CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

NCM 0109 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)
c. Explaining the procedure
OUTLINE d. Providing privacy
I Identifying Client at Risk
A Assessment of Risk Factors 2. After extracting blood samples for percutaneous
i Pre-Pregnancy, Pregnancy, and Labor/Delivery
Factors umbilical blood sampling (PUBS), the nurse
· Psychological, Social, and Physical submits the blood sample to the laboratory for
B Screening Procedures, Diagnostic Tests, and what kind of test to ensure that it is fetal blood?
Laboratory Procedures
i Biophysical Assessment
a. Alpha-fetoprotein test
· Daily Fetal Movement Count b. Coomb’s test
· Ultrasonography c. Kleihauer-Betke test
· Magnetic Resonance Imaging
d. Maternal assay
ii Biochemical Assessment
· Amniocentesis
· Percutaneous Umbilical Blood Sampling 3. During a nonstress test, you have noted that there
· Chorionic Villus Sampling is no increase in fetal heart rate. Which among the
· Maternal Assays
iii Electronic Fetal Monitoring following are you going to do next?
· Non-Stress Test a. Administer orange juice to awaken the fetus
· Vibroacoustic Stimulation b. Inform the client that the fetus is dead
· Contraction Stress Test
c. Wait for another 10 minutes, then notes for
changes in FHT
INTRODUCTION d. Call the physician

● PREGNANCY 4. To provide a more sound diagnosis of DM, the

○ Significant highlight in the life of a woman physician will most likely order which of the
○ Marked by various changes reflected in the following diagnostic procedures because it reflects
physical, mental, and emotional aspects of the blood glucose over the past 4 to 6 weeks?
person a. Lecithin-Sphingomyelin ratio
○ Complications may occur that can put the b. Fasting blood glucose
woman and unborn child at risk c. Glycosylated hemoglobin
● MATERNAL MORTALITY d. Western blot test
○ DOH (2018) shows that maternal mortality
rates decreased in the past years 5. The baby of a pregnant woman with GDM is at risk
● 58/100,000 (2018) from 74/100,000 to develop respiratory distress syndrome. In order
(2015) to check for lung maturity, this client needs to
○ Leading Causes: hemorrhage and undergo which diagnostic test?
hypertension (70% of direct causes) a. Alpha-fetoprotein test
● Maternal Sepsis: accounts for 9% of b. Coomb’s test
total maternal deaths c. Kleihauer-Betke test
● RESPONSIBILITY OF NURSES d. Lecithin-Sphingomyelin ratio
○ Conducting thorough assessment, monitoring,
and provision of care 6. A woman with Rh (-) blood is usually given with
○ Familiarizing themselves with complications Rho Gam how many hours after delivery of the Rh
and their respective implications, medical (+) baby?
treatment/management, and nursing care a. 36 hours
b. 72 hours
PRETEST c. 48 hours
d. 24 hours
1. A woman is scheduled for an ultrasound (UTZ). You
know which of the following is important before the 7. Which of the following signs and symptoms is
start of this procedure? readily assessed on a person with anemia?
a. Obtain consent a. Pale palpebral conjunctiva
b. Full bladder

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

b. Easy fatigability ● IMPORTANT NURSING ROLE: IDENTIFICATION

c. Restlessness ○ Illness: can complicate pregnancy
d. Delayed capillary refill ○ Lifestyle: alcohol consumption, tobacco,
environmental factors (e.g., work)
8. A pregnant client with AIDS is taking Zidovudine. As ○ Family: history of illness
a knowledgeable nurse, you know that the side ● HOW WILL WE IDENTIFY CLIENTS AT RISK?
effect of this drug is: ○ Assessment of risk factors
a. Decreased WBC count ○ Screening procedures
b. Decreased platelet ○ Diagnostic tests
c. Increased WBC count ○ Laboratory procedures
d. Increased platelet
I. IDENTIFYING CLIENT AT RISK
9. A woman with AIDS had just delivered her baby.
Which of the following activities is contraindicated? IA. ASSESSMENT OF RISK FACTORS
a. Sexual intercourse
b. Breastfeeding ● Problem identification
c. Receiving drug via IV route ● Pregnancies can be designated as high risk for any
d. Blood transfusion of several undesirable outcomes
○ The number of risk factors that are present
10. The following are withdrawal symptoms except: contributes to the categorization of pregnancy
a. Lethargy risk
b. Nervousness ○ The presence of more than one risk factor
c. Irritability equates to a higher classification of
d. Apathy pregnancy risk

ASSESSMENT AND CATEGORIZATION

HIGH-RISK PREGNANCY

One in which a concurrent disorder, ● Affected by the presence of individual coping

●
pregnancy-related complication, or external factor mechanisms and levels of support
jeopardizes the health of the pregnant person, the ● Minimal risk
fetus, or both ○ Ex. The mother is dealing with mental illness
but has access to counseling
○ CONCURRENT DISORDER: mother’s health
before the pregnancy; also refers to a ● Moderate risk
co-existing, parallel or simultaneous condition ● Extensive risk
○ PREGNANCY-RELATED COMPLICATION: could ○ Ex. The mother is dealing with mental illness
give danger to the health of the fetus (e.g., and has no access to counseling
anemia, hypertension, heart problems)
CLASSIFICATION OF RISK FACTORS
○ EXTERNAL FACTOR: danger in the health of all
both (e.g., socioeconomic status, trauma,
● PERIOD OF GESTATION
injury, vehicular accidents, falls)
○ Pre-pregnancy
● PATIENTS CONSIDERED HIGH-RISK
○ Pregnancy
○ A woman who enters pregnancy in good
○ Labor and delivery
health, but then develops a complication of
● DISTURBANCE
pregnancy that causes it to become high-risk
○ Physical: body systems, functions, and
○ A woman who enters pregnancy with a
processes
chronic illness that, when superimposed on
○ Social: environment, society, and personal
the pregnancy, makes it high-risk
relationships
○ A woman who enters pregnancy with a
○ Psychological: mental health and emotional
combination of particular circumstances
factors
(poverty, lack of support people [teenage
pregnancies], poor coping mechanisms,
genetic inheritance [muscular dystrophy], or
past history of pregnancy complications
[placenta previa, GDM])

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

FACTORS THAT CATEGORIZE A PREGNANCY AS ● Phenytoin: folic acid displacement (neural

HIGH-RISK tube defects, decreased coagulation factors
[bleeding tendencies])
I. PRE-PREGNANCY
● Survivor of childhood sexual abuse (trauma)
A. PSYCHOLOGICAL FACTORS ○ May lead to personality disorders

● Mental and emotional factors of the client B. SOCIAL FACTORS

● History of drug dependence
○ Ex. Alcohol intake ● The environment, society, and personal
● When a drug dependent pt is advised to relationships of the client
stop, this can cause anxiety ● Occupation involving handling of toxic substances
● History of intimate-partner abuse ○ Radiation and anesthesia gasses
○ Violence of a relationship ● ANESTHESIA: can be given via IV sedation,
○ More children = increase abuse epidural/spinal, or inhalation
● They choose to be pregnant for them to not ○ Some anesthesia are contraindicated
be hurt by their partner during pregnancy as they are considered
○ May lead to PROM and preterm labor teratogenic (inhalation/general
● History of mental illness anesthesia)
○ Stressors of pregnancy may or may not ○ General anesthesia may cause
exacerbate mental illness premature contractions
○ May happen before or during pregnancy ● Environmental contaminants at home
○ Managed and cared by the psychiatric care ○ Insecticides should not come in contact with
team and prenatal care group to lessen the pregnant clients
exacerbation of the mental illness ● Isolation and/or lack of support people
● AGE GROUP: adolescents and young adults ● Lower economic level (problem with finances to
(coping mechanisms are still immature, role sustain the pregnancy)
confusion and independence) ● Poor access to transportation for care
○ DEPRESSION: most common in pregnant ● High altitude (higher altitude = lower and thinner
patients oxygen concentration)
● Women are 4x more at risk than men ○ Low/Thin oxygen levels results to low oxygen
because of hormonal changes supply for the fetus
[menstruation, postpartum blues] ● Highly-mobile lifestyle (no specific records of
○ SCHIZOPHRENIA: highest incidence among pregnancy kasi palipat-lipat)
young pregnant women ● Poor housing
○ TERATOGENS: important to consider the
consequences if given to pregnant clients [will C. PHYSICAL FACTORS
the benefits outweigh the risks?]
● Antidepressants ● Body systems, functions, and processes
● Lithium: “mood-do” medication; for mood ● Visual and hearing challenges
disorders (bipolar); improves the mood of ○ Visual impairment: braille watch (time
the patient contractions by counting instead; no second
● Serotonin-reuptake inhibitors: depression hand)
● History of poor coping mechanisms ○ Auditory impairment: hand infant ASAP; check
○ Ex. Overeating for breathing and crying; use sign language;
● Cognitively-challenged give the baby to the mother immediately as a
○ Visual, hearing, and neurological problems way of reassurance
○ Check medications for pregnancy category ○ Spinal cord injury: unable to feel contractions;
○ NI: Always check for the safety of the forceps delivery or cesarean section (no urge
medication to bear down and contractions are not felt);
○ SEIZURE MEDICATIONS labor watch (touch and place the hand on the
● Reduce dosage to the lowest possible stomach of the mother); tachogram
dosage as these drugs are teratogenic and ● Pelvic inadequacy, misshape, or inflammatory
seizures would not occur disease

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

○ Android, anthropoid, and platypelloid pelvis: ● Cigarette smoker and substance abuser
difficulty delivering via NSD
○ Pelvic inflammatory disease: infection of the C.1. SECONDARY MAJOR ILLNESS
organs during pregnancy
● Uterine incompetence, position, or structure A. HEART DISEASE
○ Uterine contractions are not strong enough to ● FETAL VALVE DAMAGE
deliver the baby ○ Rheumatic fever or Kawasaki disease
○ Bicornuate uterus ○ Congenital anomalies (atrial septal defect/ASD
○ Uterine prolapse or uncorrected coarctation of the aorta/COA)
● Secondary major illness ● INCREASED CIRCULATORY BLOOD VOLUME
○ Heart disease ○ 28–32 weeks AOG is the most dangerous as it is
○ Diabetes Mellitus the peak of increased blood volume (30-50%)
● May develop during pregnancy which can ● Functional (innocent) or transient murmurs
progress into Type 2 DM postpartum can be heard in many without heart disease
○ Kidney disease ○ Toward the end of pregnancy, the heart may
○ Hypertension (circulatory volume increases by become so overwhelmed by the increase in
50% during pregnancy) blood volume
○ Chronic infections (e.g., tuberculosis, ● Increased workload to circulate blood
hematopoietic/blood disorders, malignancy [1st ● Decreased cardiac output
trimester/do not metastasize]) ● Poor placental perfusion (decreased
● 📌 REMEMBER: Pregnancy does not circulating blood to the fetus and decreased
precipitate cancer cell development and do oxygen supply)
not metastasize to the growing fetus unless ● PATIENTS WITH SPECIAL NEEDS
genetic in nature. ○ Those with an artificial but well-functioning
● However, if the mother has acquired cancer heart valve, pacemaker implant, and a heart
during pregnancy, cancer treatment is transplant can expect to have successful
delayed during the first trimester as cancer pregnancies as long as they have effective
medications are teratogenic, and because prenatal and postnatal care
of organogenesis and development of the
placenta CLASSIFICATIONS OF HEART DISEASE
● Poor gynecologic or obstetric history (e.g., G4P0) CLASS I (Normal)
● History of previous poor pregnancy outcomes
Uncompromised. Ordinary physical activity causes
○ Miscarriage: occurred before the 20 weeks AOG 1 no discomfort. No symptoms of cardiac
○ Intrauterine Fetal Demise: occurred after 20 insufficiency and no anginal pain. Can proceed
weeks AOG with pregnancy and normal birth.
○ Stillbirth: full-term pregnancy (37–38 weeks of CLASS II (Normal)
pregnancy) Slightly compromised. Ordinary physical activity
● History of child with congenital anomalies 2 causes excessive fatigue, palpitation, and
● Obesity (BMI >30) or underweight (BMI <18.5) dyspnea or anginal pain. Can get pregnant as
long as there is an increase in rest.
● History of inherited disorders
CLASS III
● Small stature
Potential of blood incompatibility Markedly compromised. During less-than-ordinary
●
3 activity, patient experiences excessive fatigue,
○ Rh- and Rh+ may lead to erythroblastosis palpitations, dyspnea, or anginal pain. Can
fetalis or hemolytic anemia complete pregnancy with complete bed rest
● Age without bathroom privileges.
○ <18 years old: pregnancy-induced CLASS IV
hypertension, iron-deficiency anemia, preterm Severely compromised. Patient is unable to carry
labor, cephalopelvic disproportion, conflicting out any physical activity without experiencing
developmental crisis, lack of knowledge about 4 discomfort (cardiomyopathy). Even at rest,
infant care symptoms of cardiac insufficiency or anginal pain
are present. Poor candidate for pregnancy.
○ >35 years old: pregnancy-induced Advised not to have a pregnancy.
hypertension, preterm/postterm birth, cesarean
delivery, postpartum hemorrhage,
chromosomal abnormalities

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

NURSING PROCESS ○ Penicillin: not teratogenic; pregnancy category

ASSESSMENT B; valvular damage (adhesion in the valve of
MATERNAL ASSESSMENT bacteria)
● Level of exercise/performance ○ Clindamycin, Ampicillin, and Amoxicillin: safe
for pregnancy; streptococcal infection
● Shortness of breath, cyanosis, cough, rapid/difficult
respirations INTERVENTIONS DURING LABOR/DELIVERY
● Vital Signs (BP, RR, PR) ● Assess vital signs (tachycardia [>100 bpm])
● Irregular pulse, chest pain ○ Ineffective heart pumping
● Capillary refill and jugular vein distention ○ Extreme maternal hypotension = fetal demise
● Liver size (indicative of right-side heart failure) ○ CVD + labor = inability to pump adequately →
● Edema tachycardia
○ Location should be thoroughly assessed ● Assess fetal heart tone and uterine contractions
● Normal: lower extremities due to poor ○ Normal FHT: 120–160 bpm
venous return from pressure of uterus ● Place the client in a left side-lying position; in
● Not normal: upper extremities; may be a high/semi-Fowler’s with rolled towel under right hip
sign of PIH for those with pulmonary edema
○ Assess edema with associated symptoms ○ Prevents hypotension (removes pressure on
FETAL ASSESSMENT vena cava) and improves uteroplacental
● Inadequate blood supply and nutrients reaching circulation
the placenta → LBW/SGA d/t acidosis (can result to ● Provide oxygenation
preterm labor; CS delivery may take place) ● Provide epidural anesthesia (px cannot push with
● UTEROPLACENTAL INSUFFICIENCY contractions)
○ Due to decreased cardiac output ● Forceps delivery
○ Causes late deceleration ○ Crowning is necessary
○ Associated with low birth weight and small for ○ Done when there is maternal exhaustion, cord
gestational age infants coil, and/or improper bearing-down technique
○ Causes fetal acidosis (leads to distress)
DIAGNOSIS B. DIABETES MELLITUS
● Endocrine disorder in which the pancreas cannot
Deficient knowledge regarding steps to reduce effects
of maternal CV disease on pregnancy and fetus produce adequate insulin to regulate body glucose
levels
THERAPEUTIC MANAGEMENT
● RISK FOR PATIENTS
● Iron and Sodium ○ Increased risk for thromboembolic events
○ Prevents iron-deficiency anemia (anemia among overweight diabetic clients
causes extra burden to the heart)
○ Diabetic for >20 years: no longer a candidate
○ Has enough oxygen binding ability for estrogen-containing birth control
○ Supports blood volume by maintaining sodium ● Use progestin-only methods and
= adequate CBV long-acting reversible contraceptives
● Given in minimal amounts as it is only used ○ Increased risk for hypoglycemia and
to balance the blood volume ketoacidosis due to constant fetal use of
● Limited but not severely restricted glucose
● Digoxin ○ Patients with preexisting kidney disease =
○ Improves cardiac output increased risk for pregnancy-induced
○ Strengthens quality contractions due to (+) hypertension
inotropic effect
● FETAL OUTCOMES
● Anti-arrhythmics ○ Large for gestational age or with birth
○ Irregular impulses = controls rhythm of the anomalies
heart
● Increased insulin the fetus must produce to
○ Reduces hypertension counteract the overload of glucose they
● Nitroglycerin receive acts as a growth stimulant
○ For cardiac pain or angina ● May create birth problems at the end of the
● Antibiotics pregnancy because of cephalopelvic
disproportion

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● Cesarean birth may be necessary ensure optimal absorption and decrease

○ Polyhydramnios: high glucose concentration infection.
causes extra fluid to shift and enlarge the
amount of amniotic fluid C. KIDNEY DISEASE
○ More prone to hypoglycemia, respiratory ● Determine desire to have children and history of
distress syndrome, hypocalcemia, and renal transplants
hyperbilirubinemia ○ Can cause progressive deterioration of kidney
○ Increased risk for congenital anomalies, function
spontaneous miscarriage, and stillbirth ● ERYTHROPOIETIN
especially if glucose is poorly-controlled during ○ Precursor in the formation of RBC
the first trimester ○ Erythropoiesis takes place in the bone marrow
● Most important time for fetal development ○ Synthetic and safe in pregnancy
● RISK FACTORS ● GLOMERULAR FILTRATION RATE
○ Obesity ○ Identified through serum creatinine
○ Age over 25 years ○ Normal: 0.7 mg/100 mL
○ History of large babies (10 lb or more) ○ Pregnancy: 0.5 mg/100 mL
○ History of unexplained fetal or perinatal loss ● If >2 mg/dL, the patient is not advised for
○ History of congenital anomalies in previous pregnancy
pregnancies ● DIALYSIS AND PROGESTERONE
○ History of polycystic ovary syndrome ○ May induce preterm labor
○ Family history of diabetes (one close relative or ● Progesterone is removed with dialysis
two distant ones) thereby causing uterine contractions
○ Member of a population with a high risk of (walang nag-i-inhibit sa contractions)
diabetes ● Nursing Responsibility: Administer IM
● THERAPEUTIC MANAGEMENT progesterone before procedure
○ Insulin therapy ● Associated problems include anemia (extra burden
● Needed by patients with pregestational on heart function), proteinuria, glycosuria,
diabetes and gestational diabetes who are hypertension, increased serum creatinine, edema
uncontrolled with diet or oral therapy ● URINARY TRACT INFECTION
● Necessary for the cells to take glucose from ○ Factors: asymptomatic bacteriuria, urinary
the bloodstream stasis (dilation of ureters d/t effect of
● NURSING RESPONSIBILITIES: Early in progesterone), glycosuria (ideal medium for
pregnancy, insulin needs may be less. Later microorganism growth), vesicoureteral reflux
in pregnancy, increased insulin may be (back flow of urine into the ureter)
needed. Remind patients to eat immediately ○ Asymptomatic infections are potentially
after injecting insulin to avoid hypoglycemia. dangerous because they can progress to
Different body areas take up insulin at pyelonephritis (i.e., infection of the pelvis of the
different rates. Rotate within the same type kidney) and are associated with preterm labor
of injection site. and premature rupture of membranes
○ Blood glucose monitoring ● Pyelonephritis: begins with pain in the right
● The patient pricks their finger and uses a side of the lumbar region that radiates
glucometer to determine their blood glucose downward
● NURSING RESPONSIBILITY: If the patient is ○ Right Side: greater compression and
hypoglycemic, they should have some urinary stasis on the right ureter from the
carbohydrate-rich food, like crackers, and a uterus being pushed that way by the
protein, like milk large bulk of the intestine on the left side
○ Insulin pump therapy ○ Vesicoureteral Reflux
● An automatic pump with thin tubing, which ● Results to backflow of urine to ureters
is placed subcutaneously, most often on the ● Tend to develop UTIs or pyelonephritis more
abdomen often than others
● NURSING RESPONSIBILITY: Remind the ○ Escherichia coli: organism most commonly
patient to clean the site daily and cover it responsible for UTI; ascending infection
with a dressing to keep it clean. The site also ○ Streptococcus B: descending infection;
needs to be changed every 24–48 hours to associated with pneumonia in newborns

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● Patients will automatically be treated with ○ Recent inactive tuberculosis may also become
antibiotics in labor active during the postpartum period as the
● Strep B vaginal culture lung returns to its more vertical prepregnant
○ Therapeutic Management position following birth
● Amoxicillin, Ampicillin, and Cephalosporins: ● A patient who had tuberculosis earlier in life must
effective against most organisms causing be especially careful to maintain an adequate level
UTIs and are safe antibiotics during of calcium during pregnancy to ensure the calcium
pregnancy tuberculosis pockets in the lungs are not broken
● Sulfonamides: can be used early in down and the disease is not reactivated.
pregnancy but not near term because they ● THERAPEUTIC MANAGEMENT
can interfere with protein binding of bilirubin ○ Isoniazid, Rifampin, and Ethambutol
○ May lead to hyperbilirubinemia in the Hydrochloride may be given without apparent
newborn teratogenic effects (pyrazinamide and
● Tetracyclines: contraindicated during streptomycin are teratogenic)
pregnancy as they cause retardation of ● Take INH with Vitamin B6/pyridoxine to
bone growth and staining of the deciduous prevent peripheral neuritis
teeth ● Optic atrophy and loss of green color
○ Nursing Interventions/Preventive Measures recognition may occur with ethambutol;
● Frequent voiding (at least every 2 hours) make sure to have monthly eye check-ups
● Urinate as soon as urge is felt ○ Increased calcium intake to prevent
● Wipe from front to back reactivation
● Wear cotton underwear ● Ensures that tuberculosis pockets are not
● Void immediately after sexual intercourse broken down
● Drink a glass of cranberry/buko juice or ● Also prevents preeclampsia
water (alternative) daily

D. HYPERTENSION
● Pressure due to increased afterload leads to
increased workload from the heart
● After some time, hindi na nakakayanan ng heart
‘yung workload kaya nagkakaroon ng decreased
cardiac output → decreased oxygen supply

E. CHRONIC INFECTION: TUBERCULOSIS

● Lung tissue is invaded by Mycobacterium
tuberculosis, an acid-fast bacillus ● INFANT CARE
○ Macrophages and T lymphocytes surround the ○ The baby must be isolated from the mother
invading bacillus, but rather than actually killing ○ Must have 3 negative cultures before caring for
it, they merely surround and confine it and breastfeeding the infant
○ Positive Mantoux test (does not immediately ○ If TB is at home, infant must receive INH and
confirm TB but because of certain factors undergo skin test every 3 months
[exposure to TB patients where the immune ○ If the mother is taking INH, breastfeeding is
system develops antibodies, recent BCG contraindicated as INH may be toxic to the
vaccination, you are a TB patient)] infant
○ CHEST X-RAY: confirmatory test of tuberculosis
● Wait for 1–2 years before conceiving after infection II. PREGNANCY
becomes inactive
○ Pressure on the diaphragm d/t enlarging uterus A. PSYCHOLOGICAL FACTORS
changes the shape of the lungs → break open
● Poor gynecologic or obstetric history
the recently-calcified pockets more readily
● History of previous poor pregnancy outcomes
than well-calcified lesions → reactivates TB
(miscarriage, IUFD/stillbirth)
○ Increased intrapulmonary pressure from
● History of child with congenital anomalies
pushing may also break the pockets open
● Obesity (>30) /underweight (<18.5)

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● Pelvic inflammatory disease (permanent scarring ○ Chemotherapy: no adverse effects if given on

of the uterus) the 2nd–3rd trimester
● History of inherited disorder ○ Radiation to treat cancer: fetal defects and
● Small stature (difficult to carry pregnancy) fetal death
● Potential of blood incompatibility (Rh- is the ○ Thalidomide: used to treat nausea among
mother) pregnant clients in the 1960s
● Younger than 18 years old or older than 35 years old ● Causes amelia/phocomelia (limb defects)
● Drug abuse, cigarette smoker and substance ○ Finasteride and Minoxidil
abuser ● Used to address hair loss
● Loss of support person ● Prevents prostate gland enlargement
● Illness of a family member (leads to stress) ○ HPV, Measles, Mumps, Rubella, and Polio live
● Decrease in self-esteem vaccines
○ Feelings of inadequacy to continue pregnancy ● Do not administer without consulting the
● Poor acceptance of pregnancy (unplanned physician
pregnancies) ● Live/weakened vaccines may still cross the
○ Teenage pregnancy placenta
○ Low socioeconomic status ○ Ginseng (general well-being), Senna (laxative
○ Victim of sexual abuse for constipation), and Green tea (absorption of
folic acid)
B. SOCIAL FACTORS ○ Alcohol: fetal alcohol syndrome
○ Analgesics (aspirin or NSAIDS [indomethacin]):
● Refusal of/or neglected prenatal care maternal bleeding and/or keeps the ductus
● Exposure to environmental teratogens arteriosus open or patent
(physical/chemical forms) ○ Antineoplastics (methotrexate): multiple
○ Ex: violence, abuse anomalies
○ Stress also increases blood glucose d/t action ○ Anticonvulsants (phenytoin): fetal anomalies
of cortisol ○ Anti-coagulants (warfarin): fetal bleeding
○ Affects the fetus based on the following: ○ Antidepressants (lithium, tofranil):
● Timing: during 2nd to 8th week, produces cardiovascular anomalies
fetal injury (major body organs forming) ○ Anti-diabetics (insulin [gold standard
● Strength: amount introduced treatment]): neonatal hypoglycemia
● Affinity to specific tissue ● Metformin: oral hypoglycemic agent that is
○ Lead/Mercury: nervous tissue death non-teratogenic
○ Thalidomide: prevents nausea during ○ Anti-schizophrenic (lithium): hydramnios
pregnancy in the 1960s; limb defects; ○ Antibiotics (tetracycline): long bone deformities
amelia or phocomelia (arms and limbs
are closely attached to the trunk) PREGNANCY RISK CATEGORIES
○ Finasteride: restore hair growth
○ Tetracycline: tooth enamel/bone ● NO RISK IN HUMAN STUDIES
● Lahat ng tests ginawa without evidence
deformities A of teratogenic effects and risks for the
○ Rubella: eyes, ears, heart, and brain fetus
affectation
● NO RISK IN ANIMAL STUDIES
● Disruptive family incident ● Walang human testing, pero may
● Decreased economic support animal testing (we cannot conclude
● Conception less than 1 year after last pregnancy or that they are teratogenic as there was
pregnancy within 12 months of the first pregnancy no human testing)
○ DOH recommends a 2-year interval
● Teratogens (medications that directly affect fetal
B ● Walang data na nagsa-suggest na
mayro’ng human risk and affectation,
development) pero mayro’ng data that pregnant
○ Intimate partner violence animals failed to demonstrate risk to
● May lead to intensified abuse their growing fetus
● If the newly-pregnant mother has been ● Little or no risk to fetus
subjected to abuse, the risk of PROM
increases
C ● RISK CANNOT BE RULED OUT

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● Animal reproduction studies have C. PHYSICAL FACTORS

shown an adverse effect on the fetus
● Risk in animals ● Subject to trauma (automobile accidents, suicide,
● Determine risk vs benefit poor balance, fainting)
● May still be prescribed to patients but ○ Leads to PROM, premature placental separation
be extra careful in using these as it has (abruptio placenta), and preterm labor
potential risks ● Fluid or electrolyte imbalance
● EVIDENCE OF RISK ● Intake of teratogens
● There is positive evidence of human ● Multiple gestations
fetal risk based on adverse reaction ○ Increased risk for PIH, hydramnios, placenta
previa (low-lying placenta position; placenta
D data
● Benefits may outweigh the risk but also may also cover the cervix kaya pwedeng siya
be extra careful in monitoring the yung unang lumabas), preterm labor,
patient postpartum bleeding, and anemia
● CONTRAINDICATED ● Bleeding disruption
● Definitely teratogenic and totally ● Poor placental formation or position
avoided; huwag nang ipilit pa ● Gestational diabetes
X ● There are no chances that the risks ● Nutritional deficiencies (iron, folic acid, protein)
would be outweighed by the potential ● Poor weight gain
benefits ● Pregnancy-induced hypertension (poor vision,
headache; affects the mother physically)
○ Caffeine and nicotine: low birth weight and ● Infections
growth restriction (bloatedness = hindi kakain; ● Amniotic fluid abnormality
vasoconstriction d/t nicotine = decreased ● Post-maturity (danger of meconium staining)
blood supply)
○ ToRCH/ToRSCH Infection III. LABOR AND DELIVERY
● Toxoplasmosis: uncooked meat and cat
A. PSYCHOLOGICAL FACTORS
litter
○ Cross placenta and cause fetal harm ● Severely frightened by labor and delivery
○ CNS damage and retinal deformities experience
○ Sulfonamide: high serum bilirubin (can ○ More common among clients younger than 18
cause kernicterus) years old
○ Pyrimethamine: reduces folic acid levels ○ Anxiety makes it difficult for them to understand
(neural tube defects) how to bear down
● Rubella (German measles) ● Inability to participate due to anesthesia
○ Multiorgan damage (eyes, heart, and
○ Epidural (cannot push properly)
brain) Separation of infant at birth
●
● Syphilis and other infections ● Lack of preparation for labor
○ Hepatitis B and Chlamydia ● Birth of infant who is disappointing in some way
● Cytomegalovirus (droplet infection) ○ Sex, appearance, congenital abnormalities, etc.
○ CNS impairment (hydrocephalus,
● Illness in newborn (e.g., down syndrome and
microcephaly, spasticity), eye damage, autism)
hearing impairment, liver damage, and
blueberry-muffin lesions (extramedullary B. SOCIAL FACTORS
erythropoiesis)
○ May be recurrent ● Lack of support person
● Herpes Simplex ○ Left by their partner or living alone
○ 1st trimester: congenital anomalies and ● Inadequate home for infant care
spontaneous miscarriage ○ Not enough that the baby has a house to live in,
○ 2nd–3rd trimester: premature birth and the home must be conducive to infant care
IUGR ● Unplanned cesarean birth
○ Stress response may increase sympathetic
stimulation, heart rate, blood pressure, and
blood sugar (hyperglycemia)

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● Caused by stress hormone cortisol C. PHYSICAL FACTORS

○ Interference with body defenses (breakage in
the integrity of the skin), circulatory function ● Hemorrhage and infection
(may increase blood pressure), body organ ○ Normal Blood Loss: 500 cc (NSD) or 1000 cc
function (increases risk of postpartum (CS)
hemorrhage [uterus is not well-contracted]), ○ Beyond these levels, mother might need blood
edema, self-image, and self-esteem transfusion
○ Maternal factors ● Fluid/electrolyte imbalance (because of losing
● Active genital herpes and HPV blood during delivery)
○ If nag-deliver vaginally, baka ● Dystocia (difficult/obstructed birthing)
ma-contract ng baby ‘yung infection ○ Shoulder dystocia: the shoulder is too wide
● CPD compared to the pelvis; hindi malabas ‘yung
○ Hindi magkakasya kasi the size of the shoulders
mother’s pelvis is not enough to ● Precipitous birth (fast/rapid delivery)
accommodate the fetal head ○ Be careful kasi may cases na sa isang push
● Cervical cerclage lang, lumalabas na ‘yung baby
○ Nag-o-open or nagkakaroon na ng ○ Risk for cervical/vaginal lacerations and
effacement yung cervix kahit first immediate decrease of pressure in the uterus
trimester palang ● Cervical/vaginal lacerations
○ Stitching during the 2nd trimester d/t ● Cephalopelvic disproportion
incompetent cervix ● Internal fetal monitoring (device inserted internally
○ Done to close the cervix and continue the that may affect the mother physically)
pregnancy ● Retained placental fragments (uterus remains
● Severe PIH non-contracted and the mother is at risk for
○ Fetal distress d/t decreased oxygenation bleeding)
● Failed induction/failure to progress in labor
○ Could cause fetal distress kaya II. SCREENING PROCEDURES, DIAGNOSTIC TESTS,
kailangan ng emergency CS AND LABORATORY PROCEDURES
● Obstructive benign/malignant tumor IIA. BIOPHYSICAL ASSESSMENT
● Previous CS
○ NSD/vaginal birth after CS (VBAC) is still BIOPHYSICAL PROFILE (BPP)
possible but wait for 2–3 years
○ If hindi nag-wait, baka mag-rupture ● Non-invasive test that combines fetal heart rate
‘yung cesarean scar on the uterus monitoring (nonstress test) and fetal ultrasound
○ Placental factors (breathing movement, fetal body movement,
● Placenta previa, abruptio/premature muscle tone, and amniotic fluid volume) to
separation (mother may suffer severe evaluate five parameters into one assessment
bleeding/hemorrhage), umbilical cord ○ The nonstress test and ultrasound
prolapse measurements are then each given a score
○ Fetal factors based on whether certain criteria are met
● Macrosomia in breech (babies that are ○ MANNING’S SCORE
bigger than normal; common among ● Score system used
diabetic mothers) ● More accurate in predicting fetal
● Extreme LBW well-being than any single assessment
● Fetal Distress ● BPP is not normally performed before the
● Hydrocephalus second half of pregnancy due to absence
● Multigestation and conjoined twins of fetal movements
○ If uncomplicated, pwede naman
mag-deliver vaginally NORMAL ABNORMAL
[2 PTS] [0 PT]
○ Sa conjoined twins, CS lang ‘yung pwede
INTERPRETATIONS
● Transverse fetal lie ● 8–10: reassuring; fetus is doing well
○ Shoulder ‘yung presenting part ● 6: suspicious
● Lack of access to continued healthcare and to ● 0–4: fetus is in jeopardy; immediate delivery is
emergency personnel/equipment needed

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

FETAL BREATHING MOVEMENT — SONOGRAM ● Obesity reduces ability to check fetal movement
○ The abdominal wall is thicker
At least 1 episode of
30-second sustained ● Place the client in a left side-lying position to ensure
None or <30 seconds proper uteroplacental blood flow (vena cava is not
breathing movements
within 30 minutes compressed)
FETAL BODY MOVEMENT — SONOGRAM ○ To prevent supine hypotensive syndrome
○ The blood vessels of the uterus compress when
At least 3 separate in supine position = decreased blood flow
movements of the torso
Less than 3 movements ○ Position the mother in semi-fowler’s, reclining,
or limbs within 30
minutes side-lying position
● Conduct this test after meals and before bedtime
FETAL MUSCLE TONE — SONOGRAM
○ Fetus is more active due to increased glucose
At least 1 episode of delivered (kapag kakain si mommy, kakain din
extension and flexion of si baby; baby becomes stronger and active)
No movement
the limb or trunk within ○ More relaxed environment at night
30 minutes
● Ask the mother to observe and record fetal
AMNIOTIC FLUID INDEX — SONOGRAM movements until they have counted 10 movements
○ <10 movements during 1st hour: walk and
Amniotic fluid pocket of
Less than 5 cm recount during the next hour
5–25 cm
○ <10 movements after two hours: contact HCP
FETAL HEART REACTIVITY — NONSTRESS TEST, DOPPLER,
OR STETHOSCOPE
I. SADOVSKY METHOD
At least 2 accelerations
of at least 15 bpm above
baseline and of 15 Less than 2 accelerations ● Client records the number of fetal movements they
seconds duration in 20 feel over the next hour
minutes ○ Each kick/position change = 1 movement
● NORMAL: A fetus is expected to move a minimum
DAILY FETAL MOVEMENT COUNT (DFMC) of twice every 10 minutes (10–12 times/hour)
○ If <10 movements are detected, the procedure
● Used to monitor the fetus in pregnancies is repeated for the next hour
complicated by conditions that may affect ● Call HCP if it is still <10 within 2 hours
oxygenation ○ If there are no fetal movements, assess if the
● The pregnant client is placed in the left lateral fetus is sleeping
position after a meal and records fetal movements ● Stimulate by drinking orange juice or by
over an hour vibroacoustic stimulation
○ The result may vary depending on the fetus ● Position the mother in left-recumbent, left
sleep cycle and the time of the client’s last side-lying, or left tilted position after meals

●
meal
QUICKENING
● 💡 MAIN IDEA: Sa isang hour, ilan ‘yung movement?

○ First motion of the fetus felt by the mother

II. CARDIFF METHOD
○ Occurs at 18–20 weeks of pregnancy
● DFMC is especially conducted at 28–38 ● Count-to-ten
weeks AOG The mother records the time interval it takes for her
●
○ A healthy fetus moves at least 10x a day to feel 10 fetal movements, which typically occurs
○ Warning Sign: sudden increase or decrease in within 60 minutes
movements mean placental insufficiency (not
receiving enough nutrients) or fetal
● 💡 MAIN IDEA: Gaano katagal bago makaabot ng 10
‘yung movement?
hypoxia/demise
ROLL-OVER TEST (ROT)
NURSING RESPONSIBILITIES
● Presumptive test used for early diagnosis of
● Take note of alcohol, depressants, and tobacco hypertension and proteinuria at 20 weeks of
consumed by the client as these can temporarily gestation
reduce fetal movement

NCM 0109|11
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● 98% ROT is positive = preeclampsia (hypertension + ● Determining whether the baby is LGA or
proteinuria + edema) macrosomic
● Done during the 28th–32nd weeks of pregnancy ○ Identify fetal number, lie, presentation, position,
● PROCEDURE and weight
○ Take BP in lateral recumbent position until ○ Determine presence of IUD, ectopic pregnancy,
stable placenta previa, abruptio placenta, uterine
○ Roll client to supine position tumors (H-mole), and multiple pregnancy
○ Check BP immediately (diastolic pressure) ○ Fetal viability in a suspected fetal demise
● It is NOT NORMAL to have an increase ● High frequency sound waves (transducers) are
immediately after rolling placed on the abdomen/vagina → send sound
○ Wait for 5 minutes waves into the body and identify those that bounce
○ Check BP again, focusing on diastolic reading back → reflected in oscilloscope screen
● RESULTS: Record and report regardless of result ● KINDS
○ Positive: increase of >20 mmHg in the diastolic ○ B-mode Scanning: grayscale imaging; still
pressure after 5 minutes picture
○ Negative: increase of <20 mmHg in the ○ Real-time Scanning: provides visual image of
diastolic pressure after 5 minutes movement
● TYPES OF PELVIC ULTRASOUND
ULTRASONOGRAPHY ○ Abdominal: very common for pregnant clients;
laid supine; make sure the bladder is full
● Exposing a part of the body to high-frequency ○ Vaginal: placed in dorsal lithotomy; use
sound waves to produce a picture of the inside of protective cover and gel; empty the bladder;
the body pictures are clearer since the probe is nearer
● Provides critical information to HCPs regarding fetal the cervix/fetal structures; helps in early
activity, gestational age, fetal growth curves, fetal confirmation of pregnancy
and placental anatomy, and well-being ○ Rectal: prostate; done when the client is
○ FHT and fetal breathing movements are suspected of having prostate cancer
identified through the movement of the chest ○ Transrectal: recommended for patients that
and diaphragm have not yet engaged in any sexual activity
● Produces real-time imaging
● Also assists with visualization of invasive tests PREPARATION
(amniocentesis [obtaining amniotic fluid],
intrauterine balloon tamponade/BT [inserting a ● Explain procedure and obtain consent
catheter to stop uterine bleeding], fetoscopy ● If pregnancy is <20 weeks, full bladder is necessary
[surgical procedure inside the uterus]) ○ Client will be advised to drink 1-1/2 qt of water
● PURPOSES 1.5-2 hrs before the procedure
○ Placental location for amniocentesis ● Do not void 3 hours before the procedure:
○ Discover complications of pregnancy ○ Increases ultrasonic resolution
○ Determine fetal anomaly (HAM: hydrocephalus, ○ Elevates biparietal diameter measurements
anencephaly, meningocele), genetic ○ SPECIAL CONSIDERATIONS
abnormalities, and fetal death ● An empty bladder is needed for
○ Diagnose pregnancy (positive sign of amniocentesis d/t possibility of puncturing
pregnancy) the bladder IF the test is conducted during
○ Confirm presence, size, and location (grading) the 2nd–3rd trimester
of placenta and amniotic fluid ○ A full bladder is needed for better
● 0: 12–24 weeks AOG visualization during the 1st trimester since
● 1: 30–32 weeks AOG the uterus is still small
● 2: 36 weeks AOG ● Transvaginal ultrasounds require an empty
● 3: 38 weeks AOG (mature fetus) bladder as well
○ Determine biological sex of the baby ○ Magkakaroon ng added discomfort and
○ Estimate gestational age and growth uterine distortion and baka maihi if full
● Measuring the biparietal diameter (BPD ‘yung bladder
9.5-9.8 = mature) ● If pregnancy is >20 weeks, full bladder is not
necessary

NCM 0109|12
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

○ Pregnancy is already large enough to 2. In order to conclude a good fetal well-being, how
give better ultrasonic resolution many fetal movements should be recorded in 1 hour?
● Placenta previa: pre- and post-void views a. 5
○ Check with full bladder and check again b. 7
with empty bladder c. 9
d. 10
NURSING RESPONSIBILITIES
3. Which instruction should be given to a pregnant
● Ensure full bladder to displace the uterus upward client undergoing ultrasound?
(shows good result) a. Void every 15 minutes
○ Give full glass of water every 15 minutes (90 b. Hold breath for 15 seconds
minutes before procedure) c. Avoid voiding until after the procedure
○ Avoid voiding until after the procedure d. Drink sugary fluids before the procedure
○ PLAIN UTZ: full bladder for better visualization
○ UTZ + AMNIOCENTESIS: empty bladder (to 4. What should you do if there are only 7 fetal
prevent puncture) movements recorded in one hour?
● Drape client and expose only the abdomen a. Assure the client that everything is fine
(transabdominal) or the vagina-foot (transvaginal) b. Ask the client to walk
● Position the patient lying supine with a rolled towel c. Ask the client to rest
under right hip or in a left recumbent position to
prevent supine hypotension IIB. BIOCHEMICAL ASSESSMENT
● Apply warm gel to improve contact of the
transducer AMNIOCENTESIS
○ Make sure that the gel is warmed to room
● Amnion (sac) and kentesis
temperature to prevent uterine cramping
(to puncture)
● Intravaginal ultrasound is not used routinely
● An invasive procedure that
● Assure the client that the procedure is safe for both
involves aspiration of
the mother and the fetus but they might feel
amniotic fluid from the
uncomfortable due to the messy feeling from the
pregnant uterus
lubricant and the strong urge to void
● Scheduled between
14–16th weeks gestation
MAGNETIC RESONANCE IMAGING
(AF reaches 200 mL;
● Provides excellent pictures of soft tissue procedure needs 20 mL)
● Unlike CT, ionizing radiation is not used; thus, ● Assess color of amniotic fluid
vascular structures within the body can be ○ Expected color is clear with white specks
visualized and evaluated without injection of an ○ Late pregnancy = slight yellow
iodinated contrast medium (eliminates any known ○ Strong yellow color indicates blood
biologic risk) incompatibility (bilirubin from RBC lysis)
○ As there is no use of dye or contrast medium, ○ Green indicates meconium
there are no harmful effects to the mother and ● PURPOSES
fetus ○ Diagnose genetic disorders and congenital
● Used to diagnose complications such as ectopic anomalies (alpha fetoprotein)
pregnancy and hydatidiform mole ○ Assess fetal lung maturity
(lecithin:sphingomyelin ratio should be 2:1 or
SELF-CHECK greater [L>S]; usually happens by 35 weeks
1. Which is a parameter in the assessment of fetal AOG)
biophysical profile (BPP)? ○ Diagnose fetal hemolytic disease
a. Fetal breathing movement ○ Diagnose inborn errors of metabolism (NBS)
b. Fetal crying ○ Chromosomal abnormalities
c. Fetal urine output ○ CNS disorders
d. CSF index ○ AFP to check neural tube defects
○ Diagnose preterm labor by detecting fetal
fibronectin

NCM 0109|13
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● If evaluated between 24–36 weeks AOG, ● Administer RhoGAM after the procedure if the client
preterm birth is expected is Rh-
● Delivery is expected within 7–10 days after ● Monitor the client after the procedure
positive results ○ Check for temperature elevation, for leaking of
● KNOWN RISKS amniotic fluid from puncture site/vagina,
○ Fetal and maternal hemorrhage bleeding, and contractions
○ Infection (possible introduction of ● Remind the client to have bedrest all day
microorganisms upon aspiration)
○ Amniotic fluid emboli CARING FOR THE PATIENT
○ PROM
● INDICATIONS ● Painless; sensation of pressure, cramping (local)
○ Clients with ↑ maternal age ● BEFORE
○ History of child with genetic defect ○ During the 1st trimester, make sure the bladder
○ History of either parent carrying a is full to elevate the uterus and increase
chromosomal abnormality visualization of fluid pocket
● Possibility of frequent miscarriage ○ During the 2nd–3rd trimester, empty the
○ History of recurrent pregnancy loss bladder to avoid injury and to prevent
○ Abnormal MSAFP (maternal serum alpha aspirating urine instead of AF
feto-protein) ○ Learn how to differentiate amniotic fluid from
● COMPLICATIONS urine
○ Mild discomfort at needle site ● AF is high in protein and has a pH level of
○ Slight abdominal wall hematoma 7–7.5 while urine does not contain protein
○ Risk for miscarriage and pH is 4.5-8
● Uterine contractions may occur afterwards, ○ Obtain baseline maternal VS and FHR
which, if prolonged, may cause miscarriage ● DURING
○ Hemolysis of fetal blood cells in Rh- woman ○ Place the client in supine position
● Give RhoGAM ● Place rolled towel under right hip to prevent
● Ipa-puncture ‘yung placenta ng Rh+ baby → hypotension (to prevent SHS with s/sx of
baka mag-enter sa maternal circulation = light-headedness, faintness, nausea,
sensitization diaphoresis) in late pregnancy
● During early pregnancy, the uterus is still
NURSING RESPONSIBILITIES not big enough to compress the vena cava
○ Prep the abdomen using cleansing agents or
● Position the patient lying on their left side or supine Betadine
with a rolled towel under right hip to prevent ● AFTER
hypotension ○ Apply pressure and dressings on site of
● Attach fetal heart rate and uterine contraction aspiration (breakage of skin integrity)
monitors to gather baseline data (FHT and ○ Monitor the client for 30–40 minutes
maternal vital signs) before and after ● Auscultate FHT and VS every 15 minutes
amniocentesis to monitor status of fetus and uterus ● Palpate the fundus for fetal activity and
● Drape client and expose only the abdomen uterine contractions
● Clean abdomen with antiseptic solution ○ Rest until contractions or cramping
(Chlorhexidine, betadine) and apply local subside
anesthetic ○ Reportable Signs
● Void prior to the procedure ● Bleeding/drainage
● Avoid holding breath as distraction to discomfort ● Changes in fetal activity
○ Lowers abdomen and shifts intrauterine ● Severe uterine cramping or abdominal pain
contents; may puncture fetus or placenta (risk for premature labor)
● 15 mL of amniotic fluid is withdrawn ● Amnionitis (fever/chills, tachycardia, foul
● Place the client in a left lateral position after the odor of AF drainage)
procedure ○ Infection of amniotic sac/membrane
● Monitor FHT, uterine contractions, and maternal ○ Needs immediate delivery
vital signs for 30 minutes ○ Do not engage in strenuous activity, heavy
lifting, and sexual intercourse within 24 hours

NCM 0109|14
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● May cause further bleeding CHORIONIC VILLUS SAMPLING

● After amniocentesis, mayroong mild uterine
cramping and participating in these ● Biopsy and analysis of chorionic villi (extends
activities might lead to premature surface of the placenta) from growing placenta to
contractions and delivery determine genetic abnormalities
○ Chorionic villus is
PERCUTANEOUS UMBILICAL BLOOD SAMPLING subject to
chromosomal or
● Cordocentesis/Funicentesis DNA analysis
● Similar to the process of ● Done at 10–12 weeks
amniocentesis AOG
○ Involves aspiration ○ This is when the
● Blood is aspirated from the chorionic villus is
umbilical vein most prominent
○ Pierced using a thin ○ If done earlier,
needle guided with fetal limb defect is possible since
ultrasound organogenesis
● PURPOSES is still ongoing
○ Conduct laboratory tests such as complete ● Provides highly
blood count, Coomb’s test, blood gas studies, accurate results
and karyotyping of malformed fetus since chorionic villi
(chromosomal testing for genetic problems) cells are rapidly
○ Conduct fetal blood sampling and transfusion dividing and has
○ Treat isoimmunization and thrombocytopenia the same genetic
(decreased platelet count) structure with the
○ Diagnose inherited blood disorders fetus
○ Diagnose fetal hemolysis using bilirubin levels ● Main purpose is to detect genetic disorders
○ Determine acid-base status of fetus with ● Results are available the next day
intrauterine growth restriction/IUGR
○ Detect fetal infection NURSING RESPONSIBILITIES

NURSING RESPONSIBILITIES ● Ensure that the bladder is full prior to the procedure
● Obtain baseline fetal and maternal assessment
● Blood is subjected to Kleihauer-Betke test ● If the client is Rh-, RhoGAM is given after the
○ A blood test used during pregnancy to screen procedure
maternal blood for the presence of fetal red ● If done on clients with multiple pregnancies, cells
blood cells should be gathered from each placenta
● If the client is Rh-, RhoGAM is given after the ● Provide counseling especially when results reveal
procedure presence of genetic abnormalities
○ Prevents sensitization (the blood of an Rh+
baby may enter maternal circulation, causing MATERNAL ASSAYS
hemolysis)
● Continuous FHR monitoring for up to 2 hours
I. ALPHA-FETOPROTEIN
post-procedure
● Alpha-fetoprotein
○ Make sure that there is no bleeding and
(AFP) is a
hematoma on the site
glycoprotein
● Monitor fetal activity before and after the
produced by the
procedure using a nonstress test for one hour
fetal liver and
● Conduct follow-up ultrasound an hour after the
reaches a peak
procedure to check for bleeding tendencies
amount in the
maternal serum
between 13–32
weeks AOG
● Done on the 15-20th week of pregnancy

NCM 0109|15
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

○ Not routinely done on first visit since it is most

accurate between 16–18 weeks SELF-CHECK
○ If elevated or decreased, a confirmatory 1. How will you position a pregnant client undergoing
diagnostic test is done through amniocentesis amniocentesis?
or sonogram a. Left side-lying position
● Present in amniotic fluid and maternal serum b. Supine with rolled towel under right hip
○ The test primarily uses amniotic fluid c. Supine with knees flexed

RESULTS (NORMAL AMT: 2.5 MoM) 2. As a general rule, RhoGAM is given to a pregnant
client undergoing PUBS who:
● ELEVATED a. Is Rh-
○ Multiple fetuses; died b. Is Rh+
○ Presence of neural tube (spina bifida or c. Has a history of miscarriage
anencephaly) or abdominal defect
(gastroschisis or omphalocele [abdominal 3. A test that specifically determines presence of
cavity did not completely close]) maternal antibodies in Rh incompatibility:
● DECREASED a. Alpha-fetoprotein
○ Chromosomal anomaly (trisomy 21/Down b. Cordocentesis
syndrome) c. Coombs test
● Amniocentesis may be done to confirm
chromosomal abnormality 4. When is the most appropriate time to conduct
chorionic villus sampling?
II. COOMBS TEST a. 2 months AOG
b. 4 months AOG
● Determination of whether Rh antibodies are c. 3 months AOG
present in an Rh negative woman
○ Checks if maternal titer for antibodies is greater IIIB. ELECTRONIC FETAL MONITORING
than 1:8
○ Bilirubin determination in AF NON-STRESS TEST
○ These antibodies can attack RBCs (Rh
incompatibility) ● Ideal screening test; non-invasive procedure
● Repeated at 28 weeks ○ No risk to either the mother or the baby
● Primary method of antepartum fetal assessment
○ If titer is not elevated: offer RhoGAM
RhoGAM is also offered after any procedure that ● Basis is that the normal fetus will produce
●
might cause placental bleeding and within 72 hours characteristic heart rate patterns in response to
of delivery fetal movement
DIRECT COOMBS TEST: determines antibodies ● Done over 28 weeks gestation
●
attached in the red blood cells ○ Fetal movements are not well-established <28
INDIRECT COOMBS TEST: determines antibodies weeks AOG
●
present in the serum ● Can be done at home daily especially if there are
complications of pregnancy
○ May pose harm during blood transfusion and in
an Rh+ fetus ○ Mother senses that the baby is not moving as
frequently as usual
RESULTS ○ Mother is overdue (wala pang contractions)
○ There is any reason to suspect that the
DIRECT INDIRECT placenta is not functioning adequately
(uteroplacental insufficiency)
Presence of antibodies
Presence of antibodies ○ High risk
● Incompatibility
● Transfusion of ○ Baby is not receiving enough oxygen due to
with donor blood
incompatible blood
+ ● Hemolytic anemia
● Blood can cause problems with the placenta and/or umbilical
Rh sensitization to cord (sudden increase followed by decrease)
● Hemolytic disease
Rh+ fetus (leads to ○ Fetal dis1tress
of the newborn
HDN)

No antibodies in
- No antibodies in RBC
serum

NCM 0109|16
 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● NORMAL FINDINGS: when the fetus moves, the FHR VIBROACOUSTIC STIMULATION
should increase 15 bpm and remain elevated for 15
seconds ● Fetal Acoustic Stimulation Test
○ No increase in FHR: indicates poor oxygen ● Another method of testing antepartum FHR
perfusion, maternal smoking, drug use, or response
hypoglycemia ● Sometimes used in conjunction with the NST
○ No movement (within 10-20 minutes): fetus is ● Specially-designed acoustic stimulator applied to
sleeping; stimulate by giving the client oral the abdomen to produce 80 decibels of sharp
carbohydrates (orange juice/light meals to sound frequency to startle and wake the fetus
increases glucose levels) or loud sound ○ A single 1–2-second sound stimulation is given
(vibroacoustic stimulation) ○ Repeated at the end of 10 minutes if no
spontaneous movement is noted
RESULTS ● Evaluates 2 movements within the
20-minute period in NST
● REACTIVE: normal or negative
○ Indicates healthy fetus with adequate perfusion CONTRACTION STRESS TEST
○ Two or more FHT accelerations of at least 15
bpm from baseline that lasts for at least 15 ● One of the first electronic methods developed for
seconds during a 20-minute period assessment of fetal health
● NON-REACTIVE: abnormal ● Devised as a graded test of the fetus
○ No fetal movement or accelerations ● The FHT is analyzed in conjunction with
○ No presence of accelerations at least 15 bpm contractions
from baseline that lasts for at least 15 seconds ● Has a lower risk of false-positive results
during a 40-minute period ● PURPOSES
○ Additional tests (contraction stress test ○ Identify the jeopardized fetus that was stable at
[near-term], oxytocin challenge, and rest but showed evidence of compromise after
biophysical profile) will be conducted stress
● UNSATISFACTORY: poor FHT tracing; results cannot ○ Provides an earlier warning of fetal compromise
be interpreted vs the NST
● COMPARISON OF PRACTICES
NURSING RESPONSIBILITIES ○ Old: IV infusion of oxytocin to initiate
contractions (produces sustained
● Done for 10–20 minutes
contractions)
● Assess baseline FHT and maternal vital signs
● Start baseline assessment then stay with the
○ Accelerations in FHT will be checked
patient for monitoring
● Position the client in left lateral position to supply
● Contractions are difficult to stop which may
oxygenation and blood flow
lead to premature labor
● Place UTZ transducer and tocodynamometer in
○ Current: nipple stimulation
proper position
● Send signals to hypothalamus which then
● Attach both fetal heart rate and uterine contraction
produces mild contractions
monitor
● (d/t oxytocin release) with less pain
○ Belt for uterine contractions will always be
● Produces Braxton Hicks contractions (3
placed on top since the fundus is the most
contractions that last for 40 seconds or
contracted part during labor
longer within 10 minutes)
○ Belt for FHT may be positioned anywhere
● INDICATIONS
depending on the fetal presentation
○ Pre-existing maternal conditions (diabetes
● Client presses a button/buzzer whenever she feels
mellitus, heart disease, hypertension,
fetal movement
hyperthyroidism, renal disease, etc.)
○ Marked at each point as a reference to assess
○ Postmaturity
FHT response with fetal movement
○ Intrauterine Growth Retardation (IUGR)
● Create a dark mark on the paper tracing
○ Non-reactive NST result
○ Preeclampsia

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 MODULE 01.1 – HIGH-RISK PRENATAL CLIENT (IDENTIFYING CLIENT AT RISK)

● CONTRAINDICATIONS ● PROCEDURE
○ Third trimester bleeding (placenta previa or ○ Place the client in a semi-Fowler’s position
abruptio placenta) ○ Brush the palm across one nipple for 2–3
○ Previous CS delivery (risk for uterine rupture; minutes
cannot undergo labor) ● RESULTS
○ Risk for preterm labor (PROM, incompetent ○ (+) Present Contractions: stop nipple
cervical os, multiple gestations; tuloy-tuloy na stimulation
siyang manganganak) ○ (-) Absent Contractions massage for 10 more
minutes
RESULTS
II. OXYTOCIN CHALLENGE TEST
● NEGATIVE (reassuring): normal
○ No late decelerations are present ● Used in case of suspected placental insufficiency to
● POSITIVE (non-reassuring): abnormal evaluate the fetal tolerance of uterine contractions
○ 50% or more of the contractions cause late ○ Oxytocin is delivered via IV
decelerations of FHT in the absence of ○ LATE DECELERATIONS
hyperstimulation of the fetus ● Uteroplacental insufficiency; hypoxia;
● LATE DECELERATIONS: delayed 30–40 corrected through O2 with face mask and
seconds after the onset of contractions and repositioning (left lateral recumbent) 0.5
continued beyond end of contraction; mU/min
caused by uteroplacental insufficiency ○ Double dose every 20 minutes until
○ INTERVENTION: Place the client in a contractions of 3 per 10 minutes then
left-lateral position and/or slow down or discontinue
discontinue administration of oxytocin ● The client is placed on NPO and in a semi-Fowler’s
● UNSATISFACTORY: adequate uterine contractions position (prevents hypotension)
cannot be achieved or poor FHT tracing
RESULTS
NURSING RESPONSIBILITIES
● NEGATIVE: reassuring; normal
● Assess baseline FHT and maternal vital signs ○ No late decelerations are present with uterine
● External fetal monitor is applied and a contractions
20–30-minute baseline strip is recorded ○ Adequate placental support = adequate
● Uterus is stimulated to produce 3 palpable oxygenation
contractions with a duration of 40 seconds in a ● POSITIVE: non-reassuring
10-minute period ○ Late deceleration on 50% or more of
○ Administration of a diluted dose of oxytocin contractions
(presents risk of preterm labor)
○ Nipple stimulation (may be insufficient)
ANSWER KEY
● Gentle release of oxytocin SELF-CHECK 01: A, D, C, B
● No medications administered SELF-CHECK 02: A/B, A, C, C
● Only mild to no pain is felt during the test
● Encourage client to remain in the facility for at least
30 minutes after the procedure to ascertain that Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Navarro,
Paras, Tapnio | BSN 2025
contractions have quieted and there is no presence
of preterm labor REFERENCES
Synchronous Lecture: 30 Jan & 02–03 Feb 2023
○ Call the physician if contractions are present Module: NCM 0109 High-Risk Prenatal Client
during the 30-minute monitoring period Book: Maternal and Child Health Nursing
Practice Questions:
I. BREAST SELF-EXAMINATION A. Question Bank 1
B. Question Bank 2
● ADVANTAGES
○ Less time to perform
○ Less expensive
○ Less discomfort

NCM 0109|18