OUR LADY OF FATIMA UNIVERSITY

QUEZON CITY

NCMA 219 LEC

CARE OF MOTHER & CHILD

AT RISK OR PROBLEMS
(ACUTE & CHRONIC)
LECTURE

Rein Ramos
ACADEMICIAN
 Prelim
Week 3

Problems During Labor

and Delivery
Week 1

Genetic Assessment and

Counselling
Week 4

Post-Partum
Complications
Week 2

High-Risk Pregnant Client

(Bleeding Disorder &
Gestational Condition)
Week 5

Male and Female Clients

with General and Specific
Problems in Reproduction
and Sexuality

Rein Ramos
ACADEMICIAN
 Week 1:
Genetic Assessment and Counselling

NATIONAL HEALTH SITUATION GENETIC DISORDERS

ON MCN
The maternal and child population is disorders are disorders that can be passed
constantly changing because of changes in from one generation to the next. They
social structure, variations in family result from some disorder in gene or
lifestyle, and changing patterns of illness. chromosome structure and occur in 5% to
Client advocacy, participating in cost 6% of newborns.
containment measures, focusing on health The study of the way such disorders occur.
education, and creating new nursing roles
are ways in which nurses have adapted to CYTOGENETICS
these changes. is the study of chromosomes by light
Client advocacy is safeguarding and microscopy and the method by which
advancing the interests of clients and their chromosomal aberrations are identified.
families.
Genetic disorders may occur:
THE ROLE INCLUDES: when an ovum and sperm fuse or even
knowing the health care services earlier, in the meiotic division phase of
available in a community the gametes (ovum and sperm).
establishing a relationship with families
and helping them make informed Some genetic abnormalities are so severe
choices about what course of action or that normal fetal growth cannot continue
service would be best for them. past that point.

NATIONAL HEALTH GOALS ARE:

intended to help citizens more easily NATURE OF INHERITANCE
understand the importance of health
promotion and disease prevention Genes are the basic units of heredity that
and to encourage wide participation in determine both the physical and cognitive
improving health in the next decade. characteristics of people.
In humans, each cell, except for the sperm
It is important for maternal and child health and ovum, contains 46 chromosomes (22
nurses to be familiar with these goals pair of autosomes and 1 pair of sex
because nurses play such a vital role in chromosomes).
helping the nation achieve these objectives process by which genetic information is
through both practice and research. passed on from parent to child. This is why
The goals also serve as the basis for grant members of the same family tend to have
funding and financing of evidence-based similar characteristics. Inheritance
practice. describes how genetic material is passed
on from parent to child.
FOCUS ON NATIONAL HEALTH GOALS
(LEADING HEALTH INDICATORS): (source:https://www.yourgenome.org/facts/what-is-
inheritance)
Physical Activity
Overweight and Obesity A person’s phenotype
Tobacco abuse refers to his or her outward appearance
Substance abuse or the expression of genes.
Responsible sexual behavior
Mental Health A person’s genotype
Injury and Violence refers to his or her actual gene
Environmental Quality composition.
Immunization
Access to Health Care

Rein Ramos
ACADEMICIAN
 Week 1:
Genetic Assessment and Counselling

A person’s genome is the complete set of AUTOSOMAL RECESSIVE INHERITANCE

genes present (about 50,000 to 100,000).
Both Parent
A normal genome is abbreviated Both parents of a child with the disorder
as 46XX or 46XY (designation of the are clinically free of the disorder
total number of chromosomes plus a Sex
graphic description of the sex The sex of the affected individual is
chromosomes present). unimportant in terms of inheritance
History
The family history for the disorder is
MENDELIAN INHERITANCE: DOMINANT AND negative—that is, no one can identify
RECESSIVE PATTERNS anyone else who had it (a horizontal
A person who has two like genes for a trait transmission pattern).
—two healthy genes Ancestor
A known common ancestor between the
ex: parents sometimes exists. This explains
(one from the mother and one from the how both male and came to possess a like
father)—on two like chromosomes is gene for the disorder
said to be homozygous for that trait.
If the genes differ (a healthy gene from
the mother and an unhealthy gene from
the father, or vice versa), the person is
said to be heterozygous for that trait.

HOMOZYGOUS DOMINANT
An individual with two homozygous genes
for a dominant trait

HOMOZYGOUS RECESSIVE
An individual with two genes for a
recessive trait.
X-LINKED DOMINANT INHERITANCE
INHERITANCE OF DISEASE
Dominant gene
AUTOSOMAL DOMINANT DISORDERS All individuals with the gene are affected
One Parent Affected
One of the parents of a All female children of affected men are
child with the disorder affected; all male children of affected men
also will have the are unaffected
disorder Generation
Sex It appears in every generation
The sex of the affected Homozygous/ Heterozygous
individual is All children of homozygous affected
unimportant in terms women are affected. Fifty percent of the
of inheritance. children of heterozygous affected women
History are affected
There is usually a
history of the disorder
in other family
members

Rein Ramos
ACADEMICIAN
 Week 1:
Genetic Assessment and Counselling

IMPRINTING

Refers to the differential expression of

genetic material
Allows researchers to identify whether
chromosomal material comes from the
male or female parent

CHROMOSOMAL ABNORMALITIES
X-LINKED DOMINANT INHERITANCE (CYTOGENIC DISORDERS)
In some instances of genetic disease, the
X-LINKED RECESSIVE INHERITANCE abnormality occurs not because of
dominant or recessive gene patterns but
Males through a fault in the number or structure
Only males in the family will have disorder of chromosomes which results in missing
History or distorted genes.
A history of girls dying at birth for When chromosomes are photographed
unknown reasons often exists (females and displayed, the resulting arrangement is
who had the affected gene on both X termed a karyotype.
chromosomes). The number of chromosomes and specific
Unaffected parts of chromosomes can be identified by
Sons of an affected man are unaffected karyotyping or by a process termed
Parents fluorescent in situ hybridization (FISH).
• The parents of affected children do not have
the disorder NONDISJUNCTION ABNORMALITIES

Abnormalities occur if the division in

uneven
If spermatozoon or ovum with 24 or 22
chromosomes fuses with a normal
spermatozoon or ovum. The zygote will
have either 47 or 45 chromosomes, not the
normal 46 chromosomes
45 Chromosomes is not compatible with
life and could lead to abortion.

DELETION ABNORMALITIES

Part of the chromosomes break during cell

division causing the affected person to
MULTIFACTORIAL (POLYGENIC) have an extra portion of a chromosome.
INHERITANCE
TRANSLOCATION ABNORMALITIES
Many childhood disorders tend to have
higher- than usual incidence
A child gains additional chromosome
Occur from multiple gene combinations
through another route.
possibly combined with environmental
factors
Do not follow the mendelian laws
No set patterns in family history

Rein Ramos
ACADEMICIAN
 Week 1:
Genetic Assessment and Counselling

MOSAICISM Nursing Responsibilities

Abnormal condition that is present when Explain what procedures to undergo
the nondisjunction disorder occurs after Explain how different genetic screening
fertilization of the ovum as the structure tests are done and when offered
begins mitotic division. Support the couple during the wait for
Different cells in the body will have tests results
different chromosome counts. Assist couples in values clarification,
planning, and decision making based on
test results.
ISOCHROMOSOMES

Results from chromosome accidentally

dividing not by vertical separation but by GENETIC DISORDERS ASSESSMENT
horizontal one so a new chromosome with 1.HISTORY
mismatched long and short arms Obtain information and document
diseases in family members for a
minimum of three generations.
GENETIC COUNSELLING Remember to include half brothers and

sisters or anyone related in any way as
family.
Provide concrete, accurate information Document the mother’s age because
about the process of inheritance and some disorders increase in incidence
inherited disorders with age.
Reassure people who are concerned that Document also whether the parents are
their child may inherit a particular disorder consanguineous or related to each
or that the disorder will not occur other.
Allow people who are affected by inherited Documenting the family’s ethnic
disorders to make informed choice about background can reveal risks for certain
future reproduction disorders that occur more commonly in
Offer support to people who are affected some ethnic groups than others. If the
by genetic disorders. couple seeking counseling is unfamiliar
with their family history, ask them to
talk to senior family members about
WHO SHOULD GO FOR GENETIC other relatives (grandparents, aunts,
COUNSELLING? uncles) before they come for an
interview. Have them ask specifically for
Couple who has a child with congenital instances of spontaneous miscarriage
disorder or an inborn error of metabolism. or children in the family who died at
Couple whose close relatives have a child birth.
with a genetic disorder. Extensive prenatal history of any
Any individual who is known balanced affected person should be obtained to
translocation carrier. determine whether environmental
Any individual who has an inborn error or conditions could account for the
metabolism or chromosomal disorder condition.
A consanguineous (closely related) couple
Any woman older than 35 years and any 2.PHYSICAL ASSESSMENT
man older than 55 years. A careful physical assessment of any
Couple of ethnic backgrounds in which family member with a disorder, child’s
specific illnesses are known to occur. siblings, and the couple seeking
counseling is needed.

Rein Ramos
ACADEMICIAN
 Week 1:
Genetic Assessment and Counselling

During inspection, pay particular AMNIOCENTESIS

attention to certain body areas, such as the withdrawal of amniotic fluid through
the space between the eyes; the height, the abdominal wall for analysis at the 14th
contour, and shape of ears; the number to 16th week of pregnancy.
of fingers and toes, and the presence of
webbing. PERCUTANEOUS UMBILICAL BLOOD
Dermatoglyphics (the study of surface SAMPLING
markings of he skin) PUBS, or cordocentesis, is the removal of
Note any abnormal findings blood from the fetal umbilical cord at
Careful inspection of newborns is often about 17 weeks using an amniocentesis
sufficient to identify a child with a technique.
potential chromosomal disorder. This allows analysis of blood components
Infants with multiple congenital as well as more rapid karyotyping than is
anomalies, those born at less than 35 possible when only skin cells are removed.
weeks’ gestation, and those whose
parents have had other children with
chromosomal disorders need extremely
close assessment.

3.DIAGNOSTIC TESTING

KARYOTYPING
A sample of peripheral venous blood or a
scraping of cells from the buccal
membrane is taken. Cells are allowed to FETOSCOPY
grow until they reach metaphase, the most The insertion of a fiberoptic fetoscope
easily observed phase. through a small incision in the mother’s
abdomen into the uterus and membranes
MATERNAL SERUM SCREENING to visually inspect the fetus for gross
Alpha-fetoprotein (AFP) is a glycoprotein abnormalities.
produced by the fetal liver that reaches a It can be used to confirm an ultrasound
peak in maternal serum between the 13th finding, to remove skin cells for DNA
and 32nd week of pregnancy. analysis, or to perform surgery for a
Most pregnant women have an MSAFP congenital disorder such as a stenosed
test done routinely at the 15th week of urethra.
pregnancy.

CHORIONIC VILLI SAMPLING

diagnostic technique that involves the
retrieval and analysis of chorionic villi from
the growing placenta for chromosome or
DNA analysis.
The test is highly accurate and yields no
more false-positive results than does PREIMPLANTATION DIAGNOSIS
amniocentesis. possible for in vitro fertilization procedures.
Although this procedure may be done as It may be possible in the future for a
early as week 5 of pregnancy, it is more naturally fertilized ovum to be removed
commonly done at 8 to 10 weeks. from the uterus by lavage before
implantation and studied for DNA analysis
this same way.

Rein Ramos
ACADEMICIAN
 Week 2:
Republic Act 9262: Anti- Violence against women
and their children
RA 9262: ANTI-VIOLENCE AGAINST PROTECTION ORDER
WOMEN AND THEIR
an order issued under this act for the
CHILDREN
purpose of preventing further acts of
Refers to any act or a series of acts violence against women or her child. And
committed by an intimate partner granting other relief as may be needed.
Against a woman who is his wife, The relief granted under a protection order
former wife serve the purpose of safeguarding the
Against a woman with whom the victim from further harm, minimizing any
person has or had sexual or dating disruption in the victim’s daily life, and
relationship facilitating the opportunity and ability of
Against a woman with whom he has a the victim to independently regain control
common child of her life.
Against her child whether legitimate or The provisions of the protection order shall
illegitimate within or without the family be enforced by law enforcement agencies.
abode
KINDS OF PROTECTION ORDER
TYPES OF ABUSE:
BARANGAY PROTECTION ORDERS (BPO
PHYSICAL VIOLENCE refer to the protection order issued by the
acts that include bodily or physical harm to Punong Barangay ordering the perpetrator
a woman or her child (battery) to desist from committing acts under
Causing/ threatening/ attempting to Section 5 (a) and (b) of R.A. 9262. BPO
cause physical harm to the woman or shall be effective for 15 days.
her child.
Placing the woman or her child in fear TEMPORARY PROTECTION ORDERS (TPO)
of imminent physical harm refers to the protection order issued by the
court on the date of the filing of the
SEXUAL VIOLENCE application after ex parte determination
the acts which are sexual in nature that such order should be issued.
committed against a woman or her child. The court shall order the immediate
personal service of the TPO on the
PSYCHOLOGICAL VIOLENCE respondent by the court sheriff who may
Acts or omissions causing or likely to cause obtain the assistance of law enforcement
mental or emotional suffering of the victim agents for the service.
ECONOMIC ABUSE PERMANENT PROTECTION ORDER (PPO)
Acts that make or attempt to make woman refers to the protection order issued by the
financially dependent upon her abuser court after notice and hearing.
The court shall not deny the issuance of
protection order based on the lapse of time
between the act of violence and the filing
of the application.
PPO shall be effective until revoked by the
court upon application of the person in
whose favor it was issued.

Rein Ramos
ACADEMICIAN
 Week 2:
Republic Act 9262: Anti- Violence against women
and their children
INTIMATE PARTNER ABUSE Nursing Interventions
Abuse by a family member against another
adult living in the household Support any ability the woman had to
make constructive decisions
Common injuries suffered by abused women: Discuss how she can call the police any
Burns time and take her to shelter
Lacerations Help to file charges or obtain restraining
Bruises order to keep the abusive person from
Head injuries coming near the woman if necessary
Be careful not to blame the victim
Abused women may: Help find a shelter where the woman will
Have unintended and unwanted feel safe
pregnancy Do not leave an abused woman without
Desire pregnancy because she believes support system after the birth of her child
having a child will change the partner’s
behavior
Be grateful for the pregnancy

Behaviors of abused women:

May come for care late in pregnancy or
not at all
Purchase no maternity clothing
Decline laboratory tests if they involve
additional transportation or money
Difficulty following recommended
pregnancy nutrition
Anxious if her appointment is running
late
Call and cancel appointments
frequently
Dress inappropriately for warm
weather, wearing long-sleeved, tight-
necked blouses to cover up bruises

ASSESSMENT:
Presence of bruises or lacerations on
breasts, abdomen, or back she cannot
explain during physical examination
Ask woman with bruises to account for
them and determine whether explanation
correlates with the extent and placement
of bruise or laceration
Ultrasound may reveal minimal placental
infarcts from blunt abdominal trauma
Record fetal heart tones and fundal height

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)
Assessment of the blood flow through
HIGH RISK PREGNANCY uterine blood vessels is helpful to
determine the vascular resistance
Threatens the health or life of the mother present in women with diabetes or
or her fetus. hypertension of pregnancy and
Concurrent disorder, pregnancy-related whether resultant placental
complication, or external factor that
jeopardizes the health of the mother, the Placental Grading
fetus, or both. Based particularly on the amount of
Requires specialized care from specially calcium deposits in the base of the
trained providers. placenta.

placentas can be graded by ultrasound as:

0 (a placenta 12–24 weeks)
1 (30–32 weeks)
2 (36 weeks)
3 (38 weeks).
Because fetal lungs are apt to be
mature at 38 weeks, a grade 3 placenta
suggests that the fetus is mature.

Amniotic Fluid Volume Assessment

amount of amniotic fluid present is yet
another way to estimate fetal health
because a portion of the fluid is formed
SCREENING PROCEDURES by fetal kidney output.

ULTRASONOGRAPHY ELECTROCARDIOGRAPHY
also be used to discover complications of Fetal ECGs may be recorded as early as the
pregnancy such as: 11th week of pregnancy.
the presence of an intrauterine device The ECG is inaccurate before the 20th
hydramnios or oligohydramnios week, however, because until this time fetal
ectopic pregnancy electrical conduction is so weak that it is
missed miscarriage easily masked by the mother’s ECG tracing.
abdominal pregnancy It is rarely used unless a specific heart
placenta previa anomaly is suspected.
premature separation of the placenta
coexisting uterine tumors MAGNETIC RESONANCE IMAGING (MRI)
multiple pregnancy may be used to assess the fetus. Because
or genetic disorders such as Down the technique apparently causes no
syndrome. harmful effects to the fetus or woman
Fetal anomalies (neural tube disorders, MRI has the potential to replace or
diaphragmatic hernia, or urethral complement ultrasonography as a fetal
stenosis) assessment technique.

Biparietal Diameter It may be most helpful in diagnosing

used to predict fetal maturity by complications such as:
measuring the biparietal diameter of ectopic pregnancy or trophoblastic disease
the fetal head. because later in a pregnancy fetal
movement (unless the fetus is sedated)
Doppler Umbilical Velocimetry (Doppler can obscure the findings.
ultrasonography)
measures the velocity at which RBCs in
the uterine and fetal vessels travel.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)
SCREENING PROCEDURES (CONTINUATION) FETOSCOPY
fetus is visualized by inspection through a
MATERNAL SERUM ALPHA- FETOPROTEIN fetoscope
substance produced by the fetal liver that can be helpful to assess fetal well-being.
is present in both amniotic fluid and The earliest time in pregnancy that
maternal serum. fetoscopy can be performed is about the
level is abnormally high in maternal serum 16th or 17th week.
(MSAFP) if the fetus has an open spinal or
abdominal defect such as spina bifida or The procedure is used to:
omphalocele, because the open defect Confirm the intactness of the spinal
allows more AFP to enter the mother’s column
circulation. Obtain biopsy samples of fetal tissue and
80% of Down syndrome babies can be fetal blood samples
detected by this method. Perform elemental surgery, such as
inserting a polyethylene shunt into the
TRIPLE SCREENING fetal ventricles to relieve hydrocephalus or
analysis of three indicators (MSAFP, anteriorly into the fetal bladder to relieve a
unconjugated estriol, and hCG), stenosed urethra
CHORIONIC VILLUS SAMPLING BIOPHYSICAL PROFILE
a biopsy and chromosomal analysis of combines five parameters (fetal reactivity,
chorionic villi that is done at 10–12 weeks fetal breathing movements, fetal body
of pregnancy. movement, fetal tone, and amniotic fluid
volume) into one assessment.
Coelocentesis (transvaginal aspiration of fluid
from the extraembryonic cavity)
an alternative method to remove cells BLEEDING DISORDERS
for fetal analysis.

AMNIOCENTESIS Vaginal bleeding during pregnancy is always a

the aspiration of amniotic fluid from the deviation from the normal, may occur at any
pregnant uterus for examination. point during pregnancy, and is always
typically scheduled between the 14th and frightening.
16th weeks of pregnancy to allow for a
generous amount of amniotic fluid to be It must always be carefully investigated
present. can be used again near term to because if it occurs in sufficient amount or for
test for fetal maturity. sufficient cause, it can impair both the
outcome of the pregnancy and a woman’s life
PERCUTANEOUS UMBILICAL CORD BLOOD or health.
SAMPLING
also called cordocentesis or funicentesis 1.ABORTION
the aspiration of blood from the umbilical
vein for analysis. Termination of pregnancy before the age
of viability usually before 20 – 24 weeks
AMNIOSCOPY Miscarriage
the visual inspection of the amniotic fluid
through the cervix and membranes with an CAUSES:
amnioscope (a small fetoscope). Defective ovum/ congenital defects
The main use of the technique is to detect Unknown causes
meconium staining. It carries some risk of
membrane rupture.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

SIGNS
MATERNAL FACTORS
Viral infection Vaginal bleeding or spotting, mild to severe
Malnutrition Uterine/ abdominal cramps
Trauma Passage of tissues or products of
Congenital defects of the reproductive conception
tract Signs related to blood loss/ shock:
Incompetent cervix Pallor
Hormonal Tachycardia
Increased temperature Tachypnea
Systemic diseases in the mother Cold clammy skin
Environmental hazards Restlessness
Rh incompatibility Oliguria
Hypotension
Air hunger
TYPES:

INDUCED ABORTION
With medical or mechanical
intervention

Legal Aspects
Only allowed for medical indications
If continuation of pregnancy is risk to life
of the woman
At least two medical doctors should reach
the decision and sign
Elective abortions unlawful, considered a
criminal act

Complications
Perforation of uterus, intestines, urinary TREATMENT
bladder
Severe hemorrhage w/c may lead to Surgery
hypovolemic shock Antibiotics
Sepsis and its associated complications, Blood, plasma, fluid replacement
Habitual abortion:
SPOTANEOUS ABORTION Determine etiology
Without medical or mechanical Treatment of underlying causes
intervention Cerclageoperation/cervicalclosure for
incompetent cervix (McDonald surgery,
Shirodkar-Barter surgery)
Blood tests

MANAGEMENT OF ABORTION
THREATENED
Activity: Bed rest
Medications: Tocolytics (Ritodrine,
Isoxsuprine, Terbutaline)

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

MANAGEMENT OF ABORTION
(CONTINUATION)
INEVITABLE
Fluid replacement: IVF (LR/ PNSS)
Medications: Oxytocin (>12)
Procedure/ surgery: Vacuum aspiration
(<12) Completion Currettage
Blood tests: Bld. Typing/ Cross-matching

INCOMPLETE
Fluid replacement: IVF (LR/ PNSS)
Medications: Oxytocin (>12) Antibiotics
(Ampicilin/ metronidazole) Analgesics
Procedure/ surgery: Vacuum aspiration
(<12) Completion Currettage
Blood tests: Bld. Typing/ Cross-matching PREDISPOSING FACTORS

MISSED Fallopian tube narrowing or constriction

Medications: Oxytocin (>12) Prostaglandin Pelvic Inflammatory Disease (PID)
Procedure/ surgery: If no spontaneous Puerperal and postpartal sepsis
expulsion (4 weeks), Dilation & Evacuation Surgery of the fallopian tubes
Congenital anomalies of the fallopian tubes
HABITUAL Adhesions, spasms, tumors
Medications: Tocolytics Oxytocin, Prosta- IUD usage
glandin, Misoprostol RhoGam
Procedure/ surgery: Counselling D&C ASSESSMENT FINDINGS
SEPTIC Amenorrhea or abnormal menstrual
Fluid replacement: IVF (LR/ PNSS) period/ spotting
Medications: Oxytocin (>12) Antibiotics Early signs of pregnancy ◦ Tubal rupture
(Cephalosporins, Ampicilin/metronidazole) signs
Hematinics Sudden, acute low abdominal pain
Procedure/ surgery: Urethral Cathete- radiating to the shoulder (Kehr’s sign)
rization Currettage or neck pain
Blood tests: Bld. Typing/ Cross-matching Nausea and vomiting
Bluish navel (Cullen’s sign)
Rectal pressure
Positive pregnancy test (50%)
2.ECTOPIC PREGNANCY
Sharp localized pain when cervix is touched
A condition where pregnancy develops Signs of shock/ circulatory collapse
outside the uterine cavity
DIAGNOSTICS
TYPES: Ultrasonography
Tubal (Fallopian tube - interstitial, isthmic, Culdocentesis
ampulla, infundibulum & fimbrial portion) Laparoscopy
Cervical Serial testing of HCG beta- subunit
Abdominal
Ovarian

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

LABORATORY FINDINGS CAUSE

Low hemoglobin and hematocrit Unknown cause
Low HCG (normal value at its peak:
400,000 IU/ 24 hours) RISK FACTORS
Elevated WBC
Low protein intake.
Women older than 35 years old.
TREATMENT Asian women.
Women with a blood group of A who marry
(Unruptured) Methotrexate, Leucovorin men with blood group O.
Surgical removal of ruptured tube
(Salphingectomy) PATHOPHYSIOLOGY
Management of profound shock if
ruptured (Blood replacement) Fertilization occurs as the sperm enters the
Antibiotics ovum. In instances of a partial mole, two
sperms might fertilize a single ovum.
Reduction division or meiosis was not able
Nursing Management to occur in a partial mole. In a complete
mole, the chromosome undergoes
Carry out an ongoing assessment for shock duplication.
Implement promptly shock treatment The embryo fails to develop completely.
Position on modified Trendelenburg There are 69 chromosomes that develop
Infuse D5LR for plasma administration, for the partial mole, and 46 chromosomes
blood for the complete mole.
transfusion or drug administration as The trophoblastic villi start to proliferate
ordered rapidly and become fluid-filled grape-like
Monitor VS, bleeding, I & O vesicles.
Provide physical and psychological
support.
ASSESSMENT FINDINGS
COMPLICATIONS Brownish or reddish, intermittent or
profuse vaginal bleeding by 12 weeks
Hemorrhage Expulsion, spontaneous, of molar cyst
Infection usually occurs between the 16th to 18th
Rh sensitization weeks of pregnancy
Rapid uterine enlargement inconsistent
with the age of gestation
3.HYDATIDIFORM MOLE Symptoms of PIH before 20 weeks
Excessive nausea and vomiting because of
also known as Gestational Trophoblastic excessive HCG (1 to 2 million IU/L/24
Disease hours)
Abnormal proliferation and then Positive pregnancy test
degeneration of the trophoblastic villi. No fetal signs – heart tones, parts,
As the cells degenerate, they become filled movements
with fluid and appear as clear fluid-filled, Abdominal pain
grape-sized vesicles

TYPES OF MOLE GROWTH

Complete Mole
Partial Mole

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

DIAGNOSTICS (CONTINUATION) 4.INCOMPETENT CERVIX

Passage of vesicles – 1st sign that aids to A condition characterized by a mechanical

diagnosis defect in the cervixcausing cervical
TRIAD signs: effacement and dilation and expulsion of
Biguterus the POC.
Vaginal bleeding
HCG greater than 1 million RISK FACTORS
Ultrasound
Flat plate of the abdomen done after 15 CONGENITAL INCOMPETENCE
weeks Diethylstilbestrol(DES) exposure in- utero
Women with a bicornuate uterus
TREATMENT
ACQUIRED INCOMPETENCE
Evacuation by Suction D & C or Inflammation
hysterectomy if no spontaneous Infection
evacuation Subclinical uterine activity
Hysterectomy if above 45 years old and no Cervical trauma
future pregnancy is desired or with Increased uterine volume
increased chorionic gonadotropin levels
after D & C ASSESSMENT FINDINGS
HCG titer monitoring for one year (no
pregnancy for 1 year) Painless contractions resulting in delivery
Medical replacement: blood, fluid, plasma of a dead or non-viable fetus
Chemotherapy for malignancy: History of abortions
Methotrexate is drug of choice Relaxed cervical os on pelvic examination
Chest X-ray
TREATMENT
Nursing Management
CONSERVATIVE MANAGEMENT:
Advise bed rest Bed rest; avoidance of heavy lifting; no
Monitor VS, blood loss, molar/ tissue coitus
passage, I & O
Maintain fluid and electrolyte balance, FOR WOMEN WITH PREVIOUS LOSSES:
plasma, and blood volume through elective cervical cerclage (late first trimester or
replacements as ordered early second trimester)
Prepare for suction D & C, hysterotomy or Shirodkar procedure
hysterectomy as indicated McDonald procedure
Provide psychological support
Prepare for discharge Nursing Management
Emphasize need for follow-up HCG titer
determination for 1 year Provide psychological support to client
Reinforce instructions on NO who may have negative feelings
PREGNANCY FOR ONE YEAR; give Provide post-cerclage procedure care
instructions related to contraceptions Advise limitation of physical activities
within 2 weeks after treatment
COMPLICATIONS Maternal and fetal growth monitoring
Instruct to report promptly signs of labor
Choriocarcinoma Assessment for signs of labor, infection or
Hemorrhage premature rupture of membranes
Uterine perforation In labor, prepare STITCH REMOVAL SET in
Infection addition to delivery set
(post- McDonald surgery)
Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

5.ABRUPTIO PLACENTA TYPES OF SEPARATION

Premature separation of the implanted Marginal/low separation
placenta before the birth of the fetus Moderate/high separation
Severe/complete separation
PREDISPOSING FACTORS
Maternal hypertension: PIH, renal disease
Sudden uterine decompression (multiple
pregnancy, polyhydramnios)
Advance maternal age
Multiparity
Short umbilical cord
Trauma; fibrin defects
ASSESSMENT FINDINGS
TYPES Painful, vaginal bleeding
Rigid, board-like, and painful abdomen
Enlarged uterus due to concealed bleeding
TYPE I: Concealed, Covert or Central type If in labor:
tetanic contractions with the absence of
alternating contraction and relaxation of
the uterus

DIAGNOSIS
Clinical diagnosis (signs and symptoms)
Ultrasound
detects the retroplacental bleeding
Clotting studies
reveal DIC, clotting defects
The thromboplastin from retroplacental
clot enters maternal circulation and
consumes maternal free fibrinogen
TYPE II: Marginal, Overt or External bleeding resulting in:
type DIC: small fibrin clots in circulation
Hypofibrinogenemia: decrease normal
fibrinogen results in absence of normal
blood coagulation

COMPLICATIONS
Hemorrhagic shock
Couvelaire uterus
Disseminated intravascular coagulation
(DIC)
Cerebrovascular accident (CVA) from DIC
Hypofibrinogenemia
Renal failure
Infection
Prematurity, fetal distress/ demise
(IUFD)

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)

Nursing Management RISK FACTORS ( CONTINUATION)

Maintain bed rest, LLR FETAL FACTORS
Careful monitoring: Maternal VS, FHT, Multiple pregnancy
Labor onset/ progress, I & O, oliguria/ Infections
anuria, uterine pain, bleeding Polyhydramnios
Administer IV fluids, plasma, or blood as Congenital Adrenal Hyperplasia
ordered Fetal malformations
Prepare for diagnostic examinations
Provide psychological support PLACENTAL FACTORS
Prepare for emergency birth Placental separation
Placental disorders
Observe for associated problems after
delivery: UNKNOWN FACTORS
Poorly contracting uterus
Disseminated Intravascular Coagulation
Hypofibrinogenemia COMPLICATIONS
Prematurity, neonatal distress Prematurity
Fetal death
Small-for-gestational age (SGA)/ IUGR
6.PRETERM LABOR Increase perinatal morbidity and mortality
Labor that occurs after the 20th week and
before 37th week of gestation
TREATMENT (HOSPITALIZATION)
Bed rest on LLR
ETIOLOGY
Adequate hydration
In >30% cases exact cause of preterm labor Monitoring:
is not known Uterine contractions and irritability
Occurs approximately 9- 11% of all
pregnancies
(every 1-2 hours) ◦ VS
I& O
Any woman having persistent uterine Signs of infection
contractions (4 every 20 minutes) Cardiac and respiratory status and
distress signs
RISK FACTORS Cervical consistency, dilatation, and
effacement
MATERNAL FACTORS Fetal well being
Maternal infection, illness or disease, DM Early signs of edema
Premature rupture of membranes (PROM) Promotion of physical and emotional
Bleeding comfort
Uterine abnormalities/ overdistention, Administration of Tocolytics (magnesium
incompetent cervix sulfate, Terbutaline, Ritodrine)
Previous preterm labor, spontaneous or Contraindications:
induced abortion, preeclampsia, short Advanced pregnancy
interval (less than 1 year) between Ruptured bag of waters
pregnancies Maternal distress (bleeding
Trauma, poor nutrition, no prenatal care, complications, PIH, cardiovascular
lack of childbirth experience disease)
Extremes of age, decreased weight (<100 Fetal distress
lbs) and less height (<5 ft)lack of rest/ Presence of fetal problems (Rh
excessive fatigue isoimmunization)
Smoking
Extreme emotional stress

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy ( Bleeding Disorder)
TREATMENT (HOSPITALIZATION) DIAGNOSIS (CONTINUATION)
Administration of corticosteroids FERNING TEST
Betamethasone (12mg IM every 24 Amniotic fluid, high in sodium content, will
hours x 2 doses) assume a ferning pattern when dried on
Dexamethasone (6mg IM every 12 the slide
hours x 4 doses)
Assess effects of drugs on labor and fetus STERILE SPECULUM EXAMINATION
Monitor for side effects Direct visualization of fluid from cervical os
is the most reliable diagnosis
DISCHARGE (PREMATURE LABOR
STOPPED)
Maintain bed rest, LLR preferred COMPLICATIONS
Well-balanced diet (high in iron, vitamins, Maternal infection/ chorioamniotnitis
and important minerals) Cord prolapse
Continuation of oral medications Premature labor
Frequent prenatal visit every week
Activity/ Lifestyle evaluated and restricted
as necessary MANAGEMENT OF PROM
Illnesses: Chronic – monitored; Acute – Initial Assessment - objectives of the initial
treated stat assessment are:
Provide client teaching Confirm the diagnosis of PROM
Symptoms of preterm labor To determine the gestation of the fetus
Prompt reporting to physician To identify the women who need to deliver
If Pregnancy is >37 weeks and with
presence of:
7.PREMATURE RUPTURE OF MEMBRANES Congenital anomalies
(PROM) Fetal distress , cord prolapse
Spontaneous rupture of fetal membrane Signs of chorioamnionitis
any time after the period of viability but

before the onset of labor Then deliver....

Associated with infection of the Induction of labor- if no contraindication
membranes (Chorioamnionitis) Balance between risk of infection in
Occurs in 5-10% of pregnancies expectant management & Premature labor
Shift the patient where the facility for
CAUSE neonatal care is available .
If pregnancy is >34 and <37 weeks
Unknown cause but it is associated with
CBC, cervical swab c/s
infection of the membranes
Antibiotics
(chorioamnionitis).
Careful watch on signs of
chorioamnionitis
ASSESSMENT FINDINGS
Maternal report of passage of fluid per Maternal & fetal conditions
vagina If no spontaneous labor in 24-48hrs-
Determination of alkaline amniotic fluid induction of labor
and not acidic urine or vaginal discharge If pregnancy <34 weeks
Expectant Management- The aim is to
DIAGNOSIS prolong the pregnancy for fetal maturity
Bed rest
NITRAZINE TEST CBC & Cervical swab c/s
Change in color of Nitrazine paper from give corticosteroid & tocolytics
yellow (acidic vaginal pH = 4-6) to blue Antibiotics
color because of neutral to slightly alkaline Watch for signs of chorioamnionitis,
amniotic fluid (pH = 7-7.5) Maternal & fetal condition.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

GRAVIDO-CARDIAC Stroke volume +27

Early correction of congenital heart Systemic vascular

disease, had significantly decreased the - 21
resistance
cases of women of childbearing age who
have heart disease.
Hypertension, which was once a major Pulmonary resistance - 34
threat, has only affected only
approximately 1% of all pregnancies. CRITICAL PERIODS:
Pregnancy adds up to the work of the
circulatory system of every woman, even Changes start from – 6 weeks AOG
without cardiac problem, as both the blood Maximum changes around –30 weeks
volume and cardiac output increased Intrapartum period
approximately 30%. Half of the increase Just after delivery •Second week of
happens by 8 weeks and is maximized by puerperium
mid pregnancy.
PREGNANCY CHANGES MIMIC CARDIAC
THE MOST COMMON CARDIOVASCULAR DISEASE
DISEASES THAT CAUSE DIFFICULTY DURING
PREGNANCY ARE: Symptoms
breathlessness
valve damage caused by rheumatic fever weakness
or Kawasaki disease edema
congenital anomalies such as: syncope
atrial septal defect
uncorrected coarctation of the aorta. Tachycardia
Splitting of 1st heart sound
THERE IS ALSO AN INCREASED INCIDENCE Murmur – systolic , breast bruit
OF: Displacement of apex beat – upwards to
left
coronary artery disease
varicosities for primigravida.
Peripartum heart disease SYMPTOMS OF HEART DISEASE
heart disease that occurs specifically with
pregnancy still only rarely occurs because Progressive dyspnea or orthopnea
it is apparently unrelated to age. Nocturnal cough
Cough which is active at night
Syncope
HEMODYNAMIC CHANGES IN NORMAL Chest pain
PREGNANCY Hemoptysis

PARAMETER CHANGE (PERCENT) Note!

Orthopnea
Plasma volume +40 find it harder to breathe when you lie
down because of fluid in your lungs.
Cardiac output +43 Nocturnal Cough
Frequently coughing at night
Heart rate +17 your cough is active at night
Hemomptysis
Mean arterial pressure +4 coughing up of blood

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
CLINICAL FINDINGS OF HEART DISEASE ADDITIONAL RISK FACTORS
Cyanosis Anaemia
Clubbing of fingers Infections
Persistent neck vein distention Hypertension
Systolic murmur Physical labour
Diastolic murmur Weight gain
Cardiomegaly Multiple pregnancy
Persistent arrythmia Caffein , alcohol intake
Persistent split second sound Pain
Pulmonary hypertension Drugs – tocolytic

DIAGNOSTICS
ECG
cardiac arrhythmias, hypertrophy
ECHOCARDIOGRAPHY
cardiac status and structural anomalies
X-RAY CHEST
cardiomegaly, vascular prominence

NYHA (NEW YORK HEART ASSOCIATION)

FUNCTIONAL GRADING OF HEART DISEASE
GRADE I (UNCOMPROMISED)
No limitation of physical activity-
asymptomatic with normal activity

GRADE II (SLIGHTLY COMPROMISED)

Mild limitation of physical activity -
Symptoms with normal physical activity

GRADE III (MARKEDLY COMPROMISED)

Marked limitation of physical activity -
Symptoms with less than normal activity, EFFECT OF HEART DISEASE ON PREGNANCY
comfortable at rest
Abortion
GRADE IV (SEVERELY COMPROMISED) Preterm labour
Severe limitation of physical activity- IUGR
symptoms at rest Congenital heart disease in baby – 5%
Intrauterine fetal demise
Note!
A WOMAN WITH LEFT-SIDED HEART
Grade I and Grade II:
heart disease can expect to experience a
FAILURE
normal pregnancy and birth. occurs in conditions such as mitral
stenosis, mitral insufficiency, and aortic
Grade III: coarctation.
can complete a pregnancy by maintaining
almost complete bed rest. In these instances, the left ventricle cannot
move the volume of blood forward that it
Grade IV: has received by the left atrium from the
heart disease are poor candidates for pulmonary circulation. The heart becomes
pregnancy because they are in cardiac failure so overwhelmed it fails to function.
even at rest and when they are not pregnant.
They are usually advised to avoid pregnancy. The reason for the failure is most often at
the level of the mitral valve

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

Common signs and symptoms are those Note!

associated with pulmonary hypertension and
IF AN ANTICOAGULANT IS REQUIRED
pulmonary edema and may include:
HEPARIN
Decreased systemic blood pressure is the drug of choice for early pregnancy
Productive cough with blood-streaked because it does not have teratogenic
sputum effects, as does sodium warfarin
(Coumadin).
Tachypnea
Dyspnea on exertion, progressing to WARFARIN
dyspnea at rest can be used after week 12 but a woman will
Tachycardia then be returned to heparin therapy during the
Orthopnea last month of pregnancy so the fetus will not
develop a coagulation disorder at birth.
Paroxysmal nocturnal dyspnea
Edema, pulmonary edema

A WOMAN WITH RIGHT-SIDED HEART

PRESCRIBED MEDICATIONS: FAILURE
Right-sided heart failure can be a result of
IF A MITRAL STENOSIS IS PRESENT congenital heart defects such as
pulmonary valve stenosis and atrial and
it is so difficult for blood to leave the left ventricular septal defects.
atrium that a secondary problem or occurs when the output of the right
thrombus formation can occur from non ventricle is less than the blood volume
circulating blood. received by the right atrium from the vena
may need to be prescribed an cava.
anticoagulant to prevent this. Back-pressure from this results in
congestion of the systemic venous
IF COARCTATION OF THE AORTA circulation and decreased cardiac output
to the lungs.
causing the difficulty, dissection of the Women who have an uncorrected anomaly
aorta from high blood pressure from trying of this type may be advised not to become
to push blood past the constriction can pregnant. If they do become pregnant,
occur they can expect to be hospitalized for the
Antihypertensives, diuretics and beta- last part of the pregnancy to monitor and
blockers may be prescribed to improve ensure maternal well-being and fetal
ventricular filling. growth.

If these complications result in impaired blood SIGNS AND SYMPTOMS MAY INCLUDE:
flow to the uterus, poor placental perfusion, Hypotension
intrauterine growth restriction, and fetal Jugular vein distention
mortality can occur. Liver and spleen enlargement
Ascites
woman needs serial ultrasound and non- Dyspnea and pain.
stress tests done after weeks 30 to 32 of
pregnancy to monitor fetal health.
Balloon valve angioplasty to loosen mitral A WOMAN WITH PERIPARTUM HEART
valve adhesions can be performed safely DISEASE
during pregnancy. Peripartal cardiomyopathy is an extreme
rare condition which occurs in women with
no previous history of heart disease.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
The cause is not known, but it is apparently ANTENATAL CARE
because of the effect of the pregnancy on Clear counseling of risk and prognosis
the circulatory system. ANC every 2 weeks up to 30 weeks then
A woman develops signs of myocardial weekly
failure such as shortness of breath, chest On each visit-note-pulse rate, BP, cough
pain, and edema. dyspnea, weight, anemia, auscultate lung
bases, re- evaluate functional grade
CARDIOMEGALY Ensure treatment compliance
occurs which would warrant a reduce in her Exclude fetal congenital anomaly by level-
physical activity. III USG and fetal ECHO at 20 weeks in
maternal congenital heart disease
Diuretic and digitalis therapy Fetal monitoring
may be needed to maintain heart action.
HEALTH TEACHINGS
Low-molecular-weight heparin Rest, Avoid undue excitement/strain
may be administered to decrease the risk Diet/ Iron and vitamins
of thromboembolism. Immunosuppressive Hygiene, dental care to prevent any
therapy may improve the symptoms. infection
Dietary salt restriction (4-6g/d)
If cardiomegaly persists past the postpartum Avoid smoking, drugs – betamimetics
period Early diagnosis and treatment of PIH,
it is generally suggested that a woman infections
avoid further pregnancies. Therapeutic/prophylactic cardiac
Oral contraceptives are contraindicated interventions as applicable-
because of the danger of Benzathine Penicillin - to prevent
thromboembolism they could create. recurrence of rheumatic fever
Heart transplant may be needed if the Diuretics, Beta Blockers, Digitalis,
condition worsens. Anticoagulants
Surgical treatment as applicable -
PRE-CONCEPTIONAL COUNSELING balloon mitral valvotomy
No pregnancy unless most especially in
high risk types INDICATIONS FOR ADMISSION
Maternal mortality varies directly with ELECTIVE ADMISSION
functional classification at pregnancy onset NYHA 1 – 2 weeks before EDD
Optimal Medical/Surgical treatment pre- NYHA2–28to30weeks
pregnancy NYHA-III/IV- Irrespective of AOG as soon
Counselling as patient comes
Maternal & Fetal risks To change from oral anticoagulants to
Prognosis heparin-early pregnancy, 36 weeks in
Social and cost considerations patients on anticoagulant
Hospital delivery- Preferable at tertiary
care center EMERGENCY ADMISSION
Deterioration of functional grade
Symptoms and signs of complications-
MEDICAL TERMINATION OF PREGNANCY Fever
Termination advised in early pregnancy in persistent cough
high risk group only basal crepts
Primary pulmonary Ht tachyarrhythias (P/R >100 min
Eisenmenger syndrome JVP>2cm
Coarctation of aorta Anemia
Marfan syndrome with dilated aortic Infections
root PET
Only in 1st trimester, better before 8 weeks Abnormal weight gain
Suction evacuation preferred other medical disorders
Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
MANAGEMENT IN FIRST STAGE OF LABOR ADVICE AT TIME OF DISCHARGE
Confined to bed- position to upright or Continue medical treatment
semi recumbent Avoid infection
Intermittent oxygen inhalation 5-6 lpm Re-assesment after 6 weeks or earlier if
Sedation and analgesia- (Epidural, some complication occurs
pethidine, tramadol) Iron supplementation
Cautious use of I.V. fluids (not >75ml/hr Cardiological consultation for definitive
except in aortic stenosis and VSD) management of heart disease
Stop anticoagulants
Digitalize if in CHF,P.R.>110/ min, R/R CONTRACEPTIVE ADVICE AT TIME OF
>24/min DISCHARGE
Contraception- Barrier,
Diuretics in pulmonary congestion Progesterone – good option- DMPA,
Bronchodilators Norplant
Prevention of infective endocarditis IUCD-Less preferred
Cardiac monitoring and pulse oximetry COC - contraindicated
±pulmonary artery catheterization- Sterilization- vasectomy-best
continuous hemodynamic monitoring Tubal ligation-Interval, puerperial can be
Evaluation by Anaesthetist and done
Cardiologist

MANAGEMENT OF SECOND STAGE OF GESTATIONAL DIABETES MELLITUS

LABOR
Delivery in upright or semi-fowlers position INTRODUCTION TO GDM
Avoid forceful bearing down For nurses, diabetes mellitus, whether
Adequate pain relief-epidural/pudendal gestational or pre gestational, represents
block avoid spinal/Saddle block one of the most challenging medical
Cut short second stage of labor- complications encountered in pregnancy.
episiotomy, vacuum, forceps – but not A comprehensive and multidisciplinary
always approach is required to improve maternal
Strict Cardiovascular monitoring and neonatal outcomes.
Before discovery of insulin in 1922, it was
uncommon for a woman with diabetes to
MANAGEMENT OF THIRD STAGE OF LABOR give birth to a healthy baby
10 U oxytocin IM
Avoid bolus syntocinon/Ergometrine INCIDENCE AND SIGNIFICANCE
upright - semi fowlers, oxygen inhalation
GDM, defined as any degree of glucose
Furosemide IV 40 mg
intolerance with onset or first recognition
Morphine (15mg)
during pregnancy, is reported to have a
Watch for signs of CHF & Pulmonary
prevalence of 14% in the Philippines
Edema
In the United States, 23 million people (8
Treat PPH
percent of the total population) have
diabetes (CDC, 2008)
FIRST HOUR AFTER DELIVERY The prevalence of diabetes is 2 to 4 times
Propped up/sitting position, oxygen greater for non- Hispanic black, Hispanic/
Watch for signs of pulm edema Latino American, American Indian and
Sedation Asian/Pacific Islander women than for non-
Antibiotics Hispanic white women (CDC, 2008).
Factors that contribute to the increasing
prevalence of diabetes are the aging
population, urbanization, the obesity
epidemic and physical inactivity
(Hunt & Schuller, 2007).
Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

INCIDENCE AND SIGNIFICANCE THERE IS A HIGH INCIDENCE OF

(CONTINUATION) CONGENITAL ANOMALY SUCH AS:
A significant factor contributing to the
development of diabetes and obesity is caudal regression syndrome (failure of the
exposure to hyperglycemia in the lower extremities to develop)
intrauterine environment spontaneous miscarriage
Pregnancies complicated by diabetes are stillbirth in infants of women with
at increased risk of perinatal morbidity and uncontrolled diabetes.
mortality.
AT BIRTH, THE NEONATES ARE MORE
PRONE TO:
DEFINITION OF DIABETES MELLITUS
hypoglycemia
Diabetes mellitus is a metabolic disorder respiratory distress syndrome
caused by defects in insulin secretion or hypocalcemia
action, which lead to abnormalities in the hyperbilirubinemia.
metabolism of carbohydrates, lipids and
protein (ADA, 2008a) If a woman can be kept from becoming
The primary problem of any woman with hyperglycemic during the first trimester,
DM is controlling the balance between the chances of a congenital anomaly are
insulin and blood glucose levels to prevent greatly lessened.
hypo- or hyperglycemia.
Infants of diabetic mothers are five times Note!
more apt to be born with heart anomalies. MACROSOMIA
Long-term effects of diabetes mellitus are term that describes a baby who is born much
vascular narrowing that leads to kidney, larger than average for their gestational age
heart, and retinal dysfunction. HUMAN PLACENTAL LACTOGEN
a hormone produced in the placenta that helps
PLACENTAL INSULINASE may cause break down fat from the mother to provide
energy for the fetus
increased breakdown or degradation of
insulin. PLACENTAL INSULINASE
This resistance to or destruction of another hormone from the placenta that
inactivates insulin
insulin is helpful in a usual pregnancy source: https://www.everydayhealth.com/gestational-diabetes/guide/
because it prevents the blood glucose
from falling to dangerous limits, despite
the increased insulin secretion that
occurs.
It causes difficulty for a pregnant woman CLASSIFICATION
with diabetes in that she must increase her TYPE 1 DM
insulin dosage beginning at about week 24
Formerly known as insulin-dependent
of pregnancy to prevent hyperglycemia.
diabetes mellitus. A state characterized by
the destruction of the beta cells that
Infants of poorly controlled diabetic
usually leads to absolute insulin deficiency
mothers tend to be large (>10 lb) because
An immune-mediated disorder
the increased insulin the fetus must
characterized by destruction of the beta
produce to counteract the overload of
cells of the pancreas, which leads to an
glucose he or she receives acts as a growth
absolute insulin deficiency
stimulant.
Accounts for 5-10% of all diabetes and 1%
MACROSOMIA infant may create birth
of diabetes in pregnancy (ADA, 2008 a;
problems at the end of the pregnancy
Lethbridge- Cejku et al., 2004)
because of cephalopelvic disproportion
and increased risk of shoulder dystocia.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

IMPAIRED GLUCOSE HOMEOSTASIS

A state between “normal” and “diabetes” in

which the body is no longer using and/ or
secreting insulin properly.

Impaired fasting glucose

A state when fasting plasma glucose is
at least 110 but under 126mg/dL.

TYPE 2 DM Impaired glucose tolerance

Formerly known as non-insulin dependent A state when results of the oral glucose
diabetes mellitus tolerance test are at least 140 but
Is the most prevalent form of diabetes, under 200mg/dL in the 2-hour sample.
accounting for 90- 95 % of cases
(CDC,2008) OTHER CLASSIFICATIONS:
A state that usually arises because of
insulin resistance combined with a relative THE WHITE CLASSIFICATION
deficiency in the production of insulin. named after Priscilla White, who pioneered
Can be controlled with lifestyle research on the effect of diabetes types on
modification and oral medications perinatal outcome, is widely used to assess
maternal and fetal risk.
It distinguishes between gestational
diabetes (type A) and diabetes that existed
before pregnancy (pregestational
diabetes). These two groups are further
subdivided according to their associated
risks and management

THERE ARE 2 CLASSES OF GESTATIONAL

DIABETES (DIABETES WHICH BEGAN
DURING PREGNANCY):

GESTATIONAL DIABETES MELLITUS (GDM) Class A1

gestational diabetes; diet controlled
A condition of abnormal glucose
Class A2
metabolism that arises during pregnancy.
gestational diabetes; medication
Any degree of glucose intolerance with
controlled
onset or first recognition during pregnancy
Accounts for 90% of all pregnancies
complicated by diabetes; prevalence
ranges from 1-14%, depending on the THE SECOND GROUP OF DIABETES WHICH
population (ADA, 2008a) EXISTED BEFORE PREGNANCY CAN BE
Possible signal of an increased risk for type SPLIT UP INTO THESE CLASSES:
2 diabetes later in life. The symptoms fade
again at the completion of pregnancy, but Class B
the risk of developing type 2 diabetes. onset at age 20 or older or with
duration of less than 10 years
Class C
onset at age 10-19 or duration of 10-
19 years

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
THE SECOND GROUP OF DIABETES WHICH In pregnant women, hepatic glucose
EXISTED BEFORE PREGNANCY CAN BE productions is 1.3 times higher than it is in
SPLIT UP INTO THESE CLASSES: non pregnant women ( Lain & Catalano,
(CONTINUATION 2007)

Class D Note!
onset before age 10 or duration greater EUGLYCEMIA
than 20 years. Normal concentration of glucose in the blood
Class E
overt diabetes mellitus with calcified
pelvic vessels
Class F PERINATAL IMPLICATIONS OF DIABETES
diabetic nephropathy Fetal growth abnormalities most frequently
Class R seen in women with pregestational or
proliferative and nephropathy gestational diabetes are macrosomia and
Class RF IUGR.
retinopathy and nephropathy Poorly controlled diabetes, wether
Class H pregestational or gestatational, increase
ischemic heart disease the risk of RDS in the infant.
Class T
prior kidney transplant Note!
INTRAUTERINE GROWTH RESTRICTION, OR
IUGR
RISK FACTORS FOR GDM INCLUDE when a baby in the womb (a fetus) does not
Obesity grow as expected. The baby is not as big as
would be expected for the stage of the
Age over 25 years mother's pregnancy.
History of large babies (10lb or more)
NEONATAL RESPIRATORY DISTRESS
History of unexplained fetal or perinatal SYNDROME (RDS)
loss is a problem often seen in premature babies.
The condition makes it hard for the baby to
History of congenital anomalies in previous breathe.
pregnancies common breathing disorder that affects
History of PCOS newborns.
Family history of DM (one close relative or source:https://medlineplus.gov/ency/article/001563.htm
two distant ones)
Member of a population with a high risk for
DM (Native American, Hispanic, Asian)
SCREENING AND DIAGNOSIS OF GDM

METABOLIC ALTERATIONS OF PREGNANCY

During the first trimester, fasting blood
glucose decreases because of insulin
production, and sensitivity slightly
increases (Catalano, Huston, Amini &
Kalhan, 1999)
By the end of the first trimester, insulin
sensitivity decreases, with a responding
increase in insulin production; this change
creates the diabetogenic state of
pregnancy.
Euglycemia is maintained in pregnancy
because the pancreatic beta cells produce
enough insulin to counteract increasing
insulin resistance

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

SCREENING AND DIAGNOSIS OF GDM ANTERPARTUM CARE

(CONTINUATION)
Women are assessed for GDM at the first GDM typically does not cause any
prenatal visit. High-risk women are tested noticeable signs or symptoms. This is why
as soon as possible; women of average risk screening tests are so important. Rarely, an
receive the Glucose Challenge Test at 24- increased thirst or increased urinary
28 AOG. frequency may be noticed.
Women at high risk for GDM(ADA,2008a): The initial assessment of women with
Marked obesity preexisting diabetes, whether done before
Personal history of GDM or early in pregnancy, includes a thorough
Glycosuria medical and obstetric evaluation.
Strong family history of diabetes Evaluation includes;
complete health, obstetric, gynecologic
4 STEPS IN SCREENING AND DIAGNOSING OF and diabetes history
GDM physical examination
Laboratory test
1. Fasting for 8 to 12 hours
2. Blood is withdrawn to test fasting blood
glucose level TREATMENT FOR GDM
3. Glucose drink
4. Blood samples are drawn Diet
Exercise
Monitor blood glucose levels
ABNORMAL Pharmacologic therapy
NORMAL Maternal & Fetal Surveillance
Time after glucose blood sugar
blood sugar
load (after drinking values of 3hrs.
values of 3hrs.
100 grams of glucose screening
glucose )
glucose screening
test
MEDICAL NUTRITION THERAPY (MNT)
test

MNT by registered dietitian is the

95 mg/dL
cornerstone for diabetes management in
Fasting (5.3 mmol/L) or > 95 mg/dL
women with pregestational and gestational
lower
diabetes
1 hour
> 180 mg/dL (10.0
> 180 mg/dL
The nutritional management of women
mmol/L) or lower with preexisting and gestational diabetes
> 155 mg/dL
does not differ and has the same
2 hours (8.6 mmol/L) or > 155 mg/dL
therapeutic goals:
lower adequate nutrition and weight gain
plus prevention of ketosis and
> 140 mg/dL postprandial hyperglycemia
3 hours (7.8 mmol/L) or > 140 mg/dL
lower After thorough assessment, the dietitian
and the woman develop an individualized
A fasting plasma glucose of 126 mg/dl, or meal plan to achieve desired treatment
a random plasma glucose of 200 mg/dl, goals
meets the threshold for the diagnosis of The dietitian and the woman examine and
DM and needs to be confirmed on a discuss lifestyle influences that have a
subsequent test usually done using 100g bearing on MNT.
oral GCT. According to Reader & Thomas, 2008 The
diet for woman with diabetes includes at
least
175 g of carbohydrate
28 g of fiber
1.1 g of protein per kg/day

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
MEDICAL NUTRITION THERAPY (MNT)
CONTNUATION

All pregnant women should take a prenatal

vitamin with 600 mcg of folic acid daily
(IOM, 1998)
All pregnant women should limit caffeine
to 200 mg/day (March of Dimes, 2008)

EXERCISE

Exercise may be beneficial for women with

diabetes for metabolic control and well
being.
The health care provider must thoroughly SELF-MONITORED BLOOD GLUCOSE (SMBG)
evaluate diabetes- associated
complications before the woman begins or The most important parameter used to
continues an exercise program during determine the level of metabolic control is
pregnancy. evaluation of SMBG levels.
Vascular disease precludes exercise during Professional organizations have yet to
pregnancy agree on glycemic thresholds and timing
and frequency of testing
Before exercising, the woman should check To determine the effectiveness of the diet
blood glucose and urine ketones: in controlling blood glucose, women with
If blood sugar is ≥250 mg/dl and if GDM or diet-controlled type 2 diabetes
ketones are positive, she should delay that is managed by medical nutrition
exercise therapy (MNT) should initially test when
If blood sugar is <250 and ketones are fasting and then 1 hour postprandially.
moderate, she should call her provider Preprandial and postprandial measurement
If blood sugar is >250 and ketones are of blood glucose allow for accurate and
negative, she can exercise. safe adjustment of insulin.
( Harris & White, 2005)

In women with type 1 diabetes, exogenous URINE-KETONE TESTING

insulin concentrations do not fall during
exertion, and the usual increase in hepatic To ensure adequate intake ruling out
glucose production does not occur starvation ketosis, pregnant women should
(Carpenter & Gabbe, 2004) test urine for ketones daily from the first
Frequent monitoring of blood glucose void.
before, during and after exercise improves Hyperglycemic levels >200mg/dl warrant
safety and allows for early detection of ketone testing.
hypoglycemia and prompt intervention. Hyperglycemia and ketosis may indicate an
infection and should be evaluated
thoroughly.

RECORD KEEPING

Accurate records of blood- glucose levels,

urine-ketone testing , dietary intake, timing
and dosage of insulin and activity level
allow for appropriate adjustment of the
diabetes regimen.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
RECORD KEEPING (CONTINUATION) PHARMACOLOGIC COMPLICATION:

To detect falsification or over-or under- HYPOGLYCEMIA

reporting, the nurse periodically correlates
logged values to the meter memory. Intensive metabolic management during
pregnancy carries an increased incidence
of hypoglycemia.
PHARMACOLOGIC THERAPY: Hypoglycemia can be caused by too much
insulin, inadequate food intake, vomiting or
PREGESTATIONAL DIABETES increased activity.
Symptoms of hypoglycemia are
Women with type 2 diabetes controlled by individualized and can change over time as
oral anti diabetic agents who become hormonal counter regulatory function
pregnant should discontinue these agents becomes impaired.
and begin insulin (ADA, 2008b)
When a pregnant woman has type 1
diabetes, she should review all aspects of
insulin administration with the nurse.
When MNT and exercise do not achieve
glycemic control, insulin is indicated.
Women with pregestational diabetes,
particularly type 1, are prone to
hypoglycemia and may have
hypoglycaemia unawareness (Herman &
Kitzmiller, 2008)
The nurse reviews the increasing insulin
requirements of pregnancy and advises the
woman that the dosage at the end of
pregnancy increases dramatically and
warrants weekly adjustments.

GESTATIONAL DIABETES MELLITUS

Euglycemia is best achieved when insulin

therapy is prescribed in a physiologic basal ACUTE COMPLICATIONS:
bolus pattern.
Neutral protamine of Hagedorn (NPH) is PRETERM LABOR
the only basal insulin approved for use
duting pregnancy (Brown & Jovanovic, The incidence of preterm birth is increased
2008) in women with GDM and more significantly
Dosage and timing of insulin are based on increased (relative risk of 7) in women with
the results of SMBG and calculated based preexisting diabetes that is uncontrolled
on the woman’s weight and gestational (Jensen et al., 2004, Leperca et al., 2004;
age. Rosenberg et al., 2005)
Physiologic administration of insulin Vascular disease, hypertensive disorders
requires three to four injections daily, with and obesity contribute to the increased risk
50 percent to 60 percent of the total daily of preterm birth in women with diabetes.
dose (TDD) as the basal insulin. Women with diabetes who present with
Oral antidiabetic medications have been preterm labor are evaluated and managed
studied during pregnancy but are not yet in the same manner as women without
approved for use. diabetes, with particular attention to
maintaining euglycemia.

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ACADEMICIAN
 Week 2:
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ACUTE COMPLICATIONS (CONTINUATION)

PRETERM LABOR (CONTINUATION)

Health care providers must be careful when

using tocolytics to treat preterm labor in
women with diabetes. Commonly used
tocolytics for these women include:
Magnesium sulfate
Prostaglandin synthetase inhibitors
Beta adrenergic agonists
Calcium channel blockers

Antenatal glucocorticoids are indicated in CHRONIC COMPLICATIONS

gestations from 24 to 33 weeks to
(ACOG,2002a) RETINOPATHY
Enhance fetal lung maturation
Reduce the risk for RDS, Diabetic retinopathy, the leading cause of
Intraventricular hemorrhage and death blindness between ages 24 and 64, is the
most common vascular complication in
Use of corticosteroids results in pregnancy (Brown & Jovanovic, 2008)
hyperglycemia in women with diabetes; the Development in pregnancy is rare;
condition is treated aggressively with however, the rate of progression doubles in
insulin usually for several days. pregnancy (Brown & Jovanovic, 2008)
Postpartum regression of diabetic
retinopathy usually occurs and warrants
DIABETIC KETOACIDOSIS (DKA) close follow up

DKA is an uncommon, but life threatening, NEPHROPATHY

complication associated with
pregestational diabetes, an absolute or Diabetic nephropathy is a progressive
relative insulin deficiency causes DKA. disease that affects 20 to 40% of
It occurs 1-4 % of pregnancies affected by individuals with diabetes and 5 to 10% of
PGD all pregnancies (ADA, 2008; Carr et al.,
Occurs more often in women with type 1 2006)
diabetes, but it can occur in women with Without intervention, end-stage renal
type 2 diabetes. It does not occur in disease (ESRD) results.
women with GDM. Management during pregnancy involves
attainment of glycemic control, with
frequent SMBG to detect episodes of
hypoglycemia.
Control of hypertension improves perinatal
outcome.
Monitoring of serum creatinine provides an
indirect measure of GFR.
For women with overt nephropathy, a
registered dietitian is consulted to help
restrict daily protein intake.
Nephropathy significantly affects perinatal
morbidity and mortality; it increases the
risk of preeclampsia, nephrotic syndrome,
preterm birth, stillbirth and fetal growth
restriction (Khoury et al., 2002)

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

NEUROPATHY
Diagnosing gastroparesis requires tests
Diabetic neuropathies cause damage to the that evaluate and measure the stomach's
peripheral motor, sensory and autonomic neuromuscular activity.
nerves; individuals with type 1 and type 2
disease are affected (ADA, 2008b)
Pregnant women face an increased risk of
neuropathy directed at the gastrointestinal CARDIOVASCULAR DISEASE (CVD)
and cardiovascular systems. Pregnancy
does not appear to accelerate neuropathy CVD carries a significant risk for maternal
progression. mortality
The goal of treatment is stable and Treatment involves modifying risk with
optimal, glycemic control, which may smoking cessation and managing risk of
improve neuropathic symptoms. hypertension, dislipidemia and
Painful symptoms require pharmacologic hyperglycemia while avoiding
intervention. hypoglycemia (Paramsothy & Knopp, 2008)
Cardiac monitoring in labor is
recommended, and an epidural is advised
(Paramsothy & Knopp, 2008)
Peripheral vascular disease (PVD) is a
common finding in long-standing diabetics
who smoke.
The incidence of PVD in women of
reproductive age ranges from 2 percent to
12 percent (Hillier & Padula, 2003)
Absence of peripheral pulses is an
indication of PVD; this is more common in
GASTROPARESIS women with type 2 diabetes than in type 1
diabetes ( Vinicor 2003)
Gastroparesis involves autonomic
neuropathy of the viscera, causing
decreased intervention of the stomach and MATERNAL SURVEILLANCE
intestines.
Preprandial and postprandial blood- PREGESTATIONAL DIABETES
glucose testing are recommended to
detect hyperglycemia and hypoglycemia A comprehensive antepartum assessment
(Funnel & Feldman, 2003) includes a history, physical exam and
Maternal and fetal morbidity is high laboratory evaluation at the first prenatal
because of difficulty in maintaning visit.
adequate nutrition; hospitalization and Providers should see women who require
total parenteral nutrition often are frequent insulin adjustments weekly or
required. twice weekly;

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
FETAL SURVEILLANCE (CONTINUATION)
PREGESTATIONAL DIABETES
(CONTINUATION) MATERNAL SERUM SCREENING
Offered in the late- first trimester to screen
they should see women who achieve a for neural tube defects (NTDs) and
higher level of metabolic control every chromosomal abnormalities (Conway &
other week. Catalano, 2008).

FETAL ANATOMICAL SURVEYS

GESTATIONAL DIABETES Offered to all women with type 1 or 2
diabetes between 18 and 22 weeks
Nursing surveillance of women with gestation. Should include
pregestational and gestational diabetes; echocardiography.
Take vital signs.
Check the woman’s weight. FETAL MOVEMENT COUNT
Test urine for protein, glucose and A noninvasive way to evaluate fetal well-
ketones being in high-risk pregnancy; a decrease in
Review the self- management log. perceived fetal activity warrants further
Inspect injection sites for, bruising, exploration by NST or BPP.
infection, lipodystrophy and atrophy.
NONSTRESS TEST (NST)
If diagnosed in the first trimester, providers An electronic fetal monitor records fetal
should monitor women with GDM similarly heart rate and uterine activity.
to how they monitor women with
preexisting diabetes. BIOPHYSICAL PROFILE (BPP)
Women diagnosed with GDM at 24 to 28 An ultrasound that measures fetal
weeks require weekly visits to evaluate the breathing, gross body movements, fetal
level of glycemic control. tone and amniotic fluid volume.
Women who initiate insulin may need more
frequent visits. CONTRACTION STRESS TEST (CST)
Has some risk of initiating labor because
nipple stimulation and low- dose oxytocin
FETAL SURVEILLANCE induce contractions.
ACOG (2005) recommends fetal testing in
women with pregestational diabetes
between 32 and 34 weeks. INDICATIONS FOR DELIVERY IN PREGNANT
WOMEN WITH DIABETES
ULTRASOUND Poorly controlled blood glucose
Early ultrasound confirms viability and Abnormal fetal testing
provides accurate dating. Fetal growth restriction
In second or third trimester, serial Deterioration of vascular complications
ultrasounds can assess growth and Significant macrosomia
detect macrosomia or IUGR.

Note!
Children who are exposed to high blood
glucose in the womb are at higher risk of
developing Type 2 diabetes later in life.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
ISOIMMUNIZATION
A person without the Rh factor is said to be
RH-negative.
RH INCOMPATIBILITY The person will produce anti- Rh
antibodies.
occurs when an Rh-negative mother (one
negative for a D antigen or one with a dd Therefore an RH (+) person may receive
genotype) carries a fetus with an Rh- both an RH (+) and an Rh (-) transfusion.
positive blood type (DD or Dd genotype). but an Rh (-) person can only receive Rh (-)
blood.
RH ISOIMMUNIZATION

Isoimmunization is when the blood from

the baby makes the mother's body create
antibodies that can harm the baby's blood RH INCOMPATIBILITY CAN OCCUR BY 2 MAIN
cells. MECHANISMS

The most common type occurs when an

Note!
Rh-negative pregnant mother is exposed
HEMOLYSIS to Rh-positive fetal red blood cells
red blood cells destruction secondary to fetomaternal hemorrhage
during the course of pregnancy from
spontaneous or induced abortion, trauma,
invasive obstetric procedures, or normal
RHESUS FACTOR (RH FACTOR) delivery.
Rh incompatibility can also occur when an
In 1937, Karl Landsteiner and Alexander Rh-negative female receives an Rh-positive
Weiner discovered a new blood type: the blood transfusion.
rhesus blood type, or Rh factor.
The rhesus protein is named for the rhesus
monkey, which also carries the gene, and is TAKE NOTE:
a protein that lives on the surface of the The most common cause of Rh
red blood cells. incompatibility is exposure from an Rh-
This protein is also often called the D negative mother by Rh-positive fetal blood
antigen. during pregnancy or delivery.
When it comes to blood transfusion, As a consequence, blood from the fetal
anyone who is Rh positive can receive circulation may leak into the maternal
blood from someone who is Rh negative, circulation, and, after a significant
but those with negative blood types cannot exposure, sensitization occurs leading to
receive from anyone with a positive blood maternal antibody production against the
type. foreign Rh antigen.
Landsteiner and Weiner discovered that Once produced, maternal Rh
blood types can be either Rh positive or Rh immunoglobulin G (1gG) antibodies persist
negative, doubling the commonly known for life and may cross freely from the
blood types from four (A, B, AB, and O), to placenta to the fetal circulation, where they
the eight we know today. form antigen-antibody complexes with Rh-
positive fetal erythrocytes and eventually
are destroyed, resulting in a fetal
TAKE NOTE: alloimmune-induced hemolytic anemia.
A person with the Rh factor on his or her
blood cells is said to be RH-positive.
Since the person has the factor, he or
she will not make anti- Rh antibodies.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
Congenital Anemia: mildly affected
The mother and the baby's blood do not mix in
utero. But sometimes, a small amount of fetal Baby develops anemia, jaundice is not so
blood enters the maternal circulation. evident or is mild, prognosis is good
Ectopic pregnancy
Abruptio placenta
Placenta previa
Abdominal/Pelvic Trauma
In utero fetal death
Invasive procedures

When an Rh-positive fetus grows inside an

Rh-negative mother who is sensitized, her
body reacts in the same manner it would if
the invading factor were a substance such
as a virus
she forms antibodies against the RH INCOMPATIBILITY IN PREGNANCY
invading substance.

The Rh factor exists as a portion of the BC,

so these maternal antibodies cross the
placenta and cause destruction (hemolysis)
to the fetal RBC
A fetus can become so deficient in red
blood cells that sufficient oxygen transport
to body cannot be maintained.
This condition is termed hemolytic
disease of the newborn or
erythroblastosis fetalis.

ASSESSMENT
All women with Rh negative blood should
have an anti-D antibody titer done at first
pregnancy visit.
if normal or the titer is minimal (normal
is 0; a ratio below 1:8 is minimal), the
test is repeated at 28 weeks.
if the repeat test at 28 weeks is also
normal, no therapy is needed.
MANIFESTATION OF ERYTHROBLASTOSIS If the anti-D antibody titer is elevated at a
FETALIS first assessment (1:16 or greater), showing
sensitization, the well-being of the fetus is
Depending upon the degree of the fetal RBCs monitored every 2 weeks (or more often)
Hydrops Fetalis: Fetus is severely affected; by Doppler velocity of the fetal middle
can cause IUFD cerebral artery.
Neonatal Jaundice: Relatively less affected

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
This can predict when anemia is present or
fetal cells are being destroyed.
If the artery velocity remains high, a
fetus is not developing and most likely
is an Rh negative fetus.
If the reading is low, it means a fetus is
in danger, and immediate birth will be
carried out providing the fetus is near
term.
If not near term, efforts to reduce the
maternal antibodies in the woman or
replace damaged BC in the fetus is
began. Either the fetus' own type (determined by
PBS) or group O negative if the fetal blood
type is unknown
From 75 to 150 ml of washed red cells are
THERAPEUTIC MANAGEMENT used, depending on the age of the fetus.
RhIg, a commercial preparation of passive The woman is urged to rest for
Rh (D) antibodies against the Rh factor is approximately 30 minutes while fetal heart
administered to women who are Rh sounds and uterine activity are monitored.
negative at 28 weeks of pregnancy.
These cannot cross the placenta and
destroy the fetal RBCs because the
antibodies are not the gG class, the only
type that crosses the placenta.
Rhig (Rhogam) is given again by injection
to the mother in the first 72 hours after
birth of an Rh-positive child to further
prevent the woman from forming
antibodies.
RhIg are passive antibody protection and in
2 weeks to 2 months, the passive
Cord blood vessels could be lacerated or
antibodies are destroyed.
the uterus could be so irritated by the
For this reason, every pregnancy is like a
invasive procedure that labor contractions
first pregnancy in terms of antibodies
begin.
present.
The mother receives an Rhlg injection after
Rhogam must be given in every pregnancy
the transfusion to help reduce increased
with an Rh-positive baby.
sensitization.
Transfusion is sometimes done once during
After birth, the infant's blood type will be
pregnancy, or may be repeated as often as
determined from sample of the cord blood.
every 2 weeks.
If Rh positive, the mother will receive
Once fetal maturity is reached as
Rhogam.
evidenced by mature LS ratio, birth will be
If Rh negative, the mother will not
induced.
receive not Rhogam anymore.

INTRAUTERINE INFUSION
Done to restore fetal red blood cells
Done by injecting RBCs by amniocentesis
technique directly into a vessel in the fetal
cord or depositing them in the fetal
abdomen where they migrate into the fetal
circulation.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
Phototherapy lights to reduce the level of
bilirubin released from the hemolysis or an
exchange transfusion to remove the
hemolyzed RBCs and replaced with healthy
RBCS
A woman should be provided with
contraceptive information if she does not
want to undergo the strain of another
pregnancy.

ANTENATAL DIAGNOSIS OF RH ISO

IMMUNINIZATION

the history and physical exam.

the maternal and paternal Rh blood type
Anti- Rh Ab screen ( monthly after 20th
week) by indirect coombs test; if positive as
1/8-1/32, there is needed further
ADDITIONAL INFORMATIONS assessment
ultrasound exams
INCIDENCE OF RHESUS BLOOD GROUP fetal anemia and hyperbilirubinemia- by
SYSTEM ultrasound guided amniocentesis
spectrophotometry of amniotic fluid
Incidence of Rh negative varies in different (Liley Chart)
races and ethnic groups CORDOCENTESIS- Fetal blood tests
Mongoloids= nil
Chinese, Japanese = 1-2%
Indians = 5% POSTNATAL DIAGNOSIS OF RH
Africans = 5-8% ISOIMMUNIZATION
Caucasians = 15-17%
Baques = 30-35% HEMOLYTIC DISEASE OF THE NEWBORN
Hemolytic anemia (Hb= 13- 14g%; bilirubin
< 3.5mg%)
Icterus gravis neonatorum (Hb= 7-12g%;
PATHOGENESIS OF RH ISO-IMMUNIZATION bilirubin> 10mg%)
Kernicterus (bilirubin> 18mg%)
Chances of feto-maternal hemorrhage/ Hydrops fetalis (Hb< 7-12g%; bilirubin
passage are only 5% in 1st trimester but 10mg%)
47% in 3rd trimester many conditions can
increase the risk. LABORATORY TESTS (NEWBORN)
Chances of primary sensitization during 1st ABO and Rh blood group test
pregnancy is only 1-2%, but 10-15% of Hb and Ht
patients may become sensitized after Reticulocyte count
delivery Bilirubin level
ABO incompatibility and Rh non-responder Direct Coombs test
status may protect
Amount of antibodies that enter the fetal
circulation will determine the degree of
hemolysis.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
PREVENTION OF RH ISOIMMUNIZATION Fetus Rh Positive + anemia
Intrauterine transfusion of Rh-negative
Premarital counseling. blood in selected cases
Blood grouping for every woman, before Planned preterm delivery any time after
1st pregnancy 34 weeks or as soon as the lung
Proper management of unsensitized Rh maturity is documented by including
negative pregnancies. the labor or cesarean section (for
Blood typing at 1st visit, severely affected fetuses)
If negative - husband's typing
Anti-Rh Ab screen (indirect Coomb's test) POSTPARTUM (MANAGEMENT OF THE
of Rh- negative mother INFANT)
At about 28 weeks
negative Monitor up to 8 weeks
300 ug anti D Exchange transfusion in newborn umbilical
In abortion, ectopic pregnancy, abruption vein
of placenta, placenta praaevia, molar Phototheraphy
pregnancy, abdominal trauma, CVS, In cases of severely sensitized women,
amniocentesis, fetal-maternal hemorrhage consider medical termination of pregnancy
150-300 ug anti D and sterilization
At birth
cord blood for ABO Rh typing- baby Rh
positive ANEMIAS OF PREGNANCY
300 ug anti D within 72 hours of
delivery WHAT IS ANEMIA?
IN CASE OF LARGE FETAL-MATERNAL A decreased amount of red blood cells or
HEMORRHAGE: hemoglobin in the body. These
components play a huge role in carrying
The Kleihauer-Betke test estimates the oxygen throughout the body. Presence of
mount of fetal blood in circulation low RBCs or hemoglobin, body won’t
The indirect Coombs tests receive enough oxygen to function
An additional does of anti-D, if needed properly.
Commonest medical disorder in pregnancy
ERRORS- CAUSES OF SENSITIZATION It is important contributor to maternal &
perinatal morbidity & mortality as a direct
Misinterpretation of maternal Rh type or indirect cause
Rh+ blood transfusion A condition where circulating levels of Hb
Unprotected pregnancy and labour are quantitatively or qualitatively lower
Inadequate dose/ improper use of IgG on than normal
previous occasions
Immunization to cross-reacting antigen Hb < 12gm%
Non pregnant women

MANAGEMENT OF RH ISOIMMUNIZATION Hb < 11 gm%

PREGNANCY Haematocrit
Pregnant women (WHO)
< 33%
ANTEPARTUM

Careful planning during anterpartum, Pregnant women (CDC)

intrapartum and neonatal period Hb <11 gm%
1st&3rd Trimester
Known repeated maternal anti- D Ab titer
Intrauterine fetl monitoring with repeated Pregnant women (CDC)
Hb < 10.5 gm%
US examinations, Cordocentesis and Fetal 2nd Trimester
blood sampling/ amniocentesis.

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

EXTRA IRON REQUIREMENT & LOSS DURING

PREGNANCY

Due to cessation of menses & contraction

CAUSES OF ANEMIA IN PREGNANCY of blood volume after delivery conservation
of iron is around 400 mg
Nutritional / Iron deficiency anemia
Pre-pregnancy poor nutrition very
important
Besides Iron, folate and B12 deficiency are ABSORPTION OF IRON / DAILY
also important REQUIREMENT
Chronic blood loss due to parasitic Normal diet contain about 14 mg of iron
infections – Hookworm & malaria Absorption of iron is 5-10% (1-2 mg) & 3-
Multiparity 4% in pure veg diet
Multiple pregnancy Additional daily iron demand in early
Acute blood loss in APH, PPH pregnancy 2-3 mg/day
Recurrent infections (UTI) In late pregnancy 6-7 mg/day
anemia due to impaired erythropoiesis So daily supplement of 40-60 mg of
Hemolytic anemia in PIH elemental iron is required during
Hemoglobinopathies pregnancy
like Thalassemia, sickle cell anemia Folic acid requirement is also increased
Aplastic anemia is rare 400-600 ug/day
In strict veg Vit B 12 is also deficient

PATHOPHYSIOLOGY OF NUTRITIONAL
ANEMIA IN PREGNANCY

Augmented erythropoiesis in pregnancy

Blood volume increases 40-45% in
pregnancy
Increase in plasma is more as compared to
red cell mass leading to hemodilution &
decrease in Hb level
Iron stores are depleted with each
pregnancy
Too soon & too many pregnancies result in
higher prevalence of iron deficiency
anemia

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
ASSESSMENT ON MOTHER
Susceptibility to infection
Depends on severity of anemia Heart decompensation and Heart failure
High risk women – adolescent, Preterm labour and Preterm delivery
multiparous, multiple pregnancy, lower Postpartum hemorrhage
socio economic status Mental lassitude and Loss of working hours
Mild anemic - asymptomatic Death
Cardiac murmurs, cardiac failure
Glossitis, stomatitis, chelosis, brittle hair
Watch out for Signs and Symptoms TREATMENT FOR IRON DEFICIENCY ANEMIA

Improving diet rich in iron & fruits & leafy

SYMPTOMS vegetables
Treat worm infections, maintain general
pallor hygiene
weakness Food fortification with iron & genetic
fatigue modification of food
dyspnoea Iron & folic acid supplementation in young
palpitation girls & during pregnancy
swelling over feet & body Heme iron better, present in animal
food & is better absorbed
Iron absorption enhanced by citrous
SIGNS fruits, Vitamin C
Avoid tea, coffee, Ca, phytates,
pallor phosphates, oxalates, egg, cereals with
facial puffiness iron
raised Jugular vein
tachycardia Iron-rich foods
tachypnea lean red meat, poultry, and fish
crepitations in lungbases leafy, dark green vegetables (such as
hepato-splenomegaly spinach, broccoli, and kale)
pitting edema over abdominal wall& legs iron-enriched cereals and grains
beans, lentils, and tofu
nuts and seeds
MOST CRITICAL PERIOD eggs
28-30 weeks of pregnancy
In labor IRON SUPPLEMENTATION IN PREGNANCY
Immediately after delivery
Early Puerperium 60 mg elemental iron & 400 ug of folic acid
CHF (Failure to cope up with pregnancy daily during pregnancy and 3 months there
induced cardiac load) after
In anemia therapeutic doses are
180-200mg/d
EFFECT OF ANEMIA ON PREGNANCY Route of administration depends on,
severity of anemia, Gestational age,
ON FETUS compliance & tolerability of iron
Neutal tube defects (esp. folate def.,) Various preparations
Miscarriage fumarate, gluconate, succinate, sulfate,
IUGR/ Low birth weight ascorbate
Prematurity Oral iron can have side effects like nausea,
Anemia in infancy vomiting, gastritis, diarrheas, constipation
IUFD

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ACADEMICIAN
 Week 2:
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IRON SUPPLEMENTATION IN PREGNANCY Associated Infection

(CONTINUATION) Patient not responding to oral or
parenteral therapy
Iron supplementation is not recommended Anemic & symptomatic pregnant
in first trimester women(dyspneic, with heart failure etc)
Higher incidence of miscarriage irrespective of gestational age
Birth defects
Bacterial infection (bacteria grow after
taking iron from supplementation) A WOMAN WITH FOLIC-ACID DEFICIENCY
ANEMIA
ORAL IRON Pregnant women need to get enough folic
acid. The vitamin is important to the
Hb 8-11 gm%, early pregnancy growth of the fetus's spinal cord and brain.
Folic acid deficiency can cause severe birth
Contraindication to Oral Iron Therapy defects known as neural tube defects. The
Intolerance to oral iron Recommended Dietary Allowance (RDA)
Severe anemia in for folate during pregnancy is 600
advanced pregnancy micrograms(µg)/day.
Noncompliant Because the fetal effects of deficiency
occur in the first few weeks of fetal
Failure to Respond development, women expecting to become
Inaccurate diagnosis pregnant are advised to begin a
Faulty absorption supplement of 400 μg folic acid daily in
Continuous blood loss addition to eating folacin-rich foods (green
Co-existant infection leafy vegetables, oranges, dried beans) and
Concomitant folate deficiency During pregnancy, the folic acid
requirement increases to 600 μg/day.
Indicators of response to therapy
Feeling of well being
Improved look of patient A decrease in RBC’s due to a lack of B9
Better appetite vitamin called folate (or folic acid)
Rise in Hb .5-.7 gm/dl per week (starts When there isn’t enough folic acid, the
after 3 weeks) RBC’s are formed unusually large and don’t
Reticulocytosis in 7-10 days work right
Can co-exist with Vitamin B12 deficiency
PARENTERAL IRON TRANSFUSION A megaloblastic anemia
Folate stores are small and can be depleted
Iron sucrose for parenteral use within 4 months
Dose calculated - Wt in Kg x iron deficit x
2.2 + 1000 mg for iron stores
Response - by increase in Hb level 1g/week CAUSES OF FOLIC ACID ANEMIA
Increase in Reticulocyte count with in 5-
10days Inadequate dietary intake
Clinical symptoms improve Excessive alcohol intake
Pregnancy
Certain medications
Diseases of absorption
INDICATIONS FOR BLOOD TRANSFUSION Inherited condition
Severe anemia first seen after 36 weeks of
pregnancy
Anemia due to acute bloodLoss – APH &
PPH

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ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
CLINICAL MANIFESTATIONS OF FOLIC ACID NURSING DIAGNOSIS
DEFICIENCY ANEMIA
Activity intolerance related to weakness,
The same as a Vitamin B12 Deficiency fatigue and general malaise
(except no neuro-symptoms) Imbalanced nutrition, less than body
Fatigue requirements
headache Ineffective tissue perfusion related to
pale skin inadequate blood volume or HCT
sore mouth and smooth Noncompliance with prescribed theraphy
sore tongue
decreased appetite
irritability WHAT NURSING INTERVENTIONS ARE
diarrhea USEFUL FOR FOLIC ACID DEFICIENCY
curly ANEMIA?
graying hair
decreased skin color pigment Advise patient to eat folate rich foods-
infertility Green, leafy vegetables, liver, fresh fruits,
worsening of heart disease or heart failure cereals, meats, yeast
Inspect skin, mucous membranes and
tongu
HOW IS FOLIC ACID DEFICIENCY ANEMIA Inspect for jaundice
DIAGNOSED? Hair for premature graying

Folic Acid levels

CBC A WOMAN WITH SICKLE CELL ANEMIA
Rarely a bone marrow exam
Sickle cell anemia is a recessively inherited
HOW IS FOLIC ACID DEFICIENCY ANEMIA hemolytic anemia caused by an abnormal
MANAGED? amino acid in the beta chain of
hemoglobin. If the abnormal amino acid
Identify and treat the cause of the folate replaces the amino acid valine, sickle
deficiency hemoglobin (HbS) results; if it is
Replace folate in the diet or with substituted for the amino acid lysine, non-
supplements sickling hemoglobin (HbC) results. An
Prefer PO, IM only with malabsorption individual who is heterozygous (has only
Decrease alcohol consumption one gene in which the abnormal
Supplements before and during pregnancy substitution has occurred), sickle cell
disease (HbSS) results.

With the disease, most RBCs are irregular,

or sickle shaped so they cannot carry as
much hemoglobin as can normally shaped
RBCs. When oxygen tension becomes
reduced, as occurs at high altitudes, or
blood becomes more viscid than usual
(dehydration), the cells tend to clump
because of the irregular shape. This
clumping can result in vessel blockage with
reduced blood flow to organs. The cells
then will hemolyze, reducing the number
available and causing a severe anemia.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

A WOMAN WITH SICKLE CELL ANEMIA THERAPEUTIC MANAGEMENT

(CONTINUATION)
Interventions to prevent sickle cell crisis can
Although the sickle cell trait does not include periodic exchange transfusions
appear to influence the course of throughout pregnancy to replace sickled cells
pregnancy, prematurity, miscarriage, or with non-sickled cells.
perinatal mortality rates of these may be
higher for women with the homozygous If a crisis occurs, controlling pain,
disease. Women with the trait seem to administering oxygen as needed, and
have an increased incidence of increasing the fluid volume of the
asymptomatic bacteriuria, resulting in an circulatory system to lower viscosity are
increased incidence of pyelonephritis. important interventions.
fluid administered is often hypotonic (0.45
At any time in life, sickle cell anemia is a saline) to keep plasma tension low because
threat to life if vital blood vessels such as of the difficulty a woman has
those to the liver, kidneys, heart, lungs, or concentrating urine to remove large
brain become blocked. In pregnancy, amounts of fluid.
blockage to the placental circulation can As a rule, women with sickle cell disease
directly compromise the fetus, causing low are not given an iron supplement during
birth weight and possibly fetal death. pregnancy

ASSESSMENT If a woman contracts an infection that

causes fever
Hemoglobin levels for all women with sickle increased perspiration, or lowered PO2,
cell disease should be obtained throughout hospitalization for observation may be
pregnancy. necessary to rule out the development
A woman with sickle cell disease may of a sickle cell crisis and subsequent
normally have a hemoglobin level of 6 hemolysis of crowded cells.
to 8 mg/100 ml.
When the fetus is mature,
Pregnant woman with sickle cell anemia is the time and method of birth are
more susceptible to bacteriuria than other individualized.
women, a clean catch urine sample is Keep a woman well hydrated in labor.
collected periodically during pregnancy to If an operative birth is necessary, she
detect developing bacteriuria while a generally receives epidural anesthesia
woman is still asymptomatic. as general anesthesia poses a possible
risk of hypoxia.
Monitor a woman’s diet to be certain she is In the postpartum period, early
consuming enough folic acid and possibly ambulation and wearing pressure
an additional folic acid supplement, which stockings can help reduce the risk of
may be necessary to build new RBCs thromboembolism from stasis in lower
She should consume at least eight extremities.
glasses of fluids daily. Early in
pregnancy, when she may be Because the disorder is recessively
nauseated, her fluid intake can easily inherited,
decrease, and dehydration and a if one of the parents has the disease
subsequent sickle cell crisis may occur. and the other is free of the disease and
trait, the chances that the child will
Assess a woman’s lower extremities at inherent the disease are zero.
prenatal visits for varicosities or pooling of If a woman has the disease and her
blood in leg veins, which are apt to occur partner has the trait, the chances that
from uterine pressure as pregnancy the child will be born with the disease
advances. are 50%.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
If both parents have the disease, all TREATMENT (CONTINUATION)
their children will also have the disease.
Symptoms of sickle cell disease do not Pernicious Anaemia – Oral Vit B12
become clinically apparent until an Total Gastrectomy – 1000 microgram
infant’s fetal hemoglobin converts to a Vitamin B12 IM every month.
largely adult pattern (in 3 to 6 months). Partial gastrectomy – Ser. Vitamin B12
levels measured.

VITAMIN B12 DEFICIENCY

WHAT IS MEGALOBLASTIC ANEMIA?
If you're pregnant, not having enough
vitamin B12 can increase the risk of your Anemia with very large, immature,
baby developing a serious birth defect incompletely developedRBC’s.
known as a neural tube defect. The neural The RBC’s do not function properly and die
tube is a narrow channel that eventually early Caused by folic acid or vitamin B12
forms the brain and spinal cord. deficiency Caused by alcohol abuse,
(source: chemotherapy, leukemia, drugs, genetic
https://www.nhs.uk/conditions/vitamin-b12- conditions, chemicals
or-folate-deficiency-anaemia/complications/)

PATHOPHYSIOLOGY

Vitamin B12 absorption is unaltered during

pregnancy
Tissue uptake is increased
Decreased serum B12
Recommended B12 intake
3 microgram /day

CAUSES OF VITAMIN B12 DEFICIENCY

Strict Vegetarian diet

Use of proton pump inhibitors
Metformin
Gastritis HYPEREMESIS GRAVIDARUM
Gastrectomy
Ileal bypass Excessive nausea and vomiting (possibly
Crohn’s related to elevated HCG levels) that is
H. Pylori infection prolonged past 12 weeks of gestation and
results in a 5% weight loss from pre-
pregnancy weight, electrolyte imbalance,
DIAGNOSIS acetonuria, and ketosis.
It occurs at an incidence of 1 in 200 to 300
Serum Vitamin B12 levels ,100 pg /ml women.
Radio active Vit B12 absorption test women with the disorder may have
(Schilling Test ) increased thyroid function because of the
thyroid stimulating properties of human
chorionic gonadotropin. Some studies
TREATMENT reveal that it is associated with
Helicobacter pylori, the same bacteria that
1000 microgram parenteral cause peptic ulcers.
cyanocobalamin every wk * 6 weeks

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
With hyperemesis gravidarum, a woman’s Metabolic alkalosis due to excessive
nausea and vomiting are so severe that she vomiting
cannot maintain her usual nutrition. She Elevated liver enzymes
may show an elevated hematocrit Bilirubin level
concentration at her monthly prenatal visit
because her inability to retain fluid has Thyroid test indicating hyperthyroidism
resulted in hemoconcentration. CBC: Hct concentration is elevated
Concentrations of sodium, potassium, and because inability to retain fluid results in
chloride may be reduced because of her hemoconcentration.
low intake, and hypokalemic alkalosis may
result if vomiting is severe.
There is risk to the fetus for IUGR or NURSING CARE
preterm birth if the condition persists.
Monitor I and O
Assess skin turgor and mucous membranes
RISK FACTORS Monitor vital signs
Monitor weight
Maternal age younger than 30 years Have the client remain NPO for 24 to 48
History of migraines hours as ordered
Obesity
First pregnancy MEDICATIONS
Multifetal gestation
GTD or fetus with chromosomal anomaly Give the client IV lactated Ringer's for
Psychosocial issues and high levels of hydration.
emotional stress Give pyridoxine (Vit B6) and other vitamin
Clinical hyperthyroid disorders supplements as tolerated.
DM Use antiemetic medications (ondansetron,
GI disorders metoclopramide) cautiously for
Family history of hyperemesis uncontrollable nausea and vomiting.
Use corticosteroids to treat refractory
PHYSICAL ASSESSMENT FINDINGS hyperemesis gravidarum.

Excessive vomiting for prolonged periods

Dehydration with possible electrolyte CLIENT EDUCATION: DISCHARGE
imbalance INSTRUCTIONS
Weight loss
Increased pulse rate Advance the client to clear liquids after 24
Decreased BP hours if no vomiting
Poor skin turgor and dry mucous Advance the client to DAT with frequent
membranes small meals. Start with dry toast, or cereal;
then move to a soft diet; and finally to a
normal diet as tolerated.
LABORATORY TESTS In severe cases, or if vomiting returns,
enteral nutrition per feeding tube or total
UA for ketones and acetones (breakdown parenteral nutrition can be considered.
of fat) is the most important initial
laboratory test: Elevated urine specific
gravity
Chemical profile revealing electrolyte
imbalances
Na, K, Cl reduced from vomiting
Metabolic acidosis (secondary to
starvation)

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

PREGNANCY INDUCED HYPERTENSION Vasoconstriction occurs and blood

(PIH) pressure increases dramatically
With hypertension, the cardiac system can
become overwhelmed because the heart is
Pregnancy Induced Hypertension (PIH) is a forced to pump against rising peripheral
condition characterized by high blood resistance. This reduces the blood supply
pressure during pregnancy. to organs, most markedly the kidney,
a condition in which vasospasm occurs pancreas, liver, brain, and placenta.
during pregnancy Poor placental perfusion may reduce the
also referred to as toxemia of pregnancy fetal nutrient and oxygen supply. Ischemia
in the pancreas may result in epigastric
pain and an elevated amylase–creatinine
PREDISPOSING FACTORS
ratio.
with a multiple pregnancy, Spasm of the arteries in the retina leads to
primiparas younger than 20 years or older vision changes. If retinal hemorrhages
than 40 years, occur, blindness can result.
women from low socioeconomic
backgrounds (perhaps because of poor CLASSIFICATIONS OF PIH
nutrition),
those who have had five or more 1.GESTATIONAL HYPERTENSION
pregnancies,
those who have hydramnios Onset of BP elevation without proteinuria
(overproduction of amniotic fluid; refer to & edema after 20th week of pregnancy and
discussion later), returns to normal by 12 wks. Postpartum
those who have an underlying disease such
as heart disease, diabetes with vessel or Mild- SBP 140-159 DBP 90-109
renal involvement, and essential Severe- SBP ≥ 160 DBP ≥ 110
hypertension.
hereditary Perinatal mortality is not increased with
simple gestational hypertension, so no
drug therapy is necessary.
SYMPTOMS OF PIH A woman is said to be mildly pre-eclamptic
when she has proteinuria and blood
affect almost all organs. pressure rises to 140/90 mm Hg, taken on
vascular spasm may be caused by the two occasions at least 6 hours apart.
increased cardiac output that occurs with The diastolic value of blood pressure is
pregnancy and injures the endothelial cells extremely important to document because
of the arteries or the action of it is this pressure that best indicates the
prostaglandins (notably decreased degree of peripheral arterial spasm present
prostacyclin, a vasodilator, and excessive A second criterion for evaluating blood
production of thromboxane, a pressure is a systolic blood pressure
vasoconstrictor and stimulant of platelet greater than 30 mm Hg and a diastolic
aggregation). pressure greater than 15 mm Hg above
Normally, blood vessels during pregnancy pre-pregnancy values.
are resistant to the effects of pressor This rule is helpful, but the value of
substances such as angiotensin and 140/90 mm Hg is a more useful cutoff
norepinephrine, so blood pressure remains point when there are no baseline data
normal during pregnancy. With PIH, this available, such as when a woman seeks
reduced responsiveness to blood pressure prenatal care late in pregnancy.
changes appears to be lost.
Vasoconstriction occurs and blood
pressure increases dramatically.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
MANAGEMENT OF MILD GESTATIONAL If proteinuria is present without other signs
HYPERTENSION of PIH (no hypertension and no edema),
check to see when the specimen was
Educate patient about s/s of preeclampsia obtained.
and when to call the HCP Ask her to bring in a first morning urine
Patient assess daily for signs of sample. Edema develops, as mentioned,
preeclampsia and decrease fetal because of the protein loss, sodium
movement retention, and lowered glomerular filtration
B/P evaluated twice at week, one being rate.
done by provider along with assessing for The edema is not just the typical ankle
proteinuria, liver enzymes and platelets edema of pregnancy but begins to
accumulate in the upper part of the body.
MANAGEMENT OF SEVERE GESTATIONAL A weight gain of more than 2 lb/wk in the
HYPERTENSION second trimester or 1 lb/wk in the third
trimester usually indicates abnormal tissue
Admit to hospital for stabilization fluid retention.
Lower B/P to < 160/110: IV Hydralazine or
labetalol
Monitor B/P and s/s of preeclampsia 3.SEVERE PRE-ECLAMPSIA
Administer oral antihypertensive to control
B/P A woman has passed from mild to severe
Delivery based on fetal status and pre-eclampsia when her blood pressure
gestational age rises to 160 mm Hg systolic and 110 mm
Hg diastolic or above on at least two
occasions 6 hours apart at bed rest (the
PRE-ECLAMPSIA position in which blood pressure is lowest)
or her diastolic pressure is 30 mm Hg
Hypertension develops after 20 weeks of above her pre-pregnancy level.
gestation in previously normotensive Marked proteinuria, 3+ or 4+ on a random
woman with proteinuria and edema urine sample or more than 5 g in a 24-hour
sample, and extensive edema are also
present.
CLINICAL MANIFESTATIONS With severe pre- eclampsia, the extreme
edema is most readily palpated over bony
Classic Triad hypertension, proteinuria, and surfaces, such as over the tibia on the
edema anterior leg, the ulnar surface of the
New study * edema does not have to be forearm, and the cheekbones, where the
present sponginess of fluid-filled tissue can be
Proteinuria can also be absent if palpated against bone. If there is swelling
hypertension present along with signs of or puffiness at these points to a palpating
multi-system involvement finger but the swelling cannot be indented
with finger pressure, the edema is non-
pitting
2.MILD PRE-ECLAMPSIA IF THE TISSUE CAN BE:
indented slightly, this is 1+ pitting
In addition to the hypertension a woman edema;
has proteinuria (1+ or 2+ on a reagent test moderate indentation is 2+;
strip on a random sample). deep indentation is 3+;
Many women show a trace of protein and indentation so deep it remains
during pregnancy. Actual proteinuria is after removal of the finger is 4+ pitting
said to exist when it registers as 1+ or more edema.
(this represents a loss of 1 g/L).

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
Some women have severe epigastric pain
and nausea and vomiting, possibly because
of abdominal edema or ischemia to the
pancreas and liver.
If pulmonary edema develops, a woman
may report feeling short of breath. If
cerebral edema occurs, reports may be
voiced of visual disturbances such as
blurred vision or seeing spots before the
eyes. CLINICAL MANIFESTASTION
Cerebral edema also produces symptoms
of severe headache and marked Headache
hyperreflexia and perhaps ankle clonus (a Epigastric Pain
continued motion of the foot). Visual Changes
CNS Irritability

ADDITIONAL:
CHRONIC HYPERTENSION

exist in women with high blood pressure

(over 140/90) before pregnancy, early in
pregnancy (before 20weeks), or continue
to have it after delivery.
Oral antihypertensive are used (avoid ACEs
& ARBs due to fetogenic side effects)

NURSING INTERVENTIONS FOR A WOMAN

WITH MILD PIH
4.ECLAMPSIA
CONSERVATIVE TREATMENT- BED REST
This is the most severe classification of AT HOME CAN BE MANAGED AT HOME
PIH. A woman has passed into this stage IF:
when cerebral edema is so acute that a BP is 140/90 and below
grand-mal seizure (tonic-clonic) or coma no proteinuria
occurs. no fetal growth retardation
With eclampsia, the maternal mortality rate Patient is not a young primipara
is as high as 20% from causes such as
cerebral hemorrhage, circulatory collapse, MONITOR ANTIPLATELET THERAPY
or renal failure. Because of the increased tendency for
The fetal prognosis with eclampsia is also platelets to cluster along arterial walls,
poor because of hypoxia and consequent a mild anti-platelet agent, such as low-
fetal acidosis. dose aspirin, may prevent or delay
If premature separation of the placenta development of pre- eclampsia.
from vasospasm occurs, the fetal prognosis Be certain they are taking low-dose
is even graver. aspirin (50–150 mg) as excessive
If a fetus must be born before term, all the salicylic levels can cause maternal
risks of immaturity will be faced. bleeding at the time of birth.
In preeclampsia, the fetal mortality rate
is approximately 10%.
If eclampsia develops, the mortality
rate increases to as high as 20%.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

NURSING INTERVENTIONS FOR A WOMAN NURSING INTERVENTIONS FOR A WOMAN

WITH MILD PIH (CONTINUATION) WITH SEVERE PIH

PROMOTE BED REST NEEDS HOSPITAL CARE, SUPPORT BED

When the body is in a recumbent REST
position, sodium tends to be excreted With severe pre-eclampsia, most
at a faster rate than during activity. women are hospitalized so that bed rest
Bed rest, therefore, is the best method can be enforced and a woman can be
of aiding increased evacuation of observed more closely than she can be
sodium and encouraging diuresis. on home care.
Rest should always be in a lateral Visitors are usually restricted to support
recumbent position to avoid uterine people such as a husband, father of the
pressure on the vena cava and prevent child, mother, or older children.
supine hypotension syndrome. Because a loud noise such as a
crying baby or a dropped tray of
PROMOTE GOOD NUTRITION equipment can be sufficient to
A woman needs to continue her usual trigger a seizure initiating
pregnancy nutrition. At one time, eclampsia, a woman with severe
stringent restriction of salt was advised preeclampsia is admitted to a
to reduce edema. private room so she can rest as
This is no longer true because stringent undisturbed as possible
sodium restriction may activate the Room should be dim, quiet, away
renin angiotensin-aldosterone system from areas of activity
and result in increased blood pressure, Raise side rails to help prevent injury if
compounding the problem. a seizure should occur. Darken the
room if possible because a bright light
PROVIDE EMOTIONAL SUPPORT. can also trigger seizures.
It is difficult for a woman with pre- Rest in left lateral position to promote
eclampsia to appreciate the potential feto-placental perfusion
seriousness of symptoms because they Leave BP cuff in place so as not to
are so vague. disturb the patient
Neither high blood pressure nor protein
in urine is something she can see or MONITOR MATERNAL WELL-BEING
feel. Take blood pressure frequently (at least
Most women with PIH, therefore, are every 4 hours) or with a continuous
being asked to take a leave of absence monitoring device to detect any
from work. A woman with small increase, which is a warning that a
children must usually make child care woman’s condition is worsening.
arrangements so she can get sufficient Obtain blood studies such as a
rest. complete blood count, platelet count,
liver function, blood urea nitrogen, and
PROVIDE DETAILED INSTRUCTIONS creatine and fibrin degradation
ABOUT WARNING SIGNS SUCH AS: products as ordered to assess renal and
Visual disturbances liver function and the development of
Severe headache DIC, which often accompanies severe
Nausea & Vomiting vasospasm.
Epigastric pain Daily hematocrit levels are used to
monitor blood concentration. This
level will rise if increased fluid is
leaving the bloodstream for
interstitial tissue (edema).

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
Also, anticipate the need for ADMINISTER MEDICATIONS TO PREVENT
frequent plasma estriol levels (a test ECLAMPSIA.
of placenta function) and electrolyte Hydralazine
levels. given IV when diastolic pressure
A woman’s optic fundus is assessed reaches 110 mm/Hg but should not
daily for signs of arterial spasm, be lower than 80-90 mm/Hg or
edema, or hemorrhage. Obtain daily inadequate placental perfusion may
weights at the same time each day occur
as another evaluation of fluid Magnesium Sulfate
retention. Ensure that a woman is drug of choice to prevent Eclampsia
wearing the same amount of act as CNS depressant - lessens the
clothing at each weighing so any possibility of seizures by blocking
change in weight is not influenced the peripheral neuromuscular
by a change in the weight of her transmission (Loading dose 4-6 g,
clothing. given slow over 15-30 minutes and
An indwelling urinary catheter may maintenance dose 1-2 g/hr given
be inserted to allow accurate thru a piggyback method or deep
recording of output and comparison IM using buttocks
with intake. Urinary output should The most evident symptoms of
be more than 600 mL per 24 hours overdose from magnesium sulfate
(more than 30 mL/hr); administration include:
an output lower than this suggests decreased urine output,
oliguria. Urinary proteins and depressed respirations, reduced
specific gravity are measured and consciousness, and decreased
recorded with voiding or hourly if an deep tendon reflexes.
indwelling catheter is present. A 24-
hour urine sample may be collected
for protein and creatinine clearance NURSING RESPONSIBILITIES ON MGS04
determinations to evaluate kidney ADMINISTRATION:
function
Check RR, should be at least 12
MONITOR FETAL WELL-BEING breaths/min
Fetal movement counting UO, should be at least 100 ml/hr
Non Stress test/biophysical profile to DTR should be present (Knee jerk or
assess uterplacental perfusion patellar reflex)
Doppler flow studies Prepare the antidote, Calcium Gluconate if
02 administration to the mother to MgSo4 toxicity develops & notify physician
maintain adequate fetal oxygenation & at once
prevent bradycardia UO, RR, DTR, LOC

SUPPORT A NUTRITIOUS DIET MgS04 is given up to 24H after delivery or

moderate to high protein, I sodium from the last convulsion
Start IV therapy If given during postpartum, monitor for
Usually initiated and maintained to uterine atony as it can cause uterine
serve as an emergency route for relaxation
drug administration as well as to
administer fluid to reduce
hemoconcentration and
hypovolemia.

Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition

NURSING INTERVENTIONS FOR A WOMAN STAGES OF CONVULSION (CONTINUATION)

WITH ECLAMPSIA
may stop from breathing which last for
Goal of care is to ensure safety and prevention 15-20 seconds
of injury
Stabilize patient's condition CLONIC PHASE
Continuous monitoring of VS, FHR jaws & eyelids close and open violently,
Seizure precautions foaming of the mouth, face becomes
Raise padded side rails at all times to congested & purple, muscles of the
prevent the woman from falling body contract & relax alternately. The
Put bed on its lowest position contractions are so violent that the
Have emergency equipment available woman may throw herself out of bed.
for immediate use such as padded his phase lasts for about one
tongue blade, suction apparatus,
MgSo4,Calcium Gluconate, oxygen POSTICTAL STATE
equipment woman is semi comatose, no more
violent muscular contractions. The
Degeneration of a woman’s condition from woman will not remember the
severe preeclampsia to eclampsia occurs convulsion and the events immediately
when cerebral irritation from increasing before & after that condition
cerebral edema becomes so acute that a
seizure occurs. This usually happens late in
pregnancy but can happen up to 48 hours CARE OF THE WOMAN IN CONVULSION
after childbirth.
Immediately before a seizure, a woman’s Monitor patient for impending signs of
blood pressure rises suddenly from convulsions: epigastric pain, severe
additional vasospasm. Her temperature headache, N&V, blurring of vision
rises sharply to 103° to 104° F (39.4° to 40° Priority gods are to maintain patent airway
C) from increased cerebral pressure. and to protect patient from injury
She notices blurring of vision or severe Insert a padded mouth gag or tongue
headache (from the increased cerebral blade only before convulsion to prevent
edema) and her reflexes become patient from biting her tongue
hyperactive. She may experience a Turn patient on her side to allow drainage
premonition that “something is of saliva and prevent aspiration, may do
happening.” suctioning if needed
Vascular congestion of the liver or Never leave an eclamptic patient alone
pancreas can lead to severe epigastric pain Do not restrict movement during attack as
and nausea. Urinary output may decrease this could result to fractures
abruptly to less than 30 mL/hour. Watch for signs of abruptio placenta
Eclampsia has occurred, however, only Take VS & FHR after a convulsion
when a woman experiences a seizure. Do not give anything by mouth unless fully
awake
STAGES OF CONVULSION
ALTERNATIVE ANTICONVULSANTS
STAGE OF INVASION
facial twitching, rolling of the eyes to Have not been shown to be as effective as
one side, staring fixedly in space magnesium sulfate and may result in
sedation that makes evaluation of the
TONIC PHASE patient more difficult
body betomes rigid as all muscles go Diazepam 5-10 mg IV
into violent spasms or contractions, Sodium Amytal 100 mg IV
eyes protrude, arms are flexed with legs Pentobarbital 125 mg IV
inverted, hands are clenched, woman Dilantin 500-1000 mg IV infusion
Rein Ramos
ACADEMICIAN
 Week 2:
High Risk Pregnancy- Gestational Condition
AFTER THE SEIZURE MgSo4 and antihypertensive medications
Laboratory testing of liver, urine and blood
The cure of PI is termination of pregnancy Betamethasone, a corticosteroid may be
or by delivery. Signs and symptoms usually administer to help mature the fetal lungs
disappear once pregnancy is terminated. Deliver immediately, if HELP syndrome
Watchful waiting is performed, in severe worsens and endangers the well being of
cases, labor induction is performed the mother and fetus
irregardless of gestational age

Postpartum Care:
Frequently assess maternal and fetal
well-being
The danger of convulsion exists until 24
hours after delivery. MgS04
Watch for uterine relaxation and
increase lochial flow if the woman is
receiving MgS04
Ergot products are contraindicated
Advise woman to delay next pregnancy
for at least 2 years

HELLP (HEMOLYSIS, ELEVATED LIVER

ENZYMES AND LOW PLATELETS )
SYNDROME

A serious complication of severe PIH w/c

occurs in about 10% of women w/ 1BP. It
usually develops before delivery but may
also occur postpartum
Hepatic Dysfunction characterized by:
Hemolysis - BC breakdown
Elevated liver enzymes - damage to
liver cells causing changes in liver
function laboratory test
Low platelets - cells found in the blood
which act as clotting factor

INCREASE RISK FOR:

Placental abruption
Acute renal failure
Subcapsular hepatic hematoma
Hepatic rupture
Fetal and maternal death
DIC

MANAGEMENT:

Bed rest
Transfusion of Fresh Frozen plasma or
platelets to reverse thrombocytopenia
(count below 100,000)

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
COMPLICATIONS WITH POWER The resting tone of the uterus remains less
(FORCE OF LABOR) than 10 mm Hg, and the strength of
contractions does not rise above 25 mm
Hg.
INERTIA Hypotonic contractions are most apt to
occur during the active phase of labor
is a time-honored term to denote that
They may occur after the administration of
sluggishness of contractions, or the force
analgesia, especially if the cervix is not
of labor, has occurred. A more current term
dilated to 3 to 4 cm or if bowel or bladder
used is dysfunctional labor.
distention prevents descent or firm
Dysfunction can occur at any point in labor,
engagement.
but it is generally classified as primary
(occurring at the onset of labor) or
THEY MAY OCCUR IN A UTERUS THAT IS:
secondary(occurring later in labor).
The risk of maternal postpartal infection,
overstretched by a multiple gestation
hemorrhage, and infant mortality is higher
a larger-than-usual single fetus
in women who have a prolonged labor than
hydramnios
in those who do not. Therefore, it is vital to
or in a uterus that is lax from grand
recognize and prevent dysfunctional labor
multiparity.
to the extent possible.
Prolonged labor appears to result from
Such contractions are not exceedingly
several factors.It is most likely to occur if a
painful, because of their lack of intensity.
fetus is large. Hypotonic, hypertonic, and
Keep in mind, however, that the strength of
uncoordinated contractions all play
a contraction is a subjective symptom.
additional roles.
Some women may interpret these
contractions as very painful.
INEFFECTIVE UTERINE FORCE Hypotonic contractions increase the length
of labor, because more of them are
UTERINE CONTRACTIONS necessary to achieve cervical dilatation.
This can cause the uterus to not contract
are the basic force moving the fetus as effectively during the postpartal period
through the birth canal. They occur because of exhaustion, increasing a
because of the interplay of the contractile woman’s chance for postpartal
enzyme adenosine triphosphate and the hemorrhage
influence of major electrolytes such as
calcium, sodium, and potassium, specific
contractile proteins (actin and HYPERTONIC CONTRACTIONS
myosin),epinephrine and norepinephrine,
oxytocin (a posterior pituitary hormone), Hypertonic uterine contractions are
estrogen, progesterone, and marked by an increase in resting tone to
prostaglandins. more than 15 mm Hg.
About 95% of labors are completed with However, the intensity of the contraction
contractions that follow a predictable, may be no stronger than that associated
normal course. When they become with hypotonic contractions.
abnormal or ineffective, ineffective labor In contrast to hypotonic contractions,
occurs. hypertonic ones tend to occur frequently
and are most commonly seen in the latent
HYPOTONIC CONTRACTIONS phase of labor.
This type of contraction occurs because
With hypotonic uterine contractions, the the muscle fibers of the myometrium do
number of contractions is unusually low or not repolarize or relax after a contraction,
infrequent (not more two or three thereby “wiping it clean” to accept a new
occurring in a 10-minute period). pacemaker stimulus.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
They may occur because more than one Applying a fetal and a uterine external
pacemaker is stimulating contractions monitor and assessing the rate, pattern,
They tend to be more painful than usual, resting tone, and fetal response to
because the myometrium becomes tender contractions for at least 15 minutes (or
from constant lack of relaxation and the longer if necessary in early labor) reveals
anoxia of uterine cells that results. the abnormal pattern.
A woman may become frustrated or Oxytocin administration may be helpful in
disappointed with her breathing exercises uncoordinated labor to stimulate a more
for childbirth, because such techniques are effective and consistent pattern of
ineffective with this type of contraction. contractions with a better, lower resting
tone.
A danger of hypertonic contractions is
that the lack of relaxation between
contractions may not allow optimal
uterine artery filling; this could lead to DYSFUNCTION AT THE FIRST STAGE OF
fetal anoxia early in the latent phase of LABOR
labor.
PROLONGED LATENT PHASE
If deceleration in the fetal heart rate (FHR)
or an abnormally long first stage of labor or When contractions become ineffective
lack of progress with pushing (“second- during the first stage of labor, a prolonged
stage arrest”) occurs, cesarean birth may latent phase can develop
be necessary. A prolonged latent phase, as defined by
Both the woman and her support person Friedman (1978), is a latent phase that
need to understand that, although the is longer than 20 hours in a nullipara or
contractions are strong, they are 14 hours in a multipara.
ineffective and are not achieving cervical
dilatation This may occur if the cervix is not “ripe” at
the beginning of labor and time must be
spent getting truly ready for labor. It may
UNCOORDINATED CONTRACTIONS occur if there is excessive use of an
analgesic early in labor.
Normally, all contractions are initiated at •With a prolonged latent phase, the uterus
one pacemaker point high in the uterus. A tends to be in a hypertonic state.
contraction sweeps down over the organ, Relaxation between contractions is
encircling it; repolarization occurs; inadequate, and the contractions are only
relaxation or a low resting tone is achieved; mild (less than 15 mm Hg on a monitor
and another pacemaker activated printout) and therefore ineffective. One
contraction begins. segment of the uterus may be contracting
With uncoordinated contractions, more with more force than another segment.
than one pacemaker may be initiating
contractions, or receptor points in the MANAGEMENT OF A PROLONGED LATENT
myometrium maybe acting independently PHASE IN LABOR THAT HAS BEEN CAUSED
of the pacemaker. BY HYPERTONIC CONTRACTIONS
Uncoordinated contractions may occur so
closely together that they do not allow involves helping the uterus to rest
good cotyledon (one of the visible providing adequate fluid for hydration,
segments on the maternal surface of the and pain relief with a drug such as
placenta) filling. morphine sulfate.
Because they occur so erratically such as
one on top of another and then a long Changing the linen and the woman’s gown,
period without any, it may be difficult for a darkening room lights, and decreasing
woman to rest between contractions or to noise and stimulation can also be helpful.
use breathing exercises with contractions.
Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

PROTRACTED ACTIVE PHASE or 2.0 cm/hr in a multipara.

A protracted active phase is usually It can be suspected if the second stage

associated with cephalopelvic lasts over 3 hours in a multipara(Cheng et
disproportion (CPD) or fetal malposition, al., 2007).
although it may reflect ineffective
If everything is normal except for the
myometrial activity.
suddenly faulty contractions and CPD and
poor fetal presentation have been ruled out
This phase is prolonged if cervical
by ultrasound, then rest and fluid intake, as
dilatation does not occur at a rate
advocated for hypertonic contractions, also
apply.
of at least 1.2 cm/hr in a nullipara or
If the membranes have not ruptured,
1.5 cm/hr in a multipara,
rupturing them at this point may be
helpful. Intravenous (IV)oxytocin may be
or if the active phase lasts longer than
used to induce the uterus to contract
12 hours in a primigravida or
effectively.
6 hours in a multigravida.

If the cause of the delay in dilatation is ARREST OF DESCENT

fetal malposition or CPD, cesarean birth
maybe necessary.
Arrest of descent results when no descent
has occurred
PROLONGED DECELERATION PHASE for 1 hour in a multipara
or 2 hours in a nullipara.
A deceleration phase has become
prolonged when it extends Failure of descent has occurred when
beyond 3 hours in a nullipara or expected descent of the fetus does not
1 hour in a multipara. begin or engagement or movement
beyond 0 (zero) station has not occurred.
Prolonged deceleration phase most often The most likely cause for arrest of descent
results from abnormal fetal head position. during the second stage is CPD.Cesarean
A cesarean birth is frequently required. birth usually is necessary. If there is no
contraindication to vaginal birth, oxytocin
may be used to assist labor.
SECONDARY ARREST OF DILATATION.

A secondary arrest of dilatation has CONTRACTION RINGS

occurred if there is no progress in cervical
dilatation for longer than 2 hours. Again, A contraction ring is a hard band that
cesarean birth may be necessary. forms across the uterus at the junction of
the upper and lower uterine segments and
interferes with fetal descent. The most
frequent type seen is termed a pathologic
DYSFUNCTION AT THE SECOND STAGE OF retraction ring (Bandl’s ring).
LABOR The ring usually appears during the second
stage of labor and can be palpated as a
horizontal indentation across the abdomen.
PROLONGED DESCENT. It is a warning sign that severe
dysfunctional labor is occurring as it is
Prolonged descent of the fetus occurs if formed by excessive retraction of the
the rate of descent upper uterine segment; the uterine
is less than 1.0 cm/hr in a nullipara myometrium is much thicker above than
below the ring.
Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

When a pathologic retraction ring occurs in UTERINE RUPTURE

early labor, it is usually caused by
uncoordinated contractions. In the pelvic Rupture of the uterus during labor,
division of labor, it is usually caused by although rare, is always a possibility
obstetric manipulation orby the (Scearce & Uzelac, 2007).It is always
administration of oxytocin. serious, because it accounts for as many as
Contraction rings often can be identified 5% of all maternal deaths.
by ultrasound. Such a finding is extremely Uterine rupture occurs when a uterus
serious and should be reported promptly. undergoes more strain than it is capable of
Administration of IV morphine sulfate or sustaining.
the inhalation of amyl nitrite may relieve a Rupture occurs most commonly when a
retraction ring. A tocolytic can also be vertical scar from a previous cesarean birth
administered to halt contractions. If the or hysterotomy repair tears (it occurs in
situation is not relieved, uterine rupture less than 1%of women who have a low
and neurologic damage to the fetus may transverse cesarean scar from a previous
occur pregnancy; about 4% to 8% of women who
have a classic cesarean incision)
(Szymanski & Bienstock, 2007).
PRECIPITATE LABOR When uterine rupture occurs, fetal death
will follow unless immediate cesarean birth
precipitate labor and birth occur when can be accomplished. In these instances,
uterine contractions are so strong that a fetal outcome can be optimal
woman gives birth with only a few, rapidly Rupture can be complete, going through
occurring contractions. the endometrium, myometrium, and
It is often defined as a labor that is peritoneum layers, or incomplete, leaving
completed in fewer than 3 hours. the peritoneum intact
With a complete rupture, uterine
Precipitate dilatation is cervical dilatation contractions will immediately stop.
that occurs at
a rate of 5 cm or more per hour in a Two distinct swellings will be visible on the
primipara woman’s abdomen:
or 10 cm or more per hour in a the retracted uterus and the
multipara. extrauterine fetus

Such rapid labor is likely to occur with Hemorrhage from the torn uterine arteries
grand multiparity, or it may occur after floods into the abdominal cavity and
induction of labor by oxytocin or possibly into the vagina
amniotomy. Signs of shock begin, including rapid, weak
Contractions can be so forceful that they pulse; falling blood pressure; cold and
lead to premature separation of the clammy skin; and dilatation of the nostrils
placenta, placing the woman at risk for from air hunger. Fetal heart sounds fade
hemorrhage. and then are absent.
Rapid labor also poses a risk to the fetus,
because subdural hemorrhage may result
from the rapid release of pressure on the CONTRIBUTING FACTORS MAY INCLUDE
head.
A woman may sustain lacerations of the prolonged labor
birth canal from the forceful birth. She also abnormal presentation
can feel overwhelmed by the speed of multiple gestation
labor. unwise use of oxytocin
obstructed labor
and traumatic maneuvers of forceps or
traction.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
Administer emergency fluid replacement If a line is already in place, open it to
therapy as ordered.Anticipate use of IV achieve optimal flow of fluid to restore
oxytocin to attempt to contract the uterus fluid volume.Administer oxygen by mask,
and minimize bleeding. and assess vital signs. Be prepared to
Prepare the woman for a possible perform cardiopulmonary resuscitation
laparotomy as an emergency measure to (CPR)if the woman’s heart should fail from
control bleeding and achieve a repair. the sudden blood loss.

The viability of the fetus depends on

the extent of the rupture and PROBLEMS WITH PASSENGER
the time elapsed between rupture
and abdominal extraction Birth complications may arise if an infant is
immature or preterm. Complications may
A woman’s prognosis depends on the also occur if the maternal pelvis is so
extent of the rupture and the blood loss. undersized, such as occurs in early
Most women are advised not to conceive adolescence or in women with altered bone
again after a rupture of the uterus, unless growth from a disease such as rickets that
the rupture occurred in the inactive lower its diameters are smaller than the fetal skull
segment. diameters.
Inversion occurs in various degrees. The It also can occur if the umbilical cord
inverted fundus may lie within the uterine prolapses, if more than one fetus is
cavity or the vagina, or, in total inversion, it present, or if a fetus is malposition or too
may protrude from the vagina. When an large for the birth canal.
inversion occurs, a large amount of blood
suddenly gushes from the vagina. The
fundus is not palpable in the abdomen. PROLAPSE OF THE UMBILICAL CORD

If the loss of blood continues unchecked In umbilical cord prolapse, a loop of the
for longer than a few minutes, the woman umbilical cord slips down in front of the
will show signs of blood loss: presenting fetal part. Prolapse may occur
hypotension, at anytime after the membranes rupture if
dizziness, the presenting fetal part is not fitted firmly
paleness, into the cervix.
or diaphoresis.
Because the uterus is not contracted in this IT TENDS TO OCCUR MOST OFTEN WITH:
position, bleeding continues, and
exsanguination could occur within a period Premature rupture of membranes
as short as 10 minutes. Fetal presentation other than cephalic
Placenta previa
Never attempt to replace an inversion, Intrauterine tumors preventing the
because handling of the uterus may presenting part from engaging
increase the bleeding. A small fetus
Never attempt to remove the placenta if it Cephalopelvic disproportion preventing
is still attached, because this only creates a firm engagement
larger surface area for bleeding. Hydramnios
In addition, administration of an oxytocin Multiple gestation
drug only compounds the inversion or The incidence is about 0.5% of cephalic
makes the uterus more tense and difficult births; this rises as high as15% to20%
to replace. with breech or transverse lies
An IV fluid line needs to be started, if one is
not already present (use a large-gauge
needle, because blood will need to be
replaced).

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
ASSESSMENT AMNIOINFUSION

In rare instances, the cord may be felt as Amnioinfusion is the addition of a sterile
the presenting part on an initial vaginal fluid into the uterus to supplement the
examination during labor. It may also be amniotic fluid
identified in this position on an ultrasound. The technique neither shortens nor
When this happens, cesarean birth is prolongs labor; it just prevents additional
necessary before rupture of the cord compression.
membranes occurs. Otherwise, membrane For this, a sterile catheter is introduced
rupture would cause the cord to slide down through the cervix into the uterus after
into the vagina from the pressure exerted rupture of the membranes. It is attached to
by the amniotic fluid. intravenous tubing, and a solution of
More often, however, cord prolapse is first warmed normal saline or lactated Ringer’s
discovered only after the membranes have solution is rapidly infused.
ruptured, when a variable deceleration FHR Initially, approximately 500 mL is infused,
pattern suddenly becomes apparent.The and then the rate is adjusted to infuse the
cord may be visible at the vulva. To rule out least amount necessary to maintain a
cord prolapse, always assess fetal heart monitor pattern without variable
sounds immediately after rupture of the decelerations.
membranes whether this occurs Help maintain strict aseptic technique
spontaneously or by amniotomy. during insertion and while caring for the
catheter.
Continuously monitor FHR and uterine
THERAPEUTIC MANAGEMENT contractions internally during the infusion.
Record maternal temperature hourly to
Cord prolapse automatically leads to cord detect infection.
compression, because the fetal presenting Be sure the solution is warmed to body
part presses against the cord at the pelvic temperature before the infusion, to
brim. prevent chilling of the woman and fetus.
Management is aimed at relieving pressure This can be done by placing the bag of
on the cord, thereby relieving the fluid on a radiant heat warmer or by using
compression and the resulting fetal anoxia. a blood/fluid warmer before
This may be done by placing a gloved hand administration.
in the vagina and manually elevating the
fetal head off the cord, or by placing the
woman in a knee–chest or Trendelenburg
position, which causes the fetal head to fall FETAL BLOOD SAMPLING
back from the cord
Administering oxygen at 10 L/min by face Although obtaining a fetal oxygen
mask to the woman is also helpful to saturation level by inserting a fetal
improve oxygenation to the fetus. oximeter into the uterus to rest next to the
A tocolytic agent may be prescribed to fetal cheek or obtaining a positive response
reduce uterine activity and pressure on the to scalp stimulation usually supplies the
fetus. Amnioinfusion is yet another way to information as to whether a fetus is
relieve pressure on the cord becoming acidotic, this information canal
If the cord has prolapsed to the extent that so be obtained by scalp blood or fetal
it is exposed to room air, drying will begin, blood sampling.
leading to atrophy of the umbilical vessels. After cervical dilatation of 3 to 4 cm and
Do not attempt to push any exposed cord rupture of the membranes, the fetal head is
back into the vagina. This may add to the visualized by the use of anamnio scope—a
compression by causing knotting or small, cone-shaped instrument with a light
kinking. Instead, cover any exposed portion source at the far end.
with a sterile saline compress to prevent
drying.
Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
The scalp is cleaned with povidone-iodine Because of the multiple fetuses, abnormal
and sprayed with silicon. A small scalpel is fetal presentation may occur. Uterine
introduced vaginally into the cervix, and dysfunction from a long labor, an over
the fetal scalp is nicked. The silicon causes stretched uterus, unusual presentation,
blood to form in beads, which are caught and premature separation of the placenta
by a capillary tube after the birth of the first child may also be
Although a blood sample obtained in this more common.
way may be analyzed for many parameters, Most twin pregnancies present with both
usually only the pH results are necessary. twins vertex. This is followed in frequency
If the fetus is hypoxic, the pH will fall by vertex and breech, breech and vertex,
(become acidotic). A scalp blood pH and then breech and breech.
greater than 7.25 is considered normal for Multiple gestations of three or more
a fetus during labor. A pH between 7.21 fetuses have extremely varied
and 7.25 should be remeasured in 30 presentations. After the birth of the first
minutes child, the lie of the second fetus is
determined by external abdominal
MULTIPLE GESTATION palpation or ultrasound.
If the presentation is not vertex, external
A woman with a multiple gestation usually version may beat tempted to make it so. If
causes a flurry of excitement in a birthing this is not successful, a decision for a
room. breech birth or cesarean birth must be
Additional personnel are needed for the made
birth (as many nurses to attend to possibly Occasionally, the placenta of the first
immature infants as there are infants, plus infant separates before the second fetus is
additional pediatricians or neonatal nurse born, and there is sudden, profuse
practitioners). bleeding at the vagina. This creates a risk
In the middle of all the preparatory activity, for the woman. The uterus cannot contract
it is easy to forget that a woman having a as it normally would, because it is still full
multiple birth may be more frightened than with the second twin, so it is difficult to halt
excited. the bleeding.
Be sure to focus on her needs as well as If the separation of the first placenta
those of her babies.Twins maybe born by caused loosening of additional placentas,
cesarean birth to decrease the risk that the or if a common placenta is involved, the
second fetus will experience anoxia; this fetal heart sounds of the other fetuses will
also is often the situation in multiple register distress immediately.
gestations of three or more, because of the They need to be born at once if they are to
increased incidence of cord entanglement survive.For this reason, with most multiple
and premature separation of the placenta. gestations today, if all of the fetuses are
Anemia and pregnancy-induced not vertex presentations, they will be born
hypertension occur at higher-than-usual by cesarean birth.
incidences during multiple gestations. To Assess the woman carefully in the
detect these, be certain to assess the immediate postpartal period, because the
woman’s hematocrit level and blood uterus that has been overly distended
pressure closely during labor or while owing to the multiple gestation may have
waiting for cesarean surgery. more difficulty contracting than usual,
If possible, monitor each FHR by a separate placing her at risk for hemorrhage from
fetal monitor during labor. Because the uterine atony (lacking normal tone).
babies are usually small, firm head In addition, the risk for uterine infection
engagement may not occur, increasing the increases if labor or birth was prolonged.
risk for cord prolapse after rupture of the The infants need careful assessment to
membranes. determine their true gestational age and
whether a phenomenon such as twin-to
twin transfusion could have occurred

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

FETAL MALPOSITION Applying counter pressure on the sacrum

by a back rub may be helpful in relieving a
OCCIPITOPOSTERIOR POSITION portion of the pain.
Applying heat or cold, whichever feels
In approximately one tenth of all labors, best, also may help.Lying on the side
the fetal position is posterior rather than opposite the fetal back or maintaining a
anterior. hands-and-knees position may help the
That is, the occiput (assuming the fetus rotate.
presentation is vertex) is directed During a long labor of this type, be certain
diagonally and posteriorly, either a woman voids approximately every 2
to the right (ROP) hours to keep her bladder empty, because
or to the left (LOP). a full bladder could further impede descent
In these positions, during internal rotation, of the fetus.
the fetal head must rotate, not through a Be aware of how long it has been since the
90-degree arc, but through an arc of woman last ate. During a long labor, she
approximately 135degrees. may need an oral sports drink or IV glucose
solution to replace glucose stores used for
Rotation from a posterior position can be energy.
aided by having the woman assume a If contractions are ineffective, or if the
hands and knees position, squatting, or fetus is larger than average or not in good
lying on her side (on her left side if the flexion, rotation through the 135- degree
fetus is right occiput posterior; on her right arc may not be possible. Uterine
side if the fetus is left occiputposterior) dysfunction may result from maternal
Posterior positions tend to occur in women exhaustion.
with android, The fetal head may arrest in the
anthropoid, transverse position (transverse arrest),
or contracted pelves. or rotation may not occur at all
A posterior position is suggested by a (persistent occipitoposterior position).
dysfunctional labor pattern such as a
prolonged active phase, arrested descent, In these instances, the fetus must be born
or fetal heart sounds heard best at the by cesarean birth. . If forceps are used to
lateral sides of the abdomen. help the fetus rotate, this places a woman
A posteriorly presenting head does not fit at risk for cervical lacerations, hemorrhage,
the cervix as snugly as one in an anterior and infection in the postpartum period.
position. Because this increases the risk of
umbilical cord prolapse, the position of the
fetus is confirmed by vaginal examination FETAL MALPRESENTATION
or by ultrasound.
The majority of fetuses presenting in BREECH PRESENTATION
posterior positions, if they are of average
size and in good flexion and aided by Most fetuses are in a breech presentation
forceful uterine contractions, rotate early in pregnancy.However, by week 38, a
through the large arc, arrive at a good birth fetus normally turns to a cephalic
position for the pelvic outlet, and are born presentation. Although the fetal head is
satisfactorily with only increased molding the widest single diameter, the fetus’s
and caput formation. buttocks (breech), plus the legs, actually
Because the fetal head rotates against the take up more space.
sacrum, a woman may experience pressure The fact that the fundus is the largest part
and pain in her lower back owing to sacral of the uterus is probably the reason why, in
nerve compression. These sensations may approximately 97% of all pregnancies, the
be so intense that she asks for medication fetus turns so that the buttocks and lower
for relief, not for her contractions but for extremities are in the fundus.
the intense back pressure and pain

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
Breech presentation is more hazardous to a BIRTH TECHNIQUE
fetus than a cephalic presentation, because
there is a higher risk of: If the infant will be born vaginally, a woman
Anoxia from a prolapsed cord is allowed to push after full dilatation is
Traumatic injury to the after coming head achieved, and the breech, trunk, and
(possibility of intracranial hemorrhage or shoulders are born. As the breech
anoxia) spontaneously emerges from the birth
Fracture of the spine or arm canal, it is steadied and supported by a
Dysfunctional labor sterile towel held against the infant’s
Early rupture of the membranes because of inferior surface. The shoulders present to
the poor fit of the presenting part the outlet with their widest diameter
anteroposterior
The inevitable contraction of the fetal If they are not born readily, the arm of the
buttocks from cervical pressure often posterior shoulder maybe drawn down by
causes meconium to be extruded into the passing two fingers over the infant’s
amniotic fluid before birth. This, unlike shoulder and down the arm to the elbow,
meconium staining that occurs because of then sweeping the flexed arm across the
fetal anoxia, is not a sign of fetal distress infant’s face and chest and out. The other
but is expected from the buttock pressure. arm is delivered in the same way.
Such meconium excretion can ,however, External rotation is allowed to occur, to
lead to meconium aspiration if the infant bring the head into the best outlet
inhales amniotic fluid. diameter. Birth of the head is the most
hazardous part of a breech birth.
Because the umbilicus precedes the head,
ASSESSMENT a loop of cord passes down alongside the
head. The pressure of the head against the
With a breech presentation, fetal heart pelvic brim automatically compresses this
sounds usually are heard high in the loop of cord.
abdomen. A second danger of a breech birth is
Leopold’s maneuvers and a vaginal intracranial hemorrhage. With a cephalic
examination usually reveal the presentation, molding to the confines of
presentation. the birth canal occurs over hours. With a
If the breech is complete and firmly breech birth, pressure changes occur
engaged, the tightly stretched gluteal instantaneously
muscles of the fetus maybe mistaken on Tentorial tears, which can cause gross
vaginal examination fora head; motor and mental in capacity or lethal
the cleft between the buttocks may be damage to the fetus, may result. The infant
mistaken for the sagittal suture line. If the who is born suddenly to reduce the
presentation is unclear, ultrasound clearly duration of cord compression may suffer
confirms a breech presentation an intracranial hemorrhage. In contrast, the
Such a study also gives information on infant who is born gradually to reduce the
pelvic diameters, fetal skull diameters, and possibility of intracranial injury may suffer
evidence of possible placenta previa hypoxia.
causing the breech presentation. In a
breech birth, the same stages of flexion,
descent, internal rotation, expulsion, and TRANSVERSE LIE
external rotation occur as in a vertex birth.
Always monitor FHR and uterine Transverse lie occurs in women with
contractions continuously, if possible, pendulous abdomens, with uterine fibroid
during this time. This allows early detection tumors that obstruct the lower uterine
of fetal distress from a complication such segment, with contraction of the pelvic
as prolapsed cord and allows for prompt brim, with congenital abnormalities of the
intervention. uterus, or with hydramnios.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
It may occur in infants with hydrocephalus FETAL SIZE
or another abnormality that prevents the
head from engaging. OVERSIZED FETUS (MACROSOMIA)
It may also occur in prematurity if the
infant has room for free movement, in Size may become a problem ina fetus who
multiple gestation (particularly in a second weighs more than 4000 to 4500 g
twin), or if there is a short umbilical cord. (approximately 9 to 10 lb). Babies of this
A transverse lie usually is obvious on size complicate up to10%of all births and
inspection, because the ovoid of the uterus are most frequently born to women who
is found to be more horizontal than enter pregnancy with diabetes or develop
vertical. gestational diabetes.
The abnormal presentation can be Large babies are also associated with
confirmed by Leopold’s maneuvers. An multiparity, because each infant born to a
ultrasound maybe taken to further confirm woman tends to be slightly heavier and
the abnormal lie and to provide larger than the one born just before.
information on pelvic size. An oversized infant may cause uterine
A mature fetus cannot be delivered dysfunction during labor or at birth
vaginally from this presentation. Often, the because of overstretching of the fibers of
membranes rupture at the beginning of the myometrium.
labor. Because there is no firm presenting The wide shoulders may pose a problem at
part, the cord oran arm may prolapse, or birth, because they can cause fetal pelvic
the shoulder may obstruct the cervix. disproportion or even uterine rupture from
Cesarean birth is necessary. obstruction. If the infant is so oversized
that he or she cannot be born vaginally,
cesarean birth becomes the birth method
of choice.
BROW PRESENTATION The perinatal mortality rate of larger
infants is substantially increased to
A brow presentation is the rarest of the about15%, compared with the normal 4%
presentations. It occurs in a multipara or a In addition, a large infant born vaginally
woman with relaxed abdominal muscles. It has a higher than-normal risk of cervical
almost invariably results in obstructed nerve palsy, diaphragmatic nerve injury, or
labor because the head becomes jammed fractured clavicle because of shoulder
in the brim of the pelvis as the dystocia. Postpartally, the woman has an
occipitomental diameter presents. increased risk of hemorrhage, because the
Unless the presentation spontaneously over distended uterus may not contract as
corrects, cesarean birth will be necessary readily as usual.
to birth the infant safely. Brow
presentations also leave an infant with
extreme ecchymotic bruising on the face. SHOULDER DYSTOCIA
On seeing this bruising over the same area
as the anterior fontanelle, or “soft spot,” Shoulder dystocia is a birth problem that is
parents may need additional reassurance increasing in incidence along with the
that the child is well after birth. increasing average weight of newborns.
The problem occurs at the second stage of
labor, when the fetal head is born but the
shoulders are too broad to enter and be
born through the pelvic outlet.
This is hazardous to the woman because it
can result in vaginal or cervical tears. It is
hazardous to the fetus if the cord is
compressed between the fetal body and
the bony pelvis.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
The force of birth can result in a fractured Following the general rule that “what goes
clavicle or a brachial plexus injury for the in, comes out,” a head that engages or
fetus. proves it fits into the pelvic brim will
Shoulder dystocia is most apt to occur in probably also be able to pass through the
women with diabetes, in multiparas, and in midpelvis and through the outlet.
post-date pregnancies. The problem often If engagement does not occur in a
is not identified until the head has already primigravida, then either a fetal
been born and the wide anterior shoulder abnormality (larger-than-usual head) or a
locks beneath the symphysis pubis. pelvic abnormality (smaller-than-usual
The condition may be suspected earlier if pelvis) should be suspected.
the second stage of labor is prolonged, if Every primigravida should have pelvic
there is arrest of descent, or if, when the measurements taken and recorded before
head appears on the perineum(crowning), week 24 of pregnancy. Based on these
it retracts instead of protruding with each measurements and the assumption the
contraction (a turtle sign). fetus will be of average size, a birth
Although there is no evidence-based data, decision can be made.
asking a woman to flex her thighs sharply With CPD, because the fetus does not
on her abdomen (McRobert’s maneuver) engage but remains “floating,” malposition
may widen the pelvic outlet and allow the may occur, further complicating an already
anterior shoulder to be born. difficult situation. Should the membranes
Applying suprapubic pressure may also rupture, the possibility of cord prolapse
help the shoulder escape from beneath the increases greatly
symphysis pubis and be born

OUTLET CONTRACTION
PROBLEMS WITH PASSAGE
Outlet contraction is narrowing of the
Another reason that dystocia can occur is a transverse diameter at the outlet to less
contraction or narrowing of the passageway or than 11 cm. This is the distance between
birth canal. This can happen at the inlet, at the the ischial tuberosities, a measurement
midpelvis, or at the outlet. The narrowing that is easy to make during a prenatal visit,
causes CPD, or a disproportion between the so the narrow diameter can be anticipated
size of the fetal head and the pelvic diameters. before labor begins. It is also easily
This results in failure to progress in labor reassessed during labor.

TRIAL LABOR
ABNORMAL SIZE OR SHAPE OF THE PELVIS
If a woman has a borderline (just adequate)
INLET CONTRACTION inlet measurement and the fetal lie and
position are good, her physician or nurse-
Inlet contraction is narrowing of the midwife may allow her a“trial” labor to
anteroposterior diameter to less than determine whether labor can progress
11cm, or of the transverse diameter to12 normally.
cm or less. It usually is caused by rickets in A trial labor continues as long as descent
early life or by an inherited small pelvis. of the presenting part and dilatation of the
In primigravidas, the fetal head normally cervix continue to occur. Monitor fetal
engages between weeks36to 38 of heart sounds and uterine contractions
pregnancy. If this occurs before labor continuously, if possible, during this
begins, it is proof that the pelvic inlet is time.Urge the woman to void every 2 hours
adequate. so that her urinary bladder is as empty as
possible, allowing the fetal head to use all
the space available.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
After rupture of the membranes, assess Contraindications to the procedure include
FHR carefully; if the fetal head is still high, multiple gestation, severe
there is an increased danger of prolapsed oligohydramnios, contraindications to
cord and anoxia to the fetus. If after a vaginal birth, a cord that wraps around the
definite period (6 to 12 hours) adequate fetal neck, and unexplained third-trimester
progress in labor cannot be documented, bleeding, which might be a placenta previa
or if at any time fetal distress occurs, the External version can be uncomfortable fora
woman will be scheduled for a cesarean woman because of the feeling of pressure.
birth.

CEPHALOPELVIC DISPROPORTION PROBLEMS WITH PLACENTA

PLACENTA PREVIA
Cephalopelvic disproportion is suggested
by lack of engagement at the beginning of Abnormal implantation of placenta in the
labor, a prolonged first stage of labor, and lower uterine segment, partially or
poor fetal descent. Adolescent labor does completely covering the internal cervical os
not differ from labor in the older woman if
cephalopelvic disproportion is absent. CLASSIFICATION:
Graphing labor progress is a good way to
detect labor that is becoming abnormal. Be TOTAL PLACENTA PREVIA
certain an adolescent has a support person
with her in labor so she can relax and Complete
breathe effectively with contractions. If this The placenta completely covers the cervix
person is also an adolescent, you may need
to serve as the true support person, or at
least spend considerable time coaching so
this person can support the girl in labor.

EXTERNAL CEPHALIC VERSION

External cephalic version is the turning of a PARTIAL PLACENTA PREVIA

fetus from a breech to a cephalic position
before birth. It may be done as early as 34 The placenta is partially over the planning
to 35 weeks, although the usual time is 37
to 38 weeks of pregnancy (Hofmeyr &
Gyte, 2009). For the procedure, FHR and
possibly ultrasound are recorded
continuously.
A tocolytic agent may be administered to
help relax the uterus. The breech and
vertex of the fetus are located and grasped
trans abdominally by the examiner’s hands MARGINAL PLACENTA PREVIA
on the woman’s abdomen. Gentle pressure The placenta is partially over the planning
is then exerted to rotate the fetus in a
forward direction to a cephalic lie
Although not always successful, the use of
external version can decrease the number
of cesarean births necessary from breech
presentations (Kish & Collea,2007).

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
Frequently monitor mother and fetus
Administer IV fluids as prescribed
Position on side to promote placental
perfusion
Administer oxygen as face mask as
indicated (8-10 per min)

Fluid Volume Deficit related to excessive

blood loss

Establish and maintain a large- bore IV

line, as prescribed and draw blood for
type and screen for blood replacement
Position in a sitting position to allow
weight of fetus to compress the
placental and decrease bleeding
COMPLICATIONS: Maintain strict bed rest during any
bleeding episode
Placenta accereta Prepare woman for a cesarean delivery
Immediate hemorrhage, with possible Administer blood or blood products
shock and maternal death protocol per institutional policy
Increased risk for anemia secondary to
increased blood loss and infection
secondary to invasive procedures to Risk for infection related to excessive
resolve bleeding blood loss
Intrauterine growth restriction (IUGR)
Congenital anomalies Use aseptic technique when providing
Fetal mortality resulting from hypoxia in care
utero and prematurity Evaluate temperature every 4 hours
unless elevated; then evaluate every 2
hours
ASSESSMENT: Evaluate WBC and differential count
Teach perineal care and hand washing
Determine the amount and type of techniques
bleeding Assess odor of all vaginal bleeding or
Inquire as to presence or absence of pain in lochia
association with the bleeding
Record maternal and fetal VS Anxiety related to excessive blood loss
Palpate for the presence of uterine
contractions Explain all treatments and procedure
Evaluate laboratory data on Hct and Hgb Encourage verbalization of feeling by
Assess fetal status with continuous fetal patient and family
monitoring Provide information on a CS delivery
Never perform a vaginal examinations esp. Discuss the effects of long-term
when patient is bleeding hospitalization or prolonged bed rest

NURSING DIAGNOSIS AND NURSING Fear related to outcome of pregnancy after

INTERVENTIONS: episodes of blood loss

Altered Tissue Perfusion related to Explain all treatments and procedure

excessive blood loss causing fetal Encourage verbalization of feelings by
compromise patient and family
Provide information on CS delivery
Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

PLACENTA CIRCUMVALLATA

Ordinarily, the chorion membrane begins at

the edge of the placenta and spreads to
envelop the fetus; no chorion covers the
fetal side of the placenta. In placenta
circumvallata, the fetal side of the placenta
is covered to some extent with chorion.
The umbilical cord enters the placenta at
the usual midpoint, and large vessels
spread out from there. They end abruptly
at the point where the chorion folds back
ANOMALIES OF THE PLACENTA on to the surface.

The placenta and cord are always

examined for the presence of anomalies VELAMENTOUS INSERTION OF THE CORD
after birth. The normal placenta weighs
approximately 500 g and is 15 to 20 cm in Velamentous insertion of the cord is a
diameter and 1.5 to 3.0 cm thick. Its weight situation in which the cord, instead of
is approximately one sixth that of the fetus. entering the placenta directly, separates
A placenta may be unusually enlarged in into small vessels that reach the placenta
women with diabetes. In certain diseases, by spreading across a fold of amnion.
such as syphilis orerythroblastosis, the This form of cord insertion is most
placenta may be so large that it weighs half frequently found with multiple gestation.
as much as the fetus. Because it may be associated with fetal
If the uterus has scars or a septum, the anomalies, an infant born with this type of
placenta may be wide in diameter because placenta should be examined carefully
it was forced to spread out to find
implantation space.
BATTLEDORE PLACENTA

In a battledore placenta, the cord is

PLACENTA SUCCENTURIATA inserted marginally rather than centrally.
This anomaly is rare and has no known
A placenta succenturiata is a placenta that clinical significance either.
has one or more accessory lobes
connected to the main placenta by blood
vessels. PLACENTA ACCRETA
No fetal abnormality is associated with this
type.However, it is important that it be Placenta accreta is an unusually deep
recognized, because the small lobes may attachment of the placenta to the uterine
be retained in the uterus after birth, myometrium so deeply the placenta will
leading to severe maternal hemorrhage. not loosen and deliver (Poggi, 2007).
On inspection, the placenta appears torn at Attempts to remove it manually may lead
the edge, or torn blood vessels extend to extreme hemorrhage because of the
beyond the edge of the placenta. The deep attachment. Hysterectomy or
remaining lobes are removed from the treatment with methotrexate to destroy
uterus manually to prevent maternal the still-attached tissue may be necessary.
hemorrhage from poor uterine contraction

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
VASA PREVIA Occasionally, a cord actually forms a knot,
but the natural pulsations of the blood
In vasa previa, the umbilical vessels of a through the vessels and the muscular
velamentous cord insertion cross the vessel walls usually keep the blood flow
cervical os and therefore deliver before the adequate.
fetus. It is not unusual for a cord to wrap once
The vessels may tear with cervical around the fetal neck (nuchal cord) but,
dilatation, just as a placenta previa may again, with no interference to fetal
tear. Before inserting any instrument such circulation
as an internal fetal monitor, be certain to
identify structures to prevent accidental
tearing of a vasa previa as tearing would
result in sudden fetal blood loss.
If sudden, painless bleeding occurs with
the beginning of cervical dilatation, either PROBLEMS WITH PSYCHE
placenta previa or vasa previa is suspected.
It can be confirmed by ultrasound. If vasa A WOMAN WITHOUT A SUPPORT PERSON
previa is identified, the infant needs to be
born by cesarean birth.
Some women have chosen to reject or
ANOMALIES OF THE CORD want to labor without the infant’s father,
who is the usual support person during
TWO-VESSEL CORD labor. Such women may appreciate having
a family member or close friend act as their
A normal cord contains one vein and two support person. A woman who has no
arteries. The absence of one of the support person needs a supportive nurse
umbilical arteries is associated with to be with her.
congenital heart and kidney anomalies, A woman whose acceptance of her
because the insult that caused the loss of pregnancy was slow to develop because of
the vessel may have affected other lack of adequate support people may not
mesoderm germ layer structures as well. have completed the psychological tasks of
Inspection of the cord as to how many pregnancy by the time she is in labor.
vessels are present must be made This could make her more apprehensive
immediately after birth, before the cord about a new life role and calls for increased
begins to dry, because drying distorts the assessment of parent–child bonding in the
appearance of the vessels. Document the immediate postpartal period.
number of vessels present conscientiously.
An infant with only two vessels needs to be
observed carefully for other anomalies VAGINAL BIRTH AFTER CESAREAN BIRTH
during the newborn period.
Women who have had a previous cesarean
birth that involved a low transverse uterine
UNUSUAL CORD LENGTH incision are usually candidates for vaginal
birth with their next pregnancy. The length
Although the length of the umbilical cord of labor for vaginal birth after cesarean
rarely varies, some abnormal lengths may birth (VBAC) is usually comparable to that
occur. An unusually short umbilical cord of primiparas, not multiparas, because it is
can result in premature separation of the the first vaginal birth.
placenta or an abnormal fetal lie. Most women are anxious for vaginal birth
An unusually long cord may be easily to be successful so that they do not have
compromised because of its tendency to to undergo surgery again.
twist or knot.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

At the same time, they may be surprised THE PRIMARY REASONS FOR INDUCING
and dismayed at the length and discomfort LABOR INCLUDE:
of labor and wish that they could have
another cesarean. the presence of pre-eclampsia
Keep the woman well informed and urge eclampsia
her to breathe with contractions and to severe hypertension
push effectively to make the experience a diabetes
positive one for her. Afterward, many Rh sensitization
women are relieved to realize that, prolonged rupture of the membranes
although they did have more discomfort intrauterine growth restriction
before birth, they have appreciably less and postmaturity (a pregnancy lasting
pain afterward. beyond 42 weeks)
If during the previous labor a complication
occurred that necessitated the cesarean all situations that increase the risk for a
birth, a woman cannot help but worry that fetus to remain in utero. Augmentation of
this will happen again. She needs a support labor or assistance to make uterine
person with her and health care providers contractions stronger may be necessary if
who are aware of her possible level of the contractions are hypotonic or too weak
apprehension. Women having a VBAC or infrequent to be effective
usually have external electronic monitoring
because of the risk for uterine rupture. BEFORE INDUCTION OF LABOR IS BEGUN,
The outcome of VBAC is usually without THE FOLLOWING CONDITIONS SHOULD BE
complication. If necessary, oxytocin PRESENT:
augmentation can be used to strengthen
uterine contractions; vacuum extraction The fetus is in a longitudinal lie.
and forceps birth can be used as The cervix is ripe, or ready for birth.
necessary. A presenting part is engaged.
There is no CPD.
The fetus is estimated to be mature by
date, demonstrated by a lecithin–
THERAPEUTIC MANAGEMENT sphingomyelin ratio or ultrasound
biparietal diameter to rule out preterm
INDUCTION AND AUGMENTATION OF LABOR birth

When labor contractions are ineffective,

several interventions, such as induction
and augmentation of labor with oxytocin or CERVICAL RIPENING
amniotomy (artificial rupture of the
membranes), may be initiated to Cervical ripening, or a change in the
strengthen them (Howarth & Botha, 2009). cervical consistency from firm to soft, is
Induction of labor means that labor is the first step the uterus must complete in
started artificially. early labor. Until this has occurred,
Augmentation of labor refers to assisting dilatation and coordination of uterine
labor that has started spontaneously but is contractions will not occur. To determine
not effective. Induction may be necessary whether a cervix is “ripe,” or ready for
to initiate labor before the time when it dilatation.
would have occurred spontaneously Bishop (1964) established criteria for
because a fetus is in danger or because scoring the cervix. Using this scale, if a
labor does not occur spontaneously and woman’s total score is 8 or greater, the
the fetus appears to be at term. cervix is considered ready for birth and
should respond to induction.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery

To “ripen” a cervix, various methods can be Because the half-life of oxytocin is

instituted. One is known as “stripping the approximately 3 minutes, the falling serum
membranes,” or separating the membranes level and effects are apparent almost
from the lower uterine segment manually, immediately after discontinuation of IV
using a gloved finger in the cervix. This is administration.
an easy procedure performed during an Usually a form of oxytocin, such as Pitocin,
office visit. is mixed in the proportion of 10 IU in 1000
Possible complications of this mechanical mL of Ringer’s lactate.
method include bleeding from an Ten international units of oxytocin is the
undetected low-lying placenta, inadvertent same as 10,000 milliunits (mU), so each
rupture of membranes, and the possibility milliliter of this solution contains 10 mU of
of infection if membranes should rupture. oxytocin. An alternative dilution method is
A more commonly used method of to add 15 IU of oxytocin to 250 mL of an IV
speeding cervical ripening is the solution; this yields a concentration of 60
application of a prostaglandin gel, such as mU/1 mL.
misoprostol, to the interior surface of the After cervical dilatation reaches 4 cm,
cervix by a catheter or suppository, or to artificial rupture of the membranes may be
the external surface by applying it to a performed to further induce labor, and the
diaphragm and then placing the diaphragm infusion may be discontinued at that point.
against the cervix. For other women, the infusion is continued
Additional doses may be applied every 6 through full dilatation. Peripheral vessel
hours. Two or three doses are usually dilatation, a side effect of oxytocin, may
adequate to cause ripening. Women should cause extreme hypotension. To ensure safe
remain in bed in a side-lying position to induction, take the woman’s pulse and
prevent leakage of the medication, and the blood pressure every 15 minutes.
FHR should be monitored continuously for Monitor uterine contractions and FHR
at least 30 minutes after each application conscientiously. Contractions should occur
(perhaps up to 2 hours after vaginal no more often than every 2 minutes,
insertion). should not be stronger than 50 mm Hg
Women should remain in bed in a side- pressure, and should last no longer than 70
lying position to prevent leakage of the seconds. The resting pressure between
medication, and the FHR should be contractions should not exceed 15 mm Hg
monitored continuously for at least 30 by monitor.
minutes after each application (perhaps up If stopping the oxytocin infusion does not
to 2 hours after vaginal insertion). stop the hyper-stimulation, a beta-
As a rule, they should be used with caution adrenergic receptor drug such as
in women with asthma, renal or terbutaline sulfate (Brethine) or
cardiovascular disease, or glaucoma. They magnesium sulfate may be prescribed to
are contraindicated for women who have decrease myometrial activity. Oxytocin has
had past cesarean births (Lawson & an antidiuretic side effect that can result in
Bienstock, 2007) decreased urine flow, possibly leading to
water intoxication.

Water intoxication
INDUCTION OF LABOR BY OXYTOCIN is first manifested by headache and
vomiting. If you observe these danger
Administration of oxytocin (synthetic form signs in a woman during induction of
of naturally occurring pituitary hormone) labor, report them immediately and halt
initiates contractions in a uterus at the infusion. Water intoxication in its
pregnancy term (Archie, 2007). most severe form can lead to seizures,
Oxytocin is always administered coma, and death because of the large
intravenously, so that, if hyper-stimulation shift in interstitial tissue fluid.
should occur, it can be quickly
discontinued.
Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
AUGMENTATION BY OXYTOCIN FORCEPS MAY BE NECESSARY, HOWEVER,
IF ANY OF THE FOLLOWING CONDITIONS
Augmentation of labor is required if labor OCCUR:
contractions begin spontaneously but then
become so weak, irregular, or ineffective A woman is unable to push with
(hypotonic) that assistance is needed to contractions in the pelvic division of labor
strengthen them. such as might happen with a woman who
Precautions regarding oxytocin receives regional anesthesia or has a spinal
augmentation are the same as for primary cord injury.
induction of labor. A uterus may be very Cessation of descent in the second stage
responsive or respond very effectively to of labor occurs.
oxytocin used as augmentation. Be certain A fetus is in an abnormal position or is
that the drug is increased in small immature.
increments only and that fetal heart A fetus is in distress from a complication
sounds are well monitored during the such as a prolapsed cord.
procedure.

A FORCEPS BIRTH
ACTIVE MANAGEMENT OF LABOR is a forceps outlet procedure in which
the forceps are applied after the fetal
A technique of active management of labor head reaches the perineum. The term
began in Europe and has spread to some low forceps birth may be used to
centers in the United States. It includes the indicate that the fetal head is at a 2
aggressive administration of oxytocin station or more. If the fetal head is
(increases of 6 mU/min rather than 1 or 2 engaged but at less than 2 station, the
mU/min) to shorten labor to 12 hours, procedure is called a midforceps birth.
which presumably reduces the incidence of This type of forceps extraction is rarely
cesarean birth and postpartal infection. justified, because it has been
The maximum dosage of oxytocin used associated with birth trauma to both
may be as high as 36 to 40 mU/min. Active the woman and the fetus, and cesarean
management is controversial because it birth involves less risk.
violates the tradition of birth as a normal,
procedure-free process. Because it can Some anesthesia, at least a pudendal
shorten labor, it has the potential to reduce block, is necessary for forceps application
the number of postpartal fevers that occur to achieve pelvic relaxation and reduce
from infection or dehydration. pain. Usually, an episiotomy is performed
to prevent perineal tearing due to pressure
on the perineum.
FORCEP DELIVERY Record FHR before forceps application.
Because there is a danger that the cord
Obstetrical forceps are steel instruments could be compressed between the forceps
constructed of two blades that slide blade and the fetal head, assess FHR again
together at their shaft to form a handle. immediately after application. The
One blade is slipped into the woman’s woman’s cervix needs to be carefully
vagina next to the fetal head, and then the assessed after forceps birth to be certain
other is slipped into place on the other side that no laceration has occurred. To rule out
of the head. Next, the shafts of the bladder injury, record the time and amount
instrument are brought together in the of the first voiding.
midline to form the handle. The physician In addition, assess the newborn to be
then applies pressure on the handle to certain that no facial palsy or subdural
manually extract the fetus from the birth hematoma exists. A forceps birth may
canal. leave a transient erythematous mark on the
newborn’s cheek. This mark will fade
in 1 to 2 days with no long-term effects

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
VACUUM EXTRACTION Cesarean birth may reduce the transfer of
the human immunodeficiency virus (HIV),
A woman may need reassurance that the hepatitis C, or herpes type 2 from mother
caput swelling is harmless to her infant and to newborn, so it is recommended for
will decrease rapidly. Vacuum extraction women who have these infections.
should not be used as a method of birth if It can reduce mortality among infants
fetal scalp blood sampling was used, presenting breech (Hofmeyr & Hannah,
because the suction pressure can cause 2009). It may be advantageous for a
severe bleeding at the sampling site. preterm birth to avoid pressure on the fetal
Moreover, vacuum extraction is not head or to avoid postprocedure stress
advantageous for preterm infants because incontinence but whether this last
of the softness of the preterm skull. procedure helps is controversial. It is
generally contraindicated when there is a
documented dead fetus (labor can be
CESAREAN BIRTH induced to avoid a surgical procedure).

Currently, cesarean birth is used most

often as a prophylactic measure, to EMERGENT CESAREAN BIRTH
alleviate problems of birth such as
cephalopelvic disproportion or failure to Emergent cesarean births are done for
progress in labor. A major concern in reasons such as placenta previa, premature
maternal and child health nursing is the separation of the placenta, fetal distress, or
increasing number of cesarean births being failure to progress in labor. An emergent
performed annually (Clark et al., 2007). cesarean birth carries with it the risk of any
The increase in rate may also be related to emergent surgery: the woman may not be
physicians’ fears of malpractice suits a prime candidate for anesthesia and is
should a fetus be allowed to be born psychologically unprepared for the
vaginally and then be discovered to have experience.
suffered anoxia. In addition, the woman may have a fluid
and electrolyte imbalance and be both
physically and emotionally exhausted from
SCHEDULED CESAREAN BIRTH a long labor.

Although many cesarean births are done EFFECTS OF SURGERY ON A WOMAN

because the woman had a past cesarean
birth, with new surgical techniques, STRESS RESPONSE
particularly the use of a low cervical
incision, “once a cesarean, always a Whenever the body is subjected to
cesarean” no longer applies. Most women stress, either physical or psychosocial, it
who have had a cesarean birth within the responds with measures to preserve the
past 10 years are eligible to give birth function of major body systems. This
vaginally in subsequent pregnancies if the results in release of epinephrine and
circumstances otherwise are appropriate norepinephrine from the adrenal
for vaginal birth (Dodd et al., 2009). medulla. Epinephrine causes an
The incidence of women electing a vaginal increased heart rate, bronchial
birth after a previous cesarean birth dilatation, and elevation of the blood
(VBAC) ranges from about 11% to 13% of glucose level. It also leads to peripheral
women (NVSS, 2008). vasoconstriction, which forces blood to
Cesarean birth is mandatory when there is the central circulation and increases
a physical indication such as a transverse blood pressure.
presentation, genital herpes, or
cephalopelvic disproportion.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
INTERFERENCE WITH BODY DEFENSES INTERFERENCE WITH SELF-IMAGE OR SELF-
ESTEEM
The skin serves as the primary line of
defense against bacterial invasion. When Surgery always leaves an incisional scar
skin is incised for a surgical procedure, this that will be noticeable to some extent
important line of defense is lost. Strict afterward. Fortunately, the scar resulting
adherence to aseptic technique during from cesarean birth (a horizontal one
surgery and in the days following the across the lower abdomen) is not overly
procedure are necessary to compensate for noticeable, but its appearance may cause a
this impaired defense. woman to feel self- conscious later.
Many women receive prophylactic
antibiotics, such as ampicillin (Omnipen), or
a cephalosporin such as Ancef to ensure NURSING CARE OF A WOMAN ANTICIPATING
protection against postsurgical A CAESARIAN BIRTH
endometritis, even if the membranes were
intact PREOPERATIVE INTERVIEW

Both the physician and the

INTERFERENCE WITH CIRCULATORY anesthesiologist or nurse-anesthetist will
FUNCTION interview a woman preoperatively to obtain
a health history and make an assessment
Although vessels that must be cut for and decision for safe use of anesthesia. A
surgery are immediately clamped and nursing assessment is also essential. Be
ligated, some blood loss always occurs with sure to ask about any past surgeries,
surgery. Extensive blood loss can lead to secondary illnesses, allergies to foods or
hypovolemia and lowered blood pressure. drugs, reactions to anesthesia, bleeding
This could lead to ineffective perfusion of problems, and current medications to help
all body tissues if the problem is not establish surgical risk.
quickly recognized and corrected. The
amount of blood lost in cesarean birth is OPERATIVE RISK FOR A WOMAN
comparatively high, because pelvic vessels
are congested with blood waiting to supply For any surgery to be performed safely, a
the placenta woman must be in the best possible
physical and psychological state. Women
who are in less than optimal physical or
INTERFERENCE WITH BODY ORGAN psychological health are at risk for a
FUNCTION complicated surgical outcome unless the
risk factor is identified and special
When any body organ is handled, cut, or precautions are taken.
repaired in surgery, it may respond with a Poor Nutritional Status
temporary disruption in function. Pressure - a woman who is obese because of
from edema or inflammation as fluid moves poor nutrition is at risk because such a
into the injured area further impairs condition interferes with wound
function of the primary organ involved, as healing. Tissue that contains an
well as that of surrounding organs. If blood abundance of fatty cells is difficult to
vessels become compressed as a result of suture, so the incision may take longer
edema, distant organs may be deprived of to heal. A prolonged healing period
blood flow, leading to reduced function in increases the risk for infection and
those organs. Postoperatively, close rupture of the incision (dehiscence).
assessment, not only of the primary organ The woman’s heart may also have an
involved but of total body function, is increased workload. Therefore, the
necessary, therefore, to determine the total physiologic shock of surgery may place
degree of disruption. greater stress on the already
overworked organ

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
In addition, an obese woman often has A woman who began labor and later
more difficulty turning and ambulating was told that she is to have a cesarean
postoperatively than does a woman of birth may fall into this category,
normal weight and therefore has an because she may have had nothing to
increased risk for development of eat or drink for almost 24 hours. Recent
respiratory or circulatory complications vomiting, diarrhea, or a chronic poor
such as pneumonia or thrombophlebitis fluid intake can compound her risk.
(Datta & Gutman, 2007). Intravenous fluid replacement usually is
A woman with a protein or vitamin initiated preoperatively and continued
deficiency is also at risk for poorer healing, postoperatively to prevent fluid and
because protein and vitamins C and D are electrolyte imbalances
necessary for new cell formation at the
incision site. In addition, vitamin K is Fear
necessary for blood clotting after surgery. women who are extremely worried need
a very detailed explanation of the
Age Variations procedure before they can enter
age affects surgical risk because it can surgery without intense fear. Most
cause decreased circulatory and renal cesarean births currently are performed
function. Fortunately, most pregnant under epidural anesthesia, so they are
women fall within the young adult age less frightening for women than when
group, so they are excellent candidates general anesthesia was used. With all
for surgery. A woman older than 40 anesthesia, a woman who is frightened
years falls into a category of slightly is at a greater risk for cardiac arrest
higher risk. during anesthesia administration than a
woman who is calm and relaxed. In
Altered General Health many instances, just helping a woman
a woman who has a secondary illness acknowledge that her fear of surgery is
such as cardiac disease, diabetes normal can be helpful.
mellitus, anemia, or kidney or liver
disease is at greater than usual surgical
risk, depending on the extent of OPERATIVE RISK TO THE NEWBORN
disease, because the pathology from
the secondary illness may interfere with Cesarean birth places a newborn at a
her ability to adjust physically to the greater risk than does a vaginal birth for a
demands of surgery. A woman with a number of reasons. When a fetus is pushed
secondary illness may also have an through the birth canal, pressure on the
accompanying nutritional or electrolyte chest helps to rid the newborn’s lungs of
imbalance caused by her primary fluid. This makes respirations more likely to
illness. Therefore, asking about any be adequate at birth than if a fetus had not
secondary illnesses is an essential been subjected to this pressure. For this
component of a preoperative nursing reason, more infants born by cesarean
history. While waiting for surgery, birth develop some degree of respiratory
people are under stress, a condition difficulty for a day or two after birth than
that can limit their reasoning and those born vaginally
decision-making abilities.

Fluid and Electrolyte Imbalance PREOPERATIVE DIAGNOSTIC PROCEDURES

a woman who enters surgery with a
lower than normal blood volume will Preoperative diagnostic procedures for a
feel the effect of surgical blood loss woman who is to have a cesarean birth
more than a woman who has a normal include assessments of circulatory and
blood volume. renal function and fetal heart rate
including:

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
Vital sign determination Because stasis always has the potential
Urinalysis to cause infection, preventing this helps
Complete blood count prevent lung infection such as
Coagulation profile (prothrombin time pneumonia. A typical exercise is to take
[PT], partial thromboplastin time [PTT]) 5 to 10 deep breaths every hour. Teach
Serum electrolytes and pH a woman to do this simply by inhaling
Blood typing and cross-matching as deeply as possible, holding her
Ultrasound to determine fetal breath for a second or two, and then
presentation and maturity exhaling as deeply as possible.

Incentive Spirometry.
PREOPERATIVE TEACHING A common device used postoperatively
to encourage deep breathing is an
Fear of the unknown is one of the hardest incentive spirometer. These devices
fears to conquer. Preoperative teaching is which cause a small ping-pong-like ball
aimed at acquainting a woman with to rise in a narrow tube or cause lights
cesarean procedure and any special to flash, are not only easy and fun to
equipment to be used, to make her as operate but give a woman a sense of
informed as possible. Activities that help reward for her effort.
maintain respiratory and skeletal muscle
function, to prevent post surgical Turning.
complications, should also be included in Women do not need to practice turning
teaching. side to side before surgery, because
Be certain to explain the preoperative this activity is tiring for them to do
measures that will be necessary, such as while pregnant. They should
surgical skin preparation, eating nothing understand, however, that turning
before the time of surgery, premedication postoperatively is important to prevent
(if this will be used), and method of both respiratory and circulatory stasis.
transport to surgery. Review the necessity
for an indwelling catheter, intravenous Ambulation.
fluid administration, placement of an The most effective way to stimulate
epidural catheter (if used for post lower extremity circulation after a
procedural pain relief), and the advantage cesarean birth is by early ambulation.
of early ambulation afterward. For this reason, most surgeons prefer a
woman to be out of bed and walking by
4 hours after surgery (as soon as the
TEACHING TO PREVENT COMPLICATIONS effect of the epidural anesthesia has
worn off). Some women may be
Women who practice exercises to maintain prescribed anti-embolic stockings
good respiratory and circulatory function (TEDS) to support and encourage
postoperatively will tend to experience venous return in addition to ambulation
fewer postoperative respiratory and
circulatory complications than those who
do not. These preventive exercises are best IMMEDIATE PREOPERATIVE CARE
taught during the preoperative period, MEASURES
when the woman is free of pain and can
concentrate on learning Informed Consent
Obtaining operative consent is the
Deep Breathing. surgeon’s responsibility, but seeing that
Periodic deep breathing exercises fully it is obtained is everyone’s
aerate the lungs and help to prevent responsibility. You may be asked to
the stasis of lung mucus from the witness a woman’s signature on such a
prolonged time spent in the supine form.
position during surgery.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
Before signing as a witness, be certain Catheterization can be done in the
that it was informed consent, or one in birthing or delivery room after the
which the risks and benefits of the anesthetic agent is given.
procedure were explained in terms the
woman could easily understand
IMMEDIATE PREOPERATIVE CARE
Overall Hygiene MEASURES HYDRATION
Most women who are having a planned
cesarean birth are admitted to the Most women have an intravenous fluid line
facility on the morning of surgery and begun before surgery with a fluid such as
have showered or bathed at home. On lactated Ringer’s solution. Doing so helps
admission, provide a clean hospital to ensure that a woman is fully hydrated
gown. If a woman’s hair is long, and will not experience hypotension from
encourage her to braid it or put it into a epidural anesthesia administration,
ponytail so that it will more easily fit temporary use of a supine position, or
under the surgical cap she will wear. blood loss at birth.
Hair contained by a cap that way is less
likely to spread microorganisms during Preoperative Medication
surgery. Follow institutional procedure A minimum of preoperative medication
about removing nail polish, jewelry, is used with a woman having a cesarean
contact lenses, piercings, or hair birth, to prevent compromising the
ornaments before surgery. fetal blood supply and to ensure that
the newborn is wide awake at birth and
Gastrointestinal Tract Preparation can initiate respirations spontaneously.
A gastric emptying agent such as
metoclopramide (Reglan) to speed Patient Chart and Presurgery
stomach emptying or a histamine Checklist Documentation of nursing
blocker such as ranitidine (Zantac) to care up until the time a woman leaves
decrease stomach secretions may be the nursing care unit or labor room
prescribed prior to surgery. Yet another must be completed before a woman
possibility is an oral antacid such as leaves for the surgical suite.
sodium citrate (Bicitra), which acts to
neutralize acid stomach secretions. Transport to Surgery
These precautions are necessary A woman may be transferred to surgery
because the woman will be lying on her in her bed, or she may be helped to
back during the procedure, making move to a stretcher. If a stretcher is
esophageal reflux and aspiration highly used, be certain to hold it tightly
possible. against the side of the woman’s bed or
use a slide board for safe transfer. A
Baseline Intake and Output Determinations woman is awkward in her movements at
To reduce bladder size and keep the term and could easily slip and fall if the
bladder away from the surgical field, an stretcher moved. Cover her with a
indwelling urinary catheter may be blanket or sheet to avoid her feeling
prescribed before transport for surgery chilled. Check that her identification is
or after arrival in the surgical suite. secure before she leaves the patient
Catheterizing a pregnant woman is unit. Make sure that her chart with the
more difficult than catheterizing a surgical checklist accompanies her.
nonpregnant woman, because the
pressure of the fetal head puts pressure Role of the Support
on the urethra and distorts anatomic Person In most instances, a woman’s
landmarks. family can be as involved in a cesarean
If catheterization is difficult before birth as they would be for a vaginal
surgery, do not traumatize the urethra birth.
by repeated attempts.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
A support person may need more During transport or in surgery, encourage
encouragement to watch a cesarean the woman to remain on her side, or insert
birth than a vaginal one, because he or a pillow under her right hip to keep her
she may believe that the surgery will be body slightly tilted to the side, to prevent
much bloodier than it actually is. supine hypotension syndrome.
If a spinal anesthetic (which may be used in
an emergency) is to be administered, the
NURSING CARE OF A WOMAN HAVING AN anesthesiologist usually will do this with
EMERGENT CAESARIAN BIRTH the woman sitting up. The anesthesiologist
may ask you to help the woman curve her
Many women who will have a cesarean back to separate the vertebrae and
birth have no warning during pregnancy facilitate entry of the spinal needle.
that this will be necessary. Suddenly,
during labor, they develop a complication Skin Preparation
such as prolapsed cord or fetal distress, Reducing the number of bacteria on
and it becomes necessary. the skin before surgery automatically
A woman who was having severe pain with reduces the possibility of bacteria
labor and is told an emergent procedure is entering the incision at the time of
necessary actually may be relieved that surgery. Shaving away abdominal hair,
surgery has been suggested, because the if indicated, and washing the skin area
surgery will alleviate the pain. In contrast, over the incision site with soap and
another woman might feel great water accomplishes this. The skin
disappointment when told her baby must preparation area for a cesarean birth
be born by cesarean birth. varies among agencies. Some require
Preoperative preparation measures such as extensive skin preparation, from above
vital signs, urinalysis, and blood work have the umbilicus to below the pubic hair,
also been obtained. Immediate preparation whereas others require only a limited
concerns such as informed consent, preparation of the immediate incisional
application of elastic stockings (if area.
appropriate), gastrointestinal tract
preparation, bladder catheterization, and Surgical Incision
establishment of an intravenous line will be The incision area on the woman’s
the same. abdomen is then scrubbed with an
Available time must be spent explaining antiseptic such as iodine, and
the immediate procedures to the woman appropriate drapes are placed around
such as transfer, abdominal preparation, the area of incision, so that only a small
and anesthesia. Document carefully what area of skin is left exposed.
was taught, so that the nurse caring for the
woman postoperatively will be aware of the IN A CLASSIC CESAREAN INCISION
need for additional teaching.
the incision is made vertically through both
the abdominal skin and the uterus. It is
INTRAOPERATIVE CARE MEASURES made high on the uterus so that it can be
used with a placenta previa, to avoid
A surgical nurse will assist a woman to cutting the placenta. A disadvantage of
move from the transport stretcher or bed this type of incision is that it leaves a wide
to the operating room table and will remain skin scar and also runs through the active
with her while anesthesia is administered. contractile portion of the uterus. Because
If the woman has an epidural catheter in this type of scar could rupture during labor,
place from labor, be careful not to dislodge it is likely, if this type of incision is used,
it while she is being moved. that a woman will not be able to have a
subsequent vaginal birth.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
A LOW SEGMENT INCISION (COMMONLY If the woman wishes to have a tubal
REFERRED TO AS A LOW TRANSVERSE ligation, it can be done at this time.
INCISION) The uterus, subcutaneous tissues, and
skin incisions are then closed. Be sure
is one made horizontally across the to remind a woman and her support
abdomen just over the symphysis pubis person that closing the incision can be
and also horizontally across the uterus just a long process, so they do not become
over the cervix. This is the most common concerned that something is going
type of cesarean incision. It is also referred wrong. Metal staples are usually used
to as a Pfannenstiel incision or a “bikini” on the exterior skin, because they leave
incision, because even a low-cut bathing the least amount of scarring (Anderson
suit will cover the scar. Because this type of & Gates, 2009).
incision is through the nonactive portion of
the uterus (the part that contracts Birth of the Infant Introduction of the
minimally with labor), it is less likely to Newborn
rupture in subsequent labors. The major Once it is determined that the newborn
disadvantage of this incision is that it takes is breathing spontaneously, he or she is
longer to perform, possibly making it shown to the mother and support
impractical for an emergent cesarean birth. person, just as is done after a vaginal
birth. The support person may hold the
Birth of the Infant baby immediately.
Once the surgical incision is complete, Women are able to breastfeed after
retractors (long, curved, metal cesarean births the same as after
instruments) are slipped into the vaginal births, but initial breastfeeding
incision. Gentle traction on the handles is usually delayed until the woman has
by an assistant keeps the incision been moved to a recovery room,
spread apart, allowing good because breastfeeding initiates uterine
visualization of the uterus and the contractions and that may interfere
internal incision. Sterile towels may be with suture placement.
placed in the incision to separate the
uterus from other organs.
The uterus is then cut, and the child’s POST PARTAL CARE MEASURES
head is born manually or by the
application of forceps. Women who have infants by cesarean birth
The mouth and nose of the baby are develop an additional care concern in the
suctioned by a bulb syringe, the same immediate postpartal period because they
as in a vaginal birth, before the are not only postpartal patients but
remainder of the child is born. postsurgical ones as well. Due to the strain
The mouth and nose of the baby are of the unexpected procedure, they may
suctioned by a bulb syringe, the same have increased difficulty bonding with their
as in a vaginal birth, before the new infant.
remainder of the child is born. They have postsurgical pain in additional to
Oxytocin is administered intravenously afterpains. As with all postpartal women,
by the anesthesiologist as the child or the postpartal phase for a woman who has
placenta is delivered, to increase her child by cesarean birth can be divided
uterine contraction and reduce blood into an immediate recovery period (the so-
loss. called fourth stage of labor) and an
After full birth, the uterus is pulled extended postpartal period.
forward onto the abdomen and covered
with moist gauze. The internal cavity of
the uterus is then inspected, and the
membranes and placenta are manually
removed.

Rein Ramos
ACADEMICIAN
 Week 3:
Problems During Labor and Delivery
DISCHARGE PLANNING

A woman being discharged after cesarean

birth takes home not only her new baby
but a fair amount of pain and discomfort.
Be certain to discuss home care
arrangements, emphasizing the need for
adequate help with her newborn and other
responsibilities at home, before discharge.
Be sure a woman is aware of any
restrictions on exercise or activity.that she
needs to follow (common restrictions are
not to lift any object heavier than 10 lb or
walk upstairs more than once a day for the
first 2 weeks).

Also teach her to recognize signs of possible

complications directly related to the surgery,
such as:

Redness or drainage at the incision line

Lochia heavier than a normal menstrual
period
Abdominal pain (other than suture line
or after pain discomfort)
Temperature greater than 38° C
(100.4° F)
Frequency or burning on urination

A woman can plan on resuming coitus as

soon as the act is comfortable for her,
possibly as early as 1 week after discharge.
Cesarean birth does not interfere with
future fertility so be sure that she has
contraceptive information, if desired (Oral
& Elter, 2007). Also ensure that she has an
appointment for a return visit with her
health care provider (usually in 2 weeks),
for both herself and her newborn.
Unless the reason for the cesarean birth
was cephalopelvic disproportion, a woman
can probably have her next child vaginally.
Being certain the woman is aware of this
not only makes her an informed consumer
of health care but also can influence
whether she plans an additional pregnancy.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
POST-PARTUM COMPLICATION CONDITIONS THAT INCREASE A WOMAN'S
RISK FOR A POSTPARTAL HEMORRHAGE
Although the puerperium is usually a
Conditions that distend the uterus beyond
period of health, complications can occur.
the average capacity
When they do, immediate intervention is
Multiple gestation
essential to prevent long-term disability
Polyhydramnios
and interference with parent– child
Macrosomia
relationships. A woman with a post-partal
Uterine myomas
complication is at risk from three points of
view: her own health, her future
Conditions that could have caused cervical
childbearing potential, and her ability to
or uterine lacerations
bond with her new infant.
An operative birth
One of the primary causes of maternal
A rapid birth
mortality associated with childbearing
Major threat during pregnancy, labor, and
Conditions that lead to inadequate blood
continue into the postpartum
coagulation
Fetal death
Vaginal birth - blood loss of 500 ml or
DIC
more
CS- blood loss of 1.000 ml or a 10%
Conditions that leave the uterus unable to
decrease in the hct level
contract readily
Deep anesthesia or analgesia
May occur early (within the first 24 hours
Labor initiated or assisted with an
following birth) or late (from 24 hours to 6
oxytocin agent
weeks after birth).
Maternal age greater than 35 years
Greatest danger is in the first 24 hours.
High parity
Previous uterine surgery
Prolonged and difficult labor
Chorioamnionitis and endometritis
Secondary maternal illness (e.g.,
anemia)
Prior history of postpartum
hemorrhage
Prolonged use of magnesium sulfate or
other tocolytic therapy

POSTPARTAL HEMORRHAGE

4 MAIN REASONS FOR PPH Hemorrhage, one of the most important

causes of maternal mortality associated
Uterine atony with childbearing, poses a possible threat
Trauma (lacerations, hematomas, uterine throughout pregnancy and is also a major
inversion or uterine rupture) potential danger in the immediate
Retained placental fragments postpartum period.
Disseminated intravascular coagulation Postpartum hemorrhage has been defined
as any blood loss from the uterus greater
than 500 mL within a 24-hour period.
ALSO CALLED THE 4 T'S OF PPH In specific agencies, the loss may not be
Tone considered hemorrhage until it reaches
Trauma 1000 mL. Hemorrhage may occur either
Tissue early (within the first 24 hours)
Thrombin

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
POSTPARTAL HEMORRHAGE FACTORS THAT PREDISPOSE TO POOR
(CONTINUATION) UTERINE TONE OR ANY INABILITY TO
MAINTAIN A CONTRACTED STATE ARE:
or late (any time after the first 24 hours
during the remaining days of the 6-week Deep anesthesia or analgesia
puerperium). Labor initiated or assisted with an oxytocin
The greatest danger of hemorrhage is in agent
the first 24 hours because of the grossly Maternal age greater than 35 years
denuded and unprotected uterine area left High parity
after detachment of the placenta. Previous uterine surgery
Prolonged and difficult labor
There are five main causes for postpartum Possible chorio amnionitis Secondary
hemorrhage: maternal illness (e.g., anemia)
uterine atony Prior history of postpartum hemorrhage
lacerations Endometritis
retained placental fragments Prolonged use of magnesium sulfate or
uterine inversion other tocolytic therapy
disseminated intravascular coagulation

THERAPEUTIC MANAGEMENT IN THE EVENT

UTERINE ATONY OF UTERINE ATONY:

Uterine atony, or relaxation of the uterus, is BIMANUAL MASSAGE

the most frequent cause of postpartum If fundal massage and administration of
hemorrhage oxytocin or methylergonovine are not
Occur most often in Asian, Hispanic, and effective in stopping uterine bleeding, a
Black women sonogram may be done to detect
The uterus must remain in a contracted possible retained placental fragments.
state after birth to keep the open vessels at this procedure, the physician or nurse-
the placental site from bleeding. midwife inserts one hand into a
If the uterus suddenly relaxes, there will be woman’s vagina while pushing against
an abrupt gush of blood vaginally from the the fundus through the abdominal wall
placental site. with the other hand.
If the vaginal bleeding is extremely
copious, a woman will exhibit symptoms of PROSTAGLANDIN ADMINISTRATION
shock and blood loss. promote strong, sustained uterine
This can occur immediately after birth contractions. Intramuscular injection of
or more gradually, over the first prostaglandin F22 is another way to
postpartum hour, as the uterus slowly initiate uterine contractions.
becomes un-contracted.
BLOOD REPLACEMENT
Blood transfusion to replace blood loss
with postpartum hemorrhage may be
necessary.
Women who experience postpartum
hemorrhage tend to have a longer than
average recovery period, because the
physiologic exhaustion of body systems
can interfere with their recovery
Iron therapy may be prescribed to
ensure good hemoglobin formation.
Activity level, exertion, and postpartum
exercise may be restricted
somewhat.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
Monitor her temperature closely in the If extensive, a regional anesthesia may be
postpartum period, to detect the given to relax the uterine muscle and to
earliest signs of developing infection. prevent pain.
Be certain that the physician has adequate
HYSTERECTOMY OR SUTURING space to work, adequate sponges and
Usually, therapeutic management is suture supplies, and a good light source.
effective in halting bleeding. In the rare
instance of extreme uterine atony,
sutures or balloon compression may be VAGINAL LACERATIONS
used to halt bleeding (Nelson &amp;
O’Brien, 2007). Easier to locate and assess than cervical
Embolization of pelvic and uterine lacerations because they are easier to view
vessels by angiographic techniques Because vaginal tissue is friable, vaginal
may be successful. lacerations are also hard to repair. Some
As a last resort, ligation of the uterine oozing often occurs after a repair, so the
arteries or a hysterectomy may be vagina may be packed to maintain pressure
necessary. on the suture line. If packing is inserted,
document in a woman’s nursing care plan
when and where it was placed, so you can
LACERATIONS be certain it will be removed after 24 to 48
hours or before discharge.
Small lacerations or tears of the birth canal An indwelling urinary catheter (Foley
are common and may be considered a catheter) may be placed at the same time
normal consequence of childbearing. Large because the packing causes pressure on
lacerations, however, can cause the urethra and can interfere with voiding.
complications.
THERAPEUTIC MANAGEMENT:
THEY OCCUR MOST OFTEN:
With difficult or precipitate births Difficult to suture because vaginal tissue is
In primigravida friable.
With the birth of a large infant ( 9 lb) A balloon tamponade can be used if
With the use of a lithotomy position and suturing does not achieve homeostasis.
instruments Vaginal packing may be placed; document
presence and be sure to remove after 24 to
CERVICAL LACERATIONS 48 hours or prior to discharge.

Lacerations of the cervix are usually found

on the sides of the cervix, near the PERINEAL LACERATIONS
branches of the uterine artery.
If the artery is torn, the blood loss may be More apt to occur when a woman is in a
so great that blood gushes from the lithotomy position as it increases the
vaginal opening. Because this is arterial tension on the perineum.
bleeding, it is brighter red than the venous Perineal lacerations are sutured and
blood lost with uterine atony. treated as an episiotomy repair. Make
This bleeding occurs immediately after certain that the degree of the laceration is
detachment of the placenta documented, because women with fourth
degree lacerations need extra precautions
to avoid having repair sutures loosened or
THERAPEUTIC MANAGEMENT: infected.
Any woman who has a third- or fourth-
Usually requires sutures and can be degree laceration should not have an
difficult because it can obstruct the enema or a rectal suppository prescribed
visualization of the area. or have her temperature taken

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
rectally, because the hard tips of A blood serum sample that contains
equipment could open sutures near to or human chorionic gonadotropin hormone
including those of the rectal sphincter (hCG) also reveals that part of a placenta is
still present.
CLASSIFICATIONS: Removal of the retained placental
fragment is necessary to stop the bleeding.
1st - vaginal mucous membrane and skin Usually, a dilatation and curettage (D&C) is
of the perineum to the fourchette performed to remove the placental
2nd - vagina, perineal skin, fascia, levator fragment. Methotrexate may be prescribed
ani muscle and perineal body to destroy the retained placental tissue.
3rd - entire perineum, to external sphincter
of the rectum THERAPEUTIC MANAGEMENT:
4th - up to some of the mucous membrane
of the rectum Removal of the retained fragments by D
and C.
If cannot be removed, methotrexate may
be prescribed to destroy the retained
fragment.
Instruct the woman to observe the color of
lochia and report is the color changes from
serosa or alba back to rubra.
Balloon occlusion and embolization of the
internal iliac arteries may be necessary to
minimize blood loss.
Hysterectomy may also be performed.

UTERINE INVERSION (PROLAPSE)

THERAPEUTIC MANAGEMENT: Prolapse of the fundus of the uterus

through the cervix so that the uterus turns
Sutured and treated the same as an inside out with either birth of the fetus or
episiotomy repair; both tend to heal in the delivery of the placenta.
same length of time This may occur if traction is applied to the
Diet high in fluid and a stool softener in the umbilical cord to remove the placenta or if
first week pressure is applied to the uterine fungus
No enema, rectal suppository, or rectal when the uterus is not contracted.
temp monitoring for 3rd to 4th degree It may occur in various degrees and the
laceration inverted fundus may lie within the uterine
cavity or the vagina.
In total inversion, it may protrude from the
RETAINED PLACENTAL FRAGMENTS vagina.

Occasionally, a placenta does not deliver in ASESSMENT:

its entirety; fragments of it separate and
are left behind. Because the portion Large mount of blood gushes from the
retained keeps the uterus from contracting vagina and the fundus is no longer
fully, uterine bleeding occurs. To detect the palpable in the abdomen.
complication of retained placenta, every Complete inversion as evidenced by a
placenta should be inspected carefully large, red, rounded mass that protrudes 20
after birth to see that it is complete. to 30 cm outside the introitus.
Retained placental fragments may also be Partial inversion as evidenced by the
detected by ultrasound. palpation oof a smooth mass through the
dilated cervix.
Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications

The woman begins to show signs of blood May occur during pregnancy
loss: hypotension, dizziness, paleness, or Maintain maternal blood volume and
diaphoresis. correction of shock
Bleeding cannet be halted because the Repair if woman can still bear a child
uterus is not able to contract and may Large - hysterectomy
result to exsanguination within 10 minutes. BT

THERAPEUTIC MANAGEMENT:
DISSEMINATED INTRAVASCULAR
Never attempt to replace an inversion to COAGULATION
avoid increased bleeding.
Never attempt to remove the placenta if is a deficiency in clotting ability caused by
still attached as this would create a larger vascular injury. It may occur in any woman
surface area for bleeding. in the postpartum period, but it is usually
Discontinue oxytocin to avoid the uterus to associated with premature separation of
be more tensed and difficult to replace. the placenta, a missed early miscarriage, or
Large-bore needle, IVF, 02, vital signs fetal death in utero.
monitoring; be prepared to perform CPR The overactive coagulation depletes
The woman will be given general platelet and clotting factors needed to
anesthesia or a tocolytic drug to relax the control bleeding causing excessive
uterus. bleeding.
The physician then replaces the funds A coagulopathy in which the clotting and
manually followed by administration of anti clotting mechanisms occur at the same
oxytocin to help the uterus contract and time.
remain in natural place. The client is at risk for both internal and
Antibiotic therapy external bleeding, as well as damage to
Possible cesarean delivery for future organs resulting from ischemia caused by
pregnancies microclottings.
Also associated with premature separation
of the placenta, missed early miscarriage or
fetal death in utero.

MANAGEMENT OF DIC:

Correction of the cause

Missed abortion- delivery of the fetus
and the placenta ends the production
of thromboplastin, which is fueling the
process
Blood transfusion

Monitor for bleeding - IV site, lab works,

nosebleeds, spontaneous bruising.

SUBINVOLUTION
UTERINE RUPTURE - TEAR IN THE WALL OF
THE UTERUS
Subinvolution is incomplete return of the
uterus to its pre-pregnant size and shape.
Abdominal pain, something ripped
With subinvolution, at a 4- or 6week
Chest pain, pain bet the scapulae or pain
postpartum visit, the uterus is still enlarged
on inspiration - irritation of blood below
and soft. Lochia discharge usually is still
the woman's diaphragm
present.
Hypovolemic shock

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications

Subinvolution may result from a small SAFETY ALERT!

retained placental fragment, a mild
endometritis (infection of the SIGNS OF POSTPARTUM HEMORRHAGE
endometrium), or an accompanying INCLUDE:
problem such as a uterine myoma that is
interfering with complete contraction. A uterus that does not contract or does not
Oral administration of methylergonovine, remain contracted.
0.2 mg four times daily, usually is Large gush or slow, steady trickle, ooze or
prescribed to improve uterine tone and dribble of blood from the vagina
complete involution. If the uterus is tender Saturation of one peripad per 15 mins
to palpation, suggesting endometritis, an Severe, unrelieved perineal or rectal pain
oral antibiotic also will be prescribed. III. Tachycardia
Treatment of underlying causes.
TO DETERMINE THE AMOUNT OF BLOOD
LOSS:
PERINEAL HEMATOMAS
Weigh all blood-soaked items (peripads,
A perineal hematoma is a collection of linens).
blood in the subcutaneous layer of tissue Weigh similar clean items.
of the perineum. Subtract the weight of the dry items from
The overlying skin, as a rule, is intact with that of the wet items.
no noticeable trauma. Such blood 1 g weight = 1 ml of blood.
collections can be caused by injury to
blood vessels in the perineum during birth.
They are most likely to occur after rapid,
spontaneous births and in women who PUERPERAL INFECTION
have perineal varicosities.
They may occur at the site of an Infection of the reproductive tract is
episiotomy or laceration repair if a vein was another leading cause of maternal
punctured during repair. mortality. When caring for a woman who
May appear as an area of purplish has any of these circumstances, be aware
discoloration with obvious swelling; minor that the risk for postpartum infection is
bleeding greatly increased.
Describe in definite size (cm) The uterus is sterile during pregnancy and
Analgesic, ice pack up until the membranes rupture.
If the episiotomy incision line is opened to After rupture, the pathogens can begin to
drain a hematoma, it may be left open and invade; risk of infection is greater if tissue
packed with gauze rather than re-sutured. edema and trauma are present.
If with vaginal packing, removal after 24 to A postpartum infection is always
48 hours botentially serious; it may start as a local
infection but it has the potential to spread
to the peritoneum (peritonitis) or
circulatory system (septicemia).
Commonly caused by group B strep,
staphylococci, and anaerobic gram-
negative bacilli such as E. coli.
Management is starting an antibiotic after
culture and sensitivity of the culture
organism.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
ENDOMETRITIS Notify the woman's physician or nurse-
midwife of the localized symptoms, and
An infection of the endometrium, the lining culture the discharge using a sterile
of the uterus cotton-tipped applicator touched to the
Bacteria enter through the vagina and the secretions.
uterus either at the time of birth or during
the postpartal period THERAPEUTIC MANAGEMENT:
Usually associated with chorioamnionitis
and cesarean birth Removal of perineal sutures, to open the
area and allow for drainage.
ASSESSMENT: Packing, such as iodoform gauze, may be
placed in the open lesion to keep it open
Fever on the 3rd or 4th postpartal day; and allow drainage.
suspect endometritis if with fever unless Typically, a systemic or topical antibiotic is
proven otherwise. ordered even before the culture report is
Chills, loss of appetite, general malaise returned. An analgesic may be prescribed
Uterus is not well contracted and painful to alleviate discomfort.
Dark brown lochia and has a foul odor Sitz baths, moist warm compresses, or
Could be due to retained placental Hubbard tank treatments may be ordered
fragments to hasten drainage and cleanse the area.
Remind the woman to change perineal
THERAPEUTIC MANAGEMENT: pads frequently.
Be certain a woman wipes front to back of
Clindamycin (Cleocin), as determined by a the perineum.
culture of the lochia. Culture from the
vagina, using a sterile swab, rather than
from a perineal pad.
Oxytocic agent such as methylergonovine PERITONITIS
encourage uterine contraction.
Increased OFI and analgesic Peritonitis, or infection of the peritoneal
Ambulation or sitting in a Fowler's position cavity, usually occurs as an extension of
to allow Lochia drainage by gravity. endometritis.
Monitor lochia and keep uterus contracted. It is one of the gravest complications of
childbearing and is a major cause of death
from puerperal infection.
The infection spreads through the
INFECTION OF THE PERINEUM (INFECTION lymphatic system or directly through the
OF THE SUTURE LINE) fallopian tubes or uterine wall to the
peritoneal cavity.
A suture line on the perineum from an Peritonitis can interfere with future fertility,
episiotomy or a laceration repair could be a because it leaves scarring and adhesions in
portal of entry for bacterial invasion. the peritoneum

ASSESSMENT:

Symptoms similar to any suture-line

infection, such as pain, heat, inflammation
and a feeling of pressure.
The suture line may be open with purulent
drainage present
With or without fever, depending on the
systemic effect and spread the infection.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications

ASSESSMENT: THROMBOPHLEBITIS

Rigid abdomen, abdominal pain, high Phlebitis is inflammation of the lining of a

fever, rapid pulse, vomiting, and the blood vessel.
appearance of being acutely ill. Thrombophlebitis is inflammation with the
The occurrence of a rigid abdomen formation of blood clots.
(guarding) is one of the first symptoms of When thrombophlebitis occurs in the
peritonitis. postpartal period, it is usually an extension
of an endometrial infection.

IT TENDS TO OCCUR BECAUSE:

THERAPEUTIC MANAGEMENT Fibrinogen level is still elevated from
pregnancy, leading to increased blood
Insertion of a nasogastric tube to prevent clotting.
vomiting and rest the bowel. Intravenous Dilatation of lower extremity veins is
fluid or total parenteral nutrition may be still present as a result of pressure of
necessary. the fetal head during pregnancy and
Peritonitis is often accompanied by birth.
paralytic ileus (blockage of inflamed Inactivity and use of stirrups.
intestines). This requires insertion of a Obesity from increased weight before
nasogastric tube to prevent vomiting and pregnancy and pregnancy weight qain
rest the bowel. Intravenous fluid or total can lead to relative inactivity and lack
parenteral nutrition may be necessary. A of exercise.
woman will need analgesics for pain relief. Smoking
She will be administered large doses of
antibiotics to treat the infection. Her Prevention of endometritis by the use of
hospital stay will be extended, but with good aseptic technique during birth helps
effective antibiotic therapy, the outcome to prevent thrombophlebitis.
usually is good. Ambulation and limiting the time a woman
Analgesics for pain relief. remains in obstetric stirrups encourages
Antibiotics to treat the infection. circulation in the lower extremities,
promotes venous return, and decreases the
possibility of clot formation, also helping to
prevent thrombophlebitis.
If stirrups of examining or delivery tables
are used, be certain they are well padded,
to prevent any sharp pressure against the
calves of the legs.
If a woman had varicose veins during
pregnancy, wearing support stockings for
the first 2 weeks after birth can help
increase venous circulation and prevent
stasis.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications

FEMORAL THROMBOPHLEBITIS THERAPEUTIC MANAGEMENT

The femoral, saphenous, or popliteal veins Bed rest with the affected leg elevated
are involved. Never massage the skin over the clot; this
Inflammation site in thrombophlebitis is a could loosen the clot, causing a pulmonary
vein, but an accompanying arterial spasm or cerebral embolism.
often occurs, diminishing arterial Heat supplied by a moist, warm compress
circulation to a leg as well. can help decrease inflammation.
Has a white or drained appearance and was The pain of thrombophlebitis is usually
formerly believed that breast milk drained severe enough to require administration of
into the leg, giving it its white appearance. an analgesic. No salicylic acid for pain.
The condition was, therefore, formerly An appropriate antibiotic to reduce the
called milk leg or phlegmasia alba doles initial infection is prescribed.
("white inflammation"). Measure the client's leg circumferences.

Often, an anticoagulant (coumadin

ASSESSMENT: derivative or heparin) or a thrombolytic
agent such as streptokinase or urokinase is
Elevated temperature, chills, pain, and prescribed to dissolve the clot and prevent
redness in the affected leg about 10 days further clot formâtion.
after birth. Baseline activated partial thromboplastin
Her leg begins to swell below the lesion at time (aPTT) or prothrombin time (PT) is
the point at which venous circulation is obtained.
blocked. Heparin, an anticoagulant, can be
Her skin becomes so stretched from administered by continuous intravenous
swelling that it appears shiny and white. infusion or intermittently by intravenous or
Homans' sign (pain in the calf of the leg on subcutaneous injection. Protamine sulfate,
dorsiflexion of the foot) may be positive; the antagonist for heparin, should be
however, a negative Homans' sign does not readily available any time heparin is
rule out obstruction. administered.
The diameter of the leg at thigh or calf Lochia usually increases in amount in a
level may be increased compared with the woman who is receiving an anticoagulant.
other leg. Be sure to keep a meaningful record of the
Doppler ultrasound or contrast venography amount of this discharge so that it can be
usually is ordered to confirm the diagnosis. estimated.

Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications
MASTITIS - INFECTION OF THE BREAST She may also have a low-grade fever and
discomfort from lower abdominal pain.
May occur as early as the7th postpartal
day or not until the baby is weeks or THERAPEUTIC MANAGEMENT
months old
The organism causing the infection usually Broad-spectrum antibiotic such as
enters through cracked and fissured ampicillin will be prescribed to treat a
nipples. postpartal urinary tract infection or the full
Occasionally, the organism that causes 5 to 7 days to eradicate the infection
mastitis comes from the nasal-oral cavity completely.
of the infant and has usually acquires Encourage a woman to drink large
staphylococcus aureus, a methicillin- amounts of fluid (a glass every hour) to
resistant s. aureus, or candidiasis while in help flush the infection from her bladder.
the hospital. She may need an oral analgesic, such as
The infant introduces the organisms into acetaminophen (Tylenol), to reduce the
the milk ducts by sucking where they pain of urination
proliferate.
Can become a localized abscess if left
untreated EMOTIONAL AND PSYCHOLOGICAL
COMPLICATIONS OF PUERPERIUM

ASSESSMENT:
POSTPARTUM DEPRESSION
Usually unilateral
Painful, appears swollen and reddened Almost every woman notices some
Fever immediate (1 to 10 days postpartum)
Breastmilk becomes scant feelings of sadness (postpartum “blues”)
after childbirth. This probably occurs as a
response to the anticlimactic feeling after
THERAPEUTIC MANAGEMENT: birth and probably is related to hormonal
shifts as the levels of estrogen,
Antibiotics effective against penicillin progesterone, and gonadotropin-releasing
resistant staphylococci such as dicloxacillin hormone in her body decline or rise.
and cephalosphorin The sensations of overwhelming sadness
Continue breastfeeding, empty the breast can interfere with breastfeeding, childcare,
regularly and returning to work. In addition to an
Cold/ice compress overall feeling of sadness, a woman may
Supportive bra notice extreme fatigue, an inability to stop
Warm/wet compresses can also be helpful crying, increased anxiety about her own or
her infant’s health, insecurity
(unwillingness to be left alone or inability to
URINARY TRACT INFECTION make decisions), psychosomatic symptoms
(nausea and vomiting, diarrhea), and either
A woman who is catheterized at the time of depressive or manic mood fluctuations.
childbirth or during the postpartal period is Depression of this kind is termed
prone to development of a urinary tract postpartum depression and reflects a more
infection, because bacteria may be serious problem than normal “baby blues”.
introduced into the bladder at the time of Risk factors for postpartum depression
catheterization. include a history of depression, a troubled
childhood, low self-esteem, stress in the
ASSESSMENT: home or at work, and lack of effective
Burning on urination, possibly blood in the support people. Different expectations
urine (hematuria), and a feeling of between partners or disappointment in the
frequency or that she always has to void. child could play major roles.
Rein Ramos
ACADEMICIAN
 Week 4:
Post-Partum Complications

It is difficult to predict which women will She may respond with anger or become
develop postpartum depression before equally threatening. A psychosis is a severe
birth, because childbirth can result in so mental illness that requires referral to a
many varied reactions; if factors could be professional psychiatric counselor and
identified, pregnancy counseling might be antipsychotic medication. Do not leave the
able to prevent symptoms. In the woman alone, because her distorted
postpartum period, discovery of the perception might lead her to harm herself.
problem as soon as symptoms develop Nor should you leave her alone with her
nursing priority. infant.
Several depression scales to help detect
postpartum depression are available but
conscientious observation and discussion COMPARING POSTPARTAL BLUES,
with women can reveal symptoms just as DEPRESSION, AND PSYCHOSIS
well. A woman may need counseling and
possibly antidepressant therapy to
integrate the experience of childbirth into
POSTPARTAL BLUES
her life. This is crucial to development of a
healthy maternal–infant bond, to the Onset Symptoms 1-10 days after birth Sadness, tears
health of any other children in the family,
and to overall family functioning. Ask at Incidence Etiology (possible) 70% of all births Probable hormonal

changes, stress of life changes
postpartum return visits and well-child
visits about symptoms that would suggest Support, empathy Offer compassion
depression and recommend an appropriate Therapy Nursing role and
referral. understanding

POSTPARTAL DEPRESSION

POSTPARTUM PSYCHOSIS 1-12 months after birth Anxiety, feeling

Onset Symptoms of loss,
As many as 1 woman in 500 has enough sadness

symptoms during the year after the birth 10% of all births History of previous
Incidence Etiology (possible)
of a child to be considered psychiatrically

depression, hormonal response, lack of

social support
ill. When the illness coincides with the

postpartum period, it is called postpartum

Counselling, drug therapy Refer to
psychosis. Rather than being a response to Therapy Nursing role counselling
the physical aspects of childbearing,

however, it is probably a response to the

crisis of childbearing. Most of these women
POSTPARTAL PSYCHOSIS
have had symptoms of mental illness
before pregnancy. If the pregnancy had Within first year after birth Delusions
not precipitated the illness, a death in the Onset Symptoms or hallucinations of harming infant or
self
family, loss of a job or income, divorce, or
some other major life crisis would probably 1% - 2% of all births Possible activation
have precipitated the same recurrence. Incidence Etiology (possible)
of
insist that she was never pregnant. She

previous mental illness, hormonal

changes, family history of bipolar
may voice thoughts of infanticide or that disorder
her infant is possessed. If observation tells
you that a woman is not functioning, you Psychotherapy, drug therapy
cannot improve her concept of reality by a Therapy Nursing role
Refer to psychiatric care,
safeguarding mother from injury to self
simple measure such as explaining what a or to newborn
correct perception is.
Her sensory input is too disturbed to
comprehend this. In addition, she may
interpret your attempt as threatening.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

INFERTILITY The chance of subfertility increases with

age. Because of this gradual decline in
fertility, women who defer pregnancy to
SUBFERTILITY their late 30s are apt to have more
difficulty conceiving than their younger
exist when a pregnancy has not occurred counterparts.
after at least 1 year of engaging in Women who are using oral, injectable, or
unprotected coitus. implanted hormones for contraception may
In primary subfertility, there have been have difficulty becoming pregnant for
no previous conceptions; several months after discontinuing these
in secondary subfertility, there has been medications, because it takes that long for
a previous viable pregnancy but the the body to restore normal functioning.
couple is unable to conceive at present.

Sterility is the inability to conceive because MALE SUBFERTILITY FACTORS

of a known condition, such as the absence
of a uterus. Several factors typically lead to male
subfertility:
In about 40% of couples with a subfertility
problem, Disturbance in spermatogenesis
the cause of subfertility is Obstruction in the seminiferous tubules,
multifactorial; ducts, or vessels preventing movement of
spermatozoa
in about 30% of couples, Qualitative or quantitative changes in the
it is the man who is subfertile. In seminal fluid preventing sperm motility
women seen for a fertility concern, Development of autoimmunity that
immobilizes sperm
20 % to 25% experience ovulatory failure; Problems in ejaculation or deposition
another 20% experience ovulatory failure; preventing spermatozoa from being placed
another 20% experience close enough to a woman’s cervix to allow
tubal, vaginal, cervical, or uterine ready penetration and fertilization.
problems.

In about 10% of couples,

no known cause for the subfertility can INADEQUATE SPERM COUNT.
be discovered despite all the diagnostic
tests currently available.
he sperm count is the number of sperm in a
Such couples are categorized as having single ejaculation or in a milliliter of semen.
unexplained subfertility. The minimum sperm count considered
When engaging in coitus an average of normal is 20 million/ml of seminal fluid, or
four times per week, 50% of couples will 50 million per ejaculation.
conceive within 6 months, and 85% within At least 50% of sperm should be motile,
12 months. These periods will be longer if and 30% should be normal in shape and
sexual relations are less frequent. form. Spermatozoa must be produced and
Couples who engage is coitus daily may maintained at a temperature slightly lower
actually have more difficulty conceiving than body temperature to be fully motile.
than those who space coitus to every other Any condition that significantly increases
day. This is because too-frequent coitus body temperature such as a chronic
can lower a man’s sperm count to a level infection from tuberculosis or recurrent
below optimal fertility. sinusitis can lower a sperm count.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

Actions that increase scrotal heat, such as Other conditions that may inhibit sperm
working at desk jobs or driving a great deal production are trauma to the testes;
everyday may produce lower sperm counts surgery on or near the testis that results in
compared with men whose occupations impaired testicular circulation; and
allow them to be ambulatory at least part endocrine imbalances, particularly of the
of each day. thyroid, pancreas, or pituitary glands.
Frequent use of hot tubs or saunas may Drug use or excessive alcohol use and
also lower sperm counts appreciably. environmental factors such as exposure to
x-rays or radioactive substances have also
been found to negatively affect
spermatogenesis.
Men who are exposed to radioactive
substances in their work environment
should be provided adequate protection of
the testes. When undergoing pelvic
radiography, be certain that men and boys
are always furnished with a protective lead
testes shield.

OBSTRUCTION OR IMPAIRED SPERM

MOTILITY
Congenital abnormalities such as Obstruction may occur at any point along
cryptorchidism (undescended testes) may the pathway that spermatozoa must travel
lead to lowered sperm production if to reach the outside: the seminiferous
surgical repair of this problem was not tubules, the epididymis, the vas deferens,
completed until after puberty or if the the ejaculatory duct, or the urethra.
spermatic cord became twisted after the Diseases such as mumps orchitis,
surgery. epididymitis, and tubal infections such as
A varicocele or varicosity of the spermatic gonorrhea or ascending urethral infection
vein could increase temperature within the can result in this type of obstruction
testes and slow and disrupt because adhesions form and occlude
spermatogenesis although whether this sperm transport.
actually causes much difference is in Congenital stricture of a spermatic duct
doubt. If this is happening, surgery to may occasionally be seen. Benign
repair the varicocele has the potential to hypertrophy of the prostate gland occurs
increase the chance for conception. in most men beginning at about 50 years
of age. Pressure from the enlarged gland
on the vas deferens can interfere with
sperm transport.
Infection of the prostate, through which
the seminal fluid must pass, or infection of
the seminal vesicles can change the
composition of the seminal fluid enough to
reduce sperm motility.
Anomalies of the penis, such as
hypospadias (urethral opening on the
ventral surface of the penis) or epispadias
(urethral opening on the dorsal surface),
can cause sperm to be deposited too far
from the sexual partner’s cervix to allow
optimal cervical penetration.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

Extreme obesity in a male may also ANOVULATION

interfere with effective penetration and
deposition. This is the most common cause of
subfertility in women and may occur from a
genetic abnormality such as Turner’s
EJACULATION PROBLEMS. syndrome (hypogonadism) in which there
are no ovaries to produce ova.
Psychological problems, diseases such as: Ovarian tumors may also produce
cerebrovascular accident, anovulation because of feedback
diabetes, stimulation on the pituitary. Chronic or
or Parkinson’s disease, excessive exposure to x-rays or radioactive
and some medications (certain substances, general ill health, poor diet,
antihypertensive agents) and diet may all contribute to poor ovarian
> may result in erectile dysfunction function.
(formerly called impotence or the inability to When either glucose or insulin levels are
achieve an erection). too high, they can disrupt the production
of follicle-stimulating hormone (FSH) and
This condition is primary if the man has luteinizing hormone (LH) leading to
never been able to achieve erection and subfertility from ovulation failure.
ejaculation in the past but now has Women should maintain an ideal body
difficulty weight and height, as represented by a BMI
Erectile dysfunction can be a difficult of 20 to 24.
problem to solve if it is associated with Eating slowly digested carbohydrate foods
stress, because this is not easily relieved. such as
brown rice, pasta,
Solutions to the problem can include dark bread,
psychological or sexual counseling as beans,
well as use of a drug such as sildenafil. and fiber-rich vegetables

Premature ejaculation (ejaculation before rather than food such as

penetration) is another factor that may white bread and
interfere with the proper deposition of cold breakfast cereals that have easily
sperm. It is another problem often digested carbohydrates can not only
attributed to psychological causes. increase fertility but perhaps prevent
Adolescents may experience it until they gestational diabetes when an woman
become more experienced in sexual does become pregnant.
techniques.
It is also important to consume
unsaturated fatty acids rather than
saturated or trans-fatty acids. Although
FEMALE SUBFERTILITY FACTORS eating adequate protein is important for
fertility, excessive intake of protein may be
The factors that cause subfertility in yet another deterrent to fertility. Exercising
women are analogous to those causing 30 minutes a day by walking or doing mild
subfertility in men: anovulation (faulty or aerobics can help regulate blood glucose
inadequate production on ova), problems levels.
of ova transport through the fallopian Some women ovulate only a few times a
tubes to the uterus, uterine factors such as year because of polycystic ovary syndrome.
tumors or poor endometrial development, This is associated with the metabolic
and cervical and vaginal factors that syndrome (a waist circumference of 35 or
immobilize spermatozoa. In addition, above in women,
nutrition, body weight, and exercise may
be responsible.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

Actions that increase scrotal heat, such as ENDOMETRIOSIS

working at desk jobs or driving a great deal
everyday may produce lower sperm counts Endometriosis refers to the implantation of
compared with men whose occupations uterine endometrium, or nodules, that have
allow them to be ambulatory at least part spread from the interior of the uterus to
of each day. locations outside the uterus. The most
common sites of endometrium spread
TUBAL TRANSPORT PROBLEMS. include Douglas’s cul-de-sac, the ovaries,
the uterine ligaments, and the outer
Difficulty with tubal transport usually surface of the uterus and bowel.
occurs because scarring has developed in the abnormal growth of extrauterine
the fallopian tubes. endometrial cells, often in the cul-de- sac
This is typically caused by chronic of the peritoneal cavity or on the uterine
salphingitis (chronic PID). ligaments or ovaries. This abnormal tissue
It can result from a ruptures appendix or results from excessive endometrial
from abdominal surgery involving infection production and a reflux of blood and tissue
that spread to the fallopian tubes and left through the fallopian tubes during a
adhesion formation in the tubes. Tubal menstrual flow.
transport is the chief problem if a woman The occurrence of endometriosis may
had a tubal ligation in years past but now indicate that the endometrial tissue has
wants to become pregnant. different or more friable qualities than
usual (perhaps because of a luteal phase
defect) and therefore is a type of
PELVIC INFLAMMATORY DISEASE (PID). endometrium that does not support
embryo implantation as well as usual.
This is infection of the pelvic organs: the Symptoms of endometriosis can begin in
uterus, fallopian tubes, ovaries, and their adolescence. The condition can be treated
supporting structures. A sexually both medically and surgically.
transmitted disease is usually the initial
source of the infection. In some women,
infection can spread even further than CERVICAL PROBLEMS
reproductive organs or involve the pelvis,
callusing pelvic peritonitis. At the time of ovulation, the cervical mucus
Many organisms can cause PID, but is thin and watery and can be easily
chlamydia and gonorrhea are among those penetrated by spermatozoa for a period of
most frequently seen. About 12% of those 12 to 72 hours. If coitus is not
who acquire PID are left subfertile. There is synchronized with this time period, the
apparently a higher incidence of PID cervical mucus may be too thick to allow
among women who use IUDs although this spermatozoa to penetrate the cervix.
may not bear out in practice. Infection or inflammation of the cervix
(erosion) is another reason that cervical
mucus can thicken so much that
UTERINE PROBLEMS spermatozoa cannot penetrate it easily or
survive in it.
Tumors such as fibromas (leiomyomas) A stenotoc cervical os or obstruction of the
may be a rare cause of subfertility if they os by a polyp may further compromise
block the entrance of the fallopian tubes sperm penetration.
into the uterus or limit the space available A woman who has undergone dilatation
on the uterine wall for effective and curettage (D&C) procedures several
implantation. times or cervical conization (cervical
A congenitally deformed uterine cavity surgery) should be evaluated in light of the
may also limit implantation sites, but this is possibility that scar tissue and tightening
also rare. of the cervical os has occurred.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality
Although some health care plans or
VAGINAL PROBLEMS
specific settings set limits on the age range
in which fertility testing can be scheduled
Infection of the vagina can cause the pH of
(e.g., not before age 18 years and not after
the vaginal secretions to become acidotic,
age 45 years), other settings do not
limiting or destroying the motility of
establish such limits, allowing couples of
spermatozoa.
any age to benefit from assessment.
Some women appear to have sperm-
Referral is recommended sooner for older
immobilizing or sperm- agglutinating
women because of possible age limitations
antibodies in their plasma that act to
associated with adoption, assisted
destroy sperm cells in the vagina or cervix.
reproductive strategies such as in vitro
fertilization (IVF), and embryo transfer,
UNEXPLAINED SUBFERTILITY
common alternatives to natural
childbearing.
In a small proportion of couples, no known
It would be doubly unfortunate if a couple
cause for subfertility can be discovered.
delayed fertility testing so long that they
It is obviously discouraging for couples to
not only learned they could not conceive
complete a fertility evaluation and be told
but also were “too old” to be prospective
that their inability to conceive cannot be
parents by an adoption agency or assisted
explained.
reproductive setting. If the couple is
Offer support to help the couple find
extremely apprehensive or know of a
alternative solutions, such as continuing to
specific problem, studies should never be
try to conceive, using an assisted
delayed, regardless of the couple’s age.
reproductive technique, choosing to adopt,
or agreeing to a child-free life.
As a rule, if a woman is younger than 35
years of age, it is usually suggested that
she have an evaluation after 1 year of FERTILITY ASSESSMENT
subfertility; if older than 35 years, after 6
As a rule, if a woman is younger than 35
months of subfertility. Basic fertility
years of age, it is usually suggested that
assessment begins with a health history
she have an evaluation after 1 year of
and physical examination of both sexual
subfertility; if older than 35 years, after 6
partners.
months of subfertility. Basic fertility
assessment begins with a health history
and physical examination of both sexual
partners.
DIAGNOSTIC EXAMINATIONS
HEALTH HISTORY
Not all couples who desire fertility testing
want to have children immediately. Some
Nurses often assume the responsibility for
just want to know for their own peace of
initial history taking with a subfertile
mind that they are fertile. Others want to
couple. The minimum history for the man
know that they are indeed subfertile, so
should include:
that they can discontinue contraceptive
General health
measures (although they need to be
Nutrition
cautioned to maintain safer sex practices).
Alcohol, drug, tobacco use
The age of the couple and the degree of
Congenital health problems such as
apprehension they feel about possible
hypospadias or cryptorchidism
subfertility make a difference in
Illness such as mumps orchitis, UTI, or STIs
determining when they should be referred
Radiation to his testes because of
for fertility evaluation.
childhood cancer or another cause

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

Operations such as surgical repair of a Any difficulties experienced, such as

hernia, which could have resulted in a dysmenorrhea or premenstrual
blood compromise to the testes dysphoric disorder (PDD)
Current illnesses, particularly endocrine History of contraceptive use
illnesses or low-grade infections History of any previous pregnancies or
Past and current occupation and work abortions
habits
Sexual practices such as frequency of
coitus and masturbation, failure to achieve A frank discussion centered on resolving
ejaculation, premature ejaculation, coital the couple’s fears and clearing up any
positions used, and use of lubricants long-standing confusion or misinformation
Past contraceptive measures, and will help to set a positive tone for future
existence of any children produced from a interactions, establish a feeling of trust
previous relationship with health care personnel, and increase
Any complementary alternative therapy self-esteem.
such as herbal additives the couple is using Obtaining a sexual history is often difficult
because cultural taboos can make couples
feel uncomfortable discussing this part of
FOR A THOROUGH WOMEN’S HEALTH their life.
HISTORY, ASK ABOUT: Simple factors, such as how often couples
engage in sexual relations, for example, are
Current or past reproductive tract influenced by culture and religion.
problems, such as infections Being aware of cultural differences this
Overall health, emphasizing endocrine way can influence how a couple reacts to a
problems such as galactorrhea (breast diagnosis of subfertility and help you
nipple secretions) or symptoms of appreciate the meaning of this diagnosis to
thyroid dysfunction an individual couple.
Abdominal or pelvic operations that
could have compromised blood flow to
pelvic organs PHYSICAL ASSESSMENT
Past history of a childhood cancer
treated with radiation that night have After a thorough history, both men and
reduced ovarian function women need a complete physical
The use of douches or intravaginal examination.
medications or sprays that could For the man, important aspects of this re
interfere with vaginal pH detection of the presence of secondary
Exposure to occupational hazards such sexual characteristics and genital
as x-rays or toxic substances abnormalities, such as the absence of a vas
Nutrition including an adequate source deferens or the presence of undescended
of folic acid and avoidance of trans-fats testes or a varicocele (enlargement of a
If she can detect ovulation through testicular vein).
such symptoms as breast tenderness, The presence of a hydrocele is rarely
midcycle “wetness”, or lower abdominal associated with subfertility but should be
pain (mittelschmerz) documented if present.
For a woman, a thorough physical
assessment including breast and thyroid
examination is necessary to rule out
MENSTRUAL HISTORY WHICH INCLUDES: current illness.
Of particular importance are secondary sex
Age of menarche characteristics which indicate maturity and
Length, regularity, and frequency of good pituitary function.
menstrual periods A complete pelvic examination including a
Amount of flow Pap test is needed to rule out anatomic
disorders and infection

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

FERTILITY TESTING SPERM PENETRATION ASSAY AND

ANTISPERM ANTIBODY TESTING
Basic fertility testing involves only three
tests: semen analysis in the male and This may be scheduled to determine
ovulation monitoring and tubal patency whether a man’s sperm, once they reach an
assessment in female. ovum, can penetrate it effectively.
Nurses play key roles in preparing couples With the use of an assisted reproductive
for these tests, helping them schedule the technique such as IVF, poorly motile sperm
studies appropriately, and supporting them or those with poor penetration can be
while they wait for results. injected directly into a woman’s ovum
Additional testing for men, if warranted, under laboratory conditions
can include urinalysis, a complete blood (intracytoplasmic sperm injection),
count; blood typing, including RH factor; a bypassing the need for sperm to be fully
serologic test for syphilis, HIV, ESR, motile.
protein-bound iodine, cholesterol level, and
gonadotropin and testosterone levels.
For women, advanced testing may include OVULATION MONITORING
a rubella titer, a serologic test for syphilis,
and an HIV evaluation. Thyroid uptake This is the least costly way to determine a
determination and TSH level may be woman’s ovulation pattern. A woman must
ordered. record her basal body temperature (BBT)
If a woman has a history of menstrual for at least 4 months
irregularities, FSH, estrogen, LH, and A woman takes her temperature each
progesterone levels may be determined. If morning, before getting out of bed or
with galactorrhea, a serum prolactin level engaging in any activity, eating, or
will be obtained. A pelvic ultrasound may drinking, using a special BBT or tympanic
be performed to rule out ovarian, tubal, or thermometer.
uterine structural disorders. She plots this daily temperature on a
monthly graph, noticing conditions that
might affect her temperature (colds, other
infections, sleeplessness).
SEMEN ANALYSIS At the time of ovulation, the basal
temperature can be seen to dip slightly
For a semen analysis, after 2 to 4 days of (about 0.5 deg F); it then rises to a level
sexual abstinence, the man ejaculates by until 3 or 4 days before the next menstrual
masturbation into a clean, dry specimen flow. This increase in BBT marks the time
jar. The number of sperm in the specimen of ovulation, because it occurs immediately
are counted and then examined under a after ovulation.
microscope within 1 hour.
An average ejaculation should produce 2.5
to 5 ml of semen and should contain a OVULATION DETERMINATION BY TEST
minimum of 20 million spermatozoa per ml STRIP
of fluid (the average of normal sperm
count is 50 to 200 million per milliliter).
The analysis may need to be repeated after There are various brands of commercial
2 or 3 months, because spermatogenesis is kits available to assess the upsurge of LH
an ongoing process, and 30 to 90 days is that occurs just before ovulation and can
needed for new sperm to reach maturity. be used in place of BBT monitoring.
A woman dips a test strip into a
midmorning urine specimen and then
compares it with the kit instructions for a
color change.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

Another type of testing kit (Fertell) ADVANCED SURGICAL PROCEDURES

contains both materials to test FSH the
third day of a woman’s menstrual cycle ( an UTERINE ENDOMETRIAL BIOPSY
abnormally high level is an indicator that
her ovaries are not responding well to This may be used to reveal an endometrial
ovulation) and a sperm motility test for the problem such as luteal phase defect.
male. Endometrial biopsies are being performed
The kits are expensive but can be helpful to less commonly than previously, having
a couple as a first step in fertility testing. been replaced with serum progesterone
level evaluation that also suggest that
ovulation occurred.
TUBAL PATENCY Endometrial biopsies are done 2 or 3 days
before an expected menstrual flow (day 25
or 26 of a typical 28-day menstrual cycle).
SONOHYSTEROGRAPHY. After a paracervical block, a thin probe and
biopsy forceps are introduced through the
This is an ultrasound technique designed cervix.
for inspecting the uterus. The uterus is A woman may experience mild to moderate
filled with sterile saline, introduced through discomfort from the maneuvering of the
a narrow catheter inserted into the uterine instruments. There may be a moment of
cervix. sharp pain as the biopsy specimen is taken
A transvaginal ultrasound transducer is from the anterior or posterior uterine wall.
then inserted into the vagina to inspect the
uterus for abnormalities such as septal POSSIBLE COMPLICATIONS INCLUDE
deviation or presence of a myoma. pain
This is a minimally invasive technique and excessive bleeding
can be done anytime during the menstrual infection
cycle. and uterine perforation.

This procedure is contraindicated if

HYSTEROSALPHINGOGRAPHY. pregnancy is suspected or if an infection
such as acute PID or cervicitis is present.
This is a radiologic examination of the
fallopian tubes using a radiopaque medium
and is the second frequently used HYSTEROSCOPY
technique.
The procedure is scheduled immediately
after a menstrual flow to avoid reflux of This is a visual inspection of the uterus
menstrual debris up the rubes and through the insertion of a hysteroscope, a
unintentional irradiation of a growing thin hollow tube, through the vagina,
zygote. cervix, and into the uterus.
It is contraindicated if infection of the This is helpful to further evaluate uterine
vagina, cervix, or uterus is present. Iodine- adhesions or other abnormalities that were
based radiopaque material is introduced discovered on hysterosalpingogram.
into the cervix under pressure.
The radiopaque material outlines the
uterus and both tubes, provided that the LAPAROSCOPY
tubes are patent
This is the introduction of a thin, hollow,
lighted tube through a small incision in the
abdomen, just under the umbilicus, to
examine the position and state of the
fallopian tubes and ovaries.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

This is rarely done unless the results of The administration of corticosteroids to a

uterosalphingography are abnormal. It is woman may have some effect in
scheduled during the follicular phase of a decreasing sperm immobilization because
menstrual period and is done under it reduces her immune response and
general anesthesia because of the pain antibody production.
caused by extensive maneuvering.
Carbon dioxide is introduced into the REDUCING THE PRESENCE OF INFECTION.
abdomen to move the abdominal wall
outward and offer better visualization. If a vaginal infection is present, the
During the procedure, dye can be injected infection will be treated according to the
into the uterus through a polyethylene causative organism based on the culture
cannula placed in the cervix to assess tubal reports. Vaginal infections such as
patency. trichomoniasis and moniliasis tend to
Tubes are patent if the dye appears in the occur, requiring close supervision and
abdominal cavity. follow up.
A scope may be passed directly into a
fallopian tube to reveal information about HORMONE THERAPY.
the presence and condition of the fimbria
and endometrium lining the tube. If the problem appears to be a disturbance
of ovulation, administration of GnRH is a
possibility.
Therapy with clomiphene citrate may also
SUBFERTILITY MANAGEMENT be used to stimulate ovulation.
In other women, ovarian follicular growth
CORRECTION OF THE UNDERLYING can be stimulated by the administration of
PROBLEM human menopausal gonadotropins,
combinations of FSH and LH derived from
INCREASING SPERM COUNT AND MOTILITY. postmenopausal urine in conjunction with
administration of hCG to produce
If sperm are not motile because the vas ovulation.
deferens is obstructed, the obstruction is If increased prolactin levels are identified,
most likely to be extensive and difficult to bromocriptine (Parlodel) is added to the
relieve by surgery. medication regimen to reduce prolactin
If sperm are present but the total count is levels and allow for the rise of
low, a man may be advised to abstain from gonadotropins.
coitus for 7 to 10 days at a time to increase
the count.
Ligation of a varicocele (if present) and SURGERY
changes in lifestyle may be helpful to
reduce scrotal heat and increase the sperm Fallopian tubes that have been ligated can
count. be reopened surgically but the success of
Sperm can be extracted by syringe from a the operation is not greater than 70% or
point proximal to vas deferens blockage 80%.
and used for intrauterine insemination. Also, the irregular line left by the surgery
If the problem appears to be that sperm may result in an ectopic pregnancy if a
are immobilized by vaginal secretions fertilized ovum is stopped at the irregular
because of an immunologic factor, the point.
response can be reduced by abstinence or If a myoma is interfering with fertility, a
condom use for about 6 months. myomectomy, or surgical removal of the
However, to avoid this prolonged time tumor, can be scheduled. For problems of
interval, washing of the sperm and abnormal uterine formation, such as
intrauterine insemination may be septate uterus, surgery is also available.
preferred.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

ASSISTED REPRODUCTIVE TECHNIQUE Sperm from sperm banks can be selected

according to desired physical or mental
THERAPEUTIC INSEMINATION. characteristics.

This is the instillation of sperm into the

female reproductive tract to aid
conception. The sperm is instilled into the
cervix (intracervical insemination) or
directly into the uterus (intrauterine
insemination).
Either the husband’s sperm (therapeutic
insemination by husband) or donor sperm
(therapeutic insemination by donor or
therapeutic donor insemination) can be
used.
Therapeutic insemination is used if the
man has an inadequate sperm count or a
woman has a vaginal or cervical factor that
interferes with sperm motility.
Donor insemination can be used if the man IN VITRO FERTILIZATION.
has a known genetic disorder that he does
not want transmitted to children or if a In IVF, one or more mature oocytes are
woman has no male partner. removed from a woman’s ovary by
Today, sperm can be cryopreserved laparoscopy and fertilized by exposure to
(frozen) in a sperm bank before radiation or sperm under laboratory conditions outside
chemotherapy and then used for a woman’s body.
insemination afterward. One disadvantage About 40 hours after fertilization, the
of using frozen sperm is that it tends to laboratory-grown fertilized ova are inserted
have slower motility than unfrozen into a woman’s uterus, where ideally one or
specimens. An advantage of cryopreserved more of them will implant and grow.
sperm is that it can be used even after It is most often used for couples who have
years of storage. not been able to conceive because a
woman has blocked or damaged fallopian
To prepare for therapeutic insemination, a tubes. It is also used when the man has
woman must record her: oligospermia or a very low sperm count.
BBT IVF may be helpful to couples when an
assess her cervical mucus absence of cervical mucus prevents sperm
or use an ovulation predictor kit to from traveling to or entering the cervix, or
predict her likely day of ovulation. anti-sperm antibodies cause
immobilization of sperm. In addition,
On the day after ovulation, the selected couples with unexplained subfertility of
sperm are instilled into her cervix using a long duration may be helped by IVF.
device similar to a cervical cap or
diaphragm, or they are injected directly
into the uterus using a flexible catheter.
If therapeutic donor insemination is
selected, the donors are volunteers who
have no history of disease and no family
history of possible inheritable disorders.
The blood type, or at least the Rh factor,
can be matched with the women to prevent
incompatibility.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

GAMETE INTRAFALLOPIAN TRANSFER SURROGATE EMBRYO TRANSFER

In GIFT procedures, ova are obtained from

ovaries exactly as in IVF. This is an assisted reproductive technique
Both ova and sperm are instilled within a for a woman who does not ovulate. The
matter of hours, using a laparoscopic process involves use of an oocyte that has
technique, into the open end of a patent been donated by a friend or relative or
fallopian tube. provided by an anonymous donor.
Fertilization then occurs in the tube, and The menstrual cycles of the donor and
the zygote moves to the uterus for recipient are synchronized by
implantation. administration of gonadotropic hormones.
This procedure has a pregnancy rate equal At the time of ovulation, the donor’s ovum
to that of IVF. The procedure is is removed by a transvaginal, ultrasound-
contraindicated if a woman’s fallopian guided procedure.
tubes are blocked, because this could lead The oocyte is then fertilized in the
to ectopic pregnancy. laboratory by the recipient woman’s male
partner’s sperm (or donor sperm) and
placed in the recipient woman’s uterus by
embryonic transfer. Once pregnancy
occurs, it progresses the same as an
unassisted pregnancy.

ALTERNATIVES TO CHILDBIRTH

SURROGATE MOTHERS

A surrogate mother is a woman who

agreed to carry a pregnancy to term for a
ZYGOTE INTRAFALLOPIAN TRANSFER sub fertile couple. In other instances, the
ova and sperm both may be donated by
the sub fertile couple, or donor ova and
ZIFT involves oocyte retrieval by sperm may be used.
transvaginal, ultrasound-guided aspiration, Surrogate mothers are often friends or
followed by culture and insemination of the family members who assume the role out
oocytes in the laboratory. Within 24 hours, of friendship or compassion, or they can be
the fertilized eggs are transferred by referred to the couple through an agency
laparoscopic technique into the end of a or attorney and receive monetary
waiting fallopian tube. reimbursement for their expenses.
ZIFT differs from GIFT in that fertilization Several ethical and legal problems may
has occurred before the growing structure arise in surrogacy. For these reasons, the
is reintroduced. couple and the surrogate mother must be
certain they have given adequate thought
to the process, and to what will be the
outcome should these problems occur,
before they attempt surrogate mothering

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

CHILD-FREE LIVING ADOPTION

Adoption, once a ready alternative for

Child-free living is an alternative lifestyle subfertile couples, is still a viable
available to both fertile and subfertile alternative, although today there are fewer
couples. For many subfertile couples who children available for adoption from official
have been through the rigors and agencies than for merly.
frustrations of subfertility testing and Urge couples to consider foreign-born or
unsuccessful treatment regimens, child- physically or cognitively challenged
free living may emerge as the option they children or children of other races to make
finally wish to pursue. their family feel complete.
A couple amid fertility testing may begin to
reexamine their motives for pursuing METHODS OF ADOPTION:
pregnancy and may decide that pregnancy
and parenting are not worth the emotional AGENCY ADOPTION
or financial cost of future treatments.
They may decide that the additional stress In traditional agency adoption, a couple
of going through an adoption is not for usually contacts an agency by first
them, or they may simply decide that attending an informational meeting.
children are not necessary for them to If the couple decides to apply to the
complete their family unit. For these agency, they are then put on a waiting list
couples, child-free living is a positive for processing that will include extensive
choice. interviewing and a home visit by an agency
social worker to determine whether the
couple can be relied on to provide a safe
RECTOCELE/ CYSTOCELE and nurturing environment for an adopted
child.
The uterus is suspended in the pelvic cavity Once approved by the agency, the couple
by several ligaments that also help support is placed on a second waiting list until a
the bladder and is further supported by a child is available.
combination of fascia and muscle. Because Depending on the area of the country and
it is not fixed, the uterus is free to enlarge the couple’s particular requests, this
without discomfort during pregnancy. If its second waiting period may extend from a
ligaments become overstretched during few months to 5 or 6 years.
pregnancy, they may not support the
bladder well afterward, and the bladder
can then herniate into the anterior vagina
(a cystocele). If the rectum pouches into INTERNATIONAL ADOPTION.
the vaginal wall, a rectocele develop
If the walls of the vagina are weakened, a International adoption can often provide a
cystocele (outpouching of the bladder into baby in less time than a traditional agency
the vaginal wall) or a rectocele adoption but may create unanswered
(outpouching of the rectum into the questions about prenatal health care or the
vaginal wall) may occur. birth parent’s background.
These problems tend to develop most In addition, countries that are willing to
frequently in women with a high parity and permit abandoned or orphaned children to
after a forceps birth. be adopted internationally are often poor
Surgery to repair such conditions may be or war torn, meaning the child’s health or
necessary. If stress incontinence development may have suffered. War
(involuntary voiding on exertion) occurs, conditions may allow children to be
Kegel exercises to strengthen perineal released from the country one day but not
muscles may be helpful. the next.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

This means that couples who are waiting Ethnicity refers to the cultural group
for an international adoption must be into which a person was born, although
ready at a moment’s notice to travel to the the term is sometimes used in a
foreign country or to a neutral location to narrower context to mean only race
pick up their child or to give up the Race refers to a category of people who
adoption because political reforms have share a socially recognized physical
stopped the release of children. characteristic.
A home visit from a local agency and a
significant amount of paperwork and Assessing sociocultural status, ethnicity,
communication with the international and cultural beliefs of families and clients
agency are usually required before a family can reveal why people take the type of
can be approved for this type of adoption. preventive health measures that they do or
Typically, the adoption is final before the seek a particular type of care for illness,
child enters the country or shortly because the way people react to health
afterward. care is a cultural value.
Cultural values differ from nation to nation
because they often arise from
environmental conditions (in a country
PRIVATE ADOPTION where water is scarce, daily bathing is not
valued; in a country where meat is scarce,
For families who have exhausted other ethnic recipes use little meat).
options or who cannot wait for the The usual values of a group are termed
traditional agency adoption process, mores or norms. Expecting women to come
private adoption is another alternative. for prenatal care and parents to bring
With private adoption, the adopting children for immunizations are examples of
parents usually agree to pay a certain norms in the United States, but these are
amount of money to a birth mother, part of not beliefs worldwide (Niederhauser &
which presumably goes toward the birth Markowitz, 2007).
mother’s prenatal and medical expenses. Cultural values are formed early in life and
Sometimes, strict anonymity is maintained strongly influence the way people plan for
between the two parties; in other childbearing and childrearing, as well as
instances, the adopting couple and birth the way they respond to health and illness
mother come to know each other well. (Whitley & Kirmayer, 2008).
Some pregnant women prefer to place In a culture in which men are the authority
their child for adoption directly with a figures,
couple this way rather than through an for example, it might be the father
agency, so they can approve of the couple rather than the mother who expects to
and maintain contact with the child answer questions about an ill child at a
afterward. health care visit. If you are from a
The adopting parents might even attend culture in which women usually provide
the child’s birth if the birth mother wishes. all childcare, and were not aware of this
family’s norms, you might direct your
questions to the wrong parent during a
CULTURE, VALUES AND PRACTICES IN health interview. The way people
RELATION TO DIFFICULT CHILDBEARING AND respond to pain is heavily culturally
CHILDREARING influenced.

Culture is a view of the world and a set If you are from a culture in which women
of traditions that a specific social group usually provide all childcare, and were not
uses and transmits to the next aware of this family’s norms, you might
generation. direct your questions to the wrong parent
Cultural values are preferred ways of during a health interview.
acting based on those traditions.

Rein Ramos
ACADEMICIAN
 Week 5:
Male and Female Clients with General and Specific
Problems in Reproduction and Sexuality

The way people respond to pain is heavily

culturally influenced. If you believe that
stoic behavior is the “proper” response to
pain, and were unaware that there are
cultural differences, you might be
impatient with a woman who has been
raised to believe that expressing
discomfort during childbirth is “proper.”

REMINDER

All contents from this reviewer is based

on the given ppts of the professor and
modules from our canvas. Thank you
and Good luck future RN's

'Do not be anxious about anything, but in every situation, by prayer and petition, with
thanksgiving, present your requests to God. And the peace of God, which transcends
all understanding, will guard your hearts and your minds in Christ Jesus.'
-Philippians 4 : 6-7