OBSTETRICS AND GYNECOLOGY

I. High Risk Pregnancy b. Problems of the Passageway

a. Gravida cardia  CPD
b. Anemia  Forcep Delivery
c. Rh Incompatibility  Cesarean Section
d. Gestational diabetes
c. Problems of the Power
II. First Trimester Bleeding  Hypotonic uterine
a. Abortion contractions
b. Ectopic pregnancy  Hypertonic uterine
contractions
III. Second Trimester Bleeding  Induction vs.
a. Incompetent cervix Augmentation of Labor
b. H-mole
VIII. Therapeutic Management
IV. Third Trimester Bleeding a. Uterine Rupture
a. Abruptio placenta b. Inversion of the Uterus
b. Placenta previa c. Amniotic fluid embolism
c. PROM
d. DIC IX. High Risk Post Partal Client
a. Uterine Atony
V. Pregnancy-Induced Hypertension b. Lacerations
c. Retained placental
VI. Sexually Transmitted Infections fragments
d. Subinvolution
VII. High Risk Labor & Delivery e. Perineal hematomas
a. Problems of the Passenger
 Cord Prolapse X. Puerperial Infections
 Nuchal Cord a. Endometriosis
 Fetal Distress b. Endometritis
 Malpresentation c. Infection of perineum
 Multiple Gestation
XI. Infertility & Sterility

Maternal & Child Health Nursing:

Care of the Childbearing & Childrearing Family, Edition 6.
❉
Adele Pillitteri
I . H I G H R I S K P R E G N A N C Y
-One in which a concurrent disorder, pregnancy-related complication, or external factor
jeopardizes the health of the woman, the fetus, or both.

a. Gravida Cardia /Peripartum Heart Disease

Normal in pregnancy: 28-32 weeks = most dangerous; BV peaks
 Functional / transient murmurs
 Heart palpitations on sudden exertions

4 categories:
Uncompromised
Class I Asymptomatic
No limitation of physical activity
Normal pregnancy &
Slightly compromised
birth
Asymptomatic at rest
Class II
Symptoms occur with ordinary physical activity
Slight limitation of physical activity
Markedly compromised
Can complete
Class III Comfortable at rest
pregnancy with CBR
Symptoms occur with less than ordinary physical activity
Severely compromised
Poor candidates for
Class IV Symptomatic at rest
pregnancy
Discomfort with carrying out any physical activity

Management:
LSHF RSHF
 Anticoagulant – Heparin = DOC  O2
o AVOID warfarin = teratogenic  ABG analysis – to ensure fetal growth
– can be used after 12 weeks but will  Pulmonary Artery Catheter - during labor –
be switched to heparin during last to monitor pulmonary pressure
month of pregnancy
 Monitor fetal health:
o Done after 30-32 weeks
o UTZ
o Non-stress test
 Balloon valve angioplasty – to loosen mitral
valve adhesions

DURING LABOR: POSTPARTUM:

 Monitor FHR & uterine contractions  Stabilize maternal circulation:
 Assess VS frequently o Decrease physical activity
 POSITIONS: o Anti-coagulant
o Side-lying - to prevent supine o Digoxin
hypotension syndrome  Antiembolic stockings and ambulation
o Semi-Fowler's  Antibiotics - prophylaxis to endocarditis
 O2  Oxytocin - use with caution, can BP
 Swan-Ganz catheter - for continuous  Stool softener
hemodynamic monitoring
 Epidural - anesthetic of choice
 Use low forceps / vacuum extractor
 AVOID pushing
b. Anemia
Pseudo-anemia - blood volume expands slightly ahead of the red cell count
-normal; should not be confused with true types of anemia

True Anemia Hgb Hct

1st/3rd trimester <11 g/dL <33 %
2nd trimester <10.5 g/dL <32%

1. Iron Deficiency Anemia –a microcytic (small red blood cell), hypochromic (less
hemoglobin than the average red cell) anemia because when an inadequate supply of
iron is ingested, iron is unavailable for incorporation into red blood cells

Risk Factors:
 Low iron diet
 Heavy menstrual periods
 Unwise weight-reducing programs
 <2 years pregnancy gap
 Low socioeconomic

Signs & Symptoms:

Extreme fatigue
Poor exercise tolerance

Diagnostic Tests:
Hemoglobin <12 mg/dL
Hematocrit <33%

Confirmed if with:
Low serum iron level
Increased iron-binding capacity

Management:
a. Iron-rich diet
b. Ferrous sulfate / ferrous gluconate
Prophylaxis: 60 mg Best absorbed in acidic medium
Therapeutic: 120-200mg Take with orange juice/vitamin C
Normal = black stool

If with gastric irritation: If severe/unable to tolerate:

 Increase fiber intake IM/IV iron dextran
 Take the pills with food
2. Folic Acid Deficiency Anemia / Megaloblastic Anemia
Apparent during 2nd trimester

Risk Factors: Complications:

 ↑fetal demand  Early miscarriage
 Women with secondary hemolytic illness  Premature separation of the
 Taking hydantoin (interferes with folate placenta
absorption
 Taking oral contraceptives Diagnostic Result:
 Gastric bypass ↑MCV (enlarged RBCs)

Management:
 Prophylaxis: 400 µg folic acid daily
 Therapeutic: 600 µg folic acid daily
 Folacin-rich foods (green leafy vegetables, oranges, dried beans)

3. Sickle Cell Anemia - recessively inherited hemolytic anemia caused by an abnormal

amino acid in the beta chain of hemoglobin.

Sickle hemoglobin (HbS) – abnormal amino acid replaces the amino acid valine
Nonsickling hemoglobin (HbC) – abnormal amino acid substitutes the amino acid
lysine

Sickle cell trait (HbAS) - heterozygous substitution

Sickle cell disease (HbSS) - homozygous substitution

Pathophysiology: Complications:
Irregular or sickle shaped RBCs Impaired placental circulation due to
↓ blockage
Inability to carry hemoglobin
↓
Assessment
Reduced oxygen tension
Hemoglobin
↓
Clumping of the cells  normal (with sickle cell) = 6 to 8
↓ mg/100 mL
Vessel blockage  If (+) hemolysis = 5 or 6 mg/100
↓ mL
Reduced blood flow to organs ↑indirect bilirubin level
↓ Clean catch urine - to detect
Cell hemolysis developing asymptomatic bacteriuria
↓
Severe anemia

Management:
 Folic acid supplement
 Increase fluid intake – DHN may lead to sickle cell crisis
 Assess lower extremities
o Varicosities or pooling of blood & pressure = may lead to hemolysis
o Decrease pressure:
 Avoid standing for long periods
 Elevate the legs
 Modified Sims' position
  Monitor fetal health
o UTZ at 16-24 weeks: Assess for intrauterine growth restriction
o Weekly at 30 weeks
o Measure blood flow velocity (uterus and placenta)
↓ = ↑chance of intrauterine growth restriction
 Periodic exchange transfusions - to replace sickled cells with non-sickled cells

 CRISIS
o Pain control
o Administer oxygen PRN
o Inc fluid volume
o Hypotonic solution (0.45 saline) – to keep plasma tension low

 Iron supplement is not given during pregnancy

Inability to incorporate iron = excessive iron buildup

 Folic acid supplement - to prevent new cells from being megaloblastic

 (+) infection = admit to hospital

 Temp
Diaphoresis
 PO2 d/to RTI

 Labor – keep the woman hydrated

 CS – epidural anesthesia
GA = hypoxia
 Post-partum
 Reduce the risk of thromboembolism
o Early ambulation
o Wear pressure stockings

 Infant Screening
Parent 1 Parent 2 Child
Disease  (-) (-)
Trait (-)
Disease  50% chance
Trait (+)
Disease   

Sickle cell trait is carried on hemoglobin’s beta chain (appears in adulthood)

Electrophoresis
Percutaneous umbilical blood sampling
Amniocentesis
c. Rh Incompatibility / Isoimmunization
- occurs when an Rh-negative mother (one negative for a D antigen or one with a dd
genotype) carries a fetus with an Rh-positive blood type (DD or Dd genotype).

D antigen – protein factor; Rh (+)

Father Mother Baby Separation of the placenta
Rh(+) Rh(-) Rh(+) 
  Mixture of fetal & maternal blood

Homozygous DD Dd 72 hours post partum:
Heterozygous Dd Dd (50%)
Mother builds antibodies
Hemolytic Disease of 
the Newborn / Fetal hemolysis: 2nd pregnancy – antibodies attacks
Erythroblastosis fetalis RBC, O2 Rh+ fetus through placenta

Assessment:
Anti-D antibody titer – NORMAL = 0; done at 1st visit, repeated at 28 weeks
1:16 = Rh sensitization
If  = monitor fetus q 2 weeks by Doppler velocity of the fetal middle cerebral
artery (detects anemia / hemolysis)
If high = (-) anemia ; Rh(-)
If low = immediate birth if at term
If not near term = reduce the number of antibodies (mother)
= replace damaged RBCs (fetus)
Fetal blood-typing
Coombs test (direct antiglobulin test)  If (+) = RhIG to mother

MATERNAL Management:
Reduce Rh antibodies
 Rh (D) immunoglobulin (RhIG) – ROUTE IM
- passive antibody; cannot cross the placenta
DOSES 5 doses q 12
o Adm at 28 weeks
EFFECTS 2 weeks – 2 months
o First 72 hours post partum

HEMORRHAGIC DISEASE OF THE NB – results from Vitamin K deficiency

May lead to:  prothrombin function & impaired blood coagulation

Assessment: Diagnostic tests:

Bleeding –day 2 to 5 of life (prothrombin at lowest level) Dipstick guaiac test
Petechiae Prolonged prothrombin time
Hemorrhage - conjunctival, mucous membrane or Prolonged coagulation time
retinal
Hematemesis
Melena

Management: Prevent further bleeding:

Administer vitamin K IM: to mother before birth  Handle infants gently
to NB after birth - 1mg  Avoid heavy pressure
WOF subdural hemorrhage
If severe bleeding:
BT - fresh, whole blood -  prothrombin level stat
d. Gestational diabetes – a condition of abnormal glucose metabolism that arises during
pregnancy.
- Women who are not diabetic before the pregnancy but becomes diabetic during
pregnancy. Symptoms fade at the end of pregnancy.
-At risk for developing type 2 DM later in life

Assessment:
 Fasting plasma glucose ≥126 mg/dl
 Nonfasting plasma glucose ≥ 200 mg/dl
 50-g oral glucose challenge test:
o After 1 hour: >140 md/dL  schedule for 100-g, 3-hour fasting
 2/4 blood samples >95 mg/dL = (+) GDM
 Glycosylated hemoglobin – measures of the amount of glucose attached to hemoglobin
- Average blood glucose level over the past 4 to 6 weeks
Upper normal level of HbA = 6% of total hemoglobin

 Ophthalmic examination – done at each trimester

WOF:
 Exudate = “cloud-like”
 Dot hemorrhage
 Macular edema

 Urine culture – done at each trimester to detect asymptomatic UTI

Management:
a. Diet – 1800- to 2400-calorie diet divided into 3 meals & 3 snacks
 Calories are evenly distributed to keep the serum glucose level constant
 Low fat, low cholesterol, high fiber diet CHON < FAT< CHO
 AVOID <1800-calories = fat breakdown = acidosis

 If (+) n/v or heartburn= notify HCP = temporary intravenous fluid supplement

 Prevent nocturnal hypoglycemia: Final snack should be CHON & complex CHO = for
slow digestion

b. Exercise – consistent exercise program everyday

 BEFORE exercise – eat CHON & complex CHO
 AVOID using the arm injected with insulin
= insulin is released quickly = hypoglycemia
 AVOID extreme exercise = hyperglycemia & ketoacidosis

c. Insulin therapy – will begin only if diet alone is unsuccessful

 Early in pregnancy – less insulin needed, glucose is used by fetus for rapid cell growth
 Later in pregnancy – increased insulin
 AVOID changing the type & dosage of insulin, only re-regulate
 AVOID OHA – crosses placenta & teratogenic

 Short-acting insulin (regular) combined with immediate type

 Eat immediately after injecting – to avoid hypoglycemia

 Monitor peak level of insulin

AM 2/3 of the dose 30 min before breakfast 2:1(intermediate to regular)
PM 1/3 of remaining dose 30 min before dinner 1:1
 Blood glucose monitoring:
Fasting blood glucose level < 95 to 100 mg/dL IDEAL VALUES
2-hour postprandial level < 120 mg/dL

If hypoglycemic: If hyperglycemic:
Sustained CHO + less-concentrated fluid – Assess urine for ketones (in 2 separate
to avoid rebound phenomenon specimens)
Common time: 2nd & 3rd months AVOID maternal acidosis = fetal anoxia
Before insulin resistance peaks Common time: 6th month
Insulin resistance most pronounced

d. Insulin Pump Therapy (Continuous Subcutaneous Insulin Infusion)

o Continuous rate of 1U/hr is infused
o Clean the insertion site daily
o Cover with sterile gauze
o Site is changed 24-48 hours
o Blood glucose determination 4x a day - to assess whether the pump is delivering insulin at
the designated rate
o AVOID getting the pump wet

e. Assess Fetal Well-Being

o Serum alpha-fetoprotein at 15-17 weeks – to assess for neural tube defect
o UTZ at 18-20 weeks – to detect gross abnormalities
o Creatinine
o Monitor movement per hour = 10 movements/hour
o Assess amount of amniotic fluid
 Oligohydramnios/hydramnios – at risk for hemorrhage post partum
o Lecithin–sphingomyelin ratio by amniocentesis at 36th week – to detect fetal maturity
 Phosphatidylglycerol – used to indicate lung maturity
 Corticosteroid is not recommended
 Impairs fetal insulin release
 Impairs fetal pancreatic islet development

f. Assess Placental Functioning:

Weekly at last trimester:
 Nonstress test
 Biophysical profile

g. Timing for Birth

CS at 37 weeks
Cervix is not yet ripe or unresponsive to labor contractions.
Babies are macrosomic
Cephalopelvic disproportion
 risk for shoulder dystocia
To prevent respiratory distress syndrome
Induce labor by rupture of the membranes or an oxytocin infusion
Early detection of placental dysfunction:
Monitor continuously:
o Labor contractions
o Fetal heart sounds
Regulate glucose level during labor – IV regular insulin
I I . F I R S T T R I M E S T E R B L E E D I N G

a. Abortion – any interruption of pregnancy before the age of viability (<20 weeks/<500g)

Vaginal spotting Cramping Cervical dilatation Expulsion

Threatened  Slight Closed cervix
Loss of product of
Imminent   
conception
Missed  slight No apparent loss
Incomplete    Incomplete
Complete    Complete

1. Spontaneous Miscarriage
Early miscarriage if it occurs before week 16 of pregnancy; late miscarriage if it
occurs between weeks 16 and 24

CAUSES: General Management:

Alcohol  Flat on bed; left lateral position
Teratogenic drugs  PLRS with 16- or 18- gauge
Implantation abnormalities  O2 - 6-10L/min via face mask
Corpus luteum fails to produce  Monitor uterine contractions & FHR
progesterone  AVOID IE
Abnormal fetal development  NPO
Systemic infection  Blood typing & cross-matching
Immunologic factors (rejection of the  Measure I&O
embryo)  VS
 Assist with placement of CVP / PCWP
 Measure blood loss
 Observe blood drawn for 5 mins for clot
formation
 UTZ

COMPLICATIONS
Hemorrhage Infection – E. coli
 Monitor VS – WOF hypovolemic shock Danger signs:
 Flat on bed o Fever
 Massage the fundus – to aid o Abdominal pain or tenderness
contraction o Foul vaginal discharge
 BT  Proper perineal care
 Direct replacement of fibrinogen /  AVOID tampons
clotting factor
 WOF abnormalities: Septic abortion - an abortion that is
o >1 pad / hour complicated by infection; self-abortion
o Color changes in bleeding  May lead to toxic shock syndrome
o Unusual odor  Complete blood count
o Passing of large clots  Serum electrolytes
 Methylergonovine maleate  Serum creatinine
(Methergine) – to aid in uterine  Blood type and crossmatch
contraction  Cultures - cervical, vaginal, and
urine
 Management:
 IFC
 IVF
 High-dose, broad-spectrum antibiotic therapy
 Penicillin (gram-positive coverage)
 Gentamicin (gram-negative aerobic coverage),
 Clindamycin (gram-negative anaerobic coverage)
 Central venous pressure or pulmonary artery catheter - to monitor left atrial
filling pressure and hemodynamic status
 D&C / D&E
 Tetanus toxoid SQ
 Tetanus Ig IM
 Dopamine & digitalis – to maintain CO
 O2 / ventilatory support

 Threatened Miscarriage  Imminent (Inevitable) Miscarriage –

Management: Products of conception are lost
hCg – drawn at the start of bleeding, Management:
then 48 hours (level should be Vacuum extraction / dilation & extraction /
doubled) suction curettage
If not = poor placental function  Removal of all products of conception
AVOID strenuous activities for 24-48  Prevent infection
hours Tissue fragments – examined for abnormality
AVOID coitus for 2 weeks after the (H-mole)
bleeding Assess the amount of vaginal bleeding
>1 pad / hour = abnormally heavy bleeding

 Complete
Entire products of conception (fetus, membranes & placenta) are expelled
spontaneously without any assistance

 Incomplete
Fetus is expelled, membrane / placenta are retained

2. Missed Miscarriage – “Early Pregnancy Failure”

- Fetus dies in utero but is not expelled
- No increase in fundal height
- (-) Fetal heart sound

D&E
Induce labor – if >14 weeks
Prostaglandin suppository or misoprostol (Cytotec) – to dilate the cervix
Oxytocin stimulation or administration of mifepristone

Complication:
DIC – disseminated intravascular coagulation
May develop if the dead fetus remains too long in the utero

3. Recurrent Pregnancy Loss

-3 spontaneous miscarriages occurred at the same gestational age
b. Ectopic pregnancy – implantation occurs outside the uterine cavity
Most common site: Fallopian tube
Most dangerous: Interstitial / fimbrial

Causes:
 Obstructions
 Adhesions
 Scars
 Tumors
 Congenital anomalies - webbing

Assessment:
 Vaginal spotting
 Progression of internal bleeding to acute hemorrhage = WOF shock
 Sharp, stabbing pain at lower abdominal quadrant
 Cullen’s sign
 Shoulder pain – phrenic nerve irritation d/to blood in peritoneal cavity
 Tender mass - Douglas’ cul-de-sac

Diagnostic Tests:
 Transvaginal UTZ
 hCG / serum progesterone level = pregnancy has ended
 Insertion of needle to aspirate blood from posterior vaginal fornix into the cul-de-sac
 Laparoscopy / culdoscopy

Management:
 If unruptured –given until negative hCG titer:
o Methotrexate - folic acid antagonist chemotherapeutic agent, attacks and destroys
fast-growing cells
o Leucovorin – antidote for methotrexate
o Mifepristone – abortifacient; progesterone antagonist – to slough off the tubal
implantation site

 If ruptured –
 Get blood sample
o Hgb level
o Typing & cross-matching
o hCG
 IVF with large gauge cath
 BT
 Laparoscopy – to ligate the bleeding vessels; remove / repair the fallopian tube
o Suture line will cause another scarring
 Salpingectomy
III. S E C O N D T R I M E S T E R B L E E D I N G

a. Incompetent cervix / Premature Cervical Dilatation

Cervix that dilates prematurely, cannot hold fetus until term
Risk Factors: Assessment:
Increased maternal age Painless dilatation
Congenital structure defects Show – pink-stained vaginal discharge
Cervical trauma  Pelvic pressure

Management:
Cervical cerclage – done at 12-14 weeks
- Purse-string suture that strengthens the cervix and prevents it from dilating
- Regional anesthesia
 McDonald – temporary
- Nylon sutures placed horizontally & vertically across the cervix and pulled tight
 Shirodkar – permanent
- Sterile tape is threaded in a purse-string manner
o Removed at 37-38 weeks for NSD
o Postop:
 Bed rest – Slight or modified Trendelenburg

b. Gestational Trophoblastic Disease (Hydatidiform Mole)

- Abnormal proliferation and then degeneration of the trophoblastic villi
- Associated with choriocarcinoma

2 types of molar growth:

a. Complete mole - all trophoblastic villi swell and become cystic
b. Partial mole – some of the villi form normally

Assessment:
 Rapid expansion of the uterus
 Dark brown spotting with clear fluid-filled vesicles

Diagnostic Tests:
 UTZ – snowflake pattern
 hCG – d/to overgrowth of trophoblast cells = manifested by n/v
 (-) fetal heart sound

Management:
 Suction curettage – for mole extraction
 Oral contraceptive for 12 months – to avoid confusion for increasing hCG levels
 Monitoring of hCG: WOF choriocarcinoma
o Analyzed q 2 weeks post partum until normal
o Then every 4 weeks for the next 6-12 months
(-) 6 months = (-) CA
(-) 12 months = can have pregnancy
 Methotrexate prophylaxis – DOC for choriocarcinoma
o Interferes with WBC formation
 Dactinomycin – if with metastasis
IV. T H I R D T R I M E S T E R B L E E D I N G

a. Abruptio placenta / Premature Separation of the Placenta

Types:
Partial separation Complete separation
Apparent hemorrhage Concealed hemorrhage

Degrees of Separation:
Grade Separation Bleeding Maternal Fetal
0 None
1 Minimal  Changes in VS None
2 Moderate Uterine tenderness (+) distress
3 Extreme Shock Death

Assessment:
 Dark red bleeding ĉ sharp, stabbing pain
 Uterine tenderness
 Couvelaire uterus / uteroplacental apoplexy – hard, board-like uterus ĉ no/minimal bleeding

Complication: DIC

Diagnostic Tests:
 WOF DIC:
o Hemoglobin level
o Typing and cross-matching
o Fibrinogen level and fibrin breakdown
 Assess blood clotting ability:
o Draw 5 mL, place in a clean, dry test tube, set aside untouched for 5 minutes.
Abnormal if (-) clot formation

Management:
 IVF ĉ large gauge
 O2
 Monitor FHT & maternal VS q 15 minutes
 Left lateral position
 AVOID abdominal, vaginal, pelvic exams
 Fibrinogen or cryoprecipitate IV
 BT
 Hysterectomy – last resort; to prevent exsanguination
b. Placenta previa – low implantation of the placenta

4 degrees:
1. Low-lying – lower portion of the uterus
2. Marginal implantation – the placenta edge approaches the cervical os
3. Partial – occludes a portion of the cervical os
4. Total – totally obstructs the cervical os

Assessment:
Abrupt, painless, bright red bleeding

Diagnostic Tests:
 Apt or Kleihauer-Betke test – a strip used to detect if fetal or maternal blood
 Abdominal exam = head is not engaged
 Vaginal exam – done if (-) previa; to rule out other causes of bleeding

Management:
 CBR ŝ BRP – side-lying for 48 hours
 Avoid coitus, IE, enema
 Determine blood loss
 WOF shock
 Assess BP q 15 minutes
 IVF ĉ large bore needle
 Monitor UO q 1 hour
 Monitor fetal heart sounds & uterine contractions
 BASELINE: Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time,
fibrinogen, platelet count, type and cross-match, and antibody screen

Deliver the baby if: NSD if <30% Expectant watching:

 Labor CS if >30% Bleeding has stopped
Continuous bleeding FHT is good
 Fetus is compromised Maternal VS is good

Rx: Betamethasone IM – hastens fetal maturity if fetus is <34 weeks gestation

Complications:
Hemorrhage
Endometritis – placental site is close to the cervix, portal of entry for pathogens
c. Disseminated Intravascular Coagulation – acquired disorder of blood clotting in which the
fibrinogen level falls to below effective limits
- Occurs when there is such extreme bleeding and so many platelets and fibrin from
the general circulation rush to the site that not enough are left in the rest of the body

Diagnostic tests:
 Platelets ≤100,000/μL
  Prothrombin
  thrombin time
 fibrinogen <150mg/dL
 fibrin split products >40μg/mL

Management:
 IV heparin – restore normal clotting function
 Antithrombin III factor, fibrinogen, or cryoprecipitate
 Blood / FFP / platelet transfusion – correct bleeding

d. Premature Rupture of Membrane – rupture of fetal membranes with loss of amniotic fluid
during pregnancy before 37 weeks

Complications:
 Infection – uterine & fetus
  pressure on umbilical cord
= impaired fetal circulation = impaired fetal nutrient supply
 Potter-like syndrome – distorted facial features & pulmonary hypoplasia

Assessment:
 Sudden gush of clear liquid

Diagnostic Tests:
 Nitrazine paper
 Blue = Alkaline = Amniotic fluid
 Yellow = Acidic = urine
  AFP in vagina
 UTZ – to assess amniotic fluid index
 Cultures - Neisseria gonorrhoeae, Streptococcus B, and Chlamydia
 WBC count
  C-reactive protein

Management:
 AVOID IE
 Oxytocin IV – induce labor

 If fetus is non-viable:
o Bed rest
o Corticosteroid
o Broad-spectrum antibiotics
o IV Penicillin / ampicillin – for Strep B

 If (-) infection = tocolytics

 Fibrin-based commercial sealant – to reseal membranes

V. P R E G N A N C Y - I N D U C E D H Y P E R T E N S I O N
- is a condition in which vasospasm occurs during pregnancy

 Hypertension
 Proteinuria
 Edema

RISK FACTORS:
 Women of color
 Multiple pregnancy
 Primipara <20 y/o or > 40
 Low socioeconomic backgrounds (d/to poor nutrition)
 Multipara - >5 pregnancies
 Hydramnios (overproduction of amniotic fluid)
 Underlying disease - heart disease, diabetes with vessel or renal involvement
 Essential hypertension

Classification BP Proteinuria Edema

GESTATIONAL
140/90 mmHg - - No drug therapy necessary
HYPERTENSION
140/90 mmHg taken 1+ to 2+ on Face & weight gain > 2lb/wk in
MILD PRE-
on 2 occasions at a random upper second trimester and 1lb/wk
ECLAMPSIA
least 6 hours apart sample extremities in third trimester
160/110 mmHg 3+ to 4+ on ↓ UO = 400-600mL/24hrs
taken on 2 random Extensive Serum crea = >1.2mg/dL
SEVERE PRE-
occasions at least 6 sample peripheral Severe epigastric pain, n/v,
ECLAMPSIA
hours apart at Or >5g in a edema SOB, severe headache
bedrest 24-hr sample Ankle clonus
ECLAMPSIA s/sx of pre-eclampsia Grand-mal seizure or coma

Management:
MILD PIH
 Monitor antiplatelet therapy
o Low dose aspirin (50-150 mg)
 Bed rest – lateral recumbent position
 Diet – continue usual pregnancy diet
o AVOID salt restriction
 Emotional support – instruction compliance

SEVERE PIH
 Bed rest – visitors are restricted
o Private room
o Side rails up
o Dim the lights
 Diet – continue usual pregnancy diet
o AVOID salt restriction
 Emotional support – instruction compliance
 Diet - moderate to high protein; moderate sodium
 Salt-poor albumin
 BP q 4 hours
 Blood studies: Prior to administering MgSO4:
 CBC platelet count LFT BUN Crea  UO > 25-30 mL/hr
 Fibrin degradation products  Specific gravity = 1.010 or lower
 Sample for type and cross-match  RR >12/minute
 Daily hct levels  Check LOC
 Frequent plasma estriol levels  Minimal ankle clonus
 Electrolyte levels  (+) DTR - if epidural block is given, assess
 Optic fundus biceps or triceps reflex
WOF:
 Arterial spasm *Assess q1 if continuous IV infusion
 Edema
 Hemorrhage ANTIDOTE: Ready at bedside
 Daily weights 10ml of 10% calcium gluconate (1g)
 IFC - expected UO = >600mL/24hrs
 Urinary proteins Fetal well-being
 Specific gravity  Single Doppler auscultation q 4 hours
 Protein and creatinine clearance  Continuous fetal heart rate monitoring
 Nonstress test or biophysical profile - to
Rx: assess uteroplacental sufficiency
 Antihypertensives:  Oxygen – face mask
 Hydralazine (Apresoline)
 Labetalol (Normodyne) On the day of birth:
 Nifedipine Notify the pediatrician if (+) MgSO4
 Magnesium sulfate - DOC
 IV in a loading or bolus dose continuously for If given within 2 hrs of baby's birth:
15 minutes, effect lasts only 30-60 minutes  Respiratory depression
 Blood serum levels maintained at 5-  Loss of variability of heartbeart
8mg/100mL  Reduced fetal breathing movements

WOF TOXICITY! WOF other signs of fetal effects:

 ↓ UO Late deceleration with labor contractions
 Depressed respirations
 Reduced consciousness MgSO4 is continued for 12-24 hours after birth
 ↓ DTR – Tapered
– Discontinued
Monitor UO Delay breastfeeding until medication is
continued
Long term effect: Osteoporosis
Rx: Calcium supplements
PIH COMPLICATION: H E L L P S Y N D R O M E

Hemolysis that leads to anemia

Elevated Liver enzymes that lead to epigastric pain
Low Platelets that lead to abnormal bleeding/clotting and petechia

Assessment:
 Proteinuria
 Edema
 Hypertension
 Nausea
 Epigastric pain
 General malaise
 Right upper quadrant tenderness from liver inflammation

Diagnostic Tests:
 RBC hemolysis
 Thrombocytopenia = platelet count <100,000/mm3
 ALT & AST – d/to hemorrhage & necrosis of the liver

Management:
 Bleeding precaution
 FFP / platelet transfusion
 IV glucose infusion – if hypoglycemic

Complications:
Subcapsular liver hematoma Mothers: Fetus:
Hyponatremia Cerebral hemorrhage Growth restriction
Renal failure Aspiration pneumonia Preterm birth
Hypoglycemia Hypoxic encephalopathy
VI. S E X U A L L Y T R A N S M I T T E D I N F E C T I O N S

a. Candidiasis
Etiologic Agent: Candida albicans (fungus) – thrives on glycogen

Causes: Assessment:
 estrogen   glycogen  Vulvar & vaginal bleeding, burning &
 Oral contraceptives itching
 Antibiotic therapy: normal flora < fungi  White, thick, cream cheese-like
 Immunosuppressed – HIV discharge
 Diabetes Mellitus  Pain – coitus / tampon insertion

Diagnostic Tests:
 20% potassium hydroxide solution: 3-4 drops on sample discharge on glass slide
 Vagasil Screening Kit:
o Normal pH + itching and/or burning + unusual discharge + yeasty odor

Management:
 Anti-fungal: Complication:
 Vaginal suppositories / cream Oral thrush in newborn – white adherent
o Dose: OD x 3-7 days at bedtime patches on the tongue, palate, and
o Miconazole (Monistat) inner aspects of the cheeks that cannot
o Clotrimazole (Lotrimin) be removed
 Fluconazole (Diflucan) PO single dose
Management:
 Wear sanitary pad – to avoid staining Nystatin - 1mL QID / q6 x 2 weeks after
 If frequent candidal infection, test urine feedings
for glucose to r/o DM Fluconazole PO x 2 weeks
Gentian violet - for chronic cases
 For pregnant mothers:
o Miconazole (Monistat) x 7 days
o Fluconazole (Diflucan) PO single dose

b. Trichomoniasis
Etiologic Agent: Trichomonas vaginalis – protozoan
Mode of Transmission: Sexual contact

Assessment: Diagnostic Test:

Male: Asymptomatic  Sample of discharge in LRS / PNSS
Female: o Trichomonads = rounded, mobile
 Vaginal irritation structures
 Frothy-white or grayish-green  Pap test may produce false positive result
malodorous vaginal discharge d/to inflammatory changes in the cervix
 “strawberry spots” on cervix &
vaginal walls – petechiae
 Extreme vulvar itching

Management:
 Metronidazole (Flagyl) PO single dose
o AVOID alcohol ingestion – can cause n/v
 Condom
c. Bacterial Vaginosis
Etiologic agent: Gardnerella vaginalis – thrives in O2 level

Assessment: Diagnostic Test:

 Milk-white to gray discharge  Sample of discharge in NSS
 Fish-like odor o Gram-negative rods adhered to
 Intense pruritus vaginal epithelial cells (clue cells)

Management: Complications:
 PO/vaginal x 7 days  Amniotic fluid infection
o Clindamycin  Preterm labor
o Metronidazole  PROM

d. Chlamydia
Etiologic agent: Chlamydia trachomatis – most common
- Has strong association with gonorrhea
Incubation period: 1-5 weeks

Assessment: Diagnostic test:

 Heavy, grayish-white discharge  Culture – done at first prenatal visit
 Vulvar itching
Complications in newborn:
Management:  Ophthalmia neonatorum
 PO x 7days:  Pneumonia
o Doxycycline – CI with pregnancy
o Tetracycline
 Azithromycin PO single dose
 Amoxicillin

e. Gonorrhea
Etiologic agent: Neisseria gonorrhoeae
- Gram-positive diplococcus
- Thrives on mucous membrane ĉ columnar transitional epithelium
- Occurs with chlamydia
Incubation period: 2-7 days

Assessment: Management:
Male: o Cefixime PO
o Urethritis – frequency and pain on o Ceftriaxone IM 7 days
urination o Doxycycline PO  CI with pregnancy
o Urethral discharge o Amoxicillin / Azithromycin =  preg

Female: Post-treatment:
o Slight yellowish discharge 24 hours = no longer infectious
o Pain & inflamed Bartholin’s glands 7 days = follow-up culture

Diagnostic Tests: Complications:

Female: Urine culture = gonococcal bacillus o Arthritis / heart disease
Male: First void = gonococci o Male: Permanent sterility
o Female: PID
o Newborn: Ophthalmia neonatorum
f. Syphilis
Etiologic agent: Treponema pallidum – spirochete
Mode of transmission: Sexual contact; oral-genital / genital-oral
- Can cross the placenta during the last 4 months of pregnancy
Incubation period: 10-90 days

Assessment:
 Chancre – painless, deep ulcer
 Swollen lymph nodes

 If without treatment:
o 6 weeks: Chancre lasts ≈ 6 weeks then fades
o 2-4 weeks: Macular, copper-colored rash at soles & palms
o Low-grade fever
o Latency Period – lasts years to decades
o Final stage: Destructive neurologic disease = fatal

o A week after birth:

 Copper-colored rash – at the face, soles & palms
 Bullous lesions – soles & palms
 Changes in epiphyseal lines seen at x-ray at 1-3 months of age
 Hutchinson’s teeth - abnormal permanent upper central incisors that are peg-
shaped and notched
 Interstitial keratitis – corneal inflammation = scarring & blindness

Diagnostic Tests:
 Serologic test
 Done at first prenatal visit:
o VDRL – Venereal Disease Research Laboratory test
o ART – Automated Reagin Test
o RPR – Rapid Plasma Reagin Test
o FTA-ABS – Fluorescent Treponemal Antibody-Absorption Test
 Cord blood sample – for newborns

Management:
 Benzathine Pen G IM 1 dose
 If (+) allergy: Erythromycin / Tetracycline PO x 10-15 days

 Infants: Penicillin at birth

 After therapy:
o Jarisch –Herxheimer reaction – d/to sudden spirochete destruction; lasts 24 hours
 BP
 HR
 Fever
 Muscle aches
g. Human Papillomavirus
- Causes fibrous tissue overgrowth (genital warts / condyloma acuminatum)
- Associated with cervical cancer

Assessment:
 Lesions
o Discrete papillary structures  large, cauliflower-like lesions
o No effect on fetus but can obstruct the birth canal = CS

Management:  Large lesions:

 Small lesions: o Laser therapy
o Podophyllin (Podofin) – CI in o Cryocautery
pregnancy Edema at the site
o Trichloroacetic acid or Gangrenous lesions
bichloroacetic acid – applied Sloughing in 7days
weekly Healing 4-6 weeks with slight
depigmentation
 Yearly Pap test lifetime Sitz bath & lidocaine
o Knife excision
 Vaccine: Gardasil
 Given to early teenage girls x 3 doses
@2 and 6 months

h. Herpes Genitalis (Herpes Simplex Type 2 / HSV-2)

Etiologic Agent: Herpesvirus hominis type 2
Mode of Transmission: Skin-to-skin contact
- Virus can cross the placenta & to the newborn at birth
Incubation Period: 3-14 days
No known cure

Assessment:
 Group of pinpoint vesicles on an erythematous base
 Vesicles ulcerate and become moist, painful, draining, open lesions ĉ profuse discharge
 Flu-like symptoms ĉ  temperature
 Intense pain upon contact
 Lesions heal but the virus lingers in latent form –flare up and become active during illness

Diagnostic Tests:
 Culture – lesion secretion
 Isolation of HSV antibodies in serum
 Pap smear
 ELISA (enzyme-linked immunosorbent assay

Management:  For resistant lesions: topical

 DOC:  Imiquimod
 Acyclovir (Zovirax) – topical; use gloves  Foscarnet
 Valacyclovir
 Sitz bath 3x a day  Yearly Pap test lifetime
 Emollient
 Condom  CS if (+) active lesions
 Warm, moist tea bags
i. Hepatitis B and Hepatitis C j. Group B Streptococcal Infection
Mode of Transmission: Sexual contact Screened at 35-38 weeks
(semen / blood) DOC: Ampicillin

Management: Vaccine

k. Human Immunodeficiency Virus (HIV)

Mode of Transmission: Exposure to infected bodily fluids / blood
Incubation period: ADULTS: 10 years
CHILDREN: 6 months with onset of symptoms at 1-3 y/o

PATHOPHYSIOLOGY:
HIV enters the cell Diagnostic Tests:
  PCR – Polymerase Chain Reaction)
Attacks the lymphoreticular system – to detect the antigen
(CD4-bearing helper T lymphocytes)

 ELISA – Enzyme-Linked Immunosorbent
Virus replaces own RNA & DNA of the cell Assay – to test for antibody
  Western blot
Replicates in the lymphocytes  CD4 count – varies according to age

Cell destruction

Loss of CD4 /
ineffective B-lymphocyte response

 antibody production

CHILD MOTHER
Assessment
 Poor resistance to infection Mild, flu-like symptoms
 Fever Wasting syndrome: Weight loss & fatigue
 Swollen lymph nodes
 RTI
 Thrush

Management
Nutritional supplements GOAL of Therapy:
Vaccines Maintain CD4 count >500 cells/mm3
Highly Active Antiretroviral Therapy (HAART)
Antibacterial agents Zidovudine
SE: Thrombocytopenia
Ritonavir
Indinavir
Nucleoside Reverse Transcriptase Inhibitor
CS
VII. H I G H R I S K L A B O R & D E L I V E R Y

a. Problems of the Passenger

1. Umbilical Cord Prolapse
- A loop of the umbilical cord slips down in front of the presenting fetal part

Management:
 Cover with sterile saline gauze
 Place a gloved hand in the vagina & manually elevate the fetal head off the cord
 POSITION: Knee-chest or Trendelenburg
 O2 at 10L/min via face mask
 Rx: Tocolytic agent

 Amnioinfusion – rapid infusion of NSS/LRS into the uterus to supplement the amniotic
fluid
o Prevents additional cord compression
o Lateral recumbent position
o Monitor FHR & uterine contractions continuously
o Record maternal temperature hourly
o Vaginal leakage stop = fetal head is firmly engaged = all fluid are infused =
DANGEROUS!
o May lead to hydramnios

 Fetal blood sampling –checking of the pH if the fetus is hypoxic

>7.25 Normal
7.21-7.25 Remeasure in 30 minutes
<7.20 Acidotic = fetal distress

DO NOT ATTEMPT TO PUSH ANY EXPOSED CORD BACK INTO THE VAGINA

2. Nuchal Cord
Cord is looped around the baby’s head

Cause: long umbilical cord

Complications
o Fetal hypoxia
o Tearing of the cord / placenta & total placenta removal
o Inversion of the uterus

Method of delivery: NSD

3. Fetal Distress
Lack of fetal reserve or the presence of fetal hypoxia, acidosis, or asphyxia

Causes: Assessment:
Prolonged cord compression Fetal tachycardia / bradycardia
Placenta previa & abruptio placenta Passage of meconium-stained amniotic
PIH fluid
Prolonged contractions
Maternal heart condition

Complications: Management:
Mental retardation High Fowler’s
Seizures Stop oxytocin STAT
Cerebral palsy O2 = 6-10 L/min via face mask
Intrauterine fetal death FHT monitoring
CS / NSD ĉ episiotomy / forceps

Validating Fetal Distress:

BIOPHYSICAL PROFILE
At least 1 episode of 30-second of
Fetal breathing sustained fetal breathing movements
within 30 minutes of observation
At least 3 separate episodes of fetal limb
Fetal movement or trunk movement within a 330-minute
Parameters observation
in scoring The fetus must extend & then flex the
Fetal muscle tone extremities or spine at least once in 30
minutes
Reactivity of the heart rate
A range of amniotic fluid between 5 and
Amniotic fluid volume
25 must be present

RESULT
8-10 Fetal well-being
4-6 Suspected chronic asphyxia
0-2 Strong suspicion of chronic asphyxia

DAILY FETAL MOVEMENT COUNTING – begins at 27th week

Result: Normal = 10 movements / hour
WARNING SIGNS: Fetal distress
1. >1 hour to reach 10 movements
2. < 10 movements in 12 hours
3. Longer time to reach 10 FM than previous days
4. Movements are becoming weaker & less vigorous
5. <3 FM in 12 hours

REPORT TO HCP STAT: PERFORM OTHER TESTING

NON-STRESS TEST – to determine the response of accelerations in fetal heart rate to fetal
movement

Procedure:
 Semi-Fowlers
 Attach external fetal monitor
o Tocotransducer – fundus
o UTZ transducer

RESULT
Reactive Response is Real Good Non-reactive Non-stress is Not Good

1. Baseline FHR between 120-160 bpm 1. Criteria for reactive result not met
2. At least 2 FHR accelerations of at least 2. Compromised fetus
15 bpm, lasting at least 15 seconds in a 3. If (-) FM after 40 minutes, provide
10-20-minute period as a result of fetal mother with light snack or gently
movement stimulate fetus
3. Normal results to intact CNS 4. If (-) FM in 1 hour, further testing is
4. At least 2 FM within 20 minutes needed
5. Normal irregularity of cardiac rhythm

12:05 = 135 bpm

12:08 = 150 – First acceleration for 15 sec
12:09 = 130
12:12 = 155 – 2nd acceleration for 15 sec
12:15 = 140

TYPES OF ACCELERATION
Acceleration – occurs with contractions, fetal movements, vaginal examination &
maternal movements
Normal = 15 bpm from baseline

a. Early Deceleration
 FHT decreases (not as low as 100) d/to fetal head compression which
stimulates the vagus nerve
 Not indicative of fetal distress
 Onset: Before acme – peak of contraction

b. Late Deceleration
 FHT decreases (not as low as 100) d/to uteroplacental insufficiency related to
maternal hypotension, analgesic, anesthetic, placental abnormalities.
 Onset: After acme
 Interventions:
 Change to left lateral
 Oxytocin off & O2 on
 IVF
 Lower head of bed (Trendelenburg)

c. Variable Deceleration
 FHT decreases as a result of cord compression related to cord prolapse, cord
around the neck, oligohydramnios, maternal position
 Sudden drop in FHT
4. Malpresentation

Problems with the fetal presentation:

a. Complete – thighs tightly flexed into the abdomen
b. Frank – hips are flexed but the knees are extended
c. Footling – feet are the presenting part

Causes:
 Hydrocephalus
 Hydramnios
 Tumors
 Multiple gestation

5. Multiple Gestation

Characteristics:
 Small babies / LBW
 Abnormal presentation
 Uterine dysfunction
 Overstretched uterus
 Premature separation of the placenta

Types:
Umbilical
Placenta Chorion Amnion Gender
cord
Identical
1 1 2 2 Same
(Monozygotic)
Non-identical Same or
2 2 2 2
(Dizygotic) different

Assessment:
 Uterus increase in faster rate
 Quickening at different spots
 Multiple set of FHS

Diagnostic Tests:
AFP
UTZ = multiple gestation/amniotic sacs
 H I G H R I S K L A B O R & D E L I V E R Y

b. Problems of the Passageway

1. Cephalopelvic disproportion
Degree of disproportion between the presenting part and the maternal pelvis

Lack of engagement at the beginning of labor, a prolonged first stage of labor, and
poor fetal descent.

2. Forcep Delivery
- Manual extraction of the fetus from the birth canal using forceps, which is applied after
the fetal head reaches the perineum.

Complications:
Rectal sphincter tear

Conditions:
Unable to push with contractions
Cessation of descent
Fetus in abnormal position / immature
Fetus is in distress from a complication

Types:
Low forceps – fetal head at ≥+2 station
Mid forceps – fetal head at ≤+2 station

 Pudendal block – for pelvic relaxation & reduce pain

 Episiotomy – to prevent perineal tearing
 Membranes must be ruptured
 CPD must not be present
 The cervix must be fully dilated
 Woman’s bladder must be empty

Record FHR before & after

Record the time & amount of first void – r/o bladder injury
Assess the cervix for any laceration
Assess the newborn
 Facial palsy
 Subdural hematoma
 Transient erythematous mark on the cheek for 1-2 days
3. Cesarean Section

2 types:
 Scheduled
 Emergent

Preop Teachings:
 DBE – 5-10 deep breaths every hour
 Incentive spirometry
 Turn from side to side
 Ambulate 4 hours post op
 Use anti-embolic stockings

Types of Incision:
 Classic – vertical
 Low segment / low transverse / Pfannenstiel – horizontal

Management:
PAIN:
 Oxytocin IV BLADDER DISTENTION / RETENTION
 Analgesics: AVOID aspirin  IFC – 4-24 hours postop
 Morphine  Assess bladder filling
 Ambulation o Palpate and percuss
Empty = dull
BLEEDING Full = resonant
 Monitor VS Extended = hyperresonant
 q15 for the first hour  Analgesics
 q30 for the next 2 hours  Assist to the bathroom q2 hours
 q1 for the next 4 hours  Pour warm water over vulva
 WOF hemorrhage:
o BP IMMOBILITY
o Change in pulse rate  Leg exercises
o Tachypnea  Thrombohemolytic stockings
o Restlessness & sense of thirst  Assess for thrombus formation:
 Assess lochia Pain
 Palpate fundal height gently Erythema
 Assess uterus for firmness Redness
 Assess abdomen for softness Warmth
o Hard abdomen = peritonitis  Prevent orthostatic hypotension

HYPOVOLEMIA AVOID lifting objects >10lb

 IVF
 Monitor I&O REPORT STAT IF:
 Turn frequently & ambulate • Redness or drainage at the incision
 NPO until (+)BM line
• Lochia heavier than a normal
CONSTIPATION menstrual period
 Stool softener / suppository / • Abdominal pain (other than suture
enema line or afterpain discomfort)
 Diet: roughage • Temperature >38° C (100.4° F)
 OFI • Frequency or burning on urination
 H I G H R I S K L A B O R & D E L I V E R Y

c. Problems of the Power

1. Hypotonic uterine contractions
Unusually low or infrequent number of contractions (≤3 in a 10-minute period)

May occur:
 During the active phase of labor
 After the administration of analgesia
 In a uterus that is overstretched by a multiple gestation, a larger-than-usual single
fetus, hydramnios, or in a uterus that is lax from grand multiparity

Management:
 Palpate the uterus
 Assess lochia every 15 minutes

2. Hypertonic uterine contractions

Marked by an increase in resting tone to more than 15 mm Hg
Latent phase of labor

May lead to: Fetal anoxia

Management:
 Uterine and a fetal external monitor
 CS:
Deceleration in FHR
Abnormally long first stage of labor
Lack of progress with pushing (“second-stage arrest”)

3. Induction vs. Augmentation of Labor

Induction – artificially started labor

Augmentation – assisting an ineffective spontaneous labor to make uterine contractions

stronger

Criteria for Induction of Labor:

 Fetus is in longitudinal lie
 Cervix is ripe
 Presenting part is engaged
 No CPD
 Fetus is mature as per LS ratio

Oxytocin Precautions
 Oxytocin 10 IU in 1000mL LRS
 Administer via piggyback
 Use infusion pump
 Infusion port is closest
 Rate > 20 mU/min may cause tetanic contractions
 Rate is increased in small increments
 Artificial rupture of membranes once cervical dilation = 4cm
 Monitor maternal pulse & BP q 15min
  Monitor FHR & uterine contractions
 Contractions:
o Not more than every 2 minutes
o Not stronger than 50mmHg STOP the infusion if exceeded
o No longer than 70 seconds from these limits
 May lead to uterine hyperstimulation =tonic uterine contractions =
 Administer terbutaline sulfate if hyperstimulation does not stop
 O2
 Monitor I&O accurately
 Newborn: WOF hyperbilirubinemia & jaundice

Misoprostol (Cytotec) Oxytocin for Labor Induction

Classification: Synthetic prostaglandin (PGE1 Classification: Synthetic form of the naturally
analog). occurring posterior pituitary hormone.
Action: Produces cervical dilatation Action: Used to initiate uterine contractions in a
Pregnancy Risk Category: X term pregnancy
Dosage: 50 to 100 _g orally or 25 to 50 _g placed Pregnancy Risk Category: C
intravaginally in the posterior fornix Dosage: Initially 1 to 2 mU/min by intravenous
Possible Adverse Effects: Uterine (IV) infusion, increased at a rate no more than 1
hyperstimulation, nonreassuring fetal heart rate to 2 U/min at 15- to 30-minute intervals until a
pattern, nausea, diarrhea, flatulence, contraction pattern similar to normal labor is
headache achieved
Possible Adverse Effects: Nausea, vomiting,
Nursing Implications cardiac arrhythmias, uterine hypertonicity,
• Ensure that the woman’s condition is rated as tetanic contractions, uterine rupture (with
safe for cervical dilatation and vaginal birth excessive dosages), severe water intoxication,
(absence of placenta previa, vasa previa, or and fetal bradycardia
cephalopelvic disproportion and the fetus is
mature) before administration. Nursing Implications
• Anticipate the need for a nonstress test to • Prepare IV solution by adding 1 mL (10 IU) to
ensure fetal health before the drug is used. 1000 mL of designated intravenous fluid
• Continuously monitor uterine activity and fetal • Use an infusion pump to ensure accurate
heart rate. control of infusion rate.
• Have an intravenous fluid line and a tocolytic • Regulate infusion rate to establish uterine
readily available should uterine hyperstimulation contractions similar to a normal labor pattern.
occur. • Monitor frequency, duration, and strength of
contractions.
• Assess maternal pulse and blood pressure,
and watch for possible hypertension. If
hypertension occurs, discontinue drug and
notify physician.
• Continuously monitor fetal heart rate for signs
of fetal distress.
• Monitor I&O and watch for signs of possible
water intoxication, such as headache or
vomiting. Limit IV fluids to 150 mL/hr.
• Prepare the woman for birth
VIII. T H E R A P E U T I C M A N A G E M E N T

a. Uterine Rupture – uterus undergoes more strain than it is capable of sustaining

Types of Rupture:
Complete – all layers Incomplete – peritoneum is intact
Contractions immediately stop Localized tenderness
Visible swellings: Retracted uterus & Pain at the lower uterine segment
extrauterine fetus Fetal & maternal distress

Assessment: Management:
 Severe pain reported as “tearing”  Fluid replacement therapy
 Hemorrhage  hypovolemic shock  IV oxytocin
 cerebral perfusion  Laparotomy – to control bleeding &
for repair
Diagnostic Test: UTZ  Hysterectomy

b. Inversion of the Uterus – Uterus turning inside out

Assessment:
 Sudden gush of large amount of blood
 Fundus is not palpable
 S/sx of blood loss
 Exsanguination

Management:
 IVF ĉ large gauge NEVER attempt to replace an inversion
 O2 by mask NEVER attempt to remove the placenta if it is
 Assess VS still attached
 GA / NTG / tocolytics – to relax the uterus NEVER administer oxytocin before manual
 Manual replacement replacement
 Oxytocin after
 Antibiotic therapy
 CS birth for future pregnancies

c. Amniotic fluid embolism– Amniotic fluid is forced into the maternal circulation
- Humoral / anaphylactoid response
- Not preventable because it cannot be predicted

Assessment (DURING LABOR):

Sits up suddenly grasping her chest
Sharp pain Pulmonary artery constriction
Inability to breathe
Pale Pulmonary embolism
Typical bluish gray Pulmonary constriction

Management: Complications:
O2 by face mask / cannula DIC
CS Endotracheal intubation
Fibrinogen therapy
IX. H I G H R I S K P O S T - P A R T A L C L I E N T

a. Uterine atony – relaxation of uterus

Diagnostic Test:
UTZ – to detect retained placental fragments

Management:
 Empty the bladder – to relieve pressure  IV oxytocin
 O2 by facemask at 4L/min  IM Carboprost tromethamine (Hemabate),
 Supine a prostaglandin F2a derivative
 Monitor VS – WOF shock q15-90 minutes x 8 doses
SE: diarrhea
 Uterine massage Nausea
 Bimanual massage Tachycardia
 Uterine packing Hypertension
 Anesthetics / analgesics
 IM Methylergonovine maleate
 BT (Methergine)
 Iron therapy q2-4minutes x 5 doses
 Restrict activity
 Observe lochia  Hysterectomy – last resort

b. Lacerations
Cervical Vaginal Perineal
 Bright red bleeding  Vaginal pack – to maintain  Episiotomy repair
 Occurs immediately after pressure on the suture line  OFI
placental delivery  Proper documentation  Stool softener
 Regional anesthetic – d/to  Remove after 24-48 hours /  AVOID: 3rd & 4th laceration
extensive/difficult to repair before discharge o Enema
 IFC o rectal suppository

c. Retained placental fragments

Diagnostic Tests:
UTZ
(+) hCG in blood sample

Assessment:
Large fragment = apparent bleeding immediately post partum
Small fragments = abrupt discharge -10 days post partum

Management:
 Inspect placenta carefully after birth
 D&C
 Methotrexate
 Observe the color of lochia
d. Subinvolution – incomplete return of the uterus to pre-pregnant form 4-6 weeks post partum

Assessment:
Uterus is still enlarged & soft
(+) lochia

Management:
Methylergonovine PO 0.2 mg QID – to improve uterine tone & complete involution
Antibiotic PO – if uterus is tender to palpation

e. Perineal Hematomas
Collection of blood in the SQ layer of tissue of the perineum

Assessment:
 Severe pain
 Feeling of pressure between the legs
 Area of purplish discoloration with obvious swelling
 Tender to palpation

Management:
 Assess the size – measure in centimeters
 Mild analgesic
 Apply an icepack covered with towel
X. P U E R P E R I A L I N F E C T I O N S

a. Endometriosis
- Presence and growth of endometrial tissue outside of the uterus.

Assessment:
 (+) Nodules
 Pelvic pain
 Dysmenorrhea
 Dyspareunia

Management:
 Oral contraceptives – estrogen/PGE based
 Danazol – synthetic androgen – to help shrink the abnormal tissue
o CI: liver disease
 Leuprolide acetate – GnRH agonist – reduce hormone stimulation
 Laparotomy with excision by laser surgery

b. Endometritis – infection of the uterine lining

Course of infection = 7 to 10 days

Postpartum:
1st day – benign  temperature An increase in oral temperature to more than 100.4° F (38° C)
3rd – 4th day - fever for two consecutive 24-hour periods, excluding the first 24-
hour period after birth, is defined as a febrile condition
Chills suggesting infection
Anorexia
General malaise
Uterus is not well contracted & is painful to touch
 Lochia = dark brown & foul odor

Management:
 Clindamycin
 Methylergonovine
 Analgesic
  OFI
 Fowler’s position / walking – for lochia drainage
 Wear gloves when handling perineal pads

c. Infection of perineum

Removal of perineal sutures – to allow drainage

Iodoform gauze packing
Antibiotics – topical / systemic
Sitz bath / moist warm compress
Hubbard tank treatment
Frequent change of perineal pads
Proper perineal care (front to back)
XI. I N F E R T I L I T Y & S T E R I L I T Y

SUBFERTILITY / INFERTILITY
Inability to conceive a child after at least 1 year of engaging in unprotected coitus

Primary – no previous conception

Secondary – with previous but cannot conceive now

STERILITY – inability to conceive because of known condition

Causes of subfertility factors:

Male: Female:
 Inadequate sperm count  Anovulation
 Obstruction / impaired sperm motility  Tubal transport problems
 Ejaculation problems  Uterine problems
 Cervical problems
 Vaginal problems

Fertility Testing
 Semen analysis
 Ovulation monitoring – BBT for 4 months
 Tubal patency assessment

Health Teachings for Conception

 Determine ovulation day & cervical mucus
 Coitus every other day
 Sex position
 Do not douche
 Position after sex – supine with pillows under the hips

MANAGEMENT:
a. Increase sperm count & motility
 Abstain 7-10 days
 Ligation of varicocele
 Reduce scrotal heat
b. Reduce infection – treat according to the causative agent
c. Hormone therapy
 Clomiphene citrate (Clomid)
 Human menopausal gonadotropins (Pergonal) – stimulates ovarian follicular growth
 hCG – to produce ovulation
 Bromocriptine (Parlodel) – to reduce prolactin level & to  gonadotropins
 Conjugated estrogen (Premarin) – to  mucus production during days 5-10 of cycle
 Progesterone vaginal suppositories
d. Surgery
 Removal of obstruction
 Reduce adhesions by lysis
e. Therapeutic Insemination – instillation of sperm into the female reproductive tract
BBT – to assess cervical mucus
f. In Vitro Fertilization – one or more mature oocytes are removed from a woman’s ovary by
laparoscopy and fertilized by exposure to sperm under laboratory conditions outside a
woman’s body