jeopardizes the health of the mother and/or fetus Malnourished pregnant women - may lead to low birth weight

weight Mothers who are too young, too old and pregnant too frequently Too frequent pregnancies Presence of physical deformity Psychological/mental illness/mental retardation Marginalized because of: Poverty Unemployment Lack of education or low educational achievement Exposure to teratogens due to occupation Victims of abuse or domestic violence, rape, incest Single or separated mother

MEDICAL CONDITIONS AFFECTING PREGNANACY OUTCOME (PREGESTATIONAL CONDITIONS) 1. RHEUMATIC HEART DISEASE In pregnancy there is an increase level of CO, HR, Blood volume; the normal heart is able to adapt to this changes without difficulty but women with cardiac problem has decrease cardiac reserve making it more difficult for the heart to accommodate the high workload of pregnancy. Classifications according to the indivituals ability to perform physical activities: Class I assymptomatic; can work w/o difficulty Class II assymptomatic at rest but symptomatic during ordinary physical activity Class III marked leinitation of physical activity Class IV inability to carry out any physical activity without difficulty/discomfort Class I & II NSD with adequate pain relief Class III & IV use of low forceps with lumbar and epidural anesthesia to reduce stress of pushin CS used only if fetal and maternal indications exist

 Requires invasive cardiac monitoring Should be hospitalized before the onset of labor for cardiac stabilization Clinical Management Echocardiogram Chest X-ray Auscultation of heart sounds Thorough assessment of severity of the cardiac impairment

Drug Therapy Penicillin based antibiotic Heparin treatment (to avoid embolism) Thiazide diuretics/furosemide (to excrete excess fluid in the heart) Digitalis glycosides (a thyroxine to treat arrhythmigs) Notes: Regurgitation: inability of the valve to close completely

Valvular stenosis: inability of the valve to open Lead to increase cardiac workload

Increase risk of developing congestive heart failure (excess fluid in the heart) Nursing Diagnosis: Decreased cardiac output; easy fatigability Impaired gas exchange r/t pulmonary edema secondary to cardiac decompensation Fear r/t the effects of the maternal cardiac condition on fetal well being

Nursing Care: Close monitoring of fetal and maternal VS Position client in semi-fowlers or side lying position Ensures administration of O2 Provides a calm environment Provides emotional support Plan activities together with the client and family Assist client in breastfeeding if not contraindicated with the medications the client take

2. DIABETIS MELLITUS endocrine disorder of CHD metabolism results from inadequate production or use of insulin Risk Factors MSGH Markedly obese Notes: Cardinal signs of DM: a. Polyaria b. Polydipsia c. Polyphagia

History of previous GDM, Dm Glycosuria Strong familia history of DM Influence of Pregnancy on DM DM maybe difficult to control during pregnancy because insulin requirements are changeable 1st trimester need for insulin is frequently decrease Decrease level of hPL (insulin antagonist) Human placental lactogen

 Fetal needs are minimal mother may consume less food because of N/V N/V causes dietary fluctuations and increase the risk of hypoglycemic formerly called insulin shock 2nd trimester increase insulin requirement Insulin requirement mayb e double or quadruple by the end of pregnancy as a result of placental maturation and hPL production Increase energy needs during labor and delivery Abrupt decrease in insulin; after passage of placenta and the resulting loss of hPL in the maternal circulation Diagnostic Exams: OGTT (Oral Glucose Tolerance Test) done at 24-28 weeks (give 50g glucose after 1hour it should have been absorbed already AOG; those with history of DM/GDM should be screend earlier in pregnancy OGCT (oral glucose challenge test) in hypoglycemic patients: give candies or orange juice Goals of Management Maintain a physiologic equilibrium of insulin availability and glucose utilization during pregnancy Ensure an optimally healthy mother and newborn Antepartial Management (GIDE) Diet regulation Glucose monitoring Insulin administration Evaluation of fetal status includes AFP screening at 16-20 weeks AOG; UTZ done at 18weeks AOG then repeated at 28weeks; fetal biophysical profile Daily maternal evaluation of fetal activity begun at 23 weeks Non stress test Flw-up visits are usually 2x/month for the 1st and 2nd trimester, then 1x/week on the 3rd trimester

Intrapartial Management (LT) Timing of Birth Labor management Post partial Management With pre existing DM requires little amount of insulin Mild DM does not require any therapy With DM but didnt have insulin therapy during pregnancy does not require insulin treatment Women should be reassessed 6 weeks after post partum then if she has a normal glucose level, reassessment is done at maximum 3 years interval Nursing Diagnosis Risk for imbalanced nutrition: more than body requirements r/t imbalance between intake and available insulin Risk for injury r/t possible complication secondary to hypoglycemia or hyperglycemia Interrupted family process r/t the need for hospitalization secondary to DM Nursing Care Glucose monitoring Discuss s/sx of hypoglycemia and hyperglycemia Prepare mother for chances of CS birth Encourage involvement of the whole family in are and treatment of the mother and newborn Provide dietary instructions or assist in referral to a dietician

3. SUBSTANCE ABUSE POSSIBLE SIGNS OF SUBSTANCE ABUSE: History: History of vague or unusual medical complaint

Familial history History of childhood physical, sexual, emotional abuse History of cirrhosis, pancreatitis, hepatitis, gastritis History of high-risk sexual behavior History of psychiatric treatement/hospitalization

PHYSICAL SIGNS Dilated or constricted pupils Inflamed nasal mucosa Needle track marks, abscesses Poor nutitional status Slurred speech Staggering gait Odor of alcohol on breath

BEHAVIORAL SIGNS Memory lapse, mood swings, hallucinations Patterns of frequently missed appointments Frequent accidents, fells Signs of depression, agitation, euphoria Suicidal gestures

ALCOHOL CNS depressant, potent teratogen Signs of Alcohol Use Drowsiness Odor of alcohol on breath Slurred speech Staggering gait History of alcoholism

Clinical Management Hospitalization to initiate detoxification COLD TURKEY Regular urine screening done throughout the pregnancy

Nursing Diagnosis: Imbalance nutrition less than body requirements r/t inadequate food intake secondary to substance abuse Risk for ineffective health maintenance r/t lack of information about the impact of substance abuse in the fetus

Nursing Care Provide information regarding the relationship between substance abuse and existing health problem and the implication for the humans unborn child Establish a relationship of trust and support Discuss possible strategies to help mother quit and suggest referral for more in depth assessment bya specialist Prepare mother for labor and delivery Ensure that immediate intensive care is ready for the delivery of the fetus of a mother who used illicit drugs or alcohol during pregnancy

4. HIV/AIDS HIV Human Immunodeficiency Virus Affects specific T cells that decrease the bodys immune response, leading the individual more susceptible to opportunistic infections AIDS Acquired Immunodeficiency Syndrome Positive in HIV with an existing opportunistic injection Risk Factors: IV drug abuse

 Promiscuousity Prostitutes Bisexual partners Mode of transmission Blood Blood products Body fluids 5. RH SENSITIZATION Rh Rhesus RhD (-) doesnt have the D antigen RhD (+) has the D antigen The term Rhesus (Rh) blood group system refers to the 5 main Rhesus antigens (C, c, D, E and e) as well as the many other less frequent Rhesus antigens. The terms Rhesus factor and Rh factore are equivalent and referto the RhD antigen only Rh factor is present on the surface of erythrocytes of a majority of the population Rh sensitization happens when an Rh (-) mother is preagnant with an Rh (+) fetus Assessment of Rh incompatibility History of previous sensitization, abortions, blood transfusions or children who develop jaundice/anemia during newborn period Determine maternal blood type, Rh factor, and do a routing

Rh antibody screening test Identify other complication such as DM, infection, Hypertension

Diagnostic Exam Indirect Coombs test done on the mothers blood to measure the number of Rh (+) antibodies

 Direct Coombs Test done on the infants blood to detect antibodycoated Rh (+) RBCs

Treatment Administration of ThoGAm/RhIG (Rh immune globulin) at 28week AOG If mothers indirect Coombs test is negative, infants direct Coombs test is also negative, RhpGam/RhIG is injected to the mother IM within 72hours Intra-uterine transfusion Nursing Diagnosis Health Seeking Behaviours: Information about Rh immune globulin r/t an expressed need to understand the implications of being Rh negative and pregnant Ineffective individual coping r/t depression secondary to the development of indications of the need for getal exchange transfusion Nursing Care Provide health education regarding the process of Rh sensitization, its implication to her unborn child and administration of RhoGam/RhIG Provide emotional support to the patient and her family Monitor VS o the infant closely

6. ANEMIA Indicates inadequate levels of hemoglobin in the blood during pregnancy CAUSES Insufficient hemoglobin production without nutritional deficiency in iron or folic acid

 Hemoglobin destruction in an inherited disorder as sickle cell anemia

Types: Iron Deficiency Anemia Inadequate iron intake resulting to decrease levels of hemoglobin

Sickle Cell Anemia Recessive autosomal sickle cell anemia and brings vaso-occlusive crisis. Sickling of the RBCs in the presence of decreased oxygenation Folic Acid Deficiency Anemia Most common cause of megablastic anemia. In the absence of FA, mature RBCs fail to divide, becomes emerged and are fewer in number Treatment: Reduce anemia and maintain good health Additional FA supplement Infections are treated promptly because dehydration and fever can trigger sickling and crisis O2 supplementation Intravenous therapy Close monitoring of FHT Encourage increase intake of foods rich in iron and FA GESTATIONAL CONDITIONS AFFECTING PREGNANCY CAUSES OF BLEEDING DURING 1ST TRIMESTER Abortion Ectopic Pregnancy

Abortion The expulsion of the fetus and other products of conception from the uterus before the fetus is viable (age of viability 20 wks AOG, weigh less than 500g Induced abortion occurring as a result of mechanical or artificial interruption Spontaneous abortion (miscarriage) occurring naturally Types of Spontaneous Abortion: Threatened abortion cramping and vaginal bleeding in early pregnancy w/o cervical dilatation Imminent or inevitable theres separation of placenta from the uterine wall, increased vaginal bleeding, cramping with cervical dilatation. Termination cannot be prevented. Incomplete abortion expulsion of only a part of conception (fetus). Bleeding occurs with cervical dilatation Complete abortion complete expulsion of all the products of conception Missed Abortion early fetal intrauterine death without expulsion of the product of conception. Closed cervix, brownish vaginal discharge. May lead to DIC if products of conception are retained beyond 6weeks. Notes: DIC Disseminated intravascular coagulation condition resulting from overstimulation of blood clotting mechanisms in response to disease or injury such as IUD, abruptioplacentae, etc. Habitual Abortion/recurrent pregnancy loss spontaneous abortion of 3 or more consecutive abortion Septic abortion presence of infection Possible causes of Spontaneous Abortion Fetal factors defective embryonic development from abnormal chromosome division, faulty implantation, failure for the endometrium to accept the fertilized ovum. Poor placental perfusion

 Maternal factors infection, severe malnutrition, and abnormality of the reproductive organs, incompetent cervix and endocrine problems Management For imminent hospitalization, IV therapy and blood transfusion, D&C administration of Rho GAm/RhiG within 72 hours For missed hospitalization, D&C if 1st trimester, induced labor if 2nd trimester Nursing Diagnosis Acute pain r/t abdominal cramping secondary to threatened abortion Anticipatory grieving r/t expected loss of unborn child Nursing Care Keep patient in BCR without BRPs Monitor for signs of hypovolemia Assess VS closely Provide emotional/psychological support Assist client in all her needs Administration of pain relievers as ordered

Ectopic Pregnanacy Implantation of the product of conception outside the uterus, such as Fallopian tubes, ovary, cervix or peritoneal cavity Occurs when the fertilized ovum is prevented or slowed in its passage through the tube and thus implants before it reaches the uterus Signs/Symptoms Dizziness and syncope Sharp one-sided abdominal pain and referred shoulder pain Vaginal bleeding Adnexal (areas of the lower abdomen located over eash ovary and fallopian tube) mass and tenderness

Diagnostic Test: Serum pregnancy test Hcg levels normally doubles during 48-72 hours but with ectopic, theres no doubling of the hcg UTZ Culdocentesis/ colpotomy ( incision made into the wall of vagina, usually posterior vaginal wall, close to the cervix) (PETTSCD) Physical exam Risk Factors Endosalpingitis Inflammatory reaction that causes the folds of the tubal mucosa Diverticula Blind pouches that cause tubal abnormality Tumors pressing against the tube Previous surgery, tubal ligation, tubal resection, or adhesions from previous abdominal surgery Transmigration of the ovum from one ovary to the opposite tube resulting in delayed implantation Congenital defect of the fallopian tube STD Management Surgical management Laparoscopic salpingostomy Laparoscopic sapingectomy Non-surgical management Administration of methotrexate if not ruptured Correction of anemia High protein diet Grief counseling Nursing Diagnosis: Acute pain r/t abdominal bleeding secondary to tubal rupture Anticipatory grieving r/t expected loss of unborn child

Nursing Management Ask for the LMP Obtain serum hCG levels as ordered Assess v/s, color of vaginal bleeding, pad count Placed on NPO Assess for signs of hypovolemic shock Administer BT as ordered Assess for the characteristics of pain Provide emotional support for the patient and family

CAUSES OF BLEEDING DURING 2ND TRIMESTER GTD H-MOLE INCOMPETENT CERVIX

Gestational Trophoblastic disease Pathologic proliferation of trophoblastic cells (trophoblast-outer most layer of the embryonic cells)

Hydatiarform mole Is an alteration of early embryonic growth causing placental disruption, rapid proliferation of abnormal cells and destruction of embryo. Trophoblast cells are located in the outer ring of the blastocyst and they begin to deteriorate, they filled with fluids, appearing as grapelike

Causes: Genetics Ovular or hormonal imbalances Nutritional abnormalities (protein and folic acid) Signs/Symptoms Vaginal bleeding (like prune juice due liquefaction of the uterine clot) Uterus larger than expected duration of pregnancy Increased hcg level Abdominal cramping from uterine distention Anemia s/s of pre-eclampsia before 20-24 weeks severe nausea and vomiting (hyperemesis gravidarum) no fetal heart tone, no fetal movement palpated

Diagnostic tests Radioimmunoassay Histological exam UTZ Amniography CBC Prothrombin time Fribrinogen level Hepatic and renal function test

Management Medical management Surgical management Suction curettage Hysterectomy

Nursing Diagnosis Rear r/t possible development of choriocarcinoma Anticipatory grieving r/t the loss of the pregnancy secondary to GTD

Nursing Care Provide emotional support Monitor VS closely and signs of hemorrhage Monitor and alleviate pain Health teachings regarding therapeutic regimen and management Observe the signs of complication Prepare patient for surgery Instruct the pt to report new s/sx promptly (cough, hemoptysis, suspected pregnancy, nausea and vomiting) Explain to the patient that she must use contraceptive to prevent pregnancy for at least 1 year

INCOMPETENT CERVIX/PREMATURE CERVICAL DILATION Premature dilatation of cervix usually in the 4th or 5th month of pregnancy Associated with repeated second-trimester abortions CAUSES Cervical trauma Cervical infection Congenital cervical or uterin anomalies Increased uterine volume (associated with multiple pregnancy)

Signs/Symptoms Painless Pink-stained vaginal discharge Increased pelvic pressure followed by rupture of membrane and discharge of amniotic fluid Management Shirodkar Barter operation (cerciage) Mcdonaid Note: CS may be done NSD may be done also

Nursing Care Monitor for presence of vaginal bleeding or passage of amniotic fluid Instruct mother to elevate buttocks Keep mother in all her needs Provide emotional support

CAUSES OF BLEEDING DURING 3RD TRIMESTER Low implantation of the placenta Types: Low-Lying implantation in the lower portion of the uterus Marginal Implantation placenta edge approaches that of the cervical os Partial Placenta Previa implantation that occludes a portion of the cervical os TOTAL PLACENTA PREVIA Implantation that totally obstructs the cervical os

Risk Factors: Defective vascularization of the deciduas Multiple pregnancy Previous uterine surgery Multiparity Advanced maternal age Large placenta

Signs/Symptoms Painless, bright red vaginal bleeding during the last 3 months of pregnancy Fetal presentation is often unengaged or transverse li

Nursing Diagnosis CBR with or without BRP No vaginal exams Monitor blood loss, pain, uterine contraction Monitor FHT Monitor VS closely Complete laboratory evaluation IV therapy Blood transfusion Prepare patient for CS

Abruptio Placentae Premature separation of a normal implanted placenta after 20 weeks of pregnancy Clinical s/s: 1) Intense, localized uterin pain with or without vaginal bleeding 2) Concealed or extra dark red bleeding 3) Uterus firm to bard like with severe continuous pain. 4) Uterine outline possibly enlarged or changing shape 5) FHT present or absent 6) Fetal presenting part may be engaged Risk Factors 1) Uterine abnormalities 2) Multiparity 3) Pre elampsia 4) Previsou CS 5) Renal or vascular diseases 6) Trauma to the abdomen 7) Previous 3rd trimester bleeding 8) Abnormally large placenta 9) Short umbilical cord Possible Complications DIC Hypofibrogenemia

 Hemorrhagic shock Post partum renal failure Fetal hypoxia Diagnostic Exam UTZ Thorough assessment of blood components and clotting mechanism to determine possible DIC CS is the safest option of delivery IV therapy BT CVP monitoring Nursing Care Assess VS, fht closely Monitor uterine contractions Administer oxytocin as ordered Monitor abdominal girth/fundic height hourly

Premature Rupture of Membrane (PROM) PROM is a spontaneous break or tear of the amniotic sac before the onset of labor Its results in progressive cervical dilation Lead to premature labor or premature delivery Occurs before 37weeks Maternal risk 1) Endometritis 2) Amnionitis 3) Septic shock and death Neonatal Risk: 1) Risk for respiratory distress syndrome 2) Asphyxia 3) Pulmonary hypoplasia 4) Congenital anomalies 5) Malpresentation 6) Cord prolapsed

7) Severe fetal distress that can result in neonatal death Predisposing Factors 1) Lack of proper prenatal care 2) Poor nutrition and hygiene 3) Smoking 4) Incompetent cervix 5) Increased intrauterine tension from hydramnios or multiple gestation 6) Reduced amniotic membrane tensile strength 7) Uterine infection Signs: Blood-tinged amniotic fluid gushed or leak from the vagina Maternal fever Fetal tachycardia Foul smelling vaginal discharge indicate infection

Diagnostic Test: Internal examination Leopoids maneuver Alkaline pH using nitrazine paper (blue) Smear Vaginal UTZ visualization of the tear BPP

Nursing Diagnosis Risk for infection r/t premature rupture of membrane Impaired gas exchange in the fetus r/t compression of the cord secondary cord prolapsed Risk for infeffective individual coping related to unknow outcome of pregnancy Treatments Against infection If AOG above 36wks, induction of labor

 Less than 36 weeks, tocolysis, replacement of fluids and treatment of infection Administer antibiotics (penicillin, cefuroxime and gentamycin) Daily perineal care Bed rest Avoidance of coitus Monitor maternal and fetal well being

PREMATURE LABOR Preterm labor the onset of rhythmic uterin contractions that produce cervical changes after the fetal viability It occurs between 20-37 weeks of gestation Fetal prognosis depends on the birth weight and the length of gestation Causes PROM, gestational HPN, CHVD, hydramnios, multiple pregnancy, placenta previa, incompetent cervix, abdominal surgery, trauma, structural anomalies of the uterus, infection and fetal death Signs Uterine contractions 4 in 20 minutes or 8 in 1 hour Cervical dilatation > 1 cm Cervical effacement of 80% Vaginal spotting Presence of pelvic pressure

Nursing Diagnosis Fear r/t early labor and birth Ineffective individual coping r/t need for constant attention to pregnancy Nursing care/treatment Administer tocolysis as ordered

 Monitor maternal and fetal heart tone/activity closely Monitor contractions Pregnancy Induced Hypertension: Preeclampsia Is a multisystem, vasospastic disease process characterized by hemoconcentration, hypertension, proteinuria and edema

Eclampsia is an extension of pre eclampsia and is characterized by the client experiencing seizure Signs/Symptoms S/Sx of Eclampsia Cerebral edema Seizure/coma BP > 160/110 mmHg Marked proteinuria +3, +4 pr > Extreme edema

Nursing Diagnosis Ineffective tissue perfusion r/t vasoconstriction of blood vessels Fluid volume deficit r/t fluid loss to subcutaneous tissue Risk for fetal injury r/t reduced placental perfusion secondary to vasospasm Social isolation r/t prescribed complete bed rest Nursing Care/Treatment Administer magnesium sulfate as ordered Administer apresoline as ordered Keep patient on CBR with/without BRPs as ordered (encouraged on left lateral position Instruct to avoid intake of salty foods or foods that are high in sodium Provide a non stimulating environment Monitor maternal VS and FHT/fetal activity closely

 Monitor for presence of impending seizure HELLP SYNDROME A variation of PIH named for common symptoms that occur; hemolysis, elevated liver enzymes, low platelets Cause is unknown Occurs in both primigravidas and multigravidas Hemolysis result because the RBCs are damaged by their travel through small, impaired blood vessels Elevated liver enzymes results from obstruction in liver flow by fibrin deposits. Low platelets results for the vascular damage due to vasospasms S/s: RUQ may be tender on palpation Epigastric area, and lower chest pain (distended liver) Nausea Vomiting General malaise Severe edema Management Treatment MgSo4 Transfusion of fresh frozen plasma Delivery of the fetus Bed rest Bleeding precaution Monitor maternal and fetal well being MOST COMMON COMPLICATION: Subcapsular liver hematoma Hyponatremia Renal failure Hypoglycemia

Nursing Care of the High Risk Post-Partal Client Postpartal Infection Puerperal infection affects the reproductive tract It is associated with childbirth and occurs anytime with in 6 weeks postpartum (puer, parere) Postpartal uterine infection: Endometritis or metritis Inflammation of the endometrium 24 36 hours post partum casued by GBS Late onset caused by genital mycoplasmas and Chlamydia trachomatis

S/Sx: Bloody, foul smelling either scanty or profuse vaginal discharge Sawtooth temperature spikes (38.3 40 degree celcius) Tachycardia Chills Four smelling lochia is the classic is the classic sign of metritis but with GBS the lochia may be scanty, serosaguinous, odorless Endomyometritis Endoparametritis Risk Factors: CS Birth Prolonged premature rupture of amniotic membranes (PPROM) Prolonged labor preceding CS birth Multiple vaginal examination Compromised health (low socio-economic status, anemia, obesity, smoking, drugs and alcohol use) Obstetric trauma Lapses in aseptic techinique Instrument assisted childbirth

Pre existing bacterial vaginosis or chlamydial infection Manual removal of the placenta DM Use of scalp electrode or intrauterine pressure catheter Chorioamnionitis

PERITONITIS Infection of the peritoneal cavity which is usually an extension of endometritis Major cause of death from puerperial infection An abscess may form in the cul-de-sac of Douglas, because this is the lowest point at the peritoneal cavity and fravity causes infected material to localize there. Assessment Rigid abdomen (guarding) Abdominal pain High fever Rapid pulse Vomiting Appearance of being acutely ill

Therapeutic Management Insertion of NGT to rest the bowel and prevent vomiting IVF, TPN Analgesics for pain Large doses of antibiotics

Perineal Wound Infection infection of the episotomy, vaginal and cervical laceration. Signs/Sx: Redness Warmth

Edema Purulent drainage Gaping of wound of the previously approximated wound Severe local pain

Treatment Draining of purulent discharge Administration of broad spectrum antibiotics Suture may be removed and left open, if the wound is already free from exudates and his granulation of tissue, the patient may return to the Dr. for secondary closure of wound under local anesthesia Cesarean Wound Infection infection of the incision site Signs/Sx: Erythema Warmth Skin discoloration Edema Tenderness Purulent discharge Gaping of the wound edges wound Abdominal distention Fever

Treatment Drainage of purulent discharge Culture and sensitivity test of the wound discharge Administration of brad spectrum antibiotics Aseptic wound dressing

Nursing care/Treatments IV infusion of brad spectrum antibiotics Isolate patients with signs of infection Analgesic and antipyretics for pain and fever Increased fluid intake

Encouraged patient to void freely and defecate regularly Bed rest High caloric/ high protein/ high fiber diet Encouraged perineal hygiene and change pads frequently

Urinary Tract Infection Symptoms Burning on urination Hematuria Feeling of voiding becomes frequent Painful urination Low grade fever Lower abdominal pain

Cystitis lower urinary tract infection retention of residual urine S/S: Pain or burning sensation during urination Low back pain and suprapubic pain Frequency, urgency, dysuria, and nocturia Fever and chills

Risk Factors Normal post partial dieresis Increased bladder capacity Decreased bladder sensitivity (trauma and stretching) Possible inhibited neural control of the bladder after general and regional anesthesia Insertion of foley catheter Therapeutic Management Antibiotic Therapy Advise client for a good perineal hygiene Increase fluid intake

 Wearing of cotton underwear Empty bladder before going to bed If sexual intercourse resumes, client should empty bladder before and after coitus Urinary retention Occurs as a result of inadequate bladder emptying Associated with the use of anesthesia and forceps Always measure the amount of the first voiding after birth. As a rule, if a voiding is less than 100ml. urinary retention should be suspected Therapeutic management catheterization (indwelling/foley) Nursing diagnosis Risk for infection r/t urinary stasis secondary to overdistention Urinary retention r/t decreased bladder sensitivity and normal post partal delivery Treatments Anti-biotic therapy Assist client in emptying bladder Aseptic technique in catherterization Advise client for a good perineal hygiene Increase fluid intake Wearing of cotton underwear Empty bladder before going to bed If sexual intercourse resumes, client should empty bladder before and after coitus

HEPATITIS Liver disease that may occur from the invasion of the A, B, C, D and E virus Types: Hep A fecal-oral route Incubation period of 2-6 weeks

 Maybe given with prophylactic gamma globulin to prevent the disease after exposure Not known to be transmitted to the fetus Hep B - blood-borne, body fluids Incubation period of 6 weeks 6 months Receives immunoglobulin and HBV vaccine Hep C blood borne, body fluids Symptoms may not be present for 12months after exposure Hep D blood borne, body fluids, rare case in pregnant women Hep E Signs/Symptoms N/V Liver is tender and palpable Dark yellow urine Light colored stools Jaundice Elevated billirubin level Elevated liver enzymes level

Management Bed rest High caloric diet After delivery, infant should be washed well Administration of HBV to the newborn, right after delivery

MASTITIS Infection of the breast

 May occur as early as the 7th postpartal day or not until the baby is weeks or months old Occasionally, the organism that causes mastitis comes from the nasal oral cavity of the infant Staphylococcus aureus infection, candidiasis Prevention of cracked nipples also prevents mastitis Thromboembolic Disease Deep Vein Thrombosis - inflammation of the lining or the blood vessel that occurs in conjunction with clot formation DVT can affect small veins, (saphenous vein) or large veins (iliac, femoral, pelvic and popliteal veins and the vena cava DVT is idiopathic Risk Factors of DVT History of varicose veins Obesity Previous DVT Multiple gestation Increased age (older than 30) Family history of DVT Smoking Cesarean birth Multiparity

Nursing Diagnosis Altered tissue perfisuion r/t obstructed venous return Acute pain r/t tissue hypoxia and edema secondary to vascular obstruction Risk for altered parenting r/t decreased maternal-infant interaction secondary to bed rest and intravenous lines

Pulmunory embolus Obstruction of the pulmonary artery by a blood clot

 Usually occurs as a complication of thrombophlebitis S/S : sudden sharp chest pain, tachypnea, tachycardia, orthopnea and cyanosis Managemen: stat O2 patient is at high risk for cardio-pulmonary arrest, transferred to ICU for strict monitoring

Post-Partal Hemorrhage Blood loss from the uterus greater than 500ml within a 24-hour period Greatest danger of hemorrhage is in the 1st 24 hours because of the grossly denuded and unprotected area left after detachment of the placenta 4 Main Causes: uterine atony, lacerations, retained placental fragments, disseminated intravascular coagulation Uterine Atony Relaxation of the uterus Most frequesnt cause of postpartal hemorrhage Nursing Diagnosis: Deficient fluid volume r/t excessive blood loss after birth Nursing Interventions: 1) Estimate amount of blood loss by counting the number of perineal pads saturated in given lengths of time or by weighing the perineal pads before and after use 2) Palpate fundus at frequent intervals 3) Frequent assessment of lochia and V/S Therapeutic Management 1) Fundal massage 2) Bimanual massage 3) Prostaglandin administration 4) Blood replacement 5) Hysterectomy

Lacerations Occurs most often in the following circumstances With difficult or precipitate birth In primigravidas With birth of a large infant (more than 9lbs) With the use of a lithotomy position and instruments Types: cervical, vaginal, perineal

Perineal Lacerations Ususally occur when woman is delivered from a lithotomy position because this position increases tension on the perineum 4 Categories: 1st degree involves the vaginal mucus membrane, skin of the perineum to the forchette 2nd degree vagina, perineal skin, fascia, levator ani-muscle and perineal body 3rd degree - entire perineum and reach the external sphincter of the rectum 4th degree involve the entire perineum, rectal sphincter and some of the mucus membrane of the rectum. Retained placental fragments Placenta is not delivered in its entirety Every placenta should be inspected; a blood serum sample that contains hCG reveals that part of the placenta is still present Large fragments cause bleeding immediately after birth; small fragments may not be detected until the 6th -10th postpartum day Therapeutic management: D*C; methotrexate

Disseminated intravascular coagulation An acquired disorder of blood clotting in which the fibrinogen level falls below effective limist Occurs when there is such extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that not enough are left in the body for further clotting Usually associated with: 1) Premature separation of the placenta 2) Missed early miscarriage 3) Fetal death in utero Therapeutic management: heparin IV; blood or platelet transfusion, antithrombin III factor, fibrinogen, cryoprecipitate; fresh frozen plasma

Subinvolution Incomplete return of the uterus to its pre-pregnant size and shape May result from a small retained placental fragment, a mild endometritis, or myoma that is interfering with complete contraction Therapeutic management: methergine 0.2mg QID PO to improve uterine tone and complete involution Perineal hematoma Collection of blood in the subcutaneous layer of tissue of the perineum Therapeutic management: 1) Assess the size (cm) 2) Mild analgesic for pain 3) Ice pack 4) Incision under local anesthesia to ligate the bleeding vessel

Post Partum Psychiatric Discorder Postpartum blues baby blues (adjustment reaction with depressed mood) 50% of post partum women experience Usually occur 2 to 5days after birth lasting for few hours 10days or longer Hormonal generated Risk for those mother delivered prematurely and sick infant. Signs & Symptoms/Management Reports feeling overwhelmed Unable to cope Fatique Anxious Irritable Oversensitive Episodic fearfulness often without an identifiable reason Assistance in self and infant care Family support Accept it as a real but with normal adjustment reaction Provide

Postpartum depression 15% of new mothers It interfere in the mother-infant relationship and also interfere with child development and reaction with the child, with the other children, family and friends. Causes unknow Previous history of depression of psychiatric illness Anxiety during pregnancy Teenage pregnancy Multiple births Lack of social support Stressful life situations other than pregnancy Socioeconomic status

 Obstetric complication If untreated: Poor self-care Noncompliance with prenatal/postpartal care Negative effecton maternal-infant bonding High risk of obstetric complication Drug, tobacco, or alcohol abuse Termination of pregnancy Suicide

Signs and symptom: Feeling sad or down Decreased interest in normal activities Appetite problems and weight changes Anxiety and agitation Difficulty in sleeping Fatigue and reduced energy Feeling of guilty or worthless Feeling of suicide or thoughts of harming the infant

Treatment Our patient psycho-therapy Serotonin reuptake inhibitor; paroxetine (Paxil), fluoxetine (proza), and sertraline (Zoloft)

Postpartum psychosis It usually appears within the first 2 to 3 weeks after birth Requires immediate intervention Risk Factors include: Changing hormonal levels Lack of support systems

 Low sense of self esteem Financial difficulties Major life changes Signs and Symptoms Feeling that her baby is dead or defective Hallucinations that may include voices telling her to harm the baby and herself Severe agitation, irritability, or restlessness Poor judgement and confusion Feelings of worthlessness, guilt, isolation, or over concern with the babys health Sleep disturbances Euphoria, hyperactivity, or little concern for self or infant Treatments Requires hospitalization Medication such as antipsychotic and anti-depressants are used Placed on suicide precaution The family should be involved in the patienss treatment plan

Nursing Diagnosis Ineffective individual coping r/t post partum depression Risk for altered parenting r/t post partal mental illness Nursing Care of Clients with General Disturbances in Reproduction and Sexuality INFERTILITY Exists when a pregnancy has not occurred after 1 year of engaging in unprotected coitus In about 30% of couples with ingertility problems, it is the man who is infertile 20% to 25% experience ovulatory failure 20% experience tubal, vaginal, or uttering problems

 In aobut 25%, no known cause can be discovered despite all diagnostic tests PRIMARY INFERTILITY there has been no previous conception SECONDARY INFERTILITY there has been previous viable pregnancy but couple cannot conceive at present STERILITY is the ability to conceive because of a known condition Male Infertility Factors 1) Disturbance in spermatogenesis Sperm count number of sperm in a single ejaculation; normal is 20 million per milliliter or seminal fluid or 50 million per ejaculation Cause of low sperm count Increased body temperature Congenital abnormalities Vericocele Trauma to the testes Surgery near the testes Endocrine imbalance Drug use Excessive alcohol use Environmental factors 2) Obstruction or impaired sperm motility ST L VD ED U Causes: Mumps or orchitis Epdidymitis Gonorrhea Ascending urethral infections Congenital structure of spermatic duct Pressure from enlarged gland on the vas deferens Infections of seminal vesicles

 Anomalies of the penis Extreme obesity 3) Problems in ejaculation or deposition Erectile dysfunction (impotence) considered primary if the man has never been able to achieve erection and ejaculation and secondary if the man has been able to achieve erecton and ejaculation and secondary if the man has been able to achieve ejaculation in the past but now has difficulty Causes: Psychological problems Debilitating disease Medications Premature ejaculation ejaculation before penetration

4) Changes in seminal fluid that prevent sperm motility Obstruction in vas deferens Development of autoimmunity that immobilizes sperm Vasectomy

Female Infertility Factors 1) Anovulation most common cause of infertility in women Genetic abnormality (Tumers syndrome/hypogonadism) Ovarian tumors Chronic or excessive exposure to x-rays General ill health Poor diet Stress Polycystic ovary syndrome ovaries fail to respond to FSH, ovulation takes place only a few time a year

2) Tubal Transport problems Chronic salphingitis/PID (inflammation of the pelvic organs Raptured appendicitis Abdominal surgery 3) Uterine problems Tumors Congenitally deformed uterine cavity Poor secretion of estrogen Endometriosis (implantation of uterine endometrium or nodules that have spread from the interior of the uterus to locations outside the uterus)

4) Cervical Problmes Infection cervical polyps D&C or cervical surgery 5) Vaginal problems Infection Sperm-immobilizing or sperm-agglutinating antibodies in the blood plasma

Fertility assessment Health History General health Nutrition Alcohol, drug, or tobacco use Congenital problems Illness such as mumps, UTI Operations such as surgical repair of hernia Current illness Past occupations Sexual practices

 Secondary sex characteristics Genital abnormalities (in women) Age of menarche, length, regularity, and frequency, amount of flog Menstrual disorders History of contraceptive use History of previous pregnancies and abortion Thorough assessment of breast, thyroid gland, secondary sex characteristics Physical Assessment (Man) Inspect secondary sexual characteristics and genital abnormalities such as: Absence of vas deferens Presence of undescended testes Varicocele Hydrocele (collection of fluid in the tunica vahinalis of the scrotum) (Woman) Breast and thyroid examination Secondary sex characteristics Complete pelvic exam Pap test

Infertility Management A. Assisted Reproductive Technique 1) ARTIFICIAL INSEMINATION Instillation of sperm into the female reproductive tract to aid conception

 Intracervical Intrauterine Cryopreserved sperm frozen sperms which can be stored for years

2) IN VITRO FERTILIZATION/IVF fertilized outside (laboratory) by exposure to sperm One or more mature oocytes are removed from a womans ovary by laparoscopy and fertilized by exposure to sperm under laboratory conditions outside the womans body. 40 hours after fertilization, the ova are inserted into the womans uterus Prior to the procedure, ovulation stimulating agent such as GnRH, clomiphene citrate (Clomid), or human menopausal gonadotropin (Pergonal) is given to the woman 10th day of menstrual cycle, upon confirmation that ovarian follicles are mature, hCG is oocytes are incubated for 8hours. Oocytes and husband or donor fresh semen specimen are mixed and allowed to incubate in a growth medium After fertilization of the zygotes formed almost immediately begin to divide and grow After 40hours, the fertilized egg are examined, and if normal are transferred back to the uterine cavity through the cervix by means of a think catheter Serum pregnancy test can be done after 11days to confirm implantation 3) GAMETE INTRA FALLOPIAN TRANSFER/GIFT (fertilization occurs in the fallopian tube)

 Ova are obtained from ovaries exactly as in IVF but fertilization occurs in the fallopian tube Laparoscopic technique is performed to instill both ova and sperm into the open end of a patient fallopian tube 4) ZYGOTE INTRA FALLOPIAN TRANSFER/ZIFT (fertilization outside the body) Involves oocyte retrieval by transvaginal, UTZ guided aspiration, followed by culture and insemination of the oocytes in the laboratory ZIFT differs from GIFT in that fertilization takes place outside the body 5) SURROGATE EMBRYO TRANSFER Is an assisted reproductive technique for a woman who does not ovulate 6) INTRAVAGINAL CULTURE Following ovulation induction and oocyte retrieval, up to 10 oocytes are placed into a 3ml ture completely filled with culture medium B. ALTERNATIVE SURROGATE CHILDBIRTH 1) Surrogate Mothers A woman who agrees to carry a pregnancy to term for an infertile couple 2) Adoption 3) Child Free Living

SEXUAL DYSFUNCTION ERECTILE DYSFUNCTION Inability to achieve or maintain an erection for sexual intercourse Organic erectile dysfunction Functional erectile dysfunction Assessment Medical, social, sexual history Complete physical examination Duplex Doppler ultrasonography test

Interventions Drug therapy includes sildenafil, vardenafil, tadalafil Avoid alcohol before sexual intercourse Common side effects include headaches, facial flushing, diarrhea Men who take nitrates should not take these drugs in addition

Vacuum Devices/Penis pump A device which may be used just prior to sexual intercourse This works by placing the penis in a vacuum cylinder device. This cylinder fits over the penis and sits firmly against the body. The device helps draw blood into the penis by applying negative pressure A tension ring is applied at the base of the penis to help maintain the erection

Intraurethral Applications Prostaglandin E is a self-administered suppository that is placed in the urethra with an applicator Erection occurs in about 10 minutes and lasts 30 to 60 minutes Burning of the urethra occurs after application

Priapism Uncontrolled and long-maintained erection without sexual desire, causes the penis to become large and painful Can occur from: Thrombosis of veins of corpora cavemosa Leukemia Sickle cell disease Diabetes mellitus Malignancies Abnormal reflex Some drug effects Recreational drugs Prolonged sexual activity Collaborative Manangement Urologic emergency Goal of intervention: To improve the venous drainage of the corpora cavernosa (two chambers in the penis which run the length of the organ and are filled with spongy tissue. Blood flows in and fill the open spaces in the spongy tissue to create an erection) Meperidine Warm enemas Urinary or suprapubic catheterization Large-bore needle or surgical intervention Infections Bacterial Protatitis Prostate inflammation Often occurs with urethritis or an infection of the lower urinary tract S/S: Fever, chills, dysuria, urethral discharge and boggy tender prostate Nonbacterial/Chronic Pelvic Pain Syndrome Can occur after a viral illness or may be associated with sexually transmitted diseases

 Other causes: auto immune, neuromuscular etiologies, allergymediated reactions, psychosexual problems S/S pelvic floor pain without evidence of UTI, dysuria, arthralgia, myalgia, unexplained fatigue, abdominal pain, constant burning pain in t he penis Epididymitis Inflammation of the epididymis resulting from an infection or noninfectious source such as trauma S/S: This condition may be mildly to very painful, and the scrotum may become red, warm and swollen Treatment: bed rest with scrotum elevated on a towel, scrotal support when ambulating, comfort measures; Epididymectomy Orchitis Acute testicular inflammation resulting from trauma or infection ; can also be seen during active mumps particularly in adolescent boys. S/s: ejaculation of blood, hematuria, severe pain, visible swelling of a testicle or testicides and often the inguinal lymph nodes on the affected side Treatment: bed rest with scrotal elevation, application of ice, and administration of