National Health Situation

Maternal & Child Health

GOAL
Improve the survival, health and
well being of mothers and the
unborn through a package of
services for the:

pre-pregnancy
prenatal
natal
postnatal stages

2a.2

Where are we now?

Population of over 80 million will double

in 30 years at current growth rate of
2.36%
Rice production in 2002 grew by an
average of only 1.9% -- more hungry
people competing for a decreasing
volume of rice

2a.3

Where are we now?

The lack of family planning

places a disproportionate
burden on the poor.

It is the poorest
Filipinos (57.1%) who
are not using family
planning because of
poor access and
ineffective outreach
20.5% of married
women say they need
family planning but
are not using any
method

The Philippine Situation

3.1 million pregnancies occur each year. Half of these pregnancies are
unintended and one third ends in abortion
About 473,000 abortions annually with induced abortion as 4th
leading cause of maternal deaths

10 mothers die everyday due to childbirth and pregnancy related

complications

Every mom who dies leaves 3 orphans. In effect, 30 children are orphaned
every day

Maternal Mortality Ratio

Note: To show progress of MMR based on MDG, UNFPA estimated MMR based on the
average rate of progress in 2003.

Health
Indicators
Selected Asian Countries
Japan

So.Korea

Malaysia

Thailand

Philippines

Life Expectancy

81

75

73

70

70

Infant Mort.
Rate

24

29

Underfivemortal
ity

28

40

Maternal
Mortality

20

41

44

160

Population
Growth

0.3

0.8

2.2

1.4

2.3

70 %

of births were delivered

in the

home

Only 60 % of births were attended by a

health care professional

Source: MCHS-PNSO, Philippines 2002

Why do women die?

Complications related to pregnancy occurring in
the course of labor, delivery and puerperium.
( obstructed labor, infection)
Hypertension complicating pregnancy,
childbirth, and puerperium( eclampsia etc.)
Postpartum Hemorrhage due to uterine atony,
placental retention
Pregnancy with abortive outcome
Hemorrhage related to pregnancy ( ectopic
pregnancy, placenta previa etc.)

7 Direct Obstetric
Complications

Hemorrhage (antepartum / postpartum)

Prolonged / Obstructed labor
Postpartum sepsis
Complications of abortion
Pre-eclampsia / Eclampsia
Ectopic pregnancy
Ruptured uterus

High Risk Pregnancy

Is one in which a concurrent disorder, pregnancyrelated complication, or external factor
jeopardizes the health of the mother, the fetus, or
both
Some women enter pregnancy with a chronic
illness that, when superimposed on the
pregnancy, makes it high risk
Other women enter pregnancy in good health but
then develop a complication of pregnancy that
causes it to become high risk.

Factors that Categorize a Pregnancy as High

Risk
A. Pre-Pregnancy
Psychological

Social

Physical

a. history of drug
dependence
b. History of mental
illness
c. History of poor
coping mechanism

a. Occupation handling
of toxic substances
b. Environmental
contaminants at home
c. Isolated
d. Lower economic
level
e. Poor access to
transportation for care
f. Poor housing
g. Lack of support
people

a. Visual or hearing
challenges
b. Pelvic inadequacy
(CPD)
c. Secondary major
illness (heart disease,
DM, kidney disease,
hypertension etc.)
d. Poor gynecologic or
obstetric history

Psychological

Social

Physical
e. History of previous
poor pregnancy
outcome(miscarriage,
stillbirth, intrauterine
fetal death)
f. Pelvic inflammatory
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
Psychological

Social

Physical

a. Loss of support
b. Illness of a family
member
c. Decrease selfesteem
d. Poor acceptance of
pregnancy

a. Refusal of or
neglected prenatal
care
b. Exposure to
environmental
teratogens
c. Decreased
economic support
d. Conception less
than 1 year after last
pregnancy or
pregnancy within 12
months of the first
pregnancy

a. Intake of teratogen
b. Multiple gestation
c. Poor placental
formation or
position
d. Gestational
diabetes
e. Nutritional
deficiency
f. Poor weight gain
g. PIH
h. Infection
i. Amniotic fluid
abnormality
j. post maturity

C. Labor and Delivery

Psychological

Social

Physical

a. Severely
frightened by labor
and delivery
experience
b. Inability to
participate due to
anesthesia
c. Lack of preparation
for labor
d. Birth of infant who
is disappointing in
some way

a. Lack of support
person
b. Unplanned CS
c. Lack of access to
continued health care
d. Lack of access to
emergency personnel
or equipment

a. Hemorrhage
b. Infection
c. Dystocia
d. Precipitate birth
e. Lacerations of
cervix or vagina
f. CPD
h. Retained placenta

HIGH RISK PREGNANCY:

The Woman who
develops a Complication of pregnancy
A. Bleeding during Pregnancy:

- vaginal bleeding is a deviation from the normal

that may occur at any time during pregnancy

- a woman with any degree of bleeding needs to

be evaluated for the possibility of blood loss and
hypovolemic shock.

- signs of hypovolemic shock occurs when 10%

of blood volume or approximately two units of
blood, have been lost; fetal distress occurs when
25% of blood volume is lost

 Signs and symptoms of Hypovolemic

Shock

1. increased pulse rate

2. decreased blood pressure

3. increased respiratory rate

4. cold, clammy skin

5. decreased urine output

6. dizziness or decreased level of

consciousness

7. decreased central venous pressure

 The Process of SHOCK due to blood loss (hypovolemia):

BLOOD LOSS
Decreased intravascular volume
Decreased venous return, decreased cardiac output, and lowered blood pressure
Body compensating by increasing heart rate to circulate the decreased volume
faster;

Vasoconstriction of peripheral vessels

Increased respiratory rate and a feeling of apprehension at body changes also

occur

 Cold, clammy skin, decreased uterine perfusion.

In the face of continued blood loss, although the
body shifts from interstitial spaces into
intravascular spaces, blood pressure will continue
to fall

Reduced renal, uterine and brain perfusion

Lethargy, coma, decreased renal output

Renal failure

Maternal and fetal death

CONDITIONS ASSOCIATED WITH

FIRST- TRIMESTER BLEEDING:
- two most common causes of bleeding during the first
trimester are Abortion and ectopic Pregnancy
MISCARRIAGE/ABORTION
A.
1. Spontaneous Abortion
- abortion (defined as any interruption of pregnancy before the
age of viability)
- when the interruption occurs spontaneously, it is clear to
refer to it as a MISCARRIAGE
- when pregnancy is medically or surgically interrupted, this is
typically termed as ABORTION
- stage of viability ( a stage when the fetus is capable of
surviving outside the uterus, more than 20- 24 weeks)

 - occurs in 15% to 30% of all

pregnancies and occurs from natural
causes

- a spontaneous miscarriage is an
early miscarriage if it occurs week 16
of pregnancy and a late miscarriage if
it occurs between weeks 16 and 24.

- its presenting symptoms is almost

always vaginal spotting

 Causes:

- the most frequent cause of miscarriage in the first trimester

of pregnancy is abnormal fetal formation, due to either to a
teratogenic factor or to chromosomal aberration

- implantation abnormalities. Approximately 50% of zygotes

are never implanted

- corpus luteum fails to produce enough progesterone to

maintain the deciduas basalis

- infection (i.e rubella, syphilis, poliomyelitis, cytomegalovirus

and toxoplasmosis infections readily cross the placenta and
possibly causing fetal death

- ingestion of teratogenic drug

 2. Threatened Abortion

- is manifested by vaginal bleeding, initially

beginning as scant bleeding and usually bright red.
There may be slight cramping, but no cervical
dilatation is present on vaginal examination.

- limiting activity to no strenuous activity for 2448 hours is the key intervention to stop vaginal
bleeding. complete bed rest is usually not indicated

- coitus is usually restricted for 2 weeks after the

bleeding episode to prevent infection and to avoid
inducing further bleeding

 3. Imminent (Inevitable) Abortion

- it happens with uterine contraction, cramping and

cervical dilatation

- the loss of the products of conception cannot be

halted because of cervical dilatation

- instruct the mother to save tissue fragments that has

passed and bring to the clinic to be examined

- the physician may perform D & C (dilatation and

curettage) to ensure that all products of conception are
removed, preventing further complication such as infection

- after D & C the woman is advised to record the

number of pads used to assess for heavy bleeding

 4. Complete Abortion

- the entire products of conception

(fetus, membranes and placenta) are
expelled spontaneously without any
assistance

- the bleeding usually slows within 2

hours and then ceases within a few days
after passage of the products of
conception

 5. Incomplete Abortion

- part of the conceptus (usually the

fetus) is expelled, but the membranes
or placenta is retained in the uterus

- the physician will usually perform

a D & C or a suction curettage to
evacuate the remainder of the
pregnancy from the uterus

 6. Missed Abortion

- commonly referred to as early pregnancy failure, the

fetus dies in the utero but is not expelled

- a sonogram can establish that the fetus is dead. Often

the embryo actually died 4-6 weeks before the onset of
miscarriage symptoms. After the sonogram, a D & C most
commonly will be done

- if the pregnancy is over 14 weeks, labor may be induced

by a prostaglandin suppository or Misoprostol (Cytotec) to
dilate the cervix, followed by oxytocin administration

- DIC (disseminated intravascular coagulation),

coagulation defect, may develop if the dead fetus remains tool
long in utero

 7. Recurrent Pregnancy Loss

- commonly referred to as habitual abortion

- 3 or more consecutive pregnancies result in miscarriage
usually related to incompetent cervix.
- Management (suture of cervix)
McDonald procedure
Temporary Circlage
Side effect infection
May have NSD
Shirodkar
CS delivery

McDonald Procedure - Cervical Cerclage

Complication of Abortion:
1. Hemorrhage

- a woman who develops DIC has a major possibility for

hemorrhage

1. if excessive vaginal bleeding is occurring, immediately

position the woman flat and massage the uterine fundus to aid
contraction

2. monitor vital signs for changes to detect possible

hypovolemic shock

3. a BT may be necessary to replace blood loss

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 bleeding (gradually changing to a dark color and
then to the color of serous fluid) and any unusual odor or passage of
large clots is also abnormal

 2. Infection

- the possibility of infection is minimal when pregnancy loss

occurs a short period, bleeding is self limiting and instrumentation is
limited

1. educate the woman about the danger signs of infection, such

as fever, abdominal pain or tenderness and a foul smelling discharge

2. organism responsible for infection after miscarriage is usually

Escherichia Coli (E Coli)

3. caution the woman to wipe the perineal area from front to

back after voiding and particularly after defecation to prevent the
spread of bacteria from rectal area

4. caution the woman not to use tampons to control vaginal

discharge because stasis of any blood increases the risk of infection

3. Isoimmunization
- happens when the mother s blood is Rh negative, while the
fetus is Rh positive.
- after spontaneous abortion or D & C. some Rh positive fetal
blood may enter the maternal circulation and mother will develops
antibodies against Rh positive fetus blood.
- during the succeeding pregnancies when the fetus is Rh
positive again, those antibodies would attempt to destroy the
fetus RBC
- so after miscarriage, because the blood of the fetus is not
known, all women with Rh negative blood should receive Rhogam
(Rh Immune Globulin) to prevent the build up of Rh antibodies

 4. Powerlessness

- sadness and grief over the loss

or a feeling that she has lost control of
her life is to be expected

- emotional support

Procedures Used in Pregnancy

Termination
A. Vacuum Curettage
- aka. Vacuum aspiration
- cervical dilation followed by controlled suction
through a plastic cannula to remove all
products of conception
- used for first trimester abortions, also used to
remove remaining products of conception after
spontaneous abortion
- local anesthesia of the cervix is needed

 B. Dilatation and Curettage

- aka.

Dilatation and Evacuation

- dilation of cervix followed by gentle
scraping of the uterine walls to remove
products of conception
- Used for first-trimester abortions and to
remove all products of conception after
spontaneous abortions
- Greater risk of cervical or uterine trauma
and excessive blood loss
- local anesthesia or general anesthesia is
needed

Nursing Care of Clients with Abortion

1. Document the amount and character of
bleeding and saves tissues or clots for
evaluation.
2. Check the bleeding and vitals signs to
identify hypovolemic shock resulting from
blood loss
3. After vacuum aspiration or curettage, the
amount of vaginal bleeding is observed

4. Provide home health teaching after

curettage such as:
a. report increase bleeding
b. take temperature every 8 hours for 3
days
c. take an oral iron supplement if
prescribed
d. resume sexual activity as
recommended by the health care
provider
e. return to the health care provider at
the recommended time for a check up.

5. Check laboratory test such as

hemoglobin level and hematocrit
6. Promote expression of grief by
providing privacy, allowing support
persons to help in pregnancy loss

B.

ECTOPIC PREGNANCY

- is one in which implantation occurs outside the

uterine cavity.

- the most common site (in approximately 95% of

such pregnancies) is in a fallopian tube. Of these
fallopian tube sites, approximately 80% occur in the
ampullar portion. 12% occur in the isthmus and 8% in
interstitial

- approximately 2% of pregnancies are ectopic;

ectopic pregnancy is the second most frequent cause
of bleeding early in pregnancy

 Risk Factors:

- increase incidence in women who have PID

(pelvic inflammatory disease) which leads to tubal
scarring

- occurs more frequently in women who smoke

- occurs more frequently in women who douche,

possibly due to risk of introducing an infection

- used of IUD (intrauterine device) for

contraception

 Signs and Symptoms:

Before Rupture

- no menstrual flow occurs

- nausea and vomiting

- positive pregnancy test for hCG

- Abdominal pain within 3- 5wks of missed
period (maybe generalized or one sided)
- Scant, dark brown vaginal bleeding

 During rupture

- sharp, stabbing pain in one of the lower abdominal

quadrants at the time of rupture, followed by scant vaginal
bleeding

- lightheadedness, rapid pulse and signs of shock (rapid

thread pulse, rapid respirations and falling blood pressure)

- rigid abdomen from peritoneal irritation(Board-like

abdomen)

- Cullens sign (bluish tinged umbilicus) because blood

seeping into the peritoneal cavity

- dull, excruciating pain on the abdomen that may radiate

on the shoulder caused by irritation of the phrenic nerve

 Diagnostics:

1. Transvaginal UTZ will demonstrate ruptured

tube

2. insertion a needle through the postvaginal

fornix into the cul-de-sac under the sterile conditions
to see whether blood that has collected there from
internal bleeding can be aspirated(Culdocentesis)

3. Laparoscopy Culdoscopy can be used to

visualize the fallopian tube

Culdocentesis

Transvaginal UTZ

Laparoscopy

 Management:
1. once an ectopic pregnancy ruptures, it is an
emergency situation and the womans conditions
must be evaluated quickly (monitor for the symptoms
of shock)
2. therapy for a ruptured ectopic pregnancy is
laparoscopy to ligate the bleeding vessels and to
remove or repair the damaged fallopian tube
3. women with Rh negative blood should receive Rh
immune globulin (Rhogam) after an ectopic pregnancy
for isoimmunization protection in future childbearing

 4. treated medically by the oral administration

of Methotrexate, a folic acid antagonist
chemotherapeutic agent, attacks and destroys
fast growing cells. Because trophoblast and
zygote growth is rapid, the drug is drawn to the
site of ectopic pregnancy
5. Hysterosalphingogram performed after
chemotherapy to assess the patency of the
tube
6. provide emotional support

CONDITIONS ASSOCIATED WITH

SECOND- TRIMESTER BLEEDING

A. GESTATIONAL TROPHOBLASTIC DISEASE

(HYDATIDIFORM MOLE OR H- MOLE)

- is proliferation and degeneration of the

trophoblastic villi, which becomes filled with
fluid and appear as grape-sized vesicles

- incidence is approximately 1 in every 2,000

pregnancies

 Causes:

- unknown
Risk Factors:

- occurs most often in women who have

a low protein intake

- in young women (under age 18 years)

- in older women older than 35 years

 Types;
- there are two distinct types of hydatidiform mole

complete/partial

1. Complete mole all trophoblastic villi swell and

become cystic.

- embryo dies early at only 1 to 2 mm in size with no

fetal blood present in the villi
- on chromosomal analysis, although the karyotype is a

normal 46XX or 46XY, this chromosome component was

contributed only by the father or an empty ovum was
fertilized and the chromosome material was duplicated
- this type usually lead to choriocarcinoma

 2. Partial mole some of the villi form

normally

- although no embryo is present, fetal blood

may be present in the villi

- has 69 chromosomes ( a triploid formation

in which there are three chromosomes instead
of two for every pair, one set supplied by an
ovum that was fertilized by two sperm or an
ovum fertilized by one sperm in which meiosis
or reduction division did not occur)

 Signs and Symptoms:

1. uterus tends to expand than normally
2. no Fetal heart sounds are heard because there is no viable
fetus
3. hCG serum levels are abnormally high
4. severe nausea and vomiting
5. symptoms of hypertension of pregnancy is present before
week 20 of pregnancy
6. a sonogram/UTZ will show dense growth (typically a
snowstorm pattern) but no fetal growth in the uterus
7. vaginal spotting of dark brown blood
8. discharge of the clear fluid filled vesicles

Management:
1. suction curettage to evacuate the mole
2. after extraction, women should have a baseline serum
test for the beta subunit of hCG
3. educate on avoiding pregnancy for at least one year
4. hCG is analyzed every 2-4 weeks for 6-12 months
(gradually declining hCG suggest no complications)
5. prophylactic course of Methotrexate is the drug of choice
for choriocarcinoma. This must be weigh carefully because
it interferes with WBC formation which can lead to
leucopenia
6. observe for bleeding and hypovolemic shock

 B. PREMATURE CERVICAL DILATATION

- previously termed as Incompetent

cervix

- refers to a cervix that dilates

prematurely and therefore cannot hold a
fetus until term

- commonly occurs at approximately

week 20 of pregnancy

 Causes:

- unknown
Risk factors

1. associated with increased maternal

age, congenital structural defects and
trauma to the cervix such as might
occurred with biopsy or repeated D & C

 Signs and Symptoms:

1. often the first symptom is show (a pinkstained vaginal discharge) or increased
pelvic pressure followed by rupture of
membranes and discharge of amniotic fluid
2. painless cervical dilatation
3. uterine contractions followed by birth of
fetus

Management:
1. bed rest in trendelenburg position
2. monitor FHT
3. observe for the rupture of BOW
4. avoid coitus and limit activities
5. avoid vaginal douche
6. Surgical Operation termed as Cervical Cerlage is
performed

- as soon as sonogram confirms that the fetus of a second

pregnancy is healthy, at approximately week 12-14, pursingstring sutures are placed in the cervix by vaginal route under
regional anesthesia

 - types:

1. McDonald Procedure nylon sutures

are placed horizontally and vertically across the
cervix and pulled tight to reduce the cervical
canal to a few millimeters in diameter

2. Shirodkar technique sterile tape is

threaded in a purse-string manner under the
sub mucosal layer of the cervix and sutured in
place to achieve a closed cervix

- sutures may be placed trans-abdominally

CONDITIONS ASSOCIATED WITH

THIRD TRIMESTER BLEEDING

A. PLACENTA PREVIA
- is low implantation of the placenta
- it occurs in four degrees:
1. Low- lying placenta implantation in the lower rather than in the
upper portion of the uterus
2. Partial placenta previa implantation that occludes a portion of
the cervical OS
3. Marginal placenta edge approaches the cervical OS. Lower
border is within 3 cm from internal cervical OS but does not cover
the OS
4. Total placenta previa implantation that totally obstructs the
cervical OS
- incidence is approximately 5 per 1000 pregnancies

 Risk Factors
- increased parity

- advanced maternal age

- past cesarean births

- past uterine curettage

- multiple gestation

Complication:
1. postpartum hemorrhage
2. hypovolemic shock
3. preterm labor
4. fetal distress

 Signs and symptoms;

1. sudden onset of painless bright red

vaginal bleeding (latter half of pregnancy)
2. bleeding may be profuse or scanty

Note:

- site of bleeding: uterine deciduas (maternal

blood) places the mother at risk for hemorrhage

- bleeding may not occur until the onset of

cervical dilatation causing the placenta to loosen
from the uterus

 Management;
1. bleeding is an emergency. (fetal oxygen may be compromised
and preterm birth may occur)
2. assess the amount of blood loss (duration, time of bleeding
began, accompanying pain, and color of the blood)
3. bed rest with oxygenation prescribed
4. side-lying or trendelenburg position (for 72 hours)
5. NO internal exams (IE) or rectal exams, may initiate massive
hemorrhage (if necessary, must have double set up; OR/ DR)
6. keep IV line and have blood available (X-matched and typed)
7. Apt or Kleihauer- Betke test (test strip procedure to determine if
blood is fetal or maternal in origin)

 Fetal Assessment:
1. monitor fetal status; heart tone and
movement
2. determine fetal lung maturity;
amniocentesis L/S ratio
3. Bethamethasone may be prescribed
(encourage maturity of fetal lungs; if fetus is
less than 34 weeks gestation)

 B. ABRUPTIO PLACENTA

- premature separation of a
normally implanted placenta either
partial/marginal or complete/total

- occurs after 20-24 weeks of

pregnancy

 Causes:

-unknown
Risk Factors
- high parity

- advanced maternal age

- short umbilical cord

- chronic hypertensive disease

- PIH

- direct trauma (from VA)

- cocaine or cigarette use (Vasoconctrction)

Complications:
1. fetal distress (altered HR)
2. Couvelaire uterus or Uteroplacental apoplexy
3. disseminated intravascular coagulation (DIC)
Signs and symptoms:
1. vaginal bleeding (may not reflect the true amount of blood loss)
2. abdominal and low back pain (dull or aching)
3. sharp stabbing pain high in the fundus
4. uterine irritability (frequent low intensity contractions)
5. high uterine resting tone
6. uterine tenderness

 Degrees of Separation Grade criteria:

0
- no symptoms of separation. Slight separation
occurs after birth. When placenta is examined, a segment
shows recent adherent clots

1
- minimal separation, enough to cause bleeding
and changes in vital signs. However, there is no
occurrence of fetal distress and hemorrhagic shock

2
- moderate separation. There is evidence of fetal
distress, and the uterus is tense and painful on palpation

3
- extreme separation, and maternal shock or
fetal death will result

Management:
1. keep the client in lateral position, not supine
2. oxygen therapy (limit fetal anoxia)
3. monitor FHT and record maternal vital signs
every5 to 15 minutes
4. baseline fibrinogen(if bleeding is extensive.
Fibrinogen reserve may be used up in the bodys
attempt to accomplish effective clot formation)
5. NO IE or rectal exam. No Enema
6. keep IV line open (possible BT)

PRETERM LABOR
- aka. Premature Labor
- labor that occurs after 20 weeks and before
the end
- approximately 9-10% of all pregnancies
- labor contractions that happens every 10-20
minutes
-usually leads to progressive cervical dilatation
of >2 cm and effacement of >80%

 Causs:

- unknown
Risk Factors

1. Dehydration (stimulates APG to release ADH/Oxytocin that strengthen

uterine contractions)

2. UTI

3. Chorioamnionitis (infection of the fetal membranes and fluid)

4. Younger than 17 and over 35 years old

5. Inadequate prenatal care

6. Emotional and physical stress

7. Previous pre-term labor

8. Low socio-economic class

 Signs and Symptoms:

Early Signs and symptoms

1. persistent low back pain

2. vaginal spotting

3. cramping

4. increase vaginal discharge

5. uterine contractions

6. Pelvic pressure or a feeling that the
fetus is pushing down
7. Pain or discomfort in the vulva or
thighs

Management:
FOCUS: Prevention of the delivery of premature fetus
1. The woman should first admitted to the hospital
2. Place in Left lateral position
3. BEDREST to relieve the pressure of the fetus on the
cervix
4. Intravenous fluid therapy to promote hydration
5. Medical Management
a. Bethamethasone/Glucocorticoids steroid, given in
an attempt to hasten fetal lung maturity
- given in 2 dose, 12 mg IM 24 hours apart

b. Tocolytic agents (halt labor)

1. Calcium channel blockers Beta adrenergic drugs
2. Indomethacin (prostaglandin antagonist)
- it can decrease fetal urine output, causing a decrease in amniotic fluid, not
DOC because it can stimulate the early closure of ductus arteriosus
3. Magnesium Sulfate often the first drug used to halt contractions
- CNS depressant
- halts uterine contraction
4. Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine)
- acts on entire beta 2 receptors sites (uterine and bronchial smooth muscles)
causing mild hypotension and tachycardia effects, hypokalemia, hyperglycemia,
pulmonary edema
Side Effects:
a. Headache (most common) due to dilatation of cerebral blood vessels
b. Nausea and vomiting

 Nursing Responsibilities before administration of Tocolytic

Therapy:
1. assess baseline blood data i.e. hct, glucose, potassium,
NaCl, ECG (tachycardia)
2. Uterine and fetal monitoring (external fetal monitors)
3. mix the drug with lactated Ringers solution to prevent
hyperglycemia (piggyback administration, so that it can be
stop immediately if tachycardia occurs)
4. assess BP and pulse every 15 minutes and every 30
minutes until contractions stop
5. reports PR>120 bpm, BP < 90/60 chest pain, dyspnea,
rales

PREMATURE RUPTURE OF MEMBRANES

(PROM)
- rupture and loss of amniotic fluid that
occurs before labor begins

- occurs in 2-18 % of pregnancies

Cause:

- unknown, but associated with infection

of fetal membranes (Chorioamnionitis)
- nutritional deficiency involving ascorbic
acid

 Complication:
1. Fetal infections after the rupture of BOW, the seal
to the fetus is lost
2. Cord Compression pressure on the umbilical cord
because of the loss of the amniotic fluid, which can
cut off the nutrient supply to the fetus (fetal distress)
3. Cord prolapsed the extension of the umbilical
cord into the vagina which can also interfere with
fetal blood circulation

 Signs and Symptoms:

1. Sudden gush of clear fluid from the vagina

- fluid should be tested for:

a. Nitrazine Paper test amniotic fluid causes alkaline

(>6.5 ph) reaction to the paper (turns to blue) and urine
causes acidic reaction (remains yellow)

b. Ferning test get the sample of fluid then place on

the slide and viewing it under the microscope

- + ferning patterns means BOW

Management:
1. Strict Bed Rest
2. Observe, document and report maternal temperature above
38C, fetal tachycardia
3. Monitor for signs of infections (fever, uterine tenderness)
4. Avoid sexual intercourse/Orgasm
5. avoid vaginal exams (risk of infection)
6. avoid breast stimulation
7. record fetal movements daily and report fewer than 10 in a
12 hour period
8. administer broad spectrum ATBC to reduce the risk of
infection e.g. Penicillin/Ampicillin

PREGNANCY- INDUCED HYPERTENSION (PIH)

- originally called Toxemia of Pregnancy

- condition in which vasospasm occurs

during pregnancy accompanied by
hypertension, protenuria and edema

- onset: occurs after 20th week of

pregnancy and may appear up to 48 hours
(2 weeks) postpartum

- occurs 5-10% pregnancies

 Cause:

- Unknown
Risk Factors:

- related to different associative factors

1. Primipara - < 20 years old and > 40 years old

2. Low socio-economic status (poor nutrition decrease CHON intake)

3. Women who have 5 or more pregnancies

4. Multiple pregnancies

5. Hydramnios (pre-exisiting)

6. Underlying HPN/DM

7. Poor calcium/Magnesium intake

8. H-mole

Pathophysiology:
Pregnancy Induced Hypertension
Peripheral Vascular Spasms (Vasospasm)

Vascular Effects

Vasoconstriction

Kidney Effects

Decrease GFR and increase

Permeability of Glomeruli
membranes

Interstitial Effects

Diffusion of fluid from

blood stream into the
interstitial tissue

Increased BP
Increase Serum BUN, uric acid and
Creatinine

Decrease urine output and

protenuria

Edema

 Kidney Effects:

- Vasospasm in the kidney increases blood flow

resistance

- leads to increase permeability of the

glomerular membranes, allowing the serum
CHONS and globulin to escape in the urine
(protenuria)

- Results in decreased glomerular filtration

lowers urine output

 Interstitials Effects:

- Because of more CHON is lost, the osmotic pressure is

decreased and the excessive fluid shifts/diffuses from
vascular spaces to the interstitials spaces

- leads to edema (extreme edema can lead to pulmonary

edema and seizure (Eclampsia) and it increases tubular
reabsorption of Na in kidneys

Feto-placental effects:

- poor placental perfusion may reduce the fetal nutrient

and oxygen supply

Signs and symptoms:

Triad of Symptoms (classic signs of PIH)
1. HPN
2. Protenuria
3. Edema

Classification of PIH:
1. Gestational HPN aka, Transcient HPN

- develops Increase BP (>140/90) but has no protenuria and

edema

- decrease maternal mortality so no drug therapy is necessary

- BP returns to normal by 10th day of postpartum

 2. Mild Pre-Eclampsia

a. 1st criteria Increase BP of >140/90 mmHg taken on 2 occasion at

least 6 hours apart

2nd criteria Systolic BP is > 30 mmHg and Diastolic BP is >15

mm Hg above baseline BP

b. Protenuria

- +1 or +2 (represents a loss of 1 g/dl of CHON

c. Edema (weight gain)

- due to CHON loss, sodium retention and decrease GFR

- begins to accumulate on the upper part of the body (hands/face)

- weight gain of >2 lb/wk in the second semester or > 1 lb/wk in the
3rd trimester (abnormal)
Normal Weight Gain; 1st Trimester 1 lb/month, 2nd/3rd trimester 4
lbs/mos

 Nursing management:

- can be managed at home with frequent follow-ups

1. BED REST (bathroom priviliges)

- facilitate Na excretion

- decreases oxygen demand

- position on left lateral position to prevent uterine pressure on the

vena cava
2. Assess the BP in sitting/left lateral position, CHON level in the urine,
changes in LOC, fetal movements and FHT
3. regular diet with NO salt restriction

- Na restriction may activate the RAAS (rennin-angiotensinaldosterone system) which can result in increase BP
4. if symptoms progress to Severe Pre-Eclampsia REFER immediately to
HOSPITAL.

 3. Severe Pre-Eclampsia

- Presence of any of the following:

a. increase BP >160/110 mm Hg
on at least 2 occasions 6 hours apart at
bed rest (the position in which BP is
lowest)

b. marked protenuria 3+ or 4+
on a random urine sample

 c. generalized edema noticeable in womans

face (facial edema) and hands (wedding ring
cant be removed), pulmonary edema
(dyspnea, crackles on auscultation), cerebral
edema (visual disturbances i.e blurred vision,
headache)
d. urine output oliguria (less than 500 ml/24
hrs) or 30 ml/hr

 Nursing Management:

- usually hospitalized until the baby is delivered

1. BED REST (patient must be observe more closely)
2. Provide a quiet and calm environment any noise can trigger a
seizure activity and leads to eclampsia
3. administer precautions on the patients room:

a. patients bed must be near nurses station with code cart

nearby

b. placed in private room (undisturbed)

c. the room should be darkened (because bright light can trigger

seizure)

d. raise padded side rails to prevent falls or injury from seizure

activity

 4. frequent maternal assessments every 4 hours (seizure precautions)

a. sudden rise of BP

b. blood studies CBC, platelet count, liver function, BUN, Creatinine,

urine CHONS

c. urine output normal 600ml/24hours or 30 ml/hour

d. daily weights same time each day

e. impeding seizure signs (aura) such as headache, visual disturbances,

epigastric pain
5. Monitor Fetal Well-being

- placed in External fetal Monitors to asses for FHR and fetal movements

- Non-Stress test/Biophysical Profile to assess for Utero-placental

sufficiency
6. Moderate high protein diet to compensate for CHON lost (proteinuria)

Medical Management:
- to prevent Eclampsia
1. Hydralazine (Apresoline) antihypertensive to reduce HPN by peripheral
dilatation
- side effects Tachycardia
- check for PR and BP before and after administration
2. Magnesium Sulfate
- DOC to prevent eclampsia
- action:
a. Cathartic reduces edema by causing fluid shifting from extracellular
spaces into the intestine (removed by bowel elimination)
b. CNS depressant (anti-convulsant) lessens the possibility of seizure activity
c. decrease neuromuscular irritability (muscle relaxant effect)
d. Promotes maternal vasodilatation promotes better feto-placental
circulation or tissue perfusion

 Nursing responsibilities during MgSO4 administration:

1. Given IV via Piggyback infusing over 15-30 minutes, loading dose
4-6g/hr and maintenance dose 1-2 g/hr
2. assess RR, urine output, DTR and ankle clonus before after
administration
3. Monitor for magnesium sulfate toxicity:

a. depressed respiration of <12Breaths/min

b. decrease urine output of <30 ml/hr

c. decrease DTR

d. decrease LOC
4. Antidote: Calcium Gluconate a solution of 10 ml of 10% calcium
gluconate solution given for MGSO4 toxicity

- must be readily available at bedside

 4. Eclampsia the most severe

classification of PIH

- when cerebral edema occurs onset of

seizure or coma occurs

- maternal mortality rate is high 20%

due to hemorrhage (circulatory collapse
or renal failure)

 Signs and Symptoms:

1. Increase HPN precedes SEIZURE
- impending signs of seizure are headache, visual disturbances and
epigastric pain) followed by circulatory hypotension and collapse
Stages:

a. Tonic phase all body contracts, arching of back, arms and legs
are stiff

b. Clonic phase = all of the muscle of body will contract and relax

c. Post-Ictal phase semicomatose/ patient cannot be arouse except

for painful stimuli
2. may lead to coma
3. labor may begin because of premature separation of placenta
secondary to vasospasm which might lead to preterm delivery

 Nursing Management:

- Priority care for the mother with seizure is to:

1. Maintenance of Patent Airway

- administer oxygen by face mask

- turning the mother to the side to allow the secretions to drain in the mouth
(preventing aspiration)

2. Raised padded side rails

3. avoid placing a tongue depressor (during the seizure activity) because it can
obstruct the airway

4. minimize environmental stimuli

5. administer medications as ordered i.e MgSO4 and diazepam IV

6. continue to assess FHT and uterine contractions

7. check for maternal bleeding

8. mother can deliver via NSD, CS is very hazardous because hypotension might
result secondary to anesthesia

9. IV therapy as ordered

 HELLP SYNDROME

- a variation of PIH abbreviated as

Hemolysis, Elevated liver enzymes and low
platelet count

- occurs in 4-12% of patients with PIH

- a life threatening complication of PIH

(because maternal mortality is high at 24%
and infant mortality is 25%)

 Cause: Unknown
Associated Factors
primipara/Multipara mothers
Signs and Symptoms:

- nausea

- epigastric pain

- general malaise

- right upper quadrant tenderness

 Laboratory data:

a. hemolytic RBC

b. thrombocytopenia (low platelet

count of below 100,000/m3)

c. elevated lover enzyme (because of

hemorrhage and necrosis of liver)

- serum ALT (Alanine

Aminotransferase), and ALT (Aspartate
aminotransferase)

 Medical Management: (no known

cure)
1. Blood transfusion of fresh frozen
plasma or platelets
2. infant is deliver ASAP via NSD or
CS (lab. Results will return to normal
after delivery
3. monitor for bleeding

MULTIPLE PREGNANCIES
- a pregnancy in which there is more
than one fetus in the uterus at the
same time

- Incidence rate is 2% of
pregnancies

 Types:
1. Monozygotic twins

- aka. Identical twins

- begins with single ovum and spermatozoa,

during the process of fusion, the zygote divides
into two identical individuals

- have 1 placenta, 1 chorion, 2 amnion, 2

umbilical cords

- always of the same sex

 2. Dizygotic Twins

- aka. Non-identical/fraternal twins

- the result of fertilization of two separate

ova by two separate spermatozoa

- have 2 placenta, 2 chorions, 2 amnions, 2

umbilical cords

- twins may be of the same or different sex

- 2/3 of twins are dizygotic

 Associative Factors:
a. more frequent in non-whites
than in whites
b. increase in parity
c. advance maternal age
d. familial inheritance

 Diagnostic procedure:
Sonogram/Ultrasound
Signs and Symptoms:

1. Increase uterine size faster than usual

2. quickening at the different portion of

the abdomen

3. more than expected fetal activity

4. multiple sets of FHT

5. extreme fatigue and backache

 Management:

- mother is more susceptible to

complications of pregnancy i.e. PIH,
hydramnios, placenta previa, pre-term labor,
anemia than a women carrying only one
fetus
1. BED REST (during the 2 or 3 months of
pregnancy to decrease risk of preterm labor
2. Closer prenatal supervision

HYDRAMNIOS (Polyhydramnios)
- Excessive fluid formation of >2000ml or an
amniotic fluid index of above 24 cm (normal 5001000ml)
Complication:
1. Fetal Malpresentation (because of extra-uterine
space)
2. Premature rupture of membranes that leads
to infection and prolapsed cord
3. Preterm labor (because of increasing pressure,
prostaglandin release)

 Risk Factors:
1. Maternal diabetes hyperglycemia in
the fetus causes increase urine production
leading to increase urine output
2. Anencephaly
3. Esophageal atresia fetus becomes
unable to swallow the amniotic fluid
because of intestinal anomalies or
obstruction

Esophageal Atresia

Anencephaly

 Signs and Symptoms:

1. Rapid enlargement of the uterus (first
sign)
2. difficulty in palpating and auscultating the
fetus due to excessive fluid
3. shortness of breath due to compression of
the diaphragm
4. ultrasound finding of increase excessive
fluid

 Management:
1. maintain bed rest to reduce pressure on
cervix and to prevent premature labor
2. monitor for rupture or uterine contraction
3. avoid constipation (it will increase uterine
pressure and rupture of membranes)
4. amniocentesis (slow and controlled release
of fluid to prevent premature separation of
the placenta) guided by ultrasound

POST-TERM PREGNANCY
- a pregnancy that exceeds 42 weeks
of gestation (term pregnancy 37-42
weeks)

- incidence rate 3-12% of all

pregnancies

 Risk Factors:
1. Women who have long menstrual cycles (40-45 days)

- they do not ovulate on day 14 in a typical

menstrual cycle. They ovulate 14 days from the end of
the cycle or on day 26 or 31. Their child will be late by
12 or 17 days.
2. Women receiving high dose of Salicylates (interferes
with synthesis of prostaglandins that initiates labor)
3. associates with myometrial quiescence (uterus that
do not respond to normal labor)

Complication:
1. meconium aspiration
2. macrosomia fetus continues to grow
3. fetal distress due to placental aging it causes decreased
blood prefusion and inadequate supply of oxygenated blood and
nutrients to fetus

Management:
1. Induction of labor prostaglandins or inoprostol (cytotec)
applied to cervix to stimulate ripening or stripping of membranes.
Followed by oxytocin infusion to stimulate contraction
2. CS delivery

RH INCOMPATIBILITY
(Isoimmunization)
- occurs when the mother is Rh negative (-)
who carries a fetus with an Rh positive (+)
blood

- normally there is no direct contact

between maternal and fetal blood

- villi ruptures a drop or two of fetal

blood enters maternal circulation or during
amniocentesis

 - small amount of blood (drop) of Rh + fetal blood leaks

across the placenta and goes to the blood stream of the
mother. Mother will be sensitized and start to make Rh
antibodies (first pregnancy is not affected)

- an injection of Rh immune globulin (Rhogam) is given

ASAP within 72 hours after the delivery (because most of
maternal antibodies are formed during the first 72 hours after
birth)

- During the subsequent pregnancy (if fetus is again Rh

+), the Rh antibodies of the mother crosses the placenta,
enters the blood stream of the fetus causing antigen-antibody
reaction and Hemolysis of the fetal RBC (Erythroblastosis
Fetalis)

 Diagnosis:
1. Indirect Coombs test to check if Rh
antibodies are present within RBC
surface
2. Antibody titer determine at first
pregnancy visit and then again at 28
weeks AOG and after delivery (normal
is 0)

Management:
1. Rh Immune globulin (Rhogam) is administered at 28 weeks of
pregnancy and in the 1st 72 hours after delivery
2. Determine blood typed of infants after birth from a sample of
the cord blood
3. Blood transfusion through Intrauterine Transfusion
- done to give restore fetal RBC
- 75-150ml of RBC is administered
- after BT, the mother is encouraged to rest for 30 min. while
FHT and uterine activity are monitored
4. As soon as fetal maturity is reached, induction of labor is
followed

GESTATIONAL DIABETES MELLITUS

- a condition in which women exhibit high glucose
levels during pregnancy

- an abnormal CHO, fat and CHON metabolism

that is first diagnosed during pregnancy (at the
midpoint of pregnancy when insulin resistance
becomes noticeable)

- but the symptoms fade again at the

completion of pregnancy (resolves in delivery)

- risk of developing type 2 diabetes is high as

56-60% later in life

 Cause: Unknown (related to excessive insulin

resistance)
Risk Factors:
1. obesity
2. age over 25 years old (about 50% of the these
women develop diabetes within 22-28 years old)
3. history of large babies/macrosomia (16 lbs or
more)
4. family history of DM/GDM

Pathophysiology of DM
Pancreas produces no insulin or inadequate insulin

Inadequate insulin
Inability to move glucose from the blood to body cells
Cellular
starvation

Polyphagia

Metabolize FAT/CHON for energy

Causes ketones and

acids to accumulate
in the blood

Hyperglycemia

Glycosuria

Exerts osmotic pressure in th

kidneys

Polydipsia
Attracts more water

Polyuria
Metabolic
acidosis

 Diagnosis: women who are high risk for DM should be

screened at first prenatal visit and again at 24-28
weeks.
1. Glucose Challenge Test done at first prenatal
visit and again at 24-28 weeks

- usually consists of 8 hour fasting for FBS

- mother is given 50g of glucose load and a blood

sample is taken for serum glucose 1 hour after

- diabetic if FBS is more than 95mg/dl or after 1

hour the serum glucose is >140mg

Glucometer

2. Oral Glucose Tolerance Test

- the gold standard for diagnosing diabetes
- mother is given 100g of CHO/glucose then 3 hours fasting
Test type Pregnancies glucose level (mg/dl)
Fasting 95
1 hour 180
2 hours 155
3 hours 140
- rate is abnormal if 2 of the 4 blood samples collected are
abnormal

- <70 hypoglycemia, >130 hyperglycemia (normal 80120mg/dl)

 Maternal effects of DM;

1. Hypoglycemia during the first trimester
glucose is being utilized by the fetus for the
development of the brain
2. Hyperglycemia during the 2nd /3rd trimester at
6 months due to HPL effects (causes insulin
resistance)

Insulin requirements for insulin during:

1st trimester decrease in insulin by 33%
2nd/3rd trimester increase insulin by 50%,
Postpartum drops suddenly to 25%due to
delivery of placenta
3. prone to frequent infections e.g.
Moniliasis/Candidiasis
4. Polyhydramnios
5. Dystocia due to abnormality in fetus/mother

 Fetal Effects of DM
1. Hypoglycemia during the 1st
trimester
2. Hyperglycemia during the 2nd/3rd
trimester
3. Macrosomia abnormally large for
gestational age(baby is delivered
>4000 g or 4kg)

Macrosomia

 Newborn Effects:
1. Hyperinsulinism because insulin from the mother does not
cross the placenta which lead to increase insulin production
from the baby
2. Hypoglycemia when the umbilical cord is cut the supply
of glucose from the mother also stops which results in very
hypoglycemia newborn (normal glucose in NB 45-55mg/dl)
Signs and Symptoms: (newborn)
1. High pitched shrill cry
2. tremors
3. jitteriness
Diagnosis: Heel Stick Test to check glucose level

 Management:
1. Frequent prenatal visits for close monitoring]
2. Insulin (regular/Intermediate acting insulin) given
subcutaneously (slow absorption)

- do not massage the site of injection

- rotate the site of injection (to prevent lipodystrohy- inhibits

insulin absorption)
- gently roll vial in between the palms (do not shake)

3. Monitor blood glucose assess once a week

- using finger stick technique, using on fingertips as the site

of lancet puncture, the strip is then inserted into a glucose meter
to determine glucose level (normal <95mg/dl FBS, <120mg/dl 2
hours post prandial (after very meal) level

 4. Monitor fetal well being

a. ultrasound/Sonogram to determine fetal growth, amniotic fluid

volume, placental location and b-parietal diameter

b. daily fetal movement count (DFMC) monitoring for movements of

fetus for 1 hour (normal 10 movement/hour)

c. amniocentesis to determine LS ratio by 36 weeks of pregnancy

and to assess fetal lung maturity
5. CS delivery

- cervix is not yet ripe or not yet responsive to contractions

- babies of diabetic mother are abnormally large making vaginal

delivery difficult
6. woman with gestational diabetes usually demonstrates normal glucose
levels by 24 hours after birth (and needs no further insulin therapy)

Heart Disease
- Origin: 90% Rheumatic (incidence expected to
decrease as incidence of rheumatic fever
decreases), 10% congenital lesions or syphilis
- Normal hemodynamics of pregnancy that adversely
affect the client with heart disease:
- a. oxygen consumption increased 10% to 20%;
related to the needs of the growing fetus
- b. plasma level and blood volume increase; RBCs
remain the same (physiologic anemia)

 Functional or Therapeutic Classification of Heart

Disease during Pregnancy:
CLASS I no limitation of physical activity; no symptoms
of cardiac insufficiency or angina
CLASS II sight limitation of physical activity; may
experience excessive fatigue, palpitation, angina or
dyspnea; slight limitations as indicated
CLASS III moderate to marked limitation of physical
activity; dyspnea, angina and fatigue occur with slight
activity and bed rest is indicated during most of
pregnancy
CLASS IV marked limitation of physical activity; angina,
dyspnea and discomfort occur at rest; pregnancy should
be avoided; indication for termination of pregnancy

Nursing Care of Pregnant Client with heart

Disease:
1. Assessment:
a. Prenatal period
- vital signs; weight gain; dietary patterns,
knowledge about self care; signs of heart failure,
stress factors such as work, household duties
b. Intrapartal period
- vital signs (heart rate will increase); respiratory
changes (dyspnea, coughing, crackles); FHR patterns
c. Postpartal period
- signs of heart failure or hemorrhage related to
fluid shifts, intake and output

2. Analysis/ Nursing Diagnosis

a. activity intolerance related to increased cardiac
workload
b. anxiety related to unknown course of pregnancy,
possible los of fetus and inability to perform role
responsibilities
c. decreased cardiac output related to stress of
pregnancy and pathology associated with heart
disease
d. fear related to possible death
e. excess fluid volume related to fluid shifts resulting
from a decrease in intra-abdominal pressure following
birth
f. risk for impaired parenting related to increased
responsibility of caring for a neonate

3. Nursing Interventions
A. Prenatal period
1. teach importance of rest and avoidance of stress
2. instruct regarding use of elastic stockings and
periodic evaluation of legs
3. teach appropriate (dietary intake; adequate
calories to ensure appropriate, but not excessive,
weight gain; limited, not restricted salt intake
4. administer medications as ordered; heparin,
furosemide (lasix), digitalis, beta blockers (inderal)
5. monitor for signs of heart failure such as
respiratory distress and tachycardia; may be
precipitated by severe anemia of pregnancy

B. Intrapartal period
1. encourage mother to remain in semi Fowlers
position or left lateral position
2. provide continuous cardiac monitoring
3. provide electronic fetal monitoring
4. assist mother to cope with discomfort; minimal
analgesia and anesthesia are used
5. assist with forceps delivery in second stage of
labor to avoid work of pushing
6. monitor for signs of heart failure, such as
respiratory distress and tachycardia

C. Postpartal period (most critical time because of

increased circulating blood volume after birth of
placenta)
1. institute early ambulation schedule; apply
elastic stockings
2. monitor for signs of heart failure, such as
respiratory distress and tachycardia
3. monitor heart rate; accelerated heart rate of
mother in latter half of pregnancy puts extra
workload on her heart
4. provide for adequate rest; the increase in
oxygen consumption with contractions during labor
makes length of labor a significant factor

5. provide close supervision; sudden tachycardia

during birth or sudden bradycardia and normal
increase in cardiac output following birth may
cause cardiac arrest
6. administer prescribed prophylactic antibiotics to
mother with history of rheumatic fever
7. refer to various agencies for family support, if
necessary on discharge
8. newborn risks include intrauterine growth
retardation, prematurity and hypoxia fetal demise
may occur

INTRAPARTUM COMPLICATIONS
occur in as many as 31% of all births
- broad term for abnormal or difficult labor and
delivery
- arise from 3 main components of the labor
process

1. Power (uterine contractions)

2. Passenger (the fetus)

3. Passageway (the birth canal)

 Problems with the Power: (Force of Labor)

1. Uterine Inertia sluggishness of contractions or the
force of labor or defined as difficult, painful, prolonged labor
due to mechanical factors

- current term Dysfunctional Labor

Common Causes:
a. inappropriate use of analgesia (excessive or too early
administration)
b. unusually large baby/multiple gestation
c. poor fetal position (posterior rather than anterior position)
d. pelvic bone contraction (leads to narrowing of the pelvic
diameter so the fetus cant pass)
e. primigravida
f. hypotonic, hypertonic and prolonged labor

2 types:
1. Primary occurring at the onset of labor
2. Secondary occurring later in labor

Signs and Symptoms;

- irregular uterine contractions

- ineffective uterine contractions

(strength/duration)

 Management:
1. Monitor uterine contractions by palpation and with the
use of electronic monitor
2. Prevent unnecessary fatigues check the client level of
fatigue
3. Prevent complications of labor

a. assess urinary bladder (catheterize as needed)

b. assess maternal VS

c. monitor condition of fetus by monitoring FHR, fetal

activity and color of amniotic fluid
4. Provide comfort measures

a. frequent position changes

b. walking

c. quiet/calm environment

d. breathing/relaxation technique

2. Ineffective Uterine Force

- ineffective uterine contractions which can result in
ineffective labor
types;
1. Hypotonic Contractions the number of
contractions is usually low or infrequent (not
increasing beyond 2 or 3 in a 10 minute period)

- occurs during the active phase of labor

- normal : 3-4/10 min period with duration of 30

seconds

 Risk Factors
- bowel/bladder distention prevents
descent/engagement
- multiple gestation
-large fetus
- hydramnios
- multiparity

 Signs and Symptoms: Painless less frequent

Contraction
Management:
1. oxytocin administration to strengthen
contractions and increase effectiveness
2. Amniotomy (artificial rupture of membranes
to further speed labor
3. Palpate the uterus and assess lochia every 15
minutes to prevent postpartum bleeding
4. monitor maternal VS and FHR
5. position changes to relieve discomfort and
enhance progress

 2. Hypertonic Contractions

- intensity of the contractions may not stronger or very active

and frequent contractions but ineffective

- occurs more frequently and commonly seen in latent phase of

labor

- the muscle fibers of the uterus (myometrium) do not repolarize

Signs and Symptoms;
1. Painful nonproductive contractions
2. uterine tenderness
3. fetal anoxia/distress
4. dehydration due to excessive perspiration
5. fatigue and exhaustion

 Management:
1. assess quality of contractions by uterine/fetal
external monitor applied at least 15 minutes
interval
2. adequate rest
3. pain relief with morphine sulfate
4. changing linen/gowns
5. darkened room lights
6. decreasing environmental stimuli
7. CS delivery

PRECIPITATE LABOR
- define as labor that is completed in fewer than 3 hours
(normal length of labor; Primipara 14-20 hours, Multi 8-14
hours)

- a forceful contractions that can lead to premature

separation of the placenta (placing the mother and fetus at
risk for hemorrhage)

Risk Factors:

1. likely to occur in multiparity mothers

2. women undergo premature separation of the placenta

3. previous history of precipitate labor

Complications
1. hemorrhage
2. Intracranial hemorrhage in fetus
3. lacerations (because of forceful birth)
4. Fetal distress

Signs and symptoms:

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


Nursing Management:
1. Inform mother at 28 weeks of pregnancy that labor
may be shorter than normal
2. Tocolytic agent administration to reduce the force
and frequency of contractions
3. Cold applications to limit bruising, pain and edema
4. In time of hemorrhage position the mother in
modified trendelenburg position
5. IVF replacement fast drip

UTERINE RUPTURE
- rupture of the uterus during labor

- accounts for 5% of maternal death

- incidence rate is 1 in 1500 births

Risk Factors:

- commonly occur from a vertical scar during the previous CS or

hysterectomy repair tears

- prolong labor

- faulty presentation

- multiple gestation

- use of oxytocin

- traumatic maneuvers

 - usually preceded by pathologic refraction ring (an indentation is apparent

across the abdomen over the uterus) and strong uterine contractions without any
cervical dilatation, the fetus is gripped by retraction ring and cannot descent)
Signs and Symptoms:

1. sudden severe pain during a strong labor contractions

2. report a tearing sensation

3. hemorrhage from a torn uterus into the abdominal cavity and into the
vagina

4. signs of shock (rapid, weak pulse, falling blood pressure, cold clammy
skin)

5. absent fetal heart sounds

6. localized tenderness and aching pain from the lower segment

7. fetal distress

 Nursing Management:
1. Administer emergency fluid replacement therapy as
ordered
2. Anticipate use of intravenous oxytocin to attempt to
contract the uterus and minimize bleeding
3. prepare mother from a Laparotomy as an emergency
measure to control bleeding and effect a repair
4. Physician may perform hysterectomy (removal of a
damaged uterus) or BTL at the time of Laparotomy
5. monitor VS and FHR
6. administer BT as ordered

UTERINE INVERSION
- uterus turns completely or partially inside out, it occurs
immediately following delivery of the placenta or in the immediate
postpartum period

- incidence rate is 1 in 15, 000 births

Causes:

- occurs after birth of the infant if traction is applied to umbilical

cord to remove placenta

- pressure is applied to the uterine fundus when uterus is not

contracted

- occurs when placenta attached at the fundus (the passage of

the fetus pulls the fundus down)

Signs and Symptoms:

1. sudden gushes of blood from vagina
2. fundus is not palpable
3. show signs of blood loss (hypotension, dizziness and paleness)
4. bleeding

Nursing Management;
1. recognize signs of impending inversion and immediately notify
the physician
2. never attempt to replace the inversion because handling may
increase the bleeding
3. never attempt to remove the placenta if it still attached

 4. take steps to prevent or limit hypovolemic shock

a. use large gauge IV catheter for fluid replacement

b. measure and record maternal VS every 5 to 15

minutes to establish baseline changes
5. administer oxygen by mask
6. be prepared to perform CPR if the heart fails due to
sudden blood loss
7. the mother will be given general anesthesia or
nitroglycerin or a tocolytic drug IV to immediately relax the
uterus
8. physician/nurse midwife replaces the fundus manually
(push the uterus back inside)

AMNIOTIC FLUID EMBOLISM

- occurs when amniotic fluid is force to enter the
maternal blood circulation because of some defect in
the membranes or after membranes rupture (not
preventable because it cannot be predicted)

- incidence rate is 1 in 8000 births

Risk factors:
1. oxytocin administration
2. abruption placenta
3. hydramnios

Signs and Symptoms:

1. sharp pain on the chest
2. dyspnea (secondary to pulmonary artery constriction)
3. mother becomes pale and cyanotic due to pulmonary embolism
and lack of blood flow to the lungs

Nursing Management:
1. immediate management is oxygen administration by face mask
or cannula
2. prepare the mother for CPR (may be ineffective because these
procedures do not relieve the pulmonary constriction)
3. Endotracheal intubation to maintain pulmonary function
4. The mother should be transferred to ICU

 Complication:
1. DIC disseminated intravascular
coagulation

- bleeding to all portion of body (eyes,

nose, gums, IV sites)

- therapy with fibrinogen to counteract

DIC

PROBLEMS WITH THE PASSENGER

1. PROLPASE OF UMBILICAL CORD

descent of the umbilical cord into the vagina

ahead of the fetal presenting part with
resulting compression of the cord (cord
compression)

- emergency situation , immediate

delivery is attempted to save the baby

- incidence rate is 0.2-0.6% of births or 1

of 200 pregnancies

 Associative Factors:
1. premature rupture of membranes (the fetal fluid may rush and carry the
cord along toward the birth canal)
2. breech presentation
3. placenta previa
4. intrauterine tumors preventing the presenting part from engagement
5. small fetus
6. CPD preventing engagement
7. hydramnios
8. multiple gestation

Signs and Symptoms;
1. the umbilical cord seen or felt during vaginal exam
2. reports feeling of cord into the vagina

 Management: (relieve compression on the cord and fetal

anoxia)
1. periodically evaluate FHR especially after the rupture of
membranes (fetal distress)
2. Physician will place a glove hand in the vagina and
manually elevate the fetal head off the cord
3. place the mother in knee-chest position/trendelenburg
position (causes the fetal head to fall back from the cord)
4. administer oxygen at 10 Liters/minute by facemask to
improve oxygenation of the fetus
5. do not attempt to push any exposed cord back into the
vagina (adds to compression)

 6. cover any exposed portion of the cord with

sterile gauge soaked in NSS around the prolapsed
cord
7. if the cervix is fully dilated at the time of
prolapsed (the most emergent delivery route is
NSD and encourage mother to push)
8. if not fully dilated, mother is delivered via CS
(upward pressure on the presenting part to keep
pressure off the cord)

PROBLEMS WITH POSITION,

PRESENTATION OR SIZE:
1. OCCIPITO-POSTERIOR POSITION

- LOA (left occipito-anterior) is the most ideal and

common fetal position

- LOP (left occipito-posterior) is located on left and

posterior quadrant pelvis

- ROP (right occipito-posterior) is located at the right

and posterior quadrant pelvis
ROP in this position, during the internal rotation, the
fetal head must rotate not through a 90 degree arc but
through an arc of approximately 135 degrees

 Risk Factors:
1. Women with android/anthropoid pelvis.

 Signs and Symptoms;

- Intense lower back pain (lumbosacral pain) due to

compression of sacral nerves during rotation

- Shooting leg pains

Nursing Management;
1. provide back rub
2. change of position (squatting position) may help fetus to
rotate
3. encourage voiding every 2 hours to keep bladder empty
(because full bladder impedes descent of the fetus)
4. apply hot/cold compress
5. delivered via CS

 2. BREECH PRESENTATIONS presenting

parts are usually buttocks and feet
Complications:
1. anoxia (due to prolapsed umbilical cord)
2. intracranial hemorrhage
3. fracture of the pine/extremities
4. dysfunctional labor

Risk Factors:
1. gestational age under 40 weeks
2. abnormality in the fetus such as anencephaly, hydrocephalus
3. hydramnios (allows for free fetal movement)
4. congenital anomaly of the uterus
5. multiple gestation

Signs and Symptoms;

1. Fetal heart sounds usually heard high in the abdomen (URQ, ULQ)
2. fetal distress
Diagnosis; Leopolds maneuver, vaginal exams and ultrasounds will
reveal breech presentations

 Nursing Management;
1. External version is being used to avoid some CS
deliveries for a breech presentations
VERSION is a method of changing the fetal presentation
usually from breech to cephalic.
- done after 37 weeks of gestation but before the onset of
labor
- begins with non-stress test and BPF to determine of the
fetus is in good condition and if there is adequate amount
of amniotic fluid
- mother is given tocolytic drug to relax her uterus during
version

- UTZ is used to guide the procedure while

physician pushes the fetal buttocks upward out of
the pelvis while pushing the fetal head downward
toward the pelvis in either clockwise or
counterclockwise direction
3. the head may also be delivered using forceps
delivery to control the flexion and rate of descent
4. CS delivery

THERAPEUTIC MANAGEMENT OF PROBLEMS

OR POTENTIAL PROBLEMS IN LABOR AND
BIRTH
1. Induction of labor done when labor
contractions are ineffective

- means that labor is started artificially

Indications;
1. pre-eclampsia
2. eclampsia
3. severe hypertension/DM
4. Rh sensitization
5. prolong rupture of membranes
6. post maturity

Requirements for labor induction;

1. fetus must be in longitudinal lie
2. cervix must be ripe
3. presenting part must be engaged
4. No CPD
5. fetus is matured by date, LS ratio or sonogram (bi-parietal diameter)

Pharmacological Methods:
1. Cervical Ripening softening of the
cervix/consistency

- is the FIRST STEP the uterus must complete in

early labor

- necessary for dilatation and uterine contractions

Criteria:
Scoring of cervix for readiness in elective conductions
(if the scale is 8 or above, the woman is considered
ready for birth and induction)

Scoring
Factor

Dilatation (cm)

1-2

3-4

5-6

Effacement (%) 0-30

40-50

60-70

80

Station

-3

-2

-1, 0

+1, +2

Consistency

Firm

Medium

Soft

Position

Posterior

Mid-Posterior

Anterior

Prostaglandin Gel commonly used method

of speeding cervical ripening and is applied
to the inferior surface of the cervix
- applied before labor induction
- can also be applied on the external
surface by applying the gel to the
diaphragm then placing the diaphragm
against the cervix
- apply every 6 hours for 2-3 doses

 Nursing Considerations;
1. Place women in flat position to prevent leakage of medication
2. the woman remains on bed rest for 1 to 2 hours and is
monitored for uterine contractions
3. monitor FHR continuously for at least 30 minutes after each
application up to 2 hours
4. IV line with saline is initiated in case uterine hyperstimulation
occurs such as contractions longer than 90 seconds or more than
5 contraction in 10 minutes
5. explain the side effects vomiting, fever, diarrhea and
hypertension
6. oxytocin induction can be started 6-12 hours after the last
prostaglandin dose

 2. Induction of Labor by Oxytocin a synthetic

form of pituitary hormone initiates contractions in
uterus
Nursing Considerations;
1. Given IV (to hasten effect), IV form of oxytocin

needs to be diluted

2. the drug is traditionally mixed in the proportion

of 10 IU in 1000ml of Ringers Lactated (LR)
3. Administer the medication by piggyback attach

to D5W as the main IV line (if oxytocin needs to be

discontinued, the main line will be maintain)

 4. when cervical dilatations reaches 4 cm, artificial

rupture of membranes is performed to further
induce labor and oxytocin infusion is discontinued
5. Monitor FHR/uterine contractions and cervical
dilatation during the procedure
6. side effects: extreme hypotension due to
peripheral vasodilatation, headache, vomiting
7. monitor VS every 15 minutes
8. complications to watch; fetal distress and uterine
rupture

ANOMALIES OF THE PLACENTA AND

CORD;
1. Anomalies of the placenta

a. Placenta Succenturiata has one or

more accessory lobes connected to the main
placenta by blood vessels

- no fetal abnormality
associated with it

- can lead to maternal

hemorrhage (small lobes retain in the uterus
after birth)

 b. Placenta Circumvallata fetal side of the placenta is

covered with chorion (normally, no chorion covers the fetal side
of the placenta)

- no abnormalities is associated with this types of placental

anomaly

c. Battledore Placenta the cord is inserted marginally
rather than centrally

- rare/unknown clinical significance

d. Velamentous Insertion of the Cord situation in which
the cord instead of entering the placenta directly, separated
into small vessels that reach the placenta by spreading across
a fold of amnion

Postpartum Complications

1. Postpartum hemorrhage major cause of

maternal death, occurs in 4% of deliveries
- defined as blood loss greater than 500 ml
after vaginal birth or 1000 ml after CS
Classifications:
According to severity:
a. Mild 750 1250 ml
b. Moderate 1250 1750 ml
c. Severe 2500 ml

According to time:
1. Early Postpartum hemorrhage occurs within 24 hours of birth
2. Late postpartum hemorrhage occurs after 24 hours until 6 weeks
after birth
Major Risk: Hypovolemic Shock (low volume)
- occurs when the circulating blood volume is decreased which interrupts
blood flow to body cells
- manifested as:
a. Tachycardia (first sign)
b. hypotension
c. cold and clammy skin
d. mental changes such as anxiety, confusion, restleness
e. decrease urine output

Conditions that increase risk for PP hemorrhage

1. Over distension of the uterus
Multiple births
Hydramnios
Macrosomia

2.
3.
4.
5.

Trauma r/t forceps, uterine manipulation

Prolonged labor
Uterine infection
Trauma removing placenta

Causes of Postpartum hemorrhage

1. Uterine Atony: Uterus without tone or
lack of normal muscle tone (90% of
cases)
- uterine atony allows blood vessels at
the placenta site to bleed freely and
usually massively.

- uterine muscle unable to contract

around blood vessels at placental site

Risk Factors:
1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion
Symptoms:
1. uterus is difficult to feel and is boggy (soft)
2. lochia is increased and may have large blood clots
3. Blood may gush or come out slowly

Nursing Management:
1. Massage the uterus until firm
2. have mother to urinate or catheterize because bladder
distension pushes the uterus upward or in the side and
interferes with the ability of the uterus to contract
3. Encourage mother to breastfeed because sucking
stimulation causes the release of oxytocin from PPG
4. Administration of IV oxytocin or Methylergonovine
(Methergine) to control uterine atony
5. Hysterectomy is performed to remove the bleeding
uterus that does not respond to other measures

2. Lacerations tearing of the birth canal

- normally occurs as a result of child
bearing
Risk factors:
a. difficult or precipitate births
b. primigravidas
c. birth of a large infant
d. use of a lithotomy position and
instruments (forceps)

Sites of lacerations:
1. Cervical Lacerations
- characterized by gushes of bright red blood from
the vaginal opening if uterine artery is torn
- difficult to repair because the bleeding may be so
intense that it can obstruct visualization of the area.
2. Vaginal Lacerations
- rare case but easier to assess
- oozing of blood after repair, vaginal packing is
necessary to maintain pressure from the suture line
- catheterize the mother because packing causes
pressure on urethra
- packing is removed after 24-48 hours (at risk for
infection)

3. Perineal Lacerations
- usually occurs when mother is placed on lithotomy
positions (increases pressure on perineum)
Classifications:
a. First Degree vaginal mucous membranes and
skin of the perineum to the fourchette
b. Second Degree vagina, perineal skin, fascia and
perineal body
c. Third Degree entire perineum and reaches the
external sphincter of the rectum
d. Fourth Degree entire perineum, rectal sphincter
and some of the mucous membrane of the rectum

Management (Perineal)
1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool softener is
prescribed for the first week postpartum to prevent
constipation which could break the sutures
3. do not take rectal temperatures because the
hard tips of equipment could open sutures

3. Retained Placental Fragments placenta does

not deliver its entire fragments and left behind leading to
uterine bleeding
Causes:
a. Placenta Succenturiata a placenta with accessory lobe
b. Placenta Accreta a placenta that fuses with myometrium
because of an abnormal basalis layer
Signs and Symptoms:
1. if Large fragments
- Patient bleeds immediately at delivery
- Uterus is boggy
2. if Small fragments
- bleeding occurs at 6th 10th day PP
- Can cause subinvolution

Management:
1. Dilatation and Curettage (D&C) will be
performed to remove placental fragments and to
stop bleeding
2. administration of Methotrexate to destroy the
retained placental tissue
3. instruct the mother to observe the color of lochia
discharge
4. check the completeness of the placenta after
birth

4. Disseminated Intravascular Coagulation

(DIC)
- deficiency in clotting ability caused by
vascular injury characterized by bleeding the IV
sites, nose, gums etc.
Associative Factors:
a. premature separation of the placenta
b. missed early miscarriage
c. fetal death in utero

5. Perineal Hematoma is a collection of blood in

the subcutaneous layer tissue of the perineum caused
by injury to blood vessels after birth
Risk Factors:
a. rapid spontaneous birth
b. perineal varicosities
c. episiotomy or laceration repair sites
Signs and Symptoms:
1. severe pain in the perineal area
2. feeling of pressure between the legs
3. purplish discoloration/swelling on perineum
4. concealed bleeding

Management:
1. assess the size by measuring it in
centimeters
2. administer a mild analgesic as pain relief
3. apply an ice pack (covered by towel to
prevent thermal injury to the skin)
4. incision and drainage of the site of
hematoma and is packed with gauze

Puerperal Infection
- Infection of the reproductive tract associated with
giving birth
- Usually occurs within 10 days of birth
- Another leading cause of maternal death
- Predisposing factors:
a. Prolonged rupture of membranes (>24 hours)
b. C-section
c. Trauma during birth process
d. Maternal anemia
e. Retained placental fragments

- Infection may be localized or systemic

a. Local infection can spread to peritoneum (peritonitis) or
circulatory system (septicemia).
b. Fatal to woman already stressed with childbirth
Assessment findings:
1. Temp of 100.4 for more than 2 consecutive days, excluding
the first 24 hours.
2. Abdominal, perineal, or pelvic pain
3. Foul-smelling vaginal discharge
4. Burning sensation with urination
5. Chills, malaise
6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity
(Remember, 20-25,000 is normal after deliveryMASKING
infection)

Nursing interventions
1. Force fluids; may need more than 3L/day
2. Administer antibiotics after culture and sensitivity of
the organism (Group B streptococci and E. Coli) and
other meds as ordered
3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote drainage
and prevent reflux higher into reproductive tract
6. Use of sterile equipments on birth canal during labor,
birth and postpartum
7. Educate the mother about proper perineal care
including wiping from front to back

Endometritis
- refers to the infection of the endometrium, the lining
of the uterus at the time of birth or during Postpartal
period
Signs and Symptoms:
1. fever on the third or fourth day postpartum(increase
in oral temperature above 38C for 2 consecutive 24
hour periods, excluding the first 24 hours period after
birth)
2. chills, loss of appetite and general body malaise
3. uterine tenderness
4. foul smelling lochia

Management:
1. ATBC administration such as Clindamycin after culture
2. oxytocin is given to encourage uterine contraction
3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after pains
and abdominal discomforts
5. encourage client to ambulate or in Fowlers position to
promote lochia drainage and prevent pooling of infected
secretions
6. IV therapy

Perineal Infection
- localized infection of the suture line from an episiotomy
site
Signs and Symptoms:
1. feeling of heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines
Management:
1. removal of perineal sutures to open and allow for
drainage

2. Topical, systemic ATBC as ordered

3. Analgesic to alleviate discomfort
4. Provide Sitz bath or warm compress to hasten
drainage and cleanse the area
5. Remind the mother to change perineal pads
frequently to prevent contamination/infection
6. Teach proper perineal care wiping from front to
back after bowel movement (to prevent bringing
the feces to the healing area)