breathing and collection of fluid (edema) in the legs.
I.
Prayer (video presentation) presentation)
III.
Commonly seen in diabetic patients.
a. Hemorrhagic Complications during
h. Oligohydramnios - a decreased amount of
II.
Definition of terms
amniotic fluid. It is typically caused by fetal urinary tract
a. Dystocia and dysfunctional labor -
abnormalities such as bilateral renal agenesis, fetal
difficult labor or failure to progress in labor can arise
polycystic kidneys or genitourinary obstruction.
from any of the three main components of the labor
Uteroplacental insufficiency is another common cause.
process: (1) the force that propels the fetus (uterine
Complications may include cord compression,
contractions); (2) the passenger (the fetus); or (3) the
musculoskeletal abnormalities such as facial distortion
passageway (the birth canal). b. Abruptio placenta – A normally implanted placenta that separates prematurely (between the 20 th
i.
j.
uterine contraction with poor intensity; low resting
uterine contraction with dark red bleeding; usually
tone between contractions which leads to prolong
occurs on the 24 th week of gestation.
labor. They may occur because more than one
th
at the 14 to 16 week of pregnancy.
pacemaker is stimulating the contractions k.
Abortion is the expulsion of the fetus prior to
Macrosomia - birth weight above the 90 th
Removal or destructions of an embryo or fetus before birth
Hypotonic labor dysfunction - infrequent
implanted in the lower portion of the uterus; painless
th
1. Abortion
or weight of less than 500 g.
lead to maternal exhaustion and fetal distress.
amniotic fluid through the abdominal wall for analysis
Abortion
viability, which is considered 20 w eeks gestation
and associated with dark red vaginal bleeding.
d. Amniocentesis Amniocentesis - is the withdrawal of
Pregnancy State
and clubfoot, pulmonary hypoplasia and intrauterine
week of gestation and birth of the infant). It is painful
Placenta previa - the placenta is
Childbirth Stage/ Bleeding During Early
growth restriction.
Hypertonic labor dysfunction - painful uterine contraction which is more frequent which can
c.
Discussion
Either spontaneous, occurring naturally, or induced, occurring as a result of artificial or mechanical interruption.
2. Spontaneous abortion or miscarriage
Occurring without medical or other intervention
About 25% of all pregnancy results in miscarriages,
percentile on an intrauterine growth chart for that
women older than 35 or younger than 17 years old
gestational age. Associated with poorly controlled
and couples who have difficulty in achieving
amniotic fluid is forced into an open maternal uterine
maternal diabetes due to excessive production of fetal
pregnancy; women who have had at least
blood sinus through some defect in the membranes or
insulin and hence the increased deposition of glycogen
miscarriage has a higher chance of experience
after membrane rupture or partial premature
in the fetus.
marriage.
e. Amniotic fluid fluid embolism embolism -occurs when
separation of the placenta. f.
), also known as Cerclage - (tracheloplasty ),
a cervical stitch, purse-string sutures are placed in the cervix usually by a vaginal route although this can be done abdominally. g.
Hydramnios - an excessive amount of
amniotic fluid (generally over 2,000 ml). The chronic
l.
Prolonged labor - labor lasting for more
than 24 hours.
trimester (first three months, or 12 weeks of
m. Precipitate labor – labor occurring for a very short time, can last for as early as 3 hours. n. Prolapsed cord - a loop of the umbilical
About 90% of miscarriage occurs during the first pregnancy).
Some cases of miscarriage happen even before even before a woman realizes that she is
cord slips down in front of the presenting fetal part.
pregnant, and she even may not realize that she
Prolapsed may occur at any time after the membranes
has aborted.
form of the disorder causes discomfort from
rupture if the presenting part is not fitted firmly into
enlargement of the abdomen; it also causes difficulty in
the cervix.
3. Habitual abortion
one year, approximately every 4 months.
st
5. Missed abortion is a case in which an
Characterized by having 3 or more abortions in
pregnancy is in the 1 trimester. Beyond 12 weeks gestation, induction of labor by intravenous oxytocin and prostaglandins may be use to expel the dead fetus.
intrauterine pregnancy is present but is no longer developing normally. Before widespread use of
A. Spontaneous abortion
Classifications
1. Threatened abortion is a condition of
ultrasonography, the term missed abortion was applied to pregnancies with no uterine growth over a prolonged period of time, typically 6 weeks after its (fetus) death.
pregnancy, occurring before the 20 th week of gestation,
Missed abortion is usually indicated by the
the patient usually experience vaginal bleeding with or
disappearance of the signs o pregnancy except for the
without cramping, the cervix is closed. Bed rest is
continual absence of menstrual periods. Missed
usually the only treatment needed. In a few cases the
abortions are usually treated by induction of labor by
symptoms disappear and the rest of the pregnancy is
dilation (or dilatation) and curettage (D&C).
o
o
6. Septic abortion is a condition when the
normal. 2. Inevitable / imminent abortion is when the
products of conception become infected during
bleeding continues and becomes heavy; it usually
abortion. There is fever (38 0C), foul odor, elevated
means that the cervix and the contents of the uterus
WBC, chills. There may be the presence of retained
(products of conception) are being expelled. Pregnant
placental parts.
woman will experience lower abdominal cramping and bleeding. 3. Incomplete abortion is a name give to the
abortion when the uterus retains parts or the entire placenta. Bleeding may occur because part of the placenta may adhere to the uterine wall and the uterus does not contract to seal the large blood vessels that
feed the placenta. The usual treatment is a drug that induces labor by stimulating uterine contractions, a surgical procedure called curettage ca also be done to
remove the remaining material from the uterus. 4. Complete abortion is when all of the products of conception is expelled. There is no treatment other then rest is usually needed. All of the tissues that come out should be saved for examination by the doctor to make sure hat the abortion is complete. The laboratory examination of the saved tissue may determine the cause of the abortion.
o
Medical Management: One of the more reliable indicators of potential spontaneous abortion is the presence of pelvic cramping and backache. These symptoms are usually absent in bleeding caused by polyps, ruptured cervical blood vessels, or cervical erosion The therapy prescribed for the pregnant woman with bleeding is abstinence from coitus and perhaps sedation. If bleeding persist and abortion is imminent or incomplete, the woman may hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilatation and curettage or suction evacuation is performed to remove the remainder of the products of conception. In missed abortions, the products of conception eventually are expelled spontaneously. If this does not occur within 4-6 weeks after fetal death, hospitalization is necessary. Dilatation and curettage or suction evacuation is done if the
o
o
Nursing Management: Threatened A woman may be asked to come to the clinic or office to have fetal heart sounds assessed or a sonogram done to evaluate the viability of the fetus. Blood for human chorionic gonadotropin hormone (hCG) may be drawn at the start of bleeding and again in 48 hours (if the placenta is still intact, the level in the bloodstream should double in this time). Avoiding strenuous activity for 24 to 48 hours is the key intervention, assuming the threatened abortion involves a live fetus and presumed placental bleeding. Complete bed rest is usually not indicated. Bed rest may stop the vaginal bleeding, but only because blood is pooling vaginally. When a woman does ambulate again, bleeding will recur. Women are apt to be extremely worried at the sight of bleeding. They need to talk with a sympathetic, supportive person about how distressed they feel. Be certain to convey concerned reassurance that miscarriages happen spontaneously, not because of anything a woman did. Women with threatened miscarriages look for reasons why this could have happened, such as running up a flight of stairs, forgetting to take an iron pill, or getting angry with an older child. Being told that none of these events causes miscarriage can help to minimize the guilt that many women feel. Imminent (Inevitable) Miscarriage
o
o
Save any tissue fragments passed in the labor room, along with any brought from home, so they can be examined for an abnormality such as gestational trophoblastic disease (hydatidiform mole) or for assurance that all the products of conception have been removed from the uterus. After the D&E, a woman should assess vaginal bleeding by recording the number of pads she uses. Saturating more than one pad per hour is abnormally heavy bleeding.
Complete Miscarriage After a self-limiting complete miscarriage, a woman needs clear instructions on how much bleeding is abnormal (a rule of thumb is that more than one sanitary pad per hour i s excessive) and what color changes she should expect in bleeding (gradually changing to a dark color and then to the color of serous fluid as it does with the postpartum woman). She should know that any unusual odor or passing of large clots is also abnormal. If her physician has prescribed an oral medication such as oral methlergonovine maleate (Methergine) to aid with contraction, be sure she understands why it is being prescribed an the importance of taking it.
o
o
o
o
Incomplete Miscarriage In an incomplete miscarriage, there is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively in this condition. The physician will usually perform a dilation and curettage (D&C) or suction curettage to evacuate the remainder of the pregnancy from the uterus. Be certain a woman knows that pregnancy is already lost and that this procedure is being done only to protect her from hemorrhage and infection, not to end the pregnancy.
Missed Abortion
causing hyper or hypothyroidism, thyroxin and triiodothyronine, and calcitonin), and diabetes mellitus (type 1 & 2).
2. Maternal infection TORCH infections during
gestations. Toxoplasmosis (a protozoan infection associated with the consumption of infected or poorly cooked meat and poor hand hygiene after handling infected cal litters). Other infections (AIDS, Lyme disease). Rubella (german measles or a 3-day measles. Can lead to congenital defect). Cytomegalovirus herpes virus (transmitted
through respiratory droplets and also from the semen, vaginal secretions, breast milk, placental tissue, urine, feces, and blood). Herpes simplex 2.
B. Induced abortion
This type of abortion uses drugs or instruments to stop the normal course of pregnancy
o
A sonogram can establish the fetus is dead. Often the embryo actually died 4 to 6 weeks before the onset of miscarriage symptoms or failure of growth was noted. After the sonogram, a D&E most commonly will be done. If the pregnancy is over 14 weeks, labor may be induced by a prostaglandin, suppository or misoprostol (Cytotec) to dilate the cervix, followed by oxytocin stimulation or administration of mifepristone. If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously within 2 weeks. There is a danger of allowing this normal course to happen, however, because disseminated intravascular coagulation (DIC), a coagulation defect, may develop if the dead (and possibly toxic) fetus remains too long in utero.
3. Acquired anatomic abnormalities
Disruption in the normal anatomy
and physiology of the female reproductive system
Induced abortions are done for a number of
can pose problems during pregnancy. Uterine
reasons: to end the pregnancy of a woman whose
fibroids (solid, pedunculated benign tumors found
life is in danger because if the pregnancy (such as
on the muscles layers of the uterus). Endometritis
woman who have IV heart disease); to prevent
(inflammation of the inner uterine lining). Uterine
the growth of a fetus who has been found on
rupture (rupture of scars from previous CS and
amniocentesis to have a chromosomal defect; to
hysterectomy repairs). Inversion of the uterus (is a
end a pregnancy that is the result of rape or
rare occurrence in which the uterus is turned
incest; or to terminate the pregnancy of a woman
inside out due to increased traction applied on
who choose not to have a child at this time in her
the umbilicus). Amniotic fluid embolism (occurs
life. The majority of induced abortions are done
when amniotic fluid is forced into an open
for the last reason.
maternal blood sinus through some defect in the membranes or partial premature separation of
Causes
the placenta).
1. Endocrine abnormalities
Women suffering from endocrine
system dysfunctions like: thyroid dysfunction (imbalance in thyroid-stimulating hormones -
4. Immunologic factors
Rh incompatibility (When carrying
an Rh-positive child, the mother will build up
antibodies to the Rh 0 factor in about 5 percent of
If bleeding is excessive – D&C.
of the placenta. Often partial moles are recognized
all cases. These antibodies will usually be too
Woman having induced abortions need the same
only after spontaneous abortion, and they may go
weak to harm the first child. But during labor and
kind of explanations that women in labor
unnoticed even then.
delivery some of the baby's Rh-positive blood
receive.
may get into the mother's bloodstream and
i.
trigger or sensitize her immune system. Her
2.Hydatidiform Mole (H-Mole) / Molar
antibodies will then attack the red blood cells of
pregnancy / Gestational Trophoblastic
any subsequent Rh-positive children. This
Disease
reaction produces erythroblastosis fetalis, or Rh
Clinical features same to that of pregnancy
Classis signs: vaginal bleeding (brownish , like prune juice or bright red); uterine enlargement,
From a proliferation and degeneration of the
hyperemesis gravidarum; (-) fatal heart tones and
disease, which results in jaundice, anemia, brain
trophoblast villi. As the cell degenerate, they
movement
damage, and often death, either before or shortly
become filled with fluid, appearing as a fluid filled,
after birth).
grape-sized vesicle, in this condition; the embrayo
5. Environmental factors
Hyperthermia and hypothermia in extreme
carcinoma.
ii.
pregnancy will strongly positive – 1 to 2 million IU
approximately 1 in every 1000 pregnancies.
compared to a normal pregnancy level of 400,000 IU- because HCG, the substance tested for
imbalances).
Types: Complete mole is more common than partial moles. It develops from an ovum containing
pregnancy test, is produced by the trophoblast cells).
no maternal genetic material that is fertilized by a
the rapid proliferation of the trophoblastic cells
often indicates spontaneous abortion
normal sperm. The embryo dies very early, no
that occur with complete moles, uterine
Cramping is usually absent if the vaginal bleeding
circulation is established, the hydropic vesicles are
enlargement may be greater than expected for
is cause by other conditions such as polyps
avascular, and no embryonic ti ssue or membranes
Most reliable indicator of pregnancy with an early
are found.
gestational age).
Partial mole usually has a triploid
Anemia (At approximately week 16 of pregnancy,
it will identify itself with vaginal bleeding).
gonadotropin hormone (HCG’s) and vaginal
karyotype (69 chromosomes), generally because of
examination of the pelvis.
failure of either the ovum or sperm to undergo the
spotting of dark brown blood or as a profuse fresh
Depression
first meiotic division. There may be fetal sack or
flow. As the bleeding progresses, it i s accompanied
even a fetus with a heartbeat. The fetus has
Abnormal enlargement of abdomen (Because of
Uterine cramping coupled with vaginal bleeding
abortion: serial serum B-human chorionic
Signs and symptoms
Positive pregnancy (A blood or urine test for
The incidence of hydatidiform mole is
weather conditions (affecting blood flow and F/E
Manifestations
PIH prior to 24 weeks gestation strongly suggest a molar pregnancy
must be identified as they are associated with
Heavy Metal and chemical hazards
Radiation (Fallout, x-rays, CT scans).
fails to develop beyond a primitive start. They
(insecticides, carbon monoxide, Lead, Mercury).
Manifestations
Passage of vesicles (Bleeding may begin as vaginal
by discharge of the clear fluid-filled vesicles).
Management Bed rest
multiple anomalies because of the triploidy and little chance for survival. The villi are often
sounds will be heard and absence of movement
vascularized and may be hydropic in only portions
will be noticed because there is no viable fetus).
Avoiding vaginal intercourse
Absence of fetal movement or parts (no fetal heart
b. Mild Preeclampsia (a woman is said to be mildly
iii.
o
o
o
o
o
Nursing responsibilities
Nurses, in providing care for clients with such complications should: Include in the assessment during prenatal visits, observations for signs of molar pregnancy during the first 24 weeks. Provide the woman and her family, information about the disease process, the necessity for a long course of follow- up, and the possible consequences of the disease. Help the woman understand and cope with pregnancy loss and recognize that the pregnancy was abnormal. Encourage the woman and her family to express their feelings and provide information about support groups or counseling resources if needed. Provide explanations about the importance of the need to postpone a subsequent pregnancy and contraceptive counseling to emphasize the importance of consistent and reliable use of the method chosen.
c.
condition is worsening. Obtain blood studies as
preeclamptic when her blood pressure rises to
ordered. Obtain daily weights as the same time
140/90 mmHg, taken in two occasions at least 6
each day to evaluate tissue fluid retention.
hours apart. Urine output less than 30 ml/hour.
d) Monitor fetal well-being. Generally, single
May have edema at the face and fingers).
Doppler auscultation at approximately 4-hour
Severe Preeclampsia (a woman has passed from
intervals is sufficient at this stage of development.
mild to severe preeclampsia when her blood
Fetal heart rate may be assessed continuously with
pressure has risen to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions
an external fetal monitor. e) Administer medications to prevent eclampsia. a
6 hours apart at bed rest or her diastolic pressure
hypotensive drugs such as hydralazine (Apresoline)
is 30 mmHg above the pregnancy level. May yield a
or labetalol (Normodyne) may be prescribed to
+4 albumin result found in urine).
reduce hypertension. These drugs act to lower
d. Eclampsia (it is the most severe classification of
blood pressureby peripheral dilatation and thus do
hypertension of pregnancy. A woman has passed
not interfere with placental circulation. They can
into this third stage when cerebral edema is so
cause tachycardia. Therefore, assess pulse and
acute that a seizure or coma occurs).
blood pressure after administration. Diastolic pressure should not be lowered below 80 to 90
mmHg. Despite these new drugs, magnesium
Management
sulfate remains the drug of choice to prevent
a) Promote bed rest. When the body is in a
eclampsia.
recumbent position, sodium tends to be excreted faster than during activity. Bed rest is the best
b. Bleeding during late pregnancy
method in aiding increased evacuation of sodium
i. Pregnancy-Induced Hypertension
and encouraging dieresis. Rest should always be in
Where the pregnant women experienced high
except bone. Major causes are heart or kidney
pressure on the vena cava. th
failure, low blood serum protein after starvation or
b) Promote good nutrition. A woman should
week of gestation
liver failure, shock, and impaired return of blood
continue her usual pregnancy diet but should not
from extremities).
have a stringent restriction of salt because it can
Hypertension Types
activate rennin-angiotensin-aldosterone system
a. Gestational Edema (Blood pressure is 140/90 or
and result in increased blood pressure,
systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above prepregnancy
compounding the problem. c)
Monitor maternal well-being. Take the blood
level; no proteinuria or edema; blood pressure
pressure frequently (at least every 4 hours) or with
retuenrs to normal after birth).
continuous monitoring device to detect any increase, which is a warni ng that a woman’s
Edama (is a general term for the accumulation of excess fluid in any body tissue, cavity, or organ,
a lateral recumbent position to avoid uterine
blood pressure; presence of protein in urine and edema. The symptoms usually occur after the 20
-
Types 1. Dependent edema is most likely to occur around the sacrum or heels of the client who sits up in bed or in the feet and lower legs of the client who sits in a chair.
2. Pitting Edema is edema that leaves a small
c.
Common Pathologic Changes During
depression or pit after finger pressure is
Intrapartum
Nursing
applied to the swollen area. The pit is caused
responsibilities i. Dystonia / dysfunctional labor
by movement of fluid to adjacent tissue, away from the point of pressure. Within 10 to 30
Oxytocin is not as effective as effective with
“Inertia” is a time -honored term to denote that
seconds the pit normally disappears. May be
hypertonic contractions as is rest and possibly
sluggishness of contractions has occurred.
shiny and cold. Can be graded as +1 = if
sedation. Change the linen and her patient gown; darken
indention is 2mm in depth; +2 = 4mm in depth, +3 = 6mm in depth, +4 = 8mm in depth.
room lights, decrease noise and stimulation.
Causes
1. Inappropriate use of analgesia (excessive or too
If there is late deceleration in the fetus, an
abnormally long stage of labor, or lack of progress
early administration)
Protenuria (late stage of preeclampsia) is the
pelvic diameter so that the fetus cannot pass,
glucose and protein in the urine are common
such as might have occurred in a client with
during pregnancy because of increased glomerular
scheduled for a cesarean delivery. Both the woman and her support person need
support to understand why contractions that feel
rickets.
as if they must be effective because they feel
3. Poor fetal positioning (posterior rather than
a woman’s individualized prepregnancy level to be
meaningful.
(“second stage arrest”), the woman will be
2. Pelvic bone contraction that has narrowed the
presence of protein in the urine. Trace amounts of
permeability, so proteinuria must be compared to
Management and
strong are in reality ineffective and are nor
anterior position).
achieving cervical dilation.
4. Extension rater than flexion of the f etal head. 5. Overdistention of the uterus, as with multiple
Theories regarding PIH
in labor) /Hypotonic uterine dysfunction
fetus.
sensitivity to circulating pressors such as
6. Cervical rigidity
angiotensin II and possibly imbalance between
7. Presence of a full rectum or urinary bladder that
prostaglandin and prostacylin Endothelial cell activation – due to decreased
placental perfusion; endothelial damage;
2. Secondary Uterine Inertia (occurring later
pregnancy, hydramios or an excessive o versized
Increased vasoconstriction – due to an increase
Nursing
impedes fetal descent
responsibilities
8. Mother becoming exhausted from labor 9. Primigravida
An infusion of oxytocin to “assist” labor is usually
arteriolar vasospasm contribute to the increased capillary permeability.
helpful to strengthen contractions and increase
their effectiveness.
Types
Increased edema – can lead to decrease
intravascular volume – which predispose to pulmonary edema Immunologic factor – the presence of foreign
protein, the placenta or the fetus may trigger adverse immunologic response
Management and
Membranes may be artificially ruptured
(amniotomy).
1. Primary Dysfunctional Labor (occurring at the onset of labor) /Hypertonic Uterine
Mark in the woman’s chart that hypotonic
contractions occurred.
Dysfunction IV.
In the first hour post partum, the uterus needs to be palpated every 15 minutes and l ochia should be assessed carefully to ensure that postpartal contractions are adequate.
