OB NOTES

NORMAL LABOR (THEORIES OF LABOR ONSET) 3RD STAGE

5 – 20 MINS
1. Oxytocin Stimulation Theory 5 – 20 MINS
4TH STAGE
2. Uterine Stretch Theory 2 – 4 HOURS
2 – 4 HOURS
3. Progesterone Deprivation Theory ESSENTIAL FACTORS OF LABOR (5Ps)
1. Passages
4. Prostaglandin Theory 2. Power
3. Passenger
5. Theory of the Aging Placenta 4. Person
5. Position
6. Fetal Adrenal Response Theory
PASSAGES
SIGNS OF LABOR (WRISLIR)
FUNCTIONS (Sit Sit)
Weight Loss – 2-3 pounds (progesterone) Serves as birthcanal
Ripening of the Cervix – “soft” It proves attachment to muscles, fascia and
Increased Braxton Hicks – “irregular, ligaments
painless” Supports uterus during pregnancy
Show – “ruptured capillaries + operculum = It provides protection to the organs found
pinkish color” within the pelvic cavity
Lightening – “the baby dropped” TYPES (GAPA)
 2 weeks (primi) and before or during (multi) Gynecoid – normal female type of pelvis
Relief of respiratory discomfort  most ideal for childbirth
Increased frequency of urination  round shape, found in 50% of women
Leg pains Android – male pelvis
Muscle spasms  presents the most difficulty during childbirth
Increased vaginal discharge  found in 20% of women
Decreased fundal height Platypelloid – flat pelvis, rarest, occurs to 5%
Increased Level of Activity – large amount of of women
epinephrine (AG) Anthropoid – apelike pelvis, deepest type of
Rupture of Membranes – gush or steady pelvis found in 25% of women
trickle of clear fluid DIVISION OF PELVIS
1. False Pelvis – “provide and direct”
FALSE LABOR 2. True Pelvis – “the tunnel” IPO
(CANDAC)  Inlet or Pelvic Brim – entrance to true
Contraction disappear with ambulation pelvis
Absence of cervical dilation ANTEROPOSTERIOR DIAMETER DOT
No ↑ DIF (duration, intensity, frequency) 1. Diagonal Conjugate – midpoint of sacral
Discomfort @ abdomen promontory to the lower margin of symphysis pubis
Absence of show (12.5 cm)
Contraction stops when sedated 2. Obstetric Conjugate – midpoint of sacral
promontory to the midline of symphysis pubis (11
TRUE LABOR cm)
(CUPPAD) 3. True Conjugate – midpoint of sacral promontory to
Contraction persists when sedated the upper margin of symphysis pubis (11.5 cm)
Uterine contraction ↑ DIF (duration, Pelvic Canal -situated between inlet and outlet
intensity, frequency) designed to control the speed of descent of the fetal
Progressive cervical dilation head
Presence of show Outlet - most important diameter of the outlet
Ambulation increase contractions
Discomfort radiates to lumbosacral area POWERS 3I’s
⦿ Involuntary – not within the control of the
LENGTH OF LABOR parturient
(STAGE OF LABOR) ⦿ Intermittent – alternating contraction and
 PRIMI (VIRGIN) relaxation
 MULTI (DIS-VIRGIN) ⦿ Involves discomfort (compression, stretching and
1ST STAGE hypoxia)
10 – 12 HOURS
6 – 8 HOURS ⦿ PHASES OF UTERINE CONTRACTIONS
2ND STAGE 1. Increment/Crescendo – “ready, get set”
30 MINS – 2 HOURS 2. Acme/Apex – “go”
Ave: 50 mins 3. Decrement/Decrescendo – “stop”
20 – 90 MINS
Ave: 20 mins ⦿ INTENSITY - strength of uterine contraction
 OB NOTES
Mild – slightly tensed fundus Occipitomental – head is extended and
Moderate – firm fundus the presenting part is the face
Strong – rigid, board like fundus - measured from the chin to the posterior
fontanel
⦿ FREQUENCY – rate of uterine contraction - average size is 13.5 cm
- measured from the beginning of a contraction to the
beginning of the next contraction ⦿ FETAL LIE – relationship of the long axis of the
fetus to the long axis of the mother
⦿ DURATION – length of uterine contraction Longitudinal Lie – “parallel”
- measured from the beginning of a contraction to the Transverse Lie – “right angle/lying
end of the same contraction crosswise”
Oblique Lie – “slanting”
⦿ INTERVAL – measured from the end of contraction
to the beginning of the next contraction ⦿ Attitude or Habitus – degree of flexion or
relationship of the fetal parts to each other
PASSENGER
PRESENTATION AND PRESENTING PART
⦿ HEAD (BOTu) LIE
Biggest part of the fetal body PRESENTATION ATTITUDE
Always the presenting part A. Longitudinal Lie
Turn to present smallest diameter 1. Cephalic (head)
2. Breech (butt)
⦿ CRANIAL BONES 1 FOSE, 2 PaTe
1 frontal bone2 parietal bone B. Transverse Lie
1 occipital bone2 temporal bone Causes:
1 sphenoid bone 1. relaxed abdominal wall
1 ethmoid bone 2. placenta previa

⦿ SUTURE LINES – allow skull bones to overlap Vertex – most ideal

(molding) and for further brain development (SFC  suboccipitobregmatic is presented (9.5
La) cm)
Sagittal Suture – between 2 parietal bones  Brow – occipitomental is presented (13.5
Frontal Suture – between 2 frontal bones cm)
Coronal Suture – between frontal and parietal  Sinciput – occipitofrontal is presented
Lamdiodal Suture – between parietal and (12.5 cm)
occipital  Face presentation
 Chin presentation
⦿ FONTANELS – intersection of suture lines
Anterior Fontanel or Bregma – intersection Complete breech - feet & legs flexed on the
of SFC. diamond shaped, closes b/n 12 – 18 thighs and the thighs are flexed on the
months 3 x 4 cm abdomen
Posterior Fontanel or Lambda – intersection
of Sla. triangular shaped, closes b/n 2 – 3 Frank breech - hips flexed and legs extended
months (MOST COMMON)

⦿ DIAMETERS OF THE FETAL HEAD Footling Breech – one or both feet are the
AP > T (fetal head) presenting parts
1.Tranverse Diameters BBB
Biparietal – most important TD Shoulder Presentation – fetus is lying
 greatest diameter presented to the pelvic perpendicular to the long axis of the mother
inlet’s AP and at the outlet’s TD  vaginal delivery is NOT POSSIBLE
 average measurement is 9.5 cm
Bitemporal – average measurement is 8 cm Compound Presentation – when there is
Bimastoid – average measurement is 7 cm prolapsed of the fetal hand alongside the
vertex, breech or shoulder.
Anteroposterior Diameters SOO  Complete flexion
Suboccipitobregmatic – smallest APD  Moderate flexion
- fully flexed (presenting part)  Partial flexion (military position)
- measured from the inferior aspect of occiput to  Extension
the anterior fontanel  Hyperextended
- average measurement is 9.5 cm  Good flexion
Occipitofrontal – head partially extended  Moderate flexion
and presenting part is the anterior  Very poor flexion
fontanel
 Flexion
- average size is 12. 5 cm
 OB NOTES
POSITION  uterus not relaxing completely after each
⦿ LOA (Left Occipitoanterior) – most favorable & contraction
common fetal position 4. Show – slightly blood-tinged mucus discharge
fetus in vertex presentation (occiput) 5. Internal Examination – to assess status of amniotic
fetus usually accommodates itself on the left fluid, consistency of cervix, effacement/dilatation,
because the placement of the bladder is at the presentation, station and pelvic measurement.
right  do it during relaxation
⦿ LOP/ROP – mother will suffer more back pains  less IE done once membrane have ruptured
⦿ FHT Breech: Upper R or L Quadrant (above  start with middle finger then index finger
Umbilicus) 6. Status of Amniotic Fluid (if ruptured)
⦿ FHT Vertex: Lower R or L Quadrant (below ● Danger of cord prolapse if fetal head is not yet
Umbilicus) engaged.
⦿ STATION - relationship of the presenting part of ● Danger of serious intrauterine infection if delivery
the fetus to the ischial spine of the mother does not occur in 24 hours
Minus (-) station – presenting part is above NITRAZINE PAPER TEST
the ischial spine used to assess whether membrane ruptured
Zero (0) station – presenting part is at the or not.
level of the ischial spine ● Procedure: “Insert and Touch”
Positive (+) station – presenting part is below Yellow – intact BOW
the level of the ischial spine Blue – ruptured
FLOATING – head is movable above the pelvic ● Normal Color of AF – clear, colorless to straw
inlet colored
+1 station – fetus is engaged ● Green tinged – meconium stain (fetal distress in
+2 station – fetus is in midpelvis non – breech presentation)
+4 station – perineum is bulging ● Yellow/Gold – hemolytic disease
● Gray/Cloudy – infection
⦿ THE PERSON ● Pinkish/Red stained – bleeding
FACTORS affecting labor PRC PCP ● Brownish/Tea Colored/Coffee Colored – fetal death
Perception & meaning of childbirth
Readiness & preparation for childbirth OTHER TEST TO DETERMINE STATUS OF
Coping skills AMNIOTIC FLUID
Past experiences
Cultural & social background ⦿ Ferning pattern of cervical mucus
Presence of significant others and support (“swab – dry – view”)
system
STAGES OF LABOR ⦿ Nile blue sulfate staining of fetal squamous cells
STAGE 1 – DILATATION STAGE
Starts from first true uterine contraction until FETAL ASSESSMENT DURING LABOR FHT
the cervix is completely effaced and dilated. Monitoring Latent Phase – every hour
 Dilatation – widening of cervical os to 10 cm Active Phase – every 30 minutes
 Effacement – thinning to 1- 2 cm Second Stage of Labor – every 15 minutes
CAUSES: FHT is taken more frequently in high – risk
1. Pergusion Reflex cases
2. Fetal head and intact BOW serves as a wedge to
dilate the cervix ⦿ Normal FHT Pattern
Maternal Assessment During Labor Baseline rate: 120 – 160 bpm
1. PIPIT PEPA HF Early Deceleration – FHT @ contraction,
2. Check V/S q 4hrs during the first stage Normal @ end of contraction (head
 temp q hour if membranes are already compression)
ruptured (risk of infection) Acceleration - FHT when fetus moves
 BP b/n contractions, in left lateral pos, q 15 –
20 mins after giving anesthesia ⦿ Abnormal FHT Pattern
 a rapid pulse indicates hemorrhage & Bradycardia – 100 – 119 bpm – moderate
dehydration below 100 bpm – marked
3. Uterine contraction
 Manual: fingers over fundus, you feel it about CAUSES:
5 secs before the client feels it 1. Fetal hypoxia (analgesia & anesthesia)
Techniques: 2. Maternal hypotension
1. assess contraction (DIIF) 3. Prolonged cord compression
2. check contraction q 15 – 30 mins during the first MGT:
stage 1. place mother on left side
3. Refer immediately if: 2. assess for cord prolapse
 duration more than 90 secs 3. administer oxygen
 interval less than 30 secs Tachycardia – 161 – 180 bpm – moderate
above 180 bpm – marked
 OB NOTES
CAUSES: Nsg Responsibilities: RRE
1. maternal fever, dehydration 1. Reassure woman that labor is nearing end &
2. drugs (atrophine, terbutaline, ritodrine, etc. baby will be born soon
MGT: 2. Reinforce breathing and relaxation
1. D/C oxytocin, position on LLP techniques
2. give 02 at 8 – 10 lpm 3. Encourage fast-blow breathing to remove the
3. prepare for birth if no improvement urge to bear down

Variable Pattern – deceleration at ⦿ CARE OF THE BLADDER – encourage the woman

unpredictable times of uterine contraction to void q 2 hrs to: DIPC
CAUSE: sign of cord compression Delay fetal descent
MGT: release pressure on the cord Increases the discomfort of labor
Sinusoidal Pattern – no variability in FHT Predispose to UTI
CAUSE: hypoxia, fetal anemia & prematurity Can be traumatized during labor
⦿ FOODS & FLUIDS – NPO on active phase
CARE OF THE PARTURIENT Clear fluids on latent phase
1. LATENT PHASE ⦿ POSITIONING – LLP - best position bcoz J RIPES
○ Cervical Dilation: 0 – 4 cm Relieves pressure – IVC
○ Nature of Contraction: Duration: < 30 secs Improves urinary function
Interval: 3 – 5 mins Prevent hypotensive syndrome
○ Length of Latent Phase:Primis – 6 hours Encourage anterior rotation of the fetal head
Multis – 4 – 5 hours Squatting is ideal position – directs
○ Attitude of mother: feel comfortable, walking and presenting part towards the cervix promoting
sitting at this time dilatation
○ Nsg Responsibilties:TGC ⦿ AMBULATION – during the latent phase to shorten
1. Teach breathing techniques the first stage, to decrease the need for analgesia,
2. Give instructions FHT abnormalities & to promote comfort
3. Conversation is possible (cooperative & focus NO WALKING IF BOW IS RUPTURED
mother) ⦿ IV FLUIDS – reasons: PLUA
Prevent dehydration/fluid & electrolyte
2. ACTIVE PHASE imbalances
 Cervical Dilation: 4 – 7 cm Life – line for emergencies
 Nature of contractions: Duration: 30 – 50 secs Usually required before administration of
Intensity: moderate to strong A/A
 Length of Active Phase:Primis – 3 hours Administration of oxytocin after delivery to
 Multis – 2 hours prevent atony
 Attitude of mother:prefer to stay in bed, ⦿ PERINEAL PREP
withdraws from her environment and self – Clean & disinfect the external genitalia
focused Provide better visualization of the perineum
Nsg Responsibilities: CPIC ⦿ ENEMA – emptying the colon of fecal matters to:
Prevent infection
1. Coach woman on breathing and relaxation Facilitate descent of fetus
techniques Stimulate uterine contractions
2. Prescribed analgesics given during active CONTRAINDICATIONS: NIRVAA
phase  Not given during active phase
3. Instruct woman to remain in bed, minimize  If premature labor bcoz of danger of cord
noise, raise side rails, NPO prolapse
4. Check BP 30 mins after giving analgesics  Rupture of BOW
(hypotension)  Vaginal bleeding
 Abnormal fetal presentation & position
3. TRANSITION PHASE  Abnormal fetal heart rate pattern
 Cervical Dilatation: 8 – 10 cm SECOND STAGE – EXPULSIVE STAGE
 Nature of Contractions:Duration: 50 – 60 secs  MECHANISM OF LABOR: EDFIRE ERE
Interval: 2 -3 mins Engagement
Intensity: moderate to strong Descent – entrance of the greatest biparietal
 Length of Transition Phase: diameter of the fetal head to the pelvic inlet
 Primis – 1 hour (baby delivered within 10 Flexion – the chin of the fetus touches his
contractions or 20 mins) chest enabling the smallest diameter
 Multis – 30 mins (baby delivered within 10 (suboccipitobregmatic) to be presented to the
contractions or 20 mins) pelvis for delivery
 Attitude of mother: feel discouraged, ask Internal Rotation – when the head reach the
midwife/nurse repeatedly when labor will level of the ischial spine, it rotates from
end, not in control of her emotions and transverse diameter to AP diameter so that its
sensations, irritated, may not want to be largest diameter is presented to the largest
touched
 OB NOTES
diameter of the outlet. This movement allows
the head to pass through the outlet. 1. Schultz Mechanism – separation of the placenta
Extension – the head of the fetus extend starts from the center
towards the vaginal opening. As the head  The shiny & smooth fetal side is delivered
extend, the chin is lifted up and then it is first
born.  80% of placental separation
External Rotation – when the head comes 2. Duncan Mechanism – separation begins from the
out, the shoulder which enters the pelvis in edges of placenta
transverse position turns to anteroposterior  The dirty maternal side is delivered first
position for it become in line with the  20% of placental separation
anteroposterior diameter of the outlet & pass
through the pelvis. MANAGEMENT:
Expulsion – when the head is born, the 1. Watchful waiting.
shoulder & the rest of the body follows  Do not hurry placental delivery.
without much difficulties.  Rest a hand over the fundus to make sure the
Duration of Second Stage: Primis – 50 mins uterus remains firm
 Multis – 20 mins  Wait for signs of placental delivery
Assessment: monitor FHT q 15 mins in normal case Calkin’s sign – uterus is firm, globular & rising
and every 5 mins in high risk cases if not yet to the level of umbilicus
delivered Sudden gush of blood from vagina
Transfer to the DR: Primis – cervix fully dilated Lengthening of the cord
 Multis – cervix is 8 cm dilated 2. Manage the uterus to keep it contracted.
3. Administer methergin as prescribed.
Delivery Position 4. Never leave the client unattended.
1. Lithotomy – used when forcep delivery & 5. Oxygen & emergency equipment made available.
episiotomy are to be performed.
2. Dorsal Recumbent – head of the bed is 35 – 45˚ THE FOURTH STAGE – PUERPERIUM
elevated, knees are flexed & feet flat on bed. This MANAGEMENT:
position facilitates the pushing effort of the mother. 1. Repair of lacerations.
3. Left Lateral Position – indicated for woman with CLASSIFICATION OF PERINEAL LACERATIONS
heart disease. First Degree – fourchette, vaginal mucous
membrane, perineal skin
⦿ ASSISTING THE MOTHER IN THE DR Second Degree – fourchette, vaginal mucous
1. Coach the mother to push effectively membrane, perineal skin, muscles of perineal
2. Instruct the woman to pant body
3. Dorsiflex the affected foot and straigthen the Third Degree – fourchette, vaginal mucous
leg until the cramps disappear membrane, perineal skin, muscles of perineal
4. Perform ironing on vaginal orifice if the body & anal sphincter
presenting part moves towards the outlet
5. When the head is crowning, instruct the Fourth Degree - fourchette, vaginal mucous
mother to pant. membrane, perineal skin, muscles of perineal
6. Perform Ritgen’s Maneuver while delivering body, anal sphincter & mucous membrane of
the fetal head to: rectum
 Slows down delivery of the head 2. After repair of lacerations & episiotomy, perineum
 Lets the smallest diameter of the head is cleansed, the legs are lowered from stirrups at the
to be born same time.
 Facilitates extension of the head 3. Check V/S of the mother every 15 mins for the first
7. Just after delivery, immediately wipe the hour & every 30 mins for the next 2 hours until
nose & mouth of secretions then suction. stable.
8. Take note of the exact time of baby’s birth 4. Check uterus & bladder q 15 mins.
9. After the delivery of the baby, place the HYPEREMESIS GRAVIDARUM
newborn in dependent position to facilitate Causes:(UTEP)
drainage of secretions. 1. Unknown
10. Place the infant over the mother’s abdomen 2. Thyroid dysfunction
to help contract the uterus. 3. Elevated HCG
11. Clamping the cord: 4. Psychological stress
 After the pulsation stops
 Clamp the cord twice and cut in S/Sx:
between 8 – 10 inches from umbilicus 1. Excessive N/V – persist beyond 12 weeks
 After cutting the cord, look for 2 2. Signs of dehydration (thirst, dry skin, weight loss,
arteries & 1 vein concentrated and scanty urine)
12. Wrap the infant & bring to the nursery

THIRD STAGE – PLACENTAL DELIVERY

METHODS OF PLACENTAL SEPARATION:
 OB NOTES
Management:  provide necessary referrals
1. Differential diagnosis (liver & thyroid function (counseling)
studies, urinalysis, Hct/Hgb and WBC)
2. Conservative management ABORTION
 dry, low fat, high carbohydrate and bland Definition of Terms:
diet
-dry crackers 1. Abortion – most common bleeding d/o of early
-small frequent feedings & sips of water pregnancy (before 20 weeks/fetus weighs 500
(gastric distention – trigger vomiting grams)
reflex)
-avoid very hot or very cold food & 2. Early Abortion – before 12 weeks pregnancy.
beverages
3. Late Abortion – between 12 – 20 weeks
 avoid noxious stimuli
- motion and pressure around the 4. Abortus – fetus that is aborted weighing less than
stomach (tight waistbands) 500 grams
- temporary cessation of iron
supplement (gastric upset) 5. Occult Pregnancy – zygotes that were aborted
- avoid highly seasoned and spicy foods before pregnancy is diagnosed or recognized
- avoid strong odors (perfumes)
- avoid loud noises, bright and blinking 6. Clinical Pregnancy – pregnancies that were
lights
diagnosed
 take vitamin supplement to correct 7. Blighted Ovum – small macerated fetus,
nutritional deficiencies from decreased
sometimes there is no fetus, surrounded by a fluid
food intake
 have enough relaxation & rest inside an open sac.
 take prescribed medications
- Promethazine (Phenergan) 8. Carneous Mole – zygote that is surrounded by a
- Prochlorperazine (Compazine) capsule of clotted blood
- Ondansentron (Zofran)
- Droperidol (Inapsine) 9. Fetus Compressus – fetus compressed upon itself
- Metoclorpramide (Reglan) and desiccated with dried amniotic fluid
- Diphenhydramine (Benadryl)
- Meclizine (Antivert) 10. Fetus Papyraceous – fetus that is so dry that it
resembles a parchment
3. Hospitalization (correct dehydration and F&E
imbalances) 11. Lithopedion – a calcified embryo
 IV fluids (lactated ringers)
 Vitamin supplementation 12. Immature Infant – having a birth weight b/n 500
 NPO for 24 – 48 hours (rest – 1000 grams
GIT)
 Oral fluid intake after 13. Full Term Infant – born between 38 – 42 weeks
hydrated and nausea subside
 when patient begins oral Types of Abortion:
intake of foods:
- administer antiemetics before meals  1. Elective/Therapeutic Abortion – “the
- see patient is relaxed & comfortable deliberate termination of pregnancy”
- introduce food gradually starting with
clear liquids a. EA – initiated by personal choice
- small frequent feedings
- do not serve odorous, spicy & greasy b. TA – recommended by the healthcare provider
foods
- do not force patient to eat  2. Spontaneous Abortion – “loss of a fetus due
4. Parenteral or enteral therapies to natural causes”
5. Complementary therapies
 acupressure (pericardium 6 or P6) Causes of Spontaneous Abortion:
 herbal remedy (ginger – carminative
effect/aroma) A. Fetal Causes (80% – 90%)
 . vitamin supplementation
1. Developmental anomalies
 Provide emotional support
 show sincere concern for the
2. Chromosomal abnormalities (Trisomy 16)
women’s welfare
 empower patient with knowledge &  B. Maternal Causes (congenital/acquired
encouragement
conditions)
 OB NOTES
1. Advanced maternal age (after 35 years of age) 4. rest for a few days to 2 weeks (coitus&douching for
approx 2 weeks)
 <35 y/o (15% miscarriage rate)
 b/n 35 – 39 y/o (20 – 25% miscarriage rate) 5. may experience intermittent menstrual-like flow
 b/n 40 – 42 y/o (about 35% miscarriage rate) and cramps (next menstrual period occurs after 4 – 5
 >42 y/o (about 50% miscarriage rate) weeks)

2. Structural abnormalities of the reproductive 6. Reassure patient that her next pregnancy is likely
tract to last to term if she is young and has no other risk
factors. (no pregnancy for the next 3 months)
3. Inadequate progesterone production (corpus
luteum/placenta) 7. Determine woman’s Rh factor

4. Maternal infections (rubella virus, 8. Advise patient to return if:

cytomegalovirus, listeria infection,
toxoplasmosis)  - profuse vaginal bleeding
 - severe pelvic pain
5. Chronic and systemic maternal diseases  - temperature greater than 100˚F

6. Exogenous factors (tobacco, alcohol, cocaine, 2. Inevitable or Imminent Abortion – “can not be
caffeine, radiation) prevented”, (+) complete dilatation

Complications of Abortion:  S/Sx:

1. Hemorrhage 1. Moderate to profuse bleeding

2. Infection or septic abortion 2. Moderate to severe uterine cramping

3. Disseminated intravascular coagulation (DIC) 3. Open cervix or dilatation of cervix

Types of Spontaneous Abortion: 4. Rupture of membranes

1. Threatened Abortion – “possible” 5. No tissue has passed yet

 - (+) bleeding, (-) cervical dilatation Management:

 S/Sx:
 -Light vaginal bleeding (bright red)  *Avoiding complications of infection or
 -None to mild uterine cramping excessive blood loss
 Management: 1. Hospitalization
1. Assess for: 2. D&C
 - LMP 3. Oxytocin after D&C
 - Save all pads for examination
 - ask for presence of clots 4. Sympathetic understanding and emotional support
 - abdominal pain
3. Complete Abortion – “spontaneous expulsion”
2. Conservative management
 S/Sx:
 - bedrest until 3 days after bleeding has
stopped 1. Vaginal bleeding, abdominal pain and passage of
 - no coitus up to 2 weeks after bleeding tissue
stopped
2. On examination:
3. Educate mothers.  - light bleeding or some blood in the vaginal
Management: vault
 - no tenderness in the cervix, uterus or
1. Monitor V/S abdomen
 - none to mild uterine cramping
2. Monitor closely for bleeding or signs of infection  - closed cervix
3. Regular diet (high in iron foods)  - empty uterus on utrasound
 OB NOTES
4. Incomplete Abortion – “expulsion of some parts 6. Habitual Abortion – “repeated 3 or more”
and retention of other parts of conceptus in
utero” Causes:

 S/Sx: 1. Incompetent cervix

1. Heavy vaginal bleeding 2. IUGR

2. Severe uterine cramping 3. Congenital, genetic & chromosomal abnormalities

3. Open cervix Management:

4. Passage of tissue 1. Treating the cause

5. ultrasound shows some products of conception 2. Specific treatment according to cause:

Management:  a. Cervical Cerclage (modified Shirodkar, Mc
1. D&C Donald’s) – suturing the cervix
 b. Fertility drugs (Clomiphene, Pergonal, etc.)
 - uterus must kept contracted after D&C  c. Aspirin or Mini – Heparin
 - inspect fundus frequently  d. Luteal Phase Progesterone Support
 - a danger of D&C (uterine perforation)  e. correction of defects
 f. treatment of medical illness
2. Monitor blood loss
7. Infected Abortion – “infection @ POC & MRO”
 - inspect perineal pads (60 – 100ml of blood)
 - monitor v/s (BP & PR) 8. Septic Abortion – “dissemination of bacteria in
 - monitor the blood studies of patient’s maternal circulatory and organ system
clotting factors
 - monitor I & O (Oliguria – decrease renal Causative Organisms:
perfusion – shock) 1. E. Coli
3. Sympathetic understanding and emotional 2. Enterobacter Aerogenes
support.
3. Proteus Vulgaris
 - encourage verbalization of feelings
4. Hemolytic Streptococci
5. Missed Abortion – “retention after death”
5. Staphylococci
S/Sx:
S/Sx:
1. Absence of FHT
1. Foul smelling vaginal discharges
2. Signs of pregnancy disappear
2. Uterine cramping
 - uterus fails to enlarge
 - no FHT 3. Fever, chills and peritonitis
 - serum or urine test for the subunit of HCG is
negative 4. Leukocytosis – WBC count 16, 000 – 22,000/uL
 - ultrasound showing no cardiac activity 5. Critically ill patients
Management: Management:
1. Product of conception be removed to prevent DIC 1. Treat abortion
2. Insert 20mg Dinoprostone (Prostaglandin E) 2. high dose IV antibiotic therapy (Penicillin – gram
suppository into the vagina q 3 or 4 hours PRN (<28 negative, Clindamycin/Tobramycin – gram positive)
weeks gestation)
3. D&C if accompanied by incomplete abortion
3. Oxytocin IV infusion (late missed abortion)
4. Infertility may occur
 OB NOTES
ECTOPIC PREGNANCY S/Sx:

Causes: 1. missed menstrual period of two weeks

duration (68%)
1. Mechanical Factors – “delay passage of ovum”
2. Unilateral lower abdominal pain (99%)
 salphingitis
 peritubal adhesions 3. Irregular vaginal bleeding (75%)
 developmental abnormalities
 previous ectopic pregnancy 4. before rupture
 tumors that distort the tube  brief amenorrhea
 past induced abortions  pelvic and abdominal pain on the side of the
2. Functional Factors affected tube
 “Arias – Stella Reaction”
 external migrations of the ovum
 menstrual reflux 5. Ruptured ectopic pregnancy:
 altered tubal motility A. pain
3. Assisted Reproduction  sudden severe and knife like pain
 ovulation induction(Clomid)  radiating to the neck and shoulder
 gamete intrafallopian transfer  -cervical pain during IE
 in vitro fertilization B. spotting or bleeding – darkbrown
 ovum transfer
C. Cullen’s Sign or bluish discoloration of the
4. Failed contraception umbilicus due to the presence of blood in the
Types of Ectopic Pregnancy: peritoneal cavity

1. Tubal - >95% FALLOPIAN TUBE D. Hard or boardlike abdomen

A. Ampulla (most common site, 55%) E. Signs of shock

B. Isthmic (25%) 6. Diagnosis
C. Fimbrial (17%)
D. Interstitial (2%) A. Transvaginal Utrasound (TVUS)
E. Bilateral (very rare)
TVUS + serial HCG det. = most reliable
2. Ovarian (cystectomy/oophorectomy, 0.5%)
B. Serial HCG
3. Abdominal (1/15,000 pregnancies) C. Pregnancy Test
D. Culdocentesis
a. Primary – original implantation outside the tube E. Serum Progesterone Level
b. Secondary – implantation in the abdomen after  >25ng/ml –normal viable pregnancy
rupture and expulsion  <5ng/ml – nonviable pregnancy
F. Uterine Curettage
4. Cervical (due to in vitro fertilization and embryo G. Colpotomy
transfer H. Laparoscopy
I. CBC
5. Heterotypic Pregnancy (TP accompanied by J. Elevated WBC
intrauterine pregnancy)
Management:
6. Tubo – Uterine ( partly implanted in the tube and
uterus) 1. Therapeutic Abortion – unruptured EP

7. Tubo – Abdominal ( fimbriated implantation a. Methotrexate Therapy

extends into the peritoneal cavity
2. Surgical removal – ruptured EP
8. Tubo – Ovarian (partly implanted in the tub and
partly in the ovary)
 OB NOTES
Nursing Interventions: 4. Rapid increase in uterine size (out of
proportion)
1. Prevent and treat hemorrhage
5. Signs of preeclampsia before 24 weeks (HEP)
 IVF to prevent shock
 type & cross match blood 6. Absence of FHT and fetal skeleton
 place flat in bed with legs elevated
 provide extra blanket to keep warm 7. Ultrasound (mass of fluid filled vesicles –
“snowflake pattern”)
2. Assist in positioning the patient
8. Elevated plasma thyroxine levels
3. Post – op interventions:
9. Elevated serum gonadotropin level (>100 days)
 monitor v/s
 assistance with positioning & ambulation Management:
 monitor IV fluids therapy 1. D&C
 If patient is Rh-negative, RhoGAM is given
within 72 hours and before discharge 2. Methotrexate (Choriocarcinoma)
 provide contraceptive counseling
3. HCG monitoring for 1 year
4. Meet emotional needs of patient
 HCG should be negative 2-8 weeks after
5. Prevention removal of mole (every 2 weeks)
 monthly for 6 months
 safe sex practices  every 2 months for another 6 months
 importance of gynecological exams  chest x-ray every 3 months for 6 months
 S/Sx of STDs
 possible risks associated with the use of an 4. Woman advised not to be pregnant for one year
IUD
 contraceptives should not contain estrogen
HYDATIDIFORM MOLE - benign disorder of the
placenta characterized by degeneration of the 5. Hysterectomy
chorion and death of the embryo  above 40 years old
Types:  who have completed child bearing
 who desire or require sterilization
1. Complete Molar Pregnancy – “only placental
parts, no embryo” Complications of H – Mole:

2. Partial Molar Pregnancy – “2 fathers, 1 mother” 1. Gestational Trophoblastic Tumors – “trophoblastic

“placenta and fetus formed but incomplete” proliferation”

Risk Factors/Incidence: a. Choriocarcinoma – most severe complication

1. Geography  conversion of chorionic villi into cancer cells

that erode blood vessels and uterine muscles.
2. High in women below 18 and above 40 years old  “lungs”

3. High in low socioeconomic status (low protein b. Invasive Mole – developed during the first 6
intake) months

4. History of molar pregnancy  excessive formation of trophoblastic villi that

penetrates the myometrium
S/Sx:
c. Placental Site Trophoblastic Tumor – composes of
1. Excessive N/V due to elevated HCG levels cytotrophoblastic cells arising from the site of the
2. Bleeding from spotting to profuse (brown placenta.
bleeding)  produce both prolactin and HCG
3. Passage of grape like vesicles around the 4th  main symptom is “bleeding”
month **Management of all trophoblastic tumors is
HYSTERECTOMY
 OB NOTES
INCOMPETENT CERVIX Types of Placenta Previa:

Diagnosis: 1. Complete/Total PP – covers the internal os

1. Pelvic examination or IE 2. Partial PP – partially covers the internal os

2. Ultrasonography – (cervical os is >2.5cm or
length is shortened to <20mm)
 “funneling”
3. Marginal PP – edge of the placenta is lying at
Predisposing Factors/Causes: the margin of the internal os

1. DES exposure in utero 4. Low Lying PP – implants near the internal os

with its margin located about 2cm – 5 cm from
2. Cervical trauma from previous difficult the internal os
deliveries (forcep deliveries)
Frequency:
3. Hormonal influences
1. approx 3.5 – 8 pregnancies per 1000 after 20
4. Congenitally short cervix wks AOG

5. Forced D&C 2. Maternal mortality assoc. with PP is <1%

6. Uterine anomalies 3. Maternal morbidity is about 5%

S/Sx: Predisposing Factors/Causes:

1. Painless vaginal bleeding or pinkish show 1. Unknown

accompanied by cervical dilatation (first sign) 2. Decreased blood supply or scarring @ upper
segment
2. Rupture of membranes and passage of
amniotic fluid  multiparity
 previous molar pregnancy
Management:  endometritis
 age (above 35 y/o)
1. Cervical cerclage @ 14 weeks (“earlier the  previous CS
better”)  abortion
 repeated D&C
2. Prerequisites of cervical cerclage: cervix not 3. Decreased blood supply to the endometrial lining
dilated beyond 3 cm 4. Short umbilical cord
5. Abnormal placentas (placenta increta and accreta)
 intact membranes 6. Large placenta
 no vaginal bleeding and uterine cramping
Complications:
3. Types of cervical cerclage: 1. Hemorrhage
 Shirodkar Suture – “permanent suture” 2. Infection
 Mc Donald Suture – “temporary suture” 3. Prematurity
 38 – 39 weeks removal of suture 4. Obstruction of birth canal
5. DIC
4. After suturing the cervix: 6. Abnormal adhesion of placenta
 place woman on bedrest for 24 hours – 7. Renal failure may occur r/t shock caused from
several days hemorrhage or DIC
 observe for bleeding, contraction and rupture 8. Anemia
 report passage of fluid or signs of PROM 9. More lacerations
 if uterine contracts, RITODRINE may be given 10. Fetal effects/neonatal effects
 restrict activities after application for the next 11. Brain damage or neurological abnormalities
weeks including coitus **Ultrasonography best way to differentiate AP from
PP
PLACENTA PREVIA- occurs when a baby's placenta
partially or totally covers the mother's cervix the S/Sx:
outlet for the uterus. Placenta Previa can cause 1. Sudden painless vaginal bleeding (24 – 30 weeks)
severe bleeding during pregnancy and delivery 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”
 OB NOTES
4. Decreased urinary output  sexual arousal, intercourse or orgasm should
**Ultrasound is the earliest and safest diagnostic tool be avoided
for PP  avoid enema and douche
 stop working or employment
Management:  provide diversional activities
1. IE by MD only under double set up (done in
the OR – patient is prepped and draped) 5. Inform patient and family to be observant
 bleeding, contraction & decreased fetal
Double Setup is Indicated When: activity
1. ultrasound is not available 6. Diet
2. the ultrasound evidence is inconclusive
3. patient with ongoing but not life-threatening  foods high in iron
vaginal bleeding in labor  prenatal vitamins (Iron + Vitamin C)
4. mother has a marginal previa and is well-  increase fiber intake
established labor
7. Clinic visit is usually once or twice a week
2. Assess extent of blood loss
 visual estimates (most often used but the  ultrasound tests (2-4 weeks interval)
most inaccurate)  regular NST
 Vital signs  biophysical profile
 Tilt Test (woman bleeds profusely but has
normal blood pressure and pulse in 8. Labor and delivery
recumbent position will develop hypotension A. delivery is implemented when:
and tachycardia when placed in sitting  fetus is mature
position)  persistent hemorrhage
 Urine flow  intrauterine infection
3. If pregnancy is below 36 weeks  rupture of membranes persistent uterine
 Watchfulwaiting/expectant contractions unresponsive to tocolysis
management/conservative management  mother develops coagulation defects (DIC)

Nursing Interventions: B. method of delivery

 CS - delivery of choice (profuse maternal
a) Monitor: hemorrhage and fetal hypoxia)
✓ FHT and activity  VD – for marginal/partial previa
✓ Vaginal bleeding
✓ Uterine contractions C. Nursing Care:
✓ Maternal V/S
 Anticipate doctor orders for:
✓ Maternal I&O
 Ultrasound
b) Woman in CBR (if no bleeding after 48 hours,
 IVF (LRS, gauge needle #16 or #18)
mother is allowed bathroom privileges)
 CBC, blood type and cross match for at least 2
c) Manage bleeding episodes
units of whole blood, DIC panel, PTT, PT and
✓ Keep woman on NPO electrolytes. H/H may order every 12 hours.
✓ Monitor V/S, FHR, vaginal bleeding
✓ Maintain on absolute bedrest  In case of profuse bleeding:
✓ Start fluid replacement therapy and blood  CBR s BRP, quiet environment (+ bleeding)
transfusion  Keep on NPO
d) If woman is in active labor, tocolytics may be  Administer O2 tight mask @ 6lpm
given.  Do not perform enemas
e) Betamethasone (Celestone)is given to hasten fetal  Discourage bearing down
lung maturity (12mg IM q 12 hrs for 2 doses)
f) Amniocentesis (lung maturity)  Position
 Semi – Fowler’s Position
4. Outpatient management  Trendelenburg Position

a. live close to the hospital (within 5 – 10  Examinations & Monitoring

minutes) and 24 hours transportation availability  No IE
and close supervision by family or friends @  Place mother on continuous fetal monitoring
home  Monitor vaginal bleeding q 15 minutes then
30 minutes after bleeding stopped
b. restricted activities @ home  V/S q 15 minutes then 30 mins if stable and
 bed rest most part of the day bleeding subsides
 heavy lifting is strictly prohibited no  Assess I&O
vacuuming or standing for long periods of  Observe signs of DIC
time  Observe for shock
 OB NOTES
 Post – partum nursing care:  bleeding may or may not be present (<250cc)
 WOF hemorrhage  uterine irritability with no fetal distress
 Oxytocin, gentle massage and close  some uterine tenderness and vague backache
monitoring
 Surgical management such as ligation of the 2. Moderate – approx 1/6 – 2/3 of placenta
hypogastric arteries (internal iliac) or  dark vaginal bleeding may or may not be
hysterectomy present (<1000ml)
 Puerperal infection  uterine tenderness and tetany is present
 Observe elevation of temp above 39˚C or  fetal distress d/t uteroplacental insufficiency
100.4˚F
 Low – grade fever during 24 hours 3. Severe - >2/3 of the placenta
(dehydration)  uterine tenderness and rigidity along with
 Aseptic technique and handwashing severe pain
 Teach proper perineal care and good  dark vaginal bleeding (>1000cc)
handwashing technique  fetal distress if not delivered fetal death is
 Front-to-back motion when applying imminent
perineal pads  entire placental separation (maternal shock,
 Reinforce aseptic techniques during fetal death, severe pain and possible DIC
bathroom usage
S/Sx:
 Anemia
 Moderate to severe anemia d/t amount of 1. Vaginal bleeding occurs in 80% of women
blood lost Normal hemoglobin 12 – 13 g/dl  Dark red vaginal bleeding (CAP)
 Moderate anemia 9 – 11 g/dl  Bright red vaginal bleeding (OAP)
 Severe anemia below 9 g/dl
2. Abdominal pain
ABRUPTIO PLACENTA - “ablation placenta,  Uterine irritability and low back pain (2/3 of
placental abruption & accidental hemorrhage” or patient)
premature separation of the placenta from the  Complain “labor-like pains” (mild AP)
uterus.  Gradual or abrupt pain (moderate AP)
 Sudden and knife-sharp pain, localized and
Causes: diffused over the abdomen (severe AP)
1. Maternal hypertension  Sharp pain over the fundus – placental
2. Advanced maternal age (>35y/o) separates
3. Trauma to the uterus  Escalating abdominal pain – concealed bleed
4. Rapid decompression of an over-distended uterus
5. Grand multiparity (thinning of endometrium) 3. Board like abdomen – accumulation of blood
6. Short umbilical cord behind the placenta with fetal parts hard to
7. Uterine leiomyoma or fibroids palpate.
8. Behavioral factors:
 cigarette smoking, methamphetamine and 4. Signs of shock and fetal distress if bleeding
cocaine abuse are severe.
 maternal alcohol consumption (14 or more
drinks) Management:
1. Hospitalization is a must
Types of Abruptio Placenta: 2. If fetus is below 36 weeks
a. manage @ prolonging pregnancy
A. Classification According to Placental with the hope of improving fetal
Separation maturity if:
1. Covert/Central AP – “bleeding is internal and not  bleeding is not life threatening
obvious”  FHT are normal
2. Overt/Marginal AP – “bleeding is external”  mother is not in active labor

B. Classification According to Signs and Symptoms b. manage bleeding episode

1. Grade 0 – no symptoms
2. Grade 1 – some external bleeding, uterine tetany  place in bedrest (sidelying position)
and tenderness, absence of fetal distress and shock  IFC to accurately record I&O (at least
3. Grade 2 – external bleeding, uterine tetany, uterine 30cc/hr)
tenderness and fetal distress  NPO status
4. Grade 3 – internal bleeding and external bleeding  oxygen therapy (NC @ 4 – 6 lpm)
(>1000ccc), uterine tetany, maternal shock, probably  observe & record bleeding q 30 mins or more
fetal death and DIC (saturated perineal pad can absorb approx 60
– 100ml of blood)
Classification According to Extent of Separation  assess status of abdomen
1. Mild – <1/6 of the placenta is separated
 OB NOTES
 mark fundus of the uterus (concealed PREECLAMPSIA
bleeding) EFFECT
 monitor V/S  The amount of circulating plasma volume
 assess uterine contractions falls
 blood typing and cross matching  Rise in hemoglobin and hematocrit
 administer IVF (LRS 125cc/hr)  Decreased blood supply to kidney and
 monitor fetal condition by daily nonstress hemoconcentration stimulates release of
test and kick counts aldosterone, ADH and angiotensin
 administer prescribed medications  Sodium retention leading to edema
(hypernatremia)
 Bethametasone (hasten fetal maturity)  Vasospasm and hypertension
 Tocolytic therapy (MgSO4, Ritodrine or  Vasospasm cause damage to the endothelium
Terbutaline) promotes coagulation and increase sensitivity
 observe for signs of DIC to pressor agents.
 Assess bleeding  Elevated platelets
 “clot test”  Patient’s renal perfusion is affected.
 Coagulation studies (fibrinogen level, Decreased blood supply to kidneys resulting
prothrombin time (PT), partial prothrombin in decreased GFR. Efficiency of the kidney to
time (PTT), CBC, anticoagulant factor and remove metabolic waste is impaired.
electrolytes) Decreased renal perfusion results in damage
 delivery to kidney structures allowing passage of large
 CS – distressed fetus or uncontrolled molecules
bleeding (30 minutes)  Serum levels of BUN, creatinine and uric acid
 VD – fetus is dead, maternal bleeding is rise leading to acidosis and decreased urine
mild and if the mother is in stable output.
condition  Proteinuria
 postpartum (WOF couvelaire uterus)  Vasospasms decreases blood supply to the
brain resulting in cerebral ischemia
PREGNANCY INDUCED HYPERTENSION (PIH)-  Hyperreflexia
happens any time after the 24th week gestation – 2  Convulsions
weeks postpartum  Decreased blood supply to the uterus and
placenta
TRIAD SYMPTOMS:  IUGR
 hypertension (2 successive BP of 140/90 and  Fetal hypoxia and distress
above taken 4 - 6 hours apart)  Continuous vasospasm cause diminished
 edema (upper part of the body – hands and blood supply resulting in damage to blood
face) vessels and tissues in the placenta and
 proteinuria decidua
*specifically albuminuria  Abruptio Placenta
 albumin (water soluble protein)
Signs/Symptoms
Predisposing Factors:  Mild Preeclampsia
1. Age (<20y/o & >35y/o)  Severe Preeclampsia
2. Gravida – 5 or more pregnancies  Blood Pressure
3. Low socio-economic status  140/90, diastolic BP is more than 100mmHg
4. Extra-large fetus  Diastolic is 110mmHg or higher
5. Familial tendency  Proteinuria
 +1 - +2 by dipsticks
2 Types:  300mg/24 hour urine collection
1. Preeclampsia – 140/90, develops after 20  +2 - +4
weeks gestation accompanied by proteinuria  5g/24 hour urine collection
(300mg/24hrs) and edema.  Liver enzymes
 Slightly elevated
2. Eclampsia – all S and Sx of preeclampsia  Markedly elevated
accompanied by convulsion or coma that is Laboratory studies
not caused by other conditions.  Normal hematocrit, uric acid, creatinine
Causes:  Increased Hct, Crea and UA;
1. Unknown thrombocytopenia may be present
2. Genetic predisposition  Fetus
3. Autoimmune reaction and an immune reaction to  No IUGR
paternally derived antigens  IUGR present
4. Protein deficiency theory and dietary deficiencies  Edema
5. Endothelin theory  Digital edema, dependent edema
 Pitting edema (4+)
 Generalized edema
 OB NOTES
 Weight Gain ✓ Weight gain more than 1 lb a week
 1 – 2 lb/week ✓ Abnormal fetal movement and abdominal pain
 More rapid weight gain
 Urinary Output
 Not less than 400ml/24 hours Hospital Management:
 Less than 400 ml/24 hours a. Hospitalization is necessary if:
 Cerebral Disturbances • BP is equal or greater than 160/100mmHg
 Occasional headache • Proteinuria of 3+ or 4+
 Severe frontal headache, photophobia, • Rapid weight gain
blurring, spots before the eyes (scomata), n/v • Oliguria
 Reflexes • Visual disturbances
 Normal to 3+ • Abnormal fetal movement
 Hyperreflexia, 4+ b. Expectant management
 Epigastric Pain ● Treatment with Bethamethasone (2 doses)
 Absent c. Fluid therapy
 RUQ pain (aura to convulsion) d/t swelling of ● Crystalloid infusion (LRS & NSS, 100ml/hr –
hepatic capsule 125ml/hr)
● Close monitoring
S/Sx of Eclampsia: d. Medications
● Magnesium Sulfate
1. All the S/Sx of preeclampsia ✓ Prevent convulsion and seizures
2. Convulsion followed by coma ✓ Reduce edema
3. Oliguria
✓ Reduce BP
4. Pulmonary edema
Nursing Considerations:
Management:
Loading dose: 4gm over 20 mins, followed by 2 –
1. Roll – Over Test (increase of 20mmHg or greater
3gm/hr (ACOG)
diastolic pressure)
Check the ff before giving:
2. Tolerance Hyperbaric Test (portable BP cuff – 48
hours) ✓ RR above 14cpm
✓ UO at least 100ml/4hr
Ambulatory Management: ✓ DTR are present (loss of DTR – first sign of
1. Home management is allowed only if: toxicity/hypermagnesemia)
• BP is 140/90 or below ✓ Serum magnesium levels are evaluated
• Low proteinuria periodically
• No fetal growth retardation and good fetal 7 – 8 mg/dL (therapeutic level)
movement 10 - 12 mg/dL (developing toxicity)
2. Bed rest (when lying down, assume LLP) *If MST develops (1gm (10ml) 10% Calcium
3. Consult every two weeks Gluconate)
4. Home management also include phone calls and Antihypertensives
home visits by the N – M Hydralazine (Apresoline)
5. Diet: high in protein and carbohydrates with ID: 5mg IV bolus
moderate sodium restriction RD: 5mg – 10mg q 20 mins if diastole is above
6. Hospitalization is necessary if condition worsens 110mmHg
7. Provide detailed instructions about: Labetolol (Normodyne) 20mg IV q 10 mins to max
a. Dietary modifications of 300mg
✓ High in protein Safety measures
✓ Moderate sodium restriction ✓ Raise padded side rails
✓ Eat a balanced diet that include 1200mg calcium ✓ Put bed at lowest position
✓ Avoid salty foods, such as canned foods, soda, ✓ Have emergency equipment’s available
chips and pickles Care of the woman during convulsion
✓ Eat foods with roughage
✓ Drink 8 – 10 glasses of water daily Stages of Convulsion:
✓ Avoid alcohol 1. Stage of Invasion or Aura – facial twitching,
rolling of the eyes to one side, staring fixedly
✓ Take daily weight measurement
in space, sudden severe headache, screaming
✓ Measure and record fluid intake and urine output and epigastric pain
b. Monitor her own health condition and report to
health care provider immediately if the following 2. Tonic Phase – rigid body, eyes protrude, arms
occur: are flexed with legs inverted, hands are
✓ Take and record her BP twice daily clenched, woman stop breathing lasts for 15 –
✓ Count fetal movements per hour (3/h) 20 seconds.
✓ Take and record weight daily
✓ Report for increased BP, epigastric pain and visual 3. Clonic Phase – jaws and eyelids close and
disturbances open violently, foaming of the mouth, face
 OB NOTES
becomes congested and purple, muscles of ● Occurs during placental separation (0.5 ml fetal Rh
the body contract and relaxes alternately last positive blood can produce massive production of
for about 1 minute. antibodies during the first 72 hours of life)
● Erythroblastosis Fetalis during pregnancy and
Hemolytic Disease after delivery.
• Anemia
4. Postictal State – contractions cease and • Splenomegaly and hepatomegaly
woman enters a semicomatose state. • Hyperbilirubinemia
• Hydrops fetalis
Nursing Responsibilities: • Stillbirth
✓ Always monitor patient for impending signs of
convulsions Prevention:
✓ Two main resp: maintenance of patient airway and 1. Prenatal screening
protection of patient from self-injury a. History
✓ Turn patient on her side to allow drainage of b. Screening test
secretions Antibody Titer Test (Coomb’s Test)
✓ Never leave an eclamptic patient alone Indirect Coomb’s Test – maternal serum
✓ Do not restrict movement during a convulsion as Direct Coomb’s Test – fetal cord blood
this could result in fractures
Antibody titer is negative:
• Repeat: 16 – 20 weeks and 26 – 27 weeks of
After convulsion:
pregnancy
• WOF signs of AP, vaginal bleeding, abdominal pain,
• Anti-Rho(D) Gamma Globulin (RhoG
FHT
• Take v/s
• Suction nasopharyngeal secretions and administer
oxygen
• Sedatives, Diazepam (Valium) if MgSO4 cannot
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