Professional Documents
Culture Documents
Signs and symptoms of Hypovolemic Shock Signs and symptoms of Hypovolemic Shock
1. increased pulse rate 1. increased pulse rate
2. decreased blood pressure 2. decreased blood pressure
33. increased respiratory rate . increased respiratory rate
4. cold, clammy skin 4. cold, clammy skin
5. decreased urine output 5. decreased urine output
6. dizziness or decreased level of consciousness 6. dizziness or decreased level of consciousness
7. decreased central venous pressure 7. decreased central venous pressure
The Process oI The Process oI SHCK SHCK due to blood loss (hypovolemia): due to blood loss (hypovolemia):
B SS B SS
ecreased intravascular volume ecreased intravascular volume
ecreased venous return, decreased cardiac output, and lowered blood ecreased venous return, decreased cardiac output, and lowered blood
pressure pressure
Body compensating by increasing heart rate to circulate the decreased Body compensating by increasing heart rate to circulate the decreased
volume Iaster; volume Iaster;
Vasoconstriction oI peripheral vessels Vasoconstriction oI peripheral vessels
Increased respiratory rate and a Ieeling oI apprehension at body changes Increased respiratory rate and a Ieeling oI apprehension at body changes
also occur also occur
Cold, clammy skin, decreased uterine perIusion. In the Iace oI Cold, clammy skin, decreased uterine perIusion. In the Iace oI
continued blood loss, although the body shiIts Irom interstitial continued blood loss, although the body shiIts Irom interstitial
spaces into intravascular spaces, blood pressure will continue spaces into intravascular spaces, blood pressure will continue
to Iall to Iall
Reduced renal, uterine and brain perIusion Reduced renal, uterine and brain perIusion
Lethargy, coma, decreased renal output Lethargy, coma, decreased renal output
. Infection . Infection
- - the possibility oI inIection is minimal when pregnancy loss the possibility oI inIection is minimal when pregnancy loss
occurs a short period, bleeding is selI limiting and instrumentation is limited occurs a short period, bleeding is selI limiting and instrumentation is limited
1. educate the woman about the danger signs oI inIection, such as Iever, 1. educate the woman about the danger signs oI inIection, such as Iever,
abdominal pain or tenderness and a Ioul smelling discharge abdominal pain or tenderness and a Ioul smelling discharge
2. organism responsible Ior inIection aIter miscarriage is usually 2. organism responsible Ior inIection aIter miscarriage is usually
Escherichia Coli (E Coli) Escherichia Coli (E Coli)
3. caution the woman to wipe the perineal area Irom Iront to back aIter 3. caution the woman to wipe the perineal area Irom Iront to back aIter
voiding and particularly aIter deIecation to prevent the spread oI bacteria Irom voiding and particularly aIter deIecation to prevent the spread oI bacteria Irom
rectal area rectal area
4. caution the woman not to use tampons to control vaginal discharge 4. caution the woman not to use tampons to control vaginal discharge
because stasis oI any blood increases the risk oI inIection because stasis oI any blood increases the risk oI inIection
. Isoimmunization . Isoimmunization
- - happens when the mother` s blood is Rh negative, while happens when the mother` s blood is Rh negative, while
the Ietus is Rh positive. the Ietus is Rh positive.
- - aIter spontaneous abortion or & C. some Rh positive aIter spontaneous abortion or & C. some Rh positive
Ietal blood may enter the maternal circulation and mother will Ietal blood may enter the maternal circulation and mother will
develops antibodies against Rh positive Ietus blood. develops antibodies against Rh positive Ietus blood.
- - during the succeeding pregnancies when the Ietus is Rh during the succeeding pregnancies when the Ietus is Rh
positive again, those antibodies would attempt to destroy the Ietus positive again, those antibodies would attempt to destroy the Ietus
RBC RBC
- - so aIter miscarriage, because the blood oI the Ietus is not so aIter miscarriage, because the blood oI the Ietus is not
known, all women with Rh negative blood should receive known, all women with Rh negative blood should receive Rhogam Rhogam
(Rh Immune lobulin) (Rh Immune lobulin) to prevent the build up oI Rh antibodies to prevent the build up oI Rh antibodies
. Powerlessness . Powerlessness
- - sadness and grieI over the loss or a sadness and grieI over the loss or a
Ieeling that she has lost control oI her liIe is to be Ieeling that she has lost control oI her liIe is to be
expected expected
- - emotional support emotional support
Procedures &sed in Pregnancy %ermination Procedures &sed in Pregnancy %ermination
. Vacuum Curettage . Vacuum Curettage
- - aka. Vacuum aspiration aka. Vacuum aspiration
- - cervical dilation Iollowed by controlled suction through a cervical dilation Iollowed by controlled suction through a
plastic cannula to remove all products oI conception plastic cannula to remove all products oI conception
- - used Ior Iirst trimester abortions, also used to remove used Ior Iirst trimester abortions, also used to remove
remaining products oI conception aIter spontaneous remaining products oI conception aIter spontaneous
abortion abortion
- - local anesthesia oI the cervix is needed local anesthesia oI the cervix is needed
B. ilatation and Curettage B. ilatation and Curettage - - aka. ilatation and aka. ilatation and
Evacuation Evacuation
- - dilation oI cervix Iollowed by gentle scraping oI the dilation oI cervix Iollowed by gentle scraping oI the
uterine walls to remove products oI conception uterine walls to remove products oI conception
- - Used Ior Iirst Used Ior Iirst- -trimester abortions and to remove all trimester abortions and to remove all
products oI conception aIter spontaneous abortions products oI conception aIter spontaneous abortions
- - Greater risk oI cervical or uterine trauma and excessive Greater risk oI cervical or uterine trauma and excessive
blood loss blood loss
- - local anesthesia or general anesthesia is needed local anesthesia or general anesthesia is needed
Nursing Care of Clients with bortion Nursing Care of Clients with bortion
1. ocument the amount and character oI bleeding and 1. ocument the amount and character oI bleeding and
saves tissues or clots Ior evaluation. saves tissues or clots Ior evaluation.
2. Check the bleeding and vitals signs to identiIy 2. Check the bleeding and vitals signs to identiIy
hypovolemic shock resulting Irom blood loss hypovolemic shock resulting Irom blood loss
3. AIter vacuum aspiration or curettage, the amount oI 3. AIter vacuum aspiration or curettage, the amount oI
vaginal bleeding is observed vaginal bleeding is observed
4. Provide home health teaching aIter curettage such 4. Provide home health teaching aIter curettage such
as: as:
a. report increase bleeding a. report increase bleeding
b. take temperature every 8 hours Ior 3 days b. take temperature every 8 hours Ior 3 days
c. take an oral iron supplement iI prescribed c. take an oral iron supplement iI prescribed
d. resume sexual activity as recommended by the d. resume sexual activity as recommended by the
health care provider health care provider
e. return to the health care provider at the e. return to the health care provider at the
recommended time Ior a check up. recommended time Ior a check up.
5. Check laboratory test such as hemoglobin 5. Check laboratory test such as hemoglobin
level and hematocrit level and hematocrit
6. Promote expression oI grieI by providing 6. Promote expression oI grieI by providing
privacy, allowing support persons to help in privacy, allowing support persons to help in
pregnancy loss pregnancy loss
B. B. EC1OPIC PRECAAACY EC1OPIC PRECAAACY
- - is one in which implantation occurs outside the uterine is one in which implantation occurs outside the uterine
cavity. cavity.
- - the most common site (in approximately 95 oI such the most common site (in approximately 95 oI such
pregnancies) is in a Iallopian tube. OI these Iallopian tube pregnancies) is in a Iallopian tube. OI these Iallopian tube
sites, approximately 80 occur in the ampullar portion. sites, approximately 80 occur in the ampullar portion.
12 occur in the isthmus and 8 in interstitial 12 occur in the isthmus and 8 in interstitial
- - approximately 2 oI pregnancies are ectopic; ectopic approximately 2 oI pregnancies are ectopic; ectopic
pregnancy is the second most Irequent cause oI bleeding pregnancy is the second most Irequent cause oI bleeding
early in pregnancy early in pregnancy
Culdocentesis Culdocentesis
%ransvaginal &% %ransvaginal &%
aparoscopy aparoscopy
Management: Management:
1. once an ectopic pregnancy ruptures, it is an 1. once an ectopic pregnancy ruptures, it is an emergency emergency
situation situation and the woman`s conditions must be evaluated quickly and the woman`s conditions must be evaluated quickly
(monitor Ior the symptoms oI shock) (monitor Ior the symptoms oI shock)
2. therapy Ior a ruptured ectopic pregnancy is laparoscopy to 2. therapy Ior a ruptured ectopic pregnancy is laparoscopy to
ligate the bleeding vessels and to remove or repair the damaged ligate the bleeding vessels and to remove or repair the damaged
Iallopian tube Iallopian tube
3. women with Rh negative blood should receive Rh immune 3. women with Rh negative blood should receive Rh immune
globulin (Rhogam) aIter an ectopic pregnancy Ior globulin (Rhogam) aIter an ectopic pregnancy Ior
isoimmunization protection in Iuture childbearing isoimmunization protection in Iuture childbearing
4. treated medically by the oral administration oI 4. treated medically by the oral administration oI
Methotrexate, a Iolic acid antagonist chemotherapeutic Methotrexate, a Iolic acid antagonist chemotherapeutic
agent, attacks and destroys Iast growing cells. Because agent, attacks and destroys Iast growing cells. Because
trophoblast and zygote growth is rapid, the drug is trophoblast and zygote growth is rapid, the drug is
drawn to the site oI ectopic pregnancy drawn to the site oI ectopic pregnancy
5. Hysterosalphingogram perIormed aIter chemotherapy 5. Hysterosalphingogram perIormed aIter chemotherapy
to assess the patency oI the tube to assess the patency oI the tube
6. provide emotional support 6. provide emotional support
CNI%INS SSCI%E WI%H CNI%INS SSCI%E WI%H
SECN SECN- - %RIMES%ER BEEIN %RIMES%ER BEEIN
A. A. CES1A1IOAAL 1ROPHOBLAS1IC DISEASE CES1A1IOAAL 1ROPHOBLAS1IC DISEASE
(HYDA1IDIFORM MOLE OR H (HYDA1IDIFORM MOLE OR H- - MOLE) MOLE)
- - is proliIeration and degeneration oI the trophoblastic is proliIeration and degeneration oI the trophoblastic
villi, which becomes Iilled with Iluid and appear as grape villi, which becomes Iilled with Iluid and appear as grape- -
sized vesicles sized vesicles
- - incidence is approximately 1 in every 2,000 incidence is approximately 1 in every 2,000
pregnancies pregnancies
Causes: Causes:
- - unknown unknown
Risk Factors: Risk Factors:
- - occurs most oIten in women who have a low occurs most oIten in women who have a low
protein intake protein intake
- - in young women (under age 18 years) in young women (under age 18 years)
- - in older women older than 35 years in older women older than 35 years
%ypes; %ypes;
- - there are two distinct types oI hydatidiIorm mole there are two distinct types oI hydatidiIorm mole
complete/partial complete/partial
1. Complete mole 1. Complete mole all trophoblastic villi swell and become all trophoblastic villi swell and become
cystic. cystic.
- - embryo dies early at only 1 to 2 mm in size with no Ietal embryo dies early at only 1 to 2 mm in size with no Ietal
blood present in the villi blood present in the villi
- - on chromosomal analysis, although the karyotype is a on chromosomal analysis, although the karyotype is a
normal 46XX or 46XY, this chromosome component was contributed normal 46XX or 46XY, this chromosome component was contributed
only by the Iather or an 'empty ovum was Iertilized and the only by the Iather or an 'empty ovum was Iertilized and the
chromosome material was duplicated chromosome material was duplicated
- - this type usually lead to choriocarcinoma this type usually lead to choriocarcinoma
2. Partial mole 2. Partial mole some oI the villi Iorm normally some oI the villi Iorm normally
- - although no embryo is present, Ietal blood may be although no embryo is present, Ietal blood may be
present in the villi present in the villi
- - has 69 chromosomes ( a triploid Iormation in which has 69 chromosomes ( a triploid Iormation in which
there are three chromosomes instead oI two Ior every pair, there are three chromosomes instead oI two Ior every pair,
one set supplied by an ovum that was Iertilized by two one set supplied by an ovum that was Iertilized by two
sperm or an ovum Iertilized by one sperm in which meiosis sperm or an ovum Iertilized by one sperm in which meiosis
or reduction division did not occur) or reduction division did not occur)
Signs and Symptoms: Signs and Symptoms:
1. uterus tends to expand than normally 1. uterus tends to expand than normally
2. no Fetal heart sounds are heard because there is no viable Ietus 2. no Fetal heart sounds are heard because there is no viable Ietus
3. hCG serum levels are abnormally high 3. hCG serum levels are abnormally high
4. severe nausea and vomiting 4. severe nausea and vomiting
5. symptoms oI hypertension oI pregnancy is present beIore week 20 5. symptoms oI hypertension oI pregnancy is present beIore week 20
oI pregnancy oI pregnancy
6. a sonogram/UTZ will show dense growth (typically a 'snowstorm 6. a sonogram/UTZ will show dense growth (typically a 'snowstorm
pattern) but no Ietal growth in the uterus pattern) but no Ietal growth in the uterus
7. vaginal spotting oI dark brown blood 7. vaginal spotting oI dark brown blood
8. discharge oI the clear Iluid Iilled vesicles 8. discharge oI the clear Iluid Iilled vesicles
Management: Management:
1. suction curettage to evacuate the mole 1. suction curettage to evacuate the mole
2. aIter extraction, women should have a baseline serum test Ior the 2. aIter extraction, women should have a baseline serum test Ior the
beta subunit oI hCG beta subunit oI hCG
3. educate on avoiding pregnancy Ior at least one year 3. educate on avoiding pregnancy Ior at least one year
4. hCG is analyzed every 2 4. hCG is analyzed every 2- -4 weeks Ior 6 4 weeks Ior 6- -12 months (gradually 12 months (gradually
declining hCG suggest no complications) declining hCG suggest no complications)
5. prophylactic course oI Methotrexate is the drug oI choice Ior 5. prophylactic course oI Methotrexate is the drug oI choice Ior
choriocarcinoma. This must be weigh careIully because it interIeres choriocarcinoma. This must be weigh careIully because it interIeres
with WBC Iormation which can lead to leucopenia with WBC Iormation which can lead to leucopenia
6. observe Ior bleeding and hypovolemic shock 6. observe Ior bleeding and hypovolemic shock
B. B. PREMA1URE CERJICAL DILA1A1IOA PREMA1URE CERJICAL DILA1A1IOA
- - previously termed as 'Incompetent cervix previously termed as 'Incompetent cervix
- - reIers to a cervix that dilates prematurely reIers to a cervix that dilates prematurely
and thereIore cannot hold a Ietus until term and thereIore cannot hold a Ietus until term
- - commonly occurs at approximately week commonly occurs at approximately week
20 oI pregnancy 20 oI pregnancy
Causes: Causes:
- - unknown unknown
Risk Iactors Risk Iactors
1. associated with increased maternal age, 1. associated with increased maternal age,
congenital structural deIects and trauma to the congenital structural deIects and trauma to the
cervix such as might occurred with biopsy or cervix such as might occurred with biopsy or
repeated & C repeated & C
Signs and Symptoms: Signs and Symptoms:
1. oIten the Iirst symptom is show (a pink 1. oIten the Iirst symptom is show (a pink- -stained stained
vaginal discharge) or increased pelvic pressure vaginal discharge) or increased pelvic pressure
Iollowed by rupture oI membranes and discharge oI Iollowed by rupture oI membranes and discharge oI
amniotic Iluid amniotic Iluid
2. painless cervical dilatation 2. painless cervical dilatation
3. uterine contractions Iollowed by birth oI Ietus 3. uterine contractions Iollowed by birth oI Ietus
Management: Management:
1. bed rest in trendelenburg position 1. bed rest in trendelenburg position
2. monitor FHT 2. monitor FHT
3. observe Ior the rupture oI BOW 3. observe Ior the rupture oI BOW
4. avoid coitus and limit activities 4. avoid coitus and limit activities
5. avoid vaginal douche 5. avoid vaginal douche
6. Surgical Operation termed as 'Cervical Cerlage is 6. Surgical Operation termed as 'Cervical Cerlage is
perIormed perIormed
- - as soon as sonogram conIirms that the Ietus oI a second as soon as sonogram conIirms that the Ietus oI a second
pregnancy is healthy, at approximately week 12 pregnancy is healthy, at approximately week 12- -14, pursing 14, pursing- -
string sutures are placed in the cervix by vaginal route under string sutures are placed in the cervix by vaginal route under
regional anesthesia regional anesthesia
- - types: types:
1. Mconald Procedure 1. Mconald Procedure nylon sutures are placed nylon sutures are placed
horizontally and vertically across the cervix and pulled tight horizontally and vertically across the cervix and pulled tight
to reduce the cervical canal to a Iew millimeters in diameter to reduce the cervical canal to a Iew millimeters in diameter
2. Shirodkar technique 2. Shirodkar technique sterile tape is threaded in a sterile tape is threaded in a
purse purse- -string manner under the sub mucosal layer oI the string manner under the sub mucosal layer oI the
cervix and sutured in place to achieve a closed cervix cervix and sutured in place to achieve a closed cervix
- - sutures may be placed trans sutures may be placed trans- -abdominally abdominally
CNI%INS SSCI%E WI%H CNI%INS SSCI%E WI%H
%HIR %HIR -- %RIMES%ER BEEIN %RIMES%ER BEEIN
A. A. PLACEA1A PREJIA PLACEA1A PREJIA
- - is low implantation oI the placenta is low implantation oI the placenta
- - it occurs in Iour degrees: it occurs in Iour degrees:
1. Low 1. Low- - lying placenta lying placenta implantation in the lower rather than in the upper implantation in the lower rather than in the upper
portion oI the uterus portion oI the uterus
2. Partial placenta previa 2. Partial placenta previa implantation that occludes a portion oI the implantation that occludes a portion oI the
cervical OS cervical OS
3. Marginal 3. Marginal placenta edge approaches the cervical OS. Lower border is placenta edge approaches the cervical OS. Lower border is
within 3 cm Irom internal cervical OS but does not cover the OS within 3 cm Irom internal cervical OS but does not cover the OS
4. Total placenta previa 4. Total placenta previa implantation that totally obstructs the cervical OS implantation that totally obstructs the cervical OS
- - incidence is approximately 5 per 1000 pregnancies incidence is approximately 5 per 1000 pregnancies
Risk Factors Risk Factors
- - increased parity increased parity
- - advanced maternal age advanced maternal age
- - past cesarean births past cesarean births
- - past uterine curettage past uterine curettage
- - multiple gestation multiple gestation
Complication: Complication:
1. postpartum hemorrhage 1. postpartum hemorrhage
2. hypovolemic shock 2. hypovolemic shock
3. preterm labor 3. preterm labor
4. Ietal distress 4. Ietal distress
Signs and symptoms; Signs and symptoms;
1. sudden onset oI 1. sudden onset oI painless bright red vaginal painless bright red vaginal
bleeding bleeding (latter halI oI pregnancy) (latter halI oI pregnancy)
2. bleeding may be proIuse or scanty 2. bleeding may be proIuse or scanty
Note: Note:
- - site oI bleeding: uterine deciduas (maternal site oI bleeding: uterine deciduas (maternal
blood) places the mother at risk Ior hemorrhage blood) places the mother at risk Ior hemorrhage
- - bleeding may not occur until the onset oI bleeding may not occur until the onset oI
cervical dilatation causing the placenta to loosen Irom the cervical dilatation causing the placenta to loosen Irom the
uterus uterus
Management; Management;
1. bleeding is an emergency. (Ietal oxygen may be compromised and 1. bleeding is an emergency. (Ietal oxygen may be compromised and
preterm birth may occur) preterm birth may occur)
2. assess the amount oI blood loss (duration, time oI bleeding began, 2. assess the amount oI blood loss (duration, time oI bleeding began,
accompanying pain, and color oI the blood) accompanying pain, and color oI the blood)
3. bed rest with oxygenation prescribed 3. bed rest with oxygenation prescribed
4. side 4. side- -lying or trendelenburg position (Ior 72 hours) lying or trendelenburg position (Ior 72 hours)
5. NO internal exams (IE) or rectal exams, may initiate massive hemorrhage 5. NO internal exams (IE) or rectal exams, may initiate massive hemorrhage
(iI necessary, must have double set up; OR/ R) (iI necessary, must have double set up; OR/ R)
6. keep IV line and have blood available (X 6. keep IV line and have blood available (X- -matched and typed) matched and typed)
7. Apt or Kleihauer 7. Apt or Kleihauer- - Betke test (test strip procedure to determine iI blood is Betke test (test strip procedure to determine iI blood is
Ietal or maternal in origin) Ietal or maternal in origin)
Causes: Causes:
- -unknown unknown
Risk Factors Risk Factors
- - high parity high parity
- - advanced maternal age advanced maternal age
- - short umbilical cord short umbilical cord
- - chronic hypertensive disease chronic hypertensive disease
- - PIH PIH
- - direct trauma (Irom VA) direct trauma (Irom VA)
- - cocaine or cigarette use (Vasoconctrction) cocaine or cigarette use (Vasoconctrction)
Complications: Complications:
1. Ietal distress (altered HR) 1. Ietal distress (altered HR)
2. Couvelaire uterus or Uteroplacental apoplexy 2. Couvelaire uterus or Uteroplacental apoplexy
3. disseminated intravascular coagulation (IC) 3. disseminated intravascular coagulation (IC)
Signs and symptoms: Signs and symptoms:
1. vaginal bleeding (may not reIlect the true amount oI blood 1. vaginal bleeding (may not reIlect the true amount oI blood
loss) loss)
2. abdominal and low back pain (dull or aching) 2. abdominal and low back pain (dull or aching)
3. sharp stabbing pain high in the Iundus 3. sharp stabbing pain high in the Iundus
4. uterine irritability (Irequent low intensity contractions) 4. uterine irritability (Irequent low intensity contractions)
5. high uterine resting tone 5. high uterine resting tone
6. uterine tenderness 6. uterine tenderness
Nursing Responsibilities beIore administration oI Tocolytic Nursing Responsibilities beIore administration oI Tocolytic
Therapy: Therapy:
1. assess baseline blood data i.e. hct, glucose, potassium, NaCl, 1. assess baseline blood data i.e. hct, glucose, potassium, NaCl,
ECG (tachycardia) ECG (tachycardia)
2. Uterine and Ietal monitoring (external Ietal monitors) 2. Uterine and Ietal monitoring (external Ietal monitors)
3. mix the drug with lactated Ringers solution to prevent 3. mix the drug with lactated Ringers solution to prevent
hyperglycemia (piggyback administration, so that it can be stop hyperglycemia (piggyback administration, so that it can be stop
immediately iI tachycardia occurs) immediately iI tachycardia occurs)
4. assess BP and pulse every 15 minutes and every 30 minutes until 4. assess BP and pulse every 15 minutes and every 30 minutes until
contractions stop contractions stop
5. reports PR~120 bpm, BP 90/60 chest pain, dyspnea, rales 5. reports PR~120 bpm, BP 90/60 chest pain, dyspnea, rales
PREM%&RE R&P%&RE F MEMBRNES PREM%&RE R&P%&RE F MEMBRNES
(PRM) (PRM)
- - rupture and loss oI amniotic Iluid that occurs beIore rupture and loss oI amniotic Iluid that occurs beIore
labor begins labor begins
- - occurs in 2 occurs in 2- -18 oI pregnancies 18 oI pregnancies
Cause: Cause:
- - unknown, but associated with inIection oI Ietal unknown, but associated with inIection oI Ietal
membranes (Chorioamnionitis) membranes (Chorioamnionitis)
- - nutritional deIiciency involving ascorbic acid nutritional deIiciency involving ascorbic acid
Complication: Complication:
1. Fetal inIections 1. Fetal inIections aIter the rupture oI BOW, the seal to aIter the rupture oI BOW, the seal to
the Ietus is lost the Ietus is lost
2. Cord Compression 2. Cord Compression pressure on the umbilical cord pressure on the umbilical cord
because oI the loss oI the amniotic Iluid, which can cut oII because oI the loss oI the amniotic Iluid, which can cut oII
the nutrient supply to the Ietus (Ietal distress) the nutrient supply to the Ietus (Ietal distress)
3. Cord prolapsed 3. Cord prolapsed the extension oI the umbilical cord into the extension oI the umbilical cord into
the vagina which can also interIere with Ietal blood the vagina which can also interIere with Ietal blood
circulation circulation
b. Ferning test b. Ferning test get the sample oI Iluid then place on the get the sample oI Iluid then place on the
slide and viewing it under the microscope slide and viewing it under the microscope
- - Ierning patterns means Ierning patterns means BOW BOW
Management: Management:
1. Strict Bed Rest 1. Strict Bed Rest
2. Observe, document and report maternal temperature above 38C, 2. Observe, document and report maternal temperature above 38C,
Ietal tachycardia Ietal tachycardia
3. Monitor Ior signs oI inIections (Iever, uterine tenderness) 3. Monitor Ior signs oI inIections (Iever, uterine tenderness)
4. Avoid sexual intercourse/Orgasm 4. Avoid sexual intercourse/Orgasm
5. avoid vaginal exams (risk oI inIection) 5. avoid vaginal exams (risk oI inIection)
6. avoid breast stimulation 6. avoid breast stimulation
7. record Ietal movements daily and report Iewer than 10 in a 12 7. record Ietal movements daily and report Iewer than 10 in a 12
hour period hour period
8. administer broad spectrum ATBC to reduce the risk oI inIection 8. administer broad spectrum ATBC to reduce the risk oI inIection
e.g. Penicillin/ e.g. Penicillin/Ampicillin Ampicillin
PRENNCY PRENNCY- - IN&CE HYPER%ENSIN (PIH) IN&CE HYPER%ENSIN (PIH)
- - originally called 'Toxemia oI Pregnancy originally called 'Toxemia oI Pregnancy
- - condition in which vasospasm occurs during condition in which vasospasm occurs during
pregnancy accompanied by hypertension, protenuria pregnancy accompanied by hypertension, protenuria
and edema and edema
- - onset: occurs aIter 20 onset: occurs aIter 20
th th
week oI pregnancy and week oI pregnancy and
may appear up to 48 hours (2 weeks) postpartum may appear up to 48 hours (2 weeks) postpartum
- - occurs 5 occurs 5- -10 pregnancies 10 pregnancies
Cause: Cause:
- - Unknown Unknown
Risk Factors: Risk Factors:
- - related to diIIerent associative Iactors related to diIIerent associative Iactors
1. Primipara 1. Primipara - - 20 years old and ~ 40 years old 20 years old and ~ 40 years old
2. Low socio 2. Low socio- -economic status (poor nutrition economic status (poor nutrition decrease decrease
CHON intake) CHON intake)
3. Women who have 5 or more pregnancies 3. Women who have 5 or more pregnancies
4. Multiple pregnancies 4. Multiple pregnancies
5. Hydramnios (pre 5. Hydramnios (pre- -exisiting exisiting) )
6. Underlying HPN/M 6. Underlying HPN/M
7. Poor calcium/Magnesium intake 7. Poor calcium/Magnesium intake
8. H 8. H- -mole mole
Pathophysiology: Pathophysiology:
Pregnancy Induced Hypertension Pregnancy Induced Hypertension
Peripheral Vascular Spasms (Vasospasm)
Vascular EIIects Kidney EIIects
Interstitial EIIects
Vasoconstriction
ecrease GFR and increase
Permeability oI Glomeruli
membranes
iIIusion oI Iluid Irom
blood stream into the
interstitial tissue
Increased 8
Increase Serum BUN, uric acid and
Creatinine
Ldema
Decrease ur|ne output and protenur|a
Kidney EIIects: Kidney EIIects:
- - Vasospasm in the kidney increases blood Ilow Vasospasm in the kidney increases blood Ilow
resistance resistance
- - leads to increase permeability oI the glomerular leads to increase permeability oI the glomerular
membranes, allowing the serum CHONS and membranes, allowing the serum CHONS and
globulin to escape in the urine (protenuria) globulin to escape in the urine (protenuria)
- - Results in decreased glomerular Iiltration Results in decreased glomerular Iiltration
lowers urine output lowers urine output
Management: Management:
1. maintain bed rest to reduce pressure on cervix and to 1. maintain bed rest to reduce pressure on cervix and to
prevent premature labor prevent premature labor
2. monitor Ior rupture or uterine contraction 2. monitor Ior rupture or uterine contraction
3. avoid constipation (it will increase uterine pressure 3. avoid constipation (it will increase uterine pressure
and rupture oI membranes) and rupture oI membranes)
4. amniocentesis (slow and controlled release oI Iluid to 4. amniocentesis (slow and controlled release oI Iluid to
prevent premature separation oI the placenta) guided by prevent premature separation oI the placenta) guided by
ultrasound ultrasound
PS% PS%- -%ERM PRENNCY %ERM PRENNCY
- - a pregnancy that exceeds 42 weeks oI a pregnancy that exceeds 42 weeks oI
gestation (term pregnancy gestation (term pregnancy 37 37- -42 weeks) 42 weeks)
- - incidence rate incidence rate 33- -12 oI all pregnancies 12 oI all pregnancies
Risk Factors: Risk Factors:
1. Women who have long menstrual cycles (40 1. Women who have long menstrual cycles (40- -45 days) 45 days)
- - they do not ovulate on day 14 in a typical menstrual they do not ovulate on day 14 in a typical menstrual
cycle. They ovulate 14 days Irom the end oI the cycle or on cycle. They ovulate 14 days Irom the end oI the cycle or on
day 26 or 31. Their child will be late by 12 or 17 days. day 26 or 31. Their child will be late by 12 or 17 days.
2. Women receiving high dose oI Salicylates (interIeres 2. Women receiving high dose oI Salicylates (interIeres
with synthesis oI prostaglandins that initiates labor) with synthesis oI prostaglandins that initiates labor)
3. associates with myometrial quiescence (uterus that do not 3. associates with myometrial quiescence (uterus that do not
respond to normal labor) respond to normal labor)
Complication: Complication:
1. meconium aspiration 1. meconium aspiration
2. macrosomia 2. macrosomia Ietus continues to grow Ietus continues to grow
3. Ietal distress 3. Ietal distress due to placental aging it causes decreased blood due to placental aging it causes decreased blood
preIusion and inadequate supply oI oxygenated blood and nutrients preIusion and inadequate supply oI oxygenated blood and nutrients
to Ietus to Ietus
Management: Management:
1. Induction oI labor 1. Induction oI labor prostaglandins or inoprostol (cytotec) prostaglandins or inoprostol (cytotec)
applied to cervix to stimulate ripening or stripping oI membranes. applied to cervix to stimulate ripening or stripping oI membranes.
Followed by oxytocin inIusion to stimulate contraction Followed by oxytocin inIusion to stimulate contraction
2. CS delivery 2. CS delivery
RH INCMP%IBII%Y RH INCMP%IBII%Y
(Isoimmunization) (Isoimmunization)
- - occurs when the mother is Rh negative ( occurs when the mother is Rh negative (- -) who carries ) who carries
a Ietus with an Rh positive () blood a Ietus with an Rh positive () blood
- - normally there is no direct contact between normally there is no direct contact between
maternal and Ietal blood maternal and Ietal blood
- - villi ruptures villi ruptures a drop or two oI Ietal blood enters a drop or two oI Ietal blood enters
maternal circulation or during amniocentesis maternal circulation or during amniocentesis
- - small amount oI blood (drop) oI Rh Ietal blood leaks across the small amount oI blood (drop) oI Rh Ietal blood leaks across the
placenta and goes to the blood stream oI the mother. Mother will be placenta and goes to the blood stream oI the mother. Mother will be
sensitized and start to make Rh antibodies (Iirst pregnancy is not sensitized and start to make Rh antibodies (Iirst pregnancy is not
aIIected) aIIected)
- - an injection oI Rh immune globulin (Rhogam) is given ASAP an injection oI Rh immune globulin (Rhogam) is given ASAP
within 72 hours aIter the delivery (because most oI maternal within 72 hours aIter the delivery (because most oI maternal
antibodies are Iormed during the Iirst 72 hours aIter birth) antibodies are Iormed during the Iirst 72 hours aIter birth)
- - uring the subsequent pregnancy (iI Ietus is again Rh ), the uring the subsequent pregnancy (iI Ietus is again Rh ), the
Rh antibodies oI the mother crosses the placenta, enters the blood Rh antibodies oI the mother crosses the placenta, enters the blood
stream oI the Ietus causing antigen stream oI the Ietus causing antigen- -antibody reaction and Hemolysis antibody reaction and Hemolysis
oI the Ietal RBC (Erythroblastosis Fetalis) oI the Ietal RBC (Erythroblastosis Fetalis)
iagnosis: iagnosis:
1. Indirect Coomb`s test 1. Indirect Coomb`s test to check iI Rh to check iI Rh
antibodies are present within RBC surIace antibodies are present within RBC surIace
2. Antibody titer 2. Antibody titer determine at Iirst pregnancy determine at Iirst pregnancy
visit and then again at 28 weeks AOG and visit and then again at 28 weeks AOG and
aIter delivery (normal is 0) aIter delivery (normal is 0)
Management: Management:
1. Rh Immune globulin (Rhogam) is administered at 28 weeks oI 1. Rh Immune globulin (Rhogam) is administered at 28 weeks oI
pregnancy and in the 1 pregnancy and in the 1
st st
72 hours aIter delivery 72 hours aIter delivery
2. etermine blood typed oI inIants aIter birth Irom a sample oI the 2. etermine blood typed oI inIants aIter birth Irom a sample oI the
cord blood cord blood
3. Blood transIusion through Intrauterine TransIusion 3. Blood transIusion through Intrauterine TransIusion
- - done to give restore Ietal RBC done to give restore Ietal RBC
- - 75 75- -150ml oI RBC is administered 150ml oI RBC is administered
- - aIter BT, the mother is encouraged to rest Ior 30 min. aIter BT, the mother is encouraged to rest Ior 30 min.
while FHT and uterine activity are monitored while FHT and uterine activity are monitored
4. As soon as Ietal maturity is reached, induction oI labor is 4. As soon as Ietal maturity is reached, induction oI labor is
Iollowed Iollowed
ES%%IN IBE%ES MEI%&S ES%%IN IBE%ES MEI%&S
- - a condition in which women exhibit high glucose levels a condition in which women exhibit high glucose levels
during pregnancy during pregnancy
- - an abnormal CHO, Iat and CHON metabolism that is an abnormal CHO, Iat and CHON metabolism that is
Iirst diagnosed during pregnancy (at the midpoint oI Iirst diagnosed during pregnancy (at the midpoint oI
pregnancy when insulin resistance becomes noticeable) pregnancy when insulin resistance becomes noticeable)
- - but the symptoms Iade again at the completion oI but the symptoms Iade again at the completion oI
pregnancy (resolves in delivery) pregnancy (resolves in delivery)
- - risk oI developing type 2 diabetes is high as 56 risk oI developing type 2 diabetes is high as 56- -60 60
later in liIe later in liIe
Cause: Unknown (related to excessive insulin Cause: Unknown (related to excessive insulin
resistance) resistance)
Risk Factors: Risk Factors:
1. obesity 1. obesity
2. age over 25 years old (about 50 oI the these women 2. age over 25 years old (about 50 oI the these women
develop diabetes within 22 develop diabetes within 22- -28 years old) 28 years old)
3. history oI large babies/macrosomia (16 lbs or more) 3. history oI large babies/macrosomia (16 lbs or more)
4. Iamily history oI M/GM 4. Iamily history oI M/GM
Pathophysiology oI M Pathophysiology oI M
Metabolize FAT/CHON Ior energy
Pancreas produces no insulin or inadequate insulin
Inadequate insulin
Inability to move glucose Irom the blood to body cells
Cellular
starvation
Hyperglycemia
Glycosuria
Exerts osmotic pressure in the
kidneys
Attracts more water
Polyuria
Causes ketones and
acids to accumulate
in the blood
Polyphagia
Metabolic
acidosis
Polydipsia
iagnosis: women who are high risk Ior M should be iagnosis: women who are high risk Ior M should be
screened at Iirst prenatal visit and again at 24 screened at Iirst prenatal visit and again at 24- -28 weeks. 28 weeks.
1. lucose Challenge %est 1. lucose Challenge %est done at Iirst prenatal visit and done at Iirst prenatal visit and
again at 24 again at 24- -28 weeks 28 weeks
- - usually consists oI 8 hour Iasting Ior FBS usually consists oI 8 hour Iasting Ior FBS
- - mother is given 50g oI glucose load and a blood mother is given 50g oI glucose load and a blood
sample is taken Ior serum glucose 1 hour aIter sample is taken Ior serum glucose 1 hour aIter
- - diabetic iI FBS is more than 95mg/dl or aIter 1 hour diabetic iI FBS is more than 95mg/dl or aIter 1 hour
the serum glucose is ~140mg the serum glucose is ~140mg
lucometer lucometer
2. ral lucose %olerance %est 2. ral lucose %olerance %est
- - the gold standard Ior diagnosing diabetes the gold standard Ior diagnosing diabetes
- - mother is given 100g oI CHO/glucose then 3 hours Iasting mother is given 100g oI CHO/glucose then 3 hours Iasting
Test type Test type Pregnancies glucose level (mg/dl) Pregnancies glucose level (mg/dl)
Fasting Fasting 95 95
1 hour 1 hour 180 180
2 hours 2 hours 155 155
3 hours 3 hours 140 140
- - rate is abnormal iI 2 oI the 4 blood samples collected are rate is abnormal iI 2 oI the 4 blood samples collected are
abnormal abnormal
- - 70 hypoglycemia, ~130 hyperglycemia (normal 70 hypoglycemia, ~130 hyperglycemia (normal 80 80- -
120mg/dl) 120mg/dl)
Maternal effects of M; Maternal effects of M;
1. 1. Hypoglycemia Hypoglycemia during the Iirst trimester during the Iirst trimester glucose is being glucose is being
utilized by the Ietus Ior the development oI the brain utilized by the Ietus Ior the development oI the brain
2. 2. Hyperglycemia Hyperglycemia during the 2 during the 2
nd nd
/3 /3
rd rd
trimester at 6 months trimester at 6 months
due to HPL eIIects (causes insulin resistance) due to HPL eIIects (causes insulin resistance)
Insulin requirements Insulin requirements Ior insulin during: Ior insulin during:
11
st st
trimester trimester decrease in insulin by 33 decrease in insulin by 33
22
nd nd
/3 /3
rd rd
trimester trimester increase insulin by 50, increase insulin by 50,
Postpartum Postpartum drops suddenly to 25due to delivery oI drops suddenly to 25due to delivery oI
placenta placenta
3. prone to Irequent inIections e.g. 3. prone to Irequent inIections e.g.
Moniliasis/ Moniliasis/Candidiasis Candidiasis
4. Polyhydramnios 4. Polyhydramnios
5. ystocia 5. ystocia due to abnormality in Ietus/mother due to abnormality in Ietus/mother
Problems with the Power: (Force of abor) Problems with the Power: (Force of abor)
1. &terine Inertia 1. &terine Inertia sluggishness oI contractions or the Iorce oI labor or sluggishness oI contractions or the Iorce oI labor or
deIined as diIIicult, painIul, prolonged labor due to mechanical Iactors deIined as diIIicult, painIul, prolonged labor due to mechanical Iactors
- - current term current term ysIunctional Labor ysIunctional Labor
Common Causes: Common Causes:
a. inappropriate use oI analgesia (excessive or too early administration) a. inappropriate use oI analgesia (excessive or too early administration)
b. unusually large baby/multiple gestation b. unusually large baby/multiple gestation
c. poor Ietal position (posterior rather than anterior position) c. poor Ietal position (posterior rather than anterior position)
d. pelvic bone contraction (leads to narrowing oI the pelvic diameter so the d. pelvic bone contraction (leads to narrowing oI the pelvic diameter so the
Ietus cant pass) Ietus cant pass)
e. primigravida e. primigravida
I. hypotonic, hypertonic and prolonged labor I. hypotonic, hypertonic and prolonged labor
2 types: 2 types:
1. Primary 1. Primary occurring at the onset oI labor occurring at the onset oI labor
2. Secondary 2. Secondary occurring later in labor occurring later in labor
Management: Management:
1. Monitor uterine contractions by palpation and with the use oI 1. Monitor uterine contractions by palpation and with the use oI
electronic monitor electronic monitor
2. Prevent unnecessary Iatigues 2. Prevent unnecessary Iatigues check the client level oI Iatigue check the client level oI Iatigue
3. Prevent complications oI labor 3. Prevent complications oI labor
a. assess urinary bladder (catheterize as needed) a. assess urinary bladder (catheterize as needed)
b. assess maternal VS b. assess maternal VS
c. monitor condition oI Ietus by monitoring FHR, Ietal c. monitor condition oI Ietus by monitoring FHR, Ietal
activity and color oI amniotic Iluid activity and color oI amniotic Iluid
4. Provide comIort measures 4. Provide comIort measures
a. Irequent position changes a. Irequent position changes
b. walking b. walking
c. quiet/calm environment c. quiet/calm environment
d. breathing/relaxation technique d. breathing/relaxation technique
2. Ineffective &terine Force 2. Ineffective &terine Force
- - ineIIective uterine contractions which can result in ineIIective ineIIective uterine contractions which can result in ineIIective
labor labor
types; types;
1. Hypotonic Contractions 1. Hypotonic Contractions the number oI contractions is usually the number oI contractions is usually
low or inIrequent (not increasing beyond 2 or 3 in a 10 minute low or inIrequent (not increasing beyond 2 or 3 in a 10 minute
period) period)
- - occurs during the active phase oI labor occurs during the active phase oI labor
- - normal : 3 normal : 3- -4/10 min period with duration oI 30 seconds 4/10 min period with duration oI 30 seconds
Risk Factors Risk Factors
- - bowel/bladder distention prevents bowel/bladder distention prevents
descent/engagement descent/engagement
- - multiple gestation multiple gestation
- -large Ietus large Ietus
- - hydramnios hydramnios
- - multiparity multiparity
Signs and Symptoms Signs and Symptoms: Painless less Irequent Contraction : Painless less Irequent Contraction
Management: Management:
1. oxytocin administration 1. oxytocin administration to strengthen contractions and to strengthen contractions and
increase eIIectiveness increase eIIectiveness
2. Amniotomy (artiIicial rupture oI membranes 2. Amniotomy (artiIicial rupture oI membranes to Iurther to Iurther
speed labor speed labor
3. Palpate the uterus and assess lochia every 15 minutes to 3. Palpate the uterus and assess lochia every 15 minutes to
prevent postpartum bleeding prevent postpartum bleeding
4. monitor maternal VS and FHR 4. monitor maternal VS and FHR
5. position changes to relieve discomIort and enhance 5. position changes to relieve discomIort and enhance
progress progress
2. Hypertonic Contractions 2. Hypertonic Contractions
- - intensity oI the contractions may not stronger or very active and intensity oI the contractions may not stronger or very active and
Irequent contractions but ineIIective Irequent contractions but ineIIective
- - occurs more Irequently and commonly seen in latent phase oI occurs more Irequently and commonly seen in latent phase oI
labor` labor`
- - the muscle Iibers oI the uterus (myometrium) do not repolarize the muscle Iibers oI the uterus (myometrium) do not repolarize
- - usually preceded by usually preceded by pathologic refraction ring pathologic refraction ring (an indentation is apparent (an indentation is apparent
across the abdomen over the uterus) and strong uterine contractions without any across the abdomen over the uterus) and strong uterine contractions without any
cervical dilatation, the Ietus is gripped by retraction ring and cannot descent) cervical dilatation, the Ietus is gripped by retraction ring and cannot descent)
Signs and Symptoms: Signs and Symptoms:
1. sudden severe pain during a strong labor contractions 1. sudden severe pain during a strong labor contractions
2. report 'a tearing sensation 2. report 'a tearing sensation
3. hemorrhage Irom a torn uterus into the abdominal cavity and into the 3. hemorrhage Irom a torn uterus into the abdominal cavity and into the
vagina vagina
4. signs oI shock (rapid, weak pulse, Ialling blood pressure, cold clammy 4. signs oI shock (rapid, weak pulse, Ialling blood pressure, cold clammy
skin) skin)
5. absent Ietal heart sounds 5. absent Ietal heart sounds
6. localized tenderness and aching pain Irom the lower segment 6. localized tenderness and aching pain Irom the lower segment
7. Ietal distress 7. Ietal distress
c. Battle c. Battle--dore dore Placenta Placenta the cord is inserted marginally rather than the cord is inserted marginally rather than
centrally centrally
- - rare/unknown clinical signiIicance rare/unknown clinical signiIicance
d. Velamentous Insertion of the Cord d. Velamentous Insertion of the Cord situation in which the cord situation in which the cord
instead oI entering the placenta directly, separated into small vessels that instead oI entering the placenta directly, separated into small vessels that
reach the placenta by spreading across a Iold oI amnion reach the placenta by spreading across a Iold oI amnion
Postpartum Complications Postpartum Complications
1. 1. Postpartum hemorrhage Postpartum hemorrhage major cause oI maternal major cause oI maternal
death, occurs in 4 oI deliveries death, occurs in 4 oI deliveries
- - deIined as blood loss greater than 500 ml aIter deIined as blood loss greater than 500 ml aIter
vaginal birth or 1000 ml aIter CS vaginal birth or 1000 ml aIter CS
ClassiIications: ClassiIications:
According to severity: According to severity:
a. Mild a. Mild 750 750 1250 ml 1250 ml
b. Moderate b. Moderate 1250 1250 1750 ml 1750 ml
c. Severe c. Severe 2500 ml 2500 ml
According to time: According to time:
1. Early Postpartum hemor 1. Early Postpartum hemorrhage rhage occurs within 24 hours oI birth occurs within 24 hours oI birth
2. ate postpartum hemorrhage 2. ate postpartum hemorrhage occurs aIter 24 hours until 6 weeks aIter occurs aIter 24 hours until 6 weeks aIter
birth birth
Major Risk: Major Risk: Hypovolemic Shock Hypovolemic Shock (low volume) (low volume)
- - occurs when the circulating blood volume is decreased which occurs when the circulating blood volume is decreased which
interrupts blood Ilow to body cells interrupts blood Ilow to body cells
- - maniIested as: maniIested as:
a. Tachycardia (Iirst sign) a. Tachycardia (Iirst sign)
b. hypotension b. hypotension
c. cold and clammy skin c. cold and clammy skin
d. mental changes such as anxiety, conIusion, restleness d. mental changes such as anxiety, conIusion, restleness
e. decrease urine output e. decrease urine output
Conditions that increase risk for PP hemorrhage Conditions that increase risk for PP hemorrhage
1. Over distension oI the uterus 1. Over distension oI the uterus
Multiple births Multiple births
Hydramnios Hydramnios
Macrosomia Macrosomia
2. Trauma r/t Iorceps, uterine manipulation 2. Trauma r/t Iorceps, uterine manipulation
3. Prolonged labor 3. Prolonged labor
4. Uterine inIection 4. Uterine inIection
5. Trauma removing placenta 5. Trauma removing placenta
Causes of Postpartum hemorrhage Causes of Postpartum hemorrhage
1. 1. &terine tony &terine tony: Uterus without tone or lack oI : Uterus without tone or lack oI
normal muscle tone (90 oI cases) normal muscle tone (90 oI cases)
- - uterine atony allows blood vessels at the uterine atony allows blood vessels at the
placenta site to bleed Ireely and usually massively. placenta site to bleed Ireely and usually massively.
- - uterine muscle unable to contract around blood uterine muscle unable to contract around blood
vessels at placental site vessels at placental site
Risk Factors: Risk Factors:
1. eep anesthesia 1. eep anesthesia
2. ~30 years old 2. ~30 years old
3. prolonged use oI magnesium sulIate 3. prolonged use oI magnesium sulIate
4. previous uterine surgery 4. previous uterine surgery
5. Over exhaustion 5. Over exhaustion
Symptoms: Symptoms:
1. uterus is diIIicult to Ieel and is boggy (soIt) 1. uterus is diIIicult to Ieel and is boggy (soIt)
2. lochia is increased and may have large blood clots 2. lochia is increased and may have large blood clots
3. Blood may 'gush or come out slowly 3. Blood may 'gush or come out slowly
Nursing Management: Nursing Management:
1. Massage the uterus until Iirm 1. Massage the uterus until Iirm
2. have mother to urinate or catheterize because bladder distension 2. have mother to urinate or catheterize because bladder distension
pushes the uterus upward or in the side and interIeres with the pushes the uterus upward or in the side and interIeres with the
ability oI the uterus to contract ability oI the uterus to contract
3. Encourage mother to breastIeed because sucking stimulation 3. Encourage mother to breastIeed because sucking stimulation
causes the release oI oxytocin Irom PPG causes the release oI oxytocin Irom PPG
4. Administration oI IV oxytocin or Methylergonovine 4. Administration oI IV oxytocin or Methylergonovine
(Methergine) to control uterine atony (Methergine) to control uterine atony
5. Hysterectomy is perIormed to remove the bleeding uterus that 5. Hysterectomy is perIormed to remove the bleeding uterus that
does not respond to other measures does not respond to other measures
2. acerations 2. acerations tearing oI the birth canal tearing oI the birth canal
- - normally occurs as a result oI child bearing normally occurs as a result oI child bearing
Risk Iactors: Risk Iactors:
a. diIIicult or precipitate births a. diIIicult or precipitate births
b. primigravidas b. primigravidas
c. birth oI a large inIant c. birth oI a large inIant
d. use oI a lithotomy position and instruments d. use oI a lithotomy position and instruments
(Iorceps) (Iorceps)
Sites of lacerations: Sites of lacerations:
1. Cervical acerations 1. Cervical acerations
- - characterized by gushes oI bright red blood Irom the vaginal characterized by gushes oI bright red blood Irom the vaginal
opening iI uterine artery is torn opening iI uterine artery is torn
- - diIIicult to repair because the bleeding may be so intense that it diIIicult to repair because the bleeding may be so intense that it
can obstruct visualization oI the area. can obstruct visualization oI the area.
2. Vaginal acerations 2. Vaginal acerations
- - rare case but easier to assess rare case but easier to assess
- - oozing oI blood aIter repair, vaginal packing is necessary to oozing oI blood aIter repair, vaginal packing is necessary to
maintain pressure Irom the suture line maintain pressure Irom the suture line
- - catheterize the mother because packing causes pressure on catheterize the mother because packing causes pressure on
urethra urethra
- - packing is removed aIter 24 packing is removed aIter 24- -48 hours (at risk Ior inIection) 48 hours (at risk Ior inIection)
3. Perineal acerations 3. Perineal acerations
- - usually occurs when mother is placed on lithotomy positions usually occurs when mother is placed on lithotomy positions
(increases pressure on perineum) (increases pressure on perineum)
ClassiIications: ClassiIications:
a. First egree a. First egree vaginal mucous membranes and skin oI the vaginal mucous membranes and skin oI the
perineum to the Iourchette perineum to the Iourchette
b. Second egree b. Second egree vagina, perineal skin, Iascia and perineal body vagina, perineal skin, Iascia and perineal body
c. %hird egree c. %hird egree entire perineum and reaches the external sphincter entire perineum and reaches the external sphincter
oI the rectum oI the rectum
d. Fourth egree d. Fourth egree entire perineum, rectal sphincter and some oI the entire perineum, rectal sphincter and some oI the
mucous membrane oI the rectum mucous membrane oI the rectum
Management Management (Perineal) (Perineal)
1. sutured and treated using episiotomy repair 1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool soItener is prescribed Ior 2. diet high in carbohydrate and a stool soItener is prescribed Ior
the Iirst week postpartum to prevent constipation which could the Iirst week postpartum to prevent constipation which could
break the sutures break the sutures
3. do not take rectal temperatures because the hard tips oI 3. do not take rectal temperatures because the hard tips oI
equipment could open sutures equipment could open sutures
3. Retained Placental Fragments 3. Retained Placental Fragments placenta does not deliver its placenta does not deliver its
entire Iragments and leIt behind leading to uterine bleeding entire Iragments and leIt behind leading to uterine bleeding
Causes: Causes:
a. Placenta Succenturiata a. Placenta Succenturiata a placenta with accessory lobe a placenta with accessory lobe
b. Placenta Accreta b. Placenta Accreta a placenta that Iuses with myometrium because oI an a placenta that Iuses with myometrium because oI an
abnormal basalis layer abnormal basalis layer
Signs and Symptoms: Signs and Symptoms:
1. iI Large Iragments 1. iI Large Iragments
- - Patient bleeds immediately at delivery Patient bleeds immediately at delivery
- - Uterus is boggy Uterus is boggy
2. iI Small Iragments 2. iI Small Iragments
- - bleeding occurs at 6 bleeding occurs at 6
th th
10 10
th th
day PP day PP
- - Can cause subinvolution Can cause subinvolution
Management: Management:
1. ilatation and Curettage (&C) will be perIormed to remove 1. ilatation and Curettage (&C) will be perIormed to remove
placental Iragments and to stop bleeding placental Iragments and to stop bleeding
2. administration oI Methotrexate to destroy the retained 2. administration oI Methotrexate to destroy the retained
placental tissue placental tissue
3. instruct the mother to observe the color oI lochia discharge 3. instruct the mother to observe the color oI lochia discharge
4. check the completeness oI the placenta aIter birth 4. check the completeness oI the placenta aIter birth
4. isseminated Intravascular Coagulation (IC) 4. isseminated Intravascular Coagulation (IC)
- - deIiciency in clotting ability caused by vascular injury deIiciency in clotting ability caused by vascular injury
characterized by bleeding the IV sites, nose, gums etc. characterized by bleeding the IV sites, nose, gums etc.
Associative Factors: Associative Factors:
a. premature separation oI the placenta a. premature separation oI the placenta
b. missed early miscarriage b. missed early miscarriage
c. Ietal death in utero c. Ietal death in utero
5. Perineal Hematoma 5. Perineal Hematoma is a collection oI blood in the is a collection oI blood in the
subcutaneous layer tissue oI the perineum caused by injury to blood subcutaneous layer tissue oI the perineum caused by injury to blood
vessels aIter birth vessels aIter birth
Risk Factors: Risk Factors:
a. rapid spontaneous birth a. rapid spontaneous birth
b. perineal varicosities b. perineal varicosities
c. episiotomy or laceration repair sites c. episiotomy or laceration repair sites
Signs and Symptoms: Signs and Symptoms:
1. severe pain in the perineal area 1. severe pain in the perineal area
2. Ieeling oI pressure between the legs 2. Ieeling oI pressure between the legs
3. purplish discoloration/swelling on perineum 3. purplish discoloration/swelling on perineum
4. concealed bleeding 4. concealed bleeding
Management: Management:
1. assess the size by measuring it in centimeters 1. assess the size by measuring it in centimeters
2. administer a mild analgesic as pain relieI 2. administer a mild analgesic as pain relieI
3. apply an ice pack (covered by towel to prevent thermal 3. apply an ice pack (covered by towel to prevent thermal
injury to the skin) injury to the skin)
4. incision and drainage oI the site oI hematoma and is 4. incision and drainage oI the site oI hematoma and is
packed with gauze packed with gauze
Puerperal Infection Puerperal Infection
- - InIection oI the reproductive tract associated with giving birth InIection oI the reproductive tract associated with giving birth
- - Usually occurs within 10 days oI birth Usually occurs within 10 days oI birth
- - Another leading cause oI maternal death Another leading cause oI maternal death
- - Predisposing Iactors: Predisposing Iactors:
a. Prolonged rupture oI membranes (~24 hours) a. Prolonged rupture oI membranes (~24 hours)
b. C b. C- -section section
c. Trauma during birth process c. Trauma during birth process
d. Maternal anemia d. Maternal anemia
e. Retained placental Iragments e. Retained placental Iragments
- - InIection may be localized or systemic InIection may be localized or systemic
a. Local inIection can spread to peritoneum (peritonitis) or circulatory a. Local inIection can spread to peritoneum (peritonitis) or circulatory
system (septicemia). system (septicemia).
b. Fatal to woman already stressed with childbirth b. Fatal to woman already stressed with childbirth
ssessment findings: ssessment findings:
1. Temp oI 100.4 Ior more than 2 consecutive days, 1. Temp oI 100.4 Ior more than 2 consecutive days, excluding the Iirst 24 excluding the Iirst 24
hours hours. .
2. Abdominal, perineal, or pelvic pain 2. Abdominal, perineal, or pelvic pain
3. Foul 3. Foul- -smelling vaginal discharge smelling vaginal discharge
4. Burning sensation with urination 4. Burning sensation with urination
5. Chills, malaise 5. Chills, malaise
6. Rapid pulse and respirations 6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity 7. Elevated WBC, positive culture and sensitivity
(Remember, 20 (Remember, 20- -25,000 is normal aIter delivery 25,000 is normal aIter delivery MASKING inIection) MASKING inIection)
Nursing interventions Nursing interventions
1. Force Iluids; may need more than 3L/day 1. Force Iluids; may need more than 3L/day
2. Administer antibiotics aIter culture and sensitivity oI the organism 2. Administer antibiotics aIter culture and sensitivity oI the organism
(Group B streptococci and E. Coli) and other meds as ordered (Group B streptococci and E. Coli) and other meds as ordered
3. Treat symptoms as they arise 3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet 4. Encourage high calorie, high protein diet
5. Position patient in a semi 5. Position patient in a semi- -Fowlers to promote drainage and prevent Fowlers to promote drainage and prevent
reIlux higher into reproductive tract reIlux higher into reproductive tract
6. Use oI sterile equipments on birth canal during labor, birth and 6. Use oI sterile equipments on birth canal during labor, birth and
postpartum postpartum
7. Educate the mother about proper perineal care including wiping Irom 7. Educate the mother about proper perineal care including wiping Irom
Iront to back Iront to back
Endometritis Endometritis
- - reIers to the inIection oI the endometrium, the lining oI the uterus at reIers to the inIection oI the endometrium, the lining oI the uterus at
the time oI birth or during Postpartal period the time oI birth or during Postpartal period
Signs and Symptoms: Signs and Symptoms:
1. Iever on the third or Iourth day postpartum(increase in oral 1. Iever on the third or Iourth day postpartum(increase in oral
temperature above 38C Ior 2 consecutive 24 hour periods, excluding temperature above 38C Ior 2 consecutive 24 hour periods, excluding
the Iirst 24 hours period aIter birth) the Iirst 24 hours period aIter birth)
2. chills, loss oI appetite and general body malaise 2. chills, loss oI appetite and general body malaise
3. uterine tenderness 3. uterine tenderness
4. Ioul smelling lochia 4. Ioul smelling lochia
Management: Management:
1. ATBC administration such as Clindamycin aIter culture 1. ATBC administration such as Clindamycin aIter culture
2. oxytocin is given to encourage uterine contraction 2. oxytocin is given to encourage uterine contraction
3. encourage increase Iluid intake to combat Iever 3. encourage increase Iluid intake to combat Iever
4. analgesic as ordered Ior pain relieI due to aIter pains and 4. analgesic as ordered Ior pain relieI due to aIter pains and
abdominal discomIorts abdominal discomIorts
5. encourage client to ambulate or in Fowler`s position to 5. encourage client to ambulate or in Fowler`s position to
promote lochia drainage and prevent pooling oI inIected promote lochia drainage and prevent pooling oI inIected
secretions secretions
6. IV therapy 6. IV therapy
Perineal Infection Perineal Infection
- - localized inIection oI the suture line Irom an episiotomy site localized inIection oI the suture line Irom an episiotomy site
Signs and Symptoms: Signs and Symptoms:
1. Ieeling oI heat, pain and pressure on the suture line 1. Ieeling oI heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away 2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines 3. purulent discharges on suture lines
Management: Management:
1. removal oI perineal sutures to open and allow Ior drainage 1. removal oI perineal sutures to open and allow Ior drainage
2. Topical, systemic ATBC as ordered 2. Topical, systemic ATBC as ordered
3. Analgesic to alleviate discomIort 3. Analgesic to alleviate discomIort
4. Provide Sitz bath or warm compress to hasten drainage and 4. Provide Sitz bath or warm compress to hasten drainage and
cleanse the area cleanse the area
5. Remind the mother to change perineal pads Irequently to 5. Remind the mother to change perineal pads Irequently to
prevent contamination/inIection prevent contamination/inIection
6. Teach proper perineal care wiping Irom Iront to back aIter 6. Teach proper perineal care wiping Irom Iront to back aIter
bowel movement (to prevent bringing the Ieces to the healing bowel movement (to prevent bringing the Ieces to the healing
area) area)