NCM 109 – Lesson 4 - the physician will usually perform a D & C or a suction

curettage to evacuate the remainder of the pregnancy

COMPLICATIONS DURING PREGNANCY, LABOR and
DELIVERY and POSTPARTUM PERIODS 6. Missed Abortion – commonly referred to as early
pregnancy failure, the fetus dies in the utero but is not
1. CONDITIONS ASSOCIATED WITH FIRST- expelled
TRIMESTER BLEEDING
- a sonogram can establish that the fetus is dead. Often
CONDITIONS ASSOCIATED WITH FIRST- TRIMESTER the embryo actually died 4-6 weeks before the onset of
BLEEDING: miscarriage symptoms.

- two most common causes of bleeding during the first - labor may be induced by a prostaglandin suppository or
trimester are Abortion and Ectopic Pregnancy Misoprostol (Cytotec) to dilate the cervix, followed by
oxytocin administration
A. MISCARRIAGE/ABORTION
- DIC (Disseminated Intravascular Coagulation), a
1. Spontaneous Abortion – any interruption of pregnancy coagulation defect, may develop if the dead fetus remains
before the age of viability too long in utero
- when the interruption occurs spontaneously, it is clear to 7. Recurrent Pregnancy Loss/Habitual Abortion –
refer to it as a MISCARRIAGE commonly referred to as habitual abortion
- when pregnancy is medically or surgically interrupted, - 3 or more consecutive pregnancies result in miscarriage
this is typically termed as ABORTION usually related to incompetent cervix.
- Stage of viability - a stage when the fetus is capable of Management (suture of cervix)
surviving outside the uterus (>20- 24 weeks)
1. McDonald procedure
- occurs in 15% to 30% of all pregnancies and occurs from
natural causes - temporary cerclage

- a spontaneous miscarriage is an early miscarriage if it - Side effect – infection

occurs week 16 of pregnancy and a late miscarriage if it
occurs between weeks 16 and 24. - May have NSD

- its presenting symptoms is almost always vaginal 2. Shirodkar

spotting Ceasarean Section delivery
Causes:

- abnormal fetal formation, due to either to a teratogenic

factor or to chromosomal aberration

- implantation abnormalities. Approximately 50% of

zygotes are never implanted - corpus luteum fails to
produce enough progesterone to maintain the decidua
basalis

- infection (i.e rubella, syphilis, poliomyelitis,

cytomegalovirus and toxoplasmosis infections readily
cross the placenta and possibly causing fetal death

- ingestion of teratogenic drug READ MORE and DIFFERENTIATE THE 2 TYPES

2. Threatened Abortion – is manifested by vaginal

bleeding, initially beginning as scant bleeding and usually
McDonald Procedure - Cervical Cerclage
bright red, slight cramping, but no cervical dilatation on
vaginal examination.

- no strenuous activity for 24-48 hours

- coitus is usually restricted for 2 weeks after the bleeding

3. Imminent (Inevitable) Abortion – it happens with

uterine contraction, cramping and cervical dilatation

- the loss of the products of conception cannot be halted

because of cervical dilatation - save tissue fragments that
has passed and bring to the clinic to be examined
Complications of Abortion:
- the physician may perform D & C (Dilatation and
Curettage) 1. Hemorrhage - a woman who develops DIC has a
major possibility for hemorrhage
- record the number of pads used to assess for heavy
bleeding MANAGEMENT

4. Complete Abortion – the entire products of conception 1. position the woman flat and massage the uterine fundus
(fetus, membranes and placenta) are expelled
spontaneously without any assistance 2. monitor vital signs

- the bleeding usually slows within 2 hours and then 3. a BT may be necessary to replace blood loss
ceases within a few days
4. instruct the woman on how much bleeding is abnormal
5. Incomplete Abortion – part of the conceptus (usually (more than one sanitary pad per hour is excessive), what
the fetus) is expelled, but the membranes or placenta is color changes she should expect in bleeding (gradually
retained in the uterus changing to a dark color and then to the color of serous
fluid) and any unusual odor or passage of large clots is
also abnormal

2. Infection - the possibility of infection is minimal when

pregnancy loss occurs a short period, bleeding is self
limiting and instrumentation is limited

MANAGEMENT

1. Educate the woman about the danger signs of infection,

such as fever, abdominal pain or tenderness and a foul
smelling discharge
Nursing Care of Clients with Abortion
2. Organism responsible for infection after miscarriage is
usually Escherichia Coli (E Coli) 1. Document the amount and character of bleeding and
save tissues or clots for evaluation.
3. Caution the woman to wipe the perineal area from front
to back after voiding and particularly after defecation 2. Check the bleeding and vital signs to identify
hypovolemic shock resulting from blood loss
4. Caution the woman not to use tampons to control
vaginal discharge 3. After vacuum aspiration or curettage, the amount of
vaginal bleeding is observed and should be documented
3. Isoimmunization/Rh Sentisization - happens when
the mother’ s blood is Rh negative, while the fetus is Rh 4. Provide home health teaching after curettage such as:
positive. a. report increase bleeding
- after spontaneous abortion or D & C. some Rh positive b. take temperature every 8 hours for 3 days
fetal blood may enter the maternal circulation and mother
develops antibodies against Rh positive fetus blood. c. take an oral iron supplement if prescribed

- during the succeeding pregnancies when the fetus is Rh d. resume sexual activity as recommended by the health
positive again, those antibodies would attempt to destroy care provider
the fetus RBC
e. return to the health care provider at the recommended
- so after miscarriage, because the blood of the fetus is not time for a check up.
known, all women with Rh negative blood should receive
Rhogam (Rh Immune Globulin) to prevent the build up of f. Check laboratory test such as hemoglobin level and
Rh antibodies and to prevent the succeeding pregnancies hematocrit

4. Powerlessness - sadness and grief over the loss or a g. Promote expression of grief by providing privacy,
feeling that she has lost control of her life is to be expected allowing support persons to help in pregnancy loss

MANAGEMENT: - emotional support

B. ECTOPIC PREGNANCY - is one in which
implantation occurs outside the uterine cavity.
Procedures Used in Pregnancy Termination 1.Vacuum
Curettage/Vacuum Aspiration - cervical dilation followed - the most common site (in approximately 95%) is in a
by controlled suction through a plastic cannula fallopian tube. Of these fallopian tube sites, approximately
80% occur in the ampullar portion, 12% occur in the
- used for first trimester abortions, also used to remove isthmus and 8% in interstitial
remaining products of conception after spontaneous
abortion - local anesthesia of the cervix is needed - approximately 2% of pregnancies are ectopic;

- ectopic pregnancy is the second most frequent cause of

bleeding early in pregnancy

Risk Factors of ECTOPIC PREGNANCY:

2. Dilatation and Curettage/Dilatation and Evacuation - - increase incidence in women who have PID (Pelvic
dilation of cervix followed by gentle scraping of the uterine Inflammatory Disease) which leads to tubal scarring
walls
- occurs more frequently in women who smoke
- used for first-trimester abortions to remove all products of
conception after spontaneous abortions - occurs more frequently in women who douche, possibly
due to risk of introducing an infection
- Greater risk of cervical or uterine trauma and excessive
blood loss - used of IUD (Intrauterine Device) for contraception

- local anesthesia or general anesthesia is needed Signs and Symptoms:

Before Rupture

- no menstrual flow occurs/amenorrhea

- nausea and vomiting

- positive pregnancy test for hCG

- abdominal pain within 3- 5wks of missed period (maybe

generalized or one sided)

- scant, dark brown vaginal bleeding

During rupture

- sharp, stabbing pain in one of the lower abdominal

quadrants at the time of rupture, followed by scant vaginal
bleeding
Management:
- lightheadedness, rapid pulse and signs of shock (rapid
thread pulse, rapid respirations and falling blood pressure) 1. once an ectopic pregnancy ruptures, it is an emergency
situation and the woman’s conditions must be monitored
- rigid abdomen from peritoneal irritation (Board-like for the symptoms of shock
abdomen)
2. laparoscopy to ligate the bleeding vessels and to
- Cullen’s sign (bluish tinged umbilicus) – because blood remove or repair the damaged fallopian tube
seeping into the peritoneal cavity
3. women with Rh negative blood should receive Rh
- dull, excruciating pain on the abdomen that may radiate immune globulin (Rhogam)
on the shoulder caused by irritation of the phrenic nerve
4. Oral administration of Methotrexate, a folic acid
Diagnostics: antagonist chemotherapeutic agent, to attack and destroy
fast growing cells because trophoblast and zygote growth
1. Transvaginal UTZ will demonstrate ruptured tube is rapid, the drug is drawn to the site of ectopic pregnancy
2. Needle insertion through the post-vaginal fornix into the 5. Hysterosalphingogram is performed after chemotherapy
cul-de-sac under the sterile conditions to see whether to assess the patency of the tube
blood that has collected there from internal bleeding can
be aspirated (Culdocentesis) 6. provide emotional support

3. Laparoscopy Culdoscopy can be used to visualize the

fallopian tube
2. CONDITIONS ASSOCIATED WITH SECOND-
TRIMESTER BLEEDING
1. GESTATIONAL TROPHOBLASTIC DISEASE
(HYDATIDIFORM MOLE OR H- MOLE) - is proliferation
and degeneration of the trophoblastic villi, which becomes
filled with fluid and appear as grape-sized vesicles

- incidence is approximately 1 in every 2,000 pregnancies

Transvaginal UTZ:

Laparoscopy

Causes:

- unknown

Risk Factors:

- occurs most often in women who have a low protein

intake

- in young women (under age 18 years)

- in older women (older than 35 years)

Types;

- there are two distinct types of Hydatidiform Mole –

Complete and Partial 1. often the first symptom is show (a pinkstained vaginal
discharge) or increased pelvic pressure followed by
1. Complete mole – all trophoblastic villi swell and become rupture of membranes and discharge of amniotic fluid
cystic. - embryo dies early at only 1 to 2 mm in size with
no fetal blood present in the villi 2. painless cervical dilatation

- on chromosomal analysis, although the karyotype is a 3. uterine contractions followed by birth of fetus
normal 46XX or 46XY, this chromosome component was
contributed only by the father or an “empty ovum” was MANAGEMENT
fertilized and the chromosome material was duplicated
1. bed rest in trendelenburg position
- this type usually lead to choriocarcinoma
2. monitor FHT
2. Partial mole – some of the villi form normally
3. observe for the rupture of BOW
- although no embryo is present, fetal blood may be
4. avoid coitus and limit activities
present in the villi
5. avoid vaginal douche
- has 69 chromosomes (a triploid formation in which there
are three chromosomes instead of two for every pair, one 6. Surgical Operation termed as “Cervical Cerlage” is
set supplied by an ovum that was fertilized by two sperm performed
or an ovum fertilized by one sperm in which meiosis or
reduction division did not occur) - as soon as sonogram confirms that the fetus of a second
pregnancy is healthy, at approximately 12 - 14 weeks,
Signs and Symptoms: pursing-string sutures are placed in the cervix by vaginal
route under regional anesthesia
1. uterus tends to expand than normally
Types of Cervical Cerclage:
2. no Fetal heart sounds are heard because there is no
viable fetus 1. McDonald Procedure – nylon sutures are placed
horizontally and vertically across the cervix and pulled tight
3. hCG serum levels are abnormally high
to reduce the cervical canal to a few millimeters in
4. severe nausea and vomiting diameter

5. symptoms of hypertension of pregnancy is present 2. Shirodkar Technique – sterile tape is threaded in a

before week 20 of pregnancy purse-string manner under the sub mucosal layer of the
cervix and sutured in place to achieve a closed cervix
6. a sonogram/UTZ will show dense growth (typically a
“snowstorm” pattern) but no fetal growth in the uterus - sutures may be placed trans-abdominally

7. vaginal spotting of dark brown blood

8. discharge of the clear fluid filled vesicles

Management:

1. suction curettage to evacuate the mole

2. after extraction, women should have a baseline serum

test for the beta subunit of hCG

3. educate on avoiding pregnancy for at least one year

4. hCG is analyzed every 2-4 weeks for 6-12 months

(gradually declining hCG suggest no complications)

5. prophylactic course of Methotrexate is the drug of

choice for choriocarcinoma. This must be weigh carefully
because it interferes with WBC formation which can lead
to leukopenia

6. observe for bleeding and hypovolemic shock

2. PREMATURE CERVICAL DILATATION

3. CONDITIONS ASSOCIATED WITH THIRD –
- previously termed as “Incompetent Cervix” TRIMESTER BLEEDING
- refers to a cervix that dilates prematurely and therefore A. PLACENTA PREVIA
cannot hold a fetus until term
- is low implantation of the placenta
- commonly occurs at approximately week 20 of
pregnancy - it occurs in four degrees:

Causes: 1. Low- lying placenta – implantation in the lower rather

than in the upper portion of the uterus
- unknown
2. Partial placenta previa – implantation that occludes a
Risk factors portion of the cervical OS
1. associated with increased maternal age, congenital 3. Marginal – placenta edge approaches the cervical OS.
structural defects and trauma to the cervix such as Lower border is within 3 cm from internal cervical OS but
might occurred with biopsy or repeated D & C does not cover the OS
Signs and Symptoms: 4. Total placenta previa – implantation that totally
obstructs the cervical OS - incidence is approximately 5
per 1000 pregnancies
 B. ABRUPTIO PLACENTA - premature separation of a
normally implanted placenta either partial/marginal or
complete/total

- occurs after 20-24 weeks of pregnancy

Risk Factors

– increased parity

- advanced maternal age

- past cesarean births

- past uterine curettage

- multiple gestation

Complication:

1. postpartum hemorrhage
Causes:
2. hypovolemic shock
-unknown
3. preterm labor
Risk Factors
4. fetal distress
- high parity
Signs and symptoms;
- advanced maternal age
1. sudden onset of painless bright red vaginal bleeding
(latter half of pregnancy) - short umbilical cord

2. bleeding may be profuse or scanty - chronic hypertensive disease

Note: - PIH

- site of bleeding: uterine deciduas (maternal blood) places - direct trauma (from VA)
the mother at risk for hemorrhage
- cocaine or cigarette use (Vasoconstriction)
- bleeding may not occur until the onset of cervical
dilatation causing the placenta to loosen from the uterus

Management

1. bleeding is an emergency. (fetal oxygen may be

compromised and preterm birth may occur)

2. assess the amount of blood loss (duration, time of

bleeding began, accompanying pain, and color of the
blood)

3. bed rest with oxygenation prescribed

4. side-lying or trendelenburg position (for 72 hours)

5. NO Internal Exams (IE) or Rectal Exams, may initiate

massive hemorrhage (if necessary, must have double set
up; OR/ DR)

6. keep IV line and have blood available (X-matched and

typed)

7. Apt or Kleihauer- Betke Test (test strip procedure to

determine if blood is fetal or maternal in origin)

8. Fetal Assessment:

a. monitor fetal status; heart tone and movement

b. determine fetal lung maturity; amniocentesis – L/S ratio

c. Bethamethasone may be prescribed (encourage

maturity of fetal lungs; if fetus is less than 34 weeks
gestation)
 aka. Premature Labor
 labor that occurs after 20 weeks and before the
end of 37-week gestation
 approximately 9-10% of all pregnancies
 labor contractions that happens every 10-20
minutes
 usually leads to progressive cervical dilatation of
>2 cm and effacement of >80%

Causes:

- unknown

Risk Factors:
Complications:
1. Dehydration (stimulates APG to release
1. fetal distress (altered HR) ADH/Oxytocin that strengthen uterine
contractions)
2. Couvelaire uterus or Uteroplacental apoplexy 2. UTI
3. Chorioamnionitis (infection of the fetal
3. disseminated intravascular coagulation (DIC)
membranes and fluid)
Signs and symptoms: 4. Younger than 17 and over 35 years
5. Inadequate prenatal care
1. vaginal bleeding (may not reflect the true amount of 6. Emotional and physical stress
blood loss) 7. Previous pre-term labor
8. Low socio-economic class
2. abdominal and low back pain (dull or aching)

3. sharp stabbing pain high in the fundus

4. uterine irritability (frequent low intensity contractions)

5. high uterine resting tone

6. uterine tenderness

SIGNS AND SYMPTOMS

Early Signs and symptoms

1. Persistent low back pain

2. Vaginal spotting
3. Cramping
4. Increase vaginal discharge
5. Uterine contractions
6. Pelvic pressure or a feeling that the fetus is
pushing Down
7. Pain or discomfort in the vulva or thighs

Management:
Degrees of Separation Grade criteria:
FOCUS: Prevention of the delivery of premature fetus
1. The woman should first admitted to the hospital
0 - no symptoms of separation. Slight separation
2. Place/position in Left lateral position
occurs after birth. When placenta is examined, a
3. BEDREST to relieve the pressure of the fetus on
segment shows recent adherent clots
the cervix
4. Intravenous fluid therapy to promote hydration
1 - minimal separation, enough to cause bleeding and
5. Medical Management
changes in vital signs. However, there is no
occurrence of fetal distress and hemorrhagic
a. Betamethasone/Glucocorticoids – steroid, given in an
shock
attempt to hasten fetal lung maturity
- given in 2 dose, 12 mg IM 24 hours apart
2 - moderate separation. There is evidence of fetal
distress, and the uterus is tense and painful on
b. Tocolytic agents (halt labor)
palpation
1. Calcium channel blockers – Beta adrenergic
drugs
3 - extreme separation, and maternal shock or fetal
2. Indomethacin (prostaglandin antagonist)- it can
death will result
decrease fetal urine output, causing a decrease
in amniotic fluid, not DOC because it can
Management:
stimulate the early closure of ductus arteriosus
3. Magnesium Sulfate – often the first drug used to
1. keep the client in lateral position, not supine
halt contractions
2. oxygen therapy (limit fetal anoxia)
3. monitor FHT and record maternal vital signs
every5 to 15 minutes
Others:
4. baseline fibrinogen (if bleeding is extensive.
- CNS depressant- halts uterine
Fibrinogen reserve may be used up in the body’s
contraction
attempt to accomplish effective clot formation)
4. Ritodrine Hydrochloride (Yutopar) and
5. No IE or rectal exam. No enema
Terbutaline (Brethine) - acts on entire beta 2
6. Keep the IV line open (Possible BT)
receptors sites (uterine and bronchial smooth
muscles) causing mild hypotension and
C. Preterm Labor (Vaginal bleeding or spotting during
tachycardia effects, hypokalemia, hyperglycemia,
pregnancy)
pulmonary edema
 - onset: occurs after 20th week of pregnancy and
Side Effects: may appear up to 48 hours (2 weeks) postpartum
- occurs 5-10% pregnancies
a. Headache (most common) – due to dilatation
of cerebral blood vessels Cause:
b. Nausea and vomiting - Unknown

Nursing Responsibilities BEFORE administration of Risk Factors:

Tocolytic Therapy: - related to different associative factors

1. Assess baseline blood data i.e. hct, glucose, 1. Primipara - < 20 years old and > 40 years old
potassium, NaCl, ECG (tachycardia) 2. Low socio-economic status (poor nutrition –
2. Uterine and fetal monitoring (external fetal decrease CHON intake)
monitors) 3. Women who have 5 or more pregnancies
3. Mix the drug with lactated Ringers solution to 4. Multiple pregnancies
prevent hyperglycemia (piggyback administration, 5. Hydramnios (pre-exisiting)
so that it can be stop immediately if tachycardia 6. Underlying HPN/DM
occurs) 7. Poor calcium/Magnesium intake
4. Assess BP and pulse every 15 minutes and every 8. H-mole
30 minutes until contractions stop
5. Report PR>120 bpm, BP < 90/60 chest pain,
dyspnea, rales

D. PREMATURE RUPTURE OF MEMBRANES (PROM)

- rupture and loss of amniotic fluid that occurs

before labor begins
- occurs in 2-18 % of pregnancies

Cause:
- unknown, but associated with infection of fetal
membranes (Chorioamnionitis)
- nutritional deficiency involving ascorbic acid
Signs and symptoms:
Complication:
Triad of Symptoms (classic signs of PIH)
1. Fetal infections – after the rupture of BOW, the
seal to the fetus is lost
1. HPN
2. Protenuria
2. Cord Compression – pressure on the umbilical
3. Edema
cord because of the loss of the amniotic fluid,
which can cut off the nutrient supply to the fetus
Interstitials Effects:
(fetal distress)
- Because of more CHON is lost, the osmotic
pressure is decreased and the excessive fluid
3. Cord prolapsed – the extension of the umbilical
shifts/diffuses from vascular spaces to the
cord into the vagina which can also interfere with
interstitial’s spaces
fetal blood circulation
- leads to edema (extreme edema can lead to
pulmonary edema and seizure (Eclampsia) and it
Signs and Symptoms: increases tubular reabsorption of Na in kidneys’
1. Sudden gush of clear fluid from the vagina
Feto-placental effects:
Fluid should be tested for: - poor placental perfusion may reduce the fetal
nutrient and oxygen supply
a. Nitrazine Paper test – amniotic fluid causes
alkaline (>6.5 ph) reaction to the paper (turns to blue) and Classification of PIH:
urine causes acidic reaction (remains yellow)
1. Gestational HPN – Transient HPN
b. Ferning test – get the sample of fluid then
place on the slide and viewing it under the - Develops increase BP (>140/90) but has no
microscope protenuria and edema
- Decrease maternal mortality so no drug therapy
- + ferning patterns means –BOW is necessary
- BP returns to normal by 10th day of postpartum
Management:
1. Strict Bed Rest 2. Mild Pre-Eclampsia
2. Observe, document and report maternal a. 1st criteria – Increase BP of >140/90 mmHg
temperature above 38oC, fetal tachycardia taken on 2 occasion at least 6 hours apart
3. Monitor for signs of infections (fever, uterine
tenderness) - 2nd criteria – Systolic BP is > 30 mmHg and
4. Avoid sexual intercourse/Orgasm Diastolic BP is >15 mm Hg above baseline BP
5. Avoid vaginal exams (risk of infection)
6. Avoid breast stimulation b. Protenuria
7. Record fetal movements daily and report fewer - +1 or +2 (represents a loss of 1 g/dl of CHON
than 10 in a 12-hour period
8. Administer broad spectrum ATBC to reduce the c. Edema (weight gain)
risk of infection e.g. Penicillin/Ampicillin - due to CHON loss, sodium retention and
decrease GFR
PART 2 OF LESSON 4 - begins to accumulate on the upper part of the
body (hands/face)
1. PREGNANCY- INDUCED HYPERTENSION (PIH) - weight gain of >2 lb/wk in the second semester or
> 1 lb/wk in the 3rd trimester (abnormal)
- originally called “Toxemia of Pregnancy”
- condition in which vasospasm occurs during Normal Weight Gain; 1st Trimester – 1 lb/month, 2nd/3rd
pregnancy accompanied by hypertension, trimester – 4 lbs/month
protenuria and edema
Nursing Management:
 - check for PR and BP before and after
- can be managed at home with frequent follow- administration
ups 2. Magnesium Sulfate
- DOC to prevent eclampsia
1. BED REST (bathroom privileges) Action:
- facilitate Na excretion a. Cathartic – reduces edema by causing fluid shifting
- decreases oxygen demand from extracellular spaces into the intestine (removed by
- position on left lateral position to prevent uterine bowel elimination)
pressure on the vena cava b. CNS depressant (anti-convulsant) – lessens the
possibility of seizure activity
2. Assess the BP in sitting/left lateral position, c. Decreases neuromuscular irritability (muscle
CHON level in the urine, changes in LOC, fetal relaxant effect)
movements and FHT d. Promotes maternal vasodilatation – promotes better
feto-placental circulation or tissue perfusion
3. regular diet with NO salt restriction
Nursing responsibilities during MgSO4 administration:
- Na restriction may activate the RAAS (rennin- 1. Given IV via Piggyback infusing over 15-30 minutes,
angiotensin- aldosterone system) which can loading dose 4-6g/hr and maintenance dose 1-2 g/hr
result in increased BP 2. Assess RR, urine output, DTR and ankle clonus before
after administration
4. if symptoms progress to Severe Pre-Eclampsia –
REFER immediately to HOSPITAL. 3.Monitor for magnesium sulfate toxicity:
a. depressed respiration of <12breaths/min
3. Severe Pre-Eclampsia b. decrease urine output of <30 ml/hr
c. decrease DTR
- Presence of any of the following: d. decrease LOC
a. Increase BP >160/110 mm Hg on at least 2
occasions 6 hours apart at bed rest (the position 4. Antidote: Calcium Gluconate – a solution of 10 ml of
in which BP is lowest) 10% calcium gluconate solution given for MGSO4 toxicity
- must be readily available at bedside
b. Marked protenuria – 3+ or 4+ on a random urine
sample 4.Eclampsia
- the most severe classification of PIH
c. Generalized edema noticeable in woman’s face - when cerebral edema occurs onset of seizure or
(facial edema) and hands (wedding ring can’t be coma occurs
removed), pulmonary edema (dyspnea, crackles - maternal mortality rate is high at 20% due to
on auscultation), cerebral edema (visual hemorrhage (circulatory collapse or renal failure)
disturbances i.e blurred vision, headache) -
Signs and Symptoms:
d. Urine output – oliguria (less than 500 ml/24 hrs) 1. Increase HPN precedes SEIZURE
or 30 ml/hr) - impending signs of seizure are headache, visual
disturbances and epigastric pain) followed by
circulatory hypotension and collapse
Nursing Management:
- usually hospitalized until the baby is delivered Stages of Seizure:
1. BED REST (patient must be observed more a. Tonic phase – all body contracts, arching of back, arms
closely) and legs are stiff
2. Provide a quiet and calm environment – any
noise can trigger a seizure activity and leads to b. Clonic phase = all of the muscle of body will contract
eclampsia and relax

3. Administer precautions on the patient’s room: c. Post-Ictal phase – semicomatose/ patient cannot be
a. Patient’s bed must be near nurse’s station with arouse except for painful stimuli
code cart nearby
b. Placed in private room (undisturbed) 2. May lead to coma
c. The room should be darkened (because bright 3. Labor may begin because of premature
light can trigger seizure) separation of placenta secondary to vasospasm
d. Raise padded side rails to prevent falls or injury which might lead to preterm delivery
from seizure activity
Nursing Management:
4. Frequent maternal assessments every 4 - Priority care for the mother with seizure is to:
hours (seizure precautions) 1. Maintenance of Patent Airway
a. sudden rise of BP - administer oxygen by face mask
b. blood studies – CBC, platelet count, liver - turning the mother to the side to allow the
function, BUN, Creatinine, urine CHONS secretions to drain in the mouth (preventing
c. urine output – normal 600ml/24hours or 30 aspiration)
ml/hour 2. Raised padded side rails
d. daily weights – same time each day 3. Avoid placing a tongue depressor (during the
e. impending seizure signs (aura) such as seizure activity) because it can obstruct the
headache, visual disturbances, epigastric pain airway
4. minimize environmental stimuli
5. Monitor Fetal Well-being 5. administer medications as ordered i.e MgSO4
- placed in External fetal Monitors to asses for FHR and diazepam IV
and fetal movements 6. continue to assess FHT and uterine contractions
- Non-Stress test/Biophysical Profile to assess for 7. check for maternal bleeding
Utero-placental sufficiency 8. mother can deliver via NSD, CS is very
hazardous because hypotension might result
6. Moderate high protein diet to compensate for secondary to anesthesia
CHON lost (proteinuria) 9. IV therapy as ordered

Medical Management: COMPLICATION OF PIH:

- to prevent Eclampsia
1. Hydralazine (Apresoline) – antihypertensive – to HELLP SYNDROME
reduce HPN by peripheral dilatation
- side effects – Tachycardia - a variation of PIH abbreviated as Hemolysis,
Elevated
 a. more frequent in non-whites than in
Liver enzymes and Low Platelet count whites
b. increase in parity
- occurs in 4-12% of patients with PIH c. advance maternal age
- a life-threatening complication of PIH (because d. familial inheritance
maternal mortality is high at 24% and infant
mortality is 25%)

Cause: Unknown

Associated Factors
- primipara/Multipara mothers

Signs and Symptoms:

- nausea
- epigastric pain
- general malaise
- right upper quadrant tenderness

Laboratory data:
a. hemolytic RBC
b. thrombocytopenia (low platelet count of below
100,000/m3) Diagnostic procedure:
- Sonogram/Ultrasound
c. elevated liver enzyme (because of hemorrhage and
necrosis of liver)
Signs and Symptoms:
- serum ALT (Alanine Aminotransferase), and ALT
(Aspartate aminotransferase) 1. Increase uterine size faster than usual
2. quickening at the different portion of the abdomen
Medical Management: (no known cure) 3. more than expected fetal activity
4. multiple sets of FHT
1. Blood transfusion of fresh frozen plasma or
platelets 5. extreme fatigue and backache
2. infant is delivering ASAP via NSD or CS (lab.
results will return to normal after delivery Management:
- mother is more susceptible to complications of
3. monitor for bleeding
pregnancy i.e. PIH, hydramnios, placenta previa,
pre-term labor, anemia than a woman carrying
2. MULTIPLE PREGNANCIES
- a pregnancy in which there is only one fetus
1. BED REST (during the 2 or 3 months of pregnancy to
more than one fetus in the uterus
at the same time decrease risk of preterm labor
2. Closer prenatal supervision
- Incidence rate is
2% of pregnancies
3. HYDRAMNIOS (Polyhydramnios)
Types:
- excessive fluid formation of >2000ml or an
1. Monozygotic twins amniotic fluid index of above 24 cm (normal 500-
1000ml)
- aka. Identical twins
- begins with single ovum and spermatozoa, during
Complications:
the process of fusion, the zygote divides into two
identical individuals
1. Fetal Malpresentation (because of extra-uterine
- have 1 placenta, 1 chorion, 2 amnion, 2 umbilical
cords space)
2. Premature rupture of membranes – that leads to
- always of the same sex
infection and prolapsed cord
3. Preterm labor (because of increasing pressure,
prostaglandin release)

Risk Factors:

1. Maternal diabetes – hyperglycemia in the fetus

causes increase urine production leading to
increase urine output
2. Anencephaly
3. Esophageal atresia – fetus becomes unable to
2. Dizygotic Twins swallow the amniotic fluid because of intestinal
- aka. Non-identical/fraternal twins anomalies or obstruction
- the result of fertilization of two separate ova by
two separate spermatozoa
- have 2 placenta, 2 chorions, 2 amnions, 2
umbilical cords
- twins may be of the same or different sex
- 2/3 of twins are dizygotic

Anencephaly
Signs and Symptoms:

1. rapid enlargement of the uterus (first sign)

Associative Factors:
 2.difficulty in palpating and auscultating the fetus
due to excessive fluid
3. shortness of breath due to compression of the
diaphragm
4. ultrasound finding of increase excessive fluid
Management:
1. maintain bed rest to reduce pressure on cervix
and to prevent premature labor
2. monitor for rupture or uterine contraction
3. avoid constipation (it will increase uterine
pressure and rupture of membranes)
4. amniocentesis (slow and controlled release of
fluid to prevent premature separation of the
placenta) guided by ultrasound