Abc Ob 2010

ACUTE BIOLOGIC
CRISIS
Cj
OBJECTIVES
GENERAL
OBJECTIVE:
At the end of the lecture-discussion the

students shall have gained advanced
knowledge, skills and expressed
appreciation in the care of patients
suffering from acute biologic crisis
across the lifespan
SPECIFIC
OBJECTIVES:
HIGH-RISK
Describe
PREGNANCY:
complications of pregnancy that

place the pregnant woman at risk.
Assess the woman who is experiencing a
complication of pregnancy.
Formulate nursing diagnoses that address
the needs of the woman and her family.
Identify expected outcomes to minimize
the risks to the pregnant woman and her
fetus.
High Risk Pregnancy
First
Then,
And then . . . . . .
Fetal Development
The babys slowly growing inside
And finally,
A) HIGH RISK PREGNANT CLIENT

BLEEDING IN
PREGNANCY
PRETERM
LABOR
PRETERM
RUPTURE OF
MEMBRANE
PREGNANCY
INDUCED
HYPERTENSION
MULPTIPLE
PREGNANCY
HYDRAMNIOS
POST-TERM
PREGNANCY
PSEUDOCYESIS
ISOIMMUNIZATION
(Rh INCOMP)
FETAL DEATH IN
UTERO
DIFFICULT
LABOR R/T UTRN
HYPOFXN
B) PATIENTS W/ PRE-EXISTING
OR NEWLY ACQUIRED ILLNESS
STD
GASTROINTESTI ENDOCRINE
NAL DISORDER DISORDER
HEMATOLOGIC
DISORDER
NEUROLOGIC
DISORDER
RENAL AND
URINARY
DISORDER
MUSCULOSKELET
MENTAL ILLNESS
AL DISORDER
RHEUMATIC
DISORDER
CARDIOVASCULA
TRAUMA
R DISORDER
CANCER
C) HIGH RISK NEWBORN AND

FAMILY
ALTERED GESTATIONAL AGE
OR BIRTH WEIGHT
ILLNESS IN THE NEWBORN
NEWBORN AT RISK DUE TO MATERNAL INFECTION
OR ILLNESS
NURSING ASSESSMENT
NURSING HISTORY WHICH

INCLUDES PATIENTS PROFILE
AND CHIEF COMPLAINTS.
NURSING
RESPONSILBILITIES OF PRE AND

POST DIAGNOSTIC EXAMS.
Subjective Assessment
When pregnant female comes to you, you should ask:

Name
Age
Medical history
Genetic history
Previous surgeries
Current/past medications
If they have ever or are using street drugs or smoking
Alcohol/caffeine use
Occupation and current working status
Marital status and children
Objective Assessment
When
observing the client, evaluate:
Height
Weight
BMI
Blood
Pressure
General alignment
Range painful movement
OTHER ASSESSMENT PARAMETERS

Vital
signs taking especially BP

include weight for baseline
1st tri - 1.5-3lbs
2nd and 3rd tri 10-11 lbs with
total allowable wt gain of 20-25lbs
(10-12 kg) for the entire period
Pelvic
exam empty the bladder first

Internal exam and pap smear position and
drape the client, do not leave the client during
the entire procedure especially with a male
doctor.
Do the leopolds maneuver to determine
presentation, position and attitude, estimated
fetal weight through fundic hieght (FH-13x.32),
locate fetal parts and FHT
FUNDIC
HEIGHT
MEASURING
FUNDIC HEIGHT
Assessment of Fetal Health

Nurses
responsibility
Preparing
patient properly for test

Explaining reason for test
Clarifying and interpreting results in collaboration
with other HCPs
Providing support to patient
ULTRASOUND IMAGES
4D US Images
Kick Count Assessment Tool
Amniocentesis
NST
Conditions During Pregnancy
Constipation
Affects half of pregnant women
Causes:
increase
in progesterone
the colon absorbing more water
worse in first 13-14 weeks
Treatment:
Drink
plenty of fluids
Eat high fiber foods
Take fiber supplements
EXERCISE!
Fatigue
Almost all women report increased fatigue in the 1st

trimester.
Causes:
Body is working harder
More levels of progesterone,
Treatment:
Take naps
Drink plenty of fluids, but avoid fluids 2-3hr before bed.
Exercise
Gentle stretches before bedtime can help prevent night
time cramping
Eat foods rich in protein
Back Ache
Many women experience back aches during 2nd and 3rd trimesters
Causes:
Poor posture
Extra weight
Change in centre of gravity
Hormones
Treatment:
Pay attention to posture
Exercise
Swimming
Pillow support in bed
Ask for assistance when lifting heavy objects
Heat/cold
Massage
Support belt
Wear supportive low heel shoes
HIGH RISK PREGNANCY

Is
one in which concurrent disorder,

pregnancy-related complication, or
external factor jeopardizes the health of the
mother, the fetus, or both
A. HIGH RISK PREGNANCY

DANGER
SIGNS OF PREGNANCY:
Vaginal bleeding
Persistent vomiting
Chills & fever
Sudden gush of fluid
Abdominal or chest pain
Increase/decrease in fetal
movements
PIH
HIGH RISK PREGNANCY
CARE . . .
refers to the identification and
management of a high-risk
pregnancy to promote healthy
outcomes for the mother and
the baby.
Risk factors
factors
Age below 18
Causes and Complications

High maternal and infant mortality.
Immature physically and
psychologically
Precipitating factor for placental

Age older than 35 accidents, toxemia, uterine atony,
hemorrhoids, low birth weight babies
physical
Depletion of nutritional reserves due

to the rapid growth of adolescent
pregnant and fetus
Risk factors
factors
Psychological
Adolescent is a developmental crisis,

unable to resolve additional conflict.
They are the age most likely to develop
toxemia.
Chromosomal
abnormalities
in advanced
age
Trisomy 21 commonly associated with

menopause.
Parity
Risk increases from gravida 5 and

above, especially in age over 40.
Risk factors
factors
Birth Interval
Subsequent pregnancy within 3

months of a previous delivery. And a
birth interval of more than 5 years.
Weight
Pre pregnant weight of less than 70lbs

or more than 180lbs
Height
A primi of short stature less than 4ft

10inches could mean a contracted
pelvis or CPD.
QUESTIONS TO BE ASK DURING

ASSESSMENT
ASSESSMENT
POTENTIAL PROBLEM
Have you had any problem

General assessment
with this pregnancy?
Have you had blurred
vision?
Have you had severe
headache?
Have you had swelling?
Have you ever had high
blood pressure?
PIH

ASSESSMENT
Have you been persistently
Hyperemesis Gravidarum
vomiting?
Have you had any

infections?
STIs/vaginal infections
Have you had difficulty

breathing?
Cardiac Disease
Have you had palpitations?
Were all your pregnancies
term?
Preterm labor

ASSESSMENT
Have you ever had
diabetes?
DM/Gestational DM
Have you ever had

anemia?
Anemia
Do you take drugs?

Prescription medicine?
Do you drink alcohol?
Do you Smoke?
Substance abuse
History taking as part of

assessment
Personal
data- clients name, age, address,

civil status,family history, familial diseases
that could possibly affect the pregnancy.
Obstetrical data- gravida, para
OB score (FPAL)
Past pregnancy- method of delivery (NSVD,CS
and its indication, home delivery or
institutional)
Danger signs of Pregnancy

Vaginal
bleeding no matter how slight

Swelling of face and hands
Severe continuous headache
Dimness or blurring of vision
Flashes of light or dots before eyes
Pain in the abdomen
Persistent vomiting
Danger signs of Pregnancy

Fever and chills
sudden escape of
fluids from the vagina
Absence of fetal heart
sounds
PREGNANCY-INDUCED
HYPERTENSION ( PIH )
A condition in which vasospasm occurs during
pregnancy
Hypertension During Pregnancy
High blood pressure in pregnancy (PIH)

Preeclampsia
Eclampsia
PIH + proteinuria
PIH + proteinuria + convulsions/seizures
Toxemia old terminology
Cause of disorder s till unknown. PIH tends to occur

more frequently I primiparas younger than 20 years or
older than 40 years; women from a low socioeconomic background (poor nutrition);women who
have 5 pregnancies(multiple pregnancies)
CLASSIFICATION
Gestational
hypertension - simple
Mild preeclampsia inc. BP 140/90mmHg
+ proteinuria 1+ or 2+
Severe preeclampsia BP 160/110mmHg,
proteinura 3+ or 4+
Eclampsia cerebral edema causing
seizure
ASSESSMENT
BP
over 140/90 or an increase of 30

mmHg SBP and 15 mmHg DBP over
baseline obtained on two occasions at
least 4 to 6 hours apart
Increase in generalized edema associated
with sudden weight gain of more than 5
lb (2.3kg) per week
Usually appears 20th and 24th weeks of
gestation and disappears within 42 days
after delivery
preeclampsia
KEY FACTS
PREECLAMPSIA
Nonconvulsive form
Occurs after 20 weeks
gestation
ECLAMPSIA
Convulsive form
Occurs between 24
weeks gestation and
the end of the 1st
postpartum week
May be mild or severe
Higher incidence in low

socio-economic groups
Higher incidence with

first pregnancies,
multiple gestation, and
history of vascular
disease
Goal of Medical Management

Prevention
of cerebral hemorrhage,
convulsion, hepatologic complications and
renal and hepatic diseases.
Birth of an uncompromised newborn as closed
to term sa possible.
Managament in
Preeclampsia
Dietary Approach : supplementation with calcium,

magnesium, fish oil, and vitamins C and E.
Fetal movement recording.
Nonstress test
USD at least every 3 to 4 weeks
Serum creatinine determinations
Amniocentesis to determine fetal lung maturity
Blood Pressure four times daily
Daily weight
Urinalysis
Serum creatinine, uric acid, liver function test
(AST, ALT, LDH, bilirubin) one to two times per week.
Management in Severe
Preeclampsia
Complete bed rest

Diet : high protein, moderate sodium
Anticonvulsants : MgSO4 (DTR checking before
giving the
medication)
Corticosteriods : Betamethasone or
Dexamethasone
Fluid and electrolyte replacement.
Antihypertensive : Methyldopa (for long term)
Hydralazine
Labetalol
Management in Eclampsia
Invasive hemodynamic monitoring or either
central venous pressure (CVP) or pulmonary
artery wedge pressure (PAWP)
Anticonvulsant : MgSO4
Antihypertensive
Blood pressure should be monitored at least
weekly during the postpartum period.
Birth is the only known cure for
preeclampsia and eclampsia.
Nursing Management
Blood pressure should be determined q1 to q4 hours.

Temperature should be determined q4 hours, q2 if
elevated or if PROM has occurred.
Pulse and respiration should be determine with blood
pressure.
Fetal heart rate should be determine with the blood
pressure .
Intake and output. The women will have an indwelling
catheter.
Urinary protein is determined hourly if an indwelling
catheter is in place or with each voiding.
The face, fingers, hands, arms, legs, ankles, feet, and
sacral area are inspected for edema.
The patient is weighed daily.
During placental separation pt should be

assessed hourly for vaginal bleeding and
uterine rigidity.
The patient should be questioned about any
visual blurring, headache, epigastric pain.
Laboratory blood test daily. (hematocrit, BUN,
creatinine, uric acid level, clotting studies,
liver enzymes and electrolyte levels.
Patient is observed for alertness, mood
changes.
Emotional response should be carefully
assessed so that support and teaching can be
Example of Nursing Diagnosis

Fluid
Volume Deficit related to fluid shift

from the intravascular to extravascular space
secondary to vasospasm and endothelial
injury.
Risk of injury to the mother related to
convulsion secondary to cerebral edema.
Anxiety related to uncertain maternal and
fetal status.
BLEEDING DURING PREGNANCY

VAGINAL BLEEDING is a deviation from
normal that may occur at any time during
pregnancy.
Bleeding During Pregnancy
Causes:
First tri;
1. Abortion
2. Ectopic
Pregnancy
Second tri;
1. hydatidiform mole 2. Incompetent
cervix
Third tri;
1. Placenta Previa 2. Abruptio
Conditions associated with

FIRST-TRIMESTER BLEEDING
1. ABORTION defined as any
interruption of a pregnancy before

the fetus is viable. This is medically
or surgically interrupted.
* interruption occurs
spontaneously without medical
intervention.
TYPES OF SPONTANEOUS
MISCARRIAGE
Threatened
miscarriage manifested by
vaginal bleeding initially in the beginning as
scant bleeding, and usually bright red.
Imminent (inevitable) miscarriage
uterine contraction and cervical dilatation
occur. With cervical dilation, products of
conception cannot be halted.
Complete miscarriage entire products of
conception (fetus, membranes, and placenta)
are expelled spontaneously w/o any assistance.
Spontaneous Miscarriage
TYPES OF SPONTANEOUS
MISCARRIAGE
Incomplete
miscarriage part of the

conceptus (usually the fetus) is expelled,
but the membranes or placenta is
retained in the uterus.
Missed miscarriage early pregnancy
failure, the fetus dies in utero but is not
expelled.
Recurrent pregnancy loss description
used for women who had three
spontaneous miscarriages
A
miscarriage pattern.
ASSESSMENT
SIGNS AND SYMPTOMS

Spontaneous vaginal bleeding
Passage of clots or tissue through the vagina
Low uterine cramping or contractions
Cervical Dilatation
Hemorrhage and shock
DIAGNOSTICS
Decreased
hCG levels suggest spontaneous
abortion
Pelvic exam reveals size of the uterus, which is
inconsistent with the length of pregnancy
Tissue cytology indicates products of conception
Lab test reflect decreased hgb levels and hct from
blood loss
Ultrasonography positive for presence or absence
CAUSES OF SPONTANEOUS
MISCARRIAGE
FETAL
FACTORS
Defective
embryonic development
Faulty implantation of the fertilized ovum
Failure of the endometrium to accept the
fertilized ovum.
PLACENTAL
Premature
FACTORS
separation of the normally

implanted placenta
Abnormal placenta
CAUSES OF SPONTANEOUS MISCARRIAGE

MATERNAL
FACTORS
Maternal
infection
Severe malnutrition
Abnormalities of the reproductive tract eg,
incompetent cervix
OTHERS
Blood
ingestion
Trauma, including surgical manipulation
Blood group incompatibility and Rh
isoimmunization
7 WEEKS
8 WEEKS
9 WEEKS
10 WEEKS
22 WEEKS
MANAGEMENT OF SPONTANEOUS
MISCARRIAGE
TYPE OR STAGE
MANAGEMENT
Limitation
THREATENED
IMMINENT OR
INCOMPLETE
of activities for 24 to 48 hours
Bed
rest
Pad count
Restriction of coitus for about 2 weeks
Dilatation and Curettage or vacuum and
aspiration to ensure emptying of the
uterus.
Rest
Monitoring
COMPLETE
for temperature elevation and
bleeding
If uterus emptied on its own and the
patients has no signs of infection, no
COMPLICATIONS OF
MISCARRIAGE
Hemorrhage
Infection
Septic
abortion
Isoimmunization
Powerlessness
NURSING DIAGNOSES
Acute
or chronic pain
Risk for infection
Sexual dysfunction
Anxiety
Situational low self-esteem
Ineffective coping
Deficient knowledge
Risk for fluid volume deficit
NURSING MANAGEMENT
Do not allow bathroom privileges because
the patient may expel uterine contents
w/o knowing it.
After bedpan use, inspect contents
carefully for intrauterine material
Note the amount, color, and odor of
vaginal bleeding.
Save all pads the patient uses for
evaluation.
Administer an analgesic and oxytocin as
ordered.
Assess vital signs q 4hrs for 24hrs or more
frequently, depending on the extent of
Provide good perineal hygiene

Check the patients blood type and administer
RhoGam as ordered.
Provide emotional support and counseling
during the grieving process.
Encourage the patient and her partner to
express their feeling
Some couples may want to talk to a member of the

clergy
Others, depending on their religion, may wish to
have the fetus baptized.
Help the patient and her partner to develop

effective coping strategies.
Explain all procedures and treatments to the
Bleeding During Pregnancy

Nursing management
Dependent and
collaborative:
Carry out order to

establish venoclysis
stat and regulate so
as to prevent
hypovolemia.
Carry out order of

O2 inhalation @
6-10Lpm by face
mask to provide
adequate fetal
oxygenation.
Carry out order of 2 u

whole blood of
patients b type and xmatch in preparation
for restoring
circulating maternal
blood volume.
Do not attempt vaginal
exam to prevent
tearing of the placenta.
2. ECTOPIC
PREGNANCY
refers to
implantation
of the ovum
outside the
uterine cavity
Ectopic
Pregnanc
y
ECTOPIC PREGNANCY
Most
common location: fallopian
tube
Second most common cause of
vaginal bleeding during pregnancy
Results from any condition that
prevents or retards the passage of a
fertilized ovum through the fallopian
tube.
ASSESSMENT
Symptoms
of normal pregnancy or no
symptoms other than mild abdominal
pain ( the latter especially likely in
abdominal pregnancy)
Amenorrhea
or abnormal menses (after

fallopian tube implantation)
Abnormally low hCG titers
Rupture
of the tube produces sudden,

severe abdominal pain often radiating to
the shoulder as the abdomen fills with
blood.
Pain
is commonly precipitated by activities
Ruptured tube. . .
Extreme pain with the movement of the
cervix and palpation during pelvic exam
Uterus boggy and tender
Rectal pressure if blood collects in
Douglas cul-de-sac
Syncope
Nausea and vomiting
Shock with profuse hemorrhage
Initial Normal Sign and Symptoms of

Ectopic Pregnancy
Amenorrhea
Breast
tenderness
Nausea and vomiting
Chadwicks Sign
Hegars sign
Presence of hCG in the blood and urine
DIAGNOSTIC FINDINGS
Serum pegnancy test (hCG) tets result
shows an abnormally low level of hCG
Real-time ultrasonography determination of
intrauterine pregnancy or ovarian cyst
(performed if serum pregnancy test results
are positive)
Careful pelvic exam
Culdocentesis
(aspiration of fluid from the

vaginal cul-de-sac) detects free blood in
the peritoneum (performed if ultrasound
detects absence of a gestational sac in the
uterus.
Laparoscopy
may reveal pregnancy

outside the uterus (performed if
culdocentesis is positive)
MANAGEMENT
RUPTURE OF ECTOPIC PREGNANCY
AMBULANCE
AMB ULAN
CE
is an emergency situation
and the womans condition must be
evaluated quickly!
MEDICAL MANAGEMENT
Some
ectopic pregnancies resolve

spontaneously, requiring no treatment.
Laparoscopic removal of the ruptured
tube (salpingectomy); if ovarian
pregnancy, oophorectomy.
Incision on the tube to remove the
pregnancy (salpingostomy).
Methotrexate administered to stop
division of embryo.
Careful follow-up of the hCG levels until
not detectable.
Supportive
treatment:
transfusion
with whole blood or packed RBCs

to replace excessive blood loss
Administration of a broad spectrum IV
antibiotic for sepsis
Administration of supplemental iron (given
orally or IM)
Institution of a high protein diet.
Emotional
support for parents grieving

over the loss of the pregnancy.
NURSING DIAGNOSES
Risk
for deficient fluid volume related

to bleeding or hemorrhage with ectopic
rupture
Parental role conflict related to fetal
loss
Powerlessness related to early loss of
pregnancy secondary to ectopic pregnancy
Pain related to abdominal bleeding
secondary to tubal rupture
Anticipatory Grieving related to the loss
NURSING MANAGEMENT
Ask
the patient the date of her last

menses and obtain serum hCG levels as
ordered.
Assess vital signs and monitor vaginal
bleeding for extent of fluid loss.
Check the amount, color, and odor of
vaginal bleeding; monitor pad count.
Withhold oral food or fluid (maintain
nothing by mouth status) in
anticipation of possible surgery;
prepare the patient for surgery, as
Assess
the patient for signs of

hypovolemic shock secondary to blood
loss from tubal rupture, and monitor
urine output closely for a decrease
suggesting fluid volume deficit.
Administer blood transfusions (for
replacement) as ordered and provide
emotional support.
Record the location and character of the
pain, and administer an analgesic as
ordered.
Provide
a quiet, relaxing environment,

and offer the patient emotional support
To prevent recurrent ectopic pregnancy,
urge the patient to have pelvic infections
treated promptly to prevent diseases of
the fallopian tube.
Inform patients who have undergone
surgery involving the fallopian tubes or
those with confirmed pelvic inflammatory
disease that theyre at increased risk for
another ectopic pregnancy.
CONDITIONS ASSOCIATED
SECOND TRIMESTER BLEEDING
1.
GESTATIONAL
TROPHOBLASTIC DISEASE
(HYDATIDIFORM MOLE)
2. PREMATURE CERVICAL
DILATATION
(INCOMPETENT CERVIX)
HYDATIDIFORM MOLE
H-MOLE
A.k.a.
molar pregnancy
Is proliferation and degeneration of the
trophoblastic cells results in the formation of
a placenta characterized by hydropic (fluidfilled).
Exact cause: unknown
Types Molar Pregnancy

Complete
Mole - develops from an nuclear

ovum that contains no maternal genetic
material, an empty egg. Choriocarcinoma
seems to be associated.
Partial Mole a normal ovum with 23
chromosomes if fertilized by two sperm
(dispermy) or sperm that has failed to
undergo the 1st meiosis.
Invasive Mole is similar to a complete
mole but involves the uterine myometrium.
Pathophysiology:
A complete mole contains no fetal tissue. Ninety

percent are 46,XX, and 10% are 46,XY. All
chromosomes are of paternal origin. An enucleate egg is
fertilized by a haploid sperm (which then duplicates its
chromosomes), or the egg is fertilized by 2 sperm. In
a complete mole, the chorionic villi have grapelike
(hydatidiform) swelling, and there is trophoblastic
hyperplasia.
With a partial mole, fetal tissue is often present. The
chromosomal complement is 69,XXX or 69,XXY. This
results from fertilization of a haploid ovum and
duplication of the paternal haploid chromosomes or from
dispermy. As in a complete mole, there is
ASSESSMENT
Disproportionate
enlargement of the
uterus; possible grapelike clusters noted
in vagina on pelvic examination.
Intermittent or continuous bright red or
brownish vaginal bleeding by the 12th
week of gestation.
Passage of tissue resembling grapelike
clustres
Symptoms of PIH before the 20th week of
gestation
DIAGNOSTICS
Histologic
exam of possible vesicles

help confirm diagnosis
hCG levels extremely elevated for early
pregnancy
Ultrasound after the 3rd month reveal
grape-like clusters rather than a fetus,
no fetal skeleton detected by
ultrasound.
Abnormal blood levels
MEDICAL MANAGEMENT
Induced abortion if a spontaneous one
doesnt occur ( such as, suction curettage )
Follow-up care is vital because of increased
risk of choriocarcinoma
Weekly monitoring of hCG levels until they
remain normal for 3 consecutive weeks
Periodic follow-up for 1 to 2 years
Pelvic exam and x-rays at regular intervals
Emotional support for the couple who are
grieving for the lost pregnancy and an unsure
obstetric and medical future.
Avoidance of pregnancy until hCG levels are
normal (may take up to 1 year).
NURSING MANAGEMENT
Assess
the patients vital signs to

obtain a baseline for future
comparison.
Preoperatively, observe the patient for
signs of complications such as
hemorrhage and uterine infection, and
vaginal passage of vesicles, saving any
expelled tissue for laboratory analysis.
Prepare the patient for surgery.
Postoperatively, monitor vital signs,
fluid I&O, and patient for signs of
Encourage the patient and her family to

express their feelings about the disorder.
Offer emotional support and help them
through the grieving process for their lost
infant.
Help the patient and her family develop
effective coping strategies, referring them to
a mental health professional for additional
counseling , if needed.
Help obtain baseline information, including
pelvic exam, chest x-ray, and serum hCG
levels and help with ongoing monitoring.
Stress the need for regular monitoring of

hCG levels and chest x-ray to detect any
malignant changes.
Instruct the patient to promptly report new
signs and symptoms ( hemoptysis, cough,
suspected pregnancy, nausea, vomiting,
etc.)
Explain to the patient why she must use
contraceptives to prevent pregnancy for at
least a year after hCG levels return to
normal and her body reestablishes regular
ovulation and menstrual cycles.
Nursing Diagnosis
Fear related to the possible development
of choriocarcinoma
Anticipatory
Grieving related to the
loss of the pregnancy
INCOMPETENT CERVIX
Refers
to a cervix that dilates prematurely and

therefore cannot hold a fetus until term.
Dilatation is usually painless.
Generally occurs in the 4th to 5th month of
gestation, most commonly around the 20th
week of gestation.
Associated with congenital structural defects or
previous cervical trauma resulting from surgery
or delivery
Also associated with increasing maternal age.
Factors
Congenital
Factor congenitally
incompetent cervix may be found in woman
exposed to diethylbestrol (DES) or those with
a bicornuate uterus.
Acquired Factor cervical incompetence
may be related to inflammation, infection,
subclinical uterine activity, cervical trauma,
late second trimester elective abortions and
increased uterine volume (as with a multiple
gestation).
Biochemical
(Hormonal) Factor hormone relaxin

Others :repetitive second trimester losses,
previous preterm birth, progressive earlier
births with each subsequent pregnancy, short
labors, previous elective abortion and cervical
manipulation.
Factors that increase the

likelihood of suffering from an
incompetent cervix are:
DES
exposure
Cervical Trauma
Hormonal influences
Congenitally short cervix
Forced D & C
Uterine anomalies
ASSESSMENT
History
of repeated 2nd trimester

spontaneous abortions
Cervical dilatation in the absence of
contraction or pain
Pink-stained vaginal discharge
Increased pelvic pressure with possible
rupture membranes and release of
amniotic fluid.
DIAGNOSTICS
Ultrasound
revealing defect
Nitrazine test result indicates rupture of
the membranes (if occurred)
MEDICAL MANAGEMENT
Placement of a purse-string suture, known as

CERCLAGE, in the cervix to keep the cervix closed
until term or the patient goes into labor.
McDonalds procedure uses nylon sutures
horizontally and vertically to close off the cervix to only a
few millimeters in size.
Shirodkar procedure using a sterile tape in a pursestring fashion to close off cervix entirely
Bed rest after surgery

Removal of sutures at 37 to 39 weeks gestation
Emotional support
Tocolytics
Broad-spectrum
antibiotics
Nursing Diagnoses
Altered
Nutrition : Less than Body

Requirements related to persistent vomiting
secondary to hyperemesis
Fear related to the effects of hyperemesis or
its treatment on fetal well-being
NURSING MANAGEMENT
Assess complaints of vaginal discharge and investigate
history for a previous cervical surgeries.
Prepare the woman for cervical cerclage under
regional anesthesia as indicated; maternal vital signs
and fetal heart rate patterns closely.
Instruct woman in signs and symptoms of labor with
the need to notify health care provider if any occur.
Maintain bed rest after surgery as ordered; if
necessary, place the woman in a slight or modified
trendelenburg position to alleviate pressure of the
uterus on the sutured area.
Advise the woman that the sutures will be removed
around the 37th to 39th week of pregnancy
CONDITIONS ASSOCIATED WITH

THIRD TRIMESTER BLEEDING
1.
PLACENTA PREVIA
2.
ABRUPTIO PLACENTA
PLACENTA PREVIA
Occurs when the placenta implants in the

lower uterine segment where it encroaches
on the internal cervical os.
Low implantation placenta implants in the lower
uterine segment.
Partial placenta previa placenta partially occludes
the cervical os
Total placenta previa placenta totally occluded the
cervical os
Marginal placenta previa - edge of the placenta is
at the margin of the internal os.
Exact cause is unknown
Placenta
previa
Factors Associated with

Placenta Previa
Multiparity
Increasing Age
Placenta Accreta
Defective development of blood vessels in the
decidua
Prior cesarean birth
Smoking
Recent spontaneous or induced abortion
Large placenta
ASSESSMENT
Painless,
bright red vaginal bleeding is

most common after the 20th week of
gestation, especially during the third
trimester.
Initially, scant bleeding is noted, before
the onset of labor.
Episodic,
starting w/o warning and stopping

spontaneously
Bleeding increases with each successive
incident
Abdominal
examination using leopolds

maneuver reveals various
malpresentations due to interference
with the descent of fetal head caused
by the placentas abnormal location
Minimal
descent of the fetal presenting

part may indicate placenta previa
The fetus remains active, however, with
good heart tones audible on auscultation.
DIAGNOSTICS
Pelvic
examination under a double

setup (preparations for an
emergency cesarean delivery)
likelihood of hemorrhage to confirm the
diagnosis
Performed
only immediately before delivery
Laboratory
studies may reveal

decreased maternal hemoglobin levels
Transvaginal ultrasound scanning
used to determine placental position.
Radiologic
studies, such as femoral

angiography, retrograde
catheterization, or radioisotope
scanning or localization may be done
to locate the placenta
These
tests have limited value and are risky

Usually performed when ultrasound is
unavailable
MANAGEMENT
Dependent
on when the first episode

occurred and the amount of bleeding
Limitation of maternal activities
Monitoring of all relevant vital signs
Emotional support
Rectal or vaginal examination, which
could stimulate uterine activity,
shouldnt be performed unless
equipment is available for vaginal or
cesarean delivery; the placenta may be
located via ultrasound
Vaginal
delivery is considered only when

the bleeding is minimal and the placenta
previa is marginal or when the labor is
rapid.
Immediate cesarean delivery performed
as soon as the fetus is sufficiently mature
or in the case of intervening severe
hemorrhage.
Nursing Diagnoses
Fluid
Volume Deficit related to hypovolemia

secondary to excessive blood loss
Risk for Altered Tissue Perfusion related
to blood loss secondary to uterine atony
following birth.
Anxiety related to concern for own personal
status and babys safety
Risk for Impaired Gas Exchange related
to decreased blood volume and hypotension
NURSING MANAGEMENT
Teach the pt to immediately identify and
report signs and symptoms of placenta
previa (bleeding, cramping)
If with active bleeding, continuous
monitoring of VS, CVP, I&O, and amount of
vaginal bleeding, as well as FHT and rhythm
Anticipate the need for electronic FHT
monitoring
Have oxygen readily available for use should
fetal distress occur (evidenced by
bradycardia, tachycardia, or late or variable
decelerations)
Institute
complete bed rest

Prepare the patient and her family for
a possible cesarean delivery and the
birth of a preterm neonate.
Expect administration of
betemethasone to aid promoting fetal
lung maturity.
Provide emotional support during
labor
Because
of the neonates prematurity, pt

may not be given an analgesic and labor
pain may be intense
Anticipate
the need for a referral for

home care once the patients bleeding
ceases and she has to return home on
bed rest
Postpartum period, monitor the pt for
signs of hemorrhage and shock caused
by the uterus diminished ability to
contract
Tactfully discuss the possibility of
neonatal death
Encourage the pt and her family to
verbalize their feelings, develop
ABRUPTIO PLACENTA
Premature
separation of the
normally implanted placenta from
the uterine wall.
Usually occurs after 20 to 24 weeks
of pregnancy but may occur as late
as during first or second stage of
labor.
Placenta
abruptio is separation of the

placenta (the organ that nourishes the
fetus) from the site of uterine
Permanent
separation of placenta from

implantation site
Predisposing factors include
Hypertension
Cocaine
or Alcohol Use
Smoking
Poor Nutrition
Abdominal Trauma
Prior History of Abruption Placentae
Folate deficiency
Risk factors include:

Advanced maternal age
Cigarette smoking
Cocaine use
Diabetes
Drinking more than 14 alcoholic drinks per week
during pregnancy
High blood pressure during pregnancy -- About half of
placental abruptions that lead to the baby's death are
linked to high blood pressure
History of placenta abruptio
Increased uterine distention (as may occur with
multiple pregnancies or abnormally large volume of
amniotic fluid)
Large number of prior deliveries
Manifestations of Abruptio
Placentae
Bleeding
with abdominal or low back pain

Bleeding may be concealed at first
Dark red vaginal bleeding when blood
leaks past placenta
Uterine tenderness and firm
May have cramp-like contractions
Fetus may or may not be in distress
Fetus/Neonate may have anemia or
hypovolemic shock
DIAGNOSTICS
Confirmed when theres heavy maternal

bleeding, which generally necessitates
termination of the pregnancy.
Fetal prognosis depends on the gestational
age and amount of blood lost
Maternal prognosis is good if hemorrhage can
Tests
may
include
:
be controlled
Abdominal ultrasound
Complete blood count
Fibrinogen level
Partial thromboplastin time
Pelvic exam
Prothrombin time
Nursing Diagnoses
Fluid
Volume Deficit related to hypovolemia

secondary to excessive blood loss
Risk for Altered Tissue Perfusion related
to blood loss secondary to uterine atony
following birth
Anxiety related to concern for personal
status and the babys safety
Risk for Impaired Gas Exchange in the
Fetus related to decreased blood volume and
hypotension
Nursing Care
Observe
for vaginal blood loss

Observe for S/S of shock
Vital signs q 15 minutes if actively bleeding
and oxygen administered
NO VAGINAL EXAMS
Continuous fetal monitoring
Prepare for Cesarean if indicated
Supportive Care
PRE-TERM
LABOR
PRETERM LABOR
Onset
of rhythmic uterine
contraction that produce
cervical changes after fetal
viability but before the age
of maturity.
Usually occurs between 20
and 37 weeks gestation
Fetal prognosis depends on
the birth weight and length
of gestation.
Factors
1. Maternal factors:
preeclampsia (also known as toxemia or high
blood pressure of pregnancy)
chronic medical illness (such as heart or
kidney disease)
infection (such as group B streptococcus,
urinary tract infections, vaginal infections,
infections of the fetal/placental tissues)
drug abuse (such as cocaine)
abnormal structure of the uterus
cervical incompetence (inability of the cervix
to stay closed during pregnancy)
previous preterm birth
2. Factors involving the pregnancy:
abnormal or decreased function of the placenta

placenta previa (low lying position of the placenta)
placental abruption (early detachment from the
uterus)
premature rupture of membranes (amniotic sac)
hydramnios (too much amniotic fluid)
3. Factors involving the fetus:
when fetal behavior indicates the intrauterine

environment is not healthy
multiple gestation (twins, triplets, or more)
erythroblastosis fetalis (Rh/blood group
incompatibility)
ASSESSMENT
Onset
of rhythmic uterine contraction

Persistent, dull, low backache
Vaginal spotting
A feeling of pelvic pressure or abdominal
tightening
Menstrual-like cramping
Increased vaginal discharge
Intestinal cramping
Symptoms:
Regular contractions for an hour. This means about 4
or more in 20 minutes, or about 8 or more within 1
hour, even after you have had a glass of water and are
resting.
Leaking or gushing of fluid from your vagina. You may
notice that it is pink or reddish.
Pain that feels like menstrual cramps, with or without
diarrhea.
A feeling of pressure in your pelvis or lower belly.
A dull ache in your lower back, pelvic area, lower
belly, or thighs that does not go away.
Not feeling well, including having a fever you can't
explain and being overly tired. Your belly may hurt
DIAGNOSTICS
Vaginal
mucus reveals a fetal

fibronectin, a protein produced by the
trophoblast cells.
Cervical examination
Ultrasound shortened cervix
NST
MEDICAL MANAGEMENT
Bed
rest to relieve the pressure of the

fetus on the cervix
Intravenous therapy to
prevent dehydration
Drug
therapy using tocolytic
Terbutaline
beta-adrenergic blocker,; a beta2

receptor stimulator that causes smooth muscle
relaxation; most commonly use tocolytic
Magnesium sulfate first drug to halt
contraction; CNS depressant that prevents calcium
into the myometrial cells, thereby keeping the
uterus relax.
Indomethacin (Indocid) a prostaglandin
synthesis inhibitor; NSAID that decreases
production of prostaglandins, which are lipid
compounds associated with the initiation of labor.
Nifedipine a calcium channel blocker; also
initiate labor
Corticosteroid
medications - medications
that may help mature the lungs of the fetus.
Lung immaturity is a major problem of
premature babies.
Antibiotics (to treat infection)
Delivery - if treatments do not stop preterm
labor or if the fetus or mother is in danger,
delivery of the baby may occur. Cesarean
delivery may be recommended in certain
cases.
NURSING DIAGNOSES
Fear
related to uncertain outcome of

pregnancy
Fear related to labor contractions
Situational low self-esteem related to
inability to carry pregnancy to term
Risk for fetal injury related to
preterm birth
Preterm Labor
Nursing Management
Institute
bedrest on left
side to enhance uterine
perfusion and relieve
pressure of fetus on
cervix.
Head of bed slightly
elevated to facilitate
breathing
Assess
for chest pain and dyspnea

Auscultation lungs for changes in
breath sounds, maternal pulse over
120bpm or persistent tachycardia or
tachypnea,chest pain, or
adventitious breath sounds may
indicate impending pulmonary
edema due to prolong bed rest and
fluid overload.
Monitor
FHR and
patterns of uterine
contractions q1530min. Fetal
tachycardia, late or
variable decelerations
indicate possible
uterine bleeding or
fetal distress, which
requires emergency
delivery.
Monitor
uterine contractions
including frequency and duration.
This provides evidence of
effectiveness of therapy.
Health teaching includes enhancing
understanding of the situation and
promotes compliance of therapy,
and bedrest improving for a
successful outcome.
Dependent/collaborative
functions:
Begin
IV fluid therapy
ASAP as ordered for
venoclysis and hydration,
which may help to
minimize contractions.
Administer tocolytic
(terbutaline,duvadilan or
isoxsuprine HCl) IV piggy
or side drip solution in
microdrip tubing. A beta2
selective agonist that acts
Dependent/collaborative functions:
Continue
infusion for 12 to 24 hours

after cessation of contractions, and
anticipate shift to oral tocolytic
therapy.
Anticipate administration of steroid
betamethasone IV 3 doses as
ordered to hasten lung maturity,
helping to decrease respiratory
distress syndrome incase of preterm
delivery.
PREMATURE RUPTURE OF
MEMBRANES ( PROM )
Membrane rupture 1 or more

hours before the onset of labor.
Spontaneous break or tear in the

amniotic sac before onset of regular
contractions, resulting in
progressive uterine dilation.
Factors that may be linked

to PROM include the
following:
low socioeconomic conditions (as women in

lower socioeconomic conditions are less likely
to receive proper prenatal care)
sexually transmitted infections such as
chlamydia and gonorrhea
previous preterm birth
vaginal bleeding
cigarette smoking during pregnancy
unknown causes
ASSESSMENT
Suggested by the history:

Sudden gush of clear fluid from the vagina,
with continued minimal leakge
Blood-tinged amniotic fluid containing vernix
caseosa particles
Maternal fever, fetal tachycardia, and foulsmelling vaginal discharge indicate infection
Alkaline pH of fluid collected from the
posterior fornix turns nitrazine paper deep
blue
a smear of fluid placed on a slide and
allowed to dry, takes on a fern-like pattern
(because of the high-sodium and protein
content of amniotic fluid) considered a
Diagnostics
examination
of the cervix (may show fluid

leaking from the cervical opening)
testing of the pH (acid or alkaline) of the
fluid
looking at the dried fluid under a
microscope (may show a characteristic fernlike pattern)
ultrasound
Medical Management
Hospitalization
Expectant management ( some cases of PPROM,
the membranes may seal over and the fluid may
stop leaking without treatment)
Monitoring for signs of infection and
laboratory tests
Corticosteroids - it may mask an infection in the
uterus.
Antibiotics
Delivery (if PROM endangers the well-being of the
mother or fetus, then an early delivery may be
necessary to prevent further complications)
Nursing Diagnoses
Risk
for Infection related to premature

rupture of membrane
Impaired Gas Exchange in the fetus
related to compression of the umbilical cord
secondary to prolapse of the cord
Risk for Ineffective Individual Coping
related to unknown outcome of the pregnancy
NURSING INTERVENTIONS
Place client on bed rest if labor does begin and
fetus is too young to be delivered
Prophylactic administration of broad spectrum
antibiotics as ordered to delay onset of labor
and reduce infection in the newborn.
If at home, instruct client to take her
temperature twice a day to report a fever(100.4
F) uterine tenderness or odorous vaginal
discharge .
Instruct patient to refrain from tub bathing,
coitus and douching because of the danger of
introducing infection is present.
NURSING MANAGEMENT
Bed
rest in a lateral position

High-protein diet with adequate fluid
intake with restriction of excessive salty
foods
Close observance of BP, FHR, edema,
proteinuria, and signs of pending
eclampsia
Monitor changes in the VS, FHR, LOC, and
deep tendon reflexes, and for headache.
Monitor results of NST
MULTIPLE PREGNANCY
Is considered a
complication of
pregnancy.
Presence of more than
one fetus inside the
womb.
Terminology
Monozygotic multiple (typically two) fetuses

produced by the splitting of a single zygote
Dizygotic multiple (typically two) fetuses
produced by two zygotes
Polyzygotic multiple fetuses produced by two or
more zygotes
Twins - 2 fetuses
Triplets - 3 fetuses
Quadruplets - 4 fetuses
Quintuplets - 5 fetuses
Sextuplets - 6 fetuses
Septuplets - 7 fetuses
Factors in Multiple Pregnancy

Hereditary
Older
Age
High Parity
Race African American woman
Caucasian woman over 35 years old
Ovulation Stimulating medication ex. Clomid
In Vitro Fertilization
Signs and Symptoms of Multilple

Pregnancy
Weight
gain
Measuring large for gestational age
Excessive Morning sickness
Extreme fatigue
Feeling of fetal movement early in pregnancy
Elevated HCG level
Abnormal AFP ( alphafetoprotien ) test result
Diagnostics
Ultrasound
confirmation
Doppler heartbeat count
Test for HCG level
Test for AFP
Possible
Complications
increased rate of spontaneous abortion

greater risk of developing severe hypertension or
preeclampsia
maternal anemia
PROM
incompetent cervix
intrauterine growth restriction
preterm labor due to overstretched uterus
abnormal fetal presentations
need for cesarean section
rare complications with twins, such as twin-totwin-transfusion syndrome
conjoined twins
Management of Multiple
Pregnancy
increased nutrition
more calories, protein, and other nutrients, including
iron, recommends women carrying twins gain at
least 35 to 45 pounds.
more frequent prenatal visits
referrals
Perinatologist
increased rest
maternal and fetal testing
tocolytic medications
corticosteroid medications
THERAPEUTIC MANAGEMENT
Provide
rest side lying position to

increase tissue perfusion.
Maintain nutrition advise patient to
eat six small meals each day to
increase her appetite.
Advise patient to refrain from coitus to
decrease risk of preterm labor.
Assist patient for monthly UTZ
examination or weekly. Non-stress test
for fetal monitoring.
Nursing Diagnosis
Fear
Ineffective
Individual Coping or
Ineffective Family Coping
Risk for Impaired Gas Exchange
Fatigue
Amniotic fluid fills the sac
surrounding your developing baby and plays

several important roles.
It has a cushioning effect that protects
your baby from trauma.
It prevents the umbilical cord from being
compressed and reducing your babys
oxygen supply.
It helps maintain a constant temperature
in the womb.
It
protects against infections.

It allows your baby to move around so
that his muscles and bones develop
properly.
The baby swallow amniotic fluid and
inhales and exhales it from the lungs.
The fluid and the special factors it
contains his digestive and respiratory
systems develop normally.
HYDRAMNIOS OR
POLYHYDRAMNIOS
Excessive amniotic fluid formation.
An amount of more than 2000ml or an
amniotic fluid index above 24cm is
considered hydramnios.
Causes of Polyhydramnios include:

A birth defect that affects the baby's
gastrointestinal tract or central nervous
system
Maternal diabetes
Twin-twin transfusion
A lack of red blood cells in the baby (fetal
anemia)
Blood incompatibilities between mother and
baby
Symptoms
Rapid growth of
uterus
Unusual abdominal
discomfort
Increased back pain
Shortness of breath
Extreme swelling of
feet and ankles
Polyhydramnios may increase the

risk of:
Premature birth
PIH
UTI
PROM
Excess fetal growth
Placental abruption
Umbilical cord prolapse
C-section delivery
Stillbirth
Heavy bleeding due to lack of uterine muscle tone after
DIAGNOSTICS
Amniocentesis
Glucose
challenge test
Maternal serum screening.
This group of blood

tests checks for abnormal levels of substances linked with
certain birth defects.
Karyotype is used to screen the baby's chromosomes

for abnormalities.
Nonstress test.
Biophysical profile
Doppler ultrasound
Contraction stress test
Treatments and Drugs

Amnioreduction. Amnioreduction carries a
small risk of complications, including preterm labor,
placental abruption and premature rupture of the
membranes.
Medication. Indomethacin to help

reduce fetal urine production and amniotic fluid
volume. Indomethacin isn't recommended beyond 31
weeks of pregnancy. Due to the risk of fetal heart
problems, your baby's heart may need to be
monitored with a fetal echocardiogram and Doppler
ultrasound. Other side effects may include nausea,
Maintain
bed rest to help increase

uteroplacental circulation and reduce
pressure on the cervix.
Report any sign of PROM or
contractions.
Encourage patient to increase high
fiber diet to prevent constipation.
Vital Sign and signs of LE edema
Nursing Diagnosis
Risk
for Impaired Gas Exchange related

to pressure on the diaphragm secondary to
hydramnios.
Fear related to unknown outcomes of the
pregnancy
OLIGOHYDRAMNIOS
Amniotic
fluid is <
500 ml and is highly
concentrated
EFFECTS:
Prolonged,
dysfunctional labor
Places the fetus at
risk for various
conditions like fetal
hypoxia, increased
skeletal deformities,
etc
Factors
1.
2.
3.
LBOW or PROM
Placental problems ex. Partial abruptio
Medical conditions such as chronic high
blood pressure, Preeclampsia, diabetes and

lupus can result in low amniotic fluid.
4. Carrying twins or multiples twin to twin
transfusion syndrome in which the donor twin
suffers from too little amniotic fluid while the
recipient twin creates too much.
5.
Fetal abnormalities if found to have low
amniotic fluid during the 1st and 2nd trimester, it
may mean that the baby has a birth defect
NURSING MANAGEMENT
Maintain
bed rest increase uteroplacental

perfusion and decrease pressure on the cervix
Monitor for S/S of preterm labor
Encourage to avoid straining on
defecation
Monitor VS, FHR for any changes
Prepare possible labor induction.
Amniotransfusion (oligohydramnios)
Ultrasound. Amniotic fluid index (AFI)
normal measure for the 3rd trimester is

somewhere between 5 and 25 centimeters. A
total 5 cm or less is considered low.
Frequent
ultrasound and non stress test

monitoring.
Labor will be induced if near term.
Increase oral fluid intake.
Do fetal kick counts.
During labor physician may pass a flexible
catheter through the patients cervix and
pump a steady supply of warm saline
solution into the amniotic sac to reduce the
risk of the cord compression.
Recommend cesarean section if the baby
cant safely tolerate labor.
POST TERM PREGNANCY

postmature
postdate or
dysmature
Exceeds 42 weeks and
with evidence that
placental insufficiency
has interfered with
fetal growth
pregnancy that lasts more than 42

weeks (294 days since the first day of the
last menstrual period) is considered postterm.
Factors
1. Mother
with post-mature birth history

2. Miscalculated menstrual period.
3. Irregular menstrual cycles.
Most Common Feature of Post

Term Baby
dry skin
overgrown nails
creases on the baby's palms and soles of their
feet
minimal fat,
lot of hair on their head
brown, green, or yellow discoloration of their
skin
Doctors diagnose post-mature birth based on

the baby's physical appearance and the length of the
mother's pregnancy.
Nonstress
test or biophysical profile

Assist in delivery by inducing labor.
Prostaglandin gel applied to the cervix
as ordered to initiate ripening or stripping of
membranes followed by an Oxytocin
infusion used to induced labor.
Contraction Stress Test
Ultrasound
NURSING MANAGEMENT
Prepare
for
induction of labor
Close monitoring of
FHR
Explain all
procedure to the
patient
PSEUDOCYESIS
A False
Pregnancy.
Symptoms of False Pregnancy

Amenorrhea
Swollen
belly
Enlarged and tender breasts, changes in
the nipples, and possibly milk production
Feeling of fetal movements
Nausea and vomiting
Weight gain
THEORIES why the phenomenon

occurs
WISH-FULFILLMENT
THEORY: womans
desire to be pregnant actually causes
physiologic changes to occur
CONFLICT THEORY: a desire for and fear of
pregnancy create an internal conflict leading to
changes
DEPRESSION THEORY : attributes the cause
to major depression
Step by Step Coping Strategies

1.
2.
3.
Verify that there is no real pregnancy.

Ultrasound
Treat the physical symptoms.
Menstrual period
Test for any underlying endocrine
disorders. An imbalance hormones like high levels of
prolactin and estrogen. Some including a malfunctioning
pituitary gland.
4.
Seek the help of a psychotherapist.

The majority of pseudocyesis cases are a result of an
underlying psychological issue that includes an intense
desire to become pregnant, an intense fear of
becoming pregnant, wish-fulfillment, and
ISOIMMUNIZATION
Rh
Incompatibility
A.k.a Rh sensitivity
Hemolytic disease of the
newborn or
erythroblastosis fetalis
Refers to a condition in
w/c the pregnant
woman is Rh negative
but her fetus is Rh
positive
Description of Isoimmunization
Development of a significant titer

of specific antibody as a result of
antigenic stimulation with material
contained on or in the red blood cells of
another individual of the same species;
e.g., isoimmunization is likely to occur
when an Rh-negative person is treated
with a transfusion of Rh-positive blood
from another human being, or an Rhnegative woman has a pregnancy in
Risk Factors
Miscarriage
Induce
abortion
Ectopic Pregnancy
Amniocentesis or other Invasive
Proceduce
Incompatible blood transfusion
Symptoms of the Fetus or

Newborn
Anemia
Swelling of the body (also called hydrops fetalis),
which may be associated with:

Heart failure
Respiratory problems
Kernicterus (a neurological syndrome), which can occurs
in stages:
Early:
High bilirubin level (greater than 18 mg/cc)
Extreme jaundice
Absent startle reflex
Poor suck
Lethargy
Late:
High-pitched hearing loss
Mental retardation
Muscle rigidity
Intermediate:
High-pitched cry
Arched back with neck hyperextended backwards
(opisthotonos)
Bulging fontanel (soft spot)
Seizures
Speech difficulties
Seizures
Movement disorder
Treatment
Since Rh incompatibility is almost

completely preventable with the use of
prophylactic immunization
(immune globulin injection of
RhoGAM), prevention remains the best
treatment.
Women
w/ Rh negative blood should

have an anti-D antibody titer done at
1st check up.
Monitor well-being of the fetus q 2
weeks by amniocentesis.
Perform blood transfusion to fetus in
utero by injecting RBC directly into a
vessel in the fetal cord to restore
Fetal RBC as ordered.
Assist in delivery by induction as
FETAL DEATH
(FDIU)
The most like causes of
this care chromosomal
abnormalities,
congenital
malformation, infections
such as Hepatitis B,
immunologic cases and
complications of
maternal diseases.
NURSING DIAGNOSIS
Powerlessness
related to fetal death

Grieving related to the death of the
anticipated baby
Altered Family Processes related to
loss of a family member
Ineffective Individual Coping related
to depression in response to loss of child
Give patient
opportunities to
express how she
feels about fetal
loss.
Encourage a support
to remain w/ the
woman during the
labor.
Ask the parents if
they wish to see the
child. If they do,
wash away the
obvious blood,
swaddle the baby as
if he or she wore a
well newborn and
bring the baby to
them.
Encourage
the parents to name the child

to make him or her real.
Explain the cause of death of the fetus
Be certain that she has a return
appointment for a gynecologic check-up
so both her physiologic and psychological
health can be evaluated at that time.
DYSTOCIA
Difficult
labor that is prolonge
DYSTOCIA (DIFFICULT LABOR)
May be due to either

Mechanical or
Functional factors or
to a Combination of
Both.
Mechanical dystocia
If
occiput posterior position :
*relieve
back pain as much as possible

by sacral pressure, back rubs, frequent
change of position from side to side(
may also assist fetal head to rotate)
IV fluids are used to prevent
dehydration and provide glucose needed
for effective contractions.
Observe
the
character and
frequency of
contractions and
monitor fetal heart
rate.
When cervix is
completely dilated,
fetal head may be
rotated by physician.
Provide
encouragement and
reassurance to the
woman throughout
@if breech
presentation:
Labor may be
longer, since in a
breech delivery, the
soft buttocks do
not aid in cervical
dilation as well as
the head does in a
vertex presentation.
Analgesia may be
limited in order not
to interfere with
mothers ability to
Knee breech
Complete breech
Footling breech
Amniotomy
is not done until breech is well

engaged because the is greater danger of
prolapse of the cord with footling presentation or
breech that does not fill the pelvic cavity.
Breech presentations may be delivered
spontaneously with strong contractions,
particularly in multiparas.
Application of Piper Forceps to aid in head
delivery, especially primigravidas.
Cesarean delivery is
performed when
there is a shoulder
presentation.
Functional Dystocia
Hypertonic uterine dysfunction
music of the uterus is in a state of greater
than normal tension , so that contractions are
ineffective for accomplishing dilation.
Contractions may be uncoordinated and involve only
portions of the uterus.
Provide rest with aid of sedatives

(morphine,16 mg., on prescription, usually
stops contractions).
B. Provide fluids to maintain hydration
and electrolyte balance.
A.
Hypotonic uterine dysfunction

contractions are inadequate(lack intensity);
usually occurs in active phase of labor.
A. Pelvis is reevaluated for size.

B. IV fluids are provided to maintain
hydration and electrolyte balance.
C. Oxytocin administration
p D. Amniotomy may be performed to
augment labor
NURSING MANAGEMENT
Assess
FHR; monitor for fetal distress.

Monitor uterine contractions
Monitor maternal temperature and heart
rate
Assist with pelvic examination,
measurements, ultrasounds, and other
procedures.
Administer prophylactic antibiotic
Administer IV fluids as prescribed
Monitor I&O
Assess for dehydration
Monitor
fetal heart rate and

contractions for character and
frequency. If contractions last more
than 60-70 seconds, decrease or stop
infusion. (Tetanic contractions may cause
premature separation of the placenta,
rupture of the uterus, and fetal hypoxia.)
Observe IV drip.
Report any maternal or fetal distress
immediately.
Anxiety-Reducing measures
Keep the woman/couple informed of the
progress of labor and any changes in plan of
care.
Promote rest and comfort.
Keep room lights low and noise to a minimum,

and limit the number of visits by nonessential
personnel.
Give frequent back rubs and massage sacral area,
Assist the womans labor coach if needed or coach
the woman in breathing and relaxation
techniques during contractions.
Administer sedatives or analgesics as needed

and prescribed.
Pregnancy Complicated
by Medical Condition
1.
SEXUALLY-TRANSMITTED
DIASEASE
Spread through sexual contact with an

infected partner
Regardless of the cause, the organism
invades the body, placing the mother
and the fetus at risk.
WITH PREEXISTING OR NEWLY

ACQUIRED ILLNESS
STDs
1. Candidiasis a vaginal
A.
infection spread by the fungus Candida.

The woman notices a thick, cream cheese like
vaginal discharge and extreme pruritus. Vagina
appears red and irritated. Candidiasis
occurs more frequently during pregnancy
because of the increased estrogen level present
during pregnancy w/c changes vaginal pH to
be less acidic.
ASSESSMENT:
Signs
and symptoms typically involves

some type of vaginal discharge or lesion.
Vulvar or vaginal irritation, such as itching
or pruritus, commonly accompany the
discharge or lesion.
MANAGEMENT:
Pharmacologic
therapy with antifungal or
antimicrobial
Safe
sex practices
Treatment of the partner
NURSING
INTERVENTIONS
(Candidiasis)
Explain
the mode of transmission of the

STD and educate the patient about
measures to reduce the risk of transmission
Administer drug therapy as ordered
Urge the patient to refrain from sexual
intercourse until the active infection is
completely gone
Instruct to have her partner examined so
that treatment can be initiated
Provide comfort measures for the patient
to reduce vulvar and vaginal irritation
Suggest
the use of cool or tepid sitz

bath to relieve itching
Encourage to wear cotton underwear
and avoid tight-fitting clothing as much
as possible.
Instruct safer sex practices, including
the use of condoms and spermicides
Encourage follow-up to ensure
complete resolution of the infection (if
possible)
(Candidiasis)
1.
2.
Diagnosed by the microscopic analysis

of a wet slide.
Treated by the local application of
antifungal cream such as Monistat
(miconazole) or Gyne lotrimin (clotrimazole).
Infection should be treated during
pregnancy because if the infection is present
at the time of childbirth, it may cause
candidal infection or thush newborn.
2. Trichomoniasis Vaginalis a
single-cell protozoan spread by coitus. The

woman notices a yellow-gray frothy vaginal
discharge.
Diagnosed
by examination of vaginal
secretion in a wet slide
Treated with Potassium hydrochloride. It is
important that Trichomoniasis infections are
identified because they are possibly
associated w/ preterm labor,premature
rupture of membranes and post cesarean
Administer
Metronidazole as ordered, but

is probably teratogenic during the 1st trimester
of pregnancy. Thus, the disorder is usually
treated with topical clotrimazole.
3. Bacterial Vaginosis gardnerella
infection is a local infection of the vagina by
the invasion of Gardnerella Organisms.
Discharge is gray and has a fishlike odor. Pruritus
may be intense
(Bacterial Vaginosis)
Metronidazole is contraindicated during the
first trimester of pregnancy, women are
usually treated w/ topical cream during this
time.
4. Chlamydia infection causative
organism is chlamydia trachomatis,

caused by a gram-negative intracellular
parasite,causes a heavy, gray-like vaginal
discharge.
Screened for chlamydial infection by a
vaginal culture at first prenatal visit. If they
have multiple sexual partners, they usually
screened again in the third trimester.
Administer
medications as ordered.
Erythromacine and Amoxicillin.
5. Syphilis a systematic disease caused
by the Spirochete Treponema Pallidum.

The 1st stage of syphilis results is a painless
ulcer on the vulva or vagina. After this, the
placenta appears impervious to the disease
organism, the spirochete crosses the
placenta freely and maybe responsible for
spontaneous abortion, preterm labor,
stillbirth or congenital anomalities in
newborn.
Screened for syphilis at the 1st prenatal
visit antibody reaction test.
One or more injection of benzathine
penicilin G (drug of choice)
Monitor for signs of Jarisch-Herxheimer
reaction after therapy. The woman may
experience a sudden episode of
hypotension, fever, tachycardia and ms
aches caused by sudden destruction
spirochete. Reaction last about 24h and then
fades.
6. Herpes infection caused by the

Herpes Simplex Virus (HSV) type 2
woman develops painful, small, pinpoint
surrounded by crythema on the vulva or vagina 3-7

post exposure.
Papsmear and ELISA.
Acyclovir (Zovirax) in an ointment or oral
form.
Sitz bath or applying warm, moist tea bags
on lesions to reduce pain.
7. Gonorrhea sexually transmitted disease

caused by gram (-) coccus, Neisseria
gonorrheoeae. Yellow green discharge may be
present. Gonorrhea is associated w/ spontaneous
abortion, preterm birth and endometritis.
Diagnosis is made by culture of the organisms
from the vagina, rectum or urethra.
Oral cefixime and cefriaxone Na Im are the drugs
of choice.It is important that gonorrhea can be
identified and treated @ childbirth to prevent severe
eye infection (opthalmia neonatorum) that can
lead to blindness in the newborn.
HEMATOLOGIC DISORDER
1.IRON DEFICIENCY ANEMIA
most common anemia of
pregnancy.
Cause: diet low in iron,
heavy menstrual periods, or
unwise weight reduction
program.
Hemoglobin level is <
11mg/dl ( hct under 33%)
THERAPEUTIC MANAGEMENT:
Prophylactic
therapy 60mg of elemental
iron.
Oral iron therapy, IM or IV iron dextran.
Take Vitamin C. or eat leafy vegetables.
2. FOLIC ACID DEFICIENCY ANEMIA
occurs most often in multiple

pregnancies because of the increased fetal
demand, in women with secondary
hemolytic illness in which there is rapid
destruction and production of RBC, and in
women who are taking hydantoin, a drug
that interferes with folate absorption.
Advise patient to begin a Vitamin
supplement or conscious about eating
folacin- rich food this time ( green leafy
vegetables, orange, dried beans)
IRON-DEFICIENCY
Encourage the use of prenatal vitamins
Monitor complete blood count and iron levels
Assess the familys dietary habits
Assess FHR
Encourage frequent rest periods
FOLIC-ACID DEF
Encourage to eat green leafy vegetables, wheat
products, peanut butter and liver.
Eat foods high in vitamin C
Monitor blood studies
Assess maternal VS and FHR
3. SICKLE CELL ANEMIA

A recessively inherited hemolytic anemia
caused by an abnormal amino acid in the
beta chain of hemoglobin.
Majority of RBC are irregular or sickle shaped
they cannot carry as much as hemoglobin as
normally shaped RBC. When oxygenation become
reduces as happens at high attitudes of blood becomes

more viscid than usual, the cells tends to clump ,
because of the irregular shape. This clumping
can result in blockage of vessels in infants
organs. The cells will then hemolyze, reducing
the number causing severe anemia.
Exchange
transfusions periodically thru

out pregnancy.
If crisis occurs, controlling pain,
administering oxygen as needed and
increasing the fluid volume of the
circulatory system to lower viscosity.
Hospitalization for observation when
patient develops infection.
4. COAGULATION DISORDERS
Normal
platelet count but bleeding time

is prolonged. Infusion of cryoprecipitate
or fresh frozen plasma maybe necessary
before labor to prevent excessive bleeding.
Percutaneous umbilical cord sampling is
done during labor to detect whether fetus has
the disease.
5. IDIOPATHIC THROMBOCYTOPENIC
PURPURA(ITP)
Decreased
number of platelets is
unknown, but it is assumed to be an
autoimmune illness ( an anti platelet antibody
that destroys platelets is apparently released without an
adequate level of platelets. Miniature petechiae or large
ecchymoses appear on the womans body).
Frequent nose bleeds may occur

laboratory studies will reveal a marked
thrombocytopenia ( platelet count may be as
THERPAEUTIC MANAGEMENT:
Administer
platelet transfusion to
temporarily increase the platelet count.
Administer prednisone daily
Platelet count monitoring.
RENAL AND URINARY

PROBLEMS
1.
CYSTITIS refers to the inflammation

and infection of the lower urinary tract;
involves the bladder.
CAUSES:
Vesicoureteral reflux
Urinary stasis
Compression of the ureters.
2. URINARY TRACT INFECTION
In pregnant because of the dilated
meters from the effect of the

progesteron, stasis of urine occurs. The
minimal glucosuria that occurs with
pregnancy contributes to the growth of
the microorganisms.
An increased incidence of pre term

labor; preterm premature rupture of
membrane; and fetal loss may be
NURSING INTERVENTIONS:
Proper
perineal hygiene
Instruct not hold urine
Increased fluid intake (at least 3 to 4 L)
Urine culture to identify organism
Medication therapy
SAFE TO USE: Ampicillin, Amoxicillin, and
Cephalosporins
3. Chronic Renal Disease
Manifest elevated BP from poor

kidney function, proteinuria, burning
sensation in urination, stark pain( if UTI is
present), increased serum creatinine and
edema.
THERAPEUTIC
MANAGEMENT:
Corticosteroids
@ maintenance levels as
ordered.
Synthetic erythropoietin for patient with
severe anemia.
Dialysis to aid kidney function in pregnancy.
4. PYELONEPHRITIS
Infection of the upper urinary

tract due to bacterial invasion.
NURSING INTERVENTIONS:
Antipyretic as ordered
Increase OFI to achieve urine output of
>2L/day
Urinalysis and culture as ordered
Check for patients voiding pattern and urine
characteristics. Proper perineal care.
Monitor VS and FHR.
RESPIRATORY DISORDERS
1. ACUTE NASOPHARYNGITIS
Common colds, during this period estrogen

stimulation normally causes some degree of nasal
congestion in pregnancy.
Caution in taking Acetaminophen unless they
have a fever. Aspirin should be avoided during
pregnancy (interference with blood clotting in both
mother and the fetus and the possibility of prolonged
pregnancy at term.)
Antibiotic for primary infections as ordered.
2.
INFLUENZA
Accompanied by high fever, extreme
prostration, aching pains in the back and

extremities and generally a sore, raw throat.
Antipyretics for fever as ordered.
Prophylactic antibiotic to prevent a secondary
infection.
May be immunized with influenza vaccines
safely during pregancy.
3. PNEUMONIA
A bacterial and viral invasion of lung
tissue. Poses a serious complication of pregnancy

because fluid collects in alveolar spaces causing
limited oxygen carbon dioxide exchange in the lungs
and limit the oxygen available to fetus.
Appropriate Antibiotic therapy as ordered.
Administration of Oxygen as ordered.
During labor, oxygen should be administered so
the fetus has adequate oxygen resources
during contraction.
4. ASTHMA
A paroxysmal wheezing and

dyspnea in response to inhaled allergen
this will reduce the oxygen supply to the fetus
if major attack occur during pregnancy.
Beta adrenergic agonists such as terbutaline
and albuterol (drugs of choice.) If ineffective,
theophylline or cromolyn Na may be assed to
the regimen.
Monitor serum levels of theophylline to avoid
toxicity.
5. TUBERCULOSIS
Lung dse invaded by Mycobacterium
tubercle, an acid fast bacillus. Macrophages and Tlymphocytes surround the invasion site. Fibrosis
calcification and a final ring of collagenous scar
develop, effectively sealing off the organisms from the
body and any further invasion or spread.
Transmitted airborne route .
Symptoms:
Chronic cough , wt. loss, hemoptysis,
night sweats, low grade fever, chronic fatigue.
NURSING
INTERVENTION(Tuberculosis)
Administration
of INH, ethambutol,
and rifampicin for 6 to 12 months
during and after pregancy
Pyridoxine should be administered
with INH to pregnant women to
prevent development of peripheral
neuropathy.
Breastfeeding is not contraindicated
with INH, ethambutol, or rifampicin
6. CYSTIC FIBROSIS
Generalized dysfunction of the exocrine
glands. This dysfunction leads to mucus secretions,

particularly in pancreas and lungs, becoming a viscid
or thick normal secretion is blocked.
Pancrelipase ( pancreas) to supplement
pancreatic enzymes and bronchodilator or
Antibiotic to reduced pulmonary symptoms.
NEUROLOGIC DISORDER
1.
SEIZURE DISORDER
May be due to head trauma

or meningitis
Drugs prescribed for the control of seizures:

Phenytoin Na (Dilantin), Trimethadione,
Valpoic Acid, Carbamzine, Ethosuxime
Baseline BP should be established early in
pregnancy.
Serum
evaluations of drug level late

pregnancy or early in pregnancy.
Give folic acid as ordered.
Sonogram can confirm neural tube defect.
Give Vit.. K during labor or the last 4 weeks
of gestation to prevent heart damage.
2. MYASTHENIA GRAVIS
Autoimmune disorder characterized by the

presence antibody against acetylcholine
receptors in striated muscle. Disease course
is variable, pregnant patients face risks of

exacerbation, respiratory failure,
adverse drug response, crisis, and
death.
THERAPEUTIC MANAGEMENT :
Administer anti-cholinesterase (muscle
stimulant).
Plasmapheresis to remove immune complexes
from the blood stream to reduce symptoms.
Administer cortecosteroids, antimetabolites,
3. MULTIPLE SCLEROSIS
With muscles, nerve fibers become

demyelinated and therefore loose function.
Women develop symptoms of fatigue,
numbness, blurring of vision & loss of
coordination.
Administer Corticosteroid.
Plasmapheresis (withdrawal & replacement of
plasma)
Administer epidural anesthetic to prevent
MUSCULOSKELETAL DISORDER
1.
SCOLIOSIS
A lateral curvature of the spine.

It occurs most commonly in females approximately
12 years of age. Can cause cosmetic deformity
and even interferes with respiration, heart
action because of chest compression. Pelvic
distortion can interfere with child birth especially
at pelvic inlet.
Milwaukee brace should be worn during
adolescent years to maintain an erect posture.
Harrington rods (stainless steel rods) implants on
both sides of spinal vertebrae to strengthen and
straighten their spine.
If womans pelvic is distorted, caesarean birth may
need to be anticipated for a safe birth.
CARDIOVASCULAR
DISORDERS
1. LEFT SIDED HEART FAILURE
Occurs with condition such as mitral
stenosis, mitral insufficiency and aortic

coarctation. Occurs when LV is unable to move
forward the volume of blood received by LA from
the pulmonary circulation.
THERAPUTIC MANAGEMENT :
Administer antihypertensive to control upper body

blood pressure & may be prescribed Beta-blockers to
decrease the force of myocardial contractions.
Woman needs serial ultrasound and nonstress
tests done after 30-32 weeks of pregnancy to
monitor fetal health.
Cardiac medications are relatively safe for the
fetus (diuretics, beta-blocking agents, digoxin)

Counselling and management of pregnant
women by cardiologists and obstetricians .
2. RIGHT SIDED HEART FAILURE
Occurs with conditions such as pulmonary valve

stenosis and atrial and ventricular septal defects.
Occurs when the output of right ventricle is less than
the blood volume the heart receives at the right
atrium from the vena cava. Back pressure from this
results in congestion of the systemic venous circulation and
decreases cardiac output to the lungs.
Oxygen administration.
Arterial blood gases monitoring.
During labor, they may need Swan-Ganz catheter
inserted for monitoring of pulmonary rescue.

1.
2.
3.
4.
5.
Medical treatment:
Digoxin: is indicated in atrial fibrillation to slow
the ventricular response and in acute heart
failure to increase myocardial contractility.
Diuretics are used in acute and chronic heart
failure with potassium supplements in prolonged
therapy.
Beta-adrenergic blockers: as propranolol may
be indicated for arrhythmia associated with
ischaemic heart disease.
Aminophylline: relieves bronchospasm.
Heparin: is indicated in patients with artificial
valves or atrial fibrillation.
More frequent antenatal visits.

More rest.
Diet is directed to restrict weight gain and
prevent anemia as it increases cardiac strain.
Infection should be avoided and properly treated.
Hospitalisation: if signs of decompensation
occur, the earliest evidence is tachycardia exceeding
100 beats/ minute and crepitations at the lung
bases. Rest in a hospital is desirable in the last
2 weeks of pregnancy.
3. PERIPORTAL HEART DISEASE
Originate late in pregnancy in women with no

previous history of heart disease. Apparently due to
the effect of pregnancy on the circulatory
system. Late in pregnancy, the woman
develops signs of myocardial failure (SOB,
chest pain and edema)
Give diuretic and digitalis therapy.
Give low dose heparin to decrease the risk of
thromboembolism.
Promote rest.
Nursing Intervention
Assess maternal VS and cardiopulmonary status
Monitor weight gain
Encourage frequent rest periods
Assess nutritional status
Educate patient about the signs and symptoms
of infection
POST PARTAL NURSING INTEVENTIONS

Decreased activity and possibly anti coagulant and
digitalis therapy until circulation stabilizes.
Ambulation to avoid formation of emboli, wear
elastic stockings to increase venous return from the
legs.
Methylergometrine maleate must be used
with caution because they tend to increase BP
Women can breastfeed without difficulty.
Kegels exercise for perinial strengthening
Give stool softener to prevent her from straining
with bowel movements
Continue periods of adequate rest
4. CHRONIC HYPERTENSIVE
VASCULAR DSE.
Elevated BP of 140/90 above

associated with arteriosclerosis or renal dse.
Management is similar to that of Pregnancy
Induced Hypertension.
5. VENOUS THROMBOEMBOLIC DSE.

Increase incidence due to a combination of
stasis of blood in the lower extremities from
the uterine placenta and hypercoagulability.
Pressure of the fetal head at birth puts additional pressure on

LE veins actual damage occur to the walls of vessels. Triad of
effects stasis, vessel damage, hyper coagulation, the
Symptoms of pulmonary embolism
include:
chest pain,
sudden onset of dyspnea
cough with hemoptysis
tachycardia
severe dizziness
fainting.
THEAPEUTIC MANAGEMENT:
Bed rest
Heparin IV for 24 48 hrs. subcutaneous, site
for injection in lower abdomen
PT ( Partial Thromboplastin Time)
monitoring.
Administer corticosteriods to preven formation of
additional anibodies.
After pregnancy, avoid oral contraceptive
ENDOCRINE DISORDER
1.
HYPOTHYROIDISM
Difficulty increasing thyroid

functioning to a pregnancy level. Fatigues
so easily and tends to be obese; her skin is dry
and she has little tolerance for cold. Associated
with extreme nause and vomiting during
pregnancy.
Thyroxine to supplement lack of thyroid

hormone
2. HYPERTHYROIDISM
Causes the ff symptoms: rapid heart

rate, exopthalmus, heat intolerance,
nervousness, heart palpitation, wt. loss. If
undiagnosed, women may develop heart failure
during pregnancy.
THERAPUETIC MANAGEMENT:
Thiomides ( methimazole or
prophylthiouracil) to reduce thyroid activity at
the lowest dose.
Surgical removal of thyroid if the woman wishes
or desire other children.
Advise pt. not to breastfeed babies because
3. DIABETES MELLITUS
Termed gestational diabetes mellitus
(GDM) Risk factors for GDM include; obesity, age

over 30 years, hx of unexplained perinatal loss,
family hx of diabetes
Endocrine disorder in which the pancreas

is unable to produce adequate insulin to
regulate body glucose. N
THERAPEUTIC MANAGEMENT;
Nutrition therapy strict diabetic diet 1800 200
kcal diet a day.
Short acting insulin( regular) combined with
intermediate type is given 2/3 in the a.m. and
1/3 in the evening is given as dosage of insulin.
Monitor serum glucose to determine if
hyperglycemia exist once a week.
Test for placental function or fetal well being
by recording how many movements occur in an
hour.
Cesarean birth for diabetic women
MENTAL ILLNESS In
Pregnancy
SCHIZOPHRENIA
Tends to occur with pregnancy and

depression is the most common mental
illness seen in pregnancy. The woman with a
psychiatric disorder should be cared for by both
a psychiatric care team and a prenatal care
group to ensure that the stress of pregnancy is
no increasing mental illness and distorted
perceptions or depression from mental illness is
not causing complications of pregnancy.
CANCER In Pregnancy
Malignancies most commonly seen

with pregnancy: cervical , breast, ovarian,
thyroid, leukemia, melanoma,
lymphomas.
If a woman is in the 1st trimester when the

malignancy is diagnosed, she and her partner are
asked to make a difficult decision; delay
treatment to avoid teratogenic risks to a
fetus abort the pregnancy to allow for
chemotherapy or radiation treatment.
TRAUMA In Pregnancy
Trauma in women occurs at a high

incidence during the child bearing years
because, for this age group automobile
accidents, homicide and suicide are
among the three leading causes of
deaths.
LACERATION:
Bleeding
should be halted by pressure on the edge of

laceration
After cleaning area is sutured with used of anesthesia,
xylocaine.
PUNCTURE
WOUNDS:
Administer
tetanus toxoid
Fistulogram to determine the depth and extent of the
wound
X-ray determines the extent of puncture
Celiotomy or an exploratory surgical procedure into the
abdominal cavity if there is suspicious bleeding.
ANIMAL
BITES:
BLUNT ABDOMINAL TRAUMA

Diagnostic
peritoneal lavage may be done
Ultrasound
Careful
assessment that the pregnancy.

Traumatic blow to the abdomen could cause
dislodgement of the placenta.
Doppler monitoring is helpful to assure the
woman that her fetus is unharmed
Pelvic examination is usually performed.
Kleihaver Betke test to determine
presence of fetal blood cells in the maternal
GUNSHOT WOUNDS
Surgically cleaned and debrided.
Treated with high concentration of antibiotics,
Ampicillin is frequently prescribed.
Poisoning
Ipecac syrup is the best emetic to

cause vomiting and discharge poison from the
body.
CHOKING
Chest thrust instead of Heimlich
maneuver
ORTHOPEDIC INJURIES
Apply
ice to the area to decease swelling.

X-ray may be necessary to determine whether
a fracture is present. Use abdominal shield
during radiation exposure
Wearing of an immobilizer for a 6 week
therapy to the affected parts.
Bed rest for 4-6 weeks if separation of
symphysis pubis is present at the time of birth.
BURNS
Fluid
and electrolyte hydration

Assess for carbon monoxide poisoning
POST MORTEM CESAREAN BIRTH

If
pregnant woman does not survive trauma,

child is born safely by post mortem caesarian
birth if fetus is past 24 wks. And fewer that 20
minutes have passed since the mother expired.
BATTERED WOMAN
Unable
to resist sexual advances from their

abusive partner.
HIGH RISK NEWBORN &

FAMILY
ALTERED GESTATIONAL AGE OR

BIRTH WEIGHT
Small for Gestational Age
Birth wt is below 10th percentile

on an intrauterine growth curve for that
age. The infant may be born preterm,
term or post term. Infants are SGA because
they have experienced intrauterine growth
restriction (IUGR) or fail to grow at the
expected rate in utero.
CAUSE: lack of adequate

1.
Biophysical
profile: NST, placental grading
and ultrasound
Blood studies at Birth high in hematocrit level

and increase number of RBC; if hematocrit level is more than
65% - 75%, an exchange transfusion to dilute concentration
of blood may be necessary.
IV glucose to sustain blood sugar until they
are able to suck vigorously enough to take sufficient oral
feedings to combat hypoglycemia.
Closely observe both respiratory rate and

character in the first few hours of life.
Control environment to keep the infants body
temperature in a neutral zone.
2. Large for Gestational Age Infant

(MACROSOMIA)
Birth Wt. is above 90th percentile on

an intrauterine growth chart for that
gestational age.
Causes are over production of

growth hormone in utero, eg mothers with
diabetes mellitus, muliparous women, transposition of
the great vessels, Beckwiths syndrome and congenital
anomalies such as omphalocele.
THERAPEUTIC MANGEMENT:
NST
to assess the placentas ability to sustain the

large fetus during labor.
Cesarean birth may be necessary immediately to
prevent hypoglycemia.
The infant may need supplemental formula
feedings after breastfeeding to supply enough
fluid and glucose for larger than normal size for
the first few days.
PRETERM INFANT
A live born infant born before the
end of week 37 of gestation; a weight

of 2500(5lbs., 8oz.) at birth.
Infants who are born with a weight of
1,500 2,500 grams are considered low
birth weight infants
Born weighing 1000 to 1500 grams
are considered very low birth weight (VLBW)
Infants extremely very low birth
weight (EVLBW) infants are 500 -100 grams
in weight.
POTENTIAL COMPLICATIONS:
Anemia of prematurity develop a normochromic,

normolytic anemia
Kernicterus
Persistent Patent Ductus Arteriosus lack of
surfactant leads o pulmonary artery hypertension, which

interferes with the closure of Ductus Arteriosus
Periventricular/ Intraventicular Hemorrhage
bleeding into the tissue surrounding the ventricles and bleeding

into the ventricle, respectively. Capillaries rupture because of
rapid change in cerebral blood pressure, such as hypoxia,
intravenous infusion, ventilation and pneumothorax.
Other potential complications respiratory distress
syndrome, apnea, retinopathy of prematurity, apnea and
necrotizing enterocolitis.
Administer Vit. E to stimulate RBS production as
ordered
Phototherapy or exchange transfusion to prevent
kernicterus
Indomethacin to initiate closure of PDA (Patent
Ductus Arteiosus)
To prevent irreversible acidosis, infant must be
resuscitated within 2 minutes after birh
IV fluids administration to fulfill fluid requirement of
160-200cc of fluid per kg of body weight daily.
Calorie intake of 115 140 calories/kg body wt.
Gavage feeding of 1ml/hr drip feedings
Environmental temp.is controlled at 62 F- 68
POST TERM INFANT
Born after 42 weeks of
pregnancy. Fetus who remains in utero with a

failing placenta may die or develop post term
syndrome.
Non stress Test and complete biophysical

profile to establish whether the placenta is still
functioning.
Cesarean birth may be indicated.
ILLNESS IN NEWBORN
1. CAPUT SUCCEDANEUM
Is a serosanguineous,
subcutaneous, extraperiosteal fluid

collection with poorly defined margins
caused by the pressure of the presenting
part against the dilating cervix(tourniquet
effect of the cervix)
Symptoms: extends across the midline
and over suture lines and is associated
with head moulding.
Monitor
VS of the client .
A complete and fast recovery will normally occur.
If the babys scalp contour has changed, a normal
contour should be regained.
Breastfeeding
3. RESPIRATORY DISTRESS
SYNDROME/ ATELECTASIS
Hyaline membane disease, the pathologic

feature of RDS is a hyalinelike(fibrous)
membrane comprised of products formed

from an exudates of the infants blood
that lines the terminal bronchioles,
alveolar ducts and alveoli. It prevents
exchange of oxygen and carbon dioxide at the
alveolar capillary membrane.
Cause of RDS is a low level or

absence of surfactant, the phosoholipid that
normally lines the alveoli and resist suface tension on
Surfactant replacement and rescue synthetic
surfactant is sprayed into the lungs

Oxygen adminstation to correct PO2 and PH levels; CPAP
and PEEP
Ventilation@I/E ratio of 1:2
Muscle relaxants Pancuronium (pauvlon) is
administered IV
Extracorporeal Membrane Oxygenation management of
chronic sever hypoxemia a means of oxygenating the blood
during cardiac surgery
Liquid ventilation Perfluorocarbons
Nitric Oxide causes pulmonary vasodilation
Supportive care infant must be kept warm, provide
hydration and nutrition with IV fluids glucose or gavage
4. MECONIUM ASPIRATION
SYNDROME
An infant may aspirate meconium either in utero

or with the first breath after birth Meconium can
cause severe respiratory distress in 3 ways:
It can bring about inflammation of bronchioles

It can block small bronchioles by mechanical
plugging
It can cause a decrease in surfactant production
Amniotransfusion
Oxygen administration and assisted ventilation
Antibiotic therapy may be use to prevent pneumonia
Monitor increase RR and respiratory distress.
Maintain thermal neural environment
Chest physiotherapy like clapping and vibration
5. APNEA
Pause in respirations longer than 20

seconds with accompanying bradycardia
.Beginning cyanosis maybe present. High
incidence of apnea where infants with hyperbilirubinnemia,

hypoglycemia or hypothermia.
Gently shaking on infant or flicking the sole of the foot

often stimulates the baby to breath again, if does not
respond, resuscitate.
Ventilation. Record respiratory movements
Maintain a neural thermal environment and use gentle
handling to avoid excessive fatigue
NGT tubes
Careful burping
Administer Theophylline or caffeine, Na benzoate to
SUDDEN INFANT DEATH
Sudden unexplained death in

infancy. Prone to SIDS are infant of adolescence
mothers. Infants of closely spaced pregnancies.

Underweight infants and preterm infants preterm
infants twins and siblings of another child with SID
CONTRIBUTING FACTORS:
viral respiratory or botulism infection
distorted familial breathing patterns
Possible lack of surfactant in alveoli
sleeping prone rather than on the side or back
THERAPEUITC MANAGEMENT
Patient
should be counseled by a nurse

or someone else trained in counseling
at the time of infants death
Supportive organizations are available
for help.
HEMOLYTIC DISEASE OF THE

NEWBORN
THERAPEUIC MANAGEMENT
Initiation of early feeding to stimulate bowel

peristalsis and removal of bilirubin suspension of
breastfeeding Pregnanediol- the breakdown product of
progesterone, interferes with the coagulation of indirect
bilirubin is excreted in the breastmilk.
Phototherapy exposure to light apparently triggers the
liver to assume the function of the liver to process
bilirubin.
Home Phototherapy allows for interrupted contact
between the parents and potential to aid in bonding..
Exchange Transfusion umbilical vein is catheterized
and alternately withdrawing small amount of (2-10cc) of
HEMORRHAGIC DISEASE OF
NEWBORN
Deficiency of vit. K .Vit. K is

essential for the formation of prothrombin
lack of it causes impaired blood coagulation.
IM administration of 1 mg. vit K to all
newborns immediately after birth.
Handle infant with extreme gentle to
prevent further bleeding.
RETINOPATHY OF PREMAURITY
An acquired ocular disease that leads to

partial or total blindness in children, due to
vasoconstriction of immature retinal blood vessels.
High concentration of oxygen is the causative
agent.
Preterm infants with oxygen should be monitored

with pulse oximeter, oxygen saturaion or blood gas
monitoring.
Vit. E and antioxidant modifies tissue response to

the effect of oxygenation
Cryosurgery therapy to preserve light.
NEWBORN AT RISK BECAUSE OF

MATERNAL INFECTIONS/ILLNESS
Maternal
infection newborn appears ill@

birth or becomes ill shortly after birth usually
screened by a TORSCH assay, which test for the
presence of antibodies to toxoplasmosis rubella,
syphilis, cyomegalovirus, and herpes organisms.
BETAHEMOLYTIC GROUP B STREPTOCOCCAL

INFECTIONS
Group B streptococcal organisms are

gram (+) bacterium and a natural inhabitant of
Good hand washing technique before handling newborns.
Antibiotic therapy
Immunization of women against streptococcal B decrease
the incidence of infection
Congenital rubella
Cause extensive congenital fetal malformations if mother is

infected during the 1st trimester of pregnancy
Culture live rubella virus from nasopharyngeal
secretions of affected infants at birth
Follow contact precautions when caring for infected newborn
Rubella vaccine to sure that rubella infection does not
occur with future pregnancy
OPHALMIA NEONATORUM
Eye infection at birth during the 1st montth

of life. The most common causative organisms
include NEISSERIA GONORRHEA or CHLAMYDIA
TRACHOMATIS . The infant contacts the organisms
during vaginal birth.
If gonococci are identified, IV ceftriaxone and
penicillin are effective drugs
If Chlamydia is identified an opthalmic solution of
erythromycin is used
Eyes are irrigated with sterile saline solution to
clear the copious decidum.
Generalized herpes virus infection
Acyclovir
drugs that inhibit viral

deoxyribonucleic acid synthesis, are effective
in combating herpes simplex virus
Prevention is the newborns best protection
Cesarean birth to minimize the newborns
exposure
Mother and health care personnel who have
herpes simplex infection must not care for
newborn infants until lesions are crusted.
HEPA B VIRUS INFECTION (HBV)
Transmitted to the newborn infant through

contact with in feced vaginal blood at birth when the
mother is positive for the virus.
Infant is administered immune serum
immunoglobulin within 12h of birth to decrease the
possibility of infection
Infant should be bathed as soon as possible after
birth to remove HBV infected blood and secretions
Suctions should be gentle technique to possible trauma
to the mucous membrane
Once immunoglobilin has been administered, women may
breastfeed without risk to the infant.
INFANT OF DIABETIC MOTHER
Typically longer and weighs more than

other babies. Greater chance of congenital
anomaly such as cardiac defect. Caudal regression
syndrome or hypoplasia of the LE is a syndrome
that occurs almost exclusively in such infants.
IDM infants are fed early with formula or
administered a continuous infusion of glucose to
avoid serum glucose level to fall down.
Some IDM infants have a small left colon, which
limits the amount of oral feedings they can take in
their first days of life.
INFANT OF DRUG DEPENDENT

MOTHER
Tends too be small for

gestational stage. Infant will show
withdrawal symptoms ( neonatal abstinence
syndrome) w/c include irritability, disturbed sleep
patterns, tremors, frequent sneezing, shrill, high pitched
cry, convulsions, tachypnea, vomiting and diarrhea.
Therapeutic Management:
Assess infants status with neonatal abstinence

scoring
Firmly swaddle the infant for comfort
Infants should be kept in an environment free

from excessive stimuli
Give infant a pacifier
Gavage Feeding
Breastfeeding is encouraged, regardless of the
drugs that have been taken by the mother.
Parents are expected and will be encouraged
to spend as much time as possible with their
baby.
INFANT WITH FETAL

ALCOHOL SYNDROME
Alcohol crosses the placenta in the

same concentration or is present in the maternal
blood stream. Possible problems at birth which
are characterized by marked syndrome such as pre
and post natal growth restriction; CNS involvement like
cognitive impairment, microcephaly and cerebral palsy; and
facial features like a short palpebral fissures and a thin
upper lip.
During the neonatal period, the
infant may be tremolous, fidgety, irritable and may
demonstrate a weak sucking reflex.
THERAPEUIC MANAGEMENT
There is no cure for FAS, because the CNS
damage creates a permanent disability, but
treatment is possible because CNS damage,
symptoms, secondary disabilities, and needs vary
widely by individual though, there is no one
treatment type that works for everyone.
Advise pregnant women to avoid alcohol
intake to prevent any tetralogenic effects on their
newborn
Monitoring of infant status. Laboratory test.
Medical interventions (i.e., psychoactive
drugs) are frequently tried on those with FAS because
ACUTE RENAL FAILURE
A sudden and almost complete loss

of kidney function associated with an
accumulation of nitrogenous waste in the
blood) that is not due to extra renal factors. It
can be acute or chronic; the acute syndrome unlike the
chronic syndrome is usually reversible. The creatinine
clearance drops suddenly.
Prepare
patient for dialysis

Monitor I&O and check for V/S q4h, weigh daily
Diet : high calorie, low protein diet.
Monitor
fluids and electrolytes and acids

and bases
Monitor cardiac status
Administer drug to control symptoms as
ordered.
NaHCO3, sodium lactate or sodium
acetate to correct metabolic acidosis
Dopamine hydrochloride to activate dopamine
receptors in the kidney
Sorbitol an osmotic cathartic to eliminate potassium
ions.
END STAGE RENAL DISEASE
A slow insidious and

irreversible impairment of renal
function. Nephrons are permanently
destroyed by various processes that occur
in the course of renal dse.
An excessive amount of
nitrogenous waste (BUN, creatinine)
accumulate in the blood, the kidneys are
unable to maintain homeostasis.
Chronic Renal failure progresses in 3
stage
1.
2.
3.
4.
5.
6.
Institute dialytic therapy.

Administer medications as ordered:
Calcium preparation and phosphorous binders to
promote bone mineralization by increasing intestinal
absorption of calcium.
Antihypertensive drugs ACE inhibitors and calcium
channel blockers
Diuretics stimulate excretion of water by the kidney
Vitamins and mineral
Sodium bicarbonate use to correct metabolic
acidosis
Erythropoietin hormone produces in kidney that
stimulates RBC production
Diet
regulate intake of Na, K, Ca
Monitor
fluids and electrolyte.
HEPATIC COMA
A
.K.A. Liver Encephalopathy
disorder in which brain function
deteriorates because of toxic

substances normally removed by
the liver build up in the blood. Many
of these toxins are normally breakdown

products of the digestion of protein but in
liver encephalopathy toxins are not removed
because liver function is impaired.
Nursing Management
Assess precipitating factors that cause deterioration in

brain function such as an infection or a drug that the patient
is taking
Restrict intake of food high in protein
Encourage to use vegetable protein rather than animal

protein for protein balance without worsening the
encephalopathy
Administer lactulose, as ordered lactulose is a synthetic
sugar, taken by mouth has beneficial effect.
IT ALTERS THE ACIDITY OF THE INTESTINES

ACTS AS LAXATIVE WHICH TENDS TO SPEED UP PASSAGE OF
FOOD THROUGH THE INTESTINES
HELPING DECREASE THE AMMONIA.
Administer
Neomycin, it reduces the quantity of intestinal
THE END.
cj
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Abc Ob 2010

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ACUTE BIOLOGIC

At the end of the lecture-discussion the

complications of pregnancy that

High Risk Pregnancy

The babys slowly growing inside

A) HIGH RISK PREGNANT CLIENT

C) HIGH RISK NEWBORN AND

NURSING HISTORY WHICH

RESPONSILBILITIES OF PRE AND

When pregnant female comes to you, you should ask:

observing the client, evaluate:

OTHER ASSESSMENT PARAMETERS

signs taking especially BP

exam empty the bladder first

Assessment of Fetal Health

patient properly for test

Kick Count Assessment Tool

Conditions During Pregnancy

Conditions During Pregnancy

Almost all women report increased fatigue in the 1st

Conditions During Pregnancy

HIGH RISK PREGNANCY

one in which concurrent disorder,

A. HIGH RISK PREGNANCY

HIGH RISK PREGNANCY

Causes and Complications

Precipitating factor for placental

Depletion of nutritional reserves due

Causes and Complications

Adolescent is a developmental crisis,

Trisomy 21 commonly associated with

Risk increases from gravida 5 and

Causes and Complications

Subsequent pregnancy within 3

Pre pregnant weight of less than 70lbs

A primi of short stature less than 4ft

QUESTIONS TO BE ASK DURING

Have you had any problem

QUESTIONS TO BE ASK DURING

Have you had any

Have you had difficulty

QUESTIONS TO BE ASK DURING

Have you ever had

Do you take drugs?

History taking as part of

data- clients name, age, address,

Danger signs of Pregnancy

bleeding no matter how slight

Danger signs of Pregnancy

High blood pressure in pregnancy (PIH)

Toxemia old terminology

Cause of disorder s till unknown. PIH tends to occur

over 140/90 or an increase of 30

May be mild or severe

Higher incidence in low

Higher incidence with

Goal of Medical Management

Dietary Approach : supplementation with calcium,

Complete bed rest

Blood pressure should be determined q1 to q4 hours.

During placental separation pt should be

Example of Nursing Diagnosis