Maternal & Child Health in the Philippines: Risks, Indicators & Solutions

National Health Situation National Health Situation
Maternal & Child Health Maternal & Child Health

Prepared by: Prepared by:
Rhenier S. Ilado RN Rhenier S. Ilado RN
Introduction Introduction
Pregnancy poses a risk to the liIe oI every woman. Some Pregnancy poses a risk to the liIe oI every woman. Some
pregnancies are riskier than the others. Woman who have co pregnancies are riskier than the others. Woman who have co- -
existing health problems as diabetes ,anemia, malaria etc. are existing health problems as diabetes ,anemia, malaria etc. are
more likely to develop complications. Healthy women can also more likely to develop complications. Healthy women can also
suIIer Irom complications. suIIer Irom complications.
It also poses a risk to babies. Complication and other health It also poses a risk to babies. Complication and other health
problems oI the woman can harm babies too. problems oI the woman can harm babies too.
eath and disabilities Irom pregnancy can be eath and disabilities Irom pregnancy can be
prevented or treated. These can be achieved by a prevented or treated. These can be achieved by a
combination oI interventions. combination oI interventions.
Family Planning can help avoid and prevent Family Planning can help avoid and prevent
unplanned too early, too late, too close, too sickly unplanned too early, too late, too close, too sickly
and too many pregnancies particularly among very and too many pregnancies particularly among very
high risk women. high risk women.
"uality prenatal, delivery and postpartum "uality prenatal, delivery and postpartum
services can prevent complications, detect services can prevent complications, detect
problems early and allow prompt treatment problems early and allow prompt treatment
and management, mobilizing communities and and management, mobilizing communities and
local government will help improve the status local government will help improve the status
oI women who needed care. oI women who needed care.

Improve the survival, health and well Improve the survival, health and well
being of mothers and the unborn being of mothers and the unborn
through a package of services for the: through a package of services for the:
pre pre- -pregnancy pregnancy
prenatal prenatal
natal natal
postnatal stages postnatal stages
\crc |rc .c no. \crc |rc .c no.
Population of over Population of over 80 million 80 million will double in 30 will double in 30
years at current growth rate of years at current growth rate of 2.36 2.36
Rice production in 2002 grew by an average of Rice production in 2002 grew by an average of
only only 1.9 1.9 -- -- more hungry people competing for a more hungry people competing for a
decreasing volume of rice decreasing volume of rice
,
It is the It is the poorest Filipinos poorest Filipinos
(57.1) who are not using (57.1) who are not using
family planning because of family planning because of
poor access and ineffective poor access and ineffective
outreach outreach
20.5 of married women say 20.5 of married women say
they need family planning they need family planning but but
are not using any method are not using any method
The Iack of famiIy pIanning
pIaces a disproportionate
burden on the poor.
\crc |rc .c no. \crc |rc .c no.
,
Situationer Situationer
%he Philippine Situation %he Philippine Situation
J.1 mIllIon pregnancIes occur each year. Half of these pregnancIes are J.1 mIllIon pregnancIes occur each year. Half of these pregnancIes are
unIntended and one thIrd ends In abortIon unIntended and one thIrd ends In abortIon
About 4ZJ,000 cbortons cnnuclly wth nduced cborton cs 4th About 4ZJ,000 cbortons cnnuclly wth nduced cborton cs 4th
lecdny ccuse o] mcterncl decths lecdny ccuse o] mcterncl decths
10 mothers dIe everyday due to chIldbIrth and pregnancy related 10 mothers dIe everyday due to chIldbIrth and pregnancy related
complIcatIons complIcatIons
Every mom who dIes leaves J orphans. n effect, J0 chIldren are orphaned Every mom who dIes leaves J orphans. n effect, J0 chIldren are orphaned
every day every day
%he Philippine Situation %he Philippine Situation
W W nly 25.1 of bIrths In poorest quIntIle were delIvered nly 25.1 of bIrths In poorest quIntIle were delIvered
by a professIonal attendant compared to 92.4 of the by a professIonal attendant compared to 92.4 of the
rIchest quIntIle (200J N0HS) rIchest quIntIle (200J N0HS)
!oor women are not consIstently able to access !oor women are not consIstently able to access
servIces. nly 1.7 have delIvered by caesarean servIces. nly 1.7 have delIvered by caesarean
sectIon. sectIon.
W W %# Is hIghest among the poor %# Is hIghest among the poor
Fertility Rate Fertility Rate
Wealth status Wealth status
Low Low Second Second Middle Middle Fourth Fourth High High Total Total
(In percent) (In percent)
Total Iertility rate Total Iertility rate
(Average number oI (Average number oI
children) children) 5.9 5.9 4.6 4.6 3.5 3.5 2.8 2.8 2.0 2.0 3.5 3.5
Wanted Iertility rate Wanted Iertility rate
(PreIerred number oI (PreIerred number oI
children) children) 3.8 3.8 3.1 3.1 2.6 2.6 2.2 2.2 1.7 1.7 2.5 2.5
%FR is highest among the poor . %FR is highest among the poor .
Source: NSO and ORC Macro, $, 2003
SI%&%INER SI%&%INER
Population Population - - 86 M 86 M
nnual rowth Rate nnual rowth Rate - - 2.36 2.36
Fertility Rate Fertility Rate - - 3.6 urban; 4 rural 3.6 urban; 4 rural
Maternal Mortality Rate Maternal Mortality Rate
- - 162 / 100,000 live births 162 / 100,000 live births
Infant Mortality Rate Infant Mortality Rate
- - 29/1,000 live births 29/1,000 live births
haternaI hortaIIty Pate
20
172
162
52.2
20
172
162
13.6
0
25
50
75
100
125
150
175
200
225
250
13 18 2006 2015
Year
h
h
P
h0C CoaI ActuaI Trend
aternaI ortaIity Ratio
Note: To show progress of MMR based on MDG, UNFPA estimated MMR based on the
average rate of progress in 2003.
Health Indicators Health Indicators
Selected Selected Asian Countries Asian Countries
Japan Japan
So.Korea So.Korea
Malaysia Malaysia
Thailand Thailand Philippines Philippines
LiIe Expectancy LiIe Expectancy 81 81 75 75 73 73 70 70 70 70
InIant Mort. InIant Mort.
Rate Rate
33 55 88 24 24 29 29
UnderIivemortal UnderIivemortal
ity ity
55 55 88 28 28 40 40
Maternal Maternal
Mortality Mortality
88 20 20 41 41 44 44 160 160
Population Population
Growth Growth
0.3 0.3 0.8 0.8 2.2 2.2 1.4 1.4 2.3 2.3
Situationer.. Cont. Situationer.. Cont.
Contraceptive Prevalence Rate Contraceptive Prevalence Rate- - 49.3 49.3
%he top 5 most commonly used FP Methods: %he top 5 most commonly used FP Methods:
Pills Pills
B% B%
Calendar Calendar
Withdrawal Withdrawal
I& I&
Basic ata Basic ata
Poor women have 3x more children Poor women have 3x more children
Poor women are more likely to start sexual activity, get Poor women are more likely to start sexual activity, get
married and have children the earliest married and have children the earliest
Closely Closely- - spaced pregnancies higher among young mothers. spaced pregnancies higher among young mothers.
Less educated, poor rural males are more likely to become Less educated, poor rural males are more likely to become
Iathers early Iathers early
Husbands preIer more children than their wives. Husbands preIer more children than their wives.
On the average, women want 3 children On the average, women want 3 children
How are our mothers? How are our mothers?
360,000 pregnancies experienced obstetrical complications that 360,000 pregnancies experienced obstetrical complications that
require hospitalization. require hospitalization.
Roughly, 10 women die every 24 hrs. Irom causes related to Roughly, 10 women die every 24 hrs. Irom causes related to
pregnancy and childbirth pregnancy and childbirth
3,650 maternal deaths / year.. most are in the rural areas. 3,650 maternal deaths / year.. most are in the rural areas.
7 out oI 10 deaths occur during labor or within 1 day aIter delivery. 7 out oI 10 deaths occur during labor or within 1 day aIter delivery.
473,000 unsaIe abortions take place every year 473,000 unsaIe abortions take place every year
37.9
9.
44.8
29.1
25.7
49.4
45.8
15.7
21.9
20.7
39.8
33.4
15.
28.9
41.0
23.1
2.1
10.7
|rths 0e||vered |n a hea|th Fac|||ty, by Reg|on: 2003 |rths 0e||vered |n a hea|th Fac|||ty, by Reg|on: 2003
!ercent
n Central Visayas, only four in 10 births occurs in a health
facility. The national average is less than four in every 10
births, which is also very low by WHO standards.
Phil NCR CAR R1 R2 R3 R4A R4B R5 R6 R7 R8 R9 R10 R11 R12Caraga ARMM
70 70 of births were delivered of births were delivered
in the in the home home
Hospital
27
Home
70
thers
3
59.8
87.9
59.
74.2
53.2
85.8
74.7
29.3
21.9
3.0
8.3
47.4
31.0
41.0
47.
37.2
42.5
21.7
|rths 0e||vered w|th Ass|stance from hea|th Profess|ona|s*, by Reg|on: 2003 |rths 0e||vered w|th Ass|stance from hea|th Profess|ona|s*, by Reg|on: 2003
!ercent
Cerlra| v|sayas |s arorg lre reg|ors W|lr r|grer percerlage |r
lerrs ol o|rlr de||very ass|slarce oy rea|lr proless|ora|s.
eaIth !rofessionaIs (Doctors,
idwives and Nurses)
Phil NCR CAR R1 R2 R3 R4A R4B R5 R6 R7 R8 R9 R10 R11 R12 Caraga ARMM
others
1
%raditional Birth
ttendant
39
Nurse
1
octor
33
Midwife
26
nly 60 of births were attended by a nly 60 of births were attended by a
health care proIessional health care proIessional
Source: $!N$, !hiIippines 2002
Why do women die? Why do women die?
Complications related to pregnancy occurring in the course Complications related to pregnancy occurring in the course
oI labor, delivery and puerperium.( obstructed labor, oI labor, delivery and puerperium.( obstructed labor,
inIection) inIection)
Hypertension complicating pregnancy, childbirth, and Hypertension complicating pregnancy, childbirth, and
puerperium( eclampsia etc.) puerperium( eclampsia etc.)
Postpartum Hemorrhage due to uterine atony, placental Postpartum Hemorrhage due to uterine atony, placental
retention retention
Pregnancy with abortive outcome Pregnancy with abortive outcome
Hemorrhage related to pregnancy ( ectopic pregnancy, Hemorrhage related to pregnancy ( ectopic pregnancy,
placenta previa etc.) placenta previa etc.)
7 irect bstetric Complications 7 irect bstetric Complications
Hemorrhage ( Hemorrhage (antepartum antepartum / postpartum) / postpartum)
Prolonged / Obstructed labor Prolonged / Obstructed labor
Postpartum sepsis Postpartum sepsis
Complications oI abortion Complications oI abortion
Pre Pre- -eclampsia / Eclampsia eclampsia / Eclampsia
Ectopic pregnancy Ectopic pregnancy
Ruptured uterus Ruptured uterus
High Risk Pregnancy High Risk Pregnancy
Is one in which a concurrent disorder, pregnancy Is one in which a concurrent disorder, pregnancy- -related related
complication, or external Iactor jeopardizes the health oI the complication, or external Iactor jeopardizes the health oI the
mother, the Ietus, or both mother, the Ietus, or both
Some women enter pregnancy with a chronic illness that, Some women enter pregnancy with a chronic illness that,
when superimposed on the pregnancy, makes it high risk when superimposed on the pregnancy, makes it high risk
Other women enter pregnancy in good health but then develop Other women enter pregnancy in good health but then develop
a complication oI pregnancy that causes it to become high risk. a complication oI pregnancy that causes it to become high risk.
Factors that Categorize a Pregnancy as High Risk Factors that Categorize a Pregnancy as High Risk
. Pre . Pre- -Pregnancy Pregnancy
Psychological Social Physical
a. history oI drug dependence
b. History oI mental illness
c. History oI poor coping
mechanism
a. Occupation handling oI
toxic substances
b. Environmental
contaminants at home
c. Isolated
d. Lower economic level
e. Poor access to
transportation Ior care
I. Poor housing
g. Lack oI support people
a. Visual or hearing
challenges
b. Pelvic inadequacy (CP)
c. Secondary major illness
(heart disease, M, kidney
disease, hypertension etc.)
d. Poor gynecologic or
obstetric history
e. History oI previous poor
pregnancy
outcome(miscarriage,
stillbirth, intrauterine Ietal
death)
I. Pelvic inIlammatory
disease
g. Obesity
h. Small stature
i. Younger than age 18
years or older than 35 years
j. Cigarette smoker
k. Substance abuse
B. Pregnancy B. Pregnancy
a. Loss oI support
b. Illness oI a Iamily
member
c. ecrease selI-esteem
d. Poor acceptance oI
pregnancy
a. ReIusal oI or neglected
prenatal care
b. Exposure to
environmental teratogens
c. ecreased economic
support
d. Conception less than 1
year aIter last pregnancy or
pregnancy within 12
months oI the Iirst
pregnancy
a. Intake oI teratogen
b. Multiple gestation
c. Poor placental Iormation
or position
d. Gestational diabetes
e. Nutritional deIiciency
I. Poor weight gain
g. PIH
h. InIection
i. Amniotic Iluid
abnormality
j. post maturity
C. abor and elivery C. abor and elivery
a. Severely Irightened by
labor and delivery
experience
b. Inability to participate
due to anesthesia
c. Lack oI preparation Ior
labor
d. Birth oI inIant who is
disappointing in some
way
a. Lack oI support person
b. Unplanned CS
c. Lack oI access to
continued health care
d. Lack oI access to
emergency personnel or
equipment
a. Hemorrhage
b. InIection
c. ystocia
d. Precipitate birth
e. Lacerations oI cervix or
vagina
I. CP
h. Retained placenta
HIH RISK PRENNCY: HIH RISK PRENNCY: %he Woman who %he Woman who
develops a Complication of pregnancy develops a Complication of pregnancy
. . Bleeding during Pregnancy: Bleeding during Pregnancy:
- - vaginal bleeding is a deviation Irom the normal vaginal bleeding is a deviation Irom the normal
that may occur at any time during pregnancy that may occur at any time during pregnancy
- - a woman with any degree oI bleeding needs to be a woman with any degree oI bleeding needs to be
evaluated Ior the possibility oI blood loss and hypovolemic evaluated Ior the possibility oI blood loss and hypovolemic
shock. shock.
- - signs oI hypovolemic shock occurs when 10 oI signs oI hypovolemic shock occurs when 10 oI
blood volume or approximately two units oI blood, have been blood volume or approximately two units oI blood, have been
lost; Ietal distress occurs when 25 oI blood volume is lost lost; Ietal distress occurs when 25 oI blood volume is lost
Signs and symptoms of Hypovolemic Shock Signs and symptoms of Hypovolemic Shock
1. increased pulse rate 1. increased pulse rate
2. decreased blood pressure 2. decreased blood pressure
33. increased respiratory rate . increased respiratory rate
4. cold, clammy skin 4. cold, clammy skin
5. decreased urine output 5. decreased urine output
6. dizziness or decreased level of consciousness 6. dizziness or decreased level of consciousness
7. decreased central venous pressure 7. decreased central venous pressure
The Process oI The Process oI SHCK SHCK due to blood loss (hypovolemia): due to blood loss (hypovolemia):
B SS B SS
ecreased intravascular volume ecreased intravascular volume
ecreased venous return, decreased cardiac output, and lowered blood ecreased venous return, decreased cardiac output, and lowered blood
pressure pressure
Body compensating by increasing heart rate to circulate the decreased Body compensating by increasing heart rate to circulate the decreased
volume Iaster; volume Iaster;
Vasoconstriction oI peripheral vessels Vasoconstriction oI peripheral vessels
Increased respiratory rate and a Ieeling oI apprehension at body changes Increased respiratory rate and a Ieeling oI apprehension at body changes
also occur also occur
Cold, clammy skin, decreased uterine perIusion. In the Iace oI Cold, clammy skin, decreased uterine perIusion. In the Iace oI
continued blood loss, although the body shiIts Irom interstitial continued blood loss, although the body shiIts Irom interstitial
spaces into intravascular spaces, blood pressure will continue spaces into intravascular spaces, blood pressure will continue
to Iall to Iall
Reduced renal, uterine and brain perIusion Reduced renal, uterine and brain perIusion
Lethargy, coma, decreased renal output Lethargy, coma, decreased renal output
Renal Iailure Renal Iailure
Maternal and fetal death Maternal and fetal death

CNI%INS SSCI%E WI%H CNI%INS SSCI%E WI%H
FIRS% FIRS%- - %RIMES%ER BEEIN: %RIMES%ER BEEIN:
- - two most common causes of bleeding during the first trimester two most common causes of bleeding during the first trimester
are bortion and ectopic Pregnancy are bortion and ectopic Pregnancy
A. A. MISCARRIACE/ABOR1IOA MISCARRIACE/ABOR1IOA
1. Spontaneous Abortion 1. Spontaneous Abortion
- - abortion (deIined as any interruption oI pregnancy beIore the age oI viability) abortion (deIined as any interruption oI pregnancy beIore the age oI viability)
- - when the interruption occurs spontaneously, it is clear to reIer to it as a when the interruption occurs spontaneously, it is clear to reIer to it as a
MISCARRIAGE MISCARRIAGE
- - when pregnancy is medically or surgically interrupted, this is typically when pregnancy is medically or surgically interrupted, this is typically
termed as ABORTION termed as ABORTION
- - stage oI viability ( a stage when the Ietus is capable oI surviving outside the stage oI viability ( a stage when the Ietus is capable oI surviving outside the
uterus, more than 20 uterus, more than 20- - 24 weeks) 24 weeks)
- - occurs in 15 to 30 oI all pregnancies and occurs in 15 to 30 oI all pregnancies and
occurs Irom natural causes occurs Irom natural causes
- - a spontaneous miscarriage is an early a spontaneous miscarriage is an early
miscarriage iI it occurs week 16 oI pregnancy miscarriage iI it occurs week 16 oI pregnancy
and a late miscarriage iI it occurs between and a late miscarriage iI it occurs between
weeks 16 and 24. weeks 16 and 24.
- - its presenting symptoms is almost always its presenting symptoms is almost always
vaginal spotting vaginal spotting
Causes: Causes:
- - the most Irequent cause oI miscarriage in the Iirst trimester oI the most Irequent cause oI miscarriage in the Iirst trimester oI
pregnancy is abnormal Ietal Iormation, due to either to a teratogenic pregnancy is abnormal Ietal Iormation, due to either to a teratogenic
Iactor or to chromosomal aberration Iactor or to chromosomal aberration
- - implantation abnormalities. Approximately 50 oI zygotes are implantation abnormalities. Approximately 50 oI zygotes are
never implanted never implanted
- - corpus luteum Iails to produce enough progesterone to maintain corpus luteum Iails to produce enough progesterone to maintain
the deciduas basalis the deciduas basalis
- - inIection ( inIection (i.e i.e rubella, syphilis, poliomyelitis, cytomegalovirus rubella, syphilis, poliomyelitis, cytomegalovirus
and toxoplasmosis inIections readily cross the placenta and possibly and toxoplasmosis inIections readily cross the placenta and possibly
causing Ietal death causing Ietal death
- - ingestion oI teratogenic drug ingestion oI teratogenic drug
2. %hreatened bortion 2. %hreatened bortion

- - is maniIested by vaginal bleeding, initially beginning as is maniIested by vaginal bleeding, initially beginning as
scant bleeding and usually bright red. There may be slight scant bleeding and usually bright red. There may be slight
cramping, but no cervical dilatation is present on vaginal cramping, but no cervical dilatation is present on vaginal
examination. examination.
- - limiting activity to no strenuous activity Ior 24 limiting activity to no strenuous activity Ior 24- -48 hours is 48 hours is
the key intervention to stop vaginal bleeding. complete bed rest is the key intervention to stop vaginal bleeding. complete bed rest is
usually not indicated usually not indicated
- - coitus is usually restricted Ior 2 weeks aIter the bleeding coitus is usually restricted Ior 2 weeks aIter the bleeding
episode to prevent inIection and to avoid inducing Iurther bleeding episode to prevent inIection and to avoid inducing Iurther bleeding
3. Imminent (Inevitable) bortion 3. Imminent (Inevitable) bortion
- - it happens with uterine contraction, cramping and cervical it happens with uterine contraction, cramping and cervical
dilatation dilatation
- - the loss oI the products oI conception cannot be halted because the loss oI the products oI conception cannot be halted because
oI cervical dilatation oI cervical dilatation
- - instruct the mother to save tissue Iragments that has passed and instruct the mother to save tissue Iragments that has passed and
bring to the clinic to be examined bring to the clinic to be examined
- - the physician may perIorm & C (dilatation and curettage) to the physician may perIorm & C (dilatation and curettage) to
ensure that all products oI conception are removed, preventing ensure that all products oI conception are removed, preventing
Iurther complication such as inIection Iurther complication such as inIection
- - aIter & C the woman is advised to record the number oI aIter & C the woman is advised to record the number oI
pads used to assess Ior heavy bleeding pads used to assess Ior heavy bleeding
4. Complete bortion 4. Complete bortion
- - the entire products oI conception (Ietus, the entire products oI conception (Ietus,
membranes and placenta) are expelled membranes and placenta) are expelled
spontaneously without any assistance spontaneously without any assistance
- - the bleeding usually slows within 2 hours and the bleeding usually slows within 2 hours and
then ceases within a Iew days aIter passage oI the then ceases within a Iew days aIter passage oI the
products oI conception products oI conception
5. Incomplete bortion 5. Incomplete bortion
- - part oI the conceptus (usually the Ietus) is part oI the conceptus (usually the Ietus) is
expelled, but the membranes or placenta is expelled, but the membranes or placenta is
retained in the uterus retained in the uterus
- - the physician will usually perIorm a & the physician will usually perIorm a &
C or a suction curettage to evacuate the C or a suction curettage to evacuate the
remainder oI the pregnancy Irom the uterus remainder oI the pregnancy Irom the uterus
6. Missed bortion 6. Missed bortion
- - commonly reIerred to as early pregnancy Iailure, the Ietus dies in commonly reIerred to as early pregnancy Iailure, the Ietus dies in
the utero but is not expelled the utero but is not expelled
- - a sonogram can establish that the Ietus is dead. OIten the embryo a sonogram can establish that the Ietus is dead. OIten the embryo
actually died 4 actually died 4- -6 weeks beIore the onset oI miscarriage symptoms. AIter 6 weeks beIore the onset oI miscarriage symptoms. AIter
the sonogram, a & C most commonly will be done the sonogram, a & C most commonly will be done
- - iI the pregnancy is over 14 weeks, labor may be induced by a iI the pregnancy is over 14 weeks, labor may be induced by a
prostaglandin suppository or Misoprostol (Cytotec) to dilate the cervix, prostaglandin suppository or Misoprostol (Cytotec) to dilate the cervix,
Iollowed by oxytocin administration Iollowed by oxytocin administration
- - IC (disseminated intravascular coagulation), coagulation deIect, IC (disseminated intravascular coagulation), coagulation deIect,
may develop iI the dead Ietus remains tool long in utero may develop iI the dead Ietus remains tool long in utero
7. Recurrent Pregnancy oss 7. Recurrent Pregnancy oss
- - commonly reIerred to as habitual abortion commonly reIerred to as habitual abortion
- - 3 or more consecutive pregnancies result in miscarriage 3 or more consecutive pregnancies result in miscarriage
usually related to incompetent cervix. usually related to incompetent cervix.
- - Management Management (suture oI cervix) (suture oI cervix)
Mconald procedure Mconald procedure
Temporary Circlage Temporary Circlage
Side eIIect Side eIIect inIection inIection
May have NS May have NS
Shirodkar Shirodkar
CS delivery CS delivery
Mconald Procedure Mconald Procedure - - Cervical Cerclage Cervical Cerclage
Complication of bortion: Complication of bortion:
1. Hemorrhage 1. Hemorrhage
- - a woman who develops IC has a major possibility Ior a woman who develops IC has a major possibility Ior
hemorrhage hemorrhage
1. iI excessive vaginal bleeding is occurring, immediately position the 1. iI excessive vaginal bleeding is occurring, immediately position the
woman Ilat and massage the uterine Iundus to aid contraction woman Ilat and massage the uterine Iundus to aid contraction
2. monitor vital signs Ior changes to detect possible hypovolemic shock 2. monitor vital signs Ior changes to detect possible hypovolemic shock
3. a BT may be necessary to replace blood loss 3. a BT may be necessary to replace blood loss
4. instruct the woman on how much bleeding is abnormal (more than one 4. instruct the woman on how much bleeding is abnormal (more than one
sanitary pad per hour is excessive), what color changes she should expect in sanitary pad per hour is excessive), what color changes she should expect in
bleeding (gradually changing to a dark color and then to the color oI serous bleeding (gradually changing to a dark color and then to the color oI serous
Iluid) and any unusual odor or passage oI large clots is also abnormal Iluid) and any unusual odor or passage oI large clots is also abnormal
. Infection . Infection
- - the possibility oI inIection is minimal when pregnancy loss the possibility oI inIection is minimal when pregnancy loss
occurs a short period, bleeding is selI limiting and instrumentation is limited occurs a short period, bleeding is selI limiting and instrumentation is limited
1. educate the woman about the danger signs oI inIection, such as Iever, 1. educate the woman about the danger signs oI inIection, such as Iever,
abdominal pain or tenderness and a Ioul smelling discharge abdominal pain or tenderness and a Ioul smelling discharge
2. organism responsible Ior inIection aIter miscarriage is usually 2. organism responsible Ior inIection aIter miscarriage is usually
Escherichia Coli (E Coli) Escherichia Coli (E Coli)
3. caution the woman to wipe the perineal area Irom Iront to back aIter 3. caution the woman to wipe the perineal area Irom Iront to back aIter
voiding and particularly aIter deIecation to prevent the spread oI bacteria Irom voiding and particularly aIter deIecation to prevent the spread oI bacteria Irom
rectal area rectal area
4. caution the woman not to use tampons to control vaginal discharge 4. caution the woman not to use tampons to control vaginal discharge
because stasis oI any blood increases the risk oI inIection because stasis oI any blood increases the risk oI inIection
. Isoimmunization . Isoimmunization
- - happens when the mother` s blood is Rh negative, while happens when the mother` s blood is Rh negative, while
the Ietus is Rh positive. the Ietus is Rh positive.
- - aIter spontaneous abortion or & C. some Rh positive aIter spontaneous abortion or & C. some Rh positive
Ietal blood may enter the maternal circulation and mother will Ietal blood may enter the maternal circulation and mother will
develops antibodies against Rh positive Ietus blood. develops antibodies against Rh positive Ietus blood.
- - during the succeeding pregnancies when the Ietus is Rh during the succeeding pregnancies when the Ietus is Rh
positive again, those antibodies would attempt to destroy the Ietus positive again, those antibodies would attempt to destroy the Ietus
RBC RBC
- - so aIter miscarriage, because the blood oI the Ietus is not so aIter miscarriage, because the blood oI the Ietus is not
known, all women with Rh negative blood should receive known, all women with Rh negative blood should receive Rhogam Rhogam
(Rh Immune lobulin) (Rh Immune lobulin) to prevent the build up oI Rh antibodies to prevent the build up oI Rh antibodies
. Powerlessness . Powerlessness
- - sadness and grieI over the loss or a sadness and grieI over the loss or a
Ieeling that she has lost control oI her liIe is to be Ieeling that she has lost control oI her liIe is to be
expected expected
- - emotional support emotional support
Procedures &sed in Pregnancy %ermination Procedures &sed in Pregnancy %ermination
. Vacuum Curettage . Vacuum Curettage
- - aka. Vacuum aspiration aka. Vacuum aspiration
- - cervical dilation Iollowed by controlled suction through a cervical dilation Iollowed by controlled suction through a
plastic cannula to remove all products oI conception plastic cannula to remove all products oI conception
- - used Ior Iirst trimester abortions, also used to remove used Ior Iirst trimester abortions, also used to remove
remaining products oI conception aIter spontaneous remaining products oI conception aIter spontaneous
abortion abortion
- - local anesthesia oI the cervix is needed local anesthesia oI the cervix is needed
B. ilatation and Curettage B. ilatation and Curettage - - aka. ilatation and aka. ilatation and
Evacuation Evacuation
- - dilation oI cervix Iollowed by gentle scraping oI the dilation oI cervix Iollowed by gentle scraping oI the
uterine walls to remove products oI conception uterine walls to remove products oI conception
- - Used Ior Iirst Used Ior Iirst- -trimester abortions and to remove all trimester abortions and to remove all
products oI conception aIter spontaneous abortions products oI conception aIter spontaneous abortions
- - Greater risk oI cervical or uterine trauma and excessive Greater risk oI cervical or uterine trauma and excessive
blood loss blood loss
- - local anesthesia or general anesthesia is needed local anesthesia or general anesthesia is needed
Nursing Care of Clients with bortion Nursing Care of Clients with bortion
1. ocument the amount and character oI bleeding and 1. ocument the amount and character oI bleeding and
saves tissues or clots Ior evaluation. saves tissues or clots Ior evaluation.
2. Check the bleeding and vitals signs to identiIy 2. Check the bleeding and vitals signs to identiIy
hypovolemic shock resulting Irom blood loss hypovolemic shock resulting Irom blood loss
3. AIter vacuum aspiration or curettage, the amount oI 3. AIter vacuum aspiration or curettage, the amount oI
vaginal bleeding is observed vaginal bleeding is observed
4. Provide home health teaching aIter curettage such 4. Provide home health teaching aIter curettage such
as: as:
a. report increase bleeding a. report increase bleeding
b. take temperature every 8 hours Ior 3 days b. take temperature every 8 hours Ior 3 days
c. take an oral iron supplement iI prescribed c. take an oral iron supplement iI prescribed
d. resume sexual activity as recommended by the d. resume sexual activity as recommended by the
health care provider health care provider
e. return to the health care provider at the e. return to the health care provider at the
recommended time Ior a check up. recommended time Ior a check up.
5. Check laboratory test such as hemoglobin 5. Check laboratory test such as hemoglobin
level and hematocrit level and hematocrit
6. Promote expression oI grieI by providing 6. Promote expression oI grieI by providing
privacy, allowing support persons to help in privacy, allowing support persons to help in
pregnancy loss pregnancy loss
B. B. EC1OPIC PRECAAACY EC1OPIC PRECAAACY
- - is one in which implantation occurs outside the uterine is one in which implantation occurs outside the uterine
cavity. cavity.
- - the most common site (in approximately 95 oI such the most common site (in approximately 95 oI such
pregnancies) is in a Iallopian tube. OI these Iallopian tube pregnancies) is in a Iallopian tube. OI these Iallopian tube
sites, approximately 80 occur in the ampullar portion. sites, approximately 80 occur in the ampullar portion.
12 occur in the isthmus and 8 in interstitial 12 occur in the isthmus and 8 in interstitial
- - approximately 2 oI pregnancies are ectopic; ectopic approximately 2 oI pregnancies are ectopic; ectopic
pregnancy is the second most Irequent cause oI bleeding pregnancy is the second most Irequent cause oI bleeding
early in pregnancy early in pregnancy
Risk Factors: Risk Factors:

- - increase incidence in women who have PI increase incidence in women who have PI
(pelvic inIlammatory disease) which leads to tubal (pelvic inIlammatory disease) which leads to tubal
scarring scarring
- - occurs more Irequently in women who smoke occurs more Irequently in women who smoke
- - occurs more Irequently in women who douche, occurs more Irequently in women who douche,
possibly due to risk oI introducing an inIection possibly due to risk oI introducing an inIection
- - used oI IU (intrauterine device) Ior used oI IU (intrauterine device) Ior
contraception contraception
Signs and Symptoms: Signs and Symptoms:

Before Rupture Before Rupture
- - no menstrual Ilow occurs no menstrual Ilow occurs
- - nausea and vomiting nausea and vomiting
- - positive pregnancy test Ior hCG positive pregnancy test Ior hCG
- - Abdominal pain within 3 Abdominal pain within 3- - 5wks oI missed 5wks oI missed
period (maybe generalized or one sided) period (maybe generalized or one sided)
- - Scant, dark brown vaginal bleeding Scant, dark brown vaginal bleeding
uring rupture uring rupture
- - sharp, stabbing pain in one oI the lower abdominal sharp, stabbing pain in one oI the lower abdominal
quadrants at the time oI rupture, Iollowed by scant vaginal bleeding quadrants at the time oI rupture, Iollowed by scant vaginal bleeding
- - lightheadedness, rapid pulse and signs oI shock (rapid lightheadedness, rapid pulse and signs oI shock (rapid
thread pulse, rapid respirations and Ialling blood pressure) thread pulse, rapid respirations and Ialling blood pressure)
- - rigid abdomen Irom peritoneal irritation(Board rigid abdomen Irom peritoneal irritation(Board- -like like
abdomen) abdomen)
- - Cullen`s sign Cullen`s sign (bluish tinged umbilicus) (bluish tinged umbilicus) because blood because blood
seeping into the peritoneal cavity seeping into the peritoneal cavity
- - dull, excruciating pain on the abdomen that may radiate dull, excruciating pain on the abdomen that may radiate
on the shoulder caused by irritation oI the phrenic nerve on the shoulder caused by irritation oI the phrenic nerve
iagnostics: iagnostics:
1. Transvaginal UTZ will demonstrate ruptured 1. Transvaginal UTZ will demonstrate ruptured
tube tube
2. insertion a needle through the postvaginal 2. insertion a needle through the postvaginal
Iornix into the cul Iornix into the cul- -de de- -sac under the sterile conditions sac under the sterile conditions
to see whether blood that has collected there Irom to see whether blood that has collected there Irom
internal bleeding can be aspirated(Culdocentesis) internal bleeding can be aspirated(Culdocentesis)
3. Laparoscopy Culdoscopy can be used to 3. Laparoscopy Culdoscopy can be used to
visualize the Iallopian tube visualize the Iallopian tube
Culdocentesis Culdocentesis
%ransvaginal &% %ransvaginal &%
aparoscopy aparoscopy
Management: Management:
1. once an ectopic pregnancy ruptures, it is an 1. once an ectopic pregnancy ruptures, it is an emergency emergency
situation situation and the woman`s conditions must be evaluated quickly and the woman`s conditions must be evaluated quickly
(monitor Ior the symptoms oI shock) (monitor Ior the symptoms oI shock)
2. therapy Ior a ruptured ectopic pregnancy is laparoscopy to 2. therapy Ior a ruptured ectopic pregnancy is laparoscopy to
ligate the bleeding vessels and to remove or repair the damaged ligate the bleeding vessels and to remove or repair the damaged
Iallopian tube Iallopian tube
3. women with Rh negative blood should receive Rh immune 3. women with Rh negative blood should receive Rh immune
globulin (Rhogam) aIter an ectopic pregnancy Ior globulin (Rhogam) aIter an ectopic pregnancy Ior
isoimmunization protection in Iuture childbearing isoimmunization protection in Iuture childbearing
4. treated medically by the oral administration oI 4. treated medically by the oral administration oI
Methotrexate, a Iolic acid antagonist chemotherapeutic Methotrexate, a Iolic acid antagonist chemotherapeutic
agent, attacks and destroys Iast growing cells. Because agent, attacks and destroys Iast growing cells. Because
trophoblast and zygote growth is rapid, the drug is trophoblast and zygote growth is rapid, the drug is
drawn to the site oI ectopic pregnancy drawn to the site oI ectopic pregnancy
5. Hysterosalphingogram perIormed aIter chemotherapy 5. Hysterosalphingogram perIormed aIter chemotherapy
to assess the patency oI the tube to assess the patency oI the tube
6. provide emotional support 6. provide emotional support
SECN SECN- - %RIMES%ER BEEIN %RIMES%ER BEEIN
A. A. CES1A1IOAAL 1ROPHOBLAS1IC DISEASE CES1A1IOAAL 1ROPHOBLAS1IC DISEASE
(HYDA1IDIFORM MOLE OR H (HYDA1IDIFORM MOLE OR H- - MOLE) MOLE)
- - is proliIeration and degeneration oI the trophoblastic is proliIeration and degeneration oI the trophoblastic
villi, which becomes Iilled with Iluid and appear as grape villi, which becomes Iilled with Iluid and appear as grape- -
sized vesicles sized vesicles
- - incidence is approximately 1 in every 2,000 incidence is approximately 1 in every 2,000
pregnancies pregnancies
Causes: Causes:
- - unknown unknown
- - occurs most oIten in women who have a low occurs most oIten in women who have a low
protein intake protein intake
- - in young women (under age 18 years) in young women (under age 18 years)
- - in older women older than 35 years in older women older than 35 years
%ypes; %ypes;
- - there are two distinct types oI hydatidiIorm mole there are two distinct types oI hydatidiIorm mole
complete/partial complete/partial
1. Complete mole 1. Complete mole all trophoblastic villi swell and become all trophoblastic villi swell and become
cystic. cystic.
- - embryo dies early at only 1 to 2 mm in size with no Ietal embryo dies early at only 1 to 2 mm in size with no Ietal
blood present in the villi blood present in the villi
- - on chromosomal analysis, although the karyotype is a on chromosomal analysis, although the karyotype is a
normal 46XX or 46XY, this chromosome component was contributed normal 46XX or 46XY, this chromosome component was contributed
only by the Iather or an 'empty ovum was Iertilized and the only by the Iather or an 'empty ovum was Iertilized and the
chromosome material was duplicated chromosome material was duplicated
- - this type usually lead to choriocarcinoma this type usually lead to choriocarcinoma
2. Partial mole 2. Partial mole some oI the villi Iorm normally some oI the villi Iorm normally
- - although no embryo is present, Ietal blood may be although no embryo is present, Ietal blood may be
present in the villi present in the villi
- - has 69 chromosomes ( a triploid Iormation in which has 69 chromosomes ( a triploid Iormation in which
there are three chromosomes instead oI two Ior every pair, there are three chromosomes instead oI two Ior every pair,
one set supplied by an ovum that was Iertilized by two one set supplied by an ovum that was Iertilized by two
sperm or an ovum Iertilized by one sperm in which meiosis sperm or an ovum Iertilized by one sperm in which meiosis
or reduction division did not occur) or reduction division did not occur)
1. uterus tends to expand than normally 1. uterus tends to expand than normally
2. no Fetal heart sounds are heard because there is no viable Ietus 2. no Fetal heart sounds are heard because there is no viable Ietus
3. hCG serum levels are abnormally high 3. hCG serum levels are abnormally high
4. severe nausea and vomiting 4. severe nausea and vomiting
5. symptoms oI hypertension oI pregnancy is present beIore week 20 5. symptoms oI hypertension oI pregnancy is present beIore week 20
oI pregnancy oI pregnancy
6. a sonogram/UTZ will show dense growth (typically a 'snowstorm 6. a sonogram/UTZ will show dense growth (typically a 'snowstorm
pattern) but no Ietal growth in the uterus pattern) but no Ietal growth in the uterus
7. vaginal spotting oI dark brown blood 7. vaginal spotting oI dark brown blood
8. discharge oI the clear Iluid Iilled vesicles 8. discharge oI the clear Iluid Iilled vesicles
1. suction curettage to evacuate the mole 1. suction curettage to evacuate the mole
2. aIter extraction, women should have a baseline serum test Ior the 2. aIter extraction, women should have a baseline serum test Ior the
beta subunit oI hCG beta subunit oI hCG
3. educate on avoiding pregnancy Ior at least one year 3. educate on avoiding pregnancy Ior at least one year
4. hCG is analyzed every 2 4. hCG is analyzed every 2- -4 weeks Ior 6 4 weeks Ior 6- -12 months (gradually 12 months (gradually
declining hCG suggest no complications) declining hCG suggest no complications)
5. prophylactic course oI Methotrexate is the drug oI choice Ior 5. prophylactic course oI Methotrexate is the drug oI choice Ior
choriocarcinoma. This must be weigh careIully because it interIeres choriocarcinoma. This must be weigh careIully because it interIeres
with WBC Iormation which can lead to leucopenia with WBC Iormation which can lead to leucopenia
6. observe Ior bleeding and hypovolemic shock 6. observe Ior bleeding and hypovolemic shock
B. B. PREMA1URE CERJICAL DILA1A1IOA PREMA1URE CERJICAL DILA1A1IOA
- - previously termed as 'Incompetent cervix previously termed as 'Incompetent cervix
- - reIers to a cervix that dilates prematurely reIers to a cervix that dilates prematurely
and thereIore cannot hold a Ietus until term and thereIore cannot hold a Ietus until term
- - commonly occurs at approximately week commonly occurs at approximately week
20 oI pregnancy 20 oI pregnancy
Causes: Causes:
- - unknown unknown
Risk Iactors Risk Iactors
1. associated with increased maternal age, 1. associated with increased maternal age,
congenital structural deIects and trauma to the congenital structural deIects and trauma to the
cervix such as might occurred with biopsy or cervix such as might occurred with biopsy or
repeated & C repeated & C
1. oIten the Iirst symptom is show (a pink 1. oIten the Iirst symptom is show (a pink- -stained stained
vaginal discharge) or increased pelvic pressure vaginal discharge) or increased pelvic pressure
Iollowed by rupture oI membranes and discharge oI Iollowed by rupture oI membranes and discharge oI
amniotic Iluid amniotic Iluid
2. painless cervical dilatation 2. painless cervical dilatation
3. uterine contractions Iollowed by birth oI Ietus 3. uterine contractions Iollowed by birth oI Ietus
1. bed rest in trendelenburg position 1. bed rest in trendelenburg position
2. monitor FHT 2. monitor FHT
3. observe Ior the rupture oI BOW 3. observe Ior the rupture oI BOW
4. avoid coitus and limit activities 4. avoid coitus and limit activities
5. avoid vaginal douche 5. avoid vaginal douche
6. Surgical Operation termed as 'Cervical Cerlage is 6. Surgical Operation termed as 'Cervical Cerlage is
perIormed perIormed
- - as soon as sonogram conIirms that the Ietus oI a second as soon as sonogram conIirms that the Ietus oI a second
pregnancy is healthy, at approximately week 12 pregnancy is healthy, at approximately week 12- -14, pursing 14, pursing- -
string sutures are placed in the cervix by vaginal route under string sutures are placed in the cervix by vaginal route under
regional anesthesia regional anesthesia
- - types: types:
1. Mconald Procedure 1. Mconald Procedure nylon sutures are placed nylon sutures are placed
horizontally and vertically across the cervix and pulled tight horizontally and vertically across the cervix and pulled tight
to reduce the cervical canal to a Iew millimeters in diameter to reduce the cervical canal to a Iew millimeters in diameter
2. Shirodkar technique 2. Shirodkar technique sterile tape is threaded in a sterile tape is threaded in a
purse purse- -string manner under the sub mucosal layer oI the string manner under the sub mucosal layer oI the
cervix and sutured in place to achieve a closed cervix cervix and sutured in place to achieve a closed cervix
- - sutures may be placed trans sutures may be placed trans- -abdominally abdominally
%HIR %HIR -- %RIMES%ER BEEIN %RIMES%ER BEEIN
A. A. PLACEA1A PREJIA PLACEA1A PREJIA
- - is low implantation oI the placenta is low implantation oI the placenta
- - it occurs in Iour degrees: it occurs in Iour degrees:
1. Low 1. Low- - lying placenta lying placenta implantation in the lower rather than in the upper implantation in the lower rather than in the upper
portion oI the uterus portion oI the uterus
2. Partial placenta previa 2. Partial placenta previa implantation that occludes a portion oI the implantation that occludes a portion oI the
cervical OS cervical OS
3. Marginal 3. Marginal placenta edge approaches the cervical OS. Lower border is placenta edge approaches the cervical OS. Lower border is
within 3 cm Irom internal cervical OS but does not cover the OS within 3 cm Irom internal cervical OS but does not cover the OS
4. Total placenta previa 4. Total placenta previa implantation that totally obstructs the cervical OS implantation that totally obstructs the cervical OS
- - incidence is approximately 5 per 1000 pregnancies incidence is approximately 5 per 1000 pregnancies
Risk Factors Risk Factors
- - increased parity increased parity
- - advanced maternal age advanced maternal age
- - past cesarean births past cesarean births
- - past uterine curettage past uterine curettage
- - multiple gestation multiple gestation
Complication: Complication:
1. postpartum hemorrhage 1. postpartum hemorrhage
2. hypovolemic shock 2. hypovolemic shock
3. preterm labor 3. preterm labor
4. Ietal distress 4. Ietal distress
Signs and symptoms; Signs and symptoms;
1. sudden onset oI 1. sudden onset oI painless bright red vaginal painless bright red vaginal
bleeding bleeding (latter halI oI pregnancy) (latter halI oI pregnancy)
2. bleeding may be proIuse or scanty 2. bleeding may be proIuse or scanty
Note: Note:
- - site oI bleeding: uterine deciduas (maternal site oI bleeding: uterine deciduas (maternal
blood) places the mother at risk Ior hemorrhage blood) places the mother at risk Ior hemorrhage
- - bleeding may not occur until the onset oI bleeding may not occur until the onset oI
cervical dilatation causing the placenta to loosen Irom the cervical dilatation causing the placenta to loosen Irom the
uterus uterus
Management; Management;
1. bleeding is an emergency. (Ietal oxygen may be compromised and 1. bleeding is an emergency. (Ietal oxygen may be compromised and
preterm birth may occur) preterm birth may occur)
2. assess the amount oI blood loss (duration, time oI bleeding began, 2. assess the amount oI blood loss (duration, time oI bleeding began,
accompanying pain, and color oI the blood) accompanying pain, and color oI the blood)
3. bed rest with oxygenation prescribed 3. bed rest with oxygenation prescribed
4. side 4. side- -lying or trendelenburg position (Ior 72 hours) lying or trendelenburg position (Ior 72 hours)
5. NO internal exams (IE) or rectal exams, may initiate massive hemorrhage 5. NO internal exams (IE) or rectal exams, may initiate massive hemorrhage
(iI necessary, must have double set up; OR/ R) (iI necessary, must have double set up; OR/ R)
6. keep IV line and have blood available (X 6. keep IV line and have blood available (X- -matched and typed) matched and typed)
7. Apt or Kleihauer 7. Apt or Kleihauer- - Betke test (test strip procedure to determine iI blood is Betke test (test strip procedure to determine iI blood is
Ietal or maternal in origin) Ietal or maternal in origin)
Fetal ssessment: Fetal ssessment:

1. monitor Ietal status; heart tone and movement 1. monitor Ietal status; heart tone and movement
2. determine Ietal lung maturity; amniocentesis 2. determine Ietal lung maturity; amniocentesis
L/S ratio L/S ratio
3. Bethamethasone may be prescribed (encourage 3. Bethamethasone may be prescribed (encourage
maturity oI Ietal lungs; iI Ietus is less than 34 weeks maturity oI Ietal lungs; iI Ietus is less than 34 weeks
gestation) gestation)
B. B. ABRUP1IO PLACEA1A ABRUP1IO PLACEA1A

- - premature separation oI a normally premature separation oI a normally
implanted placenta either partial/marginal or implanted placenta either partial/marginal or
complete/total complete/total
- - occurs aIter 20 occurs aIter 20- -24 weeks oI pregnancy 24 weeks oI pregnancy
Causes: Causes:
- -unknown unknown
- - high parity high parity
- - advanced maternal age advanced maternal age
- - short umbilical cord short umbilical cord
- - chronic hypertensive disease chronic hypertensive disease
- - PIH PIH
- - direct trauma (Irom VA) direct trauma (Irom VA)
- - cocaine or cigarette use (Vasoconctrction) cocaine or cigarette use (Vasoconctrction)
Complications: Complications:
1. Ietal distress (altered HR) 1. Ietal distress (altered HR)
2. Couvelaire uterus or Uteroplacental apoplexy 2. Couvelaire uterus or Uteroplacental apoplexy
3. disseminated intravascular coagulation (IC) 3. disseminated intravascular coagulation (IC)
Signs and symptoms: Signs and symptoms:
1. vaginal bleeding (may not reIlect the true amount oI blood 1. vaginal bleeding (may not reIlect the true amount oI blood
loss) loss)
2. abdominal and low back pain (dull or aching) 2. abdominal and low back pain (dull or aching)
3. sharp stabbing pain high in the Iundus 3. sharp stabbing pain high in the Iundus
4. uterine irritability (Irequent low intensity contractions) 4. uterine irritability (Irequent low intensity contractions)
5. high uterine resting tone 5. high uterine resting tone
6. uterine tenderness 6. uterine tenderness
egrees of Separation rade criteria: egrees of Separation rade criteria:

00 - - no symptoms oI separation. Slight separation no symptoms oI separation. Slight separation
occurs aIter birth. When placenta is examined, a segment shows occurs aIter birth. When placenta is examined, a segment shows
recent adherent clots recent adherent clots
1 1 - - minimal separation, enough to cause bleeding minimal separation, enough to cause bleeding
and changes in vital signs. However, there is no occurrence oI Ietal and changes in vital signs. However, there is no occurrence oI Ietal
distress and hemorrhagic shock distress and hemorrhagic shock
22 - - moderate separation. There is evidence oI Ietal moderate separation. There is evidence oI Ietal
distress, and the uterus is tense and painIul on palpation distress, and the uterus is tense and painIul on palpation
33 - - extreme separation, and maternal shock or extreme separation, and maternal shock or
Ietal death will result Ietal death will result
1. keep the client in lateral position, not supine 1. keep the client in lateral position, not supine
2. oxygen therapy (limit Ietal anoxia) 2. oxygen therapy (limit Ietal anoxia)
3. monitor FHT and record maternal vital signs every5 to 15 3. monitor FHT and record maternal vital signs every5 to 15
minutes minutes
4. baseline Iibrinogen(iI bleeding is extensive. Fibrinogen 4. baseline Iibrinogen(iI bleeding is extensive. Fibrinogen
reserve may be used up in the body`s attempt to accomplish reserve may be used up in the body`s attempt to accomplish
eIIective clot Iormation) eIIective clot Iormation)
5. NO IE or rectal exam. No Enema 5. NO IE or rectal exam. No Enema
6. keep IV line open (possible BT) 6. keep IV line open (possible BT)
PRE%ERM BR PRE%ERM BR
- - aka. Premature Labor aka. Premature Labor
- - labor that occurs aIter 20 weeks and beIore the end labor that occurs aIter 20 weeks and beIore the end
- - approximately 9 approximately 9- -10 oI all pregnancies 10 oI all pregnancies
- - labor contractions that happens every 10 labor contractions that happens every 10- -20 minutes 20 minutes
- -usually leads to progressive cervical dilatation oI ~2 cm usually leads to progressive cervical dilatation oI ~2 cm
and eIIacement oI ~80 and eIIacement oI ~80
Causs Causs::
- - unknown unknown
1. ehydration (stimulates APG to release AH/Oxytocin 1. ehydration (stimulates APG to release AH/Oxytocin
that strengthen uterine contractions) that strengthen uterine contractions)
2. UTI 2. UTI
3. Chorioamnionitis (inIection oI the Ietal membranes and 3. Chorioamnionitis (inIection oI the Ietal membranes and
Iluid) Iluid)
4. Younger than 17 and over 35 years old 4. Younger than 17 and over 35 years old
5. Inadequate prenatal care 5. Inadequate prenatal care
6. Emotional and physical stress 6. Emotional and physical stress
7. Previous pre 7. Previous pre- -term labor term labor
8. Low socio 8. Low socio- -economic class economic class

Early Signs and symptoms Early Signs and symptoms
1. persistent low back pain 1. persistent low back pain
2. vaginal spotting 2. vaginal spotting
3. cramping 3. cramping
4. increase vaginal discharge 4. increase vaginal discharge
5. uterine contractions 5. uterine contractions
6. Pelvic pressure or a Ieeling that the Ietus is 6. Pelvic pressure or a Ieeling that the Ietus is
pushing down pushing down
7. Pain or discomIort in the vulva or thighs 7. Pain or discomIort in the vulva or thighs
FOCUS: Prevention oI the delivery oI premature Ietus FOCUS: Prevention oI the delivery oI premature Ietus
1. The woman should Iirst admitted to the hospital 1. The woman should Iirst admitted to the hospital
2. Place in LeIt lateral position 2. Place in LeIt lateral position
3. BEREST to relieve the pressure oI the Ietus on the cervix 3. BEREST to relieve the pressure oI the Ietus on the cervix
4. Intravenous Iluid therapy to promote hydration 4. Intravenous Iluid therapy to promote hydration
5. Medical Management 5. Medical Management
a. Bethamethasone/ a. Bethamethasone/Glucocorticoids Glucocorticoids steroid, given in an steroid, given in an
attempt to hasten Ietal lung maturity attempt to hasten Ietal lung maturity
- - given in 2 dose, 12 mg IM 24 hours apart given in 2 dose, 12 mg IM 24 hours apart
b. Tocolytic agents (halt labor) b. Tocolytic agents (halt labor)
1. Calcium channel blockers 1. Calcium channel blockers Beta adrenergic drugs Beta adrenergic drugs
2. Indomethacin (prostaglandin antagonist) 2. Indomethacin (prostaglandin antagonist)
- - it can decrease Ietal urine output, causing a decrease in amniotic Iluid, it can decrease Ietal urine output, causing a decrease in amniotic Iluid,
not OC because it can stimulate the early closure oI ductus arteriosus not OC because it can stimulate the early closure oI ductus arteriosus
3. Magnesium SulIate 3. Magnesium SulIate oIten the Iirst drug used to halt contractions oIten the Iirst drug used to halt contractions
- - CNS depressant CNS depressant
- - halts uterine contraction halts uterine contraction
4. Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine) 4. Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine)
- - acts on entire beta 2 receptors sites (uterine and bronchial smooth muscles) acts on entire beta 2 receptors sites (uterine and bronchial smooth muscles)
causing mild hypotension and tachycardia eIIects, hypokalemia, hyperglycemia, causing mild hypotension and tachycardia eIIects, hypokalemia, hyperglycemia,
pulmonary edema pulmonary edema
Side EIIects: Side EIIects:
a. Headache (most common) a. Headache (most common) due to dilatation oI cerebral blood vessels due to dilatation oI cerebral blood vessels
b. Nausea and vomiting b. Nausea and vomiting
Nursing Responsibilities beIore administration oI Tocolytic Nursing Responsibilities beIore administration oI Tocolytic
Therapy: Therapy:
1. assess baseline blood data i.e. hct, glucose, potassium, NaCl, 1. assess baseline blood data i.e. hct, glucose, potassium, NaCl,
ECG (tachycardia) ECG (tachycardia)
2. Uterine and Ietal monitoring (external Ietal monitors) 2. Uterine and Ietal monitoring (external Ietal monitors)
3. mix the drug with lactated Ringers solution to prevent 3. mix the drug with lactated Ringers solution to prevent
hyperglycemia (piggyback administration, so that it can be stop hyperglycemia (piggyback administration, so that it can be stop
immediately iI tachycardia occurs) immediately iI tachycardia occurs)
4. assess BP and pulse every 15 minutes and every 30 minutes until 4. assess BP and pulse every 15 minutes and every 30 minutes until
contractions stop contractions stop
5. reports PR~120 bpm, BP 90/60 chest pain, dyspnea, rales 5. reports PR~120 bpm, BP 90/60 chest pain, dyspnea, rales
PREM%&RE R&P%&RE F MEMBRNES PREM%&RE R&P%&RE F MEMBRNES
(PRM) (PRM)
- - rupture and loss oI amniotic Iluid that occurs beIore rupture and loss oI amniotic Iluid that occurs beIore
labor begins labor begins
- - occurs in 2 occurs in 2- -18 oI pregnancies 18 oI pregnancies
Cause: Cause:
- - unknown, but associated with inIection oI Ietal unknown, but associated with inIection oI Ietal
membranes (Chorioamnionitis) membranes (Chorioamnionitis)
- - nutritional deIiciency involving ascorbic acid nutritional deIiciency involving ascorbic acid
1. Fetal inIections 1. Fetal inIections aIter the rupture oI BOW, the seal to aIter the rupture oI BOW, the seal to
the Ietus is lost the Ietus is lost
2. Cord Compression 2. Cord Compression pressure on the umbilical cord pressure on the umbilical cord
because oI the loss oI the amniotic Iluid, which can cut oII because oI the loss oI the amniotic Iluid, which can cut oII
the nutrient supply to the Ietus (Ietal distress) the nutrient supply to the Ietus (Ietal distress)
3. Cord prolapsed 3. Cord prolapsed the extension oI the umbilical cord into the extension oI the umbilical cord into
the vagina which can also interIere with Ietal blood the vagina which can also interIere with Ietal blood
circulation circulation

1. Sudden gush oI clear Iluid Irom the vagina 1. Sudden gush oI clear Iluid Irom the vagina
- - Iluid should be tested Ior: Iluid should be tested Ior:
a. Nitrazine Paper test a. Nitrazine Paper test amniotic Iluid causes alkaline amniotic Iluid causes alkaline
(~6.5 ph) reaction to the paper (turns to blue) and urine causes acidic (~6.5 ph) reaction to the paper (turns to blue) and urine causes acidic
reaction (remains yellow) reaction (remains yellow)
b. Ferning test b. Ferning test get the sample oI Iluid then place on the get the sample oI Iluid then place on the
slide and viewing it under the microscope slide and viewing it under the microscope
- - Ierning patterns means Ierning patterns means BOW BOW
1. Strict Bed Rest 1. Strict Bed Rest
2. Observe, document and report maternal temperature above 38C, 2. Observe, document and report maternal temperature above 38C,
Ietal tachycardia Ietal tachycardia
3. Monitor Ior signs oI inIections (Iever, uterine tenderness) 3. Monitor Ior signs oI inIections (Iever, uterine tenderness)
4. Avoid sexual intercourse/Orgasm 4. Avoid sexual intercourse/Orgasm
5. avoid vaginal exams (risk oI inIection) 5. avoid vaginal exams (risk oI inIection)
6. avoid breast stimulation 6. avoid breast stimulation
7. record Ietal movements daily and report Iewer than 10 in a 12 7. record Ietal movements daily and report Iewer than 10 in a 12
hour period hour period
8. administer broad spectrum ATBC to reduce the risk oI inIection 8. administer broad spectrum ATBC to reduce the risk oI inIection
e.g. Penicillin/ e.g. Penicillin/Ampicillin Ampicillin
PRENNCY PRENNCY- - IN&CE HYPER%ENSIN (PIH) IN&CE HYPER%ENSIN (PIH)
- - originally called 'Toxemia oI Pregnancy originally called 'Toxemia oI Pregnancy
- - condition in which vasospasm occurs during condition in which vasospasm occurs during
pregnancy accompanied by hypertension, protenuria pregnancy accompanied by hypertension, protenuria
and edema and edema
- - onset: occurs aIter 20 onset: occurs aIter 20
th th
week oI pregnancy and week oI pregnancy and
may appear up to 48 hours (2 weeks) postpartum may appear up to 48 hours (2 weeks) postpartum
- - occurs 5 occurs 5- -10 pregnancies 10 pregnancies
Cause: Cause:
- - Unknown Unknown
- - related to diIIerent associative Iactors related to diIIerent associative Iactors
1. Primipara 1. Primipara - - 20 years old and ~ 40 years old 20 years old and ~ 40 years old
2. Low socio 2. Low socio- -economic status (poor nutrition economic status (poor nutrition decrease decrease
CHON intake) CHON intake)
3. Women who have 5 or more pregnancies 3. Women who have 5 or more pregnancies
4. Multiple pregnancies 4. Multiple pregnancies
5. Hydramnios (pre 5. Hydramnios (pre- -exisiting exisiting) )
6. Underlying HPN/M 6. Underlying HPN/M
7. Poor calcium/Magnesium intake 7. Poor calcium/Magnesium intake
8. H 8. H- -mole mole
Pathophysiology: Pathophysiology:
Pregnancy Induced Hypertension Pregnancy Induced Hypertension
Peripheral Vascular Spasms (Vasospasm)
Vascular EIIects Kidney EIIects
Interstitial EIIects
Vasoconstriction
ecrease GFR and increase
Permeability oI Glomeruli
membranes
iIIusion oI Iluid Irom
blood stream into the
interstitial tissue
Increased 8
Increase Serum BUN, uric acid and
Creatinine
Ldema
Decrease ur|ne output and protenur|a
Kidney EIIects: Kidney EIIects:
- - Vasospasm in the kidney increases blood Ilow Vasospasm in the kidney increases blood Ilow
resistance resistance
- - leads to increase permeability oI the glomerular leads to increase permeability oI the glomerular
membranes, allowing the serum CHONS and membranes, allowing the serum CHONS and
globulin to escape in the urine (protenuria) globulin to escape in the urine (protenuria)
- - Results in decreased glomerular Iiltration Results in decreased glomerular Iiltration
lowers urine output lowers urine output
Interstitials EIIects: Interstitials EIIects:

- - Because oI more CHON is lost, the osmotic pressure is Because oI more CHON is lost, the osmotic pressure is
decreased and the excessive Iluid shiIts/diIIuses Irom vascular decreased and the excessive Iluid shiIts/diIIuses Irom vascular
spaces to the interstitials spaces spaces to the interstitials spaces
- - leads to edema (extreme edema can lead to pulmonary leads to edema (extreme edema can lead to pulmonary
edema and seizure (Eclampsia) and it increases tubular edema and seizure (Eclampsia) and it increases tubular
reabsorption oI Na in kidneys` reabsorption oI Na in kidneys`
Feto Feto- -placental eIIects: placental eIIects:

- - poor placental perIusion may reduce the Ietal nutrient and poor placental perIusion may reduce the Ietal nutrient and
oxygen supply oxygen supply

Triad oI Symptoms (classic signs oI PIH) Triad oI Symptoms (classic signs oI PIH)
1. HPN 1. HPN
2. Protenuria 2. Protenuria
3. Edema 3. Edema
ClassiIication oI PIH: ClassiIication oI PIH:
1. estational HPN 1. estational HPN -- aka, %ranscient HPN aka, %ranscient HPN
- - develops Increase BP (~140/90) but has no protenuria and develops Increase BP (~140/90) but has no protenuria and
edema edema
- - decrease maternal mortality so no drug therapy is necessary decrease maternal mortality so no drug therapy is necessary
- - BP returns to normal by 10 BP returns to normal by 10
th th
day oI postpartum day oI postpartum
2. Mild Pre 2. Mild Pre- -Eclampsia Eclampsia
a. 1 a. 1
st st
criteria criteria Increase BP oI ~140/90 mmHg taken on 2 occasion at least 6 Increase BP oI ~140/90 mmHg taken on 2 occasion at least 6
hours apart hours apart
22
nd nd
criteria criteria Systolic BP is ~ 30 mmHg and iastolic BP is ~15 mm Hg Systolic BP is ~ 30 mmHg and iastolic BP is ~15 mm Hg
above baseline BP above baseline BP
b. Protenuria b. Protenuria
- - 1 or 2 (represents a loss oI 1 g/dl oI CHON 1 or 2 (represents a loss oI 1 g/dl oI CHON
c. Edema (weight gain) c. Edema (weight gain)
- - due to CHON loss, sodium retention and decrease GFR due to CHON loss, sodium retention and decrease GFR
- - begins to accumulate on the upper part oI the body (hands/Iace) begins to accumulate on the upper part oI the body (hands/Iace)
- - weight gain oI ~2 lb/wk in the second semester or ~ 1 lb/wk in the weight gain oI ~2 lb/wk in the second semester or ~ 1 lb/wk in the
33
rd rd
trimester (abnormal) trimester (abnormal)
Normal Weight Gain; 1 Normal Weight Gain; 1
st st
Trimester Trimester 1 lb/month, 2 1 lb/month, 2
nd nd
/3 /3
rd rd
trimester trimester 4 lbs/ 4 lbs/mos mos
Nursing management: Nursing management:
- - can be managed at home with Irequent Iollow can be managed at home with Irequent Iollow- -ups ups
1. BE REST (bathroom 1. BE REST (bathroom priviliges priviliges) )
- - Iacilitate Na excretion Iacilitate Na excretion
- - decreases oxygen demand decreases oxygen demand
- - position on leIt lateral position to prevent uterine pressure on the vena position on leIt lateral position to prevent uterine pressure on the vena
cava cava
2. Assess the BP in sitting/leIt lateral position, CHON level in the urine, 2. Assess the BP in sitting/leIt lateral position, CHON level in the urine,
changes in LOC, Ietal movements and FHT changes in LOC, Ietal movements and FHT
3. regular diet with NO salt restriction 3. regular diet with NO salt restriction
- - Na restriction may activate the RAAS (rennin Na restriction may activate the RAAS (rennin- -angiotensin angiotensin- -
aldosterone aldosterone system) which can result in increase BP system) which can result in increase BP
4. iI symptoms progress to Severe Pre 4. iI symptoms progress to Severe Pre- -Eclampsia Eclampsia REFER immediately to REFER immediately to
HOSPITAL. HOSPITAL.
3. Severe Pre 3. Severe Pre- -Eclampsia Eclampsia
- - Presence oI any oI the Iollowing: Presence oI any oI the Iollowing:
a. increase BP ~160/110 mm Hg on at least a. increase BP ~160/110 mm Hg on at least
2 occasions 6 hours apart at bed rest (the position in 2 occasions 6 hours apart at bed rest (the position in
which BP is lowest) which BP is lowest)
b. marked protenuria b. marked protenuria 3 or 4 on a 3 or 4 on a
random urine sample random urine sample
c. generalized edema noticeable in woman`s Iace (Iacial c. generalized edema noticeable in woman`s Iace (Iacial
edema) and hands (wedding ring can`t be removed), edema) and hands (wedding ring can`t be removed),
pulmonary edema (dyspnea, crackles on auscultation), pulmonary edema (dyspnea, crackles on auscultation),
cerebral edema (visual disturbances cerebral edema (visual disturbances i.e i.e blurred vision, blurred vision,
headache) headache)
d. urine output d. urine output oliguria (less than 500 ml/24 hrs) or 30 oliguria (less than 500 ml/24 hrs) or 30
ml/hr ml/hr
Nursing Management: Nursing Management:
- - usually hospitalized until the baby is delivered usually hospitalized until the baby is delivered
1. BE REST (patient must be observe more closely) 1. BE REST (patient must be observe more closely)
2. Provide a quiet and calm environment 2. Provide a quiet and calm environment any noise can trigger a any noise can trigger a
seizure activity and leads to eclampsia seizure activity and leads to eclampsia
3. administer precautions on the patient`s room: 3. administer precautions on the patient`s room:
a. patient`s bed must be near nurse`s station with code cart nearby a. patient`s bed must be near nurse`s station with code cart nearby
b. placed in private room (undisturbed) b. placed in private room (undisturbed)
c. the room should be darkened (because bright light can trigger c. the room should be darkened (because bright light can trigger
seizure) seizure)
d. raise padded side rails to prevent Ialls or injury Irom seizure d. raise padded side rails to prevent Ialls or injury Irom seizure
activity activity
4. Irequent maternal assessments every 4 hours (seizure precautions) 4. Irequent maternal assessments every 4 hours (seizure precautions)
a. sudden rise oI BP a. sudden rise oI BP
b. blood studies b. blood studies CBC, platelet count, liver Iunction, BUN, Creatinine, CBC, platelet count, liver Iunction, BUN, Creatinine,
urine CHONS urine CHONS
c. urine output c. urine output normal 600ml/24hours or 30 ml/hour normal 600ml/24hours or 30 ml/hour
d. daily weights d. daily weights same time each day same time each day
e. impeding seizure signs (aura) such as headache, visual disturbances, e. impeding seizure signs (aura) such as headache, visual disturbances,
epigastric pain epigastric pain
5. Monitor Fetal Well 5. Monitor Fetal Well- -being being
- - placed in External Ietal Monitors to asses Ior FHR and Ietal placed in External Ietal Monitors to asses Ior FHR and Ietal
movements movements
- - Non Non- -Stress test/Biophysical ProIile to assess Ior Utero Stress test/Biophysical ProIile to assess Ior Utero- -placental placental
suIIiciency suIIiciency
6. Moderate high protein diet to compensate Ior CHON lost ( 6. Moderate high protein diet to compensate Ior CHON lost (proteinuria proteinuria) )
Medical Management: Medical Management:

- - to prevent Eclampsia to prevent Eclampsia
1. 1. Hydralazine Hydralazine ( (Apresoline Apresoline) ) antihypertensive antihypertensive to reduce HPN by peripheral to reduce HPN by peripheral
dilatation dilatation
- - side eIIects side eIIects Tachycardia Tachycardia
- - check Ior PR and BP beIore and aIter administration check Ior PR and BP beIore and aIter administration
2. Magnesium SulIate 2. Magnesium SulIate
- - OC to prevent eclampsia OC to prevent eclampsia
- - action: action:
a. Cathartic a. Cathartic reduces edema by causing Iluid shiIting Irom reduces edema by causing Iluid shiIting Irom
extracellular spaces into the intestine (removed by bowel elimination) extracellular spaces into the intestine (removed by bowel elimination)
b. CNS depressant (anti b. CNS depressant (anti- -convulsant convulsant) ) lessens the possibility oI lessens the possibility oI
seizure activity seizure activity
c. decrease neuromuscular irritability (muscle relaxant eIIect) c. decrease neuromuscular irritability (muscle relaxant eIIect)
d. Promotes maternal vasodilatation d. Promotes maternal vasodilatation promotes better promotes better Ieto Ieto- -placental placental
circulation or tissue perIusion circulation or tissue perIusion
Nursing responsibilities during MgSO4 administration: Nursing responsibilities during MgSO4 administration:
1. Given IV via Piggyback inIusing over 15 1. Given IV via Piggyback inIusing over 15- -30 minutes, loading dose 4 30 minutes, loading dose 4- -
6g/hr and maintenance dose 1 6g/hr and maintenance dose 1- -2 g/hr 2 g/hr
2. assess RR, urine output, TR and ankle 2. assess RR, urine output, TR and ankle clonus clonus beIore aIter beIore aIter
administration administration
3. Monitor Ior magnesium sulIate toxicity: 3. Monitor Ior magnesium sulIate toxicity:
a. depressed respiration oI 12Breaths/min a. depressed respiration oI 12Breaths/min
b. decrease urine output oI 30 ml/hr b. decrease urine output oI 30 ml/hr
c. decrease TR c. decrease TR
d. decrease LOC d. decrease LOC
4. Antidote: Calcium 4. Antidote: Calcium Gluconate Gluconate a solution oI 10 ml oI 10 calcium a solution oI 10 ml oI 10 calcium
gluconate gluconate solution given Ior MGSO4 toxicity solution given Ior MGSO4 toxicity
- - must be readily available at bedside must be readily available at bedside
4. Eclampsia 4. Eclampsia the most severe classiIication oI PIH the most severe classiIication oI PIH
- - when cerebral edema occurs onset oI seizure or when cerebral edema occurs onset oI seizure or
coma occurs coma occurs
- - maternal mortality rate is high 20 due to maternal mortality rate is high 20 due to
hemorrhage (circulatory collapse or renal Iailure) hemorrhage (circulatory collapse or renal Iailure)

1. Increase HPN precedes SEIZURE 1. Increase HPN precedes SEIZURE
- - impending signs oI seizure are headache, visual disturbances and epigastric impending signs oI seizure are headache, visual disturbances and epigastric
pain) Iollowed by circulatory hypotension and collapse pain) Iollowed by circulatory hypotension and collapse
Stages: Stages:
a. Tonic phase a. Tonic phase all body contracts, arching oI back, arms and legs are all body contracts, arching oI back, arms and legs are
stiII stiII
b. b. Clonic Clonic phase all oI the muscle oI body will contract and relax phase all oI the muscle oI body will contract and relax
c. Post c. Post- -Ictal Ictal phase phase semicomatose semicomatose/ patient cannot be arouse except Ior / patient cannot be arouse except Ior
painIul stimuli painIul stimuli
2. may lead to coma 2. may lead to coma
3. labor may begin because oI premature separation oI placenta secondary 3. labor may begin because oI premature separation oI placenta secondary
to vasospasm which might lead to preterm delivery to vasospasm which might lead to preterm delivery

- - Priority care Ior the mother with seizure is to: Priority care Ior the mother with seizure is to:
1. Maintenance oI Patent Airway 1. Maintenance oI Patent Airway
- - administer oxygen by Iace mask administer oxygen by Iace mask
- - turning the mother to the side to allow the secretions to drain in the turning the mother to the side to allow the secretions to drain in the
mouth (preventing aspiration) mouth (preventing aspiration)
2. Raised padded side rails 2. Raised padded side rails
3. avoid placing a tongue depressor (during the seizure activity) because it can 3. avoid placing a tongue depressor (during the seizure activity) because it can
obstruct the airway obstruct the airway
4. minimize environmental stimuli 4. minimize environmental stimuli
5. administer medications as ordered 5. administer medications as ordered i.e i.e MgSO4 and diazepam IV MgSO4 and diazepam IV
6. continue to assess FHT and uterine contractions 6. continue to assess FHT and uterine contractions
7. check Ior maternal bleeding 7. check Ior maternal bleeding
8. mother can deliver via NS, CS is very hazardous because hypotension 8. mother can deliver via NS, CS is very hazardous because hypotension
might result secondary to anesthesia might result secondary to anesthesia
9. IV therapy as ordered 9. IV therapy as ordered
HEP SYNRME HEP SYNRME
- - a variation oI PIH abbreviated as Hemolysis, a variation oI PIH abbreviated as Hemolysis,
Elevated liver enzymes and low platelet count Elevated liver enzymes and low platelet count
- - occurs in 4 occurs in 4- -12 oI patients with PIH 12 oI patients with PIH
- - a liIe threatening complication oI PIH (because a liIe threatening complication oI PIH (because
maternal mortality is high at 24 and inIant maternal mortality is high at 24 and inIant
mortality is 25) mortality is 25)
Cause: Unknown Cause: Unknown

Associated Factors Associated Factors
primipara/ primipara/Multipara Multipara mothers mothers
- - nausea nausea
- - epigastric pain epigastric pain
- - general malaise general malaise
- - right upper quadrant tenderness right upper quadrant tenderness
Laboratory data: Laboratory data:
a. hemolytic RBC a. hemolytic RBC
b. thrombocytopenia (low platelet count oI b. thrombocytopenia (low platelet count oI
below 100,000/m3) below 100,000/m3)
c. elevated lover enzyme (because oI c. elevated lover enzyme (because oI
hemorrhage and necrosis oI liver) hemorrhage and necrosis oI liver)
- - serum ALT (Alanine serum ALT (Alanine
AminotransIerase), and ALT (Aspartate AminotransIerase), and ALT (Aspartate
aminotransIerase) aminotransIerase)
Medical Management: (no known cure) Medical Management: (no known cure)
1. Blood transIusion oI Iresh Irozen plasma or 1. Blood transIusion oI Iresh Irozen plasma or
platelets platelets
2. inIant is deliver ASAP via NS or CS (lab. 2. inIant is deliver ASAP via NS or CS (lab.
Results will return to normal aIter delivery Results will return to normal aIter delivery
3. monitor Ior bleeding 3. monitor Ior bleeding
M&%IPE PRENNCIES M&%IPE PRENNCIES
- - a pregnancy in which there is more than one a pregnancy in which there is more than one
Ietus in the uterus at the same time Ietus in the uterus at the same time
- - Incidence rate is 2 oI pregnancies Incidence rate is 2 oI pregnancies
Types: Types:
1. Monozygotic twins 1. Monozygotic twins
- - aka. Identical twins aka. Identical twins
- - begins with single ovum and begins with single ovum and
spermatozoa, during the process oI Iusion, the spermatozoa, during the process oI Iusion, the
zygote divides into two identical individuals zygote divides into two identical individuals
- - have 1 placenta, 1 chorion, 2 amnion, 2 have 1 placenta, 1 chorion, 2 amnion, 2
umbilical cords umbilical cords
- - always oI the same sex always oI the same sex
2. izygotic Twins 2. izygotic Twins

- - aka. Non aka. Non- -identical/Iraternal twins identical/Iraternal twins
- - the result oI Iertilization oI two separate the result oI Iertilization oI two separate
ova by two separate spermatozoa ova by two separate spermatozoa
- - have 2 placenta, 2 chorions, 2 amnions, 2 have 2 placenta, 2 chorions, 2 amnions, 2
umbilical cords umbilical cords
- - twins may be oI the same or diIIerent sex twins may be oI the same or diIIerent sex
- - 2/3 oI twins are dizygotic 2/3 oI twins are dizygotic
Associative Factors: Associative Factors:

a. more Irequent in non a. more Irequent in non- -whites than in whites than in
whites whites
b. increase in parity b. increase in parity
c. advance maternal age c. advance maternal age
d. Iamilial inheritance d. Iamilial inheritance
iagnostic procedure: Sonogram/Ultrasound iagnostic procedure: Sonogram/Ultrasound
1. Increase uterine size Iaster than usual 1. Increase uterine size Iaster than usual
2. quickening at the diIIerent portion oI the 2. quickening at the diIIerent portion oI the
abdomen abdomen
3. more than expected Ietal activity 3. more than expected Ietal activity
4. multiple sets oI FHT 4. multiple sets oI FHT
5. extreme Iatigue and backache 5. extreme Iatigue and backache
- - mother is more susceptible to complications mother is more susceptible to complications
oI pregnancy i.e. PIH, hydramnios, placenta oI pregnancy i.e. PIH, hydramnios, placenta
previa, pre previa, pre- -term labor, anemia than a women term labor, anemia than a women
carrying only one Ietus carrying only one Ietus
1. BE REST (during the 2 or 3 months oI 1. BE REST (during the 2 or 3 months oI
pregnancy to decrease risk oI preterm labor pregnancy to decrease risk oI preterm labor
2. Closer prenatal supervision 2. Closer prenatal supervision
HYRMNIS (Polyhydramnios) HYRMNIS (Polyhydramnios)
- - Excessive Iluid Iormation oI ~2000ml or an amniotic Iluid Excessive Iluid Iormation oI ~2000ml or an amniotic Iluid
index oI above 24 cm (normal 500 index oI above 24 cm (normal 500- -1000ml) 1000ml)
1. Fetal Malpresentation (because oI extra 1. Fetal Malpresentation (because oI extra- -uterine space) uterine space)
2. Premature rupture oI membranes 2. Premature rupture oI membranes that leads to inIection that leads to inIection
and prolapsed cord and prolapsed cord
3. Preterm labor (because oI increasing pressure, 3. Preterm labor (because oI increasing pressure,
prostaglandin release) prostaglandin release)
1. Maternal diabetes 1. Maternal diabetes hyperglycemia in the hyperglycemia in the
Ietus causes increase urine production leading Ietus causes increase urine production leading
to increase urine output to increase urine output
2. Anencephaly 2. Anencephaly
3. Esophageal atresia 3. Esophageal atresia Ietus becomes unable Ietus becomes unable
to swallow the amniotic Iluid because oI to swallow the amniotic Iluid because oI
intestinal anomalies or obstruction intestinal anomalies or obstruction
Esophageal tresia Esophageal tresia
nencephaly nencephaly
1. Rapid enlargement oI the uterus (Iirst sign) 1. Rapid enlargement oI the uterus (Iirst sign)
2. diIIiculty in palpating and auscultating the 2. diIIiculty in palpating and auscultating the
Ietus due to excessive Iluid Ietus due to excessive Iluid
3. shortness oI breath due to compression oI 3. shortness oI breath due to compression oI
the diaphragm the diaphragm
4. ultrasound Iinding oI increase excessive 4. ultrasound Iinding oI increase excessive
Iluid Iluid
1. maintain bed rest to reduce pressure on cervix and to 1. maintain bed rest to reduce pressure on cervix and to
prevent premature labor prevent premature labor
2. monitor Ior rupture or uterine contraction 2. monitor Ior rupture or uterine contraction
3. avoid constipation (it will increase uterine pressure 3. avoid constipation (it will increase uterine pressure
and rupture oI membranes) and rupture oI membranes)
4. amniocentesis (slow and controlled release oI Iluid to 4. amniocentesis (slow and controlled release oI Iluid to
prevent premature separation oI the placenta) guided by prevent premature separation oI the placenta) guided by
ultrasound ultrasound
PS% PS%- -%ERM PRENNCY %ERM PRENNCY
- - a pregnancy that exceeds 42 weeks oI a pregnancy that exceeds 42 weeks oI
gestation (term pregnancy gestation (term pregnancy 37 37- -42 weeks) 42 weeks)
- - incidence rate incidence rate 33- -12 oI all pregnancies 12 oI all pregnancies
1. Women who have long menstrual cycles (40 1. Women who have long menstrual cycles (40- -45 days) 45 days)
- - they do not ovulate on day 14 in a typical menstrual they do not ovulate on day 14 in a typical menstrual
cycle. They ovulate 14 days Irom the end oI the cycle or on cycle. They ovulate 14 days Irom the end oI the cycle or on
day 26 or 31. Their child will be late by 12 or 17 days. day 26 or 31. Their child will be late by 12 or 17 days.
2. Women receiving high dose oI Salicylates (interIeres 2. Women receiving high dose oI Salicylates (interIeres
with synthesis oI prostaglandins that initiates labor) with synthesis oI prostaglandins that initiates labor)
3. associates with myometrial quiescence (uterus that do not 3. associates with myometrial quiescence (uterus that do not
respond to normal labor) respond to normal labor)
1. meconium aspiration 1. meconium aspiration
2. macrosomia 2. macrosomia Ietus continues to grow Ietus continues to grow
3. Ietal distress 3. Ietal distress due to placental aging it causes decreased blood due to placental aging it causes decreased blood
preIusion and inadequate supply oI oxygenated blood and nutrients preIusion and inadequate supply oI oxygenated blood and nutrients
to Ietus to Ietus
1. Induction oI labor 1. Induction oI labor prostaglandins or inoprostol (cytotec) prostaglandins or inoprostol (cytotec)
applied to cervix to stimulate ripening or stripping oI membranes. applied to cervix to stimulate ripening or stripping oI membranes.
Followed by oxytocin inIusion to stimulate contraction Followed by oxytocin inIusion to stimulate contraction
2. CS delivery 2. CS delivery
RH INCMP%IBII%Y RH INCMP%IBII%Y
(Isoimmunization) (Isoimmunization)
- - occurs when the mother is Rh negative ( occurs when the mother is Rh negative (- -) who carries ) who carries
a Ietus with an Rh positive () blood a Ietus with an Rh positive () blood
- - normally there is no direct contact between normally there is no direct contact between
maternal and Ietal blood maternal and Ietal blood
- - villi ruptures villi ruptures a drop or two oI Ietal blood enters a drop or two oI Ietal blood enters
maternal circulation or during amniocentesis maternal circulation or during amniocentesis
- - small amount oI blood (drop) oI Rh Ietal blood leaks across the small amount oI blood (drop) oI Rh Ietal blood leaks across the
placenta and goes to the blood stream oI the mother. Mother will be placenta and goes to the blood stream oI the mother. Mother will be
sensitized and start to make Rh antibodies (Iirst pregnancy is not sensitized and start to make Rh antibodies (Iirst pregnancy is not
aIIected) aIIected)
- - an injection oI Rh immune globulin (Rhogam) is given ASAP an injection oI Rh immune globulin (Rhogam) is given ASAP
within 72 hours aIter the delivery (because most oI maternal within 72 hours aIter the delivery (because most oI maternal
antibodies are Iormed during the Iirst 72 hours aIter birth) antibodies are Iormed during the Iirst 72 hours aIter birth)
- - uring the subsequent pregnancy (iI Ietus is again Rh ), the uring the subsequent pregnancy (iI Ietus is again Rh ), the
Rh antibodies oI the mother crosses the placenta, enters the blood Rh antibodies oI the mother crosses the placenta, enters the blood
stream oI the Ietus causing antigen stream oI the Ietus causing antigen- -antibody reaction and Hemolysis antibody reaction and Hemolysis
oI the Ietal RBC (Erythroblastosis Fetalis) oI the Ietal RBC (Erythroblastosis Fetalis)
iagnosis: iagnosis:
1. Indirect Coomb`s test 1. Indirect Coomb`s test to check iI Rh to check iI Rh
antibodies are present within RBC surIace antibodies are present within RBC surIace
2. Antibody titer 2. Antibody titer determine at Iirst pregnancy determine at Iirst pregnancy
visit and then again at 28 weeks AOG and visit and then again at 28 weeks AOG and
aIter delivery (normal is 0) aIter delivery (normal is 0)
1. Rh Immune globulin (Rhogam) is administered at 28 weeks oI 1. Rh Immune globulin (Rhogam) is administered at 28 weeks oI
pregnancy and in the 1 pregnancy and in the 1
st st
72 hours aIter delivery 72 hours aIter delivery
2. etermine blood typed oI inIants aIter birth Irom a sample oI the 2. etermine blood typed oI inIants aIter birth Irom a sample oI the
cord blood cord blood
3. Blood transIusion through Intrauterine TransIusion 3. Blood transIusion through Intrauterine TransIusion
- - done to give restore Ietal RBC done to give restore Ietal RBC
- - 75 75- -150ml oI RBC is administered 150ml oI RBC is administered
- - aIter BT, the mother is encouraged to rest Ior 30 min. aIter BT, the mother is encouraged to rest Ior 30 min.
while FHT and uterine activity are monitored while FHT and uterine activity are monitored
4. As soon as Ietal maturity is reached, induction oI labor is 4. As soon as Ietal maturity is reached, induction oI labor is
Iollowed Iollowed
ES%%IN IBE%ES MEI%&S ES%%IN IBE%ES MEI%&S
- - a condition in which women exhibit high glucose levels a condition in which women exhibit high glucose levels
during pregnancy during pregnancy
- - an abnormal CHO, Iat and CHON metabolism that is an abnormal CHO, Iat and CHON metabolism that is
Iirst diagnosed during pregnancy (at the midpoint oI Iirst diagnosed during pregnancy (at the midpoint oI
pregnancy when insulin resistance becomes noticeable) pregnancy when insulin resistance becomes noticeable)
- - but the symptoms Iade again at the completion oI but the symptoms Iade again at the completion oI
pregnancy (resolves in delivery) pregnancy (resolves in delivery)
- - risk oI developing type 2 diabetes is high as 56 risk oI developing type 2 diabetes is high as 56- -60 60
later in liIe later in liIe
Cause: Unknown (related to excessive insulin Cause: Unknown (related to excessive insulin
resistance) resistance)
1. obesity 1. obesity
2. age over 25 years old (about 50 oI the these women 2. age over 25 years old (about 50 oI the these women
develop diabetes within 22 develop diabetes within 22- -28 years old) 28 years old)
3. history oI large babies/macrosomia (16 lbs or more) 3. history oI large babies/macrosomia (16 lbs or more)
4. Iamily history oI M/GM 4. Iamily history oI M/GM
Pathophysiology oI M Pathophysiology oI M
Metabolize FAT/CHON Ior energy
Pancreas produces no insulin or inadequate insulin
Inadequate insulin
Inability to move glucose Irom the blood to body cells
Cellular
starvation
Hyperglycemia
Glycosuria
Exerts osmotic pressure in the
kidneys
Attracts more water
Polyuria
Causes ketones and
acids to accumulate
in the blood
Polyphagia
Metabolic
acidosis
Polydipsia
iagnosis: women who are high risk Ior M should be iagnosis: women who are high risk Ior M should be
screened at Iirst prenatal visit and again at 24 screened at Iirst prenatal visit and again at 24- -28 weeks. 28 weeks.
1. lucose Challenge %est 1. lucose Challenge %est done at Iirst prenatal visit and done at Iirst prenatal visit and
again at 24 again at 24- -28 weeks 28 weeks
- - usually consists oI 8 hour Iasting Ior FBS usually consists oI 8 hour Iasting Ior FBS
- - mother is given 50g oI glucose load and a blood mother is given 50g oI glucose load and a blood
sample is taken Ior serum glucose 1 hour aIter sample is taken Ior serum glucose 1 hour aIter
- - diabetic iI FBS is more than 95mg/dl or aIter 1 hour diabetic iI FBS is more than 95mg/dl or aIter 1 hour
the serum glucose is ~140mg the serum glucose is ~140mg
lucometer lucometer
2. ral lucose %olerance %est 2. ral lucose %olerance %est
- - the gold standard Ior diagnosing diabetes the gold standard Ior diagnosing diabetes
- - mother is given 100g oI CHO/glucose then 3 hours Iasting mother is given 100g oI CHO/glucose then 3 hours Iasting
Test type Test type Pregnancies glucose level (mg/dl) Pregnancies glucose level (mg/dl)
Fasting Fasting 95 95
1 hour 1 hour 180 180
2 hours 2 hours 155 155
3 hours 3 hours 140 140
- - rate is abnormal iI 2 oI the 4 blood samples collected are rate is abnormal iI 2 oI the 4 blood samples collected are
abnormal abnormal
- - 70 hypoglycemia, ~130 hyperglycemia (normal 70 hypoglycemia, ~130 hyperglycemia (normal 80 80- -
120mg/dl) 120mg/dl)
Maternal effects of M; Maternal effects of M;
1. 1. Hypoglycemia Hypoglycemia during the Iirst trimester during the Iirst trimester glucose is being glucose is being
utilized by the Ietus Ior the development oI the brain utilized by the Ietus Ior the development oI the brain
2. 2. Hyperglycemia Hyperglycemia during the 2 during the 2
nd nd
/3 /3
rd rd
trimester at 6 months trimester at 6 months
due to HPL eIIects (causes insulin resistance) due to HPL eIIects (causes insulin resistance)
Insulin requirements Insulin requirements Ior insulin during: Ior insulin during:
11
st st
trimester trimester decrease in insulin by 33 decrease in insulin by 33
22
nd nd
/3 /3
rd rd
trimester trimester increase insulin by 50, increase insulin by 50,
Postpartum Postpartum drops suddenly to 25due to delivery oI drops suddenly to 25due to delivery oI
placenta placenta
3. prone to Irequent inIections e.g. 3. prone to Irequent inIections e.g.
Moniliasis/ Moniliasis/Candidiasis Candidiasis
4. Polyhydramnios 4. Polyhydramnios
5. ystocia 5. ystocia due to abnormality in Ietus/mother due to abnormality in Ietus/mother
Fetal Effects of M Fetal Effects of M

1. Hypoglycemia during the 1 1. Hypoglycemia during the 1
st st
trimester trimester
2. Hyperglycemia during the 2 2. Hyperglycemia during the 2
nd nd
/3 /3
rd rd
trimester trimester
3. Macrosomia 3. Macrosomia abnormally large Ior abnormally large Ior
gestational age(baby is delivered ~4000 g or gestational age(baby is delivered ~4000 g or
4kg) 4kg)
Macrosomia Macrosomia
Newborn EIIects: Newborn EIIects:
1. Hyperinsulinism 1. Hyperinsulinism because insulin Irom the mother does not because insulin Irom the mother does not
cross the placenta which lead to increase insulin production Irom cross the placenta which lead to increase insulin production Irom
the baby the baby
2. Hypoglycemia 2. Hypoglycemia when the umbilical cord is cut when the umbilical cord is cut the supply the supply
oI glucose Irom the mother also stops which results in very oI glucose Irom the mother also stops which results in very
hypoglycemia newborn (normal glucose in NB 45 hypoglycemia newborn (normal glucose in NB 45- -55mg/dl) 55mg/dl)
Signs and Symptoms: (newborn) Signs and Symptoms: (newborn)
1. High pitched shrill cry 1. High pitched shrill cry
2. tremors 2. tremors
3. jitteriness 3. jitteriness
iagnosis: Heel Stick Test to check glucose level iagnosis: Heel Stick Test to check glucose level
1. Frequent prenatal visits Ior close monitoring| 1. Frequent prenatal visits Ior close monitoring|
2. Insulin (regular/Intermediate acting insulin) 2. Insulin (regular/Intermediate acting insulin) given subcutaneously (slow given subcutaneously (slow
absorption) absorption)
- - do not massage the site oI injection do not massage the site oI injection
- - rotate the site oI injection (to prevent lipodystrohy rotate the site oI injection (to prevent lipodystrohy- - inhibits insulin inhibits insulin
absorption) absorption)
- - gently roll vial in between the palms (do not shake) gently roll vial in between the palms (do not shake)
3. Monitor blood glucose 3. Monitor blood glucose assess once a week assess once a week
- - using Iinger stick technique, using on Iingertips as the site oI lancet using Iinger stick technique, using on Iingertips as the site oI lancet
puncture, the strip is then inserted into a glucose meter to determine glucose puncture, the strip is then inserted into a glucose meter to determine glucose
level (normal 95mg/dl level (normal 95mg/dl FBS, 120mg/dl 2 hours post prandial (aIter very FBS, 120mg/dl 2 hours post prandial (aIter very
meal) level meal) level
4. Monitor Ietal well being 4. Monitor Ietal well being
a. ultrasound/Sonogram a. ultrasound/Sonogram to determine Ietal growth, amniotic Iluid to determine Ietal growth, amniotic Iluid
volume, placental location and b volume, placental location and b- -parietal diameter parietal diameter
b. daily Ietal movement count (FMC) b. daily Ietal movement count (FMC) monitoring Ior movements oI monitoring Ior movements oI
Ietus Ior 1 hour (normal 10 movement/hour) Ietus Ior 1 hour (normal 10 movement/hour)
c. amniocentesis c. amniocentesis to determine LS ratio by 36 weeks oI pregnancy and to determine LS ratio by 36 weeks oI pregnancy and
to assess Ietal lung maturity to assess Ietal lung maturity
- - cervix is not yet ripe or not yet responsive to contractions cervix is not yet ripe or not yet responsive to contractions
- - babies oI diabetic mother are abnormally large making vaginal babies oI diabetic mother are abnormally large making vaginal
delivery diIIicult delivery diIIicult
6. woman with gestational diabetes usually demonstrates normal glucose 6. woman with gestational diabetes usually demonstrates normal glucose
levels by 24 hours aIter birth (and needs no Iurther insulin therapy) levels by 24 hours aIter birth (and needs no Iurther insulin therapy)
Heart isease Heart isease

- - Origin: 90 Rheumatic (incidence expected to decrease as Origin: 90 Rheumatic (incidence expected to decrease as
incidence oI rheumatic Iever decreases), 10 congenital lesions incidence oI rheumatic Iever decreases), 10 congenital lesions
or syphilis or syphilis
- - Normal hemodynamics oI pregnancy that adversely aIIect the Normal hemodynamics oI pregnancy that adversely aIIect the
client with heart disease: client with heart disease:
- - a. oxygen consumption increased 10 to 20; related to the a. oxygen consumption increased 10 to 20; related to the
needs oI the growing Ietus needs oI the growing Ietus
- - b. plasma level and blood volume increase; RBC`s remain the b. plasma level and blood volume increase; RBC`s remain the
same (physiologic anemia) same (physiologic anemia)
Functional or %herapeutic Classification of Heart isease during Functional or %herapeutic Classification of Heart isease during
Pregnancy: Pregnancy:
CSS I CSS I no limitation oI physical activity; no symptoms oI cardiac no limitation oI physical activity; no symptoms oI cardiac
insuIIiciency or angina insuIIiciency or angina
CSS II CSS II sight limitation oI physical activity; may experience sight limitation oI physical activity; may experience
excessive Iatigue, palpitation, angina or dyspnea; slight limitations as excessive Iatigue, palpitation, angina or dyspnea; slight limitations as
indicated indicated
CSS III CSS III moderate to marked limitation oI physical activity; moderate to marked limitation oI physical activity;
dyspnea, angina and Iatigue occur with slight activity and bed rest is dyspnea, angina and Iatigue occur with slight activity and bed rest is
indicated during most oI pregnancy indicated during most oI pregnancy
CSS I CSS IV V marked limitation oI physical activity; angina, dyspnea and marked limitation oI physical activity; angina, dyspnea and
discomIort occur at rest; pregnancy should be avoided; indication Ior discomIort occur at rest; pregnancy should be avoided; indication Ior
termination oI pregnancy termination oI pregnancy
Nursing Care of Pregnant Client with heart isease: Nursing Care of Pregnant Client with heart isease:
1. ssessment: 1. ssessment:
a. Prenatal period a. Prenatal period
- - vital signs; weight gain; dietary patterns, knowledge about vital signs; weight gain; dietary patterns, knowledge about
selI care; signs oI heart Iailure, stress Iactors such as work, selI care; signs oI heart Iailure, stress Iactors such as work,
household duties household duties
b. Intrapartal period b. Intrapartal period
- - vital signs (heart rate will increase); respiratory changes vital signs (heart rate will increase); respiratory changes
(dyspnea, coughing, crackles); FHR patterns (dyspnea, coughing, crackles); FHR patterns
c. Postpartal period c. Postpartal period
- - signs oI heart Iailure or hemorrhage related to Iluid shiIts, signs oI heart Iailure or hemorrhage related to Iluid shiIts,
intake and output intake and output
2. nalysis/ Nursing iagnosis 2. nalysis/ Nursing iagnosis
a. activity intolerance related to increased cardiac workload a. activity intolerance related to increased cardiac workload
b. anxiety related to unknown course oI pregnancy, possible los oI b. anxiety related to unknown course oI pregnancy, possible los oI
Ietus and inability to perIorm role responsibilities Ietus and inability to perIorm role responsibilities
c. decreased cardiac output related to stress oI pregnancy and c. decreased cardiac output related to stress oI pregnancy and
pathology associated with heart disease pathology associated with heart disease
d. Iear related to possible death d. Iear related to possible death
e. excess Iluid volume related to Iluid shiIts resulting Irom a e. excess Iluid volume related to Iluid shiIts resulting Irom a
decrease in intra decrease in intra- -abdominal pressure Iollowing birth abdominal pressure Iollowing birth
I. risk Ior impaired parenting related to increased responsibility oI I. risk Ior impaired parenting related to increased responsibility oI
caring Ior a neonate caring Ior a neonate
3. Nursing Interventions 3. Nursing Interventions
. Prenatal period . Prenatal period
1. teach importance oI rest and avoidance oI stress 1. teach importance oI rest and avoidance oI stress
2. instruct regarding use oI elastic stockings and periodic 2. instruct regarding use oI elastic stockings and periodic
evaluation oI legs evaluation oI legs
3. teach appropriate (dietary intake; adequate calories to ensure 3. teach appropriate (dietary intake; adequate calories to ensure
appropriate, but not excessive, weight gain; limited, not restricted salt appropriate, but not excessive, weight gain; limited, not restricted salt
intake intake
4. administer medications as ordered; heparin, Iurosemide (lasix), 4. administer medications as ordered; heparin, Iurosemide (lasix),
digitalis, beta blockers (inderal) digitalis, beta blockers (inderal)
5. monitor Ior signs oI heart Iailure such as respiratory distress 5. monitor Ior signs oI heart Iailure such as respiratory distress
and tachycardia; may be precipitated by severe anemia oI pregnancy and tachycardia; may be precipitated by severe anemia oI pregnancy
B. Intrapartal period B. Intrapartal period
1. encourage mother to remain in semi Fowler`s position or 1. encourage mother to remain in semi Fowler`s position or
leIt lateral position leIt lateral position
2. provide continuous cardiac monitoring 2. provide continuous cardiac monitoring
3. provide electronic Ietal monitoring 3. provide electronic Ietal monitoring
4. assist mother to cope with discomIort; minimal analgesia 4. assist mother to cope with discomIort; minimal analgesia
and anesthesia are used and anesthesia are used
5. assist with Iorceps delivery in second stage oI labor to avoid 5. assist with Iorceps delivery in second stage oI labor to avoid
work oI pushing work oI pushing
6. monitor Ior signs oI heart Iailure, such as respiratory 6. monitor Ior signs oI heart Iailure, such as respiratory
distress and tachycardia distress and tachycardia
C. Postpartal period C. Postpartal period (most critical time because oI increased (most critical time because oI increased
circulating blood volume aIter birth oI placenta) circulating blood volume aIter birth oI placenta)
1. institute early ambulation schedule; apply elastic stockings 1. institute early ambulation schedule; apply elastic stockings
2. monitor Ior signs oI heart Iailure, such as respiratory 2. monitor Ior signs oI heart Iailure, such as respiratory
distress and tachycardia distress and tachycardia
3. monitor heart rate; accelerated heart rate oI mother in latter 3. monitor heart rate; accelerated heart rate oI mother in latter
halI oI pregnancy puts extra workload on her heart halI oI pregnancy puts extra workload on her heart
4. provide Ior adequate rest; the increase in oxygen 4. provide Ior adequate rest; the increase in oxygen
consumption with contractions during labor makes length oI labor consumption with contractions during labor makes length oI labor
a signiIicant Iactor a signiIicant Iactor
5. provide close supervision; sudden tachycardia during birth or 5. provide close supervision; sudden tachycardia during birth or
sudden bradycardia and normal increase in cardiac output sudden bradycardia and normal increase in cardiac output
Iollowing birth may cause cardiac arrest Iollowing birth may cause cardiac arrest
6. administer prescribed prophylactic antibiotics to mother with 6. administer prescribed prophylactic antibiotics to mother with
history oI rheumatic Iever history oI rheumatic Iever
7. reIer to various agencies Ior Iamily support, iI necessary on 7. reIer to various agencies Ior Iamily support, iI necessary on
discharge discharge
8. newborn risks include intrauterine growth retardation, 8. newborn risks include intrauterine growth retardation,
prematurity and hypoxia Ietal demise may occur prematurity and hypoxia Ietal demise may occur
IN%RPR%&M CMPIC%INS IN%RPR%&M CMPIC%INS
occur in as many as 31 oI all births occur in as many as 31 oI all births
- - broad term Ior abnormal or diIIicult labor and delivery broad term Ior abnormal or diIIicult labor and delivery
- - arise Irom 3 main components oI the labor process arise Irom 3 main components oI the labor process
1. Power (uterine contractions) 1. Power (uterine contractions)
2. Passenger (the Ietus) 2. Passenger (the Ietus)
3. Passageway (the birth canal) 3. Passageway (the birth canal)
Problems with the Power: (Force of abor) Problems with the Power: (Force of abor)
1. &terine Inertia 1. &terine Inertia sluggishness oI contractions or the Iorce oI labor or sluggishness oI contractions or the Iorce oI labor or
deIined as diIIicult, painIul, prolonged labor due to mechanical Iactors deIined as diIIicult, painIul, prolonged labor due to mechanical Iactors
- - current term current term ysIunctional Labor ysIunctional Labor
Common Causes: Common Causes:
a. inappropriate use oI analgesia (excessive or too early administration) a. inappropriate use oI analgesia (excessive or too early administration)
b. unusually large baby/multiple gestation b. unusually large baby/multiple gestation
c. poor Ietal position (posterior rather than anterior position) c. poor Ietal position (posterior rather than anterior position)
d. pelvic bone contraction (leads to narrowing oI the pelvic diameter so the d. pelvic bone contraction (leads to narrowing oI the pelvic diameter so the
Ietus cant pass) Ietus cant pass)
e. primigravida e. primigravida
I. hypotonic, hypertonic and prolonged labor I. hypotonic, hypertonic and prolonged labor
2 types: 2 types:
1. Primary 1. Primary occurring at the onset oI labor occurring at the onset oI labor
2. Secondary 2. Secondary occurring later in labor occurring later in labor
Signs and Symptoms; Signs and Symptoms;

- - irregular uterine contractions irregular uterine contractions
- - ineIIective uterine contractions (strength/duration) ineIIective uterine contractions (strength/duration)
1. Monitor uterine contractions by palpation and with the use oI 1. Monitor uterine contractions by palpation and with the use oI
electronic monitor electronic monitor
2. Prevent unnecessary Iatigues 2. Prevent unnecessary Iatigues check the client level oI Iatigue check the client level oI Iatigue
3. Prevent complications oI labor 3. Prevent complications oI labor
a. assess urinary bladder (catheterize as needed) a. assess urinary bladder (catheterize as needed)
b. assess maternal VS b. assess maternal VS
c. monitor condition oI Ietus by monitoring FHR, Ietal c. monitor condition oI Ietus by monitoring FHR, Ietal
activity and color oI amniotic Iluid activity and color oI amniotic Iluid
4. Provide comIort measures 4. Provide comIort measures
a. Irequent position changes a. Irequent position changes
b. walking b. walking
c. quiet/calm environment c. quiet/calm environment
d. breathing/relaxation technique d. breathing/relaxation technique
2. Ineffective &terine Force 2. Ineffective &terine Force
- - ineIIective uterine contractions which can result in ineIIective ineIIective uterine contractions which can result in ineIIective
labor labor
types; types;
1. Hypotonic Contractions 1. Hypotonic Contractions the number oI contractions is usually the number oI contractions is usually
low or inIrequent (not increasing beyond 2 or 3 in a 10 minute low or inIrequent (not increasing beyond 2 or 3 in a 10 minute
period) period)
- - occurs during the active phase oI labor occurs during the active phase oI labor
- - normal : 3 normal : 3- -4/10 min period with duration oI 30 seconds 4/10 min period with duration oI 30 seconds
- - bowel/bladder distention prevents bowel/bladder distention prevents
descent/engagement descent/engagement
- -large Ietus large Ietus
- - hydramnios hydramnios
- - multiparity multiparity
Signs and Symptoms Signs and Symptoms: Painless less Irequent Contraction : Painless less Irequent Contraction
1. oxytocin administration 1. oxytocin administration to strengthen contractions and to strengthen contractions and
increase eIIectiveness increase eIIectiveness
2. Amniotomy (artiIicial rupture oI membranes 2. Amniotomy (artiIicial rupture oI membranes to Iurther to Iurther
speed labor speed labor
3. Palpate the uterus and assess lochia every 15 minutes to 3. Palpate the uterus and assess lochia every 15 minutes to
prevent postpartum bleeding prevent postpartum bleeding
4. monitor maternal VS and FHR 4. monitor maternal VS and FHR
5. position changes to relieve discomIort and enhance 5. position changes to relieve discomIort and enhance
progress progress
2. Hypertonic Contractions 2. Hypertonic Contractions
- - intensity oI the contractions may not stronger or very active and intensity oI the contractions may not stronger or very active and
Irequent contractions but ineIIective Irequent contractions but ineIIective
- - occurs more Irequently and commonly seen in latent phase oI occurs more Irequently and commonly seen in latent phase oI
labor` labor`
- - the muscle Iibers oI the uterus (myometrium) do not repolarize the muscle Iibers oI the uterus (myometrium) do not repolarize
Signs and Symptoms Signs and Symptoms;;

1. PainIul nonproductive contractions 1. PainIul nonproductive contractions
3. Ietal anoxia/distress 3. Ietal anoxia/distress
4. dehydration due to excessive perspiration 4. dehydration due to excessive perspiration
5. Iatigue and exhaustion 5. Iatigue and exhaustion
1. assess quality oI contractions by uterine/Ietal external monitor 1. assess quality oI contractions by uterine/Ietal external monitor
applied at least 15 minutes interval applied at least 15 minutes interval
2. adequate rest 2. adequate rest
3. pain relieI with morphine sulIate 3. pain relieI with morphine sulIate
4. changing linen/gowns 4. changing linen/gowns
5. darkened room lights 5. darkened room lights
6. decreasing environmental stimuli 6. decreasing environmental stimuli
PRECIPI%%E BR PRECIPI%%E BR
- - deIine as labor that is completed in Iewer than 3 hours (normal length deIine as labor that is completed in Iewer than 3 hours (normal length
oI labor; Primipara 14 oI labor; Primipara 14- -20 hours, Multi 20 hours, Multi 88- -14 hours) 14 hours)
- - a IorceIul contractions that can lead to premature separation oI the a IorceIul contractions that can lead to premature separation oI the
placenta (placing the mother and Ietus at risk Ior hemorrhage) placenta (placing the mother and Ietus at risk Ior hemorrhage)

1. likely to occur in multiparity mothers 1. likely to occur in multiparity mothers
2. women undergo premature separation oI the placenta 2. women undergo premature separation oI the placenta
3. previous history oI precipitate labor 3. previous history oI precipitate labor
Complications Complications
1. hemorrhage 1. hemorrhage
2. Intracranial hemorrhage in Ietus 2. Intracranial hemorrhage in Ietus
3. lacerations (because oI IorceIul birth) 3. lacerations (because oI IorceIul birth)
4. Fetal distress 4. Fetal distress

1. tachycardia (earliest sign) 1. tachycardia (earliest sign)
2. restleness 2. restleness
3. hypotension (late sign) 3. hypotension (late sign)
4. signs oI hypovolemic shock 4. signs oI hypovolemic shock
5. vulvar pain and bruising 5. vulvar pain and bruising

1. InIorm mother at 28 weeks oI pregnancy that labor may be 1. InIorm mother at 28 weeks oI pregnancy that labor may be
shorter than normal shorter than normal
2. Tocolytic agent administration to reduce the Iorce and Irequency 2. Tocolytic agent administration to reduce the Iorce and Irequency
oI contractions oI contractions
3. Cold applications to limit bruising, pain and edema 3. Cold applications to limit bruising, pain and edema
4. In time oI hemorrhage position the mother in modiIied 4. In time oI hemorrhage position the mother in modiIied
trendelenburg position trendelenburg position
5. IVF replacement 5. IVF replacement Iast drip Iast drip
&%ERINE R&P%&RE &%ERINE R&P%&RE
- - rupture oI the uterus during labor rupture oI the uterus during labor
- - accounts Ior 5 oI maternal death accounts Ior 5 oI maternal death
- - incidence rate is 1 in 1500 births incidence rate is 1 in 1500 births
- - commonly occur Irom a vertical scar during the previous CS commonly occur Irom a vertical scar during the previous CS
or hysterectomy repair tears or hysterectomy repair tears
- - prolong labor prolong labor
- - Iaulty presentation Iaulty presentation
- - use oI oxytocin use oI oxytocin
- - traumatic maneuvers traumatic maneuvers
- - usually preceded by usually preceded by pathologic refraction ring pathologic refraction ring (an indentation is apparent (an indentation is apparent
across the abdomen over the uterus) and strong uterine contractions without any across the abdomen over the uterus) and strong uterine contractions without any
cervical dilatation, the Ietus is gripped by retraction ring and cannot descent) cervical dilatation, the Ietus is gripped by retraction ring and cannot descent)
1. sudden severe pain during a strong labor contractions 1. sudden severe pain during a strong labor contractions
2. report 'a tearing sensation 2. report 'a tearing sensation
3. hemorrhage Irom a torn uterus into the abdominal cavity and into the 3. hemorrhage Irom a torn uterus into the abdominal cavity and into the
vagina vagina
4. signs oI shock (rapid, weak pulse, Ialling blood pressure, cold clammy 4. signs oI shock (rapid, weak pulse, Ialling blood pressure, cold clammy
skin) skin)
5. absent Ietal heart sounds 5. absent Ietal heart sounds
6. localized tenderness and aching pain Irom the lower segment 6. localized tenderness and aching pain Irom the lower segment

1. Administer emergency Iluid replacement therapy as ordered 1. Administer emergency Iluid replacement therapy as ordered
2. Anticipate use oI intravenous oxytocin to attempt to contract 2. Anticipate use oI intravenous oxytocin to attempt to contract
the uterus and minimize bleeding the uterus and minimize bleeding
3. prepare mother Irom a Laparotomy as an emergency measure 3. prepare mother Irom a Laparotomy as an emergency measure
to control bleeding and eIIect a repair to control bleeding and eIIect a repair
4. Physician may perIorm 'hysterectomy (removal oI a 4. Physician may perIorm 'hysterectomy (removal oI a
damaged uterus) or BTL at the time oI Laparotomy damaged uterus) or BTL at the time oI Laparotomy
5. monitor VS and FHR 5. monitor VS and FHR
6. administer BT as ordered 6. administer BT as ordered
&%ERINE INVERSIN &%ERINE INVERSIN
- - uterus turns completely or partially inside out, it occurs immediately uterus turns completely or partially inside out, it occurs immediately
Iollowing delivery oI the placenta or in the immediate postpartum Iollowing delivery oI the placenta or in the immediate postpartum
period period
- - incidence rate is 1 in 15, 000 births incidence rate is 1 in 15, 000 births
Causes: Causes:
- - occurs aIter birth oI the inIant iI traction is applied to umbilical occurs aIter birth oI the inIant iI traction is applied to umbilical
cord to remove placenta cord to remove placenta
- - pressure is applied to the uterine Iundus when uterus is not pressure is applied to the uterine Iundus when uterus is not
contracted contracted
- - occurs when placenta attached at the Iundus (the passage oI the occurs when placenta attached at the Iundus (the passage oI the
Ietus pulls the Iundus down) Ietus pulls the Iundus down)

1. sudden gushes oI blood Irom vagina 1. sudden gushes oI blood Irom vagina
2. Iundus is not palpable 2. Iundus is not palpable
3. show signs oI blood loss (hypotension, dizziness and paleness) 3. show signs oI blood loss (hypotension, dizziness and paleness)
4. bleeding 4. bleeding
Nursing Management; Nursing Management;
1. recognize signs oI impending inversion and immediately notiIy the 1. recognize signs oI impending inversion and immediately notiIy the
physician physician
2. never attempt to replace the inversion because handling may 2. never attempt to replace the inversion because handling may
increase the bleeding increase the bleeding
3. never attempt to remove the placenta iI it still attached 3. never attempt to remove the placenta iI it still attached
4. take steps to prevent or limit hypovolemic shock 4. take steps to prevent or limit hypovolemic shock
a. use large gauge IV catheter Ior Iluid replacement a. use large gauge IV catheter Ior Iluid replacement
b. measure and record maternal VS every 5 to 15 minutes to b. measure and record maternal VS every 5 to 15 minutes to
establish baseline changes establish baseline changes
5. administer oxygen by mask 5. administer oxygen by mask
6. be prepared to perIorm CPR iI the heart Iails due to sudden 6. be prepared to perIorm CPR iI the heart Iails due to sudden
blood loss blood loss
7. the mother will be given general anesthesia or nitroglycerin or a 7. the mother will be given general anesthesia or nitroglycerin or a
tocolytic drug IV to immediately relax the uterus tocolytic drug IV to immediately relax the uterus
8. physician/nurse midwiIe replaces the Iundus manually (push the 8. physician/nurse midwiIe replaces the Iundus manually (push the
uterus back inside) uterus back inside)
MNI%IC F&I EMBISM MNI%IC F&I EMBISM
- - occurs when amniotic Iluid is Iorce to enter the maternal blood occurs when amniotic Iluid is Iorce to enter the maternal blood
circulation because oI some deIect in the membranes or aIter circulation because oI some deIect in the membranes or aIter
membranes rupture (not preventable because it cannot be membranes rupture (not preventable because it cannot be
predicted) predicted)
- - incidence rate is 1 in 8000 births incidence rate is 1 in 8000 births
Risk Iactors: Risk Iactors:

1. oxytocin administration 1. oxytocin administration
2. abruption placenta 2. abruption placenta
3. hydramnios 3. hydramnios
1. sharp pain on the chest 1. sharp pain on the chest
2. dyspnea (secondary to pulmonary artery constriction) 2. dyspnea (secondary to pulmonary artery constriction)
3. mother becomes pale and cyanotic due to pulmonary embolism and 3. mother becomes pale and cyanotic due to pulmonary embolism and
lack oI blood Ilow to the lungs lack oI blood Ilow to the lungs
1. immediate management is oxygen administration by Iace mask or 1. immediate management is oxygen administration by Iace mask or
cannula cannula
2. prepare the mother Ior CPR (may be ineIIective because these 2. prepare the mother Ior CPR (may be ineIIective because these
procedures do not relieve the pulmonary constriction) procedures do not relieve the pulmonary constriction)
3. Endotracheal intubation to maintain pulmonary Iunction 3. Endotracheal intubation to maintain pulmonary Iunction
4. The mother should be transIerred to ICU 4. The mother should be transIerred to ICU
1. 1. IC IC disseminated intravascular coagulation disseminated intravascular coagulation
- - bleeding to all portion oI body (eyes, nose, bleeding to all portion oI body (eyes, nose,
gums, IV sites) gums, IV sites)
- - therapy with Iibrinogen to counteract IC therapy with Iibrinogen to counteract IC
PRBEMS WI%H %HE PSSENER PRBEMS WI%H %HE PSSENER
1. PRPSE F &MBIIC 1. PRPSE F &MBIIC CR CR
descent oI the umbilical cord into the vagina ahead oI descent oI the umbilical cord into the vagina ahead oI
the Ietal presenting part with resulting compression oI the the Ietal presenting part with resulting compression oI the
cord (cord compression) cord (cord compression)
- - 'emergency situation ', immediate delivery is 'emergency situation ', immediate delivery is
attempted to save the baby attempted to save the baby
- - incidence rate is 0.2 incidence rate is 0.2- -0.6 oI births or 1 oI 200 0.6 oI births or 1 oI 200
pregnancies pregnancies
ssociative Factors: ssociative Factors:
1. premature rupture oI membranes (the Ietal Iluid may rush and carry 1. premature rupture oI membranes (the Ietal Iluid may rush and carry
the cord along toward the birth canal) the cord along toward the birth canal)
2. breech presentation 2. breech presentation
3. placenta previa 3. placenta previa
4. intrauterine tumors preventing the presenting part Irom engagement 4. intrauterine tumors preventing the presenting part Irom engagement
5. small Ietus 5. small Ietus
6. CP preventing engagement 6. CP preventing engagement
7. hydramnios 7. hydramnios
8. multiple gestation 8. multiple gestation

1. the umbilical cord seen or Ielt during vaginal exam 1. the umbilical cord seen or Ielt during vaginal exam
2. reports Ieeling oI cord into the vagina 2. reports Ieeling oI cord into the vagina
Management Management: (relieve compression on the cord and Ietal anoxia) : (relieve compression on the cord and Ietal anoxia)
1. periodically evaluate FHR especially aIter the rupture oI 1. periodically evaluate FHR especially aIter the rupture oI
membranes (Ietal distress) membranes (Ietal distress)
2. Physician will place a glove hand in the vagina and manually 2. Physician will place a glove hand in the vagina and manually
elevate the Ietal head oII the cord elevate the Ietal head oII the cord
3. place the mother in knee 3. place the mother in knee- -chest position/trendelenburg position chest position/trendelenburg position
(causes the Ietal head to Iall back Irom the cord) (causes the Ietal head to Iall back Irom the cord)
4. administer oxygen at 10 Liters/minute by Iacemask to improve 4. administer oxygen at 10 Liters/minute by Iacemask to improve
oxygenation oI the Ietus oxygenation oI the Ietus
5. do not attempt to push any exposed cord back into the vagina (adds 5. do not attempt to push any exposed cord back into the vagina (adds
to compression) to compression)
6. cover any exposed portion oI the cord with sterile gauge 6. cover any exposed portion oI the cord with sterile gauge
soaked in NSS around the prolapsed cord soaked in NSS around the prolapsed cord
7. iI the cervix is Iully dilated at the time oI prolapsed (the most 7. iI the cervix is Iully dilated at the time oI prolapsed (the most
emergent delivery route is NS and encourage mother to push) emergent delivery route is NS and encourage mother to push)
8. iI not Iully dilated, mother is delivered via CS (upward 8. iI not Iully dilated, mother is delivered via CS (upward
pressure on the presenting part to keep pressure oII the cord) pressure on the presenting part to keep pressure oII the cord)
PRBEMS WI%H PSI%IN, PRBEMS WI%H PSI%IN,

PRESEN%%IN R SIE: PRESEN%%IN R SIE:
1. CCIPI% 1. CCIPI%- -PS%ERIR PSI%IN PS%ERIR PSI%IN
- - LOA (leIt occipito LOA (leIt occipito- -anterior) is the most ideal and common Ietal anterior) is the most ideal and common Ietal
position position
- - LOP (leIt occipito LOP (leIt occipito- -posterior) is located on leIt and posterior posterior) is located on leIt and posterior
quadrant pelvis quadrant pelvis
- - ROP (right occipito ROP (right occipito- -posterior) is located at the right and posterior) is located at the right and
posterior quadrant pelvis posterior quadrant pelvis
ROP ROP in this position, during the internal rotation, the Ietal head must in this position, during the internal rotation, the Ietal head must
rotate not through a 90 degree arc but through an arc oI approximately rotate not through a 90 degree arc but through an arc oI approximately
135 degrees 135 degrees
1. Women with android/anthropoid pelvis. 1. Women with android/anthropoid pelvis.
Signs and Symptoms Signs and Symptoms; ;
- - Intense lower back pain (lumbosacral pain) Intense lower back pain (lumbosacral pain) due to due to
compression oI sacral nerves during rotation compression oI sacral nerves during rotation
- - Shooting leg pains Shooting leg pains
1. provide back rub 1. provide back rub
2. change oI position (squatting position) 2. change oI position (squatting position) may help Ietus to may help Ietus to
rotate rotate
3. encourage voiding every 2 hours to keep bladder empty 3. encourage voiding every 2 hours to keep bladder empty
(because Iull bladder impedes descent oI the Ietus) (because Iull bladder impedes descent oI the Ietus)
4. apply hot/cold compress 4. apply hot/cold compress
5. delivered via CS 5. delivered via CS
2. BREECH PRESEN%%INS 2. BREECH PRESEN%%INS presenting presenting
parts are usually buttocks and Ieet parts are usually buttocks and Ieet
Complications: Complications:
1. anoxia (due to prolapsed umbilical cord) 1. anoxia (due to prolapsed umbilical cord)
2. intracranial hemorrhage 2. intracranial hemorrhage
3. Iracture oI the pine/extremities 3. Iracture oI the pine/extremities
4. dysIunctional labor 4. dysIunctional labor

1. gestational age under 40 weeks 1. gestational age under 40 weeks
2. abnormality in the Ietus such as anencephaly, hydrocephalus 2. abnormality in the Ietus such as anencephaly, hydrocephalus
3. hydramnios (allows Ior Iree Ietal movement) 3. hydramnios (allows Ior Iree Ietal movement)
4. congenital anomaly oI the uterus 4. congenital anomaly oI the uterus
5. multiple gestation 5. multiple gestation

1. Fetal heart sounds usually heard high in the abdomen (UR", 1. Fetal heart sounds usually heard high in the abdomen (UR",
UL") UL")
iagnosis; Leopold`s maneuver, vaginal exams and ultrasounds iagnosis; Leopold`s maneuver, vaginal exams and ultrasounds
will reveal breech presentations will reveal breech presentations
1. External version is being used to avoid some CS deliveries Ior a 1. External version is being used to avoid some CS deliveries Ior a
breech presentations breech presentations
VERSION VERSION is a method oI changing the Ietal presentation usually is a method oI changing the Ietal presentation usually
Irom breech to cephalic. Irom breech to cephalic.
- - done aIter 37 weeks oI gestation but beIore the onset oI labor done aIter 37 weeks oI gestation but beIore the onset oI labor
- - begins with non begins with non- -stress test and BPF to determine oI the Ietus stress test and BPF to determine oI the Ietus
is in good condition and iI there is adequate amount oI amniotic is in good condition and iI there is adequate amount oI amniotic
Iluid Iluid
- - mother is given tocolytic drug to relax her uterus during mother is given tocolytic drug to relax her uterus during
version version
- - UTZ is used to guide the procedure while physician pushes the UTZ is used to guide the procedure while physician pushes the
Ietal buttocks upward out oI the pelvis while pushing the Ietal Ietal buttocks upward out oI the pelvis while pushing the Ietal
head downward toward the pelvis in either clockwise or head downward toward the pelvis in either clockwise or
counterclockwise direction counterclockwise direction
3. the head may also be delivered using Iorceps delivery to 3. the head may also be delivered using Iorceps delivery to
control the Ilexion and rate oI descent control the Ilexion and rate oI descent
%HERPE&%IC MNEMEN% F %HERPE&%IC MNEMEN% F
PRBEMS R P%EN%I PRBEMS IN PRBEMS R P%EN%I PRBEMS IN
BR N BIR%H BR N BIR%H
1. Induction of labor 1. Induction of labor done when labor done when labor
contractions are ineIIective contractions are ineIIective
- - means that labor is started artiIicially means that labor is started artiIicially
Indications; Indications;
1. pre 1. pre- -eclampsia eclampsia
2. eclampsia 2. eclampsia
3. severe hypertension/M 3. severe hypertension/M
4. Rh sensitization 4. Rh sensitization
5. prolong rupture oI membranes 5. prolong rupture oI membranes
6. post maturity 6. post maturity
Requirements for labor induction; Requirements for labor induction;

1. Ietus must be in longitudinal lie 1. Ietus must be in longitudinal lie
2. cervix must be ripe 2. cervix must be ripe
3. presenting part must be engaged 3. presenting part must be engaged
4. No CP 4. No CP
5. Ietus is matured by date, LS ratio or sonogram (bi 5. Ietus is matured by date, LS ratio or sonogram (bi- -parietal parietal
diameter) diameter)
Pharmacological Methods: Pharmacological Methods:
1. Cervical Ripening 1. Cervical Ripening soItening oI the cervix/consistency soItening oI the cervix/consistency
- - is the FIRST STEP the uterus must complete in early is the FIRST STEP the uterus must complete in early
labor labor
- - necessary Ior dilatation and uterine contractions necessary Ior dilatation and uterine contractions
Criteria: Criteria:
Scoring oI cervix Ior readiness in elective conductions (iI Scoring oI cervix Ior readiness in elective conductions (iI
the scale is 8 or above, the woman is considered ready Ior the scale is 8 or above, the woman is considered ready Ior
birth and induction) birth and induction)
$cor|ng
Factor
0 1 2 3
||alal|or (cr) 0 1-2 3-1 5-
Ellacererl () 0-30 10-50 0-Z0 80
3lal|or -3 -2 -1, 0 1, 2
Cors|slercy F|rr Ved|ur 3oll
Pos|l|or Posler|or V|d-Posler|or Arler|or
Prostaglandin el Prostaglandin el commonly used method oI speeding commonly used method oI speeding
cervical ripening and is applied to the inIerior surIace oI cervical ripening and is applied to the inIerior surIace oI
the cervix the cervix
- - applied beIore labor induction applied beIore labor induction
- - can also be applied on the external surIace by can also be applied on the external surIace by
applying the gel to the diaphragm then placing the applying the gel to the diaphragm then placing the
diaphragm against the cervix diaphragm against the cervix
- - apply every 6 hours Ior 2 apply every 6 hours Ior 2- -3 doses 3 doses
Nursing Considerations; Nursing Considerations;
1. Place women in Ilat position to prevent leakage oI medication 1. Place women in Ilat position to prevent leakage oI medication
2. the woman remains on bed rest Ior 1 to 2 hours and is monitored Ior 2. the woman remains on bed rest Ior 1 to 2 hours and is monitored Ior
uterine contractions uterine contractions
3. monitor FHR continuously Ior at least 30 minutes aIter each 3. monitor FHR continuously Ior at least 30 minutes aIter each
application up to 2 hours application up to 2 hours
4. IV line with saline is initiated in case uterine hyperstimulation 4. IV line with saline is initiated in case uterine hyperstimulation
occurs such as contractions longer than 90 seconds or more than 5 occurs such as contractions longer than 90 seconds or more than 5
contraction in 10 minutes contraction in 10 minutes
5. explain the side eIIects 5. explain the side eIIects vomiting, Iever, diarrhea and hypertension vomiting, Iever, diarrhea and hypertension
6. oxytocin induction can be started 6 6. oxytocin induction can be started 6- -12 hours aIter the last 12 hours aIter the last
prostaglandin dose prostaglandin dose
2. Induction of abor by ytocin 2. Induction of abor by ytocin a synthetic Iorm oI a synthetic Iorm oI
pituitary hormone initiates contractions in uterus pituitary hormone initiates contractions in uterus
Nursing Considerations; Nursing Considerations;
1. Given IV (to hasten eIIect), IV Iorm oI oxytocin needs to 1. Given IV (to hasten eIIect), IV Iorm oI oxytocin needs to
be diluted be diluted
2. the drug is traditionally mixed in the proportion oI 10 IU 2. the drug is traditionally mixed in the proportion oI 10 IU
in 1000ml oI Ringer`s Lactated (LR) in 1000ml oI Ringer`s Lactated (LR)
3. Administer the medication by piggyback attach to 5W 3. Administer the medication by piggyback attach to 5W
as the main IV line (iI oxytocin needs to be discontinued, the as the main IV line (iI oxytocin needs to be discontinued, the
main line will be maintain) main line will be maintain)
4. when cervical dilatations reaches 4 cm, artiIicial rupture oI 4. when cervical dilatations reaches 4 cm, artiIicial rupture oI
membranes is perIormed to Iurther induce labor and oxytocin membranes is perIormed to Iurther induce labor and oxytocin
inIusion is discontinued inIusion is discontinued
5. Monitor FHR/uterine contractions and cervical dilatation 5. Monitor FHR/uterine contractions and cervical dilatation
during the procedure during the procedure
6. side 6. side eIIects: extreme hypotension due to peripheral eIIects: extreme hypotension due to peripheral
vasodilatation, headache, vomiting vasodilatation, headache, vomiting
7. monitor VS every 15 minutes 7. monitor VS every 15 minutes
8. complications to watch; Ietal distress and uterine rupture 8. complications to watch; Ietal distress and uterine rupture
NMIES F %HE PCEN% N NMIES F %HE PCEN% N
CR;` CR;`
1. nomalies of the placenta 1. nomalies of the placenta
a. Placenta Succenturiata a. Placenta Succenturiata has one or more has one or more
accessory lobes connected to the main placenta by blood accessory lobes connected to the main placenta by blood
vessels vessels
- - no Ietal abnormality associated with it no Ietal abnormality associated with it
- - can lead to maternal hemorrhage can lead to maternal hemorrhage
(small lobes retain in the uterus aIter birth) (small lobes retain in the uterus aIter birth)
b. Placenta Circumvallata b. Placenta Circumvallata Ietal side oI the placenta is covered with Ietal side oI the placenta is covered with
chorion (normally, no chorion covers the Ietal side oI the placenta) chorion (normally, no chorion covers the Ietal side oI the placenta)
- - no abnormalities is associated with this types oI no abnormalities is associated with this types oI
placental anomaly placental anomaly
c. Battle c. Battle--dore dore Placenta Placenta the cord is inserted marginally rather than the cord is inserted marginally rather than
centrally centrally
- - rare/unknown clinical signiIicance rare/unknown clinical signiIicance
d. Velamentous Insertion of the Cord d. Velamentous Insertion of the Cord situation in which the cord situation in which the cord
instead oI entering the placenta directly, separated into small vessels that instead oI entering the placenta directly, separated into small vessels that
reach the placenta by spreading across a Iold oI amnion reach the placenta by spreading across a Iold oI amnion
Postpartum Complications Postpartum Complications
1. 1. Postpartum hemorrhage Postpartum hemorrhage major cause oI maternal major cause oI maternal
death, occurs in 4 oI deliveries death, occurs in 4 oI deliveries
- - deIined as blood loss greater than 500 ml aIter deIined as blood loss greater than 500 ml aIter
vaginal birth or 1000 ml aIter CS vaginal birth or 1000 ml aIter CS
ClassiIications: ClassiIications:
According to severity: According to severity:
a. Mild a. Mild 750 750 1250 ml 1250 ml
b. Moderate b. Moderate 1250 1250 1750 ml 1750 ml
c. Severe c. Severe 2500 ml 2500 ml
According to time: According to time:
1. Early Postpartum hemor 1. Early Postpartum hemorrhage rhage occurs within 24 hours oI birth occurs within 24 hours oI birth
2. ate postpartum hemorrhage 2. ate postpartum hemorrhage occurs aIter 24 hours until 6 weeks aIter occurs aIter 24 hours until 6 weeks aIter
birth birth
Major Risk: Major Risk: Hypovolemic Shock Hypovolemic Shock (low volume) (low volume)
- - occurs when the circulating blood volume is decreased which occurs when the circulating blood volume is decreased which
interrupts blood Ilow to body cells interrupts blood Ilow to body cells
- - maniIested as: maniIested as:
a. Tachycardia (Iirst sign) a. Tachycardia (Iirst sign)
b. hypotension b. hypotension
c. cold and clammy skin c. cold and clammy skin
d. mental changes such as anxiety, conIusion, restleness d. mental changes such as anxiety, conIusion, restleness
e. decrease urine output e. decrease urine output
Conditions that increase risk for PP hemorrhage Conditions that increase risk for PP hemorrhage
1. Over distension oI the uterus 1. Over distension oI the uterus
Multiple births Multiple births
Hydramnios Hydramnios
Macrosomia Macrosomia
2. Trauma r/t Iorceps, uterine manipulation 2. Trauma r/t Iorceps, uterine manipulation
3. Prolonged labor 3. Prolonged labor
4. Uterine inIection 4. Uterine inIection
5. Trauma removing placenta 5. Trauma removing placenta
Causes of Postpartum hemorrhage Causes of Postpartum hemorrhage
1. 1. &terine tony &terine tony: Uterus without tone or lack oI : Uterus without tone or lack oI
normal muscle tone (90 oI cases) normal muscle tone (90 oI cases)
- - uterine atony allows blood vessels at the uterine atony allows blood vessels at the
placenta site to bleed Ireely and usually massively. placenta site to bleed Ireely and usually massively.
- - uterine muscle unable to contract around blood uterine muscle unable to contract around blood
vessels at placental site vessels at placental site
1. eep anesthesia 1. eep anesthesia
2. ~30 years old 2. ~30 years old
3. prolonged use oI magnesium sulIate 3. prolonged use oI magnesium sulIate
4. previous uterine surgery 4. previous uterine surgery
5. Over exhaustion 5. Over exhaustion
Symptoms: Symptoms:
1. uterus is diIIicult to Ieel and is boggy (soIt) 1. uterus is diIIicult to Ieel and is boggy (soIt)
2. lochia is increased and may have large blood clots 2. lochia is increased and may have large blood clots
3. Blood may 'gush or come out slowly 3. Blood may 'gush or come out slowly
1. Massage the uterus until Iirm 1. Massage the uterus until Iirm
2. have mother to urinate or catheterize because bladder distension 2. have mother to urinate or catheterize because bladder distension
pushes the uterus upward or in the side and interIeres with the pushes the uterus upward or in the side and interIeres with the
ability oI the uterus to contract ability oI the uterus to contract
3. Encourage mother to breastIeed because sucking stimulation 3. Encourage mother to breastIeed because sucking stimulation
causes the release oI oxytocin Irom PPG causes the release oI oxytocin Irom PPG
4. Administration oI IV oxytocin or Methylergonovine 4. Administration oI IV oxytocin or Methylergonovine
(Methergine) to control uterine atony (Methergine) to control uterine atony
5. Hysterectomy is perIormed to remove the bleeding uterus that 5. Hysterectomy is perIormed to remove the bleeding uterus that
does not respond to other measures does not respond to other measures
2. acerations 2. acerations tearing oI the birth canal tearing oI the birth canal
- - normally occurs as a result oI child bearing normally occurs as a result oI child bearing
Risk Iactors: Risk Iactors:
a. diIIicult or precipitate births a. diIIicult or precipitate births
b. primigravidas b. primigravidas
c. birth oI a large inIant c. birth oI a large inIant
d. use oI a lithotomy position and instruments d. use oI a lithotomy position and instruments
(Iorceps) (Iorceps)
Sites of lacerations: Sites of lacerations:
1. Cervical acerations 1. Cervical acerations
- - characterized by gushes oI bright red blood Irom the vaginal characterized by gushes oI bright red blood Irom the vaginal
opening iI uterine artery is torn opening iI uterine artery is torn
- - diIIicult to repair because the bleeding may be so intense that it diIIicult to repair because the bleeding may be so intense that it
can obstruct visualization oI the area. can obstruct visualization oI the area.
2. Vaginal acerations 2. Vaginal acerations
- - rare case but easier to assess rare case but easier to assess
- - oozing oI blood aIter repair, vaginal packing is necessary to oozing oI blood aIter repair, vaginal packing is necessary to
maintain pressure Irom the suture line maintain pressure Irom the suture line
- - catheterize the mother because packing causes pressure on catheterize the mother because packing causes pressure on
urethra urethra
- - packing is removed aIter 24 packing is removed aIter 24- -48 hours (at risk Ior inIection) 48 hours (at risk Ior inIection)
3. Perineal acerations 3. Perineal acerations
- - usually occurs when mother is placed on lithotomy positions usually occurs when mother is placed on lithotomy positions
(increases pressure on perineum) (increases pressure on perineum)
ClassiIications: ClassiIications:
a. First egree a. First egree vaginal mucous membranes and skin oI the vaginal mucous membranes and skin oI the
perineum to the Iourchette perineum to the Iourchette
b. Second egree b. Second egree vagina, perineal skin, Iascia and perineal body vagina, perineal skin, Iascia and perineal body
c. %hird egree c. %hird egree entire perineum and reaches the external sphincter entire perineum and reaches the external sphincter
oI the rectum oI the rectum
d. Fourth egree d. Fourth egree entire perineum, rectal sphincter and some oI the entire perineum, rectal sphincter and some oI the
mucous membrane oI the rectum mucous membrane oI the rectum
Management Management (Perineal) (Perineal)
1. sutured and treated using episiotomy repair 1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool soItener is prescribed Ior 2. diet high in carbohydrate and a stool soItener is prescribed Ior
the Iirst week postpartum to prevent constipation which could the Iirst week postpartum to prevent constipation which could
break the sutures break the sutures
3. do not take rectal temperatures because the hard tips oI 3. do not take rectal temperatures because the hard tips oI
equipment could open sutures equipment could open sutures
3. Retained Placental Fragments 3. Retained Placental Fragments placenta does not deliver its placenta does not deliver its
entire Iragments and leIt behind leading to uterine bleeding entire Iragments and leIt behind leading to uterine bleeding
Causes: Causes:
a. Placenta Succenturiata a. Placenta Succenturiata a placenta with accessory lobe a placenta with accessory lobe
b. Placenta Accreta b. Placenta Accreta a placenta that Iuses with myometrium because oI an a placenta that Iuses with myometrium because oI an
abnormal basalis layer abnormal basalis layer
1. iI Large Iragments 1. iI Large Iragments
- - Patient bleeds immediately at delivery Patient bleeds immediately at delivery
- - Uterus is boggy Uterus is boggy
2. iI Small Iragments 2. iI Small Iragments
- - bleeding occurs at 6 bleeding occurs at 6
th th
10 10
th th
day PP day PP
- - Can cause subinvolution Can cause subinvolution
1. ilatation and Curettage (&C) will be perIormed to remove 1. ilatation and Curettage (&C) will be perIormed to remove
placental Iragments and to stop bleeding placental Iragments and to stop bleeding
2. administration oI Methotrexate to destroy the retained 2. administration oI Methotrexate to destroy the retained
placental tissue placental tissue
3. instruct the mother to observe the color oI lochia discharge 3. instruct the mother to observe the color oI lochia discharge
4. check the completeness oI the placenta aIter birth 4. check the completeness oI the placenta aIter birth
4. isseminated Intravascular Coagulation (IC) 4. isseminated Intravascular Coagulation (IC)
- - deIiciency in clotting ability caused by vascular injury deIiciency in clotting ability caused by vascular injury
characterized by bleeding the IV sites, nose, gums etc. characterized by bleeding the IV sites, nose, gums etc.
Associative Factors: Associative Factors:
a. premature separation oI the placenta a. premature separation oI the placenta
b. missed early miscarriage b. missed early miscarriage
c. Ietal death in utero c. Ietal death in utero
5. Perineal Hematoma 5. Perineal Hematoma is a collection oI blood in the is a collection oI blood in the
subcutaneous layer tissue oI the perineum caused by injury to blood subcutaneous layer tissue oI the perineum caused by injury to blood
vessels aIter birth vessels aIter birth
a. rapid spontaneous birth a. rapid spontaneous birth
b. perineal varicosities b. perineal varicosities
c. episiotomy or laceration repair sites c. episiotomy or laceration repair sites
1. severe pain in the perineal area 1. severe pain in the perineal area
2. Ieeling oI pressure between the legs 2. Ieeling oI pressure between the legs
3. purplish discoloration/swelling on perineum 3. purplish discoloration/swelling on perineum
4. concealed bleeding 4. concealed bleeding
1. assess the size by measuring it in centimeters 1. assess the size by measuring it in centimeters
2. administer a mild analgesic as pain relieI 2. administer a mild analgesic as pain relieI
3. apply an ice pack (covered by towel to prevent thermal 3. apply an ice pack (covered by towel to prevent thermal
injury to the skin) injury to the skin)
4. incision and drainage oI the site oI hematoma and is 4. incision and drainage oI the site oI hematoma and is
packed with gauze packed with gauze
Puerperal Infection Puerperal Infection
- - InIection oI the reproductive tract associated with giving birth InIection oI the reproductive tract associated with giving birth
- - Usually occurs within 10 days oI birth Usually occurs within 10 days oI birth
- - Another leading cause oI maternal death Another leading cause oI maternal death
- - Predisposing Iactors: Predisposing Iactors:
a. Prolonged rupture oI membranes (~24 hours) a. Prolonged rupture oI membranes (~24 hours)
b. C b. C- -section section
c. Trauma during birth process c. Trauma during birth process
d. Maternal anemia d. Maternal anemia
e. Retained placental Iragments e. Retained placental Iragments
- - InIection may be localized or systemic InIection may be localized or systemic
a. Local inIection can spread to peritoneum (peritonitis) or circulatory a. Local inIection can spread to peritoneum (peritonitis) or circulatory
system (septicemia). system (septicemia).
b. Fatal to woman already stressed with childbirth b. Fatal to woman already stressed with childbirth
ssessment findings: ssessment findings:
1. Temp oI 100.4 Ior more than 2 consecutive days, 1. Temp oI 100.4 Ior more than 2 consecutive days, excluding the Iirst 24 excluding the Iirst 24
hours hours. .
2. Abdominal, perineal, or pelvic pain 2. Abdominal, perineal, or pelvic pain
3. Foul 3. Foul- -smelling vaginal discharge smelling vaginal discharge
4. Burning sensation with urination 4. Burning sensation with urination
5. Chills, malaise 5. Chills, malaise
6. Rapid pulse and respirations 6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity 7. Elevated WBC, positive culture and sensitivity
(Remember, 20 (Remember, 20- -25,000 is normal aIter delivery 25,000 is normal aIter delivery MASKING inIection) MASKING inIection)
Nursing interventions Nursing interventions
1. Force Iluids; may need more than 3L/day 1. Force Iluids; may need more than 3L/day
2. Administer antibiotics aIter culture and sensitivity oI the organism 2. Administer antibiotics aIter culture and sensitivity oI the organism
(Group B streptococci and E. Coli) and other meds as ordered (Group B streptococci and E. Coli) and other meds as ordered
3. Treat symptoms as they arise 3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet 4. Encourage high calorie, high protein diet
5. Position patient in a semi 5. Position patient in a semi- -Fowlers to promote drainage and prevent Fowlers to promote drainage and prevent
reIlux higher into reproductive tract reIlux higher into reproductive tract
6. Use oI sterile equipments on birth canal during labor, birth and 6. Use oI sterile equipments on birth canal during labor, birth and
postpartum postpartum
7. Educate the mother about proper perineal care including wiping Irom 7. Educate the mother about proper perineal care including wiping Irom
Iront to back Iront to back
Endometritis Endometritis
- - reIers to the inIection oI the endometrium, the lining oI the uterus at reIers to the inIection oI the endometrium, the lining oI the uterus at
the time oI birth or during Postpartal period the time oI birth or during Postpartal period
1. Iever on the third or Iourth day postpartum(increase in oral 1. Iever on the third or Iourth day postpartum(increase in oral
temperature above 38C Ior 2 consecutive 24 hour periods, excluding temperature above 38C Ior 2 consecutive 24 hour periods, excluding
the Iirst 24 hours period aIter birth) the Iirst 24 hours period aIter birth)
2. chills, loss oI appetite and general body malaise 2. chills, loss oI appetite and general body malaise
4. Ioul smelling lochia 4. Ioul smelling lochia
1. ATBC administration such as Clindamycin aIter culture 1. ATBC administration such as Clindamycin aIter culture
2. oxytocin is given to encourage uterine contraction 2. oxytocin is given to encourage uterine contraction
3. encourage increase Iluid intake to combat Iever 3. encourage increase Iluid intake to combat Iever
4. analgesic as ordered Ior pain relieI due to aIter pains and 4. analgesic as ordered Ior pain relieI due to aIter pains and
abdominal discomIorts abdominal discomIorts
5. encourage client to ambulate or in Fowler`s position to 5. encourage client to ambulate or in Fowler`s position to
promote lochia drainage and prevent pooling oI inIected promote lochia drainage and prevent pooling oI inIected
secretions secretions
6. IV therapy 6. IV therapy
Perineal Infection Perineal Infection
- - localized inIection oI the suture line Irom an episiotomy site localized inIection oI the suture line Irom an episiotomy site
1. Ieeling oI heat, pain and pressure on the suture line 1. Ieeling oI heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away 2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines 3. purulent discharges on suture lines
1. removal oI perineal sutures to open and allow Ior drainage 1. removal oI perineal sutures to open and allow Ior drainage
2. Topical, systemic ATBC as ordered 2. Topical, systemic ATBC as ordered
3. Analgesic to alleviate discomIort 3. Analgesic to alleviate discomIort
4. Provide Sitz bath or warm compress to hasten drainage and 4. Provide Sitz bath or warm compress to hasten drainage and
cleanse the area cleanse the area
5. Remind the mother to change perineal pads Irequently to 5. Remind the mother to change perineal pads Irequently to
prevent contamination/inIection prevent contamination/inIection
6. Teach proper perineal care wiping Irom Iront to back aIter 6. Teach proper perineal care wiping Irom Iront to back aIter
bowel movement (to prevent bringing the Ieces to the healing bowel movement (to prevent bringing the Ieces to the healing
area) area)

Maternal & Child Health in the Philippines: Risks, Indicators & Solutions

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Maternal & Child Health in the Philippines: Risks, Indicators & Solutions

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National Health Situation National Health Situation

Maternal & Child Health Maternal & Child Health

Renal Iailure Renal Iailure

Maternal and fetal death Maternal and fetal death

2. %hreatened bortion 2. %hreatened bortion

Risk Factors: Risk Factors:

Signs and Symptoms: Signs and Symptoms:

Fetal ssessment: Fetal ssessment:

B. B. ABRUP1IO PLACEA1A ABRUP1IO PLACEA1A

egrees of Separation rade criteria: egrees of Separation rade criteria:

Signs and Symptoms: Signs and Symptoms:

Signs and Symptoms: Signs and Symptoms:

Interstitials EIIects: Interstitials EIIects:

Feto Feto- -placental eIIects: placental eIIects:

Signs and symptoms: Signs and symptoms:

Medical Management: Medical Management:

Signs and Symptoms: Signs and Symptoms:

Nursing Management: Nursing Management:

Cause: Unknown Cause: Unknown

2. izygotic Twins 2. izygotic Twins

Associative Factors: Associative Factors:

Fetal Effects of M Fetal Effects of M

Heart isease Heart isease

Signs and Symptoms; Signs and Symptoms;

Signs and Symptoms Signs and Symptoms;;

Risk Factors: Risk Factors:

Signs and symptoms: Signs and symptoms:

Nursing Management: Nursing Management:

Nursing Management: Nursing Management:

Signs and Symptoms: Signs and Symptoms:

Risk Iactors: Risk Iactors:

Signs and Symptoms; Signs and Symptoms;

PRBEMS WI%H PSI%IN, PRBEMS WI%H PSI%IN,

Risk Factors: Risk Factors:

Signs and Symptoms; Signs and Symptoms;

Requirements for labor induction; Requirements for labor induction;

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