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FALSE LABOR
CANDAC
Contraction disappear with ambulation
Absence of cervical dilation
No DIF (duration, intensity, frequency)
Discomfort @ abdomen
Absence of show
Contraction stops when sedated
TRUE LABOR
CUPPAD
Contraction persists when sedated
Uterine contraction DIF (duration, intensity, frequency)
Progressive cervical dilation
Presence of show
Ambulation increase contractions
Discomfort radiates to lumbosacral area
LENGTH OF LABOR
STAGE OF LABOR
PRIMI (VIRGIN)
MULTI (DIS-VIRGIN)
1ST STAGE
10 12 HOURS
6 8 HOURS
2ND STAGE
30 MINS 2 HOURS
Ave: 50 mins
20 90 MINS
Ave: 20 mins
3RD STAGE
5 20 MINS
5 20 MINS
4TH STAGE
2 4 HOURS
2 4 HOURS
PASSAGES
FUNCTIONS (Sit Sit)
Serves as birthcanal
It proves attachment to muscles, fascia and ligaments
Supports uterus during pregnancy
It provides protection to the organs found within the pelvic cavity
TYPES (GAPA)
Gynecoid normal female type of pelvis
- most ideal for childbirth
- round shape, found in 50% of women
Android male pelvis
- presents the most difficulty during childbirth
- found in 20% of women
Platypelloid flat pelvis, rarest, occurs to 5% of women
Anthropoid apelike pelvis, deepest type of pelvis found in 25% of women
DIVISION OF PELVIS
1. False Pelvis provide and direct
2. True Pelvis the tunnel IPO
Inlet or Pelvic Brim entrance to true pelvis
ANTEROPOSTERIOR DIAMETER DOT
1. Diagonal Conjugate midpoint of sacral promontory to the lower margin of symphysis pubis (12.5 cm)
2. Obstetric Conjugate midpoint of sacral promontory to the midline of symphysis pubis (11 cm)
3. True Conjugate midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)
Pelvic Canal situated between inlet and outlet
- designed to control the speed of descent of the fetal head
Outlet most important diameter of the outlet.
POWERS 3Is
Involuntary not within the control of the parturient
Intermittent alternating contraction and relaxation
Involves discomfort (compression, stretching and hypoxia)
PHASES OF UTERINE CONTRACTIONS
1. Increment/Crescendo ready, get set
2. Acme/Apex go
3. Decrement/Decrescendo stop
INTENSITY - strength of uterine contraction
Mild slightly tensed fundus
Moderate firm fundus
Strong rigid, board like fundus
FREQUENCY rate of uterine contraction
- measured from the beginning of a contraction to the beginning of the next contraction
DURATION length of uterine contraction
- measured from the beginning of a contraction to the end of the same contraction
INTERVAL measured from the end of contraction to the beginning of the next contraction
PASSENGER
HEAD (BOTu)
- Biggest part of the fetal body
- Olways the presenting part
- Turn to present smallest diameter
2. Breech (butt)
B. Transverse Lie
Causes:
1. relaxed abdominal wall
2. placenta previa
Face presentation
Chin presentation
Complete breech - feet & legs flexed on the thighs and the thighs are flexed on the abdomen
Shoulder Presentation fetus is lying perpendicular to the long axis of the mother
- vaginal delivery is NOT POSSIBLE
*Compound Presentation when there is prolapsed of the fetal hand alongside the vertex, breech or
shoulder.
Complete flexion
Moderate flexion
Extension
Hyperextended
Good flexion
Moderate flexion
Flexion
POSITION
LOA (Left Occipitoanterior) most favorable & common fetal position
- fetus in vertex presentation (occiput)
- fetus usually accommodates itself on the left because the placement of the bladder is at the right
LOP/ROP mother will suffer more back pains
FHT Breech: Upper R or L Quadrant (above Umbilicus)
FHT Vertex: Lower R or L Quadrant (below Umbilicus)
STATION - relationship of the presenting part of the fetus to the ischial spine of the mother.
Minus (-) station presenting part is above the ischial spine
Zero (0) station presenting part is at the level of the ischial spine
Positive (+) station presenting part is below the level of the ischial spine
FLOATING head is movable above the pelvic inlet
+1 station fetus is engaged
+2 station fetus is in midpelvis
+4 station perineum is bulging
THE PERSON
STAGES OF LABOR
STAGE 1 DILATATION STAGE
Starts from first true uterine contraction until the cervix is completely effaced and dilated.
Dilatation widening of cervical os to 10 cm
Effacement thinning to 1- 2 cm
CAUSES: 1. Pergusion Reflex
2. Fetal head and intact BOW serves as a wedge to dilate the cervix
Maternal Assessment During Labor
1. PIPIT PEPA HF
2. Check V/S q 4hrs during the first stage
- temp q hour if membranes are already ruptured (risk of infection)
- BP b/n contractions, in left lateral pos, q 15 20 mins after giving anesthesia
- a rapid pulse indicates hemorrhage & dehydration
3. Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the client feels it
Techniques:
1. assess contraction (DIIF)
2. check contraction q 15 30 mins during the first stage
3. refer immediately if:
- duration more than 90 secs
- interval less than 30 secs
- uterus not relaxing completely after each contraction
4. Show slightly blood-tinged mucus discharge
5. Internal Examination to assess status of amniotic fluid, consistency of cervix, effacement/dilatation,
presentation, station and pelvic measurement.
- do it during relaxation
- less IE done once membrane have ruptured
- start with middle finger then index finger
6. Status of Amniotic Fluid (if ruptured)
Danger of cord prolapse if fetal head is not yet engaged.
Danger of serious intrauterine infection if delivery does not occur in 24 hours
NITRAZINE PAPER TEST
- used to assess whether membrane ruptured or not.
Procedure: Insert and Touch
Yellow intact BOW
Blue ruptured
Normal Color of AF clear, colorless to straw colored
Green tinged meconium stain (fetal distress in non breech presentation)
Yellow/Gold hemolytic disease
Gray/Cloudy infection
Pinkish/Red stained bleeding
Brownish/Tea Colored/Coffee Colored fetal death
OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID
Ferning pattern of cervical mucus
(swab dry view)
Nile blue sulfate staining of fetal squammous cells
FETAL ASSESSMENT DURING LABOR FHT Monitoring
Latent Phase every hour
Active Phase every 30 minutes
Second Stage of Labor every 15 minutes
FHT is taken more frequently in high risk cases
Normal FHT Pattern
Baseline rate: 120 160 bpm
Early Deceleration FHT @ contraction, Normal @ end of contraction (head compression)
Acceleration - FHT when fetus moves
Abnormal FHT Pattern
Bradycardia 100 119 bpm moderate
- below 100 bpm marked
CAUSES: 1. fetal hypoxia (analgesia & anesthesia)
2. maternal hypotension
3. prolonged cord compression
MGT: 1. place mother on left side
2. assess for cord prolapse
3. administer oxygen
Tachycardia 161 180 bpm moderate
- above 180 bpm marked
CAUSES:1. maternal fever, dehydration
2. drugs (atrophine, terbutaline, ritodrine, etc.
MGT: 1. D/C oxytocin, position on LLP
2. give 02 at 8 10 lpm
3. prepare for birth if no improvement
Types of Abortion:
1. Elective/Therapeutic Abortion the deliberate termination of pregnancy
a. EA initiated by personal choice
b. TA recommended by the healthcare provider
2. Spontaneous Abortion loss of a fetus due to natural causes
Causes of Spontaneous Abortion:
A. Fetal Causes (80% 90%)
1. Developmental anomalies
2. Chromosomal abnormalities (Trisomy 16)
B. Maternal Causes (congenital/acquired conditions)
1. Advanced maternal age (after 35 years of age)
- <35 y/o (15% miscarriage rate)
- b/n 35 39 y/o (20 25% miscarriage rate)
- b/n 40 42 y/o (about 35% miscarriage rate)
- >42 y/o (about 50% miscarriage rate)
2. Structural abnormalities of the reproductive tract
3. Inadequate progesterone production (corpus luteum/placenta)
4. Maternal infections (rubella virus, cytomegalovirus, listeria infection, toxoplasmosis)
5. Chronic and systemic maternal diseases
6. Exogenous factors (tobacco, alcohol, cocaine, caffeine, radiation)
Complications of Abortion:
1. Hemorrhage
2. Infection or septic abortion
3. Disseminated intravascular coagulation (DIC)
Types of Spontaneous Abortion:
1. Threatened Abortion possible
- (+) bleeding, (-) cervical dilatation
S/Sx:
-Light vaginal bleeding (bright red)
-None to mild uterine cramping
Management:
1. Assess for:
- LMP
- Save all pads for examination
- ask for presence of clots
- abdominal pain
2. Conservative management
- bedrest until 3 days after bleeding has stopped
- no coitus up to 2 weeks after bleeding stopped
3. Educate mothers.
Management:
1. Monitor V/S
2. monitor closely for bleeding or signs of infection
3. regular diet (high in iron foods)
4. rest for a few days to 2 weeks (coitus&douching for approx 2 weeks)
5. may experience intermittent menstrual-like flow and cramps (next menstrual period occurs after 4 5
weeks)
6. Reassure patient that her next pregnancy is likely to last to term if she is young and has no other risk
factors. (no pregnancy for the next 3 months)
7. determine womans Rh factor
8. Advise patient to return if:
- profuse vaginal bleeding
- severe pelvic pain
- temperature greater than 100F
2. Inevitable or Imminent Abortion can not be prevented, (+) complete dilatation
S/Sx:
1. Moderate to profuse bleeding
2. moderate to severe uterine cramping
3. open cervix or dilatation of cervix
4. rupture of membranes
5. no tissue has passed yet
Management:
*Avoiding complications of infection or excessive blood loss
1. Hospitalization
2. D&C
3. Oxytocin after D&C
4. Sympathetic understanding and emotional support
3. Complete Abortion spontaneous expulsion
S/Sx:
1. Vaginal bleeding, abdominal pain and passage of tissue
2. On examination:
- light bleeding or some blood in the vaginal vault
- no tenderness in the cervix, uterus or abdomen
- none to mild uterine cramping
- closed cervix
- empty uterus on utrasound
4. Incomplete Abortion expulsion of some parts and retention of other parts of conceptus in utero
S/Sx:
1. heavy vaginal bleeding
2. severe uterine cramping
3. open cervix
4. passage of tissue
5. ultrasound shows some products of conception
Management:
1. D&C
- uterus must kept contracted after D&C
- inspect fundus frequently
- a danger of D&C (uterine perforation)
2. Monitor blood loss
- inspect perineal pads (60 100ml of blood)
- monitor v/s (BP & PR)
- monitor the blood studies of patients clotting factors
- monitor I & O (Oliguria decrease renal perfusion shock)
3. Sympathetic understanding and emotional support.
- encourage verbalization of feelings
5. Missed Abortion retention after death
S/Sx:
1. Absence of FHT
2. Signs of pregnancy disappear
- uterus fails to enlarge
- no FHT
- serum or urine test for the subunit of HCG is negative
- ultrasound showing no cardiac activity
Management:
1. Product of conception be removed to prevent DIC
2. Insert 20mg Dinoprostone (Prostaglandin E) suppository into the vagina q 3 or 4 hours PRN (<28
weeks gestation)
3. Oxytocin IV infusion (late missed abortion)
ECTOPIC PREGNANCY
Causes:
1. Mechanical Factors delay passage of ovum
- salphingitis
- peritubal adhesions
- developmental abnormalities
- previous ectopic pregnancy
- tumors that distort the tube
- past induced abortions
2. Functional Factors
- external migrations of the ovum
- menstrual reflux
- altered tubal motility
3. Assisted Reproduction
- ovulation induction(Clomid)
- gamete intrafallopian transfer
- in vitro fertilization
- ovum transfer
4. Failed contraception
Types of Ectopic Pregnancy:
1. Tubal - >95%
a. Ampulla (most common site, 55%)
b. Isthmic (25%)
c. Fimbrial (17%)
d. Interstitial (2%)
e. Bilateral (very rare)
2. Ovarian (cystectomy/oophorectomy, 0.5%)
3. Abdominal (1/15,000 pregnancies)
a. Primary original implantation outside the tube
b. Secondary implantation in the abdomen after rupture and expulsion
4. Cervical (due to in vitro fertilization and embryo transfer
5. Heterotypic Pregnancy (TP accompanied by intrauterine pregnancy)
6. Tubo Uterine ( partly implanted in the tube and uterus)
7. Tubo Abdominal ( fimbriated implantation extends into the peritoneal cavity
8. Tubo Ovarian (partly implanted in the tub and partly in the ovary)
S/Sx:
1. missed menstrual period of two weeks duration (68%)
2. unilateral lower abdominal pain (99%)
3. irregular vaginal bleeding (75%)
4. Before rupture
- brief amenorrhea
- pelvic and abdominal pain on the side of the affected tube
- Arias Stella Reaction
5. Ruptured ectopic pregnancy:
a. pain
- sudden severe and knife like pain
- radiating to the neck and shoulder
- cervical pain during IE
b. spotting or bleeding darkbrown
c. Cullens Sign or bluish discoloration of the umbilicus due to the presence of blood in the peritoneal
cavity
d. Hard or boardlike abdomen
e. Signs of shock
6. Diagnosis
a. Transvaginal Utrasound (TVUS)
TVUS + serial HCG det. = most reliable
b. Serial HCG
c. Pregnancy Test
d. Culdocentesis
e. Serum Progesterone Level
>25ng/ml normal viable pregnancy
<5ng/ml nonviable pregnancy
f. Uterine Curettage
g. Colpotomy
h. Laparoscopy
i. CBC
j. Elevated WBC
Management:
1. Therapeutic Abortion unruptured EP
a. Methotrexate Therapy
2. Surgical removal ruptured EP
Nursing Interventions:
1. Prevent and treat hemorrhage
- IVF to prevent shock
- type & cross match blood
- place flat in bed with legs elevated
- provide extra blanket to keep warm
2. Assist in positioning the patient
3. Post op interventions:
- monitor v/s
- assistance with positioning & ambulation
- monitor IV fluids therapy
- If patient is Rh-negative, RhoGAM is given within 72 hours and before discharge
- provide contraceptive counseling
4. Meet emotional needs of patient
5. Prevention
- safe sex practices
- importance of gynecological exams
- S/Sx of STDs
- possible risks associated with the use of an IUD
HYDATIDIFORM MOLE
- benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo.
Types:
1. Complete Molar Pregnancy only placental parts, no embryo
2. Partial Molar Pregnancy 2 fathers, 1 mother
- placenta and fetus formed but incomplete
Risk Factors/Incidence:
1. Geography
2. High in women below 18 and above 40 years old
3. High in low socioeconomic status (low protein intake)
4. History of molar pregnancy
S/Sx:
1. Excessive N/V due to elevated HCG levels
2. Bleeding from spotting to profuse (brown bleeding)
3. Passage of grape like vesicles around the 4th month
4. Rapid increase in uterine size (out of proportion)
5. Signs of preeclampsia before 24 weeks (HEP)
6. Absence of FHT and fetal skeleton
7. Ultrasound (mass of fluid filled vesicles snowflake pattern)
8. Elevated plasma thyroxine levels
9. Elevated serum gonadotropin level (>100 days)
Management:
1. D&C
2. Methotrexate (Choriocarcinoma)
3. HCG monitoring for 1 year
- HCG should be negative 2-8 weeks after removal of mole (every 2 weeks)
- monthly for 6 months
- every 2 months for another 6 months
- chest x-ray every 3 months for 6 months
4. Woman advised not to be pregnant for one year
- contraceptives should not contain estrogen
5. Hysterectomy
- above 40 years old
- who have completed child bearing
- who desire or require sterilization
Complications of H Mole:
1. Gestational Trophoblastic Tumors trophoblastic proliferation
a. Choriocarcinoma most severe complication
- conversion of chorionic villi into cancer cells that erode blood vessels and uterine muscles.
- lungs
b. Invasive Mole developed during the first 6 months
- excessive formation of trophoblastic villi that penetrates the myometrium
c. Placental Site Trophoblastic Tumor composes of cytotrophoblastic cells arising from the site of the
placenta.
- produce both prolactin and HCG
- main symptom is bleeding
INCOMPETENT CERVIX
Diagnosis:
1. Pelvic examination or IE
2. Ultrasonography (cervical os is >2.5cm or length is shortened to <20mm)
- funneling
Predisposing Factors/Causes:
1. DES exposure in utero
2. Cervical trauma from previous difficult deliveries (forcep deliveries)
3. Hormonal influences
4. Congenitally short cervix
5. Forced D&C
6. Uterine anomalies
S/Sx:
1. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)
2. Rupture of membranes and passage of amniotic fluid
Management:
1. Cervical cerclage @ 14 weeks (earlier the better)
2. Prerequisites of cervical cerclage:
cervix not dilated beyond 3 cm
- intact membranes
- no vaginal bleeding and uterine cramping
3. Types of cervical cerclage:
Shirodkar Suture permanent suture
Mc Donald Suture temporary suture
- 38 39 weeks removal of suture
4. After suturing the cervix:
- place woman on bedrest for 24 hours several days
- observe for bleeding, contraction and rupture
- report passage of fluid or signs of PROM
- if uterine contracts, RITODRINE may be given
- restrict activities after application for the next 2 weeks including coitus
ABRUPTIO PLACENTA
- ablation placenta, placental abruption & accidental hemorrhage
Causes:
1. Maternal hypertension
2. Advanced maternal age (>35y/o)
3. Trauma to the uterus
4. Rapid decompression of an over-distended uterus
5. Grand multiparity (thinning of endometrium)
6. Short umbilical cord
7. Uterine leiomyoma or fibroids
8. Behavioral factors:
- cigarette smoking, methamphetamine and cocaine abuse
- maternal alcohol consumption (14 or more drinks)
PLACENTA PREVIA
Types of Placenta Previa:
1. Complete/Total PP covers the internal os
2. Partial PP partially covers the internal os
3. Marginal PP edge of the placenta is lying at the margin of the internal os
4. Low Lying PP implants near the internal os with its margin located about 2cm 5 cm from the
internal os
Frequency:
1. approx 3.5 8 pregnancies per 1000 after 20 wks AOG
2. Maternal mortality assoc. with PP is <1%
3. Maternal morbidity is about 5%
Predisposing Factors/Causes:
1. Unknown
2. Decreased blood supply or scarring @ upper segment
- multiparity
- previous molar pregnancy
- endometritis
- age (above 35 y/o)
-previous CS
- abortion
- repeated D&C
3. Decreased blood supply to the endometrial lining
4. Short umbilical cord
5. Abnormal placentas (placenta increta and accreta)
6. Large placenta
Complications:
1. Hemorrhage
2. Infection
3. Prematurity
4. Obstruction of birth canal
5. DIC
6. Abnormal adhesion of placenta
7. Renal failure may occur r/t shock caused from hemorrhage or DIC
8. Anemia
9. More lacerations
10. Fetal effects/neonatal effects
11. Brain damage or neurological abnormalities
S/Sx:
1. Sudden painless vaginal bleeding (24 30 weeks)
2. Bright red bleeding occurs in gushes and is rarely continuous (usually @ night with the patient
awakening and finding herself lying in a pool of blood)
3. Fetus assumed transverse position, no engagement
4. Decreased urinary output
**Ultrasound is the earliest and safest diagnostic tool for PP
Management:
1. IE by MD only under double set up (done in the OR patient is prepped and draped)
Double Setup is Indicated When:
1. ultrasound is not available
2. the ultrasound evidence is inconclusive
3. patient with ongoing but not life-threatening vaginal bleeding in labor
4. mother has a marginal previa and is well-established labor
2. Assess extent of blood loss
visual estimates (most often used but the most inaccurate)
Vital signs
Tilt Test (woman bleeds profusely but has normal blood pressure and pulse in recumbent position will
develop hypotension and tachycardia when placed in sitting position)
Urine flow
3. If pregnancy is below 36 weeks
Watchful waiting/expectant management/conservative management
Nursing Interventions:
a) Monitor:
FHT and activity
Vaginal bleeding
Uterine contractions
Maternal V/S
Maternal I&O
b) Woman in CBR (if no bleeding after 48 hours, mother is allowed bathroom privileges)
c) Manage bleeding episodes
Keep woman on NPO
Monitor V/S, FHR, vaginal bleeding
Maintain on absolute bedrest
Start fluid replacement therapy and blood transfusion
d) If woman is in active labor, tocolytics may be given.
e) Betamethasone (Celestone)is given to hasten fetal lung maturity (12mg IM q 12 hrs for 2 doses)
f) Amniocentesis (lung maturity)
4. Outpatient management
a. live close to the hospital (within 5 10 minutes) and 24 hours transportation availability and close
supervision by family or friends @ home
b. restricted activities @ home
- bed rest most part of the day
- heavy lifting is strictly prohibited
- no vacuuming or standing for long periods of time
- sexual arousal, intercourse or orgasm should be avoided
- avoid enema and douche
- stop working or employment
- provide diversional activities
5. Inform patient and family to be observant
- bleeding, contraction & decreased fetal activity
6. Diet
- foods high in iron
- prenatal vitamins (Iron + Vitamin C)
- increase fiber intake
7. Clinic visit is usually once or twice a week
- ultrasound tests (2-4 weeks interval)
- regular NST
- biophysical profile
8. Labor and delivery
a. delivery is implemented when:
- fetus is mature
- persistent hemorrhage
- intrauterine infection
- rupture of membranes
- persistent uterine contractions unresponsive to tocolysis
- mother develops coagulation defects (DIC)
b. method of delivery
CS delivery of choice (profuse maternal hemorrhage and fetal hypoxia)
VD for marginal/partial previa
c. Nursing Care:
Anticipate doctor orders for:
Ultrasound
IVF (LRS, gauge needle #16 or #18)
CBC, blood type and cross match for at least 2 units of whole blood, DIC panel, PTT, PT and
electrolytes. H/H may order every 12 hours.
In case of profuse bleeding:
CBR s BRP, quiet environment (+ bleeding)
Keep on NPO
Administer O2 tight mask @ 6lpm
Do not perform enemas
Discourage bearing down
Position
Semi Fowlers Position
Trendelenburg Position
Examinations & Monitoring
No IE
Place mother on continuous fetal monitoring
Monitor vaginal bleeding q 15 minutes then 30 minutes after bleeding stopped
V/S q 15 minutes then 30 mins if stable and bleeding subsides
Assess I&O
Observe signs of DIC
Observe for shock
Post partum nursing care:
WOF hemorrhage
Oxytocin, gentle massage and close monitoring
Surgical management such as ligation of the hypogastric arteries (internal iliac) or hysterectomy
Puerperal infection
Observe elevation of temp above 39C or 100.4F
Low grade fever during 24 hours (dehydration)
Aseptic technique and handwashing
Teach proper perineal care and good handwashing technique
Front-to-back motion when applying perineal pads
Reinforce aseptic techniques during bathroom usage
Anemia
Moderate to severe anemia d/t amount of blood lost
Normal hemoglobin 12 13 g/dl
Moderate anemia 9 11 g/dl
Severe anemia below 9 g/dl
PREECLAMPSIA
EFFECT
The amount of circulating plasma volume falls
Rise in hemoglobin and hematocrit
Decreased blood supply to kidney and hemoconcentration stimulates release of aldosterone, ADH and
angiotensin
Sodium retention leading to edema (hypernatremia)
Vasospasm and hypertension
Vasospasm cause damage to the endothelium promotes coagulation and increase sensitivity to pressor
agents.
Elevated platelets
Patients renal perfusion is affected. Decreased blood supply to kidneys resulting in decreased GFR.
Efficiency of the kidney to remove metabolic waste is impaired. Decreased renal perfusion results in
damage to kidney structures allowing passage of large molecules
Serum levels of BUN, creatinine and uric acid rise leading to acidosis and decreased urine output.
Proteinuria
Vasospasms decreases blood supply to the brain resulting in cerebral ischemia
Hyperreflexia
Convulsions
Decreased blood supply to the uterus and placenta
IUGR
Fetal hypoxia and distress
Continuous vasospasm cause diminished blood supply resulting in damage to blood vessels and tissues
in the placenta and decidua
Abruptio Placenta
Signs/Symptoms
Mild Preeclampsia
Severe Preeclampsia
Blood Pressure
140/90, diastolic BP is more than 100mmHg
Diastolic is 110mmHg or higher
Proteinuria
+1 - +2 by dipsticks
300mg/24 hour urine collection
+2 - +4
5g/24 hour urine collection
Liver enzymes
Slightly elevated
Markedly elevated
Laboratory studies
Normal hematocrit, uric acid, creatinine
Increased Hct, Crea and UA; thrombocytopenia may be present
Fetus
No IUGR
IUGR present
Edema
Digital edema, dependent edema
Pitting edema (4+)
Generalized edema
Weight Gain
1 2 lb/week
More rapid weight gain
Urinary Output
Not less than 400ml/24 hours
Less than 400 ml/24 hours
Cerebral Disturbances
Occasional headache
Severe frontal headache, photophobia, blurring, spots before the eyes (scomata), n/v
Reflexes
Normal to 3+
Hyperreflexia, 4+
Epigastric Pain
Absent
RUQ pain (aura to convulsion) d/t swelling of hepatic capsule
S/Sx of Eclampsia:
1. All the S/Sx of preeclampsia
2. Convulsion followed by coma
3. Oliguria
4. Pulmonary edema
Management:
1. Roll Over Test (increase of 20mmHg or greater diastolic pressure)
2. Tolerance Hyperbaric Test (portable BP cuff 48 hours)
Ambulatory Management:
1. Home management is allowed only if:
BP is 140/90 or below
Low proteinuria
No fetal growth retardation and good fetal movement
2. Bed rest (when lying down, assume LLP)
3. Consult every two weeks
4. Home management also include phone calls and home visits by the N M
5. Diet: high in protein and carbohydrates with moderate sodium restriction
6. Hospitalization is necessary if condition worsens
7. Provide detailed instructions about:
a. Dietary modifications
High in protein
Moderate sodium restriction
Eat a balanced diet that include 1200mg calcium
Avoid salty foods, such as canned foods, soda, chips and pickles
Eat foods with roughage
Drink 8 10 glasses of water daily
Avoid alcohol
Take daily weight measurement
Measure and record fluid intake and urine output
b. Monitor her own health condition and report to health care provider immediately if the following
occur:
Take and record her BP twice daily
Count fetal movements per hour (3/h)
Take and record weight daily
Report for increased BP, epigastric pain and visual disturbances
Weight gain more than 1 lb a week
Abnormal fetal movement and abdominal pain
Hospital Management:
a. Hospitalization is necessary if:
BP is equal or greater than 160/100mmHg
Proteinuria of 3+ or 4+
Rapid weight gain
Oliguria
Visual disturbances
Abnormal fetal movement
b. Expectant management
Treatment with Bethamethasone (2 doses)
c. Fluid therapy
Crystalloid infusion (LRS & NSS, 100ml/hr 125ml/hr)
Close monitoring
d. Medications
Magnesium Sulfate
Prevent convulsion and seizures
Reduce edema
Reduce BP
Nursing Considerations:
Loading dose: 4gm over 20 mins, followed by 2 3gm/hr (ACOG)
Check the ff before giving:
RR above 14cpm
UO at least 100ml/4hr
DTR are present (loss of DTR first sign of toxicity/hypermagnesemia)
Serum magnesium levels are evaluated periodically
7 8 mg/dL (therapeutic level)
10 - 12 mg/dL (developing toxicity)
*If MST develops (1gm (10ml) 10% Calcium Gluconate)
Antihypertensives
Hydralazine (Apresoline)
ID: 5mg IV bolus
RD: 5mg 10mg q 20 mins if diastole is above 110mmHg
Labetolol (Normodyne) 20mg IV q 10 mins to max of 300mg
Safety measures
Raise padded side rails
Put bed at lowest position
Have emergency equipments available
Care of the woman during convulsion
Stages of Convulsion:
1. Stage of Invasion or Aura facial twitching, rolling of the eyes to one side, staring fixedly in space,
sudden severe headache, screaming and epigastric pain
2. Tonic Phase rigid body, eyes protrude, arms are flexed with legs inverted, hands are clenched,
woman stop breathing lasts for 15 20 seconds.
3. Clonic Phase jaws and eyelids close and open violently, foaming of the mouth, face becomes
congested and purple, muscles of the body contract and relaxes alternately last for about 1 minute.
4. Postictal State contractions cease and woman enters a semicomatose state.
Nursing Responsibilities:
Always monitor patient for impending signs of convulsions
Two main resp: maintenance of patient airway and protection of patient from self injury
Turn patient on her side to allow drainage of secretions
Never leave an eclamptic patient alone
Do not restrict movement during a convulsion as this could result in fractures
After convulsion:
WOF signs of AP, vaginal bleeding, abdominal pain, FHT
Take v/s
Suction nasopharyngeal secretions and administer oxygen
Sedatives, Diazepam (Valium) if MgSO4 can not control convulsion
Do not give anything by mouth unless conscious
HEMOLYTIC DISEASE
Incidence:
About 10% of women are risk for Rh isoimmunization
1:1000 births incidence of Rh-related neonatal morbidity
ABO Incompatibility:
Occurs when maternal blood type is O and fetus is:
Type A most common
Type B most serious
Type AB rare
Maternal antibodies attack the fetal RBC and destroy it
Happens during placental separation
Rh Incompatibility:
1. Rh Factor
Rh factor is a distinct protein antigen found in the covering of RBC
85% Rh positive and 15% Rh negative
If person has the genes ++, the Rh factor is positive
If person has the genes +-, the Rh factor is positive
If person has the gene - - , the Rh factor is negative
Rh Sensitization/Isoimmunization:
Exposure of Rh negative blood to an Rh positive blood
Occurs during placental separation (0.5 ml fetal Rh positive blood can produce massive production of
antibodies during the first 72 hours of life)
Erythroblastosis Fetalis during pregnancy and Hemolytic Disease after delivery.
Anemia
Splenomegaly and hepatomegaly
Hyperbilirubinemia
Hydrops fetalis
Stillbirth
Prevention:
1. Prenatal screening
a. History
b. Screening test
Antibody Titer Test (Coombs Test)
Indirect Coombs Test maternal serum
Direct Coombs Test fetal cord blood
Antibody titer is negative:
Repeat: 16 20 weeks and 26 27 weeks of pregnancy
Anti-Rho(D) Gamma Globulin (RhoGRAM) @ 28 weeks and within 72 hours after delivery
Rho(D) Gamma Globulin be given to all Rh(-) women who:
Delivered Rh positive fetus
Untypeable pregnancies
Received ABO compatible Rh positive blood
Have invasive diagnostic procedure (amniocentesis)
S/Sx:
1. No signs and symptoms unless the baby dies in the utero and is not born right away.
Management:
1. Fetal surveillance (mothers antibody titer test (+) >1:16 )
2. Intrauterine Blood Fetal Transfusion (IUFT)
Blood transfusion to the fetus either intraperitoneal or intravascular
3. Labor and delivery
Do not remove placenta manually to avoid squeezing fetal cells
Clamp cord immediately after birth
Kleihauer Betke Blood Test