Abnormal Obstetrics
Arlene D. Latorre RN
CONTENTS
• RISK FACTORS
ASSOCIATED WITH PREGNANCY
• BLEEDING
COMPLICATIONS IN
PREGNANCY
First Trimester Abortion, Ectopic
Pregnancy
Second Trimester
Hydatidiform Mole,
Incompetent Cervix
Third Trimester Abruptio/Ablatio
Placenta, Placenta Previa
• HYPERTENSIVE DISORDER
IN PREGNANCY
Gestational Hypertension
Chronic Hypertension
Pregnancy Induced
Hypertension
• Pre-eclampsia
• Eclampsia
• METABOLIC DISORDER IN
PREGNANCY
Diabetes Mellitus
• MEDICAL CONDITIONS
COMPLICATING PREGNANCY
Heart Disease
Anemias
Infertility
DEFINITION of TERMS
• Risk Pregnancy – is a
pregnancy with a pre-existing or
developing condition that threatens
the progression of the pregnancy,
labor and delivery of a healthy
term infant.
• Risk Factors – are
characteristics or circumstances of
a person or group that are
associated with an increased risk of
developing or affected by a morbid
process.
• At Risk Individual – is a
person with an increased
expectation of disease or
complication.
Risk Factors associated with
Pregnancy
• Maternal age factor
– Teenage pregnancy of 16
yrs. and below is considered a
high risk pregnancy from both
physical and psychosocial
standpoint
• Physical
• Because of the physical task
of adolescence
– Rapid growth during
adolescence
– Rapid growth of the fetus
• Psychosocial
– Lack of motivation
– Denial
– Ignorance
– Rebellion against authority
– Failure to complete education
– Dependence on others for
support
– Failure to establish a stable
family life
– High rate of marital failure
– High incidence of repeated
out of wedlock pregnancy
– Advanced age of 35 yrs and
above is a high risk of pregnancy
because of increased incidence of :
– Placenta previa
– Chromosomal abnormalities
– Abruptio / Ablatio placenta
– Hypertension
– Toxemia
– Low birth weight babies
• Parity
• First pregnancy – is the
period of highest risk
• Second / Third and Fourth
pregnancy – the risk of death for
the mother is at its lowest
• Fifth pregnancy – marked
increase especially when the
pregnant mother is over 40 years
of age.
Risk Factors associated with
Pregnancy
• Civil status and Cultural
groups
• Unwed mothers and
widow
– Difficulty in providing
financial support
– Inability to give personal care
• Cultural minorities – lack
information about
– Sexual behavior
– Marriage and family life
– Parenthood and pregnancy
responsibilities
– Nutritional inadequacies
– Absence of immunizations
– Lack of prenatal care
• Socioeconomic Status
• Poverty – the frontrunner of
societal ills which stem directly or
indirectly the risk factor of
pregnancy
– Lack of money – is the
principal cause of low birth weight
infants that influence morbidity
and mortality rate.
1
COMPLICATIONS OF
PREGNANCY
A. FIRST TRIMESTER
BLEEDING:
1. ABORTION - THE EXPULSION OF
THE PRODUCTS OF CONCEPTION
BEFORE THE AGE OF VIABILITY (
FETUS CAN SURVIVE
EXTRAUTERINE LIFE)
- FETUS IS LESS THAN 20 WEEKS
OR LESS THAN 500 GRAMS
Terminologies
• Abortus – a fetus that is
aborted before it is 500 gms in
weight
• Blighted ovum – a small
macerated fetus, (sometimes there
is no fetus) surrounded by a fluid
inside an open sac
• Maceration – a dead fetus
undergoing necrosis
• Fetus Papyraceous – a
fetus that is so dry that it
resembles a parchment
• Lithopedion – a calcified
embryo
• Occult pregnancy – refers
to those zygotes that were aborted
before pregnancy is diagnosed
CAUSES OF ABORTION:
1. ABNORMAL DEVLOPMENT OF
THE ZYGOTE – WHICH WOULD
HAVE RESULTED IN SEVERE
CONGENITAL ANOMALIES
2. ABNORMALITY IN THE
IMPLANTATION PROCESS - IUD
3. TRAUMA – PSYCHOLOGICAL,
PHYSICAL
4. HORMONAL IMBALANCE ( LOW
PROGESTERONE)
5. INTAKE OF DRUGS – CYTOTEC
6. INFECTIOUS DISEASES –
GERMAN MEASLES, PTB, HERPES
7. PRESENCE OF VENEREAL
DISEASES
8. ABNORMALITY IN THE
REPRODUCTIVE SYSTEM –
INCOMPETENT CERVIX
8. SEVERE MALNUTRITION
EARLY ABORTION – HAPPENS
BEFORE 16 WEEKS
LATE ABORTION – HAPPENS
BETWEEN 16 – 20 WEEKS
Types of Abortion:
• SPONTANEOUS =
UNINTENDED TERMINATION
OF PREGNANCY AT ANY TIME
BEFORE THE FETUS HAS
ATTAINED VIABILITY.
• THREATENED – POSSIBLE
LOSS OF THE PRODUCTS OF
CONCEPTION
S/SX: SLIGHT BLEEDING; MILD
UTERINE CRAMPING BUT NO
CERVICAL DILATATION ON VAGINAL
EXAMINATION;NO PASSAGE OF
TISSUE
Management:
– Bed rest
– Save all pads
– No coitus up to 2 weeks after
bleeding has stopped
• INEVITABLE OR
IMMINENT ABORTION - is a loss
of pregnancy that cannot be
prevented.
Clinical Manifestations:
• Moderate to profuse Bleeding
• Moderate to severe uterine
cramping
• Cervix dilated
• Membranes rupture
Management:
– Hospitalization
– D&C
– Oxytocin after D & C
– Emotional support
TYPES OF INEVITABLE
ABORTION:
 Complete – all products of
conception are expelled.
Sxs of complete abortion:
• Moderate bleeding
• Mild uterine cramping
• Passage of tissue
Management:
• Sympathetic understanding &
emotional support
 Incomplete – not all products
of conception are expelled from
the uterus.
Signs and Sxs:
• Profuse vaginal bleeding
• Severe uterine cramping
• Open cervix
• Passage of tissue
• Other products are retained
Treatment and MX:
• D and C
• Oxytocin after D & C
• Emotional support
▪ Missed Abortion -
Retention of all products of
conception after the death of the
fetus in the uterus
2
S/Sx:
- No FHT
- Signs of pregnancy
disappear
Management:
D&C
▪ Septic Abortion- Abortion
complicated by infection
S/Sx:
• Foul smelling vaginal
dischrage
• Uterine cramping
• Fever
Management:
• Treat abortion
• Antibiotics
▪ HABITUAL OR RECURRENT
PREGNANCY LOSS –
SPONTANEOUS ABORTION IN
THREE OR MORE SUCCESSIVE
PREGNANCIES USUALLY DUE TO
INCOMPETENT CERVIX.
 Induced Abortion – is an
intentional loss of pregnancy
through direct stimulation either by
chemical or mechanical means.
Types of induced abortion:
 Therapeutic abortion – to
preserve the life of the mother
2) Elective abortion
Reasons for Induced Abortion:
• Therapeutic – to end a
pregnancy that is life threatening
to the mother
• To end a pregnancy of a
fetus found to have severe
congenital abnormalities that may
be incompatible with life
• To end an unwanted
pregnancy that is a result of rape
or incest
• To end a pregnancy because
of woman’s choice not to have a
child yet
Prevention of abortion:
• Prepregnancy correction of
maternal disorders
• Immunization against
infectious diseases
• Proper early antenatal care
• Treatment of pregnancy
complications
• Correction of cervical
incompetency
Complications:
• Hemorrhage
• Sepsis
• Rh sensitization
2. ECTOPIC PREGNANCY - ANY
PREGNANCY THAT OCCURS
OUTSIDE THE UTERINE CAVITY.
- SECOND LEADING CAUSE OF
BLEEDING IN EARLY PREGNANCY.
TYPES:
1. AMPULAR
2. INTESTINAL
3. OVARIAN
4. CERVICAL
5. ABDOMINAL
Predisposing causes:
• Salpingitis
• Peritubal adhesions
• Previous ectopic pregnancy
• Previous tubal surgery
• Multiple previous abortion
• Tumors that distort the tubes
• External migration of the
ovum
• Intrauterine device (IUD)
Signs and Sxs:
• Vaginal spotting or bleeding
• Cul de sac mass
• Absence of amniotic sac
• Amenorrhea or abnormal
menstruation followed by slight
uterine bleeding
Signs of tubal rupture:
Severe sharp knife like pain
in the lower quadrant of the
abdomen
• Abdominal rigidity
• Nausea and vomiting
• Low hgb. And hct.
• Sharp localized pain in the
cervix on internal examination
( wiggling sign)
• Signs of hemorrhage:
• - Cullen’s sign – bluish
discoloration of the umbilicus due
to the presence of blood in the
peritoneal cavity
-Hard or rigid boardlike
abdomen
. Signs of shock:
- Falling BP, rapid pulse
- Light headedness
- Pallor
- Cyanotic nail beds
- Cold clammy skin
Diagnostic Aids
3
• Culdocentesis – aspiration of
bloody fluid from Cul de sac of
Douglas
• Ultrasound reveals presence
of the gestational sac outside of
the uterine cavity
Treatment and management:
• If not yet ruptured:
– Salpingostomy – removal of
a conceptus less than 2 cm located
at the distal portion of the fallopian
tube by performing a linear incision
over the ectopic pregnancy. The
conceptus will extrude from the
incision & removed manually.
– Salpingotomy – longitudinal
incision is made over the ectopic
pregnancy & the conceptus is
removed using forceps or gentle
suction
– Fimbrial evacuation –
removal of the conceptus by
milking & suctioning of the
fallopian tube
• If ruptured:
- Removal of the ruptured tube
because the presence of a scar
if tube is repaired & left can
lead to another tubal
pregnancy.
Surgical treatment:
-Salpingotomy
-Salpingectomy – removal
of the oviducts
• Prevent and treat
hemorrhage which is the main
danger of ectopic pregnancy.
– Blood transfusion
– Place patient flat in bed with
legs elevated
– Monitor Vital signs, I & O, &
amount of blood loss
• Prevent infection as the
woman who lost so much blood is
susceptible to infection
• Contraception must be
started upon discharge from
hospital. Ovulation begins as early
as 19 days or 3 weeks after
resection of ectopic pregnancy.
B. SECOND TRIMESTER
BLEEDING
1. GESTATIONAL
TROPHOBLASTIC DISEASE
(HYDATIDIFORM MOLE OR H-
MOLE)) - A benign disorder
characterized by degeneration of
the chorion & death of the embryo.
The chorionic villi will rapidly
proliferate and become GRAPELIKE
VESICLES THAT PRODUCE LARGE
AMOUNTS OF HCG.
CAUSES:
1. SPERM ( 23) + OVUM ( 0) +
DUPLICATION = 46
(COMPLETE MOLE)
2. SPERM (46) + OVUM (23) =
69 (PARTIAL MOLE)
3. SPERM ( 23) + OVUM + ( 23)
= 69 (PARTIAL
+
SPERM ( 23)
MOLE)
Predisposing factors:
• 17 years old below and 35
yrs. Above
• Low socioeconomic status
• Low protein intake
• Previous mole
• Higher incidence in Asian
women
TYPES:
1. COMPLETE MOLE – IF AN
EMBRYO FORMS, IT DIES EARLY AT
ONLY 1 TO 2 MM IN SIZE WITH NO
FETAL BLOOD PRESENT IN THE
VILLI.
2. PARTIAL MOLE – NO
EMBRYO PRESENT BUT FETAL
BLOOD MAY BE PRESENT. HAS 69
CHROMOSOMES ( TRIPLOID
FORMATION)
Signs and Sxs:
• Rapid increase in uterine size
greater than gestational age of the
fetus
• Marked increase HCG titer;
NV:400,00 iu
• Excessive nausea and
vomiting due to elevated HCG
• Brownish vaginal discharge
around 4th month containing
grapelike vesicles
• No FHT, no fetal movement
• No fetal parts
• Bleeding which may vary
from spotting to profuse
hemorrhage is a common sign
• No fetal skeleton
• Increase WBC
• Hypertension & other sx
of preeclampsia
• Symptoms of PIH before
24th week gestation
**difference bet.H-mole & pre-
eclampsia
4
 - before 20 weeks =H
mole
- after 20 weeks up to 2
weeks post partum =
preeclampsia
Treatment and management:
• D and C to remove the mole.
( If the woman is more than 40 yrs
old, hysterectomy is done since she
has a higher chance of developing
CHOROCARCINOMA
• Monitor HCG for 1 year ( HCG
shld be negative 2-6 weeks after
removal of H-mole.)
-when HCG level is normal it
is monitored monthly for 6 mos,
then every 2 mos until 2 years
• Chest X ray every 3 mos for 6
mos. The lungs are the most
common site of metastasis of
choriocarcinoma Chemotherapy
( Methotrexate) if:
-HCG titers are increased for
3 consecutive weeks or double at
anytime
-HCG titers remain elevated
3-4 mos. after delivery
• The woman is advised not to
get pregnant for 1 year,
contraceptive method shld NOT be
the pills. Pills contain estrogen
which promote regrowth of the
chorionic villi.
• Hysterectomy is the method
of tx for women above 40 yrs old
because of the higher incidence of
malignancies & to clients who have
completed childbearing & require
sterilization.
Prognosis:
• Favorable if HCG titers do not
recur after evacuation of the mole
• Unfavorable if malignancy
develops and is untreated
Complications of H-Mole:
• Gestational Trophoblastic
Tumors – persistent trophoblastic
proliferation after H-mole.
1. Choriocarcinoma – most
severe malignant complication that
involve the transformation of
chorion into cancer cells that
invade & erode blood vessels &
uterine muscles.
2. Invasive mole – locally invasive
& is characterized by excessive
formation of trophoblastic villi that
penetrates the myometrium.
Develops during the first 6 months
after H-mole.
3. Placental Site Trophoblastic
Tumor – arises from the site of the
placenta.
*** Management of all
trophoblastic tumors is
HYSTERECTOMY ****
NURSING MANAGEMENT:
1. MAINTAIN F & E BALANCE.
2. EMPHASIZE THAT
PREGNANCY SHOULD BE AVOIDED
FOR 1 YEAR ( GREATER CHANCE OF
IT RECURRING & MAY EVEN LEAD
TO CHORIOCARCINOMA)
3. ADMINISTER BLOOD
REPLACEMENT AS ORDERED.
4. PROVIDE EMOTIONAL
SUPPORT
5. USE MECHANICAL
EQUIPMENTS AGAINST PREGNANCY
( Ex. Condom)
2. INCOMPETENT CERVIX OR
PREMATURE CERVICAL
DILATATION: - PAINLESS
CERVICAL EFFACEMENT &
DILATATION IN EARLY
MIDTRIMESTER RESULTING IN
EXPULSION OF PRODUCTS OF
CONCEPTION.
- MOST COMMON CAUSE OF
HABITUAL ABORTION
CAUSES:
1. INCREASED MATERNAL AGE
2. CONGENITAL MALDEVELOPMENT
OF THE CERVIX – short cervix
3. TRAUMA TO THE CERVIX
( HISTORY OF REPEATED D & C’S;
CERVICAL LACERATIONS WITH
PREVIOUS PREGNANCIES )
Signs and Sxs:
• Slight vaginal bleeding
• Presence of uterine
contractions in midtrimester
• Rupture of the bag of waters
• Expulsion of the conceptus
• Presence of painless cervical
dilatation
• Relaxed cervical os on pelvic
examination
MX:
1. CERVICAL CERCLAGE –
MEDICAL MANAGEMENT WHEREIN
THE PHYSICIAN SUTURES A
CERTAIN PART OF THE CERVIX
BETWEEN 14 AND 16 WEEKS
GESTATION TO PREVENT CERVICAL
DILATATION.
5
 a. MCDONALD’S –
( temporary) NYLON SUTURES ARE
PLACED HORIZONTALLY &
VERTICALLY ACROSS THE CERVIX &
PULLED TIGHT TO REDUCE THE
CERVICAL CANAL TO A FEW
MILLIMETERS IN DIAMETER.
b. SHIRODKAR –
( permanent) STERILE TAPE IS
THREADED IN A PURSE-STRING
MANNER UNDER THE SUBMUCUS
LAYER OF THE CERVIX & SUTURED
IN PLACE TO ACHIEVE A CLOSED
CERVIX.
• After suturing the cervix:
– Place woman on bed rest for
24 hours
– Observe for bleeding, uterine
contractions, and rupture of BOW
– If BOW ruptures – the sutures
are removed
– If uterine contractions occur,
the woman is given ritodrine to
stop the contractions
– Post-op care: Restrict
activities for the next 2 weeks
including coitus
Prerequisites of Cervical
Cerclage
• Cervix not dilated
• Intact membranes
• No vaginal bleeding & uterine
cramping
C. THIRD TRIMESTER BLEEDING
1. PLACENTA PREVIA -
LOW IMPLANTATION OF THE
PLACENTA
TYPES:
1. LOW-LYING –
IMPLANTATION OF THE PLACENTA
IN THE LOWER RATHER THAN IN
THE UPPER PORTION OF THE
UTERUS
2. MARGINAL – PLACENTA
EDGE APPROACHES THAT OF THE
CERVICAL OS
3. PARTIAL – IMPLANTATION
THAT OCCLUDES A PORTION OF
THE CERVICAL OS
4. COMPLETE ( TOTALIS) –
PLACENTA THAT TOTALLY
OBSTRUCTS THE CERVICAL OS
Predisposing factors:
• Multiparity
• Advanced maternal age –
over 35 yo
• Multiple pregnancy
• Uterine tumor
• Cigarette smoking
• Scarring from previous
previous CS
• Decreased vascularity of
upper uterine
segment
Past uterine D&C
Signs and Sxs:
• Painless, bright red
vaginal bleeding during the 3rd
trimester
• Abdomen soft, non tender
• Ultrasound reveals placenta
previa
NURSING MANAGEMENT:
1. MONITOR VITAL SIGNS &
BLEEDING ( WEIGH UNUSED
PERINEAL PAD, THEN WEIGH
PERINEAL PAD SOAKED IN BLOOD,
THEN SUBTRACT. THE DIFFERENCE
IS THE WEIGHT OF THE BLOOD
LOSS.)
2. PROVIDE STRICT BED REST
TO MINIMIZE THE RISK TO FETUS.
( CBR without BRP’s )
3. OBSERVE FOR FURTHER
BLEEDING EPISODES.( PREPARE
FOR BT) ( Hgb & Hct)
4. AVOID VAGINAL
EXAMINATIONS ( NO IE). IF IE IS
INDICATED, IT SHOULD BE DONE IN
A DOUBLE SET-UP
ENVIRONMENT. ( MEANING: OR/DR)
WHEREIN THE PATIENT HAS
ALREADY SIGNED A CONSENT
FORM, PRE-OP MEDS HAVE BEEN
GIVEN, ABDOMINAL PREP HAS
BEEN DONE SO THAT IF THE
PLACENTA IS ACCIDENTALLY
DETACHED BECAUSE OF
MANIPULATIONS, CS CAN BE DONE
IMMEDIATELY.
5. PROVIDE EMOTIONAL
SUPPORT DURING THE GRIEVING
PROCESS.
6. ** CLASSICAL CESARIAN
SECTION ( UTERUS IS INCISED IN
THE VERTICAL SEGMENT) IS DONE
IN CASE OF SEVERE BLEEDING.**
** BLEEDING WITH PLACENTA
PREVIA OCCURS WHEN THE LOWER
UTERINE SEGMENT BEGINS TO
DIFFERENTIATE FROM THE UPPER
SEGMENT LATE IN PREGNANCY
( APPROXIMATELY WEEK 30) & THE
CERVIX BEGINS TO DILATE. THE
BLEEDING PLACES THE MOTHER AT
RISK FOR HEMORRHAGE. BECAUSE
THE PLACENTA IS LOOSENED, THE
6
FETAL OXYGEN MAY BE
COMPROMISED”
IMMEDIATE CARE MEASURES:
** TO ENSURE AN ADEQUATE
BLOOD SUPPLY TO THE MOTHER &
FETUS, PLACE THE WOMAN ON BED
REST IN A LEFT SIDE LYING
POSITION.**
• Assess fetal lung maturity
• Observe for PP hemorrhage
• Observe strict aseptic
technique
Complications of placenta
previa:
• Hemorrhage
• Infection
• Prematurity
2. ABRUPTIO PLACENTA -
ABRUPT SEPARATION OF AN
OTHERWISE NORMALLY IMPLANTED
PLACENTA AFTER 20 WEEKS AOG.
TYPES:
1. MARGINAL ( OVERT)
SEPARATION BEGINS AT THE
EDGES OF THE PLACENTA
ALLOWING BLOOD TO ESCAPE
FROM THE UTERUS. BLEEDING IS
EXTERNAL.
2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE
CENTER RESULTING IN BLOOD
BEING TRAPPED BEHIND THE
PLACENTA. BLEEDING THEN IS
INTERNAL AND NOT OBVIOUS.
CAUSES:
1.MATERNAL HYPERTENSION
( CHRONIC OR PREGNACY
INDUCED)
2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – MORE
THAN 5 PREGNANCIES
4. TRAUMA TO THE UTERUS
5. SUDDEN RELEASE OF AMNIOTIC
FLUID THAT CAUSE SUDDEN
DECOMPRESSION OF TE UTERUS.
6. SHORT UMBILICAL CORD
7. CIGARETTE SMOKING & COCAINE
ABUSE
S/SX:
1. SHARP PAIN IN THE FUNDAL
AREA AS THE PLACENTA
SEPARATES
2.PAINFUL DARK RED VAGINAL
BLEEDING IN COVERT TYPE
3.PAINFUL BRIGHT RED VAGINAL
BLEEDING IN OVERT TYPE
4.HARD, RIGID, FIRM,BOARD-LIKE
ABDOMEN CAUSED BY
ACCUMULATION OF BLOOD BEHIND
THE PLACENTA WITH FETAL PARTS
HARD TO PALPATE.
5. ABNORMAL TENDERNESS DUE
TO DISTENTION OF THE UTERUS
WITH BLOOD.
6. SIGNS OF SHOCK & FETAL
DISTRESS AS THE PLACENTA
SEPARATES.
PREMATURE SEPARATION OF
THE PLACENTA
CLASSIFICATION ACCORDING
TO PLACENTAL SEPARATION:
1. GRADE 0 = NO SYMPTOMS
OF PLACENTAL SEPARATION,
DIAGNOSED AFTER DELIVERY
WHEN PLACENTA IS EXAMINED &
FOUNDTO HAVE DARK, ADHERENT
CLOT ON THE SURFACE.
2. GRADE 1 = SOME
EXTERNAL BLEEDING, NO FETAL
DISTRESS, NO SHOCK, SLIGHT
PLACENTAL SEPARATION
3. GRADE 2 = EXTERNAL
BLEEDING, MODERATE PLACENTAL
SEPARATION, UTERINE
TENDERNESS, FETAL DISTRESS
4. GRADE 3 = INTERNAL &
EXTERNAL BLEEDING, MATERNAL
SHOCK, FETAL DEATH, DIC
MX:
1. WHEN PLACENTA ABRUPTIO IS
SUSPECTED OR DIAGNOSED,
HOSPITALIZATION IS A MUST.
2. BEDREST OR SIDE LYING
POSITION FOR OPTIMUM
PLACENTAL PERFUSION.
3. MONITOR VITAL SIGNS, FHT,
AMOUNT OF BLOOD LOSS – GIVE
MASK O2 IF FETAL DISTRESS IS
PRESENT.
4. DELIVERY:
** VAGINAL DELIVERY – IF THERE
IS NO SIGN OF FETAL DISTRESS,
BLEEDING IS MINIMAL & VITAL
SIGNS ARE STABLE.
** CESARIAN DELIVERY – IF
BLEEDING IS SEVERE, FETAL
DISTRESS IS PRESENT & FETUS
CANNOT BE DELIVERED
IMMEDIATELY WITH VAGINAL
METHOD.
7
COMPLICATIONS:
1. COUVELAIRE UTERUS OR
UTERINE APOPLEXY – INFILTRATION
OF BLOOD INTO THE UTERINE
MUSCULATURE RESULTING IN THE
UTERUS BECOMING HARD &
COPPER COLORED.
2. HEMORRHAGE & SHOCK –
TREATED BY BLOOD TRANSFUSION
3. DIC – MANAGED BY
FIBRINOGEN & CRYOPRECIPITATE
Disseminated Intravascular
Coagulation (DIC)
• Disorder of blood clotting
 Fibrinogen levels fall below
effective limits
( Hypofibrinogenemia)
• Symptoms
 Bruising or bleeding
 massive hemorrhage initiates
coagulation process causing
massive numbers of clots in
peripheral vessels (may result in
tissue damage from multiple
thrombi), which in turn stimulate
fibrolytic activity, resulting in
decreased platelet and fibrinogen
levels and
 signs and symptoms of local
generalized bleeding (increased
vaginal blood flow, oozing IV site,
ecchymosis, hematuria, etc)
 monitor PT, PTT, and Hct,
protect from injury; no IM injections
HYDRAMNIOS /
POLYHYDRAMNIOS
- CHARACTERIZED BY EXCESSIVE
AMOUNT OF AMNIOTIC FLUID,
MORE THAN 2000 ML.
- NORMAL AMOUNT OF AMNIOTIC
FLUID AT TERM IS 500 TO 1200 ML
CAUSES:
1. MULTIPLE PREGNANCY = ONE
FETUS USURPS THE GREATER PART
OF THE CIRCULATION RESULTING
IN CARDIOMEGALY, WHICH IN TURN
RESULTS IN INCREASED URINE
OUTPUT.
2. FETAL ABNORMALITIES:
a. ESOPHAGEAL ATRESIA –
FETAL SWALLOWING OF AMNIOTIC
FLUID IS ONE OF THE MECHANISMS
THAT REGULATE THE AMOUNT OF
AMNIOTIC FLUID. IN ATRESIA, THE
FETUS CANNOT SWALLOW
b. SPINA BIFIDA – INCREASED
TRANSUDATION OF AMNIOTIC
FLUID FROM THE EXPOSED
MENINGES.
S/SX:
1. EXCESSIVE UTERINE SIZE,
OUT OF PROPORTION TO AOG WITH
DIFFICULTY PALPATING FETAL
PARTS & FINDING FHT – PRIMARY
CLINICAL FINDINGS
2. SHORTNESS OF BREATH
CAUSED BY PRESSURE OF THE
OVERLY DISTENDED UTERUS
AGAINST THE DIAPHRAGM.
3. BACK PAIN, VARICOSITIES,
CONSTIPATION, FREQUENCY OF
URINATION & HEMORRHOIDS
DIAGNOSTIC AIDS:
1. ULTRASOUND
2. RADIOGRAPHY
COMPLICATIONS:
1. PREMATURE LABOR &
DELIVERY
2. ABRUPTIO PLACENTA
3. POSTPARTUM HEMORRHAGE
DUE TO OVERDISTENTION
4. CORD PROLAPSE
MX:
1. MILD TO MODERATE
DEGREES USUALLY DOES NOT
REQUIRE TREATMENT.
2. HOSPITALIZATION IF SX
INCLUDES DYSPNEA, ABDOMINAL
PAIN, DIFFICULT AMBULATION.
3. AMNIOCENTESIS – REMOVAL
OF AMNIOTIC FLUID TO RELIEVE
MATERNAL DISTRESS
4. INDOMETHACIN THERAPY – A
DRUG THAT DECREASES FETAL
URINE FORMATION.
SE: POTENTIAL PREMATURE
CLOSURE OF THE DUCTUS
ARTERIOSUS.
5. HEALTH INSTRUCTIONS FOR
RELIEF OF SYMPTOMS:
1. PLACE IN SEMI-FOWLERS
POSITION TO ASSIST IN BREATHING
2. EMPTY BLADDER
FREQUENTLY
3. INCREASE FLUID INTAKE &
HIGH FIBER DIET TO PREVENT
CONSTIPATION
4. REST FREQUENTLY ON LEFT
LATERAL POSITION TO PREVENT
FATIGUE & BACK PAIN.
5. WATCH CLOSELY FOR
HEMORRHAGE AFTER DELIVERY.
OLIGOHYDRAMNIOS - AMNIOTIC
FLUID LESS THAN 500 ML
CAUSES:
1. FETAL RENAL ANOMALIES
THAT RESULTS IN ANURIA
2. PREMATURE RUPTURE OF
MEMBRANES
MX:
8
 1. OBSERVE NEWBORN FOR
COMPLICATIONS THROUGHOUT
THE REMAINDER OF PREGNANCY.
a. CLUBFOOT
b. AMPUTATION
c. ABORTION
d. STILLBIRTH
e. FETAL GROWTH
RETARDATION
f. ABRUPTIO PLACENTA
2. DURING LABOR & DELIVERY
a. CORD COMPRESSION
b. FETAL HYPOXIA AS A
RESULT OF CORD
COMPRESSION
c. PROLONGED LABOR
PSEUDOCYESIS
• Or spurious pregnancy occurs
in women nearing menopause & in
women who have intense desire to
become pregnant. These women
develop the belief that they are
pregnant when in fact they are not.
The women often experiences all
the subjective symptoms of
pregnancy: fatigue, amenorrhea,
tingling sensations & fullness of the
breast, nausea & vomiting. Some
of these women repost feeling fetal
movements which are actually
movement of air in the intestines
or muscular contractions of the
abdominal wall.
Management:
– Explain pregnancy test
result, clarify misconceptions &
false beliefs
– Provide referrals when
necessary, psychologic counselling
– Provide emotional support &
understanding
Hyperemesis Gravidarum
• Excessive nausea & vomiting
that persists beyond 12 weeks
gestation & which leads to
complications like
dehydration,weight loss, starvation
& fluid & electrolyte imbalance.
S/Sx:
1.Excessive nausea & vomiting not
relieved by ordinary remedies
persisting beyond 12 weeks
2. Signs of dehydration: thirst, dry
skin, increased pulse rate, weight
loss, concentrated & scanty urine.
Management:
D10NSS 3000 ML IN 24 HOURS IS
THE PRIORITY OF TREATMENT
> REST
> ANTI-EMETIC – ( EX. PLASIL)
HYPERTENSIVE DISORDERS IN
PREGNANCY:
GESTATIONAL HYPERTENSION: -
HYPERTENSION THAT DEVELOPS
DURING PREGNANCY OR DURING
THE FIRST 24 HOURS AFTER
DELIVERY WHICH IS NOT
ACCOMPANIED BY EDEMA,
PROTEINURIA & CONVULSIONS &
DISAPPEARS WITHIN 10 DAYS
AFTER DELIVERY.
CHRONIC HYPERTENSION:
- THE PRESENCE OF
HYPERTENSION BEFORE
PREGNANCY OR HYPERTENSION
THAT DEVELOP BEFORE 20 WEEKS
GESTATION IN THE ABSENCE OF H-
MOLE & PERSIST BEYOND THE
POSTPARTUM PERIOD.
PREGNANCY INDUCED
HYPERTENSION (TOXEMIA):
- HYPERTENSION THAT
DEVELOPS AFTER THE 20TH WEEK
OF GESTATION TO A PREVIOUSLY
NORMOTENSIVE WOMAN.
PREDISPOSING FACTORS:
1. SAID TO BE A DISEASE OF
PRIMIPARAS – HIGHER INCIDENCE
IN PRIMIPARAS BELOW 17 & ABOVE
35 YEARS.
2. LOW SOCIO ECONOMIC
STATUS ( LOW PROTEIN INTAKE )
3. HISTORY OF CHRONIC
HYPERTENSION ON THE MOTHER,
H-MOLE, DIABETES
MELLITUS,MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL
DISEASE, HEART DISEASE
4. HEREDITARY
CAUSES:
1. UNKNOWN
2. PROTEIN DEFICIENCY
THEORY
3. UTERINE ISCHEMIA
4. ARTERIAL VASOSPASM
TRIAD SX:
1. HYPERTENSION
2. EDEMA ( INCRESE IN WEIGHT)
3. PROTEINURIA
VASCULAR EFFECTS →
VASOCONSTRICTION → POOR
ORGAN PERFUSION → INCREASED
BP
VASOSPASM KIDNEY EFFECTS →
DECREASED
GLOMERULI FILTRATION RATE &
INCREASED
PERMEABILITY OF PERMEABILITY
OF GLOMERULI MEMBRANES →
SERUM BLOOD UREA NITROGEN,
URIC ACID, CREATININE
9
 DECREASED URINE OUTPUT
& PROTEINURIA
INTERSTITIAL EFFECTS →
DIFFUSION OF FLUID
FROM BLOOD STREAM INTO
INTERSTITIAL
TISSUE → EDEMA
SIGNS & SYMPTOMS:
** IF MgSO4 IS GIVEN
POSTPARTUM, MONITOR FOR
UTERINE ATONY AS IT CAN CAUSE
UTERINE RELAXATION.
SIGNS & SYMPTOMS OF
ECLAMPSIA:
1. ALL THE SIGNS & SYMPTOMS OF
PREECLAMPSIA

EDEMA: S & SX MILD SEVERE

(+1) – PHYSIOLOGIC TYPE IN PREECLAM PREECLAM
PREGNANCY, THERE IS SLIGHT PSIA PSIA
EDEMA IN THE LOWER BLOOD 140/90; 160/110
EXTREMITIES ( DUE TO PRESSURE PRESSUR Systolic
& POSTURE) E elevation of
(+2) – MARKED EDEMA OF LOWER 30 mm/Hg
EXREMITIES (PATHOLOGIC) Diastolic
(+3) – EDEMA FOUND ON THE FACE elevation of
& FINGERS. 15 mm/Hg
(+4) – GENERALIZED EDEMA Proteinuri +1 to +2 +3 to +4 or
( ANASARCA) a 300 mg/24 5 g/24 hour
SEIZURE PRECAUTIONS: hour urine urine
1. SIDE RAILS UP collection collection
2.PAD THE SIDE RAILS Edema Digital Pitting
3. PUT BED AT LOWEST POSITION. edema ( +1 edema (+3
4. ROOM SHOULD BE DIM, QUIET,& +2) +4)
AWAY FROM AREAS OF ACTIVITY. Dependent Generalized
( AVOID BRIGHT LIGHTS SUCH AS edema edema
FLASHLIGHTS) Weight 2 lb/week More rapid
5. RESTRICT VISITORS TO ALLOW Gain weight gain
PATIENT TO REST. Urinary Not less thanLess than
6. HAVE EMERGENCY EQUIPMENT Output 500 ml/24 500 ml/24
AVAILBLE: hours hours
- SUCTION APPARATUS, HeadacheOccasional Severe
MAGNESIUM SULFATE, CALCIUM headache headache
GLUCONATE, O2 Reflexes Normal to Hyperreflexi
MEDICATIONS: 3+ a, 4+
1. HYDRALAZINE – Visual Absent Photophobia,
( APRESOLINE ) Disturban blurring
- ANTIHYPERTENSIVE ces spots before
2. MAGNESIUM SULFATE the eyes
( MgSO4) Epigastric Absent Right upper
- DRUG OF CHOICE TO TREAT & Pain quadrant
PREVENT CONVULSIONS. pain (aura to
ACTIONS OF MgSO4: convulsion)
a. PREVENT CONVULSION 2. CONVULSION FOLLOWED BY
b. REDUCE BLOOD PRESSURE COMA IS THE MAIN DIFFERENCE OF
CHECK THE FOLLOWING FIRST ECLAMPSIA & PREECLAMPSIA
BEFORE ADMINISTERING 3. OLIGURIA
MgSO4: MANAGEMENT:
1. DEEP TENDON REFLEX PRESENT A. AMBULATORY MX
- +2 ( NORMAL) 1. HOME MANAGEMENT IS
2. RR SHOULD BE AT LEAST 12 BPM ALLOWED ONLY IF:
3. URINE OUTPUT SHOULD BE AT a. BP IS 140/90 O BELOW
LEAST 30 ML/HR b. THERE IS NO PROTEINURIA
** IF MgSO4 TOXICITY DEVELOPS c. THERE IS NO FETAL
AS SHOWN BY RR DEPRESSION TO GROWTH RETARDATION
LESS THAN 12 BPM & d. THE PATIENT IS NOT A
DISAPPEARANCE OF THE DTR, GIVE YOUNG PRIMIPARA.
THE ANTIDOTE CALCIUM 2. BED REST – THE WOMAN
GLUCONATE & NOTIFY PHYSICIAN. SHOULD BE IN BED REST FOR

10
MOST PART OF THE DAY & FREE
FROM PHYSICAL & EMOTIONAL
STRESS.
3. THE WOMAN SHOULD CONSULT
THE CLINIC AS OFTEN AS
NECESSARY.
4. DIET SHOULD BE HIGH IN
PROTEIN & CARBOHYDRATES WITH
MODERATE SODIUM RESTRICTION.
5. HOSPITALIZATION IS NECESSARY
IF CONDITION WORSENS.
6. PROVIDE DETAILED
INSTRUCTIONS ABOUT WARNING
SIGNS:
a. EPIGASTRIC PAIN –AURA
TO CONVULSION
b. VISUAL DISTURBANCES
c. SEVERE CONTINUOUS
HEADACHE
d. NAUSEA & VOMITING
B. HOSPITAL MANAGEMENT:
1. BP GOES ABOVE 140/90 mm Hg
2. BED REST IS ONE OF THE MOST
IMPORTANT PRINCIPLES OF CARE.
a. REST IN LEFT LATERAL POSITION
TO PROMOTE BLOOD SUPPLY TO
THE PLACENTA & THE FETUS.
STAGES OF CONVULSION:
1. STAGE OF INVASION – FACIAL
TWITCHING, ROLLING OF THE EYES
TO ONE SIDE, STARING FIXEDLY IN
SPACE.
2. TONIC PHASE – BODY BECOMES
RIGID, AS ALL MUSCLES GO INTO
VIOLENT SPASMS OR
CONTRACTIONS, EYES PROTRUDE,
HANDS ARE CLENCHED, WOMAN
STOPS BREATHING FOR 15-20
SECONDS.
3. CLONIC PHASE – JAWS & EYELIDS
CLOSE & OPEN VIOLENTLY,
FOAMING OF THE MOUTH, FACE
BECOMES CONGESTED &
PURPLE,MUSCLES OF THE BODY
CONTRACT & RELAX ALTERNATELY.
THE CONTRACTIONS ARE SO
VIOLENT THAT THE WOMAN MAY
THROW HERSELF OUT OF BED.
LASTS FOR ABOUT A FEW MINUTES.
4. POST ICTAL PHASE –WOMAN IS
SEMICOMATOSE, NO MORE
VIOLENT MUSCULAR
CONTRACTIONS. THE PATIENT WILL
NOT REMEMBER THE CONVULSION
& THE EVENTS IMMEDIATELY
BEFORE & AFTER.
RESPONSIBILITIES DURING A
CONVULSION
1. ALWAYS MONITOR PATIENT FOR
IMPENDING SIGNS OF
CONVULSION: EPIGASTRIC PAIN,
SEVERE HEADACHE, NAUSEA &
VOMITING.
2 THE MAIN RESPONSIBILITIES OF
A NURSE DURING A CONVULSION
ARE: MAINTENANCE PF PATENT
AIRWAY & PROTECTION OF
PATIENT FROM INJURY.
3. TURN PATIENT TO HER SIDE TO
ALLOW DRAINAGE OF SALIVA &
PREVENT ASPIRATION.
4. NEVER LEAVE AN ECLAMPTIC
PATIENT ALONE
5. DO NOT RESTRICT MOVEMENT
DURING A CONVULSION AS THIS
COULD RESULT IN FRACTURES.
6. WATCH FOR SIGNS OF ABRUPTIO
PLACENTA: VAGINAL BLEEDING,
ABDOMINAL PAIN, DECREASED
FETAL ACTIVITY.
7. TAKE VITAL SIGNS & FHT AFTER
A CONVULSION.
8. DO NOT GIVE ANYTHING BY
MOUTH UNLESS THE WOMAN IS
FULLY AWAKE AFTER A
CONVULSION
** THE ONLY KNOWN CURE OF PIH
IS DELIVERY OF THE BABY.
** AS SOON AS THE BABY IS
STABLE, THE BABY IS DELIVERED.
** THE PREFERRED METHOD OF
DELIVERY IS VAGINAL .
** IF LABOR INDUCTION IS
UNSUCCESSFUL & FETAL DISTRESS
IS SO SEVERE THAT THE FETUS
NEED TO BE DELIVERED, CESARIAN
SECTION IS PERFORMED.
POSTPARTUM CARE:
1.THE DANGER OF CONVULSION
EXISTS UNTIL 24 HOURS AFTER
DELIVERY. MgSO4 THERAPY IS
CONTINUED UNTIL THE
IMMEDIATE 24 HOUR
POSTPARTUM.
2. ERGOT PRODUCTS ARE
CONTRAINDICATED BECAUSE THEY
ARE HYPERTENSIVES.
3. TWO YEARS SHOULD ELAPSE
BEFORE ANOTHER PREGNANCY IS
ATTEMPTED TO DECREASE THE
LIKELIHOOD THAT PIH WILL RECUR
ON THE SUBSEQUENT PREGNANCY.
HELLP Syndrome
 Serious complication of
pregnancy induced hypertension.
 Usually develops before
delivery but may occur postpartum
as well.
 HELLP syndrome consists of
the following problems:
 Hemolysis – red blood cells
break down
11
 Elevated liver enzymes –
damage to liver cells cause
changes in liver function lab tests
 Low platelets – cells found in
the blood that are needed to help
clot the blood to control bleeding
HELLP syndrome can cause
other problems
 Anemia – breakdown of
RBC’s may cause anemia
 DIC – may lead to severe
bleeding
 Placenta abruptio – may also
occur
SSx of HELLP syndrome:
 Right sided upper abdominal
pain around the stomach
( epigastric area)
 Nausea & vomiting
 Headache
 Increased BP
 Protein in the urine
 edema
How is HELLP diagnosed?
 BP measurement
 RBC count ( hemolysis)
 Bilirubin level – substance
produced by the breakdown of RBC
 Liver function tests ( ALT &
AST)
 Platelet count
( thrombocytopenia )
 Urine tests for protein
Treatment:
 Bedrest
 Blood transfusion
 MgSO4 ( as anti convulsant)
 Antihypertensive medications
 Lab testing of liver, urine &
blood ( for changes that may signal
worsening of HELLP syndrome
 Corticosteroids – to help in
the maturity of fetal lungs
 Delivery ( if HELLP syndrome
worsens & endangers the well
being of the mother or fetus)
Multiple Pregnancy
 When 2 ( twin), 3 (triplet), 4
(quadruplet) or even 5 ( quintuplet)
fetuses develop in the uterus at the
same time
 Associated with more risks
than a singleton pregnancy
TYPES:
 MONOZYGOTIC or
IDENTICAL TWIN
 Develop from one ovum &
one sperm cell that undergo rapid
cell division after fertilization that
resulted in two or more individuals.
Since they come from only one
sperm and one ovum, these
individuals possess the same
genetic traits and are always of the
same sex.
 If twinning occurred within 72
hours after fertilization, there will
be:
 2 amnions ( diamnionic)
 2 chorions ( dichorionic)
 2 embryos
 If twinning occurred between
the 4th & 8th day after fertilization,
there will be :
 2 amnions
 1 chorion ( monochorionic)
 2 embryos
 If twinning occurred after 8
days, there will be :
 1 amnion ( monoamnionic)
 1 chorion
 2 embryos
 If twinning occurred after the
embryonic disc is formed,
CONJOINED TWINS will develop.
Conjoined twins are classified
according to the part of the body
where they are attached.
 Anterior – Thoracopagus
 Posterior – pyopagus
 Cephalic – craniopagus
 Caudal – Ischiopagus
 DIZYGOTIC TWINS or
FRATERNAL TWINS
 Develop from 2 or more ova
and sperm cells that were fertilized
at the same time. They have the
same genetic traits, may or may
not be of the same sex and always
have 2 chorions & 2 amnions.
** More females than males
because female zygote has a
higher tendency to divide into
twins
** Female zygotes have higher rate
of survival than male zygotes
 Predisposing factors of
Dizygotic Twinning
 Race – highest in black
women
 Heredity – more common in
women with familial history of
twinning
Age & parity – increased

incidence in high parity &
advanced maternal age
 Higher incidence in women
taking fertility drugs that promote
12
ovulation & release of several ova
at the same time
 Higher incidence within the
first months after stopping oral
contraceptives because of the
sudden & greater amount of
pituitary gonadotropin released at
this time
 In vitro fertilization –
stimulation of formation of
numerous follicles, harvesting
them in the ovary & fertilizing them
in vitro. All zygotes that were
fertilized are returned to the uterus
to grow & develop
Complications of Multiple
Fetuses:
 Abortion
 Death of one fetus
 Perinatal mortality
 Preterm labor – as the
number of fetuses increases, the
duration of pregnancy decreases
 Low birth weight
 Congenital malformations
 Hydramnios
 Maternal hypertension
 Placenta previa & Abruptio
placenta
 Intrauterine growth
retardation
 Cord entanglement, prolapse
& compression
 Maternal anemia
S/Sx
 1. Uterus large for
gestational age
 2. Auscultation of two or
more fetal heart tone
 3. Hx of twins in the family
 Palpation of three or more
large fetal parts
 Ultrasound reveals two or
more gestational sac
Management:
 Clinic Visit:
 First Trimester – every month
 Second Trimester – every 2
weeks
 Third Trimester – every week
 Nutrition – additional 300
kcal to the normal pregnancy
requirement
 6 small meals rather than 3
large meals to decrease discomfort
of a large uterus compressing a full
stomach
Labor and Delivery:
 The cord is cut right after
delivery of the first infant
 Presentation of second infant
is ascertained after birth of first
twin either by ultrasound or
Leopold’s or both
 The normal interval of
delivery of the first twin and
second twin is (30 minutes)
 If the second twin cannot be
delivered vaginally because of
abnormal position, CS is done.
 Cesarean delivery – delivery
of choice if the twins or one of
them cannot be delivered normally
or if complications arise that
necessitate immediate delivery.
 Post partum period – watch
out for Hemorrhage due to
overdistention of the uterus.
Premature Labor:
 Is labor that occurs between
20 weeks to 37 weeks gestation
characterized by regular uterine
contraction that lasts more than 30
seconds & result in cervical
dilatation & effacement. It is the
greatest cause of neonatal
mortality & morbidity.
Causes:
 PROM – most often
associated with infection
 Infection of amniotic fluid –
responsible microorganisms are
trichomonas vaginalis, chlamydia
trachomatis & mycoplasma
 Retained IUD
 Fetal death
 History of premature labor &
abortion
 Overdistention of the uterus –
caused by multiple pregnancy,
hydramnios
 Abnormal placentation
 Uterine abnormalities
 Incompetent cervix
 Serious maternal conditions
SSx:
 Dx is made when there is
regular uterine contractions
occuring 5-8 minutes apart
accompanied by:
 Progressive cervical changes
 Cervical dilatation of more
than 2 cm
 Cervical effacement of 80%
or more
 Duration of at least 30 secs
 10 mins apart
13
 Menstrual like cramping
 Watery or bloody vaginal
discharge
 Low back pain
MX:
1. Prevention – regular prenatal
check up
2. If fetus is less than 32-34
weeks, still premature labor to be
delivered, so labor must be
arrested:
1. Bedrest on LLP to
promote blood flow to the placenta
2. Hydration – IV fluids
3. Tocolytics –
medications to stop uterine
contractions
1. Ritodrine Hcl
2. Terbutaline –
( check pulse rate because it can
cause tachycardia)
3. Prostaglandin
inhibitors ( Indomethacin)
Drugs to hasten fetal lung
maturity:
- GLUCOCORTICOID therapy
if labor can be delayed for 48 hours
– administration of
BETAMETHASONE accelerate fetal
lung maturity & prevents
respiratory distress & hyaline
membrane disease ( most common
problem of the premature
neonate).
Medical Conditions
Complicating Pregnancy
HEART DISEASE
CLASSIFICATION:
1. CLASS I = NO LIMITATION,
UNCOMPROMISED
= ASYMPTOMATIC, NO
DISCOMFORT WITH ORDINARY
PHYSICAL ACTIVITY.
2. CLASS II =SLIGHT
LIMITATION, SLIGHTLY
COMPROMISED, ORDINARY
ACTIVITY CAUSES DYSPNEA,
FATIGUE, CHEST PAIN &
PALPITATIONS.
3. CLASS III = MARKED
LIMITATION LESS THAN ORDINARY
ACTIVITY CAUSE EXCESSIVE
FATIGUE; PALPITATIONS, CHEST
PAIN & DYSPNEA.
4. CLASS IV =SEVERE
LIMITATION; PATIENT EXPERIENCES
SYMPTOMS EVEN AT REST; UNABLE
TO PERFORM ANY PHYSICAL
ACTIVITY WITHOUT DISCOMFORT.
SIGNS & SYMPTOMS:
1.DIFFICULTY OF BREATHING –
DYSPNEA, ORTHOPNEA,
NOCTURNAL DYSPNEA
2. HEMOPTYSIS
3. SYNCOPE WITH EXERTION
4. CHESTPAIN
5. CYANOSIS
7. CLUBBING OF FINGERS
8. NECK VEIN DISTENTION
9. SYSTOLIC & DIASTOLIC
MURMURS
NURSE ALERT:
** REMEMBER A PREGNANT
WOMAN WITH HEART DISEASE
SHOULD AVOID INFECTION,
EXCESSIVE WEIGHT GAIN,
EDEMA & ANEMIA BECAUSE
THESE CONDITIONS INCREASE THE
WORKLOAD OF THE HEART.
MX:
A. PRENATAL CARE:
1. PROMOTION OF REST ( CLASS I &
CLASS II)
* 8 HOURS OF SLEEP DURING
THE NIGHT & HAVE FREQUENT
REST PERIODS DURING THE DAY.
* LIGHT WORK IS ALLOWED
BUT NO HEAVY WORK, NO STAIR
CLIMBING, NO EXHAUSTION.
2. DIET
* HIGH IN IRON, PROTEIN,
MINERALS & VITAMINS
3. AVOID HIGH ALTITUDES,
SMOKING AREAS, UNPRESSURIZED
PLANES & OVERCROWDED AREAS.
CIGARETTE SMOKING & ALCOHOLIC
BEVERAGES ARE STRICTLY
PROHIBITED.
4. PREVENTION OF INFECTION
* AVOID PERSONS WITH
ACTIVE INFECTIONS (COLDS,
COUGH).
* EARLY TREATMENT OF
INFECTIONS
5. PROVIDE INSTRUCTIONS ON
DANGER SIGNS OF HEART FAILURE:
* COUGH WITH CRACKLES IS
USUALLY THE FIRST SIGN OF AN
IMPENDING HEART FAILURE.
* INCREASING DYSPNEA,
TACHYCARDIA, RALES, EDEMA
MEDICATIONS:
>IRON SUPPLEMENTATION TO
PREVENT ANEMIA >DIGITALIS TO
STRENGTHEN MYOCARDIAL
CONTRACTION AND SLOW DOWN
HEART RATE >NITROGLYCERINE TO
RELIEVE CHEST PAIN >ANTIBIOTICS
TO PREVENT AND TREAT
INFECTION
14
>DIURETICS MAY BE PRESCRIBED
IN CASE OF HEART FAILURE
INTRAPARTAL CARE
1. EARLY HOSPITALIZATION-
WOMAN IS HOSPITALIZED BEFORE
LABOR BEGINS TO PROMOTE REST,
FOR CLOSER SUPERVISION AND
PREVENT INFECTION
2. WOMAN LABOR’S IN SEMI-
FOWLER’S POSITION OR LEFT
LATERAL RECUMBENT POSITION.
NO LITHOMY POSITION.
3. VITAL SIGNS- VITAL SIGNS ARE
MONITORED CONTINUOUSLY.
TACHYCARDIA AND RESPIRATORY
RATE MORE THAN 24 ARE SIGNS
OF IMPENDING CARDIAC
DECOMPENSATION. DURING THE
FIRST STAGE, MONITOR VITAL
SIGNS EVERY 15 MINUTES AND
MORE FREQUENTLY DURING THE
SECOND STAGE
4. EPIDURAL ANESTHESIA- IS
INSTITUTED FOR PAINLESS AND
PUSHLESS DELIVERY. FORCEPS IS
USED TO SHORTEN THE SECOND
STAGE. PUSHING IS
CONTRAINDICATED
5. WOMEN WITH HEART DISEASE
ARE POOR CANDIDATE FOR CS DUE
TO INCREASED RISK FOR
HEMORRHAGE, *INFECTION AND
THROMBOEMBOLISM
POSTPARTUM CARE
1. THE MOST DANGEROUS
PERIOD IS THE IMMEDIATE
POSTPARTUM BECAUSE OF THE
SUDDEN INCREASE IN
CIRCULATORY BLOOD VOLUME..
2. MONITOR VITAL SIGNS.
3. PROMOTE REST- RESTRICT
VISITORS TO ALLOW PATIENT TO
REST, THE WOMAN STAYS IN THE
HOSPITAL LONGER, UNTIL CARDIAC
STATUS HAS STABILIZED.
4. EARLY BUT GRADUAL
AMBULATION TO PREVENT
THROMBOPHLEBITIS.
5. MEDICATIONS
*ANTIBIOTICS
*STOOL SOFTENERS TO
PREVENT STRAINING AT STOOL
CAUSED BY CONSTIPATION.
SEDATIVES MAY BE ORDERED TO
PROMOTE REST.
6. BREASTFEEDING IS ALLOWED
IF THERE ARE NO SIGNS OF
CARDIAC DECOMPENSATION
DURING PREGNANCY, LABOR AND
PUEPERIUM
The Anemias of Pregnancy
 Hemoglobin level of less than
11g/dl in the first and third
trimester and less than 10.5g/dl in
the second trimester.
Iron Deficiency Anemia
 Most common type of anemia
during pregnancy. Most women
enter pregnancy without enough
iron reserve so that deficiency
develops particularly on the 2nd and
3rd trimester when iron
requirements increases.
Predisposing Factors:
 Poor diet and poor nutrition
 Heavy menses
 Pregnancies at close
intervals, successive pregnancies
 Unwise reducing programs
**Nurse Alert**
“ The newborn of the severely
anemic mother IS NOT AFFECTED
by iron deficiency anemia. This is
because the amount of iron
transported to the fetus of an
anemic mother is almost the same
as the amount transported to the
fetus of a mother without anemia”
Signs and Symptoms
 Easy fatigability
 Sensitivity to cold
 Proneness to infection
 Dizziness
 Laboratory findings
Effects of Anemia to Pregnancy
 Decreased resistance to
infection
 Associated with prematurity
& low birth weight infants
 Predispose to heavy bleeding
during labor & puerperium
 May increase digestive
discomfort of pregnancy
Management:
1. Oral iron supplementation – 200
mg of elemental iron daily in the
form of:
– Ferrous Sulfate – the most
absorbable form of iron
– Ferrous Fumarate
– Ferrous Gluconate
 Inform the mother about the
possible side effects. Tarry stool,
constipation, GI discomfort
 Never take with milk but with
citrus juice
 If given in liquid form, use
straw to prevent staining the teeth.
Tell patient to rinse mouth.
 If iron is to be given
parenterally, give IM b Z tract
technique to prevent tissue
15
staining. Do not massage after
injection.
 Oral iron should be continued
until 3 months after anemia has
been corrected.
 Increase intake of iron rich
foods: lean meat, liver, dark green
leafy vegetables. Good food
sources of iron include the
following:
– Meats – beef, pork, lamb,
liver,& other organ meats
– Poultry – chicken, duck,
turkey, liver ( especially dark meat)
– Fish – shellfish, including
clams, mussels, oysters, sardines
and anchovies
– Leafy greens of the cabbage
family such as broccoli
– Legumes such as lima beans
& green peas; dry beans & peas
– Yeast-leavened whole wheat
bread & rolls
– Iron enriched, white bread,
pasta, rice & cereals
Folic Acid Deficiency Anemia
 Folic acid is necessary for the
normal formation and nutrition of
red blood cells. Deficiency in folic
acid leads to the formation of large
and immature blood cells that have
shorter life span than normal red
blood cells. Women who have folic
acid deficiency during pregnancy
are more at risk of giving birth to
babies with neural tube defects.
Effects on Pregnancy:
– ABORTION, Abruptio
placenta, Neural defect in fetus
Predisposing Factors:
– 1. Long term use of oral
contraceptives
– 2. Poor nutrition
– 3. Multiple pregnancies
– 4. Successive pregnancies
Signs and Symptoms
– 1. Nausea
– 2. Vomiting
– 3. Anorexia – lack of appetite
Management:
 Folic acid supplementation of
1 mg/day accompanied oral iron.
RDA for all women – 0.4mg/day
 Vit supplements containing
400 micrograms of folic acid are
now recommended for all women
of chilbearing age and during
pregnancy. These supplements are
needed because natural food
sources of folate are poorly
absorbed and much of the vitamin
is destroyed in cooking. Food
sources of folate include the ff:
 Leafy dark green vegetables,
dried beans & peas, citrus fruits &
juices & most berries, fortified
breakfast cereals, enriched grain
products
Hemolytic Disease:
ISOIMMUNIZATION / RH
INCOMPATIBILITY
- OCCURS WHEN AN RH-NEGATIVE
MOTHER IS CARRYING AN RH-
POSITIVE FETUS.
- FOR SUCH A SITUATION TO
OCCUR, THE FATHER OF THE CHILD
MUST EITHER BE A HOMOZYGOUS (
DD) OR HETEROZYGOUS ( Dd) RH
POSITIVE.
- IF THE FATHER OF THE CHILD IS
HOMOZYGOUS (DD), 100% OF THE
COUPLE’S CHILDREN WILL BE RH
(+).
-PEOPLE WHO HAVE RH (+) BLOOD
HAVE A PROTEIN FACTOR ( D
ANTIGEN) THAT RH (-) PEOPLE DO
NOT.
- WHEN AN RH(+) FETUS BEGINS
TO GROW INSIDE AN RH (-)
MOTHER, IT IS THOUGH HER BODY
IS BEING INVADED BY FOREIGN
AGENT, OR ANTIGEN.
- THEORETICALLY, THERE IS NO
CONNECTION BETWEEN FETAL
BLOOD & MATERNAL BLOOD
DURING PREGNANCY BUT
SOMETIMES ACCIDENTAL BREAKS
IN THE PLACENTAL VILLI RESULTS
IN FETAL BLOOD ENTERING THE
MATERNAL BLOODSTREAM. (also
AMNIOCENTESIS , PUBS).
- ONLY A FEW ANTIBODIES ARE
FORMED THIS WAY SO THAT IT
DOES NOT AFFECT THE FIRST
INFANT.
- DURING PLACENTAL SEPARATION
AND DELIVERY, A GREAT AMOUNT
OF MATERNAL & FETAL BLOOD ARE
MIXED, CAUSING THE MOTHER TO
PRODUCE LARGE AMOUNTS OF
ANTIBODIES DURING THE FIRST 72
HOURS AFTER PLACENTAL
DELIVERY.
- IF THE FETUS IN SUBSEQUENT
PREGNANCIES IS RH (+), THE
ANTIBODIES ALREADY PRESENT IN
THE BLOODSTREAM WILL ATTACK
& DESTROY THE FETAL RED BLOOD
CELLS ( HEMOLYSIS). THE FETUS
BECOMES SO DEFICIENT IN RBC’S
16
THAT SUFFICIENT O2 TRANSPORT
TO BODY CELLS CANNOT BE
MAINTAINED. THIS CONDITION IS
TERMED “ HEMOLYTIC DISEASE
OF THE NEWBORN” OR
ERYTHROBLASTOSIS FETALIS.
DX:
1.INDIRECT COOMB’S TEST –
PRESENCE OF ANTIBODIES IN
MATERNAL SERUM.
2. DIRECT COOMB’S TEST –
PRESENCE OF ANTIBODIES IN
FETAL CORD BLOOD.
Prevention:
 Administration of Rh ( anti D)
globulin (Rhogam) at 28 weeks
gestation and within the first 72
hours after delivery to a woman
who:
– Have delivered Rh positive
fetus
– Have had untypeable
pregnancies such as ectopic
pregnancies, stillbirth & abortion
– Have received ABO
compatible Rh positive blood
– Have had invasive diagnostic
procedure such as amniocentesis,
PUBS ( cordocentesis)
 ABO INCOMPATIBILITY
– Occurs when maternal blood
type is O and fetus is:
 Type A – most common
 Type B – most serious
 Type AB – rare
MX of HEMOLYTIC DISEASE:
1. SUSPENSION OF
BREASTFEEDING DURING THE
FIRST 24 HOURS TO PREVENT
PREGNANEDIOL (BREAKDOWN
PRODUCT OF PROGESTERONE
EXCRETED IN BREASTMILK) FROM
INTERFERING WITH THE
CONJUGATION OF INDIRECT
BILIRUBIN TO DIRECT BILIRUBIN.
2. PHOTOTHERAPY –
DESTRUCTION OF RBC’S RESULTS
IN THE FORMATION OF INDIRECT
BILIRUBIN. INDIRECT BILIRUBIN
MUST FIRST BE CONVERTED TO
DIRECT BILIRUBIN BY THE LIVER
CELLS BEFORE IT CAN BE
EXCRETED IN THE BODY. THE
LIVER IS IMMATURE AT BIRTH SO
IT CANNOT CONVERT LARGE
AMOUNTS OFBILIRUBIN FORMED
DURING HEMOLYSIS OF RBC.
a. USES BILI OR FLUORESCENT
LIGHTS POSITIONED 12 – 30
INCHES ABOVE THE INFANT.
NURSING CARE DURING
PHOTOTHERAPY:
1. COVER EYES WITH DRESSING
2. COVER GENITALS TO
PREVENT PRIAPISM.
3. EXPECT THE STOOL TO BE
LOOSE & BRIGHT GREEN FROM
EXCESSIVE BILIRUBIN EXCRETION
& THE SKIN TO BE DARK BROWN (
BRONZE BABY SYNDROME).
4. PROVIDE GOOD SKIN CARE
BECAUSE STOOL CAN BE
IRRITATING TO THE SKIN.
5. EXPECT THE URINE TO BE
DARK COLORED BECAUSE OF
UROBILINOGEN FORMATION.
6. ASSESS FOR DEHYDRATION (
I & O ; SKIN TURGOR). FLUID LOSS
THROUGH INSENSIBLE WATER
LOSS MAY OCCUR BECAUSE OF
THE HEAT FROM THE
FLUORESCENT LIGHT ABOVE THE
INFANT.
7. OFFER GLUCOSE WATER
EVERY 3 HOURS TO PREVENT
DEHYDRATION.
8. MAINTAIN BODY TEMP
BETWEEN 36C & 37C.
EXCHANGE TRANSFUSION:
1. INTRAUTERINE
TRANSFUSION:
- DONE BY INJECTING RBS’C
DIRECTLY INTO A VESSEL IN THE
FETAL CORD OR DEPOSITING THEM
IN THE FETAL ABDOMEN USING
AMNIOCENTESIS TECHNIQUE.
- BLOOD USED FOR
TRANSFUSION IS EITHER THE
FETUS’ OWN TYPE OR GROUP O
NEGATVE IF THE FETAL BLOOD
TYPE IS UNKNOWN.
-FROM 75 TO 150 ML OF
WASHED RBC’S WILL BE USED,
DEPENDING ON THE AGE OF THE
FETUS.
- INTRAUTERINE
TRANSFUSION IS NOT WITHOUT
RISK. A CORD VESSEL MAY BE
17
LACERATED BY THE NEEDLE. BUT
FOR A FETUS WHO IS SEVERELY
AFFECTED BY ISOIMMUNIZATION,
HOWEVER, SUCH A RISK IS NO
GREATER THAN LEAVING THE
FETUS UNTREATED.
- MOTHER RECEIVES AN RhIG
INJECTION( RhoGAM) AFTER THE
TRANSFUSION TO HELP REDUCE
ISOIMMUNIZATION FROM THE
AMNIOCENTESIS.
- AS SOON AS FETAL
MATURITY IS REACHED ( L:S RATIO
2:1), DELIVERY WILL BE INDUCED.
NOTE:
ADMINISTER RhoGAM TO ALL Rh
(-) MOTHERS DURING PREGNANCY (
AT 28 WEEKS GESTATION) AND
WITHIN 72 HOURS OF DELIVERY OR
ABORTION OF AN Rh (+) FETUS **
- AFTER BIRTH, THE INFANT
MAY REQUIRE AN EXCHANGE
TRANSFUSION TO REMOVE
HEMOLYZED BLOOD CELLS &
REPLACE THEM WITH HEALTHY
ONES.
Notify your healthcare provider if
your baby has any of the following
after returning home:
> Fever
> Jaundice
> Poor appetite or poor
weight gain
> Excessive crying that does
not stop when the baby is held.
Signs in the newborn:
 Paleness
 Jaundice that begins within
24 hours after delivery
 Unexplained bruising or
blood spots under the skin
 Tissue swelling ( edema)
 Seizures
 Lack of normal movement
 Poor reflex response
Toxic Shock syndrome
Reproductive age, near menses or
postpartum period
D/t S. Aureus
R/t use of tampons, cervical cap
or diaphragm
Manifestations: fever, rash on
trunk, desquamation of skin,
hypotension, dizziness, vomiting,
diarrhea, myalgia, inflamed
mucous membranes
Management:
IV fluids
Antibiotics
Client education – change tampons
3-6 hours, avoid tampons 6-8 wks
after childbirth, do not leave
diaphragms>48 hours
Endometriosis
Endometrial tissue outside the
uterine cavity
Pelvis most common location
Bleeding results to inflammation,
scarring of peritoneum and
adhesions
Cause unknown
Common in 20-45 yrs old
Common Sites 0f Endometriosis
Formation
Risk Factors:
Retrograde menstrual flow of
endometrium
Physiologic disruption after gyne
surgery or cesarean birth
Hereditary
Possible immunologic effect
Manifestations:
Pelvic pain – dull/cramping, r/t
menstruation
Dyspareunia
Abnormal uterine bleeding
Fixed tender retroverted uterus
Palpable nodules in the cul de sac
Diagnostics:
laparoscopy
Management:
OCP-combination contraceptives to
induce amenorrhea
Analgesics
NSAIDS
Danazol – antiprogesterone;
suppresses GnRH, low estrogen
and high androgens to suppress
ovulation, promote amenorrhea
and decrease endometrial
supportGnRH agonists ie leuprolide
suppress the menstrual cycle
through estrogen
antagonismProgestins ie
18
Medroxyprogesterone –
antiendometrial effect
Metabolic Disorders in
Pregnancy
Gestational Diabetes Mellitus
-is hereditary endocrine disorder
due to inadequate or lack of insulin
production that results in impaired
glucose absorption & metabolism.
SSx:
1. Hyperglycemia – pancreas
does not produce enough insulin ,
thus glucose is unable to enter the
cells & accumulates in the
bloodstream resulting in
hyperglycemia
2. Glycosuria –when blood
glucose levels goes beyond the
renal threshold for sugar, glucose
spills on the urine.
3. Polyuria – glucose attracts
water so that when it is excreted in
the kidney, it brings along with it
large amounts of water resulting in
the woman excreting large
amounts of urine, a condition
called, POLYURIA.
4. Polydipsia – the excretion of
large amounts of fluid from the
body leads to dehydration.
Excessive thirst or polydipsia is an
important symptom of dehydration.
5. Weight loss – since glucose
cannot be utilized as a source of
energy, the body uses its protein &
fats stores in the muscles &
adipose tissue resulting in weight
loss.
6. Ketoacidosis – breakdown
of proteins & fats result to
excessive formation of ketone
bodies that the body cannot
excrete right away causing them to
accumulate.
Effects of Diabetes:
Mother:
1. Increased tendency to pre-
eclampsia & eclampsia, UTI, &
candidiasis
2. Increased risk for postpartum
hemorrhage d/t overdistention of
the uterus.
3. Maternal mortality
4. Preterm delivery
Infant:
1. Macrosomia
2. Hydramnios
3. Prematurity
4. Intrauterine growth retardation
( IUGR)
5. Hypoglycemia
6. Predisposition to diabetes
mellitus later in life as the disease
is hereditary
Complications:
1. Macrosomia – baby that is
larger than normal. All the
nutrients that the fetus receives
comes directly from the mother’s
blood.
2. Birth Injury – may occur
due to the baby’s large size and
difficulty being born.
3. HYPOGLYCEMIA – refers to
low blood sugar in the baby
immediately after delivery. This
problem occurs if the mother’s
blood sugar levels have been
consistently high, causing the fetus
to have a high level of insulin in its
circulation. After delivery, the baby
continues to have a high insulin
level, but no longer has the high
level of sugar from its mother,
resulting in the newborn’s blood
sugar level becoming very low. The
baby’s blood sugar level is checked
after birth, and if the level is too
low, it may be necessary to give
the baby glucose intravenously
4. Respiratory distress
(difficulty breathing) – too much
insulin or too much glucose in a
baby’s system may delay lung
maturation and cause respiratory
difficulties in babies. This is more
likely if they are born before 37
weeks of pregnancy.
Prenatal Management:
1.Diagnosis; Suspect DM in a
woman
• With family history of DM
• With history of unexplained
repeated abortions and stillbirth
• With glycosuria
• Who are obese
• Who have history of giving
birth to large infants, over 10 lbs.
and infants with congenital
anomaly
2. Screening tests
• Universal screening- 50 gram
oral glucose tolerance test ( OGTT)
between 24-28 weeks gestation
irregardless of the time of the day
and meals taken for all pregnant
women. If the plasma value is more
than 140 mg/dl after one hour, 100
gram three hour oral glucose
tolerance test is performed to
19
confirm if the woman is having
hypergycemia. Time of Venous Plasma
Test Level Level
Criteria of 100 gram Oral Fasting 90mg/dl 105mg/dl
Glucose Tolerance Test-
(Instruct not to eat after 1-hour 165mg/dl 190mg/dl
midnight)

2-hour 145mg/dl 165mg/dl

• Blood tests for sugar by

Testape and Clinistix. Benedict’s 3-hour 125mg/dl 145mg/dl
• test and Clinitest are
inaccurate when testing sugar
• Advise woman to eat
during pregnancy because these
complex carbohydrates before
test measure all kinds of sugar
exercising to prevent
including lactose which is normally
hypoglycemia.
present in the urine of pregnant
Remember that hypoglycemia
women, thereby, giving false
could occur in persons undergoing
positive result.
insulin therapy during peak action
• Urine test for acetone by
hour of insulin:
acetest.
 Short acting or regular insulin
3.Diet
– after 2-3 hours of injection
• Caloric intake should be
 Intermediate or Lente insulin
enough to meet needs of
– after 6-8 hours of injection
pregnancy, fetus and mother
 Long-acting or ultralente –
(1,800 to 2,400 cal/day) but not too
after 16 – 18 hours of injection
much to promote excessive weigh
 The sign of hypoglycemia
gain. 20% of caloric intake should
are: dizziness, diaphoresis,
come from protein foods, 50% from
weakness, blurring of vision
carbohydrates, 30% from fats.
 Give a hypoglycemic person
• Weight gain should be about
a glass of orange juice.
24 lbs. Too much weight gain can
5. Insulin therapy
lead to large infants and
• Insulin requirements increase
cephalopevic disproportion.
during pregnancy
• Teach and instruct to:
• Oral hypoglycemics such as
 Reduce saturated fat
Tolbutamide and Diamicron are
 Reduce cholesterol
contraindicated during pregnancy
 Increase dietary fiber
because they are teratogenic for
 Avoid fasting and feasting
they can cross the placenta and
• Have the woman become
may cause fetal and new born
familiar with food exchange list and
hypoglycemia.
caloric values of foods she usually
• Combined fast acting and
eats to enable her to plan her diet
intermediate insulin made up of
properly and estimate her caloric
human derivative/humulin.
intake accurately.
Humulin is the insulin of choice
• The goal is to maintain a
during pregnancy because it is the
fasting blood sugar level of 80
least allergic
mg/dl and postprandial blood sugar
• 2/3 in the morning, 1/3 at
level of 110mg/dl
dinner administered
4. Exercise
subcutaneously ½ hour before
• A liberal cardiovascular-
meals.
conditioning exercise and diet
• Insulin requirement is
therapy is the management for
decreased on the first trimester
Gestational Diabetes Mellitus
due to nausea & vomiting and
• Exercise lowers blood
highest during the third trimester.
glucose levels and decreases the
6.Home blood glucose monitoring-
need for insulin.
• Dextrometer
• The exercise regimen should
• 4x a day, upon rising in the
be individualized, performed
morning, before breakfast, lunch,
regularly and under supervision.
dinner

20
• Normal fasting – 80 mg/dl,
postprandial - 110mg/dl
7. Observe for urinary and vaginal
tract infections particularly
candidiasis
8. Fetal well-being assessment
• Uteroplacental Function Tests
– NST and CST
• Amniocentesis to determine
fetal lung maturity
Delivery:
• Delivery is effected when the
fetus is mature enough after 38
weeks gestation, but not too large
so as to cause cephalopelvic
disproportion. Thus, early
hospitalization and labor induction
is performed to deliver the baby
before it becomes too large to pass
the birth canal
• If cervix is not yet ripe, baby
is macrosomic and fetal distress
occurs, CS is performed
• Regular insulin is given on
the day of delivery not long acting
insulin because insulin requirement
drop immediately after delivery.
The woman may not require insulin
during the first 24 hours
postpartum and her insulin
requirements usually fluctuates
during the next few days.
Postpartum:
1.Recurrence of diabetes may
occur in subsequent pregnancies.
2.Women who develop gestational
diabetes have higher tendency to
develop overt diabetes later in life.
3.Newborn Care:
 Keep warm because of poor
temperature control mechanisms
 Observe respiration (stomach
aspiration necessary at time of
birth, since hydramnios inflates
stomach which pushes up and
interferes with diaphragm and lung
expansion)
 Observe for signs of
hypoglycemia (shrill cry, weakness)
– give glucose water
 Observe for signs of
hypocalcemia (tetany, tremors) –
give calcium gluconate
 Observe for congenital
anomalies: esophageal atresia,
neural tube defect
4. Contraception:
• IUD and combined oral
contraceptives are contraindicated
• Norplant (progestin implant
system) and progestin only pill
(minipills) may be used safely by
diabetic women
COMPLICATIONS OF LABOR
1. DYSTOCIA – PROLONGED &
DIFFICULT LABOR ( LABOR THAT
LASTS MORE THAN 24 HOURS).
CAUSES:
A. ABNORMALITIES OF THE
POWER / UTERINE
DYSFUNCTION
a. HYPOTONIC UTERINE
CONTRACTION – WEAK &
INFREQUENT CONTRACTIONS
WHICH ARE INSUFFICIENT TO
DILATE THE CERVIX. USUALLY
OCCURS DURING THE ACTIVE
PHASE
CAUSES:
1. OVERDISTENTION OF THE
UTERUS
2. PELVIC BONE CONTRACTION
3. UNRIPE OR RIGID CERVIX
4. CONGENITAL ANOMALIES OF
THE UTERUS.
MX:
1. REEVALUATE PELVIC SIZE TO
RULE OUT FETOPELVIC
DISPROPORTION
2. AMNIOTOMY IF MEMBRANES ARE
NOT YET RUPTURED
3. AUGMENT LABOR BY OXYTOCIN
ADMINISTRATION
4. IF CONTRACTED PELVIS IS THE
CAUSE, CS IS PERFORMED.
b. HYPERTONIC UTERINE
CONTRACTIONS
- CONTRACTIONS THAT ARE
TOO FREQUENT BUT
UNCOORDINATED, THE UTERUS
DOES NOT RELAX COMPLETELY IN
BETWEEN CONTRACTIONS &
CONTRACTIONS ARE MORE
PAINFUL BUT INEFFECTIVE.
MX:
1. THERAPEUTIC REST – GIVEN
ANALGESICS ( MORPHINE) &
SEDATIVES ( PHENOBARBITAL) TO
PROMOTE REST. WOMAN USUALLY
AWAKENS WITH NORMAL LABOR
PATTERNS.
2. SIDE LYING POSITION TO
MAXIMIZE BLOOD FLOW TO THE
FETUS & THE PLACENTA.
2. PRECIPITATE LABOR /
PRECIPITATE BIRTH:
-labor lasting < 3 hrs from the
onset of contractions to the
birth of infant
MATERNAL COMPLICATIONS:
1.increase risk of uterine rupture
21
2. laceration of cervix, vagina and
perineum
3. postpartum hemorrhage
FETAL COMPLICATION:
1.hypoxia
3. PREMATURE RAPTURE OF
MEMBRANES (PROM/ EROM/)
** THE SPONTANEOUS RUPTURE OF
MEMBRANES PRIOR TO THE ONSET
OF LABOR RESPECTIVE OF THE
GESTATIONAL AGE.
INITIAL SIGN: PASSAGE OF THE
AMNIOTIC FLUID
PREDISPOSING FACTORS:
** MALPRESENTATION
** POSSIBLE WEAK AREA IN THE
AMNION AND CHORION
** INFECTION
** INCOMPETENT CERVIX
DANGERS ASSOCIATED:
1. CORD PROLAPSE
2. INFECTION
3. POTENTIAL NEED FOR
PREMATURE DELIVERY
PATHOPHYSIOLOGY:
1. AMNIOTIC FLUID LEAKS FROM
THE VAGINA IN THE ABSENCE OF
CONTRACTIONS
2. INCREASED RISK OF
ASCENDING INTRAUTERINE
INFECTION (CHORIOAMNIONITIS)
3. THE LEADING CAUSE OF
DEATH ASSOCIATED WITH PROM IS
ASCENDING INFECTION
++NURSE ALERT++
RISK OF INFECTION MAY BE
DIRECTLY RELATED TO TIME
INVOLVED BETWEEN MEMBRANE
RUPTURING AND LABOR ONSET.
MECONIUM STAIN INDICATES FETAL
DISTRESS.
4. PROLAPSED UMBILICAL
CORD (CORD PROLAPSE)
** DISPLACEMENT OF THE
UMBILICAL CORD BELOW THE
PRESENTING PART, THE CORD MAY
PROTRUDE THROUGH THE CERVIX
AND INTO THE VAGINAL CANAL.
CAUSES:
1. RUPTURE OF THE MEMBRANES
BEFORE ENGAGEMENT
2.ABNORMAL PRESENTATION
3.PREMATURE INFANT,
PRESENTING PART
DOES NOT FILL THE BIRTH CANAL,
ALLOWING THE CORD TO SLIP
THROUGH.
4. POLYHYDRAMNIOS
5. MAY FOLLOW RUPTURE OF
AMNIOTIC MEMBRANES BECAUSE
THE FLUID RUSH MAY CARRY THE
CORD ALONG TOWARD THE BIRTH
CANAL
6. WHEN DELIVERY IS
ACCOMPLISHED WITHIN 15-30
MINUTES, FETAL SURVIVAL IS 70-
75%. FETAL MORTALITY MAY
EXCEED 50% IF DELIVERY IS
DELAYED MORE THAN 1 HOUR.
ASESSMENT:
1. VAGINAL EXAMINATION
IDENTIFIES CORD PROLAPSE INTO
VAGINA
2. SIGNS OF ACUTE DISTRESS
MANAGEMENT:
1. PREVENTION – PLACE THE
WOMAN ON BEDREST AFTER
MEMBRANES HAVE RUPTURED.
2. REDUCE PRESSURE ON THE
CORD BY:
a. PLACING THE PATIENT ON
KNEE CHEST OR
TRENDELENBURG POSITION
b. IF CORD IS EXPOSED TO
AIR, COVER IT WITH A SALINE
MOISTENED STERILE
COMPRESS.
c. NEVER REPLACE CORD
BACK INTO THE VAGINA AS THIS
WILL RESULT IN CORD KINKING.
d. ADMINISTER MASK
OXYGEN UNTIL DELIVERY IS
COMPLETED.
e. DELIVER THE BABY AS
SOON AS POSSIBLE.
** VAGINAL DELIVERY IF CERVIX
IS FULLY DILATED WITHOUT FETAL
DISTRESS.
22
** CESARIAN SECTION IF CERVIX
IS NOT YET COMPLETELY DILATED
& IF FETAL DISTRESS IS PRESENT.
++NURSE ALERT++
CORD PROLAPSE IS AN
EMERGENCY SITUATION,
IMMEDIATE DELIVERY WILL BE
ATTEMPTED TO SAVE THE FETUS.
IF COMPRESSION OF THE CORD
OCCURS, FETAL HYPOXIA MAY
OCCUR RESULTING IN CNS
DAMAGE.
Abnormal Labor Patterns
Uterine Rupture
 Tearing of the muscles of the
uterus. This occurs when the uterus
can no longer withstand the strain
placed upon it.
 It is a serious complication of
labor that can lead to maternal &
fetal death.
Causes:
 Rupture of scar from previous
cs
 Multiple gestation
 Injudicious use of oxytocin
 Forceps & vacuum extraction
 Precipitate labor & delivery
 Overdistention of the uterus
 External trauma- sharp or
blunt
 Gestational trophoblastic
neoplasia
Ssx:
 Impending uterine rupture is
often manifested by a pathologic
retraction ring
 During the peak of a
contraction, the woman suddenly
complain of a sharp tearing pain
after which, relief will be felt as the
uterus will no longer contract.
Types of uterine rupture:
 Complete rupture –when the
uterus ruptures, the woman
experiences a SUDDEN
EXCRUCIATING PAIN at the peak of
a contraction, cessation of fetal
heart tones, then contractions stop.
Internal hemorrhage follows &
vaginal bleeding may or may not
be present. Two swellings will be
visible in the abdomen, the uterus
& the extrauterine fetus. Rupture
results in separation of the
placenta from the uterus cutting
blood supply to the fetus resulting
in hypoxia & fetal death
 Incomplete rupture –
characterized by localized
tenderness & persistent pain over
the abdomen. Contractions may
continue or stop.
MX:
 BT & IVF to correct shock
 Administer mask O2
 “E” laparotomy to deliver the
baby
 Post-op care:
– Explain need to avoid driving
for 3-6 weeks
– Explain need to avoid
jogging, sexual intercourse,
dancing & lifting heavy objects for
6-8 weeks
Bandl’s ring
 Or Pathologic retraction ring
 seen as a horizontal
indentation running across the
abdomen
MX:
 Morphine SO4 to relax the
uterus
 CS section for immediate
delivery of the fetus & prevent
uterine rupture if Morphine SO4 is
ineffective
 If Bandl’s ring develop during
the placental stage, woman is
placed under anesthesia & the
placenta is removed manually.
Inversion of the Uterus
 Uterus is completely turned
inside out
Causes:
 Pulling of the umbilical cord
 Applying pressure on
uncontracted uterus
 Placenta accreta
 Sudden increase in
intraabdominal pressure such as
when coughing, sneezing or
straining
Ssx:
 Fundus is no longer palpable
 Sudden gush of blood from
the vagina
 Uterus appear in the vulva
Prevention:
23
 Never apply pressure on an
uncontracted uterus
 Never pull the cord to hasten
placental delivery
2. Lower uterine segment is
inserted first manually & fundus
last.
3. BT & IVF to combat shock
4. Do not attempt to remove the
placenta if it still attached to the
uterus as this will only enlarge the
bleeding area
5. Give oxytocin only after the
uterus is properly replaced
6. If the placenta is still attached to
the uterus, remove it when the
uterus is replaced & contracted
Complications of the
Postpartum Period
1. Postpartum Hemorrhage – is
the leading cause of maternal
mortality.
 Blood loss of more than 500
ml is considered hemorrhage.
 The most dangerous time at
which hemorrhage is likely to occur
is during the first hour postpartum
Predisposing factors
 Uterine atony
 Lacerations & episiotomy
 Placenta previa complication
 Inversion of the uterus
 Rupture of the uterus
 DIC
 Overdistention of the uterus –
twins, hydramnios
 Prolonged & rapid labor
Types of postpartum
hemorrhage
 Early postpartum
hemorrhage – occurs during the
first 24 hrs after delivery
– Causes:
 . Uterine atony
 Laceration of the birth canal
 Inversion of the uterus
 Late postpartum hemorrhage
– occurs from 24 hrs after birth
until 4 weeks postpartum
Uterine Atony
 Most common cause of
EARLY postpartum hemorrhage.
When the uterus fails to contract,
open blood vessels in the placental
site continue to bleed resulting in
hemorrhage.
Causes of Uterine Atony:
 Overdistention of the uterus –
hydramnios, multiple pregnancy
 Complication of labor –
precipitate, prolonged labor
 High parity & advanced
maternal age
 Presence of fibroid tumors
 Overmassage of the uterus
 Retained placental fragments
Management
 First action taken when
uterus is relaxed & boggy is to
MASSAGE IT GENTLY.
 Keep bladder empty since a
full bladder interferes with effective
uterine contractions
 Monitor vital signs & amount
of blood loss during the early
postpartal period
 Administer oxytocin if uterus
is not contracted
 BT & IVF to replace blood loss
 If retained placental
fragments is the cause, curettage
is performed
 If bleeding cannot be
controlled by the above measures,
HYSTERECTOMY is performed as
the last resort.
Lacerations
 When bright red blood
continue to gush from the vagina &
the uterus is firmly contracted,
lacerations of the birth canal are
usually the cause of bleeding.
Lacerations can occur anywhere in
the cervix, vagina, & perineum.
Causes of laceration
 Operative delivery – forceps
delivery
 Precipitate delivery
 Large infant – over 9 lbs
 Multiple pregnancy
 Primigravidas
 Abnormal fetal presentation
& position
Management
 Return woman to delivery
room for inspection & repair, if
laceration is suspected.
 Vaginal packing to maintain
pressure on suture line. Be sure to
remove packing after 24 to 48 hrs
 3rd & 4th degree lacerations –
no enema or rectal suppository.
Constipation should be avoided &
temp should not be taken rectally.
Retained Placental Fragments
 Uterus will not be able to
contract effectively if placental
24
fragments are retained resulting in
uterine atony & hemorrhage.
 Most common cause of LATE
postpartum hemorrhage.
Causes of retained placenta
 Partial separation of a normal
placenta
 Manual removal of the
placenta
 Entrapment of placenta in
the uterus
 Abnormal adherent placenta
– acreta, increta, percreta
Management
 D & C to remove adherent
placenta
 Hysterectomy – for severe
cases
Subinvolution of the Uterus
 Occurs when there is a delay
in the return of the uterus to its
prepregnant size, shape & function
Causes:
 Retained placental fragments
 Infection – Endometritis
 Uterine tumors
SSx:
 Enlarged & boggy uterus
 Prolonged lochial discharge –
persistent lochia rubra
 Backache
Management:
 Methergin to stimulate
uterine contractions .2 mg 4x/day
for 3 days
 Antibiotics to prevent or treat
infection
 D & C if there are retained
fragments
 Instruct woman to report the
following signs – fever, vaginal
bleeding, passage of tissue
Hematomas
 This is due to injury to blood
vessels during delivery or during
repair of episiotomy resulting in
blood escaping to the connective
tissue under the skin.
Causes:
 Vulvar varicosities
 Precipitate labor
 Forceps delivery
 Inadequate suturing of
episiotomy or lacerations
Signs and Symptoms:
 Perineal pain
 Swelling
 Discoloration of skin over the
swollen area
 Feeling of pressure over the
vagina
Management:
 Application of ice packs
wrapped with towel to stop
bleeding by vasoconstriction
 Large hematomas are
potentially dangerous because they
may rupture & cause severe
bleeding & infection. The woman is
brought back to the DR for incision
& ligation of bleeding vessels.
 Analgesics for pain
 Broad spectrum antibiotics to
prevent or treat infection
 Blood transfusion to combat
hypovolemia
Puerperal Sepsis
 “Childbed fever”
 Infection of the genital tract
after delivery.
Predisposing factors:
 PROM
 Prolonged labor
 Postpartum hemorrhage
 Anemia
 Malnutrition
 Retained placental fragments
 CS
 Excessive vaginal
manipulation
 Sexual intercourse near labor
or after membranes have ruptured
SSx:
 Fever
 Foul smelling lochia
 Rapid pulse, chills
 Abdominal pain or
tenderness
 Body malaise
 Lack of appetite
 Perineal discomfort
 Nausea & vomiting
Prevention
 Good prenatal nutrition
 Prevention of anemia &
hemorrhage
 Good maternal hygiene
 Strict adherence to aseptic
technique by hospital personnel
 Well balanced diet to
promote healing – Increased Vit. C,
Chon, adequate calories
Urinary Tract Infection
25
 Most common during
puerperium because of trauma to
the bladder after delivery, urinary
retention, & overdistention of the
bladder due to anesthesia or
infection may be introduced during
catheterization.
SSX:
 Painful urination, frequency &
urgency of urination
 Flank pain
 Fever
 Hematuria
Management
 Increase fluid intake
( 3,000cc/day) to flush away
infection from the bladder.
 Regular emptying of the
bladder to prevent stasis of urine
 Analgesics for pain,
antibiotics for infection
 Collect urine specimen
( clean catch) for examination
Mastitis
 Infection of the breast tissue
commonly occurring in
breastfeeding mothers.
 Usually appears during the
2nd & 3rd week postpartum when
milk supply is already established
 Staphylococcus aureus –
most common causative agent
found in the oral nasal cavity of the
infant ( acquired from health care
personnel in the nursery or from
cracks & fissures in the nipples)
 Engorgement or swelling of
affected breast & chills are usually
the first signs
 Fever, tachycardia,body
malaise
 Hard & reddened breast
 Reduced milk supply as
edema & engorgement obstruct
milk flow
 Breast abscess – about 10%
of women with mastitis develop
breast abscess.
Management
1. Prevention:
– Prevent nipple cracks &
fissures by correct placement of
infant’s mouth on the nipple
( latch-in) not feeding the baby too
long, using correct technique when
releasing the baby from the nipple
after feeding , proper breast care .
– Express excess milk after
feeding the baby to prevent milk
stasis which is a good medium for
bacterial growth
 Isolation of infants with cord
or skin infections
 Persons with known or
suspected staphylococci infections
should not be allowed to care for
newborn in the nursery
 Proper handwashing
technique in between handling of
newborns. Observance of strict
aseptic technique.
 Wash hands before and after
changing perineal pads, good
personal hygiene on the part of the
mother
2. Comfort Measures:
– Instruct mother to wear
supportive brassiere
– Application of heat to the
breast to promote comfort &
relieve engorgement
– Discontinue breastfeeding
from the affected breast. Express
milk every 4 hours to maitain
lactation
3. Antibiotic therapy to fight
infection
4. If abscess develops, the affected
area is incised & drained.
Thrombophlebitis / Deep Vein
Thrombosis
 Inflammation in the lining of
the blood vessels with formation of
blood clots or thrombi.
Causes:
 Stasis of circulation
 Increased fibrinogen during
pregnancy
Types:
1. Femoral Thrombophlebitis:
infection of the veins of the legs
( femoral, saphenous, popliteal
veins)
SSx:
 Homan’s sign- calf pain when
the foot is dorsiflexed
 Milk leg or Phlegmasia alba
dolens – leg is shiny white
 Swelling of affected leg, pain
& stiffness
 Fever
2. Pelvic Thrombophlebitis –
infection of the ovarian, uterine
and pelvic veins
SSx:
26
 Fever & chills
 Pain in the lower abdomen or
flank
 Palpable parametrial mass in
some cases
Management:
1. Prevention:
> Early ambulation after delivery
> Use of support stocking in
women with varicosities to promote
circulation & prevent stasis – put
on stocking before rising from bed
in the morning
2. Bedrest until signs & symptoms
disappear
3. Anticoagulant medications to
prevent further clot formation.
 Heparin – not passed to
breastmilk
– Protamine Sulfate – antidote
of heparin
 Dicumerol – passed to
breastmilk so mother must stop
breastfeeding
4. Do not give Aspirin or ASA if
patient is receiving anticoagulant
drugs because aspirin increases
coagulation time. Watch for signs
of bleeding: bleeding gums,
ecchymotic skin, increased lochial
discharge.
5. Antibiotic therapy to combat
infection, analgesics for pain.
6. Gradual ambulation after
symptoms disappear
7. Never massage the affected leg
8. Warm wet compress dressings to
promote circulation & for comfort
BREAST CANCER
** PRESENCE OF MALIGNANT
TUMORS USUALLY IN THE UPPER
OUTER QUADRANT OF THE
BREAST. IT IS ASSOCIATED WITH
NULLIPARITY OR HAVING THE FIRST
CHILD AFTER AGE 35.
1. MOST COMMON NEOPLASM
IN WOMEN
2. LEADING CAUSE OF DEATH
IN WOMEN AGE 40 above
MEDICAL MANAGEMENT:
1. USUALLY SURGICAL
EXCISION; OPTIONS ARE SIMPLE
LUMPECTOMY, SIMPLE
MASTECTOMY, MODIFIED RADICAL
MASTECTOMY AND RADICAL
MASTECTOMY
2. TREATMENT WITH
CHEMOTHERAPY, RADIATION
AND HORMONE THERAPY
** PARTIAL MASTECTOMY =
(LUMPECTOMY) REMOVAL OF LUMP
& SURROUNDING BREAST TISSUE
**SIMPLE MASTECTOMY =
REMOVAL OF THE BREAST
** RADICAL MASTECTOMY =
REMOVAL OF THE BREAST,
PECTORAL MUSCLES, PECTORAL
FASCIA & NODES (PECTORAL,
SUBCLAVICULAR, APICAL AND
AXILLARY)
** MODIFIED RADICAL
MASTECTOMY = RADICAL
MASTECTOMY BUT PECTORAL
MUSCLES ARE NOT REMOVED
MOST COMMON SITE OF
METASTASIS:
** BONE, BONE MARROW, SOFT
TISSUE, LUNGS, LIVER AND BRAIN.
C. ASSESSMENT FINDINGS:
1. PALPATION OF LUMP (UPPER
OUTER QUADRANT MOST
FREQUENT SITE) USUALLY FIRST
SYMPTOM
2. SKIN OF BREAST DIMPLED
3. NIPPLE DISCHARGE
4. ASSYMETRY OF BREAST
5. SURGICAL BIOPSY PROVIDES
DEFINITE DIAGNOSIS
**BREAST BIOPSY**
1. EXCISION =REMOVAL OF MASS
FOR CYTOLOGIC STUDIES
2. INCISION= REMOVAL OF TISSUE
FROM MASS OF CYTOLOGIC
STUDIES
3. NEEDLE= (ASPIRATION) =
REMOVAL OF TISSUE OR FLUID
FROM MASS THROUGH A NEEDLE
FOR CYTOLOGIC STUDY
LABORATORY DATA:
- MAMMOGRAPHY REVEALS THE
PRESENCE OF NON-PALPABLE
LESION.
- BASELINE MAMMOGRAPHY
SHOULD BE MADE BETWEEN AGES
35-40.
NURSING INTERVENTIONS:
1. PROVIDE ROUTINE PRE-OP &
POST-OP CARE.
2. ELEVATE CLIENT’S ARM ON
OPERATIVE SIDE ON PILLOWS TO
MINIMIZE EDEMA.
3. DO NOT USE ARM ON AFFECTED
SIDE FOR BLOOD PRESSURE
MEASUREMENTS, IV’S OR
INJECTIONS
4. TURN ONLY TO BACK &
UNAFFECTED SIDE
5. MONITOR CLIENT FOR BLEEDING
( CHECK UNDER AFFECTED ARM)
27
MENOPAUSE = PERMANENT
CESSATION OF MENSTRUAL
CYCLES THAT OCCURS BETWEEN
45 & 55 Y/O; ave: 50y/o
= THE POINT AT WHICH NO
FUNCTIONING OOCYTES REMAIN IN
THE OVARIES
S/SX OF MENOPAUSE:
1. HOT FLASHES – SENSATION OF
HEAT THAT BEGINS IN THE FACE
TO THE CHEST & PROFUSE
PERSPIRATION.
2. LOSS OF BREAST MASS &
FIRMNESS, ATROPHY OF
REPRODUCTIVE ORGANS.
3. DYSPAREUNIA ( PAINFUL
INTERCOURSE) DUE TO
DECREASED VAGINAL
LUBRICATION.
4. OSTEOPOROSIS - ESTROGEN
PROMOTES CALCIUM DEPOSITION
IN THE BODY. A FALL IN ESTROGEN
LEVELS WILL LIBERATE CALCIUM
FROM THE BONES MAKING THEM
BRITTLE
MX:
1.ESTROGEN REPLACEMENT
THERAPY ( HRT; ERT)
2. CALCIUM ( 1g/DAY AT HS) & VIT.
D SUPPLEMENTATION
3. LIBERAL FLUID INTAKE TO
DILUTE URINE AS MORE CALCIUM
IS LIBERATED FROM THE BONES &
COULD CAUSE RENAL CALCULI.
4. WEIGHT BEARING EXERCISES
MX OF HOT FLASHES:
1.DRESS IN LAYERED LOOK,
REMOVE OUTER CLOTHING DURING
ATTACKS.
2. AVOID HOT ENVIRONMENT
VAGINAL LUBRICANT FOR PAINFUL
INTERCOURSE.
5. INSTRUCT TO AVOID SMOKING &
ALCOHOL
6. REGULAR PHYSICAL
EXAMINATION.
3. AVOID EMOTIONAL STRESS
4. AVOID FOODS THAT COULD
TRIGGER HOT FLUSHES: SPICY
FOODS, COFFEE, TEA, ALCOHOL
5.USE COOLING TECHNIQUES:
FANS, SHOWERS, ICE CUBES
NURSING CARE:
1.ENCOURAGE WOMAN TO
ENGAGE IN REGULAR EXERCISE
PROGRAM TO MAINTAIN MUSCLE
TONE
2. EMPHASIZE ADEQUATE INTAKE
OF CALCIUM
3. VIT D FOR BETTER CALCIUM
ABSORPTION.
4.INSTRUCT ON PROPER USE OF
WATER SOLUBLE
Sexuality and Sexual Identity
 Terms
 Biologic gender-chromosomal
sex
male: XY female: XX
 Gender identity/ sexual
identity-inner sense of being a
male or female
 Gender role- male or female
behavior a person exhibits
Sexual Orientation
 Heterosexuality-opposite sex
 Homosexuality- same sex
 Bisexuality- both sex
 Transsexuality- person of one
biologic gender, feels as if he/she
should be of the opposite gender
Sexual Expression
 Celibacy- abstinence from
sex
 Masturbation-self stimulation
for erotic pleasure
 Erotic stimulation-use of
visual materials for sexual arousal
 Fetishism-sexual arousal
from objects or situation
Sexual Expression
 Transvestism-dresses to take
on the role of the opposite person
 Voyeurism-peeping tom
 Sadomasochism:sadism-
inflicting pain;masochism-receiving
pain
 Necrophilia – sex with the
dead
 Zoophilia – sex with animals
 Urophilia – sex after urinating
the partner
 Pedophilia – sex with children
 Exhibitionism
 Cuprophilia – sex after
defecating the partner
Sexual Harassment
 Unwanted, repeated sexual
advances, remarks or behavior
toward another
 Offensive to recipient
 Interferes with job
performance
TYPES: 1. quid pro quo/equal
exchange
2. hostile work
environment
28
Disorders of Sexual
Functioning
 Sexual Desire Disorders- lack
of desire for sexual relation
 Inhibited sexual desire
 Sexual Arousal Disorders
 Failure to achieve orgasm
Disorders of Sexual
Functioning
 Orgasm Disorders
 Erectile
dysfunction/impotence
causes: aging,
atherosclerososis, diabetes
mgt: sildenafil (viagra), tadalafil
( cialis)
 Premature ejaculation
Pain Disorders
- Vaginismus-involuntary
contraction
- Dyspareunia/Vestibulitis
Reproductive Life Planning
FAMILY PLANNING
Contraceptive
 Any device used to prevent
fertilization of an egg
 Kinds of Contraceptive Use:
 Natural Methods
 Abstinence
 Rhythmn or Calendar Mehtod
 Basal Body Temperature
 Billing’s Method or Cervical
Mucus Method
 Coitus Interruptus or
Withdrawal
 Lactation
 Hormonal Methods
 Oral Contraceptives
 Injected or IMPLANTED
Steroidal Contraceptives
Barrier Methods
 Chemical Barriers
 Spermicides
 Gels
 Vaginal suppositories
 Sponges
 Mechanical Barriers
 Condoms
 Cervical cap
 Diaphragm
 Intrauterine Device
 Permanent Methods
 Tubal Ligation
 Vasectomy
Natural Methods
 Advantages:
 1. Safe & has no side effects
 2. Inexpensive
 3. Acceptable to religious
affiliations that do not accept
artificial methods of contraception
 4. Helpful for planning
pregnancy & avoiding pregnancy
 5.Promotes communication
about family planning &
contraception between couples
 Disadvantages
 1. Involves long preparation
& intensive recording before it can
be used.
 2. There is a need to abstain
on certain days which may be
inconvenient for the couple
 3. Not ideal to women with
irregular cycles
 4. Not very reliable because
of menstrual cycle variations that
may occur anytime.
Types of Natural Methods of
Contraception:
1. Abstinence
 0% failure rate
 Most effective method to
prevent STDs
 Difficult to comply with
1. Calendar/ Rhythm (Natural
Family Planning)
 Action – periodic abstinence
from intercourse during fertile
period; based on the regularity of
ovulation; variable effectiveness
 Entails keeping a day-by-day
record of your cycle for 6
consecutive months
 This 6 month record will show
you your longest and shortest
cycles- from which you can
calculate your FERTILE days
 The first day of menstrual
bleeding (day 1 of your period)
counts as the first day of the cycle.
 Approximately 14 days (or 12
to 16 days) before the start of the
29
next period, an egg will be released
by one of the ovaries.
 While the egg from the
woman lives for only around 24
hours, sperm from the man can
survive for up to 3 days, possibly
longer.
 First unsafe day: subtract 18
from the number of days in your
shortest cycle
 Last unsafe day: subtract 11
from the number of days in your
longest cycle
 Ex: shortest: 26 – 18 = day
8
longest: 31 – 11 = day 20
UNSAFE PERIOD!! Days 8
-20
-avoid coitus or use a contraceptive
2. Basal Body Temperature
 Involves taking the
temperature every morning
BEFORE the woman gets out of bed
and recording it
 About 12 to 24 hours before
ovulation, BBT drops by 0.3 to 0.6
degrees F due to the very low
progesterone level.The sudden
drop is followed by a sudden rise
by 1 degree F after ovulation due
to rising progesterone levels. The
temp remains elevated until 2-4
days before menstruation.
 The temperature drops
slightly 24 hours before ovulation,
then rises to about half a degree
higher than normal and remains
thus for up to three days: UNSAFE
period!
 Not a very efficient method
unless combined with calendar and
mucus methods
3. Cervical Mucus (Billings)
Method
 Involves becoming aware of
the normal changes in the cervical
secretions that occur throughout
your cycle by inserting the
forefinger into the vagina first thing
in the morning
 Before ovulation, the normal
vaginal discharge is either absent
or it is thick & scant. Just before
ovulation, mucus discharge
becomes clear, abundant, slippery
& stretchable due to high estrogen
level. Ovulation most likely occurs
24 hours after the last day of the
abundant slippery & thin discharge.
 A few days after menstrual
bleeding: little secretion, vagina is
dry
 Gradually, secretion
increases and becomes thicker,
cloudy white and sticky
 As ovulation approaches, this
secretion or mucus becomes
copious, clear, thin, less viscous,
more liquid, slippery or stringy; as
soon as this change begins and for
3 full days later: UNSAFE PERIOD!!
Cervical Changes
 Spinnbarkeit test =
 Cervical mucus is thin,
watery and can be stretched into
long strands
 high level of estrogen:
ovulation is about to occur
 Ferning or arborization of
cervical mucus
 At the height of estrogen
stimulation just before ovulation
 Ferning- due to crystallization
of sodium chloride on mucus fibers
Symptothermal method
 Combines BBT and cervical
mucus methods & awareness of
symptoms during the different
phases of the menstrual cycle.
Ovulation detection test kits
 Use of over-the-counter OTC
ovulation test kit which detects the
midcycle LH (luteinizing hormone)
surge in the urine 12 to 24 hours
before ovulation
 98 to 100% accurate
Lactation amenorrhea method
 As long as a woman is
breastfeeding an infant, there is
some natural suppression of
ovulation
 Not dependable- woman
may be fertile even if she has not
had a period since childbirth
 After 6 months, she should
use another method of
contraception
Coitus interruptus
 Oldest method
 Couple proceeds with coitus
until the moment of ejaculation,
then the man withdraws and
spermatozoa are emitted outside
the vagina
30
 Offers little protection
because ejaculation may occur
before withdrawal is complete and
despite the care used,
spermatozoa may be deposited in
the vagina
Client Instructions
 Completely wipe off any fluid
at the tip of the penis before
inserting it into the vagina. Millions
of sperm cells may be present in
the preejaculatory fluid.
 When the man feels that he
is about to ejaculate, he must
withdraw his penis from the vagina.
 A supply of birth control foam
or spermicide should be readily
available in case of accident.
Hormonal Methods
Oral Contraceptives
 Composed of varying
amounts of estrogen combined
with small amount of progesterone
99.5% effective
 Estrogen suppresses FSH and
LH, thereby suppressing ovulation
Progesterone decreases the
permeability of cervical mucus
 Monophasic - Fixed doses of
estrogen and progesterone ; 21-28
day cycle
 Biphasic - Constant amount
of estrogen with increased
progesterone
 Triphasic - Varying levels of
estrogen and progesterone
Benefits of OC’s:
DECREASED incidences of:
 Dysmenorrhea
 Premenstrual dysphoric
syndrome
 Iron deficiency anemia
 Acute PID with tubal scarring
 Endometrial and ovarian
cancer and ovarian cysts
 Fibrocystic breast disease
Side Effects
 Nausea
 Weight gain
 Headache
 Breast tenderness
 Breakthrough bleeding
 Monilial vaginal infections
 Mild hypertension
 Depression
Absolute Contraindications to
OC’s
 Breastfeeding
 Family history of CVA or CAD
 History of thromboembolic
disease
 History of liver disease
 Undiagnosed vaginal
bleeding
Possible Contraindications to OC’s
 Age 40+
 Breast or reproductive tract
malignancy
 Diabetes Mellitus
 Elevated cholesterol or
triglycerides
 High blood pressure
 Mental depression
 Migraine or other vascular
type headaches
 Obesity
 Pregnancy
 Seizure disorders
 Smoking
 Use of drug with interaction
effect
Other Contraceptives
 Continuous or extended
regimen pills
 Mini-pills
 Estrogen-progesterone patch
 Vaginal rings
Estrogen-progesterone patch
 Highly effective, weekly
hormonal birth control patch that’s
worn on the skin
 Combination of estrogen and
progestin
 Absorbed on the skin and
then transferred into the
bloodstream
 Can be worn on the upper
outer arm, buttocks, upper torso or
abdomen
 Worn for 1 week, replaced on
the same day of the week for 3
consecutive weeks. No patch-4th
week
Emergency Postcoital
Contraceptives
31
 “Morning-after pills” MAP
 High level of estrogen
 Must be initiated within 72
hours of unprotected intercourse
4. Other Contraceptives
Subcutaneous implants (eg,
Norplant)
 6 nonbiodegradable Silastic
implants with synthetic
progesterone embedded under the
skin on the inside of the upper arm
 Slowly release the hormone
over the next 5 years
 Suppress ovulation,
stimulating thick cervical mucus
and changing the endometrium so
implantation is difficult
INTRAUTERINE DEVICES
 T-shaped plastic device with
copper
 With progesterone
 Mechanism of action not fully
understood
 Must be fitted by physician,
nurse practitioner or midwife
 Insertion performed in
ambulatory setting after pelvic
examination and pap smear
 Ideally inserted during
menses because the cervix is
slightly dilated & there is no danger
of pregnancy at this time
 Device is contained within
uterus – string protrudes into
vagina
 Effective for 5-7 years
(mirena type) or 8 years (Copper
T380)
Side Effects:
 Spotting or uterine cramping
 Increased risk for PID
 Heavier menstrual flow
 Dysmenorrhea
 Ectopic pregnancy
6. Barrier Methods
 Vaginally inserted
spermicidal products
 Diaphragms
 Cervical caps
 Condoms
 SPERMICIDAL AGENT
goal: to kill the sperm before the
sperm enters the cervix
-Nonoxynol-9
-gel, creams, films,foams,
suppositories
 DIAPHRAGM
-mechanically blocks sperm from
entering the cervix
-soft latex dome supported by a
metal rim
-can be inserted 2 hours before
intercourse; removed at least 6
hours after coitus or within 24
hours
-size must fit the individual
- initially fitted by a doctor
-washable, may be used for 2-3
years
Contraindications:
 Allergy to latex
 History of TSS
 Pelvic pain
 PID
 Tight introitus
Client Instructions:
 A woman should be fitted by
an obstetrician during the first if
use & refitted after every delivery,
abortion, & weight loss of at least
10 lbs. The largest size that fits the
woman is chosen.
 Normally becomes brownish
with use. Before inserting into the
vagina, it should be inspected for
tears & holes by holding it against
the light
32
 Spermicide gel is applied at
its rim before insertion
 Diaphragm can be inserted 2
hours before coitus but must be
left for 6 hours after intercourse.
 After use, diaphragm is
washed with soap & water, dried
with a towel & can dusted with
cornstarch. Do not use talcum
powder, perfumed substances &
petrolatum jelly because they may
damage the diaphragm & irritate
the vagina. It should be stored in a
plastic container in a cool dry
place.
 Can last 2-3 years
 If there is difficulty in
removing the diaphragm after
intercourse, bear down to bring it
forward where you can reach it
with your fingers.
 Do not douche while it s
inside the vagina
 Prevent TSS by:
 Washing hands before
insertion or removal
 Do not leave more than 24
hours in the vagina
 Never use during menses
 Wait 12 weeks after delivery
before using the contraceptive
 Remove right away if there
ssx of TSS & consult physician
 CERVICAL CAP
-similar to diaphragm but smaller
-thimble-shaped rubber cap held
onto the cervix by suction
 MALE CONDOM
 FEMALE CONDOM
7. Surgical Methods
 Tubal Ligation
-28% of all women in US
-fallopian tubes are cut,/tied/
cauterized to block passage of ova
and sperm
LAPAROSCOPY
FOR TUBAL STERILIZATION
 Vasectomy
- 11% of all men in US
-incisions are made in the sides of
scrotum; vas deferens is cut and
tied, then plugged or cauterized
-blocks passage of sperm
-viable sperm for 6 months post op
-reversible 95%
8. Elective Termination of
Pregnancy
Procedure to deliberately end a
pregnancy before fetal viability
 Induced
(mifepristone-progesterone
antagonist; misoprostol-
prostaglandin analog
 Medically induced
D&C, D&E, saline induction,
hysterotomy
Sterilization
 Surgical procedure intended
to discontinue the capacity of a
person to have children.Passages
of the ova and sperm cells are
occluded to render the person
infertile
Reasons for sterilization
 Genetic abnormalities
 Medical reasons
hypertensive, renal or
cardiovascular disease
 The couple have reached
their desired number of children
 Persons who have no wish to
have children
Braided Technique
Used in counseling clients about
sterilization
B – Benefits: permanent,
unexpensive, no chemical & other
devices are used, convenient
R – Risks: infectious, pregnancy;
surgical complications
A – Alternatives: there are other
forms of contraception aside from
sterilization
I – Inquiries: the client is
encouraged to voice out concerns
& questions for clarification
D – Decision to say “NO”; the client
has the right to decide against the
procedure
E – Explanation: the sterilization
procedure is explained completely
including risks, advantages,
disadvantages in the level &
language that the client can
understand
D – Documentation: Written signed
consent must be obtained before
the procedure can be carried out
Types of Sterilization
Female Sterilization
1.Hysterectomy
2.Oophorectomy
3.BTL – Bilateral Tubal Ligation –
most commonly used method
33
 The fallopian tubes are
occluded by cauterization,
blocking, crushing or clamping the
fallopian tubes. Sterility is
immediate after BTL.
 BTL can be done as early as
4-6 hours after delivery but it is
often done after 12-24 hours.
Sexual intercourse can be engaged
In after 3 days.
Operations Used:
 Mini laparotomy- after local
anesthetic is applied, a 2-3 cm
vertical incision is made
suprapubically to visualize & ligate
the fallopian tubes. Operation is
completed after 20 minutes.
 Fimbriectomy – ligation of the
oviducts & removal of the fimbria
to prevent the ovum from entering
the oviducts
 Vaginal tubal sterilization –
 Laparoscopy – also known as
“ Band-Aid surgery”
Male Sterilization = ligation of
the vas deferens to block passage
of sperm cells.
 A small incision is made in
each side of the scrotum
 totally effective
 Man will continue to have
erections & semen ejaculations but
unlike BTL, the client must have 2
negative sperm count first in his
seminal fluid which can be
achieved after 20 ejaculations
before sterility can be achieved.
Sexually Transmitted Disease /
STD
Gonorrhea, Morning drop, Clap,
Jack
= Sexually transmitted disease
caused by gram (+) Neisseria
gonorrhea, which causes
inflammation of the mucus
membrane of the genito urinary
tract.
IP: 3-7 days
S/sx:
Male: Painful urination; pelvic pain
& fever; purulent yellow penile
discharge; urethritis
- decreased sperm count
Females: - Greenish vaginal
discharge
- usually asymptomatic or minimal
urethral discharge w/ lower
abdominal pain
- dyspareunia
- causes sterility or ectopic
pregnancy
DX:
gram stain and culture of cervical
secretions on Thayer Martin VCN
medium
CX:
PID, ectopic pregnancy and
infertility, chorioamnionitis,
Ophthalmia neonatorum in
newborns, preterm delivery,
sterility & pelvic inflammatory
disease
Mgmt: single dose only
 Ceftriaxone (Rocephin) 125
mg IM( drug of choice for pregnant
women)
 Ofloxacin (Floxin) 400 mg
orally
 treat concurrently with
Doxycycline or Azithromycin for
50% infected w/ Clamydia
 Tetracycline opthalmic
ointment is routinely given as
Credes prophylaxis to prevent
opthalmia neonatorum
Health Teachings:
 Avoid sexual intercourse until
cured of the infection or use
condom to prevent transmitting the
infection.
 Examinations and treatment
of sexual partner to prevent
reinfection is necessary.
 Return to clinic for check-up
in 4 to 7 days after completion to
treatment.
 Monitor treatment
Syphilis
 Treponema pallidum,
spirochete
 “ Beautiful” fast moving but
delicate spiral thread
 IP: 10-90 days
S/sx:
 Primary (3-6 wks after
contact) – nontender
lymphadenopathy and appearance
of painless chancre; most
infectious; resolves 4-6 wks
 Secondary – systemic;
generalized macular papular rash
including palms and soles and
painless wartlike lesions in vulva or
scrotum (condylomata lata) and
lymphadenopathy
 Tertiary – (6-40 yyears) –
most destructive stage;
34
neurosyphilis/permanent damage
(insanity); gumma (necrotic
granulomatous lesions), aortic
aneurysm
DX:
Fluorescent Treponemal Antibody
Test ( FTAT)– specific test for
syphilis
Dark-field examination of lesion-
1st and 2nd stage
Non specific VDRL and RPR
Kahn & Wasserman test
Mgmt
 Primary and secondary - Pen
G Management:
 Tertiary - IV Pen G
 Erythromycin & Cefriaxone
are the drug of choice for pregnant
women.
Health Teachings:
 Educate women to recognize
signs of syphilis
 Educated women to seek
immediate treatment if known
exposure occurs
 Encourage women to wear
cotton underwear
 Use condom during
intercourse
Sexual partners must also be
treated to prevent re-infection.
 No sexual intercourse until
lesions disappear
 After completion of tx, the
woman is treated monthly & the
sexual partner at 3 months, 6 mos
& 12 mos.
 Fetus will not be affected if
the mother is treated before the 5th
month. Emphasize the importance
of screening for syphilis during the
first prenatal visit for early
detection & treatment.
 Inform patients treated with
penicillin about Jarish Herxheimer
reaction, a reaction to penicillin
characterized by: fever, chills,
malaise, headache, nausea, &
tachycardia. This is a normal
reaction that subsides within 24
hours.
Complications:
 Congenital syphilis in
newborn if untreated in late
pregnancy
 Late abortion
 Stillbirth
Chlamydia
 Chlamydia trachomatis, gram
(-)
IP: 2-10 days
S/sx:
 Maybe asymptomatic
 Gray white vaginal discharge,
Burning and itchiness
DX:
 Gram stain
 Antigen detection test on
cervical smear
 Doxycycline ( CAUSES FETAL
LONG BONE DEFORMITY IF USED IN
PREGNANCY)
 Azithromycin ( Zithromax)
 Erythromycin and Ofloxacin
 Use condom during sex
CX:
 PID
 Ectopic pregnancy
 Fetus transmittal (vaginal
birth)& may cause conjunctivitis
 Preterm labor
Herpes Genitalis
= Sexually transmitted disease
caused by the Herpes Simplex
Virus 2 (HSV 2)
S/sx:
Painful vesicles (cervix, vagina,
perineum, glans penis);
dyspareunia
Dx:
 Viral culture
 Pap smear (shows cellular
changes)
 Tzanck smear (scraping of
ulcer for staining)
Mgmt:
- wear cotton underwear
Anti viral - acyclovir (zovirax)
CX:
 Meningitis
 Neonatal infection (vaginal
birth)
 Trigeminal herpes zoster
( facial muscle paralysis)
 Inform the patient that
infection with the virus increases
the incidence of CERVICAL CANCER
 Therefore: Annual PAP smear
is indicated
Genital Warts,
Condyloma Acuminatum
35
 HPV type 6 & 11, Human
papilloma virus
S/sx: Single or multiple soft, fleshy
painless growth of the vulva,
vagina, cervix, urethra, or anal
area, Vaginal bleeding, discharge,
odor and dyspareunia
DX:
 Pap smear-shows cellular
changes (koilocytosis)
 Acetic acid swabbing (will
whiten lesion)
Mgmt:
Laser treatment is more
effective
CX:
 Neoplasia
 Neonatal laryngeal
papillomatosis (vaginal birth)
 Inform the patient that
infection with the virus increases
the incidence of CERVICAL CANCER
 Therefore: Annual PAP smear
is indicated
Candidiasis, Moniliasis
Candida Albicans, Yeast or fungus
S/sx: Thick cream Cheese white
vaginal
Discharge; Extreme itchiness;
Patches of curdlike, cheesy
Material that adhere to the
Vaginal wall; dyspareunia;
Pruritus & redness of the
perineum
Predisposing Factors:
 DM
 Obesity
 Antibiotic therapy
 Tight clothing
 AIDS
 Frequent douching
Lab Data:
 KOH wet smear indicates
presence of candida Albicans
Management:
 Local application of anti
fungal agents Ex. Nystatin
 Inform the patient that the
disease can be transmitted to the
newborn leading to the
development of ORAL THRUSH
 Medications:
 Nystatin –vaginal suppository
twice a day for 7 to 14 days or
 Clotrimoxazole vaginal
suppository at bedtime for 7 days
or
 Miconazole nitrate vaginal
cream applied nightly for 7 days
Home Remedies:
 Vaginal douche of two
teaspoons ordinary baking powder
dissolved in one quart of warm
water
 Application of gentian violet
to the vagina & perineum. Use
sanitary pad to prevent staining of
undergarments.
Trichomoniasis
Trichomona vaginalis, single cell
protozoan
S/sx: Females: Yellow gray frothy
malodorous vaginal discharge,
Vaginal irritation & inflammation
Dyspareunia
Dyauria
Vulvar itching
Males: usually asymptomatic
Dx: microscopic exam of vaginal
discharge
- elevated vaginal pH 5.5+
( alkaline)
Mgmt: Metronidazole (Flagyl);250
mg 3x a day for one week.( This
drug is contraindicated during
pregnancy) include partners
CX: PROM
Home Remedies:
 Acidic vaginal douche – 1
tablespoon vinegar with 1 liter
water to counteract the alkaline
environment of the vagina that
favors the growth of trichomonas
vaginalis
Bacterial Vaginosis
 Caused by Gardnerella
Vaginalis
SSx:
• Gray, frothy & fishy odor
discharge
• Pruritus
Management:
1. metronidazole
HIV and AIDS
 Retrovirus (HIV1 & HIV2)
 Attacks and kills CD4+
lymphocytes (T-helper)
 Capable of replicating in the
lymphocytes undetected by the
immune system
 Immunity declines and
opportunistic microbes set in
 No known cure
36
MOT:
 Sexual intercourse ( vaginal
and anal)
 Exposure to contaminated
blood, semen, breast milk and
other body fluids
 Blood Transfusion
 IV drug use
 Transplacental
 Needlestick injuries
HIGH RISK GROUP
 Homosexual or bisexual
 Intravenous drug users
 BT recipients before 1985
 Sexual contact with HIV+
 Babies of mothers who are
HIV+
 THE INFECTED MOTHER CAN
PASS THE VIRUS TO THE FETUS
DURING PREGNANCY &
CHILDBIRTH OR VIA THE BREAST
MILK
S/sx:
• Acute viral illness (1 mo after
initial exposure) – fever, malaise,
lymphadenopathy
• Clinical latency – 8 yrs w/ no
sx; towards end, bacterial and skin
infections and constitutonal sx –
AIDS related complex; CD4 counts
400-200
• AIDS – 2 yrs; CD4 T
lymphocyte < 200 w/ (+) ELISA or
Western Blot and opportunistic
infections
Effects on the Infant:
 Encephalopathy
 Microencephaly
 CNS lymphomas
 CVA’s
 Respiratory failure
 Lymphadenopathy
 Developmental anomalies
HIV CLASSIFICATION
 CATEGORY 1 – CD4+ 500
OR MORE
 CATEGORY 2 – CD4+ 200-
499
 CATEGORY 3 – CD4+ LESS
THAN 200
HIV TEST
 Elisa – Enzyme Link
Immunosorbent Assay ( first
test conducted)
 Western Blot -
confirmatory
 Rapid hiv test
 Suds hiv-1
 Results are obtained in
less than 10 minutes
 Color indicator similar to
pregnancy test
 Positive result needs a
confirmatory test
How to Diagnose
 HIV+
2 consecutive positive ELISA
and
1 positive Western Blot Test
 AIDS+
HIV+
CD4+ count below 500/ml
Exhibits one or more of the ff:
(next slide)
 Full blown AIDS
CD4 is less than 200/ml
Exhibits one or more of the ff:
 Extreme fatigue
 Intermittent fever
 Night sweats
 Chills
 Lymphadenopathy
 Enlarged spleen
 Anorexia
 Weight loss
 Severe diarrhea
 Apathy and depression
 PTB
 Kaposis sarcoma
 Pneumocystis carinii
 AIDS dementia
Treatment
 Anti-retroviral Therapy (ART)
– ziduvirine (AZT) ( Azidothymidine)
a. Prolong life
b. Reduce risk of opportunistic
infection
c. Prolong incubation period
Health teachings
For infected persons:
1. Avoid infections
2. Use latex condom to protect
partner during sexual intercourse
3. Do not donate blood, sperm,
organs or other body tissues
4. Do not share items with other
persons that may be contaminated
with blood & other body fluids
5. Do not breastfeed infant
37
For non-infected persons:
1. Stick to one partner, practice
monogamous relationship
2. Use condoms
3. Avoid anal & oral sex
4. Practice good personal hygiene
5. Practice healthful living:
exercise, adequate rest, nutritional
diet, safe sex
6. Be aware of the signs &
symptoms of infections:
 Weight loss of greater than
10% of body weight
 Chronic diarrhea, more than
one month
 Prolonged fever, lasting more
than one month
 AIDS cannot be transmitted
by sharing foods, eating utensils,
toilet, swimming pools, water
Precautionary measures for
health workers:
 Handle all sharp instruments
with care, use disposable needles
& do not reuse as much as possible
 Protect yourself, increase
resistance to infection by proper
diet, exercise, rest & sleep
 Avoid body fluids – label
blood & other specimens of a
person known or suspected with
AIDS properly, clean blood spills
with disinfectant
 Practice strict aseptic
technique – handwashing,wear
gloves, clean, disinfect & sterilize
 Wear, protective clothing
when necessary – gloves, masks,
goggles
DRUGS
1. Nucleoside Reverse
Transcriptase Inhibitors NRTI’s
 INTERFERES WITH DNA
CHAIN
 Zidovudine (AZT)
 SE – NEUROPATHY AND
RASH
DRUGS
2. Non-nucleoside Reverse
Transcriptase Inhibitors
NNRTI’s
- BINDS TO REVERSE
TRANSCRIPTASE AND BLOCKS
RNA AND DNA REPLICATION
 Ritonavir (Norvir)
 SE – RASH,
HEPATOTOXICITY, BONE
MARROW DEPRESSION
3. Protease Inhibitors PI
 BLOCK VIRUS ABILITY TO
BREAK DOWN LARGER PROTEIN
MOLECULES
 Indinavir (Crixivan)
 SE – HEPATOTOXICITY,
NV, ABDOMINAL PAIN, RENAL
CALCULI
PREVENTION
A – ABSTINENCE
B – BE FAITHFUL
C – CONDOMS
D – DON’T USE DRUGS
ALWAYS KNOW YOUR DATE
Infertility
 Inability to conceive a child
or sustain a pregnancy to childbirth
 Pregnancy has not occurred
after at least 1 year of engaging in
unprotected sexual intercourse
Types of infertility:
 Primary infertility - refers to a
couple who have never
established a pregnancy
 Secondary infertility - refers
to couple who have conceived
previously but are currently unable
to establish a subsequent
pregnancy
Male Infertility Factors
 Inadequate sperm count
 Obstruction or impaired
sperm motility
 Ejaculation problems
 Causes of inadequate
sperm:
 Chronic infection
 Congenital anomalies
 Varicocele
 Increase in body temperature
 Trauma to the testes
 Endocrine imbalances
 Drug or excessive alcohol use
 Environmental factor
 Obstruction or impaired
sperm motility:
• Mumps or orchitis
• Anomalies of the penis
• Extreme obesity
Female Infertility Factors
 Cervical problems
38

 Vaginal problems
 Unexplained infertility
 Ovarian factor:
 Anovulation- most
common cause of infertility in
women
1. genetic abnormality
2.hormonal imbalance
3. ovarian tumor
4. stress
5.decreased body weight
 Tubal factor:
 Pelvic inflammatory disease
 Uterine factor:
 Tumor ( fibroma)
 Congenitally deformed
uterine cavity
 Endometriosis
 Inadequate endometrium
formation
 Cervical factor:
 Characteristic of cervical
mucus
 Infection/inflammation of
cervix
 Coital factor :
 pH of the vagina: alkaline pH
is optimum (8)
 Presence of sperm-
immobilizing/sperm agglutinating
antibodies
Fertility Assessment
 Fertility testing
 Semen analysis
 Ovulation monitoring
 Tubal patency assessment
Semen Analysis
 Number of sperm
 Appearance of sperm
 Motility of sperm
 Sperm penetration
semen analysis:
 count: 20 million / ml or
50 million /ejaculation
 volume: 2.5ml - 6 ml
 Motility: >75%
 Quality of motion: graded
1-4 (poor to excellent)
 Morphology: more than
70% normal
Ovulation Monitoring
 Record basal body
temperature
 Ovulation by test strip
 Assesses upsurge of LH that
occurs before ovulation
Tubal Patency
 Sonohysterography
 Ultrasound to inspect uterus
 Hysterosalpingography
 Radiologic exam of fallopian
tubes
Advanced Surgical Procedures
 Uterine endometrial biopsy
 Hysteroscopy
 Laparoscopy
Infertility evaluation:
 Male factor:
 Semen analysis
 Post-coital test-mucus is
examined microscopically between
2- 12hrs after coitus
• Satisfactory test- many
motile spermatozoa seen per high
power field
• Unsatisfactory result:
 No spermatozoa are seen
 Majority of spermatozoa are
immotile
 Very few spermatozoa are
present
 Motility is characterized as
shaking movement rather than
forward movement
 Hostile cervical mucus is
present
 Sperm antibodies: maybe
measured in
• Seminal plasma
• Male serum
• Female reproductive tract
fluids
• Female serum
 Test of fertilizing capacity of
spermatozoa:
 Measurement of sperm
acrosin-enzyme in sperm head that
responsible for preliminary
changes in the sperm
 zona-free hamster ovum
penetration test
39
 Human ovum fertilization test
 Coital factor:
 Taking history of coital
frequency, pattern and technique
 Anatomic evaluation of the
position of the cervix with
relationship to the vagina
 Post coital testing
 Cervical factor:
 Cervix is the first major
barrier encountered by sperm
after arrival in the female
reproductive tract
1.Abnormalities in the cervix or
the cervical mucus
• Abnormal position of the
cervix( prolapse or uterine
retroversion
• Chronic infection
• Previous cervical surgery
• Presence of sperm
antibody in the cervical mucus
2.mucus quality:
- pH
-bacteriologic culture for
microorganism
 Uterine factor:
* role of uterus in
reproduction:
- retention of the zygote after
arrival from the fallopian
tube
- provision of suitable
environment for implantation
- protection of embryo /fetus
from the external environment
• Hysterography- visualize
contour of the uterine cavity
• Hysteroscopy –visualize
uterine cavity to detect
anomalous development,
polyps or tumors
 Tubal factor:
- functions:
1.mechanical function- act to :
-conveys recently ovulated ova into
fallopian tube
-permits spermatozoa to enter the
oviduct
-effects transfer of the blastocyst
into the
uterine cavity
 Ovarian factor:
-function: serve as repository for
oocytes, they release mature
oocytes at regular interval
throughout reproductive life
- secrete steroid hormones that
influence the structure and
function of tissue in reproductive
tract, promoting fertility
*documentation of ovulation:
a. basal body temperature records
demonstrate a 14 day elevation of
basal temp.( progesterone-
thermogenic effect)
b. Blood progesterone level
c. endometrial biopsy- secretory
endometrial pattern
 Treatment :
 Correction of male factor:
a. Medical - correction of
underlying deficiencies
- artificial donor insemination
b. surgical - reversal of
sterilization
- varicocele surgery
c. assisted reproductive
technologies
1. in vitro fertilization and embryo
transfer IVF)
2. gamete intrafallopian tube
transfer(GIFT)
3. assisted fertilization
 Correction of ovarian factor:
1. induction of ovulation:
- correction of underlying endocrine
disorder
- clomiphene citrate to correct
hypothalamic function
- human menopausal gonadotropin
- bromocryptine for anovulation
due to prolactin excess -
glucocorticoids for androgen
excess
Assisted Reproductive
Techniques
 Artificial insemination
 In vitro fertilization
 Gamete intrafallopian
transfer
 Zygote intrafallopian transfer
 Surrogate embryo transfer
 Preimplantation genetic
diagnosis
ARTIFICIAL INSEMINATION
 Artificial insemination –
instillation of sperm into the female
reproductive tract to aid
conception
technique of micromanipulation
that thins the zona pellucida and
inject sperm into the ovum in an
effort to enhance fertilization
40
 In vitro fertilization (IVF)–
removing 1 or more mature
oocytes from a woman’s ovary by
laparoscopy and then fertilizing
them by exposing them to sperm
under laboratory conditions outside
the woman’s body (placed on a
dish together with the sperm)
 Embryo Transfer (ET)– ova
transfer; insertion of laboratory
grown fertilized ovum into the
wopman’s uterus approx. 40 hours
after fertilization where 1 or more
of them will implant and grow
 Gamete intrafallopian
transfer (GIFT) –ova and sperm are
instilled in the patent fallopian tube
within a matter of hours without
waiting for the fertilization t o occur
in the laboratory
 Zygote intrafallopian transfer
(ZIFT) – retrieval of oocytes, culture
and insemination of oocytes in the
laboratory; fertilized eggs are
transferred in the patent fallopian
tube within 24 hours
 Surrogate embryo transfer –
oocyte from a donor is fertilized by
the recipient woman’s male
partner’s sperm and placed in the
recipient’s uterus by ET or GIFT
 Intravaginal culture
 Blastomere analysis
Childbirth Alternatives
 Surrogate mothers

 Adoption
 Male factor:
 Obstruction in seminiferous
tubules , duct, or vessels
preventing movement of
spermatozoa
 Qualitative or quantitative
changes in the seminal fluid
preventing sperm mobility
(movement of sperm)
 Development of
autoimmunity that immobilizes
sperm
 Problem in ejaculation or
deposition preventing spermatozoa
from being placed close enough to
the woman’s cervix to allow ready
penetration and fertilization

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