National Health Situation

Maternal & Child Health

Prepared by:
Rhenier S. Ilado RN
 GOAL
 Improve the survival, health and well
being of mothers and the unborn
through a package of services for the:
 pre-pregnancy
 prenatal
 natal
 postnatal stages
 2a.2
Where are we now?

Population of over 80 million will double in 30

years at current growth rate of 2.36%

Rice production in 2002 grew by an average of

only 1.9% -- more hungry people competing for a
decreasing volume of rice
2a.3
Where are we now?
The lack of family planning  It is the poorest Filipinos
places a disproportionate (57.1%) who are not using
burden on the poor. family planning because of
poor access and ineffective
outreach
 20.5% of married women say
they need family planning but
are not using any method
 The Philippine Situation
 3.1 million pregnancies occur each year. Half of these pregnancies are
unintended and one third ends in abortion
 About 473,000 abortions annually with induced abortion as 4th

leading cause of maternal deaths

 10 mothers die everyday due to childbirth and pregnancy related

complications

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

Note: To show progress of MMR based on MDG, UNFPA estimated MMR based on the
average rate of progress in 2003.
 Health Indicators
Selected Asian Countries
Japan So.Korea Malaysia Thailand Philippines

Life Expectancy 81 75 73 70 70

Infant Mort. 3 5 8 24 29
Rate

Underfivemortal 5 5 8 28 40
ity

Maternal 8 20 41 44 160
Mortality

Population 0.3 0.8 2.2 1.4 2.3

Growth
 70 % of births were delivered
in the home

Hospital
27%

Home
Others 70%
3%
 Only 60 % of births were attended by a
health care professional

Nurse
1%

Doctor
33% Midwife
26%

Traditional Birth
Attendant
others
39%
1%

Source: MCHS-PNSO, Philippines 2002

 Why do women die?
 Complications related to pregnancy occurring in the course
of labor, delivery and puerperium.( obstructed labor,
infection)
 Hypertension complicating pregnancy, childbirth, and
puerperium( eclampsia etc.)
 Postpartum Hemorrhage due to uterine atony, placental
retention
 Pregnancy with abortive outcome
 Hemorrhage related to pregnancy ( ectopic pregnancy,
placenta previa etc.)
7 Direct Obstetric Complications
 Hemorrhage (antepartum / postpartum)
 Prolonged / Obstructed labor
 Postpartum sepsis
 Complications of abortion
 Pre-eclampsia / Eclampsia
 Ectopic pregnancy
 Ruptured uterus
 High Risk Pregnancy
 Is one in which a concurrent disorder, pregnancy-related
complication, or external factor jeopardizes the health of the
mother, the fetus, or both
 Some women enter pregnancy with a chronic illness that,
when superimposed on the pregnancy, makes it high risk
 Other women enter pregnancy in good health but then develop
a complication of pregnancy that causes it to become high
risk.
 Factors that Categorize a Pregnancy as High Risk
A. Pre-Pregnancy

Psychological Social Physical

a. history of drug dependence a. Occupation handling of a. Visual or hearing
b. History of mental illness toxic substances challenges
c. History of poor coping b. Environmental b. Pelvic inadequacy (CPD)
mechanism contaminants at home c. Secondary major illness
c. Isolated (heart disease, DM, kidney
d. Lower economic level disease, hypertension etc.)
e. Poor access to d. Poor gynecologic or
transportation for care obstetric history
f. Poor housing
g. Lack of support people
Psychological Social Physical

e. History of previous poor

pregnancy
outcome(miscarriage,
stillbirth, intrauterine fetal
death)
f. Pelvic inflammatory
disease
g. Obesity
h. Small stature
i. Younger than age 18
years or older than 35 years
j. Cigarette smoker
k. Substance abuse
B. Pregnancy
Psychological Social Physical

a. Loss of support a. Refusal of or neglected a. Intake of teratogen

b. Illness of a family prenatal care b. Multiple gestation
member b. Exposure to c. Poor placental formation
c. Decrease self-esteem environmental teratogens or position
d. Poor acceptance of c. Decreased economic d. Gestational diabetes
pregnancy support e. Nutritional deficiency
d. Conception less than 1 f. Poor weight gain
year after last pregnancy or g. PIH
pregnancy within 12 h. Infection
months of the first i. Amniotic fluid
pregnancy abnormality
j. post maturity
 C. Labor and Delivery
Psychological Social Physical

a. Severely frightened by a. Lack of support person a. Hemorrhage

labor and delivery b. Unplanned CS b. Infection
experience c. Lack of access to c. Dystocia
b. Inability to participate continued health care d. Precipitate birth
due to anesthesia d. Lack of access to e. Lacerations of cervix or
c. Lack of preparation for emergency personnel or vagina
labor equipment f. CPD
d. Birth of infant who is h. Retained placenta
disappointing in some
way
HIGH RISK PREGNANCY: The Woman who
develops a Complication of pregnancy

 A. Bleeding during Pregnancy:

 - vaginal bleeding is a deviation from the normal
that may occur at any time during pregnancy
 - a woman with any degree of bleeding needs to
be evaluated for the possibility of blood loss and hypovolemic
shock.
 - signs of hypovolemic shock occurs when 10% of
blood volume or approximately two units of blood, have been
lost; fetal distress occurs when 25% of blood volume is lost
  
 Signs and symptoms of Hypovolemic Shock
 1. increased pulse rate
 2. decreased blood pressure
 3. increased respiratory rate
 4. cold, clammy skin
 5. decreased urine output
 6. dizziness or decreased level of consciousness
 7. decreased central venous pressure
 The Process of SHOCK due to blood loss (hypovolemia):

 BLOOD LOSS

Decreased intravascular volume

 Decreased venous return, decreased cardiac output, and lowered blood pressure

 Body compensating by increasing heart rate to circulate the decreased volume faster;

 Vasoconstriction of peripheral vessels

Increased respiratory rate and a feeling of apprehension at body changes also occur
 Cold, clammy skin, decreased uterine perfusion. In the face of
continued blood loss, although the body shifts from interstitial
spaces into intravascular spaces, blood pressure will continue
to fall


Reduced renal, uterine and brain perfusion



 Lethargy, coma, decreased renal output



Renal failure


 Maternal and fetal death

 CONDITIONS ASSOCIATED WITH
FIRST- TRIMESTER BLEEDING:
- two most common causes of bleeding during the first trimester
are Abortion and ectopic Pregnancy
 
 A. MISCARRIAGE/ABORTION
 1. Spontaneous Abortion
 - abortion (defined as any interruption of pregnancy before the age of
viability)
 - when the interruption occurs spontaneously, it is clear to refer to it as a
MISCARRIAGE
 - when pregnancy is medically or surgically interrupted, this is typically
termed as ABORTION
 - stage of viability ( a stage when the fetus is capable of surviving outside the
uterus, more than 20- 24 weeks)
 - occurs in 15% to 30% of all pregnancies and
occurs from natural causes
 - a spontaneous miscarriage is an early
miscarriage if it occurs week 16 of pregnancy
and a late miscarriage if it occurs between
weeks 16 and 24.
 - its presenting symptoms is almost always
vaginal spotting
 Causes:
 - the most frequent cause of miscarriage in the first trimester of pregnancy is
abnormal fetal formation, due to either to a teratogenic factor or to chromosomal
aberration
 - implantation abnormalities. Approximately 50% of zygotes are never
implanted
 - corpus luteum fails to produce enough progesterone to maintain the deciduas
basalis
 - infection (i.e rubella, syphilis, poliomyelitis, cytomegalovirus and
toxoplasmosis infections readily cross the placenta and possibly causing fetal death
 - ingestion of teratogenic drug
  
 2. Threatened Abortion
 - is manifested by vaginal bleeding, initially beginning as
scant bleeding and usually bright red. There may be slight
cramping, but no cervical dilatation is present on vaginal
examination.
 - limiting activity to no strenuous activity for 24-48 hours is
the key intervention to stop vaginal bleeding. complete bed rest is
usually not indicated
 - coitus is usually restricted for 2 weeks after the bleeding
episode to prevent infection and to avoid inducing further
bleeding
 3. Imminent (Inevitable) Abortion
 - it happens with uterine contraction, cramping and cervical dilatation
 - the loss of the products of conception cannot be halted because of
cervical dilatation
 - instruct the mother to save tissue fragments that has passed and
bring to the clinic to be examined
 - the physician may perform D & C (dilatation and curettage) to
ensure that all products of conception are removed, preventing further
complication such as infection
 - after D & C the woman is advised to record the number of pads
used to assess for heavy bleeding
 4. Complete Abortion
 - the entire products of conception (fetus,
membranes and placenta) are expelled
spontaneously without any assistance
 - the bleeding usually slows within 2 hours and
then ceases within a few days after passage of the
products of conception
 5. Incomplete Abortion
 - part of the conceptus (usually the fetus) is
expelled, but the membranes or placenta is
retained in the uterus
 - the physician will usually perform a D &
C or a suction curettage to evacuate the
remainder of the pregnancy from the uterus
 6. Missed Abortion
 - commonly referred to as early pregnancy failure, the fetus dies in
the utero but is not expelled
 - a sonogram can establish that the fetus is dead. Often the embryo
actually died 4-6 weeks before the onset of miscarriage symptoms. After
the sonogram, a D & C most commonly will be done
 - if the pregnancy is over 14 weeks, labor may be induced by a
prostaglandin suppository or Misoprostol (Cytotec) to dilate the cervix,
followed by oxytocin administration
 - DIC (disseminated intravascular coagulation), coagulation defect,
may develop if the dead fetus remains tool long in utero
 7. Recurrent Pregnancy Loss
 - commonly referred to as habitual abortion
 - 3 or more consecutive pregnancies result in miscarriage usually related to
incompetent cervix.
 - Management (suture of cervix)
 McDonald procedure

 Temporary Circlage

 Side effect – infection

 May have NSD

 Shirodkar

 CS delivery
McDonald Procedure - Cervical Cerclage
 Complication of Abortion:
 1. Hemorrhage
 - a woman who develops DIC has a major possibility for
hemorrhage
 1. if excessive vaginal bleeding is occurring, immediately position the
woman flat and massage the uterine fundus to aid contraction
 2. monitor vital signs for changes to detect possible hypovolemic shock
 3. a BT may be necessary to replace blood loss
 4. instruct the woman on how much bleeding is abnormal (more than one
sanitary pad per hour is excessive), what color changes she should expect in
bleeding (gradually changing to a dark color and then to the color of serous
fluid) and any unusual odor or passage of large clots is also abnormal
  
 2. Infection
 - the possibility of infection is minimal when pregnancy loss
occurs a short period, bleeding is self limiting and instrumentation is limited
 1. educate the woman about the danger signs of infection, such as fever,
abdominal pain or tenderness and a foul smelling discharge
 2. organism responsible for infection after miscarriage is usually
Escherichia Coli (E Coli)
 3. caution the woman to wipe the perineal area from front to back after
voiding and particularly after defecation to prevent the spread of bacteria from
rectal area
 4. caution the woman not to use tampons to control vaginal discharge
because stasis of any blood increases the risk of infection
 3. Isoimmunization
 - happens when the mother’ s blood is Rh negative, while the fetus is
Rh positive.
 - after spontaneous abortion or D & C. some Rh positive fetal blood
may enter the maternal circulation and mother will develops antibodies
against Rh positive fetus blood.
 - during the succeeding pregnancies when the fetus is Rh positive again,
those antibodies would attempt to destroy the fetus RBC
 - so after miscarriage, because the blood of the fetus is not known, all
women with Rh negative blood should receive Rhogam (Rh Immune
Globulin) to prevent the build up of Rh antibodies
  
 4. Powerlessness
 - sadness and grief over the loss or a
feeling that she has lost control of her life is to be
expected
 - emotional support
 
 Procedures Used in Pregnancy Termination
 A. Vacuum Curettage
- aka. Vacuum aspiration
- cervical dilation followed by controlled suction through a
plastic cannula to remove all products of conception
- used for first trimester abortions, also used to remove
remaining products of conception after spontaneous
abortion
- local anesthesia of the cervix is needed
 B. Dilatation and Curettage - aka. Dilatation and
Evacuation
- dilation of cervix followed by gentle scraping of the
uterine walls to remove products of conception
- Used for first-trimester abortions and to remove all
products of conception after spontaneous abortions
- Greater risk of cervical or uterine trauma and excessive
blood loss
- local anesthesia or general anesthesia is needed
 Nursing Care of Clients with Abortion

1. Document the amount and character of bleeding and

saves tissues or clots for evaluation.
2. Check the bleeding and vitals signs to identify
hypovolemic shock resulting from blood loss
3. After vacuum aspiration or curettage, the amount of
vaginal bleeding is observed
4. Provide home health teaching after curettage such
as:
a. report increase bleeding
b. take temperature every 8 hours for 3 days
c. take an oral iron supplement if prescribed
d. resume sexual activity as recommended by the
health care provider
e. return to the health care provider at the
recommended time for a check up.
5. Check laboratory test such as hemoglobin
level and hematocrit
6. Promote expression of grief by providing
privacy, allowing support persons to help in
pregnancy loss
 B. ECTOPIC PREGNANCY
 - is one in which implantation occurs outside the uterine
cavity.
 - the most common site (in approximately 95% of such
pregnancies) is in a fallopian tube. Of these fallopian tube
sites, approximately 80% occur in the ampullar portion. 12%
occur in the isthmus and 8% in interstitial
 - approximately 2% of pregnancies are ectopic; ectopic
pregnancy is the second most frequent cause of bleeding
early in pregnancy
  
 Risk Factors:
 - increase incidence in women who have PID (pelvic
inflammatory disease) which leads to tubal scarring
 - occurs more frequently in women who smoke
 - occurs more frequently in women who douche,
possibly due to risk of introducing an infection
 - used of IUD (intrauterine device) for contraception
  
 Signs and Symptoms:
 Before Rupture
 - no menstrual flow occurs
 - nausea and vomiting
 - positive pregnancy test for hCG
 - Abdominal pain within 3- 5wks of missed period

(maybe generalized or one sided)

 - Scant, dark brown vaginal bleeding
 During rupture
 - sharp, stabbing pain in one of the lower abdominal
quadrants at the time of rupture, followed by scant vaginal bleeding
 - lightheadedness, rapid pulse and signs of shock (rapid
thread pulse, rapid respirations and falling blood pressure)
 - rigid abdomen from peritoneal irritation(Board-like
abdomen)
 - Cullen’s sign (bluish tinged umbilicus) – because blood
seeping into the peritoneal cavity
 - dull, excruciating pain on the abdomen that may radiate
on the shoulder caused by irritation of the phrenic nerve
 Diagnostics:
 1. Transvaginal UTZ will demonstrate ruptured tube
 2. insertion a needle through the postvaginal fornix
into the cul-de-sac under the sterile conditions to see
whether blood that has collected there from internal
bleeding can be aspirated(Culdocentesis)
 3. Laparoscopy Culdoscopy can be used to visualize
the fallopian tube
  
Culdocentesis
Transvaginal UTZ
Laparoscopy
 Management:
 1. once an ectopic pregnancy ruptures, it is an emergency
situation and the woman’s conditions must be evaluated quickly
(monitor for the symptoms of shock)
 2. therapy for a ruptured ectopic pregnancy is laparoscopy to
ligate the bleeding vessels and to remove or repair the damaged
fallopian tube
 3. women with Rh negative blood should receive Rh immune
globulin (Rhogam) after an ectopic pregnancy for
isoimmunization protection in future childbearing
 4. treated medically by the oral administration of
Methotrexate, a folic acid antagonist chemotherapeutic
agent, attacks and destroys fast growing cells. Because
trophoblast and zygote growth is rapid, the drug is
drawn to the site of ectopic pregnancy
 5. Hysterosalphingogram performed after chemotherapy
to assess the patency of the tube
 6. provide emotional support
 CONDITIONS ASSOCIATED WITH
SECOND- TRIMESTER BLEEDING
 
 A. GESTATIONAL TROPHOBLASTIC DISEASE
(HYDATIDIFORM MOLE OR H- MOLE)
 - is proliferation and degeneration of the trophoblastic
villi, which becomes filled with fluid and appear as grape-
sized vesicles
 - incidence is approximately 1 in every 2,000
pregnancies
 Causes:
 - unknown

 Risk Factors:
 - occurs most often in women who have a low
protein intake
 - in young women (under age 18 years)
 - in older women older than 35 years
 Types;
 - there are two distinct types of hydatidiform mole – complete/partial
 1. Complete mole – all trophoblastic villi swell and become cystic.
 - embryo dies early at only 1 to 2 mm in size with no fetal blood
present in the villi
 - on chromosomal analysis, although the karyotype is a normal
46XX or 46XY, this chromosome component was contributed only by
the father or an “empty ovum” was fertilized and the chromosome
material was duplicated
 - this type usually lead to choriocarcinoma
 2. Partial mole – some of the villi form normally
 - although no embryo is present, fetal blood may be
present in the villi
 - has 69 chromosomes ( a triploid formation in which
there are three chromosomes instead of two for every pair,
one set supplied by an ovum that was fertilized by two
sperm or an ovum fertilized by one sperm in which meiosis
or reduction division did not occur)
 Signs and Symptoms:
 1. uterus tends to expand than normally
 2. no Fetal heart sounds are heard because there is no viable fetus
 3. hCG serum levels are abnormally high
 4. severe nausea and vomiting
 5. symptoms of hypertension of pregnancy is present before week 20 of
pregnancy
 6. a sonogram/UTZ will show dense growth (typically a “snowstorm”
pattern) but no fetal growth in the uterus
 7. vaginal spotting of dark brown blood
 8. discharge of the clear fluid filled vesicles
Management:
 1. suction curettage to evacuate the mole

 2. after extraction, women should have a baseline serum test for the

beta subunit of hCG

 3. educate on avoiding pregnancy for at least one year

 4. hCG is analyzed every 2-4 weeks for 6-12 months (gradually

declining hCG suggest no complications)

 5. prophylactic course of Methotrexate is the drug of choice for

choriocarcinoma. This must be weigh carefully because it interferes

with WBC formation which can lead to leucopenia
 6. observe for bleeding and hypovolemic shock
 B. PREMATURE CERVICAL DILATATION
 - previously termed as “Incompetent cervix”
 - refers to a cervix that dilates prematurely
and therefore cannot hold a fetus until term
 - commonly occurs at approximately week
20 of pregnancy
 Causes:
 - unknown

 Risk factors
 1. associated with increased maternal age,
congenital structural defects and trauma to the
cervix such as might occurred with biopsy or
repeated D & C
 Signs and Symptoms:
 1. often the first symptom is show (a pink-stained
vaginal discharge) or increased pelvic pressure
followed by rupture of membranes and discharge of
amniotic fluid
 2. painless cervical dilatation
 3. uterine contractions followed by birth of fetus
  
 Management:
 1. bed rest in trendelenburg position
 2. monitor FHT
 3. observe for the rupture of BOW
 4. avoid coitus and limit activities
 5. avoid vaginal douche
 6. Surgical Operation termed as “Cervical Cerlage” is performed
 - as soon as sonogram confirms that the fetus of a second pregnancy
is healthy, at approximately week 12-14, pursing-string sutures are
placed in the cervix by vaginal route under regional anesthesia
 - types:
 1. McDonald Procedure – nylon sutures are placed
horizontally and vertically across the cervix and pulled tight
to reduce the cervical canal to a few millimeters in diameter
 2. Shirodkar technique – sterile tape is threaded in a
purse-string manner under the sub mucosal layer of the
cervix and sutured in place to achieve a closed cervix
 - sutures may be placed trans-abdominally
CONDITIONS ASSOCIATED WITH
THIRD – TRIMESTER BLEEDING
 A. PLACENTA PREVIA
 - is low implantation of the placenta
 - it occurs in four degrees:
 1. Low- lying placenta – implantation in the lower rather than in the upper
portion of the uterus
 2. Partial placenta previa – implantation that occludes a portion of the
cervical OS
 3. Marginal – placenta edge approaches the cervical OS. Lower border is
within 3 cm from internal cervical OS but does not cover the OS
 4. Total placenta previa – implantation that totally obstructs the cervical OS
 - incidence is approximately 5 per 1000 pregnancies
 Risk Factors
 - increased parity
 - advanced maternal age
 - past cesarean births
 - past uterine curettage
 - multiple gestation
  

Complication:
1. postpartum hemorrhage
2. hypovolemic shock
3. preterm labor
4. fetal distress
 Signs and symptoms;
 1. sudden onset of painless bright red vaginal bleeding
(latter half of pregnancy)
 2. bleeding may be profuse or scanty
 Note:
 - site of bleeding: uterine deciduas (maternal blood)
places the mother at risk for hemorrhage
 - bleeding may not occur until the onset of cervical
dilatation causing the placenta to loosen from the uterus
 Management;
 1. bleeding is an emergency. (fetal oxygen may be compromised and preterm birth
may occur)
 2. assess the amount of blood loss (duration, time of bleeding began, accompanying
pain, and color of the blood)
 3. bed rest with oxygenation prescribed
 4. side-lying or trendelenburg position (for 72 hours)
 5. NO internal exams (IE) or rectal exams, may initiate massive hemorrhage (if
necessary, must have double set up; OR/ DR)
 6. keep IV line and have blood available (X-matched and typed)
 7. Apt or Kleihauer- Betke test (test strip procedure to determine if blood is fetal or
maternal in origin)

 Fetal Assessment:
 1. monitor fetal status; heart tone and movement
 2. determine fetal lung maturity; amniocentesis –
L/S ratio
 3. Bethamethasone may be prescribed (encourage
maturity of fetal lungs; if fetus is less than 34 weeks
gestation)
  
 B. ABRUPTIO PLACENTA
 - premature separation of a normally
implanted placenta either partial/marginal or
complete/total
 - occurs after 20-24 weeks of pregnancy
  
 Causes:
 -unknown

 Risk Factors
 - high parity
 - advanced maternal age
 - short umbilical cord
 - chronic hypertensive disease
 - PIH
 - direct trauma (from VA)
 - cocaine or cigarette use (Vasoconctrction)
 Complications:
 1. fetal distress (altered HR)
 2. Couvelaire uterus or Uteroplacental apoplexy
 3. disseminated intravascular coagulation (DIC)
 Signs and symptoms:
 1. vaginal bleeding (may not reflect the true amount of blood loss)
 2. abdominal and low back pain (dull or aching)
 3. sharp stabbing pain high in the fundus
 4. uterine irritability (frequent low intensity contractions)
 5. high uterine resting tone
 6. uterine tenderness
  
 Degrees of Separation Grade criteria:
 0 - no symptoms of separation. Slight separation occurs
after birth. When placenta is examined, a segment shows recent
adherent clots
 1 - minimal separation, enough to cause bleeding and
changes in vital signs. However, there is no occurrence of fetal
distress and hemorrhagic shock
 2 - moderate separation. There is evidence of fetal distress,
and the uterus is tense and painful on palpation
 3 - extreme separation, and maternal shock or fetal death
will result
 Management:
 1. keep the client in lateral position, not supine
 2. oxygen therapy (limit fetal anoxia)
 3. monitor FHT and record maternal vital signs every5 to 15
minutes
 4. baseline fibrinogen(if bleeding is extensive. Fibrinogen reserve
may be used up in the body’s attempt to accomplish effective clot
formation)
 5. NO IE or rectal exam. No Enema
 6. keep IV line open (possible BT)
 PRETERM LABOR
 - aka. Premature Labor
 - labor that occurs after 20 weeks and before the end
 - approximately 9-10% of all pregnancies
 - labor contractions that happens every 10-20 minutes
 -usually leads to progressive cervical dilatation of >2 cm
and effacement of >80%
 Causs:
 - unknown

 Risk Factors
 1. Dehydration (stimulates APG to release ADH/Oxytocin that strengthen uterine
contractions)
 2. UTI
 3. Chorioamnionitis (infection of the fetal membranes and fluid)
 4. Younger than 17 and over 35 years old
 5. Inadequate prenatal care
 6. Emotional and physical stress
 7. Previous pre-term labor
 8. Low socio-economic class
  
 Signs and Symptoms:
 Early Signs and symptoms
 1. persistent low back pain
 2. vaginal spotting
 3. cramping
 4. increase vaginal discharge
 5. uterine contractions
   6. Pelvic pressure or a feeling that the fetus is
pushing down
7. Pain or discomfort in the vulva or thighs
 Management:
 FOCUS: Prevention of the delivery of premature fetus
 1. The woman should first admitted to the hospital
 2. Place in Left lateral position
 3. BEDREST to relieve the pressure of the fetus on the cervix
 4. Intravenous fluid therapy to promote hydration
 5. Medical Management
 a. Bethamethasone/Glucocorticoids – steroid, given in an
attempt to hasten fetal lung maturity
 - given in 2 dose, 12 mg IM 24 hours apart
 b. Tocolytic agents (halt labor)
 1. Calcium channel blockers – Beta adrenergic drugs
 2. Indomethacin (prostaglandin antagonist)
 - it can decrease fetal urine output, causing a decrease in amniotic fluid, not DOC because it
can stimulate the early closure of ductus arteriosus
 3. Magnesium Sulfate – often the first drug used to halt contractions
 - CNS depressant
 - halts uterine contraction
 4. Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine)
 - acts on entire beta 2 receptors sites (uterine and bronchial smooth muscles) causing mild
hypotension and tachycardia effects, hypokalemia, hyperglycemia, pulmonary edema
 Side Effects:
 a. Headache (most common) – due to dilatation of cerebral blood vessels
 b. Nausea and vomiting
  
 Nursing Responsibilities before administration of Tocolytic Therapy:
 1. assess baseline blood data i.e. hct, glucose, potassium, NaCl, ECG
(tachycardia)
 2. Uterine and fetal monitoring (external fetal monitors)
 3. mix the drug with lactated Ringers solution to prevent
hyperglycemia (piggyback administration, so that it can be stop
immediately if tachycardia occurs)
 4. assess BP and pulse every 15 minutes and every 30 minutes until
contractions stop
 5. reports PR>120 bpm, BP < 90/60 chest pain, dyspnea, rales
 PREMATURE RUPTURE OF MEMBRANES
(PROM)

 - rupture and loss of amniotic fluid that occurs before

labor begins
 - occurs in 2-18 % of pregnancies
  
 Cause:
 - unknown, but associated with infection of fetal
membranes (Chorioamnionitis)
 - nutritional deficiency involving ascorbic acid
 Complication:
 1. Fetal infections – after the rupture of BOW, the seal to the
fetus is lost
 2. Cord Compression – pressure on the umbilical cord because
of the loss of the amniotic fluid, which can cut off the nutrient
supply to the fetus (fetal distress)
 3. Cord prolapsed – the extension of the umbilical cord into the
vagina which can also interfere with fetal blood circulation
  
 Signs and Symptoms:
 1. Sudden gush of clear fluid from the vagina
 - fluid should be tested for:
 a. Nitrazine Paper test – amniotic fluid causes alkaline (>6.5 ph)
reaction to the paper (turns to blue) and urine causes acidic reaction
(remains yellow)
  
 b. Ferning test – get the sample of fluid then place on the slide and
viewing it under the microscope
 - + ferning patterns means –BOW

Management:
 1. Strict Bed Rest

 2. Observe, document and report maternal temperature above 38C, fetal

tachycardia
 3. Monitor for signs of infections (fever, uterine tenderness)

 4. Avoid sexual intercourse/Orgasm

 5. avoid vaginal exams (risk of infection)

 6. avoid breast stimulation

 7. record fetal movements daily and report fewer than 10 in a 12 hour period

 8. administer broad spectrum ATBC to reduce the risk of infection e.g.

Penicillin/Ampicillin
PREGNANCY- INDUCED HYPERTENSION (PIH)

 - originally called “Toxemia of Pregnancy”

 - condition in which vasospasm occurs during
pregnancy accompanied by hypertension, protenuria
and edema
 - onset: occurs after 20th week of pregnancy and
may appear up to 48 hours (2 weeks) postpartum
 - occurs 5-10% pregnancies
 Cause:
 - Unknown

 Risk Factors:
 - related to different associative factors
 1. Primipara - < 20 years old and > 40 years old
 2. Low socio-economic status (poor nutrition – decrease CHON intake)
 3. Women who have 5 or more pregnancies
 4. Multiple pregnancies
 5. Hydramnios (pre-exisiting)
 6. Underlying HPN/DM
 7. Poor calcium/Magnesium intake
 8. H-mole
  
 Pathophysiology:
 Pregnancy Induced Hypertension

Peripheral Vascular Spasms (Vasospasm)

Vascular Effects Kidney Effects Interstitial Effects

Vasoconstriction Decrease GFR and increase Diffusion of fluid from

Permeability of Glomeruli blood stream into the
membranes interstitial tissue

Increased BP

Increase Serum BUN, uric acid and

Creatinine Edema

Decrease urine output and protenuria

 Kidney Effects:
 - Vasospasm in the kidney increases blood flow
resistance
 - leads to increase permeability of the glomerular
membranes, allowing the serum CHONS and globulin to
escape in the urine (protenuria)
 - Results in decreased glomerular filtration – lowers
urine output
  
 Interstitials Effects:
 - Because of more CHON is lost, the osmotic pressure is decreased
and the excessive fluid shifts/diffuses from vascular spaces to the
interstitials spaces
 - leads to edema (extreme edema can lead to pulmonary edema and
seizure (Eclampsia) and it increases tubular reabsorption of Na in kidneys’
  
 Feto-placental effects:
 - poor placental perfusion may reduce the fetal nutrient and oxygen
supply
  
 Signs and symptoms:
 Triad of Symptoms (classic signs of PIH)
 1. HPN
 2. Protenuria
 3. Edema

 Classification of PIH:
 1. Gestational HPN – aka, Transcient HPN
 - develops Increase BP (>140/90) but has no protenuria and edema
 - decrease maternal mortality so no drug therapy is necessary
 - BP returns to normal by 10th day of postpartum
 2. Mild Pre-Eclampsia
 a. 1st criteria – Increase BP of >140/90 mmHg taken on 2 occasion at least 6
hours apart
 2nd criteria – Systolic BP is > 30 mmHg and Diastolic BP is >15 mm Hg above
baseline BP
 b. Protenuria
 - +1 or +2 (represents a loss of 1 g/dl of CHON
 c. Edema (weight gain)
 - due to CHON loss, sodium retention and decrease GFR
 - begins to accumulate on the upper part of the body (hands/face)
 - weight gain of >2 lb/wk in the second semester or > 1 lb/wk in the 3 rd trimester
(abnormal)
 Normal Weight Gain; 1st Trimester – 1 lb/month, 2nd/3rd trimester – 4 lbs/mos
 Nursing management:
 - can be managed at home with frequent follow-ups
 1. BED REST (bathroom priviliges)
 - facilitate Na excretion
 - decreases oxygen demand
 - position on left lateral position to prevent uterine pressure on the vena cava
 2. Assess the BP in sitting/left lateral position, CHON level in the urine, changes in
LOC, fetal movements and FHT
 3. regular diet with NO salt restriction
 - Na restriction may activate the RAAS (rennin-angiotensin-aldosterone system)
which can result in increase BP
 4. if symptoms progress to Severe Pre-Eclampsia – REFER immediately to
HOSPITAL.
 3. Severe Pre-Eclampsia
 - Presence of any of the following:
 a. increase BP >160/110 mm Hg on at least
2 occasions 6 hours apart at bed rest (the position in
which BP is lowest)
 b. marked protenuria – 3+ or 4+ on a
random urine sample
 c. generalized edema noticeable in woman’s face (facial
edema) and hands (wedding ring can’t be removed),
pulmonary edema (dyspnea, crackles on auscultation),
cerebral edema (visual disturbances i.e blurred vision,
headache)

 d. urine output – oliguria (less than 500 ml/24 hrs) or 30

ml/hr
 Nursing Management:
 - usually hospitalized until the baby is delivered
 1. BED REST (patient must be observe more closely)
 2. Provide a quiet and calm environment – any noise can trigger a seizure
activity and leads to eclampsia
 3. administer precautions on the patient’s room:
 a. patient’s bed must be near nurse’s station with code cart nearby
 b. placed in private room (undisturbed)
 c. the room should be darkened (because bright light can trigger
seizure)
 d. raise padded side rails to prevent falls or injury from seizure activity
 4. frequent maternal assessments every 4 hours (seizure precautions)
 a. sudden rise of BP
 b. blood studies – CBC, platelet count, liver function, BUN, Creatinine, urine
CHONS
 c. urine output – normal 600ml/24hours or 30 ml/hour
 d. daily weights – same time each day
 e. impeding seizure signs (aura) such as headache, visual disturbances, epigastric
pain
 5. Monitor Fetal Well-being
 - placed in External fetal Monitors to asses for FHR and fetal movements
 - Non-Stress test/Biophysical Profile to assess for Utero-placental sufficiency
 6. Moderate high protein diet to compensate for CHON lost (proteinuria)
  
 Medical Management:
 - to prevent Eclampsia
 1. Hydralazine (Apresoline) – antihypertensive – to reduce HPN by peripheral dilatation
 - side effects – Tachycardia
 - check for PR and BP before and after administration
 2. Magnesium Sulfate
 - DOC to prevent eclampsia
 - action:
 a. Cathartic – reduces edema by causing fluid shifting from extracellular spaces into the
intestine (removed by bowel elimination)
 b. CNS depressant (anti-convulsant) – lessens the possibility of seizure activity
 c. decrease neuromuscular irritability (muscle relaxant effect)
 d. Promotes maternal vasodilatation – promotes better feto-placental circulation or tissue
perfusion
 Nursing responsibilities during MgSO4 administration:
 1. Given IV via Piggyback infusing over 15-30 minutes, loading dose 4-6g/hr
and maintenance dose 1-2 g/hr
 2. assess RR, urine output, DTR and ankle clonus before after administration
 3. Monitor for magnesium sulfate toxicity:
 a. depressed respiration of <12Breaths/min
 b. decrease urine output of <30 ml/hr
 c. decrease DTR
 d. decrease LOC
 4. Antidote: Calcium Gluconate – a solution of 10 ml of 10% calcium gluconate
solution given for MGSO4 toxicity
 - must be readily available at bedside
 4. Eclampsia – the most severe classification of PIH
 - when cerebral edema occurs onset of seizure or
coma occurs
 - maternal mortality rate is high 20% due to
hemorrhage (circulatory collapse or renal failure)
  
 Signs and Symptoms:
 1. Increase HPN precedes SEIZURE
 - impending signs of seizure are headache, visual disturbances and epigastric pain)
followed by circulatory hypotension and collapse
 Stages:
 a. Tonic phase – all body contracts, arching of back, arms and legs are stiff
 b. Clonic phase = all of the muscle of body will contract and relax
 c. Post-Ictal phase – semicomatose/ patient cannot be arouse except for painful
stimuli
 2. may lead to coma
 3. labor may begin because of premature separation of placenta secondary to
vasospasm which might lead to preterm delivery
  
 Nursing Management:
 - Priority care for the mother with seizure is to:
 1. Maintenance of Patent Airway
 - administer oxygen by face mask
 - turning the mother to the side to allow the secretions to drain in the mouth (preventing
aspiration)
 2. Raised padded side rails
 3. avoid placing a tongue depressor (during the seizure activity) because it can obstruct the airway
 4. minimize environmental stimuli
 5. administer medications as ordered i.e MgSO4 and diazepam IV
 6. continue to assess FHT and uterine contractions
 7. check for maternal bleeding
 8. mother can deliver via NSD, CS is very hazardous because hypotension might result secondary
to anesthesia
 9. IV therapy as ordered
 HELLP SYNDROME
 - a variation of PIH abbreviated as Hemolysis,
Elevated liver enzymes and low platelet count
 - occurs in 4-12% of patients with PIH
 - a life threatening complication of PIH (because
maternal mortality is high at 24% and infant
mortality is 25%)
  
 Cause: Unknown

 Associated Factors
 primipara/Multipara mothers

 Signs and Symptoms:

 - nausea
 - epigastric pain
 - general malaise
 - right upper quadrant tenderness
 Laboratory data:
 a. hemolytic RBC
 b. thrombocytopenia (low platelet count of
below 100,000/m3)
 c. elevated lover enzyme (because of
hemorrhage and necrosis of liver)
 - serum ALT (Alanine Aminotransferase),
and ALT (Aspartate aminotransferase)
 Medical Management: (no known cure)
 1. Blood transfusion of fresh frozen plasma or
platelets
 2. infant is deliver ASAP via NSD or CS (lab.
Results will return to normal after delivery
 3. monitor for bleeding
 MULTIPLE PREGNANCIES

 - a pregnancy in which there is more than one

fetus in the uterus at the same time
 - Incidence rate is 2% of pregnancies
 Types:
 1. Monozygotic twins
 - aka. Identical twins
 - begins with single ovum and spermatozoa, during the
process of fusion, the zygote divides into two identical
individuals
 - have 1 placenta, 1 chorion, 2 amnion, 2 umbilical
cords
 - always of the same sex
  
 2. Dizygotic Twins
 - aka. Non-identical/fraternal twins
 - the result of fertilization of two separate ova by
two separate spermatozoa
 - have 2 placenta, 2 chorions, 2 amnions, 2
umbilical cords
 - twins may be of the same or different sex
 - 2/3 of twins are dizygotic
  
 Associative Factors:
 a. more frequent in non-whites than in
whites
 b. increase in parity
 c. advance maternal age
 d. familial inheritance
 Diagnostic procedure: Sonogram/Ultrasound
 Signs and Symptoms:
 1. Increase uterine size faster than usual
 2. quickening at the different portion of the
abdomen
 3. more than expected fetal activity
 4. multiple sets of FHT
 5. extreme fatigue and backache
 Management:
 - mother is more susceptible to complications
of pregnancy i.e. PIH, hydramnios, placenta
previa, pre-term labor, anemia than a women
carrying only one fetus
 1. BED REST (during the 2 or 3 months of
pregnancy to decrease risk of preterm labor
 2. Closer prenatal supervision
 HYDRAMNIOS (Polyhydramnios)
 - Excessive fluid formation of >2000ml or an amniotic fluid
index of above 24 cm (normal 500-1000ml)
 Complication:
 1. Fetal Malpresentation (because of extra-uterine space)
 2. Premature rupture of membranes – that leads to infection
and prolapsed cord
 3. Preterm labor (because of increasing pressure,
prostaglandin release)
 Risk Factors:
 1. Maternal diabetes – hyperglycemia in the
fetus causes increase urine production leading
to increase urine output
 2. Anencephaly
 3. Esophageal atresia – fetus becomes unable
to swallow the amniotic fluid because of
intestinal anomalies or obstruction
Esophageal Atresia
Anencephaly
 Signs and Symptoms:
 1. Rapid enlargement of the uterus (first sign)
 2. difficulty in palpating and auscultating the
fetus due to excessive fluid
 3. shortness of breath due to compression of the
diaphragm
 4. ultrasound finding of increase excessive fluid
  
 Management:
 1. maintain bed rest to reduce pressure on cervix and to
prevent premature labor
 2. monitor for rupture or uterine contraction
 3. avoid constipation (it will increase uterine pressure
and rupture of membranes)
 4. amniocentesis (slow and controlled release of fluid to
prevent premature separation of the placenta) guided by
ultrasound
 POST-TERM PREGNANCY

 - a pregnancy that exceeds 42 weeks of

gestation (term pregnancy – 37-42 weeks)
 - incidence rate – 3-12% of all pregnancies
 Risk Factors:
 1. Women who have long menstrual cycles (40-45 days)
 - they do not ovulate on day 14 in a typical menstrual cycle.
They ovulate 14 days from the end of the cycle or on day 26 or
31. Their child will be late by 12 or 17 days.
 2. Women receiving high dose of Salicylates (interferes with
synthesis of prostaglandins that initiates labor)
 3. associates with myometrial quiescence (uterus that do not
respond to normal labor)
  
 Complication:
 1. meconium aspiration
 2. macrosomia – fetus continues to grow
 3. fetal distress – due to placental aging it causes decreased blood prefusion
and inadequate supply of oxygenated blood and nutrients to fetus
  
 Management:
 1. Induction of labor – prostaglandins or inoprostol (cytotec) applied to
cervix to stimulate ripening or stripping of membranes. Followed by
oxytocin infusion to stimulate contraction
 2. CS delivery
 RH INCOMPATIBILITY
(Isoimmunization)
 - occurs when the mother is Rh negative (-) who carries
a fetus with an Rh positive (+) blood
 - normally there is no direct contact between
maternal and fetal blood
 - villi ruptures– a drop or two of fetal blood enters
maternal circulation or during amniocentesis
 - small amount of blood (drop) of Rh + fetal blood leaks across the
placenta and goes to the blood stream of the mother. Mother will be
sensitized and start to make Rh antibodies (first pregnancy is not
affected)
 - an injection of Rh immune globulin (Rhogam) is given ASAP
within 72 hours after the delivery (because most of maternal
antibodies are formed during the first 72 hours after birth)
 - During the subsequent pregnancy (if fetus is again Rh +), the
Rh antibodies of the mother crosses the placenta, enters the blood
stream of the fetus causing antigen-antibody reaction and Hemolysis
of the fetal RBC (Erythroblastosis Fetalis)
 Diagnosis:
 1. Indirect Coomb’s test – to check if Rh
antibodies are present within RBC surface
 2. Antibody titer – determine at first pregnancy
visit and then again at 28 weeks AOG and
after delivery (normal is 0)
  
Management:
1. Rh Immune globulin (Rhogam) is administered at 28 weeks of
pregnancy and in the 1st 72 hours after delivery
2. Determine blood typed of infants after birth from a sample of the cord
blood
3. Blood transfusion through Intrauterine Transfusion
- done to give restore fetal RBC
- 75-150ml of RBC is administered
- after BT, the mother is encouraged to rest for 30 min. while FHT and
uterine activity are monitored
4. As soon as fetal maturity is reached, induction of labor is followed
 GESTATIONAL DIABETES MELLITUS
 - a condition in which women exhibit high glucose levels
during pregnancy
 - an abnormal CHO, fat and CHON metabolism that is
first diagnosed during pregnancy (at the midpoint of
pregnancy when insulin resistance becomes noticeable)
 - but the symptoms fade again at the completion of
pregnancy (resolves in delivery)
 - risk of developing type 2 diabetes is high as 56-60%
later in life
 Cause: Unknown (related to excessive insulin
resistance)
 Risk Factors:
 1. obesity
 2. age over 25 years old (about 50% of the these women
develop diabetes within 22-28 years old)
 3. history of large babies/macrosomia (16 lbs or more)
 4. family history of DM/GDM
 Pathophysiology of DM
Pancreas produces no insulin or inadequate insulin

Inadequate insulin

Inability to move glucose from the blood to body cells

Cellular
Hyperglycemia
starvation Polyphagia
Metabolize FAT/CHON for energy Exerts osmotic pressure in th
Glycosuria
kidneys

Causes ketones and Polydipsia

acids to accumulate Attracts more water
in the blood

Polyuria
Metabolic
acidosis
 Diagnosis: women who are high risk for DM should be
screened at first prenatal visit and again at 24-28 weeks.
 1. Glucose Challenge Test – done at first prenatal visit and
again at 24-28 weeks
 - usually consists of 8 hour fasting for FBS
 - mother is given 50g of glucose load and a blood
sample is taken for serum glucose 1 hour after
 - diabetic if FBS is more than 95mg/dl or after 1 hour
the serum glucose is >140mg
Glucometer
 2. Oral Glucose Tolerance Test
 - the gold standard for diagnosing diabetes
 - mother is given 100g of CHO/glucose then 3 hours fasting
 Test type Pregnancies glucose level (mg/dl)
 Fasting 95
 1 hour 180
 2 hours 155
 3 hours 140
 - rate is abnormal if 2 of the 4 blood samples collected are abnormal
 - <70 hypoglycemia, >130 hyperglycemia (normal – 80-120mg/dl)
 Maternal effects of DM;
 1. Hypoglycemia during the first trimester – glucose is being
utilized by the fetus for the development of the brain
 2. Hyperglycemia during the 2nd /3rd trimester at 6 months –
due to HPL effects (causes insulin resistance)

 Insulin requirements for insulin during:
 1st trimester – decrease in insulin by 33%
 2nd/3rd trimester – increase insulin by 50%,
 Postpartum – drops suddenly to 25%due to delivery of
placenta
 3. prone to frequent infections e.g. Moniliasis/Candidiasis
 4. Polyhydramnios
 5. Dystocia – due to abnormality in fetus/mother
  
 Fetal Effects of DM
 1. Hypoglycemia during the 1st trimester
 2. Hyperglycemia during the 2nd/3rd trimester
 3. Macrosomia – abnormally large for
gestational age(baby is delivered >4000 g or
4kg)
Macrosomia
 Newborn Effects:
 1. Hyperinsulinism – because insulin from the mother does not cross the
placenta which lead to increase insulin production from the baby
 2. Hypoglycemia – when the umbilical cord is cut – the supply of
glucose from the mother also stops which results in very hypoglycemia
newborn (normal glucose in NB 45-55mg/dl)
 Signs and Symptoms: (newborn)
 1. High pitched shrill cry
 2. tremors
 3. jitteriness
 Diagnosis: Heel Stick Test to check glucose level
 Management:
 1. Frequent prenatal visits for close monitoring]
 2. Insulin (regular/Intermediate acting insulin) – given subcutaneously (slow
absorption)
 - do not massage the site of injection
 - rotate the site of injection (to prevent lipodystrohy- inhibits insulin
absorption)
 - gently roll vial in between the palms (do not shake)
 3. Monitor blood glucose – assess once a week
 - using finger stick technique, using on fingertips as the site of lancet
puncture, the strip is then inserted into a glucose meter to determine glucose level
(normal <95mg/dl – FBS, <120mg/dl 2 hours post prandial (after very meal) level
 4. Monitor fetal well being
 a. ultrasound/Sonogram – to determine fetal growth, amniotic fluid volume,
placental location and b-parietal diameter
 b. daily fetal movement count (DFMC) – monitoring for movements of fetus for
1 hour (normal 10 movement/hour)
 c. amniocentesis – to determine LS ratio by 36 weeks of pregnancy and to assess
fetal lung maturity
 5. CS delivery
 - cervix is not yet ripe or not yet responsive to contractions
 - babies of diabetic mother are abnormally large making vaginal delivery difficult
 6. woman with gestational diabetes usually demonstrates normal glucose levels by 24
hours after birth (and needs no further insulin therapy)
  
 Heart Disease
- Origin: 90% Rheumatic (incidence expected to decrease as
incidence of rheumatic fever decreases), 10% congenital lesions
or syphilis
- Normal hemodynamics of pregnancy that adversely affect the

client with heart disease:

- a. oxygen consumption increased 10% to 20%; related to the

needs of the growing fetus

- b. plasma level and blood volume increase; RBC’s remain the

same (physiologic anemia)

 Functional or Therapeutic Classification of Heart Disease during
Pregnancy:
CLASS I – no limitation of physical activity; no symptoms of cardiac
insufficiency or angina
CLASS II – sight limitation of physical activity; may experience
excessive fatigue, palpitation, angina or dyspnea; slight limitations as
indicated
CLASS III – moderate to marked limitation of physical activity;
dyspnea, angina and fatigue occur with slight activity and bed rest is
indicated during most of pregnancy
CLASS IV – marked limitation of physical activity; angina, dyspnea and
discomfort occur at rest; pregnancy should be avoided; indication for
termination of pregnancy
Nursing Care of Pregnant Client with heart Disease:
1. Assessment:
a. Prenatal period
- vital signs; weight gain; dietary patterns, knowledge about
self care; signs of heart failure, stress factors such as work,
household duties
b. Intrapartal period
- vital signs (heart rate will increase); respiratory changes
(dyspnea, coughing, crackles); FHR patterns
c. Postpartal period
- signs of heart failure or hemorrhage related to fluid shifts,
intake and output
2. Analysis/ Nursing Diagnosis
a. activity intolerance related to increased cardiac workload
b. anxiety related to unknown course of pregnancy, possible los of
fetus and inability to perform role responsibilities
c. decreased cardiac output related to stress of pregnancy and
pathology associated with heart disease
d. fear related to possible death
e. excess fluid volume related to fluid shifts resulting from a
decrease in intra-abdominal pressure following birth
f. risk for impaired parenting related to increased responsibility of
caring for a neonate
3. Nursing Interventions
A. Prenatal period
1. teach importance of rest and avoidance of stress
2. instruct regarding use of elastic stockings and periodic
evaluation of legs
3. teach appropriate (dietary intake; adequate calories to ensure
appropriate, but not excessive, weight gain; limited, not restricted salt
intake
4. administer medications as ordered; heparin, furosemide (lasix),
digitalis, beta blockers (inderal)
5. monitor for signs of heart failure such as respiratory distress
and tachycardia; may be precipitated by severe anemia of pregnancy
B. Intrapartal period
1. encourage mother to remain in semi Fowler’s position or left
lateral position
2. provide continuous cardiac monitoring
3. provide electronic fetal monitoring
4. assist mother to cope with discomfort; minimal analgesia
and anesthesia are used
5. assist with forceps delivery in second stage of labor to avoid
work of pushing
6. monitor for signs of heart failure, such as respiratory distress
and tachycardia
C. Postpartal period (most critical time because of increased
circulating blood volume after birth of placenta)
1. institute early ambulation schedule; apply elastic stockings
2. monitor for signs of heart failure, such as respiratory distress
and tachycardia
3. monitor heart rate; accelerated heart rate of mother in latter
half of pregnancy puts extra workload on her heart
4. provide for adequate rest; the increase in oxygen
consumption with contractions during labor makes length of labor a
significant factor
5. provide close supervision; sudden tachycardia during birth or
sudden bradycardia and normal increase in cardiac output
following birth may cause cardiac arrest
6. administer prescribed prophylactic antibiotics to mother with
history of rheumatic fever
7. refer to various agencies for family support, if necessary on
discharge
8. newborn risks include intrauterine growth retardation,
prematurity and hypoxia fetal demise may occur
 INTRAPARTUM COMPLICATIONS

– occur in as many as 31% of all births

- broad term for abnormal or difficult labor and delivery
- arise from 3 main components of the labor process
 1. Power (uterine contractions)
 2. Passenger (the fetus)
 3. Passageway (the birth canal)
  
 Problems with the Power: (Force of Labor)
 1. Uterine Inertia – sluggishness of contractions or the force of labor or
defined as difficult, painful, prolonged labor due to mechanical factors
 - current term – Dysfunctional Labor
 
Common Causes:
 a. inappropriate use of analgesia (excessive or too early administration)

 b. unusually large baby/multiple gestation

 c. poor fetal position (posterior rather than anterior position)

 d. pelvic bone contraction (leads to narrowing of the pelvic diameter so the

fetus cant pass)

 e. primigravida

 f. hypotonic, hypertonic and prolonged labor

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

 Signs and Symptoms;

 - irregular uterine contractions
 - ineffective uterine contractions (strength/duration)
  
 Management:
 1. Monitor uterine contractions by palpation and with the use of
electronic monitor
 2. Prevent unnecessary fatigues – check the client level of fatigue
 3. Prevent complications of labor
 a. assess urinary bladder (catheterize as needed)
 b. assess maternal VS
 c. monitor condition of fetus by monitoring FHR, fetal
activity and color of amniotic fluid
 4. Provide comfort measures
 a. frequent position changes
 b. walking
 c. quiet/calm environment
 d. breathing/relaxation technique
 2. Ineffective Uterine Force
 - ineffective uterine contractions which can result in ineffective
labor
 types;
 1. Hypotonic Contractions – the number of contractions is usually
low or infrequent (not increasing beyond 2 or 3 in a 10 minute
period)
 - occurs during the active phase of labor
 - normal : 3-4/10 min period with duration of 30 seconds
 Risk Factors
 - bowel/bladder distention prevents
descent/engagement
 - multiple gestation
 -large fetus
 - hydramnios
 - multiparity
 Signs and Symptoms: Painless less frequent Contraction

 Management:
 1. oxytocin administration – to strengthen contractions and
increase effectiveness
 2. Amniotomy (artificial rupture of membranes – to further
speed labor
 3. Palpate the uterus and assess lochia every 15 minutes to
prevent postpartum bleeding
 4. monitor maternal VS and FHR
 5. position changes to relieve discomfort and enhance
progress
 2. Hypertonic Contractions
 - intensity of the contractions may not stronger or very active and frequent
contractions but ineffective
 - occurs more frequently and commonly seen in latent phase of labor’
 - the muscle fibers of the uterus (myometrium) do not repolarize
  
 Signs and Symptoms;
 1. Painful nonproductive contractions
 2. uterine tenderness
 3. fetal anoxia/distress
 4. dehydration due to excessive perspiration
 5. fatigue and exhaustion
 Management:
 1. assess quality of contractions by uterine/fetal external monitor
applied at least 15 minutes interval
 2. adequate rest
 3. pain relief with morphine sulfate
 4. changing linen/gowns
 5. darkened room lights
 6. decreasing environmental stimuli
 7. CS delivery
 PRECIPITATE LABOR
 - define as labor that is completed in fewer than 3 hours (normal length
of labor; Primipara 14-20 hours, Multi – 8-14 hours)
 - a forceful contractions that can lead to premature separation of the
placenta (placing the mother and fetus at risk for hemorrhage)
  
 Risk Factors:
 1. likely to occur in multiparity mothers
 2. women undergo premature separation of the placenta
 3. previous history of precipitate labor
 Complications
 1. hemorrhage
 2. Intracranial hemorrhage in fetus
 3. lacerations (because of forceful birth)
 4. Fetal distress
  
 Signs and symptoms:
 1. tachycardia (earliest sign)
 2. restleness
 3. hypotension (late sign)
 4. signs of hypovolemic shock
 5. vulvar pain and bruising

 
  
 Nursing Management:
1. Inform mother at 28 weeks of pregnancy that labor may be
shorter than normal
2. Tocolytic agent administration to reduce the force and frequency
of contractions
3. Cold applications to limit bruising, pain and edema
4. In time of hemorrhage position the mother in modified
trendelenburg position
5. IVF replacement – fast drip
 UTERINE RUPTURE
 - rupture of the uterus during labor
 - accounts for 5% of maternal death
 - incidence rate is 1 in 1500 births

 Risk Factors:
 - commonly occur from a vertical scar during the previous CS or hysterectomy repair
tears
 - prolong labor
 - faulty presentation
 - multiple gestation
 - use of oxytocin
 - traumatic maneuvers

 - usually preceded by pathologic refraction ring (an indentation is apparent across the
abdomen over the uterus) and strong uterine contractions without any cervical dilatation,
the fetus is gripped by retraction ring and cannot descent)

 Signs and Symptoms:

 1. sudden severe pain during a strong labor contractions
 2. report “a tearing sensation”
 3. hemorrhage from a torn uterus into the abdominal cavity and into the vagina
 4. signs of shock (rapid, weak pulse, falling blood pressure, cold clammy skin)
 5. absent fetal heart sounds
 6. localized tenderness and aching pain from the lower segment
 7. fetal distress
  
 Nursing Management:
 1. Administer emergency fluid replacement therapy as ordered
 2. Anticipate use of intravenous oxytocin to attempt to contract
the uterus and minimize bleeding
 3. prepare mother from a Laparotomy as an emergency measure
to control bleeding and effect a repair
 4. Physician may perform “hysterectomy” (removal of a
damaged uterus) or BTL at the time of Laparotomy
 5. monitor VS and FHR
 6. administer BT as ordered
 UTERINE INVERSION
 - uterus turns completely or partially inside out, it occurs immediately
following delivery of the placenta or in the immediate postpartum period
 - incidence rate is 1 in 15, 000 births
 
 Causes:
 - occurs after birth of the infant if traction is applied to umbilical cord to
remove placenta
 - pressure is applied to the uterine fundus when uterus is not contracted
 - occurs when placenta attached at the fundus (the passage of the fetus
pulls the fundus down)

 Signs and Symptoms:
 1. sudden gushes of blood from vagina
 2. fundus is not palpable
 3. show signs of blood loss (hypotension, dizziness and paleness)
 4. bleeding

 Nursing Management;
 1. recognize signs of impending inversion and immediately notify the physician
 2. never attempt to replace the inversion because handling may increase the
bleeding
 3. never attempt to remove the placenta if it still attached
 4. take steps to prevent or limit hypovolemic shock
 a. use large gauge IV catheter for fluid replacement
 b. measure and record maternal VS every 5 to 15 minutes to
establish baseline changes
 5. administer oxygen by mask
 6. be prepared to perform CPR if the heart fails due to sudden blood
loss
 7. the mother will be given general anesthesia or nitroglycerin or a
tocolytic drug IV to immediately relax the uterus
 8. physician/nurse midwife replaces the fundus manually (push the
uterus back inside)
 AMNIOTIC FLUID EMBOLISM
 - occurs when amniotic fluid is force to enter the maternal blood
circulation because of some defect in the membranes or after
membranes rupture (not preventable because it cannot be predicted)
 - incidence rate is 1 in 8000 births
  
 Risk factors:
 1. oxytocin administration
 2. abruption placenta
 3. hydramnios
 Signs and Symptoms:
 1. sharp pain on the chest
 2. dyspnea (secondary to pulmonary artery constriction)
 3. mother becomes pale and cyanotic due to pulmonary embolism and lack of
blood flow to the lungs

 Nursing Management:
 1. immediate management is oxygen administration by face mask or cannula
 2. prepare the mother for CPR (may be ineffective because these procedures do
not relieve the pulmonary constriction)
 3. Endotracheal intubation to maintain pulmonary function
 4. The mother should be transferred to ICU
 Complication:
 1. DIC – disseminated intravascular coagulation
 - bleeding to all portion of body (eyes, nose,
gums, IV sites)
 - therapy with fibrinogen to counteract DIC
 PROBLEMS WITH THE PASSENGER

1. PROLPASE OF UMBILICAL CORD

 – descent of the umbilical cord into the vagina ahead of
the fetal presenting part with resulting compression of the
cord (cord compression)
 - “emergency situation “, immediate delivery is
attempted to save the baby
 - incidence rate is 0.2-0.6% of births or 1 of 200
pregnancies
 Associative Factors:
 1. premature rupture of membranes (the fetal fluid may rush and carry the cord along toward the
birth canal)
 2. breech presentation
 3. placenta previa
 4. intrauterine tumors preventing the presenting part from engagement
 5. small fetus
 6. CPD preventing engagement
 7. hydramnios
 8. multiple gestation
  
 Signs and Symptoms;
 1. the umbilical cord seen or felt during vaginal exam
 2. reports feeling of cord into the vagina
 Management: (relieve compression on the cord and fetal anoxia)
 1. periodically evaluate FHR especially after the rupture of
membranes (fetal distress)
 2. Physician will place a glove hand in the vagina and manually
elevate the fetal head off the cord
 3. place the mother in knee-chest position/trendelenburg position
(causes the fetal head to fall back from the cord)
 4. administer oxygen at 10 Liters/minute by facemask to improve
oxygenation of the fetus
 5. do not attempt to push any exposed cord back into the vagina (adds
to compression)
 6. cover any exposed portion of the cord with sterile gauge
soaked in NSS around the prolapsed cord
 7. if the cervix is fully dilated at the time of prolapsed (the most
emergent delivery route is NSD and encourage mother to push)
 8. if not fully dilated, mother is delivered via CS (upward
pressure on the presenting part to keep pressure off the cord)
  
 PROBLEMS WITH POSITION,
PRESENTATION OR SIZE:
 1. OCCIPITO-POSTERIOR POSITION
 - LOA (left occipito-anterior) is the most ideal and common fetal
position
 - LOP (left occipito-posterior) is located on left and posterior
quadrant pelvis
 - ROP (right occipito-posterior) is located at the right and
posterior quadrant pelvis
 ROP – in this position, during the internal rotation, the fetal head must
rotate not through a 90 degree arc but through an arc of approximately
135 degrees
 Risk Factors:
 1. Women with android/anthropoid pelvis.
 Signs and Symptoms;
 - Intense lower back pain (lumbosacral pain) – due to compression of
sacral nerves during rotation
 - Shooting leg pains
 Nursing Management;
 1. provide back rub
 2. change of position (squatting position) – may help fetus to rotate
 3. encourage voiding every 2 hours to keep bladder empty (because full
bladder impedes descent of the fetus)
 4. apply hot/cold compress
 5. delivered via CS
 2. BREECH PRESENTATIONS – presenting parts
are usually buttocks and feet
 Complications:
 1. anoxia (due to prolapsed umbilical cord)
 2. intracranial hemorrhage
 3. fracture of the pine/extremities
 4. dysfunctional labor
  
 Risk Factors:
 1. gestational age under 40 weeks
 2. abnormality in the fetus such as anencephaly, hydrocephalus
 3. hydramnios (allows for free fetal movement)
 4. congenital anomaly of the uterus
 5. multiple gestation
  
 Signs and Symptoms;
 1. Fetal heart sounds usually heard high in the abdomen (URQ, ULQ)
 2. fetal distress
 Diagnosis; Leopold’s maneuver, vaginal exams and ultrasounds will reveal breech
presentations
 Nursing Management;
 1. External version is being used to avoid some CS deliveries for a

breech presentations
VERSION – is a method of changing the fetal presentation usually
from breech to cephalic.
- done after 37 weeks of gestation but before the onset of labor
- begins with non-stress test and BPF to determine of the fetus is in
good condition and if there is adequate amount of amniotic fluid
- mother is given tocolytic drug to relax her uterus during version
 - UTZ is used to guide the procedure while physician pushes the
fetal buttocks upward out of the pelvis while pushing the fetal
head downward toward the pelvis in either clockwise or
counterclockwise direction

 3. the head may also be delivered using forceps delivery to

control the flexion and rate of descent

 4. CS delivery
 THERAPEUTIC MANAGEMENT OF
PROBLEMS OR POTENTIAL PROBLEMS IN
LABOR AND BIRTH

 1. Induction of labor – done when labor

contractions are ineffective
 - means that labor is started artificially
 Indications;
 1. pre-eclampsia
 2. eclampsia
 3. severe hypertension/DM
 4. Rh sensitization
 5. prolong rupture of membranes
 6. post maturity
  
 Requirements for labor induction;
 1. fetus must be in longitudinal lie
 2. cervix must be ripe
 3. presenting part must be engaged
 4. No CPD
 5. fetus is matured by date, LS ratio or sonogram (bi-parietal diameter)
Pharmacological Methods:
1. Cervical Ripening – softening of the cervix/consistency
 - is the FIRST STEP the uterus must complete in early
labor
 - necessary for dilatation and uterine contractions
Criteria:
 Scoring of cervix for readiness in elective conductions (if

the scale is 8 or above, the woman is considered ready for

birth and induction)
Scoring Factor 0 1 2 3

Dilatation (cm) 0 1-2 3-4 5-6

Effacement (%) 0-30 40-50 60-70 80

Station -3 -2 -1, 0 +1, +2

Consistency Firm Medium Soft

Position Posterior Mid-Posterior Anterior

Prostaglandin Gel – commonly used method of speeding
cervical ripening and is applied to the inferior surface of
the cervix
- applied before labor induction
- can also be applied on the external surface by
applying the gel to the diaphragm then placing the
diaphragm against the cervix
 - apply every 6 hours for 2-3 doses
 Nursing Considerations;
 1. Place women in flat position to prevent leakage of medication
 2. the woman remains on bed rest for 1 to 2 hours and is monitored for
uterine contractions
 3. monitor FHR continuously for at least 30 minutes after each application up
to 2 hours
 4. IV line with saline is initiated in case uterine hyperstimulation occurs such
as contractions longer than 90 seconds or more than 5 contraction in 10
minutes
 5. explain the side effects – vomiting, fever, diarrhea and hypertension
 6. oxytocin induction can be started 6-12 hours after the last prostaglandin
dose
 2. Induction of Labor by Oxytocin – a synthetic form of
pituitary hormone initiates contractions in uterus
 Nursing Considerations;
 1. Given IV (to hasten effect), IV form of oxytocin needs to
be diluted
 2. the drug is traditionally mixed in the proportion of 10 IU
in 1000ml of Ringer’s Lactated (LR)
 3. Administer the medication by piggyback attach to D5W
as the main IV line (if oxytocin needs to be discontinued, the
main line will be maintain)
 4. when cervical dilatations reaches 4 cm, artificial rupture of
membranes is performed to further induce labor and oxytocin
infusion is discontinued
 5. Monitor FHR/uterine contractions and cervical dilatation
during the procedure
 6. side –effects: extreme hypotension due to peripheral
vasodilatation, headache, vomiting
 7. monitor VS every 15 minutes
 8. complications to watch; fetal distress and uterine rupture
 ANOMALIES OF THE PLACENTA AND
CORD;’

 1. Anomalies of the placenta

 a. Placenta Succenturiata – has one or more
accessory lobes connected to the main placenta by blood
vessels
 - no fetal abnormality associated with it
 - can lead to maternal hemorrhage
(small lobes retain in the uterus after birth)
 b. Placenta Circumvallata – fetal side of the placenta is covered with
chorion (normally, no chorion covers the fetal side of the placenta)
 - no abnormalities is associated with this types of
placental anomaly
  
 c. Battle–dore Placenta – the cord is inserted marginally rather than
centrally
 - rare/unknown clinical significance
 d. Velamentous Insertion of the Cord – situation in which the cord
instead of entering the placenta directly, separated into small vessels that
reach the placenta by spreading across a fold of amnion
 Postpartum Complications
 
1. Postpartum hemorrhage – major cause of maternal
Postpartum hemorrhage – major cause of maternal
death, occurs in 4% of deliveries
- defined as blood loss greater than 500 ml after vaginal
birth or 1000 ml after CS
Classifications:
According to severity:
a. Mild – 750 – 1250 ml
b. Moderate – 1250 – 1750 ml
c. Severe – 2500 ml
According to time:
1. Early Postpartum hemorrhage – occurs within 24 hours of birth
2. Late postpartum hemorrhage – occurs after 24 hours until 6 weeks after birth

Major Risk: Hypovolemic Shock (low volume)

- occurs when the circulating blood volume is decreased which interrupts blood flow to
body cells
- manifested as:
a. Tachycardia (first sign)
b. hypotension
c. cold and clammy skin
d. mental changes such as anxiety, confusion, restleness
e. decrease urine output
Conditions that increase risk for PP hemorrhage
1. Over distension of the uterus
 Multiple births
 Hydramnios
 Macrosomia
2. Trauma r/t forceps, uterine manipulation
3. Prolonged labor
4. Uterine infection
5. Trauma removing placenta
 Causes of Postpartum hemorrhage

1. Uterine Atony: Uterus without tone or lack of

normal muscle tone (90% of cases)
- uterine atony allows blood vessels at the
placenta site to bleed freely and usually massively.
 - uterine muscle unable to contract around blood
vessels at placental site
Risk Factors:
1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion

Symptoms:
1. uterus is difficult to feel and is boggy (soft)
2. lochia is increased and may have large blood clots
3. Blood may “gush” or come out slowly
Nursing Management:
1. Massage the uterus until firm
2. have mother to urinate or catheterize because bladder distension
pushes the uterus upward or in the side and interferes with the ability
of the uterus to contract
3. Encourage mother to breastfeed because sucking stimulation causes
the release of oxytocin from PPG
4. Administration of IV oxytocin or Methylergonovine (Methergine) to
control uterine atony
5. Hysterectomy is performed to remove the bleeding uterus that does
not respond to other measures
2. Lacerations – tearing of the birth canal
- normally occurs as a result of child bearing

Risk factors:
a. difficult or precipitate births
b. primigravidas
c. birth of a large infant
d. use of a lithotomy position and instruments
(forceps)
Sites of lacerations:
1. Cervical Lacerations
- characterized by gushes of bright red blood from the vaginal
opening if uterine artery is torn
- difficult to repair because the bleeding may be so intense that it
can obstruct visualization of the area.
2. Vaginal Lacerations
- rare case but easier to assess
- oozing of blood after repair, vaginal packing is necessary to
maintain pressure from the suture line
- catheterize the mother because packing causes pressure on
urethra
- packing is removed after 24-48 hours (at risk for infection)
3. Perineal Lacerations
- usually occurs when mother is placed on lithotomy positions
(increases pressure on perineum)

Classifications:
a. First Degree – vaginal mucous membranes and skin of the
perineum to the fourchette
b. Second Degree – vagina, perineal skin, fascia and perineal body
c. Third Degree – entire perineum and reaches the external sphincter
of the rectum
d. Fourth Degree – entire perineum, rectal sphincter and some of the
mucous membrane of the rectum
Management (Perineal)
1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool softener is prescribed for
the first week postpartum to prevent constipation which could
break the sutures
3. do not take rectal temperatures because the hard tips of
equipment could open sutures
3. Retained Placental Fragments – placenta does not deliver its
entire fragments and left behind leading to uterine bleeding
Causes:
a. Placenta Succenturiata –a placenta with accessory lobe
b. Placenta Accreta – a placenta that fuses with myometrium because of an
abnormal basalis layer

Signs and Symptoms:

1. if Large fragments
- Patient bleeds immediately at delivery
- Uterus is boggy
2. if Small fragments
- bleeding occurs at 6th – 10th day PP
- Can cause subinvolution
Management:
1. Dilatation and Curettage (D&C) will be performed to remove
placental fragments and to stop bleeding
2. administration of Methotrexate to destroy the retained
placental tissue
3. instruct the mother to observe the color of lochia discharge
4. check the completeness of the placenta after birth
4. Disseminated Intravascular Coagulation (DIC)
- deficiency in clotting ability caused by vascular injury
characterized by bleeding the IV sites, nose, gums etc.
Associative Factors:
a. premature separation of the placenta
b. missed early miscarriage
c. fetal death in utero
5. Perineal Hematoma – is a collection of blood in the
subcutaneous layer tissue of the perineum caused by injury to blood
vessels after birth
Risk Factors:
a. rapid spontaneous birth
b. perineal varicosities
c. episiotomy or laceration repair sites

Signs and Symptoms:

1. severe pain in the perineal area
2. feeling of pressure between the legs
3. purplish discoloration/swelling on perineum
4. concealed bleeding
Management:
1. assess the size by measuring it in centimeters
2. administer a mild analgesic as pain relief
3. apply an ice pack (covered by towel to prevent thermal
injury to the skin)
4. incision and drainage of the site of hematoma and is
packed with gauze
 Puerperal Infection
- Infection of the reproductive tract associated with giving birth
- Usually occurs within 10 days of birth
- Another leading cause of maternal death
- Predisposing factors:
a. Prolonged rupture of membranes (>24 hours)
b. C-section
c. Trauma during birth process
d. Maternal anemia
e. Retained placental fragments
 - Infection may be localized or systemic
a. Local infection can spread to peritoneum (peritonitis) or circulatory
system (septicemia).
b. Fatal to woman already stressed with childbirth

Assessment findings:
1. Temp of 100.4 for more than 2 consecutive days, excluding the first 24
hours.
2. Abdominal, perineal, or pelvic pain
3. Foul-smelling vaginal discharge
4. Burning sensation with urination
5. Chills, malaise
6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity
(Remember, 20-25,000 is normal after delivery—MASKING infection)
Nursing interventions
1. Force fluids; may need more than 3L/day
2. Administer antibiotics after culture and sensitivity of the organism
(Group B streptococci and E. Coli) and other meds as ordered
3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote drainage and prevent
reflux higher into reproductive tract
6. Use of sterile equipments on birth canal during labor, birth and
postpartum
7. Educate the mother about proper perineal care including wiping from
front to back
  
 Endometritis
- refers to the infection of the endometrium, the lining of the uterus at
the time of birth or during Postpartal period

Signs and Symptoms:

1. fever on the third or fourth day postpartum(increase in oral
temperature above 38C for 2 consecutive 24 hour periods, excluding
the first 24 hours period after birth)
2. chills, loss of appetite and general body malaise
3. uterine tenderness
4. foul smelling lochia
Management:
1. ATBC administration such as Clindamycin after culture
2. oxytocin is given to encourage uterine contraction
3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after pains and
abdominal discomforts
5. encourage client to ambulate or in Fowler’s position to
promote lochia drainage and prevent pooling of infected
secretions
6. IV therapy
 Perineal Infection
- localized infection of the suture line from an episiotomy site

Signs and Symptoms:

1. feeling of heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines

Management:
1. removal of perineal sutures to open and allow for drainage
2. Topical, systemic ATBC as ordered
3. Analgesic to alleviate discomfort
4. Provide Sitz bath or warm compress to hasten drainage and
cleanse the area
5. Remind the mother to change perineal pads frequently to
prevent contamination/infection
6. Teach proper perineal care wiping from front to back after
bowel movement (to prevent bringing the feces to the healing
area)