I. Definition of Terms 1. Dystocia y Difficulty in labor; may be due to different physiologic (e.g.

, big baby, small/abnormal pelvic of the mother) or psychologic (e.g., low emotional support from significant others.) factors. 2. Dysfunctional Labor y Sluggish uterine contraction or weak force of labor. It is generally classified as primary (occurring at the onset of labor) or secondary (occurring later in labor). 3. Abruptio Placenta y It is the premature separation of the placenta. It may occur on the 20th week of gestation to the time of labor. 4. Placenta Previa y Low implantation of the placenta in such a way that the internal os of the cervix is covered. Usually, the fetus gets lesser blood supply and nutrients from the maternal circulation since these are richer in the fundus. 5. Amniocentesis y The withdrawal of amniotic fluid from the uterus by means of introduction of a needle through the abdominal and uterine wall. It is usually performed between the 16th and 20th weeks of gestation to aid in the diagnosis of fetal abnormalities. 6. Amniotic fluid embolism y A quantity of amniotic fluid that enters the maternal blood system during labor and/or delivery and becomes lodged in a vessel. It is usually fatal to the mother if it is a pulmonary embolism. 7. Cerclage y An obstetric procedure in which a nonabsorbable suture is used for holding the cervix closed to maintain a pregnancy and prevent premature cervical dilatation in a woman who has an incompetent cervix. 8. Hydramnios y An excessive amount of amniotic fluid, generally over 2000ml. 9. Oligohydramnios y A decreased amount or absence of amniotic fluid, lesser than 500 ml. 10. Hypertonic uterine contractions y Contractions with an increase in resting tone to more than 15 mmHg. Mostly occurs in the latent phase of labor. 11. Hypotonic uterine contractions y The number of contractions are low or infrequent (not increasing beyond two or three in a ten-minute period) or ineffective. Usually occurs in the active phase of labor. 12. Macrosomia y Birth weight above 90th percentile on an intrauterine growth chart for that gestational age. Usually, it is when the fetus weighs more than 4,000- 4,500 grams (approx. 9-10 lbs). 13. Prolonged labor y Prolongation of the first stage of labor. 14. Precipitate Labor y The uterine contractions are so strong that the woman gives birth with only a few rapidly occurring contractions. The labor is usually completed within less than 3 hrs. 15. Prolapsed cord y A loop of the umbilical cord slips down in front of the presenting fetal part after the membranes rupture, subjecting it into compression between the fetus and the pelvis. I. Discussion A. Hemorrhagic Complications during Childbearing Stage/ Bleeding during Early Pregnancy state 1. Abortion y Abortion- it is the loss of pregnancy before the fetus is viable (< 20 weeks of

gestation or weighing <500g), or capable of living outside the uterus. y Spontaneous abortion- is a termination of pregnancy without action taken by the woman or another person. y Habitual Abortion- spontaneous termination of 3 successive pregnancies before the 20th week of gestation. a. Spontaneous Abortion y Classifications y Threatened Abortion a.1 Clinical manifestations y First sign: vaginal bleeding (spotting), common during the early pregnancy. y 50% of the pregnancies having spotting end in spontaneous abortion. y Vaginal bleeding may be followed by rhythmic uterine cramping, persistent backache, or feelings of pelvic pressure. a.2 Therapeutic Management y Advice the pregnant woman to notify the physician immediately if brownish or red vaginal bleeding is noted. Bleeding during the first half of pregnancy should be considered a threatened abortion. y Upon assessment, nurse must obtain a detailed history that includes the LMP and the onset, duration, and amount of vaginal bleeding; any discomfort such as cramping, backache or abdominal pain. y Determine the woman s chorionic gonadotropin ( -hCG) levels if it is normal for the gestational age. This help determines whether the pregnancy is likely to continue. y Vaginal Ultrasound examination is performed to determine if the fetus is still in the uterus and if it s still alive. y Advice the pregnant woman to limit sexual activity until bleeding has ceased. Complete Bed rest is advised. y Instruct the woman to count the number of perineal pads used and to note the quantity and color of the blood. Note evidence of tissue passage. y The nurse should offer accurate information and avoid false reassurance. y Inevitable/ imminent abortion - occurs when the abortion is imminent or cannot be prevented. b.1 Clinical Manifestations y Rupture of membranes is experienced as a loss of fluid from the vagina and subsequent uterine contractions and active bleeding. y Excessive bleeding or infection may occur when complete evacuation of the products of pregnancy doesn t occur spontaneously. b.2 Therapeutic Management y Vacuum Curettage is used to clean out the uterus if the natural process is ineffective or incomplete. y Dilatation and curettage (D&C) is done if pregnancy is more advanced or if bleeding is excessive. y IV Sedation or anesthesia is administered to manage the pain. y Incomplete Abortion - occurs when some but not all of the products of conception are expelled from the uterus before the time of birth.

c.1 Clinical Manifestations y Active uterine bleeding and severe abdominal cramping (major manifestations) y The cervix is open, and fetal and placental tissue is passed. Although it is expelled from the uterus, they tend to remain in the vagina because of their small size, often smaller than a ping-pong ball. c.2 Therapeutic management y The initial treatment should focus in stabilizing the woman s cardiovascular status. The retained tissue prevents the uterus from contracting, thus profuse bleeding may occur. A blood specimen is drawn for blood type and screen or cross-match, and an IV line is inserted to replace the fluid loss. y When the woman s condition is stable, D&C is performed to remove the remaining tissue, followed by IV administration of oxytocin or IV methergine to contract the uterine muscles and control bleeding. y If the pregnancy has advanced beyond 14 weeks, D&C may not be performed because of the danger of excessive bleeding. Instead, oxytocin or prostaglandin is administered to stimulate uterine contractions until all products of conception (fetus, placenta and amniotic fluid) are expelled. y Complete Abortion -occurs when all products of conception are expelled from the uterus. d.1 Clinical manifestations y Uterine contraction and bleeding subside and cervix closes after all the products of conception are passed. y The uterus feels smaller than the expected size based on the length of gestation. y The symptoms of pregnancy are no longer present, and pregnancy test becomes negative as hormone levels fall. d.2 Therapeutic management y Once it happened, no additional intervention is required unless excessive bleeding and infection develops. y The woman is advised to rest and monitor for further bleeding, pain or fever. y The woman should not have coitus until it is already advised. Contraception is discussed at the follow-up visit if she wishes to prevent pregnancy. y Missed abortion -occurs when the fetus dies during the first half of pregnancy but is retained in the uterus. e.1 Clinical Manifestations y The early symptoms of pregnancy, such as nausea, breast tenderness, urinary frequency, disappear. y The uterus stops growing and decreases in size, reflecting the absorption of the amniotic fluid and maceration of the fetus. y Vaginal bleeding of a red or brownish color may or may not occur. e.2 Therapeutic Management y The ultrasound examination can confirm fetal death.. y In most cases, the woman can expel the contents of her uterus spontaneously. But if it not possible, D&C can usually be done when the

missed abortion occurred in the first trimester. y If it occurred in the second trimester, D&C may not be advised because the fetus is large already. Administration of prostaglandin E2 or misoprostol (Cytotec) may be needed to induce uterine contractions to expel the fetus. y Septic abortion - Spontaneous or induced termination of a pregnancy in which the mother s life may be threatened because of the invasion of germs into the endometrium, myometrium and beyond. f.1 Clinical Manifestations y Signs of infection may be present, such as elevation in temperature, vaginal bleeding with foul odor, or abdominal pain. y Products of conception may still be present inside the uterus. y Uterine tenderness is also present. f.2 Therapeutic Management y Obtain a specimen for culture and sensitivity. y Evacuation of the uterus may be delayed until culture is obtained and antibacterial therapy is initiated. y parenteral antibiotics (penicillin or ampecillin plus an aminoglycoside) before, during, and after removal of any necrotic tissue by curettage to prevent septic shock. b. Induced Abortion - An abortion done by the pregnant woman through the help of medical or nonmedical assistance. Although the term can include abortions induced through legal, over-the-counter medication, it also refers to efforts to terminate a pregnancy through alternative, often more dangerous means. Such practices are illegal in most jurisdictions even where abortion itself is legal and may present a grave threat to the life of a woman. An unsuccessful attempt to induce such an abortion can also cause lasting damage to the fetus. Presently this is fairly common where abortion is illegal or unavailable, but it does occur in developed countries as well. Self-induced abortion is easier to accomplish in the earliest stages of pregnancy (the first eight weeks LMP). y Causes y Endocrine Abnormalities miscarriage will also occur if the corpus luteum fails to produce enough progesterone to maintain the deciduas basalis. Progesterone therapy may be attempted to prevent this if this cause is documented. y Maternal Infection y Infection in the maternal circulation of the maternal bady may compromise the fetus. Rubella, syphilis, polio myelitis, cytomegalovirus, toxoplasmosis infections readily cross the placenta, possibly causing fetal death. Urinary tract infection also increases the incidence of miscarriage. y Acquired Anatomic Abnormalities (eg., Uterine Fibroids, endometriosis, etc.) y Involves implantation abnormalities, as up to 50% of zygotes are probably never implanted. Poor implantation may result from inadequate endometrial formation or from inappropriate site of implantation. This may also include CPD. y Immunologic Factors y Incompatibility of the maternal and fetal blood is possible and rejection of the embryo through an immune response may occur. y Environmental factors y The mother s safety from her external environment is highly vital in the fetus growth and development. Intake of teratogenic substances may put the mother and the fetus at risk. Her lifestyle also affects how the fetus is nourished. Ingestion of alcohol at the time of

conception is also linked to early pregnancy loss. y Nursing Responsibilities y Nurses must consider the psychologIcal needs of the woman experiencing spontaneous abortion. Vaginal bleeding is frightening, and waiting and watching are often difficult. y Many women and their families feel an acute sense of loss and grief with spontaneous abortion. Nurses may help by emphasizing that abortions usually occur as the result of factors or abnormalities that could not be avoided. y Recognizing the meaning of the loss to each woman and her significant others are important. Nurses must listen carefully to what the woman says and observe how she behaves. y Nurse must convey acceptance of the feelings expressed or demonstrated. y Providing information and simple brief explanation of what has occurred and what will be done facilitates the family s ability to grieve. 2. Hydatidiform Mole (H-mole)/ Molar Pregnancy/ Gestational Trophoblastic Disease y Causes: - Women who have low protein intake are most likely to experience H-Mole. - women older than age 35 years - Women of Asian heritage. y Types of H-mole: a. Complete- all trophoblastic villi swell and become cystic; it may develop into an invasive cancer in a small percentage of cases so specialist treatment is needed. Signs and symptoms: i. Positive pregnancy no embryo is present in the pregnancy sac but the placental tissue develops rapidly in an uncontrolled fashion resembling a bunch of grapes on ultrasound scan. ii. Abnormal enlargement of abdomen the size of the uterus is usually larger than expected for the menstrual dates. iii. Anemia - medical condition caused by an abnormally low number of red blood cells (erythrocytes) which contain haemoglobin iv. Passage of vesicles v. Absence of fetal movements or parts b. Incomplete / Partial they are more common and usually mimic the appearance of an inevitable or incomplete miscarriage. It contains a fetus or embryo which has three sets of chromosomes instead of 2 (triploidy). It may only be distinguish from a miscarriage when the pathologist examines the tissue removed from the uterus. Signs and symptoms: i. Positive pregnancy the partial mole contains a fetus or embryo which has 3 sets of chromosomes instead of 2. ii. Abnormal enlargement of abdomen the placental cells swell and proliferate but not to the same degree as occurs in the complete mole. iii. Anemia - medical condition caused by an abnormally low number of red blood cells (erythrocytes) which contain haemoglobin. iv. Passage of vesicles v. Absence of fetal movement or parts y Nursing Responsibilities the nurse in the antepartum setting should be aware of the signs of molar pregnancy. When the woman is hospitalized the nurse should monitor the amount and type of bleeding and vital signs. The woman may experience grief for the pregnancy loss and fear for own well being. She and her family will require information together with emotional support and that s where the nurse comes in. B. Bleeding During Late Pregnancy 1. Pregnancy-Induced Hypertension - It is a condition in which vasospasm occurs during pregnancy in both small and large arteries. Signs of hypertension, proteinuria and edema develop. Originally it was called toxemia. y Hypertension Type: a. Gestational Type a woman develops an elevated blood pressure

y y

(140/90mmHg) but has no proteinuria or edema. y Management: Perinatal mortality is not increased with simple gestation hypertension, so no drug therapy is necessary. b. Mild Preeclampsia it is any status above gestational hypertension and below a point of seizures. y Management: Promote bed rest; promote good nutrition; provide emotional support c. Severe Preeclampsia a woman s blood pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least two occasions 6 hrs. Apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30mmHg above her pregnancy level. y Management: Support bed rest; monitor maternal well-being; monitor fetal well-being; support a nutritious diet; administer medications to prevent eclampsia d. Eclampsia the most severe classification of PIH. The woman s cerebral edema is so acute that a seizure or comma occurs. y Management: Convulsion may be prevented by bed rest in a quiet dimly lit room and parenteral administration of magnesium sulfate and antihypertensive medications Edema abnormal accumulation of fluid in interstitial spaces of tissues such as in the pericardial sack, intrapleural space, peritoneal cavity or joint capsules Types of Edema: a. Dependent Edema a fluid accumulation in the tissues that is influence by gravity. It is usually greater in the lower part of the body than in the part above the level of the heart. b. Pitting Edema an edema characterized by a condition in which a finger pressed into the skin over an accumulation of fluid will result in a temporary depression in the skin; normal skin and subcutaneous tissue quickly rebound when the pressure is released Proteinuria the presence in the urine of abnormally large quantities of protein usually albumin. Therapeutic Management understanding and compliance of the patient should be reinforce; health teaching for the pregnant woman and her family regarding PIH; regular, adequate prenatal care is the best insurance for control of the complication.

C. Common Pathologic Changes During Intrapartum 1. Dystocia / dysfunctional labor pathologic or difficult labor that may be caused by an obstruction or constriction of the birth passage or abnormal size, shape, position, or condition of the fetus. Causes of Dystocia: 1. inappropriate use of analgesia (excessive or too early administration) 2. pelvic bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass (e.g. in a client with rickets) 3. poor fetal position (posterior rather than interior position) 4. an extension rather than flexion of the fetal head 5. overdistention of the uterus, as with multiple pregnancy, hydramnios, or an excessively oversized fetus 6. cervical rigidity (unripe) 7. presence of a full rectum or urinary bladder that impides descent 8. mother becoming exhausted from labor 9. primigravida status Types of Dystocia: a. Primary Dysfunctional Labor Hypertonic Uterine Dysfunction is mark by an increase in resting tone to more than 15mmHg. However the intensity of the contraction may be no stronger than that associated with hypotonic contractions. y Management rest and pain relief with a drug such as morphine sulfate; changing the linen and the clients gown, darkening room lights and decreasing noise and stimulation; if deceleration in fetal heart rate, an abnormally long first stage of

labor, or lack of progress with pushing ( second stage arrest ) occurs, cesarean birth may be necessary. b. Secondary Uterine Inertia / Hypotonic Uterine Dysfunction the number of contractions is usually low or infrequent (not increasing beyond 2 or 3 in a 10 minute period). y Management in the first hour after birth, palpate the uterus and assess lochia every 15 minutes to ensure that postpartal contractions are not also hypotonic and therefore inadequate to halt bleeding.