ABNORMAL OBSTETRICS

Prof. Robelita N. Varona

Faculty UPMSHS
 HIGH RISK PREGNANCY

Factors that make a woman and fetus at

high risk:
✓Concurrent disorder – with medical condition now
she is pregnant
✓Pregnancy related complication – hypertensive
disorder / diabetes/ others
✓External factors – environment where she lives,
family situation
✓HBMR –home based mother’s record
 RISK FACTORS
✓ A. AGE - 15 below, 35 above, 40 above
✓ B. MATERNAL PARITY – how many pregnancies
✓ C. MATERNAL OBSTETRIC & GYNECOLOGIC
HISTORY – lack of prenatal care, poor self-care
capacities
✓ D. Maternal Medical History – other diseases
✓ E. Family culture & ethnicity – beliefs & practices
related to pregnancy
✓ F. Family history – hereditary diseases
BLEEDING DISORDERS
OF PREGNANCY
ABORTION
 ABORTION
✓ Termination of pregnancy before the fetus is viable

✓ Expulsion of the products of conception from the

uterus before fetal viability

✓ Fetal weight is less than 17 ½ oz or 500g

✓ AOG is less than 20 weeks

✓ 75% occur during the first trimester

 Main Cause:
chromosomal abnormality
 Complete Loss of all products of conception, contraction of uterus

Habitual Loss of three or more consecutive pregnancies

Incomplete Loss of some products of conception, uterus don’t contract well

Inevitable Threatened loss that cannot be prevented, membranes rupture & cervix dilate, concepts is
expelled

Missed Retention of products of conception in uteri after fetal death

Septic Infection accompanies abortion (unsterile technique)

Threatened A developing spontaneous abortion, the fetus can still be saved, cervix not dilated

Spontaneous Pregnancy ends because of natural causes.

Medical A medical abortion is a type of non-surgical abortion in which abortifacient pharmaceutical

drugs are used to induce abortion. An oral preparation for medical abortion is commonly
referred to as an abortion pill.
 Assessment (Signs & Symptoms)

✓ Spontaneous vaginal bleeding

✓ Passage of clots or tissue (meat) through
the vagina
✓ Lower uterine cramping or contractions
✓ Hemorrhage and shock
 Diagnostic examinations:

✓ Levels of HCG (low)

✓ Pelvic exam
✓ Tissue cytology (tissue
examination)
✓ Hemoglobin/ hematocrit (↓)
✓ Ultrasonography - confirms
 Management
Threatened:
✓ Assess for LMP, save all pads, ask for presence of clots
✓ Conservative: BED REST, but if bleeding persist with
cramps report to the hospital
Inevitable or Imminent
✓ Avoid complication and infection:
✓ Hospitalization
✓ Dilatation & Curettage (D&C)
✓ Oxytocin after D&C
✓ Emotional support
 Complete Abortion

✓ Observed for continued bleeding

or signs of infection
✓ Expelled products of conception –
evaluated
✓Test for CBC, HCG, Rh factor
Incomplete Abortion
Dilatation & Curettage
Monitor blood loss
Missed Abortion
Removed from uterus to prevent DIC
(disseminated intravascular coagulation)
Up to 28 weeks Prostaglandin E2 (dinoprostone)
inserted to vagina for contraction
Late – IVF with oxytocin – for contraction and
delivery, after which D&C
Habitual Abortion
Requires extensive diagnostic
investigation with genetic & chromosomal
studies
Manage according to cause
Septic Abortion
Common causative agent
 E. Coli – common
 Enterobacter aerogenes
 Proteus vulgaris
 Hemolytic streptococci
 staphylococci
Treat abortion
High dose antibiotic – penicillin, clindamycin,
tobramycin
D&C
ECTOPIC PREGNANCY
ECTOPIC PREGNANCY

 Implantation of fertilized ovum outside the

uterine cavity.
 Second most common cause of bleeding during
pregnancy.
 Most common site is fallopian tubes (ampulla),
others are ovary, cervical os, abdominal viscera
Causes:
o Any condition that prevents or retards/ block the passage of
a fertilized ovum through the fallopian tube, these are:
1.Hormonal factors
2.Tubal damage because of previous pelvic or tubal surgery
(scar)
3.Pelvic inflammatory disease
4.Tubal atony
5.Tubal spasm
6. Malformation of fallopian tubes related to
endosalphingitis, diverticula, tumors pressing the tube,
previous surgery to the tubes, transmigration of the
ovum
7. Congenital defects in reproductive tract
8. Sexually transmitted disease (STD) – cause Pelvic
Inflammatory Disease
9. Intrauterine device (IUD)
 Assessment (Signs and symptoms)
o Pain unilateral (pelvic area / abdominal area), amenorrhea, abnormal
menses, slight dark vaginal bleeding abnormal HCG titers, mass in Cul-
de-Sac of Douglas, nausea & vomiting, fever
o Rupture of the tubes – severe abdominal pain, radiating to shoulders,
extreme pain in cervix, uterus is boggy, tender/ rectal pressure in Cul-
de-Sac, syncope, nausea & vomiting, profound shock
o Tachycardia, leukocytosis, low hemoglobin & hematocrit levels,
elevated Erythrocyte sedimentation rate (ESR)
o Cullen’s sign – bluish discoloration in umbilicus
Diagnostic Examinations:
o HCG (low)
o Ultrasound
o Culdocentesis (Culdesac of Douglas) (detects free
blood in peritoneum)
o Laparoscopy – to reveal/ confirm (if culdocentesis is
positive)
 Complications:
o Rupture of the tube – may cause
hemorrhage, shock (hypovolemic),
peritonitis (infection of the peritoneum)
o Infertility
HYDATIDIFORM MOLE
(H-mole)
HYDATIDIFORM MOLE (H-mole),
Gestational Trophoblastic Disease
A developmental anomaly of the placenta that converts the
chorionic villi into a mass of clear vesicles

A condition in which a proliferation of trophoblastic cells

results in the formation of a placenta characterized by hydropic
(fluid-filled) grapelike clusters

The condition maybe nonmalignant or may develop into

CHORIOCARCINOMA
 Incidence:

• Increased with extremes of age (under 18 & above 35)

• Women from low socio-economic group (low protein
intake)
• Oriental Origin
• Receiving
CLOMID (Clomiphene citrate) for ovulation
Causes:
• Associated with poor maternal nutrition
(insufficient protein/ folic acid)
• Defective ovum, chromosomal abnormalities,
hormonal imbalances
Assessment (Signs & Symptoms)
• Disproportionate enlargement of the uterus or large for
date uterus (Fundal height is greater than expected)
• Vaginal bleeding which usually occurs by week 12,
bright red or brown color; may be slight, profuse or
intermittent/ or late in 2nd trimester
• FHT (-)
• On IE, grapelike vesicles are seen (diagnostic for H-
mole)
•
o Symptoms of Pregnancy Induced
Hypertension (PIH) or Pre-eclampsia:
elevated BP, edema, proteinuria, appears
before week 20

o Hyperemesis gravidarum (high HCG)

o Markedly elevated HCG level
o Very low levels of maternal serum alpha-
fetoprotein
Diagnostic Examinations:
• HCG (High level)
• Ultrasound (grapelike clusters, snowstorm
pattern)
• Blood exams abnormal (WBC, ESR increased)
Management:
• Induced abortion
• D&C to evacuate the moles
• Hysterectomy if necessary
• Monitor HCG levels for one year - Avoid pregnancy
until HCG levels normalize
• Thorough pelvic exam, general P.E., Chest x-ray to
detect for malignancy
• Administer chemotherapeutic agents if necessary &
as prescribed
Complications:
• Anemia
• Hyperthyroidism
• Infection
• Disseminated intravascular coagulation (DIC)
• Throphoblastic embolization of the lung
• Ovarian cyst
• Choriocarcinoma
PLACENTA PREVIA
PLACENTA PREVIA
Occurs when the placenta implants in the lower uterine segment
near or over the internal cervical os
Types:
Total The internal os is entirely covered by the placenta when the
cervix is fully dilated
Partial Incomplete coverage of the internal os
Marginal Only an edge of the placenta extends to the internal os
but may extend onto the os during dilation of the cervix during
labor
Low-lying The placenta is implanted in the lower uterine
segment but does not reach the os
Factors that affect the site of attachment
Exact cause is unknown
o Defective vascularization (blood supply) of the decidua
o Uterine scars
Risk factors
oMultiparity
oMultiple spontaneous or induced abortion
oPrevious cesarean section
oAdvanced age
oLarge placenta
oAbnormal uterine position or shape
oSmoking
oPlacenta accreta
Assessment (Signs & Symptoms)
o Painless bright red vaginal bleeding (3rd trimester) may occur
as early as 7 months, bleeding may be mild to hemorrhage
o On palpation – soft, non-tender uterus
o Minimal descent of the presenting part during labor
o Ultrasound: placental position is confirmed
o Abnormal fetal position of breech or transverse lie
oHigh presenting part
oUterine contractions
oAnemia
oIf pelvic examination done: DOUBLE SET UP
(for emergency CS) because bleeding may
occur
 Diagnostic Examinations:
oBased on signs and symptoms presented
oUltrasound

Management:
oDepending on when the first episode occurred and
the amount of bleeding:
Medical Management:
o Preterm Fetus
Bed rest on close observation (without toilet
privileges)
Blood is ready for transfusion
Wait until 37th week for delivery

Within 3 weeks of term fetus

Cesarean section (CS) but test for lung maturity first
o Labor is in progress
 With minimal bleeding – observe “double
set-up” examination
 CS for marginal, low lying, posterior
implantation
o Hemorrhage is severe
 Deliver the fetus despite fetal immaturity
 Blood transfusion
 Cesarean section delivery (best method)
 Incidence:
o Common in multigravidas
o Fetal prognosis depends on gestational age and
amount of blood loss
o Maternal prognosis is good if hemorrhage can be
controlled
 Complications:
o Most common:
 Postpartum hemorrhage
 Infection
ABRUPTIO PLACENTA
 ABRUPTIO PLACENTA
 Premature separation of the normally implanted placenta
from the uterine wall after
the 20 week of gestation and before the fetus
th

is delivered.
 Separation may occur at 20-24 weeks AOG or
during the 1 & 2 stage of labor
st nd

 Common in multigravidas (age 35 or older)

 Fetal prognosis depends on the
gestational age and amount of blood loss
 Maternal prognosis depend on the bleeding
Decreased blood flow to the placenta, is the basic
pathophysiologic mechanism
 PAINFUL bleeding, bright red or dark red in color
bleeding, non-clotting
 Abdominal or low back pain
 Uterine hypertonus & tenderness (Couvelaire’s uterus)
 Fetal distress
 In concealed bleeding, hypovolemia, increase abdominal
girth & fundic height - as blood enters the muscle fibers,
complete relaxation of uterus is possible, increasing uterine
tone & irritability, if bleeding is profuse, the uterus turns
blue or purple and the accumulation of blood prevents its
normal contraction after delivery (COUVELAIRE UTERUS).
 Medical Management:
o Monitor vital signs & bleeding (count perineal
pads)
o NSVD and Cesarean Section (for moderate to
severe AP)
o Fluid and electrolytes (I.V.F.)
o Blood transfusion
 Complications:
o Maternal mortality because of bleeding, coagulation
defects, hypofibrinogenemia, and the time of
separation
o Postpartum patients – at risk for vascular spasm,
intravascular clotting or hemorrhage/ renal failure
o Most serious neonatal complications – hypoxia,
prematurity, anemia
INCOMPETENT CERVIX
 Painless Premature dilatation & effacement of the cervix
which occurs most often in the 4th-5th month of pregnancy

 Not associated with uterine contractions resulting in

spontaneous abortion or preterm birth

 Associated with congenital structural defects or previous

cervical trauma from surgery or delivery

 Associated with increasing maternal age (exposure to

diethylstilbestrol (DES), cervical inflammation or previous
cervical trauma
 Assessment (Signs & Symptoms)

o History of repeated 2nd trimester spontaneous

abortion
o Cervical dilatation in the absence of contractions or
pain
o Pink-stained vaginal discharge increase pelvic
pressure with rupture of membranes & release of
amniotic fluid
o Fetal membranes visible through cervix
 Diagnostic Examinations:
o Ultrasound
o Nitrazine test (rupture of membrane)
 Management:
o Monitor VS & FHT
o Bed rest
o Prepare for surgical procedure:
 Purse string (cerclage) around the cervix – or
MCDONALD’S procedure uses nylon suture
 Stitch through the cervix – or SHIRODKAR’S procedure
uses sterile tape
o Bed rest after surgery, monitor for complications like
rupture of membranes or contractions of the uterus
o Removal of suture at 37-39 weeks
PREMATURE RUPTURE OF MEMBRANES
(PROM)
 Amniotic membrane rupture before labor
begins (labor may begin within 24 H of
rupture)
 Occur before 38th week AOG
 Prolonged, may be more than 12 H before
birth
 Risk Factors:
o Infection
o Incompetent cervix
 Assessment (Signs & Symptoms)
o Gush of watery, clear, meconium stained fluid
from the vagina with continued leakage
o Amniotic fluid turns the Nitrazine paper blue
(alkaline pH)
o Amniotic fluid shows characteristics FERNING
pattern on microscopic examination
 The unengaged fetus is at risk for a prolapsed cord
when the membranes rupture.
 Management:
o Assess FHT when membranes rupture to rule out
prolapsed cord, note the time, color, & amniotic fluid
o Obtain baseline maternal temperature
o Evaluate client’s temperature every 2 hours
o Avoid vaginal exams to prevent introduction of
microorganisms that may cause an ascending
infection
o Monitor for development of contractions & evaluate
fetal well-being – decreased amniotic fluid may cause
variable deceleration
Monitor client for signs of chorioamnionitis –
elevated temperature, abdominal tenderness,
increased WBC & ESR
Obtain vaginal culture for group B streptococcus
Provide client teaching & inform that amniotic fluid
is produced continuously so there is no “dry labor”
Administer antibiotics if ordered
HYPERTENSIVE DISORDERS OF PREGNANCY

 An acute hypertensive state that develops after the

20th week of gestation.
 The condition can be mild or severe and can
progress to seizures (eclampsia).
 Basic pathophysiology – systemic vasospasm
affecting every organ system, vasoconstriction
may impair organ perfusion and hypertension
occur
The classic signs of preeclampsia are:
hypertension, generalized edema and proteinuria
 Predisposing Conditions
 Primigravida
 Teenagers and women over 35 years of age
 Poor nutrition
 Low socioeconomic status
 Chronic hypertension
 Diabetes mellitus
 Chronic renal disease
 History of PIH
 Mild Preeclampsia
 Assessment
o Hypertension of 15 to 30 mmHg above baseline
o Weight gain of 1 lb or more per week in last
trimester
o Mild, generalized edema
o Proteinuria of 1+
 Management
o Provide bed rest and position in left lateral position
o Monitor blood pressure & weight
o Monitor neurological status –changes can indicate cerebral
hypoxia or impending seizure
o Monitor deep tendon reflexes and clonus, hyperreflexia
indicates increased CNS irritability
 Assessement of Reflexes
 Patellar – strike the patellar tendon, normal response –
extension or kicking out of leg
 Biceps – normal response is flexion of the arm at the
elbow
 Clonus – dorsiflex the foot as the legs dangle, normal
response – foot will remain steady in the dorsiflex
position, no rhythmic oscillation or jerking of the foot
o Provide adequate fluids
o Monitor intake & output (Normal urine
output – 30 ml/ hour)
o Increase dietary protein and carbohydrate
with no salt
o Administer medications as prescribed to
lower BP
 Severe Preeclampsia
 Assessment:
o Severe hypertension, 30-40 mmHg above baseline while on bed
rest
o Massive generalized edema and weight gain
o Proteinuria 4+
o Less than 400 ml urine output in 24 hours
o Severe headache
o Dizziness
o Blurred vision and spots before the eyes
o Nausea and vomiting
o Epigastric pain
o CNS irritability
 Management:
o Administer Magnesium sulfate as prescribed
Magnesium sulfate is a neuromuscular
sedative that reduces the amount of
acetylcholine thus preventing seizures.
Administer deep IM. Monitor for toxicity:
 ↓ deep tendon reflexes
 ↓ respiratory rate
 ↓ renal function
 Muscle flaccidity
 CNS depression
o Administer antihypertensive (Hydralazine –
Apresoline) or Methyldopa
Eclampsia
 Assessment (Signs & Syptoms)
o Severe edema
o Proteinuria 4+
o Sudden large increase in weight
o BP greater than 160/110 mmHg
o Cyanosis
o Fetal distress
o Seizures
o Coma
 Management:
o Protect the client from injury
o Administer oxygen
o Monitor fetal heart rate and contractions
o Initiate seizure precautions
o Administer anti-seizure medications
o Prepare for deliver after stabilization of the
client
 Signs of Worsening PIH or Impending
Seizures
o BP 160/110 mmHg
o Epigastric pain
o Decrease urine output
o Visual changes
o Headache
o Excessive proteinuria
HELLP SYNDROME
 A category of gestational hypertension that primarily
involves changes in blood components and liver function
 H – hemolysis, EL – elevated liver enzymes, LP – low
platelets
 Assessment (Signs & Symptoms)
o Pain - RUQ, epigastric area or lower chest
o Nausea & vomiting
o General malaise
o Severe edema
o RUQ tenderness on palpation
o Signs & symptoms of pre-eclampsia
 Laboratory Findings:
o Hemolysis of RBC
o Thrombocytopenia
o Elevated liver enzymes
 Management:
o Assess maternal VS & FHT
o Drugs: MgSo4 & antihypertensive
o Blood transfusion
o Delivery of baby ASAP
o Maintain a quiet-calm-dimly lit environment

o Institute bleeding precautions

 Complications:
o Fetaldeath & maternal death
o Hemorrhage
o Hypoglycemia
o Subscapular liver hematoma
o Renal failure
MEDICAL CONDITIONS AFFECTING
PREGNANCY
A. HYPEREMESIS GRAVIDARUM
 Severe nausea and vomiting that persists after first
trimester
 Related to high levels HCG, H-Mole, Multiple gestation
(because of high HCG)
 Assessment (Signs & Symptoms)
o Severe nausea & vomiting
o Substantial weight loss thirst
o Oliguria
o Electrolyte imbalance
o Dehydration
o Metabolic acidosis
 Assessment (Signs & Symptoms)
o Severe nausea & vomiting
o Substantial weight loss thirst
o Oliguria
o Electrolyte imbalance
o Dehydration
o Metabolic acidosis
 Management:
o Restore fluids and electrolytes by IVF administration
o Anti-emetic administration
o Maintain adequate nutrition & rest
o Diet: oral-clear liquid, full liquid, small-frequent
meals of high protein
o Monitor intake & output, weight
 CARDIAC DISEASE
o Right sided heart failure occurs when the output of the right ventricle
is less than the blood volume received by the right atrium from the
vena cava
o Back pressure from this result in congestion of the systemic venous
circulation and decreased cardiac output to the lungs
o Blood pressure decreases in the aorta because less blood is
reaching it; pressure is high in the vena cava, both jugular venous
distention and increased portal circulation occurs.
- A patient with a cardiac disorder is at greatest risk when hemodynamic
changes reach their maximum, between the 28th & 32nd week of gestation
 Dyspnea (on exertion, rest,  i) fatigue
paroxysmal nocturnal)
 j) hemoptysis
 b) Diastolic murmur (apex)
 k) crackles at base of
 c) Tachycardia
lung
 d) Cough
 l) edema of varying
 e) Fatigue
degree (pedal, pitting,
 f) Hemoptysis anasarca, pulmonary)
 g) Orthopnea
 m) palpitations
 h) cough
 n) cyanosis
 o) chest pain
Class Patient Symptoms

No limitation of physical activity. Ordinary physical activity does not

I
cause undue fatigue, palpitation, dyspnea (shortness of breath).

Slight limitation of physical activity. Comfortable at rest. Ordinary

II physical activity results in fatigue, palpitation, dyspnea (shortness of
breath).

Marked limitation of physical activity. Comfortable at rest. Less than

III
ordinary activity causes fatigue, palpitation, or dyspnea.

Unable to carry on any physical activity without discomfort.

IV Symptoms of heart failure at rest. If any physical activity is
undertaken, discomfort increases.
Management
a) Monitor maternal & fetal well-being frequently (pregnancy)
b) Teach adequate nutrition for pregnancy and provide prenatal
vitamins & iron (to prevent anemia); monitor for signs of infection
c) Instruct to avoid excessive weight gain or emotional stress
(increase stress on cardiac reserves)
d) Teach to report signs of infection immediately to start treatment
early
e) Maternal diagnostic procedures: AUSCULTATION, ECG,
ECHOCARDIOGRAM, POSSIBLE CARDIAC CATHETERIZATION
f) Fetal status monitoring: ULTRASOUND, NON-STRESS TEST,
BIOPHYSICAL PROFILE
a) Medication therapy:
1.Prophylactic antibiotic (PENICILLIN) – for
invasive procedures, dental work, and at time
of birth, to prevent bacterial endocarditis
2.Cardiac glycosides (DIGITALIS) – to increase
contractility of the cardiac muscles and slow
the HR for effective filling
3.Antidysrhythmia
4.Diuretic furosemide (LASIX) – to decrease
fluid excess (edema)
5.HEPARIN anticoagulant if needed
a)Avoid over exertion& plan frequent rest
periods (LEFT LATERAL RECUMBENT
POSITION)
b)During Labor aim to AVOID EXCESSIVE
maternal stress
1.Adequate pain relief
2.Vaginal delivery with epidural anesthesia,
with oxygen
3.Low forceps delivery
4.Monitor FHT, uterine contractions
c)Encourage early ambulation (prevent
clotting)
a)Observe for possible complications
1.Cardiac decompensation (myocardial
failure, cardiomyopathy)
2.IUGR
3.Fetal distress
4.Premature birth
DIABETES MELLITUS
oA metabolic disorder of carbohydrate, protein and fat
metabolism characterized by hyperglycemia, it
results from lack of INSULIN.
o Three general classifications:
- A. type 1 : (IDDM) absolute insulin insufficiency
- B. type 2 : (NIDDM) insulin resistance with varying
degrees of insulin secretory defect
- C. Gestational diabetes: results when the pancreas is
unable to meet the increased demands for insulin
production during pregnancy (HPL)
o In GESTATIONAL DIABETES, a woman not previously
diagnosed will develop during pregnancy.
- Risk factors: obesity, history of delivering large infants (more than 4.5
kg), unexplained fetal or perinatal loss, evidence of congenital
anomalies in previous pregnancies over age 25, family history
o Effects of Pregnancy on Glucose Metabolism:
- During the first half of pregnancy – increasing maternal hormones
increase the demand for insulin production to facilitate increased
storage of glycogen in maternal tissue
- During the last half of pregnancy – HPL, human placental lactogen
from the placenta causes resistance to the action of maternal insulin
- The fetus produces his own insulin but obtains glucose from the
mother across the placenta
o Effects of Diabetes on Pregnancy and the Fetus
- Related to the degree of control of blood glucose
levels within a range of 80mg/dl-120mg/dl and the
degree of vascular involvement; complications are
more common with IDDM and include:
1. Polyhydramnios
2. PIH
3. Still birth after 36 weeks

4. Neonatal macrosomia, hypoglycemia,

hyperbilirubinemia, delayed fetal lung maturity
resulting in RDS and increased incidence of
congenital anomalies (including neural tube
defects)
o Assessment / Signs & Symptoms:
1. Risk factors: family history of diabetes, obesity, LGA
infants, previous unexplained still birth
2. Classic symptoms: Polyuria, polydipsia, polyphagia,
weight loss
3. Client have more frequent UTI & vaginal candidiasis
(yeast) infections caused by altered pH in the
reproductive tract
4. Urine testing for glycosuria and ketones as part of
routine prenatal care
1. Diabetes screening should be done around
28 weeks gestation with a 50 g oral glucose
tolerance test; if blood glucose is greater
than 140 mg/dl at 1 hour, a 3-hour 100 g
OGTT is done
2. Two abnormal levels or a fasting glucose
level greater than 95 mg/dl confirms
diagnosis of gestational diabetics
1. Long
term glucose control is estimated with the
glycosylated hemoglobin blood test which
measures the percent of hemoglobin with
glucose bound to it (glycohemoglobin); levels
depend on the amount of glucose available
during the RBC 120 day lifespan (every 3 months
as an overall indicator of blood glucose control)
o Management:
a)Teach: Prescribed anti-diabetic diet, no
concentrated sweets, avoid excessive weight
gain, caloric needs will increase as pregnancy
increases
b)Medications: Oral hypoglycemic NOT allowed
during pregnancy; INSULIN needs to be
regulated, four-fold dose increase needed at
term.
a)Encourage walking
b) Monitor fetal being: Alpha fetoprotein at
16-18 weeks, ultrasound, amniotic fluid
volume, fetal size, fetal movement count,
weekly NST from 28-32 weeks, possible
Oxytocin challenge test and amniocentesis
for lung maturity
1.L/S ratio needs to be 2:1 / 3:1
2. Phosphatidylglycerol should be present
a)Monitor for complications: infection, PIH,
diabetic ketoacidosis
b)Prepare for possible induction of labor at
38-39 weeks for clients with IDDM to reduce
the risk for stillbirth caused by premature
placental aging
c)Insulin requirements drop dramatically after
delivery of the placenta
o Possible Complications:
a)Congenital anomalies e) spontaneous abortion
b) Hydramnios f) fetal death
c)Macrosomia g) sacral agenesis – incomplete formation of
d) Gestational hypertension spinal
column
ANEMIA
o A woman who becomes pregnant has pseudo anemia because of
expansion of blood volume (normal physiologic occurrence).
o IRON DEFICIENCY ANEMIA In Pregnancy
- A disorder of oxygen transport in which hemoglobin synthesis is
deficient, the most common anemia during pregnancy
- Associated with low fetal birth weight and preterm birth.
- Related to the pregnancy, which results in the maternal iron stores being used for
fetal RBC production
- A microcytic type of anemia (small-sized RBC), Hypochromic anemia
(less Hgb than the average RBC). (Cells are not as large or as rich in Hgb as they
normally are)
- If iron intake is low – it is unavailable for incorporation into RBCs.
- Assessment / Signs & Symptoms:
1.Fatigue 4. Exercise intolerance
2.Pallor 5. Exertional dyspnea
3.Pica 6. Tachycardia
- Diagnostic/ Laboratory Test:
1.Low Hgb (less 10 g/dl); Low Hct (Less
33%); low serum iron, low serum ferritin
2.Low RBC count – microcytic/
hypochromic
- Management:
1.Iron supplementation – ferrous sulfate /
ferrous fumarate (Oral; IM by Z-track injection)
(Side effect of Iron: stains the teeth,
constipation)
2. Encourage prenatal vitamins (Vit C)
3. Well balanced diet
4. Assess FHT
5. Encourage frequent rest periods
 6. Oxygen administration
7. Evaluate for s/s of decreased perfusion to
vital organs – dyspnea, chest pain, dizziness
and symptoms of neuropathy (tingling
sensation)
8. If on Iron supplementation – prevent
constipation by high roughage diet &
increase fluids, and inform beforehand that
stools will appear black & tarry

- Complications:
1.Low birth weight neonates
2.Preterm birth
FOLIC ACID DEFICIENCY ANEMIA In Pregnancy
- A common slowly progressive megaloblastic
anemia (enlarge RBC)
- Folic acid (B vitamins – folacin) is important for
the normal formation of RBC & synthesis of DNA,
This prevents neural tube defect.
- Folic acid is found in most body tissues, plenty
in well-balanced diets, it is water soluble vitamin,
heat-labile, easily destroyed by cooking
 - An insufficient intake less than 50 mcg/
day results into anemia within 4 months
- This anemia occurs in patients with
multiple gestations, as a result of the
increased demand for folic acid by the
fetuses.

Hydantoin drug (anticonvulsant interfere

with folate absorption) as well as
hormone contraceptives counteract the
absorption of folic acid
- Assessment/ Signs & Symptoms:
1. Severe, progressive fatigue (hall mark of folic
acid deficiency)
2. Pallor or jaundice
3. Shortness of breath
4. Palpitations
5. Diarrhea
6. Nausea & anorexia
7. Headaches, weakness or light headedness
8. Forgetfulness
9. Irritability
- Laboratory findings:
1. Macrocytic RBCs
2. Decreased reticulocyte count
3. Increased MCV
4. Abnormal platelet count
5. Decreased serum folate levels below 4 mg/ml
- Management:
1.Folic acid supplementation orally (1-5
mg/day) or parenterally
2.Diet high in folic acid – green leafy
vegetables, peanut butter, liver
3.High vitamin C diet to increase folic
acid absorption
4.Rest periods, plan activities
- Possible Complications:
1.Early spontaneous abortion
2.Premature separation of placenta
3.Fetal neural tube defects
ASTHMA DURING PREGNANCY
 Prevalence is increasing mainly due to environmental factors such
as change in indoor environment, smoking, family size, pollution
and diet.
 Effects are due to maternal circulating hormones (cortisol,
estradiol, progesterone), altered beta-adrenoreceptor
responsiveness and immune function
 Those with poor control of asthma – preterm labor may occur
 Management: Inhaled Bronchodilators / inhaled steroids
 Antenatal care: medications used in the treatment of asthma are
considered safe during pregnancy, Respiratory tract infection
should be treated promptly to prevent acute asthma attack.
 Intrapartum care:
o Increase in cortisone & adrenaline (epinephrine) from
the adrenal glands during labor is thought to prevent
asthma attacks during labor.
o Oxytocin & prostaglandin E2 are safe for use to induce
labor
o AVOID: beta adrenergic antagonist, ergometrine,
carboprost (prostaglandin F2a)
o Parenteral hydrocortisone given parenterally during
labor

Postnatal care: breastfeeding is encouraged;

drugs for asthma may not be secreted in
breastmilk in sufficient quantities to harm the baby.
URINARY TRACT INFECTION
 The presence of bacteria in a clean-catch or catheter
specimen of urine (a colony of at least 100,000 bacteria/ ml
of urine)
 Symptoms of lower UTI include burning or pain on urination,
frequency, Hematuria, change in smell of urine, discomfort
in suprapubic area
 Symptoms of pyelonephritis: fever, rigors, tachycardia,
nausea & vomiting may lead to dehydration pain and
tenderness over the kidney area
 Acute pyelonephritis is common in nulliparous women – the
younger age group (20-29 y.o) and at the end of second/beginning
of the 3rd trimester and the Puerperium. Urine exam shows it to be
cloudy with (+) WBC and the infecting organism Escherichia coli.
 UTI need prompt treatment to prevent maternal morbidity [chronic
renal insufficiency, transient renal failure, acute respiratory distress
syndrome, sepsis & shock]; prevent fetal morbidity and mortality
[pre-labor rupture of membranes, chorioamnionitis, preterm labor
and birth
 Vaginal infections and sexually transmitted disease such as
Chlamydia trachomatis may mimic symptoms of UTI. This should
be ruled out.
 Management:
o For fever, tepid sponging antipyretics
o Antibiotic therapy as prophylaxis throughout
pregnancy for recurrent UTI.
o Repeat cultures (microorganism)
PULMONARY TUBERCULOSIS
 An airborne infectious disease caused by the
tubercle bacillus, Mycobacterium tuberculosis.
 Signs / symptoms: fatigue, malaise, loss of
appetite, loss of weight, alteration in bowel
habit, low grade fever (early in pregnancy);
chronic cough, intermittent fever, night sweats,
hemoptysis, dyspnea, chest pain (late)
 Mantoux test (if with risk factors), if with positive result
– chest x-ray to evaluate further, then microscopic
examination & culture of sputum to confirm active
infection.
 Increase in maternal morbidity & mortality where active
TB remains untreated and when treatment is started
late in pregnancy
 Neonates of women with TB have a higher risk of
prematurity and perinatal death and low birth weight
 Management:
o Standard anti-tuberculous therapy is considered
safe in pregnancy in two phases
 First phase – rifampicin, isoniazid, pyrazinamide,
ethambutol daily for 2 months
 Second phase – rifampicin, isoniazid for 4 months
 Drug combination: to prevent the bacillus being
resistant to the drugs
o Rest, good nutrition, education to prevent the
spread
 Postnatal care:
o Babies born to mothers with infectious TB should be
protected by the prophylactic use of isoniazid syrup and
pyridoxine for 6 weeks, then tuberculine test. If negative, BCG
given and drug therapy discontinued. If positive – assess the
baby for congenital or perinatal infection and drugs continued
if.
o Encourage breast feeding because bacteria will not pass
through the breast milk unless tuberculos mastitis. Avoid
further pregnancies until disease-free for 2 years, and if taking
RIFAMPICIN for family planning this drug reduces the
effectiveness of oral contraception.
DISSEMINATED INTRAVASCULAR
COAGULATION (DIC)
 Exaggerated clotting process that increases the formation
of clots in microcirculation.
 Thromboplastin from placental tissue and clots enter the
bloodstream through open vessels at the placental site &
initiate an exaggeration of the normal clotting process.
 The rapid and extensive formation of clots

 Causes the platelets & clotting factors to be depleted

 Results in bleeding and the potential vascular occlusion of
organs from thromboembolus formation
 Predisposing Conditions:
o Abruptio placenta
o Intrauterine fetal death
o Amniotic fluid embolism
o PIH
o Liver disease
o Sepsis
 Assessment (Signs & Symptoms) :
o Uncontrolled bleeding
o Bruising, purpura, petechiae, and ecchymosis
o Presence of occult blood
o Hematuria, hematemesis, or vaginal bleeding
o Signs of shock
o Decreased fibrinogen level, platelet count, hematocrit
level
o Increased prothrombin time, clotting time, & fibrin
degradation products
 Management:
o Monitor vital signs
o Administer oxygen
o Assess for bleeding & signs of shock
o Administer heparin as prescribed to prevent clot formation and
increase available fibrinogen, coagulation factors, and platelets
o Administer blood or blood products as prescribed (Fresh
frozen plasma, platelets)
 CHORIOAMNIONITIS
 A bacterial infection of the amniotic cavity which can occur as a
result of premature rupture of membrane, vaginitis,
amniocentesis, or intrauterine procedures.
 This causes the development of postpartum endometritis and
causes perinatal mortality and maternal morbidity.
 Assessment (Signs & Symptoms)
o Uterine tenderness and contractions
o Elevated temperature
o Maternal or fetal tachycardia
o Foul odor amniotic fluid
o Leukocytosis
 Management:
o Monitor maternal VS & FHT
o Monitor for uterine tenderness, contractions and
fetal activity
o Monitor results of blood culture
o Prepare for amniocentesis (for Gram stain &
leukocyte count)
o Administer antibiotics, administer oxytocin
o Prepare for delivery
ENDOMETRITIS
 An infection of the lining of the uterus following
delivery; caused by bacteria that invade the
uterus at the placental site;

 The infection may spread & involve the entire

endometrium & cause peritonitis, pelvic
thrombophlebitis or cellulitis
 Assessment (Signs & Symptoms):
o Chills & fever
o Increased pulse
o Decreased appetite
o Headache, backache
o Prolonged, severe after pains
o Tender, large uterus
o Fould odor to lochia, reddish-brown lochia
o Ileus
o Elevated WBC
 Management:
o Monitor VS, I&O
o Position in Fowler’s position to facilitate drainage of
lochia
o Provide private room
o Instruct for proper handwashing
o Initiate wound & skin precaution as necessary
o Encourage fluids
o Antibiotics (I.V.)
o Administer comfort measures, back rubs, position
changes & pain meds
o Administer oxytocic meds
 HEPATITIS B
 An inflammation of the liver caused by the Hepa
B virus
 Maternal fetal risk in uncomplicated Hepa B is
not generally increased unless infection occurs in
the third trimester or immediate postpartum
period.
 Intrapartum risks include increased risk for
prematurity, premature delivery, & vertical fetal
transmission
 Transmission to Fetus & Neonate
o Transplacental
o Intrapartum exposure to infected blood,
amniotic fluid, or vaginal secretions
o Through postpartum exposure
o Through breastfeeding
 Risk to Fetus & Neonate
o Infections in early life are asymptomatic
o The neonate is identified as an HbsAg carrier
o Chronic hepatitis
o Associated with glumerulonephritis and nephritis
 Management:
o Limit number of vaginal examination
o Limit the risk for intrapartum ascending infections
o Double glove for extended periods of blood contact
o Remove maternal blood from neonate immediately
after birth
o Suction immediately after birth
o Bathe the neonate prior to invasive procedure
o Clean & dry the face & eyes before eye prophylaxis
o Support breastfeeding after maternal or neonatal
treatment
o Immune globulin & vaccine are given to all HbsAg
positive neonates within 2 to 12 hours of delivery, at
least before 24 hours and not more than 7 days after
birth
o HBV vaccine to neonate:
 1st dose – before newborn leaves the hospital
 2nd dose – at 1 month
 3rd dose – at 6 months
 COMPLICATIONS DURING LABOR & BIRTH
A. FETAL MALPOSITIONS
a. Occiput Posterior Position (OPP)
- Head fail to rotate – it becomes persistent OPP
- Maternal risks: Prolonged labor, potential operative
delivery, extension of episiotomy, 3rd to 4th degree
laceration
- Signs & Symptoms: intense back pain,
dysfunctional labor pattern, prolonged active phase,
secondary arrest of dilatation, arrest of descent.
a.Occiput Transverse Position
- Fetal head in horizontal or transverse
position
- Cause: Ineffective contractions & flat
pelvis
- If Pelvis is NOT abnormal – NSVD with
Oxytocin induction & forceps delivery
- Facilitate rotation by POSITIONING –
Knee chest position / pelvic rocking
- Apply sacral counter pressure for back
pain
A. FETAL MALPRESENTATION
a. Vertex
– if the fetus fail to assume flexed
position
(a)Face presentation
- Prolonged labor & operative delivery at risk
- NSVD if the chin is in anterior position
- CS if Mentum is in posterior position or if
there is fetal distress
- Edema & bruising of the fetal face
 (a) Brow presentation
- The forehead presents
- But this may convert to face
presentation or vertex presentation
(a) Sincipital ( Military Attitude)
- Large diameter of the fetal head
presents
- Labor is slow and there is slow
descent of fetal head
 (d) Breech Presentation
(a) Complete Breech – fetus has thighs tightly flexed
on the abdomen, both the buttocks and the tightly
flexed feet presents to the cervix
(b)Frank Breech - the attitude is moderate because the
hips are flexed but the knees are extended to rest on
chest, the buttocks alone presents to the cervix
(c) Footling breech – neither the thighs nor lower legs
are flexed, if one foot present – single footling, if both,
double footling
o Maternal risks
 Prolonged labor
 PROM – risk is infection
 CS/ forceps delivery
 Trauma to birth canal from manipulation &
forceps
 Intrapartum or postpartum hemorrhage
o Fetal risks
 Compression / prolapsed cord
 Entrapment of fetal head
 Aspiration & asphyxia
 Birth trauma

o Manner of delivery
 CS
 Vaginal delivery

o External cephalic version (Podalic

version)
 Manipulation of fetus to become vertex
 Shoulder Presentation
o Delivery is only by CS
f. Compound Presentation
o The hand or arm prolapse beside the head
o Risk: cord compression and prolapsed
o Size of fetus, fetal distress and labor progress will
determine delivery method
FETAL DISTRESS

 Insufficient oxygen supply to meet the demands

of the fetus
 Causes:
o Compression of the umbilical cord
o Utero-placental insufficiency
 Signs & symptoms
o Meconium stained amniotic fluid
o Changes in fetal heart rate baseline
- Tachycardia [ above 160 bpm – early sign]
- Bradycardia [ below 110 bpm – late sign]
o Decreased or absence of variability of Heart
rate
- Less than 2-5 beats per minute
- Depression of autonomic nervous system (ANS)
- Fetal sleep, hypoxia, sedation
o Late deceleration
- FHT slows after the peak of contraction and returns to
baseline at rest
- Response to hypoxia from uteroplacental insufficiency
- Goal of management: to improve maternal blood flow
to the placenta
a) Position – left side lying
b) Oxygen
c) IV fluid
d) D/C Oxytocin
e) Notify physician
o Severe Variable deceleration
- FHT repeatedly decelerates below 90 beats per
minute for over 60 sec before returning to
baseline
- Interference of blood flow from fetal compression
- Fetal hypoxia and low APGAR
- Goal of Management: to relieve pressure on cord
- Position either on left or right side
- Oxygen administration
- Knee chest position
- Perform vaginal examination
PLACENTAL ABNORMALITIES
a. Unusually large (causes – diabetic, syphilitic,
erythroblastosis fetalis)
b. Wide diameter (risk – placenta previa)
c. Placenta succenturiata – one or more accessory
lobes are connected to the main placenta by
blood vessels
d. Placenta circumvallata – no chorion totally
covering fetal side of placenta
e. Velamentous insertion of cord – the cord
separates into small vessels that reach the
placenta by spreading across a fold of amnion
a. Placenta marginata – fold of chorion reaches
just to the edge of the placenta
b. Battledore placenta – cord inserted at margin
c. Placenta accreta – chorionic villi deeply
attached to the myometrium, unusually deep
attachment
d. Vasa previa – umbilical cord insertion crosses
the cervical os, cord delivered before the fetus
 ABNORMALITIES OF THE CORD
a. Two vessel cord
b. False knots / true knots
c. Short/ long umbilical cord
d. Nuchal cord
e. Achordia
f. Torsion of the cord/ stricture
g. Single artery cord
h. Hematoma
i. Marginal cord insertion
DISORDERS OF THE AMNIOTIC FLUID
a. Oligohydramnios
- Occur in post term pregnancies
- Risk for cord compression/ fetal distress
- If this occurs early in pregnancy – result to amputation / club foot
- Causes:
1. Fetal chromosomal abnormality, growth restriction, ruptured
membrane, congenital anomaly, post term, Kidney problem

2. Placental problem – abruption / twin-twin transfusion

3. Maternal problem – uteroplacental insufficiency, hypertension,
diabetes, pre-eclampsia
4. Drugs – prostaglandin inhibitor, ACE inhibitor
5. Idiopathic
a. Hydramnios / Polyhydramnios
- Associated with fetal malformations (Central
Nervous System / GIT)
1.Anencephaly
2.Esophageal atresia
3.Spina bifida
- Early Labor
- Amniocentesis / Amniotomy
PROBLEMS WITH THE POWER
a.Dysfunctional Labor
o Sluggishness in the force of labor
contractions
o Results in prolonged labor
o Occur at any point in labor, PRIMARY –
occur at onset / SECONDARY – occur
later
o Incidence of infection/ hemorrhage in
postpartum is high and infant mortality
o Causes:
- Fetal malposition / malpresentation
- Pelvic contractures
- Hypotonic, hypertonic, uncoordinated
uterine contractions
- Analgesic or analgesia too early in labor
- Distended bladder or bowel
 o Assessment / Signs & symptoms:
(1) Hypotonic
- Common in the active phase
- Number of contractions is low or
infrequent
- Irregular contractions and doesn’t
cause pain
- Resting tone below 10 mmHg
- Strength doesn’t rise above 25 mmHg
 Maternal & Fetal risks:
@ nonprogressive labor (prolonged rupture of membrane)
@ Infection (because of frequent IE)
-Management of Hypotonic:
@ rule out cephalopelvic disproportion
@ improve uterine contractions:
1.Induce labor (Oxytocin administration)
2.Cervical ripening via stripping or prostaglandin
application
) Hypertonic
- Common in latent phase
- Results in prolonged latent phase
- Intensity is not strong
- Contractions occur frequently
- Increase resting tone to more than 15 mmHg
- Complains of pain
- Uncoordinated contractions
- Maternal risks:
@ prolonged / non progressive labor
@ pain
@ fatigue
-Fetal risks:
@ Hypoxia
@ Decreased uteroplacental blood flow
Management of Hypertonic:
@ Promoting rest
@ Providing analgesia
@ Induce sedation
@ Hydration, monitor intake & output
@ Cesarean section if FHT decelerates, 1st
stage is abnormally long or progress
Isn’t made with pushing
 ABNORMAL PROGRESS IN LABOR

o Prolonged latent phase

 >20 Hrs in nulliparous patient or >14
hours in multipara
 CPD, False labor, sedation, rest
(Causes)
o Protracted active phase
 < 1.2 cm dilatation in nulliparous / or /
<1.5 cm in multiparous
 Related to Malposition, CPD (Causes)
 Assess fetal presentation and position
o Protracted Descent
 < 1cm per hr change in station in
nulliparous client / or / < 2 cm per hr in
multipara
 CPD is ruled out
 Assess contraction intensity, duration
 Labor is augmented by Oxytocin
o Secondary arrest of dilatation
 Cessation of dilatation for > 2 hrs in
nullipara /or/ > 1 hr in multipara
 CPD is ruled out, if (-) labor is augmented
o Arrest of Descent
 If there is no progress in fetal
position for > 1 hr
 CPD is assessed, labor augmented
 Retraction Rings

o Physiologic Retraction Ring

 Boundary between upper uterine segment and
lower uterine segment that normally forms
during labor
 Upper segment contracts and becomes thicker
as muscles fibers shorten
 Lower segment distends and becomes thinner
o Bandl’s Ring
 A pathological retraction that forms when
labor is obstructed caused by CPD or
other complications
 Upper segment continue to thicken
 Lower segment continue to distend
 Risk of uterine rupture increase if
contraction continue
 Cesarean section is the means of delivery
or management
o Constriction Ring
 Retraction ring forms and impedes/
prevents fetal descent
 Relaxation of the constriction ring with
analgesic, anesthetics or both
 Allow vaginal delivery
 PROBLEMS WITH PASSAGEWAY

A. Abnormal Size or Shape of the Pelves

1) Contracted Pelvic Inlet
 AP diameter less 10 cm,
 Transverse diameter less 12 cm
 Engagement difficult, influence fetal position
and presentation
2) Contracted Midpelvis
 Interspinous diameter less than 9.5 cm
 Hampers/ prevents internal rotation of
the head
 Results:
 Secondary arrest of dilatation
 Arrest of descent of fetal head
3) Contracted Pelvic Outlet
 Interischial tuberosities diameter less than 8 cm
 Trial Labor – is recommended:
With Oxytocin, when pelvic measurement are
borderline, to see if vaginal delivery is
possible
• Cesarean section, if no progress happens
Cephalopelvic Disproportion
 Fetal head too large to pass the pelvis
 Signs & symptoms:
 Head no descent even with strong
contractions
 Maternal risks:
 prolonged labor, exhaustion, hemorrhage,
infection
 Fetal risks:
 Hypoxia, birth trauma
 Management: Cesarean section
Shoulder Dystocia
 An obstetric emergency resulting from difficulty or
inability to deliver the shoulders
 Fetal macrosomia increases the risk for shoulder
dystocia
 Maternal complications:
o Lacerations and tears of birth canal
o Postpartum hemorrhage
 Neonatal complications:
o Hypoxia
o Fracture of the clavicle

Injury to neck and head

 Management:
o Non-invasive Procedures
 Change in maternal position
 McRobert’s Maneuver
 Woman flexes thighs on abdomen
 Position changes the angle of the pelvis, increase
pelvic diameter and facilitates delivery of baby
 Suprapubic pressure
 All fours position (or Gaskin Maneuver) – assist
unto her hands and knees
Manipulative Procedures
 Positioning – McRoberts / Lithotomy
 Episiotomy
 Rubin’s maneuver – posterior shoulder is identified
on vaginal exam, then to push the posterior shoulder
in the direction of the fetal chest, thus rotating the
anterior shoulder away from the symphysis pubis.
By adducting the shoulders, this reduces the 12 cm
bisacromial diameter
 Wood’s Maneuver – requires the
midwife to insert her hand into the
vagina and identify the fetal chest, then
by exerting pressure on to the posterior
fetal shoulder, rotation is achieved.
 Delivery of the posterior arm
 Zavanelli maneuver – last hope for delivery
of live baby, the head is reinserted into the
vagina, and delivery is by cesarean section .
 Symphysiotomy – is the surgical separation
of the symphysis pubis and is used to
enlarge the pelvis to enable the birth.
Performed in CPD.
 . PRETERM PRELABOUR RUPTURE OF THE MEMBRANES

- Rupture of the fetal membranes occurs without the onset of

spontaneous uterine activity resulting in cervical dilatation,
occurs before 37 weeks gestation
o Can be associated with cervical incompetence
o A strong association with maternal vaginal
colonization with potentially pathogenic
microorganism, with incidence of subclinical
chorioamnionitis.
o Predisposing factors:
 Maternal – chronic pyelonephritis, multiple pregnancies,
previous history, sepsis of fetus, placental disorders
 Fetal – infection hydramnios, multiple pregnancy
o Consequence:
 Labor leading to preterm birth
 Chorioamnionitis leading to systemic infection
 Oligohydramnios associated with pulmonary
hypoplasia
 Cord prolapsed
 Malpresentation associated with prematurity

Primary antepartum hemorrhage

o Management:
 Positive Nitrazine test should not be considered
conclusive when it is the only sign.
 If diagnosis in doubt – fetal fibronectin
immunoenzyme test is useful in confirming
rupture of membranes and ultrasound.
 Avoid digital vaginal examination to prevent
infection.
 Monitor FHT (tachycardia mean infection),
maternal – monitor temperature, pulse, uterine
tenderness and any purulent or offensively
 If less than 32 weeks, uncompromised fetus –
hospitalized for monitoring, TOCOLYTIC drug to
prolong pregnancy
 Infection is positive – antibiotics, and if
asymptomatic – prophylactic antibiotics
 If membranes rupture before 24 weeks – outlook is
not good, pregnancy may be terminated.
 If more than 32 weeks, fetus is compromised, active
management is needed – induction of labor or
Cesarean section
 MULTIPLE PREGNANCIES
The development of more than one fetus in utero
at the same time.
 Types of twins
o A. Monozygotic / uniovular (IDENTICAL TWINS)
 Develop from the fusion of one oocyte and one
spermatozoon
 Same sex twins, same genes, same blood groups and
physical features
 However, may be of different sizes & very different
personalities & characters
 Dizygotic / Binovular Twins (NON-
IDENTICAL TWINS)
 Develop from two separate oocytes that are
fertilized by two different spermatozoon
 Can be of the same sex or different sex
 Can be boy-girl pairs
 Diagnosis of Twin Pregnancy
o Ultrasoundas early as 6 weeks
o Abdominal Examination
 Inspection:
o Size of the uterus larger than
expected particularly after 20th week
o Uterus is broad or round and fetal
movement over a wide area
o Amniotic fluid twice the amount
 Palpation
o Fundal height greater than expected for the
period of gestation
o Two fetal poles (head or breech) in the fundus
of the uterus
o Multiple fetal limbs, head small in relation to
the size
o Two fetal backs or limbs on both sides
o Location of three poles in total is diagnostic of
at least two fetuses
 Auscultation
o Hearing two fetal heart beat is NOT
DIAGNOSTIC.
o The pregnancy:
 Tends to be shorter than a single
pregnancy
o Average for twins – 37 weeks
o Average for triplets – 34 weeks
o Average for quadruplets – 33 weeks
o Effects of pregnancy
 Exacerbation of common disorders –
because of high levels of hormones,
sickness, nausea and heartburn
 Anemia I iron deficiency & folic acid
deficiency
 Polyhydramnios – with monochorionic twins.
This can lead to miscarriage or premature
labour
 Pressure symptoms – increase tendency to
varicose veins and edema, backache is
common, marked dyspnea and indigestion
o Labor and Birth
 Onset of labor is early, term for twins is 37 weeks
and approximately born pre-term, small for
gestational age (SGA),
 If labor is early, chance of survival outside is small.
Mother given drugs to inhibit uterine activity
(Intravenous Salbutamol & Sulindac tablets). If with
UTI, treat ASAP with antibiotics
 Induction of labor at 38 weeks, if first twin is
cephalic, normal vaginal delivery can occur, but if
other way then elective cesarean section
 Birth by Forceps

o Forceps are used to expedite delivery of the fetal

head or to protect the fetus or the mother, or both,
from trauma and exhaustion.
o Forceps are also used to assist the delivery of the
aftercoming head of the breech or to draw the head
of the baby up and out of the pelvis at cesarean
section birth.
o Types of forceps:
 Wrigley’s forceps, Neville-Barnes or Simpson’s
forceps, Kielland’s forceps
o Indications for use:
 Three main indications:
 delay in the second stage of labor,
 fetal compromise,
 maternal distress
 Delay in the second stage could be:
 Insufficient contractions (but this is better corrected by
Oxytocin infusion)
 Epidural anesthesia
 Malrotation of the head
 Maternal fatigue
 Cesarean Section
o Anoperative procedure which is carried
out under anesthesia whereby the fetus,
placenta and membranes are delivered
through an incision in the abdominal
wall and the uterus. This is carried out
after viability has been reached (24
weeks gestation onwards).
o Elective Cesarean Section
 Decision carried out during pregnancy before
labor starts.
 Definite indications: cephalopelvic disproportion,
major degree of placenta previa, high order
multiple pregnancy
 Possible Indications: breech presentation,
moderate to severe pre-eclampsia, diabetes
mellitus, intrauterine growth restriction,
antepartum hemorrhage, certain fetal
abnormalities (hydrocephalus)
o Emergency Cesarean Section
 Carried out when adverse conditions
develop during pregnancy or labor
 Reasons: antepartum hemorrhage, cord
prolapse, uterine rupture, CPD diagnosed
in labor, pre-eclampsia, failure to progress
in the first or second stage of labor, fetal
compromise & birth not imminent
POSTPARTUM COMPLICATIONS
A. HEMORRHAGE
 Bleeding of 500ml or more following delivery (NSVD),
or 1000 ml or more (CS)
 Causes: Uterine atony, lacerations, retained placental
fragments
 Early hemorrhage:
o Happens during the first 24 hours after delivery
o Caused by uterine atony, lacerations or inversion of the uterus
 Late hemorrhage:
o Happens after the first 24 hours after delivery
o Caused by retained placental fragments
 Management:
o Palpate the fundus (firm/ relaxed), monitor vital
signs (BP-PR), assess vaginal bleeding, Hgb &
Hct determination
o Inspect vagina and perineal area
o Massage the uterus (fundus)
o Raise the legs for increase venous return
o Keep patient warm
o Blood transfusion and IV fluids
o Administer oxygen
A. UTERINE ATONY
 The inability of the uterus to contractand constrict the
blood vessels, resulting in open sinuses at the site of
placental separation.
 May occur following delivery of the baby, or up to 24
hours after the delivery of the placenta
 The cause of 90% of early postpartum hemorrhage
 Causes:
o Overdistention: hydramnios, multiple pregnancy,
macrosomia
o Complication of labor: precipitate and prolonged labor
o Uterine relaxing agents: anesthesia, analgesia,
terbutaline, magnesium sulfate, nitroglycerine
o Oxytocin given during labor
o High parity and advance maternal age
o Infection: amnionitis and chorioamnionitis
o Presence of fibroid tumors that interfere with
uterine contraction
o Over massage of the uterus that results in very
strong uterine contraction and eventual fatigue
o Retained placental fragments
o Prolonged third stage of labor: more than 30
minutes
o Uterine relaxing agents: anesthesia, analgesia,
terbutaline, magnesium sulfate, nitroglycerine
o Oxytocin given during labor
o High parity and advance maternal age
o Infection: amnionitis and chorioamnionitis
o Presence of fibroid tumors that interfere with uterine
contraction
o Over massage of the uterus that results in very strong
uterine contraction and eventual fatigue
o Retained placental fragments
o Prolonged third stage of labor: more than 30 minutes
SUBINVOLUTION

The delay in the return of the uterus to its

prepregnant size and shape and function.
Lochia is still present, uterus remains large, soft, at
4-6 weeks postpartum
Causes:
Retained placental fragments
Infection – endometritis
Uterine tumors
 Signs and symptoms:
o Enlarged and boggy uterus
o Prolonged or reversal pattern in lochial discharge (alba-returns
to rubra)
o Foul odor in Lochia
o Backache
 Management:
o Initially, Ergonovine maleate will be ordered for 2 weeks, if it
persist – D&C
o Treat the cause:
 If infection – antibiotics, if tumors – removal
 Evacuation of placental fragments – D&C
URINARY TRACT INFECTION
 A bacterial infection of the bladder or urethra that is confirmed
when greater than 105 colony-forming units from a clean-catch
urine specimen or greater than 10,000 colony forming units on
a catheterized specimen is revealed.
 Common in the Puerperium because of trauma to the bladder
after delivery, urinary retention and over distention of the
bladder due to anesthesia.
 Infection can be introduced during catheterization.
 Infecting organism: coliform bacteria, coli, kleibsheilla
pneumonia and enterococci
 Risk factors:
o Cesarean delivery Forceps and vacuum delivery
o Tocolysis Induction of labor
o Maternal renal disease Preeclampsia, eclampsia
o Epidural anesthesia Bladder catheterization
o Prolonged hospital stay Previous UTI during
pregnancy
 Signs and symptoms:
o Painful urination
o Frequency and urgency of urination
o Suprapubic pain & tenderness, flank pain
o Fever
o Hematuria
 Management:
o Increase fluid intake (3,000 cc/ day)
o Regular emptying of the bladder
o Analgesics for pain, antibiotic for infection
o Take Vit C, avoid carbonated drinks
o Antibiotic for 7 days
 Trimethoprim / sulfamethoxazole / ciprofloxacin /
norfloxacin / amoxicillin
 Trimethoprim / sulfamethoxazole should not be given
if breastfeeding
SHEEHAN’S SYNDROME
 This may occur with severe hemorrhage during
labor and delivery. Severe blood loss results in
poor blood supply to the pituitary gland causing
tissue death that eventually cause hypopituitarism
 Hormones that are not produced, affecting the milk
production (prolactin), growth, reproductive
function (FSH-LH), thyroid (TSH) and adrenal
glands.
 Management:
o Lifelong hormone replacement therapy.
PUERPERAL INFECTION

 PUERPERAL FEVER or infection, is an infection of

the genital tract after delivery
 Causative agent:
o Those that normally inhibit the colon, vagina, cervix
(anaerobic streptococci) and those that are part of the
normal flora of the woman’s body (E. coli)
o Some agents may have been introduced by the hospital
personnel
 MASTITIS
 Infection of breast tissue occurring in
breastfeeding mothers. This appears on the
2nd and 3rd postpartum when milk supply
is already established.
 Commonly the baby’s mouth is not properly
positioned on the breast causing soreness,
cracks, and abrasion making the point of
entry for microorganism from the baby.
 Affects the glandular tissue, milk is a good
medium for microbial growth.
 Infecting organisms: staphylococcus aureus
from oral-nasal cavity of the infant (most common
agent)
 Coagulase -negative streptococci – veridans,
streptococci
Signs and symptoms
o Engorgement or swelling of breast, chills. (first) Breast
hard and appears reddened.
o Fever, tachycardia, body malaise
o Reduced milk supply due to edema and engorgement
o Breast abscess
o Accurate diagnosis: sample of breast milk from infected
breast and culture it for proper identification of
causative agent, so to give the appropriate antibiotic
 Management:
o Prevention:
 Prevent nipple cracks and fissures, proper placement
of baby’s mouth
 Proper breast care of feeding
 Apply warm compress before nursing
 Express excess milk after feeding
 Isolate infant with cord or skin infection
 Proper hand washing technique, strict sterile
technique
 Comfort measures
 Wear supportive brassiere
 Apply ice or heat
 Discontinue breast feeding from affected breast, express
milk every 4 hours to maintain lactation and prevent
abscess formation
 Bedrest – 24 hours
 Antibiotic of choice – dicloxacillin & erythromycin,
Other antibiotics – clindamycin / vancomycin.
Women can continue breastfeeding
 If abscess develops, it is incised and drained.
 POSTPARTUM THROMBOEMBOLIC
DISORDERS
 Thrombi or blood clots are formed when there is stasis of
circulation or repair of damaged tissue.

 The postpartum woman is especially susceptible to the

formation of thrombi because of increased fibrinogen and
Prothrombin levels which increases blood coagulability.
Thrombi have a tendency to occlude circulation and are a
good medium of bacterial growth
 Two major complications:
o A. THROMBOPHLEBITIS – infection with lining of the
vein with formation of thrombi.
o If the inflammation is minor and involves only the superficial
veins of the extremities it is called VENOUS THROMBOSIS OR
PHLEBOTHROMBOSIS.
o If the inflammation involves deep veins, it is called
THROMBOPHLEBITIS.
o PULMONARY EMBOLISM – thrombi that are formed in the deep
leg veins are carried by circulation to the pulmonary artery and
obstruct blood flow to the lung.
 Predisposing factors:
o Varicosities of the legs
o Obesity

o Over 30 – age
o Multiparity
o Use of estrogen supplement
o History of thromboembolic disease
o Anesthesia, surgery
o Smoking
o Trauma to extremities
o Diabetes
 Causes:
o Injury to blood vessels during delivery,
indwelling catheter, infection
o Increase blood clotting during pregnancy and
after delivery as normal occurrence and with
use of oral contraceptives.
o Blood stasis that occurs as a result of
varicose veins, bed rest after Cesarean and
prolonged inactivity.
 TYPES
o A.Femoral thrombophlebitis – infection of
the veins of the legs, saphenous, popliteal
vein
 Homan’s sign – calf pain when the foot is
dorsiflexed
 Milk leg or phlegmasia alba dolens – leg is
shiny white in appearance because of
extreme swelling and lack of circulation
 Swelling of affected leg, pain and stiffness
 Fever
o B. Pelvic thrombophlebitis – infection of
the ovaries, uterine and pelvic veins
 Fever and chills
 Pain in lower abdomen and flank
 Palpable parametrial mass in some
cases
 Management:
o Prevention
 Early ambulation after delivery
 Use of support stocking in women, to
promote circulation, put on before rising from
bed in the morning
 Provide adequate hydration
 Avoid trauma on the extremities
 If post CS, encourage leg exercise
 Avoid prolonged bed rest, standing and sitting
o Superficial thrombosis, relief of pain and
resolution of clot
 Application of heat to relieve pain
 Aspirin & ibuprofen – anti-inflammatory
 Avoid massaging the area
o Deep vein thrombosis (DVT), intensive
management to prevent complication
 Hospitalization during acute phase

o Bed rest until s/s disappear, gradual

ambulation, wear elastic stockings
 Leg elevation to prevent venous stasis
 Anticoagulants:
 Heparin – safe for breastfeeding mothers,
antagonist is Protamine sulfate
 Dicumarol – not safe for breastfeeding mothers,
antagonist is Vit K
 Monitor Partial thromboplastin time (PTT)
 Apply warm wet compress dressings to
promote circulation and for comfort
 Administer prescribed antibiotic to combat
infection and analgesic for pain
 Surgery
 POSTPARTUM PSYCHIATRIC DISORDERS

POSTPARTUM POSTPARTUM POSTPARTUM PSYCHOSIS

BLUES DEPRESSION
Onset 1-2 days 1-2 months after Within first month after birth
birth
Signs / Sadness, tears Anxiety, feeling of Delusion and hallucination
symptoms loss, sadness
Therapy Support and Counseling Psychotherapy and drug
empathy therapy
Health Worker Offering Refer for Refer for counseling/
Role compassion and counseling safeguarding from injury to
understanding self or newborn
Hospitalization needed
SEXUALLY TRANSMITTED DISEASES
Reproductive Tract Infection
GONORRHEA

Gonorrhea is a bacterial infection caused by

Neisseria gonorrheae (or gonococcus
bacteriae) - transmitted by sexual contact.

Penicillin
 burning or frequent urination,
 yellowish vaginal discharge,
 redness and swelling of the genitals,
 burning or itching of the vaginal area.
 If untreated, leads to a severe pelvic infection with
inflammation of the Fallopian tubes and ovaries- lead
to PID
 can also spread through the body to infect joints to
cause gonococcal arthritis.
 CHLAMYDIA
Chlamydia (Chlamydia trachomatis) similar to
gonorrhea in the way that it is spread and the symptoms
it produces.
= destructive to the fallopian tubes, can cause
premature birth
Single-dose therapy for chlamydia is oral azithromycin
(Zithromax, Zmax).
Alternative treatments -most common is doxycycline
(Vibramycin, Oracea, Adoxa, Atridox, and others),
tetracycline, erythromycin
Many women do not have symptoms. Cervicitis
most common manifestation
Vaginal discharge - pus
Abdominal pain
Transmission to babies cause conjunctivitis
In men this cause epididymitis
SYPHILIS
Caused by spirochete - Treponema pallidum. The spirochete is a wormlike,
spiral-shaped organism. Infects by burrowing into the moist, mucous-covered
lining of the mouth or genitals. The spirochete produces a classic, painless
ulcer known as a chancre.
Long-acting penicillin
Neurosyphilis – I.V. penicillin.
Alternative treatments include oral doxycycline or tetracycline.
Women who are infected during pregnancy can pass on the infection to the
fetus through the placenta.
Left untreated, syphilis can lead to blindness or even death of the infant.
There are three stages of syphilis,
Inactive (latent) stage. Formation of an ulcer (chancre) is the
first stage. Syphilis is highly contagious when the ulcer is
present.
Second stage of the infection called "secondary" syphilis a
systemic stage of the disease, meaning that it can involve
various organ systems of the body. They develop a skin rash,
typically appearing on the palms of the hands or the bottoms
of the feet, Lesions look like genital warts. Can be
transmitted by casual contact.
Third (tertiary) stage of the disease can develop. At this stage,
syphilis usually is no longer contagious. Tertiary syphilis is a
systemic stage
 HERPES
Genital herpes, called "herpes," is a viral infection by the
herpes simplex virus (HSV) transmitted through intimate
contact with the mucous-covered linings of the mouth or the
vagina or the genital skin. The virus enters the linings or skin
through microscopic tears. Once inside, the virus travels to
the nerve roots near the spinal cord and settles there
permanently.
Two types of herpes viruses are associated with genital
lesions: herpes simplex virus-1 (HSV-1)- blisters of the mouth
area and herpes simplex virus-2 (HSV-2)- genital sores or
lesions in the area around anus.
No known cure for herpes, there are treatments for the
outbreaks.
Oral medications (ANTIVIRAL) such as acyclovir (Zovirax),
famciclovir (Famvir), or valacyclovir (Valtrex) that prevent
the virus from multiplying and even shorten the length of
the eruption.
Incubation period 3 to 7 days before a lesion develops. No
symptoms and the virus cannot be transmitted to others.
Itching or tingling sensation followed by redness of the skin.
Blister forms. When the blisters break, are usually very
painful to touch and may last from 7 days to 2 weeks.
The infection is definitely contagious from the time of
itching to the time of complete healing of the ulcer, usually
within 2 to 4 weeks. However, as noted above, infected
individuals can also transmit the virus to their sex partners
in the absence of a recognized outbreak.
HUMAN PAPILLOMA VIRUS (HPV) INFECTION
CONDYLOMATA ACUMINATA
VENEREAL WARTS

HPV, the cause of genital warts (also known as

condylomata acuminata or venereal warts)
Infects the genital tract of men and women.
Warts are primarily transmitted during sexual contact. HPV
cause of cervical cancer and other anogenital cancers, and
it is linked with both anal and penile cancer in men.
No cure or treatment. The only treatment is to remove the lesions.
A treatment that can be administered by the patient is a 0.5%
solution or gel of podofilox (podophyllotoxin). The medication is
applied to the warts until the lesions are gone.
Genital warts appear as small, fleshy, raised bumps,
but they can sometimes be extensive and have a
cauliflower-like appearance. They may occur on
any sexually-exposed area. In many cases genital
warts do not cause any symptoms, but they are
sometimes associated with itching, burning, or
tenderness.
CHANCROID
Caused by Hemophilus ducreyi
Made from the medical history and physical
examination) if the patient has one or more
painful ulcers in the genital area and tests are
negative for syphilis or herpes..
CHANCROID resemble a CHANCRE (syphilis) –
but soft
Chancroid is almost always cured with
a single oral dose of azithromycin
(Zithromax) or a single injection of
ceftriaxone (Rocephin).
Alternative medications are
ciprofloxacin (Cipro) or erythromycin.
The ulcer is painful
The diagnosis of chancroid can be confirmed by a
culture of the material from within the ulcer for the
bacterium Hemophilus ducreyi.
VAGINITIS
CANDIDIASIS / MONILIASIS
Caused by CANDIDA ALBICANS
A yeast or fungal infection,
Transmitted by sexual intercourse.
Cause inflammation of the vulva and vagina

Antifungal – metronidazole
Causes:

Poor hygiene
Prolonged antibiotic use
Using oral contraceptives
Sexual intercourse
RISK FACTORS:

Diabetes
HIV infection
Pregnancy
Obese
Broad-spectrum antibiotic
Signs and symptoms:
Redness and burning sensation
Vaginal pain
Internal or external genital itching
Clumped discharge resembling cottage cheese
Irritation of the cervix
Bread-like “yeasty” odor from genital area
Vaginal discharge
Anti-fungal products:

Miconazole nitrate vaginal suppository (bed time)

Butoconazole 2% cream 5 g intravaginal (bed
time)
Intense vaginal itching,
burning sensation, vaginal
discharge (cottage cheese)
VAGINITIS

Or TRICHOMONIASIS , transmitted by sexual

intercourse or contact with infected vaginal secretions

Antibiotic both for men and women

Thick, yellow or gray vaginal
discharge, unpleasant odor, vaginal
itching, pain during urination
VAGINITIS

GARDNERELLA VAGINALIS identified for nonspecific

vaginitis. Happens when there is over abundance of
bacteria, affecting balance of normal flora and lactic
acid in vagina.

Antibiotic
Abnormal vaginal discharge, with
vaginal itching/ burning on
urination, dyspareunia, discharge is
fishy odor, yellow and green in
color
DYSTOCIA

A broad term referring to prolonged and difficult labor (any labor that lasts more than 24
hours)
Caused by an abnormality or a combination of abnormalities in the essential factors of
labor.
Also known as:
a. Difficult labor
b. Abnormal labor
c. Difficult childbirth
d. Abnormal childbirth
e. Dysfunctional labor
EUTOCIA – normal labor
TYPES of DYSTOCIA

1. Uterine Dysfunction: Abnormalities of the powers

a. Hypotonic uterine dysfunction
b. Hypertonic uterine dysfunction
c. Inadequate secondary forces
2. Abnormalities with Passageway
a. Pelvic dystocia
1. Inlet dystocia
2. Midpelvis dystocia
3. Outlet dystocia
b. Soft tissues dystocia
a. Placenta previa that partially or completely obstructs the birth canal.
b. Presence of tumors that obstructs the birth canal
3. Fetal Dystocia - abnormal passenger
a. Malposition – persistent occiput posterior position
b. Breech presentation
c. Face presentation
d. Brow presentation
e. Shoulder presentation
f. Multiple presentation
g. Macrosomia
h. Hydrocephalus
PRECIPITATE LABOR AND DELIVERY

A labor that occurs within 3 hours from onset of contraction to delivery of the baby.
A delivery that occurs without warning.

Classification
a. Precipitate dilatation
- cervical dilatation progressing at a rate of 5 cm or more per hour in NULLIPARA / and
10 cm per hour or more in MULTIPARA
b. Precipitate descent
- when fetal descent is progressing at a rate of 5 cm per hour or more in NULLIPARA /
and 10 cm per hour or more in MULTIPARA
Thank You!

END