NORMAL LABOR (THEORIES OF LABOR ONSET)

1. Oxytocin Stimulation Theory

2 .Uterine Stretch Theory
3. Progesterone Deprivation Theory
4. Prostaglandin Theory
5. Theory of the Aging Placenta
6 .Fetal Adrenal Response Theory

SIGNS OF LABOR (WRISLIR)

Weight Loss 2-3 pounds (progesterone)
Ripening of the Cervix soft
Increased Braxton Hicks irregular, painless
Show ruptured capillaries + operculum = pinkish color
Lightening the baby dropped
- 2 weeks (primi) and before or during (multi)
Relief of respiratory discomfort
Increased frequency of urination
Leg pains
Muscle spasms
Increased vaginal discharge
Decreased fundal height
Increased Level of Activity large amount of epinephrine (AG)
Rupture of Membranes gush or steady trickle of clear fluid

FALSE LABOR
CANDAC
Contraction disappear with ambulation
Absence of cervical dilation
No DIF (duration, intensity, frequency)
Discomfort @ abdomen
Absence of show
Contraction stops when sedated

TRUE LABOR
CUPPAD
Contraction persists when sedated
Uterine contraction DIF (duration, intensity, frequency)
Progressive cervical dilation
Presence of show
Ambulation increase contractions
Discomfort radiates to lumbosacral area

LENGTH OF LABOR
STAGE OF LABOR
PRIMI (VIRGIN)
MULTI (DIS-VIRGIN)
1ST STAGE
10 12 HOURS
6 8 HOURS
2ND STAGE
30 MINS 2 HOURS
Ave: 50 mins
20 90 MINS
Ave: 20 mins
3RD STAGE
5 20 MINS
5 20 MINS
4TH STAGE
2 4 HOURS
2 4 HOURS

ESSENTIAL FACTORS OF LABOR (5Ps)

1. Passages
2. Power
3. Passenger
4. Person
5. Position

PASSAGES
FUNCTIONS (Sit Sit)
Serves as birthcanal
It proves attachment to muscles, fascia and ligaments
Supports uterus during pregnancy
It provides protection to the organs found within the pelvic cavity
TYPES (GAPA)
Gynecoid normal female type of pelvis
- most ideal for childbirth
- round shape, found in 50% of women
Android male pelvis
- presents the most difficulty during childbirth
- found in 20% of women
Platypelloid flat pelvis, rarest, occurs to 5% of women
Anthropoid apelike pelvis, deepest type of pelvis found in 25% of women
DIVISION OF PELVIS
1. False Pelvis provide and direct
2. True Pelvis the tunnel IPO
Inlet or Pelvic Brim entrance to true pelvis
ANTEROPOSTERIOR DIAMETER DOT
1. Diagonal Conjugate midpoint of sacral promontory to the lower margin of symphysis pubis (12.5 cm)
2. Obstetric Conjugate midpoint of sacral promontory to the midline of symphysis pubis (11 cm)
3. True Conjugate midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)
Pelvic Canal situated between inlet and outlet
- designed to control the speed of descent of the fetal head
Outlet most important diameter of the outlet.
POWERS 3Is
Involuntary not within the control of the parturient
Intermittent alternating contraction and relaxation
Involves discomfort (compression, stretching and hypoxia)
PHASES OF UTERINE CONTRACTIONS
1. Increment/Crescendo ready, get set
2. Acme/Apex go
3. Decrement/Decrescendo stop
INTENSITY - strength of uterine contraction
Mild slightly tensed fundus
Moderate firm fundus
Strong rigid, board like fundus
FREQUENCY rate of uterine contraction
- measured from the beginning of a contraction to the beginning of the next contraction
DURATION length of uterine contraction
- measured from the beginning of a contraction to the end of the same contraction
INTERVAL measured from the end of contraction to the beginning of the next contraction

PASSENGER
HEAD (BOTu)
- Biggest part of the fetal body
- Olways the presenting part
- Turn to present smallest diameter

CRANIAL BONES 1 FOSE, 2 PaTe

1 frontal bone2 parietal bone
1 occipital bone2 temporal bone
1 sphenoid bone
1 ethmoid bone
SUTURE LINES allow skull bones to overlap (molding) and for further brain development (SFC La)
Sagittal Suture between 2 parietal bones
Frontal Suture between 2 frontal bones
 Coronal Suture between frontal and parietal
Lamdiodal Suture between parietal and occipital
FONTANELS intersection of suture lines
Anterior Fontanel or Bregma intersection of SFC
- diamond shaped, closes b/n 12 18 months
- 3 x 4 cm
Posterior Fontanel or Lambda intersection of Sla- triangular shaped, closes b/n 2 3 months
DIAMETERS OF THE FETAL HEAD
AP > T (fetal head)
1.Tranverse Diameters BBB
Biparietal most important TD
- greatest diameter presented to the pelvic inlets AP and at the outlets TD
- average measurement is 9.5 cm
Bitemporal average measurement is 8 cm
Bimastoid average measurement is 7 cm
2. Anteroposterior Diameters SOO
Suboccipitobregmatic smallest APD
- fully flexed (presenting part)
- measured from the inferior aspect of occiput to the anterior fontanel
- average measurement is 9.5 cm
Occipitofrontal head partially extended and presenting part is the anterior fontanel
- average size is 12. 5 cm
Occipitomental head is extended and the presenting part is the face
- measured from the chin to the posterior fontanel
- average size is 13.5 cm
FETAL LIE relationship of the long axis of the fetus to the long axis of the mother
Longitudinal Lie parallel
Transverse Lie right angle/lying crosswise
Oblique Lie slanting
Attitude or Habitus degree of flexion or relationship of the fetal parts to each other.

PRESENTATION AND PRESENTING PART

LIE
PRESENTATION
ATTITUDE
A. Longitudinal Lie
1. Cephalic (head)

2. Breech (butt)

B. Transverse Lie
Causes:
1. relaxed abdominal wall
2. placenta previa

Vertex most ideal

- suboccipitobregmatic is presented (9.5 cm)

Brow occipitomental is presented (13.5 cm)

Sinciput occipitofrontal is presented (12.5 cm)

Face presentation

Chin presentation

Complete breech - feet & legs flexed on the thighs and the thighs are flexed on the abdomen

Frank breech - hips flexed and legs extended (MOST COMMON)

Footling Breech one or both feet are the presenting parts

Shoulder Presentation fetus is lying perpendicular to the long axis of the mother
- vaginal delivery is NOT POSSIBLE

*Compound Presentation when there is prolapsed of the fetal hand alongside the vertex, breech or
shoulder.
Complete flexion

Moderate flexion

Partial flexion (military position)

Extension

Hyperextended

Good flexion

Moderate flexion

Very poor flexion

Flexion
POSITION
LOA (Left Occipitoanterior) most favorable & common fetal position
- fetus in vertex presentation (occiput)
- fetus usually accommodates itself on the left because the placement of the bladder is at the right
LOP/ROP mother will suffer more back pains
FHT Breech: Upper R or L Quadrant (above Umbilicus)
FHT Vertex: Lower R or L Quadrant (below Umbilicus)
STATION - relationship of the presenting part of the fetus to the ischial spine of the mother.
Minus (-) station presenting part is above the ischial spine
Zero (0) station presenting part is at the level of the ischial spine
Positive (+) station presenting part is below the level of the ischial spine
FLOATING head is movable above the pelvic inlet
+1 station fetus is engaged
+2 station fetus is in midpelvis
+4 station perineum is bulging

THE PERSON

FACTORS affecting labor PRC PCP

Perception & meaning of childbirth
Readiness & preparation for childbirth
Coping skills
Past experiences
Cultural & social background
Presence of significant others and support system

STAGES OF LABOR
STAGE 1 DILATATION STAGE
Starts from first true uterine contraction until the cervix is completely effaced and dilated.
Dilatation widening of cervical os to 10 cm
Effacement thinning to 1- 2 cm
CAUSES: 1. Pergusion Reflex
2. Fetal head and intact BOW serves as a wedge to dilate the cervix
Maternal Assessment During Labor
1. PIPIT PEPA HF
2. Check V/S q 4hrs during the first stage
- temp q hour if membranes are already ruptured (risk of infection)
- BP b/n contractions, in left lateral pos, q 15 20 mins after giving anesthesia
- a rapid pulse indicates hemorrhage & dehydration
3. Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the client feels it
Techniques:
1. assess contraction (DIIF)
2. check contraction q 15 30 mins during the first stage
3. refer immediately if:
- duration more than 90 secs
- interval less than 30 secs
- uterus not relaxing completely after each contraction
4. Show slightly blood-tinged mucus discharge
5. Internal Examination to assess status of amniotic fluid, consistency of cervix, effacement/dilatation,
presentation, station and pelvic measurement.
- do it during relaxation
- less IE done once membrane have ruptured
- start with middle finger then index finger
6. Status of Amniotic Fluid (if ruptured)
Danger of cord prolapse if fetal head is not yet engaged.
Danger of serious intrauterine infection if delivery does not occur in 24 hours
NITRAZINE PAPER TEST
- used to assess whether membrane ruptured or not.
Procedure: Insert and Touch
Yellow intact BOW
Blue ruptured
Normal Color of AF clear, colorless to straw colored
Green tinged meconium stain (fetal distress in non breech presentation)
Yellow/Gold hemolytic disease
Gray/Cloudy infection
Pinkish/Red stained bleeding
Brownish/Tea Colored/Coffee Colored fetal death
OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID
Ferning pattern of cervical mucus
(swab dry view)
Nile blue sulfate staining of fetal squammous cells
FETAL ASSESSMENT DURING LABOR FHT Monitoring
Latent Phase every hour
Active Phase every 30 minutes
Second Stage of Labor every 15 minutes
FHT is taken more frequently in high risk cases
Normal FHT Pattern
Baseline rate: 120 160 bpm
Early Deceleration FHT @ contraction, Normal @ end of contraction (head compression)
Acceleration - FHT when fetus moves
Abnormal FHT Pattern
Bradycardia 100 119 bpm moderate
- below 100 bpm marked
CAUSES: 1. fetal hypoxia (analgesia & anesthesia)
2. maternal hypotension
3. prolonged cord compression
MGT: 1. place mother on left side
2. assess for cord prolapse
3. administer oxygen
Tachycardia 161 180 bpm moderate
- above 180 bpm marked
CAUSES:1. maternal fever, dehydration
2. drugs (atrophine, terbutaline, ritodrine, etc.
MGT: 1. D/C oxytocin, position on LLP
2. give 02 at 8 10 lpm
3. prepare for birth if no improvement

Variable Pattern deceleration at unpredictable times of uterine contraction

CAUSE: sign of cord compression
MGT: release pressure on the cord
Sinusoidal Pattern no variability in FHT
CAUSE: hypoxia, fetal anemia & prematurity

CARE OF THE PARTURIENT

1. LATENT PHASE
Cervical Dilation: 0 4 cm
Nature of Contraction: Duration: < 30 secs
Interval: 3 5 mins
Length of Latent Phase:Primis 6 hours
Multis 4 5 hours
Attitude of mother: feel comfortable, walking and sitting at this time
Nsg Responsibilties:TGC
1. Teach breathing techniques
2. Give instructions
3. Conversation is possible (cooperative & focus mother)
2. ACTIVE PHASE
Cervical Dilation: 4 7 cm
Nature of contractions: Duration: 30 50 secs
Intensity: moderate to strong
Length of Active Phase:Primis 3 hours
Multis 2 hours
Attitude of mother:prefer to stay in bed, withdraws from her environment and self focused
Nsg Responsibilities: CPIC
1. Coach woman on breathing and relaxation techniques
2. Prescribed analgesics given during active phase
3. Instruct woman to remain in bed, minimize noise, raise side rails, NPO
4. Check BP 30 mins after giving analgesics (hypotension)
3. TRANSITION PHASE
Cervical Dilatation: 8 10 cm
Nature of Contractions:Duration: 50 60 secs
Interval: 2 -3 mins
Intensity: moderate to strong
Length of Transition Phase:
Primis 1 hour (baby delivered within 10 contractions or 20 mins)
Multis 30 mins (baby delivered within 10 contractions or 20 mins)
Attitude of mother: feel discouraged, ask midwife/nurse repeatedly when labor will end, not in control
of her emotions and sensations, irritated, may not want to be touched
Nsg Responsibilities: RRE
1. Reassure woman that labor is nearing end & baby will be born soon
2. Reinforce breathing and relaxation techniques
3. Encourage fast-blow breathing to remove the urge to bear down
CARE OF THE BLADDER encourage the woman to void q 2 hrs to: DIPC
Delay fetal descent
Increases the discomfort of labor
Predispose to UTI
Can be traumatized during labor
FOODS & FLUIDS NPO on active phase
Clear fluids on latent phase
POSITIONING LLP - best position bcoz J RIPES
Relieves pressure IVC
Improves urinary function
Prevent hypotensive syndrome
Encourage anterior rotation of the fetal head
Squatting is ideal position directs presenting part towards the cervix promoting dilatation
AMBULATION during the latent phase to shorten the first stage, to decrease the need for analgesia,
FHT abnormalities & to promote comfort
NO WALKING IF BOW IS RUPTURED
IV FLUIDS reasons: PLUA
Prevent dehydration/fluid & electrolyte imbalances
Life line for emergencies
Usually required before administration of A/A
Administration of oxytocin after delivery to prevent atony
PERINEAL PREP
Clean & disinfect the external genitalia
Provide better visualization of the perineum
ENEMA emptying the colon of fecal matters to:
Prevent infection
Facilitate descent of fetus
 Stimulate uterine contractions
CONTRAINDICATIONS: NIRVAA
Not given during active phase
If premature labor bcoz of danger of cord prolapse
Rupture of BOW
Vaginal bleeding
Abnormal fetal presentation & position
Abnormal fetal heart rate pattern
SECOND STAGE EXPULSIVE STAGE
MECHANISM OF LABOR: EDFIRE ERE
Engagement
Descent entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet
Flexion the chin of the fetus touches his chest enabling the smallest diameter (suboccipitobregmatic)
to be presented to the pelvis for delivery
Internal Rotation when the head reach the level of the ischial spine, it rotates from transverse
diameter to AP diameter so that its largest diameter is presented to the largest diameter of the outlet.
This movement allows the head to pass through the outlet.
Extension the head of the fetus extend towards the vaginal opening. As the head extend, the chin is
lifted up and then it is born.
External Rotation when the head comes out, the shoulder which enters the pelvis in transverse
position turns to anteroposterior position for it become in line with the anteroposterior diameter of the
outlet & pass through the pelvis.
Expulsion when the head is born, the shoulder & the rest of the body follows without much
difficulties.
Duration of Second Stage: Primis 50 mins
Multis 20 mins
Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high risk cases if not yet
delivered
Transfer to the DR: Primis cervix fully dilated
Multis cervix is 8 cm dilated
Delivery Position
1. Lithotomy used when forcep delivery & episiotomy are to be performed.
2. Dorsal Recumbent head of the bed is 35 45 elevated, knees are flexed & feet flat on bed. This
position facilitates the pushing effort of the mother.
3. Left Lateral Position indicated for woman with heart disease.
ASSISTING THE MOTHER IN THE DR
1. Coach the mother to push effectively
2. Instruct the woman to pant
3. Dorsiflex the affected foot and straigthen the leg until the cramps disappear
4. Perform ironing on vaginal orifice if the presenting part moves towards the outlet
5. When the head is crowning, instruct the mother to pant.
6. Perform Ritgens Maneuver while delivering the fetal head to:
1. Slows down delivery of the head
2. Lets the smallest diameter of the head to be born
3. Facilitates extension of the head
7. Just after delivery, immediately wipe the nose & mouth of secretions then suction.
8. Take note of the exact time of babys birth
9. After the delivery of the baby, place the newborn in dependent position to facilitate drainage of
secretions.
10. Place the infant over the mothers abdomen to help contract the uterus.
11. Clamping the cord:
After the pulsation stops
Clamp the cord twice and cut in between 8 10 inches from umbilicus
After cutting the cord, look for 2 arteries & 1 vein
12. Wrap the infant & bring to the nursery

THIRD STAGE PLACENTAL DELIVERY

METHODS OF PLACENTAL SEPARATION:
1. Schultz Mechanism separation of the placenta starts from the center
- the shiny & smooth fetal side is delivered first
- 80% of placental separation
2. Duncan Mechanism separation begins from the edges of placenta
- the dirty maternal side is delivered first
- 20% of placental separation
MANAGEMENT:
1. Watchful waiting.
a) Do not hurry placental delivery.
b) Rest a hand over the fundus to make sure the uterus remains firm
c) Wait for signs of placental delivery
Calkins sign uterus is firm, globular & rising to the level of umbilicus
Sudden gush of blood from vagina
Lengthening of the cord
2. Manage the uterus to keep it contracted.
3. Administer methergin as prescribed.
4. Never leave the client unattended.
5. Oxygen & emergency equipment made available.

THE FOURTH STAGE PUERPERIUM

MANAGEMENT:
1. Repair of lacerations.
CLASSIFICATION OF PERINEAL LACERATIONS
First Degree fourchette, vaginal mucous membrane, perineal skin
Second Degree fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body
Third Degree fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body & anal
sphincter
Fourth Degree - fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body, anal
sphincter & mucous membrane of rectum
2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from stirrups at
the same time.
3. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours until
stable.
4. Check uterus & bladder q 15 mins.
HYPEREMESIS GRAVIDARUM
Causes:(UTEP)
1. Unknown
2. Thyroid dysfunction
3. Elevated HCG
4. Psychological stress
S/Sx:
1. Excessive N/V persist beyond 12 weeks
2. Signs of dehydration (thirst, dry skin, weight loss, concentrated and scanty urine)
Management:
1. Differential diagnosis (liver & thyroid function studies, urinalysis, Hct/Hgb and WBC)
2. Conservative management
a. dry, low fat, high carbohydrate and bland diet
- dry crackers
- small frequent feedings & sips of water (gastric distention trigger vomiting reflex)
- avoid very hot or very cold food & beverages
b. avoid noxious stimuli
- motion and pressure around the stomach (tight waistbands)
- temporary cessation of iron supplement (gastric upset)
- avoid highly seasoned and spicy foods
- avoid strong odors (perfumes)
- avoid loud noises, bright and blinking lights
c. take vitamin supplement to correct nutritional deficiencies from decreased food intake
d. have enough relaxation & rest
e. take prescribed medications
- Promethazine (Phenergan)
- Prochlorperazine (Compazine)
- Ondansentron (Zofran)
- Droperidol (Inapsine)
- Metoclorpramide (Reglan)
- Diphenhydramine (Benadryl)
- Meclizine (Antivert)
3. Hospitalization (correct dehydration and F&E imbalances)
a. IV fluids (lactated ringers)
b. Vitamin supplementation
c. NPO for 24 48 hours (rest GIT)
d. Oral fluid intake after hydrated and nausea subside
e. when patient begins oral intake of foods:
- administer antiemetics before meals
- see patient is relaxed & comfortable
- introduce food gradually starting with clear liquids
- small frequent feedings
- do not serve odorous, spicy & greasy foods
- do not force patient to eat
4. Parenteral or enteral therapies
5. Complementary therapies
a. acupressure (pericardium 6 or P6)
b. herbal remedy (ginger carminative effect/aroma)
c. vitamin supplementation
6. Provide emotional support
a. show sincere concern for the womens welfare
b. empower patient with knowledge & encouragement
c. provide necessary referrals (counseling)
ABORTION
Definition of Terms:
1. Abortion most common bleeding d/o of early pregnancy (before 20 weeks/fetus weighs 500 grams)
2. Early Abortion before 12 weeks pregnancy.
3. Late Abortion between 12 20 weeks
4. Abortus fetus that is aborted weighing less than 500 grams
5. Occult Pregnancy zygotes that were aborted before pregnancy is diagnosed or recognized
6. Clinical Pregnancy pregnancies that were diagnosed
7. Blighted Ovum small macerated fetus, sometimes there is no fetus, surrounded by a fluid inside an
open sac.
8. Carneous Mole zygote that is surrounded by a capsule of clotted blood
9. Fetus Compressus fetus compressed upon itself and desiccated with dried amniotic fluid
10. Fetus Papyraceous fetus that is so dry that it resembles a parchment
11. Lithopedion a calcified embryo
12. Immature Infant having a birth weight b/n 500 1000 grams
13. Full Term Infant born between 38 42 weeks

Types of Abortion:
1. Elective/Therapeutic Abortion the deliberate termination of pregnancy
a. EA initiated by personal choice
b. TA recommended by the healthcare provider
2. Spontaneous Abortion loss of a fetus due to natural causes
Causes of Spontaneous Abortion:
A. Fetal Causes (80% 90%)
1. Developmental anomalies
2. Chromosomal abnormalities (Trisomy 16)
B. Maternal Causes (congenital/acquired conditions)
1. Advanced maternal age (after 35 years of age)
- <35 y/o (15% miscarriage rate)
- b/n 35 39 y/o (20 25% miscarriage rate)
- b/n 40 42 y/o (about 35% miscarriage rate)
- >42 y/o (about 50% miscarriage rate)
2. Structural abnormalities of the reproductive tract
3. Inadequate progesterone production (corpus luteum/placenta)
4. Maternal infections (rubella virus, cytomegalovirus, listeria infection, toxoplasmosis)
5. Chronic and systemic maternal diseases
6. Exogenous factors (tobacco, alcohol, cocaine, caffeine, radiation)
Complications of Abortion:
1. Hemorrhage
2. Infection or septic abortion
3. Disseminated intravascular coagulation (DIC)
Types of Spontaneous Abortion:
1. Threatened Abortion possible
- (+) bleeding, (-) cervical dilatation
S/Sx:
-Light vaginal bleeding (bright red)
-None to mild uterine cramping
Management:
1. Assess for:
- LMP
- Save all pads for examination
- ask for presence of clots
- abdominal pain
2. Conservative management
- bedrest until 3 days after bleeding has stopped
- no coitus up to 2 weeks after bleeding stopped
3. Educate mothers.
Management:
1. Monitor V/S
2. monitor closely for bleeding or signs of infection
3. regular diet (high in iron foods)
4. rest for a few days to 2 weeks (coitus&douching for approx 2 weeks)
5. may experience intermittent menstrual-like flow and cramps (next menstrual period occurs after 4 5
weeks)
6. Reassure patient that her next pregnancy is likely to last to term if she is young and has no other risk
factors. (no pregnancy for the next 3 months)
7. determine womans Rh factor
8. Advise patient to return if:
- profuse vaginal bleeding
- severe pelvic pain
- temperature greater than 100F
2. Inevitable or Imminent Abortion can not be prevented, (+) complete dilatation
S/Sx:
1. Moderate to profuse bleeding
2. moderate to severe uterine cramping
3. open cervix or dilatation of cervix
4. rupture of membranes
5. no tissue has passed yet
Management:
*Avoiding complications of infection or excessive blood loss
1. Hospitalization
2. D&C
3. Oxytocin after D&C
4. Sympathetic understanding and emotional support
3. Complete Abortion spontaneous expulsion
S/Sx:
1. Vaginal bleeding, abdominal pain and passage of tissue
2. On examination:
- light bleeding or some blood in the vaginal vault
- no tenderness in the cervix, uterus or abdomen
- none to mild uterine cramping
- closed cervix
- empty uterus on utrasound
4. Incomplete Abortion expulsion of some parts and retention of other parts of conceptus in utero
S/Sx:
1. heavy vaginal bleeding
2. severe uterine cramping
3. open cervix
4. passage of tissue
5. ultrasound shows some products of conception
Management:
1. D&C
- uterus must kept contracted after D&C
- inspect fundus frequently
- a danger of D&C (uterine perforation)
2. Monitor blood loss
- inspect perineal pads (60 100ml of blood)
- monitor v/s (BP & PR)
- monitor the blood studies of patients clotting factors
- monitor I & O (Oliguria decrease renal perfusion shock)
3. Sympathetic understanding and emotional support.
- encourage verbalization of feelings
5. Missed Abortion retention after death
S/Sx:
1. Absence of FHT
2. Signs of pregnancy disappear
- uterus fails to enlarge
- no FHT
- serum or urine test for the subunit of HCG is negative
- ultrasound showing no cardiac activity
Management:
1. Product of conception be removed to prevent DIC
2. Insert 20mg Dinoprostone (Prostaglandin E) suppository into the vagina q 3 or 4 hours PRN (<28
weeks gestation)
3. Oxytocin IV infusion (late missed abortion)

6. Habitual Abortion repeated 3 or more

Causes:
1. incompetent cervix
2. IUGR
3. congenital, genetic & chromosomal abnormalities
Management:
1. Treating the cause
2. Specific treatment according to cause:
a. Cervical Cerclage (modified Shirodkar, Mc Donalds) suturing the cervix
b. Fertility drugs (Clomiphene, Pergonal, etc.)
c. Aspirin or Mini Heparin
d. Luteal Phase Progesterone Support
e. correction of defects
f. treatment of medical illness
7. Infected Abortion infection @ POC & MRO

8. Septic Abortion dissemination of bacteria in maternal circulatory and organ system

Causative Organisms:
1. E. Coli
2. Enterobacter Aerogenes
3. Proteus Vulgaris
4. Hemolytic Streptococci
5. Staphylococci
S/Sx:
1. foul smelling vaginal discharges
2. uterine cramping
3. fever, chills and peritonitis
4. leukocytosis WBC count 16, 000 22,000/uL
5. critically ill patients
Management:
1. Treat abortion
2. high dose IV antibiotic therapy (Penicillin gram negative, Clindamycin/Tobramycin gram positive)
3. D&C if accompanied by incomplete abortion
4. Infertility may occur

ECTOPIC PREGNANCY
Causes:
1. Mechanical Factors delay passage of ovum
- salphingitis
- peritubal adhesions
- developmental abnormalities
- previous ectopic pregnancy
- tumors that distort the tube
- past induced abortions
2. Functional Factors
- external migrations of the ovum
- menstrual reflux
- altered tubal motility
3. Assisted Reproduction
- ovulation induction(Clomid)
- gamete intrafallopian transfer
- in vitro fertilization
- ovum transfer
4. Failed contraception
Types of Ectopic Pregnancy:
1. Tubal - >95%
a. Ampulla (most common site, 55%)
b. Isthmic (25%)
c. Fimbrial (17%)
d. Interstitial (2%)
e. Bilateral (very rare)
2. Ovarian (cystectomy/oophorectomy, 0.5%)
3. Abdominal (1/15,000 pregnancies)
a. Primary original implantation outside the tube
b. Secondary implantation in the abdomen after rupture and expulsion
4. Cervical (due to in vitro fertilization and embryo transfer
5. Heterotypic Pregnancy (TP accompanied by intrauterine pregnancy)
6. Tubo Uterine ( partly implanted in the tube and uterus)
7. Tubo Abdominal ( fimbriated implantation extends into the peritoneal cavity
8. Tubo Ovarian (partly implanted in the tub and partly in the ovary)
S/Sx:
1. missed menstrual period of two weeks duration (68%)
2. unilateral lower abdominal pain (99%)
3. irregular vaginal bleeding (75%)
4. Before rupture
- brief amenorrhea
- pelvic and abdominal pain on the side of the affected tube
- Arias Stella Reaction
5. Ruptured ectopic pregnancy:
a. pain
- sudden severe and knife like pain
- radiating to the neck and shoulder
- cervical pain during IE
b. spotting or bleeding darkbrown
c. Cullens Sign or bluish discoloration of the umbilicus due to the presence of blood in the peritoneal
cavity
d. Hard or boardlike abdomen
e. Signs of shock
6. Diagnosis
a. Transvaginal Utrasound (TVUS)
TVUS + serial HCG det. = most reliable
b. Serial HCG
c. Pregnancy Test
d. Culdocentesis
e. Serum Progesterone Level
>25ng/ml normal viable pregnancy
<5ng/ml nonviable pregnancy
f. Uterine Curettage
g. Colpotomy
h. Laparoscopy
i. CBC
j. Elevated WBC

Management:
1. Therapeutic Abortion unruptured EP
a. Methotrexate Therapy
2. Surgical removal ruptured EP
Nursing Interventions:
1. Prevent and treat hemorrhage
- IVF to prevent shock
- type & cross match blood
- place flat in bed with legs elevated
- provide extra blanket to keep warm
2. Assist in positioning the patient
3. Post op interventions:
- monitor v/s
- assistance with positioning & ambulation
- monitor IV fluids therapy
- If patient is Rh-negative, RhoGAM is given within 72 hours and before discharge
- provide contraceptive counseling
4. Meet emotional needs of patient
5. Prevention
- safe sex practices
- importance of gynecological exams
- S/Sx of STDs
- possible risks associated with the use of an IUD

HYDATIDIFORM MOLE
- benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo.

Types:
1. Complete Molar Pregnancy only placental parts, no embryo
2. Partial Molar Pregnancy 2 fathers, 1 mother
- placenta and fetus formed but incomplete
Risk Factors/Incidence:
1. Geography
2. High in women below 18 and above 40 years old
3. High in low socioeconomic status (low protein intake)
4. History of molar pregnancy
S/Sx:
1. Excessive N/V due to elevated HCG levels
2. Bleeding from spotting to profuse (brown bleeding)
3. Passage of grape like vesicles around the 4th month
4. Rapid increase in uterine size (out of proportion)
5. Signs of preeclampsia before 24 weeks (HEP)
6. Absence of FHT and fetal skeleton
7. Ultrasound (mass of fluid filled vesicles snowflake pattern)
8. Elevated plasma thyroxine levels
9. Elevated serum gonadotropin level (>100 days)
Management:
1. D&C
2. Methotrexate (Choriocarcinoma)
3. HCG monitoring for 1 year
- HCG should be negative 2-8 weeks after removal of mole (every 2 weeks)
- monthly for 6 months
- every 2 months for another 6 months
- chest x-ray every 3 months for 6 months
4. Woman advised not to be pregnant for one year
- contraceptives should not contain estrogen
5. Hysterectomy
- above 40 years old
- who have completed child bearing
- who desire or require sterilization
Complications of H Mole:
1. Gestational Trophoblastic Tumors trophoblastic proliferation
a. Choriocarcinoma most severe complication
- conversion of chorionic villi into cancer cells that erode blood vessels and uterine muscles.
- lungs
b. Invasive Mole developed during the first 6 months
- excessive formation of trophoblastic villi that penetrates the myometrium
c. Placental Site Trophoblastic Tumor composes of cytotrophoblastic cells arising from the site of the
placenta.
- produce both prolactin and HCG
- main symptom is bleeding

**Management of all trophoblastic tumors is HYSTERECTOMY

INCOMPETENT CERVIX
Diagnosis:
1. Pelvic examination or IE
2. Ultrasonography (cervical os is >2.5cm or length is shortened to <20mm)
- funneling

Predisposing Factors/Causes:
1. DES exposure in utero
2. Cervical trauma from previous difficult deliveries (forcep deliveries)
3. Hormonal influences
4. Congenitally short cervix
5. Forced D&C
6. Uterine anomalies
S/Sx:
1. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)
2. Rupture of membranes and passage of amniotic fluid
Management:
1. Cervical cerclage @ 14 weeks (earlier the better)
2. Prerequisites of cervical cerclage:
cervix not dilated beyond 3 cm
- intact membranes
- no vaginal bleeding and uterine cramping
3. Types of cervical cerclage:
Shirodkar Suture permanent suture
Mc Donald Suture temporary suture
- 38 39 weeks removal of suture
4. After suturing the cervix:
- place woman on bedrest for 24 hours several days
- observe for bleeding, contraction and rupture
- report passage of fluid or signs of PROM
- if uterine contracts, RITODRINE may be given
- restrict activities after application for the next 2 weeks including coitus

ABRUPTIO PLACENTA
- ablation placenta, placental abruption & accidental hemorrhage
Causes:
1. Maternal hypertension
2. Advanced maternal age (>35y/o)
3. Trauma to the uterus
4. Rapid decompression of an over-distended uterus
5. Grand multiparity (thinning of endometrium)
6. Short umbilical cord
7. Uterine leiomyoma or fibroids
8. Behavioral factors:
- cigarette smoking, methamphetamine and cocaine abuse
- maternal alcohol consumption (14 or more drinks)

Types of Abruptio Placenta:

A. Classification According to Placental Separation
1. Covert/Central AP bleeding is internal and not obvious
2. Overt/Marginal AP bleeding is external
B. Classification According to Signs and Symptoms
1. Grade 0 no symptoms
2. Grade 1 some external bleeding, uterine tetany and tenderness, absence of fetal distress and shock
3. Grade 2 external bleeding, uterine tetany, uterine tenderness and fetal distress
4. Grade 3 internal bleeding and external bleeding (>1000ccc), uterine tetany, maternal shock,
probably fetal death and DIC
Classification According to Extent of Separation
1. Mild <1/6 of the placenta is separated
- bleeding may or may not be present (<250cc)
- uterine irritability with no fetal distress
- some uterine tenderness and vague backache

2. Moderate approx 1/6 2/3 of placenta

- dark vaginal bleeding may or may not be present (<1000ml)
- uterine tenderness and tetany is present
- fetal distress d/t uteroplacental insufficiency

3. Severe - >2/3 of the placenta

- uterine tenderness and rigidity along with severe pain
- dark vaginal bleeding (>1000cc)
- fetal distress if not delivered fetal death is imminent
- entire placental separation (maternal shock, fetal death, severe pain and possible DIC
S/Sx:
1. Vaginal bleeding occurs in 80% of women
Dark red vaginal bleeding (CAP)
Bright red vaginal bleeding (OAP)
2. Abdominal pain
Uterine irritability and low back pain (2/3 of patient)
Complain labor-like pains (mild AP)
Gradual or abrupt pain (moderate AP)
Sudden and knife-sharp pain, localized and diffused over the abdomen (severe AP)
Sharp pain over the fundus placental separates
Escalating abdominal pain concealed bleed
3. Board like abdomen accumulation of blood behind the placenta with fetal parts hard to palpate.
4. Signs of shock and fetal distress if bleeding are severe.
Management:
1. Hospitalization is a must
2. If fetus is below 36 weeks
a. manage @ prolonging pregnancy with the hope of improving fetal maturity if:
- bleeding is not life threatening
- FHT are normal
- mother is not in active labor
b. manage bleeding episode
- place in bedrest (sidelying position)
- IFC to accurately record I&O (at least 30cc/hr)
- NPO status
- oxygen therapy (NC @ 4 6 lpm)
- observe & record bleeding q 30 mins or more (saturated perineal pad can absorb approx 60 100ml of
blood)
- assess status of abdomen
- mark fundus of the uterus (concealed bleeding)
- monitor V/S
- assess uterine contractions
- blood typing and cross matching
- administer IVF (LRS 125cc/hr)
- monitor fetal condition by daily nonstress test and kick counts
- administer prescribed medications
Bethametasone (hasten fetal maturity)
Tocolytic therapy (MgSO4, Ritodrine or Terbutaline)
- observe for signs of DIC
Assess bleeding
clot test
Coagulation studies (fibrinogen level, prothrombin time (PT), partial prothrombin time (PTT), CBC,
anticoagulant factor and electrolytes)
- delivery
CS distressed fetus or uncontrolled bleeding (30 minutes)
VD fetus is dead, maternal bleeding is mild and if the mother is in stable condition
- postpartum (WOF couvelaire uterus)

PLACENTA PREVIA
Types of Placenta Previa:
1. Complete/Total PP covers the internal os
2. Partial PP partially covers the internal os
3. Marginal PP edge of the placenta is lying at the margin of the internal os
4. Low Lying PP implants near the internal os with its margin located about 2cm 5 cm from the
internal os
Frequency:
1. approx 3.5 8 pregnancies per 1000 after 20 wks AOG
2. Maternal mortality assoc. with PP is <1%
3. Maternal morbidity is about 5%
Predisposing Factors/Causes:
1. Unknown
2. Decreased blood supply or scarring @ upper segment
- multiparity
- previous molar pregnancy
- endometritis
- age (above 35 y/o)
-previous CS
- abortion
- repeated D&C
3. Decreased blood supply to the endometrial lining
4. Short umbilical cord
5. Abnormal placentas (placenta increta and accreta)
6. Large placenta

Complications:
1. Hemorrhage
2. Infection
3. Prematurity
4. Obstruction of birth canal
5. DIC
6. Abnormal adhesion of placenta
7. Renal failure may occur r/t shock caused from hemorrhage or DIC
8. Anemia
9. More lacerations
10. Fetal effects/neonatal effects
11. Brain damage or neurological abnormalities

**Ultrasonography best way to differentiate AP from PP

S/Sx:
1. Sudden painless vaginal bleeding (24 30 weeks)
2. Bright red bleeding occurs in gushes and is rarely continuous (usually @ night with the patient
awakening and finding herself lying in a pool of blood)
3. Fetus assumed transverse position, no engagement
4. Decreased urinary output
**Ultrasound is the earliest and safest diagnostic tool for PP
Management:
1. IE by MD only under double set up (done in the OR patient is prepped and draped)
Double Setup is Indicated When:
1. ultrasound is not available
2. the ultrasound evidence is inconclusive
3. patient with ongoing but not life-threatening vaginal bleeding in labor
4. mother has a marginal previa and is well-established labor
2. Assess extent of blood loss
visual estimates (most often used but the most inaccurate)
Vital signs
Tilt Test (woman bleeds profusely but has normal blood pressure and pulse in recumbent position will
develop hypotension and tachycardia when placed in sitting position)
Urine flow
3. If pregnancy is below 36 weeks
Watchful waiting/expectant management/conservative management
Nursing Interventions:
a) Monitor:
FHT and activity
Vaginal bleeding
Uterine contractions
Maternal V/S
Maternal I&O
b) Woman in CBR (if no bleeding after 48 hours, mother is allowed bathroom privileges)
c) Manage bleeding episodes
Keep woman on NPO
Monitor V/S, FHR, vaginal bleeding
Maintain on absolute bedrest
Start fluid replacement therapy and blood transfusion
d) If woman is in active labor, tocolytics may be given.
e) Betamethasone (Celestone)is given to hasten fetal lung maturity (12mg IM q 12 hrs for 2 doses)
f) Amniocentesis (lung maturity)

4. Outpatient management
a. live close to the hospital (within 5 10 minutes) and 24 hours transportation availability and close
supervision by family or friends @ home
b. restricted activities @ home
- bed rest most part of the day
- heavy lifting is strictly prohibited
- no vacuuming or standing for long periods of time
- sexual arousal, intercourse or orgasm should be avoided
- avoid enema and douche
- stop working or employment
- provide diversional activities
5. Inform patient and family to be observant
- bleeding, contraction & decreased fetal activity

6. Diet
- foods high in iron
- prenatal vitamins (Iron + Vitamin C)
- increase fiber intake
7. Clinic visit is usually once or twice a week
- ultrasound tests (2-4 weeks interval)
- regular NST
- biophysical profile
8. Labor and delivery
a. delivery is implemented when:
- fetus is mature
- persistent hemorrhage
- intrauterine infection
- rupture of membranes
- persistent uterine contractions unresponsive to tocolysis
- mother develops coagulation defects (DIC)
b. method of delivery
CS delivery of choice (profuse maternal hemorrhage and fetal hypoxia)
VD for marginal/partial previa
c. Nursing Care:
Anticipate doctor orders for:
Ultrasound
IVF (LRS, gauge needle #16 or #18)
CBC, blood type and cross match for at least 2 units of whole blood, DIC panel, PTT, PT and
electrolytes. H/H may order every 12 hours.
In case of profuse bleeding:
CBR s BRP, quiet environment (+ bleeding)
Keep on NPO
Administer O2 tight mask @ 6lpm
Do not perform enemas
Discourage bearing down
Position
Semi Fowlers Position
Trendelenburg Position
Examinations & Monitoring
No IE
Place mother on continuous fetal monitoring
Monitor vaginal bleeding q 15 minutes then 30 minutes after bleeding stopped
V/S q 15 minutes then 30 mins if stable and bleeding subsides
Assess I&O
Observe signs of DIC
Observe for shock
Post partum nursing care:
WOF hemorrhage
Oxytocin, gentle massage and close monitoring
Surgical management such as ligation of the hypogastric arteries (internal iliac) or hysterectomy
Puerperal infection
Observe elevation of temp above 39C or 100.4F
Low grade fever during 24 hours (dehydration)
Aseptic technique and handwashing
Teach proper perineal care and good handwashing technique
Front-to-back motion when applying perineal pads
Reinforce aseptic techniques during bathroom usage
 Anemia
Moderate to severe anemia d/t amount of blood lost
Normal hemoglobin 12 13 g/dl
Moderate anemia 9 11 g/dl
Severe anemia below 9 g/dl

PREGNANCY INDUCED HYPERTENSION (PIH)

- anytime after the 24th week gestation 2 weeks postpartum
TRIAD SYMPTOMS:
- hypertension (2 successive BP of 140/90 and above taken 4 - 6 hours apart)
- edema (upper part of the body hands and face)
- proteinuria
*specifically albuminuria
- albumin (water soluble protein)
Predisposing Factors:
1. Age (<20y/o & >35y/o)
2. Gravida 5 or more pregnancies
3. Low socio-economic status
4. Extra large fetus
5. Familial tendency
2 Types:
1. Preeclampsia 140/90, develops after 20 weeks gestation accompanied by proteinuria
(300mg/24hrs) and edema.
2. Eclampsia all S and Sx of preeclampsia accompanied by convulsion or coma that is not caused by
other conditions.
Causes:
1. Unknown
2. Genetic predisposition
3. Autoimmune reaction and an immune reaction to paternally derived antigens
4. Protein deficiency theory and dietary deficiencies
5. Endothelin theory

PREECLAMPSIA
EFFECT
The amount of circulating plasma volume falls
Rise in hemoglobin and hematocrit
Decreased blood supply to kidney and hemoconcentration stimulates release of aldosterone, ADH and
angiotensin
Sodium retention leading to edema (hypernatremia)
Vasospasm and hypertension
Vasospasm cause damage to the endothelium promotes coagulation and increase sensitivity to pressor
agents.
Elevated platelets
Patients renal perfusion is affected. Decreased blood supply to kidneys resulting in decreased GFR.
Efficiency of the kidney to remove metabolic waste is impaired. Decreased renal perfusion results in
damage to kidney structures allowing passage of large molecules
Serum levels of BUN, creatinine and uric acid rise leading to acidosis and decreased urine output.

Proteinuria
Vasospasms decreases blood supply to the brain resulting in cerebral ischemia
Hyperreflexia
Convulsions
Decreased blood supply to the uterus and placenta
IUGR
Fetal hypoxia and distress
Continuous vasospasm cause diminished blood supply resulting in damage to blood vessels and tissues
in the placenta and decidua
Abruptio Placenta

Signs/Symptoms
Mild Preeclampsia
Severe Preeclampsia
Blood Pressure
140/90, diastolic BP is more than 100mmHg
Diastolic is 110mmHg or higher
Proteinuria
+1 - +2 by dipsticks
300mg/24 hour urine collection
+2 - +4
5g/24 hour urine collection
Liver enzymes
Slightly elevated
Markedly elevated
Laboratory studies
Normal hematocrit, uric acid, creatinine
Increased Hct, Crea and UA; thrombocytopenia may be present
Fetus
No IUGR
IUGR present
Edema
Digital edema, dependent edema
Pitting edema (4+)
Generalized edema
Weight Gain
1 2 lb/week
More rapid weight gain
Urinary Output
Not less than 400ml/24 hours
Less than 400 ml/24 hours
Cerebral Disturbances
Occasional headache
Severe frontal headache, photophobia, blurring, spots before the eyes (scomata), n/v
Reflexes
Normal to 3+
Hyperreflexia, 4+
Epigastric Pain
Absent
RUQ pain (aura to convulsion) d/t swelling of hepatic capsule

S/Sx of Eclampsia:
1. All the S/Sx of preeclampsia
2. Convulsion followed by coma
3. Oliguria
4. Pulmonary edema

Management:
1. Roll Over Test (increase of 20mmHg or greater diastolic pressure)
2. Tolerance Hyperbaric Test (portable BP cuff 48 hours)
Ambulatory Management:
1. Home management is allowed only if:
BP is 140/90 or below
Low proteinuria
No fetal growth retardation and good fetal movement
2. Bed rest (when lying down, assume LLP)
3. Consult every two weeks
4. Home management also include phone calls and home visits by the N M
5. Diet: high in protein and carbohydrates with moderate sodium restriction
6. Hospitalization is necessary if condition worsens
7. Provide detailed instructions about:
a. Dietary modifications
High in protein
Moderate sodium restriction
Eat a balanced diet that include 1200mg calcium
Avoid salty foods, such as canned foods, soda, chips and pickles
Eat foods with roughage
Drink 8 10 glasses of water daily
 Avoid alcohol
Take daily weight measurement
Measure and record fluid intake and urine output

b. Monitor her own health condition and report to health care provider immediately if the following
occur:
Take and record her BP twice daily
Count fetal movements per hour (3/h)
Take and record weight daily
Report for increased BP, epigastric pain and visual disturbances
Weight gain more than 1 lb a week
Abnormal fetal movement and abdominal pain

Hospital Management:
a. Hospitalization is necessary if:
BP is equal or greater than 160/100mmHg
Proteinuria of 3+ or 4+
Rapid weight gain
Oliguria
Visual disturbances
Abnormal fetal movement

b. Expectant management
Treatment with Bethamethasone (2 doses)
c. Fluid therapy
Crystalloid infusion (LRS & NSS, 100ml/hr 125ml/hr)
Close monitoring
d. Medications
Magnesium Sulfate
Prevent convulsion and seizures
Reduce edema
Reduce BP
Nursing Considerations:
Loading dose: 4gm over 20 mins, followed by 2 3gm/hr (ACOG)
Check the ff before giving:
RR above 14cpm
UO at least 100ml/4hr
DTR are present (loss of DTR first sign of toxicity/hypermagnesemia)
Serum magnesium levels are evaluated periodically
7 8 mg/dL (therapeutic level)
10 - 12 mg/dL (developing toxicity)
*If MST develops (1gm (10ml) 10% Calcium Gluconate)
Antihypertensives
Hydralazine (Apresoline)
ID: 5mg IV bolus
RD: 5mg 10mg q 20 mins if diastole is above 110mmHg
Labetolol (Normodyne) 20mg IV q 10 mins to max of 300mg
Safety measures
Raise padded side rails
Put bed at lowest position
Have emergency equipments available
Care of the woman during convulsion
Stages of Convulsion:
1. Stage of Invasion or Aura facial twitching, rolling of the eyes to one side, staring fixedly in space,
sudden severe headache, screaming and epigastric pain
2. Tonic Phase rigid body, eyes protrude, arms are flexed with legs inverted, hands are clenched,
woman stop breathing lasts for 15 20 seconds.
3. Clonic Phase jaws and eyelids close and open violently, foaming of the mouth, face becomes
congested and purple, muscles of the body contract and relaxes alternately last for about 1 minute.
4. Postictal State contractions cease and woman enters a semicomatose state.
Nursing Responsibilities:
Always monitor patient for impending signs of convulsions
Two main resp: maintenance of patient airway and protection of patient from self injury
Turn patient on her side to allow drainage of secretions
Never leave an eclamptic patient alone
Do not restrict movement during a convulsion as this could result in fractures
After convulsion:
WOF signs of AP, vaginal bleeding, abdominal pain, FHT
Take v/s
Suction nasopharyngeal secretions and administer oxygen
Sedatives, Diazepam (Valium) if MgSO4 can not control convulsion
Do not give anything by mouth unless conscious

HEMOLYTIC DISEASE
Incidence:
About 10% of women are risk for Rh isoimmunization
1:1000 births incidence of Rh-related neonatal morbidity
ABO Incompatibility:
Occurs when maternal blood type is O and fetus is:
Type A most common
Type B most serious
Type AB rare
Maternal antibodies attack the fetal RBC and destroy it
 Happens during placental separation
Rh Incompatibility:
1. Rh Factor
Rh factor is a distinct protein antigen found in the covering of RBC
85% Rh positive and 15% Rh negative
If person has the genes ++, the Rh factor is positive
If person has the genes +-, the Rh factor is positive
If person has the gene - - , the Rh factor is negative
Rh Sensitization/Isoimmunization:
Exposure of Rh negative blood to an Rh positive blood
Occurs during placental separation (0.5 ml fetal Rh positive blood can produce massive production of
antibodies during the first 72 hours of life)
Erythroblastosis Fetalis during pregnancy and Hemolytic Disease after delivery.
Anemia
Splenomegaly and hepatomegaly
Hyperbilirubinemia
Hydrops fetalis
Stillbirth
Prevention:
1. Prenatal screening
a. History
b. Screening test
Antibody Titer Test (Coombs Test)
Indirect Coombs Test maternal serum
Direct Coombs Test fetal cord blood
Antibody titer is negative:
Repeat: 16 20 weeks and 26 27 weeks of pregnancy
Anti-Rho(D) Gamma Globulin (RhoGRAM) @ 28 weeks and within 72 hours after delivery
Rho(D) Gamma Globulin be given to all Rh(-) women who:
Delivered Rh positive fetus
Untypeable pregnancies
Received ABO compatible Rh positive blood
Have invasive diagnostic procedure (amniocentesis)
S/Sx:
1. No signs and symptoms unless the baby dies in the utero and is not born right away.

Management:
1. Fetal surveillance (mothers antibody titer test (+) >1:16 )
2. Intrauterine Blood Fetal Transfusion (IUFT)
Blood transfusion to the fetus either intraperitoneal or intravascular
3. Labor and delivery
Do not remove placenta manually to avoid squeezing fetal cells
 Clamp cord immediately after birth
Kleihauer Betke Blood Test