HYPEREMESIS GRAVIDARUM

Primary neonatal complications:

COMPLICATION: 1. Respiratory distress syndrome
Dehydration 2. Intracranial bleeding
Weight loss 3. Chronic lung disease
Acidosis/Alkalosis (associated with Hcg 4. Infection
hormones) 5. Visual impairments
6. Cerebral palsy
Diagnostic Test: Serum analysis will show
 CHON ,Chloride, Sodium and Medical managements:
Potassium levels Suppress premature labor for:
 Inc. BUN  Immature fetal lungs
 Ketonuria  Cervical dilatation of <4 cm
 Inc. Hemoglobin and WBC level
1. Bedrest – to relieve the pressure of
Management: fetus to the cervix.
 Hospitalization 2. Hydration- may help stop contractions
IV fluids (IVF/ enough fluids)
Bedrest When dehydrated, oxytocin is produced
Parenteral vitamin supplements that promotes contractions.
Potassium replacement 3. Tocolytic theraphy – to halt labor.
 If condition improved: 4. Adequate nutrition and avoid smoking
Small, frequent feedings 5. Corticosteroid- accelerates formation of
Avoid strong odour foods surfactant.
 Emotional support
Medication:
PSEUDOCYESIS = “false pregnancy” Betamethasone - 12mg IM every 24 hours for 2
doses (preferred-more potent).
Management:
1. Explain pregnancy test result and clarify Dexamethasone - 6mg IM every 12 hours for 4
misconception and false beliefs. doses (cheaper).
2. Provide referrals when necessary.
3. Provide emotional support and Preterm labor that can’t be halted
understanding.  Avoide amniotomy – to prevent cord
prolapse and damage to the fetus’ soft
Nursing Diagnosis: skull
 Cesarian birth – to reduce pressure on
the fetal head.

Nursing diagnosis:

PREMATURE LABOR

-Labor after fetal viability, but before fetal PRETERM RUPTURE OF MEMBRANES
maturity.  Rupture of fetal membranes with loss of
-24th – 37th GA amniotic fluid before 37 weeks.
- Prognosis depends on birth weight and length Risk factors:
of gestation. Infection of membranes
Incompetent cervix
“The lower the birth weight the earlier the baby Trauma
is born, the lower is the chance for survival”
Complications: Infection, cord compression, Complication:
cord prolapse and preterm labor. - Fetal malpresentation
- Amniotic fluid embolism
Assessment: - PROM flowed by preterm labor
1. Slow steady trickle or a gush of fluid in - Infection
the vagina. - Prolapsed cord
2. The fluid is positive for nitrazine paper
test (blue)
3. Positive fernlike pattern on slide (due to Anaphylactic syndrome of pregnancy
estrogen) - The escape of AF containing debris (
meconium, lanugo, vernix caseosa) into
Nursing responsibility: maternal circulation
Assess for signs of labor. - Causing deposition of fluid/debris in the
 If labor does not begin and fetus is still pulmonary arterioles.
young to survive. - Resulting to rapid respiratory distress,
o Bedrest shock, and possible development of
o Prophylactic antibiotics DIC.
o Fibrin based sealant
CAUSES: S/S
Nursing diagnosis. Oxytocin admin. Sudden sharp pan
 Risk for infection Abruptio placenta Inability to breath
 Anxiety Hydramnios Pale to cyanotic skin
 Risk for injury
Management:
Implementation and collaborative care 1. Immediate oxygen inhalation
1. Assess FHR 2. CPR
2. Evaluate client’s temp every 2 hours 3. Baby should be delivered C/S (within 5
3. Avoid vaginal exams. minutes)
4. If woman survives the initial insult,
POLYHYDRAMNIOS/ HYDRAMNIOS there is increased risk of DIC.

- Excessive AF formation >2000 ml due to Nursing Diagnosis.

fetal polyuria. Normal range is 800 –
1200 ml.
Possible cause:
1. Difficulty of the fetus to swallow/ Oligohydramnios
absorb. Marked decreased of AF in the amniotic sac.
TRACHEO – ESOPHAGEAL FISTULA
2. Excessive production of urine. Complications:
1. Corp prolapse
SIGNS AND SYMPTOMS 2. Fetal compromise
1. Unusual rapid uterine enlargement. - Pulmonary hyperplasia
2. Small parts difficulty to palpate - Skeletal abnormalities (1st to
3. Difficult FHR auscultation 2nd)
4. Shortness of breath Etiology:
5. Lower extremities varicosities/ 1. Fetal problems (obstruction in the
hemorrohoids and edema. urinary tract, renal agenesis and IUGR)
6. Increase weight gain. 2. Prom
3. Severe problems
Dx test: ULTRASOUND 4. Placental sufficiency
Clinical manifestation: 4. Alcohol – congnitive fetal alcohol
Prominent fetal parts on palpation. syndrome and Vitamin b12 deficiency.
Small for date uterine size. 5. Cigarettes – LBW
6. Caffeine – LBW
Management
1. Frequent evaluation of fetal status TERATOGENIC MATERNAL INFECTION
2. UTZ T - TOXOPLASMOSIS
3. Amniounfusion – installation of fluid O – OTHER INFECTION
800ml into the amniotic cavity to R - RUBELLA
replace normal volume of AF. C - CYTOMEGALOVIRUS
H – HERPES SIMPLEX

Teratogen TOXOPLASMOSIS
Types Maternal effects:
1. Ingested agents Swollen lymph nodes
2. Maternal infection Flu-like symptoms
3. Environmental agents Fetal effects:
Severe malformations (skull & eyes)
Ingested agents: Active infection in the liver
MEDICATION Stillbirth
1. Dilantin – Cleft palate
2. Steroids – Cleft palate; abortion RUBELLA
3. Vitamin K – hemolysis; MATERNAL EFFECT: MILD RASH
hyperbilirubinemia FETAL EFFECTS:
4. Aspirin/ phenobarbital – bleeding DEAFNESS, MENTAL AND MOTOR
disorders CHALLENGES, CATARCTS AND CARDIAC DEFECTS
5. Streptomycin and quanine – 8th cranial
nerve damage CYTOMEGALOVIRUS
6. Iodine – Enlargement of fetal thyroid MOT: Droplet infection
gland, leading to tracheal compression Fetal effects:
7. Tetracycline – damage to developing 1. Neurologic symptoms
dental and osseous tissues (hydrocephaly/microcephaly) with
8. Chemotheraphy - major congenital deafness.
malformations esp. CNS 2. Chronic liver disease.

VACCINES Characteristic: Blueberry muffin lesions

Thalidomide- for morning sickness Management:
Cause:  Hand washing and avoiding crowds of
Amelia- total absence of extremities. young kids.
Phocomelia – Partial absence of extremities
HERPES SIMPLEX VIRUS
Isoretinoin – for MMR and Polio 1ST TRI – Severe congenital anomalies
Effect: transmission of viral infection to the Miscarriages
fetus. ND
2 TRI - Premature birth and IUGR
For genital lesions – CS and IV acyclovir is given
ILLEGAL DRUGS
1. Narcotics – IUGR Environmental Teratogen:
2. Cocaine – IUGR, preterm labor and  Maternal and chemical hazards
meconium staining.  Radiation
3. Inhalants  Hypothermia and hyperthermia
 Maternal stress.
Chemicals
1. Pesticides – Low birth weight HYPOTONIC CONTRACTION
Fetal loss  WEAK/INFREQUENT CONTRACTION
Childhood cancer  CONTRACTION NOT PAINFUL
2. Mercury – Neurologic damage  UTERUS IS EASILY INDENTABLE AT THE
Blindness PEAK OF CONTRACTION.
Radiation – Most damaging time is rom
implantation to 6 weeks. Complication: - Postpartum haemorrhage
Complication: - Prolonged labor.
Neurologic damage
Congenital malformations. Management:
- Rule out CPD
Hyperthermia – interferes cell metabolism with - Augmentation of labor/
Fever for 4-6 weeks AOG. stimulation of contraction
Fetal Effects: (oxytocin)
1. Abnormal fetal brain developments Causes: Multiparity, multiple gestation,
2. Possible seizures disorders macrosmia, hydramnious, bowel distention,
3. Hypotonia early/excessive use of analgesia.
4. Skeletal deformities.
HYPERTONIC CONTRACTION
Maternal effects: Low birth weight  Contraction are frequent
 Uterus does not relax completely in
POST TERM PREGNANCY between contractions and tend to be
PREGNANCY THAT EXCEEDS 38 – 42 WEEKS. more painful.
Maternal risk:
Causes:  Prolonged labor
 The trigger that initiates labor did not  Pain; fatigue
turn on. Fetal risk
Ex. High dose of salicylates interferes  Hypoxia
prostaglandins synthesis.
 Failure of the uterus to respond to Medical treatment:
normal labor stimulation 1. Sedation – to promote rest
- To stop contraction
Complications: - Allow normal labor pattern to
 Meconium staining develop.
 Macrosomia 2. Hydration
 Lack of growth 3. Relaxation.
 Decreased blood perfusion
 Oligohydramnious A. Ineffective uterine force.
 Fetal distress. B. Contraction ring –
 appears as a horizontal indentation
Managements : across the abdomen when labor is
1. Misoprostol tablet/ cerprim gel - obstructed cause by:
initiates cervical opening 1. CPD
2. Oxytocin infusion. 2. Uncoordinated contractions in
early labor
DYSCTOCIA 3. Ob. Manipulation
-Abnormal progression of labor. 4. Oxytocin use.
-Result from a malfunction in  Pathologic retraction ring (Bandl’s ring)
one or more of the 4Ps of labor.
POWER, PSYCHE, PASSENGER AND PASSAGE.
  A hard band that forms at the junction
of the upper and lower uterine
segments.
Management:
 IV morphine sulfate or amyl nitrite
inhalation to relieve retraction ring
 Tocolytic
 Cesarian delivery.
Complication:
 Uterine prolapse
 Neurologic damage
 Maternal haemorrhage.
UMBILICAL CORD PROLAPSE
A LOOP OF THE UMBILICAL CORD SLIPS DOWN
IN FRONT OF THE FETAL PRESENTING PART.
Assessment:
 the cord is felt as the presenting
part.
 With BOW rupture, the cord
slips down into the vagina.
Causes:
Fetal bradycardia
Cord visible at the vulva.
Predisposing factors:
1. PROM
2. PP
3. CPD
4. Hydramnios
5. Multiple gestation.
Managements:
1. Relieve pressure on the cord
 Knew-chest position/
Trendelenburg position
 Place a gloved hand in the
vagina and manually elevate
fetal head off the cord.
 O2 inhalation @ 10 L/min (face
mask)
 Tocolytic
 Cover the exposed cord with a
gauze and a sterile saline.
 Do not push back the cord
 If cervix is fully dilated, quick
delivery should be done with
the help of forceps.
Surgical management: Caesarean section.
Nursing diagnosis:
 Impaired gas exchange
 Ineffective tissue perfusion
 Risk for infection
 Anxiety
 Fatigue
Multifetal pregnancy/ Multiple gestation.
 Two, three, four or even five foetuses
are conceived, grow and develop in the
uterus at the same time.
TYPES OF TWINNING
1. Monozygotic or identical
- Develop from 1 ovum and 1
sperm
- Same genetic traits; same sex
- Only one placenta, one chorion,
2 amnions, 2 umbilical cord.
2. Dizygotic or fraternal
- Develop 2 or more ova and
sperm cells that were fertilized
at the same time.
- Different genetic traits; may or
may not of the same sex.
- Always have separate
placentas, chorions, amnions
and umbilical cords.
Complications:
1. Abortion
2. Preterm labor
3. PIH
4. Anemia
5. Birth defects
6. Twin to twin transfusion syndrome
7. CS delivery
8. Postpartum haemorrhage
9. Hyramnious
10. LBW
Managements:
1. Prenatal care
Additional 300kcal to normal pregnancy
requirement.
 More bed rest during 3rd trimester
2. Labor and delivery
Monitor for possible complications
C/S if the twins or one of them can’t be
delivered normally.
3. Postpartum
Watch out for haemorrhage.
Fetal malpresentation and malposition
Fetal malpresentation – fetal presentation other
than vertex.
Types of malpresentation:
1. Brow – partial extension of fetal head
MGT : if fetus is alive or dead, deliver by
C/S
2. Chin anterior – descent and delivery of
the head by flexion may occur
Management :
If cervix is fully dilated:
 Vaginal delivery
 Augment labor with oxytocin
 Forceps delivery
If cervix is not fully dilated and no signs of
obstruction:
 Augment labor with oxytocin.
3. Chin posterior – The fully extended
head is blocked by the sacrum which
prevents descent.
4. Sinciput
– the larger diameter of the fetal head
is presented.
– slower descent of fetal head.
5. Face – caused by hyper extension of the
fetal head.
6. Transverse – management : turn the
fetus to a vertical lie
- If infant is preterm and smaller
than usual.
Maternal risks:
Prolonged labor
PROM
CS or forceps delivery
Trauma to birth canal
Hemorrhage (intra or postpartum)
Fetal risks:
1. Compression or prolapse of UC
2. Entrapment of fetal head in
incompletely dilated cervix
3. Aspiration and asphyxia at birth
4. Birth trauma
Common cause:
 Multiparity
 Multiple gestation
 Poly/oligohydramnios
 Uterine anatomic abnormality
 Abnormal growths
 PP
 Prematurity
Types of breech presentation
1. Frank breech – buttocks come first, legs
are flexed at the hip and extended at
the knees.
2. Complete breech – hips and knees are
flexed, baby is sitting cross legged.
3. Footling breech – common with
premature fetus
4. Kneeling breech – extremely rare.
Management: External version
Attempt external version if:
1. Breech presentation is at or after 37
weeks
2. Vaginal delivery is possible
3. Membranes are intact and amniotic
fluid is adequate
4. There are no complications
Management: Vaginal delivery is safe and
feasible under the ff. condition.
 Complete or frank breech
 Adequate pelvimetry
 Fetus is not too large
 No previous C/S for CPD
 Flexed head
Maternal risk:
 prolonged labor
 extension of episiotomy
 3rd and 4th degree of laceration of the
perineum
Maternal symptoms
 intense back pain in labor
  prolonged active phase Managements:
 arrest of descent.  C/S – if with signs of obstruction or the
fhr os abnormal
Diagnosis:  Amniotomy
Abdominal exam  Oxytocin – if cervix not fully dilated and
Vaginal exam no signs of obstruction.
UTZ
Forceps delivery – provides traction or a means
of rotating the fetal head.
Management: Cesarian section is safer than
vaginal breech delivery in cases of: Risks:
 Fetal ecchymosis or edema of the face
 Double footling breech  Transient facial paralysis
 Small/malformed pelvis  Maternal lacerations
 Very large fetus  Episiotomy extensions
 Previous C/s for CPD
 Hyperextended / unflexed head. Vacuum extraction – provides traction to
shorten the 2nd stage of labor.
Management: Mauriceaus’s manuever.
Risks:
Fetal malposition  cephalhematoma
-position other than an occipitoanterior  Retinal haemorrhage
-include occipitoposterior and
 Intracranial haemorrhage
occipitotransverse.
Nursing managements:
1. Encourage mother to lie on her side
Types of fetalmalposition.
from the fetal back
1. Occipitotransverse position
2. Pelvic-rocking
– incomplete rotation to OA
3. Knee chest position
4. Apply sacral counter – pressure with
2. Left occipitoanterior rotation
heel of hand.
a. Fetus in cephalic pres. LOA position.
The fetus rotates 90 degree
b. Descent and flexion
Nursing diagnosis:
c. Internal rotation complete
Impaired gas exchange
d. Extension, the face and chin are
1. Encourage the mother to lie on her side
born
from the fetal back
e.
2. Knee chest position
3. Left occipitoposterior rotation
3. Monitor FHB appropriately
a. Fetus in cephalic pres. LOP. Fetus
4. Be prepared for childbirth emergencies
rotates 135 degree
such as cs section, forceps assisted
b. Descent and flexion
delivery and neonatal resuscitation
c. Internal rottion beginning head will
rotate in alonger arc.
Pain
d. D. internal rotation complete.
1. Encourage relaxation with contraction
e. E. extension; the face and the chin
2. Apply sacral counter
are born.
3. Provide comfortable environment
f. F. external rotation: the fetus
4. Teach breathing exercises for use
rotates to place the shoulder in an
during early labor until client receives
antero-posterior position.
pharmacologic relief.
Passages:
1. Problems with maternal soft tissues
-may impede the progress of labor
 A full bladder
 Uterine myoma
 Cervical edema
 Scar tissue
 Uterine congenital
anomalies
- Emptying the bladder, may
allow labor to continue other
conditions may necessitate C/S
birth.
2. CPD: abnormal pelvis
- Cephalopelvic disproportion
- Baby’s head too large to fit
through mothers pelvis.
Risk factors:
Inc. fetal weight
Malpresentation/malposition.
Problems with pelvis
 Anterior sacrococcygeal tumors
 Small pelvis; non-gynecoid pelvis
 Rickets osteomalacia; polio
 Previous accident.
Types of CPD:
1. Inlet contraction – narrowing of the AP
diameter
2. Outlet contraction – narrowing of the
transverse diameter
Assessments:
 Pelvic inlet/ outlet <11cm
 Diabetic mother
 No engagement between 36-38
weeks of pregnancy
 Primigravida.
 Situational low self-esteem
SHOULDER DYSTOCIA.
-fetal head is born but the shoulders can’t be
delivered thru the oulet.
Causes: macrosomia
Complication:
vaginal/cervical tears
Brachial plexus injury (fractured clavicle)
Management:
1. Mcroberts maneuver – to widen pelvic
oulet.
2. Applying suprapubic pressure- to help
the shoulder to escape from beneath
the symphysis pubis.
Last resort:
 GA induced and C/s is performed
 The surgeon rotates the infant trans-
abdominally thru incision, allowing
shoulder to rotate.
 Vaginal extraction s the accomplished.
SYPHYSIOTOMY:
-intentional division of the fibrous cartilage of
the symphysis pubis.
C/S Section:
Major indications:
1. Dystocia
2. CPD
3. Fteal distress
4. Breech presentation
5. Previous C/S
Maternal risks – aspiration, haemorrhage,
infection, injury to bowel, thrombophlebitis,
pulmonary embolism.

S/S: Fetal risks: prematurity, injury at birth,

 Prolonged labor respiratory problems.
Dx test: Clinical/ xray pelvimetry and UTZ
Surgical techniques.
Nursing management: C/s section 1. Skin incision
Nursing diagnosis: a. Vertical
 Anxiety b. Pfannenstiels (transverse lower
 Fatigue abdominal incision)
 Impaired skin integrity 2. Uterine incisions
 Risk for infection A. Low transverse incisions-most
common
 B. Classical incisions- for rapid
delivery/pregnancies with
complications.
C. Low vertical incisions- used if the
body is in an awkward position.

VBAC – vaginal birth after caesarean.

-labor and vaginal birth after a previous
cesarian.

Contraindications:
a. previous classical/incision of uterus.
b. Large infant (>400g)
c. Malpresentation
d. Inadequate pelvimetry

Risks:
1. Possible uterine rupture and
haemorrhage.
2. Failure of trial of labor requires a repeat
C/S
Benefits:
1. Ability to experience labor and vaginal
delivery
2. Less costly
3. Faster, easier recovery period.

Nursing diagnosis:
 Potential injury
 Anxiety
 Fear
 Knowledge deficit.