ABNORMAL OBSTETRICS

CONTENTS

 RISK FACTORS ASSOCIATED WITH

PREGNANCY
 BLEEDING COMPLICATIONS IN PREGNANCY
First Trimester Abortion
Ectopic Pregnancy
Second Trimester Hydatidiform Mole
Incompetent Cervix
Third Trimester Abruptio/Ablatio Placenta
Placenta Previa
 HYPERTENSIVE DISORDERS IN PREGNANCY
Gestational Hypertension
Chronic Hypertension
 Pregnancy Induced Hypertension
 Pre-eclampsia
 Eclampsia
 METABOLIC DISORDER IN PREGNANCY
 Gestational Diabetes Mellitus
 MEDICAL CONDITIONS COMPLICATING
PREGNANCY
 Heart Disease
 Anemias
Infertility
 Risk Factors associated with Pregnancy
 Maternal age factor
 Teenage pregnancy of 16 yrs. and below is considered a high risk
pregnancy from both physical and psychosocial standpoint
 Physical
 Because of the physical task of adolescence
 Rapid growth during adolescence
 Rapid growth of the fetus
 Psychosocial
 Lack of motivation
 Denial
 Ignorance
 Rebellion against authority
 Failure to complete education
 Dependence on others for support
 Failure to establish a stable family life
 High rate of marital failure
 High incidence of repeated out of wedlock pregnancy
Risk Factors associated with Pregnancy
 Advanced age of 35 yrs and above is a high risk of pregnancy
because of increased incidence of :
 Placenta previa
 Chromosomal abnormalities
 Abruptio / Ablatio placenta
 Hypertension
 Toxemia
 Low birth weight babies
 Parity
 First pregnancy – is the period of highest risk
 Second / Third and Fourth pregnancy – the risk of
death for the mother is at its lowest
 Fifth pregnancy – marked increase especially when
the pregnant mother is over 40 years of age.
 DANGER SIGNS OF PREGNANCY
1. VAGINAL BLEEDING = VAGINAL BLEEDING
SHOULD BE REPORTED IMMEDIATELY FOR
FURTHER EVALUATION
2. PERSISTENT VOMITING ( HYPEREMESIS
GRAVIDARUM) = NAUSEA & VOMITING THAT
CONTINUES PAST THE 12 WEEK OF
PREGNANCY IS EXTENDED VOMITING. IT
DEPLETES THE NUTRITIONAL SUPPLY
AVAILABLE TO THE FETUS.
3. CHILLS & FEVER = MAY BE EVIDENCE OF
INTRAUTERINE INFECTION WHICH IS A
SERIOUS COMPLICATION FOR BOTH THE
WOMAN & THE BABY.
4. SUDDEN ESCAPE OF FLUID FROM THE
VAGINA = MEANS THAT THE MEMBRANES
HAVE RUPTURED. BOTH THE MOTHER & THE
FETUS ARE THREATENED BECAUSE UTERINE
CAVITY IS NO LONGER SEALED AGAINST
INFECTION.
** IF FETUS IS SMALL & HIS HEAD DOES NOT
FIT INTO THE CERVIX, THE UMBILICAL CORD
MAY PROLAPSE WITH THE RUPTURED
MEMBRANE , THE HEAD MAY BE
COMPRESSED AGAINST THE CORD. ANOTHER
DANGEROUS COMPLICATION IS ASCENDING
INFECTION.
5. ABDOMINAL OR CHEST PAINS = ABDOMINAL
PAINS MAY MEAN TUBAL PREGNANCY THAT
HAVE RUPTURED, SEPARATION OF THE
PLACENTA, PRETERM LABOR WHILE CHEST
PAINS MAY INDICATE PULMONARY EMBOLUS
THAT FOLLOWS THROMBOPHLEBITIS.
6. ABSENCE OF FETAL HEART SOUNDS AFTER
THEY HAVE INITIALLY BEEN AUSCULTATED ON
THE 4TH & 5TH MONTH ( MAY INDICATE
INTRAUTERINE FETAL DEATH - IUFD)
7. SWELLING OF THE FACE & FINGERS =
EDEMA
8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA)
9. BLURRING OF VISION
10. SEVERE HEADACHE & DIZZINESS
** MAY MEAN SIGNS OF PREGNANCY
INDUCED HYPERTENSION
 COMPLICATIONS OF PREGNANCY
A.FIRST TRIMESTER BLEEDING:
1. ABORTION
- THE EXPULSION OF THE
PRODUCTS OF CONCEPTION BEFORE
THE AGE OF VIABILITY ( FETUS CAN
SURVIVE EXTRAUTERINE LIFE)
- FETUS IS LESS THAN 20 WEEKS OR
LESS THAN 500 GRAMS
CAUSES OF ABORTION:
1. ABNORMAL DEVELOPMENT OF THE ZYGOTE –
WHICH WOULD HAVE RESULTED IN SEVERE
CONGENITAL ANOMALIES
2. ABNORMALITY IN THE IMPLANTATION
PROCESS - IUD
3. TRAUMA – PSYCHOLOGICAL,
PHYSICAL
4. HORMONAL IMBALANCE ( LOW
PROGESTERONE)
5. INTAKE OF DRUGS – CYTOTEC
6. INFECTIOUS DISEASES – GERMAN
MEASLES, PTB, HERPES
7. PRESENCE OF VENEREAL DISEASES
8. ABNORMALITY IN THE REPRODUCTIVE
SYSTEM – INCOMPETENT CERVIX
8. SEVERE MALNUTRITION
EARLY ABORTION – HAPPENS BEFORE 16 WEEKS
LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS
Types of Abortion:
• SPONTANEOUS = UNINTENDED
TERMINATION OF PREGNANCY AT ANY
TIME BEFORE THE FETUS HAS
ATTAINED VIABILITY.
THREATENED – POSSIBLE LOSS OF THE
PRODUCTS OF CONCEPTION
S/SX: SLIGHT BLEEDING; MILD UTERINE
CRAMPING BUT NO CERVICAL
DILATATION ON VAGINAL
EXAMINATION;NO PASSAGE OF TISSUE
 Management:
 Bed rest
 Save all pads
 No coitus up to 2 weeks after bleeding has
stopped
 INEVITABLE OR IMMINENT ABORTION -
is a loss of pregnancy that cannot be
prevented.
Clinical Manifestations:
 Moderate to profuse Bleeding
 Moderate to severe uterine cramping
 Cervix dilated
 Membranes rupture
 Management:
 Hospitalization
D&C
 Oxytocin after D & C
 Emotional support
TYPES OF INEVITABLE ABORTION:

1) Complete – all products of conception are

expelled.
Sxs of complete abortion:
 Moderate bleeding
 Mild uterine cramping
 Passage of tissue
Management:
 Sympathetic understanding & emotional
support

2) Incomplete – not all products of

conception are expelled from the uterus.
Signs and Sxs:
 Profuse vaginal bleeding
 Severe uterine cramping
 Open cervix
 Passage of tissue
 Other products are retained
Treatment and MX:
 D and C

 Oxytocin after D & C

 Emotional support
 Missed Abortion
 Retention of all products of conception after the
death of the fetus in the uterus
S/Sx:
- No FHT
- Signs of pregnancy disappear
Management:
D&C
 Septic Abortion
 Abortion complicated by infection

S/Sx:
 Foul smelling vaginal dischrage
 Uterine cramping
 Fever

Management:
 Treat abortion
 Antibiotics
 HABITUAL OR RECURRENT PREGNANCY
LOSS –SPONTANEOUS ABORTION IN
THREE OR MORE SUCCESSIVE
PREGNANCIES USUALLY DUE TO
INCOMPETENT CERVIX.
B. Induced Abortion – is an intentional loss of
pregnancy through direct stimulation either by
chemical or mechanical means.
Types of induced abortion:
1) Therapeutic abortion – to preserve the life of
the mother
2) Elective abortion
Reasons for Induced Abortion:
 Therapeutic – to end a pregnancy that is life

threatening to the mother

 To end a pregnancy of a fetus found to have

severe congenital abnormalities that may be

incompatible with life
 To end an unwanted pregnancy that is a result of

rape or incest
 To end a pregnancy because of woman’s choice

not to have a child yet

Prevention of abortion:
 Prepregnancy correction of maternal disorders

 Immunization against infectious diseases

 Proper early antenatal care

 Treatment of pregnancy complications

 Correction of cervical incompetency

Complications:
 Hemorrhage

 Sepsis

 Rh sensitization
2. ECTOPIC PREGNANCY
- ANY PREGNANCY THAT OCCURS
OUTSIDE THE UTERINE CAVITY.
---SECOND LEADING CAUSE OF
BLEEDING IN EARLY PREGNANCY.
TYPES:
1.AMPULAR 4. CERVICAL
2. INTESTINAL 5. ABDOMINAL
3. OVARIAN
Predisposing causes:
 Salpingitis

 Peritubal adhesions

 Previous ectopic pregnancy

 Previous tubal surgery

 Multiple previous abortion

 Tumors that distort the tubes

 External migration of the ovum

 Intrauterine device (IUD)

Signs and Sxs:

 Vaginal spotting or bleeding

 Cul de sac mass
 Absence of amniotic sac
 Amenorrhea or abnormal menstruation
followed by slight uterine bleeding
Signs of tubal rupture:

Severe sharp knife like pain in the lower

quadrant of the abdomen
 Abdominal rigidity
 Nausea and vomiting
 Low hgb. And hct.
 Sharp localized pain in the cervix on internal
examination ( wiggling sign)
 Signs of hemorrhage:
 - Cullen’s sign – bluish discoloration of the

umbilicus due to the presence of blood in the

peritoneal cavity
-Hard or rigid boardlike abdomen
. Signs of shock:
- Falling BP, rapid pulse
- Light headedness
- Pallor
- Cyanotic nail beds
- Cold clammy skin
 Diagnostic Aids
 Culdocentesis – aspiration of bloody fluid from
Cul de sac of Douglas
 Ultrasound reveals presence of the gestational
sac outside of the uterine cavity
Treatment and management:
 If not yet ruptured:
 Salpingostomy – removal of a conceptus less
than 2 cm located at the distal portion of the
fallopian tube by performing a linear incision
over the ectopic pregnancy. The conceptus will
extrude from the incision & removed manually.
 Salpingotomy – longitudinal incision is made
over the ectopic pregnancy & the conceptus is
removed using forceps or gentle suction
 Fimbrial evacuation – removal of the conceptus
by milking & suctioning of the fallopian tube
 If ruptured:
- removal of the ruptured tube
because the presence of a scar if tube is
repaired & left can lead to another tubal
pregnancy.
Surgical treatment:
-Salpingotomy
-Salpingectomy – removal of the
oviducts
 Prevent and treat hemorrhage which is the main
danger of ectopic pregnancy.
 Blood transfusion
 Place patient flat in bed with legs elevated
 Monitor Vital signs, I & O, & amount of blood loss
 Prevent infection as the woman who lost so
much blood is susceptible to infection

 Contraception must be started upon discharge

from hospital. Ovulation begins as early as 19
days or 3 weeks after resection of ectopic
pregnancy.
B. SECOND TRIMESTER BLEEDING
1. GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE OR H-
MOLE))
- is a mass of abnormal rapidly growing
trophoblastic tissue in which avascular
vesicles hang in grapelike clusters THAT
PRODUCE LARGE AMOUNTS OF HCG.
Predisposing factors:
cause is unknown
 17 years old below and 35 yrs. Above

 Low socioeconomic status

 Low protein intake

 Previous mole

 Higher incidence in Asian women

TYPES:
1.COMPLETE MOLE – LACKS AN EMBRYO
OR FETUS
2. PARTIAL MOLE – INVOLVES A
CHROMOSOMALLY ABNORMAL
EMBRYO OR FETUS.
- 69 XXX or 69 XXY
CAUSES:
1. SPERM + OVUM + DUPLICATION =46 (COMPLETE
( 23) ( 0) MOLE)
2. SPERM + OVUM =69 (PARTIAL
(46) (23) MOLE)
3. SPERM
( 23) OVUM
+ + ( 23) =69 (PARTIAL
SPERM MOLE)
( 23)
Gestational trophoblastic disease
(hydatidiform mole)
Signs and Sxs:
 Rapid increase in uterine size greater
than gestational age of the fetus
 Marked increase HCG titer; NV:400,00 iu
 Excessive nausea and vomiting due to
elevated HCG
 Brownish vaginal discharge around 4th
month containing grapelike vesicles
 No FHT is detected after 10 to 12 weeks,
no fetal movement after 18-20 weeks
 No fetal parts
 Bleeding which may vary from spotting
to profuse hemorrhage and is usually
brownish but may be bright red
 No fetal skeleton

 Hypertension & other sx of

preeclampsia
 Symptoms of PIH before 24th week
gestation

**difference bet.H-mole & pre-eclampsia

- before 20 weeks =H mole
- after 20 weeks up to 2 weeks post
partum = preeclampsia
 DX:
 Ultrasound will identify the characteristic

vesicles.
Treatment and management:
 D and C or D & E to remove the mole. ( If the

woman is more than 40 yrs old, hysterectomy is

done since she has a higher chance of developing
CHORIOCARCINOMA
 Monitor HCG for 1 year ( HCG shld be negative

2-6 weeks after removal of H-mole.)

 Chest X ray every 3 mos for 6 mos. The lungs are
the most common site of metastasis of
choriocarcinoma
 Chemotherapy ( Methotrexate) if:
-HCG titers are increased for 3 consecutive
weeks or double at anytime
-HCG titers remain elevated 3-4 mos. after
delivery
 The woman is advised not to get pregnant for 1
year, contraceptive method should NOT be the
pills. Pills contain estrogen which promote
regrowth of the chorionic villi.
 Hysterectomy is the method of tx for women
above 40 yrs old because of the higher incidence
of malignancies & to clients who have completed
childbearing & require sterilization.
Prognosis:
 Favorable if HCG titers do not recur after

evacuation of the mole

 Unfavorable if malignancy develops and is

untreated
 Complications of H-Mole:
 Gestational Trophoblastic Tumors – persistent
trophoblastic proliferation after H-mole.
** Choriocarcinoma – most severe malignant
complication that involve the transformation of
chorion into cancer cells that invade & erode blood
vessels & uterine muscles.
*** Management of all trophoblastic tumors is
HYSTERECTOMY ****
NURSING MANAGEMENT:
1.MAINTAIN F & E BALANCE.
2. EMPHASIZE THAT PREGNANCY
SHOULD BE AVOIDED FOR 1 YEAR
( GREATER CHANCE OF IT RECURRING
& MAY EVEN LEAD TO
CHORIOCARCINOMA)
3. ADMINISTER BLOOD REPLACEMENT
AS ORDERED.
4. PROVIDE EMOTIONAL SUPPORT
5. USE MECHANICAL EQUIPMENTS
AGAINST PREGNANCY ( Ex. Condom)
2. INCOMPETENT CERVIX OR
PREMATURE CERVICAL DILATATION:
- PAINLESS CERVICAL EFFACEMENT &
DILATATION IN EARLY MIDTRIMESTER
RESULTING IN EXPULSION OF
PRODUCTS OF CONCEPTION.
- MOST COMMON CAUSE OF HABITUAL
ABORTION
CAUSES:
1.INCREASED MATERNAL AGE
2. CONGENITAL MALDEVELOPMENT OF
THE CERVIX – short cervix
3. TRAUMA TO THE CERVIX ( HISTORY OF
REPEATED D & C’S; CERVICAL
LACERATIONS WITH PREVIOUS
PREGNANCIES )
Signs and Sxs:
 Slight vaginal bleeding

 Presence of uterine contractions in

midtrimester
 Rupture of the bag of waters

 Expulsion of the conceptus

 Presence of painless cervical dilatation

 Relaxed cervical os on pelvic examination

MX:
1. CERVICAL CERCLAGE – MEDICAL
MANAGEMENT WHEREIN THE PHYSICIAN
SUTURES A CERTAIN PART OF THE
CERVIX BETWEEN 14 AND 16 WEEKS
GESTATION TO PREVENT CERVICAL
DILATATION.
a.MCDONALD’S – ( temporary) NYLON
SUTURES ARE PLACED HORIZONTALLY
& VERTICALLY ACROSS THE CERVIX &
PULLED TIGHT TO REDUCE THE
CERVICAL CANAL TO A FEW
MILLIMETERS IN DIAMETER.
b. SHIRODKAR – ( permanent) STERILE
TAPE IS THREADED IN A PURSE-
STRING MANNER UNDER THE
SUBMUCUS LAYER OF THE CERVIX &
SUTURED IN PLACE TO ACHIEVE A
CLOSED CERVIX.
 After suturing the cervix:
 Place woman on bed rest for 24 hours
 Observe for bleeding, uterine contractions, and
rupture of BOW
 If BOW ruptures – the sutures are removed
 If uterine contractions occur, the woman is given
ritodrine to stop the contractions
 Post-op care: Restrict activities for the next 2
weeks including coitus
 Prerequisites of Cervical Cerclage
 Cervix not dilated
 Intact membranes
 No vaginal bleeding & uterine cramping
C. THIRD TRIMESTER BLEEDING
1.PLACENTA PREVIA
- LOW IMPLANTATION OF THE
PLACENTA
TYPES:
1. LOW-LYING – IMPLANTATION OF THE
PLACENTA IN THE LOWER RATHER
THAN IN THE UPPER PORTION OF THE
UTERUS
2. MARGINAL – PLACENTA EDGE
APPROACHES THAT OF THE CERVICAL
OS
3.PARTIAL – IMPLANTATION THAT
OCCLUDES A PORTION OF THE
CERVICAL OS
4. COMPLETE ( TOTALIS) – PLACENTA
THAT TOTALLY OBSTRUCTS THE
CERVICAL OS
Predisposing factors:
 Multiparity

 Advanced maternal age – over 35 yo

 Multiple pregnancy

 Uterine tumor

 Cigarette smoking

 Scarring from previous previous CS

 Decreased vascularity of upper uterine

segment
Past uterine D&C
Signs and Sxs:
 Painless, bright red vaginal bleeding

during the 3rd trimester

 Abdomen soft, non tender

 Ultrasound reveals placenta previa

NURSING MANAGEMENT:
1. MONITOR VITAL SIGNS & BLEEDING
( WEIGH UNUSED PERINEAL PAD, THEN
WEIGH PERINEAL PAD SOAKED IN
BLOOD, THEN SUBTRACT. THE
DIFFERENCE IS THE WEIGHT OF THE
BLOOD LOSS.)
2.PROVIDE STRICT BED REST TO MINIMIZE THE
RISK TO FETUS.( CBR without BRP’s )
3.OBSERVE FOR FURTHER BLEEDING
EPISODES.( PREPARE FOR BT) ( Hgb & Hct)
4. AVOID VAGINAL EXAMINATIONS ( NO IE). IF IE
IS INDICATED, IT SHOULD BE DONE IN A
DOUBLE SET-UP ENVIRONMENT. ( MEANING:
the DR is prepared for vaginal exam and for
cesarean birth in case the examination precipitates
profuse bleeding) WHEREIN THE PATIENT HAS
ALREADY SIGNED A CONSENT FORM, PRE-OP
MEDS HAVE BEEN GIVEN, ABDOMINAL
PREP HAS BEEN DONE SO THAT IF THE
PLACENTA IS ACCIDENTALLY DETACHED
BECAUSE OF MANIPULATIONS, CS CAN
BE DONE IMMEDIATELY.
6. PROVIDE EMOTIONAL SUPPORT
DURING THE GRIEVING PROCESS.
** CLASSICAL CESARIAN SECTION
UTERUS IS INCISED IN THE VERTICAL
SEGMENT) IS DONE IN CASE OF SEVERE
BLEEDING.**
 Assess fetal lung maturity
 Observe for PP hemorrhage
 Observe strict aseptic technique

Complications of placenta previa:

 Hemorrhage

 Infection

 Prematurity
 ** BLEEDING WITH PLACENTA PREVIA
OCCURS WHEN THE LOWER UTERINE
SEGMENT BEGINS TO DIFFERENTIATE
FROM THE UPPER SEGMENT LATE IN
PREGNANCY ( APPROXIMATELY WEEK 30
because of uterine contractions ) & THE
CERVIX BEGINS TO DILATE. THE
BLEEDING PLACES THE MOTHER AT RISK
FOR HEMORRHAGE. BECAUSE THE
PLACENTA IS LOOSENED, THE FETAL
OXYGEN MAY BE COMPROMISED”
IMMEDIATE CARE MEASURES:
** TO ENSURE AN ADEQUATE BLOOD
SUPPLY TO THE MOTHER & FETUS,
PLACE THE WOMAN ON BED REST IN A
LEFT SIDE LYING POSITION.**
2. ABRUPTIO PLACENTA
- ABRUPT SEPARATION OF AN
OTHERWISE NORMALLY IMPLANTED
PLACENTA AFTER 20 WEEKS AOG.
TYPES:
1.MARGINAL ( OVERT)
SEPARATION BEGINS AT THE EDGES
OF THE PLACENTA ALLOWING BLOOD
TO ESCAPE FROM THE UTERUS.
BLEEDING IS EXTERNAL.
2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE CENTER
RESULTING IN BLOOD BEING TRAPPED
BEHIND THE PLACENTA. BLEEDING
THEN IS INTERNAL AND NOT OBVIOUS.
CAUSES:
1.MATERNAL HYPERTENSION ( CHRONIC
OR PREGNACY INDUCED)
2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – MORE THAN 5
PREGNANCIES
4. TRAUMA TO THE UTERUS
5. SUDDEN RELEASE OF AMNIOTIC FLUID
THAT CAUSE SUDDEN DECOMPRESSION
OF TE UTERUS.
6. SHORT UMBILICAL CORD
7. CIGARETTE SMOKING & COCAINE
ABUSE
8. PROM
S/SX:
1. SHARP PAIN IN THE FUNDAL AREA AS
THE PLACENTA SEPARATES
2.PAINFUL DARK RED VAGINAL BLEEDING
IN COVERT TYPE
3.PAINFUL BRIGHT RED VAGINAL
BLEEDING IN OVERT TYPE
4.HARD, RIGID, FIRM,BOARD-LIKE
ABDOMEN CAUSED BY ACCUMULATION
OF BLOOD BEHIND THE PLACENTA WITH
FETAL PARTS HARD TO PALPATE.
5. ABNORMAL TENDERNESS DUE TO
DISTENTION OF THE UTERUS WITH
BLOOD.
6. SIGNS OF SHOCK & FETAL DISTRESS
AS THE PLACENTA SEPARATES.
PREMATURE SEPARATION OF THE PLACENTA
 CLASSIFICATION ACCORDING TO
PLACENTAL SEPARATION:
1.GRADE 0 = NO SYMPTOMS OF
PLACENTAL SEPARATION, DIAGNOSED
AFTER DELIVERY WHEN PLACENTA IS
EXAMINED & FOUNDTO HAVE DARK,
ADHERENT CLOT ON THE SURFACE.
2. GRADE 1 = SOME EXTERNAL
BLEEDING, NO FETAL DISTRESS, NO
SHOCK, SLIGHT PLACENTAL
SEPARATION
3. GRADE 2 = EXTERNAL BLEEDING,
MODERATE PLACENTAL SEPARATION,
UTERINE TENDERNESS, FETAL DISTRESS
4. GRADE 3 = INTERNAL & EXTERNAL
BLEEDING, MATERNAL SHOCK, FETAL
DEATH, DIC
MX:
1. WHEN PLACENTA ABRUPTIO IS
SUSPECTED OR DIAGNOSED,
HOSPITALIZATION IS A MUST.
2. BEDREST OR SIDE LYING POSITION
FOR OPTIMUM PLACENTAL PERFUSION.
3. MONITOR VITAL SIGNS, FHT, AMOUNT
OF BLOOD LOSS – GIVE MASK O2 IF
FETAL DISTRESS IS PRESENT.
4. DELIVERY:
** VAGINAL DELIVERY – IF THERE IS NO
SIGN OF FETAL DISTRESS, BLEEDING IS
MINIMAL & VITAL SIGNS ARE STABLE.
** CESARIAN DELIVERY – IF BLEEDING
IS SEVERE, FETAL DISTRESS IS PRESENT
& FETUS CANNOT BE DELIVERED
IMMEDIATELY WITH VAGINAL METHOD.
COMPLICATIONS:
1.COUVELAIRE UTERUS OR UTERINE
APOPLEXY – INFILTRATION OF BLOOD
INTO THE UTERINE MUSCULATURE
RESULTING IN THE UTERUS
BECOMING HARD & COPPER
COLORED.
2. HEMORRHAGE & SHOCK – TREATED
BY BLOOD TRANSFUSION
3. DIC – MANAGED BY FIBRINOGEN &
CRYOPRECIPITATE
 3. Disseminated Intravascular Coagulation (DIC)
 Disorder of blood clotting
 Fibrinogen levels fall below effective limits
( Hypofibrinogenemia)
 Symptoms
 Bruising or bleeding
 massive hemorrhage initiates coagulation process
causing massive numbers of clots in peripheral vessels
(may result in tissue damage from multiple thrombi),
which in turn stimulate fibrinolytic activity, resulting in
decreased platelet and fibrinogen levels
 signs and symptoms of local generalized bleeding
(increased vaginal blood flow, oozing IV site,
ecchymosis, hematuria, etc)
 monitor PT, PTT, and Hct, protect from injury; no IM
injections
 3. Disseminated Intravascular Coagulation (DIC)
 Result from an imbalance between clot formation systems
and clot breakdown systems that results in hemorrhage.
This problem begins with the excessive triggering of
coagulation mechanisms, most commonly encountered in
abruptio placenta, PIH, amniotic fluid embolism. This
overstimulation of the coagulation system leads to rapid
formation of massive numbers of clots. In turn, the
fibrinolytic system is overactivated & clots are broken
down. As a result, clotting factors are used up &
generalized hemorrhage occurs leading to shock & death.
 Tx:
 Replacement of clotting factors _ Cryoprecipitate or fresh frozen
plasma or platelet transfusion
 HYDRAMNIOS / POLYHYDRAMNIOS
- CHARACTERIZED BY EXCESSIVE
AMOUNT OF AMNIOTIC FLUID, MORE
THAN 2000 ML.
- NORMAL AMOUNT OF AMNIOTIC FLUID
AT TERM IS 500 TO 1200 ML
CAUSES:
1. MULTIPLE PREGNANCY = ONE FETUS
USURPS THE GREATER PART OF THE
CIRCULATION RESULTING IN
CARDIOMEGALY, WHICH IN TURN
RESULTS IN INCREASED URINE OUTPUT.
2. FETAL ABNORMALITIES:
a. ESOPHAGEAL ATRESIA – FETAL
SWALLOWING OF AMNIOTIC FLUID IS ONE
OF THE MECHANISMS THAT REGULATE
THE AMOUNT OF AMNIOTIC FLUID. IN
ATRESIA, THE FETUS CANNOT SWALLOW
 b. SPINA BIFIDA – INCREASED
TRANSUDATION OF AMNIOTIC FLUID
FROM THE EXPOSED MENINGES.
S/SX:
1. EXCESSIVE UTERINE SIZE, OUT OF
PROPORTION TO AOG WITH DIFFICULTY
PALPATING FETAL PARTS & FINDING FHT
– PRIMARY CLINICAL FINDINGS
2. SHORTNESS OF BREATH CAUSED BY
PRESSURE OF THE OVERLY
DISTENDED UTERUS AGAINST THE
DIAPHRAGM.
3. BACK PAIN, VARICOSITIES,
CONSTIPATION, FREQUENCY OF
URINATION & HEMORRHOIDS
DIAGNOSTIC AIDS:
1.ULTRASOUND
2. RADIOGRAPHY
COMPLICATIONS:
1.PREMATURE LABOR & DELIVERY
2. ABRUPTIO PLACENTA
3. POSTPARTUM HEMORRHAGE DUE TO
OVERDISTENTION
4. CORD PROLAPSE
MX:
1.MILD TO MODERATE DEGREES USUALLY
DOES NOT REQUIRE TREATMENT.
2. HOSPITALIZATION IF SX INCLUDES
DYSPNEA, ABDOMINAL PAIN, DIFFICULT
AMBULATION.
3. AMNIOCENTESIS – REMOVAL OF
AMNIOTIC FLUID TO RELIEVE MATERNAL
DISTRESS
4. INDOMETHACIN THERAPY – A DRUG
THAT DECREASES FETAL URINE
FORMATION.
SE: POTENTIAL PREMATURE CLOSURE
OF THE DUCTUS ARTERIOSUS.
5. HEALTH INSTRUCTIONS FOR RELIEF
OF SYMPTOMS:
1.PLACE IN SEMI-FOWLERS POSITION TO
ASSIST IN BREATHING
2.EMPTY BLADDER FREQUENTLY
3. INCREASE FLUID INTAKE & HIGH FIBER
DIET TO PREVENT CONSTIPATION
4. REST FREQUENTLY ON LEFT LATERAL
POSITION TO PREVENT FATIGUE & BACK
PAIN.
5. WATCH CLOSELY FOR HEMORRHAGE
AFTER DELIVERY.
 OLIGOHYDRAMNIOS
- AMNIOTIC FLUID LESS THAN 500 ML
CAUSES:
1.FETAL RENAL ANOMALIES THAT
RESULTS IN ANURIA
2. PREMATURE RUPTURE OF MEMBRANES
MX:
1.OBSERVE NEWBORN FOR
COMPLICATIONS THROUGHOUT THE
REMAINDER OF PREGNANCY.
a. CLUBFOOT
b. AMPUTATION
c. ABORTION
d. STILLBIRTH
e. FETAL GROWTH RETARDATION
 f. ABRUPTIO PLACENTA
2. DURING LABOR & DELIVERY
a. CORD COMPRESSION
b. FETAL HYPOXIA AS A RESULT OF
CORD COMPRESSION
c. PROLONGED LABOR
 PSEUDOCYESIS
 Or spurious pregnancy occurs in women
nearing menopause & in women who have
intense desire to become pregnant. These
women develop the belief that they are
pregnant when in fact they are not. The women
often experiences all the subjective symptoms
of pregnancy: fatigue, amenorrhea, tingling
sensations & fullness of the breast, nausea &
vomiting. Some of these women repost feeling
fetal movements which are actually movement
of air in the intestines or muscular contractions
of the abdominal wall.
 Management:
 Explain pregnancy test result, clarify misconceptions
& false beliefs
 Provide referrals when necessary, psychologic
counselling
 Provide emotional support & understanding
 Hyperemesis Gravidarum
 Excessive nausea & vomiting that persists
beyond 12 weeks gestation & which leads to
complications like dehydration, weight loss,
starvation & fluid & electrolyte imbalance.
 Etiology: Unknown

SSx:
1.Excessive nausea & vomiting not relieved by
ordinary remedies persisting beyond 12 weeks
2. Signs of dehydration: thirst, dry skin, increased
pulse rate, weight loss, concentrated & scanty
urine.
Management:
MX: D10NSS 3000 ML IN 24 HOURS IS THE
PRIORITY OF TREATMENT
> REST
> ANTI-EMETIC – ( EX. PLASIL)
HYPERTENSIVE DISORDERS IN
PREGNANCY:
GESTATIONAL HYPERTENSION:
- HYPERTENSION THAT DEVELOPS
DURING PREGNANCY OR DURING THE
FIRST 24 HOURS AFTER DELIVERY
WHICH IS NOT ACCOMPANIED BY
EDEMA, PROTEINURIA & CONVULSIONS
& DISAPPEARS WITHIN 10 DAYS AFTER
DELIVERY.
CHRONIC HYPERTENSION:
- THE PRESENCE OF HYPERTENSION BEFORE
PREGNANCY OR HYPERTENSION THAT DEVELOP
BEFORE 20 WEEKS GESTATION IN THE ABSENCE
OF H-MOLE & PERSIST BEYOND THE POSTPARTUM
PERIOD.
PREGNANCY INDUCED HYPERTENSION
(TOXEMIA):
- HYPERTENSION THAT DEVELOPS AFTER THE
20TH WEEK OF GESTATION TO A PREVIOUSLY
NORMOTENSIVE WOMAN.
RISK FACTORS:
1. SAID TO BE A DISEASE OF PRIMIPARAS – HIGHER
INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35
YEARS.
2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE
)
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER,
H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE
4. HEREDITARY – hx of preeclampsia in mothers or sisters
5. H-mole
6. Previous hx of preeclampsia
CAUSES:
1. UNKNOWN
2. PROTEIN DEFICIENCY THEORY
3. UTERINE ISCHEMIA
4. ARTERIAL VASOSPASM
TRIAD SX:
I HYPERTENSION
2. EDEMA ( INCRESE IN WEIGHT)
3. PROTEINURIA
= 2nd leading cause of maternal death
= chief causes of maternal death due to PIH:
- cerebral hemorrhage
- cardiac failure with pulmonary edema
- rena, hepatic or resp. failure
- obstetric hemorrhage assoc. with abruptio placenta
 VASOSPASM – due to damge to the endothelium
VASCULAR EFFECTS KIDNEY EFFECTS INTERSTITIAL EFFECTS

VASOCONSTRICTION DECREASED DIFFUSION OF FLUID

GLOMERULI FILTRATION FROM BLOOD
STREAM
RATE & INCREASED INTO INTERSTITIAL
PERMEABILITY OF TISSUE
GLOMERULI MEMBRANES

POOR ORGAN Inc BLOOD EDEMA

PERFUSION UREA NITROGEN, URIC
ACID, CREATININE
INCREASED BP DECREASED URINE OUTPUT
& PROTEINURIA
Warning Signs:
 Rapid weight gain, 4-5 lbs in a single week
 Sudden swelling
 Swelling of face & hands
 Swelling of ankles or feet that does not go away after
12 hours rest
 A rise in BP
 Protein in the urine
 Severe headaches
 Blurry vision
 Seeing spots in the eyes
 Severe pain over the stomach, under the ribs
 Decrease in the amount of urine
SIGNS & SYMPTOMS:
S & SX MILD PREECLAMPSIA SEVERE
PREECLAMPSIA
BLOOD PRESSURE 140/90; Systolic elevation 160/110
of 30 mm/Hg
Diastolic elevation of 15
mm/Hg
Proteinuria +1 to +2 +3 to +4 in clean catch
300 mg/ L24 hour urine urine or 5 g/24 hour urine
collection collection
Edema Digital edema ( +1 +2) Pitting edema (+3 +4)
Dependent edema Generalized edema
Weight Gain 3 lb/week More rapid weight gain
Urinary Output Not less than 500 ml/24 Less than 500 ml/24
hours hours; oliguria
Headache Occasional headache Severe headache
Reflexes Normal to +1 +2 Hyperreflexia,+3 +4
Visual Disturbances Absent Photophobia, blurring
spots before the eyes
Epigastric Pain (liver Absent Right upper quadrant
involvement) pain (aura to
convulsion)
EDEMA:
(+1) – PHYSIOLOGIC TYPE IN PREGNANCY, THERE
IS SLIGHT EDEMA IN THE LOWER EXTREMITIES
( DUE TO PRESSURE & POSTURE)
(+2) – MARKED EDEMA OF LOWER EXREMITIES
(PATHOLOGIC)
(+3) – EDEMA FOUND ON THE FACE & FINGERS.
(+4) – GENERALIZED EDEMA ( ANASARCA)
SEIZURE PRECAUTIONS:
1. SIDE RAILS UP
2.PAD THE SIDE RAILS
3. PUT BED AT LOWEST POSITION.
4. ROOM SHOULD BE DIM, QUIET,& AWAY FROM
AREAS OF ACTIVITY. ( AVOID BRIGHT LIGHTS
SUCH AS FLASHLIGHTS)
5. RESTRICT VISITORS TO ALLOW PATIENT TO
REST.
6. HAVE EMERGENCY EQUIPMENT AVAILBLE:
- SUCTION APPARATUS, MAGNESIUM SULFATE,
CALCIUM GLUCONATE, O2
MEDICATIONS:
1.HYDRALAZINE – ( APRESOLINE )
- ANTIHYPERTENSIVE ( PERIPHERAL
VASODILATOR) USED TO DECREASE Hpn
Dosage – 5-10 mg/IV - administer slowly to avoid
sudden fall in BP
- Maintain diastolic pressure at 90 mm/Hg to
ensure adequate placental filling
2. MAGNESIUM SULFATE ( MgSO4)
- DRUG OF CHOICE TO TREAT & PREVENT
CONVULSIONS, also a muscle relaxant
- Loading dose is 4-6g. Maintenance dose is 1-
2g/h IV
- Infuse loading dose slowly over 15-30 min.
- Always administer as a piggyback infusion
- Serum Mg level should remain below 7.5 mEq/L
ACTIONS OF MgSO4:
a. PREVENT CONVULSION
b. REDUCE BLOOD PRESSURE
CHECK THE FOLLOWING FIRST BEFORE
ADMINISTERING MgSO4:
1. DEEP TENDON REFLEX PRESENT - +2 ( NORMAL)
2. RR SHOULD BE AT LEAST 12 BPM
3. URINE OUTPUT SHOULD BE AT LEAST 30 ML/HR
 Diazepam ( Valium)
 Halt seizures
 5-10 mg/IV
 Administer slowly
 Dose may be repeated every 5-10 mins ( up to 30
mg/hr)
 Observe for respiratory depression or hypotension in
mother & respiratory depression & hypotonia in
infant at birth.
** IF MgSO4 TOXICITY DEVELOPS AS SHOWN BY
RR DEPRESSION TO LESS THAN 12 BPM &
DISAPPEARANCE OF THE DTR, GIVE THE ANTIDOTE
CALCIUM GLUCONATE & NOTIFY PHYSICIAN.
- 1g/IV ( 10 ml of a 10% sol)
- have prepared at bedside when administering
MgSO4
** IF MgSO4 IS GIVEN POSTPARTUM, MONITOR
FOR UTERINE ATONY AS IT CAN CAUSE UTERINE
RELAXATION.
SIGNS & SYMPTOMS OF ECLAMPSIA:
1. ALL THE SIGNS & SYMPTOMS OF PREECLAMPSIA
2. CONVULSION FOLLOWED BY COMA IS THE MAIN
DIFFERENCE OF ECLAMPSIA & PREECLAMPSIA
3. OLIGURIA
MANAGEMENT:
A. AMBULATORY MX
1. HOME MANAGEMENT IS ALLOWED ONLY IF:
a. BP IS 140/90 O BELOW
b. THERE IS NO PROTEINURIA
c. THERE IS NO FETAL GROWTH
RETARDATION
d. THE PATIENT IS NOT A YOUNG
PRIMIPARA.
2. BED REST – THE WOMAN SHOULD BE IN BED
REST FOR MOST PART OF THE DAY & FREE
FROM PHYSICAL & EMOTIONAL STRESS.
3. THE WOMAN SHOULD CONSULT THE CLINIC AS
OFTEN AS NECESSARY.
4. DIET SHOULD BE HIGH IN PROTEIN &
CARBOHYDRATES WITH MODERATE SODIUM
RESTRICTION.
5. HOSPITALIZATION IS NECESSARY IF CONDITION
WORSENS.
6. PROVIDE DETAILED INSTRUCTIONS ABOUT
WARNING SIGNS:
a. EPIGASTRIC PAIN –AURA TO CONVULSION
b. VISUAL DISTURBANCES
c. SEVERE CONTINUOUS HEADACHE
 d. NAUSEA & VOMITING
B. HOSPITAL MANAGEMENT:
1. BP GOES ABOVE 140/90 mm Hg
2. BED REST IS ONE OF THE MOST IMPORTANT
PRINCIPLES OF CARE.
a. REST IN LEFT LATERAL POSITION TO
PROMOTE BLOOD SUPPLY TO THE PLACENTA &
THE FETUS.
 STAGES OF CONVULSION:
1. STAGE OF INVASION – FACIAL TWITCHING,
ROLLING OF THE EYES TO ONE SIDE, STARING
FIXEDLY IN SPACE.
2. TONIC PHASE – BODY BECOMES RIGID, AS ALL
MUSCLES GO INTO VIOLENT SPASMS OR
CONTRACTIONS, EYES PROTRUDE, HANDS ARE
CLENCHED, WOMAN STOPS BREATHING FOR 15-
20 SECONDS.
3. CLONIC PHASE – JAWS & EYELIDS CLOSE & OPEN
VIOLENTLY, FOAMING OF THE MOUTH, FACE
BECOMES CONGESTED & PURPLE,MUSCLES OF
THE BODY CONTRACT & RELAX ALTERNATELY.
THE CONTRACTIONS ARE SO VIOLENT THAT THE
WOMAN MAY THROW HERSELF OUT OF BED.
LASTS FOR ABOUT A FEW MINUTES.
4. POST ICTAL PHASE –WOMAN IS
SEMICOMATOSE, NO MORE VIOLENT MUSCULAR
CONTRACTIONS. THE PATIENT WILL NOT
REMEMBER THE CONVULSION & THE EVENTS
IMMEDIATELY BEFORE & AFTER.
 RESPONSIBILITIES DURING A CONVULSION
1. ALWAYS MONITOR PATIENT FOR IMPENDING
SIGNS OF CONVULSION: EPIGASTRIC PAIN, SEVERE
HEADACHE, NAUSEA & VOMITING.
2 THE MAIN RESPONSIBILITIES OF A NURSE
DURING A CONVULSION ARE: MAINTENANCE PF
PATENT AIRWAY & PROTECTION OF PATIENT FROM
INJURY.
3. TURN PATIENT TO HER SIDE TO ALLOW
DRAINAGE OF SALIVA & PREVENT ASPIRATION.
4. NEVER LEAVE AN ECLAMPTIC PATIENT ALONE
5. DO NOT RESTRICT MOVEMENT DURING A
CONVULSION AS THIS COULD RESULT IN
FRACTURES.
6. WATCH FOR SIGNS OF ABRUPTIO PLACENTA:
VAGINAL BLEEDING, ABDOMINAL PAIN,
DECREASED FETAL ACTIVITY.
7. TAKE VITAL SIGNS & FHT AFTER A CONVULSION.
8. DO NOT GIVE ANYTHING BY MOUTH UNLESS
THE WOMAN IS FULLY AWAKE AFTER A
CONVULSION
** THE ONLY KNOWN CURE OF PIH IS DELIVERY
OF THE BABY.
** AS SOON AS THE BABY IS STABLE, THE BABY
IS DELIVERED.
** THE PREFERRED METHOD OF DELIVERY IS
VAGINAL .
** IF LABOR INDUCTION IS UNSUCCESSFUL &
FETAL DISTRESS IS SO SEVERE THAT THE FETUS
NEED TO BE DELIVERED, CESARIAN SECTION IS
PERFORMED.
POSTPARTUM CARE:
1. THE DANGER OF CONVULSION EXISTS UNTIL 24
HOURS AFTER DELIVERY. MgSO4 THERAPY IS
CONTINUED UNTIL THE IMMEDIATE 24 HOUR
POSTPARTUM.
2. ERGOT PRODUCTS ARE CONTRAINDICATED
BECAUSE THEY ARE HYPERTENSIVES.
3. TWO YEARS SHOULD ELAPSE BEFORE ANOTHER
PREGNANCY IS ATTEMPTED TO DECREASE THE
LIKELIHOOD THAT PIH WILL RECUR ON THE
SUBSEQUENT PREGNANCY.
 HELLP Syndrome
 Serious complication of pregnancy induced
hypertension & the client develops multiple
organ damage.
 Usually develops before delivery but may
occur postpartum as well.
 HELLP syndrome consists of the following
problems:
 Hemolysis – red blood cells break down
 Elevated liver enzymes – damage to liver cells cause
changes in liver function lab tests
 Low platelets – cells found in the blood that are
needed to help clot the blood to control bleeding
 HELLP syndrome can cause other problems
 Anemia – breakdown of RBC’s may cause anemia
 DIC – may lead to severe bleeding
 Placenta abruptio – may also occur
SSx of HELLP syndrome:
 Right sided upper abdominal pain around

the stomach ( epigastric area)

 Nausea & vomiting

 Headache

 Increased BP

 Protein in the urine

 edema
How is HELLP diagnosed?
 BP measurement

 RBC count ( hemolysis)

 Bilirubin level – substance produced by the

breakdown of RBC
 Liver function tests ( ALT & AST)

 Platelet count ( thrombocytopenia )

 Urine tests for protein

Treatment:
 Bedrest
 Blood transfusion
 MgSO4 ( as anti convulsant)
 Antihypertensive medications
 Lab testing of liver, urine & blood ( for

changes that may signal worsening of

HELLP syndrome
 Corticosteroids – to help in the maturity of

fetal lungs
 Delivery ( if HELLP syndrome worsens &

endangers the well being of the mother or

fetus)
 Multiple Pregnancy
 When 2 ( twin), 3 (triplet), 4 (quadruplet) or even
5 ( quintuplet) fetuses develop in the uterus at the
same time
 Associated with more risks than a singleton
pregnancy
 TYPES:
 MONOZYGOTIC or IDENTICAL TWIN
› Develop from one ovum & one sperm cell that
undergo rapid cell division after fertilization that
resulted in two or more individuals. Since they come
from only one sperm and one ovum, these individuals
possess the same genetic traits and are always of the
same sex.
 If twinning occurred within 72 hours after
fertilization, there will be:
› 2 amnions ( diamnionic)
› 2 chorions ( dichorionic)
› 2 embryos
 If twinning occurred between the 4th & 8th day
after fertilization, there will be :
› 2 amnions
› 1 chorion ( monochorionic)
› 2 embryos
 If twinning occurred after 8 days, there will be :
› 1 amnion ( monoamnionic)
› 1 chorion
› 2 embryos
 If twinning occurred after the embryonic disc is
formed, CONJOINED TWINS will develop.
Conjoined twins are classified according to the
part of the body where they are attached.
› Anterior – Thoracopagus
› Posterior – pyopagus
› Cephalic – craniopagus
› Caudal – Ischiopagus
 DIZYGOTIC TWINS or FRATERNAL TWINS
› Develop from 2 or more ova and sperm cells that were
fertilized at the same time. They have the same genetic
traits, may or may not be of the same sex and always
have 2 chorions & 2 amnions.
** More females than males because female zygote has a
higher tendency to divide into twins
** Female zygotes have higher rate of survival than male
zygotes
 Predisposing factors of Dizygotic Twinning
› Race – highest in black women
› Heredity – more common in women with familial history of
twinning
› Age & parity – increased incidence in high parity &
advanced maternal age
› Higher incidence in women taking fertility drugs that
promote ovulation & release of several ova at the same time
› Higher incidence within the first months after stopping oral
contraceptives because of the sudden & greater amount of
pituitary gonadotropin released at this time
› In vitro fertilization – stimulation of formation of numerous
follicles, harvesting them in the ovary & fertilizing them in
vitro. All zygotes that were fertilized are returned to the
uterus to grow & develop
 Complications of Multiple Fetuses:
› Abortion
› Death of one fetus
› Perinatal mortality
› Preterm labor – as the number of fetuses increases, the
duration of pregnancy decreases
› Low birth weight
› Congenital malformations
› Hydramnios
› Maternal hypertension
› Placenta previa & Abruptio placenta
› Intrauterine growth retardation
› Cord entanglement, prolapse & compression
› Maternal anemia
 S/Sx
› 1. Uterus large for gestational age
› 2. Auscultation of two or more fetal heart tone
› 3. Hx of twins in the family
› Palpation of three or more large fetal parts
› Ultrasound reveals two or more gestational sac
 Management:
 Clinic Visit:
 First Trimester – every month
 Second Trimester – every 2 weeks
 Third Trimester – every week
 Nutrition – additional 300 kcal to the normal
pregnancy requirement
 6 small meals rather than 3 large meals to
decrease discomfort of a large uterus
compressing a full stomach
Labor and Delivery:
 The cord is cut right after delivery of the first infant
 Presentation of second infant is ascertained after
birth of first twin either by ultrasound or Leopold’s
or both
 The normal interval of delivery of the first twin and
second twin is (30 minutes)
 If the second twin cannot be delivered vaginally
because of abnormal position, CS is done.
 Cesarean delivery – delivery of choice if the
twins or one of them cannot be delivered
normally or if complications arise that necessitate
immediate delivery.
 Post partum period – watch out for Hemorrhage
due to overdistention of the uterus.
 Premature Labor:
 Is labor that occurs between 20 weeks to 37
weeks gestation characterized by regular
uterine contraction that lasts more than 30
seconds & result in cervical dilatation &
effacement. It is the greatest cause of neonatal
mortality & morbidity.
Causes:
 PROM – most often associated with infection
 Infection of amniotic fluid –
 Retained IUD
 Fetal death
 History of premature labor & abortion
 Overdistention of the uterus – caused by
multiple pregnancy, hydramnios
 Abnormal placentation
 Uterine abnormalities
 Incompetent cervix
 Serious maternal conditions
SSx:
 Dx is made when there is regular uterine contractions
occuring 5-8 minutes apart accompanied by:
 Progressive cervical changes
 Cervical dilatation of more than 2 cm
 Cervical effacement of 80% or more
 Duration of at least 30 secs
 10 mins apart
 Menstrual like cramping
 Watery or bloody vaginal discharge
 Low back pain
MX:
1. Prevention – regular prenatal check up
2. If fetus is less than 32-34 weeks, and still premature to be
delivered, labor must be arrested:
1. Bedrest on LLP to promote blood flow to the placenta
2. Hydration – IV fluids
3. Tocolytics – medications to stop uterine contractions
( relaxes smooth muscles)
1. Ritodrine Hcl
2. Terbutaline –( check pulse rate because it can
cause tachycardia)
3. Prostaglandin inhibitors ( Indomethacin)
Drugs to hasten fetal lung maturity:
- GLUCOCORTICOID therapy if labor can be
delayed for 48 hours – administration of
BETAMETHASONE accelerate fetal lung maturity &
prevents respiratory distress & hyaline membrane
disease ( most common problem of the premature
neonate).
-
MEDICAL CONDITIONS COMPLICATING PREGNANCY
 HEART DISEASE
CLASSIFICATION:
1. CLASS I = NO LIMITATION,UNCOMPROMISED
= ASYMPTOMATIC, NO DISCOMFORT
WITH ORDINARY PHYSICAL
ACTIVITY.
2. CLASS II =SLIGHT LIMITATION, SLIGHTLY
COMPROMISED, ORDINARY
ACTIVITY CAUSES DYSPNEA,
FATIGUE, CHEST PAIN &
PALPITATIONS.
3. CLASS III = MARKED LIMITATION LESS THAN
ORDINARY ACTIVITY CAUSE
EXCESSIVE FATIGUE;
PALPITATIONS, CHEST PAIN & DYSPNEA.
4. CLASS IV =SEVERE LIMITATION; PATIENT
EXPERIENCES SYMPTOMS EVEN
AT REST; UNABLE TO PERFORM ANY
PHYSICAL ACTIVITY WITHOUT
DISCOMFORT.
SIGNS & SYMPTOMS:
1.DIFFICULTY OF BREATHING – DYSPNEA,
ORTHOPNEA, NOCTURNAL DYSPNEA
2. HEMOPTYSIS
3. SYNCOPE WITH EXERTION
4. CHESTPAIN
5. CYANOSIS
7. CLUBBING OF FINGERS
8. NECK VEIN DISTENTION
9. SYSTOLIC & DIASTOLIC MURMURS
NURSE ALERT:
** REMEMBER A PREGNANT WOMAN WITH
HEART DISEASE SHOULD AVOID INFECTION,
EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA
BECAUSE THESE CONDITIONS INCREASE THE
WORKLOAD OF THE HEART.
MX:
A.PRENATAL CARE:
1. PROMOTION OF REST ( CLASS I & CLASS II)
* 8 HOURS OF SLEEP DURING THE NIGHT &
HAVE FREQUENT REST PERIODS DURING THE
DAY.
* LIGHT WORK IS ALLOWED BUT NO HEAVY
WORK, NO STAIR CLIMBING, NO EXHAUSTION.
2. DIET
* HIGH IN IRON, PROTEIN,MINERALS &
VITAMINS
3. AVOID HIGH ALTITUDES, SMOKING AREAS,
UNPRESSURIZED PLANES & OVERCROWDED AREAS.
CIGARETTE SMOKING & ALCOHOLIC BEVERAGES
ARE STRICTLY PROHIBITED.
4.PREVENTION OF INFECTION
* AVOID PERSONS WITH ACTIVE INFECTIONS
(COLDS, COUGH).
* EARLY TREATMENT OF INFECTIONS
5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF
HEART FAILURE:
* COUGH WITH CRACKLES IS USUALLY THE
FIRST SIGN OF AN IMPENDING HEART FAILURE.
 * INCREASING DYSPNEA, TACHYCARDIA, RALES,
EDEMA

MEDICATIONS:
>IRON SUPPLEMENTATION TO PREVENT ANEMIA
>DIGITALIS TO STRENGTHEN MYOCARDIAL
CONTRACTION AND SLOW DOWN HEART RATE
>NITROGLYCERINE TO RELIEVE CHEST PAIN
>ANTIBIOTICS TO PREVENT AND TREAT
INFECTION
>DIURETICS MAY BE PRESCRIBED IN CASE OF
HEART FAILURE
INTRAPARTAL CARE
1.EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED
BEFORE LABOR BEGINS TO PROMOTE REST, FOR
CLOSER SUPERVISION AND PREVENT INFECTION
2.WOMAN IN LABOR IS IN SEMI-FOWLER’S POSITION
OR LEFT LATERAL RECUMBENT POSITION. NO
LITHOMY POSITION.
3.VITAL SIGNS- VITAL SIGNS ARE MONITORED
CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY
RATE MORE THAN 24 ARE SIGNS OF IMPENDING
CARDIAC DECOMPENSATION. DURING THE FIRST
STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES
AND MORE FREQUENTLY DURING THE SECOND STAGE
4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR
PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS
USED TO SHORTEN THE SECOND STAGE. PUSHING IS
CONTRAINDICATED
5. WOMEN WITH HEART DISEASE ARE POOR
CANDIDATE FOR CS DUE TO INCREASED RISK FOR
HEMORRHAGE, *INFECTION AND
THROMBOEMBOLISM
POSTPARTUM CARE
1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE
POSTPARTUM BECAUSE OF THE SUDDEN INCREASE
IN CIRCULATORY BLOOD VOLUME.
2. MONITOR VITAL SIGNS.
3. PROMOTE REST- RESTRICT VISITORS TO ALLOW
PATIENT TO REST, THE WOMAN STAYS IN THE
HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS
STABILIZED.
4. EARLY BUT GRADUAL AMBULATION TO PREVENT
THROMBOPHLEBITIS.
5. MEDICATIONS
*ANTIBIOTICS
*STOOL SOFTENERS TO PREVENT STRAINING AT
STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE
ORDERED TO PROMOTE REST.
6. BREASTFEEDING IS ALLOWED IF THERE ARE NO
SIGNS OF CARDIAC DECOMPENSATION DURING
PREGNANCY, LABOR AND PUEPERIUM.
 The Anemias of Pregnancy
 Hemoglobin level of less than 11g/dl in the
first and third trimester and less than 10.5g/dl
in the second trimester.
 Iron Deficiency Anemia
 Most common type of anemia during
pregnancy. Most women enter pregnancy
without enough iron reserve so that deficiency
develops particularly on the 2nd and 3rd
trimester when iron requirements increases.
Predisposing Factors:
 Poor diet and poor nutrition

 Heavy menses

 Pregnancies at close intervals, successive

pregnancies
 Unwise reducing programs
 **Nurse Alert**
“ The newborn of the severely anemic mother
IS NOT AFFECTED by iron deficiency
anemia. This is because the amount of iron
transported to the fetus of an anemic mother
is almost the same as the amount
transported to the fetus of a mother without
anemia”
Signs and Symptoms
 Easy fatigability

 Sensitivity to cold

 Proneness to infection

 Dizziness

 Laboratory findings will reveal low hgb

 Effects of Anemia to Pregnancy
 Decreased resistance to infection
 Associated with prematurity & low birth
weight infants
 Predispose to heavy bleeding during labor &
puerperium
 May increase digestive discomfort of
pregnancy
 Management:
1. Oral iron supplementation – 200 mg of
elemental iron daily in the form of:
 Ferrous Sulfate – the most absorbable form of iron
 Ferrous Fumarate
 Ferrous Gluconate
 Inform the mother about the possible side effects. Tarry
stool, constipation, GI discomfort
 Never take with milk but with citrus juice
 If given in liquid form, use straw to prevent
staining the teeth. Tell patient to rinse mouth.
 If iron is to be given parenterally, give IM by Z
tract technique to prevent tissue staining. Do
not massage after injection.
 Oral iron should be continued until 3 months
after anemia has been corrected.
 Increase intake of iron rich foods: lean meat,
liver, dark green leafy vegetables. Good food
sources of iron include the following:
 Meats – beef, pork, lamb, liver,& other organ meats
 Poultry – chicken, duck, turkey, liver ( especially
dark meat)
 Fish – shellfish, including clams, mussels, oysters,
sardines and anchovies
 Leafy greens of the cabbage family such as
broccoli
 Legumes such as lima beans & green peas; dry
beans & peas
 Yeast-leavened whole wheat bread & rolls
 Iron enriched, white bread, pasta, rice & cereals
 Folic Acid Deficiency Anemia
 Folic acid is necessary for the normal formation
and nutrition of red blood cells. Deficiency in
folic acid leads to the formation of large and
immature blood cells that have shorter life span
than normal red blood cells. Women who have
folic acid deficiency during pregnancy are
more at risk of giving birth to babies with
neural tube defects.
Effects on Pregnancy:
 ABORTION, Abruptio placenta, Neural defect in
fetus
Predisposing Factors:
 1. Long term use of oral contraceptives
 2. Poor nutrition
 3. Multiple pregnancies
 4. Successive pregnancies
Signs and Symptoms
 1. Nausea
 2. Vomiting
 3. Anorexia – lack of appetite
 Management:
 Folic acid supplementation of 1 mg/day accompanied
oral iron. RDA for all women – 0.4mg/day
 Vit supplements containing 400 micrograms of folic
acid are now recommended for all women of
chilbearing age and during pregnancy. These
supplements are needed because natural food sources
of folate are poorly absorbed and much of the vitamin
is destroyed in cooking. Food sources of folate include
the ff:
 Leafy dark green vegetables, dried beans & peas, nuts,
citrus fruits & juices & most berries, fortified breakfast
cereals, enriched grain products
Hemolytic Disease:
ISOIMMUNIZATION / RH INCOMPATIBILITY
- OCCURS WHEN AN RH-NEGATIVE MOTHER IS
CARRYING AN RH-POSITIVE FETUS.
- FOR SUCH A SITUATION TO OCCUR, THE
FATHER OF THE CHILD MUST EITHER BE A
HOMOZYGOUS ( DD) OR HETEROZYGOUS ( Dd) RH
POSITIVE.
- IF THE FATHER OF THE CHILD IS
HOMOZYGOUS (DD), 100% OF THE COUPLE’S
CHILDREN WILL BE RH (+).
 -PEOPLE WHO HAVE RH (+) BLOOD HAVE A
PROTEIN FACTOR ( D ANTIGEN) THAT RH (-)
PEOPLE DO NOT.
- WHEN AN RH(+) FETUS BEGINS TO GROW
INSIDE AN RH (-) MOTHER, IT IS THOUGH HER
BODY IS BEING INVADED BY FOREIGN AGENT, OR
ANTIGEN.
- THEORETICALLY, THERE IS NO CONNECTION
BETWEEN FETAL BLOOD & MATERNAL BLOOD
DURING PREGNANCY BUT
BUT SOMETIMES ACCIDENTAL BREAKS IN THE
PLACENTAL VILLI RESULTS IN FETAL BLOOD
ENTERING THE MATERNAL BLOODSTREAM. (also
AMNIOCENTESIS , PUBS).
- ONLY A FEW ANTIBODIES ARE FORMED THIS
WAY SO THAT IT DOES NOT AFFECT THE FIRST
INFANT.
- DURING PLACENTAL SEPARATION AND
DELIVERY, A GREAT AMOUNT OF MATERNAL &
FETAL BLOOD ARE MIXED, CAUSING THE MOTHER
TO PRODUCE LARGE AMOUNTS OF ANTIBODIES
DURING THE FIRST 72 HOURS AFTER PLACENTAL
DELIVERY.
 - IF THE FETUS IN SUBSEQUENT PREGNANCIES
IS RH (+), THE ANTIBODIES ALREADY PRESENT IN
THE BLOODSTREAM WILL CROSS THE PLACENTA
ATTACK & DESTROY THE FETAL RED BLOOD CELLS
( HEMOLYSIS). THE FETUS BECOMES SO
DEFICIENT IN RBC’S THAT SUFFICIENT O2
TRANSPORT TO BODY CELLS CANNOT BE
MAINTAINED. THIS CONDITION IS TERMED “
HEMOLYTIC DISEASE OF THE NEWBORN” OR
ERYTHROBLASTOSIS FETALIS.
DX:
1. INDIRECT COOMB’S TEST – TEST TO CHECK
FOR THE PRESENCE OF ANTIBODIES IN
MATERNAL SERUM.
2. DIRECT COOMB’S TEST –TEST TO CHECK THE
PRESENCE OF ANTIBODIES IN FETAL CORD
BLOOD.
 Prevention:
 Administration of Rh ( anti D) globulin
(Rhogam) at 28 weeks gestation and within the
first 72 hours after delivery to a woman who:
 Have delivered Rh positive fetus
 Have had untypeable pregnancies such as ectopic
pregnancies, stillbirth & abortion
 Have received ABO compatible Rh positive blood
 Have had invasive diagnostic procedure such as
amniocentesis, PUBS ( cordocentesis)
 ABO INCOMPATIBILITY
 Occurs when maternal blood type is O and fetus is:
 Type A – most common
 Type B – most serious
 Type AB – rare
MX of HEMOLYTIC DISEASE:
1. SUSPENSION OF BREASTFEEDING DURING THE
FIRST 24 HOURS TO PREVENT PREGNANEDIOL
(BREAKDOWN PRODUCT OF PROGESTERONE
EXCRETED IN BREASTMILK) FROM INTERFERING
WITH THE CONJUGATION OF INDIRECT
BILIRUBIN TO DIRECT BILIRUBIN.
2. PHOTOTHERAPY – DESTRUCTION OF RBC’S
RESULTS IN THE FORMATION OF INDIRECT
BILIRUBIN. INDIRECT BILIRUBIN MUST FIRST BE
CONVERTED TO DIRECT BILIRUBIN BY THE LIVER
CELLS BEFORE IT CAN BE EXCRETED IN THE
BODY. THE LIVER IS IMMATURE AT BIRTH SO IT
CANNOT CONVERT LARGE AMOUNTS OF
BILIRUBIN FORMED DURING HEMOLYSIS OF RBC.
a. USES BILI OR FLUORESCENT LIGHTS
POSITIONED 12 – 30 INCHES ABOVE THE
INFANT.
NURSING CARE DURING PHOTOTHERAPY:
1. COVER EYES WITH DRESSING
2. COVER GENITALS TO PREVENT PRIAPISM.
3. EXPECT THE STOOL TO BE LOOSE & BRIGHT
GREEN FROM EXCESSIVE BILIRUBIN EXCRETION
& THE SKIN TO BE DARK BROWN ( BRONZE
BABY SYNDROME).
4. PROVIDE GOOD SKIN CARE BECAUSE STOOL
CAN BE IRRITATING TO THE SKIN.
5. EXPECT THE URINE TO BE DARK COLORED
BECAUSE OF UROBILINOGEN FORMATION.
6. ASSESS FOR DEHYDRATION ( I & O ; SKIN
TURGOR). FLUID LOSS THROUGH INSENSIBLE
WATER LOSS MAY OCCUR BECAUSE OF THE HEAT
FROM THE FLUORESCENT LIGHT ABOVE THE
INFANT.
7. OFFER GLUCOSE WATER EVERY 3 HOURS TO
PREVENT DEHYDRATION.
8. MAINTAIN BODY TEMP BETWEEN 36C & 37C.
EXCHANGE TRANSFUSION:
1. INTRAUTERINE TRANSFUSION:
- DONE BY INJECTING RBC’S DIRECTLY INTO A
VESSEL IN THE FETAL CORD OR DEPOSITING
THEM IN THE FETAL ABDOMEN USING
AMNIOCENTESIS TECHNIQUE.
- BLOOD USED FOR TRANSFUSION IS EITHER
THE FETUS’ OWN TYPE OR GROUP O NEGATVE
IF THE FETAL BLOOD TYPE IS UNKNOWN.
-FROM 75 TO 150 ML OF WASHED RBC’S WILL
BE USED, DEPENDING ON THE AGE OF THE
FETUS.
 - INTRAUTERINE TRANSFUSION IS NOT
WITHOUT RISK. A CORD VESSEL MAY BE
LACERATED BY THE NEEDLE. BUT FOR A FETUS
WHO IS SEVERELY AFFECTED BY
ISOIMMUNIZATION, HOWEVER, SUCH A RISK IS
NO GREATER THAN LEAVING THE FETUS
UNTREATED.
- MOTHER RECEIVES AN RhIG
INJECTION( RhoGAM) AFTER THE TRANSFUSION
TO HELP REDUCE ISOIMMUNIZATION FROM THE
AMNIOCENTESIS.
- AS SOON AS FETAL MATURITY IS REACHED
( L:S RATIO 2:1), DELIVERY WILL BE INDUCED.
NOTE:
ADMINISTER RhoGAM TO ALL Rh (-) MOTHERS
DURING PREGNANCY ( AT 28 WEEKS GESTATION)
AND WITHIN 72 HOURS OF DELIVERY OR
ABORTION OF AN Rh (+) FETUS **
 - AFTER BIRTH, THE INFANT MAY REQUIRE AN
EXCHANGE TRANSFUSION TO REMOVE
HEMOLYZED BLOOD CELLS & REPLACE THEM
WITH HEALTHY ONES.
Notify your healthcare provider if your baby has
any of the following s/s after returning home:
> Fever
> Jaundice
> Poor appetite or poor weight gain
> Excessive crying that does not stop when the
baby is held.
Signs in the newborn:
 Paleness
 Jaundice that begins within 24 hours after
delivery ( pathologic jaundice)
 Unexplained bruising or blood spots under
the skin
 Tissue swelling ( edema)
 Seizures
 Lack of normal movement
 Poor reflex response
Metabolic Disorders in Pregnancy
 Gestational Diabetes Mellitus
-is a hereditary endocrine disorder due to
inadequate or lack of insulin production that
results in impaired glucose absorption &
metabolism.
- all women appear to develop an insulin
resistance as pregnancy progresses ( insulin does
not seem normally effective during pregnancy) a
phenomenon that is probably caused by the
presence of the hormone Human Placental
Lactogen (HPL)
SSx:
1. Hyperglycemia – pancreas does not produce
enough insulin , thus glucose is unable to enter
the cells & accumulates in the bloodstream
resulting in hyperglycemia
2. Glycosuria –when blood glucose levels goes
beyond the renal threshold for sugar, glucose spills on
the urine.
3. Polyuria – glucose attracts water so that when it is
excreted in the kidney, it brings along with it large
amounts of water resulting in the woman excreting
large amounts of urine, a condition called, POLYURIA.
4. Polydipsia – the excretion of large amounts of fluid
from the body leads to dehydration. Excessive thirst or
polydipsia is an important symptom of dehydration.
5. Weight loss – since glucose cannot be utilized as
a source of energy, the body uses its protein & fats
stores in the muscles & adipose tissue resulting in
weight loss.
6. Ketoacidosis – breakdown of proteins & fats
result to excessive formation of ketone bodies that
the body cannot excrete right away causing them to
accumulate.
Effects of Diabetes:
Mother:
1. Increased tendency to pre-eclampsia &
eclampsia, UTI, & candidiasis
2. Increased risk for postpartum hemorrhage d/t
overdistention of the uterus.
3. Maternal mortality
4. Preterm delivery
Infant:
1. Macrosomia
2. Hydramnios
3. Prematurity
4. Intrauterine growth retardation ( IUGR)
5. Hypoglycemia ( lowered serum glucose levels)
6. Predisposition to diabetes mellitus later in life as
the disease is hereditary
Complications:
1. Macrosomia – Infants of women with poorly
controlled diabetes tend to be large ( more than
10 lbs) because glucose can cross the placental
barrier, it acts acts as a growth stimulant. The
increased glucose adds subcutaneous fat
deposits. All the nutrients that the fetus receives
comes directly from the mother’s blood.
2. Birth Injury – may occur due to the baby’s large
size and difficulty being born.( may cause CPD
which may necessitate being born by CS)
3. HYPOGLYCEMIA – refers to low blood sugar
in the baby immediately after delivery. This
problem occurs if the mother’s blood sugar
levels have been consistently high, causing the
fetus to have a high level of insulin in its
circulation. After delivery, the baby continues
to have a high insulin level, but no longer has
the high level of sugar from its mother,
resulting in the newborn’s blood sugar level
becoming very low. The baby’s blood sugar
level is checked after birth, and if the level is
too low, it may be necessary to give the baby
glucose intravenously
4. Respiratory distress (difficulty breathing) – too
much insulin or too much glucose in a baby’s
system may delay lung maturation and cause
respiratory difficulties in babies. This is more
likely if they are born before 37 weeks of
pregnancy.
Prenatal Management:
1. Diagnosis; Suspect DM in a woman
a. With family history of DM
b. With history of unexplained repeated abortions and
stillbirth
c. With glycosuria
d. Who are obese
e. Who have history of giving birth to large infants,
over 10 lbs. and infants with congenital anomaly
2. Screening tests
a. Universal screening- 50 gram oral glucose tolerance
test ( OGTT) between 24-28 weeks gestation
irregardless of the time of the day and meals taken
for all pregnant women. If the plasma value is more
than 140 mg/dl after one hour, 100 gram three hour
oral glucose tolerance test is performed to confirm if
the woman is having hypergycemia.
Criteria of 100 gram Oral Glucose Tolerance Test-
(Instruct not to eat after midnight)
Time of Test Venous Level Plasma Level
Fasting 90mg/dl 105mg/dl

1-hour 165mg/dl 190mg/dl

2-hour 145mg/dl 165mg/dl

3-hour 125mg/dl 145mg/dl

b. Blood tests for sugar by Testape and Clinistix.
Benedict’s test and Clinitest are inaccurate when
testing sugar during pregnancy because these test
measure all kinds of sugar including lactose which
is normally present in the urine of pregnant
women, thereby, giving false positive result.
c. Urine test for acetone by acetest.
3. Diet
a. Caloric intake should be enough to meet needs of
pregnancy, fetus and mother (1,800 to 2,400
cal/day) but not too much to promote excessive
weigh gain. 20% of caloric intake should come from
protein foods, 50% from carbohydrates, 30% from
fats.
b. Weight gain should be about 24 lbs. Too much
weight gain can lead to large infants and
cephalopevic disproportion.
c. Teach and instruct to:
 Reduce saturated fat
 Reduce cholesterol
 Increase dietary fiber
 Avoid fasting and feasting
d. Have the woman become familiar with food
exchange list and caloric values of foods she usually
eats to enable her to plan her diet properly and
estimate her caloric intake accurately.
e. The goal is to maintain a fasting blood sugar level of
80 mg/dl and postprandial blood sugar level of
110mg/dl
4. Exercise
 A liberal cardiovascular-conditioning exercise and
diet therapy is the management for Gestational
Diabetes Mellitus
 Exercise lowers blood glucose levels and decreases
the need for insulin.
 The exercise regimen should be individualized,
performed regularly and under supervision.
 Advise woman to eat complex carbohydrates before
exercising to prevent hypoglycemia.
Remember that hypoglycemia could occur in
persons undergoing insulin therapy during
peak action hour of insulin:
 Short acting or regular insulin – after 2-3 hours of
injection
 Intermediate or Lente insulin – after 6-8 hours of
injection
 Long-acting or ultralente – after 16 – 18 hours of
injection
 The sign of hypoglycemia are: dizziness, diaphoresis,
weakness, blurring of vision
 Give a hypoglycemic person a glass of orange juice.
5. Insulin therapy
 Insulin requirements increase during pregnancy
 Oral hypoglycemics such as Tolbutamide and
Diamicron are contraindicated during pregnancy
because they are teratogenic for they can cross the
placenta and may cause fetal and new born
hypoglycemia.
 Combined fast acting and intermediate insulin
made up of human derivative/humulin. Humulin
is the insulin of choice during pregnancy because it
is the least allergenic
 2/3 in the morning, 1/3 at dinner administered
subcutaneously ½ hour before meals.
 Insulin requirement is decreased on the first
trimester due to nausea & vomiting and highest
during the third trimester.
6. Home blood glucose monitoring-
a. Dextrometer
b. 4x a day, upon rising in the morning, before
breakfast, lunch, dinner
c. Normal fasting – 80 mg/dl, postprandial -
110mg/dl

7. Observe for urinary and vaginal tract infections

particularly candidiasis
8. Fetal well-being assessment
a. Uteroplacental Function Tests – NST and CST
b. Amniocentesis to determine fetal lung maturity
Delivery:
1. Delivery is effected when the fetus is mature
enough after 38 weeks gestation, but not too large
so as to cause cephalopelvic disproportion. Thus,
early hospitalization and labor induction is
performed to deliver the baby before it becomes too
large to pass the birth canal
2. If cervix is not yet ripe, baby is macrosomic and
fetal distress occurs, CS is performed
3. Regular insulin is given on the day of delivery not
long acting insulin because insulin requirement
drop immediately after delivery. The woman may
not require insulin during the first 24 hours
postpartum and her insulin requirements usually
fluctuates during the next few days.
Postpartum:
1. Recurrence of diabetes may occur in subsequent
pregnancies.
2. Women who develop gestational diabetes have
higher tendency to develop overt diabetes later in
life.
3. Newborn Care:
 Keep warm because of poor temperature control
mechanisms
 Observe respiration (stomach aspiration necessary at time
of birth, since hydramnios inflates stomach which pushes
up and interferes with diaphragm and lung expansion)
 Observe for signs of hypoglycemia (shrill cry, weakness) –
give glucose water
 Observe for signs of hypocalcemia (tetany, tremors) – give
calcium gluconate
 Observe for congenital anomalies: esophageal atresia,
neural tube defect
4. Contraception:
a. IUD and combined oral contraceptives are
contraindicated
*Progesterone interferes with insulin activity
therefore increases blood glucose levels.
*Estrogen increases lipid & cholesterol levels & risk
for increased blood coagulation
b. Norplant (subcutaneous progestin implant system)
or Depo -provera may be good choices & safely
used by diabetic women
Complications of Labor
 COMPLICATIONS OF LABOR
1. DYSTOCIA – PROLONGED & DIFFICULT
LABOR ( LABOR THAT LASTS MORE THAN 24
HOURS).
CAUSES:
A. ABNORMALITIES OF THE POWER / UTERINE
DYSFUNCTION
a. HYPOTONIC UTERINE CONTRACTION –
WEAK & INFREQUENT CONTRACTIONS WHICH
ARE INSUFFICIENT TO DILATE THE CERVIX.
USUALLY OCCURS DURING THE ACTIVE PHASE
CAUSES:
1. OVERDISTENTION OF THE UTERUS
2. PELVIC BONE CONTRACTION
3. UNRIPE OR RIGID CERVIX
4. CONGENITAL ANOMALIES OF THE UTERUS.
MX:
1. REEVALUATE PELVIC SIZE TO RULE OUT
FETOPELVIC DISPROPORTION
2. AMNIOTOMY IF MEMBRANES ARE NOT YET
RUPTURED
3. AUGMENT LABOR BY OXYTOCIN
ADMINISTRATION
4. IF CONTRACTED PELVIS IS THE CAUSE, CS IS
PERFORMED.
b. HYPERTONIC UTERINE CONTRACTIONS
- CONTRACTIONS THAT ARE TOO FREQUENT BUT
UNCOORDINATED, THE UTERUS DOES NOT
RELAX COMPLETELY IN BETWEEN
CONTRACTIONS & CONTRACTIONS ARE MORE
PAINFUL BUT INEFFECTIVE.
MX:
1. THERAPEUTIC REST – GIVEN ANALGESICS
( MORPHINE) & SEDATIVES ( PHENOBARBITAL)
TO PROMOTE REST. WOMAN USUALLY AWAKENS
WITH NORMAL LABOR PATTERNS.
2. SIDE LYING POSITION TO MAXIMIZE BLOOD
FLOW TO THE FETUS & THE PLACENTA.
2. PRECIPITATE LABOR /
PRECIPITATE BIRTH:
-labor lasting < 3 hrs from the onset of
contractions to the birth of infant
MATERNAL COMPLICATIONS:
1.increase risk of uterine rupture
2. laceration of cervix, vagina and perineum
3. postpartum hemorrhage
FETAL COMPLICATION:
1.hypoxia
3. PREMATURE RAPTURE OF MEMBRANES
(PROM/ EROM/)
** THE SPONTANEOUS RUPTURE OF
MEMBRANES PRIOR TO THE ONSET OF
LABOR RESPECTIVE OF THE GESTATIONAL
AGE.
INITIAL SIGN: PASSAGE OF THE AMNIOTIC
FLUID
PREDISPOSING FACTORS:
** MALPRESENTATION
** POSSIBLE WEAK AREA IN THE AMNION
AND CHORION
** INFECTION
** INCOMPETENT CERVIX
DANGERS ASSOCIATED:
1. CORD PROLAPSE
2. INFECTION
3. POTENTIAL NEED FOR PREMATURE
DELIVERY
PATHOPHYSIOLOGY:
1. AMNIOTIC FLUID LEAKS FROM THE
VAGINA IN THE ABSENCE OF
CONTRACTIONS
2. INCREASED RISK OF ASCENDING
INTRAUTERINE INFECTION
(CHORIOAMNIONITIS)
3. THE LEADING CAUSE OF DEATH
ASSOCIATED WITH PROM IS ASCENDING
INFECTION
2 Risks associated with ruptured membranes :
 1. Intrauterine infection

 2. Cord Prolapse
 ++NURSE ALERT++

RISK OF INFECTION MAY BE DIRECTLY

RELATED TO TIME INVOLVED BETWEEN
MEMBRANE RUPTURING AND LABOR
ONSET. MECONIUM STAIN INDICATES FETAL
DISTRESS.
 4. PROLAPSED UMBILICAL CORD (CORD
PROLAPSE)
** DISPLACEMENT OF THE UMBILICAL CORD
BELOW THE PRESENTING PART, THE CORD
MAY PROTRUDE THROUGH THE CERVIX AND
INTO THE VAGINAL CANAL.
CAUSES:
1. RUPTURE OF THE MEMBRANES BEFORE
ENGAGEMENT
2. ABNORMAL PRESENTATION
3. PREMATURE INFANT, PRESENTING PART
DOES NOT FILL THE BIRTH CANAL, ALLOWING
THE CORD TO SLIP THROUGH.
4. MAY FOLLOW RUPTURE OF AMNIOTIC
MEMBRANES BECAUSE THE FLUID RUSH MAY
CARRY THE CORD ALONG TOWARD THE BIRTH
CANAL
5. WHEN DELIVERY IS ACCOMPLISHED WITHIN
15-30 MINUTES, FETAL SURVIVAL IS 70-75%.
FETAL MORTALITY MAY EXCEED 50% IF
DELIVERY IS DELAYED MORE THAN 1 HOUR.
ASESSMENT:
1. VAGINAL EXAMINATION IDENTIFIES CORD
PROLAPSE INTO VAGINA
2. SIGNS OF ACUTE DISTRESS
MANAGEMENT:
1. PREVENTION – PLACE THE WOMAN ON
BEDREST AFTER MEMBRANES HAVE RUPTURED.
2. REDUCE PRESSURE ON THE CORD BY:
a. PLACING THE PATIENT ON KNEE CHEST
OR TRENDELENBURG POSITION
b. IF CORD IS EXPOSED TO AIR, COVER IT
WITH A SALINE MOISTENED STERILE
COMPRESS.
c. NEVER REPLACE CORD BACK INTO THE
VAGINA AS THIS WILL RESULT IN CORD
KINKING.
 d. ADMINISTER MASK OXYGEN UNTIL
DELIVERY IS COMPLETED.
e. DELIVER THE BABY AS SOON AS
POSSIBLE.
** VAGINAL DELIVERY IF CERVIX IS FULLY
DILATED WITHOUT FETAL DISTRESS.
** CESARIAN SECTION IF CERVIX IS NOT
YET COMPLETELY DILATED & IF FETAL DISTRESS
IS PRESENT.
 ++NURSE ALERT++

CORD PROLAPSE IS AN EMERGENCY

SITUATION, IMMEDIATE DELIVERY WILL BE
ATTEMPTED TO SAVE THE FETUS. IF
COMPRESSION OF THE CORD OCCURS,
FETAL HYPOXIA MAY OCCUR RESULTING IN
CNS DAMAGE.
Abnormal Labor Patterns
 Uterine Rupture
 Tearing of the muscles of the uterus. This
occurs when the uterus can no longer
withstand the strain placed upon it.
 It is a serious complication of labor that can
lead to maternal & fetal death.
 Causes:
 Rupture of scar from previous cs
 Multiple gestation
 Injudicious use of oxytocin
 Forceps & vacuum extraction
 Overdistention of the uterus
 External trauma- sharp or blunt
 Gestational trophoblastic neoplasia
 Ssx:
 Impending uterine rupture is often manifested
by a pathologic retraction ring or Bandl’s ring
 During the peak of a contraction, the woman
suddenly complain of a sharp tearing pain after
which, relief will be felt as the uterus will no
longer contract.
 Complete rupture –when the uterus
ruptures, the woman experiences a SUDDEN
EXCRUCIATING PAIN at the peak of a
contraction, cessation of fetal heart tones, then
contractions stop. Internal hemorrhage follows &
vaginal bleeding may or may not be present. Two
swellings will be visible in the abdomen, the
uterus & the extrauterine fetus. Rupture results in
separation of the placenta from the uterus cutting
blood supply to the fetus resulting in hypoxia &
fetal death.
 MX:
 BT & IVF to correct shock
 Administer mask O2
 “E” laparotomy to deliver the baby
 Post-op care:
 Explain need to avoid driving for 3-6 weeks
 Explain need to avoid jogging, sexual intercourse,
dancing & lifting heavy objects for 6-8 weeks
 Bandl’s ring
 Or Pathologic retraction ring
 seen as a horizontal indentation running
across the abdomen
 MX:
 Morphine SO4 to relax the uterus
 CS section for immediate delivery of the fetus
& prevent uterine rupture if Morphine SO4 is
ineffective
 If Bandl’s ring develop during the placental
stage, woman is placed under anesthesia & the
placenta is removed manually.
 Inversion of the Uterus
 Uterus is completely turned inside out
Causes:
 Pulling of the umbilical cord

 Applying pressure on uncontracted uterus

 Placenta accreta

 Sudden increase in intraabdominal pressure

such as when coughing, sneezing or straining

 Ssx:
 Fundus is no longer palpable
 Sudden gush of blood from the vagina
 Uterus appear in the vulva
1. Prevention:
1. Never apply pressure on an uncontracted
uterus
2. Never pull the cord to hasten placental
delivery
2. Lower uterine segment is inserted first
manually & fundus last.
3. BT & IVF to combat shock
4. Do not attempt to remove the placenta if it
still attached to the uterus as this will only
enlarge the bleeding area
5. Give oxytocin only after the uterus is
properly replaced
6. If the placenta is still attached to the uterus,
remove it when the uterus is replaced &
contracted
Complications of the Post
partum period
 Complications of the Postpartum
Period
1. Postpartum Hemorrhage – is the leading cause
of maternal mortality.
 Blood loss of more than 500 ml is considered

hemorrhage.
 The most dangerous time at which hemorrhage

is likely to occur is during the first hour

postpartum
 Predisposing factors
 Uterine atony
 Lacerations & episiotomy
 Placenta previa complication
 Inversion of the uterus
 Rupture of the uterus
 DIC
 Overdistention of the uterus – twins,
hydramnios
 Prolonged & rapid labor
 Types of postpartum hemorrhage
 Early postpartum hemorrhage – occurs during
the first 24 hrs after delivery
 Causes:
 . Uterine atony
 Laceration of the birth canal
 Inversion of the uterus
 Late postpartum hemorrhage – occurs from 24
hrs after birth until 4 weeks postpartum
 Uterine Atony
 Most common cause of EARLY postpartum
hemorrhage. When the uterus fails to contract,
open blood vessels in the placental site
continue to bleed resulting in hemorrhage.
 Causes of Uterine Atony:
 Overdistention of the uterus – hydramnios,
multiple pregnancy
 Complication of labor – precipitate, prolonged
labor
 High parity & advanced maternal age
 Presence of fibroid tumors
 Overmassage of the uterus
 Retained placental fragments
 Management
 First action taken when uterus is relaxed & boggy is to
MASSAGE IT GENTLY.
 Keep bladder empty since a full bladder interferes with
effective uterine contractions
 Monitor vital signs & amount of blood loss during the
early postpartal period
 Administer oxytocin if uterus is not contracted
 BT & IVF to replace blood loss
 If retained placental fragments is the cause, curettage is
performed
 If bleeding cannot be controlled by the above
measures, HYSTERECTOMY is performed as the last
resort.
 Lacerations
 When bright red blood continue to gush from
the vagina & the uterus is firmly contracted,
lacerations of the birth canal are usually the
cause of bleeding. Lacerations can occur
anywhere in the cervix, vagina, & perineum.
 CATEGORIES OF LACERATIONS
1.FIRST DEGREE – INVOLVES THE
FOURCHETTE, PERINEAL SKIN VAGINAL
MUCUS MEMBRANES
2. SECOND DEGREE – INCLUDES THE
MUSCLES OF THE PERINEAL BODY.
3. THIRD DEGREE – EXTENDS TO THE
ANAL SPHINCTER
4. FOURTH DEGREE – EXTENDS TO THE
MUCOSA OR LUMEN OF THE RECTUM.
 Causes of laceration

 Operative delivery – forceps delivery

 Precipitate delivery
 Large infant – over 9 lbs
 Multiple pregnancy
 Primigravidas
 Abnormal fetal presentation & position
 Management
 Return woman to delivery room for inspection
& repair, if laceration is suspected.
 Vaginal packing to maintain pressure on suture
line. Be sure to remove packing after 24 to 48
hrs
 3rd & 4th degree lacerations – no enema or rectal
suppository. Constipation should be avoided &
temp should not be taken rectally.
 Retained Placental Fragments
 Uterus will not be able to contract effectively if
placental fragments are retained resulting in
uterine atony & hemorrhage.
 Most common cause of LATE postpartum
hemorrhage.
 Causes of retained placenta
 Partial separation of a normal placenta
 Manual removal of the placenta
 Entrapment of placenta in the uterus
 Abnormal adherent placenta – acreta, increta,
percreta
 Management
 D & C to remove adherent placenta
 Hysterectomy – for severe cases
 Subinvolution of the Uterus
 Occurs when there is a delay in the return of
the uterus to its prepregnant size, shape &
function
Causes:
 Retained placental fragments

 Infection – Endometritis

 Uterine tumors
SSx:
 Enlarged & boggy uterus
 Prolonged lochial discharge – persistent lochia

rubra
 Backache

Management:
 Methergin to stimulate uterine contractions .2

mg 4x/day for 3 days

 Antibiotics to prevent or treat infection
 D & C if there are retained fragments
 Instruct woman to report the following signs –

fever, vaginal bleeding, passage of tissue

 Hematomas
 This is due to injury to blood vessels during
delivery or during repair of episiotomy
resulting in blood escaping to the connective
tissue under the skin.
Causes:
1. Vulvar varicosities
2. Precipitate labor
3. Forceps delivery
4. Inadequate suturing of episiotomy or
lacerations
Signs and Symptoms:
 Perineal pain

 Swelling

 Discoloration of skin over the swollen area

 Feeling of pressure over the vagina

 Management:

 Application of ice packs wrapped with

towel to stop bleeding by vasoconstriction
 Large hematomas are potentially
dangerous because they may rupture &
cause severe bleeding & infection. The
woman is brought back to the DR for
incision & ligation of bleeding vessels.
 Analgesics for pain
 Broad spectrum antibiotics to prevent or treat
infection
 Blood transfusion to combat hypovolemia
 Puerperal Sepsis
 “Childbed fever”
 Infection of the genital tract after delivery.
Predisposing factors:
 PROM
 Prolonged labor
 Postpartum hemorrhage
 Anemia
 Malnutrition
 Retained placental fragments
 CS
 Excessive vaginal manipulation
 Sexual intercourse near labor or after membranes have
ruptured
 SSx:
 Fever
 Foul smelling lochia
 Rapid pulse, chills
 Abdominal pain or tenderness
 Body malaise
 Lack of appetite
 Perineal discomfort
 Nausea & vomiting
 Prevention
 Good prenatal nutrition
 Prevention of anemia & hemorrhage
 Good maternal hygiene
 Strict adherence to aseptic technique by
hospital personnel
 Well balanced diet to promote healing –
Increased Vit. C, Chon, adequate calories
 Urinary Tract Infection
 Most common during puerperium because of
trauma to the bladder after delivery, urinary
retention, & overdistention of the bladder due
to anesthesia or infection may be introduced
during catheterization.
SSX:
 Painful urination, frequency & urgency of

urination
 Flank pain
 Fever
 Hematuria
 Management
 Increase fluid intake ( 3,000cc/day) to flush
away infection from the bladder.
 Regular emptying of the bladder to prevent
stasis of urine
 Analgesics for pain, antibiotics for infection
 Collect urine specimen ( clean catch) for
examination
 Mastitis
 Infection of the breast tissue commonly
occurring in breastfeeding mothers.
 Usually appears during the 2nd & 3rd week
postpartum when milk supply is already
established
 Staphylococcus aureus – most common
causative agent found in the oral nasal cavity
of the infant ( acquired from health care
personnel in the nursery or from cracks &
fissures in the nipples)
 Engorgement or swelling of affected breast &
chills are usually the first signs
 Fever, tachycardia,body malaise
 Hard & reddened breast
 Reduced milk supply as edema & engorgement
obstruct milk flow
 Breast abscess – about 10% of women with
mastitis develop breast abscess.
 Management
1. Prevention:
 Prevent nipple cracks & fissures by correct
placement of infant’s mouth on the nipple ( latch-in)
not feeding the baby too long, using correct
technique when releasing the baby from the nipple
after feeding , proper breast care .
 Express excess milk after feeding the baby to prevent
milk stasis which is a good medium for bacterial
growth
 Isolation of infants with cord or skin infections
 Persons with known or suspected
staphylococci infections should not be allowed
to care for newborn in the nursery
 Proper handwashing technique in between
handling of newborns. Observance of strict
aseptic technique.
 Wash hands before and after changing perineal
pads, good personal hygiene on the part of the
mother
2. Comfort Measures:
 Instruct mother to wear supportive brassiere
 Application of heat to the breast to promote comfort
& relieve engorgement
 Discontinue breastfeeding from the affected breast.
Express milk every 4 hours to maintain lactation
 3. Antibiotic therapy to fight infection
 4. If abscess develops, the affected area is
incised & drained.
 Thrombophlebitis / Deep Vein
Thrombosis
 Inflammation in the lining of the blood vessels
with formation of blood clots or thrombi.
Causes:
 Stasis of circulation

 Increased fibrinogen during pregnancy

Types:
1. Femoral Thrombophlebitis: infection of the
veins of the legs ( femoral, saphenous,
popliteal veins)
SSx:
 Homan’s sign- calf pain when the foot is

dorsiflexed
 Milk leg or Phlegmasia alba dolens – leg is

shiny white
 Swelling of affected leg, pain & stiffness

 Fever
2. Pelvic Thrombophlebitis – infection of the
ovarian, uterine and pelvic veins
SSx:
 Fever & chills

 Pain in the lower abdomen or flank

 Palpable parametrial mass in some cases

 Management:
1. Prevention:
> Early ambulation after delivery
> Use of support stocking in women with
varicosities to promote circulation & prevent
stasis – put on stocking before rising from bed
in the morning
2. Bedrest until signs & symptoms disappear
3. Anticoagulant medications to prevent
further clot formation.
 Heparin – not passed to breastmilk
 Protamine Sulfate – antidote of heparin
 Dicumerol – passed to breastmilk so
mother must stop breastfeeding
4. Do not give Aspirin or ASA if patient is
receiving anticoagulant drugs because
aspirin increases coagulation time.
Watch for signs of bleeding: bleeding
gums, ecchymotic skin, increased lochial
discharge.
5. Antibiotic therapy to combat infection,
analgesics for pain.
6. Gradual ambulation after symptoms
disappear
7. Never massage the affected leg
8. Warm wet compress dressings to
promote circulation & for comfort
ALWAYS KNOW YOUR DATE
END
 GOOD LUCK and thank you!
 HOPE YOU REACH YOUR DREAMS OF
BECOMING NURSES!!!!

 From:
 Arlene d. latorre rn man