
4. Continued laboratory testing of urine and blood
5. Medications called corticosteroids that may help mature the lungs of the fetus
6. Delivery of the baby ( if treatment do not control the PIH, if the fetus or the mother is
in danger), C/S is recommended

For The General Nursing Care, remember this acronym:

P
E
A
C
E
GENERAL NURSING CARE:
P – PROMOTE BED REST
 > Prevent convulsion by nursing measures: seizure precautions
• *Quiet and calm environment
• *Minimal handling
• *Avoid jarring the bed
• *Provide tongue guard – to prevent biting the tongue in case of seizure attack
• *All side rails up (at all times) – to ensure safety of the client
• *Prepare the following at bed side:
 >Suction machine
 >Oxygen
 >Suction tip
 >NSS
 Note: make sure all machine and equipment are functioning well and in good status,
this is considered as one of the nurse’s responsibilities
• >During seizure attack – stay with the patient; do not restrict movements of
extremities to prevent contracture deformity; ensure patient’s safety (prevent patient
from falling)
• > After the attack – turn patient to side

E - NSURE HIGH PROTEIN INTAKE ( 1 G/KG/DAY)

A – NTIHYPERTENSIVE DRUG : HYDRALIZE
C - NS DEPRESSANT (MGSO4) ANTICONVULSANT DRUG
E – VALUATE PHYSICAL PARAMETERS FOR MAGNESIUM SULFATE TOXICITY

B – BP decreased
U – urine output decreased
R – RR less than 12/min
P – patellar reflex absent

Note: if one of these is present, hold the 2nd dose, report the findings to the physician,
document the findings and actions taken
E. Oligohydramnios
 Refers to a pregnancy with less than the average amount of amniotic fluid.
 Part of the volume of amniotic fluid is formed by the addition of fetal urine, this reduced amount of fluid is
usually caused by a bladder or renal disorder in the fetus that is interfering with voiding
 Another cause: due to growth restriction of the fetus, he/she is not voiding as much as usual
Diagnosis:
1.Physical Assessment: Inspection: suspected during pregnancy if the uterus fails to meet its expected growth
rate
2.Ultrasound – pockets of amniotic fluid are less than average
Effects on the fetus after birth:
 Muscles are weak due to cramped space during pregnancy
 Lungs fail to develop that can lead to hypoplastic lungs- difficulty of breathing
 Potter syndrome- distorted features of the face
Potter syndrome

Nursing Consideration:
> Careful inspection among infants at birth to rule out kidney disease and compromised lung development
F. Polyhydramnios
 Occurs when there is excess fluid of more than 2,000ml or an amniotic fluid index above 24 cm.
 Normal volume at term: 500 to 1000 ml
Effects on Pregnancy:
 Can cause fetal malpresentation due to the additional uterine space and can allow the fetus to turn on a
transverse lie
 Can lead to premature rupture of the membranes from the increased pressure that can lead to risks for
infection, prolapsed cord and preterm birth
Normal Process during Pregnancy:
> Amniotic fluid is formed by a combination of the cells of the amniotic membrane and from fetal urine
 It is evacuated by being swallowed by the fetus, absorbed across the intestinal
membrane into the fetal bloodstream and transferred across the placenta
 With polyhydramnios, accumulation of amniotic fluid suggests difficulty with the fetus’s
ability to swallow or absorb fluid
Causes of inability to swallow fluids:
 Anencephalic
 Fetus with tracheoesophageal fistula with stenosis
 Fetus with intestinal obstruction
 Occurs among infant with diabetic mother
Assessment/Diagnosis:
1. Physical Assessment: Inspection- rapid enlargement of the uterus
2. Difficulty to palpate fetal parts because the uterus is unusually tense
3. Difficulty in auscultating the FHR due to the depth of the increased amount of fluid
surrounding the fetus
4. Woman may have extreme shortness of breath due to pushing up of the uterus against
her diaphragm
5. Presence of varicosities and hemorrhoids due to blockage of venous return from the
lower extremities by extensive uterine pressure
6.Increased weight gain due to increased amount of amniotic fluid
7.Ultrasound
Therapeutic Management:
1. Hospitalization or home care
Goal:
a. For adequate rest
b. For further evaluation
c. To maintain adequate uteroplacental circulation
d. To reduce pressure on the cervix and prevent preterm labor
2.Advice woman to report any sign of ruptured membranes or uterine contractions
3.Advice woman to have high fiber diet and consult her doctor for stool softener if diet
is ineffective-to prevent constipation and straining during defecation to prevent
uterine pressure
4.Monitor vital signs if in the hospital
5.Monitor presence of edema in the lower extremities
6.Amniocentesis – to remove excess some of the extra fluid
7.Tocolytics- to prevent or halt preterm labor
If preterm rupture of the membranes occurs:
 Membranes can be “Needled” (insertion of a thin needle vaginally to pierce them) to
slow, control the release of fluid and to prevent prolapsed cord during labor
 Assess infant after birth for gastrointestinal blockage.
G. Postterm Pregnancy
> A term pregnancy is 38 to 42 weeks
 Any pregnancy that extends this period is postterm
Causes:
1. Women who have long menstrual cycle
 40 to 45 days: they do not ovulate on day 14 which is the normal period
 They ovulate 14 days from the end of their cycle, or on day 26 or 31, children will be
considered “late” by 12 to 17 days
2. Women who are receiving high dose of salicylates for their severe sinus headaches or
rheumatoid arthritis- this interferes with the synthesis of prostaglandin
3.Myometrial quiescence-uterus that does not respond to normal labor stimulation
Danger to the fetus:
1.Meconium aspiration
2.Macrosomia
3.Lack of growth-placenta is functioning for only 40-42 weeks-exposes the fetus to
decreased blood perfusion, oxygen, fluid and nutrients
Management:
1. Biophysical profile- to evaluate the placental perfusion and amount of amniotic fluid
present;
 if normal, it is assumed miscalculation occurs
 If abnormal result or physical examination or biparietal diameter on ultrasound result
the fetus is in term size, labor will be induced
How to induce labor:
1.Prostaglandin gel or misoprostol (Cytotec) –applied to the vagina to initiate uterine
contraction followed by an oxytocin infusion
2.If oxytocin is ineffective, C/S is performed
Nursing Consideration during the labor process:
1.Monitor FHR, V/S
After Birth:
1.Assess newborn for meconium aspiration
>Establish and maintain patent airway
2.Assess for polycythemia – due to decreased oxygenation in the final weeks
>hematocrit may be elevated due to polycythemia and dehydration that leads to
lowered circulating plasma level.
3.Asess for hypoglycemia-because fetus had to use stores of glycogen for
nourishment in the final weeks of intrauterine life
4.Maintain an adequate temperature
 Newborn has low subcutaneous fats levels
5. Follow up care until at least school age to track their developmental abilities
Care of the Woman:
 Allow woman to stay a longer period of time with her newborn and let her or
assist her in providing appropriate interventions to her newborn
H. Preterm Labor
 Labor that occurs before the end of week 37 of gestation
Danger:
 Infant is immature
Assessment:
> Any pregnant woman having persistent uterine contractions, mild and widely
spaced should be considered to be in labor, if contractions have caused cervical
effacement or dilatation over 1 cm
Measures on How to Prevent Preterm Labor:
1.Remain on bed rest except to use on bathroom.
2.Drink 8 to 10 glasses of fluids daily
3.Keep mentally active by reading or working on a project to prevent boredom
4.Avoid activities that could stimulate labor
5. Consult your primary care giver whether sexual relations should be restricted
6.Immediately report signs of ruptured membranes9sudden gush of fluid from the
vagina) or vaginal bleeding
7.Report signs of urinary tract infections or vaginal infection (burning or frequency
of urination, vaginal itching or pain)
8.Keep appointments for prenatal care.
9.Empty bladder to prevent pressure on the uterus
10.Lie down on your left or right side to encourage blood return to the fetus
Signs and Symptoms:
 persistent, dull, and low backache
 vaginal spotting
 Feeling of pelvic pressure
 Abdominal tightening
 Menstrual-like cramping
 Increased vaginal discharge
 Uterine contractions
 Intestinal cramping
Diagnosis:
 Analyzing changes in the length of the cervix by ultrasound
 Analysis of vaginal mucus for the presence of fetal fibronectin, a protein produced by
trophoblast cells
* If this is present in vaginal mucus, preterm labor occurs, labor will not occur if the
protein is absent for at least 14 days
Therapeutic Management:
1.Medical attempts can be made to stop preterm labor if:
a. The fetal membranes have not ruptures
b. No fetal distress
c. No evidence of bleeding
d. Cervix is not dilated more than 4 to 5 cm
e. Effacement is not more than 50%
2.If in preterm labor:
a.Admission in the hospital
b. Bed rest – to relieve the pressure of the fetus in the cervix
c. Monitoring the uterine contractions
d. IVF therapy-to keep the woman well hydrated
e. Vaginal and cervical cultures and a clean catch urine sample- to rule out
infection
Drug Administration:
1.Tocolytic drugs- an agent to halt labor
>Terbutaline-drug of choice
*carries a “black box” warning- should not be used for over 48 to 72 hours
*Reason: could cause serious maternal heart problems and death
*should not be used in out patient or home setting-requires constant professional
assessment
2.Magnesium Sulfate-used traditionally to treat pre eclampsia and prevent
eclamptic seizures, can also be used
*recent research does not support this as tocolytic agent
3.Corticosteroid
> betamethasone- to promote the formation of lung surfactant to prevent
respiratory distress syndrome among newborn
Fetal Assessment: if woman is sent home:
1.Advice woman to keep herself well hydrated
2.Maintain adequate nutrition
3.Mainatin bed rest and avoid strenuous activities
4.Advice the woman to have a record of daily” kick” count or “count to 10” test of
her baby’s movements inside her womb.
LABOR THAT CANNOT BE HALTED
 Membranes have ruptured-point of no return
 Effacement is more than 50%
 Cervical dilatation is more than 3 to 4 cm
Management:
> If fetus is very immature, C/S – to reduce pressure on the fetal head and reduce
the possibility of subdural or intraventricular hemorrhage from a vaginal birth
What to expect:
 First stage of labor-the longest stage
 Second stage of labor- maybe shorter
 Artificial rupture of the membranes is not done because of the risk for prolapse of
the cord around a small head
 Analgesics are administered with caution- immature infant have difficulty of
breathing at birth
 Epidural anesthesia is preferred if the woman wants pharmacological pain
management
I. Intrauterine Fetal Death
 Fetal death is determined by the point of gestation when death occurs
 Missed abortion – when the fetus dies before 20 weeks of gestation and is not
aborted spontaneously
 Fetal death – occurs after 20 weeks of gestation and may be used when labor does
not begin within 48H of death
Signs and Symptoms:
 Painless spotting
 Uterine contractions with cervical effacement and dilatation
 Fetus is born lifeless and emaciated
Dx:
 > (-) fetal movement
 > (-) FHB
 > Uterine growth ceases
 > Uterine size decrease
 > Fetal heart movement cannot be visualized by UTZ
 > X-ray detected by the appearance of intravascular or intra abdominal fetal gas
(Robert’s sign)
Management:
1.Induced labor- combination of misoprostol(Cytotec) applied to the vagina to effect
cervical ripening and oxytocin administration to begin uterine contraction
2.Bllod studies: test for DIC
J. Rh Incompatibility
> Occurs when an Rh-negative mother (one negative for a D antigen or one with a dd
genotype0 carries a fetus with an Rh positive blood type (DD or Dd genotype)
For this to happen:
> The father of the child must either be homozygous (DD) or heterozygous (Dd) Rh
positive
If the father of the child is homozygous (DD) for the factor, 100% of the couple’s children
will be Rh positive (Dd)
 If the father is heterozygous for the trait, 50% of their children can be Rh positive (Dd)
 People who have Rh-positive blood have a protein factor (the D antigen) that Rh –
negative people do not, when an Rh –positive fetus begins to grow inside an Rh-
negative mother who is sensitized, her body reacts by forming antibodies against the
invading substance-the fetus.
> The Rh factor exists as a portion of the red blood cells so these maternal
antibodies cross the placenta and cause destruction
 A fetus can become so deficient in RBC from this that a sufficient oxygen
transport to body cells cannot be maintained
 This condition is termed as hemolytic disease of the newborn or
erythroblastosis fetalis
Assessment:
1.Antibody titer
>if results are normal: 0, a ratio below 1:8 is minimal, the test is repeated at week
28 of pregnancy, if the result is normal, no therapy is needed
 If the woman anti-D antibody is elevated (1:16 or greater, showing Rh
sensitization- the fetus will be monitored for 2 weeks or more by Doppler velocity
- a technique that can predict when anemia is present or fetal red cells are being
destroyed
 If the results are high-fetus is not developing anemia and mostly an Rh-negative
 If the results are low – fetus is in danger, immediate birth will be carried out if near
term; if not near term, efforts to reduce the number of antibodies in the woman will
be made or replacing damaged red cells in the fetus began
THERAPEUTIC MANAGEMENT:
1. RhIG, a commercial preparation of passive Rh (D) antibodies against the Rh factor is
administered to women who are Rh negative at 28 weeks of pregnancy
 It cannot cross the placenta and destroy fetal red cells because the antibodies are
not the IgG class which is the only type that crosses the placenta
 RhIG (Rhogam)-given again by injection to the woman in the first 72 hours after
birth of an Rh-positive child- to further prevent the woman from forming natural
antibodies
Nursing consideration after birth:
1.Determine the infant’s blood type
>if Rh positive, the mother will receive the RhIG injection
If Rh negative, no antibodies have been formed in the mother’s circulation during
pregnancy and none will form-no need for RhoGAM injection
PROM- premature rupture of membrane
 Rupture of fetal membrane with loss of amniotic fluid
before 37 weeks of pregnancy.
 Causes unknown
 But strongly associated with infection of the
membrane(i.,e.chrioamnionitis)
 s/sx 1. sudden gush of clear fluid from the vagina, with
continued minimal leakage
 Nitrazine paper test-amniotic fluid causes an alkaline
reaction paper from yellow to blue.
MULTIPLE PREGNANCY

 Multiple gestation is considered a complication of pregnancy because the

body must adjust to the effects of more than one fetus.
 An ultrasound can reveal multiple gestation sacs early in pregnancy.
 Susceptible complications
 - hyperemesis, gestational hypertension, poly hydramnios, placenta previa,
preterm labor, and anemia
 A patient with a twin pregnancy needs closer prenatal supervision than a
patient with single gestation to detect problems or risk for complications

 POST TERM PREGNANCY

 A Term pregnancy is 38 to 42 weeks long
 Post mature or dysmature infant
 Reasons: faulty due dates, long menstrual cycle of the mother and labor is not
initiated.
 Complication: meconium stain, macrosomic newborn and variable
deceleration
 Nonstress test and biophysical profile , UTZ
 OXYTOCIN administration used to begin labor.
 INTRAUTERINE TRANSFUSION
 -to restore fetal rbc, blood transfusion can be performed on the fetus in
utero.
 Done by injecting rbc by amniocentesis technique directly into a vessel in the
fetal cord or depositing them in the fetal abdomen where they migrate into
the fetal circulation.
 Blood can be from the fetus itself or same type from unknown donor
 Risky procedure that can harm the fetus and the uterus
 FETAL DEATH
 Most severe complication of pregnancy
 s/sx ( no fetal movements, no heart beat, painless spotting, uterine
contraction with cervical effacement and dilatation.
 An Ultrasound will reveal that no fetal heart beat is present.
 Mngt: once fetal death is confirmed induction of pregnancy may apply and
birthing and extraction will be needed.
 END OF WEEK 3 TOPICS

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